EUGLOREH project
THE STATUS OF HEALTH IN THE EUROPEAN UNION:
TOWARDS A HEALTHIER EUROPE

FULL REPORT

PART II - HEALTH CONDITIONS

9. MAIN HEALTH ISSUES AND TRENDS FOR DIFFERENT AGE AND GENDER POPULATION GROUPS

9.1. Newborns and perinatal health.

9.1.1. Foetal, neonatal and infant mortality and morbidity

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9.1.1. Foetal, neonatal and infant mortality and morbidity

 

 

9.1.1.1. Introduction

 

The principal determinants of foetal and neonatal death in Europe today include congenital anomalies, very preterm birth, and stillbirths associated with foetal growth restriction (De Galan-Roosen et al, 1998; Glinianaia et al, 2000; Holt et al, 2000; De Reu et al, 2000). Preterm birth and low birth weight are important risk factors for morbidity in infancy and childhood. Data are available in international reporting systems on rates of death in the perinatal period, the causes of infant deaths and on the percentage of low birth weight babies. Other topics covered by the EURO-PERISTAT indicators on morbidity, including the preterm birth rate, the APGAR score (Apgar, 1953) and hypoxic ischemic encephalopathy (HIE) are not currently available in international reporting systems.

 

Foetal and neonatal mortality have declined dramatically in the past decades, but large disparities still exist among EU Member States. Table 9.1.1.1 provides definitions and some methodological caveats to take into consideration when comparing these rates between countries and over time.

 

Table 9.1.1.1. Definitions of foetal, neonatal and infant mortality and points to consider when comparing rates between countries.

 

 

Indicator

Definition

Points to consider in interpretation

Fetal mortality

The number of fetal deaths at or after 22 completed weeks of gestation in a given year per 1000 live and stillbirths in the same year.

WHO recommends that registration of fetal deaths begin at 22 weeks or 500 g, but that fetal mortality rates be presented for infants 1000 or more.

EURO-PERISTAT recommends that data be presented separately by gestational age and birthweight groups.

Countries differ in their legal criteria for birth registration and in their inclusion criteria for other data collection systems. For example, in Spain and Sweden, only fetal deaths after 28 or more completed weeks of gestation are registrable as stillbirths. Other countries, including Austria, Germany and Portugal, add a minimum birth weight criterion. The absence of common criteria distorts comparisons between countries.

Neonatal mortality

The number of deaths in the neonatal period (up to 28 completed days after birth) after live birth at or after 22 complete weeks of gestation in a given year, expressed per 1000 live births in the same . This rate is sub-divided by timing of death into early neonatal deaths (at 0-6 days after live birth) and late neonatal deaths (at 7-27 days after live birth).

Comparisons of the neonatal mortality rate at early gestations must be combined with an analysis of fetal mortality, since it is possible that early neonatal deaths may be recorded as fetal deaths. Some data recording systems impose a lower limit of 500 grams for registration of births, which can create a bias when comparing neonatal mortality rates at low gestational ages.

Infant mortality

The number of deaths (day 0-364) after live birth at or after 22 completed weeks gestation in a given year expressed per 1000 live births in the same year.

Same as neonatal mortality

 

Table 9.1.1.2. Births, deaths and rates of foetal, neonatal and infant mortality in selected EUGLOREH countries

 

9.1.1.2. Data sources

 

9.1.1.2. Information Sources

 

International comparisons of data relating to pregnancy outcome and maternity care date back at least to the mid-nineteenth century (Le Fort, 1866; US Center for Disease Control, 1992; Semenow, 1872). In the twentieth century, the post-war focus on maternal and child health programmes in many countries furthered the development and use of perinatal health indicators. Today, perinatal, infant and maternal mortality rates are among the most commonly used indicators of population health status. These rates, derived from civil and medical registers of births and deaths, are published regularly and historical series exist for many countries.

 

There are limits to the available perinatal health data, however. As perinatal and maternal health have improved, absolute differences in mortality rates between countries have declined and other measures of health status have become increasingly necessary. Despite this need for information, there are no comparative data available on the principal morbidities affecting pregnant women and their newborns. Furthermore, the methodological shortcomings of many indicators, whether mortality or other measures of health status, have generated scepticism about the data sources, the derivation of the numbers, and their usefulness in comparing health status and quality of care (Macfarlane and Chalmers, 1981; Garne, 2001; Kramer et al, 2002). 

