Canadian Perinatal Health Report 2 0 0 0

Canadian Perinatal Health Report 2 0 0 0
Canada
Santé
Canada
Canadian Perinatal Health Report
2000
Health
Canada
Canada
Canadian
Perinatal
Health Report
2000
Canadian
Perinatal
Health Report
2000
Our mission is to help the people of Canada
maintain and improve their health.
Health Canada
Copies of this report are available from:
Reproductive Health Division
Bureau of Reproductive and Child Health
Centre for Healthy Human Development
Population and Public Health Branch
Health Canada
HPB Bldg. #7, A.L. 0701D
Tunney’s Pasture
Ottawa, Ontario
K1A 0L2
Telephone: (613) 941-2395
Fax: (613) 941-9927
This publication can also be accessed electronically via the Internet at:
http://www.hc-sc.gc.ca/hpb/lcdc/brch/reprod.html
Également disponible en français sous le titre :
Rapport sur la santé périnatale au Canada, 2000
Suggested citation: Health Canada. Canadian Perinatal Health Report, 2000.
Ottawa: Minister of Public Works and Government Services Canada, 2000.
Published by authority of the Minister of Health
©Minister of Public Works and Government Services Canada, 2000
Cat. No. H49-142/2000E
ISBN 0-662-29309-6
Table of Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
Canadian Perinatal Surveillance System Steering Committee Members (2000) . . . . . xiii
The State of Perinatal Health in Canada — An Overview . . . . . . . . . . . . . . . . . . . . xv
Section A Determinants of Maternal, Fetal and Infant Health
1. Behaviours and Practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Prevalence of Prenatal Smoking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Prevalence of Prenatal Alcohol Consumption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Prevalence of Breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Rate of Live Births to Teenage Mothers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Rate of Live Births to Older Mothers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
2. Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Labour Induction Rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Cesarean Section Rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Rate of Operative Vaginal Deliveries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Rate of Trauma to the Perineum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Rate of Early Maternal Discharge from Hospital after Childbirth . . . . . . . . . . . . . 30
Rate of Early Neonatal Discharge from Hospital after Birth . . . . . . . . . . . . . . . . . 33
Section B
Maternal, Fetal and Infant Health Outcomes
3. Maternal Health Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Maternal Mortality Ratio . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Induced Abortion Ratio . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Ectopic Pregnancy Rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Severe Maternal Morbidity Ratio . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Rate of Maternal Readmission after Discharge following Childbirth . . . . . . . . . . 50
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Canadian Perinatal Health Report, 2000
Table of Contents
4. Fetal and Infant Health Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Preterm Birth Rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Postterm Birth Rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Fetal Growth: Small-for-Gestational-Age Rate, Large-for-Gestational-Age Rate . . . . 59
Fetal and Infant Mortality Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Severe Neonatal Morbidity Rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Multiple Birth Rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Prevalence of Congenital Anomalies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Rate of Neonatal Hospital Readmission after Discharge at Birth . . . . . . . . . . . . . 73
Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Section C
Appendices
Appendix A: Data Sources and Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Appendix B: List of Perinatal Health Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Appendix C: List of Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Appendix D: Components of Fetal-Infant Mortality . . . . . . . . . . . . . . . . . . . . . . . . . 99
Appendix E: Data Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Appendix F: Canadian Perinatal Surveillance System Publications
(as of September 2000) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
Appendix G: Evaluation Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
iv
Canadian Perinatal Health Report, 2000
List of Figures and Tables
Figures
Figure I
Figure 1
Figure 2
Figure 3
Figure 4
National Health Surveillance ......................................................... x
Temporal trends in infant mortality rates in provinces/territories,
Canada, 1961-1965 to 1991-1995 .............................................. xvi
Trends in infant mortality rates due to selected congenital
anomalies, Canada (excluding British Columbia, Ontario
and Newfoundland), 1981-1983 and 1993-1995..................... xviii
Rates of twin and triplet births (live and stillbirths), Canada,
1974-1997 .................................................................................. xviii
Rate of preterm birth among multiple live births, Canada,
1974-1997..................................................................................... xix
Figure 1.1
Prevalence of prenatal smoking, by maternal age, Canada
(excluding the territories), 1996-1997........................................... 4
Figure 1.2 Prevalence of prenatal smoking, by region/province, Canada
(excluding the territories), 1996-1997........................................... 4
Figure 1.3 Prevalence of prenatal alcohol consumption, by maternal age,
Canada (excluding the territories), 1996-1997 ............................. 7
Figure 1.4 Prevalence of prenatal alcohol consumption, by region/province,
Canada (excluding the territories), 1996-1997 ............................. 7
Figure 1.5 Prevalence of breastfeeding, by maternal age, Canada
(excluding the territories), 1996-1997......................................... 10
Figure 1.6 Prevalence of breastfeeding, by region/province, Canada
(excluding the territories), 1996-1997......................................... 10
Figure 1.7 Age-specific live birth rate, females 10-14 years, Canada
(excluding Newfoundland), 1981-1997 ...................................... 13
Figure 1.8 Age-specific live birth rate, females 15-19 years, Canada
(excluding Newfoundland), 1981-1997....................................... 13
Figure 1.9 Percent of live births to teenage mothers, Canada
(excluding Newfoundland), 1981-1997 ...................................... 14
Figure 1.10 Age-specific live birth rate, females 30-39 years, Canada
(excluding Newfoundland), 1981-1997 ...................................... 16
Figure 1.11 Age-specific live birth rate, females 40-49 years, Canada
(excluding Newfoundland), 1981-1997 ...................................... 16
Figure 1.12 Percent of live births to older mothers (≥ 30 years), Canada
(excluding Newfoundland), 1981-1997 ...................................... 17
v
Canadian Perinatal Health Report, 2000
List of Figures and Tables
Figure 2.1
Labour induction rate, by province/territory, Canada
(excluding Québec), 1997-1998................................................... 20
Figure 2.2 Primary cesarean section (CS) rate, by maternal age,
Canada (excluding Québec, Nova Scotia and Manitoba),
1994-1995 to 1997-1998............................................................... 22
Figure 2.3 Rate of operative vaginal deliveries, by province/territory,
Canada (excluding Québec), 1997-1998 ..................................... 24
Figure 2.4 Rate of vaginal deliveries by forceps, by province/territory,
Canada (excluding Québec), 1997-1998 ..................................... 25
Figure 2.5 Rate of vaginal deliveries by vacuum extraction, by province/
territory, Canada (excluding Québec), 1997-1998 ...................... 25
Figure 2.6 Trauma to the perineum by episiotomy and perineal laceration
rates, Canada, 1989-1990 to 1997-1998 ...................................... 28
Figure 2.7 Episiotomy rate, by province/territory, Canada (excluding
Québec), 1997-1998 ..................................................................... 28
Figure 2.8 Rate of short maternal length of stay (LOS) in hospital for
childbirth, Canada (excluding Québec, Nova Scotia and
Manitoba), 1989-1990 to 1997-1998........................................... 30
Figure 2.9 Rate of short maternal length of stay (LOS) in hospital for
childbirth, by province/territory, Canada (excluding Québec),
1997-1998 ...................................................................................... 32
Figure 2.10 Rate of early neonatal discharge from hospital after birth,
Canada (excluding Québec, Nova Scotia and Manitoba),
1989-1990 to 1997-1998............................................................... 33
Figure 2.11 Rate of early neonatal discharge from hospital after birth, by
province/territory, Canada (excluding Québec), 1997-1998......... 34
Figure 3.1
Figure 3.2
Figure 3.3
Figure 3.4
Figure 3.5
Figure 3.6
Figure 3.7
Figure 3.8
Figure 3.9
Maternal mortality ratio (MMR), Canada, 1973-1997 .............. 41
Induced abortion ratio and rate, Canada, 1990-1997 ................ 43
Induced abortion ratio and rate, by province/territory,
Canada, 1997................................................................................. 43
Age-specific induced abortion rate, Canada, 1997 ..................... 44
Ectopic pregnancy rate, Canada (excluding Québec, Nova
Scotia and Manitoba), 1989-1990 to 1997-1998 ........................ 46
Ectopic pregnancy rate, by province/territory, Canada
(excluding Québec), 1997-1998................................................... 46
Ectopic pregnancy rate, by maternal age, Canada
(excluding Québec), 1997-1998.................................................... 47
Rate of maternal readmission within three months of discharge
from hospital following childbirth, Canada (excluding Québec,
Nova Scotia and Manitoba), 1990-1991 to 1997-1998............... 50
Rate of maternal readmission within three months of discharge
from hospital following childbirth, by province/territory, Canada
(excluding Québec), 1995-1996 to 1997-1998............................ 51
vi
Canadian Perinatal Health Report, 2000
List of Figures and Tables
Figure 4.1
Figure 4.2
Figure 4.3
Figure 4.4
Figure 4.5
Figure 4.6
Figure 4.7
Figure 4.8
Figure 4.9
Figure 4.10
Figure 4.11
Figure 4.12
Figure 4.13
Figure 4.14
Figure 4.15
Figure 4.16
Figure 4.17
Figure 4.18
Figure 4.19
Figure 4.20
Figure 4.21
Preterm birth rate, Canada (excluding Ontario and
Newfoundland), 1981-1997.......................................................... 54
Preterm birth rates, by single and multiple births, Canada
(excluding Ontario), 1997............................................................ 54
Preterm birth rate, by province/territory, Canada (excluding
Ontario), 1997 .............................................................................. 55
Postterm birth rate, Canada (excluding Ontario and
Newfoundland), 1988-1997 .......................................................... 56
Postterm birth rate, by province/territory, Canada (excluding
Ontario), 1997 ............................................................................. 57
Rates of small for gestational age (SGA) and large for
gestational age (LGA), Canada (excluding Ontario and
Newfoundland), 1988-1997 ......................................................... 60
Small-for-gestational-age (SGA) rate, by province/territory,
Canada (excluding Ontario), 1997 .............................................. 60
Large-for-gestational-age (LGA) rate, by province/territory,
Canada (excluding Ontario), 1997 .............................................. 61
Rates of fetal, neonatal and postneonatal deaths, Canada
(excluding Newfoundland), 1988-1997 ...................................... 64
Fetal death rate, by province/territory, Canada (excluding
Ontario), 1997 .............................................................................. 64
Neonatal death rate, by province/territory, Canada, 1997 ......... 65
Postneonatal death rate, by province/territory, Canada, 1997 ....... 65
Respiratory distress syndrome (RDS) rate, Canada (excluding
Québec, Nova Scotia and Manitoba), 1989-1990 to
1997-1998...................................................................................... 67
Respiratory distress syndrome (RDS) rate, by province/territory,
Canada (excluding Québec), 1997-1998 ..................................... 68
Rate of multiple births, Canada (excluding Newfoundland),
1988-1997...................................................................................... 69
Rate of multiple births, by province/territory, Canada, 1997........ 70
Neural tube defect (NTD) rate, Canada (excluding Québec
and Nova Scotia), 1989-1997....................................................... 72
Neural tube defect (NTD) rate, by province/territory, Canada
(excluding Québec), 1997 ............................................................ 72
Rate of neonatal hospital readmission after discharge at birth,
Canada (excluding Québec, Nova Scotia and Manitoba), 19891990 to 1997-1998 ........................................................................ 74
Rate of neonatal hospital readmission after discharge at birth, by
province/territory, Canada (excluding Québec and Manitoba),
1997-1998...................................................................................... 74
Principal diagnosis for readmitted newborns, Canada
(excluding Québec, Nova Scotia and Manitoba), 1989-1990
and 1997-1998 .............................................................................. 75
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Canadian Perinatal Health Report, 2000
List of Figures and Tables
Tables
Table 2.1
Table 2.2
Table 2.3
Table 2.4
Table 2.5
Table 2.6
Table 3.1
Table 3.2
Table 3.3
Table 4.1
Table 4.2
Cesarean section (CS) rate and percent of women who have
had a previous CS, Canada (excluding Québec, Nova Scotia
and Manitoba), 1994-1995 to 1997-1998.................................... 22
Percent of births that were first births, by maternal age,
Canada, 1994-1997 ....................................................................... 22
Average maternal length of stay (LOS) in hospital for childbirth,
Canada (excluding Québec, Nova Scotia and Manitoba),
1989-1990 to 1997-1998............................................................... 31
Average maternal length of stay (LOS) in hospital for
childbirth, by province/territory, Canada (excluding Québec)
1997-1998...................................................................................... 31
Average neonatal length of stay (LOS) in hospital after
birth, Canada (excluding Québec, Nova Scotia and Manitoba),
1989-1990 to 1997-1998............................................................... 35
Average neonatal length of stay (LOS) in hospital after
birth, by province/territory, Canada (excluding Québec),
1997-1998...................................................................................... 35
Direct maternal deaths by cause, Canada, 1973-1977 and
1993-1997...................................................................................... 40
Number, recorded incidence and case fatality rate for amniotic
fluid embolism, Canada (excluding Québec, Nova Scotia and
Manitoba), 1989-1990 to 1997-1998 ........................................... 49
Percent of maternal readmissions within three months of
discharge from hospital following childbirth, by primary
diagnosis, Canada (excluding Québec), 1995-1996 to
1997-1998...................................................................................... 52
Framework for the estimation of preventable feto-infant
mortality according to birth weight and age at death................ 63
Rate (per 1,000 births) of excess feto-infant mortality and number
of deaths, by type of intervention opportunity and province/
territory, Canada (excluding Ontario), 1992-1996 .....................66
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Canadian Perinatal Health Report, 2000
Introduction
he Canadian Perinatal Health Report, 2000 is the first national surveillance
report from the Canadian Perinatal Surveillance System (CPSS), and was
produced by Health Canada’s Bureau of Reproductive and Child Health and the
CPSS Steering Committee. Together, the Bureau and the Steering Committee
have developed the conceptual framework for the CPSS, identified appropriate
perinatal health indicators and their data sources, and undertaken analysis and
interpretation of the data. This report and subsequent national surveillance
reports (to be released at regular intervals) will be complemented by the ongoing
publication of fact sheets and peer-reviewed scientific papers.
The CPSS has prepared a companion document to this and future
surveillance reports: Perinatal Health Indicators for Canada: A Resource Manual.1
This manual, which provides information on the indicators being monitored by
the CPSS, is intended as a reference guide for readers of this national surveillance
report and for those undertaking perinatal health data collection, analysis, interpretation and response at provincial, territorial or regional levels.
T
Background
The Bureau of Reproductive and Child Health began the development of the
CPSS in 1995, as part of Health Canada’s initiative to fill gaps in national public
health surveillance. The work of the Canadian Perinatal Regionalization Coalition
(now the Canadian Perinatal Programs Coalition) on the development of a
national perinatal database was an important foundation for the CPSS. The CPSS
collaborates with Statistics Canada, the Canadian Institute for Health Information (CIHI), provincial and territorial governments, health professional
organizations, advocacy groups and university-based researchers. Representatives
of these groups and several international experts serve on the CPSS Steering
Committee and its study groups. The mission, principles and objectives of the
CPSS are described elsewhere.2,3
CPSS Conceptual Framework
The CPSS considers a health surveillance system to be a core system of ongoing
data collection, analysis and interpretation on vital public health issues. The
result is information that is used to develop and evaluate interventions, with the
aim of reducing health disparities and promoting health.2 Figure I depicts the
cycle of surveillance, adapted from a conceptual framework described by Dr.
Brian McCarthy, Centers for Disease Control and Prevention, Atlanta, Georgia.4
ix
Canadian Perinatal Health Report, 2000
The CPSS
considers
a health
surveillance
system to be a
core system of
ongoing data
collection,
analysis and
interpretation
on vital public
health issues.
The result is
information
that is used
to develop
and evaluate
interventions,
with the aim of
reducing health
disparities and
promoting
health.
Introduction
Figure I
National Health Surveillance
Expert analysis and
interpretation
Data
collection
Communication
of information
for action
Source: Adapted from CDC
Overlying this concept of health surveillance is the concept of the determinants of health: that health status is influenced by a range of factors including,
but not limited to, health care.5 Therefore, it is important to monitor not only
health outcomes, but also factors — such as behaviours, physical and social
environments, and health services — that may affect those outcomes. Health
surveillance aims to contribute to improved health outcomes — that is the end
point. However, information on trends and patterns in various risk and
protective factors helps to explain patterns of morbidity and mortality, and may
point the way to effective interventions and allocation of health resources that
will improve outcomes. Monitoring of health determinants and monitoring of
health outcomes go hand in hand in health surveillance systems.
CPSS Indicators
A health indicator is “a measurement that, when compared to either a standard
or desired level of achievement, provides information regarding a health outcome
or important health determinant.”2 The Bureau of Reproductive and Child
Health and the CPSS Steering Committee undertook a process to identify the
perinatal health indicators that should be monitored by a national perinatal
surveillance system.1 The group considered the importance of the health
outcome or determinant, the scientific properties of the indicator, such as its
validity in measuring that outcome or determinant, and the feasibility of
x
Canadian Perinatal Health Report, 2000
Introduction
collecting the data required to construct it. Appendix B contains the set of
indicators that resulted from this process. The first 43 indicators listed are ranked
according to the Steering Committee’s assessment of health importance. Nine
additional indicators were added to the list after subsequent consultations.
The principal data sources currently available for national perinatal health
surveillance are described in Appendix A and in more detail in Perinatal Health
Indicators for Canada. Using these available data sources (vital statistics,
hospitalization data and national health surveys), the CPSS can report on only a
subset of the indicators in Appendix B. The program is supporting efforts to
improve existing databases and fill data gaps. This work, accompanied by ongoing
developments in information technology and health information systems, will
provide more perinatal health data at the national level, so that the number of
indicators on which the CPSS can report will increase, as will our ability to
understand and explain temporal trends and geographic and other disparities in
the indicators.
Outline of the Report
This report contains information on 24 perinatal health indicators, grouped as
indicators of health determinants (behaviours and practices and health services)
and indicators of outcomes (maternal, fetal and infant health). For each indicator,
surveillance results are presented, data limitations discussed and key references
listed. Statistics for each indicator consist mainly of temporal trends at the
national level and interprovincial/territorial comparisons for the most recent
year for which data are available.
Summary
Perinatal health surveillance is a necessary component of managing the health
system to improve the health status of pregnant women, mothers and infants in
Canada. It is far more than a static database for perinatal health. Rather, it
comprises a dynamic, integrated system of data collection, linkage, validation,
analysis, interpretation and reporting that permits timely identification of “red
flags,” tracking of temporal trends and geographic and other disparities, as well as
assessment of the effect of changes in clinical practice and public health policy.
Perinatal health surveillance provides both a measurement tool (where we have
been in the past, where we are at present) and a stimulus to action (where we need
to be in the future).
Catherine McCourt, MD, MHA, FRCPC
Director, Bureau of Reproductive and
Child Health
Centre for Healthy Human Development
Population and Public Health Branch
Health Canada
Michael S. Kramer, MD
Professor of Epidemiology and
Biostatistics and Pediatrics
McGill University
Chairperson, CPSS Steering
Committee
xi
Canadian Perinatal Health Report, 2000
Perinatal health
surveillance
provides both
a measurement
tool (where we
have been in
the past, where
we are at
present) and
a stimulus to
action (where
we need to be
in the future).
Introduction
References
1.
2.
3.
4.
5.
Health Canada. Perinatal Health Indicators for Canada: A Resource Manual. Ottawa:
Minister of Public Works and Government Services Canada, 2000 (Catalogue No. H49135/2000E).
Health Canada. Canadian Perinatal Surveillance System Progress Report. Ottawa: Minister
of Supply and Services Canada, 1995.
Health Canada. Canadian Perinatal Surveillance System Progress Report 1997-1998. Ottawa:
Minister of Public Works and Government Services Canada, 1999.
McCarthy B. The risk approach revisited: A critical review of developing country
experience and its use in health planning. In: Liljestrand J, Povey WG (Eds.), Maternal
Health Care in an International Perspective. Proceedings of the XXII Berzelius Symposium,
1991 May 27-29, Stockholm, Sweden. Sweden: Uppsala University, 1992: 107-24.
Federal, Provincial and Territorial Advisory Committee on Population Health. Strategies
for Population Health: Investing in the Health of Canadians. Ottawa: Minister of Supply
and Services Canada, 1994.
xii
Canadian Perinatal Health Report, 2000
Contributors
Authors
Editors
Tye Arbuckle, PhD
Susie Dzakpasu, MHSc
Shiliang Liu, MB, PhD
Jocelyn Rouleau
I.D. Rusen, MD, MSc, FRCPC
Linda Turner, PhD
Shi Wu Wen, MB, PhD
Susie Dzakpasu, MHSc
K.S. Joseph, MD, PhD
I.D. Rusen, MD, MSc, FRCPC
Research Assistants
Jennifer Haughton
Fay McLaughlin, RN, BScN
Administrative Support
Ernesto Delgado
Canadian Perinatal Surveillance System
Steering Committee Members (2000)
Chairperson
Michael Kramer, MD
Departments of Pediatrics and
Epidemiology and Biostatistics
McGill University
Montréal, Québec
Representatives
Alexander Allen, MD, FRCPC
Canadian Perinatal Programs
Coalition
Halifax, Nova Scotia
Christine Fitzgerald
Canadian Institute for Health
Information
Ottawa, Ontario
Madeline Boscoe, RN
Women’s Health Network
Winnipeg, Manitoba
Maureen Heaman, RN, MN, PhD(c)
Association of Women’s Health,
Obstetric and Neonatal Nurses
Canadian Nurses Association
Winnipeg, Manitoba
xiii
Canadian Perinatal Health Report, 2000
CPSS Steering Committee Members
Pearl Herbert, BN, BEd, MSc
Canadian Confederation of
Midwives
St. John’s, Newfoundland
Ken Milne, MD, FSOGC, FRCSC
Society of Obstetricians and
Gynaecologists of Canada
Ottawa, Ontario
Sue Hodges, RN, BScN
Canadian Institute of Child Health
Ottawa, Ontario
Patricia Niday, EdD
Canadian Perinatal Programs
Coalition
Ottawa, Ontario
Vania Jimenez, MDCM, CCFP, FCFP
College of Family Physicians of
Canada
Montréal, Québec
Reg Sauve, MD, MPH, FRCPC
Canadian Paediatric Society
Calgary, Alberta
Robert Liston, MB, ChB, FRCSC,
FRCOG
Society of Obstetricians and
Gynaecologists of Canada
Vancouver, British Columbia
Marianne Stewart, BScN, MHSA
Canadian Public Health Association
Edmonton, Alberta
Individual Experts
Beverley Chalmers, PhD
The Centre for Research in Women’s
Health
University of Toronto
Toronto, Ontario
Sylvie Marcoux, MD, PhD
Associate Dean, Research
Université Laval
Québec, Québec
Brian McCarthy, MD
Centers for Disease Control and
Prevention
Atlanta, Georgia, U.S.A.
K.S. Joseph, MD, PhD
Departments of Obstetrics and
Gynecology and Pediatrics
Dalhousie University
Halifax, Nova Scotia
Arne Ohlsson, MD, MSc, FRCPC
Departments of Paediatrics,
Obstetrics and Gynaecology,
Public Health Sciences
University of Toronto
Toronto, Ontario
Judith Lumley, MB, PhD
Centre for the Study of Mothers’
and Children’s Health
La Trobe University
Carlton, Victoria, Australia
Federal Government Representatives
Alexa Brewer, MBA, BScN
First Nations and Inuit Health
Branch
Health Canada
Ottawa, Ontario
Martha Fair
Occupational and Environmental
Health Research Section
Statistics Canada
Ottawa, Ontario
Gary Catlin
Health Statistics Division
Statistics Canada
Ottawa, Ontario
Carolyn Harrison
Child, Youth and Family Health Section
Health Canada
Ottawa, Ontario
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Canadian Perinatal Health Report, 2000
An Overview
The State of Perinatal
Health in Canada
his report on perinatal health in Canada represents an important initiative of
the Canadian Perinatal Surveillance System (CPSS). Available information on
determinants and outcomes related to fetal, infant and maternal health has been
compiled from various sources and provides a broad description of the state of
perinatal health in Canada. The focus has been on documenting the magnitude
of specific indicators of perinatal health and describing temporal trends and
interprovincial/territorial differences in indicator values. This overview briefly
summarizes specific topics of contemporary concern in perinatal health and
highlights areas requiring attention from a public health, health care or surveillance
standpoint.
T
Overview of Perinatal Health in Canada
Infant Mortality
It appears to be the best of times for perinatal health in Canada, at least when
assessed in terms of infant mortality. Infant mortality rates in Canada have
declined substantially over the last several decades and are among the lowest in
the world. Perhaps as noteworthy is the reduction in regional disparities in infant
mortality rates (Figure 1). The magnitude of the reduction in infant mortality
since the early 1960s (i.e., before the introduction of national medical insurance)
has been higher in provinces and territories where the infant mortality rate was
the highest in the early 1960s.1 For example, the Northwest Territories and the
Yukon, which had the highest rates of infant mortality four decades ago (92.9 and
42.0 per 1,000 live births in 1961-1965, respectively) achieved the largest reductions
in infant mortality by 1991-1995 (82% and 86% reduction, respectively). This is
in contrast to the substantial but relatively smaller reductions in infant mortality
(between 68% and 81%) that occurred elsewhere in Canada.1
Since enactment of the Medicare Act in 1968, the Canadian experience contrasts
with the international situation where relative differences between nations have
increased; countries with low rates of infant mortality have posted much larger
declines than those with higher rates.1 Although some industrialized countries
have slightly lower rates than Canada, the ranking of countries based on small
differences in infant mortality is compromised because birth registration
practices are not standardized, especially for live births near the borderline of
viability.2,3
Between 1990 and 1995, Canadian infant mortality rates fluctuated between
6.1 and 6.8 per 1,000 live births (see chapter 4). The crude infant mortality rate
in 1993 (6.3 per 1,000 live births) exceeded the infant mortality rate of the
previous year (6.1 per 1,000 live births) for the first time in several decades. This
led to reports about the dire state of perinatal health in Canada.4 Diverse factors
xv
Canadian Perinatal Health Report, 2000
It appears to
be the best of
times for
perinatal health
in Canada, at
least when
assessed in
terms of infant
mortality.
Infant mortality
rates in Canada
have declined
substantially
over the last
several decades
and are among
the lowest in
the world.
Overview
Temporal trends in infant mortality rates in provinces/territories,
Canada, 1961-1965 to 1991-1995
FIGURE 1
Infant deaths per 1,000 live births
100
90
80
Newfoundland
Prince Edward Island
Nova Scotia
New Brunswick
Québec
Ontario
Manitoba
70
60
Saskatchewan
Alberta
British Columbia
Yukon
Northwest Territories
50
40
30
20
10
0
1961-1965
1971-1975
1981-1985
1991-1995
Calendar year
Source: Statistics Canada. Canadian Vital Statistics System, 1961-1995.
such as maternal poverty and environmental pollution were implicated in this
apparent downturn in perinatal health. Others suggested a more innocuous
explanation, arguing that the increase in infant mortality in 1993 was artificial
and related to increases in the birth registration of live births < 500 g.5 With
previously defined limits on viability (e.g., a birth weight of 500 g) being steadily
breached due to advances in obstetrics and neonatal care, attitudes towards such
extremely immature live births have changed in recent years. If extremely
immature live births are increasingly registered as live births, crude infant
mortality comparisons over time would be compromised5,6 as a result of the
extremely high mortality among such births.7
This was not a new argument; the World Health Organization (WHO)
recommended that international comparisons of infant mortality be restricted to
live births ≥ 1,000 g for similar reasons.8 Unfortunately, while trends in crude infant
mortality rates in Canada could be assessed easily, trends in infant mortality
among live births ≥ 500 g or ≥ 1,000 g could only be examined indirectly (using
analyses requiring assumptions or based on statistical modeling).5 A direct assessment of the issue was not possible, because information on birth weight-specific
(or gestational age-specific) rates of infant mortality was not available in Canada.
xvi
Canadian Perinatal Health Report, 2000
Overview
This uncertainty is behind us. Crude infant mortality rates in Canada
dropped substantially to 5.6 per 1,000 live births in 1996 and 5.5 per 1,000 live
births in 1997 (see chapter 4). Furthermore, work carried out by the CPSS (along
with Statistics Canada) has led to the creation of a mechanism by which
information on live births and infant deaths has been linked from 1985 onwards.
This linkage means that information on birth weight- and gestational age-specific
infant mortality9,10 is available for Canada and for each province/territory (see
Appendix E), and that such information will become available on an ongoing
basis in the future. Analyses carried out after this linkage9 have demonstrated that
crude infant mortality rates in Canada (excluding Newfoundland and Ontario)
decreased by 22.1% from 8.1 per 1,000 live births in 1985-1987 to 6.3 per 1,000
live births in 1992-1994. Over the same period, infant mortality rates among live
births ≥ 500 g decreased by 25.4 % (from 7.6 to 5.7 per 1,000 live births) and by
26.3% among live births ≥ 1,000 g (from 5.9 to 4.4 per 1,000 live births). The
divergence between trends in crude infant mortality rates and among live births
≥ 500 g confirms that assessment of trends in infant mortality needs to account
for changes in the registration of live births at the borderline of viability. Details
regarding rates of fetal, neonatal, postneonatal and infant mortality in Canada
and in each province/territory are provided in chapter 4 and in Appendix E.
Congenital Anomalies
One of the noteworthy changes in perinatal health in Canada in recent years has
been the decline in infant deaths due to congenital malformations. Infant
mortality due to major congenital anomalies decreased significantly from 3.1 per
1,000 live births in 1985 to 1.9 per 1,000 live births in 1995. The pattern of this
decrease11,12 is suggestive of increases in prenatal diagnosis and termination of
affected pregnancies, coupled with improvements in the care of infants with
congenital anomalies. Figure 2 shows categories of congenital anomalies which
recorded substantially fewer infant deaths in recent years. Regional differences in
rates of infant death due to congenital anomalies are pronounced, however.11
Chapter 4 presents data on neural tube defects in Canada, an area of particular
interest from the perinatal surveillance standpoint, given recent initiatives related
to food fortification with folic acid.13
Multiple Births
Multiple births have become an issue of increasing concern in Canada in recent
years for two reasons: a substantial increase in the frequency of multiple births
and in the rates of preterm birth among multiple birth pregnancies. Both changes
are part of a long-standing trend, although the increase in frequency has
accelerated in recent years (Figure 3). The frequency of multiple births increased
in Canada from 18.2 per 1,000 total births in 1974 to 19.3 in 1980,14 20.8 in 1990
and 25.0 per 1,000 total births in 1997 (see chapter 4).
xvii
Canadian Perinatal Health Report, 2000
Infant mortality
due to major
congenital
anomalies
decreased
significantly
from 3.1 per
1,000 live births
in 1985 to
1.9 per 1,000
live births in
1995.
Overview
Trends in infant mortality rates due to selected congenital anomalies,
Canada (excluding British Columbia, Ontario and Newfoundland), 1981-1983 and 1993-1995
FIGURE 2
Infant deaths per 1,000 live births
1993-1995
1981-1983
1.2
1.0
0.8
0.6
0.4
0.2
0.0
Anencephaly
Other CNS
Spina bifida
Respiratory
Cardiovascular
Musculoskeletal
Digestive
Chromosomal
Urinary
Multiple
Type of congenital anomaly
Source: Wen et al., 2000.12
CNS — central nervous system.
Rates of twin and triplet births (live and stillbirths),*
Canada, 1974-1997
FIGURE 3
Twins
Triplets
25
23
90
70
21
50
19
30
10
17
1974
1976
1978
1980
1982
1984
1986
1988
1990
1992
1994 1996 1997
Calendar year
Source: Statistics Canada. Canadian Vital Statistics System, 1974-1997.
* Rates of twin births are expressed per 1,000 total births (primary y-axis), while triplet births are per 100,000 total
births (secondary y-axis).
xviii
Canadian Perinatal Health Report, 2000
Triplets per 100,000 total births
Twins per 1,000 total births
110
Overview
The increase in the frequency of multiple births in Canada is paralleled by
similar increases in other industrialized countries and is associated with increases
in the proportion of older mothers and in infertility treatments, including
pharmacologic treatments and in vitro fertilization. Insofar as these trends
represent an increase in choice for women with regard to fertility and timing of
pregnancy, they constitute a triumph of science and medicine. However, multiple
births are associated with higher rates of fetal and infant mortality.15-18 Serious
morbidity is also higher among twins and triplets; cerebral palsy rates among
triplets and twins are estimated to be 47 times and eight times higher,
respectively, than among singletons.19 As a result, triplet pregnancies are being
increasingly viewed as a procedure-related complication, and a consensus is
building around limits to the number of embryos transferred per in vitro
fertilization cycle.20,21
The second concern related to multiple births is the increasing rate of preterm
birth among multiple births (Figure 4). Preterm birth among multiple live births
increased from 33% in 1974 to approximately 40% in 1981-1983 and 50% in
1992-1994.22 In 1997, the rate of preterm birth among multiple live births in
Canada (excluding Ontario) was 53.5% (see chapter 4). These increases in preterm
birth are dramatic compared with the modest increase in preterm birth among
singleton live births.22 Preliminary studies carried out by the CPSS suggest that
the increases are due to more preterm labour induction and preterm cesarean
section at 34-36 weeks’ gestation. These, along with various other obstetric and
neonatal interventions, have resulted in reductions in fetal and infant mortality
among multiple births. Nevertheless, live births at 34-36 weeks’ gestation
continue to contribute substantially to overall infant mortality among both
singleton and multiple births.23
Rate of preterm birth among multiple live births,
Canada,* 1974-1997
FIGURE 4
Preterm births per 100 multiple live births
60
50
40
30
20
10
0
1974
1981-1983
1988-1991 1992-1994
1997
Calendar year
Source: Statistics Canada. Canadian Vital Statistics System, 1974-1997.
* Data from British Columbia, Ontario and Newfoundland are not included for estimates from 1981-1994, and data
from Ontario are not included for 1997 estimate.
xix
Canadian Perinatal Health Report, 2000
The increase in
the frequency of
multiple births
in Canada is
paralleled by
similar increases
in other
industrialized
countries and is
associated with
increases in the
proportion of
older mothers
and in infertility
treatments,
including
pharmacologic
treatments
and in vitro
fertilization.
Overview
Preterm and Postterm Birth
Preterm
birth remains
the most
important
perinatal
challenge
facing
industrialized
countries.
Rates of preterm birth have increased in Canada in recent years, whereas rates of
postterm birth have declined. The increase in preterm birth, from 6.4% of all live
births in 1981 to 7.1% in 1997 (see chapter 4), appears to be related to changes in
multiple births, increases in obstetric intervention and the increasing use of
ultrasound-based measures of gestational age.22,24 Although preterm birth is an
important determinant of perinatal mortality, the recent increases in preterm
birth have been associated with declines in stillbirth rates, suggesting that
obstetric intervention is largely responsible for both the increase in preterm birth
and the decrease in stillbirth.22,24 Another related trend is the improvement in
fetal growth rates; temporal decreases in small-for-gestational-age live births are
also described in chapter 4. These explanations do not alter the higher burden of
illness implied by the increase in preterm birth, however. More importantly, it
underscores our failure to reduce preterm birth, which remains the most
important perinatal challenge facing industrialized countries.25,26
Postterm births have decreased markedly in recent years from 4.3% of total
births in 1988 to 1.8% of total births in 1997 (see chapter 4); this reduction also
appears to be due to obstetric intervention and changes in the modality of
gestational age ascertainment. Elective labour induction is now the recommended
management option for pregnancies over 41 weeks’ gestation.27 Recent Canadian
studies have shown that stillbirth rates beyond term have declined as a result of
increases in such labour induction, without a corresponding increase in cesarean
section rates.28 There appears to be a substantial variation in rates of postterm
birth between provinces/territories, however (see chapter 4).
Maternal Health
Maternal health outcomes are described in chapter 3. The maternal mortality
ratio in Canada reached 4.4 per 100,000 live births in 1993-1997 (from 8.2 per
100,000 live births in 1973-1977) and is currently one of the lowest in the world.
The most common causes of maternal death in Canada are hypertensive
disorders of pregnancy (9.1 per million live births in 1993-1997), pulmonary
embolism (8.6 per million live births in 1993-1997), antepartum and postpartum
hemorrhage (6.9 per million live births in 1993-1997) and ectopic pregnancy (4.8 per
million live births in 1993-1997). The relative rarity of maternal death suggests
the need for an alternative indicator of maternal health. Chapter 3 also examines issues
surrounding severe maternal morbidity, as well as the rate of maternal readmission
following hospital discharge after childbirth. Rates of maternal readmission
following vaginal delivery (within three months after hospital discharge for
reasons such as postpartum hemorrhage, cholelithiasis, puerperal infection, etc.)
remained stable between 1990 and 1997 at approximately 2.5 per 100 deliveries.
Maternal readmission rates following cesarean delivery increased slightly from 3.2
in 1990 to 3.9 per 100 deliveries in 1997, however. Maternal readmission rates
after childbirth among those delivering by cesarean section have been shown to
be associated with a short hospital stay (< 2 days versus 5 days),29 suggesting that
the practice of sending women home soon after delivery by cesarean section
needs closer examination.
xx
Canadian Perinatal Health Report, 2000
Overview
In 1989, episiotomies were performed on 55% of women who delivered vaginally.
By 1997, this rate had decreased to 25%. Sharply decreasing trends in episiotomy rates
(see chapter 2) are in keeping with recent evidence in the medical literature that
routine use of episiotomy may not be justified and consequent changes in obstetric
practice. Rates of severe perineal lacerations remained stable over this period.
Behaviours and Practices in Pregnancy
A number of behaviours and practices during pregnancy and after childbirth are
outlined in chapter 1. The rate of breastfeeding initiation (and the duration of
breastfeeding) varied widely across Canada, with the highest rates of breastfeeding
initiation present in western parts of the country (58% in Québec versus 89% in
British Columbia). On average, approximately 77% of children born in Canada
in the mid-1990s were breastfed for some duration. The east-to-west gradient
was also apparent in rates of maternal cigarette smoking, with 25% of mothers in
the Atlantic Provinces and Québec smoking during pregnancy, as compared with
19% in British Columbia. Information on alcohol consumption during
pregnancy is also provided in chapter 1. Also documented are increasing rates of
birth among older mothers and relatively low and stable rates of live births to
teenage mothers.
Health Service Issues
Labour induction, operative vaginal delivery and cesarean section rates are
presented in chapter 2. The recent increase in cesarean section rates (from 17.8%
in 1994 to 19.1% in 1997) was due to increases in primary cesarean section rates,
and an argument is made in chapter 2 that examining trends in crude rates of
cesarean section is helpful only if changes in parity and maternal age are considered
simultaneously. The rate of operative vaginal delivery varied widely between the
provinces and territories in 1997. Forceps deliveries ranged from a low of less
than 3 per 100 vaginal deliveries in hospitals in the territories and in Manitoba to
a high of about 8 per 100 vaginal deliveries among hospitals in New Brunswick,
Newfoundland, Nova Scotia and Ontario. Vacuum deliveries were least common
in the Northwest Territories, Nova Scotia and Prince Edward Island (4-5 per 100
vaginal deliveries in hospital), and most frequent in Saskatchewan and the Yukon
(14-15 per 100 vaginal deliveries in hospital).
