AN EXPERT VIEW ON PERINATAL INDICATORS

1. AN EXPERT VIEW ON PERINATAL INDICATORS Class 18 – 2010/11 Introdução à Medicina II

2. Summary • Background • Motivations • Aims • Methodology • Results • Discussion • Conclusion • References • Acknowledgments

3. Background Quality in health: • a multidimensional and subjective concept [1]; Clinical indicators: • measure the quality of care; • selected parameters, which are able to monitor health care in regard to particular features and (adverse) events (evaluated for their feasibility, reliability and validity)[2] Perinatal period: • from the 24th week of gestation to the end of the first week of life[3]; Motivations Aims Methodology Results Discussion Conclusion Perinatal indicators References Acknowledgements [1] Reinhardt U. Qualityinconsumer-drivenhealthsystems. InternationalJournal for HealthCare. 1998;10(5):385-94. [2]Schrapp M. Conceptofindicators: central elementofqualitymanagement. MedKlin (Munich). 2001;96(10):642-7. 5.Troszyński M. Canimplementationofintensifiedperinatalsurveybeeffectiveinimprovingthequalityofperinatalcare? MedWiekuRozwoj. 2010;14(2):138-49. [3] World Health Organization. Definitions and Indicators in Family Planning – Maternal & Child Health and Reproductive Health. 2010.

4. Background Motivations Aims Methodology Results Discussion Conclusion References Acknowledgements [4]Zeithlin; J, Mohangoo A. EuropeanPerinatalHealthReport. [internet]; 2004. Availablefrom: http://www.europeristat.com/publications/european-perinatal-health-report.shtml

5. Background Motivations Aims Methodology Results Discussion Conclusion References Acknowledgements

6. Routine reporting on a wide range of perinatal health indicators is possible in Europe Background Motivations However... Aims Methodology Results Discussion Conclusion References Acknowledgements

7. Research questionandaims Which are themostrelevantperinatalindicatorsinthespecialists perspective?

8. Background • Study which indicators are commonly used in Europe, comparing national and international data; • Investigate, according to obstetricians and neonatal specialists, which are the most relevant and should be used from now on; Motivations Aims Methodology Results Discussion Studying the relevance of Perinatal Indicators allows the development of a standardised list with the prospect of uniforming new born child´s care. Conclusion References Acknowledgements

9. Questionnaire creation Background Motivations Aims Methodology Results Discussion Conclusion References Acknowledgements

10. Calendar Background Intermediatepresentation Motivations Aims Methodology Thequestionnairewasresent Project submission to moodle Results Thequestionnairewassent Discussion Conclusion References Thequestionnairewasresent Acknowledgements Resultsanalysis Final presentation

11. journal selection criteria Background Motivations Aims Methodology Results Discussion Conclusion References Acknowledgements Final Journal Selection: n = 19

12. Background Motivations Aims Methodology Results Discussion Conclusion References Acknowledgements

13. Article selection Background • Database: MedLine via PubMed or ISI Web of Knowledge; Motivations Aims Methodology Results Discussion Conclusion References Acknowledgements

14. Data extraction Background • Search for e-mail contacts in included articles • Extract the 1st contact available Motivations Aims Methodology Results Discussion Conclusion References Acknowledgements Total number of contacts = 860

15. Data management Background • Send an e-mail for each contact with: • an introductory letter; • a link, available in Medquest, for the questionnaire Motivations Aims Methodology Results Discussion Conclusion Author’s contact References Acknowledgements

16. Statisticalanalysis Background • Data (from the questionnaire) was processed using Statistical Package for Social Sciences (SPSS): • Analysis of the frequency of each answer; • Comparison of the answers according to: • Age (cutoff 46 years); • Gender; • HDI (Elevated vs High/Medium, according to 2007 Report from United Nations Development Programme (UNDP); • Geographic localization; • Head of department; • Specialist (Mother – OB & GYN; Child – Pediatrics, Neonatologist and Perinatologist) • Qui-Square Test (p value <0,05 was considered statistically significative, only these will be presented) to compare the answers; • Construction of explanatory graphics with the aim of emphasizing the main indicator within each group; • Comparison with Europeristat data; • Comparison with database introduction systems in different countries. Motivations Aims Methodology Results Discussion Conclusion References Acknowledgements The data analysis was done with the 52 responses we got out of 860 questionaries that were sent LOW RESPONSE RATE (6,04%)

17. ENQUIRED DATA ANALYSIS Background Motivations Aims Methodology Results Table 1: Frequency and percentage of the enquired by gender. Discussion Conclusion References Acknowledgements Table 2: Summary of the enquired age (N valid=51; N missing=1). Table 3: Frequency and percentage of the enquired by speciality.

