Better statistics for better health

for pregnant women and their babies

Non catégorisé

Editorial in France

How perinatal health in France compared with other European countries in 2015: some progress but also some concerns about newborn health by Béatrice Blondel, Mélanie Durox and Jennifer Zeitlin.

 

Summary

This editorial compares Euro-Peristat’s perinatal health indicators in France with other European countries to assess its strengths and weaknesses. The authors, members of the Euro-Peristat coordination team in France, express concern about indicators of newborn health. In 2015, the stillbirth rate was 3.0 per 1000, a rank of 22 out of 33 countries, and stillbirth rates in 2015 were not significantly lower than in 2010. The neonatal mortality rate among all live born children was 2.4 per 1000, yielding the same relative position of 22 out of 33. Neonatal mortality remained stable between 2010 and 2015 while decreases were observed in many other countries. Data currently available in routine information systems in France are insufficient for investigating the reasons for stagnating mortality rates, leading the authors to call for audits of perinatal deaths and reinforced health registers.

More favourably, France has a caesarean rate of 20.2%, in 7th place out of 33 countries. The rate has remained stable in France since 2010, while significant increases have been found elsewhere. This is seen as reflecting the efforts of health professionals who have been working together to promote evidence-based guidelines for caesarean section. The authors note that “countries with low caesarean delivery rates (Finland and Norway, for example) are also those with the lowest fetal and neonatal mortality rates. This observation argues against concerns that the level of mortality in France may be explained in part by the lower caesarean section rates.”

For more analysis and data on other indicators, the editorial is available here:

J Gynecol Obstet Hum Reprod. 2019 Jan 25. pii: S2468-7847(19)30030-3. doi: 10.1016/j.jogoh.2019.01.013.

and

Arch Pediatr. 2019 Jul 4. pii: S0929-693X(19)30104-6. doi: 10.1016/j.arcped.2019.06.001.

Luxembourg’ participation at EuroPeristat 2015 report - main results and outcomes

Authors: Guy Weber, Ministry of Health, Directorate of Health, Epidemiology and Statistics Unit and Aline Lecomte, Luxembourg Institute of Health, Department of Population Health, Luxembourg

Luxembourg has developed an exhaustive, voluntary registry on perinatal health.

With about 6500 births per year, plurennial statistics are privileged in Luxembourg, just as in other small countries, to better assess the occurrence of rare events such as maternal mortality and stillbirth. Indeed, there are high year-to-year random variations. Specifically for maternal mortality, the Grand Duchy would need to collect data on maternal deaths over half a century or more to provide figures as robust as those of the largest EU countries.

The calculation of harmonised indicators at European level and the comparison of results with all participating countries represent a real added-value for Luxembourg’s public health political stakeholders.

In 2019, Luxembourg is able to calculate all 10 core and 20 recommended indicators.

In 2015, the multiple birth rate was reported to be 17.9‰ for twins and 0.4‰ for triplets or more. The national birth rate is high for primiparous women (47.6%) and for primiparous women who delivered after 35 (27.4%); this birth rate for primiparous women is steadily increasing since 2010 where it was 23.3%. 10.7% of smoking women continue smoking during the 3rd trimester of pregnancy. A decrease is noted compared with the result published in 2010, which was 12.5%.

Luxembourg has a high rate of caesarean sections (32.7%) as well as a high rate of instrumental vaginal delivery (11.2%). The percentages of caesarean delivery without labour/elective (16.9%) and caesarean section during labour/emergency (15.8%) are similar. An overall increase of caesarean delivery occurred when comparing with data from 2010 (30.0%).

In 2014, the perinatal national steering committee established national recommendations on elective caesarean section after 37 weeks of pregnancy that were subsequently validated by the scientific council “Conseil Scientifique dans le Domaine de la Santé”. To create awareness, a flyer presenting the major advantages and risks of caesarean section based on the new recommendations was designed and since then is distributed to all future new parents.

The preterm live birth rate (< 37 weeks) is relatively high in Luxembourg (7.3%): 1.1 % for births before 32 weeks of pregnancy and 6.3% for births between 32 to 36 weeks of pregnancy.

There was an increase in the stillbirth rate at ≥28 weeks of gestation between 2010 (2.9‰) and 2015 (3.9‰), but this is a rare event and variations from year to year are expected. Neonatal mortality at ≥22 weeks remains relatively low: 1.3‰ for early neonatal mortality and 0.3‰ for late neonatal mortality.

The infant mortality rate for live births is 2.3‰. The national infant mortality rate is probably not entirely accurate: it is estimated that 14% of child deaths occur abroad when infants are transferred for care to specialised centres in neighbouring countries. Cause of death registries are not notified about these deaths and they are not included in the statistics presented here.

Women are having children later in Portugal

Authors: Henrique Barros, University of Porto Medical School, Department of Public Health, Forensic Sciences and Medical Education, and Diana Seabra, Public Health Institute Porto University, Portugal

Women are having children later in Portugal. By 2015, mothers aged 35 or older accounted for almost 30% of all childbearing women, putting the country in the fifth position of the European Union in this variable, according to data from the European Perinatal Health Report. According to data from the report, there is a general trend towards having children later in the continent, with the exception of Germany, Estonia, the Netherlands and Sweden. In Portugal, Spain, Greece and Ireland, the percentage of late mothers increased between 2010 and 2015.

According to Henrique Barros, President of the Instituto de Saúde Pública da Universidade do Porto (ISPUP) is partner and one of the authors of the report, "it is interesting to note that especially in the countries most affected by the economic and financial crisis women postponed maternity”. The researcher stresses that "policies are needed to support working mothers and fathers in order to encourage motherhood at younger ages. In addition, health services in countries with mothers at more advanced ages have to guarantee that the needs of these women are ensured during pregnancy".

The report analysed data on five million deliveries in 2015 and compared them with the 2010 figures, showing that Portugal is well positioned in indicators such as infant mortality and maternity in adolescence (before the age of 20). However, there are other indicators with not as positive results.

For example, there is an increasing number of low birthweight newborns (under 2500 grams) in the country, 8.9% in 2015, one of the highest proportions in EU countries, which is partly a result of late motherhood, the presence of chronic disease and the increase in the number of multiple pregnancies (twins).

Regarding this indicator, Henrique Barros points out that "fewer preterm babies and more underweight babies suggest the occurrence of circumstances that hinder fetal nutrition".

The report also includes data from 19 countries on smoking during pregnancy, but there are no figures for Portugal. Smoking is a cause of low weight.

As for neonatal mortality rates (up to 28 days of life), it was found that, overall, the situation improved, with rates dropping about 10% compared to 2010. Portugal is well placed in this regard, but there is still room for improvement considering that there are countries with lower neonatal mortality numbers. Furthermore, it is necessary to know how many babies die and under which circumstances, as well as to gather data from maternity hospitals and private hospitals, where about 15% of deliveries are made.

