Use of Medication to Treat Attention-Deficit/Hyperactivity Disorder in Young Children: The Role of Maternal History of Psychotropic Medication Use

We examine whether, among children diagnosed with ADHD, are those whose mothers have a history of psychotropic medication use more likely to treat their ADHD with medication? Children born in Manitoba, Canada from 2000 to 2010 diagnosed with ADHD between their 4th and 8th birthday. Maternal psychotropic medication use was assessed from one year before the child's birth to the child's fourth birthday. Logistic regression models examine the relationship between maternal history of psychotropic medication use and the use of medication to treat ADHD in children. Among the 2384 children diagnosed with ADHD, the rate of ADHD medication use was higher for those whose mother had a history of psychotropic medication use (76.6%) than for those whose mothers did not (72.5%) (OR 1.24, 95% CI 1.03, 1.49). Children whose mothers have a history of psychotropic medication use are more likely to have their ADHD treated with medication.

Unwinding the tangle of adolescent pregnancy and socio-economic functioning: leveraging administrative data from Manitoba, Canada

BACKGROUND

Understanding the relationship between adolescent pregnancy and adult education and employment outcomes is complicated due to the endogeneity of fertility behaviors and socio-economic functioning. Studies exploring adolescent pregnancy have often relied on limited data to measure adolescent pregnancy (i.e. birth during adolescence or self-reports) and lack access to objective measures of school performance during childhood.

METHODS

We use rich administrative data from Manitoba, Canada, to assess women's functioning during childhood (including pre-pregnancy academic performance), fertility behaviors during adolescence (live birth, abortion, pregnancy loss, or no history of pregnancy), and adult outcomes of high school completion and receipt of income assistance. This rich set of covariates allows calculating propensity score weights to help adjust for characteristics possibly predictive of adolescent pregnancy. We also explore which risk factors are associated with the study outcomes.

RESULTS

We assessed a cohort of 65,732 women, of whom 93.5% had no teen pregnancy, 3.8% had a live birth, 2.6% had abortion, and < 1% had a pregnancy loss. Women with a history of adolescent pregnancy were less likely to complete high school regardless of the outcome of that pregnancy. The probability of dropping out of high school was 7.5% for women with no history of adolescent pregnancy; after adjusting for individual, household, and neighborhood characteristics, the probability of dropping out of high school was 14.2 percentage points (pp) higher (95% CI 12.0-16.5) for women with live birth, 7.6 pp. higher (95% CI 1.5-13.7) for women with a pregnancy loss, and 6.9 pp. higher (95% CI 5.2-8.6) for women who had abortion. They key risk factors for never completing high school are poor or average school performance in 9th grade. Women who had a live births during adolescence were much more likely to receive income assistance than any other group in the sample. Aside from poor school performance, growing up in poor households and in poor neighborhoods were also highly predictive of receiving income assistance during adulthood.

DISCUSSION

The administrative data used in this study enabled us to assess the relationship between adolescent pregnancy and adult outcomes after controlling for a rich set of individual-, household-, and neighborhood-level characteristics. Adolescent pregnancy was associated with higher risk of never completing high school regardless of the pregnancy outcome. Receipt of income assistance was significantly higher for women having a live birth, but only marginally higher for those who had a pregnancy that ended in loss or termination, underlining the harsh economic consequences of caring for a child as a young mother. Our data suggest that interventions targeting young women with poor or average school marks may be especially effective public policy priorities.

Examining the relationship between maternal mental health-related hospital admissions and childhood developmental vulnerability at school entry in Canada and Australia

BACKGROUND

It is well established that maternal mental illness is associated with an increased risk of poor development for children. However, inconsistencies in findings regarding the nature of the difficulties children experience may be explained by methodological or geographical differences.

AIMS

We used a common methodological approach to compare developmental vulnerability for children whose mothers did and did not have a psychiatric hospital admission between conception and school entry in Manitoba, Canada, and Western Australia, Australia. We aimed to determine if there are common patterns to the type and timing of developmental difficulties across the two settings.

METHOD

Participants included children who were assessed with the Early Development Instrument in Manitoba, Canada (n = 69 785), and Western Australia, Australia (n = 19 529). We examined any maternal psychiatric hospital admission (obtained from administrative data) between conception and child's school entry, as well as at specific time points (pregnancy and each year until school entry).

RESULTS

Log-binomial regressions modelled the risk of children of mothers with psychiatric hospital admissions being developmentally vulnerable. In both Manitoba and Western Australia, an increased risk of developmental vulnerability on all domains was found. Children had an increased risk of developmental vulnerability regardless of their age at the time their mother was admitted to hospital.

CONCLUSIONS

This cross-national comparison provides further evidence of an increased risk of developmental vulnerability for children whose mothers experience severe mental health difficulties. Provision of preventative services during early childhood to children whose mothers experience mental ill health may help to mitigate developmental difficulties at school entry.

Familial associations in adolescent substance use disorder: a population-based cohort study

BACKGROUND AND AIMS

Family history of substance use disorder (SUD) affects a child's risk of the disorder through both genetic and shared environmental factors. We aimed to estimate the association between parental or older sibling SUD history with the risk of adolescent SUD diagnosis.

DESIGN, SETTING AND PARTICIPANTS

We conducted a population-based cohort study using administrative health-care databases in the Province of Manitoba, Canada, which has a universal and publicly funded health-care system. We included all children born from 1984 to 2000 who have linkages to both parents and were followed until age 18 years. We used generalized estimating equation models to produce unadjusted and adjusted relative risk (RR) estimates of adolescent SUD risk. The study cohort included 134 389 children and 31 307 full sibling pairs; 51.3% were male and 35.4% first-born.

MEASUREMENTS

The exposure was SUD diagnosis in a mother or father in either hospitalization or outpatient physician visit records before the children's age of 13 years. The secondary exposure was an adolescent SUD diagnosis in an older full sibling. The outcome was SUD diagnosis during adolescence (13 and 18 years of age) identified in either hospitalization or physician visit records. Children demographics and characteristics associated with SUD diagnosis were included in the models.

FINDINGS

Of the 134 389 children, 9.5% had a mother with a history of SUD, 11.3% had a father and 1.3% had an older sibling with a history of SUD diagnosis; 2566 (1.9%) had an adolescent SUD diagnosis. An increased risk of adolescent SUD was observed with SUD history in mothers [adjusted RR (aRR) = 2.50; 95% confidence interval (CI) = 2.26, 2.79], fathers (aRR = 2.15; 95% CI = 1.95, 2.37), both parents (aRR = 3.74; 95% CI = 3.24, 4.31) and older sibling (aRR = 3.85; 95% CI = 2.53, 5.87).

CONCLUSIONS

A family history of substance use disorder in parents or older siblings appears to be associated with increased SUD risk in adolescents.

Linking Canadian Administrative Data: Income Trajectories, Residential and School Mobility, and Grade 3 Academic Achievement

ObjectiveThe objective is to examine the association between trajectories of childhood residential and school mobility and academic achievement (literacy, numeracy) in Grade 3 using linked whole-population administrative data in Manitoba, Canada. Secondarily, we assessed childhood residential/school mobility based on neighbourhood income levels (moving in/out of low- or mid-/high-income neighbourhoods). ApproachThis retrospective cohort study used linkable, de-identified administrative data (health, education, national census, provincial survey) from the provincial Population Research Data Repository housed at the Manitoba Centre for Health Policy (MCHP). Among kindergarteners from 2005 to 2014 (n = 83,894), those not having continuous residency in Manitoba, valid education assessments, and relevant family-level covariates were excluded. We followed this eligible cohort from kindergarten to Grade 3 based on various neighbourhood income trajectories of residential and school mobility. To assess Grade 3 literacy and numeracy scores based on trajectories, log-binomial regression models were conducted using SAS® version 9.4. ResultsThe total cohort included 36,754 children; at the end of kindergarten, 14.2% resided in low-income neighbourhoods, and 84.8% lived in mid-/high-income neighbourhoods. Moving between two low-income neighborhoods between kindergarten to Grade 3 was associated with an increased risk of poor Grade 3 numeracy and literacy scores (numeracy aRR=1.39 [1.16,1.67]; literacy aRR=1.31 [1.08,1.59]). When moving between neighborhood income levels, the association was stronger for children moving into low-income neighbourhoods (e.g., mid-/high-income to low-income: numeracy aRR=1.41 [1.19,1.67]) than children moving into mid/high-income neighbourhoods (e.g., low-income to mid-/high-income: numeracy aRR=1.31 [1.08,1.59]). Changing schools between kindergarten and Grade 3 was also associated with poorer numeracy and literacy scores in Grade 3 (numeracy aRR=1.31 [1.22,1.40]; literacy aRR=1.34 [1.24,1.44]); however, the strength varied based on residential mobility patterns. ConclusionMoving homes/schools can differentially impact children’s educational attainment depending upon the income level of residing neighborhood(s). Stakeholders should recognize different levels of risks related to mobility and provide support accordingly to reduce the adverse impact. Support systems should be tailored to not only children but also families and neighbourhoods.

