Stillbirths: results of a pilot population-based surveillance system in Italy (SPItOSS)

OBJECTIVES: to describe the results of a pilot population-based perinatal mortality surveillance system, with regards to stillbirths; to study maternal, obstetric, and foetal characteristics, evaluating risk factors and understanding causes. DESIGN: a cross-sectional study was conducted on incident cases of stillbirths collected by the surveillance system from July 2017 to June 2019 in three Italian Regions (Lombardy, Tuscany, and Sicily). SETTING AND PARTICIPANTS: data on stillbirths, resulting from the in-hospital multidisciplinary audits, organised using the Significant Event Audit methodology, were analysed. According to the World Health Organization (WHO) definitions, the project identified stillbirths as foetuses born dead >=28 weeks of gestation. The WHO International Classification of Diseases-Perinatal Mortality was used to categorise the causes of foetal death. MAIN OUTCOMES MEASURES: maternal characteristics, obstetric and foetal findings were investigated. Unadjusted relative risks and 95% confidence intervals were computed with respect to the background population. Finally, causes of death and contributing maternal conditions have been considered. RESULTS: the maternity and neonatal units of the three participating Regions notified 520 stillbirths, of which 435 cases underwent to the multidisciplinary audit (83.7%); 40.0% of cases occurred in the gestational age range between 36 and 39 weeks. The risk of stillbirth was significantly increased in mothers with foreign citizenship (RR: 1.39; 95%CI: 1.13-1.71), multiple pregnancies (RR: 1.59; 95%CI 1.05-2.42), and pregnancies conceived with assisted reproductive technologies (RR: 2.15; 95%CI 1.45-3.19). The rate of congenital malformations was 6.0%. A diagnosis of foetal growth restriction was reported in 10.3% of cases, although the percentage of dead foetuses weighting <10° centile was at least twice in almost all gestational age periods. Post-mortem and placental histological examinations were carried out in more than 70% and more than 90% of cases, respectively. CONCLUSIONS: the implementation of a population-based surveillance system with high participation rate of maternity units and the use of universally accepted definitions could improve the identification of stillbirth avoidable risk factors and potentially modifiable predisposing maternal conditions, highlighting issues of perinatal assistance in need of improvement.

Perinatal care in SARS-CoV-2 infected women: the lesson learnt from a national prospective cohort study during the pandemic in Italy.

BACKGROUND: Despite the growing importance given to ensuring high-quality childbirth, perinatal good practices have been rapidly disrupted by SARS-CoV-2 pandemic. This study aimed at describing the childbirth care provided to infected women during two years of COVID-19 emergency in Italy. METHODS: A prospective cohort study enrolling all women who gave birth with a confirmed SARS-CoV-2 infection within 7 days from hospital admission in the 218 maternity units active in Italy during the periods February 25, 2020-June 30, 2021, and January 1-May 31, 2022. Perinatal care was assessed by evaluating the prevalence of the following indicators during the pandemic: presence of a labour companion; skin-to-skin; no mother-child separation at birth; rooming-in; breastfeeding. Logistic regression models including women' socio-demographic, obstetric and medical characteristics, were used to assess the association between the adherence to perinatal practices and different pandemic phases. RESULTS: During the study period, 5,360 SARS-CoV-2 positive women were enrolled. Overall, among those who had a vaginal delivery (n = 3,574; 66.8%), 37.5% had a labour companion, 70.5% of newborns were not separated from their mothers at birth, 88.1% were roomed-in, and 88.0% breastfed. These four indicators showed similar variations in the study period with a negative peak between September 2020 and January 2021 and a gradual increase during the Alpha and Omicron waves. Skin-to-skin (mean value 66.2%) had its lowest level at the beginning of the pandemic and gradually increased throughout the study period. Among women who had a caesarean section (n = 1,777; 33.2%), all the indicators showed notably worse outcomes with similar variations in the study period. Multiple logistic regression analyses confirm the observed variations during the pandemic and show a lower adherence to good practices in southern regions and in maternity units with a higher annual number of births. CONCLUSIONS: Despite the rising trend in the studied indicators, we observed concerning substandard childbirth care during the SARS-CoV-2 pandemic. Continued efforts are necessary to underscore the significance of the experience of care as a vital component in enhancing the quality of family-centred care policies.

Trend in Breakfast Consumption among Primary School Children in Italy.

