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A survey of low birth weight in Vancouver and resulting implications for public health programming Kendall, Perry R. W. 1983

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A SURVEY OF LOW BIRTH WEIGHT IN VANCOUVER AND RESULTING IMPLICATIONS FOR P U B L I C HEALTH PROGRAMMING b y PERRY R . W . KENDALL MB. B S . U N I V E R S I T Y C O L L E G E H O S P I T A L MEDICAL SCHOOL 1 9 6 8 . T H E S I S SUBMITTED IN P A R T I A L F U L F I L L M E N T OF THE REQUIREMENT FOR THE DEGREE OF MASTER OF S C I E N C E i n THE F A C U L T Y OF GRADUATE STUDIES DEPARTMENT OF HEALTH CARE AND( EPIDEMIOLOGY We a c c e p t t h i s T h e s i s as c o n f o r m i n g t o t h e r e q u i r e d s t a n d a r d : The U n i v e r s i t y o f B r i t i s h C o l u m b i a August 1983 © Perry R.W. Kendall, 1983 I n p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t o f t h e r e q u i r e m e n t s f o r an a d v a n c e d d e g r e e a t t h e U n i v e r s i t y o f B r i t i s h C o l u m b i a , I a g r e e t h a t t h e L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e a n d s t u d y . I f u r t h e r a g r e e t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y i n g o f t h i s t h e s i s f o r s c h o l a r l y p u r p o s e s may be g r a n t e d by t h e he a d o f my d e p a r t m e n t o r by h i s o r h e r r e p r e s e n t a t i v e s . I t i s u n d e r s t o o d t h a t c o p y i n g o r p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l n o t be a l l o w e d w i t h o u t my w r i t t e n p e r m i s s i o n . D e p a r t m e n t o f lJjif5.ll The U n i v e r s i t y o f B r i t i s h C o l u m b i a 1956 Main Mall V a n c o u v e r , Canada V6T 1Y3 D a t e Mr-re DE-6 (.3/81) i i ABSTRACT The l i t e r a t u r e on maternal and c h i l d health suggests that infant b i r t h weight i s the best single predictor of infant health and that the low b i r t h weight rate of a community i s a p r a c t i c a l indicator of the p e r i n a t a l health care status of that community. Two groups of Vancouver mothers were surveyed betwen June 1st, 1981 and November 30th, 1981. The 'case' group consisted of mothers who delivered infants weighing less than 2501gm at b i r t h (Low B i r t h Weight). The control group consisted of mothers who delivered infants weighing 2501gm or more at b i r t h (Non Low B i r t h Weight). For each low b i r t h weight mother a non low birth weight mother was selected by time and geographic proximity. The mothers were interviewed by Community Health Nurses. Data from multiple births were excluded from the subsequent analyses. The p r i n c i p l e hypotheses being tested were that mothers of low b i r t h weight infants would: 1) Have a d i f f e r e n t biomedical p r o f i l e ; 2) Have a d i f f e r e n t sociodemographic p r o f i l e ; 3) Have a higher prevalence of p o t e n t i a l l y alterable behaviours that have been associated with low b i r t h weight, than mothers of non low b i r t h weight infants. S i g n i f i c a n t d i f f e r e n c e s were f o u n d between t h e two g r o u p s of m o t h e r s . W i t h r e g a r d t o b i o m e d i c a l p r o f i l e s , m o t h e r s o f low b i r t h w e i g h t i n f a n t s were f o u n d t o h a v e : - more i l l n e s s d u r i n g p r e g n a n c y ( H y p e r t e n s i o n , E p i l e p s y and R e n a l D i s e a s e ) - more c o m p l i c a t i o n s o f p r e g n a n c y ( T o x a e m i a , A n t e P a r t u m , Haemorrhage and P l a c e n t a p r a e r i a ) - more d e l i v e r i e s p r i o r t o 38 weeks o f g e s t a t i o n - more m i s c a r r i a g e s , a b o r t i o n o r s t i l l b i r t h s i n p r e v i o u s p r e g n a n c i e s - l e s s l i k e l i h o o d o f h a v i n g g a i n e d 251b i n t h i s p r e g n a n c y . No s i g n i f i c a n t d i f f e r e n c e s were f o u n d f o r m a t e r n a l age o r p a r i t y . D i f f e r e n c e s f o u n d w h i c h d i d n o t r e a c h t h e .05 l e v e l o f s i g n i f i c a n c e were, p r e v i o u s low b i r t h w e i g h t ( a l l c a s e m o t h e r s ) and c l o s e i n t e r p r e g n a n c y i n t e r v a l ( l e s s t h a n 12 months) f o r women o f C h i n e s e and I n d i a n o r i g i n s . W i t h r e g a r d t o s o c i o d e m o g r a p h i c p r o f i l e s , no s i g n i f i c a n t d i f f e r e n c e s were f o u n d b u t some t r e n d s a p p r o a c h i n g t h e .05 l e v e l o f s i g n i f i c a n c e were n o t e d ; - more low b i r t h w e i g h t b a b i e s a r e b o r n t o m o t h e r s who r e s i d e i n t h e p o o r e r E a s t s i d e o f t h e c i t y . - more low b i r t h w e i g h t b a b i e s were b o r n t o m o t h e r s o f I n d i a n o r i g i n , and fewer t o m o t h e r s o f C h i n e s e o r i g i n . there i s a strong suggestion that lack of support during pregnancy (defined as no l i v e - i n partner) and being a r e c i p i e n t of s o c i a l assistance are associated with the b i r t h of small for gestational age infants. This finding only applies to Caucasian mothers. no s i g n i f i c a n t differences in English comprehension were found between case and control mothers of Chinese or Indian o r i g i n , the majority were in fact rated f a i r or good in English comprehension. With regard to the prevalence of p o t e n t i a l l y alterable behaviours, s i g n i f i c a n t differences between case and control groups were found. Mothers of low b i r t h weight infants were more l i k e l y to: have gained less than 251b during t h i s pregnancy have smoked during t h i s pregnancy (Caucasians only). Some trends approaching the .05 l e v e l of significance were found; mothers of low b i r t h weight infants were less l i k e l y to attend prenatal classes and l e s s l i k e l y , i f Canadian, to have presented for physician care during the f i r s t trimester. In' t h i s sample there was no s t a t i s t i c a l difference between Chinese and Canadian low b i r t h weight mothers i n prenatal class attendance but s i g n i f i c a n t differences were found between these two groups and mothers of Indian o r i g i n . One other finding of i n t e r e s t was that non low b i r t h weight Canadian mothers v i s i t their physicians s i g n i f i c a n t l y more frequently than do non low b i r t h weight mothers of Indian or Chinese o r i g i n . V These findings are consistent with the l i t e r a t u r e reviewed and confirm the p r i n c i p l e hypotheses being tested. A survey of the l i t e r a t u r e on the effectiveness of prenatal class interventions, suggests that these interventions are: a) less e f f e c t i v e than has often been claimed b) often not designed to address factors which may adversely a f f e c t b i r t h weight. Prenatal classes in Vancouver appear to be u t i l i z e d most by those mothers who are at lowest r i s k for low b i r t h weight children. Based on the findings of t h i s study, some recommendations are made for the public health prenatal programs of the Cit y of Vancouver. The recommendations are probably equally applicable to other j u r i s d i c t i o n s . v i TABLE OF CONTENTS TITLE PAGE ABSTRACT i i TABLE OF CONTENTS v i LIST OF TABLES v i i i ACKNOWLEDGEMENTS xi CHAPTER I BACKGROUND OF STUDY Indications of Prenatal Health 1 - Changing Outlook for Low B i r t h Weight Infants in North America Incidence and Medical Management 3 - Components of Low B i r t h Weight 5 Antecedents to Low B i r t h Weight 8 Prevention of Low B i r t h Weight 17 N u t r i t i o n a l Supplementation 18 - Reduction i n Maternal Smoking 20 - Reduction i n Maternal Alcohol Intake 21 - E f f e c t s of L i f e Stress and i t s Reduction on B i r t h Weight 21 Bibliography Chapter I 23 CHAPTER II THEORY, RATIONALE AND OBJECTIVES OF STUDY Theory and Rationale 30 Hypotheses 31 - Research Objectives 32 - Significance 32 CHAPTER III METHODS Research Design 33 Selection of Categories 33 Cases 33 - Controls 33 - Choice of Interviewer 34 - Choice of Face to Face Inter-viewers to C o l l e c t Data 35 Process 36 The Instrument 37 Implementation 42 - Bibliography Chapter III 43 v i i CHAPTER IV RESULTS - Tables I - XVI 44-59 C l a s s i f i c a t i o n of newborns by b i r t h weight and gestation age 60 Comments on Results 61 - Tables XVII-XVIII 64-81 In Regard to Hypothesis I 82 In Regard to Hypothesis II 82 In Regard to Hypothesis III 83 Analysis of Low B i r t h Weight by Development and Gestation 85 Summary of Findings 85 - Relative Risk for Low B i r t h Weight 87 CHAPTER V ETHNICITY AND LOW BIRTH WEIGHT - East Indian 90 - Chinese 92 - Bibliography Chapter V 94 CHAPTER VI DEMOGRAPHY, PERINATAL HEALTH AND PUBLIC HEALTH SERVICES IN VANCOUVER - Demography 96 '- Vancouver Health Department Prenatal Programs 100 Prenatal Classes 100 Current Objectives of VHD Prenatal Classes 101 - Program Effectiveness 103 E f f e c t on Health of Prenatal Classes 103 - Bibliography Chapter VI 110 CHAPTER VII RECOMMENDATIONS 113-116 APPENDIX I QUESTIONNAIRE 117 APPENDIX II PROTOCOL FOR COMMUNITY HEALTH NURSES INVOLVED IN LBW SURVEY 120 APPENDIX III LOW BIRTH WEIGHT SURVEY CONSENT FORM 121 v i i i LIST OF TABLES TITLE PAGE CHAPTER I CHAPTER IV TABLE I 7 - Hazards of Low B i r t h Weight from Dunn TABLE II 10 - Percentages of Low B i r t h Weight and Preterm Infants Attributed to Different Factors TABLE III 12 - Attributable Percentage of Low B i r t h Weight/Preterm Delivery by Risk TABLE I 44 - For Singleton Live B i r t h - Low B i r t h Weight Infants by Unit and E t h n i c i t y TABLE II 45 Low B i r t h Weight and Non Low B i r t h Weight Infants by E t h n i c i t y of Mother TABLE III 46 Low B i r t h Weight and Non Low B i r t h Weight Infants by Maternal Risk Factors: Canadian, Chinese, East Indian TABLE IV 47 Low B i r t h Weight and Non Low B i r t h Weight Infants by Maternal Medical Problem and by Complication of Pregnancy for Mothers: Canadian, Chinese, East Indian TABLE V 48 - Mothers of Low B i r t h Weight Infants Term and Preterm by Ethnic Group, P a r i t y , Care, Tobacco and Alcohol TABLE VI 49 - Ethnic Group by Care During Pregnancy Low B i r t h Weight and Non Low B i r t h Weight Mothers TABLE VII 50 Case and Control Chinese and East Indian Mothers by English Comprehension TABLE VIII 51 Case and Control Mothers by Ethnic Group and Alcohol Use TABLE IX 52 Case and Control Mothers by Pa r i t y ix TABLE X 53 Case and Control Mothers by Age TABLE XI 54 - Case and Control Mothers: Pro-portional Representation of Three Ethnic Groups TABLE XII 55 - Low B i r t h Weight Infants by E t h n i c i t y Characterized by Lubchenco Scale as: Small for Gestational Age (SGA), or Appropriate for Gestational Age (AGA) TABLE XIII 56 Low B i r t h Weight and Non Low B i r t h Weight Infants by E t h n i c i t y and Prematurity (<38 weeks) TABLE XIV 57 - Canadian Mothers: Comparison by Risks SGA and AGA TABLE XV 58 - Canadian Mothers: Comparison by Risks SGA Mothers and Non Low B i r t h Weight Mothers TABLE XVI 59 - Country of B i r t h of Chinese and East Indian Mothers TABLE XVII 64 - Low Weight Births by Location and Reporting in Survey TABLE XVIII 80 - Under 2501gm Infants Subgrouped by Weight and Maternal E t h n i c i t y TABLE XIX 89 - Risk Factor for Low B i r t h Weight and Relative Risk CHAPTER IV FIGURE I 60 - C l a s s i f i c a t i o n of newborns by b i r t h weight and gestation age FIGURE II 77 E t h n i c i t y : Canadian. Under 2501 gm. FIGURE III 78 E t h n i c i t y : Chinese. Under 2501 gm. FIGURE IV 79 - E t h n i c i t y : East Indian. Under 2501 gm. CHAPTER VI TABLE I 96 - Vancouver: Per i n a t a l Mortality Rates and Low B i r t h Weight Rates 1978-1982 X TABLE II 98 - Maternal Population by E t h n i c i t y South and East Health Units 1980 TABLE III 99 - Vancouver Health Units C h a r a c t e r i s t i c s of Residents 1976 TABLE IV 100 Maternal Population by Unit, Prenatal Class Attendance, and L.B.W. CHAPTER VI FIGURE I 102 Health Unit Areas and Populations 1976 Vancouver 410,953 xi ACKNOWLEDGEMENTS I would l i k e t o a c k n o w l e d g e t h e c o - o p e r a t i o n , h e l p and a s s i s t a n c e o f many p e o p l e i n t h e p r e p a r a t i o n o f t h i s p a p e r ; The V a n c o u v e r H e a l t h D e p a r t m e n t f o r t h e i r a p p r o v a l o f t h e s u r v e y , and V a n c o u v e r s ' Community H e a l t h N u r s e s f o r i m p l e m e n t i n g t h e s u r v e y . I would l i k e t o p a r t i c u l a r l y a c k n o w l e d g e t h e h e l p o f D r . T. A n d e r s o n o f t h e U n i v e r s i t y o f B r i t i s h C o l u m b i a , Dr. Ned G l i c k o f t h e U n i v e r s i t y o f B r i t i s h C o l u m b i a and D r . R. T o n k i n f o r t h e i r h e l p i n p r e p a r i n g t h e p a p e r . I was f o r t u n a t e enough t o have a s s i s t a n c e f r o m D r . James R o b i n s o n i n t h e i n i t i a l and m i d d l e p h a s e s o f t h i s p a p e r , and I would l i k e t o pay a s p e c i a l t r i b u t e t o h i s memory. Thanks a l s o t o Don Brown and h i s basement word p r o c e s s o r . 1 CHAPTER ONE BACKGROUND OF STUDY INDICATORS OF PERINATAL HEALTH Infant and peri n a t a l mortality rates have dropped drama-t i c a l l y in Canada during t h i s century. The Canadian p e r i n a t a l mortality rate dropped from 31.0/1000 l i v e births in 1955 to 16.7/1000 l i v e births in 1974.[3] In B r i t i s h Columbia during the decade 1970-1979 the rate dropped from 18.01/1000 to 11.3/ 1000.[4] This decline i s noted in the United States of America - Infant mortality rate 99.9/1000 l i v e births in 1915 [1] and under 13/1000 in 1980.[2] Declines similar to those in B r i t i s h Columbia, over the same decade are also reported from West Germany, Japan and Sweden.[4] The use of mortality data to assess any health status, including that of humans in the p e r i n a t a l period, may be questioned. I t i s a measure of the most extreme expression of maladaption, and reveals l i t t l e of pr e d i c t i v e value about the health prospects of the survivors. Chalmers [5] states that: " . . . death c l e a r l y remains an unsatisfactory basis for contrasting the health of d i f e r e n t p e r i n a t a l populations." B i r t h Weight however i s a predictor of p e r i n a t a l mortality, of mortality after the f i r s t week of l i f e , of infant morbidity and of subsequent quality of infant l i f e . [5,6,7,11,12,13,14,15] 2 C h a l m e r s [ 5 ] , Hemmincki & S t a r f i e l d [6] and t h e Wynns [7] s t a t e t h a t b i r t h w e i g h t i s t h e b e s t s i n g l e p r e d i c t o r o f p e r i n a t a l m o r t a l i t y and m o r b i d i t y . The s m a l l e r t h e i n f a n t t h e l e s s i t s c h a n c e o f s u r v i v a l , and i f i t s u r v i v e s , t h e g r e a t e r t h e c h a n c e o f a t t e n d a n t m o r b i d i t y . T h i s a p p l i e s i n N o r t h A m e r i c a , E u r o p e , A f r i c a , C h i n a , New G u i n e a and I n d i a . [7,17,18,19,20] The W o r l d H e a l t h O r g a n i z a t i o n u s e s a b i r t h w e i g h t o f 2500 gm t o d e f i n e Low B i r t h W e i g h t . T h i s w e i g h t was f i r s t s u g g e s t e d by t h e F i n n i s h P a e d i a t r i c i a n YLLPO o v e r 50 y e a r s ago. [9] A l t h o u g h t h i s d e f i n i t i o n does n o t t a k e g e s t a t i o n a l age o f t h e i n f a n t i n t o a c c o u n t i t i s u s e f u l as a c o m p a r i s o n a c r o s s n a t i o n s where d a t a on g e s t a t i o n a l l e n g t h i s f r e q u e n t l y u n o b t a i n a b l e [21] (mean g e s t a t i o n a l l e n g t h s a r e s i m i l a r i n c o u n t r i e s where t h e p e r c e n t a g e s o f Low B i r t h W e i g h t i n f a n t s r a n g e f r o m 5.9 t o 2 9 . 0 ) . [ 1 0 ] The l i t e r a t u r e r e v i e w e d s u g g e s t s f a i r l y c o n v i n c i n g l y t h a t t h e p e r c e n t a g e o f low b i r t h w e i g h t i n f a n t s i s a good i n d i c a t o r t o t h e s t a t e o f p e r i n a t a l h e a l t h o f t h e community. The l o w e r t h e b i r t h w e i g h t t h e h i g h e r t h e i n c i d e n c e o f r e s i d u a l h a n d i c a p s r a n g i n g f r o m s e v e r e d i s o r d e r s , c e r e b r a l p a l s y , m e n t a l r e t a r d a t i o n , d e a f n e s s and b l i n d n e s s t o m i n i m a l b r a i n d i s f u n c t i o n , l e a r n i n g , r e a d i n g and b e h a v i o u r a l d i s o r d e r s . [22,24,25,26,27,28,36] 3 A higher percentage of low b i r t h weight i n f a n t s w i l l thus r e s u l t i n a higher percentage of r e s i d u a l handicapping c o n d i t i o n s . The Greater Vancouver area has a p e r i n a t a l m o r t a l i t y r a t e of 39.2/1000 l i v e b i r t h s of i n f a n t s weighing l e s s than 2501 gm and 3.6/1000 l i v e b i r t h s of i n f a n t s of b i r t h weight more than 3000 gms., an eleven f o l d d i f f e r e n c e . [ 8 ] Dunn, [22] a l o c a l r e s e a r c h e r , has estimated that more than 50% of deaths o c c u r i n g i n the f i r s t year of l i f e are d e r i v e d from the lou b i r t h weight i n f a n t c o h o r t . Low b i r t h weight r a t e s i n the d i f f e r e n t h e a l t h U n i t s w i t h i n Vancouver show c o n s i s t e n t d i s p a r i t i e s . In 1978 the lowest area r a t e was 4.4% and the h i g h e s t 8,7%. i t was t h i s apparent d i s p a r i t y t h at prompted t h i s researcher to undertake t h i s p a r t i c u l a r t h e s i s p r o j e c t . CHANGING OUTLOOK FOR LOW BIRTH WEIGHT INFANTS IN  NORTH AMERICA, INCIDENCE & MEDICAL MANAGEMENT. Three p e r i o d s can be i d e n t i f i e d . That p e r i o d p r i o r to 1940 i s c h a r a c t e r i z e d by high p r e n a t a l m o r t a l i t y r a t e s among low b i r t h weight i n f a n t s . Long term outcomes were good f o r the s e l e c t s u r v i v o r s . [30,31] The mid 40's to the e a r l y 60's was a p e r i o d of ag g r e s s i v e management of low b i r t h weight i n f a n t s which was accompanied by an unforeseen epidemic of i a t o g e n i c d i s o r d e r s . [32] R e t r o l e n t a l F i b r o p l a s i a , s t a r v a t i o n , hypoglycaemia, dehydration and k e r n i c t e r u s i n c r e a s e d markedly as d i d n e u r o l o g i c a l damage when over e n t h u s i a s t i c oxygen therapy was subsequently cut back.[33] 4 F o l l o w up s t u d i e s f r o m t h i s p e r i o d r e v e a l d i s a p p o i n t i n g o u t c o m e s . D e f i c i t s i n m e n t a l and p h y s i c a l d e v e l o p m e n t were f o u n d i n up t o 60% o f t h e s u r v i v o r s . [26,27,34] The t h i r d p e r i o d marks t h e c o u p l i n g o f a g g r e s s i v e management i n N e o n a t a l I n t e n s i v e C a r e U n i t s w i t h an u n d e r s t a n d i n g o f t h e p h y s i o l o g i c a l r e q u i r e m e n t s o f t h e p r e t e r m i n f a n t . [ 3 5 ] The i n c i d e n c e o f s p a s t i c d i p l e g i a d r o p p e d f r o m 7-12% i n t h e l a t e 50's t o l e s s t h a n 4% a d e c a d e l a t e r . T h e r e were c o m p a r a b l e r e d u c t i o n s i n t h e i n c i d e n c e o f b l i n d n e s s and s e v e r e h e a r i n g l o s s . By t h e 70's 80-90% o f s u r v i v i n g low b i r t h w e i g h t i n f a n t s were f r e e f r o m s e r i o u s p h y s i c a l or m e n t a l h a n d i c a p . [35] R a t e s o f s u r v i v a l ( r e p o r t e d f r o m C l e v e l a n d , O h i o , between 1976 and 1 9 7 8 ) , f o r t h e s e low b i r t h w e i g h t i n f a n t s a r e 500-1000gm 47% s u r v i v a l , 1001-1500gm 81%, 1501-2500 95%. [35] [37] W h i l e s u r v i v a l r a t e s f o r low b i r t h w e i g h t i n f a n t s have i m p r o v e d d r a m a t i c a l l y , a l m o s t d o u b l i n g i n Canada, [38] t h e U.K. [39] and t h e U.S.A. [40] i n t h e l a s t 25 y e a r s , t h e improvements i n a l l c a s e s have been due t o i m p r o v e d m e d i c a l c a r e . R e d u c t i o n s i n m o r t a l i t y have been due t o r e d u c t i o n i n b i r t h w e i g h t s p e c i f i c m o r t a l i t y r a t e s i n t h e under 2501 gm i n f a n t . The i n c i d e n c e o f low b i r t h w e i g h t i t s e l f has shown o n l y modest d e c l i n e s i n t h e s e c o u n t r i e s . [38,39,40,41,42] 5 COMPONENTS OF LOW BIRTH WEIGHT In 1948 the World Health Assembly defined infants as "premature" i f they were born weighing less than 2501gm. Th i s accounts for 4-8% of a l l infants born in developed countries and may account for approximately one-sixth of the t o t a l number of global l i v e b i r t h s . [43] About 30-40% of the under 2501 gm infants in the developed countries are actually born at term (at or after 37 completed weeks of gestation) The proportion i s higher in an unfavourable socio-economic environment and in the developing nations. [22] In 1961 the Expert Committee on Maternal and Child Health, established by the World Health Organization recommended that the babies weighing 2500 gm or less should no longer a l l be referred to as "premature" and that the previously defined concept of prematurity give way to that of "Low B i r t h Weight". This accords better with the findings of a 'Continuum of Reproductive Casualty' reported by Knoblock and her Associates [28,45] and by D r i l l i e n . [26,27] Subsequent work by Lubchenco and her colleagues [46,47] and by Babson, et al [48] subdivided children of Low Bi r t h Weight into two major categories. The "premature", born prior to 37 completed weeks of gestation whose weight l i e s between the 90th and the 10th percentiles, are b i r t h weight 'appropriate for gestational age' 6 (AGA), whereas b a b i e s whose b i r t h w e i g h t i s b e l o w t h e 1 0 t h p e r c e n t i l e a r e h y p o t r o p h i c , d y s m a t u r e o r ' s m a l l f o r g e s t a t i o n a l age' (SGA). T h e s e two m a j o r c a t e g o r i e s , b a b i e s b o r n p r e t e r m b u t who have grown a p p r o p r i a t e l y and t h o s e b o r n a t t e r m b u t who a r e assumed t o be u n d e r g r o w n , f a c e d i f f e r e n t r i s k s , b o t h i n t h e immediate p e r i n a t a l p e r i o d [22,47] ( s e e T a b l e 1) and i n t o i n f a n c y and c h i l d h o o d . [49,50,57,52,53] The d i s t i n c t i o n i s t h u s i m p o r t a n t f o r s h o r t t e r m and l o n g t e r m management. T h e r e i s a t h i r d g r o u p o f SGA b a b i e s who a r e b o r n " p r e t e r m " ; t h i s g r o u p i s l i a b l e t o have mix e d h a n d i c a p s . 