Quarterly Digest
Volume 7 - Number 1 July 1997

Preface

Due to the fact that Vital Statistics Agency files are continually being updated, totals compiled by addition of the annual quarters will not correspond exactly to year-to-date and year-end figures. For the same reason, depending on the date the data are extracted, there will be differences in numbers presented in this year's Quarterly Digests and those eventually reported in the Vital Statistics 1997 Annual Report. Therefore, the numbers provided in this report should be considered provisional. Finally, the usual cautions regarding random fluctuations in values, particularly those involving small numbers, must be noted.

This issue's feature article was written and provided for publication by Cathy Hull, Non-Communicable Disease Epidemiology, Preventive Health Branch, Public and Preventive Health Division, B.C. Ministry of Health. "Pregnancy Outcomes in British Columbia" incorporates data about live births, stillbirths, abortions and miscarriages which are derived from two separate databases: the vital statistics registration system and the hospital morbidity database. Using an amalgamated data set, this article describes trends, regional comparison, and age differences of pregnancy outcomes in British Columbia for the period 1987/88 to 1995/96. It also offers some national and international comparisons. Further, this basic pregnancy outcome information provides examples and suggests ways in which such information can be applied to assist in planning, implementing, and evaluating reproductive health programs and services.

Wherever possible, changes such as additional cause of death categories, percent, or year-to-date totals, have been added to the Quarterly Digest as requested by our readers. Suggestions for article topics or contributions are also welcome. Your support and input into this publication is greatly appreciated.

R.J. Danderfer Director British Columbia Vital Statistics Agency

Soo-Hong Uh Manager Information and Resource Management Branch Vital Statistics Agency

[Return to Table of Contents]

British Columbia
Local Health Areas

British Columbia:
Local Health Areas (LHA)
within Health Regions

Abstract

* Non-Communicable Disease Epidemiology Preventive Health Branch Public and Preventive Health Division B.C. Ministry of Health

Introduction

Table 1
Basic Elements of Reproductive Health

In British Columbia, data about pregnancy outcomes are contained in two separate databases: the vital statistics registration system (live births and stillbirths) and the hospital morbidity database (hospitalizations due to pregnancy and childbirth, including abortions and miscarriages). As a result, past practice has been to report statistics about births and abortive outcomes separately.

Recently, cooperative efforts among data sources have resulted in a more complete, consolidated set of data on pregnancies. Using the amalgamated data set, this article describes pregnancy outcomes in British Columbia for the period 1987/88 to 1995/96 and provides examples of ways this basic information can be applied to reproductive health programs and services.

Table 2
Terms and Defintions

Methods

In most Vital Statistics Agency publications, live births and stillbirths are reported by calendar year. For this analysis, Vital Statistics data were re-grouped to fiscal years, so that time periods would correspond to hospital statistics.

Since April 1993 (the beginning of the 1993/94 fiscal year), data on clinic abortions have been included in provincial hospitalization statistics. For earlier years, clinic summary statistics were not consistently tracked by the Ministry of Health. To assist in preparing this paper, clinics were able to provide the total number of abortions for 1992/93 and partial data for 1990/91 and 1991/92; breakdowns by women's age and region of residence were not available. Thus, in terms of the provincial picture, abortion data are complete for 1987/88 (before the clinics were established), from 1992/93 on (for provincial totals), and from 1993/94 on (for age group and regional breakdowns).

As the number of stillbirths is small, stillbirths are combined with miscarriages in this paper. The category "miscarriages/stillbirths" is sometimes referred to as "fetal loss" (Wadhera & Millar, October 1996; Ventura, Taffel, & Mosher, 1988). Breakdowns by age group are based on the woman's age at the time of pregnancy outcome, not at the time of conception. Thus, a woman who conceives at age 19 and gives birth at age 20 will be counted in the 20-24 age group, rather than as a "teen pregnancy".

