New Mothers' Survey
1996

A project of the Prenatal Committee
Division of Maternal & Child Health
Author: Karen J. Oby, MPH, LRD
Edited by: Alana Knudson-Buresh, Ph.D., Debra Anderson and
MCH Staff Members
Graphics: Barb Nechiporenko
Vital Statistics: David Mayer
Statistical Analysis: Beth Arrindell, MPH, RD
Published: August 1997

Governor
Edward T. Schafer

State Health Officer
Jon R. Rice, M.D.

North Dakota Department of Health
600 E. Boulevard Avenue
Bismarck, ND 58505-0200
(701) 328 2493
Fax (701) 328-1412

Comments can be e-mailed to: koby@state.nd.us

Table of Contents

Introduction and Survey Methods
Highlights
Recommendations

Pre-pregnancy Behaviors

Planned Pregnancies
Alcohol Use and Smoking
Vitamin Use

Access to Prenatal Care

Entry into Prenatal Care
Improving Prenatal Care
Access to Dental Care

Educational Content of Prenatal Visits

Nutrition and Exercise
Seat Belt Use
HIV/AIDS Testing
Teratogens
Smoking Advice
Alcohol Advice
Toxoplasmosis and E-Coli
Genetic considerations/Special Medical Problems
Most Useful Source of Information during Pregnancy

Pregnancy and Stress

Life Stressors
Domestic Violence

Access to Infant Health Care

Well Baby and Sick Care
Home Visits

Education about Infant Care

SIDS-Related Behaviors
Breastfeeding
Injury Prevention
Most Useful Source of Help in Learning to Care for Baby

Appendix: 1995 Vital Records Information and Healthy People 20000 Goals
Glossary
Bibliography
Quick Summary


Introduction and Survey Methods

Purpose

As part of its mission to ensure healthy women, children, and families, the Maternal and Child Health Division (MCH) of the North Dakota Department of Health conducted a survey of new mothers. The mothers were questioned about preconceptual behaviors such as tobacco and alcohol use and about health care and education received during pregnancy. Their infants were about 3 months old at the time of the survey, so mothers also were asked about infant health care and behaviors such as car-safety seat use and infant sleep position.

Questions in the survey were chosen to provide information that would help the Division of Maternal and Child Health develop better program interventions. It also was hoped the information would prove useful to both private and public health care providers in tailoring health care services to the needs of prenatal clients and infants in North Dakota.

Methods

A 58-question survey was mailed between March and May, 1996, to 2,500 mothers who had given birth in North Dakota during November and December 1995 and January 1996. After adjusting for out-of-state resident surveys and undelivered surveys, 1,268 surveys were matched with North Dakota resident birth certificate demographic and health information. These 1,268 surveys represent 60 percent of the resident North Dakota births during this time period.

The large survey sample allowed MCH to break the data down into these subgroups: primiparas (44 percent of sample were first-time mothers) and multipara (mothers of other children) and the WIC versus the non-WIC population. (WIC is a nutrition program that serves families with low to moderate incomes who are at risk due to nutrition and health reasons.) One-third of the survey respondents (422) were WIC participants. The prenatal care for about 200 of the WIC participants was paid for by Medicaid. The results for this Medicaid group of very low-income women were also analyzed.

Matching birth certificate information with the survey results and the statistical analysis of this project were accomplished through the MCH Information Resource Center Graduate Student Internship Program. A candidate for a Masters Degree in Public Health was assigned to the North Dakota Department of Health for three months to work on this project.

For copies of the survey questions (Adobe Acrobat PDF) or for more detailed information about the survey contact:

Karen J. Oby, MPH, LRD
MCH/WIC Nutrition Services Director
North Dakota Department of Health
Division of Maternal and Child Health
(701) 328-2493
1-800-472-2286
koby@state.nd.us
August, 1997


Highlights*

*Throughtout this report, the results have been rounded to the nearest whole number.


Recommendations for Health Care Providers


Recommendations for Community Health Programs



Pre-Pregnancy Behaviors

Planned Pregnancies

Sixty percent of the survey respondents said they had planned their pregnancies (wanted to be pregnant now or would have liked to be pregnant sooner). This is higher than the national average of 43 percent. The WIC population rate of planned pregnancies, however, was 43 percent. More subsequent pregnancies in the WIC population were planned (51 percent) than first-time pregnancies (33 percent). In the non-WIC population, 70 percent of pregnancies were planned. More first-time pregnancies (71 percent) were planned in the non-WIC population than subsequent pregnancies (68%).

"Because healthy women are more likely to have healthy babies, assuring good health prior to conception simply makes good sense and should be standard care. Diagnosis and interventions to treat medical illness and psychosocial risks prior to conception will eliminate or reduce hazards to the mother and baby. Care is also likely to be more effective prior to conception because evaluation and treatment can be initiated without harm to the fetus." (Alcohol, Tobacco, and other Drugs May Harm the Unborn - DHHS Publication No. (ADM)90-1711, 1990 reprinted 1994).

Table 1

Feelings About Being Pregnant

How did you feel about becoming pregnant? Survey Population
(N=1245)
WIC Primiparas
(N=192)
WIC Multiparas
(N=228)
Non-WIC primiparas
(N=358)
Non-WIC multiparas
(N=457)
Medicaid (N=230)
Wanted to be pregnant sooner15% 9%10%21% 15%10%
Wanted to be pregnant later17% 34%20%12% 12%29%
Wanted to be pregnant then45% 23%40%50% 53%25%
Didn't want to be pregnant then or in the future 3% 4% 6% 1% 4% 6%
Unsure how I felt13% 22%17%10% 11%24%
Other* 6% 8% 7% 6% 6% 6%
Total100%100% 100%100%100% 100%

*Many "other" comments were related to wanted to be pregnant later, but were happy they had the baby.


Later on in the survey, the mothers were asked if a health professional had talked to them about family planning, either during the pregnancy or right after the baby's birth. Between 69 percent and 72 percent of the women said they had talked about family planning, with no major difference between primiparas, multiparas, or the WIC population. Primiparas were at the upper end of the range, and Medicaid mothers at the lower end of the range.

Current Use of Family Planning Services:

WIC primiparas and Medicaid mothers were less likely to be using some method of birth control at the time of the survey (infants were about 3 or 4 months old). Sixteen percent of WIC primparas were not using a birth control method compared to 9% of non-WIC primparas.

Table 2

Where Women Currently Received Birth Control or Family Planning Services

Responses Survey Population WIC Primiparas WIC Multiparas Non-WIC Primiparas Non-WIC Multiparas Medicaid
Family Planning Agency 7%19% 7%7% 2% 14%
Private Physician/ Clinic 40%31% 28%48% 44% 31%
Community Health Center 2%2% 2%2% 2% 4%
UND Family Practice Center 2%3% 2%1% <1% 3%
Indian Health Service 2%4% 5% 0% <1% 4%
Military Health System 8%12% 12%8% 4% 0%
Over-the- Counter (condoms, foam, etc.) 12%8% 9%16% 13% 11%
Tubes Tied/ Vasectomy 10%1% 21%< 1% 15% 13%
Natural Family Planning 9%5% 5% 9% 12% 5%
No Birth Control 10% 16% 9% 9% 7% 15%
Total100% 100%100% 100%100% 100%


Pre-Pregnancy Behaviors

Alcohol Use and Smoking

Pre-Pregnancy Alcohol Use

A woman who plans her pregnancy is more likely to protect the baby from harmful substances by not smoking or drinking alcohol. In contrast, the child of an unwanted conception is at greater risk of being low birth weight, of dying in its first year, of being abused, and of not receiving sufficient resources for healthy development.

