A C TA Obstetricia et Gynecologica
AOGS G U E S T E D I T O R I A L
The reduction in fetal death rates; a result of improved identification of high-risk pregnancies? ANNE ESKILD & JOSTEIN GRYTTEN
DOI: 10.1111/aogs.12226
The decline in perinatal deaths has been significant in most European countries over the last 40 years (1). The magnitude of the decline is similar for early neonatal deaths as for stillbirths (2). In Norway, there has been an 80 percent decline in the fetal death rate in term pregnancies since 1967 (2). There is no longer an increased risk of fetal death in post-term pregnancies (3), except among women more than 35 years old. Also there is no longer an increased risk of fetal death in pregnancies with preeclampsia (4). Thousands of fetal deaths have been prevented. For Norway with 55–60 000 births per year, we have estimated that 16 000 fetal deaths have been prevented during the period 1967–2005 (5). More boys than girls have been prevented from being stillborn (5). How has such success been achieved? The answer is likely to be that the health care system is important; a health care system that provides timely interventions in high-risk pregnancies independent of the pregnant woman’s social and geographical background. For such achievement, diagnostic facilities to identify pregnancies with high risk of fetal death must be available to all pregnant women. In the Nordic countries nearly all deliveries take place at hospitals that are publically owned and financed. Also antenatal services are fully financed through taxes, and almost all pregnant women follow the antenatal program (6–8). High-risk pregnancies are referred to hospitals, and the hospitals have, during the last decades, been equipped with advanced technology for diagnosing fetal distress (9). Concomitant with the introduction of technology in antenatal and obstetric care the rates of intervention have increased. The relatively high cesarean section rate has been a concern for many obstetricians and the benefits have been questioned (10,11). However, along with an increase in cesarean delivery rate from 2 percent to 16 percent during forty years in Norway (www.mfr.no), an 80 percent decline in fetal death rate has been achieved (2). Besides the more widely used technology for diagnosing fetal distress, increasing maternal age and increasing proportions of women with prior cesarean delivery are
important determinants of the cesarean delivery rates (9,12). Obstetric interventions because of maternal emotional distress have become increasingly common in the last decade, but have probably little effect on the newborn’s health or on maternal mental health postpartum (13,14). Cesarean delivery is likely to be equally available to all women living in Norway (15). Forty years ago women with high education or a husband with high education had a greater chance of being delivered by cesarean section than those with low education. Nowadays there is no association of education with cesarean delivery (15). Also, the cesarean delivery rate among immigrant women gradually has changed, and the rate changes in accordance with their length of stay in Norway, from the rate in their home country to the mean rate in Norway (16). Consequently, the social disparity in fetal death has decreased. In Norway today there is no social disparity in fetal deaths in term pregnancies (17). This finding suggests that the large reduction in fetal deaths has been most beneficial for women with low socioeconomic status. Screening for maternal preeclampsia and diabetes in antenatal care, increased use of modern fetal diagnostic technology, timely induction of labour and interventions during labor may explain the decline in stillbirth rates. Hence, increased use of diagnostic technology and obstetric interventions may have been important in reducing social disparity in offspring mortality in term pregnancies. It is likely that diagnostic technology used in obstetric care, such as cardiotocography and fetal ultrasonographic examination, provide objective fetal diagnosis. Objective diagnosis is likely to reduce social disparity in treatment. However, the offspring of immigrant women in Norway still have increased perinatal mortality (18). The increased mortality in these women could be explained by inadequate use or access to health care in Norway. Despite the success story of antenatal and obstetric care, the organization and use of health care resources have been questioned in Norway (19). During the last few years, the number of recommended visits in the
