Miguel Ángel Luque Fernández

Abstract: Dans les populations à faible couverture vaccinale, les épidémies se produisent régulièrement tous les deux ou trois ans. L'augmentation de la couverture vaccinale entraîne une allongé des périodes inter-épidémiques. Cependant à Lubutu il faut s'attendre dans les années à venir une plus grande proportion des cas parmi les enfants plus âgés de 24 mois. La vaccination permet de réduire l'incidence de la maladie en offrant une immunité aux enfants vulnérables. La morbidité et la mortalité de ces foyers peuvent être particulièrement élevées si ces groupes présentent également des facteurs de risque sous-jacent pour des maladies graves, telles que la suppression immunitaire, la malnutrition et les carences en vitamine A. L'effectivité vaccinale estimée pour la zone rurale (supérieur au 90%) nous indique que la campagne de vaccination menée par Médecins Sans Frontières a eu un impact assez important. Toutefois, pour éviter les épidémies à répétition il faudra continuer de vacciner les nouvelles cohortes d'enfants nés dans la zone de santé dans le cadre du programme de vaccination élargie et reprendre les campagnes de vaccination de masse dans les aires de santé à faible couverture.

Abstract: Ce troisième Tableau de bord de la santé en Région bruxelloise offre une vision globale de la santé de la population bruxelloise, enrichie de 10 années d�observation (1998-2007) et intégrée au contexte démographique, social et multiculturel de la région. Ce Tableau de bord 2010 s�adresse à tous ceux qui, d�une manière ou d�une autre, participent à l�élaboration et à la mise en oeuvre d�une politique coordonnée de santé : responsables politiques, professionnels de santé ou acteurs impliqués dans les nombreux domaines qui déterminent la santé de la population. Ce Tableau de bord ne se veut pas exhaustif. Le développement de certaines thématiques dépend non seulement de l�existence ou non de données et des limites en termes de temps et de moyens d�analyse, mais correspond également à un choix. La place importante faite, dans cette édition, aux inégalités sociales de santé (Partie III) veut mettre en lumière le fait que le statut social reste le déterminant le plus puissant de l�état de santé. L�amélioration de la santé de la population ne peut se faire uniquement à travers l�offre de services et de soins mais nécessite également une mobilisation concertée de tous les acteurs pouvant agir sur les déterminants sociaux (dans les domaines de l�emploi, du revenu, du logement, de l�éducation, de l�environnement �). La Commission communautaire commune en est d�ailleurs consciente puisqu�elle a mis au centre de sa déclaration gouvernementale 2009-2014 la lutte contre les inégalités sociales de santé. En plus d�un rappel du Contexte général (Partie I) et de la partie développant l��tat de santé (Partie II), on trouvera également dans cette troisième édition, une section intitulée Cycle de vie (Partie IV), qui reprend et détaille certaines informations par phase de la vie ; une section Offre et consommations de soins (Partie V), encore peu étoffée, clôture cet ouvrage. Il n�y a pas de section concernant la santé et l�environnement car nous prévoyons de creuser certains aspects de cette thématique ultérieurement. Les sources utilisées sont multiples : les bulletins statistiques de naissance et de décès, les résultats d�enquêtes, mais également des données quantitatives et qualitatives recueillies par des administrations, des professionnels de santé, des associations ou des chercheurs. On trouvera des précisions sur ces sources, ainsi que des explications sur la méthodologie employée dans les analyses, dans la section Sources et éléments de méthodologie (Partie VI) ; les notions explicitées sont signalées dans le texte par un style en italique et une *. Pour faciliter la lecture du rapport, nous avons volontairement limité les tableaux complexes et les données par commune ; ces données sont cependant disponibles sur notre site, dans d�autres publications ou à l�Observatoire, sur demande. Ce Tableau de bord est un outil complémentaire à nos autres publications. Nous encourageons vivement les lecteurs à compléter les informations à l�aide de nos autres publications : Atlas de la santé et du social, Atlas «Vivre chez soi après 65 ans», Indicateurs de santé périnatale, �valuation du programme de dépistage organisé du cancer du sein, Fiches statistiques sanitaires et sociales communales, Rapports sur l�état de la pauvreté. Enfin ce Tableau de bord se veut un outil d�aide à la décision : c�est de la discussion avec les acteurs, de la confrontation des chiffres avec la réalité et l�expertise de terrain que se dégageront les pistes pour améliorer la santé et la qualité de vie de tous les Bruxellois. Cette publication ne se veut donc pas l�aboutissement mais le début d�un processus que nous espérons riche d�échanges et de questionnements. L�équipe de l�Observatoire de la Santé et du Social de Bruxelles-Capitale