More than one-half (59 percent) of the women said they didn't drink alcohol at all during the three months before they become pregnant. Sixty-two percent of the WIC population said they didn't drink during the three months prior to pregnancy, compared to 57 percent of the non-WIC population.

Fifty-six percent of primiparas reported not drinking, compared to 61 percent of the multiparas.

Ten percent of the survey population did not seek early prenatal care because they did not know they were pregnant. Of these 128 women, 45 percent consumed alcohol during the three months prior to pregnancy. These women may have unknowingly placed their fetuses at significant risk for Fetal Alcohol Syndrome/Fetal Alcohol Effects (FAS/FAE) and other alcohol-related birth defects.

"The universal message that women should abstain from drinking alcohol prior to conception and throughout pregnancy should be emphasized and expanded to `no drinking if there is any chance you could become pregnant.' Binge drinking of more than five drinks on any occasion and drinking during the first two months of pregnancy are two of the strongest maternal predictors of later neurobehavioral deficits among offspring." (Alcohol, Tobacco, and other Drugs May Harm the Unborn—DHHS Publication No. (ADM)90-1711, 1990 reprinted 1994).

Pre-Pregnancy Smoking

"Cigarette smoking is the major single and preventable cause of disease and premature death in the United States." (Alcohol, Tobacco, and other Drugs May Harm the Unborn - DHHS Publication No. (ADM)90-1711, 1990 reprinted 1994).

Twenty-two percent of the entire survey population smoked prior to pregnancy. However, most smokers were in the lower income population; 38 percent of the WIC population reported smoking compared to 13 percent of the non-WIC population.


Pre-Pregnancy Behaviors

Vitamin Use

Vitamin Use Prior to Pregnancy


Folic acid (folate/folacin) is a water-soluble vitamin that recently has been shown to help prevent serious birth defects of the brain and spine (known as neural tube defects) when taken daily prior to conception and in the early weeks of pregnancy. Several recent studies have hinted that multivitamin supplements (as well as vitamin-fortified cereals) taken before conception and in the first months of pregnancy may also reduce the incidence of cleft lip/palette, some heart defects, and limb defects. Even though the United States soon will start fortifying grain products with folic
acid, women of childbearing potential should take a daily vitamin supplement that contains 400 micrograms of folic acid.

Overall, the WIC population was less likely to have taken multivitamins during the three months prior to pregnancy. Sixty-two percent of the WIC population did not take vitamins prior to pregnancy compared to 48 percent of the non-WIC population.

Table 3

Vitamin Use during the Three Months prior to Pregnancy

Frequency Total Survey WIC*Non-WIC*
Every day 30% 22% 33%
4-6 days/wk 8% 5% 9%
1-3 days/wk 8% 8% 8%
<1 day/wk 2% 3% 2%
None 53% 62% 47%
Total100% 100%100%
(*The above proportions for the WIC and non-WIC populations hold true for primiparas and multiparas in each population.)

New mothers were asked if a doctor, nurse, or other health professional had talked to them either during the pregnancy or right after the baby's birth about the importance of folic acid in food or vitamin supplements to prevent birth defects. Slightly more than one-half the women remember discussing it. More WIC than non-WIC primiparas had been told about folic acid. Since most primiparas will have another child, all of them should be encouraged to take a folic acid supplement between pregnancies. Table 4

Discussed Importance of Folic Acid to Prevent Birth Defects

ResponsesSurvey Population WIC Primiparas WIC Multiparas Non-WIC Primiparas Non-WIC Multiparas Medicaid
% yes 55% 64% 55% 57% 50% 55%
% no 45% 36% 45% 43% 50% 45%
Total100% 100%100% 100%100% 100%


Access to Prenatal Care

Entry into Prenatal Care


Seventy-two percent of women surveyed said they had no problems getting prenatal care and obtained it early. The most common reasons for not seeking early care were "I didn't know I was pregnant" (13 percent) followed by "couldn't get an appointment earlier" (7 percent) and "not enough money" (4 percent)

About 87 percent of respondents had initiated prenatal care in the first trimester. This is higher than the 1995 North Dakota statewide average of 83 percent and the 1995 national rate of 80 percent. The Healthy People 2000 goal is 90 percent of women beginning care in the first trimester of pregnancy.

The following table shows client satisfaction with various aspects of prenatal office visits.

Table 5

Feelings About the Prenatal Clinic Visit

VisitVery satisfied Somewhat satisfied It was OKSomewhat dissatisfied Very dissatisfied Total
Waiting time 44% 20%25% 8%3% 100%
Time with doctor or nurse 58%19% 16%5% 1%100%
Advice on self care 64%18% 13%3% <1%100%
Office or clinic ours 66%17% 14%2% <1%100%
Respect shown by staff 73%14% 9%2% <1%100%


Access to Prenatal Care

Improving Prenatal Care

Generally clients were satisfied with the care received, however, when asked what they would change about their prenatal care, more than 400 women responded. The change most mentioned (152 women) was the desire for more time with the physician to answer questions or to provide more information about prenatal care, and they wished the doctor would be more concerned about them personally.

I wish the "doctor would take his time in answering questions you might have. I know they are busy but sometimes you need reassuring." It was "my fourth pregnancy and I felt the doctor and nurses assumed I knew it all, but it has been six years since my last baby and things have changed. I would have liked more of a review."

The second item that the women wanted was to change physicians or clinics or go to a midwife. "I changed doctors at six months, the second doctor answered all my questions."

The third most frequent type of comments related to the military, Indian Health Services and HMOs where women saw more than one physician/nurse practitioner during this pregnancy or a different doctor delivered their baby. "I would have liked to have seen one doctor/midwife instead of rotating between the two."

Thirty-three commented that the cost of prenatal/delivery care was too high.

Twenty-eight commented that they wanted ultrasounds. "I was concerned about my baby's growth and development and requested an ultrasound but was turned down by my doctor several times before she agreed."

Twenty-five commented that they would have gone earlier for prenatal care or wanted to go more often.

Fourteen women mentioned the long distances they had to travel to get care. This comment sums up their feelings: I would change "the distance I traveled; however, I felt it necessary to do so to receive the best care possible."

Eleven mentioned that they would like expanded clinic hours and more flexible appointment times. Some wanted evening appointments so their husbands could go along. Others wanted evening appointments so their husbands could stay home and care for older children.

Seven commented that they wanted more family involvement. They wanted children to feel more welcome. "Allow family participation in prenatal visits—leaving siblings out of the loop makes them feel unwelcome in the new birth experience." "Make it more convenient to bring other children along during checkups (have child care facilities available).


Access to Prenatal Care

Access to Dental Care

Fifty-seven percent of the survey respondents did not see a dentist during pregnancy. Women in the western part of the state were less likely to visit a dentist during pregnancy than those in the eastern part.

The most common reason women gave for not seeing a dentist was they were not having any problems (47 percent), followed by "I did not have enough money or insurance to pay for my visits" (14 percent). However, 12 percent said that they "didn't think about going to a dentist." Another 11 percent listed other reasons which included the belief that they should not go to the dentist while pregnant, had been told by a health care provider not to go while pregnant, and did not go because they were concerned about dental anesthetic or x-rays affecting the baby, or had not been informed they should visit the dentist.

