A list of the members of the EuroNatal International Audit Panel and the EuroNatal Working Group may be found on page 104Objective A European concerted action (the EuroNatal study) investigated the background of differences in perinatal mortality between countries of Europe. The study aimed to determine the contribution of differences in quality of care, by looking at differences in the presence of suboptimal factors in individual cases of perinatal death. Design Retrospective audit study.Setting Regions of 10 European countries.Population 1619 cases of perinatal death.Methods Perinatal deaths between 1993 and 1998 in regions of 10 European countries were identified.Reviewed were singleton fetal deaths (28 or more weeks of gestational age), intrapartum deaths (28 or more weeks) and neonatal deaths (34 or more weeks). Deaths with (major) congenital anomalies were excluded. Cases were blinded for region and an international audit panel reviewed them using explicit audit criteria. Main outcome measures Presence of suboptimal factors.Results The audit covered 1619 cases of perinatal death, representing 90% of eligible cases in the regions.Consensus was reached on 1543 (95%) cases. In 715 (46%) of these cases, suboptimal factors, which possibly or probably had contributed to the fatal outcome, were identified. The percentage of cases with such suboptimal care factors was significantly lower in the Finnish and Swedish regions compared with the remaining regions of Spain, the Netherlands, Scotland, Belgium, Denmark, Norway, Greece and England. Failure to detect severe IUGR (10% of all cases) and smoking in combination with severe IUGR and/or placental abruption (12%) was the most frequent suboptimal factor. There was a positive association between the proportion of cases with suboptimal factors and the overall perinatal mortality rate in the regions. Conclusions The findings of this international audit suggest that differences exist between the regions of the 10 European countries in the quality of antenatal, intrapartum and neonatal care, and that these differences contribute to the explanation of differences in perinatal mortality between these countries. The background to these differences in quality of care needs further investigation.

The Bangladesh Acute Nerve Damage Study (BANDS) is a prospective cohort study designed to investigate epidemiological, diagnostic, therapeutic and operational aspects of acute nerve function impairment in leprosy. The study is based at a single centre in Bangladesh, in an area with a high prevalence of leprosy. The centre, Danish Bangladesh Leprosy Mission, has a well-established vertical leprosy control programme. In this paper, the study design and methodology are described, together with definitions of nerve function impairment (NFl) used in this and subsequent papers. The study recruited 2664 new leprosy cases in a 12-month period. The male:femaJe ratio is 1•25: I, and 17•61 % of the cohort are under 15 years of age. In all, 83•33% of the cohort are paucibacillary (PB), and 16•67% multibacillary (MB). However, the MB rate amongst males is 19•72%, and amongst females is 12•85%, despite an equal period of delay to diagnosis. 55% of patients presented for treatment within 12 months of developing symptoms. 6• 12% of the total number of cases were smear positive, and 36•71% of the MB cases were smear positive. 9•61% of the total number of cases were graded as having World Health Organisation (WHO) disability grade I, and 5•97% had grade 2. Amongst MB cases, 27-48% had WHO grade 1 disability present, and 18•24% had grade 2 present, compared with 6•04% and 3 •5 1 %, respectively, amongst PB cases. A total of 11•90% of the cohort had sensory NFl of any kind, and 7•39% had motor NFL Ninety patients presented with NFl needing treatment (3•38%), and of these, 61 (67•78%) had silent NFL MB patients had a prevalence of reactionlNFI needing treatment nearly 7 times higher than PB cases (15•32% amongst MB; 2•30% amongst PB), and males nearly double that of females (5•67% amongst males, 2•96% amongst females). The most

Two methods, one direct and one indirect, were used for adjusting these officially published rates for differences in registration laws or publication practices. For the indirect method adjustment factors were derived from an analysis of a large Finnish database using different cutoff points for gestational age and birthweight. For the direct method a common cutoff point was imposed for birthweight (1000g) and gestational age (28 completed weeks) on national perinatal mortality data, obtained from civil registration or hospital/obstetrics databases in each country. Results The published perinatal mortality rates ranged from 5.4 per 1000 total births in Sweden and Finland to 9.7 in Greece and Northern Ireland. The indirect adjustment method showed that some countries apply cutoff points for registration or publication of perinatal mortality which may raise the perinatal mortality rate by up to 17% above the most commonly used threshold for including live and stillbirths. The direct adjustment method showed that a common lower limit of 1000g for birthweight or 28 weeks for gestational age would reduce the perinatal mortality rate, but by a differing extent ranging from 14% to 40%. Both adjustment methods reduced the contrast between the countries' perinatal mortality rates, and changed their rank order. Conclusion These quantitative results confirm that international differences in countries' published perinatal mortality rates partly reflect differences between countries' criteria for registration and publication of perinatal deaths.

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