Reproductive, Maternal and Infant Health in Waterloo Region

Acknowledgements Authors Jessica Deming, Laura Armstrong, Mike Delorme, Stephen Drew, Lindsay Steckley, Amanda Tavares and Jennifer Toews Coordinating Committee Dr. Hsiu-Li Wang, Andrea Reist, Karen Quigley-Hobbs, Sue Morris, Chris Harold, Heidy ChoiKeirstead, Asma Razzaq Other Contributors Deborah Azim Fleming, Gayle Jessop, Judy Maan Miedema, Aimee White Suggested Citation Region of Waterloo Public Health (2012). Reproductive, Maternal and Infant Health in Waterloo Region: a Health Status Report. Waterloo, ON: Authors For more information, please contact: Epidemiology and Health Analytics Region of Waterloo Public Health 99 Regina Street South, 3rd floor Waterloo, Ontario N2J 4V3 Phone: 519-883-2004 x5413 Email: [email protected] http://www.region.waterloo.on.ca/ph Internal access to report: DOCS# 1076840

Subject to the following limitations, this resource may be reproduced, stored in a retrieval system, and transmitted in any form and by any means as long as the source is acknowledged. No part of this resource may be used or reproduced for commercial purposes or to generate monetary profits. Written permission is required if any adaptations or changes are made. This permission does not cover the use or reproduction of any third-party copyrighted material which appears in this resource. Written permission to use such material must be obtained from the cited source. © Region of Waterloo Public Health, 2012

Reproductive, Maternal and Infant Health Status Report

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Region of Waterloo Public Health

Message from the Medical Officer of Health

The Ontario Public Health Standards (OPHS) establish requirements for the fundamental programs and services carried out by public health units. As part of its mandate, Region of Waterloo Public Health works to fulfill the following objectives: to enable individuals and families to achieve optimal preconception health, experience a healthy pregnancy, and have the healthiest newborn(s) possible; to enable individuals to be prepared for parenthood; and to enable all children to attain and sustain optimal health and development potential. The OPHS also mandate public health units to assess current health status in the local population and to conduct epidemiological analysis of surveillance data, including in the areas of preconception health, healthy pregnancies, reproductive health outcomes, preparation for parenting, and breastfeeding. In addition, Region of Waterloo Public Health is also mandated to share this valuable information with the public, community partners, and health care providers. Therefore, in accordance with these areas of our mandate, I am pleased to introduce Reproductive, Maternal and Infant Health Status in Waterloo Region: a Health Status Report. This report provides a detailed picture of reproductive, maternal and infant health of Waterloo Region residents from preconception through to birth, as well as selected health outcomes of infants up to one year of age. I hope that you find the information in this report both useful and meaningful. As always, Region of Waterloo Public Health continually works to improve its programs, services and reporting of reproductive and maternal health topics, in our efforts to build healthy and supportive communities in partnership.

Dr. Liana Nolan Commissioner/Medical Officer of Health Region of Waterloo Public Health


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Table of Contents Acknowledgements.......................................................................................................................... i Message from the Medical Officer of Health .................................................................................iii Table of Contents ............................................................................................................................iv List of Tables ...................................................................................................................................vi List of Figures ...................................................................................................................................x List of Abbreviations ..................................................................................................................... xiii Executive Summary....................................................................................................................... xiv Introduction .................................................................................................................................... 1 1 Preconception Demographics and Health............................................................................... 3 1.1 Population of Females of Reproductive Age .................................................................... 3 1.2 Social Determinants of Health.......................................................................................... 8 1.3 Presence of a Family Doctor ........................................................................................... 12 1.4 Healthy Body Weight...................................................................................................... 18 1.5 Folic Acid Intake ............................................................................................................. 27 2 Fertility and Pregnancy .......................................................................................................... 33 2.1 Fertility ........................................................................................................................... 33 2.2 Pregnancies .................................................................................................................... 38 2.3 Therapeutic Abortions .................................................................................................... 44 2.4 Parity .............................................................................................................................. 49 3 Healthy Pregnancies .............................................................................................................. 53 3.1 Larson Prenatal Screen for At-Risk Pregnant Women.................................................... 53 3.2 Prenatal Class Attendance ............................................................................................. 57 3.3 Depression ...................................................................................................................... 61 3.4 Tobacco Use ................................................................................................................... 65 3.5 Alcohol Use ..................................................................................................................... 73 3.6 Illicit Drug Use ................................................................................................................ 75 3.7 Prenatal HIV Testing ....................................................................................................... 77 4 Birth Outcomes ...................................................................................................................... 81 4.1 Live Births ....................................................................................................................... 81 4.2 Multiple Births ................................................................................................................ 89 4.3 Stillbirths ......................................................................................................................... 92 4.4 Age of Mother and Father at Infant’s Birth.................................................................... 95 4.5 Gestational Age ............................................................................................................ 101 4.6 Birth Weight ................................................................................................................. 105

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4.7 Birth Weight for Gestational Age ................................................................................. 113 4.8 Assisted and Caesarean Deliveries ............................................................................... 119 4.9 Health Care Providers ................................................................................................... 124 5 Infant Health Outcomes ...................................................................................................... 129 5.1 Infant Mortality ............................................................................................................ 129 5.2 Congenital Infections .................................................................................................... 131 5.3 Congenital Anomalies................................................................................................... 134 5.4 Parkyn Postpartum Screen for At-Risk Infants ............................................................. 140 5.5 Breastfeeding ............................................................................................................... 146 6 Methodology, Data Sources and Limitations ...................................................................... 157 6.1 Overall Methodological Notes...................................................................................... 159 6.2 Canadian Census .......................................................................................................... 159 6.3 Canadian Community Health Survey (CCHS) ................................................................ 160 6.4 Canadian Congenital Anomalies Surveillance System (CCASS) .................................... 161 6.5 Discharge Abstract Database (DAD) ............................................................................ 161 6.6 Integrated Services for Children Information System (ISCIS) ....................................... 163 6.7 Niday Perinatal Database ............................................................................................ 164 6.8 Ontario HIV Prenatal Testing Data............................................................................... 165 6.9 Population Estimates and Projections .......................................................................... 165 6.10 Therapeutic Abortion Summary ................................................................................... 166 6.11 Vital Statistics – Births, Stillbirths and Deaths ............................................................. 166 References .................................................................................................................................. 168 Appendix A. Glossary of Terms ................................................................................................... 177 Appendix B. Map of Neighbourhoods and Municipalities in Waterloo Region ......................... 180 Appendix C. Larson and Parkyn Screening Tools ........................................................................ 181 Appendix D. Data Tables ............................................................................................................. 183


