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

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A  DESCRIPTIVE  SURVEY  OF THE  HEALTH  BEHAVIORS  OF  PRENATAL  CLASS  ATTENDERS  BY LINDA B.S.N.,  A  ANN  The U n i v e r s i t y  THESIS  SUBMITTED  THE  of  IN  REQUIREMENTS MASTER  OF  KISS B r i t i s h  Columbia,  PARTIAL  FULFILLMENT  FOR  DEGREE  SCIENCE  THE IN  OF  NURSING  in THE  FACULTY  OF  (School  We  accept to  THE  this  GRADUATE of  thesis  OF  December ©  Nursing)  the required  UNIVERSITY  Linda  STUDIES  as  conforming  standard  BRITISH 1983  Ann K i s s ,  1983  COLUMBIA  1977  OF  In  presenting  requirements  this for  thesis  an  B r i t i s h Columbia,  i t  freely  for  available  that  or  by  for  understood  that  his  The  University  Vancouver,  V6T 1Y3 Date  DE-6 (3/81)  of  Canada  University shall  reference  and  study.  I  extensive be  her or  shall  B r i t i s h  copying  granted  by  the  of  publication  not  be  allowed  Columbia  of  this  It  this  without  make  further  head  representatives.  of  1956 Main Mall  the  the  Library  permission.  Department  at  of  the  may  or  fulfilment  that  for  copying  f i n a n c i a l gain  degree  agree  purposes  department  for  I  permission  scholarly  p a r t i a l  advanced  of  agree  i n  thesis  of  my  i s thesis my  written  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 to identify alcohol,  t h e i r h e a l t h behaviors w i t h regard to smoking,  non-prescription drugs,  caffeine,  and d i e t .  attenders  intake  The  of  reported  changes and f a c t o r s w h i c h i n f l u e n c e d the changes i n h e a l t h  behaviors  were a l s o i n v e s t i g a t e d .  question-  naires,  D a t a were c o l l e c t e d u t i l i z i n g two  one 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 ,  the other  later  in  pregnancy. Findings  indicated that  consumed a l c o h o l , vitamins,  15% o f  t h e p r e g n a n t women s m o k e d ,  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  89% c o n s u m e d t e a ,  coffee or colas,  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  than  48%  prenatal  a n d 81% h a d d i e t s w h i c h  Canada's Food Guide.  Most  respondents r e p o r t e d a change i n h e a l t h b e h a v i o r s d u r i n g  pregnancy.  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  knowledge,  books,  magazines and pamphlets,  change i n c r a v i n g ,  and  doctor.  P r e g n a n t women who 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 l e s s education than non-smokers, b o r n i n Canada.  and w e r e more l i k e l y  t o have  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 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 more l i k e l y born i n Canada.  tended  t o have  8% o f  been Food  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  adequate d i e t s and were a l s o l e s s only  been  Respondents whose d i e t s d i d n o t meet C a n a d a ' s  Guide recommendations  findings of  and had  likely  t o be Canadian b o r n .  The  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  did not warrant  some i m p r o v e m e n t s ,  need f o r h e a l t h  education.  suggests there  is a  continuing  that  i i i TABLE OF CONTENTS  Abstract  i i  L i s t of Tables  v i  List  of Figures  viii  Acknowledgements  ix  CHAPTER I  II  INTRODUCTION Statement o f t h e Problem  2  Purpose o f t h e Study  3  D e f i n i t i o n o f Terms  4  Limitations  5  Assumptions  5  Human R i g h t s a n d E t h i c s  5  Description of the Following Chapters  6  REVIEW OF THE Effects  LITERATURE  o f H e a l t h Behaviors During Pregnancy  Smoking Alcohol Drugs Caffeine Diet Previous Investigations During Pregnancy  8 13 18 22 23 of Health  American Studies Overseas S t u d i e s Canadian Studies  Behaviors 29  '  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 Change III  8  29 32 34 37  RESEARCH METHODOLOGY Q u e s t i o n n a i r e Development  43  Setting  45  Sample S e l e c t i o n  47  Data C o l l e c t i o n  48  Data A n a l y s i s  50  iv  CHAPTER TV STUDY RESULTS D e s c r i p t i o n o f t h e Sample  52  Respnse Rate  52  Demographic C h a r a c t e r i s t i c s  53  Health Behaviors of Prenatal Class Attenders  58  Smoking Alcohol N o n - p r e s c r i p t i o n Drugs Tea, Coffee, Cola Diet Overall Health Behaviors of Prenatal Class Attenders  58 61 66 70 73 84  R e l a t i o n s h i p Between Demographic C h a r a c t e r i s t i c s and Health Behaviors  84  V OTHER F I N D I N G S Results of Prenatal Class Registrants on the Waiting List . 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 Prenatal Education  89 of  Recommendations o f P r e n a t a l C l a s s A t t e n d e r s 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 Waiting L i s t V I D I S C U S S I O N OF THE R E S U L T S , CONCLUSION, RECOMMENDATIONS FOR FURTHER RESEARCH  92 92 94  I M P L I C A T I O N S AND  Discussion of the Results  95  Health Behaviors of the Participants I n f l u e n c e s t o Change H e a l t h B e h a v i o r s During Pregnancy Demographic 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 Health Behaviors D i s c u s s i o n o f the Study 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  95 99 103 105  Conclusion  106  I m p l i c a t i o n s o f the Study  107  Recommendations f o r F u r t h e r REFERENCES  Research  109 112  APPENDICES A  Covering Letter to Prenatal Class Attenders  124  B  Covering Letter to Registrants on the Waiting L i s t  126  C  Health Habits Questionnaire  128  D  P r e n a t a l Assessment Form  137  E  Diet Analysis  141  vi L I S T OF T A B L E S  TABLE 4-1  Response Rate by H e a l t h U n i t  53  4-2  Age o f Respondents  53  4-3  Country o f O r i g i n o f the Respondents  54  4-4  Language B e s t U n d e r s t o o d b y t h e Respondents  55  4-5  A n n u a l G r o s s F a m i l y Income 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 Respondents  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 During Pregnancy  4-8  59  Number o f C i g a r e t t e s Smoked B e f o r e a n d During Pregnancy  60  4-9  I n f l u e n c e s o n Smoking B e h a v i o r  4-10  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  4-11  During Pregnancy 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 During Pregnancy  4-12  61  62 63  Type a n d F r e q u e n c y o f A l c o h o l Consumed B e f o r e a n d During Pregnancy  64  4-13  Influences on A l c o h o l Intake  4-14  Type a n d Frequency o f N o n - P r e s c r i p t i o n Drugs  4-15  During Pregnancy 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 Were S t a r t e d o r Increased During Pregnancy  68  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 Drugs W h i c h Were Stopped o r Decreased During Pregnancy  69  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 Consumed D u r i n g P r e g n a n c y  70  Frequency o f T e a , C o f f e e and C o l a Consumption During Pregnancy  71  4-16  4-17  4-18  66 Taken 67  vii  TABLE 4-19  F r e q u e n c y o f R e p o r t e d Changes i n T e a ,  Coffee  and  Cola Intake  72  4-20  Influences on Tea,  C o f f e e and C o l a Intake  . . . .  4-21  D i e t Assessment From the P r e n a t a l Assessment Form  75  4-22  T o t a l Diet Score  76  4-23  D i e t Assessment From 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  4-24  T o t a l D i e t Score  78  4-25  Change i n Food I n t a k e A c c o r d i n g t o t h e F o u r Food Groups  4-26  Influences on D i e t Intake  80  4-27  Health Behavior P r o f i l e of Prenatal Class Attenders  83  4-28  Country of O r i g i n by H e a l t h Behaviors  86  4-29  A n n u a l G r o s s F a m i l y Income 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 by H e a l t h Behaviors  87  5- 1  Health Behavior P r o f i l e of  6- 1  Waiting L i s t Frequency of Reported I n f l u e n c e s t o Health Behaviors  ( P r e n a t a l A s s e s s m e n t Form)  (Health Habits Questionnaire)  Registrants on  ...  73  79  the 91  Change 100  viii  L I S T OF FIGURES  FIGURE 1  2  A Schematic Outline o f a Personal Choice Health Behavior Model  40  E l a b o r a t i o n o f Factors Governing Cessation (or o t h e r m o d i f i c a t i o n o f t h e Behavior)  41  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 this  study p o s s i b l e . F i r s t of 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  Elfert,  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 and encouragement throughout r e s e a r c h p r o c e s s and L i n d a Leonard, c r i t i c a l reviews,  t h e s i s c o m m i t t e e member,  for  the  her  e d i t o r i a l comments 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  "the l i g h t at the end". I  a l s o thank Dr.  Mark 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 and  a s s i s t a n c e w i t h computer a n a l y s i s o f  the  data.  A p p r e c i a t i o n i s extended t o the Vancouver H e a l t h Department 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 ,  and t o the p r e n a t a l  for class  i n s t r u c t o r s and 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 and 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 study and t o A r l e n e Schmidt f o r t y p i n g the f i n a l d r a f t d u r i n g  the  the  holiday season. Last,  but not least,  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  who 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 , this  encouragement and t y p i n g  t h e s i s would n o t have been completed.  Les,  skills,  1  CHAPTER I  INTRODUCTION  It  i s e v i d e n t now t h a t  environment,  further  improvements  i n the  reductions i n self-imposed r i s k s and 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 Canadians a r e t o l i v e a f u l l , free l i f e  (Lalonde,  Since Marc Lalonde"s Canadians"  i n 1974,  portance of healthy  happy,  long and i l l n e s s -  1974, p . 6 ) .  report  " A New P e r s p e c t i v e o n t h e H e a l t h  lifestyles.  human a n d e c o n o m i c r e s o u r c e s .  health  of  there h a s been a n i n c r e a s i n g awareness o f t h e i m Improvements  i n health behaviors can  d r a m a t i c a l l y decrease t h e r i s k o f i l l n e s s and thus save  imperative  more  significant  I n times o f economic r e s t r a i n t ,  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  i t is  t o reduce a l l self-imposed  risks.  The  impact o f h e a l t h behaviors c a n be observed as e a r l y as and  even p r i o r t o c o n c e p t i o n . be c o s t l y t o t h e mother, Smoking,  Poor  l i f e s t y l e h a b i t s d u r i n g pregnancy  could  the c h i l d and t o the s o c i e t y i n which they  a l c o h o l and drug u s e , and poor d i e t a r y  live.  i n t a k e a r e known  t o have s e r i o u s e f f e c t s o n t h e outcome o f pregnancy a n d t h e h e a l t h o f the newborn.  These h e a l t h b e h a v i o r s  involve personal responsibility.  The 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 and improve  these  i s to influence  behaviors.  Research i n d i c a t e s that attenders of higher socioeconomic status,  better  of p r e n a t a l classes tend t o be educated and motivated  and 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 i n 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). L i t t l e research has been done to describe the health behaviors of pregnant women who attend prenatal classes and to investigate changes i n health behaviors during pregnancy. Do prenatal classes teach the "already converted"? Whether the majority of prenatal class attenders have healthy lifestyles already, that i s ; refrain from smoking, use of alcohol or non-prescription drugs and have adequate diets, has not been documented. The changes i n health behaviors these pregnant women make and the factors which influence these changes are unknown. This study i s intended to provide a composite picture of the health behaviors of prenatal class attenders. The findings should prove useful to community health nurses and health care administrators i n 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.  I t i s therefore suggested that pregnant women avoid  3 or l i m i t these behaviors. pregnancy  Many women a r e m o t i v a t e d  to attend prenatal classes.  known a b o u t t h e s m o k i n g ,  However,  enough  during  at present,  little  a l c o h o l , drug and d i e t b e h a v i o r o f  women who a t t e n d p r e n a t a l c l a s s e s ;  whether  pregnant  t h e y change t h e i r  b e h a v i o r s d u r i n g pregnancy and the f a c t o r s which i n f l u e n c e  is  health  these  changes.  Purpose of  The p u r p o s e o f  The  Study  t h i s s t u d y was 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  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 .  The s p e c i f i c  of  objectives  were: 1.  to d e s c r i b e the reported h e a l t h behaviors —  smoking,  non-prescription drugs,  intake of  class 2.  attenders. prenatal  attenders.  to identify attribute  4.  prenatal  t o d e s c r i b e the r e p o r t e d changes i n h e a l t h b e h a v i o r s o f class  3.  c a f f e i n e and d i e t a r y  alcohol,  the major  these  influences to which prenatal class  attenders  changes.  t o d e s c r i b e the demographic c h a r a c t e r i s t i c s of p r e n a t a l  class  attenders. 5.  to determine  the r e l a t i o n s h i p between s e l e c t e d demographic  c h a r a c t e r i s t i c s and r e p o r t e d h e a l t h  behaviors.  4 Definition  alcohol — beer, demographic  wine,  family  health behaviors habits, drugs, influence —  —  age,  country of b i r t h ,  language,  income,  lifestyle habits;  regarding the use of caffeine,  Terms  liquor.  characteristics —  education,  of  and d i e t a r y  to modify or a f f e c t  synonymously  cigarettes,  used w i t h  alcohol,  health  non-prescription  intake, i n some w a y ;  to  sway,  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 a physican's p r e s c r i p t i o n such as a s p i r i n , prenatal class attenders  cough s y r u p ,  vitamins,  — p r e g n a n t women who a r e r e g i s t e r e d a 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 by the Vancouver prenatal class registrants  Health  for  classes or are on  the  list.  prenatal class waiting  list —  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  p r e n a t a l c l a s s e s b u t who 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 are  attend-  Department,  — p r e g n a n t women who a r e r e g i s t e r e d  p r e n a t a l c l a s s e s and a r e e i t h e r a t t e n d i n g waiting  without  for  classes  booked.  