1. 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

2. 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

3. 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

4. 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

5. 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 women die in childbirth and more than half of these deaths are avoidable. For every woman dying during pregnancy, women suffer serious life threatening morbidity...„

6. 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 women die in childbirth and more than half of these deaths are avoidable. For every woman dying during pregnancy, 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.

7. Maternal mortality in Europe Europeristat data 2010
„The range in Europe is from lows under 3 per (in Estonia, Italy, Austria, and Poland) to highs over 10 per 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 May 2013

8. 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.

9. 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

10. 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 „

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

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

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

14. 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 May 2013

15. 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 May 2013
Velebil 2017

16. % 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 May 2013
Velebil 2015

18. 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.“

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

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

21. 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 ), RR for neonatal mortality was 7.0 (95% CI )
PAR for prematurity – 21.6%
PAR for fetal death (28+wks) – 4.4%
PAR for neonatal death – 13.4%

22. 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 May 2013

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

24. 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.“

25. 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 May 2013

26. Transport in utero Czech Republic 2015-2016
Centralization of newborns in the lowest birthweight groups
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
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

27. 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
414.06
818.18
110.70
609.76
46.35
300.00
23.08
57.02
9.41
14.64
Sekce perinatální a feto-maternální medicíny
Velebil 2017

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

29. 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 May 2013

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

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

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

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

34. 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

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

36. 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 May 2013

37. WHO statement on caesarean section rates. April 2015

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

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

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

41. 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

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

43. 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

44. Institute for the Care of Mother and Child, Prague

45. 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
Institute for the Care of Mother and Child, Prague

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

47. Selected countries of Europe in 2010
Maternal morbidity
Selected countries of Europe in 2010
Eclampsia
Hysterectomy ‰
Source: EUROPERISTAT 2013 (
Velebil 2015

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