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List of Tables Table 1.1. Number and proportion of females of reproductive age*, by place of residence, Waterloo Region and Ontario, 2009 ......................................................................................... 5 Table 1.2. Proportion of mothers by level of education, Waterloo Region, 2008-2010 ................ 9 Table 1.3. Proportion of mothers by first language, Waterloo Region, 2008-2010 ..................... 10 Table 1.4. Proportion of females of reproductive age* with low income status†, by ten-year age group, Waterloo Region and Ontario, 2006..................................................................... 10 Table 1.5. Proportion of females of reproductive age* by immigrant status, by ten-year age group, Waterloo Region and Ontario, 2006 ........................................................................... 11 Table 1.6. Proportion of females of reproductive age* with a regular family doctor, by place of residence, Waterloo Region and Ontario, 2007-2009 ............................................................ 13 Table 1.7. Adult body mass index (BMI) classifications and associated risk for developing health problems ...................................................................................................................... 19 Table 1.8. Proportion of females* who took a folic acid supplement prior to knowing they were pregnant, by place of residence, Waterloo Region and Ontario, 2007-2009 ............... 28 Table 2.1. General fertility rates per 1,000 females aged 15 to 49 years, by place of residence, Waterloo Region, 2000-2007 .................................................................................................. 35 Table 2.2. Age-specific fertility rates per 1,000 females aged 15 to 49 years, by five-year age groups and place of residence, Waterloo Region, 2007......................................................... 37 Table 2.3. Total pregnancy rates per 1,000 females aged 15 to 49 years, by place of residence, Waterloo Region, 2001-2009 .................................................................................................. 41 Table 2.4. Age-specific pregnancy rates per 1,000 females aged 15 to 49 years, by five-year age groups and place of residence, Waterloo Region, 2009 .................................................. 43 Table 2.5. Total therapeutic abortion rates per 1,000 females aged 15 to 49 years, by place of residence, Waterloo Region, 2001-2009 ................................................................................ 46 Table 2.6. Age-specific therapeutic abortion rates per 1,000 females aged 15 to 49 years, by five-year age groups and place of residence, Waterloo Region, 2009 ................................... 48 Table 2.7. Proportion of births, by mother’s parity, Waterloo Region, 2008-2010 ..................... 50 Table 2.8. Proportion of births, by mother’s parity and five-year age groups, Waterloo Region, 2010 ........................................................................................................................................ 51 Table 3.1. Proportion of pregnant women with an at-risk Larson score*, by five-year age group, Waterloo Region, 2008-2010 ...................................................................................... 54 Table 3.2. Proportion of pregnant women with an at-risk Larson score*, by place of residence, Waterloo Region, 2008-2010 .................................................................................................. 54 Table 3.3. Proportion of pregnant women who attended a prenatal class, by parity, Waterloo Region, 2008-2010 .................................................................................................................. 58 Table 3.4. Proportion of pregnant women who attended a prenatal class, by five-year age group, Waterloo Region, 2008-2010 ...................................................................................... 59

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Table 3.5. Proportion of pregnant women who attended a prenatal class, by place of residence, Waterloo Region, 2008-2010 ................................................................................ 59 Table 3.6. Proportion of women who smoked during pregnancy, by gestational weeks when smoking occurred, Waterloo Region, 2008-2010 ................................................................... 66 Table 3.7. Proportion of women who smoked during pregnancy, by five-year maternal age group, Waterloo Region, 2008-2010 ...................................................................................... 67 Table 3.8. Proportion of women who smoked during pregnancy, by place of residence, Waterloo Region, 2008-2010 .................................................................................................. 68 Table 3.9. Proportion of women who smoked during pregnancy, by number of cigarettes smoked per day, Waterloo Region, 2008-2010 ...................................................................... 70 Table 3.10. Proportion of mothers who were smokers at time of birth, by financial situation, Waterloo Region, 2008-2010 .................................................................................................. 72 Table 3.11. Proportion of females* who abstained from alcohol during pregnancy, by age group, Waterloo Region and Ontario, 2007-2008 .................................................................. 74 Table 3.12. Five-year cumulative newborn hospitalization rate per 1,000 live births for effects of maternal use of drugs of addiction, Waterloo Region and Ontario, 2005-2009 ............... 76 Table 4.1. Number of live births and crude birth rate per 1,000 population, Canada, 20002008 ........................................................................................................................................ 81 Table 4.2. Crude birth rate per 1,000 population, by place of residence, Waterloo Region, 2000-2007 ............................................................................................................................... 84 Table 4.3. Number of live births, by place of residence, Waterloo Region, 2000-2007 .............. 85 Table 4.4. Number of live births, by place of residence, Waterloo Region, 2008-2010 .............. 85 Table 4.5. Multiple birth rate, by place of residence, Waterloo Region, 2008-2010 ................... 90 Table 4.6. Stillbirth rate, by type of infant, Canada, 2000-2008 .................................................. 93 Table 4.7. Average age of mother and father at infant’s birth, by place of residence, Waterloo Region and Ontario, 2007 ....................................................................................................... 97 Table 4.8. Proportion of infants by gestational age category, Waterloo Region, 2008-2010 .... 102 Table 4.9. Proportion of infants by birth weight category, Waterloo Region, 2008-2010......... 106 Table 4.10. Proportion of infants by birth weight for gestational age, Waterloo Region, 20082010 ...................................................................................................................................... 116 Table 4.11. Assisted delivery rate, by place of residence, Waterloo Region and Ontario, 20072009 ...................................................................................................................................... 121 Table 4.12. Caesarean delivery rate, by place of residence, Waterloo Region and Ontario, 2007-2009 ............................................................................................................................. 122 Table 4.13. Proportion of hospital births by type of prenatal health care provider, Waterloo Region, 2008-2010 ................................................................................................................ 125 Table 4.14. Proportion of hospital births by type of health care provider at delivery, Waterloo Region, 2008-2010 ................................................................................................................ 126


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Table 4.15. Proportion of infants born in hospital by type of prenatal health care provider and type of health care provider at delivery, Waterloo Region, 2008-2010 .............................. 127 Table 5.1. Infant mortality rate, by age of infant, Canada, 2001-2007 ...................................... 129 Table 5.2. Five-year cumulative rates of neural tube defects (NTDs) per 10,000 total births, by type, Waterloo Region and Ontario, 2003-2007 .................................................................. 139 Table 5.3. Proportion of infants with an at-risk Parkyn score*, by five-year maternal age group, Waterloo Region, 2008-2010 .................................................................................... 141 Table 5.4. Proportion of infants with an at-risk Parkyn score*, by place of residence, Waterloo Region, 2008-2010 ................................................................................................................ 142 Table 5.5. Proportion of infants by social situation and Parkyn risk level*, Waterloo Region, 2008-2010 ............................................................................................................................. 144 Table 5.6. Proportion of infants by financial situation and Parkyn risk level*, Waterloo Region, 2008-2010 ............................................................................................................................. 144 Table 6.1. Summary of data sources used by chapter, section and indicator............................ 157 Table 6.2. ICD-10-CA codes used to classify selected congenital anomalies (CAs) .................... 161 Table D.1. Number of females and proportion of total female population, by five-year age groups, Waterloo Region and Ontario, 2009 ........................................................................ 183 Table D.2. Proportion of females of reproductive age* with a regular family doctor, by fiveyear age group, Waterloo Region and Ontario, 2007-2009 ................................................. 184 Table D.3. Proportion of females of reproductive age* with a regular family doctor, by highest level of household education attained, Waterloo Region and Ontario, 2007-2009 ............ 184 Table D.4. Proportion of females of reproductive age* with a regular family doctor, by marital status, Waterloo Region and Ontario, 2007-2009 ................................................................ 185 Table D.5. Proportion of females of reproductive age* with a regular family doctor, by annual household income, Waterloo Region and Ontario, 2007-2009 ........................................... 185 Table D.6. Proportion of females of reproductive age* with healthy and overweight/obese body weight, by place of residence, Waterloo Region and Ontario, 2007-2009 ................. 186 Table D.7. Proportion of females of reproductive age* with healthy and overweight/obese body weight, by five-year age group, Waterloo Region and Ontario, 2007-2009 ............... 186 Table D.8. Proportion of females of reproductive age* with healthy and overweight/obese body weight, by highest level of household education attained, Waterloo Region and Ontario, 2007-2009 ............................................................................................................... 187 Table D.9. Proportion of females of reproductive age* with healthy and overweight/obese body weight, by marital status, Waterloo Region and Ontario, 2007-2009 ........................ 187 Table D.10. Proportion of females of reproductive age* with healthy and overweight/obese body weight, by annual household income, Waterloo Region and Ontario, 2007-2009 ..... 188 Table D.11. Proportion of females* who took a folic acid supplement prior to knowing they were pregnant, by five-year age group, Waterloo Region and Ontario, 2007-2009 ........... 188 Table D.12. Proportion of females* who took a folic acid supplement prior to knowing they were pregnant, by marital status, Waterloo Region and Ontario, 2007-2009 .................... 189 viii