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Abstract: ABSTRACT: BACKGROUND: In highly populated African urban areas where access to clean water is a challenge, water source contamination is one of the most cited risk factors in a cholera epidemic. During the rainy season, where there is either no sewage disposal or working sewer system, runoff of rains follows the slopes and gets into the lower parts of towns where shallow wells could easily become contaminated by excretes. In cholera endemic areas, spatial information about topographical elevation could help to guide preventive interventions. This study aims to analyze the association between topographic elevation and the distribution of cholera cases in Harare during the cholera epidemic in 2008 and 2009. METHODS: We developed an ecological study using secondary data. First, we described attack rates by suburb and then calculated rate ratios using whole Harare as reference. We illustrated the average elevation and cholera cases by suburbs using geographical information. Finally, we estimated a generalized linear mixed model (under the assumption of a Poisson distribution) with an Empirical Bayesian approach to model the relation between the risk of cholera and the elevation in meters in Harare. We used a random intercept to allow for spatial correlation of neighbouring suburbs. RESULTS: This study identifies a spatial pattern of the distribution of cholera cases in the Harare epidemic, characterized by a lower cholera risk in the highest elevation suburbs of Harare. The generalized linear mixed model showed that for each 100 meters of increase in the topographical elevation, the cholera risk was 30\% lower with a rate ratio of 0.70 (95\% confidence interval=0.66-0.76). Sensitivity analysis confirmed the risk reduction with an overall estimate of the rate ratio between 20\% and 40\%. DISCUSSION: This study highlights the importance of considering topographical elevation as a geographical and environmental risk factor in order to plan cholera preventive activities linked with water and sanitation in endemic areas. Furthermore, elevation information, among other risk factors, could help to spatially orientate cholera control interventions during an epidemic.

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Abstract: This ecological study describes the cholera epidemic in Harare during 2008-2009 and identifies patterns that may explain transmission. Rates ratios of cholera cases by suburb were calculated by a univariate regression Poisson model and then, through an Empirical Bayes modelling, smoothed rate ratios were estimated and represented geographically. Mbare and southwest suburbs of Harare presented higher rate ratios. Suburbs attack rates ranged from 1.2 (95% Cl = 0.7-1.6) cases per 1000 people in Tynwald to 90.3 (95% Cl = 82.8-98.2) in Hopley. The identification of this spatial pattern in the spread, characterised by low risk in low density residential housing, and a higher risk in high density south west suburbs and Mbare, could be used to advocate for improving water and sanitation conditions and specific preparedness measures in the most affected areas.

Abstract: Numerous studies have highlighted poorer reproductive and perinatal health outcomes among migrant mothers in developed countries. Due to the fact that no conclusive data is currently available at national level in Spain, this study aimed to explore potential differences by comparing the prevalence of low and multiple live births and the proportion of live births by maternal age and country of origin during 1996-2006.

Abstract: We performed a descriptive study of tuberculosis cases detected by the Epidemiological Surveillance System in the Balearic Islands in the triennium 2005-2007. Our goal was to characterize underreported cases in sociodemographic terms and their contact with primary care. Overall, underreporting of tuberculosis was approximately 20%. Significant factors in multivariate analysis were social marginality (consisting of alcoholism, intravenous drug use or indigence) (aOR: 2.6 [1.2 to 5.3]), contact with primary care (aOR: 3.2 [1.4 to 7.1]), and extrapulmonary tuberculosis (aOR: 5.5[3.2-9.6]). We recommend strengthening notification by hospital specialists through the use of hospital electronic records. Our findings show that the information obtained from the primary care computerized history is helpful in improving the epidemiological surveillance of tuberculosis.

