Open Collections

UBC Theses and Dissertations

UBC Theses Logo

UBC Theses and Dissertations

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

Your browser doesn't seem to have a PDF viewer, please download the PDF to view this item.

Item Metadata

Download

Media
831-UBC_1983_A6_7 K46.pdf [ 5.5MB ]
Metadata
JSON: 831-1.0095743.json
JSON-LD: 831-1.0095743-ld.json
RDF/XML (Pretty): 831-1.0095743-rdf.xml
RDF/JSON: 831-1.0095743-rdf.json
Turtle: 831-1.0095743-turtle.txt
N-Triples: 831-1.0095743-rdf-ntriples.txt
Original Record: 831-1.0095743-source.json
Full Text
831-1.0095743-fulltext.txt
Citation
831-1.0095743.ris

Full Text

A  SURVEY  RESULTING  OF  LOW B I R T H  IMPLICATIONS  WEIGHT  FOR  IN  PUBLIC  VANCOUVER AND  HEALTH  PROGRAMMING  by  PERRY MB.  BS.  THESIS  UNIVERSITY  SUBMITTED  R.W.  KENDALL  COLLEGE HOSPITAL  IN  PARTIAL FOR  FULFILLMENT  THE DEGREE  MASTER  MEDICAL  OF  SCHOOL  OF T H E  REQUIREMENT  OF  SCIENCE  in THE  F A C U L T Y OF GRADUATE  STUDIES  DEPARTMENT OF HEALTH CARE AND EPIDEMIOLOGY (  We a c c e p t  The  t h i s T h e s i s as c o n f o r m i n g required standard:  University  of  British  Columbia  August 1983 ©  Perry R.W.  Kendall,  1983  to  1968.  the  DE-6  In  presenting  requirements of  British  it  freely  agree for  this  thesis  f o r an a d v a n c e d  Columbia, available  that  I agree  degree that  f o r reference  permission  scholarly  i n partial  may  at the University  the Library  shall  and study.  I  f o rextensive  purposes  fulfilment of the  copying  be g r a n t e d  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 .  understood  that  for  copying  f i n a n c i a l gain  shall  or publication n o t be a l l o w e d  permission.  Department o f  lJjif5.ll  The U n i v e r s i t y o f B r i t i s h 1956 Main M a l l Vancouver, Canada V6T 1Y3  Date  (.3/81)  Mr-re  Columbia  further  of this  by t h e head  department  make  thesis  o f my  I ti s  of this without  thesis my  written  ii  ABSTRACT  The infant health  literature birth  and  practical  on maternal and  weight  that  is  the low  the  best  birth  child  health  single  weight  suggests  predictor  of  that  infant  r a t e o f a community  is a  i n d i c a t o r of the p e r i n a t a l h e a l t h care s t a t u s of  that  community. Two  groups  1 s t , 1981 of  (Low  low  delivered  Birth  mothers who (Non Low  mothers were surveyed  and November 30th, 1981.  mothers who  birth  of Vancouver  Weight).  delivered  weight  'case' group  weighing  The  infants  B i r t h Weight).  birth  infants  The  less  control  weighing  betwen June  than  group  consisted 2501gm a t  consisted  2501gm or more at  of  birth  For each low b i r t h weight mother a non  mother  was  selected  by  time  and  geographic  proximity. The Data  mothers  from  were  multiple  i n t e r v i e w e d by  births  were  Community  excluded  from  Health the  Nurses.  subsequent  analyses. The  p r i n c i p l e hypotheses  low b i r t h weight  being t e s t e d were that mothers of  i n f a n t s would:  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 ; 2) Have a d i f f e r e n t sociodemographic  profile;  3) Have  potentially  a  higher  behaviours  that  prevalence have  been  of  associated  with  weight, than mothers of non low b i r t h weight  alterable low  birth  infants.  Significant of  mothers.  birth  With  weight -  more  Renal  differences regard  infants illness  were  found  between  the  to biomedical p r o f i l e s ,  were  found  to  two  mothers  groups of  low  have:  during pregnancy  (Hypertension, Epilepsy  and  Disease) -  more  Haemorrhage  complications of pregnancy and  Placenta  (Toxaemia,  Ante  Partum,  praeria)  -  more  deliveries  prior  t o 38  -  more  miscarriages, abortion  weeks or  of  gestation  stillbirths  in  previous  pregnancies -  less  No  likelihood  significant  of having  differences  gained were  251b  found  in this  pregnancy.  f o r maternal  age  or  parity. Differences significance and  close  women  regard were  significance -  reside Indian  which  previous  d i d not  reach  the  low b i r t h  weight  ( a l l case  interpregnancy interval  differences of  were,  of Chinese With  found  more  and  found were  low b i r t h  low b i r t h  origin,  and  than  12  level  of  mothers)  months)  for  origins.  to sociodemographic  i n the poorer more  Indian  (less  .05  b u t some  profiles,  trends  no  approaching  significant the  .05  level  noted; weight East  side  weight  fewer  babies  are  of the  babies  to mothers  born  to  mothers  who  city. were  born  of Chinese  to  mothers  origin.  of  there during  is  pregnancy  r e c i p i e n t of small  a  for  strong  (defined  suggestion as  no  s o c i a l assistance  gestational  age  that  live-in  are  lack  partner)  associated  infants.  of  This  support  and  being  a  with the  birth  of  f i n d i n g only  applies  to Caucasian mothers. no were  significant  found  Indian  between  origin,  differences  case  and  the m a j o r i t y  in  control  English mothers  were i n f a c t  rated  comprehension of  Chinese  fair  or  or  good i n  E n g l i s h comprehension. With  regard  to  the  behaviours,  significant  groups  found.  were  more l i k e l y  prevalence differences  Mothers  of  low  have smoked d u r i n g Some trends  between birth  prenatal  low  birth  classes  during  case  weight  and  control  i n f a n t s were  .05  weight  and  less  In' t h i s sample there was  no  (Caucasians o n l y ) .  level  of  s i g n i f i c a n c e were  i n f a n t s were l e s s l i k e l y  likely,  presented f o r p h y s i c i a n care d u r i n g  Canadian low  t h i s pregnancy  t h i s pregnancy  approaching the  found; mothers of  Chinese and  potentially alterable  to:  have gained l e s s than 251b  attend  of  i f Canadian,  the f i r s t  statistical  to  to  have  trimester. d i f f e r e n c e between  b i r t h weight mothers i n p r e n a t a l  class  attendance but  significant  d i f f e r e n c e s were found between these  two  mothers of  Indian  groups and  interest their  was  that  physicians  non  low  birth  significantly  origin. weight  One  other  f i n d i n g of  Canadian mothers  more f r e q u e n t l y  than do  b i r t h weight mothers of Indian or Chinese o r i g i n .  non  visit low  V  These f i n d i n g s are c o n s i s t e n t  with the l i t e r a t u r e  and c o n f i r m the p r i n c i p l e hypotheses A  survey  prenatal  of  class  the  literature  interventions,  being on  suggests  reviewed  tested. the  that  effectiveness these  of  interventions  are: a) l e s s e f f e c t i v e than has o f t e n been claimed b) o f t e n  not  adversely Prenatal by  designed  affect birth  classes  those mothers who  to  address  which  may  utilized  most  weight.  i n Vancouver are  factors  a t lowest  appear  to be  risk  f o r low  birth  weight  children. Based  on  the  findings  of  are made f o r the p u b l i c h e a l t h Vancouver. to other  The  t h i s study, some recommendations prenatal  programs of the C i t y of  recommendations are probably e q u a l l y  jurisdictions.  applicable  vi  TABLE OF CONTENTS TITLE  PAGE  ABSTRACT TABLE OF CONTENTS LIST OF TABLES ACKNOWLEDGEMENTS CHAPTER I BACKGROUND OF STUDY  i i vi viii xi  -  CHAPTER I I  1 3 5 8 17 18 20 21 21 23  THEORY, RATIONALE AND OBJECTIVES OF STUDY  CHAPTER I I I  Indications of Prenatal Health Changing Outlook f o r Low B i r t h Weight I n f a n t s i n North America Incidence and M e d i c a l Management Components o f Low B i r t h Weight Antecedents t o Low B i r t h Weight P r e v e n t i o n o f Low B i r t h Weight N u t r i t i o n a l Supplementation - Reduction i n M a t e r n a l Smoking - Reduction i n M a t e r n a l A l c o h o l Intake - E f f e c t s o f L i f e S t r e s s and i t s Reduction on B i r t h Weight B i b l i o g r a p h y Chapter I  Theory and R a t i o n a l e Hypotheses Research O b j e c t i v e s Significance  30 31 32 32  METHODS  -  -  Research Design Selection of Categories Cases - Controls Choice o f I n t e r v i e w e r Choice o f Face t o Face I n t e r viewers t o C o l l e c t Data Process The Instrument Implementation B i b l i o g r a p h y Chapter I I I  33 33 33 33 34 35 36 37 42 43  vii  CHAPTER IV  RESULTS -  -  CHAPTER V  44-59 60 61 64-81 82 82 83 85 85 87  ETHNICITY AND LOW BIRTH WEIGHT -  CHAPTER VI  Tables I - XVI C l a s s i f i c a t i o n o f newborns by b i r t h weight and g e s t a t i o n age Comments on R e s u l t s Tables XVII-XVIII In Regard t o Hypothesis I In Regard t o Hypothesis I I In Regard t o Hypothesis I I I A n a l y s i s o f Low B i r t h Weight by Development and G e s t a t i o n Summary o f F i n d i n g s R e l a t i v e R i s k f o r Low B i r t h Weight  E a s t Indian Chinese B i b l i o g r a p h y Chapter V  90 92 94  DEMOGRAPHY, PERINATAL HEALTH AND PUBLIC HEALTH SERVICES IN VANCOUVER '-  -  Demography Vancouver Health Department P r e n a t a l Programs Prenatal Classes Current O b j e c t i v e s o f VHD Prenatal Classes Program E f f e c t i v e n e s s E f f e c t on H e a l t h o f P r e n a t a l Classes B i b l i o g r a p h y Chapter VI  CHAPTER V I I  RECOMMENDATIONS  APPENDIX I  QUESTIONNAIRE  APPENDIX I I  PROTOCOL FOR COMMUNITY HEALTH NURSES  96 100 100 101 103 103 110 113-116 117  INVOLVED IN LBW SURVEY  120  APPENDIX I I I LOW BIRTH WEIGHT SURVEY CONSENT FORM  121  viii  LIST OF TABLES TITLE CHAPTER I  CHAPTER IV  PAGE TABLE I - Hazards o f Low B i r t h Weight from Dunn TABLE I I - Percentages o f Low B i r t h Weight and Preterm I n f a n t s A t t r i b u t e d t o Different Factors TABLE I I I - A t t r i b u t a b l e Percentage of Low B i r t h Weight/Preterm D e l i v e r y by R i s k 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 I n f a n t s by U n i t and E t h n i c i t y TABLE I I Low B i r t h Weight and Non Low B i r t h Weight I n f a n t s by E t h n i c i t y o f Mother TABLE I I I Low B i r t h Weight and Non Low B i r t h Weight I n f a n t s by M a t e r n a l Risk F a c t o r s : Canadian, C h i n e s e , E a s t Indian TABLE IV Low B i r t h Weight and Non Low B i r t h Weight I n f a n t s by M a t e r n a l M e d i c a l Problem and by C o m p l i c a t i o n o f Pregnancy f o r Mothers: Canadian, Chinese, E a s t Indian TABLE V - Mothers o f Low B i r t h Weight I n f a n t s Term and Preterm by E t h n i c Group, P a r i t y , C a r e , Tobacco and A l c o h o l TABLE VI - E t h n i c Group by Care During Pregnancy Low B i r t h Weight and Non Low B i r t h Weight Mothers TABLE V I I Case and C o n t r o l Chinese and E a s t Indian Mothers by E n g l i s h Comprehension TABLE V I I I Case and C o n t r o l Mothers by E t h n i c Group and A l c o h o l Use TABLE IX Case and C o n t r o l Mothers by P a r i t y  7 10  12  44 45 46  47  48  49  50 51 52  ix  TABLE X Case and C o n t r o l Mothers by Age TABLE XI - Case and C o n t r o l Mothers: P r o p o r t i o n a l R e p r e s e n t a t i o n of Three E t h n i c Groups TABLE XII - Low B i r t h Weight I n f a n t s by E t h n i c i t y C h a r a c t e r i z e d by Lubchenco S c a l e a s : Small f o r G e s t a t i o n a l Age (SGA), or 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) TABLE XIII Low B i r t h Weight and Non Low B i r t h Weight I n f a n t s by E t h n i c i t y and P r e m a t u r i t y (<38 weeks) TABLE XIV - Canadian Mothers: Comparison by R i s k s SGA and AGA TABLE XV - Canadian Mothers: Comparison by R i s k s SGA Mothers and Non Low B i r t h Weight Mothers TABLE XVI - Country o f B i r t h of Chinese and E a s t Indian Mothers TABLE XVII - Low Weight B i r t h s by L o c a t i o n and Reporting i n Survey TABLE XVIII - Under 2501gm I n f a n t s Subgrouped by Weight and M a t e r n a l E t h n i c i t y TABLE XIX - Risk F a c t o r f o r Low B i r t h Weight and R e l a t i v e Risk CHAPTER IV  CHAPTER VI  FIGURE I - C l a s s i f i c a t i o n o f newborns by b i r t h weight and g e s t a t i o n age FIGURE I I Ethnicity: Canadian. Under 2501 gm. FIGURE I I I Ethnicity: C h i n e s e . Under 2501 gm. FIGURE IV - Ethnicity: E a s t I n d i a n . Under 2501 gm. TABLE I - Vancouver: P e r i n a t a l M o r t a l i t y Rates and Low B i r t h Weight Rates 1978-1982  53 54  55  56  57 58  59 64 80 89  60 77 78 79 96  X  TABLE I I - Maternal P o p u l a t i o n by E t h n i c i t y South and E a s t H e a l t h U n i t s 1980 TABLE I I I - Vancouver Health U n i t s C h a r a c t e r i s t i c s o f Residents 1976 TABLE IV Maternal P o p u l a t i o n by U n i t , P r e n a t a l C l a s s Attendance, and L.B.W. CHAPTER VI  FIGURE I Health U n i t Areas and P o p u l a t i o n s 1976 Vancouver 410,953  98 99 100  102  xi  ACKNOWLEDGEMENTS  I would l i k e t o acknowledge the co-operation, help 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 Vancouver H e a l t h Department f o r their approval of the survey, and V a n c o u v e r s ' Community H e a l t h Nurses f o r implementing the 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 acknowledge the help of Dr. 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 , D r . Ned G l i c k of t h e U n i v e r s i t y o f B r i t i s h Columbia and Dr. R. Tonkin f o r their help i n preparing the paper. I was f o r t u n a t e e n o u g h t o h a v e a s s i s t a n c e from Dr. James Robinson i n t h e i n i t i a l and m i d d l e phases o f t h i s p a p e r , and I w o u l d l i k e t o p a y a s p e c i a l t r i b u t e t o h i s memory. Thanks  also  t o Don B r o w n  and h i s basement  word  processor.  1 CHAPTER ONE BACKGROUND OF STUDY  INDICATORS OF PERINATAL HEALTH Infant tically  and  i n Canada during  mortality  rate  16.7/1000 l i v e the  perinatal mortality  decade  dropped  from  births  century.  The  31.0/1000  live  i n 1974.[3]  1970-1979 the r a t e  1000.[4]  This decline  -  mortality  Infant  this  over  rate  the  have  births  In B r i t i s h  dropped  same  decade  drama-  i n 1955  Columbia  States  births  to  during  from 18.01/1000 to  99.9/1000 l i v e Declines  dropped  Canadian p e r i n a t a l  i s noted i n the United  under 13/1000 i n 1980.[2] Columbia,  rates  11.3/  of America  i n 1915  [1]  and  s i m i l a r t o those i n B r i t i s h  are  also  reported  from  West  Germany, Japan and Sweden.[4] The  use  including  of  that  mortality of  data  humans  in  to  a s s e s s any  the  perinatal  health period,  questioned.  I t i s a measure o f the most extreme  maladaption,  and  reveals  little  of  h e a l t h p r o s p e c t s of the s u r v i v o r s . "... for  death c l e a r l y  contrasting  the  predictive Chalmers  may  value  about  [5] s t a t e s  of  diferent  a  predictor  be  expression  remains an u n s a t i s f a c t o r y health  status,  of the  that:  basis  perinatal  populations." Birth  Weight  however  m o r t a l i t y , of m o r t a l i t y morbidity  and  of  [5,6,7,11,12,13,14,15]  is  a f t e r the f i r s t  subsequent  of  week of l i f e ,  quality  of  perinatal of i n f a n t  infant  life.  2  Chalmers[5], state  that  perinatal The if  and  birth  smaller  applies India. The  gm  to  by  the  World  define  nations  The the to  into  residual palsy, brain  chance  and  the  single  i t s chance of  Europe,  Wynns  [7]  predictor  of  of  survival,  and  attendant  morbidity.  A f r i c a , China,  Weight.  account  the to  of  lower  New  Guinea  birth  weight over  was  50  not  take  useful  as  a  (mean  gestational  lengths Low  first ago.  [9] age  is  of  across  frequently  are  Birth  2500  suggested  comparison  length  of  of  gestational  gestational  percentages  weight  years  on  low  birth  perinatal the  birth  weight  weight  ranging  fairly  infants  of the  from  deafness  learning,  [22,24,25,26,27,28,36]  suggests  health  retardation,  disfunction,  YLLPO  a  similar  Weight  in  infants  29.0).[10]  handicaps  mental  This  i t is  l i t e r a t u r e reviewed of  uses  d e f i n i t i o n does  [21]  5.9  state  The  the  Organization  data  percentage the  less  Paediatrician  where  from  best  the  America,  Birth  this  unobtainable  range  the  [6]  morbidity.  greater  North  Low  where  countries  is  infant  Health  Finnish  infant  the  Starfield  [7,17,18,19,20]  Although the  and  the  in  &  weight  mortality  i t survives,  This  Hemmincki  reading  the  convincingly  is a  good  that  indicator  community.  higher severe  the  incidence  disorders,  and  blindness  and  behavioural  of  cerebral  to  minimal  disorders.  3  A higher result  in  percentage  a  higher  o f low b i r t h  percentage  weight  of  infants  will  residual  thus  handicapping  conditions. The of  Greater  39.2/1000  and  live  fold  year  of l i f e  Vancouver r a t e was  weight  4.4%  and  that  particular  thesis  rates  the  NORTH AMERICA,  [22]  than  a  50% of deaths  weight  i n the d i f f e r e n t h e a l t h  highest  local  occuring weight  this  Units  In 1978 t h e  8,7%.  i t  was  researcher  to  within  lowest  this  area  apparent  undertake  this  BIRTH WEIGHT INFANTS IN  INCIDENCE & MEDICAL  characterized  MANAGEMENT.  c a n be i d e n t i f i e d .  by h i g h  prenatal  i n f a n t s . Long  term  That p e r i o d  mortality outcomes  prior  rates  were  to  among  good  1940 low  f o r the  s u r v i v o r s . [30,31]  The  mid 4 0 ' s t o t h e e a r l y  management  o f low b i r t h  unforeseen  Fibroplasia, kernicterus over  Dunn,  more  gm  project.  Three p e r i o d s  an  weight  2501  from t h e l o u b i r t h  disparities.  prompted  CHANGING OUTLOOK FOR LOW  select  are derived  show c o n s i s t e n t  disparity  birth  more t h a n  than  rate  cohort.  Low b i r t h  is  that  mortality  less  of b i r t h  difference.[8]  has e s t i m a t e d  the f i r s t  infant  b i r t h s of i n f a n t s  an e l e v e n  researcher,  a r e a has a p e r i n a t a l  b i r t h s of i n f a n t s weighing  3.6/1000 l i v e  3 0 0 0 gms.,  in  Vancouver  epidemic  weight  enthusiastic  d i s o r d e r s . [32]  hypoglycaemia,  aggressive  t h e r a p y was s u b s e q u e n t l y  by  Retrolental  dehydration  m a r k e d l y as d i d n e u r o l o g i c a l  oxygen  of  i n f a n t s w h i c h was a c c o m p a n i e d  of i a t o g e n i c  starvation, increased  6 0 ' s was a p e r i o d  damage  and when  cut back.[33]  4  Follow outcomes. in  up  to  up  studies  Deficits 60%  The  of  management  understanding  marks  Neonatal of  and  period physical  reveal  disappointing  development  were  found  s u r v i v o r s . [26,27,34]  period  in  this  i n mental  the  third  from  the  the  coupling  Intensive  of  Care  aggressive  Units  p h y s i o l o g i c a l requirements  of  with the  an  preterm  infant.[35] The late  incidence  50's  to  reductions loss. were  By  Rates 1976  i n the  the  free  and  less  70's  of than  80-90%  from  serious  of  survival  47%  4%  d i p l e g i a dropped  a decade  incidence  1978),  500-1000gm  spastic  of  of  surviving or  (reported these  survival,  There  blindness  physical  for  later.  low  mental  from  low  81%,  7-12%  were  in  the  comparable  and  severe  hearing  birth  weight  infants  h a n d i c a p . [35]  Cleveland,  birth  1001-1500gm  from  Ohio,  weight  between  infants  1501-2500  are  95%.  [35]  infants  have  [37] While  survival rates  improved  dramatically,  [39]  the  and  U.S.A.  for  almost  [40]  low  birth  doubling  i n the  last  25  in  a l l cases  have  been  due  to  improved  in  mortality  have  been  due  to  reduction  mortality  rates  low  weight  birth  countries.  i n the itself  under has  [38,39,40,41,42]  2501 shown  gm  weight  i n Canada, years,  the  in birth  modest  The  the  U.K.  improvements  medical care.  infant.  only  [38]  Reductions  weight  specific  incidence  declines  in  of  these  5 COMPONENTS OF LOW BIRTH WEIGHT In 1948  the World  Health  Assembly  defined  "premature" i f they were born weighing l e s s  than  infants 2501gm.  as This  accounts f o r 4-8% of a l l i n f a n t s born i n developed c o u n t r i e s and may account f o r approximately o n e - s i x t h of the t o t a l  number  of  g l o b a l l i v e b i r t h s . [43] About  30-40% of the under 2501 gm i n f a n t s i n the developed  c o u n t r i e s are a c t u a l l y born a t term  (at or  after  37  completed  weeks of g e s t a t i o n ) The p r o p o r t i o n i s higher i n an unfavourable socio-economic environment and i n the d e v e l o p i n g n a t i o n s . [22] In 1961 the Expert Committee on Maternal and C h i l d e s t a b l i s h e d by the World Health  Organization  the babies weighing 2500 gm or l e s s referred  to as  "premature"  and  should  that  recommended no  longer  the p r e v i o u s l y  concept of p r e m a t u r i t y g i v e way to that of "Low B i r t h This accords b e t t e r with the f i n d i n g s of  a  Reproductive C a s u a l t y ' r e p o r t e d by Knoblock and [28,45] and by D r i l l i e n .  Health, that  all  defined  Weight".  'Continuum her  be  of  Associates  [26,27]  Subsequent work by Lubchenco  and her c o l l e a g u e s  by Babson, e t a l [48] s u b d i v i d e d c h i l d r e n of i n t o two major c a t e g o r i e s . The "premature",  [46,47] and  Low  Birth  Weight  born  prior  to 37  completed weeks of g e s t a t i o n whose weight l i e s between the 90th and the 10th p e r c e n t i l e s , g e s t a t i o n a l age'  are b i r t h  weight  'appropriate f o r  6  (AGA),  whereas  percentile age'  have  babies  whose  birth  weight  are  h y p o t r o p h i c , dysmature  These  two  major  grown  appropriately  or  is  below  'small for  the  10th  gestational  (SGA).  assumed  to  immediate infancy  be  There "preterm";  undergrown,  perinatal  and  important  categories,  is this  a  born  born  at  different  [22,47]  third  and  long  group  is liable  term of  term  but both  Table  The  1)  but  who  who  are  in and  distinction  the into  is  thus  are  born  management.  SGA  to have  preterm  risks,  (see  [49,50,57,52,53]  term  group  those  face  period  childhood.  for short  and  babies  babies mixed  who  handicaps.  7  TABLE I  Hazards  o f Low B i r t h  Weight  "True  f r o m Dunn  Premature" AGA  Congenital Malformations Transplacental infections Intrauterine hypoxia, birth asphyxia Respiratory Difficulties - H y a l i n e M e m b r a n e D. -Meconium A s p i r a t i o n -Pulmonary Haemorrhage -Apnoeic Attachments Metabolic D i f f i c u l t i e s -Hypoglycaemia -Acidosis -Hypocalcaemia -Jaundice, Kernicterus Alimentary D i f f i c u l t i e s -Inability suck/swallow -Functional intest.obstruct. -Enterolcoli tis Other -Polycythaemia -Anaemia - C e r e b r a l Oedema, N e u r o n a -Necroses -Retrolental Fibroplasia -Sensori-neural deafness -Infection-prone -Thermo l a b i l i t y -Renal function  0 +  - I n c i d e n c e as i n normal  term  I n c i d e n c e m o r e common t h a n  [22]  "Small f o r dates" SGA a t t e r m  + + +  ++ ++ ++  ++ + + ++  ++ ++ +  + + ++ ++  ++ ++ + +  ++ ++  +  0  ++  + ++ ++ ++ ++ Urine Concentration decreased  ++ + + + + Normal  0  0  0  ++  infant. i n normal  ++ - F o u n d m a i n l y i n g r o u p d e s i g n a t e d .  term  infant.  Antecedents  with  t o Low  Birth  Low  Birth  low  socio-economic  In  Weight,  North  higher  status  groups.  countries This  The  Low  an  pregnancy  on  e.g.  education,  Birth  Weight  i n North  act  rates  through  low  duration  nutrition,  age,  obstetric  in  2-3  is  linked  the  lowest  times  incidence America.  relationship  maternal past  Weight  were r e p o r t e d as  that  cause,  [54,55,5,56]  Birth  a direct  factors  rates  Low  i s three times i s not  the antecedent  status.  group  intercurrent effect  whatever  America  socio-economic  8  Weight  as  a  tobacco  developing  multitude  fetal  in  [57]  socio-economic  and  in  that  of  status  other to  intrauterine  usage,  growth  alcohol  performance  and  race  o f Low  Weight,  have  intake,  not  white.  [ 1 2 , 1 3 , 1 4 , 1 5 , 1 7 , 2 3 , 7 7 , 8 0,81] In  their  Starfield  1  review  [6] p r o p o s e a  Birth  categorization  s  Weight and/or adapted  excellent  prematurity. This  of causes  Hemmincki  of both  i s presented below  in  format.  Causes  o f Low  Birth  Social  Factors - Before  -  Poor  Nutrition  -  Smoking  -  Excess  -  Exposure  physical to  Weight  and  toxins  and  and/or  Preterm  during  psychological  Birth.  pregnancy  stress  a  Low  and Birth  slightly  9  2  -  5  pregnancy  -  Premature  -  Before  pregnancy  -  Previous  Caesarian  -  Previous  Induced  poor  capacity  4  During  maternal -  3  -  general  (e.g.  (not  Maternal  of  Toxaemia  -  Anaemia  -  Insufficient and  Hormonal  poor  physical  Related)  Cord  Excretion  Diseases  Placentae  -  Placental  Insufficiency  -  Placenta  -  Prolapse  Praevia of  Umbilical  Cord  Factors  -  Multiple  births  -  Infected  Infant  -  Congenitally  -  Intoxicated two  defective  significance  authors  of of  (Hemmincki  studies  some the  Infant  Infant  epidemiological  directly  i.eluding  ^  Abruptio  attributed  Abortions.  Related)  health,  (Pregnancy  -  (percentage  Section  deseases  -  Infant  induction  volume)  Diseases  Placental  Pregnancy  state  Cardiac  Specific  These of  Diseases  elect  in  and  S t a r f i e l d ) analysed  an  attempt  to  of  the  above  factors.  total  Low  Birth  Weight  to  the  specific  from  the  quoted  factor)  studies.  was  (See  number  estimate  the  Attributable or  Preterm  calculated  Table  a  II)  or  risk  Infants obtained  TABLE I I 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  FREQUENCY AMONG PREGNANT WOMEN WHITE NON-WHITE  ATTRIBUTABLE PERCENTAGE LOW BIRTH WEIGHT INFANTS WHITE NON-WHITE  Maternal Disease Not Pregnancy Related  Niswander & Gordon 1972  12.0  7.7  Toxaemia  Ontario Perinatal Study 1967  20.0  S h a p i r o E t A l 1968  1.2  B u t l e r & Alberman 1969  11.0  11.0  3.8  20.0 2.8  0.68  0.75  14.0  Anaemia Hb<9  Kaltretder & Johnson 1976  Anaemia H b < l l  Ontario Perinatal Study 1967  24.0  Incopetent C e r v i x  Niswander & Gordon 1972  0.34  0.36  2.6  1.5  Abruptio  Placenta  Niswander & Gordon 1972  2.4  1.9  6.5  4.9  Placenta  Previa  Niswander & Gordon 1972  0.77  0.56  2.8  1.7  Cord P r o l a p s e  Niswander & Gordon 1972  1.1  0.78  0.74  0.59  Multiple Births Congenitally or  B u t l e r & Alberman 1969  2.4  14.5  Genetically Defetive Infant  Page 1967  0.81  1.5  Smoking Poor N u t r i t i o n  Meyer e t a l 1976  43.0  30.0  During Pregnancy Poor P h y s i c a l  Niswander & Gordon  90.0  Condition  Raiha & Kauppinen 1963  11.0  T e r r i s & G o l d 1969  1.7  1.1  1.4.  88.0  65.0  57.0 o f term  29.0  11.0  11.0  11  Johnson review  with  Statistical  Dubin that  [85] of  in  the  attributable  percentage  to -certain  findings  are  1980  combined  Kaltreider  Co-operative  calculated  Their  &  Data of  &  presented  Kohl  Review a l l  complications  the  or  aforementioned (Obstectrical  1970-1976)  Preterm  deliveries  characteristics.  i n Table  III.  and  TABLE I I I ATTRIBUTABLE PERCENTAGE OF  LOW  BIRTH WEIGHT/PRETERM DELIVERY BY RISK  TYPE OF RISK  %  Low socio-economic s t a t u s (includes l a c k o f s u p p o r t , poor n u t r i t i o n , l e s s e d u c a t i o n , s h o r t s t a t u r e , underweight p r e g r a v i d , i n c r e a s i n g p a r i t y and mate r n a l age l e s s than 19)  40-60*  R e p e t i t i v e P r e m a t u r i t y (and A b o r t i o n s )  18 **  Unwanted P r e g n a n c i e s  14 ***  Smoking  4-14 *  M u l t i p l e Pregnancies  10 **  P l a c e n t a P r a e v i a and A b r u p t i o P l a c e n t a e  10 **  Maternal I l l n e s s  9 **  F e t a l Malformation  6 **  Iatrogenic  3 **  Sources: * ** ***  D e r i v e d from Hemminki and S t a r f i e l d [6] D e r i v e d from K a l t r e i d e r and Kohl O.S.C. d a t e s 1970-1976 D e r i v e d from Z e l n i k and Kantner [86]  b([Rl/E2]-l) ATTRIBUTABLE PERCENTAGE=100X b([R1/R2]-1)+1 b = f r e q u e n c y o f c o m p l i c a t i o n i n whole p o p u l a t i o n R l = f r e q u e n c y o f low b i r t h w e i g h t / p r e m a t u r i t y i n p a t i e n t s w i t h c o m p l i c a t i o n R2 = f r e q u e n c y o f low b i r t h w e i g h t / p r e m a t u r i t y i n p a t i e n t s w i t h o u t c o m p l i c a t i o n  An  additional factor  Weight  to  prenatal  prematurity [58]  in  all  report  secondary  Oppenheimer  [59]  two with  or  prematurity".  reflect  Shwartz  and  premature  relationship,  in  live  and  1970  could  only  care  was  1958  and  incidences  failure of  [60]  in  Eastnam in  however  obtain  which  that  1961  "prematurity"  may  to  living  care.  Pakter  This  Birth  axiomatic  prenatal  care.  "the  [62]  in  levels  presumed  effect  1965  i n f a n t s and  varying  "The  Milton  on  [54]  conclude  probably  medical  of  been  Low  be  prenatal  are  a  care  responsible  the  studied  over  attempted  to  of  had  care  30,000  women  determine on  causal  relation  was  overall  incidence  of  100,000  live  what  outcome. shown  to  prematurity  population."  Nemer  and  born  i f any,  study  in  habits  Vinyard  negligible  the  lack  prenatal  other  long  of  [58]  conclusion, a  of  relationship  has  fold  association since  for  have  three  lack  merely  Their  It with  may  with  care.  the  is associated  1947,  associated  is  an  in  that  index  f a c t o r s which  a  study  the  for in  of  trimester  other  fact  of  onset  births of  socio-economic,  influenced  in  prenatal cultural  pregnancy  outcome  adversely. Glasser single  live  initiation was  their  Infants, causal  of  and  Terris,  births  found  prenatal  finding initiated  in  that  care  1972 that  rather  mothers  care  r e l a t i o n s h i p could  later be  [61]  of  in  a  "Early than  imputed  of  50,000  versa".  mature  this  black  prevents  prematures"  the to  birth  vice  "false  than  study  Of  interest i.e.  controls.  finding  the  however.  SGA No  ft  Of that  two s t u d i e s  inadequate  i n 1979, that  prenatal  Weight  only  Eisner  [55] e t a l f o u n d  In  of  care.  of onset  recent  by a Health  non H e a l t h  marginally  better  mean B i r t h  Weight)  Organization, less  care.  maternal Low  Birth  Weight  members compared with  medical  very  them  so  i s measured  by  of v i s i t s " . of care,  with  that  physicians  patients  received  relationship  held  good  A statistically f o rHealth  to the general high  content services provided found  Weight  and  Maintenance significantly  independently  of  a l l  significant  difference i n  Maintenance  Organization  population  risk  could  and  i n the Health  quantitatively  I  or  the prenatal  Organization  Organization  f o rthese  obstetrical  a  of  lacked i t " .  ( a s m e a s u r e d b y Low B i r t h  incidence  Birth  That  make  care"  of q u a l i t y  [64] compared  Maintenance  factors.  Low  was  who  which  and "frequency  study  results  care  women  "prenatal  a t impact  who i n f a c t  This  risk  studies  Maintenance  with status.  prenatal  group  suggested  discussed.  of care"  looking  A very  "no  small  a r e n o t , however,  no s t u d i e s  provided by  this  [63]  associated  f a c t o r t o t h e 1.4% o f  t h e above quoted  "trimester find  risk  Gortmaker  socio-economic  that  factors effecting  "selected"  was  f o r women o f l o w e r  significant Other  care  of  was  conditions.  found  in  women  iS Hall, between 1900  Chng,  MacGi11ivray  perinatal mortality  Scottish births.  Terris  [61]  that  complications,  and  morbidity  of  will a  be  large  the  will  incurred number  cause Reed  of  of  full  [66]  and  status  population.  They  the  program  however  nor  could  abortion a  the and  decline  in  significantly It  would  Chalmers.[5] hence  low  promoting  could  not  as  that  risk  the  seem  study  weight  for  Grasser  and  secondary  fetal  mortality  prenatal  visits,  pregnancy, as  to  the  and than  "where  result  not  a  of  care,  increased  these  not  (The  the  target  definitely be  ruled  i.e.  Planning  based  birthweight  in  results  factors  Family  hospital  birth  out,  access  Clinics rate  to  to  caused did  drop  area.) at  between  i s so  perinatal health of  a l l  (author's  variables  sphere  Quantity  pregnancies.  reasonable relation  with  evaluated  other  the in  fewer  s e l e c t i o n could  introduced  birth  traditional  1979  recently high  increased  accumulate  ascribe  self  concur  visits  condition".  birth  possibility  "The  environmental  in  relationship  prenatal  uncomplicated  visits  program. at  of  the  pregnancy,  involve  uncomplicated  prenatal  health  with  term  prenatal  Morris  number  shorter  neccessity a  studied  essentially  a  nurse-midwife a  and  associated  in  the  and  They  [65]  this risk  of  almost of  that  the  certainly medical  to  agree  perinatal  interpolation)  strong  influence  point  and  death  and  social  and  greatest lies  workers".  with  scope  outside  for the  lie To  summarize  briefly  therefore;  decline  in infant  mortality  The countries  management birth. have  over of  increased  of  very  little  medical the  at  U.K  50  to  years  risk,  delivery  access  sophisticated [38]  past  infants  Frequency  changed  Canada,  the  over and  has  both  of  and  been  infants  past  30  availability  technologies. This [39]  morbidity in  shortly  such  the  and  the  U.S.A.  due before at  risk  to  improved and  of  after  appears  years,[85]  statement [40]  developed  to  despite  increasingly applies  to  17 PREVENTION  OF  LOW  Hemmincki  BIRTH  and  WEIGHT  Starfield  [6]  controlled  intervention studies  Weight  preterm  1977,  and noted  compared such  as  quoted, labour these  the  to  marked  research  diet, 31  in  exercise  19  researchers  administration  were  of  beneficial.  Of  the  and  and  invalidating  author's  Two criteria the  were for  on  intervention Their additional  none  health  three smoking met  design  review material  is  January  drug  in other stress.  Low 1930  Of  the  37  only  2  vitamins  8  design  reported  the  studies,  were  3  without  May  factors  and  only  to  exogeneus  of  adequate  Birth  research  of  iron  37  therapy  inhibitions  education and  on  on  cervical criteria by  no  i s reviewed  diet,  showed  studies, and  preventing  of  to  studies premature (15).  support  the  intervention involved  design  Of  as  dietary drawbacks  conclusions.  acceptability  remaining  education  on  of  review  either  remaining  supplementation the  and  sufficiently  conclusions  at  between  improvements  on  comprehensive  aimed  preponderance  smoking,  or  a  published  concentrated  (16) 31,  birth,  in  a  one  which  beneficial  hospital suture,  and  of  bed  only  i t reported  result. rest,  the no  means  comprehensive  in  following  the  met  the Of  health  educational benefit. and  sections.  much  IS NUTRITIONAL  SUPPLEMENTATION  Despite  the  post  strongly  associated  pregnancy  weight  conflicting  Following supplementation  The  [68,69],  Taiwan  birth  a  highly  cautiously  concludes  supplements  will  first  studies  Rush  [69]  reappraisal than  that  of  of  The  Moderate  or  protein  and  The  "We  he  density  their  cost".  expect  poor  there  are  6  dietary  nutritional  [ 6 7 ] , The  that  [71],  [73],  Susser  prenatal  in fetal  is  Montreal  Study  Study  increments  energy  growth  considerably  by  Rush  to  same  the  authors  studies  Dispensary  gains  where  protein  women w o u l d benefit  and  of  Guatemala  Famine  with may  be  self  supplements  concludes, most  "We  benefit  d e r i v e d from  and  is  his  be  supplementation.  density  the  [ 7 0 ] , The  agrees  weight  high  whether  of  Study  This  Diet  also  use  of  review  York  these  Montreal  fetal  retardation.  is  under less  of  the  while  his  listed.  in a l l studies  subgroups  can  [74]  that  growth  Weight  weight  effectiveness  Dutch  modest  caveat of  New  Study  reviewed the  the  c o n c l u s i o n s reached  Susser,  above. low  the  Birth  prepregnant  critical  conditions. than  Low  weight.  produce  optimistic five  to  Bogota  [72]  that  [54,55,5,56,57,6,77]  as  on  The  low  gain,  programs,  Study  appropriate  findings  with  opinions  supplementation  Study  hoc  more  conclusion  achieved Both  by  authors  selection  from such  cited  moderate add  the  i s removed,  the  is associated must  favorable  next  dietary  with  decide services  services  fetal which and  justifies  19  The  largest  studied  i n  North  Program  f o r Woman,  administered Department  supplementation  America  the  through  t h e Food  that  of North  pregnant  program  gained  initial  p o p u l a t i o n and t h a t  also  increased.  duplicated Birth  more  Weight  program, The medical  weight  results  incidence  care  f o r Low B i r t h  of  3.1:1 f a v o u r e d  at  risk populations.  located  WIC  that  taking  Weight  into  Infants a  the implementation  i n 14  states  of Public  participated than  program  o f n o n WIC  o f WIC  Food  o f t h e U.S.  i n the  women  i n the  birthweight of their  showed  be  [75]  a  babies  evaluation reduction  1 0 . 1 % t o 6.0% b e t w e e n  groups  concluded  Services  pregnancy  t h e mean  and a l s o  from  a n d two c o n t r o l author  during  who  to  The program i s  by the School  Carolina.  women  The M a s s a c h u s e t t s  these  (W.I.C.).  19 WIC p r o j e c t s conducted  program  Supplemental  and N u t r i t i o n  i n the evaluation  found  Special  I n f a n t s and C h i l d r e n  at the University  They  i s  of Agriculture.  participated Health  nutritional  [76]  in  women  Low  i n the  woman. account  the  cost  benefit-cost type  of  ratio  programming f o r  JLO  REDUCTION  I N MATERNAL  There cigarette in  i s convincing smoking  [78] r e v i e w s h a v e  prematurity offspring the  o f smoking question  inadequate genetic  of  and d e l a y e d  food  factor  the f e t a l  under  Picone action  importantly mothers  appears growth  notes  consumption  effect  and Gordon  Weight  rates  increased.  cigarette  growth  that [77] for  Subsequent  smoking  retardation  with  in  the  mothers.  intake  smoking  i n Low B i r t h  and p r o l o n g e d  t o have  that  s t o p p e d smoking  could to  been  retardation  genetic  on  this  secondary  e t a l [87] r e i n f o r c e d of  the  Niswander  implicated  of whether  nutrition,  regarding  Weight.  