The recent publication of the third European Report on Perinatal Health, developed by the group EUROPERISTAT and funded by the European Commission, consolidates progress started ten years ago in the european coordination on health statistics. Perinatal health (understood as referring to the mother, the fetus and the newborn) has improved dramatically in Europe over the last decades. These improvements reflect technological advances in obstetrical and neonatal care, an important development of the maternal and child health services, as well as the improvement of the standard of living of european countries. Despite these improvements, around 20,000 children are born dead each year in the European Union, and many others die in the first year of life. The impairments and disabilities that arise throughout the perinatal period, by affecting the younger members of the society, carry a great burden to families and society. It is noteworthy that this disease burden is not distributed equitably. There are large inequalities in perinatal health among the european countries and within each country the poverty and low social status are associated with poor outcomes of pregnancy.
The epidemiological surveillance of perinatal health has a long tradition, but the existing data, despite of the remarkable advances that have occurred, are insufficient to monitor the current needs of the face to improve the health strategies aimed at mothers and newborns. It is for this reason that over the past fifteen years has grown the awareness of the need to incorporate new indicators of perinatal health to the traditionally existing ones. The third European Report on Perinatal Health represents a new step in the development and monitoring of these new indicators. Another of the problems with the existing information in the international data bases makes reference to the quality and comparability of the information. Differences between european countries in the definition of fetal or neonatal death adopted, as well as in the registry of these deaths make the data not strictly comparable. This report, using definitions of homogeneous and collect the information in a uniform way to present comparable data at the european level.
The main indicators used in the report make reference to the characteristics of the mothers, as well as the mortality and morbidity in pregnancy and during the first year of life, indicators, which we describe briefly below.
On the set of the 31 european countries that have participated, Spain, followed by Italy and Ireland, is the european country with the highest percentage of mothers over 35 years, and the proportion has continued to increase in recent years. The comparison with the previous European Report on Perinatal Health (data relating to 2010) allows to observe that the increase in mothers over 35 years has taken place in all Europe, except Sweden, Estonia, Germany and the Netherlands, where the decline has been very small. These circumstances may have a significant impact on child mortality as well as on the indicators of outcome of the pregnancy and childbirth. Related to the above, Spain is also one of the european countries with the highest percentage of women primiparous women among those who gave birth, in 2015, behind only Italy, Portugal and Romania. The fact of delaying the age of childbearing has led to an increase in the number of pregnancies achieved by assisted reproduction, which until recently meant an increase of multiple births. In fact, Spain is the second european country with the highest number of multiple births (twins and triplets), behind only Cyprus.
maternal obesity, associated with an increased risk, is also increasing, although the vision of the report is very biased since only 12 of the 31 countries that participate in Euro-Peristat have been able to provide this information, not being Spain among them. The average prevalence of obesity prior to pregnancy was 13.2% in these countries, with a range of 7.8 at 25.6.
The consumption of tobacco, understood as the proportion of women who smoke during pregnancy, is one of the factors that are preventable most important associated with adverse pregnancy outcome. In general, the percentage of women who smoke during pregnancy in 2015 was 13% lower than in 2010. However, in many countries it is necessary to advance policies on the consumption of tobacco. In a fourth part of the 19 countries that have been able to provide data on smoking during pregnancy, most of the 12.5% of women smoked, with higher percentages in Valencia (Spain) (18,3), Wales (17,3), France (16,3) and Northern Ireland (14,3). In contrast, in Norway, Sweden and Lithuania, less than 5% of women smoked during pregnancy.
With regard to mortality and morbidity in pregnancy and during the first year of life, almost half of the deaths Betmatik that occur in the perinatal period are fetal deaths, which are understood as those deaths of 22 or more weeks of gestation. The rate of fetal mortality, which provides information on the causes of mortality are avoidable, and on the quality of the health care perinatal, presents a great variability among european countries due to differences in the definitions of fetal death and to the inclusion or not in this section of the voluntary termination of pregnancy. Spain figure in the middle of the european countries in the rate of fetal mortality of more than 28 weeks of gestation, which is the indicator more comparable across countries (2.7 per every thousand births and fetal deaths).
neonatal mortality (deaths up to 28 days after birth) is also a very sensitive measure of health in the perinatal period and, in good part, is the result of the care they receive newborns in the first week of life (early neonatal). Therefore, the explanation of the variability of this indicator among the european countries lies in large measure in the different quality of antenatal services and, to a lesser extent, in the different policies of resuscitation to children at the limit of viability. They also reflect differences in the inclusion criteria as a neonatal death which makes it necessary to standardize these criteria across the different countries. Spain, despite our high percentage of multiple births which carry a risk of neonatal mortality between 4 and 8 times greater than the births simple, presents a neonatal mortality rate of 1.8 per thousand live births), similar to those of the more developed countries of Europe, where the range is between 0.7 and 4.4 per thousand, which is indicative of good quality of neonatal services hospital.
