COVID-19 vaccination intention at the beginning of COVID-19 pandemic in Slovenia

Background: With the successful development and introduction of vaccines to protect against COVID-19 disease, the pandemic is expected to end. The success of a vaccination programme depends on the uptake rates in the Slovenian population and especially among healthcare workers (HCWs), who are at higher risk of infection. Recently, several studies have examined the readiness of different population groups worldwide to be vaccinated. This study compares COVID-19 vaccination intentions between lay people and HCWs, and relationships between socio-demographic characteristics, attitudes and beliefs about COVID-19 vaccination, and vaccination intentions reported in the early stages of epidemics. Methods: A cross-sectional study based on an online survey was performed in Slovenia between 13 and 14 March 2020, when the epidemic was officially announced in the country. Data from 2,494 eligible respondents were analysed. Results: The study has shown that 33.2% of all respondents expressed the intention to get vaccinated against COVID-19 disease. This intention was expressed slightly more frequently among HCWs (38.9%) than among lay respondents (30.3%). Men compared to women, older and younger HCWs compared to middle-aged adults, and university graduates compared to HCWs with lower levels of education were more likely to get vaccinated against the disease. More HCWs than lay respondents believed that the COVID-19 vaccine would be safe and effective, and they were also more in favour to support vaccination of high-risk groups than mandatory vaccination of the general population. Conclusion: It is critical to communicate the importance of vaccination against COVID-19 appropriately and on a sound scientific basis through various health education programmes and the media, as only one-third of respondents and less than a half of HCWs indicated that they would be willing to get vaccinated once a vaccine is available

Relationship between labour analgesia modalities and types of anaesthetic techniques in categories 2 and 3 intrapartum caesarean deliveries

General anaesthesia is typically recommended for category 1 emergency caesarean delivery (CD). For categories 2-4 emergencies, either regional and general anaesthesia could be used. However, the factors influencing the choice of anaesthetic technique in these categories remain poorly understood. We analysed the association between the type of labour analgesia and subsequent anaesthetic techniques employed for intrapartum categories 2 and 3 CD. A prospective longitudinal cohort study was conducted at the University Medical Centre Ljubljana. A total of 300 women who underwent emergency CD between March and October 2021 were consecutively enrolled and categorised according to Lucas's classification of CD urgency. Parturients with category 1 and category 4 emergency CD were excluded from the analysis. Demographic, obstetric, and anaesthetic data were recorded. The techniques of anaesthesia (general, spinal, and epidural anaesthesia) employed for CD were analysed with respect to labour analgesia methods (remifentanil patient-controlled analgesia [remifentanil-PCA], epidural analgesia, and nitrous oxide). Of the participants, 124 (41.3%) had category 2, and 96 (32%) had category 3 emergency CD. Epidural analgesia was the most frequent analgesic option (43.8%), followed by remifentanil-PCA (20.7%) anditrous oxide (5.1%), while 30.4% of parturient women received no analgesia. All anaesthetic methods showed a significant relationship with analgesic modalities (P < 0.001). Remifentanil-PCA was associated with a higher incidence of general anaesthesia. Contraindication to epidural analgesia was the primary factor related to the transition from remifentanil-PCA to general anaesthesia. Most parturients who received epidural analgesia were successfully converted to epidural anaesthesia. Spinal anaesthesia was the most common technique in women using N2O and those without labour analgesia. General anaesthesia was associated with lower 5 min Apgar scores. The method of labour analgesia is associated with the anaesthesia technique employed for categories 2 and 3 CD. This finding may guide patient counselling and intrapartum anaesthetic planning. However, the analysis should be cautiously interpreted as the selection of anaesthesia is a complex decision influenced by several clinical considerations.

Cross-Country Individual Participant Analysis of 4.1 Million Singleton Births in 5 Countries with Very High Human Development Index...

