a consensus development conference on healthy mothers ... · low birth weight babies are more...

Healthy Mothers – Healthy Babies:

How to Prevent Low Birth Weight

A Consensus Development Conference on

ConferenceProgram

May 23 to 25, 2007Sheraton Suites Calgary Eau Claire Calgary / Alberta / Canada

Hosted By:

Platinum Sponsor:

The short and long term impactof low birth weight babies onfamilies, the health care systemand the community is profound

and of growing public health concern.Low birth weight babies are more likelyto experience respiratory, vision, hearingand cognitive difficulties, are more likelyto require hospital readmission and havea higher rate of mortality than babiesweighing greater than 2500 grams.

Low birth weight results from a numberof complex interactions that are notclearly understood. Advancedtechnology and medical interventionsaimed at enhancing the likelihood ofconception and pregnancy, anddecreasing fetal mortality and morbiditymay be contributing to low birth weightrates. Despite sophisticatedprogramming, a high standard of living,availability of clinical and communityresources, and many thoughtfuldiscussions, the rate of low birth weightin Alberta has been resistant toreduction and continues to increase at asteady rate.

Promoting maternal health, optimal birthoutcomes, reducing premature deathand the burden of illness resulting fromlow birth weight are worthy public healthgoals. This conference will provide anopportunity to consult the experts, to

learn about factors contributing to thelow birth weight rate in Alberta, todevelop consensus on the most relevantfactors, and to tailor interventions toaddress the contributing factors.

The ConsensusConference FormatThe purpose of a ConsensusDevelopment Conference is to evaluateavailable scientific evidence on a healthissue and develop a statement thatanswers a number of predeterminedquestions. A group of experts presentsthe evidence to a panel, or “jury,” whichis an independent, broad-based, non-government, non-advocacy group. Thepanel listens to and questions theexperts. The audience is also given theopportunity to pose questions to theexperts. The panel convenes anddevelops the consensus statement,which is read to the experts and theaudience on the morning of the final day.This statement will be distributed widelyin the Canadian health care system.

Program AccreditationThe program has been submitted tovarious professional agencies foraccreditation. Please visit theregistration desk for more details.




ConferenceObjective

To develop

a consensus

statement

on how to

prevent low

birth weight.

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23

45

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1 What is Low Birth

Weight and how

frequently does it

occur?

What are the

implications of

Low Birth Weight?

What are the

factors that

contribute to Low

Birth Weight?

What can we do to

reduce Low Birth

Weight?

What are the most

effective service

delivery models to

reduce Low Birth

Weight?

What further

research is

needed (clinical

and policy)?

Steering CommitteeDr. Anthony Armson, University of TorontoMs. Laurie Blahitka, Calgary Health Region Ms. Brenda Fischer, Calgary Health Region Ms. Corine Frick, Alberta Perinatal Health

Program Dr. William Hnydyk, Alberta Medical Association Ms. Selikke Janes-Kelley, Capital HealthDr. Egon Jonsson, Institute of Health Economics Dr. Kevin Keough, Alberta Heritage Foundation for

Medical ResearchDr. Shoo Lee, Child and Family Research Institute Ms. Joanna Pawlyshyn, Capital Health

Planning CommitteeMs. Laurie Blahitka, Calgary Health RegionMs. Nancy Bott, Alberta Perinatal Health ProgramMs. Lesly Deuchar-Fitzgerald, Alberta Perinatal

Health ProgramMs. Nonie Fraser-Lee, Capital Health Ms. Corine Frick, Alberta Perinatal Health

ProgramMs. Grace Guyon, Alberta Perinatal Health

ProgramMs. Selikke Janes-Kelley, Capital HealthMr. David Johnston, Calgary Health RegionDr. Egon Jonsson, Institute of Health EconomicsMs. Debbie McNeil, Calgary Health RegionDr. Reg Sauve, Calgary Health RegionDr. Don Schopflocher, Institute of Health

EconomicsMs. Jeannie Yee, Alberta Perinatal Health

Program Dr. Jacques Magnan, Alberta Heritage Foundation

for Medical Research

Program CommitteeDr. Heather Baxter, Calgary Health Region, Dr. Wylam Faught, Capital Health Ms. Nonie Fraser-Lee, Capital HealthMs. Corine Frick, Alberta Perinatal Health

ProgramDr. Brent Friesen, Medical Officer of Health,

Calgary Health RegionMs. Selikke Janes-Kelley, Capital HealthDr. Jo-Ann Johnson, University of CalgaryDr. Thierry Lacaze, Capital Health; University of

AlbertaMs. Debbie McNeil, Calgary Health RegionDr. Christine Newburn-Cook, University of AlbertaDr. Reg Sauve, University of CalgaryDr. Paul Schnee, Medical Officer of Health,

Palliser Health AuthorityDr. Suzanne Tough, Alberta Centre for Child,

Family and Community ResearchDr. Stephen Wood, Calgary Health RegionMs. Heather Young, Health Canada

Communications CommitteeMs. Ronna Bremer, Capital HealthMs. Corine Frick, Alberta Perinatal Health

ProgramMs. Jocelyn Kaup, Alberta Medical AssociationMs. Rhonda Lothammer, Institute of Health

EconomicsMs. Lynda Phelan, Calgary Health RegionMs. Kathleen Thurber, Alberta Heritage

Foundation for Medical Research

Scientific Research CommitteeMs. Nancy Bott, Alberta Perinatal Health ProgramDr. Rhada Chari, Capital Health; University of

AlbertaDr. Sandy Davidge, University of Alberta Dr. Sandra de la Ronde, Calgary Urban Project

Society Maternal Child Clinic Ms. Lesly Deuchar-Fitzgerald, Alberta Perinatal

Health ProgramMs. Nonie Fraser-Lee, Capital HealthMs. Corine Frick, Alberta Perinatal Health

ProgramMs. Grace Guyon, Alberta Perinatal Health

ProgramMs. Christa Harstall, Institute of Health Economics Ms. Selikke Janes-Kelley, Capital Health Dr. Jo-Ann Johnson, University of CalgaryDr. Carolyn Lane, University of CalgaryDr. Andrew Lyon, University of CalgaryMs. Debbie McNeil, Calgary Health Region Dr. Peter Mitchell, Capital Health Dr. Christine Newburn-Cook, University of AlbertaDr. Beverley O’Brien, University of AlbertaDr. Reg Sauve, University of CalgaryDr. Don Schopflocher, Institute of Health

EconomicsDr. Fu-Lin Wang, Alberta Health and WellnessMs. Jeannie Yee, Alberta Perinatal Health

Program Dr. Wendy Yee, Calgary Health Region Ms. Sharon Zhang, Alberta Perinatal Health

Program

PanelPANEL CHAIRDr. Shoo Lee, Scientific Director, Integrated

Centre for Care Advancement throughResearch (iCARE), Capital Health, Edmonton

PANEL MEMBERSMs. Tracy Bailey, Health Law, University of

Alberta, EdmontonDr. Rhada Chari, Perinatologist, Capital Health;

University of Alberta, EdmontonDr. Gillian Currie, Assistant Professor, Health

Economics, University of Calgary, CalgaryDr. Don Davis, Obstetrician, Medicine Hat;

President, Society of Obstetricians andGynaecologists of Canada

Dr. Sandra de la Ronde, Calgary Urban ProjectSociety Maternal Child Clinic, Calgary

Ms. Catherine Ford, University of Calgary, CalgaryDr. Maureen Heaman, Professor and Associate

Dean, Research, Faculty of Nursing, Universityof Manitoba, Winnipeg

Dr. Thierry Lacaze, Neonatologist, Capital Health;University of Alberta, Edmonton

Ms. Taunya Madge, Parent, Preterm Quads,Calgary

Mr. Rory North, Parent, Chief Operating Officerand Portfolio Manager, North GrowthManagement, Vancouver

Ms. Lesley Paulette, Practicing Midwife, FortSmith, NWT

Dr. Jim Ruiter, Family Physician, BonnyvilleDr. Richard Stanwick, Chief Medical Health

Officer, Victoria

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Wednesday, May 23, 20077:00 – 8:00 am Breakfast and Registration Wildrose Ballroom Foyer

8:00 – 9:00 am Introduction

� Welcome and introduction of speakersConference Moderator: Dr. Ian Lange, Regional Clinical Department Head, Department of Obstetrics andGynaecology, University of Calgary, Calgary

� Assessing the economic, social and ethical implications of prenatal careLorne Tyrrell, Chair, Institute of Health Economics

� Effective care during pregnancy and child birth – a research priority for AHFMRDr. Kevin Keough, President and CEO, Alberta Heritage Foundation for Medical Research, Edmonton

� Healthy Mothers, Healthy Babies: a priority for Calgary Health Region and Capital HealthJack Davis, President and CEO, Calgary Health Region, CalgarySheila Weatherill, President and CEO, Capital Health, Edmonton

� A vision for the Alberta Perinatal Health ProgramCorine Frick, Program Director, Alberta Perinatal Health Program

� The Government of Alberta’s commitment to Healthy Mothers – Healthy BabiesPaddy Meade, Deputy Minister, Alberta Health and Wellness

� Low birth weight: a complex issueDr. Anthony Armson, Expert Chair, University of Toronto, Toronto

9:00 – 9:40 am What is Low Birth Weight (LBW) and how frequently does it occur?

� What is the definition of low birth weight, preterm birth, and small for gestational age? How frequently does low birth weight occur in Canada and the world? Dr. K.S. Joseph, Associate Professor, Department of Obstetrics & Gynaecology and Paediatrics, Dalhousie University,IWK Health Centre, Halifax

� How frequent is low birth weight in Alberta? Dr. Suzanne Tough, Associate Professor, Departments of Community Health Sciences and Paediatrics, University ofCalgary




Program

All sessions will take place in the Wildrose Ballroom unless otherwise noted.

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WEDNESDAY MAY 23, 2007 CONTINUED

9:40 – 10:20 am What are the implications of Low Birth Weight?

� The Parent’s Perspective Videotape: the parent’s experience of having a preterm, low birth weight baby

� What are the health effects of low birth weight? Dr. Reg Sauve, Professor, Departments of Community Health Sciences and Paediatrics, University of Calgary

10:20 – 10:50 am Refreshment Break Wildrose Ballroom Foyer

10:50 – 11:10 am � What are the economic implications of low birth weight to the family and to society? Dr. Donald Schopflocher, Director of Research, Institute of Health Economics; Senior Biostatistician, Alberta Healthand Wellness, Edmonton

11:10 am – 12:00 pm Questions and Discussion

12:00 – 1:00 pm Lunch

1:00 – 3:00 pm What are the factors that contribute to Low Birth Weight?

� What factors contribute to low birth weight?Dr. Prakeshkumar Shah, Assistant Professor, Departments of Paediatrics and Health Policy, Management andEvaluation, University of Toronto; Staff Neonatologist, Department of Paediatrics, Mount Sinai Hospital, Toronto

� How does the health of the mother affect low birth weight rates? Dr. Paul Gibson, Assistant Professor, Departments of Medicine and Obstetrics and Gynaecology, University of Calgary

� How do age and factors that influence the age of conception affect low birth weight rates? Dr. K.S. Joseph, Associate Professor, Department of Obstetrics & Gynaecology and Paediatrics, Dalhousie University,IWK Health Centre, Halifax

Dr. Suzanne Tough, Associate Professor, Departments of Community Health Sciences and Paediatrics, University ofCalgary

� How do poverty, substance use, smoking, alcohol, violence, and alternative medicines affect low birthweight rates? Nancy Poole, Research Associate, British Columbia Centre of Excellence for Womens Health; Research Consultant,Women & Substance Use Issues, BC Women’s Hospital, Vancouver

� What is the association between socioeconomic factors, i.e. neighbourhoods and low birth weight? Dr. Patricia O’Campo, Director, Centre for Research in Inner City Health, St. Michael’s Hospital; Professor, PublicHealth Sciences, University of Toronto

3:00 – 3:30 pm Refreshment Break Wildrose Ballroom Foyer

3:30 – 4:35 pm � Can public policy affect low birth weight? Dr. Gérard Breart, Professor, Public Health, University Pierre et Marie Curie; Director, INSERM EpidemiologicalResearch on Perinatal and Women’s Health, Paris, France

continued

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WEDNESDAY MAY 23, 2007 CONTINUED

� What screening tests and obstetrical interventions, including elective caesarean section andinductions, affect low birth weight? Dr. Anthony Armson, Expert Chair, University of Toronto, TorontoDr. Jo-Ann Johnson, Professor, Department of Obstetrics and Gynaecology, University of Calgary

� How does having multiples (twins, triplets etc) affect low birth weight? Dr. John Collins, Professor Emeritus, McMaster University, Adjunct Professor, Dalhousie University, Halifax

4:35 – 4:50 pm What can we do to reduce Low Birth Weight?

� What evidence is available to guide policy on assisted reproductive technology in order to reduce lowbirth weight? Dr. John Collins, Professor Emeritus, McMaster University, Adjunct Professor, Dalhousie University, Halifax

4:50 – 5:30 pm Questions and Discussion

Thursday, May 24, 2007 7:00 – 8:00 am Breakfast and Registration Wildrose Ballroom Foyer

8:00 – 10:00 am What can we do to reduce Low Birth Weight?

