annual report ver 21 cc - prince edward island also used to complement other provincial databases,...

Prince Edward Island Reproductive Care Program

Perinatal Database Report 2008

Acknowledgements The PEI Reproductive Care Program is a joint initiative that operates under the direction of a multidisciplinary planning committee representing the PEI Medical Society, Department of Health and Wellness, and Health PEI. As one component of its mandate, the Program has been responsible for the development of standardized assessment tools, and of a Provincial Perinatal Database. The PEI Perinatal Database is a product of the efforts of an early advocate of the Program, Dr. Douglas Cudmore and the diligent work and dedication of past Board members and coordinators as well as current Joint Planning Committee members. The PEI Reproductive Care Program is pleased to present the 2008 PEI Perinatal Database Report and wishes to thank all previous and current board members for their dedication and support. The Laboratory Centre for Disease Control’s Bureau of Reproductive and Child Health, under the Action Plan for Health and the Environment, provided funding for the initial development of the database and this support is also greatly appreciated. Data for the Perinatal Database is collected from medical records in the Prince County Hospital and Queen Elizabeth Hospital. The PEI Reproductive Care Program gratefully acknowledges the assistance of these medical records departments. Physicians and nurses who collect the data and enter it on the records are key to the success of the database and are thanked for their assistance. Reproductive Care Program Crystal Bell Diane Boswall Connie Cheverie Heather Murphy Dr. Carolyn Sanford September 2011

Background

This report contains an analysis of the data collected about pregnant women and their newborns during the period from January 1 to December 31, 2008. The PEI Reproductive Care Program believes that pregnancy outcomes are influenced by events that occur in the perinatal period, which includes the pre-conception, prenatal, intra-partum and postnatal periods. There is growing recognition regarding the importance of the perinatal periods in laying the foundation for a child’s development and in impacting on health and well-being throughout life. In recognition of this, the database holds information regarding a variety of variables including maternal demographics and lifestyle behaviors, prenatal status and interventions, intra-partum and postnatal status and interventions, births, and perinatal morbidity and mortality statistics. Analysis of the data from the Perinatal Database provides a basis to inform providers and decision makers about the outcomes of the care provided; promotes ongoing improvement in perinatal outcomes through enhanced knowledge; and has the potential to form the basis for initiating changes in maternal/newborn care throughout the Province. The information collected is also used to complement other Provincial databases, including the Public Health Nursing and Nutrition databases. The level of inquiry in this report is primarily descriptive. The PEI Reproductive Care Program ensures the integrity, security and confidentiality of all data deposited in the database.

Executive Summary

The 2008 Perinatal Database Report is a document that summarizes key maternal and infant health data which is collected exclusively from the Prince Edward Island Reproductive Care Program. The current report is presented in four sections: Maternal Demographics, Prenatal Risk and Prenatal Care, Labour and Delivery, Maternal Health Outcomes, and Fetal and Infant Health Outcomes. Below is a summary of some of the key findings within the report.

• In PEI, as in Canada and other developed countries, the average maternal age at time of delivery has been increasing over time. The average maternal age at delivery for all PEI mothers in 2008 was 28.9 years. The proportion of young mothers has been decreasing over the past 10 years. Conversely, the proportion of older mothers has been increasing. In 2008, almost half (43%) of the women in PEI who gave birth were 30 years of age or older. While the overall trend shows increasing maternal age over time, this varies by region. Mothers in West Prince were the youngest in province with almost half (46%) under 25 years.

• In 2008, 60% of mothers less than 25 years of age were single compared to 11% of mothers 25 years of age and older. Pregnancy outcomes are poorer among mothers in common-law unions versus traditional marriage relationships, but better than among mothers living alone.

• Women of childbearing age living in Canada today weigh significantly more than in the past. Women with a higher body mass index (BMI) are more likely to have poor health and poor pregnancy outcomes. For instance, women with a high BMI are more likely to develop gestational diabetes mellitus and have a Caesarean birth. In 2008 4.4% of women giving birth in PEI were underweight, while 45.2% were either overweight or obese (BMI >25) prior to pregnancy, with 21.1% being obese (BMI>30).

• In PEI in 2008, the incidence of gestational diabetes ranged from 1.2% in normal weight women to 6.4% in women who were obese. The rates of gestational hypertension varied from 5.1% of women within the normal weight category to 15.3% in women who were obese.

• Pre-pregnancy BMI also impacts the infant’s birth weight. In singleton births as the maternal

pre-pregnancy BMI increased, so did the likelihood the baby would be either high birth weight or macrosomic (>4000 grams).

• Only 42% of nulliparous teenage mothers participated in prenatal education/information sessions which is unfortunate given this group would greatly benefit from this knowledge.

• Smoking during pregnancy and exposure to second hand smoke have declined over the past 10 years which is hopefully reflective of education and smoke free legislation. However, cigarette smoking and exposure to second hand smoke, alcohol and drug use are most common in younger women.

• The induction rate remains consistent with the rate reported in 2002 at approximately 32%. This compares with the Canadian induction rate of approximately 24% reported for 2004-2005.

• In 2008, spontaneous vaginal births were most common, followed by Caesarean births and assisted vaginal births. The percentage of births by Caesarean has increased in the ten year period and the percentage of assisted vaginal births has decreased. The Canadian Institute for Health Information (CIHI) Health Indicators 2010 report noted a Caesarean birth rate of 30.5% for PEI compared with 26.9% in Canada for 2008-2009.

• Caesarean births have risen globally, particularly in developed countries. This decision of Caesarean births (either elective or planned) is made based on balancing health risks of the mother and baby and also on external factors. Some studies are attributing this increase to changes in maternal characteristics, medico-legal concerns, and to changes in obstetric practice.

• Women who are having their first baby and present in spontaneous labour with a normal presentation singleton at full term have higher rates of Caesarean births than would be expected for this group. Repeat Caesarean births account for over one third of the overall rate in PEI.

• The rate of episiotomies has decreased significantly over time from 33.1% in 1998 to 10.2% in 2008. Despite decreases in the episiotomy rate there has not been any increase in the rates of third or fourth degree tears.

• In 2008 the average newborn birth weight was 3,464 grams which is higher than the Canadian mean birth weight for babies (3,374 grams). PEI is amongst the provinces with the greatest percentage of high birth weight newborns. In Canada 1.9% of newborns weighed ≥4,500 grams compared with 2.7% in Prince Edward Island. PEI also has a lower rate of low birth weight babies compared with Canada, 5.0% compared with 5.9% respectively.

• In PEI, in 2008, approximately 71% of all mothers were breastfeeding their newborns at discharge from hospital which is lower than the national average. Age continues to have an impact on breastfeeding rates in PEI. Those under 25 years of age were less likely to be breastfeeding at discharge (63%) than older mothers (73%), however both these rates have improved over time. In 2003 these rates were 50% (<25 years) and 67% (older) respectively.

• Women in partnerships (married or common-law) were more likely to be breastfeeding at discharge (75%) than women in no relationship (single, separated, or divorced) (57%). Breastfeeding rates vary in different regions of the province. West Prince (at just over 50%) has the lowest rate of breastfeeding at discharge from hospital when compared to other regions of PEI.

• There is a sharp increase in multiple births after age 40 years. Increased use of assisted human reproduction (AHR) and higher maternal age at conception have been attributed to the rise in the rate of multiple births in the past decades.

Table of Contents

Contents 1 Maternal Demographics, Prenatal Risks, and Prenatal Care ................................................ 1

1.1 Number of Mothers .............................................................................................................. 2

1.2 Maternal Age ....................................................................................................................... 3

1.3 Maternal Weight .................................................................................................................. 7

1.4 Prenatal Care .................................................................................................................... 12

1.5 Prenatal Classes ............................................................................................................... 12

1.6 Substance Use and Exposure ........................................................................................... 14

2 Labour and Delivery ............................................................................................................. 19

2.1 Births ................................................................................................................................. 20

2.2 Methods of Delivery ........................................................................................................... 21

2.3 Inductions .......................................................................................................................... 22

2.4 Perinatal Trauma ............................................................................................................... 24

2.5 Caesarean Births ............................................................................................................... 25

3 Maternal Health Outcomes .................................................................................................. 31

3.1 Diabetes and Hypertension ............................................................................................... 32

3.2 Maternal Length of Stay .................................................................................................... 35

3.3 Maternal Morbidity and Mortality ....................................................................................... 36

4 Fetal and Infant Health Outcomes ....................................................................................... 39

4.1 Newborns .......................................................................................................................... 40

4.2 Infant Feeding ................................................................................................................... 42

4.3 Multiple births .................................................................................................................... 46

4.4 Fetal Mortality .................................................................................................................... 47

4.5 Infant Mortality Rate .......................................................................................................... 47

4.6 Gestational Age at Birth .................................................................................................... 48

4.7 Neonatal Morbidity ............................................................................................................ 49

4.8 Length of Stay ................................................................................................................... 52

4.9 Congenital Anomalies ....................................................................................................... 53

4.10 Newborn Readmissions .................................................................................................. 53

Maternal Demographics, Prenatal Risks, and Prenatal Care

Perinatal Database Report 2008 1

1 Maternal Demographics, Prenatal Risks, and Prenatal Care


2 Perinatal Database Report 2008

1.1 Number of Mothers In 2008, data was captured for 1,434 mothers who gave birth in Prince Edward Island. In previous years, the report included PEI mothers who were transferred out of province for care. The 2008 numbers presented in this report do not include PEI mothers who received care/gave birth in another province, for example at the IWK in Nova Scotia. The number of women giving birth decreased steadily over time from 1992 to an all time low in 2002.