Regarding caesarean deliveries, the study showed that between 2010 and 2015 the situation improved in Portugal, but, according to the President of ISPUP, the numbers remain high.

Highlights on the EPHR from a Croatian perspective

Authors: Urelija Rodin, Department for Vulnerable Groups Health Care, Croatian National Institute of Public Health, and Boris Filipovic-Grcic, School of Medicine University of Zagreb, Croatia

It is well known that monitoring of perinatal health in European countries by using the same methodogical criteria (harmonisation of definitions for gathering and calculation of the indicators) enables fair comparisons between countries. Croatia became a Euro-Peristat member very recently, two years ago and our perinatal data couldn't be included in the European Perinatal Health Reports (EPHR) on 2004 and 2010 births. However, participation in this EPHR 2015 has been very useful and the opportunity for comparison provides important information for the decision-making process among health policy-makers, managers and clinicians, especially obstetricians and neonatologists, for improving perinatal health care on the national level.

Below are the highlights from the EPHR 2015 which could help Croatian perinatologists and the Ministry of Health in future perinatal care planning:

1. The key indicators for measuring fetal and infant health outcomes in Croatia are worse than in many other members of the Euro-Peristat Network (EPN):

-          fetal mortality ≥24 gestational weeks was 4.3‰ (EPN median rate 3.4‰)

-          fetal mortality ≥28 gestational weeks was 3.2‰ (EPN median rate 2.7‰)

-          neonatal mortality ≥22 gestational age was 3.2‰ (EPN median rate 2.2‰)

-          early neonatal mortality ≥22 gestational age was 2.3‰ (EPN range 0.6‰ to 3.1‰)

-          late neonatal mortality ≥22 gestational age was 0.9‰ (EPN range 0.1‰ to 1.3‰)

-          infant mortality (cohort) was 3.8‰ (EPN median rate 3.1‰)

2. Premature birth, especially extreme prematuirty before 32 weeks of pregnancy, is closely related to poor perinatal outcome, including high mortality and long-term or permanent impairment. Consequently, it is important to know the proportion of premature births for the purpose of planning and the development of appropriate intensive neonatal care unit networks:

-          percentage of premature births <37 weeks of pregnancy was 6.5% of livebirths (EPN median rate 7.3%; range 5.4% to 12%)

-          percentage of very premature births <32 weeks of pregnancy was 0.9% (EPN range 0.8% to 1.4%)

-          percentage of low birth weight <2500 g was 5.1% (EPN range 4.2% to 10.6%)

3. Any death of a woman in pregnancy, childbirth or puerperium is recorded as maternal death, either due to direct causes (a disease or disorder directly related to pregnancy or childbirth) or indirect reasons (any cause related to or aggravated by the pregnancy like malignant or other chronic illness). It is considered that due to missing links between health and cause-of-death data systems, the number of deceased women in pregnancy, childbirth or puerperium can be underestimated. However, in Croatia, we have a link between these two systems and we can provide „enhanced“ data. Multiple linkage and matching is performed between death certificates, records from hospital discharge databases, medical birth databases and abortion databases of the Croatian Institute for Public Health:

-       maternal mortality ratio for direct and indirect causes of death in the period 2011-2015 was 5.5/100.000 livebirths (EPN range 0-24.7/100.000 livebirths)

Measures for improving maternal and perinatal health care in Croatia

Measures for improving maternal and perinatal health in Croatia are directed towards health promotion, prevention, early detection and treatment of complications in pregnancy as well as treatment of severe obstetric complications and severe disorders in newborns, very similar to other European countries.

It is questionable what to do for better perinatal outcomes and better perinatal care according to Croatian perinatal indicators published in EPHR 2015.

Strategic priorities in Croatia should be:

-         to maintain the low proportion of pregnant women who are overweight or obese and the low proportion of maternal smoking by developing health literacy (public awareness campaigns and health   information websites)

-         to maintain relatively low proportion of cesarean sections, using it according evidence-based standards and protocols

-         to establish a regional organization of perinatal care with the aim of reducing neonatal and infant mortality caused by immaturity and very low birth weight

-          to develop perinatal audit in order ensure adequate quality control and evaluation of perinatal care

NATIONAL HIGHLIGHTS FROM THE EPHR 2015: Croatia, Luxembourg and Portugal 

CROATIA

Authors: Urelija Rodin, Department for Vulnerable Groups Health Care, Croatian National Institute of Public Health, and Boris Filipovic-Grcic, School of Medicine University of Zagreb, Croatia

 

LUXEMBOURG

Authors: Guy Weber, Ministry of Health, Directorate of Health, Epidemiology and Statistics Unit and Aline Lecomte, Luxembourg Institute of Health, Department of Population Health, Luxembourg

 

PORTUGAL

Authors: Henrique Barros, University of Porto Medical School, Department of Public Health, Forensic Sciences and Medical Education, and Diana Seabra, Public Health Institute Porto University, Portugal

MATERNITY AND NEONATAL UNIT RANKINGS IN EUROPE

In many countries, hospitals are ranked nationally on their quality of care. These rankings give healthcare providers and policy planners feedback on the organization of their services, and provide benchmarks to improve performance and promote better health.


The goal in making these rankings public is to increase accountability and contribute to patients’ sense of self efficacy. National or regional variations in health outcomes and health care raise important questions for patients and their families as they navigate through the care pathway: “Am I at the right place? and getting the best care for my particular needs?


One of the difficulties, however, is making sure that these rankings take into consideration each hospital’s patient-mix; some specialized or tertiary hospitals care for sicker patients and this will make these hospitals look worse unless it is possible to adjust their outcomes for their specific patient characteristics.


Many European countries provide official assessments of individual maternity or neonatal units through their health and research agencies. In other countries, parental networks and non-profit organizations have come together to provide quality assurance data to pregnant women and their families. Across countries, pregnant mothers and their care providers do not have equal access to the information there is.


We asked
Euro-Peristat Scientific Committee members to give us information on sources of maternity and neonatal unit rankings in their country. Have a look at our overview of scientific committee responses to our questions, below. Click on the links to official reports and websites for more details about the indicators that are used to describe maternity units. Many of these reports rank maternity units within their level of care to take into consideration patient case-mix.

