Perinatal health in the Nordic countries - current challenges

Perinatal health refers to the health of a baby at the time of birth and immediately after. It is measured by various indicators, either predicting or describing health, such as pre-term (too early) birth, low birth weight, small for gestational age (poor growth), large for gestational age, malformations, diseases and perinatal mortality (stillbirths and deaths in the first week of life). With the exception of birth weight, these indicators suffer problems with definition and measurement. Due in large part to a lack of other available data, it has been traditional to make surveillance and place/time comparisons using perinatal mortality or birth weight as indicators. The time in a mother’s womb is an important determinant for health in later life. It is obvious for babies who have congenital anomalies, other developmental handicaps or brain injury. But the theory of programming, supported by a number of epidemiological studies, suggests a broader health impact. In international comparisons perinatal health indicators in the Nordic countries show good health. For example, in 2004 Finland, Norway and Sweden were among the countries having low early neonatal mortality (two per 1,000 live births or less), and only Denmark was among the high-rate countries (three or more per 1,000) [1]. The proportion of low birth weight infants of all live births was less than 5% in Finland, Norway and Sweden, and in Denmark it was 5.3. In the rest of Europe the proportions were typically around 7% or more. This may explain why Nordic interest in perinatal health research has focused on risk factors, and studies from a population health perspective have been less in evidence. Internationally the importance of the fetal period to later health has been the focus of much recent discussion and may have contributed to the growing interest, even in the Nordic countries, in studying the level and determinants of and variation in perinatal health. Furthermore, new health challenges for childbearing women (and the fathers of the babies to be born) have been identified. These new challenges include older age in childbearing, alcohol and other intoxicant use, mothers’ obesity, and migrant women who often have different health habits and health status. Furthermore, increasing use of medical technology before and during pregnancy and birth, such as assisted reproduction techniques, fetal screening and caesarean section, has raised concern. A Nordic research group, NorCHASE, which was supported by the Nordic Council of Ministers, has collected from four Nordic countries (excluding Iceland) an impressive database on perinatal health indicators available from birth registers and linked it to parents’ social background as available from population registers. The Nordic countries have a unique research possibility for linking at the individual level health indicators to population registers, including information on demography, socioeconomic conditions, education, income etc. Country comparisons showed that in 1981 to 2000, neonatal deaths, and infant deaths as a whole, decreased in all countries; there was an inverse association between maternal education and risk of death, and the strength of the association varied by time and country [2]. Infant mortality declined over time, but was notably higher in Denmark and Norway (in the 1980s over seven per 1,000 births and at the end of 1990s over four in Denmark) than in Finland and Sweden (less than six in the 1980s and less than four in the 1990s). In all countries and at all times boys had a higher mortality than girls [3].