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UBC Theses and Dissertations

A descriptive survey of the health behaviors of prenatal class attenders Kiss, Linda Ann 1983

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A D E S C R I P T I V E S U R V E Y O F T H E H E A L T H B E H A V I O R S O F P R E N A T A L C L A S S A T T E N D E R S B Y L I N D A A N N K I S S B . S . N . , 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 , 1 9 7 7 A T H E S I S S U B M I T T E D I N P A R T I A L F U L F I L L M E N T O F T H E R E Q U I R E M E N T S F O R T H E D E G R E E O F M A S T E R O F S C I E N C E I N N U R S I N G i n T H E F A C U L T Y O F G R A D U A T E S T U D I E S ( S c h o o l o f N u r s i n g ) We a c c e p t t h i s t h e s i s a s c o n f o r m i n g t o t h e r e q u i r e d s t a n d a r d 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 e c e m b e r 1 9 8 3 © L i n d a A n n K i s s , 1 9 8 3 I n p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t o f t h e r e q u i r e m e n t s f o r a n a d v a n c e d d e g r e e a t t h e U n i v e r s i t y o f B r i t i s h C o l u m b i a , I a g r e e t h a t t h e L i b r a r y s h a l l m a k e i t f r e e l y a v a i l a b l e f o r r e f e r e n c e a n d s t u d y . I f u r t h e r a g r e e t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y i n g o f t h i s t h e s i s f o r s c h o l a r l y p u r p o s e s m a y b e g r a n t e d b y t h e h e a d o f m y d e p a r t m e n t o r b y h i s o r h e r r e p r e s e n t a t i v e s . I t i s u n d e r s t o o d t h a t c o p y i n g o r p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l n o t b e a l l o w e d w i t h o u t m y w r i t t e n p e r m i s s i o n . D e p a r t m e n t o f 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 1956 Main Mall V a n c o u v e r , C a n a d a V6T 1Y3 D a t e DE-6 (3/81) ABSTRACT A d e s c r i p t i v e s u r v e y w a s c o n d u c t e d o n 220 p r e n a t a l c l a s s a t t e n d e r s t o i d e n t i f y t h e i r h e a l t h b e h a v i o r s w i t h r e g a r d t o s m o k i n g , i n t a k e o f a l c o h o l , n o n - p r e s c r i p t i o n d r u g s , c a f f e i n e , a n d d i e t . T h e r e p o r t e d c h a n g e s a n d f a c t o r s w h i c h i n f l u e n c e d t h e c h a n g e s i n h e a l t h b e h a v i o r s w e r e a l s o i n v e s t i g a t e d . D a t a w e r e c o l l e c t e d u t i l i z i n g t w o q u e s t i o n -n a i r e s , o n e a d m i n i s t e r e d e a r l y i n p r e g n a n c y , t h e o t h e r l a t e r i n p r e g n a n c y . F i n d i n g s i n d i c a t e d t h a t 15% o f t h e p r e g n a n t women s m o k e d , 48% c o n s u m e d a l c o h o l , 40% u s e d n o n - p r e s c r i p t i o n d r u g s o t h e r t h a n p r e n a t a l v i t a m i n s , 89% c o n s u m e d t e a , c o f f e e o r c o l a s , a n d 81% h a d d i e t s w h i c h d i d n o t m e e t t h e nxLnimum r e q u i r e m e n t s o f C a n a d a ' s F o o d G u i d e . M o s t r e s p o n d e n t s r e p o r t e d a c h a n g e i n h e a l t h b e h a v i o r s d u r i n g p r e g n a n c y . M a j o r i n f l u e n c e s o n c h a n g i n g b e h a v i o r s w e r e own p e r s o n a l k n o w l e d g e , b o o k s , m a g a z i n e s a n d p a m p h l e t s , c h a n g e i n c r a v i n g , a n d d o c t o r . P r e g n a n t women w h o s m o k e d d u r i n g p r e g n a n c y w e r e y o u n g e r a n d h a d l e s s e d u c a t i o n t h a n n o n - s m o k e r s , a n d w e r e m o r e l i k e l y t o h a v e b e e n b o r n i n C a n a d a . Women who c o n s u m e d a l c o h o l d u r i n g p r e g n a n c y t e n d e d t o b e o l d e r t h a n n o n - d r i n k e r s a n d w e r e a l s o m o r e l i k e l y t o h a v e b e e n b o r n i n C a n a d a . R e s p o n d e n t s w h o s e d i e t s d i d n o t m e e t C a n a d a ' s F o o d G u i d e r e c o m m e n d a t i o n s t e n d e d t o h a v e l e s s e d u c a t i o n t h a n women w i t h a d e q u a t e d i e t s a n d w e r e a l s o l e s s l i k e l y t o b e C a n a d i a n b o r n . T h e f i n d i n g s o f o n l y 8% o f p r e g n a n t women r e p o r t i n g h e a l t h b e h a v i o r s t h a t d i d n o t w a r r a n t some i m p r o v e m e n t s , s u g g e s t s t h e r e i s a c o n t i n u i n g n e e d f o r h e a l t h e d u c a t i o n . i i i TABLE OF CONTENTS A b s t r a c t i i L i s t o f T a b l e s v i L i s t o f F i g u r e s v i i i A c k n o w l e d g e m e n t s i x CHAPTER I INTRODUCTION S t a t e m e n t o f t h e P r o b l e m 2 P u r p o s e o f t h e S t u d y 3 D e f i n i t i o n o f T e r m s 4 L i m i t a t i o n s 5 A s s u m p t i o n s 5 Human R i g h t s a n d E t h i c s 5 D e s c r i p t i o n o f t h e F o l l o w i n g C h a p t e r s 6 I I REVIEW OF THE LITERATURE E f f e c t s o f H e a l t h B e h a v i o r s D u r i n g P r e g n a n c y 8 S m o k i n g 8 A l c o h o l 13 D r u g s 18 C a f f e i n e 22 D i e t 2 3 P r e v i o u s I n v e s t i g a t i o n s o f H e a l t h B e h a v i o r s D u r i n g P r e g n a n c y 29 A m e r i c a n S t u d i e s 29 O v e r s e a s S t u d i e s 32 C a n a d i a n S t u d i e s ' 34 T h e o r e t i c a l M o d e l s f o r H e a l t h B e h a v i o r C h a n g e 37 I I I RESEARCH METHODOLOGY Q u e s t i o n n a i r e D e v e l o p m e n t 43 S e t t i n g 4 5 S a m p l e S e l e c t i o n 47 D a t a C o l l e c t i o n 48 D a t a A n a l y s i s 50 i v CHAPTER TV STUDY RESULTS D e s c r i p t i o n o f t h e S a m p l e 5 2 R e s p n s e R a t e 52 D e m o g r a p h i c C h a r a c t e r i s t i c s 5 3 H e a l t h B e h a v i o r s o f P r e n a t a l C l a s s A t t e n d e r s 58 S m o k i n g 58 A l c o h o l 6 1 N o n - p r e s c r i p t i o n D r u g s 66 T e a , C o f f e e , C o l a 70 D i e t 73 O v e r a l l H e a l t h B e h a v i o r s o f P r e n a t a l C l a s s A t t e n d e r s 84 R e l a t i o n s h i p B e t w e e n D e m o g r a p h i c C h a r a c t e r i s t i c s a n d H e a l t h B e h a v i o r s 84 V OTHER FINDINGS R e s u l t s o f P r e n a t a l C l a s s R e g i s t r a n t s o n t h e W a i t i n g L i s t . 89 Comments a n d R e c o m m e n d a t i o n s f o r t h e I m p r o v e m e n t o f P r e n a t a l E d u c a t i o n 92 R e c o m m e n d a t i o n s o f P r e n a t a l C l a s s A t t e n d e r s 92 R e c o m m e n d a t i o n s o f P r e g n a n t Women o n t h e W a i t i n g L i s t 94 V I D I S C U S S I O N OF THE R E S U L T S , CONCLUSION, I M P L I C A T I O N S AND RECOMMENDATIONS FOR FURTHER RESEARCH D i s c u s s i o n o f t h e R e s u l t s 95 H e a l t h B e h a v i o r s o f t h e P a r t i c i p a n t s 95 I n f l u e n c e s t o C h a n g e H e a l t h B e h a v i o r s D u r i n g P r e g n a n c y 99 D e m o g r a p h i c C h a r a c t e r i s t i c s o f S p e c i f i c H e a l t h B e h a v i o r s 1 0 3 D i s c u s s i o n o f t h e S t u d y P a r t i c i p a n t s ' Comments a n d R e c o m m e n d a t i o n s 105 C o n c l u s i o n 106 I m p l i c a t i o n s o f t h e S t u d y 107 R e c o m m e n d a t i o n s f o r F u r t h e r R e s e a r c h 109 REFERENCES 112 APPENDICES A C o v e r i n g L e t t e r t o P r e n a t a l C l a s s A t t e n d e r s 124 B C o v e r i n g L e t t e r t o R e g i s t r a n t s o n t h e W a i t i n g L i s t 126 C H e a l t h H a b i t s Q u e s t i o n n a i r e 128 D P r e n a t a l A s s e s s m e n t F o r m 137 E D i e t A n a l y s i s 1 4 1 v i L I S T OF TABLES TABLE 4 - 1 R e s p o n s e R a t e b y H e a l t h U n i t 5 3 4 - 2 A g e o f R e s p o n d e n t s 53 4 - 3 C o u n t r y o f O r i g i n o f t h e R e s p o n d e n t s 54 4 - 4 L a n g u a g e B e s t U n d e r s t o o d b y t h e R e s p o n d e n t s 55 4 - 5 A n n u a l G r o s s F a m i l y I n c o m e o f R e s p o n d e n t s 56 4 - 6 E d u c a t i o n a l L e v e l o f R e s p o n d e n t s 57 4 - 7 Number o f S m o k e r s a n d N o n - S m o k e r s B e f o r e a n d D u r i n g P r e g n a n c y 59 4 - 8 Number o f C i g a r e t t e s S m o k e d B e f o r e a n d D u r i n g P r e g n a n c y 60 4 - 9 I n f l u e n c e s o n S m o k i n g B e h a v i o r 6 1 4 - 1 0 Number o f A l c o h o l U s e r s a n d A b s t a i n e r s B e f o r e a n d D u r i n g P r e g n a n c y 62 4 - 1 1 Number o f A l c o h o l S e r v i n g s C o n s u m e d B e f o r e a n d D u r i n g P r e g n a n c y 63 4 - 1 2 T y p e a n d F r e q u e n c y o f A l c o h o l C o n s u m e d B e f o r e a n d D u r i n g P r e g n a n c y 64 4 - 1 3 I n f l u e n c e s o n A l c o h o l I n t a k e 66 4 - 1 4 T y p e a n d F r e q u e n c y o f N o n - P r e s c r i p t i o n D r u g s T a k e n D u r i n g P r e g n a n c y 67 4 - 1 5 F r e q u e n c y o f N o n - P r e s c r i p t i o n D r u g s W h i c h W e r e S t a r t e d o r I n c r e a s e d D u r i n g P r e g n a n c y 68 4 - 1 6 F r e q u e n c y o f N o n - P r e s c r i p t i o n D r u g s W h i c h W e r e S t o p p e d o r D e c r e a s e d D u r i n g P r e g n a n c y 69 4 - 1 7 Number o f S e r v i n g s o f T e a , C o f f e e a n d / o r C o l a s C o n s u m e d D u r i n g P r e g n a n c y 70 4 - 1 8 F r e q u e n c y o f T e a , C o f f e e a n d C o l a C o n s u m p t i o n D u r i n g P r e g n a n c y 71 v i i TABLE 4 - 1 9 F r e q u e n c y o f R e p o r t e d C h a n g e s i n T e a , C o f f e e a n d C o l a I n t a k e 72 4 - 2 0 I n f l u e n c e s o n T e a , C o f f e e a n d C o l a I n t a k e . . . . 73 4 - 2 1 D i e t A s s e s s m e n t F r o m t h e P r e n a t a l A s s e s s m e n t F o r m 75 4 - 2 2 T o t a l D i e t S c o r e ( P r e n a t a l A s s e s s m e n t Form) 76 4 - 2 3 D i e t A s s e s s m e n t F r o m t h e H e a l t h H a b i t s Q u e s t i o n n a i r e 77 4 - 2 4 T o t a l D i e t S c o r e ( H e a l t h H a b i t s Q u e s t i o n n a i r e ) 78 4 - 2 5 C h a n g e i n F o o d I n t a k e A c c o r d i n g t o t h e F o u r F o o d G r o u p s . . . 79 4 - 2 6 I n f l u e n c e s o n D i e t I n t a k e 80 4 - 2 7 H e a l t h B e h a v i o r P r o f i l e o f P r e n a t a l C l a s s A t t e n d e r s 83 4 - 2 8 C o u n t r y o f O r i g i n b y H e a l t h B e h a v i o r s 86 4 - 2 9 A n n u a l G r o s s F a m i l y I n c o m e b y H e a l t h B e h a v i o r s 86 4 - 30 E d u c a t i o n a l L e v e l b y H e a l t h B e h a v i o r s 87 5 - 1 H e a l t h B e h a v i o r P r o f i l e o f R e g i s t r a n t s o n t h e W a i t i n g L i s t 9 1 6 - 1 F r e q u e n c y o f R e p o r t e d I n f l u e n c e s t o C h a n g e H e a l t h B e h a v i o r s 100 v i i i L I S T OF FIGURES FIGURE 1 A S c h e m a t i c O u t l i n e o f a P e r s o n a l C h o i c e H e a l t h B e h a v i o r M o d e l 40 2 E l a b o r a t i o n o f F a c t o r s G o v e r n i n g C e s s a t i o n ( o r o t h e r m o d i f i c a t i o n o f t h e B e h a v i o r ) 4 1 ACKNO^IXSEMENTS I w o u l d l i k e t o e x p r e s s a s i n c e r e t h a n k y o u t o t h o s e who made t h i s s t u d y p o s s i b l e . F i r s t o f a l l , I t h a n k my t h e s i s c o m m i t t e e c h a i r m a n , H e l e n E l f e r t , f o r h e r c o n t i n u a l g u i d a n c e , e x p e r t i s e a n d e n c o u r a g e m e n t t h r o u g h o u t t h e r e s e a r c h p r o c e s s a n d L i n d a L e o n a r d , t h e s i s c o m m i t t e e m e m b e r , f o r h e r c r i t i c a l r e v i e w s , e d i t o r i a l c o m m e n t s a n d i n s i s t e n c e t h a t I w o u l d r e a c h " t h e l i g h t a t t h e e n d " . I a l s o t h a n k D r . M a r k S t a r r f o r h i s s t a t i s t i c a l a d v i c e a n d a s s i s t a n c e w i t h c o m p u t e r a n a l y s i s o f t h e d a t a . A p p r e c i a t i o n i s e x t e n d e d t o t h e V a n c o u v e r H e a l t h D e p a r t m e n t f o r a l l o w i n g me a c c e s s t o t h e i r p r e n a t a l c l a s s e s , a n d t o t h e p r e n a t a l c l a s s i n s t r u c t o r s a n d p r e n a t a l c l e r k s f o r t h e i r a s s i s t a n c e a n d c o - o p e r a t i o n . S p e c i a l t h a n k s g o t o t h e p r e g n a n t women who p a r t i c i p a t e d i n t h e s t u d y a n d t o A r l e n e S c h m i d t f o r t y p i n g t h e f i n a l d r a f t d u r i n g t h e h o l i d a y s e a s o n . L a s t , b u t n o t l e a s t , I am e s p e c i a l l y g r a t e f u l t o my h u s b a n d L e s , w h o w i t h o u t h i s s u s t a i n e d s u p p o r t , e n c o u r a g e m e n t a n d t y p i n g s k i l l s , t h i s t h e s i s w o u l d n o t h a v e b e e n c o m p l e t e d . 1 CHAPTER I INTRODUCTION I t i s e v i d e n t now t h a t f u r t h e r i m p r o v e m e n t s i n t h e e n v i r o n m e n t , r e d u c t i o n s i n s e l f - i m p o s e d r i s k s a n d a g r e a t e r k n o w l e d g e o f human b i o l o g y a r e n e c e s s a r y i f m o r e C a n a d i a n s a r e t o l i v e a f u l l , h a p p y , l o n g a n d i l l n e s s -f r e e l i f e ( L a l o n d e , 1 9 7 4 , p . 6 ) . S i n c e M a r c L a l o n d e " s r e p o r t " A New P e r s p e c t i v e o n t h e H e a l t h o f C a n a d i a n s " i n 1 9 7 4 , t h e r e h a s b e e n a n i n c r e a s i n g a w a r e n e s s o f t h e i m -p o r t a n c e o f h e a l t h y l i f e s t y l e s . I m p r o v e m e n t s i n h e a l t h b e h a v i o r s c a n d r a m a t i c a l l y d e c r e a s e t h e r i s k o f i l l n e s s a n d t h u s s a v e s i g n i f i c a n t human a n d e c o n o m i c r e s o u r c e s . I n t i m e s o f e c o n o m i c r e s t r a i n t , i t i s i m p e r a t i v e t h a t C a n a d i a n s make e v e r y e f f o r t t o r e d u c e a l l s e l f - i m p o s e d h e a l t h r i s k s . T h e i m p a c t o f h e a l t h b e h a v i o r s c a n b e o b s e r v e d a s e a r l y a s a n d e v e n p r i o r t o c o n c e p t i o n . P o o r l i f e s t y l e h a b i t s d u r i n g p r e g n a n c y c o u l d b e c o s t l y t o t h e m o t h e r , t h e c h i l d a n d t o t h e s o c i e t y i n w h i c h t h e y l i v e . S m o k i n g , a l c o h o l a n d d r u g u s e , a n d p o o r d i e t a r y i n t a k e a r e k n o w n t o h a v e s e r i o u s e f f e c t s o n t h e o u t c o m e o f p r e g n a n c y a n d t h e h e a l t h o f t h e n e w b o r n . T h e s e h e a l t h b e h a v i o r s i n v o l v e p e r s o n a l r e s p o n s i b i l i t y . T h e u l t i m a t e o b j e c t i v e o f h e a l t h e d u c a t i o n i n p r e g n a n c y i s t o i n f l u e n c e a n d i m p r o v e t h e s e b e h a v i o r s . R e s e a r c h i n d i c a t e s t h a t a t t e n d e r s o f p r e n a t a l c l a s s e s t e n d t o b e o f h i g h e r s o c i o e c o n o m i c s t a t u s , b e t t e r e d u c a t e d a n d m o t i v a t e d a n d a t 2 lower risk than those who do not attend (Latchford, Milne, Vaughan, McClinton and Harris, 1970; Thordarson and Costanzo, 1976; Yarie, 1977). Such findings suggest that prenatal programs should be structured for the hard-to-reach at-risk groups rather than for the general public. However, programs that attempt to change attitudes and behavior in the hard-to-reach groups have slow rates of change. Efforts have to be more intensive and education costs per acceptor are high (Green, 1979). Little research has been done to describe the health behaviors of pregnant women who attend prenatal classes and to investigate changes in health behaviors during pregnancy. Do prenatal classes teach the "already converted"? Whether the majority of prenatal class attenders have healthy lifestyles already, that is; refrain from smoking, use of alcohol or non-prescription drugs and have adequate diets, has not been documented. The changes in health behaviors these pregnant women make and the factors which influence these changes are unknown. This study is intended to provide a com-posite picture of the health behaviors of prenatal class attenders. The findings should prove useful to community health nurses and health care administrators in planning more effective prenatal programs and to researchers for further study in this area. Statement of The Problem Current research demonstrates that smoking, alcohol, drug and inadequate dietary intake during pregnancy may have harmful effects on the fetus. It is therefore suggested that pregnant women avoid 3 o r l i m i t t h e s e b e h a v i o r s . M a n y women a r e m o t i v a t e d e n o u g h d u r i n g p r e g n a n c y t o a t t e n d p r e n a t a l c l a s s e s . H o w e v e r , a t p r e s e n t , l i t t l e i s k n o w n a b o u t t h e s m o k i n g , a l c o h o l , d r u g a n d d i e t b e h a v i o r o f p r e g n a n t women who a t t e n d p r e n a t a l c l a s s e s ; w h e t h e r t h e y c h a n g e t h e i r h e a l t h b e h a v i o r s d u r i n g p r e g n a n c y a n d t h e f a c t o r s w h i c h i n f l u e n c e t h e s e c h a n g e s . P u r p o s e o f T h e S t u d y T h e p u r p o s e o f t h i s s t u d y w a s t o d e s c r i b e t h e h e a l t h b e h a v i o r s o f p r e g n a n t women a t t e n d i n g p r e n a t a l c l a s s e s . T h e s p e c i f i c o b j e c t i v e s w e r e : 1. t o d e s c r i b e t h e r e p o r t e d h e a l t h b e h a v i o r s — s m o k i n g , a l c o h o l , n o n - p r e s c r i p t i o n d r u g s , c a f f e i n e a n d d i e t a r y i n t a k e o f p r e n a t a l c l a s s a t t e n d e r s . 2. t o d e s c r i b e t h e r e p o r t e d c h a n g e s i n h e a l t h b e h a v i o r s o f p r e n a t a l c l a s s a t t e n d e r s . 3. t o i d e n t i f y t h e m a j o r i n f l u e n c e s t o w h i c h p r e n a t a l c l a s s a t t e n d e r s a t t r i b u t e t h e s e c h a n g e s . 4. t o d e s c r i b e t h e d e m o g r a p h i c c h a r a c t e r i s t i c s o f p r e n a t a l c l a s s a t t e n d e r s . 5. t o d e t e r m i n e t h e r e l a t i o n s h i p b e t w e e n s e l e c t e d d e m o g r a p h i c c h a r a c t e r i s t i c s a n d r e p o r t e d h e a l t h b e h a v i o r s . D e f i n i t i o n o f T e r m s 4 a l c o h o l — b e e r , w i n e , l i q u o r . d e m o g r a p h i c c h a r a c t e r i s t i c s — a g e , c o u n t r y o f b i r t h , l a n g u a g e , e d u c a t i o n , f a m i l y i n c o m e , h e a l t h b e h a v i o r s — l i f e s t y l e h a b i t s ; s y n o n y m o u s l y u s e d w i t h h e a l t h h a b i t s , r e g a r d i n g t h e u s e o f c i g a r e t t e s , a l c o h o l , n o n - p r e s c r i p t i o n d r u g s , c a f f e i n e , a n d d i e t a r y i n t a k e , i n f l u e n c e — t o m o d i f y o r a f f e c t i n some w a y ; t o s w a y , n o n - p r e s c r i p t i o n d r u g s — m e d i c a t i o n s w h i c h may b e p u r c h a s e d w i t h o u t a p h y s i c a n ' s p r e s c r i p t i o n s u c h a s a s p i r i n , c o u g h s y r u p , v i t a m i n s , p r e n a t a l c l a s s a t t e n d e r s — p r e g n a n t women w h o a r e r e g i s t e r e d a n d a t t e n d -i n g p r e n a t a l c l a s s e s o f f e r e d b 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 , p r e n a t a l c l a s s r e g i s t r a n t s — p r e g n a n t women who a r e r e g i s t e r e d f o r p r e n a t a l c l a s s e s a n d a r e e i t h e r a t t e n d i n g c l a s s e s o r a r e o n t h e w a i t i n g l i s t . p r e n a t a l c l a s s w a i t i n g l i s t — a l i s t o f p r e g n a n t women r e g i s t e r e d f o r p r e n a t a l c l a s s e s b u t w h o a r e u n a b l e t o a t t e n d b e c a u s e t h e c l a s s e s a r e b o o k e d . e a r l y b i r d p r e n a t a l c l a s s — a n e d u c a t i o n a l c l a s s o f f e r e d i n t h e f i r s t o r s e c o n d t r i m e s t e r f o c u s i n g o n h e a l t h h a b i t s d u r i n g p r e g n a n c y , p r e n a t a l i n t e r v i e w — a n i n d i v i d u a l i n t e r v i e w w i t h a c o m m u n i t y h e a l t h n u r s e f o c u s i n g o n l i f e s t y l e a n d h e a l t h h a b i t s d u r i n g p r e g n a n c y , s e r i e s o f p r e n a t a l c l a s s e s — a s e t n u m b e r o f c l a s s e s w h i c h f o c u s e s o n a s p e c t s o f p r e n a t a l c a r e , l a b o r a n d d e l i v e r y , c a r e o f t h e n e w b o r n a n d t h e p o s t p a r t u m p e r i o d , s m o k i n g — u s e o f c i g a r e t t e s . 5 Limitations 1. The information was obtained through questionnaires and is therefore subject to the limitations of self-reported data. 2. Findings of the study are generalizable only to the population of prenatal class attenders with similar characteristics. 3. The sample was limited to prenatal class registrants who had completed the Vancouver Health Department Prenatal Assessment Form. 4. Sampling took place during the months of March, April, May and June of 1983, therefore some seasonal bias may have been present. Assumptions Participants of the study will report behaviors as practiced or with a small degree of error. Health behaviors are under the control of each individual and involve personal responsibility. Change in health behaviors can occur. Human Rights and Ethics Written and verbal explanations by the investigator were given to a l l subjects (refer to Appendices A'& B) . Subjects were also informed that they could withdraw from the study at any time or refuse to participate without prejudicing their future care from the health department. Anonymity and confidentiality of the responses were stressed. The Prenatal Assessment Form and the Health Habits Question-6 naire were number coded to ensure anonymity. The Health Habits Questionnaire, covering letters and an outline of the proposed study were submitted for ethical review to the University of British Columbia Screening Committee for Research Involving Human Subjects. The procedure of the study, handling of data to ensure confidentiality and the benefits, costs and risks to participants were critiqued and found not to violate the rights of human subjects. The study was implemented following approval by this committee. Description of the Following Chapters This thesis is organized into six chapters. Chapter II consists of a review of selected related literature under three major headings: 1) effects of smoking, alcohol, drugs, caffeine and diet during pregnancy, 2) previous investigations of health behaviors during pregnancy, 3) theoretical models of health behavior change. Chapter III describes the research methodology, including the development and administration of the questionnaire and statistical procedures. Chapter IV presents major study results and Chapter V presents the other findings. Chapter VI contains the discussion of the findings, conclusion and implications of the study as well as recommendations for further study. 7 CHAPTER II REVIEW OF THE LITERATURE Overview The literature is reviewed under three major headings: 1. Effects of health behaviors during pregnancy. Since the research in this area is voluminous, selected research studies on the effects of smoking and alcohol, drug, caffeine, and diet intake during pregnancy are discussed. This review supports the importance of studying health behaviors in a pregnant population and delineates the lower limits of each health behavior which may have detrimental effects i f practiced during pregnancy. 2. Previous investigations of health behaviors during pregnancy. Recent studies are grouped and reviewed according to American, Overseas or Canadian studies as generalizations of surveys are often limited to their setting. 3. Theoretical models on health behavior changes. The model or theoretical framework used for this study is discussed. 8 E f f e c t s o f H e a l t h B e h a v i o r s D u r i n g P r e g n a n c y S m o k i n g J u s t o v e r t w e n t y - f i v e y e a r s a g o , S i m p s o n (1957) f i r s t r e p o r t e d t h e h a z a r d s o f s m o k i n g d u r i n g p r e g n a n c y . H i s s t u d y f o u n d a s i g n i f i -c a n t l y g r e a t e r i n c i d e n c e o f s m a l l b i r t h w e i g h t b a b i e s ( 2 5 0 0 g m s . o r l e s s ) b o r n t o m o t h e r s who s m o k e d . Two y e a r s l a t e r , Lowe (1959) r e p o r t e d i n f a n t s o f s m o k i n g m o t h e r s t o h a v e m e a n b i r t h w e i g h t s 6 o z . l o w e r t h a n i n f a n t s o f n o n - s m o k i n g m o t h e r s . T h e s e e a r l i e r f i n d i n g s h a v e s i n c e b e e n c o n f i r m e d b y many s u b s e q u e n t s t u d i e s . C u r r e n t r e s e a r c h h a s r e l a t e d s m o k i n g d u r i n g p r e g n a n c y t o : 1 . I n c r e a s e d c o m p l i c a t i o n s a s s o c i a t e d w i t h p r e g n a n c y s u c h a s p l a c e n t a l a b n o r m a l i t i e s ( G o u j a r d , Rumeau a n d S c h w a r t z , 1 9 7 5 ; M e y e r a n d T o n a s c i a , 1 9 7 7 ; N a e y e , 1 9 7 8 ) . C o m p l i c a t i o n s o f p r e g n a n c y c a n , o f t h e m s e l v e s , l e a d t o i n t r a u t e r i n e h y p o x i a r e s u l t i n g i n i n t r a u t e r i n e g r o w t h r e t a r d a t i o n a n d / o r d e a t h . 