In the Netherlands, the threshold for offering active treatment for spontaneous birth was lowered from 25
to 24
weeks' gestation in 2010. This study aimed to evaluate the impact of guideline ...implementation on survival and causes and timing of death in the years following implementation.
National cohort study, using data from the Netherlands Perinatal Registry.
The study population included all 3312 stillborn and live born infants with a gestational age (GA) between 24
and 26
weeks born between January 2011 and December 2017. Infants with the same GA born between January 2007 and December 2009 (N=1400) were used as the reference group.
Survival to discharge, as well as cause and timing of death.
After guideline implementation, there was a significant increase in neonatal intensive care unit (NICU) admission rate for live born infants born at 24 weeks' GA (27%-69%, p<0.001), resulting in increased survival to discharge in 24-week live born infants (13%-34%, p<0.001). Top three causes of in-hospital mortality were necrotising enterocolitis (28%), respiratory distress syndrome (19%) and intraventricular haemorrhage (17%). A significant decrease in cause of death either complicated or caused by respiratory insufficiency was seen over time (34% in 2011-2014 to 23% in 2015-2017, p=0.006).
Implementation of the 2010 guideline resulted as expected in increased NICU admissions rate and postnatal survival of infants born at 24 weeks' GA. In the years after implementation, a shift in cause of death was seen from respiratory insufficiency towards necrotising enterocolitis and sepsis.
Objective
Robson's Ten Group Classification System (TGCS) creates clinically relevant sub‐groups for monitoring caesarean birth rates. This study assesses whether this classification can be derived ...from routine data in Europe and uses it to analyse national caesarean rates.
Design
Observational study using routine data.
Setting
Twenty‐seven EU member states plus Iceland, Norway, Switzerland and the UK.
Population
All births at ≥22 weeks of gestational age in 2015.
Methods
National statistical offices and medical birth registers derived numbers of caesarean births in TGCS groups.
Main outcome measures
Overall caesarean rate, prevalence and caesarean rates in each of the TGCS groups.
Results
Of 31 countries, 18 were able to provide data on the TGCS groups, with UK data available only from Northern Ireland. Caesarean birth rates ranged from 16.1 to 56.9%. Countries providing TGCS data had lower caesarean rates than countries without data (25.8% versus 32.9%, P = 0.04). Countries with higher caesarean rates tended to have higher rates in all TGCS groups. Substantial heterogeneity was observed, however, especially for groups 5 (previous caesarean section), 6, 7 (nulliparous/multiparous breech) and 10 (singleton cephalic preterm). The differences in percentages of abnormal lies, group 9, illustrate potential misclassification arising from unstandardised definitions.
Conclusions
Although further validation of data quality is needed, using TGCS in Europe provides valuable comparator and baseline data for benchmarking and surveillance. Higher caesarean rates in countries unable to construct the TGCS suggest that effective routine information systems may be an indicator of a country's investment in implementing evidence‐based caesarean policies.
Tweetable
Many European countries can provide Robson's Ten‐Group Classification to improve caesarean rate comparisons.
Tweetable
Many European countries can provide Robson's Ten‐Group Classification to improve caesarean rate comparisons.
•Maternal Tdap vaccination between 20 and 24 weeks of gestation is well-tolerated.•67.5 % of pregnant women experienced ≥ 1 local reaction and 63.6 % ≥1 systemic AE.•0.6 % of pregnant women reported ...mild-to-moderate fever (≥38.0˚C) post-vaccination.•Tdap vaccination between 20 and 24 vs 30-33w GA shows no increased reactogenicity.•Maternal Tdap vaccination yields no increased risks adverse pregnancy outcomes.
Maternal tetanus-diphtheria-and-acellular-pertussis (Tdap) vaccination is offered to all pregnant women during their second trimester in the Netherlands since December 2019. We assessed second trimester Tdap vaccination reactogenicity and compared with third trimester data from a similar study. For safety assessment, adverse pregnancy outcomes were compared with national data from 2018, before Tdap vaccine-introduction.
Pregnant women were included between August 2019-December 2021 and received Tdap vaccination between 20 and 24w gestational age (GA). Participants completed a questionnaire on solicited local reactions and systemic adverse events (AEs) within one week after vaccination. Results were compared with historical data on reactogenicity from women vaccinated between 30 and 33w GA (n = 58). Regarding safety-related outcomes, each participant was matched to four unvaccinated pregnant women from the Dutch Perinatal Registry, based on living area, parity and age.
Among 723 participants who completed the questionnaire, 488 (67.5 %) experienced ≥ 1 local reaction with pain at the injection site as most reported reaction (62.3 %), and 460 (63.6 %) experienced ≥ 1 systemic AE with stiffness in muscles/joints (38.9 %), fatigue (28.9 %), headache (14.5 %) and common cold-like symptoms (11.0 %) most frequently reported. 4 women (0.6 %) reported fever (≥38.0˚C). Symptoms were considered mild and transient within days. No difference in AEs were found between vaccination at 20-24w versus 30-33w GA. 723 participants were matched to 2,424 unvaccinated pregnant women with no increased rates of premature labor, small-for-gestational-age, or other adverse pregnancy outcomes.