e a r l y b i r d p r e n a t a l c l a s s — an educational c l a s s o f f e r e d or second t r i m e s t e r  f o c u s i n g on h e a l t h h a b i t s d u r i n g  i n the  pregnancy,  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 community nurse f o c u s i n g on l i f e s t y l e and h e a l t h h a b i t s d u r i n g 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 number o f aspects of prenatal care, and t h e postpartum smoking — use o f  period,  cigarettes.  first  health  pregnancy,  classes which focuses  l a b o r and d e l i v e r y ,  care of  the  on  newborn  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 w i l l 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 i s 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 Effects  of Health Behaviors During  Pregnancy  Smoking  Just over twenty-five the hazards of  years ago,  smoking d u r i n g pregnancy.  cantly greater incidence of less)  Simpson  first  Two y e a r s l a t e r ,  (2500 g m s .  Lowe  non-smoking mothers.  r e s e a r c h has r e l a t e d smoking d u r i n g pregnancy  (1959) oz.  Current  to:  Increased 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 pregnancy such as p l a c e n t a l  abnormalities 1977;  Naeye,  (Goujard, 1978).  Rumeau a n d S c h w a r t z ,  1975;  Meyer and T o n a s c i a ,  Complications of pregnancy can, of  themselves,  to i n t r a u t e r i n e hypoxia r e s u l t i n g i n i n t r a u t e r i n e growth and/or  lead  retardation  death.  Increased p r o b a b i l i t y of  Brown and Cohen,  1978).  spontaneous a b o r t i o n  (Butler,  G o l d s t e i n and R o s s ,  and Cooper,  1982;  Dalton,  1982;  1959;  M i l l e r and M e r r i t t ,  Ferris,  1982;  times that of  the  the non-  groups.  Reduced b i r t h w e i g h t  Lowe,  12,914  spontaneous a b o r t i o n f o r  h e a v y smoker was f o u n d t o b e a s much a s 1.7 smoker i n c e r t a i n r i s k  (Himmelberger,  I n Himmelberger e t a l . ' s study o f  p r e g n a n c i e s and 10,523 l i v e b i r t h s ,  3.  or  These 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 .  2.  signifi-  s m o k i n g m o t h e r s t o h a v e mean b i r t h w e i g h t s 6  lower than i n f a n t s of  1.  reported  H i s study found a  small b i r t h weight babies  b o r n t o m o t h e r s who s m o k e d .  reported infants of  (1957)  Rantakallio,  Hughes and C o g s w e l l ,  1979;  1979;  1981;  1972;  Cardozo  Doughtery and  Picone, Allen,  Olsen  Jones,  and  R a n t a k a l l i o and H a r t i k a i n e n - S o r r i ,  9 1981;  Russell,  T a y l o r and Law, 1968).  B i r t h weights of babies born to  m o t h e r s who smoked 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 when 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 were c o n t r o l l e d .  B i r t h w e i g h t i s known t o b e a f a i r l y  accurate index o f p e r i n a t a l and neonatal m o r t a l i t y as w e l l as a p r e d i c t o r o f subsequent development.  Both i n f a n t and neonatal m o r t a l i t y  decrease a s b i r t h weight i n c r e a s e s (except f o r an 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 4000 g m s . )  4.  (Chase,  1977).  Increased l i k e l i h o o d of congenital malformations  e t a l . , 1978; Lowe,  1959).  (Himmelberger  Himmelberger e t a l . found 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 smoking mothers t o be as much 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 and other  5.  factors.  Increased incidence of prematurity  Hunter,  1977;  Meyer and T o n a s c i a ,  1977).  (Dunn, McBurney,  Ingram and  Dunn e t a l . f o u n d t h a t  more  m o t h e r s o f p r e m a t u r e b a b i e s smoked 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 of  full  t e r m b a b i e s a n d t h a t more m o t h e r s o f p r e m a t u r e b a b i e s smoked  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  6. 1975;  Increased p e r i n a t a l death rate Meyer and T o n a s c i a ,  1977;  term babies.  ( B u t l e r e t a l . , 1972; Goujard e t a l . ,  Rantakallio,  1979; R u s s e l l e t a l . , 1968).  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 deaths due t o a n o x i a ,  fetal  o r t o unknown 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 mainly because o f p r e n a t a l d e l i v e r y .  Butler e t a l . estimated  t h a t b a b i e s b o r n t o m o t h e r s w h o 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% increase i n r i s k o f e i t h e r being s t i l l b o r n o r dying soon a f t e r  birth.  7.  Lowered Apgar scores (Garn, Johnston, R i d e l l a and P e t z o l d , 1981).  I n Garn e t a l . ' s study of 43,492 l i v e b i r t h s , lower Apgar scores o f i n f a n t s born t o mothers who smoked one pack o f c i g a r e t t e s per day during pregnancy was apparent. A t the 41 t o 60 c i g a r e t t e a day range, the p r o p o r t i o n of low Apgar scores increased approximately f o u r f o l d . Socioeconomic d i f f e r e n c e s d i d not e r a d i c a t e the smoking e f f e c t i n the study group. 8.  Increased postneonatal morbidity (Rantakallio, 1979). The r e s u l t s  of R a n t a k a l l i o ' s study showed the c h i l d r e n born t o mothers t h a t smoked had more diseases and admissions t o p e d i a t r i c departments than the nonsmoking c o n t r o l s — h o w e v e r since most mothers t h a t smoke during pregnancy continue t o 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 t o d i s t i n g u i s h whether the f i n d i n g s are a r e s u l t o f smoking before o r a f t e r b i r t h . 9.  Reduced long-term growth (Davie, B u t l e r and Goldstein, 1972; Dunn,  McBurney, Ingram and Hunter, 1977; Picone e t a l . , 1982).  I n Dunn e t  a l . ' s prospective study, the height and weight of c h i l d r e n born t o nonsmoking mothers exceeded those of smoking mothers a t 6 1/2 years o f 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), a l s o found c h i l d r e n of smoking  mothers t o be smaller than c h i l d r e n of non-smoking mothers up u n t i l 6 months; however, the d i f f e r e n c e was not s i g n i f i c a n t a t one year. f u r t h e r follow-up was done.  No  Russell e t a l . attributed this rapid  growth o r "catch up" o f the c h i l d r e n o f smoking mothers t o the theory t h a t i f maternal smoking a c t s by s l i g h t l y poisoning the f e t u s , babies  s o p o i s o n e d m i g h t grow more q u i c k l y a f t e r  10.  Adversely  Dunn e t a l . ,  birth.  a f f e c t i n g the b e h a v i o r a l development  1977;  Picone e t a l . , 1982).  (Davie e t a l . ,  Picone e t a l . found  smoking d u r i n g pregnancy 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 , and automatic r e g u l a t i o n of  the i n f a n t as measured by the  Neonatal Assessment S c a l e .  Auditory  sounds)  the source of  ponses were seen a t evidence that  the sound.  2 weeks a f t e r  Brazelton  ( a b i l i t y to adapt  birth.  S t u d i e s have a l s o  of  the c h i l d .  480 C a n a d i a n i n f a n t s  res-  found  f r o m b i r t h t o t h e age  pregnancy d i d not perform as w e l l on p s y c h o l o g i c a l t e s t s scores)  Other adverse e f f e c t s of investigation.  Everson  (1980)  of  during  those  smoke.  smoking d u r i n g pregnancy a r e s t i l l suggests that  individuals  under  transplacent-  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 adult  life.  a  (including  and i n s c h o o l b e h a v i o r and placement t h a n d i d  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  of  Dunn e t a l . , i n  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  to  to  there are p e r s i s t e n t long-term detrimental e f f e c t s  prospective study of  Q.  orientation  No r e c o v e r y i n t h e a u d i t o r y  m a t e r n a l smoking on the development  I.  that  was i n c r e a s e d , b u t t h e r e was a d e c r e a s e i n t h e a b i l i t y  orientate  6 1/2  habituation  1972;  T h i s hypothesis however,  remains to be t e s t e d  in  epidemiolog-  ically. The 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 be s a f e l y smoked d u r i n g  has n o t been d e t e r m i n e d .  Butler et a l .  (1972)  found an increased  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 cigarettes per day.  S t u d i e s show t h a t  pregnancy  the e f f e c t s on pregnancy  1-4 outcome  a r e d o s e r e l a t e d t o t h e number 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 (Cardozo e t a l . , 1982; moderate smoking (1-15 of  107  Dougherty and J o n e s , c i g a r e t t e s p e r day)  gms. o f b i r t h w e i g h t ,  p e r day)  1982).  I n one  study,  was a s s o c i a t e d w i t h a  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  was 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 —  a f t e r a l l o t h e r f a c t o r s were t a k e n i n t o account  (Dougherty and  The " 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 when s m o k i n g h a s  even  Jones).  the  g r e a t e s t impact o n f e t a l growth and development i s a l s o n o t Studies,  loss  clear.  however 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 and low  b i r t h weight are greater i f  smoking i s c o n t i n u e d d u r i n g the l a t t e r  of pregnancy.  (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  Meyer e t a l .  d e a t h i n u t e r o i s about d o u b l e d i n t h e e a r l i e r weeks i f 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 o smoke d u r i n g p r e g n a n c y .  Butler et a l .  (1972)  the  part of  mother  the mother c o n t i n u e s  found t h a t the  amount  smoked a f t e r t h e f o u r t h month 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 fetal survival.  S t u d i e s by Papoz e t a l .  (1982)  a n d Lowe  (1959)  t h a t s m o k e r s who 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 and non-smokers gave b i r t h t o s i m i l a r b a b i e s .  Cessation of  as l a t e as j u s t p r i o r t o d e l i v e r y has advantages.  showed  pregnancy smoking even  Women who s t o p p e d 48  hours b e f o r e d e l i v e r y were found t o have an 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 Jones, of  V e a l e and Wardrop,  1979).  Thus,  (Davies,  i t appears evident t h a t c e s s a t i o n  smoking a t any t i m e d u r i n g pregnancy i s b e n e f i c i a l and t h a t  c e s s a t i o n e a r l y i n pregnancy i s most  smoking  favorable.  The 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 i n c l u d e s hundreds of  Latto,  smoking d u r i n g pregnancy  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, i n general, i t i s now accepted that infants born to mothers who smoke during pregnancy w i l l be approximately 6-8 oz. (170-230 gins.) lighter at birth than i f the mothers had not smoked and w i 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. I t 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 i n the 18th century.  In 1973, Jones and Smith termed the  pattern of c l i n i c a l features commonly found i n infants born to alcoholic mothers as "the fetal alcohol syndrome". Fetal alcohol syndrome i s characterized by: 1.  prenatal and postnatal growth retardation,  2.  evidence of central nervous system dysfunction including hypotonia, i r r i t a b i l i t y , tremors, mental retardation, poor coordination and hyperactivity i n 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).  At present,  t h i s syndrome 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  stages of maternal alcoholism.  advanced  C h i l d r e n born t o a l c o h o l i c mothers 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 . number 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 unknown. (Hanson,  In a Seattle  study,  t h e r a t e w a s 1 p e r 750 l i v e  S t r e i s s g u t h and Smith,  births  the e f f e c t s of alcohol  consumption c a n be b e s t e x p l a i n e d i n terms o f a gross  dose-response  A t the severe end o f the continuum i s the c l a s s i c  a l c o h o l syndrome" at  is  1978).  From t h e c u r r e n t r e s e a r c h , i t appears t h a t  continuum.  The  "fetal  — the r e s u l t o f advanced m a t e r n a l a l c o h o l i s m , and  the other end are the " f e t a l a l c o h o l e f f e c t s "  moderate o r s o c i a l d r i n k i n g .  — the r e s u l t  of  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  associated with maternal a l c o h o l use a r e : 1.  Spontaneous  Kaminski,  abortion or s t i l l b i r t h  Rumeau a n d S c h w a r t z ,  Warburton,  1980).  (Harlap and Shiono,  1978; K l i n e ,  Shrout,  Stein,  1980; Susser and  Harlap and Shiono found a s i g n i f i c a n t increase i n  second t r i m e s t e r spontaneous 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 when compared t o n o n - d r i n k e r s .  K l i n e e t a l . found  s t r o n g a s s o c i a t i o n between spontaneous a b o r t i o n and d r i n k i n g p r e g n a n c y w h i c h was s t i l l e v i d e n t when s e v e r a l p o t e n t i a l l y  a  during  confounding  v a r i a b l e s were c o n t r o l l e d i n t h e a n a l y s i s .  2.  Prematurity  deMazaubrun  (Hingson e t a l . , 1982; K a m i n s k i , F r a n c ,  and Rumeau-Roquette,  1981).  LeBouvier,  Although Hingson e t a l . d i d  not f i n d the l e v e l of maternal drinking to influence i n f a n t  size,  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 was s i g n i f i c a n t l y r e l a t e d  to  shorter gestation.  of  Kaminski e t a l . ' s finding of a higher rate  pre-term deliveries i n moderate or heavy drinkers than i n 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 a l . , 1978;  Kaminski et a l . , 1981; Kaminski et a l . , 1978; L i t t l e , 1977; Rosett,et a l . , 1983; Rosett, Weiner, Zuckerman, McKinlay and Edelin, 1980; Silva, Laranjeira, Dolnikoff, Grinfeld and Masur, 1981; Streissguth, Martin, Martin-and Barr, 1981).  