Changing clinical activity in Paediatrics in Malta, 1996-2011

Aim: This study reviews the clinical workload in paediatrics in Malta over a 16-year period. Methods: National statistics for live birth rates were obtained from the Directorate of Health Information and Research. Data for paediatric (birth to 14 completed years) and neonatal admissions, day cases, outpatient visits, attendance at Paediatric Accident and Emergency and the Community-based Developmental Unit were obtained from the Annual Reports, Department of Paediatrics, for the period 1996-2011. Results: During the study period, live births fell by 11% from 4,349 in 1996 to 3,857 in 2005, and recovered to 4,283 in 2011. Whereas neonatal admissions to NPICU remained constant at around 340(±22) per annum, inpatient admissions to the general Paediatric wards decreased by 19% (from 3,151 to 2,550), and casualty reviews dropped by 35% (11,831 to 7,773). In contrast, day care reviews increased by 66% (1,347 to 3,928), the total outpatient workload increased by 70% (13,500 to 22,998), and cases reviewed in the Community-based Child Developmental Unit increased by 184% from 413 to 1174. Changes observed in the clinical activity in Gozo General Hospital were similar but less marked. Conclusion: Over a 16 year period, there has been a significant shift in the paediatric workload in Malta from an in-patient bias in 1996 to increased day care and outpatient reviews in 2011. This shift is largely the result of improved hospital and community day health care services, and can be increased further with augmented community care. Health resources and future paediatric health care programmes will need to take heed of these trends.peer-reviewe

Health information systems in Malta : past, present and future

It is well documented and recognized internationally that good quality health information is essential to public health in its endeavor to protect and promote the health of a nation. The need for dedicated health information systems within the Ministry for Health in Malta was felt more than 30 years ago, when the Chief Government Medical Officer at the time called for the introduction and implementation of a health service information system. This led to the development of a dedicated unit with the aims of providing basic statistical and epidemiological information, conducting surveys and evaluating health programmes. Over the years, this unit has developed into the current Directorate for Health Information and Research which is now responsible for maintaining ten population-based Health Registers and a five yearly National Health Interview Survey, in addition to other ad hoc research. This article traces the development of health information systems in Malta from their inception in the early 1980s to date.peer-reviewe

Higher order multiple pregnancy outcomes in the Maltese islands 2000-2004

Higher order multiple births have increased significantly in the last decades throughout the developed world. In spite of advances in obstetric care seen throughout the second half of the twentieth century, the perinatal outcomes associated with a multiple pregnancy remain associated with increased morbidity and mortality for the mother and the infants. This study attempts to assess the characteristics and outcomes of these maternities in the Maltese population. The National maternity data for 2000-2004 was analysed (19,935 maternities; 20,215 births) and various outcome parameters were statistically compared between higher order births to singleton births using the chi square test. While the twin maternity rate during the period stood at 1.26%, the triplet maternity rate stood at 0.06% and quadruplet maternities 0.01%. Artificial reproductive technology was used in 27.8% of triplets and 50.0% in quadruplets; in contrast to 0.7% in singleton maternities (p<0.001). High order multiple maternities were more likely to be terminated by Caesarean section (25.2% vs 100%; p<0.001) and be the result of a spontaneous or iatrogenic premature delivery (4.6% vs 84.0%; p<0.001). Infant outcome was more likely to be complicated by low birth weight under 2.5 kg (9.7% vs 97.6%; p<0.001), and the associated complications of respiratory distress (1.9% vs 22.0%; p<0.001), low Apgar score (1.4% vs 7.3%; p<0.001), and perinatal deaths (stillbirth: 0.4% vs 2.4%; p<0.001; neonatal deaths 0.4% vs 4.9%; p<0.001). There did not appear to be a greater risk of major malformations.peer-reviewe

Embryonal risks in gestational diabetes mellitus

Diabetes mellitus is generally associated with a higher incidence of early pregnancy loss and congenital anomalies, though this relationship should be strictly restricted to patients with previously existing diabetes. In gestational diabetes mellitus, which often develops during the third trimester, no such relationship should exist, though the birth of a previous infant with a congenital anomaly is often assumed to be a risk factor for gestational diabetes. Objective: The study attempts to analyse the congenital anomaly rate in women with gestational diabetes and compare this to the rates in women known to have normal glucose tolerance. Results: The prevalence of infants/fetuses with congenital anomalies born to women with gestational diabetes amounted to 4.48%, a rate similar to that recorded in women with normal glucose tolerance (4.54%). Conclusions: The development of gestational diabetes, in contrast to pre-existing diabetes, does not appear to be associated with an increased risk for teratogenesis.peer-reviewe

The male to female ratio at birth in different regions in Malta

Males are usually born in excess of females and the ratio of male births to female births is conventionally referred to as M/F. Many factors, including stress, privation and natural disasters are associated with a lowering of M/F. Malta has a North-South divide, with a more affluent North as opposed to a more industrialised and less prosperous South. This study was carried out in order to ascertain whether regional economic differences influenced M/F in Malta. Births by gender, year of birth and locality from 1999 to 2013 were subdivided into ten regions in a geographic distribution devised by the Department of Health Information and Research. Regions were also amalgamated into two groups of five which represented North-West and South-East Malta. The island of Gozo was considered separately. There were no statistically significant differences in M/F between the ten regions nor between North-West, South-East and Gozo regions. There were no significant secular trends in M/F in these regions. M/F declines under adverse environmental factors (including economic stress) but despite the overall poorer economic circumstances in the South of the Island, this study failed to show a significant difference in M/F by region. This may be due at least in part to the relatively small numbers involved. Alternatively, the purported socio-economic differences may not have been sufficiently large so as to skew M/F to statistically significant levels.peer-reviewe

