BACKGROUND:

Approximately half of women with intellectual and developmental disabilities (IDDs) lose custody of their children at some point in their child’s development, but their rates of and risk factors for newborn discharge to child protective services from the birth hospitalization are relatively unknown.

METHODS:

We conducted a population-based study of newborns of 3845 women with IDDs and 379 834 women without IDDs in Ontario, Canada (2002–2012). We used modified Poisson regression to estimate adjusted relative risks (aRRs) and 95% confidence intervals (CIs) for discharge to child protective services directly from the birth hospitalization (1) comparing newborns of women with and without IDDs and (2) among newborns of women with IDDs according to sociodemographic, health, service, and perinatal characteristics.

RESULTS:

Approximately 5.7% of newborns of women with IDDs, compared with 0.2% of newborns of women without IDDs, were discharged to child protective services (aRR 8.10; 95% CI 6.51–10.09). Among newborns of women with IDDs, risk factors were maternal psychotic disorder (aRR 2.58; 95% CI 1.90–3.50), social assistance receipt (aRR 2.55; 95% CI 1.87–3.47), failure to receive an ultrasound by 20 weeks’ gestation (aRR 1.76; 95% CI 1.32–2.34), and receipt of <4 prenatal visits by 36 weeks’ gestation (aRR 1.71; 95% CI 1.05–2.78).

CONCLUSIONS:

Although women with IDDs are at risk for custody loss immediately postdelivery, certain subgroups are at higher risk than others. Women with vulnerabilities related to comorbid psychotic disorders, poverty, and inadequate prenatal care may benefit from tailored, behavior-based parenting interventions before and during pregnancy to prevent maternal-newborn separations.

What’s Known on This Subject:

Between 40% and 60% of women with intellectual and developmental disabilities lose custody of their children at some point during the child’s development, but child protective services involvement immediately after the birth hospitalization is relatively unknown.

What This Study Adds:

One in 20 newborns of women with intellectual and developmental disabilities is discharged to child protective services, a rate 32 times higher than the general population; high-risk subgroups are women with comorbid mental illness, inadequate prenatal care, and social assistance.

One in every 100 women has an intellectual and developmental disability (IDD), defined based on limitations in intellectual functioning (eg, learning, problem-solving) or adaptive behaviors related to everyday practical, conceptual, and social skills (eg, personal care, language, and interpersonal skills, respectively), with onset before 18 years of age.1 Examples include intellectual disability, genetic conditions associated with intellectual disability (eg, Down syndrome), and developmental disability (eg, autism spectrum disorder).2 Institutionalization and sterilization were historically used to prevent pregnancy in women with IDDs because of concerns about parenting.3 However, deinstitutionalization and repeal of involuntary sterilization laws, coupled with greater recognition of the rights of parents with disabilities, have expanded opportunities for childbearing.3 Reports from midwifery services in the United Kingdom of a rising number of women with IDDs seeking pregnancy care suggest an increasing frequency of pregnancy,4 with Canadian data confirming that young women with and without IDDs now have similar fertility rates.5 

Evidence of a rising fertility rate has been mirrored by reports of an increasing caseload of parents with IDDs in child protective services.6 Child protective services involvement in this population frequently reflects concerns about parenting skills,7 although there is evidence that behavior-based parent training can improve parenting and reduce risk of child removal.8,9 Early infancy is critical for breastfeeding and bonding.10 Separation of mothers and newborns has harmful effects, including increased risk of maternal suicide11 and child developmental problems.10 Yet, we know little about removal of newborns of women with IDDs. Researchers suggest that 40% to 60% of women with IDDs lose custody of their children at some point12,16 and that poverty, isolation, and mental illness increase risk of custody loss.15,17,20 However, only 2 studies have been focused on the newborn period,15,16 with authors of most studies failing to consider age at removal.12,14,17,18 Other than 1 population-based study,16 data are primarily from court documents12,13,18,20 and social service agency records,14,15,17 which are used to capture high-risk groups. Also, many studies do not have comparison groups without IDDs or with IDDs but no custody loss, making it difficult to explain disparities.14,15,18 

In a population-based cohort in Ontario, Canada, our objectives were to (1) estimate and compare the risk of discharge to child protective services directly from the birth hospitalization in newborns of women with IDDs versus without IDDs and (2) identify risk factors for discharge to child protective services among newborns of women with IDDs.

This was a population-based study in Ontario, Canada, which has 13.6 million residents and 145 000 births annually.21 Ontario’s universal health care delivers physician and hospital services to residents at no direct cost to the patient. Child protective services are funded provincially and delivered by 48 local children’s aid societies that operate on the basis of the Child and Family Services Act.22 This study’s cohort comprised newborns of women with and without IDDs who were conceived between April 1, 2002, and March 31, 2012. The study was approved by the Sunnybrook Health Sciences Centre Research Ethics Board (Institute for Clinical Evaluative Sciences [ICES] logged study 2014-0990-5520-000).

Linked databases were accessed and analyzed at the ICES in Toronto. We obtained health data on birth date, postal code, and death date (Registered Persons Database); outpatient physician visits (Ontario Health Insurance Plan database); emergency department visits (National Ambulatory Care Reporting System); hospitalizations (Canadian Institutes of Health Information Discharge Database and Ontario Mental Health Reporting System); and publicly funded drug benefits (Ontario Drug Benefits database). Databases were linked by using a unique encoded identifier. Data are recorded by using the International Statistical Classification of Diseases and Related Health Problems or Diagnostic and Statistical Manual of Mental Disorders for hospital data and physician billing codes for outpatient data and are reliable and valid.23 We obtained data on Ontario Disability Support Program receipt from the Ministry of Community and Social Services and linked these with health data using name, sex, date of birth, and postal code.24 

Women with IDDs were identified from a larger population-based cohort comprising all adults with IDDs in Ontario. The entry criterion was an IDD diagnosis (1) recorded in ≥2 outpatient physician visits or ≥1 hospitalizations or emergency department visits, as abstracted from medical records and submitted to physician billing and hospital databases, since database inception or (2) listed in Ministry of Community and Social Services data as the reason for Ontario Disability Support Program receipt.24 Ontario legislation25 and frequently used clinical definitions2 were used to conceptualize this definition; diagnoses are listed in Supplemental Table 5.26 For the current study, we identified all 18- to 49-year-old women with IDDs who had a singleton live birth at ≥20 weeks’ gestational age with a conception date of April 1, 2002, to March 31, 2012. These births and their conception dates (date of birth minus gestational age) were identified in MOMBABY, a linked maternal-newborn data set derived from the Canadian Institute for Health Information Discharge Abstract Database that is used to identify 98.0% of Ontario births.21 As a referent, we included a 20% random sample of 18- to 49-year-olds without IDDs who had a singleton live birth with a conception date during the study period. This size was chosen to maximize study power while minimizing computing requirements.

