AN EXPERT VIEW ON PERINATAL INDICATORS

Class 18 – 2010/11

Introdução à Medicina II

SUMMARY1. Background2. Motivations3. Aims4. Methodology5. Results6. Discussion 7. Conclusion8. References9. Acknowledgments

Quality in health: a multidimensional and subjective concept [1];

Clinical indicators: measure the quality of care; selected parameters, which are able to monitor health care in regard to particular features and (adverse) events (evaluated for their feasibility, reliability and validity)[2]

Perinatal period: from the 24th week of gestation to the end of the first week of life[3];

Perinatal indicators

Background

Motivations

Aims

Methodology

Discussion

References

Acknowledgements

Results

Conclusion

[1] Reinhardt U. Quality in consumer-driven health systems. International Journal for Health Care. 1998;10(5):385-94.[2] Schrapp M. Concept of indicators: central element of quality management. Med Klin (Munich). 2001;96(10):642-7. 5.Troszyński M. Can implementation of intensified perinatal survey be effective in improving the quality of perinatal care? Med Wieku Rozwoj. 2010;14(2):138-49.[3] World Health Organization. Definitions and Indicators in Family Planning – Maternal & Child Health and Reproductive Health. 2010.

Previous Studies (we based our Project in):

European Perinatal Health Report [4] Background

Motivations

Aims

Methodology

Discussion

References

Acknowledgements

Results

Conclusion

[4]Zeithlin; J, Mohangoo A. European Perinatal Health Report. [internet]; 2004. Available from: http://www.europeristat.com/publications/european-perinatal-health-report.shtml

FETAL, NEONATAL AND CHILD HEALTHC: Fetal mortality rate by gestational age, birth weight, pluralityC: Neonatal mortality rate by gestational age, birth weight, pluralityC: Infant mortality rate by gestational age, birth weight, pluralityC: Birth weight distribution by vital status, gestational age, pluralityC: Gestational age distribution by vital status, pluralityR: Prevalence of selected congenital anomaliesR: Distribution of Apgar score at 5 minutesR: Causes of perinatal deaths due congenital anomaliesR: Prevalence of cerebral palsy

F: Prevalence of hypoxic-ischemic encephalopathy F: Prevalence of late induced abortions

F: Severe neonatal morbidly among babies at night risk

HEALTH CARE SERVICES

C: Mode of delivery by parity, presentation, previous caesarean sectionR: Percentage of all pregnancies following fertility treatment R: Distribution of timing of first antenatal visit

R: Distribution of births by mode of onset of labour

R: Distribution of place of birth (according to number of annual deliveries in the maternity unit)R: Percentage of infants breast fed at birth

R: Percentage of very preterm babies delivered in units without a neonatal intensive care unit (NICU)F: Positive outcomes of pregnancy (births without medical intervention) F: Neonatal screening policies

F: Content of antenatal care

POPULATION CHARACTERISTICS / RISK FACTORS C: Multiple birth by number of fetuses

C: Distribution of maternal age

C: Distribution of parity

R: Percentage of women who smoke during pregnancyR: Distribution of mother’s education

F: Distribution of mother’s country of origin

MATERNAL HEALTH

C: Maternal mortality ratio by age, mode of deliveryR: Maternal mortality ratio by cause of deathR: Prevalence of severe maternal morbidlyF: Prevalence of trauma to the perineum F: Prevalence of faecal incontinence

F: Postpartum depression

Background

Motivations

Aims

Methodology

Discussion

References

Acknowledgements

Results

Conclusion

Routine reporting on a wide range of perinatal health indicators is possible in Europe

However...

... problems persist and a significant effort is necessary from all

European countries.

So, we first have to know which indicators

better express the reality of healthcare...

... to promote a more objective evaluation

that allows comparasions between

different countries.

Motivations

Background

Aims

Methodology

Discussion

References

Acknowledgements

Results

Conclusion

WHICH ARE THE MOST RELEVANT PERINATAL INDICATORS IN THE

SPECIALISTS PERSPECTIVE?

Research question and aims

Study which indicators are commonly used in Europe, comparing national and international data;

Investigate, according to obstetricians and neonatal specialists, which are the most relevant and should be used from now on;

Studying the relevance of Perinatal Indicators

allows the development of a standardised list

with the prospect of uniforming new born child

´s care.