7 TABLE I H a z a r d s o f Low B i r t h W e i g h t f r o m Dunn [22] " T r u e P r e m a t u r e " " S m a l l f o r d a t e s " AGA SGA a t t e r m C o n g e n i t a l M a l f o r m a t i o n s + + + T r a n s p l a c e n t a l i n f e c t i o n s + ++ I n t r a u t e r i n e h y p o x i a , b i r t h a s p h y x i a + + + R e s p i r a t o r y D i f f i c u l t i e s - H y a l i n e Membrane D. ++ 0 -Meconium A s p i r a t i o n + ++ - P u l m o n a r y H a e m o r r h a g e + ++ - A p n o e i c A t t a c h m e n t s ++ + M e t a b o l i c D i f f i c u l t i e s - H y p o g l y c a e m i a + ++ - A c i d o s i s + ++ - H y p o c a l c a e m i a ++ + - J a u n d i c e , K e r n i c t e r u s ++ + A l i m e n t a r y D i f f i c u l t i e s - I n a b i l i t y s u c k / s w a l l o w ++ 0 - F u n c t i o n a l i n t e s t . o b s t r u c t . ++ + - E n t e r o l c o l i t i s O t h e r - P o l y c y t h a e m i a 0 ++ -Anaemia ++ 0 - C e r e b r a l Oedema, N e u r o n a - N e c r o s e s + ++ - R e t r o l e n t a l F i b r o p l a s i a ++ + - S e n s o r i - n e u r a l d e a f n e s s ++ + - I n f e c t i o n - p r o n e ++ + -Thermo l a b i l i t y ++ + - R e n a l f u n c t i o n U r i n e C o n c e n t r a - N o r m a l t i o n d e c r e a s e d 0 -+ ++ -I n c i d e n c e as i n n o r m a l t e r m i n f a n t . I n c i d e n c e more common t h a n i n n o r m a l t e r m i n f a n t . F ound m a i n l y i n g r o u p d e s i g n a t e d . A n t e c e d e n t s t o Low B i r t h W e i g h t 8 Low B i r t h W e i g h t , w h a t e v e r t h e a n t e c e d e n t c a u s e , i s l i n k e d w i t h low s o c i o - e c o n o m i c s t a t u s . [ 5 4 , 5 5 , 5 , 5 6 ] I n N o r t h A m e r i c a Low B i r t h W e i g h t r a t e s i n t h e l o w e s t s o c i o - e c o n o m i c s t a t u s g r o u p were r e p o r t e d a s 2-3 t i m e s t h a t i n h i g h e r g r o u p s . The Low B i r t h W e i g h t i n c i d e n c e i n d e v e l o p i n g c o u n t r i e s i s t h r e e t i m e s t h a t i n N o r t h A m e r i c a . [57] T h i s i s n o t a d i r e c t r e l a t i o n s h i p as a m u l t i t u d e o f o t h e r i n t e r c u r r e n t f a c t o r s a c t t h r o u g h l o w s o c i o - e c o n o m i c s t a t u s t o h a v e an e f f e c t on p r e g n a n c y d u r a t i o n and f e t a l i n t r a u t e r i n e g r o w t h r a t e s e . g . m a t e r n a l n u t r i t i o n , t o b a c c o u s a g e , a l c o h o l i n t a k e , e d u c a t i o n , a g e , p a s t o b s t e t r i c p e r f o r m a n c e and r a c e n o t w h i t e . [ 1 2 , 1 3 , 1 4 , 1 5 , 1 7 , 2 3 , 7 7 , 8 0,81] I n t h e i r e x c e l l e n t r e v i e w o f Low B i r t h W e i g h t , H e m m i n c k i and S t a r f i e l d [6] p r o p o s e s a c a t e g o r i z a t i o n o f c a u s e s o f b o t h Low B i r t h W e i g h t a n d / o r p r e m a t u r i t y . T h i s i s p r e s e n t e d b e l o w i n a s l i g h t l y a d a p t e d f o r m a t . C a u s e s o f Low B i r t h W e i g h t a n d / o r P r e t e r m B i r t h . 1 S o c i a l F a c t o r s - B e f o r e and d u r i n g p r e g n a n c y - P o o r N u t r i t i o n - S moking - E x c e s s p h y s i c a l and p s y c h o l o g i c a l s t r e s s - E x p o s u r e t o t o x i n s 9 - D u r i n g p r e g n a n c y - P r e m a t u r e e l e c t i n d u c t i o n - B e f o r e p r e g n a n c y - P r e v i o u s C a e s a r i a n S e c t i o n - P r e v i o u s I n d u c e d A b o r t i o n s . 2 m a t e r n a l D i s e a s e s ( n o t P r e g n a n c y R e l a t e d ) - p o o r g e n e r a l s t a t e o f h e a l t h , i . e l u d i n g p o o r p h y s i c a l c a p a c i t y ( e . g . C a r d i a c volume) - S p e c i f i c d e s e a s e s 3 M a t e r n a l D i s e a s e s ( P r e g n a n c y R e l a t e d ) - Toxaemia ^ - Anaemia - I n s u f f i c i e n t Hormonal E x c r e t i o n 4 P l a c e n t a l and C o r d D i s e a s e s - A b r u p t i o P l a c e n t a e - P l a c e n t a l I n s u f f i c i e n c y - P l a c e n t a P r a e v i a - P r o l a p s e o f U m b i l i c a l C o r d 5 I n f a n t F a c t o r s - M u l t i p l e b i r t h s - I n f e c t e d I n f a n t - C o n g e n i t a l l y d e f e c t i v e I n f a n t - I n t o x i c a t e d I n f a n t These two a u t h o r s (Hemmincki and S t a r f i e l d ) a n a l y s e d a number o f e p i d e m i o l o g i c a l s t u d i e s i n an a t t e m p t t o e s t i m a t e t h e s i g n i f i c a n c e o f some o f t h e above f a c t o r s . A t t r i b u t a b l e r i s k ( p e r c e n t a g e o f t h e t o t a l Low B i r t h W e i g h t o r P r e t e r m I n f a n t s a t t r i b u t e d t o t h e s p e c i f i c f a c t o r ) was c a l c u l a t e d or o b t a i n e d d i r e c t l y f r o m t h e q u o t e d s t u d i e s . (See T a b l e I I ) TABLE II  PERCENTAGES OF LOW BIRTH WEIGHT AND PRETERM INFANTS  ATTRIBUTED TO DIFFERENT FACTORS (From Henmincki & S t a r f i e l d 1978) FACTOR AUTHOR & DATE Maternal Disease Not Pregnancy Related Toxaemia Anaemia Hb<9 Anaemia Hb<ll Incopetent Cervix Abruptio Placenta Placenta Previa Cord Prolapse Mul t i p l e B i r t h s Congenitally or G e n e t i c a l l y Defetive Infant Smoking Poor N u t r i t i o n FREQUENCY AMONG PREGNANT WOMEN WHITE NON-WHITE Niswander & Gordon 12.0 11.0 1972 Ontario Per i n a t a l Study 1967 20.0 Shapiro Et A l 1968 1.2 2.8 Butler & Alberman 11.0 1969 Kaltretder & 1.7 Johnson 1976 Ontario P e r i n a t a l 24.0 Study 1967 Niswander & Gordon 0.34 0.36 1972 Niswander & Gordon 2.4 1.9 1972 Niswander & Gordon 0.77 0.56 1972 Niswander & Gordon 1.1 0.78 1972 Butler & Alberman 2.4 1969 Page 1967 0.81 ATTRIBUTABLE PER-CENTAGE LOW BIRTH WEIGHT INFANTS WHITE NON-WHITE 7.7 3.8 20.0 0.68 0.75 14.0 Meyer et a l 1976 43.0 1.4. 2.6 6.5 2.8 0.74 14.5 1.5 30.0 1.1 1.5 4.9 1.7 0.59 During Pregnancy Poor Physical Condition Niswander & Gordon 90.0 88.0 Raiha & Kauppinen 11.0 1963 65.0 57.0 of term 29.0 T e r r i s & Gold 1969 11.0 11.0 11 J o h n s o n & D u b i n [85] i n 1980 combined t h e a f o r e m e n t i o n e d r e v i e w w i t h t h a t o f K a l t r e i d e r & K o h l ( O b s t e c t r i c a l S t a t i s t i c a l C o - o p e r a t i v e D a t a Review 1970-1976) and c a l c u l a t e d t h e p e r c e n t a g e o f a l l P r e t e r m d e l i v e r i e s a t t r i b u t a b l e t o - c e r t a i n c o m p l i c a t i o n s or c h a r a c t e r i s t i c s . T h e i r f i n d i n g s a r e p r e s e n t e d i n T a b l e I I I . TABLE III ATTRIBUTABLE PERCENTAGE OF LOW  BIRTH WEIGHT/PRETERM DELIVERY BY RISK TYPE OF RISK % Low socio-economic status (includes lack of support, poor n u t r i t i o n , l e s s education, short stature, underweight pregravid, increasing p a r i t y and mat-ernal age les s than 19) 40-60* Repetitive Prematurity (and Abortions) 18 ** Unwanted Pregnancies 14 *** Smoking 4-14 * Mul t i p l e Pregnancies 10 ** Placenta Praevia and Abruptio Placentae 10 ** Maternal I l l n e s s 9 ** F e t a l Malformation 6 ** Iatrogenic 3 ** Sources: * Derived from Hemminki and S t a r f i e l d [6] ** Derived from K a l t r e i d e r and Kohl O.S.C. dates 1970-1976 *** Derived from Zelnik and Kantner [86] b([Rl/E2]-l) ATTRIBUTABLE PERCENTAGE=100X b([R1/R2]-1)+1 b = frequency of complication i n whole population R l = frequency of low b i r t h weight/prematurity i n patients with complication R2 = frequency of low b i r t h weight/prematurity i n patients without complication An a d d i t i o n a l f a c t o r i s t h e r e l a t i o n s h i p o f Low B i r t h W e i g h t t o p r e n a t a l c a r e . I t has l o n g been a x i o m a t i c t h a t p r e m a t u r i t y i s a s s o c i a t e d w i t h l a c k o f p r e n a t a l c a r e . Eastnam [58] i n 1947, Oppenheimer [59] i n 1958 and P a k t e r [60] i n 1961 a l l r e p o r t two o r t h r e e f o l d i n c i d e n c e s i n " p r e m a t u r i t y " a s s o c i a t e d w i t h l a c k o f p r e n a t a l c a r e . T h i s may however be a s e c o n d a r y a s s o c i a t i o n s i n c e " t h e f a i l u r e t o o b t a i n p r e n a t a l c a r e may m e r e l y r e f l e c t o t h e r h a b i t s o f l i v i n g w h i c h a r e r e s p o n s i b l e f o r p r e m a t u r i t y " . [58] S h w a r t z and V i n y a r d [62] i n 1965 s t u d i e d o v e r 30,000 women w i t h p r e m a t u r e l i v e b o r n i n f a n t s and a t t e m p t e d t o d e t e r m i n e what r e l a t i o n s h i p , i f any, v a r y i n g l e v e l s o f c a r e had on outcome. T h e i r c o n c l u s i o n , "The presumed c a u s a l r e l a t i o n was shown t o h a v e a n e g l i g i b l e e f f e c t on t h e o v e r a l l i n c i d e n c e o f p r e m a t u r i t y i n t h e s t u d y p o p u l a t i o n . " Nemer and M i l t o n [54] i n a s t u d y o f 100,000 l i v e b i r t h s i n 1970 c o u l d o n l y c o n c l u d e t h a t t h e t r i m e s t e r o f o n s e t o f p r e n a t a l c a r e was p r o b a b l y an i n d e x f o r o t h e r s o c i o - e c o n o m i c , c u l t u r a l and m e d i c a l f a c t o r s w h i c h i n f a c t i n f l u e n c e d p r e g n a n c y outcome a d v e r s e l y . G l a s s e r and T e r r i s , i n 1972 [61] i n a s t u d y o f 50,000 b l a c k s i n g l e l i v e b i r t h s f o u n d t h a t " E a r l y b i r t h p r e v e n t s t h e i n i t i a t i o n o f p r e n a t a l c a r e r a t h e r t h a n v i c e v e r s a " . Of i n t e r e s t was t h e i r f i n d i n g t h a t m o t h e r s o f " f a l s e p r e m a t u r e s " i . e . SGA I n f a n t s , i n i t i a t e d c a r e l a t e r t h a n t h e m a t u r e c o n t r o l s . No c a u s a l r e l a t i o n s h i p c o u l d be i m puted t o t h i s f i n d i n g however. ft Of two s t u d i e s i n 1 9 7 9 , t h a t o f G o r t m a k e r [63] s u g g e s t e d t h a t i n a d e q u a t e p r e n a t a l c a r e was a s s o c i a t e d w i t h Low B i r t h W e i g h t o n l y f o r women o f l o w e r s o c i o - e c o n o m i c s t a t u s . T h a t o f E i s n e r [55] e t a l f o u n d t h a t "no p r e n a t a l c a r e was a v e r y s i g n i f i c a n t r i s k f a c t o r t o t h e 1.4% o f women who l a c k e d i t " . O t h e r f a c t o r s e f f e c t i n g t h i s s m a l l g r o u p w h i c h make them s o " s e l e c t e d " a r e n o t , h o w e v e r , d i s c u s s e d . I n t h e abo v e q u o t e d s t u d i e s " p r e n a t a l c a r e " i s m e a s u r e d b y " t r i m e s t e r o f o n s e t o f c a r e " and " f r e q u e n c y o f v i s i t s " . I c o u l d f i n d no s t u d i e s l o o k i n g a t i m p a c t o f q u a l i t y o f c a r e , o r c o n t e n t o f c a r e . A v e r y r e c e n t s t u d y [64] compared t h e p r e n a t a l s e r v i c e s p r o v i d e d b y a H e a l t h M a i n t e n a n c e O r g a n i z a t i o n w i t h t h a t p r o v i d e d b y non H e a l t h M a i n t e n a n c e O r g a n i z a t i o n p h y s i c i a n s and f o u n d m a r g i n a l l y b e t t e r r e s u l t s ( a s m e a s u r e d b y Low B i r t h W e i g h t and mean B i r t h W e i g h t ) f o r t h e s e p a t i e n t s i n t h e H e a l t h M a i n t e n a n c e O r g a n i z a t i o n , who i n f a c t r e c e i v e d q u a n t i t a t i v e l y s i g n i f i c a n t l y l e s s c a r e . T h i s r e l a t i o n s h i p h e l d g ood i n d e p e n d e n t l y o f a l l m a t e r n a l r i s k f a c t o r s . A s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e i n Low B i r t h W e i g h t i n c i d e n c e f o r H e a l t h M a i n t e n a n c e O r g a n i z a t i o n members c o m p a r e d t o t h e g e n e r a l p o p u l a t i o n was f o u n d i n women w i t h m e d i c a l o b s t e t r i c a l h i g h r i s k c o n d i t i o n s . iS H a l l , Chng, M a c G i 1 1 i v r a y [65] s t u d i e d t h e r e l a t i o n s h i p b etween p e r i n a t a l m o r t a l i t y and number o f p r e n a t a l v i s i t s f o r 1900 S c o t t i s h b i r t h s . They e s s e n t i a l l y c o n c u r w i t h G r a s s e r and T e r r i s [61] t h a t a s h o r t e r p r e g n a n c y , s e c o n d a r y to c o m p l i c a t i o n s , and a s s o c i a t e d w i t h i n c r e a s e d f e t a l m o r t a l i t y and m o r b i d i t y w i l l o f n e c c e s s i t y i n v o l v e fewer p r e n a t a l v i s i t s , t h a n w i l l be i n c u r r e d i n a f u l l t e r m u n c o m p l i c a t e d p r e g n a n c y , "where a l a r g e number of p r e n a t a l v i s i t s a c c u m u l a t e as t h e r e s u l t n o t t h e c a u s e o f t h e u n c o m p l i c a t e d c o n d i t i o n " . Reed and M o r r i s [66] i n 1979 e v a l u a t e d a h o s p i t a l b a s e d n u r s e - m i d w i f e p r e n a t a l p r o g r a m . Q u a n t i t y o f c a r e , b i r t h w e i g h t and a h e a l t h s t a t u s a t b i r t h a l l i n c r e a s e d i n t h e t a r g e t p o p u l a t i o n . They c o u l d n o t a s c r i b e t h e s e r e s u l t s d e f i n i t e l y t o t h e p r o g r a m however as s e l f s e l e c t i o n c o u l d n o t be r u l e d o u t , n o r c o u l d t h e p o s s i b i l i t y t h a t o t h e r f a c t o r s i . e . a c c e s s t o a b o r t i o n and r e c e n t l y i n t r o d u c e d F a m i l y P l a n n i n g C l i n i c s c a u s e d a d e c l i n e i n t h e h i g h r i s k p r e g n a n c i e s . (The b i r t h r a t e d i d d r o p s i g n i f i c a n t l y i n t h e s t u d y a r e a . ) I t w ould seem r e a s o n a b l e a t t h i s p o i n t t o a g r e e w i t h C h a l m e r s . [ 5 ] "The r e l a t i o n between r i s k o f p e r i n a t a l d e a t h and h e n c e low b i r t h w e i g h t ( a u t h o r ' s i n t e r p o l a t i o n ) and s o c i a l and e n v i r o n m e n t a l v a r i a b l e s i s so s t r o n g t h a t t h e g r e a t e s t s c o p e f o r p r o m o t i n g p e r i n a t a l h e a l t h a l m o s t c e r t a i n l y l i e s o u t s i d e t h e t r a d i t i o n a l s p h e r e o f i n f l u e n c e o f m e d i c a l w o r k e r s " . lie To summarize b r i e f l y t h e r e f o r e ; The d e c l i n e i n i n f a n t m o r t a l i t y and m o r b i d i t y i n d e v e l o p e d c o u n t r i e s o v e r t h e p a s t 50 y e a r s has been due t o i m p r o v e d management o f i n f a n t s a t r i s k , b o t h s h o r t l y b e f o r e and a f t e r b i r t h . F r e q u e n c y o f d e l i v e r y o f s u c h i n f a n t s a t r i s k a p p e a r s t o have changed v e r y l i t t l e o v e r t h e p a s t 30 y e a r s , [ 8 5 ] d e s p i t e i n c r e a s e d a c c e s s t o and a v a i l a b i l i t y o f i n c r e a s i n g l y s o p h i s t i c a t e d m e d i c a l t e c h n o l o g i e s . T h i s s t a t e m e n t a p p l i e s t o C a n a d a , [38] t h e U.K [39] and t h e U.S.A. [40] 17 PREVENTION OF LOW BIRTH WEIGHT Hemmincki and S t a r f i e l d [6] i n a c o m p r e h e n s i v e r e v i e w o f 37 c o n t r o l l e d i n t e r v e n t i o n s t u d i e s aimed a t p r e v e n t i n g Low B i r t h W e i g h t and p r e t e r m b i r t h , p u b l i s h e d between J a n u a r y 1930 t o May 1977, n o t e d t h e marked p r e p o n d e r a n c e o f d r u g t h e r a p y r e s e a r c h compared t o r e s e a r c h i n improvements i n o t h e r e x o g e n e u s f a c t o r s s u c h as d i e t , s m oking, e x e r c i s e and s t r e s s . Of t h e 37 s t u d i e s q u o t e d , 31 c o n c e n t r a t e d on e i t h e r i n h i b i t i o n s o f p r e m a t u r e l a b o u r (16) or a d m i n i s t r a t i o n o f i r o n and v i t a m i n s o n l y ( 1 5 ) . Of t h e s e 31, 19 were o f s u f f i c i e n t l y a d e q u a t e d e s i g n t o s u p p o r t t h e r e s e a r c h e r s c o n c l u s i o n s and o n l y 2 r e p o r t e d t h e i n t e r v e n t i o n as b e n e f i c i a l . Of t h e r e m a i n i n g 8 s t u d i e s , 3 i n v o l v e d d i e t a r y s u p p l e m e n t a t i o n and none were w i t h o u t d e s i g n drawbacks i n v a l i d a t i n g t h e a u t h o r ' s c o n c l u s i o n s . Two were on h e a l t h e d u c a t i o n on d i e t , one o f w h i c h met t h e c r i t e r i a f o r a c c e p t a b i l i t y and showed a b e n e f i c i a l r e s u l t . Of t h e r e m a i n i n g t h r e e s t u d i e s , on h o s p i t a l bed r e s t , h e a l t h e d u c a t i o n on smoking and c e r v i c a l s u t u r e , o n l y t h e e d u c a t i o n a l i n t e r v e n t i o n met d e s i g n c r i t e r i a and i t r e p o r t e d no b e n e f i t . T h e i r r e v i e w i s b y no means c o m p r e h e n s i v e and much a d d i t i o n a l m a t e r i a l i s r e v i e w e d i n t h e f o l l o w i n g s e c t i o n s . IS NUTRITIONAL SUPPLEMENTATION D e s p i t e t h e p o s t hoc f i n d i n g s t h a t Low B i r t h W e i g h t i s s t r o n g l y a s s o c i a t e d w i t h low p r e p r e g n a n t w e i g h t and p o o r p r e g n a n c y w e i g h t g a i n , [54,55,5,56,57,6,77] t h e r e a r e c o n f l i c t i n g o p i n i o n s as t o t h e e f f e c t i v e n e s s o f d i e t a r y s u p p l e m e n t a t i o n on b i r t h w e i g h t . F o l l o w i n g a h i g h l y c r i t i c a l r e v i e w o f 6 n u t r i t i o n a l s u p p l e m e n t a t i o n p r o g r a m s , The New York S t u d y [ 6 7 ] , The M o n t r e a l S t u d y [ 6 8 , 6 9 ] , The B o g o t a S t u d y [ 7 0 ] , The G u a t e m a l a S t u d y [ 7 1 ] , The Taiwan S t u d y [72] and The D u t c h Famine S t u d y [ 7 3 ] , S u s s e r c a u t i o u s l y c o n c l u d e s "We c a n e x p e c t t h a t p r e n a t a l e n e r g y s u p p l e m e n t s w i l l p r o d u c e modest i n c r e m e n t s i n f e t a l g r o w t h under a p p r o p r i a t e c o n d i t i o n s . [74] T h i s i s c o n s i d e r a b l y l e s s o p t i m i s t i c t h a n t h e c o n c l u s i o n s r e a c h e d by t h e a u t h o r s o f t h e f i r s t f i v e s t u d i e s l i s t e d . Rush [69] r e v i e w e d t h e s e same s t u d i e s and w h i l e h i s r e a p p r a i s a l of t h e M o n t r e a l D i e t D i s p e n s a r y i s more f a v o r a b l e t h a n t h a t o f S u s s e r , he a l s o a g r e e s w i t h h i s c o n c l u s i o n c i t e d a b o v e . M o d e r a t e f e t a l w e i g h t g a i n s may be a c h i e v e d by m o d e r a t e o r low p r o t e i n d e n s i t y s u p p l e m e n t a t i o n . B o t h a u t h o r s add t h e c a v e a t t h a t i n a l l s t u d i e s where s e l f s e l e c t i o n i s removed, t h e use o f h i g h d e n s i t y p r o t e i n s u p p l e m e n t s i s a s s o c i a t e d w i t h f e t a l g r o w t h r e t a r d a t i o n . Rush c o n c l u d e s , "We must n e x t d e c i d e w h i c h s u b g r o u p s o f women would most b e n e f i t f r o m d i e t a r y s e r v i c e s and w h ether th e b e n e f i t t o be d e r i v e d f r o m s u c h s e r v i c e s j u s t i f i e s t h e i r c o s t " . 19 The l a r g e s t n u t r i t i o n a l s u p p l e m e n t a t i o n p r o g r a m t o be s t u d i e d i n N o r t h A m e r i c a i s t h e S p e c i a l S u p p l e m e n t a l Food Program f o r Woman, I n f a n t s and C h i l d r e n (W.I.C.). The program i s a d m i n i s t e r e d t h r o u g h t h e Food and N u t r i t i o n S e r v i c e s o f t h e U.S. Dep a r t m e n t o f A g r i c u l t u r e . 19 WIC p r o j e c t s l o c a t e d i n 14 s t a t e s p a r t i c i p a t e d i n t h e e v a l u a t i o n c o n d u c t e d b y t h e S c h o o l o f P u b l i c H e a l t h a t t h e U n i v e r s i t y o f N o r t h C a r o l i n a . [75] They f o u n d t h a t p r e g n a n t women who p a r t i c i p a t e d i n t h e pro g r a m g a i n e d more w e i g h t d u r i n g p r e g n a n c y t h a n women i n t h e i n i t i a l p o p u l a t i o n and t h a t t h e mean b i r t h w e i g h t o f t h e i r b a b i e s a l s o i n c r e a s e d . The M a s s a c h u s e t t s WIC p r o g r a m e v a l u a t i o n [76] d u p l i c a t e d t h e s e r e s u l t s and a l s o showed a r e d u c t i o n i n Low B i r t h W e i g h t i n c i d e n c e f r o m 10.1% t o 6.0% between women i n t h e progr a m , and two c o n t r o l g r o u p s o f non WIC woman. The a u t h o r c o n c l u d e d t h a t t a k i n g i n t o a c c o u n t t h e c o s t o f m e d i c a l c a r e f o r Low B i r t h W e i g h t I n f a n t s a b e n e f i t - c o s t r a t i o o f 3.1:1 f a v o u r e d t h e i m p l e m e n t a t i o n o f WIC t y p e programming f o r a t r i s k p o p u l a t i o n s . JLO REDUCTION IN MATERNAL SMOKING T h e r e i s c o n v i n c i n g e v i d e n c e r e g a r d i n g t h e e f f e c t t h a t c i g a r e t t e smoking has on B i r t h W e i g h t . Niswander and Gordon [77] i n 1972 d e m o n s t r a t e d t h e i n c r e a s e i n Low B i r t h W e i g h t r a t e s f o r b l a c k s and w h i t e s as c i g a r e t t e c o n s u m p t i o n i n c r e a s e d . S u b s e q u e n t l i t e r a t u r e [78] r e v i e w s have i m p l i c a t e d c i g a r e t t e smoking w i t h p r e m a t u r i t y and d e l a y e d and p r o l o n g e d g r o w t h r e t a r d a t i o n i n t h e o f f s p r i n g o f smoking m o t h e r s . t h e q u e s t i o n o f w h e t h e r t h i s c o u l d be m e d i a t e d t h r o u g h i n a d e q u a t e f o o d i n t a k e s e c o n d a r y t o smoking o r b y a common g e n e t i c f a c t o r a p p e a r s t o have been s e t t l e d by Naeye [79] who fo u n d t h e f e t a l g r o w t h r e t a r d a t i o n i n smokers t o be i n d e p e n d e n t o f under n u t r i t i o n , g e n e t i c f a c t o r s or p l a c e n t a l u n d e r f u n c t i o n . P i c o n e e t a l [87] r e i n f o r c e d t h i s f i n d i n g f o r an i n d e p e n d e n t a c t i o n o f smoking on Low B i r t h W e i g h t . Naeye a l s o , and i m p o r t a n t l y n o t e s t h a t f e t a l g r o w t h r e t a r d a t i o n was a b s e n t when m o t h e r s s t o p p e d smoking d u r i n g p r e g n a n c y . .2.1 REDUCTION IN MATERNAL ALCOHOL INTAKE M a t e r n a l a l c o h o l i n t a k e d u r i n g p r e g n a n c y may r e s u l t i n s e v e r e p r e n a t a l g r o w t h r e t a r d a t i o n . L i t t l e [80] and K a m i n s k i e t a l [81] b o t h r e p o r t a r e d u c t i o n i n b i r t h w e i g h t f o l l o w i n g l i t t l e o r m o d e r a t e a l c o h o l i n g e s t i o n b e f o r e p r e g n a n c y and i n l a t e p r e g n a n c y . B o t h f o u n d t h e a s s o c i a t i o n t o be i n d e p e n d e n t o f t o b a c c o u s a g e . R o s s e t t , e t a l [82] r e p o r t s a d e c r e a s e i n growth r e t a r d a t i o n i n t h e o f f s p r i n g o f women who s t o p p e d d r i n k i n g d u r i n g p r e g n a n c y . EFFECTS OF L I F E STRESS AND ITS REDUCTION ON BIRTH WEIGHT Low B i r t h W e i g h t i s f r e q u e n t l y c o n s i d e r e d t o be one o f t h e c o m p l i c a t i o n s r e s u l t i n g f r o m m a t e r n a l a n x i e t y or l i f e s t r e s s . [88] P i c o n e e t a l [87] d e m o n s t r a t e d a n e g a t i v e c o r r e l a t i o n between s t r e s s and p r e g n a n c y w e i g h t g a i n . In a companion p a p e r , [89] low w e i g h t g a i n i s c o r r e l a t e d p o s i t i v e l y t o l o w e r b i r t h w e i g h t s . O t h e r r e v i e w s and a r t i c l e s e . g . t h a t o f Pohlman [83] 1969 and L a u t e r m a n [84] 1980 have d e a l t w i t h " m a t e r n a l a t t i t u d e " and presumed s t r e s s i n d i c a t o r s i . e . wanted o r unwanted s t a t u s o f p r e g n a n c y . Pohlman c o n c l u d e d t h a t " d i r e c t e v i d e n c e e i t h e r p o s i t i v e o r n e g a t i v e i s a l m o s t c o m p l e t e l y l a c k i n g " . L a u t e r m a n f o u n d no e f f e c t on e i t h e r b i r t h w e i g h t or g e s t a t i o n . XL H i s r e s u l t c a n n o t be g e n e r a l l y e x t r a p o l a t e d as o t h e r s t r e s s e s p h y s i c a l and m e n t a l e x i s t f o r d i f f e r e n t p o p u l a t i o n s . No c o n v i n c i n g i n t e r v e n t i o n s t u d i e s c o n c e r n i n g d e c r e a s i n g m a t e r n a l s t r e s s and i n c r e a s e d b i r t h w e i g h t were f o u n d . F u r t h e r s t u d y i n t h i s a r e a i s c a l l e d f o r . C e r t a i n l y f a c t o r s a s s o c i a t e d w i t h s t r e s s e . g . p o v e r t y , s i n g l e s t a t u s , a d o l e s c e n c e a r e a l s o a s s o c i a t e d w i t h b o t h p r e m a t u r i t y and low b i r t h w e i g h t . [5,6,23,45,54,55,77] I t i s a p p r o p r i a t e t o c o n c l u d e t h i s s e c t i o n w i t h a comment f r o m two n e o n a t o l o g i s t s ' w r i t i n g i n t h e e a r l y 1970's on n e o n a t a l i n t e n s i v e c a r e : " . . . l e t us n o t f o r g e t t h a t t h i s i s a s e a r c h and r e s c u e e x e r c i s e and i t i s q u i t e l e g i t i m a t e t o q u e s t i o n w hether we s h o u l d be e x e r t i n g o u r e f f o r t s i n p r e v e n -t i n g t h e wreck r a t h e r t h a n i n a s a l v a g e o p e r a t i o n . " [90] A3 BIBLIOGRAPHY CHAPTER I 1. U.S. Depa r t m e n t H.E. & W.: I n f a n t M o r t a l i t y Each S t a t e and T e r r i t o r y and S p e c i f i e d P o s s e s s i o n 1953, V i t a l S t a t s S p e c i a l R e p o r t s N a t i o n a l Summaries V o l . 