Deprived neighborhoods and adverse perinatal outcome: a systematic review and meta-analysis

Validation of the 'EPICES' social deprivation score in a population of women who have just given birth: a French cross-sectional study

OBJECTIVES

To assess the diagnostic performance of the EPICES score for identifying social deprivation during pregnancy in a population of women in the immediate postpartum period.

STUDY DESIGN

This cross-sectional survey took place between 5th June and 5th August 2017, among women who had just given birth in either of the maternity units in Clermont-Ferrand, France.

METHODS

A self-administered questionnaire was completed by women. The questionnaire came in two parts: the EPICES index and the criteria for social deprivation defined by French law. These criteria were chosen to define the reference standard. The women were classified into two groups, living in precarious circumstances or not, according to the criteria defined by the French law (reference standard). To determine the most relevant threshold of the EPICES score, the precision associated with the threshold (the fraction of those predicted positive who are true positives: positive predictive value) was balanced with its sensitivity. EPICES scores above the threshold were classified as deprived, those below as non-deprived.

RESULTS

Of the 947 women who gave birth during the study period, 700 (73.9%) completed the self-administered questionnaire. The best trade-off between precision and sensitivity was obtained with a threshold of 22. For this threshold value, the positive predictive value was 42.3% and the sensitivity 70.3%.

CONCLUSIONS

The EPICES score with a threshold validated in the population of pregnant women is a useful, rapid, and easy-to-use tool that makes it possible to identify maternal deprivation at an individual level.

Health Agency and Perfectionism: The Case of Perinatal Health Inequalities

Poor pregnancy outcomes and inequalities in these outcomes remain a major challenge, even in prosperous societies that have high-quality health care and public health policy in place. In this article, we propose that justice demands the improvement of what we call the ‘health agency’ of parents-to-be as part of a response to these poor outcomes. We take health agency to have three aspects: (i) the capacity to form health-goals one has reason to value, (ii) the control one perceives to have over achieving those health-goals and (iii) the freedom(s) one has to achieve those health-goals. We will moreover argue that this demand of justice can be best based on a perfectionist rather than neutralist method of justification. Subsequently, we will argue that perfectionist policy may be paternalistic but not wrongfully paternalistic. This leads us to conclude that perfectionism should be adopted to inform and justify public health policy that is aimed at improving health agency in general and counteracting poor pregnancy outcomes and inequalities in perinatal health outcomes in particular.

Call to Action: Maternal Health and Saving Mothers: A Policy Statement From the American Heart Association

The United States has the highest maternal mortality rates among developed countries, and cardiovascular disease is the leading cause. Therefore, the American Heart Association has a unique role in advocating for efforts to improve maternal health and to enhance access to and delivery of care before, during, and after pregnancy. Several initiatives have shaped the time course of major milestones in advancing maternal and reproductive health equity in the United States. There have been significant strides in improving the timeliness of data reporting in maternal mortality surveillance and epidemiological programs in maternal and child health, yet more policy reforms are necessary. To make a sustainable and systemic impact on maternal health, further efforts are necessary at the societal, institutional, stakeholder, and regulatory levels to address the racial and ethnic disparities in maternal health, to effectively reduce inequities in care, and to mitigate maternal morbidity and mortality. In alignment with American Heart Association's mission "to be a relentless force for longer, healthier lives," this policy statement outlines the inequities that influence disparities in maternal outcomes and current policy approaches to improving maternal health and suggests additional potentially impactful actions to improve maternal outcomes and ultimately save mothers' lives.

An innovative postnatal risk assessment and corresponding care pathways in Preventive Child Healthcare

Aims

This study aims to evaluate the effectiveness of an innovative postnatal risk assessment (the postnatal Rotterdam Reproductive Risk Reduction checklist: R4U) and corresponding care pathways in Preventive Child Healthcare (PCHC), along with PCHC professional satisfaction.

Design

Four PCHC organizations located in three municipalities with a higher adverse perinatal outcome than the national average were selected for participation. The study concerns a historically controlled study design.

Methods

The study enrolled participants from September 2016 until December 2017. The historical cohort existed of children born in previous years from 2008 until 2016. The outcome measure was defined as catch‐up growth: more than 0.67 standard deviation score weight for height increase in the first 6 months of life. PCHC professional opinion was assessed with a digital survey.