2 . I n c r e a s e d p r o b a b i l i t y o f s p o n t a n e o u s a b o r t i o n ( H i m m e l b e r g e r , B r o w n a n d C o h e n , 1 9 7 8 ) . I n H i m m e l b e r g e r e t a l . ' s s t u d y o f 1 2 , 9 1 4 p r e g n a n c i e s a n d 1 0 , 5 2 3 l i v e b i r t h s , s p o n t a n e o u s a b o r t i o n f o r t h e h e a v y s m o k e r w a s f o u n d t o b e a s m u c h a s 1 . 7 t i m e s t h a t o f t h e n o n -s m o k e r i n c e r t a i n r i s k g r o u p s . 3 . R e d u c e d b i r t h w e i g h t ( B u t l e r , G o l d s t e i n a n d R o s s , 1 9 7 2 ; C a r d o z o a n d C o o p e r , 1 9 8 2 ; D a l t o n , H u g h e s a n d C o g s w e l l , 1 9 8 1 ; D o u g h t e r y a n d J o n e s , 1 9 8 2 ; L o w e , 1 9 5 9 ; M i l l e r a n d M e r r i t t , 1 9 7 9 ; P i c o n e , A l l e n , O l s e n a n d F e r r i s , 1 9 8 2 ; R a n t a k a l l i o , 1 9 7 9 ; R a n t a k a l l i o a n d H a r t i k a i n e n - S o r r i , 9 1 9 8 1 ; R u s s e l l , T a y l o r a n d L a w , 1 9 6 8 ) . B i r t h w e i g h t s o f b a b i e s b o r n t o m o t h e r s who s m o k e d w e r e s i g n i f i c a n t l y l o w e r e v e n w h e n s o c i o d e m o g r a p h i c c h a r a c t e r i s t i c s w e r e c o n t r o l l e d . B i r t h w e i g h t i s k n o w n t o b e a f a i r l y a c c u r a t e i n d e x o f p e r i n a t a l a n d n e o n a t a l m o r t a l i t y a s w e l l a s a p r e -d i c t o r o f s u b s e q u e n t d e v e l o p m e n t . B o t h i n f a n t a n d n e o n a t a l m o r t a l i t y d e c r e a s e a s b i r t h w e i g h t i n c r e a s e s ( e x c e p t f o r a n e l e v a t i o n i n t h e b i r t h w e i g h t g r o u p s o v e r 4 0 0 0 g m s . ) ( C h a s e , 1 9 7 7 ) . 4 . I n c r e a s e d l i k e l i h o o d o f c o n g e n i t a l m a l f o r m a t i o n s ( H i m m e l b e r g e r e t a l . , 1 9 7 8 ; L o w e , 1 9 5 9 ) . H i m m e l b e r g e r e t a l . f o u n d t h e r i s k f o r c o n g e n i t a l a b n o r m a l i t y f o r b a b i e s b o r n o f s m o k i n g m o t h e r s t o b e a s m u c h a s 2 - 3 t i m e s o f t h a t o f n o n - s m o k e r s d e p e n d i n g o n a g e , p r e g n a n c y h i s t o r y a n d o t h e r f a c t o r s . 5 . I n c r e a s e d i n c i d e n c e o f p r e m a t u r i t y ( D u n n , M c B u r n e y , I n g r a m a n d H u n t e r , 1 9 7 7 ; M e y e r a n d T o n a s c i a , 1 9 7 7 ) . D u n n e t a l . f o u n d t h a t m o r e m o t h e r s o f p r e m a t u r e b a b i e s s m o k e d d u r i n g p r e g n a n c y t h a n d i d m o t h e r s o f f u l l t e r m b a b i e s a n d t h a t m o r e m o t h e r s o f p r e m a t u r e b a b i e s s m o k e d m o r e t h a n 10 c i g a r e t t e s p e r d a y t h a n d i d t h o s e w i t h f u l l t e r m b a b i e s . 6 . I n c r e a s e d p e r i n a t a l d e a t h r a t e ( B u t l e r e t a l . , 1 9 7 2 ; G o u j a r d e t a l . , 1 9 7 5 ; M e y e r a n d T o n a s c i a , 1 9 7 7 ; R a n t a k a l l i o , 1 9 7 9 ; R u s s e l l e t a l . , 1 9 6 8 ) . P e r i n a t a l m o r t a l i t y a s s o c i a t e d w i t h m a t e r n a l s m o k i n g i s made u p o f f e t a l d e a t h s d u e t o a n o x i a , o r t o u n k n o w n c a u s e s a n d o f n e o n a t a l d e a t h s o c c u r r i n g m a i n l y b e c a u s e o f p r e n a t a l d e l i v e r y . B u t l e r e t a l . e s t i m a t e d t h a t b a b i e s b o r n t o m o t h e r s who smoke t h r o u g h o u t p r e g n a n c y h a v e a 28% i n c r e a s e i n r i s k o f e i t h e r b e i n g s t i l l b o r n o r d y i n g s o o n a f t e r b i r t h . 7. Lowered Apgar scores (Garn, Johnston, R i d e l l a and Petzold, 1981). In Garn et a l . ' s study of 43,492 l i v e b i r t h s , lower Apgar scores of infants born to mothers who smoked one pack of cigarettes per day during pregnancy was apparent. At the 41 to 60 cigarette a day range, the proportion of low Apgar scores increased approximately f o u r f o l d . Socioeconomic differences d i d not eradicate the smoking e f f e c t i n the study group. 8. Increased postneonatal morbidity (Rantakallio, 1979). The res u l t s of Rantakallio's study showed the children born to mothers that smoked had more diseases and admissions to p e d i a t r i c departments than the non-smoking controls —however since most mothers that smoke during pregnancy continue to do so during the infancy of the c h i l d i t i s d i f f i c u l t to dis t i n g u i s h whether the findings are a r e s u l t of smoking before or a f t e r b i r t h . 9. Reduced long-term growth (Davie, Butler and Goldstein, 1972; Dunn, McBurney, Ingram and Hunter, 1977; Picone et a l . , 1982). In Dunn et a l . ' s prospective study, the height and weight of children born to non-smoking mothers exceeded those of smoking mothers at 6 1/2 years of age. S o c i a l c l a s s , maternal height and weight and the c h i l d ' s sex were not s i g n i f i c a n t . Russell et a l . , (1968), also found children of smoking mothers to be smaller than children of non-smoking mothers up u n t i l 6 months; however, the difference was not s i g n i f i c a n t at one year. No further follow-up was done. Russell e t a l . attributed t h i s rapid growth or "catch up" of the children of smoking mothers to the theory that i f maternal smoking acts by s l i g h t l y poisoning the fetus, babies s o p o i s o n e d m i g h t g r o w m o r e q u i c k l y a f t e r b i r t h . 1 0 . A d v e r s e l y a f f e c t i n g t h e b e h a v i o r a l d e v e l o p m e n t ( D a v i e e t a l . , 1 9 7 2 ; D u n n e t a l . , 1 9 7 7 ; P i c o n e e t a l . , 1 9 8 2 ) . P i c o n e e t a l . f o u n d t h a t s m o k i n g d u r i n g p r e g n a n c y s i g n i f i c a n t l y a f f e c t e d h a b i t u a t i o n , o r i e n t a t i o n a n d a u t o m a t i c r e g u l a t i o n o f t h e i n f a n t a s m e a s u r e d b y t h e B r a z e l t o n N e o n a t a l A s s e s s m e n t S c a l e . A u d i t o r y h a b i t u a t i o n ( a b i l i t y t o a d a p t t o s o u n d s ) w a s i n c r e a s e d , b u t t h e r e w a s a d e c r e a s e i n t h e a b i l i t y t o o r i e n t a t e t h e s o u r c e o f t h e s o u n d . N o r e c o v e r y i n t h e a u d i t o r y r e s -p o n s e s w e r e s e e n a t 2 w e e k s a f t e r b i r t h . S t u d i e s h a v e a l s o f o u n d e v i d e n c e t h a t t h e r e a r e p e r s i s t e n t l o n g - t e r m d e t r i m e n t a l e f f e c t s o f m a t e r n a l s m o k i n g o n t h e d e v e l o p m e n t o f t h e c h i l d . D u n n e t a l . , i n a p r o s p e c t i v e s t u d y o f 480 C a n a d i a n i n f a n t s f r o m b i r t h t o t h e a g e o f 6 1 / 2 y e a r s f o u n d t h a t c h i l d r e n b o r n t o m o t h e r s who s m o k e d d u r i n g p r e g n a n c y d i d n o t p e r f o r m a s w e l l o n p s y c h o l o g i c a l t e s t s ( i n c l u d i n g I . Q . s c o r e s ) a n d i n s c h o o l b e h a v i o r a n d p l a c e m e n t t h a n d i d t h o s e c h i l d r e n b o r n t o m o t h e r s who d i d n o t s m o k e . O t h e r a d v e r s e e f f e c t s o f s m o k i n g d u r i n g p r e g n a n c y a r e s t i l l u n d e r i n v e s t i g a t i o n . E v e r s o n (1980) s u g g e s t s t h a t i n d i v i d u a l s t r a n s p l a c e n t -a l l y e x p o s e d t o m a t e r n a l s m o k i n g may b e a t i n c r e a s e d c a n c e r r i s k i n a d u l t l i f e . T h i s h y p o t h e s i s h o w e v e r , r e m a i n s t o b e t e s t e d e p i d e m i o l o g -i c a l l y . T h e n u m b e r o f c i g a r e t t e s t h a t c a n b e s a f e l y s m o k e d d u r i n g p r e g n a n c y h a s n o t b e e n d e t e r m i n e d . B u t l e r e t a l . (1972) f o u n d a n i n c r e a s e d p e r i n a t a l m o r t a l i t y r a t e w h e n p r e g n a n t women s m o k e d a s f e w a s 1 - 4 c i g a r e t t e s p e r d a y . S t u d i e s s h o w t h a t t h e e f f e c t s o n p r e g n a n c y o u t c o m e a r e d o s e r e l a t e d t o t h e n u m b e r o f c i g a r e t t e s s m o k e d d u r i n g p r e g n a n c y ( C a r d o z o e t a l . , 1 9 8 2 ; D o u g h e r t y a n d J o n e s , 1 9 8 2 ) . I n o n e s t u d y , m o d e r a t e s m o k i n g ( 1 - 1 5 c i g a r e t t e s p e r d a y ) w a s a s s o c i a t e d w i t h a l o s s o f 107 g m s . o f b i r t h w e i g h t , a n d h e a v y s m o k i n g (16 o r m o r e c i g a r e t t e s p e r d a y ) w a s a s s o c i a t e d w i t h a l o s s o f 158 g m s . o f b i r t h w e i g h t — e v e n a f t e r a l l o t h e r f a c t o r s w e r e t a k e n i n t o a c c o u n t ( D o u g h e r t y a n d J o n e s ) . T h e " c r i t i c a l p e r i o d " d u r i n g g e s t a t i o n w h e n s m o k i n g h a s t h e g r e a t e s t i m p a c t o n f e t a l g r o w t h a n d d e v e l o p m e n t i s a l s o n o t c l e a r . S t u d i e s , h o w e v e r i n d i c a t e t h a t t h e r i s k s o f p e r i n a t a l m o r t a l i t y a n d l o w b i r t h w e i g h t a r e g r e a t e r i f s m o k i n g i s c o n t i n u e d d u r i n g t h e l a t t e r p a r t o f p r e g n a n c y . M e y e r e t a l . (1977) e s t i m a t e d t h a t t h e p r o b a b i l i t y o f d e a t h i n u t e r o i s a b o u t d o u b l e d i n t h e e a r l i e r w e e k s i f t h e m o t h e r s m o k e s a n d i s e v e n h i g h e r f r o m 32 w e e k s t o t e r m i f t h e m o t h e r c o n t i n u e s t o smoke d u r i n g p r e g n a n c y . B u t l e r e t a l . (1972) f o u n d t h a t t h e a m o u n t s m o k e d a f t e r t h e f o u r t h m o n t h o f p r e g n a n c y s i g n i f i c a n t l y i n f l u e n c e d f e t a l s u r v i v a l . S t u d i e s b y P a p o z e t a l . (1982) a n d Lowe (1959) s h o w e d t h a t s m o k e r s w h o s t o p p e d s m o k i n g b e f o r e t h e s i x t h m o n t h o f p r e g n a n c y a n d n o n - s m o k e r s g a v e b i r t h t o s i m i l a r b a b i e s . C e s s a t i o n o f s m o k i n g e v e n a s l a t e a s j u s t p r i o r t o d e l i v e r y h a s a d v a n t a g e s . Women w h o s t o p p e d 48 h o u r s b e f o r e d e l i v e r y w e r e f o u n d t o h a v e a n i n c r e a s e d a v a i l a b i l i t y o f o x y g e n w h e n c o m p a r e d t o t h o s e who c o n t i n u e d t o smoke ( D a v i e s , L a t t o , J o n e s , V e a l e a n d W a r d r o p , 1 9 7 9 ) . T h u s , i t a p p e a r s e v i d e n t t h a t c e s s a t i o n o f s m o k i n g a t a n y t i m e d u r i n g p r e g n a n c y i s b e n e f i c i a l a n d t h a t s m o k i n g c e s s a t i o n e a r l y i n p r e g n a n c y i s m o s t f a v o r a b l e . T h e r e s e a r c h o n t h e a d v e r s e e f f e c t s o f s m o k i n g d u r i n g p r e g n a n c y i n c l u d e s h u n d r e d s o f s t u d i e s — many o f w h i c h c o n t r a d i c t e a c h o t h e r . 13 However, in general, i t is now accepted that infants born to mothers who smoke during pregnancy will be approximately 6-8 oz. (170-230 gins.) lighter at birth than i f the mothers had not smoked and wi l l consequently have higher perinatal mortality rates (Baric, MacArthur and Sherwood, 1976). Current evidence associating smoking during pregnancy with other harmful effects as was previously outlined, requires additional research before definite conclusions can be made. It appears evident then, from the research on smoking, that pregnant women who smoke should be encouraged to stop or at least decrease their smoking. Alcohol The adverse effects of alcohol intake during pregnancy were f i r s t identified in the 18th century. In 1973, Jones and Smith termed the pattern of clinical features commonly found in infants born to alcoholic mothers as "the fetal alcohol syndrome". Fetal alcohol syndrome is characterized by: 1. prenatal and postnatal growth retardation, 2. evidence of central nervous system dysfunction including hypotonia, irritability, tremors, mental retardation, poor coordination and hyperactivity in childhood, 3. craniofacial abnormalities such as microcephaly, short palpebral fissures, epicanthal folds, strabismus, ptosis and midfacial hypoplasia evidenced by a hypoplastic philtrum, thin upper l i p and up turned nose, 4. a number of associated abnormalities of the ears, eyes, mouth, heart, musculoskeletal and genitourinary system (Sokol, 1981). A t p r e s e n t , t h i s s y n d r o m e h a s b e e n a s s o c i a t e d o n l y w i t h a d v a n c e d s t a g e s o f m a t e r n a l a l c o h o l i s m . C h i l d r e n b o r n t o a l c o h o l i c m o t h e r s a r e a t r i s k f o r f e t a l a l c o h o l s y n d r o m e a s w e l l a s many o t h e r p r o b l e m s . T h e n u m b e r o f c h i l d r e n w i t h f e t a l a l c o h o l s y n d r o m e i n o u r c o u n t r y i s u n k n o w n . I n a S e a t t l e s t u d y , t h e r a t e w a s 1 p e r 750 l i v e b i r t h s ( H a n s o n , S t r e i s s g u t h a n d S m i t h , 1 9 7 8 ) . F r o m t h e c u r r e n t r e s e a r c h , i t a p p e a r s t h a t t h e e f f e c t s o f a l c o h o l c o n s u m p t i o n c a n b e b e s t e x p l a i n e d i n t e r m s o f a g r o s s d o s e - r e s p o n s e c o n t i n u u m . A t t h e s e v e r e e n d o f t h e c o n t i n u u m i s t h e c l a s s i c " f e t a l a l c o h o l s y n d r o m e " — t h e r e s u l t o f a d v a n c e d m a t e r n a l a l c o h o l i s m , a n d a t t h e o t h e r e n d a r e t h e " f e t a l a l c o h o l e f f e c t s " — t h e r e s u l t o f m o d e r a t e o r s o c i a l d r i n k i n g . Some o f t h e f e t a l a l c o h o l e f f e c t s a s s o c i a t e d w i t h m a t e r n a l a l c o h o l u s e a r e : 1 . S p o n t a n e o u s a b o r t i o n o r s t i l l b i r t h ( H a r l a p a n d S h i o n o , 1 9 8 0 ; K a m i n s k i , Rumeau a n d S c h w a r t z , 1 9 7 8 ; K l i n e , S h r o u t , S t e i n , S u s s e r a n d W a r b u r t o n , 1 9 8 0 ) . H a r l a p a n d S h i o n o f o u n d a s i g n i f i c a n t i n c r e a s e i n s e c o n d t r i m e s t e r s p o n t a n e o u s a b o r t i o n s f o r women d r i n k i n g o n e o r m o r e d r i n k s p e r d a y w h e n c o m p a r e d t o n o n - d r i n k e r s . K l i n e e t a l . f o u n d a s t r o n g a s s o c i a t i o n b e t w e e n s p o n t a n e o u s a b o r t i o n a n d d r i n k i n g d u r i n g p r e g n a n c y w h i c h w a s s t i l l e v i d e n t w h e n s e v e r a l p o t e n t i a l l y c o n f o u n d i n g v a r i a b l e s w e r e c o n t r o l l e d i n t h e a n a l y s i s . 2 . P r e m a t u r i t y ( H i n g s o n e t a l . , 1 9 8 2 ; K a m i n s k i , F r a n c , L e B o u v i e r , d e M a z a u b r u n a n d R u m e a u - R o q u e t t e , 1 9 8 1 ) . A l t h o u g h H i n g s o n e t a l . d i d n o t f i n d t h e l e v e l o f m a t e r n a l d r i n k i n g t o i n f l u e n c e i n f a n t s i z e , m a t e r n a l d r i n k i n g p r i o r t o p r e g n a n c y w a s s i g n i f i c a n t l y r e l a t e d t o s h o r t e r g e s t a t i o n . K a m i n s k i e t a l . ' s f i n d i n g o f a h i g h e r r a t e o f pre-term deliveries in moderate or heavy drinkers than in non or light drinkers was not explained by any other of the confounding factors studied. 3. Decreased fetal growth e.g., birth weight (Hanson et al., 1978; Kaminski et al., 1981; Kaminski et al., 1978; Little, 1977; Rosett,et al., 1983; Rosett, Weiner, Zuckerman, McKinlay and Edelin, 1980; Silva, Laranjeira, Dolnikoff, Grinfeld and Masur, 1981; Streissguth, Martin, Martin-and Barr, 1981). Streissguth et al . (1981) also found a dose-response relationship to be apparent — as alcohol intake increased; birth weight, birth length and head circumference decreased. At the 8th month follow-up, slightly lower length and weight were s t i l l evident in infants born to mothers with increased maternal alcohol intakes. 4. Major and minor malformations (Hanson et al., 1978; Ouellette, Rosett, Rosman and Weiner, 1977; Rosett et al., 1983; Silva et al., 1981; Sokol, Miller and Reed, 1980). Ouellette et al . reported that the frequency of congenital abnormalities and functional abnormalities among the infants born to mothers who were drinking heavily during pregnancy was 2 to 3 times greater than those born to mothers who drank moderately or abstained. Other studies have reported no increase in congenital malformations (Kaminski et al., 1981). 5. Mental, motor and behavioral effects (Ouellette et al., 1977; Streissguth et al., 1981). In Streissguth et al.'s Seattle study of 1529 pregnant women, increased maternal alcohol use was found to be related to infants with lower Apgar scores, poorer neonatal habitation, d e c r e a s e d s u c k i n g p r e s s u r e , i n c r e a s e d t r e m u l o u s n e s s a n d h e a d - t u r n s - t o -l e f t , d e c r e a s e d v i g o r o u s a c t i v i t y a n d o t h e r m i n o r a b n o r m a l i t i e s . O t h e r v a r i a b l e s s u c h a s s m o k i n g , c a f f e i n e a n d d r u g u s e a n d d i e t w e r e c o n t -r o l l e d a n d d i d n o t a f f e c t t h e r e s u l t s . S i g n i f i c a n t l o w e r m e n t a l a n d m o t o r d e v e l o p m e n t w e r e f o u n d a t t h e 8 t h m o n t h f o l l o w - u p o n c h i l d r e n w h o s e m o t h e r s c o n s u m e d a l c o h o l . R e s e a r c h h a s n o t y e t i d e n t i f i e d t h e s p e c i f i c " s a f e " l i m i t s o f a l c o h o l c o n s u m p t i o n d u r i n g p r e g n a n c y n o r t h e e f f e c t s r e l a t e d t o a g i v e n d o s e ( L i t t l e a n d S t r e i s s g u t h , 1 9 8 1 ) . One o f t h e r e a s o n s f o r t h i s l a c k o f i d e n t i f i c a t i o n i s t h a t t h e s t u d i e s h a v e r e l i e d o n s e l f - r e p o r t o f c o n s u m p t i o n . Human r e c a l l i s o f t e n i n c o m p l e t e a n d p e o p l e t e n d t o u n d e r r e p o r t e i t h e r k n o w i n g l y o r u n k n o w i n g l y , e s p e c i a l l y o n s e n s i t i v e t o p i c s ( L a n d e s m a n - D w y e r , 1 9 8 2 ) . T h e m e a n i n g o f l i g h t , m o d e r a t e o r h e a v y d r i n k i n g v a r i e s b e t w e e n t h e s t u d i e s w h i c h o f t e n r e s u l t s i n i n c o n s i s t e n t f i n d i n g s . T h e h a r m f u l e f f e c t s o f a l c o h o l o n t h e f e t u s may b e t h e p r o d u c t o f a n a c c u m u l a t i o n o f f a c t o r s r a t h e r t h a n t h e d i r e c t r e s u l t o f t h e a m o u n t o f a l c o h o l c o n s u m e d . I n a F r e n c h s t u d y ( K a m i n s k i e t a l . , 1978) t h e r i s k o f s t i l l b i r t h w a s i n c r e a s e d 2 1 / 2 t i m e s f o r women who r e p o r t e d d r i n k i n g 3 o r m o r e g l a s s e s o f w i n e p e r d a y ; t h i s r i s k w a s e v e n g r e a t e r w h e n t h e m o t h e r s a l s o s m o k e d , came f r o m l o w e r s o c i o e c o n o m i c c l a s s e s , h a d m o r e p r i o r p r e g n a n c i e s o r w e r e o l d e r . S t r e i s s g u t h e t a l . (1981) a n d H a r l a p a n d S h i o n o (1980) r e p o r t e d i n t a k e s o f 1 - 2 d r i n k s p e r d a y d u r i n g p r e g n a n c y t o b e h a r m f u l a n d K l i n e e t a l . (1980) f o u n d a d v e r s e e f f e c t s a s s o c i a t e d w i t h d r i n k i n g a s l i t t l e a s 1 17 o u n c e o f a b s o l u t e a l c o h o l ^ " t w i c e a w e e k d u r i n g p r e g n a n c y . T h e t i m i n g o f m a t e r n a l a l c o h o l i n t a k e s e e m s t o b e c r i t i c a l t o p r e g n a n c y o u t c o m e . A l t h o u g h some s t u d i e s s h o w t h a t i t i s t h e a m o u n t o f a l c o h o l c o n s u m e d p r i o r t o a n d d u r i n g t h e e a r l y s t a g e s o f p r e g n a n c y t h a t i s m o s t h a r m f u l t o t h e f e t u s , o t h e r s t u d i e s h a v e i d e n t i f i e d a l c o h o l c o n s u m p t i o n i n t h e l a t t e r s t a g e s o f p r e g n a n c y a s m o s t c r u c i a l . H a n s o n e t a l . (1978) d i s c o v e r e d t h a t m a t e r n a l a l c o h o l i n t a k e i n t h e m o n t h s p r e c e e d i n g r e c o g n i t i o n o f p r e g n a n c y a n d d u r i n g e a r l y p r e g n a n c y w a s a s s o c i a t e d w i t h f e t a l a n o m a l i e s . R o s e t t e t a l . (1983) f o u n d i n f a n t s who w e r e b o r n t o women who r e d u c e d h e a v y d r i n k i n g d i d n o t d i f f e r i n . g r o w t h f r o m i n f a n t s o f r a r e o r m o d e r a t e d r i n k e r s , b u t d e m o n s t r a t e d a h i g h e r f r e q u e n c y o f a b n o r m a l i t i e s . T h e s e f i n d i n g s w h i c h i m p l y t h a t a l t h o u g h s u s t a i n e d h e a v y d r i n k i n g r e p r e s e n t s a m a j o r r i s k , r e d u c t i o n i n m i d p r e g n a n c y c a n b e n e f i t t h e n e w b o r n . L i t t l e (1977) f o u n d t h a t t h e i n g e s t i o n o f a n a v e r a g e o f 1 o u n c e o f a b s o l u t e a l c o h o l d a i l y b e f o r e p r e g n a n c y w a s a s s o c i a t e d w i t h a n a v e r a g e d e c r e a s e i n b i r t h w e i g h t o f 9 1 g r a m s , b u t t h e same a m o u n t i n l a t e p r e g n a n c y w a s a s s o c i a t e d w i t h a d e c r e a s e o f 160 g r a m s . S i m i l a r i l y , a s u b s e q u e n t s t u d y ( R o s e t t e t a l . , 1980) f o u n d i n f a n t s b o r n t o women w h o r e d u c e d t h e i r h e a v y a l c o h o l c o n s u m p t i o n b e f o r e t h e t h i r d t r i m e s t e r s h o w e d l e s s g r o w t h r e t a r d a t i o n t h a n d i d t h e i n f a n t s b o r n t o women who c o n t i n u e d t o d r i n k h e a v i l y t h r o u g h o u t t h e i r p r e g n a n c y . T h e f i n d i n g s o f t h e s e s t u d i e s i m p l y t h a t a l t h o u g h a l c o h o l c o n s u m p t i o n e a r l y i n p r e g -n a n c y may h a v e a d v e r s e e f f e c t s , r e d u c t i o n o f a l c o h o l i n t a k e d u r i n g " ' ' l o z . o f a b s o l u t e a l c o h o l = 2 d r i n k s o r a p p r o x i m a t e l y 2 b o t t l e s o f b e e r , 2 g l a s s e s o f w i n e o r 2 h i g h b a l l s . p r e g n a n c y i s b e n e f i c i a l — e s p e c i a l l y t o t h e n e w b o r n . N o n e o f t h e human s t u d i e s c a n i d e n t i f y t h e a m o u n t o f a l c o h o l a p r e g n a n t woman c a n c o n s u m e w i t h o u t h a r m f u l f e t a l e f f e c t s . I t i s w e l l e s t a b l i s h e d t h a t a l c o h o l c r o s s e s t h e p l a c e n t a u n c h a n g e d s o t h a t f e t a l b l o o d l e v e l s e q u a l t h a t o f t h e m o t h e r . M a t e r n a l c o n s u m p t i o n o f a l c o h o l e a r l y i n p r e g n a n c y i s a s s o c i a t e d w i t h s p o n t a n e o u s a b o r t i o n s , p r e m -a t u r i t y a n d m a l f o r m a t i o n s , w h i l e m a t e r n a l c o n s u m p t i o n o f a l c o h o l l a t e r i n p r e g n a n c y i s a s s o c i a t e d w i t h f e t a l g r o w t h r e t a r d a t i o n . F r o m t h e c u m u l a t i v e e v i d e n c e o f t h e s t u d i e s r e v i e w e d , a n d t h e q u e s t i o n s a b o u t d r i n k i n g i n p r e g n a n c y t h a t r e m a i n t o b e a n s w e r e d , o n e c o n c l u d e s t h a t i t i s b e t t e r f o r t h e i n f a n t s i f t h e i r m o t h e r s d o n o t d r i n k a l c o h o l d u r i n g p r e g n a n c y . D r u g s S i n c e t h e t h a l i d o m i d e t r a g e d y o f 1 9 6 0 t o 1 9 6 2 , p r e g n a n t women h a v e b e e n c a u t i o n e d a b o u t t a k i n g d r u g s d u r i n g p r e g n a n c y . T h e r o l e o f m a t e r -n a l d r u g u s e i n t h e e t i o l o g y o f f e t a l m a l f o r m a t i o n i s n o t e n t i r e l y c l e a