Routine dental care should be recommended early in pregnancy. A 1991-1992 study points to a possible link between periodontal (gum) infection and the premature delivery of low birth weight (LBW) babies. The study conducted at the University of North Carolina at Chapel Hill found that women who had periodontal disease were seven times more likely to have preterm low birth weight (PLBW) babies that women who were not affected by the disease.

Hormonal changes during pregnancy can cause tender, swollen fiery red gums that bleed easily (gingivitis). When untreated, the severity tends to increase during pregnancy. It particularly may be noticed during the second trimester or late in the first trimester. Periodontal infections are both preventable and readily treated. Regular flossing and brushing to reduce plaque is needed to control this gingival inflammation.

Nausea during pregnancy may lead to poor oral hygiene, and dental caries may develop. There is no scientific evidence that filling teeth or dental extraction with the use of local or nitrous oxide-oxygen anesthesia causes abortion or premature labor. Antibacterial therapy should be considered for sepsis, however, especially in gravidas who have had rheumatic heart disease or nephritis. If a women needs extensive dental surgery, this is usually postponed until after delivery, if possible.

If a pregnant woman needs extensive dental work, the second trimester is the safest time. A fetus is more susceptible to environmental influences during the first trimester; the woman, more at risk for premature delivery during the third trimester.


Educational Content Of Prenatal Visit

Nutrition and Exercise


To achieve ideal weight gain, pregnant women with low or high pre-pregnancy weight should be referred to a dietitian or nutritionist for nutrition assessment and counseling. Any pregnant woman, regardless of pre-pregnancy weight, who fails to gain the recommended amount of weight during pregnancy also should be referred to a dietitian. The WIC program's licensed registered dietitians and nutritionists provide nutrition assessment and counseling for low to moderate-income families.

Proper nutrition and appropriate weight gain1 have long been recognized as necessary for a good pregnancy outcome. According to the survey, how to eat during pregnancy was discussed with 80 percent of the women. Doctors and nurses were more likely to discuss nutrition with primiparas (86 percent) than with multiparas (75 percent).

A full-term healthy, normal weight infant is the desired outcome of pregnancy. Appropriate maternal weight gain during pregnancy has been shown to have a positive effect on the weight of the newborn. Pre-pregnancy weight and prenatal weight gain are the primary predictors of an infant's birth weight.

Table 6

Pre-Pregnancy Weight Status

StatusTotal Survey WIC Non-WIC
Underweight
(BMI <19.8)
12% 13% 12%
Normal weight
(BMI 19.8-26.0)
60% 54% 63%
Overweight
(BMI >26)
28% 33% 25%
Total100% 100%100%

1 See glossary for description of ideal weight gains based on Body Mass Index (BMI).

Weight Gain During Pregnancy

Seventy-one percent of survey respondents achieved at least the minimum recommended weight gain during pregnancy. (Thirty-seven percent of respondents had ideal weight gains during pregnancy, 34 percent gained more than the ideal amount, and twenty-nine percent gained less than the ideal amount.) The Healthy People 2000 goal is to increase to at least 85% the proportion of mothers who achieve the minimum recommended weight gain during pregnancy.

Birth Weight for WIC and Non-WIC Populations

There was a slight, but interesting difference in birth weights between WIC and non-WIC respondents. The WIC population had more normal weight babies than the non-WIC population (slightly fewer low birth weight and fewer high birth weight babies). Further study of this data is needed.
One-third of the survey respondents were enrolled in the WIC program and, therefore, were assessed and counseled by nutritionists and received nutritious foods during their pregnancies. National studies show that participation in WIC reduces the incidence of low birth weight and saves Medicaid dollars. On a statewide basis, 40 percent of the infants born are enrolled in WIC. Some families may not realize they qualify for WIC until after the baby arrives and, therefore, miss out on the protective effects of WIC participation. Currently a family of three can earn up to $24,661 per year ($2,056/month) and still qualify for WIC.

Most women (47 percent) reported sporadic physical activity (walking once or twice per week, volleyball, or bowling once per week). Sporadic physical activity was most often performed by women age 20 to 34 (47 percent) and 35 to 45 year olds (48 percent). Twenty-four percent reported very little physical activity (spent leisure time watching TV, reading). A greater proportion of teens (31 percent) exercised very little, compared to women age 20 to 34 (23 percent) and age 35 to 45 (27 percent).

Pregnancy is a time of change that creates added demands on the expectant mother's system. Women can handle these changes in many positive ways, including physical activity. Pregnancy is a time to maintain or slightly improve fitness and prepare for labor. It also can be a time to design a physical activity program to develop a healthy lifestyle that will carry over after pregnancy.

Women who have led sedentary lifestyles should begin with physical activity of very low intensity (walking or marching in place) and advance gradually. Because all goals, guidelines and recommendations will vary with each woman, be sure to discuss this with your health care provider.

Exercise

Moderate levels of exercise are recommended for pregnant women, just as they are for the rest of the population. Only 28 percent of the women reported moderate levels of physical activity (regular walking, swimming, etc., for about 30 minutes per day or vigorous physical activity for 20 minutes at least three times per week). A higher proportion of primiparas (30 percent) participated in moderate physical activity compared to 26 percent of multiparas. Women living in frontier (less than six people per square mile) counties were more likely to have moderate levels of physical activity (36 percent) than women living in more populous counties (26 percent).


Educational Content Of Prenatal Visit

Seat Belts

Only 47 percent of women said that a doctor or nurse had talked about the importance of wearing a vehicle safety belt when traveling during pregnancy. The American College of Obstetricians and Gynecologists (ACOG) strongly recommends use of seat belts during pregnancy. There is no evidence that safety belts increase the chance of injury to the fetus, uterus or placenta, no matter how severe the collision. Mothers who wear seat belts suffer fewer injuries and deaths than those who do not wear them.

Always Wear Your Seat Belt

Use seat belts correctly. Place the lap belt under your abdomen as low on the hip as possible and across your upper thighs. Never place the lap portion of the belt above your abdomen. Position the shoulder belt between the breasts.

Sit as far away from the air bag as possible and don't hunch forward in your seat. Some officials recommend 12 inches as a safe distance from the wheel or passenger-side dash.

If the steering wheel tilts or can be moved forward or back, position it as far away from you as possible and aim it at your chest, not your face.


Educational Content Of Prenatal Visit

HIV/AIDS Testing

HIV/AIDS

Only 30 percent of the survey population said a doctor or nurse asked if they wanted to be tested for HIV/AIDS. Other Health Department data indicate that closer to 44 percent of pregnant women are actually being tested. Every pregnant woman should be offered an HIV test as part of her normal prenatal care. North Dakota law requires physicians to obtain informed consent prior to testing for HIV/AIDS.

HIV/AIDS Facts

  • Many women do not know that they have been exposed to HIV because they don't think they have put them selves at risk. A woman is at risk if she had unprotected sex even one time with someone who may be infected, or if she has shared needles or syringes with an infected person.

  • In North Dakota, four pregnant women have been diagnosed with HIV infection since 1994.

  • Twenty-five percent of babies born to HIV-infected women will be infected with HIV.

