The Well-Being of Canada s Young Children

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1 The Well-Being of Canada s Young Children Government of Canada Report 2011 SP E

2

3 The Well-Being of Canada s Young Children Government of Canada Report 2011

4 This publication is also available on the Internet at the following address: This report is co-published by Human Resources and Skills Development Canada, the Public Health Agency of Canada and Indian and Northern Affairs Canada. Her Majesty the Queen in Right of Canada, 2008 Paper Cat. No.: HS1-7/2012E ISBN: PDF Cat. No.: HS1-7/2012E-PDF ISBN:

5 Table of Contents Preface Chapter 1 Introduction Chapter 2 Who Are Canada s Young Children? Chapter 3 How Healthy Are Canada s Young Children? 3.1 Birth Related Indicators Healthy Birth Weight Pre-Term Birth Rate Infant Mortality Rate 3.2 Breastfeeding Intention, Initiation, and Duration 3.3 Obesity 3.4 Allegies and Asthma Allergies Asthma 3.5 Childhood Cancer 3.6 Injury Hospitalization Rate 3.7 Immunization 3.8 Mental Health and Illness Chapter 4 How Are Young Children in Canada Developing? 4.1 Motor and Social Development 4.2 Emotional Health Emotional Problems Anxiety Hyperactivity Inattention Aggression 4.3 Social Knowledge and Competence Personal-Social Score 4.4 Cognitive Learning and Language Communication Peabody Picture Vocabulary Test Revised Who Am I? Assessment Number Knowledge Assessment

6 Chapter 5 What Do We Know About Family Influences on Young Children s Development? 5.1 Who Are the Parents of Canada s Young Children? Mother s and Father s Education Parent Work/Study Status Level of Income 5.2 What Do We Know About the Child Care Arrangements of Families with Young Children? 5.3 What Do We Know About Prenatal Practices? Tobacco Use During Pregnancy Alcohol Consumption During Pregnancy 5.4 What Do We Know About the Well-Being of Parents? Parental Depression Parental Smoking 5.5 What Do We Know About Parenting Practices? Family Functioning and Parental Interactions Reading by an Adult Chapter 6 How Are Children in Middle Childhood in Canada Developing? 6.1 Physical Development Physical Activity Level 6.2 Cognitive Development Standardized Classical Scaled Math Score 6.3 Social Development Emotional Health Hyperactivity Inattention Physical and Indirect Aggression 6.4 Family Family Type Family Functioning and Positive Interaction with Parents Parents and Children Reading Together Parents and Children Eating Meals Together 6.5 Daily Activities Time Spent Daily Watching TV, DVDs, Playing Video Games Time Spent on Computer Outside of School 6.6 Neighbourhood Neighbourhood Cohesion and Safety

7 Chapter 7 Monitoring the Well-Being of Canada s Young Children Chapter 8 What Do We Know About the Well-Being of Young Aboriginal Children in Canada? 8.1 Introduction 8.2 Overview of the Population of Aboriginal Children 8.3 Family Arrangements 8.4 Early Learning Experiences 8.5 Participation in Traditional Activities 8.6 Child Care Arrangements Chapter 9 What Do We Know About Young Children with Disabilities in Canada? 9.1 Introduction 9.2 Who Are Young Children with Disabilities in Canada? 9.3 What Are the Impacts of Having a Child with a Disability? Annex A Technical Notes for Indicators Presented

