January 2015 Volume 6, Issue 1 BORN BULLETIN BORN & Public Health In this Issue:

January 2015 Volume 6, Issue 1 BORN BULLETIN BORN & Public Health In this Issue: BORN & Public Health.... 1 Delving into the Cube: Using BORN Data to Inform Public Health Programs and Services. 2 Locally Driven Collaborative Project: Breastfeeding Update... 3 BORN Ontario Data Requests from Public Health Units.... 4 BORN Collaboration with the Ontario Baby- Friendly Hospital Initiative... 5 Smoking in Pregnancy.... 5 BORN Partners with PHAC to Enhance Congenital Anomaly Surveillance... 6 Healthy Babies Healthy Children Screening Tool and BORN: successful partnerships... 7 Gestational Weight Gain: A Core Indicator for Public Health... 8 Enhancing Immunization Data Collection in Ottawa: BORN Joins Collaboration... 9 BORN Public Health Coordinator!... 10 New Online Resources from Best Start Resource Centre:Prenatal Education in Ontario.... 10 By Tammy Kuepfer, BORN Coordinator, BORN Ontario Children are our future, and their mothers are its guardians. ~ Kofi Annan, Former Secretary-General of the United Nations Ontario Public Health practitioners serve mothers and children through a number of programs and services. Whether though the Healthy Babies Health Children Program, smoking cessation campaigns, prenatal classes, breast feeding clinics, the Infant Hearing Program, or immunization schedules, well baby clinics, public health has a key role to play in improving the health of the maternal-child population. In order to succeed, public health practitioners need high-quality data. A number of assessment and surveillance requirements are stipulated in the Ontario Public Health Standards; data is needed for public health research; program evaluation is dependent on good data, and the list goes on. BORN is proud to have Public Health Ontario as one of our key partners and endeavors to support provincial efforts as well as individual public health units with specific data requirements. The BORN Information System (BIS) is a great resource for information for public health practitioners. A number of Public Health Standard Reports are available in the BIS as well as the recently launched Public Health Cube a tool designed for custom queries (allowing the user to select multiple dimensions and measures). We hope you enjoy this edition of the BORN Bulletin which highlights examples of BORN-Public Health partnerships to advance maternal-child health.

2 Delving into the Cube: Using BORN Data to Inform Public Health Programs and Services By Caryn Thompson, Epidemiology Student, Toronto Public Health Toronto Public Health (TPH) gained access to BORN standard reports and the Public Health Cube in May 2014. As a practicum epidemiology student with TPH, my role was to assess the quality of the Toronto data. Program staff from the Healthy Babies Healthy Children (HBHC) program, the Maternal-Infant Health program, and Healthy Public Policy teams, were consulted to identify the best indicators for informing their programs and services. The list of indicators (Cube dimensions) was reduced to a manageable number. We used the Cube to investigate the amount of missing data for those indicators and, to a limited extent, to determine if certain subpopulation(s) were missing. Since the HBHC program began in 1998, postpartum screening to identify risks related to parenting capacity and child growth and development has been conducted in all Ontario hospitals using the Parkyn Tool (13 questions). In 2012, a review of the HBHC Protocol resulted in a new postpartum assessment tool (36 questions). TPH implemented the new HBHC Protocol on April 8, 2013. The Public Health Cube was used to analyze HBHC-specific data. Infants born between April-December 2012 were compared with infants born between April-December 2013. HBHC Screen Completed ( Complete but not returned to HU and Incomplete ) were crossed with HBHC Not Completed Reason ( Mother refused ). Organization was added and filtered to only include the major birthing hospitals in Toronto. HBHC Screen Completed = Complete but not returned to HU and Incomplete crossed with HBHC Not Completed Reason = Mother refused. Organization was added and filtered to only include the major birthing hospitals in Toronto. Findings were reported back to the HBHC team. Results showed a notable decrease in HBHC completeness after the new screening tool was implemented; the most common reason the screening was not completed was because the mother refused to participate. The completion rates and magnitude of change varied greatly by hospital. The Public Health Cube provided key information to support further investigation by the HBHC program. Why did completion rates at some hospitals decrease after implementation of the new screening tool? How did hospitals that maintained completion rates accomplish this? Are further supports and assistance needed to increase completion rates? The conversation needs to continue, but the beginning was made possible by TPH s access to BORN data. With more knowledge, we hope to improve HBHC screening completion rates and ultimately, postpartum outcomes. NEW Cube for hospital users! Similar to the Public Health Cube highlighted in this issue, a new cube for maternal-newborn hospital users will soon be released. Start making your data-query wish list and stay tuned for more details.

