Developing and testing a protocol using a common data model for federated collection and analysis of national perinatal health indicators in Europe

Context: International comparisons of the health of mothers and babies provide essential benchmarks for guiding health practice and policy, but statistics are not routinely compiled in a comparable way. These data are especially critical during health emergencies, such as the coronavirus disease (COVID-19) pandemic. The Population Health Information Research Infrastructure (PHIRI) project aimed to promote the exchange of population data in Europe and included a Use Case on perinatal health. Objective: To develop and test a protocol for federated analysis of population birth data in Europe. Methods: The Euro-Peristat network with participants from 31 countries developed a Common Data Model (CDM) and R scripts to exchange and analyse aggregated data on perinatal indicators. Building on recommended Euro-Peristat indicators, complemented by a three-round consensus process, the network specified variables for a CDM and common outputs. The protocol was tested using routine birth data for 2015 to 2020; a survey was conducted assessing data provider experiences and opinions. Results: The CDM included 17 core data items for the testing phase and 18 for a future expanded phase. 28 countries and the four UK nations created individual person-level databases and ran R scripts to produce anonymous aggregate tables. Seven had all core items, 17 had 13-16, while eight had ≤12. Limitations were not having all items in the same database, required for this protocol. Infant death and mode of birth were most frequently missing. Countries took from under a day to several weeks to set up the CDM, after which the protocol was easy and quick to use. Conclusion: This open-source protocol enables rapid production and analysis of perinatal indicators and constitutes a roadmap for a sustainable European information system. It also provides minimum standards for improving national data systems and can be used in other countries to facilitate comparison of perinatal indicators.

Setting targets for population health improvements: Trends in perinatal health in Europe over the past five years

Background

The Euro-Peristat network documented disparities in perinatal outcomes between countries in Europe in its reports published every 5 years, but trend analyses were limited because data were not collected annually.

Methods

Using the Euro-Peristat PHIRI protocol, we estimated rates and assessed trends between 2015 and 2019 for preterm birth, stillbirth, neonatal mortality and caesarean delivery. Country-specific relative risks (RR) for year, modelled as a continuous variable, were estimated and random effects meta-analysis used to generate pooled RRs. Heterogeneity was measured with the I2 statistic (percentage of variability in estimates due to heterogeneity rather than sampling error).

Results

Stillbirth rates ≥24 weeks of gestational age (GA) varied in 2019 from <2.5 per 1000 births in Denmark, Estonia, Finland and Slovenia to over 4 per 1000 in Belgium, Cyprus, UK Wales and Lithuania. Preterm birth rates ranged from <6% in Lithuania, Finland, Latvia, Estonia and Denmark to 8% or more in Portugal, Belgium, UK Scotland and Cyprus. Fewer than 20% of births were by caesarean in Norway, the Netherlands, Finland, Estonia in comparison to one-third in Cyprus, Ireland, Italy, UK Scotland. Trends over time differed between countries and were not related to the level of the indicator: the pooled RR by year for preterm birth was 0.99 [0.99; 1.00] with five countries having significant decreases and three countries having increases. Caesarean section rates were stable overall (RR: 1.00 [0.99; 1.01]RR:1.00, 95% CI: 0.99-1.01), but with high heterogeneity (I2=99%); in six countries rates increased significantly, whereas in nine rates decreased between 2015 and 2019.

Conclusions

European countries have varying rates and trends of the principal perinatal health indicators. Investigation of policies in high-performing countries could provide guidance for improvement elsewhere.

Clarity and consistency in stillbirth reporting in Europe: why is it so hard to get this right?

Background

Stillbirth is a major public health problem, but measurement remains a challenge even in high-income countries. We compared routine stillbirth statistics in Europe reported by Eurostat with data from the Euro-Peristat research network.

Methods

We used data on stillbirths in 2015 from both sources for 31 European countries. Stillbirth rates per 1000 total births were analyzed by gestational age (GA) and birthweight groups. Information on termination of pregnancy at ≥22 weeks’ GA was analyzed separately.