  • Zidovudine therapy for infected pregnant women can reduce the proportion of infected babies by two-thirds from 25 percent to 8 percent.

  • For treatment to be given with optimum success, the woman must be identified as HIV positive either before or as early as possible during the pregnancy.


Educational Content Of Prenatal Visit

Teratogens

Over-The-Counter (OTC) Medications and Illicit Drugs

Use of over-the-counter drugs was discussed with 82 percent of the respondents. However, only 50 percent of the respondents said a doctor or nurse asked them if they were using drugs such as marijuana or crack cocaine.

Vasoconstrictors are substances that reduce blood flow. They have long been suspected as a possible cause of gastrocshisis, a condition in which the infant is born with intestines protruding through a hole in the abdomen. Aspirin, ibuprofen, and decongestants are all known to alter blood circulation. Small interview studies have suggested links between gastroschisis and both aspirin and decongestants. Taking any medication involves weighing risks and benefits. Pregnant women should always consult their health care provider before using any medication—including those sold over the counter.

The North Dakota Teratogen Project

For more information about specific toxic substances, contact the North Dakota Teratogen Project at the University of North Dakota School of Medicine. This program provides health care providers with a central, up-to-date source of information on teratogens. For easy, access call 1-800-962-0143.

Teratogens are any environmental agents that potentially can harm the developing fetus. This includes cigarette smoke; alcohol; prescribed or over-the-counter medications;
vaccination, diseases, or infections before or during pregnancy; drugs; chemicals such as inhalants, pesticides, paints, and varnishes; physical agents such as excessive heat or radiation; or pollutants.

Paint Fumes/Chemicals

Only 47 percent of the women said a doctor or nurse talked to them about avoiding paint fumes, other chemicals, pesticides or radiation exposure in the work place or at home. Fifty-six percent of primiparas received this advice compared to 40 percent of multiparas.

Recent interview-based research points to the increased risk of birth defects when pregnant women are exposed to organic solvents such as benzene, toluene, propane, some aerosol propellants, antifreeze, or rubbing alcohol. Solvents are found in a wide range of products such as gasoline, motor oil, paint thinner, polyurethane, spray paint, aerosol sprays, nail polish remover, and many cleaning products. Women who engaged in hobbies with solvent exposure—auto mechanics, furniture stripping and painting—may have two to four times the risk of having babies with birth defects. Expectant mothers should use caution as they consider possible exposures from their activities at home and in the workplace. Even seemingly harmless hobbies may raise the risk of birth defects. Occasional low exposure to solvents or colorants such as doing your nails is probably OK, but pregnant women should try to avoid frequent or intense exposures. (Secondhand exposure to solvents—through the activities of another person in the household—did not show an increased risk in these studies.)


Educational Content Of Prenatal Visit

Smoking Advice

Advice from Health Professionals Impacted Smoking Cessation During Pregnancy

By far, tobacco is the teratogen affecting the most pregnancies in North Dakota. Almost all pregnant women (97 percent) had been asked by a doctor or nurse if they smoked. However, fewer women were told of the harmful effects of smoking on the infant and even fewer were told of the dangers of passive smoke to the pregnant woman and her developing fetus. More WIC clients were told of the dangers of smoking than the non-WIC population. This is appropriate since 38 percent of the WIC population smoke compared to 13 percent of the non-WIC
Passive Smoke
population.

Knowledge of the dangers of passive smoking for pregnant women has been growing. Women exposed to passive smoke have a greater risk of delivering low birth weight-infants. In a recent study of North Dakota WIC client data, passive smoke was associated with a greater risk of low birth-weight infants born to women over the age of thirty. The New Mothers' Survey showed that more primiparas received advice about the dangers of passive smoke than did the multiparas who were more likely to be older. The survey showed that 24 percent of both primiparas and multiparas lived in households where someone else smoked. The survey did not ask about exposure to smoke in the workplace. Table 7

During Your Previous Visits, What Did Your Doctor or Nurse Say to You About Smoking?

Advice Survey WIC Non-Wic Primiparas Multiparas
Asked if smoked 97% 98%97% 98% 96%
Talked about harmful effects 66% 78%60% 72% 61%
Told passive smoke harmful in pregnancy 53% 70%44% 59% 48%
Told passive smoke harmful for baby 58% 77%49% 66% 52%


Table 8

Smoking Changes during Pregnancy

BehaviorSurvey WICNon-WIC Primiparas Multiparas
Decreased 41% 40% 42% 32% 51%
Stopped 44% 43% 47% 52% 36%
Tried to stop, but failed 14% 17% 11% 16% 13%
Total100% 100%100% 100%100%

Advice from Health Professionals Impacts Smoking Cessation During Pregnancy

Of the women who smoked before pregnancy and who received advice about the harmful effects of smoking, 12 percent stopped smoking during pregnancy. Of the women who smoked and did not receive advice, only 7 percent stopped smoking. Of those women
who smoked less than 10 cigarettes per day, 42 percent decreased and 45 percent stopped smoking during pregnancy. However, of those women who smoked 11 to 20 cigarettes per day, 51 percent decreased, but only 23 percent stopped smoking during pregnancy.


Educational Content Of Prenatal Visit

Alcohol Advice

Advice Regarding Alcohol Intake

Overall, one in five women in the survey population indicated they had not received any information about the dangers of drinking alcohol during pregnancy. This proportion held true when examining data from those women who reported drinking during the three months before they became pregnant.

The WIC population reported less drinking in the three months prior to pregnancy. Sixty-two
percent of the WIC population said they did not drink compared to 57 percent of the non-WIC population. However, a larger proportion of the WIC population (80 percent) reported that a doctor or nurse talked to them about the harmful effects of alcohol during pregnancy compared to only 62 percent of the non-WIC population.

Table 9

During your prenatal visits, what Did Your Doctor Or Nurse Say to You about Drinking Alcohol?

AdviceSurvey WICNon-WIC Primiparas Multiparas
Asked if I drank 88% 96%84% 74%64%
Told about harm to baby 68%80% 62%76% 61%
Told not to drink any alcohol 68%77% 64%74% 64%
Told me I could drink for special events 7% 5% 8% 8% 6%
Told me I could have one drink a day 1% 1% 1% 1% 1%
Did not give me any advice about alcohol 24%18% 27%17% 30%

It appears that the non-WIC population and second-time mothers are less likely to receive warning information about alcohol consumption during pregnancy. Some health care providers still condone drinking alcohol during pregnancy by telling women they can drink for special events.


Educational Content Of Prenatal Visit

Toxoplasmosis and E-Coli

Preventing Toxoplasmosis and E-Coli Infections:

Congenital Toxoplasmosis occurs when a pregnant women is infected with T. gondii excreted by cats or by eating undercooked meats. The newborn's immune system can't fight the toxoplasm infection, and infants can develop severe consequences including mental retardation, convulsions, and severely impaired vision if not treated promptly. (Note: Women who were infected with T. gondii prior to conception do not need treatment to prevent congenital infection of the fetus.)

E-coli is a serious infection that has been linked to undercooked ground meat, unpasteurized apple juice, and unwashed fruits and vegetables. Because pregnant women have lowered immune function, they are more susceptible to this infection.

Only 51 percent of the women had been warned of the dangers of taking care of a cat during pregnancy and only 32 percent had been told the importance of thoroughly cooking meats.