Limitations

Incomplete data on clinic abortions for the years 1988/89 through 1992/93 make it difficult to interpret time trends. However, there is now a mechanism to incorporate clinic data into provincial statistics on an ongoing basis. This provides a more complete picture of pregnancy outcomes, beginning with 1993/94 data.

Hospital and clinic data do not include "medical abortions" carried out on an out-patient basis (medical abortions are early first-trimester pregnancy terminations that involve administering medication(s), without the need for a surgical procedure; see Winikoff, 1995). At this time, however, the number of medical abortions is relatively small.

Live births and stillbirths occurring in Alberta to B.C. residents are not recorded in British Columbia's vital statistics registration system. Negotiations are under way to obtain these data on an ongoing basis. Until such an arrangement is in place, birth rates for the East Kootenay and Peace Liard regions in particular require cautious interpretation.

Data on miscarriages are incomplete because they include only hospitalized cases. A miscarriage can occur very early in pregnancy. Many women who miscarry are not aware of their pregnancy and/or do not require admission to hospital. The proportion of miscarriages resulting in hospitalization depends on several factors, including medical necessity, the availability of hospital beds and alternate types of care, and patterns of medical practice. The extent to which miscarriages are under-counted in hospital data will vary over time (hospitalization rates have been declining overall due to bed pressures and changes in perception of medical necessity) and between regions (hospitalization rates are generally higher in northern and rural areas of the province).

Studies in other jurisdictions have used various methods to estimate the total number of pregnancies in a population. Table 3 shows three methods of estimating miscarriages applied to British Columbia data. The three methods, which are based on research in the United States, result in estimates of 71,164 to 76,710 pregnancies, 4% to 12% higher than those obtained from Ministry of Health data alone. According to the methods in Table 3, between 13% and 19% of pregnancies end in miscarriage, compared with 10% based on hospital data. Although the data presented in this paper under-estimate the number of pregnancies, routinely-collected data offer advantages in terms of availability.

Finally, due to differences in definitions and data availability, the numbers and rates in this paper may not correspond to statistics previously published in British Columbia and may not be directly comparable with statistics reported by other studies and jurisdictions.

Table 3
Estimated Number of Pregnancies, BC, 1995/96

Number of Pregnancies

Between 1987/88 and 1995/96, the annual number of pregnancies increased by 15%. However, the population of women in their childbearing years (15-44) increased at a greater rate of 19% over this time period. As a rate per 1,000 women, pregnancies actually declined from 81.9 in 1987/88 to 78.8 in 1995/96 (Figure 1).

Figure 1
Number of Pregnancies and Pregnancy Rate
BC, 1987/88 - 1995/96

Figure 2
Pregnancy Outcomes, Women Age 15-44
BC, 1987/88 - 1995/96

Figure 3
Miscarriage/Stillbirth Rates
BC, 1987/88 - 1995/96

Outcomes

Over the nine-year period 1987/88 to 1995/96, there has been a shift in outcomes, with fewer pregnancies ending in live birth and miscarriage/stillbirth, and more ending in abortion. Per 1,000 women, the live birth rate declined 6% (from 57.5 to 54) while the abortion rate rose 10% (from 15.6 to 17.1) (Figure 2 and Appendix A).

The rate of miscarriage/stillbirth fell 14%, from 8.9 to 7.6 per 1,000 women. Within the miscarriage/stillbirth category, hospitalizations for spontaneous abortion and ectopic pregnancy decreased while cases of "other miscarriage" increased. The number and rate of stillbirths remained fairly constant over the past nine years (Figure 3).

Age Differences

Figure 4
Pregnancy Rates by Age of Women
BC, 1987/88 and 1995/96

Figure 5
Percent of Pregnancies Ending in Live Birth, Abortion,
and Miscarriage/Stillbirth by Age of Women
BC, 1987/88 - 1995/96

Figure 6
Pregnancy Outcomes, Women Age 15 - 19
BC, 1987/88 - 1995/96

Women in their teens have fewer pregnancies than women in their twenties and thirties. In 1995/96, there were an estimated 5,780 pregnancies among women age 15-19, and 108 among women age 10-14. Over the past nine years, the teen pregnancy rate (age 15-19) has remained at about 50 per 1,000 women with just under half of pregnancies ending in abortion (Figure 6).

