Quarterly Digest
Volume 6 - Number 4 April 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-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 Digest and those eventually reported in the 1996 Vital Statistics' Annual Report. Therefore, the numbers provided in this publication should be considered provisional. Finally, the usual cautions regarding random fluctuations in values, particularly those involving small numbers, must be noted.

In the late 1980s and early 90s, there was much focus on increasing Cesarean section rates Nationally and in British Columbia. This issue's feature article re-examines the situation to a more current view. It reviews the practice patterns and changing trends of all delivery modes; examines delivery approaches to breech presentation and suggests common and selected indications for specific methods of delivery. This article represents, for some of the Vital Statistics' data used, (e.g. maternal complications, infant abnormalities, or event hospital) a unique application.

Whenever possible, changes such as additional cause of death category, percentage, 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 Regional Health Boards (RHB)

Introduction

Methods

Data source

Delivery mode was identified by reviewing Physician's Notice of Birth (PNOB) and grouped by spontaneous [vertex] (code 1), forceps/vacuum (code 2), spontaneous breech (code 3), first cesarean (code 4), second cesarean (code 5), and third + cesarean (code 6). To distinguish forceps and vacuum, vacuum was defined as mode of delivery code 2 plus ICD-9 perinatal code 7633 (delivery by vacuum). All breech presentation cases were identified by ICD code 6522. Vaginal deliveries included all deliveries but cesarean sections. Percentages of maternal complications and fetal abnormalities were calculated for the six delivery methods using 1995 live birth data. Using a single year of data provided sufficient counts and 1995 represents consistent coding practices, editing processes and the most current picture. The top 10 percentages for each specific delivery mode were listed. These percentages quantify relative frequencies of complications and abnormalities under each delivery method. They provide possible indications or reasons for each method of delivery. However, because individual complications or abnormalities can vary in severity and also because the presence of multiple complications and/or abnormalities was not addressed, caution is advised when interpreting the results.

Limitations

In 1995, there were 990 live born multiple birth infants which accounted for 2 multiple birth infants per 100 live borns. The rate of multiple live borns by mode of delivery was 1.2% for spontaneous vertex, 2.3% for forceps/vacuum, 19.2% for spontaneous breech, 6.3% for first cesarean, 1.9% for second cesarean, and 2.0% for third+ cesarean. There were 6 multiple births with method of delivery unknown. An appreciable effect of multiple counting, which results in overestimated rates, would likely be observed in the rate of twin pregnancy among spontaneous breech deliveries, and the rate among cesarean deliveries.

Live Birth Trends by Methods of Delivery, BC, 1987 to 1995

• Due to a two-decade upward trend in cesarean rates and a turnaround starting in 1991, the proportion of vaginal delivery versus cesarean delivery in 1995 was almost the same as the proportion in 1987. The vaginal birth rate was 77.5 per 100 live births in 1987 and 79.0 in 1995, more than three-quarters of all deliveries. For cesarean section, the rate was 21.0% in 1987 and 19.8% in 1995.

• It was among vaginal births that the methods of deliveries somewhat shifted. In 1987, the rate of spontaneous vertex delivery was 84.7 per 100 vaginal births. By 1995, this rate was 86.7%. The rate of forceps delivery declined from 13.0% in 1987 to 7.4% in 1995. Noticeable change was observed in the use of vacuum devices. In 1987, this rate was merely 8 vacuum deliveries per 1,000 vaginal births (0.8%). By 1995, this rate was 4.9%, more than 6 times the 1987 rate. The rate of spontaneous breech delivery declined from 1.5 per 100 vaginal births in 1987 to 1.1% in 1995. Of live born infants delivered vaginally, 13.8% in 1987 and 12.3% in 1995 were assisted deliveries.

• Of all cesarean deliveries, the rate of first cesarean increased from 58.8 per 100 cesareans in 1987 to 63.4 % in 1995. As a result, the rate of repeat cesarean declined from 41.2% in 1987 to 36.6% in 1995.

