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Objective To compare maternal mortality in eight countries with enhanced surveillance systems. Design Descriptive multicountry population based study. Setting Eight countries with permanent surveillance systems using enhanced methods to identify, document, and review maternal deaths. The most recent available aggregated maternal mortality data were collected for three year periods for France, Italy, and the UK and for five year periods for Denmark, Finland, the Netherlands, Norway, and Slovakia. Population 297 835 live births in Denmark (2013-17), 301 169 in Finland (2008-12), 2 435 583 in France (2013-15), 1 281 986 in Italy (2013-15), 856 572 in the Netherlands (2014-18), 292 315 in Norway (2014-18), 283 930 in Slovakia (2014-18), and 2 261 090 in the UK (2016-18). Outcome measures Maternal mortality ratios from enhanced systems were calculated and compared with those obtained from each country’s office of vital statistics. Age specific maternal mortality ratios; maternal mortality ratios according to women’s origin, citizenship, or ethnicity; and cause specific maternal mortality ratios were also calculated. Results Methods for identifying and classifying maternal deaths up to 42 days were very similar across countries (except for the Netherlands). Maternal mortality ratios up to 42 days after end of pregnancy varied by a multiplicative factor of four from 2.7 and 3.4 per 100 000 live births in Norway and Denmark to 9.6 in the UK and 10.9 in Slovakia. Vital statistics offices underestimated maternal mortality by 36% or more everywhere but Denmark. Age specific maternal mortality ratios were higher for the youngest and oldest mothers (pooled relative risk 2.17 (95% confidence interval 1.38 to 3.34) for women aged Conclusions Variations in maternal mortality ratios exist between high income European countries with enhanced surveillance systems. In-depth analyses of differences in the quality of care and health system performance at national levels are needed to reduce maternal mortality further by learning from best practices and each other. Cardiovascular diseases and mental health in women during and after pregnancy must be prioritised in all countries.

Aim Severe acute maternal morbidity (SAMM) is a state of the woman, when she nearly died, but survived. The aim of study was to find out the exact incidence of SAMM in Slovakia, establishment of functional surveillance system and improve quality of health care. Materials and methods The regular annual analyses of SAMM cases in Slovakia from January 1st 2012 to December 31st 2016. Observed SAMM included: peripartum haemorrhage, peripartum hysterectomy, uterine rupture, abnormally invasive placenta, HELLP syndrome, eclampsia, sepsis, transport to intensive care unit or anaesthesiology and non-fatal amniotic fluid embolism. Results The response rate of questionnaires was 84.8 %. The overall confirmed incidence of SAMM was 6.35/1,000 births (95% CI 6.03-6.67). The most often causes of SAMM were: peripartum haemorrhage (2.1/1,000 births), transport to intensive care unit or anaesthesiology (1.46/1,000 births), peripartum hysterectomy (0.84/1,000 births) and HELLP syndrome (0.63/1,000 births). The average age of women with SAMM was 30.3 years (14-46) and average parity was 1.16 (0-15). Conclusion The incidence of SAMM and especially incidence of peripartum haemorrhage and peripartum hysterectomy in Slovakia is one of the highest in Europe. To decrease incidence and improve management and outcome of patients, regular audit of SAMM is needed (Tab. 3, Fig. 2, Ref. 30).

Objective Hemolysis, Elevated Liver Enzymes, Low Platelets syndrome (HELLP syndrome) is one of the actively haunted maternal morbidity through Slovak Obstetric Survey System (SOSS), the organisation for surveillance of severe maternal morbidity and mortality in Slovakia. Methods The questionaires were sent in 55 Obstetric Units in Slovakia. The analyzed and here presented data had been collected cases those happened in the period from 1.1.2012 till 31.12.2014. Controls were women from SR during observed years, who delivered without HELLP syndrome. Results The return rate of questionnaires was 89.67 %, thus covering 146 972 deliveries during the study period in Slovakia. The exact incidence of HELLP syndrome was 0.63/1000 deliveries (CI 95 % 0.51-0.78). Risk factors were age > 30 (OR = 1.63), nuliparous (OR = 2.96), pregnancy after assisted reproduction technology (OR = 8.29) and multiple pregnancy OR = 9.19). The mean gestation age at delivery was 33.8th weeks. Vaginal delivery was by 10 (10.8 %) patients with HELLP syndrome and in the 83 (89.2 %) patients pregnancy was terminated with acute caesarean section. There were reported 45 050 cases (30.7 %) of the caesarean section in the control group throughout the study period. Conclusion The older age, nulliparity, multiple pregnancy and pregnancy after assisted reproduction techniques was identified as a significant risk factors of HELLP syndrome (Tab. 5, Fig. 1, Ref. 21).