Eating breakfast daily improves cognitive function, may contribute to learning and academic performance in children and can decrease the risk of childhood obesity. The aim of this study was to analyse how breakfast consumption changed in the period from 2008/9 to 2019 in Italy among children aged 8-9 years old participating in the OKkio alla SALUTE surveys and to explore the associations with some socio-demographic and lifestyle factors. Information about children's daily breakfast consumption (adequate, inadequate, and no breakfast) and the socio-demographic characteristics of the children and their mothers was collected through four questionnaires addressed to parents, children, teachers and head teachers. Data were analysed for the 272,781 children from 21 Italian regions from 2008/9 to 2019. The prevalence of adequate breakfast decreased from 60.7% in 2008/9 to 55.7% in 2019 and no breakfast from 10.9 to 8.7%; conversely, inadequate breakfast increased from 28.4 to 35.6%. Logistic regression models showed that the occurrence of inadequate or no breakfast consumption was significantly higher among girls, children living in the southern regions and children with less educated mothers. These findings highlight the need for effective interventions to increase daily breakfast consumption and its adequacy among children.

Inequalities in Childhood Nutrition, Physical Activity, Sedentary Behaviour and Obesity in Italy.

Unhealthy diets, physical inactivity and high body mass index (BMI) are preventable risk factors for non-communicable diseases throughout a person's lifespan. The higher prevalence of these risk factors in children from lower socio-economic groups has been generally observed. The aim of this study is to explore the effect of parents' socio-economic conditions on children's consumption of fruit, vegetables and sugar-sweetened drinks, and inactivity, sedentary behaviour, overweight and obesity. This study used data from the sixth cross-sectional survey of the surveillance "OKkio alla Salute" (Italian COSI), involving 2467 schools and 53,275 children in 2019. All the information was collected through four questionnaires addressed to parents, children, teachers and head teachers. The weights and heights of the children were measured with standard techniques and equipment to classify overweight/obesity according to the WOF-IOTF cut-offs. The results showed a high percentage of children who do not adhere to health recommendations and a high prevalence of overweight and obesity. In particular, "less healthy" behaviours and higher BMI were more frequent in children from families with a lower socio-economic status and those residing in Southern Italy. These findings highlight the need for effective interventions that address the differences in these health-related behaviours.

Vaccination against SARS-CoV-2 in pregnancy during the Omicron wave: the prospective cohort study of the Italian obstetric surveillance system.

OBJECTIVES: Evidence on the effects of the SARS-CoV-2 Omicron variant on vaccinated and unvaccinated pregnant women is sparse. This study aimed to compare maternal and perinatal outcomes of women infected with SARS-CoV-2 during the Omicron wave in Italy, according to their vaccine protection. METHODS: This national prospective cohort study enrolled pregnant women with a positive SARS-CoV-2 nasopharyngeal swab within 7 days of hospital admission between 1 January and 31 May, 2022. Women who received at least one dose of vaccine during pregnancy and those who completed the vaccine cycle with the first booster were considered protected against moderate or severe COVID-19 (MSCD). A multivariable logistic regression model evaluated the association between vaccine protection and disease severity. Maternal age, educational level, citizenship, area of birth, previous comorbidities, and obesity were analysed as potential risk factors. RESULTS: MSCD was rare (41/2147, 1.9%; 95% CI, 1.4-2.6), and the odds of developing it were significantly higher among unprotected women (OR, 2.78; 95% CI, 1.39-5.57). Compared with protected women (n = 1069), the unprotected (n = 1078) were more often younger, with lower educational degrees, and foreigners. A higher probability of MSCD was found among women with previous comorbidities (OR, 2.86; 95% CI, 1.34-6.12) and those born in Asian countries (OR, 3.05; 95% CI, 1.23-7.56). The percentage of preterm birth was higher among women with MSCD compared with milder cases (32.0% [8/25] versus 8.4% [161/1917], p < 0.001) as well as the percentage of caesarean section (52.0% [13/25] versus 31.6% [606/1919], p 0.029). DISCUSSION: Although severe maternal and perinatal outcomes were rare, their prevalence was significantly higher among women without vaccine protection. Vaccination during pregnancy has the potential to protect both the mother and the baby, and it is therefore strongly recommended.

A large series of molecular and serological specimens to evaluate mother-to-child SARS-CoV-2 transmission: a prospective study from the Italian Obstetric Surveillance System.