Figure 7
Pregnancy Outcomes, Women Age 20 - 24
BC, 1987/88 - 1995/96

Figure 8
Pregnancy Outcomes, Women Age 25 - 29
BC, 1987/88 - 1995/96

Women in their twenties have traditionally had the highest pregnancy rates. However, these rates have been declining. Since 1987/88, birth rates for women in their twenties have decreased by almost 15% for women 20-24 and 10% for those age 25-29. An increasing proportion of pregnancies are ending in abortion (Figures 7 and 8).

Figure 9
Pregnancy Outcomes, Women Age 30 - 34
BC, 1987/88 - 1995/96

Figure 10
Pregnancy Outcomes, Women Age 35 - 39
BC, 1987/88 - 1995/96

Among women in their thirties, pregnancy rates have increased, primarily due to rising birth rates. Since 1987/88, birth rates increased 11% among women in their early thirties and 29% among women age 35-39 (Figures 9 and 10). Because the number of women in their thirties also increased due to the aging of the baby boom generation, the number of births to women in their thirties continued to rise throughout the period.

Figure 11
Pregnancy Outcomes, Women Age 40 - 44
BC, 1987/88 - 1995/96

Women age 40-44 have the lowest pregnancy rate of all women of childbearing age. However, their pregnancy rate has been increasing, from 7.7 per 1,000 in 1987/88 to 11.4 in 1995/96 (Figure 11). In 1995/96, there were 1,716 pregnancies in this age group compared with 799 in 1987/88.

Regional Differences

Figure 12
Pregnancy Rates, Women Age 15 - 44
Health Regions, BC, 1995/96

Figure 13
Pregnancy Rates by Age of Women
Thompson, Okanagan, and Kootenay Regions, 1995/96

In the Thompson/Okanagan/Kootenay regions, the age distribution is similar to the provincial pattern in the mid-1980s: rates are highest in the 25-29 age group, followed by the 20-24 year group (Figure 13).

For additional data, see Analysis of Status Indians in British Columbia: Updated Report, 1987 - 1994, prepared by the BC Vital Statistics Agency for Medical Services Branch, Health Canada, March 1996.

Figure 14
Pregnancy Rates by Age of Women
Northern Regions, 1995/96

In the North of the province, pregnancy rates are high in the 15-19 and 20-24 age groups, indicating a pattern of having children earlier in life (Figure 14).

Figure 15
Pregnancy Rates by Age of Women
Island/Coast Regions, 1995/96

In the Island/Coast areas, three regions (Coast Garibaldi, Central Vancouver Island, and Upper Island) have patterns that are similar to those in the North, with relatively high rates among women in their teens and early twenties. The Capital region has pregnancy rates that are lower than the provincial average, except among women in their teens (Figure 15 and Appendix D).

Figure 16
Pregnancy Rates by Age of Women
Fraser Valley Regions, 1995/96

Compared to other parts of the province, the Fraser Valley region has high pregnancy rates among women in their twenties and early thirties (Figure 16).

Figure 17
Pregnancy Rates by Age of Women
Lower Mainland Regions, 1995/96

In the Lower Mainland, pregnancy rates are lower than other parts of the province, and show a pattern of postponing childbearing to the older age groups (Figure 17).

Using Pregnancy Outcome Data

Sexual Education, Knowledge, and Practices

Unintended pregnancies provide one indication of the extent to which women are able to control the timing and spacing of their pregnancies. A high rate of unintended pregnancies may indicate problems with sexual health education or other barriers to informed decision-making regarding reproductive health. For example, education programs may not be reaching school-aged youth and other high-risk groups, or problems such as poverty or low self-esteem may be preventing people from seeking the information they need to prevent unwanted pregnancy.

