Luule Sakkeus

Preterm birth time trends in Europe: a study of 19 countries

To investigate time trends in preterm birth in Europe by multiplicity, gestational age, and onset of delivery.

Perinatal health monitoring in Europe: results from the EURO-PERISTAT project.

Data about deliveries, births, mothers and newborn babies are collected extensively to monitor the health and care of mothers and babies during pregnancy, delivery and the post-partum period, but there is no common approach in Europe. We analysed the problems related to using the European data for international comparisons of perinatal health. We made an inventory of relevant data sources in 25 European Union (EU) member states and Norway, and collected perinatal data using a previously defined indicator list. The main sources were civil registration based on birth and death certificates, medical birth registers, hospital discharge systems, congenital anomaly registers, confidential enquiries and audits. A few countries provided data from routine perinatal surveys or from aggregated data collection systems. The main methodological problems were related to differences in registration criteria and definitions, coverage of data collection, problems in combining information from different sources, missing data and random variation for rare events. Collection of European perinatal health information is feasible, but the national health information systems need improvements to fill gaps. To improve international comparisons, stillbirth definitions should be standardised and a short list of causes of fetal and infant deaths should be developed.

The European data protection legislation and its consequences for public health monitoring: a plea for action

The Network of Competent Authorities (NCA) is one of the implementing structures of the Health Information and Knowledge Strand of the EU Public Health Programme 2003–08.1 The NCA became aware of problems in the field of European public health monitoring related to data protection legislation, and established in 2005, on a voluntary basis, a Work Group on Data Protection, consisting of six members of the NCA with a specific interest in the topic, and two staff members from the NCAs Scientific Assistance Office.2 The Work Group carried out an explorative survey among researchers in the European public health field, experts on health data protection and the national Data Protection Offices. This exercise resulted in a (non-exhaustive) overview of problems encountered in public health monitoring, and of major differences between national data protection systems regarding possibilities for using person identifiable health data for public health purposes. The major conclusions that can be drawn from this overview is that the legal possibilities for such usage differ to great extents between the Member States, and that this diversity can be traced back to the improper transposition of the EU Directive on Data Protection (Directive 95/46/EC).3 EU directives are addressed to the Member States, who are obliged to transpose the directive into national law. By now, all Member States indeed have transposed Directive 95/46/EC,4 though, as the results of the inventory of the Work Group showed, not in a harmonized way; for instance, Article 8 on the processing of sensitive data (e.g. health data), has not been fully transposed by all Member States. This …

Variations in very preterm birth rates in 30 high-income countries: are valid international comparisons possible using routine data?

Concerns about differences in registration practices across countries have limited the use of routine data for international very preterm birth (VPT) rate comparisons.

Family Formation in the Baltic Countries: A Transformation in the Legacy of state socialism

This article examines the transformation of nuptiality patterns in the Baltic countries since the late 1960s, in the context of long-term trends. The aim of the study is to compare the entry into first conjugal union in Estonia, Latvia and Lithuania, and analyze the position of the Baltic countries in a broader European perspective. The analyses employ microdata from national surveys conducted in the framework of the European Family and Fertility Surveys program. Our main results on the timing and mode of union formation show that in Estonia and Latvia the shift from direct marriage to cohabitation started well before the fall of the state socialist regime, and followed a trajectory close to Scandinavian countries. In Lithuania, on the other hand, the change in the pattern of union formation has been much slower. The article discusses the factors underlying the observed similarities and dissimilarities in union formation.

Self-reported activity limitations among the population aged 20–79 in Estonia: a cross-sectional study

BACKGROUND Along with population ageing, limitations in activities of daily living constitute a rising health-related burden in demographically advanced countries. The present study aims to assess the prevalence of self-reported activity limitations derived from chronic conditions and social variation of limitations in the subgroups of the population aged 20-79 years in Estonia. METHODS A cross-sectional study employs data from the second round of the Estonian Family and Fertility Survey, a national project in the framework of Gender and Generation Programme. The target population covers age groups of 20-79 years. A nationally representative probability sample was drawn from the 2000 population census. Face-to-face interviews (n = 7855) were conducted in 2004-05. RESULTS The estimated prevalence of activity limitations with chronic conditions is 18.5% (95% CI 17.6-19.4) and the prevalence of severe limitations is 10.6% (95% CI 9.9-11.3) among the population. The logistic regression model shows significant differences in activity limitations associated with age, educational attainment and marital status. CONCLUSIONS Judging from our results and the EU structural indicators on health, the prevalence of activity limitations derived from chronic conditions is comparatively high in Estonia. The measures to prevent activity limitations and disability should receive a higher priority in Estonia.

Linking databases on perinatal health: a review of the literature and current practices in Europe

Background: International comparisons of perinatal health indicators are complicated by the heterogeneity of data sources on pregnancy, maternal and neonatal outcomes. Record linkage can extend the range of data items available and thus can improve the validity and quality of routine data. We sought to assess the extent to which data are linked routinely for perinatal health research and reporting. Methods: We conducted a systematic review of the literature by searching PubMed for perinatal health studies from 2001 to 2011 based on linkage of routine data (data collected continuously at various time intervals). We also surveyed European health monitoring professionals about use of linkage for national perinatal health surveillance. Results: 516 studies fit our inclusion criteria. Denmark, Finland, Norway and Sweden, the US and the UK contributed 76% of the publications; a further 29 countries contributed at least one publication. Most studies linked vital statistics, hospital records, medical birth registries and cohort data. Other sources were specific registers for: cancer (70), congenital anomalies (56), ART (19), census (19), health professionals (37), insurance (22) prescription (31), and level of education (18). Eighteen of 29 countries (62%) reported linking data for routine perinatal health monitoring. Conclusion: Research using linkage is concentrated in a few countries and is not widely practiced in Europe. Broader adoption of data linkage could yield substantial gains for perinatal health research and surveillance.

