Description | Specific Indicators | Ontario Public Health Standards | Corresponding Health Indicator(s) from Statistics Canada and CIHI | Corresponding Indicator(s) from Other Sources | Data Sources |  Alternative Data Sources | Analysis Check List | Method of Calculation |  Basic Categories | Indicator Comments | Definitions | Cross-References to Other Indicators | Cited References | Changes Made | Acknowledgements

• The number of pregnancies per 1,000 females of reproductive age (15 - 49 years of age) or age-specific pregnancy rate by 5-year age group. Pregnancies include live births, stillbirths (or deliveries), and therapeutic abortions.

• Total pregnancy rate
• Age-specific pregnancy rate
• Teen pregnancy rate or Adolescent pregnancy rate

• Board of Health Outcome (Reproductive Health): The board of health is aware of and uses epidemiology to influence the development of healthy public policy and its programs and services for the promotion of reproductive health.
• Board of Health Outcome (Sexual Health sexually transmitted infections and blood-borne infections (including HIV)): The board of health is aware of and uses epidemiology to influence the development of healthy public policy and its programs and services to promote healthy sexuality and to prevent or reduce the burden of sexually transmitted infections and blood-borne infections.
• Board of Health Outcome (Foundational Standard): The public, community partners, and health care providers are aware of relevant and current population health information Assessment and/or Surveillance Requirements Related to this Indicator

• The board of health shall conduct epidemiological analysis of surveillance data, including monitoring of trends over time, emerging trends, and priority populations....in the area of reproductive health outcomes.

The Internet publication Health Indicators, produced jointly by Statistics Canada and the Canadian Institute for Health Information, provides over 80 indicators measuring the health of the Canadian population and the effectiveness of the health care system. Designed to provide comparable information at the health region and provincial/territorial levels, these data are produced from a wide range of the most recently available sources.

Teen pregnancy

While teen pregnancy is still considered an indicator in the Health Indicators Framework, the link in the e-publication has been removed because the Pregnancy Outcomes publication is no longer being maintained by Statistics Canada (1). Old versions of the Pregnancy Outcomes publication are still available providing pregnancy rates by age group at the provincial level only, but not for public health units. Note that there are three key differences between the APHEO Core Indicator definition and Statistics Canada's indicator. Statistics Canada's teen pregnancy indicator has the following characteristics:

1. Live birth counts were based on registrations in the Birth Database from Statistics Canada.
2. Fetal loss included miscarriages as well as stillbirths. Miscarriages were extracted from the Hospital Morbidity Database using ICD-9 code 634 and ICD-10-CA code O03, depending upon the year. Other included fetal loss codes from ICD-9 were 636 (illegally induced abortion which is no longer a valid code in ICD-10-CA) and 637 (unspecified abortion which is also no longer a valid code in ICD-10-CA). The ICD-10-CA code O05 was included. This code captured "other abortion", including self-inflicted abortion, and abortion following trauma. These categories were not captured in ICD-9 (2).
3. Therapeutic abortions occurring in selected American states for Canadian residents were included prior to 2004. From 1971 to 2003, health departments in several American states, especially those along the Canada and United States border supplied information about abortions obtained by Canadian residents. These counts, however, should be regarded as a minimum estimate because not all American states submitted reports, some private clinics may not have reported to the state health department or the residence of the patient was not reported. As of 2004, this information was no longer collected.
   

Note that the APHEO Core Indicator uses live birth counts that may not necessarily be from Vital Statistics, does not include fetal losses, and does not include therapeutic abortions occurring outside of Ontario. 

• None

Note that 3 data sources are listed for use: 1) Vital statistics, 2) Hospitalization, 3) BORN. The choice of data source will depend upon data quality within a health unit as well as data access and the specific analysis questions. For information related to the data sources, refer to the Data Source resources and the Reproductive Health Core Indicators Documentation Report.

AND 

Numerator: Therapeutic Abortions (TAs)
Original source: Hospital TAs: Canadian Institute for Health Information (CIHI), Clinic TAs: Ontario MOHLTC, Private Physician Office (PPO) TAs: Ontario MOHLTC
Distributed by: Ontario Ministry of Health and Long-Term Care (MOHLTC): IntelliHEALTH ONTARIO (IntelliHEALTH)
Suggested citation (see Data Citation Notes): Hospital and Medical Services Data [years], Ontario Ministry of Health and Long-Term Care, IntelliHEALTH ONTARIO, Date Extracted: [date].