Substantial changes in health care services have occurred in Canada in recent
years, including reductions in the neonatal and maternal length of hospital stay
following childbirth. The proportion of newborns and mothers discharged from
hospital after a short stay following birth, trends over time and interprovincial/
territorial variations have been described previously,30,31 and updates are presented
in chapter 2. In 1997, approximately 29% of normal birth weight newborns were
discharged from hospital within two days following birth (up from 3.1% in
1989). Similarly, short hospital stays for mothers have also increased following
both vaginal delivery (3.2% stayed < 2 days in 1989 versus 25.6% in 1997) and
delivery by cesarean section (2.1% stayed < 4 days in 1989 versus 25.6% in 1997).
The consequences of these trends in terms of changes in readmission rates for
mothers and babies have also been documented previously,32,33 and recent
information is presented in chapters 3 and 4.
xxi
Canadian Perinatal Health Report, 2000
The rate of
breastfeeding
initiation (and
the duration of
breastfeeding)
varies widely
across Canada,
with the highest
rates of
breastfeeding
initiation present
in Western parts
of the country.
On average,
approximately
77% of children
born in Canada
in the mid-1990s
were breastfed
for some
duration.
Overview
A Framework for Action
Benchmarking as a Strategy for Improving Perinatal Health
Although the
current state
of perinatal
health in
Canada is
better than it
has been in
previous years,
some disparities
between
subpopulations
persist. Despite
access to
universal health
care, socioeconomic status
remains a
determinant of
perinatal health.
A framework of surveillance which uses benchmarking to identify rates of excess
mortality and direct public health efforts is described in chapter 4. The premise
is that if one segment of the population has achieved a high standard of health in
a particular domain, improvements in that dimension of health are possible for
other populations as well. Benchmark rates of birth weight-specific fetal and
infant mortality were estimated among mothers in Québec who had high levels
of education (since education is known to positively influence perinatal
outcomes).34 The benchmark population chosen was identified within Québec,
as it was the only province with information on the educational status of all
mothers. Birth weight-specific rates of fetal and infant mortality were then
calculated for each province and territory and compared with the benchmark to
identify excess rates of mortality. The categorization of deaths by birth weight
and age at death permits broad generalizations to be made about the particular
components of maternal and child health that may be responsible for excess
mortality (e.g., maternal care versus newborn care).
The appeal of this approach to surveillance is that it provides the health
system with a clear direction for decentralized program evaluation, program
planning and public health action. For instance, high rates of fetal mortality
among births ≥ 1,500 g in a province/territory (relative to the benchmark) suggest
that maternal care issues need to be examined in that region. The excess fetal
deaths could be indicative of problems with timely access to high quality obstetric
care (especially in rural areas). However, excess mortality may also be due to other
factors, including differences in rates of specific behaviours in pregnancy. A
careful investigation can build on the information in this report, identify the
issues responsible for excess mortality in a region and help direct public health
policy so that it has maximum impact on the subpopulation most in need of
attention.
Areas of Perinatal Health Concern
Although the current state of perinatal health in Canada is better than it has been
in previous years, some disparities between subpopulations persist. Despite universal
health insurance, socioeconomic status remains a determinant of perinatal health.
Infant mortality rates among the lowest income groups in urban Canada were
two-fold higher than infant mortality rates among the highest income groups in
1971.35 This difference appears to have been slightly attenuated but not eliminated
two decades later; low income groups experienced a 1.6 times greater risk of
infant death compared with high income groups in 1991.36
Perinatal health among the First Nations, Métis and Inuit populations needs
particular attention. The rates of stillbirth and perinatal mortality among
registered Indians have been estimated to be about double the Canadian average,
while rates among the Inuit in the Northwest Territories are about two and a half
times the rates for Canada as a whole.37 Similarly, infant mortality rates among
registered Indians and the Inuit were estimated to be approximately 14 and 20 per
1,000 live births, respectively (while infant mortality rates were 7 per 1,000 live
births for Canada as a whole).37 Studies have shown38 that deaths due to sudden
infant death syndrome among First Nations infants (relative to other infants)
were five times higher in British Columbia and 10 times as high in Alberta.
xxii
Canadian Perinatal Health Report, 2000
Overview
Addressing these perinatal disparities represents a challenge for Canada (“a test
of its national character”)39 for various reasons, including the need to delineate the
proper approach to health promotion in the context of Aboriginal culture and
empowerment.39
Crude infant mortality rates in Saskatchewan have shown an unexpected
trend over the last decade, increasing from 7.6 (95% confidence interval 6.4 to
9.1) per 1,000 live births in 199040 to 8.9 (95% confidence interval 7.3 to 10.6)
per 1,000 live births in 1997 (see chapter 4). Rates in Canada as a whole declined
from 6.8 to 5.5 per 1,000 live births over the same period. However, this phenomenon
was identified at an early stage and provincial initiatives to address this issue are
under way in Saskatchewan.
Regional differences in the use of various medical procedures (i.e., interprovincial/territorial differences in the use of forceps/vacuum, differences in rates
of postterm birth, etc.) require consideration from the obstetric community, as
well as further study. Temporal trends of concern include small but significant
increases in neonatal hospital readmission and maternal hospital readmission
following childbirth by cesarean section. These trends imply that the policy towards
short hospital stays for mothers and newborns needs to be refined through
improved routine assessment of patients prior to hospital discharge.
Maternal smoking, alcohol consumption during pregnancy and breastfeeding
initiation/duration are priority areas of social and public health concern. The
absolute rates of these indicators and regional differences in rates underscore the
need for additional supportive public health programs designed to inform women
about the effects of particular behaviours in pregnancy. Beyond providing
information and creating a social climate which encourages healthy behaviours,
public health programs also face the challenge of supporting and helping women
who are addicted to harmful behaviours.
Areas for Improvement in Perinatal Health Surveillance
Much of the information in this report provides a generally accurate picture of
the current perinatal health situation in Canada. For example, the relatively high
rate of postterm birth in Nova Scotia in 1997 (4.7% of total births; see chapter 4)
obtained from the Discharge Abstract Database (DAD) of the Canadian Institute
for Health Information (CIHI) concurs with a similar rate obtained from the
Nova Scotia Atlee Perinatal Database (4.2% of all deliveries).41
Some of the regional variation identified in this report may be due to chance
or differences in data quality, however. Sifting through the information,
correlating it with regional information from other sources and identifying
potential errors will, over time, help to improve the quality of perinatal
surveillance in Canada. We have completed a preliminary examination of the
discrepancy between rates of respiratory distress syndrome (RDS) in Nova Scotia
obtained from CIHI data (10.7 per 1,000 live births in 1997, see chapter 4) and
from the Nova Scotia Atlee Perinatal Database (18.2 per 1,000 live births in
1997).41 A validation study of CIHI data and a closer examination of potential
discrepencies in information are under way.
This report clearly identifies several areas where surveillance information is
insufficient for the purpose of quantifying and fully understanding the state of
perinatal health in this country. Inadequacies include areas where little or no
information is available for Canada as a whole (e.g., on the use of assisted
reproduction), areas where routine information is not collected (e.g., parity in
xxiii
Canadian Perinatal Health Report, 2000
Efforts are
being made
to increase
the content
of national
vital statistics
and hospital
discharge
databases so
as to better
serve perinatal
health
surveillance.
The ultimate
goal of these
efforts is the
creation of
a national
database
that captures
information
critical for
perinatal
surveillance in a
timely manner.
Overview
A system of
high quality
perinatal
health
surveillance
is critical to
understanding
and improving
perinatal
health.
relation to cesarean section rates, on behaviours and experiences in pregnancy
and in the postpartum period, including maternal drug use and postpartum
depression) and areas where the quality of routine information is inadequate (e.g.,
the province of Ontario in previous years). The lack of routine surveillance
information on Aboriginal Canadians also indicates a serious gap in the current
system of perinatal health surveillance in Canada.
The CPSS is attempting to address some of these shortcomings through
various initiatives. Efforts are being made, in conjunction with Statistics Canada
and the CIHI, to increase the content of national vital statistics and hospital
discharge databases so as to better serve perinatal health surveillance. The
ultimate goal of these efforts is the creation of a national database that captures
information critical for perinatal surveillance in a timely manner. Another
initiative involves conducting regular surveys in order to document important
behaviours and practices during pregnancy. Efforts are also ongoing, in conjunction
with Statistics Canada and the First Nations and Inuit Health Branch of Health
Canada, to develop a national system which routinely reports on First Nations
and Inuit fetal and infant mortality. The creation of a common perinatal clinical
record for collecting standardized information across Canada is also a long-term
goal. However, these initiatives should be viewed as complementary to regional
efforts to improve data quality and increase the amount of detailed information
collected. Such independent efforts will allow regional health systems to identify
local issues more quickly, explore areas of regional concern and better respond to
disparities identified by national level surveillance.
Conclusion
This surveillance report highlights various components of perinatal health in
Canada. By identifying trends over recent years and reporting on regional
differences, it provides useful information that can be utilized by practitioners
and policy makers to further improve perinatal health. The report also highlights
gaps in perinatal health information. Although efforts are under way to address
these deficiencies, this report will spur on greater progress in data collection,
analysis and interpretation by highlighting both the strengths and weaknesses of
perinatal health surveillance in Canada.
A system of high quality perinatal health surveillance is critical to understanding and improving perinatal health. Although the information presented in
this report confirms the enviable status of perinatal health in Canada from a global
perspective, several specific areas of perinatal health are identified as needing
further support. Both public health programs and those working in the field of
perinatal health will benefit from the information contained in this report.
K.S. Joseph, MD, PhD
Assistant Professor
Perinatal Epidemiology Research Unit
Departments of Obstetrics and Gynecology and Pediatrics
Dalhousie University, Halifax, Nova Scotia
Member, Steering Committee of the Canadian Perinatal Surveillance System
xxiv
Canadian Perinatal Health Report, 2000
Overview
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trimester pregnancy loss in twins? Clin Obstet Gynecol 1998; 41: 37-45.
Petterson B, Nelson KB, Watson L, Stanley F. Twins, triplets, and cerebral palsy in births
in Western Australia in the 1980’s. Br Med J 1993; 307: 1239-43.
Fisk NM, Trew G. Two’s company, three’s a crowd for embryo transfer. Lancet 1999; 354:
1572-3.
Society of Obstetricians and Gynaecologists of Canada. The SOGC consensus statement
on the management of twin pregnancies. Part two: Report of focus group on impact of twin
pregnancies. Barrett J. (Ed.). (Available: www.sogc.org/multiple/sogcconsensus.htm)
Joseph KS, Kramer MS, Marcoux S, Ohlsson A, Wen SW, Allen A et al. Determinants of
preterm birth rates in Canada from 1981 through 1983 and from 1992 through 1994.
N Engl J Med 1998; 339: 1434-9.
xxv
Canadian Perinatal Health Report, 2000
Overview
23. Kramer MS, Demissie K, Yang H, Platt RW, Sauve R, Liston R for the Fetal and Infant
Health Study Group of the Canadian Perinatal Surveillance System. The contribution of
mild and moderate preterm birth to infant mortality. J Am Med Assoc 2000; 284: 843-9.
24. Kramer MS, Platt R, Yang H, Joseph KS, Wen SW, Morin L et al. Secular trends in preterm
birth: A hospital-based cohort study. J Am Med Assoc 1998; 280: 1849-54.
25. Morrison JC. Preterm birth: a puzzle worth solving. Obstet Gynecol 1990; 76: 5S-12S.
26. Creasy RK, Merkatz IR. Prevention of preterm birth: clinical opinion. Obstet Gynecol
1990; 76: 2S-4S.
27. Crowley P. Interventions for preventing or improving the outcome of delivery at or
beyond term (Cochrane Review). In: The Cochrane Library, Issue 1. Oxford: Update
Software, 2000.
28. Sue-A-Quan AK, Hannah ME, Cohen MM, Foster GA, Liston RM. Effect of labour
induction on rates of stillbirth and cesarean section in post-term pregnancies. Can Med
Assoc J 1999; 160: 1145-9.
29. Liu S, Heaman M, Kramer MS, Demissie K, Turner L for the Maternal Mortality and
Morbidity Study Group of the Canadian Perinatal Surveillance System. Association between
length of hospital stay, obstetric conditions at childbirth, and maternal rehospitalization
[submitted for publication].
30. Wen SW, Liu S, Marcoux S, Fowler D. Trends and variations in length of hospital stay for
childbirth in Canada. Can Med Assoc J 1998: 158: 875-80.
31. Wen SW, Liu S, Fowler D. Trends and variations in neonatal length of in-hospital stay in
Canada. Can J Public Health 1998; 89: 115-9.
32. Liu S, Wen SW, McMillan D, Trouton K, Fowler D, McCourt C. Increased neonatal
readmission rate associated with decreased length of hospital stay at birth in Canada. Can
J Public Health 2000; 91: 46-50.
33. Liu S, Heaman M, Demissie K, Wen SW, Marcoux S, Kramer MS. Association between
maternal readmission and obstetric conditions at childbirth: a case-control study.
Presented at the 13th Annual Meeting of the Society for Pediatric and Perinatal
Epidemiologic Research, Seattle, Washington, June 2000.
34. Chen J, Fair M, Wilkins R, Cyr M and the Fetal and Infant Mortality Study Group of the
Canadian Perinatal Surveillance System. Maternal education and fetal and infant
mortality in Quebec. Health Rep 1998; 10: 53-64.
35. Wilkins R, Adams O, Branker A. Changes in mortality by income in urban Canada from
1971 to 1986. Health Rep 1989; 1: 137-74.
36. Wilkins R. Mortality by neighbourhood income in urban Canada, 1986-1991. Presentation
at the Canadian Society for Epidemiology and Biostatistics, Newfoundland, Canada,
August 1995.
37. Final Report of the Royal Commission on Aboriginal Peoples. Ottawa, 1996. (Available:
www.inac.gc.ca/ch/rcap/index_e.html).
38. SIDS Fact Sheet. Assembly of First Nations. National Indian Brotherhood 2000. (Available:
www.afn.ca/Programs/Health%20Secretariat/sids_fact_sheet.htm).
39. Postl B. Native health: it’s time for action. Can Med Assoc J 1997; 157: 165-6.
40. Canadian Centre for Health Information. Births 1990. Ottawa: Statistics Canada, 1992
(Catalogue No. 82-003S14).
41. Reproductive Care Program of Nova Scotia. Nova Scotia Atlee Perinatal Database Report:
Maternal and Infant Discharges from January 1-December 31, 1997. Halifax: 2000.
xxvi
Canadian Perinatal Health Report, 2000
A
Determinants
of Maternal,
Fetal and
Infant Health
1
Behaviours and Practices
Prevalence of Prenatal Smoking
he prevalence of prenatal smoking is defined as the number of pregnant
women who smoked cigarettes during pregnancy expressed as a proportion
of all pregnant women (in a given place and time).
Prenatal cigarette smoking can have adverse health effects on the fetus and
child. It increases the risk of intrauterine growth restriction (IUGR), preterm
birth, spontaneous abortion and stillbirth.1-4 It also increases the risk of sudden
infant death syndrome and has been associated with impaired physical and
intellectual development of the child. Prenatal smoking is related to an overall
increased risk of infant mortality and morbidity, due in part to increases in IUGR
and preterm birth.
The relationship between prenatal smoking and adverse pregnancy outcomes
is linked to the amount and duration of smoking. Women who stop smoking
before becoming pregnant or during the first trimester of pregnancy are at
significantly reduced risk of having a low birth weight baby compared with
women who smoke throughout pregnancy.4 Although pregnant women are more
likely to quit smoking and smoke fewer cigarettes than women who are not pregnant,
prenatal smoking remains an important public health problem. It is important to
continue to promote non-smoking among women in general, and to help smoking
women who become pregnant to stop smoking as early as possible.
Since there are no data on prenatal smoking for all pregnancies in Canada,
rates were estimated using the 1996-1997 National Longitudinal Survey of Children
and Youth (NLSCY).
T
Results
•
•
•
In Canada in 1996-1997, 21.3% of children under the age of three had
mothers who reported smoking during their pregnancy. Seven percent
reported smoking more than 10 cigarettes per day. Among smokers, 90.9%
reported smoking in the third trimester of pregnancy, when the negative
effect on fetal growth is greatest.
Younger mothers were more likely to report smoking. In 1996-1997, 40.5%
(this estimate was based on a small sample) of children whose mothers were
under 20 years of age were exposed to tobacco prenatally, compared with
17.2% of children whose mothers were 35 years or older (Figure 1.1). This
inverse relationship between smoking and age is also present in the general
(non-pregnant) Canadian female population.
Reported rates of prenatal smoking varied by region. Rates ranged from lows
of 18.6% and 18.8% in British Columbia and Ontario, respectively, to highs
of 25.8% in Québec and 25.2% in the Atlantic Provinces (Figure 1.2).
3
Canadian Perinatal Health Report, 2000
Although
pregnant
women are
more likely to
quit smoking
and smoke
fewer cigarettes
than women
who are not
pregnant,
prenatal
smoking
remains an
important
public health
problem.
Behaviours and Practices
FIGURE 1.1
Prevalence of prenatal smoking, by maternal age,
Canada (excluding the territories),* 1996-1997
All ages
21.3%
< 20**
40.5%
20-24
33.5%
25-29
24.5%
30-34
16.9%
≥ 35
17.2%
Percent of children 0-3 years old whose mothers reported smoking prenatally
Source: Statistics Canada. National Longitudinal Survey of Children and Youth (Public Use Microdata Files), 1996-1997.
* Data for the territories are not available in the Public Use Microdata Files.
** Estimate for this age group is based on a small sample size.
FIGURE 1.2
Prevalence of prenatal smoking, by region/province,
Canada (excluding the territories),* 1996-1997
Atlantic Provinces
25.2%
Québec
Ontario
25.8%
18.8%
Prairie Provinces
British Columbia
21.0%
18.6%
21.3%
CANADA*
Percent of children 0-3 years old whose mothers reported smoking prenatally
Source: Statistics Canada. National Longitudinal Survey of Children and Youth (Public Use Microdata Files), 1996-1997.
* Data for the territories are not available in the Public Use Microdata Files.
4
Canadian Perinatal Health Report, 2000
Behaviours and Practices
Data Limitations
The knowledge that smoking during pregnancy can adversely affect the outcome
of the pregnancy may have led mothers to under-report their smoking behaviour
during pregnancy.5 Therefore, rates of prenatal smoking in Canada are probably
higher than those reported in the NLSCY.
References
1.
2.
3.
4.
5.
Edwards N, Sims-Jones N, Hotz S. Pre and Postnatal Smoking: A Review of the Literature.
Ottawa: Health Canada, 1996.
Werler MM. Teratogen update: smoking and reproductive outcomes. Teratology 1997; 55:
382-8.
Tuormaa TE. The adverse effects of tobacco smoking on reproduction and health: a review
from the literature. Nutr Health 1995; 10: 105-20.
U.S. Department of Health and Human Services. The Health Benefits of Smoking Cessation.
U.S. Department of Health and Human Services, Public Health Service, Centers for
Disease Control, Center for Chronic Disease Prevention and Health Promotion, Office of
Smoking and Health, 1990 (DHHS Publication No. (CDC) 90-8416).
Patrick DL, Cheadle A, Thompson DC, Diehr P, Koepsell T, Kinne S. The validity of selfreported smoking: a review and meta analysis. Am J Public Health 1994; 84: 1086-93.
5
Canadian Perinatal Health Report, 2000
Behaviours and Practices
Prevalence of Prenatal Alcohol Consumption
he prevalence of prenatal alcohol consumption is defined as the number of
pregnant women who consumed alcoholic beverages during pregnancy
expressed as a proportion of all pregnant women (in a given place and time).
Prenatal alcohol consumption can result in alcohol-related birth defects
(ARBD). ARBDs exhibit a continuum of severity, with spontaneous abortion,
intrauterine growth restriction (IUGR) and fetal alcohol syndrome (FAS) being
among the more severe effects.1-3 Other effects include cognitive and behavioural
abnormalities, which can persist into adulthood and significantly impair an
individual’s quality of life. The effects of prenatal alcohol consumption are
thought to depend on a number of factors, including the quantity of alcohol
consumed, the stage(s) during pregnancy when the alcohol is consumed, the
mother’s ability to metabolize alcohol and the genetic makeup of the fetus.1,2
However, since a safe level of alcohol consumption during pregnancy has not
been determined, Health Canada recommends that women abstain from alcohol
consumption if they are pregnant or planning to become pregnant.3
Since there are no data on prenatal alcohol consumption for all pregnancies
in Canada, rates were estimated using the 1996-1997 National Longitudinal
Survey of Children and Youth (NLSCY).
T
In Canada in
1996-1997,
16.6% of
children under
the age of three
had mothers
who reported
drinking
alcohol during
pregnancy.
Results
•
•
•
In Canada in 1996-1997, 16.6% of children under the age of three had
mothers who reported drinking alcohol during pregnancy. This percentage
includes all mothers who reported drinking, regardless of amount. ARBDs are
likely related to chronic, heavy alcohol exposure, rather than low, steady rates
of drinking.4,5 Unfortunately, the proportion of children with chronic, heavy
prenatal alcohol exposure could not be determined reliably using NLSCY data.
Older mothers were more likely to report prenatal alcohol consumption. In
1996-1997, 11.7% of children whose mothers were under 25 years of age were
exposed to some alcohol prenatally compared with 22.6% of children whose
mothers were 35 years and older (Figure 1.3). However, previous studies have
suggested that binge drinking (consumption of five or more drinks per
occasion) may be more prevalent among younger women.6
Reported rates of prenatal alcohol consumption varied by region. Rates
ranged from a low of 7.7% in the Atlantic Provinces (this estimate was based
on a small sample) to a high of 24.9% in Québec (Figure 1.4).
6
Canadian Perinatal Health Report, 2000
Behaviours and Practices
FIGURE 1.3
Prevalence of prenatal alcohol consumption, by maternal age,
Canada (excluding the territories),* 1996-1997
All ages
16.6%
< 25**
11.7%
25-29
14.1%
30-34
16.4%
≥ 35
22.6%
Percent of children 0-3 years old whose mothers reported drinking alcohol prenatally
Source: Statistics Canada. National Longitudinal Survey of Children and Youth (Public Use Microdata Files), 1996-1997.
* Data for the territories are not available in the Public Use Microdata Files.
** Further categorization of age was not possible due to a small sample size.
FIGURE 1.4
Prevalence of prenatal alcohol consumption, by region/province,
Canada (excluding the territories),* 1996-1997
Atlantic Provinces**
7.7%
24.9%
Québec
Ontario
13.8%
Prairie Provinces
16.1%
14.9%
British Columbia
16.6%
CANADA*
Percent of children 0-3 years old whose mothers reported drinking alcohol prenatally
Source: Statistics Canada. National Longitudinal Survey of Children and Youth (Public Use Microdata Files), 1996-1997.
* Data for the territories are not available in the Public Use Microdata Files.
** Estimate for the Atlantic Provinces is based on a small sample size.
Data Limitations
There may be systematic under-reporting of maternal alcohol consumption in
surveys, because prenatal alcohol consumption is considered socially undesirable
and known to incur risk to the fetus.7 Therefore, rates of prenatal alcohol
consumption are probably higher than those reported in the NLSCY.
7
Canadian Perinatal Health Report, 2000
Behaviours and Practices
References
1.
2.
3.
4.
5.
6.
7.
Abel EL (Ed.). Fetal Alcohol Syndrome, from Mechanism to Prevention. New York: CRC
Press, 1996.
Huebert K, Rafts C. Fetal Alcohol Syndrome and Other Alcohol Related Birth Defects, 2nd
Edition. Edmonton: Alberta Alcohol and Drug Abuse Commission, 1996.
Health Canada. Joint Statement: Prevention of Fetal Alcohol Syndrome (FAS), Fetal Alcohol
Effects (FAE) in Canada. Ottawa: Health Canada, October 1996 (Catalogue No. H39348/1996E).
Abel EL. “Moderate” drinking during pregnancy: cause for concern? Clin Chim Acta
1996; 246: 149-54.
Gladstone J, Nulman I, Koren G. Reproductive risks of binge drinking during pregnancy.
Reprod Toxicol 1996; 10: 3-13.
Gladstone J, Levy M, Nulman I, Koren G. Characteristics of pregnant women who engage
in binge alcohol consumption. Can Med Assoc J 1997; 156: 789-94.
Stoler JM, Huntington KS, Peterson CM, Peterson KP, Daniel P, Aboagye KK et al. The
prenatal detection of significant alcohol exposure with maternal blood markers. J Pediatr
1998; 133: 346-52.
8
Canadian Perinatal Health Report, 2000
Behaviours and Practices
Prevalence of Breastfeeding
he prevalence of breastfeeding is defined as the number of women who
delivered and ever breastfed a live born child expressed as a proportion of all
women who delivered a live born child (in a given place and time).
There is compelling evidence that breastfeeding is beneficial to infants and
mothers. Human milk protects the infant from gastrointestinal and respiratory
infections and otitis media, and has also been associated with enhanced cognitive
development.1-3 Beneficial effects for mothers associated with breastfeeding include
reduced postpartum bleeding and delayed resumption of ovulation which helps to
increase the spacing between pregnancies. There is also evidence that lactating
women have improved postpartum bone remineralization and a reduced risk of
ovarian and breast cancers.1,2
Breastfeeding prevalence rates in Canada were estimated using data from the
1996-1997 National Longitudinal Survey of Children and Youth (NLSCY).
T
Results
•
•
•
In Canada in 1996-1997, 76.7% of children under the age of three had been
breastfed for some period of time. Among children between the ages of three
months and three years, 53.6% had been breastfed for at least three months. The
Canadian Paediatric Society (CPS), Dieticians of Canada (DC) and Health
Canada recommend exclusive breastfeeding for at least the first four months of
life, and continuing breastfeeding and complementary foods for up to two years
of age and beyond.2
Breastfeeding initiation rates varied slightly by maternal age. Rates among
mothers 30 years and older were slightly higher compared with rates among
younger mothers (Figure 1.5). Breastfeeding duration also increased with
increasing maternal age. Among children between the ages of three months and
three years, only 31.6% born to mothers less than 20 years of age were breastfed
for at least three months, compared with 59.2% of children whose mothers were
35 years or older.
Breastfeeding initiation varied by region, with rates ranging from a low of 57.7%
in Québec to highs of 89.0% in British Columbia and 88.0% in the Prairie
Provinces (Figure 1.6). Mothers in regions with higher breastfeeding initiation
rates also tended to breastfeed for a longer duration. In Québec, only 34.8% of
children between three months and three years old were breastfed for at least three
months compared with 65.2% in British Columbia.
Data Limitations
The NLSCY did not ask mothers if breastfeeding was exclusive.
9
Canadian Perinatal Health Report, 2000
There is
compelling
evidence that
breastfeeding
is beneficial
to infants
and mothers.
Human milk
protects the
infant from
gastrointestinal
and respiratory
infections and
otitis media,
and has also
been associated
with enhanced
cognitive
development.
Behaviours and Practices
FIGURE 1.5
Prevalence of breastfeeding, by maternal age,
Canada (excluding the territories),* 1996-1997
Ever breastfed
76.7%
All ages
53.6%
Breastfed at least
three months***
72.5%
< 20**
31.6%
70.7%
20-24
38.9%
74.1%
25-29
47.7%
79.4%
30-34
59.1%
78.2%
≥ 35
59.2%
Percent of children 0-3 years old whose mothers reported breastfeeding
Source: Statistics Canada. National Longitudinal Survey of Children and Youth (Public Use Microdata Files), 1996-1997.
* Data for the territories are not available in the Public Use Microdata Files.
** Estimate of the proportion of children breastfed for at least three months is based on a small sample size.
*** Children less than three months old were excluded from “breastfed at least three months” calculations.
FIGURE 1.6
Prevalence of breastfeeding, by region/province,
Canada (excluding the territories),* 1996-1997
65.3%
Atlantic Provinces
Québec
Ever breastfed
40.6%
Breastfed at least
three months**
57.7%
34.8%
81.2%
Ontario
59.2%
88.0%
Prairie Provinces
63.2%
89.0%
British Columbia
65.2%
76.7%
CANADA*
53.6%
Percent of children 0-3 years old whose mothers reported breastfeeding
Source: Statistics Canada. National Longitudinal Survey of Children and Youth (Public Use Microdata Files), 1996-1997.
* Data for the territories are not available in the Public Use Microdata Files.
** Children less than three months old were excluded from “breastfed at least three months” calculations.
10
Canadian Perinatal Health Report, 2000
Behaviours and Practices
References
1.
2.
3.
American Academy of Pediatrics, Work Group on Breastfeeding. Breastfeeding and the use
of human milk. Pediatrics 1997; 100: 1035-9.
Canadian Paediatric Society, Dieticians of Canada and Health Canada. Nutrition for Healthy
Term Infants. Ottawa: Minister of Public Works and Government Services Canada, 1998.
Breastfeeding Committee for Canada. Breastfeeding Statement of the Breastfeeding Committee
for Canada, 1996.
11
Canadian Perinatal Health Report, 2000
Behaviours and Practices
Rate of Live Births to Teenage Mothers
he age-specific live birth rate for teenage mothers is defined as the number of
live births to mothers aged 10-14 or 15-19 years per 1,000 females in the same
age category (in a given place and time). A related indicator is the proportion of
live births to teenage mothers which refers to the number of live births to
mothers aged 10-14 or 15-19 years expressed as a percentage of all live births (in
a given place and time).
Various adverse maternal and infant effects of teenage pregnancy have been
documented in the scientific literature, including biological and social effects.
Typically, teen pregnancies are characterized by delayed entry into prenatal care
and lower rates of prenatal care. Tobacco, alcohol and other substance abuse is
reported to be higher among pregnant adolescents.1 A relatively higher proportion
of teenagers report physical and sexual abuse during pregnancy. Compared with
mothers 20-24 years of age, mothers aged 17 years or less have an increased risk
for delivering babies who are preterm or growth restricted.2 Other adverse
outcomes associated with teen pregnancies include preeclampsia, anemia, urinary
tract infection and postpartum hemorrhage.3
Rates of live births to teenage mothers were calculated using vital statistics data.
T
Compared
with mothers
20-24 years
of age,
mothers aged
17 years or
less have an
increased risk
for delivering
babies who
are preterm
or growth
restricted.
Results
•
•
•
Since 1981, the age-specific live birth rate among teenagers 10-14 years of age
has declined slightly from a high of 0.29 per 1,000 teenagers of the same age
to 0.22 per 1,000 in 1997 (Figure 1.7).
For older teenagers (aged 15-19 years), the age-specific live birth rate showed
peaks in the early 1980s and again in the early 1990s (Figure 1.8). The peak
in the early 1990s was also observed in the U.S.4 Since 1991, the live birth rate
for teens 15-19 years of age has declined to a low of 19.9 births per 1,000
females in 1997.
In 1997, 5.6% of all live births in Canada were to women aged 15-19 years of
age, an absolute decline of 2.5% since 1981 (Figure 1.9). Live births to females
less than 15 years of age account for less than 1% of all live births in Canada.
Data Limitations
Canadian data on maternal age are obtained from birth certificates and are
unstated in a small fraction of records. Late registered births, stillbirths, ectopic
pregnancies and aborted pregnancies are not included in the above statistics.
12
Canadian Perinatal Health Report, 2000
Behaviours and Practices
Age-specific live birth rate, females 10-14 years,
Canada (excluding Newfoundland),* 1981-1997
FIGURE 1.7
Live births per 1,000 females
0.4
0.3 0.29
0.31
0.28
0.25
0.26
0.27
0.24
0.26
0.27
0.29 0.28
0.27
0.24
0.25
0.24 0.23
0.22
0.2
0.1
0.0
1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997
Calendar year
Sources: Statistics Canada. Canadian Vital Statistics System, 1981-1997.
Statistics Canada. Canadian female population estimates, 1981-1997.
* Newfoundland is excluded because data are not available nationally prior to 1991.
Age-specific live birth rate, females 15-19 years,
Canada (excluding Newfoundland),* 1981-1997
FIGURE 1.8
Live births per 1,000 females
30
25.8
25
26.0
24.5
23.9
23.2
24.5
22.9
22.7
25.3 25.7
25.5
22.9
24.9
24.9
24.3
22.1
19.9
20
15
10
5
0
1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997
Calendar year
Sources: Statistics Canada. Canadian Vital Statistics System, 1981-1997.
Statistics Canada. Canadian female population estimates, 1981-1997.
* Newfoundland is excluded because data are not available nationally prior to 1991.
13
Canadian Perinatal Health Report, 2000
Behaviours and Practices
Percent of live births to teenage mothers,
Canada (excluding Newfoundland),* 1981-1997
FIGURE 1.9
Percent of all live births
Mothers aged 10-14 years
Mothers aged 15-19 years
10
8
6
4
2
0
1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997
Calendar year
Source: Statistics Canada. Canadian Vital Statistics System, 1981-1997.
* Newfoundland is excluded because data are not available nationally prior to 1991.
References
1.
2.
3.
4.
Huizinga D, Loeber R, Thornberry TP. Longitudinal study of delinquency, drug use,
sexual activity and pregnancy among children and youth in three cities. Public Health Rep
1993; 108 (S1): 90-6.
Fraser AM, Brockert JE, Ward RH. Association of young maternal age with adverse
reproductive outcomes. N Engl J Med 1995; 332: 1113-7.
Miller HS, Lesser KB, Reed KL. Adolescence and very low birth weight infants:
A disproportionate association. Obstet Gynecol 1996; 87: 83-8.
Ventura SJ, Martin JA, Curtin SC, Mathews TJ. Births: Final Data for 1997. National vital
statistics reports; vol 47, no. 18. Hyattsville, Maryland: National Center for Health
Statistics, 1999.
14
Canadian Perinatal Health Report, 2000
Behaviours and Practices
Rate of Live Births to Older Mothers
he age-specific live birth rate for older mothers is defined as the number of
live births to women aged 30-34, 35-39, 40-44 or 45 years and older per 1,000
women in the same age category (in a given place and time). A related indicator
is the proportion of live births to older mothers which refers to the number of
live births to mothers aged 30-34, 35-39, 40-44 or 45 years and older expressed as
a percentage of all live births (in a given place and time).
The proportion of women who are delaying childbearing to later years has
increased markedly in Canada in recent years. There is some evidence that this
may be associated with adverse outcomes to both mother and infant. For example,
the frequency of Down’s syndrome increases with advancing maternal age from less
than 1 per 1,000 births at age 20 years to 2.5-3.9 per 1,000 at age 35 years, 8.5-13.7
per 1,000 at age 40 years and 28.7-52.3 per 1,000 births at age 45 years.1
Antepartum complications shown to be associated with delayed childbearing
include increased risks for spontaneous abortion, gestational diabetes,
prepregnancy diabetes mellitus, hypertension, other chronic medical conditions,2
preeclampsia, placenta previa and prenatal hospital admission.3 Labour complications shown to increase with advanced maternal age include malpresentation,
cephalopelvic disproportion, protraction and arrest disorders, intrapartum decelerations, prolonged second stage labour,2 operative deliveries3 and postpartum
hemorrhage.
Studies have shown that babies of older mothers are at increased risk for
preterm birth, small for gestational age, low one-minute apgar scores and admission
to newborn intensive care. Some recent evidence suggests, however, that older
women with prudent health behaviours (e.g., smoking abstinence) who receive
good quality obstetric care are not at increased risk for complications such as
preterm birth and small for gestational age.2,4
Rates of live births to older mothers were calculated using vital statistics data.
T
Results
•
•
The live birth rate among older mothers increased steadily between 1981 and
1997. Among women aged 30-34 years, the rate increased from 66.9 per 1,000 in
1981 to 84.9 per 1,000 in 1997 (Figure 1.10). Similarly, increases in rates were
observed for older age groups (for example, for women aged 40-44 years, the
rate increased from 3.2 in 1981 to 5.3 per 1,000 in 1997) (Figure 1.11).
The proportion of live births to older mothers has also been steadily increasing
over the past 17 years. In 1997, 30.2% of all live births in Canada were to
women aged 30-34 years, while women aged 35-39 years accounted for 12.4%,
and women 40 years and older accounted for 1.9%. In 1981, these percentages
were 18.8%, 4.3%, and 0.6%, respectively (Figure 1.12).
15
Canadian Perinatal Health Report, 2000
The proportion
of women who
are delaying
childbearing to
later years has
increased
markedly in
Canada in recent
years. There is
some evidence
that this may
be associated
with adverse
outcomes to
both mother
and infant.
Behaviours and Practices
Age-specific live birth rate, females 30-39 years,
Canada (excluding Newfoundland),* 1981-1997
FIGURE 1.10
Live births per 1,000 females
Mothers aged 30-34 years
Mothers aged 35-39 years
100
80
60
40
20
0
1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997
Calendar year
Source: Statistics Canada. Canadian Vital Statistics System, 1981-1997.
* Newfoundland is excluded because data are not available nationally prior to 1991.
Age-specific live birth rate, females 40-49 years,
Canada (excluding Newfoundland),* 1981-1997
FIGURE 1.11
Live births per 1,000 females
Mothers aged 40-44 years
Mothers aged 45-49 years
6
5
4
3
2
1
0
1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997
Calendar year
Source: Statistics Canada. Canadian Vital Statistics System, 1981-1997.
* Newfoundland is excluded because data are not available nationally prior to 1991.
16
Canadian Perinatal Health Report, 2000
Behaviours and Practices
Percent of live births to older mothers (≥ 30 years),
Canada (excluding Newfoundland),* 1981-1997
FIGURE 1.12
Percent of all live births
50
Mothers aged:
30-34 years
40
35-39 years
≥ 40 years
30
20
10
0
1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997
Calendar year
Source: Statistics Canada. Canadian Vital Statistics System, 1981-1997.
* Newfoundland is excluded because data are not available nationally prior to 1991.
Data Limitations
Canadian data on maternal age are obtained from birth certificates and are
unstated in a small fraction of records. Late registered births, stillbirths, ectopic
pregnancies and pregnancies that end in abortion are not included in the above
statistics.
References
1.
2.
3.
4.
Hook EB. Rates of chromosomal abnormalities at different maternal ages. Obstet Gynecol
1981; 58: 282-5.
Berkowitz GS, Skovron ML, Lapinski RH, Berkowitz RL. Delayed childbearing and the
outcome of pregnancy. N Engl J Med 1990; 322: 659-64.
Leyland AH, Boddy FA. Maternal age and outcome of pregnancy. N Engl J Med 1990;
323: 413-4.
Prysak M, Lorenz RP, Kisly A. Pregnancy outcome in nulliparous women 35 years and
older. Obstet Gynecol 1995; 85: 65-70.
17
Canadian Perinatal Health Report, 2000
2
Health Services
Labour Induction Rate
he labour induction rate is defined as the number of delivering women whose
labour was induced by medical or surgical means (prior to the onset of
labour) expressed as a proportion of all delivering women (in a given place and time).
Induction is an obstetric intervention associated with potential risks to both
mother and fetus, including neonatal immaturity, uterine hyperstimulation, and
prolonged labour.1 In certain situations, the risks of continuing pregnancy for
either mother or fetus will outweigh the risks associated with induction.
Indications for labour induction include placental insufficiency (intrauterine
growth restriction (IUGR)), poorly-controlled diabetes, insulin-requiring diabetes,
prolonged rupture of membranes, postdatism, severe pre-eclampsia and renal
failure.1
Labour induction rates were estimated using hospitalization data. Ideally,
induction rates would include both medical and surgical methods of induction.
However, the data presented are limited to medical induction for the following
reasons: it is difficult to distinguish between induction and augmentation when
considering surgical methods, only a small proportion of all inductions are
completed with surgical methods alone, and some jurisdictions only record
medical methods in their data.