Record Linkage and Big Data-Enhancing Information and Improving Design

OBJECTIVE

To highlight the potential of multiple file record linkage. Linkage increases the value of existing information by supplying missing data or correcting errors in existing data, through generating important covariates, and by using family information to control for unmeasured variables and expand research opportunities.

STUDY DESIGN AND SETTING

Recent Manitoba papers highlight the use of linkage to produce better studies. Specific ways in which linkage helps deal with different substantive issues are described.

RESULTS

Wide data files-files containing considerable amounts of information on each individual-generated by linkage improve research by facilitating better design. Nonexperimental work in particular benefits from such linkages. Population registries are especially valuable in supplying family data to facilitate work across different substantive fields.

CONCLUSION

Several examples show how record linkage magnifies the value of information from individual projects. The results of observational studies become more defensible through the better designs facilitated by such linkage.

Multigenerational health research using population-based linked databases: an international review

Family health history is a well-established risk factor for many health conditions but the systematic collection of health histories, particularly for multiple generations and multiple family members, can be challenging. Routinely-collected electronic databases in a select number of sites worldwide offer a powerful tool to conduct multigenerational health research for entire populations. At these sites, administrative and healthcare records are used to construct familial relationships and objectively-measured health histories. We review and synthesize published literature to compare the attributes of routinely-collected, linked databases for three European sites (Denmark, Norway, Sweden) and three non-European sites (Canadian province of Manitoba, Taiwan, Australian state of Western Australia) with the capability to conduct population-based multigenerational health research. Our review found that European sites primarily identified family structures using population registries, whereas non-European sites used health insurance registries (Manitoba and Taiwan) or linked data from multiple sources (Western Australia). Information on familial status was reported to be available as early as 1947 (Sweden); Taiwan had the fewest years of data available (1995 onwards). All centres reported near complete coverage of familial relationships for their population catchment regions. Challenges in working with these data include differentiating biological and legal relationships, establishing accurate familial linkages over time, and accurately identifying health conditions. This review provides important insights about the benefits and challenges of using routinely-collected, population-based linked databases for conducting population-based multigenerational health research, and identifies opportunities for future research within and across the data-intensive environments at these six sites.

Association of Epidural Labor Analgesia With Offspring Risk of Autism Spectrum Disorders

IMPORTANCE

Epidural labor analgesia (ELA) has been associated with an increased offspring risk of autism spectrum disorder (ASD). Whether this finding may be explained by residual confounding remains unclear.

OBJECTIVE

To assess the association between ELA and offspring risk of ASD.

DESIGN, SETTING, AND PARTICIPANTS

Longitudinal cohort study of vaginal deliveries of singleton live infants born from 2005 to 2016 from a population-based data set linking information from health care databases in Manitoba, Canada; offspring were followed from birth until 2019 or censored by death or emigration. Data were analyzed from October 19, 2020, to January 22, 2021.

EXPOSURES

Epidural labor analgesia.

MAIN OUTCOMES AND MEASURES

At least 1 inpatient or outpatient diagnosis of ASD in offspring aged at least 18 months. For the full population and a sibling cohort, inverse probability of treatment-weighted Cox proportional hazards regression analyses were used to control for potential confounders.

RESULTS

Of the 123 175 offspring included in this study (62 647 boys [50.9%]; mean [SD] age of mothers, 28.2 [5.8] years), 47 011 (38.2%) were exposed to ELA; 2.1% (985 of 47 011) of exposed vs 1.7% (1272 of 76 164) of unexposed offspring were diagnosed with ASD in the follow-up period (hazard ratio [HR], 1.25; 95% CI, 1.15-1.36). After adjusting for maternal sociodemographic, prepregnancy, pregnancy, and perinatal covariates, ELA was not associated with an offspring risk of ASD (inverse probability of treatment-weighted HR, 1.08; 95% CI, 0.97-1.20). In the within-siblings design adjusting for baseline covariates, ELA was not associated with ASD (inverse probability of treatment-weighted HR, 0.97; 95% CI, 0.78-1.22). Results from sensitivity analyses restricted to women without missing data who delivered at or after 37 weeks of gestation, firstborn infants only, and offspring with ASD classified with at least 2 diagnostic codes were consistent with findings from the main analyses.

CONCLUSIONS AND RELEVANCE

In a Canadian population-based birth cohort study, no association between ELA exposure and an increased offspring risk of ASD was found.

The association of objectively ascertained sibling fracture history with major osteoporotic fractures: a population-based cohort study

We investigated the association of objectively ascertained sibling fracture history with major osteoporotic fracture (hip, forearm, humerus, or clinical spine) risk in a population-based cohort using administrative databases. Sibling fracture history is associated with increased major osteoporotic fracture risk, which has implications for fracture risk prediction.

INTRODUCTION

We aimed to determine whether objectively ascertained sibling fracture history is associated with major osteoporotic fracture (MOF; hip, forearm, humerus, or clinical spine) risk.

METHODS

This retrospective cohort study used administrative databases from the province of Manitoba, Canada, which has a universal healthcare system. The cohort included men and women 40+ years between 1997 and 2015 with linkage to at least one sibling. The exposure was sibling MOF diagnosis occurring after age 40 years and prior to the outcome. The outcome was incident MOF identified in hospital and physician records using established case definitions. A multivariable Cox proportional hazards regression model was used to estimate the risk of MOF after adjustment for known fracture risk factors.

RESULTS

The cohort included 217,527 individuals; 91.9% were linked to full siblings (siblings having the same father and mother) and 49.0% were females. By the end of the study period, 6255 (2.9%) of the siblings had a MOF. During a median follow-up of 11 years (IQR 5-15), 5235 (2.4%) incident MOF were identified in the study cohort, including 234 hip fractures. Sibling MOF history was associated with an increased risk of MOF (hazard ratio [HR] 1.67, 95% confidence interval [CI] 1.44-1.92). The risk was elevated in both men (HR 1.57, 95% CI 1.24-1.98) and women (HR 1.74, 95% CI 1.45-2.08). The highest risk was associated with a sibling diagnosis of forearm fracture (HR 1.81, 95% CI 1.53-2.15).

CONCLUSION

Sibling fracture history is associated with increased MOF risk and should be considered as a candidate risk factor for improving fracture risk prediction.

Maternal Depression in Early Childhood and Developmental Vulnerability at School Entry

IntroductionStudies on the relationship between exposure to maternal depression in early childhood and childhood development have been limited by small samples, lack of information on timing of maternal depression, and use of a composite measure of childhood development. Objectives and ApproachWe linked multiple Manitoba datasets to examine the relationship between exposure to maternal depression in early childhood and childhood development at school entry across five domains, and age at exposure to maternal depression on developmental outcomes using a population-based cohort (n = 52,103). Maternal depression was defined using physician visits, hospitalizations, and pharmaceutical data, while developmental vulnerability was assessed using the well-validated Early Development Instrument. Relative risk of developmental vulnerability was assessed using log-binomial regression models, adjusted for maternal and childhood characteristics at the birth of the child. ResultsChildren exposed to maternal depression before age 5 had a 17% higher risk of having at least one developmental vulnerability at school entry than children not exposed to such depression before age 5. Exposure to maternal depression before age 5 was most strongly associated with social competence (aRR = 1.28, 95% CI 1.20, 1.38), physical health and well-being (aRR = 1.28, 95% CI 1.20, 1.36), and emotional maturity (aRR = 1.27, 95% CI 1.18, 1.37). For most developmental domains, exposure to maternal depression before age 1 and between ages 4 and 5 had the greatest association with developmental vulnerability. Conclusion / ImplicationsOur findings that children exposed to maternal depression were at higher risk of developmental vulnerability at school entry is consistent with previous studies. However, we found that the association between exposure to maternal depression and development varied across developmental domains, and the relationship varied depending on the age of exposure to maternal depression. Ongoing analyses of discordant cousins will shed more light on the causal nature of this relationship.

The Association of Sibling Fracture History with Major Osteoporotic Fractures in Individuals from A Population-Based Cohort

IntroductionMajor osteoporotic fractures (MOF) are associated with significant morbidity and healthcare system burden. Objectives and ApproachWe aimed to determine whether sibling fracture history is associated with MOF risk amongst individuals from a population-based cohort using objectively-ascertained measures of fracture history. This retrospective cohort study used administrative databases from the province of Manitoba, Canada, which has a universal healthcare system. The cohort included individuals aged 40 years and older between 1997 and 2015 with linkage to at least one sibling. The exposure was MOF diagnosis occurring at age 40 years or older in a randomly selected sibling. The outcome was incident clinically-diagnosed MOF (hip, wrist, humerus or spine) identified in hospital and physician records using established case definitions. A multivariable Cox proportional hazards regression was used to test the association of sibling fracture history with the risk of MOF in individuals after adjustment for known fracture risk factors. ResultsThe cohort included 217,519 individuals; 92% were linked to full siblings (i.e., same mother/father) and 49% were females. During a median follow-up of 11 years (IQR 5 -15), 7274 (3.3%) incident MOF cases were identified. Sibling MOF history was associated with increased risk of MOF (HR 1.71, 95% CI 1.48–1.97). The risk was elevated in both men (HR 1.63, 95% CI 1.29-2.06) and women (HR 1.78, 95% CI 1.48-2.13) but was higher among sisters (HR 2.08, 95% CI 1.65-2.61) compared to brothers (HR 1.67, 95% CI 1.20-2.32). In a secondary analysis of sibling fracture site, the highest risk was observed with diagnosis of wrist followed by spine fractures (HR 1.86, 95% CI 1.57-2.21 and HR 1.46, 95% CI 1.08-1.98, respectively). ConclusionSibling fracture history is associated with increased MOF risk in individuals and should be considered as a candidate risk factor for improving fracture risk prediction.