Figure 1
Live Birth Rate by Methods of Delivery
British Columbia, 1987 to 1995

• Changing trends were observed in the rates of live births by methods of delivery. From 1987 to 1995, the rate of spontaneous vertex increased from 65.6 per 100 live births to 68.4%. The rate of spontaneous breech declined from 1.1% in 1987 to 0.7% in 1990, and from 1990 to 1995 this rate stayed relatively the same, with a marginal increase of less than 0.1% (0.8% in 1995) . Marked change was observed in the use of assisted vacuums, with a fivefold rate increase from 0.6% in 1987 to 3.8% in 1995. On the other hand, the rate of assisted forceps dropped from 10.1% in 1987 to 5.8% in 1995.

• The upward trend of first cesarean rate reached its peak at 13.4 per 100 live births in 1990. Entering the 90s, this rate moved downward, ending at 12.6% in 1995. The rate of repeat cesarean declined gradually from 8.7 per 100 live births in 1987 to 7.3% in 1995.

Maternal Complications and Infant Abnormalities by Methods of Delivery, BC, 1995

• In 1995, of all spontaneous vertex deliveries, the most frequent maternal complications related to gestation with a rate of early (< 37 weeks) onset of delivery of 5.3 per 100 spontaneous vertex births and a rate of 2.6 that occurred post-term (42+ weeks). Also, pre-delivery fetal distress was noted at a rate of 2.5 per 100 spontaneous vertex deliveries.

• The most frequently recorded maternal indications for assisted (forceps/vacuum) vaginal delivery were fetal distress (10.8 per 100) and secondary uterine inertia (10.0%). Prolonged second stage of labour and transverse arrest or POP position were also relatively frequent at rates of 6.6 and 6.1 respectively. No indication was recorded for nearly half (47.8%) of forceps/vacuum assisted deliveries.

• Among deliveries that were unassisted breech, 28.6% occurred earlier than 37 weeks gestation and 17.4% involved delivery of a twin.

• In 1995, the most frequently noted maternal conditions among first cesarean deliveries were fetopelvic disproportion (15.0%), fetal distress (11.8%), breech presentation (11.3%), early onset of delivery (10.8%), and failed trial of labour (10.4%). For the nearly one quarter of first cesarean deliveries in which there was no mention of any indications, the proportion of elective c-sections cannot be determined.

• Of women who had cesarean for the second time, 5.9% had a failed trial of labour. Perhaps because trial of labour is less frequent after two previous c-sections, failed trial was reported in only 1.1% of third + cesareans. Fetopelvic disproportion (7.0%) was the leading maternal indication for second cesarean and early onset of delivery was the most frequently (7.8%) cited complication among third+ cesareans.

• In 1995, regardless of the mode of delivery, mild or moderate birth asphyxia and prematurity (28-36 weeks) were the most frequent infant abnormalities. Among the various delivery modes, both these conditions were proportionately highest (34.0% and 21.7% respectively) in spontaneous breech deliveries.

• Moderate birth asphyxia made up the largest proportion of infant abnormalities reported for forceps/vacuum deliveries (26.7%) and was least evident among abnormalities of infants delivered by repeat cesarean (13.4 and 12.8%).

• Infants delivered by first cesarean were more than twice as likely (11.0%) to be between 28 and 36 weeks gestation than infants delivered by forceps or vacuum extraction (4.4%) and unassisted vertex (5.1%).

• Severe birth asphyxia, characterized by an APGAR score of three or less, was also evident (ranked third or fourth) across all delivery modes, most prominently (16.9%) among infants delivered unassisted breech.

Notes to Tables 4 & 5

• Table 4 shows that a majority of the women who had conditions such as placenta previa, herpes genitalis, malpresentation, disproportion, and obstruction delivered their babies by first cesarean. The corresponding rates of first cesarean was 76.6 per 100 placenta previa cases, 70.2 per 100 herpes genitalis cases, 60.6 per 100 malpresentation cases, 70.4 per 100 disproportion cases, and 53.8 per 100 obstruction cases. However, the overall rate of first cesarean was only 12.6 per 100 live births. These conditions, except for herpes genitalis, also resulted in higher rates of repeat cesarean, compared with the rate of repeat cesarean per 100 live births (7.3%).

