The way to move beyond the numbers: the lesson learnt from the Italian Obstetric Surveillance System

Objective.To describe the Italian Obstetric Surveillance System (ItOSS) investigating maternal death through incident case reporting and confidential enquiries.Methods. All maternal deaths occurred in any public and private health facility in 8 Italian regions covering 73% of national births have been notified to the ItOSS. Every incident case is confidentially reviewed to assess quality of care and establish the cause and avoidability of the death.Findings. A total of 106 maternal deaths among 1.455.545 new-borns have been notified to the surveillance system in 2013-17. Haemorrhage, sepsis and hypertensive disorders of pregnancy are the leading causes of direct maternal deaths due to obstetric causes.Conclusions. A maternal mortality surveillance system, including incidence reporting and confidential enquiries along with a retrospective analysis of administrative data sources, emerged as the best option for case ascertainment and for promoting avoidable maternal deaths. 

Management of major obstetric hemorrhage prior to peripartum hysterectomy and outcomes across nine European countries

Introduction Peripartum hysterectomy is applied as a surgical intervention of last resort for major obstetric hemorrhage. It is performed in an emergency setting except for women with a strong suspicion of placenta accreta spectrum (PAS), where it may be anticipated before cesarean section. The aim of this study was to compare management strategies in the case of obstetric hemorrhage leading to hysterectomy, between nine European countries participating in the International Network of Obstetric Survey Systems (INOSS), and to describe pooled maternal and neonatal outcomes following peripartum hysterectomy. Material and methods We merged data from nine nationwide or multi-regional obstetric surveillance studies performed in Belgium, Denmark, Finland, France, Italy, the Netherlands, Slovakia, Sweden and the UK collected between 2004 and 2016. Hysterectomies performed from 22 gestational weeks up to 48 h postpartum due to obstetric hemorrhage were included. Stratifying women with and without PAS, procedures performed in the management of obstetric hemorrhage prior to hysterectomy between countries were counted and compared. Prevalence of maternal mortality, complications after hysterectomy and neonatal adverse events (stillbirth or neonatal mortality) were calculated. Results A total of 1302 women with peripartum hysterectomy were included. In women without PAS who had major obstetric hemorrhage leading to hysterectomy, uterotonics administration was lowest in Slovakia (48/73, 66%) and highest in Denmark (25/27, 93%), intrauterine balloon use was lowest in Slovakia (1/72, 1%) and highest in Denmark (11/27, 41%), and interventional radiology varied between 0/27 in Denmark and Slovakia to 11/59 (79%) in Belgium. In women with PAS, uterotonics administration was lowest in Finland (5/16, 31%) and highest in the UK (84/103, 82%), intrauterine balloon use varied between 0/14 in Belgium and Slovakia to 29/103 (28%) in the UK. Interventional radiology was lowest in Denmark (0/16) and highest in Finland (9/15, 60%). Maternal mortality occurred in 14/1226 (1%), the most common complications were hematologic (95/1202, 8%) and respiratory (81/1101, 7%). Adverse neonatal events were observed in 79/1259 (6%) births. Conclusions Management of obstetric hemorrhage in women who eventually underwent peripartum hysterectomy varied greatly between these nine European countries. This potentially life-saving procedure is associated with substantial adverse maternal and neonatal outcome.Peer reviewe

Do Italian pregnant women use periconceptional folate supplementation?

