CLINICAL AND COMMUNITY STUDIES

ETUDES CLINIQUES ET COMMUNAUTAIRES

Birthing experience of adolescents at the Ottawa

General Hospital Perinatal Centre

Suji M. Lena, MD; Emily Marko, MD; Carl Nimrod, MD; Leonide Merritt, RN; Gilberte Poirier, RN;
Elizabeth Shein, MSW
Objective: To study the experiences of prenatal care, prenatal classes and birthing among
adolescents.
Design: Anonymous self-report questionnaire survey.
Setting: Ottawa General Hospital Perinatal Centre.
Patients: A total of 100 adolescents (aged less than 20 years) and 100 control subjects
(aged over 19 years) who gave birth at the Perinatal Centre from June 1989 to August
1990.
Main outcome measures: Prenatal experiences, attendance at prenatal classes, ex-
periences in labour and delivery, postpartum care.
Results: Only 26% of the adolescent patients sought prenatal care in the first trimester,
and only 27% attended prenatal classes, as compared with 87% and 91% of the control
subjects (p < 0.001). Most of the adolescents felt uncomfortable in the same waiting
room as adult women. During labour and delivery 50% of the adolescents had their
mothers with them for support, whereas 83% of the adults had their husbands with them
(p < 0.001). Over half (59%) of the adolescents stated that they were not prepared for
labour and delivery, as compared with 26% of the adults (p < 0.001). Of the adolescents
85% opted to care for their babies after birth.
Conclusion: Pregnant adolescents do not avail themselves adequately of the medical and
psychosocial services available to them through the health care system. Our findings
suggest features of prenatal clinics that would make them attractive and accessible to
such patients.

Objectif: Etudier les experiences de soins prenatals, de cours prenatals et de l'accouche-

ment chez les adolescentes.
Conception: Enquete par questionnaire d'autoevaluation anonyme.
Contexte: Centre perinatal de I'H6pital General d'Ottawa.
Patientes: Un total de 100 adolescentes (agees de moins de 20 ans) et de 100 sujets
temoins (ages de plus de 19 ans) qui ont accouche au Centre perinatal de juin 1989 a
aouit 1990.
Principales mesures des resultats: Experiences prenatales, participation aux cours
prenatals, experiences du travail et de l'accouchement, soins post-partum.
Resultats: Seulement 26 % des patientes adolescentes ont demande des soins prenatals
pendant le premier trimestre, et seulement 27 % ont suivi des cours prenatals, par

Dr. Lena is a clinical assistant professor in the Department ofPediatrics, University of Ottawa and Children's Hospital ofEastern Ontario
(CHEO), codirector of the Eating Disorder Clinic, Smyth Medical Centre, and a member ofthe Child and Adolescent Sexual Abuse
Management Team, CHEO, Ottawa, Ont. At the time ofwriting, Dr. Marko was a third-year resident in obstetrics and gynecology,
Ottawa General Hospital and University of Ottawa. Dr. Nimrod is professor ofobstetrics and gynecology, University of Ottawa.
Mrs. Merritt is retired; she was the head nurse in the Department ofObstetrics and Gynecology, Ottawa General Hospital. Ms. Poirier is
head nurse on the Postnatal Ward, Ottawa General Hospital. At the time ofwriting, Mrs. Shein was a medical social worker on the
Postnatal Ward and was in the Department of Social Services, Ottawa General Hospital.

Reprint requests to: Dr. Suji M. Lena, Smyth Medical Centre, 314-1929 Russell Rd., Ottawa, ON KIG 4G3

JUNE 15, 1993 CAN MED ASSOCJ 1993; 148 (12) 2149
 comparaison avec 87 % et 91 % des sujets temoins (p < 0,001). La plupart des
adolescentes se sentaient mal a l'aise dans la meme salle d'attente que les femmes d'age
adulte. Pendant le travail et l'accouchement, 50 % des adolescentes ont eu le soutien de
leur mere, alors que 83 % des adultes etaient accompagnees de leur mari (p < 0,001).
Plus de la moitie (59 %) des adolescentes ont declare qu'elles n'ont pas ete preparees au
travail et a l'accouchement, par comparaison avec 26 % des adultes (p < 0,001). Au
total, 85 % des adolescentes ont choisi de s'occuper de leurs bebes apres la naissance.
Conclusion: Les adolescentes enceintes ne se prevalent pas adequatement des services
medicaux et psychosociaux qui leur sont offerts par l'entremise du reseau de soins de
sante. Nos constatations suggerent des caracteristiques qui rendraient les cliniques
prenatales interessantes et accessibles a ces patientes.