Note: Data are not available from 2004 to 2007 Most pregnant women in 2008 were involved in an on-going partnership, 60% married and 16% common-law. Approximately one quarter of pregnant women were not in a relationship (23% single and 1% divorced or separated).

1851

17491710

17541683

15821493 1498

14281358

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1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

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Number of Mothers, PEI, 1992-2008



1.2 Maternal Age Maternal age is defined as age in years, at the time of the birth and is calculated using the mother’s date of birth and the date of birth of the baby. Age is one factor to consider in the context of prenatal care. Teen pregnancy and pregnancy with advanced maternal age (35 years and older) have been identified as being associated with potential risks. The experience of pregnancy is different for the younger teen compared to the older, more physically mature teen. Teen pregnancy and birth has been noted to be related to low birth weight (LBW) and preterm labour. These outcomes may result from poor prenatal nutrition, substance use and lack of prenatal care, factors also related to socioeconomic disadvantage. With access to prenatal care and support, a teen mother, and her child, is generally not at any greater risk of medical complications than older women.1 Although age 35 is not an absolute number for when risks increase for women in pregnancy and childbirth, there are some prenatal complications for which there is increased risk. Age alone is an important risk factor for chromosomal anomalies. Pre-existing hypertension and diabetes are also more likely after age 35. Complications of labour and birth including placenta previa, placental abruption, preterm and very preterm birth, LBW and Caesarean birth are common. There are also advantages to pregnancy after age 35. These women are more likely to have planned the pregnancy, used folic acid, accessed early prenatal care, been informed, prepared psychologically, and breastfed the baby. Older women today, especially those who have no chronic conditions, generally have healthy pregnancies and healthy babies.2 The average maternal age at delivery for all mothers in 2008 was 28.9 years, and this ranged from 15 to 44 years. The average age has increased from 2003 when it was 28.1 years.

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Maternal Age at Delivery, PEI, 2008



The proportion of young mothers has been decreasing over the past 10 years. Conversely, the proportion of older mothers has been increasing. The proportion of births to teenage women has been steadily decreasing over time. In 2008, almost half (43%) of the women in PEI who gave birth were 30 years of age or older. Mothers aged 35 years and older showed the greatest increase in the percentage of the total births in the province. In 2008, the percent of women 35 years and older who gave birth was 16.4%, up from 12.4% in 1998.

In PEI, as in Canada and other developed countries, the average maternal age at time of birth has been increasing over time although mothers are slightly younger in PEI.3

1998 2003 2008<20 9.8 6.7 5.620-24 22.9 20 20.425-29 30 32.1 31.130-34 24.9 28.2 26.635-39 10.8 11.1 14.440+ 1.6 1.9 2

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Maternal Age Categories at Delivery, PEI, 1998/2003/2008

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Average Maternal Age at Delivery (Live Births), PEI and Canada, 1991-2008

PEI

Canada



While the overall trend shows increasing maternal age over time, this varies by region. Mothers in West Prince were the youngest in province with almost half (46%) under 25 years.

While the overall trend shows an increasing maternal age over time, the increase is more substantial for multiple births. Increased use of assisted human reproduction (AHR) and higher maternal age at conception have been attributed to the rise in the rate of multiple births in the past decade.4

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

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Proportion of Women with Live Births by Age Group and Region, PEI, 2008

<20 20-24 25-29 30-34 35-39 40+

1998 2003 2008Multiple Live Births 28.2 29.5 32Singleton Live Births 28 28.1 28.9Stillbirths 26.5 27.7 27.3

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Average Maternal Age by Selected Birth Types, PEI, 1998/2003/2008



The average maternal age among mothers who had at least one birth in the past (parity ≥1) was 30.8 years. The average maternal age for first time mothers (nulliparous) was 26.5 years. There has been a steady increase in the average age of first time mothers since 1998. Age of the mother at first birth is of interest to both researchers and the public as it influences the total number of births a woman might have in her life, which impacts the size, composition and future growth of the population.5

In 2008, 44% of all mothers were having their first baby. Of the women 35 years and older who gave birth, 21% were having their first baby. Percent Composition of Maternal Age Groupings by Parity, PEI, 2008 Parity 0 (%) Parity 1 (%) Parity 2+ (%) <20 years 93.8 6.2 0 20-24 years 61.4 31.1 7.5 25-29 years 47.2 35.3 17.5 30-34 years 31.2 42.8 26.0 35+ years 20.8 38.3 40.9 Overall 44.1 35.3 20.6 In 2008, 60% of mothers less than 25 years of age were single (43% in 2003) compared to 11% of mothers 25 years of age and older (4% in 2003). Pregnancy outcomes are worse among mothers in common-law unions versus traditional marriage relationships but better than among mothers living alone.6

1998 2003 2008Nulliparous 25.5 26 26.5Parity≥ 1 29.7 29.7 30.8

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Average Maternal Age at Delivery by Parity, PEI, 1998/2003/2008



1.3 Maternal Weight Woman’s height and pre-pregnancy weight was used to calculate body mass index (BMI). BMI was calculated and grouped according to the classification guide below (for the purpose of this report all ≥30 were classed as obese): Health Risk Classification According to Body Mass Index (BMI).7

Classification BMI Category (kg/m2) Risk of developing health problems

Underweight <18.5 Increased

Normal Weight 18.5 - 24.9 Least

Overweight 25.0 - 29.9 Increased

Obese Class I 30.0 - 34.9 High

Obese Class II 35.0 - 39.9 Very high

Obese Class III >=40.0 Extremely high

Women of childbearing age living in Canada today are significantly heavier than in the past. One third of Canadian women enter pregnancy with a BMI equal to or greater than 25. Women with a higher BMI are more likely to have poor health and poor pregnancy outcomes. For instance, women with a high BMI are more likely to develop gestational diabetes mellitus and have a Caesarean birth. Women who have a higher pre-pregnancy BMI are also more likely to have a large-for-gestational-age infant or an infant with a birth-weight of more than 4,000 g (8.8 lbs). More recent evidence also points to a potential increased risk of preterm birth in women with a high pre-pregnancy BMI. Infants of these women are less likely to be breastfed and more likely to be overweight in childhood.8 It is estimated that less than 10 percent of Canadian women enter pregnancy at a low BMI. However, low pre-pregnancy BMI also remains a public health concern. Women with a BMI less than 18.5 are at risk for poor health and poor pregnancy outcomes. For example, low pre-pregnancy weight is linked to preterm birth and small-for-gestational-age infants.8 In 2008, 4.4% of women giving birth in PEI were underweight, while 45.2% were either overweight or obese (BMI >25) prior to pregnancy, with 21.1% being obese (BMI>30).



There were slight regional differences in pre-pregnancy BMI. East Prince had the highest proportion of mothers with a pre-pregnancy BMI <18.5 and also with a BMI>30 while West Prince had the highest proportion of mothers considered to be overweight prior to pregnancy (BMI 25-30).

Note: Data to calculate BMI was missing for 101 women Maternal obesity has long been correlated with an increased risk of chronic hypertension and diabetes prior to pregnancy and adverse pregnancy outcomes including preeclampsia, gestational diabetes, fetal macrosomia, Caesarean births, postpartum endometritis and a prolonged postpartum stay.9

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Pre-pregnancy Body Mass Index (BMI) by Region, PEI, 2008

Normal Weight Overweight Obese Underweight



In PEI in 2008, the incidence of gestational diabetes ranged from 1.2% in normal weight women to 6.4% in women who were obese. Looking at gestational hypertension, the rates varied from 5.1% of women within the normal weight category to 15.3% in women who were obese.

The proportion of women who experience a spontaneous vaginal delivery decreases as pre-pregnancy BMI increases. Obesity is also associated with an increased likelihood of a Caesarean birth compared to normal weight and overweight mothers.