The main outcome was newborn discharge to child protective services directly from the birth hospitalization. This information was derived from the discharge disposition variable in the infant’s hospital record, which is used to identify the location to which the patient was discharged. We also had information on maternal and infant postal codes when the infant reached 12 months of age. Sustained separation of mother and infant was defined as newborn discharge to child protective services and discordant maternal and infant postal code 12 months after delivery.

Sociodemographic variables were maternal age, parity, neighborhood income quintile, and region of residence.27 Maternal health variables were a composite of chronic medical conditions that are common in women with IDDs (diabetes, hypertension, thyroid disease, epilepsy),28,29 psychotic disorder,30 nonpsychotic mental illness,31 and substance use disorders. Service variables were social assistance receipt,32 failure to receive an ultrasound by 20 weeks, and receipt of <4 prenatal care visits by 36 weeks. Perinatal variables were a composite of serious pregnancy complications, cesarean delivery, preterm birth, neonatal morbidity, and congenital anomalies (Supplemental Table 6).

To estimate and compare risk of discharge to child protective services in newborns of women with versus without IDDs, we first described their characteristics using frequencies and percentages and compared them using standardized differences (SDs).33 In preparation for multivariable modeling, covariates were tested for multicollinearity.34 We estimated the relative risk (RR) and 95% confidence interval (CI) of discharge to child protective services comparing newborns of women with versus without IDDs using modified Poisson regression, which allows direct estimation of risk with binary outcomes.35 Because there could be >1 delivery to the same woman during the study period, we used generalized estimating equations to adjust for clustering.36 We generated crude RRs and RRs adjusted for sociodemographic, health, service, and perinatal characteristics associated with IDD status and with risk of newborn discharge to child protective services.14,17,20 Because poverty, isolation, and mental illness increase the risk of child custody loss,14,17,20 we tested for interactions between IDD status and maternal age (<25 vs ≥25 years old), income (quintiles 1–2 vs 3–5), comorbid mental illness (any mental illness or substance use disorder vs none), and social assistance (receiving vs not) and then conducted analyses stratified on these variables.

Among women with IDDs only, to identify risk factors for newborn discharge to child protective services, we first described the characteristics of women who did and did not experience the outcome, as above. We generated crude RRs for the associations between each covariate and the outcome, followed by RRs adjusted in separate blocks: sociodemographic, health, service, and perinatal characteristics.32 The final multivariable model included only covariates that had P < .20.

In additional analyses, we estimated and compared the risk of sustained maternal-infant separation in women with versus without IDDs and identified risk factors for sustained maternal-infant separation among women with IDDs. Analyses used SAS 9.4 (SAS Institute, Inc, Cary, NC).

There were 3845 live births to women with IDDs and 379 834 to women without IDDs. Women with IDDs were more likely than those without IDDs to be <20 years of age and to live in low-income neighborhoods and rural areas. They were more likely to have chronic medical conditions, mental illness, and substance use disorders and to receive social assistance. Their infants were more likely to be born preterm and to have neonatal morbidity and congenital anomalies (Table 1).

TABLE 1

Baseline Characteristics of Women With and Without IDDs and Their Newborns, n (%)

Conceptual CategoryVariableIDD, N = 3845No IDD, N = 379 834SDa
Sociodemographic characteristics Maternal age, y    
 <20 444 (11.6) 10 713 (2.8) 0.35 
 20–34 2921 (76.0) 290 211 (76.4) −0.01 
 ≥35 480 (12.5) 78 910 (20.8) −0.22 
Multiparous 2114 (55.0) 211 068 (55.6) −0.01 
Neighborhood income quintile    
 Q1 (lowest) 1516 (39.7) 83 678 (22.1) 0.39 
 Q2 876 (22.9) 75 698 (20.0) 0.07 
 Q3 625 (16.4) 77 571 (20.5) −0.11 
 Q4 439 (11.5) 78 606 (20.8) −0.25 
 Q5 (highest) 365 (9.6) 62 514 (16.5) −0.21 
Rural residence 546 (14.2) 39 235 (10.3) 0.12 
Health characteristics Chronic medical conditionb 613 (15.9) 44 313 (11.7) 0.12 
Psychotic mental illness 191 (5.0) 1100 (0.3) 0.30 
Nonpsychotic mental illness 1968 (51.2) 108 169 (28.5) 0.48 
Substance use disorder 341 (8.9) 7789 (2.1) 0.30 
Service characteristics Social assistance receipt 1633 (42.5) 16 002 (4.2) 1.02 
No ultrasound by 20 wk 900 (23.4) 83 862 (22.1) 0.03 
<4 prenatal care visits by 36 wk 178 (4.6) 16 419 (4.3) 0.01 
Perinatal characteristics Pregnancy complicationsc 513 (13.3) 44 761 (11.8) 0.04 
Cesarean delivery 1087 (28.3) 104 317 (27.4) 0.02 
Preterm delivery at <37 wk 418 (10.9) 23 745 (6.3) 0.16 
Neonatal morbidityd 219 (5.7) 10 150 (2.7) 0.15 
Congenital anomalye 372 (9.7) 17 841 (4.7) 0.20 
Conceptual CategoryVariableIDD, N = 3845No IDD, N = 379 834SDa
Sociodemographic characteristics Maternal age, y    
 <20 444 (11.6) 10 713 (2.8) 0.35 
 20–34 2921 (76.0) 290 211 (76.4) −0.01 
 ≥35 480 (12.5) 78 910 (20.8) −0.22 
Multiparous 2114 (55.0) 211 068 (55.6) −0.01 
Neighborhood income quintile    
 Q1 (lowest) 1516 (39.7) 83 678 (22.1) 0.39 
 Q2 876 (22.9) 75 698 (20.0) 0.07 
 Q3 625 (16.4) 77 571 (20.5) −0.11 
 Q4 439 (11.5) 78 606 (20.8) −0.25 
 Q5 (highest) 365 (9.6) 62 514 (16.5) −0.21 
Rural residence 546 (14.2) 39 235 (10.3) 0.12 
Health characteristics Chronic medical conditionb 613 (15.9) 44 313 (11.7) 0.12 
Psychotic mental illness 191 (5.0) 1100 (0.3) 0.30 
Nonpsychotic mental illness 1968 (51.2) 108 169 (28.5) 0.48 
Substance use disorder 341 (8.9) 7789 (2.1) 0.30 
Service characteristics Social assistance receipt 1633 (42.5) 16 002 (4.2) 1.02 
No ultrasound by 20 wk 900 (23.4) 83 862 (22.1) 0.03 
<4 prenatal care visits by 36 wk 178 (4.6) 16 419 (4.3) 0.01 
Perinatal characteristics Pregnancy complicationsc 513 (13.3) 44 761 (11.8) 0.04 
Cesarean delivery 1087 (28.3) 104 317 (27.4) 0.02 
Preterm delivery at <37 wk 418 (10.9) 23 745 (6.3) 0.16 
Neonatal morbidityd 219 (5.7) 10 150 (2.7) 0.15 
Congenital anomalye 372 (9.7) 17 841 (4.7) 0.20 