� What strategies are known to work to reduce low birth weight? Dr. Arne Ohlsson, Professor, Departments of Paediatrics, Obstetrics and Gynaecology, and Health Policy,Management and Evaluation, University of Toronto; Director, Mount Sinai Hospital, Toronto

� A promising therapy to reduce LBW: progesterone therapy Dr. Mark Klebanoff, Director, Division of Epidemiology, Statistics and Prevention Research, National Institute of ChildHealth and Human Development, Rockville, MarylandDr. Anthony Armson, Expert Chair, University of Toronto, Toronto

� How should programs be structured to reduce the rate of low birth weight? Dr. Brian McCarthy, Medical Epidemiologist, WHO Collaborating Center for Reproductive Health Division ofReproductive Health, Center for Disease Control and Prevention, Atlanta, Georgia

10:00 – 10:30 am Refreshment Break Wildrose Ballroom Foyer

10:30 – 11:20 am � What do people need to know before pregnancy to prevent low birth weight? Merry-K Moos, Professor, Maternal Foetal Medicine Division, Department of Obstetrics and Gynaecology, Universityof North Carolina

11:20 – 11:50 am What are the most effective service delivery models to reduce Low Birth Weight?

� What can we learn from the experiences of other countries? Dr. Hildur Har ardóttir, Chief of Obstetrics and Prenatal Diagnosis Unit, National University Hospital, Reykjavik,Iceland

11:50 am – 12:50 pm Lunch

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THURSDAY MAY 24, 2007 CONTINUED

12:50 – 1:20 pm � What can we learn from the experiences of other countries? Dr. Kerstin Hagenfeldt, Professor Emeritus, Department of Woman and Child Health, Division of Obstetrics andGynecology, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden

1:20 – 1:45 pm � Do different service delivery models for prenatal care affect low birth weight?Dr. Jeannette Ickovics, Professor, Yale University, New Haven, Connecticut


2:40 – 3:10 pm What further research is needed (clinical and policy)?� Expert Group: Dr. Heather Baxter, Department of Family Medicine Regional Obstetrical and Newborn Program Leader, CalgaryHealth RegionDr. Suzanne Tough, Associate Professor, Departments of Community Health Sciences and Paediatrics, University ofCalgaryDr. Stephen Wood, Associate Professor, Department of Obstetrics and Gynecology, University of CalgaryPenny Lightfoot, Director of Population Health and Research, Capital Health, Edmonton

� Synthesis: Dr. Michael Kramer, Scientific Director, Canadian Institutes of Health Research, Ottawa


Friday, May 25, 2007 8:00 – 9:00 am Breakfast and Registration Wildrose Ballroom Foyer

9:00 – 9:30 am Reading of the Consensus Statement

Consensus Panel Chair: Dr. Shoo Lee, Scientific Director, Integrated Centre for Care Advancement through Research(iCARE); Capital Health, Edmonton

9:30 – 10:30 am Open Discussion

10:30 – 11:00 am Closing Remarks

Implications of consensus statement:

� For clinical practiceDr. Anthony Armson, Expert Chair, University of Toronto, Toronto

� For policy assessment Professor Egon Jonsson, Executive Director and CEO, Institute of Health Economics, Edmonton

� For priorities in researchDr. Kevin Keough, President and CEO, Alberta Heritage Foundation for Medical Research, Edmonton

� Next stepsCorine Frick, Program Director, Alberta Perinatal Health Program, Calgary

11:00 – 11:30 am Press Conference

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Speakersand

Abstracts

EXPERT CHAIR

B. Anthony ArmsonMD MScInterim Director, Maternal, Infant andReproductive Health Research Unit,University of Toronto

B. Anthony Armson received his medicaltraining at Dalhousie University andobtained a Master of Science degree inCommunity Health and Epidemiology fromDalhousie University, May 2000. Dr. Armsonis the Interim Director of the Maternal,Infant and Reproductive Health ResearchUnit, Professor of Obstetrics andGynaecology, University of Toronto, andResearch Scientist at Women’s CollegeHospital and Sunnybrook Health SciencesCentre. As a perinatal clinician scientist, Dr.Armson has conducted research inmaternal, fetal and neonatal health. Hisprimary research interests are theprediction and prevention of preterm birthand the epidemiology and management ofdiabetes in pregnancy. Dr. Armson has alsobeen actively involved in perinatal clinicaltrials as site Principal Investigator for theCanadian Early Amniotomy Study, theCanadian Early and Mid-trimesterAmniocentesis Trial (CEMAT), and the Trial

to Reduce IDDM in the Genetically at Risk(TRIGR). He currently serves on the SteeringCommittees for Multiple Courses ofAntenatal Corticosteroid Study (MACS),Multiple Courses of AntenatalCorticosteroids for Preterm Birth Study-5Year Follow-up (MACS-5), Twin Birth Study(TBS), Early External Cephalic Version-2 Trial(EECV2) and Control of Hypertension inPregnancy Study (CHIPS). He is principalinvestigator of the proposed Prevention ofProblems of Preterm Birth in Women atIncreased Risk Trial (POPPI).

ABSTRACT 1

A Promising Therapy to Reduce LBW:Progesterone Prophylaxis

Numerous secondary preterm birthstrategies have been evaluated but, untilrecently, none have been shown toeffectively reduce preterm birth rates inwomen at increased risk. Two recentstudies have suggested that progesteronereduces preterm deliveries in women withsingleton pregnancies at high risk. daFonseca and colleagues compared vaginalprogesterone (100mg daily from 24 – 34weeks gestation in 142 women) to placeboand found a reduction of preterm birth (PTB<37 weeks) from 28.5% to 13.8%.1 Meisrandomised 459 women with prior history ofspontaneous preterm birth to 250mgintramuscular (IM) 17-hyprodroxyprogesterone (17P) or placebo from 16 – 20weeks until 37 weeks or delivery.2 The risk ofPTB (<35 weeks) was reduced from 30.7%to 20.6%. However, neither trialdemonstrated significant reductions inperinatal death or serious neonatalmorbidity. These results were consistentwith smaller, lower quality trials conducted

in the 70s and early 80s.3-6

Following the publication of the Meis trial,the American College of Obstetrics andGynecology recommended thatconsideration be given to progesteroneprophylaxis for women with a prior historyof spontaneous preterm birth butacknowledged that further studies wereneeded to evaluate the use of progesteronein women with other risk factors for pretermbirth including multiple gestation, shortcervical length, and positive fetal fibronectinresults.7 Five systematic reviews haveevaluated the effectiveness of progesteroneprophylaxis in preventing preterm birth.8-12

Using different criteria to select recent andolder clinical trials, the meta-analysesprovide further evidence that both vaginaland IM progestational agents reduce therisk of PTB. Most authors emphasize thatclinical trials are needed to confirm thatprogesterone prophylaxis also reducesperinatal mortality and serious neonatalmorbidity.

Three recently completed, but yetunpublished, trials have yielded conflictingresults. In an RCT of 655 healthy twins,Caritis showed no reduction in the risk ofpreterm birth in women allocated to 17P orplacebo. Creasy also showed no reductionin preterm birth rates in 500 singletonpregnancies with previous preterm birthhistory treated with vaginal 8%progesterone gel (90mg) or placebo. Incontrast, Nicolaides investigated theeffectiveness of progesterone in womenwith short cervix (<15 mm) anddemonstrated a decrease in PTB rates (< 34weeks) from 34% to 19%, and a 50%reduction in perinatal mortality (5.6% to2.4%) using vaginal progesterone 200mg

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daily from 22 weeks to 34 weeks or delivery.

A number of other clinical trials have beeninitiated to evaluate the benefits and risks ofprogesterone therapy for women atincreased risk of spontaneous preterm birth.Many trials are evaluating the effects of 17P,which is not currently available for publicuse and requires weekly intramuscularinjections. Vaginal progesterone may bemore acceptable to women. Six trials areevaluating vaginal progesterone and noneof these trials is adequately powered toevaluate the effects of progesterone on therisk of perinatal mortality or seriousneonatal morbidity. Primary data from anongoing survey of more than 300 prenatalpatients from three tertiary perinatal centresin Canada to assess women’s views onprogesterone prophylaxis found that 47% ofwomen preferred self administered vaginalprogesterone and 45% preferredintramuscular injection. The 50/50 split inwomen’s preferred route of administrationwas observed in both high and low riskgroups. These findings may have importantimplications in terms of patient compliance,the implementation of practice guidelinesand national health policy discussionsregarding drug approval shouldprogesterone prophylaxis become anestablished standard of practice.

REFERENCES

1. daFonseca EB, Bittar RE, Carvalho MH, Zugaib M. Prophylacticadministration of progesterone by vaginal suppository to reducethe incidence of spontaneous preterm birth in women at increasedrisk: a randomized placebo-controlled double-blind study. Am JObstet Gynecol 2003; 188(2):419-424.

2. Meis PJ, Klebanoff M, Thom E, Dombrowski MP, Sibai B,Moawad AH et al. Prevention of recurrent preterm delivery by 17alpha-hydroxyprogesterone caproate. N Engl J Med 2003;348(24):2379-2385.

3. Papiernik E. Double blind study of an agent to prevent pretermdelivery among women at increased risk. Edition Schering 1970;3:65-68

4. Johnson JW, Austin KL, Jones GS, Davis GH, King TM. Efficacyof 17alpha-hydroxyprogesterone caproate in the prevention ofpremature labor. N Engl J Med 1975; 293(14):675-680.

5. Hartikainen-Sorri AL, Kauppila A, Thimala R. Inefficacy of 17alpha hydroxyprogesterone in the prevention of prematurity in twinpregnancy. Obstet Gynecol 1980; 56:692-695.

6. Yemini M, Borenstein R, Dreazen E, Apelman Z, Mogilner BM,Kessler I, Lancet M. Prevention of premature labor by 17 “-hydroxyprogesterone caproate. Am J Obstet Gynecol 1985; 151:574-577.

7. Use of progesterone to reduce preterm birth. ACOG CommitteeOpinion No 291. American College of Obstetricians andGynecologists. Obstet Gynecol 2003; 102:1115-6.

8. MacKenzie R., Walker MC, Armson A, Hannah M. Progesteronefor the prevention of preterm birth among women at increasedrisk: a systematic review and meta-analysis of randomizedcontrolled trials. Am J Obstet Gynecol 2006;194:1234-42.

9. Sanchez-Ramos L, Kaunitz AM, Delke I. Progestational agents toprevent preterm birth: a meta-analysis of randomized controlledtrials. Obstet Gynecol. 2005; 105(2):273-9.

10. Dodd JM, Crowther CA, Cincotta R, Flenady V, Robinson JS.Progesterone supplementations for preventing preterm birth: asystematic review and meta-analysis. Acta Obstet Gynecol Scand.2005 June; 84(6):526-33.

11. Dodd JM, Flenady V, Cincotta R, Crowther CA. Prenataladministration of progesterone for preventing preterm birth.Cochrane Database Syst Rev 2006 Jan 25;(1):CD004947.

12. Coomarsamy A, Thangaratinam S, Gee H, Khan KS.Progesterone for the prevention of preterm birth: A criticalevaluation of evidence. European Journal of Obstetrics &Gynecology and Reproductive Biology; 129(2006): 111-8.

ABSTRACT 2

What screening tests and obstetricalinterventions affect low birth weight?

Late preterm birth, defined as deliverybetween 340/7 and 366/7 weeks gestation, isresponsible for 70-75% of all preterm birthsin Canada. Most of the increase in thepreterm birth rate is due to a steadyincrease in the rate of late preterm births. In fact, the rate of early preterm births(< 34 weeks) has remained relatively stableover the past decade. Although seriousneonatal morbidity is uncommon, latepreterm infants are at two to three fold riskof mild to moderate morbidity includinghypothermia, hypoglycaemia, respiratorydistress, delayed lung fluid clearance, poorfeeding, jaundice, infection and readmissionafter discharge. Since there is significantgrowth and maturation of the developingbrain in the final weeks of gestation, infantsborn in the late preterm period may also beat risk for neurodevelopmental problemsand learning disabilities.

The factors responsible for the increase inlate preterm births are complex andmultifactorial. Gestational age determinationby first trimester ultrasound has beenassociated with a decrease in post termpregnancy rates and in increase in latepreterm birth. Practice guidelines regardingthe management of post term pregnancyhave also tended to shift the meangestational age of delivery to the leftresulting in higher late preterm birth rates.The most important factors associated withthe rise in late preterm births are highermultiple gestation rates secondary to ARTand obstetrical interventions for maternaland fetal indications such as preeclampsia,diabetes, preterm prelabour rupture ofmembranes and suspected fetal growth

restriction. Concerns about maternal andfetal health identified through increasedmaternal surveillance of maternal medicalcomplications and improved monitoring offetal growth and well being using ultrasoundhas resulted in higher rates of induction andcaesarean delivery in the late pretermperiod. An apparent positive consequenceof this trend has been a reduction in thestillbirth rate. Delayed childbearing,maternal obesity and fetal macrosomia havealso been associated with increased risk oflate preterm birth.

