Prenatal diagnosis of congenital anomalies and birth institution complexity levels in Argentina

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We aimed to assess the prevalence and prenatal diagnosis rates of selected congenital abnormalities and the complexity levels of birth institutions in a sample of public maternity hospitals in Argentina. Data sources were 1) National Congenital Anomalies Registry, covering the period from 2013 to 2021; and 2) Categorization of birth institutions according to their complexity (high or low). Newborns with the following anomalies were selected for analysis: spina bifida, hydrocephalus, critical congenital heart defects, diaphragmatic hernia, gastroschisis, and omphalocele. Prevalence at birth and prenatal diagnosis rates were calculated according to the birth institution complexity level. A total of 2.214.102 births across 131 institutions were evaluated, with 1.202.311 births in high-complexity institutions and 1.011.791 in low-complexity institutions. The prevalence per 10.000 births and the prenatal diagnosis percentage for the entire sample were: spina bifida 5,40(95%CI 5,10 − 5,71) 68,54%; hydrocephalus 6,96(95% CI 6,62 − 7,32) 78,92%; critical congenital heart defects 11,05(95% CI 10,62 − 11,49) 43,21%; diaphragmatic hernia 3,88(95%CI 3,62 − 4,14) 68,65%; gastroschisis 7,85(95%CI 7,48 − 8,22) 79,27%; omphalocele 2,01(95%CI 1,83 − 2,20) 76,18%. Prevalence and prenatal diagnosis rates were significantly higher in high-complexity institutions. Prenatal diagnosis and perinatal care networks must be improved to ensure that patients with major congenital anomalies are delivered in high-complexity birth institutions. The prevalence and prenatal diagnosis rate, stratified by the complexity level of institutions, can serve as management indicators to evaluate improvements in care quality. congenital anomalies prenatal diagnosis public health perinatal care Figures Figure 1 Introduction Congenital anomalies (CA) in Argentina have a strong impact on infant morbidity and mortality. In 2022, the prevalence at birth of major congenital anomalies was 1,83 per 100 births (RENAC 2023 ) and this group of pathologies accounts for approximately one-third of deaths in the first year of life in our country (DEIS 2023). Prenatal diagnosis of congenital anomalies aims to provide the pregnant person with early information on fetal health, as well as timely referral during pregnancy to an institution with the appropriate complexity for monitoring and birth. These measures allow early planning of medical and/or surgical interventions, in some cases, even during pregnancy (Gagnon 2009 ). Additionally, prenatal diagnosis of CA allows women to make informed and autonomous decisions to terminate or continue the pregnancy. In Argentina, the Ministry of Health’s “Guide to Practice for Prenatal Care” recommends a minimum of 8 prenatal visits for low-risk pregnancies, as well as a systematic ultrasound examination between weeks 19 and 24, and a routine ultrasound examination between weeks 11 and 13.6 (Dirección de Salud Perinatal y Niñez 2023). Since 2008, Argentina has initiated a process of regionalization of perinatal care health services, focusing on concentrating births in institutions with a greater number of deliveries that meet essential obstetric and neonatal conditions (CONE, by its acronym in Spanish), establishing a health system with increasing and coordinated complexity. Public sector maternity wards have been classified according to their complexity in three levels according to the CONE (Speranza and Kurlat 2011 ). The highest complexity level (3B) is where patients with major congenital anomalies should be delivered. Prenatal diagnosis of CA allows for the referral of pregnant women to an institution of adequate complexity, which constitutes an intervention that reduces neonatal mortality (Bidondo et al. 2014 ; Sewell and Keene 2018 ). This work aimed to determine the prenatal detection rate (PDR) of selected fetal abnormalities and the level of complexity of birth institutions in a sample of public maternity wards in Argentina. Material and Methods Design and procedures The present study is a cross-sectional study. The data sources were: 1) The RENAC database (National Network of Congenital Anomalies of Argentina) and 2) The categorization of public maternity wards according to their complexity level (CONE). RENAC data was used for the period between January 1st, 2013 and December 31st, 2021. RENAC is the national hospital surveillance system for major structural congenital anomalies, which has been operating since 2009 in hospitals with maternity wards across the 24 jurisdictions of the country (Groisman et al. 2013). Cases born in institutions not part of the aforementioned network and cases from institutions in the private or social security subsector were excluded. For this study, newborns with the following anomalies and their respective ICD-10 codes were selected: spina bifida (Q05), hydrocephalus (Q03), critical congenital heart defects (Q20.0, Q20.3, Q20.4, Q21.3, Q21.82, Q22.00, Q22.40, Q22.5, Q23.4, Q25.1-Q25.19, Q25.2, Q26.2, Q26.20), diaphragmatic hernia (Q79.0-Q79.01), gastroschisis (Q79.3), and omphalocele (Q79.2). For the categorization of public maternity wards according to their level of complexity, the criteria of Essential Obstetric and Neonatal Conditions (CONE) were used, as defined by Resolutions 641/2012 and 670/2019 of the National Directorate of Maternity and Childhood of the Ministry of Health of the Nation (Ministerio de Salud de la Nación 2012 ; 2019 ) (Fig. 1 ). For this study, the complexity level of the birth institutions was analyzed in a dichotomous way: high complexity corresponded to institutions categorized as 3B and low complexity to those categorized as 3A and 2. Data analysis The birth prevalence of each selected anomaly was calculated for the entire country and by the level of complexity of the birthplace. Prevalences were measured as the proportion of cases over the total number of births in the participating facilities, with 95% confidence intervals according to the Poisson distribution, using STATA software version 13. The proportion of PDR was estimated from the quotient between the number of cases with selected CAs detected prenatally (numerator) and the total number of births affected by the selected CAs (denominator). Statistical analysis was performed using Pearson's chi-square calculation to compare the proportion of prenatal diagnosis between the two levels of complexity. Results During the study period, RENAC evaluated a total of 2,214,102 births in 131 maternity wards within the public subsector across all jurisdictions in the country. From this sample, 1,202,311 births were examined in 3B maternity wards (high complexity), while 1,011,791 births were examined in 2 and 3A maternity wards (low complexity). The anomalies analyzed with the highest prevalence were critical congenital heart defects, while omphalocele was the least frequent defect (Table 1 ). When analyzing the prevalence by the complexity of the birth institutions, it was observed that all the selected anomalies exhibited a significantly higher prevalence in high-complexity maternity wards. (Table 1 ). When evaluating the PDR rate, it was observed that gastroschisis was the most frequently detected defect, while critical congenital heart defects showed the lowest percentage. All anomalies showed a significantly higher percentage of PDR in the more complex institutions (Table 2 ). Table 1. Prevalence of selected congenital anomalies according to level of complexity, public subsector, RENAC, period 2013-2021 Congenital anomalies Total High complexity Low complexity N Prevalence per 10,000 (IC 95%) N (%) Prevalence per 10,000 (IC 95%) N (%) Prevalence per 10.000 (IC 95%) Spina bifida 1195 