A dolescent childbearing is a public health con-
cern because of the significant medical, psy-
chologic and social risks to the mother and
her infant.'~' Poor outcomes have been attributed to
inadequate prenatal care, low socioeconomic status,
nutritional deficiencies, lifestyle, ethnic background
and marital status.4-6
Unfortunately many pregnant teenagers are re-
luctant to seek prenatal care until near the end of
their pregnancy or simply show up at the hospital in
labour.7 Because they are poorly prepared many have
a difficult labour and delivery.
Adequate prenatal care for adolescents improves
nutrition, discourages substance abuse, identifies
and treats gynecologic infections early and offers
interdisciplinary support.8 It has been associated
with delivery of infants of higher birth weight and
later gestational age.9 Such care should be based on
"age-appropriate" classes and should address the
adolescent's struggle for identity and independence,
nutritional issues, labour and delivery, parenting and
social aspects such as completion of education, living
accommodations, financial aspects of independent
living and substance abuse.'0-12
Studies of adult women have shown that their
use of antenatal care is diminished by lack of
comfort, limited waiting space,'3 inconvenient clinic
hours, long waiting time,'4 language and cultural
barriers,'5 depersonalized services, a change in phys-
ician at each visit, lack of child care, lack of
transportation and inadequate psychosocial care.'6'17
Little attention has been paid to the specific needs of
pregnant adolescents. Beliefs and teachings regarding
adolescent childbearing have changed markedly in
the past three decades.'8 Studies in Sweden'9 and
Greece20 have shown that adolescents may actually
have an easier labour with fewer complications and a
lower cesarean section rate than adults. Statistical
analyses have accounted for the effects on pregnancy
outcomes of confounding conditions such as parity,
socioeconomic status, marital status, size and health
habits.2' Low maternal age was considered a cause of
morbidity during pregnancy.2' However, it is now
known to be only a primary marker for an increased
risk of obstetric complications and neonatal morbid-
ity.
2150 CAN MED ASSOC J 1993; 148 (12)
The purpose of this survey was to (a) discover
why pregnant adolescents fail to seek medical care
during the prenatal period, (b) review the birthing
experiences of adolescents and (c) identify ways to
improve these experiences and make prenatal ser-
vices more accessible.
Methods
The Ottawa General Hospital, a teaching hospi-
tal affiliated with the University of Ottawa, accepts
patients referred from various practitioners and
university teaching staff. Adolescents choose this
facility to give birth if it is close to their residence at
the onset of labour. Others choose it if it is the one
at which their family practitioner or obstetrician has
privileges. Some are transferred there if they or their
baby is at risk.
All 102 patients less than 20 years of age who
gave birth at the Ottawa General Hospital Perinatal
Centre from June 1989 to August 1990 were asked to
complete a questionnaire during their postpartum
period in hospital. For comparison, we asked 100
women 20 years old and over who gave birth at the
centre during the same shifts to complete the ques-
tionnaire. There were no exclusion criteria as long as
the age and timing of delivery were met.
The sample size required for this study was
based on the following assumptions: (a) the propor-
tion of adult women expected to be satisfied with the
prenatal care that they received is 85%, (b) an
important difference in the rate of satisfaction with
prenatal care between the two groups is 20%, (c) the
a error rate is 0.05 (two-tailed), and (d) the d error
rate is 0.10 with a power of 90%. Therefore, we
required 190 subjects (95 per group). Allowing for a
nonresponse rate of 5%, we estimated that 200
subjects (100 per group) would be appropriate.22
Informed consent was obtained. Anonymity,
confidentiality and the option to participate in the
study was assured. Approval was obtained from the
hospital's Human Experimental Procedures Com-
mittee. In a pilot study 10 pregnant adolescents were
randomly selected 1 month before the study period
to complete the questionnaire and comment on the
clarity of the questions.
LE 15 JUIN 1993
 The questionnaire consigted of 36 questions
divided into four sections. There were several open-
ended questions inviting participants to comment on
or suggest improvements in prenatal care and in
labour and delivery. The first section included
general questions about such characteristics as age,
language, education level, ability to continue edu-
cation during pregnancy, living situation and finan-
cial situation.
In the second section, which pertained to prena-
tal care, participants were asked how they discovered
they were pregnant, how soon they first started
receiving medical care, how often they returned for
visits and what information they received. They
were also asked about prenatal classes: how many
they attended, why they did not attend and wheth-
er they felt prepared for labour and delivery. Most of
the questions required a simple Yes or No answer or
were multiple choice.
The third section involved questions about la-
bour and delivery. Participants were asked about
episodes of false labour, the admitting routine, how
they felt about labour and delivery and how much
support they received.