Results

After the inclusion period, 1,953 children were included in the intervention cohort and 7,436 children in the historical cohort. Catch‐up growth was significantly less common in the intervention cohort; 14.9% versus 19.5% in the historical cohort (p < 0.001). A regression sensitivity analysis, using matching, showed an odds ratio of 0.957 (95% CI 0.938–0.976) for the intervention cohort. In the survey, 74 PCHC physicians and nurses participated; most of them were neutral concerning the benefits of the postnatal R4U.

Conclusion

This study shows that the implementation of a novel postnatal risk assessment including in PCHC is feasible and effective. Final efforts to ensure a widespread implementation should be taken.

Impact

PCHC offers a unique opportunity to recognize and address risk factors for growth and development in children and to implement care pathways. Effective and widely implemented risk assessments in antenatal and PCHC are scarce. To our knowledge, this kind of evidence‐based postnatal risk assessment has not been implemented in PCHC before and seizes the opportunity to prevent catch‐up growth and its long‐term effects.

Preterm birth among pregnant women living in areas with high social vulnerability

BACKGROUND

Communities and individuals widely vary in their resources and ability to respond to external stressors and insults. To identify vulnerable communities, the Centers for Disease Control and Prevention developed the Social Vulnerability Index, an integrated tool to assess community resources and preparedness; it is based on 15 factors and includes individual scores in the following 4 themes: socioeconomic status (theme 1), household composition and disability (theme 2), minority status and language (theme 3), and housing type and transportation (theme 4) and an overall composite score. Several Social Vulnerability Index components have been independently associated with an increased risk of preterm birth.

OBJECTIVE

We sought to investigate the association of the Social Vulnerability Index for each patient's residence during pregnancy, personal clinical risk factors, and preterm birth.

STUDY DESIGN

This was a retrospective cohort study of women carrying nonanomalous singleton or twin gestations delivering at a large university health system from April 2014 to January 2020. Women at high risk of spontaneous and medically indicated preterm birth were assigned to a census tract based on their geocoded home address, and a Social Vulnerability Index score was assigned to each individual by linking each patient's home address at the census tract level. Higher scores indicate greater social vulnerability. The primary outcome was preterm birth at <37 weeks' gestation; secondary outcomes were preterm birth at <34 and <28 weeks' gestation and composite major neonatal morbidity before initial hospital discharge (death, intraventricular leukomalacia or intraventricular hemorrhage, necrotizing enterocolitis, or bronchopulmonary dysplasia). Data were analyzed using the chi-square test, t test, and backward stepwise logistic regression. In addition, because race is a social construct, we conducted regression models omitting Black race. For all regression models, independent variables with a P value of <.20 remained in the final models.

RESULTS

Overall, 15,364 women met the inclusion criteria, of which 18.5%, 6.5%, 2.1% of women delivered at <37, <34, and <28 weeks' gestation, respectively, and 3.1% of neonates were diagnosed with major composite morbidity. Women delivering before term at <37, <34, and <28 weeks' gestation were more likely to live in an area with a higher overall Social Vulnerability Index and higher social vulnerability in each Social Vulnerability Index theme. In regression models, the adjusted odds ratio of preterm birth increased with increasing Social Vulnerability Index scores (across all themes and the composite value); these effects were the greatest at the earliest gestational ages (eg, for the composite Social Vulnerability Index: adjusted odds ratio of preterm birth at <37 weeks' gestation for models, including Black race, 1.32 [95% confidence interval, 1.14-1.53]; adjusted odds ratio at <34 weeks' gestation, 1.60 [95% confidence interval, 1.27-2.01]; adjusted odds ratio at <28 weeks' gestation, 2.21 [95% confidence interval, 1.50-3.25]; adjusted odds ratio for composite major neonatal morbidity, 2.30 [95% confidence interval, 1.67-3.17]). Similar trends were seen for each Social Vulnerability Index theme. In addition, an increased adjusted odds ratio of composite major neonatal morbidity was recognized for each Social Vulnerability Index theme. Results were similar when Black race was removed from the models.

CONCLUSION

The Social Vulnerability Index is a valuable tool that may further identify communities and individuals at the highest risk of preterm birth and may enable clinicians to integrate information regarding the local home environment of their patients to further refine preterm birth risk assessment.