Table D.13. Rates of births with congenital anomalies (CAs) per 10,000 total births, Waterloo Region and Ontario, 2003-2007............................................................................................ 189 Table D.14. Rates of Down syndrome per 10,000 total births, Waterloo Region and Ontario, 2003-2007 ............................................................................................................................. 190 Table D.15. Rates of neural tube defects (NTDs) per 10,000 total births, by type, Ontario, 2003-2007 ............................................................................................................................. 190 Table D.16. Proportion of females* who breastfed or exclusively breastfed their last child for at least six months, Waterloo Region and Ontario, 2007-2009 ........................................... 190


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List of Figures Figure 1.1. Proportion of total female population by five-year age groups, Waterloo Region and Ontario, 2009 ..................................................................................................................... 4 Figure 1.2. Number and proportion of females of reproductive age*, Waterloo Region and Ontario, 2000-2009 ................................................................................................................... 6 Figure 1.3. Projected number and proportion of females of reproductive age*, Waterloo Region and Ontario, 2010-2035................................................................................................ 7 Figure 1.4. Proportion of females of reproductive age* with a regular family doctor, by fiveyear age group, Waterloo Region and Ontario, 2007-2009 ................................................... 14 Figure 1.5. Proportion of females of reproductive age* with a regular family doctor, by highest level of household education attained, Waterloo Region and Ontario, 2007-2009 .............. 15 Figure 1.6. Proportion of females of reproductive age* with a regular family doctor, by marital status, Waterloo Region and Ontario, 2007-2009 .................................................................. 16 Figure 1.7. Proportion of females of reproductive age* with a regular family doctor, by annual household income, Waterloo Region and Ontario, 2007-2009 ............................................. 17 Figure 1.8. Proportion of females of reproductive age* with healthy and overweight/obese body weight, by place of residence, Waterloo Region and Ontario, 2007-2009 ................... 20 Figure 1.9. Proportion of females of reproductive age* with healthy and overweight/obese body weight, by age group, Waterloo Region and Ontario, 2007-2009 ................................ 21 Figure 1.10. Proportion of females of reproductive age* with healthy and overweight/obese body weight, by highest level of household education attained, Waterloo Region and Ontario, 2007-2009 ................................................................................................................. 22 Figure 1.11. Proportion of females of reproductive age* with healthy and overweight/obese body weight, by marital status, Waterloo Region and Ontario, 2007-2009 .......................... 23 Figure 1.12. Proportion of females of reproductive age* with healthy and overweight/obese body weight, by annual household income, Waterloo Region and Ontario, 2007-2009 ....... 25 Figure 1.13. Proportion of females* who took a folic acid supplement prior to knowing they were pregnant, by age group, Waterloo Region and Ontario, 2007-2009............................. 29 Figure 1.14. Proportion of females* who took a folic acid supplement prior to knowing they were pregnant, by marital status, Waterloo Region and Ontario, 2007-2009 ...................... 30 Figure 2.1. General fertility rates per 1,000 females aged 15 to 49 years, Waterloo Region and Ontario, 2000-2007 ................................................................................................................. 34 Figure 2.2. Age-specific fertility rates per 1,000 females aged 15 to 49 years, by five-year age groups, Waterloo Region and Ontario, 2000 and 2007.......................................................... 36 Figure 2.3. Total (15 to 49 years) and teen (15 to 19 years) pregnancy rates per 1,000 females, Waterloo Region and Ontario, 2001-2009 ............................................................................. 40 Figure 2.4. Age-specific pregnancy rates per 1,000 females aged 15 to 49 years, by five-year age groups, Waterloo Region and Ontario, 2001 and 2009 ................................................... 42

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Figure 2.5. Total therapeutic abortion rates per 1,000 females aged 15 to 49 years, Waterloo Region and Ontario, 2001-2009.............................................................................................. 45 Figure 2.6. Age-specific therapeutic abortion rates per 1,000 females aged 15 to 49 years, by five-year age groups, Waterloo Region and Ontario, 2001 and 2009 .................................... 47 Figure 3.1. Proportion of pregnant women with an at-risk Larson score*, by neighbourhood quintile, Waterloo Region, 2008-2010 ................................................................................... 55 Figure 3.2. Proportion of pregnant women with depression, by type and year, Waterloo Region, 2008-2010 .................................................................................................................. 62 Figure 3.3. Proportion of pregnant women with depression, by type and age group, Waterloo Region, 2008-2010 .................................................................................................................. 63 Figure 3.4. Proportion of pregnant women with depression, by type and place of residence, Waterloo Region, 2008-2010 .................................................................................................. 64 Figure 3.5. Proportion of women who smoked during pregnancy, by neighbourhood quintile, Waterloo Region, 2008-2010 .................................................................................................. 69 Figure 3.6. Proportion of women who smoked during pregnancy, by number of cigarettes smoked per day and five-year age group, Waterloo Region, 2008-2010............................... 71 Figure 3.7. Proportion of pregnant females prenatally screened for HIV and rate of HIV test positivity per 1,000 prenatal HIV tests, Waterloo Region and Ontario, 2001-2010 .............. 78 Figure 4.1. Number of live births and crude birth rate per 1,000 population, Waterloo Region and Ontario, 2000-2007 .......................................................................................................... 83 Figure 4.2. Number of live births, by neighbourhood quintile, Waterloo Region, 2010.............. 86 Figure 4.3. Projected number of live births and projected crude birth rate per 1,000 population, Waterloo Region and Ontario, 2015-2035 .......................................................... 87 Figure 4.4. Multiple birth rate, by maternal age group, Waterloo Region, 2008-2010 ............... 91 Figure 4.5. Number of stillbirths and stillbirth rate per 1,000 births, Waterloo Region and Ontario, 2000-2007 ................................................................................................................. 94 Figure 4.6. Proportion of infants by age group of mothers and fathers, Waterloo Region and Ontario, 2007 .......................................................................................................................... 98 Figure 4.7. Average age of mother at infant’s birth, by neighbourhood quintile, Waterloo Region, 2010 ........................................................................................................................... 99 Figure 4.8. Preterm birth rate, by place of residence, Waterloo Region, 2008-2010 ................ 103 Figure 4.9. Preterm birth rate, by maternal age group, Waterloo Region, 2008-2010 ............. 104 Figure 4.10. Proportion of infants with low and high birth weight, by gestational age category, Waterloo Region, 2008-2010 ................................................................................................ 107 Figure 4.11. Proportion of infants with low and high birth weight, by maternal age group, Waterloo Region, 2008-2010 ................................................................................................ 108 Figure 4.12. Proportion of infants with low and high birth weight, by place of residence, Waterloo Region, 2008-2010 ................................................................................................ 109 Figure 4.13. Proportion of infants with low birth weight, by neighbourhood quintile, Waterloo Region, 2008-2010 ................................................................................................................ 110 Reproductive, Maternal and Infant Health Status Report

