High maternal age at delivery.  Maternal demographic characteristics affect rates of perinatal mortality and morbidity (Maher and Macfarlane, 2004). Older mothers and nulliparas both face increased risks of stillbirth (Canterino et al, 2004; Raymond et al, 1994; Reddy et al, 2006). Studies report higher rates of antepartum, intrapartum and neonatal complications including pregnancy induced hypertension, preterm labor, caesarean births and neonatal intensive care unit admissions in older women (Clearly-Goldman et al, 2005; Luke and Brown, 2007a; Prysak et al, 1995). Parity is known to be associated with maternal and neonatal conditions such as hypertension, pre-eclampsia and fetal growth restriction. Parity also impacts the use of services and intervention during pregnancy, labour, and delivery (Bai et al, 2002; Cnattingius et al, 1993; Huang et al, 2000). Multiple pregnancies also carry a much higher fetal and neonatal mortality risk than singleton pregnancies (Kahn et al, 2003; Luke and Brown, 2007b; Magee 2004). This increased risk is mostly due to the higher preterm birth rate in multiple pregnancies (Ananth et al, 2005; Garite et al, 2004).  Figures 9.T1.1 and 9.T1.2. present data on the proportion of childbearing women in the EU who are aged under 20 years and 35 years and older. The relationship between maternal age and perinatal health outcomes is U-shaped and it is thus pertinent to compare the extremes of the age distribution. The risk of many adverse outcomes begins to increase at approximately 35 years of age. For younger mothers, the increased risk of perinatal mortality is  associated with social and health care factors, including lack on antenatal care (Olausson et al, 1997).

Figure 9.T1.1. Percentage of mothers under 20 in 2005 or most recent year

Figure 9.T1.2a. Percent of mothers 35 years and older in EU15 and Norway

Figure 9.T1.2b. Percent of mothers 35 years and older in new members States

Differences between the new and old member States are also apparent with respect to childbearing at older ages. There is a trend towards later childbearing in the 15 old member States, while this trend is much less evident in the new member States. Although many fewer women bear children late in life in the new member states, there is a large variation in both groups.

Smoking during pregnancy. The harmful effects of smoking on perinatal outcomes, in particular their birthweight and fetal mortality, are well documented in the scientific literature (Stillman et al, 1986; Castles et al, 1999; Cnattingius, 2004). These effects concern not only the perinatal period but also the infant’s long-term development. Smoking cessation may be the most effective intervention to improve both short- and long-term outcome for mothers and children and is an indicator of effective antenatal preventive health services. Finally, perinatal health outcomes are linked to social factors (Kaminski et al, 2000; Kramer et al, 2000b). Mortality and morbidity rates are higher among socially disadvantaged population groups, defined by educational status or parental occupation as well as neighbourhood deprivation scores. The rate of smoking among women of childbearing age varies across Europe, as Figure 9.1c illustrates. This information is not sufficient for monitoring the impact of smoking on perinatal outcomes, however, because many women stop smoking during pregnancy, as shown by the data from the EUROPERISTAT project on smoking during pregnancy. In the countries that could provide data, the proportion of women smoking during pregnancy varies from under 10% to almost 25%.

Figure 9.T1.3. Rates of Smoking Among all Women 25-34 vs Women During 3rd Trimester of Pregnancy

Drinking alcohol during pregnancy. Prenatal exposure to alcohol can be associated with a distinctive pattern of intellectual deficits  that become apparent later in childhood, including reductions in general intellectual functioning and academic skills as well as deficits in verbal learning, spatial memory and reasoning, reaction time, balance and other cognitive  and motor skills. There is a typical constellation of facial features and developmental delay and learning disability, and diagnosis is often made in early childhood rather than the first year of life. Special surveys are therefore needed to supplement congenital anomaly registers to determine numbers. Trends regarding alcohol drinking among young women in some countries, especially binge drinking, are of great concern. The effects of binge drinking on the fetus are largely unknown.

Congenital anomalies

In the majority of individual cases of congenital anomaly, the cause of the condition is unknown, but suspected to be an interaction of multiple environmental and genetic factors. For about 15% of cases, there is an identifiable chromosomal abnormality. Under 5% of cases can be attributed to a known single gene mutation, and under 5% to exposure to a single environmental teratogen (such as a drug taken during early pregnancy). Congenital anomalies are usually grouped under “medical genetics”, but the study of socioeconomic differences emphasizes the importance of environmental factors as causes, and these are at present the most amenable to prevention. Genetic susceptibility to environmental exposures is likely to vary importantly in the population.