Streissguth et a l . (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 i n infants born to mothers with increased maternal alcohol intakes. 4.  Major and minor malformations (Hanson et a l . , 1978; Ouellette,  Rosett, Rosman and Weiner, 1977; Rosett et a l . , 1983; Silva et a l . , 1981; Sokol, Miller and Reed, 1980).  Ouellette et a l . 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 a l . , 1981). 5.  Mental, motor and behavioral effects (Ouellette et a l . , 1977;  Streissguth et a l . , 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,  decreased sucking pressure, left,  decreased vigorous  activity  v a r i a b l e s such as smoking, r o l l e d and d i d n o t a f f e c t motor development whose mothers  i n c r e a s e d tremulousness and  and o t h e r minor a b n o r m a l i t i e s .  c a f f e i n e and drug use and d i e t were the r e s u l t s .  were found a t the  of  ( L i t t l e and S t r e i s s g u t h ,  (Landesman-Dwyer,  heavy d r i n k i n g v a r i e s between inconsistent findings. be the p r o d u c t of  et a l . ,  1981).  One o f  t h e amount o f  1978)  or  in  than the  In a French study  Streissguth et a l . of  1-2  (1980)  a l s o smoked,  (Kaminski  times  came f r o m  had more p r i o r p r e g n a n c i e s o r were  (1981)  and H a r l a p and Shiono  d r i n k s per day d u r i n g pregnancy  (1980)  may  direct  for  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 ;  socioeconomic c l a s s e s ,  to  sensitive  moderate  s t i l l b i r t h was i n c r e a s e d 2 1/2  r i s k was e v e n g r e a t e r when t h e m o t h e r s  this  a l c o h o l on the fetus  factors rather  a l c o h o l consumed.  the r i s k of  light,  tend  the s t u d i e s which o f t e n r e s u l t s  The h a r m f u l e f f e c t s o f  a  self-report  e s p e c i a l l y on  The m e a n i n g o f  an accumulation of  of  the reasons f o r  i n c o m p l e t e and p e o p l e  or unknowingly,  1982).  limits  nor the e f f e c t s r e l a t e d to  Human r e c a l l i s o f t e n  under r e p o r t e i t h e r knowingly  result of  and  8 t h month f o l l o w - u p o n c h i l d r e n  i d e n t i f i c a t i o n i s t h a t the s t u d i e s have r e l i e d on  consumption.  topics  cont-  S i g n i f i c a n t lower mental  i d e n t i f i e d the s p e c i f i c "safe"  a l c o h o l consumption d u r i n g pregnancy  lack of  Other  consumed a l c o h o l .  Research has n o t y e t  g i v e n dose  head-turns-to-  this lower  older.  reported  intakes  to be h a r m f u l and K l i n e e t  found adverse 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 as l i t t l e as  al. 1  17 ounce o f  a b s o l u t e a l c o h o l ^ " t w i c e a week d u r i n g  pregnancy.  The 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 seems t o b e c r i t i c a l pregnancy outcome.  Although  some s t u d i e s s h o w t h a t  i t  i s t h e amount  a l c o h o l consumed p r i o r t o and d u r i n g t h e e a r l y s t a g e s o f i s most harmful to the f e t u s ,  other  to  pregnancy  (1978)  discovered that maternal a l c o h o l intake i n the  preceeding recognition of  Hanson  months  p r e g n a n c y and d u r i n g e a r l y p r e g n a n c y was  associated with f e t a l anomalies.  Rosett et a l .  (1983)  found  infants  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 growth from i n f a n t s of higher frequency of  abnormalities.  i n midpregnancy can b e n e f i t the (1977)  These f i n d i n g s w h i c h i m p l y  that  newborn.  found that the i n g e s t i o n of  decrease i n b i r t h weight of  a  reduction  an average of  1 ounce  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 was a s s o c i a t e d w i t h a n 9 1 g r a m s , b u t t h e same a m o u n t i n  p r e g n a n c y was 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 subsequent study  in .  r a r e o r moderate d r i n k e r s , b u t demonstrated  a l t h o u g h s u s t a i n e d heavy d r i n k i n g r e p r e s e n t s a major r i s k ,  Little  that  s t u d i e s have i d e n t i f i e d a l c o h o l  consumption i n the l a t t e r stages of pregnancy as most c r u c i a l . et a l .  of  ( R o s e t t e t a l . , 1980)  160 g r a m s .  of  average  late  Similarily,  a  f o u n d i n f a n t s b o r n t o women who  reduced t h e i r heavy a l c o h o l consumption b e f o r e the t h i r d  trimester  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 continued to d r i n k h e a v i l y throughout  t h e i r pregnancy.  The  findings  these s t u d i e s imply t h a t although a l c o h o l consumption 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 ,  reduction of  alcohol intake  during  "''l o z . of a b s o l u t e a l c o h o l = 2 d r i n k s o r approximately 2 b o t t l e s of beer, 2 g l a s s e s of wine o r 2 h i g h b a l l s .  of  pregnancy i s b e n e f i c i a l — e s p e c i a l l y t o the newborn. 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 .  It  is well  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 unchanged s o t h a t blood l e v e l s equal that of the mother.  Maternal consumption of a l c o h o l  e a r l y i n pregnancy i s a s s o c i a t e d w i t h spontaneous a b o r t i o n s , a t u r i t y and malformations,  fetal  prem-  w h i l e maternal consumption of a l c o h o l l a t e r  i n pregnancy i s a s s o c i a t e d w i t h f e t a l growth r e t a r d a t i o n . cumulative evidence of the studies reviewed,  From t h e  and the questions  about  d r i n k i n g i n pregnancy t h a t r e m a i n t o be answered, one c o n c l u d e s t h a t i s better  f o r the infants  i t  i f t h e i r mothers do n o t d r i n k a l c o h o l d u r i n g  pregnancy.  Drugs  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 been cautioned about t a k i n g drugs d u r i n g pregnancy.  The r o l e o f  mater-  n a l drug use i n the e t i o l o g y of f e t a l malformation i s not e n t i r e l y clear.  It  i s estimated that  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  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 1981).  have (Beeley,  The 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 ,  fetal  growth 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 from drug use i s d i f f i c u l t to estimate.  T e r a t o g e n i c i t y o f a g i v e n drug i s dependent on the dose  r e a c h i n g t h e embryo o r f e t u s , duration of exposure,  g e s t a t i o n a l age a t t h e time o f  genotypes o f t h e mother and f e t u s ,  o f o t h e r a g e n t s t o w h i c h t h e embryo o r f e t u s (lams and Rayburn,  1981).  exposure,  and the e f f e c t  i s simultaneously exposed  Variances i n these f a c t o r s add t o the  19 complexity of drug research. Drugs that have been identified as known teratogenes i n humans during pregnancy include anticonvulsants (trimethadione, phenytoin), anti-coagulants (Coumadin and congeners), alcohol, f o l i c acid antagonists (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 i n 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, antihistamines 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 a l . , 1981) hemorrhage.  Turner  and Collins (1975) also found that chronic salicylate ingestion was associated with an increase i n perinatal mortality and decreased  u t e r i n e growth. of  antacids,  Although  little  information i s available on the effects  o n e s t u d y d i d show a s i g n i f i c a n t i n c r e a s e o f  abnormalities  i n i n f a n t s exposed t o a n t a c i d s d u r i n g the f i r s t t r i m e s t e r Forfar,  1971).  (Nelson and  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 .  Even though s t u d i e s have f a i l e d t o demonstrate g e n i t a l malformations ( S h a p i r o e t a l . , 1977;  an incidence of  con-  associated with antiemetic intake during S m i t h e l l s and Sheppard,  antiemetics a r e s t i l l under review.  Saxen  1978),  (1974)  pregnancy  the effects  of  found o r a l c l e f t s  be p s o i t i v e l y a s s o c i a t e d w i t h maternal i n t a k e s o f diphenhydramine e a r l y pregnancy.  Withdrawal  i n i n f a n t s born to chronic abusers  antihistamines and decongestants i r r i t a b i l i t y and poor f e e d i n g  includes tremulousness,  (Schad and Rayburn,  Bernhardt and Dorsey,  1974)  (Strange,  of  1981).  Excessive congenital  Carlstrom and E r i k s s o n ,  but warrants  further  in  aggitation,  doses o f V i t a m i n A d u r i n g organogenesis has been l i n k e d w i t h a n o m a l i e s i n two c a s e r e p o r t s  to  1978;  study.  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 .  Marijuana  use d u r i n g pregnancy has been 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 and decreased maternal weight gain meconium s t a i n i n g (1982)  (Greenland,  (Fried,  1982) a n d w i t h m o r e  S t a i s c h , Brown and G r o s s ,  frequent  1982).  Fried  found t h a t babies born t o marijuana users demonstrated  marked  tremors, and s t a r t l e s and a l t e r e d v i s u a l responsiveness a t 2 t o 4 days of  age.  T h e s e symptoms h o w e v e r ,  developmental  had attenuated  b y 30 d a y s a n d n o  impairments were observed a t one year o f a g e .  Although  most o f the reported 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 have n o t been c o n f i r m e d ,  they do p r e s e n t evidence t o doubt t h e  o f a n y d r u g when u s e d d u r i n g  pregnancy.  drugs  safety  The t i m i n g o f  drugs taken d u r i n g pregnancy i s u l t i m a t e l y  as t o the a b n o r m a l i t i e s produced. after  important  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 week  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 has o c c u r r e d p r o b a b l y have an a l l -  or-nothing effect;  e i t h e r t h e e m b r y o d i e s o r t h e damaged c e l l s  replaced by normal c e l l s .  During the p e r i o d of organogenesis  the second and t e n t h week), (teratogenicity)  are (between  drugs can produce c o n g e n i t a l malformations  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 .  During the second and t h i r d t r i m e s t e r s , drugs can a f f e c t the growth f u n c t i o n a l development o f  the fetus — e s p e c i a l l y the c e n t r a l  system which continues to develop throughout  pregnancy  nervous  (Beeley,  1981)  Thus t h e r e i s no 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 when t h e f e t u s t o t a l l y protected from maternal drug Evidence  1964).  .  is  levels.  from r e s e a r c h s t u d i e s on v a r i o u s drugs and m e d i c a t i o n s  supports minimal drug use throughout (Apgar,  and  At  pregnancy,  l a b o r and  delivery  t h e p r e s e n t t i m e t h e r e a r e no d r u g s p r o v e n t o  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 .  The a b s e n c e  r e p o r t s a s s o c i a t i n g a g i v e n drug t o a t e r a t o g e n i c e f f e c t does imply i t s safety.  of not  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  based on animal 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  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 .  be  are  teratogenic  Thalidomide i s  an  example o f one s u c h d r u g . From t h e r e s u l t s o f  the p r e s e n t r e s e a r c h and the l a c k o f  human r e s e a r c h o n t h e m a j o r i t y o f it  t h e d r u g s when u s e d d u r i n g  extensive pregnancy,  seems 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  pregnancy.  during  22 Caffeine  Caffeine,  one o f t h e w o r l d ' s most w i d e l y used drugs was regarded  harmless u n t i l r e c e n t l y .  Caffeine  c o l a s and other carbonated Although  i s present i n coffee,  t e a , cocoa,  beverages.  research studies on the effects of caffeine  during  pregnancy 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 known.  In an adult,  cups o f coffee)  1 5 0 - 2 5 0 mgm. o f c a f f e i n e  a c t s a s a nervous  and  basal metabolic rate,  acid  (Consumers R e p o r t s ,  8 t o 10 c u p s o f c o f f e e ) insomnia,  (approximately  system s t i m u l a n t i n c r e a s i n g the heart  u r i n e production and s e c r e t i o n o f  1981).  Caffeine  intoxication  p r e s e n t s symptoms  (Martin,  stomach  (approximately  t h a t may i n c l u d e r e s t l e s s n e s s ,  sensory disturbances, muscle tremor,  irregularities  1 to 2  d i a r r h e a and c a r d i a c  1982).  Caffeine readily crosses the placenta into 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 (Goldstein and Warren,  1962).  Caffeine has been l i n k e d w i t h mutations (Ostertag,  plasma  Duisberg and Sturman,  s t i l l b i r t h and premature b i r t h  i n human c e l l s  1965) a n d w i t h s p o n t a n e o u s (Weatherbee,  demographic survey by v a n den Berg  (1977)  Olsen and Lodge,  i n culture abortion, 1977).  A  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 more 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 weight babies.  As f o r t y - f i v e  p e r c e n t o f t h i s sample a l s o  the a s s o c i a t i o n between c a f f e i n e i n t a k e and l o w b i r t h w e i g h t S t u d i e s have been 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 specific birth defects.  Rosenberg,  Mitchell,  smoked,  i s unclear. with  Shapiro and Slone  (1982)  s t u d i e d 2,030 malformed between  infants  a n d w e r e u n a b l e t o show a r e l a t i o n s h i p  the b i r t h defect and i n g e s t i o n o f c a f f e i n e during  One o f t h e m a j o r p r o b l e m s pregnancy  i n researching the e f f e c t s of caffeine on  i s t h e l a c k o f women w h o d r i n k  c o n t a i n i n g beverages Although at this time,  during  caffeine's  pregnancy.  large quantities  of  caffeine  pregnancy.  t e r a t o g e n i c p o t e n t i a l has n o t been  demonstrated  i t s e f f e c t s on animal models has caused g r e a t  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 malformations  such as c l e f t palate  (Terada and N i s h i m u r a ,  reduced body,  l i v e r and b r a i n weight a t b i r t h  (Groisser,  and p o s t n a t a l growth r e t a r d a t i o n  concern. congenital  1975), Rosso and  Winick,  1982),  1981).  