OBJECTIVES: To assay the presence of the SARS-CoV-2 genome in vaginal, rectal, and placental swabs among pregnant women and in newborn nasopharyngeal swabs and to investigate the immunological response and maternal antibody transfer through the umbilical cord blood and milk of unvaccinated mothers. METHODS: Vaginal, rectal, and placental specimens, maternal and neonatal serum, and milk were collected from a wide cohort of pregnant Italian women with confirmed SARS-CoV-2 infection admitted to the hospital between February 25, 2020 and June 30, 2021. Samples were tested in selected reference laboratories according to a shared interlaboratory protocol. RESULTS: Among 1086 enrolled women, the SARS-CoV-2 positive rate detected in all specimens ranged from 0.7% to 8.4%. Respectively, 45.2% of maternal sera collected during pregnancy and 39.7% of those collected at birth tested positive for immunoglobulin G, whereas 50.5% tested positive among neonates. Nasopharyngeal swabs were positive in 0.8% of the newborns, and immunoglobulin G was detected in 3.0% of the milk samples. The highest immunological response was recorded within 30 days during pregnancy and within 60 days of birth and in the neonatal population. CONCLUSION: Vertical transmission should be considered a rare event; although, a good maternal immunological response and antibodies transfer throughout the umbilical cord blood was detected.

Dietary habits, lifestyle, and gestational diabetes in immigrant women: a survey in Northwestern Tuscany (Central Italy).

BACKGROUND: immigrant women diagnosed with gestational diabetes mellitus (GDM) have additional language and cultural obstacles in following lifestyle and dietary recommendations within a Western health care setting. OBJECTIVES: to describe: • sociodemographic characteristics and dietary and lifestyle behaviours in Italian and immigrant pregnant women who underwent a GDM screening; • any differences in these aspects among GDM Italian and immigrant women; • any differences in terms of primary maternal-neonatal outcomes among GDM and normal glucose tolerance (NGT) cohorts. DESIGN: survey. SETTING AND PARTICIPANTS: this survey was conducted in three hospitals located in Tuscany Region (Central Italy). According to a convenience sampling, an ad hoc questionnaire was administered both to Italian and immigrant women who underwent an oral glucose tolerance test. MAIN OUTCOME MEASURES: information about nutrition and lifestyle, medical and obstetric history, clinical and therapy data, maternal and neonatal primary outcomes was analysed. Eating habits have been investigated referring to the prudent diet, in order to also include those foods specifically consumed by the immigrant women, in addition to the Mediterranean Diet which is more widespread among Italians. RESULTS: a total of 117 Italian women (42 diagnosed with GDM) and 95 immigrant women (36 with GDM) were enrolled. Immigrant women showed lower adherence to the prudent diet compared to Italian women (p<0.05) and a broader use of unhealthy food preparation (e.g., frying; p<0.05). Primary maternal and neonatal outcomes (preterm birth, caesarean section, macrosomia) showed no statistical differences among GDM and NGT cohorts. CONCLUSIONS: even if immigrant and Italian women gained similar pregnancy outcomes, immigrant women showed lower adherence to the prudent diet at the time of GDM screening. An ethnic and tailored meal plan is needed to overcome cultural barriers in dietary recommendations during pregnancy in immigrant women.

Placental Characteristics of a Large Italian Cohort of SARS-CoV-2-Positive Pregnant Women.

The variety of placental morphological findings with SARS-CoV-2 maternal infections has raised the issue of poor agreement in histopathological evaluation. The aims of this study were: to describe the histopathological placental features of a large sample of SARS-CoV-2-positive women who gave birth in Italy during the COVID-19 pandemic, to analyse the factors underlying these lesions, and to analyse the impact of placental impairment on perinatal outcomes. From 25 February 2020 to 30 June 2021, experienced perinatal pathologists examined 975 placentas of SARS-CoV-2-positive mothers enrolled in a national prospective study, adopting the Amsterdam Consensus Statement protocol. The main results included the absence of specific pathological findings for SARS-CoV-2 infections, even though a high proportion of placentas showed signs of inflammation, possibly related to a cytokine storm induced by the virus, without significant perinatal consequences. Further research is needed to better define the clinical implications of placental morphology in SARS-CoV-2 infections, but the results of this large cohort suggest that placentas do not seem to be a preferential target for the new Coronavirus infection.

A nationwide surveillance system to reduce perinatal death cases in Italy: implementing a population-based pilot project.