Parental cardiorespiratory conditions and offspring fracture: A population-based familial linkage study

BACKGROUND

The role of parental cardiorespiratory conditions on fracture risk is unclear. We examined the associations between parental cardiorespiratory conditions and offspring fracture risk.

METHODS

In this population-based retrospective cohort study, we identified 279,085 offspring aged≥40 years between April 1, 1997 and December 31, 2015 with successful linkage to 273,852 mothers and 254,622 fathers. Parental cardiorespiratory conditions, including cerebral vascular disease, congestive heart failure, hypertension, ischemic heart disease, myocardial infarction, chronic obstructive pulmonary disease (COPD) and peripheral vascular disease, were ascertained using physician and hospital records dating back to 1979. The outcome was offspring incident major osteoporotic fracture (MOF).

RESULTS

During an average of 11.8 years of offspring follow-up, we identified 8762 (3.1%) incident MOF. Either parent congestive heart failure (adjusted hazard ratio [HR]: 1.13; 95% confidence interval [CI] 1.07-1.19) and COPD (adjusted HR: 1.12; 95% CI 1.07-1.17) were independently associated with increased offspring MOF risk; all their false discovery rates were <0.001. Similar risk estimates were observed when analyses were performed for fathers only, mothers only or both parents, in multivariable models with and without adjustment for offspring cardiorespiratory conditions, and stratified by offspring sex and offspring incident fracture site. Parental cerebrovascular disease, hypertension, ischemic heart disease and myocardial infarction were not associated with offspring MOF.

CONCLUSIONS

Parental congestive heart failure and parental COPD are independent risk factors for offspring MOF.

Maternal Depression in Early Childhood and Developmental Vulnerability at School Entry

OBJECTIVES

To assess the relation between exposure to maternal depression before age 5 and 5 domains of developmental vulnerability at school entry, overall, and by age at exposure.

METHODS

This cohort study included all children born in Manitoba, Canada, who completed the Early Development Instrument between 2005 and 2016 (N = 52 103). Maternal depression was defined by using physician visits, hospitalizations, and pharmaceutical data; developmental vulnerability was assessed by using the Early Development Instrument. Relative risk of developmental vulnerability was assessed by using log-binomial regression models adjusted for characteristics at birth.

RESULTS

Children exposed to maternal depression before age 5 had a 17% higher risk of having at least 1 developmental vulnerability at school entry than did children not exposed to maternal depression before age 5. Exposure to maternal depression was most strongly associated with difficulties in social competence (adjusted relative risk [aRR] = 1.28; 95% confidence interval [CI]: 1.20-1.38), physical health and well-being (aRR = 1.28; 95% CI: 1.20-1.36), and emotional maturity (aRR = 1.27; 95% CI: 1.18-1.37). For most developmental domains, exposure to maternal depression before age 1 and between ages 4 and 5 had the strongest association with developmental vulnerability.

CONCLUSIONS

Our finding that children exposed to maternal depression are at higher risk for developmental vulnerability at school entry is consistent with previous findings. We extended this literature by documenting that the adverse effects of exposure to maternal depression are specific to particular developmental domains and that these effects vary depending on the age at which the child is exposed to maternal depression.

Effect of Study Duration and Outcome Measurement Frequency on Estimates of Change for Longitudinal Cohort Studies in Routinely-Collected Administrative Data

Introduction

When designing longitudinal cohort studies, investigators must make decisions about study duration (i.e. length of follow-up) and frequency of outcome measurement. This research explores these design decisions for longitudinal cohort studies constructed using routinely-collected administrative data.

Objectives

To illustrate the effects of varying study duration and frequency of outcome measurement in longitudinal cohort studies conducted using routinely-collected administrative data using a numeric example.

Methods

Linked administrative data from Manitoba, Canada were used. The cohort included mothers who experienced the death of an infant between April 1, 1999 and March 31, 2012 and a matched (three:one) group of mothers who did not experience an infant death. A generalized linear model was used to test for differences between groups in the non-linear (i.e. quadratic) and linear trend over time for the number of healthcare contacts. Holding sample size constant, models were fit to the data for various combinations of study duration and measurement frequency. Regression coefficient estimates and their standard errors were compared.

Results

A total of 2576 mothers were included; 644 experienced an infant death and 1932 were matches. Thirteen combinations of measurement frequency (one, two, three, four periods/year) and study duration (one, two, three, four years) were investigated. As frequency increased from one to four periods/year, the standard errors of the regression coefficients for the group difference in the non-linear trend (i.e. group-time-time interaction) decreased up to 98.9%. As duration increased from one to fours years, the standard errors decreased up to 96.9%. As frequency and duration increased, the estimated regression coefficients trended toward zero. Similar results were observed for the linear trend model.

Conclusion

Longitudinal cohort studies based on administrative data offer flexibility in time-related design elements, but present potential challenges. Recommendations about how to select and report design decisions in studies should be included in reporting guidelines.

The Concept Dictionary and Glossary at MCHP: Tools and Techniques to Support a Population Research Data Repository

The Manitoba Centre for Health Policy’s Concept Dictionary and Glossary, and the Data Repository they document, broaden the analytic possibilities associated with administrative data. The aim of the Repository is to describe and explain patterns of health care and illness, while the Concept Dictionary and Glossary create consistency in documenting research methodologies. The Concept Dictionary alone contains detailed operational definitions and programming code for measures used in MCHP research that are reusable in future projects.

Making these tools available on the internet allows reaching a heterogeneous audience of academic and government health service partners, epidemiologists, planners, programmers, clinicians, and students extending around the globe. They aid in the retention of corporate knowledge, facilitate researcher/analyst communication, and enhance the Centre’s knowledge translation activities. Such documentation has saved countless hours for programmers, analysts and researchers who frequently need to tread paths previously taken by others.

Prenatal care among mothers involved with child protection services in Manitoba: a retrospective cohort study

BACKGROUND

Prenatal care is one of the most widely used preventive health services; however, use varies substantially. Our objective was to examine prenatal care among women with a history of having a child placed in out-of-home care, and whether their care differed from care among women who did not.

METHODS

We used linkable administrative data to create a population-based cohort of women whose first 2 children were born in Manitoba, Canada, between Apr. 1, 1998, and Mar. 1, 2015. We measured the level of prenatal care using the Revised Graduated Prenatal Care Utilization Index, which categorizes care into 5 groups: intensive, adequate, intermediate, inadequate and no care. We compared level of prenatal care for women whose first child was placed in care with level of prenatal care for women who had no contact with care services, using 2 multinomial logistic regression models to calculate odds ratios (ORs).

RESULTS

In a cohort of 52 438 mothers, 1284 (2.4%) had their first child placed in out-of-home care before conception of their second child. Mothers whose first child was placed in care had much higher rates of inadequate prenatal care during the pregnancy with their second child than mothers whose first child was not placed in care (33.0% v. 13.4%). The odds of having inadequate rather than adequate prenatal care were more than 4 times higher (OR 4.29, 95% CI 3.68 to 5.01) for women who had their first child placed in care than for women who did not have their first child placed in care.

INTERPRETATION

Mothers with a history of having a child taken into care by the child protection services system are at higher risk of having inadequate or no prenatal care in a subsequent pregnancy compared with mothers with no history of involvement with child protection services.