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  offspring of rats  f e d coffee during pregnancy.  (Dunlop and C o u r t ,  Although  findings  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 , i n v e s t i g a t i o n o f t h e phenomenon  in of  further  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 , it  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  caffeine  intake.  Diet  Maternal d i e t and n u t r i t i o n a l status are considered factors  i n f l u e n c i n g t h e outcome o f p r e g n a n c y .  maternal requirement  f o r many n u t r i e n t s  breasts,  During pregnancy,  i s increased.  a r e n e c e s s a r y f o r g r o w t h demands o f t h e f e t u s ,  important  These i n c r e a s e s  placenta,  amniotic f l u i d and i n c r e a s e d blood volume.  maternal metabolic r a t e and metabolism o f the f e t u s  the  uterus,  An i n c r e a s e d a l s o adds t o t h e  energy requirement for pregnancy (National Research Council, 1981). In developed countries, most mothers who deliver fetally malnourished infants do not show evidence of serious malnutrition.  Research,  however, supports the consensus that maternal nutrition influences f e t a l 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 i t s mother. Although the impact of specific nutrient deficiencies during pregnancy i s not f u l l y 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 L i t t l e , 1967) and fetal malformations (Hibbard  and Smithells, 1965). However, subsequent studies have not been successful i n 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 i n 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 a l . , 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). Norman  Fancourt, Campbell, Harvey and  (1976) found that prolonged slow growth i n 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 midpregnancy rather than to excesses or deficiencies of specific nutrients. Metcoff et a l . (1981) found the nutritive patterns i n pregnant women who delivered small babies were quite different from those mothers who delivered large babies, even though gross nutritional deficiencies or  26 excesses were n o t i d e n t i f i e d i n e i t h e r  group.  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 recommended b y t h e N a t i o n a l Research C o u n c i l Committee o n M a t e r n a l N u t r i t i o n  (1970).  The  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 seems l o w e s t a n d o u t c o m e t h e best with t h i s gain i n weight  ( L e a d e r , Wong a n d D e i t e l ,  1981).  rate of weight gain i n the t h i r d trimester i s a p a r t i c u l a r l y determinant of b i r t h weight  (Stein and Susser,  1975a).  The important  However,  while  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 on the i n f a n t ' s  anthropometric measures,  adequate  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 o p t i m a l development.  Picone,  Allen,  Olsen and F e r r i s  for  (1982) f o u n d  s i g n i f i c a n t r e l a t i o n s h i p between n e o n a t a l b e h a v i o r  (overall  scores on the B r a z e l t o n Neonatal Assessment Scale)  and weight  d u r i n g the second  performance  pregnancy  rank second o n l y t o g e s t a t i o n a l age a s determinants o f b i r t h Research C o u n c i l ,  ceptual weight  gain  trimester.  Maternal preconception weight and weight g a i n d u r i n g  (National  a  1981).  weight  A p r e g n a n t women w i t h a p r e c o n -  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  an increased r i s k o f developing o b s t e t r i c a l complications and i s a t risk  f o r d e l i v e r i n g a low b i r t h weight  infant  (Pitkin,  1981).  The 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 low preconception weight Merritt dates  (1979)  i s coupled with-inadequate  diet.  found the 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  (crown-heel lengths -  were underweight  f i f t h percentile)  M i l l e r and  term  short-for-  i n f a n t among women who  a t c o n c e p t i o n and h a d l o w w e i g h t g a i n was t h r e e  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  when  and had low weight  times gain.  27 S t u d i e s have demonstrated t h a t b i r t h w e i g h t s c a n be i n c r e a s e d t h r o u g h d i e t improvement 1982;  Ross and R u t t e r ,  (Higgins,  1978).  1976; O j o f e i t m i ,  Ojofeitmi  Elegbe and Babafemi,  e t a l . found 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 through n u t r i t i o n a l c o u n s e l l i n g and use o f a fear-mechanism technique. 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 foods f o r fear o f having b i g babies which would lead t o d i f f i c u l t labors and cesarean s e c t i o n s . Nutrition  supplement s t u d i e s have a l s o demonstrated t h e e f f e c t  maternal n u t r i t i o n on b i r t h weight. New Y o r k ,  Montreal,  Bogota,  of  B i r t h weights as reported i n the  Guatemala and Taiwan s t u d i e s were 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  (Susser,  1981).  The 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 mother.  The 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  intake of supplements,  the greater the increase i n maternal  weight following supplementation.  In studies such as Osofsky's  where s u b j e c t s d i d n o t appear t o be n u t r i t i o n a l l y d e p r i v e d , mentation d i d not a f f e c t b i r t h  birth  supple-  weight.  Long term e f f e c t s on c o g n i t i v e f u n c t i o n i n g as a r e s u l t of 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 have a l s o been r e p o r t e d Takenaka,  (1975),  1 9 8 2 ; Waber e t a l . , 1 9 8 1 ) .  (Hicks,  early  Langham a n d  Hicks e t a l . found t h a t the  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 showed s i g n i f i c a n t enhancement o f most i n t e l l e c t u a l and b e h a v i o r a l measures i n c l u d i n g I.  Q.,  a t t e n t i o n span, v i s u a l - m o t o r s y n t h e s i s and s c h o o l grade  when compared 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 . however,  average  Additional research i s ,  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 made.  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 deprivation, 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 Previous Investigations of Health Behaviors During  Pregnancy  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 .  How-  ever there a r e few c u r r e n t surveys which i n v e s t i g a t e a l l o f the h e a l t h p r a c t i c e s — smoking and i n t a k e o f a l c o h o l , during pregnancy.  drugs,  c a f f e i n e and d i e t  Surveys o f h e a l t h h a b i t s on populations o f  c l a s s a t t e n d e r s a r e e v e n more s c a r c e .  prenatal  Many 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 more 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 prevalence and influences o f these 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 smoking, a l c o h o l , habits during pregnancy.  drug,  c a f f e i n e and/or  dietary  In order to a s s i s t i n the organization of the  review and since h e a l t h behaviors a r e i n f l u e n c e d by environmental and societal factors, American,  American  Overseas  t h e s t u d i e s a r e d e s c r i b e d under t h e headings o f and Canadian  Investigations  A C a l i f o r n i a study of over Kissinger, drink  Investigations.  1 2 , 0 0 0 p r e g n a n t women (Kuzma a n d  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  (51%) a n d smoke  (35%) d u r i n g p r e g n a n c y .  (both e d u c a t i o n a n d income)  Socioeconomic status  was 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  moderate 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  smoking.  S i m i l a r f i n d i n g s were r e v e a l e d i n t h e study conducted a t t h e Boston C i t y Hospital prenatal c l i n i c (1981)  (1974-1977).  Rosett and Weiner  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 p a r t i c i 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 i n heavy drinkers. In a subsequent study at the Boston City Hospital between 1977 and 1979  (Hingson et a l . , 1982), 1,692 women who delivered infants were  interviewed on a variety of factors thought to influence fetal development. 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 drinking 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 i n 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 prepregnancy 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 i n the f i r s t four  months. Reasons cited for the decrease i n alcohol and coffee intake were:  1) adverse physiological effect e.g., nausea, stomach i r r i t a t i o n ,  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 i n 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 i n dietary habits and reasons which  contributed to these changes. The m a j o r i t y  Only 2 of  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  an increase i n m i l k consumption. stated for  t h e 46 women h a d a d e q u a t e  Appetite  s m a l l sample s i z e and use o f  reported  change was t h e m a j o r  increasing or decreasing food intake.  Because of  g r o s s measurements,  specific  reason  this  study*  statements  about 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 pregnancy c o u l d b e made.  The d a t a d i d however  pregnancy  i n the population  Lillien,  indicate general patterns of  diet  not  during  sampled.  Huber and R a j a l a  (1982)  days postpartum and a l s o found t h a t  interviewed  578 women o n e t o  l e s s t h a n one t h i r d  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 . of  diets  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  (30%)  of  Eighty-two  a t l e a s t once d u r i n g  four  the  percent  pregnancy.  T h e number o f women who 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%)  increased d u r i n g pregnancy  more  (18%)  ounces p e r month b e f o r e pregnancy  and those t h a t drank twenty o r (16%)  decreased  (3%).  Recall  n a t a l l y o f d i e t and a l c o h o l i n t a k e d u r i n g pregnancy c o u l d have the  biased  results.  Overseas  investigations  In a French study 1982) At  post-  of  (Papoz, Eschwege,  534 p r e g n a n t women,  t h e s i x t h month, h a l f o f  consumption.  Mean c a l o r i c  37% o f  (53%)  A B r i t i s h study of  B a r r a t and  t h e s a m p l e smoked b e f o r e  Schwartz,  pregnancy.  them h a d s t o p p e d and o t h e r s r e d u c e d  their  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  smoke a n d l o w e s t i n n o n - s m o k e r s . smoking were nausea  Pequignot,  or  The r e a s o n s m e n t i o n e d f o r  ' i t was b e t t e r  195 m o t h e r s  for  the baby'  decreased  (33%) .  ( S m i t h e l l s e t a l . , 1977)  reported  to  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 a l . , 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 i n 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 i n  diet, most women reported they knew what to do (55%), but that mass media (21%) and health professionals (24%) were major sources of i n 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 i n 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 i n 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 i n 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 i n 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 negatively with heavy smoking. The major limitation of this study i s 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 i n Canada have patterns of food consumption similar to that of a 20 to 29 year old female except for modest increases i n milk and f r u i t .  Nutrient intakes for folate, iron  and calcium were below the recommended levels.  Eighty-eight percent of  the women said they made some changes i n 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 c l i n i c . A food intake study of 981 expectant mothers attending prenatal classes i n Toronto (Latchford, Milne, Vaughan, McClinton and Harris, 1970) reported that 57% of the women made changes i n 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 commonly reported as reduced i n 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 substantiated i n another study.  Dietary intakes of 29 pregnant women who were  attending obstetric c l i n i c s at MacMaster University Centre (Field-Zimmer  and Miles, 1981).showed that the women were not consuming the recommended Canadian Dietary Standard levels for energy and iron during pregnancy. The weaknesses of this study, however, are i t s 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) i n 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 i n 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 i n their habits.  Changes made i n health habits were not described nor were the  reasons for changes. Another f a i r l y 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 i n the study were referred by physicans practicing i n 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 d i f f i c u l t as the classifications used for light, moderate and heavy smoking or alcohol intake and the c r i t e r i a 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 i s  based on the decision making concepts of valence and subjective probability.  The theory argues that whether or not an individual w i l l  undertake a recommended h e a l t h a c t i o n i s dependent upon the perceptions  individual'  of:  1)  l e v e l of personal s u s c e p t i b i l i t y to that i l l n e s s or c o n d i t i o n ,  2)  t h e d e g r e e o f s e v e r i t y o f t h e consequences  r e s u l t i n g from the  condition, 3)  the h e a l t h a c t i o n ' s  potential  benefits,  4)  estimates 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 or other  costs  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 a l o n e a r e n o t enough t o change b e h a v i o r s . s t i m u l i o r " c u e s t o a c t i o n " must o c c u r t o t r i g g e r health behavior.  the  Relevant appropriate  D i v e r s e demographic and s o c i o p s y c h o l o g i c a l  variables  were n o t seen as d i r e c t l y c a u s a l t o c o m p l i a n c e , b u t were r e c o g n i z e d 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 m o t i v a t i o n s and p e r c e p t i o n s H a e f n e r , Maiman, K i r s c h t and Drachman,  as  (Becker,  1977).  