8 List of Figures Figure 1 Figure 2 Figure 3 Percentage of Children from Birth to 5 Years of Age by Place of Residence, to Percentage of Children from Birth to 5 Years of Age by Family Type, to Percentage of Children Born at Low Birth Weight and High Birth Weight by Gender, Figure 4 Low Birth Weight Infants, 2007 Figure 5 Pre-Term Birth Rate by Gender, Figure 6 Figure 7 Figure 8 Figure 9 Prevalence of Diagnosed Asthma Among Children from Birth to 5 Years of Age in Rural and Urban Areas, to Reported Incidence (per 100,000) of Measles, Invasive Meningococcal Group C Disease, and Invasive Haemophilus Influenzae Type B Disease Among Children from Birth to 5 Years of Age, Percentage of Children from Birth to 3 Years of Age Displaying Average to Advanced Motor and Social Development Percentage of Children from 4 to 5 Years of Age by Score on the PPVT-R, Who Am I? and Number Knowledge Assessment Figure 10 Percentage of Males and Females Who Displayed Average and Advanced Levels on the Who Am I? Test Figure 11 Percentage of Male and Female Children Who Displayed Average to Advanced Levels on the Number Knowledge Test Figure 12 Children from 4 to 5 Years of Age with Delayed Cognitive Test Scores by Level of Parental Education, to Figure 13 Work/Study Status of Parents with Children from Birth to 5 Years of Age by Family Type, to Figure 14 Percentage of Families Living Below the Post-Tax Low-Income Cut-Off (LICO), Figure 15 Primary Child Care Arrangement for Children from 1 to 5 Years of Age by Type of Child Care Used, and Figure 16 Non-Parental Child Care for Children from 1 to 5 Years of Age by Number of Hours per Week, and Figure 17 Parental Depression and Outcomes of Children from 2 to 5 Years of Age, Figure 18 Incidence of Smoking Among Parents with Children from Birth to 5 Years of Age by Rural/Urban Status, and Figure 19 Percentage of Children from Birth to 5 Years of Age Living in Well-Functioning Families and Having Positive Interactions with Their Parents by Location, and Figure 20 Percentage of Children from Birth to 5 Years of Age by Frequency of Reading Activities, Figure 21 Cognitive Development of Children from 4 to 5 Years of Age by Frequency of Reading Activities, Figure 22 Physical Activity Level of Males and Females from 6 to 9 Years of Age in Urban and Rural Locations,

9 Figure 23 Standardized Classical Scaled Math Scores of Males and Females from 6 to 9 Years of Age in Urban and Rural Locations Figure 24 Emotional Anxiety Level of Children from 6 to 9 Years of Age by Rural/Urban Status, Figure 25 Hyperactivity Inattention Levels of Males and Females from 6 to 9 Years of Age, Figure 26 Indirect and Physical Aggression of Males and Females from 6 to 9 Years of Age, Figure 27 Level of Family Functioning Within Families of Children from 6 to 9 Years of Age, Figure 28 Frequency of Reading to or Listening to a Child Read for Children from 6 to 9 Years of Age Figure 29 Number of Days per Week Children from 6 to 9 Years of Age and Their Parents Ate Meals Together Figure 30 Time Spent Daily Watching TV, DVDs, and Playing Video Games or Using a Computer Outside of School by Children from 6 to 9 Years of Age Figure 31 Level of Neighbourhood Cohesion and Safety for Children from 6 to 9 Years of Age by Urban/Rural Status Figure 32 Percentage of Aboriginal Children form 2 to 5 Years of Age Who Hear Stories, Read Books and Count at Least Once per Day Figure 33 Percentage of First Nations, Inuit and Métis Children Who Have Ever Participated in Traditional Activities, Seasonal Activities or Hunting, Fishing and Camping Figure 34 Use of Child Care for Aboriginal Children Under 6 Years of Age Figure 35 Type of Disability for Children from Birth to 4 Years of Age in Canada, 2006 Figure 36 Employment Impacts on Parents of Children with Disabilities from Birth to 4 Years of Age in Canada, 2006 Figure 37 Requirements for Supports Within the Home for Parents of Children with Disabilities from Birth to 4 Years of Age in Canada,

10 List of Tables Table 1 Measured Child Body Mass Index (BMI) of Children from 2 to 5 Years of Age in Canada, 2004 (%) Table 2 Prevalence of Reported Allergies Among Children form Birth to 5 Years of Age (%) Table 3 Age Standardized Incidence Rates of Cancer Among Children form Birth to 4 Years of Age (per 100,000 Population) Table 4 Percentage of Injury Hospitalization, Selected Injuries, Table 5 Table 6 Table 7 Overview of Indicators of Child Well-Being Means and Confidence Intervals for Indicators of Child Well-Being Living Arrangements of Children from Birth to 5 Years of Age by Aboriginal Group, Canada, 2006 Census