18. Background Motivations Aims Methodology Results Discussion Conclusion References Acknowledgements Table 4: Frequency and percentage of work country of the enquired.

19. Answeranalysis Background Motivations Aims Methodology Results Discussion Conclusion References Acknowledgements Table 5: Frequency (%) of each answer to each indicator listed, in a decrescent order of the percentage number of high relevance.

20. Others (each one was suggested by a different person) • Epidural anesthesia use rate • Deliveries using oxytocin • Rate of preeclampsia • Perinatal mortality rate • Fetal heart rate distribution • Umbilical artery pulsatily index • Distribution of mothers by BMI • Maternal drug therapy prenatally Background Motivations Aims Methodology Results Discussion Conclusion References Acknowledgements the specialists were asked to select which indicator was more relevant, in each of the four groups. FURTHERMORE

21. Graph 1: Percentage of answers by indicator in group 1 - Population characteristics/Risk factors. Background Motivations Aims Methodology Results Discussion Conclusion References Acknowledgements

22. Graph 2: Percentage of answers by indicator in group 2 - Health Care Services. Background Motivations Aims Methodology Results Discussion Conclusion References Acknowledgements

23. Graph 3: Percentage of answers by indicator in group 3 - Maternal health. Background Motivations Aims Methodology Results Discussion Conclusion References Acknowledgements

24. Graph 4: Percentage of answers by indicator in group 4 - Fetal, neonatal and child health. Background Motivations Aims Methodology Results Discussion Conclusion References Acknowledgements

25. Statisticalanalysis Background Motivations Aims Methodology Results Discussion Conclusion References Acknowledgements

26. Statisticalanalysis Background Motivations Aims Methodology Results Discussion Conclusion References Acknowledgements

27. Group 1Population characteristics/ Risk factors Background Motivations Aims Methodology Results Discussion Conclusion References Acknowledgements [4] Zeithlin J, Mohangoo A. European Perinatal health report. [internet]; 2004. Available from: http://www.europeristat.com/publications/european-perinatal-health-report.shtml

28. Group 1Population caracteristics/ Risk factors Background The distribution of parity and distribution of mother’s education Motivations Aims Based on the European Perinatal Health Report, it was expected that the distribution of parity w7ould be among the most chosen indicators. As a core indicator, it allows the measurement of adverse outcomes. Methodology Results Discussion HOWEVER Conclusion The distribution of mother’s education was considered to be, by the enquired, more relevant than the distribution of parity. References WHY? Acknowledgements Because it is a easily measurable indicator

29. Group 2Health care services Background Percentageofallpregnanciesfollowingfertilitytreatments Motivations Aims Methodology • The great relevance attributed to this indicator was not expected • only thirteen European countries are able to provide data on this indicator [4]; • and • there is a low percentage of deliveries following fertility treatments [4]. • Fertility treatments are associated with higher risk of perinatal death, preterm delivery, low birth weight, and congenital anomalies.[5] Results BECAUSE Discussion Conclusion References DESPITE OF THIS Acknowledgements (4) Zeithlin J, Mohangoo A. European Perinatal health report. [internet]; 2004. Available from: http://www.europeristat.com/publications/european-perinatal-health-report.shtml [5] Ericson A, Kallen B. Congenital malformations in infants born after IVF: a population basedstudy. Hum Reprod. 2001; 16: 504-509.

30. Group 2Health care services Background Modeofdelivery Motivations Aims The great relevance attributed to this indicator was expected: the substantial rise in caesarean section rates in developed countries[6], associated with maternal morbidity[7] (caesarean section quadruples that risk); and caesarean section may increase the risk of repeated operative delivery in subsequent pregnancies.[7] Methodology Results DUE TO Discussion Conclusion References Acknowledgements BECAUSE [6] Betrán AP, Merialdi M, Lauer JA, Bing-Shun W, Thomas J, Van Look P, Wagner M. Rates ofcaesarean section: analysis of global, regional and national estimates. Paediatr PerinatalEpidemiol. 2007; 21: 98-113. [7) Wildman K, Blondel B, Nijhuis J, Defoort P, Bakoula C. European indicators of health care duringpregnancy, delivery and the postpartum period. Eur J Obstet Gynec Reprod Biol. 2003; 111:S53-S65.