As most induced abortions represent unintended pregnancies, abortion rates are often used as an indirect indicator of unintended pregnancy (Working Group on Community Health Information Systems, 1995). Teen pregnancy is of particular concern, because teen mothers face higher risks during pregnancy, and their children are at risk of problems such as low birthweight and growing up in poverty (Scott, 1996). Teen pregnancy is also an indicator of social and economic conditions in a community; poverty, emotional deprivation, school failure, and lack of hope for the future are important factors in explaining teen pregnancy (Schorr, 1989).

Figure 18
Pregnancy Rates Women Age 15 - 17
High and Low Regional Rates and BC Average,
1987/88 - 1995/96

Figure 19
Pregnancy Rates, Women Age 15 - 19
Health Regions, BC, 1995/96

Figure 20
Number and Percent of Pregnancies
Ending in Induced Abortion
BC, 1995/96

While teen pregnancy is an important indicator to track, the problem of unintended pregnancies is not limited to women in their teens. Unintended pregnancies, as measured by abortion rates, occur in all age groups. Programs to reduce unintended pregnancy could be targeted to other age groups, such as women in their early twenties, who account for almost one-third (30%) of abortions (4,423 of 14,904 in 1995/96, Figure 20).

Access to Contraception and Abortion Services

Abortion rates provide an indirect measure of people's ability to access and use contraceptive methods. A high rate of abortion may indicate that some groups face obstacles in accessing contraceptive services and products.

Access to safe abortion services is also an essential component of reproductive care. A region's self-sufficiency in abortion services has been proposed as an indicator of access to abortion services (B.C. Task Force on Access to Contraception and Abortion Services, 1994). A high number of women who travel out of their region of residence to receive abortion services may indicate problems with access or a desire for confidentiality.

In 1995/96, just over half (55%) of the province's abortion cases were treated in the woman's health region of residence. Within the province, there was a wide range in the percentage of cases treated locally (Table 4).

Having a low rate of regional self-sufficiency does not necessarily imply lack of access, nor does a high rate of self-sufficiency mean that access is adequate. Distances, travel times, and women's reasons for seeking care outside their region of residence need to be taken into account. In rural areas of the province or wherever communities are geographically dispersed, some women may need to travel long distances to obtain abortion services, although their region has a high rate of self-sufficiency. Some lower mainland regions have low rates of self-sufficiency. However, because services are readily available in Vancouver, lower mainland residents face fewer geographic barriers to service than do those in rural areas. More discussion will be needed to determine whether self-sufficiency provides a useful indicator of access to abortion services.

Table 4
Percentage of Abortion Cases Treated in their
Local Health Area (LHA) and Region of Residence
Health Regions, BC, 1995/96

Maternal Care

Maternal care accounts for a large proportion of the health services provided to women in the childbearing years, a relatively healthy age group. About half of all hospitalizations to women age 15-44 are related to pregnancy and childbirth. There are also a range of prenatal and postnatal services. Pre-conception services help couples who wish to have children identify health problems that need to be addressed before pregnancy, such as smoking, substance misuse, poor nutrition, or genetic history. Prenatal care and education - for all women, as well as targeted programs for women at risk - help to prepare women and their families for childbirth and childrearing. Early infancy programs help infants to achieve the best possible start in life.

Pregnancy rates and patterns can assist in planning services for maternal care. For example, trends in the number of pregnancies can be used in estimating future needs for prenatal education or obstetrical care. The number of births and/or pregnancies provides "denominators" or target audiences for prevention programs (such as programs to encourage folic acid as a daily supplement for all women who may become pregnant) and screening programs (such as prenatal screening for HIV or birth defects).

Pregnancy rates and patterns can also assist in targeting programs and services to those at greatest risk of poor pregnancy outcomes. For example, health problems and complications in pregnancy are more common among adolescents, poor women, and older women. Regions could use information about the age-specific pregnancy patterns, such as that shown in Figures 13 to 17, to plan the mix of services required for their region's needs.

