clustering of risk factors among postpartum families in ontario

Clustering of Risk Factors among Postpartum Families in OntarioCanadian Public Health Association May 28,2014 | Toronto, ON

Anne Philipneri, MPH, PhD(c)

Helen Cerigo, MSc

Adrienne Alayli, MSc, PhD

Eunice Chong, MPH

Lori Webel-Edgar, RN, MN, CCHN(C)

Natalie Bocking, MD

Sarah Muir, MPH

Heather Manson, MD, FRCPC, MHSc

http://www.publichealthontario.ca/

PublicHealthOntario.ca

Background

• Early life experiences set the stage for lifelong health and wellbeing

• Early childhood development begins before conception and can impact development of chronic diseases, neurodevelopment, school performance, and behaviors

• In Ontario, there is currently a lack of comprehensive knowledge regarding the clustering of risk in postpartum population

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OBJECTIVE

To examine the clustering of risk factors in postpartum families in Ontario

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Methods: Data

Healthy Babies Healthy Children

• Foundational program by the Ministry of Children and Youth Services (MCYS) introduced in 1998. Recent enhancements introduced in 2013

• Designed to help children in Ontario have a healthy start in life and reach their full potential

• Implemented in all 36 public health units

• Universal screening (HBHC Screen) with targeted services for vulnerable families

• In 2013/14, at the request of MCYS, PHO accessed HBHC-IRSS to undertake a process implementation evaluation of the renewed HBHC program

• Cluster analysis was completed as an add-on to the HBHC evaluation4



Methods: Sample

• Screened HBHC postpartum population in Ontario• Families with infants from birth to 6 weeks of age• Recruited in the first six months of implementation of the enhanced program• Feb 2013-Oct 2013 (staggered implementation)

• Screen data entered by staff into HBHC-ISCIS; extracted from HBHC-IRSS database by PHO HBHC evaluation epidemiologist

• Exclusion criteria:• Families with infants over 6 weeks of age• Non-HBHC clients• Families with missing HBHC Screen data who did not receive HBHC services

• Final sample included 56,903 infants• Provides a good perspective of Ontario’s postpartum population because this

represents over 80% of provincial births

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Methods: Indicators

• HBHC Screen has 36 items:• Pregnancy and birth • (i.e., birth-weight, multiple births, premature, Apgar score, labor and delivery

complications)• Socio-demographics (family)• (i.e., age, educational attainment, access to OHIP, concerns about money)

• Infant/child • (i.e., congenital or acquired health challenge )

• Risk behaviours during pregnancy• (i.e., smoking, alcohol use, drug use)

• Parenting and parenting-related • (i.e., parenting concerns, history of depression/anxiety/mental illness in

parent(s))• Other infant/child development risk factors

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Methods: Analysis

• Tetrachoric correlations were used to create a matrix of association among screen questions

• Exploratory cluster analysis was used to identify risk profile• Agglomerative hierarchical clustering• Visual representation using dendrogram• Average distance was used to determine clusters

• All analyses were preformed using SAS 9.3

• Ethics approval was obtained from Public Health Ontario’s Ethics Review Board (ERB)

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Results

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Figure 1: Top Ranked HBHC Screen Risk Factors among Postpartum Clients (n=56,873)

Single parent (Q16)

Premature (Q2)

Birth weight > 4000g (Q4)

Smoked during pregnancy (Q8)

HP has concerns for client/baby (Q36)

Health conditions (pregnancy) (Q6)

Depression/anxiety/mental illness (Q27)

Smoked > 100 cigarettes before pregnancy (Q9)

Experienced previous loss (Q15)

Labour/delivery complications (Q7)

0 5 10 15 20 25

6

8

9

10

11

11

13

15

20

23

Per Cent (%)

Note: Only infants with a response to at least one screen question were included in the analysis


PublicHealthOntario.ca 9

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 1.1

Multiple birth (Q1)Premature (Q2)

Low birth weight (Q3)Maternal separation >5 days (Q21)

Apgar score <5 (Q5)Labour/delivery complications (Q7)