Results

Routinely collected stillbirth rates were higher than those reported by the research network. For stillbirths with a birthweight ≥500 g, the difference between the mean rates of the countries for Eurostat and Euro-Peristat data was 22% [4.4/1000, versus 3.5/1000, mean difference 0.9 with 95% confidence interval (CI) 0.8–1.0]. When using a birthweight threshold of 1000 g, this difference was smaller, 12% (2.9/1000, versus 2.5/1000, mean difference 0.4 with 95% CI 0.3–0.5), but substantial differences remained for individual countries. In Euro-Peristat, missing data on birthweight ranged from 0% to 29% (average 5.0%) and were higher than missing data for GA (0–23%, average 1.8%).

Conclusions

Routine stillbirth data for European countries in international databases are not comparable and should not be used for benchmarking or surveillance without careful verification with other sources. Recommendations for improvement include using a cut-off based on GA, excluding late terminations of pregnancy and linking multiple sources to improve the quality of national databases.

Using Robson's Ten-Group Classification System for comparing caesarean section rates in Europe: an analysis of routine data from the Euro-Peristat study

Objective

Robson's Ten Group Classification System (TGCS) creates clinically relevant sub‐groups for monitoring caesarean birth rates. This study assesses whether this classification can be derived from routine data in Europe and uses it to analyse national caesarean rates.

Design

Observational study using routine data.

Setting

Twenty‐seven EU member states plus Iceland, Norway, Switzerland and the UK.

Population

All births at ≥22 weeks of gestational age in 2015.

Methods

National statistical offices and medical birth registers derived numbers of caesarean births in TGCS groups.

Main outcome measures

Overall caesarean rate, prevalence and caesarean rates in each of the TGCS groups.

Results

Of 31 countries, 18 were able to provide data on the TGCS groups, with UK data available only from Northern Ireland. Caesarean birth rates ranged from 16.1 to 56.9%. Countries providing TGCS data had lower caesarean rates than countries without data (25.8% versus 32.9%, P = 0.04). Countries with higher caesarean rates tended to have higher rates in all TGCS groups. Substantial heterogeneity was observed, however, especially for groups 5 (previous caesarean section), 6, 7 (nulliparous/multiparous breech) and 10 (singleton cephalic preterm). The differences in percentages of abnormal lies, group 9, illustrate potential misclassification arising from unstandardised definitions.

Conclusions

Although further validation of data quality is needed, using TGCS in Europe provides valuable comparator and baseline data for benchmarking and surveillance. Higher caesarean rates in countries unable to construct the TGCS suggest that effective routine information systems may be an indicator of a country's investment in implementing evidence‐based caesarean policies.

Tweetable abstract

Many European countries can provide Robson's Ten‐Group Classification to improve caesarean rate comparisons.

Many European countries can provide Robson's Ten‐Group Classification to improve caesarean rate comparisons.

Risk of stillbirth in older mothers: a specific delivery plan might be considered for prevention

OBJECTIVE

In recent decades, the trend for women is to delay childbearing. However, worldwide, advanced maternal age is an independent risk factor for stillbirth, as well as advanced gestational age. National data are not available about stillbirths in the Italian population. We explored whether, at term of pregnancy, advanced maternal age is associated with an increased risk of stillbirth in Italy. We speculate that a policy of induction of labor at term of pregnancy in older mothers may significantly reduce the stillbirth.

METHODS

Data provided by Italian Ministry of Health and National Statistical Institute were used to identify all singleton deliveries ≥22 weeks of gestation during a four years study period. We evaluated the outcome of pregnancy (livebirths or stillbirths) and we stratified data by gestational age and by maternal age at delivery. The hazard risk and the relative risk of stillbirth were calculated.