Second trimester maternal Tdap vaccination appears safe and well-tolerated. Comparison between second versus third trimester vaccination yielded no reactogenicity concerns.
After lowering the Dutch threshold for active treatment from 25 to 24 completed weeks' gestation, survival to discharge increased by 10% in extremely preterm live born infants. Now that this ...guideline has been implemented, an accurate description of neurodevelopmental outcome at school age is needed.
Population-based cohort study.
All neonatal intensive care units in the Netherlands.
All infants born between 24
and 26
weeks' gestation who were 5.5 years' corrected age (CA) in 2018-2020 were included.
Main outcome measure was neurodevelopmental outcome at 5.5 years. Neurodevelopmental outcome was a composite outcome defined as none, mild or moderate-to-severe impairment (further defined as neurodevelopmental impairment (NDI)), using corrected cognitive score (Wechsler Preschool and Primary Scale of Intelligence Scale-III-NL), neurological examination and neurosensory function. Additionally, motor score (Movement Assessment Battery for Children-2-NL) was assessed. All assessments were done as part of the nationwide, standardised follow-up programme.
In the 3-year period, a total of 632 infants survived to 5.5 years' CA. Data were available for 484 infants (77%). At 5.5 years' CA, most cognitive and motor (sub)scales were significantly lower compared with the normative mean. Overall, 46% had no impairment, 36% had mild impairment and 18% had NDI. NDI-free survival was 30%, 49% and 67% in live born children at 24, 25 and 26 weeks' gestation, respectively (p<0.001).
After lowering the threshold for supporting active treatment from 25 to 24 completed weeks' gestation, a considerable proportion of the surviving extremely preterm children did not have any impairment at 5.5 years' CA.
Abstract Objective To compare stillbirth rates and risks for small for gestational age (SGA), large for gestational age (LGA) and appropriate for gestational age (AGA) pregnancies at 24–44 completed ...weeks of gestation using a birth‐based and fetuses‐at‐risk approachs. Design Population‐based, multi‐country study. Setting National data systems in 15 high‐ and middle‐income countries. Population Live births and stillbirths. Methods A total of 151 country‐years of data, including 126 543 070 births across 15 countries from 2000 to 2020, were compiled. Births were categorised into SGA, AGA and LGA using INTERGROWTH‐21st standards. Gestation‐specific stillbirth rates, with total births as the denominator, and gestation‐specific stillbirth risks, with fetuses still in utero as the denominator, were calculated from 24 to 44 weeks of gestation. Main Outcome Measures Gestation‐specific stillbirth rates and risks according to size at birth. Results The overall stillbirth rate was 4.22 per 1000 total births (95% CI 4.22–4.23) across all gestations. Applying the birth‐based approach, the stillbirth rates were highest at 24 weeks of gestation, with 621.6 per 1000 total births (95% CI 620.9–622.2) for SGA pregnancies, 298.4 per 1000 total births (95% CI 298.1–298.7) for AGA pregnancies and 338.5 per 1000 total births (95% CI 337.9–339.0) for LGA pregnancies. Applying the fetuses‐at‐risk approach, the gestation‐specific stillbirth risk was highest for SGA pregnancies (1.3–1.4 per 1000 fetuses at risk) prior to 29 weeks of gestation. The risk remained stable between 30 and 34 weeks of gestation, and then increased gradually from 35 weeks of gestation to the highest rate of 8.4 per 1000 fetuses at risk (95% CI 8.3–8.4) at ≥42 weeks of gestation. The stillbirth risk ratio (RR) was consistently high for SGA compared with AGA pregnancies, with the highest RR observed at ≥42 weeks of gestation (RR 9.2, 95% CI 15.2–13.2), and with the lowest RR observed at 24 weeks of gestation (RR 3.1, 95% CI 1.9–4.3). The stillbirth RR was also consistently high for SGA compared with AGA pregnancies across all countries, with national variability ranging from RR 0.70 (95% CI 0.43–0.97) in Mexico to RR 8.6 (95% CI 8.1–9.1) in Uruguay. No increased risk for LGA pregnancies was observed. Conclusions Small for gestational age (SGA) was strongly associated with stillbirth risk in this study based on high‐quality data from high‐ and middle‐income countries. The highest RRs were seen in preterm gestations, with two‐thirds of the stillbirths born as preterm births. To advance our understanding of stillbirth, further analyses should be conducted using high‐quality data sets from low‐income settings, particularly those with relatively high rates of SGA.
Abstract
Objective
To examine the contribution of preterm birth and size‐for‐gestational age in stillbirths using six ‘newborn types’.
Design
Population‐based multi‐country analyses.