 

To address these limitations, the EURO-PERISTAT project was charged with developing an indicator set for monitoring and describing perinatal health in Europe. The EURO-PERISTAT indicators, listed in Table 1, were developed after an extensive review of existing perinatal health indicators using a DELPHI consensus process with scientific committees composed of clinicians, epidemiologists and statisticians from all European member states and Norway (Zeitlin et al, 2003).  The resulting EURO-PERISTAT indicator set reflects a solid base of scientific evidence, as well as the consensus of epidemiologists, clinicians and data providers across Europe.

 

The EURO-PERISTAT indicators are grouped into four themes: fetal, neonatal and child health; maternal health; population characteristics and risk factors; and health services. Core indicators are defined as those essential to monitoring perinatal health, recommended indicators are those considered desirable for a more complete picture of perinatal health across the member states, and indicators for further development represent important aspects of perinatal health, but require additional work before they can be operationalised in the member states.

 

Table 9.1.1.2.1. EURO-PERISTAT Indicators by category; Data on indicators in bold italics are available in international routine databases such as EUROSTAT, WHO, OECD or European networks of condition-specific registers.

 

 

(C=core, R=recommended, F=for further development)

 

Neonatal health

   C: Fetal mortality rate by gestational age, birth weight, plurality

C: Neonatal mortality rate by gestational age, birth weight, plurality

C: Infant mortality rate by gestational age, birth weight, plurality

C: birth weight distribution by vital status, gestational age, plurality

C: Gestational age distribution by vital status, plurality

R: Prevalence of selected congenital anomalies

R: Distribution of APGAR score at 5 minutes

F: Causes of perinatal death/deaths due to congenital anomalies

F: Prevalence of cerebral palsy

F: Prevalence of hypoxic-ischemic encephalopathy

  F: Prevalence of late induced abortions

  F: Severe neonatal morbidity among babies at high risk

  F: Neonatal screening policies

Maternal health

  C: Maternal mortality ratio by age, mode of delivery

R: Maternal mortality by cause of death

R: Prevalence of severe maternal morbidity

F: Prevalence of trauma to the perineum

F: Prevalence of faecal incontinence

F: Postpartum depression

Population characteristics/Risk factors

C: Multiple birth rate by number of fetuses

C: Distribution of maternal age

C: Distribution of parity

R: Percentage of women who smoke during pregnancy

R: Distribution of motherseducation

F: Distribution of mothers' country of origin

Health care services

C: Distribution of births by mode of delivery by parity, plurality, presentation, prev. Caesarean

R: Percentage of all pregnancies following fertility treatment

R: Distribution of timing of 1st antenatal visit

R: Distribution of births by mode of onset of labour

R: Distribution of place of birth

R: Percentage of infants breast-feeding at birth

F: Indicator of support to women

F: Indicator of maternal satisfaction

F: Births attended by midwives

F: Births without medical intervention

 

The indicators that were developed by EURO-PERISTAT are not yet reported routinely in Europe. However, data from existing international health databases are available on many of them, although they do not always follow the exact definitions specified by EURO-PERISTAT. These data systems include EUROSTAT, WHO and OECD, as well as international networks of data registers such as SCPE (European Cerebral Palsy Network) and ESHRE (European Society for Human Reproduction and Embryology). Table 9. 1. 1. 2. 1 indicates in bold italics the indictors for which at least some data are available in these sources. Illustrations from the EURO-PERISTAT feasibility studies and other published data are presented here to show how these indicators, once they are part of a routine reporting system in Europe, will enrich our understanding of key issues in perinatal health.

 

9.1.1.3. Data presentation and analysis

 

Foetal, neonatal and infant mortality

 

Table 9.1.1.2 provides rates of foetal, neonatal and infant mortality for 2005 or most recent available year using EUROSTAT data, while Figures 9.1.1.1 and 9.1.1.2 show the evolution of neonatal and foetal mortality over the past 30 years.

