[Prognosis of the level of perinatal care in the Czech Republic in near future III. From the current medicine point of view]. / Prognóza vývoje perinatální medícíny v Ceské republice do nejblizsí budoucnosti III. Z pohledu soucasného rozvoje medicíny.

AIM OF THE STUDY: Resolution of discrepancy between advances in medicine and limited resources. STUDY DESIGN: Evaluation of the international stand on this issue. METHODS: Comparison of international approaches and management in the Czech Republic. SETTING: Institute for the Care of Mother and Child, Prague-Podolí. RESULTS: The aim of international projects "The Goals of Medicine" and "Social Determinants of Health" was to solve the discrepancy in between current advances in medicine and possibilities to introduce them in the environment of limited resources, coming predominantly from general medical insurance and partly from the government budget. These advances are on one hand the possibility to prolong life of several newborns who were to die before due to better diagnosis and treatment - this though drains substantial proportion of limited resources, on the other hand the improved and resources-demanding prevention measures can maintain good health status of numerous selected risk groups of the population. One of the recommendations of these projects was suggestion to governments to relay and interpret this information to general public this conflict and in discussions with care providers and consumers to balance such level of care which is available to all with respect to social equity. The extent of completion of recommendation of the two international projects and WHO HFA 21 Goals is the matter of summary discussion of all three parts of publication. It is also a base for prognosis of perinatal care level in the Czech Republic in near future. CONCLUSION: Two international projects suggested recommendations how to deal with disparity in between advances in medicine and limited resources. The stand of the Czech Republic on this issue is a matter of summary discussion to all three parts of this publication. It is also a basis for prognosis of level of perinatal care in the Czech Republic in near future.

[Prognosis of the level of perinatal care in the Czech Republic in near future. I. Development of perinatal indicators in the Czech Republic]. / Prognóza úrovne perinatální péce v Ceské republice do nejblizsí budoucnosti I. Z pohledu vývoje ukazatelu v CR.

AIM OF THE STUDY: Prognosis of the development of perinatal care in the Czech Republic in near future. STUDY DESIGN: Nation-wide perinatal epidemiological study. SETTING: Institute for the Care of Mother and Child, Prague-Podoli. METHODS: Four basic conditions for prognosis: previous prognosis, current status (previous and actual nationwide perinatal data), current environment, and international data for comparison. RESULTS: Prognosis of the Czechoslovak Academy of Science from the beginning of eighties to lower perinatal mortality from 15/1000 to 10/1000 until the year 2000 was accomplished already in 1989. Prognosis of Scientific Board of the Czech Ministry of Health from 2004 analyzed in the first part the causes of improvement of perinatal mortality before and after 1990 and the reasons for increase of newborns under 2000 grams and cesarean sections in 90s. The second part of this prognosis predicted stagnation of perinatal mortality around 4/1000 until the year 2000 and postulated two alternatives for low birth-weight rate from 5.9% to a) 6.9% and b) 8.0% and cesarean section rates increase from 13.5% to a) 17% and b) 22%. This projection was based on previous two prognoses, on the data from the year 2000, and on the analysis of demographic and economic circumstances, and on the comparison of international perinatal data. According to the prognosis, the perinatal mortality decreased to 3.4/1000 in 2009, and the low birth-weight rate and cesarean section rate increased according to the alternative b). Increase of centralization of preterm newborns under 1500 grams and improvement of their birth-weight specific early neonatal mortality (the factors which played the main role in decrease of perinatal mortality before) have already stopped. In the situation of further increase of low birth-weight rate and further deterioration of other negative factors we could expect increase of perinatal mortality above 4/1000. CONCLUSION: According to the two previous prognoses we observed improvements of perinatal care. While the reserves for the continuing improvement (medical and organizational) are already exhausted and while the conditions for provision of care are worsening, we could expect worse perinatal results in terms of further increase of low birth-weight rate, increase of cesarean section rate, and elevation of perinatal mortality above 4/1000.