To Prevent Toxoplasmosis and E-Coli Infection


Educational Content Of Prenatal Visit

Genetic Considerations/Special Medical Problems

Genetic Considerations/Special Medical Problems at Birth

Eighty parents responded that their babies had special medical problems, thirty-six of which were congenital anomalies (defects present at birth). Seventy-two parents responded that older siblings had special medical problems, fourteen of which were congenital anomalies.

Infants with birth defects are at increased risk of early death. They may require multiple hospitalizations or suffer long-term developmental and physical effects. Their families may be faced with difficult and expensive care, a situation further complicated when more than one child in the family is born with a birth defect.

Although the causes of birth defects are often unknown, a better understanding of the characteristics of mothers who have a high risk of delivering a second child with a birth defect may provide clues for prevention and help target women for intervention methods as they become available.

Eighty-six percent of the women said a doctor or nurse had asked about a family history of birth defects or genetic disease.

In North Dakota, Birth Defects/Genetics Counseling Clinics are provided through the Department of Pediatrics, Division of Medical Genetics, at the University of North Dakota (UND) School of Medicine. Staff help parents who have had a child with a serious abnormality at birth understand the chances of this condition reoccurring. Services also are available to people suffering from specific handicaps who are concerned about the risk of recurrence for their children, as well as for families in which frequent miscarriages or still births have occurred.


Educational Content Of Prenatal Visit

Most Useful Source of Information during Pregnancy

Most Useful Source of Information during Pregnancy

The most useful sources of information for primiparas were books and magazines, while multiparas indicated "my previous experiences with pregnancy." The Medicaid population
said "my doctor." This response may reflect fewer resources to buy or locate books or magazines.

Table 10

Which Was Most Useful in Educating You about Your Pregnancy and How to Take Care of Yourself?

(Bolded numbers indicate most useful source in each category)

SourceSurvey Primpars Survey Multiparas WIC Pimiparas WIC Multiparas Non-WIC Primiparas Non- Wic Multiparas Medicaid
Books / magazines 37% 16% 30% 10% 42% 20% 18%
Doctor 19% 24% 18% 28% 20% 23% 23%
Previous Experience NA 34% NA 32% NA35% 15%
Packet from Drs. Office 8% 7% 6% 4% 10%8% 8%
Prenatal Class 8% 3% 6% 2% 10% 4% 4%
Nurse 4% 2% <1% 2% 4% 3% 3%
Midwife 4% 3% 4% 3% 4% 3% 4%
WIC Staff 2% 3% 5% 8% NA NA 8%
Other* 18% 8% 30% 11% 10% 4% 17%
Total100% 100%100% 100%100% 100%100%

* Other includes: OPOP staff, Healthy Start Staff, Public Health Nurses, family and friends, and the woman's educational/professional background - nursing, diabetes, etc.


Pregnancy and Stress

Life Stressors

Life Stressors Impacted Low Birth Weight and Prematurity

Eighteen questions were asked regarding significant events that might have happened to respondents during the 12 months before delivery (illness, death, job loss, arrest, etc.). Fifty-two percent of the population reported no stressors, 33 percent had two or fewer stressors, and 15 percent had more-than-two stressors. The usual type of stressors for the population with two or fewer stressors were: a sick family member, a family member who died, personal debt, and a friend with a drug problem.

The top four stessors for those with more-than-two stressors were: a sick family member, another close relative was sick, personal debt, and a family member who died. Sickness in "another close relative" was far greater in this group than in the two or fewer stressors group. It should be noted that four events were cited by this group that were not mentioned in the group with two or fewer stressors: arrest, charged or convicted of an offense, homelessness, and death of a partner.

The proportion of infants born prematurely in this group (14 percent or 27 babies) was almost double that of women who identified two or fewer stressors. Women with more-than-two stressors were more likely to be Native American or teenagers. In this group, the infant's father was more likely to have less than a college education. The proportion of unmarried mothers in the group with more-than-two stressors was three times higher than for women in the group with two or fewer stressors. Sixty-five percent of mothers in the more-than-two stressors group had incomes
under $30,000. Sixty-two percent of women in the two or fewer stressors group had household incomes of more than $30,000.

Employment and Stress

Over 75 percent of the survey respondents worked outside the home during their pregnancy. The majority of women indicated that the mental stress of their job was "somewhat stressful." The proportion of women with "extremely stressful" jobs was 19 percent.


Pregnancy and Stress

Domestic Violence

Battered women are more likely to suffer miscarriages and to give birth to babies with low birth weights (Surgeon General, United States, 1992). The problem of domestic violence and abuse during pregnancy is believed to be significantly under reported.

Two and a half percent of the survey population answered yes to the question "did your husband or partner physically hurt you"? If we applied this percentage to the number of births in 1995 (approximately 8400), we can estimate that approximately 210 women were abused during their pregnancy. The North Dakota Council on Abused Women's Services provided services to 131 pregnant women in
1995, indicating that prenatal domestic abuse is under reported in North Dakota.

Five percent of the WIC population reported physical abuse (six percent primiparas; three percent multiparas) and one percent of non-WIC population reported physical abuse (one percent primiparas; one percent multiparas).

In addition to looking for physical signs of abuse, a question such as this should be a standard part of prenatal assessments: "During this pregnancy or within the last year, have you been slapped, hit, kicked or otherwise physically hurt by someone?"

Suggestions for Helping an Abused Woman:


Access to Infant Health Care

Well Baby and Sick Care

The vast majority of babies (90 percent) were taken regularly for well baby check-ups. Eighteen comments indicated the parents or doctor did not see the need for frequent well-baby check-ups. Thirteen said they had been in to see the doctor so often with illnesses that they didn't need additional visits. Twelve respondents said they didn't go because of the expense. Some mentioned going to public health for their immunizations.

When asked about medical care for illness, 68 percent replied that "nothing has kept us from medical care," and the remaining 32 percent said "my baby has not been sick."


Access to Infant Health Care

Home Visits

In a North Dakota Department of Health report entitled Newborn Home Visiting in North Dakota, 24 percent of the agencies surveyed said infants were more than fourteen days old when visited. Home visiting agencies that received information about newborns from health care facilities where the babies were born were more likely to provide a home visit within the first seven days. Agencies that used newspaper birth announcements to find out about new births were less likely to see the infant in the first seven days.

Content of Home Visits

One-half of all agencies included the following assessment factors in their initial home visit: physical assessment of the infant; physical assessment of the mother; infant feeding assessment/breastfeeding assessment; psycho-social assessment of the family; infant height, weight and head circumference measurements; immunization record/information; and home safety assessment. Visits lasted between 30 and 90 minutes and were made by registered nurses. Eighty-seven percent of the agencies indicated no fee was charged to the family for the visit. Twenty-seven percent of the agencies billed a third party for the visit.


Comments about Home Visiting

Survey respondents were asked what was helpful about the home visit they received.

The overwhelming reponses were "provided reassurance" (88) and "answered questions" (80). Another 71 mothers commented that they really appreciated having the baby weighed and measured so they knew that feeding was going fine. Fifty-three mothers
One-third of mothers and infants received home visits. They were more likely to receive a home visit if the baby was low birth weight or premature, or if the mother was under age 19, had an income of less than $10,000, was a primipara, had more than two stressors or was a Medicaid recipient.

Age at Home Visit

Mothers were asked how old their babies were at the time they were visited at home by someone from public health, the hospital, the Optimal Pregnancy Outcome Program (OPOP), or the Healthy Start Program.