5,40 (5,10-5,71) 932 (77,99) 7,75 (7,62-8,27) 263 (22,01) 2,60 (2,30-2,93 Hydrocephalus 1542 6,96 (6,62-7,32) 1261 (81,78) 10,49 (9,92-11,08) 281 (18,22) 2,78 (2,46-3,12) Critical congenital heart defects 2446 11,05 (10,62-11,49) 1777 (72,65) 14,78 (14,10-15,48) 669 (27,35) 6,60 (6,12-7,13) Diaphragmatic hernia 858 3,88 (3,62- 4,14) 653 (76,11) 5,43 (5,02-5,86) 205 (23,89) 2,02 (1,76-2,32) Gastroschisis 1737 7,85 (7,48- 8,22) 1447 (83,30) 12,04 (11,42-12,67) 290 (16,70) 2,87 (2,55-3,22) Omphalocele 445 2,01 (1,83- 2,20) 371 (83,37) 3,70 (3,37-4,06) 74 (16,63) 0,73 (0,57-0,92) Table 2. Prenatal diagnosis rate (PDR) of selected congenital anomalies according to level of complexity, public subsector, RENAC, period 2013-2021 Congenital anomalies Total High complexity Low complexity P ( χ²) Total cases Prenatal diagnosis N (%) Total cases DPN N (%) Total cases Prenatal diagnosis N (%) Spina bifida 1195 819 (68,54) 932 691 (74,14) 263 128 (48,67) <0,001 Hydrocephalus 1542 1217 (78,92) 1261 1009 (80,02) 281 208 (74,02) 0,026 Critical congenital heart defects 2446 1057 (43,21) 1777 900 (50,65) 669 157 (23,47) <0,001 Diaphragmatic hernia 858 589 (68,65) 653 468 (71,67) 205 121 (59,02) 0,002 Gastroschisis 1737 1377 (79,27) 1447 1190 (82,24) 290 187 (64,48) <0,001 Omphalocele 445 339 (76,18) 371 293 (78,98) 74 46 (62,16) 0,002 Discussion This study is one of the first investigations carried out in Argentina aimed at understanding the relationship between the prevalence of congenital abnormalities, the rate of prenatal diagnosis of fetal abnormalities, and the level of complexity of public birth institutions. Critical congenital heart defects had the lowest rate of prenatal diagnosis, with only one in four affected children diagnosed prenatally in cases born in low-complexity institutions. The prenatal diagnosis of heart defects should be performed primarily by detailed morphological ultrasound, which should be performed in all pregnancies between weeks 19–24 (Dirección de Salud Perinatal y Niñez 2023). A study that included data from 15 registries across different countries around the world reported that the PDR of critical congenital heart defects varied between 13% and 87% (Bakker et al. 2019 ). Prenatal screening for congenital heart defects has been shown to have a direct impact on perinatal health, as evidenced by a reduction in infant mortality due to heart disease in Denmark following the implementation of this public health measure (Lytzen et al. 2019). The low rate of prenatal diagnosis of congenital heart defects observed in our study could mainly be attributed to difficulties in accessing the health system for pregnant women and a lack of training for sonographers in evaluating the fetal heart, which is a complex anatomical structure. Spina bifida is usually detected by specific ultrasound signs in the second trimester of pregnancy (Nicolaides et al. 1986 ; Meller et al. 2021 ) and according to some authors, ultrasound could detect almost all cases of spina bífida (Lennon and Gray 1999 ). In the European Network of Congenital Anomalies Registries (EUROCAT), the PDR of spina bifida in the period 2017 to 2021 was greater than 75% in 28 of the 31 registries (EUROCAT 2024). The overall PDR in our study was 68.54%, however, in low-complexity institutions the percentage was only 48.67%. Unlike other congenital anomalies, the surgical approach to spina bifida can be started in the prenatal stage, which reduces neurological sequelae. Although the upper limit has been extended to 27–28 weeks, this fetal intervention is usually performed before the 26th week of gestation (Meller et al. 2021 ; Adzick et al. 2011 ). For this reason, it is necessary to improve the PDR and ensure that detection is performed at an early stage. The PDR for congenital diaphragmatic hernia and congenital hydrocephalus observed in our study was similar to the rates reported in registries from other countries. As with spina bifida, in congenital diaphragmatic hernia, there is a prenatal intervention that has been shown to increase survival after birth (Deprest et al. 2021 ; Van Calster et al. 2022 ). Therefore prenatal diagnosis and referral to a more complex center would be beneficial. The rate of prenatal diagnosis of gastroschisis and omphalocele varies by country. In 26 of the 31 registries that comprise the EUROCAT network, the percentage of diagnosis was higher than 90% of cases (EUROCAT 2024). These rates were higher than those observed in our study. However, research conducted in developing countries shows percentages still below those reported in our work (Bilibio et al. 2019 ; Muniz et al. 2023 ; Amado et al. 2023 ). In a previous study by RENAC, which included all the institutions in the network, it was observed that the PDR in public institutions was lower than in private and social security hospitals (Bidondo et al. 2020 ). Conversely, another study conducted by the Latin American Collaborative Study of Congenital Malformations (ECLAMC), which included 13 hospitals in Argentina found no differences in the PDR between public and non-public institutions; however, in public institutions, the diagnosis was made at a significantly later gestational age (Campaña et al. 2010 ). From a health perspective, prenatal care is considered efficient when it meets certain basic requirements: it should begin early in gestation, be periodic throughout pregnancy, be comprehensive, and have broad coverage within the population. The guidelines of the Ministry of Health of Argentina recommend a minimum of 8 prenatal consultations, however in 2021, only 10.9% of pregnant women attended more than 9 consultations, 61.9% attended between 5 and 9 consultations and 27.2% made fewer than 5 consultations. Furthermore, regarding gestational age at the first prenatal visit, it was observed that only 38.8% consulted in the first trimester (Dirección de Salud Perinatal y Niñez 2023). This situation indicates that there are still barriers to accessing the health system, which, among other implications, affects the potential for early diagnosis of fetal abnormalities. Pregnant women face social, cultural, and economic barriers, as well as challenges related to domestic responsibilities and the care of children or dependent individuals at home. Additionally, there are barriers within the health system itself; in this regard, a study conducted in a maternity ward in the city of Buenos Aires showed that the main barrier to access for pregnant women in the first trimester of pregnancy was the inability to secure an appointment for care at the establishment (Pécora et al. 2008 ). In perinatology, poor organization is considered to be as significant a factor as the lack of clinical competence in the origin of morbidity and mortality for both mothers and children (Schwarcz 2011 ). For several years, Argentina has organized perinatal care to reduce maternal and neonatal morbidity and mortality. To this end, essential obstetric and neonatal conditions (CONE) were established, along with a regionalization and classification system based on complexity (Speranza and Kurlat 2011 ) Regionalization implies a coordinated system between institutions and health teams. The prevalence of the selected congenital anomalies was significantly higher in institutions of greater complexity, which likely reflects the effectiveness of prenatal diagnosis and timely referral to these centers for follow-up and care at birth. However, a significant percentage of cases were born in low-complexity institutions despite being detected prenatally. This situation may be attributed to deficiencies in the referral and counter-referral system for pregnant women with a prenatal diagnosis of CA to higher-complexity centers. Limitations Our study has some limitations. The analysis has been restricted to public institutions, however, it