Deficiency of Folic Acid (FA) has been identified as a risk factor for neural tube defects (NTDs) as well as other congenital abnormalities. Thus, periconceptional folate supplementation is recommended for all women planning to get pregnant.We conducted a KAP (knowledge, attitude, practice) survey to investigate the use of FA and its appropriateness. The survey included a sample of 562 women who delivered in Lazio region between 2013 and 2014. Two logistic regression analyses were performed to evaluate the association between the characteristics of participating women and both the information received on FA intake and its use. The prevalence of periconceptional FA assumption was  19.4% although 82.2% of the interviewed women had planned their pregnancies. It shows that more periconceptional counseling is needed to increase women's awareness on the opportunity of FA supplementation

Epidemiological analysis of peripartum hysterectomy across nine European countries

Introduction Peripartum hysterectomy is a surgical procedure performed for severe obstetric complications such as major obstetric hemorrhage. The prevalence of peripartum hysterectomy in high-resource settings is relatively low. Hence, international comparisons and studying indications and associations with mode of birth rely on the use of national obstetric survey data. Objectives were to calculate the prevalence and indications of peripartum hysterectomy and its association with national cesarean section rates and mode of birth in nine European countries. Material and methods We performed a descriptive, multinational, population-based study among women who underwent peripartum hysterectomy. Data were collected from national or multiregional databases from nine countries participating in the International Network of Obstetric Survey Systems. We included hysterectomies performed from 22 gestational weeks up to 48 hours postpartum for obstetric hemorrhage, as this was the most restrictive, overlapping case definition between all countries. Main outcomes were prevalence and indications of peripartum hysterectomy. Additionally, we compared prevalence of peripartum hysterectomy between women giving birth vaginally and by cesarean section, and between women giving birth with and without previous cesarean section. Finally, we calculated correlation between prevalence of peripartum hysterectomy and national cesarean section rates, as well as national rates of women giving birth after a previous cesarean section. Results A total of 1302 peripartum hysterectomies were performed in 2 498 013 births, leading to a prevalence of 5.2 per 10 000 births ranging from 2.6 in Denmark to 10.7 in Italy. Main indications were uterine atony (35.3%) and abnormally invasive placenta (34.8%). Relative risk of hysterectomy after cesarean section compared with vaginal birth was 9.1 (95% CI 8.0-10.4). Relative risk for hysterectomy for birth after previous cesarean section compared with birth without previous cesarean section was 10.6 (95% CI 9.4-12.1). A strong correlation was observed between national cesarean section rate and prevalence of peripartum hysterectomy (rho = 0.67, P < .05). Conclusions Prevalence of peripartum hysterectomy may vary considerably between high-income countries. Uterine atony and abnormally invasive placenta are the commonest indications for hysterectomy. Birth by cesarean section and birth after previous cesarean section are associated with nine-fold increased risk of peripartum hysterectomy

Indicatori PNE. Ieri, oggi e domani

L’edizione 2019 di PNE analizza 176 indicatori (72 di esito/processo, 74 di volumi di attività e 30 di ospedalizzazione), coprendo 11 aree cliniche. In questo articolo, riportiamo a titolo esemplificativo una selezione di indicatori riguardanti 4 aree cliniche con il duplice intento di rappresentare alcuni dei contenuti del PNE e di illustrare i cambiamenti temporali che è possibile apprezzare attraverso questo strumento di valutazione

Studio internazionale sulle pratiche della "care" nelle unità di terapia intensiva neonatale