Background: Preterm birth is the most common single cause of perinatal and infant mortality, affecting 15 million infants worldwide each year with global rates increasing. Understanding of risk factors remains poor, and preventive interventions have only limited benefit. Large differences exist in preterm birth rates across high income countries. We hypothesized that understanding the basis for these wide variations could lead to interventions that reduce preterm birth incidence in countries with high rates. We thus sought to assess the contributions of known risk factors for both spontaneous and provider-initiated preterm birth in selected high income countries, estimating also the potential impact of successful interventions due to advances in research, policy and public health, or clinical practice. Methods: We analyzed individual patient-level data on 4.1 million singleton pregnancies from four countries with very high human development index (Czech Republic, New Zealand, Slovenia, Sweden) and one comparator U.S. state (California) to determine the specific contribution (adjusting for confounding effects) of 21 factors. Both individual and population-attributable preterm birth risks were determined, as were contributors to cross-country differences. We also assessed the ability to predict preterm birth given various sets of known risk factors. Findings: Previous preterm birth and preeclampsia were the strongest individual risk factors of preterm birth in all datasets, with odds ratios of 4.6–6.0 and 2.8–5.7, respectively, for individual women having those characteristics. In contrast, on a population basis, nulliparity and male sex were the two risk factors with the highest impact on preterm birth rates, accounting for 25–50% and 11–16% of excess population attributable risk, respectively (p < 0.001). The importance of nulliparity and male sex on population attributable risk was driven by high prevalence despite low odds ratios for individual women. More than 65% of the total aggregated risk of preterm birth within each country lacks a plausible biologic explanation, and 63% of difference between countries cannot be explained with known factors; thus, research is necessary to elucidate the underlying mechanisms of preterm birth and, hence, therapeutic intervention. Surprisingly, variation in prevalence of known risk factors accounted for less than 35% of the difference in preterm birth rates between countries. Known risk factors had an area under the curve of less than 0.7 in ROC analysis of preterm birth prediction within countries. These data suggest that other influences, as yet unidentified, are involved in preterm birth. Further research into biological mechanisms is warranted. Conclusions: We have quantified the causes of variation in preterm birth rates among countries with very high human development index. The paucity of explicit and currently identified factors amenable to intervention illustrates the limited impact of changes possible through current clinical practice and policy interventions. Our research highlights the urgent need for research into underlying biological causes of preterm birth, which alone are likely to lead to innovative and efficacious interventions

Variations in Multiple Birth Rates and Impact on Perinatal Outcomes in Europe

Objective Infants from multiple pregnancies have higher rates of preterm birth, stillbirth and neonatal death and differences in multiple birth rates (MBR) exist between countries. We aimed to describe differences in MBR in Europe and to investigate the impact of these differences on adverse perinatal outcomes at a population level. Methods We used national aggregate birth data on multiple pregnancies, maternal age, gestational age (GA), stillbirth and neonatal death collected in the Euro-Peristat project (29 countries in 2010, N = 5 074 643 births). We also used European Society of Human Reproduction and Embryology (ESHRE) data on assisted conception and single embryo transfer (SET). The impact of MBR on outcomes was studied using meta-analysis techniques with random-effects models to derive pooled risk ratios (pRR) overall and for four groups of country defined by their MBR. We computed population attributable risks (PAR) for these groups. Results In 2010, the average MBR was 16.8 per 1000 women giving birth, ranging from 9.1 (Romania) to 26.5 (Cyprus). Compared to singletons, multiples had a nine-fold increased risk (pRR 9.4, 95% Cl 9.1–9.8) of preterm birth (<37 weeks GA), an almost 12-fold increased risk (pRR 11.7, 95% CI 11.0–12.4) of very preterm birth (<32 weeks GA). Pooled RR were 2.4 (95% Cl 1.5–3.6) for fetal mortality at or after 28 weeks GA and 7.0 (95% Cl 6.1–8.0) for neonatal mortality. PAR of neonatal death and very preterm birth were higher in countries with high MBR compared to low MBR (17.1% (95% CI 13.8–20.2) versus 9.8% (95% Cl 9.6–11.0) for neonatal death and 29.6% (96% CI 28.5–30.6) versus 17.5% (95% CI 15.7–18.3) for very preterm births, respectively). Conclusions Wide variations in MBR and their impact on population outcomes imply that efforts by countries to reduce MBR could improve perinatal outcomes, enabling better long-term child health