The final section dealt with the postpartum
period: what information participants received post
partum, how they felt in the same room as older
women (only the adolescents were asked this ques-
tion), if they felt ready to go home and what plans
they had for the baby.
The questionnaire was available in English and
French.
The data analysis consisted mainly of descrip-
tive statistics and frequencies. Statistical significance
of differences between the two groups was deter-
mined using the x2 test. The open-ended questions
were examined individually, and repetitive responses
and suggestions for improvement were documented
in the results. Each patient chart was reviewed by
one of us (E.M.) to compare entries made by health
care professionals during admission, labour and
delivery with the information given by the patients.
Results
General information
A total of 200 patients (100 of the 102 adoles-
cent patients and all of the adult patients) completed
the questionnaire. The adolescent patients were from
14 to 19 years of age, the largest group comprising
those 16 to 17 years (43 patients); 37 patients were
18 to 19 years old, and 20 were 14 to 15 years old.
The mean age of the control subjects was 26 (ex-
tremes 21 and 42) years. The remainder of the
results were analysed in relation to the final three
sections of the questionnaire.
JUNE 15, 1993
In all, 89% of the adolescents and 80% of the
adults used the English questionnaire. The propor-
tions of the patients who were primiparous were 91%
and 83% respectively. Twelve of the adolescents
were married at the time of admission to hospital, as
compared with 93 of the adults.
The educational levels of the adolescent partici-
pants were as follows: 65 had completed grade 10 or
11, 20 had completed grade 8 or 9, and 5 had
finished grade 12 or 13. Since becoming pregnant
only 36 were continuing their education: 67% of
them requested home tutoring, 15% opted for corre-
spondence courses, 12% remained in the same
school, and 6% wished to drop out altogether.
Forty-three of the adolescent subjects continued
to live with their parents, 30 lived with a boyfriend
or the father of the baby, 16 lived with another
adolescent friend, and 10 lived alone.
In all, 53% of the adolescents were supported
financially by their parents, 33% by social services
and 14% by the boyfriend or father of the baby.
Prenatal care
Most (60%) of the adolescents found out they
were pregnant through their physician's diagnosis.
This did not differ significantly from the rate in the
control group.
The delay in seeking medical prenatal care was
significantly longer in the adolescent group than in
the adult group. Only 26% of the adolescents started
receiving such care within the first trimester, as
compared with 87% of the adults (p < 0.001) (Table
1). The largest group (47%) gave fear of going to
clinics as the reason for the delay. Other reasons
were not knowing where to go (given by 18%), no
transportation (by 6%) and just not getting around to
it earlier (by 29%). Most (47%) of the adolescents
saw a family physician for prenatal care, whereas
most (61%) of the adults saw an obstetrician (p <
0.001) (Table 1). When asked whether they felt
comfortable with older women in the waiting room
66% of the adolescents answered No.
Prenatal classes were specified as being group
sessions involving instruction, discussion and exer-
cises for labour and delivery. Only 27% of the
adolescents attended such classes, as compared with
91% of the adults (p < 0.001) (Table 1). The reasons
for not attending included "fear," "feeling uncom-
fortable with couples and older women," "everyone
asking where my husband is," "people staring at me"
and "no transportation." Of the adolescents 86%
stated that they did not feel comfortable with older
couples at the prenatal classes. Most of the ad-
olescents felt awkward about going to classes with-
out a partner. In all, 59% of the adolescents did
not feel prepared for labour and delivery, as com-
CAN MED ASSOC J 1993; 148 (12) 2151
 or-~5 5
f. _-'.A-'fW_
pared with 26% of the adults (p < 0.001) (Table 1).
Labour and delivery
The participants were asked if they were ever
sent home from the hospital because of false labour:
46% of the adolescents and 35% of the adults
answered Yes.
During labour and delivery 50% of the adoles-
cents had their mother with them for support,
whereas 83% of the adults had their husband with
them (p < 0.001) (Table 2).
The most common comments about the partici-
pants' experiences were about fear, not knowing
what to expect and being poorly prepared. Most
(63%) of the adolescents suggested that a prenatal
class for teenagers would have been useful.
The review of the charts revealed that fear of
what to expect during delivery was inversely pro-
portional to the number of visits to prenatal
clinics and classes. Participation and cooperation by
adolescents during delivery was directly propor-
tional to the number of visits to prenatal clinics
and classes.
Postpartum care
In all, 59% of the adolescents stated that they
were uncomfortable in the same room as adults
during the postpartum period. The adolescents stat-
ed that they received adequate instruction on breast-
feeding, infant care, contraception, breast care and
nutrition. Surprisingly, 33% of the adolescents did
not receive instruction about contraception, as com-
pared with 1 1% of the adults.
Finally, of the 95 adolescents whose babies
survived 85 responded that they were keeping them
and 10 that they were giving them up for adoption.

