Bollettino epidemiologico nazionale

Sample Survey on Pre-, Peri- and Post-natal Care, Caserta (Campania), 2001

Angela Maffeo, Clementina Vatiero

Maternal Child Health Unit, ASL Caserta 2

Contributors : P. Savarese , G. Mottola , R. Broccoletti , V. Corvino , C. Mendes , G. Ventriglia , D’ Angiolillo , G. De Chiara, M. Monaco.

In 2002, the Local Health Agencies of Caserta 2 participated in a national survey on pre-, peri- and post-natal care coordinated by the Istituto Superiore di Sanità and conducted in collaboration with 61 local health agencies in 14 regions of Italy. The study had as its objective to evaluate maternal and infant outcomes one year after birth, with an emphasis on the services and care offered during pregnancy and delivery and during the first year of life.

The study population consisted on women who had given birth during the previous year in the local health agencies participating in the study. Questionnaires were administered by specially trained personnel and covered pre-natal care, events surrounding delivery, and during the first year of life of the infant.

In Caserta, a large province of the Campania region in southern Italy, 9 of the 10 districts with maternal health units agreed to participate. Each unit identified a coordinator and two interviewers, who were chosen among the staff of the outpatient consultation clinics. Interviewers received training questionnaire administration.

The sampling strategy called for between 100 and 200 interviews per ASL. All women delivering within a certain period of time after January 15, 2001 were contacted; the period chosen was based on the number of births during the preceding year obtained from the local vital registers. Home visits with no advance notice were made to each of the women who had given birth. Responses were coded and the data entered and analyzed in Epi Info.

One-hundred-fifty-one women of the 181 in the sample who had delivered during the specified period were interviewed; of the remaining women, 20 could not be found and 10 refused to participate, yielding a response rate of 83,4%.

The average age of the women interviewed was 29 years. Fifty percent had 9 years or less of schooling; 66% were housewives. Of the 50 women who worked outside the house prior to the pregnancy, 39 (78%) had gone back to work by the time of the interview.

As shown in the table, 84% of the women stated that they had been followed during their pregnancy by a private gynecologist, and 93% stated that they had had their first prenatal visit during the first trimester. Sixty-two percent had received 7 or more sonograms during the pregnancy, 31% had had 4-6, and 7% had 3 or less.

Only 10.6% participated in pre-natal preparation courses. In 22% of those who did not attend, the reason given was that such courses were locally not available.

A total of 52.6% of the women had Cesarean deliveries and 42.6% had spontaneous vaginal deliveries; one woman had a surgical delivery, and the remainder had assisted vaginal deliveries. A total of 56.7% delivered in a public structure, 32.7% in a private structure under contract by the local health agency, and 10.7% in a private structure.

During hospitalization, the percentage of women who exclusively breastfed was 57%; of the remainder, 9% predominantly breast-fed, 24% resorted to mixed feeling, and 10% exclusively bottle-fed. Among those who breastfed, 17% did so within 2 hours of delivery, while in 72% the first breastfeeding occurred between 2 and 24 hours and in 11% more at than 24 hours after delivery.

After returning home, 58% exclusively breastfed, 7% predominantly breastfed, 28% both breast- and bottle-fed, and 13% exclusively bottle-fed their infants. The median duration of breast-feeding was 4 months.

Only 9 women were visited by a midwife at home after the delivery, all whom were visited by midwives working in the private sector. Among those that were not seen at home after the delivery, 31% were not asked to return for any postpartum visits, and 24% of the survey population reported that they had not been seen by a gynecologist within two months of delivery.

The babies were followed in the first year of life primarily by pediatricians under contract with the local health authority (61%); the remainder were followed by private pediatricians even though 94% were enrolled with the contract pediatricians. Fifty percent had 3-4 well-child visits during the first year, while 20% had 9 or more. Only 4% of the children were in public nurseries during the first year of life, largely because of the lack of such structures.

Comment

Michele Grandolfo and Serena Donati

Laboratory of Epidemiology and Biostatistics, ISS

The study conducted in Caserta is one of a series of studies conducted at national level to evaluate the quality of care during the pre-, peri- and post-natal periods in Italy (1-3). The results of this study demonstrate various critical points regarding the appropriateness of care during what is a major life event for most women. Despite the fact that most pregnancies represent normal physiologic events, in almost all countries with developed health care systems, pregnancy and delivery are subject to increasing levels of diagnostic and therapeutic procedures that are both complex and often invasive. From these data, it is clear that there is an over-utilization of diagnostic testing in pregnancy, which not only increases costs but also may increase the risk of iatrogenic problems and reduce the quality of health care.

In the Caserta study population, despite the finding that few of the women had serious complications, very few (7%) had only the 3 sonograms recommended by the Minister of Health, with the majority having 7 or more. Additionally, the percentage of Cesarean sections continues to rise in Italy (11.2% in 1980 and 33.2% in 2000) (4, 5) and represents one of the most extreme elements of the excessive medicalization of pregnancy. The percent reported in Caserta exceeds 50%, which is in keeping with data from the rest of the Campania region, which has the highest rate in Italy.

In the face of this excessive use of diagnostic and therapeutic procedures that are not based on scientific evidence, there is also a lack of information and awareness among the women, who are often excluded from the decisional process. Greater knowledge as well as assuming a more active role in decision-making on the part of the women themselves will be essential to reduce the “defensive” obstetrics currently being practiced. Unfortunately, only 10% of the women in Caserta had attended childbirth preparation classes, and the information given during the peri-partum period is often fragmented and inadequate, This lack of continuity represents another critical deficit of the current system.

The information obtained from surveys such as this should lead to the implementation of corrective steps, which should be monitored and which should include a more holistic approach to the training and updating of personnel, the use of practices based on clinical evidence, and clinical audits.  To this end, it should be underlined that the minimal care guidelines (6) for maternal-infant care promulgated in Italy describe the above-mentioned objectives and actions (www.ministerosalute.it).

References

1.  Donati S, Spinelli A, Grandolfo ME, et al. L’assistenza in gravidanza, al parto e durante il puerperio in Italia. Ann Ist Super Sanità 1999;35:289-296.

2.  Donati S., Andreozzi S., Grandolfo M.E. Valutazione delle attività di sostegno e informazione alle partorienti: indagine nazionale Rapporti ISTISAN 01/5 Istituto Superiore di Sanità.

3.  ISTAT. Il percorso della maternità: gravidanza, parto e allattamento al seno. Indagine multiscopo sulle famiglie -“Condizioni di salute e ricorso ai servizi sanitari” Anni 1999-2000. Istituto Nazionale di Statistica 2002

4. Istituto Nazionale di Statistica (ISTAT) Annuario di statistiche demografiche. Roma: 1980 Istituto Nazionale di Statistica.

5. Ministero della Salute – Direzione generale della programmazione sanitaria – sistema informativo sanitario – Rapporto annuale sull’attività di ricovero ospedaliero – Dati SDO; 2000.

6.  Supplemento ordinario alla “Gazzetta Ufficiale” n.19 del 23 gennaio 2002 – Serie generale, pag. 37.

Table. Variables relating to pre-natal, intra-partum, and post-partum care, Caserta, 2001