Underweight Normal Weight Overweight ObeseGestational Diabetes 1.7 1.2 3.4 6.4Gestational Hypertension 1.7 5.1 8.7 15.3

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Incidence of Gestational Diabetes and Gestational Hypertension by Pre-pregnancy BMI, PEI, 2008

Underweight Normal Weight Overweight ObeseSpontaneous Vaginal 71.2 68.9 67.0 52.8Assisted Vaginal 5.1 4.0 5.0 3.5C-Birth 23.7 27.0 28.0 43.6

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Type of Delivery by Maternal Pre-pregnancy BMI, PEI, 2008



Pre-pregnancy BMI also appears to impact on the infant’s birth weight. When singleton births were reviewed, it was noted that as the maternal pre-pregnancy BMI increased, so did the likelihood the baby would be either high birth weight or macrosomic. Newborn Birth Weight Classifications:

• Low Birth Weight: <2,500 grams • High Birth Weight: 4,000 – 4,499 grams • Macrosomic: 4,500 grams

Underweight Normal Weight Overweight ObeseLow Birth Weight 1.7 1.4 0 1.1High Birth Weight 6.9 10.7 14.1 16.9Macrosomic 1.7 2.4 2.7 3.8

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Newborn Birth Weight by Maternal Pre-pregnancy BMI, PEI, 2008



The average birth weight for singleton infants born to mothers whose pre-pregnancy BMI put them in the obese category was 3,596 grams. This compares to 3,502 grams for infants whose mothers whose pre-pregnancy BMI put them in the normal weight category.

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Average Birth Weight for Term Singletons by Maternal Pre-pregnancy BMI, PEI, 2008



1.4 Prenatal Care Prenatal care has important implications for maternal health and ongoing health care for women, infants and families. The Public Health Agency of Canada (PHAC) recommends women seek prenatal care early in pregnancy, preferably within the first trimester (defined as 14 weeks of gestation or earlier). Early prenatal care is most effective as it allows for early risk assessment, treatment of medical conditions or risk reduction and education. Less than 1% of PEI women who gave birth in PEI in 2008 did not receive prenatal care. Further analysis to determine the timing of the first prenatal visit was not conducted.10

1.5 Prenatal Classes Prenatal education/information in preparation for pregnancy, birth and parenthood, is offered in each of the health regions by Public Health Nursing, Community Dietitians, and Family Resource Centers. Of all pregnant women across PEI 59% reported receiving some form of formal prenatal education/information during their pregnancy. This is an increase from 33% in 2002. There were 87 women for whom this information was not reported. In PEI 59% of nulliparous women received some form of prenatal education in 2008 (down from 61.4% in 2002). First time mothers aged 25 years and older were most likely to seek prenatal education. Only 42% of nulliparous teenage mothers participated in prenatal education/information sessions.

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Attendance at Prenatal Classes for Nulliparous by Age, PEI, 2008



Of nulliparous mothers who gave birth in 2008, those who lived in Queens County and East Prince were more likely than those in West Prince or Kings County to seek prenatal education/information.

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Attendance at Prenatal Classes for Nulliparous by Region, PEI, 2008



1.6 Substance Use and Exposure Cigarette smoking is the single most important modifiable cause of adverse pregnancy outcomes. Maternal cigarette smoking has been associated with intrauterine growth restriction (IUGR), and is also related to an increased risk of preterm birth, spontaneous abortion, placental complications, stillbirth and sudden infant death syndrome. Longer-term adverse effects on children of mothers who smoked during pregnancy include respiratory illness, asthma, and neurodevelopmental and behavioural problems. The relationship between maternal smoking and adverse pregnancy outcomes is influenced by the amount and duration of smoking. Women who stop smoking before becoming pregnant or during their pregnancy are at significantly reduced risk of IUGR and preterm birth compared with women who smoke throughout pregnancy. Rates of smoking during pregnancy and exposure to second hand smoke have declined over the past ten years. The Smoke Free Places Act came into effect in 2003 in PEI banning smoking in public places. Introduction of this legislation has increased the opportunity to reduce exposure to second hand smoke. There is a wide variation in rates of cigarette smoking in PEI based on place of residence. Mothers in West Prince had the highest rates of cigarette smoking and exposure to second hand smoke during pregnancy. Alcohol is a teratogen and prenatal exposure can lead to a range of conditions known as Fetal Alcohol Spectrum Disorder (FASD). The cognitive, behavioural, neurodevelopmental, physiological or physical impairments that may occur with FASD have implications for the individual over their lifespan. Specific outcomes vary with the timing of the exposure, the amount of alcohol consumed, the frequency and pattern of consumption, as well as the health, nutritional status and genetic makeup of the pregnant women and other social and environmental factors. The diagnosis of a FASD is challenging because the effects of prenatal exposure to alcohol vary widely and clinical signs are difficult to recognize in newborns and infants. The condition is often detected as children advance in school or during the teenage years. Estimates suggest that fetal alcohol syndrome (FAS), the most severe of the diagnostic conditions within the spectrum, is present in three out of 1,000 live births, whereas a FASD (including FAS, partial fetal alcohol syndrome, alcohol-related neurodevelopmental disorders and alcohol-related birth defects) is present in nine out of 1,000 live births. Research suggests that drinking even a small amount of alcohol during pregnancy can have a negative impact on the developing fetal brain. Clinical guidelines have recommended that when planning a pregnancy and during pregnancy no alcohol is best. In August 2010 The Society of Obstetricians and Gynaecologists of Canada (SOGC) released the comprehensive Alcohol Use and Pregnancy Consensus Clinical Guideline reinforcing ‘Abstinence is the prudent choice for a woman who is or might become pregnant’.11



Alcohol use during pregnancy was reported by less than 1% of all women in PEI. In the PHAC report “What Mothers Say: The Canadian Maternity Experiences Survey” it was noted that 28.2% of PEI women reported that they did not drink alcohol in the 3 months before becoming pregnant. This same report indicated 97.3% of PEI women reported not drinking once they found out they were pregnant. There is concern that self-reports of alcohol consumption may be underestimates due to the potential under-reporting of socially undesirable behaviours by women.10 Use of street or illicit drugs around the time of pregnancy is a concern, but obtaining accurate data is difficult because of the social undesirability and illegal nature of this activity. Illicit drug use during pregnancy is associated with LBW, preterm birth, developmental and behavioural issues during childhood. It is unclear whether adverse pregnancy outcomes are a direct result of exposure to street drugs, or exposure to a combination of street drugs and other adverse exposures (smoking, alcohol use), or lack of prenatal care. Women who use street drugs are often of lower socio-economic standing and/or have poor nutrition, further complicating the ability to study the specific effects of illicit drug use on mother and infant health. Women often reduce or eliminate their use of street drugs when they discover that they are pregnant. Substance use and exposure varies by region in PEI.

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Substance Use and Exposure to Second Hand Smoke by Region, PEI, 2008

Smoking During Pregnancy Exposure to Second Hand Smoke Alcohol Risk Factors Drug Risk Factors



Smoking during pregnancy has declined over time. Exposure to second hand smoke has dropped by almost 50% since 1998.

Cigarette smoking and exposure to second hand smoke, alcohol and drug use are most common in younger women.

1998 2003 2008Smoking During Pregnancy 33.3 23.3 21.8Exposure to Second Hand Smoke 45.5 22.4 26.3Alcohol Risk Factors 3.2 3.2 0.6Drug Risk Factors 0.7 1 1.4

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Substance Use in Pregnancy, PEI, 1998/2003/2008

<20 20-24 25-29 30-34 35-39 40+Smoking During Pregnancy 48.8 35.8 20.9 12.3 11.7 17.2Exposure to Second Hand Smoke 47.6 42.1 26.4 14.2 19.3 28Alcohol Risk Factors 3.8 0.3 0.7 0 0.5 0Drug Risk Factors 3.8 4.1 1.1 0 0 0

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Smoking, Exposure to Second Hand Smoke, Alcohol and Drug Use During Pregnancy by Maternal Age Group, PEI, 2008



Cigarette smoking, exposure to second hand smoke and alcohol consumption during pregnancy appear to be associated with an increased rate of preterm birth for singleton pregnancies. In addition to the above risk behaviors, drug use is also associated with LBWs for term singletons when compared with birth weights of infants born to mothers without these high-risk behaviors.

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Preterm Birth Rate by Substance Use Categories and Exposure to Second Hand Smoke, PEI, 2008

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Average Birth Weight for Term Singletons by Substance Use Categories and Exposure to Second Hand Smoke, PEI, 2008



Congenital anomalies were more likely in newborns with exposure to alcohol and drug use risk factors noted than in newborns without these risk factors.

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Rates of Congenital Anomalies by Substance Use and Exposure to Second Hand Smoke, PEI, 2008

Labour and Delivery


2 Labour and Delivery

Labour and Delivery


2.1 Births The focus of this chapter is the care provided during labour and birth. This includes labour induction, use of epidural for pain management in labour, assisted vaginal births, episiotomies and treated lacerations, Caesarean births and vaginal births after Caesarean.