 

Country Data source Weblink Comments
Croatia Public Health Institute http://rodilista.roda.hr Generalist website (not specific to maternal and newborn health, no data on outcomes)
Cyprus NA
Finland Public Health Institute https://www.thl.fi/en/web/thlfi-en/statistics/statistical-databases/database-reporting#Sexual
France Media org. http://maternites.doctissimo.fr/palmares-des-maternites.htm 

Germany

Health Insurance companies

https://www.g-ba.de/institution/themenschwerpunkte/qualitaetssicherung/qualitaetsdaten/qualitaetsbericht/suche/  

Very Low Birth Weight quality of care indicators: www.perinatalzentren.org

Quality indicators of hospital care are published by health insurance companies

 

www.perinatalzentren.org is designed for patients and experts, and pertains mainly to quality of care indicators in neonatal units

Latvia NA Perinatal Committee data are not publicly available.
Lithuania NA Rankings are not publicly available.
Luxembourg NA http://www.liewensufank.lu/ No information on interventions.
Other NGO http://enca.info/ European Network of Childbirth Associations
Poland NGO www.gdzierodzic.info
Portugal NGO

http://www.birthadvisor.pt/

www.associacaogravidezeparto.pt

Romania Public Health Institute published in the Official Romanian Monitor Ministry of Health ranks departments of Obstetrics-Gynaecology and Neonatology internally. These data are not publicly available.
Slovakia Public Health Institute http://tehotenstvo.rodinka.sk/sprievodca-porodnicami/ Maternity Ward Guide
Spain NGO https://www.elpartoesnuestro.es/informacion/el-parto-en-cifras "El Parto es Nuestro" (Birth is Ours) has data available for each Spanish region, official assessments of individual maternity or neonatal units from health or research agencies.
Switzerland Public Health Institute

http://which-hospital.ch/

http://sanowatch.com/en/

Generalist websites (not specific to maternal and newborn health)
UK Public Health Institute ; consumer organisation

https://indicators.rcog.org.uk/results/indicators

http://www.which.co.uk/birth-choice/

http://image.guardian.co.uk/sys-files/Guardian/documents/2008/01/24/HOSPITALS.pdf

consultation 2017 on-going

FREQUENTLY ASQUED QUESTIONS ABOUT THE CORE DATA COLLECTION 2015

 

Clarifying the categories:

 

1.QUESTION : for the requested categories, could you confirm the following :

  • <500 = ≤499
  • <20 years of age = ≤ 19 years of age


RESPONSE : Yes, this is correct

 

2. QUESTION : For mode of onset, we only have data on Induction (yes/no). How should we code this item.

RESPONSE : Please provide the data that you have, please let us know (with the exact codes in the data summary sheet).

 

Deidentified data:

 

QUESTION : It is possible for us to submit the individual level data on the variables as these are deidentified data and this would be easiest for us. Is that possible ?

RESPONSE : Yes. This is not a problem.

 

Generating aggregated tables:

 

QUESTION : Do you have any relevant SAS code for generating aggregated tables ?

RESPONSE : Yes, the SAS command that corresponds to contract in STATA is: (where var are the different variables up to var12 or whatever you have in your database).

proc freq data=table ;
table  var1*var2*var3*var4*var5 / out=resultat;
run;

Ensuring safe pregnancy and childbirth is a goal of all health systems in Europe.

The European Perinatal Health Reports provide comparable indicators of maternal and infant health and care in 31 European countries in 2004 and 2010. The Euro-Peristat indicators have highlighted wide gaps in health information and striking health inequalities among european countries. National perinatal health reports are an important tool to better understand international rate comparisons.

Countries routinely publish on the health status of pregnant women and babies. We are pleased to share with you the most recent data available from 21 of the 31 countries participating in our project.

Perinatal yearbooks are compiled from vital statistics, medical birth registers, hospital discharge data and representative surveys conducted at the local, regional, and national level. These  reports provide a more in-depth picture of countries' health systems performance and important information about trends over time and risk factors for poor maternal and newborn health.

In addition to official statistics on births and deaths, you can also access from our website national publications on key topics including: multiple births, congenital anomalies, fertility treatments, alcohol and smoking, cesarean sections, episiotomies, and breastfeeding.

If you have any questions, feel free to contact our country teams.

national Perinatal Health REPORTING 1

INVITED COMMENTARIES ON A GRAPH : Proportion of women smoking during pregnancy in European countries in 2010

 smoking rates 2

Graph from the European Perinatal Health Report 2010: Smoking during pregnancy, table 4.1 p.65

In Scotland:

The graph shows estimates of the proportion of women smoking during pregnancy in a range of European countries in 2010.  Scotland is top of the league: not a position we would wish to retain.

First: data quality.  Can the Scottish figure be trusted?  The unfortunate answer is, broadly, yes.  The Euro-Peristat indicator is defined as women smoking in the third trimester of pregnancy.  In Scotland we do not have data on that specifically but national records returned after women deliver in NHS hospitals do contain information on whether women reported smoked throughout pregnancy and this is what our figure is based on.  In 2010, 6% of delivery records contained no information on smoking throughout pregnancy.  Among women with information available, 19% (as shown in the figure) were recorded as smoking throughout pregnancy.

Other sources of information on maternal smoking that corroborate this figure are available.  Delivery records also contain information on the smoking status of women at their antenatal booking appointment (based on self report but accurate reporting is encouraged by routine use of carbon monoxide breath testing).  In 2009/10, 21% of women with smoking status recorded were current smokers.  Similarly, Health Visitors record the self reported smoking status of new mothers at their first postnatal visit (when the baby is 10-14 days old): in 2009/10, 19% of new mothers reported current smoking.  These figures show a high degree of consistency and further suggest that few women still smoking at antenatal booking manage to give up during or immediately after pregnancy, despite the widespread availability of stop smoking services.

Maternal smoking is strongly socially patterned in Scotland.  In 2014/15 around 40% of mothers aged under 20 years smoked at antenatal booking compared to 10% of mothers aged over 35 years.  Similarly, around 30% of mothers living in the most deprived quintile of areas smoked compared to 5% of those from the least deprived quintile.

The glimmer of good news is that smoking levels are falling in Scotland.  By 2014/15 the proportion of women reporting current smoking at antenatal booking had fallen from the 21% seen in 2009/10 to 18%.  This reflects trends seen in the wider population.  The Scottish Health Survey (SHeS) estimates that current smoking rates have fallen in the female adult (16-64 years) population from 34% in 1995 to 24% in 2015.  Even more encouragingly, the Scottish Schools Adolescent Lifestyle and Substance Use Survey (SALSUS) estimates that current regular (at least one cigarette per week) smoking among 15 year old girls has fallen from 29% in 1982 to 7% in 2015.  These encouraging trends reflect concerted policy efforts to tackle Scotland’s historically high smoking rates.  In 2006, Scotland was the first country within the United Kingdom to ban smoking in public places.  A comprehensive national tobacco control strategy was published in 2013.

