Achieving more with less: lessons from country-level analyses of caesarean delivery and perinatal outcomes in Europe

Abstract 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 (cluster-adjusted 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.


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.

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European Journal of Public Health, Volume 32 Supplement 3, 2022