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Figure 4.14. Proportion of infants with high birth weight, by neighbourhood quintile, Waterloo Region, 2008-2010 ................................................................................................ 111 Figure 4.15. Relationship between birth weight and gestational age, and 90th and 10th percentile birth weight for gestational age cut-offs ............................................................. 114 Figure 4.16 Proportion of infants that were small for gestational age (SGA), by place of residence, Waterloo Region, 2008-2010 .............................................................................. 117 Figure 4.17. Proportion of infants that were small for gestational age (SGA), by maternal age group, Waterloo Region, 2008-2010 .................................................................................... 118 Figure 4.18. Caesarean delivery rate, by maternal age group, Waterloo Region and Ontario, 2009 ...................................................................................................................................... 123 Figure 5.1. Number of infant deaths and rates of infant mortality per 1,000 births, Waterloo Region and Ontario, 2001-2007............................................................................................ 130 Figure 5.2. Rate of congenital infections* per 1,000 live births, Waterloo Region and Ontario, 2002-2007 ............................................................................................................................. 133 Figure 5.3. Rates of births with congenital anomalies (CAs) per 10,000 total births, Waterloo Region and Ontario, 2003-2007............................................................................................ 136 Figure 5.4. Rates of Down syndrome per 10,000 total births, Waterloo Region and Ontario, 2003-2007 ............................................................................................................................. 137 Figure 5.5. Rates of neural tube defects (NTDs) per 10,000 total births, by type, Ontario, 20032007 ...................................................................................................................................... 138 Figure 5.6 Proportion of infants with an at-risk Parkyn score*, by neighbourhood quintile, Waterloo Region, 2008-2010 ................................................................................................ 143 Figure 5.7. Proportion of infants by feeding method at hospital discharge, Waterloo Region, 2008-2010 ............................................................................................................................. 148 Figure 5.8. Proportion of infants by feeding method at hospital discharge, by maternal age group, Waterloo Region, 2008-2010 .................................................................................... 149 Figure 5.9. Proportion of infants by feeding method at hospital discharge, by place of residence, Waterloo Region, 2008-2010 .............................................................................. 150 Figure 5.10. Proportion of infants fed breastmilk* at hospital discharge, by neighbourhood quintile, Waterloo Region, 2010 ........................................................................................... 151 Figure 5.11. Proportion of infants fed breastmilk only at hospital discharge, by neighbourhood quintile, Waterloo Region, 2010 ........................................................................................... 153 Figure 5.12. Proportion of females* who breastfed or exclusively breastfed their last child for at least six months, Waterloo Region and Ontario, 2007-2009 ........................................... 154 Figure B.1. Neighbourhoods and municipalities in Waterloo Region ........................................ 180 Figure C.1. Region of Waterloo Public Health Healthy Babies Healthy Children (HBHC) Prenatal Screening and Assessment with Larson pre-birth screening tool ........................................ 181 Figure C.2. Region of Waterloo Public Health Healthy Babies Healthy Children (HBHC) Post Partum Assessment with Parkyn post partum screening tool ............................................. 182

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List of Abbreviations Abbreviation AIDS BMI BORN CA CCASS CCHS CI CIHI DAD FAS FASD HBHC HIV ICD ISCIS IRSS LICOs LGA MOHLTC NA NTD NR OHEMU OHIP PHAC ROWPH SGA SPSS TA

Name Acquired immunodeficiency syndrome Body mass index Better Outcomes Registry and Network (Ontario) Congenital anomaly Canadian Congenital Anomalies Surveillance System Canadian Community Health Survey Confidence interval Canadian Institute for Health Information Discharge Abstract Database Fetal Alcohol Syndrome Fetal Alcohol Spectrum Disorder Healthy Babies Healthy Children Human immunodeficiency virus International Classification of Diseases Integrated Services for Children Information System ISCIS Reporting Sub-System Low Income Cut-Offs Large for gestational age (Ontario) Ministry of Health and Long Term Care Not available or not applicable Neural tube defect Not reportable Ontario HIV Epidemiologic Monitoring Unit Ontario Health Insurance Plan Public Health Agency of Canada Region of Waterloo Public Health Small for gestational age Statistical Package for the Social Sciences Therapeutic abortion


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Executive Summary This report provides a snapshot of reproductive, maternal and infant health in Waterloo Region, using the most accurate and timely information possible from a variety of data sources. There are approximately 6,000 births each year in Waterloo Region. This number is projected to increase in the future, up to approximately 8,000 births annually by 2035. The total fertility rate in Waterloo Region is 1.7 children per woman, which is below the level at which a population will naturally replenish itself without immigration. Sub-replenishment total fertility rates are often seen in stable, industrialized countries like Canada. The average age of mothers and fathers in Waterloo Region has increased as parents are delaying childbearing to later in life. •

As the general population ages, the proportion of women in Waterloo Region of reproductive age is decreasing. However, in absolute numbers, the number of women of reproductive age is increasing as the size of the general population in Waterloo Region continues to grow.

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There has been shift in the past decade in the age group with the highest pregnancy rate, from women aged 25 to 29 years to women aged 30 to 34 years.

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Teen pregnancy rates declined slightly from 2001 to 2009, with the highest rates being in Kitchener and Cambridge.

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The average age of mothers in Waterloo Region is approximately 29 years, similar to Canada but lower than Ontario. On average, fathers are two to three years older than mothers.

The changes in age at childbearing are important, since there are numerous age differences in socio-demographics, maternal health behaviours, and infant health outcomes. • Younger females (aged 15 to 24 years) are slightly more likely to have low income in Waterloo Region, compared to females of all ages. • About seven per cent of females in the peak of reproductive age (25 to 34 years) are recent immigrants, a proportion twice as high as that for females of all ages. • About one-third of females of reproductive age in Waterloo Region are overweight or obese. Rates of overweight and obesity are higher in older women, women with less education, and women who are married or common-law. • Overall, therapeutic abortion rates have been stable for the past 10 years in Waterloo Region; trends show that therapeutic abortions are declining in teens and increasing in older women (aged 35 years and older).

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• Just over half of women in Waterloo Region take a supplement containing folic acid prior to knowing they are pregnant. At the provincial level, rates of folic acid supplementation increase with age. • Mothers under 20 years old have the highest rates of past and current depression, while mothers aged 40 years and over have the highest rates of postpartum mood disorder. Maternal depression during the perinatal period is likely underreported, and therefore is not well understood in Waterloo Region. • Approximately twelve per cent of pregnant women in Waterloo Region smoke during pregnancy. The prevalence of smoking during pregnancy decreases with advancing maternal age; however, older pregnant women who do smoke tend to smoke more heavily. • Almost all mothers report abstaining from alcohol during pregnancy and evidence suggests use of illicit drugs during pregnancy is even less common than alcohol. • Almost half of pregnant women attend a prenatal class; prenatal class attendance rates are highest in teen mothers and first-time mothers. • Approximately three per cent of all births are multiples (e.g., twins, triplets); multiple birth infants are more common among older women and with use of assisted reproductive technology. • Approximately one-quarter of births in Waterloo Region occur by caesarean section. Caesarean delivery rates increase with advancing maternal age, with approximately half of women aged 45 to 49 years having a caesarean delivery. • Teen mothers are the most likely to feed their infant formula within the first few days following birth; both younger and older mothers are less likely to feed their infants breastmilk alone, compared to mothers aged 25 to 34 years. Within Waterloo Region, there are geographical differences in reproductive, maternal and infant health status. •

Nearly half of all births in Waterloo Region occur to residents of Kitchener, which is expected due to its large population. North Dumfries is the only municipality to experience a declining number of births relative to the size of the population.

•

Approximately 46 infants are born per 1,000 females in Waterloo Region. Fertility rates are higher in Wellesley, Wilmot and Woolwich townships than in the three cities and North Dumfries. Age-specific fertility rates reveal that more live births in these townships occur to women in their twenties.