Setting
Births ...collected through routine data systems in 13 countries.
Sample
125 419 255 total births from 22
+0
to 44
+6
weeks’ gestation identified from 2000 to 2020.
Methods
We included 635 107 stillbirths from 22
+0
weeks’ gestation from 13 countries. We classified all births, including stillbirths, into six ‘newborn types’ based on gestational age information (preterm, PT, <37
+0
weeks versus term, T, ≥37
+0
weeks) and size‐for‐gestational age defined as small (SGA, <10th centile), appropriate (AGA, 10th–90th centiles) or large (LGA, >90th centile) for gestational age, according to the international newborn size for gestational age and sex INTERGROWTH‐21st standards.
Main outcome measures
Distribution of stillbirths, stillbirth rates and rate ratios according to six newborn types.
Results
635 107 (0.5%) of the 125 419 255 total births resulted in stillbirth after 22
+0
weeks. Most stillbirths (74.3%) were preterm. Around 21.2% were SGA types (PT + SGA 16.2%, PT + AGA 48.3%, T + SGA 5.0%) and 14.1% were LGA types (PT + LGA 9.9%, T + LGA 4.2%). The median rate ratio (RR) for stillbirth was highest in PT + SGA babies (RR 81.1, interquartile range IQR, 68.8–118.8) followed by PT + AGA (RR 25.0, IQR, 20.0–34.3), PT + LGA (RR 25.9, IQR, 13.8–28.7) and T + SGA (RR 5.6, IQR, 5.1–6.0) compared with T + AGA. Stillbirth rate ratios were similar for T + LGA versus T + AGA (RR 0.7, IQR, 0.7–1.1). At the population level, 25% of stillbirths were attributable to small‐for‐gestational‐age.
Conclusions
In these high‐quality data from high/middle income countries, almost three‐quarters of stillbirths were born preterm and a fifth small‐for‐gestational age, with the highest stillbirth rates associated with the coexistence of preterm and SGA. Further analyses are needed to better understand patterns of gestation‐specific risk in these populations, as well as patterns in lower‐income contexts, especially those with higher rates of intrapartum stillbirth and SGA.
Abstract
Background
Stillbirth is a major public health problem, but measurement remains a challenge even in high-income countries. We compared routine stillbirth statistics in Europe reported by ...Eurostat with data from the Euro-Peristat research network.
Methods
We used data on stillbirths in 2015 from both sources for 31 European countries. Stillbirth rates per 1000 total births were analyzed by gestational age (GA) and birthweight groups. Information on termination of pregnancy at ≥22 weeks’ GA was analyzed separately.
Results
Routinely collected stillbirth rates were higher than those reported by the research network. For stillbirths with a birthweight ≥500 g, the difference between the mean rates of the countries for Eurostat and Euro-Peristat data was 22% 4.4/1000, versus 3.5/1000, mean difference 0.9 with 95% confidence interval (CI) 0.8–1.0. When using a birthweight threshold of 1000 g, this difference was smaller, 12% (2.9/1000, versus 2.5/1000, mean difference 0.4 with 95% CI 0.3–0.5), but substantial differences remained for individual countries. In Euro-Peristat, missing data on birthweight ranged from 0% to 29% (average 5.0%) and were higher than missing data for GA (0–23%, average 1.8%).
Conclusions
Routine stillbirth data for European countries in international databases are not comparable and should not be used for benchmarking or surveillance without careful verification with other sources. Recommendations for improvement include using a cut-off based on GA, excluding late terminations of pregnancy and linking multiple sources to improve the quality of national databases.
To compare changes in foetal, neonatal and perinatal mortality in the Netherlands in 2015, relative to 2004 and 2010, with changes in other European countries and regions.
Descriptive population-wide ...study.
Data from 32 European countries and regions within the Euro-Peristat registration area were analysed. These countries and regions were grouped into: the Netherlands, Scandinavia, Western Europe and Eastern Europe. International differences in registration and policies were taken into account by using rates from 28 weeks gestation for foetal mortality and for 24 weeks gestation and beyond for neonatal mortality. Ranking was based on individual countries and regions.
Foetal mortality decreased by 24% in the Netherlands, from 2.9 per 1,000 births in 2010 to 2.2 per 1,000 births in 2015; neonatal mortality decreased by 9%, from 2.2 to 2.0 per 1,000 live births. Perinatal mortality (the sum of foetal mortality and neonatal mortality) decreased by 18% from 5.1 to 4.2 per 1,000 births. The Netherlands moved from the 18th place in the European ranking in 2004 to the 10th place in 2015.
Foetal, neonatal and perinatal mortality in the Netherlands decreased in 2015 when compared with 2004 and 2010. The country's position in the European ranking also improved. Explanations for this decrease are related to changes in the areas of organisation of care, population and risk factors. When mortality rates in other European countries and regions - particularly Scandinavia - are considered there is room for further improvement.
PDF