THE COMPARISON OF SLOVENIAN AND EUROPEAN PERINATAL DATA OR AS MORE BACK WE LOOK FURTHER INTO THE FUTURE WE WILL SEE

Background: Slovenian perinatal results are compared with European results: sometimes they are in the higher, sometimes in the lower range. Analysing trends and comparisons with other countries helps in planning changes in organisation and function so we are prepared for future challenges. Introduction of new technologies demands appropriate answers to challenges, including ethical ones. Methods: We compared perinatal results in Slovenia from 1987 to 1996, the PERISTAT project results from the year 2000 and the EURO-PERISTAT project with 2004 perinatal results including the Slovenian. Results: Some of the more prominent Slovenian perinatal results are shown. Cesarean section rate is the lowest among 26 countries in Europe. Deliveries after artificial reproductive techniques are second most frequent. Teenage pregnancies are very rare. Seemingly high maternal mortality mirrors also strict recording and cross checking with other data bases. Relatively high stillbirth rate may reflect the fact that all induced labours for fetal malformations are recorded. Conclusions: In Slovenia we do have tools for quality collection of perinatal results which should be used and audited. To have comparable results inside Slovenia, definitions should be written at http://www.obgyn-si.org/. When changing delivery record markers of prenatal care should be added – they could be easily obtained from maternity booklets (electronic or paper). In maternity booklet there is a place to write about grand dad prostate cancer; let us replace it with risk factors for preterm delivery (medical history and cervical length), 12 weeks screening for preeclampsia and intrauterine growth restriction (ultrasonic and biochemi- cal markers), gestational diabetes and obesity (body mass index, waist – hips ratio) and hypothyroidism; let us leave some free space for the future screening tests. Known and proven efficient management (e.g. progesterone for recurrent preterm delivery prevention) should be used

Risk factors for osteoporosis in postmenopausal women – from the point of view of primary care gynecologist

Osteoporosis is a highly prevalent public health problem with osteoporosis-related fractures that account for high morbidity and mortality. Therefore, prevention strategies and early detection of osteoporosis should be carried out in primary gynaecological care units, so as to substantially reduce the risk of fractures and allow the best treatment option for a particular woman

USEFULNESS OF THE DATA COLLECTED BY THE NATIONAL PERINATAL INFORMATION SYSTEM OF SLOVENIA FOR QUALITY CONTROL IN PERINATOLOGY

Bacground: The quality of work has been increasingly given more emphasis in all areas of life, the health care being no exception. Without appropriate measures or indicators of health care outcomes, a health care system cannot be improved. The results of quality of work are of utmost importance as they serve as the basis for various comparisons, e.g.among units, department, individual doctors. The aim of this analysis was to establish the results of work in tertiary and secondary centres, and with individual doctors, and compare them in order to approve the good ones and to find those that need be improved. Methods: The analysis involved 32 parameters concerning the results of work, the same parameters as used elsewhere in Europe, with all deliveries and newborns in Slovenia in the time period 2003–2007. We established the differences in the work of tertiary and secondary centres and used them in various comparisons. Results: We found no significant differences among the Slovene maternity hospitals in the incidence of eclampsia during labour, hysterectomy and in the incidence of lethal malformations among early neonatal deaths. We did find numerous significant differences in the manage- ment of labour, termination of labour and in the newborn's condition after birth. Conclusions: Slovenian perinatal information system is unique in Europe for as long as 22 years it has enabled a steady gathering of a large number of perinatal data for every woman who has given birth in Slovenia. Annual analyses that are done on the basis of the collected data for selected quality indicators within the project »Quality of Health Care in Slovenia« make it possible for every maternity hospital in Slovenia or every obstetrician to get an insight into the quality of their work and to compare it with the work of other maternity departments and individual doctors. The system gives the professional bodies and individual doctors an opportunity to improve the results of their professional work which deviate negatively from Slovenian standards