Introduction Peripartum hysterectomy is applied as a surgical intervention of last resort for major obstetric hemorrhage. It is performed in an emergency setting except for women with a strong suspicion of placenta accreta spectrum (PAS), where it may be anticipated before cesarean section. The aim of this study was to compare management strategies in the case of obstetric hemorrhage leading to hysterectomy, between nine European countries participating in the International Network of Obstetric Survey Systems (INOSS), and to describe pooled maternal and neonatal outcomes following peripartum hysterectomy. Material and methods We merged data from nine nationwide or multi-regional obstetric surveillance studies performed in Belgium, Denmark, Finland, France, Italy, the Netherlands, Slovakia, Sweden and the UK collected between 2004 and 2016. Hysterectomies performed from 22 gestational weeks up to 48 h postpartum due to obstetric hemorrhage were included. Stratifying women with and without PAS, procedures performed in the management of obstetric hemorrhage prior to hysterectomy between countries were counted and compared. Prevalence of maternal mortality, complications after hysterectomy and neonatal adverse events (stillbirth or neonatal mortality) were calculated. Results A total of 1302 women with peripartum hysterectomy were included. In women without PAS who had major obstetric hemorrhage leading to hysterectomy, uterotonics administration was lowest in Slovakia (48/73, 66%) and highest in Denmark (25/27, 93%), intrauterine balloon use was lowest in Slovakia (1/72, 1%) and highest in Denmark (11/27, 41%), and interventional radiology varied between 0/27 in Denmark and Slovakia to 11/59 (79%) in Belgium. In women with PAS, uterotonics administration was lowest in Finland (5/16, 31%) and highest in the UK (84/103, 82%), intrauterine balloon use varied between 0/14 in Belgium and Slovakia to 29/103 (28%) in the UK. Interventional radiology was lowest in Denmark (0/16) and highest in Finland (9/15, 60%). Maternal mortality occurred in 14/1226 (1%), the most common complications were hematologic (95/1202, 8%) and respiratory (81/1101, 7%). Adverse neonatal events were observed in 79/1259 (6%) births. Conclusions Management of obstetric hemorrhage in women who eventually underwent peripartum hysterectomy varied greatly between these nine European countries. This potentially life-saving procedure is associated with substantial adverse maternal and neonatal outcome.