Denominator: Population Estimates
Original source: Statistics Canada
Distributed by: Ontario Ministry of Health and Long-Term Care (MOHLTC): IntelliHEALTH ONTARIO (IntelliHEALTH)
Suggested citation (see Data Citation Notes): Population Estimates [years], Ontario Ministry of Health and Long-Term Care, IntelliHEALTH ONTARIO, Date Extracted: [date].

• None

• The IntelliHEALTH licensing agreement does not require suppression of small cells, but caution should be used when reporting at a level that could identify individuals, (e.g. reporting at the postal code level by age and sex). Please note that privacy policies may vary by organization. Prior to releasing data, ensure adherence to the privacy policy of your organization.
• Aggregation (e.g. combining years, age groups, categories) should also be considered when small numbers result in unstable rates.
• Exclude births to mothers that reside out-of-province.
• Births to Ontario mothers that occur out-of-province are not included in the data.
• Include live births with birth weight <500g. For more information, refer to the Reproductive Health Core Indicators Documentation Report.
• HELPS Data: Historically, PHUs obtained data for live births, stillbirths, therapeutic abortions, congenital anomalies, and deaths from the Ministry of Health through HELPS (the HEalthPlanning System). Although these data are no longer commonly used, some PHUs may still be accessing these data files. Information about the data can be found in the HELPS Data Source resource.

• In IntelliHEALTH under Standard Reports, folder "01 Vital Stats", open "Birth Summary V2". This report summarizes information on births by age group and mother's residence (Ontario, PHU and LHIN). IntelliHEALTH also provides population data (total population, female population aged 15-49 years) for the calculation of rates. Refer to the Notes tab for information. Open tab "1.2 Births x PHU x Type x Age" to obtain public health unit data and tab "1.1 ON Births x Type x Age" to obtain Ontario data. The report can be modified, renamed and saved under your own folder or can be exported into Excel.
• The predefined report provides birth and population data for the calendar years from 1986 to the most recent available. Table options can be edited to change the number of years of data presented. For years that are not displayed modify the calendar year filter to include the required years.
• Age is grouped by 5-year categories from 10-14 to 55-59 years of age but can be edited to obtain single years. For calculation of teen pregnancy rate, select births 15-19 years of age.
• Use the total number of births (live births and stillbirths) for pregnancy rate calculations.
• The data contained in the Birth Summary v2 report includes births to Ontario mothers in Ontario only.
• The notes section of the report provides important data caveats and information and should be consulted.
• Refer to the Vital Statistics Live Birth Data Source and Vital Statistics Stillbirth Data Source for more information about the data.

• Since this indicator requires the number of births by age of mother, and maternal age is not available in the newborn record, the number of deliveries rather than number of newborns is used.
• Predefined reports have been created for teen pregnancy, located in Standard Reports > 50 APHEO Public Health Indicators. There is the static report "Teen Pregnancy Rates, by PHU 2003-[most recent year]" and the predefined report "Teen Pregnancy, by PHU".
• Alternatively, in IntelliHEALTH under Standard Reports, folder "05 Inpatient Discharges", open "Hospital Births - obstetric deliveries". Refer to the Notes tab for information. Open "PHU - Deliveries x Birth Type x Mother's Age" to obtain public health unit data and "ON - Deliveries x birth type x mother's age" to obtain Ontario data. The report can be modified, renamed and saved under your own folder or can be exported into Excel.
• Select the appropriate calendar years and PHU as prompted from the pre-defined filters.
• Group the birth types (Z37 codes).
• Age is grouped by 5-year categories from 10-14 to 55-59 years of age. For calculation of teen pregnancy rate, select deliveries by females 15-19 years of age.
• The report can be edited to obtain more specific geographic information including municipality and postal code.
• The calendar year for date of admission is used (Admit CYear) rather than date of discharge. This may or may not correspond to when the baby was born since date of admission is taken from the maternal record. If the mother was admitted a significant time before the birth, then the admission year may be different from the discharge year. Even though counts are grouped by calendar year of admission, it is the actual numbers of discharges that are counted.
• The predefined reports provide data for the calendar years from 2003 to the most recent available. The query is updated when the hospital inpatient table is refreshed.
• The notes section of the report provides important data caveats and information and should be consulted.
• Refer to the Hospitalization Data Source for more information about the data, including births and deliveries.