r . I t i s e s t i m a t e d t h a t 10% o f a l l c o n g e n i t a l a b n o r m a l i t i e s h a v e a n i d e n t i f i e d e n v i r o n m e n t a l c a u s e w h i c h i n some c a s e s i s a d r u g ( B e e l e y , 1 9 8 1 ) . T h e e v i d e n c e o f o t h e r a d v e r s e s e q u e l a s u c h a s m i s c a r r i a g e , f e t a l g r o w t h r e t a r d a t i o n o r s t i l l b i r t h s r e s u l t i n g f r o m d r u g u s e i s d i f f i c u l t t o e s t i m a t e . T e r a t o g e n i c i t y o f a g i v e n d r u g i s d e p e n d e n t o n t h e d o s e r e a c h i n g t h e e m b r y o o r f e t u s , g e s t a t i o n a l a g e a t t h e t i m e o f e x p o s u r e , d u r a t i o n o f e x p o s u r e , g e n o t y p e s o f t h e m o t h e r a n d f e t u s , a n d t h e e f f e c t o f o t h e r a g e n t s t o w h i c h t h e e m b r y o o r f e t u s i s s i m u l t a n e o u s l y e x p o s e d ( l a m s a n d R a y b u r n , 1 9 8 1 ) . V a r i a n c e s i n t h e s e f a c t o r s a d d t o t h e 19 complexity of drug research. Drugs that have been identified as known teratogenes in humans during pregnancy include anticonvulsants (trimethadione, phenytoin), anti-coagulants (Coumadin and congeners), alcohol, folic acid anta-gonists (methotrexate, aminopterin), hormones (diethylstilbestrol and congeners, androgens), methyl mercury and thalidomide. Drugs which are highly suspected of causing teratogenic effects include alkyalating agents, hormones (oral contraceptives, progestins), lithium carbonate, nicotine, sulfonylureas and tranquilizers (benzodiazepines) (lams and Rayburn, 1981). Many drugs, even though they are not proven to be teratogenic, are reported to have adverse effects on the fetus. A compilation of these drugs would be too lengthy to be included in this paper. Instead, only a few of the more commonly used drugs are discussed. Over-the-counter drugs are reported to be taken four times more often than prescribed medications during pregnancy (Forfar and Nelson, 1983). Many pregnant women do not recognize over-the-counter drugs as medications with potentially harmful effects. Commonly used drugs include analgesics, especially aspirin, antacids, antiemetics, anti-histamines and decongestants, and vitamins. Research indicates these drugs cannot be regarded as totally "safe" when used during pregnancy. Studies have associated aspirin with prolonged gestation and labor (Lewis and Schulman, 1973) and with increased maternal (Collins and Turner, 1975) and neonatal (Rumack et al., 1981) hemorrhage. Turner and Collins (1975) also found that chronic salicylate ingestion was associated with an increase in perinatal mortality and decreased u t e r i n e g r o w t h . A l t h o u g h l i t t l e i n f o r m a t i o n i s a v a i l a b l e o n t h e e f f e c t s o f a n t a c i d s , o n e s t u d y d i d s h o w a s i g n i f i c a n t i n c r e a s e o f a b n o r m a l i t i e s i n i n f a n t s e x p o s e d t o a n t a c i d s d u r i n g t h e f i r s t t r i m e s t e r ( N e l s o n a n d F o r f a r , 1 9 7 1 ) . No s i n g l e a n t a c i d w a s i m p l i c a t e d f o r t h e i n c r e a s e . E v e n t h o u g h s t u d i e s h a v e f a i l e d t o d e m o n s t r a t e a n i n c i d e n c e o f c o n -g e n i t a l m a l f o r m a t i o n s a s s o c i a t e d w i t h a n t i e m e t i c i n t a k e d u r i n g p r e g n a n c y ( S h a p i r o e t a l . , 1 9 7 7 ; S m i t h e l l s a n d S h e p p a r d , 1 9 7 8 ) , t h e e f f e c t s o f a n t i e m e t i c s a r e s t i l l u n d e r r e v i e w . S a x e n (1974) f o u n d o r a l c l e f t s t o b e p s o i t i v e l y a s s o c i a t e d w i t h m a t e r n a l i n t a k e s o f d i p h e n h y d r a m i n e i n e a r l y p r e g n a n c y . W i t h d r a w a l i n i n f a n t s b o r n t o c h r o n i c a b u s e r s o f a n t i h i s t a m i n e s a n d d e c o n g e s t a n t s i n c l u d e s t r e m u l o u s n e s s , a g g i t a t i o n , i r r i t a b i l i t y a n d p o o r f e e d i n g ( S c h a d a n d R a y b u r n , 1 9 8 1 ) . E x c e s s i v e d o s e s o f V i t a m i n A d u r i n g o r g a n o g e n e s i s h a s b e e n l i n k e d w i t h c o n g e n i t a l a n o m a l i e s i n t w o c a s e r e p o r t s ( S t r a n g e , C a r l s t r o m a n d E r i k s s o n , 1 9 7 8 ; B e r n h a r d t a n d D o r s e y , 1974) b u t w a r r a n t s f u r t h e r s t u d y . One o f t h e m o r e r e c e n t d r u g s i n v e s t i g a t e d i s m a r i j u a n a . M a r i j u a n a u s e d u r i n g p r e g n a n c y h a s b e e n a s s o c i a t e d w i t h s h o r t e r g e s t a t i o n a n d d e c r e a s e d m a t e r n a l w e i g h t g a i n ( F r i e d , 1982) a n d w i t h m o r e f r e q u e n t m e c o n i u m s t a i n i n g ( G r e e n l a n d , S t a i s c h , B r o w n a n d G r o s s , 1 9 8 2 ) . F r i e d (1982) f o u n d t h a t b a b i e s b o r n t o m a r i j u a n a u s e r s d e m o n s t r a t e d m a r k e d t r e m o r s , a n d s t a r t l e s a n d a l t e r e d v i s u a l r e s p o n s i v e n e s s a t 2 t o 4 d a y s o f a g e . T h e s e s y m p t o m s h o w e v e r , h a d a t t e n u a t e d b y 30 d a y s a n d n o d e v e l o p m e n t a l i m p a i r m e n t s w e r e o b s e r v e d a t o n e y e a r o f a g e . A l t h o u g h m o s t o f t h e r e p o r t e d f i n d i n g s o f t h e e f f e c t s o f n o n - p r e s c r i p t i o n d r u g s h a v e n o t b e e n c o n f i r m e d , t h e y d o p r e s e n t e v i d e n c e t o d o u b t t h e s a f e t y o f a n y d r u g w h e n u s e d d u r i n g p r e g n a n c y . T h e t i m i n g o f d r u g s t a k e n d u r i n g p r e g n a n c y i s u l t i m a t e l y i m p o r t a n t a s t o t h e a b n o r m a l i t i e s p r o d u c e d . H a r m f u l d r u g s t a k e n i n t h e f i r s t w e e k a f t e r c o n c e p t i o n b e f o r e i m p l a n t a t i o n h a s o c c u r r e d p r o b a b l y h a v e a n a l l -o r - n o t h i n g e f f e c t ; e i t h e r t h e e m b r y o d i e s o r t h e d a m a g e d c e l l s a r e r e p l a c e d b y n o r m a l c e l l s . D u r i n g t h e p e r i o d o f o r g a n o g e n e s i s ( b e t w e e n t h e s e c o n d a n d t e n t h w e e k ) , d r u g s c a n p r o d u c e c o n g e n i t a l m a l f o r m a t i o n s ( t e r a t o g e n i c i t y ) a n d s e v e r e damage w h i c h may r e s u l t i n a b o r t i o n . D u r i n g t h e s e c o n d a n d t h i r d t r i m e s t e r s , d r u g s c a n a f f e c t t h e g r o w t h a n d f u n c t i o n a l d e v e l o p m e n t o f t h e f e t u s — e s p e c i a l l y t h e c e n t r a l n e r v o u s s y s t e m w h i c h c o n t i n u e s t o d e v e l o p t h r o u g h o u t p r e g n a n c y ( B e e l e y , 1981) . T h u s t h e r e i s n o c o n f i r m e d t i m e p e r i o d i n p r e g n a n c y w h e n t h e f e t u s i s t o t a l l y p r o t e c t e d f r o m m a t e r n a l d r u g l e v e l s . E v i d e n c e f r o m r e s e a r c h s t u d i e s o n v a r i o u s d r u g s a n d m e d i c a t i o n s s u p p o r t s m i n i m a l d r u g u s e t h r o u g h o u t p r e g n a n c y , l a b o r a n d d e l i v e r y ( A p g a r , 1 9 6 4 ) . A t t h e p r e s e n t t i m e t h e r e a r e n o d r u g s p r o v e n t o b e s a f e f o r t h e d e v e l o p i n g f e t u s i n human p r e g n a n c y . T h e a b s e n c e o f r e p o r t s a s s o c i a t i n g a g i v e n d r u g t o a t e r a t o g e n i c e f f e c t d o e s n o t i m p l y i t s s a f e t y . M o s t c o n c l u s i o n s a b o u t d r u g e f f e c t s o n humans a r e b a s e d o n a n i m a l s t u d i e s . H o w e v e r t h e a g e n t s w h i c h may b e t e r a t o g e n i c i n humans may n o t b e h a r m f u l t o a n i m a l s p e c i e s . T h a l i d o m i d e i s a n e x a m p l e o f o n e s u c h d r u g . F r o m t h e r e s u l t s o f t h e p r e s e n t r e s e a r c h a n d t h e l a c k o f e x t e n s i v e human r e s e a r c h o n t h e m a j o r i t y o f t h e d r u g s w h e n u s e d d u r i n g p r e g n a n c y , i t s e e m s o b v i o u s t h a t p r e g n a n t women s h o u l d a v o i d t a k i n g d r u g s d u r i n g p r e g n a n c y . 22 C a f f e i n e C a f f e i n e , o n e o f t h e w o r l d ' s m o s t w i d e l y u s e d d r u g s w a s r e g a r d e d h a r m l e s s u n t i l r e c e n t l y . C a f f e i n e i s p r e s e n t i n c o f f e e , t e a , c o c o a , c o l a s a n d o t h e r c a r b o n a t e d b e v e r a g e s . A l t h o u g h r e s e a r c h s t u d i e s o n t h e e f f e c t s o f c a f f e i n e d u r i n g p r e g n a n c y a r e l i m i t e d , t h e e f f e c t s o f c a f f e i n e i n a n a d u l t a r e w e l l k n o w n . I n a n a d u l t , 1 5 0 - 2 5 0 mgm. o f c a f f e i n e ( a p p r o x i m a t e l y 1 t o 2 c u p s o f c o f f e e ) a c t s a s a n e r v o u s s y s t e m s t i m u l a n t i n c r e a s i n g t h e h e a r t a n d b a s a l m e t a b o l i c r a t e , u r i n e p r o d u c t i o n a n d s e c r e t i o n o f s t o m a c h a c i d ( C o n s u m e r s R e p o r t s , 1 9 8 1 ) . C a f f e i n e i n t o x i c a t i o n ( a p p r o x i m a t e l y 8 t o 10 c u p s o f c o f f e e ) p r e s e n t s s y m p t o m s t h a t may i n c l u d e r e s t l e s s n e s s , i n s o m n i a , s e n s o r y d i s t u r b a n c e s , m u s c l e t r e m o r , d i a r r h e a a n d c a r d i a c i r r e g u l a r i t i e s ( M a r t i n , 1 9 8 2 ) . C a f f e i n e r e a d i l y c r o s s e s t h e p l a c e n t a i n t o f e t a l c i r c u l a t i o n . One s t u d y o f t h e r a p e u t i c a l l y a b o r t e d human f e t u s e s f o u n d t h e c a f f e i n e c o n c e n t r a t i o n i n t h e f e t u s t o b e t h e same a s i n t h e m a t e r n a l p l a s m a ( G o l d s t e i n a n d W a r r e n , 1 9 6 2 ) . C a f f e i n e h a s b e e n l i n k e d w i t h m u t a t i o n s i n human c e l l s i n c u l t u r e ( O s t e r t a g , D u i s b e r g a n d S t u r m a n , 1965) a n d w i t h s p o n t a n e o u s a b o r t i o n , s t i l l b i r t h a n d p r e m a t u r e b i r t h ( W e a t h e r b e e , O l s e n a n d L o d g e , 1 9 7 7 ) . A d e m o g r a p h i c s u r v e y b y v a n d e n B e r g (1977) f o u n d t h a t p r e g n a n t women w h o d r a n k m o r e t h a n 7 c u p s o f c o f f e e p e r d a y h a d a h i g h e r i n c i d e n c e o f l o w b i r t h w e i g h t b a b i e s . A s f o r t y - f i v e p e r c e n t o f t h i s s a m p l e a l s o s m o k e d , t h e a s s o c i a t i o n b e t w e e n c a f f e i n e i n t a k e a n d l o w b i r t h w e i g h t i s u n c l e a r . S t u d i e s h a v e b e e n s u c c e s s f u l i n l i n k i n g c a f f e i n e i n t a k e w i t h s p e c i f i c b i r t h d e f e c t s . R o s e n b e r g , M i t c h e l l , S h a p i r o a n d S l o n e (1982) s t u d i e d 2 , 0 3 0 m a l f o r m e d i n f a n t s a n d w e r e u n a b l e t o s h o w a r e l a t i o n s h i p b e t w e e n t h e b i r t h d e f e c t a n d i n g e s t i o n o f c a f f e i n e d u r i n g p r e g n a n c y . One o f t h e m a j o r p r o b l e m s i n r e s e a r c h i n g t h e e f f e c t s o f c a f f e i n e o n p r e g n a n c y i s t h e l a c k o f women w h o d r i n k l a r g e q u a n t i t i e s o f c a f f e i n e c o n t a i n i n g b e v e r a g e s d u r i n g p r e g n a n c y . A l t h o u g h c a f f e i n e ' s t e r a t o g e n i c p o t e n t i a l h a s n o t b e e n d e m o n s t r a t e d a t t h i s t i m e , i t s e f f e c t s o n a n i m a l m o d e l s h a s c a u s e d g r e a t c o n c e r n . A n i m a l r e s e a r c h i n d i c a t e s h i g h d o s e s o f c a f f e i n e may c a u s e c o n g e n i t a l m a l f o r m a t i o n s s u c h a s c l e f t p a l a t e ( T e r a d a a n d N i s h i m u r a , 1 9 7 5 ) , r e d u c e d b o d y , l i v e r a n d b r a i n w e i g h t a t b i r t h ( G r o i s s e r , R o s s o a n d W i n i c k , 1 9 8 2 ) , a n d p o s t n a t a l g r o w t h r e t a r d a t i o n ( D u n l o p a n d C o u r t , 1 9 8 1 ) . G r o i s s e r e t a l . (1982) a l s o f o u n d b e h a v i o r a l a b n o r m a l i t i e s i n o f f s p r i n g o f r a t s f e d c o f f e e d u r i n g p r e g n a n c y . A l t h o u g h f i n d i n g s o f a n i m a l s t u d i e s c a n n o t b e d i r e c t l y a p p l i e d t o human s p e c i e s , f u r t h e r i n v e s t i g a t i o n o f t h e p h e n o m e n o n i n humans i s i n d i c a t e d . F r o m t h e e v i d e n c e o f a n i m a l s t u d i e s a n d e x i s t i n g human r e s e a r c h , i t i s s u g g e s t e d t h a t p r e g n a n t women l i m i t o r d i s c o n t i n u e t h e i r c a f f e i n e i n t a k e . D i e t M a t e r n a l d i e t a n d n u t r i t i o n a l s t a t u s a r e c o n s i d e r e d i m p o r t a n t f a c t o r s i n f l u e n c i n g t h e o u t c o m e o f p r e g n a n c y . D u r i n g p r e g n a n c y , t h e m a t e r n a l r e q u i r e m e n t f o r many n u t r i e n t s i s i n c r e a s e d . T h e s e i n c r e a s e s a r e n e c e s s a r y f o r g r o w t h d e m a n d s o f t h e f e t u s , p l a c e n t a , u t e r u s , b r e a s t s , a m n i o t i c f l u i d a n d i n c r e a s e d b l o o d v o l u m e . A n i n c r e a s e d m a t e r n a l m e t a b o l i c r a t e a n d m e t a b o l i s m o f t h e f e t u s a l s o a d d s t o t h e energy requirement for pregnancy (National Research Council, 1981). In developed countries, most mothers who deliver fetally malnour-ished infants do not show evidence of serious malnutrition. Research, however, supports the consensus that maternal nutrition influences fetal growth. The Dutch famine of 1944 to 1946, often described as a natural experiment or "experiment of opportunity" clearly demonstrates the effects of food deprivation on fetal growth (Susser, 1981) . Maternal starvation seemed to,;firstly affect maternal weight, secondly birth weight, and thirdly, placental weight (Stein and Susser, 1975a). Birth weights declined 9% during food shortages and again increased 9% when the famine was over (Stein and Susser, 1975b). Rosso (1981), however, interpreted the findings of the Dutch famine to suggest that the mothers were proportionately less affected than their infants. The developing fetus therefore, may not be a successful parasite during nutritional deprivation, as was once thought, but may be more severely affected than its mother. Although the impact of specific nutrient deficiencies during pregnancy is not fully understood and requires further research, some associations have been made. Several obstetrical complications have resulted from maternal nutritional deficiencies. Anemia, for example; can be caused by an iron deficiency (Pitkin, 1981), and a hemoglobin of 6 gms. or less has been associated with an increase perinatal mortality rate (Beischer, 1971). Megablastic anemia can result from a folate deficiency (Pitkin, 1981). Deficiencies of folate have also been associated with abruptio placentae (Streiff and Little, 1967) and fetal malformations (Hibbard and Smithells, 1965). However, subsequent studies have not been successful in substantiating these findings (Alperin, Haggard and McGanity, 1969; Scott, Whalley and Pritchard, 1970). Jameson (1976) found serum zinc concentrations during early pregnancy to be linked with abnormal labor and atonic bleeding. Studies have associated small-for-dates infants and intrauterine growth retardation with maternal deficiencies in plasma levels of calcium (Bogden, Thind, Louria and Caterini, 1978), zinc (Jameson, 1976) and various amino acids (Churchill, Moghissi, Evans and Fronham, 1969; Crosby et al., 1977; McClain and Metcoff, 1978). Deficient maternal intakes of calcium and/or Vitamin D have been correlated with hypocalcemia in neonates (Rosen, Roginsky, Scott and Thompson, 1974). Human fetal malnutrition may be associated with a decreased number of brain cells (Winick and Rosso, 1969), as well as impaired mental (Fitzhardinge and Steven, 1972) and physical (Cruise, 1973) postnatal development. Small-for-dates infants have congenital abnormalities eight times more frequently than normally grown infants (van den Berg and Yerushalmy, 1966). Fancourt, Campbell, Harvey and Norman (1976) found that prolonged slow growth in utero seemed to be followed by slow growth and development after birth. Current research, however suggests that birth weight may be more closely related to the mother's nutrient pattern or profile at mid-pregnancy rather than to excesses or deficiencies of specific nutrients. Metcoff et al. (1981) found the nutritive patterns in pregnant women who delivered small babies were quite different from those mothers who delivered large babies, even though gross nutritional deficiencies or 26 e x c e s s e s w e r e n o t i d e n t i f i e d i n e i t h e r g r o u p . A w e i g h t g a i n o f 11 k g . d u r i n g p r e g n a n c y i s r e c o m m e n d e d b y t h e N a t i o n a l R e s e a r c h C o u n c i l C o m m i t t e e o n M a t e r n a l N u t r i t i o n ( 1 9 7 0 ) . T h e i n c i d e n c e o f o b s t e t r i c a l c o m p l i c a t i o n s s e e m s l o w e s t a n d o u t c o m e t h e b e s t w i t h t h i s g a i n i n w e i g h t ( L e a d e r , Wong a n d D e i t e l , 1 9 8 1 ) . T h e r a t e o f w e i g h t g a i n i n t h e t h i r d t r i m e s t e r i s a p a r t i c u l a r l y i m p o r t a n t d e t e r m i n a n t o f b i r t h w e i g h t ( S t e i n a n d S u s s e r , 1 9 7 5 a ) . H o w e v e r , w h i l e i m p r o v i n g m a t e r n a l f o o d i n t a k e d u r i n g t h e t h i r d t r i m e s t e r may h a v e b e n e f i c i a l e f f e c t s o n t h e i n f a n t ' s a n t h r o p o m e t r i c m e a s u r e s , a d e q u a t e i n t a k e d u r i n g t h e s e c o n d t r i m e s t e r may b e t h e m o s t i m p o r t a n t f o r o p t i m a l d e v e l o p m e n t . P i c o n e , A l l e n , O l s e n a n d F e r r i s (1982) f o u n d a s i g n i f i c a n t r e l a t i o n s h i p b e t w e e n n e o n a t a l b e h a v i o r ( o v e r a l l p e r f o r m a n c e s c o r e s o n t h e B r a z e l t o n N e o n a t a l A s s e s s m e n t S c a l e ) a n d w e i g h t g a i n d u r i n g t h e s e c o n d t r i m e s t e r . M a t e r n a l p r e c o n c e p t i o n w e i g h t a n d w e i g h t g a i n d u r i n g p r e g n a n c y r a n k s e c o n d o n l y t o g e s t a t i o n a l a g e a s d e t e r m i n a n t s o f b i r t h w e i g h t ( N a t i o n a l R e s e a r c h C o u n c i l , 1 9 8 1 ) . A p r e g n a n t women w i t h a p r e c o n -c e p t u a l w e i g h t 10% o r m o r e b e l o w t h e s t a n d a r d f o r h e i g h t a n d a g e h a s a n i n c r e a s e d r i s k o f d e v e l o p i n g o b s t e t r i c a l c o m p l i c a t i o n s a n d i s a t r i s k f o r d e l i v e r i n g a l o w b i r t h w e i g h t i n f a n t ( P i t k i n , 1 9 8 1 ) . T h e r i s k o f d e l i v e r i n g a l o w b i r t h w e i g h t i n f a n t i s m a g n i f i e d w h e n l o w p r e c o n c e p t i o n w e i g h t i s c o u p l e d w i t h - i n a d e q u a t e d i e t . M i l l e r a n d M e r r i t t (1979) f o u n d t h e i n c i d e n c e o f d e l i v e r i n g a f u l l t e r m s h o r t - f o r -d a t e s ( c r o w n - h e e l l e n g t h s - f i f t h p e r c e n t i l e ) i n f a n t among women who w e r e u n d e r w e i g h t a t c o n c e p t i o n a n d h a d l o w w e i g h t g a i n w a s t h r e e t i m e s h i g h e r t h a n among m o t h e r s who w e r e o v e r w e i g h t a n d h a d l o w w e i g h t g a i n . 27 S t u d i e s h a v e d e m o n s t r a t e d t h a t b i r t h w e i g h t s c a n b e i n c r e a s e d t h r o u g h d i e t i m p r o v e m e n t ( H i g g i n s , 1 9 7 6 ; O j o f e i t m i , E l e g b e a n d B a b a f e m i , 1 9 8 2 ; R o s s a n d R u t t e r , 1 9 7 8 ) . O j o f e i t m i e t a l . f o u n d s i g n i f i c a n t l y h i g h e r b i r t h w e i g h t s among N i g e r i a n m o t h e r s w h o s e d i e t s w e r e m o d i f i e d t h r o u g h n u t r i t i o n a l c o u n s e l l i n g a n d u s e o f a f e a r - m e c h a n i s m t e c h n i q u e . P r i o r t o c o u n s e l l i n g , m o s t o f t h e women a v o i d e d p r o t e i n a n d e n e r g y f o o d s f o r f e a r o f h a v i n g b i g b a b i e s w h i c h w o u l d l e a d t o d i f f i c u l t l a b o r s a n d c e s a r e a n s e c t i o n s . N u t r i t i o n s u p p l e m e n t s t u d i e s h a v e a l s o d e m o n s t r a t e d t h e e f f e c t o f m a t e r n a l n u t r i t i o n o n b i r t h w e i g h t . B i r t h w e i g h t s a s r e p o r t e d i n t h e New Y o r k , M o n t r e a l , B o g o t a , G u a t e m a l a a n d T a i w a n s t u d i e s w e r e i n c r e a s e d 28 t o 100 g r a m s t h r o u g h m a t e r n a l n u t r i t i o n s u p p l e m e n t s ( S u s s e r , 1 9 8 1 ) . T h e r a t e o f i n c r e a s e a p p e a r s t o d e p e n d o n t h e n u t r i t i o n a l s t a t e o f t h e m o t h e r . T h e g r e a t e r t h e d e g r e e o f m a t e r n a l m a l n o u r i s h m e n t p r i o r t o t h e i n t a k e o f s u p p l e m e n t s , t h e g r e a t e r t h e i n c r e a s e i n m a t e r n a l b i r t h w e i g h t f o l l o w i n g s u p p l e m e n t a t i o n . I n s t u d i e s s u c h a s O s o f s k y ' s ( 1 9 7 5 ) , w h e r e s u b j e c t s d i d n o t a p p e a r t o b e n u t r i t i o n a l l y d e p r i v e d , s u p p l e -m e n t a t i o n d i d n o t a f f e c t b i r t h w e i g h t . L o n g t e r m e f f e c t s o n c o g n i t i v e f u n c t i o n i n g a s a r e s u l t o f e a r l y n u t r i t i o n a l s u p p l e m e n t a t i o n h a v e a l s o b e e n r e p o r t e d ( H i c k s , L a n g h a m a n d T a k e n a k a , 1 9 8 2 ; W a b e r e t a l . , 1 9 8 1 ) . H i c k s e t a l . f o u n d t h a t t h e p e r i n a t a l l y s u p p l e m e n t e d s c h o o l - a g e c h i l d r e n s h o w e d s i g n i f i c a n t e n h a n c e m e n t o f m o s t i n t e l l e c t u a l a n d b e h a v i o r a l m e a s u r e s i n c l u d i n g I . Q . , a t t e n t i o n s p a n , v i s u a l - m o t o r s y n t h e s i s a n d s c h o o l g r a d e a v e r a g e w h e n c o m p a r e d t o t h e g r o u p s u p p l e m e n t e d l a t e r . A d d i t i o n a l r e s e a r c h i s , h o w e v e r , w a r r a n t e d b e f o r e d e f i n t e c o n c l u s i o n s c a n b e m a d e . 