 

Neonatal mortality

As shown in Figure 9.1.1.1, there has been a significant decline in the rate of neonatal mortality in the last thirty years. In 1975, neonatal mortality rates ranged from 6.4 to 22.1 per 1 000 total births in the current EU Member States. By 2004, they ranged from 1.6 to 9.5 per 1 000 births. Neonatal mortality rates are about 2 per 1 000 births in Sweden, Luxembourg, Czech Republic, Norway and Finland, but over 5 per 1 000 in Bulgaria, Latvia and Romania. There are differences in rates of neonatal mortality between countries based on their year of accession to the European Union. Among EU15 Member States and Norway, the median rate of neonatal mortality in 2004 was 2.7 per 1 000 births. This median rate was much higher (4.4/1 000) among countries that joined the EU in 2004 (Czech Republic, Cyprus, Estonia, Hungary, Latvia, Lithuania, Malta, Poland, Slovenia, and Slovak Republic), and was more than three times greater (8.5/1 000) among countries that acceded in 2007 (Bulgaria and Romania).

 

Figure 9.1.1.1. Trends in neonatal mortality rates

 

Foetal mortality

As Figure 9.1.1.2 illustrates, foetal mortality has also decreased, but less markedly. Measuring foetal mortality is more complicated than neonatal mortality, as explained in Table 9.1.1.1. In addition, data systems are undoubtedly better at registering these deaths today, which may mask a greater downward trend. Using 2004 data, there was no difference in the median rate of foetal mortality (3.9 per 1 000 births) between the original members of the EU and those who joined in 2004. The median rate of foetal mortality among countries that acceded in 2007, however, was higher at 6.9 per 1 000 births.

 

Figure 9.1.1.2. Trends in foetal mortality rates

 

Infant mortality and its causes

Data on the causes of infant deaths are available in international databases. Unfortunately, all of the causes associated to conditions originating from the perinatal period are grouped together, whilst there is no available information on the specific causes of perinatal deaths. Nonetheless, these data show that a large proportion of infant deathsi.e.  nearly three-quarters - are due to conditions originating in the perinatal period, mainly prematurity and congenital anomalies. Data on congenital anomalies are presented elsewhere in this volume and are not reproduced here (see below). The remaining 25% of deaths are due, in part, to infectious diseases and accidental deaths which are largely preventable. Among the EU Member States, the highest rates of these other causes are reported for Bulgaria (48%), Romania and Cyprus1 (40%) and Estonia (36%). These data also illustrate that as the rate of infant mortality declines, perinatal causes are responsible for a greater proportion of deaths in the first year of life.

 

Table 9.1.1.3. Infant mortality by cause in selected EUGLOREH countries in 2005 or most recent year

 

Congenital malformations

 

See Chapter 9.1.2 for a detailed and specific treatment of congenital malformations.

 

Low birth weight and preterm delivery

 

Figure 9.1.1.3 presents rates of low birth weight in the EU. Between 4 and 9% of all live births have a birth weight less than 2500 grams. These babies include those that are preterm, with normal or low birth weights and babies born at term with growth restriction; all these groups are at a higher risk of having longer-term impairments in childhood than term babies with normal birth weight.

 

Figure 9.1.1.3. Percentage of live births with a birth weight less than 2500 g, most recent data available

 

Data on preterm babies are not currently reported routinely, but this information is very important for evaluating perinatal health outcomes. Very preterm babies have the highest rates of long-term health problems, including cerebral palsy, severe learning disabilities, chronic lung disease, visual and hearing impairments and poor growth. However, even babies born between 33 and 35 weeks of gestation, often termed mildly or moderately preterm births, have higher mortality and are more likely than others to have motor and learning difficulties than term babies (Escobar et al, 2006; Kramer et al, 2000a; Marret et al, 2007). The preterm birth rate has increased in many countries over the past decade (Langhoff-Ross et al, 2006); these trends, which cannot be monitored using currently reported indicators, are essential for monitoring the health of babies in the EU. The EURO-PERISTAT feasibility study showed that these data are available in most European countries.

 

Cerebral palsy

 

Cerebral Palsy (CP) is the most common disabling condition in childhood, occurring in 1.5 to 2.5 per 1 000 live births. Cerebral Palsy is a group of permanent disorders of movement and/or posture that result from a non-progressive interference, lesion, or abnormality of the developing/immature brain (DMCN, 2000).