3 Locally Driven Collaborative Project: Breastfeeding Update By: Gillian Alton, Epidemiologist, Oxford County Public Health & Emergency Services In public health we depend on high-quality data to help inform programs and practice. A data gap related to breastfeeding surveillance was identified by public health units in 2012 through the Locally Driven Collaborative Project (LDCP) Program at Public Health Ontario. Currently, there is no standardized province-wide post hospital discharge breastfeeding data collection method or tool in Ontario. A brave group of over 40 members from 27 Ontario public health units have been working collaboratively for the past two years to tackle this issue. the BORN Information System (e.g. breastfeeding rates at entry to public health services) This project is supported through the LDCP program at Public Health Ontario. Views expressed in the update are the views of the LDCP Breastfeeding team members and do not necessarily reflect those of Public Health Ontario. The objective of the project was to identify the features of a feasible standardized tool and data collection method for population-based breastfeeding surveillance. The ultimate goal was to enable Ontario public health units to have accurate, standardized and comparable breastfeeding surveillance data. Through a scoping review, environmental scan of current breastfeeding data collection, and consultation with an advisory panel of key stakeholders, a proposed surveillance tool and data collection procedure was developed. The proposed surveillance system was pilot tested for nine months at seven public health units in Ontario. After the pilot test, the surveillance system was evaluated both qualitatively and quantitatively to assess the quality of the data, response rates, feasibility, and usability. This project is anticipated to be completed by the end of December 2014, with dissemination of our findings from January March 2015. We plan to disseminate a toolkit including the following documents: A final report Recommended questionnaires in French and English Recommended time points for data collection Recommended process for data analysis Recommended variables and/or reports to be included in

4 BORN Ontario Data Requests from Public Health Units: April 1, 2012 October 31, 2014 By Daniel Bedard, Research Coordinator, BORN Ontario Public Health Units (PHUs) were used to accessing data through the Niday Perinatal Database, until it was retired in 2012 and replaced by the BORN Information System (BIS). Currently, most PHUs have access to reports and data query software in the BIS and the remaining units are finishing their application process. However, during the 2 year transition phase (i.e. the closure of the Niday system and the ramping up of the BIS), PHUs were able to submit specific data requests to the BORN Data Analysis and Research Team (DART) in order to obtain information. BORN received a total of 13 data requests for various indicators in fiscal year 2012-13; 27 for 2013-14; and, as of October 31, 2014, 10 requests. The most recent request was received in July 2014; most PHUs can now get data directly from the BIS, so we expect the number of requests to the BORN DART team to decline. Of the 36 PHUs in Ontario, 17 have contacted BORN for data. All but one request was for aggregate data tables. Frequency of requests varied from 1 request to 7 requests from April 2012 to October 2014. Some of the requests were complex in nature and required up to 35 tables; others were relatively simple. Topics of particular interest were as follows: numbers of Data Analysis Review Team (DART) live births, rates of breastfeeding, mental health, alcohol and substance use, smoking, distribution of Body Mass Index (BMI) and gestational weight gain, teen pregnancies, and midwifery-attended births. The purpose of the majority of the requests was to fulfill the data need for a reproductive health indicator. INTERESTED IN JOINING ONE OF BORN S COMMITTEES? If so, please send your CV and committee preference to committees@bornontario.ca to have your application considered for upcoming calls for expressions of interest