Labour induction rates refer to the use of medical or surgical means to initiate labour and are separate from labour augmentation rates, as augmentation occurs after spontaneous labour. Amniotomy, and/or oxytocin infusion are useful for enhancing inadequate uterine contractions or slowly progressing labour. Labour induction may be considered in situations such as post date pregnancy, premature rupture of membranes, or other maternal or fetal risks where the risk of continuing the pregnancy outweighs the risk of inducing labour to facilitate the birth.12 In PEI the induction rate remains consistent with the rate reported in 2002 at approximately 32%. This compares with the Canadian induction rate of approximately 24% reported for 2004-2005.2 In capturing ‘augmentation of labour’ the PEI Reproductive Care Program Perinatal Database uses the following description: Use of oxytocin to improve contractions after labour has started spontaneously. If the cervical dilatation is ≥3cm and regular contractions are present when the oxytocin is initiated, code labour as augmented. In 2008 approximately 1 in 5 spontaneous labours were augmented. Also included is a review of Caesarean birth using the Robson 10-group classification of Caesarean sections.13 Published in 2001 by Dr. Michael Robson, the classification system is intended to explore the rates of Caesarean births among different sub-groups of women.

Spontaneous34%

Induced32%

Augmented19%

Planned Cesarean Birth15%

Types of Labour, PEI, 2008

Labour and Delivery


1998 2003 2008Spontaneous Vaginal 69.7 64.5 65.5Assisted Vaginal 8.2 5.8 4.5C-Birth 22.1 29.7 30.1

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Method of Delivery, PEI, 1998/2003/2008

2.2 Methods of Delivery In 2008, the majority of births were spontaneous vaginal births, followed by Caesarean births and assisted vaginal births. The percentage of births by Caesarean has increased in the ten year period and the percentage of assisted vaginal births has decreased. The Canadian Institute for Health Information (CIHI) “Health Indicators 2010” report noted a Caesarean birth rate of 30.5% for PEI compared with 26.9% in Canada for 2008-2009.14

Assisted vaginal deliveries include vacuum (60%), forceps (31%) and vacuum & forceps (9%). In 2008, nulliparous women were more likely to undergo a Caesarean birth or assisted vaginal birth than multiparous women.

Spontaneous Vaginal Assisted Vaginal C-BirthOverall 65.5 4.5 30.1Nulliparous 57.7 8.1 34.3Parity>=1 71.7 1.6 26.7

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Method of Delivery by Parity, PEI, 2008

Labour and Delivery


2.3 Inductions The rate of induction in these figures has been calculated excluding women where it was noted that a Caesarean birth was planned prior to labour initiation. In 2008 the rate of induction was similar regardless of parity. This differed from previous years when nulliparous women had higher induction rates than multiparous women.

Older nulliparous women are most often induced and this trend has remained consistent over time. Similarly, teenage nulliparous women are least likely to be induced.

1998 2003 2008Overall 34.4 38.1 37.4Nulliparous 38 41 38.2Parity>=1 31.8 34 36.6

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Rate of Labour Induction by Parity, PEI, 1998/2003/2008

1998 2003 2008<20 26.1 32.9 26.720-24 33.7 39.6 41.125-29 42.9 38.1 33.830-34 37.1 40.2 35.335+ 44.7 45.5 44.9

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Labour Induction by Maternal Age for Nulliparous Women, PEI, 1998/2003/2008

Labour and Delivery


For women whose labour was induced the majority had a combined method of induction, most often oxytocin and artificial rupture of membranes (ARM).

Overall, post dates were the most frequently noted indication for induction. The SOGC suggests: Women should be offered induction at 41+0 to 42+0 weeks, as the present evidence reveals a decrease in perinatal mortality without increased risk of Caesarean birth. When reviewing instances where post dates was noted as the indication for induction, 78% of the women were ≥41 weeks gestation. This varied by parity, 85% of first time mothers where postdates was given as the reason for induction were ≥41 weeks gestation compared with 68% of multiparous women. Primary Reason for Induction by Parity, PEI, 2008 Overall Nulliparous Parity≥1 Fetal Compromise* 3.1 2.6 3.5 Maternal Condition** 16.8 21.8 11.8 Other*** 24.5 11.8 37.1 Post Dates 31.2 35.4 27.1 PROM 24.5 28.4 20.5 *Fetal Compromise: isoimmunization, suspected fetal distress, oligohydramnios, polyhydramnios, fetal anomaly, suspect IUGR **Maternal Condition: gestational diabetes, diabetes, antepartum hemorrhage, hypertension, PUPP, cholestatic jaundice, thrombocytopenia, seizures ***Other: social/elective, history of precipitate labour, current intrauterine death, previous fetal death, poor obstetrical history, geographic, maternal age, multiple pregnancy, unstable lie, macrosomia

Combined Method ARM Other Oxytocin ProstaglandinOverall 38.4 11.4 2.2 22.7 25.3Nulliparous 38.9 5.2 0 25.8 30.1Parity>=1 38 17.5 4.4 19.7 20.5

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Method of Induction by Parity, PEI, 2008

Labour and Delivery


The rate of epidural administration for labour has increased significantly over the ten year period of 1998 to 2008 from 7.1% to 38.5%. According to the CIHI report “Giving Birth in Canada 2005” ‘In Canada, epidurals were used in nearly half (45.7%) of all vaginal deliveries in 2001-2002’.15 This report noted regional variations as well as the role of the availability of staff and resources. Epidural for labour is not universally available across PEI. 2.4 Perinatal Trauma Vaginal birth maternal morbidity looks at episiotomies and third and fourth degree lacerations. The rate of episiotomies has decreased significantly over time from 33.1% in 1998 to 10.2% in 2008. Of all episiotomies performed over 60% were for first time mothers. Despite decreases in the episiotomy rate there has not been any increase in the rates of third or fourth degree tears. In fact rates for both decreased from 1998 to 2008. Rate of Third and Fourth Degree Lacerations, PEI, 1998/2003/2008

Third Degree Fourth Degree 1998 3.1 0.8 2003 2.4 0.3 2008 2.4 0.6 Based on the 2008 Canadian Perinatal Health Report, 20.4% of women in Canada received an episiotomy (2004/05), compared to 14.6% of women in PEI. Third and fourth degree lacerations in that same time period were similar, 3.2% in PEI and 3.8% nationally.2

Labour and Delivery


2.5 Caesarean Births Vaginal Birth After Caesarean (VBAC) The SOGC recommends that a woman with one previous transverse low-segment Caesarean birth should be offered the opportunity to attempt a vaginal birth in a subsequent pregnancy provided there are no contradictions, with appropriate discussion of maternal and perinatal risks and benefits. In 2008, 19.6% of mothers who had a previous Caesarean birth gave birth vaginally (19.2% in 2002). One of the challenges associated with analysis of the rate of VBAC is the determination of a woman’s eligibility for a trial of labour. Not all women who had a previous Caesarean birth would be considered candidates to attempt a VBAC. In the absence of other complications, such as placenta previa, women with a term singleton pregnancy (≥37 weeks’ gestation), in a cephalic presentation might be offered a VBAC. The spacing of pregnancies and the type of Caesarean birth scar may also be determining factors. The PEI Reproductive Care Program database does not capture the number of mothers who had a previous Caesarean birth that are candidates for VBAC. Compared with 1998, the rate of primary and repeat Caesarean birth has increased.

1998 2003 2008Primary Caesarean Birth 16 16 17.8Repeat Caesarean Birth 6.1 13.7 12.3

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Rate of Primary and Repeat Caesarean Birth,PEI, 1998/2003/2008

Labour and Delivery


As the rate of primary Caesarean birth increases, so subsequently does the rate of repeat Caesarean births. In 2008, the most common indication for Caesarean birth was previous Caesarean births and this has been a consistent increase over time. The second most reported indication for Caesarean birth in 2008 was dystocia.