the increase  and w h i t e s as c i g a r e t t e  literature  found  evidence  h a s on B i r t h  1972 d e m o n s t r a t e d  blacks  SMOKING  factors this  Low fetal  Birth growth  during  be  mediated  smoking  settled  or  by  i n smokers  Naeye t o be  or p l a c e n t a l finding Weight.  for  a  common  [79]  who  independent  underfunction. an  Naeye  retardation  pregnancy.  by  through  independent also,  and  was a b s e n t  when  .2.1 REDUCTION  IN  MATERNAL  Maternal severe al or  alcohol  both  moderate  pregnancy. tobacco  report  Both  intake  during  EFFECTS  OF  LIFE  Birth  Picone  between low  the  Rossett,  pregnancy.  STRESS  et  AND  stress  and  weight  al  [82] of  ITS  from  [87]  [80]  weight  to  women  ON  is correlated  Kaminski  et  following and  in  to  be  or  a  positively  late  in  of  growth drinking  WEIGHT  one  life  negative In  little  independent  BIRTH  anxiety  gain.  in  stopped  considered  a  result  decrease  who  REDUCTION  weight  and  be  reports a  maternal  may  pregnancy  demonstrated  pregnancy  gain  before  is frequently  resulting al  Little  association  offspring  Weight  et  pregnancy  reduction in birth ingestion  i n the  complications  retardation.  found  during  Low  a  alcohol  usage.  retardation  [89]  INTAKE  p r e n a t a l growth  [81]  [88]  ALCOHOL  of  stress.  correlation  companion to  the  paper,  lower  birth  weights. Other and  reviews  Lauterman  presumed  [84]  stress  and 1980  articles have  indicators  e.g.  dealt  that  with  i . e . wanted  or  Pohlman  concluded  that  positive  or  negative  i s almost  completely  found  effect  on  either  birth  weight  Pohlman  "maternal  pregnancy.  no  of  or  1969  attitude"  unwanted  "direct  [83]  status  evidence  lacking". gestation.  and of  either Lauterman  XL His  result  stresses  physical  cannot  be  and m e n t a l  generally exist  convincing  intervention studies  stress  increased  this  and  area  stress  is  e.g.  associated  birth  called  for.  poverty, with  both  for different  concerning  weight  were  Certainly  single  extrapolated  factors  prematurity  and  No  maternal  Further  study  associated  adolescence low  other  populations.  decreasing  found.  status,  as  are  birth  in with also  weight.  [5,6,23,45,54,55,77] It from  i s appropriate  two  intensive  to conclude  neonatologists'  writing  this  section with  i n the e a r l y  care:  " . . . 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 h e t h e r we s h o u l d b e e x e r t i n g our e f f o r t s i n prevent i n g t h e wreck r a t h e r than i n a s a l v a g e o p e r a t i o n . " [90]  1970's  a  comment  on  neonatal  A3 BIBLIOGRAPHY CHAPTER  I  1. U . S . D e p a r t m e n t H.E. & W.: I n f a n t M o r t a l i t y E a c h S t a t e and T e r r i t o r y a n d S p e c i f i e d P o s s e s s i o n 1 9 5 3 , 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 S u m m a r i e s V o l . 42 N o . 15 J a n . 1 9 5 6 . 2. U . S . D e p a r t m e n t o f H e a l t h a n d Human S e r v i c e s , N a t i o n a l Centre f o rH e a l t h S t a t i s t i c s . Monthly V i t a l S t a t i s t i c s Report V o l . 29 No. 9 B i r t h M a n a g e r D i v o r c e s a n d D e a t h s f o r S e p t . 1 9 8 0 . 3.  Vital  Statistics  Annual  Reports  of S t a t i s t i c s  Canada.  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 Unpublished D a t a 1 9 7 0 - 1 9 7 9 . 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. Health:A 6. Weight Health 7. of  Chalmers,I.iThe Search f o rIndices Better S u r v e y from The L a n c e t Nov. 17, 1979.  H e m m i n c k i , 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 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 , and S o c . Vol.56,No.3, 1978.  Wynn a n d Wynn: P r e v e n t i o n o f H a n d i c a p Women. R o u t l e d g e a n d K e g e n , L o n d o n , 1 9 7 9 .  8. Infant  Child Outcome:  and t h e Health  Health P r o f i l e : Miniseries No.l Birth D r . R.Tonkin, U . B . C , 1981.  9. Rooth,G.:Low 22, 1 9 8 0 .  Birthweight  1  Rep. S e r . No.457, 1970.  ,  Perinatal  w.h.O. T e c h .  Events and  R e v i s i t e d : The L a n c e t ,  March  11. Abernathy,J.R., Greenberg,B.G., Donnelly,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. S h a h , F . K . , A b b y , H . : E f f e c t s o f Some F a c t o r s o n Neonatal and Post Neonatal 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 Memorial Fund Q u a r t e r l y , 1971, 19:33-57. 13. Bergner,L., S u s s e r , M . W . : Low B i r t h W e i g h t a n d 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 . 1 9 7 0 4 6 : 9 4 6 - 9 6 6 . 14. Ressner,D.M., S i n g e r , J . , Kalk,C.E., Schlesinger,L.R.: I n f a n t D e a t h , An A n a l y s i s b y M a t e r n a l R i s k a n d H e a l t h Care. I n s t i t u t e o f M e d i c i n e , Washington, 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 1 9 6 2 - 6 6 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. Birth,  Wynn,G. a n d Wynn,M.: T h e H o p e o f P r e v e n t i n g C h a p t e r One, 1 9 7 7 .  Preterm  17. ' Verhoestrate,L.J., Puffer,R.R.: Challenge of Fetal L o s s P r e m a t u r i t y a n d 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, 1 9 5 8 . 18. Neonatal  Jansen,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 M o r t a l i t y i n New G u i n e a . T r o p . a n d G e o g . M e d . 1 4 , 1 9 6 2 .  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 a n d i n A b e r d e e n , S c o t l a n d . J . O b s t . a n d G y n e c o l . B r i t . Comm. 7 0 , 1 9 6 3 . 20. Scrage,R.F.R.: B i r t h Weight, P r e m a t u r i t y and Growth R a t e t o 30 M o 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. Abramowicz,M. , Kass,E.H.: Pathogenesis and Prognosis 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. Weight:  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 Canadian I n s t i t u t e o f C h i l d Health, 1981.  23. Chase,H. (Ed.): A Study o f R i s k s , M e d i c a l M o r t a l i t y . A.J.P.H. (63) Supp.1973.  and Infant  24. B e r g n e r , L . , Sussner,M.W.: Low B i r t h W e i g h t a n d 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 N o . 6 , Dec.1970. 25. Akesson,H.0.: C o n d i t i o n a t B i r t h and Mental D e f i c i e n c y . A c t a Genet. 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 Study o f t h e Growth and Development o f Prematurely and Maturely Born C h i l d r e n . Arch. D i s . C h i l d r e n 34:37 1 9 5 9 . 27. D r i l l i e n , C M . : The I n c i d e n c e o f Mental and 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 A g e d 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 . Paed. 27:452 1 9 6 1 . 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 Sequelae o f Prematurity, A L o n g i t u d i n a l Study. J.A.M.A. 1 6 1 : 5 8 1 1 9 5 6 . 29. King,J.F.: Guest 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 a n d I n f a n t O u t c o m e : R o g e r S. T o n k i n , B r i t i s h Columbia, 1981.  AS 30. Hess,J.H.: Experiences Gained i n a 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 4 2 5 - 4 3 4 ,  30-Year 1953.  Study  of  31. Douglas,J.W.B., Gear,R.: C h i l d r e n o f Low B i r t h Weight 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 a n d 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 . 51 820-827, 1976. 32. Sci.Am.  Silverman,W.A.: The L e s s o n 236(6) 100-107, 1977.  of Retrolental  Fibroplasia.  33. Bolton,D.P.G., Cross,K.W.: Further O b s e r v a t i o n s on Cost o f Preventing Retrolental Fibroplasia. Lancet l:445*-448, 1974. 34. Lubchenko,L.O., H o r n e r ,F.A., Reed,L.H., Et. A l . : Sequalae o f Premature B i r t h : E v a l u a t i o n o f Premature I n f a n t s o f Low Birth Weight a t 10 Years of Age. Am.J.Dis.Child. 106:101-115, 1963. 35. Weight 1979.  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 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,  36. Weight 1974.  Francis-Williams,J., and L a t e r I n t e l l i g e n c e .  Davies,P.A.: Very Dev.Med.ChiId.Neur.  Low Birth 16:709-728,  37. Fanaroff,A.A., Merkatz,I.R.: Modern Obstetrical Management o f t h e Low B i r t h Weight Infant Clin.Perinatol 4:215-237, 1977. 38. Kwang-Sun,L., Lawrence,M.G., Paneth,M., Recent Trends i n Neonatal M e n t a l i t y : The Canadian C M . A. J o u r n a l F e b . 1 5 V o l . 1 2 6 , 1982.  Tyler,S.: Experience.  39. Weight Child.  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 I n f a n t s i n England and Wales from 1953-1979. Arch.Dis.of 1 9 8 1 56 8 6 - 8 9 .  40. Centre Vol.29  U.S. D e p t . o f H e a l t h a n d Human f o r Health S t a t i s t i c s : Monthly Vital #9 S e p t . 1980.  41. Challenge  Services, National Statistics Report  S h a p i r o , S . : New R e d u c t i o n i n Infant Mortality: 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  42. Leek,S., Paneth,M., M o r t a l i t y : An A n a l y s i s o f t h e A m . J . P u b . H . 1 9 8 0 70 1 5 - 2 1 .  The No.4.  Gartner,L.M., E t A l . : Neonatal Recent Improvement i n t h e U.S.  43. 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 B e D o n e 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 1 9 7 8 32:231-232. 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 L o w 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 G e n e v a W.H.O., 1 9 6 1 .  45. Knobloch,H., Pasaminich,B.: Environmental Factors A f f e c t i n g Human D e v e l o p m e n t B e f o r e a n d A f t e r B i r t h . Paed. 1960 26:210-218. 46. Lubchenko,L.O., Hansman,C, Cressler,M., Boyd 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 Live Born Birth Weight D a t a a t 2 4 - 4 2 W e e k s o f G e s t a t i o n . P a e d . 1963 32:793-800. f  47. Lubchenko,L.0., Searls,D.T., Brazie,J.V.: Neonatal M o r t a l i t y Rate: Relationship to Birth Weight and Gestational A g e . J . o f P a e d . O c t . 1972 V o l . 81 #4 814-882. 48. Liveborn Infants.  B a b s o n , S . C , Behrman,R.E., Birthweights for Gestational P a e d . 1970 4 5 : 9 3 7 - 9 4 4 .  49. McDonald,A.: Children M.E.I.U. R e s e a r c h Monograph #1 S o c i e t y Heineman 1967. 50. and  D r i l l i e n , C M . : The S m a l l Prognosis. Paedeiatric C l i n i c s  Lesser,R.: Fetal Growth. Age o f W h i t e M i d d l e Class  of Very Low Birth London M.E.I.U. of  Weight. Spastics  f o r Dates Infants: Etiology 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 Birth Weight Postnatal Physical Development. Dev.Med.Child Neurol. 11:314-329.  and 1969  52. Neligan,G.A., Kolvin,I., Scott,D.M., Garside,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 I n . t l .Med . P u b . H e i n e m a n , 1976. 53. Pape,K.E., W i g g l e s w o r t h , J . J . : Haemmorhage, Ischaemia 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 of Develop. 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. Birth  Waner,G., M i l t o n , T . : W e i g h t . A m . J . E p i d . V o l 91  55. A.J.P.H.  Eisner,V., Et A l . : S e p t . 7 9 . V o l . 6 9 #9.  Demographic Correlates No.3 1 9 7 0 p.260-272.  The  Risk  of  Low  Birth  of  Low  Weight.  56. I n f a n t D e a t h : An A n a l y s i s b y M a t e r n a l R i s k a n d Health Care Contrasts i n Health Status Vol.1. Institute of Medicine, 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. Klein,R.: Mortality Perinatal  Lechtig,A., Delgado,H., Martorell,R., Yarborough,C., 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 Infants Growth and in a Developing Country. 5th European Congress Medicine 1976.  XI 58. Eastman,J.J.: O b s t e t r i c i a n . Am.Pract. 59. Mortality. 1961.  P r e m a t u r i t y from the 1:343-352, 1947.  Viewpoint  Oppenheimer,E: Population Changes and Amer.Jour. P u b l i c J o u r n a l P u b l i c Health  of  the  Perinatal 51:208-216,  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., Greenstein,F.: O u t o f W e d l o c k B i r t h s i n New York City I I . Medical Aspects. Amer.Jour. P u b l i c H e a l t h 51:846-865, 1961. 61. Terris,M., Glasser,M.: A L i f e Table Analysis of R e l a t i o n of P r e n a t l Care to P r e m a t u r i t y . A.J.P.H., Sept. Vol.64 No.9. 62. Public  Shwartz,A, V i n y a r d , J . : P r e n a t a l Care and H e a l t h R e p o r t s V o l . 80 N o . 3 , M a r c h 1965.  63. Health  of  65. Antenatal page 78.  Prematurity  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 t h e Newborn. A.J.P.H. J u l y 1979, V o l 6 9 #7.  64. Quick,J., Pregnancy Outcome M u l t i v a r i a t e Cohert  the 1974  on  the  G r e e n l i c k , M . , Roughman,K.: P r e n a t a l C a r e in a H.M.O. a n d General Population: A n a l y s i s . A . J . P . H . A p r i l 81 V o l . 69 #7.  Hall,M., Chng,P.K., MacGi11ivray,I.: C a r e W o r t h W h i l e . The L a n c e t , July 12,  66. Reid,M.L., Effectiveness. Medical  Is 168  M o r r i s , J . B . :•. P e r i n a t a l Care C a r e , May 79 V o l . X V I I No.5.  67. R u s h , D . , S t e r n , Z . , S u s s e r ,M.: Diet in Randomized Controlled Trial of Prenatal @ 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 . 1 9 7 9 . 68. Higgins,A.C.: Nutritiona, t l t u s and the 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 37:17-35.  and A  Routine No.8185 and  Cost  Pregnancy: A Nutritional Outcome  of  69. Rush,D.: Nutrition Services During Pregnancy and Birthweight: A Retrospective Matched Pain Analysis. CM.A.J. S e p t . 15 1 9 8 1 , V i o l . 1 2 5 p a g e 5 6 7 . 70. Nutritional Jour. C l i n .  Mora,J.O., deParades,B., Wagner,M., Et Supplementation and t h e Outcome o f - P r e g n a n c y . N u t r i t i o n 1979 32:455-62.  Al.: Amer.  71. Habicht,J.P., Yarborough,C., Lechtig,A., Klein,R.E.: R e l a t i o n of M a t e r n a l Supplementary Feeding During Pregnancy to 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 Factors. In: Winich,M. Ed. Nutrition and Fetal Development. Proceedings on the Symposium on Nutrition and Fetal Development 1974 Correct 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. John Wiley and Sons, 1974 127-146.  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 Maternal Diet on O f f s p r i n g . <A S t u d y i n Juilien, Thailand 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 . , Susser,M., Saenger,G., E t A l . : Famine and Human D e v e l o p m e n t . T h e D u t c h H u n g e r W i n t e r o f 1 9 4 4 / 4 5 . New Y o r k , Oxford U n i v e r s i t y Press. 1975. 74. Susser, M.: P r e n a t a l Nutrition, 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 Development: An O v e r v i e w o f Experiments, Quasi Experiments and Natural Experiments i n t h e Past Decade. Amer. J o u r . C l i n . N u t r i t i o n 34 A p r i l 1 9 8 1 7 8 4 - 8 0 3 . 75. Edozien,J.C., S w i t z e r ,B.R., Bryan,R.B.: Medical 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 F o o d P r o j e c t f o r Women, Infants 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 , School of Public Health, U n i v e r s i t y o f North C a r o l i n a , Chapel H i l l , N.C., 1976. 76. K e n n e d y , 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 o n B i r t h Weight. 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 (Doctoral Thesis). 77. Niswander,J., Gordon.: The Women P r e g n a n c i e s . I.S.Department,H.E.and W. National H e a l t h , 1972.  and Their Institute of  78. Smoking and H e a l t h : A Report o f t h e Surgeon H.E.W. P u b . N o . ( P H S ) 7 9 - 5 0 0 6 6 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 During Pregnancy on F e t a l and Childhood G y n e c o l . V o l . 57 N o . l , J a n . 1 9 8 1 . 80. Decreased 12.  Little,R.E.: Infant Birth  General.  Cigarette Smoking Growth. Obs. and  Moderate A l c o h o l Use D u r i n g Pregnancy and W e i g h t . A . J . P . H . D e c . 1 9 7 7 V o l . 67 N o .  81. Kaminski,M., Rumeau-Roquette,C., Schwartz,D.: C o n s u m m a t i o n d ' A l c o o l C h e z L e s Femmes Enceintes e t Issue de G r o s s e s s . Rev. Epidem. e t Saute P u b l . 24:27-40, 1976. 82. Rossett,H.K., Weiner,L., E t A l . : Reduction i n Alcohol Consumption During Pregnancy With Benefits 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 1 9 8 0 . 83. Pohlman,E.W.: U n d e s i r a b l e Consequences.  Unwanted Conceptions: C h i l d F a m . 9:240 1 9 6 9 .  Research  on  84. Laukern,V.H., Vandenberg,B.J.: The R e l a t i o n s h i p o f Maternal Attitude to Pregnancy Outcomes and Obstetric C o m p l i c a t i o n s . A . J . O b s t e t . a n d G y n e c o l . V o l . 136 No. 3 February 1980.  85. Clin.  Johnson,J.W., Dubin,N.: P r e v e n t i o n o f Preterm Labour. O b s t e t . a n d G y n e c o l . V o l . 23 N o . 1 M a r c h 1 9 8 0 , p a g e 5 1 .  86. Zelnik,M., Kantner,J.F.: Sexual 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 Y o u n g U n m a r r i e d Women i n t h e U.S. 1 9 7 6 a n d 1 9 7 1 . Family Plan Perspect. 9 55, 1977. 87. Picone,T.A., Lindsay,H.A., Schramm,M.M., 01sen,P.N.: P r e g n a n c y O u t c o m e i n N o r t h A m e r i c a n Woman I : E f f e c t s of Diet, S m o k i n g a n d P s y c h o l o g i c a l S t r e s s o n 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 , 1205-1213. 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 as 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 . Psychosom. M e d i c i n e 1974 36:352-362. 89. Picone,T.A., Lindsay,H.A., Schramm,M.M., 01sen,P.N.: P r e g n a n c y O u t c o m e 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 of Diet, S m o k i n g , S t r e s s a n d W e i g h t G a i n on P l a c e n t a s and on Neonatal P h y s i c a l and B e h a v i o u r a l Characteristics. Amer. Jour. Clin. N u t r i t i o n 36, Dec.82 1214-1224. 90. Walters,J.H., Effer,S., Ramapralash,H. Et A l . : E x p e r i e n c e With 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 Care U n i t . Amer. J o u r . O b s t e t . and G y n e c o l . 1 9 7 3 . 115:307-315.  3o  CHAPTER THEORY, R A T I O N A L E THEORY AND  the  low  measure  Pedietry,  conclusion  birth  of  it  more  as  i t does  terms  than  it  of  to  "A  a  mortality,  areas  outcomes. to  Obtain  better  a  is  and  In  real  risk"  that of  on  best  i s that  is a  a  measure  better  outcome  mortality  infant  order the  rates,  morbidity  to  and  a mechanism  and  these  Child  and  resources resources  this  Health  of  the  in  (adopted  Care").[1]  population.  where h e a l t h  of  human  information  surveillance the  be  allocation,  measurement  for  make  of  development  the of  care.  individuals  or  segments  anticipatory  characteristics  funding  exercises  facilitate  Make p r e d i c t i o n s r e g a r d i n g  Provide  of  ensure  needs  diagnosis  care  preventive  following  health  will  health  use  i n communities  provide  standards  different 4  STUDY.  are  scarce  to Maternal  2  3  the  undertake  Approach  "at  that  t h a t make  the  realistic  than  restraints  Identify  population  I,  community  infant  1  deficient  of  care  casualties  with  rate  health  reproductive  by  i n Chapter  imperative  improved  Risk  reached  economic  ever  i s neccessary  from  OF  disorders.  present  allocated  weight  maternal  developmental The  OBJECTIVES  RATIONALE  A major of  AND  II  indicative  the  level  of  of  a  care  to  individuals  of  special  a  care  required  community.  