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In Waterloo and North Dumfries, the average age of mothers is just over 30 years, while in Cambridge and Wellesley it is less than 29 years.


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Overall, approximately six per cent of infants in Waterloo Region are born with low birth weight (less than 2,500 grams). The highest rates of low birth weight infants occur mainly in Wellesley and within some neighbourhoods in the three cities.

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Residents of Wellesley and some neighbourhoods in downtown Kitchener and Cambridge are more likely to be screened as at-risk on the Larson prenatal screen and Parkyn postpartum screen, likely as a result of more young mothers in these areas.

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Woolwich has the highest proportion of infants fed breastmilk only within the first few days of birth, whereas Cambridge has some of the lowest proportions of infants being fed breastmilk only.

Most women in Waterloo Region receive prenatal care from obstetricians and family physicians; most infants are delivered in hospital. •

Evidence suggests most women of reproductive age have a regular family doctor, although women aged 20 to 24 years may be slightly less likely to have a family doctor.

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Family physicians provide prenatal care for over half of pregnancies resulting in hospital births in the region, but very few births are attended by family physicians.

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Obstetricians provide prenatal care for over three quarters of hospital births, and attend over 85 per cent of hospital deliveries.

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One third of obstetricians in Ontario plan on retiring in the next five years, which has raised concerns about the capacity of the provincial health care system to meet reproductive and perinatal health needs into the future.

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Approximately three per cent of all births in Waterloo Region occur at home, attended by a midwife. Less than ten per cent of hospital births are attended by a midwife, but compared to Ontario, women in Waterloo Region are more likely to use midwifery services.

Few infants in Waterloo Region experience poor health outcomes; the causes of poor infant health outcomes are often difficult to modify.

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Advanced maternal age is associated with high birth weight (more than 4,000 grams), low birth weight and postterm birth (42 weeks’ gestation or later).

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Postterm births are rare, but preterm birth rates are increasing, likely associated with the increase in average maternal age at infant’s birth.

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There are approximately six to eight stillbirths per 1,000 births in Waterloo Region.

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Approximately eight per cent of infants are small for gestational age (less than 10th percentile) while eleven per cent are large for gestational age (greater than 90th percentile). Young maternal age is associated with small for gestational age births.


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Smoking is associated with higher rates of small for gestational age births and stillbirths.

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Very few infants acquire congenital infections or are born with congenital anomalies.

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Prenatal testing rates for HIV are almost at 100 per cent in Waterloo Region and Ontario.

In general, the health of Waterloo Region mothers and infants is on par with the rest of Ontario and Canada.

• Fertility and pregnancy rates in Waterloo Region are similar to those in Ontario and Canada. •

Rates of infant mortality, congenital infection, Down syndrome, maternal alcohol use, maternal illicit drug use, prenatal HIV testing and stillbirth are similar to the rates for all of Ontario.

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Waterloo Region has lower rates of therapeutic abortions, smoking during pregnancy, preterm birth, low birth weight, and small for gestational age, compared to Ontario.

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Caesarean rates in Waterloo Region were similar to Ontario, until 2009 when the local rate decreased and the provincial rate increased.

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Crude birth rates are slightly higher in Waterloo Region than in Canada or Ontario.

There are still things we do not know about reproductive, maternal and infant health and what will change in the future. Better and more integrated data sources at the provincial level are needed. •

Many data sources exist, all with certain drawbacks, and none which might be considered a ‘gold standard’ of reproductive health information in Waterloo Region.

•

While it is less than ideal to work with multiple data sources, ultimately it was decided that the best and most appropriate data source should be used for each indicator.

•

One timely, high quality and comprehensive source of reproductive, maternal and infant health information in Ontario is needed to allow public health units to better measure and track local trends in reproductive, maternal and infant health status.


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xviii


Introduction The current status of reproductive, maternal and infant health in Waterloo Region is described in this report. ‘Reproductive health’ refers to the physical, mental and social well-being of individuals and families in the context of reproduction, including preconception and preparation for pregnancy, prenatal health, healthy births and newborns, parenthood and beyond. ‘Maternal health’ refers to the health and well-being of women during pregnancy, childbirth and the postpartum period. In addition, this report also describes selected components of infant health which are of public health significance. Reproductive, maternal and infant health in Canada has improved dramatically over the past century. There has been a major decline in maternal and infant death rates in Canada and other developed countries as a result of improved sanitation, nutrition, standard of living and level of education, as well as medical advances, improved access to health care and better disease surveillance.1 Recently, the Canadian Public Health Association cited ‘healthier mothers and babies’ and ‘family planning’ as two of twelve great public health achievements in Canada in the past 100 years.2 Much progress has been made, and today “the health of mothers and children in Canada is among the best in the world.”1 Even so, opportunities remain for improving the reproductive, maternal and infant health in the Canadian and Waterloo Region populations. It is important to monitor the health and wellbeing of mothers, infants and their families from preconception through to post-birth to identify areas of success, areas where improvement is needed, and priority populations for which focused efforts are required. This report describes thirty-one indicators of reproductive, maternal and infant health, broadly categorized into five stages: (1) preconception demographics and health; (2) fertility and pregnancy; (3) healthy pregnancies; (4) birth outcomes; and (5) infant health outcomes. It is worth noting that the content of this report was determined in part by availability of data. Particularly in the area of preconception health, there are other indicators of public health importance which could not be included as no data currently exist. For each indicator described in this report, background information is provided, including national data wherever possible to provide Canadian context. Local data are reported using tables, graphs and maps, including provincial or regional comparators wherever possible. Multiple data sources are used. The best possible data source was selected for each indicator, based on data quality, availability and timeliness, data collection methods, data element definitions and availability. Data limitations are provided with each indicator throughout the report; data sources and methodology are described in detail in the seventh chapter. Wherever possible, data were reported for 2008 to 2010 to provide an up-to-date picture of reproductive, maternal and infant health in Waterloo Region.


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2


1 Preconception Demographics and Health This first chapter provides demographic context for the population of women of reproductive age in Waterloo Region, and also describes selected aspects of preconception health that can have an impact on maternal and infant health outcomes. There are other aspects of preconception health which are of public health importance, such as nutrition, management of chronic diseases and drug use; however, these could not be described here due to an absence of data. Preconception health indicators described in this chapter include the presence of a regular family doctor, preconception body weight, and folic acid intake prior to becoming pregnant. Maternal health prior to conception is increasingly recognized as influential on the health outcomes of mothers and their infants. Given that almost half of pregnancies in North America are unintended,3 ‘pregnancy-readiness’ for women of reproductive age is an important step to ensure optimal maternal and infant health. Preparation for a healthy pregnancy may include counselling and behaviour modification in areas such as maternal body weight, smoking, alcohol and drug use.1

1.1 Population of Females of Reproductive Age 1.1.1 Background ‘Reproductive age’ in women is a stage of the lifespan often defined as age 15 to 44 years in international comparisons, or more frequently as 15 to 49 years in developed countries. For the purposes of this report, the definition of 15 to 49 years will be used in reference to women of reproductive age. In Canada in 2006, 48.9 per cent of the total female population were women of reproductive age; this proportion represented 24.9 per cent of the entire Canadian population.4

1.1.2 Local Picture The proportion of women of reproductive age within Waterloo Region is explored using population estimates and population projections. Figure 1.1 illustrates the proportion of the total female population represented by women of reproductive age for Waterloo Region and Ontario in 2009.