Background Infections are among the leading causes of maternal mortality and morbidity. The Global Maternal Sepsis and Neonatal Initiative, launched in 2016 by WHO and partners, sought to reduce the burden of maternal infections and sepsis and was the basis upon which the Global Maternal Sepsis Study (GLOSS) was implemented in 2017. In this Article, we aimed to describe the availability of facility resources and services and to analyse their association with maternal outcomes. Methods GLOSS was a facility-based, prospective, 1-week inception cohort study implemented in 713 health-care facilities in 52 countries and included 2850 hospitalised pregnant or recently pregnant women with suspected or confirmed infections. All women admitted for or in hospital with suspected or confirmed infections during pregnancy, childbirth, post partum, or post abortion at any of the participating facilities between Nov 28 and Dec 4 were eligible for inclusion. In this study, we included all GLOSS participating facilities that collected facility-level data (446 of 713 facilities). We used data obtained from individual forms completed for each enrolled woman and their newborn babies by trained researchers who checked the medical records and from facility forms completed by hospital administrators for each participating facility. We described facilities according to country income level, compliance with providing core clinical interventions and services according to women's needs and reported availability, and severity of infection-related maternal outcomes. We used a logistic multilevel mixed model for assessing the association between facility characteristics and infection-related maternal outcomes. Findings We included 446 facilities from 46 countries that enrolled 2560 women. We found a high availability of most services and resources needed for obstetric care and infection prevention. We found increased odds for severe maternal outcomes among women enrolled during the post-partum or post-abortion period from facilities located in low-income countries (adjusted odds ratio 1middot84 [95% CI 1middot05-3middot22]) and among women enrolled during pregnancy or childbirth from non-urban facilities (adjusted odds ratio 2middot44 [1middot02-5middot85]). Despite compliance being high overall, it was low with regards to measuring respiratory rate (85 [24%] of 355 facilities) and measuring pulse oximetry (184 [57%] of 325 facilities). Interpretation While health-care facilities caring for pregnant and recently pregnant women with suspected or confirmed infections have access to a wide range of resources and interventions, worse maternal outcomes are seen among recently pregnant women located in low-income countries than among those in higher-income countries; this trend is similar for pregnant women. Compliance with cost-effective clinical practices and timely care of women with particular individual characteristics can potentially improve infection-related maternal outcomes. Funding UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, WHO, Merck for Mothers, and US Agency for International Development. Copyright (c) 2021 World Health Organization; licensee Elsevier. This is an Open Access article under the CC BY 3.0 IGO license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. In any use of this article, there should be no suggestion that WHO endorses any specific organisation, products, or services. The use of the WHO logo is not permitted. This notice should be preserved along with the article's original URL.

Introduction Peripartum hysterectomy is a surgical procedure performed for severe obstetric complications such as major obstetric hemorrhage. The prevalence of peripartum hysterectomy in high-resource settings is relatively low. Hence, international comparisons and studying indications and associations with mode of birth rely on the use of national obstetric survey data. Objectives were to calculate the prevalence and indications of peripartum hysterectomy and its association with national cesarean section rates and mode of birth in nine European countries. Material and methods We performed a descriptive, multinational, population-based study among women who underwent peripartum hysterectomy. Data were collected from national or multiregional databases from nine countries participating in the International Network of Obstetric Survey Systems. We included hysterectomies performed from 22 gestational weeks up to 48 hours postpartum for obstetric hemorrhage, as this was the most restrictive, overlapping case definition between all countries. Main outcomes were prevalence and indications of peripartum hysterectomy. Additionally, we compared prevalence of peripartum hysterectomy between women giving birth vaginally and by cesarean section, and between women giving birth with and without previous cesarean section. Finally, we calculated correlation between prevalence of peripartum hysterectomy and national cesarean section rates, as well as national rates of women giving birth after a previous cesarean section. Results A total of 1302 peripartum hysterectomies were performed in 2 498 013 births, leading to a prevalence of 5.2 per 10 000 births ranging from 2.6 in Denmark to 10.7 in Italy. Main indications were uterine atony (35.3%) and abnormally invasive placenta (34.8%). Relative risk of hysterectomy after cesarean section compared with vaginal birth was 9.1 (95% CI 8.0-10.4). Relative risk for hysterectomy for birth after previous cesarean section compared with birth without previous cesarean section was 10.6 (95% CI 9.4-12.1). A strong correlation was observed between national cesarean section rate and prevalence of peripartum hysterectomy (rho = 0.67, P