42 No. 15 J a n . 1956. 2. U.S. Depa r t m e n t o f H e a l t h and Human S e r v i c e s , N a t i o n a l C e n t r e f o r H e a l t h S t a t i s t i c s . M o n t h l y V i t a l S t a t i s t i c s R e p o r t V o l . 29 No. 9 B i r t h Manager D i v o r c e s and D e a t h s f o r S e p t . 1980. 3. V i t a l S t a t i s t i c s A n n u a l R e p o r t s o f S t a t i s t i c s C a n a d a . 4. M.O.H. B.C. D i v i s i o n o f V i t a l S t a t i s t i c s U n p u b l i s h e d D a t a 1970-1979. P u b l i s h e d i n C h i l d H e a l t h P r o f i l e D r . R. T o n k i n 1981. 5. C h a l m e r s , I . i T h e S e a r c h f o r I n d i c e s B e t t e r P e r i n a t a l H e a l t h : A S u r v e y from The L a n c e t Nov. 17, 1979. 6. Hemmincki,E., S t a r f i e l d , B . : P r e v e n t i o n o f Low B i r t h W e i g h t and P r e t e r m B i r t h - M i l l b a n k M e m o r i a l Fund Q u a r t e r l y , H e a l t h and S o c . V o l . 5 6 , N o . 3 , 1978. 7. Wynn and Wynn: P r e v e n t i o n o f H a n d i c a p and t h e H e a l t h o f Women. R o u t l e d g e and Kegen, L o n d o n , 1979. 8. C h i l d H e a l t h P r o f i l e : M i n i s e r i e s N o . l B i r t h E v e n t s and I n f a n t Outcome: D r . R . T o n k i n , U . B . C , 1981. 9. Rooth,G.:Low B i r t h w e i g h t R e v i s i t e d : The L a n c e t , March 22, 1980. 1 , w.h.O. T e c h . Rep. S e r . No.457, 1970. 11. A b e r n a t h y , J . R . , G r e e n b e r g , B . G . , D o n n e l l y , J . F . : A p p l i c a t i o n o f D i s c r i m i n e n t F u n c t i o n s i n P e r i n a t a l Death and S u r v i v a l : Am.J. O b s t . G y n e c o l . , 1966;95, 860-867. 12. Shah,F.K., Abby,H.: E f f e c t s o f Some F a c t o r s on N e o n a t a l and P o s t N e o n a t a l M o r t a l i t y . A n a l y s i s b y a B i n a r y V a r i a b l e M u l t i p l e R e g r e s s i o n Method. M i l l b a n k M e m o r i a l Fund Q u a r t e r l y , 1971, 19:33-57. 13. B e r g n e r , L . , Susser,M.W.: Low B i r t h W e i g h t and P r e n a t a l N u t r i t i o n : An I n t e r p r e t a t i v e Review. Paed. 1970 46:946-966. 14. Ressner,D.M., S i n g e r , J . , K a l k , C . E . , S c h l e s i n g e r , L . R . : I n f a n t D e a t h , An A n a l y s i s by M a t e r n a l R i s k and H e a l t h C a r e . I n s t i t u t e o f M e d i c i n e , W a s h i n g t o n , 1973. 15. E l w o o d , J . H . , M a c K e n z i e , G . : O b s e r v a t i o n s on S i n g l e B i r t h s t o Women R e s i d e n t i n B e l f a s t 1962-66 P t . l : F a c t o r s A s s o c i a t e d w i t h P e r i n a t a l M o r t a l i t y . J . A r c h . D i s . 1974 27:517-535. 16. Wynn,G. and Wynn,M.: The Hope o f P r e v e n t i n g P r e t e r m B i r t h , C h a p t e r One, 1977. 17. ' V e r h o e s t r a t e , L . J . , P u f f e r , R . R . : C h a l l e n g e o f F e t a l L o s s P r e m a t u r i t y and I n f a n t M o r t a l i t y - A W o r l d V i e w . J.A.M.A. 167, 1958. 18. J a n s e n , A . A . : B i r t h w e i g h t , B i r t h l e n g t h , P r e m a t u r i t y and N e o n a t a l M o r t a l i t y i n New G u i n e a . T r o p . and Geog. Med. 14, 1962. 19. Thomson,A.M., Chun,D., B a i r d , D . : P e r i n a t a l M o r t a l i t y i n Hong Kong and i n A b e r d e e n , S c o t l a n d . J . O b s t . and G y n e c o l . B r i t . Comm. 70, 1963. 20. S c r a g e , R . F . R . : B i r t h W e i g h t , P r e m a t u r i t y and G r o w t h R a t e t o 30 Mo n t h s i n New G u i n e a N a t i v e C h i l d r e n . M . J . A u s t r a l i a 1:1955. 21. A b r a m o w i c z , M . , K a s s , E . H . : P a t h o g e n e s i s and P r o g n o s i s o f P r e m a t u r i t y . N.E.J.M. O c t . 2 0 , V o l . 2 7 5 A l 6 , 1 9 6 6 . 22. Dunn,H.G.: R e s i d u a l H a n d i c a p s i n C h i l d r e n o f Low B i r t h W e i g h t : C a n a d i a n I n s t i t u t e o f C h i l d H e a l t h , 1 9 8 1 . 23. C h a s e , H . ( E d . ) : A S t u d y o f R i s k s , M e d i c a l and I n f a n t M o r t a l i t y . A . J . P . H . (63) Su p p . 1 9 7 3 . 24. B e r g n e r , L . , Sussner,M.W.: Low B i r t h W e i g h t and P r e n a t a l N u t r i t i o n : An I n t e r p r e t a t i v e R e v i e w . P a e d . V o l . 4 6 No.6, Dec . 1 9 7 0 . 25. A k e s s o n , H . 0 . : C o n d i t i o n a t B i r t h and M e n t a l D e f i c i e n c y . A c t a G e n e t . B a s e l . 16.283 1966. 26. D r i l l i e n , C . M . : A L o n g i t u d i n a l S t u d y o f t h e G r o w t h and D e v e l o p m e n t o f P r e m a t u r e l y and M a t u r e l y B o r n C h i l d r e n . A r c h . D i s . C h i l d r e n 34:37 1959. 27. D r i l l i e n , C M . : The I n c i d e n c e o f M e n t a l a n d P h y s i c a l H a n d i c a p s i n S c h o o l Aged C h i l d r e n o f V e r y Low B i r t h W e i g h t . P a e d . 27:452 1 9 61. 28. K n o b l o c k , H . , R i d e r , R . , H a r p e r , P . , P a s a m a n i c k , B . : The N e u r o p h y c h i a t r i c S e q u e l a e o f P r e m a t u r i t y , A L o n g i t u d i n a l S t u d y . J.A.M.A. 161:581 1956. 29. K i n g , J . F . : G u e s t E d i t o r i a l " P e r i n a t a l H e a l t h " : C h i l d H e a l t h P r o f i l e B i r t h E v e n t s and I n f a n t Outcome: R o g e r S. T o n k i n , B r i t i s h C o l u m b i a , 1 9 8 1 . AS 30. H e s s , J . H . : E x p e r i e n c e s G a i n e d i n a 3 0 - Y e a r S t u d y o f P r e m a t u r e l y B o r n I n f a n t s . P a e d s . 11 42 5 - 4 3 4 , 1953. 3 1 . D o u g l a s , J . W . B . , G e a r , R . : C h i l d r e n o f Low B i r t h W e i g h t i n t h e 1946 N a t i o n a l C o h e r t : B e h a v i o u r and E d u c a t i o n A c h i e v e m e n t i n A d o l e s c e n c e . A r c h . D i s . C h i I d . 51 82 0 - 8 2 7 , 1976. 32. S i l v e r m a n , W . A . : The L e s s o n o f R e t r o l e n t a l F i b r o p l a s i a . S c i . A m . 2 3 6 ( 6 ) 1 0 0 - 1 0 7 , 1977. 33. B o l t o n , D . P . G . , C r o s s , K . W . : F u r t h e r O b s e r v a t i o n s on C o s t o f P r e v e n t i n g R e t r o l e n t a l F i b r o p l a s i a . L a n c e t l:445*-448, 1974. 34. L u b c h e n k o , L . O . , H o r n e r ,F.A., Reed,L.H., Et. A l . : S e q u a l a e o f P r e m a t u r e B i r t h : E v a l u a t i o n o f P r e m a t u r e I n f a n t s o f Low B i r t h W e i g h t a t 10 Y e a r s o f A g e . A m . J . D i s . C h i l d . 1 0 6 : 1 0 1 - 1 1 5 , 19 6 3 . 35. Hack,M., F a n a r o f f , A . A . , M e r k a t z , I . R . : The Low B i r t h W e i g h t I n f a n t - E v o l u t i o n o f a C h a n g i n g O u t l o o k . M.E.J.M. Nov.22, 197 9 . 36. F r a n c i s - W i l l i a m s , J . , D a v i e s , P . A . : V e r y Low B i r t h W e i g h t and L a t e r I n t e l l i g e n c e . D e v . M e d . C h i I d . N e u r . 1 6 : 7 0 9 - 7 2 8 , 1974. 37. F a n a r o f f , A . A . , M e r k a t z , I . R . : Modern O b s t e t r i c a l Management o f t h e Low B i r t h W e i g h t I n f a n t C l i n . P e r i n a t o l 4 : 2 1 5 - 2 3 7 , 1977. 38. Kwang-Sun,L., Lawrence,M.G., P a n e t h , M . , T y l e r , S . : R e c e n t T r e n d s i n N e o n a t a l M e n t a l i t y : The C a n a d i a n E x p e r i e n c e . C M . A. J o u r n a l F e b . 1 5 V o l . 1 2 6 , 1982. 39. P h a r o a h , P . 0 . D . , A l b e r m a l , e . d . 8 m o p t a l i t y o f Low B i r t h W e i g h t I n f a n t s i n E n g l a n d and W a l e s f r o m 1 9 5 3 - 1 9 7 9 . A r c h . D i s . o f C h i l d . 1981 56 86-89. 40. U.S. D e p t . o f H e a l t h and Human S e r v i c e s , N a t i o n a l C e n t r e f o r H e a l t h S t a t i s t i c s : M o n t h l y V i t a l S t a t i s t i c s R e p o r t V o l . 2 9 #9 S e p t . 1980. 4 1 . S h a p i r o , S . : New R e d u c t i o n i n I n f a n t M o r t a l i t y : The C h a l l e n g e o f Low B i r t h W e i g h t . A . J . P . H . A p r i l , 1981 V o l . 7 1 No.4. 4 2 . L e e k , S . , P a n e t h , M . , G a r t n e r , L . M . , E t A l . : N e o n a t a l M o r t a l i t y : An A n a l y s i s o f t h e R e c e n t Improvement i n t h e U.S. Am.J.Pub.H. 1980 70 15 - 2 1 . 4 3 . P e t r o s - B a v a r a z i a n , A , Beharm,M.: Low B i r t h W e i g h t , What S h o u l d Be Done W i t h T h i s G l o b a l P r o b l e m ? W.H.O. C h r o n i c l e 1978 32 : 2 3 1 - 2 3 2 . 44. W.H.O. P u b l i c H e a l t h A s p e c t s o f Low B i r t h W e i g h t T h i r d R e p o r t E x p e r t C o m m i t t e e on M a t e r n a l and C h i l d H e a l t h . W.H.O. T e c h . R e p . S e r i e s #217 Geneva W.H.O., 1961. 45. K n o b l o c h , H . , P a s a m i n i c h , B . : E n v i r o n m e n t a l F a c t o r s A f f e c t i n g Human Dev e l o p m e n t B e f o r e and A f t e r B i r t h . Paed. 1960 26:210-218. 46. Lubchenko,L.O., H a n s m a n , C , C r e s s l e r , M . , B o y d f E . : I n t r a u t e r i n e Growth as E s t i m a t e d From L i v e B o r n B i r t h W e i g h t D a t a a t 24-42 Weeks o f G e s t a t i o n . Paed. 1963 32:793-800. 47. L u b c h e n k o , L . 0 . , S e a r l s , D . T . , B r a z i e , J . V . : N e o n a t a l M o r t a l i t y R a t e : R e l a t i o n s h i p t o B i r t h W e i g h t and G e s t a t i o n a l Age. J . o f P a e d . O c t . 1972 V o l . 81 #4 814-882. 48. B a b s o n , S . C , Behrman,R.E., L e s s e r , R . : F e t a l Growth. L i v e b o r n B i r t h w e i g h t s f o r G e s t a t i o n a l Age o f W h i t e M i d d l e C l a s s I n f a n t s . Paed. 1970 45:937-944. 49. McDonald,A.: C h i l d r e n o f V e r y Low B i r t h W e i g h t . M.E.I.U. R e s e a r c h Monograph #1 London M.E.I.U. o f S p a s t i c s S o c i e t y Heineman 1967. 50. D r i l l i e n , C M . : The S m a l l f o r D a t e s I n f a n t s : E t i o l o g y and P r o g n o s i s . P a e d e i a t r i c C l i n i c s N o r t h A m e r i c a 1970 17:9-24. 51. S i n c l a i r , J . C . , C o l d i r o n , J . S . : Low B i r t h W e i g h t and P o s t n a t a l P h y s i c a l D e v e l o p m e n t . D e v . M e d . C h i l d N e u r o l . 1969 11:314-329. 52. N e l i g a n , G . A . , K o l v i n , I . , S c o t t , D . M . , G a r s i d e , R . F . : B o r n Too Soon or B o r n Too S m a l l . C l i n i c s i n Develop.Med. No.61 L o n d o n : S p a s t i c s In.tl .Med . Pub. Heineman, 1976. 53. Pape,K.E., W i g g l e s w o r t h , J . J . : Haemmorhage, I s c h a e m i a and t h e P e r i n a t a l B r a i n C l i n i c s o f D e v e l o p . Med. Nos. 69/70 London: S p a s t i c s I n t l . M e d . P u b . Heineman 1979. 54. Waner,G., M i l t o n , T . : D e m o g r a p h i c C o r r e l a t e s o f Low B i r t h W e i g h t . Am.J.Epid. V o l 91 No.3 1970 p.260-272. 55. E i s n e r , V . , E t A l . : The R i s k o f Low B i r t h W e i g h t . A.J.P.H. S e p t . 7 9 . V o l . 6 9 #9. 56. I n f a n t D e a t h : An A n a l y s i s by M a t e r n a l R i s k and H e a l t h C a r e C o n t r a s t s i n H e a l t h S t a t u s V o l . 1 . I n s t i t u t e o f M e d i c i n e , N a t i o n a l Academy o f S c i e n c e s , W a s h i n g t o n , D . C 1973. 57. L e c h t i g , A . , D e l g a d o , H . , M a r t o r e l l , R . , Y a r b o r o u g h , C . , K l e i n , R . : E f f e c t s o f M a t e r n a l N u t r i t i o n on I n f a n t s Growth and M o r t a l i t y i n a D e v e l o p i n g C o u n t r y . 5 t h E u r o p e a n C o n g r e s s P e r i n a t a l M e d i c i n e 1976. XI 58. E a s t m a n , J . J . : P r e m a t u r i t y f r o m t h e V i e w p o i n t o f t h e O b s t e t r i c i a n . A m . P r a c t . 1:343-352, 1947. 59. O p p e n h e i m e r , E : P o p u l a t i o n C h a nges and P e r i n a t a l M o r t a l i t y . A m e r . J o u r . P u b l i c J o u r n a l P u b l i c H e a l t h 5 1 : 2 0 8 - 2 1 6 , 1 9 6 1 . 60. P a k t e r , J . , R o s n e r , H . J . , J o c o b z i n e r ,H., G r e e n s t e i n , F . : Out o f W e d l o c k B i r t h s i n New Y o r k C i t y I I . M e d i c a l A s p e c t s . A m e r . J o u r . P u b l i c H e a l t h 5 1 : 8 4 6 - 8 6 5 , 1 9 6 1 . 6 1 . T e r r i s , M . , G l a s s e r , M . : A L i f e T a b l e A n a l y s i s o f t h e R e l a t i o n o f P r e n a t l C a r e t o P r e m a t u r i t y . A . J . P . H . , S e p t . 1974 V o l . 6 4 No.9. 62. S h w a r t z , A , V i n y a r d , J . : P r e n a t a l C a r e and P r e m a t u r i t y P u b l i c H e a l t h R e p o r t s V o l . 80 No.3, M a r c h 1965. 63. G o r t m a k e r , S . L . : The E f f e c t s o f P e r i n a t a l C a r e on t h e H e a l t h o f t h e Newborn. A . J . P . H . J u l y 1 9 7 9 , V o l 6 9 #7. 64. Q u i c k , J . , G r e e n l i c k , M . , Roughman,K.: P r e n a t a l C a r e and P r e g n a n c y Outcome i n a H.M.O. and G e n e r a l P o p u l a t i o n : A M u l t i v a r i a t e C o h e r t A n a l y s i s . A . J . P . H . A p r i l 81 V o l . 69 #7. 6 5 . H a l l , M . , Chng,P.K., M a c G i 1 1 i v r a y , I . : I s R o u t i n e A n t e n a t a l C a r e W o r t h W h i l e . The L a n c e t , J u l y 1 2 , 168 No.8185 page 78. 66. R e i d , M . L . , M o r r i s , J.B. :•. P e r i n a t a l C a r e and C o s t E f f e c t i v e n e s s . M e d i c a l C a r e , May 79 V o l . X V I I No.5. 67. Rush,D., S t e r n , Z . , S u s s e r ,M.: D i e t i n P r e g n a n c y : A R a n d o m i z e d C o n t r o l l e d T r i a l o f P r e n a t a l N u t r i t i o n a l @ u @ p l e m e l t a t i o n . New Y o r k , A l a n . L i s s . 1979. 68. H i g g i n s , A . C . : N u t r i t i o n a , t l t u s and t h e Outcome o f P r e g n a n c y . J . C a n . D i e t A s s o c i a t i o n 1976 3 7 : 1 7 - 3 5 . 69. Rush,D.: N u t r i t i o n S e r v i c e s D u r i n g P r e g n a n c y and B i r t h w e i g h t : A R e t r o s p e c t i v e M a t c h e d P a i n A n a l y s i s . C M . A . J . S e p t . 15 1 9 8 1 , V i o l . 1 2 5 page 567. 70. M o r a , J . O . , d e P a r a d e s , B . , Wagner,M., E t A l . : N u t r i t i o n a l S u p p l e m e n t a t i o n and t h e Outcome o f - P r e g n a n c y . Amer. J o u r . C l i n . N u t r i t i o n 1979 3 2 : 4 5 5 - 6 2 . 7 1 . H a b i c h t , J . P . , Y a r b o r o u g h , C . , L e c h t i g , A . , K l e i n , R . E . : R e l a t i o n o f M a t e r n a l S u p p l e m e n t a r y F e e d i n g D u r i n g P r e g n a n c y t o B i r t h W e i g h t and O t h e r S o c i o b i o l o g i c a l F a c t o r s . I n : W i n i c h , M . E d . N u t r i t i o n and F e t a l D e v e l o p m e n t . P r o c e e d i n g s on t h e Symposium on N u t r i t i o n and F e t a l D e v e l o p m e n t 1974 C o r r e c t C o n c e p t s i n N u t r i t i o n V o l . I l l N.Y. J o h n W i l e y and S o n s , 1974 1 2 7 - 1 4 6 . 72. H e r r i o t t , R . M . , Hsveha,M., A i t c h i s o n , R . : I n f l u e n c e o f M a t e r n a l D i e t on O f f s p r i n g . <A S t u d y i n J u i l i e n , T h a i l a n d i n i t i a t e d b y B.F.Chow. ( R e p o r t t o A . I . D . ) > . 73. S t e i n , Z . , S u s s e r , M . , S a e n g e r , G . , E t A l . : Fa m i n e and Human D e v e l o p m e n t . The D u t c h Hunger W i n t e r o f 19 4 4 / 4 5 . New Y o r k , O x f o r d U n i v e r s i t y P r e s s . 1975. 74. S u s s e r , M.: P r e n a t a l N u t r i t i o n , B i r t h w e i g h t , and P s y c h o l o g i c a l D e v e l o p m e n t : An O v e r v i e w o f E x p e r i m e n t s , Q u a s i E x p e r i m e n t s and N a t u r a l E x p e r i m e n t s i n t h e P a s t D e c a d e . Amer. J o u r . C l i n . N u t r i t i o n 34 A p r i l 1981 784 - 8 0 3 . 75. E d o z i e n , J . C . , S w i t z e r ,B.R., B r y a n , R . B . : M e d i c a l E v a l u a t i o n o f t h e S u p p l e m e n t a l Food P r o j e c t f o r Women, I n f a n t s and C h i l d r e n I , I I . Summary D e p a r t m e n t o f N u t r i t i o n , S c h o o l o f P u b l i c H e a l t h , U n i v e r s i t y o f N o r t h C a r o l i n a , C h a p e l H i l l , N.C., 1976. 76. Kennedy,E.T.: E f f e c t o f W.I.C. S u p p l e m e n t a l F e e d i n g on B i r t h W e i g h t . B o s t o n : H a r v a r d S c h o o l o f P u b l i c H e a l t h , Dec. 1978 ( D o c t o r a l T h e s i s ) . 77. N i s w a n d e r , J . , G o r d o n . : The Women and T h e i r P r e g n a n c i e s . I . S . D e p a r t m e n t , H . E . a n d W. N a t i o n a l I n s t i t u t e o f H e a l t h , 1972. 78. S m o k i n g and H e a l t h : A R e p o r t o f t h e S u r g e o n G e n e r a l . H.E.W. Pub. No. (PHS)79-50066 U.S. D e p t . H.E.W. 79. Naeye,R.L.: I n f l u e n c e o f M a t e r n a l C i g a r e t t e S m o k i n g D u r i n g P r e g n a n c y on F e t a l and C h i l d h o o d G r o w t h . Obs. and G y n e c o l . V o l . 57 N o . l , J a n . 1981. 80. L i t t l e , R . E . : M o d e r a t e A l c o h o l Use D u r i n g P r e g n a n c y and D e c r e a s e d I n f a n t B i r t h W e i g h t . A . J . P . H . D ec. 1977 V o l . 67 No. 12. 8 1 . K a m i n s k i , M . , R u m e a u - R o q u e t t e , C . , S c h w a r t z , D . : C o n s u m m a t i o n d ' A l c o o l Chez L e s Femmes E n c e i n t e s e t I s s u e de G r o s s e s s . Rev. E p i d e m . e t S a u t e P u b l . 2 4 : 2 7 - 4 0 , 1976. 82. R o s s e t t , H . K . , W e i n e r , L . , E t A l . : R e d u c t i o n i n A l c o h o l C o n s u m p t i o n D u r i n g P r e g n a n c y W i t h B e n e f i t s t o t h e Newborn. A l c o h o l i s m : C l i n i c a l annnd E x p t l . R e s . V o l . 4 No. 2 A p r i l 1980. 83. Pohlman,E.W.: Unwanted C o n c e p t i o n s : R e s e a r c h on U n d e s i r a b l e C o n s e q u e n c e s . C h i l d Fam. 9:240 1969. 84. L a u k e r n , V . H . , V a n d e n b e r g , B . J . : The R e l a t i o n s h i p o f M a t e r n a l A t t i t u d e t o P r e g n a n c y Outcomes and O b s t e t r i c C o m p l i c a t i o n s . A . J . O b s t e t . and G y n e c o l . V o l . 136 No. 3 F e b r u a r y 1980. 85. J o h n s o n , J . W . , D u b i n , N . : P r e v e n t i o n o f P r e t e r m L a b o u r . C l i n . O b s t e t . and G y n e c o l . V o l . 23 No. 1 M a r c h 1 9 8 0 , page 5 1 . 86. Z e l n i k , M . , K a n t n e r , J . F . : S e x u a l and C o n t r a c e p t i v e E x p e r i e n c e o f Young U n m a r r i e d Women i n t h e U.S. 1976 and 1971. F a m i l y P l a n P e r s p e c t . 9 5 5 , 1977. 87. P i c o n e , T . A . , L i n d s a y , H . A . , Schramm,M.M., 0 1 s e n , P . N . : P r e g n a n c y Outcome i n N o r t h A m e r i c a n Woman I : E f f e c t s o f D i e t , S m o k i n g and P s y c h o l o g i c a l S t r e s s on M a t e r n a l W e i g h t Gain'. Amer. J o u r . C l i n . N u t r i t i o n 36. Dec. 1 9 8 2 , 120 5 - 1 2 1 3 . 88. G o r s v a h , R . L . , Key,M.K.: A b n o r m a l i t i e s o f P r e g n a n c y a s a F u n c t i o n o f A n x i e t y and L i f e S t r e s s . P s y c h o s o m . M e d i c i n e 1974 3 6 : 3 5 2 - 3 6 2 . 89. P i c o n e , T . A . , L i n d s a y , H . A . , Schramm,M.M., 0 1 s e n , P . N . : P r e g n a n c y Outcome i n N o r t h A m e r i c a n Women I I : E f f e c t s o f D i e t , S m o k i n g , S t r e s s and W e i g h t G a i n on P l a c e n t a s and on N e o n a t a l P h y s i c a l and B e h a v i o u r a l C h a r a c t e r i s t i c s . Amer. J o u r . C l i n . N u t r i t i o n 36, Dec.82 1 2 1 4 - 1 2 2 4 . 90. W a l t e r s , J . H . , E f f e r , S . , R a m a p r a l a s h , H . E t A l . : E x p e r i e n c e W i t h an O b s t e t r i c a l and N e o n a t a l I n t e n s i v e C a r e U n i t . Amer. J o u r . O b s t e t . and G y n e c o l . 1 973. 1 1 5 : 3 0 7 - 3 1 5 . 3o CHAPTER I I THEORY, RATIONALE AND OBJECTIVES OF STUDY.  THEORY AND RATIONALE A m a j o r c o n c l u s i o n r e a c h e d i n C h a p t e r I , i s t h a t a measure o f t h e low b i r t h w e i g h t r a t e o f a community i s a b e t t e r outcome measure o f m a t e r n a l h e a l t h c a r e t h a n a r e m o r t a l i t y r a t e s , P e d i e t r y , as i t does i n f a n t m o r t a l i t y , i n f a n t m o r b i d i t y and d e v e l o p m e n t a l d i s o r d e r s . The p r e s e n t e c o n o m i c r e s t r a i n t s on h e a l t h c a r e f u n d i n g make i t more t h a n e v e r i m p e r a t i v e t h a t s c a r c e p r e v e n t i v e r e s o u r c e s be a l l o c a t e d t o a r e a s t h a t make t h e b e s t u s e o f t h e s e r e s o u r c e s i n t e r m s o f i m p r o v e d outcomes. In o r d e r t o e n s u r e t h i s a l l o c a t i o n , i t i s n e c c e s s a r y t o u n d e r t a k e t h e f o l l o w i n g e x e r c i s e s ( a d o p t e d f r o m "A R i s k A p p r o a c h t o M a t e r n a l and C h i l d H e a l t h C a r e " ) . [ 1 ] 1 I d e n t i f y t h e r e a l h e a l t h needs o f t h e p o p u l a t i o n . 2 O b t a i n a b e t t e r d i a g n o s i s and measurement o f human r e p r o d u c t i v e c a s u a l t i e s i n c o m m u n i t i e s where h e a l t h i n f o r m a t i o n i s d e f i c i e n t and p r o v i d e a mechanism f o r s u r v e i l l a n c e o f t h e p o p u l a t i o n " a t r i s k " t h a t w i l l f a c i l i t a t e t h e d e v e l o p m e n t o f r e a l i s t i c s t a n d a r d s o f c a r e . 3 Make p r e d i c t i o n s r e g a r d i n g t h e l e v e l o f c a r e r e q u i r e d b y d i f f e r e n t i n d i v i d u a l s o r segments o f a community. 4 P r o v i d e a n t i c i p a t o r y c a r e t o i n d i v i d u a l s and g r o u p s w i t h c h a r a c t e r i s t i c s i n d i c a t i v e o f a s p e c i a l r i s k . SI 5 Improve knowledge and d e v e l o p c r i t e r i a f o r t h e a l l o c a t i o n o f h e a l t h r e s o u r c e s i n o r d e r t o c o n t r i b u t e t o t h e r a t i o n a l p l a n n i n g , o r g a n i z a t i o n , a d m i n i s t r a t i o n and e v a l u a t i o n o f h e a l t h s e r v i c e s . T h i s p r o c e s s would m i n i m i z e u n p l a n n e d u t i l i z a t i o n o f r e s o u r c e s . S i m p l y s t a t e d t h e r i s k a p p r o a c h t o h e a l t h c a r e p r o p o s e s t h a t w i t h o u t s u c h p l a n n i n g , s e r v i c e s a r e u t i l i z e d by a p a r t o f t h e p o p u l a t i o n " s e l f s e l e c t e d by e d u c a t i o n , income, i n f l u e n c e , p l a c e o f r e s i d e n c e and p r o x i m i t y t o r e s o u r c e s . A t b e s t t h e i r r i s k s c o r e s a r e r a n d o m l y d i s t r i b u t e d ; more u s u a l l y t h e y c o n t a i n d i s p o r p o r t i o n a t e l y few h i g h r i s k c a s e s " . [1] [1] R i s k A p p r o a c h f o r M a t e r n a l & C h i l d H e a l t h C a r e . W.H.O O f f s e t Pub. No. 39 WHO Geneva 1978. H y p o t h e s e s The h y p o t h e s e s t o be t e s t e d i n t h i s s t u d y a r e t h a t m o t h e r s o f s i n g l e t o n , l i v e b o r n , low b i r t h w e i g h t i n f a n t s w i l l : 1 have a d i f f e r e n t b i o m e d i c a l p r o f i l e t h a n m o t h e r s o f non low b i r t h w e i g h t i n f a n t s ; 2 have a d i f f e r e n t s o c i o d e m o g r a p h i c p r o f i l e t h a n m o t h e r s o f non low b i r t h w e i g h t i n f a n t s ; 3 have a h i g h e r p r e v a l e n c e o f p o t e n t i a l l y a l t e r a b l e b e h a v i o u r a l t r a i t s t h a t have been a s s o c i a t e d w i t h t h e s u b s e q u e n t d e l i v e r y o f a low b i r t h w e i g h t i n f a n t , t h a n m o t h e r s o f non low b i r t h w e i g h t i n f a n t s . 