T h i s o r i g i n a l model has been r e f o r m u l a t e d by Becker and Maiman  (1975) and expanded t o i n c l u d e : 1)  general health  motivations,  2)  broader perceptions o f h e a l t h  3)  g e n e r a l f a i t h i n p h y s i c a n s and m e d i c a l c a r e ,  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  threat,  m i g h t enhance o r i m p a i r c o m p l i a n c e , 5)  demographic, variables  Horn's  structural  r e l a t i o n s h i p which  and  and e n a b l i n g f a c t o r s as  dependent  to compliant behaviors.  (1976) 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 model i s s i m i l a r t o  the h e a l t h b e l i e f m o d e l .  It  attempts t o e x p l a i n the f o u r s t a g e s o f  39 risk-taking behaviors:  initiation, establishment, maintenance, and  cessation or modification.  The factors which f a c i l i t a t e or inhibit the  cessation or modification of behavior are: change,  2) the perception of the threat,  1) values underlying the 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 i n fluences, mass commonications, influences generated by key groups which are a l l capable of playing an important role i n determining whether or not change i s attempted and successfully carried through i n personal choice behavior (Horn, 1976).  (See Figure 2).  This study w i l l use the cessation or modification stage of riskbehaviors i n Horn's model as i t s framework to investigate the factors which f a c i l i t a t e or influence change i n health behaviors.  Summary  A review of the literature reveals the d i f f i c u l t i e s i n 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 i n 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  ^Figure 1. A schematic outline of a personal choice health behavior model.  MAINTENANCE  INITIATION  ESTABLISHMENT  - Availability  H Costs-benefits balance  Reinforcement  Sterotyping  Social Support  - Example  Counteraction  Psycho-personal structure  Psychological utility  CESSATION (or modification)  1  Contemplation of change  Motivational change  The decision to change  Perception of the threat  Short-term change  Psychological utility  Long-term change  Environmental facilitation  T  T T  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 governing c e s s a t i o n (or o t h e r m o d i f i c a t i o n o f t h e behavior)  CESSATION  (OR OTHER R I S K - R E D U C I N G MODIFICATION) 1  1  MOTIVATION FOR CHANGE  PERCEPTION OF THE THREAT  PSYCHOLOGICAL UTILITY  ENVIRONMENTAL FACILITATION  a.  Health  a.  Importance  a.  Stimulation  a.  b.  Exemplar r o l e  b.  Personal  b.  Handling  c.  Esthetics  influence  c.  Accentuation  d.  Control  of  change  influence  Value of  d.  Capability of  pleasurable  making change  relaxation Reduction of negative  addiction "craving" Habit, affect  without  General of  c.  climate  opinion  Influence  of  advertising d.  Influence key  effect  e. Psychological  f.  b.  pleasure,  c.  d.  Physician  e.  of  groups  Interpersonal influences  practices are combined, the risks are amplified.  However, just as one  cannot guarantee that a l l pregnant women who have good health habits w i l l have good pregnancy outcomes, one cannot predict that a l l pregnant women with poorer health habits w i l l 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 i n 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 i n which they were studied. The health behaviors of pregnant women who attend prenatal classes have not been recently researched.  The changes this group makes i n 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 i n health behavior involves personal responsibility. The research methodology i s presented i n 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 u t i l i z i n g 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 complete 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 i t s access. The Health Habits Questionnaire, the second tool for data collection, 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 f a c i l i t a t e 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 i n 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 i s most efficient for characterizing a group by i t s mean group intake (Chalmers et a l . , 1952).  The r e l i a b i l i t y of the 24-hour diet r e c a l l 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 r e l i a b i l i t y and piloted with a prenatal class i n 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 f a i r l y high degree of r e l i a b i l i t y  between the responses, especially for the questions on smoking, alcohol and diet change.  I t i s already well established that one-day diet  record i s reliable for groups over 40.  Minor adjustments i n format of  the questionnaire were made following the r e l i a b i l i t y test. The Health Habits Questionnaire provided the investigator with information on the health behaviors later i n pregnancy while attending prenatal classes and on the changes and factors which influenced change i n health behaviors during pregnancy.  Setting This study took place i n the six health units of the Vancouver Health Department.  The health units of West, Burrard, Mid-Main, East,  North and South are situated i n 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 i n 1980 the number of live births was 4,773 (Province of B.C. Ministry of Health, 1980). Although Vancouver's population i s multicultural, the majority of the people are English speaking (Statistics Canada, 1981). The six leading health risk factors i n 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 i n 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 i n 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 i n 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 planning methods. These classes were offered later i n pregnancy, usually during the third trimester.  The number of these late classes varied  from four to six among the individual units. As pregnant women registered for prenatal classes, they were requested to complete a City of Vancouver Health Department Prenatal Assessment Form. Registrants were assigned to classes i n 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 i n 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 c r i t e r i a 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 i n 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 confidenti a l 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  The  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 and  among p r e n a t a l c l a s s a t t e n d e r s . ber an opportunity  In an e f f o r t  to participate,  to give every class  t o be g i v e n  Names c o r r e s p o n d i n g t o t h e number  on the q u e s t i o n n a i r e s were w r i t t e n on the c o v e r i n g l e t t e r s the q u e s t i o n n a i r e s f o r  the b e n e f i t of  the nature of  investigator kept a record of  p o n d e d t o t h e number c o d e s o f  the  study  the questionnaires  from the i n v e s t i g a t o r w i t h the assent of  On c o m p l e t i o n o f  the p r e n a t a l c l a s s  series,  i g a t o r c o l l e c t e d the returned questionnaires from the  sometimes  the  E a c h h e a l t h u n i t was s a m p l e d f i v e c l a s s e s between March 15,  times,  1983 a n d J u n e 1 5 ,  a  prenatal  the  invest-  prenatal  i n s t r u c t o r s and r e l e v a n t d a t a on the P r e n a t a l Assessment Form 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  the  administered.  g i v e n by p r e n a t a l i n s t r u c t o r s a t the next p r e n a t a l c l a s s o r by  instructor.  codes  t h e names w h i c h c o r r e s -  V e r b a l reminders t o r e t u r n the q u e s t i o n n a i r e s were  telephone c a l l  for  Questionnaire. totalling thirty  prenatal  1983.  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 and June 15,  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  group i n the study. the coordinator of to notify  The  out  The  c o u l d be e a s i l y removed f r o m the 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 The  those  accompanying  the prenatal i n s t r u c t o r .  covering l e t t e r p r o v i d i n g an explanation of  instructor.  mem-  number c o d e d q u e s t i o n n a i r e s f o r  a b s e n t were 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 , l a t e r i n the c l a s s or s e r i e s .  tardiness  to provide a  15  control  investigator contacted the prenatal c l e r k s  the w a i t i n g l i s t t o e x p l a i n the study and ask  them  t h e i n v e s t i g a t o r when 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 Forms  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 .  The  investigator  and  communicated frequently with the coordinator of the waiting l i s t for current additions and deletions. Subjects who met the study c r i t e r i a were sent a covering letter explaining the study (refer to Appendix B), the Health Habits Questionnaire 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  c a l 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 information 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 i n 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 i s 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 i n 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 i s described i n 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 i n Chapter IV.  CHAPTER IV STUDY RESULTS Overview  The major findings of this study are presented i n four sections. The f i r s t section provides a description of the response rate and the demographic characteristics of the participants i n 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 i n 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 i n Table 4-1.  Table 4-1 Response Rate by Health Unit Eligible Health Unit  % of Total  Subjects  Participants  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  285  220  Total  % of Unit  Sample  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 i s presented i n 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  220  100.0  Total  Countxy of Origin The majority of prenatal class attenders were born i n Canada (65.5%). Others of the sample were born i n China, Europe, United States, England, Phillipines, Africa, F i j i , India, Vietnam and other countries as evidenced i n Table 4-3.  Table 4-3 Country of Origin of the Respondents Country  Absolute Frequency  Relative Frequency (%)  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  Fiji  3  1.4  India  3  1.4  Vietnam  3  1.4  Other  9  4.1  2  0.9  220  100.0  Canada  a  Unknown Total Si  Includes Afghanistan, Ceylon, Korea, Malaysia and Mexico.  Indonesia, Japan,  Language The language b e s t u n d e r s t o o d by the respondents was E n g l i s h (89.1%) w i t h f r e q u e n c i e s o f o t h e r b e s t u n d e r s t o o d languages shown i n Table  Table  4-4.  4-4  Language B e s t Understood by the  Language  Respondents  A b s o l u t e Frequency  R e l a t i v e Frequency  English  196  89.1  Chinese  11  5.0  French  2  0.9  German  2  0.9  Other  7  3.2  2  0.9  220  100.0  a  Unknown Total  Includes Japanese, and T a m i l .  Italian,  Persian,  P u n j a b i , Portuguese,  Spanish  (%)  F a m i l y Income The a n n u a l g r o s s $10,000 and $30,000.  income o f 41.0% o f respondents was between T h i r t y - n i n e p e r c e n t o f t h e p a r t i c i p a n t s had  incomes between $30,000 and $60,000. was p r o p o r t i o n a l l y below $10,000 T a b l e 4-5 r e p r e s e n t s  The remainder o f t h e group  (11.0%)  and o v e r $60,000  (10.0%).  t h e g r o s s f a m i l y income d i s t r i b u t i o n o f t h e  participants.  T a b l e 4-5 Annual Gross F a m i l y Income o f Respondents  F a m i l y Income $0  Absolute  Relative  Frequency  Frequency  Adjusted (%)  Frequency  -  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  $ 60,000  21  9.5  10.1  13  5.9  220  100.0  over unknown  Total  missing 100.0  Education Most o f t h e r e s p o n d e n t s had Grade 12 o r f u r t h e r e d u c a t i o n w i t h a p p r o x i m a t e l y 59.0% o f t h e r e s p o n d e n t s h a v i n g p o s t education.  T a b l e 4-6 p r e s e n t s  (88.2%)  secondary  the d i s t r i b u t i o n o f the l e v e l s o f  education a t t a i n e d by the study group.  Table 4-6 Education Levels of Respondents Highest Level of Education  Absolute  Relative  Cumulative  Frequency  Frequency (%)  Frequency (%)  2  0.9  0.9  23  10.5  11.4  Grade 12  64  29.1  40.5  Technical Training  27  12.3  52.8  College Diploma  38  17.3  70.1  University  59  26.8  96.9  Other  6  2.7  99.6  Unknown  1  0.5  0.5  220  100.0  100.0  Grades 1 —  7  Grades 8 —  11  Total  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 i n their f i r s t half  of pregnancy on completion of the Prenatal Assessment Form and 17.0% were i n their f i r s t trimester.  The Health Habits Questionnaire was  completed i n the second half of pregnancy —  the majority of respond-  ents being i n 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 i n  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. majority of the respondents  The  (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 i n 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 Questionnaire were f a i r l y 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  Smoker Non-smoker Unknown Total  HHQ  no.  (%)  no.  (%)  no.  (%)  67  30.5  29  13.2  33  15.0  153  69.5  188  85.5  187  85.0  3  1.4  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 i n 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 HHQ  PAF  No. of Cigarettes per day  no.  (%)  no.  (%)  no.  (%)  0  153  69.5  188  85.5  187  85.5  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  220  100.0  220  100.0  220  100.0  Occasional  Total  Change i n Smoking Of the 33 prenatal class attenders who smoked during pregnancy 30 (90.9%) reported they decreased smoking, 2 (6.1%) reported no change i n smoking and 1 (3.0%) reported an increase i n smoking. influences on Smoking Behavior Thirty-seven respondents identified factors which influenced a change i n 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 Frequency  5  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  More than one influence may be reported by respondents b n = 37 a  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 i n pregnancy, as reported on the Health Habits Questionnaire, 105 (47.7%) reported drinking alcohol (this number i s more than reported on the PAF earlier i n pregnancy, and w i l l be discussed further i n 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  no.  (%)  128  58.2  Alcohol Abstainer  92  41.8  Unknown  —  —  —  —  220  100.0  220  100.0  Alcohol User  Total  no.  HHQ (%)  no.  (%)  54  24.6  105  47.7  166  75.5  113  51.4  2  0.9  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 i n 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 i n the 4 or more servings categories, but increased i n the 3 or less servings categories.  63 Table 4-11 Number of Alcohol Servings  Consumed Before and During Pregnancy During Pregnancy  Before Pregnancy No. of Servings per week  PAF no.  HHQ  (%>  no.  (%)  no.  (%)  92  41.8  166  75.5  113  51.4  Occasional*  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  5  2.3  -  -  —  —  —  —  220  100.0  220  100.0  0 3  15 & Over Unkown Total  -  3  1.4  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 o f A l c o h o l Consumed B e f o r e and D u r i n g Pregnancy Before  Wine  Beer S e r v i n g s p e r Week  no.  Pregnancy  (%)  no.  Liquor (%)  no.  (%)  163  74.1  107  48.6  162  73.6  11  5.0  17  7.7  14  6.4  1 - 3  32  14.5  61  27.7  32  14.5  4 - 6  7  3.2  28  12.7  7  3.2  7-9  2  0.9  3  1.4  1  0.5  4  1.8  4  1.8  3  1.4  1  0.5  _  —  1  0.5  220  100.0  220  100.0  0 Occasional'  10 15  3  14  +  Total  D u r i n g Pregnancy Beer S e r v i n g s p e r Week  no.  220 :  (PAF)  Wine (%)  no.  100.0  Liquor (%)  no.  (.%)•  199  90.5  174  79.1  6  2.7  15  6.8  3  1.4  1-3  14  6.4  30  13.6  7  3.2  4 - 6  -  -  1  0.5  -  220  100.0  220  0 Occasional*  3  7-9 Total  1  0.5  220  100.0  210  (table  95.5  -  100.0  continues)  During Pregnancy (HHQ) Beer  Liquor  Wine  Servings Per Week  no.  (%)  no.  (%)  no.  (%)  0  193  87.7  135  61.4  195  88.6  a  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  -  -  -  -  Occasional'  3  7-9  -  -  -  -  10  -  -  -  -  1  0.5  1.4  3  1.4  +  Unknown  3 Total  220  1.4 100.0  3 220  100.0  220  100.0  a. = 12 oz. beer, or 5 oz.wine, or 1 oz. :liquor. One servxng ^Occasional = less than one serving per week or specified :  as occasional drinker.  Change i n 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 i n fluenced a change i n alcohol intake during pregnancy. Own personal knowledge, books, magazines and pamphlets, change i n 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 Frequency  3  Percent of Cases  Own personal knowledge  98  89.9  Books/magazines/pamphlets  47  43.1  Change i n 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 i n personal stress  3  2.8  Other  3  2.8  More than one influence may be reported by respondents  a  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 i n 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 (%)  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  10  4.5  Prenatal vitamins  Other  ^ o r e than one drug may be reported by the respondents b  N = 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 i n 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 (%)  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  Prenatal vitamins  More than one drug may be reported by the respondents  a  b  N = 220  Painkillers, antihistamines and marijuana were the nonprescription 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  More than one drug may be reported by respondents  a  b  N = 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 i n 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  5  2.3  1  0.5  220  100.0  220  100.0  +  Unkown Total  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 f a i r l y consistent (Refer to Table 4-18). Table 4-18  Coffee  Tea Servings Per Day  no.  (.%)  no.  (%)  Colas 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  220  100.0  220  100.0  220  100.0  Total  -  -  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  220  100.0  220  100.0  220  100.0  Total  -  -  -  -  -  -  Change i n 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 i n tea, coffee and cola intake of the prenatal class attenders.  Table 4-19 Frequency of Reported Changes i n Tea, Coffee and Cola Intake Tea  Coffee  Cola  Change  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  179  100.0  160  100.0  139  100.0  Total  .  no.  (%)  no.  (%)  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 i n fluenced their change.  As shown i n Table 4-20, own personal knowledge,  books, pamphlets and magazines, change i n craving and doctor were the most frequent influences reported.  Table 4-20 Influences on Tea, Coffee and Cola Intake Absolute Frequency  Influences  Percent of <  121  69.9  Books/magazines/panphlets  72  41.6  Changes i n 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 i n stress  6  3.5  Social pressure  2  1.2  Own, personal knowledge  More than one influence may be reported by the respondents  a  b  n  =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 f r u i t 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  f r u i t 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'  Cum.%  Abs. Adj.%  Cum.%  Abs.  Adj.%  Cum.%  Adj.%  Currf.%  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  -  100.0  -  100.0  36  16.8  100.0  14  6.5  100.0  Frequencies  Abs.  Abs.  Adj.%  Bread/Cereal  Fruit/Veg.  Meat  Milk  No. of Servings 0  7.0 & over Unknown  -  6 missing 100.0 Total Note:  220  100.0  100.0  Abs. = Absolute;  -  6 missing 100.0 220  100.0  Adj. = Adjusted;  100.0  _  6 missing 100.0 220  100.0  100.0  6 missing 100.0 220  Cum. = Cumulative.  ^ i e t s were assessed according to Canada's Food Guide minimum recommendations: Milk and Milk Products Meat and Alternates Fruit and Vegetables Breads and Cereals  = = = =  4 2 4 4  servings, servings, servings, servings.  100.0  100.0  76  Table 4-22 Total Diet Score  (Prenatal Assessment Form)  Absolute Frequency  Score  Adjusted Freq.(%)  Cumulative Freq.(%)  10.0 or less  15  7.0  7.0  10.5 - 13.0  70  32.7  39.7  13.5 - 15.5  98  45.8  85.5  16.0  31  14.5  100.0  6  missing  missing  100.0  100.0  Unknown Total  220  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 f r u i t 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 f r u i t 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 Questionnaire Milk  0  Fruit/Veg.  Meat Adj.%  Cum.%  Adj.%  Cum.%  Abs.  Adj.%  Cum.%  4  1.9  1.9  2  0.9  0.9  -  -  -  17.0  33  15.6  17.5  5  2.4  3.3  9  4.2  4.2  15.1  32.1  82  38.7  56.2  16  7.5  10.8  20  9.4  13.6  66  31.1  63.2  64  30.2  86.4  21  9.9  20.7  45  21.2  34.8  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  Frequencies  Abs.  Adj.%  Cum.%  8  3.8  3.8  1.0 - 1.5  28  13.2  2.0 - 2.5  32  3.0 - 3.5  Abs.  Abs.  Bread/Cereal  No. of Servings 0  4.-0  -  Total  220  100.0  100.0 100.0  Note: Abs. = Absolute;  8 missing 100.0 220  100.0  Adj. = Adjusted;  100.0  8 missing 220  100.0  100.0 100.0  8 missing 220  Cum. = Cumulative  ^ i e t s were assessed according to Canada's Food Guide minimum recommendations: Milk and Milk Products Meat and Alternates Fruit and Vegetables Breads and Cereals  = = = =  4 2 4 4  servings, servings, servings, servings.  100.0  100.0 100.0  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 Score  (Health Habits Questionnaire)  Absolute Frequency  Adjusted Freq.(%)  Cumulative Freq.(%)  10.0 or less  13  6.1  6.1  10.5 - 13.0  63  29.7  35.8  13.5 - 15.5  96  45.3  81.1  16  40  18.9  100.0  Unknown  8 Total  220  missing  missing  100.0  100.0  Change i n 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 f r u i t and vegetables, 106 (48.8%) increased their meat consumption, and 98 (45.4%) increased their intake of bread and cereals. by 89 (41.0%).  Consumption of sweets was reported as decreased  The frequency of reported changes i n food consumption  during pregnancy i s illustrated i n Table 4-25.  Table 4-25 Change i n Food Intake According to the Four Food Groups  Milk  Meat  Fruit/  Bread/  Vegetables  Cereal  Sweets  Abs.  Adj.%  Abs.  Adj.%  Abs.  Adj.%  Abs.  Adj.%  Ads.  Adj.%  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  3  missing  Frequencies Change  Missing  2 Total  220  missing 100.0  3 220  100.0  220  Note: Abs. = Absolute; Adj. = Adjusted.  100.0  4 220  missing 100.0  3 220  missing 100.0  Influences on Diet Intake Two hundred and seventeen respondents identified factors which influenced their diet changes during pregnancy. As indicated i n Table 4-26, own personal knowledge, books, magazines and pamphlets, change i n appetite or craving, and doctor were most frequently reported.  Table 4-26 Influences on Diet Intake Influences Own personal knowledge  a Absolute Frequency 145  ] Percent of Cases 66.8  Books/magazines/pamphlets  108  49.8  Change i n 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  More than one influence may be reported by the respondents.  a  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 i n craving, and doctor, i n 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%) respondents 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, i n 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. 7 or more servings per day.  Two  (1.0%) respondents reported intakes of  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, i n this order, were most frequently reported as influencing change i n 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 f r u i t and vegetables, and 175 (82.5%) met the recommended intake of meat and alternates. A l l of the respondents reported making some change i n their diet intakes during pregnancy and 204 increased their milk consumption.  (90%)  Gwn personal knowledge, books, maga-  zines and pamphlets, change i n appetite or craving, and doctor, i n this order,were the most frequently reported influences to change diet during pregnancy. A profile summarizing the major health behaviors of prenatal class attenders i s presented in Table  4-27.  83 T a b l e 4-27 Health Behavior P r o f i l e o f Prenatal Class Attenders Age:  27 y e a r s  (mean).  Country o f O r i g i n :  Canada (65.5%).  Language B e s t U n d e r s t o o d :  English  (89.1%).  A n n u a l Gross F a m i l y Income: ^ $ 3 0 , 0 0 0 Education: Parity: Smoking:  Grade 12 o r f u r t h e r  (88 .2%) .  P r i m i p a r a (90.9%) B e f o r e Pregnancy (30.5%)  D u r i n g Pregnancy (15.0%)  Alcohol  (50.7%) .  B e f o r e Pregnancy (58.2%)  Intake:  D u r i n g Pregnancy  1 - 6  cigarettes/day  ( 6.4%)  7-24  (15.5%)  25 +  ( 8.2%)  1 - 6  cigarettes/day  ( 4.5%)  7-24  ( 9.5%)  25 +  ( 0.5%)  Occasional  (11.4%)  1 - 3  (18.6%)  drinks/week  4 o r more  (28.2%)  Occasional  (17.3%)  1 - 3  (19.5%)  drinks/week  4 o r more  ( 9.1%)  Non-prescription Medication Use: Medications other than p r e n a t a l v i t a m i n s  (40.0%  o r any v i t a m i n s  (18.2%  Tea, C o f f e e , Cola Intake:  Diet Intake:  D u r i n g Pregnancy  (88.6%  7 o r more s e r v i n g s p e r day  ( 1.0%  M e e t i n g C a n a d a ' s Food Guide Requirements  (18.9%  Milk  4 servings  (36.8%  Meat  2 servings  (82.5%  F r u i t and V e g e t a b l e s 4 s e r v i n g s  (79.2%  Breads and C e r e a l s  (65.1%  4 servings  84 Overall Health Behaviors of Prenatal Class Attenders 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 identi f i e d 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 i n 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 i n Canada than i n other countries.  A greater proportion of pregnant women born i n Canada  consumed alcohol during pregnancy and ate diets according to Canada's Food Guide, than pregnant women born i n other countries. Annual Gross Family Income Health behaviors were not s t a t i s t i c a l l y associated with annual gross family income. Although 64.5% of smokers had incomes below $30,000, the relationship between smoking and income was not statist i c a l l y significant.  The relationships between annual gross family  income and alcohol intake or diet were also not significant as i s indicated on Table 4-29.  Table 4-28 Country of Origin by Health Behaviors Country of Origin Health Behaviors  Canada Other than Canada  Smoking Non-smoking  29  4  115  70  Significance %  2  = 7.153  df = 1 **p < .01  Alcohol user  84  20  Alcohol abstainer  59  53  = 17.78 df = 1 ***p < .001  Diet meeting CFG  a  Diet not meeting CFG  3  33  7  111  67  %  2  = 5.045  df = 1 *£ < .05  CFG = Canada's Food Guide  Table 4-29 Annual Gross Family Income by Health Behaviors Annual Gross Family Income Health Behaviors  < $30,000  >$30,000  Significance  Smoking  20  11  %• = 2.164  Non-smoking  85  91  df = 1 E<  Alcohol user  43  56  Alcohol abstainer  61  45  %  2  .5  = 3.534  df = 1 £ < .1  Diet meeting CFG  17  21  %  Diet not meeting CFG  88  81  df = 1  21  2  = 0.406  £< a  CFG = Canada's Food Guide  1.0  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  24  9  Non-smoking  65  121  %  2  = 15.055  df = 1 ***p < .001  Alcohol user  39  66  Alcohol abstainer  49  63  %  2  = 0.726  df = 1 £ < .5  Diet meeting CFG*  10  30  Diet not meeting CFG'  79  100  %  2  = 4.200  df = 1 < .05  a  CFG = 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 i n 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 i n 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 o t h e r f i n d i n g s o f t h i s s t u d y a r e p r e s e n t e d i n two The f i r s t s e c t i o n summarizes t h e f i n d i n g s o f t h e p r e n a t a l registrants  on the w a i t i n g l i s t ,  sections. class  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 a t t e n d e r s and registrants.  Results of Prenatal Class Registrants  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 t o the end o f June 1983.  A l t h o u g h 171 women were on the w a i t i n g l i s t  at  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 o f t h e women d i d n o t meet t h e s t u d y 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 s u b s e q u e n t l y no l o n g e r o n t h e w a i t i n g l i s t . T h i r t y - s i x p r e g n a n t 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 t h e s t u d y c r i t e r i a and were s e n t a 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 , c o v e r i n g l e t t e r and a stamped,  self-addressed envelope.  