Abstract: Background: Socio-economic differences are a major determinant of perinatal outcomes. The impact of low socio-economic status on the risk of stillbirth, and the association between socio-economic status and stillbirth by maternal country of origin at a national level in Spain are unknown. We aimed to analyse the effect of maternal socio-economic status on the risk of stillbirth by maternal country of origin in Spain for the years 2007 and 2008. Methods: We designed a population-based observational study that included 970 740 live births and 2464 stillbirths from 2007 to 2008. Univariate risk ratios (RRs) of stillbirth were calculated by maternal education, country of origin, age, parity, and gestational age. Adjusted stillbirth RRs were calculated using a generalized linear model with the Poisson family. Then, adjusted attributable risks and aetiological fractions in the population were calculated as measures of impact. Results: Stillbirth rate ranged from 1.0 to 4.7 deaths per 1000 births.The stillbirth risk among mothers having secondary or lower education was double than that of mothers with a tertiary education with an adjusted RR of 2.13 [95% confidence interval (CI): 1.74�2.60]. African mothers, compared with mothers from Spain, showed an adjusted stillbirth RR of 1.75 (95% CI: 1.54�2.00). Discussion: This study confirms the differences of stillbirth risk by maternal socio-economic status. Regardless of socio-economic status, African mothers had the highest risk of stillbirth. These results point out the necessity to reduce factors related to social and health inequalities in perinatal mortality in Spain, and more specifically, to take into consideration the special vulnerability of African mothers.

Abstract: In Europe, different studies have identified immigrant women coming from developing countries as a risk group for maternal death. In Spain, an ecological study showed higher maternal mortality rates among foreign mothers compared with Spanish mothers during 2003-04. To examine whether the maternal death risk among foreign mothers in Spain is increased, we performed a population-based matched case-control study. Each case of maternal death during 1999-2006 was matched with four mothers who had given birth during the same year the case occurred. The National Statistics Institute provided the data. The variables in the study were maternal age and country of origin. We used a conditional logistic regression analysis. Adjusted by age, the risk of maternal death was 87% higher among foreign mothers. This study confirms that there is an increased risk of maternal death among foreign mothers in Spain. It would be desirable to analyse the socio-economic and healthcare circumstances surrounding the deaths.

Abstract: BACKGROUND: Socio-economic differences are a major determinant of perinatal outcomes. The impact of low socio-economic status on the risk of stillbirth, and the association between socio-economic status and stillbirth by maternal country of origin at a national level in Spain are unknown. We aimed to analyse the effect of maternal socio-economic status on the risk of stillbirth by maternal country of origin in Spain for the years 2007 and 2008. METHODS: We designed a population-based observational study that included 970�740 live births and 2464 stillbirths from 2007 to 2008. Univariate risk ratios (RRs) of stillbirth were calculated by maternal education, country of origin, age, parity, and gestational age. Adjusted stillbirth RRs were calculated using a generalized linear model with the Poisson family. Then, adjusted attributable risks and aetiological fractions in the population were calculated as measures of impact. RESULTS: Stillbirth rate ranged from 1.0 to 4.7 deaths per 1000 births. The stillbirth risk among mothers having secondary or lower education was double than that of mothers with a tertiary education with an adjusted RR of 2.13 [95% confidence interval (CI): 1.74-2.60]. African mothers, compared with mothers from Spain, showed an adjusted stillbirth RR of 1.75 (95% CI: 1.54-2.00). Discussion: This study confirms the differences of stillbirth risk by maternal socio-economic status. Regardless of socio-economic status, African mothers had the highest risk of stillbirth. These results point out the necessity to reduce factors related to social and health inequalities in perinatal mortality in Spain, and more specifically, to take into consideration the special vulnerability of African mothers.

Abstract: To determine the incidence of acute gastroenteritis in pilgrims on St. James' Way, as well as associated risk factors and microbiological characteristics.