28 The consequences of human maternal malnutrition are not well defined as there are few controlled studies in the literature. The effects of nutritional deprivation are often difficult to separate from the interrelated effects of poverty, lack of education, social depri-vation, chronic illnesses and individual characteristics. Research has largely based the impact of adequate nutrition during pregnancy on weight gain. Unfortunately, weight gain does not reflect adequate intake of a l l nutrients — only carbohydrate and protein. Pencharz (1981) recommends that pregnant women should make sure they meet their individual nutritional requirements rather than to simply follow their weight gain. Although the impact of maternal diet which is less than optimal is not fully understood, there is enough evidence to conclude that diet affects the outcome of pregnancy. Smoking and use of alcohol, drugs and caffeine during pregnancy can also have secondary effects on nutrition. These habits often affect the appetite and thereby replace nutritional intake. Alcohol is known to decrease the absorption of some nutrients. The risk to the outcome of pregnancy increases with the degree of which these habits are practiced. Thus, i t is obvious that a pregnant woman should not only ensure her nutrition intake is adequate, but should also avoid other unknown risk factors to provide the best for her baby. 29 P r e v i o u s I n v e s t i g a t i o n s o f H e a l t h B e h a v i o r s D u r i n g P r e g n a n c y S t u d i e s o n h e a l t h b e h a v i o r s o f p r e g n a n t women a r e n u m e r o u s . H o w -e v e r t h e r e a r e f e w c u r r e n t s u r v e y s w h i c h i n v e s t i g a t e a l l o f t h e h e a l t h p r a c t i c e s — s m o k i n g a n d i n t a k e o f a l c o h o l , d r u g s , c a f f e i n e a n d d i e t d u r i n g p r e g n a n c y . S u r v e y s o f h e a l t h h a b i t s o n p o p u l a t i o n s o f p r e n a t a l c l a s s a t t e n d e r s a r e e v e n m o r e s c a r c e . M a n y o f t h e s t u d i e s f o c u s o n t h e e f f e c t s o f o n e o r m o r e h e a l t h b e h a v i o r s o n p r e g n a n c y r a t h e r t h a n o n t h e p r e v a l e n c e a n d i n f l u e n c e s o f t h e s e p r a c t i c e s . T h e f o l l o w i n g i n c l u d e s a r e v i e w o f t h e f i n d i n g s o f some o f t h e i n v e s t i g a t i o n s o n s m o k i n g , a l c o h o l , d r u g , c a f f e i n e a n d / o r d i e t a r y h a b i t s d u r i n g p r e g n a n c y . I n o r d e r t o a s s i s t i n t h e o r g a n i z a t i o n o f t h e r e v i e w a n d s i n c e h e a l t h b e h a v i o r s a r e i n f l u e n c e d b y e n v i r o n m e n t a l a n d s o c i e t a l f a c t o r s , t h e s t u d i e s a r e d e s c r i b e d u n d e r t h e h e a d i n g s o f A m e r i c a n , O v e r s e a s a n d C a n a d i a n I n v e s t i g a t i o n s . A m e r i c a n I n v e s t i g a t i o n s A C a l i f o r n i a s t u d y o f o v e r 1 2 , 0 0 0 p r e g n a n t women (Kuzma a n d K i s s i n g e r , 1981) c l e a r l y d e m o n s t r a t e d t h a t a l a r g e p r o p o r t i o n o f women d r i n k (51%) a n d smoke (35%) d u r i n g p r e g n a n c y . S o c i o e c o n o m i c s t a t u s ( b o t h e d u c a t i o n a n d i n c o m e ) w a s a s s o c i a t e d p o s i t i v e l y w i t h l i g h t o r m o d e r a t e d r i n k i n g , b u t n e g a t i v e l y w i t h s m o k i n g . S i m i l a r f i n d i n g s w e r e r e v e a l e d i n t h e s t u d y c o n d u c t e d a t t h e B o s t o n C i t y H o s p i t a l p r e n a t a l c l i n i c ( 1 9 7 4 - 1 9 7 7 ) . R o s e t t a n d W e i n e r (1981) f o u n d i n i n t e r v i e w i n g 774 p r e g n a n t women t h a t o n l y h a l f o f t h e women r e p o r t e d r a r e d r i n k i n g o r t o t a l a b s t i n e n c e f r o m a l c o h o l d u r i n g pregnancy. Ten percent of the women were heavy drinkers (at least 45 drinks per month and 5 or more drinks at a time). The nutritional survey revealed that the entire population was poorly nourished; diets of heavier drinkers were similar to those of other prenatal partici-pants. The diets of a l l the women, however, improved following nutritional counselling. Use of psychoactive drugs and cigarette smoking were found to increase significantly with increased drinking. Age and parity were greater in heavy drinkers. In a subsequent study at the Boston City Hospital between 1977 and 1979 (Hingson et al., 1982), 1,692 women who delivered infants were interviewed on a variety of factors thought to influence fetal develop-ment. The majority of the sample was Black (59%), 18% were White, 15% had less than eight grade education and 32% were primiparous. Smoking was reported by 42% of the women with 14% smoking more than one pack per day. Alcohol consumption was reported by 56% of the women; 28% reported consuming less than one drink per day and 3% reported having two or more drinks per day. Most of the women (80%) ate three meals a day and 43% of the sample drank coffee; 5% of the women reported drink-ing more than 21 cups of coffee per week. The majority of the women (90%) took vitamin and mineral supplements and 22% reported using psychoactive drugs. These findings are, however, only generalizable to populations with similar characteristics. In the Seattle longitudinal Prospective Study, 1,529 women in a Health Maintenance Organization were interviewed during pregnancy regarding their alcohol and caffeine intake (Streissguth, Martin, Martin and Barr, 1981). Two thirds of the women drank alcohol less during early pregnancy than before pregnancy. The magnitude of the decrease in alcohol use after conception was directly proportional to pre-pregnancy consumption levels. The heaviest drinkers before pregnancy s t i l l reported greater consumption during pregnancy than more moderate drinkers. Coffee consumption also decreased markedly in the f i r s t four months. Reasons cited for the decrease in alcohol and coffee intake were: 1) adverse physiological effect e.g., nausea, stomach irritation, headache or i t 'smelled and tasted bad' and 2) health reasons e.g., fetal welfare or other health related concerns. These findings were similar to those of Hook (1978) who reported the reason for coffee consumption decreasing during pregnancy was nausea or loss of taste for the beverage. The reason most cited for an increase in milk consumption was craving. A mail survey of 548 women who gave birth in Los Angeles (Minor and Van Dort, 1982) showed that 96% of the sample had heard or read that i f a pregnant woman drinks, i t can harm her unborn baby; however, 59% of the sample reported drinking alcohol during pregnancy. Sources of information on alcohol were mass media/T.V./radio (77%), health care providers (62%), personal networks (56%), posters and pamphlets (56%) , and discussions with a doctor or nurse (47%). Those who reported they did not discuss drinking alcohol with a doctor or nurse were 1 1/2 times more likely to have drinking practices considered "risky" during pregnancy. In another California study (Nobman and Adams, 1970), 46 pregnant women attending tjAro prenatal clinics were interviewed to determine the adequacy of their diets, changes in dietary habits and reasons which c o n t r i b u t e d t o t h e s e c h a n g e s . O n l y 2 o f t h e 46 women h a d a d e q u a t e d i e t s T h e m a j o r i t y o f women t o o k v i t a m i n a n d m i n e r a l s u p p l e m e n t s a n d r e p o r t e d a n i n c r e a s e i n m i l k c o n s u m p t i o n . A p p e t i t e c h a n g e w a s t h e m a j o r r e a s o n s t a t e d f o r i n c r e a s i n g o r d e c r e a s i n g f o o d i n t a k e . B e c a u s e o f t h i s s t u d y * s m a l l s a m p l e s i z e a n d u s e o f g r o s s m e a s u r e m e n t s , s p e c i f i c s t a t e m e n t s a b o u t i n d i v i d u a l d i f f e r e n c e s i n d i e t h a b i t s d u r i n g p r e g n a n c y c o u l d n o t b e m a d e . T h e d a t a d i d h o w e v e r i n d i c a t e g e n e r a l p a t t e r n s o f d i e t d u r i n g p r e g n a n c y i n t h e p o p u l a t i o n s a m p l e d . L i l l i e n , H u b e r a n d R a j a l a (1982) i n t e r v i e w e d 578 women o n e t o f o u r d a y s p o s t p a r t u m a n d a l s o f o u n d t h a t l e s s t h a n o n e t h i r d (30%) o f t h e women s t u d i e d h a d a d e q u a t e d i e t s d u r i n g p r e g n a n c y . E i g h t y - t w o p e r c e n t o f t h e women d r a n k a l c o h o l i c b e v e r a g e s a t l e a s t o n c e d u r i n g p r e g n a n c y . T h e n u m b e r o f women w h o a b s t a i n e d f r o m a l c o h o l b e f o r e p r e g n a n c y (9%) i n c r e a s e d d u r i n g p r e g n a n c y (18%) a n d t h o s e t h a t d r a n k t w e n t y o r m o r e o u n c e s p e r m o n t h b e f o r e p r e g n a n c y (16%) d e c r e a s e d ( 3 % ) . R e c a l l p o s t -n a t a l l y o f d i e t a n d a l c o h o l i n t a k e d u r i n g p r e g n a n c y c o u l d h a v e b i a s e d t h e r e s u l t s . O v e r s e a s i n v e s t i g a t i o n s I n a F r e n c h s t u d y ( P a p o z , E s c h w e g e , P e q u i g n o t , B a r r a t a n d S c h w a r t z , 1982) o f 534 p r e g n a n t w o m e n , 37% o f t h e s a m p l e s m o k e d b e f o r e p r e g n a n c y . A t t h e s i x t h m o n t h , h a l f o f t h e m h a d s t o p p e d a n d o t h e r s r e d u c e d t h e i r c o n s u m p t i o n . M e a n c a l o r i c i n t a k e w a s h i g h e s t i n women who c o n t i n u e d t o smoke a n d l o w e s t i n n o n - s m o k e r s . T h e r e a s o n s m e n t i o n e d f o r d e c r e a s e d s m o k i n g w e r e n a u s e a (53%) o r ' i t w a s b e t t e r f o r t h e b a b y ' (33%) . A B r i t i s h s t u d y o f 195 m o t h e r s ( S m i t h e l l s e t a l . , 1977) r e p o r t e d that lower nutrient levels correlated with lower socioeconomic class, age under 20 years, smoking 10 or more cigarettes per day and reports of vomiting. Another British survey (Gardiner et al., 1981) of new mothers found that half of the mothers had never smoked. Of the smokers, 20% stopped smoking, 30% reduced and 50% did not alter their habits during pregnancy. The major source of information on smoking during pregnancy for these women was mass media including televison, leaflets and posters. Baric and MacCarthur (1977) conducted a study on a sample of pregnant women to measure social expectations (norms) and to identify how far women conform in their behavior to these norms. The study comprised 103 smokers, 30 ex-smokers, and 110 non-smokers. Mass media (98%) was identified as their major source of information concerning smoking during pregnancy. Friends or neighbors (63%) and health professionals (22%) were the other reported sources. For change in diet, most women reported they knew what to do (55%), but that mass media (21%) and health professionals (24%) were major sources of in-formation on diet during pregnancy. With regard to alcohol intake during pregnancy/ most women reported they "knew what to do" (74%), though mass media (15%) and friends and neighbors (11%) were also influences. Similarly, regarding medication intake during pregnancy, the women "just knew what to do" (67%); mass media (16%) and health professionals (13%) were also reported as information sources. 34 Canadian Investigations The Canada Health Survey (1978-79) identified approximately 38% of a l l women between the ages of 15 and 44 years (childbearing years) smoked cigarettes (Ableson, Paddon and Strohmenger, 1983). About 65% of the women smokers in this age group smoked 13 or more cigarettes per day. Smoking was related to social status as education and occupation showed clear relationships to current daily smoking. Current cigarette smokers were more likely to be those with low levels of education, were unemployed or in low status occupations (Health and Welfare Canada, 1981). Approximately 63% of a l l women between the ages of 15 and 44 years consumed alcohol. About 32% of women drinkers in this age group consumed 7 or more alcoholic drinks per week. Prevalence of alcohol use was significantly associated with higher income and occupational level (Health and Welfare Canada, 1981). A study in Ottawa (Fried, Watkinson, Grant and Knights, 1980), identified only 5% of the pregnant women studied to be abstainers from alcohol prior to pregnancy, but by the third trimester of pregnancy, this rate increased to 24%. The proportion of heavy drinkers (18%) prior to pregnancy was reduced substantially by the third trimester (2.6%). The percentage of women that smoked prior to pregnancy (31%) was also reduced (22%) during pregnancy. Approximately 20% of the women used marijuana before pregnancy, but only 10% of the population sample used marijuana by the third trimester of pregnancy. Income, age and education positively correlated with heavy social drinking, but neg-atively with heavy smoking. The major limitation of this study is the method of sample selection. Since the pregnant women were volunteers who had to contact the researcher, the generalizability of the results may be limited. Nutrition Canada (1976) reported from a national survey of 769 pregnant women that pregnant women in Canada have patterns of food consumption similar to that of a 20 to 29 year old female except for modest increases in milk and fruit. Nutrient intakes for folate, iron and calcium were below the recommended levels. Eighty-eight percent of the women said they made some changes in their diet and 67% of them said this change was self-imposed. Only 19% said the change was on the advice of a doctor or clinic. A food intake study of 981 expectant mothers attending prenatal classes in Toronto (Latchford, Milne, Vaughan, McClinton and Harris, 1970) reported that 57% of the women made changes in their diets during pregnancy. Of those that made changes, approximately half of them said i t was their own decision, one quarter said i t was on their doctor's recommendation and the remainder were influenced by both factors. Milk and milk products, fruits and vegetables, and meats were the foods increased and empty calorie foods and bread and cereal were most com-monly reported as reduced in their diets. Only 15% of the respondents had 4 servings of milk and milk products, 95% had satisfactory intakes of meat and 19% had 4 servings of bread and cereals. On examination of nutrient intakes, 80% were found to have low intakes of one or more nutrients, particularly calcium, iron and Vitamin A. The finding of inadequate diets among pregnant women was substan-tiated in another study. Dietary intakes of 29 pregnant women who were attending obstetric clinics at MacMaster University Centre (Field-Zimmer and Miles, 1981).showed that the women were not consuming the recom-mended Canadian Dietary Standard levels for energy and iron during pregnancy. The weaknesses of this study, however, are its small sample size, the university setting and the frequent contacts made by the investigator to encourage subjects to record their diet intakes, which may have biased the results. Schwartz and Barr (1977) in a study of 150 mothers who delivered infants at Vancouver General Hospital reported that 49% attended prenatal classes. The major human sources of nutrient information were physicans (62%), husband (38%), or prenatal instructor (30%). The major material sources of nutrition information were reported as past education and experience (62%), prenatal class booklets (44%), and pocketbooks (28%). Women who listed prenatal class instructors as a major source of prenatal information scored significantly higher on nutrition attitudes. The study did not indicate the number of women who refused to participate in the study. Yarie (1977) in interviewing 127 pregnant women — 73 of whom attended prenatal classes with the Vancouver Health Department found that 26% of the attenders smoked (as compared to 17% for non-attenders) and 74% of the attenders stated they made positive changes in their habits. Changes made in health habits were not described nor were the reasons for changes. Another fairly recent Vancouver study (Bradley, Ross and Warnyca, 1978) of 156 pregnant women reported the number of pregnant women who smoked to have decreased from 27% at the f i r s t trimester to 15% at the end of pregnancy. The number of pregnant women who consumed alcoholic 37 beverages decreased from 76% at the i n i t i a l interview to 46% at their second food record. These changes were, however, attributed to a comprehensive perinatal program. Participants in the study were referred by physicans practicing in one city hospital which limits the generalizations of these findings. From the review of previous investigations, one can appreciate the varying degrees to which health habits are practiced (or reported) by pregnant women. Comparisons between study findings are often difficult as the classifications used for light, moderate and heavy smoking or alcohol intake and the criteria used to: describe a diet as adequate are inconsistent. Many studies have investigated only one or two health habits rather than the complete profile of smoking, alcohol, drugs, caffeine and diet. The majority of the larger studies reviewed are not Canadian and do not involve prenatal class attenders. There has not been a recent survey of pregnant women attending Vancouver Health Department prenatal classes for the purposes of investigating maternal health behaviors during pregnancy, health behavior changes, and influences of change. Theoretical Models for Health Behavior Change Many conceptual models have been proposed to attempt an explanation of health behaviors. Rosenstock's (1974) health belief model has repeat-edly been tested and revised by various researchers. This theory is based on the decision making concepts of valence and subjective prob-ability. The theory argues that whether or not an individual will undertake a recommended h e a l t h a c t i o n i s dependent upon the i n d i v i d u a l ' percept ions o f : 1) l e v e l o f personal s u s c e p t i b i l i t y to t h a t i l l n e s s o r c o n d i t i o n , 2) the degree of s e v e r i t y of the consequences r e s u l t i n g from the c o n d i t i o n , 3) the h e a l t h a c t i o n ' s p o t e n t i a l b e n e f i t s , 4) est imates of p h y s i c a l , p s y c h o l o g i c a l , f i n a n c i a l o r other cos ts i n v o l v e d i n the proposed a c t i o n . B e l i e f s alone are not enough to change b e h a v i o r s . Relevant s t i m u l i o r "cues to a c t i o n " must occur to t r i g g e r the a p p r o p r i a t e h e a l t h b e h a v i o r . Diverse demographic and s o c i o p s y c h o l o g i c a l v a r i a b l e s were not seen as d i r e c t l y c a u s a l to compliance, but were recognized as p o t e n t i a l l y a f f e c t i n g h e a l t h mot ivat ions and percept ions (Becker, Haefner, Maiman, K i r s c h t and Drachman, 1977). T h i s o r i g i n a l model has been reformulated by Becker and Maiman (1975) and expanded t o i n c l u d e : 1) general h e a l t h m o t i v a t i o n s , 2) broader percept ions o f h e a l t h t h r e a t , 3) general f a i t h i n physicans and medica l care , 4) c h a r a c t e r i s t i c s o f the d o c t o r - p a t i e n t r e l a t i o n s h i p which might enhance o r impair compliance, and 5) demographic, s t r u c t u r a l and e n a b l i n g f a c t o r s as dependent v a r i a b l e s t o compliant b e h a v i o r s . H o r n ' s (1976) p e r s o n a l choice h e a l t h behavior model i s s i m i l a r to the h e a l t h b e l i e f model . I t attempts t o e x p l a i n the f o u r stages of 39 risk-taking behaviors: initiation, establishment, maintenance, and cessation or modification. The factors which facilitate or inhibit the cessation or modification of behavior are: 1) values underlying the change, 2) the perception of the threat, 3) the psychological u t i l i t y of the behavior, and 4) environmental (See Figure 1). Environmental factors include social forces, interpersonal in-fluences, mass commonications, influences generated by key groups which are a l l capable of playing an important role in determining whether or not change is attempted and successfully carried through in personal choice behavior (Horn, 1976). (See Figure 2). This study wil l use the cessation or modification stage of risk-behaviors in Horn's model as its framework to investigate the factors which facilitate or influence change in health behaviors. Summary A review of the literature reveals the difficulties in identifying the cause-effect relationship between health behaviors and the outcome of pregnancy. "Safe" levels of smoking, consumption of alcohol, caffeine, drugs and the lack of food nutrients are not yet ascertained. Research has not been totally successful in dissecting the synergistic effect of one's inherited genes and other environmental factors. The findings of the studies reviewed show that as l i t t l e as 1 to 2 oz. of alcohol twice a week, 1 to 4 cigarettes per day, 7 to 8 cups of coffee per day, various non-prescription drugs and an inadequate diet can each jeopardize maternal and/or fetal health. When these F^igure 1. A schematic outline of a personal choice health behavior model. INITIATION - Availability ESTABLISHMENT H Costs-benefits balance - Example Counteraction MAINTENANCE Sterotyping Psycho-personal structure CESSATION (or modification) 1 Reinforcement Contemplation of change Social Support T The decision to change T Psychological utility Short-term change T Long-term change Motivational change Perception of the threat Psychological utility Environmental facilitation o F i g u r e 2. E l a b o r a t i o n o f f a c t o r s g o v e r n i n g c e s s a t i o n ( o r o t h e r m o d i f i c a t i o n o f t h e b e h a v i o r ) MOTIVATION FOR CHANGE CESSATION (OR OTHER R I S K - R E D U C I N G MODIFICATION) 1 PERCEPTION OF THE THREAT PSYCHOLOGICAL U T I L I T Y 1 ENVIRONMENTAL F A C I L I T A T I O N a . H e a l t h b . E x e m p l a r r o l e c . E s t h e t i c s d . C o n t r o l a . I m p o r t a n c e b . P e r s o n a l i n f l u e n c e c . V a l u e o f c h a n g e d . C a p a b i l i t y o f m a k i n g c h a n g e a . S t i m u l a t i o n b . H a n d l i n g c . A c c e n t u a t i o n o f p l e a s u r e , p l e a s u r a b l e r e l a x a t i o n d . R e d u c t i o n o f n e g a t i v e e f f e c t e . P s y c h o l o g i c a l a d d i c t i o n " c r a v i n g " f . H a b i t , w i t h o u t a f f e c t a . P h y s i c i a n i n f l u e n c e b . G e n e r a l c l i m a t e o f o p i n i o n c . I n f l u e n c e o f a d v e r t i s i n g d . I n f l u e n c e o f k e y g r o u p s e . I n t e r p e r s o n a l i n f l u e n c e s practices are combined, the risks are amplified. However, just as one cannot guarantee that a l l pregnant women who have good health habits wil l have good pregnancy outcomes, one cannot predict that a l l pregnant women with poorer health habits will have poor outcomes. To optimize the potential outcome of pregnancy, a woman should avoid any known risk behaviors and practice good health habits during pregnancy. The review of previous investigations revealed that although most pregnant women change their habits during pregnancy, a large number s t i l l smoke, drink alcohol or have inadequate diets. The proportion of pregnant women engaged in these practices varies, depending on the population sample and the study methods used. The major influences to change health habits are also inconsistent in the studies reviewed. The findings are limited to similar populat-ions in which they were studied. The health behaviors of pregnant women who attend prenatal classes have not been recently researched. The changes this group makes in the consumption of alcohol, caffeine, drugs, diet and smoking and the major influences of change are not known. A personal choice health behavior model provides the framework for this study as change in health behavior involves personal responsibility. The research methodology is presented in Chapter III. CHAPTER III RESEARCH 1XETH0D0L0GY Overview This study was conducted to identify and describe the health behaviors of pregnant women attending prenatal classes with the Vancouver Health Department. A descriptive survey design was selected. Questionnaires were used to collect data as topics of smoking, alcohol, non-prescription drug and diet intake are often regarded as personal information. Women are less likely to deny their health problems i f they can be written down privately on paper (Russell and Bigler, 1979). This chapter describes five aspects of the methodology of this study: questionnaire development, setting, sample selection, data collection and data analysis. Questionnaire Development The data were collected utilizing two questionnaires. The f i r s t was the Prenatal Assessment Form, a questionnaire, used routinely by the Vancouver Health Department for a l l prenatal class registrants (refer to Appendix D). This form provides information on health habits prior to and during early pregnancy. As pregnant women register for prenatal classes, they are requested by the prenatal clerk to com-plete and return the form which includes questions on smoking, alcohol, drug, caffeine and diet intake. Sometimes the forms are completed and 44 returned at the early bird class or prenatal interview. The invest-igator collected information from this form only i f the subject had completed and returned the Health Habits Questionnaire which gave consent to its access. The Health Habits Questionnaire, the second tool for data col-lection, was devised, pretested and administered by the investigator. Questions on smoking and alcohol, drug, caffeine and diet intake were structured similarly to those of the Prenatal Assessment Form so that answers from the two forms could be compared. The questions regarding the influences to change behavior were designed based on Horn's framework of factors which facilitate or inhibit the cessation or modification of behavior. This questionnaire was reviewed for content validity and clarity by seven community health nurses who also taught prenatal classes and seven pregnant women who attended an early bird prenatal class in December 1982. Suggestions for revision were implemented and retested (refer to Appendix C). The one-day food record (or dietary recall) was the method used to assess dietary intake. Stunkard and Waxman (1981) found a strong linear relationship (correlation coefficient of 0.96) between measured food intake and self-reports (24 hour recall) of food intake. Mean recalled food intake does not differ significantly from actual mean intake (Gersovitz, Madden and Smicklas-Wright, 1978) and is most efficient for characterizing a group by its mean group intake (Chalmers et al., 1952). The reliability of the 24-hour diet recall used during pregnancy was tested by Rush and Kristal (1982) who concluded i t remains the best dietary tool for such research. 