Impact of Socioeconomic Status, Race and Ethnicity, and Geography on Prenatal Detection of Hypoplastic Left Heart Syndrome and Transposition of the Great Arteries

BACKGROUND

Prenatal detection (PND) has benefits for infants with hypoplastic left heart syndrome (HLHS) and transposition of the great arteries (TGA), but associations between sociodemographic and geographic factors with PND have not been sufficiently explored. This study evaluated whether socioeconomic quartile (SEQ), public insurance, race and ethnicity, rural residence, and distance of residence (distance and driving time from a cardiac surgical center) are associated with the PND or timing of PND, with a secondary aim to analyze differences between the United States and Canada.

METHODS

In this retrospective cohort study, fetuses and infants <2 months of age with HLHS or TGA admitted between 2012 and 2016 to participating Fetal Heart Society Research Collaborative institutions in the United States and Canada were included. SEQ, rural residence, and distance of residence were derived using maternal census tract from the maternal address at first visit. Subjects were assigned a SEQ z score using the neighborhood summary score or Canadian Chan index and separated into quartiles. Insurance type and self-reported race and ethnicity were obtained from medical charts. We evaluated associations among SEQ, insurance type, race and ethnicity, rural residence, and distance of residence with PND of HLHS and TGA (aggregate and individually) using bivariate analysis with adjusted associations for confounding variables and cluster analysis for centers.

RESULTS

Data on 1862 subjects (HLHS: n=1171, 92% PND; TGA: n=691, 58% PND) were submitted by 21 centers (19 in the United States). In the United States, lower SEQ was associated with lower PND in HLHS and TGA, with the strongest association in the lower SEQ of pregnancies with fetal TGA (quartile 1, 0.78 [95% CI, 0.64-0.85], quartile 2, 0.77 [95% CI, 0.64-0.93], quartile 3, 0.83 [95% CI, 0.69-1.00], quartile 4, reference). Hispanic ethnicity (relative risk, 0.85 [95% CI, 0.72-0.99]) and rural residence (relative risk, 0.78 [95% CI, 0.64-0.95]) were also associated with lower PND in TGA. Lower SEQ was associated with later PND overall; in the United States, rural residence and public insurance were also associated with later PND.

CONCLUSIONS

We demonstrate that lower SEQ, Hispanic ethnicity, and rural residence are associated with decreased PND for TGA, with lower SEQ also being associated with decreased PND for HLHS. Future work to increase PND should be considered in these specific populations.

Socioeconomic inequalities and adverse pregnancy outcomes in the UK and Republic of Ireland: a systematic review and meta-analysis

OBJECTIVE

There has been an unprecedented rise in infant mortality associated with deprivation in recent years in the United Kingdom (UK) and Republic of Ireland. A healthy pregnancy can have significant impacts on the life chances of children. The objective of this review was to understand the association between individual-level and household-level measures of socioeconomic status and adverse pregnancy outcomes.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Nine databases were searched (Medline, Embase, Scopus, ASSIA, CINAHL, PsycINFO, BNI, MIDRIS and Google Scholar) for articles published between 1999 and August 2019. Grey literature searches were also assessed.

STUDY SELECTION CRITERIA

Studies reporting associations between individual-level or household socioeconomic factors on pregnancy outcomes in the UK or Ireland.

RESULTS

Among the 82 353 search results, 53 821 titles were identified and 35 unique studies met the eligibility criteria. Outcomes reported were neonatal, perinatal and maternal mortality, preterm birth, birth weight and mode of delivery. Pooled effect sizes were calculated using random-effects meta-analysis. There were significantly increased odds of women from lower levels of occupation/social classes compared with the highest level having stillbirth (OR 1.40, 95% CI 1.23 to 1.59, I²98.62%), neonatal mortality (OR 1.39, 95% CI 1.22 to 1.57, I²97.09%), perinatal mortality (OR 1.39, 95% CI 1.23 to 1.57, I²98.69%), preterm birth (OR 1.41, 95% CI 1.33 to 1.50, I²70.97%) and low birth weight (OR 1.40, 95% CI 1.19 to 1.61, I²99.85%). Limitations relate to available data, unmeasured confounders and the small number of studies for some outcomes.