Control of Reproductive Tract Infections

As an example, untreated sexually transmitted diseases or delays in receiving treatment can lead to pelvic inflammatory disease (PID). Ectopic (tubal) pregnancy is a life-threatening condition which may occur as a result (Alexander & LaRosa, 1994). In industrial countries, approximately half of ectopic pregnancies are attributed to previous pelvic inflammatory disease (Royal Commission on New Reproductive Technologies, 1993).

Because PID is not a reportable disease, hospitalization rates for PID and ectopic pregnancy are commonly used to estimate the occurrence of untreated sexually transmitted diseases in a population. Ectopic pregnancy rates also provide an estimate of the number of women at risk for tubal infertility in the future, as about one-third of those with ectopic pregnancies will become infertile (Royal Commission on New Reproductive Technologies, 1993).

Hospitalization rates for PID are declining in British Columbia. However, because most PID cases are treated on an outpatient basis, we cannot be sure whether real rates are declining as fast; pressure on hospital beds may be playing a role.

Hospitalizations for ectopic pregnancies have shown less of a decline (Figure 21), and the risk of ectopic pregnancy increases with age (Figure 22). However, rates of ectopic pregnancy are not expected to drop for as much as a decade after real declines in PID rates.

Figure 21
Hospitalization Rates for Pelvic Inflammatory Disease (PID)
and Ectopic Pregnancy
BC, 1984/85 - 1995/96

Figure 22
Ectopic Pregnancy Rates by Age of Women
BC, 1995/96

Prevention and Management of Infertility

Delayed childbearing is also a risk factor for infertility. As women grow older, their ability to conceive declines due to the aging process. Women who wait are more likely to have difficulty conceiving and to have complications during pregnancy than women in their twenties. These risks increase with the woman's age.

The age composition of the population and the choices people make about when to start their families affect the need for reproductive health services. Although the proportion of couples who are infertile may remain stable, the number of infertile women may be increasing due to the aging of the baby boom cohort and the tendency of this group to delay marriage and childbearing. Examining pregnancy trends and patterns can assist in planning services to treat infertility.

National and International Comparisons

Figure 23
Pregnancy Rates by Age of Women
BC and Canada, 1993

Figure 24
Teen Pregnancy Rates (Age 15 - 17)
Canada and Provinces, 1993

A recent Statistics Canada report showed British Columbia's pregnancy rates to be somewhat lower than the Canada average, except for the 35-39 and 40-44 age groups (Figure 23). Our pregnancy rates for teens age 15-17 were about mid-range among the provinces, with the Prairie provinces having the highest rates (Wadhera & Millar, October 1996) (Figure 24).

Because of legal reporting requirements, the registration of births in Canada is virtually complete. Statistics and analyses based on birth data are published regularly (see Statistics Canada, 1996; Ford & Nault, 1996). For pregnancy rates, however, cross-Canada comparisons are complicated by the fact that clinic abortion data are often excluded from provincial figures (clinic data are excluded because women's age and residence information are not available). In some provinces, a significant proportion of abortions are performed in clinics (about 25% in British Columbia), while in some other provinces, all abortions are performed in hospitals.

In 1989, the most recent year for which international data are available, British Columbia's teen pregnancy rate (51 per 1,000 women 15-19) was higher than the rates in several European countries, including France (43), England and Wales (45), Sweden (35), and the Netherlands (14). Among industrial countries, the United States has the highest teen pregnancy rate - 116 per 1,000 in 1991 (Wadhera & Millar, Summer 1996). Using the best international rates (Netherlands and Sweden) as a guideline, a target of 20 pregnancies per 1,000 women 15-19 has been proposed for British Columbia (Provincial Health Officer, 1996).

Figure 25
Abortion Rates
Selected Countries and BC, 1987

International data on abortion rates show British Columbia to be about mid-range compared to industrial countries (Figure 25). However, these rates are from 1987, and may not reflect the current situation.

Data Standards

Health Canada's initiative on perinatal health is currently facilitating the development of a common set of health indicators (Health Canada, 1996). This will provide an opportunity to develop consensus on data, indicators, and benchmarks to be used in reporting on pregnancy outcomes.