Q, quintile.

a

SDs >0.10 are clinically meaningful.

b

Includes diabetes, hypertension, thyroid disease, and epilepsy.

c

Includes preeclampsia, eclampsia, venous thromboembolism, severe obstetric morbidity (obstetric embolism, placental abruption, placental infarction, septic shock, or uterine rupture), and systemic maternal complications (acute renal failure, acute respiratory distress syndrome, cardiac arrest, cardiac failure, cardiomyopathy, cerebrovascular disease, complications of anesthesia, disseminated intravascular coagulation, hepatic failure, myocardial infarction, pulmonary edema, or status epilepticus).

d

Includes congenital and/or neonatal infection, intraventricular hemorrhage, neonatal abstinence syndrome, persistent fetal circulation, respiratory distress syndrome, seizure, and sepsis in the newborn.

e

International Statistical Classification of Diseases and Related Health Problems, 10th Revision: Q00–Q99, excluding Q53, Q65, Q69, Q70, Q17.0, and Q82.5.

The rate of discharge to child protective services directly from the birth hospitalization in newborns of women with IDDs was 5.7% vs 0.2% in newborns of women without IDDs (RR 32.80; 95% CI 27.94–38.50). Risk remained statistically significant after adjusting for baseline sociodemographic, health, service, and perinatal characteristics (adjusted relative risk [aRR] 8.10; 95% CI 6.51–10.09) (Fig 1). Interactions between IDD status and age (P = .0002), income (P = .002), comorbid mental illness (P = .0001), and social assistance (P = .002) were statistically significant. In stratified analyses, IDD status had a weaker impact on outcome risk in women who lived in low-income neighborhoods, had comorbid mental illness, and received social assistance (also Fig 1).

FIGURE 1

Adjusted risks for infant discharge to child protective services among women with and without IDDs, overall and stratified by high-risk groups. Data are presented as n (%) with the outcome, followed by the adjusted relative risk and 95% confidence interval. Statistically significant covariates in the overall model were age, parity, neighborhood income quintile, mental illness, social assistance receipt, failure to receive an ultrasound by 20 weeks, receipt of <4 prenatal visits by 36 weeks, preterm delivery, and neonatal morbidity. P values refer to the interaction between IDD status and the effect measure modifier; note that P values may be statistically significant in the presence of overlapping CIs.34 

FIGURE 1

Adjusted risks for infant discharge to child protective services among women with and without IDDs, overall and stratified by high-risk groups. Data are presented as n (%) with the outcome, followed by the adjusted relative risk and 95% confidence interval. Statistically significant covariates in the overall model were age, parity, neighborhood income quintile, mental illness, social assistance receipt, failure to receive an ultrasound by 20 weeks, receipt of <4 prenatal visits by 36 weeks, preterm delivery, and neonatal morbidity. P values refer to the interaction between IDD status and the effect measure modifier; note that P values may be statistically significant in the presence of overlapping CIs.34 

In women with IDDs, those with a newborn discharged to child protective services were more likely than those without to be multiparous and to live in low-income neighborhoods but were less likely to live in rural areas. They were more likely to have chronic medical conditions, mental illness, and substance use disorders, to receive social assistance, to have no ultrasound by 20 weeks, and to have <4 prenatal care visits by 36 weeks. Their infants were less likely to be born by cesarean delivery but were more likely to have neonatal morbidity or congenital anomalies (Table 2).

TABLE 2

Baseline Characteristics of Women With IDDs Whose Newborns Were and Were Not Discharged to Child Protective Services, n (%)