is important to note that in Argentina, the non-public health system (social security and prepaid health plans), where 38.7% of births in the country occur (DEIS 2023), does not present a perinatal organization based on levels of complexity. Conclusion In our study, we observed that the six major congenital anomalies selected had higher rates of prenatal diagnosis and prevalence in the most complex public institutions. The anomalies studied require specific, highly complex perinatal management, which is why birth should occur in maternity wards categorized as 3B. For this reason, it is necessary to improve, among other aspects, the early prenatal diagnosis of CAs as well as the referral system and perinatal care networks. The regionalization of perinatal health services based on levels of complexity requires the implementation of prenatal ultrasound screening during the first and second trimester of pregnancy as a fundamental pillar at a national level. This strategy enables early diagnosis and timely referral of pregnant women to centers of adequate complexity; Universal screening has been shown to have a direct impact on reducing perinatal mortality (Sewell and Keene 2018 ). To achieve this goal, Law No. 27,611 was passed in Argentina in 2020, promoting nationwide access for pregnant individuals to fetal morphology studies via ultrasound between 18 and 22 weeks of gestation to identify major congenital malformations. However, to implement this public health measure effectively, it is necessary to advance various actions, including promoting early initiation of prenatal check-ups among the population; improving access to health services; training health professionals in the diagnosis of CA; increasing the availability of prenatal studies at all levels of care; generating a prenatal diagnosis network with different levels of complexity that facilitates consultation and/or referral between institutions and improving equipment in cases that require it, among other measures. Early diagnosis also allows pregnant women to decide whether to continue with the pregnancy or opt for termination at an earlier gestational age. Another conclusion that emerges from our study is that a proportion of patients with the congenital anomalies studied are born in low-complexity maternity wards, even in cases where there was a prenatal diagnosis. To address this situation, it is necessary not only to improve prenatal diagnosis, as previously mentioned; but also to optimize the functioning of perinatal care networks to ensure timely referral to more complex centers is made during pregnancy. Finally, we propose that the rate of prenatal diagnosis and the prevalence of major congenital anomalies stratified by the complexity of the birthing institutions could serve as management indicators to evaluate the improvements in perinatal care. These indicators may help us assess the impact of public health policies in this area of ​​perinatal health. Declarations Acknowledgments: The authors would like to thank the RENAC working group Author contributions: All authors have contributed equally to the work and jointly supervised the work. Data availability: The epidemiological data that support the findings of this study were sourced from the databases of the congenital anomalies surveillance system of Argentina (RENAC) and have been published in annual reports available at: https://ine.gov.ar/ index.php/otrasareas/renac. Ethical approval: The authors declare that there are no ethical conflicts to disclose. Consent to participate: The study was conducted using non-nominalized data, and comparisons were made based on aggregate data. These data fall within the exceptions outlined in Resolution 1480/2011 of the National Ministry of Health, which provides guidelines for research involving human subjects. Competing interests: Analizia Astudillo, Boris Groisman, Pablo Barbero, María Paz Bidondo, Rosa Liascovich, Horacio Aiello, Marianela Trotta, and Paloma Brun declare that they have no conflict of interest. References Adzick NS, Thom EA, Spong CY, Brock JW 3rd, Burrows PK, Johnson MP et al. 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Cite Share Download PDF Status: Published Journal Publication published 21 Jan, 2025 Read the published version in Journal of Community Genetics → Version 1 posted Editorial decision: Revision requested 04 Dec, 2024 Reviews received at journal 24 Nov, 2024 Reviews received at journal 18 Nov, 2024 Reviewers agreed at journal 13 Nov, 2024 Reviewers agreed at journal 09 Nov, 2024 Reviewers invited by journal 07 Nov, 2024 Editor assigned by journal 06 Nov, 2024 Submission checks completed at journal 06 Nov, 2024 First submitted to journal 04 Nov, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5388886","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":379594444,"identity":"03522750-b446-42c5-b9d6-2e392298a24a","order_by":0,"name":"Analizia Astudillo","email":"","orcid":"","institution":"Programa de Diagnóstico y Tratamiento Fetal, Unidad de Cuidados intensivos neonatales, Hospital de Pediatría Prof. Dr. Juan P. Garrahan","correspondingAuthor":false,"prefix":"","firstName":"Analizia","middleName":"","lastName":"Astudillo","suffix":""},{"id":379594445,"identity":"801b9c7f-848d-4e2c-80a4-815a9942924b","order_by":1,"name":"Boris Groisman","email":"","orcid":"","institution":"Red Nacional de Anomalías Congénitas (RENAC), Instituto Nacional de Epidemiología, ANLIS Malbrán","correspondingAuthor":false,"prefix":"","firstName":"Boris","middleName":"","lastName":"Groisman","suffix":""},{"id":379594446,"identity":"7d6aa923-3dfb-4937-b76f-83d87137383e","order_by":2,"name":"Pablo Barbero","email":"","orcid":"","institution":"Red Nacional de Anomalías Congénitas (RENAC), Instituto Nacional de Epidemiología, ANLIS Malbrán","correspondingAuthor":false,"prefix":"","firstName":"Pablo","middleName":"","lastName":"Barbero","suffix":""},{"id":379594447,"identity":"c9db04eb-424d-492b-a3da-653eaa627c7b","order_by":3,"name":"María Paz Bidondo","email":"","orcid":"","institution":"Red Nacional de Anomalías Congénitas (RENAC), Instituto Nacional de Epidemiología, ANLIS Malbrán","correspondingAuthor":false,"prefix":"","firstName":"María","middleName":"Paz","lastName":"Bidondo","suffix":""},{"id":379594448,"identity":"6a832a7d-f511-42f2-a14d-dc3d90fe4540","order_by":4,"name":"Rosa Liascovich","email":"","orcid":"","institution":"Red Nacional de Anomalías Congénitas (RENAC), Instituto Nacional de Epidemiología, ANLIS Malbrán","correspondingAuthor":false,"prefix":"","firstName":"Rosa","middleName":"","lastName":"Liascovich","suffix":""},{"id":379594449,"identity":"fda333b8-37b2-490e-9017-179a4dbed30d","order_by":5,"name":"Horacio Aiello","email":"","orcid":"","institution":"Red Nacional de Anomalías Congénitas (RENAC), Instituto Nacional de Epidemiología, ANLIS Malbrán","correspondingAuthor":false,"prefix":"","firstName":"Horacio","middleName":"","lastName":"Aiello","suffix":""},{"id":379594450,"identity":"eabd12d2-9a6a-412b-b29d-238ef9e4db3d","order_by":6,"name":"Marianela Trotta","email":"","orcid":"","institution":"Red Nacional de Anomalías Congénitas (RENAC), Instituto Nacional de Epidemiología, ANLIS Malbrán","correspondingAuthor":false,"prefix":"","firstName":"Marianela","middleName":"","lastName":"Trotta","suffix":""},{"id":379594451,"identity":"fe12c4d5-bc1a-4a86-bef1-eb6cb761a6a1","order_by":7,"name":"Paloma Brun","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1klEQVRIiWNgGAWjYBACAwhlAcTMB4CEhAyxWiSAmC0BxOAhRQsPmE1Yi7n0GbPHBTUScrrtZz6/ulFjwcPAfvjoBnxaLPtyzI1nHJMwNjuTu8065xjQYTxpaTfwOuwMj5k0D5tE4rYDuduMc9iAWiR4zIjQ8g+o5fybZ8Y5/4jVwtsG1HIjh/lxbhsRWix72MqkZ/YB/XLjmRlzbp8EDxshv5jzMG+TLvhmI2d2Pvnx55xvdXL87IeP4dUCAsxQmk0CTBJSjqyF+QMxqkfBKBgFo2DkAQDJE0Ce7IMyZwAAAABJRU5ErkJggg==","orcid":"","institution":"Red Nacional de Anomalías Congénitas (RENAC), Instituto Nacional de Epidemiología, ANLIS Malbrán","correspondingAuthor":true,"prefix":"","firstName":"Paloma","middleName":"","lastName":"Brun","suffix":""}],"badges":[],"createdAt":"2024-11-04 14:24:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5388886/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5388886/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s12687-024-00766-z","type":"published","date":"2025-01-21T15:57:09+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":70957960,"identity":"05922895-37db-4fe9-ac5b-200222a104d7","added_by":"auto","created_at":"2024-12-09 14:51:15","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":45491,"visible":true,"origin":"","legend":"\u003cp\u003eCategories of Essential Obstetric and Neonatal Conditions\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5388886/v1/526a7cff9d47b64d9a756430.png"},{"id":74858669,"identity":"5a73cc11-1d41-4f77-8c6b-7b47046eedd2","added_by":"auto","created_at":"2025-01-27 16:12:46","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":500019,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5388886/v1/76072ffc-2c69-4f50-a6cb-78babad628a7.