Reporting of perinatal health indicators for international comparisons—enhancing the appearance of geographical plots

BACKGROUND Tabulating annual national health indicators sorted by outcome may be misleading for two reasons. The implied rank order is largely a result of heterogeneous population sizes. Distinctions between geographically adjacent regions are not visible. METHODS Regional data are plotted in a geographical map shaded in terms of percentiles of the indicator value. Degree of departure is determined relative to control limits of a corresponding funnel plot. Five methods for displaying outcome and degree of departure from a reference level are proposed for four indicators selected from the 2004 European Perinatal Health Report. RESULTS Spread of indicator values was generally largest for small population sizes, with results for large populations lying mostly close to respective European medians. The high neonatal mortality rate for Poland (4.9 per 1000); high low-birthweight rates for England and Wales (7.8%), Germany (7.3%) and Estonia (4.5%); and high caesarean section rates for Italy (37.8%), Poland (26.3%), Portugal (33.1%) and Germany (27.3%) were statistically significant exceptions to this pattern. Estonia also showed an extreme result for maternal mortality (29.6 per 100 000). CONCLUSION Extreme deviations from EU reference levels are either correlated with small population sizes or may be interpreted in terms of differing medical practices, as in the case of caesarean section rate. EURO-PERISTAT has now decided to use 5-year averages for maternal mortality to reduce the variance in outcome. Use of two colours in three intensities and solid fill versus crosshatching is best suited to display rate and significance of difference.

Quantifying the burden of stillbirths before 28 weeks of completed gestational age in high-income countries: a population-based study of 19 European countries

BACKGROUND International comparisons of stillbirth allow assessment of variations in clinical practice to reduce mortality. Currently, such comparisons include only stillbirths from 28 or more completed weeks of gestational age, which underestimates the true burden of stillbirth. With increased registration of early stillbirths in high-income countries, we assessed the reliability of including stillbirths before 28 completed weeks in such comparisons. METHODS In this population-based study, we used national cohort data from 19 European countries participating in the Euro-Peristat project on livebirths and stillbirths from 22 completed weeks of gestation in 2004, 2010, and 2015. We excluded countries without national data for stillbirths by gestational age in these periods, or where data available were not comparable between 2004 and 2015. We also excluded those countries with fewer than 10 000 births per year because the proportion of stillbirths at 22 weeks to less than 28 weeks of gestation is small. We calculated pooled stillbirth rates using a random-effects model and changes in rates between 2004 and 2015 using risk ratios (RR) by gestational age and country. FINDINGS Stillbirths at 22 weeks to less than 28 weeks of gestation accounted for 32% of all stillbirths in 2015. The pooled stillbirth rate at 24 weeks to less than 28 weeks declined from 0·97 to 0·70 per 1000 births from 2004 to 2015, a reduction of 25% (RR 0·75, 95% CI 0·65-0·85). The pooled stillbirth rate at 22 weeks to less than 24 weeks of gestation in 2015 was 0·53 per 1000 births and did not significantly changed over time (RR 0·97, 95% CI 0·80-1·16) although changes varied widely between countries (RRs 0·62-2·09). Wide variation in the percentage of all births occurring at 22 weeks to less than 24 weeks of gestation suggest international differences in ascertainment. INTERPRETATION Present definitions used for international comparisons exclude a third of stillbirths. International consistency of reporting stillbirths at 24 weeks to less than 28 weeks suggests these deaths should be included in routinely reported comparisons. This addition would have a major impact, acknowledging the burden of perinatal death to families, and making international assessments more informative for clinical practice and policy. Ascertainment of fetal deaths at 22 weeks to less than 24 weeks should be stabilised so that all stillbirths from 22 completed weeks of gestation onwards can be reliably compared. FUNDING EU Union under the framework of the Health Programme and the Bridge Health Project.

Non-fatal injuries resulting in activity limitations in Estonia—risk factors and association with the incidence of chronic conditions and quality of life: a retrospective study among the population aged 20–79

Objectives Evidence about the health and quality-of-life outcomes of injuries is obtained mainly from follow-up studies of surviving trauma patients; population-based studies are rarer, in particular for countries in Eastern Europe. This study examines the incidence, prevalence and social variation in non-fatal injuries resulting in activity limitations and outcomes of injuries in Estonia. Design A retrospective population-based study. Setting Estonia. Participants 7855 respondents of the face-to-face interviews of the second round of the Estonian Family and Fertility Survey conducted between 2004 and 2005 based on the nationally representative probability sample (n=11 192) of the resident population of Estonia aged 20–79. Primary and secondary outcome measures The cumulative incidence and prevalence of injuries leading to activity limitations was estimated. Survival models were applied to analyse variations in the injury risk across sociodemographic groups. The association between injuries and the development of chronic conditions and quality of life was examined using survival and logistic regression models. Results 10% (95% CI 9.4 to 10.7) of the population aged 20–79 had experienced injuries leading to activity limitations; the prevalence of activity limitations due to injuries was 4.4% (95% CI 3.9% to 4.9%). Significant differences in injury risk were associated with gender, education, employment, marital status and nativity. Limiting injury was associated with a doubling of the likelihood of having chronic conditions (adjusted HR 1.97, 95% CI 1.58 to 2.46). Injury exhibited a statistically significant negative association with most quality-of-life measures. Although reduced, these effects persisted after recovery from activity limitations. Conclusions Substantial variation in injury risk across population groups suggests potential for prevention. Men and workers in manual occupations constitute major target groups for injury prevention in Estonia. The association of injury with the development of chronic conditions and reduced quality of life warrants further investigation.