Table 11

Age at Home Visits

Infants AgePecent/Number
< 1 week old 9% (115)
> 1 week < 2 weeks old 11% (131)
> 2 weeks old 9% (112)
Not visited 71% (875)
Total 100% (1233)

Twenty-nine percent of newborns (358) received one home visit. Two-thirds of this group were more than one week old at the time of the visit (one-third were more than two weeks old). Visiting the baby as early as possible is very important, especially in the area of breastfeeding. Problems caused by poor positioning of the baby during feeding can lead to much pain for mother and interfere with baby's milk intake. Early visits and assessments can correct problems before they become serious or cause the mother to stop breastfeeding.
mentioned the importance of the information and general education about cord care, bathing baby, safety checkups, etc. Forty-three mothers mentioned the help received to support breastfeeding. Twenty-three mothers mentioned that they had been worried about jaundice and were glad the nurse came. There were a few comments that they appreciated the nurse showing concern about the mother's health (physical and mental) and, since these babies were born in the winter, the mothers appreciated not have to take them outside to see health care providers.

"The nurse was very reassuring and informative about everything the baby was doing and that it was all normal."

"Reassurance that baby is healthy - having questions answered - good advice and caring and support."

"She was really friendly and helpful - It was real nice service. We didn't get that with our first child."

"Just reassurance that everything looked good and for someone to tell me that she was growing good."

"It assured us that our baby was doing fine, but more important, the nurse was able to help me with respect to breastfeeding problems. I had mastitis and didn't know it. She answered my questions."

"The nurse discovered what ended up to be a blood clot in my leg, and I feel probably saved my life"


Education about Infant Care

SIDS-Related Behaviors

SIDS-Related Behaviors

Sudden Infant Death Syndrome (SIDS) is the sudden death of an infant under one year of age which remains unexplained after a thorough case investigation.

Sleep Position

Babies who sleep on their stomachs have a higher risk of dying of SIDS. Babies should be laid down to sleep on their backs. Eighty-five percent of the respondents reported that a doctor, nurse or other health professional talked about laying a baby down to sleep on his or her back or side, not on the stomach.

However, in another survey question only 78 percent of the mothers said their infants were put to sleep on their backs or sides. Even though this rate is not as high as it should be (over 90 percent should be sleeping on their backs), it is a significant increase over the rate of 31 percent found in a 1991 North Dakota sleep position survey.

Ward and Grand Forks counties reported the lowest rates of babies sleeping on their backs. This lower rate was reported by women who received prenatal care through the military. Perhaps there is some loss of continuity of care due to multiple health care providers during a pregnancy, especially if a woman transfers to a different military installation during her pregnancy.

The American Academy of Pediatricians now reaffirms its 1992 recommendation that infants should sleep on their backs. The organization amended its recommendations to the following:

Infants should be laid down to sleep in a non-prone position. Supine (wholly on the back) confers the lowest risk and is preferred. The side is a reasonable alternative which also carries a significantly lower risk than prone, but a greater risk than the supine sleeping position.

If the side position is used, caregivers should be advised to bring the arm that the infant is lying on forward to lessen the likelihood of the baby rolling into a prone position.

This recommendation is for sleeping babies. A certain amount of "tummy time," while the baby is awake and observed, is recommended.

Smoking and SIDS

Only 49 percent of non-WIC participants said that a doctor, nurse or health care professional had told them how smoking around babies could affect their health. In addition to respiratory concerns, smoking during and after a pregnancy also are strongly linked to a higher risk of SIDS.

Twenty-two percent of the entire survey population smoked prior to pregnancy. However, most of the smokers were in the

lower income population. Thirty-eight percent of the WIC population smoked compared to 13 percent of the non-WIC population. Seventy-six percent of the WIC population reported that health care providers had talked to them about the effects of smoking on their babies' health.

Passive Smoke

Almost one-fourth (24 percent) of the women surveyed said at least one person in their households, other than themselves smoked. Table 12

Exposure to Passive Smoke

Survey WIC Non-WIC Medicaid
Other household member smokes 24% 39% 16% 46%
No other household member smokes 76% 61% 84% 54%
Total100% 100%100% 100%

Table 13

Smoking Behaviors around the Baby

BehaviorSurvey WICNon-WIC Medicaid
No one smokes in our house or car 72% 57% 80% 50%
No one smokes in our house or car when the baby is there 8% 12% 6% 14%
No one smokes in the same room when the baby is there 10% 17% 7% 20%
Smoking is allowed anytime, anywhere in the house or car 5% 8% 4% 9%
Other 5% 6% 3% 7%
Total100% 100%100% 100%

Families are knowledgeable about the dangers of passive smoke to infants and most are trying to create a smoke-free environment for their infants.

Comments by respondents pointed to problems with passive smoke and family visitors such as grandparents. Other comments described innovative but probably ineffective, methods to remove smoke such as only smoking in the bathroom or kitchen where fan vents the smoke out. Many husbands smoke in the basement or outside.


Other SIDS-Related Behaviors

A small subgroup of infants is at risk of SIDS due to other infant care practices that may lead to overheating such as sleeping with a cap on, using several blankets or sleeping in an overly warm room. For instance, of the infants who slept in rooms warmer than 72 degrees (427 infants), 84 percent also slept with two blankets, and 14 percent slept with three blankets. During their first month, 11 infants slept with a cap on, with three blankets, and in a room warmer than 72 degrees.

The majority of sleeping infants (98 percent) were dressed in one or two layers of clothing. However, 20 infants wore more than two layers of clothing while sleeping. At the time of the survey, only three infants wore caps while sleeping, however, one-fifth of the infants had slept wearing caps until one month of age. Another 6 percent of infants slept with caps on until two months of age.

Sixty respondents (five percent) said their infants slept on pillows. Soft surfaces and gas-trapping objects, such as pillows, should not be placed in an infant's sleeping environment (American Academy of Pediatrics - Policy Statement 1996).

Reduce the Risk of SIDS


Education about Infant Care

Breastfeeding

Breastfeeding is the preferred method of infant feeding. Ninety-five percent of the respondents said that a doctor, nurse or other health professional had talked to them about breastfeeding.

Breastfeeding Practices

The Year 2000 goal for breastfeeding is 75 percent of infants should be breastfed at hospital discharge and 50 percent should still be breastfeeding at 6 months. The rate of breastfeeding for the survey population was higher than the actual rate of breastfeeding indicated by other sources. Sixty-seven percent of the survey population breastfed their babies (59 percent WIC population; 71 percent non-WIC population).

The actual 1995 statewide rate of breastfeeding is 57 percent, according to the North Dakota Newborn Screening Report.
The breastfeeding rate for the WIC population rate is 48 percent as measured by the North Dakota WIC PedNSS Report. The high breastfeeding rate found in the survey is probably due to an under representation of very low income and Native Americans among the respondents.