OBJECTIVES: to describe the methodology of a pilot perinatal mortality surveillance system (SPItOSS) aimed to improve quality of care and prevent avoidable perinatal severe morbidity and mortality in three Italian regions. DESIGN: population-based surveillance project monitoring incident cases of stillbirths, born dead ≥ 28 weeks of gestation and live births dying within 7 days. Local multidisciplinary audits in obstetric and neonatal units were conducted to assess causes of each death. A selection of deaths was also discussed by experts in regional and national Confidential Enquiries to assess causes and avoidability. The WHO perinatal mortality definition and the ICD-PM classification were adopted to codify perinatal deaths. SETTING AND PARTICIPANTS: health professionals working in any obstetric and neonatal unit in Lombardy (Northern Italy), Tuscany (Central Italy), and Sicily (Southern Italy), accounting for 32.3% of births in Italy. Data collection started on 01.07.2017 and ended on 30.06.2019. MAIN OUTCOME MEASURES: obstetric and neonatal units' participation rate in the participating regions, facility structural organisation description, health professionals' training course participation, estimate of perinatal death rates, clinical audits and Confidential Enquiries rates. RESULTS: health professionals from all obstetric and/or neonatal units (N. 138) joined the pilot project. Overall, 830 incident perinatal deaths were reported; 699 underwent a facility-based clinical audit, and 94 selected cases were analysed in detail through regional and national Confidential Enquiries. Among the latter, 16.0% were assessed as avoidable deaths. Interregional differences related to the facility structural organisation were identified. CONCLUSIONS: SPItOSS was efficient in identifying and analysing incident cases of perinatal deaths and detecting improvable aspects of care and avoidable perinatal deaths. The next objective is to extend the surveillance at the national level, considering that stable funding and a higher number of participating healthcare professionals and experts will be needed.

Childbirth Care among SARS-CoV-2 Positive Women in Italy.

The new coronavirus emergency spread to Italy when little was known about the infection's impact on mothers and newborns. This study aims to describe the extent to which clinical practice has protected childbirth physiology and preserved the mother-child bond during the first wave of the pandemic in Italy. A national population-based prospective cohort study was performed enrolling women with confirmed SARS-CoV-2 infection admitted for childbirth to any Italian hospital from 25 February to 31 July 2020. All cases were prospectively notified, and information on peripartum care (mother-newborn separation, skin-to-skin contact, breastfeeding, and rooming-in) and maternal and perinatal outcomes were collected in a structured form and entered in a web-based secure system. The paper describes a cohort of 525 SARS-CoV-2 positive women who gave birth. At hospital admission, 44.8% of the cohort was asymptomatic. At delivery, 51.9% of the mothers had a birth support person in the delivery room; the average caesarean section rate of 33.7% remained stable compared to the national figure. On average, 39.0% of mothers were separated from their newborns at birth, 26.6% practised skin-to-skin, 72.1% roomed in with their babies, and 79.6% of the infants received their mother's milk. The infants separated and not separated from their SARS-CoV-2 positive mothers both had good outcomes. At the beginning of the pandemic, childbirth raised awareness and concern due to limited available evidence and led to "better safe than sorry" care choices. An improvement of the peripartum care indicators was observed over time.

The first SARS-CoV-2 wave among pregnant women in Italy: results from a prospective population-based study.

INTRODUCTION: This study aimed to estimate the incidence of SARS-CoV-2 infection among pregnant women during the first pandemic wave in Italy, and to describe COVID-19 disease characteristics and maternal and perinatal outcomes. MATERIALS AND METHODS: National population-based prospective cohort study collecting information on women with SARS-CoV-2 diagnosis, confirmed within 7 days from hospital admission. RESULTS: The national SARS-CoV-2 rate was 6.04 per 1,000 births (95% CI 5.62-6.49) among pregnant women and 7.54 (95% CI 7.47-7.61) among women in reproductive age. 72.1% of the cohort developed mild COVID-19 disease without pneumonia nor need for ventilatory support. Severe disease was significantly associated with women's previous comorbidities (OR 2.55; 95% CI 0.98-6.90), obesity (OR 4.76; 95% CI 1.79-12.66) and citizenship from High Migration Pressure Countries (OR 3.43; 95% CI 1.27-9.25). CONCLUSIONS: During the first pandemic wave in Italy, the SARS-CoV-2 rate among pregnant women was lower compared to that detected among women of reproductive age, and risks of severe COVID-19 disease and adverse maternal and perinatal outcomes were rare.

Area deprivation, perceived neighbourhood cohesion and mental health at older ages: A cross lagged analysis of UK longitudinal data.

Previous research on neighbourhood influences on older adults' mental health shows inconsistent evidence for effects of neighbourhood deprivation but stronger evidence for effects of perceived neighbourhood social cohesion, often proposed as a mediator of the link between neighbourhood deprivation and mental well-being. However, it is possible that mental health influences perceptions of neighbourhoods; this has rarely been considered. We use data from a large UK longitudinal study to investigate these associations. Results from cross-lagged models indicate that greater neighbourhood deprivation is associated with worse perceived social cohesion and worse mental health. Associations between change in perceived social cohesion and in mental health were reciprocal-lower perceived cohesion predicted poorer mental health and vice versa. Further research including three waves of data is needed to further unravel underlying directions of association.