Parental Atrial Fibrillation and Stroke or Atrial Fibrillation in Young Adults

Background and Purpose- Cryptogenic strokes are often the first clinical manifestation of undiagnosed atrial fibrillation (AF). We designed this study to test whether parental AF is a risk factor for stroke in young adults. Methods- Population-based cohort study using linked administrative databases from April 1, 1972 to March 31, 2016 in Manitoba, Canada for 325 333 offspring (age ≥18 years) with at least 1 linked parent (total 582 195 parents). We examined the association between parental history of AF and stroke or transient ischemic attack (TIA) in the offspring using multivariable Cox proportional hazards models. Results- Offspring median age at study entry was 18 years. During 5.533 million person-years of follow-up (mean 17 years), 8678 offspring had an incident stroke or TIA (5.2% of the 24 583 offspring with a parental history of AF compared with 2.5% of the 300 750 offspring with no parental history of AF), and 1430 were diagnosed with AF (1.9% versus 0.3%). Incidence rates for stroke/TIA were higher in offspring with a parental history of AF (195.0 versus 156.6 per 100 000 person-years). Parental AF was associated with elevated risk in offspring of stroke/TIA (hazard ratio 1.11; 95% CI, 1.04-1.18) or AF (hazard ratio 1.75; 95% CI, 1.55-1.97) and a higher frequency of other cardiovascular risk factors. After adjusting for demographics, region of residence, socioeconomic status, and other stroke risk factors in offspring, parental AF was associated with AF in their offspring in young adulthood (adjusted hazard ratio 1.61; 95% CI, 1.43-1.82); the association of parental AF with offspring stroke/TIA was attenuated (adjusted hazard ratio 1.05; 95% CI, 0.99-1.12) after adjusting for the other cardiovascular risk factors. Conclusions- Parental AF is associated with increased risk of AF and other cardiovascular risk factors in their offspring during early adulthood, resulting in increased stroke risk.

Events Within the First Year of Life, but Not the Neonatal Period, Affect Risk for Later Development of Inflammatory Bowel Diseases

BACKGROUND & AIMS

We performed a population-based study to determine whether there was an increased risk of inflammatory bowel diseases (IBD) in persons with critical events at birth and within 1 year of age.

METHODS

We collected data from the University of Manitoba IBD Epidemiology Database, which contains records on all Manitobans diagnosed with IBD from 1984 through 2010 and matched controls. From 1970 individuals' records can be linked with those of their mothers, so we were able to identify siblings. All health care visits or hospitalizations during the neonatal and postnatal periods were available from 1970 through 2010. We collected data on infections, gastrointestinal illnesses, failure to thrive, and hospital readmission in the first year of life and sociodemographic factors at birth. From 1979, data were available on gestational age, Apgar score, neonatal admission to the intensive care unit, and birth weight. We compared incident rate of infections, gastrointestinal illnesses, and failure to thrive between IBD cases and matched controls as well as between IBD cases and siblings.

RESULTS

Data on 825 IBD cases and 5999 matched controls were available from 1979. Maternal diagnosis of IBD was the greatest risk factor for IBD in offspring (odds ratio [OR], 4.53; 95% confidence interval [CI], 3.08-6.67). When we assessed neonatal events, only being in the highest vs lowest socioeconomic quintile increased risk for later development of IBD (OR, 1.35; 95% CI, 1.01-1.79). For events within the first year of life, being in the highest socioeconomic quintile at birth and infections (OR, 1.39; 95% CI, 1.09-1.79) increased risk for developing IBD at any age. Infection in the first year of life was associated with diagnosis of IBD before age 10 years (OR, 3.06; 95% CI, 1.07-8.78) and before age 20 years (OR, 1.63; 95% CI, 1.18-2.24). Risk for IBD was not affected by gastrointestinal infections, gastrointestinal disease, or abdominal pain in the first year of life.

CONCLUSIONS

In a population-based study, we found infection within the first year of life to be associated with a diagnosis of IBD. This might be due to use of antibiotics or a physiologic defect at a critical age for gut microbiome development.

Revisiting the association between maternal and offspring preterm birth using a sibling design

Background

Previous studies have reported an intergenerational association between maternal and offspring preterm birth (PTB) but the nature of the association remains unclear. We assessed the association between maternal and offspring preterm birth using a quasi-experimental sibling design and distinguishing between preterm birth types.

Methods

We conducted a retrospective intergenerational cohort study of 39,573 women born singleton in Manitoba, Canada (1980–2002) who gave birth to 79,198 singleton infants (1995–2016). To account for familial confounding we defined a subcohort of 1033 sisters with discordant PTB status who subsequently gave birth and compared offspring PTB rates between 2499 differentially exposed cousins using log-binomial fixed-effects generalized estimating equation models. PTB was defined as a delivery < 37 gestation weeks, divided into spontaneous and provider-initiated.

Results

In the population cohort, mothers born preterm were more likely to give birth preterm [Adjusted Relative Risk (ARR): 1.39; 95% Confidence Interval (CI): 1.25, 1.54] and very preterm birth [ARR: 1.76; 95% CI: 1.29, 2.41]. However, in the siblings cohort, the intergenerational association was not apparent among births to sisters with discordant PTB status [ARR: 1.02; 95% CI: 0.77, 1.34 for preterm birth and ARR: 0.88; 95% CI: 0.38, 2.02 for very preterm birth]. Mothers born at term with a sister born preterm had a similarly elevated risk of delivering a preterm infant (10%) than their preterm sisters. Intergenerational patterns were observed for spontaneous PTB but not for provider-initiated PTB.

Conclusions

Our findings suggest that it is not the fact of having been born preterm that puts women at higher risk of delivering preterm, but the fact of having been born to a mother who ever delivered preterm. Consideration of a female family history of PTB may better identify women at higher risk of preterm delivery than relying on maternal preterm birth status alone. Further research may benefit from distinguishing preterm birth types.

Poverty and Early Childhood Outcomes

BACKGROUND

Children born into poverty face many challenges. Exposure to poverty comes in different forms, and children may also transition into or out of poverty. In this study, we examine the relationships among various outcomes and different levels of poverty (household and/or neighborhood poverty) at different points during a child's first 5 years.

METHODS

We used linkable administrative databases, following 46 589 children born in Manitoba, Canada, between 2000 and 2009 to age 7. Poverty is defined as those receiving welfare and those living in low-income neighborhoods. Four outcomes are measured in the first 5 years (placement in out-of-home care, externalizing mental health diagnosis, asthma diagnosis, and hospitalization for injury), with school readiness assessed between ages 5 and 7.

RESULTS

Children born into poverty had greater odds of not being ready for school than children not born into poverty (adjusted odds ratio = 1.54, 1.59, 1.26 for children born in household and neighborhood poverty, household poverty only, and neighborhood poverty only, respectively; all significant at P < .05). Similar patterns were seen across outcomes. For those born into neighborhood poverty, the odds of school readiness were higher only if children moved before age 2.

CONCLUSIONS

The level of poverty (household or neighborhood) and its duration modify the relationship between early poverty and childhood outcomes. Covariate adjustment generally weakens but does not eliminate these relationships.

Postpartum Depression and Anxiety Among Mothers Whose Child was Placed in Care of Child Protection Services at Birth: A Retrospective Cohort Study Using Linkable Administrative Data

Objectives This study examines whether mothers involved with child protection services (CPS) at the birth of their first child had higher rates of postpartum depression and anxiety. Methods A retrospective cohort of mothers whose first child was born in Manitoba, Canada between April 1, 1995 and March 31, 2015 is used. Postpartum depression and anxiety among mothers whose first child was placed in care at birth (n = 776) was compared with mothers who received services from CPS (but whose children were not placed in care) (n = 4,270), and a 3:1 matched group of mothers who had no involvement with CPS in the first year of their firstborn's life (n = 2,328). Adjusted odds ratios (AOR) of depression and anxiety diagnoses in the first year postpartum were obtained from logistic regression models. Adjusted rate ratios (ARR) of antidepressant use obtained using Poisson models. Results Mothers whose children were taken into care have greater odds of having a postpartum depression or anxiety diagnosis than mothers receiving services (AOR = 1.31; 95% CI 1.08-1.59) and those not involved with CPS (AOR = 2.13; 95% CI 1.67-2.73). Among mothers who had a postpartum depression or anxiety diagnosis, mothers whose children were placed in care had significantly higher rates of antidepressant use than mothers receiving services only (ARR = 2.00; 1.82, 2.19) and mothers who were not involved with CPS (ARR = 2.42; 95% CI 1.94-3.51). Conclusions for Practice Targeted programs should be implemented to address postpartum mental illness among mothers who are involved with CPS at the birth of their child.

Placement in Care in Early Childhood and School Readiness: A Retrospective Cohort Study

The current study examined school readiness for children placed in care of child protection services before age 5. This association was assessed using a population-based cohort of children born in Manitoba, Canada, between 2000 and 2009 ( n = 53,477) and subcohorts of discordant siblings (one sibling taken into care, one sibling not taken into care; n = 809) and discordant cousins ( n = 517). In the population analysis, children placed in care were significantly less likely to be ready for school; this difference was not seen in the discordant sibling or cousin analysis. The findings suggested that differences in school readiness for children placed in care are a result of broader social factors affecting families, not placement into care.

Prenatal care of women who give birth to children with fetal alcohol spectrum disorder in a universal health care system: a case-control study using linked administrative data

BACKGROUND

Few studies have investigated prenatal care use among women who use alcohol during pregnancy. The objective of this study was to investigate rates of prenatal care usage of women who have given birth to children with fetal alcohol spectrum disorder (FASD).