*Dystocia: includes Cephalopelvic disproportion, failure to progress, maternal exhaustion, stenosis of the cervix, persistent occiput posterior presentation, occiput posterior presentation **Malpresentation: includes malpresentation and transverse lie ***Other: includes abruption placenta, diabetes mellitus, disease of the cervix, extreme prematurity, failed induction, failed forceps/vacuum, IUGR, hypertension, isoimmunization, placenta previa, difficult vaginal delivery, herpes, prolapsed cord, prolonged ROM, social, uterine surgery, advanced maternal age, maternal choice

1998 2003 2008Repeat C/S 27.6 31.9 41.1Dystocia 32.4 33.1 25.7Breech 10.6 12 7.4Fetal Distress 13.6 8.9 12.1Malpresentation 3 3.4 0.7Other 12.8 10.8 13

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irths

Primary Indication for Caesarean Birth, PEI, 1998/2003/2008

Labour and Delivery


Robson Classification Caesarean births have risen globally, particularly in developed countries.16,17,18,19 This rise is of public health concern and debate due to potential maternal and perinatal risks and cost issues.20,21 The decision (either elective or planned) of Caesarean births (C-birth) is made based on balancing health risks of the mother and baby and also on external factors.16 Some studies are attributing this increase to changes in maternal characteristics, medico-legal concerns, and to changes in obstetric practice.17,19 The Robson Classification system was developed to define comparable, mutually exclusive groups of mothers using clinical factors such as parity, obstetrical history, course of labour and delivery, and gestation.20 Ten groups are created and analyzed considering the size of the group, C-birth rate within the group, and the contribution of the groups to the overall C-birth rate. When data is analyzed using the Robson Classification System it follows a specific methodology designed to explore groups of mothers and their overall impact on C-births. One of the disadvantages of the Robson system is that it identifies who are having C-births, but does not explain why they are having them.21 This system has been recommended by the World Health Organization to fulfill both current international and local needs to use an internationally standard C-birth classification method. Using a single system facilitates auditing, analyzing, and comparing rates across settings, regions and over time. It will be useful to create and implement effective strategies to optimize C-birth rates.21 Caesarean births should no longer be thought of as too high or low but whether they are appropriate after taking into account all the relevant information.20

Labour and Delivery


Group Description Size of Group* C-Birth Rate** Contribution of

Each Group*** 1998 2003 2008 1998 2003 2008 1998 2003 2008

1 Nulliparous, singleton, cephalic , ≥37 weeks, spontaneous labour 22.3 22.2 23.3 12 21.8 24.9 2.7 4.8 5.8

2 Nulliparous, singleton, cephalic , ≥37 weeks, induced labour or C-section before labour 15.8 16.5 16.4 37.3 42.4 40 5.9 7.0 6.6

3 Multiparous, without uterine scar, singleton, cephalic ≥37 weeks, spontaneous labour 26.7 24.9 23.3 2.5 2.6 2.1 0.7 0.6 0.5

4 Multiparous, without uterine scar, singleton, cephalic ≥37 weeks, induced labour or C-section before labour 15.1 14.7 14.3 9.3 8.2 8.3 1.4 1.2 1.2

5 Multiparous, previous uterine scar, singleton, cephalic ≥37 weeks 11.3 12 13.7 60.7 77.5 79.7 6.8 9.3 10.9

6 Nulliparous, singleton breech 1.4 1.9 1.9 90.5 100 100 1.3 1.9 1.9

7 Multiparous, singleton breech including previous uterine scar 1.9 1.9 1.1 82.1 100 93.8 1.5 1.9 1

8 Multiples including previous uterine scar 1.1 1.5 1.4 35.3 66.7 55 0.4 1 0.8

9 Singleton, transverse or oblique lie including previous uterine scar 0.3 0.6 0 100 100 0 0.3 0.6 0

10 Singleton, cephalic, ≤36 weeks including previous uterine scar 4.0 3.8 4.6 26.7 34 30.3 1.1 1.3 1.4

*Size of group = total number women in group/overall total number of women X 100% **C-birth rate = number C-birth total /number women in each group X 100% ***Contribution of each group = number C-birth in group/overall number women X 100% The relative size of Groups 1 & 2 has remained stable over the past ten years. There has been a slight reduction in the size of Groups 3 & 4 over time along with a similar increase in Group 5. There is relatively no change in the size of Groups 6-10. The rate of Caesareans has doubled in Group 1 from 1998 to 2008 to 24.9%. A target for this group has been suggested at between 15-18%. Similarly the C-birth rate in Group 5 has risen by 30% over the past ten years to 79.7%. Ideally this should be between 50-60% and is a reflection of VBACs. The rate of Caesarean has increased in Groups 6 & 7 (breeches) which reflects the current practice standard that breech deliveries are performed via Caesarean. As a general rule, Groups 1, 2, & 5 should contribute to approximately two thirds of the total C-birth rate. The overall contribution increased from 15.4% in 1998 to 23.3% in 2008 and accounted for 77.4% of total C-births in 2008.

Labour and Delivery


Repeat C-births account for over one third of the overall rate in PEI and this has grown by 60% since 1998. Group 5 will naturally increase over time because it is a measure of repeat C-births. As the numbers of C-births increase in nulliparous women (Groups 1 & 2), the number of repeat sections will occur when they have more babies as the rate of VBAC tends to be low. The contribution of Group 1 to the overall C-birth rate has increased over time (2.7% in 1998 to 5.8% in 2008). This is the most important group in changing our future C-birth rates. This group contains nulliparous women, with a normal singleton presentation that have gone into spontaneous labour. The differences in this group demographic (maternal & newborn factors) between 1998 and 2008 were further explored in an attempt to formulate a hypothesis concerning the increased C-birth rate in this group (12% in 1998 to 24.9% in 2008). The following factors were examined: maternal age at delivery, maternal pre-pregnancy weight, pre-pregnancy BMI, weight gain during pregnancy, obesity status, newborn weight and proportion of newborns >4000g. In Group 1, mothers in 2008 weighed significantly more (p<0.05) than mothers in 1998 (average 65.7 kg versus 63.2 kg, respectively). Similarly, the pre-pregnancy BMI was higher in 2008 than 1998 (24.4 versus 23.7), however this finding was not significant. There were no significant differences in weight gain, mothers in 2008 gained on average 16.7 kg and mothers in 1998 gained 16 kg. While the proportion of obese mothers was higher in 2008 (15.4%) compared to 1998 (10.3%), this was borderline significant (p=0.06). Maternal age at delivery was also reviewed. Mothers were significantly older in 2008 (average 25.8 years) compared with mothers in 1998 (24.8 years) (p=0.01). There were no significant differences found in the newborn birth weights or the proportion of newborns weighing more than 4000 g between 2008 and 1998. Therefore it may be plausible to hypothesize that maternal weight and age play a role in the increase in C-births in PEI.

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1998 2003 2008

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eContribution of Each Group to the Caesarian Section Rate, PEI, 1998/2003/2008

1 2 3 4 5 6 7 8 9 10

Group 1

Group 2

Group 5

Labour and Delivery


While weight may have some impact on C-births in Group 1, a sub-analysis was performed using only the mothers in Group 1 with a BMI <27. When the rate of C-birth in the ‘normal weight’ mothers was compared in 1998 and 2008, there was still a significant increase in the proportion of C-births in this group. Therefore, other factors apart from weight are contributing to the increase in Caesareans. Other factors that may partially explain the increase in Caesareans over time include both administrative factors (including labour management) and maternal factors. One maternal factor that could not be explored was ‘maternal request’ for Caesarean. Heightened maternal awareness of vaginal delivery complications, women’s dissatisfaction with long labours and vaginal delivery have resulted in obstetricians having lower thresholds for advising delivery by Caesarean, which is a much safer procedure than it once was.20 A partial list of administrative factors that may contribute to Caesareans include: number of antenatal beds in a facility; ratio of antenatal beds to labour and delivery beds; electronic fetal monitoring; epidural anesthesia; reduced use of mid-pelvic forceps; labour management; proximity of patients to hospital (particularly during the winter); and proximity to a tertiary care centre.17 Based on this analysis, our rates of C-births have increased over time. This finding is similar across many other Canadian provinces.17,22,23 Women who are having their first baby and present in spontaneous labour with a normal presentation singleton at full term appear to be the most significant group to focus on. Further exploring why this group has C-births at rates higher than expected may help to determine the reasonability/appropriateness of the rate increase. A more in depth research study into the changing demographics of C-births over time with a focus on maternal and newborn outcomes is warranted.

Maternal Health Outcomes


3 Maternal Health Outcomes



3.1 Diabetes and Hypertension Diabetes and hypertension are two conditions that may be present prior to, and exacerbated during, pregnancy. Each of these conditions may also develop for the first time during pregnancy and may gradually resolve after the birth of the baby. Development of either of these conditions during pregnancy increases the risk that the woman may develop that condition later in life. Diabetes in pregnancy (both pre-existing and gestational) has been linked to maternal outcomes including induction of labour, Caesarean birth, preterm delivery (<37 weeks gestation), shoulder dystocia, and pregnancy related hypertension/preeclampsia. Perinatal outcomes associated with maternal diabetes include macrosomia, congenital anomalies, stillbirth, and LBW.24 Hypertensive disorders in pregnancy are a leading cause of maternal and perinatal morbidity and mortality in Canada and internationally. Pre-eclampsia is associated with an increased risk of preterm, small for gestational age, IUGR births. There has been a trend toward improvements in fetal survival in women with pre-eclampsia; however this has led to an increase in preterm births.25 In PEI in 2008 the rate of preterm birth (<37 weeks) was higher for mothers with pre-existing hypertension, pre-existing diabetes, gestational diabetes, and gestational hypertension as compared to mothers who did not have these conditions.

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Preterm Birth Rates by Diabetes and Hypertension, PEI, 2008



In 2008 8.7% of women were noted to have a hypertensive disorder in pregnancy and 3.4% were noted to have diabetes (pre-existing or gestational).

