Clustering of Risk Factors among Postpartum Families
in Ontario
Canadian 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
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 evaluation
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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
Figure 1: Top Ranked HBHC Screen Risk Factors among Postpartum Clients (n=56,873)
Labour/delivery complications (Q7)
23
Experienced previous loss (Q15)
20
Smoked > 100 cigarettes before pregnancy (Q9)
15
Depression/anxiety/mental illness (Q27)
13
Health conditions (pregnancy) (Q6)
11
HP has concerns for client/baby (Q36)
11
Smoked during pregnancy (Q8)
10
Birth weight > 4000g (Q4)
9
Premature (Q2)
8
Single parent (Q16)
6
0
5
10
15
Per Cent (%)
20
25
Note: Only infants with a response to at least one screen question were included in the analysis
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Results
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)
0.0
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0.1
0.2
0.3
0.4
0.5
0.6
0.7
Average Distance Between Clusters
0.8
0.9
1.0
1.1
9
Results: Cluster #1
Cluster #1: Pregnancy, labour, and delivery
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)
0.0
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0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
Average Distance Between Clusters
0.9
1.0
1.1
10
Results: Cluster #2
Cluster #2: Socio-demographic, Behavioural, and Parenting risk factors
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)
0.0
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0.1
0.2
0.3
0.4
0.5
0.6
0.7
Average Distance Between Clusters
0.8
0.9
1.0
11
1. 1
Results: Cluster #2
Closely Related Pair of Risk factors
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 seeded (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)
0.0
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0.1
0.2
0.3
0.4
0.5
0.6
0.7
Average Distance Between Clusters
0.8
0.9
1.0
12
1. 1
Results: Cluster #2
Smoking, Drug Use, and Previous Involvement with Child Protection Services
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)
0.0
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0.1
0.2
0.3
0.4
0.5
0.6
0.7
Average Distance Between Clusters
0.8
0.9
1.0
13
1. 1
Results: Cluster #2
Teen Mothers
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 seeded (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)
0.0
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0.1
0.2
0.3
0.4
0.5
0.6
0.7
Average Distance Between Clusters
0.8
0.9
1.0
14
1. 1
Results: Cluster #2
Single Parents
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)
0.0
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0.1
0.2
0.3
0.4
0.5
0.6
0.7
Average Distance Between Clusters
0.8
0.9
1.0
15
1. 1
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
31% (no identified cluster)
Cluster #1:
Pregnancy, labour,
and delivery
14%
18%
17%
5%
5%
5%
5%
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Cluster #2: Sociodemographic,
behavioural and
parenting
Cluster #3: Experienced
previous loss of pregnancy
or child
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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 clusters
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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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Questions, comments and/or feedback?
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