Abstract: OBJECTIVES: The objectives of this study were to estimate the accuracy of using mid-upper-arm circumference (MUAC) measurements to diagnose severe wasting by comparing the new standards from the World Health Organization (WHO) with those from the US National Center for Health Statistics (NCHS) and to analyze the age independence of the MUAC cutoff values for both curves. METHODS: We used cross-sectional anthropometric data for 34 937 children between the ages of 6 and 59 months, from 39 nutritional surveys conducted by Doctors Without Borders. Receiver operating characteristic curves were used to examine the accuracy of MUAC diagnoses. MUAC age independence was analyzed with logistic regression models. RESULTS: With the new WHO curve, the performance of MUAC measurements, in terms of sensitivity and specificity, deteriorated. With different cutoff values, however, the WHO standards significantly improved the predictive value of MUAC measurements over the NCHS standards. The sensitivity and specificity of MUAC measurements were the most age independent when the WHO curve, rather than the NCHS curve, was used. CONCLUSIONS: This study confirms the need to change the MUAC cutoff value from <110 mm to <115 mm. This increase of 5 mm produces a large change in sensitivity (from 16% to 25%) with little loss in specificity, improves the probability of diagnosing severe wasting, and reduces false-negative results by 12%. This change is needed to maintain the same diagnostic accuracy as the old curve and to identify the children at greatest risk of death resulting from severe wasting.

Abstract: This study aimed to compare maternal mortality by province, autonomous region and mother's country of birth in Spain during 1999-2006.

Abstract: In Europe, different studies forecast an increase in maternal mortality in the coming years, associated with advanced maternal age and delay in maternity. This study aims to analyse the age-related trend in the maternal mortality ratio among mothers in Spain for the decade 1996-2005, and to describe the causes of death and associated sociodemographic factors for the years with highest mortality.

Abstract: In this study, we aimed to describe the evolution of three cholera epidemics that occurred in Lusaka, Zambia, between 2003 and 2006 and to analyse the association between the increase in number of cases and climatic factors. A Poisson autoregressive model controlling for seasonality and trend was built to estimate the association between the increase in the weekly number of cases and weekly means of daily maximum temperature and rainfall. All epidemics showed a seasonal trend coinciding with the rainy season (November to March). A 1 degrees C rise in temperature 6 weeks before the onset of the outbreak explained 5.2% [relative risk (RR) 1.05, 95% CI 1.04-1.06] of the increase in the number of cholera cases (2003-2006). In addition, a 50 mm increase in rainfall 3 weeks before explained an increase of 2.5% (RR 1.02, 95% CI 1.01-1.04). The attributable risks were 4.9% for temperature and 2.4% for rainfall. If 6 weeks prior to the beginning of the rainy season an increase in temperature is observed followed by an increase in rainfall 3 weeks later, both exceeding expected levels, an increase in the number of cases of cholera within the following 3 weeks could be expected. Our explicative model could contribute to developing a warning signal to reduce the impact of a presumed cholera epidemic.

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Abstract: To determine fertility trends in Spain and whether women's specific fertility rates differ by age and nationality during the period 1996-2006.

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Abstract: To describe trends in fertility, fetal death rate, prematurity and low birth weight, as well as their association with advanced maternal age, in Spain from 1996 to 2005.

Abstract: OBJECTIVES: To estimate the prevalence of genital ulcer and urethral discharge in Pweto, Democratic Republic of Congo, and to analyze the association between the estimated prevalence and age, marital status, profession, and number of sexual partners. METHODS: We performed a descriptive cross-sectional study through a survey conducted in May 2004 in a representative sample of 106 men in Pweto aged between 15 and 65 years old, with a precision of 9.5%. Questionnaire items about current or previous ulceration and urethral discharge where self-reported and referred to the previous year as of the date of the survey. To study the associations, crude and adjusted odds ratios (OR) were calculated using multivariate logistic regression. RESULTS: The prevalence was 39.6% (95% confidence interval [CI], 30-49) for urethral discharge and 33% (95%CI, 24-42) for genital ulcer. Soldiers were identified as a risk group independently of age, the number of sexual partners during the previous year, and marital status. The multivariate analysis showed an adjusted OR of 3.25 (95%CI, 1.10-9.95) (p < 0.05) for the frequency of urethral discharge in soldiers compared with other professions. CONCLUSIONS: The high prevalence of sexually transmitted infections in Pweto and the associated factors identified prompted the initiation of a controlled condom donation program for soldiers. In conflict situations with a high prevalence of sexually transmitted infections and lack of health services, humanitarian aid organizations should implement prevention activities focused on risk groups.