Mothers with diabetes or hypertension, either pre-existing or gestational, were more likely experience a Caesarean birth and were more likely to have a longer stay in hospital (some of this may be attributed to longer hospital stay associated with Caesarean birth as compared to vaginal birth).

1998 2003 2008Pre-existing Hypertension 1.5 1.0 0.8Gestational Hypertension 9.7 11.1 7.9Pre-existing Diabetes 0.1 0.7 0.4Gestational Diabetes 4.2 1.6 3.0

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Rate of Diabetes and Hypertension, PEI, 1998/2003/2008

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Method of Delivery by Diabetes and Hypertension, PEI, 2008

C‐Section Assisted Vaginal Spontaneous Vaginal



0 25 50 75 100 125 150 175 200 225 250



Pre-existing Diabetes

Gestational Diabetes

Neither Hypertension nor Diabetes

Average Length of Stay (Hours)

Length of Stay by Diabetes or Hypertension, PEI, 2008



3.2 Maternal Length of Stay The appropriate length of hospital stay for childbirth has been a controversial issue for decades. A number of factors, other than the mother’s health condition, affect length of stay, including healthcare policies and resources, characteristics of the health care delivery system, the availability of follow-up resources in the community and socio-demographic characteristics of the mother.2

Government and professional guidelines have recommended a postpartum follow-up visit shortly after hospital discharge. In PEI all women are offered a postpartum home visit by Public Health Nursing, with continuing follow-up as necessary. The length of hospital stay for childbirth varies by delivery method. Results are presented separately for vaginal and Caesarean births. Women who had a Caesarean birth had a postpartum hospital stay of an average 40.3 hours longer than those women who had a vaginal birth. In 2008 the total length of hospital stay for vaginal births was 69.6 hours (2.9 days) and for Caesarean births 114 hours (4.7 days). The Canadian Perinatal Health Report 2008 indicated the PEI length of stay in 2004-2005 as 3.1 days for vaginal births and 5.0 days for Caesarean births.2 It is noted that it is preferable to report on postpartum length of stay (from the time of birth) rather than overall length of stay. Average postpartum length of stay for PEI women in 2008 is shown below.

0 50 100 150 200 250

Vaginal

C-Birth

Vaginal C-BirthAverage Antepartum LOS 9.8 14Average Postpartum LOS 59.8 100.1Average Total LOS 69.6 114

Length of Stay by Delivery, PEI, 2008



3.3 Maternal Morbidity and Mortality There were no reported maternal deaths in PEI in 2008. Maternal deaths are defined as deaths of women while pregnant or within 42 days of the termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes.26 As the incidence of maternal deaths has declined in industrialized countries, including Canada, the importance of surveillance of severe maternal morbidity has been recognized as a way to monitor the quality of maternity care.

The Canadian Perinatal Surveillance System’s (CPSS) Maternal Health Study Group selected a number of conditions and procedures suggestive of severe maternal morbidity. These include: amniotic fluid embolism (AFE); obstetrical pulmonary embolism; eclampsia; shock (obstetrical, septic and other); pulmonary, cardiac and central nervous system (CNS) complications of anaesthesia; cerebrovascular disorders in the puerperium (including intra-cranial, venous sinus thrombosis); uterine rupture; adult respiratory distress syndrome; pulmonary edema; myocardial infarction; acute renal failure following labour and delivery; cardiac arrest/failure or cerebral anoxia following obstetrical surgery; severe post-partum hemorrhage (PPH) requiring hysterectomy or transfusion; and assisted ventilation. A number of these conditions are so rare that there were no cases reported in PEI in 2008. The most common severe maternal morbidity in 2008 was severe pregnancy-induced hypertension (PIH) (0.8%) followed by PPH with transfusion (0.6%) and anesthetic complications (0.4%). As would be expected, length of stay was increased when complications occurred.

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Average Length of Stay by Severe Maternal Morbidity, PEI, 2008



Women with any severe maternal morbidity were more likely to experience a Caesarean birth than women with no severe condition.

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Method of Delivery by Severe Maternal Morbidity, PEI, 2008

Vaginal Caesarean birth

Fetal and Infant Health Outcomes


4 Fetal and Infant Health Outcomes



4.1 Newborns In 2008 there were 1,454 babies born on Prince Edward Island. There were also approximately 25 babies born at the IWK Hospital in Nova Scotia to Island mothers who required more complex care. These mothers and babies are not included in this report as the information for these babies is incomplete to date in this database. Statistics Canada reported the number of babies born in 2008 was up by 2.7% from 2007 with the largest percentage increases occurring in Newfoundland and Labrador (+7.6%) and Prince Edward Island (+6.8%).27

Birth weight is the most important determinant of perinatal, neonatal, and post-natal outcomes. Poor growth during the intrauterine period increases the risks of perinatal and infant mortality and morbidity throughout life. An adverse intrauterine environment may result in either LBW or preterm birth. Low birth weight is a multifaceted problem that may result in a wide spectrum of diseases in later life such as hypertension, ischemic heart disease, stroke, metabolic syndrome, diabetes, malignancies, osteoarthritis and dementia. Low birth weight can result from preterm or IUGR birth, or a combination of the two. Owing to the difficulty in ascertaining gestational ages and the relative simplicity, accuracy, validity, and reproducibility of measurement of birth weight, it is the most commonly used indicator worldwide to compare population characteristics.25 In 2008 the average newborn birth weight was 3,464 grams. The Statistics Canada report, “Births 2008", indicates the mean birth weight for babies born in Canada is 3,374 grams.27 The same report finds PEI among the provinces with the greatest percentage of high birth weight newborns (>4,500 g). In Canada 1.9% of newborns weighed ≥4,500 grams compared

1868

17681723

17701696

15981509 1521

14401377

1331

14261372

13141389 1367

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Number of Babies Born, PEI, 1992-2008

Data f rom Vital Statistics (births registered in PEI)



with 2.7% in Prince Edward Island. High birth weight babies can be associated with both infant and maternal birth complications and may increase the risk of Type 2 diabetes later in life.2 For this report LBW is considered ≥500 grams to 2,500 grams. “Births 2008” notes that in Canada, 5.9% of newborns were LBW with 5.0% of babies born in PEI being in this category.27

3250

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3450

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NL PE NS NB QC ON MB SK AB BC YK NT NU

Gra

ms

Average Birth Weight for Provinces and Territories, 2008

----- Canada



4.2 Infant Feeding Health Canada and the PHAC promote breastfeeding as the best method of feeding infants as it provides optimal nutritional, immunological and emotional benefits for the growth and development of infants.28 Additionally, the Canadian Paediatric Society recommends exclusive breastfeeding for the first six months of life for healthy, term infants. Breast milk is the optimal food for infants, and breastfeeding may continue for up to two years and beyond.29 This opinion is shared by the SOGC, the United Nations Children’s Fund, and the World Health organization.30 Beginning at 6 months of age babies need to replenish their iron reserves by adding a variety of foods in addition to breast milk, which continues to provide nutrition and protection. Many mothers continue to breastfeed until their babies are two years old or more.31 In PEI, in 2008, approximately 71% of all mothers were breastfeeding their newborns at discharge from hospital (this rate is calculated based on live born infants who were discharged to the care of their birth mother). According to ‘Breastfeeding Initiation in Canada: Key Statistics and Graphics (2007-2008)’, 87.9% of Canadian mothers breastfed or tried to breastfeed their last child. Rates were lowest in the Atlantic region at 73.8% and highest in British Columbia at 94.8%.32 Breastfeeding rates have been found to be related to:

• Income levels - At the national level, the percent of mothers who breastfed or tried to breastfeed their baby increased with increasing income.

• Education levels - Breastfeeding initiation rates increased with the mothers’ highest level of education achieved. Significantly more mothers who were post-secondary graduates initiated breastfeeding (90.8%) than did mothers with secondary graduation (83.7%) or less than secondary graduation (69.6%).

• Age - At the national level, the percent of mothers who breastfed or tried to breastfeed their baby increased with increasing age. Significantly fewer mothers aged 15-24 (82.9%) initiated breastfeeding than did mothers aged 35-55 (89.2%).

• Marital status- Significantly more married and common-law mothers (89.4%) initiated breastfeeding than did mothers who were widowed, separated, divorced, or single (79.7%).

• Area of residence - Overall, significantly more mothers residing in urban areas (88.7%) breastfed or tried to breastfeed their baby than did mothers in rural areas (81.5%).32

Age continues to have an impact on breastfeeding rates in PEI. Those under 25 years of age were less likely to be breastfeeding at discharge (63%) than older mothers (73%), however both these rates have improved over time. In 2003 these rates were 50% (<25 years) and 67% (older) respectively.

Women in partnerships (married or common-law) were more likely to be breastfeeding at discharge (75%) than women in no relationship (single, separated, or divorced) (57%).