T
Results
•
•
In 1997, the labour induction rate was 18.5% in Canada. This rate is based on
cases with a Canadian Classification of Diagnostic, Therapeutic and Surgical
Procedures (CCP) code of medical induction and is consistent with the rate
of 10%-25% previously estimated by the Society of Obstetricians and
Gynaecologists of Canada (SOGC).2
Labour induction rates varied substantially among Canadian provinces and
territories, from a low of 10.4% in the Northwest Territories to a high of
22.1% in Alberta (Figure 2.1). These regional differences may be due in part
to variations in clinical practice.
19
Canadian Perinatal Health Report, 2000
Labour
induction
rates varied
substantially
among
Canadian
provinces
and territories,
from a low of
10.4% in the
Northwest
Territories to a
high of 22.1%
in Alberta.
Health Services
FIGURE 2.1
Labour induction rate, by province/territory,
Canada (excluding Québec),* 1997-1998
Newfoundland
Prince Edward Island
Nova Scotia
New Brunswick
Ontario
Manitoba
Saskatchewan
Alberta
British Columbia
Yukon
Northwest Territories
CANADA*
0
5
10
15
20
25
Inductions (95% CI) per 100 hospital deliveries
Sources: Canadian Institute for Health Information. Discharge Abstract Database, 1997-1998.
Manitoba Health, Epidemiology Unit. Perinatal Surveillance Database, 1997-1998.
* Québec data are not included in the Discharge Abstract Database (DAD).
CI — confidence interval.
Data Limitations
Limitations in identifying the proportion of delivering women with induced
labour relate to errors in identifying whether the labour was induced or whether
existing labour was augmented. Augmentation is defined as the use of medical or
surgical means to enhance labour that has already begun spontaneously.
References
1.
2.
Keirse MJNC, Chalmers I. Methods of inducing labor. In: Chalmers I, Enkin M, Keirse
MJNC (Eds.), Effective Care in Pregnancy and Childbirth. Oxford: Oxford University Press,
1989.
Society of Obstetricians and Gynaecologists of Canada. Induction of Labour, SOGC Clinical
Practice Guidelines for Obstetrics, Number 23. Ottawa: SOGC, 1996.
20
Canadian Perinatal Health Report, 2000
Health Services
Cesarean Section Rate
he cesarean section (CS) rate is defined as the number of deliveries by CS
expressed as a percentage of the total number of deliveries (in a given place
and time). The primary CS rate is the number of cesarean deliveries to women
who have not previously had a cesarean delivery expressed as a percentage of all
deliveries to women who have not had a cesarean delivery previously. This rate
includes primiparas (i.e., women giving birth for the first time) and multiparas
(i.e., women who have given birth one or more times previously) who have not
had a cesarean delivery previously. The repeat CS rate is the number of cesarean
deliveries to women who have had a cesarean delivery previously expressed as a
percentage of all deliveries to women who have had a previous cesarean delivery.
The proportion of women delivered by CS increased from approximately
5% to nearly 20% in Canada and the United States between the late 1960s and the
early 1980s.1 In Canada today, nearly 20% of births are cesarean births.2 While
this seemingly high rate continues to be of concern because of the potentially
increased risks to the mother and the additional costs and lengths of hospital stay
associated with cesarean delivery, the rate has remained at the same level — 18%
to 19% — for approximately 15 years in spite of efforts to lower it.2,3 The main
strategies to lower the CS rate in Canada have been the establishment of clinical
guidelines for CS and efforts to encourage women who have had a previous cesarean
delivery to attempt a vaginal delivery (or “VBAC,” vaginal birth after cesarean).4-9
CS rates were estimated using hospitalization data.
T
Results
•
•
•
Between 1994 and 1997, the CS rate increased from 17.8% to 19.1% (Table
2.1). This increase is due to an increase in the primary CS rate, which was
more pronounced among women 25 years and older than among younger
women (Figure 2.2).
Primiparous women are more likely to require cesarean delivery than women
having their second or third birth who have not had a cesarean delivery
previously. Data from Statistics Canada for 1994 to 1997 indicate an increase
in the percentage of first births among women aged 25-34 years and 35 years and
older (Table 2.2). The percentage of first births to women less than 25 years
old did not increase during the same period. Slight increases in the percentage
of first births to women in the two older age groups is a possible explanation for
the larger increase in the primary CS rate in these two age groups.
The proportion of women who have had a previous cesarean delivery
increased from 9.3% to 10.0% between 1994 and 1997 (Table 2.1). This may
be a function of an increasing tendency to record previous cesarean delivery
on hospital discharge abstracts rather than a real increase in the proportion
of women who have had a previous cesarean delivery. The rate of repeat
cesareans decreased somewhat during this time period. Recent efforts to
increase the rate of VBAC, as a primary strategy to reduce the rate of cesarean
delivery, may have contributed to this trend.
21
Canadian Perinatal Health Report, 2000
Between 1994
and 1997,
the CS rate
increased from
17.8% to
19.1%. This
increase is due
to an increase
in the primary
CS rate, which
was more
pronounced
among women
25 years and
older than
among younger
women.
Health Services
Cesarean section (CS) rate and percent of women who have
had a previous CS, Canada (excluding Québec, Nova Scotia and Manitoba),*
1994-1995 to 1997-1998
Table 2.1
Year
CS per 100
hospital
deliveries
Primary CS
per 100 hospital
deliveries
Percent of
women with a
previous CS**
Percent of CS
among women
with a previous CS
1994-1995
17.8
12.6
9.3
68.6
1995-1996
18.0
12.8
9.7
66.5
1996-1997
18.6
13.4
9.9
66.5
1997-1998
19.1
13.8
10.0
66.8
Source: Canadian Institute for Health Information. Discharge Abstract Database, 1994-1995 to 1997-1998.
* Québec data are not included in the Discharge Abstract Database (DAD). Nova Scotia and Manitoba
are excluded because complete data for all years are not available in the DAD.
** The observed increase over time in the percent of women with previous cesarean delivery may be
due to an increased tendency to record previous cesarean delivery in the hospital discharge abstract.
Percent of births that were first births,
by maternal age, Canada, 1994-1997
Table 2.2
Mother’s age
Year
< 25
25-34
≥ 35
1994
63.5
38.3
24.7
1995
63.7
38.6
25.0
1996
63.5
38.9
25.5
1997
63.1
39.3
25.6
Source: Statistics Canada. Canadian Vital Statistics System, 1994-1997.
Primary cesarean section (CS) rate, by maternal age,
Canada (excluding Québec, Nova Scotia and Manitoba),* 1994-1995 to 1997-1998
FIGURE 2.2
Cesarean sections per 100 hospital deliveries
20
16.3
16.6
16.8
12.7
12.8
13.5
13.9
11.3
11.3
11.4
11.8
15.3
15
≥ 35 years
25-34 years
< 25 years
10
5
0
1994-1995
1995-1996
1996-1997
1997-1998
Fiscal year
Source: Canadian Institute for Health Information. Discharge Abstract Database, 1994-1995 to 1997-1998.
* Québec data are not included in the DAD. Nova Scotia and Manitoba are excluded because complete data
for all years are not available in the DAD.
22
Canadian Perinatal Health Report, 2000
Health Services
Data Limitations
Because women having their first baby (particularly women having their first
baby at a later age) are at increased risk of cesarean delivery, and because of a
continuing trend for women to delay first births, it is preferable to adjust for both
of these factors when considering trends over time. Adjustment for both age of
mother and parity could not be made, as the latter is not recorded in the DAD.
Another possible limitation is that the denominator used in the calculation of
the above CS rates includes hospital deliveries only. While the number of births
that occur outside of hospital is small, temporal variation in this number could
contribute to variation in CS rates, though any effect is likely small.
Calculation of primary and repeat CS rates using the DAD is not possible
before 1994, as the database did not identify vaginal deliveries after cesarean prior
to 1994.
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
Notzon FC, Placek PJ, Taffel SM. Comparisons of national cesarean-section rates. N Engl
J Med 1987; 316: 386-9.
Millar WJ, Nair C, Wadhera S. Declining cesarean section rates: a continuing trend?
Health Rep 1996; 8: 17-24.
Nair, C. Trends in cesarean deliveries in Canada. Health Rep 1991; 3: 203-19.
Helewa M. Cesarean sections in Canada: what constitutes an appropriate rate? J Soc
Obstet Gynaecol Can 1995; 17: 237-46.
Society of Obstetricians and Gynaecologists of Canada. Dystocia. Society of Obstetricians
and Gynaecologists of Canada Policy Statement. Ottawa: SOGC, 1995.
Society of Obstetricians and Gynaecologists of Canada. Vaginal Birth after a Previous
Cesarean. Society of Obstetricians and Gynaecologists of Canada Policy Statement. Ottawa:
SOGC, 1993.
Society of Obstetricians and Gynaecologists of Canada. The Canadian Consensus Conference
on Breech Management at Term. Society of Obstetricians and Gynaecologists of Canada
Policy Statement. Ottawa: SOGC, 1994.
Society of Obstetricians and Gynaecologists of Canada. Fetal Health Surveillance in Labour,
Parts 1 through 4. Society of Obstetricians and Gynaecologists of Canada Policy Statement.
Ottawa: SOGC, 1995.
Society of Obstetricians and Gynaecologists of Canada. Fetal Health Surveillance in Labour,
Conclusion. Society of Obstetricians and Gynaecologists of Canada Policy Statement.
Ottawa: SOGC, 1996.
23
Canadian Perinatal Health Report, 2000
Health Services
Rate of Operative Vaginal Deliveries
Operative
vaginal delivery
rates varied
considerably
among
Canadian
provinces and
territories in
1997.
he rate of operative vaginal deliveries is defined as the number of vaginal
births assisted by means of forceps or vacuum extraction expressed as a
proportion of all vaginal births (in a given place and time).
Appropriate use of operative vaginal delivery leads to potential benefits for
the mother and baby; inappropriate or improper use, however, can be harmful.
The choice of forceps or vacuum extraction has been based largely on tradition
and training.1,2 There is a tendency in North America to shift from forceps to
vacuum extraction because results from randomized trials have shown that
vacuum extraction causes less trauma to mothers and infants.2,3 However, these
randomized trials were too small to assess rare and important outcomes such as
intracranial hemorrhage and mortality in infants. There is a need to monitor
infant outcomes following forceps and vacuum extractions in routine practice.
Rates of operative vaginal deliveries were estimated using hospitalization data.
T
Results
•
•
FIGURE 2.3
In 1997 in Canada, the overall rate of operative vaginal deliveries was 17.2%. The
rate of forceps use was 7.4% and the rate of vacuum extraction was 10.5%.
Deliveries in which both forceps and vacuum extraction were used account
for the discrepancy between the overall rate and the sum of the individual
forceps use and vacuum extraction rates.
Operative vaginal delivery rates varied considerably among Canadian provinces
and territories in 1997 (Figures 2.3, 2.4, 2.5). These regional differences may be
due in part to variations in clinical practice.
Rate of operative vaginal deliveries, by province/territory,
Canada (excluding Québec),* 1997-1998
Newfoundland
Prince Edward Island
Nova Scotia
New Brunswick
Ontario
Manitoba
Saskatchewan
Alberta
British Columbia
Yukon
Northwest Territories
CANADA*
0
5
10
15
Operative vaginal deliveries (95% CI) per 100 hospital vaginal deliveries
Sources: Canadian Institute for Health Information. Discharge Abstract Database, 1997-1998.
Manitoba Health, Epidemiology Unit. Perinatal Surveillance Database, 1997-1998.
* Québec data are not included in the Discharge Abstract Database (DAD).
CI — confidence interval.
24
Canadian Perinatal Health Report, 2000
20
Health Services
FIGURE 2.4
Rate of vaginal deliveries by forceps, by province/territory,
Canada (excluding Québec),* 1997-1998
Newfoundland
Prince Edward Island
Nova Scotia
New Brunswick
Ontario
Manitoba
Saskatchewan
Alberta
British Columbia
Yukon
Northwest Territories
CANADA*
0
5
10
15
20
Forceps use (95% CI) per 100 hospital vaginal deliveries
Sources: Canadian Institute for Health Information. Discharge Abstract Database, 1997-1998.
Manitoba Health, Epidemiology Unit. Perinatal Surveillance Database, 1997-1998.
* Québec data are not included in the DAD.
CI — confidence interval.
FIGURE 2.5
Rate of vaginal deliveries by vacuum extraction, by province/territory,
Canada (excluding Québec),* 1997-1998
Newfoundland
Prince Edward Island
Nova Scotia
New Brunswick
Ontario
Manitoba
Saskatchewan
Alberta
British Columbia
Yukon
Northwest Territories
CANADA*
0
5
10
15
20
Vacuum extractions (95% CI) per 100 hospital vaginal deliveries
Sources: Canadian Institute for Health Information. Discharge Abstract Database, 1997-1998.
Manitoba Health, Epidemiology Unit. Perinatal Surveillance Database, 1997-1998.
* Québec data are not included in the DAD.
CI — confidence interval.
25
Canadian Perinatal Health Report, 2000
Health Services
Data Limitations
Operative vaginal delivery rates were calculated from hospital discharge data.
Since instrumental deliveries are considered minor procedures, coding of these
procedures may not be as complete as coding for major procedures (e.g., cesarean
delivery).
References
1.
2.
3.
Editorial. Vacuum versus forceps. Lancet 1984; i: 144.
Johanson RB. Vacuum extraction versus forceps delivery. In: Enkin M, Keirse M, Renfrew
M, Neilson J (Eds.), The Cochrane Collaboration: Pregnancy and Childbirth Database,
1994, Disk Issue I.
Johanson RB, Rice C, Doyle M, Arthur J, Anyanwu L, Ibrahim J et al. A randomised
prospective study comparing the new vacuum extractor policy with forceps delivery. Br J
Obstet Gynaecol 1993; 100: 524-30.
26
Canadian Perinatal Health Report, 2000
Health Services
Rate of Trauma to the Perineum
he rate of trauma to the perineum is defined as the number of women who
had an episiotomy or a delivery resulting in a first-, second-, third- or fourthdegree laceration (tear) of the perineum expressed as a proportion of all women
who had a vaginal delivery (in a given place and time).
Episiotomy is one of the most common surgical procedures in Western medicine,
yet there is no evidence to support its liberal or routine use.1,2 Spontaneous
lacerations of the perineum range from minor lacerations that do not require
repair with sutures to fourth-degree tears which extend through the rectal mucosa
to expose the lumen of the rectum. Higher rates of trauma are consistently
observed in first vaginal births and with instrumental delivery.3 Perineal trauma
can result in short-term morbidity, such as pain and hemorrhage. Potential longterm morbidity includes protracted pain and difficulties in bowel, urinary and
sexual function.3
Rates of trauma to the perineum were estimated using hospitalization data.
T
Results
•
•
•
In 1997, the Canadian episiotomy rate was 25.4 per 100 vaginal births. The
decreasing episiotomy rate in Canada between 1989 and 1997 (Figure 2.6) is due
to changes in obstetric practice. These changes may reflect a response to research
which demonstrated that the routine use of episiotomy is not justified.
Increasing laceration rates over the same time period may be a result of a
decreased use of episiotomies and/or an increased reporting of lacerations. The
increase in lacerations is for first- and second-degree lacerations (Figure 2.6). It
is noteworthy that the decline in use of episiotomy has not been accompanied
by an increase in the more serious third- and fourth-degree lacerations.
The 1997 provincial/territorial episiotomy rates ranged from 6.0 per 100
vaginal births in the Yukon to 35.1 per 100 vaginal births in Prince Edward
Island (Figure 2.7). These regional differences may be due in part to variations
in clinical practice.
Data Limitations
An important limitation in the surveillance of trauma to the perineum in Canada
is the variation that exists in the classification and case definition of perineal
trauma. For example, spontaneous lacerations which are minor and do not
require suturing may not be enumerated.3 Alternatively, greater attention to the
occurrence of lacerations due to decreasing use of episiotomies may result in
increased reporting of less serious lacerations. As well, under-reporting of episiotomies may occur as a result of collection and coding practices.1
27
Canadian Perinatal Health Report, 2000
The decreasing
episiotomy rate
in Canada
between 1989
and 1997 is
due to changes
in obstetric
practice.
Health Services
FIGURE 2.6
Trauma to the perineum by episiotomy and perineal laceration
rates, Canada,* 1989-1990 to 1997-1998
Trauma per 100 hospital vaginal deliveries
60
55.0
51.5
47.8
50
42.6
40
29.9
31.8
44.7
42.4
46.6
48.2
48.8
27.0
25.4
First- and seconddegree lacerations
34.9
39.1
37.7
30
Episiotomies*
20
10
3.8
0
1989-1990
4.1
4.1
4.1
1991-1992
3.9
4.0
1993-1994
3.7
3.9
1995-1996
3.8
Third- and fourthdegree lacerations
1997-1998
Fiscal year
Sources: Canadian Institute for Health Information. Discharge Abstract Database, 1989-1990 to 1997-1998.
Graham et al., 1997.1
* 1996-1997 and 1997-1998 episiotomy data and all laceration data exclude Nova Scotia, Québec and Manitoba.
There were no available episiotomy data for 1994-1995 or 1995-1996.
FIGURE 2.7
Episiotomy rate, by province/territory,
Canada (excluding Québec),* 1997-1998
Newfoundland
Prince Edward Island
Nova Scotia
New Brunswick
Ontario
Manitoba
Saskatchewan
Alberta
British Columbia
Yukon
Northwest Territories
CANADA*
0
10
20
30
Episiotomies (95% CI) per 100 hospital vaginal deliveries
Sources: Canadian Institute for Health Information. Discharge Abstract Database, 1997-1998.
Manitoba Health, Epidemiology Unit. Perinatal Surveillance Database, 1997-1998.
* Québec data are not available in the Discharge Abstract Database (DAD).
CI — confidence interval.
28
Canadian Perinatal Health Report, 2000
40
Health Services
References
1.
2.
3.
Graham ID, Fowler-Graham D. Episiotomy counts: Trends and prevalence in Canada,
1981/1982 to 1993/1994. Birth 1997; 24: 141-7.
Argentine Episiotomy Trial Collaborative Group. Routine vs selective episiotomy: A randomised controlled trial. Lancet 1993; 342: 1517-8.
Renfrew MJ, Hannah W, Albers L, Floyd E. Practices that minimize trauma to the genital
tract in childbirth: A systematic review of the literature. Birth 1998; 25: 143-60.
29
Canadian Perinatal Health Report, 2000
Health Services
Rate of Early Maternal Discharge
from Hospital after Childbirth
he rate of early maternal discharge from hospital after childbirth is defined as
the number of women discharged from hospital early (within two days after
vaginal birth or within four days after cesarean birth) expressed as a proportion
of all women discharged from hospital after childbirth (in a given place and time).
Early maternal discharge is associated with the quality, efficiency and accessibility
of hospital services for childbirth. The length of time that mothers should stay in
hospital for childbirth remains controversial. Early postpartum discharge may
pose risks to the health of mothers and their infants.1-3 However, most studies
evaluating early postpartum discharge in terms of major maternal outcomes have
not yet established significant adverse effects on mothers.1,4
Rates of early maternal discharge were estimated using hospitalization data.
Results are presented separately for vaginal and cesarean births.
T
Between 1989
and 1997,
the average
maternal length
of hospital stay
for childbirth
declined
significantly
from 4.0 to
2.3 days for
vaginal births
and from 6.7
to 4.5 days for
cesarean births.
Results
•
Between 1989 and 1997, the proportion of mothers who stayed in hospital for
less than two days for a vaginal birth showed a marked increase from 3.2% to
25.6% (Figure 2.8). Similarly, the proportion of mothers who stayed in hospital
for less than four days for a cesarean birth increased from 2.1% to 31.3%.
Between 1989 and 1997, the average maternal length of hospital stay for
childbirth declined significantly from 4.0 to 2.3 days for vaginal births and from
6.7 to 4.5 days for cesarean births (Table 2.3).
In 1997, women in Alberta were discharged from hospital following childbirth
sooner than women in any other province or territory (Table 2.4, Figure 2.9).
•
•
Rate of short maternal length of stay (LOS) in hospital for childbirth,
Canada (excluding Québec, Nova Scotia and Manitoba),* 1989-1990 to 1997-1998
FIGURE 2.8
Percent of hospital births with short maternal LOS
35
31.3
30
LOS < 4 days
(cesarean birth)
26.3
23.2
25
25.6
20
22.2
17.3
15
LOS < 2 days
(vaginal birth)
23.0
16.6
9.6
10
6.0
5 3.2
2.1
0
1989-1990
3.5
2.5
9.0
4.5
5.5
3.3
1991-1992
1993-1994
1995-1996
1997-1998
Fiscal year
Source: Canadian Institute for Health Information. Discharge Abstract Database, 1989-1990 to 1997-1998.
* Québec data are not included in the Discharge Abstract Database (DAD). Nova Scotia and Manitoba are
excluded because complete data for all years are not available in the DAD.
30
Canadian Perinatal Health Report, 2000
Health Services
Table 2.3
Average maternal length of stay (LOS) in hospital for childbirth,
Canada (excluding Québec, Nova Scotia and Manitoba),* 1989-1990 to 1997-1998
Year
Mean LOS in days (SD)
Vaginal delivery
Cesarean delivery
1989-1990
4.0 (2.0)
6.7 (2.8)
1990-1991
3.8 (1.9)
6.4 (2.8)
1991-1992
3.5 (1.9)
6.2 (2.7)
1992-1993
3.2 (1.8)
5.8 (2.7)
1993-1994
2.9 (1.6)
5.4 (2.6)
1994-1995
2.6 (1.6)
5.0 (2.5)
1995-1996
2.4 (1.6)
4.7 (2.5)
1996-1997
2.3 (1.5)
4.6 (2.4)
1997-1998
2.3 (1.5)
4.5 (2.4)
Source: Canadian Institute for Health Information. Discharge Abstract Database, 1989-1990 to 1997-1998.
* Québec data are not included in the DAD. Nova Scotia and Manitoba are excluded because complete
data for all years are not available in the DAD.
SD — standard deviation.
Table 2.4
Average maternal length of stay (LOS) in hospital for childbirth,
by province/territory, Canada (excluding Québec),* 1997-1998
Province/Territory
Mean LOS in days (SD)
Vaginal delivery
Cesarean delivery
Newfoundland
3.6 (2.3)
5.5 (3.2)
Prince Edward Island
3.2 (1.7)
5.6 (2.1)
Nova Scotia
2.9 (2.0)
4.8 (3.0)
New Brunswick
2.9 (1.5)
4.8 (2.6)
Ontario
2.1 (1.3)
4.4 (2.3)
Manitoba
2.7 (1.6)
5.1 (2.9)
Saskatchewan
3.0 (1.7)
4.9 (2.6)
Alberta
2.0 (1.4)
4.2 (2.5)
British Columbia
2.5 (1.6)
4.5 (2.5)
Yukon
3.2 (1.9)
4.5 (2.1)
Northwest Territories
2.6 (1.7)
4.8 (1.8)
CANADA*
2.3 (1.5)
4.5 (2.5)
Sources: Canadian Institute for Health Information. Discharge Abstract Database, 1997-1998.
Manitoba Health, Epidemiology Unit. Perinatal Surveillance Database, 1997-1998.
* Québec data are not included in the DAD.
SD — standard deviation.
31
Canadian Perinatal Health Report, 2000
Health Services
FIGURE 2.9
Rate of short maternal length of stay (LOS) in hospital for childbirth,
by province/territory, Canada (excluding Québec),* 1997-1998
LOS < 2 days (vaginal birth)
LOS < 4 days (cesarean birth)
Newfoundland
Prince Edward Island
Nova Scotia
New Brunswick
Ontario
Manitoba
Saskatchewan
Alberta
British Columbia
Yukon
Northwest Territories
CANADA*
0
5
10
15
20
25
30
35
40
Percent of hospital births with short maternal LOS (95% CI)
Sources: Canadian Institute for Health Information. Discharge Abstract Database, 1997-1998.
Manitoba Health, Epidemiology Unit. Perinatal Surveillance Database, 1997-1998.
* Québec data are not included in the DAD.
CI — confidence interval.
Data Limitations
Information regarding the time of birth is not available on the mother’s file in the
DAD. As a result, the maternal length of hospital stay reported includes the time
between admission and childbirth.
References
1.
2.
3.
4.
Dalby DM, Williams JI, Hodnett E, Rush J. Postpartum safety and satisfaction following
early discharge. Can J Public Health 1996; 87: 90-4.
Gloor JE, Kissoon N, Joubert GI. Appropriateness of hospitalization in a Canadian
pediatric hospital. Pediatrics 1993; 91: 70-4.
Wen SW, Liu S, Marcoux S, Fowler D. Trends and variations in length of hospital stay for
childbirth in Canada. Can Med Assoc J 1998; 158: 875-80.
Meikle SF, Lyons E, Hulac P, Orleans M. Rehospitalizations and outpatient contacts of
mothers and neonates after hospital discharge after vaginal delivery. Am J Obstet Gynecol
1998; 179: 166-71.
32
Canadian Perinatal Health Report, 2000
45
50
Health Services
Rate of Early Neonatal Discharge
from Hospital after Birth
he rate of early neonatal discharge from hospital after birth is defined as the
number of newborns discharged from hospital early (within 24 or 48 hours
of birth) expressed as a proportion of all newborns discharged from hospital after
birth (in a given place and time).
Appropriate early discharge of newborns, taking into account their health
status, may increase the efficiency of hospital services and provide other benefits
to newborns and their families.1 However, the question of how long a newborn
should stay in hospital after birth remains controversial. Potential risks and benefits
of newborn early discharge policies have not been adequately examined by
randomized clinical trials. 1-3
Rates of early neonatal discharge were estimated using hospitalization data.
Results are presented separately for low birth weight (1,000-2,499 g) and normal
birth weight (≥ 2,500 g) babies.4
T
The rate of
early discharge
of newborns
weighing
≥ 2,500 g
increased from
3.1% in 1989
to 28.7% in
1997.
Results
•
Between 1989 and 1997, the proportion of newborns weighing 1,000-2,499 g
who stayed in hospital for less than two days after birth varied, peaking at
15.0% in 1995 (Figure 2.10). The rate of early discharge of newborns weighing
≥ 2,500 g increased from 3.1% in 1989 to 28.7% in 1997.
Rate of early neonatal discharge from hospital after birth,
Canada (excluding Québec, Nova Scotia and Manitoba),* 1989-1990 to 1997-1998
FIGURE 2.10
Percent of newborns with short hospital LOS
35
30
25.2
28.7
LOS < 2 days (birth
weight ≥ 2,500 g)
13.7
LOS < 2 days (birth
weight 1,000-2,499 g)
25.9
25
19.5
20
13.9
15
11.2
10.3
10.4
10.9
10
15.0
11.6
14.2
10.7
5
3.1
0
1989-1990
3.8
5.1
1991-1992
7.1
1993-1994
1995-1996
1997-1998
Fiscal year
Source: Canadian Institute for Health Information. Discharge Abstract Database, 1989-1990 to 1997-1998.
* Québec data are not included in the Discharge Abstract Database (DAD). Nova Scotia and Manitoba are
excluded because complete data for all years are not available in the DAD.
LOS — length of stay.
33
Canadian Perinatal Health Report, 2000
Health Services
•
•
FIGURE 2.11
For newborns weighing 1,000-2,499 g at birth, the average length of hospital
stay at birth decreased from 9.0 days in 1989 to 7.7 days in 1995, and then
increased to 7.9 days in 1997 (Table 2.5). For newborns weighing ≥ 2,500 g,
the average length of hospital stay after birth decreased steadily, from 3.9 days
in 1989 to 2.4 days in 1997.
In 1997, the Yukon and Northwest Territories had the shortest average neonatal
length of stay (LOS) for low birth weight newborns (1,000-2,499 g). However,
Alberta had the shortest average LOS for normal birth weight babies (≥ 2,500 g)
(Table 2.6). The Northwest Territories had the largest proportion of low birth
weight newborns discharged within two days, while Alberta had the largest
proportion of normal birth weight newborns discharged within two days
(Figure 2.11).
Rate of early neonatal discharge from hospital after birth,
by province/territory, Canada (excluding Québec),* 1997-1998
LOS < 2 days (birth weight ≥ 2,500 g)
LOS < 2 days (birth weight 1,000-2,499 g)
Newfoundland
Prince Edward Island
Nova Scotia
New Brunswick
Ontario
Manitoba
Saskatchewan
Alberta
British Columbia
Yukon
Northwest Territories
CANADA*
0
5
10
15
20
25
30
35
Percent of newborns with short hospital LOS (95% CI)
Sources: Canadian Institute for Health Information. Discharge Abstract Database, 1997-1998.
Manitoba Health, Epidemiology Unit. Perinatal Surveillance Database, 1997-1998.
* Québec data are not included in the DAD.
LOS — length of stay.
CI — confidence interval.
34
Canadian Perinatal Health Report, 2000
40
45
50
Health Services
Table 2.5
Average neonatal length of stay (LOS) in hospital after birth,
Canada (excluding Québec, Nova Scotia and Manitoba),* 1989-1990 to 1997-1998
Year
Mean LOS in days (SD)
Birth weight 1,000-2,499 g
Birth weight ≥ 2,500 g
1989-1990
9.0 (6.7)
3.9 (1.8)
1990-1991
8.9 (6.7)
3.7 (1.8)
1991-1992
8.5 (6.6)
3.5 (1.8)
1992-1993
8.2 (6.7)
3.2 (1.7)
1993-1994
8.1 (6.8)
2.9 (1.7)
1994-1995
7.8 (6.8)
2.6 (1.6)
1995-1996
7.7 (6.8)
2.5 (1.6)
1996-1997
7.8 (6.8)
2.4 (1.6)
1997-1998
7.9 (6.8)
2.4 (1.6)
Source: Canadian Institute for Health Information. Discharge Abstract Database, 1989-1990 to 1997-1998.
* Québec data are not included in the DAD. Nova Scotia and Manitoba are excluded because complete data
for all years are not available in the DAD.
SD — standard deviation.
Table 2.6
Average neonatal length of stay (LOS) in hospital after birth,
by province/territory, Canada (excluding Québec),* 1997-1998
Province/
Territory
Mean LOS in days (SD)
Birth weight 1,000-2,499 g
Birth weight ≥ 2,500 g
Newfoundland
8.3 (6.8)
3.1 (1.6)
Prince Edward Island
9.6 (7.3)
3.4 (1.8)
Nova Scotia
11.1 (7.3)
2.7 (1.8)
New Brunswick
11.0 (7.2)
3.1 (1.8)
7.9 (6.7)
2.3 (1.6)
10.5 (7.2)
2.7 (1.8)
Saskatchewan
9.6 (7.1)
2.9 (1.7)
Alberta
7.7 (6.8)
2.0 (1.6)
British Columbia
7.0 (6.4)
2.5 (1.6)
Yukon
5.1 (2.8)
2.9 (1.7)
Northwest Territories
5.3 (5.3)
2.4 (1.6)
CANADA*
7.9 (6.8)
2.4 (1.6)
Ontario
Manitoba
Sources: Canadian Institute for Health Information. Discharge Abstract Database, 1997-1998.
Manitoba Health, Epidemiology Unit. Perinatal Surveillance Database, 1997-1998.
* Québec data are not included in the DAD.
SD — standard deviation.
35
Canadian Perinatal Health Report, 2000
Health Services
Data Limitations
In the DAD the hour of birth is not recorded. Therefore it is not possible to
obtain the exact duration of hospital stay which is of interest, especially among
infants discharged on the first day of life. Ideally, analyses should also be stratified
by gestational age at birth; however the DAD does not include information on
gestational age.
References
1.
2.
3.
4.
Braverman P, Egerter S, Pearl M, Marchi K, Miller C. Problems associated with early
discharge of newborn infants. Early discharge of newborns and mothers: a critical review
of the literature. Pediatrics 1995; 96: 716-26.
Lee KS, Perlman M, Ballantyne M, Elliott I, To T. Association between duration of neonatal
hospital stay and readmission rate. J Pediatr 1995; 127: 758-66.
Liu LL, Clemens CJ, Shay DK, Davis RL, Novack AH. The safety of newborn early discharge.
The Washington State experience. J Am Med Assoc 1997; 278: 293-8.
Wen SW, Liu S, Fowler D. Trends and variations in neonatal length of in-hospital stay in
Canada. Can J Public Health 1998; 89: 115-9.
36
Canadian Perinatal Health Report, 2000
B
Maternal, Fetal
and Infant
Health Outcomes
3
Maternal Health Outcomes
Maternal Mortality Ratio
he maternal mortality ratio (MMR) is defined as the number of maternal
deaths per 100,000 live births (in a given place and time).
A country’s maternal mortality ratio is considered an important indicator of
the general health of the population, the availability and quality of medical care,
as well as the status of women.1 At approximately four maternal deaths reported
for every 100,000 live births, Canada has one of the lowest maternal mortality
ratios in the world, reflecting our universal access to high quality medical care, our
healthy population, and the generally favourable economic and social status of
Canadian women.
Statistics Canada reports all deaths annually by age, province/territory and
underlying cause. In Canada, up until January 1, 2000, underlying causes of death
were classified according to the Ninth Revision of the International Classification
of Diseases (ICD-9).2 Maternal deaths are those where the underlying cause of
death has been assigned a numerical code between 630 and 676 under Chapter 11
(Complications of Pregnancy, Childbirth and the Puerperium) of ICD-9.
The definition of maternal death under ICD-9 is:
The death of a woman while pregnant or within 42 days of the
termination of the pregnancy, irrespective of the duration and the site of
the pregnancy, from any cause related to or aggravated by the pregnancy
or its management but not from accidental or incidental causes.
Maternal deaths are considered to be either:
a. Direct obstetric deaths — that is, deaths resulting from obstetric complications of the pregnant state (pregnancy, labour and puerperium); from
interventions, omissions or incorrect treatment; or from a chain of events
resulting from any of the above; or
b. Indirect obstetric deaths — that is, deaths resulting from previous existing
disease or disease that developed during pregnancy, which were not due to
direct obstetric causes but were aggravated by the physiologic effects of
pregnancy. A definition of “indirect obstetric death” first appeared in the
Ninth Revision of the ICD system; deaths considered to be indirect
obstetric deaths have, therefore, been included in counts of maternal deaths
in Canada only since ICD-9 was adopted for use in this country in 1979.
MMRs were calculated using vital statistics data.
T
39
Canadian Perinatal Health Report, 2000
Canada has
one of the
lowest maternal
mortality ratios
in the world,
reflecting our
universal access
to high quality
medical care,
our healthy
population, and
the generally
favourable
economic and
social status
of Canadian
women.
Maternal Health Outcomes
Results
•
•
Table 3.1
The MMR decreased from 8.2 per 100,000 live births in 1973-1977 to 3.8 per
100,000 live births in 1988-1992 (Figure 3.1). The decline was most pronounced
between 1973 and 1982. Although few maternal deaths attributable to
indirect causes were reported between 1973 and 1997, a slight increase in the
number of these deaths between 1988 and 1997 led to the observed increase
in the total MMR for these years. The MMR that includes deaths from direct
obstetric causes has decreased consistently since 1973.
The most common causes of maternal death in Canada are all direct obstetric
causes — hypertensive disorders of pregnancy, pulmonary embolism, hemorrhage and ectopic pregnancy (Table 3.1). While maternal deaths from most
causes have decreased between the 1970s and 1990s, deaths associated with
ectopic pregnancy and those caused by amniotic fluid and other pulmonary
embolisms have increased between these two time periods (Table 3.1).
Direct maternal deaths by cause,*
Canada, 1973-1977 and 1993-1997
Cause
Ratio per 1,000,000 live births (number)
1973-1977
1993-1997
% change
Ectopic pregnancy
4.1 (7)
4.8 (9)
+17
Other abortive outcomes**
8.7 (15)
1.1 (2)
-87
Antepartum hemorrhage
7.6 (13)
4.8 (9)
-37
Hypertensive disorders
12.8 (22)
9.1 (17)
-29
Other pregnancy complications
3.5 (6)
0.5 (1)
-86
Postpartum hemorrhage
9.3 (16)
2.1 (4)
-77
Delivery trauma
5.2 (9)
1.1 (2)
-79
Other delivery complications
9.9 (17)
2.7 (5)
-73
Puerperal sepsis
4.1 (7)
1.1 (2)
-73
Puerperal phlebitis
3.5 (6)
1.1 (2)
-69
Amniotic fluid embolism
4.1 (7)
5.9 (11)
+44
Other pulmonary embolism
2.3 (4)
2.7 (5)
+17
Cerebrovascular disorders
4.1 (7)
3.2 (6)
-22
Other puerperal disorders
2.9 (5)
0.0 (0)
-100
82.2 (141)
40.2 (75)
-51
Total direct obstetric deaths
Source: See references 3-10 at the end of this section.
*Note that the denominator used in this table is 1,000,000 live births rather than 100,000 live births as in Figure 3.1.
**Includes: missed abortion, hydatidiform mole, induced and spontaneous abortions.
40
Canadian Perinatal Health Report, 2000
Maternal Health Outcomes
Maternal mortality ratio (MMR),
Canada, 1973-1997
FIGURE 3.1
Maternal deaths per 100,000 live births
10
8.2
8
8.2
6.0
6
5.5
4.0
3.8
3.8
3.6
1983-1987
1988-1992
4
4.4
3.4
MMR — total obstetric deaths
MMR — direct obstetric deaths only
2
0
1973-1977
1978-1982
1993-1997
Calendar year
Source: See references 3-10 below.
Data Limitations
Because a number of countries have found that maternal mortality is underreported by vital records systems, the World Health Organization (WHO) now
routinely inflates reported MMRs by a factor of 1.5 to take under-reporting into
account when comparing country-specific rates.1 The Canadian Perinatal
Surveillance System (CPSS) is completing a study to determine whether and by
how much maternal deaths are under-reported in Canada.
References
1.
World Health Organization/UNICEF. Revised 1990 Estimates of Maternal Mortality: A
New Approach by WHO and UNICEF. Geneva: WHO, 1991.
2. World Health Organization. Manual of the International Statistical Classification of Diseases,
Injuries, and Causes of Death, 9th Revision. Vol. 1. Geneva: WHO, 1977.
3. Statistics Canada. Causes of Death, 1973, 1974, 1975, 1976, 1977, 1978, 1979, 1980, 1981,
1982, 1983, 1984, 1985, 1986, 1987. Ottawa: Statistics Canada, Health Statistics Division
(Catalogue No. 84-203-XPB (annual)).
4. Statistics Canada. Causes of Death, 1988. Health Rep 1990; (11S): 2(1).
5. Statistics Canada. Causes of Death, 1989. Health Rep 1991; (11S): 3(1).
6. Statistics Canada. Causes of Death, 1990. Ottawa: Statistics Canada, Health Statistics
Division, 1992 (11S): 4(1).
7. Statistics Canada. Causes of Death, 1991, 1992, 1993, 1994, 1995, 1996, 1997. Ottawa:
Statistics Canada, Health Statistics Division (Catalogue No. 84-208-XPB (annual)).
8. Statistics Canada. Births. Vital Statistics 1973; 1.
9. Statistics Canada. Births and Deaths, 1991, 1992, 1993, 1994, 1995. Ottawa: Statistics Canada,
Health Statistics Division. (Catalogue No. 84-210-XPB (annual)).
10. Statistics Canada. Births and Deaths 1996, 1997 (shelf tables). Ottawa: Statistics Canada,
Health Statistics Division, 1999 (Catalogue No. 84F0210-XPB (annual)).