Conceptual CategoryVariableDischarged, N = 220Not Discharged, N = 3625SDa
Sociodemographic characteristics Maternal age, y    
 <20 30 (13.6) 414 (11.4) 0.07 
 20–34 170 (77.3) 2751 (75.9) 0.03 
 ≥35 20 (9.1) 460 (12.7) −0.12 
Multiparous 134 (60.9) 1978 (54.6) 1.15 
Neighborhood income quintile    
 Q1 (lowest) 115 (52.8) 1401 (38.9) 0.28 
 Q2 44 (20.2) 832 (23.1) −0.07 
 Q3 595 (16.5) 30 (13.8) 0.08 
 Q4 20 (9.2) 419 (11.6) −0.08 
 Q5 (highest) 9 (4.1) 356 (9.9) −0.23 
Rural residence 21 (9.6) 525 (14.5) −0.15 
Health characteristics Chronic medical conditionb 51 (23.2) 562 (15.5) 0.20 
Psychotic mental illness 25 (13.1) 166 (3.6) 0.35 
Nonpsychotic mental illness 130 (59.1) 1838 (50.7) 0.17 
Substance use disorder 32 (14.6) 309 (8.5) 0.19 
Service characteristics Social assistance receipt 149 (67.7) 1484 (40.9) 0.56 
No ultrasound by 20 wk 84 (38.2) 816 (22.5) 0.34 
<4 prenatal care visits by 36 wk 17 (7.7) 161 (4.4) 0.14 
Perinatal characteristics Pregnancy complicationsc 26 (11.8) 487 (13.4) −0.05 
Cesarean delivery 55 (5.1) 1032 (28.5) −0.66 
Preterm delivery at <37 wk 18 (8.2) 400 (11.0) −0.10 
Neonatal morbidityd 20 (9.2) 199 (5.5) 0.14 
Congenital anomalye 29 (13.2) 343 (9.5) 0.12 
Conceptual CategoryVariableDischarged, N = 220Not Discharged, N = 3625SDa
Sociodemographic characteristics Maternal age, y    
 <20 30 (13.6) 414 (11.4) 0.07 
 20–34 170 (77.3) 2751 (75.9) 0.03 
 ≥35 20 (9.1) 460 (12.7) −0.12 
Multiparous 134 (60.9) 1978 (54.6) 1.15 
Neighborhood income quintile    
 Q1 (lowest) 115 (52.8) 1401 (38.9) 0.28 
 Q2 44 (20.2) 832 (23.1) −0.07 
 Q3 595 (16.5) 30 (13.8) 0.08 
 Q4 20 (9.2) 419 (11.6) −0.08 
 Q5 (highest) 9 (4.1) 356 (9.9) −0.23 
Rural residence 21 (9.6) 525 (14.5) −0.15 
Health characteristics Chronic medical conditionb 51 (23.2) 562 (15.5) 0.20 
Psychotic mental illness 25 (13.1) 166 (3.6) 0.35 
Nonpsychotic mental illness 130 (59.1) 1838 (50.7) 0.17 
Substance use disorder 32 (14.6) 309 (8.5) 0.19 
Service characteristics Social assistance receipt 149 (67.7) 1484 (40.9) 0.56 
No ultrasound by 20 wk 84 (38.2) 816 (22.5) 0.34 
<4 prenatal care visits by 36 wk 17 (7.7) 161 (4.4) 0.14 
Perinatal characteristics Pregnancy complicationsc 26 (11.8) 487 (13.4) −0.05 
Cesarean delivery 55 (5.1) 1032 (28.5) −0.66 
Preterm delivery at <37 wk 18 (8.2) 400 (11.0) −0.10 
Neonatal morbidityd 20 (9.2) 199 (5.5) 0.14 
Congenital anomalye 29 (13.2) 343 (9.5) 0.12 

Q, quintile.

a

SDs >0.10 are clinically meaningful.

b

Includes diabetes, hypertension, thyroid disease, and epilepsy.

c

Includes preeclampsia, eclampsia, venous thromboembolism, severe obstetric morbidity (obstetric embolism, placental abruption, placental infarction, septic shock, or uterine rupture), and systemic maternal complications (acute renal failure, acute respiratory distress syndrome, cardiac arrest, cardiac failure, cardiomyopathy, cerebrovascular disease, complications of anesthesia, disseminated intravascular coagulation, hepatic failure, myocardial infarction, pulmonary edema, or status epilepticus).

d

Includes congenital and/or neonatal infection, intraventricular hemorrhage, neonatal abstinence syndrome, persistent fetal circulation, respiratory distress syndrome, seizure, and sepsis in the newborn.

e

International Statistical Classification of Diseases and Related Health Problems, 10th Revision: Q00–Q99, excluding Q53, Q65, Q69, Q70, Q17.0, Q82.5.

In crude analyses, neighborhood income quintile, chronic medical conditions, psychotic and nonpsychotic mental illness, substance use disorders, social assistance receipt, failure to receive an ultrasound by 20 weeks, receipt of <4 prenatal care visits by 36 weeks, neonatal morbidity, and congenital anomalies were associated with risk of discharge to child protective services among newborns of women with IDDs. In the final multivariable model, psychotic disorders (aRR 2.58; 95% CI 1.90–3.50), social assistance receipt (aRR 2.55; 95% CI 1.87–3.47), failure to receive an ultrasound by 20 weeks (aRR 1.76; 95% CI 1.32–2.34), and receipt of <4 prenatal visits by 36 weeks (aRR 1.71; 95% CI 1.05–2.78) remained statistically significant (Table 3).

TABLE 3

Unadjusted and Adjusted Risks for Discharge to Child Protective Services Among Newborns of Women With IDDs