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Figure 1.1. Proportion of total female population by five-year age groups, Waterloo Region and Ontario, 2009 90+ Waterloo Region

85-89

Ontario 80-84 75-79 70-74 65-69 60-64

50-54 45-49 40-44

Reproductive age

Age group (years)

55-59

35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4 0.0 -

2.0

4.0

6.0

8.0

10.0

Per cent of total female population

Source: Ontario Ministry of Health and Long Term Care (MOHLTC) Population Estimates (2009), IntelliHEALTH Ontario. Extracted September 22, 2010.

As shown above, women of reproductive age represented roughly half of all females in Waterloo Region and Ontario in 2009 (51.4 and 49.5 per cent, respectively). In Waterloo Region, there was a slightly higher proportion of women aged 45 to 49 years, and lower proportions of women in all younger reproductive age groups (i.e., 15 to 44 years) as compared to Ontario. Table 1.1 shows the number and proportion of women of reproductive age in Waterloo Region and Ontario in 2009, as well as for the seven area municipalities that comprise Waterloo Region.

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Table 1.1. Number and proportion of females of reproductive age*, by place of residence, Waterloo Region and Ontario, 2009 Place of residence Cambridge Kitchener Waterloo North Dumfries Wellesley Wilmot Woolwich Waterloo Region Ontario

Number of females aged 15 to 49 years 33,403 58,087 28,100 2,425 2,469 4,305 4,857 133,646 3,411,554

Per cent of all females 50.9 52.1 53.1 50.7 48.1 46.6 45.3 51.4 49.5

Source: MOHLTC. Population Estimates (2009), IntelliHEALTH Ontario. Extracted September 22, 2010. *Females of reproductive age are those aged 15 to 49 years.

As shown in Table 1.1, roughly half of all females are of reproductive age in all municipalities of Waterloo Region, as well as provincially. The proportion of females within this age range only varies slightly from municipality to municipality, with the lowest proportion of females in reproductive years in Woolwich (45.3 per cent) and the highest proportion of females of reproductive age in Waterloo (53.1 per cent). Figure 1.2 illustrates changes over time from 2000 to 2009 in the number and proportion of females of reproductive age, in Waterloo Region and Ontario.


5

100.0

200

80.0

160

60.0

120

40.0

80

20.0

40

0.0

Number of females (1,000s)


Figure 1.2. Number and proportion of females of reproductive age*, Waterloo Region and Ontario, 2000-2009

0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Waterloo (#)

119

121

123

125

127

129

131

132

133

134

Waterloo (%) 52.9

52.8

52.8

52.7

52.6

52.5

52.2

52.0

51.7

51.7

Ontario (%)

51.4

51.2

52.0

50.8

50.6

50.4

50.1

49.9

49.5

51.4

Year Source: MOHLTC. Population Estimates (2000-2009), IntelliHEALTH Ontario. Extracted September 22, 2010. *Females of reproductive age are those aged 15 to 49 years.

As seen above, the proportion of women of reproductive age decreased slightly in both Waterloo Region and Ontario, from 2000 to 2009. Waterloo Region had a consistently slightly greater proportion of the total female population that was represented by women of reproductive age, compared to Ontario. The number of females of reproductive age in Waterloo Region increased from approximately 119,000 in 2000 to 134,000 in 2009. Future projected estimates for the number and proportion of females of reproductive age for both Waterloo Region and Ontario are illustrated in Figure 1.3.

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100.0

200

80.0

160

60.0

120

40.0

80

20.0

40

0.0

Number of females (1,000s)


Figure 1.3. Projected number and proportion of females of reproductive age*, Waterloo Region and Ontario, 2010-2035

0 2010

2015

2020

2025

2030

2035

Waterloo (#)

135

142

149

157

166

174

Waterloo (%)

51.2

49.2

47.8

46.5

45.5

44.6

Ontario (%)

49.1

46.6

45.0

43.9

43.2

42.6

Year Source: MOHLTC. Population Projections (2010-2035), IntelliHEALTH Ontario. Extracted September 22, 2010. *Females of reproductive age are those aged 15 to 49 years.

As seen above, the proportion of women of reproductive age in Waterloo Region and Ontario is projected to decline from 2010 to 2035 at a steady rate. Projected estimates suggest that Waterloo Region will continue to have slightly larger proportions of females of reproductive age as compared to Ontario. Over the same time period, the number of women of reproductive age in Waterloo Region is projected to increase from 135,000 in 2010, to approximately 174,000 in 2035.

1.1.3 Data Limitations These population estimates and projections are based on 2001 and 2006 Canadian Census data. Note that population estimates were not available for 2010 or 2011, and as such, 2010 was included as a time point in the projected future data. These population estimates may differ from those presented elsewhere due to differences in methodology.

1.1.4 Implications Roughly half of the total female population in Waterloo Region and its seven area municipalities are of reproductive age. The proportion of the female population that is of reproductive age has been decreasing in Waterloo Region since 2000, and is projected to continue decreasing for at least the next 25 years. The proportion of females of reproductive age is similarly shrinking in both Waterloo Region and Ontario; this trend is occurring as a result of the aging of the


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Canadian population as a whole.5, 6 As the baby boomer generation ages and the proportion of older adults increases, the proportion of younger adults will decrease. Although the proportion of women of reproductive age in Waterloo Region and all of Canada will continue to decrease over time, it is important to note Waterloo Region is in a period of significant population growth.6 Since the population of Waterloo Region as a whole is growing, the absolute number of females of reproductive age in the region also continues to grow. This finding should be a key point for consideration in future reproductive and maternal health services planning and provision in the region; while there will be a smaller proportion of females of reproductive age in Waterloo Region over time, still the absolute number women of reproductive age will continue to increase slowly with time. Ultimately, this finding means that demand for reproductive and maternal health services will likely continue to increase in Waterloo Region.

1.2 Social Determinants of Health 1.2.1 Background Social determinants of health are the socio-economic, cultural and environmental conditions that impact the health of individuals and communities.7, 8 Social determinants of health include the following: • Income and social status, • Social support networks, • Education and literacy, • Employment/working conditions, • Social and physical environments, and • Culture and language.7 Research indicates that there are social determinants associated with reproductive, maternal and infant health outcomes. Studies have found associations between marital status and loneparenthood with preterm births and low birth weight,9 ethnicity with neonatal morbidity and mortality,10 ethnicity and neighbourhood poverty with low birth weight,11 maternal birthplace with low birthweight,12 and household income with stillbirths.13 The interactions of these social determinants with each other and with health outcomes are complex and the pathways by which social disadvantage leads to negative health outcomes are not easy to determine. However, individuals with low socio-economic status and members of racialized groups are often disadvantaged and more susceptible to negative health outcomes. As such, examining the prevalence of social determinants of health in mothers may provide some insight into the extent to which some mothers and mothers-to-be are vulnerable for having negative reproductive, maternal and infant health outcomes, such as low birth weight, preterm births, stillbirths or infant mortality.

8


1.2.2 Local Picture Local data on social determinants of health in mothers or expectant mothers specifically, are somewhat limited. It was possible to report on two characteristics in mothers, specifically level of education, and first language. Two other characteristics are also reported for all females of reproductive age, specifically immigrant status and low income status. Data on mother’s level of education and mother’s first language at time of birth were available from the Integrated Services for Children Information System (ISCIS), the database which stores data from the Region of Waterloo Public Health (ROWPH) Healthy Babies Healthy Children (HBHC) program. Ontario data were not available for comparative purposes using ISCIS data. Data on females of reproductive age and immigrant status and low income originated from 2006 Census data. Immigrants were defined as landed immigrants in Canada; recent immigrants were those who arrived in Canada within the past five years preceding the census (i.e., 2001 to 2006). Low income status was defined using Statistics Canada’s after-tax Low Income Cut-Offs (LICOs); for more details on the definition of LICOs, see Chapter 6 Methodology, Data Sources and Limitations. The proportion of mothers for Waterloo Region for 2008 to 2010 by level of education is presented in Table 1.2. Table 1.2. Proportion of mothers by level of education, Waterloo Region, 2008-2010 Level of education Less than high school diploma High school diploma Some college or university (no degree) College degree or more Total

Per cent of mothers 11.9 22.7 9.2 56.3 100.0

Source: ROWPH. HBHC-ISCIS Reporting Sub-System (2008-2010). Extracted May 13, 2011. Figures may not sum exactly to 100.0 per cent due to rounding of figures to the nearest tenth of a per cent.