N i n e t e e n women r e t u r n e d  a completed 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 g i v i n g a r e s p o n s e r a t e o f 52.8%. From t h e 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  already attending prenatal classes,  1 d i d n ' t understand E n g l i s h ,  m a i l e d t h e completed q u e s t i o n n a i r e , b u t t h e i n v e s t i g a t o r it,  and 2 had moved and had s u b s e q u e n t l y n o t r e c e i v e d the  never  1  received  questionnaire.  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 i s presented i n 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 i n 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 consumption 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  T a b l e 5-1 Health Behavior P r o f i l e of Registrants on the Waiting L i s t Age:  28 y e a r s  (mean).  Country o f O r i g i n :  Canada (52.6%).  Language B e s t U n d e r s t o o d :  English  (68.4%) .  A n n u a l Gross F a m i l y Income:£ $30,000 Education: Parity: Smoking:  Grade 12 o r f u r t h e r  Primipara  (89 .5%) .  (52.6%).  B e f o r e Pregnancy (26. 3%)  D u r i n g Pregnancy (15. 8%)  Alcohol  (88.2%).  B e f o r e Pregnancy (31. 6%)  Intake  D u r i n g Pregnancy (26. 3%)  1 - 6  cigarettes/day  ( 5.3%)  7-24  (21.1%)  25 +  '( 0.0%)  1 - 6  cigarettes/day  (10.5%)  7-24  ( 5.3%)  25 +  ( 0.0%)  Occasional  (10.5%)  1 - 3  (10.5%)  drinks/week  4 o r more  (10.5%)  Occasional  (15.8%)  1 - 3  (10.5%)  drinks/week  4 o r more  ( 0.0%)  Non-prescription Medication Use:  Tea,  Medications other than p r e n a t a l vitamins  (47.3%  o r any v i t a m i n s .  (15.8%  Coffee, Cola Intake:  Diet Intake:  D u r i n g Pregnancy  (84.2%  7 o r more s e r v i n g s p e r day  ( 5.3%  M e e t i n g C a n a d a ' s Food Guide Requirements  (11.8%  Milk  4 servings  (29.4%  Meat  2 servings  (64.7%  F r u i t and V e g e t a b l e s 4 s e r v i n g s  (88.2%  Bread and C e r e a l s  (58.8%  4 servings  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 i n their diet and a l l of those who smoked or used alcohol reported decreasing their smoking and alcohol intake during pregnancy.  Decreases i n 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. nor drink.  Before pregnancy, 10 (52.6%) subjects did not smoke  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 i n 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 i n pregnancy. Thirtyfive respondents suggested that both early bird classes as well  93 as the prenatal class series start earlier i n 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 suggested 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 i n pregnancy. 5. Prenatal education should start pre-conceptually.  Nine respond-  ents indicated a need for more information to be offered preconceptually i n 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  for existing prenatal classes.  The s u g g e s t i o n s o f n i n e t e e n r e s p o n d e n t s  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 t h a n l e c t u r e , o f updated a u d i o - v i s u a l s and r e a d i n g m a t e r i a l s , p r e s e n t a t i o n s and s m a l l e r and s h o r t e r  more f r e q u e n t use  improvements i n c l a s s  classes.  P o s i t i v e comments o n c u r r e n t p r e n a t a l e d u c a t i o n — p a r t i c u l a r l y prenatal classes  — were made b y t w e n t y - f i v e r e s p o n d e n t s .  These  comments i n d i c a t e d a g e n e r a l 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 classes  and t h a t t h e 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 future p r e n a t a l education included prenatal classes classes  o f f e r e d t h r o u g h a knowledge network b y T . V . , p r e n a t a l  f o r s i n g l e women, S a t u r d a y p r e n a t a l c l a s s e s  promotion o f p r e n a t a l  and f o r p u b l i c  classes.  Recommendations 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  The major recommendation made b y p r e n a t a l c l a s s r e g i s t r a n t s the w a i t i n g l i s t was t o i n c r e a s e  the a v a i l a b i l i t y o f p r e n a t a l  to expectant couples, regardless of t h e i r p a r i t y .  on  classes  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 e d u c a t i o n o n smoking, a l c o h o l , d r u g s , and n u t r i t i o n d u r i n g pregnancy; more T . V . programs o n 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 q u e s t i o n s o n d i e t ,  e x e r c i s e and o t h e r  c o n c e r n s t h a t p r e g n a n t women may h a v e , e s p e c i a l l y i n t h e e a r l y months. Comments t h a t B a b y ' s B e s 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 s u g g e s t i o n s f o r d o c t o r s t o i n f o r m and a d v i s e women t o a t t e n d 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 i n 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 i n 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,(LandesmanDwyer, 1982). That i s ; 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 i s 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 i s the same as the findings of another Vancouver study by Bradley, Ross and Warnyca (1978).  I t i s 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 i n the Canada Health Survey (1978-1979) for women between the ages of 15 and 44 years (Health and Welfare Canada, 1981). The rate of respondents 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 i n pregnancy (HHQ) was more than the alcohol consumption reported earlier i n pregnancy (PAF).  This finding was also observed  by L i t t l e , Mandell and Schultz (1976) and may be attributed to the presence of nausea which frequently accompanies early pregnancy or to a discrepancy i n 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 i s reported by several studies to have adverse effects on pregnancy. Non-prescription drugs other than prenatal vitamins, were consumed 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 antinauseants 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 i n this study  during pregnancy compares, to 43% reported by Hingson et a l . (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 i n pregnancy and the other later i n 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 f r u i t 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 a l . (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 f r u i t and vegetables cannot be compared as the measures used were different from those used i n 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 i n diet intake between the present study's findings and Latchford et al.'s (1970) may be a reflection of a change i n 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 f r u i t and vegetables.  The high cost of meat may be another reason for i t s  decrease consumption. Total diet scores of less than 16, obtained by prenatal class  a t t e n d e r s o n 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 s c o r e s r e p o r t e d on the 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 Latchford et a l .  (1970) a l s o f o u n d t h a t 85% o f p r e g n a n t women  o b t a i n e d inadequate d i e t The  scores.  f i n d i n g s o f the 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 o n the  w a i t i n g l i s t are r e l a t i v e l y attenders.  That i s ;  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  16% smoked, 26% consumed a l c o h o l ,  n o n - p r e s c r i p t i o n drugs o t h e r t h a n v i t a m i n s , and  (81.1%).  colas,  class  16% u s e d  84% drank t e a ,  coffee  and 88% had l e s s than adequate d i e t s d u r i n g p r e g n a n c y .  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 c o n c l u s i o n s may be based on t h e s e f i n d i n g s .  Influences  t o Change H e a l t h B e h a v i o r s D u r i n g  This study's  Pregnancy  f i n d i n g s o f 91% o f the smokers who d e c r e a s e d  their  smoking d u r i n g pregnancy i s much h i g h e r t h a n the 60% B a r i c and MacCarthur  (1977) r e p o r t e d i n t h e i r s t u d y o f p r e g n a n t 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  p o p u l a t i o n s — as the p r e s e n t s t u d y o n l y i n c l u d e d women a t t e n d i n g prenatal classes.  As shown i n T a b l e 6-1,  t h e major i n f l u e n c e s  change smoking were f o u n d t o be own p e r s o n a l knowledge, magazines and pamphlets,  doctor,  Studies by Gardiner e t a l .  and f a m i l y member o r  to  books,  friends.  (1981) and B a r i c and MacCarthur (1977)  b o t h 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 t o change smoking. Mass media  (98%), f r i e n d o r n e i g h b o r (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 change smoking.  to  100 Table  6-1  Frequency of Reported Influences to Change Health Behaviors Health Behaviors Influences  Smoking  Alcohol  (%)  (%)  a  Tea/Coffee/Cola  b  (%)  C  Diet (%)  d  Own personal knowledge  86.5  89.9  69.9  66.8  Books/magazines/pamphlets  45.9  43.1  41.6  49.8  Change i n 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. a  n = 37; n = 109; °n = 173; n = 217. b  d  The majority of the respondents in this study (98%) reported decreasing their alcohol intake during pregnancy.  This rate of decrease i s substant-  i a l l y higher than the findings by Baric and MacCarthur (50%) — and again may be attributed to the difference i n population characteristics.  As  shown i n 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 consumption 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.  I t i s 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 consumption during pregnancy, Most respondents made some change i n their diet intake during pregnancy, with 90% increasing their milk consumption.  I t i s 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 i n creased milk consumption during pregnancy.  Although change i n 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 i n 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 i n 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 i n 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 i s 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 i s the second most frequently reported influence by prenatal class attenders.  This may be a direct  result of the literature distributed i n 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 i n the last ten years and are available i n local bookstores and libraries. Change i n craving and doctors are the next most frequently reported influences to change health behaviors.  As was discussed pre-  viously, other studies have similarily found change i n 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 i s not unusual that doctors were identified as influences. What i s surprising, though,, i s 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 i n terms of the personal choice behavior model. The personal choice behavior model explains that the change i n 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), f a c i l i t a t i o n from the environment (books, magazines and pamphlets, doctor, etc.), loss of psychological u t i l i t y (nausea, change i n 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 i s reinforced by the other influences identi f i e d (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 u n t i l recently — and even now the effects of minimal drinking are not f u l l y 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 i n 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 i n 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 i n 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 i s more common i n the older women i s a finding similar to that observed by others (Kuzma and Kissinger, 1981; Streissguth, Barr, Martin and Herman, 1980; Kaminski, Franc, LeBouvier, duMazaubrun and RumeauRoquette, 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 i n pregnancy by doctors and by prenatal classes. Many of the participants expressed frustration when this information was offered late i n 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 i s associated with smaller babies, they don't know the f u 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 participants.  These comments may reflect their awareness of the importance  of prenatal health during pregnancy as well as preconceptually. More reading materials i n 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 i n this study had attained at least a Grade 12 education.  Even though  there are many books and magazines available on pregnancy from bookstores, the credibility of the information therein i s 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 i n 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 i n 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 i n health behaviors during pregnancy. Own personal knowledge, books, magazines and pamphlets, change i n 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 i s a continuing need for prenatal education.  Prenatal classes  do not teach the "already converted"; i e . , 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 i n order to prevent poor health habits from becoming established. Since smoking i s associated with a younger age group, anti-smoking education should be provided i n high school.  Health education should, i n addition to information,  also include ways which would help individuals change their habits.  Promotion of non-alcoholic beverages as alternatives to  alcohol use i s one example.  108 2.  Health education on the relationships of health behaviors and and pregnancy outcome should be offered prior to or early i n 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 i s , 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 —  5.  especially during pregnancy.  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 therefore not be neglected by health educators i n 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 recommendations for further research are suggested: 1.  