5 BORN Collaboration with the Ontario Baby-Friendly Hospital Initiative By Sandra Dunn, Knowledge Translation Specialist, BORN Ontario BORN is currently collaborating with an advisory group from the Ontario Baby-Friendly Hospital Initiative (BFI) Strategy Implementation Committee to review breastfeeding (BF) data elements and standard reports in the BORN Information System (BIS). The goal is to revise the BF data elements so they are reflective of and aligned with the BFI guidelines. This is part of the BORN initiative to assist hospitals and public health units with having accurate information to support best practice. BIS enhancements occur annually; plans for the April 2015 enhancements will be minimal and include only small wording and pick-list changes. For example, the word formula will be changed to breast milk substitute throughout the BIS. One of the pick-list choices within the Early Attachment/Feeding Initiation data element will be revised to skin-to-skin contact uninterrupted for at least 1 hour, within the first 2 hours post birth to be more in line with the BFI expectation of best practice. Additional definitions and field level help will also be added to the BIS to assist users. The April 2016 enhancements will include more extensive changes. For example, Early Attachment and Initiation of BF will be separated into 2 data elements and a more detailed pick-list will be included for the Postpartum Support data element. Work is ongoing to create a BFI Indicator status report with comparator data to help users monitor BF performance indicators and support quality improvement. Smoking in Pregnancy By Amira Ali, Epidemiologist, Ottawa Public Health The Ontario Public Health Standards (OPHS) establish requirements for the fundamental public health programs and services carried out by boards of health, which include assessment and surveillance, health promotion and policy development, disease and injury prevention, and health protection. The Reproductive Health Standard is one of the program standards of the OPHS. Its goal is To enable individuals and families to achieve optimal preconception health, experience a healthy pregnancy, have the healthiest newborn(s) possible, and be prepared for parenthood. Ottawa Public Health has been working on a Smoke-Free Ottawa strategy focused on cessation, protection, and prevention for over ten years. To inform our strategy, we need access to data on tobacco use for all ages and stages, including pregnant women. The BORN Information System is the only source of pregnancy-related smoking data available to us. We use data from the BORN Public Health Cube to inform our programming and to guide our smoking cessation promotion efforts. Even though the Public Health Cube does not give us access to record level data, we were able to perform an analysis comparing the variables smoking at first prenatal visit to smoking at the time of newborn s birth to determine if there were any differences in smoking status between these two periods. Analysis of Ottawa data for 2013 revealed that 27% of pregnant women who smoked quit smoking at some point between their first prenatal visit and their hospital admission for birth; in 2014 that number rose to 34%. In subsequent years, more data will be available in the Cube, and we will be able to asses not only changes in smoking status between the prenatal visit and the time of birth, but also trends over time.

6 BORN Partners with PHAC to Enhance Congenital Anomaly Surveillance By Heather Ramshaw, Congenital Anomalies (CA) Coordinator, BORN Ontario The Canadian Congenital Anomalies Surveillance System (CCASS), through the Public Health Agency of Canada (PHAC), is undertaking an important national initiative to improve the surveillance of congenital anomalies (CA). BORN Ontario has partnered with PHAC to enhance the surveillance of CA in Ontario. Reliably identifying CA is important to improve the provision of health care to affected infants, to identify increases and decreases in rates over time in the province, to inform research into the causative factors of CAs and to inform public health programs and policies. The objectives of BORN s Ontario CA Surveillance Initiative include: maximizing the ascertainment of CA data; enhancing the BORN Information System (BIS) to accommodate additional data sources and improving data quality; identifying and developing methods to assess environmental effects; and examining the appropriateness of care for women diagnosed with a fetal anomaly to facilitate quality of life improvement for infants living with CA and their families. Ontario s surveillance program is a population-based system which aims to capture all CA in Ontario, focusing initially on the major, reportable anomalies (called Sentinel Anomalies) recommended by the International Clearing House for Birth Defects. The program utilizes active and passive case ascertainment from multiple data sources. In an effort to capture all anomalies, we have information on CA detected for newborns (if diagnosed prior to discharge from hospital or midwifery care), stillbirths and terminations following prenatal diagnosis. Compared to what was previously available in Ontario, BORN s first year of surveillance has increased the capture of Sentinel Anomalies in Ontario by 14% in 2012-2013. With the addition of several new data sources in 2013-2014 and 2014-2015, and work by our current data submitters to further increase their ascertainment, our surveillance of CA is continuing to increase. Ontario has the largest annual number of births of any province in Canada, comprising close to 40% of all births nationally. Improving Ontario s capacity to reliably estimate the prevalence of CA and contribute to CCASS is very important in order to: increase our understanding of the trends and patterns of anomaly occurrence provincially and nationally; calculate rates of sentinel anomalies for comparison with other jurisdictions; accurately combine our cases with screening data to provide information on screening performance; help identify known or potential genetic and environmental risk factors; inform public health policy to prevent more of these defects can be. 5As of Healthy Gain Research Study Do you provide care to pregnant women in your practice? Researchers from the University of Alberta are conducting a short online survey to get a better understanding of the barriers and challenges health care providers may experience related to gestational weight gain, and about what may help and support them to help women achieve healthy weights during pregnancy. Participants will also be asked to assess the strengths and limitations of the 5As of Healthy Pregnancy Weight GainTM, a new resource from the Canadian Obesity Network. This information will help to inform the development of universal strategies that promote healthy dietary intake and appropriate weight management in pregnancy and postpartum. You can participate in this short survey by following the link below: https://redcap.med.ualberta. ca/surveys/?s=aare8jxwdf

