Karizma Mawjee’s research while affiliated with University of Toronto and other places

BACKGROUND : Both gestational diabetes mellitus (GDM) and hypertensive disorders of pregnancy (HDP) are common, and each are associated with adverse maternal and perinatal outcomes. Midwives may be the first point of care when these conditions arise. This study evaluated the experiences of midwives when providing care to women and people with pregnancies complicated by GDM or HDP. METHODS : A mixed methods study was completed in Ontario, Canada, using a sequential, explanatory approach. A total of 144 online surveys were completed by midwives, followed by 20 semi-structured interviews that were audio recorded and transcribed verbatim. Survey data were analyzed using descriptive statistics. Thematic analysis was used to generate codes from the interview data, which were mapped to the Theoretical Domains Framework (TDF), to elucidate factors that might influence management. RESULTS : Most of the midwives’ clinical behaviours relating to GDM or HDP were in keeping with guidelines and regulatory standards set by existing provincial standards. Six theoretical domains from the TDF appeared to influence midwives'care pathway: “Internal influences” included knowledge, skills and beliefs about capabilities; while “external influences” included social/professional role and identity, environmental context, and social influences. Interprofessional collaboration emerged as a significant factor on both the internal and external levels of influence. CONCLUSIONS : We identified barriers and facilitators that may improve the experiences of midwives and clients when GDM or HDP newly arises in a pregnancy, necessitating further consultation or management by another health care provider.

Objectives: Cerebro-placental ratio (CPR) is a doppler tool contributes to clinical decision-making in pregnancies affected by small for gestational age weight (SGA). Pregnancies affected by gestational diabetes mellitus (GDM) tend to have higher newborn weight, but greater risk of adverse perinatal outcomes. We hypothesized that in GDM-complicated-pregnancies CPR will be associated with adverse perinatal outcomes even in the absence of SGA. Methods: This prospective single-center cohort study included non-anomalous singleton pregnancies in women with GDM. Those with pre-pregnancy diabetes mellitus, hypertensive disorder or suspected SGA were excluded. Routine fetal sonographic assessment included CPR-defined as middle cerebral artery pulsatilty index/umbilical artery pulsatilty index. Masked CPR measurement closest to birth was used, classified as >10th (normal) or ≤10th centile (low). Primary outcome was a composite, consisting of stillbirth, Caesarean birth due to abnormal fetal heart rate pattern, 5-minute Apgar <7, cord arterial pH < 7.0, hypoxic ischemic encephalopathy, or NICU admission >24 hours. Results: Of 281 participants, 24 (8.5%) had low CPR, at a mean gestational age of 36.3 weeks (IQR 34.0-37.4). Birthweight percentile was significantly lower among the low CPR group (35th [IQR 16-31] versus 60th [IQR 31-82]; P = .002). There was no statistically difference in the primary composite outcome between the groups (8.3% versus 7.0%, P = .68). Low CPR was significantly associated with a higher risk of neonatal hypoglycemia (adjusted odds ratio 3.2, 95% CI 1.2-8.3). Conclusion: In pregnancies affected by GDM, CPR ≤10th percentile was not associated with adverse perinatal outcome but was associated with neonatal hypoglycemia.

OBJECTIVE The growing prevalence of obesity is a concern for midwives. In Canada, the absence of regulatory standards, varying protocols and consultant preferences shape clinical decision making for the midwife and may lead to inconsistent practice. Our aim was to understand the barriers, enablers, and knowledge gaps that influenced experiences of midwives in Ontario, Canada when providing care to clients impacted by obesity. METHODS Mixed methods design using a sequential, explanatory approach. Surveys conducted with midwives were administered using an online platform, followed by semi-structured interviews to understand the perspectives elicited in the survey in greater detail. Interviews were audio recorded and transcribed verbatim. Survey data were analyzed using descriptive statistics, and thematic analysis was used for generating codes, categories and themes from the interview data. RESULTS 144 midwives completed the survey and 20 participated in an interview. The participants described their clinical management when caring for those with obesity which included considerations regarding additional tests/investigations, consultation and transfer of care, and place of birth. Up to 93% of surveyed midwives believed that clients with obesity were appropriate for midwifery-led care however there was less certainty about suitability as BMI increased to higher ranges such as > 45). The care management was influenced by beliefs and attitudes, knowledge, and system-level factors. Midwives experienced barriers such as inconsistent practices and role confusion, and felt ill equipped to care for pregnancies affected by obesity due to unclear guidelines. CONCLUSIONS Overall, midwives believe clients with obesity are suitable for midwifery-led care due to its individualized, non-judgmental approach to care. Additional training for midwives and other obstetric care providers would be beneficial to help overcome barriers in providing effective care to pregnancies affected by obesity.