Introduction Peripartum hysterectomy is a surgical procedure performed for severe obstetric complications such as major obstetric hemorrhage. The prevalence of peripartum hysterectomy in high‐resource settings is relatively low. Hence, international comparisons and studying indications and associations with mode of birth rely on the use of national obstetric survey data. Objectives were to calculate the prevalence and indications of peripartum hysterectomy and its association with national cesarean section rates and mode of birth in nine European countries. Material and methods We performed a descriptive, multinational, population‐based study among women who underwent peripartum hysterectomy. Data were collected from national or multiregional databases from nine countries participating in the International Network of Obstetric Survey Systems. We included hysterectomies performed from 22 gestational weeks up to 48 hours postpartum for obstetric hemorrhage, as this was the most restrictive, overlapping case definition between all countries. Main outcomes were prevalence and indications of peripartum hysterectomy. Additionally, we compared prevalence of peripartum hysterectomy between women giving birth vaginally and by cesarean section, and between women giving birth with and without previous cesarean section. Finally, we calculated correlation between prevalence of peripartum hysterectomy and national cesarean section rates, as well as national rates of women giving birth after a previous cesarean section. Results A total of 1302 peripartum hysterectomies were performed in 2 498 013 births, leading to a prevalence of 5.2 per 10 000 births ranging from 2.6 in Denmark to 10.7 in Italy. Main indications were uterine atony (35.3%) and abnormally invasive placenta (34.8%). Relative risk of hysterectomy after cesarean section compared with vaginal birth was 9.1 (95% CI 8.0‐10.4). Relative risk for hysterectomy for birth after previous cesarean section compared with birth without previous cesarean section was 10.6 (95% CI 9.4‐12.1). A strong correlation was observed between national cesarean section rate and prevalence of peripartum hysterectomy (ρ = 0.67, P < .05). Conclusions Prevalence of peripartum hysterectomy may vary considerably between high‐income countries. Uterine atony and abnormally invasive placenta are the commonest indications for hysterectomy. Birth by cesarean section and birth after previous cesarean section are associated with nine‐fold increased risk of peripartum hysterectomy.

Introduction Peripartum hysterectomy is a surgical procedure performed for severe obstetric complications such as major obstetric hemorrhage. The prevalence of peripartum hysterectomy in high-resource settings is relatively low. Hence, international comparisons and studying indications and associations with mode of birth rely on the use of national obstetric survey data. Objectives were to calculate the prevalence and indications of peripartum hysterectomy and its association with national cesarean section rates and mode of birth in nine European countries.Material and methods We performed a descriptive, multinational, population-based study among women who underwent peripartum hysterectomy. Data were collected from national or multiregional databases from nine countries participating in the International Network of Obstetric Survey Systems. We included hysterectomies performed from 22 gestational weeks up to 48 hours postpartum for obstetric hemorrhage, as this was the most restrictive, overlapping case definition between all countries. Main outcomes were prevalence and indications of peripartum hysterectomy. Additionally, we compared prevalence of peripartum hysterectomy between women giving birth vaginally and by cesarean section, and between women giving birth with and without previous cesarean section. Finally, we calculated correlation between prevalence of peripartum hysterectomy and national cesarean section rates, as well as national rates of women giving birth after a previous cesarean section.Results A total of 1302 peripartum hysterectomies were performed in 2 498 013 births, leading to a prevalence of 5.2 per 10 000 births ranging from 2.6 in Denmark to 10.7 in Italy. Main indications were uterine atony (35.3%) and abnormally invasive placenta (34.8%). Relative risk of hysterectomy after cesarean section compared with vaginal birth was 9.1 (95% CI 8.0-10.4). Relative risk for hysterectomy for birth after previous cesarean section compared with birth without previous cesarean section was 10.6 (95% CI 9.4-12.1). A strong correlation was observed between national cesarean section rate and prevalence of peripartum hysterectomy (rho = 0.67, P < .05).Conclusions Prevalence of peripartum hysterectomy may vary considerably between high-income countries. Uterine atony and abnormally invasive placenta are the commonest indications for hysterectomy. Birth by cesarean section and birth after previous cesarean section are associated with nine-fold increased risk of peripartum hysterectomy.