[Prognosis of the level of perinatal care in the Czech Republic in near future II. From the World Health Organization point of view]. / Prognóza úrovne perinatální péce v Ceské republice do nejblizsi budoucnosti II. Z pohledu Svetové zdravotnické organizace.

AIM OF THE STUDY: Evaluation of performance according to Goals of the WHO Project Health for All 21 in the Czech Republic. STUDY DESIGN: Comparative study of the WHO recommendations and the situation in the Czech Republic. SETTING: Institute for the Care of Mother and Child, Prague-Podoli. METHODS: Comparison of completion of 4 out of 21 Goals of the WHO Project Health for All 21 related to perinatal care in the Czech Republic. RESULTS: After experience with the WHO Project HFA 2000 for Europe (introduced in late 70s) consisting of 38 goals for particular fields of medicine to be achieved by the end of 2000 (adapted in 1992), the WHO Project HFA 21 with 21 Goals to be achieved by 2020 was introduced. While in relation to the Project HFA 2000 the Czech Republic analyzed the situation in 1993 without application of individual goals into the health care system, in 2003 the group of experts prepared "Recommendation for achievements of the Goals" of the WHO Project HFA 21. In 4 goals related to perinatal care, the recommendation postulated the ways and timeline and responsibilities in effort to accomplish these tasks. The evaluation of achievements by the year 2009 is attached. In the Goal 3, related to indicators of perinatal care, we have accomplish the decrease of perinatal mortality and the Czech Republic got among countries with the best results. On contrary, we have observed increase of low birth-weight rate and increase of frequency of cesarean delivery, and increase of drug abuse among pregnant women. The legislature in the field of long-term follow-up of handicapped children was not prepared. In the Goal 15 the Czech Republic accomplished the introduction of functional organizational system of care. In the Goal 17, the financing of high level of care was underestimated. In the Goal 20, the health care policy was not prepared to fulfill the requirements of this Goal. CONCLUSION: Comparison of recommendation of the 4 goals of the WHO Project Health for All 21 related to perinatal care in the Czech Republic and the national recommendations was confronted with the results. While the improvements of indicators of level of care and introduction of organization of perinatal care were achieved, the lack of health care policy was the main deficiency of the system.

[Incidence of congenital anomalies among twins in the Czech Republic in international context]. / Vývoj vrozených vývojových vad u dvojcat v CR v mezinárodním srovnání.

AIM OF STUDY: Analysis of different development of congenital anomalies among twins and among singletons in the Czech Republic during 1996-2007 in international context. TYPE OF STUDY: Retrospective epidemiological study. MATERIAL AND METHODS: Nation-wide data from National Registry of congenital anomalies in the Czech Republic by the Institute for Health Information and Statistics (IHIS) for 1996-2007 and selected data from Report on Mothers at Childbirth database by the IHIS for 1996. The results were compared to similar international data in developed countries. RESULTS: The increase of congenital anomalies found in twins in absolute figures due to increase of twin pregnancies as well as per 10 000 live-born babies was always higher during the observed period than among singletons. This pattern was identical with results of similar studies in selected European countries. There were also more anomalies among newborns of mothers after IVF + ET which was in agreement with scarce foreign studies of this type. CONCLUSION: Incidence of congenital anomalies among twins in the Czech Republic increased during the study period and was higher than among singletons. It was also higher among newborns of mothers after IVF + ET than among spontaneously conceived women. These results were in agreement with other international studies.

[Birth defects incidence in children from single and twin pregnancies in the Czech Republic--current data]. / Incidence vrozených vad u detí z jednocetných a dvojcetných gravidit v Ceské republice--aktuální data.