41
Canadian Perinatal Health Report, 2000
Maternal Health Outcomes
Induced Abortion Ratio
he induced abortion ratio is defined as the number of induced abortions
per 100 live births (in a given place and time). A related indicator is the agespecific induced abortion rate, defined as the number of induced abortions in a
specified age category per 1,000 females in the same age category.
In 1969, a law was passed to regulate abortion under the Criminal Code. This
law permitted a qualified medical practitioner to perform an abortion, if prior
approval was obtained by a Therapeutic Abortion Committee. A 1988 Supreme
Court of Canada decision found this process to be unconstitutional. The 1969
law was rendered unenforceable and abortion was effectively decriminalized.1
Access to abortion services is now viewed as an indicator of society’s attitude
toward women and their right to reproductive choice.
Induced abortion statistics were obtained from Statistics Canada.2,3
T
Results
In 1997,
provincial
and territorial
induced
abortion ratios
ranged from
9.5 to 35.5
per 100 live
births and
the induced
abortion rates
ranged from
5.0 to 19.2 per
1,000 women
of reproductive
age.
•
•
•
In 1997, the induced abortion ratio was 32.9 per 100 live births in Canada.
The induced abortion rate was 16.8 per 1,000 females aged 15-44. The induced
abortion ratio is increasing at a faster pace than the induced abortion rate,
partly due to a decreasing number of live births over time (Figure 3.2).
In 1997, provincial and territorial induced abortion ratios ranged from 9.5 to
35.5 per 100 live births and the induced abortion rates ranged from 5.0 to 19.2
per 1,000 women of reproductive age. These variations may be attributable to
differences in the availability of abortion services, ease of travel to the United
States and other local factors4 (Figure 3.3).
According to Statistics Canada, women in their twenties accounted for half of
all women who obtained an abortion in 1996 and 1997. On average, 28 out
of every 1,000 women in their twenties obtained an abortion3 (Figure 3.4).
Data Limitations
Medically/pharmacologically induced abortions performed in physicians’ offices
are not systematically reported in abortion statistics. They may become a major
under-reporting issue as the use of these procedures increases with time.
Additional sources of under-reporting include abortions provided in physicians’
offices that have not been designated as abortion facilities, as well as abortions
provided to Canadian women in the United States. Age data were missing in 3%
of cases. This introduces a small approximation into the calculation of age-specific
induced abortion rates.
42
Canadian Perinatal Health Report, 2000
Maternal Health Outcomes
Induced abortion ratio and rate,
Canada, 1990-1997
FIGURE 3.2
40
35
30
26.9
27.6
15.2
15.5
15.7
16.0
16.4
1992
1993
1994
1995
1996
25.6
25 22.9
15
32.9
Induced abortions
per 100 live births
23.6
20
14.2
30.5
28.2
14.2
16.8
Induced abortions
per 1,000 females
15-44 years
10
5
0
1990
1991
1997
Calendar year
Sources: Statistics Canada. Therapeutic Abortions, 1995.
Statistics Canada. Canadian Vital Statistics System, 1990-1997.
Statistics Canada. The Daily : Friday, April 7, 2000.
Statistics Canada. Canadian female population estimates, 1990-1997.
FIGURE 3.3
Induced abortion ratio and rate, by province/territory, Canada,* 1997
Newfoundland
Prince Edward Island
Induced abortions (95% CI) per 1,000 females
15-44 years
Nova Scotia
Induced abortions (95% CI) per 100 live births
New Brunswick
Québec
Ontario
Manitoba
Saskatchewan
Alberta
British Columbia
Yukon
Northwest Territories
CANADA*
0
5
10
15
20
25
30
Sources: Statistics Canada. The Daily: Friday, April 7, 2000.
Statistics Canada. Canadian Vital Statistics System, 1997.
Statistics Canada. Births and Deaths, 1997 (shelf tables).
*Including abortions obtained in the U.S.A. by Canadian women.
CI — confidence interval.
43
Canadian Perinatal Health Report, 2000
35
40
45
50
Maternal Health Outcomes
FIGURE 3.4
Age-specific induced abortion rate,
Canada, 1997
All ages*
< 15**
16.8
2.6
15-19
21.5
20-24
33.9
25-29
22.6
30-34
14.0
35-39
40-44***
8.3
2.9
Induced abortions per 1,000 females
Sources: Canadian Institute for Health Information. Therapeutic Abortion Survey, 1997.
Statistics Canada. Health Statistics Division, March 2000.
* Also includes abortions to women over 44. Total includes cases with age not specified (3,547 induced abortions
were reported without age specified). Total includes 293 abortions to Canadian women in the U.S.A.
** Rates based on female population aged 14 years.
*** Includes induced abortions to women over 44 years of age at pregnancy termination. Rate based on female
population aged 40-44 years.
References
1.
2.
3.
4.
Health Canada, Bureau of Reproductive and Child Health. Induced Abortion Fact Sheet.
April 1998.
Statistics Canada. Therapeutic Abortions, 1995. Ottawa: Statistics Canada, Health Statistics
Division, 1997 (Catalogue No. 82-219-XPB).
Statistics Canada. The Daily: Friday, April 7, 2000.
Statistics Canada. Statistical Report on the Health of Canadians. Ottawa: Statistics Canada,
1999 (Catalogue No. 82-570-XPE).
44
Canadian Perinatal Health Report, 2000
Maternal Health Outcomes
Ectopic Pregnancy Rate
he ectopic pregnancy rate is defined as the number of ectopic pregnancies per
1,000 reported pregnancies (in a given place and time). In this analysis, reported
pregnancies include live births, stillbirths, hospital-based induced abortions and
ectopic pregnancies. Spontaneous abortions and clinic-based induced abortions
are not included in the denominator.
Ectopic pregnancy, defined as the implantation of the blastocyst anywhere
other than in the endometrial lining of the uterine cavity,1 is a significant cause of
maternal morbidity and mortality. In industrialized countries, ectopic pregnancy
is the leading cause of maternal death during the first trimester of pregnancy,
accounting for approximately 10% of all maternal deaths.2 Some countries have
reported an increasing ectopic pregnancy rate; potential explanations for this
increase include an increased prevalence of sexually transmitted tubal infections,
an increase in the use of contraception that prevents intrauterine but not extrauterine pregnancies, and better and earlier diagnostic techniques.1 However, other
countries have reported a decrease in the rate of ectopic pregnancies, attributed
to declining rates of genital chlamydia.3
Ectopic pregnancy rates were estimated using hospitalization data.
T
Results
•
•
•
In 1997, the ectopic pregnancy rate in Canada was 16.8 per 1,000 reported
pregnancies. The rate has been decreasing since 1992 (Figure 3.5).
The 1997 provincial/territorial ectopic pregnancy rates ranged from 12.2 per
1,000 reported pregnancies in Nova Scotia to 38.0 per 1,000 pregnancies in
the Yukon (note the wide confidence intervals for the territories with the
highest rates) (Figure 3.6).
The ectopic pregnancy rate increased with maternal age (Figure 3.7). This is
likely due in part to an increased prevalence of scarring of the fallopian tubes
among older women.
Data Limitations
An important limitation in the surveillance of ectopic pregnancy in Canada is the
reliance on hospital separation data. The availability of risk factor information in
hospital records is limited. Also, as pharmacological management of ectopic
pregnancy in outpatient settings becomes more common, the enumeration of
ectopic pregnancy may be less complete. There may also be variation in the
diagnosis of ectopic pregnancy, particularly at very early gestation, and the
frequency of subclinical ectopic pregnancy is unknown.4
45
Canadian Perinatal Health Report, 2000
In 1997,
the ectopic
pregnancy rate
in Canada was
16.8 per 1,000
reported
pregnancies.
The rate has
been decreasing
since 1992.
Maternal Health Outcomes
Ectopic pregnancy rate,*
Canada (excluding Québec, Nova Scotia and Manitoba),** 1989-1990 to 1997-1998
FIGURE 3.5
Ectopic pregnancies per 1,000 reported pregnancies*
25
19.4
20
19.8
19.5
20.1
19.3
18.7
18.2
17.8
16.8
15
10
5
0
1989-1990
1991-1992
1993-1994
1995-1996
1997-1998
Fiscal year
Source: Canadian Institute for Health Information. Discharge Abstract Database, 1989-1990 to 1997-1998.
* Reported pregnancies include live births, stillbirths, hospital-based induced abortions and ectopic pregnancies.
** Québec data are not included in the Discharge Abstract Database (DAD). Nova Scotia and Manitoba are excluded
because complete data for all years are not available in the DAD.
FIGURE 3.6
Ectopic pregnancy rate,* by province/territory,
Canada (excluding Québec),** 1997-1998
Newfoundland
Prince Edward Island
Nova Scotia
New Brunswick
Ontario
Manitoba
Saskatchewan
Alberta
British Columbia
Yukon
Northwest Territories
CANADA**
0
10
20
30
40
50
Ectopic pregnancies (95% CI) per 1,000 reported pregnancies*
Sources: Canadian Institute for Health Information. Discharge Abstract Database, 1997-1998.
Manitoba Health, Epidemiology Unit. Perinatal Surveillance Database, 1997-1998.
* Reported pregnancies include live births, stillbirths, hospital-based induced abortions and ectopic pregnancies.
** Québec data are not included in the DAD.
CI — confidence interval.
46
Canadian Perinatal Health Report, 2000
60
Maternal Health Outcomes
FIGURE 3.7
Ectopic pregnancy rate,* by maternal age,
Canada (excluding Québec),** 1997-1998
All ages
15-19
20-24
25-29
30-34
35-39
40-44
45-49
0
20
40
60
80
100
Ectopic pregnancies (95% CI) per 1,000 reported pregnancies*
Sources: Canadian Institute for Health Information. Discharge Abstract Database, 1997-1998.
Manitoba Health, Epidemiology Unit. Perinatal Surveillance Database, 1997-1998.
* Reported pregnancies include live births, stillbirths, hospital-based induced abortions and ectopic pregnancies.
** Québec data are not included in the DAD.
CI — confidence interval.
References
1.
2.
3.
4.
Cunningham FG, MacDonald PC, Grant NF, Leveno KJ, Gilstrap LC, Hankins GDV et al.
(Eds.). Williams Obstetrics, 20th Edition. Stamford, Connecticut: Appleton & Lange, 1997:
607-34.
Coste J, Job-Spira N, Fernandez H, Papiernik E, Spira A. Risk-factors for ectopic pregnancy:
a case-control study in France, with special focus on infectious factors. Am J Epidemiol
1991; 133: 839-49.
Egger M, Low N, Smith GD, Lindblom B, Herrmann B. Screening for chlamydial
infections and the risk of ectopic pregnancy in a county in Sweden: ecological analysis.
Br Med J 1998; 316: 1776-80.
Orr P, Sherman E, Blanchard J, Fast M, Hammond G, Brunham R. Epidemiology of
infection due to Chlamydia trachomatis in Manitoba, Canada. Clin Infect Dis 1994; 19:
867-83.
47
Canadian Perinatal Health Report, 2000
Maternal Health Outcomes
Severe Maternal Morbidity Ratio
he severe maternal morbidity ratio is defined as the number of women who
experience severe (life-threatening) maternal morbidity per 100,000 live births
(in a given place and time). Severe maternal morbidity can also be reported per
100,000 deliveries.
Because maternal deaths are rare, attention has turned to the question
of whether surveillance of health hazards associated with childbearing should
include life-threatening events that do not result in death.1-3 While it has been
difficult to quantify the extent of the problem because definitions of life-threatening
maternal morbidity and ascertainment methods differ, the Canadian Perinatal
Surveillance System (CPSS) has developed a list of conditions associated with
pregnancy and childbirth that are potentially life-threatening and that are likely to
be captured on hospital discharge summaries. These are: amniotic fluid embolism,
obstetrical pulmonary embolism, eclampsia, septic shock, anesthesia complications,
cerebrovascular disorders, hemorrhage (antepartum or postpartum) requiring either
transfusion or hysterectomy, and rupture of the uterus.
This section highlights amniotic fluid embolism. In future CPSS perinatal
health reports, other life-threatening conditions related to pregnancy and
childbearing will be discussed.
Amniotic fluid embolism can be defined as the entry of amniotic fluid into
maternal blood circulation, resulting in severe disturbance of cardiorespiratory
function and coagulopathy.4 These rare events — with a reported incidence ranging
between 1 and 15 per 100,000 deliveries — have been associated with a high case
fatality rate (as high as 80%) as well as a high risk of neurological impairment
among survivors.4,5 Approximately 15% of direct maternal deaths in Canada are
attributed to amniotic fluid embolism. There are no known predisposing risk
factors,6 nor is there understanding of how to prevent this condition.7
Amniotic fluid embolism incidence rates were estimated using hospitalization
data.
T
Approximately
15% of direct
maternal
deaths in
Canada are
attributed to
amniotic fluid
embolism.
There are
no known
predisposing
risk factors,
nor is there
understanding
of how to
prevent this
condition.
Results
•
•
Amniotic fluid embolism occurs very rarely in Canada. The overall incidence for
the years 1989-1990 through 1997-1998 was 5.6 per 100,000 deliveries (Table 3.2).
No clear trend is observed in the incidence or case-fatality rate of amniotic fluid
embolism over time.
Data Limitations
There is no single criterion upon which a diagnosis of amniotic fluid embolism
can be made reliably; definitive diagnoses are made at autopsy.7 While the
accuracy of diagnoses of amniotic fluid embolism cannot be determined with the
data source used here, the low case fatality rates suggest that amniotic fluid
embolism may be over-reported in the Discharge Abstract Database (DAD).
Other diagnoses are known to be mistaken for amniotic fluid embolism.6 The
reported incidence and mortality rates are based on hospital deliveries only.
Amniotic fluid embolism may also occur in association with pregnancy
termination.
48
Canadian Perinatal Health Report, 2000
Maternal Health Outcomes
Table 3.2
Number, recorded incidence and case fatality rate for amniotic
fluid embolism, Canada (excluding Québec, Nova Scotia and Manitoba),*
1989-1990 to 1997-1998
Year
Number
of cases
Incidence (per
100,000 deliveries)
Number
of deaths
Case fatality rate
(per 100 cases)**
1989-1990
10
3.8
2
20.0
1990-1991
17
6.1
1
5.9
1991-1992
12
4.4
1
8.3
1992-1993
22
8.1
3
13.6
1993-1994
12
4.5
2
16.7
1994-1995
8
3.0
1
12.5
1995-1996
17
6.5
3
17.6
1996-1997
17
6.8
5
29.4
1997-1998
18
7.4
1
5.6
133
5.6
19
14.3
Total
Source: Canadian Institute for Health Information. Discharge Abstract Database, 1989-1990 to 1997-1998.
* Québec data are not included in the DAD. Nova Scotia and Manitoba are excluded because complete data
for all years are not available in the DAD.
** Although the annual number of occurrences and the number of deaths are small, the observed overall case
fatality rate of 14.3%, as well as case fatality rates for each year, are low in comparison to case fatality rates
of approximately 80% reported in hospital-based studies. This suggests that amniotic fluid embolism may be
over-reported in the DAD, perhaps because of a tendency to diagnose less serious events as amniotic fluid
embolisms.5
Amniotic fluid embolism is one of the indicators that will be assessed in a
current quality assurance study of the DAD, which is being carried out by the
Canadian Institute for Health Information (CIHI) with the financial support and
collaboration of the CPSS.
References
1.
2.
3.
4.
5.
6.
7.
Mantel GD, Buchmann E, Rees H, Pattinson RC. Severe acute maternal morbidity: a pilot
study of a definition for a near-miss. Br J Obstet Gynaecol 1998; 105: 985-90.
Baskett TF, Sternadel J. Maternal intensive care and near-miss mortality in obstetrics.
Br J Obstet Gynaecol 1998; 105: 981-4.
Harmer M. Maternal mortality — is it still relevant? Anesthesia 1997; 52: 99-100.
Morgan M. Amniotic fluid embolism. Anesthesia 1979; 34: 20-32.
Burrows A, Khoo SK. The amniotic fluid embolism syndrome: 10 years experience at a
major teaching hospital. Aust-N-Z-J-Obstet-Gynaecol 1995; 35: 245-50.
Clark SL, Hankins GD, Dudley DA, Dildy GA, Porter TF. Amniotic fluid embolism:
analysis of the national registry. Am J Obstet Gynecol 1995; 172: 1158-69.
Clark SL. New concepts of amniotic fluid embolism: a review. Obstet-Gynecol-Surv 1990;
45: 360-8.
49
Canadian Perinatal Health Report, 2000
Maternal Health Outcomes
Rate of Maternal Readmission after
Discharge following Childbirth
he maternal hospital readmission rate is defined as the number of mothers
readmitted to hospital within three months of initial hospital discharge
(following childbirth) expressed as a proportion of the total number of women
discharged from hospital following childbirth (in a given place and time).
The maternal readmission rate can serve as a proxy for complications related
to childbirth.1,2 Many factors influence maternal readmission rates, including the
severity of illness, availability of hospital resources, distance to hospital, hospital
admission policies and accessibility of outpatient services. Generally, maternal
readmission following childbirth is an under-researched topic and the impact of
maternal readmission on maternal and child health has not been well documented
in the scientific literature.3,4
Readmission rates were estimated using hospitalization data. Maternal
readmission cases were identified by linking obstetric delivery records and
readmission records. Results are presented separately for vaginal and cesarean births.
T
Many factors
influence
maternal readmission rates,
including the
severity of illness,
availability of
hospital resources,
distance to
hospital, hospital
admission policies
and accessibility
of outpatient
services.
Results
•
Between 1990 and 1997, the three-month maternal readmission rate following
vaginal birth remained fairly stable, ranging from 2.4% to 2.7% of deliveries.
Readmission rates following cesarean births increased, from 3.2% of deliveries
in 1990 to 3.9% of deliveries in 1997 (Figure 3.8).
Rate of maternal readmission within three months
of discharge from hospital following childbirth,*
Canada (excluding Québec, Nova Scotia and Manitoba),** 1990-1991 to 1997-1998
FIGURE 3.8
Readmissions per 100 hospital deliveries
5
4
3.7
3
3.4
3.9
4.0
3.7
3.9
Cesarean deliveries
3.4
3.2
2 2.5
2.5
2.7
2.7
2.7
2.6
2.5
2.4
Vaginal deliveries
1
0
1990-1991 1991-1992 1992-1993 1993-1994 1994-1995 1995-1996 1996-1997 1997-1998
Fiscal year
Source: Canadian Institute for Health Information. Discharge Abstract Database, 1990-1991 to 1997-1998.
* Women who were directly transferred to other institutions after childbirth and women with initial length of stay
(LOS) > 20 days were excluded from analysis.
** Québec data are not included in the Discharge Abstract Database (DAD). Nova Scotia and Manitoba are excluded
because complete data for all years are not available in the DAD.
50
Canadian Perinatal Health Report, 2000
Maternal Health Outcomes
•
•
In 1995-1997, the three-month maternal readmission rate varied widely by
province/territory, both for women with cesarean births and for those with
vaginal births (Figure 3.9). These regional differences may be due in part to
variations in hospital admission and discharge policies.
For women who gave birth in hospital between 1995 and 1997, the proportion
of readmissions attributable to a given primary diagnosis differed for cesarean
vs. vaginal births (Table 3.3).
Data Limitations
Since the identification of maternal readmission is based on record linkage, a few
cases of maternal readmission after childbirth would be missed if a link could not
be made between the obstetric record and readmission record.
FIGURE 3.9
Rate of maternal readmission within three months of discharge
from hospital following childbirth,* by province/territory,
Canada (excluding Québec),** 1995-1996 to 1997-1998
Cesarean deliveries
Vaginal deliveries
Newfoundland
Prince Edward Island
Nova Scotia
New Brunswick
Ontario
Manitoba
Saskatchewan
Alberta
British Columbia
Northwest Territories
CANADA**
0
1
2
3
4
5
6
Readmissions (95% CI) per 100 hospital deliveries
Sources: Canadian Institute for Health Information. Discharge Abstract Database, 1995-1996 to 1997-1998.
Manitoba Health, Epidemiology Unit. Perinatal Surveillance Database, 1995-1996 to 1997-1998.
* Women who were directly transferred after childbirth and women with initial length of stay (LOS) > 20 days were
excluded from analysis.
** Québec data are not included in the DAD.
CI — confidence interval.
51
Canadian Perinatal Health Report, 2000
7
8
Maternal Health Outcomes
Table 3.3
Percent of maternal readmissions within three months of
discharge from hospital following childbirth,* by primary
diagnosis, Canada (excluding Québec),** 1995-1996 to 1997-1998
Primary diagnosis at readmission (ICD-9 code)
Mode of delivery
Total (%) Cesarean (%) Vaginal (%)
1. Postpartum hemorrhage (666)
14.4
6.8
17.1
2. Cholelithiasis (574)
13.2
11.4
13.8
3. Major puerperal infection (670)
10.1
10.2
10.1
4. Other and unspecified complications of the puerperium,
not elsewhere classified (674)
7.2
20.4
2.6
5. Postpartum care and examination (V24)
3.6
4.4
3.4
6. Persons seeking consultation without complaint of sickness (V65)
3.5
1.5
4.2
7. Infection of the breast and nipple associated with childbirth (675)
3.1
1.9
3.5
8. Other current conditions in the mother classifiable elsewhere,
but complicating pregnancy, childbirth or the puerperium (648)
2.2
2.3
2.2
9. Complications of pregnancy, not elsewhere classified (646)
2.3
2.4
2.3
10. Symptoms involving abdomen and pelvis (789)
1.9
1.8
1.9
11. Encounter for contraceptive management (V25)
1.5
0.4
1.9
12. Complications of procedures, not elsewhere classified (998)
1.2
2.4
0.8
13. Venous complications in pregnancy and the puerperium (671)
1.1
1.6
1.0
34.7
32.6
35.4
100.0
100.0
100.0
14. Other diagnoses
Total
Source: Canadian Institute for Health Information. Discharge Abstract Database, 1995-1997.
Manitoba Health, Epidemiology Unit. Perinatal Surveillance Database, 1995-1997.
* Women who were directly transferred after childbirth and women with initial length of stay (LOS) > 20 days were excluded
from analysis.
** Québec data are not included in the DAD.
References
1.
2.
3.
4.
Meikle SF, Lyons E, Hulac P, Orleans M. Rehospitalizations and outpatient contacts of
mothers and neonates after hospital discharge after vaginal delivery. Am J Obstet Gynecol
1998; 179: 166-71.
Glazener CM, Abdalla M, Stroud P, Naji S, Templeton A, Russell IT. Postnatal maternal
morbidity: extent, causes, prevention and treatment. Br J Obstet Gynaecol 1995; 102: 282-7.
Grimes DA. The morbidity and mortality of pregnancy: still risky business. Am J Obstet
Gynecol 1994; 170: 1489-94.
Danel I, Johnson C, Berg C, Flowers L, Atrash H. Length of maternal hospital stay for
uncomplicated deliveries, 1988-1995: The impact of maternal and hospital characteristics.
Matern Child Health J 1997; 1: 237-42.
52
Canadian Perinatal Health Report, 2000
4
Fetal and Infant Health Outcomes
Preterm Birth Rate
he preterm birth rate is defined as the number of live births with a gestational
age at birth of less than 37 completed weeks (< 259 days) expressed as a
proportion of all live births (in a given place and time).
Preterm birth has been identified as one of the most important perinatal
health problems in industrialized nations.1 Preterm birth accounts for 75%-85%
of all perinatal mortality in Canada2 and is an important determinant of neonatal
and infant morbidity, including neurodevelopmental handicap, chronic respiratory
problems, infections and ophthalmologic problems.1 Despite the importance of
preterm birth, its etiology and prevention remain poorly understood.
Preterm birth rates were calculated using vital statistics data.
T
Results
•
•
•
In 1997, the Canadian preterm birth rate was 7.1 per 100 live births. The preterm
birth rate has been increasing since 1981 (Figure 4.1). Potential explanations
for this increase include: changes in the frequency and gestational age of multiplegestation pregnancies, increases in obstetric intervention, greater registration
of extremely early-gestation births (20-27 weeks) as live births and increases
in the use of ultrasound-based estimates of gestational age.3,4
In 1997, there were markedly higher rates of preterm birth in twins and higherorder births (Figure 4.2). However, singleton births were still responsible for
over 80% of all preterm births.
In 1997, provincial/territorial preterm birth rates ranged from 6.0% in Prince
Edward Island to 8.1% in the Northwest Territories (Figure 4.3).
Data Limitations
An important limitation in the surveillance and research of preterm birth is the
potential for error in determining gestational age, particularly where menstrual
dates are used.5 This error may be due to inaccurate maternal reporting, the
interpretation of post-conception bleeding as normal menses, irregular menstrual
cycles or intervening unrecognized pregnancy losses.1
53
Canadian Perinatal Health Report, 2000
Preterm birth
accounts for
75%-85% of
all perinatal
mortality in
Canada and is
an important
determinant
of neonatal
and infant
morbidity,
including
neurodevelopmental
handicap,
chronic
respiratory
problems,
infections and
ophthalmologic
problems.
Fetal and Infant Health Outcomes
Preterm birth rate,
Canada (excluding Ontario and Newfoundland),* 1981-1997
FIGURE 4.1
Preterm births per 100 live births**
10
8
6.4 6.3 6.2
6.4
6.1
6.1
6.3
6.7
6.5
6.6
6.6
6.7
6.6
6.8
7.0 7.1 7.1
6
4
2
0
1981
1983
1985
1987
1989
1991
1993
1995
1997
Calendar year
Source: Statistics Canada. Canadian Vital Statistics System, 1981-1997.
* Ontario is excluded due to data quality concerns. Newfoundland is excluded because data are not
available nationally prior to 1991.
** Excludes live births with unknown gestational age and gestational age < 20 weeks.
FIGURE 4.2
Preterm birth rates, by single and multiple births,
Canada (excluding Ontario),* 1997
All live births
7.1
Singleton births
5.9
Twin births
51.6
Triplet or higher
95.9
Preterm births per 100 live births**
Source: Statistics Canada. Canadian Vital Statistics System, 1997.
* Ontario is excluded due to data quality concerns.
** Excludes live births with unknown gestational age and gestational age < 20 weeks.
54
Canadian Perinatal Health Report, 2000
Fetal and Infant Health Outcomes
FIGURE 4.3
Preterm birth rate, by province/territory,
Canada (excluding Ontario),* 1997
Newfoundland
Prince Edward Island
Nova Scotia
New Brunswick
Québec
Manitoba
Saskatchewan
Alberta
British Columbia
Yukon
Northwest Territories
CANADA*
0
2
4
6
8
10
Preterm births (95% CI) per 100 live births**
Source: Statistics Canada. Canadian Vital Statistics System, 1997.
* Ontario is excluded due to data quality concerns.
** Excludes live births with unknown gestational age and gestational age < 20 weeks.
CI — confidence interval.
References
1.
2.
3.
4.
5.
Berkowitz GS, Papiernik E. Epidemiology of preterm birth. Epidemiol Rev 1993; 15: 414-43.
Moutquin JM, Papiernik E. Can we lower the rate of preterm birth? Bull SOGC September
1990: 19-20.
Joseph KS, Kramer MS, Marcoux S, Ohlsson A, Wen SW, Allen A et al. Determinants
of preterm birth rates in Canada from 1981 through 1983 and from 1992 through 1994.
N Engl J Med 1998; 339: 1434-9.
Kramer MS, Platt R, Yang H, Joseph KS, Wen SW, Morin L et al. Secular trends in preterm
birth: A hospital-based cohort study. J Am Med Assoc 1998; 280: 1849-54.
Kramer MS, McLean FH, Boyd ME, Usher RH. The validity of gestational age estimation
by menstrual dating in term, preterm, and postterm gestations. J Am Med Assoc 1988;
260: 3306-8.
55
Canadian Perinatal Health Report, 2000
Fetal and Infant Health Outcomes
Postterm Birth Rate
he postterm birth rate is defined as the number of total births (stillbirths and
live births) that occur at a gestational age of 42 or more completed weeks
(≥ 294 days) of pregnancy expressed as a proportion of total births (in a given
place and time).
Postterm birth is associated with increased risk of fetal and infant mortality.1,2
The main causes for the increased perinatal mortality in postterm births are
prolonged labour, unexplained anoxia and neonatal seizures.3 Controversy exists
in the management of postterm pregnancy (intervention versus expectant
management). Randomized controlled trials suggest that elective labour induction
can reduce perinatal mortality, without an increase in the rates of cesarean
deliveries.4,5
Postterm birth rates were calculated using vital statistics data.
T
Rates of
postterm
births
decreased
dramatically
in Canada,
from 4.3% in
1988 to 1.8%
in 1997.
Results
•
Rates of postterm births decreased dramatically in Canada, from 4.3% in 1988
to 1.8% in 1997 (Figure 4.4), caused in part by more frequent use of ultrasound
dating, and in part by more frequent labour induction for postterm pregnancies.
Postterm birth rate,
Canada (excluding Ontario and Newfoundland),* 1988-1997
FIGURE 4.4
Postterm births per 100 total births**
5
4.8
4.6
4.4
4 4.3
3.8
3.7
3.1
3
2.5
2.0
2
1.8
1
0
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
Calendar year
Source: Statistics Canada. Canadian Vital Statistics System, 1988-1997.
* Ontario is excluded due to data quality concerns. Newfoundland is excluded because data are not
available nationally prior to 1991.
** Excludes live births and stillbirths with unknown gestational age and gestational age < 20 weeks.
56
Canadian Perinatal Health Report, 2000
Fetal and Infant Health Outcomes
•
FIGURE 4.5
In 1997, rates of postterm birth varied substantially among Canadian provinces
and territories, from 0.9% in Newfoundland and Québec to 5.0% in the
Yukon (Figure 4.5). These regional variations in postterm births may be due to
regional differences in the use of ultrasound dating and/or postterm induction.
Postterm birth rate, by province/territory,
Canada (excluding Ontario),* 1997
Newfoundland
Prince Edward Island
Nova Scotia
New Brunswick
Québec
Manitoba
Saskatchewan
Alberta
British Columbia
Yukon
Northwest Territories
CANADA*
0
1
2
3
4
5
6
7
8
Postterm births (95% CI) per 100 total births**
Source: Statistics Canada. Canadian Vital Statistics System, 1997.
* Ontario is excluded due to data quality concerns.
** Excludes live births and stillbirths with unknown gestational age and gestational age < 20 weeks.
CI — confidence interval.
Data Limitations
An important limitation in the surveillance and research of postterm birth is the
potential for error in determining gestational age, particularly where menstrual
dates are used.6 This error may be due to inaccurate maternal reporting, the
interpretation of post-conception bleeding as normal menses, irregular menstrual
cycles or intervening unrecognized pregnancy losses.7
57
Canadian Perinatal Health Report, 2000
Fetal and Infant Health Outcomes
References
1.
2.
3.
4.
5.
6.
7.
Hilder L, Costeloe K, Thilaganathan B. Prolonged pregnancy: evaluating gestationspecific risks of fetal and infant mortality. Br J Obstet Gynaecol 1998; 105: 169-73.
Lucas WE, Anetil AO, Callagan DA. The problem of postterm pregnancy. Am J Obstet
Gynecol 1965; 91: 241.
Naeye RL. Causes of perinatal excess deaths in prolonged gestations. Am J Epidemiol
1978; 108: 429-33.
Sue-A-Quan AK, Hannah ME, Cohen MM, Foster GA, Liston RM. Effect of labour
induction on rates of stillbirth and cesarean section in post-term pregnancies. Can Med
Assoc J 1999; 160: 1145-9.
Hannah ME, Hannah WJ, Hellmann J, Hewson S, Milner R, Willan A, and the Canadian
Multicenter Post-Term Pregnancy Trial Group. Induction of labour as compared with
serial antenatal monitoring in post-term pregnancy. A randomized controlled trial. N Engl
J Med 1992; 326: 1587-92.
Kramer MS, McLean FH, Boyd ME, Usher RH. The validity of gestational age estimation
by menstrual dating in term, preterm, and postterm gestations. J Am Med Assoc 1988;
260: 3306-8.
Berkowitz GS, Papiernik E. Epidemiology of preterm birth. Epidemiol Rev 1993; 15: 414-43.
58
Canadian Perinatal Health Report, 2000
Fetal and Infant Health Outcomes
Fetal Growth: Small-for-Gestational-Age Rate,
Large-for-Gestational-Age Rate
1) The small-for-gestational-age (SGA) rate is defined as the number of live
births whose birth weights are below the standard 10th percentile of birth
weight for gestational age expressed as a proportion of all live births (in a
given place and time).
2) The large-for-gestational-age (LGA) rate is defined as the number of live
births whose birth weights are above the standard 90th percentile of birth
weight for gestational age expressed as a proportion of all live births (in a
given place and time).
Alternative cut-offs to determine small for gestational age and large for
gestational age can also be used, including the 5th percentile and the 95th
percentile of birth weight for gestational age.
Because of the difficulty of in-utero measurement of growth, a cross-sectional
measure of fetal growth, birth weight for gestational age, has been used in both
clinical and public health practice.1,2 Fetal growth restriction is associated with
increased perinatal morbidity and mortality, whereas accelerated fetal growth can
result in macrosomia with associated birth complications.1 Surveillance of fetal
growth indicators can be helpful in identifying populations with high risk of fetal
growth restriction and/or macrosomia, and in planning public health programs
aimed at reducing risks of fetal growth restriction and macrosomia. In particular,
LGA births have been reported to be common among Canadian aboriginal women.3
SGA and LGA rates were calculated using vital statistics data. The SGA and
LGA cut-offs used for these analyses are based on a standard Canadian population
in the mid-1980s.2
Results
•
•
From 1988-1997, the rate of SGA in Canada decreased (Figure 4.6). This may be
due in part to more frequent use of ultrasound-assisted dating which
improves the accuracy of gestational age measurements. During the same time
period the rate of LGA increased. In addition to more accurate gestational age
measurements, this increase may be due in part to increases in fetal growth
over time.
In 1997, the rate of SGA ranged from 6.2% in the Northwest Territories to
9.9% in the Yukon (Figure 4.7); the rate of LGA ranged from 9.4% in Québec
to 15.0% in Prince Edward Island (Figure 4.8). These regional variations in
SGA and LGA rates may be caused in part by population profile (i.e., ethnic
group) differences. Further research is needed to better understand these
trends and variations.
59
Canadian Perinatal Health Report, 2000
From 19881997, the
rate of SGA
in Canada
decreased.
During the
same time
period the
rate of LGA
increased.
Fetal and Infant Health Outcomes
Rates of small for gestational age (SGA) and large for gestational age (LGA),
Canada (excluding Ontario and Newfoundland),* 1988-1997
FIGURE 4.6
Number per 100 live births**
14
12
10.1
10.7
10.1
9.8
10.3
10.0
10.4
10.4
11.2
10.7
LGA
10
9.8
8
9.9
9.6
9.6
SGA
8.9
9.3
9.1
9.1
8.6
1992
1993
1994
1995
1996
8.6
6
4
2
0
1988
1989
1990
1991
1997
Calendar year
Source: Statistics Canada. Canadian Vital Statistics System, 1988-1997.
* Ontario is excluded due to data quality concerns. Newfoundland is excluded because data are not
available nationally prior to 1991.
** Excludes live births with unknown gestational age and birth weight, and gestational age < 20 weeks.
FIGURE 4.7
Small-for-gestational-age (SGA) rate, by province/territory,
Canada (excluding Ontario),* 1997
Newfoundland
Prince Edward Island
Nova Scotia
New Brunswick
Québec
Manitoba
Saskatchewan
Alberta
British Columbia
Yukon
Northwest Territories
CANADA*
0
2
4
6
8
10
12
Number (95% CI) per 100 live births**
Source: Statistics Canada. Canadian Vital Statistics System, 1997.
* Ontario is excluded due to data quality concerns.
** Excludes live births with unknown gestational age and birth weight, and gestational age < 20 weeks.
CI — confidence interval.
60
Canadian Perinatal Health Report, 2000
14
Fetal and Infant Health Outcomes
FIGURE 4.8
Large-for-gestational-age (LGA) rate, by province/territory,
Canada (excluding Ontario),* 1997
Newfoundland
Prince Edward Island
Nova Scotia
New Brunswick
Québec
Manitoba
Saskatchewan
Alberta
British Columbia
Yukon
Northwest Territories
CANADA*
0
5
10
15
20
Number (95% CI) per 100 live births**
Source: Statistics Canada. Canadian Vital Statistics System, 1997.
* Ontario is excluded due to data quality concerns.
** Excludes live births with unknown gestational age and birth weight, and gestational age < 20 weeks.
CI — confidence interval.
Data Limitations
An important limitation in the surveillance and research of SGA and LGA birth
is the potential for error in determining gestational age, particularly where
menstrual dates are used.4 The accuracy of gestational age estimation can be
substantially improved by ultrasound-assisted dating early in the second
trimester.4 SGA and LGA are relative measures, and vary substantially according to
the standard used for their calculation. The standard used for this report2 is now
somewhat outdated. A new standard based on better dating information and more
sophisticated analytic methods is under development by the Canadian Perinatal
Surveillance System (CPSS).
References
1.
2.
3.
4.
Cunningham FG, MacDonald PC, Grant NF, Leveno KJ, Gilstrap LC, Hankins GDV et al.
(Eds.). Williams Obstetrics, 20th Edition. Stamford, Connecticut: Appleton & Lange, 1997.
Arbuckle TE, Wilkins R, Sherman GJ. Birth weight percentiles by gestational age in
Canada. Obstet Gynecol 1993; 81: 39-48.
Thomson M. Heavy birthweight in native Indians of British Columbia. Can J Public Health
1990; 81: 443-6.
Kramer MS, McLean FH, Boyd ME, Usher RH. The validity of gestational age estimation
by menstrual dating in term, preterm, and postterm gestations. J Am Med Assoc 1988;
260: 3306-8.
61
Canadian Perinatal Health Report, 2000
Fetal and Infant Health Outcomes
Fetal and Infant Mortality Rates
In almost all
countries, fetal
and infant
mortality have
decreased
dramatically
over the last
century with
improvements
in sanitation,
nutrition, infant
feeding, and
maternal and
child health
care, although
the decline has
been slower in
recent years.
1) The fetal mortality rate is defined as the number of stillbirths (≥ 500 g or ≥ 20
weeks of gestation) per 1,000 total births (live births and stillbirths), in a given
place and time.
2) The infant mortality rate is defined as the number of deaths of live-born
babies in the first year of life per 1,000 live births (in a given place and time).
Fetal mortality can be divided into two components: early fetal deaths (at < 28
completed weeks of gestation) and late fetal deaths (at ≥ 28 completed weeks of
gestation). Infant mortality can be divided into three components: early neonatal
deaths (0-6 days), late neonatal deaths (7-27 days) and postneonatal deaths (28-364
days). Fetal and infant mortality rates can be refined by calculation of birth weightand age at death-specific mortality rates, and gestational age- and age at deathspecific mortality rates. Fetal and infant mortality rates can also be refined by
calculation of cause-specific mortality rates. The Canadian Perinatal Surveillance
System (CPSS) is currently undertaking a study of temporal trends in cause-specific
infant mortality rates.
Infant mortality has been considered the single most comprehensive measure
of health in a society. In almost all countries, fetal and infant mortality have
decreased dramatically over the last century with improvements in sanitation,
nutrition, infant feeding, and maternal and child health care,1 although the
decline has been slower in recent years.2 Disparities in the risk of infant death
remain, however, including in countries such as Canada.