3Z R e s e a r c h O b j e c t i v e s The o b j e c t i v e s o f t h e p r e s e n t s t u d y a r e t o : 1 d i f f e r e n t i a t e t h e d i f f e r e n c e s i n b i o m e d i c a l p r o f i l e s between t h e two g r o u p s o f m o t h e r s ; 2 d e s c r i b e t h e s o c i o d e m o g r a p h i c d i f f e r e n c e s between t h e two g r o u p s o f m o t h e r s ; 3 d e f i n e t h e p o t e n t i a l l y a l t e r a b l e b e h a v i o u r a l t r a i t s w h i c h d i f f e r e n t i a t e t h e two g r o u p s o f m o t h e r s . S i g n i f i c a n c e I f low b i r t h w e i g h t i s t o be c h o s e n as a p r i o r i t y f o r p r e v e n t i v e p r e n a t a l c a r e i n t e r v e n t i o n i t i s i m p o r t a n t t o know t h e e x t e n t o f t h e c o n d i t i o n , t h e c h a r a c t e r e r i s t i c s o f t h e p o p u l a t i o n i n w h i c h t h e c o n d i t i o n o c c u r s , w h e t h e r t h e r e e x i s t s s u b p o p u l a t i o n s a t h i g h e r r i s k f o r t h e c o n d i t i o n , and whether a l t e r a b l e c a u s a t i v e f a c t o r s e x i s t i n t h e p a r t i c u l a r p o p u l a t i o n u n d e r c o n s i d e r a t i o n f o r i n t e r a c t i o n . T h i s s t u d y i s e x p e c t e d t o p r o v i d e more i n f o r m a t i o n a b o u t t h o s e f a c t o r s t h a n i s a t p r e s e n t known f o r V a n c o u v e r . A f u r t h e r e x e r c i s e i n a l a t e r c h a p t e r w i l l be a b r i e f a n a l y s i s o f t h e p r e s e n t p r e n a t a l p r e v e n t i v e p r o g r a m i n V a n c o u v e r . I t s g o a l s , c o n t e n t and outcome measures w i l l be d e s c r i b e d i n r e l a t i o n t o t h e demography and p r e s e n t m e a s u r e s o f p e r i n a t a l h e a l t h i n V a n c o u v e r . CHAPTER I I I 33 METHODS RESEARCH DESIGN The h y p o t h e s e s were t e s t e d by c o m p a r i n g p o o l e d d a t a c o l l e c t e d f r o m two g r o u p s o f m o t h e r s . -A g r o u p o f c a s e s , and a c o n t r o l g r o u p g a t h e r e d b y q u o t a s a m p l i n g . I t i s assumed t h a t q u o t a s a m p l i n g w i l l have p r o v i d e d r e l i a b l e g e n e r a l i z a t i o n s a b o u t t h e c o n t r o l p o p u l a t i o n r e p r e s e n t e d . We r e c o g n i z e t h a t we do n o t know i f t h e p e o p l e c h o s e n f u l l y r e p r e s e n t t h e i r c a t e g o r y and t h a t t h e i n t e r v i e w e r s e l e c t i o n may have been b i a s e d t o w a r d s more a c c e p t a b l e or a t t r a c t i v e e l e m e n t s o f t h e p o p u l a t i o n i n some c a s e s . C o m p a r i s o n s between sub g r o u p s o f c a s e s and c o n t r o l s , m a t c hed f o r e t h n i c i t y , were a l s o made. S e l e c t i o n o f C a t e g o r i e s C a s e s : T h e s e c o n s i s t e d o f a l l m o t h e r s d e l i v e r i n g i n f a n t s w e i g h i n g l e s s t h a n 2501 gms a t b i r t h , b o r n between June 1 s t , 1981 and November 3 0 t h , 1981. C o n t r o l s : The f o l l o w i n g c r i t e r i a were a d o p t e d f o r s e l e c t i o n o f t h e c o n t r o l q u o t a g r o u p . The i n t e r v i e w e r s would s e l e c t as a c o n t r o l f o r e a c h c a s e a mother who: 1 had d e l i v e r e d an i n f a n t w e i g h i n g more t h a n 2500 gms a t b i r t h ; 2 was t h e s u b s e q u e n t non low b i r t h w e i g h t b i r t h n o t i f i c a t i o n f o l l o w i n g t h e b i r t h o f a " c a s e " i n f a n t ; 3 r e s i d e d w i t h i n t h e s e r v i c e a r e a o f t h e i n t e r v i e w e r ; 3* 4 c o u l d be i n t e r v i e w e d by t h e same i n t e r v i e w e r as had i n t e r v i e w e d t h e " c a s e " m o t h e r . The s e l e c t i o n o f t h e c o n t r o l q u o t a sample was d e s i g n e d t o e l i m i n a t e p o s s i b l e s e a s o n a l v a r i a t i o n i n b i r t h w e i g h t between c a s e and c o n t r o l p a i r s , e l i m i n a t e m a j o r v a r i a t i o n s i n s o c i o - e c o n o m i c s t a t u s between c a s e and c o n t r o l p a i r s , p r o v i d e f o r some m a t c h i n g o f e t h n i c i t y i n e t h n i c n e i g h b o u r h o o d s " between c a s e and c o n t r o l s , and e n h a n c e i n t e r p a i r i n t e r v i e w e r c o n s i s t e n c y . I t i s a p p r e c i a t e d t h a t t h e s e l e c t i o n o f c o n t r o l s by "non low b i r t h w e i g h t " s t a t u s o n l y ( i . e . w e i g h i n g more t h a n 2500gm) does n o t o f n e c e s s i t y i m p l y n o r m a l i t y . L a r g e f o r G e s t a t i o n a l Age I n f a n t s c o u l d have been i n c l u d e d as c o u l d some i n f a n t s between 2500 & 2750gm who by g e s t a t i o n wouJ.d s t i l l be c l a s s i f i e d b y L u b c h e n c o as S m a l l f o r G e s t a t i o n a l Age. F i v e c o n t r o l i n f a n t s i n f a c t f e l l i n t o t h e L.G.A. c a t e g o r y >90th % i l e , 1 c o n t r o l i n f a n t f e l l i n t o t h e S.G.A. c a t e g o r y . C h o i c e o f I n t e r v i e w e r The V a n c o u v e r H e a l t h D e p a r t m e n t s Community H e a l t h N u r s e s were c h o s e n as i n t e r v i e w e r s f o r t h e f o l l o w i n g r e a s o n s : 1 Under t h e p r e v e n t i o n p r o g r a m mandate t h e y were a l r e a d y r e c e i v i n g n o t i f i c a t i o n o f a l l l i v e and s t i l l b i r t h s t o m o t h e r s r e s i d i n g w i t h i n V a n c o u v e r ; 2 F o l l o w i n g s u c h n o t i f i c a t i o n t h e y r o u t i n e l y v i s i t e d a l l new m o t h e r s ; SS 3 As a d i s c i p l i n e g r o u p t h e y a r e a l l t r a i n e d i n f a c e t o f a c e i n t e r v i e w t e c h n i q u e s and d a t a c o l l e c t i o n ; 4 I t was c o n s i d e r e d t h a t t h e q u a l i t y o f i n f o r m a t i o n v o l u n t e e r e d t o t h e i n t e r v i e w e r s would be h i g h e r i f t h e i n t e r v i e w e r s were v i e w e d as h e l p i n g p r o f e s s i o n a l s . C h o i c e o f F a c e t o F a c e I n t e r v i e w e r s t o C o l l e c t D a t a The q u e s t i o n a i r e and p e r s o n a l i n t e r v i e w t e c h n i q u e was c h o s e n o v e r o t h e r methods as r e s p o n s e r a t e s a r e h i g h e r , y e a s a y i n g and u n d e r r e p o r t i n g a r e l e s s e n e d , and a r e v i e w o f r e l e v a n t l i t e r a t u r e i n d i c a t e d t h a t i n t h i s s i t u a t i o n t h e a d v a n t a g e s o u t w e i g h e d t h e d i s a d v a n t a g e s . [1,2,4,5,6,7,8] A p o t e n t i a l m a j o r s o u r c e o f b i a s e x i s t s i n t h e f a c t t h a t t h e i n t e r v i e w s were c o n d u c t e d b y some 20-30 d i f f e r e n t i n d i v i d u a l s o v e r t h e s i x month p e r i o d . I n t e r p a i r i n c o n s i s t e n c y and i n t e r o b s e r v e r v a r i a t i o n may t h e r e f o r e be q u i t e h i g h . F i v e s t e p s were t a k e n t o m i n i m i z e t h i s : 1 t h e number o f s u b j e c t i v e i n t e r v i e w e r r e s p o n s e s was k e p t as s m a l l as p o s s i b l e ; 2 E x t e n s i v e d i s c u s s i o n s w i t h a l l p o t e n t i a l l y i n v o l v e d n u r s e s [88] were h e l d on f o u r d i f f e r e n t o c c a s i o n s o v e r t h e c o u r s e o f a 9 month p e r i o d . D u r i n g t h e s e m e e t i n g s c r i t e r i a were d e f i n e d and a m b i g u i t i e s removed as f a r as was p o s s i b l e ; 3 F i e l d t e s t i n g o f 20 q u e s t i o n n a i r e s r e v e a l e d a m b i g u i t i e s w h i c h were r e c t i f i e d ; 4 A s m a l l number o f i n t e r v i e w s were c o n d u c t e d w i t h i d e n t i c a l s u b j e c t s t o t e s t i n t e r o b s e r v e r v a r i a t i o n - w h i c h was low; 5 I n t e r v i e w e r s were e n c o u r a g e d t o c o n t a c t t h e i n v e s t i g a t o r whenever a m b i g u i t i e s or d o u b t s a r o s e . P r o c e s s A l l n o t i f i c a t i o n s o f b i r t h o f i n f a n t s w e i g h i n g l e s s t h a n 2501 gms, b o r n between June 1 s t , 1981 and November 3 0 t h , 1981 i n i t i a t e d a s p e c i a l p e r s o n a l i n t e r v i e w p r o c e d u r e . The a r e a Community H e a l t h N u r s e made h e r u s u a l c o n t a c t , b u t i n a d d i t i o n , c a r r i e d w i t h h e r a Low B i r t h W e i g h t q u e s t i o n n a i r e [See A p p e n d i x A ] , a s t a t e m e n t o f p r o t o c o l [ A p p e n d i x B] and an i n f o r m e d c o n s e n t f o r m [Appendix C ] . She i n f o r m e d t h e mother t h a t a s p e c i a l s u r v e y was b e i n g c a r r i e d o u t , s t a t e d t h e p u r p o s e o f t h e s u r v e y and i n f o r m e d t h e mother t h a t she was f r e e t o r e f u s e o r t o p a r t i c i p a t e as she w i s h e d and t h a t r e f u s a l i n no way compromised t h e s e r v i c e s she w ould r e c e i v e . She c o n d u c t e d h e r u s u a l a s s e s s m e n t and t h e n p r o c e d e d t o i n t e r v i e w t h e m o t h e r . C o m p l e t e d q u e s t i o n n a i r e s were r e t u r n e d f r o m t h e H e a l t h U n i t s t o t h e i n v e s t i g a t o r . D a t a was hand c o d e d and t a b l e s were g e n e r a t e d b y t h e i n v e s t i g a t o r . D i f f e r e n c e s were examined f o r g r o u p e d d a t a u s i n g t h e C h i S q u a r e s t a t i s t i c a l t e s t w i t h Y a t e s c o r r e c t i o n and t h e s t u d e n t s ' t t e s t . A s i g n i f i c a n c e l e v e l o f .05 was s e l e c t e d . The I n s t r u m e n t The q u e s t i o n n a i r e h a s n i n e s u b s e c t i o n s [See A p p e n d i x A ] : S e c t i o n A: I n f o r m a t i o n f r o m B i r t h N o t i c e . I t i s f r o m t h i s document t h a t b i r t h w e i g h t and g e s t a t i o n a l age d a t a w e re t a k e n . T hese d a t a s o u r c e s a r e u s e d 'as i s " b y t h e D e p a r t m e n t o f V i t a l S t a t i s t i c s o f t h e P r o v i n c i a l M i n i s t r y o f H e a l t h . I t i s o f i n t e r e s t t o e x a m i n e p o s s i b l e s o u r c e s o f e r r o r . M o s t b i r t h w e i g h t s (95%) a r e r e c o r d e d i n gms. Where r e c o r d i n g i n o u n c e s has o c c u r r e d , a p r o b a b l e + o r - 1 oz e r r o r may o c c u r due t o d i g i t p r e f e r e n c e . T h i s i s n o t e d by D a v i d [10] as i s t h e p o t e n t i a l f o r m i s d a t i n g g e s t a t i o n a l age f r o m LNMP, m a t e r n a l r e c a l l o r o b s t e t r i c i a n r e c o r d s . A p p r o x i m a t e l y 1.3% i n c o r r e c r t l y c o d e d and b i o l o g i c a l l y i m p l a u s i b l e l o w b i r t h w e i g h t g e s t a t i o n a l age d a t a a r e r e p o r t e d i n h i s l a r g e s e r i e s . S i m i l a r f i n d i n g s a r e r e p o r t e d b y Naeye and D i x o n . [10] T h e s e p e r c e n t a g e s a r e s m a l l e nough n o t t o b i a s t h e r e l a t i v e l y s m a l l numbers i n t h e s t u d y g r o u p . S e c t i o n B: C o n s i s t s o f a r e c o r d o f i n f a n t h e i g h t , w e i g h t and h e a d c i r c u m f e r e n c e m e a s u r e d a t t i m e o f Community H e a l t h N u r s e v i s i t . I n f a n t w e i g h t was d i s c a r d e d due t o i n a c c u r a c y o f V a n c o u v e r H e a l t h D e p a r t m e n t b a b y s c a l e s . O t h e r d a t a w e re i n c o n s i s t e n t l y r e c o r d e d and d i s c a r d e d 3? S e c t i o n C: M a t e r n a l h e i g h t , M a t e r n a l p r e p r e g n a n c y w e i g h t and p r e g n a n c y w e i g h t g a i n were g a t h e r e d s o l e l y f r o m m a t e r n a l r e c a l l . M a t e r n a l frame s i z e was e s t i m a t e d u s i n g a s i m p l e 3 c a t e g o r y a s s e s s m e n t p r o v i d e d b y ACTION B.C.. I t was a n t i c i p a t e d t h a t a c o m b i n a t i o n o f h e i g h t and frame s i z e w ould g i v e a r a n g e o f i d e a l w e i g h t a g a i n s t w h i c h p r e p r e g n a n t w e i g h t c o u l d be a s s e s s e d . The c a l c u l a t i o n s were n o t p e r f o r m e d as d i s c u s s i o n s w i t h t h e D e p a r t m e n t o f K i n e s i o l o g y a t Simon F r a s e r U n i v e r s i t y s u g g e s t e d t h a t t h e m a r g i n f o r u n c e r t a i n t y and i n a c u r r a c y was t o o g r e a t . 39 S e c t i o n D: A s s o c i a t e d R i s k F a c t o r s -S o c i o B e h a v i o u r a l I I A l c o h o l c o n s u m p t i o n i s a n a l y z e d a c c o r d i n g t o C a l l a h a n ' s V a r i a b i l i t y Index [ 9 ] . A m o n t h l y f o o d b u d g e t was c h o s e n f o r i n c l u s i o n , as a t t h e t i m e , i t was f e l t t h a t t h i s m i g h t more a c c u r a t e l y r e p r e s e n t e x p e n d i t u r e on n u t r i t i o n . In r e t r o s p e c t a c o m p o s i t e s o c i o - e c o n o m i c s t a t u s i n d e x s u c h as was d e v e l o p e d by Green a t John H o p k i n s U n i v e r s i t y [12] would have been p r e f e r a b l e . A f i g u r e o f $75.00 p e r month/mother was t h e U n i t e d Way e s t i m a t e o f minimum e x p e n d i t u r e f o r a d e q u a t e p r e g n a n c y n u t r i t i o n i n V a n c o u v e r i n 1981. S e c t i o n E : M a t e r n a l M e d i c a l H i s t o r y T h i s i n f o r m a t i o n was a c o m p i l a t i o n o f t h a t r e c a l l e d by t h e m o t h e r , and t h a t p r e s e n t e d i n P a r t A o f t h e q u e s t i o n n a i r e . S e c t i o n F: H e a l t h c a r e u t i l i z a t i o n , p r i v a t e and p u b l i c The n a t u r e and e x t e n t o f h e a l t h c a r e u t i l i z a t i o n was c o l l e c t e d s o l e l y f r o m m a t e r n a l r e c a l l . As s u c h t h e s e d a t a a r e s u b j e c t t o e r r o r s o f r e c a l l o r a c q u i e s c e n c e . S e c t i o n G; L i n g u i s t i c a b i l i t y was d e r i v e d f r o m t h e a s s e s s m e n t o f t h e Community H e a l t h N u r s e . Y a r i e [3] has shown t h a t f l u e n c y i n E n g l i s h i s c o r r e l a t e d t o p r e n a t a l a t t e n d a n c e . T h i s s e c t i o n i s d e s i g n e d t o s u b s t a n t i a t e t h i s f i n d i n g . 40 E t h n i c C h a r a c t e r i s t i c s T h i s i s r e c o g n i z e d as an a r e a c h a r a c t e r i z e d by s e n s i t i v i t y and p r a c t i c a l d i f f i c u l t y . Common usage r e c o g n i z e d a v a r i e t y o f e t h n i c " t y p e " i n V a n c o u v e r e . g . " C a n a d i a n s " , C h i n e s e , E a s t I n d i a n s , I t a l i a n s , G r e e k s , e t c . , e t c . Many o f t h e s e g r o u p s c e l e b r a t e t h e i r own c u l t u r a l d a y s , o r p a r t s o f town, t h u s a c c e p t i n g and e x p r e s s i n g a g e o g r a p h i c a l , c u l t u r a l , and l i n g u i s t i c h e r i t a g e . T h i s s u r v e y u s e d t e n c a t e g o r i z a t i o n s o f e t h n i c i t y ( e t h n i c o r i g i n ) . P l a c e m e n t i n a c a t e g o r y e s s e n t i a l l y d e p e n d e d upon t h e i n t e r v i e w e r and t h e s u b j e c t d e c i d i n g upon w h i c h c a t e g o r y b e s t f i t t e d t h e s u b j e c t . A d d i t i o n a l i n f o r m a t i o n i . e . c o u n t r y o f b i r t h and mother tongue was a l s o e l i c i t e d . The c a t e g o r i e s c h o s e n r e f l e c t e d t h o s e c h o s e n by t h e V a n c o u v e r S c h o o l B o a r d i n a 1977 s u r v e y o f E n g l i s h Second Language p u p i l s . [13] I t was e x p e c t e d t h a t t h e s e c o n d and t h i r d l a r g e s t e t h n i c g r o u p s w o u l d be C a n a d i a n s o f C h i n e s e or Indo P a k i s t a n i ( E a s t I n d i a n ) o r i g i n . The i n v e s t i g a t o r was aware b e f o r e commencing t h e s u r v e y t h a t t h e b u l k o f C h i n e s e C a n a d i a n s come o r i g i n a l l y f r o m S o u t h e a s t C h i n a and Hong Kong and t h a t I n d o - C a n a d i a n s have more d i v e r s e o r i g i n s , i . e . I n d i a , P a k i s t a n , E a s t A f r i c a , The West I n d i e s , t h e U n i t e d Kingdom and F i j i . The t h r e e l a r g e s t s u b g r o u p s o f Indo C a n a d i a n s a r e , i n d e c r e a s i n g n u m e r i c a l s i g n i f i c a n c e , P u n j a b i , F i j i a n I n d i a n s and I s m a i l i s . m C o u n t r y o f b i r t h a l o n e was d i s c o u n t e d as i n a d e q u a t e f o r t h e s u r v e y as many v i s i b l y e t h n i c C a n a d i a n s , l i v i n g l i v e s t h a t a n t h r o p o l o g i s t s d e f i n e as " m a i n t a i n i n g c u l t u r a l i n t e g r i t y " have been b o r n i n t h i s c o u n t r y . The 1982 V a n c o u v e r S c h o o l B o a r d s u r v e y o f E n g l i s h as a s e c o n d l a n g u a g e i n V a n c o u v e r s c h o o l s , d i s c o v e r e d t h a t 50% o f t h e c h i l d r e n c l a s s i f i e d E n g l i s h Second Language, a r e i n f a c t C a n a d i a n b o r n . The i n d i o s y n c r a t i c n a t u r e o f e t h n i c c a t e g o r i z a t i o n i s r e c o g n i z e d . In t h e t a b l e s n o m e n c l a t u r e w i l l be u s e d as i n t h e s u r v e y i n s t r u m e n t . In t h e d i s c u s s i o n t e r m s r e f l e c t i n g c i t i z e n s h i p and o r i g i n w i l l be u s e d . T h a t i s C h i n e s e w i l l be C a n a d i a n o f C h i n e s e o r i g i n . E a s t I n d i a n w i l l be more p r o p e r l y c a l l e d Indo C a n a d i a n s . A l i t e r a t u r e s u r v e y of C h i n e s e and E a s t I n d i a n s t a t u s and low b i r t h w e i g h t i s a t t a c h e d as an a p p e n d i x t o C h a p t e r I I I . S e c t i o n H; F u r t h e r H e a l t h Needs o f M o t h e r a n d / o r C h i l d T h i s i n f o r m a t i o n would have r e f l e c t e d t h e a s s e s s m e n t o f t h e Community H e a l t h N u r s e . The v a s t m a j o r i t y were l e f t b l a n k . The i n f o r m a t i o n was n o t t a b u l a t e d . I m p l e m e n t a t i o n The r a t i o n a l e , o b j e c t i v e s and d e s i g n o f t h e s t u d y w e re d i s c u s s e d w i t h t h e D i r e c t o r o f P r e v e n t i o n P r o g r a m s , t h e R e s e a r c h and E v a l u a t i o n C o m m i t t e e o f t h e V a n c o u v e r H e a l t h D e p a r t m e n t , t h e E x e c u t i v e C o m m i t t e e o f t h e V a n c o u v e r H e a l t h D e p a r t m e n t and t h e P r e n a t a l I n f a n t and P r e s c h o o l P l a n n i n g C o m m i t t e e o f t h e V a n c o u v e r H e a l t h D e p a r t m e n t . The c o s t o f t h e s u r v e y i n n u r s i n g t i m e was a c c e p t a b l e t o t h e d e p a r t m e n t and a p p r o v a l i n p r i n c i p l e was g i v e n f o r t h e i n v e s t i g a t o r t o p r o c e e d . The f o l l o w i n g n i n e m onths w e r e s p e n t i n o r i e n t i n g t h e Community H e a l t h N u r s e s i n t h e d e p a r t m e n t f o r t h e q u e s t i o n n a i r e , t e s t i n g and r e v i e w i n g i t , m e e t i n g t h e c r i t e r i a o f E t h i c s C o m m i t t e e U.B.C. and a s s u r i n g t h a t c l e r i c a l p r o c e d u r e s and p a p e r f l o w w e r e u n d e r s t o o d and o p e r a t i v e w i t h i n e a c h o f t h e s i x u n i t s . P r o c e d u r e Q u e s t i o n n a i r e s were d i s t r i b u t e d t o H e a l t h U n i t s . C o m p l e t e d Q u e s t i o n n a i r e s were r e t u r n e d t o t h e i n v e s t i g a t o r . D a t a was h and c o d e d and t a b l e s w e re g e n e r a t e d . D i f f e r e n c e s w e re e x a m i n e d u s i n g t h e C h i - S q u a r e and t h e S t u d e n t s ' t S t a t i s t i c a l T e s t s . A s i g n i f i c a n c e l e v e l o f .05 was s e l e c t e d . Hi BIBLIOGRAPHY CHAPTER I I I 1 Aday,L.A., S e l l e r s , C , Anderson,R.M.: P o t e n t i a l s o f L o c a l H e a l t h S u r v e y s : A S t a t e o f t h e A r t Summary. A.S.P.H. Aug. 1981 V o l . 7 1 No.8. 2 Warwiac,D.P., L i n i n g e r , C . A . : The Sample S u r v e y : T h e o r y and P r a c t i c e : McGraw H i l l Book Co. C o p y r i g h t 1975 p.72-73. 3 Y a r i e , S . F . : A s t u d y o f F a c t o r s I n f l u e n c i n g U t i l i z a t i o n o f P r e n a t a l S e r v i c e s i n V a n c o u v e r . S o c . P i and Res. Committee o f th e U n i t e d Way o f G r e a t e r V a n c o u v e r 1978 p 79. 4 Klecka,W.R., T a c h f a r b e r , A . J . : Random D i g i t D i a l l i n g : A c o m p a r i s o n t o p e r s o n a l s u r v e y s . P u b l i c Op. Q u a r t e r l y 1978 42:105-114. 5 S i e m i a t y c k i , I . : A c o m p a r i s o n o f m a i l , t e l e p h o n e and home i n t e r v i e w s t r a t e g i e s f o r h o u s e h o l d h e a l t h s u r v e y s . Am.J.Pub. H e a l t h 1979 69:238-245. 6 T y e b j e e , T . T . : T e l e p h o n e S u r v e y m e t h o d s t h e s t a t e o f t h e a r t . J . M a r k e t i n g 1979 43:68-78. 7 U s d h e n , H e a l t h S u r v e y R e s . M e t h o d s : S e c o n d B i e n n i a l C o n f e r e n c e D.H.E.W. Pub. No. (P.H.S.) 79-3207 W a s h i n g t o n D.C. U.S. G o v ' t . P r . O f f . 1979. 8 Usdhen, H e a l t h S u r v e y Res. M e t h o d s : Second B i e n n i a l C o n f e r e n c e D.H.E.W. Pub. No. (P.H.S.) 79-3207 W a s h i n g t o n D.C. U.S. G o v ' t P r . O f f . 1979. 9 C a l a h a n , D . , C i s i n , I . H . , C r o s s l e y , H . M . : A m e r i c a n D r i n k i n g P r a c t i c e s : A N a t i o n a l S t u d y o f D r i n k i n g B e h a v i o u r and A t t i t u d e s . New B r u n s w i c k , N.J. Rutgus C e n t r e o f A l c o h o l S t u d i e s , 1969. 10 Naeye,R.L., D i x o n , J . B . : D i s t o r t i o n s i n F e t a l Growth S t a n d a r d s . P e d i a t . R e s . 12:987-991, 1978. 11 D a v i d , J . R . : The Q u a l i t y and C o m p l e t e n e s s o f B i r t h w e i g h t and G e s t a t i o n age d a t a i n c o m p u t e r i z e d B i r t h f i l e s A.J.P.H. S e p t . 1980 V o l . 7 0 No.9 p.964. 12 G r e e n , L . A . : "Manual f o r s c o r i n g S.E.S. f o r r e s e a r c h on h e a l t h b e h a v i o u r " P u b l i c H e a l t h R e p o r t s V o l . 85 No.9 S e p t . 1970. 13. E l l i s , E . N . : S u r v e y o f P u p i l s i n V a n c o u v e r S c h o o l s f o r Whom E n g l i s h i s a Second Language. R e s e a r c h R e p o r t 77-01 V.S.B. May 1977. HH CHAPTER IV RESULTS TABLE I For S i n g l e t o n L i v e B i r t h - Low B i r t h Weight In f a n t s by U n i t and E t h n i c i t y U n i t Can. E.Ind. Chin. N.Ind. Th a i . P o r t . I t a l . P h i l i . Other T o t a l North 2 - 2 2 - - - - - - 6 East 11 15 3 - - 2 - - 2 1 34 South 5 3 4 - - - 1 - - - 13 MMain 6 2 1 - 2 - - 1 - - 12 B/R 16 1 2 2 1 - - - 3 - 25 West 1 - 1 - - - - - - - 2 ? 8 2 1 - - - - 1 2 1 15 TOTAL 49 23 14 4 3 2 1 2 7 2 107 RESULTS TABLE I I Low B i r t h Weight and Non-Low B i r t h Weight In f a n t s by E t h n i c i t y of Mother E t h n i c i t y No.of cases % No.of c o n t r o l s o *o No i n f o r m a t i o n 2 1.9 3 3 Canadian White 49 45.8 40 40.4 Native Indian 4 3.8 2 2 Chinese 14 13.1 18 18.2 East Indian 23 21.5 11 11.1 I t a l i a n 1 .9 4 4 Spanish - - 3 3 Portuguese 2 1.9 4 4 Thai/Lao/Viet 3 2.8 - -P h i l l i p i n o 2 1.9 7 7.1 Other 7 6.5 7 7.1 T o t a l 107 100 99 99.9 RESULTS TABLE III Low Birthweight and Non-Low Birthweight Infants by Maternal Risk Factors Canadian, Chinese & East Indian sk Canadian Chinese East Indian Case[45] Control[39] Case[13] Control[18] Case[22] Control[11] Prev. Misc/A.B. /S.B. 22 14 6 1 8 2 Previous Low B i r t h Weight 6 3 1 _ 4 _ IPI < 12/12 5 4 6 1 4 1 No support 9 2 - - - -<75/mth 1 1 1 1 1 1 SA 5 1 - - - -<= lpk/d 16 8 3 1 - -> lpk/d 6 2 - - - -< 251b. 22 8 7 3 12 2 HI RESULTS TABLE IV Low Birthweight and Non-Low Birthweight Infants by Maternal Medical Problem and by Complication of Pregnancy f o r Mothers: Canadian, Chinese & East Indian Canadian Chinese East Indian Case[49] Control[40] Case[14] Control[18] Case[23] Control[11] Medical Problem Diabetes Hypertension 7 Epilepsy 1 Cardiac Disease Renal Disease 1 Other Pregnancy  Complication Toxaemia 4 - - - 2 Placenta Praevia 2 - ' - 1 1 Placenta Insuff. 1 - 1 Ante.Partum Haem 6 - - 2 1 Ultrasound 9 2 1 1 4 •HZ RESULTS TABLE V Mothers of Low B i r t h Weight In f a n t s Term and Preterm by Ethnic Group, P a r i t y , Care, Tobacco and A l c o h o l Canadian Chinese East Indian Term Preterm Term Preterm Term P r e t e n Para 1 10 12 3 1 2 5 2 4 8 3 3 3 3 3 1 4 1 1 2 5 4 2 5 — 1 1 1 4+ — . 