Conceptual CategoryVariableN (%)Unadjusted RR (95% CI)Adjusted Model 1, RR (95% CI)Adjusted Model 2, RR (95% CI)Adjusted Model 3, RR (95% CI)Adjusted Model 4, RR (95% CI)Adjusted Model 5, RR (95% CI)
Sociodemographic characteristics Maternal age, y        
 <20 30 (6.8) 1.15 (0.78–1.72) 1.22 (0.82–1.84) — — — — 
 20–34 170 (5.8) Reference (1.00) Reference (1.00) — — — — 
 ≥35 20 (4.2) 0.76 (0.48–1.21) 0.81 (0.51–1.29) — — — — 
Parity        
 Multiparous 134 (6.3) 1.26 (0.97–1.63) 1.31 (1.00–1.72) — — — — 
 Primiparous 86 (5.0) Reference (1.00) Reference (1.00) — — — — 
Neighborhood income quintile        
 Q1 (lowest) 115 (7.6) 3.07 (1.58–6.00) 2.51 (1.28–4.91) — — — 1.87 (0.96–3.68) 
 Q2 44 (5.0) 2.04 (1.00–4.16) 1.76 (0.85–3.64) — — — 1.48 (0.71–3.07) 
 Q3 30 (4.8) 1.95 (0.93–4.09) 1.68 (0.80–3.52) — — — 1.49 (0.71–3.12) 
 Q4 20 (4.6) 1.85 (0.84–4.07) 1.67 (0.77–3.60) — — — 1.60 (0.74–3.43) 
 Q5 (highest) 9 (2.5) Reference (1.00) Reference (1.00) — — — Reference (1.00) 
Region residence        
 Rural 21 (3.9) 0.66 (0.42–1.05) 0.70 (0.44–1.11) — — — — 
 Urban 198 (6.0) Reference (1.00) Reference (1.00) — — — — 
Health Characteristics Chronic medical condition        
 Yes 51 (8.3) 1.54 (1.12–2.12) — 1.44 (1.05–1.99) — — 1.24 (0.90–1.71) 
 No 159 (5.2) Reference (1.00) — Reference (1.00) — — Reference (1.00) 
Psychotic mental illness        
 Yes 25 (13.1) 2.19 (1.38–3.49) — 1.83 (1.09–3.08) — — 2.58 (1.90–3.50) 
 No 195 (5.3) Reference (1.00) — Reference (1.00) — — Reference (1.00) 
Nonpsychotic mental illness        
 Yes 130 (6.6) 1.35 (1.02–1.77) — 1.20 (0.89–1.61) — — — 
 No 90 (4.8) Reference (1.00) — Reference (1.00) — — — 
Substance use disorder        
 Yes 32 (9.4) 1.66 (1.15–2.40) — 1.36 (0.91–2.03) — — — 
 No 188 (5.4) Reference (1.00) — Reference (1.00) — — — 
Service characteristics Social assistance receipt        
 Yes 149 (9.1) 2.69 (2.02–3.60) — — 2.80 (1.05–2.75) — 2.55 (1.87–3.47) 
 No 71 (3.2) Reference (1.00) — — Reference (1.00) — Reference (1.00) 
No ultrasound by 20 wk        
 Yes 84 (9.3) 1.86 (1.40–2.47) — — 1.85 (1.39–2.46) — 1.76 (1.32–2.34) 
 No 136 (4.6) Reference (1.00) — — Reference (1.00) — Reference (1.00) 
<4 prenatal care visits by 36 wk        
 Yes 17 (9.6) 1.73 (1.07–2.80) — — 1.85 (1.39–2.46) — 1.71 (1.05–2.78) 
 No 203 (5.5) Reference (1.00) — — Reference (1.00) — Reference (1.00) 
Perinatal characteristics Pregnancy complications        
 Yes 26 (5.1) 0.89 (0.60–1.31) — — — 0.91 (0.62–1.35) — 
 No 194 (5.8) Reference (1.00) — — — Reference (1.00) — 
Delivery mode        
 Cesarean 55 (5.1) 0.84 (0.62–1.15) — — — 0.86 (0.63–1.18) — 
 Vaginal 165 (6.0) Reference (1.00) — — — Reference (1.00) — 
Gestational age        
 Preterm 18 (4.3) 0.77 (0.48–1.24) — — — 0.67 (0.39–1.15) 0.64 (0.38–1.07) 
 Term 202 (5.9) Reference (1.00) — — — Reference (1.00) Reference (1.00) 
Neonatal morbidity        
 Yes 20 (9.1) 1.61 (1.02–2.53) — — — 1.70 (1.00–2.88) 1.49 (0.90–2.47) 
 No 197 (5.5) Reference (1.00) — — — Reference (1.00) Reference (1.00) 
Congenital anomaly        
 Yes 29 (7.8) 1.43 (0.97–2.11) — — — 1.42 (0.92–2.17) 1.28 (0.85–1.94) 
 No 191 (5.5) Reference (1.00) — — — Reference (1.00) Reference (1.00) 
Conceptual CategoryVariableN (%)Unadjusted RR (95% CI)Adjusted Model 1, RR (95% CI)Adjusted Model 2, RR (95% CI)Adjusted Model 3, RR (95% CI)Adjusted Model 4, RR (95% CI)Adjusted Model 5, RR (95% CI)
Sociodemographic characteristics Maternal age, y        
 <20 30 (6.8) 1.15 (0.78–1.72) 1.22 (0.82–1.84) — — — — 
 20–34 170 (5.8) Reference (1.00) Reference (1.00) — — — — 
 ≥35 20 (4.2) 0.76 (0.48–1.21) 0.81 (0.51–1.29) — — — — 
Parity        
 Multiparous 134 (6.3) 1.26 (0.97–1.63) 1.31 (1.00–1.72) — — — — 
 Primiparous 86 (5.0) Reference (1.00) Reference (1.00) — — — — 
Neighborhood income quintile        
 Q1 (lowest) 115 (7.6) 3.07 (1.58–6.00) 2.51 (1.28–4.91) — — — 1.87 (0.96–3.68) 
 Q2 44 (5.0) 2.04 (1.00–4.16) 1.76 (0.85–3.64) — — — 1.48 (0.71–3.07) 
 Q3 30 (4.8) 1.95 (0.93–4.09) 1.68 (0.80–3.52) — — — 1.49 (0.71–3.12) 
 Q4 20 (4.6) 1.85 (0.84–4.07) 1.67 (0.77–3.60) — — — 1.60 (0.74–3.43) 
 Q5 (highest) 9 (2.5) Reference (1.00) Reference (1.00) — — — Reference (1.00) 
Region residence        
 Rural 21 (3.9) 0.66 (0.42–1.05) 0.70 (0.44–1.11) — — — — 
 Urban 198 (6.0) Reference (1.00) Reference (1.00) — — — — 
Health Characteristics Chronic medical condition        
 Yes 51 (8.3) 1.54 (1.12–2.12) — 1.44 (1.05–1.99) — — 1.24 (0.90–1.71) 
 No 159 (5.2) Reference (1.00) — Reference (1.00) — — Reference (1.00) 
Psychotic mental illness        
 Yes 25 (13.1) 2.19 (1.38–3.49) — 1.83 (1.09–3.08) — — 2.58 (1.90–3.50) 
 No 195 (5.3) Reference (1.00) — Reference (1.00) — — Reference (1.00) 
Nonpsychotic mental illness        
 Yes 130 (6.6) 1.35 (1.02–1.77) — 1.20 (0.89–1.61) — — — 
 No 90 (4.8) Reference (1.00) — Reference (1.00) — — — 
Substance use disorder        
 Yes 32 (9.4) 1.66 (1.15–2.40) — 1.36 (0.91–2.03) — — — 
 No 188 (5.4) Reference (1.00) — Reference (1.00) — — — 
Service characteristics Social assistance receipt        
 Yes 149 (9.1) 2.69 (2.02–3.60) — — 2.80 (1.05–2.75) — 2.55 (1.87–3.47) 
 No 71 (3.2) Reference (1.00) — — Reference (1.00) — Reference (1.00) 
No ultrasound by 20 wk        
 Yes 84 (9.3) 1.86 (1.40–2.47) — — 1.85 (1.39–2.46) — 1.76 (1.32–2.34) 
 No 136 (4.6) Reference (1.00) — — Reference (1.00) — Reference (1.00) 
<4 prenatal care visits by 36 wk        
 Yes 17 (9.6) 1.73 (1.07–2.80) — — 1.85 (1.39–2.46) — 1.71 (1.05–2.78) 
 No 203 (5.5) Reference (1.00) — — Reference (1.00) — Reference (1.00) 
Perinatal characteristics Pregnancy complications        
 Yes 26 (5.1) 0.89 (0.60–1.31) — — — 0.91 (0.62–1.35) — 
 No 194 (5.8) Reference (1.00) — — — Reference (1.00) — 
Delivery mode        
 Cesarean 55 (5.1) 0.84 (0.62–1.15) — — — 0.86 (0.63–1.18) — 
 Vaginal 165 (6.0) Reference (1.00) — — — Reference (1.00) — 
Gestational age        
 Preterm 18 (4.3) 0.77 (0.48–1.24) — — — 0.67 (0.39–1.15) 0.64 (0.38–1.07) 
 Term 202 (5.9) Reference (1.00) — — — Reference (1.00) Reference (1.00) 
Neonatal morbidity        
 Yes 20 (9.1) 1.61 (1.02–2.53) — — — 1.70 (1.00–2.88) 1.49 (0.90–2.47) 
 No 197 (5.5) Reference (1.00) — — — Reference (1.00) Reference (1.00) 
Congenital anomaly        
 Yes 29 (7.8) 1.43 (0.97–2.11) — — — 1.42 (0.92–2.17) 1.28 (0.85–1.94) 
 No 191 (5.5) Reference (1.00) — — — Reference (1.00) Reference (1.00) 