A conceptual framework for perinatal surveillance that focuses on preventable
feto-infant mortality was described by Dr. Brian McCarthy, Centers for Disease
Control and Prevention, Atlanta, Georgia. Estimates of preventable feto-infant
mortality are based on a cross-tabulation of birth weight and age at death that
results in a 16-cell table (Table 4.1). Each of the 16 cells represents two aspects of
perinatal health: (a) perinatal outcomes (age at death- and birth weight-specific
mortality); and (b) determinants of these outcomes (maternal health, maternal
care, newborn care and infant environment).
According to this framework, late fetal, neonatal and postneonatal deaths
among babies less than 1,500 g may be largely attributable to factors affecting
maternal health. Late fetal deaths among babies weighing ≥ 1,500 g may result
from suboptimal maternal care. Inadequate newborn care including limited access
to neonatal intensive care is likely to contribute to early neonatal deaths among
babies with birth weights ≥ 1,500 g and late neonatal deaths among babies with
intermediate birth weight (between 1,500 and 2,499 g). Postneonatal infant deaths
among babies with a birth weight of ≥ 1,500 g and late neonatal deaths among
normal birth weight babies (≥ 2,500 g) are largely attributable to infant environment
(e.g., injury prevention and control). Estimates of excess (preventable) feto-infant
mortality suggest opportunity gaps among population subgroups in terms of
maternal health and the quality of maternal and newborn care, and infant environment. Such information is useful to public health authorities and perinatal health
care managers for developing program initiatives.
Fetal and infant mortality rates were calculated using vital statistics data. The
calculation of excess (preventable) feto-infant mortality requires a linkage of births
and infant deaths, using information from birth and death certificates. Cause-specific
mortality has not been included in the current report.
62
Canadian Perinatal Health Report, 2000
Fetal and Infant Health Outcomes
Table 4.1
Framework for the estimation of preventable feto-infant
mortality according to birth weight and age at death
Birth weight (g)
Late fetal
(≥ 28 weeks)
< 1,000
Early neonatal
(0-6 days)
Late neonatal
(7-27 days)
Postneonatal
(28-364 days)
Maternal health
1,000-1,499
1,500-2,499
Maternal care
Newborn care
Infant environment
≥ 2,500
Results
•
•
•
•
From 1988 to 1997 the fetal death rate fluctuated between 5.2 and 4.4 per
1,000 total births. The neonatal mortality rate decreased from 4.7 to 3.9 per
1,000 live births and the postneonatal mortality rate decreased from 2.7 to 1.7
per 1,000 neonatal survivors (Figure 4.9).
In 1997, there were substantial variations in fetal, neonatal and, especially,
postneonatal mortality rates among the Canadian provinces and territories
(Figures 4.10, 4.11, 4.12).
In the years 1992-1996, there were opportunities to prevent feto-infant
mortality in terms of maternal health, maternal care, neonatal care and infant
environment. These opportunities varied substantially according to
province/territory. For each province and territory, a rate and a number are
provided for maternal health, maternal care, neonatal care and infant
environment (Table 4.2). The rate represents the difference between the
provincial or territorial rate and the benchmark rate (mortality in births to
Québec women with an education of 14 years or more). The number represents
the number of excess or fewer (-) deaths in each category, calculated by
applying the difference between the provincial/territorial rate and the benchmark
to the provincial/territorial population. For example, for Newfoundland in
the maternal health category, the fetal, neonatal and postneonatal mortality
rate among babies less than 1,500 g is 2.7 per 1,000 births greater than the
benchmark, translating into an excess of 85 fetal/infant deaths that could
potentially be prevented with interventions in maternal health. For
Saskatchewan in the infant environment category, the mortality rate in the
late neonatal period among babies ≥ 2,500 g and in the postneonatal period
among babies with a birth weight of ≥ 1,500 g is 1.8 per 1,000 births greater
than the benchmark, translating into an excess of 127 infant deaths that could
potentially be prevented with interventions in infant environment.
Detailed tabulations of Canadian birth weight-specific and gestational agespecific infant mortality rates for 1994-1996 and interprovincial/territorial
variations in birth weight-specific and gestational age-specific infant mortality
for the years 1992-1996 are presented in Appendix E.
63
Canadian Perinatal Health Report, 2000
Estimates
of excess
(preventable)
feto-infant
mortality suggest
opportunity
gaps among
population
subgroups
in terms of
maternal health
and the quality
of maternal and
newborn care,
and infant
environment.
Fetal and Infant Health Outcomes
Rates of fetal, neonatal and postneonatal deaths,
Canada (excluding Newfoundland),* 1988-1997
FIGURE 4.9
6
5.2
4.9
4.9
4.9
4.8
5
4.7
4.8
4.8
4.8
Fetal deaths per 1,000 total births**
4.4
4.7
4.8
4.6
4
4.1
3.9
4.1
4.2
4.2
3.9
3.9
1.7
1.7
Neonatal deaths per 1,000 live births
3
2.7
2
2.5
2.2
2.3
2.2
2.2
2.0
2.0
1
0
1988
1989
1990
1991
1992
1993
1994
1995
1996
Postneonatal deaths per 1,000
neonatal survivors
1997
Calendar year
Source: Statistics Canada. Canadian Vital Statistics System, 1988-1997.
* Newfoundland is excluded because data are not available nationally prior to 1991.
** Fetal death rates exclude births with known birth weight of < 500 grams. Ontario is excluded from
fetal death rates due to data quality concerns.
FIGURE 4.10
Fetal death rate,* by province/territory,
Canada (excluding Ontario),** 1997
Newfoundland
Prince Edward Island
Nova Scotia
New Brunswick
Québec
Manitoba
Saskatchewan
Alberta
British Columbia
Yukon
Northwest Territories
CANADA
0
5
10
15
20
Deaths (95% CI) per 1,000 total births
Source: Statistics Canada. Canadian Vital Statistics System, 1997.
*Fetal death rates exclude births with known birth weight of < 500 grams.
** Ontario is excluded due to data quality concerns.
CI — confidence interval.
64
Canadian Perinatal Health Report, 2000
25
30
Fetal and Infant Health Outcomes
FIGURE 4.11
Neonatal death rate, by province/territory,
Canada, 1997
Newfoundland
Prince Edward Island
Nova Scotia
New Brunswick
Québec
Ontario
Manitoba
Saskatchewan
Alberta
British Columbia
Yukon
Northwest Territories
CANADA
0
2
4
6
8
10
12
14
16
14
16
Deaths (95% CI) per 1,000 live births
Source: Statistics Canada. Canadian Vital Statistics System, 1997.
CI — confidence interval.
FIGURE 4.12
Postneonatal death rate, by province/territory,
Canada, 1997
Newfoundland
Prince Edward Island
Nova Scotia
New Brunswick
Québec
Ontario
Manitoba
Saskatchewan
Alberta
British Columbia
Yukon
Northwest Territories
CANADA
0
2
4
6
8
10
Deaths (95% CI) per 1,000 neonatal survivors
Source: Statistics Canada. Canadian Vital Statistics System, 1997.
CI — confidence interval.
65
Canadian Perinatal Health Report, 2000
12
Fetal and Infant Health Outcomes
Table 4.2
Rate (per 1,000 births) of excess feto-infant mortality and number of preventable deaths,* by type of intervention opportunity and province/territory,
Canada (excluding Ontario),** 1992-1996
Province/Territory
Intervention opportunity
Maternal care
Neonatal care
Maternal health
Infant environment
Excess
mortality
rate
Number of
preventable
deaths
Excess
mortality
rate
Number of
preventable
deaths
Excess
mortality
rate
Number of
preventable
deaths
Newfoundland
2.7
85
0.7
22
0.6
19
0.7
22
Prince Edward Island
1.6
14
2.2
19
0.0
0
0.6
5
Nova Scotia
2.1
118
1.7
96
0.1
6
0.3
17
New Brunswick
1.3
58
1.7
75
0.4
18
0.7
31
Québec
1.1
499
0.7
318
0.1
45
0.3
136
Manitoba
3.9
320
1.5
123
0.2
16
1.2
98
Saskatchewan
2.7
190
1.6
113
0.5
35
1.8
127
Alberta
2.7
540
1.6
320
0.2
40
1.0
200
British Columbia
1.8
420
1.0
233
0.0
0
0.7
163
Yukon
Excess
Number of
mortality preventable
rate
deaths
(-0.1)
(-0)
2.9
7
0.0
0
2.3
6
Northwest Territories
2.6
21
2.5
20
0.7
6
6.5
52
CANADA**
1.9
2,129
1.1
1,317
0.1
188
0.7
852
Source: Statistics Canada. Canadian Vital Statistics System, 1992-1996.
* The benchmark is mortality in births to mothers in the province of Québec with an education of ≥ 14 years (1990-1991 data). In the birthinfant death linked file, all live births at < 22 weeks and < 500 g were assumed to have died on the first day of life and were classified as such.
** Ontario is excluded due to data quality concerns.
Data Limitations
Vital statistics data are subject to registration errors, particularly among extremely
small, immature newborns.3,4 The linkage of births and infant deaths results in
2%-3% of deaths remaining unlinked (this percentage excludes Ontario data).
References
1.
2.
3.
4.
Buehler JW, Kleinman JC, Hodgue CJ, Strauss LT, Smith JC. Birth weight-specific infant
mortality, United States, 1960 to 1980. Public Health Rep 1987; 102: 151-61.
Kleinman JC. The slowdown in the infant mortality decline. Paediatr Perinat Epidemiol
1990; 4: 373-81.
Joseph KS, Kramer MS. Recent trends in Canadian infant mortality rates: Effect of
changes in registration of live newborns weighing less than 500 grams. Can Med Assoc J
1996; 155: 1047-52.
Joseph KS, Allen A, Kramer MS, Cyr M, Fair M for the Fetal-Infant Mortality Study
Group of the Canadian Perinatal Surveillance System. Changes in the registration of
stillbirths less than 500g in Canada, 1985-95. Pediatr Perinat Epidemiol 1999; 13: 278-87.
66
Canadian Perinatal Health Report, 2000
Fetal and Infant Health Outcomes
Severe Neonatal Morbidity Rate
he severe neonatal morbidity rate is defined as the number of infants identified
as having severe neonatal morbidity in the first month of life expressed as a
proportion of all live born infants (in a given place and time).
Severe morbid conditions during the neonatal period are important predictors
of postneonatal morbidity and disability.1 Classification of the conditions that
constitute severe neonatal morbidity may vary. However, certain conditions are
more likely to predict long-term disability, including severe respiratory distress
syndrome (RDS), sepsis, seizures, severe intraventricular hemorrhage, persistent
fetal circulation, and multisystem congenital anomalies. Moreover, these conditions
are often associated with each other. For example, intraventricular hemorrhage is
predictive of the development of seizures and persistent fetal circulation is linked
with sepsis and RDS.
This section highlights RDS. In future Canadian Perinatal Surveillance System
(CPSS) perinatal health reports, other conditions will be discussed.
Rates of RDS were estimated using hospitalization data.
T
The rate of
RDS decreased
during the early
1990s, followed
by a stable rate
in recent years.
Results
•
In 1997, the rate of RDS was 10.7 per 1,000 live births in Canada. The rate of RDS
decreased during the early 1990s, followed by a stable rate in recent years
(Figure 4.13).
Respiratory distress syndrome (RDS) rate,*
Canada (excluding Québec, Nova Scotia and Manitoba),** 1989-1990 to 1997-1998
FIGURE 4.13
Cases per 1,000 live hospital births
20
15.5
15
15.5
14.9
13.7
10
11.1
10.8
10.2
11.0
10.7
5
0
1989-1990
1991-1992
1993-1994
1995-1996
1997-1998
Fiscal year
Source: Canadian Institute for Health Information. Discharge Abstract Database, 1989-1990 to 1997-1998.
* RDS cases include infants diagnosed during the birth admission only.
** Québec data are not included in the Discharge Abstract Database (DAD). Nova Scotia and Manitoba are excluded because
complete data for all years are not available in the DAD.
67
Canadian Perinatal Health Report, 2000
Fetal and Infant Health Outcomes
•
FIGURE 4.14
Provincial and territorial rates of RDS varied widely from 2.6 per 1,000 live
births in the Northwest Territories to 19.4 per 1,000 live births in Prince
Edward Island (Figure 4.14). This wide regional variation in rates may be due
in part to differences in the application of the case definition of RDS.
Respiratory distress syndrome (RDS) rate,* by province/territory,
Canada (excluding Québec),** 1997-1998
Newfoundland
Prince Edward Island
Nova Scotia
New Brunswick
Ontario
Manitoba
Saskatchewan
Alberta
British Columbia
Yukon
Northwest Territories
CANADA*
0
5
10
15
20
25
30
Cases (95% CI) per 1,000 live hospital births
Sources: Canadian Institute for Health Information. Discharge Abstract Database, 1997-1998.
Manitoba Health, Epidemiology Unit. Perinatal Surveillance Database, 1997-1998.
* RDS cases include infants diagnosed during the birth admission only.
** Québec data are not included in the DAD.
CI — confidence interval.
Data Limitations
Limitations in the surveillance of severe neonatal morbidity are primarily related
to limitations in the hospital discharge databases. Specifically, variations in the
case definitions and coding of particular morbidities may affect reported rates. In
general, the limitations of the databases utilized will lead to underestimates of
severe neonatal morbidity. As well, the information as coded does not distinguish
between degrees of severity of a particular condition.
References
1.
Behrman RE, Shiono PH. Neonatal risk factors. In: Fanhroff AA, Martin RJ (Eds.),
Neonatal-Perinatal Medicine. Diseases of the Fetus and Infant, 6th Edition. Vol. 1. St. Louis:
Mosby Publications, 1997: 3-12.
68
Canadian Perinatal Health Report, 2000
Fetal and Infant Health Outcomes
Multiple Birth Rate
he multiple birth rate is defined as the number of live births and stillbirths
following a multiple gestation pregnancy expressed as a proportion of all live
births and stillbirths (in a given place and time).
Multiple births are at increased risk of being preterm,1 of intrauterine growth
restriction, retinopathy, intraventricular hemorrhage and bronchopulmonary
dysplasia.2 These infants may require additional health care services, including
neonatal intensive care.
Multiple birth rates were calculated using vital statistics data.
T
Results
•
Rates of multiple birth increased steadily over time, from 2.1% in 1988 to
2.5% in 1997 (Figure 4.15). An increase in births to older mothers and increased
use of fertility treatments and assisted conception are the main reasons for
the recent increase in multiple births.3
In 1997, with the exception of the Yukon, rates of multiple birth were similar
among Canadian provinces and territories (Figure 4.16). The higher rate in
the Yukon must be interpreted with caution, as the rate is based on a small
number of births.
•
Rate of multiple births,
Canada (excluding Newfoundland),* 1988-1997
FIGURE 4.15
Multiple births per 100 total births
3.0
2.5
2.06
2.09
2.08
2.02
2.08
2.08
1989
1990
1991
1992
1993
2.25
2.28
1994
1995
2.40
2.50
2.0
1.5
1.0
0.5
0.0
1988
Calendar year
Source: Statistics Canada. Canadian Vital Statistics System, 1988-1997.
* Newfoundland is excluded because data are not available nationally prior to 1991.
69
Canadian Perinatal Health Report, 2000
1996
1997
An increase in
births to older
mothers and
increased use
of fertility
treatments
and assisted
conception
are the main
reasons for the
recent increase
in multiple
births.
Fetal and Infant Health Outcomes
FIGURE 4.16
Rate of multiple births, by province/territory,
Canada, 1997
Newfoundland
Prince Edward Island
Nova Scotia
New Brunswick
Québec
Ontario
Manitoba
Saskatchewan
Alberta
British Columbia
Yukon
Northwest Territories
CANADA
0
1
2
3
4
6
7
Multiple births (95% CI) per 100 total births
Source: Statistics Canada. Canadian Vital Statistics System, 1997.
CI — confidence interval.
Data Limitations
Canadian data on multiple births are obtained from birth certificates and may be
subject to some transcribing errors.
References
1.
2.
3.
Newman RB, Ellings JM. Antepartum management of the multiple gestation: the case for
specialized care. Semin Perinatol 1995; 19: 387-403.
Millar WJ, Wadhera S, Nimrod C. Multiple births: trends and patterns in Canada, 1974-1990.
Health Rep 1992; 4: 223-50.
Wilcox LS, Kiely JL, Melvin CL, Martin MC. Assisted reproductive technologies: estimates
of their contribution to multiple births and newborn hospital days in the United States.
Fertil Steril 1996; 65: 361-6.
70
Canadian Perinatal Health Report, 2000
Fetal and Infant Health Outcomes
Prevalence of Congenital Anomalies
he prevalence of congenital anomalies is defined as the number of individual
live born or stillborn infants with at least one congenital anomaly expressed
as a proportion of the total number of live births and stillbirths (in a given place
and time).
Congential anomalies, birth defects and congenital malformations are terms
currently used to describe developmental disorders present at birth.1 Congenital
anomalies are a leading cause of all infant deaths and one of the top 10 causes of
potential years of life lost.2 The most prevalent categories of congenital anomalies
in Canada are musculoskeletal anomalies, congenital heart defects and central
nervous system anomalies, such as neural tube defects (NTDs).
The prevalence of congenital anomalies is estimated using data from the
Canadian Congenital Anomalies Surveillance System (CCASS). This report highlights NTDs. The current interest in NTDs lies both in the disability and death
they cause, as well as the opportunity to address their occurrence through
primary prevention. Furthermore, the evaluation of primary prevention strategies,
such as the Canadian policy of fortifying food with folic acid will require careful
surveillance of NTD rates over time.
T
Results
•
•
•
In 1997, the NTD birth prevalence in Canada was 7.6 per 10,000 total births
(excludes Québec, as 1997 data for Québec were not available).
In recent years, the NTD birth prevalence has been decreasing (Figure 4.17),
possibly reflecting decreased incidence due to improved nutrition, vitamin
supplementation or both. The decreased birth prevalence may also be due to
prenatal diagnosis and termination of affected pregnancies.
In 1997, provincial and territorial NTD birth prevalence ranged from 0.0 to
11.5 per 10,000 births (Figure 4.18). Regional differences in prenatal diagnosis
with subsequent termination of affected pregnancies is probably the main
reason for variation in regional rates. However, regional differences in the
presence of both known and unknown risk factors for NTDs may also exist.
Data Limitations
One of the major limitations in tracking congenital anomalies such as NTDs is
the absence of mandatory and standardized national reporting of anomalies that
are detected prenatally and result in the termination of the affected pregnancy.
Failure to account for these cases results in an underestimate of the true NTD rate
and limits interpretation of temporal trends. As well, the availability, completeness and source of data from different regions in Canada have varied over recent
years, also limiting the comprehensiveness and consistency of temporal trends.3
71
Canadian Perinatal Health Report, 2000
Congenital
anomalies are
a leading cause
of all infant
deaths and
one of the top
10 causes of
potential years
of life lost.
Fetal and Infant Health Outcomes
Neural tube defect (NTD) rate,
Canada (excluding Québec and Nova Scotia),* 1989-1997
FIGURE 4.17
NTDs per 10,000 total births
14
12
11.6
11.5
10.9
10.7
10.2
9.8
9.6
10
7.5
8
6
7.5
S
0
1989
1990
1991
1992
1993
1994
1995
1996
1997
Calendar year
Source: Health Canada. Canadian Congenital Anomalies Surveillance System, 1989-1997.
* Québec and Nova Scotia are excluded because data are not available for all years.
FIGURE 4.18
Neural tube defect (NTD) rate, by province/territory,
Canada (excluding Québec),* 1997
Newfoundland
Prince Edward Island
No reported NTDs
Nova Scotia
New Brunswick
Ontario
Manitoba
Saskatchewan
Alberta
British Columbia
Yukon
No reported NTDs
Northwest Territories
No reported NTDs
CANADA*
0
10
20
30
NTDs (95% CI) per 10,000 total births
Source: Health Canada. Canadian Congenital Anomalies Surveillance System, 1997.
* Québec is excluded as data for 1997 were not available.
CI — confidence interval.
References
1.
2.
3.
Moore KL, Persaud TVN. Before we are born: essentials of embryology and birth defects. 5th
Edition. Philadelphia: W.B. Saunders Company, 1998.
Premature mortality due to congenital anomalies — United States. MMWR 1988; 37: 505-6.
Health Canada. Measuring Up. Ottawa: Minister of Public Works and Government Services
Canada, 1999 (Catalogue No. H42-2/82-1999E).
72
Canadian Perinatal Health Report, 2000
Fetal and Infant Health Outcomes
Rate of Neonatal Hospital Readmission
after Discharge at Birth
he neonatal hospital readmission rate is defined as the number of newborns
who are readmitted to hospital within 28 days of birth expressed as a
proportion of all newborns discharged from hospital after birth (in a given place
and time). This indicator can also be specified as the rate of readmission within
seven days after birth.
Newborn readmission rates have been used as one outcome to evaluate the
quality of perinatal health care.1-3 Newborn readmission rates are related to the
length of hospital stay after birth,4,5 and are one measure of the impact of hospital
discharge policies.
Neonatal hospital readmission rates were estimated using hospitalization
data. Cases of neonatal readmission were identified by internal record linkage of
the Discharge Abstract Database (DAD), which involves matching live birth records
to cases of readmission.
T
Results
•
•
•
The neonatal hospital readmission rate increased significantly, from 2.8 per
100 live births in 1989 to 4.0 per 100 live births in 1997 (Figure 4.19).
Although many factors may contribute to neonatal readmission, the practice
of early discharge of newborns without application of guidelines6 may be
related to recently increasing neonatal readmission.
In 1997, neonatal readmission rates varied widely across Canadian provinces
and territories (Figure 4.20). The readmission rate was highest in the Northwest
Territories (6.8 per 100 live births) and lowest in Prince Edward Island
(1.5 per 100 live births). The provinces and territories with higher neonatal
readmission rates also tended to have shorter average length of hospital stay at
birth and earlier age at readmission.7
The most common reasons for neonatal readmission were neonatal jaundice,
feeding problems, sepsis, dehydration and inadequate weight gain (Figure
4.21). The causes for neonatal readmission changed considerably over time.
For example, neonatal jaundice accounted for 21.2% of readmissions in 1989,
compared with 38.7% in 1997.
Data Limitations
Concerns with regard to the accuracy and completeness of the record linkage may
arise due to newborn transfers and home births. As well, differences in health
status at birth, initial length of hospital stay and other issues may confound the
association between length of hospital stay at birth and neonatal readmission.
73
Canadian Perinatal Health Report, 2000
Although many
factors may
contribute to
neonatal
readmission,
the practice of
early discharge
of newborns
without
application
of guidelines
may be related
to recently
increasing
neonatal
readmission.
Fetal and Infant Health Outcomes
Rate of neonatal hospital readmission after discharge at birth,
Canada (excluding Québec, Nova Scotia and Manitoba),* 1989-1990 to 1997-1998
FIGURE 4.19
Readmitted newborns per 100 hospital live births
5
3.8
4
3 2.8
2.9
3.0
3.5
3.3
3.1
4.0
3.8
2
1
0
1989-1990
1991-1992
1993-1994
1995-1996
1997-1998
Fiscal year
Source: Canadian Institute for Health Information. Discharge Abstract Database,1989-1990 to 1997-1998.
* Québec data are not included in the DAD. Nova Scotia and Manitoba are excluded because complete
data for all years are not available in the DAD.
FIGURE 4.20
Rate of neonatal hospital readmission after discharge at birth,
by province/territory, Canada (excluding Québec and Manitoba),* 1997-1998
Newfoundland
Prince Edward Island
Nova Scotia
New Brunswick
Ontario
Saskatchewan
Alberta
British Columbia
Yukon
Northwest Territories
CANADA*
0
2
4
6
8
Readmitted newborns (95% CI) per 100 hospital live births
Source: Canadian Institute for Health Information. Discharge Abstract Database, 1997-1998.
* Québec data are not included in the DAD. Complete Manitoba data were not available.
CI — confidence interval.
74
Canadian Perinatal Health Report, 2000
10
Fetal and Infant Health Outcomes
FIGURE 4.21
Principal diagnosis for readmitted newborns,
Canada (excluding Québec, Nova Scotia and Manitoba)*, 1989-1990 and 1997-1998
Jaundice
Feeding problems
Sepsis
Dehydration
Inadequate weight gain
Others
1989-1990
1997-1998
0%
20%
40%
60%
80%
Percentage of readmitted newborns by principal diagnosis
Source: Canadian Institute for Health Information. Discharge Abstract Database, 1989-1990 and 1997-1998.
* Québec data are not included in the DAD. Nova Scotia and Manitoba are excluded because complete data for all
years are not available in the DAD.
References
1.
2.
3.
4.
5.
6.
7.
Braverman P, Egerter S, Pearl M, Marchi K, Miller C. Problems associated with early
discharge of newborn infants. Early discharge of newborns and mothers: a critical review
of the literature. Pediatrics 1995; 96: 716-26.
Liu LL, Clemens CJ, Shay DK, Davis RL, Novack AH. The safety of newborn early
discharge. The Washington State experience. J Am Med Assoc 1997; 278: 293-8.
Britton JR, Britton HL, Beebe SA. Early discharge of the term newborn: a continued
dilemma. Pediatrics 1994; 94: 291-5.
Lee KS, Perlman M, Ballantyne M, Elliott I, To T. Association between duration of neonatal
hospital stay and readmission rate. J Pediatr 1995; 127: 758-66.
Lee KS, Perlman M. The impact of early obstetric discharge on newborn health care. Curr
Opin Pediatr 1996; 8: 96-101.
Canadian Paediatric Society and Society of Obstetricians and Gynaecologists of Canada.
Facilitating discharge home following a normal term birth. Paediatr Child Health 1996;
1: 165-8.
Liu S, Wen SW, McMillan D, Trouton K, Fowler D, McCourt C. Increased neonatal
readmission rate associated with decreased length of hospital stay at birth in Canada. Can
J Public Health 2000; 91: 46-50.
75
Canadian Perinatal Health Report, 2000
100%
Bibliography
Abel EL (Ed.). Fetal Alcohol Syndrome, from Mechanism to Prevention. New York: CRC Press,
1996.
Abel EL. “Moderate” drinking during pregnancy: cause for concern? Clin Chim Acta 1996;
246: 149-54.
American Academy of Pediatrics, Work Group on Breastfeeding. Breastfeeding and the use of
human milk. Pediatrics 1997; 100: 1035-9.
Arbuckle TE, Wilkins R, Sherman GJ. Birth weight percentiles by gestational age in Canada.
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Argentine Episiotomy Trial Collaborative Group. Routine vs selective episiotomy: A randomised
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Baskett TF, Sternadel J. Maternal intensive care and near-miss mortality in obstetrics. Br J Obstet
Gynaecol 1998; 105: 981-4.
Behrman RE, Shiono PH. Neonatal risk factors. In: Fanhroff AA, Martin RJ (Eds.), NeonatalPerinatal Medicine. Diseases of the Fetus and Infant, 6th Edition. Vol. 1. St. Louis: Mosby
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C
Appendices
Appendix A
Data Sources and Methods
Data Sources
The principal data sources for this perinatal health report were vital statistics,
hospitalization data and the National Longitudinal Survey of Children and Youth
(NLSCY). Population estimates and abortion statistics from Statistics Canada, as
well as other peer-reviewed research were also used. Table A1 lists the principal
data sources for each indicator presented in this report. Following the table is a
description of each principal data source.
Table A1
Principal data sources for each indicator
Indicator
Data source
Vital statistics Hospitalization
Prevalence of prenatal smoking
Prevalence of prenatal alcohol consumption
Prevalence of breastfeeding
Rate of live births to teenagers
Rate of live births to older mothers
Labour induction rate
Cesarean section rate
Rate of operative vaginal deliveries
Rate of trauma to the perineum
Rate of early maternal discharge from hospital after childbirth
Rate of early neonatal discharge from hospital after birth
Maternal mortality ratio
Induced abortion ratio*
Ectopic pregnancy rate
Severe maternal morbidity ratio
Rate of maternal readmission after discharge following childbirth
Preterm birth rate
Postterm birth rate
Fetal growth: small-for-gestational-age rate,
large-for-gestational-age rate
Fetal and infant mortality rates
Severe neonatal morbidity rate
Multiple birth rate
Prevalence of congenital anomalies
Rate of neonatal hospital readmission after discharge at birth
* Includes abortions performed in abortion clinics.
87
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NLSCY
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
Appendix A
Vital Statistics
Registration of births and deaths is compulsory under provincial and territorial
Vital Statistics Acts or equivalent legislation. While the provincial and territorial
Vital Statistics Acts may vary slightly among the provinces and territories, they
follow a model Vital Statistics Act that was developed to promote uniformity of
legislation and reporting among the provinces and territories. Every year, the
provinces and territories send their birth, stillbirth and death registration data to
Statistics Canada. Statistics Canada compiles these data into national databases of
births, stillbirths and deaths, called the Canadian Vital Statistics System.1-4
The Canadian Vital Statistics System covers all births and deaths occurring in
Canada. Births and deaths of Canadian residents occurring in the United States
are also included, being reported under a reciprocal agreement. However, births
and deaths of Canadian residents occurring in countries other than Canada and
the United States are not reported.1 The preparation and maintenance of these
national databases requires incorporation of late registrations and amendments,
as well as the elimination of duplicate registrations.
As part of the Canadian Perinatal Surveillance System (CPSS) initiative,
Statistics Canada, under contract to the Bureau of Reproductive and Child
Health, has developed a mechanism by which information on live births and
infant deaths will be linked from 1985 onwards.5 With the permission of the
provinces and territories, the resulting birth-infant death linked analysis file is an
important data source for CPSS analyses. This file has personal identifiers
removed.
The birth and death statistics in this report may differ slightly from those
previously published by Statistics Canada, as a result of updates to the data files.
Data Quality
There are numerous strengths of national vital statistics data. Coverage for births
and deaths in the Canadian Vital Statistics System is nearly complete. Due to the
large number of records, analysis within subpopulations is possible. An
additional strength is that the legislation for the collection of vital statistics data
is similar across all provinces and territories, as are data forms, definitions and
collection methods. Data are also available at the individual level and can
therefore be linked to other data sources. Finally, causes of death are coded to an
international classification.6
A major limitation of national vital statistics data is that data are not available
on as timely a basis as would be desirable. Currently, the last year of available data
is 1997, which became available to the CPSS in the second half of 1999.
Additional limitations relate to the quality or completeness of some variables. For
example, due to concerns about the quality of gestational age and birth weight
data in Ontario, Ontario data were excluded from indicators which use these
variables. There may also be a small undercount in the number of live births
reported for Ontario each year. Data for Newfoundland in the national birth
database were incomplete prior to 1991; consequently, Newfoundland data were
excluded from temporal trends. Finally, cause of death information may not
always incorporate the results of coroner and medical examiner investigations.
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Appendix A
Hospitalization Data
Three sources of hospitalization data were utilized: the Canadian Institute for
Health Information’s (CIHI’s) Discharge Abstract Database (DAD), Manitoba
Health’s Perinatal Surveillance Database and the Canadian Congenital Anomalies
Surveillance System (CCASS).
Canadian Institute for Health Information’s Discharge
Abstract Database
CIHI maintains the DAD which captures hospital separation — transfer, discharge
or death — from the majority of Canada’s acute care hospitals. The DAD is an
electronic database that includes information on inpatient acute, chronic and
rehabilitation care and day surgery, accounting for about 85% of all acute care
inpatient discharges in Canada. The information is obtained directly from
participating hospitals.7 The DAD contains considerable data on each
hospitalization, including demographic and residence information, length of stay,
most responsible diagnosis, secondary and co-morbid diagnoses and procedures
performed during the hospitalization. Diagnoses are coded in the DAD according
to the International Classification of Diseases, Ninth Revision (ICD-9) and
procedures coded according to the Canadian Classification of Diagnostic,
Therapeutic and Surgical Procedures (CCP). The DAD also categorizes
hospitalizations by case mix group (CMG), a classification according to diagnosis
and intensity of care required.
Internal record linkage of the obstetric delivery record, the newborn record
and the readmission record in the DAD was performed to provide information
on neonatal and maternal readmission.
Data Quality
The Bureau of Reproductive and Child Health investigated and evaluated the DAD
to see if it could serve the needs of a national perinatal surveillance system.8,9 The
quality of data for delivering mothers and their newborns recorded in the DAD
from April 1, 1984 to March 31, 1995 was examined. The number of illogical and
out-of-range values in the CIHI data was found to be low, the occurrence of
maternal and infant diseases estimated from the data was similar to that in the
literature, and major medical or obstetric complications recorded in the DAD
were good predictors of adverse pregnancy outcomes.8
Major diagnoses and procedures appear to be well captured; however,
complex or obscure diagnoses are likely coded variably. Accuracy is also likely to
be lower for codes other than the primary or most responsible diagnosis. CIHI is
undertaking a quality assurance study of the DAD that will involve comparison
of information in charts with information coded in the DAD for a sample of
hospitals. The CPSS is collaborating with CIHI to expand this study to include
specific maternal and newborn diagnoses.
In addition to the general limitation of potential coding errors, there are
several other problems in using the DAD for national perinatal surveillance:
• Out-of-hospital births are not captured.
• Pregnancies with non-birth outcomes (e.g., terminations) may not be captured.
89
Canadian Perinatal Health Report, 2000
Appendix A
•
•
The DAD does not include all hospital admissions/separations in Canada.
Québec data are not included in the DAD, and data for Manitoba and Nova
Scotia are not complete for some years. Indicators which were calculated
using hospitalization data therefore exclude Nova Scotia and Manitoba from
temporal trends. Québec data are excluded from both interprovincial/territorial
comparisons and temporal trends using hospitalization data.
Currently, the DAD does not capture information on gestational age and parity.
Manitoba Health’s Perinatal Surveillance Database
Statistics based on hospitalization data from Manitoba were calculated by
Manitoba Health, using its Perinatal Surveillance Database. The following
description of the database was obtained from Manitoba Health.
The bulk of the data was obtained by linking obstetrical hospital records and
newborn hospital records dated April 1, 1984 to March 31, 1997. The Manitoba
Health hospital records were searched for obstetrical (mother) or newborn
admissions. The obstetrical and newborn records were linked together by
hospital of admission, mother’s hospital record number, newborn’s hospital
record number, Manitoba Health family registration number and surname.
Extensive verification of the linkage was conducted in the cases where mother’s
surname was not the same as the newborn’s surname. Most data lines contain
both mother and newborn information. Those mother records that did not link
to a newborn record were retained only if one of the mother’s diagnoses included
a stillborn v-code (V271, V274, V277), assuming that a newborn record was not
created for these births. All newborn records were retained because a newborn
record represented a birth regardless of whether a link could be made with a
maternal record. Manitoba Health medical coverage data were merged with the
linked records by a newborn’s personal health identification number (PHIN) to
add cancel codes and dates to this database.
The linked obstetrical-newborn database only identifies pregnancies that
resulted in a live birth or a stillbirth. To capture pregnancies which did not result
in a birth, the Manitoba Health hospital records were again searched, and all
obstetrical admissions regardless of outcome were summarized into a pregnancy
database. Using this pregnancy database it was possible to calculate rates of
reported ectopic pregnancies, molar pregnancies, spontaneous abortions
(miscarriages) and induced abortions, in addition to stillbirths and live births.
Data Quality
Manitoba Health hospital records share many of the features and limitations of
the data in the DAD. For example, pregnancies resulting in a home birth, an
induced abortion at a private clinic, or an unreported spontaneous abortion are
not captured in this database.
Canadian Congenital Anomalies Surveillance System
CCASS data are largely culled from the DAD. Additional data sources are also
relied upon, particularly to provide coverage of provinces poorly represented by
the DAD. The Manitoba hospitalization database is used in Manitoba, and
Québec data are from the Système de maintenance et d’exploitation des données
90
Canadian Perinatal Health Report, 2000
Appendix A
pour l’étude de la clientèle hospitalière (Med-Écho); these two systems are similar
to the DAD. Alberta uses its own reporting system, the Alberta Congenital
Anomalies Surveillance System (ACASS). The primary sources of data for ACASS
are vital statistics, hospital reporting and special communications with genetics
clinics, specialty paediatric clinics and laboratories.
Data Quality
The definition, interpretation and diagnosis of an anomaly can differ from one
physician to another. Certain anomalies can be excluded or included, and others
are not always evaluated against the same criteria, which can make reporting
varied and inaccurate. Some anomalies may be reported as part of a syndrome or
may be reported separately. All of these circumstances can produce variations in
rates nationally, provincially or even locally. Other factors contributing to
inaccuracies are trends and variations in use of prenatal diagnosis and pregnancy
termination and in hospitalization practices. Prenatally diagnosed fetuses with
congenital anomalies that are aborted are not included in the CCASS because the
DAD does not capture them. Hospitalization practices directly influence the
potential of discovering new cases of congenital anomalies with the DAD data.
The data provided by Alberta, Manitoba and Québec are not from the same
source and, therefore, are subject to their own limitations, including the ones
mentioned in the paragraph above. Another limitation of CCASS DAD-based
data is the possibility of duplicate data, since records of separate admissions of
the same infant with sometimes different congenital anomalies are present in the
DAD. Despite the fact that the records for the same infant are linked together,
this process is successful only if the relevant variables, such as date of birth,
sex, scrambled health insurance number, postal or geographic code and ICD-9
codes, are present and accurate. The accuracy and completeness of these variables
can vary and create inflated rates for some areas.
Other limitations of the DAD data are that they only cover births that occur
in hospitals and not all hospitals participate in the DAD. Additional limitations
include the lack of exposure and behaviour risk factors and mother’s past and
current pregnancy history; these data are nonexistent in the CCASS. Other
factors, such as coding, transcription and classification errors, can also contribute
to discrepancies in rates of congenital anomalies.
National Longitudinal Survey of Children and Youth10
The primary objective of the NLSCY is to develop a national database on the
characteristics and life experiences of Canadian children as they grow from
infancy to adulthood. The survey is conducted by Statistics Canada and collects
cross-sectional information as well as longitudinal data. Data collection began in
1994-1995 and will be repeated every two years to follow the children surveyed in
1994-1995. In subsequent years, a cross-sectional sample will be added for age
groups no longer covered by the longitudinal sample.
The public use microdata file of the 1996-1997 data collection cycle was used
for analyses. This file does not include data from the territories. Information on
prenatal smoking and alcohol consumption, and breastfeeding was available for
7,040 children 0-3 years old, representing approximately 284,000 children when
weighted. All rates were calculated using sample weights.
91
Canadian Perinatal Health Report, 2000
Appendix A
Data Quality
The survey is primarily designed for national-, regional- and some provincial/
territorial-level analysis. Analysis of subpopulations is limited by insufficient
sample sizes. Attrition may further reduce the sample size in subsequent data
collection cycles. Perinatal health information was often not detailed enough to
be used for in-depth analysis, and it may be subject to incorrect recall because it
was collected retrospectively up to three years after the birth of the child.
Perinatal health information may also be subject to a small selection bias because
it was collected only for children still living at the time the sample was selected.
Methods
Statistical methods were primarily descriptive, including frequencies, rates, percentages and means. Where events were rare or rates were based on a small sample,
caution should be exercised in interpreting results. Records with key information
missing were excluded from analyses. In the birth-infant death linked file, all live
births at < 22 weeks and < 500 g were assumed to have died on the first day of life
and were classified as such.
