Perinatal health monitoring through a European lens: eight lessons from the Euro-Peristat report on 2015 births

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Variations géographiques des taux de prématurité et tendances dans le temps : une étude comparative dans 34 pays à haut niveau de développement

Preterm birth (PTB), defined as birth before 37 weeks, is a leading cause of infant mortality and morbidity. Compared to term infants, preterm infants face important risks of motor and cognitive impairments throughout childhood, as well as chronic diseases and premature death later in life. PTB represents a significant public health burden and in Europe, rates range between 5 and 10%. Such wide differences suggest that reductions may be possible, but there are few effective interventions, and these tend to target selected groups of high-risk pregnancies, based on clinical risk factors. Our aim for this thesis was to better appraise sources of population-level PTB rate variations and trends. First, we conducted an exhaustive review of the literature and found that maternal characteristics, reproductive policies, medical practices and methods of gestational age (GA) estimation affected PTB rates, but could not explain observed differences across countries. Next, using population-based data on pregnant women, newborns and stillbirths in 34 high-income countries from 1996 to 2010, we showed that: 1) reporting criteria for births and deaths affected PTB rates at early gestations and PTB rankings, but differences between countries with high and low rates are not just due to artefact 2) PTB trends were associated with broader shifts in countries’ gestational age GA distribution of births, and 3) using data from a representative sample of births in France in 2010, that there were shared maternal prenatal and socio-demographic risk factors for deliveries that did not reach full term, at 39 weeks GA. Our work confirms that recording differences in high-income countries have a limited impact on PTB rate variations. However, a broader focus on earlier delivery, including early term birth at 37-38 weeks, could shed light on the determinants of low PTB rates and provide a useful public health prevention paradigm.La prématurité, définie par une naissance avant 37 semaines d’aménorrhées (SA), est une cause majeur de mortalité et de morbidité infantile. Comparés aux enfants nés à terme, les prématurés font face à des risques importants de troubles moteurs et cognitifs durant l'enfance, ainsi que de maladies chroniques et décès prématurés à l’âge adulte. La prématurité constitue un enjeu important de santé publique et en Europe, les taux varient entre 5 et 10%. Notre objectif pour cette thèse était de mieux comprendre les sources d’hétérogénéité des taux à l’échelle des pays. Dans un premier temps, nous avons effectué une revue exhaustive de la littérature qui montre que les caractéristiques maternelles, les pratiques médicales, et les méthodes d'estimation de l'âge gestationnel ont un impact sur les taux de prématurité. Cependant, ces facteurs n'expliquent pas l’ampleur des différences observées entre les pays. Puis, en utilisant des données sur les femmes enceintes, les nouveau-nés et les mort-nés dans 34 pays à revenus élevés de 1996 à 2010, nous avons établi que: 1) les différences d'enregistrement des naissances dans les pays à revenus élevés ont un impact limité sur les taux, sauf pour les naissances à 22-23 SA, 2) les tendances de PTB dans les pays sont associées à des variations plus importantes dans la distribution des âges gestationnels 3) et enfin, en utilisant les données d'un échantillon représentatif des naissances en France en 2010, qu’il existe des facteurs de risques maternels prénatals et socio-démographiques communs aux naissances avant terme (<37SA) et proche du terme à 37-38 SA. Viser à réduire les facteurs de risques de la naissance proche du terme et de la prématurité dans une approche conjointe pourrait apporter un nouvel élan à la prévention de la prématurité. Comparés aux enfants prématurés, les enfants nés proche du terme sont individuellement moins à risque, mais à l’échelle des pays ces enfants représentent environ une naissance sur quatre et ils contribuent de manière importante au fardeau de morbi-mortalité néonatale et infantile. Au niveau national, élargir les efforts de prévention de la prématurité à cette nouvelle population-cible pourrait avoir un plus grand impact sur la santé publique

Developing a tool to monitor knowledge translation in the health system : results from an international Delphi study

Background: It is generally accepted that evidence-informed decision making contributes to better health system performance and health outcomes, yet we are lacking benchmarks to monitor the impact of national health information systems (HIS) in policy and practice. Hence in this study, we have aimed to identify criteria for monitoring Knowledge Translation (KT) capacity within countries. Methods: We conducted a web-based Delphi with over 120 public health professionals from 45 countries to reach agreement on criteria to monitor KT at the level of national HIS. Public health professionals participated in three survey rounds, in which they ranked 85 preselected criteria and could suggest additional criteria. Results: Experts working in national (public) health agencies and statistical offices, as well as in health policy and care agreed on 29 criteria which constitute the Health Information (HI)-Impact Index. The criteria cover four essential domains of evaluation: the production of high-quality evidence, broad access and dissemination, stakeholder engagement and knowledge integration across sectors and in civil society. The HI-Impact Index was pretested by officials working in ministries of health and public health agencies in eight countries; they found the tool acceptable and user-friendly. Conclusions: The HI-Impact Index provides benchmarks to monitor KT so that countries can assess whether high-quality evidence can be easily accessed and used by the relevant stakeholders in health policy and practice, by civil society and across sectors. Next steps include further refining the procedure for conducting the assessment in routine, and sharing experiences from HIS evaluations using the HI-Impact Index

The second European Perinatal Health Report: documenting changes over 6 years in the health of mothers and babies in Europe.