Health challenge (Q20)Health conditions (pregnancy) (Q6)

High birth weight (Q4)Smoked during pregnancy (Q8)

Smoked >100 cigarettes (Q9)Drugs Use during pregnancy (Q11)

Involved with CPS (Q32)Age <18 years (Q13)

Age <18 years (at 1st birth) (Q14)High school not completed (Q19)

Alcohol Use during pregnancy (Q10)Single parent (Q16)

Partner not involved (Q22)Relationship with partner strained (Q31)

Concerns about money (Q26)No support person (parenting) (Q23)No support person (child care) (Q24)

Newcomer support needed (Q25)Expressed concerns for parenting (Q29)Expressed concerns for baby care (Q30)

Child difficult to manage (Q33)Inappropriate response to child (Q34)

Has concerns for client/baby (Q36)Client/partner has disability (Q28)

Risk factor (Q35)Depression/anxiety/mental illness (Q27)

No prenatal care <6 months (Q12)No primary care provider (Q17)

No OHIP number (Q18)Experienced previous loss (Q15)

Results

Average Distance Between Clusters



Multiple birth (Q1)

Premature (Q2)

Low birth weight (Q3)

Maternal separation >5 days (Q21)

Apgar score <5 (Q5)

Labour/delivery complications (Q7)

Health challenge (Q20)

Health conditions (pregnancy) (Q6)

High birth weight (Q4)

Results: Cluster #1

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 1.1Average Distance Between Clusters

Cluster #1: Pregnancy, labour, and delivery



Smoked during pregnancy (Q8)Smoked >100 cigarettes (Q9)

Drugs Use during pregnancy (Q11)Involved with CPS (Q32)

Age <18 years (Q13)Age <18 years (at 1st birth) (Q14)High school not completed (Q19)









No OHIP number (Q18)

Results: Cluster #2

Average Distance Between Clusters0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 1.1

Cluster #2: Socio-demographic, Behavioural, and Parenting risk factors









Newcomer support seeded (Q25)Expressed concerns for parenting (Q29)Expressed Concerns for baby care (Q30)






Results: Cluster #2


Closely Related Pair of Risk factors















Results: Cluster #2


Smoking, Drug Use, and Previous Involvement with Child Protection Services









Newcomer support seeded (Q25)Expressed concerns for parenting (Q29)Expressed Concerns for baby care (Q30)






Results: Cluster #2


Teen Mothers















Results: Cluster #2


Single Parents



Results

• 69% of the population belonged to one of the three clusters; the remaining 31% had no risk factor identified (screen score = 0)

• Similar percentages were identified in pregnancy, labor, and delivery cluster (42%) and socio-demographic, behavioural, and parenting cluster (41%)

• Approximately 1 in 5 infants (19%) belonged to both cluster#1 and cluster #2

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18% 17%

Cluster #1: Pregnancy, labour,

and delivery

Cluster #2: Socio-demographic,

behavioural and parenting

5%

5%

14%

5%5%

Cluster #3: Experienced previous loss of pregnancy

or child

31% (no identified cluster)



Limitations

• The dataset is not complete for all postpartum families in Ontario• Those who did not consent for screening, were missed by the program,

or participated in the Aboriginal HBHC were not included

• Not all risk factors for child health development were examined (e.g., physical environment of the home, nutrition)

• Risk factor information was self-reported by families to staff performing screening

• Not all 36 questions were answered on the HBHC Screen

• Sensitive questions had higher rate of non-response• This will likely contribute to the underestimation of these risk factors to

the clusters18



Conclusion

• Based on 36 medical, socioeconomic, and parenting risk factors three clusters were identified

• There appears to be a separate cluster of postpartum clients with pregnancy and labour/delivery related risk factors

• Burden of socio-demographic, behavioural, and parenting risk factors appear to be similar to that of pregnancy and labour/delivery related risk factors

• Risk factors in the postpartum population are linked and these will likely impact program planning and delivery for this population

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clustering of risk factors among postpartum families in ontario

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