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Perinatal Health
Indicators for
Canada
A Resource Manual
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Authored by: |
Members of the Canadian Perinatal
Surveillance System Steering Committee
and Staff of Health Surveillance and Epidemiology Division |
Scientific Editors: |
Kitaw Demissie, MD, PhD
K.S. Joseph, MD, PhD
Susie Dzakpasu, MHSc |
Table of Contents
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Canadian Perinatal Surveillance System (CPSS) Steering
Committee Members (1995-2000) |
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Health Surveillance and Epidemiology Division Staff (1995-2000) |
Introduction |
SECTION A
Principal Sources of National Perinatal Health Data
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1. |
Vital Statistics |
2. |
Hospitalization Data
Canadian Institute for Health Information (CIHI)
Discharge Abstract Database
Hospital Morbidity Database
Système de maintenance et d'exploitation des données pour
l'étude de la clientèle hospitalière (Med-Écho)
Canadian Congenital Anomalies Surveillance System (CCASS) |
3. |
National Health Surveys
National Population Health Survey (NPHS)
National Longitudinal Survey of Children and Youth (NLSCY) |
SECTION B
Selected Indicators of Maternal, Fetal and Infant Health |
4. |
Behaviours and Practices
Prevalence of Prenatal Smoking
Prevalence of Prenatal Alcohol Consumption
Prevalence of Breastfeeding
Rate of Live Births to Teenage Mothers
Rate of Live Births to Older Mothers |
5. |
Health Services
Labour Induction Rate
Cesarean Section Rate
Rate of Operative Vaginal Deliveries
Rate of Trauma to the Perineum
Rate of Early Maternal Discharge from Hospital after Childbirth
Rate of Early Neonatal Discharge from Hospital after Birth |
6. |
Maternal Health Outcomes
Maternal Mortality Ratio
Induced Abortion Ratio
Ectopic Pregnancy Rate
Severe Maternal Morbidity Ratio
Rate of Maternal Readmission after Discharge following Childbirth |
7. |
Fetal and Infant Health Outcomes
Preterm Birth Rate
Postterm Birth Rate
Fetal Growth: Small-for-Gestational-Age Rate, Large-for-Gestational-Age
Rate
Fetal and Infant Mortality Rates
Severe Neonatal Morbidity Rate
Multiple Birth Rate
Prevalence of Congenital Anomalies
Rate of Neonatal Hospital Readmission after Discharge at Birth |
Bibliography |
APPENDICES |
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Appendix A: List of Perinatal Health Indicators
Appendix B: List of Acronyms
Appendix C: Components of Fetal-Infant Mortality |
List of Tables
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SECTION A
Principal Sources of National Perinatal Health Data |
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Table 1 |
Principal sources of national perinatal health data |
SECTION B
Selected Indicators of Maternal, Fetal and Infant Health |
4. |
Behaviours and Practices |
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Table 4.1 |
Smoking during pregnancy by maternal age (years), Nova
Scotia, 1996 |
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Table 4.2 |
Prenatal alcohol consumption by geographic region and
age (years), Canada excluding the territories, 1994-1995 |
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Table 4.3 |
Breastfeeding rates (%) by geographic region and age
(years), Canada excluding the territories, 1994-1995 |
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Table 4.4 |
Live births to teenage mothers, age-specific live birth
rates (per 1,000) and teen live births as a proportion of all live births
(%), Canada, 1995 |
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Table 4.5 |
Live births to mothers over 30 years of age, age-specific
live birth rates (per 1,000) and live births in older maternal age categories
as a proportion of all live births (%), Canada, 1970-1995 |
5. |
Health Services |
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Table 5.1 |
Temporal changes in the rates of labour induction among
women at 40 completed weeks of gestation in specific hospitals/regions of
Canada |
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Table 5.2 |
Cesarean section rates in Canada, by year |
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Table 5.3 |
Operative vaginal deliveries as a proportion (%) of all
vaginal births, cross-national comparison |
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Table 5.4 |
Episiotomy rates in Canada, 1981-1982 to 1993-1994 |
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Table 5.5 |
Temporal trends in the rate of short hospital stay (<
2 days) for childbirth in Canada, 1984-1994 |
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Table 5.6 |
Temporal trends in the rates of early neonatal discharge
from hospital (within 48 hours) after birth in Canada, 1984-1994 |
6. |
Maternal Health Outcomes |
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Table 6.1 |
Maternal mortality ratios in selected countries, 1990 |
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Table 6.2 |
Number of induced abortions, induced abortion ratios
and age-specific induced abortion rates (ASAR, per 1000), by maternal age,
Canada, 1995 |
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Table 6.3 |
Temporal trends in rate of ectopic pregnancy in Manitoba,
Canada, 1981-1990 |
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Table 6.4 |
Selected reportable causes of severe maternal morbidity |
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Table 6.5 |