45 The Health Habits Questionnaire was tested for reliability and piloted with a prenatal class in February 1983. The questionnaire was administered two weeks apart to establish a test re-test measure for reliability. Five prenatal class attenders completed and returned both questionnaires. Results indicated a fairly high degree of reliability between the responses, especially for the questions on smoking, alcohol and diet change. It is already well established that one-day diet record is reliable for groups over 40. Minor adjustments in format of the questionnaire were made following the reliability test. The Health Habits Questionnaire provided the investigator with information on the health behaviors later in pregnancy while attending prenatal classes and on the changes and factors which influenced change in health behaviors during pregnancy. Setting This study took place in the six health units of the Vancouver Health Department. The health units of West, Burrard, Mid-Main, East, North and South are situated in various areas df the city and are separated by geographical boundaries. Vancouver, a port city, has a population of approximately 414,281 (Statistics Canada, 1981) and in 1980 the number of live births was 4,773 (Province of B.C. Ministry of Health, 1980). Although Vancouver's population is multicultural, the majority of the people are English speaking (Statistics Canada, 1981). The six leading health risk factors in Vancouver are excess alcohol consumption, low infant birth weight, excess cigarette smoking, dental caries, hypertension and environment pollutants. In 1979, 5.9% (274) of the babies born in Vancouver weighed 2500 grams or less (Roberts and Weinstein, 1982). The Vancouver Health Department has offered prenatal classes since 1956. Increasing public demand has necessitated expansion of the pro-gram. Community health nurses teach the classes and the prenatal class program (or prenatal series) varies somewhat in content and format between the six health units. At the time of this study, three health units offered an "early bird class' and three health units offered a 'prenatal interview' as part df the prenatal series. The 'early bird class' or 'prenatal interview', offered early in pregnancy, focused on health behaviors during pregnancy. The remainder of the prenatal class series focused on labor, delivery, exercises, breathing techniques, the newborn, postpartum period and family plan-ning methods. These classes were offered later in pregnancy, usually during the third trimester. The number of these late classes varied from four to six among the individual units. As pregnant women reg-istered for prenatal classes, they were requested to complete a City of Vancouver Health Department Prenatal Assessment Form. Registrants were assigned to classes in the health unit serving their area of residence i f at a l l possible. Since the prenatal classes had an enrollment limit, there were a number of pregnant women who registered, but because the classes were fully enrolled, were put on a waiting l i s t for prenatal classes. Most of these registrants did not receive any prenatal teaching unless a space in a given class became available or i f they attended private prenatal classes. A number of private pre-natal classes were offered throughout the city, however, their fees were substantially higher. Sample Selection Selection of participants was based on those who were currently attending prenatal classes or on the waiting l i s t for prenatal classes between March 15, 1983 and June 15, 1983. In addition, participants were required to meet the study criteria of: 1) registering for prenatal classes with the Vancouver Health Department, 2) English speaking or having access to an English speaking interpreter, 3) willing to participate, 4) having completed a Prenatal Assessment Form at least two weeks prior to administration of the Health Habits Questionnaire, and 5) were at least 24 weeks pregnant. Concurrence of the prenatal instructor was obtained before a given prenatal class was approached by the investigator. A sample size of at least 200 participants or greater was desired because of the limitations of the validity of the one-day food record and the anticipated low rates of pregnant women who smoke cigarettes or use alcohol, caffeine or drugs. 48 Data Collection Following approval of the study by the Vancouver Health Department, the prenatal coordinators of each health unit were contacted by the investigator to explain the study, request permission to sample prenatal classes in their respective units and obtain prenatal class time schedules. Prenatal class instructors teaching between March 15, 1983 and June 15, 1983 were individually contacted in order to explain the study and obtain permission to sample their prenatal classes. Arrangements were made with each instructor for the investigator to attend one class of the prenatal series. At the prenatal class, the investigator explained the nature of the study, answered any questions and handed out the Health Habits Questionnaire with a covering letter (refer to Appendix A) to eligible class members. Subjects were informed that anonymity and confident-ial i t y of the responses would be maintained and participation was voluntary. The questionnaires were number coded so that names did not appear on the questionnaire, preserving the anonymity of the participants. In order to identify each participant's Prenatal Assessment Form, the investigator kept a record of the names and corresponding number code. Participants completed the questionnaire either during class breaktime or at home, depending on their preferences. The question-naires were returned to the prenatal class instructor who was provided with a large envelope or folder. 49 T h e i n v e s t i g a t o r o b s e r v e d a h i g h r a t e o f a b s e n t e e i s m a n d t a r d i n e s s among p r e n a t a l c l a s s a t t e n d e r s . I n a n e f f o r t t o g i v e e v e r y c l a s s mem-b e r a n o p p o r t u n i t y t o p a r t i c i p a t e , n u m b e r c o d e d q u e s t i o n n a i r e s f o r t h o s e a b s e n t w e r e l e f t w i t h c o m p l y i n g p r e n a t a l i n s t r u c t o r s , t o b e g i v e n o u t l a t e r i n t h e c l a s s o r s e r i e s . Names c o r r e s p o n d i n g t o t h e n u m b e r c o d e s o n t h e q u e s t i o n n a i r e s w e r e w r i t t e n o n t h e c o v e r i n g l e t t e r s a c c o m p a n y i n g t h e q u e s t i o n n a i r e s f o r t h e b e n e f i t o f t h e p r e n a t a l i n s t r u c t o r . T h e c o v e r i n g l e t t e r p r o v i d i n g a n e x p l a n a t i o n o f t h e n a t u r e o f t h e s t u d y c o u l d b e e a s i l y r e m o v e d f r o m t h e q u e s t i o n n a i r e o n i t s r e t u r n t o t h e i n s t r u c t o r . T h e i n v e s t i g a t o r k e p t a r e c o r d o f t h e names w h i c h c o r r e s -p o n d e d t o t h e n u m b e r c o d e s o f t h e q u e s t i o n n a i r e s a d m i n i s t e r e d . V e r b a l r e m i n d e r s t o r e t u r n t h e q u e s t i o n n a i r e s w e r e s o m e t i m e s g i v e n b y p r e n a t a l i n s t r u c t o r s a t t h e n e x t p r e n a t a l c l a s s o r b y a t e l e p h o n e c a l l f r o m t h e i n v e s t i g a t o r w i t h t h e a s s e n t o f t h e p r e n a t a l i n s t r u c t o r . On c o m p l e t i o n o f t h e p r e n a t a l c l a s s s e r i e s , t h e i n v e s t -i g a t o r c o l l e c t e d t h e r e t u r n e d q u e s t i o n n a i r e s f r o m t h e p r e n a t a l i n s t r u c t o r s a n d r e l e v a n t d a t a o n t h e P r e n a t a l A s s e s s m e n t F o r m f o r t h o s e who r e t u r n e d a c o m p l e t e d H e a l t h H a b i t s Q u e s t i o n n a i r e . E a c h h e a l t h u n i t w a s s a m p l e d f i v e t i m e s , t o t a l l i n g t h i r t y p r e n a t a l c l a s s e s b e t w e e n M a r c h 1 5 , 1 9 8 3 a n d J u n e 1 5 , 1 9 8 3 . S a m p l i n g o f p r e g n a n t women o n t h e w a i t i n g l i s t b e t w e e n M a r c h 15 a n d J u n e 1 5 , 1983 w a s a l s o p u r s u e d i n a n e f f o r t t o p r o v i d e a c o n t r o l g r o u p i n t h e s t u d y . T h e i n v e s t i g a t o r c o n t a c t e d t h e p r e n a t a l c l e r k s a n d t h e c o o r d i n a t o r o f t h e w a i t i n g l i s t t o e x p l a i n t h e s t u d y a n d a s k t h e m t o n o t i f y t h e i n v e s t i g a t o r w h e n c o m p l e t e d P r e n a t a l A s s e s s m e n t F o r m s w e r e r e t u r n e d b y women o n t h e w a i t i n g l i s t . T h e i n v e s t i g a t o r communicated frequently with the coordinator of the waiting l i s t for current additions and deletions. Subjects who met the study criteria were sent a covering letter explaining the study (refer to Appendix B), the Health Habits Question-naire and a stamped pre-addressed envelope by the investigator. The questionnaires were number coded and the investigator kept note of the names corresponding to the numbered questionnaires. A follow-up phone cal l was made to a l l those who were mailed a questionnaire, but had not returned i t within three weeks. A copy of the Prenatal Assessment Form for those participants who returned a completed questionnaire was obtained from the prenatal clerk. The number of participants on the waiting l i s t however, was insufficient to allow for valid comparisons with the study group of prenatal class attenders. The findings from both groups are presented and discussed separately. Data Analysis Data from the Health Habits Questionnaire as well as the inform-ation on smoking, alcohol, drug, caffeine and diet intake on the Prenatal Assessment Form, were coded using Fortran Coding forms for computer analysis. The one-day food records were analyzed using Canada's Food Guide and a diet score method (refer to Appendix E). This method for diet assessment was selected as a strong association has been demonstrated between the food group dietary score approach and the nutrient approach in assessing nutrient intake (Bowering, Morrison, Lowenberg and Tirado, 1977; Guthrie, 1981). According to Guthrie (1981) the correlation coefficients between dietary scores (based on food groups) and nutrient adequacy ratio (based on nutrient values) are highly significant (p of less than 0.0001). One must note however, that the diet scores based on food groups reflect adequacy of nutrients, but do not account for energy. The recommended caloric intake per day for a pregnant woman is a ndnimum of 2300 kcal. The intake of foods as recommended by Canada's Food Guide accounts for only 1000 to 1400 kcal. per day. Although sufficient calories are important during pregnancy and influence birth weight, caloric assessment of the one-day diet records was not attempted in this study. The Statistical Package for Social Sciences was used for analysis with descriptive statistics such as frequency distribution, t-test and Chi-square. The significance level used was 0.05. Responses to the open-ended question were not analyzed by computer, but rather grouped and discussed. Summary In summary, the research methodology is described in this chapter with references to the setting of the study, development of the Health Habits Questionnaire, the sample selection and the methods used for data collection and analysis. The findings are presented in Chapter IV. CHAPTER IV STUDY RESULTS Overview The major findings of this study are presented in four sections. The f i r s t section provides a description of the response rate and the demographic characteristics of the participants in the study. The second section describes their reported health behaviors of smoking and intake of alcohol, non-prescription drugs, tea, coffee and colas, and diet. Changes in health behaviors and the influences to change health behaviors are also described. The third section discusses the overall health behaviors of the respondents. The fourth section describes the relationship between demographic characteristics and health behaviors of respondents. Findings are summarized at the end of section one, two and four. Description of the Sample Response Rate Two hundred and eighty-five Health Habits Questionnaires were distributed to prenatal class attenders. Two hundred and twenty of the questionnaires were completed and returned giving a response rate of 77.2%. The response rate of participants from individual health units ranged from 69.0% to 90.0% as indicated in Table 4-1. Table 4-1 Response Rate by Health Unit Health Unit Eligible Subjects Participants % of Unit % of Total Sample West 52 36 69.2 16.4 Burrard 40 36 90.0 16.4 Mid-Main 45 35 77.8 15.9 North 49 39 79.6 17.7 East 43 32 74.4 14.5 South 56 42 75.0 19.1 Total 285 220 100.0 Demographic Characteristics  Age The ages of the respondents ranged from 18 years to 40 years. The mean age (as well as the median) was 27 years with 71.0% between 21 and 30 years. The age distribution is presented in Table 4-2. Table 4-2 Ages of Respondents Age (years) Absolute Frequency Relative Frequency (%) 20 & under 11 5.0 21 - 25 68 31.0 26 -.30 89 40.0 31 - 35 44 20.0 36 - 40 8 4.0 Total 220 100.0 Countxy of Origin The majority of prenatal class attenders were born in Canada (65.5%). Others of the sample were born in China, Europe, United States, England, Phillipines, Africa, F i j i , India, Vietnam and other countries as evidenced in Table 4-3. Table 4-3 Country of Origin of the Respondents Country Absolute Frequency Relative Frequency (%) Canada 144 65.5 China 17 7.7 Europe 15 6.8 United States '8 3.6 England 8 3.6 Phillipines 5 2.3 Africa 3 1.4 F i j i 3 1.4 India 3 1.4 Vietnam 3 1.4 Othera 9 4.1 Unknown 2 0.9 Total 220 100.0 Si Includes Afghanistan, Ceylon, Korea, Malaysia and Mexico. Indonesia, Japan, Language The language b e s t understood by the respondents was E n g l i s h (89.1%) w i t h frequencies of o t h e r b e s t understood languages shown i n Table 4-4. Table 4-4 Language Best Understood by the Respondents Language E n g l i s h Chinese French German O t h e r a Unknown Absolute Frequency 196 11 2 2 7 2 R e l a t i v e Frequency (%) 89.1 5.0 0.9 0.9 3.2 0.9 T o t a l 220 100.0 Includes Japanese, I t a l i a n , P e r s i a n , P u n j a b i , Portuguese, Spanish and T a m i l . Family Income The annual gross income of 41.0% of respondents was between $10,000 and $30,000. T h i r t y - n i n e percent o f the p a r t i c i p a n t s had incomes between $30,000 and $60,000. The remainder o f the group was p r o p o r t i o n a l l y below $10,000 (11.0%) and over $60,000 (10.0%). Table 4-5 represents the gross f a m i l y income d i s t r i b u t i o n of the p a r t i c i p a n t s . Table 4-5 Annual Gross Family Income of Respondents Absolute R e l a t i v e Adjusted Family Income Frequency Frequency (%) Frequency $0 - 10,000 20 9.1 9.7 $10,000 - 30,000 85 38.6 41.1 $30,000 - 60,000 81 36.8 39.1 over $ 60,000 21 9.5 10.1 unknown 13 5.9 m i s s i n g T o t a l 220 100.0 100.0 Educat ion Most o f the respondents had Grade 12 o r f u r t h e r educat ion (88.2%) w i t h approximately 59.0% of the respondents having p o s t secondary e d u c a t i o n . Table 4-6 presents the d i s t r i b u t i o n of the l e v e l s o f educat ion a t t a i n e d by the study group. Table 4-6 Education Levels of Respondents Highest Level of Education Absolute Frequency Grades 1 — 7 2 Grades 8 — 11 23 Grade 12 64 Technical Training 27 College Diploma 38 University 59 Other 6 Unknown 1 Total 220 Relative Cumulative Frequency (%) Frequency (%) 0.9 0.9 10.5 11.4 29.1 40.5 12.3 52.8 17.3 70.1 26.8 96.9 2.7 99.6 0.5 0.5 100.0 100.0 Parity and Gestation Two hundred (90.9%) of the respondents were expecting their f i r s t baby. Sixty-four percent of the respondents were in their f i r s t half of pregnancy on completion of the Prenatal Assessment Form and 17.0% were in their f i r s t trimester. The Health Habits Questionnaire was completed in the second half of pregnancy — the majority of respond-ents being in their third trimester of pregnancy. Prenatal Education Of the respondents, 115 (52.3%) had attended an early bird prenatal class and 109 (49.5%) had attended a prenatal interview with a community health nurse. (Sixteen (7.3%) of the respondents had attended both an early bird class and prenatal interview; eight (3.7%) 58 had attended either an early bird class or interview and a prenatal class other than from the Vancouver Health Department.) One (0.5%) person attended only a prenatal class other than from the Vancouver Health Department and eleven (5.0%) of the study sample did not have any of the aforementioned prenatal instruction. Summary The response rate of prenatal class attenders was 77%. The average age of the respondents was 27 years with 71% between 21 and 30 years. More than half (66%) of the respondents were born in Canada. English was the language best understood by the majority of the sample (89%) . Approximately half of the study group had annual gross family incomes above $30,000 and half had incomes below $30,000. Eighty-eight percent of the women had at least Grade 12 education with more than half (59%) having attained further levels of education. The majority of the respondents (91%) were expecting their f i r s t baby. Health Behaviors of Prenatal Class Attenders The health behaviors of prenatal class attenders are described in relation to smoking, intake of alcohol, non-prescription drugs, coffee, tea and cola, and diet as reported on the Prenatal Assessment Form (PAF) and the Health Habits Questionnaire (HHQ). Smoking Sixty-seven (30.5%) respondents smoked before pregnancy. Thirty-three (15.0%) of the sample reported smoking during pregnancy. Notice 59 from Table 4-7, that the rates of non-smokers during pregnancy as reported on the Prenatal Assessment Form and the Health Habits Question-naire were fairly consistent. Of the 67 respondents who smoked before pregnancy, approximately half continued to smoke during pregnancy. Table 4-7 Number of Smokers and Non-Smokers Before and During Pregnancy Before Pregnancy During Pregnancy PAF HHQ no. (%) no. (%) no. (%) Smoker 67 30.5 29 13.2 33 15.0 Non-smoker 153 69.5 188 85.5 187 85.0 Unknown - — 3 1.4 — — Total 220 100.0 220 100.0 220 100.0 Before pregnancy 14 (6.4%) respondents smoked between 1 and 6 cigarettes per day and 34 (15.5%) of the attenders smoked between 7 and 24 cigarettes per day. During pregnancy, 10 (4.5%) respondents smoked between 1 and 6 cigarettes per day and 21 (9.5%) smoked between 7 and 24 cigarettes per day. The data presented in Table 4-8 illustrates that the number of respondents who smoked 25 or more cigarettes per day before pregnancy decreased from 18 (8.2%) to 1 (0.5%) during pregnancy. Table 4-8 Number of Cigarettes Smoked Before and During Pregnancy Before Pregnancy During Pregnancy No. of Cigarettes PAF HHQ per day no. (%) no. (%) no. (%) 0 153 69.5 188 85.5 187 85.5 Occasional 1 0.5 1 0.5 - -1-6 14 6.4 7 3.2 10 4.5 7-24 34 15.5 18 8.2 21 9.5 25 & Over 18 8.2 3 1.4 1 0.5 Unknown _ — 3 1.4 1 0.5 Total 220 100.0 220 100.0 220 100.0 Change in Smoking Of the 33 prenatal class attenders who smoked during pregnancy 30 (90.9%) reported they decreased smoking, 2 (6.1%) reported no change in smoking and 1 (3.0%) reported an increase in smoking. influences on Smoking Behavior Thirty-seven respondents identified factors which influenced a change in their smoking habits. Own personal knowledge, books, magazines and pamphlets, doctor and family member or friends were most frequently reported. Table 4-9 gives a breakdown for the absolute frequency of reported influences. Table 4-9 Influences on Smoking Behavior Influences Absolute Frequency5 Percent of Cases Own personal knowledge 32 86.5 Books/magazines/pamphlets 17 45.9 Doctor 17 45.9 Family member/friend 11 29.7 Change of craving 9 24.3 Prenatal class 8 21.6 Social pressure 7 18.9 Community health nurse 5 13.5 Stress 1 2.7 aMore than one influence may be reported by respondents b n = 37 Alcohol One hundred and twenty-eight (58.2%) respondents stated that they consumed alcohol before pregnancy. During pregnancy as reported on the Prenatal Assessment Form, 54 (24.6%) respondents reported drinking alcohol. Later in pregnancy, as reported on the Health Habits Questionnaire, 105 (47.7%) reported drinking alcohol (this number is more than reported on the PAF earlier in pregnancy, and will be discussed further in Chapter V). Table 4-10 gives a comparison of the users and abstainers of alcohol before and during pregnancy. Table 4-10 Number of Alcohol Users and Abstainers Before and During Pregnancy Before Pregnancy During Pregnancy PAF HHQ no. (%) no. (%) no. (%) Alcohol User 128 58.2 54 24.6 105 47.7 Alcohol Abstainer 92 41.8 166 75.5 113 51.4 Unknown — — — — 2 0.9 Total 220 100.0 220 100.0 220 100.0 Sixty-two (28.2%) respondents reported alcohol intakes of 4 or more servings per week before pregnancy. During pregnancy, on the PAF, 9 (4.1%) reported intakes of 4 or more servings per week and later in pregnancy, on the HHQ, 20 (9.1%) respondents reported consuming that amount. The number of respondents who drank 7 or more drinks per week was reduced from 31 before pregnancy to 4 during pregnancy. As evidenced from Table 4-11, the number of respondents who drank alcohol during pregnancy decreased in the 4 or more servings categories, but increased in the 3 or less servings categories. 63 Table 4-11 Number of Alcohol Servings Consumed Before and During Pregnancy Before Pregnancy During Pregnancy No. of Servings PAF HHQ per week no. (%> no. (%) no. (%) 0 92 41.8 166 75.5 113 51.4 Occasional*3 25 11.4 18 8.2 38 17.3 1-3 41 18.6 27 12.3 43 19.5 4-6 31 14.1 7 3.2 16 7.3 7-9 15 6.8 2 0.9 3 1.4 10 - 14 11 5.0 - - 1 0.5 15 & Over 5 2.3 - - - -Unkown — — — — 3 1.4 Total 220 100.0 220 100.0 220 100.0 One serving of alcohol = approximately 12 oz. beer, or 5 oz. wine, or 1 oz. liquor. ^Occasional = less than one serving per week or specified as occasional. Wine was the form of alcohol most frequently consumed by the respondents. Table 4-12 presents a detailed description of the type and frequency of alcohol consumed before and during pregnancy. Between 1 to 3 servings per week was the most common frequency reported for any one type of alcohol. Table 4-12 Type and Frequency of A l c o h o l Consumed Before and During Pregnancy Beer Servings per Week no. (%) 0 163 74.1 O c c a s i o n a l ' 3 11 5.0 1 - 3 32 14.5 4 - 6 7 3.2 7 - 9 2 0.9 10 - 14 4 1.8 15 + 1 0.5 T o t a l 220 100.0 Servings per Week no. Beer (%) 0 199 90.5 Occasional* 3 6 2.7 1 - 3 14 6.4 4 - 6 - -7 - 9 1 0.5 T o t a l 220 100.0 Before Pregnancy Wine L i q u o r no. (%) no. (%) 107 48.6 162 73.6 17 7.7 14 6.4 61 27.7 32 14.5 28 12.7 7 3.2 3 1.4 1 0.5 4 1.8 3 1.4 _ — 1 0.5 220 100.0 220 : 100.0 During Pregnancy (PAF) Wine L i q u o r no. (%) no. (.