 

Challenges in Monitoring

CP is a recommended indicator by EURO-PERISTAT for long-term childhood health impairments because of its association with adverse perinatal events. CP is an umbrella term and difficulties can arise from variation in case definition and in the inclusion and exclusion criteria used by surveys and registers. To overcome these difficulties, a collaborative network on cerebral palsy surveys and registers, SCPE (Surveillance of Cerebral Palsy in Europe), was formed within Europe with the aim of monitoring trends in CP rates and providing a framework for collaborative research (SCPE, 2000). Data presented here concern children with CP born 1990-1998, ascertained at 4-5 years of age using a common SCPE definition and the same inclusion/exclusion criteria.

 

Rate in Europe

The overall rate of cerebral palsy, excluding post-neonatal CP cases acquired during 1990-1998 in 10 European countries, is 2.0 per 1 000 live births. As shown in Table 9.1.1.4, this rate varies between countries from 1.6 or 1.7 (Portugal, Spain, France and Norway) to 2.3 (United Kingdom).

 

Table 9.1.1.4. Cerebral palsy rates per 1 000 live births in selected EUGLOREH countries, birth cohorts 1990-1998

 

Among children with CP, some have a severe clinical presentation and are unable to walk or have moderate to severe intellectual impairment. Other children have a mild clinical CP type, i.e. they walk without aids and they have normal cognition or only mild intellectual impairment. As shown in Table 9.1.1.5, these proportions vary greatly between countries, with fewer mild cases in registers from the Southern part of Europe than in registers from the Northern part of Europe. Although it varies between countries, there is little change over time in this rate of CP.

 

Table 9.1.1.5. Proportion of severe and mild cerebral palsy cases, born 1990-1998, in selected EUGLOREH countries

 

Cerebral Palsy in Very Low birth weight Babies

Very Low birth weight (VLBW) is defined as a weight at birth below 1500g. VLBW rate among live births is not rare; it has increased during the last decades and is now around 1% in different European countries. It is well known that the risk of developing CP is 60 to 100 times higher in VLBW babies/very preterm than in normal birth weight/term babies. The CP rate among VLBW children born in the covered area of 9 different European countries is, on average, 94 per 1 000 live births during the period 1990-1998. As shown in Table 9.1.1.6, this rate varies per country from 26 per 1 000 live births (Lithuania) up to 164 per 1 000 live births (Ireland). This variation depends greatly on the rate of neonatal mortality among children born VLBW, which varies from 17% to 52% in the different countries. The overall rate of CP in VLBW has been decreasing over time, at least until 1996 birth cohort, and mainly in the group of children born 1000-1499g (Platt et al, 2007).

 

Table 9.1.1.6. CP rates among VLBW babies in 9 European countries, birth cohorts 1990-1998

 

Population characteristics and risk factors

 

In order to monitor perinatal health trends and understand the differences observed between countries, it is necessary to have information about the characteristics of childbearing women and the risk factors associated with poor outcomes. For a synthesis of available knowledge see Table 9.1 and the section on maternal health.

 

HealthCare

 

Healthcare of mothers and their conceived during pregnancy, delivery and postpartum have developed differently in EU Member States. See Chapter 9.3.2 for more information.

 

 

Conclusions and future priorities for surveillance

 

While greatly reduced, deaths and illness associated with childbearing remain a priority for surveillance in Europe, there are compelling reasons to improve national and European health information systems in order to monitor health practices and policies.

 

First of all, the data presented in this chapter reveal significant geographic inequalities in mortality in the perinatal period between the countries in Europe, suggesting that further gains are possible and necessary. For instance, if every country had the neonatal mortality rate of those countries with the lowest rates, the number of neonatal deaths every year would be halved. Better data on preterm births and neonatal morbidities would make it possible to better understand the reasons and consequences of these differences.

 

It is increasingly understood that a healthy pregnancy and infancy reduce the risk of common adult illnesses, such as hypertension and diabetes. This life-course approach to our health begins at conception – or perhaps before – and suggests that a better management of the major morbidities associated with pregnancy, such as intrauterine growth restriction or preterm birthmay reap large dividends in overall population health.

 

Further information regarding reproduction issues is presented in Chapter 9.3.2

 

9.1.1.4. References

 

Ananth CV, Joseph KS, Demissie K, Vintzileos AM (2005): Trends in twin preterm birth subtypes in the United States, 1989 through 2000: impact on perinatal mortality. Am J Obstet Gynecol 2005;193(3 Pt 2):1076-82.