AIM OF STUDY: An analysis of occurrence of birth defects in children from single and twin pregnancies in the Czech Republic in 1994-2007. An assessment of total numbers and relative incidences of birth defects in births according to Tenth Revision of International Classification of Diseases (ICD-10). TYPE OF STUDY: Retrospective epidemiological analysis of birth defects incidences from the Czech National Birth Defects Register database. MATERIAL AND METHODS: Data from the National Birth Defects Register (Institute for Health Information and Statistics) in the Czech Republic in the 1994-2007 period were used. In this study, particular diagnoses--as they were registered in the National Register--were analyzed. Birth defects were analyzed separetely for children from single and twin pregnancies. The diagoses in study were divided into following eleven birth defects groups according to ICD-10 classification: (Q00-Q07) nervous system, (Q10-Q18) eye, ear, face and neck, (Q20-Q28) circulatory system, (Q30-Q34) respiratory system, (Q35-Q37) cleft lip and cleft palate, (Q38-Q45) digestive system, (Q50-Q56) genital organs, (Q60-Q64) urinary system, (Q65-Q79) musculoskeletal system, (Q80-Q89) other defects and (Q90-Q99) chromosomal abnormalities, not elsewhere classified. Total numbers and mean incidences of birth defects separetely for children from single and twin pregnancies were assessed for all these 11 groups. RESULTS: In the Czech Republic during 1994-2007 period, totally 1,312,930 children were born (live births and stillbirts) from single pregnancies, whereas 42,448 from twin pregnancies. A twin rate (out of a total number of births) increased from 2.33% in 1997 to 4.17% in 2004. An overall incidence of diagnosed birth defects was 436.03 per 10,000 live births in singletons and 598.38 in twins. Birth defects incidence (per 10,000 livebirths)in singletons and twins in each of 11 birth defects groups under the study was during the 1994-2007 period as follows: (Q00-Q07) nervous system 9.45 in sigletons and 17.20 in twins, (Q10-Q18) eye, ear, face and neck 21.69 in singletons, and 18.38 in twins, (Q20-Q28) circulatory system 154.16 in singletons and 272.57 in twins, (Q30-Q34) respiratory system 4.92 in singletons and 5.65 in twins, (Q35-Q37) cleft lip and cleft palate 16.79 in singletons and 20.02 in twins, (Q38-Q45) digestive system 18.97 in singletons and 28.74 in twins, (Q50-Q56) genital organs 52.07 in singletons and 56.30 in twins, (Q60-Q64) urinary system 34.21 in singletons and 56.78 in twins, (Q65-Q79) musculoskeletal system 87.49 in singletons and 90.93 in twins, (Q80-Q89) other defects 26.06 in singletons and 22.14 in twins and (Q90-Q99) chromosomal abnormalities 10.20 in singletons and 9.66 in twins. CONCLUSIONS: The study gives differentiated results of incidences of selected types of birth defects in births according to pregnancy multiplicity. A statistically significant difference (p<0.001) in total birth defects incidence in twins compared to singletons was confirmed. Same statistical significance (p<0.001) was also found (twins compared to singletons) in following birth defects or their groups: (Q00-Q07) nervous system, Q20-Q28) circulatory system, (Q38-Q45) digestive system, (Q60-Q64) urinary system, congenital hydrocephalus, some congenital heart defects, cleft lip and/or palateoesophageal atresia, anorectal malformation, hypospadia, congenital hydronefrosis, polydactyly and syndactyly. A statistically significant difference (p<0.01) was found in spina bifida, hypoplastic left heart syndrome, duodenal atresia/stenosis, diaphragmatic hernia and Down syndrome.

[Tumors in children with birth defects. Current data from the Czech Republic]. / Nádorová onemocnení u detí narozených s vrozenou vadou aktuální data v Ceské republice.