11 Preface In September 2000, the Government of Canada and provincial and territorial governments reached an agreement to improve and expand the services and programs they provide for children under 6 years of age and their families. 1 In the federal/ provincial/territorial (F-P/T) Communiqué on Early Childhood Development, Canada s First Ministers committed to help young children reach their potential, and to help families and the communities in which they live support their children. Recognizing the importance of being accountable to citizens, as part of the Communiqué governments committed to report regularly to Canadians on a common set of indicators of young children s well being. These indicators provide valuable information on the physical and emotional health and early development of young children in Canada. This report fulfills the Government of Canada s commitment to report on the well being of Canada s young children. This is the fifth report on young children s well-being released by the Government of Canada. This report expands on the F-P/T common set of indicators to provide a more comprehensive portrait of children from birth to 5 years of age (inclusive) in Canada and for the first time includes information on children 6 to 9 years of age (inclusive). It includes additional indicators of children s physical and emotional health, safety and security, and early development, as well as an overview of the families and communities in which young Canadian children are growing up. The data presented in this report have been taken from government sources and are for unless otherwise indicated. As part of their commitment to public reporting in the Communiqué on Early Childhood Development, governments also agreed to report annually to Canadians on their progress in enhancing early childhood development programs and services. As a complement to the information in this report, the reader may wish to refer to the Federal Activities and Expenditures for Young Children database, available at which provides information on the progress the Government of Canada has made in enhancing federally delivered early childhood development programs and services. In addition to fulfilling the reporting commitments of the F-P/T Communiqué on Early Childhood Development, this report contributes to Canada s obligations to report on the United Nations Convention on the Rights of the Child (UNCRC). Together with the Federal Activities and Expenditures for Young Children database, this report exemplifies Canada s commitment to transparent accountability and reporting related to young children. 1 While the Government of Quebec supports the general principles of the Early Childhood Development Agreement, it did not participate in developing this initiative because it intends to preserve its sole responsibility for social matters. However, Quebec receives its share of federal funding and the Government of Quebec is making major investments in programs and services for families and children. 9 Preface

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13 1 Chapter 1 Introduction The Importance of Monitoring Child Well-Being Research continues to demonstrate that a strong start in early childhood is critical for long-term health and well-being because of the rapid social, cognitive and physical development and learning that occurs during this period. What happens in a child s early years has long term implications for the individual and for society as adults are constructed in childhood. Negative experiences in the early years may have long-lasting effects that are not easily overcome later in life. Experts and decision makers agree that it is important to monitor children s well-being and development to help build awareness and understanding of how young children in Canada are developing. It is also important to understand the role that families, communities and public services play in contributing to this development. Ongoing monitoring may also help to identify areas where children and their families may need more support in order to facilitate healthy child development in the early years. Wellbeing in the early years can be assessed by looking at several factors such as: overall health and safety; motor, social and cognitive development; and the environments in which children grow up. Healthy children emerge most often from healthy families, and healthy families are in turn promoted by healthy communities. 2 Parents, relatives and caregivers are a primary support for children and have a major role in shaping their development. This is particularly important in a child s formative years, during which most of their foundational development occurs. In turn, families are often shaped by the communities in which they live. Whether based on geography, ethnicity or interests (e.g., religious groups, parent groups), communities provide a foundation for family life that can have a profound effect on the well-being of children. The F-P/T Communiqué on Early Childhood Development Reporting on Young Children s Well-Being The September 2000 F-P/T Communiqué on Early Childhood Development, as agreed to by First Ministers, 3 commits governments to report regularly on indicators of young children s well-being. In response, F-P/T governments identified a common set of indicators that provide information on the physical health and early development of young children in Canada. While incorporating data from multiple sources, this common set of indicators is based primarily on data from the National Longitudinal Survey of Children and Youth (NLSCY), a biennial survey designed to broaden our knowledge of children in Canada, and in particular young children. To correspond with the availability of data, participating governments agreed to release a report on young children s well-being for their jurisdiction biennially. 4 Release of these reports by all participating governments will mark the fifth time that governments are reporting to the public on a set of jointly agreed indicators of young children s well-being. 2 D.P. Ross, K. Scott, and M.A. Kelly (1996). Overview: Children in Canada in the 1990s. in Growing Up in Canada National Longitudinal Survey of Children and Youth. Ottawa: Human Resources and Skills Development Canada and Statistics Canada. 3 While the Government of Quebec supports the general principles of the Early Childhood Development Agreement, it did not participate in developing this initiative because it intends to preserve its sole responsibility on social matters. However, Quebec receives its share of federal funding and the Government of Quebec is making major investments in programs and services for families and children. 4 The NLSCY currently collects data only for children living in the provinces. As a result of the lack of comparable data the Territories are not required to release reports on young children s well-being but can choose to report on available indicators, if desired. 11 Chapter 1 Introduction