Notes to Tables 4 & 5

• Relatively high rates of unassisted vaginal delivery were observed for conditions such as gestational diabetes (70.5 per 100 gestational diabetes cases), premature labour (63.9 per 100 premature labour cases), hypertension/eclampsia (56.1 per 100 hypertension/eclampsia cases). However, compared with the average rate of unassisted vaginal delivery (69.3 per 100 live births), the rates for all the selected maternal and fetal conditions, except gestational diabetes, were smaller than the average rate for all live births. The rate of unassisted vaginal deliveries among women with gestational diabetes was only marginally higher than the average rate of unassisted vaginal births per 100 live births.

• In 1995, of all women who experienced long labour, the rate of forceps/vacuum delivery was 63.5 per 100 cases. It was also observed that 46.2% of the mothers who had maternal distress delivered their babies by assisted forceps or vacuum. However, the overall rate of forceps/vacuum was merely 9.7 per 100 live births.

• Of the selected fetal abnormalities, the rates of unassisted vaginal delivery varied from 44.4 per 100 twin/triplet infants to 65.3 per 100 post-term infants. For first cesarean delivery, the highest rate was 37.7 per 100 twins/triplets and the lowest rate was 19.8 per 100 exceptionally large babies. Compared with the overall rate of first cesarean (12.6 per 100 live births), the rates of first cesarean corresponding to the selected fetal abnormalities were relatively high. Higher repeat cesarean rate was also observed among other 'heavy-for-dates' infants (14.3).

Breech Presentations by Methods of Delivery

Notes to Tables 6, 7 & 8

• In 1995, breech presentation was observed among 1,063 live births. Of all breech babies, 27.1% were delivered spontaneously, 1.0% by forceps or vacuum, 63.2% by first cesarean, and 8.6% by repeat cesarean. A majority of breech presentation babies had normal birth weight (2500 - 4499 grams). Only 8 were large in birth weight (4500+ grams). It is worth noting that of 949 breech babies with normal birth weight, 693 of them were delivered by cesarean, i.e., a rate of 73.1 per 100 breech babies of normal birth weight.

• The distribution of methods of delivery for term breech infants was 25.9% for spontaneous delivery, 1.0% for assisted forceps/vacuum, 64.1% for first cesarean, and 8.9% for repeat cesarean. A relatively higher proportion of pre-term (breech) infants were delivered spontaneously (36.0 per 100 pre-term breech infants), compared with the rate of 14.3 per 100 post-term breech infants, and 27.1 per 100 breech infants. A high rate of repeat cesarean was noted among post-term breech infants (21.4 per 100 post-term breech infants), compared with the rate of 3.6 per 100 preterm breech infants, and 8.6 per 100 breech infants.

• Of breech infants with normal birth weight (2500 - 4499 grams) and normal gestational age (37-41 weeks), 63.8% were delivered by first cesarean, 9.3% by repeat cesarean, and 26.8% by vaginal delivery.

Cesarean Deliveries by Hospital, BC, 1987 and 1995

Figure 2
Cesarean* and Repeat Cesarean Rates** by Hospital,
British Columbia, 1987

Figure 3
Cesarean* and Repeat Cesarean Rates** by Hospital,
British Columbia, 1995

Notes to Tables 9, & 10 & Figures 2 & 3

• In 1987, 40,361 live infants were born in 53 hospitals in this province. BC Women's Hospital [then Grace Hospital] where 8,217 live infants were delivered was the leading hospital. More than 2,000 live infants were also born in each of the large hospitals such as Victoria General, Royal Columbian, and Surrey Memorial. In 1995, 45,513 live infants were born in 49 hospitals. Once again, BC Women's Hospital was the leading hospital, delivering 7,578 live infants and was followed by Surrey Memorial (3,604), Victoria General (3,219), Royal Columbian (3,177), and Burnaby General (2,040).