Background: Le pratiche di Care, cioè l’insieme di strategie atte a ridurre le possibili fonti di stress durante la degenza, possono avere effetti importanti sulla salute del neonato sia a breve che a medio-lungo termine. Non è però ancora chiaro in che misura e con quali modalità le moderne Unità di Terapia Intensiva Neonatale (TIN) applichino tali procedure. Obiettivi: Descrivere le modalità e l’intensità di utilizzo delle pratiche di Care svolte nelle TIN italiane ed europee producendo dati confrontabili. Analizzare l’ambiente fisico nel quale si svolgono, le strutture, le pratiche mediche e infermieristiche in esse adottate, nonché identificare i principali ostacoli alla diffusione di queste. Metodi: Un questionario autosomministrato (composto da sezioni tematiche riguardanti: controllo dell’ambiente della TIN, management del neonato, controllo del dolore e apertura del reparto ai genitori) è stato inviato a 364 TIN di Belgio, Danimarca, Francia, Inghilterra, Italia, Olanda, Spagna e Svezia. Distribuzioni di frequenza, medie e mediane con relativi intervalli di confidenza, range e precentili sono stati calcolate per la popolazione totale e disaggregate per paese. Per l’Italia, tramite un modello logistico lineare, è stata valutata l’associazione tra gli indicatori delle Care e le caratteristiche dell’Unita (ripartizione geografica, livello, dimensione, affiliazione a ospedale Universitario). Risultati: Il tasso di risposta totale ha raggiunto il 78% (100% in Danimarca, Olanda e Svezia; 70% in Inghilterra e Italia). Il controllo dell’ambiente viene effettuato tramite un’illuminazione moderata per tutte le 24 ore nel 59% delle Unità (80% Olanda, 44% in Spagna). Riguardo al management del neonato, il contenimento è largamente utilizzato in tutti i paesi (nel 94% delle Unita). Rispetto al controllo del dolore, sono il 58% le Unità che durante l’intubazione endotracheale sedano il neonato con analgesia farmacologia (94% delle Unità danesi, 28% di quelle italiane), mentre il 50% delle TIN utilizza metodi di analgesia non-farmacologica durante le puntura lombare (94% in Danimarca, 27% in Spagna). Infine, in Danimarca e Svezia tutte le TIN concedono un orario di visita illimitato mentre in Italia e Spagna solo il 33% e il 27%. In Italia, il fattore che maggiormente influenza una diversa applicazione della Care è la ripartizione geografica: le Unità delle regioni meridionali hanno una minor attenzione nei confronti controllo del dolore rispetto alle TIN del Nord, sia in termini di analgesia farmacologia (OR 0,36; IC 95% 0,13-0,98), sia per quanto riguarda l’analgesia non-farmacologica (OR 0,34; IC 95% 0,11-0,99). Nel Sud Italia si registra una minor apertura dei reparti ai genitori rispetto al Nord (la madre può restare accanto al piccolo per tutto il tempo che desidera più frequentemente - OR Sud vs Nord 0,29; IC95% 0,10-0,87- e il padre è più frequentemente libero di praticare le cure canguro - OR Sud vs Nord 0,19; IC95% 0,06-0,58). Conclusioni: Molti elementi delle Care sono ormai consolidati nelle pratiche medico-infermieristiche delle TIN europee. Le aree d’intervento maggiormente differenziate sono il controllo del dolore e l’apertura del reparto ai genitori. I paesi del Nord Europa sono più attenti a questi aspetti rispetto a Spagna e Italia. Anche in Italia l’applicazione della Care segue l’asse Nord-Sud.Background. Developmental Care -an approach using a range of medical and nursing interventions aimed to decrease the stress of preterm neonates in Neonatal Intensive Care Units (NICUs)- have quite important effects on neonates health both in the short and medium-long run. Though, it is still not enough clear how and how frequently these procedures are used. Aims The present survey deals with forms and frequencies of use of Developmental Care in both Italian and European NICUs. Through comparable data, the survey takes into consideration the different aspects of structures and physical environment in which the Developmental Care is used, the concrete medical and nursing practices and the main obstacles in the diffusion of Care activities. Methods. A questionnaire was sent to 364 NICUs in Belgium, Denmark, France, UK, Italy, Netherlands, Spain and Sweden. The main sections of the questionnaire were the following: NICUs environment, neonate’s management, pain management, policies towards parental visiting. Frequency distribution, average value, median and relative confidence intervals, range and percentiles were computed by total population and by country. For Italy, a log-linear model has been applied in order to evaluate the association between the Developmental Care indicators and the NICUs’ main features (geographical location, unit’s level, dimension, affiliation to university). Results. The total response rate is 78% (100% in Denmark, Netherlands and Sweden and 70% in UK and Italy). The environment is controlled through a 24 hours moderate lighting in 59% of NICUs (80% in Netherlands, 44% in Spain). As for neonate’s management, the nesting is largely used in most countries (94% of NICUs). As for pain control, 58% of units use pharmacological analgesia during endotracheal intubation (94% in Denmark, 28% in Italy) and 50% of NICUs use non-pharmacological analgesia during lumbar puncture (94% in Denmark , 27% in Spain). Both Denmark and Sweden have unlimited parental visiting, when in Italy and Spain this is an opportunity offered only in respectively 33% and 27% of the cases. In Italy the most powerful factor influencing the differences in Developmental Care use is the geographical repartition. NICUs in Southern regions show, in terms of pharmacological (OR 0,36; IC 95% 0,13-0,98) and non- pharmacological (OR 0,34; IC 95% 0,11-0,99) analgesia, a lower attention to pain management than in the Northern areas. Southern Italy opens the department to parental visits much less than the rest of the country. In the first case, mothers are free to be by their child less frequently than in the North (South vs North OR = 0.29; IC 95% 0,10-0,87) and fathers less free to practice the kangaroo cares (South vs North OR=0.19; IC 95% 0,06-0,58). Conclusions. Many of the Developmental Care elements are presently consolidated in the medical and nursing practices of the European NUCUs. The areas in which a wider differentiation is shown is the pain management and the opening to parental visits. North European countries show a higher attention to these aspects than Italy and Spain and a similar North-South differentiation is also shown in Italian Developmental Care application

