Using obstetric data to improve standards of care Petr Velebil, MD, PhD Perinatal Centre WHO Collaborating Centre for Perinatal Medicine Institute for the Care of Mother and Child Prague Institute for the Care of Mother and Child Prague Third Medical School Charles University, Prague

Why data? We need (sometimes like) to compare Without comparison there is no information To compare, you need the same definitions Even if you have the same definition, you must have the proper registration/data collection If you are lucky, you get mostly summary indicators Summary indicators could hide very complex and different situations Velebil 2017

EBCOG EUROPEAN BOARD & COLLEGE OF OBSTETRICS AND GYNAECOLOGY IMPROVING THE HEALTH OF WOMEN AND THEIR BABIES EBCOG’s aim is to improve the health of women and unborn and newborn babies by promoting the highest possible standards of care

Improving the health of women and unborn and newborn babies the Launch of EBCOG’s Standards of Care for Women’s Health at the European Parliament, Brussels, 12th November 2014 Obstetric and Neonatal Services Gynaecology Services fully endorsed by the National Societies of Obstetrics and Gynaecology in all EU, EEA member countries and beyond, as well as by The Union Européenne des Médecins Spécialistes (UEMS) Precise Auditable indicators

Improving the health of women and unborn and newborn babies Standards of Care for Women´s Health in Europe - - call for action. Dr. Tahir Mahmood CBE, January 21, 2016 "...each year in Europe between 335-1000 women die in childbirth and more than half of these deaths are avoidable. For every woman dying during pregnancy, 50-60 women suffer serious life threatening morbidity...„

Improving the health of women and unborn and newborn babies „Maternal mortality and morbidity rates have declined significantly across member states of the European Union (EU). However, each year in Europe between 335-1000 women die in childbirth and more than half of these deaths are avoidable. For every woman dying during pregnancy, 50-60 women suffer serious life threatening morbidity.„ EU need to agree a common methodology for collecting and classifying deaths, in order to understand trends and compare performance. EU planners and clinicians should agree common definitions for the collection of a minimum dataset for pregnancy and birth. All member states should implement confidential enquiries into all pregnancy related deaths in order to implement policies to improve healthcare.

Maternal mortality in Europe Europeristat data 2010 „The range in Europe is from lows under 3 per 100 000 (in Estonia, Italy, Austria, and Poland) to highs over 10 per 100 000 live births (Latvia, Hungary, Slovenia, Slovakia, and Romania).“ „There is good evidence that maternal deaths derived from routine statistical systems are under-reported, ……“ „Confidential enquiries and record linkage are recommended to obtain complete data on pregnancy-related deaths and also to make it possible to understand how these deaths happened and to make recommendations to prevent the recurrence of those that could have been prevented.“ „When confidential enquiries are undertaken, as in France, the Netherlands, and the UK, almost half the maternal deaths are associated with substandard care.“ Source: EURO-PERISTAT European Perinatal Health Report 2010. May 2013

1. Identification and notification on an ongoing basis: Identification of suspected maternal deaths in facilities (maternity and other wards) and communities, followed by immediate notification (within 24 and 48 hours, respectively) to the appropriate authorities. 2. Review of maternal deaths by local maternal death review committees: Examination of medical and nonmedical contributing factors that led to the death, assessment of avoidability and development of recommendations for preventing future deaths, and immediate implementation of pertinent recommendations. 3. Analysis and interpretation of aggregated findings from reviews: Reviews are made at the district level and reported to the national level; priority recommendations for national action are made based on the aggregated data. 4. Respond and monitor response: Implement recommendations made by the review committee and those based on aggregated data analyses. Actions can address problems at the community, facility, or multi-sectoral level. Monitor and ensure that recommended actions are being adequately implemented.

Maternal mortality and serious morbidity We do not have complete and reliable data – we cannot compare We have tools, we need to implement them in order to standardize the maternal death and serious morbidity surveillance and response Even a beginning of implementation might lead to an immediate improvement of maternal health Velebil 2017

Improving the health of women and unborn and newborn babies Standards of Care for Women´s Health in Europe - - call for action. Dr. Tahir Mahmood CBE, January 21, 2016 „ Preterm birth is a major cause of neonatal morbidity. Multiple births are a significant cause of preterm birth and assisted reproduction is the major contributor to multiple births. There should be effective regulatory mechanisms throughout Europe that minimise the risk of preterm birth following assisted reproduction, including ovulation induction. As far as possible embryo replacement should be limited to one, and only occasionally, two embryos „

Perinatal outcome Prematurity (….LBW) Multiple pregnancy Prematurity Maternal age Prematurity (….LBW) Prematurity (….LBW) Velebil 2017

Perinatal outcome Prematurity (….LBW) Multiple pregnancy Prematurity Maternal age Prematurity (….LBW) Prematurity (….LBW) Velebil 2017