METHODS

We conducted a case-control study of women with children born in Manitoba between Apr. 1, 1984, and Mar. 31, 2012, with follow-up until 2013, using linkable administrative data. The study group included women whose child(ren) was (were) diagnosed with FASD (n = 702) between Apr. 1, 1999, and Mar. 31, 2012, at a centralized diagnostic clinic. The comparison group included women whose child(ren) did not have an FASD diagnosis (n = 2097), exact matched on the index child's birthdate, postal code and socioeconomic status. Adequacy of prenatal care was defined using the Revised Graduated Prenatal Care Utilization Index.

RESULTS

Women in the study group had lower socioeconomic status than women in the comparison group and were more likely to have mental disorders and involvement with the child welfare system. Rates of inadequate prenatal care were higher among women in the study group (adjusted relative risk 2.47, 95% confidence interval [CI] 2.08-2.94), as were rates of no prenatal care (adjusted relative risk 3.55, 95% CI 2.42-5.22). In the study group, 41% of women accessed inadequate or no prenatal care, and 59% received intermediate, adequate or intensive prenatal care.

INTERPRETATION

Women who give birth to children with FASD have higher rates of inadequate prenatal care and significant social complexities. Socioeconomic disparities in the use of prenatal care should be addressed; multisector interventions are needed that facilitate the uptake of prenatal care by high-risk women who use alcohol.

Public housing and healthcare use: an investigation using linked administrative data

OBJECTIVE

This study investigated whether a move to public housing affects people's use of healthcare services.

METHOD

Using administrative data from Manitoba, the number of hospitalizations, general practitioner (GP), specialist and emergency department (ED) visits, and prescription drugs dispensed in the years before and after the housing move-in date (2012/2013) were measured for a public housing and matched cohort. Generalized linear models with generalized estimating equations tested for differences between the cohorts in utilization trends. The data were modeled using Poisson (rate ratio, RR), negative binomial (incident rate ratio, IRR), and binomial (odds ratio, OR) distributions.

RESULTS

GP visits (IRR = 1.04, 95% CI 1.01-1.06) and prescriptions (IRR = 1.04, 95% CI 1.02-1.05) increased, while ED visits (RR = 0.90, 95% CI 0.82-1.00) and hospitalizations (OR = 0.95, 95% CI 0.93-0.96) decreased over time. The public housing cohort had a significantly higher rate of GP visits (IRR = 1.08, 95% CI 1.04-1.13), ED visits (RR = 1.18, 95% CI 1.01-1.37), and prescriptions (IRR = 1.09, 95% CI 1.05-1.13), and was more likely to be hospitalized (OR = 1.39, 95% CI 1.21-1.61) compared to the matched cohort. The rate of inpatient days significantly decreased for the public housing cohort, but did not change for the matched cohort.

CONCLUSION

Healthcare use changed similarly over time (except inpatient days) for the two cohorts. Public housing provides a basic need to a population who has a high burden of disease and who may not be able to obtain and maintain housing in the private market.

Intergenerational involvement in out-of-home care and death by suicide in Sweden: A population-based cohort study

BACKGROUND

Individuals involved in out-of-home care are at higher risk of death by suicide. We aimed to determine whether parents with two generations of involvement in out-of-home care (themselves as children, and their own children) are at increased risk of death by suicide than parents with no involvement or parents with one generation of involvement in out-of-home care.

METHOD

This population-based cohort study included all individuals born in Sweden between 1973 and 1980 who had at least one child between 1990 and 2012 (n = 487,948). Women (n = 259,275) and men (n = 228,673) were examined separately.

RESULTS

When compared with mothers with no involvement in out-of-home care, mothers with two generations of involvement were at more than five times greater risk of death by suicide (aHR = 5.52; 95% CI 2.91-10.46); mothers with one generation of involvement were also at significantly higher risk of death by suicide (mothers were in care as children: aHR = 2.35; 95% CI 1.27-4.35; child was placed in care: aHR = 3.23; 95% CI 1.79-5.83). Involvement in out-of-home care (in either generation) did not affect risk of death by suicide for fathers.

LIMITATIONS

Reason for placement in out-of-home care is not known; these reasons could also be associated with risk of death by suicide Conclusion: Mothers with involvement in out-of-home care, either as children or when their child was placed in care, are at significantly higher risk of death by suicide. Mental health services should be provided to individuals involved in out-of-home care.

Avoidable mortality among parents whose children were placed in care in Sweden: a population-based study

BACKGROUND

Separation from one's child can have significant consequences for parental health and well-being. We aimed to investigate whether parents whose children were placed in care had higher rates of avoidable mortality.

METHODS

Data were obtained from the Swedish national registers. Mortality rates among parents whose children were placed in care between 1990 and 2012 (17 503 mothers, 18 298 fathers) were compared with a 1:5 matched cohort of parents whose children were not placed. We computed rate differences and HRs of all-cause and avoidable mortality.

RESULTS

Among mothers, deaths due to preventable causes were 3.09 times greater (95% CI 2.24 to 4.26) and deaths due to amenable causes were 3.04 times greater (95% CI 2.03 to 4.57) for those whose children were placed in care. Among fathers, death due to preventable causes were 1.64 times greater (95% CI 1.32 to 2.02) and deaths due to amenable causes were 1.84 times greater (95% CI 1.33 to 2.55) for those whose children were placed in care. Avoidable mortality rates were higher among mothers whose children were young when placed in care and among parents whose children were all placed in care.

CONCLUSIONS

Parents who had a child placed in out-of-home care are at higher risk of avoidable mortality. Interventions targeting mothers who had a child aged less than 13 placed in care, and parents whose children were all placed in care could have the greatest impact in reducing avoidable mortality in this population.

Changes in healthcare use among individuals who move into public housing: a population-based investigation

Background

Residence in public housing, a subsidized and managed government program, may affect health and healthcare utilization. We compared healthcare use in the year before individuals moved into public housing with usage during their first year of tenancy. We also described trends in use.

Methods

We used linked population-based administrative data housed in the Population Research Data Repository at the Manitoba Centre for Health Policy. The cohort consisted of individuals who moved into public housing in 2009 and 2010. We counted the number of hospitalizations, general practitioner (GP) visits, specialist visits, emergency department visits, and prescriptions drugs dispensed in the twelve 30-day intervals (i.e., months) immediately preceding and following the public housing move-in date. Generalized linear models with generalized estimating equations tested for a period (pre/post-move-in) by month interaction. Odds ratios (ORs), incident rate ratios (IRRs), and means are reported along with 95% confidence intervals (95% CIs).

Results

The cohort included 1942 individuals; the majority were female (73.4%) who lived in low income areas and received government assistance (68.1%). On average, the cohort had more than four health conditions. Over the 24 30-day intervals, the percentage of the cohort that visited a GP, specialist, and an emergency department ranged between 37.0% and 43.0%, 10.0% and 14.0%, and 6.0% and 10.0%, respectively, while the percentage of the cohort hospitalized ranged from 1.0% to 5.0%. Generally, these percentages were highest in the few months before the move-in date and lowest in the few months after the move-in date. The period by month interaction was statistically significant for hospitalizations, GP visits, and prescription drug use. The average change in the odds, rate, or mean was smaller in the post-move-in period than in the pre-move-in period.

Conclusions

Use of some healthcare services declined after people moved into public housing; however, the decrease was only observed in the first few months and utilization rebounded. Knowledge of healthcare trends before individuals move in are informative for ensuring the appropriate supports are available to new public housing residents. Further study is needed to determine if decreased healthcare utilization following a move is attributable to decreased access.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3109-7) contains supplementary material, which is available to authorized users.

Mortality Among Mothers Whose Children Were Taken Into Care by Child Protection Services: A Discordant Sibling Analysis

This study examines whether mothers who had a child taken into care by child protection services have higher mortality rates compared with rates seen in their biological sisters who did not have a child taken into care. We conducted this retrospective cohort study using linkable administrative data from 3,948 mothers whose oldest child was born in Manitoba, Canada, between April 1, 1992, and March 31, 2015. These mothers were from 1,974 families in which one sister had a child taken into care and one sister did not. We computed rate differences and hazard ratios of all-cause, avoidable, and unavoidable mortality. There were an additional 24 deaths per 10,000 person-years among mothers who had had a child taken into care. Mothers who had a child taken into care had higher rates of mortality due to avoidable causes (hazard ratio = 3.46; 95% confidence interval: 1.41, 8.48) and unavoidable causes (hazard ratio = 2.92; 95% confidence interval: 1.01, 8.44). The number of children taken into care did not affect mortality rates among mothers with at least 1 child taken into care. The higher mortality rates-particularly avoidable mortality-among mothers who had a child taken into care indicate a need for more specific interventions for these mothers.

The Cycle of Child Protection Services Involvement: A Cohort Study of Adolescent Mothers

OBJECTIVES

To determine if adolescent mothers who were in the care of child protection services (CPS) when they gave birth to their first child are more likely to have that child taken into CPS care before the child's second birthday than adolescent mothers who were not in the care of CPS.