 

Alexander S, Wildman K, Zhang W, Langer M, Vutuc C, Lindmark G (2003): Maternal health outcomes in Europe. Eur J Obstet Gynecol Reprod Biol 2003;111 Suppl 1:S78-87.

 

Alran S, Sibony O, Oury JF, Luton D, Blot P (2002): Differences in management and results in term-delivery in nine European referral hospitals: descriptive study. Eur J Obstet Gynecol Reprod Biol 2002;103(1):4-13.

Apgar V (1953): A proposal for a new method of evaluation of the newborn infant.  Curr. Res. Anesth. Analg. 32: 260267.

 

Atrash HK, Alexander S, Berg CJ (1995) Maternal mortality in developed countries: not just a concern of the past. Obstetrics & Gynecology 1995;86(4 Pt 2):700-5.

 

Bai J, Wong FW, Bauman A, Mohsin M (2002): Parity and pregnancy outcomes. Am J Obstet Gynecol 2002;186(2):274-8.

Bertollini R, DiLallo D, Spadea T, Perucci C. Cesarean (1992): section rates in Italy by hospital payment mode: an analysis based on birth certificates. Am J Public Health 1992;82(2):257-61.

 

Blondel B, Macfarlane A, Gissler M, Breart G, Zeitlin J (2006): Preterm birth and multiple pregnancy in European countries participating in the PERISTAT project. Bjog 2006;113(5):528-35.

 

Bouvier-Colle MH, Varnoux N, Breart G (1995): Maternal deaths and substandard care: the results of a confidential survey in France. Medical Experts Committee. Eur J Obstet Gynecol Reprod Biol 1995;58(1):3-7.

 

Breart G, Barros H, Wagener Y, Prati S (2003): Characteristics of the childbearing population in Europe. Eur J Obstet Gynecol Reprod Biol 2003;111 Suppl 1:S45-52.

 

Cans C, Guillem P, Fauconnier J, Rambaud P, Jouk PS (2003): Disabilities and trends over time in a French county, 1980-91. Arch Dis Child 2003;88(2):114-7.

Canterino JC, Ananth CV, Smulian J, Harrigan JT, Vintzileos AM (2004): Maternal age and risk of fetal death in singleton gestations: USA, 1995-2000. J Matern Fetal Neonatal Med 2004;15(3):193-7.

Castles A, Adams EK, Melvin CL, Kelsch C, Boulton ML (1999): Effects of smoking during pregnancy. Five meta-analyses. Am J Prev Med 1999;16(3):208-15.

Cleary-Goldman J, Malone FD, Vidaver J, Ball RH, Nyberg DA, Comstock CH, et al (2005): Impact of maternal age on obstetric outcome. Obstet Gynecol 2005;105(5 Pt 1):983-90.

Cnattingius S (2004): The epidemiology of smoking during pregnancy: smoking prevalence, maternal characteristics, and pregnancy outcomes. Nicotine Tob Res 2004;6 Suppl 2:S125-40.

Cnattingius S, Forman MR, Berendes HW, Graubard BI, Isotalo L (1993): Effect of age, parity, and smoking on pregnancy outcome: a population-based study. Am J Obstet Gynecol 1993;168(1 Pt 1):16-21.

De Galan-Roosen AE, Kuijpers JC, Meershoek AP, van Velzen D (1998): Contribution of congenital malformations to perinatal mortality. A 10 years prospective regional study in The Netherlands. Eur J Obstet Gynecol Reprod Biol 1998;80(1):55-61.

 

De Reu PA, Nijhuis JG, Oosterbaan HP, Eskes TK (2000): Perinatal audit on avoidable mortality in a Dutch rural region: a retrospective study. Eur J Obstet Gynecol Reprod Biol 2000;88(1):65-9.

 

Doyle LW (2001): Outcome at 5 years of age of children 23 to 27 weeks' gestation: refining the prognosis. Pediatrics 2001;108(1):134-41.

 

Draper ES, Manktelow B, Field DJ, James D (1999): Prediction of survival for preterm births by weight and gestational age: retrospective population based study. Bmj 1999;319(7217):1093-7.

 

Effer SB, Moutquin JM, Farine D, Saigal S, Nimrod C, Kelly E, et al (2002): Neonatal survival rates in 860 singleton live births at 24 and 25 weeks gestational age. A Canadian multicentre study. Bjog 2002;109(7):740-5.