Barriers to Breastfeeding

Survey results showed the most significant barriers to breastfeeding involved preventable problems or concerns of the mothers. Thirty-seven percent of the women who were not currently breastfeeding their infants, listed preventable problems which resulted in an early end to breastfeeding (not enough milk) or not starting in the first place (a painful experience with a previous infant). There were no significant difference between the WIC and non-WIC populations barriers to breastfeeding. Table 14

Breastfeeding Problems and Concerns:

Types of preventable problems listed by mothers Survey Population WICNon-WIC
Tried, but baby didn't breastfeed well 41% 44% 40%
Not enough milk 27% 25% 31%
Baby preferred bottle 22% 24% 21%
No help with breastfeeding problems 8% 7% 8%
Total100% 100%100%


The next most frequently stated barriers were, "I just didn't want to" (35 percent) and "planning to go to work or school" (33 percent). Planning to go to work or school shouldn't be an automatic reason not to breastfeed. Breastfeeding supplemented with pumped breastmilk or formula can be used successfully when mothers return to work or school. Implementation of baby-to-work programs or on-site child care also can support breastfeeding and parent/child bonding. More of the non-WIC population reported that they planned to return to work or school as a reason for not breastfeeding (34 percent compared to 28 percent WIC) .

Duration of Breastfeeding

Of the survey respondents, about one-half of the women who started breastfeeding still were breastfeeding 13+ weeks after delivery. Thirty-seven percent of the women still breastfeeding were breastfeeding solely. They were not supplementing with formula or milk.

Of the WIC population 45 percent of the women who started breastfeeding still were breastfeeding 13+ weeks after delivery. Thirty-five percent of these women were breastfeeding solely. In the non-WIC population, 53 percent were still breastfeeding at 13+ weeks. Thirty-eight percent were breastfeeding solely.


Education about Infant Care

Injury Prevention


The Shaking Shocker

Only 51 percent of the respondents reported that a doctor, nurse or other health care professional talked to them about the possibility of brain damage as a result of shaking a baby.

A young child has a large heavy head, weak neck muscles, and a brain that is still developing. Because the brain has not yet fully developed its outer protective layer and because the space between the brain and skull is proportionately larger than in an adult, shaking a baby causes a whiplash effect. The brain strikes the inside of the skull and the baby's head moves rapidly back and forth. The brain starts to bleed, causing pressure which damages the tissue. The result can be permanent brain damage. Shaking also may damage the spine or cause broken bones, dislocations, blindness, seizures, mild to severe retardation, developmental delays, and poor motor or sensory
skills.

Preventing Shaken Baby Syndrome

The Never Do's

The Always Do's

Adapted from Don't Shake A Baby!
Kiwanis International

Car Seat and Other Safety Issues

While 94 percent of the respondents said a doctor, nurse or other health care professional talked to them about using car safety seats for their babies, only 54 percent discussed other safety tips, such as crib construction, dangers of baby walkers, dangers of playpens, etc.

Actual Car Safety Seat Use

Almost 100 percent of the infants were placed in safety seats when riding in a car. However, in this survey, 16 percent (199) of the vehicles had passenger side airbags. Of the vehicles with passenger side airbags, 16 percent of the babies were placed in car seats in the front seat facing backward. These 32 infants would be at significant risk of injury or death, if their
passenger side airbags would inflate.

Another area of concern involves the 4 percent of mothers who purchased used car seats from rummage sales or thrift stores and the 15 percent who received or purchased used car seats from family members or friends. The danger in this practice is that the history of the car seat, particularly its use in a crash, may not be known to the recipient. Furthermore, instructions about how to use the car seat may not accompany used car seats. Recent car seat check-ups by North Dakota Department of Health showed that more than three-fourths of all car safety seats were being used incorrectly.

Never place an infant seat in the front seat of a car with a passenger side air bag. Make sure children under 12 years old sit in the back seat and are buckled up, or are strapped into a child seat appropriate for their age and weight.


Education about Infant Care

Most Useful Source of Help in Learning to Care for Baby

Learning to Care for an Infant

As with prenatal care, non-WIC primiparas indicated "my own study of books, pamphlets, videos, etc." as the most useful source of information about infant care. "Family and
friends" was the most useful source for WIC primiparas. Multiparas and the Medicaid population indicated "experience with other children" as their most useful source.

Table 15

Most Useful Source of Help in Learning to Care for Baby

(Bold numbers indicate most useful source in each category)

SourceSurvey primipara Survey multipara WIC primipara Non-WIC primipara WIC multipara Non-WIC WIC multipara Medicaid
Books/ Pamphlets Self Study 28% 9% 22%32% 8%10% 13%
Family/ Friends 27% 8%25% 29%8% 9%15%
Doctor/ Clinic Nurse 16%12% 19%15% 14%11% 20%
Prenatal Classes 6% 1%4% 6%<1% 2%2%
Packet of Materials from Clinic 4%2% 4%4% 2%2% 3%
Experience with Other Children 3%59% 3%3% 55% 61% 29%
Other*16% 8%24% 9%13% 6%18%
Total100% 100%100% 100%100% 100%100%
*Other: Hospital nurses, WIC and OPOP staff, Parenting the First Year Newsletter, child care providers, mother's own educational/professional background (nursing, dietetics, etc.)


Baby Steps Keepsake Book

In 1992, the North Dakota Department of Human Services and the North Dakota Department of Health developed and began distributing a prenatal and infant care booklet called Baby Steps Keepsake. The booklet provides information about healthy pregnancies and infant care. It includes charts for recording important events during pregnancy and milestones in the baby's life. It is available free-of-charge to physicians, public health programs, hospitals, WIC programs, etc., for distribution to prenatal clients and to mothers of newborns. Only 20 percent of the survey population received and used this booklet. Another 25 percent received it, but didn't use it. Fifty-five percent did not receive the booklet.

Table 16

Distribution and Use of Baby Steps Keepsake Book

Received and Used Booklet20%
Received Booklet but Didn't Use25%
Did Not Receive Booklet55%
Total100%


Appendix

1995 Vital Records Information and Healthy People 2000 Goals

1979 1985 1995 10 Yr. Average H.P. 2000 Goal
Births 11,318 11,697 8,479 9,352
Birth Rate (per 1000 population) 17.34 17.92 13.27 14.64
Fertility Rate (per 1000 females ages 15-44 yrs.) 77.83 80.43 60.63 66.87
Pregnancies NA 13,211 9,474 10,498
Pregnancy Rate (per 1000 population) NA 20.24 14.83 16.43
Births To Teenagers (under 20 yrs.) 1306 914 810 797
Teenage Birth Rate (per 1000 females under 20 years) 42.05 29.43 36.32 35.75
Teenage Pregnancies (under 20 yrs.) NA 1352 1048 1089
Teen Pregnancy Rate (per 1000 females under 20 years.) NA 60.63 47.00 48.82
Births To Young Teens (15-17 yrs.) 412 268 273 234
Young Teen Birth Rate (per 1000 females 15-17 yrs.) 31.83 20.70 21.09 18.08
Young Teen Pregnancies (15-17 yrs.) NA 587 400 397
Young Teen Pregnancy Rate per 1,000 females 15-17 yrs.) 32.14 45.36 30.91 30.68 50 (per 1000 adolescents)
Out of Wedlock Pregnancies NA 2530 2782 2663
Out Of Wedlock Pregnancy Ratio ((OOWP/total pregnancies x 1000) NA 191.51 293.65 253.61
Out Of Wedlock Births 958 1342 1997 1762
Out Of Wedlock Birth Ratio (OOW births /total births x 1000) 84.64 114.73 235.52 188.40