Breastfeeding rates vary in different regions of the province. West Prince (at just over 50%) has the lowest rate of breastfeeding at discharge from hospital when compared to other regions of PEI.

“Consultation - Nutrition for Healthy Term Infants: Recommendations from Birth to Six Months – DRAFT” is a joint statement of the Canadian Paediatric Society, Dietitians of Canada, and Health Canada. It supplies health professionals with the information they need to give consistent messages about infant nutrition to parents and caregivers across Canada. This document recommends health care providers ‘Encourage breastfeeding mothers to stop or reduce smoking. However, even if smoking continues, breastfeeding is still the best choice. Advise parents who smoke that breastfeeding may mitigate some of the negative effects of smoking on the health of their infant. Smokers in the household should go outside to smoke, but always ensure the infant is supervised in their absence’.33

52

63.8

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71.6 70.6

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Breastfeeding at Discharge by Region of Residence, PEI, 2008



Despite this information, smoking mothers are much less likely to breastfeed at discharge when compared to non-smoking mothers. This trend is evident across the province.

For 74% of the babies born in PEI in 2008, breastfeeding was initiated as the feeding method of choice by their mothers. By the time of discharge, 70.5% of these babies were continuing to be breastfed. The rate of breastfeeding initiation and the rate of breastfeeding at discharge were similar regardless of whether the baby was born vaginally or a Caesarean birth.

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Breastfeeding at Discharge by Smoking Status and Region, 2008

Smoker Non-smoker

Spontaneous Vaginal Assisted Vaginal C-BirthBF Initiation 74.3 69.2 75.5BF Discharge 70.5 67.2 70.9

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Newborn Feeding by Method of Birth, PEI, 2008



Human breast milk-fed infants in the neonatal intensive care unit (NICU) have fewer severe infections, less necrotizing enterocolitis and a reduction in colonization by pathogenic organisms. There is research supporting a decreased length of hospital stay for babies fed expressed human breast milk. Importantly, there are also data documenting an improved neurodevelopmental outcome for preterm infants fed breast milk.34 There is increased awareness/acknowledgement of the added importance of breast milk for preterm infants. In 2008, preterm newborns in PEI were slightly more likely to be breastfed (both initiation and at hospital discharge) than term newborns.

Preterm TermBF Initiation 80.4 74.0BF Discharge 72.8 70.4

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Newborn Feeding for Term and Preterm Births, PEI, 2008



4.3 Multiple births There were 20 sets of twins born on PEI. Out of province births (i.e. multiples born at the IWK) are not included in this report because of the unavailability of complete data; therefore this number is an underestimation of the actual number. In 2008 the rate of multiple births increased with maternal age. There is a sharp increase in multiple births after age 40 years. Increased use of assisted human reproduction (AHR) and higher maternal age at conception have been attributed to the rise in the rate of multiple births in the past decade.4 A similar trend was not seen in 1998.

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<20 years 20-24 years 25-29 years 30-34 years 35-39 years 40+ years

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Rate of Multiple Births by Maternal Age, PEI, 1998/2008

2008 1998



4.4 Fetal Mortality The fetal mortality rate is defined as the number of fetal deaths per 1,000 total births (live births and stillbirths) in a given place and time.2 The PEI Vital Statistics Act states ’stillbirth means the complete expulsion or extraction from its mother after at least twenty weeks pregnancy, or after attaining a weight of at least 500 grams, of a product of conception in which, after the expulsion or extraction, there is no breathing, beating of the heart, pulsation of the umbilical cord or unmistakable movement of voluntary muscle’.35 Stillbirth rates fluctuate greatly from year to year in PEI, largely due to our small population and small number of births.

4.5 Infant Mortality Rate The infant mortality rate is defined as the number of deaths of live born infants in the first year after birth per 1,000 live births. Infant mortality can be divided into three components: early neonatal deaths (0-6 days), late neonatal deaths (7 - 27 days) and postnatal deaths (28 - 364 days).2 For privacy reasons this report does not provide numbers/ rates when there have been less than 5 individuals affected.

6.8

3.5

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2

4.6

3.5

4.4

3

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9

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

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Stillbirth Rates, PEI, 1995-2008



4.6 Gestational Age at Birth Preterm birth is of significant public health importance because of its association with an increase in mortality and childhood morbidities such as developmental problems, cerebral palsy, learning difficulties, hearing and visual impairments, and an increased risk of sudden death. Preterm birth is defined as an infant born at <37 weeks (259 days) gestation. The most severe effects of prematurity are noted when infants are <32 weeks gestation at birth but all infants born at <37 weeks gestation have an increased risk of morbidity or mortality. It is common practice in PEI to refer all labours occurring at <32 weeks gestation to IWK in NS. The etiology of preterm and LBW births is multifactorial. Many individual determinants have been identified but most of these factors also interact. Associated factors include individual-level behavioral and psychosocial factors, neighbourhood characteristics, environmental exposures, medical condition, infertility treatments, biological factors and genetics.2 Specific examples of these factors are single/cohabitating marital status, adolescent or older maternal age, previous preterm birth, infections (periodontal infections, urinary tract infections, sexually transmitted infections), tobacco use, heavy alcohol use, cocaine/narcotic use, low pre-pregnancy weight, low/high weight gain, multiple gestation, race/ethnicity, acute or chronic stress, violence/abuse, or maternal trauma. 25 Medically indicated preterm birth may be required for maternal medical conditions, pregnancy-related conditions or fetal conditions when the health benefits for the mother and/or baby outweigh the potential risks associated with preterm birth. In 2008, premature birth was noted for 6.4% of all live births in PEI. In total, 5.9% of these births occurred at 34-36 weeks gestation and 0.4% occurred at less than 34 weeks gestation. “The Canadian Perinatal Health Report 2008” reports a preterm birth rate of 8.2 per 100 live births in Canada (excluding Ontario) for 2004.2 The rate reported for PEI for that same year was 8.0. The 6.4% noted here may reflect a decrease in preterm births but is likely also a result of our inability to include data for mothers transferred to, and babies born at, tertiary centres out of province when the need for more complex care is anticipated. Spontaneous and Iatrogenic Preterm Birth Rates, PEI, 2008 Number Percent of Live Births (%) Spontaneous Preterm Birth 55 3.8 Preterm Labour Induction 18 1.2 Preterm Caesarean with No Labour 19 1.3 Total 92 6.4



4.7 Neonatal Morbidity Neonatal morbidity examines the number of infants identified as having severe morbidity in the first month of life. The PEI Reproductive Care Program Perinatal Database captures information for infants up to the time of discharge, including information on transfers if available, and any readmissions to hospital up to and including 28 days of age. Severe morbid conditions during the neonatal period (including severe respiratory distress syndrome (RDS), sepsis, seizures, severe intraventricular hemorrhage (IVH), persistent fetal circulation, and multiple congenital anomalies) are important predictors of postneonatal morbidity and long-term disability.2 Many of these conditions are associated with preterm birth and are factors in the higher rates of infant mortality and impaired childhood development that occur in preterm infants. Because of small numbers, infrequent occurrences (<5) of conditions are not be reported here.

*Other respiratory morbidity includes: other respiratory distress, congenital pneumonia, neonatal aspiration of meconium, pneumothorax or pneumomediastinum originating in the perinatal period, apnea and respiratory failure.

Sepsis Respiratory distress syndrome Transient tachypnea Other respiratory

morbidity*Percent of live births 0.3 0.3 4.6 7.0

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Severe Neonatal Morbidities, PEI, 2008



Transient tachypnea was most often experienced by babies who experienced a Caesarean birth as compared to a vaginal birth while other respiratory morbidity was most commonly diagnosed for babies who experienced a vaginal birth.


Sepsis Respiratory distress syndrome Transient tachypnea Other respiratory

morbidity*Caesarean Birth 0.14 0.14 2.9 2.35Assisted Vaginal 0.07 0 0.35 0.41Spontaneous Vaginal 0.14 0.21 1.31 4.2

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Newborn Diagnoses by Method of Delivery, PEI, 2008



This graph displays the percent of the preterm infants who experienced the noted conditions, i.e. 2.2% of preterm infants were diagnosed with sepsis. Eighty percent of the cases of RDS were found in infants born preterm followed by sepsis (40%), transient tachypnea (24%) and other respiratory morbidities (12%).


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Sepsis Respiratory distress syndrome

Transient tachypnea Other respiratory morbidity*

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Preterm Birth Rate by Selected Diagnoses, PEI, 2008



4.8 Length of Stay The average length of stay for newborns in 2008 was 87.5 hours (3.65 days). It is important to note again that this does not include data from newborns born outside the province such as those born at IWK. Babies born in tertiary care centres such as the IWK are often most at risk and may well be premature infants with complications that require intensive care. If their data was included these length of stay estimates would likely be higher. Newborns with none of the identified morbidities had shorter length of stays than newborns with sepsis, respiratory distress syndrome, transient tachypnea, or other respiratory morbidities. As previously noted, many of these conditions are associated with preterm birth and there may be additional compounding issues that may contribute to the prolonged length of stay.