7 Healthy Babies Healthy Children Screening Tool and BORN: successful partnerships By Paula Morrison, BORN Public Health Coordinator, BORN Ontario The BORN Information System (BIS) enables the collection of, and access to, data on every birth in Ontario with the goal of facilitating the care of women and children in the province. The purpose of Ontario s Healthy Babies Healthy Children Program is to help children get a healthy start in life. Post birth, each woman is screened to identify families at risk who may benefit from the HBHC home visiting program. BORN and the Ministry of Children & Youth (MCYS) developed a collaborative partnership to explore opportunities around the postpartum HBHC Screen. Given that the BIS collects a significant amount of the same information as the HBHC Screen, we developed a prepopulated BIS-HBHC Screen Report and deployed it to six real-time data-entry pilot sites in the summer of 2013. Once clinical and demographic information from the birth is entered by hospital staff in the BIS, the applicable fields pre-populate the applicable areas on a HBHC Screen Report which can then be printed from the BIS. Once the form is printed, the hospital nurse, midwife or public health nurse verifies and completes the rest of screen with the woman at the hospital bedside. The scope of the pilot project included: Developing and testing an electronic report in the BIS to support the HBHC Screen completion Pilot development and implementation with hospitals and public health units Evaluation (methods included: surveys, follow-up phone calls, feedback) Considerations for future steps Through the evaluation process, the participants provided feedback and suggestions to enhance the process. Some of the benefits of participation included increased accuracy, legibility and quality of the screens. Based on the success of the initial pilot, eight additional pilot sites were added in the fall of 2014. As with the initial pilot, BORN coordinators provide support as needed, collect informal feedback, and troubleshoot issues. Feedback to date has been very positive. BORN and MCYS are moving into Phase 2 which involves create a completely automated business practice around the HBHC Screens. We will work collaboratively to develop a privacy-sensitive electronic highway between the BIS and the MCYS Healthy Child Development - Integrated Services for Children Information System (HCD-ISCIS) which is accessed by the thirty-six health units throughout the province. Completing the HBHC Screen Encounter within the BIS and electronically transmitting consented screens to the appropriate health unit will be more efficient, eliminate the faxing process and improve timeliness of follow-up to women in the province.

8 Gestational Weight Gain: A Core Indicator for Public Health By Becky Blair, Public Health Nutritionist, Simcoe Muskoka District Health Unit & Mary-Anne Pietrusiak, Epidemiologist, Durham Region Health Department Excess gestational weight gain is becoming an important public health issue. In 2012/13, approximately half (49%) of pregnant women giving birth in Ontario exceeded the recommended gestational weight gain (GWG) range as defined by Health Canada s Gestational Weight Gain Guidelines (2009). GWG ranges are based on a woman s prepregnancy Body Mass Index (BMI). There are two guidelines, one for singleton infants and one for twin pregnancies. There are no recommendations for women carrying more than two fetuses or for women with a BMI greater than 34.9. Excess gestational weight gain is associated with an increased risk of caesarian section, and postpartum weight retention for the mother. Babies may be more likely to be born large-forgestational age or macrosomic and may be at increased risk of childhood obesity as they grow older. The Association of Public Health Epidemiologists in Ontario (APHEO) recently created a new Core Indicator for GWG. The BORN Information System (BIS) is the only data source for GWG and uses the Society of Obstetricians and Gynaecologists (SOGC) GWG guidelines as its reference. The Core Indicator is based on Health Canada s guidelines, which are slightly different. GWG is defined as the proportion of pregnant females that gained less, gained more, or stayed within the GWG recommendations. APHEO s Core Indicator specifies which groups should be excluded (e.g. women with a prepregnancy BMI < 18.5, those with more than two fetuses) and which should be excluded or analyzed separately (e.g. preterm pregnancies, twin pregnancies, women with a BMI of 35.0+, women with gestational diabetes). The maternal weight gain recommended group variable in the Public Health Cube is used to calculate GWG A number of other variables are required to calculate GWG, including maternal height, pre-pregnancy weight, weight at delivery and gestation. Maternal height and weight are new variables in the BIS and have high percentages of missing data (although completion is improving). In general, if the percentage of missing data is higher than 10%, the data should be interpreted with caution. In Ontario in 2013-2014, GWG could not be calculated for 31% of pregnant females with full-term singleton pregnancies because of missing data. The percentage missing ranged widely by health unit from 7% to 66%. Efforts are underway to improve maternal BMI data. More complete data will be necessary as public health units begin using this indicator as part of their surveillance and to know where to utilize resources to help women and families with healthy active living. For more information, please see the recent presentation about the GWG core indicator: http://www.apheo.ca/resources/events/2014/apheo_ workshop_2014_gwg.pdf We found both the Standard reports and the Cube to be very easy to use. The standard reports were especially easy to obtain and contained a great deal of information in a format that we were excited to finally have. The Cube was also easy to use and allowed us to undertake important comparisons not included in the Standard reports quickly and easily. We have already started to make programming and planning decisions based on this information and find it very valuable. ~Kristin Saunders, Epidemiologist, Windsor-Essex County Health Unit