risk.  and  groups  SI  5  Improve  allocation rational of  of  would  Simply  that  in  order  the  best  their  risk  they  contain  [1]  Risk  of  criteria  to  for  the  to  the  contribute and  unplanned  risk  planning,  "self  evaluation  are  and  No. 39  WHO  Maternal Geneva  by  utilized  education, to  high  &  risk  Child  of  health  care by  more  cases".  Health  a  income,  resources.  distributed;  d i s p o r p o r t i o n a t e l y few  for  to  s e r v i c e s are  proximity  randomly  utilization  approach  selected  residence  scores  Approach  Pub.  the  such  population place  minimize  stated  without  influence,  Offset  resources  develop  organization, administration  process  resources. proposes  and  services.  This  of  health  planning,  health  part  knowledge  At  usually  [1]  Care.  W.H.O  1978.  Hypotheses  The of  hypotheses  singleton, live 1  non  have  low  birth  2  a  of  3  non have  a  behavioural  traits  delivery  a  birth  of  weight  low  tested low  different  a  low  be  born,  weight  have  mothers  to  birth  this weight  biomedical  study  are  infants  profile  that  mothers  will:  than  mothers  of  infants; different  birth higher that birth  infants.  in  weight  sociodemographic  been  weight  than  infants;  prevalence have  profile  of  potentially  associated  infant,  than  with  the  mothers  of  alterable subsequent non  low  3Z Research  Objectives  The  o b j e c t i v e s of  1  differentiate  between  the  2 two  two  groups  describe  groups  of  3 which  the  the  of  the  present  study  are  to:  differences in biomedical  profiles  mothers;  sociodemographic  d i f f e r e n c e s between  the  mothers;  define  the  differentiate  potentially  the  two  alterable  groups  of  behavioural  traits  mothers.  Significance  If  low  preventive the  birth  prenatal  extent  population  of  under  care  the  at  the  higher  causative  known  more  for  A  Vancouver.  chosen  the  risk  for  exist  in  about  those  a  priority  important  whether  there  condition,  and  the  particular  This  study  factors  is  than  for  to  charactereristics  the  interaction.  information  as  intervention i t is  factors  know  of  the  exists whether  population expected  i s at  to  present  Vancouver.  further exercise  analysis  be  condition occurs,  consideration for  provide  i s to  condition,  i n which  subpopulations alterable  weight  of  the  present  Its goals,  described  in  perinatal  health  in a  relation in  later prenatal  content to  the  chapter  and  preventive outcome  demography  Vancouver.  will  and  be  brief  program  measures present  a  in  will  be  measures  of  33 CHAPTER  III  METHODS  RESEARCH  DESIGN  The  hypotheses  collected control quota the  from  group  two  know  i f the  that  the  will  population people  or  of  Cases: weighing  less  1981  November  Controls: the  control  at  quota  chosen  reliable  may  sub  were  groups  also  data  cases,  and  a  assumed  that  generalizations  about  that  their  been the of  pooled  is  recognize  have of  of  It  represent  elements  between  group  sampling.  fully  selection  we  not  category  biased  and  towards  population cases  do  more  in  and  some  controls,  made.  a l l  mothers  at b i r t h ,  delivering  born  between  infants  June  1st,  1981.  group. case  of  gms  30th,  quota  had  2501  following  f o r each  1  o f m o t h e r s . -A  consisted  than  The  control  comparing  Categories  These  and  by  r e p r e s e n t e d . We  for ethnicity,  Selection  tested  provided  attractive  Comparisons  matched  have  interviewer  acceptable cases.  groups  g a t h e r e d by  sampling  control  were  criteria The  an  adopted  interviewers  a mother  delivered  were  for selection  would  select  of  as  a  who:  infant  weighing  more  than  2500  gms  birth; 2  was  notification 3  the  following  resided  subsequent the  within  birth the  non of  a  service  low  birth  "case" area  of  weight  birth  infant; the  interviewer;  3*  4  could  interviewed The  the "case"  possible  and  some  between  by  t h e same  matching  case  variation  pairs,  status  interviewer  as  had  designed  to  mother.  seasonal  control  socio-economic for  interviewed  s e l e c t i o n of the c o n t r o l quota  eliminate case  be  in  eliminate  between of  sample  was  birth  weight  major  variations  case  and  control  ethnicity  in  ethnic  and c o n t r o l s ,  and  enhance  between  pairs,  in  provide  neighbourhoods"  interpair  interviewer  consistency. It low does  i s appreciated  birth  status  not of necessity  Infants 2500  weight"  could  have  & 2750gm who  fact  fell  into  fell  into  t h e S.G.A.  The were  included  t h e L.G.A.  controls more  s t i l l  >90th  than  "non  2500gm)  for Gestational  some  Age. F i v e  by  infants be  %ile,  between  classified  control  Age  infants  1 control  by in  infant  category.  Interviewer  Vancouver  Health  Departments  as i n t e r v i e w e r s  1  Under  the  prevent ion  mothers  residing within Following mothers;  Community  f o r the following  receiving notification  new  wouJ.d  category  already  all  Large  as c o u l d  for Gestational  chosen  2  ( i . e . weighing  normality.  by g e s t a t i o n  as Small  of  the s e l e c t i o n of  only  imply  been  Lubchenco  Choice  that  program  of a l l l i v e  Health  Nurses  reasons: mandate  and s t i l l  they births  were to  Vancouver;  such  notification  they  routinely  visited  SS  3 face  As  a discipline  interview 4  techniques  I t was  volunteered  to  interviewers  were  Choice  of Face  The  over  saying  and  and  considered the  viewed  to Face  other  methods  as  the disadvantages.  individuals and  inter  steps  as  were  conducted  to minimize  t h e number small  as  [88] w e r e  course  of a and  3 ambiguities  and  a  exists  technique  was  higher,  yea  are review  may  in  some  period.  of  relevant  the  advantages  the  fact  20-30  Inter  therefore  pair  be  that  different  inconsistency  quite  high.  Five  this:  discussions on  period.  ambiguities  which  the  Data  rates  by  of subjective  held  9 month  Field  i f  interviewer  responses  was  possible;  Extensive  nurses  information  higher  situation  of bias  variation  2  defined  source  observer taken  be  interview  this  major  t h e s i x month  were  to  [1,2,4,5,6,7,8]  over  1 kept  in  of  to C o l l e c t  are lessened,  that  i n face  professionals.  response  outweighed  interviews  quality  would  personal  indicated  the  the  Interviewers and  are a l ltrained  collection;  as h e l p i n g  underreporting  potential  data that  literature  A  they  interviewers  questionaire  chosen  group  were  four  a l l  different  During  removed  testing  with  as  of  rectified;  these  potentially occasions  meetings  f a r a s was 20  involved over  criteria  the were  possible;  questionnaires  revealed  4  A  identical  small  subjects  number  of  to  inter  test  interviews  were  observer  conducted  variation  -  with  which  was  low; 5  Interviewers  investigator  whenever  were  encouraged  ambiguities  or  to  doubts  contact  the  arose.  Process All 2501  notifications  gms,  born  between  initiated  a  Community  Health  carried A],  a  form  special  with  her  statement [Appendix She  carried mother  that  wished  and  would  to  generated grouped  correction was  the  the free  refusal  that  purpose to  B]  less  than  30th,  1981  The  area  procedure. but  questionnaire and  an  refuse  or  way  conducted  in  addition,  [See  Appendix  informed  the  the  Chi  survey  survey to  and  consent  usual  was  the  being  informed  participate  compromised  her  the  as  she  services  assessment  she  and  then  mother. were  Data  investigator.  using  special the  questionnaires  the  a  of  i n no  investigator.  and  selected.  November  contact,  [Appendix  mother  i n t e r v i e w the  data  weighing  and  usual  Weight  protocol  was  that  by  1981  interview  Birth  stated  the  infants  C].  Completed Units  personal  Low  of  1st,  a of  she  to  June  made h e r  r e c e i v e . She  proceded  birth  Nurse  informed out,  of  was  t  hand  statistical  test.  A  from  coded  Differences  Square  students'  returned  and  were  the  Health  tables  were  examined  for  test  with  significance  level  Yates of  .05  The  Instrument The  questionnaire  Section  has  nine  subsections  [See  Appendix  A]:  A:  Information that  birth  data  sources  weight  Statistics interest  of  used  the  are  misdating  This  'as  is"  Provincial  recorded +  or  i s noted  gestational  by  age  1  the  Department  oz  Where r e c o r d i n g e r r o r may  David  [10]  from  LNMP,  i m p l a u s i b l e low  are  reported  in his  large series.  by  Naeye and  Dixon.  [10]  to  bias  birth  as  1.3%  It  of  birth  to  has  occur  due  i s the  potential  for  recall  or  coded  and  gestational  i n the  is  i n ounces  are  small  study  digit  age  S i m i l a r f i n d i n g s are  numbers  Vital  Most  incorrecrtly  These percentages  These  of  maternal  weight  document  taken.  error.  Approximately  small  were  of  i n gms. -  data  this  sources  biologically  relatively  by  from  Health.  records.  Section  is  of  obstetrician  the  It  Ministry  possible  a probable  preference.  Notice.  g e s t a t i o n a l age  examine  (95%)  occurred,  and  are  to  weights  from B i r t h  data  reported  enough  not  group.  B:  Consists circumference  of  w e i g h t was  Health  Department and  record  measured  Infant  recorded  a  at  of time  discarded baby  discarded  infant of due  height,  weight  Community H e a l t h to  s c a l e s . Other  inaccuracy data  were  and  Nurse of  head visit.  Vancouver  inconsistently  3?  Section  C:  Maternal weight frame  gain size  provided of  against  were was  by  height  height,  gathered  estimated  ACTION  and  Maternal  frame  which  B.C.. size  were  Department  Kinesiology  that  the  of  solely using I t was would  prepregnant  calculations  margin  for  not  prepregnancy  a  from  weight  Simon  uncertainty  3  anticipated  performed at  maternal  simple  give  and  weight  a  as  pregnancy  recall.  Maternal  category that  range  could  and  a  of  be  assessment combination  ideal assessed.  discussions  Fraser  with  University  inacurracy  weight  was  too  The the  suggested great.  39 Section Socio  D:  Associated  Behavioural Alcohol  Risk  Variability  Index [ 9 ] .  A  food  time,  i t was  felt  expenditure  John  Hopkins A  estimate in  Section  status  and  Section  F: H e a l t h  that  solely  subject  to errors  Section  G;  Linguistic  English designed  Callahan's  a s was  at  been  month/mother  the  represent  a  developed  have  as  accurately  retrospect  [12] w o u l d  Medical  Health  was  composite by  Green  at  preferable.  was  f o r adequate  the  United  pregnancy  Way  nutrition  care  History  a compilation  presented  nature  Community  such  to  for inclusion, more  In  expenditure  information  collected  chosen might  per  according  i n 1981.  mother,  The  index  o f $75.00  E: Maternal  This  was  nutrition.  o f minimum  Vancouver  analyzed  this  University  figure  i s  budget  that  on  socio-economic  -  II  consumption  monthly  Factors  i n Part  utilization,  and  extent  from  maternal  of r e c a l l  ability Nurse.  i s correlated  A  was  of  or  this  private  recall.  As  recalled  by  the  questionnaire.  and  public  care  utilization  such  these  data  was are  acquiescence.  [3]  to prenatal  to substantiate  of the  health  derived  Yarie  of that  from has  the assessment  of  the  shown  that  fluency  in  attendance.  This  section  is  finding.  40  Ethnic  Characteristics  This and  is  recognized  practical  ethnic  in  their  accepting  and  linguistic  heritage.  which i.e.  own  category country  of  birth  categories  chosen  Board  1977  It  in  was  would  a  expected be  and  that  Canadians  the  of  or  Placement and  the  in  a  the  second or  these  thus  cultural,  and  deciding  also the  upon  information  elicited.  Second  Language  Vancouver  largest  Pakistani  of  essentially  Additional  third  groups  town,  category  was  of East  categorizations  by  Indo  variety  of  chosen  and  a  of  subject  tongue  English  Chinese  ten  sensitivity  Chinese,  parts  subject.  mother  of  Many  used  r e f l e c t e d those  survey  etc.  survey  fitted  recognized  geographical,  interviewer  best  by  "Canadians",  days, a  origin).  the  usage  etc.,  cultural  This  characterized  e.g.  expressing  (ethnic upon  Common  Greeks,  celebrate  depended  area  Vancouver  Italians,  ethnicity  an  difficulty.  "type"  Indians,  as  School  pupils. ethnic (East  The  [13] groups  Indian)  origin. The that  investigator  the  bulk  of  Southeast  China  and  diverse  origins,  Indies,  the  of  Canadians  Indo  Punjabi,  aware  Chinese Hong  i.e.  United  Fijian  was  Kingdom are,  Indians  commencing  Canadians  Kong  India,  before  and  that  come  F i j i .  The  in  decreasing  and  Ismailis.  originally  Indo-Canadians  Pakistan,  and  the  East three  Africa, largest  numerical  survey from  have  more  The  West  subgroups  significance,  m Country survey  as  of  birth  many  visibly  anthropologists been  born  survey  Language,  that are  The  Canadian  low  In  the  and  the  Indo  This Community  origin.  weight  survey  of  ethnic  have  School  Board  schools,  English  Second  will  categorization be  discussion used.  East  That  Indian  would  Health Nurse. not  as  H e a l t h Needs  information  was  of C h i n e s e  i s attached  Further  information  be  integrity"  born.  the  will  the that  Vancouver  classified  nomenclature  In  in  for  lives  Vancouver  language  nature  tables  living  cultural  1982  children  inadequate  used  as  terms is  be  the  reflecting  Chinese  will  in  is  more  will  be  properly  Canadians.  literature  H;  The  Canadian  origin  Canadians,  "maintaining  second  of  in fact  of Chinese  birth  Section  50%  a  instrument.  citizenship  A  as  indiosyncratic  recognized.  called  as  d i s c o u n t e d as  ethnic  country.  English  discovered  survey  define  in this  of  a l o n e was  The  an  and  East  appendix  of Mother  have  reflected  vast  majority  tabulated.  Indian  status  and  to Chapter I I I .  and/or the were  Child  assessment left  of  blank.  the The  Implementation The discussed and  rationale, with  the  Evaluation  D i r e c t o r of  Committee of  Executive  Committee  Prenatal  Infant  Vancouver  Health  The the  cost  of  department  investigator The  to  of  the  and  Prevention  the  Vancouver  of  the  Programs,  Vancouver  Preschool  the  survey  Health  Health  Planning  in nursing  approval  study the  were  Research  Department,  the  Department  and  the  Committee  of  the  in  time  principle  was was  acceptable given  to  for  the  in  orienting  the  the  questionnaire,  proceed.  f o l l o w i n g nine  and  design  Department.  and  Community H e a l t h testing  o b j e c t i v e s and  Nurses  months i n the  reviewing  were  spent  department  i t , meeting  C o m m i t t e e U.B.C. a n d  assuring  f l o w were understood  and  that  operative  for  the  clerical  criteria procedures  w i t h i n each  of  the  of and six  Ethics paper units.  Procedure Questionnaires Questionnaires coded the  and  were d i s t r i b u t e d  were  returned  to  t a b l e s were generated.  Chi-Square  significance  and  level  of  the .05  the  Health  Units.  i n v e s t i g a t o r . Data  Differences  Students' was  to  t  selected.  Completed was  were examined  Statistical  hand using  Tests.  A  Hi  BIBLIOGRAPHY CHAPTER  III  1 Aday,L.A., S e l l e r s , C , Anderson,R.M.: 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. 1981 V o l . 7 1 N o . 8 . 2 and  Potentials of A.S.P.H. A u g .  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 P r a c t i c e : McGraw H i l l Book C o . C o p y r i g h t 1975 p . 7 2 - 7 3 .  3 Yarie,S.F.: A study of Factors Influencing Utilization of 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 the 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 1 9 7 8 p 7 9 . 4 K l e c k a , 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 comparison to personal surveys. Public Op. Q u a r t e r l y 1 9 7 8 42:105-114. 5 Siemiatycki,I.: A comparison of m a i l , telephone and home interview strategies f o r household health surveys. Am.J.Pub. H e a l t h 1979 69:238-245. 6 the  Tyebjee,T.T.: Telephone Survey methods a r t . J . M a r k e t i n g 1979 43:68-78.  the state  of  7 Usdhen, H e a l t h Survey Res. Methods: C o n f e r e n c e D.H.E.W. P u b . N o . ( P . H . S . ) 79-3207 U.S. G o v ' t . P r . O f f . 1 9 7 9 .  Second Biennial Washington D.C.  8 Usdhen, H e a l t h Survey Res. C o n f e r e n c e D.H.E.W. P u b . No. ( P . H . S . ) U.S. G o v ' t P r . O f f . 1 9 7 9 .  Second Biennial Washington D.C.  Methods: 79-3207  9 Calahan,D., Cisin,I.H., Crossley,H.M.: American 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 Study o f D r i n k i n g Behaviour and A t t i t u d e s . New B r u n s w i c k , N . J . R u t g u s 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., Dixon,J.B.: D i s t o r t i o n s S t a n d a r d s . P e d i a t . R e s . 12:987-991, 1978.  i n  Fetal  Growth  11 David,J.R.: The Quality and Completeness 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 Birth A . J . P . H . S e p t . 1980 V o l . 7 0 No.9 p . 9 6 4 . 12 health  of files  Green,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 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 N o . 9 S e p t . 1 9 7 0 .  13. E l l i s , E . N . : Survey o f P u p i l s i n Vancouver Schools f o r Whom E n g l i s h i s a S e c o n d L a n g u a g e . R e s e a r c h R e p o r t 7 7 - 0 1 V . S . B . May 1 9 7 7 .  HH  CHAPTER I V  RESULTS  TABLE I  F o r 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 I n f a n t s b y U n i t and E t h n i c i t y Unit  Can.  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  E.Ind.  Chin.  N.Ind.  Thai.  Port.  Ital.  P h i l i . Other  Total  RESULTS  TABLE I I  Low B i r t h Weight and Non-Low B i r t h Weight I n f a n t s b y E t h n i c i t y o f Mother Ethnicity  No.of c a s e s  %  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 W h i t e  49  45.8  40  40.4  Native  4  3.8  2  2  Chinese  14  13.1  18  18.2  East Indian  23  21.5  11  11.1  Italian  1  .9  4  4  Spanish  -  -  3  3  Portuguese  2  1.9  4  4  Thai/Lao/Viet  3  2.8  -  -  Phillipino  2  1.9  7  7.1  Other  7  6.5  7  7.1  Total  107  100  99  99.9  Indian  RESULTS  TABLE I I I  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 f a n t s b y M a t e r n a l Canadian, C h i n e s e & E a s t I n d i a n sk  Canadian Case[45] C o n t r o l [ 3 9 ]  Chinese Case[13] C o n t r o l [ 1 8 ]  Risk Factors  East Indian Case[22] C o n t r o l [ 1 1 ]  Prev. Misc/A.B. /S.B.  22  14  6  1  8  2  P r e v i o u s Low B i r t h Weight  6  3  1  _  4  _  IPI < 12/12  5  4  6  1  4  1  No s u p p o r t  9  2  -  -  -  -  <75/mth  1  1  1  1  1  1  SA  5  1  -  -  -  <= l p k / d  16  8  3  1  > lpk/d  6  2  -  -  -  -  < 251b.  22  8  7  3  12  2  HI  RESULTS  TABLE IV  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 f a n t s b y M a t e r n a l M e d i c a l and b y C o m p l i c a t i o n o f Pregnancy f o r Mothers: Canadian, C h i n e s e & E a s t I n d i a n  Problem  Canadian Chinese East Indian Case[49] C o n t r o l [ 4 0 ] Case[14] C o n t r o l [ 1 8 ] Case[23] C o n t r o l [ 1 1 ] M e d i c a l Problem  Diabetes Hypertension  7  Epilepsy  1  Cardiac  Disease  Renal D i s e a s e  1  Other  Pregnancy Complication  Toxaemia  4  -  -  Placenta Praevia  2  -  ' -  Placenta Insuff.  