14 The Early Childhood Development Agreement Common Indicators of Young Children s Well-Being Physical health and motor development Emotional health Social knowledge and competence Healthy birth weight Incidence of meningococcal group C disease Incidence of measles Incidence of haemophilus influenza-b (Hib) Infant mortality rate Motor and social development Emotional problem anxiety Hyperactivity inattention Physical aggression conduct problem Personal-social behaviour Cognitive learning and language communication Peabody picture vocabulary test The Government of Canada s Fifth Report on Young Children s Well Being This is the Government of Canada s fifth report to Canadians on young children s well-being. This report provides an evidence based discussion of the common set of indicators of young children s well being identified by F-P/T governments. The data is supplemented by additional indicators of children s physical health, as well as measures of key family and community influences on child well-being. Given the commitment to continuously improve the quality of reporting over time, additional indicators beyond those presented in the first four Government of Canada reports have been added in order to provide a more comprehensive picture of child well-being. In an effort to enhance our understanding of children s development beyond the early years, this report presents information from the NLSCY on children six to nine years of age. While retaining its integrity as a monitoring report, this fifth edition examines possible relationships between the indicators presented, focusing primarily on the interaction between family determinants and child development. Despite this cursory examination, additional research is required to determine the factors that may influence the movement of the indicators presented. In an effort to expand the knowledge on young Aboriginal children and their families, this report presents information from the 2006 Aboriginal Children s Survey. The information on young children with disabilities and their families is taken from the 2006 Participation and Activity Limitations Survey. A technical annex describes the measures used to develop the indicators presented. 12 The Well-Being of Canada s Young Children Government of Canada Report 2011

15 62 Chapter 2 Who Are Canada s Young Children? The share of young children as a proportion of the Canadian population is declining According to the most recent Census, in 2006, there were 2,034,805 children from birth to 5 years of age, representing 6.4% of the total Canadian population. 5 This is a decline from the previous Census in 2001 where there were 2,076,255 children of that age, representing 6.9% of the Canadian population. Most of Canada s young children continue to live in urban centres After peaking in at 89.1%, the proportion of young children living in urban centres declined slightly to 88.3% in Figure 1 Percentage of Children from Birth to 5 Years of Age by Place of Residence, to Year Percentage (%) Rural Urban Source: National Longitudinal Survey of Children and Youth, Cycles 3 ( ) through 7 ( ). 87% of young children live in two-parent families The proportion of young children living in two-parent families declined slightly from 87.5% in to 87.0% in , although still a slight increase from when 86.1% of young children were living in two-parent families. 6 5 Statistics Canada. Custom tabulation, 2006 Census 100% data. 6 Those children who do not live with a parent were not included in the calculation of percentages. 13 Chapter 2 Who Are Canada s Young Children?

16 Figure 2 Percentage of Children from Birth to 5 Years of Age by Family Type, to Year Percentage (%) Single-parent family Two-parent family Source: National Longitudinal Survey of Children and Youth, Cycles 4 ( ) through 7 ( ). A growing proportion of young children have at least one parent who was born outside Canada In , 29% of young children had at least one parent who was not born in Canada. This figure increased gradually over the prior decade, up from 23% in The Well-Being of Canada s Young Children Government of Canada Report 2011

17 3 6 Chapter 3 How Healthy Are Canada s Young Children? Highlights In Canada, in : 82.3% of babies were born at a healthy weight. 91.6% of babies were born at term or later. The infant mortality rate was 5.1 deaths per 1,000 live births. 9.3% of children from birth to 5 years of age had at least one reported allergy. 7.3% of children from birth to 5 years of age had asthma that was diagnosed by a physician. Leukemia is the most common type of cancer among young children. 3.1 Birth Related Indicators Healthy Birth Weight More than eight out of ten infants were born at a healthy weight In 2007, 82.3% of infants were born at a healthy weight (2,500 grams to 4,499 grams), 6.0% of infants were born at a low birth weight (weighing less than 2,500 grams) and 11.7% of infants were born at a high birth weight (weighing 4,500 grams or greater). The proportion of infants born at a healthy weight is consistent with previous years (82.1% in 2005 and 82.3% in 2006). Similarly, the percentage of infants born at a low birth weight remained constant (6.0% in 2005 and 6.1% in 2006), as did the percentage of infants born with high birth weight (11.9% in 2005 and 11.6% in 2006). 7 In 2007, more females (6.4%) were born at a low birth weight than males (5.6%). Similarly, in the same year, a greater percentage of high birth weight infants were males (14.3%) compared to females (8.8%). 7 Statistics Canada, Canadian Vital Statistics Birth Database (CANSIM ). 15 Chapter 3 How Healthy Are Canada s Young Children?

