Original Title: Desigualdades Sociales en la Salud Perinatal en la CAPV

Authors' objectives: The aims we have proposed for this survey are as follows: 1) Increase our knowledge of the main factors that lead to social inequalities in perinatal health (perinatal mortality, low birth weight and prematurity) in the Basque Autonomous Community. 2) Identify the most effective interventions to reduce such inequalities.

Authors' results and conclusions: In spite of the large number of descriptive studies of SIH, it is observed that over the last decade,the number of surveys of inequalities has increased, but very few interventions and still fewer evaluative studies have been published. It should be noted that interventions should be appraised in line with the customary quality parameters, especially with regard to randomised, clinical or community design. From an analysis of the situation it is observed that health information includes analysis according to sex, rarely per gender and/or socio-economic level. A total of 6 autonomous communities are examining inequalities in the general population.This lack of information leads to a situation whereby with rare exceptions, there are neither policies nor programmes to tackle a reduction in inequalities.Tackling inequalities in health programmes is of relevance in the Basque Country,Navarre,Catalonia and the Community of Madrid. A study of 70,831 births in hospitals belonging to Osakidetza (Basque Health Service),accounted for in the MBDS, shows an increase in the age of mothers (average age of 30 compared to 32 in 2001).The percentage of low weight infants increased from 5.73% to 5.82% in 2001 and the prematurity rate rose from 2.41 to 3.22 %. The percentage of mothers of 37 or above has risen from 6.5 to 12.4%. It is observed that the higher the levels of poverty in the place of residence of the mother the greater the number of premature births with low birth weight babies (Chi2: p<0.05).Premature births are more frequent in poorer areas (OR: 1.61; IC95%: 1.46-1.77) even after fitting by the mother-s age in logistic regression analysis. By taking low birth weight as a dependent variable it can be seen that in the aforementioned areas low weight is also more frequent (OR: 1.11; IC95%:1.02-1.19) even when fitted according to the age of the mother and prematurity. CONCLUSIONS Information Systems It is important to note the limited utility of records when carrying out a detailed analysis of those SIH that must be improved in order to permit a routine analysis. Factors that contribute to infant mortality 1. Health of mothers and infant mortality Any intervention designed to improve the health of infants must be closely linked to a change in our social conditions (especially the role of the mother in our society) and to the integration of previouslyfragmented services. Although we do not have specific data on this subject, in our environment, it may prove difficult on occasions for children of first generation immigrants to find access to the health care system due to a lack of knowledge of the services available to them. Practices in order to reduce mortality and infant morbidity 1. Preconceptional Care • Ensure the access to and availability of information on family planning and contraception,especially in risk groups, for both men and women through structured programmes. • Improve the relationship between family planning centres and educational centres (including the Universities). 2. Prenatal Care • The provision of prenatal care must be appropriate for each individual case and for each differential cultural factor (let us not forget the ever-increasing number of immigrants of reproductive age) and the accessibility of the entire population must be ensured. • The development of mechanisms to help women during the prenatal stage is of fundamental importance. An adequate maternity leave policy is required and pregnant women should not be required to do heavy and/or stressful work. • Special programmes conducted by qualified personnel should be developed for women considered to be of high risk. In this sense, situations relating to our own environment, such as the access of specific groups to antenatal care, should be assessed. 3. Intra-natal care • Systematic collaboration between primary and specialised care. • Coordination and organisation of the continuity of care: - In countries such as Sweden,France and the United Kingdom,midwives play a key role in this sense. - The continuity of care would allow the care of the mother and child to be considered as a whole, avoiding problems of poor communications between different levels. The availability of a single and shared clinical history could help in this sense. – The care of the mother during birth must involve midwives, nurses, obstetricians and neonatologists. In this way, antenatal conditions, intranatal and postnatal situations must be coordinated. Ideally, this system should include: • An adequate consultation system between levels. • Efficient and safe transport systems. • Standardisation of care. • Clinical audit. • Peer review. • Evidence-based practices. • Provincial or regional reproductive care programme. 4. Intensive neonatal care Interventions such as the use of oxygen therapy, treatment with surface active agent and the use of prenatal steroids have demonstrated their effectiveness and are associated with a lower mortality risk. Prenatal and perinatal care must be based on essential technologies backed up by scientific evidence. The accessibility of the entire population to technologies of proven effectiveness in the field of postnatal care must be ensured, by guaranteeing the adequate level of care in each case. The prevention of premature birth appears to be an unattainable ideal in view of the fact that the premature birth rate has increased in the Basque Autonomous Community and in all the areas and countries in our immediate environment, even in those with higher socio-economic levels. Nevertheless, an increase in the quality of overall perinatal care, especially in the resources allocated to the treatment of Very Low Birth Weight Infants (VLBWI) seems to be more feasible. The VLBWI is a «rare» condition that accounts for more than 50% of neonatal mortality and up to 40% of infant mortality. There are strategies of proven efficiency based on the evidence of treatment for these patients.The short-term cost may seem to be high but this is not really so when analysed from a longer-term perspective, as morbimortality and disabilities drop.This decrease in disabilities involves a massive drop in general costs for the care and interventions that might be required should there be respiratory and especially neurological disability. Newly born children affected by this disability require visits to paediatric specialists, complex additional tests, speech therapists, psychologists, etc. The results are more years of healthy life. The importance of information systems developed specifically for monitoring this kind of technology and its development should not be left to one side. In this sense, initiatives such as EURONEONET (European neonatal unit collaboration network), which focuses especially on the handling of very low body weight infants, and the Basque-Navarre Neonatal Studies Group (GEN-VN) are of great interest. 5. Targets in postnatal care • Discharge from hospital after vaginal birth without complications within 24-48 hours following birth and after a Caesarean without complications within 2-4 days, if it is possible to ensure continued postnatal care. • Encouragement of maternal breast-feeding. • Use of community events and the mass media to inform the community. • Development of family resource centres, including genetic counselling, prenatal care designed according to the gender and culture of the target public. • Educational programmes that facilitate the acquisition of skills in the care of the child. 6. Targets in the community • Involvement of the community and social agents (community leaders, consumer associations, clinical and social services), both in the public and private sectors, in the provision of care.