Abstract: An outbreak of acute gastroenteritis occurred in a nursing home for elderly in Majorca between 4 and 23 February 2008. To know its aetiology and mechanism of transmission a retrospective cohort study was conducted with a fixed cohort including 146 people (96 residents and 50 employees). The data were collected from clinical histories and through a survey by questionnaire. In total 71 cases were identified (53 residents, 18 employees), corresponding to an overall attack rate (AR) of 48.6%.

Abstract: Introduction: The WHO "World Health Report 2005" calls attention to the international medical community about the invisible health crisis causing the maternal deaths in the poorest countries of the world. Under the slogan "Make every mother and child count", the maternal mortality was recognised as a huge international public health and human rights problem. Objective: Increase the number of institutional deliveries trough an action research, with the objective to reduce indirectly maternal mortality. Methods: A qualitative-quantitative community trial was conducted in Pweto (Democratic Republic of Congo) from 2002 to 2004. An intensive ethnographic research was done to obtain the key determinants of the low proportion of institutional deliveries from the mother's perspective and an intervention was started. The program's efficiency was measured through a T student test comparing the number of deliveries attended in the institution before and after the intervention. Results: The increase of 1279 deliveries observed after the intervention has statistically significance (T:-12,062 with 28 grade of liberty, p<0,01) demonstrating a strong positive lineal association between the number of institutional deliveries and the intervention carried out (R2:0,81 p<0,01). Discussion: International health cooperation projects have to consider maternal mortality as a cross-cutting problem which needs to be addressed in all their interventions. Simple intervention, focusing on answering to the problems perceived by the women, could increase the number of institutional deliveries in regions of humanitarian aid such as Pweto. Key-words: Prevention. Maternal Mortality. Community intervention. International health cooperation. International public health. Human rights.

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Abstract: To wathc behavioural patterns of cultural origin during delivery in inmigrant women which could haverd health assistance. Material and methods: Qualitative investigation based upon participating observation and twenty semi-structured interviews to inmigrant women. Results: Cultural sensitivities regarding sense of prudeness and the preference for female obstetric assistance have been found, also in perception of attitude towards labour pain, in company preferences during labour, in their experience and perception (position during third stage, acceptance of medicalised labour, etc.), as well as in patterns of inmediate interaction with the newborn. Conclusions: The differences found, which can not be generalised towards the whole of women from the same geographical origin, occasionally are misunderstood by the health profesionals, and may help us understand that our model of performance is not the only one, or the best, or the most "natural", allowing to establish a health assistance sensitive to every woman's needs.