ª 2013 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 92 (2013) 1123–1124
1123
Guest Editorial
Guest Editorial
public antenatal care program is reduced, the use of diagnostic technology during delivery is reduced in predefined low-risk pregnancies and the length of stay in hospital after delivery has been reduced. This may seem paradoxical since the proportion of high-risk pregnancies has increased due to increasing maternal age and an increasing number of migrant women. We must therefore hope that such changes in public health care recommendations will not affect fetal death rates. 1
Anne Eskild and Jostein Grytten1,2 Department of Obstetrics and Gynecology, Institute of Clinical Medicine, Akershus University Hospital, Lørenskog, Norway and 2 Institute of Community Dentistry, Faculty of Odontology, University of Oslo, Oslo, Norway (e-mail: [email protected]) 1
References 1. Lawn JE, Yakoob MY, Haws RA, Soomro T, Darmstadt GL, Bhutta ZA. 3.2 million stillbirths: epidemiology and overview of the evidence review. BMC Pregnancy Childbirth. 2009; 9 (Suppl 1): S2. 2. Sarfraz AA, Samuelsen SO, Eskild A. Changes in fetal death during 40 years -different trends for different gestational ages: a population-based study in Norway. BJOG. 2011;118:488–94. 3. Haavaldsen C, Sarfraz AA, Samuelsen SO, Eskild A. The impact of maternal age on fetal death: does length of gestation matter? Am J Obstet Gynecol. 2010; 203:554. e1–8. 4. Basso O, Rasmussen S, Weinberg CR, Wilcox AJ, Irgens LM, Skjaerven R. Trends in fetal and infant survival following preeclampsia. JAMA. 2006;296:1357–62. 5. Carlsen F, Grytten J, Eskild A. Changes in fetal and neonatal mortality during 40 years by offspring sex: a national registry-based study in Norway. BMC Pregnancy Childbirth. 2013;13:101. 6. Directorate for Health and Social Affairs. A National Clinical Guideline for Antenatal Care. Short version. IS-1339/E. Oslo: Directorate for Health and Social Affairs, 2005.
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7. Norwegian Directorate of Health. Safe deliveries. Suggestions for quality standards in Norwegian maternity wards (In Norwegian). Report IS-1803. Oslo: Norwegian Directorate of Health, 2010, pp. 44–45. 8. Ministry of Health. Reinbursement based on expenes in spesialized health care (in Norwegian). NOU 2003:1. Oslo: Ministry of Health, 2003. 9. Grytten J, Monkerud L, Sørensen R. Adoption of diagnostic technology and variation in caesarean section rates: a test of the practice style hypothesis in Norway. Health Serv Res. 2012;47:2169–89. 10. Belizan JM, Althabe F, Cafferata ML. Health consequences of the increasing Caesarean section rates. Epidemiology. 2007;18:485–6. 11. Ecker JL, Frigoletto FD. Cesarean delivery and the risk-benefit calculus. N Engl J Med. 2007;356:885–8. 12. Kol as T, Hofoss D, Daltveit AK, Nilsen ST, Henriksen T, H€ager R, et al. Indications for cesarean deliveries in Norway. Am J Obstet Gynecol. 2003;188:864–70. 13. Adams SS, Eberhard-Gran M, Hofoss D, Eskild A. Maternal emotional distress in pregnancy and delivery of a small-for-gestational age infant. Acta Obstet Gynecol Scand. 2011;90:1267–73. 14. Adams SS, Eberhard-Gran M, Sandvik AR, Eskild A. Mode of delivery and postpartum emotional distress: a cohort study of 55,814 women. BJOG. 2012;119:298–305. 15. Grytten J, Skau I, Sørensen R. Do expert patients get better treatment than others? Agency discrimination and statistical discrimination in obstetrics. J Health Econ. 2011;30:163–80. 16. Grytten J, Skau I, Sørensen R. Do mothers decide? The impact of preferences in health care. J Hum Resour. 2013;48:142–168. 17. Carlsen F, Grytten J, Eskild A. Maternal education and risk of offspring death; changing patterns from 16 weeks of gestation until one year after birth. Eur J Public Health. 2013; epub ahead of print. Available online at: http:// eurpub.oxfordjournals.org/. (accessed 20 June, 2013) 18. Naimy Z, Grytten J, Monkerud L, Eskild A. Perinatal mortality in non-western migrants in Norway as compared to their countries of birth and to Norwegian women. BMC Public Health. 2013;13:37. 19. Backe B. Overutilization of antenatal care in Norway. Scand J Public Health. 2001;29:129–32.