AIM OF STUDY: An analysis of birth defects incidences in a co-incidence with children age tumors in the Czech Republic in 1994 - 2005. Some bio-social factors (maternal age, birth weight, gestational week at birth) and their roles were studied as well. TYPE OF STUDY: Retrospective demografic-epidemiological analysis of birth defects and children age tumors incidences in children born in the Czech Republic during 1994 - 2005. MATERIAL AND METHODS: Data from the National Birth Defects Register and National Oncological Register (both run in the Institute for Health Information and Statistics) in the Czech Republic were used along with some additional data from the Register of newborns and Register of mothers at childbirth. Out of these data, a group of children with both birth defect and tumor was analyzed according to particular diagnoses and to some selected bio-social factors. Out of the total number 1707 children with tumor (934 (54.7%) boys and 773 (45.3%) girls) were 1572 children without birth defect and 135 with both tumor and birth defect. Total number of children with birth defect were 39 197 (39 059 live births and 138 stillbirths), 22 741 (58.1%) boys and 16 435 (41.9%) girls (in 21 cases the sex was not specified). In these children totally 53 539 birth defect diagnoses were registered (30 739 in boys, 22 781 in girls and 19 in children with unspecified sex). RESULTS: In 1572 children without birth defect and with tumor, a mean age at time of tumor diagnosis was 3.6 years, in 135 children with both tumor and birth defect was 2.2 years, which is significantly lower (p < 0.001, Mann-Whitney U test). No statistically significant difference was found in birthweight and birthlenght and gestational week and maternal age at time of delivery. An increased frequency of tumors in the group of children with birth defect was found in groups mesothelial tumors (C45 - C49), tumors of urinary tract (C64 - C68) and tumors of head and neck (C00 - C14, C30 - C31). On the other hand, a decreased tumor frequency in the group of children with birth defect was found in groups of lymfoid and haematopoietic tumors ((C81 - C96) and tumors of eye and brain (C69 - C72). As a risk factor of tumorigenesis in in children with birth defect was a birth defect from groups of defects of cardiovascular system, uropoietic system, chromosal aberrations and other unspecified defects. In children with both birth defect and tumor a decreased survival rate (p = 0.0437, Log-rank test) was found. A decreased survival rate was also confirmed after tumor diagnosis, although this decrease was not statistically significant (p = 0.2021, Log-rank test). There is also a highly statistically significant difference (p < 0.001, Log-rank test) in survival between groups with and without a birth defect prior to tumor diagnosis. CONCLUSIONS: A higher risk of tumorigenesis in children with birth defect (compared to children without birth defect) was confirmed. There was also a lower survival in a group of children with tumor and birth defect compared to those with tumor and without birth defects. A higher risk of tumorigenesis in some types of birt defects was also found.

[Stillbirth in the Czech Republic II. Analysis of relationship of selected data]. / Mrtvorozenost v Ceské republice v roce 2005 II. Vzájemné vztahy nekterých evidovaných údaju.

OBJECTIVE: To identify main causes of unchanged stillbirth rate in the Czech Republic. DESIGN: Nationwide retrospective analysis of stillbirth. SETTING: Institute for the Care of Mother and Child, Prague-Podoli. METHODS: Analysis of relationship of selected data on antenatal stillbirth cases of singleton fetuses with birth weight 2000 grams and more without congenital malformations. RESULTS: Among 151 women with stillborn babies who died after 31st week (differentiated to groups of pathological pregnancy, risk pregnancy and no-risk) 30 selected data items were collected. CONCLUSIONS: Prevailing insufficiency of out-patient care was no-referal or late refferal to hospital care, especially among women with pathological course of pregnancy (this is insufficiency in organization of care). On the other hand, the most prevailing insufficiency in hospital care was the underestimation of severity of pathological pregnancies and a return of patients to out-patients care or in case of hospitalization the late decision about termination of pregnancy. Using the results of the analysis the possibility to avoid an intrauterine death was quantified at the level of 0.3 per thousand, which would have impacted on possible decrease of stillbirth rate from 2.7 per thousand to 2.33 per thousand.

[Is there an increasing frequency of long-term perinatal morbidity with decreasing perinatal mortality or is it also declining]. / Zvysuje se frekvence dlouhodobé perinatální morbidity s poklesem perinatální mortality, nebo se soucasne snizuje?