METHODS

Linkable administrative data were used to create a population-based cohort of adolescent mothers whose first child was born in Manitoba, Canada between April 1, 1998, and March 31, 2013 (n = 5942). Adjusted odds ratios (aOR) of having that first child taken into care before their second birthday were compared between mothers who were in care (n = 576) and mothers who were not in care (n = 5366) at the birth of their child by using logistic regression models.

RESULTS

Adolescent mothers who were in care had greater odds of having their child taken into care before the child's second birthday (aOR = 7.53; 95% confidence interval [CI] = 6.19-9.14). Specifically, their children had higher odds of being taken into care in their first week of life (aOR = 11.64; 95% CI = 8.83-15.34), between 1 week and their first birthday (aOR = 3.63; 95% CI = 2.79-4.71), and between their first and second birthday (aOR = 2.21; 95% CIl = 1.53-3.19).

CONCLUSIONS

Findings support an intergenerational cycle of involvement with CPS. More and better services are required for adolescent mothers who give birth while in care of CPS.

Maternal Mental Health after Custody Loss and Death of a Child: A Retrospective Cohort Study Using Linkable Administrative Data

OBJECTIVE

The objective was to compare mental illness diagnoses and treatment use among mothers who lost custody of their child through involvement with child protection services and those seen in mothers dealing with the death of a child.

METHODS

We studied mental health outcomes of a cohort of women whose first child was born in Manitoba, Canada between 1 April 1997 and 31 March 2015. Of these women, 5,792 had a child taken into care, and 1,143 mothers experienced the death of a child (<18 y old) before 31 March 2015. Adjusted relative rates (ARR) of 3 mental health diagnoses and 3 mental health treatment use outcomes between these 2 groups were examined.

RESULTS

Mothers with a child taken into care had significantly greater ARR of depression (ARR = 1.90; 95% CI, 1.82 to 1.98), anxiety (ARR = 2.51; 95% CI, 2.40 to 2.63), substance use (ARR = 8.54; 95% CI, 7.49 to 9.74), physician visits for mental illness (ARR = 3.01; 95% CI, 2.91 to 3.12), and psychotropic medication use (ARR = 4.95; 95% CI, 4.85 to 5.06) in the years after custody loss compared with mothers who experienced the death of a child.

CONCLUSION

Losing custody of a child to child protection services is associated with significantly worse maternal mental health than experiencing the death of a child. Greater acknowledgement and supportive services should be provided to mothers experiencing the loss of a child through the involvement of child protection services.

Duration of maternal mental health-related outcomes after an infant's death: A retrospective matched cohort study using linkable administrative data

BACKGROUND

Mothers have increased mental illness such as anxiety and depression after the death of a child. We examine the duration of this worsening of mental health.

METHODS

The mental health of all mothers who experience the death of an infant (< 1 years old) in Manitoba, Canada between April 1, 1999 and March 31, 2011 (n = 534) is examined in the 4 years leading up to, and the 4 years following, the death of their child. Mental health-related outcomes of these mothers are compared with a matched (3:1) cohort of mothers who did not experience the death of a child (n = 1,602). Three mental health-related outcomes are examined: depression diagnoses, anxiety diagnoses, and use of psychotropic medications.

RESULTS

Compared with mothers who did not experience the death of a child, mothers experiencing this event had higher rates of anxiety diagnoses and psychotropic prescriptions starting 6 months before the death. Elevated rates of anxiety continued for the first year and elevated rates of psychotropic prescriptions continued for 6 months after the death of the child. Mothers who experienced the death of a child had higher rates of depression diagnoses in the year after the death. Relative rates (RR) of depression (RR = 4.94), anxiety (RR = 2.21), and psychotropic medication use (RR = 3.18) were highest in the 6 months after the child's death.

CONCLUSIONS

Elevated rates of depression, anxiety, and psychotropic medication use after the death of a child end within 1 year of the child's death.

Suicide Attempts and Completions among Mothers Whose Children Were Taken into Care by Child Protection Services: A Cohort Study Using Linkable Administrative Data

OBJECTIVE

The objective of this study is to examine suicide attempts and completions among mothers who had a child taken into care by child protection services (CPS). These mothers were compared with their biological sisters who did not have a child taken into care and with mothers who received services from CPS but did not have a child taken into care.

METHODS

A retrospective cohort of mothers whose first child was born in Manitoba, Canada, between April 1, 1992, and March 31, 2015, is used. Rates among discordant biological sisters (1872 families) were compared using fixed-effects Poisson regression models, and mothers involved with CPS (children in care [ n = 1872] and received services [ n = 9590]) were compared using a Poisson regression model.

RESULTS

Compared with their biological sisters and mothers who received services, the adjusted incidence rate ratio (aIRR) of death by suicide was greater among mothers whose child was taken into care by CPS (aIRR = 4.46 [95% confidence interval (CI), 1.39-14.33] and ARR = 3.45 [95% CI, 1.61-7.40], respectively). Incidence rates of suicide attempts were higher among mothers with a child taken into care compared with their sisters (aIRR = 2.15; 95% CI, 1.40-3.30) and mothers receiving services (aIRR = 2.82; 95% CI, 2.03-3.92).

CONCLUSIONS

Mothers who had a child taken into care had significantly higher rates of suicide attempts and completions. When children are taken into care, physician and social workers should inquire about maternal suicidal behaviour and provide appropriate mental health.

Predictors of having a first child taken into care at birth: A population-based retrospective cohort study

The objective of this study is to determine which maternal events and diagnoses in the two years before childbirth are associated with higher risk for having a first child taken into care at birth by child protection services. A population-based retrospective cohort of women whose first child was born in Manitoba, Canada between 2002 and 2012 and lived in the province at least two years before the birth of their first child (n=53,565) was created using linkable administrative data. A logistic regression model determined the adjusted odds ratios (AOR) of having a child taken into care at birth. Characteristics having the strongest association with a woman's first child being taken into care at birth were mother being in care at the birth of her child (AOR=11.10; 95% CI=8.38-14.71), substance abuse (AOR=8.94; 95% CI=5.08-15.71), schizophrenia (AOR=6.69; 95% CI=3.89-11.52) developmental disability (AOR=6.45; 95% CI=2.69-14.29), and no prenatal care (AOR=5.47; 95% CI=3.56-8.41). Most characteristics of women deemed to be at high risk for having their child taken into care at birth are modifiable or could be mitigated with appropriate services.

Life course epidemiology: Modeling educational attainment with administrative data

Background

Understanding the processes across childhood and adolescence that affect later life inequalities depends on many variables for a large number of individuals measured over substantial time periods. Linkable administrative data were used to generate birth cohorts and to study pathways of inequity in childhood and early adolescence leading to differences in educational attainment. Advantages and disadvantages of using large administrative data bases for such research were highlighted.

Methods

Children born in Manitoba, Canada between 1982 and 1995 were followed until age 19 (N = 89,763), with many time-invariant measures serving as controls. Five time-varying predictors of high school graduation—three social and two health—were modelled using logistic regression and a framework for examining predictors across the life course. For each time-varying predictor, six temporal patterns were tested: full, accumulation of risk, sensitive period, and three critical period models.

Results

Predictors measured in early adolescence generated the highest odds ratios, suggesting the importance of adolescence. Full models provided the best fit for the three time-varying social measures. Residence in a low-income neighborhood was a particularly influential predictor of not graduating from high school. The transmission of risk across developmental periods was also highlighted; exposure in one period had significant implications for subsequent life stages.

Conclusion

This study advances life course epidemiology, using administrative data to clarify the relationships among several measures of social behavior, cognitive development, and health. Analyses of temporal patterns can be useful in studying such other outcomes as educational achievement, teen pregnancy, and workforce participation.

Adolescent Pregnancy Outcomes Among Sisters and Mothers: A Population-Based Retrospective Cohort Study Using Linkable Administrative Data

OBJECTIVES

Female family members affect both the likelihood of adolescent pregnancy and the outcome of that pregnancy. We examined the degree to which an older sister's adolescent reproductive outcomes affect her younger sister's reproductive behavior, and whether relationships in adolescent pregnancy among sisters born to adolescent mothers differ from those born to nonadolescent mothers.

METHODS

We followed a birth cohort in Manitoba, Ontario, Canada, to age 20 using linkable administrative databases housed at the Manitoba Centre for Health Policy. The cohort consisted of 12 391 girls born in Manitoba between April 1, 1984, and March 31, 1996, who had 1 older sister. We used logistic regression models to examine the relationships among familial adolescent pregnancy outcomes.

RESULTS

Compared with adolescent girls whose older sister did not have an adolescent pregnancy, adolescent girls whose older sister had an adolescent pregnancy were more likely to have a pregnancy (adjusted odds ratio [aOR] = 2.57), regardless of whether that pregnancy was completed (aOR = 2.56) or terminated (aOR = 2.59). Relationships in adolescent pregnancy among sisters were much stronger for those born to nonadolescent mothers (aOR = 3.16 [older sister completed adolescent pregnancy] and 3.18 [older sister terminated adolescent pregnancy]) than to adolescent mothers (aOR = 1.65 [older sister completed adolescent pregnancy] and 1.77 [older sister terminated adolescent pregnancy]). For younger sisters having an adolescent pregnancy, the odds of her completing the pregnancy were reduced if her older sister had terminated an adolescent pregnancy and her mother had not been an adolescent mother (aOR = 0.38).