Introduction: Since 2013 various guidelines for hypertension in pregnancy were refined, no longer requiring proteinuria as a requisite for preeclampsia. We aimed to evaluate the impact of the new definition on preterm birth (PTB) and adverse pregnancy outcomes. Methods: Women delivering in Ontario between 4/2012-11/2016 were included. Delivery <240/7 weeks, major fetal anomalies or preexisting renal disease were excluded. The primary outcome was livebirth < 37, < 34 or < 32 weeks. Rates, adjusted rate ratios (aRR) and ratio of the rate ratio (RRR) were used to compare outcomes in the two years after the new Society of Obstetricians and Gynecologists of Canada (SOGC) guideline (12/2014-11/2016; period 2) vs. the two years before (4/2012-3/2014; period 1), among women with and without preeclampsia. Results: 268,543 and 267,964 births in periods 1 & 2 respectively were included. Respective preeclampsia rates increased significantly from 3.9% to 4.4% (p < 0.001), with no change in maternal morbidity rates. In preeclamptic women, respective rates of PTB < 37 weeks were 21.0% and 20.7% (aRR 1.01, 95% CI 1.00-1.02), with significant aRR for PTB < 34 (0.86, 95% CI 0.77-0.96) and < 32 weeks (0.79, 95% CI 0.67-0.94). A similar aRR was observed in women without preeclampsia. In preeclamptic women composite severe neonatal morbidity decreased after guideline change (aRR 0.95, 95% CI 0.91-0.99), a finding not observed in women without preeclampsia (RRR 0.95, 95% CI 0.91-0.99). Conclusion: The new definition of preeclampsia was associated with increased disease rates, a modest reduction in adverse neonatal outcomes and no change in maternal outcomes.

Objective To determine the impact of pre-pregnancy diabetes mellitus (D), obesity (O) and chronic hypertension (H) on preterm birth (PTB). Methods Retrospective population-based cohort study in Ontario, Canada between 2012–2016. Women who had a singleton livebirth or stillbirth at > 20 weeks gestation were included in the cohort. Exposures of interest were D, O and H, individually, and in various combinations. The primary outcome was PTB at 241/7 to 366/7 weeks. PTB was further analyzed by spontaneous or provider-initiated, early (< 34 weeks) or late (34–37 weeks), and the co-presence of preeclampsia, large for gestational age (LGA), and small for gestational age (SGA). Multivariable Poisson regression models with robust error variance were used to generate relative risks (RR), further adjusted for maternal age and parity (aRR). Population attributable fractions (PAF) were calculated for each of the outcomes by exposure state. Results 506,483 women were eligible for analysis. 30,139 pregnancies (6.0%) were complicated by PTB < 37 weeks, of which 7375 (24.5%) had D or O or H. Relative to women without D or O or H, the aRR for PTB < 37 weeks was higher for D (3.51; 95% CI 3.26–3.78) and H (3.81; 95% CI 3.55–4.10) than O (1.14; 95% CI 1.10–1.17). The combined state of DH was associated with a significantly higher aRR of PTB < 37 weeks (6.34; 95% CI 5.14–7.80) and < 34 weeks (aRR 10.33, 95% CI 6.96–15.33) than D alone. The risk of provider initiated PTB was generally higher than that for spontaneous PTB. Pre-pregnancy hypertension was associated with the highest risk for PTB with preeclampsia (aRR 45.42, 95% CI 39.69–51.99) and PTB with SGA (aRR 9.78, 95% CI 7.81–12.26) while pre-pregnancy diabetes was associated with increased risk for PTB with LGA (aRR 28.85, 95% CI 24.65–33.76). Conclusion Combinations of DOH significantly magnify the risk of PTB, especially provider initiated PTB, and PTB with altered fetal growth or preeclampsia.

Background: Inappropriate gestational weight gain in pregnancy may negatively impact health outcomes for mothers and babies. While optimal gestational weight gain is often not acheived, effective counselling by antenatal health care providers is recommended. It is not known if gestational weight gain counselling practices differ by type of antenatal health care provider, namely, family physicians, midwives and obstetricians, and what barriers impede the delivery of such counselling. The objective of this study was to understand the counselling of family physicians, midwives and obstetricians in Ontario and what factors act as barriers and enablers to the provision of counselling about GWG. Methods: Semi-structured interviews were conducted with seven family physicians, six midwives and five obstetricians in Ontario, Canada, where pregnancy care is universally covered. Convenience and purposive sampling techniques were employed. A grounded theory approach was used for data analysis. Codes, categories and themes were generated using NVIVO software. Results: Providers reported that they offered gestational weight gain counselling to all patients early in pregnancy. Counselling topics included gestational weight gain targets, nutrition & exercise, gestational diabetes prevention, while dispelling misconceptions about gestational weight gain. Most do not routinely address the adverse outcomes linked to gestational weight gain, or daily caloric intake goals for pregnancy. The health care providers all faced similar barriers to counselling including patient attitudes, social and cultural issues, and accessibility of resources. Patient enthusiasm and access to a dietician motivated health care providers to provide more in-depth gestational weight gain counselling. Conclusion: Reported gestational weight gain counselling practices were similar between midwives, obstetricians and family physicians. Antenatal knowledge translation tools for patients and health care providers are needed, and would seem to be suitable for use across all three types of health care provider specialties.