OBJECTIVE: To evaluate the changes of late perinatal morbidity related to the decrease perinatal mortality. DESIGN: Comparative epidemiological study. SETTING: Institute for the Care of Mother and Child, Prague. METHODS: Comparison of epidemiological national and international data on the relationship of perinatal mortality and late perinatal morbidity. RESULTS: When the value of perinatal mortality was higher than 10 per thousand (in developed countries in 90's of the previous century), the incidence of late perinatal morbidity, mostly characterised by the incidence of cerebral palsy and serious mental retardation evaluated in different periods after delivery decreased with the decrease of perinatal mortality. However, with the decrease of specific early neonatal mortality the late perinatal morbidity started to increase. This increase depends on the birthweight and on the selected criteria evaluating the relationship of perinatal mortality and long-term perinatal morbidity in different studies. On the other hand, the absolute number of newborns increases with the decrease of perinatal mortality and the number of infants with late perinatal morbidity decreases. CONCLUSIONS: When perinatal mortality is low, the decrease of specific early neonatal mortality leads to the increase of late perinatal morbidity. The extent depends on the birthweight and on the selected criteria. Absolute number of infants with late perinatal morbidity decreases.

[International comparison of perinatal care in the Czech Republic from the WHO viewpoint]. / Mezinárodní srovnání urovnë perinatálni péce v CR z pohledu WHO.

OBJECTIVE: To verify the excellent level of perinatal care in the Czech Republic in the world-wide context. DESIGN: International comparative perinatal epidemiologic study. SETTING: Institute for the Care of Mother and Child, Prague. METHODS: Analysis of the relationship of perinatal mortality and 8 other selected indicators of perinatal care in 40 countries with perinatal mortality lower than 10 per thousand out of 192 WHO members states. RESULTS: The analysis pointed out than only 6-8 countries achieved the currently lowest perinatal mortality of 4-6 per thousand (out of which less than 2 per thousand are due to the ENM and 2-3 fold more due to the stillbirts, as well the lowest infant mortality (3-5 per thousand) and maternal mortality ratio (less than 15/100 live-born babies). The frequency od CS which was not above 20% in these countries was not interrelated with either perinatal or maternal mortality. In the Czech Republic, all the indicators were closer to lower levels what indicates that the Czech Republic belongs to the countries with the best results. The decreasing perinatal and maternal mortality led to the increasing expenses for the care and these were in negative correlation with the population density. The population density has an impact on the network of health care facilities and on the transport system of pregnant women, pathological newborns and newborn of very low birthweight to perinatal centers. CONCLUSION: Based on the results of the comparative analysis of perinatal mortality and 8 other selected indicators we can evaluate their reliability and also the level of perinatal care. The Czech Republic belongs among countries with the lowest perinatal mortality in the world.

[Stillbirth in the Czech Republic at 2005 year. I. Methods and results of frequency analysis]. / Mrtvorozenost v Ceské republice v roce 2005. I. Metodika a výsledky frekvencní analýzy.

OBJECTIVE: To identify main causes of unchanged stillbirth rate in the Czech Republic. DESIGN: Nationwide retrospective analysis of stillbirth. SETTING: Institute for the Care of Mother and Child, Prague. METHODS: Frequency analysis of selected data on all antenatal stillbirth cases of singleton fetuses with birth weight 2000 grams and more without congenital malformations. RESULTS: This selected group of 151 stillborn babies contributed by more than half to the overall stillbirth rate (1.56 per thousand of 2.7 per thousand). We collected 30 data items including demographic characteristics, social data, data on prenatal care, information about maternal and fetal complications and data on time and place of delivery, using special questionnaire. The analysis has shown that the most of risk factors indentified about 30 years ago has only low value of relative risk today. Only 50% of pregnant women with those risk factors experienced development of one of the five serious pathological statuses. In 52 pregnant women there were no risk factors and no pathological statuses. The more serious clinical status (categories: no risk, risk pregnancy, and pathological pregnancy) the sooner the delivery of prenatal stillbirth. CONCLUSIONS: We created a database of selected stillbirth cases (63% of all stillbirth) using a questionnaire collecting 30 data items on each case (return of 98.1%). Analysis has identified the most frequent maternal and fetal risk factors and serious pathological statuses.