Improvements in first trimester prenataldiagnostic tests such as sonographing earlypregnancy review and first trimestermaternal serum screening have raised thepossibilities of identifying mothers andfetuses at risk for obstetric and medicalcomplications prior to the manifestation ofthe condition. Mothers and fetusesidentified to be at risk of preeclampsia,gestational diabetes or fetal growthrestriction may benefit from emergingprophylactic interventions which mayimprove neonatal outcome and may evenprevent the development or exacerbation ofsuch conditions.

MODERATOR

Ian R. LangeMB ChB FRCSCRegional Department Head, Obstetrics &Gynaecology, Calgary Health Region andUniversity of Calgary

Ian Lange is a Maternal Fetal Medicinespecialist, a New Zealander who attendedmedical school in Dunedin. His internship and residency were completed at theUniversity of Otago, New Zealand, as well as Queens University, Kingston, Ontario.

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He received his FRCS(C) in 1980. Thereafter heundertook a perinatal fellowship at theUniversity of Manitoba and was a facultymember in Winnipeg until 1987.

Dr. Lange relocated to the University ofCalgary in 1988, and in addition to a busyMaternal Fetal Medicine practice, hasbeen very active in areas of qualityassurance, regional clinical practiceguidelines and preterm labour prevention.

He was also involved with the RoyalCollege Specialty Examination Board inObstetrics and Gynecology (1998-2002) andsat on the Financial Committee of the SOGC(2001-2005).

His Alberta responsibilities include being amember of the Alberta Perinatal HealthAdvisory Committee, the Alberta PerinatalHealth Program’s Fetal FibronectinEducation Program and MOREOB SteeringCommittee.

In 1995, Dr. Lange was appointed RegionalClinical Department Head for the CalgaryHealth Region, and in 1997 was promotedto Professor and Chair, Department ofObstetrics and Gynecology, University ofCalgary.

Heather BaxterMDDepartment of Family Medicine RegionalObstetrical and Newborn Program Leader,Calgary Health Region

Heather Baxter has been a Family doctorin Calgary for 22 years. She received hermedical training at the University ofToronto in 1982, and performed herresidency in Calgary. In addition to herfamily practice, Dr. Baxter is the FacultyAdvisor for the Advanced Life Support inObstetrics (ALSO) Program, and is theDivision Chief of Obstetrics and NewbornCare, Department of Family Medicine,Calgary Health Region.

Dr. Baxter currently maintains an activepractice in low risk obstetrics as part ofthe Maternity Care Clinic in NE Calgary,dealing with women of diversemulticultural backgrounds, anddisadvantaged populations, and is acommittee member of the Maternal

Newborn Care Committee, College ofFamily Physicians of Canada.

She is also a Clinical Assistant Professorin the Department of Family Medicine,University of Calgary.

Gérard BreartMDProfessor of Public Health, University of Pierreand Marie Curie (Paris VI); Director,Epidemiological Research Unit of PerinatalHealth and Women’s Health, National Instituteof Health and Medical Research (INSERM),Paris, France

Gérard Breart received his medical training atParis University in Paris, France. He completedhis advanced studies in both ReproductiveBiology and Epidemiology, and completed hisresidency in 1975. Dr. Breart currently holdsthe positions of Professor of Public Health atthe University of Pierre and Marie Curie (ParisVI); Director of the Epidemiological ResearchUnit of Perinatal Health and Women’s Health,National Institute of Health and MedicalResearch (INSERM), Paris, France; andAdjunct Faculty, Tulane School of PublicHealth and Tropical Medicine in New Orleans.

Dr. Breart has acted as Principal and Co-Principal Investigator on numerous studies onthe topic of preterm babies, including researchfor the European Commission on the‘Organization of care for very pretermneonates’, and ‘Prevention of post-partumhaemorrhage.’ Completed research for theClinical Outreach Program includes ‘Long-termoutcome of very preterm babies’. Currently, heis Co-Principal Investigator for ‘EmergingInfectious Disease and Pregnancy’ for theFrench Embassy.

ABSTRACT 1

Preterm birth, low birthweight andprenatal care - Some data fromFrance

Decrease in preterm birth rates has beenobserved in France. It is difficult to findone explanation. It was probably due tothe modification of demographic factors(such as age and parity) combined withincrease in prenatal medical and socialintervention.

John CollinsFRCSC, FRCOG, FACOGProfessor Emeritus, McMaster University

John Collins received his MD andpostgraduate training in Obstetrics andGynaecology from the University of WesternOntario, followed by post-residency trainingin reproductive medicine at the UniversityCollege Hospital, London with Gerald Swyerand in Edinburgh with John Lorain. He hasbeen a member of the Department ofObstetrics and Gynecology at the Universityof Western Ontario and Assistant Dean,Undergraduate Medicine.

Dr. Collins has been Department Head,Obstetrics and Gynaecology at DalhousieUniversity and Chief of Staff, GraceMaternity Hospital, Halifax. He wasDepartment Chair at McMaster University.He also held a cross-appointment in ClinicalEpidemiology and Biostatistics. His clinicalpractice involved ReproductiveEndocrinology and Infertility. He was aVisiting Fellow at the World HealthOrganization Research in HumanReproduction Program and a FrancquiFoundation International Visiting Chair atBrussels Free University and the CatholicUniversity in Leuven, Belgium. He is aProfessor Emeritus at McMaster Universityand Adjunct Professor at DalhousieUniversity.

A previous member of the editorial boardsof The New England Journal of Medicine,Fertility and Sterility, Human ReproductionUpdate and Evidence-Based Medicine, Dr.Collins is a member of the Editorial Board ofObstetrics and Gynecology, and Editor-in-Chief of Human Reproduction Update. Dr.Collins is also a member of The ESHRE CapriWorkshop Group and a consultant to thePractice Committee of the American Society

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for Reproductive Medicine. He is a formerPresident of the Society of Obstetriciansand Gynecologists of Canada, the CanadianFertility and Andrology Society and theAssociation of Professors of Obstetrics andGynecology.

Dr. Collins’ research, which has beenreported in more than 160 refereedpublications, involves the evaluation ofoutcomes, such as the effectiveness, safetyand cost of interventions for reproductivehealth disorders and the long-termcardiovascular and cancer outcomesassociated with use of oral contraceptionand hormone treatment.

ABSTRACT 1

How do multiple births affect low birthweight?

Multiple births account for approximately3% of births and 14% of infant deaths.1 Theexcess mortality is due mainly to prematurebirth and low birth weight.2 Multiple birth-associated LBW rates are rising becausemultiple births are more common with oldermaternal age, and because ovulationstimulation treatments for infertility are morefrequently used.

Multiple births and low birth weightPreterm delivery rates before 37 weeks are6% to 7% in singletons, 40% to 50% in twinsand over 90% in triplets.2 Low birth weightrates <2500g are 10-fold higher in twins and15-fold higher in triplet or more pregnanciescompared with singletons.2 Rates for LBWwere 4%, 43% and 64% for singletons, twinsand triplets, respectively.

Multiple births and perinatal mortalityMaternal characteristics, lower birth

weight, earlier gestational age, mono-chorionicity, birth order and the presence ofanomalies in a sibling fetus increase the riskof perinatal mortality.3 Perinatal mortalityrates were 6.2 and 32 per 1,000 births forsingleton births and multiple births,respectively in the United States in 1999.

Temporal trends in multiple birthsMultiple birth rates began to decline in the1950s to a minimum in the 1970s, and haverisen since then, more remarkably since1980. The multiple pregnancy rates per 1,000births in England and Wales were 13.2, 9.6

and 14.4 in 1951, 1976 and 1998,respectively.4,5 In the United States theoverall multiple birth ratio increased 59%from 19.3 to 30.7 multiple births per 1,000 livebirths from 1980 to 1999.1

Maternal age and the frequency of multiplebirthThe frequency of dizygotic twinningincreases from puberty up to about 37 yearsof age,6 and the increase in the twin birthrate is associated with more dizygotic thanmonozygotic twins.7 Delayed child bearingand older mothers accounts, however, foronly about 25% to 30% of the rising trend inmultiple birth rates since 1970.4

Infertility treatment and frequency ofmultiple birthThe primary factor in rising rates of multiplebirth is wider use of treatments thatstimulate the development of multipleoocytes. In a summary of 14 studies,assisted reproduction technologyaccounted for 17% to 24% of twin births and22% to 59% of triplet births. Ovulationstimulation with clomiphene citrate orgonadotropins accounted for 22% of twinsand 31% to 38% of triplet births.4

Conclusions Twin and triplet births are associated withhigher risks of low birth weight andperinatal morbidity and mortality. Risingtrends in multiple birth are due to delayedchildbearing and increased use of ovarianstimulation treatment with or without in vitrofertilization.

REFERENCES

1. Russell RB, Petrini JR, Damus K, Mattison DR, Schwarz RH. TheChanging Epidemiology of Multiple Births in the United States.Obstet Gynecol 2003;101:129-36.

2. Blondel B, Kogan MD, Alexander GR, Dattani N, Kramer MS,Macfarlane A, et al. The impact of the increasing number ofmultiple births on the rates of preterm birth and low birthweight:an international study. Am J Public Health 2002 92:1323-30.

3. Sutcliffe AG, Derom C. Follow-up of twins: health, behaviour,speech, language outcomes and implications for parents. EarlyHum Dev 2006;82:379-86.

4. Blondel B, Kaminski M. Trends in the occurrence, determinants,and consequences of multiple births. Semin Perinatol 2002; 26:239-49.

5. Blickstein I, Keith LG. The decreased rates of triplet births:temporal trends and biologic speculations. Am J Obstet Gynecol2005; 193:327-31.

6. Hankins GV, Saade GR. Factors influencing twins and zygosity.Paediatr Perinat Epidemiol 2005 Jan;19 Suppl 1:8-9.

7. Imaizumi Y. A comparative study of zygotic twinning and tripletrates in eight countries, 1972-1999. J Biosoc Sci 2003; 35:287-302.

ABSTRACT 2

Evidence to guide policy on ART inorder to reduce LBW?

Background Reducing the frequency of multiplepregnancy in ART cycles would help toprevent the prematurity and low birth weightthat are associated with multiple births.Single embryo transfer (SET) is the mosteffective means of improving safety in ARTcycles because it reduces twin rates to lessthat 1%. Even in good prognosis patients,however, there is a small reduction in theoverall pregnancy rate.

Evidence from randomized controlled trials(RCTs) Six RCTs have evaluated SET comparedwith double embryo transfer (DET).1-6 Allcompared SET to DET, but one included acropreserved embryo transfer cycle in theSET group4 and another included two SETcycles.5 The results in both cases includedata from the first SET cycle. The RCTsincluded mainly good prognosis patients,based on female age and number of goodquality embryos available. Eligible patientscomprised from 11% to 46% of those havingART cycles in each clinic.

The average on-going pregnancy rateswere 29% and 44% per cycle in the SET andDET groups. The weighted average ratedifference was 15% (95% CI 10%, 20%)using either inverse variance or randomeffects methods. I2 was zero. The multiplebirth rates were 2% and 32% (summary ratedifference 29%, 95% CI 24, 35) (I2 = 12%). Forevery seven ART cycles (95% CI 5, 10) therewill be one more pregnancy with DET thanSET, but for every three pregnancies (95% CI2, 4) there will be one more multiple birthwith DET than SET.

Economic evaluations Premature newborns may require neonatalintensive care, drug therapy, inhalationtherapy, expensive imaging and otherdiagnostic procedures. The cost ofproviding these services reflects the extentof newborn damage. Three of the SET vsDET RCTs did cost-effectiveness analyses.7-9

A systematic review showed that DET isboth more effective and more expensivethan SET.10 Depending on the assumptions

11

and local costs, each additional DETpregnancy would cost an additional i11,000to i73,000. The studies did not include thecosts that twins with LBW incur duringinfancy and childhood, which may be ten-fold higher for twins than singleton births.11

Pragmatic evidenceThe evidence has been sufficient tointroduce SET protocols in European andAmerican ART clinics.12,13 On July 1, 2003, theBelgian government began to reimburseART laboratory costs for couples withfemale age less than 43 years for amaximum of six treatment cycles, in returnfor a liberal SET transfer policy aiming atreduced multiple pregnancy rates andassociated costs.14 ART utilization hasincreased, but the twin rate has beenreduced to below 10% with no reduction inoverall live birth rates.

AssessmentEuropean experience has shown thatmaking ART more affordable and accessiblefacilitates the uptake of SET and reducesthe utilization of ovarian stimulation in non-ART cycles.

REFERENCES

1. Gerris J, De Neubourg D, Mangelschots K, Van Royen E, Vande Meerssche M, F, Valkenburg M: Prevention of twin pregnancyafter in-vitro fertilization or intracytoplasmic sperm injectionbased on strict embryo criteria: a prospective randomized clinicaltrial. Hum Reprod 1999; 14):2581-2587.

2. Martikainen H, Tiitinen A, Tomas C, Tapanainen J, Orava M,Tuomivaara L, Vilska S, Hyden-Granskog C, Hovatta O, Finnish ETStudy group: One versus two embryo transfer after IVF and ICSI:a randomized study. Hum Reprod 2001; 16:1900-1903.