Three-month maternal readmission rate by province/territory,
Canada (excluding Québec and Yukon), 1995-1997 |
7. |
Fetal and Infant Health Outcomes |
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Table 7.1 |
Rates of preterm birth (per 100 live births with known
gestational age) in Canada (excluding Ontario) and the United States, 1990-1995 |
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Table 7.2 |
Numbers and rates (per 100 total births) of postterm
birth, Canada and the provinces/territories, 1990-1994 |
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Table 7.3 |
Small-for-gestational-age and large-for-gestational-age
rates in Canada and the provinces/territories, 1992-1994 |
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Table 7.4 |
Framework for the estimation of preventable feto-infant
mortality according to birth weight and age at death |
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Table 7.5 |
Fetal mortality (rate per 1,000 total births) and infant
mortality (rate per 1,000 live births) in Canada, 1993-1997 |
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Table 7.6 |
Feto-infant mortality rates in a Winnipeg benchmark population
and for all Manitoba, and the mortality rate differences (preventable mortality),
per 1,000 births |
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Table 7.7 |
Rates of selected neonatal morbidity, Canada, 1984-1994 |
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Table 7.8 |
Numbers and rates of twin and triplet births (live births
and stillbirths), by province/territory, 1995 |
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Table 7.9 |
Rates of selected congenital anomalies in Canada, 1985-1988 |
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Table 7.10 |
Temporal trends in the rate of neonatal hospital readmission
within 28 days of birth, Canada, 1989-1996 |
Introduction
Surveillance Using Indicators
The concept of using observation, recording and analysis of facts to guide
decision-making in health is an ancient one, going back to the time of Hippocrates.
However, it was not until the 17th century that numerical data on a population
were used to describe and understand patterns of disease. According to Eylenbosch
and Noah: "The French word 'surveillance' was introduced into English at the
time of the Napoleonic wars and meant: keeping a close watch over an individual
or group of individuals in order to detect any subversive tendencies."1
Public health surveillance was originally applied to disease and primarily
used in the context of rapidly spreading infectious disease. Modern public
health surveillance, however, is not limited to communicable diseases. The
World Health Organization's (WHO) definition of surveillance emphasizes the
concept of health rather than disease, as follows: "1. Systematic measurement
of health and environmental parameters, recording, and transmission of data.
2. Comparison and interpretation of data in order to detect possible changes
in the health and environmental status of populations."1
A public health surveillance system is a core system of ongoing data collection,
analysis and interpretation on vital public health issues. The result is information
that is used to develop and evaluate interventions, with the aim of reducing
health disparities and promoting health.2 Surveillance systems
may vary in design according to the disease or condition in question and the
country or jurisdiction of operation. Figure 1 depicts
the cycle of surveillance, adapted from a conceptual frame-work described
by Dr. Brian McCarthy, Centers for Disease Control and Prevention, Atlanta,
Georgia.
Figure 1 National Health Surveillance |
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Source: Adapted from CDC |
Public health surveillance systems report on health indicators, which the
WHO defines as "variables which help to measure changes."3 More
specifically, an indicator is "a measurement that, when compared to either
a standard or desired level of achievement, provides information regarding
a health outcome or important health determinant."2 Indicators
are used to monitor and report on progress towards health goals and objectives,
and allow for interjurisdictional comparisons of health status. If indicators
are carefully selected, they can serve an important role in focusing the attention
of policy-makers.3 Indicators should be:
- valid - that is, measure what they are supposed to measure
- reliable - the same if measurements are repeated under identical conditions
- sensitive - detect true changes in the health condition of concern
- specific - reflect changes only in the health condition of concern 3,4
In reality, few indicators will meet all of the above criteria; careful
judgment is required to ensure that appropriate inferences are made.
The Canadian Perinatal Surveillance System
The Public Health Agency of Canada (PHAC) is Canada's national public
health agency. "The Centre's core activities are national health surveillance,
disease prevention and control. These involve the monitoring and investigation
of infectious and non-infectious diseases and injuries, the study of their
associated risk factors and the evaluation of related prevention and control
programs."5
In 1995, PHAC's Bureau of Reproductive and Child Health began to develop
the Canadian Perinatal Surveillance System (CPSS), to provide expert analysis
and timely reporting on perinatal health determinants and outcomes for Canada.