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European Perinatal Health Report :Health and Care of Pregnant Women and Babies in Europe in 2010

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Varying gestational age patterns in cesarean delivery: an international comparison

Background: While international variations in overall cesarean delivery rates are well documented, less information is available for clinical sub-groups. Cesarean data presented by subgroups can be used to evaluate uptake of cesarean reduction policies or to monitor delivery practices for high and low risk pregnancies based on new scientific evidence. We studied differences and patterns in cesarean delivery rates by multiplicity and gestational age in Europe and the United States. Methods: This study used routine aggregate data from 17 European countries and the United States on the number of singleton and multiple live births with cesarean versus vaginal delivery by week of gestation in 2008. Overall and gestation-specific cesarean delivery rates were analyzed. We computed rate differences to compare mode of delivery (cesarean vs vaginal birth) between selected gestational age groups and studied associations between rates in these subgroups namely: very preterm (26–31 weeks GA), moderate preterm (32–36 weeks GA), near term (37–38 weeks GA), term (39–41 weeks GA) and post-term (42+ weeks GA) births, using Spearman’s rank tests. Results: High variations in cesarean rates for singletons and multiples were observed everywhere. Rates for singletons varied from 15% in The Netherlands and Slovenia, to over 30% in the US and Germany. In singletons, rates were highest for very preterm births and declined to a nadir at 40 weeks of gestation, ranging from 8.0% in Sweden and Norway, to 22.5% in the US. These patterns differed across countries; the average rate difference between very preterm and term births was 43 percentage points, but ranged from 14% to 61%. High variations in rate differences were also observed for near term versus term births. For multiples, rates declined by gestational age in some countries, whereas in others rates were similar across all weeks of gestation. Countries’ overall cesarean rates were highly correlated with gestation-specific subgroup rates, except for very preterm births. Conclusions: Gestational age patterns in cesarean delivery were heterogeneous across countries; these differences highlight areas where consensus on best practices is lacking and could be used in developing strategies to reduce cesareans

Association of PNC, BC, and PM2.5 Measured at a Central Monitoring Site with Blood Pressure in a Predominantly Near Highway Population

Elevated blood pressure is an indicator of cardiovascular stress and increased risk of cardiovascular-related morbidity and mortality. There is emerging evidence suggesting air pollutants, including particulate matter (PM), could promote hypertension, thereby increasing cardiovascular disease risk. Repeated measurement analyses were conducted to examine the associations of three types of PM with systolic blood pressure (SBP), diastolic blood pressure (DBP), and pulse pressure (PP) in 220 participants, (mean age = 58.5 years) from the Community Assessment of Freeway Exposure and Health study (CAFEH), most of whom live near a major highway. Ambient levels of air pollutants including particle number concentration (PNC; a measure of ultrafine particle (UFP) concentration), fine PM (PM2.5, Particle diameter <2.5 µm), and black carbon (BC) were measured at a central site <7 km from the study areas. Central sites are good at capturing short-term temporal trends in pollution associated with meteorological changes over regional areas. Linear mixed-effect models that accounted for repeated measures within one person were used to examine the associations between blood pressure variables and daily average of ambient PNC, PM2.5, or BC, controlling for demographic characteristics and major confounders including temperature. Our PNC model predicted that a higher PNC of 10,000 particles/cm3 was associated with higher DBP of 2.40 mmHg (p = 0.03), independent of other factors in the model. There were no significant associations for PM2.5 or BC. Post hoc subgroup analyses by obesity status showed that positive associations of DBP with PNC were more pronounced among obese individuals than non-obese individuals. These results suggested that PNC levels are associated with increased blood pressure, which may contribute to cardiovascular disease risk. More research is needed to assess the relationship between PNC and blood pressure and to address possible residual confounding

Prioritizing health information for national health reporting - a Delphi study of the Joint Action on Health Information (InfAct).

BACKGROUND: Health information (HI) strategies exist in several EU Member States, however, they mainly focus on technical issues and improving governance rather than on content-related priority setting. There is also little research available about national prioritization processes underlying HI development for policy support in the EU. The aim of this study was to broaden the knowledge base on HI prioritization strategies and to encourage expert exchange towards good practice models. A specific focus was put on HI produced for national health reporting, this being a crucial tool for policy advice. METHODS: We conducted a literature search to identify published and grey literature on national HI prioritization. This was followed by a two-round Policy Delphi study, where we explored which processes and methods exist in EU Member States and associated countries for the prioritization of HI collection. In the first round, information about these processes was gathered in semi-structured questions; in the second round, participants were asked to rank the identified approaches for desirability and feasibility. The survey was conducted online; participants were recruited from the membership of the Joint Action on Health Information (InfAct – Information for Action). RESULTS: 119 experts were contacted, representing 40 InfAct partner institutions in 28 EU Member States and associated countries. Of these, 28 experts responded fully or partially to the first round, and six to the second round. In the first round, more than half of the respondents reported the existence of structured HI prioritization processes in their countries. To prioritize HI, a clear preference was given in the second round for a formal, horizontal process which includes different experts and stakeholders. National public health institutes were named desirable key stakeholders in this process, and also desirable and feasible coordinators for stakeholder coordination. CONCLUSION: Health information prioritization methods and procedures reflect the heterogeneity of national public health systems in European countries. Mapping, sharing and ranking prioritization methods and procedures for “good practices” provides a meaningful basis for expert knowledge exchange on HI development. We recommend to make this process part of a future sustainable EU health information system and to use the information gathered in this project to initiate the development of a guidance “Good Practice HI Prioritization” among EU Member States and associated countries