There are therefore reasons to hope that Scotland’s position on future maternal smoking international comparison graphs may make more comfortable viewing.  There is one factor tempering that hope: the burgeoning use of e-cigarettes.  In 2015 the SHeS estimated that 7% of adult women used e-cigarettes, either alone or in conjunction with traditional cigarettes.  Even more worryingly, in 2015 SALSUS estimated that an astonishing 32% of 15 year olds had ever used e-cigarettes, and 3% were regular (at least once a week) users (with regular use generally confined to those also using traditional cigarettes).  It is currently unclear what these trends mean for the in utero exposure of future babies to nicotine and/or smoking.” 

- Dr. Rachael Wood

Dr. Rachael Wood, Consultant in Public Health Medicine – women and children’s health at the NHS National Services Scotland Information Services Division in Edinburg, Scotland.

In Poland:

Poland's proportion of women smoking during pregnancy (i.e. the third trimester) is in the mid-range among European countries. This proportion depends both on smoking rates before pregnancy and smoking cessation prevalence during pregnancy.

Smoking prevalence before pregnancy, that is among young women of childbearing age was 24.6% in 2010 according to data from the national study of women delivering which were used for the European Perinatal Health Report 2010. This proportion is average among other European countries. However, Poland's ranking may worsen in the future as according to the HBSC (Health Behavior in School-aged Children) studies report, there was an increasing trend of daily smoking prevalence among 15-years old girls between 2005 and 2006, 2009 and 2010, and 2013 and 20141. This may prognosticate an increase in smoking prevalence before pregnancy in the coming years if public health intervention is not undertaken.

Despite a potential increase in smoking rates before pregnancy, smoking levels during pregnancy seem to be rather stablein Poland. In my opinion, there is a widespread awareness of the negative consequences of smoking on the fetus in the country. This may encourage pregnant women to quit smoking in order to avoid social ostracism, and would explain a relatively high smoking cessation prevalence.

According to the randomized trial conducted in public maternity centres in Łódź in 2000-20012 , the proportion of quitters among pregnant smokers who underwent a standard intervention during pregnancy (leaflet) was 33.7%. This proportion among women who were randomized to the intervention group (four visits of the midwife at home) was 48.3% indicating that active counselling makes a difference.

- Dr. Katarzyna Szamotulska

Dr. Katarzyna Szamotulska, Head of the Department of Epidemiology and Biostatistics at the Institute of Mother and Child in Warsaw, and Euro-Peristat Scientific Committee member from Poland.

References

1) Kowalewska A, Mazur J, Dzielska A, Chełchowska M. [Smoking among 15-year-olds in Poland depending on selected sociodemographic factors--trends 2006-2014]. Przeglad Lekarski 2015;72(3):115-9. [Article in Polish]

2) Polańska K, Hanke W, Sobala W, Lowe JB. Efficacy and effectiveness of the smoking cessation program for pregnant women. International  Journal of  Occupational  Medicine and  Environmental  Health. 2004;17(3):369-77.

Contenu test

INVITED COMMENTARIES ON A GRAPH

Fig 5.9Graph from the European Perinatal Health Report 2010. The Health and care of women and babies in Europe in 2010,p.97

In Denmark:

”Between 2002 and 2012, the number of birth units was reduced from 41 to 24 in Denmark and more closures are planned. In the Copenhagen region, which is home to about 1.8 million people, the number of birth units is being reduced to four, all with an average number of births well above 2.000 per year. Antenatal care and other services are typically spread out between more locations.

In Denmark, the hospitals are run by five regions. The regions and the Danish Society of Obstetrics and Gynecology have traditionally argued for centralization to ensure easy access to specialized care such as neonatal and pediatric services. The concentration of care in large units is a continuation of a development in the health care system that has been ongoing over the last 25 years. This development is also made possible by the fact that Denmark is a small country, which means that the distance to a birth unit is comparatively short, even after centralization.” - Dr. L Mortensen

Dr. Laust Mortensen, Associate Professor, Section of Social Medicine, University of Copenhagen; Chief Advisor at Danmarks Statistik, and scientific committee member from Denmark.

In Germany:

"According to this graph, Germany is the country with the lowest number of large obstetrical departments (>3000 deliveries per year). ln Germany, pregnant women don’t prefer "Home delivery" but appreciate a "Home-like delivery" in a hospital located close to home. 98% of all live births took place in around 850 departments (2014); 2% were born out of hospital (1).

The centralization of obstetrical services for low-risk deliveries and regionalization of high-risk deliveries is unsatisfactory. The political decision makers prefer to organize the obstetrical services in Germany according to the preferences of "stakeholders" against the advice of the majority of scientific societies and the results of obstetrical evaluations in perinatal surveys.

Despite the low level of centralization and regionalization of obstetrical services in Germany, the maternal mortality in Germany (2010: 7.0 per 100.000 live births; 2013: 4.3 per 100.000 live births) and the perinatal mortality (2013: 5.4/1000 live births) are in the midrange compared to European figures (1).

But though we hypothesize, that German results would be better for high-risk and low risk deliveries, if the centralization of obstetrical services were higher, in high-risk cases in perinatal centers with presence of obstetricians, midwives, neonatologists and anesthesiologists around the clock (7/24). Furthermore the high number of hospitals with an annual volume of less than 500 deliveries contributes to a number of perinatal deaths in low-risk cases. An evaluation based on the German perinatal survey found that mortality is increased three-fold in hospitals with low volume (2). This is speculated to be caused by a lack of readiness for unexpected obstetrical complications and due to inadequate staffing in these small units.

For the health of mothers and children in Germany, the political decision makers should move towards more centralized care for high-risk cases and closing down hospitals providing medically unsafe care for low risk mothers."- Pr. J. Dudenhausen, Pr. S. Schmidts

Pr. Joachim W. Dudenhausen, Clinical Professor of Obstetrics and Gynecology - Weill Cornell Medicine, New York; Professor and Chairman Emeritus - Dept. of Obstetrics - Charite University Medicine Berlin, Editor in Chief - Journal of Perinatal Medicine

Pr. Stephan Schmidts, Professor of Obstetrics, Department of Obstetrics, University Hospital, Philipps University, Marburg, Germany

References
1. Robert Koch Insitut. (Hrsg.) Gesundheit in Deutschland. Gesundheitsbericht-erstattung des Bundes. RKI, Berlin 2015
2. Heller G,Richardson DK,et.al. Are we regionalized enough? Early-neonatal deaths in low-risk births by size of delivery units in Hesse,Germany 1990-1999.Int J Epidemiologie 2002;31:1061

In Spain:

"The relative benefits and risks of birth in different settings have been widely debated in recent years but there is a consensus that, overall, larger size units might be better able to deal with any adverse outcome.