Studio internazionale sulle pratiche della "care" nelle unità di terapia intensiva neonatale

Background: Le pratiche di Care, cioè l’insieme di strategie atte a ridurre le possibili fonti di stress durante la degenza, possono avere effetti importanti sulla salute del neonato sia a breve che a medio-lungo termine. Non è però ancora chiaro in che misura e con quali modalità le moderne Unità di Terapia Intensiva Neonatale (TIN) applichino tali procedure. Obiettivi: Descrivere le modalità e l’intensità di utilizzo delle pratiche di Care svolte nelle TIN italiane ed europee producendo dati confrontabili. Analizzare l’ambiente fisico nel quale si svolgono, le strutture, le pratiche mediche e infermieristiche in esse adottate, nonché identificare i principali ostacoli alla diffusione di queste. Metodi: Un questionario autosomministrato (composto da sezioni tematiche riguardanti: controllo dell’ambiente della TIN, management del neonato, controllo del dolore e apertura del reparto ai genitori) è stato inviato a 364 TIN di Belgio, Danimarca, Francia, Inghilterra, Italia, Olanda, Spagna e Svezia. Distribuzioni di frequenza, medie e mediane con relativi intervalli di confidenza, range e precentili sono stati calcolate per la popolazione totale e disaggregate per paese. Per l’Italia, tramite un modello logistico lineare, è stata valutata l’associazione tra gli indicatori delle Care e le caratteristiche dell’Unita (ripartizione geografica, livello, dimensione, affiliazione a ospedale Universitario). Risultati: Il tasso di risposta totale ha raggiunto il 78% (100% in Danimarca, Olanda e Svezia; 70% in Inghilterra e Italia). Il controllo dell’ambiente viene effettuato tramite un’illuminazione moderata per tutte le 24 ore nel 59% delle Unità (80% Olanda, 44% in Spagna). Riguardo al management del neonato, il contenimento è largamente utilizzato in tutti i paesi (nel 94% delle Unita). Rispetto al controllo del dolore, sono il 58% le Unità che durante l’intubazione endotracheale sedano il neonato con analgesia farmacologia (94% delle Unità danesi, 28% di quelle italiane), mentre il 50% delle TIN utilizza metodi di analgesia non-farmacologica durante le puntura lombare (94% in Danimarca, 27% in Spagna). Infine, in Danimarca e Svezia tutte le TIN concedono un orario di visita illimitato mentre in Italia e Spagna solo il 33% e il 27%. In Italia, il fattore che maggiormente influenza una diversa applicazione della Care è la ripartizione geografica: le Unità delle regioni meridionali hanno una minor attenzione nei confronti controllo del dolore rispetto alle TIN del Nord, sia in termini di analgesia farmacologia (OR 0,36; IC 95% 0,13-0,98), sia per quanto riguarda l’analgesia non-farmacologica (OR 0,34; IC 95% 0,11-0,99). Nel Sud Italia si registra una minor apertura dei reparti ai genitori rispetto al Nord (la madre può restare accanto al piccolo per tutto il tempo che desidera più frequentemente - OR Sud vs Nord 0,29; IC95% 0,10-0,87- e il padre è più frequentemente libero di praticare le cure canguro - OR Sud vs Nord 0,19; IC95% 0,06-0,58). Conclusioni: Molti elementi delle Care sono ormai consolidati nelle pratiche medico-infermieristiche delle TIN europee. Le aree d’intervento maggiormente differenziate sono il controllo del dolore e l’apertura del reparto ai genitori. I paesi del Nord Europa sono più attenti a questi aspetti rispetto a Spagna e Italia. Anche in Italia l’applicazione della Care segue l’asse