1 - - - 1 Doctor V i s i t s Mean 11 9.4 11 9 10 8 Range 6-18 3-17 8-15 6-12 3-18 4-12 VHD Pr e n a t a l 3 10 2 3 1 -Other P r e n a t a l 3 5 • - - - -H e a l t h i e s t _ 1 1 Babies P o s s i b l e -Tobacco 5 17 1 2 - -A l c o h o l * 3 6 - - - -# of cases 17 30 8 6 8 15 * Moderate or heavy i n any t r i m e s t e r . Term = 38 or more weeks of g e s t a t i o n . Preterm = l e s s than 38 weeks of g e s t a t i o n RESULTS TABLE VI Ethnic Group by Care During Pregnancy Low B i r t h Weight and Non Low B i r t h Weight Mothers Canadian Chinese East Indian Case Control Case Control Case Contro Ins t i t u t e d care i n 1st Trimester 34 33 13 14 22 8 2nd Trimester 11 5 — 3 3 3rd Trimester - - - 1 - -# Doctor V i s i t s 1 - 5 4 - - — 1 6 - 8 9 1 2 3 2 2 9 - 1 2 21 26 10 11 16 7 > 12 11 11 1 4 3 2 MEAN 10.2 12.2 10.3 10.6 9.9 10.3 Recalled Ultrasound 1st Trimester 12 11 5 2 6 _ 2nd Trimester 10 8 2 - — 5 2 3rd Trimester 6 7 3 5 5 3 Repeat v/s 15 10 4 2 5 -Prenatal Classes V.H.D. 13 12 5 8 1 1 Other 8 12 — _ _ Healthiest Babies 1 1 1 50 RESULTS TABLE VII Case and Control Chinese and East Indian Mothers by English Comprehension Engli s h Comprehension Chinese East Indian Case Control Case Control NIL 3 1 POOR - 2 1 FAIR 4 6 3 3 GOOD 10 9 16 7 NO INFORMATION 1 51 RESULTS  TABLE V I I I C a se and C o n t r o l M o t h e r s  by E t h n i c G r o u p and A l c o h o l Use A l c o h o l C a n a d i a n C h i n e s e E a s t I n d i a n C a se C o n t r o l C a s e C o n t r o l C ase C o n t r o l None 11 7 8 14 19 9 R a r e 25 28 6 4 3 2 M o d e r a t e * 7 4 - - - -Heavy* - - - - - -* I n any T r i m e s t e r R a r e = c o n s u m i n g a l c o h o l l e s s d r i n k s on any one o c c a s i o n . M o d e r a t e = l e s s t h a n h e a v y and Heavy = a t l e a s t 5-6 d r i n k s on d r i n k s p e r month. A d r i n k = 1 o z . S p i r i t s ; 4 o z . t h a n o n c e p e r month and n e v e r 5-6 more t h a n r a r e . some o c c a s i o n s and a t l e a s t 45 Wine; o r 12 o z . B e e r . RESULTS TABLE IX Case and Control Mothers by P a r i t y . Canadian Chinese East Indian Case Control Case Control Case Control PRIMIP 22 14 4 8 7 4 MULTIP 25 25 10 10 16 7 S3 RESULTS TABLE X Case and Control Mothers by Age. Age Canadian Chinese East Indian Case Control Case Control Case Control <15 - - - - -1 5 - 1 9 1 2 - - 1 20 - 24 16 9 7 3 5 3 25 - 29 13 10 1 9 13 6 30 - 34 11 12 4 4 3 1 3 5 - 4 0 6 5 2 1 - -RESULTS TABLE XI Case and Control Mothers: Proportional Representation of Three Ethnic Groups Ethnic Group Case Control # % # % Canadian 49 45.8 40 40.4 Chinese 14 13.1 18 18.2 East Indian 23 21.5 11 11.1 RESULTS TABLE XII Low B i r t h Weight Infants by E t h n i c i t y Characterized by Lubchenco Scale as: Small for Gestational Age (SGA), or Appropriate for Gestational Age (AGA). E t h n i c i t y AGA % SGA % Canadian 27 57.5 20 42.5 Chinese 7 50 7 50 East Indian 13 56.5 10 43.5 Tot a l 47 56 37 44 RESULTS TABLE X I I I Low B i r t h Weight and Non Low Birth.Weight I n f a n t s by E t h n i c i t y and Prematurity (<38 weeks) CASE CONTROL ETHNICITY TERM % PRETERM % TERM % PRETERM % Canadian 16 34 31 66 33 89 4 11 Chinese 8 57 6 43 14 82 3 18 East Indian 8 35 15 65 7 70 3 30 TOTAL 32 38 52 62 44 81.5 10 18 RESULTS TABLE XIV Canadian Mothers: Comparison by Risks SGA and AGA Risk SGA n = 20 AGA n = 27 Pr i m i p a r i t y 9 13 Weight gain <25 l b 7 15 Previous Low B i r t h Weight - 6 IPI < 12/12 3 2 Single Status 6 3 <$75/month food 1 S o c i a l Assistance 4 1 Tobacco 9 13 Alcohol (moderate) 3 6 Med Comp Pregnancy 6 10 Care 1st Trimester 17 19 Care 2nd Trimester 3 8 Care 3rd Trimester VHD Classes 5 8 Pri v a t e 7 1 HBP 1 RESULTS TABLE XV Canadian Mothers: Comparison by Risks SGA Mothers and Non Low B i r t h Weight Mothers Risk SGA n = 20 non LBW n Primiparity 9 14 Weight gain <2516 7 8 IPI < 12/12 3 4 Single Status 6 2 S o c i a l Assistance 4 1 Tobacco 9 10 Alcohol (moderate) 3 4 VHD Classes 5 12 Private 7 12 RESULTS TABLE XVI Country of B i r t h of Chinese and East Indian Mothers Country of B i r t h of Mother India F i j i Kenya Uganda England Canada East Indian Case Control 13 9 6 2 1 1 1 1 Country of B i r t h of Mother Mainland China Hong Kong Canada Taiwan Malaysia Singapore Chinese Case Control 3 5 3 1 1 1 10 6 1 1 G r a m 5000 4750 4500 4 2 5 0 4 0 0 0 3750 3500 3250 3000 2750 2500 2250 2000 1750 1500 1250 1000 750 500 Class i f i ca t ion of newborns by birth we ight a n d gesta t ion age a ! =k _ ° > J V v >n a t C e. N 'j ' ° 1 I I I 1 0th % • 1 \ 0 o< a q e _ <? A C * t— -b < < CM CN CN CN CN f N n ^ n n n n n n n n ^ ^ j ^ r ^ r W e e k s of gesta t ion Preterm erm Postterm COMMENTS ON RESULTS D u r i n g t h e s u r v e y p e r i o d J u n e 1 s t , 1981 t o November. 3 0 t h , 1 9 8 1 : Number o f l i v e b o r n l o w b i r t h w e i g h t s i n g l e t o n b a b i e s r e p o r t e d - 107 Number o f m o t h e r s o f l i v e b o r n l o w b i r t h w e i g h t s i n g l e t o n s i n t e r v i e w e d - 107 Number o f c o n t r o l s i n g l e t o n b a b i e s - 99 Number o f c o n t r o l s i n g l e t o n m o t h e r s i n t e r v i e w e d - 99 M u l t i p l e B i r t h s A t o t a l o f n i n e p a i r s o f t w i n s and one s e t o f t r i p l e t s were i n c l u d e d i n t h e s u r v e y b u t n o t i n t h e c o m p a r i s o n s w h i c h a r e r e s t r i c t e d t o s i n g l e t o n m o t h e r s . Three: o f t h e t w e n t y - o n e i n f a n t s h a d b i r t h w e i g h t s o v e r 2500gm. Some e s t i m a t e o f t h e c o m p l e t n e s s o f t h e Low B i r t h W e i g h t s u r v e y c a n be o b t a i n e d b y k n o w i n g t h a t b e t w e e n J a n u a r y 1 s t , 1981 and December 3 1 s t , 1981 271 i n f a n t s o f b i r t h w e i g h t 501-2500 were b o r n i n V a n c o u v e r . * The t o t a l number o f l i v e b i r t h s d u r i n g t h i s p e r i o d was 4589. 52% o f a l l l i v e b i r t h s o c c u r r e d i n t h e 3 r d and 4 t h q u a r t e r s o f 1981. I f we assume t h a t l o w b i r t h w e i g h t b i r t h s f o l l o w t h i s d i s t r i b u t i o n t h e n an a p p r o x i m a t i o n o f t h e s u r v e y c o m p l e t n e s s i s : * C o m m u n i c a t i o n f r o m S e n i o r R e s e a r c h O f f i c e r , D i v i s i o n o f V i t a l S t a t i s t i c s , B.C. P r o v i n c i a l M i n i s t r y o f H e a l t h . LBW s i n g l e t o n s + LBW m u l t i p l e b i r t h s / 52%. A l l LBW r e c o r d e d i n 1981 = 125/141 = 89%. The most l i k e l y e x p l a n a t i o n s f o r t h e d i s p a r i t y between t h e numbers o f c a s e s and c o n t r o l s a r e : 1) Low b i r t h w e i g h t b a b i e s a r e v i e w e d as a p r i o r i t y by Community H e a l t h N u r s e s , and t h u s r e c e i v e v i s i t s even when c a s e l o a d s a r e h i g h ; 2) J u n e , J u l y and A u g u s t a r e v a c a t i o n months. N o t i f i c a t i o n o f c o n t r o l b i r t h s , a r r i v i n g a f t e r t h e LBW n o t i f i c a t i o n may have a r r i v e d when a Community H e a l t h N u r s e i n t e r v i e w e r was on v a c a t i o n and e i t h e r n o t been p i c k e d up by h e r a l t e r n a t e , or n o t h a v e been v i s i t e d by t h e i n t e r v i e w e r on h e r r e t u r n f r o m v a c a t i o n . SES and LBW As c a n be s e e n f r o m T a b l e I , Low B i r t h W e i g h t d i s t r i b u t i o n between t h e H e a l t h U n i t s i s v e r y u n e v e n . The p r i n c i p a l i n v e s t i g a t o r was b a s e d a t E a s t U n i t where t h e l a r g e s t number o f c a s e s i s f o u n d , i t i s l i k e l y t h a t t h i s u n i t had t h e b e s t r e p o r t i n g r e c o r d and t h e p r o b a b i l i t y o f u n d e r r e p o r t i n g from o t h e r u n i t s i s c o r r e s p o n d i n g l y h i g h e r . One would have e x p e c t e d more Low B i r t h W e i g h t b a b i e s f r o m N o r t h U n i t , i n v i e w o f : a) t h e h i g h c o n c e n t r a t i o n o f low S o o c i o E c o n o m i c S t a t u s i n d i v i d u a l s ; 4,3 b) p a s t Low B i r t h W e i g h t s t a t i s t i c s as r e c o r d e d i n C i t y o f V a n c o u v e r H e a l t h U n i t P r o f i l e s . T h i s s u p p o s i t i o n i s b o r n o u t b y an a n a l y s i s o f c a s e s s u r v e y e d a g a i n s t l o c a t i o n o f LBW i n f a n t s as r e c o r d e d by t h e D i v i s i o n o f V i t a l S t a t i s t i c s f o r 1981. (See f o l l o w i n g t a b l e XVII) TABLE XVII Low Weight B i r t h s by L o c a t i o n and Reporting i n Survey UNIT 1981 SINGLETONS MULTIPLE SURVEY . 501-2500gm B i r t h s IN SURVEY BIRTH INFANTS <2501 TOTAL LBW North 51 6 - 6 East 71 34 4 38 South 48 13 6 19 West 17 2 4 6 Mid Main 31 12 - 12 Burrard 53 25 2 27 Unrecorded - 15 2 17 TOTAL 271 107 18 125 A s u b s e q u e n t breakdown by m a t e r n a l a d d r e s s r e v e a l s : # % E a s t o f Cambie a d d r e s s 70 65.5 West o f Cambie a d d r e s s 12 11. Downtown 7 6.5 Unknown 18 17. T o t a l 107 100. T h i s i f f u l l y c o n s i s t e n t w i t h p r e v i o u s r e s e a r c h f i n d i n g s on t h e i m p o r t a n t r o l e t h a t low S.E.S. p l a y s i n t h e a e t i o l o g y o f Low B i r t h W e i g h t . E t h n i c i t y and Low B i r t h W e i g h t T a b l e I I r e v e a l s t h a t 80.4% o f Low B i r t h W e i g h t b a b i e s b e l o n g t o t h r e e e t h n i c g r o u p s : C a n a d i a n 45.8% C h i n e s e 13.1% E a s t I n d i a n 21.5% 69.7% o f c o n t r o l b a b i e s b e l o n g e d t o t h e s e same g r o u p s : C a n a d i a n 40.4% C h i n e s e 18.2% E a s t I n d i a n 11.1% C a n a d i a n c a s e s a p p e a r t o be s l i g h t y o v e r r e p r e s e n t e d compared t o C a n a d i a n c o n t r o l s , C h i n e s e c a s e s a p p e a r t o be under r e p r e s e n t e d . F o r n e i t h e r g r o u p was t h e d i f f e r e n c e s t a t i s t i c a l l y s i g n i f i c a n t . The o v e r r e p r e s e n t a t i o n by E a s t I n d i a n s i s s i g n i f i c a n t a t t h e p=.10 l e v e l ( C h i s q u a r e = 3 . 0 9 9 ) . ( s e e T a b l e XI) (Jo T h i s f i n d i n g i s c o n s i s t e n t w i t h t h e l i t e r a t u r e r e v i e w o f E t h n i c i t y and Low B i r t h W e i g h t . A l l s u b s e q u e n t c a s e c o n t r o l c o m p a r i s o n s were c o n d u c t e d on t h e s e t h r e e g r o u p s : The i n d i v i d u a l c o n t r i b u t i o n s made by o t h e r e t h n i c g r o u p s were c o n s i d e r e d t o o s m a l l t o t r e a t them i n d i v i d u a l l y . R i s k s and Low B i r t h W e i g h t The l i t e r a t u r e h a s i d e n t i f i e d s e v e r a l a n t e c e d e n t b e h a v i o u r s i n Low B i r t h W e i g h t m o t h e r s . T a b l e I I I l i s t s t h e i n c i d e n c e o f 9 f a c t o r s deemed t o be s i g n i f i c a n t i n t h e l i t e r a t u r e : 1 P r e v i o u s p o o r p r e g n a n c y o utcome ( i . e . p r e v i o u s m i s c a r r i a g e o r a b o r t i o n o r s t i l l b i r t h ) . When t h e d a t a f o r C h i n e s e , E a s t I n d i a n and C a n a d i a n m o t h e r s a r e p o o l e d t h i s i s s i g n i f i c a n t ( c h i s q u a r e d f l = 4 . 5 p=<.05). 2 P r e v i o u s Low B i r t h W e i g h t among m u l t i p s C a s e (n) C o n t r o l (n) C a n a d i a n 6 25 3 26 c h i s q u a r e = 0.64 N.S. C h i n e s e 1 10 - 10 E a s t I n d i a n 4 16 - 7 T o t a l 11 51 3 43 F o r p o o l e d d a t a c h i s q u a r e = 2.85 p = <.10 >.05. L>1 3 I n t e r p r e g n a n c y i n t e r v a l l e s s t h a n 12 months C a s e (n) C o n t r o l (n) C a n a d i a n 5 25 4 26N.S. C h i n e s e 6 10 1 10 c h i s q u a r e = 2.88 .5<p<.10 E a s t I n d i a n 4 16 1 7N.S. T o t a l 15 51 6 43N.S. 4 No l i v e - i n s u p p o r t d u r i n g p r e g n a n c y . T h i s i s a p p l i c a b l e o n l y t o C a n a d i a n m o t h e r s . Case (n) C o n t r o l (n) No l i v e i n s u p p o r t 9 45 2 39 c h i s q u a r e = 2.86 .05<p<.10 5 M o n t h l y Food B u d g e t . As a measure o f p o o r d i e t / p o v e r t y an a t t e m p t t o a c c o u n t f o r m o n t h l y f o o d b u d g e t was made. T h e r e was i n a d e q u a t e r e c a l l o f t h i s datum. 6 Mother i n R e c e i p t o f S o c i a l A s s i s t a n c e . As r e p o r t e d t h i s o n l y a p p l i e d t o C a n a d i a n m o t h e r s and was n o t s t a t i s t i c a l l y s i g n i f i c a n t e ven i f a c c u r a t e . 7&8 T o b a c c o Smoking. When smoking any t o b a c c o was t a b u l a t e d a g a i n s t non smoking f o r C a n a d i a n m o t h e r s s i g n i f i c a n t d i f f e r e n c e s between c a s e and c o n t r o l were f o u n d . C a n a d i a n Case C o n t r o l Smoking 24 10 Non Smoking 21 29 c h i s q u a r e = 3.85 p<.05. 9 F a i l u r e t o g a i n t h e recommended 251b d u r i n g p r e g n a n c y . Case (n) C o n t r o l (n) c h i P C a n a d i a n 22 45 8 39 6. 14 . 025 C h i n e s e 7 13 3 18 1. 85 NS E a s t I n d i a n 12 22 2 11 2. 62 . 10 T o t a l 41 80 13 68 15. 02 .001 T h i s i s h i g h l y s i g n i f i c a n t c h i s q u a r e = 15.02. Recap P r e v i o u s Low B i r t h W e i g h t a p p r o a c h e s s i g n i f i c a n c e f o r 3 g r o u p s combined; I n t e r P r e g n a n c y I n t e r v a l o f l e s s t h a n 12 months a p p r o a c h e s s i g n i f i c a n c e o n l y f o r C h i n e s e ; No l i v e i n s u p p o r t a p p r o a c h e s s i g n i f i c a n c e o n l y f o r C a n a d i a n s ; T o b a c c o u s a g e s i s s t a t i s t i c a l l y s i g n i f i c a n t f o r C a n a d i a n s ; F a i l u r e t o g a i n w e i g h t i s s t a t i s t i c a l l y s i g n i f i c a n t f o r C a n a d i a n s and h i g h l y s i g n i f i c a n t when t h e d a t a f r o m t h e 3 g r o u p s a r e p o o l e d ; F a i l u r e t o g a i n w e i g h t c o u l d be a s s o c i a t e d w i t h a s h o r t e n e d p r e g n a n c y and t h e r e f o r e be an a s s o c i a t i o n o f p r e m a t u r i t y . Li Low B i r t h W e i g h t and M a t e r n a l M e d i c a l  and P r e g n a n c y C o m p l i c a t i o n s . T a b l e IV d e t a i l s t h e r e p o r t e d m e d i c a l and p r e g n a n c y  c o m p l i c a t i o n s f o r c a s e s and c o n t r o l m o t h e r s o f t h e 3 g r o u p s . As w o u l d be e x p e c t e d t h e r e a r e more m e d i c a l c o m p l i c a t i o n s among m o t h e r s o f Low B i r t h W e i g h t i n f a n t s , p a r t i c u l a r l y C a n a d i a n s . T h e s e c o m p l i c a t i o n s m i g h t be e x p e c t e d t o e x e r t an i n f l u e n c e e i t h e r t h r o u g h p l a c e n t a l i n s u f f i c i e n c y o r s h o r t e n e d p r e g n a n c y e . g . H y p e r t e n s i o n , T o x a e m i a , P l a c e n t a l P r a e v i a , and Ante Partum Haemorrhage. A t o t a l o f 15 o f t h e 49 Low B i r t h W e i g h t m o t h e r s r e c a l l e d s u c h c o m p l i c a t i o n s . 11 o f t h e s e m o t h e r s d e l i v e r e d p r e m a t u r e l y ( r a n g e 30-37 1/2 w e e k s ) . Low B i r t h W e i g h t and P r e m a t u r i t y (see T a b l e V) As d i s c u s s e d p r e v i o u s l y <2500gm i n f a n t s c a n r e s u l t e i t h e r f r o m s h o r t e n e d p r e g n a n c y o r f r o m f a i l u r e t o grow i n u t e r o . U s i n g a d e f i n i t i o n o f p r e t e r m as l e s s t h a n 38 weeks g e s t a t i o n ; 30/47 C a n a d i a n i n f a n t s were p r e m a t u r e - 64% 6/14 C h i n e s e i n f a n t s were p r e m a t u r e - 43% 16/24 E a s t I n d i a n i n f a n t s were p r e m a t u r e - 66.6% 70 P r e m a t u r i t y and P r e N a t a l c a r e i ) P h y s i c i a n V i s i t s The l i t e r a t u r e h as d i s c u s s e d t h e a s s o c i a t i o n between Low B i r t h W e i g h t and P r e n a t a l C a r e ( T a b l e V) a l s o shows t h a t , as m i g h t be e x p e c t e d , fewer v i s i t s t o p h y s i c i a n s a r e n o t e d by women w i t h s h o r t e r p r e g n a n c i e s . On a v e r a g e , m o t h e r s o f Low B i r t h W e i g h t i n f a n t s a l s o v i s i t e d t h e i r p h y s i c i a n s f e w e r t i m e s t h a n d i d c o n t r o l m o t h e r s ( T a b l e V I ) . i i ) P r e n a t a l C l a s s e s In c o n t r a d i s t i n c t i o n t o p h y s i c i a n c a r e t h e r e i s an a p p a r e n t r e v e r s a l f o r m o t h e r s o f p r e m a t u r e i n f a n t s more o f whom too k p r e n a t a l c l a s s e s t h a n d i d te r m m o t h e r s . T h i s d i f f e r e n c e was n o t s t a t i s t i c a l l y s i g n i f i c a n t c h i s q u a r e = 2.24. i i i ) P r e m a t u r i t y - T o b a c c o and A l c o h o l Among Low B i r t h W e i g h t m o t h e r s t h e r e i s a s t a t i s t i c a l l y s i g n i f i c a n t a s s o c i a t i o n between p r e m a t u r i t y and t o b a c c o use c h i s q u a r e = 6.45 p=.025. No s i g n i f i c a n t a s s o c i a t i o n i s f o u n d f o r p r e t e r m and a l c o h o l i n t a k e (moderate t o h e a v y a t any t i m e i n p r e g n a n c y ) . 71 Low B i r t h W e i g h t and E t h n i c i t y by C a r e ( T a b l e VI) i ) T r i m e s t e r C a r e I n s t i t u t e d . Among C a n a d i a n m o t h e r s t h e r e i s a t e n d e n c y , n o t seen among C h i n e s e or E a s t I n d i a n m o t h e r s , f o r more Low B i r t h Weight m o t h e r s t o p r e s e n t f o r c a r e a f t e r t h e 1 s t t r i m e s t e r ( c h i s q u a r e = 2.50 n . s . ) . T h i s a p p e a r s t o be r e v e r s e d f o r t h e non C a n a d i a n m o t h e r s - no non C a n a d i a n Low B i r t h W e i g h t mother p r e s e n t e d a f t e r t h e 1 s t t r i m e s t e r , i i ) Number o f v i s i t s t o p h y s i c i a n s . As has been m e n t i o n e d Low B i r t h W e i g h t m o t h e r s v i s i t e d l e s s f r e q u e n t l y t h a n non Low B i r t h W e i g h t m o t h e r s . T h i s i s p o s s i b l y due t o t h e i r s h o r t e r g e s t a t i o n s . T h e r e a r e no s i g n i f i c a n t d i f f e r e n c e s i n mean v i s i t s f o r Low B i r t h W e i g h t C a n a d i a n , C h i n e s e or E a s t I n d i a n m o t h e r s . However non Low B i r t h W e i g h t m o t h e r s o f C a n a d i a n o r i g i n had a s i g n i f i c a n t l y h i g h e r number o f mean v i s i t s t h a n d i d e i t h e r C h i n e s e or E a s t I n d i a n non Low B i r t h W e i g h t m o t h e r s s i g p=.001). (t=2.788 d f 5 5 p<.005 - t=3.394 d f 4 8 p=<.001). ( i i i ) R e c a l l o f U l t r a s o u n d U l t r a s o u n d may be e i t h e r an i n v e s t i g a t i v e p r o c e s s or a r o u t i n e measure d u r i n g p r e g n a n c y . T h e r e i s no s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e between c a s e s and c o n t r o l s or between e t h n i c g r o u p s i n t h e number o f u l t r a s o u n d r e c a l l e d by t h e m o t h e r s . 7Z P r e n a t a l C l a s s A t t e n d a n c e Non Low B i r t h W e i g h t C a n a d i a n m o t h e r s e x h i b i t a t r e n d ( c h i s q u a r e =3.35) t o w a r d s more a t t e n d a n c e o f p r e n a t a l c l a s s e s t h a n do C a n a d i a n m o t h e r s o f Low B i r t h W e i g h t i n f a n t s . T h e r e i s no s t a t i s t i c a l d i f f e r e n c e between C h i n e s e Low B i r t h W e i g h t and non Low B i r t h W e i g h t m o t h e r s i n p r e n a t a l c l a s s a t t e n d a n c e , nor i s t h e r e any s t a t i s t i c a l d i f f e r e n c e i n t h i s sample between C h i n e s e and C a n a d i a n m o t h e r s i n p r e n a t a l c l a s s a t t e n d a n c e . T h e r e a r e h i g h l y s i g n i f i c a n t d i f f e r e n c e s between C a n a d i a n and Indo C a n a d i a n ( c h i s q u a r e = 19.9) and C h i n e s e and Indo C a n a d i a n i n p r e n a t a l c l a s s a t t e n d a n c e ( c h i s q u a r e = 7.53). The t r e n d f o r C a n a d i a n non Low B i r t h W e i g h t m o t h e r s t o g r e a t e r a t t e n d a n c e i s n o t i n f l u e n c e d by an e x c e s s o f p r i m i p a r i t y i n t h i s g r o u p ( s e e T a b l e I X ) . An a n a l y s i s o f p r i m i p a r i t y and p r e n a t a l c l a s s a t t e n d a n c e shows t h a t a l t h o u g h a g r e a t e r p r o p o r t i o n o f non Low B i r t h Weight C a n a d i a n p r i m i p a r a e a t t e n d p r e n a t a l c l a s s e s t h i s i s n o t s t a t i s t i c a l l y s i g n i f i c a n t ( c h i s q u a r e = 2 . 5 ) . P r e n a t a l c l a s s a t t e n d a n c e f o r p r i m i p a r o u s C a n a d i a n women i n t h i s s m a l l sample was a p p r o x i m a t e l y e v e n l y d i v i d e d between VHD and P r i v a t e c l a s s e s . C a n a d i a n P r i m i p s Low B i r t h W e i g h t Non Low B i r t h W e i g h t V.H.D P r i v a t e None V.H.D. P r i v a t e None 6 7 9 6 5 3 73 G i v e n t h a t o v e r 50% o f t h e sampled Low B i r t h W eight c a s e l o a d a r e m u l t i p a r o u s , one c o u l d q u e s t i o n t h e p r i o r i z a t i o n o f VHD p r e n a t a l programming t o women e x p e c t i n g t h e i r f i r s t b aby. M u l t i p a r o u s Low B i r t h W e i g h t m o t h e r s a t t e n d e d p r e n a t a l c l a s s e s : s i g n i f i c a n t l y l e s s f r e q u e n t l y t h a n d i d p r i m i p a r o u s m o t h e r s o f Low B i r t h W e i g h t i n f a n t s (p-<.025) Low B i r t h W e i g h t and E n g l i s h C o m p r e h e n s i o n f o r C h i n e s e and E a s t  I n d i a n m o t h e r s o n l y . T a b l e V I I - As a s s e s s e d by t h e Community H e a l t h N u r s e a t he r v i s i t t h e r e were no s i g n i f i c a n t d i f f e r e n c e s i n E n g l i s h l a n g u a g e a b i l i t i e s between c a s e o r c o n t r o l m o t h e r s . The m a j o r i t y of a l l C h i n e s e and E a s t I n d i a n m o t h e r s were a s s e s s e d FAIR/GOOD i n u n d e r s t a n d i n g spoken E n g l i s h . E n g l i s h i s a s e c o n d l a n g u a g e f o r 96% o f E a s t I n d i a n c a s e m o t h e r s and 91% E a s t I n d i a n c o n t r o l m o t h e r s , 80% C h i n e s e c a s e m o t h e r s and 94% C h i n e s e c o n t r o l m o t h e r s . C o u n t r y o f b i r t h i s l i s t e d i n T a b l e XVI. 7H Low B i r t h W e i g h t and A l c o h o l u s e i n p r e g n a n c y . T a b l e V I I I - T h e r e were no d i f f e r e n c e s between c a s e and c o n t r o l m o t h e r s i n any o f t h e 3 g r o u p s , b u t C a n a d i a n m o t h e r s as s u r v e y e d a r e more l i k e l y t o consume a l c o h o l t h a n n o t t o consume a l c o h o l d u r i n g p r e g n a n c y and more l i k e l y t h a n e i t h e r C h i n e s e o r E a s t I n d i a n women t o consume a l c o h o l . C h i n e s e and E a s t I n d i a n women a r e more l i k e l y n o t t o consume t h a n t o consume, and t h i s i s p a r t i c u l a r l y t r u e o f E a s t I n d i a n women. Low B i r t h W e i g h t and P a r i t y T a b l e IX - P r i m i p a r i t y was n o t a s s o c i a t e d w i t h t h e o c c u r r e n c e o f Low B i r t h W e i g h t i n t h i s s u r v e y . Low B i r t h W e i g h t and Age T a b l e X - T h i s l i t e r a t u r e a s s o c i a t e s a d o l e s c e n t motherhood w i t h Low B i r t h W e i g h t . T h i s a s s o c i a t i o n was h o t f o u n d i n our s t u d y s a m p l e . Of i n t e r e s t p e r h a p s i s t h e f i n d i n g t h a t 41% o f C a n a d i a n m o t h e r s were o v e r t h e age o f 30 v e r s u s 35% o f C h i n e s e and 15% o f E a s t I n d i a n . F o r m o t h e r s 35 y e a r s and o v e r t h e p e r c e n t a g e s were 13%, 10% and 3% r e s p e c t i v e l y . 