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Prenatal diagnosis of congenital anomalies and birth institution complexity levels in Argentina","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCongenital anomalies (CA) in Argentina have a strong impact on infant morbidity and mortality. In 2022, the prevalence at birth of major congenital anomalies was 1,83 per 100 births (RENAC \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) and this group of pathologies accounts for approximately one-third of deaths in the first year of life in our country (DEIS 2023).\u003c/p\u003e \u003cp\u003ePrenatal diagnosis of congenital anomalies aims to provide the pregnant person with early information on fetal health, as well as timely referral during pregnancy to an institution with the appropriate complexity for monitoring and birth. These measures allow early planning of medical and/or surgical interventions, in some cases, even during pregnancy (Gagnon \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2009\u003c/span\u003e). Additionally, prenatal diagnosis of CA allows women to make informed and autonomous decisions to terminate or continue the pregnancy. In Argentina, the Ministry of Health\u0026rsquo;s \u0026ldquo;Guide to Practice for Prenatal Care\u0026rdquo; recommends a minimum of 8 prenatal visits for low-risk pregnancies, as well as a systematic ultrasound examination between weeks 19 and 24, and a routine ultrasound examination between weeks 11 and 13.6 (Direcci\u0026oacute;n de Salud Perinatal y Ni\u0026ntilde;ez 2023).\u003c/p\u003e \u003cp\u003eSince 2008, Argentina has initiated a process of regionalization of perinatal care health services, focusing on concentrating births in institutions with a greater number of deliveries that meet essential obstetric and neonatal conditions (CONE, by its acronym in Spanish), establishing a health system with increasing and coordinated complexity. Public sector maternity wards have been classified according to their complexity in three levels according to the CONE (Speranza and Kurlat \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). The highest complexity level (3B) is where patients with major congenital anomalies should be delivered. Prenatal diagnosis of CA allows for the referral of pregnant women to an institution of adequate complexity, which constitutes an intervention that reduces neonatal mortality (Bidondo et al. \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Sewell and Keene \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2018\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis work aimed to determine the prenatal detection rate (PDR) of selected fetal abnormalities and the level of complexity of birth institutions in a sample of public maternity wards in Argentina.\u003c/p\u003e"},{"header":"Material and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eDesign and procedures\u003c/h2\u003e \u003cp\u003eThe present study is a cross-sectional study. The data sources were: 1) The RENAC database (National Network of Congenital Anomalies of Argentina) and 2) The categorization of public maternity wards according to their complexity level (CONE).\u003c/p\u003e \u003cp\u003eRENAC data was used for the period between January 1st, 2013 and December 31st, 2021. RENAC is the national hospital surveillance system for major structural congenital anomalies, which has been operating since 2009 in hospitals with maternity wards across the 24 jurisdictions of the country (Groisman et al. 2013). Cases born in institutions not part of the aforementioned network and cases from institutions in the private or social security subsector were excluded. For this study, newborns with the following anomalies and their respective ICD-10 codes were selected: spina bifida (Q05), hydrocephalus (Q03), critical congenital heart defects (Q20.0, Q20.3, Q20.4, Q21.3, Q21.82, Q22.00, Q22.40, Q22.5, Q23.4, Q25.1-Q25.19, Q25.2, Q26.2, Q26.20), diaphragmatic hernia (Q79.0-Q79.01), gastroschisis (Q79.3), and omphalocele (Q79.2). For the categorization of public maternity wards according to their level of complexity, the criteria of Essential Obstetric and Neonatal Conditions (CONE) were used, as defined by Resolutions 641/2012 and 670/2019 of the National Directorate of Maternity and Childhood of the Ministry of Health of the Nation (Ministerio de Salud de la Naci\u0026oacute;n \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFor this study, the complexity level of the birth institutions was analyzed in a dichotomous way: high complexity corresponded to institutions categorized as 3B and low complexity to those categorized as 3A and 2.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eThe birth prevalence of each selected anomaly was calculated for the entire country and by the level of complexity of the birthplace. Prevalences were measured as the proportion of cases over the total number of births in the participating facilities, with 95% confidence intervals according to the Poisson distribution, using STATA software version 13.\u003c/p\u003e \u003cp\u003eThe proportion of PDR was estimated from the quotient between the number of cases with selected CAs detected prenatally (numerator) and the total number of births affected by the selected CAs (denominator).\u003c/p\u003e \u003cp\u003eStatistical analysis was performed using Pearson's chi-square calculation to compare the proportion of prenatal diagnosis between the two levels of complexity.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eDuring the study period, RENAC evaluated a total of 2,214,102 births in 131 maternity wards within the public subsector across all jurisdictions in the country. From this sample, 1,202,311 births were examined in 3B maternity wards (high complexity), while 1,011,791 births were examined in 2 and 3A maternity wards (low complexity).