Statistics presented for most indicators consist of:
1. Temporal trends at the national level — The time period covered in the
temporal trends dates back as far as 1981, depending on the data sources used
and the particular indicator. If complete provincial data were not available for
all years of a temporal trend, data from that province were excluded from the
Canadian rates. In some cases, where events were rare, data for several years
were aggregated.
2. Interprovincial/territorial comparisons — Interprovincial/territorial comparisons are presented for the most recent year for which data were available.
In some cases, regional differences are assessed and interpreted using standard
errors and 95% confidence intervals. Separate statistics could not be
calculated for Nunavut as the time period covered in this report preceded the
creation of this new territory.
3. Comparisons by maternal age — Some indicators are analyzed by maternal
age, where available and appropriate.
The majority of indicators are presented graphically. However, data tables
corresponding to all figures are presented in Appendix E.
References
1.
2.
3.
4.
5.
Statistics Canada. Births and Deaths 1996, 1997. Ottawa: Statistics Canada, Health
Statistics Division, 1999 (Catalogue No. 84F0210-XPB (annual)).
Fair M. The development of national vital statistics in Canada: Part 1 — From 1605 to 1945.
Health Rep 1994; 6: 355-68.
Fair M, Cyr M. The Canadian Birth Data Base: a new research tool to study reproductive
outcomes. Health Rep 1993; 5: 281-90.
Smith ME, Newcombe HB. Use of the Canadian Mortality Data Base for epidemiologic
follow up. Can J Public Health 1982; 73: 39-45.
Fair M, Cyr M, Allen AC, Wen SW, Guyon G, MacDonald RC et al. Validation Study for a
Record Linkage of Births and Infant Deaths in Canada. Ottawa: Statistics Canada, 1999
(Catalogue No. 84F0013-XIE).
92
Canadian Perinatal Health Report, 2000
Appendix A
6.
World Health Organization. Manual of the International Statistical Classification of Diseases,
Injuries and Causes of Death. Based on the Recommendation of the Ninth Revision
Conference, 1975, Geneva.
7. Canadian Institute for Health Information. Website (www.cihi.ca). Accessed February 7, 2000.
8. Wen SW, Liu S, Marcoux S, Fowler D. Uses and limitations of routine hospital
admission/separation records for perinatal surveillance. Chron Dis Can 1997; 18: 113-9.
9. Liu S, Wen SW. Development of record linkage of hospital discharge data for the study of
neonatal readmission. Chron Dis Can 1999; 20: 77-81.
10. Statistics Canada, Human Resources Development Canada. National Longitudinal Survey
of Children and Youth, Overview of the Survey Instruments for 1996-97 Data Collection,
Cycle 2. Ottawa: Statistics Canada, 1997 (Catalogue No. 89F0078-XPE).
93
Canadian Perinatal Health Report, 2000
Appendix B
List of Perinatal Health Indicators
Rank Indicator
1
2
Page
62
3
Fetal and Infant Mortality Rates
Fetal Growth: Small-for-Gestational-Age Rate,
Large-for-Gestational-Age Rate
Preterm Birth Rate
4
5
6
Postterm Birth Rate
Maternal Mortality Ratio
Rate of Live Births to Teenage Mothers
56
39
12
7
8
9
Prevalence of Congenital Anomalies
Prevalence of Prenatal Smoking
Severe Maternal Morbidity Ratio
71
3
48
10
11
12
Cesarean Section Rate
Prevalence of Breastfeeding
Prevalence of Prenatal Alcohol Consumption
21
9
6
13
14
15
Multiple Birth Rate
Rate of Neonatal Hospital Readmission after Discharge at Birth
Ectopic Pregnancy Rate
69
73
45
16
17
18
Severe Neonatal Morbidity Rate
Use of Antenatal Steroids in < 34 Weeks
Induced Abortion Ratio
67
19
20
21
Labour Induction Rate
Rate of Maternal Readmission after Discharge following Childbirth
Proportion of Mothers with Low Weight Gain Rate
19
50
22
23
24
Rate of Operative Vaginal Deliveries
Rate of Early Neonatal Discharge from Hospital after Birth
Spontaneous Abortion Rate
24
33
25
Proportion of Births in Women with No First Trimester
Prenatal Visit
Rate of Mother/Infant Separation
Proportion of Mothers with a Low Pre-pregnancy
Body Mass Index (BMI)
26
27
95
Canadian Perinatal Health Report, 2000
59
53
42
Appendix B
Rank Indicator
Page
28
29
30
Rate of Early Maternal Discharge from Hospital after Childbirth
Proportion of Pregnant Women with a Low Educational Level
Prevalence of Exposure to Environmental Tobacco
Smoke during Pregnancy
31
32
33
Proportion of Pregnant Women Living without a Partner
Proportion of Pregnant Women Reporting No Social Support
Rate of General Anesthesia Use in Cesarean Deliveries
34
35
36
Rate of Regional Anesthesia Use in Deliveries
Use of Surfactant in Pregnancies of < 34 Weeks of Gestation
Resuscitation Rate in Low Birth Weight Neonates
37
38
Rate of Trauma to the Perineum
Proportion of Low Birth Weight Neonates with Low
Five-Minute Apgar Score
Proportion of Pregnant Women Reporting Physical Abuse
39
40
41
42
43
30
27
Proportion of Pregnant Women Reporting High Psychosocial Stress
Proportion of Low Birth Weight Neonates with Low Cord Blood pH
Proportion of Low Birth Weight Neonates with Abnormal
Cord Blood Base Deficit
Circumcision Rate
Additional Perinatal Health Indicators
Rate of Live Births to Older Mothers
Prevalence of Folic Acid Use in the Periconceptional Period
Rate of Prenatal Obstetrical Ultrasound Utilization
Rate of Assisted Conception
Prevalence of Group B Streptococcal Infection
Prevalence of Illicit Drug Use during Pregnancy
Prevalence of Postpartum Depression
Rate of Electronic Fetal Monitoring
Rate of Client Satisfaction with Services
96
Canadian Perinatal Health Report, 2000
15
Appendix C
List of Acronyms
ACASS
ARBD
CCASS
Alberta Congenital Anomalies Surveillance System
alcohol-related birth defect
Canadian Congenital Anomalies Surveillance System
CCP
CI
CIHI
Canadian Classification of Diagnostic, Therapeutic and Surgical
Procedures
confidence interval
Canadian Institute for Health Information
CMG
CPS
CPSS
case mix group
Canadian Paediatric Society
Canadian Perinatal Surveillance System
CS
DAD
DC
cesarean section
Discharge Abstract Database
Dieticians of Canada
FAS
ICD-9
IUGR
fetal alcohol syndrome
International Classification of Diseases, Ninth Revision
intrauterine growth restriction
LGA
large for gestational age
Med-Écho Système de maintenance et d’exploitation des données pour l’étude
de la clientèle hospitalière
MMR
maternal mortality ratio
NLSCY
NTD
PHIN
National Longitudinal Survey of Children and Youth
neural tube defect
personal health identification number
RDS
SD
SGA
respiratory distress syndrome
standard deviation
small for gestational age
SOGC
UNICEF
VBAC
WHO
Society of Obstetricians and Gynaecologists of Canada
United Nations Children’s Fund
vaginal birth after cesarean
World Health Organization
97
Canadian Perinatal Health Report, 2000
Appendix D
Components of Fetal-Infant Mortality*
Fetal-infant mortality
Perinatal mortality
Fetal mortality
Early
Infant mortality
Late
Early
20 weeks 28 weeks
Postneonatal mortality
Neonatal mortality
Birth
Late
7 days
28 days
1 year
* Adapted from Péron Y, Strohmenger C. Demographic and Health Indicators: Presentation and Interpretation.
Ottawa: Minister of Supply and Services Canada, 1985 (Catalogue No. 82-543E); and Monnier A. Les méthodes
d’analyse de la mortalité infantile. In: Manuel d’analyse de la mortalité. Paris: INED, 1985: 52-5.
In calculating the fetal-infant mortality rate, perinatal mortality rate and stillbirth rate, the denominator reflects total
births (live births and stillbirths), whereas in calculating the infant mortality rate, neonatal mortality rate (early and
late) and postneonatal mortality rate, the denominator includes only live births.
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Canadian Perinatal Health Report, 2000
Appendix E
List of Data Tables
Table E1.1 Prevalence of selected maternal behaviours, by maternal age and
region/province, Canada (excluding the territories), 1996-1997 .................... 105
Table E1.2 Number of live births, by maternal age, Canada (excluding
Newfoundland), 1981-1997 .............................................................................. 106
Table E1.3 Number of females, by age, Canada (excluding Newfoundland),
1981-1997............................................................................................................ 106
Table E1.4 Percent of live births, by maternal age, Canada (excluding
Newfoundland), 1981-1997 .............................................................................. 107
Table E1.5 Age-specific live birth rates per 1,000 females, Canada (excluding
Newfoundland), 1981-1997 .............................................................................. 107
Table E2.1 Number and rate of labour inductions, by province/territory, Canada
(excluding Québec), 1997-1998 ........................................................................ 108
Table E2.2 Number and rate of total and primary cesarean sections (CS),
Canada (excluding Québec, Manitoba and Nova Scotia), 1994-1995 to 19971998 .................................................................................................................... 108
Table E2.3 Number and rate of repeat cesarean sections (CS), Canada
(excluding Québec, Manitoba and Nova Scotia), 1994-1995 to 1997-1998...... 108
Table E2.4 Number and rate of operative vaginal deliveries, by province/
territory, Canada (excluding Québec), 1997-1998 .......................................... 109
Table E2.5 Number and rate of vaginal deliveries by forceps, by province/
territory, Canada (excluding Québec), 1997-1998 .......................................... 109
Table E2.6 Number and rate of vaginal deliveries by vacuum extractions, by
province/territory, Canada (excluding Québec), 1997-1998 .......................... 110
Table E2.7 Number and rate of perineal lacerations, Canada (excluding Québec,
Nova Scotia and Manitoba), 1989-1990 to 1997-1998 .................................... 110
Table E2.8 Number and rate of episiotomies, Canada, 1989-1990 to
1997-1998............................................................................................................ 111
Table E2.9 Number and rate of episiotomies, by province/territory, Canada
(excluding Québec), 1997-1998 ........................................................................ 111
101
Canadian Perinatal Health Report, 2000
Appendix E
Table E2.10 Number and rate of short maternal length of stay (LOS) for
childbirth (vaginal and cesarean deliveries), Canada (excluding Québec, Nova
Scotia and Manitoba), 1989-1990 to 1997-1998 .............................................. 112
Table E2.11 Number and rate of short maternal length of stay (LOS) for
childbirth (vaginal deliveries), by province/territory, Canada (excluding
Québec), 1997-1998 .......................................................................................... 112
Table E2.12 Number and rate of short maternal length of stay (LOS) for
childbirth (cesarean deliveries), by province/territory, Canada (excluding
Québec), 1997-1998 .......................................................................................... 113
Table E2.13 Number and rate of early neonatal discharge from hospital after
birth, Canada (excluding Québec, Nova Scotia and Manitoba), 1989-1990 to
1997-1998............................................................................................................ 113
Table E2.14 Number and rate of early neonatal discharge from hospital after
birth, by province/territory, Canada (excluding Québec), 1997-1998 ............ 114
Table E3.1 Number of maternal deaths and maternal mortality ratios (MMR),
by direct and indirect causes, Canada, for five-year intervals, 1973-1977 to
1993-1997............................................................................................................ 114
Table E3.2 Number, ratio and rate of induced abortions, Canada,
1990-1997............................................................................................................ 115
Table E3.3 Number, ratio and rate of induced abortions, by province/territory,
Canada, 1997 ...................................................................................................... 115
Table E3.4 Number and rate of age-specific induced abortions, Canada,
1997 .................................................................................................................... 116
Table E3.5 Number and rate of ectopic pregnancies, Canada (excluding
Québec, Nova Scotia and Manitoba), 1989-1990 to 1997-1998...................... 116
Table E3.6 Number and rate of ectopic pregnancies, by province/territory,
Canada (excluding Québec), 1997-1998 .......................................................... 117
Table E3.7 Number and rate of ectopic pregnancies, by maternal age, Canada
(excluding Québec), 1997-1998 ........................................................................ 117
Table E3.8 Number and rate of maternal readmissions within three months
of discharge from hospital following childbirth, Canada (excluding Québec,
Nova Scotia and Manitoba), 1990-1991 to 1997-1998 .................................... 118
Table E3.9 Number and rate of maternal readmissions within three months
of discharge from hospital following childbirth (vaginal deliveries), by province/
territory, Canada (excluding Québec), 1995-1996 to 1997-1998 .................... 118
Table E3.10 Number and rate of maternal readmissions within three months of
discharge from hospital following childbirth (cesarean deliveries), by province/
territory, Canada (excluding Québec), 1995-1996 to 1997-1998 .................... 119
Table E3.11 Number of maternal readmissions within three months of
discharge from hospital following childbirth, by primary diagnosis, Canada
(excluding Québec), 1995-1996 to 1997-1998.................................................. 119
102
Canadian Perinatal Health Report, 2000
Appendix E
Table E4.1 Number and rate of preterm births, Canada (excluding
Ontario and Newfoundland), 1981-1997 ........................................................ 120
Table E4.2 Number and rate of preterm births (singleton and multiple
births), Canada (excluding Ontario), 1997 ...................................................... 120
Table E4.3 Number and rate of preterm births, by province/territory,
Canada (excluding Ontario), 1997.................................................................... 121
Table E4.4 Number and rate of postterm births, Canada (excluding
Ontario and Newfoundland), 1988-1997 ........................................................ 121
Table E4.5 Number and rate of postterm births, by province/territory,
Canada (excluding Ontario), 1997.................................................................... 122
Table E4.6 Numbers and rates of small-for-gestational-age (SGA) and
large-for-gestational-age (LGA) babies, Canada (excluding Ontario and
Newfoundland), 1988-1997 .............................................................................. 122
Table E4.7 Numbers and rates of small-for-gestational-age (SGA) and largefor-gestational-age (LGA) babies, by province/territory, Canada (excluding
Ontario), 1997 .................................................................................................... 123
Table E4.8 Number and rate of fetal deaths, Canada (excluding Ontario and
Newfoundland), 1988-1997 .............................................................................. 123
Table E4.9 Number and rate of fetal deaths, by province/territory, Canada
(excluding Ontario), 1997.................................................................................. 124
Table E4.10 Number and rate of neonatal (0-27 days) deaths, Canada
(excluding Newfoundland), 1988-1997 ............................................................ 124
Table E4.11 Number and rate of neonatal (0-27 days) deaths, by province/
territory, Canada, 1997 ...................................................................................... 125
Table E4.12 Number and rate of postneonatal (28-364 days) deaths, Canada
(excluding Newfoundland), 1988-1997 ............................................................ 125
Table E4.13 Number and rate of postneonatal (28-364 days) deaths, by
province/territory, Canada, 1997 ...................................................................... 126
Table E4.14 Number of infant deaths and infant mortality rate, Canada
(excluding Newfoundland), 1988-1997 ............................................................ 126
Table E4.15 Number of infant deaths and infant mortality rate, by province/
territory, Canada, 1997 ...................................................................................... 127
Table E4.16 Infant mortality rate, by gestational age, Canada (excluding
Ontario), 1994-1996 .......................................................................................... 127
Table E4.17 Infant mortality rate, by birth weight, Canada (excluding Ontario),
1994-1996............................................................................................................ 128
Table E4.18 Number of infant deaths, by gestational age and province/territory,
Canada (excluding Ontario), 1992-1996 .......................................................... 128
Table E4.19 Number of live births, by gestational age and province/territory,
Canada (excluding Ontario), 1992-1996 .......................................................... 129
Table E4.20 Infant mortality rate, by gestational age and province/territory,
Canada (excluding Ontario), 1992-1996 .......................................................... 130
103
Canadian Perinatal Health Report, 2000
Appendix E
Table E4.21 Number of infant deaths, by birth weight and province/territory,
Canada (excluding Ontario), 1992-1996 .......................................................... 131
Table E4.22 Number of live births, by birth weight and province/territory,
Canada (excluding Ontario), 1992-1996 .......................................................... 131
Table E4.23 Infant mortality rate, by birth weight and province/territory,
Canada (excluding Ontario), 1992-1996 .......................................................... 132
Table E4.24 Number of cases and rate of respiratory distress syndrome
(RDS), Canada (excluding Québec, Nova Scotia and Manitoba),
1989-1990 to 1997-1998 .................................................................................... 133
Table E 4.25 Number of cases and rate of respiratory distress syndrome
(RDS), by province/territory, Canada (excluding Québec), 1997-1998.......... 133
Table E4.26 Number and rate of multiple births, Canada (excluding
Newfoundland), 1988-1997 .............................................................................. 134
Table E4.27 Number and rate of multiple births, by province/territory,
Canada, 1997 ...................................................................................................... 134
Table E4.28 Number of cases and rate of neural tube defects (NTD), Canada
(excluding Québec and Nova Scotia), 1989-1997 ............................................ 135
Table E4.29 Number of cases and rate of neural tube defects (NTD), by
province/territory, Canada (excluding Québec), 1997 .................................... 135
Table E4.30 Number and rate of neonatal hospital readmissions after
discharge at birth, Canada (excluding Québec, Nova Scotia and Manitoba),
1989-1990 to 1997-1998 .................................................................................... 136
Table E4.31 Number and rate of neonatal hospital readmissions after
discharge at birth, by province/territory, Canada (excluding Québec and
Manitoba), 1997-1998........................................................................................ 136
Table E4.32 Principal diagnosis for readmitted newborns, Canada (excluding
Québec, Nova Scotia and Manitoba), 1989-1990 and 1997-1998 .................. 137
104
Canadian Perinatal Health Report, 2000
Appendix E
Data Tables
Table E1.1
Prevalence of selected maternal behaviours, by maternal age and
region/province, Canada (excluding the territories),† 1996-1997
Percent of children aged 0-3 years whose mother reported selected behaviours
Prenatal
smoking
Prenatal
alcohol
consumption
Breastfeeding
Any breast- Breastfed at least
feeding
three months*
Maternal age (years)
< 20
20-24
25-29
30-34
≥ 35
40.5**
33.5
24.5
16.9
17.2
—
11.7***
14.1
16.4
22.6
72.5
70.7
74.1
79.4
78.2
31.6**
38.9
47.7
59.1
59.2
Region/Province
Atlantic Provinces
Québec
Ontario
Prairie Provinces
British Columbia
25.2
25.8
18.8
21.0
18.6
7.7**
24.9
13.8
16.1
14.9
65.3
57.7
81.2
88.0
89.0
40.6
34.8
59.2
63.2
65.2
CANADA†
21.3
16.6
76.7
53.6
Source: Statistics Canada. National Longitudinal Survey of Children and Youth (Public Use Microdata Files), 1996-1997.
† Data for the territories are not available in the Public Use Microdata Files. Percentages were calculated from a sample
of 7,040 children weighted to represent approximately 284,000 children 0-3 years old.
* Children less than three months old were excluded from “breastfed at least three months” calculations.
** Estimate is based on a small sample size.
*** Further categorization of age was not possible due to a small sample size. Estimate based on population < 25.
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Canadian Perinatal Health Report, 2000
Appendix E
Table E1.2
Number of live births, by maternal age,
Canada (excluding Newfoundland),* 1981-1997
Year 10-14
years
15-19
years
20-24
years
25-29
years
30-34
years
35-39
years
40-44
years
45-49
years
50-54
years
Number of births Total live
unknown age
births
1981
1982
1983
268
281
222
29,054
28,258
25,377
110,535
109,915
107,199
135,581
136,880
139,651
67,668
68,704
71,506
15,328
17,092
18,293
2,080
2,113
2,111
113
95
100
3
2
0
457
216
181
361,087
363,556
364,640
1984
1985
1986
248
225
210
23,635
22,089
21,448
103,226
98,257
92,905
143,031
143,817
143,545
75,847
79,109
81,422
19,977
21,040
22,414
2,181
2,317
2,536
85
82
85
1
1
0
151
165
144
368,382
367,102
364,709
1987
1988
1989
235
224
214
20,975
21,075
22,479
86,576
83,415
83,070
142,700
146,013
150,727
84,567
89,269
96,513
23,695
25,847
28,134
2,863
3,283
3,567
100
106
96
2
1
1
164
14
22
361,877
369,247
384,823
1990
1991
1992
239
261
255
23,175
23,370
23,215
81,727
78,735
75,827
154,257 103,352
147,530 106,132
143,042 109,853
31,064
32,720
34,589
3,856
4,072
4,495
99
135
106
0
0
3
42
2,407
333
397,811
395,362
391,718
1993
1994
1995
249
239
232
22,783
23,117
22,863
73,458
71,654
69,634
133,163 110,735
127,493 112,222
119,968 113,122
36,349
38,134
40,060
4,809
5,232
5,593
139
129
192
5
13
2
274
534
483
381,964
378,767
372,149
1996
1997
221
214
21,065
19,208
66,149
62,291
114,784 109,554
108,379 103,729
42,249
42,679
6,014
6,334
204
207
4
3
206
127
360,450
343,171
Source: Statistics Canada. Canadian Vital Statistics System, 1981-1997.
* Newfoundland is excluded because data are not available nationally prior to 1991.
Table E1.3
Number of females, by age,
Canada (excluding Newfoundland),* 1981-1997
Year
10-14
years
15-19
years
20-24
years
25-29
years
30-34
years
35-39
years
40-44
years
45-49
years
50-54
years
1981
1982
1983
912,514
900,493
890,157
1,126,623
1,087,206
1,036,757
1,200,228
1,206,223
1,208,099
1,096,612
1,132,310
1,158,596
1,011,583
1,018,188
1,032,397
801,399
859,743
903,098
658,347
680,386
710,081
611,182
611,049
613,125
612,637
615,857
616,357
1984
1985
1986
879,227
870,361
859,698
988,796
952,515
938,235
1,206,945
1,196,540
1,169,683
1,174,705
1,185,387
1,200,402
1,056,864
1,088,432
1,117,845
940,317
975,230
1,004,374
739,933
769,788
804,885
622,900
633,454
649,427
614,207
610,541
609,125
1987
1988
1989
862,801
868,625
880,788
925,569
920,019
918,194
1,127,939
1,078,365
1,046,999
1,216,479
1,232,886
1,254,392
1,151,278
1,179,953
1,211,740
1,018,661
1,044,862
1,083,214
862,386
907,981
955,249
675,066
709,155
743,764
607,687
609,612
621,877
1990
1991
1992
890,472
901,471
915,144
916,469
910,497
911,820
1,018,392
1,001,166
992,553
1,249,956
1,212,408
1,176,907
1,236,814
1,258,909
1,268,587
1,121,282
1,149,248
1,182,540
1,000,838
1,039,446
1,049,562
776,940
813,224
871,527
635,391
655,438
680,688
1993
1994
1995
929,615
942,994
951,014
915,955
927,831
940,270
981,417
973,231
967,452
1,131,569
1,091,747
1,062,096
1,279,302
1,284,201
1,278,105
1,213,249
1,237,836
1,260,509
1,070,253
1,100,021
1,134,954
920,355
966,378
1,010,283
713,443
746,575
779,258
1996
1997
957,088
962,692
955,491
965,064
965,195
970,964
1,048,730
1,040,734
1,252,834
1,222,368
1,284,677
1,301,633
1,167,632
1,206,279
1,046,014
1,057,933
814,456
873,955
Source: Statistics Canada. Canadian female population estimates, 1981-1997.
* Newfoundland is excluded because data are not available nationally prior to 1991.
106
Canadian Perinatal Health Report, 2000
Appendix E
Table E1.4
Percent of live births, by maternal age,
Canada (excluding Newfoundland),* 1981-1997
Year
10-14
years
15-19
years
20-24
years
25-29
years
30-34
years
35-39
years
40-44
years
45-54
years
1981
1982
1983
0.07
0.08
0.06
8.06
7.78
6.96
30.65
30.25
29.41
37.60
37.67
38.32
18.76
18.91
19.62
4.25
4.70
5.02
0.58
0.58
0.58
0.03
0.03
0.03
1984
1985
1986
0.07
0.06
0.06
6.42
6.02
5.88
28.03
26.78
25.48
38.84
39.19
39.37
20.60
21.56
22.33
5.43
5.73
6.15
0.59
0.63
0.70
0.02
0.02
0.02
1987
1988
1989
0.06
0.06
0.06
5.80
5.71
5.84
23.93
22.59
21.59
39.45
39.54
39.17
23.38
24.18
25.08
6.55
7.00
7.31
0.79
0.89
0.93
0.03
0.03
0.03
1990
1991
1992
0.06
0.07
0.07
5.83
5.95
5.93
20.55
20.04
19.37
38.78
37.54
36.55
25.98
27.01
28.07
7.81
8.33
8.84
0.97
1.04
1.15
0.02
0.03
0.03
1993
1994
1995
0.07
0.06
0.06
5.97
6.11
6.15
19.25
18.94
18.74
34.89
33.71
32.28
29.01
29.67
30.44
9.52
10.08
10.78
1.26
1.38
1.50
0.04
0.04
0.05
1996
1997
0.06
0.06
5.85
5.60
18.36
18.16
31.86
31.59
30.41
30.24
11.73
12.44
1.67
1.85
0.06
0.06
Source: Statistics Canada. Canadian Vital Statistics System, 1981-1997.
* Newfoundland is excluded because data are not available nationally prior to 1991.
Table E1.5
Age-specific live birth rates per 1,000 females,
Canada (excluding Newfoundland),* 1981-1997
Year
10-14
years
15-19
years
20-24
years
25-29
years
30-34
years
35-39
years
40-44
years
45-49
years
50-54
years
1981
1982
1983
0.29
0.31
0.25
25.79
25.99
24.48
92.10
91.12
88.73
123.64
120.89
120.53
66.89
67.48
69.26
19.13
19.88
20.26
3.16
3.11
2.97
0.18
0.16
0.16
0.00
0.00
0.00
1984
1985
1986
0.28
0.26
0.24
23.90
23.19
22.86
85.53
82.12
79.43
121.76
121.32
119.58
71.77
72.68
72.84
21.24
21.57
22.32
2.95
3.01
3.15
0.14
0.13
0.13
0.00
0.00
0.00
1987
1988
1989
0.27
0.26
0.24
22.66
22.91
24.48
76.76
77.35
79.34
117.31
118.43
120.16
73.45
75.65
79.65
23.26
24.74
25.97
3.32
3.62
3.73
0.15
0.15
0.13
0.00
0.00
0.00
1990
1991
1992
0.27
0.29
0.28
25.29
25.67
25.46
80.25
78.64
76.40
123.41
121.68
121.54
83.56
84.30
86.59
27.70
28.47
29.25
3.85
3.92
4.28
0.13
0.17
0.12
0.00
0.00
0.00
1993
1994
1995
0.27
0.25
0.24
24.87
24.92
24.32
74.85
73.62
71.98
117.68
116.78
112.95
86.56
87.39
88.51
29.96
30.81
31.78
4.49
4.76
4.93
0.15
0.13
0.19
0.01
0.02
0.00
1996
1997
0.23
0.22
22.05
19.90
68.53
64.15
109.45
104.14
87.44
84.86
32.89
32.79
5.15
5.25
0.20
0.20
0.00
0.00
Sources: Statistics Canada. Canadian Vital Statistics System, 1981-1997.
Statistics Canada. Canadian female population estimates, 1981-1997.
* Newfoundland is excluded because data are not available nationally prior to 1991.
107
Canadian Perinatal Health Report, 2000
Appendix E
Table E2.1
Number and rate of labour inductions, by province/territory,
Canada (excluding Québec),* 1997-1998
Province/Territory
Number of
labour inductions
Number of
hospital deliveries
Inductions (95% CI)
per 100 hospital deliveries
Newfoundland
Prince Edward Island
Nova Scotia
New Brunswick
Ontario
Manitoba
Saskatchewan
Alberta
British Columbia
Yukon
Northwest Territories
1,047
277
1,974
1,295
24,170
2,918
2,703
8,024
7,171
64
122
5,290
1,481
9,756
7,963
135,616
14,833
12,318
36,254
43,529
427
1,166
19.8
18.7
20.2
16.3
17.8
19.7
21.9
22.1
16.5
15.0
10.4
(18.7-20.9)
(16.7-20.7)
(19.4-21.0)
(15.5-17.1)
(17.6-18.0)
(19.0-20.3)
(21.2-22.7)
(21.7-22.6)
(16.1-16.8)
(11.7-18.7)
(8.7-12.3)
CANADA*
49,765
268,633
18.5
(18.4-18.7)
Sources: Canadian Institute for Health Information. Discharge Abstract Database, 1997-1998.
Manitoba Health, Epidemiology Unit. Perinatal Surveillance Database, 1997-1998.
* Québec data are not included in the Discharge Abstract Database (DAD).
CI — confidence interval.
Table E2.2
Number and rate of total and primary cesarean sections (CS),
Canada (excluding Québec, Nova Scotia and Manitoba),* 1994-1995 to 1997-1998
Year
1994-1995
1995-1996
1996-1997
1997-1998
Number
of CS
Number of
hospital
deliveries
CS per 100
hospital
deliveries
Number of
primary
CS
Number of
births, no
previous CS
Primary CS per
100 hospital
deliveries
47,394
47,194
46,682
46,513
266,055
261,834
250,593
244,044
17.8
18.0
18.6
19.1
30,463
30,312
30,187
30,241
241,372
236,438
225,796
219,676
12.6
12.8
13.4
13.8
Source: Canadian Institute for Health Information. Discharge Abstract Database, 1994-1995 to 1997-1998.
* Québec data are not included in the DAD. Nova Scotia and Manitoba are excluded because complete data
for all years are not available in the DAD.
Table E2.3
Number and rate of repeat cesarean sections (CS),
Canada (excluding Québec, Nova Scotia and Manitoba),* 1994-1995 to 1997-1998
Year
1994-1995
1995-1996
1996-1997
1997-1998
Number of
women with
previous CS
Number of
hospital
deliveries
24,683
25,396
24,797
24,368
266,055
261,834
250,593
244,044
Percent of
women with a
previous CS
9.3
9.7
9.9
10.0
Number of Percent of CS
repeat
among women
CS
with a previous CS
16,931
16,882
16,495
16,272
68.6
66.5
66.5
66.8
Source: Canadian Institute for Health Information. Discharge Abstract Database, 1994-1995 to 1997-1998.
* Québec data are not included in the DAD. Nova Scotia and Manitoba are excluded because complete data
for all years are not available in the DAD.
** The observed increase over time in the percent of women with previous cesarean delivery may be due to
an increased tendency to record previous cesarean delivery in the hospital discharge abstract.
108
Canadian Perinatal Health Report, 2000
Appendix E
Table E2.4
Number and rate of operative vaginal deliveries, by province/territory,
Canada (excluding Québec),* 1997-1998
Province/Territory
Number of
operative
vaginal deliveries
Number of
hospital
vaginal deliveries
Operative vaginal
deliveries (95% CI) per 100
hospital vaginal deliveries
Newfoundland
Prince Edward Island
Nova Scotia
New Brunswick
Ontario
Manitoba
Saskatchewan
Alberta
British Columbia
Yukon
Northwest Territories
730
115
1,074
1,130
20,780
979
1,925
5,642
5,125
56
55
4,051
1,170
7,936
6,207
109,856
12,392
10,360
30,272
34,221
364
1,030
18.0
9.8
13.5
18.2
18.9
7.9
18.5
18.6
14.9
15.4
5.3
(16.8-19.2)
(8.2-11.7)
(12.8-14.3)
(17.2-19.2)
(18.7-19.1)
(7.4-8.4)
(17.8-19.3)
(18.2-19.0)
(14.6-15.3)
(11.8-19.5)
(4.0-6.9)
CANADA*
37,611
217,859
17.2
(17.1-17.4)
Sources: Canadian Institute for Health Information. Discharge Abstract Database, 1997-1998.
Manitoba Health, Epidemiology Unit. Perinatal Surveillance Database, 1997-1998.
* Québec data are not included in the DAD.
CI — confidence interval.
Table E2.5
Number and rate of vaginal deliveries by forceps, by province/territory,
Canada (excluding Québec),* 1997-1998
Province/Territory
Newfoundland
Prince Edward Island
Nova Scotia
New Brunswick
Ontario
Manitoba
Saskatchewan
Alberta
British Columbia
Yukon
Northwest Territories
CANADA*
Number of
forceps deliveries
Number of hospital
vaginal deliveries
Forceps use (95% CI) per 100
hospital vaginal deliveries
350
53
677
550
8,925
358
541
2,250
2,325
4
12
4,051
1,170
7,936
6,207
109,856
12,392
10,360
30,272
34,221
364
1,030
8.6
4.5
8.5
8.8
8.1
2.9
5.2
7.4
6.8
1.1
1.2
(7.8-9.5)
(3.4-5.9)
(7.9-9.1)
(8.2-9.6)
(8.0-8.3)
(2.6-3.2)
(4.8-5.6)
(7.1-7.7)
(6.5-7.1)
(0.3-2.8)
(0.6-2.0)
16,045
217,859
7.4
(7.2-7.5)
Sources: Canadian Institute for Health Information. Discharge Abstract Database, 1997-1998.
Manitoba Health, Epidemiology Unit. Perinatal Surveillance Database, 1997-1998.
* Québec data are not included in the DAD.
CI — confidence interval.
109
Canadian Perinatal Health Report, 2000
Appendix E
Table E2.6
Number and rate of vaginal deliveries by vacuum extractions,
by province/territory, Canada (excluding Québec),* 1997-1998
Province/Territory
Number of
vacuum extractions
Number of hospital
vaginal deliveries
Vacuum extractions (95% CI) per
100 hospital vaginal deliveries
Newfoundland
Prince Edward Island
Nova Scotia
New Brunswick
Ontario
Manitoba
Saskatchewan
Alberta
British Columbia
Yukon
Northwest Territories
387
67
407
698
12,411
621
1,534
3,778
2,972
53
43
4,051
1,170
7,936
6,207
109,856
12,392
10,360
30,272
34,221
364
1,030
9.5
5.7
5.1
11.2
11.3
5.0
14.8
12.5
8.7
14.6
4.2
(8.7-10.5)
(4.5-7.2)
(4.7-5.6)
(10.5-12.0)
(11.1-11.5)
(4.6-5.4)
(14.1-15.5)
(12.1-12.8)
(8.4-9.0)
(11.1-18.6)
(3.0-5.6)
CANADA*
22,971
217,859
10.5
(10.4-10.7)
Sources: Canadian Institute for Health Information. Discharge Abstract Database, 1997-1998.
Manitoba Health, Epidemiology Unit. Perinatal Surveillance Database, 1997-1998.
* Québec data are not included in the DAD.
CI — confidence interval.
Table E2.7
Number and rate of perineal lacerations,
Canada (excluding Québec, Nova Scotia and Manitoba),* 1989-1990 to 1997-1998
Year
Number of
first- and
second-degree
lacerations
Number of
third- and
fourth-degree
lacerations
Number of
hospital
vaginal
deliveries
First- and seconddegree lacerations
per 100 hospital
vaginal deliveries
Third- and fourthdegree lacerations
per 100 hospital
vaginal deliveries
1989-1990
1990-1991
1991-1992
63,784
70,453
77,950
8,188
9,085
9,175
213,440
221,711
223,236
29.9
31.8
34.9
3.8
4.1
4.1
1992-1993
1993-1994
1994-1995
86,255
92,228
97,735
8,962
8,611
8,599
220,579
217,595
218,661
39.1
42.4
44.7
4.1
4.0
3.9
1995-1996
1996-1997
1997-1998
100,092
98,190
96,477
7,934
7,875
7,527
214,640
203,911
197,531
46.6
48.2
48.8
3.7
3.9
3.8
Source: Canadian Institute for Health Information. Discharge Abstract Database, 1989-1990 to 1997-1998.
* Québec data are not included in the Discharge Abstract Database. Nova Scotia and Manitoba are excluded
because complete data for all years are not available in the DAD.
110
Canadian Perinatal Health Report, 2000
Appendix E
Table E2.8
Number and rate of episiotomies,
Canada,* 1989-1990 to 1997-1998
Year
Number of
episiotomies
Number of hospital
vaginal deliveries
Episiotomies per 100
hospital vaginal deliveries
1989-1990
1990-1991
1991-1992
173,128
169,077
157,093
314,936
328,364
328,601
55.0
51.5
47.8
1992-1993
1993-1994
1994-1995
139,259
121,405
No data**
327,250
321,857
218,661
42.6
37.7
No data**
1995-1996
1996-1997
1997-1998
No data**
55,118
50,140
214,640
203,911
197,531
No data**
27.0
25.4
Sources: Canadian Institute for Health Information. Discharge Abstract Database, 1989-1997.
Graham et al., 1997.
* 1996-1997 to 1997-1998 episiotomy data exclude Québec, Nova Scotia and Manitoba. Québec data
are not included in the DAD. Nova Scotia and Manitoba are excluded because complete data for all years
are not available in the DAD.
** There are no available episiotomy data for 1994-1995 or 1995-1996.
Table E2.9
Number and rate of episiotomies, by province/territory,
Canada (excluding Québec),* 1997-1998
Province/Territory
Number of
episiotomies
Number of
hospital vaginal
deliveries
Episiotomies (95% CI)
per 100 hospital
vaginal deliveries
Newfoundland
Prince Edward Island
Nova Scotia
New Brunswick
Ontario
Manitoba
Saskatchewan
Alberta
British Columbia
Yukon
Northwest Territories
1,091
411
2,073
1,994
30,479
2,678
2,383
6,680
7,004
22
76
4,051
1,170
7,936
6,207
109,856
12,392
10,360
30,272
34,221
364
1,030
26.9
35.1
26.1
32.1
27.7
21.6
23.0
22.1
20.5
6.0
7.4
(25.6-28.3)
(32.4-37.9)
(25.2-27.1)
(31.0-33.3)
(27.5-28.0)
(20.9-22.3)
(22.2-23.8)
(21.6-22.5)
(20.0-20.9)
(3.8-9.0)
(5.9-9.1)
CANADA*
54,891
217,859
25.2
(25.0-25.4)
Sources: Canadian Institute for Health Information. Discharge Abstract Database, 1997-1998.
Manitoba Health, Epidemiology Unit. Perinatal Surveillance Database, 1997-1998.
* Québec data are not included in the DAD.
CI — confidence interval.
111
Canadian Perinatal Health Report, 2000
Appendix E
Table E2.10
Number and rate of short maternal length of stay (LOS) for childbirth
(vaginal and cesarean deliveries), Canada (excluding Québec, Nova Scotia and Manitoba),*
1989-1990 to 1997-1998
Year
Vaginal deliveries LOS < 2 days
Number of
women
with LOS
< 2 days
Number of
hospital
deliveries
Hospital deliveries
with LOS < 2 days
per 100 hospital
vaginal deliveries
1989-1990
1990-1991
1991-1992
6,801
7,781
10,071
213,440
221,711
223,236
3.2
3.5
4.5
1992-1993
1993-1994
1994-1995
13,276
1,954
36,294
220,579
217,595
218,661
1995-1996
1996-1997
1997-1998
47,593
46,788
50,495
214,640
203,911
197,531
Cesarean deliveries LOS < 4 days
Number of
women
with LOS
< 4 days
Number of
hospital
deliveries
Hospital deliveries
with LOS < 4 days
per 100 hospital
cesarean deliveries
1,099
1,337
1,685
52,336
53,073
51,347
2.1
2.5
3.3
6.0
9.0
16.6
2,736
4,647
8,174
49,741
48,456
47,394
5.5
9.6
17.3
22.2
23.0
25.6
10,962
12,295
14,556
47,194
46,682
46,513
23.2
26.3
31.3
Source: Canadian Institute for Health Information. Discharge Abstract Database, 1989-1990 to 1997-1998.