As seen above, from 2008 to 2010 the majority (56.3 per cent) of mothers in Waterloo Region from 2008 to 2010 had a post-secondary education (i.e., college degree or higher). Approximately one in ten mothers (11.9 per cent) had less than a high school education and 22.7 per cent had a high school education. The remaining 9.2 per cent of mothers had some post-secondary education (some college or university with no degree). The proportion of mothers in Waterloo Region for 2008 to 2010 by first language is presented in Table 1.3.


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Table 1.3. Proportion of mothers by first language, Waterloo Region, 2008-2010 First language

Per cent of mothers

English Languages other than English 1 Arabic 2 Mandarin 3 Vietnamese 4 Spanish 5 Punjabi 6 Persian 7 Albanian 8 Urdu 9 Romanian 10 Somali Other* Total

95.5 4.5 0.7 0.5 0.4 0.4 0.2 0.2 0.2 0.1 0.1 0.1 1.7 100.0

Source: ROWPH. HBHC-ISCIS Reporting Sub-System (2008-2010). Extracted May 13, 2011. *Other first languages: Chinese, Burmese, Gujarati, Hindi, Amharic, Serbian, Farsi, Russian, Kurdish, Korean, German, French, Bengali, Lao, Tigrinya, Cambodian, Portuguese, Turkish, Thai, Low German, Pushto, Hmong, Tamil, Asyrian, Indonesian, Cantonese, Croatian, Karen, Laothian, Other Aboriginal, Bulgarian, Sign Language, Phillipine (Other), Oromo, Cushitic (Other), Japanese, Telugu, Singhalese, Iranian and Newari. Figures may not sum exactly to 100.0 per cent due to rounding of figures to the nearest tenth of a per cent.

As seen above, the vast majority of new mothers in Waterloo Region for 2008 to 2010 had English as their first language (95.5 per cent). Just less than five per cent (4.5 per cent) had a first language other than English. The top ten most frequent first languages other than English are also summarized in Table 1.3. Arabic, Mandarin and Vietnamese were the top three most frequent first languages in Waterloo Region mothers, after English (0.7, 0.5 and 0.4 per cent, respectively). The proportion of females of reproductive age with low income status in Waterloo Region and Ontario in 2006 is presented in Table 1.4. Table 1.4. Proportion of females of reproductive age* with low income status†, by ten-year age group, Waterloo Region and Ontario, 2006 Age group (years) 15 to 24 25 to 34 35 to 44 All females

Per cent of females Waterloo Region 16.3 10.5 10.0 11.1

Ontario 19.3 16.6 15.1 15.6

Source: Statistics Canada (2006).Canadian Census data. Extracted November 28, 2011. *Females of reproductive age are represented in this table as those aged 15 to 44 years. †Low income status is defined using Statistics Canada’s after-tax Low Income Cut-Offs (LICOs).

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As shown in Table 1.4, approximately 11.1 per cent of females of all ages in Waterloo Region had low income in 2006, compared to 15.6 per cent in Ontario. In females of reproductive age, those aged 15 to 24 years had higher rates of low income (16.3 per cent in Waterloo Region and 19.3 per cent in Ontario). Females aged 25 to 34 and 35 to 44 years in Waterloo Region and Ontario had rates of low income that were more comparable to the rates seen in females of all ages. The proportion of females of reproductive age in Waterloo Region and Ontario in 2006 is presented by immigrant status in Table 1.5. Table 1.5. Proportion of females of reproductive age* by immigrant status, by ten-year age group, Waterloo Region and Ontario, 2006 Place of residence Waterloo Region

Ontario

Age group (years) 15 to 24 25 to 34 35 to 44 All females 15 to 24 25 to 34 35 to 44 All females

Per cent of females Immigrants Recent immigrants 13.7 3.8 20.6 7.0 26.5 4.7 22.4 3.6 19.0 5.9 29.1 10.3 35.2 6.7 28.9 5.0

Source: Statistics Canada (2010). 2006 Census. Extracted November 28, 2011. *Females of reproductive age are represented in this table as those aged 15 to 44 years. Recent immigrants are defined as those who arrived in Canada within the past five years.

As seen above, in Waterloo Region in 2006, the proportion of females aged 15 to 24 years who were immigrants (13.7 per cent) was lower than the proportion for females of all ages (22.4 per cent). There was a higher proportion of females aged 35 to 44 years who were immigrants (26.5 per cent), compared to females of all ages. For each age category, Ontario had higher proportions of females who were immigrants, compared to Waterloo Region. In Waterloo Region in 2006, 7.0 and 4.7 per cent of females 25 to 34 and 35 to 44 years, respectively, were recent immigrants (i.e., arrived in Canada within the past five years), compared to 3.6 per cent of females of all ages. For each age category, again Ontario had higher proportions of females who were recent immigrants, compared to Waterloo Region.

1.2.3 Data Limitations There are some limitations to the data presented for social determinants of health. It is important to note that for the first language data, the categories reported are based on the options available in the ISCIS data source. However, not all language categories appear to be mutually exclusive (e.g., Mandarin and Cantonese are both dialects of Chinese language, but all


11

three are separate category options in ISCIS). Clearer and more consistent language data may yield slightly different rankings of the first languages spoken other than English. Also, ISCIS data, used to report level of education and first language of mothers, are only available for those mothers who were screened or received care from the ROWPH HBHC program. Not all pregnant women in Waterloo Region participate in the voluntary HBHC program; according to program statistics, an estimated 72 per cent of all pregnant women in Waterloo Region in 2010 were screened using the Larson prenatal screening tool. As such, the ISCIS data may not reflect the prevalence of risk for all pregnant women in Waterloo Region. With the census data, it is important to note that the data represent all females of reproductive age and not only mothers or expectant mothers. The census data are now somewhat out-ofdate from 2006, and changes in the prevalence of low income status or immigrant populations may have changed the landscape of these social determinants of health in Waterloo Region.

1.2.4 Implications Some general conclusions may be drawn from the local data on social determinants of health. Nearly twelve per cent of mothers had less than high school education and just over four per cent of mothers had first languages other than English. Young females were more likely to have low income status compared to females of all ages, and females in the peak reproductive age of 25 to 34 years had a higher proportion of immigrants, compared to females of all ages. Socio-economic and cultural characteristics reflected by these indicators may make women disadvantaged and more susceptible to negative reproductive, maternal and infant health outcomes, such as preterm birth or low birth weight infants. Therefore, it is important for public health programs and community supports for pregnant women and new mothers to consider socio-economic and cultural factors such as low education, low income, immigration status, language barriers and different cultural backgrounds when assessing for maternal and infant health risk and when targeting reproductive, maternal and infant health services.

1.3 Presence of a Family Doctor 1.3.1 Background Family doctors can act as a key source of health information and care for patients who are planning a pregnancy or are pregnant. Preconception care, counselling and primary care interventions are increasingly recognized as an important influence on the health outcomes of mothers and infants. Adequate preconception care, including care provided by family physicians, may be associated with decreased maternal morbidity and infant mortality.14, 15 It is worth noting, however, that no structure currently exists in Ontario to reinforce the provision of preconception health care by physicians, and it is not known to what extent physicians in Ontario currently provide preconception counselling and care.