1  -  1  Ante.Partum Haem  6  -  -  Ultrasound  9  2  -  2  1  1  2 1  1 1  4  •HZ  RESULTS  TABLE V  Mothers o f Low B i r t h Weight  Infants  Term and P r e t e r m b y E t h n i c Group, P a r i t y , C a r e , Tobacco and A l c o h o l  Para 1 2 3 4 4+  Canadian Term P r e t e r m  Chinese Term P r e t e r m  East Indian Term P r e t e n  10 4 1 2  3 3 1  2 3 2 1  —  12 8 4 5 . 1  1 3 1 1  -  -  -  5 3 5 1 1  —  Doctor V i s i t s Mean Range  11 6-18  9.4 3-17  11 8-15  9 6-12  10 3-18  8 4-12  VHD  3  10  2  3  1  -  •-  -  -  -  Prenatal  Other P r e n a t a l 3  5  Healthiest Babies Possible  _  Tobacco  5  17  1  2  -  -  Alcohol*  3  6  -  -  -  -  # o f cases  17  30  8  6  8  15  1  1  -  * Moderate o r heavy i n any t r i m e s t e r . Term = 38 o r more weeks o f g e s t a t i o n . P r e t e r m = l e s s t h a n 38 weeks o f g e s t a t i o n  RESULTS  TABLE VI  Low  E t h n i c Group b y Care D u r i n g Pregnancy B i r t h Weight and Non Low B i r t h Weight Mothers  Canadian Case C o n t r o l  Chinese Case C o n t r o l  East Indian Case C o n t r o  34 11  13  22  —  Instituted care i n 1st T r i m e s t e r 2nd T r i m e s t e r 3rd T r i m e s t e r  -  -  -  # Doctor 1-5 6-8 9-12 > 12 MEAN  4 9 21 11 10.2  -  -  —  1 26 11 12.2  2 10 1 10.3  3 11 4 10.6  Recalled Ultrasound 1st T r i m e s t e r 2nd T r i m e s t e r 3rd T r i m e s t e r  12 10 6  11 8 7  5 2 3  -—  Repeat v / s  15  10  Prenatal Classes V.H.D. Other  13 8  12 12  Healthiest  1  1  Visits  Babies  33 5  14 3 1  8 3  -  -  1 2 16 3 9.9  2 7 2 10.3  _  5  6 5 5  4  2  5  -  5  _  8  1  —  2  1  2 3  1  _  50  RESULTS  TABLE V I I  Case and C o n t r o l C h i n e s e and E a s t Indian Mothers b y E n g l i s h Comprehension E n g l i s h Comprehension  Chinese Case Control  NIL  3  POOR  -  FAIR  4  GOOD  10  NO INFORMATION  East Case  Indian Control  1 2  1  6  3  3  9  16  7  1  51  RESULTS TABLE  Case and C o n t r o l M o t h e r s E t h n i c G r o u p and A l c o h o l Use  by  Alcohol  VIII  Canadian Case Control  Chinese Case C o n t r o l  East Case  Indian Control  None  11  7  8  14  19  9  Rare  25  28  6  4  3  2  Moderate*  7  4  -  -  -  -  Heavy*  -  -  -  -  -  -  *In  any  Trimester  Rare = consuming a l c o h o l less d r i n k s on any one occasion. Moderate  =  Heavy = a t d r i n k s per  A  drink  =  less  than heavy  l e a s t 5-6 month.  1 oz.  drinks  Spirits;  than  once  and more  month  and  never  5-6  rare.  on some  4  than  per  occasions  and  at  oz. Wine;  or  12  oz.  Beer.  least  45  RESULTS  TABLE IX  Case and C o n t r o l Mothers by P a r i t y . Canadian Case C o n t r o l  Chinese Case C o n t r o l  E a s t Indian Case Control  PRIMIP  22  14  4  8  7  4  MULTIP  25  25  10  10  16  7  S3  RESULTS  TABLE X  Case and C o n t r o l Mothers by Age. Age  Canadian Case C o n t r o l  <15  2  Case  Chinese Control  -  -  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  35-40  6  -  -  2  -  -  15-19  5  -  -  E a s t Indian Case Control  1  1  RESULTS  TABLE XI  Case and C o n t r o l Mothers: P r o p o r t i o n a l R e p r e s e n t a t i o n o f Three E t h n i c E t h n i c Group  Case  Groups  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 X I I  Low B i r t h Weight I n f a n t s by E t h n i c i t y C h a r a c t e r i z e d b y Lubchenco S c a l e a s : Small f o r G e s t a t i o n a l Age (SGA), or 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).  Ethnicity  AGA  %  SGA  %  Canadian  27  57.5  20  42.5  Chinese  7  50  7  50  East  13  56.5  10  43.5  47  56  37  44  Total  Indian  RESULTS  TABLE X I I I  Low B i r t h Weight and Non Low B i r t h . W e i g h t I n f a n t s b y E t h n i c i t y and P r e m a t u r i t y (<38 weeks)  ETHNICITY  CASE PRETERM  TERM  %  Canadian  16  34  Chinese  8  East Indian TOTAL  CONTROL % PRETERM  %  33  89  4  11  43  14  82  3  18  15  65  7  70  3  30  52  62  44  81.5  10  18  %  TERM  31  66  57  6  8  35  32  38  RESULTS  TABLE XIV  Canadian Mothers: Comparison b y R i s k s SGA and AGA  Risk  SGA n = 20  AGA n = 27  Primiparity  9  13  Weight g a i n <25 l b  7  15  P r e v i o u s Low B i r t h Weight  -  6  IPI < 12/12  3  2  Single Status  6  3  <$75/month food  1  Social Assistance  4  1  Tobacco  9  13  (moderate)  3  6  Med Comp Pregnancy  6  10  Care 1 s t T r i m e s t e r  17  19  Care 2nd T r i m e s t e r  3  8  VHD C l a s s e s  5  8  Private  7  1  HBP  1  Alcohol  Care 3rd Trimester  RESULTS  TABLE XV  Canadian Mothers: Comparison by R i s k s SGA Mothers and Non Low B i r t h Weight Mothers  Risk  SGA n = 20  non LBW  n  Primiparity  9  14  Weight g a i n <2516  7  8  IPI <  3  4  12/12  Single  Status  6  2  Social  Assistance  4  1  9  10  3  4  5  12  7  12  Tobacco Alcohol VHD  (moderate)  Classes  Private  RESULTS  TABLE XVI  Country of B i r t h of C h i n e s e and E a s t I n d i a n Mothers  Country of B i r t h o f Mother  Country of B i r t h o f Mother  East Case  Indian Control  India  13  9  Mainland C h i n a  3  10  Fiji  6  2  Hong Kong  5  6  Kenya  1  Canada  3  Uganda  1  Taiwan  1  1  England  1  Malaysia  1  1  Canada  1  Singapore  1  Chinese Case C o n t r o l  Classification of newborns b y birth w e i g h t a n d g e s t a t i o n a g e  Gram 5000 4750 4500  =k _  a!  4250 4000 3750  °>  V  3500  J  >na t  v N  3250  ' °  3000 2750 2500  1  <?  AC*  2000 1750  t—  e.  I I I 1 0th  \0  o<  aqe_  -  1500 1250  b<  <  1000 750 500  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 g e s t a t i o n Preterm  %  'j  •  2250  1  C  erm  Postterm  COMMENTS ON  RESULTS  During  the survey period  June  1 s t , 1981 t o  November.  30th,  1981: Number o f l i v e reported  born  birth  weight  interviewed  of l i v e  born  low b i r t h  singleton  b a b i e s - 99  Number o f c o n t r o l  singleton  mothers  of nine pairs  to singleton weights  over  in  mothers.  the  and  and  i n Vancouver.*  period  was  4589.  The t o t a l  follow  survey  completness i s :  * Vital  this  Communication Statistics,  distribution  from B.C.  were  which  are  infants  Senior  Weight  1 s t , 1981  birth  weight  501-2500  number o f l i v e  then  Birth  January  births  assume  that an  Research  Provincial  Low  between  of  52% of a l l l i v e  4 t h q u a r t e r s o f 1 9 8 1 . I f we  births  comparisons  of the  that  December 3 1 s t , 1981 271 i n f a n t s  this  - 99  2500gm.  c a n be o b t a i n e d b y k n o w i n g  were born  interviewed  Three: o f t h e t w e n t y - o n e  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 survey  singletons  o f t w i n s and one s e t o f t r i p l e t s  i n the survey but not  restricted birth  weight  Births  A total included  babies  - 107  Number o f c o n t r o l  Multiple  singleton  - 107  Number o f m o t h e r s  had  low  Ministry  births  during  occurred i n the 3rd low  birth  approximation  Officer,  weight of  Division  of Health.  the  of  LBW  singletons  recorded  in  The numbers 1)  1981  most of  Community  Health  loads  high;  2) of  June,  and  arrived  when  vacation  and  have  been  a  and  for  are  thus  are  after  Community not  been  visited  by  the  the  52%.  disparity  viewed  receive  the  picked  LBW  A l l  between  a  priority  even  months.  when  LBW  the  her  interviewer  on  case  may  interviewer  by  by  Notification  notification  Nurse up  as  visits  vacation  Health  either  /  are:  August  arriving  births  89%.  babies  Nurses,  control births,  =  controls  weight  July  multiple  explanations  and  birth  LBW  125/141  likely  cases  Low  are  =  +  have  was  a l t e r n a t e , or her  return  on not from  vacation.  SES  and  As  LBW  can  between  be  the  investigator cases  more  was  Low a)  Table  Units  based i t  record  units  from  Health  i s found,  reporting other  seen  is  and  at  is  East  likely the  the  individuals;  Weight high  Low  Birth  very Unit  babies  where  that  concentration  of One  North of  the  this  higher.  from  Weight  uneven.  probability  is correspondingly  Birth  I,  low  distribution  The largest  unit  number  of  the  best  underreporting  from  would  Unit,  in  Soocio  had  principal  have view  expected of:  Economic  Status  4,3  b) of  past  Vancouver This  Health  Birth Unit  supposition  surveyed  against  Division  of  XVII)  Low  Vital  is  Weight  statistics  as  recorded  in  City  Profiles. born  l o c a t i o n of Statistics  out  LBW for  by  infants 1981.  an  analysis as  (See  of  recorded following  cases by  the table  TABLE X V I I  Low Weight B i r t h s b y L o c a t i o n and R e p o r t i n g i n S u r v e y UNIT .  1981 501-2500gm B i r t h s  SINGLETONS IN SURVEY  MULTIPLE BIRTH INFANTS <2501  SURVEY 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  107  18  125  TOTAL  271  A  subsequent  breakdown  by m a t e r n a l #  %  East  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.  Total  107  100.  This the  i f fully  important  Birth  role  that  with  low S.E.S.  previous plays  reveals:  research  findings  i n the aetiology  on  o f Low  Weight.  Ethnicity  a n d Low  Table belong  Birth  to three  ethnic 45.8%  Chinese  13.1%  East  21.5%  Indian  of control  babies  Canadian  40.4%  Chinese  18.2%  East  11.1%  Indian  Canadian  cases  to Canadian  represented. significant. significant  80.4%  belonged  appear controls,  F o r n e i t h e r group The  of  Low  Birth  Weight  babies  groups:  Canadian  compared  Weight  II reveals that  69.7%  XI)  consistent  address  over  a t t h e p=.10  to  be  Chinese was  to these  slighty cases  by  (Chi square  appear  East =  groups:  overrepresented  the difference  representation level  same  t o be  under  statistically Indians  3.099).(see  i s Table  (Jo  This Ethnicity  finding  i s consistent with  and  Birth  comparisons  Low  were conducted  contributions  made b y  small  to  treat  Risks  and  Low  The in  Low  Birth  significant 1 or  them  Birth  and  square  dfl=4.5  e t h n i c groups  were  The  identified  the  several  i n c i d e n c e of  pregnancy  still  9  birth). mothers  outcome  antecedent  factors  are  Birth  Weight  Canadian  data  pooled  this  for  be  Chinese,  East  is significant  (chi  among m u l t i p s  6 square  = 0.64  (n)  Control  (n)  25  3  26  N.S. 1  10  -  10  East  4  16  -  7  11  51  3  43  Indian  Total data  to  miscarriage  Chinese  pooled  too  behaviours  deemed  ( i . e .previous  When t h e  Case  For  individual  considered  p=<.05).  P r e v i o u s Low  control  literature:  Canadian  chi  three groups:  case  of  mothers.  i n the  P r e v i o u s poor  2  has  III lists  Indian  other  these  subsequent  review  Weight  Weight  a b o r t i o n or  on  A l l  literature  individually.  literature  Table  Weight.  the  c h i square  = 2.85  p  = <.10  >.05.  L>1  3  Interpregnancy  interval  less  than  Case  12  months  (n)  Control  (n)  Canadian  5  25  4  26N.S.  Chinese  6  10  1  10  chi East  square =  2.88  .5<p<.10  Indian  Total  4  No  live-in  only  to Canadian  support  4  16  1  7N.S.  15  51  6  43N.S.  during  pregnancy.  live  in support chi  5  Monthly  attempt  =  2.86  recall  6  Mother  only  applied  Budget.  significant Tobacco  of  As  this  in Receipt to even  i f  non  smoking  between  c a s e and  (n)  Control  45  2  (n) 39  a measure food  of poor  budget  was  diet/poverty made.  There  an was  datum.  of  Social  Canadian  Assistance.  mothers  As  and  was  any  tobacco  reported  not  this  statistically  accurate.  Smoking.  against  applicable  .05<p<.10  to account f o r monthly  inadequate  7&8  9  square  Food  is  mothers. Case  No  This  When  smoking  f o r Canadian mothers  control  were  found.  was  significant  tabulated differences  Canadian  Case  Control  Smoking  24  10  Non  21  29  Smoking chi  9  square  Failure  =  to  3.85  gain  Case  (n)  Canadian  22  Chinese  7  East  12  Indian  Total  41  This  p<.05.  the  recommended  251b  during  Control  (n)  45  8  39  6. 14  . 025  13  3  18  1. 85  NS  22  2  11  2. 62  . 10  80  13  68  1 5 . 02  .001  is highly  significant  chi  pregnancy.  P  c h i square  =  15.02.  Recap Previous groups  Low  Birth  Weight  approaches  significance  for  3  combined;  Inter  Pregnancy  significance No  only  live  Interval  of  less  than  12  months  approaches  for Chinese;  in  support  approaches  significance  only  for  Canadians; Tobacco  usages  Failure  to  Canadians are  and  gain  highly  is statistically weight  is  significant  significant  statistically when  the  data  for  Canadians;  significant from  the  3  for  groups  pooled; Failure  pregnancy  and  to gain  weight  therefore  be  could an  be  associated  association  with  a  shortened  of p r e m a t u r i t y .  Li  Low  Birth  Weight  and  Pregnancy  Table  among  IV  details for cases  would  be  mothers  Canadians.  These either  pregnancy  e.g.  Partum A  such  30-37  As from  control  there  mothers  a r e more  Birth  Weight  c o m p l i c a t i o n s might through  placental  Hypertension,  of  15  1/2  Birth  of  the of  49  be  of  and  the  3  groups.  medical  complications  infants,  particularly to  exert  insufficiency  or  shortened  Placental  Praevia,  a  Low  Birth  Weight  mothers  mothers  delivered  16/24  and  and  pregnancy definition  Canadian Chinese East  recalled  prematurely  Prematurity  or  <2500gm from  of  (see  Table  infants  failure  preterm  to  as  can grow  less  V) result in  infants  infants  Indian  were  were  infants  premature  premature were  -  -  than  64%  43%  premature  -  either  utero.  gestation;  6/14  an  weeks).  Weight  shortened  30/47  pregnancy  expected  Toxaemia,  these  discussed previously  Using  reported medical  Haemorrhage.  total  Low  and  Low  c o m p l i c a t i o n s . 11  (range  Medical  the  expected of  influence  Ante  Maternal  Complications.  complications As  and  66.6%  38  weeks  70 Prematurity  i)  Physician The  and P r e N a t a l  Visits  literature  Birth  Weight  might  be e x p e c t e d ,  with  Weight did  ii)  also  mothers  Prenatal In  fewer  visited (Table  contradistinction f o rmothers  prenatal  classes  statistically  significant square No intake  to physicians average,  their  shows  of  fewer  Low  that,  a r e noted  mothers  physicians  to physician  of premature  than  d i d term  significant  Low B i r t h  care  infants  mothers.  c h i square  as  b y women  Low times  Birth than  This  there  i s an  more  of  apparent  whom  difference  was  took not  = 2.24.  and A l c o h o l  Weight  association  = 6.45  also  between  VI).  P r e m a t u r i t y - Tobacco Among  ( T a b l e V)  visits On  association  Classes  reversal  iii)  Care  pregnancies.  infants  control  has discussed the  and P r e n a t a l  shorter  care  mothers  between  there  i s  a  statistically  p r e m a t u r i t y and tobacco  use c h i  p=.025.  significant (moderate  association  t o heavy  i s found  a t any time  f o rpreterm  i n pregnancy).  and a l c o h o l  71  Low B i r t h i)  Weight  Trimester Among  and E t h n i c i t y  Care  or East  mothers  to present  =  2.50 n . s . ) .  mothers after i i)  there  i s a tendency,  mothers,  f o r care appears  - no n o n C a n a d i a n  Number  to  of v i s i t s  has been  frequently  than  their  differences  after  for  more  Low  Birth  f o r the  Weight  among  Birth  the 1st trimester  t o be r e v e r s e d Low  not seen  Weight  (chi non  square  Canadian  mother  presented  shorter mean  or East  mothers  of Canadian  Weight  Birth Weight  gestations. visits  Indian  than  mothers  Low  n o n Low B i r t h  in  visits  to physicians.  mentioned  Chinese  mean  VI)  the 1 s t trimester,  As  due  mothers  Indian  This  (Table  Instituted.  Canadian  Chinese  by C a r e  for  mothers.  origin  d i d either  Weight  mothers  mothers. There  Low  However  This  are  Birth non  visited i s  no  s i g p=.001).  or East  (t=2.788  df55  Indian  p<.005  Canadian,  Birth  had a s i g n i f i c a n t l y h i g h e r Chinese  possibly  significant  Weight Low  -  less  Weight  number  of  n o n Low  Birth  t=3.394  df48  p=<.001). (iii)  Recall  of  Ultrasound routine  measure  There cases  i s no  Ultrasound may  during  recalled  an  investigative  process  or  a  pregnancy.  statistically  and c o n t r o l s  ultrasound  be e i t h e r  or between  significant ethnic  by the mothers.  groups  difference in  the  between  number  of  7Z  Prenatal Non square do  Class  Low B i r t h  =3.35)  Canadian  towards  and  There and  Indo  Canadian The  mothers  Canadian  in  group  shows  Canadian  and  small  6  Private 7  19.9)  attendance non  classes  than  There Weight  i s and  attendance,  sample  nor  between  and  between Chinese  ( c h i square  Low  (chi  no non i s  Chinese  attendance.  Birth  =  Canadian and  Indo  7.53).  Weight  b y an e x c e s s  and  prenatal  proportion  attend  prenatal  mothers  to  of primiparity  attendance  was a p p r o x i m a t e l y  9  6  Private 5  this  evenly  Weight None 3  Weight  is  not  = 2.5).  Primips  V.H.D.  attendance  f o r primiparous Canadian  Non Low B i r t h  None  class  o f n o n Low B i r t h classes  classes.  B i r t h Weight  V.H.D  class  a greater  class  Canadian Low  class  s i g n i f i c a n t ( c h i square  sample  Private  in this  =  of primiparity  primiparae  Prenatal this  class  i s not influenced  although  statistically  Low B i r t h  a trend  (seeTable I X ) .  analysis  that  infants.  significant differences  f o r Canadian  attendance  An  i n prenatal  ( c h i square  i n prenatal trend  Chinese  i n prenatal  exhibit  of prenatal  Weight  difference  are highly  greater this  between  mothers  mothers  attendance  o f Low B i r t h  any s t a t i s t i c a l  Canadian  Canadian  more  difference  B i r t h Weight  there  Weight  mothers  statistical Low  Attendance  divided  women i n  between  VHD  73  Given caseload VHD  that  over  50%  are multiparous,  prenatal  Multiparous  programming Low  significantly  Birth  less  Weight  infants  Low  Birth  Weight  and  Table her  visit  language  VII  - As  there  in  understanding of  could  question  Low  mothers than  Weight  the p r i o r i z a t i o n  attended  did  Birth  their  first  prenatal  primiparous  of  baby.  classes:  mothers  of  (p-<.025)  E n g l i s h Comprehension  assessed  were  abilities  a l l Chinese  96%  sampled  for Chinese  and  East  only.  of  for  the  t o women e x p e c t i n g  frequently  Birth  mothers  one  Weight  Low  Indian  of  and  East  mothers,  80%  mothers.  