Coronavirus and birth in Italy: results of a national population-based cohort study.

INTRODUCTION: The study was implemented to provide guidance to decision-makers and clinicians by describing hospital care offered to women who gave birth with confirmed SARS-CoV-2 infection. MATERIALS AND METHODS: National population-based prospective cohort study involving all women with confirmed SARS-CoV-2 infection who gave birth between February 25 and April 22, 2020 in any Italian hospital. RESULTS: The incidence rate of confirmed SARS-CoV-2 infection in women who gave birth was 2.1 per 1000 maternities at a national level and 6.9/1000 in the Lombardy Region. Overall one third of the women developed a pneumonia and 49.7% assumed at least one drug against SARS-CoV-2 infection. Caesarean rate was 32.9%, no mothers nor newborns died. Six percent of the infants tested positive for SARS-CoV-2 at birth. CONCLUSIONS: Clinical features and outcomes of COVID-19 in women who gave birth are similar to those described for the general population, most women developing mild to moderate illness.

[The preparedness of the Italian obstetric surveillance system in the response to the emergency of the SARS-CoV-2 pandemic: methodological aspects of a population-based study]. / La preparedness dell'Italian obstetric surveillance system in occasione della pandemia da SARS-CoV-2: aspetti metodologici di uno studio di popolazione.

This paper aims to describe the Italian obstetric surveillance system (ItOSS) preparedness as an element for a timely response to the new Coronavirus pandemic. ItOSS is a surveillance network that has been collecting data on maternal mortality and conducting population studies on obstetric near misses since 2013. At the beginning of the pandemic, ItOSS launched a new population-based project to monitor SARS-CoV-2 infection during pregnancy and post-partum and promptly give back information useful to clinicians and decision-makers. All the regions and autonomous provinces, for a total of 289 birth units (PN), joined the study. Data relating to pregnant or post-partum women with a confirmed SARS-CoV-2 infection diagnosis addressing the maternities for outpatient visits or hospitalization were collected. The project methodology entails that each participating maternity reports the cases to ItOSS uploading data through an open-source platform. The on-line form includes sociodemographic and clinical data and maternal-neonatal outcomes. Biological samples to detect possible vertical transmission are also collected voluntarily. A total of 534 incident cases were reported from February 25th to July 10th 2020; 7 regions also collected biological samples for 227 cases; data collection is still ongoing.A preliminary analysis of the first 146 SARS-CoV-2 positive women who gave birth between February 25th to April 22nd shows an incidence rate of the infection equal to 2.1/1,000 in Italy and 6.9/1,000 in the Lombardy Region (Northern Italy). The brief time needed to setting up and operating the project, the national coverage, the adoption of shared tools for data collection, the quality and completeness of the information collected show how the availability of active networks like ItOSS represents a crucial element to hold a high level of preparedness in case of a health emergency.

Mortality from Alzheimer's disease, Parkinson's disease, and dementias in France and Italy: a comparison using the multiple cause-of-death approach.

OBJECTIVE: We perform an in-depth analysis of all death certificates collected in France and Italy with an entry of Parkinson's disease (PD), Alzheimer's disease (AD), or another dementia. METHOD: Data are for 2008. We measure how frequently these conditions are the underlying cause of death. We then examine what other causes are reported on the certificates. RESULTS: In both countries, AD is the underlying cause for about 6 in 10 certificates with an AD entry. The proportion is lower for PD and dementia, but higher in France than in Italy. Many contributing causes reflect the circumstances surrounding the end of life in AD, PD, and dementia, often characterized by bed confinement and frailty. DISCUSSION: Our research highlights several consequences of the conditions under study that could be targeted by public health policy. It also speaks to the existence of differences in diagnosis/certification practices that may explain differences in mortality levels.

Work-related injuries among immigrant workers in Italy.

In Italy, work-related injuries among immigrant workers are an emerging concern. In this study, we compared the occurrence of work-related injuries between legally residing immigrants from High Migration Pressure Countries and Italians and evaluated the associations with potential risk factors. Using data from the 2007 Labour Force Survey conducted by Italy's National Institute of Statistics, we examined the relationship between the occurrence of work-related injuries in the previous 12 months and being an immigrant among a nationally representative sample. The occurrence of work-related injuries was significantly higher among immigrant males compared to Italian males (adjusted OR = 1.82; 95 % CI 1.53-2.16), particularly in the construction sector, for which the results showed a U-shaped trend of the odds ratios of injuries for immigrants compared to Italians with increasing number of years of work in the same job. No associations were found among women. The findings suggest that prevention programs need to be implemented to limit the burden of work-related injuries among immigrants.