Socioeconomic differences in perinatal health outcomes: perinatal health surveillance through a health-equity prism

Abstract Background Socioeconomic status (SES) is strongly associated with perinatal health outcomes, perpetuating intergenerational health inequalities. Our aim was to assess the utility of population data in Europe to monitor social inequalities in key perinatal health indicators. Methods Using the PHIRI federated analysis protocol to aggregate routine birth data from across Europe, we collected data on selected perinatal health indicators by SES from 2015 to 2020. Mothers’ education level (primary/lower secondary; upper secondary; postsecondary) was the preferred SES indicator; if unavailable, parents’ occupation or area-based deprivation scores were provided. The International Standard Classification of Occupations was used to group parents’ occupations into 4 categories, while area-based deprivation scores were measured in quintiles. For each country, we calculated risk ratios (RR) for preterm birth, stillbirth, neonatal death and caesarean delivery (CD) comparing the most with the least disadvantaged group Results 17 countries provided data on maternal education, 5 on area-based deprivation, 1 on parents’ occupation and 2 could not provide data. For preterm birth, stillbirth and neonatal death, lower SES was associated with worse outcomes with most RR between lowest and highest groups in the range of 1.5 to 3.0. In contrast, in some countries, such as Croatia, Latvia, Lithuania and Spain, CD rates were higher for socially advantaged groups whereas the gradient was reversed in others (Denmark, Luxembourg, the Netherlands and Italy). Conclusions European countries can provide perinatal health indicators by SES, revealing marked socioeconomic inequalities in perinatal health. The differing SES gradient between countries for CD raise questions about care organization and clinical practice. Further exploration of the harmonization of differing SES measure across countries is required, while countries that do not monitor SES data should aim to improve existing systems.


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.
Abstract citation ID: ckac129.111Socioeconomic differences in perinatal health outcomes: perinatal health surveillance through a health-equity prism

H Barros 10
Background: There is consensus that caesarean delivery (CD) is a lifesaving procedure for both mother and child in emergency situations and that CD without medical indication should be avoided.However, the rate that optimally balances the risks and benefits of CD is unresolved.In 1985, the World Health Organization concluded that the CD rate should be no more than 10-15%; subsequent reviews relating CD rates to infant mortality show no benefits at the country-level for rates higher than 15-19%.However, stillbirth has not been investigated because comparable international stillbirth data are not readily available.

Methods:
We conducted an ecological study in 25 European countries from 2015 to 2019 utilizing data from routine birth data sources aggregated using the Euro-Peristat PHIRI federated data analysis protocol.We assessed country-level associations between CD rates and perinatal outcomes (singleton preterm birth, stillbirth at 24 weeks' gestational age, neonatal death) for all years using Pearson correlations, adjusted for clustering of years within country.Correlations were also estimated between linear trends over time in the indicators.

Results:
The median [range] of CD rates was 23.1% [16.2 to 56.9] in 21 participating countries, while these were 6.9% [5.3 to 11.9] for preterm birth, 3.3 per 1000 total births [1.8 to 7.6] for stillbirth and 1.9 per 1000 live births [0.7 to 6.1] for neonatal mortality.The CD rate was not associated with the stillbirth rate (clusteradjusted rho: -.01, P = .94)or with the neonatal mortality rate (rho:.27,P = .27).However, there was a strong positive correlation with the preterm birth rate (rho:.81,P<.001).Results were similar in time trend analyses.Conclusions: Higher CD rates were not associated with lower stillbirth or neonatal mortality rates, but were strongly correlated with higher preterm birth rates.This study suggests no benefits and indicates potential harms for higher CD rates in Europe.

Objectives:
Recent crises in Ukraine, Afghanistan, Syria and other countries have, again, resulted in large populations of asylum seekers and other migrant groups arriving in Europe.However, European countries still grapple with questions about what level of health care should be offered to forcibly displaced people (emergency care, preventative care, multi-disease screening and catch-up vaccination?), and when and where in the migration trajectory provision should be made (should it be at borders, reception centres, once settled via the national health system, via specialist or routine services, or left to nongovernmental organisations?), and what their subsequent level of right to access the mainstream health-care system should be.Countries do not have a uniform approach to the provision of health care for these populations, with some countries more inclusive than others, and wide discrepancies between evidence and implementation in policy and practice.In this workshop we will discuss current approaches, implementation, research and policy gaps, and models of good practice from the clinic to the community to ensure both the immediate and long-term health needs of these diverse mobile populations are met.