[Analysis of stagnation of perinatal mortality in the Czech Republic]. / Analýza stagnace perinatální úmrtnosti v Ceské republice.

OBJECTIVE: Analysis of stagnation of perinatal mortality level in the CR in 2000-2004. DESIGN: Retrospective nationwide epidemiological study of selected indicators of perinatal care level. SETTINGS: Institute for the Mother and Child Care, Prague, Czech Republic. METHODS: Comparison of selected indicators of perinatal care and conditions for such care during years period 2000-2002 and 2003-2004. RESULTS: Stagnation of perinatal mortality in the Czech republic since 2000 has been the result of two opposite process. On one side it is the continuous increase of newborns of low birth weight as a result of not only biological but also demographic and socio-economic risk factors, which create unfavorable envirement for provision of perinatal care. On the other side it is the improved professional care observed in two areas (prenatal diagnosis of congenital malformations and intensive care in newborns of extremely low birth weight). During 2003-2004 we were still able to observe odds of improvement of professional care against the deteriorating conditions which led to further decrease of perinatal mortality by 0.27 per thousand on average. However, there is a danger that negative factors will prevail in the near future, because reserves for the further improvement of professional care are exhausted and analyzed unfavorable factors are continuously on the rise. This could lead to an increase of the curently low perinatal mortality level. CONCLUSIONS: Stagnation of perinatal mortality in the Czech Republic during the last five years in a range of 4.0-4.4 per thousand is a result of two opposite processes. On one side it is due to improved level of professional care in prenatal diagnosis, and due to centralized intensive care of newborns of extremely low birth weight. However, the reserves in those two areas are already exhausted. On the other side there are the deteriorating conditions (demographic and social) for such care, which are continuously on rise. While the first process has been prevailing until now with the resulting minimal decrease of perinatal mortality by 0.4 per thousand, there is a danger that the ballance will change in the near future.

[How the acceptance of WHO definition on stillbirth influences perinatal mortality in the Czech Republic]. / Jak ovlivní prijetí definice WHO o mrtvorozenosti perinatální umrtnost v CR.

OBJECTIVE: To evaluate the impact of suggested change of stillbirth definition of newborns 500-999 grams on the total perinatal mortality in the Czech Republic. DESIGN: Retrospective epidemiological analysis of stillborn fetuses of extremely low birth weight registered as miscarriages. SETTING: Institute for the Mother and Child Care, Praha, Czech Republic. METHODS: Comparison of trial nationwide registration of stillborn babies of 500-999 grams through the Czech Society of Perinatal Medicine in 2003 and 2004 with the official obligatory registration of miscarriages of the same birth weight at the Czech Office of Health Statistics and Information. RESULTS: Comparing the database of aggregated national data on stillborn babies 500-999 grams and the database of individual data on miscarriages of the same birth weight we found that the number of stillborn babies in 2003 was 15% smaller than number of miscarriages (151 versus 178). This relatively small difference due to insufficient trial registration in one of 14 regions suggests quite good nationwide readiness to new still births registration after the definition is changed. Contribution of congenital malformations was the same in both databases (41%) it should not be included in new perinatal mortality, because these cases are rather results of successful prenatal diagnosis followed by termination of pregnancy than "adverse outcome" of perinatal care. Even if the stillborn babies of 500-999 grams without congenital malformations are included, which would increase current perinatal mortality by 1.0%, the Czech Republic would still belong to countries with the lowest perinatal mortality in the world while following the WHO recommended definitions. CONCLUSION: Accepting the WHO definition which includes the stillborn babies of 500-999 grams into total perinatal mortality, which are until now registered as miscarriages in the Czech Republic, the total perinatal mortality would increase by 1.6 per thousand. If the babies after induced termination of pregnancy due to genetic indications (diagnosed until 22nd week of gestation) are not included, the increase would be of 1.0 per thousand only.