3. Gardner DK, Surrey ES, Minjarez D, Leitz A, Stevens J,Schoolcraft WB: Single blastocyst transfer: a prospectiverandomized trial. Fertil Steril 2004; 81:551-555.

4. Lukassen HGM, Braat D, Wetzels AMM, Zielhuis GA, AdangEMM, Scheenjes E, Kremer JAM: Two cycles with single embryotransfer versus one cycle with double embryo transfer: arandomized controlled trial. Hum Reprod 2005; 20:702-708.

5. Thurin A, Hausken J, Hillensjo T, Jablonowska B, Pinborg A,Strandell A, Bergh C: Elective Single-Embryo Transfer versusDouble-Embryo Transfer in in Vitro Fertilization. The New EnglandJournal of Medicine 2004; 351:2392-2402.

6. van Montfoort AP, Fiddelers AA, Janssen JM, Derhaag JG,Dirksen CD, Dunselman GA, Land JA, Geraedts JP, Evers JL,Dumoulin JC: In unselected patients, elective single embryotransfer prevents all multiples, but results in significantly lowerpregnancy rates compared with double embryo transfer: arandomized controlled trial. Hum Reprod 2006; 21:338-343.

7. Lukassen MHG, Schonbeck Y, Adang EMM, Braat DDM,Zielhuis GA, Kremer JAM: Cost analysis of singleton versus twinpregnancies after in vitro fertilization. Fertil Steril 2004; 81:1240-1246.

8. Kjellberg AT, Carlsson P, Bergh C: Randomized single versusdouble embryo transfer: obstetric and paediatric outcome and acost-effectiveness analysis. Hum Reprod 2006; 21:210-216.

9. Fiddelers AA, van Montfoort AP, Dirksen CD, Dumoulin JC,Land JA, Dunselman GA, Janssen JM, Severens JL, Evers JL:

Single versus double embryo transfer: cost-effectivenessanalysis alongside a randomized clinical trial. Hum Reprod 2006;21:2090-2097.

10. Fiddelers AA, Severens JL, Dirksen CD, Dumoulin JC, LandJA, Evers JL: Economic evaluations of single- versus double-embryo transfer in IVF. Hum Reprod Update 2007; 13:5-13.

11. Papiernik E: Social cost of twin births. Acta Genet MedGemellol 1983; 32:105-111.

12. Sparks AE, Ryan GL, Sipe CS, Dokras AJ, Syrop CH, vanVoorhis BJ: Reducing the risk of multi-fetal gestation byimplementing a single blastocyst transfer policy. Fertil Steril 2005;84(Supp):S86-S87.

13. Bergh C: Single embryo transfer: a mini-review. Hum Reprod2005; 20:323-327.

14. Ombelet W, De SP, Van der EJ, Martens G: Multiple gestationand infertility treatment: registration, reflection and reaction—theBelgian project. Hum Reprod Update 2005; 11:3-14.

Paul GibsonMDAssistant Professor, Departments ofMedicine and Obstetrics and Gynaecology,University of Calgary

Paul Gibson is an Assistant Professor ofMedicine and Obstetrics & Gynecology atthe University of Calgary. He obtained hismedical degree (1993) and InternalMedicine residency (1998) at the Universityof Manitoba, and thereafter completedFellowship training in Medical Disorders inPregnancy at Brown University inProvidence, Rhode Island, USA (2001). Dr.Gibson provides inpatient consultation formedically-complicated pregnancies atFoothills Hospital and heads up the MedicalDisorders in Pregnancy clinics in Calgary.His research interests focus on medicallycomplicated pregnancies with an emphasison thrombosis, vascular disease andmedical education.

ABSTRACT

Dr Gibson will review several commonmedical disorders which complicatepregnancy including hypertension,

diabetes, thrombosis and thrombophilia,and autoimmune disease.

Discussion will include prevalence,association with LBW and managementissues.

Kerstin Hagenfeldt MD PhDProfessor Emeritus, Karolinska Institutet,Sweden

Dr. Kerstin Hagenfeldt completed hermedical training at the Karolinska Institute,Stockholm, Sweden. She became aspecialist in obstetrics and gynaecology,and completed her postgraduate training ingynaecologic endocrinology. Dr. Hagenfeldtwas the Dean of Undergraduate MedicalEducation at the Karolinska Institute from1987 to 1993. She currently works in theDepartment of Woman and Child Health,Division of Obstetrics and Gynaecology,Karolinska University Hospital.

Dr. Hagenfeldt was a board member of theSwedish Society of Obstetrics andGynaecology from 1969 to 1985, and was thePresident in 1984-1985. She has been aboard member of the Swedish Society ofMedicine since 1986, and was the Presidentin 1994-1995. She was also a Chairpersonfor the Ethical Committee from 1999-2003.From 1994-2001, Dr. Hagenfeldt was aMember of the Board and ScholarshipCommittee for the Sweden-AmericaFoundation, whose purpose is to promotescientific and cultural exchange betweenthe USA, Canada and Sweden. She hasbeen a member of the IPPF InternationalMedical Advisory Panel since 1992, and wasthe Chairperson from 1995-1999.

Dr. Hagenfeldt has also served as a memberof the WHO Special Programme of

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Research, Development and ResearchTraining in Human Reproduction, Geneva,Switzerland. There, she was a member ofseveral Task Forces and the Scientific andTechnology Advisory Group. She hascontinued to serve as a chairperson for theScientific Review Group since 1995.

Dr. Hagenfeldt has published over 100scientific papers in obstetrics andgynaecology, reproductive endocrinologyand medical ethics.

ABSTRACT

Antenatal care in Sweden-theimportance of midwives

This presentation will report on the Swedishtradition of having qualified midwivesresponsible for the care of healthypregnant women and for the normaldelivery. Since the 1950s GPs have seldombeen involved in the antenatal care andnever in deliveries. When the midwife needsa doctor, she needs an obstetrician.

The Swedish Medical Birth Registry, whichsince 1973 registers all births in the country,is one of the most complete registers in theworld. The basis are the nowadayscomputerised records of antenatal andobstetrical care in use for several decadesin all public and private institutions. Pretermbirth contributes to the majority of neonatalmorbidity and mortality.

Smoking and alcohol use among pregnantwomen have been identified as an issuewhere training of midwives in identifyingthose problems was used in an effort toinfluence the habits of women. The pretermbirth rate in Sweden shows a significantdecrease beginning in the mid 1980s, mostevident among singleton births atgestational age 34-36 weeks. The decreaseis evident despite an increasing contributionof multiple births due to increased use ofassisted reproductive technologies andincreasing maternal age. One importantreason for this seems to be the apparentdecrease in smoking among pregnantwomen; from 31.4% in 1983 to 11.3% in 2001;a result both of national campaigns to thewhole population but also a result of theefforts of the midwives in the antenatal carecentres. Our efforts to decrease alcohol usehave not been as successful.

Hildur Har ardóttirChief of Obstetrics and Prenatal DiagnosisUnit, Landspítala University Hospital,Iceland

Hildur Har ardóttir completed her advancestudies in Obstetrics and Gynaecology atthe University of Conneticut in 1994, and in1996, she completed her advance studiesin Fetal Medicine. She is currently a part-time teacher for the Faculty of Medicine,Collegiate Iceland. She is also the Chief ofObstetrics and Prenatal Diagnosis Unit atLandspítala University Hospital atReykjavik, Iceland.

ABSTRACT

Prenatal care in Iceland

Social/demographic background.

Iceland is an island in the North Atlanticocean with approximately 300,000inhabitants, mainly Caucasians ofNorwegian and Irish decent. For centuriesthe islanders have lived off the sea, mainlyby eating fish, fowl and their eggs and lateragricultural products such as dairy andmeat products. After the second world warthe nation rose from poverty to anextremely high degree of prosperity in ashort period of time. The national grossincome per capita is ranked 5th in theworld (2005) and the level of education ishigh and illiteracy unknown. During thepast 10 years there has been an increasein immigrants, mainly from Eastern Europeand Asia.

Birth statistics.

In Iceland there are approximately 4,100births annually and the number of birthshas been rising slowly for the past decade.The birth rate is among the highest in

Europe with an average of 2.0 births perwoman. Perinatal mortality rate (PNMR) is6/1000 deliveries after 22 weeks gestation(WHO criteria) and <3/1000 after 28 weeksgestation (old criteria, birth >28 weeks),during the years 1994-2005. PNMR istenfold higher among multiple pregnancieswith preterm deliveries being the largestfactor. Seventy five percent of all deliveriestake place at the National UniversityHospital in Reykjavík (Landspitali), wherethere is a neonatal intensive care unit(NICU). Another 800 deliveries take place atfour smaller hospitals and the remaining200 hundred deliveries take place insmaller health care facilities around thecountry. The incidence of home births islow but rising and were 43 last year. Themean birthweight is 3814g at 40 weeks andhas increased by an average of 190g since1980.

The preterm birth rate is 4.6% (average1995-2005). Percentage of low birth weightinfants, i.e. infants weighing less than2500g at birth is 4.2% (average 1995-2005).The mean age at first delivery is 26.8 yearsand the mean age at delivery for themultipara is 31.7 years.

Intervention rates. The caesarean sectionrate is currently at 18% and has beenranging from 15-18% for the past 10 years.The rate of labor induction is 11.4%. Therate of vacuum deliveries is 7% andforceps deliveries is <1%. The rate ofepisiotomies is 8.4%; 13.8% for primiparaand 5.5% for multipara.

Health care system.

There is a national health care service withprimary care for pregnant women andimmunization for infants, free of charge.Each health care unit has a primary carephysician and a midwife on staff. Ifcomplications arise the woman is referredto an obstetrician in a hospital setting.Ultrasound examination at 20 weeksgestation to screen for fetal anomalies wasintroduced in 1984 and the attendance is99%. It is an integral part of prenatal carealthough it is optional and is free of charge.It is available at eight locations around thecountry. Ultrasound examination at 12weeks with nuchal translucency

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measurement was introduced in 1999 andbiochemical markers in maternal serum(free‚ -hCG and PAPP-A) This combinedrisk assessment for fetal aneuploidycurrently has an 80% uptake. Thisexamination is the only prenatal careservice which has a charge and the cost isapproximately US$ 90. It is available at twolocations and is an optional exam.Ultrasound later in gestation is performed ifthere is a suspicion for small/large infantfor gestational age and Doppler is onlyavailable in Reykjavík.

Two thirds of the population live in thegreater Reykjavík region and have easyaccess to health care, i.e. drive less thanone hour to the nearest health care facility.This part of the population can chooseprimary care or seek private care from anobstetrician at the beginning of pregnancyand subsequently have midwifery care if norisk factors are present. One third of thepopulation lives in rural areas and hasaccess to health care by car, with drivingtime from 30 minutes to three hours.

New challenges in a rapidly changingsociety include complications related tomaternal obesity and rising rates ofimmigrants with cultural differences andsometimes lack of basic education andinability to use health care.

Smoking, alcohol and use of illicit drugsduring pregnancy. Among pregnant women20% smoke at the beginning of pregnancybut the number of those who give upsmoking during pregnancy is uncertain.Statistics are not available regarding theuse of alcohol and illicit drugs duringpregnancy.

Summary:

Prenatal care in Iceland is given primarilyby midwives and primary care physicians,with referrals for pregnancy complicationsto specialized midwives and obstetriciansin a hospital setting. There is easy accessto health care and prenatal care is free ofcharge, with the exception of fetalaneuploidy screening. The level ofeducation is high and income is high withlow poverty rates. The societal structurehas strong family ties and relatively shortdistance between family members.

Jeannette Ickovics PhDProfessor, Division of Chronic DiseaseEpidemiology, Yale School of Public Health,Yale University

Dr. Jeannette R. Ickovics is Professor ofEpidemiology and Public Health and ofPsychology at Yale University. She isDirector of Social and Behavioral Sciencesat the School of Public Health. She isDeputy Director for the Yale Center forInterdisciplinary Research on AIDS, whereshe also serves as Director ofDevelopment/Education and Training. Dr.Ickovics is also Director of the Office ofYale Community Alliance for Research andEngagement (CARE), which will beestablished in 2007 as part of the new YaleCenter for Clinical Investigation. Hercommunity-based research on women’sreproductive health is characterized bymethodological rigor and culturalsensitivity. She is the author of more than90 peer-reviewed publications. Dr. Ickovicsis the recipient of several awards, includingthe Emerging Leadership Award and theEarly Distinguished Contributions forPsychology in the Public Interest from theAmerican Psychological Association. Sheis a Fellow of the American PsychologicalAssociation, and was elected tomembership in the AmericanPsychosomatic Society and the New YorkAcademy of Medicine. Dr. Ickovics hasconsulted with the Institute of Medicine,National Institutes of Health, US PublicHealth Service, and the Centers forDisease Control and Prevention as well aswith investigators at other universitiesworldwide.