Country  no  spoken Indian  Chinese  t h e Community  significant  between East  by  case  Indian  or  differences  c o n t r o l mothers.  mothers  were  English. English case case  of b i r t h  mothers mothers  is listed  Health  and  in The  assessed  is 91%  and  Nurse  a  second  East 94%  i n Table  at  English majority FAIR/GOOD language  Indian  control  Chinese  control  XVI.  7H  Low  Birth  Weight  Table control  East  is  during  Birth  Low  Birth  with study  Canadian  were  likely  Indian  Weight  than  mothers  not to  either  Chinese than  case  and  as  consume  Chinese East  t o consume,  and  or  Indian  and  this  women.  was  not  in this  associated  with  the  survey.  and Age literature This  Of i n t e r e s t  15% o f E a s t  but Canadian  a l c o h o l than  alcohol.  of East  Weight.  mothers  percentages  and more  Primiparity  X - This  sample.  t o consume  between  and P a r i t y -  Weight  Low B i r t h  differences  n o t t o consume  o f Low B i r t h  Table  no  t o consume  true  IX  occurrence  likely  likely  Weight  Table  and  women  particularly  Low  were  pregnancy  a r e more  use i n pregnancy.  i n any o f t h e 3 groups,  a r e more  Indian  women  - There  mothers  surveyed alcohol  VIII  and A l c o h o l  were  association  perhaps  over  Indian.  associates adolescent was  i s the  hot  found  finding  that  t h e a g e o f 30 v e r s u s  For  mothers  1 3 % , 1 0 % a n d 3%  35  motherhood  years  respectively.  35%  i n our 41%  of  and  of  Chinese  over  the  7*  Low  Birth  Weight  Table being  X I I - The main  born  Gestational disability for  under  2500  Age  (SGA).  than  Table  Age  classified  small  classifies  These who  of  on  i l l health infants  infants  though  face  under  f o r Canadian,  and p e r c e n t s seen  for  these  burden  who  brought are  a greater  2500  gm  on  Small  for  incidence  are  by  of  Appropriate  (AGA).  t h e numbers I t c a n be  Maturity  falls  XII - D e t a i l s  category.  62%  gm  those  Gestational  mothers,  and F e t a l  that  of  infants  the o v e r a l l  gestational  infants  Chinese  as term  and  East  falling  into  percentage  age  is  or preterm.  44%.  Indian  of  infants  Table  I t c a n be  each  XIII  seen  that  are preterm. Five  of the i n f a n t s  premature  were  of Selected  Appropriate  for Gestational  for Gestational Table  found  sample  XIV  f o r any  private  small  for gestational  age  and  (5.7%).  Comparision  Small  both  - No  differ  Age  with  (chi  from  Age  f o r Mothers  AGA  of  and  Infants.  statistically  factor  classes  Factors  significant  the exception  square=7.94). mothers  is  differences  of attendance  Why  unknown.  SGA  mothers  a t non in  are VHD this  74> Some d i f f e r e n c e s mothers would  failed  to gain  are  251b d u r i n g  group  Previous  Low B i r t h  - perhaps  percentage  showing  of mothers  Assistance  Selected Mothers  Factor  between  status  status  these  approaches  a  i s  Between  Weight a  two g r o u p s ,  more  significance  births common  of  a l l mothers  in  that  in  this  in  this  o f SGA  The  support  reporting  i n t h e SGA m a t e r n a l  Mothers  AGA  prematurity.  h a d no l i v e  Infants  group.  I n f a n t s and  (Canadian) significant  a recipient  level  More  finding  who  statistically being  a  f o r repeated  80%  a r e found  Comparison  o f N o n Low B i r t h  Single  i s also  infants  11.1%.  interest.  of premature  a tendency  o f SGA  3 0 % , o f AGA m o t h e r s  Social  Weight  of  pregnancy,  be e x p e c t e d d u e t o t h e number  group.  is  as reported  of  of Social  .05.  Other  variant Assistance  factors  of  interest are: -low vs  pregnancy  weight  gain,  present  i n 35% o f  SGA  mothers  15%  of  20.5% c o n t r o l s ; -close  mothers  interpregnancy  v s 10.25%  -tobacco  interval  present  in  SGA  controls;  consumption  present  consumption  present  i n 4 5 % o f SGA m o t h e r s  v s 25.6%  controls; -alcohol 10.25%  controls.  in  15%  of  SGA  mothers  vs  F i g . II EtbMcity:  77  Canadian.  Under 2501  Classification of  .gm.  newborns  by birth w e i g h t a n d g e s t a t i o n  Gram  age  5000 4750 4500 4250  •/. /•  'Of  4000  1y  i 'I il  3750 3500  -  1  3250 3000  r  -  10th  2750  %  1  2500  t  2250  i  2000  V  4  c  , >*  7  c r  f  V  \  <  st*  J<  ?  1750  r ^f  1500 1 250  C  : •  3  1000 750  -  500 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 Preterm  Term  Postterm  78  Fig. I l l Ethinicity: Chinese.  Under 2501  gm.  Classification of newborns by birth w e i g h t a n d g e s t a t i o n a g e  Grams 5000 4750 4500 4250  -  4000  —  -  3750  V.  y u r n  3500 _  3250 3000  ~ •  2750  !  1  '  10 th V.  -  ens  v  2500  3  2 250  »  2000  &  ^  I  s* -  ;  >  );  1750  c. >  1500 1 250 1000 750  -  500 ,  -4  io O  K co O  -„1 O  —  -  ro "V  u~)vO  N. co  O  O  '—  i  CN  n  o  W e e k s of g e s t a t i o n Preterm  j  Term  |  Postterm  7<?  F i g . IV. Ethnicity:  E a s t Indian.  Under 2501 gm.  Classification of newborns by birth w e i g h t a n d g e s t a t i o n a  Gram 5 0 0 0 4 7 5 0 4 5 0 0 4 2 5 0  rh V.  4 0 0 0  T VJ 1 I 1 / •  3 7 5 0 3 5 0 0  -  3 2 5 0  Y  /  3 0 0 0 2 7 5 0  i—•  1 0th % t  2 5 0 0 2 2 5 0 2 0 0 0 *  1750  /  /  /  : c  c  •*  %  1500  r' f  >  f  >b  1 2 5 0  •  1000  — —  7 5 0  **  '  \  v  -*  t >  5 0 0  -  •—  -X7  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 Preterm  Term  Postterm  TABLE XVIII  Under 2501gm I n f a n t s Subgrouped b y Weight and M a t e r n a l Ethnicity. ETHNICITY  500 - 1000gm % #  1001 - 1500gm % #  1501 - 2500gm % #  Canadian  1  2  4  8.2  44  89.8  Chinese  -  -  1  7.1  13  92.9  East  3  13  4  17.4  16  69.6  Indian  30% o f E a s t I n d i a n i n f a n t s o f low b i r t h weight a r e under 1500gm. C h i = 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 ethnic  II, III & groups  As  the  prognoses  infants category  by b i r t h  under  weight  literature  for  1001-1500gm  IV s h o w  different  three  a r e shown  main  i n Table  i n f a n t s from  the 3  major  and g e s t a t i o n a l a g e .  review  showed,  ranges  and 1501-2500gm.  of the  2501gm  The ethnic XVIII.  of  there  are  birthweight.  numbers groups  and  different 500-1000gm,  proportions  falling  into  of each  In  Regard  to Hypothesis  That  mothers  biomedical (Tables  of low b i r t h  profile  to mothers  weight  infants  have  o f non low b i r t h  a  different  weight  infants.  I I I , I V a n d V)  Significant mothers  I  differences  i n five  of the nine  were areas.  Intercurrent  illness  Complication  of pregnancy  Prematurity  found  between  These  case  and  control  were:  - c h i square=4.2 - c h i square=6.4  - c h i square=34.1  Pregnancy  weight  gain  Previous  miscarriage,  - c h i square=15.02 abortion  or  stillbirth  -  chi  square=4.5  No  significant  parity, interval. only  previous  interpregnancy Indo  In  Canadian  Regard  That  birth  low b i r t h  women  were  interval women  mothers  (See T a b l e s  found  weight  or  weight  for close  approached  considered  maternal  interpregnancy  significance  (chi square=2.85).  significance  age,  f o rChinese  when Close and  square=3.57).  II  o f low b i r t h profile  were  approached  (chi  to Hypothesis  sociodemographic infants.  low  Previous  multiparous  differences  weight  to mothers  III, VII,  infants of  non  X I , X I V a n d XV)  have low  a birth  different weight  8* No  significant  observations residence origin lack  were n o t e d .  i n the  Eastern  of  support of  gestational mothers birth  group  of The  rated  social  age of  associated 30%  or  i n f a n t s on  fair  of  of  weight  with  of  case  and  some  is  in  Mothers  (both  birth  of  SGA 80%  assistance  of  and  factors  the  and  Indian that  small  i n f a n t s vs of  a  confined of  to for 11.1%  a l l mothers  are  found  Indian  comprehension.  c o n t r o l were  with  being  f o r g e s t a t i o n a l age  Chinese  and  suggestion  partner)  support.  trends  associated  strong  mothers  small  English  in  the  infants.  origins  No  of  were  significant  found.  III  low  birth  potentially  associated  is a  with  social  mothers in  between  That mothers  birth  of  to Hypothesis  prevalence  of  but  city.  live  infants lacked  majority  In Regard  low  no  mothers d e l i v e r i n g  good  the  assistance,  are  AGA  of  found weight  there  as  infants.  weight  differences  been  birth  part  (defined  Canadian mothers)  low  Low  were o v e r r e p r e s e n t e d ,  recipient  of  d i f f e r e n c e s were  low  weight  infants  alterable behavioural birth  infants.  (See  weight, Tables  than  do  I I I , V,  have traits mothers  VI,  VIII,  a  higher  that  have  of  non  XIV  and  XV) Significant were  found  d i f f e r e n c e s between  case  and  control  for:  weight tobacco  gain  l e s s than  smoking  -  (chi  251b  -(  chi  square=15.02)  square=3.85)  mothers  8"/ Failure pregnancy. found  to  gain  Significant  between  i s  correlated  differences  in failure  Appropriate for Gestational  weight  mothers  weight  mothers  and S m a l l (chi  mothers  and non low  Tobacco  smoking  prevalent  251b  for Gestational  square=3.86) birth  weight  i s confined  among  mothers  and  o f SGA  to gain  251b  are  (AGA)  low  birth  Age  (SGA)  low  birth  low  mothers  infants  shortened  Age  AGA  to Canadian  with  birth  (chi  mothers a s among  weight  square=8.67).  and i s t w i c e mothers  of  as AGA  infants. Close Chinese No  interpregnancy interval  mothers  difference  Canadian mothers  o f low b i r t h  in alcohol  mothers.  weight  infants  use i s found  Alcohol  i n the survey  approaches  usage  than  significance (chi  between  square=2.85).  case  i s more p r e v a l e n t  among  mothers  of  weight  infants  recall  for  and  control  among  Canadian  Chinese  or  Indian  origin.  Physician Mothers visits.  This  Care  o f low b i r t h  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  group.  Mothers  groups  recalled  mothers  Non  fewer  origin  i n case  physician  physician among  and  visits  this  control than  did  origin.  Class  Attendance weight  towards  mothers  and I n d i a n  significantly  low b i r t h  square=3.35) Canadian  of Chinese  of Canadian  Prenatal  fewer  more  Canadian  mothers  prenatal  of low b i r t h  weight  class  exhibit  a trend  attendance  infants.  (chi  than  do  There birth  i s no  weight  (P.N.)  difference  and non low b i r t h  classes  sample  statistical  nor i s there  between  Chinese  weight  between  i n attendance  any s t a t i s t i c a l  and  Chinese  Canadians  at  Prenatal  difference  in  low  in  Prenatal  this (P.N.)  attendance. There and  Indo  are highly  Canadian  square=19.9) attendance  Analysis Tables  prenatal  and  Indo  between  class  Canadian  attendance  (chi  prenatal  class  Canadian  Weight  by Development  and G e s t a t i o n  (See  X I I and X I I I )  Small SGA  p e r c e n t of t h e low for Gestational  both  were  premature,  and p r e m a t u r e ,  prematurity associated support.  complication the  remaining  with  poor  diet,  birth  to bear  weight  East  below  weight  low  birth  deliveries  of  infants  were  Scale.  5.7%  are  The  infants  of  reasons but  for  may  and l a c k  in this and  infants  attributed  low income  of morbidity,  a birthweight  be  unclear,  usage,  Indian  weight  could  pregnancy.  70%  tobacco  a higher burden  as 30% were  of  66% o f  in  Low  birth  Age on t h e L u b c h e n c o  30% o f p r e m a t u r e  some m e d i c a l  Summary  differences  ( c h i square=7.53).  were  care  in  Chinese  o f Low B i r t h  adjudged  likely  mothers  and  Forty-four  to  significant  sample  require  be of are  extra  1500gm.  Findings  Mothers  who  delivered  low b i r t h  weight  1)  More  likely  to have  had a premature  2)  More  likely  to have  had a m e d i c a l  infants  were:  delivery;  problem  during  pregnancy;  ?6> 3)  More  likely  to have  had  an  obstetric  complication  during  pregnancy; 4)  Less  likely  t o have  gained  5)  More  likely  to have  had  6)  Equally  7)  More  likely  ( i fCanadian)  8)  Less  likely  to attend  Low side  Birth  likely  Weight  of the c i t y .  Chinese weight  mothers groups.  classes  single  status,  at risk  be  their  t o be  prenatal  mothers  under  with  less  mothers  or tobacco spaced  t o be  outcome;  primigravid;  smokers;  classes.  " E t h n i c " mothers  closely  as  pregnancy;  pregnancy  cigarette  appear  physicians  the  poor  residence t o be  represented  the ethnic  alcohol  from  a previous  i s associated  Certain  In g e n e r a l  during  t o be m u l t i g r a v i d  Indian  may  and v i s i t  mothers.  more  as  251b  than  do  in  over  among  the  not  attend  less  low  at  birth  prenatal  than  are Canadian  pregnancies.  East  represented,  frequently are  the  Canadian  risk  from  mothers,  but  £7  Relative  Risk  From  f o r Low B i r t h  these  approximation  data  Weight  i t  of Relative  i s Risks  pregnancy outcome f o r c e r t a i n used  i s that  described  possible for  low  antecedent  to  calculate  birth  weight  factors.  The  an as  a  method  b y MacMahon and Pugh* and i n v o l v e s  three  assumptions: 1)  that  both  exposed  2)  that  either 3)  t h e outcome under and non e x p o s e d  neither  exposed  that  study  i s  infrequent  in  i n  favour  of  of  the  populations;  case nor c o n t r o l s  o r non exposed  the controls  relatively  are selected  i n d i v i d u a l s ; and  are truly  representative  whole  population.  Calculation  of Relative  Suspected Cause Present Absent TOTAL Relative  a',  b', c  Risk  1  Risk  Case a' c' a'+c'  Control b' d' b'+d'  = a'd' c'b'  & d' a r e s a m p l e s  of cases  numbers o f i n d i v i d u a l s i n each  * Epidemiology: Pugh.  Little,  and c o n t r o l s  are  the  cell.  P r i n c i p l e s & Methods. B r i a n  Brown & Co. B o s t o n  and  1970 page  MacMahon 268-273  &  Thomas  Calculation  of Relative Risk  Miscarriage, Canadian,  Abortion  East  Indian  Suspected Cause ( P r e v . Poor Outcome) Present Absent TOTAL Relative  Risk  =  f o r Low  or S t i l l  Birth  and C h i n e s e  Cases (LBW) 36 44 80  Birth  Weight  i s Antecedent  Mothers  Combined  Controls (Non LBW) 17 51 68  36x51/44x17=1836/748=2.45  When  Previous  Factor  TABLE XIX  Risk Factor  f o r Low B i r t h W e i g h t a n d R e l a t i v e  RISK FACTOR  RELATIVE RISK  P r e v i o u s Low B i r t h Weight Interpregnancy I n t e r v a l  less  3.45 than  12 months No L i v e  In Support  2.40 (Canadian Only)  Smoking L e s s Than One  Pack Per  Smoking More Than One  4.03  Day  (Canadian and Chinese)  2.94 Pack Per  Day  (Canadian Only) F a i l u r e t o Gain 25  Risk  3.80 l b s During Pregnancy  4.45  Lack o f P r e n a t a l C l a s s e s (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  E T H N I C I T Y AND  This weight  LOW  B I R T H WEIGHT - E A S T  s i x month  among  survey  'East  significance  unpublished  survey  that  maternal  of  surname)  born  study p e r i o d .  This probable groups.  suggests f o r East  On  the  Weight babies times  higher It  produced  constituted  they  i s suggested  have  decreasing toxaemia,  Banerjee, mother order  at  to North  As  total  outcome of  births  years  haemorrhage an  that the variant  outcome.[1] economic than  more ethnic  Low and  American  previous  as  is  Birth  had  8-10  r a t e s . [ 1,2,3,4,5].  primiparity, partum  by  infants  other  1970's  Unit  maternal  Weight  morbidity five  previous  defined  Western  demonstrated  age.  total  f o r the  Weight  i s a more s i g n i f i c a n t or m a t e r n a l  the  A  (as  with  ante  Birth  in of  an  mothers  have h i g h e r  least  age, and  t o Low  [7] h a s  third  studied.[6]  anaemia  than  approaches  Health  Birth  as  birth  East  the  neonatal mortality  survivors  maternal  significantly  and  of  Weight  that similarly  infants, been  Birth  one  mothers  Low  subcontinent  perinatal  2 5 0 0 gm  the  low  dfl=3.099).  17%  Indian mothers,  Indian  Weight b a b i e s , the over  t h a t Low  of  of  excess  i n Vancouver's  only  30%  This  square  Indian'  comprised  they  i n the  (chi  '-East  population,  'excess'  mothers.  a l lbirths  while  INDIAN  r e v e a l e d an  Indian'  statistical  revealed  V  Low rates over  than which  populations fetal  loss,  contribute One  position  infant  Birth  sex,  author, of  the  birth  91  Indian higher  Low  mothers Birth  populations[8], Indian England and  I infants  may  behaviours  Asian  of that class  f o r Low  IV  Birth  and  may  showed  that  or  high  stillbirth  differences  between were  Singapore  Bantu  Birmingham,  authors  2798  of  this  and  the  contributary  liveborn  34  a  in  important  of  babies  Chinese,  The  be  having  i n C a l c u t t a . [9]  V  Weight  cultural  as  mixed  pertaining  r a t e s . [10]  diseases  f o r Indian  reported  European,  of the birthweights  from  tend  and  42  Indian  weeks  the  significantly Malay  the a v a i l a b l e information  t o be  smaller  backgrounds,  and  less  British  conclusion  that  general  socioeconomic antecedents  lower  comparison  babies  birth  that  than  Low  while  Indian  infants  variables  for  by  born  and  Birth  from  maternal Weight  in  weights  and  that  i s to consider  environments.[12]  the f i n d i n g s of Clarkson  i n Birmingham, are  international  studies  weights  intrapregnancy  i s supported  on A s i a n  factors,  birth  in  that  population.  reporting  conclude  than  d i e t a r y and  are important  ethnic This  are  infants.  ethnic  growth  that  Singapore  conclude  genetic  risk  mortality  weights  those  Africa  of social  i n Singapore[11]  Caucasian  al,  mothers  of maternal  birth  this  half  Analysis  infants  other  but only  speculate  factors.  than  rate  perinatal  prevalence  mean  Weight  a r e a t added  high  report  i n South  unlikely  reference  England. to  data  be be  of  et  They  due  to  used  in  the best  way  increasing  improving  the prepregnant  and  LOW  BIRTH  The mothers  third who  suggests total this  WEIGHT AND  a  largest  comprised lower  number  a  Health  area  infants The Hong  Kong;  of  their  less  infants  at  weeks  than  British  been  suggested  shorter  non  have  period  borne  Birth  out  Weight  September 15%  of  Chinese  come  from  found  Chinese. had  infants mean  of  [13]  mean  birth  similar  height, Chinese  Chinese.  In  identical  August  Birth  Weight  China  mean  Singapore, weights  [14]  difference being  of  Low  Chinese  It could  in  less has be  general  Chinese Birth  and  birth  235gm  however,  rates  East  to  have  women  Hawaii,  in  population.  dates.  birthweight  previous  southeast  to In  a  1979  a l l Low  the  unknown,  mothers 1st,  as  is  by  maternal  been  Chinese  although  unit  non  virtually  Weight, the  were  case/control ratio  the  have  this  to m a t e r n a l  than  Caucasians  that  of  gestation  Caucasian  is  produced  24.6%  than  during  survey  Their  Birth  period  mothers  i n the  total.  