Maternal risks associated with pregnancy in women with advanced maternal age

Introduction: The trend towards delayed motherhood has accelerated in developed countries over the last few decades. Advanced maternal age (AMA) is defined as age 35 years and older at the estimated date of delivery. Objective: The aim of this large retrospective cohort study is to assess for the association between AMA and adverse maternal outcomes after adjustment for confounding factors in maternal characteristics and in the obstetric history. Study Design: Mothers of 20 years and older, who delivered singleton babies in Malta and Gozo between 1st January 2000 and 31st December 2014 were studied. All data was derived from the National Obstetric Information System. Results: The study population included 55,943 singleton births. 12.2% (6,838) of mothers were between 35 – 39 years and 2.4% (1,325) were 40 years and older. Significant difference was found between maternal age and BMI (p < 0.0001), maternal smoking status (p < 0.0001), non-insulin dependent diabetes mellitus (p = 0.004), history of stillbirth (p < 0.0001), gestational diabetes (p < 0.0001), pregnancy – induced – hypertension (p = 0.008) and pre-eclampsia (p = 0.008). Significant difference was also found between maternal age and mode of delivery (p < 0.0001). Regression analysis revealed persistent significant differences between maternal age and different maternal outcomes. Conclusion: This study demonstrates that AMA in Malta significantly increases the risk for hypertension in pregnancy, gestational diabetes and caesarean delivery. Care providers need to be aware of these increased risks and adjust their obstetric management according to the individual to ensure optimal maternal outcomes.peer-reviewe

Maternal factors and the male to female birth ratio in Malta

Introduction: The sex ratio at birth is commonly calculated as the total male live births divided by all live births, and is represented as M/F. A multitude of factors influence M/F, especially stress, which increases male foetal losses during pregnancy. This study was carried out in order to ascertain whether any maternal or perinatal relevant factors influenced M/F in Malta. Methods: National Obstetric Information System data was used for the period 2012-2015. Non-Maltese mothers were excluded. Factors analysed were maternal age, marital status, education, body mass index, regularity of menses, utilisation of assisted reproductive technology, previous diabetes mellitus, previous miscarriages, abortions, ectopic pregnancies, vaginal deliveries, caesarean sections, livebirths, early and late neonatal deaths, stillbirths and premature deliveries. Intra-partum conditions included infection, cardiovascular disorders and all forms of diabetes mellitus. Results: This study analysed 14498 births. None of the above mentioned variables was significantly linked to the M/F ratio. Discussion: Our dataset failed to find any variables that influenced M/F, including stressing variables. However our study may have been underpowered due to the small numbers of births and the relative rarity of the various conditions. Alternatively, in Malta, such variables may produce little or no stress due to hitherto unknown mitigating factor/s.peer-reviewe

Maternal preconception intake of folic acid in Malta

Background: Neural tube defects (NTDs) are serious birth defects arising from abnormalities in neural tube development during early embryogenesis. Research shows that taking folic acid (FA) prior to and throughout the first 12 weeks of pregnancy will significantly decrease the occurrence of NTDs. The prevalence of NTDs in Malta is 10.0/10,000 births, yet this rate can be brought down to 5.0-6.0/10,000 births with preconception FA. This study aims to investigate the maternal intake of preconception FA in Malta. Methods: The National Obstetric Information System (NOIS) collects detailed demographic, pregnancy, delivery and infant outcome data on all births in Malta. One of the variables recorded at the first antenatal visit is whether the mother took FA prior to pregnancy. NOIS data for 2015 was obtained, Excel and SPSS were used for analysis. Results: 4385 women delivered a baby in 2015, of these 1125 (25.7%) reported taking FA before pregnancy. Both univariate and multivariate logistic regression showed that maternal age, parity, education, nationality, locality of residence, marital status, planned pregnancy and use of artificial reproductive technology were all significantly associated with taking preconception FA (p<0.001). Conclusion: Although preconception folic acid supplementation has been advised since the early 1990s, in Malta only a quarter of mothers are taking this before pregnancy. This low compliance is also documented in other countries. Several maternal factors have been found to be associated with better intake of preconception FA. Effective methods of increasing maternal preconception intake of FA are necessary to decrease the rate of NTDs in Malta.peer-reviewe

Prevention of birth defects

Folate is essential for normal cell division and as intrauterine fetal growth involves a process of rapidly dividing cells, there is a consequent increased requirement for folate at this time. Folate, and the synthetic form folic acid, is thus vital for the early development process of a healthy fetus and there is indisputable evidence that it can significantly reduce the risk of neural tube defects (NTDs). Further ongoing research suggests that folic acid supplementation in pregnancy is also associated with a decreased risk of other birth defects. This review gives an overview of the current literature related to the use of folic acid in the peri-conceptional period and prevention of birth defects, in particular NTDs.peer-reviewe

Risk of Recurrent Stillbirth in Subsequent Pregnancies

Financial Disclosure Kathleen Lamont was awarded an Elphinstone scholarship from the university of Aberdeen, Scotland. In addition, money from a NHS Grampian endowment fund financed storage of data. Sohinee Bhattacharya reports that money was paid to their institution from the NHS Grampian Endowment fund, Medical Research Scotland, and the Wellcome Trust ISSF fund. Sohinee Bhattacharya’s husband has co-authored previous publications based on a similar dataset. He is the Head of School of medicine, medical Sciences and Nutrition at the University of Aberdeen where she is also employed. The other authors did not report any potential conflicts of interest.Peer reviewedPostprin