[Importance of registry of aggregated data on women giving birth]. / Význam registru agregovaných údaju o rodicce.

OBJECTIVE: Analysis of causes of unchanging level of national perinatal mortality and identification of potential for its further decrease. DESIGN: Retrospective epidemiological analysis of aggregated data on perinatal care. SETTING: Mother and Child Care Institute, Prague 4-Podolí. METHODS: Correlation of selected national aggregated data on the level of perinatal care under current system and under influence of changing conditions for care provision. RESULTS: The analysis of some criteria of perinatal care demonstrated the influence of several contradictory processes: 1) among newborns below 2500 grams the stillbirth increased while the early neonatal mortality decreased; there was also decrease of contribution of congenital malformation in this group, 2) although there were more live born babies under 500 grams, who suffered from high mortality, their contribution to perinatal mortality was compensated by further decrease of early neonatal mortality of newborns weighing 1000-1499 grams, 3) the increasing frequency of low birthweight newborns did not influence the total perinatal mortality due to improved perinatal care. We observed the improvement of results among half of the regional perinatal centres with formerly higher early neonatal mortality figures, which represents the decrease of one of the reserves for further decrease of early neonatal mortality. There is a similar situation in centralisation of preterm deliveries--transfer in utero--which reached its maximum. Up to now we did not succeed in early referral of women with serious pregnancy complications which lead to stillbirth to perinatal centres with lower stillbirth rates. However this represents only small potential for decrease of total perinatal mortality. CONCLUSION: The 4-year stagnation of national perinatal mortality is a result of contradictory influence of improving level of care on one side and worsening of conditions on the other side. The potential for improvement under current conditions is almost exhausted.

When is it possible to meet the wish of a woman to terminate her labour by caesarean section?

The authors have evaluated 311 answers of Czech obstetricians to the questionnaire concerning their attitude towards pregnant women that want to terminate their labour by caesarean section. The questionnaire contained six model situations: (1) normal delivery; (2) previous caesarean section; (3) breech presentation; (4) previous delivery of an injured baby; (5) protracted labour and (6) caesarean section apparently indicated by another obstetrician. In each situation the obstetrician was encouraged to choose from five different answers. The results have revealed the lack of unanimity in some cases, 3, 4 and 5. Here we feel that the obstetrician should meet the wish of the woman. However, in those situations that are clear from the medical point of view and where there is no professional indication for a caesarean section, it is in accordance with the Czechoslovak rule of law not possible to meet the wish of the woman.

Countrywide perinatal surveillance in Czechoslovakia.

Countrywide perinatal surveillance in four 10-year periods of Maternal Child Health (MCH) care development in Czechoslovakia is described. During this time maternal mortality decreased from 137 to 17/100,000 live births, and perinatal mortality (PMR) from 51 to 12/1000. On the basis of study results, countrywide intervention strategies concerning organization as well as medical measures were gradually drawn up. The greatest decrease in PMR was found through basic perinatal care for all; greatest efficiency followed employment of a risk approach.

[Analysis of the increased frequency of cesarean section in the Czech Republic]. / Analýza zvýsení frekvence císarského rezu v Ceské republice.

From the results of the nationwide analysis of the quality of perinatal care made every year ensues that in the period from 1986-1993 the mean annual increase of caesarean sections (SC) increased by 0.5%. In this increment more than 90% account for deliveries of neonates with a birth weight of 2,000 g and more without VVV. The effectiveness of the increment of SC from 7 to 10% measured by the decrease of perinatal mortality rate represents a decrease by 0.7% only. This effectiveness is higher in perinatological centres than in hospitals which refer pathological pregnancies to centres, and is lowest in hospitals which do not refer these cases. As to different indications which participated in the increased frequency of SC participated mainly foetal hypoxia, preceding SC, dystocia and disproportion. The higher the frequency of SC, the more frequently the decision taking of the doctor as regards these indications is influenced also by non-medical standpoints.