Map of distribution of live births with low birth weight (< 2500 grams) in 2010 European Perinatal Health Report 2013 EUROPERISTAT Source: EURO-PERISTAT European Perinatal Health Report 2010. May 2013

European Perinatal Health Report 2013 „Preterm babies born before 28 weeks of gestational age constitute over one-third of all deaths, but data are not comparable between countries.“ „The percentage of low birthweight babies is geographically patterned, partially reflecting differences in population birth weight, and was stable over time in most countries.“ Source: EURO-PERISTAT European Perinatal Health Report 2010. May 2013

Percentage of fetal deaths by gestational-age and birthweight groups from all countries contributing data by these subgroups in 2010 Gestational Age Birthweight Source of data: EURO-PERISTAT European Perinatal Health Report 2010. May 2013 Velebil 2017

% Gestational age of live born babies Selected countries of Europe in 2010 < 32+0 32+0 – 36+6 % Source of data: EURO-PERISTAT European Perinatal Health Report 2010. May 2013 Velebil 2015

Improving the health of women and unborn and newborn babies Standards of Care for Women´s Health in Europe - - call for action. Dr. Tahir Mahmood CBE, January 21, 2016 „ Preterm birth is a major cause of neonatal morbidity. Multiple births are a significant cause of preterm birth and assisted reproduction is the major contributor to multiple births. There should be effective regulatory mechanisms throughout Europe that minimise the risk of preterm birth following assisted reproduction, including ovulation induction. As far as possible embryo replacement should be limited to one, and only occasionally, two embryos.“

Proportion of multiple deliveries in selected countries of Europe, 2010 – data EUROPERISTAT ‰ Source of data: EURO-PERISTAT European Perinatal Health Report 2010. May 2013 Velebil 2015

Perinatal mortality in singleton a multiple births Czech Republic 2004 - 2016 (all newborns from 500 g) Singletons Multiples ENMR Stillbirth rate Source: Czech Society of Perinatology and Feto-Maternal Medicine Velebil 2017

Variations in Multiple Birth Rates and Impact on Perinatal Outcomes in Europe Anna Heino, Mika Gissler, Ashna D. Hindori-Mohangoo, et al. Research Article | published 01 Mar 2016 | PLOS ONE European data for 2010, 5,074,643 births, 29 countries Multiples had nine-fold increased risk of PTB and almost 12-fold increased risk of VPTB Pooled RR for fetal mortality (from 28wks) was 2.4 (95% CI 1.5-3.6), RR for neonatal mortality was 7.0 (95% CI 6.1-8.0) PAR for prematurity – 21.6% PAR for fetal death (28+wks) – 4.4% PAR for neonatal death – 13.4%

European Perinatal Health Report 2013 „Artificial reproductive techniques (ART) are used in up to 5 to 6% of all deliveries; differences in multiple birth rates reflect, in part, the impact of these practices.“ Source: EURO-PERISTAT European Perinatal Health Report 2010. May 2013

Proportion of multiple deliveries Czech Republic 2004-2016 % Source: Czech Society of Perinatology and Feto-Maternal Medicine Velebil 2017

Improving the health of women and unborn and newborn babies Standards of Care for Women´s Health in Europe - - call for action. Dr. Tahir Mahmood CBE, January 21, 2016 „ We urge Ministers of Health to ensure that regional perinatal works be developed to ensure that women with complex pregnancies and very preterm babies be delivered and looked after in specialist maternity/neonatal units by a dedicated team of experts.“

European Perinatal Health Report 2013 „The regionalisation of care for high-risk births is associated with better survival for very preterm infants.“ Source of data: EURO-PERISTAT European Perinatal Health Report 2010. May 2013

Transport in utero Czech Republic 2015-2016 Centralization of newborns in the lowest birthweight groups 500-749 750-999 1000-1499 Inborn (born in a centre) 94.1 % 95.0 % 92.8 % Outborn (postnatal transfer) 4.6 % 4.3 % 5.4 % No centralization 1.3 % 0.7 % 1.2 % 2016 Centralization of newborns in the lowest birthweight groups 500-749 750-999 1000-1499 Inborn (born in a centre) 92.5 % 96.3 % 92.4 % Outborn (postnatal transfer) 5.5 % 3.3 % 4.9 % No centralization 2.0 % 0.4 % 2.7 % Source: Czech Society of Perinatology and Feto-Maternal Medicine Velebil 2017

BW specific perinatal mortality Centre of intensive perinatal care Czech 2016  BW specific perinatal mortality  Birthweight Centre of intensive perinatal care Others grams per mille Per mille 500-749 414.06 818.18 750-999 110.70 609.76 1000-1499 46.35 300.00 1500-1999 23.08 57.02 2000-2499 9.41 14.64 Sekce perinatální a feto-maternální medicíny Velebil 2017