Mothers’ low folic acid status in the peri-conceptional period is an established risk factor for neural tube defects (MRC, 1991) and probably a range of other anomalies (Botto et al, 2006). Other nutrients are most probably important. Particular attention has been paid also to vitamin B12, but generally a healthy diet is to be promoted for the prevention of congenital anomalies. Some dietary elements in excess, such as vitamin A, are teratogenic and high dose dietary supplements should not be promoted.

Some women are at higher risk of delivering babies with congenital anomaly due to chronic disease status. Diabetes and epilepsy are both associated with higher congenital anomaly risk (EUROCAT, 2004; Macintosh et al, 2006), and there is increasing evidence that obesity is also associated with a higher risk (Waller, 2007; EUROCAT, 2004).  In the case of epilepsy and diabetes, appropriate clinical care can reduce the risk, and there is still much to do in European countries to ensure that all women with these conditions receive the highest standard of care (Macintosh et al, 2006). The rising prevalence of obesity and diabetes are of concern in relation to the burden of congenital anomalies in the population.

Rubella vaccination programmes for babies and/or young girls are an essential continuing measure to prevent congenital rubella syndrome, associated with deafness, eye defects and congenital heart disease. Monitoring of vaccination uptake rate, as well as attention to vaccination status of immigrants, is needed. Additional information systems are needed to capture all cases of congenital rubella syndrome, as some do not present with structural malformations diagnosed at birth.

The thalidomide (softenon) tragedy turned the world’s attention to the potential dangers of therapeutic drugs taken during early pregnancy. A number of drugs are now known to be teratogenic (Schaefer et al, 2001). Some of these are to be avoided during pregnancy, others are necessary (such as antiepileptic drugs) but a careful selection of the type of drug is needed to balance risks and benefits. Pharmacovigilance or postmarketing surveillance of drugs taken during pregnancy is not systematic, and it is possible that there are more drugs currently on the market which carry a risk of congenital anomaly when taken during pregnancy.

Assisted reproductive technology (ART) is being used with increasing frequency, with new techniques being developed over time (e.g. intracytoplasmic sperm injection) to add to the range already available. Currently, there is controversy about the level of risk of congenital anomaly associated with ART (Hansen et al, 2005). Particularly stringent data confidentiality in relation to ART makes this area particularly difficult to research.

Recreational drugs such as cocaine and solvent abuse also carry teratogenic risks. These are particularly difficult to study, as the drug use may be illegal and there are often many coexisting risk factors such as smoking, alcohol, poor nutrition and other risk factors associated with deprivation.

Older maternal age is a risk factor for chromosomal anomalies such as Down syndrome. Trends towards older age at childbearing are a complex social phenomenon, but are associated with poorer reproductive outcomes.

Our knowledge of the risks of exposure to chemicals, in the occupational, domestic and community environment is very incomplete (Cordier, 1992; Cordier et al, 1997; Dolk and Vrijheid, 2003; EUROCAT, 2004). To protect the fetus, we need to adopt a precautionary approach in reducing exposure particularly to byproducts of chlorination in drinking water, releases from waste disposal sites, endocrine disrupting chemicals, pesticides and solvents.

References cited in the section on congenital anomalies are listed in Chapter 9.1.2; references cited in the other paragraphs are listed in Chapter 9.1.1

Domestic Environment. Children and their health are initially significantly influenced by their immediate family environment. Three factors in particular are well-known as influencing health, well-being and development. These are housing (including modern sanitation and appropriate heating), family income, and maternal education (see above). Data on the first two are available in most countries from national sources. Whilst in general deficiencies of housing are being addressed, it is clear from studies from UNICEF and others that great inequalities in income remain, and indeed are increasing. Some of the richest European countries still have major pockets of children living in poverty (UNICEF, 2005). Data on maternal education is more difficult to obtain other than by special studies. It has been shown that children of mothers educated only to primary school level have a higher risk of health problems that children of more educated mothers (European Commission, 2003). Poor health behaviour in a mother can influence the future health of her child. There is a direct relation between low birth weight, poor nutrition in the mother during pregnancy and the child’s vulnerability to several conditions in childhood (Middle et al, 1996; Matharu and Ozanne, 2004; Ozanne et al, 2004).