* Québec data are not included in the DAD. Nova Scotia and Manitoba are excluded because complete data for all years are not available in the
DAD.
Table E2.11
Number and rate of short maternal length of stay (LOS) for childbirth
(vaginal deliveries), by province/territory, Canada (excluding Québec),* 1997-1998
Province/Territory
Number of
women with
LOS < 2 days
Number of
hospital vaginal
deliveries
Hospital deliveries (95% CI)
with LOS < 2 days per 100
hospital vaginal deliveries
Newfoundland
Prince Edward Island
Nova Scotia
New Brunswick
Ontario
Manitoba**
Saskatchewan
Alberta
British Columbia
Yukon
Northwest Territories
215
18
1,097
240
31,247
1,113
974
10,988
6,540
44
229
4,051
1,170
7,936
6,207
109,856
11,712
10,360
30,272
34,221
364
1,030
5.3
1.5
13.8
3.9
28.4
9.5
9.4
36.3
19.1
12.1
22.2
(4.6-6.0)
(0.9-2.4)
(13.1-14.6)
(3.4-4.4)
(28.2-28.7)
(9.0-10.1)
(8.8-10.0)
(35.8-36.8)
(18.7-19.5)
(8.9-15.9)
(19.7-24.9)
CANADA*
52,705
217,179
24.3
(24.1-24.4)
Sources: Canadian Institute for Health Information. Discharge Abstract Database, 1997-1998.
Manitoba Health, Epidemiology Unit. Perinatal Surveillance Database, 1997-1998.
* Québec data are not included in the DAD.
** Manitoba LOS data are missing for some hospital deliveries; therefore, the number of deliveries included in these analyses
differs from that in Table E2.9.
CI — confidence interval.
112
Canadian Perinatal Health Report, 2000
Appendix E
Table E2.12
Number and rate of short maternal length of stay (LOS)
for childbirth (cesarean deliveries), by province/territory,
Canada (excluding Québec)*, 1997-1998
Province/Territory
Number of
women with
LOS < 4 days
Newfoundland
Prince Edward Island
Nova Scotia
New Brunswick
Ontario
Manitoba
Saskatchewan
Alberta
British Columbia
Yukon
Northwest Territories
CANADA*
Cesarean delivery LOS < 4 days
Number of
Hospital deliveries (95% CI)
hospital cesarean
with LOS < 4 days
deliveries
per 100 cesarean deliveries
196
14
607
461
7,877
513
421
2,692
2,849
20
26
1,239
311
1,820
1,756
25,760
2,433
1,958
5,982
9,308
63
136
15.8
4.5
33.4
26.3
30.6
21.1
21.5
45.0
30.6
31.7
19.1
(13.8-18.0)
(2.5-7.4)
(31.2-35.6)
(24.2-28.4)
(30.0-31.1)
(19.5-22.8)
(19.7-23.4)
(43.7-46.3)
(29.7-31.6)
(20.6-44.7)
(12.9-26.7)
15,676
50,766
30.9
(30.5-31.3)
Sources: Canadian Institute for Health Information. Discharge Abstract Database, 1997-1998.
Manitoba Health, Epidemiology Unit. Perinatal Surveillance Database, 1997-1998.
* Québec data are not included in the DAD.
CI — confidence interval.
Table E2.13
Number and rate of early neonatal discharge from hospital after birth,
Canada (excluding Québec, Nova Scotia and Manitoba),* 1989-1990 to 1997-1998
Year
Birth weight ≥ 2,500 g
Birth weight 1,000-2,499 g
Number of
newborns with
LOS < 2 days
Number of
hospital
live births
Newborns with LOS
< 2 days per 100
hospital live births
Number of
Number of
newborns with hospital
LOS < 2 days live births
Newborns with LOS
< 2 days per 100
hospital live births
1989-1990
1990-1991
1991-1992
1,519
1,419
1,454
13,566
13,824
13,989
11.2
10.3
10.4
7,942
9,864
13,255
252,782
261,811
261,480
3.1
3.8
5.1
1992-1993
1993-1994
1994-1995
1,504
1,600
1,975
13,774
13,820
14,235
10.9
11.6
13.9
18,399
27,187
49,353
257,731
253,274
253,065
7.1
10.7
19.5
1995-1996
1996-1997
1997-1998
2,078
1,885
1,771
13,866
13,252
12,974
15.0
14.2
13.7
62,804
61,741
66,735
249,093
238,656
232,509
25.2
25.9
28.7
Source: Canadian Institute for Health Information. Discharge Abstract Database, 1989-1990 to 1997-1998.
* Québec data are not included in the DAD. Nova Scotia and Manitoba are excluded because complete data for all years are not available in the
DAD.
LOS — length of stay.
113
Canadian Perinatal Health Report, 2000
Appendix E
Table E2.14
Number and rate of early neonatal discharge from hospital after birth,
by province/territory, Canada (excluding Québec),* 1997-1998
Province/Territory
Birth weight 1,000-2,499 g
Number of Number Newborns (95% CI)
newborns
of
with LOS < 2 days
LOS with
hospital
per 100 hospital
< 2 days live births
live births
Newfoundland
Prince Edward Island
Nova Scotia
New Brunswick
Ontario
Manitoba
Saskatchewan
Alberta
British Columbia
Yukon
Northwest Territories
CANADA*
Birth weight ≥ 2,500 g
Number of
Number
Newborns (95% CI)
newborns with
of
with LOS < 2 days
LOS < 2 days
hospital
per 100 hospital
live births
live births
39
7
33
12
914
37
43
330
416
1
9
288
59
545
396
7,356
698
589
2,131
2,103
14
38
13.5
11.9
6.1
3.0
12.4
5.3
7.3
15.5
19.8
7.1
23.7
(9.8-18.0)
(4.9-22.9)
(4.2-8.4)
(1.6-5.2)
(11.7-13.2)
(3.8-7.2)
(5.3-9.7)
(14.0-17.1)
(18.1-21.5)
(0.2-33.9)
(11.4-40.2)
364
21
1,655
294
40,159
1,771
1,441
14,803
9,273
55
325
5,020
1,432
9,310
7,627
129,102
13,216
11,837
34,362
41,584
417
1,128
7.3
1.5
17.8
3.9
31.1
13.4
12.2
43.1
22.3
13.2
28.8
(6.5-8.0)
(0.9-2.2)
(17.0-18.6)
(3.4-4.3)
(30.9-31.4)
(12.8-14.0)
(11.6-12.8)
(42.6-43.6)
(21.9-22.7)
(10.1-16.8)
(26.2-31.6)
1,841
14,217
12.9
(12.4-13.5)
70,161
255,035
27.5 (27.3-27.7)
Sources: Canadian Institute for Health Information. Discharge Abstract Database, 1997-1998.
Manitoba Health, Epidemiology Unit. Perinatal Surveillance Database, 1997-1998.
* Québec data are not included in the DAD.
CI — confidence interval.
Table E3.1
Number of maternal deaths and maternal mortality ratios (MMR), by direct
and indirect causes, Canada, for five-year intervals, 1973-1977 to 1993-1997
Number of maternal deaths
Maternal deaths per 100,000 live births
Five-year
interval
Due to
direct causes
Due to
indirect causes
Total
Number of live
births in interval
Due to direct
causes only
Due to direct and
indirect causes
1973-1977
1978-1982
1983-1987
141
98
69
N/A*
10
4
141
108
73
1,715,649
1,790,281
1,827,244
8.2
5.5
3.8
8.2
6.0
4.0
1988-1992
1993-1997
71
75
4
8
75
83
1,953,259
1,866,315
3.6
3.4
3.8
4.4
Sources: see chapter 3, p. 41, references 3-10.
*A definition of indirect obstetric death first appeared in the Ninth Revision of the International Classification of Diseases system and deaths
classified as indirect maternal deaths were first included in cause of death tabulations in Canada in 1980.
114
Canadian Perinatal Health Report, 2000
Appendix E
Table E3.2
Number, ratio and rate of induced abortions,
Canada, 1990-1997
Year
Number of
induced
abortions*
Number
of live
births
Number of
females
15-44 years
Induced abortions
(95% CI) per 100
live births
Induced abortions
(95% CI) per 1,000
females 15-44 years
1990
1991
1992
92,901
95,059
102,085
405,486
402,528
398,636
6,543,751
6,717,442
6,727,276
22.9
23.6
25.6
(22.8-23.0)
(23.5-23.7)
(25.5-25.7)
14.0
14.2
15.2
(14.1-14.3)
(14.1-14.2)
(15.1-15.3)
1993
1994
1995
104,403
106,255
108,248
388,386
385,108
378,008
6,736,358
6,756,678
6,782,196
26.9
27.6
28.2
(26.7-27.0)
(27.4-27.7)
(28.5-28.8)
15.5
15.7
16.0
(15.4-15.6)
(15.6-15.8)
(15.9-16.1)
1996
1997
111,659
114,848
366,198
348,587
6,809,887
6,838,788
30.5
32.9
(30.3-30.6)
(32.8-33.1)
16.4
16.8
(16.3-16.5)
(16.7-16.9)
Sources: Statistics Canada, Therapeutic Abortions, 1995.
Statistics Canada. Canadian Vital Statistics System, 1990-1997.
Statistics Canada. The Daily: Friday, April 7, 2000.
Statistics Canada. Canadian female population estimates, 1990-1997.
* Includes induced abortions to women under 15 and over 44 years of age performed in hospitals and clinics and in
the U.S.A.
CI — confidence interval.
Table E3.3
Number, ratio and rate of induced abortions, by province/territory,
Canada,* 1997
Province/Territory
Newfoundland
Prince Edward Island
Nova Scotia
New Brunswick
Québec
Ontario
Manitoba
Saskatchewan
Alberta
British Columbia
Yukon
Northwest Territories
CANADA*
Number of
induced
abortions*
Number
of live
births
Number of
females
15-44 years
Induced abortions
(95% CI) per 100
live births
Induced abortions
(95% CI) per 1,000
females 15-44 years
838
151
2,045
1,113
28,186
47,174
3,626
1,996
10,337
15,583
121
317
5,416
1,591
9,952
7,922
79,772
132,997
14,655
12,859
36,905
44,576
474
1,468
132,252
30,165
212,088
171,780
1,648,490
2,574,867
247,916
219,790
672,011
904,811
8,130
16,488
15.5
9.5
20.5
14.0
35.3
35.5
24.7
15.5
28.0
35.0
25.5
21.6
(14.5-16.5)
(8.1-11.0)
(19.8-21.4)
(13.3-14.8)
(35.0-35.7)
(35.2-35.7)
(24.0-25.4)
(14.9-16.2)
(27.6-28.5)
(34.5-35.4)
(21.7-29.7)
(19.5-23.8)
6.3
5.0
9.6
6.5
17.1
18.3
14.6
9.1
15.4
17.2
14.9
19.2
(5.9-6.8)
(4.2-5.9)
(9.2-10.1)
(6.1-6.9)
(16.9-17.3)
(18.2-18.5)
(14.2-15.1)
(8.7-9.5)
(15.1-15.7)
(17.0-17.5)
(12.4-17.8)
(17.2-21.4)
114,848
348,587
6,838,788
32.9
(32.8-33.1)
16.8
(16.7-16.9)
Sources: Statistics Canada. The Daily: Friday, April 7, 2000.
Statistics Canada. Canadian Vital Statistics System, 1997.
Statistics Canada. Births and Deaths, 1997 (shelf tables).
* Includes induced abortions to women under 15 and over 44 years of age performed in hospitals and clinics and
in the U.S.A.
CI — confidence interval.
115
Canadian Perinatal Health Report, 2000
Appendix E
Table E3.4
Number and rate of age-specific induced abortions,
Canada,* 1997
Age
Unknown age
< 15**
15-19
20-24
25-29
30-34
35-39
40-44***
All ages*
Number of
induced abortions
Number of
females†
Induced abortions (95% CI)
per 1,000 females
3,547
519
21,204
33,640
23,963
17,422
10,975
3,578
—
196,530
987,083
992,280
1,061,261
1,243,426
1,323,672
1,228,711
—
2.6
21.5
33.9
22.6
14.0
8.3
2.9
—
(2.4-2.9)
(21.2-21.8)
(33.5-34.3)
(22.3-22.9)
(13.8-14.2)
(8.1-8.4)
(2.8-3.0)
114,848
6,836,433
16.8
(16.7-16.9)
Sources: Canadian Institute for Health Information. Therapeutic Abortion Survey, 1997.
Statistics Canada. Health Statistics Division, March 2000.
* Includes abortions performed in hospitals, clinics and in the U.S.A. Also includes abortions to
women over 44 years. Totals include cases with age not specified. Totals include 293 abortions
to Canadian women in the U.S.A.
** Rates based on women aged 14 years.
*** Includes induced abortions to women over 44 years of age at pregnancy termination. Rates
based on female population aged 40-44 years.
† Population data vary from other tables because they are taken from Canadian Institute for Health
Information, Therapeutic Abortion Survey, 1997.
CI — confidence interval.
Table E3.5
Number and rate of ectopic pregnancies,
Canada (excluding Québec, Nova Scotia and Manitoba),* 1989-1990 to 1997-1998
Year
Number of ectopic
pregnancies
Number of reported
pregnancies**
Ectopic pregnancies per
1,000 reported pregnancies
1989-1990
1990-1991
1991-1992
5,732
6,003
5,866
295,563
302,983
301,110
19.4
19.8
19.5
1992-1993
1993-1994
1994-1995
5,913
5,536
5,336
294,412
286,651
284,792
20.1
19.3
18.7
1995-1996
1996-1997
1997-1998
5,057
4,717
4,315
278,231
265,358
257,480
18.2
17.8
16.8
Source: Canadian Institute for Health Information. Discharge Abstract Database, 1989-1990 to 1997-1998
* Québec data are not included in the DAD. Nova Scotia and Manitoba are excluded because complete data for
all years are not available in the DAD.
** Reported pregnancies include live births, stillbirths, hospital-based induced abortions and ectopic pregnancies.
116
Canadian Perinatal Health Report, 2000
Appendix E
Table E3.6
Number and rate of ectopic pregnancies, by province/territory,
Canada (excluding Québec),* 1997-1998
Province/Territory
Number of ectopic Number of reported
pregnancies
pregnancies**
Ectopic pregnancies (95% CI)
per 1,000 reported pregnancies
Newfoundland
Prince Edward Island
Nova Scotia
New Brunswick
Ontario
Manitoba
Saskatchewan
Alberta
British Columbia
Yukon
Northwest Territories
96
19
123
123
2,213
342
217
746
849
18
34
5,706
1,546
10,090
8,414
141,614
20,576
13,112
39,187
46,149
474
1,278
16.8
12.3
12.2
14.6
15.6
16.6
16.5
19.0
18.4
38.0
26.6
(13.6-20.5)
(7.4-19.1)
(10.1-14.5)
(12.2-17.4)
(15.0-16.3)
(14.9-18.5)
(14.4-18.9)
(17.7-20.4)
(17.2-19.7)
(22.7-59.4)
(18.5-37.0)
CANADA*
4,780
288,146
16.6
(16.1-17.1)
Sources: Canadian Institute for Health Information. Discharge Abstract Database, 1997-1998.
Manitoba Health, Epidemiology Unit. Perinatal Surveillance Database, 1997-1998.
* Québec data are not included in the DAD.
** Reported pregnancies include live births, stillbirths, hospital-based induced abortions and ectopic pregnancies
to all women.
CI — confidence interval.
Table E3.7
Number and rate of ectopic pregnancies, by maternal age,
Canada (excluding Québec),* 1997-1998
Age
Number of ectopic
pregnancies
Number of reported
pregnancies**
Ectopic pregnancies (95% CI)
per 1,000 reported pregnancies
15-19
20-24
25-29
30-34
35-39
40-44
45-49
234
716
1,287
1,474
862
195
12
18,775
52,932
88,126
85,238
36,864
5,934
216
12.5
13.5
14.6
17.3
23.4
32.9
55.6
(10.9-14.2)
(12.6-14.5)
(13.8-15.4)
(16.4-18.2)
(21.9-25.0)
(28.5-37.7)
(29.0-95.0)
Total (15-49)
4,780
288,085
16.6
(16.1-17.1)
Sources: Canadian Institute for Health Information. Discharge Abstract Database, 1997-1998.
Manitoba Health, Epidemiology Unit. Perinatal Surveillance Database, 1997-1998.
* Québec data are not included in the DAD.
** Reported pregnancies include live births, stillbirths, hospital-based induced abortions and ectopic pregnancies to
women 15-49 years old only.
CI — confidence interval.
117
Canadian Perinatal Health Report, 2000
Appendix E
Table E3.8
Number and rate of maternal readmissions within three months of discharge
from hospital following childbirth,* Canada (excluding Québec, Nova Scotia and
Manitoba),** 1990-1991 to 1997-1998
Year
Vaginal deliveries
Number of
readmissions
Number of
hospital
deliveries
Cesarean deliveries
Readmissions
per 100 hospital
deliveries
Number of
readmissions
Number of
hospital
deliveries
Readmissions
per 100 hospital
deliveries
1990-1991
1991-1992
1992-1993
5,055
5,068
5,595
199,710
201,839
206,752
2.5
2.5
2.7
1,526
1,581
1,607
48,367
46,870
46,781
3.2
3.4
3.4
1993-1994
1994-1995
1995-1996
5,490
5,578
5,219
206,248
207,678
203,084
2.7
2.7
2.6
1,691
1,752
1,758
46,157
45,271
44,394
3.7
3.9
4.0
1996-1997
1997-1998
4,880
4,672
194,288
191,390
2.5
2.4
1,664
1,747
44,514
44,888
3.7
3.9
Source: Canadian Institute for Health Information. Discharge Abstract Database, 1990-1991 to 1997-1998.
* Women who were directly transferred after childbirth and women with initial LOS > 20 days were excluded from analysis.
**Québec data are not included in the DAD. Nova Scotia and Manitoba are excluded because complete data for all years are not available
in the DAD.
Table E3.9
Number and rate of maternal readmissions within three months of discharge
from hospital following childbirth (vaginal deliveries),* by province/territory,
Canada (excluding Québec),** 1995-1996 to 1997-1998
Province/Territory
Newfoundland
Prince Edward Island
Nova Scotia
New Brunswick
Ontario
Manitoba
Saskatchewan
Alberta
British Columbia
Northwest Territories
CANADA*
Number of
readmissions
Number of
hospital deliveries
Readmissions (95% CI)
per 100 hospital deliveries
470
73
590
575
6,782
1,386
530
3,373
2,777
127
12,677
3,728
22,348
18,855
333,454
40,946
21,944
90,673
104,349
3,251
3.7
2.0
2.7
3.1
2.0
2.6
2.5
3.7
2.7
4.0
(3.4-4.1)
(1.5-2.5)
(2.4-2.9)
(2.8-3.3)
(2.0-2.1)
(3.2-3.6)
(2.2-2.6)
(3.6-3.8)
(2.6-2.8)
(3.3-4.6)
16,683
652,225
2.6
(2.5-2.6)
Sources: Canadian Institute for Health Information. Discharge Abstract Database, 1995-1996 to 1997-1998.
Manitoba Health, Epidemiology Unit. Perinatal Surveillance Database, 1995-1996 to 1997-1998.
* Women who were directly transferred after childbirth and women with initial LOS > 20 days were excluded from analysis.
** Québec data are not included in the DAD.
CI — confidence interval.
118
Canadian Perinatal Health Report, 2000
Appendix E
Table E3.10
Number and rate of maternal readmissions within three months
of discharge from hospital following childbirth (cesarean deliveries),*
by province/territory, Canada (excluding Québec),** 1995-1996 to 1997-1998
Province/Territory
Number of
readmissions
Number of
hospital deliveries
Readmissions (95% CI) per
100 hospital deliveries
Newfoundland
Prince Edward Island
Nova Scotia
New Brunswick
Ontario
Manitoba
Saskatchewan
Alberta
British Columbia
Northwest Territories
174
42
260
267
2,418
306
160
942
1,081
19
3,533
996
5,244
5,019
74,630
7,990
4,302
17,229
27,721
381
4.9
4.2
5.0
5.3
3.3
3.8
3.9
5.5
4.0
4.9
(4.2-5.7)
(3.1-5.7)
(4.4-5.6)
(4.7-6.0)
(3.1-3.4)
(3.4-4.3)
(3.2-4.3)
(5.1-5.8)
(3.7-4.1)
(3.0-7.7)
CANADA*
5,669
147,045
3.9
(3.8-4.0)
Sources: Canadian Institute for Health Information. Discharge Abstract Database, 1995-1996 to 1997-1998.
Manitoba Health, Epidemiology Unit. Perinatal Surveillance Database, 1995-1996 to 1997-1998.
* Women who were directly transferred to other institutions after childbirth and women with initial LOS > 20 days were
excluded from analysis.
** Québec data are not included in the DAD.
CI — confidence interval.
Table E3.11
Number of maternal readmissions within three months of discharge
from hospital following childbirth,* by primary diagnosis,
Canada (excluding Québec),** 1995-1996 to 1997-1998
Primary diagnosis at readmission (ICD-9 code)
1.
2.
3.
4.
Postpartum hemorrhage (666)
Cholelithiasis (574)
Major puerperal infection (670)
Other and unspecified complications of the puerperium,
not elsewhere classified (674)
5. Postpartum care and examination (V24)
6. Persons seeking consultation without complaint
of sickness (V65)
7. Infection of the breast and nipple associated
with childbirth (675)
8. Other current conditions in the mother classifiable
elsewhere, but complicating pregnancy, childbirth,
or the puerperium(648)
9. Complications of pregnancy, not elsewhere classified (646)
10.Symptoms involving abdomen and pelvis (789)
11.Encounter for contraceptive management (V25)
12.Complications of procedures, not elsewhere classified (998)
13.Venous complications in pregnancy and the puerperium (671)
14.Other diagnoses
Total
Mode of delivery (number)
All
Cesarean Vaginal
3,229
2,948
2,258
383
646
578
2,846
2,302
1,680
1,601
812
1,159
247
442
565
786
85
701
692
108
584
498
522
419
337
267
250
7,733
130
137
101
21
137
89
1,848
368
385
318
316
130
161
5,885
22,352
5,669
16,683
Source: Canadian Institute for Health Information. Discharge Abstract Database, 1995-1996 to 1997-1998.
Manitoba Health, Epidemiology Unit. Perinatal Surveillance Database, 1995-1996 to 1997-1998.
* Women who were directly transferred after childbirth and women with initial LOS > 20 days were excluded from analysis.
** Québec data are not included in the DAD.
119
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Appendix E
Table E4.1
Number and rate of preterm births,
Canada (excluding Ontario and Newfoundland),* 1981-1997
Year
Number of
preterm births
Number of
live births**
Preterm births per
100 live births
1981
1982
1983
15,292
14,961
14,689
238,059
238,231
237,686
6.4
6.3
6.2
1984
1985
1986
15,146
14,199
14,097
236,929
234,869
229,773
6.4
6.1
6.1
1987
1988
1989
14,310
15,342
15,321
227,102
229,925
235,475
6.3
6.7
6.5
1990
1991
1992
16,129
15,956
15,877
244,215
240,421
238,077
6.6
6.6
6.7
1993
1994
1995
15,262
15,655
15,707
231,988
231,295
225,578
6.6
6.8
7.0
1996
1997
15,439
14,773
218,775
208,999
7.1
7.1
Source: Statistics Canada. Canadian Vital Statistics System, 1981-1997.
* Ontario is excluded due to data quality concerns. Newfoundland is excluded because
data are not available nationally prior to 1991.
** Excludes live births with unknown gestational age and gestational age < 20 weeks.
Table E4.2
Number and rate of preterm births (singleton and
multiple births), Canada (excluding Ontario),* 1997
Birth order
Singleton births
Twin births
Triplet or higher-order births
All live births
Number of
preterm births
Number of
live births**
Preterm births per
100 live births
12,391
2,556
209
15,156
209,243
4,953
218
214,414
5.9
51.6
95.9
7.1
Source: Statistics Canada. Canadian Vital Statistics System, 1997.
* Ontario is excluded due to data quality concerns.
** Excludes live births with unknown gestational age and gestational age < 20 weeks.
120
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Appendix E
Table E4.3
Number and rate of preterm births, by province/territory,
Canada (excluding Ontario),* 1997
Province/Territory
Number of
preterm births
Number of
live births**
401
96
728
490
5,750
1,084
872
2,663
2,924
29
119
5,415
1,591
9,950
7,922
78,728
14,648
12,859
36,905
44,460
474
1,462
7.4
6.0
7.3
6.2
7.3
7.4
6.8
7.2
6.6
6.1
8.1
(6.7-8.1)
(4.9-7.3)
(6.8-7.8)
(5.7-6.7)
(7.1-7.5)
(7.0-7.8)
(6.4-7.2)
(7.0-7.5)
(6.3-6.8)
(4.1-8.7)
(6.8-9.7)
15,156
214,414
7.1
(7.0-7.2)
Newfoundland
Prince Edward Island
Nova Scotia
New Brunswick
Québec
Manitoba
Saskatchewan
Alberta
British Columbia
Yukon
Northwest Territories
CANADA*
Preterm births (95% CI)
per 100 live births
Source: Statistics Canada. Canadian Vital Statistics System, 1997.
* Ontario is excluded due to data quality concerns.
** Excludes live births with unknown gestational age and gestational age < 20 weeks.
CI — confidence interval.
Table E4.4
Number and rate of postterm births,
Canada (excluding Ontario and Newfoundland)*, 1988-1997
Year
Number of
postterm births
Number of
total births**
Postterm births per
100 total births
1988
1989
1990
10,033
11,283
11,268
231,231
236,901
245,596
4.3
4.8
4.6
1991
1992
1993
10,542
8,931
8,957
241,838
239,451
233,234
4.4
3.7
3.8
1994
1995
1996
7,237
5,646
4,305
232,560
226,874
219,946
3.1
2.5
2.0
1997
3,883
210,196
1.8
Source: Statistics Canada. Canadian Vital Statistics System, 1988-1997.
* Ontario is excluded due to data quality concerns. Newfoundland is excluded
because data are not available nationally prior to 1991.
** Excludes live births and stillbirths with unknown gestational age and
gestational age < 20 weeks.
121
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Appendix E
Table E4.5
Number and rate of postterm births, by province/territory,
Canada (excluding Ontario),* 1997
Province/Territory
Newfoundland
Prince Edward Island
Nova Scotia
New Brunswick
Québec
Manitoba
Saskatchewan
Alberta
British Columbia
Yukon
Northwest Territories
CANADA*
Number of
postterm births
Total births**
Postterm births (95% CI)
per 100 total births
49
50
473
206
701
456
335
726
892
24
20
5,446
1,596
10,018
7,969
79,056
14,746
12,919
37,151
44,785
481
1,475
0.9
3.1
4.7
2.6
0.9
3.1
2.6
2.0
2.0
5.0
1.4
(0.7-1.2)
(2.3-4.1)
(4.3-5.2)
(2.2-3.0)
(0.8-1.0)
(2.8-3.4)
(2.3-2.9)
(1.8-2.1)
(1.9-2.1)
(3.2-7.3)
(0.8-2.1)
3,932
215,642
1.8
(1.8-1.9)
Source: Statistics Canada. Canadian Vital Statistics System, 1997.
* Ontario is excluded due to data quality concerns.
** Excludes live births and stillbirths with unknown gestational age and gestational age < 20 weeks.
CI — confidence interval.
Table E4.6
Numbers and rates of small-for-gestational-age (SGA) and large-forgestational-age (LGA) babies, Canada (excluding Ontario and Newfoundland),*
1988-1997
Year
Number of
SGA babies
Number of
LGA babies
Number of
live births**
SGA babies per
100 live births
LGA babies per
100 live births
1988
1989
1990
23,123
23,698
23,855
22,364
22,448
24,015
228,797
234,549
243,303
10.1
10.1
9.8
9.8
9.6
9.9
1991
1992
1993
23,047
21,192
21,436
23,961
25,324
23,919
239,414
237,223
231,229
9.6
8.9
9.3
10.0
10.7
10.3
1994
1995
1996
21,022
20,419
18,653
23,984
23,292
24,273
231,104
224,195
217,681
9.1
9.1
8.6
10.4
10.4
11.2
1997
17,895
22,230
207,758
8.6
10.7
Source: Statistics Canada. Canadian Vital Statistics System, 1988-1997.
* Ontario is excluded due to data quality concerns. Newfoundland is excluded because data are not available nationally
prior to 1991.
** Excludes live births with unknown gestational age and birthweight, and gestational age < 20 weeks.
122
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Appendix E
Table E4.7
Numbers and rates of small-for-gestational-age (SGA) and large-for-gestationalage (LGA) babies, by province/territory, Canada (excluding Ontario),* 1997
Province/Territory
Newfoundland
Prince Edward Island
Nova Scotia
New Brunswick
Québec
Manitoba
Saskatchewan
Alberta
British Columbia
Yukon
Northwest Territories
CANADA*
Number of
SGA babies
Number of
LGA babies
Number of
live births**
SGA babies (95% CI)
per 100 live births
425
125
866
673
6,853
1,202
1,014
3,429
3,595
47
91
763
238
1,274
1,019
7,292
1,940
1,522
3,751
4,949
56
189
5,406
1,585
9,942
7,921
77,520
14,646
12,858
36,901
44,453
474
1,458
7.9
7.9
8.7
8.5
8.8
8.2
7.9
9.3
8.1
9.9
6.2
(7.2-8.6)
(6.6-9.3)
(8.2-9.3)
(7.9-9.1)
(8.6-9.0)
(7.8-8.7)
(7.4-8.4)
(9.0-9.6)
(7.8-8.3)
(7.4-13.0)
(5.1-7.6)
14.1
15.0
12.8
12.9
9.4
13.2
11.8
10.2
11.1
11.8
13.0
(13.2-15.1)
(13.3-16.9)
(12.2-13.5)
(12.1-13.6)
(9.2-9.6)
(12.7-13.8)
(11.3-12.4)
(9.9-10.5)
(10.8-11.4)
(9.0-15.1)
(11.3-14.8)
18,320
22,993
213,164
8.6
(8.5-8.7)
10.8
(10.7-10.9)
Source: Statistics Canada. Canadian Vital Statistics System, 1997.
* Ontario is excluded due to data quality concerns.
** Excludes live births with unknown gestational age and birthweight, and gestational age < 20 weeks.
CI — confidence interval.
Table E4.8
LGA babies (95% CI)
per 100 live births
Number and rate* of fetal deaths,
Canada (excluding Ontario and Newfoundland),** 1988-1997
Year
Number of
fetal deaths
Total births
Deaths per 1,000
total births
1988
1989
1990
1,128
1,252
1,213
232,321
240,778
248,117
4.86
5.20
4.89
1991
1992
1993
1,189
1,152
1,112
245,073
242,277
235,233
4.85
4.75
4.73
1994
1995
1996
1,122
1,080
981
232,825
226,968
221,422
4.82
4.76
4.43
1997
1,008
211,182
4.77
Source: Statistics Canada. Canadian Vital Statistics System, 1988-1997.
*Fetal death rates were based on all births excluding those with known birth weight of < 500 grams.
** Ontario is excluded due to data quality concerns. Newfoundland is excluded because data are not
available nationally prior to 1991.
123
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Appendix E
Table E4.9
Number and rate* of fetal deaths, by province/territory,
Canada (excluding Ontario),** 1997
Province/Territory
Number of
fetal deaths
Total births
29
4
56
34
340
62
58
179
257
6
12
5,445
1,595
10,008
7,956
80,112
14,717
12,917
37,084
44,833
480
1,480
5.3
2.5
5.6
4.3
4.2
4.2
4.5
4.8
5.7
12.5
8.1
(3.6-7.6)
(0.7-6.4)
(4.2-7.3)
(3.0-6.0)
(3.8-4.7)
(3.2-5.4)
(3.4-5.8)
(4.1-5.6)
(5.1-6.5)
(4.6-27.0)
(4.2-14.1)
1,037
216,627
4.8
(4.5-5.1)
Newfoundland
Prince Edward Island
Nova Scotia
New Brunswick
Québec
Manitoba
Saskatchewan
Alberta
British Columbia
Yukon
Northwest Territories
CANADA
Fetal deaths (95% CI)
per 1,000 total births
Source: Statistics Canada. Canadian Vital Statistics System, 1997.
*Fetal death rates were based on all births excluding those with known birth weight of < 500 grams.
** Ontario is excluded due to data quality concerns.
CI — confidence interval.
Table E4.10
Number and rate of neonatal (0-27 days) deaths,
Canada (excluding Newfoundland),* 1988-1997
Year
Number of
neonatal deaths
Number of
live births
Deaths per
1,000 live births
1988
1989
1990
1,718
1,827
1,822
369,247
384,823
397,811
4.65
4.75
4.58
1991
1992
1993
1,605
1,540
1,577
395,362
391,718
381,964
4.06
3.93
4.13
1994
1995
1996
1,598
1,550
1,409
378,767
372,149
360,450
4.22
4.16
3.91
1997
1,336
343,171
3.89
Source: Statistics Canada. Canadian Vital Statistics System, 1988-1997.
* Newfoundland is excluded because data are not available nationally prior to 1991.
124
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Appendix E
Table E4.11
Number and rate of neonatal (0-27 days) deaths,
by province/territory, Canada, 1997
Province/Territory
Number of
neonatal deaths
Newfoundland
Prince Edward Island
Nova Scotia
New Brunswick
Québec
Ontario
Manitoba
Saskatchewan
Alberta
British Columbia
Yukon
Northwest Territories
CANADA
Number of
live births
Deaths (95% CI)
per 1,000 live births
22
4
34
30
311
518
71
77
128
151
2
10
5,416
1,591
9,952
7,922
79,772
132,997
14,655
12,859
36,905
44,576
474
1,468
4.1
2.5
3.4
3.8
3.9
3.9
4.8
6.0
3.5
3.4
4.2
6.8
(2.5-6.1)
(0.7-6.4)
(2.4-4.8)
(2.6-5.4)
(3.5-4.4)
(3.6-4.2)
(3.8-6.1)
(4.7-7.5)
(2.9-4.1)
(2.9-4.0)
(0.5-15.2)
(3.3-12.5)
1,358
348,587
3.9
(3.7-4.1)
Source: Statistics Canada. Canadian Vital Statistics System, 1997.
CI — confidence interval.
Table E4.12
Number and rate of postneonatal (28-364 days) deaths,
Canada (excluding Newfoundland),* 1988-1997
Year
Number of
postneonatal deaths
Number of infants
≥ 28 days old
Deaths per 1,000 infants
≥ 28 days old
1988
1989
1990
985
967
874
367,529
382,996
395,989
2.68
2.52
2.21
1991
1992
1993
912
841
819
393,757
390,178
380,388
2.32
2.16
2.15
1994
1995
1996
768
725
604
377,171
370,599
359,042
2.04
1.96
1.68
1997
563
341,835
1.65
Source: Statistics Canada. Canadian Vital Statistics System, 1988-1997.
* Newfoundland is excluded because data are not available nationally prior to 1991.
125
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Appendix E
Table E4.13
Number and rate of postneonatal (28-364 days) deaths,
by province/territory, Canada, 1997
Province/Territory
Number of
postneonatal
deaths
Number
of infants
≥ 28 days old
Deaths (95% CI)
per 1,000 infants
≥ 28 days old
Newfoundland
Prince Edward Island
Nova Scotia
New Brunswick
Québec
Ontario
Manitoba
Saskatchewan
Alberta
British Columbia
Yukon
Northwest Territories
6
3
10
15
132
210
39
37
50
59
2
6
5,394
1,587
9,918
7,892
79,461
132,479
14,584
12,782
36,777
44,425
472
1,458
1.1
1.9
1.0
1.9
1.7
1.6
2.7
2.9
1.4
1.3
4.2
4.1
(0.4-2.4)
(0.4-5.5)
(0.5-1.8)
(1.1-3.1)
(1.4-2.0)
(1.4-1.8)
(1.9-3.6)
(2.0-4.0)
(1.0-1.8)
(1.0-1.7)
(0.5-15.2)
(1.5-8.9)
CANADA
569
347,229
1.6
(1.5-1.8)
Source: Statistics Canada. Canadian Vital Statistics System, 1997.
CI — confidence interval.
Table E4.14
Number of infant deaths and infant mortality rate,
Canada (excluding Newfoundland),* 1988-1997
Year
Number of
infant deaths
Number of
live births
Deaths per 1,000
live births
1988
1989
1990
2,703
2,794
2,696
369,247
384,823
397,811
7.32
7.26
6.78
1991
1992
1993
2,517
2,381
2,396
395,362
391,718
381,964
6.37
6.08
6.27
1994
1995
1996
2,366
2,275
2,013
378,767
372,149
360,450
6.25
6.11
5.58
1997
1,899
343,171
5.53
Source: Statistics Canada. Canadian Vital Statistics System, 1988-1997.
* Newfoundland is excluded because data are not available nationally prior to 1991.
126
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Appendix E
Table E4.15
Number of infant deaths and infant mortality rate,
by province/territory, Canada, 1997
Province/Territory
Number of
infant deaths
Newfoundland
Prince Edward Island
Nova Scotia
New Brunswick
Québec
Ontario
Manitoba
Saskatchewan
Alberta
British Columbia
Yukon
Northwest Territories
CANADA
Number of
live births
Deaths (95% CI)
per 1,000 live births
28
7
44
45
443
728
110
114
178
210
4
16
5,416
1,591
9,952
7,922
79,772
132,997
14,655
12,859
36,905
44,576
474
1,468
5.2
4.4
4.4
5.7
5.6
5.5
7.5
8.9
4.8
4.7
8.4
10.9
(3.4-7.5)
(1.8-9.0)
(3.2-5.9)
(4.1-7.6)
(5.0-6.1)
(5.1-5.9)
(6.2-9.0)
(7.3-10.6)
(4.1-5.6)
(4.1-5.4)
(2.3-21.5)
(6.2-17.6)
1,927
348,587
5.5
(5.3-5.8)
Source: Statistics Canada. Canadian Vital Statistics System, 1997.
CI — confidence interval.
Table E4.16
Infant mortality rate,* by gestational age,
Canada (excluding Ontario),** 1994-1996
Gestational age (weeks)
Number of
infant deaths
< 22
22-23
24-25
26-27
28-31
32-33
34-36
37-41
≥ 42
Unknown gestational age
Unlinked
All gestational ages
292
474
437
241
333
172
439
1,635
51
18
64
4,156
Number of
live births
298
518
869
1,085
4,314
5,530
35,511
628,056
17,492
2,389
—
696,062
Deaths (95% CI)
per 1,000 live births
979.9
915.1
502.9
222.1
77.2
31.1
12.4
2.6
2.9
7.5
—
6.0
(956.7-992.6)
(887.6-937.6)
(469.1-536.6)
(197.7-248.0)
(69.4-85.6)
(26.7-36.0)
(11.2-13.6)
(2.5-2.7)
(2.2-3.8)
(4.5-11.9)
—
(5.8-6.2)
Source: Statistics Canada. Canadian Vital Statistics System, 1994-1996.
* In the birth-infant death linked file, all live births at < 22 weeks and < 500 grams were assumed to have died on
the first day of life and were classified as such.