Jo-Ann Johnson MD, FRCS (C)Professor, Department of Obstetrics andGynecology, University of Calgary

Jo-Ann Johnson is Professor of Obstetricsand Gynecology at the University ofCalgary, Calgary Alberta. Her main areas ofclinical interest are in prenatal geneticscreening and diagnosis, and theultrasound diagnosis and management offetal anomalies. Her current researchinterests are in the evaluation of newultrasound and biochemical markers inearly pregnancy for prediction of adversepregnancy outcome. She is a frequentnational and international speaker, and is amember of the board of the InternationalSociety for Prenatal Diagnosis (ISPD) andas founder of the Fetal MedicineFoundation (FMF) Canada, has played a keyrole in the implementation of qualityassurance for nuchal translucencyscreening in the first trimester.

ABSTRACT

What screening tests and obstetricalinterventions affect low birthweight?

B. Anthony Armson MD, Maternal, Infantand Reproductive Health Research Unit,University of Toronto

Jo-Ann Johnson, Department ofObstetrics and Gynaecology, University ofCalgary

Late preterm birth, defined as deliverybetween 340/7 and 366/7 weeks gestation, isresponsible for 70-75% of all pretermbirths in Canada. Most of the increase inthe preterm birth rate is due to a steadyincrease in the rate of late preterm births.In fact, the rate of early preterm births (<

14

34 weeks) has remained relatively stableover the past decade. Although seriousneonatal morbidity is uncommon, latepreterm infants are at two to three foldrisk of mild to moderate morbidityincluding hypothermia, hypoglycaemia,respiratory distress, delayed lung fluidclearance, poor feeding, jaundice,infection and readmission after discharge.Since there is significant growth andmaturation of the developing brain in thefinal weeks of gestation, infants born inthe late preterm period may also be atrisk for neurodevelopmental problems andlearning disabilities.

The factors responsible for the increasein late preterm births are complex andmultifactorial. Gestational agedetermination by first trimester ultrasoundhas been associated with a decrease inpost term pregnancy rates and inincrease in late preterm birth. Practiceguidelines regarding the management ofpost term pregnancy have also tended toshift the mean gestational age of deliveryto the left resulting in higher late pretermbirth rates. The most important factorsassociated with the rise in late pretermbirths are higher multiple gestation ratessecondary to ART and obstetricalinterventions for maternal and fetalindications such as preeclampsia,diabetes, preterm prelabour rupture ofmembranes and suspected fetal growthrestriction. Concerns about maternal andfetal health identified through increasedmaternal surveillance of maternal medicalcomplications and improved monitoring offetal growth and well being usingultrasound has resulted in higher rates ofinduction and caesarean delivery in thelate preterm period. An apparent positiveconsequence of this trend has been areduction in the stillbirth rate. Delayedchildbearing, maternal obesity and fetalmacrosomia have also been associatedwith increased risk of late preterm birth.

Improvements in first trimester prenataldiagnostic tests such as sonographingearly pregnancy review and first trimestermaternal serum screening have raised thepossibilities of identifying mothers andfetuses at risk for obstetric and medical

complications prior to the manifestation ofthe condition. Mothers and fetusesidentified to be at risk of preeclampsia,gestational diabetes or fetal growthrestriction may benefit from emergingprophylactic interventions which mayimprove neonatal outcome and may evenprevent the development or exacerbationof such conditions.

REFERENCES

1. Late preterm pregnancy and the newborn. Guest Eds: Jain L,Ragu TNK. Clinics in Perinatology, December 2006; 33:4.

2. Semin Perinatol 2006:30:2-7. Elsevier Inc.

K.S. Joseph MD PhDAssociate Professor, Department ofObstetrics and Gynaecology, DalhousieUniversity

K.S. Joseph received his Bachelor ofMedicine and Surgery (MBBS) and MD(Community Medicine) degrees fromChristian Medical College, Vellore, India anda PhD in Epidemiology and Biostatisticsfrom McGill University. He works as aperinatal epidemiologist, with a jointappointment as an Associate Professor inthe Departments of Obstetrics andGynaecology, and Pediatrics at DalhousieUniversity and the IWK Health Centre,Halifax. His research interests includepregnancy complications, preterm birth,fetal growth, perinatal mortality and seriousneonatal morbidity.

Dr. Joseph is a member of the SteeringCommittee of the Canadian PerinatalSurveillance System (Public Health Agencyof Canada) and a member of the InstituteAdvisory Board, Institute for HumanDevelopment, Child and Youth Health(Canadian Institutes of Health Research). In

2002, he received the Peter Lougheed NewInvestigator Award from the CanadianInstitutes of Health Research. Morerecently, he was awarded the Geoffrey C.Robinson award of the Canadian PaediatricSociety for contributions to child and youthhealth through population health research.

ABSTRACT 1

How frequently does low birth weightoccur in Canada and the world?

The World Health Organization (ICD-10)defines low birth weight as birth weight lessthan 2,500g (up to and including 2,499g).Very low birth weight is defined as birthweight less than 1,500g, while extremely lowbirth weight refers to birth weight less than1,000 g. ICD-10 defines preterm birth as agestational duration less then 37 completedweeks (less than 259 days). Small-for-gestational age refers to estimated fetalweight or infant birth weight for gestationalage that is below the normative value of apopulation standard. The normative value istypically the 10th or 3rd percentile of birthweight for gestational age specified by thepopulation standard.

Low birth weight infants constitute aheterogenous group which include bothpreterm and small-for gestational ageinfants. Thus, a 2,000g female infant is lowbirth weight but could have delivered at 32weeks (70th percentile of birth weight forgestational age) or at 38 weeks (less than3rd percentile of birth weight for gestationalage). Such heterogeneity is importantbecause preterm and SGA births aredifferent from an etiologic and prognosticperspective. As an indicator of populationperinatal health as well, low birth weightcan be misleading; low birth weight rates inCanada did not change over the last decade(5.7% and 5.9% in 1995 and 2004,respectively), whereas rates of pretermbirth have increased (from 7.0% to 8.2%)and SGA rates have declined (from 10.1% to7.8%) over the same period. The advantagesof low birth weight as an indicator ofperinatal health include ease ofmeasurement (available for most countriesin the world) and the strong associationwith fetal and infant mortality and seriousneonatal morbidity.

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Approximately 15% of infants in the Worldare born low birth weight. Globally, about 20million low birth weight infants are bornannually, with 11 million being born in SouthAsia and four million in Sub-Saharan Africa(there are approximately 20,000 low birthweight infants born in Canada every year). Itis not clear whether the global burden of lowbirth weight is more appropriately addressedby attempting to reduce the occurrence oflow birth weight or by improving the care oflow birth weight and normal birth weightinfants. UNICEF favours the former approach,while others suggest that low birth weight isdifficult to prevent and improvements in birthweight-specific mortality are more easilyachieved.

ABSTRACT 2

How do age and factors that influencethe age of conception affect low birthweight rates?

The relationship between maternal age andpreterm birth (PTB) and small-for-gestationalage (SGA) birth appears J-shaped, with theextremes of age more likely to be associatedwith higher rates of these adverse perinataloutcomes. There is an almost ubiquitousassociation between adolescent pregnancyand crude rates of PTB and SGA. A studyfrom Utah showed a 90% increase in PTBand a 30% increase in SGA birth. There issome controversy, however, regarding thecause of the increased risk; biologicalimmaturity vs economic, social andbehavioural correlates of teen pregnancy arethe competing mechanisms proposed.

Older maternal age (35-39, >_40 years) is alsoassociated with higher rates of PTB and SGAbirth, with an clear dose-responserelationship. The mechanisms for thisrelationship include higher rates ofchromosomal abnormalities, multiple birthsand pregnancy complications (such ashypertension, diabetes, placenta previa)among older mothers. Recent advances inassisted reproduction techniques havehelped infertile older mothers conceive atlater ages but this has been accompanied byan excess of multiple births which are muchmore likely to be preterm and small-for-gestational age.

The proportion of live births to older mothers

has been increasing steadily in Canada; in2004 14.3% and 2.9% of live births were tomothers 35-39 and >_40 years of age,respectively. Age-specific rates of birth havedeclined substantially in all age categoriesover the last several decades. However, asmall increase has occurred in the last twodecades in the older age groups. Althoughwomen need to be aware of the higher risksassociated with older maternal age, thepopulation impact of older maternal age isnot extraordinary. If all mothers >_35 yearswere to have delivered at 20-24 years of age,the rate of preterm birth in Canada in 2004would have declined by <10% and the rate ofSGA would have declined by <5%.

Older paternal age is another factor that hasreceived increasing attention in recentyears. Although several studies have shownno excess risk associated with older paternalage, one recent study showed higher ratesof very preterm birth and another showed ahigher rate of low birth weight. Furtherstudies are need to ascertain if thisassociation is causal or confounded,although it is unlikely that paternal age playsa major role in the occurrence of PTB andSGA births.

Mark KlebanoffMD MPHDirector, Division of Epidemiology, Statisticsand Prevention Research, National Instituteof Child Health and Human Development

Dr. Klebanoff completed his undergraduateand medical degrees at Johns HopkinsUniversity. He did his pediatric residency atthe University of Rochester, and returned toJohns Hopkins for his MPH degree. Hejoined the Division of Epidemiology, Statisticsand Prevention Research at the National

Institute of Child Health and HumanDevelopment, NIH, as a fellow, and becamea tenured investigator in 1987. Since 1998 hehas been director of the Division. Dr.Klebanoff is board-certified in pediatrics, andis a member of the Editorial Board of theAmerican Journal of Epidemiology. He hasserved as president of the Society forPediatric and Perinatal EpidemiologicResearch, serves on numerous advisorycommittees, and is a member of the JohnsHopkins Society of Scholars, the AmericanEpidemiological Society and the Society forPediatric Research. Dr. Klebanoff’s researchinterests span a broad range of issues inmaternal and child health, with a focus onpreterm delivery and fetal growth.

ABSTRACT

17-Alphahydroxyprogesterone Caproate(17-OHPC) and Preterm Birth: ResearchFindings

From 1999-2002 the NICHD-MFMU Networkconducted a multicenter randomized clinicaltrial of weekly injections of 17-OHPC orplacebo among women with a singleton fetusand a documented prior spontaneous pretermbirth. Randomization occurred at 16-20 weeks;treatment continued until 36 weeks. The studywas terminated for benefit after 463 (310 17-OHPC, 153 Placebo) women enrolled.Treatment reduced delivery at <37 weeksfrom 54.9% to 46.3% (p=0.0001); and at <32weeks from 19.9% to 11.4% (p=0.018). Use of17-OHPC among all eligible women in the U.S.would reduce the total occurrence of pretermbirth only slightly, from 12.1% to 11.9%. In 2004the children were followed up; 80% wereenrolled at 48 months of age, when the Agesand Stages Questionnaire (ASQ), thePreschool Activities Inventory (PSAI), a healthsurvey, and a physical exam wereadministered. No significant differences wereseen between the groups in the ASQ, height,weight, head circumference blood pressure,physical anomalies nor reported healthconditions; values were as expected for age.Gender-specific play did not differ bytreatment, and was similar to expected. TheNetwork completed a trial of 17-OHPC in twingestations, where treatment did NOT reducethe occurrence of birth <35 weeks (relativerisk 1.1, CI 0.9-1.3). In summary, 17-OHPCappears to reduce the recurrence of preterm

16

birth in selected women, and has notmanifested side effects at four years, but useshould be confined to situations wherebenefit has been demonstrated byrandomized clinical trials. Benefit at thepopulation level is limited.

Michael S. Kramer MDJames McGill Professor, Departments ofPediatrics and Epidemiology and Biostatistics,McGill University; Scientific Director,Canadian Institutes of Health Research

Michael S. Kramer is James McGill Professorin the Departments of Pediatrics andEpidemiology and Biostatistics at McGillUniversity Faculty of Medicine. A formerNational Health Research Scholar andNational Health Research Scientist of HealthCanada’s National Health Research andDevelopment Program (NHRDP) andChercheur-boursier senior (senior researchscientist) of the Fonds de la recherche ensanté du Québec (FRSQ), he is currently aSenior Investigator of the Canadian Institutesof Health Research (CIHR). He has beenprincipal investigator on several large,multicentre epidemiologic studies andrandomized trials in the general area ofmaternal and child health. A member of fourexpert committees of the U.S. Institute ofMedicine, in 1997-98 he served as Presidentof the Society of Pediatric and PerinatalEpidemiologic Research. From 1995-2001, hechaired the Steering Committee of theCanadian Perinatal Surveillance System anduntil May 2003, chaired the Institute AdvisoryBoard of CIHR’s Institute of HumanDevelopment and Child and Youth Health(IHDCYH). He currently serves as IHDCYH’sScientific Director. He has received operatinggrant support from the Medical Research

Council (now CIHR) of Canada, NHRDP, NIH,FRSQ, and the March of Dimes.

Dr. Kramer has authored or co-authored 20books and monographs, and has publishedover 250 original articles. His recentsystematic review of the evidence on theoptimal duration of exclusive breastfeedingled directly to new infant feedingrecommendations by WHO and the WorldHealth Assembly. His current principal areasof research are the causes and prevention ofpreterm birth and intrauterine growthrestriction, the determinants of fetal andinfant mortality, and the health effects ofbreastfeeding.