Smoking.  Smoking is argued to be driven predominantly by psychosocial motives such as wanting to look older, needing to relax, feeling rebellious, boredom, or the idea that it might control weight gain. In many cases it is reported that children who smoke frequently have low self esteem, impaired psychological wellbeing, or are poor achievers at school, and tend not to be succeeding according to their own or society's terms (Jarvis, 2004).  Data from ESPAD from 16 year olds shows a range of persons who had smoked within the last 30 days between 49% in Austria and 22% in Cyprus (1993 data).

Alcohol. Despite Europeans being among the world’s highest consumers of alcohol, most national and cross-cultural studies of drinking in Europe have been of a quantitative, epidemiological nature and provide little or no insight into the social contexts and cultural roles of drinking. Cross-cultural variation in the way people behave when they drink cannot be attributed solely to different levels of consumption or genetic difference. The consumption of alcohol in society is related to different cultural beliefs about alcohol itself, expectancies regarding its effects, and social norms regarding drunken comportment. Societies which hold generally positive beliefs and expectancies about alcohol experience significantly fewer alcohol-related problems. Higher levels of alcohol-related problems are associated with negative or inconsistent beliefs and expectancies (Social Issues Research Centre, 1998). Regular consumption of alcohol is increasing in young people, often beginning at an early age. Weekly drinking is more widespread among boys than girls and rises with age from over a tenth of 11 year old boys in six countries to a fifth of 13 year old boys in eight countries and to over a third in nineteen countries by age 15. In a few countries the rates for boys and girls are very similar at age 15, such as Norway and the United Kingdom. Weekly drinking among 15-year-old girls is especially high in Denmark, the Netherlands and the United Kingdom, whilst having got drunk in the last 12 months peaks in Denmark (WHO/HSBC, 2004; www.espad.org interactive data) (see also Section 10.2).

Cannabis use. Cannabis use varies widely among 15-year-olds with reports of those who have ever used it ranging from 3% to 46%. On average, boys are more likely to use cannabis than girls: 22% and 16%, respectively, and have used it in the previous 12 months. Regular use of cannabis (3–39 times in the previous 12 months) is highest (15% or over) in Spain and Switzerland (WHO/HSBC, 2004), though in ESPAD data the Czech Republic and Ireland also fare badly (www.espad.org interactive data). Looking at other drugs also brings Estonia, Germany, and the United Kingdom into the worst group (www.espad.org interactive data) (see also Section 10.2).

Sexual health and behaviour. Sexual behaviour is an important determinant of physical and mental well-being. Unsafe sex can have implications for unwanted teenage pregnancies, fertility, infectious diseases and other reproductive health problems. Several risk factors have been identified for cervical cancer, such as early sexual activity, sexually transmitted infections (STIs) and human papilloma virus (HPV). Risk factors for STIs can include multiple sex partners and a weakened attention to protect their health and their lives because of feelings of invincibility, combined with a lack of awareness of the consequences of risky behaviour (WHO, 2005c). Sexually transmitted infections are an important health problem for young girls because of the risk of infertility, ectopic pregnancy, pelvic inflammatory disease, and chronic pelvic pain. There is a significant demand for abortion among teenagers. In Northern countries men and women have their first sexual intercourse at about the same age. Belgium and Germany are characterised by a comparatively late sexual initiation for both sexes (European Commission, 2003). In conducting the research for the WHO/HSBC report Young People’s Health in Context, only the 15 year olds were asked to respond to the survey on sexual health, as the questions were considered too sensitive for younger age groups. The ranges of reported condom use during the 15 year olds’ last intercourse are quite large: 58–89% for girls and 69–91% for boys. Rates are highest in some southern European countries, and lowest in Finland, Germany, Sweden and the United Kingdom. On average, 85% of girls and 86% of boys report using at least one form of contraception during their last sexual intercourse. However, several countries and regions did not include questions on sexual health (WHO/HSBC, 2004).

Inadequate physical activity. Less than half of young people in Europe participate in a recommended one hour or more of at least moderate physical activity on five or more days a week (European Commission, 2005b). Across all countries and regions and all age groups, girls are less active than boys and the gender gap increases with age. The countries with the highest percentages (over 40%) of boys achieving the recommended amount of physical activity are the Czech Republic, England, Ireland, and Lithuania. The Netherlands have the highest rates of physical activity for 15-year-old girls, with over 36% meeting the guidelines (WHO, 2005a).