ª 2013 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 92 (2013) 1123–1124
AOGS G U E S T E D I T O R I A L
The reduction in fetal death rates; a result of improved identification of high-risk pregnancies? ANNE ESKILD & JOSTEIN GRYTTEN
DOI: 10.1111/aogs.12226
The decline in perinatal deaths has been significant in most European countries over the last 40 years (1). The magnitude of the decline is similar for early neonatal deaths as for stillbirths (2). In Norway, there has been an 80 percent decline in the fetal death rate in term pregnancies since 1967 (2). There is no longer an increased risk of fetal death in post-term pregnancies (3), except among women more than 35 years old. Also there is no longer an increased risk of fetal death in pregnancies with preeclampsia (4). Thousands of fetal deaths have been prevented. For Norway with 55–60 000 births per year, we have estimated that 16 000 fetal deaths have been prevented during the period 1967–2005 (5). More boys than girls have been prevented from being stillborn (5). How has such success been achieved? The answer is likely to be that the health care system is important; a health care system that provides timely interventions in high-risk pregnancies independent of the pregnant woman’s social and geographical background. For such achievement, diagnostic facilities to identify pregnancies with high risk of fetal death must be available to all pregnant women. In the Nordic countries nearly all deliveries take place at hospitals that are publically owned and financed. Also antenatal services are fully financed through taxes, and almost all pregnant women follow the antenatal program (6–8). High-risk pregnancies are referred to hospitals, and the hospitals have, during the last decades, been equipped with advanced technology for diagnosing fetal distress (9). Concomitant with the introduction of technology in antenatal and obstetric care the rates of intervention have increased. The relatively high cesarean section rate has been a concern for many obstetricians and the benefits have been questioned (10,11). However, along with an increase in cesarean delivery rate from 2 percent to 16 percent during forty years in Norway (www.mfr.no), an 80 percent decline in fetal death rate has been achieved (2). Besides the more widely used technology for diagnosing fetal distress, increasing maternal age and increasing proportions of women with prior cesarean delivery are
important determinants of the cesarean delivery rates (9,12). Obstetric interventions because of maternal emotional distress have become increasingly common in the last decade, but have probably little effect on the newborn’s health or on maternal mental health postpartum (13,14). Cesarean delivery is likely to be equally available to all women living in Norway (15). Forty years ago women with high education or a husband with high education had a greater chance of being delivered by cesarean section than those with low education. Nowadays there is no association of education with cesarean delivery (15). Also, the cesarean delivery rate among immigrant women gradually has changed, and the rate changes in accordance with their length of stay in Norway, from the rate in their home country to the mean rate in Norway (16). Consequently, the social disparity in fetal death has decreased. In Norway today there is no social disparity in fetal deaths in term pregnancies (17). This finding suggests that the large reduction in fetal deaths has been most beneficial for women with low socioeconomic status. Screening for maternal preeclampsia and diabetes in antenatal care, increased use of modern fetal diagnostic technology, timely induction of labour and interventions during labor may explain the decline in stillbirth rates. Hence, increased use of diagnostic technology and obstetric interventions may have been important in reducing social disparity in offspring mortality in term pregnancies. It is likely that diagnostic technology used in obstetric care, such as cardiotocography and fetal ultrasonographic examination, provide objective fetal diagnosis. Objective diagnosis is likely to reduce social disparity in treatment. However, the offspring of immigrant women in Norway still have increased perinatal mortality (18). The increased mortality in these women could be explained by inadequate use or access to health care in Norway. Despite the success story of antenatal and obstetric care, the organization and use of health care resources have been questioned in Norway (19). During the last few years, the number of recommended visits in the