• Public Health Units access BORN data through public health reports and data cubes.
• Refer to the BORN Information System resource for more information about the data.

• In IntelliHEALTH under Standard Reports, folder "20 Ontario - Special Reports", open "Therapeutic Abortion Summary v2". Refer to the Notes tab for information. Open "PHU TAs x age group x year" to obtain public health unit data and "ON TAs x age group x year" to obtain Ontario data. The report can be modified, renamed and saved under your own folder or can be exported into Excel.
• The predefined report provides data for the calendar years from 2003 to the most recent available. The query is updated when the medical services table is refreshed.
• The report can be edited to obtain more specific geographic information including municipality and FSA.
• The "Adjusted number TAs" should be used for pregnancy rates because this adjusts for repeated TA procedures within 40 days of a previous TA and likely reflects complications from the first procedure.
• The TA query was changed in 2011 to include TAs provided in private physicians' offices (PPO) along with those performed in hospitals and free-standing abortion clinics. Because the number of PPO TAs has increased over time, teen pregnancy rates in some PHUs may have increased markedly over what was previously calculated.
• The notes section of the report provides important data caveats and information and should be consulted.
• Refer to the Therapeutic Abortion Data Source for more information about the data.

• Overall: 15-49
• Age-specific: 10-14, 15-19, 20-24, 25-29, 30-34, 35-39, 40-44, 45-49, 50-55.
• Adolescent or teen: 15-19
• Geographic areas of patient residence:
• Vital Statistics, Hospitalization, Population Estimates data: Ontario, public health unit, municipality, and smaller areas of geography based on aggregated postal code. TA data does not contain postal code.
• BORN data: Ontario, public health unit

• Some pregnancy rates also include an estimate of fetal loss (spontaneous abortion and ectopic pregnancy) in their calculation. A Health Reports, CIHI (1995) update and other reports have included miscarriages in their pregnancy rates. Some pregnancy rates use "miscarriage estimates" based on survey data rather than hospital separations for miscarriages. Still other pregnancy rates are calculated using both miscarriages and ectopic pregnancies. Determine method of calculation before making comparisons.
• Theoretically, multiple births should be adjusted to count pregnancies not births. Although this can be done analytically, it is not often done in practice. The small number of multiple births does not generally affect the pregnancy rate. If using Vital Statistics or BORN, multiple births are counted as multiple pregnancies in the numerator and no adjustments are made for them. If using hospitalization data, deliveries are counted with multiple births considered as one delivery.
• Age of mother is recorded at time of event: birth, stillbirth or therapeutic abortion. A female who becomes pregnant when 19 but who delivers at age 20 will not count as a teenage pregnancy.
• Residence of mother is recorded at time of event. An area may have a high teenage pregnancy rate as a result of pregnant teens moving to that area to have their babies because of good support services and affordable housing.
• The Core Indicators formerly had a separate indicator for Therapeutic Abortions. Given that TAs are analyzed within the context of pregnancy rate, information from that indicator has been incorporated here. Because of changes that have occurred over time in methodology (e.g. inclusion of TAs occurring in PPOs) and in accessibility to the procedure in some areas (e.g. decreasing use of hospitals and increasing use of clinics and PPOs), it may be useful for PHUs to do more detailed analysis of TA trends in their areas. This information is generally provided internally for program staff and is not released to the public due to its sensitive nature. Calculations that will help inform changes in pregnancy rates include:

• Therapeutic abortion may be an indicator of unwanted or unplanned pregnancy.
• Therapeutic abortions may be performed to discontinue pregnancies with abnormal findings (e.g. neural tube defects) as a result of prenatal screening.
• Therapeutic abortion rates and ratios may be affected by access to medical care and/or access or use of contraceptive options. Changes over time may be related to access to medical care including ease of travel to out-of-province services.
• Medically/pharmacologically-induced abortions, those induced by the emergency contraceptive pill, RU 486, or methotrexate (usually reserved for ectopic pregnancies), are not captured in the TA data.
• Abortions completed out-of-province are not included. This number may constitute a relatively large number of abortions, especially those over 20 weeks gestation.
• Some reports define teenage pregnancy for females 10 to 19 while others may use 13 to 17 years of age. Determine method before comparing.
• The teen pregnancy rate is decreasing in most developed countries, including Canada, and is most likely due to increased contraceptive use (3-6).
• Teen pregnancy is associated with a number of adverse health and social outcomes. Babies born to teen mothers are more likely to be of low birth weight, be admitted to hospital in early childhood, and to have higher infant mortality rates (7). Young females at risk for unintended pregnancy and early child-bearing are also at higher risk of substance abuse, sexual abuse, and STIs. Teen parents are less likely to complete their education or to be employed, and are more likely to live in subsidized housing (8). However, the relationship between teen parenting and these factors is complex. Teens who become pregnant are more likely to come from socio-economically disadvantaged backgrounds (9,10).
• Adolescent pregnancy rates may vary in certain religious, cultural, and ethnic groups, particularly those where birth control is not allowed and where marriage before age 20 is common.
• Pregnancy in older mothers (aged 35+) is also associated with adverse health outcomes (11).

• Live birth - the complete expulsion or extraction from its mother of a product of conception, irrespective of the duration of the pregnancy, which, after such separation, breathes or shows any other evidence of life such as heartbeat, umbilical cord pulsation, or definite movement of voluntary muscles, whether the umbilical cord has been cut or the placenta is attached. A live birth is not necessarily a viable birth.
• Stillbirth - death prior to the complete expulsion or extraction from its mother of a product of conception. The death is indicated by the fact that after such separation the fetus does not breathe or show any other evidence of life, such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles. Only fetal deaths where the product of conception has a birth weight of 500 grams or more or the duration of pregnancy is 20 weeks or longer are registered in Canada.
• Miscarriages - pregnancies that end by spontaneous abortion before 20 weeks gestation. Some pregnancy rates are calculated using an estimate of miscarriages based on survey data. This is because most miscarriages do not require in-patient treatment.
• Therapeutic abortion - the deliberate termination of a pregnancy resulting in the death of the fetus or embryo. Also called induced abortion.
• Fetal loss - includes stillbirth, miscarriage, and ectopic pregnancy. Definitions vary according to whether ectopic pregnancy is included or not.
• Pregnancy - the gestation process, from conception through to the expulsion of the product of conception from the body whether through miscarriage, therapeutic abortion, cesarean section, or vaginal delivery.

• Youth sexual activity (Section 6A: Sexual Health)

1. Personal communication, Statistics Canada, January 13, 2012.
2. Personal communication, Paul Bellinger, Statistics Canada, August 23, 2010.
3. Best Start, SIECCAN. Update report on teen pregnancy prevention. 2007.
4. Darroch JE, Singh S, Frost JJ. Differences in teenage pregnancy rates among five developed countries: the roles of sexual activity and contraceptive use. Fam Plann Perspect 2001;33:244-50, 281.
5. Santelli JS, Lindberg LD, Finer LB, Singh S. Explaining recent declines in adolescent pregnancy in the United States: the contribution of abstinence and improved contraceptive use. Am J Public Health 2007;97:150-156.
6. McKay A, Barrett M. Trends in teen pregnancy rates from 1996-2006: A comparison of Canada, Sweden, U.S.A., and England/Wales. Can J Human Sexuality 2010;19:1-2:43-51.
7. Botting B, Rosato M, Wood R. Teenage mothers and the health of their children. Popul Trends 1998;19-28.
8. Wellings K, Wadsworth J, Johnson A, Field J, Macdowall W. Teenage fertility and life chances. Rev Reprod 1999;4:184-190.
9. Kearney MS, Levine PB. Socioeconomic disadvantage and early childbearing. Cambridge, MA: National Bureau of Economic Research; 2007. Retrieved January 16, 2013 from: http://www.nber.org/papers/w13436.pdf.
10. Luong, M. Life after teenage motherhood. Perspectives on Labour and Income. 2008; 6-13. Retrieved January 16, 2013 from: http://www.statcan.gc.ca/pub/75-001-x/2008105/pdf/10577-eng.pdf. 
11. Canadian Institute for Health Information, In Due Time: Why Maternal Age Matters (Ottawa, Ont.: CIHI, 2011). Retrieved January 16, 2013 from https://secure.cihi.ca/free_products/AIB_InDueTime_WhyMaternalAgeMatters_E.pdf.