Eating habits. The eating habits of young people may be a reflection of the weakening influence of parents, and the strengthening influence of peer and media pressure (WHO/HSBC 2004). Although varying widely across countries and regions, it is observed that less than two fifths of young people eat fruit daily, while about a third eat vegetables each day. The daily consumption of sweets and soft drinks reaches a high of 40–50% in Belgium (French), Ireland, Italy, Malta, Scotland and the Former Yugoslav Republic of Macedonia. Those who choose not to eat breakfast are more likely to eat snacks with high fat and low fibre content during the day (WHO/HSBC 2004).

Disability. Regrettably, the incidence of physical disability in children, or of mental disability, is not known at the population level across Europe. Such disabilities can be either present from birth, or acquired by illness or by trauma at a subsequent stage. A physical or mental impairment clearly can affect normal development and play, education, mental wellbeing, and ultimately work and lifestyle opportunities. Some conditions such as autism only become manifest as the child matures. Though congenital abnormalities are well recorded within Europe, later acquisitions and manifestations are not, nor are the related special needs in the educational and other settings if disability is not to become a major handicap for the individual.

References cited in this table are listed in Chapter 9.2

Major modifiable risk factors for atherosclerotic CHD are similar in women and men and include dyslipidemia, hypertension, diabetes mellitus, cigarette smoking, inadequate physical activity, and obesity (especially abdominal obesity). The atherogenic risk profile of older women is appreciably more adverse than that of younger women, although it is uncertain whether age or hormone status is the primary determinant of the evolution of the adverse risk profile. Large randomized, placebo-controlled clinical trials have shown that beta-blockers, aspirin, 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors (statins), and angiotensin-converting enzyme (ACE) inhibitors reduce risk for CHD events in women as well as in men. For some of these therapies, the evidence derives largely from secondary prevention trials; in general, therapies that work in secondary prevention will work in primary prevention as well. Treatment effects appear to be similar in women and men. For example, meta-analysis of data from several major lipid-lowering statin trials showed a 29-percent reduction in risk for major CHD events in women, similar to the 31-percent reduction observed in men. At present, prevention of CHD should rely on identifying and treating the classic risk factors, such as dyslipidemia, hypertension, diabetes mellitus, smoking, obesity, and sedentary lifestyle. Vigilant management of risk for CHD in women is imperative. Despite similar stroke rates, women are more likely than men to die of stroke. The main risk factors for stroke are not gender dependant. Although strokes are more closely related to hypertension (which is probably their most important risk factor) than to hypercholesterolemia, HMG-CoA reductase inhibitors (statins) reduce risk for stroke, as do antihypertensive medications.

Smoking is a primary cause of lung cancer, although pollution and exposure to certain gases/chemicals may also be influential. 

Alcohol. The Charter establishing the European Alcohol and Health Forum notes that 7.5% of ill-health and premature death is a consequence of harmful and hazardous alcohol consumption and that alcohol contributes to about 25% of mortality in young men (as compared to 10% in women). It has been noted that a significant proportion of the cardiovascular deaths in Eastern European countries are a consequence of sudden cardiac death as a result of excess alcohol consumption (Britton & McKee, 2000). Alcohol exacerbates financial difficulties, childcare problems, infidelity or other family stressors, and creates tension and conflict between partners. Risk factors for breast cancer in women may include regular use of alcohol (especially if combined with hormone replacement therapy (Beral, 2003), and higher body mass index (BMI) in early adulthood (Michels et al, 2006)

Current EU environments favour obesity. There is an abundance of food in Europe that, while energy-rich, is often poor in nutrients. Food portion sizes are growing, though people with sedentary lifestyles actually need less energy. Social and economic pressures can mean that both work and leisure hours offer decreasing opportunities for physical activity.  It is also interesting to note the relationship across Europe between availability of fruit and vegetables at national level, and the prevalence of ischaemic heart disease (Fig.9.T1.4).

Levels of physical activity vary across the EU member states, but in general southern countries of the EU15 have lower levels of physical activity than Northern and Western countries. Physical inactivity is defined as less than 2.5 hours per week of moderate exercise or 1 hour per week of vigorous exercise. The World Health Report 2002 estimates that over 3% of all disease burden, over 20% of CHD, and 10% of stroke in developed countries is caused by physical inactivity.