• In 1987, cesarean rates by hospital varied from 10.4 per 100 live births at St. John to 29.6 at Kimberley & District. However, only 81 live infants were delivered at Kimberley & District, and 134 live infants were delivered at St. John. Cesarean rates were 22.0 at BC Women's Hospital, 23.6 at Victoria General, 24.9 at Royal Columbian, and 24.6 at Surrey Memorial.

• During the same year, the five highest repeat cesarean rates were observed at Queen Victoria (58.1 per 100 cesareans), Castlegar and District (57.9), St. Joseph's (54.5), Cranbrook & District (53.5), and Golden & District General (53.3). The five hospitals with the lowest repeat cesarean rates were, in increasing order, Bulkley Valley District (21.9), Fort Nelson General (25.0), Creston Valley (29.4), St.Paul's (33.8), and Lion's Gate (34.4).

• In 1995, the highest cesarean rate was observed at Queen Victoria (31.5 per 100 live births), and the lowest rate was observed at Burnaby General (10.3). Overall, cesarean rates by hospital declined from 1987 to 1995. However, repeat cesarean rates by hospital, in general, increased from 1987 to 1995. Repeat cesarean rates, in 1995, ranged from the lowest of 23.8 per 100 cesarean deliveries at Golden District General to the highest of 52.9 at Shuswap Lake General.

• The repeat cesarean rate declined from 37.2 per 100 cesarean deliveries in 1987 to 34.8 in 1995 at BC Women's Hospital, a women's health centre where the largest number of infants were born each year. Reduced repeat cesarean rates were also observed at Victoria General (from 38.9 per 100 in 1987 to 30.2 in 1995), Royal Columbian ( from 41.8 per 100 to 35.1 ), Surrey Memorial (from 44.3 per 100 to 37.1) and others.

• At St. Paul's Hospital, where more than 1,000 live infants were delivered in 1987 and nearly 2,000 in 1995, both the cesarean rate and repeat cesarean rate declined. In 1987, the cesarean rate at St. Paul's was 26.1. By 1995, this rate declined to 21.4. The repeat cesarean rate at St. Paul's was 33.8 in 1987 and 29.0 in 1995.

• A relatively low cesarean rate was also observed at Burnaby General, where 1,472 live infants were born in 1987 and another 2,040 live infants in 1995. The cesarean rate at this hospital was 16.0 per 100 live births in 1987, and 10.3 in 1995, the lowest rate by hospital in that year. However, the outcome of repeat cesarean at this hospital was slightly above the average, with a rate of 42.4 per 100 cesareans in 1987 and 41.9 in 1995.

• Some variations within hospital size (based on number of live births) were observed in both the cesarean rates and repeat cesarean rates. Variation between hospital sizes was also observed, however, this variation was less marked. In 1995, hospitals with less than 100 births per year had the highest cesarean rate (22.0 per 100 live births). The lowest repeat cesarean rate (34.8) was observed among hospitals with more than 2,000 annual live births. The highest repeat cesarean rate (40.7 per 100 cesareans) was observed among hospitals with 1,000 to 1,499 annual births. The gap between the highest and the lowest rate, by hospital size, was about three-percentage-points for cesarean section and nearly six-percentage-points for repeat cesarean. Repeat cesarean rate by hospital sizes declined from 1987 to 1995.

Summary

Based on 1995 birth data, the most frequently observed maternal indications for cesarean section were fetopelvic disproportion, fetal distress, breech presentation and early onset of delivery. In that year, nearly one quarter of the first cesarean sections were performed without mention of indication. The rate of failed trial of labour decreased from 10.4 percent for the first cesarean, to 5.9 percent for the second cesarean, and 1.1 percent for the third+ cesarean. Frequently observed perinatal indications for cesarean section were mild or moderate birth asphyxia, pre-term infants, multiple gestation, and disorders relating to long gestation and high birth weight. Although there were less frequently observed incidences of placenta previa and herpes genitalis, over 70 percent of the women who experienced at least one of these complications delivered their babies by cesarean section. More than 70 percent of the women who had disproportion also delivered their infants by cesarean section. Indications for cesarean section also included slow fetal growth, exceptionally large babies, other 'heavy-for-dates' infants, and post-term infants. It was reported, in MacNab, et al, 1996, that advanced maternal age (30+) is a significant risk factor for cesarean section.