dpIM '
At p vlue
... A^Mle p v*
13 30 < 0A01
12 57
Wr. 9 3
44 6
22 4
15 5 < 0.001
47
14 ;61
15 2
9 0
27 91
73 9

72
28 74
41 74 < `.Oe
.59 26

Gro-up;,.:.of h*
Per-on Adole"ttts Adults p val
M"eo50 2 <0001
-ather 2 1
17 .83 <aQ 1
Fr-of
X Sw 14 7
Ffrind 5 2
Noone 7 0

2152 CAN MED ASSOC J 1993; 148 (12) LE 15 JUIN 1993

All of the 98 adults whose babies survived stated
All of the 98 adults whose babies survived stated
that they were keeping them.
Chart review
The adolescents' answers, statements and sug-
gestions from the open-ended questions coincided
accurately with observations and information docu-
mented in their charts at the time of admission and
during labour and delivery. These entries were made
by nurses, physicians in training and attending staff.
Of particular interest were the comments about
preparedness for labour and delivery, lack of aware-
ness of anatomy and active participation in delivery.
The adolescents who had the least amount of expo-
sure to prenatal care and classes coped less well than
the others during their hospital stay.
Discussion
We found several interesting differences be-
tween the two groups, mostly in terms of prenatal
care and classes. Adult-oriented clinics and classes
made the adolescents feel out of place and uncom-
fortable. The adolescents were uneasy at insensitive
comments and attitudes of some staff during the
admission procedures.
In addition, we found that inadequate atten-
dance at prenatal clinics and classes did not prepare
the adolescents very well for recognizing the onset of
labour or for active participation in delivery. More
of the adults than of the adolescents sought prenatal
care early, attended prenatal clinics regularly and
participated in prenatal classes.
Many studies have shown that adequate prena-
tal care for adolescents leads to the delivery of
infants of higher birth weight and later gestational
age.9'20,23-25 Cartoof, Klerman and Zazueta9 suggested
that the clinic environment, its attractiveness and
the way the adolescents feel about how they are
treated by staff and medical practitioners limit the
use of prenatal care by adolescents.
Only 36 of the adolescents were able to continue
their education. Most chose home tutoring, which
gave them the chance to continue in a nonthreaten-
ing, accessible, individually tailored program. How-
ever, home tutoring is excellent but expensive and
can be used only for a fixed period.
In all, 44% of the adolescents postponed seeking
prenatal care until the last trimester, and 22% never
sought such care. No doubt the pregnant teenager is
scared, anxious, unsure and confused.
Seventy-seven percent of the adolescent preg-
nancies were diagnosed by a physician or at a family
planning clinic. There are many services and support
groups in the community for pregnant adolescents.
However, available services are apparently not al-
JUNE 15, 1993
ways brought to the attention of a pregnant teen-
ager. When a teenager is found to be pregnant it
is vital to stay in contact with her, maintain con-
fidentiality and work with her toward coming in
for prenatal care and setting up other necessary sup-
port services. The health care professional who
initially diagnoses the pregnancy must alert the
community services.
In 1979 the Committee on Adolescent Medicine
of the Canadian Paediatric Society recommended
that transportation to and from prenatal clinics and
classes be made available to all pregnant adolescents
and their partners.26 It also recommended that pre-
natal clinics and classes for adolescents be tailored to
meet the educational, nutritional, social, obstetric,
pediatric and financial needs of adolescent parents
and their infants. More than 10 years later we found
that 6% of the adolescents in our study who delayed