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Sepsis Respiratory distress syndrome

Transient tachypnea Other respiratory morbidity*

None of the indicators

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Average Length of Stay for Selected Newborn Morbidities, PEI, 2008



4.9 Congenital Anomalies Congenital anomalies, birth defects and congenital malformations are synonymous terms that describe an abnormality of structure or function present at birth.2 Of live births in 2008, 5.8% were classified with a congenital anomaly. Congenital Anomalies, PEI, 2008 System Rate per 1,000 Births Central Nervous 2.1 Cardiovascular 9.0 Gastrointestinal 2.8 Genitourinary 13.8 Musculoskeletal 13.1 Ear/Nose/Mouth/Throat 17.3 Chromosomal 0

4.10 Newborn Readmissions The PEI Reproductive Care Program Database captures information for infants for readmissions to hospital up to and including 28 days of age. In 2008, 43 newborns were readmitted for various reasons, for a total of 46 readmissions, reflecting 3% of live births; this is similar to the national rate. The most common reasons for readmission were hyperbilirubinemia, gastro-esophageal reflux disease (GERD), and feeding difficulties, accounting for 28.3%, 17.4% and 10.9% of all readmissions respectively.

References


1 Best Start, Update Report on Teen Pregnancy Prevention. Retrieved August, 2011 from: http://www.beststart.org/resources/rep_health/pdf/teen_pregnancy.pdf 2 Public Health Agency of Canada. (2008). Canadian Perinatal Health Report. Retrieved August, 2011 from : http://www.phac-aspc.gc.ca/publicat/2008/cphr-rspc/index-eng.php 3 Statistics Canada CANSIM Table 102-4504 Mean Age of Mother at time of Delivery (live births), Canada, provinces and territories, annual (years), http://www5.statcan.gc.ca/cansim/a01/lange=eng 4 Min Jason, Yuzpe Albert. Prevention of Multiple Births Associated with Infertility Treatments: A Canadian Framework. Retrieved August, 2011 from: http://www.ahrc-pac.gc.ca/v2/pubs/framework-mult-births-cadre-naiss-mult-eng.php 5 T.J. Matthews, Brady E. Hamilton D. (2009) . Delayed Childbearing: More Women Are Having Their First Child Later in Life. NCHS Data Brief No. 21 August 2009, CDC Retrieved August, 2011 from : http://www.cdc.gov/nchs/data/databriefs/db21.pdf 6 Luo ZC, Wilkins R, Kramer MS, (2004) The Fetal and Infant Health Study Group of the Canadian Perinatal Surveillance System. Disparities in Pregnancy Outcomes According to Marital and Cohabitation Status. Obstetrics & Gynecology 2004;103 7 Statistics Canada. (2000). Health Risks Classification according to Body Mass Index (BMI). Retrieved August , 2011 from: http://www.hc-sc.gc.ca/fn-an/nutrition/weights-poids/guide-ld-adult/cg_quick_ref-ldc_rapide_ref-table1-eng.php 8 Health Canada. (2010). Nutrition Guidelines for Health Professionals: Gestational Weight Gain, Retrieved August, 2011 from: http://www.hc-sc.gc.ca/fn-an/nutrition/prenatal/ewba-mbsa-eng.php#a1 9 Doherty DA, Magann, EF. (2006) Prepregnancy Body Mass Index and Pregnancy Outcomes. International Journal of Gynecology and Obstetrics, 95(3) 242-247 10 Public Health Agency of Canada. (2009). What Mothers Say: The Canadian Maternity Experiences Survey. Ottawa. Retrieved August, 2011 from http://www.phac-aspc.gc.ca/rhs-ssg/pdf/survey-eng.pdf 11Journal of Obstetrics and Gynecology Canada, Vol 32, No. 8, August 2010, Retrieved August, 2011 from: http://www.sogc.org/guidelines/documents/gui245CPG1008E.pdf 12 British Columbia Perinatal Health Program, (2010). Perinatal Health Report 2008. Retrieved August, 2011 from: http://www.perinatalservicesbc.ca/sites/bcrcp/files/AnnualReport/annual_report_2008/TOC_2008.pdf 13 Best Practice & Research Clinical Obstetrics & Gynaecology Vol. 15, No. 1, pp. 179±194, 2001, doi:10.1053/beog.2000.0156, available online at http://www.idealibrary.com

References


14 Statistics Canada, Health Indicators 2010, Canadian Institute for Health Information http://secure.cihi.ca/cihiweb/products/Healthindicators2010_en.pdf 15 Giving Birth in Canada: A Regional Profile, January 2005, Canadian Institute for Health Information, http://secure.cihi.ca/cihiweb/en/downloads/GBC2004_errata_e.pdf 16 Denk C., Kruse L., Jain N. (2006). Surveillance of Cesarean section deliveries, New Jersey, 1999-2004. Birth, 33:203 17 Jospeh K., Young D., Dodds L., O’Connell C., Allen V., Chandra S., Allen A. (2003). Changes in maternal characteristics and obstetric practice and recent increases in primary Cesarean delivery. Obstet & Gyn, 102:791 18 Betran A., Gulmezoglu A., Robson M., et al. (2009). WHO global survey on maternal and perinatal health in Latin America: classifying caesarean sections. Reprod Health, October, 6:18 19 Brennan D., Robson M., Murphy M., O’Herlihy C. (2009). Comparative analysis of international cesarean delivery rates using 10-group classification identifies significant variation in spontaneous labor. Amer J Obstet & Gyne, September, 2009 20 Robson M. (2001). Can we reduce the caesarean section rate? Best Prac & Res Clin Obs & Gyn, 15(1), 179 21 Torloni M, Betran A, Souza J, Widmer M, Allen T, Gulmezoglu M, Merialdi M. (2011). Classifications for Cesarean Section: A Systematic Review. PLoS ONE January 2011: e14566. 22 Canadian Perinatal Program Coalition (2011). Exploring Caesarean Births – A second look using the Robson 10 group classification. June 2011, Vancouver BC. 23 Allen V., Baskett T., O’Connell C. (2010). Contribution of select maternal groups to temporal trends in rates of Caesarean section. J Obstet Gynaecol Can; 32:633 24 Petica, P., Keely, E.J.,Walker, M.C., Yang, Q., Bottomley. (2009) Pregnancy Outcomes in Diabetes Subtypes: How Do They Compare? A Province-based Study of Ontario, 2005-2006, J. Journal of Obstetrics and Gynaecology June 2009 25 Ohlsson, A., Shah, P. (2008 ). Determinants and Prevention of Low Birth Weight: A Synopsis of the Evidence institute of Health Economics, Alberta, Canada 26 Health Canada (2004). Special Report on Maternal Mortality and Severe Morbidity in Canada — Enhanced Surveillance: The Path to Prevention 27 Statistics Canada, Births (2008). Retrieved August, 2011 from: http://www.statcan.gc.ca/daily-quotidien/110427/dq110427a-eng.htm 28 Health Canada, (2004) Food and Nutrition, Exclusive Breast Feeding Duration: 2004 Health Canada Recommendation. Retrieved August, 2011 from: http://www.hc-sc.gc.ca/fn-an/nutrition/infant-nourisson/excl_bf_dur-dur_am_excl-eng.php

References


29 Paediatric Child Health (2005). Exclusive breastfeeding should continue to six months. Retrieved August, 2011 from: http://www.cps.ca/english/statements/n/breastfeedingmar05.htm 30 Schurmans N, Senikas V, LaLonde A. (2009) Healthy Beginnings 4th Edition. John Wiley & Sons Canada 31 Public Health Agency of Canada. (2009). 10 Valuable Tips for Breastfeeding. Retrieved August, 2011 from: http://www.phac-aspc.gc.ca/hp-ps/dca-dea/stages-etapes/childhood-enfance_0-2/nutrition/pdf/tips-cons-eng.pdf

32 Health Canada,(2007-2008) Food and Nutrition, Breast Feeding Initiation in Canada: Key Statistics and Graphics. Retrieved August, 2011 from: http://www.hc-sc.gc.ca/fn-an/surveill/nutrition/commun/prenatal/initiation-eng.php#a2 33 Health Canada. Food and Nutrition, Consultation – 3. Breastfeeding is Rarely Contraindicated. Retrieved August, 2011 from: http://www.hc-sc.gc.ca/fn-an/consult/infant-nourrisson/recommendations/recom3-eng.php 34 Kim JH, Unger H. (2010) Human Milk Banking. Paediatric Child Health NG 2010-01 35 Government of PEI (2010). Vital Statistics Act. Retrieved August, 20111 from: http://www.gov.pe.ca/law/statutes/pdf/v-04_01.pdf?PHPSESSID=a37482661d3e6fdf84d32273b8de713e

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