7* Low B i r t h W e i g h t and F e t a l M a t u r i t y T a b l e X I I - The main b u r d e n o f i l l h e a l t h b r o u g h t on b y b e i n g b o r n under 2500 gm f a l l s on i n f a n t s who a r e S m a l l f o r G e s t a t i o n a l Age (SGA). T h e s e i n f a n t s f a c e a g r e a t e r i n c i d e n c e o f d i s a b i l i t y t h a n t h o s e who tho u g h under 2500 gm a r e A p p r o p r i a t e f o r G e s t a t i o n a l Age (AGA). T a b l e X I I - D e t a i l s f o r C a n a d i a n , C h i n e s e and E a s t I n d i a n m o t h e r s , t h e numbers and p e r c e n t s o f i n f a n t s f a l l i n g i n t o e a c h c a t e g o r y . I t can be s e e n t h a t t h e o v e r a l l p e r c e n t a g e o f i n f a n t s c l a s s i f i e d s m a l l f o r g e s t a t i o n a l age i s 44%. T a b l e X I I I c l a s s i f i e s t h e s e i n f a n t s as t e r m o r p r e t e r m . I t c a n be s e e n t h a t 62% a r e p r e t e r m . F i v e o f t h e i n f a n t s were b o t h s m a l l f o r g e s t a t i o n a l age and p r e m a t u r e ( 5 . 7 % ) . C o m p a r i s i o n o f S e l e c t e d F a c t o r s f o r M o t h e r s o f  A p p r o p r i a t e f o r G e s t a t i o n a l Age and  S m a l l f o r G e s t a t i o n a l Age I n f a n t s . T a b l e XIV - No s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e s a r e f o u n d f o r any f a c t o r w i t h t h e e x c e p t i o n o f a t t e n d a n c e a t non VHD p r i v a t e c l a s s e s ( c h i s q u a r e = 7 . 9 4 ) . Why SGA m o t h e r s i n t h i s sample d i f f e r f r o m AGA m o t h e r s i s unknown. 74> Some d i f f e r e n c e s as r e p o r t e d a r e o f i n t e r e s t . More AGA m o t h e r s f a i l e d t o g a i n 251b d u r i n g p r e g n a n c y , a f i n d i n g t h a t w o u l d be e x p e c t e d due t o t h e number o f p r e m a t u r e b i r t h s i n t h i s g r o u p . P r e v i o u s Low B i r t h W e i g h t i s a l s o more common i n t h i s g r o u p - p e r h a p s showing a t e n d e n c y f o r r e p e a t e d p r e m a t u r i t y . The p e r c e n t a g e o f m o t h e r s o f SGA i n f a n t s who had no l i v e i n s u p p o r t i s 30%, o f AGA m o t h e r s 11.1%. 80% o f a l l m o t h e r s r e p o r t i n g S o c i a l A s s i s t a n c e s t a t u s a r e f o u n d i n t h e SGA m a t e r n a l g r o u p . S e l e c t e d F a c t o r C o m p a r i s o n Between M o t h e r s o f SGA I n f a n t s and  M o t h e r s o f Non Low B i r t h W e i g h t I n f a n t s ( C a n a d i a n ) S i n g l e s t a t u s i s a s t a t i s t i c a l l y s i g n i f i c a n t v a r i a n t between t h e s e two g r o u p s , b e i n g a r e c i p i e n t o f S o c i a l A s s i s t a n c e a p p r o a c h e s a s i g n i f i c a n c e l e v e l o f .05. O t h e r f a c t o r s o f i n t e r e s t a r e : -low p r e g n a n c y w e i g h t g a i n , p r e s e n t i n 35% o f SGA m o t h e r s v s 20.5% c o n t r o l s ; - c l o s e i n t e r p r e g n a n c y i n t e r v a l p r e s e n t i n 15% o f SGA m o t h e r s vs 10.25% c o n t r o l s ; - t o b a c c o c o n s u m p t i o n p r e s e n t i n 45% o f SGA m o t h e r s v s 25.6% c o n t r o l s ; - a l c o h o l c o n s u m p t i o n p r e s e n t i n 15% o f SGA m o t h e r s v s 10.25% c o n t r o l s . Fig. II E t b M c i t y : Canadian. Under 2501 .gm. 77 G r a m 5 0 0 0 4 7 5 0 4 5 0 0 4 2 5 0 4 0 0 0 3 7 5 0 3 5 0 0 3 2 5 0 3 0 0 0 2 7 5 0 2 5 0 0 2 2 5 0 2 0 0 0 1 7 5 0 1 5 0 0 1 2 5 0 1 0 0 0 7 5 0 5 0 0 C l a s s i f i c a t i o n o f n e w b o r n s by bir th w e i g h t a n d g e s t a t i o n a g e 'Of •/. 1 y i 'I il / • - 1 r -10th % 1 t 7 , >* c i r \ c st* < V 4 ? f V J < r ^ f C 3 : • -c \ CN CN CN ( N CN n ^ n n ro n ro n n n ^ ^ ^ ^ ^ W e e k s of q e s t a t i o n P r e t e r m T e r m P o s t t e r m F i g . I l l Et h i n i c i t y : Chinese. Under 2501 gm. 7 8 G r a m s 5 0 0 0 4 7 5 0 4 5 0 0 4 2 5 0 4 0 0 0 3 7 5 0 3 5 0 0 3 2 5 0 3 0 0 0 2 7 5 0 2 5 0 0 2 2 5 0 2 0 0 0 1 7 5 0 1 5 0 0 1 2 5 0 1 0 0 0 7 5 0 5 0 0 C l a s s i f i c a t i o n o f n e w b o r n s by b i r th w e i g h t a n d g e s t a t i o n a g e -V. -— y u r n _ ! ' • -~ 1 10 th V. I v s * ens 3 & -; » ^ > ) ; c. > -, -4 - „ 1 - i io O K co O O — ro "V u~)vO N. co O O '— CN n o W e e k s of g e s t a t i o n P r e t e r m j T e r m | P o s t t e r m G r a m 5 0 0 0 4 7 5 0 4 5 0 0 4 2 5 0 4 0 0 0 3 7 5 0 3 5 0 0 3 2 5 0 3 0 0 0 2 7 5 0 2 5 0 0 2 2 5 0 2 0 0 0 1 7 5 0 1 5 0 0 1 2 5 0 1 0 0 0 7 5 0 5 0 0 F i g . IV. E t h n i c i t y : E a s t I n d i a n . Under 2501 gm. C l a s s i f i c a t i o n o f n e w b o r n s by b i r th w e i g h t a n d g e s t a t i o n a 7<? r h V . T VJ 1 I 1 / • -Y / i—• 1 0 t h % t / : / c c * / % •* r' > > f b f ** \ • — — ' v -* t > -•— - X 7 L O - O K C O O O — CN-n^fiO'OKcoOO^'NnijiO'O W e e k s of g e s t a t i o n P r e t e r m T e r m P o s t t e r m TABLE XVIII Under 2501gm Infants Subgrouped by Weight and Maternal E t h n i c i t y . ETHNICITY 500 -# 1000gm % 1001 # - 1500gm % 1501 # - 2500gm % Canadian 1 2 4 8.2 44 89.8 Chinese - - 1 7.1 13 92.9 East Indian 3 13 4 17.4 16 69.6 30% of East Indian i n f a n t s of low b i r t h weight are under 1500gm. Chi = 4.23. A s t a t i s t i c a l l y s i g n i f i c a n t f i n d i n g (p=<.05). 87 FIGURES I I , I I I & IV show under 2501gm i n f a n t s f r o m t h e 3 major e t h n i c g r o u p s by b i r t h w e i g h t and g e s t a t i o n a l age. As t h e l i t e r a t u r e r e v i e w showed, t h e r e a r e d i f f e r e n t p r o g n o s e s f o r d i f f e r e n t r a n g e s o f b i r t h w e i g h t . 500-1000gm, 1001-1500gm and 1501-2500gm. The numbers and p r o p o r t i o n s o f i n f a n t s o f t h e t h r e e main e t h n i c g r o u p s f a l l i n g i n t o e a c h c a t e g o r y a r e shown i n T a b l e X V I I I . I n R e g a r d t o H y p o t h e s i s I T h a t m o t h e r s o f low b i r t h w e i g h t i n f a n t s have a d i f f e r e n t b i o m e d i c a l p r o f i l e t o m o t h e r s o f non low b i r t h w e i g h t i n f a n t s . ( T a b l e s I I I , IV and V) S i g n i f i c a n t d i f f e r e n c e s were f o u n d between c a s e and c o n t r o l m o t h e r s i n f i v e o f t h e n i n e a r e a s . T h e s e were: I n t e r c u r r e n t i l l n e s s - c h i square=4.2 C o m p l i c a t i o n o f p r e g n a n c y - c h i square=6.4 P r e m a t u r i t y - c h i square=34.1 P r e g n a n c y w e i g h t g a i n - c h i square=15.02 P r e v i o u s m i s c a r r i a g e , a b o r t i o n o r s t i l l b i r t h - c h i square=4.5 No s i g n i f i c a n t d i f f e r e n c e s were f o u n d f o r m a t e r n a l age, p a r i t y , p r e v i o u s low b i r t h w e i g h t o r c l o s e i n t e r p r e g n a n c y i n t e r v a l . P r e v i o u s low b i r t h w e i g h t a p p r o a c h e d s i g n i f i c a n c e when o n l y m u l t i p a r o u s women were c o n s i d e r e d ( c h i s q u a r e = 2 . 8 5 ) . C l o s e i n t e r p r e g n a n c y i n t e r v a l a p p r o a c h e d s i g n i f i c a n c e f o r C h i n e s e and Indo C a n a d i a n women ( c h i s q u a r e = 3 . 5 7 ) . I n R e g a r d t o H y p o t h e s i s I I T h a t m o t h e r s o f low b i r t h w e i g h t i n f a n t s have a d i f f e r e n t s o c i o d e m o g r a p h i c p r o f i l e t o m o t h e r s o f non low b i r t h w e i g h t i n f a n t s . (See T a b l e s I I I , V I I , X I , XIV and XV) 8* No s i g n i f i c a n t d i f f e r e n c e s were f o u n d b u t some t r e n d s and o b s e r v a t i o n s were n o t e d . Low b i r t h w e i g h t i s a s s o c i a t e d w i t h r e s i d e n c e i n t h e E a s t e r n p a r t o f t h e c i t y . M o t h e r s o f I n d i a n o r i g i n were o v e r r e p r e s e n t e d , t h e r e i s a s t r o n g s u g g e s t i o n t h a t l a c k o f s u p p o r t ( d e f i n e d as no l i v e i n p a r t n e r ) and b e i n g a r e c i p i e n t o f s o c i a l a s s i s t a n c e , ( b o t h f a c t o r s c o n f i n e d t o C a n a d i a n m o t h e r s ) a r e a s s o c i a t e d w i t h t h e b i r t h o f s m a l l f o r g e s t a t i o n a l age i n f a n t s . 30% o f m o t h e r s o f SGA i n f a n t s v s 1 1 . 1 % o f m o t h e r s o f AGA i n f a n t s l a c k e d s u p p o r t . 80% o f a l l m o t h e r s o f l o w b i r t h w e i g h t i n f a n t s on s o c i a l a s s i s t a n c e a r e f o u n d i n t h e g r o u p o f m o t h e r s d e l i v e r i n g s m a l l f o r g e s t a t i o n a l age i n f a n t s . The m a j o r i t y o f m o t h e r s o f C h i n e s e and I n d i a n o r i g i n s were r a t e d good o r f a i r i n E n g l i s h c o m p r e h e n s i o n . No s i g n i f i c a n t d i f f e r e n c e s b e t w e e n c a s e and c o n t r o l were f o u n d . I n R e g a r d t o H y p o t h e s i s I I I T h a t m o t h e r s o f l o w b i r t h w e i g h t i n f a n t s h a v e a h i g h e r p r e v a l e n c e o f p o t e n t i a l l y a l t e r a b l e b e h a v i o u r a l t r a i t s t h a t h a v e b e e n a s s o c i a t e d w i t h l o w b i r t h w e i g h t , t h a n do m o t h e r s o f non l o w b i r t h w e i g h t i n f a n t s . (See T a b l e s I I I , V, V I , V I I I , X I V and XV) S i g n i f i c a n t d i f f e r e n c e s b e t w e e n c a s e and c o n t r o l m o t h e r s were f o u n d f o r : w e i g h t g a i n l e s s t h a n 251b - ( c h i s q u a r e = 1 5 . 0 2 ) t o b a c c o s m o k i n g - ( c h i s q u a r e = 3 . 8 5 ) 8"/ F a i l u r e t o g a i n 251b i s c o r r e l a t e d w i t h s h o r t e n e d p r e g n a n c y . S i g n i f i c a n t d i f f e r e n c e s i n f a i l u r e t o g a i n 251b a r e f o u n d between A p p r o p r i a t e f o r G e s t a t i o n a l Age (AGA) low b i r t h w e i g h t m o t h e r s and S m a l l f o r G e s t a t i o n a l Age (SGA) low b i r t h w e i g h t m o t h e r s ( c h i square=3.86) and AGA low b i r t h w e i g h t m o t h e r s and non low b i r t h w e i g h t m o t h e r s ( c h i s q u a r e = 8 . 6 7 ) . T o b a c c o smoking i s c o n f i n e d t o C a n a d i a n m o t h e r s and i s t w i c e as p r e v a l e n t among m o t h e r s o f SGA i n f a n t s as among m o t h e r s o f AGA i n f a n t s . C l o s e i n t e r p r e g n a n c y i n t e r v a l a p p r o a c h e s s i g n i f i c a n c e f o r C h i n e s e m o t h e r s o f low b i r t h w e i g h t i n f a n t s ( c h i s q u a r e = 2 . 8 5 ) . No d i f f e r e n c e i n a l c o h o l use i s f o u n d between c a s e and c o n t r o l C a n a d i a n m o t h e r s . A l c o h o l u s a g e i s more p r e v a l e n t among C a n a d i a n m o t h e r s i n t h e s u r v e y t h a n among m o t h e r s o f C h i n e s e o r I n d i a n o r i g i n . P h y s i c i a n C a r e M o t h e r s o f low b i r t h w e i g h t i n f a n t s r e c a l l f e wer p h y s i c i a n v i s i t s . T h i s i s p r o b a b l y due t o s h o r t e n e d g e s t a t i o n among t h i s g r o u p . M o t h e r s o f C h i n e s e and I n d i a n o r i g i n i n c a s e and c o n t r o l g r o u p s r e c a l l e d s i g n i f i c a n t l y fewer p h y s i c i a n v i s i t s t h a n d i d m o t h e r s o f C a n a d i a n o r i g i n . P r e n a t a l C l a s s A t t e n d a n c e Non low b i r t h w e i g h t C a n a d i a n m o t h e r s e x h i b i t a t r e n d ( c h i square=3.35) tow a r d s more p r e n a t a l c l a s s a t t e n d a n c e t h a n do C a n a d i a n m o t h e r s o f low b i r t h w e i g h t i n f a n t s . T h e r e i s no s t a t i s t i c a l d i f f e r e n c e between C h i n e s e low b i r t h w e i g h t and non low b i r t h w e i g h t i n a t t e n d a n c e a t P r e n a t a l (P.N.) c l a s s e s nor i s t h e r e any s t a t i s t i c a l d i f f e r e n c e i n t h i s sample between C h i n e s e and C a n a d i a n s i n P r e n a t a l (P.N.) a t t e n d a n c e . T h e r e a r e h i g h l y s i g n i f i c a n t d i f f e r e n c e s between C a n a d i a n and Indo C a n a d i a n m o t h e r s i n p r e n a t a l c l a s s a t t e n d a n c e ( c h i square=19.9) and C h i n e s e and Indo C a n a d i a n p r e n a t a l c l a s s a t t e n d a n c e ( c h i s q u a r e = 7 . 5 3 ) . A n a l y s i s o f Low B i r t h W e i g h t by D e v e l o p m e n t and G e s t a t i o n (See  T a b l e s X I I and X I I I ) F o r t y - f o u r p e r c e n t o f t h e low b i r t h w e i g h t i n f a n t s were a d j u d g e d S m a l l f o r G e s t a t i o n a l Age on t h e L u b c h e n c o S c a l e . 5.7% were b o t h SGA and p r e m a t u r e , 66% o f low b i r t h w e i g h t i n f a n t s were p r e m a t u r e , 30% o f p r e m a t u r e d e l i v e r i e s c o u l d be a t t r i b u t e d t o some m e d i c a l c o m p l i c a t i o n o f p r e g n a n c y . The r e a s o n s f o r p r e m a t u r i t y i n t h e r e m a i n i n g 70% a r e u n c l e a r , b u t may be a s s o c i a t e d w i t h p o o r d i e t , t o b a c c o u s a g e , low income and l a c k o f s u p p o r t . Low b i r t h w e i g h t E a s t I n d i a n i n f a n t s i n t h i s sample a r e l i k e l y t o b e a r a h i g h e r b u r d e n o f m o r b i d i t y , and r e q u i r e e x t r a c a r e as 30% were be l o w a b i r t h w e i g h t o f 1500gm. Summary o f F i n d i n g s M o t h e r s who d e l i v e r e d low b i r t h w e i g h t i n f a n t s were: 1) More l i k e l y t o have had a p r e m a t u r e d e l i v e r y ; 2) More l i k e l y t o have had a m e d i c a l p r o b l e m d u r i n g p r e g n a n c y ; ?6> 3) More l i k e l y t o have had an o b s t e t r i c c o m p l i c a t i o n d u r i n g p r e g n a n c y ; 4) L e s s l i k e l y t o have g a i n e d 251b d u r i n g t h e p r e g n a n c y ; 5) More l i k e l y t o have had a p r e v i o u s poor p r e g n a n c y outcome; 6) E q u a l l y as l i k e l y t o be m u l t i g r a v i d as t o be p r i m i g r a v i d ; 7) More l i k e l y ( i f C a n a d i a n ) t o be c i g a r e t t e smokers; 8) L e s s l i k e l y t o a t t e n d p r e n a t a l c l a s s e s . Low B i r t h W e i g h t i s a s s o c i a t e d w i t h r e s i d e n c e i n t h e E a s t s i d e o f t h e c i t y . I n d i a n m o t h e r s a p p e a r t o be o v e r r e p r e s e n t e d , C h i n e s e m o t h e r s may be under r e p r e s e n t e d among t h e low b i r t h w e i g h t g r o u p s . C e r t a i n " E t h n i c " m o t h e r s do n o t a t t e n d p r e n a t a l c l a s s e s and v i s i t t h e i r p h y s i c i a n s l e s s f r e q u e n t l y t h a n C a n a d i a n m o t h e r s . In g e n e r a l t h e e t h n i c m o t h e r s a r e l e s s a t r i s k f r o m s i n g l e s t a t u s , a l c o h o l or t o b a c c o t h a n a r e C a n a d i a n m o t h e r s , b u t more a t r i s k f r o m c l o s e l y s p a c e d p r e g n a n c i e s . £7 R e l a t i v e R i s k f o r Low B i r t h W e i g h t From t h e s e d a t a i t i s p o s s i b l e t o c a l c u l a t e an a p p r o x i m a t i o n o f R e l a t i v e R i s k s f o r l o w b i r t h w e i g h t as a p r e g n a n c y o u t c o m e f o r c e r t a i n a n t e c e d e n t f a c t o r s . The method u s e d i s t h a t d e s c r i b e d b y MacMahon and Pugh* and i n v o l v e s t h r e e a s s u m p t i o n s : 1) t h a t t h e outcome u n d e r s t u d y i s r e l a t i v e l y i n f r e q u e n t i n b o t h e x p o s e d and non e x p o s e d p o p u l a t i o n s ; 2) t h a t n e i t h e r c a s e n o r c o n t r o l s a r e s e l e c t e d i n f a v o u r o f e i t h e r e x p o s e d o r non e x p o s e d i n d i v i d u a l s ; and 3) t h a t t h e c o n t r o l s a r e t r u l y r e p r e s e n t a t i v e o f t h e w h o l e p o p u l a t i o n . C a l c u l a t i o n o f R e l a t i v e R i s k S u s p e c t e d C a u s e C a s e C o n t r o l P r e s e n t a' b' A b s e n t c' d' TOTAL a'+c' b'+d' R e l a t i v e R i s k = a'd' c'b' a ' , b ' , c 1 & d' a r e s a m p l e s o f c a s e s and c o n t r o l s and a r e t h e numbers o f i n d i v i d u a l s i n e a c h c e l l . * E p i d e m i o l o g y : P r i n c i p l e s & M e t h o d s . B r i a n MacMahon & Thomas Pugh. L i t t l e , Brown & Co. B o s t o n 1970 page 268-273 C a l c u l a t i o n o f R e l a t i v e R i s k f o r Low B i r t h W e i g h t When P r e v i o u s  M i s c a r r i a g e , A b o r t i o n o r S t i l l B i r t h i s A n t e c e d e n t F a c t o r C a n a d i a n , E a s t I n d i a n and C h i n e s e M o t h e r s Combined S u s p e c t e d Cause C a s e s C o n t r o l s ( P r e v . Poor Outcome) (LBW) (Non LBW) P r e s e n t 36 17 A b s e n t 44 51 TOTAL 80 68 R e l a t i v e R i s k = 36x51/44x17=1836/748=2.45 TABLE XIX R i s k F a c t o r f o r Low B i r t h W e i g h t and R e l a t i v e R i s k RISK FACTOR RELATIVE RISK Previous Low B i r t h Weight 3.45 Interpregnancy Int e r v a l l e s s than 12 months 2.40 No Live In Support (Canadian Only) 4.03 Smoking Less Than One Pack Per Day (Canadian and Chinese) 2.94 Smoking More Than One Pack Per Day (Canadian Only) 3.80 F a i l u r e to Gain 25 lbs During Pregnancy 4.45 Lack of Prenatal Classes (Canadian) 2.00 E t h n i c i t y East Indian 2.20 E t h n i c i t y Canadian 1.30 E t h n i c i t y Chinese 0.70 9o CHAPTER V ETHNICITY AND LOW BIRTH WEIGHT - EAST INDIAN T h i s s i x month s u r v e y r e v e a l e d an ' e x c e s s ' o f l o w b i r t h w e i g h t among ' E a s t I n d i a n ' m o t h e r s . T h i s e x c e s s a p p r o a c h e s s t a t i s t i c a l s i g n i f i c a n c e ( c h i s q u a r e d f l = 3 . 0 9 9 ) . A p r e v i o u s u n p u b l i s h e d s u r v e y o f a l l b i r t h s i n V a n c o u v e r ' s E a s t H e a l t h U n i t r e v e a l e d t h a t w h i l e '-East I n d i a n ' m o t h e r s (as d e f i n e d b y m a t e r n a l surname) c o m p r i s e d o n l y 17% o f t h e t o t a l m a t e r n a l p o p u l a t i o n , t h e y p r o d u c e d 30% o f t h e Low B i r t h W e i g h t i n f a n t s b o r n i n t h e s t u d y p e r i o d . T h i s s u g g e s t s t h a t Low B i r t h W e i g h t as an outcome i s more p r o b a b l e f o r E a s t I n d i a n m o t h e r s , t h a n m o t h e r s o f o t h e r e t h n i c g r o u p s . On t h e I n d i a n s u b c o n t i n e n t i n t h e 1 9 7 0 ' s Low B i r t h W e i g h t b a b i e s c o n s t i t u t e d one t h i r d o f t o t a l b i r t h s and had 8-10 t i m e s h i g h e r p e r i n a t a l and n e o n a t a l m o r t a l i t y r a t e s . [ 1 , 2 , 3 , 4 , 5 ] . I t i s s u g g e s t e d t h a t s i m i l a r l y t o N o r t h A m e r i c a n Low B i r t h W e i g h t b a b i e s , t h e s u r v i v o r s h a v e h i g h e r m o r b i d i t y r a t e s t h a n o v e r 2500 gm i n f a n t s , a t l e a s t f o r t h e f i v e y e a r s o v e r w h i c h t h e y h a v e b e e n s t u d i e d . [ 6 ] As w i t h W e s t e r n p o p u l a t i o n s d e c r e a s i n g m a t e r n a l a g e , p r i m i p a r i t y , p r e v i o u s f e t a l l o s s , t o x a e m i a , a n a e m i a and a n t e p a r t u m h a e m o r r h a g e c o n t r i b u t e s i g n i f i c a n t l y t o Low B i r t h W e i g h t as an o u t c o m e . [ 1 ] One a u t h o r , B a n e r j e e , [7] h a s d e m o n s t r a t e d t h a t t h e e c o n o m i c p o s i t i o n o f t h e m o t h e r i s a more s i g n i f i c a n t v a r i a n t t h a n i n f a n t s e x , b i r t h o r d e r o r m a t e r n a l a g e . 91 I n d i a n m o t h e r s i n S o u t h A f r i c a a r e r e p o r t e d as h a v i n g a h i g h e r Low B i r t h W e i g h t r a t e t h a n E u r o p e a n , m i x e d o r B a n t u p o p u l a t i o n s [ 8 ] , b u t o n l y h a l f o f t h a t p e r t a i n i n g i n C a l c u t t a . [9] I n d i a n m o t h e r s o f s o c i a l c l a s s IV and V i n Bi r m i n g h a m , E n g l a n d a r e a t added r i s k f o r Low B i r t h W e i g h t h i g h s t i l l b i r t h and h i g h p e r i n a t a l m o r t a l i t y r a t e s . [10] The a u t h o r s o f t h i s r e p o r t s p e c u l a t e t h a t d i e t a r y and c u l t u r a l d i f f e r e n c e s and t h e p r e v a l e n c e o f m a t e r n a l d i s e a s e s may be i m p o r t a n t c o n t r i b u t a r y f a c t o r s . A n a l y s i s o f t h e b i r t h w e i g h t s o f 2798 l i v e b o r n I n d i a n i n f a n t s i n S i n g a p o r e [ 1 1 ] showed t h a t between 34 and 42 weeks t h e mean b i r t h w e i g h t s f o r I n d i a n b a b i e s were s i g n i f i c a n t l y l e s s t h a n t h o s e S i n g a p o r e C h i n e s e , S i n g a p o r e M a l a y and B r i t i s h C a u c a s i a n i n f a n t s . I c o n c l u d e f r o m t h e a v a i l a b l e i n f o r m a t i o n t h a t w h i l e I n d i a n i n f a n t s may t e n d t o be s m a l l e r i n g e n e r a l t h a n i n f a n t s from o t h e r e t h n i c b a c k g r o u n d s , s o c i o e c o n o m i c v a r i a b l e s and m a t e r n a l b e h a v i o u r s a r e i m p o r t a n t a n t e c e d e n t s f o r Low B i r t h W e i g h t i n t h i s e t h n i c p o p u l a t i o n . T h i s c o n c l u s i o n i s s u p p o r t e d by t h e f i n d i n g s o f C l a r k s o n e t a l , r e p o r t i n g on A s i a n b a b i e s b o r n i n B i r m i n g h a m , E n g l a n d . They c o n c l u d e t h a t l o w e r b i r t h w e i g h t s a r e u n l i k e l y t o be due t o g e n e t i c f a c t o r s , t h a t i n t e r n a t i o n a l r e f e r e n c e d a t a be u s e d i n g r o w t h c o m p a r i s o n s t u d i e s and t h a t t h e b e s t way o f i n c r e a s i n g A s i a n b i r t h w e i g h t s i s t o c o n s i d e r i m p r o v i n g t h e p r e p r e g n a n t and i n t r a p r e g n a n c y e n v i r o n m e n t s . [ 1 2 ] LOW BIRTH WEIGHT AND ETHNICITY-CHINESE The t h i r d l a r g e s t e t h n i c g r o u p i n t h e s u r v e y were C h i n e s e m o t h e r s who c o m p r i s e d 16% o f t h e t o t a l . T h e i r c a s e / c o n t r o l r a t i o s u g g e s t s a l o w e r i n c i d e n c e o f Low B i r t h W e i g h t , a l t h o u g h as t h e t o t a l number o f C h i n e s e b i r t h s d u r i n g t h e p e r i o d i s unknown, t h i s r e m a i n s a s u p p o s i t i o n . I t i s b o r n e o u t by a p r e v i o u s u n p u b l i s h e d s u r v e y o f t o t a l Low B i r t h W e i g h t m o t h e r s i n E a s t H e a l t h U n i t a r e a d u r i n g t h e p e r i o d September 1 s t , 1979 to A u g u s t 3 1 s t , 1980. C h i n e s e m o t h e r s p r o d u c e d 15% o f a l l Low B i r t h W eight i n f a n t s b u t c o m p r i s e d 24.6% o f t h e u n i t m a t e r n a l p o p u l a t i o n . The b u l k o f V a n c o u v e r C h i n e s e come f r o m s o u t h e a s t C h i n a and Hong Kong; t h e i r i n f a n t s have been f o u n d t o h a v e mean b i r t h w e i g h t s 190gm l e s s t h a n non C h i n e s e . [13] In S i n g a p o r e , C h i n e s e i n f a n t s a t 40 weeks g e s t a t i o n had mean b i r t h w e i g h t s 235gm l e s s t h a n B r i t i s h C a u c a s i a n i n f a n t s o f s i m i l a r d a t e s . [14] I t has been s u g g e s t e d t h a t t h i s mean b i r t h w e i g h t d i f f e r e n c e c o u l d be a t t r i b u t e d to m a t e r n a l h e i g h t , C h i n e s e women b e i n g i n g e n e r a l s h o r t e r t h a n non C h i n e s e . I n H a w a i i , however, C h i n e s e and C a u c a s i a n s have v i r t u a l l y i d e n t i c a l r a t e s o f Low B i r t h W e i g h t . [15] Low B i r t h W e i g h t r a t e s i n S h a n g h a i and Hong Kong i n t h e e a r l y 70's a r e r e p o r t e d a r o u n d 4.7%. [16] R a t e s a r e r e p o r t e d t o be e v e n l o w e r i n P e k i n g . [17] W i t h i n M a i n l a n d C h i n a t h i s may be a t t r i b u t e d t o fewer m u l t i p l e b i r t h s , r a r i t y o f t e e n a g e p r e g n a n c y and a low i n c i d e n c e o f h y p e r t e n s i v e d i s o r d e r s and c o n g e n i t a l m a l f o r m a t i o n s . [16] 9S T h e r e i s a l s o some e v i d e n c e t h a t t h e p a t t e r n o f f e t a l growth i n C h i n e s e p o p u l a t i o n s d i f f e r s f r o m t h a t i n C a u c a s i a n s . E a r l y f e t a l g r o w t h i s more r a p i d [18,19] and t e r m b a b i e s a r e r e l a t i v e l y s m a l l e r . [19,20] C h a l m e r s a l s o i n t r o d u c e s e v i d e n c e t h a t improved n u t r i t i o n , s a n i t a t i o n and h y g i e n e have p l a y e d a l a r g e r o l e i n l o w e r i n g t h e i n c i d e n c e o f Low B i r t h W e i g h t i n C h i n e s e women i n C h i n a . [16] 9H BIBLIOGRAPHY  E t h n i c i t y and Low B i r t h W e i g h t 1 B h a r g a v a , S . K . , B a r g a v a , V . , K u m a r i , S . , Madhavan,S., Ghosh,S.: B i r t h W e i g h t , G e s t a t i o n a l Age and M a t e r n a l F a c t o r s i n L.B.W.Babies I n d i a n P a e d . 