Examples of issues that could be considered for standardization are (1) which ICD codes should be counted as "miscarriage" and (2) whether and how "medical abortions" will be tracked in federal and provincial databases.

Other Sources of Information

(¹For examples of reproductive health indicators, see Horton, J.A. (Ed.). The women's health data book: A profile of women's health in the United States (2nd edition), pp. 1-30. Washington, DC: The Jacob's Institute of Women's Health.)

Examples of other sources of information include:

• Surveys of sexual health, knowledge, attitudes, and practices. Surveys provide important information about how people think, feel, and behave. However, it can be difficult to do surveys on sexual health, because people may be reluctant to talk about these topics. Surveys can also be expensive to carry out.

One example of an ongoing, comprehensive survey is the U.S. National Survey of Family Growth, which provides information about the fertility and health of American women (Mosher & Bachrach, 1996). At this time, Canada does not have a regular national survey that documents knowledge, attitudes, and experiences regarding pregnancy, sexual behaviour, reproductive health, and associated risk factors. In developing the Canadian Perinatal Surveillance System, a study group explored the feasibility of conducting a stand-alone reproductive health survey that would allow for data analysis at the provincial level. Due to the high cost, the group was not able to recommend undertaking such a survey (Health Canada, 1996).

In recent years, several population health surveys have included content related to aspects of reproductive health. The 1990 Health Promotion Survey was the first national survey that included a section on sexual practices among the general public. Questions focused on age at first intercourse, the number of sexual partners, and knowledge and practices related to prevention of sexually transmitted diseases (STDs) (Williamson, 1993). The Canada Youth and AIDS Study assessed knowledge, attitudes, and behaviours of Canadian youth with respect to AIDS and other STDs (King, Beazley, Warren, Hankins, Robertson, & Radford, 1988; Beazley, King, & Warren, 1988). The National Population Health Survey included a question on pap smear practices (Statistics Canada, 1995), and the National Longitudinal Survey of Children and Youth looked at conditions that contribute to a health pregnancy, including the mother's prenatal health, health behaviours such as smoking and alcohol use, and the care received during pregnancy (McIntyre, 1996).

In British Columbia, the Adolescent Health Survey contained a number of questions on sexual activity, contraceptive usage, and pregnancy (McCreary Centre, 1992).

• Surveys of reproductive health services and practices, such as the Canadian Institute for Child Health Survey of routine maternity care and practices in Canadian hospitals (Levitt, Hanvey, Avard, Chance, & Kaczorowski, 1995).

• Ongoing information systems, that provide evaluative information about reproductive health services. This includes information that measures service coverage, outcomes and effectiveness, costs, quality, and client satisfaction. In British Columbia, information to assess the availability and effectiveness of sexuality education and contraceptive services has been identified as one area needing attention (Provincial Health Officer, 1996).

• Documents that contain goals, objectives, targets, and strategies for sexual and reproductive health. Health plans and frameworks provide a context for reproductive health data, by setting out what we aim to achieve and how progress will be measured.

At the national level, a Framework for Action on Sexual and Reproductive Health is currently being developed. Actions arising from the Framework could include setting national goals and targets for reproductive health, along with a method for monitoring and reporting on progress (Health Canada, 1997). Within British Columbia, the Provincial Health Officer's Annual Report has provided recommended objectives, actions, and targets for reproductive health (Provincial Health Officer, 1996).

Summary

The issues of sexual and reproductive health affect all British Columbians, women and men. Pregnancy rates are affected by the decisions people make about their sex lives and if, when, and how often they wish to become pregnant. Pregnancy rates are also affected by health and social policies, programs, and the socio-economic environment. The type of sexuality education, contraceptive services, and obstetrical care we provide, rules and regulations about contraceptives and abortion, attitudes and openness toward sexuality, birth control, and childbearing, attitudes and policies about family and work - all of these factors impact the decisions people make about reproduction.