%)• 174 79.1 210 95.5 15 6.8 3 1.4 30 13.6 7 3.2 1 0.5 - -220 100.0 220 100.0 ( table continues) During Pregnancy (HHQ) Beer Wine Liquor Servings Per Weeka no. (%) no. (%) no. (%) 0 193 87.7 135 61.4 195 88.6 Occasional'3 7 3.2 31 14.1 7 3.2 1-3 14 6.4 44 20.0 14 6.4 4-6 3 1.4 7 3.2 - -7-9 - - - - - -10+ - - - - 1 0.5 Unknown 3 1.4 3 1.4 3 1.4 Total 220 100.0 220 100.0 220 100.0 a. One servxng = 12 oz. beer, or 5 oz. wine, or 1 oz. : liquor. ^Occasional = : less than one serving per week or specified as occasional drinker. Change in Alcohol Intake Of the 105 prenatal class attenders who reported alcohol intake during pregnancy (on an occasional or on a regular basis), 103 (98.1%) reported they reduced, and 2 (1.9%) reported no change. influences on Alcohol Intake One hundred and nine respondents identified factors which in-fluenced a change in alcohol intake during pregnancy. Own personal knowledge, books, magazines and pamphlets, change in craving, and doctor were reported most frequently. Table 4-13 indicates the frequencies of influences on alcohol intake. Table 4-13. Influences on Alcohol Intake Influences Absolute Frequency3 Percent of Cases Own personal knowledge 98 89.9 Books/magazines/pamphlets 47 43.1 Change in craving 39 35.8 Doctor 24 22.0 Family member/friend 21 19.3 Prenatal class 18 16.5 Gommunity health nurse 13 11.9 T.V./radio 8 7.3 Social pressure 6 5.5 Change in personal stress 3 2.8 Other 3 2.8 aMore than one influence may be reported by respondents b n = 109 Non-Prescription Drugs Use of non-prescription drugs during pregnancy was reported by 195 (88.6%) respondents. Excluding prenatal vitamins as drugs, 88 (40.0%) respondents reported taking non-prescription drugs. Excluding a l l forms of vitamins (prenatal, multiple and single), 40 (18.2%) respondents reported taking drugs during pregnancy. As illustrated in Table 4-14, the most common non-prescription drugs consumed during pregnancy were prenatal vitamins. Other than a l l forms of vitamins, painkillers and antinauseants were most commonly reported. Analysis of reported intakes of various drug combinations was not attempted. Table 4-14 Type and Frequency of Non-prescription Drugs Taken During Pregnancy  Non-prescription Drug Absolute Frequency Relative Frequency (%) Prenatal vitamins 107 48.6 Single vitamins 51 23.2 Multiple vitamins 21 9.5 Painkillers 13 5.9 Antinauseants 11 5.0 Antacids 4 1.8 Marijuana 4 1.8 Antihistamines & cold remedies 3 1.4 Laxatives 2 0.9 Other 10 4.5 ^ore than one drug may be reported by the respondents bN = 220 The most common non-prescription drugs reported as being started or increased during pregnancy were prenatal, single and multiple vitamins. A l l other drugs which were started or increased during pregnancy had relatively low frequencies as indicated in Table 4-15. Table 4-15 Frequency of Non-prescription Drugs Which Were Started or  Increased During Pregnancy Non-prescription Drug Absolute Frequency Relative Frequency (%) Prenatal vitamins 122 55.5 Single vitamins 52 23.6 Multiple vitamins 10 4.5 Painkillers 7 3.2 Antacids 7 3.2 Antihistamines & cold remedies 4 1.8 laxatives 2 0.9 Other 3 1.4 aMore than one drug may be reported by the respondents bN = 220 Painkillers, antihistamines and marijuana were the non-prescription drugs most commonly reported to have decreased or stopped during pregnancy. Table 4-16 shows the low frequencies of a l l other drugs which were stopped or decreased during pregnancy. 69 Table 4-16 Frequency of Non-prescription Drugs Which Were Stopped or  Decreased During Pregnancy Non-prescription Drug Absolute Frequency Relative Frequency (%) Painkillers 66 30.0 Antihistamines & cold remedies 39 17.7 Marijuana 12 5.5 Multiple vitamins 10 4.5 Single vitamins 9 4.1 Prenatal vitamins 2 0.9 Laxatives 2 0.9 Antacids 1 0.5 Other 3 1.4 aMore than one drug may be reported by respondents bN = 220 Influences on Non-prescription Drug Consumption Information provided by doctors was the most frequent response recorded as being influential for drug increase. Doctors, books, magazines and pamphlets, and own personal knowledge were the most frequently identified categories influencing drug decreases. (Because the data on influences on drug change were not computer analyzed, the specific frequencies of reported influences are not described.) Tea, Coffee, Cola One hundred and ninety-five (88.6%) respondents reported on the Health Habits Questionnaire (HHQ) that they drank tea, coffee and/or colas. The number of servings of tea, coffee and colas consumed during pregnancy as reported both on the Prenatal Assessment Form (PAF) and the HHQ are identified in Table 4-17. One hundred and ninety-two (87.3%) respondents reported consuming 6 or less servings per day (HHQ). Notice the low frequencies of intakes of 7 or more servings per day. Table 4-17 Number of Servings of Tea, Coffee and/or Colas Consumed  LXiring Pregnancy During Pregnancy  PAF HHQ Servings per day no. (%) no. (%) 0 26 11.8 25 11.4 Occasional 58 26.4 64 29.1 1-3 101 45.9 100 45.5 4-6 27 12.3 28 12.7 7-9 2 0.9 1 0.5 9 + 1 0.5 1 0.5 Unkown 5 2.3 1 0.5 Total 220 100.0 220 100.0 71 Approximately 70% of the respondents consumed tea during pregnancy. Less than half of the respondents (48%) consumed coffee and about 21% drank colas during pregnancy. The frequency of intakes reported on the Prenatal Assessment Form and the Health Habits Questionnaire are fairly consistent (Refer to Table 4-18). Table 4-18 Tea Coffee Colas Servings Per Day no. (.%) no. (%) no. (%) Prenatal Assessment Form 0 71 32.3 121 55.0 167 75.9 Occasional 31 14.1 26 11.8 26 11.8 1-3 105 47.8 64 29.1 22 10.0 4-6 6 2.7 4 1.8 - -7 or more 2 0.9 - - - -Unknown 5 2.3 5 2.3 5 2.3 Total 220 100.0 220 100.0 220 100.0 Health Habits Questionnaire 0 66 30.0 114 51.8 173 78.6 Occasional 31 14.1 28 12.7 30 13.6 1-3 109 49.5 73 33.2 16 7.3 4-6 12 5.5 4 1.8 - -7 or more 1 0.5 - - - -Unknown 1 0.5 1 0.5 1 0.5 Total 220 100.0 220 100.0 220 100.0 Change in Tea, Coffee and Cola Intake Over half of the tea drinkers (50.3%) reported decreasing their tea intake during pregnancy, whereas 14.5% reported increasing their tea consumption. Of the coffee drinkers, 83.1% decreased their coffee intake, whereas 1.3% reported an increase, and 48.9% of a l l cola drinkers decreased their cola intake while only 0.7% increased cola intake during pregnancy. Table 4-19 presents the changes in tea, coffee and cola intake of the prenatal class attenders. Table 4-19 Frequency of Reported Changes in Tea, Coffee and Cola Intake Tea Coffee Cola Change no. (%) . no. (%) no. (%) Increase 26 14.5 2 1.3 1 0.7 Decrease 90 50.3 133 83.1 68 48.9 No Change 63 35.2 25 15.6 70 50.4 Total 179 100.0 160 100.0 139 100.0 Influences on Tea, Coffee and Cola Intake One hundred and seventy-three prenatal class attenders who changed their tea, coffee or cola consumption identified factors which in-fluenced their change. As shown in Table 4-20, own personal knowledge, books, pamphlets and magazines, change in craving and doctor were the most frequent influences reported. Table 4-20 Influences on Tea, Coffee and Cola Intake Influences Absolute Frequency Percent of < Own, personal knowledge 121 69.9 Books/magazines/panphlets 72 41.6 Changes in craving 66 38.2 Doctor 35 20.2 Family member/friend 29 16.8 Prenatal class 28 16.2 Community health nurse 19 11.0 T.V./radio 9 5.2 Change in stress 6 3.5 Social pressure 2 1.2 aMore than one influence may be reported by the respondents bn =173 Diet Diet was assessed from the two one-day food records — one from the Prenatal Assessment Form and the other from the Health Habits Questionnaire. Eight (3.6%) respondents indicated they were on a special diet such as low salt or low sugar. Because Canada's Food Guide can be adapted to individual diet needs, the attenders on special diets were not excluded from the study. 74 Diets were assessed according to Canada's Food Guide minimum recommendations: - 4 servings of milk and milk products, - 2 servings of meat and alternates, - 4 servings of fruit and vegetables, and - 4 servings of breads and cereals. Food Intake Reported on the Prenatal Assessment Form On the f i r s t one-day diet record, 63 (29.4%) respondents reported having 4 or more servings of milk and milk products; whereas 151 (70.6%) reported having less. One hundred and sixty-nine (79.0%) respondents reported having at least 2 servings of meat and alternates; whereas 45 (21.0%) reported having less. Intakes of at least 4 servings of fruit and vegetables were reported by 173 (80.8%) respondents; whereas 41 (19.2%) reported having less. Intakes of at least 4 servings of breads and cereals were reported by 137 (64.0%) respondents, while 77 (36.0%) reported having less. Refer to Table 4-21 for a detailed presentation of the assessed diets. Total Diet Score A total diet score of 16 which represents the minimum number of servings recommended by Canada's Food Guide was obtained by 31 (14.5%) of the respondents; while 183 (85.5%) respondents did not meet the requirements (refer to Table 4-22 for total diet score results). Nearly 40% of the respondents had diets with scores of less than 13. Table 4-21 Diet Assessment From the Prenatal Assessment Form' Frequencies Abs. Milk Adj.% Currf.% Abs. Meat Adj.% Cum.% Fruit/Veg. Abs. Adj.% Cum.% Bread/Cereal Abs. Adj.% Cum.% No. of Servings 0 12 5.6 5.6 5 2.3 2.3 _ 1.0 - 1.5 30 14.0 19.6 40 18.7 21.0 5 2.3 2.3 8 3.7 3.7 2.0 - 2.5 50 23.4 43.0 85 39.7 60.7 8 3.7 6.0 32 15.0 18.7 3.0 - 3.5 59 27.6 70.6 55 25.7 86.4 28 13.1 19.1 37 17.3 36.0 4.0 - 4.5 48 22.4 93.0 24 11.2 97.6 57 26.6 45.7 65 30.4 66.4 5.0 - 5.5 13 6.1 99.1 5 2.3 100.0 43 20.1 65.8 36 16.8 83.2 6.0 - 6.5 2 0.9 100.0 - - 100.0 37 17.2 83.0 22 10.3 93.5 7.0 & over - - 100.0 - - 100.0 36 16.8 100.0 14 6.5 100.0 Unknown 6 missing 100.0 6 missing 100.0 6 missing 100.0 6 missing 100.0 Total 220 100.0 100.0 220 100.0 100.0 220 100.0 100.0 220 100.0 100.0 Note: Abs. = Absolute; Adj. = Adjusted; Cum. = Cumulative. ^ i e t s were assessed according to Canada's Food Guide minimum recommendations: Milk and Milk Products = 4 servings, Meat and Alternates = 2 servings, Fruit and Vegetables = 4 servings, Breads and Cereals = 4 servings. 76 Table 4-22 Total Diet Score (Prenatal Assessment Form) Absolute Frequency Adjusted Freq.(%) Cumulative Freq.(%) Score 10.0 or less 15 10.5 - 13.0 70 13.5 - 15.5 98 16.0 31 Unknown 6 Total 220 7.0 32.7 45.8 14.5 missing 100.0 7.0 39.7 85.5 100.0 missing 100.0 Food Intake Reported on the Health Habits Questionnaire On the second one-day diet record, 78 (36.8%) respondents reported having 4 or more servings of milk and milk products; whereas 134 (63.2%) reported having less. One hundred and seventy-five (82.5%) respondents reported having at least 2 servings of meat and alternates; whereas 37 (17.5%) reported having less. Intakes of 4 servings of fruit and vegetables were reported by 168 (79.2%) respondents; whereas 44 (20.8%) reported having less. Intakes of at least 4 servings of breads and cereals were reported by 138 (65.1%) respondents, while 74 (34.9%) reported less. Table 4-23 illustrates a detailed description of the assessed diets. Although 21% of the participants reported less than 4 servings of fruit and vegetables, over 27% had 7 or more servings. Total Diet Score The total diet score of 16 which represents the minimum number Table 4-23 Diet Assessment From Health Habits Questionnaire0 Milk Frequencies Abs. Adj.% Cum.%  No. of Servings Meat Abs. Adj.% Cum.% Fruit/Veg. Abs. Adj.% Cum.% Bread/Cereal  Abs. Adj.% Cum.% 0 8 3.8 3.8 4 1.9 1.9 2 0.9 0.9 - - -1.0 - 1.5 28 13.2 17.0 33 15.6 17.5 5 2.4 3.3 9 4.2 4.2 2.0 - 2.5 32 15.1 32.1 82 38.7 56.2 16 7.5 10.8 20 9.4 13.6 3.0 - 3.5 66 31.1 63.2 64 30.2 86.4 21 9.9 20.7 45 21.2 34.8 4.-0 - 4.5 55 25.9 89.1 22 10.4 96.8 40 18.9 39.6 55 25.9 60.7 5.0 - 5.5 13 6.1 95.2 4 1.9 98.7 40 18.9 58.5 38 17.9 78.6 6.0 - 6.5 7 3.3 98.5 1 0.5 99.2 30 14.2 72.7 29 13.7 92.3 7.0 & over 3 1.4 100.0 2 0.9 100.0 58 27.4 100.0 16 7.5 100.0 Unknown 8 missing 100.0 8 missing 100.0 8 missing 100.0 8 missing 100.0 Total 220 100.0 100.0 220 100.0 100.0 220 100.0 100.0 220 100.0 100.0 Note: Abs. = Absolute; Adj. = Adjusted; Cum. = Cumulative ^ i e t s were assessed according to Canada's Food Guide minimum recommendations: Milk and Milk Products = 4 servings, Meat and Alternates = 2 servings, Fruit and Vegetables = 4 servings, Breads and Cereals = 4 servings. 78 of servings recommended by Canada's Food Guide was obtained by 40 (18.9%) respondents; 172 (81.1%) respondents did not meet the minimum requirements. Table 4-24 shows that 35.8% of the respondents had diets with scores of less than 13. Table 4-24 Total Diet Score (Health Habits Questionnaire) Score 10.0 or less 10.5 - 13.0 13.5 - 15.5 16 Unknown Total Absolute Frequency Adjusted Freq.(%) 13 63 96 40 8 220 6.1 29.7 45.3 18.9 missing 100.0 Cumulative Freq.(%) 6.1 35.8 81.1 100.0 missing 100.0 Change in Diet Intake Two hundred and eighteen respondents reported making some change in their diet intake during pregnancy. Of those who reported some change, 204 (93.6%) increased their milk consumption, 182 (83.5%) increased their intake of fruit and vegetables, 106 (48.8%) increased their meat consumption, and 98 (45.4%) increased their intake of bread and cereals. Consumption of sweets was reported as decreased by 89 (41.0%). The frequency of reported changes in food consumption during pregnancy is illustrated in Table 4-25. Table 4-25 Change in Food Intake According to the Four Food Groups Fruit/ Bread/ Milk Meat Vegetables Cereal Sweets Frequencies Abs. Adj.% Abs. Adj.% Abs. Adj.% Abs. Adj.% Ads. Adj.% Change Increase 204 93.6 106 48.8 182 83.9 98 45.4 49 22.6 Decrease - - 11 5.1 2 0.9 14 6.5 89 41.0 No Change 14 6.4 100 46.1 33 15.2 104 48.1 79 36.4 Missing 2 missing 3 missing 3 missing 4 missing 3 missing Total 220 100.0 220 100.0 220 100.0 220 100.0 220 100.0 Note: Abs. = Absolute; Adj. = Adjusted. Influences on Diet Intake Two hundred and seventeen respondents identified factors which influenced their diet changes during pregnancy. As indicated in Table 4-26, own personal knowledge, books, magazines and pamphlets, change in appetite or craving, and doctor were most frequently reported. Table 4-26 Influences on Diet Intake a ] Influences Absolute Frequency Percent of Cases Own personal knowledge 145 66.8 Books/magazines/pamphlets 108 49.8 Change in appetite or craving 103 47.5 Doctor 92 42.4 Prenatal class 78 35.9 tommunity health nurse 55 25.3 Tolerance 54 24.9 Family member/friend 42 19.4 Nutritionist 23 10.6 T.V./radio 1 0.5 Unknown 3 1.4 aMore than one influence may be reported by the respondents. b n = 217. Summary Smoking before pregnancy was reported by 67 (30.5%) of the prenatal class attenders. Thirty-three (15.0%) respondents reported smoking during pregnancy. Of those that smoked during pregnancy 22 (10.0%) smoked 7 or more cigarettes per day. Thirty (90.9%) prenatal class attenders who smoked during pregnancy reported decreasing their smoking. Own personal knowledge, books, magazines and pamphlets, doctor, family member and friends were most commonly reported as influencing change in smoking during pregnancy. One hundred and twenty-eight (58.2%) prenatal class attenders drank alcohol before pregnancy. Alcohol intake during pregnancy was reported by 105 (47.7%) prenatal class attenders. Twenty (9.1%) of the attenders consumed 4 or more servings of alcohol per week during pregnancy and 4 (1.8%) consumed 7 or more servings. Wine was the most commonly reported form of alcohol consumed. Of those who consumed alcohol during pregnancy, 98.1% reported decreasing their alcohol intakes. Own personal knowledge, books, magazines and pamphlets, change in craving, and doctor, in this order, were the most frequently reported influences to change alcohol intake. Use of non-prescription drugs during pregnancy was reported by 195 (88.6%) respondents. Excluding prenatal vitamins, 88 (40.0%) respondents reported taking drugs during pregnancy and excluding a l l forms of vitamins (prenatal, multiple and single), 40 (18.2%) re-spondents reported taking non-prescription drugs. The most common drugs decreased during pregnancy were painkillers and antihistamines; whereas the most (Deration drugs increased were vitamins. Doctor, books, magazines and pamphlets, and own personal knowledge, in this order, were the influences most commonly reported to change drug intake during pregnancy. Consumption of tea, coffee or cola was reported by 195 (88.6%) prenatal class attenders. Two (1.0%) respondents reported intakes of 7 or more servings per day. Tea was most frequently consumed than either coffee or colas. Ninety (50.3%) of the 179 respondents who drank tea during pregnancy decreased their intakes, 133 (83.1%) of the 160 respondents who drank coffee decreased their intakes, and 68 (48.9%) of the 139 respondents who drank colas decreased their intake during pregnancy. Again, own personal knowledge, books, magazines and pamphlets, change in craving, and doctor, in this order, were most frequently reported as influencing change in tea, coffee, or cola intake during pregnancy. Diet intakes of 40 (18.9%) respondents met the itiinimum number of servings recommended by Canada's Food Guide. Seventy-eight (36.8%) of the study group met the recommended intake of milk, 138 (65.1%) met the recommended intake of breads and cereals, 168 (79.2%) met the recommended intake of fruit and vegetables, and 175 (82.5%) met the recommended intake of meat and alternates. A l l of the respondents reported making some change in their diet intakes during pregnancy and 204 (90%) increased their milk consumption. Gwn personal knowledge, books, maga-zines and pamphlets, change in appetite or craving, and doctor, in this order,were the most frequently reported influences to change diet during pregnancy. A profile summarizing the major health behaviors of prenatal class attenders is presented in Table 4-27. Table 4-27 83 H e a l t h Behavior P r o f i l e o f P r e n a t a l C l a s s Attenders Age: 27 years (mean). Country of O r i g i n : Canada (65.5%). Language Best Understood: E n g l i s h (89.1%). Annual Gross Family Income: ^$30,000 (50.7%) . E d u c a t i o n : Grade 12 o r f u r t h e r (88 .2%) . P a r i t y : Pr imipara (90.9%) Smoking: Before Pregnancy (30.5%) 1 - 6 c i g a r e t t e s / d a y ( 6.4%) 7 - 2 4 (15.5%) 25 + ( 8.2%) During Pregnancy (15.0%) 1 - 6 c i g a r e t t e s / d a y ( 4.5%) 7 - 2 4 ( 9.5%) 25 + ( 0.5%) A l c o h o l Before Pregnancy (58.2%) O c c a s i o n a l (11.4%) Intake: 1 - 3 drinks/week (18.6%) 4 o r more (28.2%) During Pregnancy O c c a s i o n a l (17.3%) 1 - 3 drinks/week (19.5%) 4 o r more ( 9.1%) N o n - p r e s c r i p t i o n M e d i c a t i o n Use: Medicat ions other than p r e n a t a l v i tamins (40.0% o r any vi tamins (18.2% Tea, C o f f e e , C o l a Intake: During Pregnancy (88.6% 7 or more servings per day ( 1.0% D i e t Intake : Meeting Canada's Food Guide Requirements (18.9% M i l k 4 servings (36.8% Meat 2 servings (82.5% F r u i t and Vegetables 4 serv ings (79.2% Breads and Cereals 4 serv ings (65.1% Overall Health Behaviors of Prenatal Class Attenders 84 Sixty-four (29.1%) respondents reported they did not smoke or drink alcohol before they became pregnant. At the tLme of completing the Prenatal Assessment Form, 20 (9.1%) respondents reported that they did not smoke or drink alcohol and analysis indicated their diets met Canada's Food Guide minimum serving requirements. On completion of the Health Habits Questionnaire, 18 (8.2%) attenders did not smoke or drink alcohol, and analysis indicated their diets met Canada's Food Guide ndnimum serving requirements. In response to the question of "How much has the information provided by each of the following influenced your health habits during pregnancy?", the helpful sources of information were ident-ified as books, magazines and pamphlets (86.8%), doctor (82.3%), family member or friend (63.5%), community health nurse (56.4%), and prenatal class (52.7%). The most preferred sources of prenatal information on health behaviors were doctor (36%), books, magazines and pamphlets (26%), and prenatal classes (21%). Relationship Between Demographic Characteristics and Health Behaviors  Age The mean age of the sample was 27 years. Smoking was found to be related to the age of the prenatal class attenders. The pregnant women who smoked during pregnancy (N = 33, M = 25.42) were significantly younger than those who did not smoke (N = 187, M = 27.45), t (218) = -2.77, £<.01. Reported alcohol drinking was related to age. The pregnant women who drank alcohol during pregnancy (N = 105, M = 28.05) were older than those who did not drink (N = 113, M = 26.78), t (216) = 209, p_<.05. There was no significant difference in the ages of prenatal class attenders whose diets met the Canada Food Guide recommendation (N = 40, M = 27.65) and the attenders whose diets did not (N = 180, M = 27.34), t (218) = 0.39, p < .1. Country of Origin Smoking, alcohol intake and diet were found to be associated with country of origin. As can be seen from Table 4-28, more prenatal class attenders who smoked during pregnancy were born in Canada than in other countries. A greater proportion of pregnant women born in Canada consumed alcohol during pregnancy and ate diets according to Canada's Food Guide, than pregnant women born in other countries. Annual Gross Family Income Health behaviors were not statistically associated with annual gross family income. Although 64.5% of smokers had incomes below $30,000, the relationship between smoking and income was not statis-tically significant. The relationships between annual gross family income and alcohol intake or diet were also not significant as is indicated on Table 4-29. Table 4-28 Country of Origin by Health Behaviors Country of Origin Health Behaviors Canada Other than Canada Smoking 29 Non-smoking 115 Alcohol user 84 Alcohol abstainer 59 Diet meeting CFGa 33 Diet not meeting CFG3 111 4 70 20 53 7 67 Significance % 2 = 7.153 df = 1 **p < .01 = 17.78 df = 1 ***p < .001 % 2 = 5.045 df = 1 *£ < .05 CFG = Canada's Food Guide Table 4-29 Annual Gross Family Income by Health Behaviors Health Behaviors Smoking 20 Non-smoking 85 Alcohol user 43 Alcohol abstainer 61 Diet meeting CFG21 17 Diet not meeting CFG 88 Annual Gross Family Income  < $30,000 >$30,000 Significance 11 91 56 45 21 81 %• = 2.164 df = 1 E < .5 % 2 = 3.534 df = 1 £ < .1 % 2 = 0.406 df = 1 £ < 1.0 aCFG = Canada's Food Guide Education Smoking was significantly related to education as can be seen from Table 4-30. A greater proportion of pregnant women who did not smoke during pregnancy had education beyond Grade 12 and a greater proportion of smokers had Grade 12 or less education. Diet intake was statistically related to education. A greater proportion of prenatal class attenders whose diets met the Canada Food Guides recommendations had education beyond Grade 12. Alcohol intake was not significantly related to education. Table 4-30 Educational Level by Health Behaviors Educational Level Health Behaviors Grade 12 or less Post Secondary Significance Smoking Non-smoking Alcohol user Alcohol abstainer Diet meeting CFG* Diet not meeting CFG' 24 65 39 49 10 79 9 % 2 = 15.055 121 df = 1 ***p < .001 66 % 2 = 0.726 63 df = 1 £ < .5 30 % 2 = 4.200 100 df = 1 < .05 aCFG = Canada's Food Guide Summary Prenatal class attenders who smoked during pregnancy were younger and had less education than non-smokers. They were also more likely to have been born in Canada. Prenatal class attenders who consumed alcohol during pregnancy tended to be older than those that did not drink and were also more likely to have been born in Canada. Prenatal class attenders whose diets did not meet the Canada's Food Guide recommendations tended to have less education than the women with adequate diets and Canada was less likely to have been their country of origin. 8 9 CHAPTER V OTHER FINDINGS Overview The other f i n d i n g s of t h i s study are presented i n two s e c t i o n s . The f i r s t s e c t i o n summarizes the f i n d i n g s of the p r e n a t a l c l a s s r e g i s t r a n t s on the w a i t i n g l i s t , and second s e c t i o n d e s c r i b e s the comments and recommendations made by p r e n a t a l c l a s s at tenders and r e g i s t r a n t s . Resul ts of P r e n a t a l C l a s s Regis t rants on the W a i t i n g L i s t Pregnant women on the w a i t i n g l i s t f o r p r e n a t a l c l a s s e s w i t h the Vancouver H e a l t h Department were sampled between the end o f March to the end of June 1983. Although 171 women were on the w a i t i n g l i s t a t some time d u r i n g t h i s p e r i o d , the m a j o r i t y of the women d i d not meet the study c r i t e r i a o r had commenced p r e n a t a l c l a s s e s and were sub-sequently no longer on the w a i t i n g l i s t . T h i r t y - s i x pregnant women on the p r e n a t a l c l a s s w a i t i n g l i s t met the study c r i t e r i a and were sent a H e a l t h Habi ts Q u e s t i o n n a i r e , c o v e r i n g l e t t e r and a stamped, s e l f - a d d r e s s e d envelope. Nineteen women re turned a completed H e a l t h Habi ts Quest ionnaire g i v i n g a response r a t e o f 52.8%. From the f o l l o w - u p phone c a l l s , i t was d i s c o v e r e d t h a t 4 women were a l r e a d y a t t e n d i n g p r e n a t a l c l a s s e s , 1 d i d n ' t understand E n g l i s h , 1 mai led the completed q u e s t i o n n a i r e , but the i n v e s t i g a t o r never r e c e i v e d i t , and 2 had moved and had subsequently not r e c e i v e d the q u e s t i o n n a i r e . 