1979 1985 1995 10 Yr. Average H.P. 2000 Goal
Low Weight Births (<2500 grams) 595 577 449 477
Low Weight Birth Ratio (per 1000 live births) 52.57 49.33 52.95 51.04
Incidence Of Low Weight Births (percent of live births) 5.25% 4.93% 5.29% 5.10% 5% of Live Births
Very Low Weight Births (<1500 grams) 109 91 88 84
Incidence Of Very Low Weight Births (percent of live births) .96% .778% 1.038% .898% 1% of Live Births
Resident Infant Deaths 150 100 61 77
Resident Infant Death Rate (per 1000 live births) 13.25 8.55 7.19 8.26 7.00 per 1000 Live Births
Neonatal Deaths (under 28 days old) 107 63 35 45
Neonatal Death Rate (per 1000 live births) 9.45 5.39 4.13 4.83 4.5 per 1000 Live Births
Postneonatal Deaths (28 days to one year) 43 37 26 32
Postneonatal Death Rate (per 1000 live births) 3.32 2.86 3.07 2.47 2.5 Per 1000 Live Births
Fetal Deaths 95 62 67 58
Fetal Death Rate (per 1000 live births) 8.39 5.30 7.70 6.22 5.00 per 1000 Live Births

1979 1985 1995 10 Yr. Ave H.P. 2000 Goal
First Trimester Entry into Prenatal Care 80.5% 81.3% 83.4% 81.5% 90% of Pregnant Women
Percent of Women who Smoked during Pregnancy NA NA 17.7% 20.4% (seven year average) 10% of Pregnant Women
Cesarean Delivery Rate (per 100 deliveries) NA NA 18.86 NA 15 per 100 Deliveries
Primary Cesarean Delivery (per 100 women with previous cesarean) NA NA 11.57 NA 12 per 100 Deliveries
Repeat Cesarean Delivery Rate (per 100 women with previous cesarean ) NA NA 72.9 NA 64 per 100 Women with a Previous Cesarean)
Maternal Mortality 1 1 1 .5 3.3 per 100,000 Births
Incidence of Spina Bifida & other Neural Tube Defects 15 8 8 7.4 3 per 10,000 Live Births


Glossary

(BMI) Body Mass Index: Weight in pounds times 700 divided by height in inches squared.

WT# x 700
HT² inches

Ideal Weight Gain Recommendations (CDC)
Prepregnancy Weight Status Ideal Weight Gain
Very Underweight (BMI <18.0) 28-40 lbs.
Underweight (BMI 18.0-19.7) 28-40 lbs.
Normal Weight (BMI 19.8-26.0) 25-30 lbs.
Overweight (BMI 26.1-29.0) 15-25 lbs.
Very Overweight (BMI 29.0+) 15+ lbs.

CSHS Division: The Division of Children's Special Health Services (CSHS) is part of the North Dakota Department of Human Services. CSHS, like the MCH Division, is funded in part by Title V Block Grant Funds. CSHS provides and promotes health care services for children with special health care needs. This program also facilitates development of coordinated systems of care throughout North Dakota.

FAS/FAE: Fetal Alcohol Syndrome (FAS) is the name given to a characteristic pattern of severe births defects caused by maternal alcohol consumption. For a diagnosis of FAS, at least one feature from each of three categories must be present: (1) prenatal and postnatal growth retardation with abnormally small-for-age weight, length and/or head circumference, (2) central nervous system disorders with signs of abnormal brain functioning, delays in behavioral development, and/or intellectual impairment, and (3) at least two of the following abnormal craniofacial features: small head, small eyes or short eye openings, a poorly developed philtrum (the groove above the upper lip), a thin upper lip, a short nose, or a flattened midfacial area.

Prenatally alcohol-exposed babies with birth defects who do no meet all three criteria for an FAS diagnosis may be categorized as having suspected "fetal alcohol effects" (FAE). These adverse consequences of maternal alcohol use usually include growth retardation. FAE is estimated to be about three times more frequent than FAS. One perinatal specialist estimates that as many as five percent of all birth defects may be attributable to prenatal alcohol exposure.

MCH Division: The Division of Maternal and Child Health is part of the Preventive Health Section of the North Dakota Department of Health. Funding for maternal and child health programs is provided by the US Department of Health and Human Services Title V Block Grant. Programs operated by the MCH Division include:

Multipara: A woman who has had two or more pregnancies which resulted in viable offspring; adj., multiparous.

Primipara: A woman who has had only one pregnancy that resulted in a viable offspring; adj., primiparous.


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Quick Summary

For a Healthy Pregnancy

Take a daily multi-vitamin supplement or eat a fortified cereal daily (which contains 0.4 milligrams of folic acid) before you become pregnant and in the early months of pregnancy.

If there is any chance you are pregnant, don't drink.

Stop smoking.

Learn the signs of pregnancy. (Overdue mentrual period, unususally light or mistimed period, breast tenderness, nipple sensitivity, fatigue, nausea/vomiting and frequent urination).

Get early, regular prenatal care.

Eat a balanced diet. Since a fetus is nourished by what a mother eats, it can suffer if the mother eats poorly.

Gain enough weight. A woman of normal weight should gain 25 to 35 pounds.

Avoid drinking alcohol or using illicit drugs or taking prescription or over-the counter drugs not prescribed by a doctor who is aware of the pregnancy. Drug and alcohol use limit fetal growth and can cause birth defects.

Let you doctor know about any medicine you are taking. Some are not safe for your baby. Some medicines may stain your baby's teeth. A drug called "accutane" which is used to treat acne is not safe for your baby. Pain relief products, cold medicines and drugs to clear your sinuses may have aspirin or other harmful ingredients. Aspirin can cause bleeding problems for you and your baby.

Exercise moderately every day.

Practice safe food preparation. Wash hands frequently before and during food preparation. Cook meats thoroughly, wash raw fruits and vegetables and drink only pasteurized milk and juices.

When you use cleaning products, wear rubber gloves and make sure there is plenty of ventilation where you are working.

Stay away from paint fumes. They may harm your unborn child. Let someone else paint your baby's room.

Stay away from insect poison and week killers. Let someone else do jobs in the garden or work with your plants if these products have been used.

If you're under stress, share that information with your health care provider. There are programs that may help you. Having someone listen to you can help. Give yourself some time each day to relax. Exercising and eating regularly can help reduce stress.

Wear your seat belt.

Practice good dental care. Floss everyday, brush at least twice a day; and visit your dentist.

Keep Your Baby Healthy

Breastfeeding—learn as much as you can before pregnancy, ask for help and get off to a good start.

Good nutrition makes for a healthy child. As your child grows, provide a variety of nourishing foods for regular meals and planned snacks.

Put baby to sleep on his or her back or side on a firm mattress. Keep baby warm, but not overheated.

If you or your partner smoke, quit. If you can't quit, smoke outdoors to protect your child against second-hand smoke.

Have your baby immunized on time. It's the best defense against many dangerous childhood diseases.

Learn how to use your infant/child car safety seat appropriately. The safest place for the baby is in the back seat. Everyone should buckle up in the car. Help avoid the leading cause of disabilities and death of children before you turn on the engine.

Give your home a safety check. Install smoke detectors, store poisonous substances out of your child's reach and know how to access emergency services.

Prevent violence by setting a good example for your children. Remember that words can hurt. Give your kids plenty of love and attention.

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Last Updated: Tuesday, September 23, 1997 2:34:59 PM
Allen Johnson - ND Dept. of Health - ajohnson@state.nd.us