Even if there is a tendency in most European countries to concentrate births in larger size units, percent changes, with the exception of Denmark and Northern Ireland, are relatively small, and six years (2004-10) is a too short period of time to assess changes. However, this small change towards larger size birth units may have been induced by the ever growing medicalization of birth, by the alarming increase in litigation against obstetricians who act defensively referring women to larger hospitals for delivery and by the changes in the risk profile of women (greater number of older women delivering a first infant, increased rates of multiple births, increase in obesity, increase in the number of women with previous CS).

Looking at the graph it appears to me that there is a necessity of exploring ways on how to balance the need for safety with the preservation of primary level birth facilities linked to the communities.

Finally, the case of Valencia illustrates the difficulties of international comparisons. Most of the variables that may have influenced the shift towards having births in larger units also operate in Spain but the change between 2004-10 is just in the opposite direction from the rest of the European countries (with the exception of Finland). Administrative reasons are behind this discrepancy. In 2007, the Regional Government of Valencia reorganized the health sector and many births previously taking place in the consolidated largest units were derived to new tertiary hospitals which in 2010 still had a number of births below 3000."- Pr. F. Bolumar Montrull

Pr. Francisco Bolumar Montrull, Professor of Preventive Medicine and Public Health, Unit of Public Health Sciences, Universidad de Alcalá, and scientific committee member from Spain. 

INVITED COMMENTARIES ON A GRAPH: Proportion of post-term births in European countries

graph PosttermData from the European Perinatal Health Report 2010. The Health and care of women and babies in Europe in 2010

A perspective from Sweden:

"The Swedish figures reflects the obstetric guidelines that are used in most Swedish counties: If no obstetric complications are present, no interventions are carried out until the pregnancies have reached 42 completed weeks. Recently, these guidelines have been questioned and they are under revision  in many counties. A national, randomized trial is soon to be commenced, which is scheduled to last two years [i]. Most counties are waiting for the results from this trial before they reconsider the current obstetric guidelines regarding prolonged pregnancies."

-Dr. Karin Källen

Dr. Karin Källen, Professor in the Department of Obstetrics and Gynaecology at Lund University, and Methodological Support Unit, National Board of Health and Welfare, Sweden

Post-term variation in Europe:

"Maybe we are trapped by the words. A “preterm” or “post-term” birth sounds less desirable and satisfactory than a term birth. As defined by ICD-9 and 10, a term birth is between 37+0 and 41+6, suggesting that, anything outside that range is abnormal[ii]. In addition, the Cochrane systematic review gives strong evidence: routine induction at 41 weeks reduces the incidence of stillbirth[iii].
Certainly, the PERISTAT data must reflect this, and countries with the highest prevalence of births at ≥42 weeks must have the highest rates of stillbirths?

Contrary to expectations, however, the four countries with the highest prevalence of births at ≥42 weeks are Nordic countries, and their stillbirth rates are among the lowest in Europe as are their rates of induction and caesarean section (CS). In the figure describing the proportion of post-term births, the Nordic countries are followed by UK and Ireland, who are not as successful as the Nordic countries for stillbirth and CS rates, but have results which are in line with the Western European average.

Once more, it is impossible from these observational data to do anything else than generate further questions.

Some questions are purely clinical:

  • Would the stillbirth rate be lower in the Nordic countries if they did more inductions at 41 weeks? A randomised trial in Sweden should provide some answers to this question (see comment from Dr. Källen).
  • What surveillance is done in the Nordic countries, in the UK and Ireland, for women who are beyond their due date? And if there is such surveillance, when does it start?
  • Do Nordic, British and Irish women participate in decisions regarding induction or waiting after 41 weeks, and what type of information concerning advantages and drawbacks is provided?

Some other questions are conceptual, or quasi philosophical:

  • Is the evidence from the randomised trials, that induction at 41+ weeks decreases the risk of stillbirth without increasing CSs reproducible? Unselected induction of labour is associated with an increases of CS rate in many circumstances. Information in the randomised trials is insufficient regarding both the Bishop score and exact gestational age of women who participated. The likelihood of a successful induction differs substantially between a mature cervix at 41+6 weeks and an immature cervix at 41+0 weeks.
  • Is it (just) possible that Nordic women have a longer median length of gestation? Some have suggested ethnic differences in gestational length[iv].
  • Is it not tautological to wonder whether stillbirth does not increase as pregnancy duration increases? Implicitly it must. The question may well be about numbers needed of inductions to avoid one stillbirth or to bring on one caesarean? A useful example of a very similar question can be found in the RCOG green top guideline where it is shown that vaginal birth after CS (VBAC) will increase the risk of hypoxic ischaemic encephalopathy from 0,01% to 0,08% while it decreases the risk of maternal death from 0,013% to 0,004% and significantly decreases the risk of abnormally adherent placenta in a next pregnancy[v]. With such information, families assisted by maternity carers can make a balanced choice.

In summary, it would probably be unwise for countries who are routinely offering induction at 41 weeks to change their practice tomorrow. However, this is part of the more general discussion on when should interventions become routine, do babies and mothers benefit, and why do we want babies to be like calibrated apples."

-Dr. Sophie Alexander

Dr. Sophie Alexander is an obstetrician and professor in the Perinatal Epidemiology and Reproductive Health Unit at Université Libre de Bruxelles, and Euro-Peristat Scientific Committee member from Belgium 


References

[i] Elden H, Hagberg H, Wessberg A, Sengpiel V, Herbst A, Bullarbo M, Bergh C, Bolin K, Malbasic S, Saltvedt S, Stephansson O, Wikström AK, Ladfors L, Wennerholm UB. Study protocol of SWEPIS a Swedish multicentre register based randomised controlled trial to compare induction of labour at 41 completed gestational weeks versus expectant management and induction at 42 completed gestational weeks. BMC Pregnancy Childbirth. 2016 Mar 7;16:49. doi: 10.1186/s12884-016-0836-9. RCT registration: Current Controlled Trials, ISRCTN26113652

[ii] Ninth revision of the International Classification of diseases Manual of the international statistical classification of diseases, injuries, and causes of death, Volume 1. Geneva, World Health Organization, 1977.

[iii] Gülmezoglu AM, Crowther CA, Middleton P, Heatley E. Induction of labour for improving birth outcomes for women at or beyond term. Cochrane Database of Systematic Reviews 2012, Issue 6. Art. No.: CD004945. DOI: 10.1002/14651858.CD004945.pub3

[iv] Papiernik E, Alexander GR, Paneth N. Racial differences in pregnancy duration and its implications for perinatal care. Med Hypotheses. 1990 Nov;33(3):181-6

[v] RCOG Green top guideline 45 Birth after previous caesarean section, 2014 https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_45.pdf last accessed 11 June 2017

Improving maternal and child health information using data linkage

As part of the EU-funded BRIDGE Health initiative, the Euro-Peristat project is finding ways to improve maternal and child health data sharing and transfer across Member States.