‰ Perinatal mortality (stillbirths from 28+0) Selected countries of Europe in 2010 Fetal Early neonatal ‰ Source of data: EURO-PERISTAT European Perinatal Health Report 2010. May 2013 Velebil 2015

European Perinatal Health Report 2013 „Fetal, neonatal, and infant mortality rates vary widely between the countries of Europe.“ Source: EURO-PERISTAT European Perinatal Health Report 2010. May 2013

Normal birthweight (>=2500g] Total perinatal mortality Birthweight 1000-1499 grams 1500-2499 grams Normal birthweight (>=2500g] Antepartum death Intrapartum death Death in 1st wk All deaths All newborns (all birthweight) Velebil 2015

Normal birthweight (>=2500g] Total perinatal mortality Early neonatal Stillbirth Birthweight 1000-1499 grams 1500-2499 grams Normal birthweight (>=2500g] Antepartum death Intrapartum death Death in 1st wk All deaths All newborns (all birthweight) Velebil 2015

Normal birthweight (>=2500g] Antepartum death Intrapartum death Total perinatal mortality Early neonatal Stillbirth Birthweight 1000-1499 grams 1500-2499 grams Normal birthweight (>=2500g] Antepartum death Intrapartum death Death in 1st wk All deaths Perinatal mortality specific for birthweight 1000-1499 g Stillbirth specific for Early neonatal specific for normal birthweight All newborns (all birthweight) Velebil 2015

CS rate – Europe 2010 European Perinatal Health Report 2013 EUROPERISTAT Source: EURO-PERISTAT European Perinatal Health Report 2010. May 2013

CS per 1000 LB 2000-2011 (WHO HFA Database) Italy Romania Switzerland Hungary Bulgaria Poland Austria Spain GB CR France Israel Sweden Finland Netherlands Source of data: WHO HFA Database Velebil 2015

% Proportion of elective and emergency CS Selected countries of Europe in 2010 Elective Emergency % Source: EUROPERISTAT 2013 (www.europeristat.org) Velebil 2013

European Perinatal Health Report 2013 „Variations in caesarean section rates testify to differences in approaches to obstetric care.“ „Caesarean rates have risen almost everywhere, especially in eastern Europe.“   „Variations in obstetric practices raise questions about how scientific evidence is integrated into clinical decisions.“ Source: EURO-PERISTAT European Perinatal Health Report 2010. May 2013

WHO statement on caesarean section rates. April 2015

% Proportion of vaginal instrumental births Selected countries of Europe in 2010 % Source of data: EURO-PERISTAT European Perinatal Health Report 2010. May 2013 Velebil 2015

European Perinatal Health Report 2013 „Age at childbirth has increased in Europe.“ Source of data: EURO-PERISTAT European Perinatal Health Report 2010. May 2013

Maternal age at delivery Selected countries of Europe in 2010 < 20 35 + % Source of data: EURO-PERISTAT European Perinatal Health Report 2010. May 2013 Velebil 2015

Ageing mothers „The older woman is more likely to experience stillbirths, miscarriage or ectopic pregnancies.“ „In the general population, the risk of miscarriage in a woman 35–39 years of age is 24%, and doubles to 51% at 40–44 years of age if the woman conceives with her own, rather than donor, eggs.“ „Obstetric complications associated with increased maternal age include gestational diabetes, placenta praevia, placenta abruption, hypertension and caesarean section.“ Reproductive Ageing Scientific Impact Paper No. 24, 2011 © Royal College of Obstetricians and Gynaecologists

Proportion of twins by age of mother 2010, Czech Republic Source: IHSI CR Velebil 2013 %

Conclusion Some comparable obstetric data, especially on perinatal outcome Need for same definitions Need to improve perinatal surveillance data Questions how much scientific evidence is integrated into clinical decisions Need for implementation (operations) research Overall improvement of perinatal outcome in terms of mortality Velebil 2017

Institute for the Care of Mother and Child, Prague

Institute for the Care of Mother and Child, Prague Thank you for your attention Petr Velebil, MD, PhD Perinatal Centre WHO Collaborating Centre in Perinatal Medicine velebilp@seznam.cz Institute for the Care of Mother and Child, Prague

Selected countries of Europe in 2010 Apgar score – % of LB Selected countries of Europe in 2010 < 4 < 7 % Source: EUROPERISTAT 2013 (www.europeristat.org) Velebil 2015

Selected countries of Europe in 2010 Maternal morbidity Selected countries of Europe in 2010 Eclampsia Hysterectomy ‰ Source: EUROPERISTAT 2013 (www.europeristat.org) Velebil 2015

Selected countries of Europe in 2010 Infant mortality Selected countries of Europe in 2010 Early neonatal Late neonatal Post-neonatal ‰ Source: EUROPERISTAT 2013 (www.europeristat.org) Velebil 2015