\u003c/p\u003e\n\u003cp\u003eThe anomalies analyzed with the highest prevalence were critical congenital heart defects, while omphalocele was the least frequent defect (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). When analyzing the prevalence by the complexity of the birth institutions, it was observed that all the selected anomalies exhibited a significantly higher prevalence in high-complexity maternity wards. (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eWhen evaluating the PDR rate, it was observed that gastroschisis was the most frequently detected defect, while critical congenital heart defects showed the lowest percentage. All anomalies showed a significantly higher percentage of PDR in the more complex institutions (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eTable 1. Prevalence of selected congenital anomalies according to level of complexity, public subsector, RENAC, period 2013-2021\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"867\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 229px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCongenital anomalies\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 236px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHigh complexity\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 204px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLow complexity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003ePrevalence per 10,000 (IC 95%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eN (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003ePrevalence per 10,000 (IC 95%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eN (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 119px;\"\u003e\n \u003cp\u003ePrevalence per 10.000 (IC 95%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 229px;\"\u003e\n \u003cp\u003eSpina bifida\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e1195\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e5,40 (5,10-5,71)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e932 (77,99)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e7,75 (7,62-8,27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e263 (22,01)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 119px;\"\u003e\n \u003cp\u003e2,60 (2,30-2,93\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 229px;\"\u003e\n \u003cp\u003eHydrocephalus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e1542\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e6,96 (6,62-7,32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e1261 (81,78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e10,49 (9,92-11,08)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e281 (18,22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 119px;\"\u003e\n \u003cp\u003e2,78 (2,46-3,12)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 229px;\"\u003e\n \u003cp\u003eCritical congenital heart defects\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e2446\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e11,05 (10,62-11,49)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e1777 (72,65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e14,78 (14,10-15,48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e669 (27,35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 119px;\"\u003e\n \u003cp\u003e6,60 (6,12-7,13)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 229px;\"\u003e\n \u003cp\u003eDiaphragmatic hernia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e858\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e3,88 (3,62- 4,14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e653 (76,11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e5,43 (5,02-5,86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e205 (23,89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 119px;\"\u003e\n \u003cp\u003e2,02 (1,76-2,32)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 229px;\"\u003e\n \u003cp\u003eGastroschisis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e1737\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e7,85 (7,48- 8,22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e1447 (83,30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e12,04 (11,42-12,67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e290 (16,70)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 119px;\"\u003e\n \u003cp\u003e2,87 (2,55-3,22)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 229px;\"\u003e\n \u003cp\u003eOmphalocele\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e445\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e2,01 (1,83- 2,20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e371 (83,37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e3,70 (3,37-4,06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e74 (16,63)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 119px;\"\u003e\n \u003cp\u003e0,73 (0,57-0,92)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 2. Prenatal diagnosis rate (PDR) of selected congenital anomalies according to level of complexity, public subsector, RENAC, period 2013-2021\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"915\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 244px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCongenital anomalies\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHigh complexity\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLow complexity\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u003cem\u003eP (\u003c/em\u003e\u0026chi;\u0026sup2;)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eTotal cases\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003ePrenatal diagnosis N (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003eTotal cases\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003eDPN N (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003eTotal cases\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003ePrenatal diagnosis N (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 244px;\"\u003e\n \u003cp\u003eSpina bifida\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e1195\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e819 (68,54)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e932\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e691 (74,14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e263\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e128 (48,67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026lt;0,001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 244px;\"\u003e\n \u003cp\u003eHydrocephalus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e1542\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e1217 (78,92)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e1261\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e1009 (80,02)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e281\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e208 (74,02)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e0,026\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 244px;\"\u003e\n \u003cp\u003eCritical congenital heart defects\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e2446\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e1057 (43,21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e1777\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e900 (50,65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e669\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e157 (23,47)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026lt;0,001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 244px;\"\u003e\n \u003cp\u003eDiaphragmatic hernia\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e858\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e589 (68,65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e653\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e468 (71,67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e205\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e121 (59,02)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e0,002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 244px;\"\u003e\n \u003cp\u003eGastroschisis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e1737\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e1377 (79,27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e1447\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e1190 (82,24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e290\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e187 (64,48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026lt;0,001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 244px;\"\u003e\n \u003cp\u003eOmphalocele\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e445\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e339 (76,18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e371\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e293 (78,98)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e46 (62,16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e0,002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study is one of the first investigations carried out in Argentina aimed at understanding the relationship between the prevalence of congenital abnormalities, the rate of prenatal diagnosis of fetal abnormalities, and the level of complexity of public birth institutions.