seeking prenatal care did so because of a lack of
transportation, 18% did not know where to go, and
47% feared going to adult-oriented clinics. It would
be useful to hold the clinics between 2 and 6 pm and
then provide supper and prenatal classes in the same
location. These facilities should be easily accessible,
or else transportation should be provided. This
service should be advertised regularly in high schools
and all public places that teenagers frequent.
The suggestion of prenatal classes specifically
designed for adolescents was made by 63 of the
adolescent participants. Since only 17% of the ado-
lescents had their husband or boyfriend with them
during labour and delivery, it makes sense to have a
friend or companion who is most likely to partici-
pate and be supportive attend the classes.
One-third of the adolescents did not receive
contraceptive information during the postpartum
period. Consideration should be given to a specific
postpartum package for adolescents that includes
information on contraceptive care, care of the new-
born and resources for young mothers. Since most of
the adolescents decided to keep their babies, post-
partum care and follow-up are essential for this
high-risk group. The fetal death rate of 5% among
the adolescents was high but is still lower than the
rate among adult women.8,20,2'
Our findings have shown a need for prenatal
care, prenatal classes and counselling, and postpar-
tum care specifically designed to meet the needs of
adolescents. This should be established in a non-
threatening, easily accessible environment that is
available to all pregnant teenagers.
We thank Dr. Robert Stenstrom, Paediatric Research,
Children's Hospital of Eastern Ontario, Ottawa, for his
help in planning the study and analysing the data. We also
thank the labour and delivery staff and maternity ward
staff of the Ottawa General Hospital Perinatal Centre.
CAN MED ASSOC J 1993; 148 (12) 2153
References
1. Orton MJ, Rosenblatt E: Adolescent Pregnancy in Ontario,
Planned Parenthood Ontario, Toronto, 1986
2. Repke JT: Adolescent pregnancy: Can we solve the problem?
Mayo Clin Proc 1990; 65: 1152-1154
3. Poole C: Adolescent pregnancy and unfinished developmental
tasks of childhood. J School Health 1987; 57: 271-273
4. Isberner F, Wright WR: Comprehensive prenatal care for
pregnant teens. Ibid: 288-292
5. Elster AB, Lamb ME, Tavre J et al: The medical and
psychosocial impact of comprehensive care on adolescent
pregnancy and parenthood. JAMA 1987; 258: 1187-1192
6. Burts HW: Prenatal care and pregnancy outcomes. J Adolesc
Health Care 1991; 12: 583-584
7. Wells RD, McDiarmid J, Bayatpour M: Perinatal Health
Belief Scales. A cost-effective technique for predicting pre-
natal appointment keeping rates among pregnant teenagers.
J Adolesc Health Care 1990; 11: 119-124
8. Olds DL, Henderson CR, Tatelbaum R et al: Improving the
delivery of prenatal care and outcomes of pregnancy: a
randomized trial of nurse home visitation. Pediatrics 1986;
77: 16-28
9. Cartoof VG, Klerman LV, Zazueta VD: The effect of source
of prenatal care on care-seeking behavior and pregnancy
outcomes among adolescents. J Adolesc Health Care 1991; 12:
124-129
10. Chen SP, Fitzgerald MC, DeStefano LM et al: Effects of a
school nurse prenatal counselling program. Public Health
Nurs 1991; 8: 212-218
11. Marques PR, McKnight AJ: Drug abuse risk among pregnant
adolescents attending public health clinics. Am J Drug Alcohol
Abuse 1991; 17: 399-413
12. Kay FJ, Share DA, Jones K et al: Process, costs and outcomes
of community-based prenatal care for adolescents. Med Care
1991; 29: 531-542
13. Kalmuss D, Darabi KF, Lopez I et al: Barriers to Prenatal
Care: an Examination of Use of Prenatal Care among
Low-Income Women in New York City, Community Service
