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13higher fetal, neonatal, and infant mortality rates due to deaths attributed to lethal congenital anomalies.Europe experienced across-the-board declines in fetal, neonatal, and infant mortality, although rates of change differed.Most countries contributing data to Euro-PEristat in 2004 and 2010 experienced declines in their fetal, neonatal, and infant mortality rates.For fetal mortality, the decreases (on average 19%; range: 0-38%) tended to be more pronounced for western European countries with higher mortality rates in 2004 (Denmark, Italy, and the Netherlands).Some countries with low mortality rates in 2004, such as the Czech Republic, achieved significant continued improvements in outcomes.Decreases in neonatal mortality averaged 24% (range: 9% to 50%), and infant mortality fell 19% (range: 6%-40%).The largest declines were in 3 Baltic countries: Estonia, Latvia, and Lithuania.Decreases were again most pronounced for countries with higher mortality rates in 2004, although some countries with lower mortality in 2004 also showed significant continued improvements (Slovenia, Finland, and Austria, for example).Neonatal and infant mortality were low (under 2 and 3 per 1000 live births for neonatal and infant mortality, respectively) in some European countries.Preterm babies born before 28 weeks of gestational age constitute over one-third of all deaths, but data are not comparable between countries.About one-third of all fetal deaths and 40% of all neonatal deaths were of babies born before 28 weeks of gestational age.Unfortunately, between-country differences in legislation governing registration of births and deaths and misclassification of stillbirths and neonatal deaths make it difficult to compare mortality at these early gestations.Euro-PEristat presents fetal mortality rates at 28 weeks of gestation and over and neonatal mortality at 24 weeks of gestation and over because our analyses have shown that these cutoffs provide more comparable data and thus allow more useful comparisons.However, given the large proportion of deaths before 28 weeks, it is essential to improve information systems in Europe by developing common guidelines for recording these births and deaths.Another related issue is the variation in notification procedures for terminations of pregnancy at 22 weeks or later.These are included in fetal mortality rates in some but not all countries, and only some countries which include them can distinguish terminations from spontaneous deaths.Six percent of all fetal deaths were terminations in Scotland versus 40-50% in France.Terminations were 13% of fetal deaths in Hungary, 15% in Switzerland, and 19% in Italy.Preterm birth rates were similar in 2004 and 2010 in many countries; differences in rates and trends raise questions about possible preventive strategies.The preterm birth rate for live births varied in 2010 from about 5 to 10% in Europe.We observed relatively lower preterm birth rates (below 6.5%) in Iceland, Lithuania, Finland, Estonia, Ireland, Latvia, Sweden, Norway, and Denmark, and higher rates (above 8.5%) in Cyprus (10.4%) and Hungary (8.9%).Rates were around 8% in Austria, Germany, Romania, the Czech Republic, Luxembourg, Portugal, the Netherlands, and all regions of Belgium.In comparison to 2004, proportions of preterm live births were similar for many countries.However, they increased over this period in Luxembourg, the Brussels region, the Czech Republic, Slovakia, Portugal, Northern Ireland, and Italy, while they declined in Norway, Scotland, Germany, England and Wales, Denmark, and Sweden.The fact that rates are stable or declining in many countries goes against widely held beliefs that preterm birth rates are rising and raises questions about policies and practices associated with divergent trends between countries. Maternal deaths are rare in Europe, but under-reporting is widespread.Generally speaking the maternal mortality ratio in Europe is low, due to both the very low level of fertility (fewer than 2 children per woman, as shown in Chapter 2) and the high levels of care.The range in Europe is from lows under 3 per 100 000 (in Estonia, Italy, Austria, and Poland) to highs over 10 per 100 000 live births (Latvia, Hungary, Slovenia, Slovakia, and Romania).There is good evidence that maternal deaths derived from routine statistical systems are under-reported, and this must be suspected particularly where ratios are very low.Confidential enquiries and record linkage are recommended to obtain complete data on pregnancy-related deaths and also to make it possible to understand how these deaths happened and to make recommendations to prevent the recurrence of those that could have been prevented.When confidential enquiries are undertaken, as in France, the Netherlands, and the UK, almost half the maternal deaths are associated with substandard care.This should not occur in high-income countries.Because mortality is rare, Euro-PEristat also collects data