Q, quintile; —, not applicable.

The rate of sustained maternal-infant separation in women with IDDs was 4.9% compared with 0.1% in those without IDDs (RR 37.40; 95% CI 31.41–44.52) (ie, 85.9% vs 74.8% of those initially discharged to child protective services). This risk remained statistically significant in adjusted analyses (aRR 8.83; 95% CI 6.99–11.17). Among women with IDDs, risk factors for sustained maternal-infant separation were psychotic disorders (aRR 1.71; 95% CI 1.03–2.85), social assistance receipt (aRR 2.96; 95% CI 2.10–4.17), failure to receive an ultrasound by 20 weeks (aRR 1.64; 95% CI 1.21–2.23), and neonatal morbidity (aRR 1.73; 95% CI 1.05–2.86) (Table 4).

TABLE 4

Unadjusted and Adjusted Risks for Sustained Maternal-Infant Separation Among Newborns of Women With IDDs

Conceptual CategoryVariableN (%)Unadjusted RR (95% CI)Adjusted Model 1, RR (95% CI)Adjusted Model 2, RR (95% CI)Adjusted Model 3, RR (95% CI)Adjusted Model 4, RR (95% CI)Adjusted Model 5, RR (95% CI)
Sociodemographic characteristics Maternal age, y        
 <20 27 (6.1) 1.22 (0.81–1.87) 1.26 (0.82–1.96) — — — — 
 20–34 144 (4.9) Reference (1.00) Reference (1.00) — — — — 
 ≥35 18 (3.8) 0.80 (0.50–1.29) 0.85 (0.53–1.38) — — — — 
Parity        
 Multiparous 113 (5.4) 1.19 (0.90–1.58) 1.25 (0.94–4.59) — — — — 
 Primiparous 76 (4.4) Reference (1.00) Reference (1.00) — — — — 
Neighborhood income quintile        
 Q1 (lowest) 101 (6.7) 2.70 (1.38–5.28) 1.31 (1.16–4.59) — — — 1.64 (0.82–3.26) 
 Q2 36 (4.1) 1.67 (0.80–3.45) 1.49 (0.70–3.18) — — — 1.19 (0.56–2.52) 
 Q3 24 (3.8) 1.56 (0.73–3.32) 1.38 (0.64–2.98) — — — 1.19 (0.55–2.58) 
 Q4 17 (3.9) 1.57 (0.71–3.49) 1.50 (0.67–3.33) — — — 1.38 (0.63–3.05) 
 Q5 (highest) 9 (2.5) Reference (1.00) Reference (1.00) — — — Reference (1.00) 
Region residence        
 Rural 18 (3.3) 0.65 (0.39–1.07) 0.68 (0.41–1.13) — — — — 
 Urban 170 (5.2) Reference (1.00) Reference (1.00) — — — — 
Health characteristics Chronic medical condition        
 Yes 42 (6.9) 1.48 (1.05–2.08) — 1.36 (0.96–1.92) — — — 
 No 147 (4.6) Reference (1.00) — Reference (1.00) — — — 
Psychotic mental illness        
 Yes 25 (13.1) 2.72 (1.74–4.25) — 2.19 (1.30–3.68) — — 1.71 (1.03–2.85) 
 No 164 (4.5) Reference (1.00) — Reference (1.00) — — Reference (1.00) 
Nonpsychotic mental illness        
 Yes 113 (5.7) 1.39 (1.03–1.87) — 1.19 (0.86–1.63) — — — 
 No 76 (4.1) Reference (1.00) — Reference (1.00) — — — 
Substance use disorder        
 Yes 31 (9.1) 1.95 (1.34–2.84) — 1.52 (1.00–2.31) — — 1.43 (0.95–2.16) 
 No 158 (4.5) Reference (1.00) — Reference (1.00) — — Reference (1.00) 
Service characteristics Social assistance receipt        
 Yes 133 (8.1) 3.15 (2.30–4.31) — — 3.22 (2.36–4.41) — 2.96 (2.10–4.17) 
 No 56 (2.5) Reference (1.00) — — Reference (1.00) — Reference (1.00) 
No ultrasound by 20 wk        
 Yes 68 (7.6) 1.70 (1.25–2.30) — — 1.56 (0.88–2.76) — 1.64 (1.21–2.23) 
 No 111 (4.1) Reference (1.00) — — Reference (1.00) — Reference (1.00) 
<4 prenatal care visits by 36 wk        
 Yes 13 (7.3) 1.54 (0.88–2.71) — — 1.72 (1.26–2.33) — 1.52 (0.85–2.74) 
 No 176 (4.8) Reference (1.00) — — Reference (1.00) — Reference (1.00) 
Perinatal characteristics Pregnancy complications        
 Yes 20 (3.9) 0.79 (0.50–1.23) — — — 0.81 (0.51–1.27) — 
 No 169 (5.1) Reference (1.00) — — — Reference (1.00) — 
Delivery mode        
 Cesarean 46 (4.2) 0.80 (0.57–1.12) — — — 0.82 (0.58–1.15) — 
 Vaginal 143 (5.2) Reference (1.00) — — — Reference (1.00) — 
Gestational age        
 Preterm 16 (3.8) 0.79 (0.48–1.30) — — — 0.65 (0.36–1.15) 0.64 (0.37–1.11) 
 Term 173 (5.1) Reference (1.00) — — — Reference (1.00) Reference (1.00) 
Neonatal morbidity        
 Yes 20 (9.1) 1.92 (1.22–3.01) — — — 2.03 (1.19–3.45) 1.73 (1.05–2.86) 
 No 166 (4.6) Reference (1.00) — — — Reference (1.00) Reference (1.00) 
Congenital anomaly        
 Yes 27 (17.3) 1.58 (1.05–2.35) — — — 1.52 (0.97–2.38) 1.36 (0.88–2.11) 
 No 162 (4.7) Reference (1.00) — — — Reference (1.00) Reference (1.00) 
Conceptual CategoryVariableN (%)Unadjusted RR (95% CI)Adjusted Model 1, RR (95% CI)Adjusted Model 2, RR (95% CI)Adjusted Model 3, RR (95% CI)Adjusted Model 4, RR (95% CI)Adjusted Model 5, RR (95% CI)