[Importance of registry of parturient data]. / Význam registru individuálních údaju o rodicce.

OBJECTIVE: Analysis of the influence of age changes from younger parturients to older ones on the perinatal care results. DESIGN: Retrospective epidemiological study of maternal age and other selected indicators. SETTING: Institute for the Care of Mother and Child, Prague 4-Podolí. METHODS: Comparison of selected biological and social risk factors, obstetrical interventions, and perinatal mortality in maternal age groups. RESULTS: During the shift from younger to older groups of parturients there is consistent pattern of higher perinatal mortality among the youngest and older ones. The same pattern is preserved while analysed by social risk factors and risk factors from obstetrical history. In contrast, most of selected obstetrical parameters increased continuously with the increasing age of mother. The final perinatal mortality figure is a result of complex influence of all negative factors and the obstetrical intervention to paralyse them. The recent shift from the youngest mothers to older groups has had some positive impact, however the further increase of mothers 30 years old and older may show some negative influence on perinatal care results. CONCLUSION: The age shift among parturients from younger to older age groups contributed to decrease of perinatal mortality in the Czech Republic in late nineties. We suggest a possible negative influence of further increase of pregnant women 30 years old and older on the current results of perinatal care.

[The development of perinatology centers in the professional and organizational system of maternal and child care]. / Vznik a význam perinatologických center v odborne-organizacním systému péce o matku a díte.

The author analyzes the delay in historical development as regards establishment of perinatological centres in the Czech Republic, as compared with other advanced countries, the task of these centres being specialized care of women with the most serious pathological conditions during pregnancy, with premature labour before the 32nd week, and care of there newborn babies. By means of three internationally recognized criteria which evaluate the quality of this care marked improvement of care of these women and neonates was found in 12 officially established centres in the Czech Republic, as compared with other maternity hospitals. This contributed in a major way to the nationwide reduction of the perinatal mortality. At the same time considerable differences were found in the results of this care between different centres and also inadequate centralization of women with the mentioned complications into perinatological centres. The revealed shortcomings will stimulate provisions for the improvement of perinatal care in the Czech Republic.

[How can we prevent a further increase in the rate of cesarean sections in the Czech Republic?]. / Jak zabránit dalsímu zvýsení frekvence sectio caesarea v Ceské republice?

In countries with a high rate of Caesarean sections (SC) and a low perinatal mortality rate provisions are made to prevent a further increase of the rate of SC. The reason is the 4-8 times higher maternal mortality rate in SC than after vaginal delivery and the declining effectiveness of an increased rate of SC on further reduction of the perinatal mortality, if the rate of SC exceeds 10%. In the Czech Republic the nationwide mean frequency of SC in 1994 has surpassed this range (10.5% SC). A rapid rise of the rate of SC in the CR occurred in maternity homes in the field, where this upper borderline should be by 3-4% lower, as well as in perinatological centres where it should not be higher than 15%. Because investigations abroad provided evidence that mere publicity drawing attention to the mentioned risks of a rising frequency of SC does not suffice to stop the increase, the author submits proposals for professional, organizational and control measures.

[Trends in the frequency of obstetrical operations and perinatal mortality in the Czech Republic in comparison with other countries]. / Vývoj frekvence porodnických operací a perinatální úmrtnosti v Ceské republice v mezinárodním srovnání.

In an international epidemiological survey during a 10-year period the increase of obstetric operations was investigated in 11 countries with advanced perinatal care. Major differences were found as regards the frequency of Caesarean sections as well as vaginal operations (forceps and vacuum extraction). The mean effectiveness of the increase in the frequency of Caesarean sections on the reduction (evaluated by the mille drop of perinatal mortality rate is reduced when the frequency of Caesarean section) exceeds about 10%. Of all investigated countries only the Netherlands and the Czech Republic achieve a low perinatal mortality, while the frequency of Caesarean sections is low. The author discusses the reasons for the revealed differences between different countries.