1 0 . 1 6 1 , 1973. 2 G u p t a , S . , S r i v a s t a v a , G . , B e r r y , A . M . , and K h a t r i , R . L . : M o r t a l i t y i n LBW B a b i e s , P a e d . C h i n . I n d i a n 4.331, 1969. 3 Bhakoo,O.N., N a r a n g , A . , K u l k a r n i , K . N . , P a t i l , A . S . , B a n e r j e e , C . K . , W a l i a , B . N . S . : N e o n a t a l m o r t a l i t y and m o r b i d i t y i n h o s p i t a l b o r n b a b i e s 1 1 , 4 4 3 , 1975. 4 T h i r i u p a r a m , S . and G u p t a , S . : A s t u d y o f p e r i n a t a l and n e o n a t a l f a c t o r s i n r e l a t i o n t o p e r i n a t a l m o r t a l i t y I n d i a n P aed. 1 5 : 3 1 1 , 1978. 5 G u p t a , S . , C h u p r a , K . , P r a m a n i c k , A . : P e r i n a t a l and n e o n a t a l m o r t a l i t y and m o r b i d i t y i n h o s p i t a l b o r n b a b i e s . I n d i a n P a e d . 9.580 1972. 6 ' B h a r g a v a , S . K . , B a n e r j e e , S . K . , C h o v d h u r y , P . , K u m a r i , S . : A l o n g i t u d i n a l s t u d y o f m o r b i d i t y and m o r t a l i t y p a t t e r n f r o m b i r t h t o 6 y e a r s o f age i n i n f a n t s o f v a r y i n g b i r t h w e i g h t . I n d i a n P a e d . V o l . X V I p.976 No.11 Nov.1979. 7 B a n e r j e e , P . : B i r t h w e i g h t o f t h e B e n g a l i n e w b o r n ; e f f e c t o f t h e e c o n o m i c p o s i t i o n o f t h e m o t h e r Ann. Hum. Gen. 33:99 8 S a l b e r , E . J . , B r a d s h a w , E . S . : B i r t h w e i g h t s o f S o u t h A f r i c a n B a b i e s B r i t . J . S o c i a l M e d i c i n e 5:113-119 1 9 5 1 . 9 A b r a m o w i c z , M . , K a s s , E . H . : P a t h o g e n e s i s and P r o g n o s i s o f P r e m a t u r i t y N.E.J.M. V o l . 275 no 16. p . 8 8 0 , 1966. 10 T e r r y , P . B . , C o n d i e , R . G . , S e m a t r e e , R . S . : A n a l y s i s o f E t h n i c D i f f e r e n c e s i n P e r i n a t a l S t a t i s t i c s B.M.J. V o l . 281 15 Nov. 1980 p . 1 3 0 7 - 1 3 0 8 . 95 11 Cheng,C.E.M., Chew,P.C.T., Ratnam,S.S.: B i r t h w e i g h t D i s t r i b u t i o n o f S i n g a p o r e C h i n e s e , M a l a y and I n d i a n I n f a n t s f r o m 34 weeks t o 42 weeks G e s t a t i o n . The J . o f O b s t e t . and G y n e c o l , o f t h e B r . Commonwealth F e b . 1972, V o l . 79 p.p. 149-153. 12 C l a r k s o n , C . L . , B a r k e r , M . J . , M a r s h a l l , T . , Wharton,P.A.: S e c u l a r c h ange i n B i r t h W e i g h t o f A s i a n b a b i e s b o r n i n B i r m i n g h a m . A r c h . D i s . C h i l d . 1982 57:857-861. 13 B e l l , M i c h a e l : " C h i n e s e C a n a d i a n s Low on H i p T r o u b l e " r e p o r t e d i n t h e M e d i c a l P o s t A p r i l 20, 1982 p.8. 14 Cheng,M.C.E., Chen,P.C.T., and Ratnam,S.S.: B i r t h w e i g h t d i s t r i b u t i o n o f S i n g a p o r e C h i n e s e , M a l a y and I n d i a n I n f a n t s f r o m 34-42 weeks g e s t a t i o n . The J . o f O b s t . and G y n e c o l , o f t h e B r . Commonwealth F e b r u a r y 1972, V o l . 79 pp 149-153 15 B e n n e t t , C . G . , L o v i s , L . S . : Demographic F a c t o r s i n f l u e n c i n g b i r t h w e i g h t . H a w a i i M.J. 18:239-244 1959. 16 C h a l m e r s , I . S h a n g h a i - B e t t e r P e r i n a t a l H e a l t h a s u r v e y f r o m t h e L a n c e t 1980. 17 Lubic,R.W.: O b s e r v a t i o n s on M a t e r n i t y C a r e i n R e p o r t o f t h e M e d i c a l D e l e g a t i o n t o t h e P e o p l e s R e p u b l i c o f C h i n a W a s h i n g t o n , D . C , N a t . A c a d . S c i . 1973 124-35. 18 Ip,H,M.H.: I n t r a u t e r i n e g r o w t h i n Hong Kong C h i n e s e B i o l . N eonate 1978 33 253-63. 19 L i n , C C , Emmanuel, I .A. : C o m p a r i s o n s o f A m e r i c a n and C h i n e s e i n t r a u t e r i n e g r o w t h s s t a n d a r d s . A r e A m e r i c a n b a b i e s r e a l l y s m a l l e r ? Am.J. E p i d e m i a l 1972 95 418-29. 20 Chun,D., Kan,P.S., Wong,CP.: The Hong Kong C h i n e s e The p e l v i s and i t s i n f l u e n c e on l a b o r J . O b s t . and Gyn. B r . Commonwealth 1974 71 556-64. CHAPTER V I DEMOGRAPHY, PERINATAL HEALTH AND PUBLIC HEALTH SERVICES IN VANCOUVER DEMOGRAPHY V a n c o u v e r i s a c i t y o f 414,281 i n h a b i t a n t s (1981 C e n s u s ) , s i t u a t e d i n t h e P a c i f i c N o r t h w e s t o f t h e A m e r i c a n C o n t i n e n t . The h i g h e s t p a r t o f t h e c i t y r i s e s 410 f e e t a b o v e s e a l e v e l . A p p r o x i m a t e l y 4.5 t h o u s a n d l i v e b i r t h s a r e r e g i s t e r e d a n n u a l l y ( 1 9 8 1 : 4 , 5 8 1 ) . The P e r i n a t a l M o r t a l i t y R a t e and Low B i r t h W e i g h t R a t e s f o r 1978 t o 1982 a r e : S o u r c e : B.C. M i n i s t r y o f H e a l t h D i v i s i o n o f V i t a l S t a t i s t i c s u n p u b l i s h e d d a t a . TABLE I VANCOUVER: PERINATAL MORTALITY RATES AND LOW BIRTH WEIGHT RATES 19 7 8 - 1 9 8 2 . P.N.M.R. L.B.W. 1978 1979 1980 1981 1982 11.3 14.8 12.0 17. 2 13.4 6.6 5.9 5.6 5.9 5.2 97 The m a t e r n a l p o p u l a t i o n o f V a n c o u v e r i s c h a n g i n g as t h e c i t y ' s p o p u l a t i o n c h a n g e s . The i m m i g r a t i o n o f f a m i l i e s w i t h E n g l i s h as a s e c o n d l a n g u a g e , o v e r t h e p a s t 15 y e a r s , i s a p p a r e n t f r o m c i t y c e n s u s d a t a 1971 and 1976. [1] In some a r e a s o f t h e c i t y t h e p e r c e n t a g e o f f a m i l i e s w i t h C h i n e s e , H i n d i o r P u n j a b i as a f i r s t l a n g u a g e , d o u b l e d i n t h a t f i v e y e a r p e r i o d . O t h e r l a n g u a g e s i . e . T a g a l o g , V i e t n a m e s e , T h a i and L a o t i a n a r e s p o k e n b y s m a l l e r b u t s t i l l s i g n i f i c a n t l y s i z e d g r o u p s . The p r e p o n d e r a n c e o f E n g l i s h as a s e c o n d l a n g u a g e among t h e r e p r o d u c t i v e p o p u l a t i o n i s e m p h a s i z e d by t h e f i n d i n g t h a t w h i l e o v e r a l l , t h e p o p u l a t i o n o f E a s t H e a l t h U n i t i s 63.5% E n g l i s h mother t o n g u e , i t i s o n l y 41% i n t h e m a t e r n a l p o p u l a t i o n . [2] T h e s e l o c a l s u r v e y s a r e c o r r o b o r a t e d by t h e f i n d i n g s o f th e V a n c o u v e r S c h o o l B o a r d t h a t i n 1982, 46.5% o f t h e c i t y ' s s c h o o l c h i l d r e n had a l a n g u a g e o t h e r t h a n E n g l i s h as t h e i r f i r s t l a n g u a g e . Two h e a l t h u n i t s , E a s t and S o u t h , have a n a l y z e d t h e i r m a t e r n a l p o p u l a t i o n s b y e t h n i c i t y [2,3] f o r 1980. (See T a b l e I I ) 9 * TABLE I I MATERNAL POPULATION BY ETHNICITY S o u t h and E a s t H e a l t h U n i t s 1980 S o u r c e : V a n c o u v e r H e a l t h D e p a r t m e n t : U n i t P r o f i l e s . E t h n i c G r o u p S o u t h U n i t % E a s t U n i t % C h i n e s e I n d o P a k i s t a n i C a n a d i a n O t h e r 27 19 38 16 25 17 41 17 V a n c o u v e r i s a l s o a c i t y o f c o n t r a s t s , a c o m p i l a t i o n o f c e n s u s t r a c t d a t a f r o m t h e 1976 c e n s u s b y h e a l t h u n i t a r e a , T a b l e I I I , shows d i f f e r e n c e s i n l a n g u a g e and e d u c a t i o n a l a t t a i n m e n t b e t w e e n d i f f e r e n t a r e a s o f t h e c i t y , and c o r r e l a t e s them w i t h a r e a l o w b i r t h w e i g h t r a t e s . TABLE I I I VANCOUVER HEALTH UNITS C h a r a c t e r i s t i c s o f R e s i d e n t s 1976 S o u r c e : C i t y o f V a n c o u v e r P l a n n i n g D e p a r t m e n t : R e s u l t s o f 1971 & 1976 by C e n s u s T r a c t UNIT % % 1976 1977 1978 1979 1980 W i t h W i t h LBW LBW LBW LBW LBW E n g l i sh E d u c a t i o n r a t i o s r a t i o s as p a s t f i r s t Grade 13 Language B u r r a r d 72. 25 30.02 5.6 6.0 5.7 7.0 5.2 N o r t h 5 0.3 10.9 7.5 7.3 8.5 6.6 6.7 S o u t h 66.6 15.4 6.8 6.7 5.4 5.8 5.5 M i d M a i n 73.1 24.7 5.5 5.6 6.8 6.2 5.6 E a s t 63.5 12.35 . 7.4 7.7 7.3 5.3 6.0 West 87.2 45.61 3.1 5.6 4.2 4.0 3.7 /OO TABLE IV MATERNAL POPULATION BY UNIT, PRENATAL CLASS ATTENDANCE, AND L.B.W. 1978 [4] UNIT W e i g h e d L .B.W. C l a s s L i v e % # E n r o l m e n t B i r t h s % # B u r r a r d 909 5.7 52 41 372 E a s t 921 7.3 67 25.5 235 M i d M a i n i 482 6.8 33 60.6 292 N o r t h 949 8.5 83 36.6 347 S o u t h 774 5.4 42 43 333 West 547 4.2 23 67 367 TOTAL • 4582: 6.5 301 42.5 1946 V a n c o u v e r H e a l t h D e p a r t m e n t P r e n a t a l P r o g r a m s . F o r s e r v i c e d e l i v e r y , V a n c o u v e r H e a l t h D e p a r t m e n t d i v i d e s t h e c i t y i n t o 6 u n i t s , ( s e e map F i g u r e I ) . E a c h H e a l t h U n i t h a s a s t a f f a l l o c a t i o n o f Community H e a l t h N u r s e s , u n d e r t h e s u p e r v i s i o n o f a C o o r d i n a t o r who i n t u r n r e p o r t s t o t h e D i r e c t o r o f P r e v e n t i o n P r o g r a m s . P r e n a t a l s e r v i c e s c o n s i s t o f : a) P r e n a t a l c l a s s e s b) An o u t r e a c h p r o g r a m . P r e n a t a l C l a s s e s T h e s e h a v e been o f f e r e d b y t h e VHD s i n c e 1956, i n 1978, as c a n be s e e n i n T a b l e I V , t h e y r e a c h e d 42% o f V a n c o u v e r ' s m o t h e r s , w i t h i n t r a u n i t v a r i a t i o n s o f b e t w e e n 25.9% and 67% a t t h e e x t r e m e s . I n g e n e r a l i t may be s t a t e d t h a t h i g h a t t e n d a n c e c o r r e l a t e s w i t h h i g h e r s o c i o e c o n o m i c s t a t u s , E n g l i s h s p e a k i n g a b i l i t y and l o w Low B i r t h W e i g h t r a t e s . I t i s e s t i m a t e d t h a t 45% o f V a n c o u v e r s 1 b i r t h s a r e t o p r i m i p a r o u s women [ 1 2 ] , and t h e c l a s s e s a r e d e s i g n e d f o r t h e s e women. The a u t h o r s e s t i m a t e t h a t no more t h a n 25% o f a t t e n d e e s a r e e x p e c t i n g a s e c o n d or t h i r d c h i l d . E x t r a p o l a t i n g f r o m t h e s e f i g u r e s t h e n t h e VHD c l a s s e s m i g h t r e a c h 77% o f V a n c o u v e r s ' p r i m i p a r o u s women and 20% o f t h e m u l t i p a r a e . C u r r e n t O b j e c t i v e s o f VHD P r e n a t a l C l a s s e s C u r r e n t o b j e c t i v e s f o r t h e s e c l a s s e s a r e i l l - d e f i n e d b u t i n c l u d e : 1 D e c r e a s i n g P a r e n t a l R i s k B e h a v i o u r s . M o t h e r s a r e a s k e d t o f i l l i n a P r e n a t a l A s s e s s m e n t Form w h i c h i n c l u d e s a m e d i c a l h i s t o r y and d e t a i l s o f n u t r i t i o n , t o b a c c o u s a g e , s u p p o r t , e t c . R i s k s a r e n o t w e i g h t e d . F o l l o w up has n o t been s t a n d a r d i z e d . R i s k m o d i f i c a t i o n s t r a t e g i e s a r e u n d e f i n e d . 2 I n c r e a s i n g P a r e n t Knowledge o f t h e p s y c h o l o g y , anatomy and p h y s i o l o g y o f p r e g n a n c y , l a b o u r and d e l i v e r y . 3 D e c r e a s i n g P a r e n t A n x i e t y t h r o u g h i n f o r m a t i o n and g r o u p work. 4 D e c r e a s i n g Labour S t r e s s t h r o u g h t h e t e a c h i n g o f r e l a x a t i o n t e c h n i q u e s . llcflllli U n i t A r e a s HIKJ C o p u l a t i o n s 1976 V a n c o u v e r 4 1 0 , 9 5 3 UEL: 3,6'.7 BUIIRARD: 102,963 25* HE S r: 66,835 16% HID-HAIN: Figures: GV110 Planning Department Appendix: Population by Ages and Health Unit Areas NOR Tit: 66, 11 '< 16% s E AS I: 62,095 15% SOU f II: 59,919 15% S u b g o a l s a r e : More v a g i n a l d e l i v e r i e s L e s s m e d i c a t i o n d u r i n g l a b o u r L e s s o p e r a t i v e i n t e r f e r e n c e S h o r t e r l a b o u r s H e a l t h i e r n e w b o r n s 5 E n c o u r a g i n g B r e a s t F e e d i n g 6 I m p r o v i n g P a r e n t i n g S k i l l s b y a n t i c i p a t i n g some o f t h e p o s t - p a r t u m s t r e s s e s and d i f f i c u l t i e s . 7 I m p r o v i n g C o m m u n i c a t i o n s and R e l a t i o n s h i p s b e t w e e n t h e ' m o t h e r s ' and t h e ' f a t h e r s ' . P r o g r a m E f f e c t i v e n e s s L a c k i n g d e f i n e d g o a l s o r a p r i o r i z a t i o n o f e x i s t i n g g o a l s i t i s h a r d t o m e a s u r e t h e i m p a c t t h a t t h e p r o g r a m h a s on t h e p o p u l a t i o n . The o b j e c t i v e s 1 t h r o u g h 7 a l l l e n d t h e m s e l v e s t o me a s u r e m e n t - p r e and p o s t t e s t i n g , s a m p l i n g , e t c . b u t t h i s i s n o t u n d e r t a k e n . E f f e c t on H e a l t h o f P r e n a t a l C l a s s e s " T r a i n i n g " c l a s s e s b a s e d on t h e work o f G. D i c k - R e a d , V e l v o v s k y , C h e r t o k and Lamaze h a v e b e e n o f f e r e d t o p r e g n a n t women s i n c e t h e f o r t i e s . Among t h e c l a i m s made f o r s u c h c l a s s e s a r e : - D e c r e a s e d p a i n p e r c e p t i o n . [ 5 , 6 , 7 , 8 , 9 , 1 0 , 1 1 , 1 7 ] The most r e c e n t s t u d y b y M e l z a c k , e t a l , [11] i n 1 9 8 1 , r e p o r t e d s i g n i f i c a n t , b u t r e l a t i v e l y s m a l l r e d u c t i o n s i n p a i n p e r c e p t i o n f o r c l a s s a t t e n d e e s . C o n t r a r y t o e x p e c t a t i o n s , t h i s d i d n o t r e s u l t i n any d i m i n u t i o n i n t h e r a t e s o f e p i d u r a l a n a e s t h e t i c f o r t h e p r e p a r e d m o t h e r s , c o m p a r e d t o c o n t r o l s . - More r a p i d i n i t i a t i o n o f i n f a n t b r e a t h i n g . [24] ( T u p p e r , 1956) - D e c r e a s e i n need f o r u t i l i z a t i o n o f a f t e r b i r t h r e s u s i t a t i o n t e c h n i q u e s . [24] - D e c r e a s e i n n e o n a t a l m o r t a l i t y and s i c k n e s s . [25] ( S t a h l e r ) A c r i t i c a l r e v i e w o f t h e s e s t u d i e s b y B e c k and H a l l [31] s t a t e s i n p a r t : " Even a c u r s o r y e x a m i n a t i o n r e v e a l s t h a t many o f t h e s e s t u d i e s d i d n o t e v e n meet t h e most f u n d a m e n t a l and b a s i c r e q i u i r e m e n t o f t h e s c i e n t i f i c m e t h o d , e v e n t h o s e w h i c h do i n c l u d e c o n t r o l g r o u p s commit o t h e r e x p e r i m e n t a l e r r o r s w h i c h make t h e p r o d u c t i o n o f c a u s e and e f f e c t s t a t e m e n t s r e g a r d i n g t r e a t m e n t and outcome i m p o s s i b l e . " B e c k and H a l l c o n t i n u e b y r e v i e w i n g f o u r n e w e r , more p r o m i s i n g s t u d i e s : a) T h a t o f Kondas and S c e t n i k a [26] c o m p a r i n g s y s t e m a t i c d e s e n s i t i z a t i o n w i t h p s y c h o - p r o p h y l a x i s . The s t u d y g r o u p had s h o r t e r l a b o u r s , 12 h o u r s v e r s u s 16 and 6 v e r s u s 10 f o r p r i m i p s and m u l t i p s r e s p e c t i v e l y . No u n t r e a t e d c o n t r o l s w e re i n c l u d e d , t h e o b s t e t r i c i a n s r a t i n g t h e women were n o t r a t i n g ' b l i n d t o t r e a t m e n t g r o u p ' and no m e a s u r e o f a n a l g e s i c / a n a e t h e t i c u s a g e i s g i v e n . /OS b) Gregg F r a z i e r and N e s b i t t [27,28] compared b i o f e e d b a c k t r a i n i n g a g a i n s t Lamaze t e c h n e q u e t r a i n e d women. The b i o f e e d b a c k g r o u p had s h o r t e r l a b o u r s ( p r i m i p s and m u l t i p s ) , more r a p i d c e r v i c a l d i l a t i o n and f e t a l d e s c e n t , ' l e s s a n a l g e s i a / a n a e t h e s i c ( m u l t i p s o n l y ) . No d i f f e r e n c e was f o u n d i n i n f a n t s ' Apgar s c o r e s , s k i n t e m p e r a t u r e or h e a r t r a t e . A g a i n no u n t r e a t e d c o n t r o l s were compared and more s e r i o u s l y t h e women were n o t r a n d o m l y a s s i g n e d t o t r e a t m e n t / c o n t r o l g r o u p s . P r e t r e a t m e n t d i f f e r e n c e s i n a n x i e t y , m o t i v a t i o n a t t i t u d e and p a i n t o l e r a n c e c o u l d have been r e s p o n s i b l e f o r t h e r e s u l t s . c) Zax, S a m e r o f f , and Farnum [29] compared 70 Lamaze t r a i n e d p r i m i p s , 48 Lamaze t r a i n e d m u l t i p s and 41 u n t r a i n e d m u l t i p s . T r a i n e d m u l t i p s s c o r e d l o w e r on a n x i e t y l e v e l s t h a n b o t h t r a i n e d p r i m i p s and u n t r a i n e d m u l t i p s . No s i g n i f i c a n t d i f f e r e n c e s were f o u n d i n l e n g t h s o f l a b o u r between c o m p a r a b l e t r a i n e d / u n t r a i n e d g r o u p s , b u t fewer g e n e r a l a n a e s t h e t i c s were a d m i n i s t e r e d t o t r a i n e d m o t h e r s . A g a i n no p r e t r e a t m e n t m a t c h i n g was done f o r a n x i e t y l e v e l s , and t h e g r o u p s were s e l f s e l e c t e d . ( U n t r a i n e d m u l t i p s i n f a c t m a n i f e s t e d more a n x i e t y p r e t r e a t m e n t t h a n d i d t h e t r a i n e d m u l t i p s p r e t r e a t m e n t ) . d) S c o t t and Rose [30] f o u n d t h a t t r a i n e d m o t h e r s r e c e i v e d l e s s a n a l g e s i a / a n a e s t h e s i a and had a h i g h e r f r e q u e n c y o f s p o n t a n e o u s v a g i n a l d e l i v e r i e s t h a n u n t r a i n e d m o t h e r s (matched f o r age and e c o n o m i c s t a t u s ) . No d i f f e r e n c e s were f o u n d i n l e n g t h o f l a b o u r , i n c i d e n c e o f f e t a l d i s t r e s s , A p g a r s c o r e s , n e o n a t a l m o r t a l i t y , n e o n a t a l m o r b i d i t y o r m a t e r n a l c o m p l i c a t i o n s o t h e r t h a n a d e c r e a s e i n l o w f o r c e p s d e l i v e r i e s i n t h e t r a i n e d g r o u p . A g a i n no r a n d o m i z a t i o n t o e x p e r i m e n t a l / c o n t r o l g r o u p i n g was c a r r i e d o u t , p r e t r e a t m e n t d i f f e r e n c e s c o u l d a c c o u n t f o r t h e r e s u l t s . B e c k and H a l l c o n c l u d e t h a t " t h e s t u d i e s w h i c h p r e s e n t t h e most p r o m i s i n g d a t a on r e d u c t i o n i n n e o n a t a l m o r t a l i t y and m o r b i d i t y h a v e a d i s a p p o i n t i n g l a c k o f p r e c i s i o n w h i c h makes t h e c o n c l u s i o n s e x t r e m e l y q u e s t i o n a b l e . " C l o s e r t o home, t h e s t u d i e s o f T h o r d a r s e n * and Y a i r e * * f i n d a h i g h e r i n c i d e n c e o f Low B i r t h W e i g h t among n o n - a t t e n d e e s (who a r e a l s o l o w e r s o c i o e c o n o m i c s t a t u s , l e s s w e l l e d u c a t e d , y o u n g e r and w i t h d i f f e r e n t c u l t u r a l b a c k g r o u n d s t h a n a t t e n d e e s . ) N e i t h e r a u t h o r c l a i m s t h a t a r e l a t i o n s h i p e x i s t s b e t w e e n h i g h e r b i r t h w e i g h t and a t t e n d a n c e . * T h o r d a r s e n , L . , C o s t a z o , G . : E v a l u a t i o n o f t h e e f f e c t o f a p r e n a t a l (JPH V o l 7 A p r i l 1 9 7 6 ) . ** Y a i r e , S . F . : F a c t o r s i n f l u e n c i n g u t i l i z a t i o n o f p r e n a t a l s e r v i c e s i n V a n c o u v e r S.P.A.R.C. U n i t e d Way. /on Y a i r e c o n c l u d e s t h a t i t i s s o c i o d e m o g r a p h i c l o w r i s k m o t h e r s who o p t f o r p r e n a t a l c l a s s e s and s t a t e s "more e f f o r t and r e s o u r c e s s h o u l d be d e v o t e d t o r e a c h l o w e r s o c i o e c o n o m i c g r o u p s , new i m m i g r a n t s and t h o s e l e s s f l u e n t i n t h e E n g l i s h l a n g u a g e . " C o i n c i d e n t a l w i t h h e r r e p o r t was t h e p u b l i c a t i o n o f t h e e v a l u a t i o n o f an o u t r e a c h p r o g r a m a i m e d a t j u s t t h e s e g r o u p s . [14] R o s s and R u t t e r o f H e a l t h i e s t B a b i e s P o s s i b l e t a r g e t e d n u t r i t i o n a l l y a t r i s k m o t h e r s f o r home d i e t a r y e v a l u a t i o n and c o u n s e l l i n g , a s e r v i c e p r o v i d e d i n f i v e l a n g u a g e s , b y t r a i n e d and s u p e r v i s e d o u t r e a c h n u t r i t i o n a i d e s . The p r o g r a m s t a r t e d i n 1975 and i s s t i l l r u n n i n g a s p a r t o f t h e V a n c o u v e r H e a l t h D e p a r t m e n t p r e v e n t i o n p r o g r a m m i n g . The P r o g r a m R e p o r t , p u b l i s h e d i n 1978, [14] n o t e d a Low B i r t h W e i g h t r a t e among a t t e n d e e s o f 2.8% and mean b i r t h w e i g h t o f 3357 gm ( C i t y f i g u r e s 7.2% and 3300 gm 1 9 7 6 ) . 