The panel of the National Consensus Conference on Aspects of Cesarean Birth (Lomas, 1986) published the recommendation in 1986 that 'planned vaginal birth should be recommended for either frank or complete breech presentation at 36 weeks or more gestation and/or when the estimated birth weight is 2500 to 4000g.'. However, based on this study, nearly 64 percent of breech presentation live born infants in BC (in 1995) with normal birth weight (2500 - 4499g) and normal gestational age (37 - 41 weeks) were delivered by first cesarean, and another 10 percent were delivered by repeat cesarean. The panel also recommended modifications of the above guideline in the presence of complicating factors. Further study on the presence of complicating factors among breech infants may help to explain why such a high cesarean rate occurred among 'normal' (normal in terms of birth weight and gestational age) breech infants.

Variation in both the cesarean rates and repeat cesarean rates was observed among hospitals. However, a large part of the variation was due to the small number of live births delivered in some hospitals in this province which resulted in changes of crude rates reflecting small increases/decreases in numbers of cesarean or repeat cesarean. This observation was also supported by the crude rates by hospital size, where variation between hospital size, for cesarean and repeat cesarean respectively, was less pronounced.

During the last two decades, changes in methods of deliveries has reflected the shift of our demographic distribution and changes in women's role in our society and at home. As more and more women enter the workforce and delay their childbearing for educational, professional, economical, or personal reasons, we face the reality of increasing numbers of older mothers-to-be, particularly those having their first child after age 35, who may be more susceptible to different complications that result in cesarean section or assisted delivery (MacNab, et al, 1996).

Many studies have indicated that the reduction of cesarean delivery can be achieved by promoting trial of labour and by offering planned vaginal birth to women with a previous cesarean (vaginal birth after cesarean, or VBAC). Reduced repeat cesarean in this province may likely be due to the increased number of planned vaginal births after cesarean. However, this was not assessed because of the lack of collected birth data that capture the VBAC counts. A disturbingly high rate of potentially elective cesarean, which was indicated by one out of four first cesarean sections being performed with no mention of indication in this province in 1995, is an important issue which requires greater attention.

References

MacNab, Y.C., Macdonald, J., and Tuk, T. (1996). Increased maternal age and the outcome of pregnancy: An eight year population based study, British Columbia, 1987 - 1994, Vital Statistics Agency Quarterly Digest, Vol 6, No. 1. p18-46.

MacNab, Y.C., Macdonald, J., and Tuk, T. (1997). The health impact of delayed childbearing in British Columbia, 1987 - 1994, Vol. 9, No. 2. Health Report (in press), Statistics Canada.

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.

APGAR:[Return to Article]
A scoring method of evaluation done at one minute and five minutes after the complete birth of an infant (disregarding the cord and placenta). Each of five objective signs are evaluated and given a score of 0, 1 or 2. A total score of 10 indicates an infant in the best possible condition. The signs evaluated are; heart rate, respiratory effort, muscle tone, response to stimuli (generally catheter in nostril), colour. The score taken at one minute is an index of asphyxia and of the need for assisted ventilation; the five minute score is a more accurate index of likelihood of death or neurological residual.

Assignment of Regional Health Board(RHB/HB):
Cases are assigned to RHB 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.

Small for Gestational Age (SGA):[Return to Article]
A term applied to an infant whose weight at birth is inappropriately low relative to its gestational age. SGA determination is based on Lubchenco's growth chart (Lubchenco & Hansman, USA, 1963).

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.

British Columbia Vital Statistics Agency Reports and Publications

The Division of Vital Statistics continues to be actively involved in the preparation of various reports and publications which present and measure British Columbia's vital event data. These studies, reports, texts, and periodicals are intended as research tools to assist health planners, researchers, and health care administrators. Except where otherwise indicated, the following publications are available upon request from the Agecny (see "Readers' Note" for distribution contact).