\u003c/p\u003e \u003cp\u003eCritical congenital heart defects had the lowest rate of prenatal diagnosis, with only one in four affected children diagnosed prenatally in cases born in low-complexity institutions. The prenatal diagnosis of heart defects should be performed primarily by detailed morphological ultrasound, which should be performed in all pregnancies between weeks 19\u0026ndash;24 (Direcci\u0026oacute;n de Salud Perinatal y Ni\u0026ntilde;ez 2023). A study that included data from 15 registries across different countries around the world reported that the PDR of critical congenital heart defects varied between 13% and 87% (Bakker et al. \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Prenatal screening for congenital heart defects has been shown to have a direct impact on perinatal health, as evidenced by a reduction in infant mortality due to heart disease in Denmark following the implementation of this public health measure (Lytzen et al. 2019). The low rate of prenatal diagnosis of congenital heart defects observed in our study could mainly be attributed to difficulties in accessing the health system for pregnant women and a lack of training for sonographers in evaluating the fetal heart, which is a complex anatomical structure. Spina bifida is usually detected by specific ultrasound signs in the second trimester of pregnancy (Nicolaides et al. \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e1986\u003c/span\u003e; Meller et al. \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) and according to some authors, ultrasound could detect almost all cases of spina b\u0026iacute;fida (Lennon and Gray \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e1999\u003c/span\u003e). In the European Network of Congenital Anomalies Registries (EUROCAT), the PDR of spina bifida in the period 2017 to 2021 was greater than 75% in 28 of the 31 registries (EUROCAT 2024). The overall PDR in our study was 68.54%, however, in low-complexity institutions the percentage was only 48.67%. Unlike other congenital anomalies, the surgical approach to spina bifida can be started in the prenatal stage, which reduces neurological sequelae. Although the upper limit has been extended to 27\u0026ndash;28 weeks, this fetal intervention is usually performed before the 26th week of gestation (Meller et al. \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Adzick et al. \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). For this reason, it is necessary to improve the PDR and ensure that detection is performed at an early stage.\u003c/p\u003e \u003cp\u003eThe PDR for congenital diaphragmatic hernia and congenital hydrocephalus observed in our study was similar to the rates reported in registries from other countries. As with spina bifida, in congenital diaphragmatic hernia, there is a prenatal intervention that has been shown to increase survival after birth (Deprest et al. \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Van Calster et al. \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Therefore prenatal diagnosis and referral to a more complex center would be beneficial.\u003c/p\u003e \u003cp\u003eThe rate of prenatal diagnosis of gastroschisis and omphalocele varies by country. In 26 of the 31 registries that comprise the EUROCAT network, the percentage of diagnosis was higher than 90% of cases (EUROCAT 2024). These rates were higher than those observed in our study. However, research conducted in developing countries shows percentages still below those reported in our work (Bilibio et al. \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Muniz et al. \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Amado et al. \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn a previous study by RENAC, which included all the institutions in the network, it was observed that the PDR in public institutions was lower than in private and social security hospitals (Bidondo et al. \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Conversely, another study conducted by the Latin American Collaborative Study of Congenital Malformations (ECLAMC), which included 13 hospitals in Argentina found no differences in the PDR between public and non-public institutions; however, in public institutions, the diagnosis was made at a significantly later gestational age (Campa\u0026ntilde;a et al. \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2010\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFrom a health perspective, prenatal care is considered efficient when it meets certain basic requirements: it should begin early in gestation, be periodic throughout pregnancy, be comprehensive, and have broad coverage within the population. The guidelines of the Ministry of Health of Argentina recommend a minimum of 8 prenatal consultations, however in 2021, only 10.9% of pregnant women attended more than 9 consultations, 61.9% attended between 5 and 9 consultations and 27.2% made fewer than 5 consultations. Furthermore, regarding gestational age at the first prenatal visit, it was observed that only 38.8% consulted in the first trimester (Direcci\u0026oacute;n de Salud Perinatal y Ni\u0026ntilde;ez 2023). This situation indicates that there are still barriers to accessing the health system, which, among other implications, affects the potential for early diagnosis of fetal abnormalities. Pregnant women face social, cultural, and economic barriers, as well as challenges related to domestic responsibilities and the care of children or dependent individuals at home. Additionally, there are barriers within the health system itself; in this regard, a study conducted in a maternity ward in the city of Buenos Aires showed that the main barrier to access for pregnant women in the first trimester of pregnancy was the inability to secure an appointment for care at the establishment (P\u0026eacute;cora et al. \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2008\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn perinatology, poor organization is considered to be as significant a factor as the lack of clinical competence in the origin of morbidity and mortality for both mothers and children (Schwarcz \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). For several years, Argentina has organized perinatal care to reduce maternal and neonatal morbidity and mortality. To this end, essential obstetric and neonatal conditions (CONE) were established, along with a regionalization and classification system based on complexity (Speranza and Kurlat \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2011\u003c/span\u003e) Regionalization implies a coordinated system between institutions and health teams. The prevalence of the selected congenital anomalies was significantly higher in institutions of greater complexity, which likely reflects the effectiveness of prenatal diagnosis and timely referral to these centers for follow-up and care at birth. However, a significant percentage of cases were born in low-complexity institutions despite being detected prenatally. This situation may be attributed to deficiencies in the referral and counter-referral system for pregnant women with a prenatal diagnosis of CA to higher-complexity centers.