Rachael Wood, Consultant in Public Health Medicine, NHS National Services Scotland, Information Services Division
The EuroPeristat Project
The EuroPeristat project produces comparative statistics on maternal and perinatal health in countries across Europe. To date, reports have been published for births in 2000, 2004, 2010, and 2015. The most recent report on 2015 births was published in late 2018. It provides data for all 28 current EU nations (including the UK) plus Iceland, Norway, and Switzerland. The four UK nations have distinct health data systems, so submit data for most indicators separately. This post considers the 2015 results for Scotland in light of those for the rest of the UK and for all participating European countries.
EuroPeristat recommends a suite of 10 core and 20 recommended indicators to provide a balanced view of maternal and perinatal health. The 2015 report provides data on all 10 core indicators but, due to funding constraints, only two of the 20 recommended indicators. The indicators can broadly be grouped into those reflecting:
- Population characteristics,
- Obstetric interventions,
- and Maternal and perinatal outcomes
Population characteristics influencing maternal and perinatal health
Topics covered in the 2015 report include maternal age, parity, the multiple pregnancy rate, and maternal smoking and obesity. Data on wider socio-demographic characteristics of mothers (and fathers) was not included.
Not all countries were able to provide data on maternal smoking and obesity, however the data that are available suggest that rates are relatively high in Scotland. In Scotland, 16% of women delivering in 2015 reported that they were a current smoker at antenatal booking, compared to 14% in England and just 5% in Sweden.
Of the nations able to provide data, the constituent countries of the UK were very definitely top of the league table in terms of maternal overweight and obesity, with around half of women delivering in 2015 in Scotland (and elsewhere in the UK) having a BMI of 25 or over at antenatal booking. This compares to under 30% in Croatia and Austria.
Source: Euro-Peristat project https://www.europeristat.com/ Data shown for all countries that provided figures to Euro-Peristat. The % of women delivering in 2015 who had unknown/missing BMI data is shown in brackets after the country name for countries with ≥10% missing data
The 2015 report shows that Scotland has generally high obstetric intervention rates, with a relatively high proportion of deliveries being by the assisted vaginal route (forceps or Ventouse) and, in particular, by Caesarean section. In Scotland in 2015, 33% of all deliveries were by Caesarean. The proportion in the rest of the UK was lower, close to the European median of 27%. At the extremes, some nations had noticeably low section rates (16% in Finland and Iceland) whereas other had worryingly high rates (57% in Cyprus and 47% in Romania).
The reasons underlying Scotland’s high section rate are not clear and should be explored further. Preliminary data in the EuroPeristat report suggest that our section rate is relatively high across a number of important subgroups (nulliparous/parous women, women without/with a previous section, women with singleton/multiple pregnancies, cephalic/breech presentation) suggesting a generally low threshold for operative delivery rather than high rates in specific clinical scenarios only. EuroPeristat is currently looking to produce more detailed information by all Robson categories. The UK wide National Maternity and Perinatal Audit may also shed some light on variation within the UK.
Maternal and perinatal outcomes
The proportion of live, singleton babies that were born preterm (at less than 37 completed weeks gestation) in 2015 in countries contributing to EuroPeristat ranged from 4% to 9%, with Eastern and Southern Europe countries and the UK having the highest rates. The proportion was 7% in Scotland and 6% in the rest of the UK. National data shows that the prematurity rate among both singleton and multiple pregnancies is continuing to increase in Scotland. Further exploration of Scotland’s high prematurity rate, for example to understand whether this is driven by high obstetric intervention rates (leading to iatrogenic premature delivery) and/or spontaneous premature delivery, would be helpful.
Source: Euro-Peristat project https://www.europeristat.com/ Data shown for countries with ≥50,000 live births in 2015, and with gestation known for ≥95% of live births
In 2015, Scotland’s stillbirth and neonatal mortality rates were lower than those seen in England and Wales, and broadly in line with the European median. However, other countries, particularly the Nordic nations, achieve lower fetal and neonatal mortality rates than Scotland, suggesting that further improvement in our rates should be possible. Within the UK, Northern Ireland has a notably high neonatal mortality rate, at least partly due to lack of access to termination of pregnancy for fetal anomaly, including severe anomalies that are likely to be incompatible with survival. The pattern of stillbirth and neonatal mortality rates across the constituent nations of the UK reported by EuroPeristat is similar to those reported by the MBRRACE-UK programme of enhanced surveillance of perinatal mortality in the UK.
Strengths and limitations of the EuroPeristat data
The EuroPeristat 2015 report provides a helpful snapshot of broadly comparable, population based data on maternal and perinatal health from a wide range of European nations. Whilst reasonably comprehensive data was provided for all core indicators, data on the two recommended indicators that were included in the 2015 report (maternal smoking and obesity) was patchy, and many recommended indicators providing additional contextual information were not covered.
The nations included in EuroPeristat vary widely in terms of resident population and hence annual number of births and the associated stability/precision of the indicators presented. In addition, EuroPeristat does not provide easily accessible data on secular trends in participating nations. The 2015 report includes information on results previously published for 2010, however ‘trends’ based on two data points can be misleading, particularly for smaller nations. A clearer view of diverging trends would point towards international examples of countries having more or less success in establishing systems of policies and services that address challenging public health problems such as rising maternal obesity rates.
Responding to EuroPeristat
Those of us involved in EuroPeristat spend most of our time ensuring that the data and reports provided are accurate. However, the data are only the starting point. They should be used to inform specific actions in participating nations that are likely to secure the maximum (equitable) improvement in maternal and perinatal health.
The key messages that emerge from the report for Scotland that could be used to shape such action can be summarised as follows:
- Mothers in Scotland (and the rest of the UK) have relatively high smoking and, in particular, overweight and obesity rates compared to other European countries, suggesting considerable scope for public health action to improve pre-conception (and inter-pregnancy) health.
- Scotland has generally high obstetric intervention rates (compared to the rest of the UK and European nations more broadly), with a particularly high proportion of deliveries being by Caesarean section. Further work is required to understand the factors underlying this, and therefore how to reduce rates to levels that avoid unnecessary iatrogenic harm whilst still delivering timely interventions to women and babies when required.
- Scotland (and to a slightly lesser extent, the rest of the UK) has a relatively high prematurity rate. Comprehensive data are not included in the EuroPeristat report, however it is likely that this at least partially reflects our high socioeconomic inequalities, relatively poor maternal health and health related behaviours, and high obstetric intervention rates.
- Despite these challenges, fetal and neonatal mortality rates in Scotland are relatively low compared to those seen elsewhere in the UK, and broadly in line with the European median. This probably reflects equitable provision of generally high quality maternity and neonatal services. However, Scotland’s perinatal mortality rates remain substantially higher than those seen in other European countries, in particular in the Nordic nations, suggesting scope for further improvement. In addition, whilst avoiding early mortality is to be celebrated, it is very much a ‘tip of the iceberg’ outcome: reducing the less extreme/immediate risks posed by factors such as maternal obesity, possibly excessive use of operative deliveries, and premature delivery remain important public health goals.