ª 2013 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 92 (2013) 1123–1124
1123
Guest Editorial
Guest Editorial
public antenatal care program is reduced, the use of diagnostic technology during delivery is reduced in predefined low-risk pregnancies and the length of stay in hospital after delivery has been reduced. This may seem paradoxical since the proportion of high-risk pregnancies has increased due to increasing maternal age and an increasing number of migrant women. We must therefore hope that such changes in public health care recommendations will not affect fetal death rates. 1
Anne Eskild and Jostein Grytten1,2 Department of Obstetrics and Gynecology, Institute of Clinical Medicine, Akershus University Hospital, Lørenskog, Norway and 2 Institute of Community Dentistry, Faculty of Odontology, University of Oslo, Oslo, Norway (e-mail: [email protected]) 1
References 1. Lawn JE, Yakoob MY, Haws RA, Soomro T, Darmstadt GL, Bhutta ZA. 3.2 million stillbirths: epidemiology and overview of the evidence review. BMC Pregnancy Childbirth. 2009; 9 (Suppl 1): S2. 2. Sarfraz AA, Samuelsen SO, Eskild A. Changes in fetal death during 40 years -different trends for different gestational ages: a population-based study in Norway. BJOG. 2011;118:488–94. 3. Haavaldsen C, Sarfraz AA, Samuelsen SO, Eskild A. The impact of maternal age on fetal death: does length of gestation matter? Am J Obstet Gynecol. 2010; 203:554. e1–8. 4. Basso O, Rasmussen S, Weinberg CR, Wilcox AJ, Irgens LM, Skjaerven R. Trends in fetal and infant survival following preeclampsia. JAMA. 2006;296:1357–62. 5. Carlsen F, Grytten J, Eskild A. Changes in fetal and neonatal mortality during 40 years by offspring sex: a national registry-based study in Norway. BMC Pregnancy Childbirth. 2013;13:101. 6. Directorate for Health and Social Affairs. A National Clinical Guideline for Antenatal Care. Short version. IS-1339/E. Oslo: Directorate for Health and Social Affairs, 2005.
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7. Norwegian Directorate of Health. Safe deliveries. Suggestions for quality standards in Norwegian maternity wards (In Norwegian). Report IS-1803. Oslo: Norwegian Directorate of Health, 2010, pp. 44–45. 8. Ministry of Health. Reinbursement based on expenes in spesialized health care (in Norwegian). NOU 2003:1. Oslo: Ministry of Health, 2003. 9. Grytten J, Monkerud L, Sørensen R. Adoption of diagnostic technology and variation in caesarean section rates: a test of the practice style hypothesis in Norway. Health Serv Res. 2012;47:2169–89. 10. Belizan JM, Althabe F, Cafferata ML. Health consequences of the increasing Caesarean section rates. Epidemiology. 2007;18:485–6. 11. Ecker JL, Frigoletto FD. Cesarean delivery and the risk-benefit calculus. N Engl J Med. 2007;356:885–8. 12. Kol as T, Hofoss D, Daltveit AK, Nilsen ST, Henriksen T, H€ager R, et al. Indications for cesarean deliveries in Norway. Am J Obstet Gynecol. 2003;188:864–70. 13. Adams SS, Eberhard-Gran M, Hofoss D, Eskild A. Maternal emotional distress in pregnancy and delivery of a small-for-gestational age infant. Acta Obstet Gynecol Scand. 2011;90:1267–73. 14. Adams SS, Eberhard-Gran M, Sandvik AR, Eskild A. Mode of delivery and postpartum emotional distress: a cohort study of 55,814 women. BJOG. 2012;119:298–305. 15. Grytten J, Skau I, Sørensen R. Do expert patients get better treatment than others? Agency discrimination and statistical discrimination in obstetrics. J Health Econ. 2011;30:163–80. 16. Grytten J, Skau I, Sørensen R. Do mothers decide? The impact of preferences in health care. J Hum Resour. 2013;48:142–168. 17. Carlsen F, Grytten J, Eskild A. Maternal education and risk of offspring death; changing patterns from 16 weeks of gestation until one year after birth. Eur J Public Health. 2013; epub ahead of print. Available online at: http:// eurpub.oxfordjournals.org/. (accessed 20 June, 2013) 18. Naimy Z, Grytten J, Monkerud L, Eskild A. Perinatal mortality in non-western migrants in Norway as compared to their countries of birth and to Norwegian women. BMC Public Health. 2013;13:37. 19. Backe B. Overutilization of antenatal care in Norway. Scand J Public Health. 2001;29:129–32.
ª 2013 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 92 (2013) 1123–1124