\u003c/p\u003e"},{"header":"Limitations","content":"\u003cp\u003eOur study has some limitations. The analysis has been restricted to public institutions, however, it is important to note that in Argentina, the non-public health system (social security and prepaid health plans), where 38.7% of births in the country occur (DEIS 2023), does not present a perinatal organization based on levels of complexity.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn our study, we observed that the six major congenital anomalies selected had higher rates of prenatal diagnosis and prevalence in the most complex public institutions. The anomalies studied require specific, highly complex perinatal management, which is why birth should occur in maternity wards categorized as 3B. For this reason, it is necessary to improve, among other aspects, the early prenatal diagnosis of CAs as well as the referral system and perinatal care networks.\u003c/p\u003e \u003cp\u003eThe regionalization of perinatal health services based on levels of complexity requires the implementation of prenatal ultrasound screening during the first and second trimester of pregnancy as a fundamental pillar at a national level. This strategy enables early diagnosis and timely referral of pregnant women to centers of adequate complexity; Universal screening has been shown to have a direct impact on reducing perinatal mortality (Sewell and Keene \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2018\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTo achieve this goal, Law No. 27,611 was passed in Argentina in 2020, promoting nationwide access for pregnant individuals to fetal morphology studies via ultrasound between 18 and 22 weeks of gestation to identify major congenital malformations. However, to implement this public health measure effectively, it is necessary to advance various actions, including promoting early initiation of prenatal check-ups among the population; improving access to health services; training health professionals in the diagnosis of CA; increasing the availability of prenatal studies at all levels of care; generating a prenatal diagnosis network with different levels of complexity that facilitates consultation and/or referral between institutions and improving equipment in cases that require it, among other measures.\u003c/p\u003e \u003cp\u003eEarly diagnosis also allows pregnant women to decide whether to continue with the pregnancy or opt for termination at an earlier gestational age.\u003c/p\u003e \u003cp\u003eAnother conclusion that emerges from our study is that a proportion of patients with the congenital anomalies studied are born in low-complexity maternity wards, even in cases where there was a prenatal diagnosis. To address this situation, it is necessary not only to improve prenatal diagnosis, as previously mentioned; but also to optimize the functioning of perinatal care networks to ensure timely referral to more complex centers is made during pregnancy.\u003c/p\u003e \u003cp\u003eFinally, we propose that the rate of prenatal diagnosis and the prevalence of major congenital anomalies stratified by the complexity of the birthing institutions could serve as management indicators to evaluate the improvements in perinatal care. These indicators may help us assess the impact of public health policies in this area of ​​perinatal health.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eAcknowledgments: The authors would like to thank the RENAC working group\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Author contributions: All authors have contributed equally to the work and jointly supervised the work.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eData availability: The epidemiological data that support the findings of this study were\u0026nbsp;sourced from the databases of the congenital anomalies surveillance system of Argentina (RENAC) and have been published in annual reports\u0026nbsp;available at: https://ine.gov.ar/ index.php/otrasareas/renac.\u003c/p\u003e\n\u003cp\u003eEthical approval: The authors declare that there are no ethical conflicts to disclose.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Consent to participate: The study was conducted using non-nominalized data, and comparisons were made based on aggregate data. These data fall within the exceptions outlined in Resolution 1480/2011 of the National Ministry of Health, which provides guidelines for research involving human subjects.\u003c/p\u003e\n\u003cp\u003eCompeting interests: Analizia Astudillo, Boris Groisman, Pablo Barbero, Mar\u0026iacute;a Paz Bidondo, Rosa Liascovich, Horacio Aiello, Marianela Trotta, and Paloma Brun declare that they have no conflict of interest.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAdzick NS, Thom EA, Spong CY, Brock JW 3rd, Burrows PK, Johnson MP et al. A randomized trial of prenatal versus postnatal repair of myelomeningocele. N Engl J Med. 2011;364(11):993-1004.\u003c/li\u003e\n \u003cli\u003eAmado V, Dias I, Filipe M, DeUgarte DA. Gastroschisis in Mozambique: current status and priorities for improving care from Hospital Central de Maputo, the largest and referral hospital of the country. Pediatr Surg Int. 2023;39(1):95.\u003c/li\u003e\n \u003cli\u003eBakker MK, Bergman JEH, Krikov S, Amar E, Cocchi G, Cragan J, et al. Prenatal diagnosis and prevalence of critical congenital heart defects: an international retrospective cohort study. BMJ Open. 2019;9(7):e028139.\u003c/li\u003e\n \u003cli\u003eBidondo, MP, Groisman B, Gili J, Liascovich R, Barbero P. Prevalencia de anomal\u0026iacute;as cong\u0026eacute;nitas en Argentina y su potencial impacto en los servicios de salud. Rev. Argent Salud P\u0026uacute;blica. 2014;(21):38-44.\u003c/li\u003e\n \u003cli\u003eBidondo MP, Groisman B, Duarte S, Tardivo A, Liascovich R, Barbero P. Prenatal detection of congenital anomalies and related factors in Argentina. J Community Genet. 2020;11(3):313-320.\u003c/li\u003e\n \u003cli\u003eBilibio JP, Beltr\u0026atilde;o AM, Vargens AC, Gama TB, Lorenzzoni PL. Gastroschisis during gestation: prognostic factors of neonatal mortality from prenatal care to postsurgery. Eur J Obstet Gynecol Reprod Biol. 2019;237:79-84.\u003c/li\u003e\n \u003cli\u003eCampa\u0026ntilde;a H, Ermini M, Aiello HA, Krupitzki H, Castilla EE, L\u0026oacute;pez-Camelo JS; Latin American Collaborative Study of Congenital Malformations Study Group. Prenatal sonographic detection of birth defect in 18 hospital of South America. J Ultrasound Med. 2010;29(2):203\u0026ndash;212\u003c/li\u003e\n \u003cli\u003eDEIS, Direcci\u0026oacute;n de Estad\u0026iacute;sticas e Informaci\u0026oacute;n en Salud. 2023. Available at: https://www.argentina.gob.ar/sites/default/files/serie_5_nro_65_anuario_vitales_2021_-_web.pdf\u003c/li\u003e\n \u003cli\u003eDeprest JA, Nicolaides KH, Benachi A, Gratacos E, Ryan G, Persico et al TOTAL Trial for Severe Hypoplasia Investigators Randomized Trial of Fetal Surgery for Severe Left Diaphragmatic Hernia..N Engl J Med. 2021;385(2):107-118.\u003c/li\u003e\n \u003cli\u003eDirecci\u0026oacute;n de Salud Perinatal y Ni\u0026ntilde;ez, Gu\u0026iacute;a de pr\u0026aacute;ctica cl\u0026iacute;nica. Atenci\u0026oacute;n prenatal de bajo riesgo. Actualizaci\u0026oacute;n de ocho Recomendaciones priorizadas. 2023. Available at: https://bancos.salud.gob.ar/sites/default/files/2023-07/GPC%20Atenci%C3%B3n%20Prenatal%20de%20Bajo%20Riesgo%202023.pdf\u003c/li\u003e\n \u003cli\u003eEUROCAT Distribution of registries by overall proportion of cases prenatally diagnosed (2017 - 2021) Available at: https://eu-rd-platform.jrc.ec.europa.eu/eurocat/eurocat-data/prenatal-screening-and-diagnosis_en\u003c/li\u003e\n \u003cli\u003eGagnon A, the GENETICS COMMITTEE (2009) Evaluation of prenatally diagnosed structural congenital anomalies. J Obstet Gynaecol Can. 2009;31(9):875\u0026ndash;881.