Sociodemographic characteristics Maternal age, y        
 <20 27 (6.1) 1.22 (0.81–1.87) 1.26 (0.82–1.96) — — — — 
 20–34 144 (4.9) Reference (1.00) Reference (1.00) — — — — 
 ≥35 18 (3.8) 0.80 (0.50–1.29) 0.85 (0.53–1.38) — — — — 
Parity        
 Multiparous 113 (5.4) 1.19 (0.90–1.58) 1.25 (0.94–4.59) — — — — 
 Primiparous 76 (4.4) Reference (1.00) Reference (1.00) — — — — 
Neighborhood income quintile        
 Q1 (lowest) 101 (6.7) 2.70 (1.38–5.28) 1.31 (1.16–4.59) — — — 1.64 (0.82–3.26) 
 Q2 36 (4.1) 1.67 (0.80–3.45) 1.49 (0.70–3.18) — — — 1.19 (0.56–2.52) 
 Q3 24 (3.8) 1.56 (0.73–3.32) 1.38 (0.64–2.98) — — — 1.19 (0.55–2.58) 
 Q4 17 (3.9) 1.57 (0.71–3.49) 1.50 (0.67–3.33) — — — 1.38 (0.63–3.05) 
 Q5 (highest) 9 (2.5) Reference (1.00) Reference (1.00) — — — Reference (1.00) 
Region residence        
 Rural 18 (3.3) 0.65 (0.39–1.07) 0.68 (0.41–1.13) — — — — 
 Urban 170 (5.2) Reference (1.00) Reference (1.00) — — — — 
Health characteristics Chronic medical condition        
 Yes 42 (6.9) 1.48 (1.05–2.08) — 1.36 (0.96–1.92) — — — 
 No 147 (4.6) Reference (1.00) — Reference (1.00) — — — 
Psychotic mental illness        
 Yes 25 (13.1) 2.72 (1.74–4.25) — 2.19 (1.30–3.68) — — 1.71 (1.03–2.85) 
 No 164 (4.5) Reference (1.00) — Reference (1.00) — — Reference (1.00) 
Nonpsychotic mental illness        
 Yes 113 (5.7) 1.39 (1.03–1.87) — 1.19 (0.86–1.63) — — — 
 No 76 (4.1) Reference (1.00) — Reference (1.00) — — — 
Substance use disorder        
 Yes 31 (9.1) 1.95 (1.34–2.84) — 1.52 (1.00–2.31) — — 1.43 (0.95–2.16) 
 No 158 (4.5) Reference (1.00) — Reference (1.00) — — Reference (1.00) 
Service characteristics Social assistance receipt        
 Yes 133 (8.1) 3.15 (2.30–4.31) — — 3.22 (2.36–4.41) — 2.96 (2.10–4.17) 
 No 56 (2.5) Reference (1.00) — — Reference (1.00) — Reference (1.00) 
No ultrasound by 20 wk        
 Yes 68 (7.6) 1.70 (1.25–2.30) — — 1.56 (0.88–2.76) — 1.64 (1.21–2.23) 
 No 111 (4.1) Reference (1.00) — — Reference (1.00) — Reference (1.00) 
<4 prenatal care visits by 36 wk        
 Yes 13 (7.3) 1.54 (0.88–2.71) — — 1.72 (1.26–2.33) — 1.52 (0.85–2.74) 
 No 176 (4.8) Reference (1.00) — — Reference (1.00) — Reference (1.00) 
Perinatal characteristics Pregnancy complications        
 Yes 20 (3.9) 0.79 (0.50–1.23) — — — 0.81 (0.51–1.27) — 
 No 169 (5.1) Reference (1.00) — — — Reference (1.00) — 
Delivery mode        
 Cesarean 46 (4.2) 0.80 (0.57–1.12) — — — 0.82 (0.58–1.15) — 
 Vaginal 143 (5.2) Reference (1.00) — — — Reference (1.00) — 
Gestational age        
 Preterm 16 (3.8) 0.79 (0.48–1.30) — — — 0.65 (0.36–1.15) 0.64 (0.37–1.11) 
 Term 173 (5.1) Reference (1.00) — — — Reference (1.00) Reference (1.00) 
Neonatal morbidity        
 Yes 20 (9.1) 1.92 (1.22–3.01) — — — 2.03 (1.19–3.45) 1.73 (1.05–2.86) 
 No 166 (4.6) Reference (1.00) — — — Reference (1.00) Reference (1.00) 
Congenital anomaly        
 Yes 27 (17.3) 1.58 (1.05–2.35) — — — 1.52 (0.97–2.38) 1.36 (0.88–2.11) 
 No 162 (4.7) Reference (1.00) — — — Reference (1.00) Reference (1.00) 

Q, quintile; —, not applicable.

In this large, population-based study, 1 in 20 newborns of women with IDDs were discharged to child protective services immediately after the birth hospitalization. This was >30 times the rate in newborns of women without IDDs. Even after taking into account characteristics that could be used to explain the difference, maternal IDD status remained associated with an eightfold increased risk for newborn discharge to child protective services. Among women with IDDs, risk factors for newborn discharge to child protective services were maternal comorbid psychotic disorders, social assistance receipt, and indicators of inadequate prenatal care. Women with IDDs in these high-risk groups may benefit from improved support before and during pregnancy to prevent maternal-newborn separations, when possible. On the other hand, the finding that 19 out of 20 newborns of women with IDDs were discharged from the hospital with their mothers suggests that, in many cases, women with IDDs are given the opportunity to parent and should be given appropriate supports to optimize maternal-newborn bonding, breastfeeding, and early infant care.