Aims

Motivations

Background

Methodology

Discussion

References

Acknowledgements

Results

Conclusion

QUESTIONNAIRE CREATION

Development of early drafts of the survey;

1

Meeting with resident

Ricardo Santos (obstetrician);

2

Pilot survey (after modifications

suggested in the meeting);

3 Development

of an introductory

letter (description/

explanation of our project)

4Submission

to MedQuest

5Methodolog

y

Background

Motivations

Aims

Discussion

References

Acknowledgements

Results

Conclusion

CALENDAR

The questionnaire

was sent

The questionnaire

was resent

Final presentation

Intermediate presentation

Project submission to

moodle

Methodology

Discussion

References

Acknowledgements

Results

Conclusion

Background

Motivations

Aims

The questionnaire

was resent

Results analysis

JOURNAL SELECTION CRITERIA

Inclusion Criteria Exclusion CriteriaJournals registered in the Journal Citation Report® of ISI Web of KnowledgeSM

From Obstetrics and Gynaecology category: Impact Factor < 2,5 (n = 57)

Belonging to Obstetrics and Gynaecology category (n = 70)

Obstetrics’ recommendation (n = 3)

Belonging to Pediatrics category (n = 94) From Pediatrics’ category: Impact Factor < 1,5 (n = 49)

After the criteria immediately above: absence of explicit reference to Neonatal and Perinatal in the title (n = 36)

Final Journal Selection: n = 19

Methodology

Discussion

References

Acknowledgements

Results

Conclusion

Background

Motivations

Aims

Methodology

Discussion

References

Acknowledgements

Results

Conclusion

Background

Motivations

Aims

ARTICLE SELECTION

Database: MedLine via PubMed or ISI Web of Knowledge;

Inclusion Criteria Exclusion Criteria

Published in those 19 journals Full text of the article not available

Time frame: From January 2010 to February 2011 Absence of e-mail contact

Published by European authors

Methodology

Discussion

References

Acknowledgements

Results

Conclusion

Background

Motivations

Aims

DATA EXTRACTION

Search for e-mail contacts in included articles

Extract the 1st contact available

Methodology

Discussion

References

Acknowledgements

Results

Conclusion

Background

Motivations

Aims

Total number of contacts = 860

DATA MANAGEMENT

Send an e-mail for each contact with:

an introductory letter;

a link, available in Medquest, for the questionnaire

Author’s contact

Methodology

Discussion

References

Acknowledgements

Results

Conclusion

Background

Motivations

Aims

STATISTICAL ANALYSIS Data (from the questionnaire) was processed using Statistical Package for Social Sciences (SPSS): Analysis of the frequency of each answer; Comparison of the answers according to:

Age (cutoff 46 years); Gender;HDI (Elevated vs High/Medium, according to 2007

Report from United Nations Development Programme

(UNDP);Geographic localization;Head of department; Specialist (Mother – OB & GYN; Child – Pediatrics, Neonatologist and Perinatologist)

Qui-Square Test (p value <0,05 was considered statistically significative, only these will be presented) to compare the answers;

Construction of explanatory graphics with the aim of emphasizing the main indicator within each

group; Comparison with Europeristat data; Comparison with database introduction systems in different countries.

Methodology

Discussion

References

Acknowledgements

Results

Conclusion

Background

Motivations

Aims

The data analysis was done with the 52 responses we got out of 860 questionaries that were sent LOW RESPONSE RATE (6,04%)

Results

Methodology

Discussion

References

Acknowledgements

Conclusion

Background

Motivations

AimsGender Frequency (n) Percent (%)

Female 25 48.1

Male 27 51.9

Speciality Frequency (n) Percent (%)

Mother 26 50

Child 26 50

Age

Mean 45.98

Std. Deviation 9.813

Median 46

Minimum 29

Maximum 70

Table 1: Frequency and percentage of the enquired bygender.

Table 3: Frequency and percentage of the enquired byspeciality.

Table 2: Summary of the enquired age (N valid=51; N missing=1).

ENQUIRED DATA ANALYSIS

Results

Methodology

Discussion

References

Acknowledgements

Conclusion

Background

Motivations

Aims

Table 4: Frequency and percentage of work country of the enquired.