31. Group 3Maternal health: morbidity and mortality associated with fetus Background Motivations Maternal mortality Aims • Is a measure traditionally used to evaluate the status of women’s health in pregnancy; • during the 20th century, maternal death rates have decreased dramatically. • Since this decrease has been observed without a similar reduction of puerperal morbidity [8] Methodology Results HOWEVER Discussion Conclusion References Severeobstetricmorbidity Acknowledgements and its relation to mortality may be more sensitive measures of pregnancy outcome than mortality alone [9]. [8] Loverro G, Pansini V, Greco P, Vimercati A, Parisi AM, Selvaggi L. Indications and outcome for intensive care unit admission during puerperium. [9] Arch Gynecol Obstet. 2001;265(4):195-8; Waterstone M, Bewley S, Wolfe C. Incidence and predictors of severe obstetric morbidity: casecontrolstudy. BMJ. 2001;322(7294):1089-93.

32. Group 4Fetal, neonatal and child health Background Motivations Aims Methodology Results Discussion Conclusion References Acknowledgements [4] Zeithlin J, Mohangoo A. European Perinatal health report. [internet]; 2004. Available from: http://www.europeristat.com/publications/european-perinatal-health-report.shtml

33. LIMITATIONS OF THE STUDY Background Motivations Aims Methodology Results Discussion Conclusion References Acknowledgements

34. conclusion Background The use of a system of indicators requires their organization in an international level so that the standardizationof health systems is possible. Motivations Aims Methodology Results PERINATAL INDICATORS Discussion Conclusion References Acknowledgements

35. References • Reinhardt U. Qualityinconsumer-drivenhealthsystems. InternationalJournal for HealthCare. 1998;10(5):385-94. • Schrapp M. Conceptofindicators: central elementofqualitymanagement. MedKlin (Munich). 2001;96(10):642-7. 5. Troszyński M. Canimplementationofintensifiedperinatalsurveybeeffectiveinimprovingthequalityofperinatalcare? MedWiekuRozwoj. 2010;14(2):138-49. • World Health Organization. Definitions and Indicators in Family Planning – Maternal & Child Health and Reproductive Health. 2010. • Zeithlin; J, Mohangoo A. EuropeanPerinatalHealthReport. [internet]; 2004. Availablefrom: http://www.europeristat.com/publications/european-perinatal-health-report.shtml • Ericson A, Kallen B. Congenitalmalformationsininfantsbornafter IVF: a populationbasedstudy. Hum Reprod. 2001; 16: 504-509. • Betrán AP, Merialdi M, Lauer JA, Bing-Shun W, Thomas J, VanLook P, Wagner M. Rates ofcaesareansection: analysisof global, regional andnationalestimates. PaediatrPerinatalEpidemiol. 2007; 21: 98-113. • Wildman K, Blondel B, Nijhuis J, Defoort P, Bakoula C. Europeanindicatorsofhealthcareduringpregnancy, deliveryandthepostpartumperiod. Eur J ObstetGynecReprodBiol. 2003; 111:S53-S65. • Arch Gynecol Obstet. 2001;265(4):195-8;Waterstone M, Bewley S, Wolfe C. Incidence and predictors of severe obstetric morbidity: casecontrolstudy. BMJ. 2001;322(7294):1089-93. • Loverro G, Pansini V, Greco P, Vimercati A, Parisi AM, Selvaggi L. Indications and outcome for intensive care unit admission during puerperium. [6] Arch Gynecol Obstet. 2001;265(4):195-8; Waterstone M, Bewley S, Wolfe C. Incidence and predictors of severe obstetric morbidity: casecontrolstudy. BMJ. 2001;322(7294):1089-93. 7 Background Motivations Aims Methodology Results Discussion Conclusion References Acknowledgements

36. Acknowledgments • Prof. Altamiro Pereira – for the constructive criticism • Prof. Alberto Freitas– for orientation during the whole project • Prof. Armando Teixeira Pinto - for the support with the statistical analysis • Prof. Ricardo Correia - for the orientation in an initial stage • Engº Jorge Gomes – for the help with MedQuest • Dr. Ricardo Santos - for his professional opinion • Profª Amélia Ferreira • Profª AméliaRicon • Drª Vera Paiva • Drª RosárioGorgal Background Motivations Aims Methodology Results Discussion Conclusion For the availability in the survey stage References Acknowledgments