There is no single or ongoing information system to measure all aspects of reproductive health. Routinely-collected Ministry of Health data on pregnancy rates and outcomes are subject to a number of limitations. However, quality and accessibility of data are improving. With feedback from users, it will improve further.

To make continued improvements in pregnancy outcome data, some areas that could be pursued are:

• Developing consensus on indicators and statistics that are useful for monitoring and reporting on sexual and reproductive health.
  
  
• Obtaining ongoing data on out-of-province events, such as live births and stillbirths to B.C. residents that occur in Alberta and abortions provided to B.C. women in the United States.
  
  
• Developing consensus on which ICD9 codes should be counted as "miscarriage".
  
  
• Determining whether and how "medical abortions" will be tracked in federal and provincial databases.
  
  
• Undertaking additional analysis to study regional variations, the relationship between pregnancy rates and socio-economic factors, and other disparities in reproductive health.

We hope that this article will generate discussion about ways in which pregnancy outcome data can be made more useful and usable for those involved in planning and delivering reproductive health programs.

Acknowledgements

Additional breakdowns, including data by Local Health Area (LHA), are available on request.
For further information, please contact
Julie Macdonald, BC Vital Statistics Agency,
818 Fort Street, Victoria, BC V8W 1H8
telephone (250) 952-2558.

References

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Appendix A

Pregnancy Outcomes, BC, 1987/88 - 1995/96

Note: In Appendix tables, "miscarriages" includes miscarriages resulting in hospitalization (in-patient and day surgery cases for ICD9 630-634 and 637) and stillbirths.

Appendix B

Pregnancy Outcomes by Age of Women, BC, 1987/88 and 1995/96

Appendix C

Pregnancy Outcomes by Health Region, BC, 1995/96

Appendix D

Pregnancy Rates by Age of Women, Health Regions, BC, 1995/96

Appendix E

Pregnancy Rates by Age of Women, Health Regions, BC, 1995/96

Glossary

Alcohol-Related:
This category includes all deaths stated as being directly or indirectly related to alcohol. It should be noted that where alcohol is an indirect cause of death (i.e. not primary) and the direct underlying cause of death falls within one of our selected causes (e.g. motor vehicle accidents), then this death may be counted in both columns. That is, not all of "alcohol related" are exclusive. This category includes ICD-9 codes - 291, 303, 305.0, 357.5, 425.5, 535.3, 571.0-571.3, 571.5, 577.1, 648.4, 760.7, E860, 790.3.

Assignment of Health Region:
Cases are assigned to Health Regions by the aggregation of appropriate LHAs.

Assignment of Local Health Area (LHA):
Allocation of LHA, in the case of births and deaths is based upon the usual residence (by postal code) of the mother and deceased respectively. Marriages are assigned to LHAs according to the place of event. Standard Geographical Code (SGC), derived from community name, is used in the absence of postal code.

Elderly Gravida:
Any mother who was 35 years of age or older at the time of delivery of a live born infant.

External Causes of Death:
Deaths due to environmental events, circumstances and conditions as the cause of injury, poisoning, and other adverse effects. Broad categories include accidents, suicide, medical or abnormal reactions, homicide, legal intervention, misadventures and injury from war operations. Standard tables under this heading include deaths due to accidents, suicide, homicide and other. Accidents are subdivided by the following categories; motor vehicle accidents (MVA) (ICD E810-E825, E929.0), poisoning (E850-869, E929.2), falls (E880-E888, E929.3), burns/fire (E890-899, E924, E929.4), drowning (E830, E832, E910), other accidents - all codes from E800-E949 not already noted. Suicide ICD-9 codes are E950-E959; homicide (E960-969); "other" consists of legal intervention (E970-978), undetermined if accidental or purposely inflicted (E980-989) and war operations (E990-999).

Heart Disease:
Tables under this heading include deaths due to:

• rheumatic/valvular: 391-398, 424
• hypertension: 401-405
• ischemic: 410-414, 429.2
• conductive & dysrythmic: 426-427
• heart failure: 428
• congenital: 745-746
• other: pulmonary - 415-417, inflammatory - 420-423, 429.0, cardiomyopathy - 425, 429.3, degenerative - 429.1, other, ill-defined or unspecified - 429.4-429.9

Infant Deaths:
Deaths of children under one year of age.