The CPSS is undertaken in collaboration with Statistics Canada, the Canadian
Institute for Health Information (CIHI), provincial and territorial governments,
health professional organizations, advocacy groups and university-based researchers.
The mission, principles and objectives of the CPSS are described elsewhere.2,6
One of the earliest tasks in the development of the CPSS was the identification
of indicators that should be monitored by the system. The national, multidisciplinary
Steering Committee for the CPSS established a Problems, Indicators and Tables
Subcommittee, which developed a process for selecting indicators that included
consideration of scientific properties of the indicator, such as validity;
feasibility of collecting the data; and importance of the health problem.
The resulting indicators are listed in Appendix A, ranked according to the
Steering Committee's assessment of health importance. After subsequent deliberations
and consultation with perinatal health groups across the country, nine more
indicators were added, also listed in Appendix A.
This set of indicators consists of measures of health outcome and measures
of risk and protective factors. It is important to monitor not only maternal,
fetal and infant health outcomes, but also factors, such as behaviours, practices
and health services, that may affect those outcomes. This approach reflects
the concept of the determinants of health - that health status is influenced
by a range of factors including, but not limited to, health care.7
The list of indicators in Appendix A constitutes a current, best assessment
of what should be monitored in a comprehensive national perinatal surveillance
system. It serves as a goal for the CPSS as the system develops. At the present
time, the CPSS can report on a subset of these indicators, using the data
sources currently available: vital statistics, hospitalization data and national
health surveys. These data sources are described in detail in Section A. Over
time, as existing data sources are modified, systems are better integrated
and new databases are built, more perinatal health data will be available
at the national level, and the number of indicators on which the CPSS can
report will increase.
This Resource Manual provides information on 24 indicators currently being
monitored by the CPSS. The presentation of each indicator follows a standard
format: definition, relevance, background information, background data, data
limitations and key current references from the relevant health literature.
Many regions in Canada are in the midst of reviewing their perinatal health
data collection and analysis activities to ensure that the resulting information
adequately supports better targeting of programs and policies. It is the hope
of the CPSS that this Resource Manual will be useful as a reference guide
for perinatal health data collection and analysis, not only nationally, but
at provincial, territorial and regional levels as well.
The CPSS anticipates the production of a regular perinatal health status
report for Canada, based on the indicators in this document. The development
and use of indicators should be viewed as a dynamic and evolving process;
i.e., this set of 24 indicators will not remain static. In the future, some
of the indicators presented here may need to be abandoned if their validity
is inadequate or if they do not prove to be as useful for planning or evaluation
as first expected. Similarly, indicators may be excluded or added to the CPSS
as existing perinatal health problems are solved or as new issues emerge.
This evolving process will direct our data collection, analysis and reporting
plans.
This Resource Manual has been authored and peer reviewed by members of the
CPSS Steering Committee and staff of Health Surveillance and Epidemiology Division, past and present. In particular, we wish to acknowledge the hard work
and intellectual contribution of Dr. Sylvie Marcoux (as chairperson of the
Problems, Indicators and Tables Subcommittee) in developing the form and content
of indicators for the CPSS.
Michael Kramer, MD
Chairperson, CPSS Steering Committee
Catherine McCourt, MD, MHA, FRCPC
Director, Bureau of Reproductive and Child Health
References
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Eylenbosch WJ, Noah ND (Eds.). Surveillance in Health
and Disease. Oxford: Oxford University Press, 1988.
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Health Canada. Canadian Perinatal Surveillance System
Progress Report. Ottawa: Minister of Supply and Services Canada, 1995.
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World Health Organization. Development of Indicators
for Monitoring Progress Towards Health for All by the Year 2000. Geneva:
WHO, 1981.
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Péron Y, Strohmenger C. Demographic and Health Indicators:
Presentation and Interpretation. Ottawa: Minister of Supply and Services
Canada, 1985 (Catalogue No. 82-543E).
-
Health Canada. Public Health Agency of Canada
5-Year Business Plan, 1999. Ottawa: Public Health Agency of Canada, 1999 (unpublished report).
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Health Canada. Canadian Perinatal Surveillance System
Progress Report 1997-1998. Ottawa: Minister of Public Works and Government
Services Canada, 1999.
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Federal, Provincial and Territorial Advisory Committee
on Population Health. Strategies for Population Health: Investing in
the Health of Canadians. Ottawa: Minister of Supply and Services Canada,
1994.
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