Nord-Sud.Background. Developmental Care -an approach using a range of medical and nursing interventions aimed to decrease the stress of preterm neonates in Neonatal Intensive Care Units (NICUs)- have quite important effects on neonates health both in the short and medium-long run. Though, it is still not enough clear how and how frequently these procedures are used. Aims The present survey deals with forms and frequencies of use of Developmental Care in both Italian and European NICUs. Through comparable data, the survey takes into consideration the different aspects of structures and physical environment in which the Developmental Care is used, the concrete medical and nursing practices and the main obstacles in the diffusion of Care activities. Methods. A questionnaire was sent to 364 NICUs in Belgium, Denmark, France, UK, Italy, Netherlands, Spain and Sweden. The main sections of the questionnaire were the following: NICUs environment, neonate’s management, pain management, policies towards parental visiting. Frequency distribution, average value, median and relative confidence intervals, range and percentiles were computed by total population and by country. For Italy, a log-linear model has been applied in order to evaluate the association between the Developmental Care indicators and the NICUs’ main features (geographical location, unit’s level, dimension, affiliation to university). Results. The total response rate is 78% (100% in Denmark, Netherlands and Sweden and 70% in UK and Italy). The environment is controlled through a 24 hours moderate lighting in 59% of NICUs (80% in Netherlands, 44% in Spain). As for neonate’s management, the nesting is largely used in most countries (94% of NICUs). As for pain control, 58% of units use pharmacological analgesia during endotracheal intubation (94% in Denmark, 28% in Italy) and 50% of NICUs use non-pharmacological analgesia during lumbar puncture (94% in Denmark , 27% in Spain). Both Denmark and Sweden have unlimited parental visiting, when in Italy and Spain this is an opportunity offered only in respectively 33% and 27% of the cases. In Italy the most powerful factor influencing the differences in Developmental Care use is the geographical repartition. NICUs in Southern regions show, in terms of pharmacological (OR 0,36; IC 95% 0,13-0,98) and non- pharmacological (OR 0,34; IC 95% 0,11-0,99) analgesia, a lower attention to pain management than in the Northern areas. Southern Italy opens the department to parental visits much less than the rest of the country. In the first case, mothers are free to be by their child less frequently than in the North (South vs North OR = 0.29; IC 95% 0,10-0,87) and fathers less free to practice the kangaroo cares (South vs North OR=0.19; IC 95% 0,06-0,58). Conclusions. Many of the Developmental Care elements are presently consolidated in the medical and nursing practices of the European NUCUs. The areas in which a wider differentiation is shown is the pain management and the opening to parental visits. North European countries show a higher attention to these aspects than Italy and Spain and a similar North-South differentiation is also shown in Italian Developmental Care application

Coronavirus and birth in Italy: results of a national population-based cohort study

The study was implemented to provide guidance to decision-makers and clinicians by describing hospital care offered to women who gave birth with confirmed SARS-CoV-2 infection