Perinatal care and research is multidisciplinary. It involves midwives, obstetricians, paediatricians, and other sub-specialists and data are often held in separate registers or incomplete. Data linkage is a computational technique which matches unique patient records from distinct data systems. Scientific experts have made extensive use of this tool for perinatal health research, but recent data show that record linkage use for national perinatal health monitoring is limited1.

There are successful examples of national data linkage projects, however. At the Euro-Peristat 2016 annual meeting, S. Berrut, Scientific Committee member from Switzerland presented on methods in data linkage used at the Health Division of the Swiss Federal Statistical Office, N. Lack and G. Heller, representatives from Germany gave examples of neonatal data linkages, and I. Verdenik, SC member from Slovenia, presented on linkages of birth and death data. K. Kallen also shared her experience with linkage of the Swedish National registers, and N Dattani, from the UK discussed the development of a national database of birth and maternity data for England and Wales.

The idea of linking data in the general population at the individual-level, inevitably raises privacy concerns among stakeholders. At the Euro-Peristat meeting, M. Gissler, SC member from Finland discussed implications for the transfer of individual patient data. In countries such as Finland or Sweden, linkages between 5-12 different data systems can  easily be done in routine. Notably in the Nordic countries, the use of universal patient identification numbers greatly facilitates capacity to match records successfully; elsewhere in Europe, data linkage can be restricted by strict ethical frameworks and regulations.

The new EU Directive on Data protection entered into force on 5 May 2016 and the Commission’s e-HEalth Action Plan 2012-2020 is currently underway. European Member States are more than ever expected to find ways to manage big data, promote the use of electronic patient records, and find innovative solutions to facilitate cross-border health care and data transfer. The well-being of mothers and children is at the core of population health, yet the harmonization of maternal and child health routine data systems in Europe is still a real challenge that Member States need to address.
Marie Delnord, Euro-Peristat project manager

Invited speakers at the Euro-Peristat Paris 2016 Data linkage session:

  • Probabilistic data linkage using G-Link,
    S. Berrut, Swiss Federal Statistical Office, Section Health
  • Perinatal data linkage in Lower Saxony,
    N. Lack, Bavarian Institute for Quality Assurance, Germany
  • Other perinatal health linkage projects in Germany,
    G. Heller, AQUA-Institute, Institute for Applied Quality Improvement and Research in Health Care GmbH, Germany
  • Infant deaths from day 1 to 365 as a consequence of perinatal events: an example of linkage,
    I. Verdenik, University Medical Centre,Department of Obstetrics&Gynecology - Research Unit, Slovenia
  • Getting data from the Swedish National Registers,
    K.Kallen, The National Board of Health and Welfare, Department of Evaluation and Analysis, Epidemiology and Methodological Support Unit, Sweden
  • Using data linkage to create a national database of birth and maternity data for England and Wales,
    N. Dattani, School of Health Sciences, City University London, UK
  • Data linkages and the possibilities to provide microdata for EU project,
    M. Gissler, THL National Institute for Health and Welfare; Karolinska Insititute, Division of Family Medicine, Sweden

Data linkage presentations from the Euro-Peristat 2016 Paris meeting are available for Euro-Peristat members.
Please send us a request at This email address is being protected from spambots. You need JavaScript enabled to view it.

 

Reference:
1. M. Delnord; K. Szamotulska; A.D. Hindori-Mohangoo; B. Blondel; A.J. Macfarlane; N. Dattani; C. Barona; S. Berrut; I. Zile; R. Wood; L. Sakkeus; M. Gissler; J. Zeitlin, the Euro-Peristat Scienfitic Committee. Linking databases on perinatal health: a review of the literature and current practices in Europe. The European Journal of Public Health 2016; doi: 10.1093/eurpub/ckv23. Available in Open Access

 

Perinatal health surveillance in Bulgaria

Data sources:

Data collection, processing and publication of health demographics in Bulgaria is carried out by the National Statistics Institute in compliance with the Law on Statistics of Bulgaria, Regulations of the European Parliament and the Council on European statistics, Civil Registration Act, regulations of the Ministry of Health and other legal documents .

The National Center for Public Health and Analyses (NCPHA) is  a structure within the national healthcare system which carries out activities for protecting public health, promoting health and preventing diseases, providing information for healthcare management. NCPHA compiles perinatal health indicators including: infant and perinatal mortality, fertility, and others.

NCPHA information from the "Certificate of Death" and "Certificate of Perinatal Death" can be processed according to different criteria - birth weight, gender, gestational age, cause of death, type of pregnancy / singleton or multiple / data mother - age, citizenship, previous pregnancy rates and more.

"Birth Report" Data are available by sex, weight, height, child birth order, assistance at birth, age of parents, citizenship of the mother and father and others.

Bulgarian perinatal health indicators in 2013, 2014, 2015:

INDICATORS

2013

2014

2015

Birth rate

9,2 ‰

9,4 ‰

9,2 ‰

Infant Mortality

7,3 ‰

7,6 ‰

6,6 ‰

Perinatal Mortality

10,3 ‰

10,4 ‰

9,1 ‰

Data for the last three years show that infant and perinatal mortality decreased, while the birth rate remained relatively stable.

National perinatal health initiatives:

Bulgaria has adopted a National Programme for improving maternal and child health, which is part of the National Health Strategy (2014-2020). This program is synchronized with the European Strategy for Child Health and integrates the seven priority areas for action in terms of Europe - the health of the mother and newborn, nutrition, infectious diseases, injuries and violence, physical environment, health of adolescent psychosocial development and mental health.

NCPHA participate in the implementation of the program with representation in the National Coordination Council for Maternal and Child Health, which coordinate the activities and supervision of enforcement.

For more information, please contact:

Title: Mrs Rumyana Kolarova (Euro-Peristat SC member for Bulgaria)
Current position : Chief expert, head of section “Registers”, Department of ”National health data and eHealth”
Institution: National Center for Public Health and Analyses (NCPHA)
Postal address: Bulgaria, 1431 Sofia, bul. “Akad. Ivan Evstatiev Geshov” 15

Commentary on the Lancet Ending Preventable Stillbirths Series

by Jennifer Zeitlin, *

The Lancet Ending Preventable Stillbirths Series was published in January 2016 and includes five papers that develop a global agenda for ending preventable stillbirths in low, middle and high income countries [1]. The series builds on a previous set of articles published in 2011 and measures the effectiveness of actions since this first call to action [2]. One article specifically addresses the issue of stillbirths in high income countries, as in the original series [3, 4]. Euro-Peristat added to the information in this article by publishing a background paper showing that stillbirth rates are much higher among women in a lower socioeconomic position compared with women in a higher position and that routine data are available to monitor these inequalities [5].