Our aim is to assess the smoking cessation and vaping cessation activity, including quit attempts and willingness to quit among university students in Central and Eastern Europe, as well as to investigate personal characteristics associated with smoking cessation and vaping cessation attempts. Data were collected by questionnaire which included 46 questions on cigarette and e-cigarette use. Questionnaires were obtained from 14,352 university students (aged 20.9 &plusmn, 2.4 years, cooperation rate of 72.2%). For the purposes of this analysis, only data from exclusive cigarette smokers (n = 1716), exclusive e-cigarette users (n = 129), and dual users (216) were included. Of all cigarette smokers, 51.6% had previously tried to quit smoking and 51.5% declared a willingness to quit cigarette smoking in the near future. Among all e-cigarette users only 13.9% had ever tried to quit using the e-cigarette and 25.2% declared a willingness to give up using e-cigarette in the near future. The majority of the group did not use pharmacotherapy to quit cigarette (87.5%) or e-cigarette (88.9%) use. Our results indicate that while most university students have some desire to quit conventional smoking, those who use e-cigarettes do not have the same desire.

Seasonal influenza can have serious morbid consequences and can even result in death, particularly in at-risk populations, including healthcare professionals (HCPs), elderly and those living with a medical risk condition. Although in Europe recommendations exist for annual influenza vaccination in these populations in most countries, the vaccination coverage rate (VCR) is often well below the World Health Organization target of 75% coverage. In our previous survey in 2009 we showed that some elements of national vaccination policies, e.g. reminder systems, strong official recommendation, and easy access, seemed to contribute to achieving higher influenza VCRs among elderly. We repeated the survey in 2016, using the same methodology to assess changes in influenza VCRs among the elderly and in the impact of policy elements on these VCRs. In addition, we collected information about VCRs among HCPs, and those living with a medical risk condition. The median VCR in the 21 countries that had recommendations for influenza vaccination in the elderly was 35.3%, ranging from 1.1% in Estonia to 74.5% in Scotland. The average VCRs for HCPs and those living with medical risk conditions, available in 17 and 10 countries, respectively, were 28.3% (range 7% in Czech Republic to 59.1% in Portugal) and 32.2% (range from 20.0% in the Czech Republic and Hungary to 59.6% in Portugal), respectively. Fewer countries were able to provide data from HCP and those living with medical risk conditions. Since the initial survey during the 2007–2008 influenza season, VCRs have decreased in the elderly in the majority of countries, thus, achieving high VCRs in the elderly and the other target groups is still a major public health challenge in Europe. This could be addressed by the identification, assessment and sharing of best practice for influenza vaccination policies.

Background Sexual health problems are common. Therefore, training in sexual health is relevant for the clinical practice of trainees and early-career specialists in several specialties who deal with patients with sexual health problems. However, little is known about how sexual health training is provided across countries and specialties. Aim To assess (i) sexual health training during postgraduate training programs in psychiatry, obstetrics and gynecology, urology, and endocrinology across Europe; (ii) the confidence of trainees and early-career specialists in dealing with patients with sexual health problems; and (iii) their need for further training in sexual health during postgraduate training programs. Methods The study was based on a collaboration among European societies of trainees in these 4 specialties. An online survey was developed and conducted from January 2015 through June 2016. Main Outcome Measures Self-reported questionnaire. Results We collected 366 completed surveys from 40 countries. Sexual health training was considered an important or very important part of specialty training by 78.7% of participants. Overall, 62.3% of participants had not received any training in sexual health. Especially in obstetrics and gynecology, the large majority did not have training in sexual health (82.8%), followed by psychiatry (59.8%), urology (58.4%), and endocrinology (56.1%). There were statistically significant differences among specialties in the confidence of participants in managing patients with sexual health problems. In general, trainees and early-career specialists who had received sexual health training felt more confident in dealing with patients with gender dysphoria (P = .011), need for sexual therapy (P = .0004), paraphilic disorders (P = .0003), and sexual dysfunction (P = .0017). Conclusions Trainees and early-career specialists found sexual health training important for their future medical practice; however, less than half received it during their postgraduate training. Participants felt more confident in managing patients with sexual health problems when sexual health training was included in the postgraduate training program.