Low Birth Weight:
Any liveborn infant weighing less than 2500 grams.

Neoplasms (ICD-9 140-239):
Although the vast majority of deaths in this category are due to malignant cancer, also included are benign, in-situ, and unspecified "tumours". Detailed ICD-9 breakdown used in "Neoplasm Deaths" tables are;

• lung: includes trachea, bronchus, lung (ICD-162) and pleura (163)
• female breast: (ICD-174)
• colorectal: includes colon (ICD-153) and rectum, rectosigmoid junction and anus (154) other G.I. (Gastrointestinal): includes esophagus (ICD-150), stomach (151), small intestine and duodenum (152), liver & intrahepatic bile ducts (155), gallbladder and extra-hepatic ducts (156), pancreas (157), peritoneum (158), other and ill-defined within digestive organs (159).
• female reproductive: includes uterus (ICD-179), cervix (180, 182), placenta (181), ovary and adnexa (183), vagina & external genitalia (184).
• male reproductive: includes prostate (ICD-185), testis (186), penis & other genitalia (187).
• blood lymph: includes lymphatic and haematopoietic tissue (200-208).
• other malignancy: includes malignant neoplasms of other (e.g. lip, oral cavity, pharynx, nose, ear, larynx, heart, bone and connective tissue, urinary tract, eye, brain, endocrine glands), ill-defined or unspecified sites (140- 149, 160, 161, 164, 165, 170-173, 175, 188-189, 190-199).
• non-malignant & unspecified: includes benign (210-229), in-situ (230-234), and neoplasms of unspecified nature (e.g. "tumor" - 239).

• respiratory disease with four sub-categories of emphysema (ICD-492), chronic obstructive pulmonary disease (COPD) (496), pneumonia/influenza (480-487), and other respiratory diseases (ICD-460-478, 490-491, 493-495, 500-519).
  
• diabetes (250)
  
• alcohol related - see above.
  
• AIDS: includes AIDS and HIV infections (ICD-042-044).
  
• cerebro and other vascular: includes cerebrovascular disease (ICD-430-438), disease of arteries and veins (440-456), hypotension (458), and other circulatory system disease (459).
  
• liver disease: ICD-570-573.

Stillbirth:
The complete expulsion or extraction from its mother after at least 20 weeks of pregnancy or after attaining a weight of at least 500 grams, of a product of conception in which, after expulsion or extraction, there is no breathing, beating of the heart, pulsation of the umbilical cord or unmistakable movement of voluntary muscle.

Teenage Mother:
Any mother who was age 19 or less at the time of delivery.

Editor's Note:

Thank you: To Cathy Hull for this issue's feature article which is a testimonial to her skill, knowledge, and efficiency.

Re: Pie graphs following standard selected cause of death tables. Please note that the pie graphs on pages 11, 13, 15, and 17 showing proportions of all deaths for selected causes and group categories represent each current issue quarter (not year-to-date). These graphs can therefore be used to demonstrate seasonal differences at the provincial level by quarter-to-quarter comparison.

Electronic availability of part or all of this publication. Quarterly Digest standard tables will be available on the Ministry of Health's Health Planning Database (HPDB) almost simultaneously with distribution. Also, look for entire reproduction of this issue at web site address, http://www.hlth.gov.bc.ca/vs/

Contributors' Note:

The editorial staff would like to invite any readers who wish to contribute an article or paper summary for publication in this Quarterly Digest to contact the Information and Resource Management Branch of the British Columbia Vital Statistics Agency. Articles should focus on health status issues in British Columbia. It is preferable that submissions be in "electronic media" format (e.g. Word, Word Perfect, Excel, Lotus 123, Power Point, Corel Draw, etc.). Article presentation will be subject to space allowances and publishing deadlines.

Readers' Note:

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