Society, New York, 1987: 122
14. Institute of Medicine staff: Prenatal Care: Reaching Mothers,
Reaching Infants, Natl Acad Pr, Washington, 1988
15. Faller H: Perinatal needs among immigrant women. Public
Health Rep 1985; 100: 340-343
16. Larson G, Spangberg L, Theorell T et al: Maternal opinion of
psychosocial support: evaluation of an antenatal programme.
J Adv Nurs 1987; 12: 441-449
17. Poland M, Ager JW, Olson JM: Barriers to receiving adequate
prenatal care. Am J Obstet Gynecol 1987; 157: 297-303
18. McAnarney ER: Commentary on teenage pregnancy: compar-
ison with two groups of older pregnant women. J Adolesc
Health Care 1991; 12: 82-83
19. Wallace HM, Vienonen M: Teenage pregnancy in Sweden and
Finland. JAdolesc Health Care 1989; 10: 231-236
20. Creatsas G, Goumalatsos N, Deligeoroglou E et al: Teenage
pregnancy: comparison with two groups of older pregnant
women. JAdolesc Health Care 1991; 12: 77-81
21. McAnarney ER: Young maternal age and adverse neonatal
outcome. Am JDis Child 1987; 141: 1053-1059
22. Hulley SB, Cummings SR: Designing Clinical Research: an
Epidemiologic Approach, Williams & Wilkins, Baltimore, Md,
1988
23. Post S: Family centred maternity care: the Canadian picture.
Dimens Health Serv 1981; June: 25-31
24. Barr L: Special considerations in the care of the pregnant and
parenting adolescent. NAA COG Update Ser 1985; 3: 2-7
25. Lane C, Kemp J: Family planning needs of adolescents.
JOGNNurs 1984; Mar-Apr: 61, 65
26. Committee on Adolescent Medicine: The adolescent mother
and her baby. Can Paediatr Soc News Bull11979; 10: 5
2154 CAN MED ASSOC J 1993; 148 (12)
Conferences
continuedfrom page 2147
Sept. 9-13, 1993: Specialty Care in Crisis? - 62nd Annual
Meeting of the Royal College of Physicians and
Surgeons of Canada
Vancouver
Anna Lee Chabot, head, meetings and assemblies section,
Office of Fellowship Affairs, Royal College of Physicians
and Surgeons of Canada, 774 Echo Dr., Ottawa, ON
KI S 5N8; tel (613) 730-6233 or (613) 730-8177;
fax (613) 730-8830
Sept. 10, 1993: Health Care Aide Clinic Day
North York, Ont.
Sybil Gilinsky, Continuing Education Department,
Baycrest Centre for Geriatric Care, 3560 Bathurst St.,
North York, ON M6A 2E1; tel (416) 789-5131,
ext. 2365
Sept. 20-22, 1993: Alzheimer's Disease International 9th
Annual Conference - Global Challenge, Local Action
Toronto
Alzheimer Society of Canada, 201-1320 Yonge St.,
Toronto, ON M4T 1X2; tel (416) 925-3552,
fax (416) 925-1649
Sept. 27-29, 1993: 1 st International Conference on
Community Health Nursing Research
Edmonton
Shirley Stinson or Karen Mills, c/o Edmonton Board of
Health, 500-10216-124 St., Edmonton, AB T5N 4A3;
tel (403) 482-1965, fax (403) 482-4194
Oct. 6-8, 1993: Canadian Waste Management Conference
- Innovative Waste Management Solutions: an Outlook
for the Future
Saint John, NB
Susan Clarke, technical seminar coordinator, Technology
Development Branch, Environment Canada, Unit 100,
Asticou Centre, 241 Cite des Jeunes Blvd., Hull, PQ
KIA 0H3; tel (819) 953-5227, fax (819) 953-9029
Du 6 au 8 oct. 1993: Conference canadienne sur la gestion
des dechets - Solutions innovatrices en matiere de
gestion des dechets: Perspectives d'avenir
Saint-Jean, N-B
Susan Clarke, coordonnatrice des seminaires techniques,
Direction du Developpement Technologique,
Environnement Canada, Unite 100, Centre Asticou,
241, Cite des Jeunes, Hull, QC K1A OH3;
tel (819) 953-5227, fax (819) 953-9029
Oct. 7-10, 1993: 3rd Congress of the Asian Pacific Society
of Respirology (organized by the Singapore Thoracic
Society)
Singapore
Secretariat, 3rd Congress of the Asian Pacific Society of
Respirology, 336 Smith St. 06-302, New Bridge Centre,
Singapore 0105; tel 011-65-227-9811, fax 011-65-
227-0257
continued on page 2159
For prescribing information see page 2212