Burd Martha (1994). Regional Analysis of British Columbia's Status Indian Population: Birth-Related and Mortality Statistics. Division of Vital Statistics, Ministry of Health. Victoria, British Columbia.

Burr K.F., McKee B., Foster L.T., Nault F., "Interprovincial Data Requirements for Local Health Indicators: The British Columbia Experience" in Health Reports, 1995, Volume 7 No. 2, Statistics Canada, Ottawa.

Division of Vital Statistics, Ministry of Health. Victoria, British Columbia.Division of Vital Statistics, B.C. Ministry of Health for Medical Services Branch of Health Canada (March, 1996). Analysis of Status Indians in British Columbia: Updated Report, 1987 - 1994. Victoria, British Columbia.

Division of Vital Statistics, Ministry of Health, (June 1994). Client Registry. Victoria, British Columbia.

Division of Vital Statistics, Ministry of Health. Health Status Indicators in British Columbia, Birth-Related and Mortality Statistics, 1991-1995. Volume 1: Local Health Areas (Dec.,1996); Volume II: Health Units (Dec., 1996); Volume III: Communities (Mar.,1997). Victoria, British Columbia.

Division of Vital Statistics, Ministry of Health, (May,1996). Health Status Registry: Congenital Anomalies - Genetic Defects - Selected Disabilities, British Columbia to 1994. Victoria, British Columbia.

Division of Vital Statistics, Ministry of Health, (Oct., 1995). Mortality and Health Status in Vancouver: An Analysis by Neighbourhood Areas. Victoria, British Columbia.

Division of Vital Statistics, Ministry of Health, (1992). Physicians' and Coroners' Handbook on Medical Certification of Death. Victoria, British Columbia. (1997 Revision - soon available).

Division of Vital Statistics, Ministry of Health, (1991-1997). Quarterly Digest. Vol.1 (1&2) to Vol.6 (4). Victoria, British Columbia.

Division of Vital Statistics, Ministry of Health, (1996). Selected Vital Statistics and Health Status Indicators: One Hundred Twenty-Fourth Annual Report 1995.

Division of Vital Statistics, Ministry of Health, (1994). The Nineteen Eighties. A Statistical Resource for a Decade [and century] of Vital Events in British Columbia. Victoria, British Columbia.

Foster L.T.& McKee B. (June, 1994). Inter-Jurisdictional Data Exchange: Its Importance in the Use of Vital Statistics Data for Decision Support Analyses in Management Information Systems. Division of Vital Statistics, Ministry of Health. Victoria, British Columbia.

Foster L.T., Burr K.F., Mohamed J. (1994). Screening for Health Area Benchmarks in British Columbia: The Use of Vital Statistics Data. Division of Vital Statistics, Ministry of Health. Victoria, British Columbia.

Foster L.T., & Edgell M.C.R.,(Eds)(1992). The Geography of Death: Mortality Atlas Of British Columbia, 1985-1989. Western Geographical Series, Vol. 27. Victoria, British Columbia: University of Victoria. Available through the Dept. of Geography, University of Victoria, P.O. Box 3050, Victoria, B.C., V8W 3P5. Fax. (604) 721-6216, for $50.00 plus G.S.T. and $1.50 for shipping.

Foster L.T., Macdonald J.M., Tuk T.A., Uh S.H., Talbot D. (1995). "Native Health in British Columbia: A Vital Statistics Perspective; Chapter 2" in A Persistent Spirit: Towards Understanding Aboriginal Health in British Columbia. Canadian Western Geographical Series 31, University of Victoria, Victoria, British Columbia. Available through the Dept. of Geography, University of Victoria, PO Box 3050, Victoria, BC., V8W 3P5.