To describe the infrastructural differences in training in Obstetrics and Gynaecology (ObGyn) across Europe.Descriptive web-based survey of 31 national ObGyn trainee societies representing the 30 member countries of the European Network of Trainees in Obstetrics and Gynaecology. Answers were verified in a telephone interview and only countries which had completed the telephone interview were included in the final analysis.The final analysis included 28 of 31 societies representing 27 countries (response rate 90%). The median formal duration of training was 5 years (range 4-7). There were mandatory requirements in addition to medical school graduation before specialisation could be started in 20 (71%) countries. The job opportunities after completion of training varied and included academic fellowships (n=21 [75%]), clinical fellowships/junior consultancy (n=21 [75%]), consultancy (n=11 [40%]), and private practice (n=23 [82%)]. Training and working as a specialist abroad was uncommon (≤20% in 21 [78%] and 26 [96%] countries respectively). Exams during ObGyn training were offered in 24 (85%) countries. Unemployment after completion of training was rare (5% in 26 [93%] countries). Assessment of ObGyn specialists took place in 20 (71%) countries.The study illustrates that there are organisational variations in ObGyn training in Europe; A) The requirements to obtain a training post vary causing differences in the qualifications of trainees starting training. B) The duration of training varies. And C) newly trained specialists carry varying levels of responsibility. The results suggest that the content, organisation, and outcome of training differ across Europe. Differences due to political, social and cultural reasons are expected. However, further harmonisation of training across Europe still seems desirable in order to improve women's healthcare and facilitate the mobility of ObGyn trainees and specialists across Europe. There are currently several European initiatives, however, national and local measures are essential for training to improve.

We assessed the long-term persistence of humoral immunity against diphtheria in adults with childhood vaccination and the immunogenicity of a booster dose considering demographic, behavioural and vaccinating factors. We conducted a trial in 200 healthy Slovak adults aged 24&ndash, 65 years, immunised against diphtheria in childhood and against tetanus at regular 10&ndash, 15 year intervals, and receiving a dose of a tetanus-diphtheria toxoid vaccine. The response was determined by ELISA antibody concentrations of paired sera before and at 4 weeks post-vaccination. A seroprotection rate of 21% (95% confidence interval, CI 15.6&ndash, 27.3%) was found in adults up to 59 years since the last vaccination with seroprotective levels of antibodies against diphtheria &ge, 0.1 IU/mL and a geometric mean concentration of 0.05 IU/mL. Conversely, seropositive levels &ge, 0.01 IU/mL were observed in 98% of adults (95% CI 95&ndash, 99.5%). Booster-induced seroprotection was achieved in 78% of adults (95% CI 71.6&ndash, 83.5%) clearly depending on pre-booster antibody levels correlating with age and time since the last vaccination. Moreover, only 54.2% of smokers and 53.3% of patients on statins exhibited seroprotection. Booster vaccination against diphtheria was unable to confer seroprotection in all recipients of only childhood vaccination.

Vaccination against varicella rapidly reduces disease incidence, resulting in reductions in both individual burden and societal costs. Despite these benefits, there is no standardization of varicella immunization policies in Europe, including countries in Central and Eastern Europe (CEE).This systematic literature review identified publications on the epidemiology of varicella, its associated health and economic burden, and vaccination strategies within the CEE region, defined as Albania, Bosnia-Herzegovina, Bulgaria, Croatia, Cyprus, Czech Republic, Estonia, Hungary, Latvia, Lithuania, Poland, Romania, Serbia, Slovakia, and Slovenia. Twenty-six studies were identified from a search of PubMed, Embase®, and MEDLINE® biomedical literature databases, supplemented by gray literature and country-specific/global websites.Limited information exists in published studies on the burden of varicella in CEE. The wide variability in incidence rates between countries is likely explained by a lack of consistency in reporting systems. Funded universal varicella vaccination (UVV) in CEE is currently available only in Latvia as a one-dose schedule, but Hungary together with Latvia are introducing a two-dose strategy in 2019. For countries that do not provide UVV, introduction of vaccination is predicted to provide substantial reductions in cases and rates of associated complications, with important economic benefits.