Low  Low  the  infants  190gm 40  the  It  total  Vancouver  weights  attributed  of  comprised  bulk  group  births  during  Chinese  but  of  supposition.  survey  1980.  16%  Chinese  unpublished Unit  ethnic  i n c i d e n c e of  of  remains  31st,  ETHNICITY-CHINESE  and  Weight.  [15] Low early be  Birth  70's  even  lower  attributed and  a  are  low  to  Weight  i n Shanghai  r e p o r t e d around  4.7%.  i n P e k i n g . [17]  Within  fewer  births,  multiple  i n c i d e n c e of  malformations.  rates  [16]  hypertensive  and  [16]  Hong  Rates  Mainland rarity  Kong  are  China of  disorders  in  reported this  teenage and  may  the to be  pregnancy congenital  9S  There  i s also  Chinese growth  evidence  that  the p a t t e r n of f e t a l  differs  from  that  populations i s more  smaller.  lowering  rapid  [19,20]  nutrition,  China.  some  [18,19]  Chalmers  sanitation  also  term  babies  have  Birth  played  Weight  a  Early  are  introduces evidence  and h y g i e n e  t h e i n c i d e n c e o f Low  [16]  and  i n Caucasians.  growth  i n Chinese  fetal  relatively  that  large  in  improved role  in  women  in  9H  Ethnicity  BIBLIOGRAPHY a n d Low B i r t h  Weight  1 Bhargava,S.K., Bargava,V., Kumari,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 in L.B.W.Babies I n d i a n Paed. 10.161, 1973. 2 Gupta,S., S r i v a s t a v a , G . , Berry,A.M., and 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 . 3 3 1 ,  Khatri,R.L.: 1969.  3 Bhakoo,O.N., Narang,A., Kulkarni,K.N., Patil,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 11,443, 1975. 4 T h i r i u p a r a m , S . and Gupta,S.: A s t u d y o f perinatal 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 Paed. 15:311, 1978. 5 Gupta,S., Chupra,K., 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 P a e d . 9.580 1 9 7 2 .  Pramanick,A.: Perinatal and i n h o s p i t a l born babies. Indian  6 ' Bhargava,S.K., Banerjee,S.K., Chovdhury,P., Kumari,S.: A l o n g i t u d i n a l study of m o r b i d i t y and mortality pattern from birth to 6 years of age in infants of varying birth 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 of  Banerjee,P.: B i r t h w e i g h t of the Bengali 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 A n n . Hum.  8 African  newborn; e f f e c t Gen. 33:99  Salber,E.J., Bradshaw,E.S.: Birth weights of 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 1951.  9 Abramowicz,M., Kass,E.H.: P a t h o g e n e s i s and P r e m a t u r i t y N . E . J . M . V o l . 275 no 1 6 . p . 8 8 0 , 1 9 6 6 . 10 Terry,P.B., Condie,R.G., Sematree,R.S.: 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. Nov. 1980 p.1307-1308.  South  Prognosis Analysis V o l . 281  of of 15  95  11 Cheng,C.E.M., Chew,P.C.T., Ratnam,S.S.: Birth weight 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 from 34 w e e k s t o 42 w e e k s G e s t a t i o n . T h e J . o f O b s t e t . and Gynecol, o f t h e B r . C o m m o n w e a l t h F e b . 1 9 7 2 , V o l . 79 p . p . 1 4 9 - 1 5 3 . 12 Clarkson,C.L., Barker,M.J., Marshall,T., Wharton,P.A.: Secular change in Birth Weight of Asian babies born in B i r m i n g h a m . A r c h . D i s . C h i l d . 1982 5 7 : 8 5 7 - 8 6 1 . 13 reported  Bell, Michael: i n the Medical  " C h i n e s e C a n a d i a n s Low o n P o s t A p r i l 20, 1982 p . 8 .  Hip  Trouble"  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 , Malay and I n d i a n I n f a n t s from 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 the Br. C o m m o n w e a l t h F e b r u a r y 1 9 7 2 , V o l . 79 p p 1 4 9 - 1 5 3 15 Bennett,C.G., Lovis,L.S.: Demographic 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 from  Chalmers,I. Shanghai t h e L a n c e t 1980.  - Better  Perinatal  Health  Factors  a  survey  17 L u b i c , 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 the Medical Delegation to the Peoples Republic of China Washington, D . C , N a t . A c a d . S c i . 1973 1 2 4 - 3 5 . 18 Biol.  Ip,H,M.H.: N e o n a t e 1978  Intrauterine 33 2 5 3 - 6 3 .  growth  in  Hong  Kong  Chinese  19 L i n , C C , E m m a n u e l , I .A. : C o m p a r i s o n s of American and Chinese intrauterine growths standards. Are American babies r e a l l y s m a l l e r ? Am.J. E p i d e m i a l 1 9 7 2 95 4 1 8 - 2 9 . 20 Chun,D., Kan,P.S., W o n g , C P . : p e l v i s and i t s influence on labor C o m m o n w e a l t h 1974 71 5 5 6 - 6 4 .  T h e Hong K o n g C h i n e s e J. Obst. and Gyn.  The Br.  CHAPTER V I  DEMOGRAPHY, P E R I N A T A L H E A L T H AND P U B L I C H E A L T H S E R V I C E S I N VANCOUVER  DEMOGRAPHY  Vancouver situated highest  i sa city  i n t h e P a c i f i c Northwest part  of thecity  Approximately annually Birth  o f 414,281  4.5  (1981: 4,581).  Weight  Rates  rises  inhabitants  (1981 Census),  of t h e American  C o n t i n e n t . The  410 f e e t  thousand  above  live  The P e r i n a t a l  sea l e v e l .  births  are  Mortality  Rate  registered and  Low  f o r 1978 t o 1982 a r e :  TABLE I VANCOUVER: P E R I N A T A L M O R T A L I T Y AND  LOW B I R T H WEIGHT R A T E S  S o u r c e : B.C. M i n i s t r y unpublished data.  1978 1979 1980 1981 1982  of Health  Division  P.N.M.R.  L.B.W.  11.3 14.8 12.0 17. 2 13.4  6.6 5.9 5.6 5.9 5.2  RATES  1978-1982.  of  Vital  Statistics  97 The city's  maternal  population  English  from  the c i t y  Punjabi Other  city  as a f i r s t  spoken  by  reproductive overall,  census  English  local  schoolchildren  the  doubled  a  second by  Health  had a language  i n 1982,  other  and  than  is  English  areas or  period.  Laotian  are  groups.  The  among  the  that  63.5%  the  46.5%  i s  Hindi  population.  by  with  years,  year  the finding  41% i n t h e m a t e r n a l  that  five  sized  Unit  the  I n some  language  are corroborated  Board  [1]  Thai  significantly as  15  Chinese,  i n that  as  families  past  with  Vietnamese,  changing of  1971 a n d 1976.  of East  surveys  School  over  i s emphasized  i t i s only  is  immigration  of families  but s t i l l  population  Vancouver  data  language,  the population  These the  of  tongue,  The  i . e . Tagalog,  smaller  preponderance  of Vancouver  language,  the percentage  languages  mother  changes.  as a second  apparent of  population  while English [2]  findings  of  of  the  city's  as t h e i r  first  analyzed  their  language. Two maternal  health  units,  populations  East  and  by e t h n i c i t y  South,  have  [2,3] f o r 1980.  (See T a b l e  II)  9* TABLE  II  MATERNAL P O P U L A T I O N BY South  Source:  Ethnic  Vancouver  Health  Group  and  East  Department:  South  Chinese Indo P a k i s t a n i Canadian Other Vancouver  is also  tract  data  Table  III,  shows  them w i t h  from  a city the  Unit  %  differences  low  birth  Profiles.  East  contrasts, census in  areas  weight  1980  Unit  %  25 17 41 17  of  1976  between d i f f e r e n t area  Unit  Units  27 19 38 16  census  attainment  Health  ETHNICITY  by  a  health  language of  rates.  the  compilation  city,  and and  unit  of  area,  educational correlates  TABLE I I I VANCOUVER  HEALTH  Characteristics  Source:  City  Results UNIT  of Vancouver  o f 1971  %  & 1976  %  With With E n g l i sh E d u c a t i o n as past first G r a d e 13 Language Burrard North South MidMain East West  7 2 . 25 5 0.3 66.6 73.1 63.5 87.2  30.02 10.9 15.4 24.7 12.35 . 45.61  Planning  UNITS  of Residents  1976  Department:  by Census  Tract  1976 1977 LBW LBW ratios  1978 1979 LBW LBW ratios  5.6 7.5 6.8 5.5 7.4 3.1  5.7 8.5 5.4 6.8 7.3 4.2  6.0 7.3 6.7 5.6 7.7 5.6  7.0 6.6 5.8 6.2 5.3 4.0  1980 LBW  5.2 6.7 5.5 5.6 6.0 3.7  /OO  TABLE I V MATERNAL  POPULATION  PRENATAL AND  UNIT  TOTAL  the a  city  52 67 33 83 42 23  41 25.5 60.6 36.6 43 67  372 235 292 347 333 367  • 4582:  6.5  301  42.5  1946  Health service  Department  allocation  have  be seen  in  mothers, with  Figure  Community who  Prenatal  Department  I ) . Each  Health  i n turn  Health  Nurses,  reports  services  divides Unit  has  under  the  to the Director  consist of:  program.  been  offered  Table  intra  IV,  unit  extremes. In general  correlates ability  Health  Classes  These  the  Programs.  classes  b) A n o u t r e a c h  can  of  Programs.  Prenatal  Prenatal  ( s e e map  of a Coordinator  Prevention  Prenatal  d e l i v e r y , Vancouver  into 6 units,  staff  a)  Class Enrolment % #  #  5.7 7.3 6.8 8.5 5.4 4.2  supervision of  [4]  909 921 482 949 774 547  Vancouver For  L.B.W. 1978  %  UNIT,  ATTENDANCE,  L .B.W.  Weighed Live Births  Burrard East M i d M a i ni North South West  CLASS  BY  with  higher  they  since  reached  i t may b e s t a t e d economic  Weight  that  status,  rates.  1956, i n 1978,  42%  v a r i a t i o n s o f between  socio  a n d l o w Low B i r t h  b y t h e VHD  of  as  Vancouver's  25.9% a n d 67% high English  at  attendance speaking  It  i s estimated  primiparous  women  expecting  figures  then  primiparous  Current  45%  estimate  a second  that  or t h i r d  t h e VHD c l a s s e s women  of  Vancouvers  [12], and t h e c l a s s e s  women. T h e a u t h o r s are  that  are designed  no more child.  might  births  1  than  25%  for  of  Extrapolating  reach  77%  are to  attendees  from  of  these  these  Vancouvers'  and 20% o f t h e m u l t i p a r a e .  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  Current  objectives  f o r these  classes  are  ill-defined  but  include: 1  Decreasing  f i l l  i n a P r e n a t a l Assessment  history Risks  Parental Risk  and d e t a i l s  Follow  Risk  modification strategies  2  Increasing Parent  3  Form  of nutrition,  a r e not weighted.  physiology  Behaviours.  up  which  tobacco has  are  includes usage,  not  asked a  medical  support,  been  to  etc.  standardized.  are undefined.  Knowledge  of pregnancy,  Mothers  labour  Decreasing  Parent  Anxiety  Decreasing  Labour  Stress  of the psychology,  anatomy  and  and d e l i v e r y . through  information  and  group  work. 4  techniques.  through  the teaching  of  relaxation  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  410,953  NOR Tit:  BUIIRARD: UEL:  3,6'.7  66, 11 ' < 16%  s  102,963 25*  E AS I: 6 2 , 0 9 5 15% HE S r:  66,835 16%  HID-HAIN:  SOU f II:  Figures: GV110 Planning Department Appendix: Population by Ages and Health Unit Areas  59,919 15%  Subgoals a r e : More v a g i n a l  deliveries  Less medication Less  operative  Shorter  5  Encouraging  6  Improving  7  'mothers'  Program  newborns  Breast  stresses  Feeding Skills  and  by  anticipating  some  of  the  difficulties.  Communications  and  Relationships  between  the  and t h e ' f a t h e r s ' .  Effectiveness  Lacking it  interference  Parenting  Improving  labour  labours  Healthier  post-partum  during  i s hard  defined  t o measure  goals  or a p r i o r i z a t i o n  the impact  that  the  of  existing  program  has  goals on  the  themselves  to  population. The  objectives  1  through  measurement - p r e and p o s t not  7  a l l lend  testing,  sampling,  etc. but  this  i s  undertaken.  Effect  on H e a l t h  "Training" Velvovsky,  of Prenatal c l a s s e s based  Chertok  women s i n c e  Classes on  and Lamaze  the f o r t i e s .  the  have  Among  work  been  the claims  of  G.  offered made  Dick-Read, to  pregnant  f o r such  classes  are: recent  Decreased study  significant, for  class  by  pain  perception.  Melzack,  but r e l a t i v e l y  attendees.  et small  [5,6,7,8,9,10,11,17] a l , [11] reductions  in  1981,  i n pain  The  most  reported perception  Contrary diminution  to  expectations,  i n the rates  mothers, compared -  (Tupper,  1956)  Decrease  i n need  Decrease [25]  in  f o r the  any  prepared  techniques.  [24]  of after  birth  [24]  m o r t a l i t y and s i c k n e s s .  (Stahler) review  of these  s t u d i e s by Beck  and  Hall  [31]  many  of  these  and  basic  i n part:  "Even studies  a cursory  did  not  reqiuirement include  of the  promising  and  Hall  most  of cause  fundamental  method,  and  that  even  those  experimental effect  which  errors  statements  do  which  regarding  impossible." continue  by  reviewing  four  newer,  more  studies: That  o f Kondas and S c e t n i k a  desensitization labours,  with  [26] c o m p a r i n g  psycho-prophylaxis.  12 h o u r s  and  multips  the  obstetricians rating  treatment  the  scientific  and outcome  Beck  shorter  meet  reveals  c o n t r o l g r o u p s commit o t h e r  treatment  a)  examination  even  make t h e p r o d u c t i o n  given.  result  of infant breathing.  forutilization  i n neonatal  A critical states  not  of epidural anaesthetic  initiation  resusitation -  did  to controls.  More r a p i d  -  this  versus  study  16 a n d 6 v e r s u s  r e s p e c t i v e l y . No u n t r e a t e d  group'  The  t h e women w e r e  controls not  systematic group  10 f o r were  rating  had  primips  included, 'blind  a n d 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  to  usage i s  /OS b)  Gregg  training group  Frazier  against  Lamaze  had s h o r t e r  cervical  dilation  (multips  only).  scores,  skin  Again  techneque  labours  No  treatment/control  Pretreatment  f o rthe results.  trained multips. both  Zax, Sameroff, primips, Trained  trained  differences  multips  was  done  than  on  multips.  of labour  Again  more  spontaneous  (matched  found  analgesia/anaesthesia vaginal  f o r age and economic  status).  than  Lamaze  untrained  levels  No  were  comparable  self  anxiety  that  than  significant  anaesthetics  and had a  deliveries  41  no p r e t r e a t m e n t  and t h e groups  been  70  between  general  anxiety,  have  anxiety  [30]  less  in  and  manifested  Rose  to  multips  d)  and  assigned  compared  pretreatment).  Scott  more  [29]  lower  b u t fewer  i n fact  Apgar  and  could  d i dthe trained multips  received of  multips  compared  tolerance  i n lengths  levels,  rapid  infants'  differences  untrained  to t r a i n e d mothers.  in  randomly  Farnum  scored  groups,  f o ranxiety  (Untrained  not  trained  and  found  trained/untrained administered  and  48 L a m a z e  primips were  were  groups.  responsible  more  rate.  were  pain  biofeedback  analgesia/anaethesic  found  women  and  biofeedback  multips),  less  controls  attitude  c)  and  was  or heart  motivation  compared  t r a i n e d women. T h e  descent,'  difference  untreated  the  [27,28]  (primips  and f e t a l  temperature no  seriously  and N e s b i t t  were  matching selected.  pretreatment  trained higher  untrained  mothers frequency mothers  No d i f f e r e n c e s w e r e fetal  distress,  morbidity forceps  Apgar  or maternal  deliveries  Again carried  found  in  length  scores,  i n the trained  out, pretreatment  labour,  neonatal  complications  no r a n d o m i z a t i o n  of  other  incidence  mortality, than  of  neonatal  a decrease  i n low  group.  to experimental/control differences  could  grouping  account  was  f o r the  results. Beck  and H a l l  most p r o m i s i n g morbidity  Closer  are  also  data  extremely  incidence lower  Neither  author  *  weight  economic  different that  services  mortality  and  Weight  and Y a i r e * *  among n o n - a t t e n d e e s  status,  less  backgrounds  a relationship exists  well than  find (who  educated, attendees.)  between  higher  attendance.  (JPH V o l 7 A p r i l  Yaire,S.F.:  of Thordarsen*  cultural  Thordarsen,L., Costazo,G.:  prenatal **  and  neonatal  the  l a c k o f p r e c i s i o n w h i c h makes t h e  o f Low B i r t h  claims  in  present  questionable."  socio  and w i t h  "the studies which  reduction  t o home, t h e s t u d i e s  younger  birth  on  that  have a d i s a p p o i n t i n g  conclusions  a higher  conclude  Factors  i n Vancouver  Evaluation  of the  effect  of  a  1976). influencing  S.P.A.R.C. U n i t e d  utilization Way.  of  prenatal  /on  Yaire mothers  concludes  that  who o p t f o r p r e n a t a l  resources groups,  should  be  i t i s  sociodemographic  classes  and s t a t e s  devoted  new i m m i g r a n t s  to  reach  and those  less  her report  was  low  risk  "more e f f o r t a n d  lower  socio  fluent  i n  economic  the  English  language." Coincidental  with  evaluation  o f an o u t r e a c h  program  [14]  and R u t t e r  Healthiest  Ross  nutritionally counselling, and  at risk  mothers  a service  supervised  1975  of  and i s s t i l l  Department prevention in  1978, [14] noted  2.8%  a n d mean b i r t h  3 3 0 0 gm 1 9 7 6 ) . and  gains  among  approximately  those  prenatal Cantonese.  the  educational This  a r e under  programming  represented  and  started  the  trained  Vancouver Report,  among  in  Health published  attendees  figures  were  The  [15]  evaluation  The p r o g r a m  (City  intake  targeted  by  7.2%  of and  new  immigrants  program  continues,  and  has  and  increased  The  t o t h e Vancouver  broadcasting  programming  Possible  convincingly  program  weight reaches  year.  (1982) a d d i t i o n i s  groups.  these  languages,  rate  criteria  counselled.  just  The P r o g r a m  Weight  nutritional  f o ra v a r i e t y of reasons  etc.)  of  $10,000 p . a .  2 5 0 women e a c h  A recent programming  aides.  7 2 % o f t h e women a t t e n d i n g  increased  of the  dietary  o f 3 3 5 7 gm  s t r i c t e r acceptance  demonstrated  who  a Low B i r t h  publication  Babies  part  programming.  48% had incomes under  though with  as  weight  at  i n five  nutrition  running  aimed  f o r home  provided  outreach  the  over in  i s designed  Cable Hindi, to reach  (cultural, as c l i e n t s  Health  Department  Television Punjabi the  linguistic,  of the general  of and  population economic, program.  /eg Evaluation to  of  Punjabi  one-third  the  speaking of  s i x months  (90%)  recalled the  It  advice  having  the  to  households  and  on  terms  of  received  broadcasting. presented,  i f  to  population  state  prenatal  clearly  for  present  that  i s by  education,  income,  resources  distributed; high-risk  -  at  attend  this  the  are  would  classes  popular;  We  must  the  risks  of  might  not  maternal  likely  answer  parents and  ask  be  groups  this  resources?"  of  that  public  group  gain through  sufficient  Utilization  self^  residence this  a  probably  support  "Is  population  among  included.  whether  goals.  influence, place best,  further,  defined  companionship  of  and  resources  clearly  allocation  part  them,  prenatal  exceedingly  i t i s much more  mothers  they  are  defined  attendance.  justification  that  majority  programs  who  existing  confidence,  class  the  the  unspecialized prenatal  more  knowledge,  least  during  viewing,  stated  at  the  other  are  that  programming  those  confined  effects  r e d i r e c t e d to  and  Of  was  measurable  health,  demand,  the  what  fetal  more  suggests  and  improved  achieve  programming  pregnant.  