on severe maternal morbidity, which occurs in approximately 1% of all deliveries.However, the comparability of these indicators, when derived from hospital discharge systems and other routine sources, is still limited.Ongoing work is focused on assessing the quality and completeness of the data about diagnoses and procedures in routine hospital discharge systems so that we can propose better definitions.An estimated 140 000 fetuses and babies had a major congenital anomaly in the EU-27 countries in 2010.Data from EUROCAT were used to derive the overall prevalence of major congenital anomalies diagnosed during pregnancy, at birth, or in early infancy -26 per 1000 births in 2010.This prevalence has shown a recent very shallow decrease, and there is a need to improve primary prevention policies to reduce environmental risk factors in the pre-and periconceptional period.Four fifths of cases were live births, the vast majority of whom survived the neonatal period and may have special medical, educational, or social needs.The largest group of congenital anomalies is congenital heart disease.An overall 0.81 perinatal deaths per 1000 births in 2010 were associated with congenital anomalies according to data from 13 EUROCAT registries.The rate of terminations of pregnancy for fetal anomaly (TOPFA) varies widely between countries from none (Ireland and Malta) to 10.5 per 1000 births (Paris, France), reflecting differences in prenatal screening policies and uptake and in abortion laws, practices, and cultural attitudes.The rate of live births with certain anomalies, such as spina bifida and Down syndrome, in a given country is inversely related to its rate of terminations of pregnancy for fetal anomaly. 15Cerebral palsy registers in collaboration with their clinical networks make it possible to assess a group of rare conditions that develop in the perinatal period and lead to lifelong activity limitations and participation restrictions.The increased survival of newborn babies in all birthweight and gestational-age groups correlates with a decrease in the prevalence of certain subtypes of cerebral palsies.For example, the proportion of babies born between 1980 and 1998 with a birth weight over 2500 g who developed bilateral spastic cerebral palsy decreased from 58 to 33 per 100 000 live births.In the same 2 decades, the proportion of cerebral palsy in the babies born at a gestational age between 32-36 weeks decreased by 3% annually.These downward trends coincided with a decrease of one third in the proportion of bilateral spastic cerebral palsy in babies with a birth weight between 1000 and 1499 g. POPULATION RISK FACTORS Age at childbirth has increased in Europe.The age at which women bear children in Europe varies widely, and this has an impact on the health of mothers and babies.Both early and late childbearing are associated with higher than average rates of preterm birth, growth restriction, perinatal mortality, and congenital anomalies.Overall, teenage pregnancies are uncommon in Europe with a median of 2.7% of births to mothers aged younger than 20 years.However, some countries of eastern Europe have higher proportions.The UK also stands out from its neighbours with a high proportion of very young mothers (over 5%).The situation in Europe contrasts with the United States where 9.2% of births are to mothers under 20 (CDC: Births: final data for 2010: www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_01.pdf).At the other end of the age spectrum, the percentage of older mothers, defined as women giving birth at 35 years or older, ranged from 10.9% in Romania to 34.7% in Italy.The proportion of women bearing children later in life varies substantially, but in 40% of countries or regions, at least 20% of births were to women aged 35 years or more, and the proportion of births in this age group increased substantially in almost every country.Only Finland experienced a decrease between 2004 and 2010 in this proportion.The increase was relatively small in the United Kingdom (under 1 percentage point), and substantially larger (over 5 percentage points) in Italy, Estonia, Hungary, the Czech Republic, and Spain.Encouraging earlier childbearing may require policies to support young parents and working mothers, as well as informing the public about possible consequences of having children at later ages.More than 1 woman in 10 smoked during pregnancy in many countries despite declines between 2004 and 2010.Maternal smoking during pregnancy may be considered the most important preventable factor associated with adverse pregnancy outcomes.It is a well-established risk factor for adverse perinatal outcomes.It can impair normal fetal growth and development and thus increase the risk of low birth weight, preterm birth, intrauterine growth restriction, and some congenital anomalies.Smoking cessation is one of the most effective interventions for improving mothers' and children's health and thus serves as an indicator of the quality of antenatal preventive he