\u003c/li\u003e\n \u003cli\u003eGroisman B, Bidondo MP, Barbero P, Gili JA, Liascovich R; RENAC Task Force. RENAC: National Registry of Congenital Anomalies of Argentina. Arch Argent Pediatr. 2013.Dec;111(6):484-94\u003c/li\u003e\n \u003cli\u003eLennon C. A., Gray D. L. Sensitivity and specificity of ultrasound for the detection of neural tube and ventral wall defects in a high-risk population. Obstetrics \u0026amp; Gynecology. 1999;94(4):562\u0026ndash;566.\u003c/li\u003e\n \u003cli\u003eLytzen R, Vejlstrup N, Bjerre J, Petersen OB, Leenskjold S, Dodd JK J et al. Mortality and morbidity of major congenital heart disease related to general prenatal screening for malformations. Int J Cardiol. 2019 Sep 1:290:93-99\u003c/li\u003e\n \u003cli\u003eMeller C, Covini D, Aiello H, Izbizky G, Medina Portillo S, Ota\u0026ntilde;o L. Actualizaci\u0026oacute;n del diagn\u0026oacute;stico prenatal y cirug\u0026iacute;a fetal del mielomeningocele. Arch Argent Pediatr 2021;119(3):e215-e228.\u003c/li\u003e\n \u003cli\u003eMinisterio de Salud de la Naci\u0026oacute;n, 2012. Resoluci\u0026oacute;n 641/2012. Available at: https://e-legis-ar.msal.gov.ar/htdocs/legisalud/migration/pdf/19429.pdf\u003c/li\u003e\n \u003cli\u003eMinisterio de Salud de la Naci\u0026oacute;n, 2019. Resoluci\u0026oacute;n 670/2019. 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An\u0026aacute;lisis epidemiol\u0026oacute;gico de las anomal\u0026iacute;as cong\u0026eacute;nitas en reci\u0026eacute;n nacidos registradas en el a\u0026ntilde;o 2022 en la Rep\u0026uacute;blica Argentina. Buenos Aires: Ministerio Salud de la Naci\u0026oacute;n. Available at: https://www.ine.gov.ar/index.php/otrasareas/renac\u003c/li\u003e\n \u003cli\u003eSchwarcz A 2011. Regionalizaci\u0026oacute;n de la atenci\u0026oacute;n perinatal en De Mucio B, Fescina R, Schwarcz A,Garibaldi MC M\u0026eacute;ndez GC. Regionalizaci\u0026oacute;n de la atenci\u0026oacute;n perinatal OPS Available at: https://bancos.salud.gob.ar/sites/default/files/2018-10/0000000176cnt-n02-regionalizacion.pdf\u003c/li\u003e\n \u003cli\u003eSewell EK, Keene S. Perinatal Care of Infants with Congenital Birth Defects. Clin Perinatol. 2018 Jun;45(2):213-230.\u003c/li\u003e\n \u003cli\u003eSperanza AM \u0026amp; Kurlat I. Regionalizaci\u0026oacute;n del cuidado perinatal: una estrategia para disminuir la mortalidad infantil y la mortalidad materna. Rev Argent Salud P\u0026uacute;blica, 2011. 2 (7): 40-42.\u003c/li\u003e\n \u003cli\u003eVan Calster B, Benachi A, Nicolaides KH, Gratacos E, Berg C, Persico N et al. The randomized Tracheal Occlusion To Accelerate Lung growth (TOTAL)-trials on fetal surgery for congenital diaphragmatic hernia: reanalysis using pooled data. Am J Obstet Gynecol. 2022;226(4):560.e1-560.e24.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-community-genetics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jocg","sideBox":"Learn more about [Journal of Community Genetics](http://link.springer.com/journal/12685)","snPcode":"12687","submissionUrl":"https://submission.nature.com/new-submission/12687/3","title":"Journal of Community Genetics","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"congenital anomalies, prenatal diagnosis, public health, perinatal care","lastPublishedDoi":"10.21203/rs.3.rs-5388886/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5388886/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003ePatients with major congenital anomalies should be delivered in high-complexity institutions, which reduces morbidity and mortality. We aimed to assess the prevalence and prenatal diagnosis rates of selected congenital abnormalities and the complexity levels of birth institutions in a sample of public maternity hospitals in Argentina. Data sources were 1) National Congenital Anomalies Registry, covering the period from 2013 to 2021; and 2) Categorization of birth institutions according to their complexity (high or low). Newborns with the following anomalies were selected for analysis: spina bifida, hydrocephalus, critical congenital heart defects, diaphragmatic hernia, gastroschisis, and omphalocele. Prevalence at birth and prenatal diagnosis rates were calculated according to the birth institution complexity level. A total of 2.214.102 births across 131 institutions were evaluated, with 1.202.311 births in high-complexity institutions and 1.011.791 in low-complexity institutions. The prevalence per 10.000 births and the prenatal diagnosis percentage for the entire sample were: spina bifida 5,40(95%CI 5,10\u0026thinsp;\u0026minus;\u0026thinsp;5,71) 68,54%; hydrocephalus 6,96(95% CI 6,62\u0026thinsp;\u0026minus;\u0026thinsp;7,32) 78,92%; critical congenital heart defects 11,05(95% CI 10,62\u0026thinsp;\u0026minus;\u0026thinsp;11,49) 43,21%; diaphragmatic hernia 3,88(95%CI 3,62\u0026thinsp;\u0026minus;\u0026thinsp;4,14) 68,65%; gastroschisis 7,85(95%CI 7,48\u0026thinsp;\u0026minus;\u0026thinsp;8,22) 79,27%; omphalocele 2,01(95%CI 1,83\u0026thinsp;\u0026minus;\u0026thinsp;2,20) 76,18%. Prevalence and prenatal diagnosis rates were significantly higher in high-complexity institutions. Prenatal diagnosis and perinatal care networks must be improved to ensure that patients with major congenital anomalies are delivered in high-complexity birth institutions. The prevalence and prenatal diagnosis rate, stratified by the complexity level of institutions, can serve as management indicators to evaluate improvements in care quality.\u003c/p\u003e","manuscriptTitle":"Prenatal diagnosis of congenital anomalies and birth institution complexity levels in Argentina","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-09 14:51:10","doi":"10.21203/rs.3.rs-5388886/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-12-04T12:09:15+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-24T17:45:20+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-18T16:23:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"273358400083335242023636550299933583947","date":"2024-11-13T10:56:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"188954415824539339666402868633427129497","date":"2024-11-09T14:19:07+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-11-07T09:06:35+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-11-06T16:29:10+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-11-06T16:27:46+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Community Genetics","date":"2024-11-04T14:19:56+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-community-genetics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jocg","sideBox":"Learn more about [Journal of Community Genetics](http://link.springer.com/journal/12685)","snPcode":"12687","submissionUrl":"https://submission.nature.com/new-submission/12687/3","title":"Journal of Community Genetics","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"c1594fae-d44b-44d3-86f8-cb07defa4657","owner":[],"postedDate":"December 9th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-01-27T16:07:35+00:00","versionOfRecord":{"articleIdentity":"rs-5388886","link":"https://doi.org/10.1007/s12687-024-00766-z","journal":{"identity":"journal-of-community-genetics","isVorOnly":false,"title":"Journal of Community Genetics"},"publishedOn":"2025-01-21 15:57:09","publishedOnDateReadable":"January 21st, 2025"},"versionCreatedAt":"2024-12-09 14:51:10","video":"","vorDoi":"10.1007/s12687-024-00766-z","vorDoiUrl":"https://doi.org/10.1007/s12687-024-00766-z","workflowStages":[]},"version":"v1","identity":"rs-5388886","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5388886","identity":"rs-5388886","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}