The conclusions of the series are relevant for Euro-Peristat’s on-going work. First, the series highlights the importance of having more and better data on stillbirths and calls attention to the question of stillbirths among extremely preterm births. In our studies comparing stillbirth rates, we have removed stillbirths before 28 weeks of gestation to make sure that we are comparing “like with like”, but it is also important to investigate trends in this group, at least in countries where definitions have stayed the same over the years. Second, by emphasizing the importance of social inequalities in maternal and newborn outcomes, the series challenges countries to collect better and more comprehensive data on social characteristics. It may be possible in our future work to collect more of our current indicators, such as maternal age, smoking or body mass index, by our indicators of social position (mothers’ educational level and parents’ social class based on occupation), or to collect fetal and neonatal mortality by new indicators of social position (for instance, migration status). Third, the series identifies key risk factors for stillbirth that require further research, including fetal growth restriction. Being able to compare the proportions of small for gestational age babies between countries is a complex question which our group has recently started to tackle. Finally, Euro-Peristat advocates the improvement of stillbirth and infant mortality data by promoting the use of common definitions and by analysing the extent to which apparent differences in outcomes may arise from differences in recording practices. We hope that the momentum and interest generated by this series will increase awareness and concern about the shortcomings of current data and encourage investment in the high quality statistics needed to underpin effective national and international health policies.

*Research director, EPOPé Research Team, INSERM U1153, Coordinator Euro-Peristat

References

1. de Bernis L, Kinney MV, Stones W, Ten Hoope-Bender P, Vivio D, Leisher SH, Bhutta ZA, Gulmezoglu M, Mathai M, Belizan JM, Franco L, McDougall L, Zeitlin J, Malata A, Dickson KE, Lawn JE, Lancet Ending Preventable Stillbirths Series study g, Lancet Ending Preventable Stillbirths Series Advisory G, (2016) Stillbirths: ending preventable deaths by 2030. Lancet 387: 703-716

 

2. Goldenberg RL, McClure EM, Bhutta ZA, Belizan JM, Reddy UM, Rubens CE, Mabeya H, Flenady V, Darmstadt GL, (2011) Stillbirths: the vision for 2020. Lancet 377: 1798-1805

 

3. Flenady V, Wojcieszek AM, Middleton P, Ellwood D, Erwich JJ, Coory M, Khong TY, Silver RM, Smith GC, Boyle FM, Lawn JE, Blencowe H, Leisher SH, Gross MM, Horey D, Farrales L, Bloomfield F, McCowan L, Brown SJ, Joseph KS, Zeitlin J, Reinebrant HE, Ravaldi C, Vannacci A, Cassidy J, Cassidy P, Farquhar C, Wallace E, Siassakos D, Heazell AE, Storey C, Sadler L, Petersen S, Froen JF, Goldenberg RL, Lancet Ending Preventable Stillbirths study g, Lancet Stillbirths In High-Income Countries Investigator G, (2016) Stillbirths: recall to action in high-income countries. Lancet 387: 691-702

4. Flenady V, Middleton P, Smith GC, Duke W, Erwich JJ, Khong TY, Neilson J, Ezzati M, Koopmans L, Ellwood D, Fretts R, Froen JF, Lancet's Stillbirths Series steering c, (2011) Stillbirths: the way forward in high-income countries. Lancet 377: 1703-1717

5. Zeitlin J, Mortensen L, Prunet C, Macfarlane A, Hindori-Mohangoo AD, Gissler M, Szamotulska K, van der Pal K, Bolumar F, Andersen AM, Olafsdottir HS, Zhang WH, Blondel B, Alexander S, Euro-Peristat Scientific C, (2016) Socioeconomic inequalities in stillbirth rates in Europe: measuring the gap using routine data from the Euro-Peristat Project. BMC pregnancy and childbirth 16: 15

NETWORK UPDATE: Welcoming CROATIA

Data collection:

The official main source of population data in Croatia is the Central Bureau of Statistics (CBS). CBS birth data are limited to sex, vital status: live birth/ stillbirth and basic socio-demographic characteristics of mothers (permanent residence, marital status, parity, and professional birth attendance).

In 2001 and in order to facilitate perinatal health research and monitoring, new medical birth and perinatal death notification forms were introduced by the Croatian Institute of Public Health (CIPH), in cooperation with the Croatian Society of Perinatal Medicine (CSPM). These new forms collect a broader set of perinatal health data and allow for analyses of individual-level data on births and deaths, and reporting of aggregated data by birth weight (BW) and gestational age (GA) subgroups based on the WHO recommendations.

Registration criteria used for livebirths/stillbirths:

Civil registration system:

CBS registration criteria for livebirths (LB) are based on the WHO livebirth registration criteria.

The Central Bureau of Statistics used to calculate fetal mortality (FM) as the number of stillbirths after 28 completed weeks of gestation per 1,000 total births, irrespective of BW. Since 2001 however, fetal death data are collected for births ≥22 GA weeks, irrespective of BW. Early neonatal mortality (ENM), is calculated as the number of newborns who died in the first 168 hours (7 days) of life per 1,000 LB, irrespective of BW or GA.

Hospital discharge data:

CIPH collects stillbirths and ENM data for all births ≥22 GA weeks or ≥500 g.

For national analyses and evaluation of perinatal health care, routine mortality data are reported for all perinatal deaths ≥500 g as well as ≥1000 g, based on the WHO-HFA criteria for international perinatal mortality comparisons. Additional analyses have also been conducted on national level, according to GA subgroups (22-27 GA weeks; 28-31 GA weeks; 32-36 GA weeks and ≥37 GA weeks) for stillbirths, early neonatal and total perinatal deaths.

Perinatal outcomes in 2014:

Coverage for births attended by a health care professional is 99% and takes place in health institutions. In 2014 almost half of all deliveries were first deliveries, 35% were second and 15% third or higher birth order.

Concerning maternal age, deliveries were most common between 25-29 years old (91.8 deliveries per 1,000 females of the same age), followed by deliveries of mothers 30-34 (89.7‰), and 20-24 (47.5‰). On average, mothers giving birth were 30 while the average age at first birth among women was 27. About 3% of births were multiples.

According to CIPH data, 20,283 males and 19,505 females were born; the sex ratio was 1.04:1 male to female newborns. In 2014, 5.24% births were less than 2500g of which, 3.18% were 2000-2499 g, 1.08% were 1500-1999 g, 0.47% newborns were 1000-1499 g and 0.51% were extremely low birth weight – less than 1000 g.

Perinatal mortality (PNM) for total births was 4.2‰ calculated by WHO-HFA methodology criteria of BW ≥1000 g which was lower than the European Union (EU) average of less than 5‰ for the period of 2007 onwards. However, PNM for total births BW ≥500 g was 6.8‰ and 7.1‰ for total births ≥22 GA in 2014.