9 Enhancing Immunization Data Collection in Ottawa: BORN Joins Collaboration By Michael Kotuba, Senior Technical Architect, BORN Ontario In November 2014 BORN Ontario, Ottawa Public Health (OPH), the Ottawa Hospital Research Institute (OHRI) and the Canadian Public Health Association (CPHA) partnered to collaborate on a proof of concept project designed to enhance immunization data collection in the Ottawa region. This project will test the ability to collect child immunization data directly from families through the ImmunizeCA app and disclose it to a public health unit to provide them with the ability to augment their immunization surveillance data. All vaccination data collected from the app will also remain within BORN. In November of 2012 the ImmunizeCA application, developed by Sigvaria Mobile Technologies Inc., was made available for free for ios users. The CPHA supported the development of the ImmunizeCA application, in partnership with the OHRI, with funding from the Public Health Agency of Canada (PHAC). It became available to all Canadians, across 3 platforms (ios, Android, Android for BB) in March 2014 and has over 65,000 users to date The application s functionality includes A virtual vaccination record that documents immunizations (aka the yellow card) Embedded Provincial/Territorial recommended Immunization schedules updated quarterly Appointment scheduling and reminders Outbreak alerts for vaccine preventable diseases With the authority to collect, use and disclose personal health information related to child health (like immunization records), BORN is in a unique position to support efforts to: Aggregate vaccination information from multiple sources (e.g. parent or physician s office) Link with early childhood information to identify children at particular risk Identify children who may have missed key vaccinations Provide a safe and secure repository for the information Enable appropriate communications in the event of vaccine failures In addition to helping empower individuals to manage and contribute to their own health data (through their consent to send data directly from the app to a registry and onwards to public health), in a second project we are also testing the ability to extract vaccination data from primary care EMRs and transfer it into the registry. We look forward to being a partner with other groups working to enhance vaccination coverage and surveillance. Bilingual, official public health information A platform for public health to communicate with Canadians in real-time through push notifications and rolling banners on the home screen The goal of OPH s Vaccine-Preventable Program is to improve the health of Ottawa residents by continuing to reduce the incidence of vaccine-preventable disease and the associated impact of disease, disability, and death.

10 Meet Paula Morrison BORN Public Health Coordinator! Have a data request? Need help with the Public Health Cube? Interested in piloting a new tool? Call Paula! Paula s role at BORN Ontario is to advocate for and address the data needs of Ontario public health practitioners. Paula is an RN and also has a Master of Science in Psychology (with a focus on Industrial/ Organizational psychology). Paula s extensive experience with both the maternal-child health population and the public health system stem from her previous roles (e.g. Manager of the Family Birthing Centre - Windsor Regional Hospital; Program Manager - Chatham Kent Public Health Unit; Advance Practice Leader - Chatham Kent Health Alliance). Tap into Paula s knowledge she can be contacted at: pmorrison@bornontario.ca or 519-784-5516 New Online Resources from Best Start Resource Centre:Prenatal Education in Ontario The Delivery of Prenatal Education in Ontario: A Summary of Research Findings To support the development of prenatal education key messages and tools, Best Start Resource Centre gathered information from multiple sources in 2014. Collectively these sources provided key information on the delivery of prenatal education in Ontario. This information explored the current status of prenatal education in Ontario and identified existing gaps and needs. This report summarizes relevant results, including recommendations for prenatal education in Ontario. Read more at: http:// en.beststart.org/services/partnerships-and-projects Did you know BORN Ontario collects information on whether a woman attends prenatal classes? It can be found as a data variable in standard reports and in the analysis cube.

BORN BULLETIN If you have success stories you would like to share please contact info@bornontario.ca. BORN Ontario CHEO Research Instittute Centre for Practice Changing Research Building 401 Smyth Road Ottawa, ON K1H 8L1 T: 613.737.7600 x 6022 F: 613.737.6504 info@bornontario.ca www.bornontario.ca 11