90 Since the sample size was small the results unfortunately cannot be statistically compared with the major study group. The findings are, however, summarized and their profile is presented in Table 5-1. The average age of the prenatal class registrants on the waiting l i s t was 28 years ranging between 20 and 38 years. Over half of the participants (52.6%) were born in Canada and English was noted as the most understood language (68.4%). The most common range of gross annual family income was between $10,000 and $30,000 (70.6%) with 17.6% of the registrants below and 11.8% above this income range. Most of the registrants (89.5%) had Grade 12 or higher education with 57.9% having attained further education. Ten of the waiting l i s t registrants were expecting their f i r s t baby. Before pregnancy, smoking was reported by 5 (26.3%) women — 4 (21.1%) of whom smoked 10 or more cigarettes per day. Alcohol con-sumption was reported by 6 (31.6%) women — 1 (5.3%) of whom consumed more than 6 servings of alcohol per week. During pregnancy, 3 (15.8%) women smoked, with 1 woman smoking 10 or more cigarettes per day. Consumption of alcohol was reported by 5 (26.3%) of the registrants with none of them reporting intakes greater than 6 servings of alcohol per week. Non-prescription drugs other than vitamins were taken by 2 (15.8%) people and tea, coffee and colas were consumed by 16 (84.2%) of the sample. Only 1 woman had tea, coffee, or cola intakes greater than 7 servings per day. Diets which met Canada's Food Guide minimum reccmmendations were reported by 2 (11.8%) women. A majority of the women (70.6%) did not Table 5-1 H e a l t h Behavior P r o f i l e of Regis t rants on the W a i t i n g L i s t Age: 28 years (mean). Country o f O r i g i n : Canada (52.6%). Language Best Understood: E n g l i s h (68.4%) . Annual Gross Family Income:£ $30,000 (88.2%). E d u c a t i o n : Grade 12 o r fur ther (89 .5%) . P a r i t y : P r i m i p a r a (52.6%). Smoking: Before Pregnancy (26. 3%) 1 - 6 c i g a r e t t e s / d a y ( 5.3%) 7 - 2 4 (21.1%) 25 + '( 0.0%) During Pregnancy (15. 8%) 1 - 6 c i g a r e t t e s / d a y (10.5%) 7 - 2 4 ( 5.3%) 25 + ( 0.0%) A l c o h o l Before Pregnancy (31. 6%) O c c a s i o n a l (10.5%) Intake 1 - 3 drinks/week (10.5%) 4 o r more (10.5%) During Pregnancy (26. 3%) O c c a s i o n a l (15.8%) 1 - 3 drinks/week (10.5%) 4 o r more ( 0.0%) N o n - p r e s c r i p t i o n M e d i c a t i o n Use: Medicat ions other than p r e n a t a l v i tamins (47.3% o r any vi tamins . (15.8% Tea, C o f f e e , C o l a Intake: During Pregnancy (84.2% 7 o r more serv ings per day ( 5.3% D i e t Intake: Meeting Canada's Food Guide Requirements (11.8% M i l k 4 serv ings (29.4% Meat 2 servings (64.7% F r u i t and Vegetables 4 servings (88.2% Bread and Cereals 4 servings (58.8% 92 have adequate intakes of milk and milk products even though 89.5% of the sample reported to have increased their milk intakes during pregnancy. A l l the women reported making some change in their diet and a l l of those who smoked or used alcohol reported decreasing their smoking and alcohol intake during pregnancy. Decreases in non-prescription drugs and tea, coffee and cola intakes were also reported. These changes were reported to have been influenced by one's own personal knowledge, doctor, books, magazines and pamphlets. Overall, the health behaviors of waiting l i s t registrants were also identified. Before pregnancy, 10 (52.6%) subjects did not smoke nor drink. During pregnancy only 2 (10.5%) did not smoke nor drink alcohol and also reported diets meeting Canada's Food Guide minimum requirements. Comments and Reccmmendations for the Improvement of Prenatal Education The comments and recommendations are described in two sections — those made by the prenatal class attenders and those made by the pregnant women on the waiting l i s t . Recommendations of Prenatal Class Attenders The five main recommendations made by prenatal class attenders were: 1. Prenatal classes should be offered earlier in pregnancy. Thirty-five respondents suggested that both early bird classes as well 93 as the prenatal class series start earlier in pregnancy. In order to improve health habits which may potentially affect the outcome of pregnancy, the information must be obtained as soon as possible. 2. Prenatal education should emphasize and provide more information on the effects of smoking, alcohol, drugs, exercise, and nutrition. Twenty respondents indicated the need for more information on these topics either through prenatal classes, nutritionists, mass media and/or doctor's offices. Specialized classes such as quit-smoking classes or exercise classes were also suggested. 3. More prenatal classes should be offered. Ten respondents sug-gested that more prenatal classes should be available to the .' '.public and that a prenatal class series consist of more classes. 4. More books, magazines and pamphlets on pregnancy and prenatal health should also be available to the public. Ten respondents indicated the need for more handouts, pamphlets or other reading materials be accessible to pregnant women early in pregnancy. 5. Prenatal education should start pre-conceptually. Nine respond-ents indicated a need for more information to be offered pre-conceptually in order to prepare for pregnancy. Pre-conception classes, T.V., or public advertisements and high school classes were suggested as ways this information could be transmitted. Prenatal class attenders also recommended specific improvements f o r e x i s t i n g p r e n a t a l c l a s s e s . The suggestions o f nineteen respondents i n c l u d e d more group d i s c u s s i o n s r a t h e r than l e c t u r e , more f requent use o f updated a u d i o - v i s u a l s and reading m a t e r i a l s , improvements i n c l a s s p r e s e n t a t i o n s and smaller and shor ter c l a s s e s . P o s i t i v e comments on c u r r e n t p r e n a t a l educat ion — p a r t i c u l a r l y p r e n a t a l c l a s s e s — were made by t w e n t y - f i v e respondents . These comments i n d i c a t e d a general s a t i s f a c t i o n w i t h e x i s t i n g p r e n a t a l c l a s s e s and t h a t the c l a s s e s were v e r y h e l p f u l . A d d i t i o n a l suggestions f o r f u t u r e p r e n a t a l educat ion i n c l u d e d p r e n a t a l c l a s s e s o f f e r e d through a knowledge network by T . V . , p r e n a t a l c l a s s e s f o r s i n g l e women, Saturday p r e n a t a l c l a s s e s and f o r p u b l i c promotion of p r e n a t a l c l a s s e s . Recommendations o f Pregnant Women on the W a i t i n g L i s t The major recommendation made by p r e n a t a l c l a s s r e g i s t r a n t s on the w a i t i n g l i s t was to increase the a v a i l a b i l i t y of p r e n a t a l c l a s s e s t o expectant couples , regardless of t h e i r p a r i t y . Other recommend-a t i o n s i n c l u d e d p r o v i d i n g more educat ion on smoking, a l c o h o l , drugs, and n u t r i t i o n d u r i n g pregnancy; more T . V . programs on p r e n a t a l h e a l t h ; a P r e n a t a l H o t l i n e t o answer quest ions on d i e t , e x e r c i s e and other concerns t h a t pregnant women may have, e s p e c i a l l y i n the e a r l y months. Comments t h a t Baby 's Bes t Chance and P e r i n a t a l F i t n e s s were v e r y h e l p f u l and suggestions f o r doctors to inform and advise women t o at tend p r e n a t a l c l a s s e s were a l s o made. 95 CHAPTER VI DISCUSSION OF THE RESULTS, CONCLUSION, IMPLICATIONS AND RECOVMENDATTONS FOR FURTHER RESEARCH Overview The results of this study are discussed in four major sections. Section one discusses the health behaviors of the participants in the study, and Section two discusses the influences to change health behaviors during pregnancy. Section three discusses the relationship of demographic characteristics and specific health behaviors. Major comments and recommendations made by the study participants for future prenatal education are briefly presented and discussed in Section four. A conclusion, implications of the study and recommendations for further research conclude the presentation of the study. Discussion of the Results Health Behaviors of the Participants The reports from pregnant women on smoking, the intake of alcohol, non-prescription drugs, tea, coffee and cola, and their diets were examined. These findings, however, must be interpreted acknowledging the fact that self-reports of such behaviors generally tend to be under estimated and rarely tend to be over estimated,(Landesman-Dwyer, 1982). That is; the 15% of prenatal class attenders who 96 reported smoking during pregnancy should be interpreted as the ininimal number known to smoke during pregnancy. Similarly, with diet, consid-ering that people tend to over estimate small amounts of food consumed and under estimate large quantities (Stunkard and Waxman, 1981), the number of women with diet scores of 16 probably reflects the maximum number of women known to have adequate food intake during pregnancy. This study's finding of a 31% rate of women who smoked before pregnancy is lower than the 38% national rate of women smokers between the ages of 15 and 44 years (Health and Welfare Canada, 1981). However, the 15% rate of respondents who smoked during pregnancy is the same as the findings of another Vancouver study by Bradley, Ross and Warnyca (1978). It is also important to note that the number of cigarettes smoked during pregnancy decreased as did the number of smokers. The number of smokers who smoked 7 or more cigarettes during pregnancy was half the number who smoked that amount before pregnancy. This study's findings on smoking indicate that at least 15% of pregnant women smoked during pregnancy and at least 10% smoked 7 or more cigarettes per day — an amount which research has demonstrated may be harmful to the fetus. The rate of respondents who consumed alcohol before pregnancy (58%) was 5% lower than the rate of alcohol drinkers found in the Canada Health Survey (1978-1979) for women between the ages of 15 and 44 years (Health and Welfare Canada, 1981). The rate of respond-ents who reported drinking alcohol during pregnancy (48%) was similar to the 1978 study by Bradley, Ross and Warnyca which found that 46% of pregnant women consumed alcohol. The consumption of alcohol reported later in pregnancy (HHQ) was more than the alcohol consumption reported earlier in pregnancy (PAF). This finding was also observed by Little, Mandell and Schultz (1976) and may be attributed to the presence of nausea which frequently accompanies early pregnancy or to a discrepancy in reporting. The present study found that 48% of prenatal class attenders consumed alcohol during pregnancy; 9% of the respondents drank 4 or more servings of alcohol per week — an amount research has indicated may be potentially harmful to the fetus. Two percent of the respondents consumed an amount which is reported by several studies to have adverse effects on pregnancy. Non-prescription drugs other than prenatal vitamins, were con-sumed by 40% of the study group during pregnancy. When a l l forms of vitamins were excluded from the drug category, 18% of the women took non-prescription drugs during pregnancy — with painkillers and anti-nauseants being reported with the highest frequency of 6% and 5% respectively. This relatively low consumption rate of drugs other than vitamins may reflect the public's general awareness of the potential hazards of drug use during pregnancy or the under reporting of drugs consumed. The majority of respondents consumed tea, coffee or colas during pregnancy. The finding of 48% of women who drank coffee in this study during pregnancy compares, to 43% reported by Hingson et al . (1982). However, only a small proportion of participants (1%) reported intakes of 7 or more servings per day — the amount which research has demonstrated may have harmful effects during pregnancy. Diet intake was assessed using two one-day diet records — one 98 early in pregnancy and the other later in pregnancy. The results from the two records were found to be consistent. Based on the data from the Prenatal Assessment Form (PAF) and the Health Habits Questionnaire (HHQ), 71% (PAF) and 63% (HHQ) of the women had less than 4 servings of milk; 21% (PAF) and 17% (HHQ) had less than 2 servings of meat; 19% (PAF) and 21% (HHQ) had less than 4 servings of fruit and vegetables; and 36% (PAF) and 35% (HHQ) had less than 4 servings of bread and cereals. These diet results may be compared with the findings of Latchford et al. (1970) who reported that 85% of the prenatal class women had less than 4 servings of milk, 5% had less than 2 servings of meat, and 81% had less than 4 servings of breads and cereals. Servings of fruit and vegetables cannot be compared as the measures used were different from those used in this study. Nutrition Canada (1976) found that the majority of pregnant women had inadequate servings of milk and breads and cereals; results which are also similar to the findings of this study. The difference in diet intake between the present study's find-ings and Latchford et al.'s (1970) may be a reflection of a change in current diet patterns of the general public as compared to those existing 13 years ago. Recently, with the discovery of the harmful effects of cholesterol and the benefits from fiber intake, there has been a greater emphasis on educating the public to decrease intakes• of meat and to increase intakes of breads and cereals, and fruit and vegetables. The high cost of meat may be another reason for its decrease consumption. Total diet scores of less than 16, obtained by prenatal class at tenders on the P r e n a t a l Assessment Form (85.5%) were c o n s i s t e n t w i t h scores repor ted on the H e a l t h Habi ts Quest ionnaire (81.1%). L a t c h f o r d e t a l . (1970) a l s o found t h a t 85% o f pregnant women obta ined inadequate d i e t s c o r e s . The f i n d i n g s of the h e a l t h behaviors o f pregnant women on the w a i t i n g l i s t are r e l a t i v e l y s i m i l a r t o t h a t found f o r p r e n a t a l c l a s s a t t e n d e r s . That i s ; 16% smoked, 26% consumed a l c o h o l , 16% used n o n - p r e s c r i p t i o n drugs other than v i t a m i n s , 84% drank t e a , c o f f e e and c o l a s , and 88% had l e s s than adequate d i e t s d u r i n g pregnancy. However, because o f the s m a l l sample s i z e , no d e f i n i t e comparisons o r conclusions may be based on these f i n d i n g s . Inf luences t o Change H e a l t h Behaviors During Pregnancy T h i s s t u d y ' s f i n d i n g s o f 91% o f the smokers who decreased t h e i r smoking d u r i n g pregnancy i s much h i g h e r than the 60% B a r i c and Mac-Carthur (1977) reported i n t h e i r study of pregnant B r i t i s h women. T h i s d i f f e r e n c e c o u l d be a t t r i b u t e d t o c h a r a c t e r i s t i c s o f the study populat ions — as the present study o n l y i n c l u d e d women a t tending p r e n a t a l c l a s s e s . As shown i n Table 6-1, the major i n f l u e n c e s to change smoking were found to be own p e r s o n a l knowledge, books, magazines and pamphlets, doc tor , and f a m i l y member o r f r i e n d s . S tudies by Gardiner e t a l . (1981) and B a r i c and MacCarthur (1977) both r e p o r t e d mass media as the g r e a t e s t i n f l u e n c e to change smoking. Mass media (98%), f r i e n d or neighbor (63%), and h e a l t h p r o f e s s i o n a l s (22%) were i d e n t i f i e d by B a r i c and MacCarthur as the i n f l u e n c e s to change smoking. 100 Table 6-1 Frequency of Reported Influences to Change Health Behaviors Health Behaviors Influences Smoking Alcohol Tea/Coffee/Cola Diet (%)a (%)b (%)C (%)d Own personal knowledge 86.5 89.9 69.9 66.8 Books/magazines/pamphlets 45.9 43.1 41.6 49.8 Change in craving 24.3 35.8 38.2 47.5 Doctor 45.9 22.0 20.2 42.4 Family member/friend 29.7 19.3 16.8 19.4 Prenatal class 21.6 16.5 16.2 35.9 Community health nurse 13.5 11.9 11.0 25.3 Social pressure 18.9 5.5 1.2 0.0 T.V./radio 0.0 7.3 5.2 1.0 Stress 2.7 2.8 3.5 0.0 Nutritionist 0.0 0.0 0.0 10.6 Note: More than one influence may be reported by respondents. an = 37; b n = 109; °n = 173; dn = 217. The majority of the respondents in this study (98%) reported decreasing their alcohol intake during pregnancy. This rate of decrease is substant-ially higher than the findings by Baric and MacCarthur (50%) — and again may be attributed to the difference in population characteristics. As shown in Table 6-1, the major influences to change alcohol consumption during pregnancy are own personal knowledge, reading materials, and craving. These too, are comparable with Baric and MacCarthur's (1977) findings of 'just knew' (74%) and mass media (.15%). Few women in this study reported taking non-prescription drugs 101 other than vitamins during pregnancy and doctors were the major influence to increase drugs. These findings are supported by Baric and MacCarthur (1976) who reported 98% women took more care than usual with drugs during pregnancy and did not take any medications at a l l without consulting the doctor. The degree of change in tea, coffee or cola consumption during pregnancy varied with the beverage consumed — that is; 65% of tea drinkers, 84% of coffee drinkers and 49% of cola drinkers changed their consumption. Own personal knowledge, books, magazines and pamphlets, and craving were reported to have influenced the change. Hook (1978) found nausea to be the greatest influence in decreasing coffee consump-tion during pregnancy. He suggested that aversions to foods and other, items during pregnancy might be a consequence, of the presence of the feto-protective mechanism to teratogenic agents. It is interesting to note from the results of the present study, that coffee, which contains more caffeine than tea or cola had a higher rate of decreased consump-tion during pregnancy, Most respondents made some change in their diet intake during pregnancy, with 90% increasing their milk consumption. It is noteworthy that even though most women increased their milk intake, only 37% had at least 4 servings per day as recommended by Canada's Food Guide. Craving was reported by Hook (1978) to be responsible for in-creased milk consumption during pregnancy. Although change in craving was one of the major influences to change diet intake from the present study's findings, i t was not the major one. As can be seen in Table 6-1, there are many influences reported by at least 25% of the total sample. Prenatal class and community health nurse-were also identified as major 102 influences to change diet. However, they were reported less frequently than own personal knowledge, books, magazines and pamphlets, change in appetite or craving, and doctors. The study by Baric and MacCarthur (1977) found own personal knowledge and mass media to be the greatest influences to change diet — findings which are similar to the major influences of the present study. Overall, the majority of pregnant women make some change in their health habits during pregnancy. The influence consistently reported with highest frequency across a l l the health behaviors by the respondents was own personal knowledge. This finding may be explained by the fact that the state of pregnancy itself is a motivator to change health behaviors. "Because i t may harm the baby" may be the greatest motivating factor to change behavior during pregnancy. Duvall (1971) describes "acquiring knowledge about pregnancy" as a developmental task for expectant mothers. Own personal knowledge may reflect the values or beliefs that one has developed by in - . ; i tegrating the information from various sources. Books, magazines and pamphlets is the second most frequently re-ported influence by prenatal class attenders. This may be a direct result of the literature distributed in prenatal classes — especially Baby's Best Chance, a parent's manual on perinatal health published by the B.C. Ministry of Health (.1979) . An increasing number of books and magazines on pregnancy and childbirth have also been published in the last ten years and are available in local bookstores and libraries. Change in craving and doctors are the next most frequently re-ported influences to change health behaviors. As was discussed pre-viously, other studies have similarily found change in craving to 103 affect health behaviors during pregnancy. Is this nature's way of protecting the fetus? Since doctors are the health professionals who women usually see regularily and frequently during pregnancy i t is not unusual that doctors were identified as influences. What is surprising, though,, is the low reported frequency of the influence of doctor on alcohol change and tea, coffee and cola change. Are doctors not as influential or do they not give out as much advice with respect to these health behaviors? The findings of this study can be easily explained in terms of the personal choice behavior model. The personal choice behavior model explains that the change in health behaviors of the study group has occurred as a result of the presence of a high degree of perception of a threat (own personal knowledge), facilitation from the environment (books, magazines and pamphlets, doctor, etc.), loss of psychological utility (nausea, change in craving) and some evidence of motivation to change (attend prenatal classes). In terms of the health belief model, own personal knowledge represents the individual's perceptions of susceptibility to possible harmful effects, which is reinforced by the other influences ident-ified (e.g., doctor, books magazines, pamphlets, etc.). rjemographic Characteristics and Specific Health Behaviors This study's findings of a positive relationship between alcohol intake and education, and a negative relationship between smoking and education are substantiated by the Canada Health Survey (Health and 104 Welfare Canada, 1981) and the study by Kuzma and Kissinger (1981). Kuzma and Kissinger attributed this finding to well educated women being less aware of (or perceptive to) the possible adverse effects on pregnancy of drinking alcohol than they were of smoking cigarettes. Although literature discouraging heavy drinking during pregnancy has existed for some time, l i t t l e information on occasional or moderate drinking during pregnancy was available until recently — and even now the effects of minimal drinking are not fully understood. An interesting, but not surprising relationship between Canadian born women and smoking or alcohol use suggested that these behaviors are culturally influenced. Kuzma and Kissinger (1981) similarly found the lowest percentage of non-drinkers to be Whites. Although health care professionals often regard immigrants as having poorer health habits, the opposite holds true for smoking and alcohol intake. Encouraging immigrants to adopt Canadian social behaviors would be more harmful than helpful with respect to these specific health behaviors. A greater number of participants born in Canada, however, had diets meeting Canada's Food Guide as did those individuals with higher education. This perhaps reflects that those women with higher education or born in Canada may be more aware of nutrition during pregnancy and/or are more familiar with Canada's Food Guide. A negative relationship between age and smoking and a positive relationship between age and alcohol intake was identified in this study. Since cigarettes can be purchased at an earlier age than alcohol, smoking habits may be established at an earlier age than drinking habits. The observation that alcohol intake during pregnancy 105 is more common in the older women is a finding similar to that observed by others (Kuzma and Kissinger, 1981; Streissguth, Barr, Martin and Herman, 1980; Kaminski, Franc, LeBouvier, duMazaubrun and Rumeau-Roquette, 1981). Study Participants' Comments and Reaanmendations The major recamendation for future prenatal education made by the study participants was for prenatal classes to be offered earlier in pregnancy. Information on the possible adverse effects of health behaviors during pregnancy should be presented early in pregnancy by doctors and by prenatal classes. Many of the participants expressed frustration when this information was offered late in pregnancy as i t "was too late". The study group also urged that there be more prenatal education on the effects of smoking, alcohol, drugs and diet during pregnancy either through prenatal classes, doctors, reading materials or mass media. One respondent remarked that even though pregnant women may know smoking is associated with smaller babies, they don't know the fu l l implication of i t — and would prefer to give birth to a smaller baby! Recommendations for more prenatal classes and for prenatal education to be offered preconceptually were also made by the part-icipants. These comments may reflect their awareness of the importance of prenatal health during pregnancy as well as preconceptually. More reading materials in the forms of available books, magazines or pamphlets was also suggested by a number of respondents. This may 106 be attributed to the fact that the majority of the participants in this study had attained at least a Grade 12 education. Even though there are many books and magazines available on pregnancy from book-stores, the credibility of the information therein is often questioned. Reading materials provided by the Ministry of Health or a reputable health organization are usually regarded as providing accurate and current information. Conclusion The purpose of this study was to provide a descriptive overview of prenatal class attenders and selected health behaviors. Prenatal class attenders studied ranged from ages 18 to 40 years with 27 years being the average age. The majority of the women were born in Canada and English was their best understood language. Half of the prenatal class attenders had annual gross family incomes of less than $30,000. Smoking was associated with respondents who were younger, born in Canada, and had lower education. Alcohol consumption was associ-ated with women who were older, were born in Canada, and had higher education. Adequate diet intake was associated with women who were born in Canada and had higher education levels. Results of the study also revealed that during pregnancy, 15% of the women smoked, 48% of the women drank alcohol, 18% of the women took non-prescription drugs other than vitamins, 89% of the women drank tea, coffee or colas, and 81% of the women had diets that did 107 not meet Canada's Food Guide minimum recommendations. These results may be an under estimation of the proportion of the sample with these behaviors as self-reports often tend to under estimate behaviors. The majority of pregnant women reported making changes in health behaviors during pregnancy. Own personal knowledge, books, magazines and pamphlets, change in craving and doctors were reported as influencing these changes. In conclusion, the findings of 8% of the pregnant women having good health behaviors that do not warrant some improvement, suggests there is a continuing need for prenatal education. Prenatal classes do not teach the "already converted"; ie., those who have healthy lifestyles already. Implications of the Study The reported findings of this study have the following implications: 1. Health education on smoking, alcohol, non-prescription drugs, caffeine and diet should be offered to the general public — especially young adults in order to prevent poor health habits from becoming established. Since smoking is associated with a younger age group, anti-smoking education should be provided in high school. Health education should, in addition to information, also include ways which would help individuals change their habits. Promotion of non-alcoholic beverages as alternatives to alcohol use is one example. 