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Some individuals in Waterloo Region and Ontario do not have a regular family doctor, which suggests they may be even less likely to have access to preconception care. Often level of access to a family doctor is linked to social, cultural and environmental factors. In Ontario, the most commonly cited reason for not having a family doctor was that the patient had moved.16 People who immigrate to Waterloo Region, either from other countries or from other regions within Canada, are less likely to have a regular family doctor. For example, researchers from the Project for an Ontario Women’s Health Evidence-Based Report (POWER) Study, reported that 85 per cent of women aged 25 years and older who had immigrated to Canada less than five years ago had a primary care doctor, compared to 95 per cent of Canadian born women.16 According to the 2001 Statistics Canada Health Services Access Survey, approximately 88 per cent of Canadians and 94 per cent of Ontario residents over the age of 15 had a regular family doctor, and there is evidence that this proportion has declined in recent years.17

1.3.2 Local Picture Local data for the proportion of women of reproductive age who have a regular family doctor were obtained from the Canadian Community Health Survey (CCHS). Statistical significance is determined using non-overlapping 95 per cent confidence intervals. Table 1.6 summarizes the proportion of women of reproductive age with a regular family doctor in Waterloo Region and Ontario. Table 1.6. Proportion of females of reproductive age* with a regular family doctor, by place of residence, Waterloo Region and Ontario, 2007-2009 Place of residence Cambridge Kitchener Waterloo Townships† Waterloo Region Ontario

Per cent of females 96.6 (CI: 93.0-100.0) 92.3 (CI: 86.8-97.9) 85.9 (CI: 76.8-95.0) 100.0 (CI: 100.0-100.0) 92.8 (CI: 89.5-96.1) 91.2 (CI: 90.5-91.9)

Source: Statistics Canada. CCHS, Cycle 4.1 (2007-2008) and Cycle 5.1 (2009) Share Files. Extracted May 3, 2011. †Townships include North Dumfries, Wellesley, Wilmot and Woolwich. ‘CI’ refers to the 95 per cent confidence interval of the estimate. *Females of reproductive age are those aged 15 to 49 years.

As seen above, overall most females of reproductive age in Waterloo Region and Ontario in 2007 to 2009 had a regular family doctor (92.8 per cent and 91.2 per cent, respectively). This difference was not statistically significant. The proportion of women of reproductive age with family doctors varied geographically within Waterloo Region. The lowest rate was in Waterloo (85.9 per cent) and the highest was the rate for the four rural townships combined (100.0 per cent).


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Figure 1.4 shows the proportion of females of reproductive age (15 to 49 years) with a family doctor by age, in Waterloo Region and Ontario. Figure 1.4. Proportion of females of reproductive age* with a regular family doctor, by fiveyear age group, Waterloo Region and Ontario, 2007-2009 Per cent of fenales aged 15 to 49 years

100.0

80.0

60.0

40.0

20.0

0.0 15-19

20-24

25-29

30-34

35-39

40-44

45-49

Waterloo

97.9

83.5

84.8

87.5

98.1

99.4

97.9

Ontario

92.5

87.3

87.3

90.8

93.2

92.8

93.4

Age group (years) Source: Statistics Canada. CCHS, Cycle 4.1 (2007-2008) and Cycle 5.1 (2009) Share Files. Extracted May 3, 2011. Error bars indicate the 95 per cent confidence interval of the estimate. *Females of reproductive age are those aged 15 to 49 years.

As seen above, the proportion of women of reproductive age with a regular family doctor in Waterloo Region and Ontario varied by age in 2007 to 2009. Women aged 15 to 19 years (97.9 per cent (CI:94.9-100.0)) and women aged 35 to 39 years, 40 to 44 years, and 45 to 49 years (98.1 (CI:96.0-100.0), 99.4 (CI:98.3-100.0) and 97.9 per cent (CI:94.0-100.0), respectively) were significantly more likely to have a regular family doctor than women aged 25 to 29 years in Waterloo Region (84.8 per cent (CI:77.1-92.6)). For most age groups, proportions for Waterloo Region were similar to those for all of Ontario. For three age categories, (15 to 19, 35 to 39 and 40 to 44 years), females in all of Ontario were significantly less likely to have a regular family doctor (92.5 (CI: 91.0-94.1), 93.2 (CI: 91.6-94.8) and 92.8 per cent (CI: 91.2-94.4), respectively), compared to women of the same age category in Waterloo Region. Figure 1.5 shows the proportion of women of reproductive age with a regular family doctor, by level of household education in Waterloo Region and Ontario for 2007 to 2009.

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Figure 1.5. Proportion of females of reproductive age* with a regular family doctor, by highest level of household education attained, Waterloo Region and Ontario, 2007-2009 Per cent of females aged 15 to 49 years

100.0

80.0

60.0

40.0

20.0

0.0 High school or less

More than high school

Education not stated

Waterloo

97.8

91.9

93.6

Ontario

90.6

91.5

89.2

Highest level of education attained (household)

Source: Statistics Canada. CCHS, Cycle 4.1 (2007-2008) and Cycle 5.1 (2009) Share Files. Extracted May 3, 2011. Error bars indicate the 95 per cent confidence interval of the estimate. *Females of reproductive age are those aged 15 to 49 years.

As seen above, in Waterloo Region there was no significant difference in the proportion of women with a family doctor when level of household education was considered. Women in Waterloo Region from households where the highest level of education attained was high school or less were significantly more likely to have a family doctor, compared to similar women in Ontario (97.8 (CI:94.8-100.0) versus 90.6 per cent (CI:88.8-92.4), respectively). The proportion of women of reproductive age in Waterloo Region and Ontario for 2007 to 2009 with a regular family doctor is summarized by marital status in Figure 1.6.


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Figure 1.6. Proportion of females of reproductive age* with a regular family doctor, by marital status, Waterloo Region and Ontario, 2007-2009

Per cent of females aged 15 to 49 years

100.0

80.0

60.0

40.0

20.0

0.0 Married/Common law

Single/Widowed/Separated/Divorced

Waterloo

94.4

90.5

Ontario

93.1

88.9

Marital status Source: Statistics Canada. CCHS, Cycle 4.1 (2007-2008) and Cycle 5.1 (2009) Share Files. Extracted May 3, 2011. Error bars indicate the 95 per cent confidence interval of the estimate. *Females of reproductive age are those aged 15 to 49 years.

As seen above, in Waterloo Region there was no significant difference in the proportion of females of reproductive age with a regular family doctor between females with a partnered marital status (i.e., married or common law; 94.4 per cent (CI:91.4-97.4)) compared with females with a non-partnered marital status (i.e., single, widowed, separated or divorced; 90.5 (CI:84.496.6)). For Ontario as a whole, there was a significant difference in the proportion of females of reproductive age with a regular family doctor when marital status was considered; married or common law females were significantly more likely to have a family doctor compared to single, widowed, separated or divorced females of reproductive age (93.1 (CI:92.3-93.9) versus 88.9 (CI:87.890.1)). Figure 1.7 shows the proportion of women of reproductive age in Waterloo Region and Ontario for 2007 to 2009 with a regular family doctor, by annual household income.

16


Figure 1.7. Proportion of females of reproductive age* with a regular family doctor, by annual household income, Waterloo Region and Ontario, 2007-2009

Per cent of females aged 15 to 49 years

100.0

80.0

60.0

40.0

20.0

0.0