Perinatal Health Indicators for Canada

A Resource Manual

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

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Table of Contents
	Canadian Perinatal Surveillance System (CPSS) Steering Committee Members (1995-2000)
	Health Surveillance and Epidemiology Division Staff (1995-2000)
Introduction
SECTION A Principal Sources of National Perinatal Health Data
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
	Appendix A: List of Perinatal Health Indicators Appendix B: List of Acronyms Appendix C: Components of Fetal-Infant Mortality

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List of Tables
SECTION A Principal Sources of National Perinatal Health Data
	Table 1	Principal sources of national perinatal health data
SECTION B Selected Indicators of Maternal, Fetal and Infant Health
4.	Behaviours and Practices
	Table 4.1	Smoking during pregnancy by maternal age (years), Nova Scotia, 1996
	Table 4.2	Prenatal alcohol consumption by geographic region and age (years), Canada excluding the territories, 1994-1995
	Table 4.3	Breastfeeding rates (%) by geographic region and age (years), Canada excluding the territories, 1994-1995
	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
	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
	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
	Table 5.2	Cesarean section rates in Canada, by year
	Table 5.3	Operative vaginal deliveries as a proportion (%) of all vaginal births, cross-national comparison
	Table 5.4	Episiotomy rates in Canada, 1981-1982 to 1993-1994
	Table 5.5	Temporal trends in the rate of short hospital stay (< 2 days) for childbirth in Canada, 1984-1994
	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
	Table 6.1	Maternal mortality ratios in selected countries, 1990
	Table 6.2	Number of induced abortions, induced abortion ratios and age-specific induced abortion rates (ASAR, per 1000), by maternal age, Canada, 1995
	Table 6.3	Temporal trends in rate of ectopic pregnancy in Manitoba, Canada, 1981-1990
	Table 6.4	Selected reportable causes of severe maternal morbidity
	Table 6.5	Three-month maternal readmission rate by province/territory, Canada (excluding Québec and Yukon), 1995-1997
7.	Fetal and Infant Health Outcomes
	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
	Table 7.2	Numbers and rates (per 100 total births) of postterm birth, Canada and the provinces/territories, 1990-1994
	Table 7.3	Small-for-gestational-age and large-for-gestational-age rates in Canada and the provinces/territories, 1992-1994
	Table 7.4	Framework for the estimation of preventable feto-infant mortality according to birth weight and age at death
	Table 7.5	Fetal mortality (rate per 1,000 total births) and infant mortality (rate per 1,000 live births) in Canada, 1993-1997
	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
	Table 7.7	Rates of selected neonatal morbidity, Canada, 1984-1994
	Table 7.8	Numbers and rates of twin and triplet births (live births and stillbirths), by province/territory, 1995
	Table 7.9	Rates of selected congenital anomalies in Canada, 1985-1988
	Table 7.10	Temporal trends in the rate of neonatal hospital readmission within 28 days of birth, Canada, 1989-1996

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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.

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

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References

1. Eylenbosch WJ, Noah ND (Eds.). Surveillance in Health and Disease. Oxford: Oxford University Press, 1988.

2. Health Canada. Canadian Perinatal Surveillance System Progress Report. Ottawa: Minister of Supply and Services Canada, 1995.

3. World Health Organization. Development of Indicators for Monitoring Progress Towards Health for All by the Year 2000. Geneva: WHO, 1981.

4. Péron Y, Strohmenger C. Demographic and Health Indicators: Presentation and Interpretation. Ottawa: Minister of Supply and Services Canada, 1985 (Catalogue No. 82-543E).

5. Health Canada. Public Health Agency of Canada 5-Year Business Plan, 1999. Ottawa: Public Health Agency of Canada, 1999 (unpublished report).

6. Health Canada. Canadian Perinatal Surveillance System Progress Report 1997-1998. Ottawa: Minister of Public Works and Government Services Canada, 1999.

7. 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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Perinatal Health Indicators for Canada
A Resource Manual
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