 

Escobar GJ, Clark RH, Greene JD (2006): Short-term outcomes of infants born at 35 and 36 weeks gestation: we need to ask more questions. Semin Perinatol 2006;30(1):28-33.

 

EUROSTAT DATABASE. http://epp.eurostat.ec.europa.eu/extraction/evalight/EVAlight.jsp?A=1&language=en&root=/theme3/demo/demo_minfind 2006;accessed January 2008.

 

Garite TJ, Clark RH, Elliott JP, Thorp JA (2004): Twins and triplets: the effect of plurality and growth on neonatal outcome compared with singleton infants. Am J Obstet Gynecol 2004;191(3):700-7.

Garne E (2001): Perinatal mortality rates can no longer be used for comparing quality of perinatal health services between countries. Paediatr Perinat Epidemiol 2001;15(3):315-6.

 

Glinianaia SV, Pharoah P, Sturgiss SN (2000): Comparative trends in cause-specific fetal and neonatal mortality in twin and singleton births in the North of England, 1982-1994. Bjog 2000;107(4):452-60.

 

Gould JB, Davey B, Stafford RS (1989): Socioeconomic differences in rates of cesarean section. N Engl J Med 1989;321(4):233-9.

 

Hansen M, Kurinczuk JJ, Bower C, Webb S (2002): The risk of major birth defects after intracytoplasmic sperm injection and in vitro fertilization. N Engl J Med 2002;346(10):725-30.

 

Holt J, Vold IN, Odland JO, Forde OH (2000): Perinatal deaths in a Norwegian county 1986-96 classified by the Nordic-Baltic perinatal classification: geographical contrasts as a basis for quality assessment. Acta Obstet Gynecol Scand 2000;79(2):107-12.

 

Huang DY, Usher RH, Kramer MS, Yang H, Morin L, Fretts RC (2000): Determinants of unexplained antepartum fetal deaths. Obstet Gynecol 2000;95(2):215-21.

 

Kahn B, Lumey LH, Zybert PA, Lorenz JM, Cleary-Goldman J, D'Alton ME, et al (2003): Prospective risk of fetal death in singleton, twin, and triplet gestations: implications for practice. Obstet Gynecol 2003;102(4):685-92.

Kaminski M, Blondel B, Saurel-Cubizolles M-J (2000): La santé périnatale. In: INSERM LD, editor. Les inégalités sociales. Paris, 2000:173-192.

Kramer MS, Demissie K, Yang H, Platt RW, Sauve R, Liston R (2000): The contribution of mild and moderate preterm birth to infant mortality. Fetal and Infant Health Study Group of the Canadian Perinatal Surveillance System. Jama 2000;284(7):843-9.

Jackson RA, Gibson KA, Wu YW, Croughan MS (2004): Perinatal outcomes in singletons following in vitro fertilization: a meta-analysis. Obstet Gynecol 2004;103(3):551-63.

 

Kramer MS, Demissie K, Yang H, Platt RW, Sauve R, Liston R (2000a): The contribution of mild and moderate preterm birth to infant mortality. Fetal and Infant Health Study Group of the Canadian Perinatal Surveillance System. Jama 284(7):843-9.

 

Kramer MS, Seguin L, Lydon J, Goulet L (2000b): Socio-economic disparities in pregnancy outcome: why do the poor fare so poorly? Paediatr Perinat Epidemiol 14(3):194-210.

 

Kramer MS, Platt RW, Yang H, Haglund B, Cnattingius S, Bergsjo P (2002): Registration artifacts in international comparisons of infant mortality. Paediatr Perinat Epidemiol 16(1):16-22.

 

Langer B, Caneva MP, Schlaeder G (1997) : La surveillance prenatale de routine en Europe: comparaison de l'experience de 9 services de gyneco-obstetrique situes dans 8 pays differents. J Gynecol Obstet Biol Reprod (Paris) 1997;26(4):358-66.

 

Langhoff-Roos J, Kesmodel U, Jacobsson B, Rasmussen S, Vogel I (2006): Spontaneous preterm delivery in primiparous women at low risk in Denmark: population based study. Bmj 2006;332(7547):937-9.

 

Lin HC, Xirasagar S (2004): Institutional factors in cesarean delivery rates: policy and research implications. Obstet Gynecol 2004;103(1):128-36.