Penny Lightfoot Director, Population Health and Research,Capital Health

Penny Lightfoot is Director of PopulationHealth and Research within the CapitalHealth region. She is responsible forassessment of the population’s health andselected policy development. Her healthfield experience spans over 25 years andincludes clinical practice and research, witha focus on public health and policydevelopment.

Dr. Brian McCarthy MD MSc CAPT USPHS (Ret)Senior Service Fellow, WHO CollaboratingCenter in Reproductive Health; Office of theDirector, Division of Reproductive Health,National Center for Chronic DiseasePrevention and Health Promotion, NationalCenters for Disease Control and Prevention

Brian McCarthy is the Supervisory MedicalOfficer of the World Health Organization(WHO) Collaborating Centre inReproductive Health, National Center for

Chronic Disease Prevention and HealthPromotion. He has held the title of PrincipalInvestigator of the Office of the Director inthis division since August of 1990,previously acting as Chief from 1987 to1990. He also is Clinical AssociateProfessor of the Department of Pediatricsin the School of Medicine and the Divisionof International Health in the Rollins Schoolof Public Health at Emory University,Georgia.

Dr. McCarthy has worked with the Centersfor Disease Control (CDC) and the WHO inEpidemiology for over 30 years, firststarting with the Family Planning andEvaluation Division of CDC, and movingthrough the Maternal-Child Health Unit, andBirth Defects Branch, before starting in theDivision of Reproductive Health in 1986.

He completed his MD at the StateUniversity of New York in 1973, where healso undertook his residency in Pediatrics.Dr. McCarthy has been widely published innumerous Medical Journals, and hascontributed to various WHO Reports,Textbooks, and Position Papers. He wasawarded the Outstanding Service Medal in1999.

Merry-K MoosBSN FNP MPH FAANProfessor, Department of Obstetrics andGynecology, University of North Carolina

Merry-K. Moos is a Professor in theDepartment of Obstetrics and Gynecology,and Adjunct Professor in both the School ofPublic Health and the School of Nursing atthe University of North Carolina at ChapelHill. Ms. Moos is also director of theWomen’s Health Information Center at UNCHospitals in Chapel Hill. She is a

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researcher, author and clinician who isnationally and internationally recognized forher expertise in prenatal services,adolescent pregnancy and prevention,preconceptional health promotion and theorganization of well woman services. Sheand her colleague, Robert Cefalo, wrote thefirst book on preconceptional health in theUS in 1988; the book was revised in 1995and has served as a platform for change inthe delivery of reproductive health care. Inthe 1990s she consulted frequently withprovincial governments of Canada oncreating a service model in Canada. In 2005,Ms. Moos was appointed as an initialmember of the CDC Select Panel onPreconceptional Health and she is currentlyserving as chair of the Panel’ssubcommittee to create a nationalcurriculum on preconceptional health forhealth care providers of many disciplines.

Ms. Moos’ current research andprogrammatic interests center aroundintendedness of pregnancy, implementationof interconceptional care services andreframing women’s wellness care into acontinuum model of preventive services.Clinically, Ms. Moos has been an advancedpractice nurse (FNP) for more than 30years. She directs the University of NorthCarolina Hospitals’ Teenage Pregnancy andPrevention Clinic, provides services in alocal health department and overseescoordination of obstetrical servicesbetween seventeen public clinics and theUniversity of North Carolina’s Department ofObstetrics and Gynecology.

ABSTRACT

What Do Women and Providers Need toKnow to Prevent Preterm Birth?

The perinatal prevention paradigm traditionallystarts with the first prenatal visit, increases inintensity until the delivery of the infant andthen abruptly ends with little consideration ofcontinuing health concerns for the woman orfor future reproductive outcomes. However, inobstetrics most of our outcomes aredetermined before we ever meet our patients.By reframing the prevention paradigm to use awoman’s wellness perspective as thefoundation, the opportunity exists to impactwomen’s’ health through the lifespan, the

health of their pregnancies, should theybecome pregnant, and the health of the nextgeneration. By changing the focus of care toone which puts the life course perspective firstwe will achieve preconceptional healthpromotion for those women who becomepregnant. Making this change a reality willrequire reaching generations of women withinformation about the importance ofpreventing poor pregnancy outcomes beforeconception; reaching providers withcontinuing education about what we know andwhat we don’t know about the impact andprocesses of preconceptional healthpromotion; providing time efficient strategiesto reach every woman, every time she has ahealth care visit; and assuring affordable,accessible, targeted services for womenknown to have risks amenable to intensivepreconceptional care.

Patricia O’Campo PhDDirector, Centre for Research on Inner CityHealth, St. Michael’s Hospital

Patricia O’Campo is a social epidemiologist.She has been conducting research on thesocial determinants of health and well-beingamong women and children for over 17years. She pioneered the application ofmultilevel modeling in the field of maternaland child health in the early 1990s tounderstand the effects of urban residentialneighborhoods on the risk of intimate partnerviolence during the child bearing year and onlow birth weight. She has conducted anumber of clinic and community basedevaluations of programs concerning smokingcessation, prevention of perinataltransmission of HIV, and prevention of infantmortality. She has also focused on methods

development as part of her researchincluding application of multilevel modelingto understand residential and workplacecontexts on health and development ofmonitoring methods for rare health events insmall areas.

ABSTRACT

How do residential neighbourhoodsincrease the risk for adverse pregnancyoutcome? A review of the evidence.

This session will examine the relationship ofresidential neighbourhood factors in itsrelationship to adverse birth outcomes, witha focus on low birth weight. The evidencefor this association will be examined alongwith a discussion of the methodologicalstrengths and challenges of this area ofresearch

Arne OhlssonMD MSc FRCPC FAAPDirector, Evidence-Based Neonatal Care andOutcomes, Mount Sinai Hospital

Arne Ohlsson received his MD from theUniversity of Uppsala, Sweden. He qualifiedas a specialist in Paediatrics, and in Childand Youth Psychiatry in Sweden, beforeundertaking subspecialty training inNeonatology at the Karolinska Hospital inStockholm, Sweden and at the Hospital forSick Children Toronto, Canada. He workedas a Consultant Paediatrician andNeonatologist at the King Faisal SpecialistHospital and Research Centre, in Riyad,Saudi Arabia for five years. He received hisMaster of Science degree in ClinicalEpidemiology from McMaster University in1990. In 1998 he took up the position asDirector Evidence Based Neonatal Care andOutcomes Research, Division of

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Neonatology, Department of Paediatrics,University of Toronto, Department ofPaediatrics, Mount Sinai Hospital. The sameyear he became the Director of theCanadian Cochrane Network and Centreand served as such until 2005.

Areas of research include systematicreviews/meta-analysis, interventions toprevent adverse perinatal outcomes,diagnostic tests and prevention andmanagement of pain and stress in thenewborn. He currently serves on theSteering committees for the CanadianPerinatal Surveillance System and theCanadian Neonatal Network, and severalCIHR funded multicentre randomizedcontrolled trials in perinatal (obstetric orneonatal) medicine. He is a member of theBoard of Directors of the Canadian Instituteof Child Health.

He is Professor, Departments of Paediatrics,Obstetrics and Gynaecology, and HealthPolicy, Management and Evaluation,University of Toronto, Canada. He is ActiveStaff Neonatologist; Mount Sinai Hospital,Hospital for Sick Children, and ConsultantStaff Sunnybrook & Women’s College HealthSciences Centre, Toronto.

He has published more than 230 peer-reviewed papers as principal author or co-author in high impact general medicaljournals and specialty paediatric andobstetric journals.

He has served as an Editor of PediatricResearch and as a Member of the CanadianInstitutes of Research Clinical TrialsCommittee.

In 2003 he was presented with theDistinguished Neonatologist Award from theNeonatal/Perinatal Medicine Section of theCanadian Paediatric Society.

ABSTRACT

What strategies are known to work toreduce low birth weight?

A. Interventions/strategies with strong /moderate evidence of effectiveness

1. Modification of life style

a. Smoking cessation and relapseprevention as a routine component ofprenatal care, particularly

interventions that include intensivecounseling, multiple contacts,provision of supportive material andfollow up.

2. Prevention or treatment of infections

a. Treatment of infection (urinary tractinfection, syphilis, gonorrhea)

b. Screening mothers with previoushistory of preterm/LBW births forinfection

c. Antibiotic for preterm labor withrupture of membranes

3. Maternal nutrition

4. Promotion of balanced nutritious diet forall pregnant women. Provision ofnutritious food to mothers identified ashaving limited resources to meet thedemands of pregnancy may bebeneficial.

5. Treatment of maternal general medicalconditions

6. Treatment of pregnancy associatedconditions

7. Reducing multiple births following in-vitro fertilization or artificialreproductive technologies

8. Tocolytics for inhibition of threatenedpreterm labor

a. Betamimetics for inhibition ofthreatened preterm labor

b. Calcium channel blockers forinhibition of threatened preterm labor

c. Progestational agents for inhibition ofthreatened preterm labor

9. Antiplatelet agent administration tomother to improve fetal growth

B. Interventions/strategies with probableevidence of effectiveness

1. Adolescent pregnancy

a. Measures to reduce adolescentpregnancy

b. Early enrollment of pregnantadolescents in prenatal programs

c. Home visiting and psychosocialsupport to pregnant adolescents

2. Promotion of adequate weight gainduring pregnancy*

3. Improvement in maternal nutrition

a. Promotion of optimal nutrition duringthe preconceptional period*

b. Nutritional advice to mother

c. Balanced energy and protein intake

d. Iron supplementation

e. Folic acid supplementation+

f. Calcium supplementation

g. Magnesium supplementation

h. Zinc supplementation

i. Multiple micronutrientssupplementation

j. Fish oil supplementation

4. Treatment of infection

a. Treatment of bacterial vaginosis

b. Antibiotics in 2nd or 3rd trimester toall woman

c. Treatment of HIV

d. Treatment / prevention of Influenza

5. Maternal life style related factors

a. Measures to reduce alcohol exposure

b. Treatment of substance / narcotic use

6. Improvement in occupational conditions

7. Prenatal care

a. Provision of antenatal care whichprovides an opportunity for individualassessment as well as diagnosis andappropriate management of maternalmedical conditions

b. Improved content of prenatal care

c. Multicomponent preterm birthprevention programs

8. Provision of psychosocial support tohigh risk women experiencing chronicstress*

9. Legislation regarding regulation ofartificial reproductive technologies

10. Early detection of preterm labor

a. Generic education of all pregnantwomen for signs symptoms ofpreterm labor

b. Identification by ultrasound markersof preterm labor

c. Home uterine activity monitoring

11. Cervical cerclage for inhibition ofthreatened preterm labor

12. Antioxidant – lycopene administration tomother to improve fetal growth

13. Maternal transport to tertiary carecenters for threatened preterm labor

*Research regarding the effectiveness of specific strategies isrequired

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Nancy PooleResearch Associate, British ColumbiaCentre of Excellence for Women’s Health;Research Consultant, Women & SubstanceUse Issues, BC Women’s Hospital,Vancouver

Nancy Poole has over twenty yearsexperience in research, policy and practicerelating to prevention, treatment and harmreduction with women with substance useproblems. She is a Research Associate withthe British Columbia Centre of Excellence forWomen’s Health and a doctoral student withthe University of South Australia studyingvirtual knowledge translation on women’shealth and substance use. She has a CIHRfellowship with the IMPART program, atraining program in Gender, Women andAddictions. Ms. Poole also acts as aprovincial consultant on women’s substanceuse issues with BC Women’s Hospital. She isinvolved with research teams undertakingpolicy relevant research related to women’ssubstance use, facilitates national ‘virtuallearning communities’ on women andsubstance use issues, and collaborates onaddictions policy, service design andresearch with governments andorganizations across Canada. In addition sheis currently leading province wideprofessional education on reducing harmsassociated with alcohol and tobacco use inpregnancy, associated with the BCgovernmental platform entitled ActNow BC -Healthy Choices in Pregnancy.

ABSTRACT

How do alcohol, tobacco and othersubstance use, as well as relatedhealth determinants such asexperience of violence and povertyaffect low birth weight rates?

Substance use before, and duringpregnancy can affect low birth weight.Often the impact of substance use onwomen’s and fetal health is considered inisolation from important linkeddeterminants of health such as women’sexperience of violence and poverty, as wellas key related influences such as thestigma directed to mothers who usesubstances and mothering/child welfarepolicies. This presentation will offer acontextualized view of the impact ofwomen’s substance use on low birthweight, from recent literature and researchdone in several service settings inVancouver: a pregnancy outreach programin Vancouver’s poorest neighbourhood andBC Women’s Hospital’s specialized FirSquare Combined Care Unit.

Reg SauveMD FRCPCProfessor, Departments of CommunityHealth Sciences and Paediatrics,University of Calgary

Reg Sauve is a professor of Paediatricsand Community Health Sciences. Hisclinical work focuses on neonatology,which he practices at the Foothills HospitalNeonatal Intensive Care Unit andRockyview Hospital Special Care Nurseryalong with follow-up care at the AlbertaChildren’s Hospital. He is the AcademicHead, Division of Neonatology, andDirector of the Perinatal Follow-upprogram.