CONCLUSIONS

Younger sisters of adolescents who had a pregnancy may benefit from targeted interventions to reduce their likelihood of adolescent pregnancies.

Maternal health and social outcomes after having a child taken into care: population-based longitudinal cohort study using linkable administrative data

BACKGROUND

We investigated whether mothers experience changes to their health and social situation after having a child taken into care by child protection services, then compared these outcomes with those found in mothers whose children were not taken into care.

METHODS

The cohort includes mothers whose first child was born in Manitoba between 1 April 1998 and 31 March 2011. Mothers whose children were taken into care after age 2 (n=1591) were compared with a matched group of women whose children were not taken into care (n=1591).

RESULTS

The rates of mental illness diagnoses, treatment use and social factors were significantly higher for mother whose children were taken into care, both in the 2 years before and in the 2 years after the index date. These adjusted relative rates (ARRs) increased significantly for anxiety (before ARR=2.71, after ARR=3.55), substance use disorder (3.77-5.95), physician visits for mental illness (2.83-3.66), number of prescriptions (psychotropic: 4.35-5.86; overall: 2.34-2.94), number of different prescriptions (psychotropic: 2.70-3.27; overall: 1.62-1.70), residential mobility (1.40-1.63) and welfare use (2.07-2.30).

CONCLUSION

The health and social situation of mothers involved with child protection services deteriorates after their child is taken into care. Mothers would benefit from supports during this time period to ensure that the outcomes they experience after the loss of their child do not become another barrier to reunification.

Pediatric ambulatory care sensitive conditions: Birth cohorts and the socio-economic gradient

OBJECTIVES

This study examines the socio-economic gradient in utilization and the risk factors associated with hospitalization for four pediatric ambulatory care sensitive conditions (dental conditions, asthma, gastroenteritis, and bacterial pneumonia). Dental conditions, where much care is provided by dentists and insurance coverage varies among different population segments, present special issues.

METHODS

A population registry, provider registry, physician ambulatory claims, and hospital discharge abstracts from 28 398 children born in 2003-2006 in urban centres in Manitoba, Canada were the main data sources. Physician visits and hospitalizations were compared across neighbourhood income groupings using rank correlations and logistic regressions.

RESULTS

Very strong relationships between neighbourhood income and utilization were highlighted. Additional variables - family on income assistance, mother's age at first birth, breastfeeding - helped predict the probability of hospitalization. Despite the complete insurance coverage (including visits to dentists and physicians and for hospitalizations) provided, receiving income assistance was associated with higher probabilities of hospitalization.

CONCLUSIONS

We found a socio-economic gradient in utilization for pediatric ambulatory care sensitive conditions, with higher rates of ambulatory visits and hospitalizations in the poorest neighbourhoods. Insurance coverage which varies between different segments of the population complicates matters. Providing funding for dental care for Manitobans on income assistance has not prevented physician visits or intensive treatment in high-cost facilities, specifically treatment under general anesthesia. When services from one type of provider (dentist) are not universally insured but those from another type (physician) are, using rates of hospitalization to indicate problems in the organization of care seems particularly difficult.

Emergency department and inpatient coding for self-harm and suicide attempts: Validation using clinician assessment data

Administrative data have been used to determine the occurrence of suicide attempts and deliberate self-harm, but research about the accuracy of these sources is limited. This study used a clinical sample (n = 5719) containing psychiatry consultations from the emergency departments and inpatient units of the two major tertiary hospitals in Winnipeg, Canada to validate the accuracy of inpatient hospital diagnosis codes at identifying presentations for self-harm and suicide attempts. The Columbia Classification Algorithm of Suicide Assessment (C-CASA) was used as the gold standard. International Classification of Diseases version 10 Canadian Enhancement codes for intentional self-harm, undetermined intent self-harm, and accidental poisoning were assessed. Measures of validity included Kappa (κ), sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Sensitivity of hospitalized attempts was low using intentional intent codes (36.9%, 95% confidence interval [CI]: 32.4-41.4%) but improved using unknown intent and accidental poisoning codes (44.8%, 95% CI: 40.2-49.4%). Agreement for suicide attempts did not increase with the addition of unknown intent and accidental poisoning codes (κ = 0.465-0.481), but were better for any self-harm (κ = 0.395-0.478). Hospital diagnosis codes undercount attempts and self-harm admissions. Including more data sources might improve the detection of events.

Assessing the quality of administrative data for research: a framework from the Manitoba Centre for Health Policy

The growth of administrative data repositories worldwide has spurred the development and application of data quality frameworks to ensure that research analyses based on these data can be used to draw meaningful conclusions. However, the research literature on administrative data quality is sparse, and there is little consensus regarding which dimensions of data quality should be measured. Here we present the core dimensions of the data quality framework developed at the Manitoba Centre for Health Policy, a world leader in the use of administrative data for research purposes, and provide examples and context for the application of these dimensions to conducting data quality evaluations. In sharing this framework, our ultimate aim is to promote best practices in rigorous data quality assessment among users of administrative data for research.

Suicide and suicide attempts among women in the Manitoba Mothers and Fetal Alcohol Spectrum Disorder cohort: a retrospective matched analysis using linked administrative data

BACKGROUND

Women who give birth to children with fetal alcohol spectrum disorder (FASD) may be at increased risk for suicide; however, there are few data in this area. The objective of this study was to compare rates of suicide between women who had given birth to children with FASD and women who had not given birth to children with FASD during critical periods in their lives, including before pregnancy, during pregnancy, during the postpartum period (maternal death) and until the end of the study period.

METHODS

We conducted a retrospective cohort analysis of women with children born in Manitoba between Apr. 1, 1984, and Mar. 31, 2012 in whom FASD was diagnosed between Apr. 1, 1999, and Mar. 31, 2012, with follow-up until Dec. 1, 2013 (FASD group; n = 702). We generated a comparison group of women who had not given birth to children with FASD (n = 2097), matched up to 1:3 on date of birth of the index child, socioeconomic status and region of residence. We used linked administrative data to investigate suicide attempt and completion rates in the 2 groups. Regression modelling produced relative rates (RRs) adjusted for socioeconomic status and age at birth of the index child and was used to assess suicide risk.

RESULTS

The 2799 participants produced 40 390.21 person-years until the end of the study period. Compared to the comparison group, the FASD group had higher rates of suicide completion (adjusted RR 6.20 [95% confidence interval (CI) 2.36-16.31]), a higher number of women who attempted suicide after the postpartum period until the end of the study period (adjusted RR 4.62 [95% CI 2.53-8.43]) and a higher number of attempts after the postpartum period until the end of the study period (adjusted RR 3.92 [95% CI 2.30-6.09]).

INTERPRETATION

This study identified a group of women with increased rates of social complexities, mental disorders and alcohol use, which places them at risk for suicide. Interventions are needed that screen for suicidal behaviour in women who are at high risk to consume alcohol during pregnancy and have mental disorders.

The Psychiatric Morbidity of Women Who Give Birth to Children with Fetal Alcohol Spectrum Disorder (FASD): Results of the Manitoba Mothers and FASD Study

OBJECTIVE

To investigate differences in physician-diagnosed psychiatric disorders between women who gave birth to children with a fetal alcohol spectrum disorder (FASD) diagnosis (study group) compared to women who gave birth to children without FASD (comparison group).

METHODS

We linked population-level health and social services data to clinical data on FASD diagnoses to identify study group ( n = 702) and comparison group ( n = 2097) women matched 1:3 on date of birth of index child, region of residence, and socioeconomic status. Regression modeling produced relative rates (RRs) for outcomes.

RESULTS

Mothers who gave birth to children with FASD had higher adjusted rates of substance use disorder (RR, 12.65; 95% confidence interval [CI], 8.99-17.80), personality disorder (RR, 12.93; 95% CI, 4.88-34.22), and mood and anxiety disorders (RR, 1.75; 95% CI, 1.49-2.07) before the pregnancy of the child. These mothers also had higher adjusted rates of maternal psychological distress during pregnancy (RR, 5.35; 95% CI, 4.58-6.35) and higher rates of postpartum psychological distress (RR, 1.71; 95% CI, 1.53-1.90). These women also had higher adjusted rates for antidepressant prescriptions before, during, and after the pregnancy.

CONCLUSIONS

A significant psychiatric burden exists for women giving birth to children with FASD. Clinicians should recognise the high rates of psychiatric concerns facing mothers who give birth to children with FASD and should offer treatment and support to these women to improve their health and well-being and prevent further alcohol-exposed pregnancies.