QUALITY OF PERINATAL CARE IN SLOVENIA 2003–2008

Background: The purpose of this analysis was to find whether the quality indicators of perinatal care in Slovenia change. Methods: We used the same quality indicators which are used in the European project Europeristat1 to compare the quality of perinatal care among the countries of the European Union. We used two 5-year periods, from 1998 to 2002 (reference period) and from 2003 to 2008 (observed period). Data for perinatal quality were collected from the National Perinatal Information System of the Republic of Slovenia.2 Statistical significance was tested using the Pearson’s chi-square test. Results: Between 1998 and 2002, there were 87.679 labours ending in the delivery of 88.678 new- borns, and between 2003 and 2008, there were 90.662 labours ending in the delivery of 91.736 babies. In the observed period (2003 do 2008) mothers had statistically significantly higher educational level, a higher percentage came to their first pregnancy examination before the 12th week of gestation (84.0 % vs. 75.3 %), a higher percentage conceived after assisted reproductive techniques (2.0 % vs. 1.7 %), and the incidence of multiple pregnancies was higher (1.7 % vs. 1.6 %). Significantly lower were the percentages of labours without medical interventions (34.7 % vs. 41.9 %) and of spontaneous onset of labour (74.0 % vs. 92.6 %). The percentages of induced labours and of elective cesarean sections increased dramatically (20.1 % vs. 6.6 % and 6.0 % vs. 0.9 %). The increase in the overall percentage of cesarean sections (14.8 % vs. 11.0 %) is mainly due to increased incidence of elective cesarean sections, but the percentage of operative termination of vaginal labour increased as well (3.1 % vs. 2.6 %). The incidence of episiotomies was lower (48.7 % vs. 51.0 %) and so was the incidence of 2nd degree perineal lacerations (4.5 % vs. 5.4 %), while the incidence of 3rd–4th degree lacerations was higher (0.3 % vs. 0.2 %). Transfusion was required in a lower percentage (0.3 % vs. 1.0 %), but the percentage of hysterectomies increased (0.1 % vs. 0.03 %). The incidence of eclampsia was the same in the two time periods (0.1 %). Among preterm deliveries, the higher percentage occurred between 32 and 36 gestational weeks (5.9 % vs. 5.5 %), while there were no differences among the deliveries between the 22nd and 31st gestational week. Stillbirths after the 22nd gestational week was the same in both periods, 5 per 1000 of all newborns, whereas early (2 per 1000 vs. 3 per 1000) and late (0.04 per 1000 vs. 0.4 per 1000) neonatal mortality rates were lower. In both time periods lethal malformations were the cause of death in 1/3 of stillborn babies 1/3 of neonates. Conclusions: Over the last years, an increase in operative deliveries and a decrease in deliveries without medical interventions have been observed in Slovenia. Despite the fact that mothers come to their first prenatal examination earlier in pregnancy than before and that they are more educated, i.e. they have a better socio-economic status, the incidence of preterm deliveries increases, while the mother’s health and the incidence of stillbirths have not changed sig- nificantly. The decrease in neonatal mortality rate should be highlighted

A comparison of frequency of medical interventions and birth outcomes between the midwife led unit and the obstetric unit in low-risk primiparous women

Introduction: The purpose of this national research was to compare birth, maternal and newborn outcomes in the midwife led unit and the obstetric unit to ascertain whether a midwife led unit reduced medicalisation of childbirth. Methods: A prospective observational case-control study was carried out in Ljubljana Maternity Hospital in the period May - August 2013. The sample comprised 497 labouring women; 154 who attended the midwife led and 343 who attended in the obstetric unit, both matching the same inclusion criteria: low risk primiparous; singleton term pregnancies, normal foetal heart beat, cephalic presentation; spontaneous onset of labour. The primary outcome was the caesarean section rate. Chi-square test was used to compare medical interventions and birth outcomes. Results: Women in the midwife led unit had statistically significant higher spontaneous vaginal births (p < 0.001), less augmentation with oxytocin (p < 0.001), less use of analgesia (p < 0.001), less operative vaginal deliveries (p < 0.001) and less caesarean sections (p < 0.001), lower rates of episiotomy (p < 0.001) and more exclusively breastfed (p = 0.002). Discussion and conclusion: These significant findings showed that in the midwife led unit fewer medical interventions were used. For generalisation of the findings more similar studies in Slovenia are needed

The Effect of Von Willebrand Disease on Pregnancy, Delivery, and Postpartum Period: A Retrospective Observational Study

Background and Objectives Several reports indicate that women with von Willebrand disease (VWD) are at an increased risk of bleeding and other complications during pregnancy and childbirth. The aim of this study was to investigate the effect of VWD on the course of pregnancy, childbirth, and the postpartum period. Materials and Methods This was a retrospective study that compared many variables between women with VWD (n = 26) and women without VWD (n = 297,111) who gave birth between 2002 and 2016 in Slovenia. Data were obtained from the Slovenian National Perinatal Information System. Results Women with VWD were not more likely to have a miscarriage, vaginal bleeding during pregnancy, anemia, intrauterine growth restriction, or imminent premature labor. However, women with VWD were more likely to experience childbirth trauma-related bleeding (OR, 10.7; 95% CI: 1.4, 78.9), primary postpartum hemorrhage (OR, 3.7; 95% CI: 0.9, 15.8), and require blood transfusion after childbirth (OR, 16.3; 95% CI: 2.2, 120.3). No cases of stillbirth or early neonatal death were observed in women with VWD. Conclusion Although women with VWD did not demonstrate an increased risk of vaginal bleeding during pregnancy or poor fetal outcomes, they had a higher risk of primary postpartum hemorrhage and requiring blood transfusion