Dr. Sauve’s own research interests focuson Neonatal Epidemiology and Follow-upand Perinatal Surveillance. He is currentlyseconded on a part time basis to the

Maternal Infant Health Section, PublicHealth Agency of Canada, where he chairsthe Canadian Perinatal SurveillanceSystem and provides consultationregarding research and related projectsaffecting mothers and infants. Dr. Sauvealso co-chairs the recently formed AlbertaPerinatal Program at Alberta Health andWellness.

His most satisfying professionalaccomplishments have come from beingable to link together his clinical, education,administrative and research interests inmothers and infants.

ABSTRACT

What are the health effects of lowbirth weight

This session will review the health effectsof low birth weight, focusing on effectsexperienced by the baby during earlyinfancy and childhood. The topicscovered will be:

• The basis of adverse outcomes in lowbirth weight/preterm infants

• Life line approach to understanding thepathophysiology of adverse effects oninfants’ and childrens’ health

• Burden of disease due to low birthweight/preterm birth

• Mortality

• Associated with mild to moderateprematurity

• Mild to moderate prematurity and itsmanagement

• Population vs individual effects

• Associated with extreme prematurityand low birth weight

• Infants at the edge of viability

• Morbidity

• General health and influencing factors

• Growth

• Growth of AGA and SGA preterminfants

• Respiratory illnesses

• Chronic lung disease of prematurity

• Risk of “pulmonary normalcy” inpreterm infants

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• Developmental issues

• Severe vs mild to moderate impairments

• Functional vs diagnosis-basedapproaches

• Learning abilities

• Learning difficulties in non-disabled lowbirth weight infants

Donald Schopflocher PhDDirector of Research, Institute of HealthEconomics

Don Schopflocher was trained as aresearch Psychologist, obtaining his PhDin psychological measurement from theUniversity of Alberta.

Dr. Schopflocher has worked as abiostatistician for the Health SurveillanceBranch, Alberta Health and Wellnesssince 1995. He sat on the PopulationHealth Surveys Advisory Committee forStatistics Canada, and managed healthsurvey data analysis and disseminationfor Alberta Health and Wellness. He alsoanalyzed large administrative datasets forSurveillance purposes.

Dr. Schopflocher is active in academicresearch and teaching. He is an adjunctassociate professor in the School ofPublic Health at the University of Alberta,and in the Department of CommunityHealth Sciences at the University ofCalgary where he team teaches agraduate course in Public HealthSurveillance.

This year, Dr. Schopflocher has beenseconded 0.8 to the Institute of HealthEconomics where he is Director ofResearch.

Prakeshkumar Shah MBBS DCH MRCP MRCPCHAssistant Professor, Departments ofPaediatrics and Health Policy, Managementand Evaluation, University of Toronto; StaffNeonatologist, Department of Paediatrics,Mount Sinai Hospital

Prakesh Shah is a Staff Neonatologist andEpidemiologist at Mount Sinai Hospital,Toronto. He is an Assistant Professor in theDepartments of Paediatrics and HealthPolicy, Management and Evaluation at theUniversity of Toronto. He completed hismedical training in India, postgraduatetraining in India and UK followed byfellowship in Neonatal Perinatal Medicineat University of Toronto hospitals. Duringthe fellowship, he also completed MSc inClinical Epidemiology at the University ofToronto and currently teaches in theClinical Epidemiology Program at theUniversity of Toronto. His researchinterests are knowledge synthesis, birthasphyxia, clinical trials in neonates andreview of changes in practice and theirimpact on neonatal and post neonataloutcomes.

ABSTRACT

Low birth weight (LBW) is considered apublic health priority due to itsassociation with higher mortality andmorbidities that include adult-onsetdisorders such as hypertension, ischemicheart disease, stroke, metabolicsyndrome, diabetes, malignancies,osteoarthritis, and dementia. Pretermbirth (PTB) is of significant public healthimportance because of its associationwith an increase in mortality andchildhood morbidities such asdevelopmental problems, cerebral palsy,

cognitive delay and learning difficulties,blindness, deafness and an increased riskof sudden infant death. Fetal growthrestriction (FGR, variably termed SGA orintrauterine growth restriction - IUGR),status at birth has been shown to beassociated with lower educational level,lower socioeconomic functioning leveland more frequent reported mooddisorders in childhood.

Several factors are implicated to beassociated with LBW/PTB/FGR. Broadcategories include, and not limited to,maternal, paternal, fetal, societal,environmental, life style related,infectious, nutritional, genetic, andpsychosocial factors. Maternal factorsinclude maternal age, parity, birth interval,previous induced abortion, previoushistory of preterm birth, her own LBWstatus, race/ethnicity, aboriginal status,acculturation, marital status, pre-pregnancy height, body mass index,gestational weight gain, history ofinfertility and subsequent in-vitrofertilization, medical conditions andpregnancy associated conditions such ashypertension and diabetes. Paternalfactors include paternal birth weight, age,family history, and certain occupations.Fetal factors include fetal sex and fetalgenetic factors. Societal factors includesocio-economic status, types ofoccupation, occupational conditions,violence, trauma, and events that maylead to acute stress. Environmentalfactors include air and water pollution,pesticide exposure, noise, and seasonalinfluence. Life style related factorsinclude use of nicotine, alcohol, caffeine,cocaine, narcotics, other addictivesubstances, herbal and alternativemedicines, and exercise or lack there of.Infectious causes include infections withmany organisms such as aerobic oranaerobic bacteria, viruses, spirochetes,and chlamydia. Nutritional causes includedeficiencies of iron, folic acid, zinc,calcium, magnesium, and multivitamins.Genetic factors include specificsyndromes, in addition to continuallyexpanding array of genetic defects thatare identified to be associated withPTB/LBW. Psychosocial factors include

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acute and chronic stress, neighborhoodconditions and disadvantaged situationsor states. Additionally, anatomical factorssuch as uterine abnormalities andfunctional causes such as placentalfactors are implicated. These factors aresuspected as determinants ofLBW/PTB/FGR. However, various studieshave yielded differing results withreference to these determinants and theirassociation with LBW/PTB/FGR.

Suzanne ToughMSc PhDAssociate Professor, Paediatrics &Community Health Sciences, Medicine,University of Calgary; Scientific Director,Alberta Centre for Child, Family andCommunity Research

Suzanne Tough is an Associate Professorwith the Departments of Paediatrics andCommunity Health Sciences in the Facultyof Medicine at the University of Calgaryand is a Population Health Investigatorcurrently funded by Alberta HeritageFoundation for Medical Research. She isalso an Associate Director of the Instituteof Maternal and Child Health (University ofCalgary/Calgary Health Region) and theScientific Director of the Alberta Centre forChild, Family and Community Research, anorganization whose vision is to improvechild, family and community well-beingthrough applied research.

Dr. Tough’s research program focuses onthe health and well being of mothers andinfants prior to conception through infancy.Specifically, she has research interests inthe area of maternal and child health,preconception and prenatal care, low birthweight and preterm birth, delayed

childbearing, and fetal alcohol spectrumdisorders. The underlying aim of Dr. Tough’sresearch program is to create evidencethat informs the development of communityand clinical programs and influences policyto optimize birth and childhood outcomes.

ABSTRACT 1

How Frequent is Low Birth Weight inAlberta?

In 2005, the low birth weight rate was 6.6%in Alberta, which is higher than the nationalrate. The national rate of low birth weightwas 5.9% in 2004. Low birth weight rates inAlberta have increased since 1990. Thistalk will include information on thefrequency of low birth weight amongvarious regions and populations in Alberta,highlighting the need to understand factorsthat contribute to low birth weight.

ABSTRACT 2

How Do Factors that Influence the Age ofConception Affect Low Birth WeightRates?

An increasing number of women arehaving children over the age of 35, which isa significant factor affecting the low birthrate in Alberta. This talk will includeinformation on what influences the timingof childbearing for both men and women,what they know about the risks ofchildbearing at different ages, and whatstrategies may increase public knowledgeabout healthy reproduction. This data wasgathered from over 2000 Alberta men andwomen.

Stephen WoodMDAssociate Professor, Department ofObstetrics and Gynaecology, University ofCalgary

Stephen Wood is an Associate Professorin the Departments of Obstetrics andGynecology and Community HealthSciences. He received his medicaltraining at the Queen’s University, andperformed his residency at the Universityof Calgary. Dr. Wood has also completeda MSc in Epidemiology from theUniversity of Calgary.

PANEL CHAIR

Shoo Lee MD PhDScientific Director, Integrated Centre forCare Advancement through Research(iCARE), Capital Health

In September 2005, Shoo Lee wasappointed as the inaugural ScientificDirector for the Integrated Centre for CareAdvancement through Research (iCARE), ajoint venture of the University of Albertaand Capital Health. At iCARE, Dr. Lee leadsthe effort to advance the paradigm inhealth research through an integratedorganizational approach that includesimplementation, evaluation, and feedback.Dr. Lee is also a Professor of Pediatrics atthe University of Alberta and holds theCanada Research Chair (Tier I) inKnowledge Translation and HealthcareImprovement.

Dr. Lee was recruited from the University ofBritish Columbia where he was AssociateProfessor of Pediatrics, Faculty ofMedicine and served as Director of theCentre for Healthcare Innovation andImprovement (CHIi), Child and FamilyResearch Institute. While in Vancouver, theneonatologist and health economist wasthe recipient of the Aventis PasteurResearch Award from the CanadianPediatric Society. With interests thatinclude neonatal-perinatal care, healtheconomics, health services research, andquality improvement, Dr. Lee founded theCanadian Neonatal Network in 1995 todevelop models for quality improvementand to guide health policy in CanadianNICUs. The Network received theKnowledge Translation Award from CIHR in2004. He also founded the InternationalNeonatal Collaboration and the Neonatal-Perinatal Interdisciplinary Capacity

Enhancement Team to supportcollaborative research aimed at improvingneonatal-perinatal care.

Dr. Lee received his medical degree fromthe University of Singapore and completedhis residency in Newfoundland. Aftercompleting his neonatal fellowship trainingat Boston’s Children’s Hospital, Dr. Leeearned his PhD in Health Policy(Economics) at Harvard University.

PANEL MEMBERS

Tracey BaileyBA LLBExecutive Director, Health Law Institute,University of Alberta

Tracey Bailey was appointed ExecutiveDirector of the Health Law Institute at theUniversity of Alberta in July 2003. Prior tothat, she was the Institute’s ProjectManager. Ms. Bailey graduated from theFaculty of Law, University of Alberta in1991. She practiced with the firm nowknown as Fraser Milner Casgrain LLP in thearea of health law until 1997, andsubsequently worked as a legal instructorprior to joining the HLI in May 2001.

Ms. Bailey is actively involved in theeducation component of the HLI, includingcoordinating workshops and conferences,teaching in a number of health professionalfaculties at the University of Alberta,presenting at conferences, and providingoutreach education to health careprofessionals and members of the public.In addition, she is currently an AssistantAdjunct Professor with the John DossetorHealth Ethics Centre at the University ofAlberta; an Assistant Adjunct Professor inthe Postgraduate Medical Education Office,Faculty of Medicine and Dentistry; and a

sessional lecturer in the Faculty of Law.Other activities include research, bothcontract and grant funded, to assistagencies in policy making. She is editor ofthe Health Law Journal and the Health LawReview. Ms. Bailey is currently a memberof the Capital Region Health EthicsCoordinating Council, the Capital CareGroup Ethics Committee, the GlenroseHealth Ethics Committee and the HealthResearch Ethics Board Panel B (for theUniversity of Alberta, Capital HealthAuthority and Caritas). She is the Chair ofthe National Canadian Bar Association(CBA) Health Law section and a former Co-Chair of the Northern Alberta CBA HealthLaw section. Ms. Bailey has also served inthe past on the Edmonton Regional MentalHealth Planning Committee.

Radha ChariMDPerinatologist and Associate Professor,Faculty of Medicine and Dentistry,University of Alberta

Radha Chari attained her MD withDistinction in 1988 at the University ofSaskatchewan, and completed herresidency at the University of Alberta,where she is now an Associate Professorof Obstetrics and Gynecology and theDivision Director of Maternal-FetalMedicine. She also completed asubspecialty fellowship at the University ofTennessee in Memphis in 1995.

Dr. Chari acted as the Residency ProgramDirector of Obstetrics and Gynecology atthe University of Alberta from 1997 to 2001,and was on the Examination Board of theRoyal College of Physicians and SurgeonsObstetrics and Gynecology from 2000 to2005.

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PanelMembers

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Her clinical interests include Hypertensionin Pregnancy, Preterm PROM, PretermDelivery, and Prenatal Screening andDiagnosis. Currently, her research isfocused on Preterm Premature Rupture ofthe Membranes, Preterm Delivery/ FetalFibronectin, Maternal Serum Screen andthe High Risk Pregnancy, and Trauma inPregnancy.