Accuracy of Offspring-Reported Parental Hip Fractures: A Novel Population-Based Parent-Offspring Record Linkage Study

The objective of this study was to test the validity of offspring-reported parental hip fracture in a unique bone mineral density (BMD) registry linked to administrative databases spanning 4 decades. Population-based data were from Manitoba, Canada, and included hospital abstracts, health insurance registrations, and the provincewide BMD registry. The cohort included individuals aged ≥40 years with BMD tests and self-reports of parental hip fracture between 2006 and 2014. Population registry data for 1966-2014 were used to link offspring with their parents, and hospital records were used to ascertain parental fractures. Overall, 8,112 offspring met the inclusion criteria; 13.6% had a parental hip fracture diagnosis in administrative data during an average of 32.9 years of follow-up. Agreement between parental hip fracture from offspring reports and diagnoses in administrative data was good (κ = 0.68). The sensitivity of offspring reports was 0.70 (95% confidence interval: 0.67, 0.73), and specificity was 0.96 (95% confidence interval: 0.96, 0.97). Offspring characteristics associated with disagreement included male sex, northern rural residence, early BMD test year, and longer interval between BMD test and parental hip fracture diagnosis. This proof-of-concept study focused on hip fractures, but use of record linkage techniques to validate offspring-reported parental information can be extended to other conditions.

Objectively-Verified Parental Non-Hip Major Osteoporotic Fractures and Offspring Osteoporotic Fracture Risk: A Population-Based Familial Linkage Study

Parental hip fracture (HF) is associated with increased risk of offspring major osteoporotic fractures (MOFs; comprising hip, forearm, clinical spine or humerus fracture). Whether other sites of parental fracture should be used for fracture risk assessment is uncertain. The current study tested the association between objectively-verified parental non-hip MOF and offspring incident MOF. Using population-based administrative healthcare data for the province of Manitoba, Canada, we identified 255,512 offspring with linkage to at least one parent (238,054 mothers and 209,423 fathers). Parental non-hip MOF (1984-2014) and offspring MOF (1997-2014) were ascertained with validated case definitions. Time-dependent multivariable Cox proportional hazards regression models were used to estimate adjusted hazard ratios (HRs) and 95% confidence intervals (95% CIs). During a median of 12 years of offspring follow-up, we identified 7045 incident MOF among offspring (3.7% and 2.5% for offspring with and without a parental non-hip MOF, p < 0.001). Maternal non-hip MOF (HR 1.27; 95% CI, 1.19 to 1.35), paternal non-hip MOF (HR 1.33; 95% CI, 1.20 to 1.48), and any parental non-hip MOF (HR 1.28; 95% CI, 1.21 to 1.36) were significantly associated with offspring MOF after adjusting for covariates. The risk of MOF was even greater for offspring with both maternal and paternal non-hip MOF (adjusted HR 1.61; 95% CI, 1.27 to 2.02). All HRs were similar for male and female offspring (all p_interaction >0.1). Risks associated with parental HF only (adjusted HR 1.26; 95% CI, 1.13 to 1.40) and non-hip MOF only (adjusted HR 1.26; 95% CI, 1.18 to 1.34) were the same. The strength of association between any parental non-hip MOF and offspring MOF decreased with older parental age at non-hip MOF (p_trend  = 0.028). In summary, parental non-hip MOF confers an increased risk for offspring MOF, but the strength of the relationship decreases with older parental age at fracture. © 2016 American Society for Bone and Mineral Research.

Manitoba mothers and fetal alcohol spectrum disorders study (MBMomsFASD): protocol for a population-based cohort study using linked administrative data

INTRODUCTION

Fetal alcohol spectrum disorder (FASD) is a significant public health concern. To prevent FASD, factors that place women at risk for giving birth to children with FASD must be investigated; however, there are little data in this area. This paper describes the development of the Manitoba mothers and FASD study, a retrospective cohort of mothers whose children were diagnosed with FASD, generated to investigate: (1) risk factors associated with giving birth to children with FASD; (2) maternal physical and health outcomes, as well as the usage of health and social services.

METHODS

The study population will be identified by linking children diagnosed with FASD from a provincially centralised FASD assessment clinic (from 31 March 1999 to 31 March 2012) to their birth mothers using de-identified administrative health data housed at the Manitoba Centre for Health Policy. Preliminary analysis has identified over 700 mothers, which is the largest sample size in this field to date. A comparison cohort of women with children who did not have an FASD diagnosis matched on the region of residence, date of birth of child with FASD and socioeconomic status will be generated to compare exposures and outcomes. Potential demographic, socioeconomic, family history, and physical and mental health risk factors will be investigated by linking a range of health and social databases, furthering insight into the root causes of drinking during pregnancy. The longitudinal data will allow us to document the usage patterns of healthcare and social services throughout significant periods in these women's lives to identify opportunities for prevention.

ETHICS AND DISSEMINATION

Ethical approval has been obtained by the University of Manitoba's Health Research Ethics Board and the Manitoba Health Information Privacy Committee. Dissemination of study results will include engagement of stakeholders and policymakers through presentations and reports for policymakers, in parallel with scientific papers.

Using Administrative Data Banks for Research and Evaluation

This article discusses methods of organizing and checking administrative data banks to increase their usefulness for research and evaluation. Examples are drawn from the studies using the Manitoba Health Services Commission data bank. The various uses of both manual and computerized checks are explained. A problem profile is presented for the Manitoba data bank; this profile summarizes different specific problems, incor porating new threats to internal validity associated with the use of data banks. The improvements in data collection represented by data banks are discussed in terms of developing multiple control group designs.

Objectively Verified Parental Hip Fracture Is an Independent Risk Factor for Fracture: a Linkage Analysis of 478,792 Parents and 261,705 Offspring

Parental hip fracture (HF) is considered a major risk factor for offspring major osteoporotic fracture (MOF), but all studies to date have relied on self-reported information of uncertain accuracy. We tested the association of objectively verified parental HF with offspring MOF and HF. We used a population-based historical cohort study of 261,705 offspring (age ≥40 years) with at least one linked parent (total 478,792 parents) for the province of Manitoba, Canada. Cox proportional hazards models were developed to test hazard ratio (HR) for offspring MOF and HF for 1997 to 2014 according to prior parental HF dating back to 1970. The median age of offspring at study entry was 40 years (range, 40 to 50 years), and 48.3% were women. During 2.9 million person-years of offspring follow-up (median per offspring, 12 years), we identified 7323 incident MOF (4.4% versus 2.7% for those with and without a parental HF, p < 0.001), including 331 HF (0.3% versus 0.1%, p < 0.001). Parental HF was independently associated with increased risk of offspring MOF (HR, 1.30; 95% confidence interval [CI], 1.20 to 1.41). The strength of the association decreased with older parental age at HF (ptrend  < 0.001), and was no longer significant if parental HF occurred after age 80 years (adjusted HR, 1.07; 95% CI, 0.96 to 1.19). The relationship between parental HF and offspring HF was even stronger than for MOF (adjusted HR, 1.64; 95% CI, 1.21 to 2.23). Associations with MOF or HF were not affected by either the gender of the parent with HF or the gender of the offspring. Parental HF increased the risk for offspring MOF and HF but not when parental HF occurred after age 80 years. This suggests a more nuanced approach for clinicians trying to stratify fracture risk, and illustrates the enormous potential of parent-offspring record linkage for other familial disorders. © 2016 American Society for Bone and Mineral Research.

What predictors matter: Risk factors for late adolescent outcomes

OBJECTIVES

A life course approach and linked Manitoba data from birth to age 18 were used to facilitate comparisons of two important outcomes: high school graduation and Attention-Deficit/Hyperactivity Disorder (ADHD). With a common set of variables, we sought to answer the following questions: Do the measures predicting high school graduation differ from those that predict ADHD? Which factors are most important? How well do the models fit each outcome?

METHODS

Administrative data from the Population Health Research Data Repository at the Manitoba Centre for Health Policy were used to conduct one of the strongest observational designs: multilevel modelling of large population (n = 62,739) and sibling (n = 29,444) samples. Variables included are neighbourhood characteristics, measures of family stability, and mental and physical health conditions in childhood and adolescence.

RESULTS

The adverse childhood experiences important for each outcome differ. While family instability and economic adversity more strongly affect failing to graduate from high school, adverse health events in childhood and early adolescence have a greater effect on late adolescent ADHD. The variables included in the model provided excellent accuracy and discrimination.

CONCLUSION

These results offer insights on the role of several family and social variables and can serve as the basis for reliable, valid prediction tools that can identify high-risk individuals. Applying such a tool at the population level would provide insight into the future burden of these outcomes in an entire region or nation and further quantify the burden of risk in the population.

Medical School Impact On Student Career Choice

Covariance and regression techniques are used to determine whether student career preferences and choices are influenced by medical school characteristics. The results indicate that academic factors (full-time teaching and research components) have more influence on career preference and choice than clinical factors (part-time fa culty and residency programs) but also that the internship year and first few years of practice are important determinants of ultimate career choice. This raises several important questions about what the objec tives of a medical school should be—to direct graduates into careers where the highest need exists, to develop areas of strength so as to improve the quality of training, or to provide as much exposure as possible to a number of different careers.