A prospective study should be conducted to investigate the changes i n 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 cigarettes smoked, and specific intakes of alcohol, drugs, caffeine or nutrients were beyond i t s 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 i n 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 i t s validity as a guide for adequate food intake i s desperately needed. Perhaps an alternate food guide which i s 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" i s warranted.  Can the sources from which one's own  personal knowledge i s developed be identified, or i s i t the integration of information from many sources? 5.  Since the scope of this study was prenatal class registrants,  Ill 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.  This would help establish whether the  influences to change behaviors provide new information or reinforce what i s already known. Such findings would assist prenatal educators to provide more effective and efficient prenatal programs. 7.  Since doctors were reported as influencing health behaviors during pregnancy, a survey of doctors should be conducted to identify the information they give to pregnant women regarding health behaviors during pregnancy.  8. • Additional research to develop cost efficient and effective teaching methods directed at pregnancy health habit change should be pursued. 9.  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Canada:  Ojofeitimi, E., Elegbe, I., & Babafemi, J. (1982). Diet restriction by pregnant women i n Nigeria, International Journal of Obstetrics and Gynecology, 20, 99-103. Osofsky, H. (1975). Relationships between prenatal medical and nutritional measures, pregnancy outcome and early infant development in an urban poverty setting. I. The role of nutritional intake. American Journal of Obstetrics and Gynecology, 128(7), 682-691. Ostertag, W., Duisberg, E., & Sturman, M. (1965). The mutagenic activity of caffeine i n man. Mutation.Research, 2,, 293-296. Ouellette, E., Rosett, H., Rosman, N., & Weiner, L. (1977). Adverse effects on offspring of maternal alcohol abuse during pregnancy. New England Journal of Medicine, 297, 528-530. Papoz, L., Eschwege, E., Pequignot, G., Barrat, J., & Schwartz, D. (1982). Maternal smoking and birth weight i n relation to dietary habits. American Journal of Obstetrics and Gynecology, 142(7), 870-876. Pencharz, P. (1981). Maternal nutrition and the outcome of pregnancy. Canadian Medical Journal, 125(6), 529-531. Picone, T., Allen, L., Olsen, P., & Ferris, M. (1982). Pregnancy outcome i n North American women. II. Effects of cigarette smoking, stress and weight gain on placentas, and on neonatal physical and behavioral characteristics. American Journal of Clinical Nutrition, 3£, 1214-1224. Pitkin, R. (1981). Assessment of nutritional status of mother, fetus and newborn. American Journal of Clinical Nutrition, 34, 658-668. Province of B.C. Ministry of Health (1979). Baby's best chance. perinatal manual for parents. Victoria: Health Promotion and Information.  A  119 Province of B.C. Ministry of Health (1980). V i t a l Statistics of the Province of British Columbia. One hundred and ninth report, Victoria: Queens Printer for B.C. Rantakallio, P. (1979). Social background of mothers who smoke during pregnancy and influence of these factors on the offspring. SocialScience and Medicine, 13A, 423-429. 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Canadian Medical Association Journal, 125, 149-154. Rosett, H., Weiner, L., Lee, A., Zuckerman, B., Dooling, E., & Oppenheimer, E. (1983). Patterns of alcohol consumption and fetal development. Obstetrics and Gynecology, 6^(5), 539-546. Rosett, H. Weiner, L., Zuckerman, B., McKinlay, S., & Edelin, K. (1980). Reduction of alcohol consumption during pregnancy with benefits to the newborn. Alcoholism: Clinical and Experimental Research, £(2), 178-184. Rush, D., & Kristal, A. (1982). Methodologic studies during pregnancy: the r e l i a b i l i t y of the 24-hour dietary r e c a l l . American Journal of Clinical Nutrition, 35, 1259-1268. Ross, S., & Rutter, A. (1978). Healthiest babies possible. An outreach program. Vancouver: City of Vancouver and Provincial Government of B.C. Rosso, P. (1981). Nutrition and maternal-fetal exchange. Journal of C l i n i c a l Nutrition, 34, 744-755.  American  120 Rumack, C , Guggenheim, M., Rumack, B., Peterson, R., Johnson, M., & Braithwaite, W. 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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 L i s t  APPENDIX C  Health Habits Questionnaire  Registration  No.  P r e n a t a l Education  1.  2.  During t h i s pregnancy, I have attended (a)  an  "early b i r d "  prenatal class  (b)  a p r e n a t a l Interview w i t h a community h e a l t h nurse  (c)  a p r e n a t a l c l a s s not from the Vancouver Health Department  (d)  none of the above  Your h e a l t h h a b i t s d u r i n g pregnancy i n c l u d e your patterns of smoking, a l c o h o l , drug and n u t r i t i o n a l i n t a k e .  How  much has  the information provided by each o f the f o l l o w i n g i n f l u e n c e d your h e a l t h h a b i t s d u r i n g pregnancy?  Very Much  Somewhat  Not At A l l  Not Applicable  Community h e a l t h nurse Doctor Prenatal c l a s s - e a r l y b i r d Family member/friend T.V./radio Books/magazlnes/pamphlets Nutritionist Other 3.  (specify)  P r e n a t a l information on h e a l t h h a b i t s d u r i n g pregnancy can be sented l n many ways.  Please i n d i c a t e your preference  pre-  from among  these sources by p l a c i n g a "1" beside the most p r e f e r r e d , a  "2"  beside the next most p r e f e r r e d , and a "3" beside the next most preferred. personal Interview w i t h a community h e a l t h nurse prenatal c l a s s appointment w i t h my  doctor  books/magazlnes/pamphlets advice from f a m i l y member/friend T.V. / r a d i o other  (specify)  Smoking 1.  Do you smoke?  Yes  I f no, please go  i 2.  on t o S e c t i o n C.  I f yes, please I n d i c a t e : Number o f c i g a r e t t e s  How o f t e n (eg. day, week, e t c . )  3.  How has your smoking changed d u r i n g pregnancy? Increased decreased no change  ^.  I f you have increased o r decreased your smoking d u r i n g pregnancy, what i n f l u e n c e d you the most to do so? (You may y/ more than one item)  _(b)  change ln personal stress 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)  Alcohol 1.  Do you d r i n k a l c o h o l i c beverages?  Yes  No  I f no, please go on t o | 2.  3.  S e c t i o n D.  I f yes, please i n d i c a t e the number o f servings per week. Beer  (12 oz.)  Wine  ( 5 oz.)  Liquor  ( 1 oz.)  How has your a l c o h o l i c i n t a k e changed d u r i n g your pregnancy? increased decreased no change  I f you have increased o r decreased your i n t a k e o f a l c o h o l d u r i n g pregnancy, what i n f l u e n c e d you the most to do so? (You may  J  more than one item)  (a)  social  pressure  (b)  change i n personal s t r e s s  (c)  change i n c r a v i n g  (d)  personal knowledge about a l c o h o l consumption d u r i n g pregnancy  (e)  prenatal class  (f)  community h e a l t h nurse  (g)  doctor  (h)  f a m i l y member/friend  (i)  T.V./radio  (j) (k)  books/magazines/pamphlets other  (specify)  .  131 D.  N o n - P r e s c r i p t i o n Drugs and Medicines 1.  I f you have increased o r s t a r t e d t a k i n g n o n - p r e s c r i p t i o n drugs ( t h i s Includes a s p i r i n , marijuana, mineral supplements, e t c . )  c o l d remedies, v i t a m i n and  d u r i n g your pregnancy please  list  below:  Name o f Drug o r Medicine  2.  How much d i d you take?  How much do you take now?  What i n f l u e n c e d you t o increase o r s t a r t taking?  I f you have decreased o r stopped t a k i n g n o n - p r e s c r i p t i o n drugs ( t h i s i n c l u d e s a s p i r i n , marijuana, mineral supplements, e t c . )  c o l d remedies, v i t a m i n and  d u r i n g your pregnancy please  list  below: Name o f Drug or Medicine  How much d i d you take?  How much do you take now?  What i n f l u e n c e d you t o decrease or stop taking?  132 3.  Do you d r i n k t e a , c o f f e e , c o l a s ?  Yes  No  I f no,  please  go on t o S e c t i o n E. I f yes, please i n d i c a t e the number o f servings per day. Tea Coffee Cola  5.  How has your t e a , c o f f e e and c o l a intake changed d u r i n g your pregnancy?  (Please  J  )  increased  decreased  no change  Tea Coffee Cola  6.  I f you have Increased  or decreased your i n t a k e of t e a , c o f f e e ,  c o l a s , d u r i n g your pregnancy, what Influenced you the most to do so? (You may  *J more than one item)  (a)  doctor  (b)  community h e a l t h nurse  (c)  f a m i l y member/frlend  (d)  prenatal c l a s s  (e)  personal knowledge about t e a , c o f f e e , c o l a s d u r i n g pregnancy  (f)  social  (g)  T.V./radio  (h)  change i n c r a v i n g  (i)  change i n personal s t r e s s  (j)  books/magazlnes/pamphlets  (k)  other  pressure  (specify)  .  Diet  1.  Choose a t y p i c a l e a t i n g day and record a l l your food i n t a k e f o r t h a t day. f o r one day. eg.)  L i s t a l l the foods, beverages, snacks consumed State the amount of each food and d e s c r i b e ,  s a l a d - l / 2 cup l e t t u c e , l / 4 tomato, 2 tablespoons f r e n c h dressing)  1 pork chop f r i e d w i t h onions.  My food i n t a k e f o r one dayi  Time  Food Eaten  Today's date i s  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 d u r i n g your pregnancy. (Mark an  X  In the appropriate box)  Increase  Decrease  No Change  Milk ( i n c l u d e s cheese, yoghurt) Breads and C e r e a l s ( i n c l u d e s r i c e , noodles) Meat, F i s h , P o u l t r y (Includes eggs, legumes) F r u i t s and Vegetables (includes juice) Sweets ( i n c l u d e s cakes, pastry, chocolate bars, candy) Other  3.  (specify)  What i n f l u e n c e d you the most to make these changes i n your food intake? (You may  J  more than one item)  _(a)  prenatal class  _»  f a m i l y member/friend  _(c)  community h e a l t h nurse  _(*)  nutritionist  _(•)  personal knowledge about n u t r i t i o n  _<*>  T.V./radio  _(«)  doctor  _(h)  books/magazines/pamphlets  _(D  change i n a p p e t i t e o r c r a v i n g  _<J)  change i n food t o l e r a n c e other  (specify)  (heartburn, voralttlng, ga s ) .  Background Information  The f o l l o w i n g Information w i l l be used only t o d e r i v e demographic data which d e s c r i b e s the p o p u l a t i o n being sampled.  1.  Your age i s  years.  2.  What country were you born i n ?  3.  What language do you speak and understand the best?  Gross f a m i l y Income per year i s : _<»>  $0 - $10,000  _(*>  $10,000 - $30,000 $30,000 - $60,000  _<*>  5.  over  $60,000  Educational background  (Please  / highest l e v e l you have  completed) (a) __(b)  6.  Crades  1-7  Grades 8 - 1 1  (c)  High School Diploma  (d)  Technical Training  (e)  C o l l e g e Diploma  (f)  U n i v e r s i t y Degree  (g)  Other  (Grade 12)  (specify)  .  Recommendations In your o p i n i o n , how c o u l d p r e n a t a l education on h e a l t h h a b i t s f o r pregnant women be improved?  (Please use reverse s i d e o f page)  T h i s I s the end o f the q u e s t i o n n a i r e . participating.  Thank you very much f o r  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 line  Tddtiy's I Into  Yr.  Mo.  •KKNATAI. ASSESSMENT I ' O K M  I....J Unv  Utile  •  D  Yr.  r i i y s i c i i m ' s Ntiine A<ldrcss  Name Address Work  I'honc - H o m e Occupation  Partner's Name A. CURRENT  I'hone  Partncr| | or O t l i e r | | Hospital Will A t t e n d C l a s s e s A l s o For D e l i v e r y  First Baby?  PREGNANCY  ROM  How old are you? How many weeks pregnant arc you? . When d i d you first visit y o u r d o c t o r for the p r e g n a n c y ? What do you weigh now? How t a l l are you? Do you plan to breast or b o t t l e feed your baby? Have you any problems w i t h this p r e g n a n c y ? (e.g. nausea, c o n s t i p a t i o n , etc.)  li.  PREVIOUS  PREGNANCIES  many r e s u l t e d i n : Miscarriage Abortion Stillbirth D e a t h before one y e a r H a n d i c a p p e d baby Caesarian section P o s t - p a r t u m depression O t h e r p r o b l e m s d u r i n g p r e g n a n c y or d e l i v e r y PREVIOUS Birthdate  D.  Mo.  Number  Date  CHILDREN Sex  Birthweight  Comments  CONTRACEPTION What k i n d of c o n t r a c e p t i o n , i f any, were you using b e f o r e b e c o m i n g p r e g n a n t ? When d i d you stop? A s s e s s e d by  Date Assessed Yr.  Mo.  Day  C i t y of 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  C Diiy  I ' A Mil. V IIISTOIt V I I 1 1 v o you, tho Imliy's fulhor, nr n n y < m o in your families hml: Myself  My KM in ity  Him  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 Now Before pregnancy  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  Do you drink tea, coffee or colas? EXERCISE  Others  Amount/Day  Amount/Day Tea Coffee 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?  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  Date:  List a l l the foods and beverages c o n s u m e d at m e a l s and snacks. S t a t e the amount eaten of each f o o d and d e s c r i b e , e . g . s a l a d - h cup l e t t u c e K. t o m a t o , 2 tablespoons of f r e n c h d r e s s i n g , 1 pork chop f r i e d w i t h onions.  V i t a m i n s or M i n e r a l s S u p p l e m e n t s : T y p e and amounts TOTAL NUMBER O F SERVINGS  R E C O M M E N D E D NUMBER O F SERVINGS F R O M C A N A D A ' S FOOD GUIDE Adults A d o l e s c e n t s , P r e g n a n t and L a c t a t i n g W o m e n  2  4-5  4  5  CITY O F VANCOUVER H E A L T H D E P A R T M E N T  2  Zh  3-5 5  Extras  Bread Cereals  l  Meat  Fruit Vegetables  How P r e p a r e d  Milk  Food Eaten  Time  Amoun t  •  T O B E C O M P L E T E D I1Y NURSES N u m b e r of Servings  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) . I t i s widely used as a nutrition education tool to assist individuals i n achieving a nutritionally adequate diet. The one-day diet records were analyzed u t i l i z i n g 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  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  food group  TOTAL DIETARY SCORE  16  

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