Ill health increases steadily with decreasing educational level. People with low levels of education are more likely to suffer chronic health problems and resulting disability than more educated patients. Numerous studies demonstrate that life expectancy and ‘positive health experiences’ increase for those with higher levels of education. For example, people with low levels of education have an increased risk of premature death and circulatory disease.

References cited in this table are listed in Chapter 9.3.1

The natural decline in cardiac function can leave an individual with lower functional capacity than would normally be expected for his/her age. The gradient of decline may become so steep as to result in disability.

The SENECA study demonstrated that a healthy lifestyle is related to stable self-perceived health, and a delay in functional dependence and mortality. The rate of decline of a body’s biological system is largely determined by external factors relating to adult life style.  Inactivity and smoking, and to a lesser extent a low-quality diet, increase mortality risk. A healthy lifestyle at older ages is related to a delay in the deterioration of health status and a reduced mortality risk. The study showed that even at ages 70-75 years, the combined unhealthy lifestyle behaviours of smoking, having a low-quality diet, and being physically inactive were singly related to a three- to four-fold increase in mortality risk. The risk of death was further increased for all combinations of two unhealthy lifestyle behaviors (De Groot et al, 2004). Member States should consider the promotion of programmes which encourage smoking cessation and the reduction of harmful alcohol consumption among older people (European Healthy Ageing, 2007).

Smoking. The acceleration in decline caused by external factors can be reversible at any age. Smoking cessation and small increases in the level of physical fitness, for example, reduce the risk of developing coronary heart disease, including those in later life.

Alcohol. Many chronic diseases which reduce functional capacity are the result of an unhealthy life style. WHO’s 1996 ‘The Global Burden of Disease’ Report states that alcohol use is the leading cause of male disability in industrialised countries (WHO, 1999).

Social factors. Social factors, which the individual can usually do little to change, also affect functional capacity. Poor education, poverty, and harmful living and working conditions all make reduced functional capacity more likely in later life. In some countries, people with poor functional ability are more likely to become institutionalised, which in itself can lead to dependence, particularly for the small minority of older people who suffer from loss of mental function and/or confusion.

Environment. Poverty is clearly linked to a shorter life span and poorer health in older age. Less well-off people tend to live in more harmful environments where they are more likely to be exposed to higher levels of indoor air pollution and to the risk of diseases such as respiratory infections. Poor housing structure and overcrowding increase the risks of accidents and transmission of infectious diseases (WHO, 1999). 

Nutrition. Nutritional status, dietary habits and food pattern, energy and nutrient intake vary widely across Europe. The food pattern in southern countries is characterised by high intakes of grain, vegetables, fruit, lean meat and olive oil, whereas older people in northern countries consumed more milk products and report more frequent use of nutrient supplements. In some towns considerable proportions of older men and women could be at risk of vitamin or mineral deficiency (Volkert, 2005). Obtaining adequate nutrition becomes increasingly difficult with increasing age. Nutrition and lifestyle, however, are important determinants of health and outcome in the elderly (Volkert, 2005). Healthy food and eating habits should be promoted among older people, with an emphasis on low intake of saturated fats and high consumption of fibre-rich foods, green vegetables and fruits (European Healthy Ageing, 2007).

Lack of physical activity. Physical activity usually decreases with age, though great differences exist between countries with respect to physical activity of older people. In a recent pan-European survey physical activity was highest in Sweden and Finland, where more than 85 % of older subjects spent at least 3.5 h per week in physical activity, and lowest in Portugal with only 25 % of active elderly (Volkert, 2005). The level of physical activity among older people needs to be increased in order to reach the international recommendations of 30 minutes or more  at least, of moderate intensity physical activity on most, preferably all, days of the week (European Healthy Ageing, 2007).

Risk factors for falls are muscle weakness, a history of falls, gait deficit, balance deficit, use of assistive devices, visual deficit, arthritis, impaired activities of daily living, depression, cognitive impairment, and being aged over 80. The risk of falling increases exponentially with the number of risk factors. Visual performance, medical problems, slowed neurological response, decreased muscle strength and range of motion, and reduced trunk and neck mobility become significant factors with age. These difficulties can also lead to motor vehicle and pedestrian-related injuries. Although older drivers drive less than younger ones, they succumb to fatal accidents more often. This may be because many medicines can impair driving ability, but a history of falling has also been identified as an important risk factor (WHO/HEN, 2004).

References cited in this table are listed in Chapter 9.4