2.N. Workshop: Improving perinatal health and reducing inequality: the value of European population comparisons

Abstract   In Europe, maternal and child mortality and morbidity during pregnancy and childbirth have declined markedly since the turn of the 20th century, but recent data suggest this trend may be slowing or reversing. Improvements in perinatal health were due primarily to increases in overall standards of living and clinical advances in obstetrics and neonatology which successfully increased maternal and newborn survival when pregnancy complications arose. However, fewer gains have been made in prevention and, in many countries, preterm birth and low birthweight rates have increased. To further improve perinatal health, a population-level approach focusing on prevention and appropriate use of clinical interventions is required. Prevention strategies include reducing risk factors (e.g., smoking and obesity) and ensuring universal access to high-quality health care due to the key roles played by early antenatal care, regular antenatal appointments and referral pathways in the timely identification and management of pregnancy complications. A population approach is particularly essential because both the burden of disease and the dangers of poor care organization fall disproportionately on socially disadvantaged women and babies, contributing to lifelong health inequalities. A final challenge is to avoid over-medicalising pregnancy and childbirth for the large majority of women with uncomplicated pregnancies. Medical technology has contributed greatly to the decline in maternal and infant mortality and morbidity, but clinical intervention can carry risks and must be used appropriately to optimise health outcomes. Despite commonalties such as universal access to health care and access to scientific knowledge, perinatal health outcomes and approaches to maternity care differ greatly between European countries. In this context, comparisons between different European models can be powerful tools for identifying population risk factors, assessing care practices, setting targets for population policies and for understanding their strengths and weaknesses to provide insight into the efficacy of health and medical policies. Currently, European comparisons are limited by the availability, timeliness and quality of population data on maternal and newborn health. This workshop reports on a new protocol implemented by the Euro-Peristat network to provide comparable perinatal indicators from countries across Europe. Based on select core indicators collected using a common protocol, we provide a proof of concept study for a future health information system and report up-to-date data on perinatal outcomes. The four presentations in this workshop present this protocol, describe most recent trends and disparities between countries, explore social inequalities in perinatal outcomes across Europe and raise questions about approaches which can achieve low mortality and morbidity while keeping intervention rates low. Key messages • A federated analytical approach is an efficient and feasible way to collect timely, high-quality and comparable population data on perinatal health in Europe. • Marked disparities in perinatal health remain between and within European countries. Our results demonstrate a need for targeted policies in many countries and offer data to inform these initiatives.


Introduction:
The Bangladeshi community living in the East London borough of Tower Hamlets is one of the UK's most socioeconomically deprived communities. Despite being a highly disadvantaged ethnic group with suboptimal health, the data suggests the uptake of several childhood vaccinations including the MMR vaccine is notably higher amongst this group, relative to other ethnic groups in Tower Hamlets.

Methods:
This study employs a qualitative research design. One-to-one, semi-structured interviews will be conducted with Bangladeshi parents, alongside relevant healthcare and public health professionals involved in vaccination delivery in Tower Hamlets to understand the barriers and enablers to childhood vaccinations. Interviews will be conducted in English by the researcher or in Bengali/Sylheti using an interpreter. Interviews will be audiorecorded, transcribed, translated and analysed using a thematic analysis. The socioecological model will be utilised as a theoretical framework to guide the data collection and analysis. Results and discussion: The preliminary results indicate parental trust in the safety of vaccinations, perceived health importance of childhood vaccinations, ease in accessibility and positive attitudes towards vaccinations within the community are notable enablers. Regarding barriers, parents have expressed reluctance on religious grounds towards childhood vaccinations which contain animal derivatives. The data also suggests differences exist between immigrant and non-immigrant parents in the decision-making process to undertake the vaccinations, with non-immigrant parents demonstrating a higher level of agency in their decision-making.