RESULTS

The overall stillbirth rate was 3.4 per 1000, with a total of 6451 cases of stillbirths in the four years study period. Overall, the risk of stillbirth increases at term of pregnancy in all maternal age groups, especially in older mothers. A total of 674 stillbirths occurred in women aged 40 years or older and 24.2% of them (n = 163) occurred at term of pregnancy. Among women aged 40 years and above, 7.3% of stillbirths (49/674) occurred beyond 39 weeks of gestation. The hazard risk doubles from 39 to 40 weeks, from 0.60 per 1000 ongoing pregnancies to 1.16 per 1000 ongoing pregnancies; the relative risk at 40 weeks of gestation was the highest in the older mothers and was 5.17 (95% CI 3.16-8.46).

CONCLUSIONS

The effect of maternal age on birth outcomes is a relevant aspect in Italy. If the association between maternal age and stillbirth is supposed to be part of the pathophysiology of fetal death, our data indicate that induction of labor before 40 weeks of gestation in women aged 40 years old or older might prevent overall 7.3% of stillbirths for induction at 39 weeks, 13% of stillbirths for induction at 38 weeks. To reduce potentially preventable stillbirths, caregivers should perform a specific risk assessment for each pregnant woman. The impact of maternal age should be seriously considered, and an individualized approach should be planned at term of pregnancy in older mothers, including the possibility of a slightly anticipation of induction of labor if spontaneously undelivered.

Maternal suicide in Italy

Suicide has been identified as one of the most common causes of death among women within 1 year after the end of pregnancy in several high-income countries. The aim of this study was to provide the first estimate of the maternal suicide ratio and a description of the characteristics of women who died by suicide during pregnancy or within 1 year after giving birth, induced abortion or miscarriage (i.e., maternal suicide) in 10 Italian regions, covering 77% of total national births. Maternal suicides were identified through the linkage between regional death registries and hospital discharge databases. Background population data was collected from the national hospital discharge, abortion and mortality databases. The previous psychiatric history of the women who died by maternal suicide was retrieved from the regionally available data sources. A total of 67 cases of maternal suicide were identified, corresponding to a maternal suicide ratio of 2.30 per 100,000 live births in 2006-2012. The suicide rate was 1.18 per 100,000 after giving birth (n = 2,876,193), 2.77 after an induced abortion (n = 650,549) and 2.90 after a miscarriage (n = 379,583). The majority of the women who died by maternal suicide (34/57) had a previous psychiatric history; 15/18 previously diagnosed mental disorders were not registered along with the index pregnancy obstetric records. Suicide is a relevant cause of maternal death in Italy. The continuity of care between primary, mental health and maternity care were found to be critical. Clinicians should be aware of the issue, as they may play an important role in preventing suicide in their patients.

Persistent geographical disparities in infant mortality rates in Italy (1999-2001): comparison with France, England, Germany, and Portugal

BACKGROUND

Infant mortality rate (IMR) is used as a population health indicator. We provide an updated description of temporal and geographical trends of IMR in Italy.

METHODS

Regional data on infant deaths and live births were available for France, Germany, England, Portugal (1999-2000), and Italy (1990-2001). Mortality rates including 95% CIs and time-trends were computed.

RESULTS

IMR was 4.5 per 1000 live births in 1999-2001. Between 1999-2001 and 1990-1992 both neonatal and post-neonatal mortality rates declined (P < 0.05) but not the North/South ratio. In 1999-2000 the regional variability in IMR was higher in Italy than in other European countries.

CONCLUSION

Despite progresses in reducing IMR, geographical disparities persist within Italy.

[Health for All-Italia: an indicator system on health]

The Health for All - Italia information system collects health data from several sources. It is intended to be a cornerstone for the achievement of an overview about health in Italy. Health is analyzed at different levels, ranging from health services, health needs, lifestyles, demographic, social, economic and environmental contexts. The database associated software allows to pin down statistical data into graphs and tables, and to carry out simple statistical analysis. It is therefore possible to view the indicators' time series, make simple projections and compare the various indicators over the years for each territorial unit. This is possible by means of tables, graphs (histograms, line graphs, frequencies, linear regression with calculation of correlation coefficients, etc) and maps. These charts can be exported to other programs (i.e. Word, Excel, Power Point), or they can be directly printed in color or black and white.