Foster L.T., Uh S.H., Collison M.A. (1992). Death in Paradise: Considerations and Caveats in Mapping Mortality in British Columbia (1985-1989). Victoria, British Columbia, Division of Vital Statistics. Also in M.V. Hayes, L.T. Foster, H.D. Foster, (Eds.), Community, Environment and Health: Geographic Perspectives. Western Geographical Series, Vol.27. (pp. 1-37). Victoria, British Columbia, University of Victoria.

Kierans W.J., Collison M.A., Foster L.T., Uh S-H.,(1993). Charting Birth Outcome in British Columbia: Determinants of Optimal Health and Ultimate Risk. Victoria, British Columbia, Division of Vital Statistics.

Macdonald J.M., Tuk T.A., Cranfield C.(1993). Cancer Mortality in British Columbia: 1988-1992, Patterns of Underlying Cause and Multiple Cause Data. Victoria, British Columbia, Division of Vital Statistics.

Macdonald J.M., Tuk T.A., Mohamed J.H., (1992). Cardiovascular Disease Death in British Columbia: Still Number One. Victoria, British Columbia, Division of Vital Statistics.

MacNab Ying C., Macdonald J., Tuk. T., (1997), "The Health Impact of Delayed Childbearing in British Columbia, 1987-1994" in Vol. 9, No. 2, Health Report ( in press) Statistics Canada, Ottawa.

MacNab Ying C., (Feb.,1994). Mortality Mapping in British Columbia: A Bayesian Approach. Victoria, British Columbia, Division of Vital Statistics.

Strohmaier R.M., Hu W., (1992). A Deadly Affair: Smoking-attributable Deaths, British Columbia, 1985 and 1989. Victoria, British Columbia, Division of Vital Statistics.

Tuk T.A. & Macdonald J.M. (Jan., 1995). Drug-Related Deaths in British Columbia: 1981 to 1993. Division of Vital Statistics, Ministry of Health. Victoria, British Columbia.

Tuk T.A., Macdonald J.M., (1995) Suicide, Homicide, and Gun Deaths, British Columbia: 1985 to 1993. Division of Vital Statistics, Victoria, British Columbia.

In progress

Analysis of Status Indians in British Columbia, 1991 - 1995.

Physicians' and Coroners' Handbook on Medical Certification of Death and Stillbirth, 1997 Revision.

Selected Vital Statistics and Health Status Indicators, 1996 Vital Statistics Annual Report.

Index of Quarterly Digest Articles to date:

Volume 1 - Number 1 & 2 - October 1991

1. Alcohol Related Deaths
2. Status Indians in British Columbia, 1989 - A Vital Statistics Overview

Volume 1 - Number 3 - January 1992

1. Fatal Poisonings in British Columbia - 1989 - by J.M. Macdonald
2. Fatal Head Injuries in British Columbia - 1990 - by J.M. Macdonald

Volume 1 - Number 4 - April 1992

1. Mortality Mapping in British Columbia - by M.C.R. Edgell & L.T. Foster
2. Suicide Deaths in British Columbia, - by T.A. Tuk & J.M. Macdonald
3. Selected Health Status Indicators in British Columbia, 1985-1990 by K.F. Burr, L.T. Foster, & J.H. Mohamed

Volume 2 - Number 1 - July 1992

1. Charting Birth Weight of British Columbia Newborns: How do we compare? - by W.J. Kierans
2. Cardiovascular Disease Death in British Columbia: Still number one - by J.M. Macdonald, T.A. Tuk & J.H. Mohamed

Volume 2 - Numbers 2 & 3 - November 1992

1. A Deadly Affair: Cigarette Smoking - Attributable Deaths, British Columbia, 1985 and 1989 - by R.M. Strohmaier & W. Hu
2. Health Status Registry: A Health Planning Tool Revisited and Revitalized by W.J. Kierans & A.K. McBride

Volume 2 - Number 4 - February 1993

1. Recent Advances in Community Health Related Information: A Vital Statistics Perspective - by T.A. Tuk, M.A. Collison, L.T. Foster
2. Cesarean Section Rates: A British Columbia Overview Prepared by Division of Vital Statistics