Conclusions:
The study provides valuable insight into the barriers and enablers for childhood vaccinations amongst the Bangladeshi community in Tower Hamlets. This data may inform tailored initiatives to improve childhood vaccination uptake amongst other underserved communities with suboptimal uptake.
In Europe, maternal and child mortality and morbidity during pregnancy and childbirth have declined markedly since the turn of the 20th century, but recent data suggest this trend may be slowing or reversing. Improvements in perinatal health were due primarily to increases in overall standards of living and clinical advances in obstetrics and neonatology which successfully increased maternal and newborn survival when pregnancy complications arose. However, fewer gains have been made in prevention and, in many countries, preterm birth and low birthweight rates have increased. To further improve perinatal health, a population-level approach focusing on prevention and appropriate use of clinical interventions is required. Prevention strategies include reducing risk factors (e.g., smoking and obesity) and ensuring universal access to highquality health care due to the key roles played by early antenatal care, regular antenatal appointments and referral pathways in the timely identification and management of pregnancy complications. A population approach is particularly essential because both the burden of disease and the dangers of poor care organization fall disproportionately on socially disadvantaged women and babies, contributing to lifelong health inequalities. A final challenge is to avoid overmedicalising pregnancy and childbirth for the large majority of women with uncomplicated pregnancies. Medical technology has contributed greatly to the decline in maternal and infant mortality and morbidity, but clinical intervention can carry risks and must be used appropriately to optimise health outcomes. Despite commonalties such as universal access to health care and access to scientific knowledge, perinatal health outcomes and approaches to maternity care differ greatly between European countries. In this context, comparisons between different European models can be powerful tools for identifying population risk factors, assessing care practices, setting targets for population policies and for understanding their strengths and weaknesses to provide insight into the efficacy of health and medical policies. Currently, European comparisons are limited by the availability, timeliness and quality of population data on maternal and newborn health. This workshop reports on a new protocol implemented by the Euro-Peristat network to provide comparable perinatal indicators from countries across Europe. Based on select core indicators collected using a common protocol, we provide a proof of concept study for a future health information system and report up-to-date data on perinatal outcomes. The four presentations in this workshop present this protocol, describe most recent trends and disparities between countries, explore social inequalities in perinatal outcomes across Europe and raise questions about approaches which can achieve low mortality and morbidity while keeping intervention rates low.

Key messages:
A federated analytical approach is an efficient and feasible way to collect timely, high-quality and comparable population data on perinatal health in Europe. Marked disparities in perinatal health remain between and within European countries. Our results demonstrate a need

Background:
International comparisons of population indicators of maternal and newborn health are valuable for guiding health policy and practice. The Covid-19 pandemic revealed the difficulties of compiling comparable, timely data in Europe. As part of the PHIRI (Population Health Information Research Infrastructure) project, we developed a protocol to facilitate the exchange and analysis of population birth data in Europe.

Methods:
The Euro-Peristat network, which includes experts from 31 European countries, developed a common data model and R scripts to facilitate rapid exchange of anonymised aggregate tables (https://zenodo.org/record/5148032#.YmlUttpBxPY). These tables were used to compile comparable perinatal health indicators from routine population-based sources for the years 2015 to 2020. We assessed the feasibility of this approach and the availability, quality and comparability of the data.

Results:
Building on previous Euro-Peristat recommendations and a structured consensus process, the network defined a common data model including 22 variables for the testing phase. 17 additional variables were considered important and feasible for a second phase. 25 countries created patient-level data files. Most countries had 20 or more of the data items, whereas 1 had 18, 3 had 16 and 2 had 15 variables. Limiting factors included not having all data in a single database, most often the case for neonatal and infant mortality or vital statistics versus healthcare data, and the diversity or absence of data on socioeconomic status. Setting up the model was time consuming, but once established, running the R scripts was easy and quick (<15 min). The protocol requires the active participation of each country to ensure it is correctly applied.

Conclusions:
We illustrated the feasibility of using a common data model with open source scripts to facilitate rapid production of data and analysis on key perinatal health indicators in European countries

Background:
The Euro-Peristat network documented disparities in perinatal outcomes between countries in Europe in its reports published every 5 years, but trend analyses were limited because data were not collected annually.

Methods:
Using the Euro-Peristat PHIRI protocol, we estimated rates and assessed trends between 2015 and 2019 for preterm birth, stillbirth, neonatal mortality and caesarean delivery. Countryspecific relative risks (RR) for year, modelled as a continuous variable, were estimated and random effects meta-analysis used to generate pooled RRs. Heterogeneity was measured with the I2 statistic (percentage of variability in estimates due to heterogeneity rather than sampling error).

Results:
Stillbirth rates 24 weeks of gestational age (GA) varied in 2019 from <2.5 per 1000 births in Denmark, Estonia, Finland and Slovenia to over 4 per 1000 in Belgium, Cyprus, UK Wales and Lithuania. Preterm birth rates ranged from <6% in Lithuania, Finland, Latvia, Estonia and Denmark to 8% or more in Portugal, Belgium, UK Scotland and Cyprus. Fewer than 20% of births were by caesarean in Norway, the Netherlands, Finland, Estonia in comparison to one-third in Cyprus, Ireland, Italy, UK Scotland. Trends over time differed between countries and were not related to the level of the indicator: the pooled RR by year for preterm birth was 0.99 [0.99; 1.00] with five countries having significant decreases and three countries having increases. Caesarean section rates were stable overall (RR: 1.00 [0.99; 1.01]RR:1.00, 95% CI: 0.99-1.01), but with high heterogeneity (I2 = 99%); in six countries rates increased significantly, whereas in nine rates decreased between 2015 and 2019.

Conclusions:
European countries have varying rates and trends of the principal perinatal health indicators. Investigation of policies in high-performing countries could provide guidance for improvement elsewhere.