Several studies have documented the overrepresentation of parents with IDDs in child protective services cases, with rates ranging from 26.1% to 86.9%.12,14,19 Most studies were restricted to high-risk samples from court documents12,13,19 or social service agency records.14 In addition, although 1 study suggested that younger child age was associated with increased odds of court applications for guardianship orders,19 only 2 studies specifically examined custody loss directly after delivery.15,16 The only other population-based study revealed that, among 53 565 women in Manitoba, Canada, of whom 69 had an IDD, IDD status was associated with 6.54 greater odds of having an infant taken into care at birth,16 consistent with our aRR of 8.10. A case series from the United Kingdom revealed that 40% of infants born to 20 parents with IDDs were removed from their care at birth,15 a rate considerably higher than our rate of 5.7%. However, this was a high-risk sample of parents receiving disability-related services. Our findings align with those of studies identifying subgroups of women with IDDs who were at particularly high risk for custody loss.17,18,20 Two of these studies had a comparison group of women with IDDs without child protective services involvement.17,20 Authors of a Canadian study of court documents of 1243 children of parents with IDDs found that low social support and mental illness were predictive of applying to child welfare court for guardianship orders.20 A smaller Canadian study of social service agency records of 47 women with IDDs revealed that women with custody loss had higher rates of poverty and social isolation than those without custody loss.17 In an Australian study of court documents of 12 women with IDDs who were at risk for losing custody, 42% had comorbid mental illness.18 Our results build on this research by using population-based data to provide clear quantification of the burden of custody loss immediately postdelivery in women with IDDs and by introducing key risk factors for this outcome.

Several factors could be used to explain the higher rate of discharge to child protective services in newborns of women with IDDs compared with newborns of women without IDDs, including concerns about parenting ability related to memory, organizational skills, judgement, or social skills7,37 or the attitudes and perceptions of child protective services workers.3 In our study, the association between IDD status and risk of discharge to child protective services remained after accounting for sociodemographic, health, service, and perinatal characteristics that could be used to explain the difference, suggesting some impact attributable to these unmeasured factors. It is notable that the impact of IDD status on child protective services involvement was not as great in high-risk groups defined by poverty, social isolation, and poor mental health. This suggests that IDD status has a smaller impact in women already experiencing social vulnerability. As shown previously,17,18,20 a variety of factors likely interact to increase the risk of child protective services involvement. This explanation is further reflected in our analyses of risk factors for child protective services involvement among women with IDDs; psychotic disorder, social assistance receipt, and inadequate prenatal care are all indicative of marginalization and were the main predictors of newborn discharge to child protective services, suggesting the existence of high-risk subgroups. These high-risk subgroups are significant because they speak to potential targets for supports aimed at improving the parenting skills of women with IDDs.

Our work has limitations common to studies using administrative data. IDD status may have been misclassified if disability was not recorded in health care encounters and disability-related income supports were not used.24 However, the prevalence of IDD in our cohort (0.8%)26 is similar to previous reports.1 Our conceptualization of IDD includes a broad range of disabilities that may be associated with variability in parenting ability. However, we did not stratify analyses by diagnosis because many individuals with IDDs have multiple diagnoses and, even within a diagnosis, there can be considerable range in parenting ability and support needs. In addition, our broad definition is consistent with disability legislation25 and clinical definitions.2 We did not know the original method of IDD or mental illness diagnosis, because only diagnostic codes are recorded in administrative data. However, the standard of care in Ontario for the diagnosis of these disorders includes the use of standardized measures.38 We did not have data on social context, including maternal marital status or the IDD status of the father, which may influence child custody decisions. This should be addressed in future research, as interventions for parents with IDDs tend to be designed for mothers.39 We also had no data on housing (independent, group home), familial support, or previous custody losses. We were unable to determine the subsequent custody status of newborns discharged to child protective services. To measure sustained maternal-infant separation, we used a proxy comprising different maternal and infant postal codes at 12 months. This does not provide information on the continuity of separation during that period or the reasons for different residences. In addition, albeit rarely, differences in postal code could reflect a failure to update health card information as opposed to separate residences. Finally, we had no data on apprehension at older ages. Even mothers whose newborns were not discharged to child protective services directly after the birth hospitalization may have eventually lost custody.12,14 

The immediate newborn period is important for breastfeeding and maternal-infant bonding, and separation of mothers and infants during this time is a risk factor for maternal suicide11 and child developmental problems.10 Although there are cases in which custody loss among women with IDDs may be warranted, such as in instances of neglect or abuse, researchers suggest that many separations are preventable.8,9 With our findings, we suggest that evidence-based interventions to avoid preventable maternal-infant separations at delivery and to support women who retain custody of their children after delivery are warranted, especially for women in the high-risk subgroups we identified. Previous research has revealed that behavior-based approaches to teach parenting skills are most effective at reducing risk for child removal, but these must be delivered in a manner that is tailored to a mother’s learning style.8,9 Other factors, such as poverty and comorbid mental illness, would also need to be addressed by comprehensive intervention services to achieve optimal results from such interventions, and ultimately, good maternal and child outcomes.

     
  • aRR

    adjusted relative risk

  •  
  • CI

    confidence interval

  •  
  • ICES

    Institute for Clinical Evaluative Sciences

  •  
  • IDD

    intellectual and developmental disability

  •  
  • RR

    relative risk

  •  
  • SD

    standardized difference

Dr Brown conceptualized and designed the study, analyzed and interpreted the data, and drafted the article; Ms Potvin and Dr Lunsky contributed to the conceptualization and design of the study, the interpretation of the data, and critical revision of the manuscript for important intellectual content; Dr Vigod supervised the conceptualization and design of the study and the analysis and interpretation of the data and critically revised the manuscript for important intellectual content; and all authors approved the final manuscript as submitted.

FUNDING: This study is part of the Health Care Access Research and Developmental Disabilities program and was supported by the province of Ontario through their research grants program and the Institute for Clinical Evaluative Sciences, which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care. The opinions, results, and conclusions reported in this article are those of the authors and are independent from the funding sources. No endorsement by the Institute for Clinical Evaluative Sciences or the government of Ontario is intended or should be inferred. Parts of this material are based on data and information compiled and provided by the Canadian Institute for Health Information. However, the analyses, conclusions, opinions, and statements expressed herein are those of the authors and not necessarily those of the Canadian Institute for Health Information.

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

Supplementary data