Country of Work Frequency (n)

Netherlands 8

United Kingdom 7

Italy 6

France 5

Norway 4

Spain 4

Greece 2

Republic of Ireland 2

Sweden 2

Switzerland 2

Turkey 2

Andorra 1

Croatia 1

Czech Republic 1

Denmark 1

Finland 1

Portugal 1

Other 2

Total 52

Results

Methodology

Discussion

References

Acknowledgements

Conclusion

Background

Motivations

Aims

Indicator: Relevance - n (%)

High Medium Low/NoDo not know

Neonatal mortality rate 48 (94) 2 (4) 1 (2) -Prevalence of severe maternal morbidity 44 (88) 5 (10) 1 (2) -Percentage of highly preterm babies delivered in units without a NICU 44 (85) 6 (12) 2 (4) -

Prevalence of hypoxic-ischemic encephalopathy 42 (81) 7 (14) 1 (2) 2 (4)Severe neonatal morbidity among babies at high risk 42 (81) 7 (14) 1 (2) 2 (4)Fetal mortality rate 40 (78) 11 (22) - -Prevalence of cerebral palsy 40 (78) 7 (14) - 4 (8)Multiple birth rate by number of fetuses 39 (77) 9 (18) 3 (6) -Mode of delivery 38 (73) 13 (25) 1 (2) -Distribution of maternal age 37 (71) 13 (25) 2 (4) -Maternal mortality ratio by cause of death 37 (71) 7 (14) 1 (2) 7 (4)Percentage of women who smoke during pregnancy 36 (69) 14 (27) 2 (4) -Infant mortality rate 34 (67) 11 (22) 4 (8) 2 (4)Prevalence of selected congenital anomalies 30 (59) 18 (35) 2 (4) 1 (2)Gestational age distribution 28 (57) 18 (37) 1 (2) 2 (4)Birth weight distribution 27 (53) 20 (39) 2 (4) 2 (4)Distribution of mother education 24 (46) 23 (44) 5 (10) -Perinatal deaths due to congenital anomalies 24 (46) 22 (42) 6 (12) -Distribution of parity 21 (40) 23 (44) 8 (15) -Distribution of Apgar score at 5 minutes 17 (33) 28 (54) 5 (10) 2 (4)Percentage of infants breast fed at birth 17 (33) 19 (37) 15 (29) -Percentage of all pregnancies following fertility treatment 16 (31) 25 (48) 10 (19) 1 (2)Timing distribution of first antenatal visit 15 (30) 29 (48) 10 (20) 1 (2)Distribution of births by mode of onset of labor 13 (26) 25 (49) 8 (15) 5 (10)Distribution of place of birth 12 (25) 26 (59) 8 (17) 2 (4)

Table 5: Frequency (%) of each answer to each indicator listed, in a decrescent order of the percentage number of high relevance.

ANSWER ANALYSIS

Results

Methodology

Discussion

References

Acknowledgements

Conclusion

Background

Motivations

Aims

Others (each one was suggested by a different person)

• Epidural anesthesia use rate

• Deliveries using oxytocin

• Rate of preeclampsia

• Perinatal mortality rate

• Fetal heart rate distribution

• Umbilical artery pulsatily index

• Distribution of mothers by BMI

• Maternal drug therapy prenatally

the specialists were asked to select which indicator was more

relevant, in each of the four groups.

FURTHERMORE

Results

Methodology

Discussion

References

Acknowledgements

Conclusion

Background

Motivations

Aims

Graph 1: Percentage of answers by indicator in group 1 - Population characteristics/Risk factors.

Results

Methodology

Discussion

References

Acknowledgements

Conclusion

Background

Motivations

Aims

Graph 2: Percentage of answers by indicator in group 2 - Health Care Services.

Results

Methodology

Discussion

References

Acknowledgements

Conclusion

Background

Motivations

Aims

Graph 3: Percentage of answers by indicator in group 3 - Maternal health.

Results

Methodology

Discussion

References

Acknowledgements

Conclusion

Background

Motivations

Aims

Graph 4: Percentage of answers by indicator in group 4 - Fetal, neonatal and child health.

• Prevalence of selected congenital anomalies has more relevance for female specialists (p=0.008)Gender

• Neonatal mortality rate has more relevance for specialists from countries with elevated HDI (p<0.0001)

HDI (Elevated vs High/Medium,

according to 2007 Report from United Nations Development

Programme (UNDP))

• Neonatal mortality rate has more relevance for specialists from countries in Western, Northern and Southern Europe (p=0.027)

• Timing distribution of first antenatal visit has more relevance for specialists from countries in Western and Eastern Europe (p=0.017)

Geographic localization (Southern, Eastern, Western

and Northern, according to the United Nations)

STATISTICAL ANALYSIS

Results

Methodology

Discussion

References

Acknowledgements

Conclusion

Background

Motivations

Aims

• Prevalence of hypoxic-ischemic encephalopathy has more relevance for specialists that aren’t head of department (p=0.015)