Epidemiological analysis of peripartum hysterectomy across nine European countries

Introduction Peripartum hysterectomy is a surgical procedure performed for severe obstetric complications such as major obstetric hemorrhage. The prevalence of peripartum hysterectomy in high-resource settings is relatively low. Hence, international comparisons and studying indications and associations with mode of birth rely on the use of national obstetric survey data. Objectives were to calculate the prevalence and indications of peripartum hysterectomy and its association with national cesarean section rates and mode of birth in nine European countries. Material and methods We performed a descriptive, multinational, population-based study among women who underwent peripartum hysterectomy. Data were collected from national or multiregional databases from nine countries participating in the International Network of Obstetric Survey Systems. We included hysterectomies performed from 22 gestational weeks up to 48 hours postpartum for obstetric hemorrhage, as this was the most restrictive, overlapping case definition between all countries. Main outcomes were prevalence and indications of peripartum hysterectomy. Additionally, we compared prevalence of peripartum hysterectomy between women giving birth vaginally and by cesarean section, and between women giving birth with and without previous cesarean section. Finally, we calculated correlation between prevalence of peripartum hysterectomy and national cesarean section rates, as well as national rates of women giving birth after a previous cesarean section. Results A total of 1302 peripartum hysterectomies were performed in 2 498 013 births, leading to a prevalence of 5.2 per 10 000 births ranging from 2.6 in Denmark to 10.7 in Italy. Main indications were uterine atony (35.3%) and abnormally invasive placenta (34.8%). Relative risk of hysterectomy after cesarean section compared with vaginal birth was 9.1 (95% CI 8.0-10.4). Relative risk for hysterectomy for birth after previous cesarean section compared with birth without previous cesarean section was 10.6 (95% CI 9.4-12.1). A strong correlation was observed between national cesarean section rate and prevalence of peripartum hysterectomy (rho = 0.67, P <.05). Conclusions Prevalence of peripartum hysterectomy may vary considerably between high-income countries. Uterine atony and abnormally invasive placenta are the commonest indications for hysterectomy. Birth by cesarean section and birth after previous cesarean section are associated with nine-fold increased risk of peripartum hysterectomy.Peer reviewe

Characteristics and outcomes of pregnant women with placenta accreta spectrum in Italy: A prospective population-based cohort study.

IntroductionPlacenta accreta spectrum (PAS) is a rare but potentially life-threatening event due to massive hemorrhage. Placenta previa and previous cesarean section are major risk factors for PAS. Italy holds one of the highest rates of primary and repeated cesarean section in Europe; nonetheless, there is a paucity of high-quality Italian data on PAS. The aim of this paper was to estimate the prevalence of PAS in Italy and to evaluate its associated factors, ante- and intra-partum management, and perinatal outcomes. Also, since severe morbidity and mortality in Italy show a North-South gradient, we assessed and compared perinatal outcomes of women with PAS according to the geographical area of delivery.Material and methodsThis was a prospective population-based study using the Italian Obstetric Surveillance System (ItOSS) and including all women aged 15-50 years with a diagnosis of PAS between September 2014 and August 2016. Six Italian regions were involved in the study project, covering 49% of the national births. Cases were prospectively reported by a trained clinician for each participating maternity unit by electronic data collection forms. The background population comprised all women who delivered in the participating regions during the study period.ResultsA cohort of 384 women with PAS was identified from a source population of 458 995 maternities for a prevalence of 0.84/1000 (95% CI, 0.75-0.92). Antenatal suspicion was present in 50% of patients, who showed reduced rates of blood transfusion compared to unsuspected patients (65.6% versus 79.7%, P = 0.003). Analyses by geographical area showed higher rates of both concomitant placenta previa and prior CS (62.1% vs 28.7%, PConclusionsAntenatal suspicion of PAS is associated with improved maternal outcomes, also among high-risk women with both placenta previa and prior CS, likely because of their referral to specialized centers for PAS management