108 2. Health education on the relationships of health behaviors and and pregnancy outcome should be offered prior to or early in pregnancy since this study indicated that 35% of the respondents smoked and 50% drank alcohol before pregnancy (and probably during the early weeks of pregnancy). Since own personal knowledge was the most frequently reported influence to change health behaviors, consistent information must be provided by various sources, that is, doctors, preconception and prenatal classes, reading materials and community health nurses. 3. Books, magazines and/or pamphlets (on pregnancy and the effects of smoking and intake of alcohol, non-prescription drugs, caffeine and diet) should continually be developed and widely distributed by the Ministry of Health or other health care orgnahizations such as the Vancouver Health Department. Since books, magazines and pamphlets were identified as one of the major influences to change health behaviors, this method of education would not only be cost effective, but also be most influential for this population. 4. Since doctors were also reported as a major influence on the health practices of pregnant women, they should take advantage of their potential to influence and educate their clients to follow good health habits — especially during pregnancy. 5. Nursing and medical students should be provided with current research findings and information on health behaviors during 109 pregnancy. Effective teaching methods to disseminate the information and influence behaviors should also be included in their curriculum. 6. The study's findings indicated that most of the participants had health behaviors which could lend themselves to improvement. Pregnant women who register for prenatal classes should there-fore not be neglected by health educators in an effort to change "high-risk groups" who are probably less motivated to change. 7. Existing prenatal classes should be improved considering the recommendations made by the study group. Nurses who teach prenatal classes should be frequently updated on the most recent research findings related to health behaviors during pregnancy and on effective teaching methods with which to inform and influence prenatal class attenders. 8. New and innovative methods for influencing health behaviors should be continually tried by health educators and evaluated for effectiveness. Pacommendations for Further Research Based on the findings of this study, the following recommend-ations for further research are suggested: 1. A prospective study should be conducted to investigate the changes in health behaviors before, during and following pregnancy on a longitudinal basis. Do health behaviors follow-110 ing pregnancy revert back to what they were before pregnancy? 2. Since the purpose of this study was to survey and identify the health behaviors of pregnant women, specific numbers of cigar-ettes smoked, and specific intakes of alcohol, drugs, caffeine or nutrients were beyond its scope. A qualitative study using interviews would provide an indepth investigation of individual health behaviors, the degree to which they are practiced, and the major factors influencing change. Specific consumption levels, overdosages of drugs such as vitamins and degrees of change in health behaviors could be identified. Pregnant women who are "at risk" because of their health behaviors could perhaps provide insights as to what influences them to change. 3. Development of a valid, reliable and time efficient method for assessing diets of pregnant women remains a continuing challenge to nutrition researchers. Additional research of Canada's Food Guide and its validity as a guide for adequate food intake is desperately needed. Perhaps an alternate food guide which is more compatible with the usual food consumption patterns of Canadian women could be developed. 4. Further research to investigate the foundation of "own personal knowledge" is warranted. Can the sources from which one's own personal knowledge is developed be identified, or is i t the integration of information from many sources? 5. Since the scope of this study was prenatal class registrants, I l l comparison of the findings with other pregnant women was not possible. A comparison study of the health behaviors of prenatal class attenders and non-attenders would identify whether prenatal class attenders had significantly better behaviors than the average population of pregnant women. 6. Further research to compare pregnant wamens, knowledge of health behaviors to those which are actually practiced should also be undertaken. 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Antenatal exposure to doxylamine succinate and dicyclomine (Bendectin) in relation to congenital malformations, perinatal mortality rate, birth weight and intelligence quotient score. American Journal of Obstetrics and Gynecology, 128, 480-485. Silva, V., Laranjeira, R., Dolnikoff, M., Grinfeld, H., Masur, J. (1981). Alcohol consumption during pregnancy and newborn outcomes: a study in Brazil. Neurobehavioral Toxicology and Teratology, .3, 169-172. Simpson, W. (1957) . A preliminary report of cigarette smoking and the incidence of prematurity. American Journal of Obstetrics and  Gynecology, 73, 808-815. Slone, D., Siskind, V., Heinonen, O., Monson, R., Kaufman, D,, & .Shapiro, S. (1977). Antenatal exposure to phenothiazines in re-lation to congenital malformations, perinatal mortality rate, birth weight and intelligence quotient score. American Journal of  Obstetrics and Gynecology, 128, 486-488. Smithells, R., & Sheppard, S. (1978). Teratogencity testing in humans; a method demonstrating the safety of Bendectin. Teratology, 17, 31-35. 121 Smithells, R., Ankers, C, Carver, M., Lennon, D., Schorah, C., & Sheppard, S. (1977). Maternal nutrition in early pregnancy. British Journal of Nutrition, 38, 497-506. Sokol, R. (1981). Alcohol and abnormal outcomes of pregnancy. Canadian Medical Journal, 125, 143-148. Sokol, R., Miller, S., & Reed, G. (1980). Alcohol abuse during preg-nancy: an epidemiologic study. Alcoholism (NY) 4., 135-145. Stein, Z., & Susser, M. (1975a). The Dutch famine, 1944-45, and the reproductive process. I. Effects on six indices at birth. Pediatric Research, % 70-76. Stein, Z., & Susser, M. (1975b). The Dutch famine, 1944-45, and the reproductive process. II. Interreactions of caloric rations and six indices at birth. Pediatric Research, 9_, 76-83. Strange, L., Carlstrom, K., & Eriksson, M. (1978). Hypervitaminosis A in early human pregnancy and malformations of the central nervous system. Acta Obstetricia et Gynecologica Scandinavica, 57, 289-291. Statistics Canada (1981). Census of Canada. Census metropolitan areas and census agglomerations with components. Population, occupied  private dwellings, private households, census families in private  households (Catalogue No. 95-903). Ottawa: Ministry of Supply and Services. Streiff, R., & Little, B. (1967). Folic acid deficiency in pregnancy. New England Journal of Medicine, 276(14), 776-779. S t r e i s s g u t h , A . , B a r r , H . , M a r t i n , D . , & Herman, C . (1980) . E f f e c t s o f maternal a l c o h o l , n i c o t i n e and c a f f e i n e use d u r i n g pregnancy on i n f a n t mental and motor development a t e i g h t months. A l c o h o l i s m : C l i n i c a l and Experimental Research, £ ( 2 ) , 152 -164 . S t r e i s s g u t h , A . , M a r t i n , D . , M a r t i n , J . , & B a r r , H . (1981) . The S e a t t l e l o n g i t u d i n a l p r o s p e c t i v e study on a l c o h o l and pregnancy. Neurobehavioral T o x i c o l o g y and Tera to logy , 3 , 2 2 3 - 2 3 3 . Stunkard, A . , & Waxman, M. (1981) . Accuracy o f s e l f - r e p o r t s of food i n t a k e . J o u r n a l of the American D i e t e t i c A s s o c i a t i o n , 79_(5), 5 4 7 - 5 5 1 . Susser , M. (1981) . P r e n a t a l n u t r i t i o n , b i r t h weight and p s y c h o l o g i c a l development: an overview o f experiments, quasi-experiments and n a t u r a l experiments i n the l a s t decade. American J o u r n a l o f C l i n i c a l  N u t r i t i o n , 34, 7 8 4 - 8 0 3 . Terada, M . , & Nishimura , H . (1975) . M i t i g a t i o n o f c a f f e i n e - i n d u c e d t e r a t o g e n i c i t y i n mice p r i o r to chronic c a f f e i n e i n g e s t i o n . Tera to logy , 1 2 ( 1 ) , 79-82J Thordarson, L., & Costanzo, G. (1976). An evaluation of the effect-iveness of an educational program for expectant parents. Canadian  Journal of Public Health, 62(2), 117-121. Turner, G., & Collins, E. (1975). Fetal effects of regular salicylate ingestion in pregnancy. Lancet, 2, 338-339. van den Berg, B. (1977). Epidemiologic observations of prematurity: effects of tobacco and alcohol. In D. Reed & F. Stanley (Eds.) The Epidemiology of Prematurity (pp. 156-176). Baltimore: Urban & Schwarzenberg. van den Berg, B. J., & Yerushalmy, J. (1966). The relationship of the rate of intrauterine growth of infants of low birth weight to mort-ality, morbidity and congenital anomalies. Pediatrics, 69(4), 531-545. -== Waber, D., Vuori-Christiansen, L., Ortiz, N., Clement, J., Christiansen, N., Mora, J., Reed, R., & Herrera, M. (1981). Nutritional supple-mentation, maternal education, and cognitive development of infants at risk of malnutrition. American Journal of Clinical Nutrition, 34, 807-813. Watney, P.J., Chance, G.W., Scott, P., & Thompson, J.M. (1971). Maternal factors in neonatal hypocalcemia: a study in 3 ethnic groups. British Medical Journal, 2, 432-436. Weathersbee, P., Olsen, L., & Lodge, J. (1977). Caffeine and Pregnancy: A retrospective study. Postgraduate Medicine, 62(3), 64-69. Winick, M., & Rosso, P. (1969). The effect of severe early mal-nutrition on cellular growth of the human brain. Pediatric Research, 3_, 181-184. Yarie, S. (1977). A study of factors influencing utilization of  prenatal education services. Unpublished masters thesis, University of British Columbia. APPENDIX A Covering Letter to Prenatal Class Attenders APPENDIX B Covering Letter to Prenatal Class Registrants on the Waiting List APPENDIX C Health Habits Questionnaire Prenatal Education Registration No. 1. During t h i s pregnancy, I have attended (a) an "early b i r d " prenatal class (b) a prenatal Interview with a community health nurse (c) a prenatal c l a s s not from the Vancouver Health Department (d) none of the above 2. Your health habits during pregnancy include your patterns of smoking, alcohol, drug and n u t r i t i o n a l intake. How much has the information provided by each of the following influenced your health habits during pregnancy? Very Somewhat Not Not Much At A l l Applicable Community health nurse Doctor Prenatal c l a s s - early b i r d Family member/friend T.V./radio Books/magazlnes/pamphlets N u t r i t i o n i s t Other (specify) 3. Prenatal information on health habits during pregnancy can be pre-sented l n many ways. Please indicate your preference from among these sources by placing a "1" beside the most preferred, a "2" beside the next most preferred, and a "3" beside the next most preferred. personal Interview with a community health nurse prenatal c l a s s appointment with my doctor books/magazlnes/pamphlets advice from family member/friend T.V. /radio other (specify) Smoking 1. Do you smoke? Yes i 2. I f yes, please Indicate: Number of cigarettes 3. How has your smoking changed during pregnancy? Increased decreased no change ^. I f you have increased or decreased your smoking during pregnancy, what influenced you the most to do so? (You may y/ more than one item) _ ( * ) change ln personal stress _(b) change in craving _(<=) social pressure family member/friend personal knowledge about smoking during pregnancy _<*> T.V./radio _<«> books/magazines/pamphlets _(h) doctor _(D community health nurse _(J) prenatal class _00 other (specify) I f no, please go on to Section C. How often (eg. day, week, etc.) Alcohol 1. Do you drink a l c o h o l i c beverages? Yes No I f no, please go on to | Section D. 2. I f yes, please indicate the number of servings per week. Beer (12 oz.) Wine ( 5 oz.) Liquor ( 1 oz.) 3. How has your a l c o h o l i c intake changed during your pregnancy? increased decreased no change I f you have increased or decreased your intake of alcohol during pregnancy, what influenced you the most to do so? (You may J more than one item) (a) s o c i a l pressure (b) change i n personal stress (c) change i n craving (d) personal knowledge about alcohol consumption during pregnancy (e) prenatal c l a s s ( f ) community health nurse (g) doctor (h) family member/friend ( i ) T.V./radio ( j ) books/magazines/pamphlets (k) other (specify) . 131 D. Non-Prescription Drugs and Medicines 1. I f you have increased or started taking non-prescription drugs ( t h i s Includes a s p i r i n , marijuana, cold remedies, vitamin and mineral supplements, etc.) during your pregnancy please l i s t below: Name of Drug or Medicine How much did you take? How much do you take now? What influenced you to increase or s t a r t taking? 2. I f you have decreased or stopped taking non-prescription drugs ( t h i s includes a s p i r i n , marijuana, cold remedies, vitamin and mineral supplements, etc.) during your pregnancy please l i s t below: Name of Drug or Medicine How much did you take? How much do you take now? What influenced you to decrease or stop taking? 132 3. Do you drink tea, coffee, colas? Yes No I f no, please go on to Section E. I f yes, please indicate the number of servings per day. Tea Coffee Cola 5. How has your tea, coffee and cola intake changed during your pregnancy? (Please J ) increased decreased no change Tea Coffee Cola 6. I f you have Increased or decreased your intake of tea, coffee, colas, during your pregnancy, what Influenced you the most to do so? (You may *J more than one item) (a) doctor (b) community health nurse (c) family member/frlend (d) prenatal c l a s s (e) personal knowledge about tea, coffee, colas during pregnancy ( f ) s o c i a l pressure (g) T.V./radio (h) change i n craving ( i ) change i n personal stress ( j ) books/magazlnes/pamphlets (k) other (specify) . Diet 1. Choose a t y p i c a l eating day and record a l l your food intake f o r that day. L i s t a l l the foods, beverages, snacks consumed f o r one day. State the amount of each food and describe, eg.) salad - l/2 cup l e t t u c e , l/4 tomato, 2 tablespoons french dressing) 1 pork chop f r i e d with onions. My food intake f o r one dayi Today's date i s Time Food Eaten Amount 134 2. Indicate the changes you have made i n your Intake of the f o l l o w i n g food groups during your pregnancy. (Mark an X In the appropriate box) Increase Decrease No Change Milk (includes cheese, yoghurt) Breads and Cereals (includes r i c e , noodles) Meat, Fish, Poultry (Includes eggs, legumes) F r u i t s and Vegetables (includes j u i c e ) Sweets (includes cakes, pastry, chocolate bars, candy) Other (specify) 3. What influenced you the most to make these changes i n your food intake? (You may J more than one item) _ ( a ) prenatal c l a s s _» family member/friend _ ( c ) community health nurse _(*) n u t r i t i o n i s t _ ( • ) personal knowledge about n u t r i t i o n _<*> T.V./radio _(«) doctor _ ( h ) books/magazines/pamphlets _ ( D change i n appetite or craving _ < J ) change i n food tolerance (heartburn, voralttlng, g as) other (specify) . Background Information The following Information w i l l be used only to derive demographic data which describes the population being sampled. 1. Your age i s years. 2. What country were you born in? 3. What language do you speak and understand the best? Gross family Income per year i s : _<»> $0 - $10,000 _(*> $10,000 - $30,000 $30,000 - $60,000 _<*> over $60,000 5. Educational background (Please / highest l e v e l you have completed) (a) Crades 1 - 7 __(b) Grades 8 - 1 1 (c) High School Diploma (Grade 12) (d) Technical Training (e) College Diploma ( f ) University Degree (g) Other (specify) . 6. Recommendations In your opinion, how could prenatal education on health habits f o r pregnant women be improved? (Please use reverse side of page) This Is the end of the questionnaire. Thank you very much f o r p a r t i c i p a t i n g . APPENDIX D Prenatal Assessment Form 137 ll?M3-8i/U(; THIS INI'OltM ATION Wll.l. ASSIST YOUU COMMUNITY MKAI.TM Ntllt.SK TO IDKNTfl'Y KACTOILS THAT Aid- IM POKTANT TO YOU IMIKINC YOUK I'UKCNANCV Tddtiy's I Into I....J line •KKNATAI. ASSESSMENT I'OKM Utile Yr. Mo. Unv • D C Yr. M o . Diiy Name Address I'honc - Home Occupat ion Work r i i ys ic i im's Ntiine A<ldrcss I'hone Partner 's Name A . C U R R E N T P R E G N A N C Y Par tnc r| | or Ot l ie r| | Hospi ta l Wil l A t t e n d C lasses A lso For De l i very ROM Fi rs t Baby? How old are you? How many weeks pregnant arc you? . When did you f irst v is i t your doctor for the pregnancy? What do you weigh now? How ta l l are you? Do you plan to breast or bot t le feed your baby? Have you any problems wi th this pregnancy? (e.g. nausea, cons t ipat ion , etc. ) li. P R E V I O U S P R E G N A N C I E S many resulted i n : Number Date Miscar r iage A b o r t i o n S t i l l b i r t h Death before one year Handicapped baby Caesar ian sec t ion P o s t - p a r t u m depression Other problems dur ing pregnancy or de l i ve ry P R E V I O U S C H I L D R E N B i r t h d a t e Sex B i r thwe ight C o m m e n t s D. C O N T R A C E P T I O N What k ind of c o n t r a c e p t i o n , if any, were you using before b e c o m i n g pregnant? When did you stop? Date Assessed Assessed by Y r . Mo. Day C i t y of Vancouver H e a l t h Depar tment I'A Mil. V IIISTOIt V II11vo you, tho Imliy's fulhor, nr nny<mo in your families hml: Pinholes  Epilepsy  High blood pressure Kidney discuse  Other illness or surgery Genetic problem (erg, uown's Syndrome, etc) SMOKING Oid you smoke before your became pregnant? How many cigarettes per day did you smoke? How many cigarettes per day do you smoke now? ALCOHOL If you drink, please indicate: No. of servings per week Before pregnancy Now Beer (12 oz.) Wine (5 oz.) Liquor (1 oz.) DRUGS AND MEDICATIONS List all drugs and medications (including aspirin, marijuana, cold remedies, vitamins and mineral supplements, etc.) Prescription Amount/Day Others Amount/Day Do you drink tea, coffee or colas? Amount/Day Tea Coffee EXERCISE Cola Do you exercise regularly? (i.e. daily walks, swimming, etc.) Describe ST It ESS What stresses, if any, are you under? Who do you have nearby that you can turn to for support during or after your pregnancy? Do you have any concerns that you would like to discuss with your instructor? Myself My KM in ity Him NUTRITION (PLEASE COMPLETE ATTACHED ONE-DAY FOOO RECORD) Arc you on any special diet? (e.g. vegetarian, low salt, etc) Are you allergic to any foods? Which ones? 139 M Y F O O D INTAKE F O R O N E D A Y D a t e : List a l l the foods and beverages consumed at meals and snacks. State the amount eaten of each food and descr ibe , e .g . sa lad- h cup le t tuce K. tomato , 2 tablespoons of french dress ing, 1 pork chop f r i e d w i t h onions. T O BE C O M P L E T E D I1Y N U R S E S Number of Servings T i m e Food Ea ten Amoun t How Prepared Milk Fruit Vegetables Meat l • Bread Cereals Extras V i t a m i n s or M i n e r a l s Supplements : Type and amounts T O T A L N U M B E R O F S E R V I N G S R E C O M M E N D E D N U M B E R O F S E R V I N G S F R O M C A N A D A ' S F O O D G U I D E A d u l t s 2 4 -5 2 3-5 A d o l e s c e n t s , Pregnant and L a c t a t i n g Women 4 5 Zh 5 C I T Y O F V A N C O U V E R H E A L T H D E P A R T M E N T APPENDIX E Diet Analysis Diet Analysis Canada's Food Guide has been developed based on the recommended nutrient intakes required for a nutritionally adequate diet (Health and Welfare Canada, 1982) . It is widely used as a nutrition education tool to assist individuals in achieving a nutritionally adequate diet. The one-day diet records were analyzed utilizing two systems. 1. Scoring systems based on the 1982 Canada's Food Guide. Each participant's one-day diet record was analyzed by determining the recorded number of servings from each food group according to Canada's Food Guide. 2. Total dietary score based on the four food groups. A total dietary score was calculated for each one-day diet record. A total iraximum score of 16 indicated the diet record achieved the minimum intake required for an adequate dietary intake. Thus scores less than 16 did not meet the iirdnimum recommended by Canada's Food Guide. points/ possible food food group serving group score Milk & Milk Products (up to a rraximum of 4) 1 4 Meat & Meat Alternatives (up to a maximum of 2) 2 4 Fruit & Vegetables (up to a maximum of 4) 1 4 Bread & Cereals (up to a maximum of 4) 1 4 TOTAL DIETARY SCORE 16 

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