Authors' recommendations: • Employ the methodology designed in the Health Plan of the Basque Autonomous Community. • Effective screening of risk factors, paying special attention to the potential social risks. • Achieve better integration and communication between different levels of the health service. • Interventions must target sectors of the population that show major differences in health levels –not only the traditionally vulnerable classes. An attempt must be made to prevent differences from appearing– not just to alleviate the consequences. • Strategies must tend to remove barriers, increase access and the use of preventive health services in the most vulnerable sectors of the population. • Routinely include the study of inequalities in the production of health information, through independent analysis and compared according to gender and socio-economic level. Simplify variables and the analytical process as much as possible to guarantee its sustainability and so that routine production does not involve a great deal of effort. • Quantitative, feasible objectives must be included in transversal programmes and health plans and resources must be dedicated to ensure that these are carried out successfully, that they are appraised adequately and that they are published in the scientific literature. • Create a specific, integrated system of prenatal registration and monitoring that allows the integration of information available from a number of different vital statistical sources, data on discharge, and specific incentives developed by centres. • Creation of and support for a perinatal epidemiological research centre that could aid in the study and systemised research into the problems detected. This centre should work in collaboration with the statistics institutes, territorial governments, organisations of health professionals and researchers in different fields. It could be a reference centre also for different neonatal study groups.

Authors' methods: The following tasks have been performed: • Systematic review of the literature, on the one hand, in order to examine the current status of this issue with regard to factors that may have a determining effect on SIH in perinatal health, and on the other, to determine the interventions proposed or carried out in order to deal with this problem. • At the same time, an analysis has been done of the situation in the Basque Autonomous Community based on a survey intended for public hospital centres with maternity services, in order to determine whether there are databases or records that might help in efforts to tackle this problem. • Access was requested to the Minimum Basic Data Set (MBDS) of the Basque Autonomous Community during the period 1995-2001, in order to study the relationship between the level of poverty in the Basque Autonomous Community measured during the Poverty and Social Inequality Survey of 2000 and prematurity and low birth weight rate.

Project Status: Completed

Year Published: 2007

URL for published report: https://www.euskadi.eus/contenidos/informacion/2007_osteba_publicacion/es_def/adjuntos/d_07-05_inform_Desisoc.pdf

English language abstract: An English language summary is available

Publication Type: Rapid Review

Country: Spain

Organisation Name: Basque Office for Health Technology Assessment

Contact Address: C/ Donostia – San Sebastián, 1 (Edificio Lakua II, 4ª planta) 01010 Vitoria - Gasteiz

Contact Name: Lorea Galnares-Cordero

Contact Email: lgalnares@bioef.eus

Copyright: <p>Basque Office for Health Technology Assessment, Health Department Basque Government (OSTEBA)</p>