Department  Undoubtedly  to  this  i s impossible Health  better  of  advice  Vancouver  in  of  households  first  follow  penetration  selected  and are  at by  proximity randomly  disproportionately  few  This  on  paper  attempted  to:  a)  I d e n t i f y a key  b)  Identify modifiable  i n d i c a t o r of  prenatal  precursors  that  health; act  negatively  this indicator; c)  Survey  d)  Compare  e)  a population this  Identify  differences for  has  between  populations  population  an  populations  a  social and  poor  'normal'  devise  outcome;  population;  and  behavioural  some r i s k  negative  precensous;  I d e n t i f y the  services  currently offered  g)  I d e n t i f y the  populations  h)  Assess  f)  the  identified  with  biological,  the  with  with  to  ratios  maternal  populations;  The  research  effectiveness  undertaken  identified  such  -  identified  populations  -  identified  i n those  groups  risk  -  effective  that  key  as  offered.  indicator; at  risk;  populations,  prenatal  evidence  in achieving  cast effective,  doubt  are  final  allocation based  services  i n d i c a t o r s of  risk  and  services  are  not  directed  at  may  not  be  even  i f  risk;  uncovered  The  the  behaviours;  concluded at  a  of  services;  has:  -  modifiable  are  the  r e c e i v i n g the  on  their  upon  r e l a t e d to  chapter  within the  the  that  activities  goals;  whether the  will  those  activities,  chosen h e a l t h  present  prenatal  findings  service  recommendations  program  above.  indicator.  area.  The  for  resource  recommendations  no BIBLIOGRAPHY CHAPTER  1.  Vital  2. East Department  Statistics,  1976.  Health Unit Profile: Unit Profiles.  3. B a i l e y , G . : A n a l y s i s of B i r t h Attendance. Unpublished paper. 4. Communication M i n i s t r y of Health,  VI  from 1980.  City  of  Vancouver  Weight by E t h n i c i t y  Dr,G.Bontram,A.D.M.  of  5. Stone,C.I., Demchik-Stone,B.A., Moran,J.J.: 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 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 .  Health  and  Health  Meyers,E. : J.Health  7. Stevens,R.J., Heide,F.: Analgesic characteristics prepared childbirth techniques, attention focusing s y s t e m a t i c r e l a x a t i o n . J.Psychosom, Res.1977 21:429-438.  9. Nettelbladt,P., s i g n i f i c a n c e of reported 20:215-221.  B.C.  Coping with behavioural  6. Norr,K.L., Block,C.R., Charles,A., Meyering,S., Explaining pain and enjoyment in childbirth. Soc.Behaviour 1977,18:260-275.  8. Davenport-Slack,B., Boylan,C.H.: Psychological o f c h i l d b i r t h p a i n . P s y c h o s o m . M e d . 1974 3 6 : 2 1 5 - 2 2 3 .  Class  of and  correlates  Fagerstrom,C.F., Uddenberg,N.: c h i l d b i r t h p a i n . J.Psychosom Res.  The 1976,  10. J a v e r t , C . T . , Hardy,J.D.: Measurement of p a i n intensity in labour and i t s physiologic, neurologic and pharmacolgic 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 . 1 9 5 0 6 0 : 5 5 2 - 5 6 3 . 11. Melzack,R., Taenzer,P., Feldman,P., Kinch,R.A.: Labour i s s t i l l painful after prepared c h i l d b i r t h t r a i n i n g . CM.A.Journal A u g u s t 1981 V o l . 1 2 5 page 357.  ///  12. Thordarsen,L., Costanzo,G.: An evaluation e f f e c t i v e n e s s o f an e d . program f o r e x p e c t a n t p a r e n t s . V o l . 6 7 ( M a r c h - A p r i l , 1976) page 117-121.  of the C.J.P.H.  13. Yarie,S.F.: A study of factors i n f l u e n c i n g utilization of 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, Vancouver. 14. Ross,S.E., Rutter,A.C: O u t r e a c h P r o g r a m . VHD 1 9 7 8 .  Healthiest  Babies  Possible:  An  15. Kendall,P., Bell,P., Calloway,R.: Food f o r Thought: 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. Risk Approach f o r Maternal andC h i l d O f f s e t P u b . N o . 3 9 W.H.O., G e n e v a 1 9 7 8 .  Health  17. Hommel,F.: T w e l v e Y e a r s ' E x p e r i e n c e 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 49-51.  i n  Care.  W.H.O.  Psychoprophylactic  18. Huttel,F.A., Mitchell,I., Fischer,W.M., et a l : A quantitative evaluation of psychoprophylaxis i n childbirth. J.Psychosom Res. 16:81-92. 19. Enkin,M.W., S m i t h , S . L . , Dermer,S.W., e t a l : An adequately 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 62-67. 20. Flowers,C.R.: P a t i e n t p a r t i c i p a t i o n Tex.Med. 58:988-993, 1967.  i nlabour  and d e l i v e r y .  21. Galeazzi,L., Minella,E.: Statistical assessment o f 300 cases o f c h i l d b i r t h under hypnosis. Minerva Med. 63:952-954, 1972. 22. Shapiro ,H.I., Schmkitt,L.G.: p s y c h o p r o p h y l a c t i c method o f c h i l d b i r t h Conn.Med. 37:341-343, 1973. 23. for  Evaluation of the i n the primigravida.  Petrov-Maslakov,M.A.: Physiopsychoprophylactic 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. Tupper,C: Conditioning Gynecol 71:733-740, 1956.  f o r childbirth.  25. Stahler,F., Stahler,E., Gutainian,R.: of the c h i l d lowered b y p s y c h o p r o p h y l a x i s .  preparation  A.J.Obstet  and  Perinatal mortality page 56-56.  26. Kondas,0., Scetnick,B.: Systematic desensitization as a method of 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.Beh. Ther.Exp. Psychol. 3:51-54, 1972. 27. Gregg,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 training 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 clinical meeting of the American College of Obstetricians and G y n e c o l o g i s t s , B o s t o n , M a s s . May 1 9 7 5 . 28. Frazier,L.M.: Using c h i l d b i r t h . B i r t h Family  biofeedback to aid J o u r n a l 1:4, 1 9 7 4 .  relaxation  during  29. Zax,M., S a m e r o f f , A . J . , Farnum,J.E.: Childbirth education, maternal attitudes and delivery. Am.J. Obstet and Gynecol 123:185-190, 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 preparatrtion) on labour and delivery in primiparas. N.Engl.J.Med. 294:1205-1207, 1976. 31. Beck,C.N., a n a l y s i s . Obstet 371-379.  Hall,D.: Natural and G y n e c o l . V o l . 5 2  childbirth: A No.3 September  review 1978  and page  tit CHAPTER V I I RECOMMENDATIONS  RECOMMENDATION That formally  1  within the prenatal adopt  program,  the prevention  the  o f Low B i r t h  Health  Weight  Department  as  a  program  priority.  RECOMMENDATION That to  the Health  Maternal  Health  2  and C h i l d  Organization  planning  allocation  i n recognition  on t h e i n c i d e n c e  t o pay a p r e n a t a l  feed  and c a r e  allowance to  be t i e d  returns. •  defined  by  approach  i n the Public  t h e woman  the  of low  Government  that  Minister  of  the  order  as  the in  Health  World  program prenatal  3  encourage  in  Care"  Approach  program.  RECOMMENDATION That  Health  f o r m a l l y adopt a "Risk  1978 [ 2 2 ] a n d u s e t h i s  and resource  prevention  status  Department  of  role  birth  Health  of weight  to  have  to replace t o income  the final through  year  self  the  the  V.H.D. Federal  on  women,  resources  pregnancy.  of the Family reporting  the  to pregnant  the financial  f o rherself properly during  socio-economic  that  approach  family allowance  at risk  low  to This  Allowance,  and  year  tax  end  RECOMMENDATION 4 That  the Health  routinely  audit  characteristics populations  Department,  pregnancy to  outcomes  ensure  at highest  as p a r t  that  of and  services  modifiable  their  data  sample are  base,  maternal  delivered  to  risk.  RECOMMENDATION 5 That placed  i n the  prenatal  on p r e p a r a t i o n  emphasis  be p l a c e d  maintaining  program  f o rthe  birth  on b e h a v i o u r  a healthy  itself, process  directed  less  emphasis  a n d a much  be  heavier  towards developing  and  fetus.  RECOMMENDATION 6 That service to  a l l women  be s c r e e n e d  their  approaching  f o rr i s k  objectively defined  the  and r e c i e v e  Health  Department  resources  for  proportional  risks.  RECOMMENDATION 7 That findings  such  a screening  o f Johnson  tool  and Dubin  be  developed  i n "Risks  based  f o r Low B i r t h  upon  the  Weight".  RECOMMENDATION 8 That multiparous for  the Health  Department  i n recognition of the fact  women a r e a t a s g r e a t  low b i r t h  weight, include  a risk  as  them a s a t a r g e t  primiparous population.  that women  /'S RECOMMENDATION 9 That  the Health  Department  recognize  the  fact  that  many  unaware  of,  women, b y r e a s o n o f : -  unabailability  -  lack  -  domestic  commitments;  -  cultural  differences;  -  linguistic  -  transportation  and/or  care;  of knowledge;  unable  presently  of child  d i f f e r e n c e s ; and  to  difficulties,  attend  public  etc.,*  are both  health  prenatal  csare  as  provided.  RECOMMENDATION 10 That actively  i n recognition seek  information media  to  produce  pertaining  in culturally  of the and  above, promote  to prenatal  care  and l i n g u i s t i c a l l y  the  Health  the  Department  dissemination  through  the  appropriate  of  electronic programming  format.  RECOMMENDATION 1 1 That  the  outreach  continue  and i fp o s s i b l e  *  S.F.: A s t u d y  Yarie,  prenatal  education  Vancouver 1978.  service  Healthiest  Babies  Possible  be e x p a n d e d .  of  services  factor in  influencing Vancouver.  utilization  SPAR  United  of Way,  RECOMMENDATION 12 That  the  programming  Health  and t h a t  Department  monitor  a minimum d a t a  -  n u m b e r s o f women s c r e e n e d  -  number  -  changes  o f women e x p o s e d  exposure  to  -  results  of risk  -  results  of maternal  effect  of  a l l  s e t include:  and r e c e i v i n g  t o media  i n knowledge, a t t i t u d e  women f o l l o w i n g  the  services;  information;  and behaviour  of  pregnant  information;  modification  on m a t e r n a l  behavioural  change  b e h a v i o u r ; and on  infant  birth  weights.  RECOMMENDATION 1 3 That modified  as or  a  result  of  discarded  when  such  monitoring  they  fail  to  interventions demonstrate  be their  effectiveness.  RECOMMENDATION 14 That  following  the  adoption  of recommendations  1  through  13: a) and  Program content  intervention b)  new  planned  Health  t r a i n i n g to allow  screening  tools  developed  and implimented;  Department them t o  staff receive  effectively  sufficient  implement  the  programming; and c)  the  programs  The Vancouver  inservice  be r e v i s e d ,  A public  general  reallocation  information  public  the  of resources.  campaign be mounted rationale  behind  to  explain  the  to  proposed  117 APPENDIX I QUESTIONNAIRE M a t e r n a l and I n f a n t  Low B i r t h W e i g h t * Survey  (*  = 2500 gm or  less)  CASES - P l e a s e f i l l out as c o m p l e t e l y as p o s s i b l e on a l l i n f a n t s weighing 2500 gm or l e s s at b i r t h . I n c l u d e S t i l l b i r t h s and N e o n a t a l deaths and A d o p t i v e Babies. ( I n f o r m a t i o n from B i r t h N o t i c e w i l l s u f f i c e f o r these) CONTROLS - The next i n f a n t a s s i g n e d to you who i s not Low B i r t h Weight. U n i t o f Residence M o t h e r ' s name (as on i n d e x c a r d ) 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 i n )  A  U n i t o f Residence}  W | B | R | M M | N | E ( S  I.D. # M a t e r n a l Age  yrs  Live Birth  No  Yes  Date of B i r t h d  /m  B i r t h Weight  If no: /y  died before  Single  Twin  Gestation  T o t a l Pregnancies  labour  During  Triplet_  Male  Female  Total Live Births  Total  Stillbirths  T o t a l A b o r t i o n s and M i s c a r r i a g e s A b n o r m a l i t y of I n f a n t  Yes  C o m p l i c a t i o n s o f Pregnancy  No Yes  No  A n d / o r Labour o r D e l i v e r y Yes  No  Death between B i r t h and 27 days Yes  B  Date o f V i s i t d  /m  No  /y  Infant  Weight  gms.  Infant  Head C i r c u m f i r a n c e  Infant  Height  cm.  cm  Does i n f a n t have an i d e n t i f i e d h e a l t h problem?  C  Maternal Height  cm o r  ft.  M a t e r n a l Pre Pregnancy Weight Pregnancy weight g a i n Frame Small£j , Med. w  LARGE  gm. or  If  so what  in.  gm. o r  lb. lb.  Based on .Thumb and index of  oz. oz.  client  i—i  Around w r i s t at  .  Small - h" o v e r l a p thumb and i n d e x f i n g e r Medium - between s m a l l and l a r g e L a r g e - h" gap between thumb and i n d e x f i n g e r  I  i  | I  labour  condyes.  N8 D  Has mother had a p r e v i o u s L . B . W .  baby Yes j  No j  j  j  D i d l e s s than 12 months e l a p s e between t h i s pregnancy  S i n g l e parent  status  (No l i v e i n Husband, b o y f r i e n d ,  and d e l i v e r y of l a s t  Significant  Monthly Pregnancy food budget For  Was Family on S o c i a l A s s i s t a n c e Yes j  i n pregnancy „  1  |  C h i l d r e n OR  F o r Mother - d i d she spend l e s s than $75 per month Yes j  Tobacco use  No  $  A d u l t s ( i n c l u d i n g Mother and  Received $25 supplement  Other)  1  Yes |  child  d u r i n g Pregnancy Yes j j No j-  |  j No j j No j  j j  j  ,  ,  , , ,  1  1  ,  ,  ,  None I | L e s s than 1 pk/ day j | More than 1 p k / d . Does Mother, f o r R e l i e i o u s or o t h e r reasons a v o i d any p a r t i c u l a r f o o d ( s )  A l c o h o l i n Pregnancy  None  Rare*  Moderate**  Heavy*  . 1st T r i m e s t e r Yes No  *.  Rare - consuming a l c o h o l l e s s on any one  than once p e r month and n e v e r 5-6  drinks  occasion  **  Moderate - L e s s than heavy and more t h a n r a r e  ***  Heavy - A t l e a s t  5 o r 6 d r i n k s on some o c c a s i o n s and at  least  45 d r i n k s  per month. "A Drink" -  E  1 oz S p i r i t s ,  A oz Wine o r 12 oz  Maternal Medical History during t h i s D i d / d o e s mother have -  (tick)  Beer.  pregnancy  ) Diabetes  U Cardiac  1 Hypertension  Disease  £ Renal Disease  3 Epilepsy  Problems b u t d i a g n o s i s  Other Record of ' Toxaemia  (tick) ^Placenta Praevia  |_j Antepartum Haemorrhage M e d i c a t i o n i n Pregnancy What  -3 P l a c e n t a l  Insufficiency  Other Abnormal C o n d i t i o n When ( i . e .  which  trimester)  uncert;  Ill F  H e a l t h Care i n Pregnancy - P h y s i c i a n c o n s u l t e d r e pregnancy  .  How may M . D . v i s i t s  R e g u l a r i t y of v i s i t s  pregnancy i n which week of  d u r i n g pregnancy  - Monthly o r more  E v e r y 2-3 months  Only i n 3rd T r i m e s t e r D i d c l i e n t have U l t r a Sound?  1st T r i m e s t e r  2nd T r i m e s t e r  3rd T r i m e s t e r P r e n a t a l Class  Registration  and a t t e n d e d  at  least  2 c l a s s e s - V . H . D . Yes j  Private Was H e a l t h i e s t Babies  Possible  involved?  D i d mother modify any b e h a v i o u r s  Yes j  j No j  Yes j  jNoj  j  j NCJ  j  J  d u r i n g pregnancy Yes j  j No j  j  Which? Was t h i s due to a d v i c e from M . D . j  G  Linguistic/Ethnic Characteristics  | C.H.N. |  | H.B.P. j  - Length of Residence  | Other J  |  i n Canada  I f A p p l i c a b l e - 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 | If  Comprehension N i l o r Poor - Language  Ethnicity i.e. 1 4 7 10 H  jPoor j  jFair j  2 Native Indian 5 Italian 8 Thai/Loatian/Vietnamese  CHN E v a l u a t i o n F u r t h e r Support S e r v i c e s What would .you see  as needed?.  |  needed by t r a n s l a t o r  which o f the f o l l o w i n g b r o a d c l a s s i f i c a t i o n s  Caucasion/European East Indian Portuguese Other  | Good j  needed :  Yes j  applies  to  3 Chinese 6 Spanish 9 Phillipino  j No j  |  client?  120  APPENDIX I I PROTOCOL FOR COMMUNITY H E A L T H NURSES INVOLVED On  completing  the survey  I N LBW S U R V E Y  instrument  S e c t i o n A o f t h e form c a n be a b s t r a c t e d n o t i c e which i s a l r e a d y agency p r o p e r t y .  from  the birth  S e c t i o n B. T h e 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 assess h e a l t h care s t a t u s and f u t u r e h e a l t h needs of 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. O n c e 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 accomplished, I would a p p r e c i a t e i ti f you would e x p l a i n t h e purpose o f t h e survey, t o t h e mother as f o l l o w s ; "The H e a l t h women d o n o t u s e aware t h a t t h e s e who a r e m o s t l i k e  D e p a r t m e n t i s a w a r e t h a t f o r many r e a s o n s , many prenatal services that are offered. I t i s also s e r v i c e s may n o t b e o f t h e k i n d t o h e l p women l y t o have s m a l l babies."  "In order 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 , a n d 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 n u m b e r o f women. T h e s e h a v e been p i c k e d e i t h e r because they d e l i v e r e d a 'small baby', o r because they a r e a 'normal c o n t r o l ' f o r a mother w i t h a s m a l l baby." " I f y o u w i l l answer 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 m o r e i m p o r t a n t l y , o t h e r women i n t h e future." "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 a n d m e d i c a l state during pregnancy, your language s k i l l s , length o f residence i n B.C., and your use o f your d o c t o r . There a r e other questions, t o o . I f y o u do n o t w i s h t o a n s w e r a q u e s t i o n , j u s t s a y n o . " "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 computer c a r d s , and w i l l b e 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 has been t r a n s f e r r e d t o computer c a r d s , t h e papers w i t h names on w i l l be d e s t r o y e d . "  any the  P l e a s e emphasize t h a t i ft h e mother does n o t w i s h t o answer questions she has the r i g h t to say so. I t w i l l not a f f e c t 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 B I R T H WEIGHT S U R V E Y CONSENT FORM (For  signature  after  oral  presentation)  I, ,of (address) have been informed that the purpose of t h i s survey i s to c o l l e c t information f o r the Vancouver H e a l t h D e p a r t m e n t . The H e a l t h Department 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 d o 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 instruction, 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 been 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 any, I w i l l answer, and t h a t t h e e x e r c i s e o f such c h o i c e w i l l i n no way p r e j u d i c e a n y 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 from the Vancouver H e a l t h Department.  Signed  Date  Witness  Date  to  

Cite

Citation Scheme:

        

Citations by CSL (citeproc-js)

Usage Statistics

Share

Embed

Customize your widget with the following options, then copy and paste the code below into the HTML of your page to embed this item in your website.
                        
                            <div id="ubcOpenCollectionsWidgetDisplay">
                            <script id="ubcOpenCollectionsWidget"
                            src="{[{embed.src}]}"
                            data-item="{[{embed.item}]}"
                            data-collection="{[{embed.collection}]}"
                            data-metadata="{[{embed.showMetadata}]}"
                            data-width="{[{embed.width}]}"
                            async >
                            </script>
                            </div>
                        
                    
IIIF logo Our image viewer uses the IIIF 2.0 standard. To load this item in other compatible viewers, use this url:
http://iiif.library.ubc.ca/presentation/dsp.831.1-0095743/manifest

Comment

Related Items