• Prevalence of cerebral palsy has more relevance for specialists that aren’t head of department (p=0.042)

Head of Department

• Percentage of women who smoke during pregnancy has more relevance for the child specialists (p=0.042)

• Timing distribution of first antenatal visit has more relevance for the child specialists (p=0.014)

Speciality (Mother – OB & GYN;

Child – Pediatrics, Neonatologist and

Perinatologist)

• Cut-off 46 years was chosen because it is the average age reply

• Infant mortality rate has more relevance for those older than 46 years old (p=0.043)

Age

STATISTICAL ANALYSIS

Results

Methodology

Discussion

References

Acknowledgements

Conclusion

Background

Motivations

Aims

Discussion

Methodology

Results

References

Acknowledgements

Conclusion

Background

Motivations

AimsMultiple birth rate by number of fetuses

• multiple pregnancy rates have been rising in Europe [4] ;• maternal and infant mortality rates are higher in multiple than singleton

pregnancies[4] .

Distribution of maternal age

• multiple pregnancy rates are higher among older women, as are infertility problems[1] ;

• these can lead to the use of assisted conception, which carries a significantly increased risk of multiple pregnancy[1]

[4] Zeithlin J, Mohangoo A. European Perinatal health report. [internet]; 2004. Available from: http://www.europeristat.com/publications/european-perinatal-health-report.shtml

Group 1Population characteristics/ Risk factors

Discussion

Methodology

Results

References

Acknowledgements

Conclusion

Background

Motivations

Aims

Group 1Population caracteristics/ Risk factors

Based on the European Perinatal Health Report, it was expected that the distribution of parity w7ould be among the most chosen indicators. As a core indicator, it allows

the measurement of adverse outcomes.

HOWEVER

The distribution of mother’s education was considered to be, by the enquired, more relevant than the distribution of parity.

WHY?

Because it is a easily measurable indicator

The distribution of parity and distribution of mother’s education

Group 2Health care services

Discussion

Methodology

Results

References

Acknowledgements

Conclusion

Background

Motivations

Aims

Percentage of all pregnancies following fertility treatments

The great relevance attributed to this indicator was not expected

• only thirteen European countries are able to provide data on this indicator [4]; and

• there is a low percentage of deliveries following fertility treatments [4].

Fertility treatments are associated with higher risk of perinatal death, preterm delivery, low birth weight, and congenital anomalies.[5]

BECAUSE

DESPITE OF THIS

[5] Ericson A, Kallen B. Congenital malformations in infants born after IVF: a population based study. Hum Reprod. 2001; 16: 504-509.

(4) Zeithlin J, Mohangoo A. European Perinatal health report. [internet]; 2004. Available from: http://www.europeristat.com/publications/european-perinatal-health-report.shtml

Discussion

Methodology

Results

References

Acknowledgements

Conclusion

Background

Motivations

Aims

Group 2Health care services

Mode of delivery

The great relevance attributed to this indicator was expected:

the substantial rise in caesarean section rates in

developed countries[6], associated with maternal morbidity [7]

(caesarean section quadruples that risk);

and

caesarean section may increase the risk of repeated

operative delivery in subsequent pregnancies.[7]

DUE TO

BECAUSE

[6] Betrán AP, Merialdi M, Lauer JA, Bing-Shun W, Thomas J, Van Look P, Wagner M. Rates of caesarean section: analysis of global, regional and national estimates. Paediatr Perinatal Epidemiol. 2007; 21: 98-113.[7) Wildman K, Blondel B, Nijhuis J, Defoort P, Bakoula C. European indicators of health care during pregnancy, delivery and the postpartum period. Eur J Obstet Gynec Reprod Biol. 2003; 111:S53-S65.

Discussion

Methodology

Results

References

Acknowledgements

Conclusion

Background

Motivations

Aims

Group 3Maternal health: morbidity and mortality

associated with fetusMaternal mortality

Is a measure traditionally used to evaluate the status of women’s health in pregnancy;

during the 20th century, maternal death rates have decreased dramatically.

Since this decrease has been observed without a similar reduction of puerperal morbidity [8]

HOWEVER

Severe obstetric morbidity

and its relation to mortality may be more sensitive measures of pregnancy outcome than mortality alone [9].

[8] Loverro G, Pansini V, Greco P, Vimercati A, Parisi AM, Selvaggi L. Indications and outcome for intensive care unit admission during puerperium. [9] Arch Gynecol Obstet. 2001;265(4):195-8;Waterstone M, Bewley S, Wolfe C. Incidence and predictors of severe obstetric morbidity: casecontrol study. BMJ. 2001;322(7294):1089-93.