Volume 3 - Number 1 - May 1993

1. Cancer Mortality in British Columbia Part I: Cancer as an Underlying Cause of Death - by C. Cranfield, T.A. Tuk & J.M. Macdonald
2. Estimates for Health Effects Attributable to Second-Hand Smoke in British Columbia - by M.E. Thomson

Volume 3 - Number 2 - August 1993

1. Cancer Mortality in British Columbia Part II: Cancer Mortality Multiple Conditions - by J.M. Macdonald, T.A. Tuk & C. Cranfield
2. Technical Notes - An Alternative Approach to Mapping Mortality: A Bayesian Procedure - by Ying C. MacNab

Volume 3 - Number 3 - November 1993

1. Injury Facts and Prevention Strategies for Children and Youth in British Columbia - by Office for Injury Prevention
2. Ethnicity and Health Status, Part One: The IndoCanadian Community - by W.J. Kierans
3. Technical Notes - Measurement of Mortality Part I: Crude Rate - by Ying C. MacNab & T.A. Tuk

Volume 3 - Number 4 - May 1994

1. Ethnicity and Health Status, Part Two: The Chinese Immigrant Community - by W.J. Kierans
2. Potential Years of life Lost: British Columbia, 1985-1992 - by R.M. Strohmaier
3. Technical Notes - Measurement of Mortality Part II: Age Standardized Mortality Rate - by Ying Cai MacNab & T.A. Tuk

Volume 4 - Number 1 - June 1994

1. Vital Statistics in British Columbia: An Historical Overview of 100 Years, 1891 to 1990 - by J.M. Macdonald
2. Technical Notes: Measurement of Mortality Part III: Standardized Mortality Ratio - by Ying Cai MacNab & T.A. Tuk

Volume 4 - Number 2 - August 1994

1. Status Indians in British Columbia: A statistical Overview [1987-1992] - prepared by Medical Services Branch of Health Canada and B.C. Division of Vital Statistics
Volume 4 - Number 3 - November 1994

1. Drug-Related Deaths in British Columbia: 1981 to 1993 - by T.A. Tuk and J.M. Macdonald

Volume 4 - Number 4 - February 1995

1. Sudden Infant Death Syndrome in British Columbia: 1981 to 1993 - by H. Amershi

Volume 5 - Number 1 - May 1995

1. AIDS/HIV Related Mortality in British Columbia: 1985 to 1994 - by N. Fast

Volume 5 - Number 2 - August 1995

1. Suicide, Homicide, and Gun Deaths, British Columbia, 1985 to 1993 by T.A. Tuk & J. Macdonald

Volume 5 - Number 3 - November 1995

1. Respiratory Disease Mortality in British Columbia, 1985 to 1994 by Y.C. MacNab, J. Macdonald, T..A. Tuk

Volume 5 - Number 4 - March 1996

1. Diabetes in Birth and Death: British Columbia, 1987 to 1994 - by K. Stenning

Volume 6 - Number 1 - July 1996

1. Increased Maternal Age and the Outcome of Pregnancy: An eight year population based study, British Columbia, 1987 - 1994 by Y.C. MacNab, J. Macdonald, T.A. Tuk

Volume 6 - Number 2 - October 1996

1. Marriage and Family in British Columbia: 1931 - 1994 - by Z. Kashaninia

Volume 6 - Number 3 - January 1997

1. Accident Fatality in British Columbia, 1987 - 1995 [Introductory chapter of in progress longer report] by E. Demaere

Volume 6 - Number 4 - April 1997

1. A Review of Delivery Mode in British Columbia, 1987 - 1995 - by Y.C. MacNab

Editor's Note:

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.

Web site address: http://www.hlth.gov.bc.ca:80/vs/
Upcoming Quarterly Articles:
Pregnancy Outcome in British Columbia - by Cathy Hull, Non-Communicable Disease Epidemiology, Preventive Health Branch.
Cancer in Women - with Focus on Lung and Breast Cancer - by Zhila Kashaninia.
The Impact of Our Aging Population on Mortality - by Ying C. MacNab.

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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