Gillian CurrieAssistant Professor of Health Economics,University of Calgary

Gillian Currie is an Assistant Professor inthe Department of Paediatrics at theUniversity of Calgary, and is also crossappointed in the Department of CommunityHealth Sciences. She is a member of theInstitute of Maternal and Child Health atthe University of Calgary, and is also aResearch Fellow with the Institute ofHealth Economics. She received a PhD inEconomics from Yale University in 1998 andhas been doing research in healtheconomics at the University of Calgarysince that time. Her research has beenfunded by the Canadian Institutes of HealthResearch, the Alberta Heritage Foundationfor Medical Research, the CanadianDiabetes Association, and the Institute ofHealth Economics.

Dr. Currie’s research focus is in economicevaluation of health and health care, with aprimary methodological interest in statedpreference methods for assessing benefitsof health interventions.

Don DavisMDPresident, Society of Obstetricians andGynaecologists of Canada

Donald Davis is the 63rd President of theSociety of Obstetricians andGynaecologists of Canada (SOGC). Dr. Davis is an Assistant Clinical Professorin the Department of Obstetrics andGynaecology at the University of Calgary.He is also a practicingobstetrician/gynaecologist in his hometownof Medicine Hat, Alberta, where he hasbeen providing care at Medicine Hat’sMedical Arts Centre and the Medicine HatRegional Hospital since 1978.

Dr. Davis received his medical degree fromthe University of Alberta in 1973 and

completed his residency training inObstetrics and Gynaecology at LouisianaState University and at Edmonton’sUniversity Hospital from 1974 to 1978.

Dr. Davis has a long standing record ofservice with the Society of Obstetriciansand Gynaecologists of Canada, as well aswith provincial and national healthassociations. A member of the SOGC since1979, Dr. Davis served as the SOGCcouncil’s Western Region Representativefrom 1991 to 1997, Western Chair from 1992to 1995, and as a member of the Society’sMedicolegal Committee. In addition to hismany professional and time commitments,Dr. Davis also sits on the Board of Directorsof the Family YMCA in Medicine Hat.

Sandra de la Ronde MDCalgary Urban Project Society MaternalChild Clinic

Sandra de la Ronde works as anobstetrician for the women’s health programof the Calgary Urban Project Society (CUPS).This is a place for socially disadvantagedwomen to access obstetric andgynaecological care. These women includeaboriginal women who cannot access familyphysician services in their rural communityoutside of Calgary, women from drugdependency programs, sex trade workersand homeless women. Under her guidanceand leadership, the existing program ofperinatal care has grown to include aWomen’s Health Program. She has alsobeen a model for collaborative care, workingwith a nurse practitioner, a licencedpractical nurse and a social worker. Theyhave developed an innovative way ofencouraging women to reach for followupcare for themselves and their infants.

Catherine FordAuthor/Commentator

Catherine Ford retired in 2004 from her dayjob as an opinion columnist for the CalgaryHerald. Her thrice-weekly columnsappeared in newspapers across Canada,including the Vancouver Sun, MontrealGazette, Edmonton Journal, Windsor Starand, of course, the Calgary Herald. Shewas raised and educated in Calgary andEdmonton and attended the University ofAlberta majoring in English.

In her 40-year career as a journalist, Ms.Ford was Associate Editor of the CalgaryHerald for eight years and prior to that, thepaper’s editorial-page columnist. She was inthe newspaper business all her working life,joining the Herald as a reporter in 1964. Shehas worked on newspapers across Canadaand has returned to Calgary on threeseparate occasions.

Ms. Ford was awarded a SouthamFellowship for study at the University ofToronto and subsequently worked forSoutham News as the OntarioCorrespondent, based in Toronto. She is thewinner of ten Western Ontario NewspaperAwards, including the Joan May Trophy forcolumnists; is a National Media Awardwinner for the Canadian Association for theAdvancement for Women and Sports andholds an International Fire Fighters’ mediaaward. She was honoured by the Albertabranch of the Canadian Bar Association withits media award in 2000; was namedrecipient of the Freedom of ExpressionAward in 2006, and holds an Association ofOpinion Page Editors gold award. She is afrequent television and radio commentatorand has written monthly columns for EnRoute magazine, Calgary Magazine andApple. In November 2006, she was presentedwith the annual Bob Edwards Award.

Her non-fiction book, Against The Grain:AnIrreverent View of Alberta was published inhard cover in 2005 to acclaim and a positionon the best-seller lists. She is also acontributor to What Is A Canadian?published in 2006 by McClelland & Stewart.

Ms. Ford is a past president of MensaCanada, a former member of the board ofdirectors of the National Conference ofEditorial Writers, and a member of the boardof directors for Media Magazine, publishedby the Canadian Association of Journalists.In 2005, she was awarded an honourarydoctorate from the University of Calgary andin 2006 taught a course on mass media andCanadian culture at the U of C. She willreturn to the U of C in 2007.

Maureen HeamanRN PhDAssociate Professor and Associate Dean,Faculty of Nursing, University of Manitoba

Maureen Heaman is an AssociateProfessor and Associate Dean of

Research in the Faculty of Nursing at theUniversity of Manitoba, with cross-appointments in the Department ofObstetrics, Gynecology and ReproductiveSciences and the Department ofCommunity Health Sciences, Faculty ofMedicine. She obtained her Bachelor ofNursing and Master of Nursing from theUniversity of Manitoba, and completed herPhD in the Individual InterdisciplinaryProgram in 2001. Dr. Heaman is therecipient of a New Investigator awardfrom the Canadian Institutes of HealthResearch (CIHR) (2003-2008). Dr. Heamanholds Research Associate appointmentswith the Manitoba Centre for Health Policyat the University of Manitoba and thePerinatal Research Centre at theUniversity of Alberta, an AdjunctAssociate Professor appointment with theFaculty of Nursing at the University ofAlberta, and a Scientist appointment withthe Manitoba Institute of Child Health. Herresearch interests include perinatalepidemiology, risk factors for pretermbirth, utilization and quality of prenatalcare, and psychosocial and behavioralaspects of pregnancy.

Dr. Heaman is an editorial board memberfor Journal of Obstetrics and GynaecologyCanada and MCN The American Journalof Maternal Child Nursing, and a reviewerfor other scientific journals. She serves onthe Maternal Health Study Group and theMaternity Experiences Study Group for theCanadian Perinatal Surveillance System(CPSS) of the Public Health Agency ofCanada. Dr. Heaman is a member of theInstitute Advisory Board for the CIHRInstitute of Human Development, Child andYouth Health. In 2007, she was therecipient of the University of Manitoba RhAward for Outstanding Contributions toScholarship and Research in theInterdisciplinary category.

Thierry LacazeMD PhD FRCPCNeonatologist, Department of Paediatrics,University of Alberta

Thierry Lacaze grew up in France andobtained his medical degree from ReneDescartes University in Paris. Followinghis Pediatric residency, Dr. Lacazeobtained a PhD in Developmental Biology.He then joined the University Paris-Sud to

complete a fellowship in Neonatology. Hewas appointed Professor in Pediatrics atthe same University in 1997.

Dr. Lacaze is now staff Neonatologist atthe Royal Alexandra Hospital and isDirector of Research in the Department ofPediatrics. His main research interests areprematurity-related diseases and long-term consequences, lung development,pulmonary surfactant, and newborn braininjury.

Taunya Madge Parent, Preterm Quads

In July 2001 my husband Rob and I hadjust found out we were pregnant. Wewere very excited and surprised becausewe had just started trying. When we wentfor our first prenatal exam, our Doctorsuggested that I was a bit big for dates.Thinking that maybe we were going tohave twins was a very excited thought butnothing could prepare us for whathappened next.

We were scheduled for an early ultra-sound and both my husband and myselfwent to the appointment already knowingin our hearts we were having more thanone baby. The ultra sound technician tookquite awhile – checking things out beforeshe said, “We better bring your husbandin.” When Rob was seated comfortablyshe said, “Would you like me to show youyour four babies?” We could not believeour eyes or ears.

We then were referred to many specialistand support groups to help us prepare forthe arrival of the Madge Boys. We knewthat the boys would be born earlier thanfull term but never thought for a momentthat we would have any difficulty bringingin all four boys happy and healthy. It was3:00 am when I woke to a terrible pain inmy back and strong feeling of pressure. Iwoke Rob, and we went off for thehospital.

The news was heart wrenching. We werein labour and there was no stopping it. Wewere just 24 weeks along and now wewere going to deliver the boys. I beggedthe doctor to make the labour stop butthere was nothing more he could do. Allfour boys were delivered, put onrespirators and whisked off to the NICU.Baby A (as he was referred to) was

Wesley at 1 lb 1oz, Baby B was Justin at1lb 7 oz, Baby C was Matthew at 1lb 11 ozand Baby D was Avery at 1lb 1oz. Thedays that followed were such a blur. Theboys were very sick and fighting for theirlittle lives.

The odds were not great and all we coulddo as parents was hope and pray andsurround our children with love. At 10 daysold, Wesley had a massive lung insult forwhich there was no recovery. At 24 daysold, Justin’s lungs could take no morepressure from the ventilator and we had tolet him go. There is no pain like watchingyour very sick children suffer, except forthe pain of losing them. Matthew andAvery continued to fight. Lots and lots ofups and downs. PDA surgery, ROPsurgery, hernia surgery to name a few. I remember making note of every gain andevery loss in my journal each day as theycontinued to grow and thrive. 111 dayslater we were going home with our twolittle miracles.

Now they are vivacious, out going, active,inquisitive little four year olds. Matthewand Avery have been attending Renfrewsince September 2005 and we can’tbelieve where the time has gone. If wehave one message to all parents of babiesin the NICU and SCU it is this… try not tothink about tomorrow, focus your energyon today, and if you do, you will find thelittle miracles that are all around you.

Rory NorthCFAChief Operating Officer and PortfolioManager, North Growth Management

Rory North is a 37 year old father of threeboys. The oldest child, was born at 25weeks, weighing 625 grams and spent fivemonths in hospital. The middle child wasborn at 34 weeks, weighing 1870 gramsand spent three weeks in hospital. Theyoungest child was born at 37 weeks,weighing 2410 grams and spent no time inhospital.

Mr. North is the Lead Portfolio Managerand Chief Operating Officer at NorthGrowth Management Ltd, a Vancouverbased mutual fund company focused onUS equities. He is also a director of theNorth Growth Foundation, a small privatefoundation focused on hard to fund

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environmental and social issues. Rory’sprevious experience was in investmentbanking in Canada and equity research inAsia.

Lesley PauletteRegistered Midwife with the Fort SmithHealth and Social Services AuthorityFort Smith, Northwest Territories

Lesley Paulette works as a registeredmidwife in the small rural community ofFort Smith on the border of Alberta and theNorthwest Territories, where she has livedfor twenty-five years. Of Mohawk descent,she is a member of the Smith’s LandingFirst Nation.

She has helped to return birthing servicesto the community of Fort Smith and toensure the recognition of midwifery as aregulated health profession in the NWT.Her participation in the design andimplementation of a PHCTF project hasresulted in the integration of midwiferyservices into the core programming of theFort Smith Health and Social ServicesAuthority.

Jim RuiterBSc MDRural Family Doctor, Bonnyville

Jim Ruiter is a family physician fromBonnyville, a small town in rural Alberta.He qualified in general practice at theUniversity of Alberta with advancedobstetric privileges in 1989. He began workin Bonnyville in that year and this practicehas now evolved into predominantly anobstetrical one. He has been involved inPrimary Care Networks (PCN) since theirinception as a physician lead, utilising it asa vehicle to improve patient care andaccess to health care in his town. As partof the PCN, he has implemented aninnovative, and well-received Well BabyProgram and a multidisciplinary patientcentered office based Obstetric Program.As he became more involved in theprocess of change in medicine as itpertained to the PCN, he becameinterested in the process of change in theculture of medicine. He is a clinical lecturerin the department of Family Medicine at theUniversity of Alberta’s Faculty of Medicine.

Dr. Ruiter is a member of the faculty of theSociety of Obstetricians and

Gynaecologists of Canada assisting inteaching their patient safety program,MOREOB across the country; he is also amember of their Obstetric Content ReviewCommittee. He is a member of theEducation Standing Committee of theAlberta Perinatal Health Program. He iscommitted to sustainable high quality ruralobstetrics and to the world of PatientSafety. He has become vocal in forwardingthe agenda for Patient Centred Care.However, he is mostly committed to hiswife and four children who are his neverending support!

Richard StanwickMD MSc FRCPC FAAPChief Medical Officer of Health, PublicHealth/Aboriginal Experience, VancouverIsland Health Authority

Richard Stanwick is currently the ChiefMedical Health Officer for the VancouverIsland Health Authority, formerly the CapitalHealth Region, in Victoria. He completedhis medical school training and receivedhis Fellowship in Pediatrics after training atthe Winnipeg Children’s Hospital. He did aFellowship in Community Pediatrics atMcGill University, where he also receivedhis Masters Degree in Epidemiology andHealth. On his return to Manitoba, Dr.Stanwick acquired his Fellowship inCommunity Medicine and rose to the rankof Full Professor at the University ofManitoba. He spent two years with theProvince of Manitoba, including one as theActing Provincial Epidemiologist. Hebecame the Medical Officer of Health forthe City of Winnipeg in 1990, a post he heldfor five years. He joined the CapitalRegional District in September 1995 and the(now) Vancouver Island Health Authority, inApril 1997.

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