FM was 5.7‰-4.0‰ for ≥22 weeks in the period 2001-2014, mildly decreasing from 2001 to 2014. ENM was 4.4‰-3.1‰ for ≥22 weeks in the period 2001-2014, decreasing in 2012 (1.9‰) and increasing in the years 2013 (2.3‰) and 2014 (3.1‰).

ENM was the highest in very low birth weight groups (below 1500 g), where attempts are made to reduce the number of low birth weight babies using certain organisational and technological improvements.

Most perinatal deaths are due to maternal complication and premature delivery (due to the consequences of immaturity). Hence, prioritised measures for safe motherhood in Croatia are linked with the prevention, control and early detection of complications in pregnancy.

The maternal mortality ratio (MMR) for Croatia varied substantially over time with an average of 8.1/100,000 LB during the period 2001-2014 - slightly higher than the EU average in recent years. Maternal deaths from direct obstetrical causes are rare but total MMR (including direct and indirect obstetrics causes) was 2.5/100,000 LB in 2014.

Perinatal health care organisation:

Perinatal health care measures are defined by health care acts or ordinances (Health Care Measure Programme; Health Insurance Act) setting the standard for perinatal care. The recommendations of CSPM, officially adopted and completely financed through compulsory insurance are: 10 antenatal visits (AV) per healthy pregnant woman and 3 ultrasound examination (US).The low proportion of pregnant women without adequate antenatal care (1.9% with 0-2 AV and 1.3% with 0-1 US) represents the indicators of good usage and availability of prenatal care.  

In order to improve the structure of the Croatian perinatal health care system, all maternities and neonatal units are organized in a network, regionalized according to professional guidelines. However, the network is not officially confirmed by Ministry of Health of the Republic of Croatia. Pregnant women and post-partum sick newborns, are referred to facilities by level of care based on maternal and/or infant health condition. Referrals are essentially made towards maternities with NICUs, level III units, or based on the closest available perinatal unit. The most complicated pregnancies and newborns can be referred to the National Center of Perinatal Medicine or to the National Center of Neonatal Intensive Medicine (level IV). The transfer of sick newborns is organized as a “one-way transport”.

Croatia’s basic health goals directed at improving maternal and child health are:

(i) Establishing a regional organisation for perinatal care with which the mother and child care will be divided into three levels (from delivery of care to a healthy pregnant, respectively childbearing woman and child, to the care of risk pregnancies according to the level of hazard)

(ii) Developing special services, especially the neonatalogic service

(iii) Adequate monitoring and evaluation of care at every level

(iv) Intersectoral collaboration in defining the regulations promoting rights to the protection of maternal and child health

(v) Collaborating with NGOs on further advancement and humanisation of care.

INVITED COMMENTARIES: Advanced Maternal age in Europe 2004 vs. 2010

 maternal age

Graph from the European Perinatal Health Report 2010: The health and care of women and babies in Europe in 2010, p.60

In France:

“Advanced maternal age is not a new trend: the age of women giving birth in France is 30 years old on average, the same as in the 19th century and at the beginning of the 20th century, but reasons behind late childbearing have changed drastically over time. A century ago, families were larger, women gave birth many times and they married late to limit births. Now, women stay in school longer, entry into the workforce is delayed, couples form stable households later, blended families are more common and effective family planning methods are more widespread.

Today, having a child often results from a well thought out decision. It is unfortunate that many women (and men) are not aware of the sharp decline in fertility after age 35 and the risks associated with advanced maternal age. Efforts are being made to alert women and their health care providers, but this message is hard to get across in France.”
- Dr. Béatrice Blondel

Dr. Béatrice Blondel is a perinatal epidemiologist at the French National Institute of Health and Medical Research (UMR1153) and scientific committee member from France

In Finland:

“Between 2004 and 2010 the proportion of mothers aged 35 years or older increased in all Euro-Peristat countries, with the exception of Finland. National statistics show that this proportion decreased from 19.4% to 17.8% between 2005 and 2009 and the trend was similar in urban and rural areas, and in most hospital districts.

Successful national-level social policy action may be one explanation. In 2003, Prime Minister Matti Vanhanen, from the Centre Party, called for measures to increase fertility and to promote early childbearing. The government increased the level of cash benefits for families, and maternity, paternity and parental leaves qualified for pension rights starting in 2005. Families welcoming a second child before the first-born’s third birthday are also eligible for  increased allowances if the mother did not work in-between pregnancies.

There may be other reasons behind the Finnish exception. The migrant population has been increasing rapidly in Finland. In 1990, 0.3% of infants came from an “other than Finnish” background. This share increased to 3.4% in 2004 and to 9.4% in 2014. As in many other European countries, migrants from low and middle income countries initiate childbearing earlier than Finns. Nonetheless, recent trends seem to go against this “migrant hypothesis” - the share of mothers aged 35 years or older increased to an all-time high of 20.4% in 2014. Unfortunately, the Medical Birth Registry was denied the right to collect information on migrants’ background until February 2016 but more detailed data linkage analyses will be conducted on this topic before summer.”
- Prof. Mika Gissler

Prof. Mika Gissler is a perinatal epidemiologist at the National Institute for Health and Welfare (THL) and scientific committee member from Finland

In the Netherlands:

“This graph shows that the number of mothers 35 years or older increased over time. In countries with historically low numbers of pregnant women over 35, the increase is remarkable and stronger than in the majority of the other countries – except in Italy, Spain and Ireland where figures were already high in 2004 and increased still in 2010.

This increase is disturbing given the known risks associated with advanced maternal age. Health care providers usually mention the increased risks of chromosomal anomalies and preeclampsia during antenatal counseling but maternal age is also a strong independent variable for the risk of sudden intrauterine unexplained death (SIUD) without growth retardation. This has been shown in a Norwegian population-based study by Froen et al (Acta obstet Gynecol Scand 2004; 83: 801-807). The risk of SIUD increases with 16% each year and becomes significant at 35 years and older (adjusted odds ratio 4.2 [95% confidence interval 1.02-16.49]).

It would be good to confirm these results in other populations, but it is also another strong argument for having children at a younger age…work to be done!”
- Prof. Jan Nijhuis

Prof. Jan G. Nijhuis MD PhD is an obstetrician, head of the OB/GYN Dept. of the Maastricht University Medical Centre, and scientific committee member from The Netherlands. He is a former president of the Dutch Organization of Obstetrics and Gynaecology (NVOG). His main interest and research areas are foetal monitoring and ‘home delivery issues’, as well as perinatal audit.

Search

Newsletter

PHIRI

Euro-Peristat participates in the PHIRI project. 

PHIRI