18 Figure 3 Percentage of Children Born at Low Birth Weight and High Birth Weight by Gender, Percentage (%) Percentage (%) of Live Births at Low Birth Weight (>2,500 Grams) Male Female Percentage (%) of Live Births at High Birth Weight (>4,000 Grams) Source: Statistics Canada, Canadian Vital Statistics, Birth Database (CAN SIM ). while internationally In 2007, the OECD average proportion of infants born at low birth weight was 6.8%. Although Canada s rate of low birth weight was lower than this average (5.2%), the Nordic countries, such as Iceland, Sweden and Finland, reported rates of less than 4.5%. By comparison, Turkey, Japan, Greece, the United States and Hungary reported the highest rates, at rates exceeding 8%. The OECD has observed a modest increase in the rate of low birth weight among many member countries, which it suggests may be due to the rise in the number of multiple births partly from fertility treatments, older maternal age, and increases in the use of delivery management techniques such as induction of labour and caesarean delivery. 8 8 Health at a Glance 2009: OECD Indicator and Health Data The Well-Being of Canada s Young Children Government of Canada Report 2011

19 Figure 4 Low Birth Weight Infants, Iceland Sweden Finland Luxembourg Korea Ireland Norway New Zealand Poland Canada Netherlands Australia Switzerland Denmark Italy OECD France Germany United Kingdom Austria Czech Republic Slovak Republic Spain Mexico Portugal Belgium Hungary United States Greece Japan Turkey (2003) n.a n.a n.a n.a Percentage (%) of Newborns Weighing Less Than 2,500 Grams Percentage (%) Change Over Period Source: OECD Health Data Why is this important? An infant s weight is an important indicator of overall newborn health. It is also a key determinant of infant survival, health and development. Low birth weight can result when a baby is born too soon (pre-term) or when infants are born small for gestational age (SGA). 9 A low birth weight increases the risk of prolonged hospitalization, of dying during the first year of life, and of developing learning, behavioural and emotional difficulties or chronic health problems M.S. Kramer (1987). Determinants of Low Birth Weight: Methodological Assessment and Meta-Analysis. In World Health Organization Bulletin, 65(5): Institute of Health Economics (2008), Determinants and Prevention of Low Birth Weight: A Synopsis of the Evidence, IHE, Alberta, Canada. 17 Chapter 3 How Healthy Are Canada s Young Children?

20 Risk factors for low birth weight include mother s age, ethnicity, a prior history of giving birth to a low weight baby, poor maternal nutrition, use of harmful substances like tobacco, excessive alcohol consumption, low maternal Body Mass Index, poor socioeconomic status, and a history of in-vitro fertilisation treatment. 11 Large-for-gestational-age (LGA) births refer to infants whose birth weight is above the standard 90 th percentile of the sex specific birth weight for gestational age. Similarly to SGA births, infants born at a high birth weight have an increased risk of suffering injuries during birth, death within the first month of life, as well as developmental and intellectual problems. 12 Difficulties for the mother include postpartum haemorrhaging and increased rate of caesarean delivery. 13 High birth weight has been associated with maternal obesity, prolonged gestation and maternal diabetes Pre-Term Birth Rate The pre-term rate remains relatively stable at 7.8% The pre-term birth rate is the proportion of live births with a gestational age of less than 37 completed weeks or 259 days. In 2007, as in 2005, 7.8% of births were pre-term. In 2007, 91.6% of babies were born at term and 0.6% of babies were born post-term at a gestational age of 42 weeks or more. Males are consistently more likely to be born pre-term than females. In 2007, 8.1% of males and 7.4% of females were born preterm. The combined rate for both sexes has been relatively constant since 2003 (7.7% 7.9%).15 Figure 5 Pre-Term Birth Rate by Gender, Percentage (%) Male Female Both sexes Source: Canadian Vital Statistics Birth Database ( ) (Statistics Canada). 11 Health at a Glance 2009: OECD Indicator and Health Data H. Macmillan et al. (1999). Chapter 1 Children s Health. First Nations and Inuit Regional Health Survey. Ottawa: First Nations and Inuit Regional Health Survey National Steering Committee. 13 T. Harder, E. Rodekamp, K. Schellong, J.W. Dudenhausen, and A. Plagemann. Birth weight and subsequent risk of type-2 diabetes: a meta analysis. American Journal of Epidemiology. 2007:165(8): R.F. Dyck, and L.Tan. Differences in High Birth weight Rates between Northern and Southern Saskatchewan: Implications for Aboriginal Peoples. Chronic Diseases in Canada, (3). 15 Statistics Canada, Canadian Vital Statistics Birth Database (CANSIM ). 18 The Well-Being of Canada s Young Children Government of Canada Report 2011