The infant mortality rate (deaths ocurridas during the first year of life), much influenced by socio-economic factors, has decreased throughout Europe, except in Greece, Portugal and Northern Ireland, with a range that moves between 1.5 per thousand of Iceland, and 7.6 of Bulgaria. Spain appears in an intermediate position, with a rate of 2.7 per thousand.
preterm birth (born less than 37 weeks of gestation) is one of the main determinants of perinatal mortality and poor subsequent development. The rate of prematurity has increased significantly in Europe over the past two decades and requires monitoring. This increase is undoubtedly due to the higher prevalence of multiple births that result in a greater extent prematurity and are a consequence of the increase in pregnancies by assisted reproduction. In turn, the use of different methods in different countries to estimate the gestational age has had no doubt an influence on the observed variability. In the european context, whose range of prematurity varies between 5.4 and 12% of those born, Spain (7.6%), is among the countries with the highest percentage. With respect to 2010, in some european countries, the prematurity rate has increased and in others it has declined. In Spain has decreased, going from 8.0% in 2010 to 7.6% in 2015.
Finally, a crucial indicator in reproductive health is the birth weight. Low birth weight (understood as those less than 2,500 grams) is a consequence of preterm birth and/or intrauterine growth restriction, and is a good indicator of adverse pregnancy outcome and impaired cognitive and motor impairment long-term. The percentage of births with a low birth weight ranged from 4.2% in Estonia and Finland to 10.6% in Cyprus, Spain (8.3 per cent), with a certain gradient north to south, with the countries of the centre (Germany, France, United Kingdom) and south (Spain, Portugal) with the highest percentage and the nordic countries, with much lower percentage of low birth weight. These differences may be due to variability in physiologic birth weight between the various european countries due to genetic causes, and should be placed in relation to the birth weight distribution in the whole population of each country. In any case, Spain is the sixth country in the whole of Europe with the highest percentage of births with low birth weight.
comparison with other european countries highlights the need for attention in Spain the indicators of birth weight and prematurity.
With regard to the mother, Spain is one of the european countries in which the ratio of maternal mortality is lower (3.1 per hundred thousand live births, almost half of the european average. It should be noted that the definition of maternal mortality was adopted from the WHO relating the number of maternal deaths exclusively with the pregnancy, delivery and up to 40 days after this, leave out the notification of deaths after that have been shown to be related. This infranotificación would be advisable to follow the example of some countries that implement a system of surveillance specific to using committees to review the cases to detect the true magnitude of maternal mortality. It should be noted that, as has been highlighted by recent work, in Spain there is a notable underestimation of this indicator.
Finally, the Report, Euro-Peristat 2015 reflects a strong variability in care delivery in Europe:
The rate of caesarean sections have increased in some countries but in others have declined or have remained stable. Ranging from 16-20% in the nordic countries and the Netherlands up to 46.9 and 56.9% in Romania and Cyprus. Spain, with 24.6%, occupies an intermediate position on this indicator, still above the WHO recommendations.
The operative deliveries are less than 5% in several countries, while reaching 15.1% in Spain which together with Ireland is the country in which more operative deliveries are performed.
The wide variation in the use of caesarean sections and operative deliveries illustrates the variability that exists in medical practice between the european countries and question the way in which the scientific evidence is integrated into clinical decisions.
The Report puts also highlighted the lack of information that exists in Spain about of some indicators of great interest that are collected routinely in many of the countries of our environment. Therefore, on occasions there have been to resort to data of the region of Valencia and Catalonia that do collect. It would be desirable that the publication of this report stimulated the creation of an information system in the area perinatal that would allow the systematic collection of information on these indicators at the national level both in public schools as in private ones. Since we made a similar request with the publication of the previous report. To do this it would be necessary to proceed to the link records (medical history, statistical bulletin births, death certificate). This would lay the groundwork to contribute to the development of a European Information System on Perinatal Health that is being debated today and that it would be necessary to monitor the progress or setbacks that occur in this field.
Francisco Bolúmar Montrull. Professor of Preventive Medicine and Public Health. University of Alcalá. Coordinator English from the European Perinatal Health Report.
Adela Recio Warden. Upper body of Statistical of the State.