Luke B, Brown MB (2007a). Elevated risks of pregnancy complications and adverse outcomes with increasing maternal age. Hum Reprod 2007;22(5):1264-72.

Luke B, Brown MB (2007b). Contemporary risks of maternal morbidity and adverse outcomes with increasing maternal age and plurality. Fertil Steril 2007;88(2):283-93.

Magee BD (2004): Role of multiple births in very low birth weight and infant mortality. J Reprod Med 2004;49(10):812-6.

Maher J, Macfarlane A (2004): Inequalities in infant mortality: trends by social class, registration status, mother's age and birthweight, England and Wales, 1976-2000. Health Stat Q 2004(24):14-22.

Olausson PM, Cnattingius S, Goldenberg RL (1997): Determinants of poor pregnancy outcomes among teenagers in Sweden. Obstet Gynecol 1997;89(3):451-7.

Platt MJ, Cans C, Johnson A, Surman G, Topp M, Torrioli MG, et al (2007): Trends in cerebral palsy among infants of very low birthweight (<1500 g) or born prematurely (<32 weeks) in 16 European centres: a database study. Lancet 2007;369(9555):43-50.

Prysak M, Lorenz RP, Kisly A (1995): Pregnancy outcome in nulliparous women 35 years and older. Obstet Gynecol 1995;85(1):65-70.

Raymond EG, Cnattingius S, Kiely JL (1994): Effects of maternal age, parity, and smoking on the risk of stillbirth. Br J Obstet Gynaecol 1994;101(4):301-6.

Reddy UM, Ko CW, Willinger M (2006): Maternal age and the risk of stillbirth throughout pregnancy in the United States. Am J Obstet Gynecol 2006;195(3):764-70.

SCPE (Surveillance of Cerebral Palsy in Europe) (2000): Surveillance of cerebral palsy in Europe: a collaboration of cerebral palsy surveys and registers. Dev Med Child Neurol 2000;42(12):816-24.

 

Stephenson PA, Bakoula C, Hemminki E, Knudsen L, Levasseur M, Schenker J, et al (1993):

Patterns of use of obstetrical interventions in 12 countries. Paediatr Perinat Epidemiol 1993;7(1):45-54.

Stillman RJ, Rosenberg MJ, Sachs BP (1986): Smoking and reproduction. Fertil Steril 1986;46(4):545-66.

US Center for Disease Control (1992): Proceedings of the International Collaborative Effort on Perinatal and Infant Mortality. Papers presented at the Second International Symposium on Perinatal and Infant Mortality. Bethesday, Maryland: US Center for Disease Control; National Center for Health Statistics, 1992.

 

Van Reempts P, Gortner L, Milligan D, Cuttini M, Petrou S, Agostino R, et al (2007): Characteristics of neonatal units that care for very preterm infants in Europe: results from the MOSAIC study. Pediatrics 2007;120(4):e815-25.

 

van Roosmalen J, Schuitemaker NW, Brand R, van Dongen PW, Bennebroek Gravenhorst J (2002): Substandard care in immigrant versus indigenous maternal deaths in The Netherlands. Bjog 2002;109(2):212-3.

 

Wood NS, Marlow N, Costeloe K, Gibson AT, Wilkinson AR (2000): Neurologic and developmental disability after extremely preterm birth. EPICure Study Group. N Engl J Med 2000;343(6):378-84.

 

Zeitlin J, Blondel B, Alexander S, Breart G (2007): Variation in rates of postterm birth in Europe: reality or artefact? Bjog 2007;114(9):1097-103.

 

Zeitlin J, Wildman K, Breart G, Alexander S, Barros H, Blondel B, et al (2003): Selecting an indicator set for monitoring and evaluating perinatal health in Europe: criteria, methods and results from the PERISTAT project. Eur J Obstet Gynecol Reprod Biol 2003;111 Suppl 1:S5-S14.

 

9.1.1.5. Acronyms

 

APGAR

Appearance, Pulse, Grimace, Activity, Respiration

CP

Cerebral Palsy

HIE

Hypoxic Ischemic Encephalopathy

SCPE

Surveillance of Cerebral Palsy in Europe

VLBW

Very Low birth weight

 





1 The data from Cyprus is based on one year data (2005) and 25 deaths only.