21 Why is this important? Pre-term birth is the leading cause of infant death and neonatal illness in industrialized countries. 16 In particular, pre-term babies are more likely to have respiratory, gastrointestinal, immune and central nervous system complications, as well as hearing, and vision impairments. Long-term issues associated with pre-term birth include cerebral palsy, intellectual disability, behaviour and social-emotional concerns, learning difficulties, and poor growth and development. 17 One to two percent of all infants are born before 32 weeks and account for nearly 50% of all long-term neurological illnesses and about 60% of infant deaths. 18 Babies born between 32 and 36 weeks, which make up the greatest number of pre-term births, are at especially high risk for health and developmental problems compared to those born full term. 19 Maternal characteristics associated with increased likelihood of pre-term birth include single marital status, younger or older maternal age, previous pre-term delivery, infection, maternal smoking, low pre-pregnancy weight, low or high weight gain, maternal stress, multiple gestation, and ethnicity Infant Mortality Rate Canada s infant mortality rate remains relatively stable The infant mortality rate is defined as the number of babies who are born alive but who die within the first year of life per 1,000 live births. In 2007, the infant mortality rate was 5.1 deaths per 1,000 live births, slightly higher than the rate in 2006 (5.0) but lower than 2005 (5.4) and 2004 (5.3). 21 Infant mortality can be further divided into neonatal (0 to 27 days) and post-neonatal mortality (28 to 364 days). In 2007, almost three-quarters of Canadian infants who died during the first year of life were neonatal infants. Immaturity was the leading cause of death for these infants; whereas congenital anomalies were the most common cause of post-neonatal death. 22 Males, who constitute the greater proportion of pre-term births, continue to have a higher infant mortality rate than females. In 2007, the infant mortality rate for males was 5.5 deaths per 1,000 live births compared to 4.7 for females. 23 while internationally Like that of other OECD countries, Canada s infant mortality rate has declined dramatically since 1970 when the average rate was close to 30 deaths per 1,000 live births. Canada s rate of infant mortality has stabilized in recent years, above the OECD average of 3.9 deaths per 1,000 live births in K.S. Joseph, K. Demissie, and M.S. Kramer. Trends in obstetric intervention, stillbirth and preterm birth. Seminars in Perinatology. 2002, 26 (4):250 9; K.S. Joseph, M.S. Kramer, S. Marcoux, A. Ohlsson, S.W. Wen, A.C. Allen, et al. Determinants of preterm birth rates in Canada from 1981 through 1983 and from 1992 through New England Journal of Medicine, 1998;339(20):1434 9; M.S. Kramer, K. Demissie, Y. Hong, R.W. Platt, R. Sauve, and R. Liston. The contribution of mild and moderate preterm birth to infant mortality. Journal of the American Medical Association, 2000; 284(7): 843-9; M. Hack, and A.A. Fanaroff. Outcomes of children of extremely low birth weight and gestational age in the 1990s, Early Human Development, 1999, 53(3): Institute of Medicine, Report Brief. (2006, July) Preterm birth: Causes, Consequences, and Prevention. Washington: The National Academies Press. 18 M.S. Kramer, K. Demissie, Y. Hong, R.W. Platt, R. Sauve, and R. Liston. The contribution of mild and moderate preterm birth to infant mortality. Journal of the American Medical Association. 2000, 284(7): M. Hack, and A.A. Fanaroff. Outcomes of children of extremely low birthweight and gestational age in the 1990s. Early Human Development. 1999; 53(3): M.W. Varner, and M.S. Esplin. Current understanding of genetic factors in preterm birth, British Journal of Obstetrics and Gynecology. 2005;112 Supplements 1:28 31; M.C. Lu, and B. Chen. Racial and ethnic disparities in preterm birth: The role of stressful life events. American Journal of Obstetrics and Gynecology. 2004;191(3):691-9; G.R. Alexander, and M. Slay. Prematurity at birth: trends, racial disparities, and epidemiology. Mental Retardation Developmental Disability Review. 2002;8(4): Statistics Canada, CANSIM, table and Catalogue no. 84F0211X. 22 Statistics Canada, Canadian Vital Statistics System, Unlinked Files, Excludes Ontario figures. 23 Statistics Canada, CANSIM, table Health at a glance 2009: OEDC Indicators. Available at: 19 Chapter 3 How Healthy Are Canada s Young Children?

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