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  • br Stephanie Topp points to the


    Stephanie Topp points to the limitations of quality measurement in Commission on High Quality Health Systems (HQSS Commission; May, 2017) that might not fit the real-world contexts of low-income and middle-income countries (LMICs). She also takes issue with a narrow set of generic indicators and targets for quality that might be meaningless or even provide “perverse incentives to game the system”. We agree these are important concerns and aim to tackle them in the work of the Commission.
    Svetlana Popova and colleagues (March, 2017) estimated that about one quarter of pregnant women in Europe drink alcohol. The authors state that this estimate is 2·6 times higher than the global prevalence and estimate that Europe has the world\'s highest fetal alcohol syndrome (FAS) prevalence of 37·4 per 10 000 people. If true, these numbers are alarming and require urgent action; however, we are not convinced that they leukotriene receptor antagonist are valid for contemporary Europe. The estimated drinking prevalence of 45·8% for Denmark is based on six Danish studies, five of which describe pregnant women in the 1980s and 1990s. This prevalence is much higher than reported in surveillance data, which showed that, in Denmark\'s two most urbanised areas, 3% and 15% of pregnant women consumed alcohol in 2012. Drinking during pregnancy has reduced markedly in Denmark—eg, from 70% in 1998 to 15% in 2013 in the Aarhus area. We therefore consider the estimation of alcohol use in pregnancy and consequently prevalence of FAS to be seriously overestimated. We are concerned that a similar overestimation could apply to other countries. According to the National Danish Patient Registry, which covers all inpatient and outpatient contacts in Denmark, approximately 12 children are diagnosed with FAS every year, corresponding to two per 10 000 children; although record-based ascertainment is known to be underestimated, this is still considerably lower than the estimated 68 per 10 000 children reported by Popova and colleagues.
    Svetlana Popova and colleagues (March, 2017) sought to estimate the global, regional, and national prevalence of alcohol use during pregnancy and fetal alcohol syndrome (FAS). The authors reviewed international literature from 1984 for country-specific quantitative studies and for countries with one or no studies Complexity predicted gestational alcohol use prevalence by fractional response regression modelling and prevalence of FAS by an estimated quotient for the average number of women consuming alcohol during pregnancy per one case of FAS. For estimation of FAS prevalence, Italy was reported to be among the five countries worldwide with the highest prevalence of FAS per 10 000 people. On the basis of our involvement in studies about national prevalence of gestational alcohol consumption and consequent prenatal exposure to this teratogen, we have to disagree with the estimates reported by the authors. First, according to WHO, Italy is the country with the lowest annual consumption of alcohol per capita (6·7 litres), lowest percentage of women with alcohol use disorders (0·8%) and alcohol abuse dependence (0·4%), and the highest number of female lifetime abstainers (37·5%) among all European countries with the exclusion of eastern states with a prevalent Muslim faith (eg, Azerbaijan, Kyrgyzstan, and Tajikistan). Second, only a few somewhat dated studies have investigated alcohol consumption during pregnancy in Italy, which include a limited number of pregnant women in selected cities, and are therefore not representative of the general population. Additionally, self-reported drinking during pregnancy varied from one or more drinks per day to one per month or less in these studies. That women\'s self-reporting of drinking varies has been confirmed by our studies on objective assessment of prenatal exposure to alcohol through measurement of biomarkers in neonatal meconium. The overall prevalence of newborns prenatally exposed to maternal alcohol was 7·9%, within the 20–30% of pregnant women that self-reported drinking during pregnancy. Fetal exposure varied between 0% and 10% along the Italian peninsula with an isolated maximum value of 29·4% in Rome capital.