Abstract: Introduction: In the last third of the twentieth century a change occurred in reproductive patterns in Spain, characterized mainly by a sharp decline in birth rates and an increase in maternal age at first pregnancy. In 2006, with an average 1.3 children per woman of reproductive age, Spain was ranked among the countries with the lowest fertility rates in the world, just above Ukraine and Greece. However, despite this low fertility rate, the number of pregnancies in women over 35 years of age has increased steadily in the last twenty years, accounting for 21.2% of births in 2006. Several authors have found increases in fertility among women over 35 to be associated with increased maternal and fetal morbi-mortality. Maternal mortality is considered a preventable cause of death that is strongly correlated with the quality of the care system and the socio-economic status of women. Several international studies have shown that immigrant mothers in developed countries show worse obstetric and perinatal outcomes than indigenous mothers Although these changes in reproductive patterns in Spain are documented, little is known about their impact on obstetric and perinatal outcomes. Therefore, the overall objective of this thesis was to analyze the impact of changes in reproductive patterns in terms of maternal and fetal-neonatal morbi-mortality in Spain during the period of 1996-2006. The specific objectives were as follows: Specific objectives related to perinatal and fertility outcomes: 1. To describe and analyze trends in fertility, fetal mortality rate, prematurity and prevalence of low birthweight in Spain during 1996-2005. 2. To analyze the association between advanced maternal age and fertility, fetal mortality rate, prematurity and low birthweight in Spain during 1996-2005. 3. To analyze the risk of low birthweight according to the country of origin of the mother during 1996-2006 in Spain. 4. To determine fertility trends in Spain and whether women�s specific fertility rates differed by age and country of origin during the period of 1996�2006. 5. To compare the prevalence of births among mothers over 35 years of age by country of origin in Europe, including Spain, during 2000-2005. Specific objectives related to maternal mortality: 6. To analyze maternal mortality ratios in Spain during 1996-2005. 7. To describe causes of maternal death according to the International Code of Classification of Diseases, tenth version, and related socio-demographic factors. 8. To compare maternal mortality risk by political administrative region in Spain and by mother�s country of origin during 1999-2006 at an ecological level (with aggregated data). 9. To analyze the risk of maternal mortality by mother�s country of origin during 1999-2006 in Spain at an individual level (with individual data). Methods: Six studies were developed to answer the specific research objectives described above: two population-based observational studies, three ecological studies including two analyses of trends and one observational study, and an observational population-based case-control study. The methods used in each of these studies were as follows: First study: A population-based observational study. This study addresses the first two research objectives. The association of low birthweight, prematurity and stillbirth with maternal age was analyzed using a binomial probability distribution based on contingency tables. Prevalence ratios and risk ratios were presented as measures of association with their respective 95% confidence intervals. The risk of stillbirth adjusted by age and prematurity was analyzed using Poisson regression models. Second study: A population-based observational study. This study addresses the third specific research objective and describes the prevalence of low birthweight, pregnancies in women over 35 years of age and multiple pregnancies by mother�s country of origin. A logistic regression model was used to analyze the probability of low birthweight by mother�s country of origin, and odds ratios were presented as measures of association with their respective 95% confidence intervals. Third study: A population-based ecological study of trends. To address the fourth specific research objective, this ecological study of trends compared fertility rates by mother�s country of origin using a direct standardization method. The fertility rates of foreign women versus Spanish women, adjusted by maternal age and study period, were compared using a generalized linear model under the assumption of a Poisson distribution. A trend analysis of fertility rates during the study period by mother�s age and country of origin was presented using time plots and linear regression models. Fourth study: A population-based ecological study of trends. This study provides answers to the fifth, sixth and seventh specific objectives. Trends in maternal mortality rates were analyzed using Poisson regression models adjusted for age and study period. A descriptive analysis of basic socio-demographic factors associated with maternal mortality was developed for the years with a significant excess of maternal deaths. Fifth study: A population-based descriptive ecological study. To address the eighth research objective, maternal mortality rates by province, autonomous region and mother�s country of origin were calculated for the period of 1999 to 2006. To compare maternal mortality by province, standardized mortality ratios were calculated using an indirect standardization method. The risk of maternal death by autonomous region, age and mother�s country of origin was calculated using a Poisson regression. Sixth study: A population-based matched case-control study. This study addresses the last research objective. Maternal death by mother�s country of origin was analyzed using a matched case-control study. Each case of maternal death during 1999-2006 was matched with four mothers who had given birth during the same year that the case occurred. Results: Rates of fertility and stillbirth increased among women over 35 years of age, especially in women aged over 45 years. The risk of stillbirth was 2.7 times higher among women older than 45 (rate ratio, 2.7, 95% CI = 1.8-3), with an etiological fraction of exposure of 69% (95% CI = 55.2-78.6). The prevalence rates for prematurity and low birthweight were three times higher