7 2 % o f t h e women a t t e n d i n g w e r e new i m m i g r a n t s and 48% had i n c o m e s u n d e r $10,000 p . a . The p r o g r a m c o n t i n u e s , t h o u g h w i t h s t r i c t e r a c c e p t a n c e c r i t e r i a and h a s c o n v i n c i n g l y d e m o n s t r a t e d i n c r e a s e d n u t r i t i o n a l i n t a k e and i n c r e a s e d w e i g h t g a i n s among t h o s e c o u n s e l l e d . [15] The p r o g r a m r e a c h e s a p p r o x i m a t e l y 250 women e a c h y e a r . A r e c e n t (1982) a d d i t i o n t o t h e V a n c o u v e r H e a l t h D e p a r t m e n t p r o g r a m m i n g i s t h e b r o a d c a s t i n g o v e r C a b l e T e l e v i s i o n o f p r e n a t a l e d u c a t i o n a l p r o g r a m m i n g i n H i n d i , P u n j a b i and C a n t o n e s e . T h i s p r o g r a m m i n g i s d e s i g n e d t o r e a c h t h e p o p u l a t i o n who f o r a v a r i e t y o f r e a s o n s ( c u l t u r a l , l i n g u i s t i c , e c o n o m i c , e t c . ) a r e u n d e r r e p r e s e n t e d as c l i e n t s o f t h e g e n e r a l p r o g r a m . /eg E v a l u a t i o n o f t h e p e n e t r a t i o n o f t h i s programming was c o n f i n e d t o P u n j a b i s p e a k i n g h o u s e h o l d s and s u g g e s t s t h a t a t l e a s t o n e - t h i r d o f h o u s e h o l d s r e c e i v e d t h e programming d u r i n g t h e f i r s t s i x months o f b r o a d c a s t i n g . Of t h o s e v i e w i n g , t h e m a j o r i t y (90%) r e c a l l e d a d v i c e p r e s e n t e d , and s t a t e d t h a t t h e y would f o l l o w t h e a d v i c e i f p r e g n a n t . I t i s i m p o s s i b l e t o s t a t e what m e a s u r a b l e e f f e c t s t h e V a n c o u v e r H e a l t h Department u n s p e c i a l i z e d p r e n a t a l p r o g r a m s a r e h a v i n g on t h e p o p u l a t i o n who a t t e n d them, and f u r t h e r , whether i n terms o f i m p r o v e d f e t a l h e a l t h , t h e r e s o u r c e s m i g h t n o t be b e t t e r r e d i r e c t e d t o o t h e r more c l e a r l y d e f i n e d m a t e r n a l g r o u p s t o a c h i e v e more c l e a r l y d e f i n e d g o a l s . U n d o u b t e d l y e x i s t i n g p r e n a t a l c l a s s e s answer a p u b l i c demand, and a r e e x c e e d i n g l y p o p u l a r ; p a r e n t s p r o b a b l y g a i n k n o w l e d g e , c o n f i d e n c e , c o m p a n i o n s h i p and s u p p o r t t h r o u g h p r e n a t a l c l a s s a t t e n d a n c e . We must a s k " I s t h i s s u f f i c i e n t j u s t i f i c a t i o n f o r t h i s a l l o c a t i o n o f r e s o u r c e s ? " U t i l i z a t i o n a t p r e s e n t i s by t h a t p a r t o f t h e p o p u l a t i o n s e l f ^ s e l e c t e d by e d u c a t i o n , income, i n f l u e n c e , p l a c e o f r e s i d e n c e and p r o x i m i t y t o r e s o u r c e s - a t b e s t , r i s k s among t h i s g r o u p a r e r a n d o m l y d i s t r i b u t e d ; i t i s much more l i k e l y t h a t d i s p r o p o r t i o n a t e l y few h i g h - r i s k m o t h e r s a r e i n c l u d e d . T h i s p a p e r h a s a t t e m p t e d t o : a) I d e n t i f y a k e y i n d i c a t o r o f p r e n a t a l h e a l t h ; b) I d e n t i f y m o d i f i a b l e p r e c u r s o r s t h a t a c t n e g a t i v e l y on t h i s i n d i c a t o r ; c ) S u r v e y a p o p u l a t i o n w i t h an i d e n t i f i e d p o o r o u t c o m e ; d) Compare t h i s p o p u l a t i o n w i t h a ' n o r m a l ' p o p u l a t i o n ; e) I d e n t i f y b i o l o g i c a l , s o c i a l and b e h a v i o u r a l d i f f e r e n c e s b e t w e e n t h e p o p u l a t i o n s and d e v i s e some r i s k r a t i o s f o r p o p u l a t i o n s w i t h t h e n e g a t i v e p r e c e n s o u s ; f ) I d e n t i f y t h e s e r v i c e s c u r r e n t l y o f f e r e d t o m a t e r n a l p o p u l a t i o n s ; g) I d e n t i f y t h e p o p u l a t i o n s r e c e i v i n g t h e s e r v i c e s ; h) A s s e s s t h e e f f e c t i v e n e s s o f t h e s e r v i c e s as o f f e r e d . The r e s e a r c h u n d e r t a k e n h a s : - i d e n t i f i e d s u c h a k e y i n d i c a t o r ; - i d e n t i f i e d p o p u l a t i o n s a t r i s k ; - i d e n t i f i e d i n t h o s e p o p u l a t i o n s , i n d i c a t o r s o f r i s k and m o d i f i a b l e r i s k b e h a v i o u r s ; - c o n c l u d e d t h a t p r e n a t a l s e r v i c e s a r e n o t d i r e c t e d a t g r o u p s a t r i s k ; - u n c o v e r e d e v i d e n c e t h a t s e r v i c e a c t i v i t i e s may n o t be e f f e c t i v e i n a c h i e v i n g t h e i r g o a l s ; c a s t d o u b t upon w h e t h e r t h o s e a c t i v i t i e s , e v e n i f e f f e c t i v e , a r e r e l a t e d t o t h e c h o s e n h e a l t h i n d i c a t o r . The f i n a l c h a p t e r w i l l p r e s e n t r e c o m m e n d a t i o n s f o r r e s o u r c e a l l o c a t i o n w i t h i n t h e p r e n a t a l p r o g r a m a r e a . The r e c o m m e n d a t i o n s a r e b a s e d on t h e f i n d i n g s a b o v e . no BIBLIOGRAPHY CHAPTER V I 1. V i t a l S t a t i s t i c s , 1976. 2. E a s t H e a l t h U n i t P r o f i l e : C i t y o f V a n c o u v e r H e a l t h D e p a r t m e n t U n i t P r o f i l e s . 3. B a i l e y , G . : A n a l y s i s o f B i r t h W e i g h t by E t h n i c i t y and C l a s s A t t e n d a n c e . U n p u b l i s h e d p a p e r . 4. C o m m u n i c a t i o n f r o m Dr,G.Bontram,A.D.M. o f H e a l t h B.C. M i n i s t r y o f H e a l t h , 1980. 5. S t o n e , C . I . , D e m c h i k - S t o n e , B . A . , M o r a n , J . J . : C o p i n g w i t h p a i n , a component a n a l y s i s o f Lamaze and c o n g n i t i v e b e h a v i o u r a l p r o c e d u r e s . J . P s y c h o s o m R e s e a r c h 1977 2 1 : 4 5 1 - 4 5 6 . 6. N o r r , K . L . , B l o c k , C . R . , C h a r l e s , A . , M e y e r i n g , S . , M e y e r s , E . : E x p l a i n i n g p a i n and e n j o y m e n t i n c h i l d b i r t h . J . H e a l t h S o c . B e h a v i o u r 1 9 7 7 , 1 8 : 2 6 0 - 2 7 5 . 7. S t e v e n s , R . J . , H e i d e , F . : A n a l g e s i c c h a r a c t e r i s t i c s o f p r e p a r e d c h i l d b i r t h t e c h n i q u e s , a t t e n t i o n f o c u s i n g and s y s t e m a t i c r e l a x a t i o n . J . P s y c h o s o m , Res.1977 2 1 : 4 2 9 - 4 3 8 . 8. D a v e n p o r t - S l a c k , B . , B o y l a n , C . H . : P s y c h o l o g i c a l c o r r e l a t e s o f c h i l d b i r t h p a i n . Psychosom.Med. 1974 3 6 : 2 1 5 - 2 2 3 . 9. N e t t e l b l a d t , P . , F a g e r s t r o m , C . F . , U d d e n b e r g , N . : The s i g n i f i c a n c e o f r e p o r t e d c h i l d b i r t h p a i n . J . P s y c h o s o m R e s . 1976, 2 0 : 2 1 5 - 2 2 1 . 10. J a v e r t , C . T . , H a r d y , J . D . : M e a s u r e m e n t o f p a i n i n t e n s i t y i n l a b o u r and i t s p h y s i o l o g i c , n e u r o l o g i c and p h a r m a c o l g i c i m p l i c a t i o n s . Am.J. O b s t e t . a n d G y n e c o l . 1950 6 0 : 5 5 2 - 5 6 3 . 11. M e l z a c k , R . , T a e n z e r , P . , F e l d m a n , P . , K i n c h , R . A . : L a b o u r i s s t i l l p a i n f u l a f t e r p r e p a r e d c h i l d b i r t h t r a i n i n g . C M . A . J o u r n a l A u g u s t 1981 V o l . 1 2 5 page 357. / / / 12. T h o r d a r s e n , L . , C o s t a n z o , G . : An e v a l u a t i o n o f t h e e f f e c t i v e n e s s o f an e d . p r o g r a m f o r e x p e c t a n t p a r e n t s . C.J.P.H. V o l . 6 7 ( M a r c h - A p r i l , 1976) page 1 1 7 - 1 2 1 . 13. Y a r i e , S . F . : A s t u d y o f f a c t o r s i n f l u e n c i n g u t i l i z a t i o n o f p r e n a t a l e d u c a t i o n s e r v i c e s i n V a n c o u v e r . S.P.A.R. U n i t e d Way, V a n c o u v e r . 14. R o s s , S . E . , R u t t e r , A . C : H e a l t h i e s t B a b i e s P o s s i b l e : An O u t r e a c h P r o g r a m . VHD 1978. 15. K e n d a l l , P . , B e l l , P . , C a l l o w a y , R . : Food f o r T h o u g h t : N u t r i t i o n a l O u t r e a c h C o u n s e l l i n g D u r i n g P r e g n a n c y . BCMJ. 16. R i s k A p p r o a c h f o r M a t e r n a l and C h i l d H e a l t h C a r e . W.H.O. O f f s e t Pub. No.39 W.H.O., Geneva 1978. 17. Hommel,F.: T w e l v e Y e a r s ' E x p e r i e n c e i n P s y c h o p r o p h y l a c t i c P r e p a r a t i o n f o r C h i l d b i r t h , page 4 9 - 5 1 . 18. H u t t e l , F . A . , M i t c h e l l , I . , F i s c h e r , W . M . , e t a l : A q u a n t i t a t i v e e v a l u a t i o n o f p s y c h o p r o p h y l a x i s i n c h i l d b i r t h . J . P s y c h o s o m R e s . 1 6 : 8 1 - 9 2 . 19. Enkin,M.W., S m i t h , S . L . , Dermer,S.W., e t a l : An a d e q u a t e l y c o n t r o l l e d s t u d y o f t h e e f f e c t i v e n e s s o f PPM t r a i n i n g . page 6 2 - 6 7 . 20. F l o w e r s , C . R . : P a t i e n t p a r t i c i p a t i o n i n l a b o u r and d e l i v e r y . Tex.Med. 5 8 : 9 8 8 - 9 9 3 , 1967. 2 1 . G a l e a z z i , L . , M i n e l l a , E . : S t a t i s t i c a l a s s e s s m e n t o f 300 c a s e s o f c h i l d b i r t h u n d e r h y p n o s i s . M i n e r v a Med. 63:952-954, 197 2 . 22. S h a p i r o , H . I . , S c h m k i t t , L . G . : E v a l u a t i o n o f t h e p s y c h o p r o p h y l a c t i c m e thod o f c h i l d b i r t h i n t h e p r i m i g r a v i d a . Conn.Med. 3 7 : 3 4 1 - 3 4 3 , 1 9 7 3 . 23. P e t r o v - M a s l a k o v , M . A . : P h y s i o p s y c h o p r o p h y l a c t i c p r e p a r a t i o n f o r l a b o u r i n p a t h o l o g y o f p r e g n a n c y , page 59-69. 24. T u p p e r , C : C o n d i t i o n i n g f o r c h i l d b i r t h . A . J . O b s t e t and G y n e c o l 7 1 : 7 3 3 - 7 4 0 , 1956. 25. S t a h l e r , F . , S t a h l e r , E . , G u t a i n i a n , R . : P e r i n a t a l m o r t a l i t y o f t h e c h i l d l o w e r e d b y p s y c h o p r o p h y l a x i s . page 56-56. 26. K o n d a s , 0 . , S c e t n i c k , B . : S y s t e m a t i c d e s e n s i t i z a t i o n as a m e t h o d o f p r e p a r a t i o n f o r c h i l d b i r t h . J . B e h . T h e r . E x p . P s y c h o l . 3:51-54, 1972. 27. G r e g g , R . H . , F r a z i e r , L . M . , N e s b i r , R . A . : R e l a x a t i o n t r a i n i n g e f f e c t s on c h i l d b i r t h : O u t l i n e o f e x h i b i t p r e s e n t e d a t c l i n i c a l m e e t i n g o f t h e A m e r i c a n C o l l e g e o f O b s t e t r i c i a n s and G y n e c o l o g i s t s , B o s t o n , Mass. May 1975. 28. F r a z i e r , L . M . : U s i n g b i o f e e d b a c k t o a i d r e l a x a t i o n d u r i n g c h i l d b i r t h . B i r t h F a m i l y J o u r n a l 1:4, 1974. 29. Zax,M., S a m e r o f f , A . J . , F a r n u m , J . E . : C h i l d b i r t h e d u c a t i o n , m a t e r n a l a t t i t u d e s and d e l i v e r y . Am.J. O b s t e t and G y n e c o l 1 2 3 : 1 8 5 - 1 9 0 , 1975. 30. S c o t t , J . R . , Rose,N.B.: E f f e c t o f p s y c h o l p r o p h y l a x i s (Lamaze p r e p a r a t r t i o n ) on l a b o u r and d e l i v e r y i n p r i m i p a r a s . N . E n g l . J . M e d . 2 9 4 : 1 2 0 5 - 1 2 0 7 , 1976. 31 . B e c k , C . N . , H a l l , D . : N a t u r a l c h i l d b i r t h : A r e v i e w and a n a l y s i s . O b s t e t and G y n e c o l . V o l . 5 2 No.3 S e p t e m b e r 1978 page 3 7 1 - 3 7 9 . tit CHAPTER V I I RECOMMENDATIONS RECOMMENDATION 1 T h a t w i t h i n t h e p r e n a t a l p r o g r a m , t h e H e a l t h D e p a r t m e n t f o r m a l l y a d o p t t h e p r e v e n t i o n o f Low B i r t h W e i g h t a s a p r o g r a m p r i o r i t y . RECOMMENDATION 2 T h a t t h e H e a l t h D e p a r t m e n t f o r m a l l y a d o p t a " R i s k A p p r o a c h t o M a t e r n a l and C h i l d H e a l t h C a r e " a s d e f i n e d b y t h e W o r l d H e a l t h O r g a n i z a t i o n 1978 [22] and u s e t h i s a p p r o a c h i n p r o g r a m p l a n n i n g and r e s o u r c e a l l o c a t i o n i n t h e P u b l i c H e a l t h p r e n a t a l p r e v e n t i o n p r o g r a m . RECOMMENDATION 3 T h a t i n r e c o g n i t i o n o f t h e r o l e o f l o w s o c i o - e c o n o m i c s t a t u s on t h e i n c i d e n c e o f l o w b i r t h w e i g h t t h a t t h e V.H.D. e n c o u r a g e t h e M i n i s t e r o f H e a l t h t o a p p r o a c h t h e F e d e r a l G o v e r n m e n t t o pay a p r e n a t a l f a m i l y a l l o w a n c e t o p r e g n a n t women, i n o r d e r t h a t t h e woman a t r i s k h a v e t h e f i n a n c i a l r e s o u r c e s t o f e e d and c a r e f o r h e r s e l f p r o p e r l y d u r i n g t h e p r e g n a n c y . T h i s a l l o w a n c e t o r e p l a c e t h e f i n a l y e a r o f t h e F a m i l y A l l o w a n c e , and t o be t i e d t o income t h r o u g h s e l f r e p o r t i n g on y e a r end t a x r e t u r n s . • RECOMMENDATION 4 T h a t t h e H e a l t h D e p a r t m e n t , as p a r t o f t h e i r d a t a b a s e , r o u t i n e l y a u d i t p r e g n a n c y o u t c o m e s and s a m p l e m a t e r n a l c h a r a c t e r i s t i c s t o e n s u r e t h a t s e r v i c e s a r e d e l i v e r e d t o p o p u l a t i o n s a t h i g h e s t m o d i f i a b l e r i s k . RECOMMENDATION 5 T h a t i n t h e p r e n a t a l p r o g r a m i t s e l f , l e s s e m p h a s i s be p l a c e d on p r e p a r a t i o n f o r t h e b i r t h p r o c e s s and a much h e a v i e r e m p h a s i s be p l a c e d on b e h a v i o u r d i r e c t e d t o w a r d s d e v e l o p i n g and m a i n t a i n i n g a h e a l t h y f e t u s . RECOMMENDATION 6 T h a t a l l women a p p r o a c h i n g t h e H e a l t h D e p a r t m e n t f o r s e r v i c e be s c r e e n e d f o r r i s k and r e c i e v e r e s o u r c e s p r o p o r t i o n a l t o t h e i r o b j e c t i v e l y d e f i n e d r i s k s . RECOMMENDATION 7 T h a t s u c h a s c r e e n i n g t o o l be d e v e l o p e d b a s e d upon t h e f i n d i n g s o f J o h n s o n and D u b i n i n " R i s k s f o r Low B i r t h W e i g h t " . RECOMMENDATION 8 T h a t t h e H e a l t h D e p a r t m e n t i n r e c o g n i t i o n o f t h e f a c t t h a t m u l t i p a r o u s women a r e a t as g r e a t a r i s k as p r i m i p a r o u s women f o r l o w b i r t h w e i g h t , i n c l u d e them as a t a r g e t p o p u l a t i o n . /'S RECOMMENDATION 9 T h a t t h e H e a l t h D e p a r t m e n t r e c o g n i z e t h e f a c t t h a t many women, b y r e a s o n o f : - u n a b a i l a b i l i t y o f c h i l d c a r e ; - l a c k o f k n o w l e d g e ; - d o m e s t i c c o m m i t m e n t s ; - c u l t u r a l d i f f e r e n c e s ; - l i n g u i s t i c d i f f e r e n c e s ; and - t r a n s p o r t a t i o n d i f f i c u l t i e s , e t c . , * a r e b o t h u n a w a r e o f , a n d / o r u n a b l e t o a t t e n d p u b l i c h e a l t h p r e n a t a l c s a r e as p r e s e n t l y p r o v i d e d . RECOMMENDATION 10 T h a t i n r e c o g n i t i o n o f t h e a b o v e , t h e H e a l t h D e p a r t m e n t a c t i v e l y s e e k t o p r o d u c e a nd p r o m o t e t h e d i s s e m i n a t i o n o f i n f o r m a t i o n p e r t a i n i n g t o p r e n a t a l c a r e t h r o u g h t h e e l e c t r o n i c m e d i a i n c u l t u r a l l y and l i n g u i s t i c a l l y a p p r o p r i a t e p r o g r a m m i n g f o r m a t . RECOMMENDATION 11 T h a t t h e o u t r e a c h s e r v i c e H e a l t h i e s t B a b i e s P o s s i b l e c o n t i n u e and i f p o s s i b l e be e x p a n d e d . * Y a r i e , S.F.: A s t u d y o f f a c t o r i n f l u e n c i n g u t i l i z a t i o n o f p r e n a t a l e d u c a t i o n s e r v i c e s i n V a n c o u v e r . SPAR U n i t e d Way, V a n c o u v e r 1978. RECOMMENDATION 12 T h a t t h e H e a l t h D e p a r t m e n t m o n i t o r t h e e f f e c t o f a l l p r o g r a m m i n g and t h a t a minimum d a t a s e t i n c l u d e : - numbers o f women s c r e e n e d and r e c e i v i n g s e r v i c e s ; - number o f women e x p o s e d t o m e d i a i n f o r m a t i o n ; - c h a n g e s i n k n o w l e d g e , a t t i t u d e and b e h a v i o u r o f p r e g n a n t women f o l l o w i n g e x p o s u r e t o i n f o r m a t i o n ; - r e s u l t s o f r i s k m o d i f i c a t i o n on m a t e r n a l b e h a v i o u r ; and - r e s u l t s o f m a t e r n a l b e h a v i o u r a l c h a n g e on i n f a n t b i r t h w e i g h t s . RECOMMENDATION 13 T h a t a s a r e s u l t o f s u c h m o n i t o r i n g i n t e r v e n t i o n s be m o d i f i e d o r d i s c a r d e d when t h e y f a i l t o d e m o n s t r a t e t h e i r e f f e c t i v e n e s s . RECOMMENDATION 14 T h a t f o l l o w i n g t h e a d o p t i o n o f r e c o m m e n d a t i o n s 1 t h r o u g h 13: a) P r o g r a m c o n t e n t be r e v i s e d , s c r e e n i n g t o o l s d e v e l o p e d and i n t e r v e n t i o n p r o g r a m s p l a n n e d and i m p l i m e n t e d ; b) The V a n c o u v e r H e a l t h D e p a r t m e n t s t a f f r e c e i v e s u f f i c i e n t i n s e r v i c e t r a i n i n g t o a l l o w them t o e f f e c t i v e l y i m p l e m e n t t h e new p r o g r a m m i n g ; and c) A p u b l i c i n f o r m a t i o n c a m p a i g n be mounted t o e x p l a i n t o t h e g e n e r a l p u b l i c t h e r a t i o n a l e b e h i n d t h e p r o p o s e d r e a l l o c a t i o n o f r e s o u r c e s . 117 APPENDIX I QUESTIONNAIRE Maternal and Infant Low B i r t h Weight* Survey (* = 2500 gm or less ) CASES - Please f i l l out as completely as po s s ib l e on a l l in fant s weighing 2500 gm or l e s s at b i r t h . Include S t i l l b i r t h s and Neonatal deaths and Adoptive  Babies . (Information from B i r t h Not ice w i l l s u f f i c e for these) CONTROLS - The next in fant assigned to you who i s not Low B i r t h Weight. Uni t of Residence Mother 's name (as on index card) T h i s w i l l be c o n f i d e n t i a l I .D . # - (Do not f i l l in ) A U n i t of Residence} W | B | R | M M | N | E ( S I.D. # Maternal Age yr s L i v e B i r t h Yes No I f no: d ied before labour Date of B i r t h d /m /y S ingle Twin Tr ip l e t_ B i r t h Weight Gestat ion Male Female During labour T o t a l Pregnancies T o t a l L i v e B i r t h s T o t a l S t i l l b i r t h s T o t a l Abort ions and Miscarr iages Abnormality of Infant Yes No Complicat ions of Pregnancy Yes No And/or Labour or De l ivery Yes No Death between B i r t h and 27 days Yes No B Date of V i s i t d /m /y Infant Weight gms. Infant Height cm. Infant Head Circumfirance cm Does infant have an i d e n t i f i e d h e a l t h problem? I f so what C Maternal Height cm or f t . i n . Maternal Pre Pregnancy Weight gm. or l b . oz . Pregnancy weight gain gm. or l b . oz . Frame Small£j Based on .Thumb and index of c l i e n t w , i—i Around w r i s t at condyes. Med. I . i Small - h" over lap thumb and index f inger L A R G E| I Medium - between smal l and large Large - h" gap between thumb and index f i n g e r N8 D Has mother had a previous L .B .W. baby Yes j j No j j Did less than 12 months elapse between t h i s pregnancy and d e l i v e r y of l a s t c h i l d S ingle parent status (No l i v e i n Husband, b o y f r i e n d , S i g n i f i c a n t Other) Yes | 1 No | 1 Monthly Pregnancy food budget $ For Adul t s ( i n c l u d i n g Mother and C h i l d r e n OR For Mother - d id she spend le s s than $75 per month Yes j j No j j Was Family on S o c i a l Ass i s tance during Pregnancy Yes j j No j j Received $25 supplement Yes j j No j- j Tobacco use i n pregnancy „ | , , , , , 1 1 , , , None I | Less than 1 pk/ day j | More than 1 pk/d . Does Mother, for R e l i e i o u s or other reasons avoid any p a r t i c u l a r food(s) A l c o h o l i n Pregnancy None Rare* Moderate * * Heavy* . 1st Trimester Yes No * . Rare - consuming a l c o h o l l e s s than once per month and never 5-6 dr inks on any one occas ion * * Moderate - Less than heavy and more than ra re * * * Heavy - At l ea s t 5 or 6 dr inks on some occas ions and at l e a s t 45 dr inks per month. " A Dr ink" - 1 oz S p i r i t s , A oz Wine or 12 oz Beer . E Maternal Medica l H i s t o r y during t h i s pregnancy Did/does mother have - ( t i c k ) ) Diabetes U Card iac Disease 1 Hypertens ion £ Renal Disease 3 E p i l e p s y Problems but d iagnos i s uncert; Other Record of - ( t i ck ) ' Toxaemia ^ P l a c e n t a Praevia -3 P l a c e n t a l I n s u f f i c i e n c y |_j Antepartum Haemorrhage Other Abnormal C o n d i t i o n Medicat ion i n Pregnancy What When ( i . e . which t r imes ter ) Ill F Hea l th Care i n Pregnancy - P h y s i c i a n consu l ted re pregnancy i n which week of pregnancy . How may M.D. v i s i t s dur ing pregnancy R e g u l a r i t y of v i s i t s - Monthly or more Every 2-3 months Only i n 3rd Trimester D i d c l i e n t have U l t r a Sound? 1st Tr imes te r 2nd Tr imes ter 3rd Tr imes ter Prena ta l Class R e g i s t r a t i o n and attended at l e a s t 2 c l a s se s - V . H . D . Yes j jNoj j P r i v a t e Yes j j NCJ j Was Hea l th ie s t Babies P o s s i b l e involved? Yes j j No j J Did mother modify any behaviours dur ing pregnancy Yes j j No j j Which? Was t h i s due to advice from M.D. j | C . H . N . | | H . B . P . j | Other J | G L i n g u i s t i c / E t h n i c C h a r a c t e r i s t i c s - Length of Residence i n Canada I f App l i cab le - Country of B i r t h Is E n g l i s h the f i r s t language Yes j j No j j I f No - Comprehension of spoken E n g l i s h . N i l | jP o o r j j F a i r j | Good j | I f Comprehension N i l or Poor - Language needed by t r a n s l a t o r E t h n i c i t y i . e . which of the fo l lowing broad c l a s s i f i c a t i o n s a p p l i e s to c l i e n t ? 1 Caucasion/European 2 Nat ive Indian 3 Chinese 4 East Indian 5 I t a l i a n 6 Spanish 7 Portuguese 8 Tha i /Loat ian/Vie tnamese 9 P h i l l i p i n o 10 Other H CHN Eva luat ion Further Support Services needed Yes j j No j | What would .you see as needed?. : 120 APPENDIX I I  PROTOCOL FOR COMMUNITY HEALTH NURSES INVOLVED IN LBW SURVEY On c o m p l e t i n g t h e s u r v e y i n s t r u m e n t S e c t i o n A o f t h e f o r m c a n be a b s t r a c t e d f r o m t h e b i r t h n o t i c e w h i c h i s a l r e a d y a g e n c y p r o p e r t y . S e c t i o n B. The p r i m e p u r p o s e o f a new b a b y v i s i t i s t o a s s e s s h e a l t h c a r e s t a t u s and f u t u r e h e a l t h n e e d s o f t h e c l i e n t . T h i s w i l l t h u s t a k e p r e c e d e n c e o v e r c o l l e c t i n g i n f o r m a t i o n on p a r t B. Once t h e p r i m e p u r p o s e o f t h e v i s i t h a s b e e n a c c o m p l i s h e d , I w o u l d a p p r e c i a t e i t i f y o u w o u l d e x p l a i n t h e p u r p o s e o f t h e s u r v e y , t o t h e m o t h e r as f o l l o w s ; "The H e a l t h D e p a r t m e n t i s aware t h a t f o r many r e a s o n s , many women do n o t u s e p r e n a t a l s e r v i c e s t h a t a r e o f f e r e d . I t i s a l s o aware t h a t t h e s e s e r v i c e s may n o t be o f t h e k i n d t o h e l p women who a r e most l i k e l y t o h a v e s m a l l b a b i e s . " " I n o r d e r t o d e c i d e what k i n d o f p r e n a t a l s e r v i c e s a r e n e e d e d , and i n w h i c h l a n g u a g e s t h e y s h o u l d be o f f e r e d , t h e H e a l t h D e p a r t m e n t i s s u r v e y i n g a number o f women. T h e s e h a v e b e e n p i c k e d e i t h e r b e c a u s e t h e y d e l i v e r e d a ' s m a l l b a b y ' , o r b e c a u s e t h e y a r e a ' n o r m a l c o n t r o l ' f o r a m o t h e r w i t h a s m a l l b a b y . " " I f y o u w i l l a n s wer t h e q u e s t i o n s on o u r s u r v e y f o r m , t h e n you w i l l be h e l p i n g n o t o n l y t h e V a n c o u v e r H e a l t h D e p a r t m e n t i n p l a n n i n g i t s s e r v i c e s , b u t more i m p o r t a n t l y , o t h e r women i n t h e f u t u r e . " "The q u e s t i o n s a r e a b o u t y o u r h a b i t s and m e d i c a l s t a t e d u r i n g p r e g n a n c y , y o u r l a n g u a g e s k i l l s , l e n g t h o f r e s i d e n c e i n B.C., and y o u r u s e o f y o u r d o c t o r . T h e r e a r e o t h e r q u e s t i o n s , t o o . I f y o u do n o t w i s h t o an s w e r a q u e s t i o n , j u s t s a y no." "The i n f o r m a t i o n w i l l be t r a n s f e r r e d t o c o m p u t e r c a r d s , and w i l l be c o n f i d e n t i a l w i t h i n t h e H e a l t h D e p a r t m e n t . When t h e i n f o r m a t i o n h a s b e e n t r a n s f e r r e d t o c o m p u t e r c a r d s , t h e p a p e r s w i t h names on w i l l be d e s t r o y e d . " P l e a s e e m p h a s i z e t h a t i f t h e m o t h e r d o e s n o t w i s h t o answer any q u e s t i o n s s h e h a s t h e r i g h t t o s a y s o . I t w i l l n o t a f f e c t t h e c a r e o r s e r v i c e s s h e c h o o s e s t o r e c e i v e i n a n y way. 121 APPENDIX I I I LOW BIRTH WEIGHT SURVEY CONSENT FORM  ( F o r s i g n a t u r e a f t e r o r a l p r e s e n t a t i o n ) I , , o f ( a d d r e s s ) h a v e been i n f o r m e d t h a t t h e p u r p o s e o f t h i s s u r v e y i s t o c o l l e c t i n f o r m a t i o n f o r t h e V a n c o u v e r H e a l t h D e p a r t m e n t . The H e a l t h D e p a r t m e n t w i l l u s e t h i s i n f o r m a t i o n t o p l a n s e r v i c e s f o r m o t h e r s who do n o t a t p r e s e n t r e c e i v e p r e n a t a l i n s t r u c t i o n , and t o i m p r o v e t h e s e r v i c e s a l r e a d y i n o p e r a t i o n . I have f u r t h e r b e e n i n f o r m e d t h a t t h e i n f o r m a t i o n I s h a l l g i v e i s c o n f i d e n t i a l w i t h i n t h e H e a l t h D e p a r t m e n t . I u n d e r s t a n d t h a t I am f r e e t o c h o o s e w h i c h q u e s t i o n s , i f a n y , I w i l l a n s w e r , and t h a t t h e e x e r c i s e o f s u c h c h o i c e w i l l i n no way p r e j u d i c e any f u r t h e r t r e a t m e n t o r s e r v i c e s t h a t I may e l e c t t o r e c e i v e f r o m t h e V a n c o u v e r H e a l t h D e p a r t m e n t . S i g n e d D a t e W i t n e s s Date to 

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