Discussion

Methodology

Results

References

Acknowledgements

Conclusion

Background

Motivations

Aims

Group 4Fetal, neonatal and child health

Mortality rates are used as a measure of the health status of a population and of the quality of the perinatal healthcare system.

Most European countries are able to provide data on neonatal and fetal deaths [4]

Severe neonatal morbidity among babies at high risk

Neonatal mortality rate

Fetal mortality rate

[4] Zeithlin J, Mohangoo A. European Perinatal health report. [internet]; 2004. Available from: http://www.europeristat.com/publications/european-perinatal-health-report.shtml

Limitation Explanation

Low answer rate (52 out of 860)

• Results’ significance affected

Unequal answer distribution per

country

• Possible comparisons affected by HDI and geographic localization.

Contact extraction from articles

• Some of the participants enquired:

are not specialists in the field we were studying; are not doctors but statisticians

• There are possibly less articles available in the lesser developed countries, which has a direct impact in the standardisation study of European indicators.

Relevance versus effectiveness

• The relevance doesn’t necessarily have a correlation with the fact of the indicator being used in the health care services Difficulty in standardising the health services

LIMITATIONS OF THE STUDY

Discussion

Methodology

Results

References

Acknowledgements

Conclusion

Background

Motivations

Aims

CONCLUSION

The use of a system of indicators requires their organization in an international level so that the standardization of health systems is possible.

Conclusion

Methodology

Results

References

Acknowledgements

Discussion

Background

Motivations

AimsTOOLS

EVALUATE THE QUALITY OF

HEALTH CARE

LEVEL OF DEVELOPMENT

OF COUNTRIES IN PERINATAL CARE

PERINATAL INDICATORS

1. Reinhardt U. Quality in consumer-driven health systems. International Journal for Health Care. 1998;10(5):385-94.

2. Schrapp M. Concept of indicators: central element of quality management. Med Klin (Munich). 2001;96(10):642-7. 5. Troszyński M. Can implementation of intensified perinatal survey be effective in improving the quality of perinatal care? Med Wieku Rozwoj. 2010;14(2):138-49.

3. World Health Organization. Definitions and Indicators in Family Planning – Maternal & Child Health and Reproductive Health. 2010.

4. Zeithlin; J, Mohangoo A. European Perinatal Health Report. [internet]; 2004. Available from: http://www.europeristat.com/publications/european-perinatal-health-report.shtml

5. Ericson A, Kallen B. Congenital malformations in infants born after IVF: a population based study. Hum Reprod. 2001; 16: 504-509.

6. Betrán AP, Merialdi M, Lauer JA, Bing-Shun W, Thomas J, Van Look P, Wagner M. Rates of caesarean section: analysis of global, regional and national estimates. Paediatr Perinatal Epidemiol. 2007; 21: 98-113.

7. Wildman K, Blondel B, Nijhuis J, Defoort P, Bakoula C. European indicators of health care during pregnancy, delivery and the postpartum period. Eur J Obstet Gynec Reprod Biol. 2003; 111:S53-S65.

8. Arch Gynecol Obstet. 2001;265(4):195-8;Waterstone M, Bewley S, Wolfe C. Incidence and predictors of severe obstetric morbidity: casecontrol study. BMJ. 2001;322(7294):1089-93.

9. Loverro G, Pansini V, Greco P, Vimercati A, Parisi AM, Selvaggi L. Indications and outcome for intensive care unit admission during puerperium. [6] Arch Gynecol Obstet. 2001;265(4):195-8; Waterstone M, Bewley S, Wolfe C. Incidence and predictors of severe obstetric morbidity: casecontrol study. BMJ. 2001;322(7294):1089-93. 7

References

Methodology

Results

Conclusion

Acknowledgements

Discussion

Background

Motivations

Aims

REFERENCES

Prof. Altamiro Pereira – for the constructive criticism Prof. Alberto Freitas – for orientation during the whole project Prof. Armando Teixeira Pinto - for the support with the statistical analysis Prof. Ricardo Correia - for the orientation in an initial stage Engº Jorge Gomes – for the help with MedQuest Dr. Ricardo Santos - for his professional opinion Profª Amélia Ferreira Profª Amélia Ricon Drª Vera Paiva Drª Rosário Gorgal

For the availability in the survey stage

Acknowledgments

Methodology

Results

Conclusion

References

Discussion

Background

Motivations

Aims

ACKNOWLEDGMENTS