among women over 45 years of age, with relative risks of 2.9 (95% CI = 2.7-3.1) for prematurity and 3.1 (95% CI = 2.9-3.3) for low birthweight. The probability of low birthweight among European mothers (including Spanish women) by country of origin was associated with the combination of increased maternal age and multiple pregnancies, whereas among foreign mothers low birthweight occurred in all age groups and with both single and multiple births. With an odds ratio of 2.34 (95% CI = 1.2-4.8), Romanian mothers had the highest probability of low birthweight during the study period. Analysis of fertility trends in Spain showed that foreign women had more children and at younger ages than Spanish women during 1996-2006 (fertility rate: 2.0 vs. 1.2). Fertility among Spanish women increased especially in women over 35 years of age, whereas among foreign women fertility was higher in women younger than 35 and markedly higher among women under 19, who had a fertility rate ratio of 6.00 (95% CI = 2.6-13.9). At an ecological or aggregated level, maternal mortality was 30% higher in 2005 compared to 1996, with an age-adjusted mortality ratio adjusted of 1.3 (95% CI = 1.1-1.6). Maternal mortality risk was three times higher among mothers over 35 years of age, who had a risk ratio of 2.90 (95% CI = 2.01-4.06). Mothers from the sub-Saharan region presented the highest maternal mortality ratio. When data were analyzed by maternal origin and age, foreign mothers presented a 67% higher risk of maternal death, with a risk ratio of 1.67 (95% CI = 1.2-2.3). Similarly, two Spanish regions showed a significant excess of maternal deaths: Andalusia, with a risk ratio of 1.84 (95% CI = 1.3-2.6) and Asturias, with a risk ratio of 2.78 (95% CI = 1.2-6.2). Finally, individual-level risk analysis of maternal death by age showed an 87% higher risk of maternal death among foreign mothers compared to Spanish mothers. Discussion and conclusion: The strong association highlighted between worse perinatal outcomes and maternal age is closely linked to the change in reproductive patterns that has occurred in Spain in recent years. The high prevalence of pregnancies among women over 35, one of the highest in Europe, is the result of the difficulty in reconciling family and work life. Assisted reproductive techniques have addressed the problems of fertility associated with delay in childbearing. However, the association between advanced maternal age and increased risk of feto-neonatal morbi-mortality, which is stronger among women older than 45, is linked to the increased fertility rate among women over 35 years of age. Therefore, one should ask what impact assisted reproductive techniques have had on increases in fertility in these age groups and whether, independently of any other factor, they increase the risk of feto-neonatal morbi-mortality. In this regard, a recent systematic review of the literature published in �The Lancet� and three meta-analyses found an increased risk of feto-neonatal morbi-mortality for children born through assisted reproductive techniques. In any case, further studies are required in the field of perinatal epidemiology to analyze the impact of these techniques on maternal morbidity and feto-neonatal morbi-mortality. Changes in reproductive patterns were associated with advanced maternal age, stillbirth, prematurity and low birthweight during the period of 1996-2006. Furthermore, these changes were also characterized by differences in fertility and prevalence of low birthweight by maternal country of origin. The risk of low birthweight was higher among children of foreign women in all age groups, whereas among Spanish mothers, low birthweight could be explained by the combination of advanced maternal age and multiple pregnancies. Fertility among foreign women was higher than among Spanish women and this difference was greater among women under 19 years of age. Differences in fertility between foreign and Spanish women could be associated with specific social and cultural differences. Maternal mortality trends also exhibited a change, characterized by increased maternal deaths associated with advanced maternal age. Furthermore, there were confirmed inequalities in mortality risk between regions of maternal origin. This pattern justifies the need for more intense surveillance and research of maternal deaths, to prevent this phenomenon. Geographical inequalities, as well as inequalities based on maternal origin, should suffice to implement a system of active surveillance of maternal deaths in Spain. Routine performance audits for every death and qualitative surveys for deep analysis of the determinants surrounding maternal deaths may be measures of unquestionable value to understand and prevent maternal mortality. Conclusions: 1. During 1996-2006 the fertility pattern of foreign women was markedly different from that of Spanish women. Foreign women had more children and at younger ages. The observed increase in the fertility of Spanish women is primarily due to increased fertility among women over 35. The pattern of fertility among foreign women compared to that of Spanish women is characterized mainly by higher fertility, which was especially pronounced for the group of women under 19 years of age. 2. During the period 1996-2005 the significant fertility increase in women over 35 is associated with a marked increase in feto-neonatal morbi-mortality. In terms of public health impact, advanced maternal age has a high etiological fraction in stillbirth and is narrowly associated with a high prevalence of prematurity and low birthweight. This situation results in an increase of economic resources needed to provide health care due to increased feto-neonatal morbi-mortality in Spain. 3. During the period 1996-2006 mothers born outside the EU15 in Spain had higher odds of having low-birthweight infants and a higher prevalence of pregnancies in adolescence; moreover, certain EU15 mothers, including Spanish women, were found to have a higher prevalence of multiplicity and pregnancy at advanced ages. 4. During the period 1996-2006 a change in the maternal mortality pattern happened, marked by a rising trend, an increased risk at advanced maternal ages plus socio-geographical inequalities. In Spain, foreign women had higher risk of maternal death.

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