** Ontario is excluded due to data quality concerns.
127
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Appendix E
Table E4.17
Infant mortality rate,* by birth weight,
Canada (excluding Ontario),** 1994-1996
Birth weight (grams)
Number of
infant deaths
Number of
live births
< 500
500-749
750-999
1,000-1,249
1,250-1,499
1,500-1,999
2,000-2,499
2,500-3,999
≥ 4,000
Unknown birth weight
Unlinked
All birth weights
495
654
282
167
138
292
344
1,498
160
62
64
4,156
530
1,073
1,255
1,527
1,913
7,429
25,553
570,021
84,738
2,023
—
696,062
Deaths (95% CI)
per 1,000 live births
934.0
609.5
224.7
109.4
72.1
39.3
13.5
2.6
1.9
30.6
—
6.0
(909.4-953.6)
(579.6-638.8)
(201.9-248.8)
(94.1-126.1)
(60.9-84.7)
(35.0-44.0)
(12.1-15.0)
(2.5-2.8)
(1.6-2.2)
(23.6-39.1)
—
(5.8-6.2)
Source: Statistics Canada. Canadian Vital Statistics System, 1994-1996.
* In the birth-infant death linked file, all live births at < 22 weeks and < 500 grams were assumed to have died on
the first day of life and were classified as such.
** Ontario is excluded due to data quality concerns.
Table E4.18
Number of infant deaths,* by gestational age and province/territory,
Canada (excluding Ontario),** 1992-1996
Gestational
age (weeks)
NFLD
PEI
NS
< 22
14
4
21
22-23
23
6
32
24-25
29
1
39
26-27
20
3
25
28-31
28
8
32-33
18
2
34-36
29
2
37-41
73
21
≥ 42
4
0
11
NB
QUE
MAN
SASK
ALTA
9
133
14
256
41
20
107
67
55
161
28
14
242
45
69
131
139
38
41
67
25
11
13
198
38
48
12
119
19
28
33
40
253
67
121
120
962
233
5
26
15
9
BC
YUK
NWT
82
1
0
149
3
6
136
0
2
73
0
9
94
87
0
7
70
50
0
5
49
134
136
1
12
255
554
562
11
58
19
19
0
0
Unknown
gestational age
0
0
0
0
31
0
0
1
9
0
0
Unlinked
5
0
2
1
41
2
11
0
47
0
6
243
47
320
256
2,400
565
585
1,338
1,350
16
105
All gestational
ages
Source: Statistics Canada. Canadian Vital Statistics System, 1992-1996.
* In the birth-infant death linked file, all live births at < 22 weeks and < 500 grams were assumed to have died on the first day of life
and were classified as such.
**Ontario is excluded due to data quality concerns.
128
Canadian Perinatal Health Report, 2000
Appendix E
Table E4.19
Number of live births,* by gestational age and province/territory,
Canada (excluding Ontario),** 1992-1996
Gestational
age (weeks)
YUK
NWT
< 22
NFLD
15
PEI
4
NS
21
NB
9
QUE
134
MAN
41
SASK
22
ALTA
109
BC
87
1
0
22-23
25
6
36
18
287
68
60
176
157
3
6
24-25
51
8
69
44
470
89
98
277
251
1
8
26-27
59
13
97
59
662
157
117
307
372
5
23
28-31
265
51
356
274
2,520
520
408
1,264
1,374
16
88
32-33
305
55
467
337
3,430
661
539
1,652
1,829
19
78
34-36
1,499
362
2,979
2,185
23,475
4,243
3,310
9,944
10,489
115
510
37-41
28,295
8,057
47,795
63,001 179,835 208,271
2,084
7,003
766
210
3,979
1,850
8,093
4,194
2,544
5,304
8,543
147
135
10
4
50
6
6,867
19
1
1
592
2
16
31,290
8,770
55,849
70,100 198,869 231,965
2,393
7,867
≥ 42
Unknown
gestational age
All gestational
ages
39,372 405,872 71,359
44,154 451,810 81,351
Source: Statistics Canada. Canadian Vital Statistics System, 1992-1996.
* In the birth-infant death linked file, all live births at < 22 weeks and < 500 grams were assumed to have died on the first day of life and were
classified as such.
** Ontario is excluded due to data quality concerns.
129
Canadian Perinatal Health Report, 2000
Appendix E
Table E4.20
Infant mortality rate,* by gestational age and province/territory,
Canada (excluding Ontario),** 1992-1996
Gestational
age (weeks)
NFLD
PEI
NS
NB
QUE
< 22
933.3
(680.5-998.3)
1,000.0
(397.6-1,000.0)
1,000.0
(838.9-1,000.0)
1,000.0
(663.7-1,000.0)
992.5
(959.1-999.8)
22-23
920.0
(739.7-990.2)
1,000.0
(540.7-1,000.0)
888.9
(739.4-968.9)
777.8
(523.6-935.9)
892.0
(850.2-925.4)
24-25
568.6
(422.5-706.5)
125.0
(3.2-526.5)
565.2
(440.4-684.2)
636.4
(477.7-775.9)
514.9
(468.7-560.9)
26-27
339.0
(220.8-473.9)
230.8
(50.4-538.1)
257.7
(174.2-356.5)
237.3
(136.2-366.0)
210.0
(179.5-243.0)
28-31
105.7
(71.4-149.1)
156.9
(70.2-285.9)
70.2
(46.0-101.9)
47.4
(25.5-79.8)
78.6
(68.4-89.8)
32-33
59.0
(35.3-91.7)
36.4
(4.4-125.3)
23.6
(11.8-41.8)
35.6
(18.5-61.4)
34.7
(28.8-41.4)
34-36
19.3
(13.0-27.7)
5.5
(0.7-19.8)
11.1
(7.6-15.5)
18.3
(13.1-24.8)
10.8
(9.5-12.2)
37-41
2.6
(2.0-3.2)
2.6
(1.6-4.0)
2.5
(2.1-3.0)
3.0
(2.5-3.6)
2.4
(2.2-2.5)
≥ 42
5.2
(1.4-13.3)
0.0
(0.0-17.4)
2.8
(1.4-4.9)
2.7
(0.9-6.3)
3.2
(2.1-4.7)
0.0
(0.0-308.5)
0.0
(0.0-602.4)
0.0
(0.0-71.1)
0.0
(0.0-459.3)
4.5
(3.1-6.4)
7.8
(6.8-8.8)
5.4
(3.9-7.1)
5.7
(5.1-6.4)
5.8
(5.1-6.6)
5.3
(5.1-5.5)
Unknown
gestational age
All gestational
ages
Gestational
age (weeks)
MAN
SASK
ALTA
BC
1,000.0
(914.0-1,000.0)
909.1
(708.4-988.8)
981.7
(935.3-997.8)
942.5
(871.0-981.1)
1,000.0
(25.0-1000.0)
___
22-23
985.3
(920.8-999.6)
916.7
(816.1-972.4)
914.8
(863.3-951.5)
949.0
(902.1-977.7)
1,000.0
(292.4-1,000.0)
1,000.0
(540.7-1,000.0)
24-25
505.6
(397.5-613.3)
704.1
(603.4-792.1)
472.9
(412.9-533.5)
541.8
(478.0-604.6)
0.0
(0.0-975.0)
250.0
(31.9-650.9)
26-27
242.0
(177.3-316.7)
350.4
(264.5-444.1)
218.2
(173.3-268.7)
196.2
(157.1-240.3)
0.0
(0.0-521.8)
391.3
(197.1-614.6)
28-31
73.1
(52.2-98.9)
117.6
(88.0-152.9)
74.4
(60.5-90.2)
63.3
(51.0-77.5)
0.0
(0.0-205.9)
79.5
(32.6-157.0)
32-33
28.7
(17.4-44.5)
51.9
(34.8-74.2)
42.4
(33.2-53.2)
27.3
(20.4-35.9)
0.0
(0.0-176.5)
64.1
(21.1-143.3)
34-36
15.8
(12.3-20.0)
14.8
(11.0-19.5)
13.5
(11.3-15.9)
13.0
(10.9-15.3)
8.7
(0.2-47.5)
23.5
(12.2-40.7)
37-41
3.3
(2.9-3.7)
4.0
(3.6-4.6)
3.1
(2.8-3.3)
2.7
(2.5-2.9)
5.3
(2.6-9.4)
8.3
(6.3-10.7)
≥ 42
3.6
(2.0-5.9)
3.5
(1.6-6.7)
3.6
(2.2-5.6)
2.2
(1.3-3.5)
0.0
(0.0-24.8)
0.0
(0.0-27.0)
0.0
(0.0-176.5)
0.0
(0.0-975.0)
1,000.0
(25.0-1.000.0)
15.2
(7.0-28.7)
0.0
(0.0-841.9)
0.0
(0.0-205.9)
6.9
(6.4-7.5)
8.3
(7.7-9.0)
6.7
(6.4-7.1)
5.8
(5.5-6.1)
6.7
(3.8-10.8)
13.3
(10.9-16.1)
< 22
Unknown
gestational age
All gestational
ages
YUK
NWT
Source: Statistics Canada. Canadian Vital Statistics System, 1992-1996.
* Deaths (95% CI) per 1,000 live births. In the birth-infant death linked file, all live births at < 22 weeks and < 500 grams were assumed
to have died on the first day of life and were classified as such.
** Ontario is excluded due to data quality concerns.
130
Canadian Perinatal Health Report, 2000
Appendix E
Table E4.21
Number of infant deaths,* by birth weight and province/territory,
Canada (excluding Ontario),** 1992-1996
Birth weight (grams)
NFLD
PEI
NS
NB
QUE
MAN
< 500
19
3
54
21
229
500-749
49
8
43
24
750-999
23
2
26
19
1,000-1,249
9
2
14
1,250-1,499
10
3
7
1,500-1,999
19
5
2,000-2,499
22
1
2,500-3,999
70
20
≥ 4,000
13
4
Unknown birth weight
Unlinked
All birth weights
SASK
ALTA
BC
YUK
NWT
90
47
175
126
3
1
375
69
82
221
219
1
10
173
32
49
70
70
0
3
14
102
30
25
51
55
0
4
12
79
14
24
48
31
0
2
25
20
166
26
43
87
97
0
8
18
24
225
41
48
112
107
1
11
120
110
872
229
223
522
517
11
53
3
9
11
77
31
33
51
50
0
6
0
2
0
61
1
0
1
31
0
1
5
0
2
1
41
2
11
0
47
0
6
243
47
320
256
2,400
565
585
1,338
1,350
16
105
Source: Statistics Canada. Canadian Vital Statistics System, 1992-1996.
* In the birth-infant death linked file, all live births at < 22 weeks and < 500 grams were assumed to have died on the first day of life and were
classified as such.
** Ontario is excluded due to data quality concerns.
Table E4.22
Number of live births,* by birth weight and province/territory,
Canada (excluding Ontario),** 1992-1996
Birth weight (grams)
NFLD
PEI
< 500
21
3
500-749
65
750-999
68
1,000-1,249
1,250-1,499
1,500-1,999
2,000-2,499
2,500-3,999
≥ 4,000
Unknown birth weight
All birth weights
NS
NB
QUE
MAN
SASK
ALTA
BC
YUK
NWT
54
23
249
103
48
185
135
3
1
14
74
45
617
132
117
352
336
4
16
13
129
80
757
159
130
351
331
2
14
87
19
140
106
954
200
155
417
474
5
27
107
20
135
145
1,179
232
187
533
616
9
29
378
86
637
448
4,825
838
706
2,134
2,242
25
116
1,097
287
1,993
1,520
17,546
2,669
2,288
7,624
7,658
81
289
56,773 164,397 188,105
1,889
6,257
24,562 6,880
4,890 1,432
15
16
31,290 8,770
44,382 35,191 376,367 65,006
8,252
6,595
53
1
46,118 12,005
3,198
7
55,849 44,154 451,810 81,351
9,688
22,874
31,440
374
1,100
8
2
628
1
18
70,100 198,869 231,965
2,393
7,867
Source: Statistics Canada. Canadian Vital Statistics System, 1992-1996.
* In the birth-infant death linked file, all live births at < 22 weeks and < 500 grams were assumed to have died on the first day of life and were
classified as such.
** Ontario is excluded due to data quality concerns.
131
Canadian Perinatal Health Report, 2000
Appendix E
Table E4.23
Infant mortality rate,*by birth weight and province/territory,
Canada (excluding Ontario),** 1992-1996
Birth weight
(grams)
NFLD
PEI
NS
< 500
904.8
(696.2-988.3)
1,000.0
(292.4-1,000.0)
1,000.0
(934.0-1,000.0)
913.0
(719.6-989.3)
919.7
(878.7-950.2)
500-749
753.8
(631.3-852.3)
571.4
(288.6-823.4)
581.1
(460.6-694.9)
533.3
(378.7-683.4)
607.8
(568.0-646.5)
750-999
338.2
(227.9-463.2)
153.8
(19.2-454.5)
201.6
(136.1-281.2)
237.5
(149.5-345.8)
228.5
(199.1-260.1)
1,000-1,249
103.4
(48.4-187.3)
105.3
(13.0-331.4)
100.0
(55.8-162.1)
132.1
(74.1-211.7)
106.9
(88.0-128.3)
1,250-1,499
93.5
(45.7-165.2)
150.0
(32.1-378.9)
51.9
(21.1-103.9)
82.8
(43.5-140.1)
67.0
(53.4-82.8)
1,500-1,999
50.3
(30.5-77.4)
58.1
(19.1-130.5)
39.2
(25.6-57.4)
44.6
(27.5-68.1)
34.4
(29.4-39.9)
2,000-2,499
20.1
(12.6-30.2)
3.5
(0.1-19.3)
9.0
(5.4-14.2)
15.8
(10.1-23.4)
12.8
(11.2-14.6)
2,500-3,999
2.8
(2.2-3.6)
2.9
(1.8-4.5)
2.7
(2.2-3.2)
3.1
(2.6-3.8)
2.3
(2.2-2.5)
≥ 4,000
2.7
(1.4-4.5)
2.1
(0.4-6.1)
1.1
(0.5-2.1)
1.7
(0.8-3.0)
1.7
(1.3-2.1)
266.7
(77.9-551.0)
0.0
(0.0-205.9)
37.7
(4.6-129.8)
0.0
(0.0-975.0)
19.1
(14.6-24.4)
7.8
(6.8-8.8)
5.4
(3.9-7.1)
5.7
(5.1-6.4)
5.8
(5.1-6.6)
5.3
(5.1-5.5)
Unknown
birth weight
All birth weights
Birth weight
(grams)
MAN
SASK
ALTA
NB
BC
QUE
YUK
NWT
< 500
873.8
(793.8-931.1)
979.2
(889.3-999.5)
945.9
(902.8-973.8)
933.3
(877.2-969.1)
1,000.0
(292.4-1,000.0)
1,000.0
(25.0-1,000.0)
500-749
522.7
(434.1-610.3)
700.9
(609.3-782.0)
627.8
(575.0-678.5)
651.8
(598.2-702.7)
250.0
(6.3-805.9)
625.0
(354.3-848.0)
750-999
201.3
(141.9-272.1)
376.9
(293.5-466.1)
199.4
(158.9-245.1)
211.5
(168.7-259.5)
0.0
(0.0-841.9)
214.3
(46.6-508.0)
1,000-1,249
150.0
(103.5-207.2)
161.3
(107.2-228.8)
122.3
(92.4-157.7)
116.0
(88.6-148.3)
0.0
(0.0-521.8)
148.1
(41.9-337.3)
1,250-1,499
60.3
(33.4-99.2)
128.3
(84.0-184.9)
90.1
(67.1-117.6)
50.3
(34.4-70.7)
0.0
(0.0-336.3)
69.0
(8.5-227.7)
1,500-1,999
31.0
(20.4-45.1)
60.9
(44.4-81.2)
40.8
(32.8-50.0)
43.3
(35.2-52.5)
0.0
(0.0-137.2)
69.0
(30.2-131.4)
2,000-2,499
15.4
(11.0-20.8)
21.0
(15.5-27.7)
14.7
(12.1-17.6)
14.0
(11.5-16.9)
12.3
(0.3-66.9)
38.1
(19.2-67.1)
2,500-3,999
3.5
(3.1-4.0)
3.9
(3.4-4.5)
3.2
(2.9-3.5)
2.7
(2.5-3.0)
5.8
(2.9-10.4)
8.5
(6.4-11.1)
≥ 4,000
2.6
(1.8-3.7)
3.4
(2.3-4.8)
2.2
(1.7-2.9)
1.6
(1.2-2.1)
0.0
(0.0-9.8)
5.5
(2.0-11.8)
142.9
(3.6-578.7)
0.0
(0.0-369.4)
500.0
(12.6-987.4)
49.4
(33.8-69.3)
0.0
(0.0-975.0)
55.6
(1.4-272.9)
6.9
(6.4-7.5)
8.3
(7.7-9.0)
6.7
(6.4-7.1)
5.8
(5.5-6.1)
6.7
(3.8-10.8)
13.3
(10.9-16.1)
Unknown
birth weight
All birth weights
Source: Statistics Canada. Canadian Vital Statistics System, 1992-1996.
* Deaths (95% CI) per 1,000 live births. In the birth-infant death linked file, all live births at < 22 weeks and < 500 grams were assumed
to have died on the first day of life and were classified as such.
** Ontario is excluded due to data quality concerns.
132
Canadian Perinatal Health Report, 2000
Appendix E
Table E4.24
Number of cases* and rate of respiratory distress syndrome (RDS),
Canada (excluding Québec, Nova Scotia and Manitoba),** 1989-1990 to 1997-1998
Year
Number
of RDS
cases
Number of
hospital
live births
Cases per 1,000
hospital live births
1989-1990
1990-1991
1991-1992
4,153
4,300
4,123
268,171
277,138
276,748
15.5
15.5
14.9
1992-1993
1993-1994
1994-1995
3,976
2,897
2,972
291,162
267,563
267,790
13.7
10.8
11.1
1995-1996
1996-1997
1997-1998
2,684
2,794
2,645
263,484
254,737
246,708
10.2
11.0
10.7
Source: Canadian Institute for Health Information. Discharge Abstract Database, 1989-1990 to 1997-1998.
* RDS cases include infants diagnosed during the birth admission only.
** Québec data are not included in the DAD. Nova Scotia and Manitoba are excluded because complete data
for all years are not available in the DAD.
Table E4.25
Number of cases* and rate of respiratory distress syndrome (RDS),
by province/territory, Canada (excluding Québec),** 1997-1998
Province/Territory
Number of
RDS cases
Number of
hospital
live births
Cases (95% CI) per
1,000 hospital
live births
Newfoundland
Prince Edward Island
Nova Scotia
New Brunswick
Ontario
Manitoba
Saskatchewan
Alberta
British Columbia
Yukon
Northwest Territories
55
29
103
78
1,481
202
139
477
381
2
3
5,339
1,493
9,900
8,050
137,173
14,145
12,496
36,679
43,877
432
1,169
10.3
19.4
10.4
9.7
10.8
14.3
11.1
13.0
8.7
4.6
2.6
(7.8-13.4)
(13.1-27.8)
(8.5-12.6)
(7.7-12.1)
(10.3-11.4)
(12.4-16.4)
(9.4-13.1)
(11.9-14.2)
(7.8-9.6)
(0.6-16.6)
(0.5-7.5)
CANADA*
2,950
270,753
10.9
(10.5-11.3)
Sources: Canadian Institute for Health Information. Discharge Abstract Database, 1997-1998.
Manitoba Health, Epidemiology Unit. Perinatal Surveillance Database, 1997-1998.
* RDS cases include infants diagnosed during the birth admission only.
** Québec data are not included in the DAD.
CI — confidence interval.
133
Canadian Perinatal Health Report, 2000
Appendix E
Table E4.26
Number and rate of multiple births,
Canada (excluding Newfoundland),* 1988-1997
Year
Number of
multiple births
Total births
Multiple births
per 100 total births
1988
1989
1990
7,793
8,207
8,492
371,519
387,278
400,206
2.06
2.09
2.08
1991
1992
1993
8,147
8,345
8,170
397,611
394,201
384,266
2.02
2.08
2.08
1994
1995
1996
8,746
8,682
8,810
381,031
374,476
362,551
2.25
2.28
2.40
1997
8,760
345,282
2.50
Source: Statistics Canada. Canadian Vital Statistics System, 1988-1997.
* Newfoundland is excluded because data are not available nationally prior to 1991.
Table E4.27
Number and rate of multiple births, by province/territory,
Canada, 1997
Province/Territory
Number of
multiple births
Total births
Multiple births (95% CI)
per 100 total births
Newfoundland
Prince Edward Island
Nova Scotia
New Brunswick
Québec
Ontario
Manitoba
Saskatchewan
Alberta
British Columbia
Yukon
Northwest Territories
127
32
237
196
1,894
3,583
348
350
968
1,091
21
40
5,447
1,597
10,020
7,969
80,117
133,876
14,755
12,919
37,154
44,913
481
1,481
2.3
2.0
2.4
2.5
2.4
2.7
2.4
2.7
2.6
2.4
4.4
2.7
(1.9-2.8)
(1.4-2.8)
(2.1-2.7)
(2.1-2.8)
(2.3-2.5)
(2.6-2.8)
(2.1-2.6)
(2.4-3.0)
(2.4-2.8)
(2.3-2.6)
(2.7-6.6)
(1.9-3.7)
CANADA
8,887
350,729
2.5
(2.5-2.6)
Source: Statistics Canada. Canadian Vital Statistics System, 1997.
CI — confidence interval.
134
Canadian Perinatal Health Report, 2000
Appendix E
Table E4.28
Number of cases and rate of neural tube defects (NTD),
Canada (excluding Québec and Nova Scotia),* 1989-1997
Year
Number of
NTD cases
Total births
Cases (95% CI)
per 10,000 total births
1989
1990
1991
329
339
321
284,590
294,140
293,538
11.6
11.5
10.9
(10.3-12.9)
(10.3-12.8)
(9.8-12.2)
1992
1993
1994
309
281
275
289,722
285,790
286,103
10.7
9.8
9.6
(9.5-11.9)
(8.7-11.0)
(8.5-10.8)
1995
1996
1997
289
204
197
282,196
272,777
262,741
10.2
7.5
7.5
(9.1-11.5)
(6.5-8.6)
(6.5-8.6)
Source: Health Canada. Canadian Congenital Anomalies Surveillance System, 1989-1997.
* Québec and Nova Scotia are excluded because data are not available for all years.
CI — confidence interval.
Table E4.29
Number of cases and rate of neural tube defects (NTD),
by province/territory, Canada (excluding Québec),* 1997
Province/Territory
Number of
NTD cases
Total births
Cases (95% CI) per
10,000 total births
Newfoundland
Prince Edward Island
Nova Scotia
New Brunswick
Ontario
Manitoba
Saskatchewan
Alberta
British Columbia
Yukon
Northwest Territories
6
0
10
9
106
17
11
24
24
0
0
5,442
1,570
10,017
8,146
137,046
14,755
12,465
37,154
44,578
455
1,130
11.0
0.0
10.0
11.0
7.7
11.5
8.8
6.5
5.4
0.0
0.0
(4.0-24.0)
(0.0-23.5)
(4.8-18.4)
(5.1-21.0)
(6.3-9.3)
(6.7-18.4)
(4.4-15.8)
(4.1-9.6)
(3.5-8.0)
(0.0-80.7)
(0.0-32.6)
CANADA*
207
272,758
7.6
(6.6-8.7)
Source: Health Canada. Canadian Congenital Anomalies Surveillance System, 1997.
* Québec is excluded because 1997 data were not available.
CI — confidence interval.
135
Canadian Perinatal Health Report, 2000
Appendix E
Table E4.30
Number and rate of neonatal hospital readmissions after
discharge at birth, Canada (excluding Québec, Nova Scotia and Manitoba),*
1989-1990 to 1997-1998
Year
Number of
readmitted
newborns
Number of
live hospital
births
Readmitted
newborns per 100
live hospital births
1989-1990
1990-1991
1991-1992
7,518
8,101
8,231
268,171
277,138
276,748
2.8
2.9
3.0
1992-1993
1993-1994
1994-1995
8,520
8,709
9,353
291,162
267,563
267,790
3.1
3.3
3.5
1995-1996
1996-1997
1997-1998
10,000
9,609
9,748
263,484
254,737
244,264**
3.8
3.8
4.0
Source: Canadian Institute for Health Information. Discharge Abstract Database, 1989-1990 to 1997-1998.
* Québec data are not included in the DAD. Nova Scotia and Manitoba are excluded because complete data
for all years are not available in the DAD.
** Because the last year of available data was 1997-1998 and a 28-day follow-up period is needed to identify
neonatal readmissions, live births following March 3, 1998 were excluded.
Table E4.31
Number and rate of neonatal hospital readmissions after discharge at
birth, by province/territory, Canada (excluding Québec and Manitoba), 1997-1998
Province/Territory
Number of
readmitted
newborns
Number of
live hospital
births
Readmitted newborns
(95% CI) per 100
live hospital births
Newfoundland
Prince Edward Island
Nova Scotia
New Brunswick
Ontario
Saskatchewan
Alberta
British Columbia
Yukon
Northwest Territories
117
23
246
346
5,078
599
1,822
1,668
19
76
5,337
1,559
9,837
8,026
135,496
12,248
36,212
43,820
452
1,114
2.2
1.5
2.5
4.3
3.7
4.9
5.0
3.8
4.2
6.8
(1.8-2.6)
(0.9-2.2)
(2.2-2.8)
(3.9-4.8)
(3.6-3.9)
(4.5-5.3)
(4.8-5.3)
(3.6-4.0)
(2.5-6.5)
(5.4-8.5)
CANADA*
9,994
254,101
3.9
(3.9-4.0)
Source: Canadian Institute for Health Information. Discharge Abstract Database, 1997-1998.
* Québec data are not included in the DAD. Complete Manitoba data were not available. Analyses are based on March 1997March 1998 live births.
CI — confidence interval.
136
Canadian Perinatal Health Report, 2000
Appendix E
Table E4.32
Principal diagnosis for readmitted newborns,
Canada (excluding Québec, Nova Scotia and Manitoba),* 1989-1990 and 1997-1998
Principal diagnosis
1989-1990
1997-1998
Number of
readmitted
newborns
Percent of readmitted
newborns by
principal diagnosis
Number of
readmitted
newborns
Percent of readmitted
newborns by
principal diagnosis
Jaundice
Feeding problems
Sepsis
Dehydration
Inadequate weight gain
Others
1,594
534
165
45
128
5,052
21.2
7.1
2.2
0.6
1.7
67.2
3,868
809
453
245
149
4,470
38.7
8.1
4.5
2.5
1.5
44.7
Total
7,518
100.0
9,994
100.0
Source: Canadian Institute for Health Information. Discharge Abstract Database, 1989-1990 and 1997-1998.
* Québec data are not included in the DAD. Nova Scotia and Manitoba are excluded because complete data for all years are not
available in the DAD.
137
Canadian Perinatal Health Report, 2000
Appendix F
Canadian Perinatal Surveillance System
Publications (as of September 2000)
Papers Published or in Press in Peer-reviewed Journals
Chen J, Fair M, Wilkins R, Cyr M. Maternal education and fetal and infant
mortality in Quebec. Fetal and Infant Mortality Study Group of the Canadian
Perinatal Surveillance System. Health Rep 1998; 10: 53-64.
Dzakpasu S, Joseph KS, Kramer MS, Allen AC. The Matthew Effect: infant
mortality in Canada and internationally. Pediatrics 2000; 106: e5.
Fair M, Cyr M, Allen AC, Wen SW, Guyon G, MacDonald RC for the Fetal-Infant
Mortality Study Group. An assessment of the validity of a computer system
for probabilistic record linkage of birth and infant death records in Canada.
Chronic Dis Can 2000; 21: 8-13.
Joseph KS, Allen A, Kramer MS, Cyr M, Fair M, for the Fetal-Infant Mortality
Study Group of the Canadian Perinatal Surveillance System. Changes in the
registration of stillbirths less than 500g in Canada, 1985-95. Paediatr Perinat
Epidemiol 1999; 13: 278-87.
Joseph KS, Kramer MS. Canadian infant mortality: 1994 update. Can Med Assoc J
1997; 156: 161-3.
Joseph KS, Kramer MS. Recent trends in Canadian infant mortality rates: effect
of changes in registration of live newborns weighing less than 500 grams. Can
Med Assoc J 1996; 155: 1047-52.
Joseph KS, Kramer MS. Recent trends in infant mortality rates and proportions
of low-birth-weight live births in Canada. Can Med Assoc J 1997; 157: 535-41.
Joseph KS, Kramer MS. Recent versus historical trends in preterm birth in Canada
(Res let). Can Med Assoc J 1999; 161: 1409.
Joseph KS, Kramer MS, Allen AC, Cyr M, Fair M, Ohlsson A et al. for the Fetal
and Infant Health Study Group of the Canadian Perinatal Surveillance System.
Gestational age- and birth weight-specific declines in infant mortality in Canada,
1985-94. Paediatr Perinat Epidemiol (in press).
Joseph KS, Kramer MS, Allen AC, Mery LS, Platt R. Implausible birth weight for
gestational age. Am J Epidemiol (in press).
Joseph KS, Kramer MS, Marcoux S, Ohlsson A, Wen SW, Allen A et al.
Determinants of preterm birth rates in Canada from 1981 through 1983 and
from 1992 through 1994. N Engl J Med 1998; 339: 1434-9.
139
Canadian Perinatal Health Report, 2000
Appendix F
Kramer MS, Demissie K, Yang H, Platt RW, Sauve R, Liston R for the Fetal and
Infant Health Study Group of the Canadian Perinatal Surveillance System.
The contribution of mild and moderate preterm birth to infant mortality.
J Am Med Assoc 2000; 284: 843-9.
Liu S, Wen SW. Development of record linkage of hospital discharge data for the
study of neonatal readmission. Chronic Dis Can 1999; 20: 77-81.
Liu S, Wen SW, Demissie K, Marcoux S, Kramer MS. Maternal asthma and
pregnancy outcomes: a retrospective cohort study in Quebec, Canada. Am J
Obstet Gynecol (in press).
Liu S, Wen SW, McMillan D, Trouton K, Fowler D, McCourt C. Increased
neonatal readmission rate associated with decreased length of hospital stay at
birth in Canada. Can J Public Health 2000; 91: 46-50.
Wen SW, Demissie K, Liu S. Adverse outcomes in pregnancies of asthmatic
women: results from a Canadian population. Ann Epidemiol (in press).
Wen SW, Kramer MS, Liu S, Dzakpasu S, Sauve R for the Fetal and Infant Health
Study Group. Infant mortality by gestational age and birth weight in Canadian
provinces and territories, 1990-1994 births. Chronic Dis Can 2000; 21: 14-22.
Wen SW, Liu S, Fowler D. Trends and variations in neonatal length of in-hospital
stay in Canada. Can J Public Health 1998; 89: 115-9.
Wen SW, Liu S, Joseph KS, Rouleau J, Allen A. Patterns of infant mortality caused
by major congenital anomalies. Teratology 2000; 61: 342-6.
Wen SW, Liu S, Joseph KS, Trouton K, Allen A. Regional patterns of infant mortality
caused by lethal congenital anomalies. Can J Public Health 1999; 90: 316-9.
Wen SW, Liu S, Kramer MS, Joseph KS, Marcoux S, Levitt C et al. The impact of
prenatal glucose screening on the diagnosis of gestational diabetes Am J
Epidemiol (in press).
Wen SW, Liu S, Marcoux S, Fowler D. Trends and variations in length of hospital
stay for childbirth in Canada. Can Med Assoc J 1998; 158: 875-80.
Wen SW, Liu S, Marcoux S, Fowler D. Uses and limitations of routine hospital
admission/separation records for perinatal surveillance. Chronic Dis Can 1997;
18: 113-9.
Wen SW, Mery L, Kramer MS, Jimenez V, Trouton K, Herbert P et al. Attitudes of
Canadian women towards birthing centre and midwife care for childbirth.
Can Med Assoc J 1999; 161: 708-9.
Wen SW, Rouleau J, Liu S, Sibbald B. Recent trends in male reproductive tract
anomaly and cancer in Canadian provinces of Ontario and Alberta. Teratology
(in press).
Wen SW, Rouleau J, Lowry RB, Kinakin B, Anderson-Redick S, Sibbald B et al.
Congenital anomalies ascertained by two record systems run in parallel in the
Canadian province of Alberta. Can J Public Health 2000; 91: 193-6.
140
Canadian Perinatal Health Report, 2000
Appendix F
Abstracts Published or Presented
Joseph KS. Secular trends in the frequency and character of multiple births
International Symposium 5 — Twin pregnancies — A modern epidemic and the
results of the Canadian consensus. Presented to the Society of Obstetricians
and Gynaecologists of Canada, Montreal, June 2000.
Liu S, Heaman M, Demissie K, Wen SW, Marcoux S, Kramer MS. Association
between maternal readmission and obstetric conditions at childbirth: a casecontrol study. Presented at the 13th Annual Meeting of the Society for Pediatric
and Perinatal Epidemiologic Research, Seattle, Washington, June 2000: B6.
Liu S, Joseph KS, Wen SW, Kramer MS, Marcoux S, Ohlsson A, Sauve R for the
Fetal-Infant Mortality Study Group of the Canadian Perinatal Surveillance
System. Changing patterns of fetal and infant death due to congenital anomalies
in Canada. Presented at the 13th Annual Meeting of the Society for Pediatric
and Perinatal Epidemiologic Research, Seattle, Washington, June 2000: A5.
Liu S, Wen SW, Demissie K, Marcoux S, Trouton K. Maternal asthma and pregnancy
outcomes: a cohort study in Quebec, Canada. Paediatr Perinat Epidemiol
1999; 13: A17.
Liu S, Wen SW, McMillan D, Trouton K, Fowler D et al. The association between
decreased length of hospital stay at birth and increased neonatal readmission
rates in Canada. Paediatr Perinat Epidemiol 1999; 13: A18.
Turner LA, Kramer MS, Liu S, Cyr M, Fair M, Heaman M et al. Cause-specific
mortality during pregnancy and the puerperium. Presented at the 56th Annual
Meeting of the Society of Obstetrics and Gynecology of Canada, Montréal,
Québec, June 17-21, 2000.
Wen SW. Methodological considerations in human reproductive study of toxic
exposure (abstract). Teratology 1997; 55: 162.
Wen SW, Demissie K, Liu S. Adverse outcomes in pregnancies of asthmatic
women: results from a large Canadian population. Am J Epidemiol 1999; 149: S24.
Published Reports
Fair M, Cyr M, Allen AC, Wen SW, Guyon G, MacDonald RC, and the FetalInfant Mortality Study Group of the Canadian Perinatal Surveillance System.
Validation Study for a Record Linkage of Births and Infant Deaths in Canada.
Ottawa: Statistics Canada, 1999 (Catalogue No. 84F0013-XIE).
Health Canada. Canadian Perinatal Surveillance System Progress Report 1997-1998.
Ottawa: Minister of Public Works and Government Services Canada, 1999.
Health Canada. Perinatal Health Indicators for Canada: A Resource Manual.
Ottawa: Minister of Public Works and Government Services Canada, 2000
(Catalogue No. H49-135/2000E).
Health Canada. Progress Report. Canadian Perinatal Surveillance System. Ottawa:
Minister of Supply and Services Canada, 1995.
141
Canadian Perinatal Health Report, 2000
Appendix F
Published Fact Sheets
Alcohol and Pregnancy
Breastfeeding
Induced Abortion
Infant Mortality
Preterm Birth
Report on Maternal Mortality in Canada
Sudden Infant Death Syndrome
November 1998
November 1998
April 1998
March 1998
October 1999
April 1998
September 1999
142
Canadian Perinatal Health Report, 2000
(English and French)
(English and French)
(English and French)
(English and French)
(English and French)
(Bilingual)
(English and French)
Appendix G
Evaluation Form
Reader Feedback
The Canadian Perinatal Surveillance System invites you to answer a few questions
about the Canadian Perinatal Health Report. Your answers will provide feedback
on the content and usefulness of this report.
Please return the completed questionnaire to:
Reproductive Health Division
Bureau of Reproductive and Child Health
Centre for Healthy Human Development
Population and Public Health Branch
Health Canada
HPB Building #7, A.L. 0701D
Tunney’s Pasture
Ottawa, Ontario
K1A 0L2
Fax: (613) 941-9927
Overall Satisfaction with the Report
For each of the following questions, please place an X beside the most
appropriate response.
1. How did you obtain your copy of the Report?
It was mailed to me as part of the initial distribution.
I obtained my copy at work.
I accessed it through the Internet.
I ordered my own copy.
Other (please specify) _______________________________________
✃
2. To what extent have you read or browsed through the Report?
I have browsed through the entire document.
I have browsed through the entire document and read specific chapters.
I have read the entire document.
143
Canadian Perinatal Health Report, 2000
Appendix G
3. How satisfied are you with the following aspects of the Report?
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b. Language level (readability)
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c. Clarity of technical information
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d. Format and organization
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e. Use of figures/graphics
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f. Quality of discussion
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4. How can the Report be improved (e.g., content, format, etc.)?
___________________________________________________________
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Usefulness of the Report
5. One of the goals of the Report is to increase awareness and understanding
about the status of perinatal health in Canada and the factors that influence
health. Overall, how successful do you think it was in achieving this goal?
Very successful
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144
Canadian Perinatal Health Report, 2000
Appendix G
6. Have you used, or will you likely use, the information in the Report for any
of the following?
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For information only
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Other (please specify) _______________________________________
7. How useful did you find each section of the Report? (For each, please
indicate the most appropriate response with an X.)
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useful
useful
useful
Introduction
The State of Perinatal Health in
Canada — An Overview
Section A: Determinants of Maternal,
Fetal and Infant Health
Section B: Maternal, Fetal and Infant
Health Outcomes
Appendix A:
Data Sources and Methods
Appendix B: List of Perinatal
Health Indicators
Appendix C: List of Acronyms
Appendix D: Components
of Fetal-Infant Mortality
Appendix E: Data Tables
Appendix F: Canadian Perinatal
Surveillance System Publications
8. What (degree of) impact do you think the Report has had or will have among
the following groups? (Please place the appropriate number beside each item.)
1 = High impact (widely used)
3 = Little impact (little use)
5 = Unsure
2 = Some impact (some use)
4 = No impact (not read or used)
___ Health policy makers within government
___ Government policy makers within other sectors
✃
___ Local or regional health authorities
___ Non-governmental (e.g., voluntary) organizations
145
Canadian Perinatal Health Report, 2000
Appendix G
___ Service providers (e.g., clinicians, other health professionals,
social workers)
___ Academic and/or policy researchers
___ Members of the general public
___ Media
9. Do you have a copy of the companion document, Perinatal Health Indicators
for Canada: A Resource Manual?
Yes
No
If no, you may obtain a copy from:
Reproductive Health Division
Bureau of Reproductive and Child Health
Centre for Healthy Human Development
Population and Public Health Branch
Health Canada
HPB Bldg. #7, A.L. 0701D
Tunney’s Pasture
Ottawa, Ontario
K1A 0L2
Telephone: (613) 941-2395
Fax: (613) 941-9927
This publication can also be accessed electronically via the Internet at:
http://www.hc-sc.gc.ca/hpb/lcdc/brch/reprod.html
If yes, did you find it useful?
Yes
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10. Do you have other comments about the Report or suggestions for future
reports?
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146
Canadian Perinatal Health Report, 2000
2000
Rapport sur la santé périnatale au Canada
Santé
Canada
Health
Canada
Health
Canada
Santé
Canada
Rapport sur la
santé périnatale
au Canada
2000
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