CONCLUSIONS

This review identified consistent evidence that lower occupational status, especially manual occupations and unemployment, were significantly associated with increased risk of multiple adverse pregnancy outcomes. Strategies to improve pregnancy outcomes should incorporate approaches that address wider determinants of health to provide women and families with the best chances of having a healthy pregnancy and baby and to decrease pregnancy-related health inequalities in the general population.

PROSPERO REGISTRATION NUMBER

PROSPERO CRD42019140893.

The Neonatal Environment and Health Outcomes (NEHO) Birth Cohort Study: Behavioral and Socioeconomic Characteristics and Drop-Out Rate from a Longitudinal Birth Cohort in Three Industrially Contaminated Sites in Southern Italy

Pregnant women living in industrially contaminated sites (ICSs) are exposed to environmental contaminants through different pathways, and thus children’s health may be affected by pollutants. We created the Neonatal Environment and Health Outcomes (NEHO) longitudinal birth cohort in three ICSs in the Mediterranean area of southern Italy, collecting comprehensive information on personal data and lifestyles by questionnaire. Through multiple correspondence analysis, we identified possible clusters of enrolled women, and a neural network classifier analysis (NNCA) was performed to identify variables capable of predicting the attrition rate of the study. NEHO recruited 845 mother–child pairs over two years. The mothers’ mean age was 31.1 ± 5.2 SD years. We found significant differences in socioeconomic status (SES) among the three evaluated ICS, and an overall 11.1% prevalence of mothers who actively smoked during pregnancy. Active smoking during pregnancy was strongly associated with the lowest socioeconomic level (p < 0.0001). By means of the NNCA, we found that smoking during pregnancy and the lowest education level characterized the cluster with the highest attrition rate (p < 0.001). Our results demonstrate that reason for public health concern still exists regarding smoking during pregnancy and that SES influences both lifestyles, producing negative pregnancy outcomes and a higher survey attrition rate.

Suicide risk and prematurity: A study with pregnant adolescents

OBJECTIVE

To verify the association between mood and anxiety disorders, and suicide risk during pregnancy and their relationship with premature birth in a population of pregnant adolescents attending prenatal care in the public health system of Pelotas, a southern city in Brazil.

METHODS

This was a cohort study with all pregnant adolescents attending antenatal public services in the urban area of Pelotas between October 2009 and May 2011. The first assessment occurred between the 20th and 22 nd week of pregnancy and the second occurred one month after delivery. We used the Mini International Neuropsychiatric Interview (MINI) to assess mood and anxiety disorders and suicide risk.

RESULTS

A total of 645 pregnant women aged between 12 and 19 years old were interviewed. An anxiety disorder was present in 9.1% of the pregnant adolescent, and 28.5% had a mood disorder. The prevalence of suicide risk was 12.6%, and 15.3% of the babies were born premature. A multivariate analysis adjusted for maternal education, number of previous pregnancies and previous preterm birth indicated that adolescents who had suicide risk during pregnancy were approximately twice as likely to give birth prematurely when compared to those who were not diagnosed with suicide risk (PR 1.79; CI 1.06-3.03).

CONCLUSION

Our findings suggest that pregnant adolescents who were at risk of suicide during pregnancy were more likely to have premature babies. It is important to pay attention to the mental health of this specific population to prevent obstetric complications and consequently improve the health of the children.

Addressing perinatal health inequities in Dutch municipalities: Protocol for the Healthy Pregnancy 4 All-3 programme

BACKGROUND

Health inequities are already present at birth and affect individuals' health and socioeconomic outcomes across the life course. Addressing these inequities requires a cross-sectoral approach, covering the first 1,000 days of life. We believe that - in the Dutch context - municipal governments can be the main responsible actor to drive such an approach, since they are primarily responsible for organising adequate public health. Therefore, we aim to identify and develop transformative change towards the implementation of perinatal health into municipal approaches and policies concerning health inequities.

METHODS

A transition analysis will be combined with action research in six Dutch municipalities. Interviews and interactive group sessions with professionals and organisations that are relevant for the institutional embedding of perinatal health into approaches and policies regarding health inequities, will be organised in each municipality. As a follow-up, a questionnaire will be administered among all participants one year after completion of the group sessions.

DISCUSSION

We expect to gain insights into the role of municipalities in addressing perinatal health inequities, learn more about the interaction between different key stakeholders, and identify barriers and facilitators for a cross-sectoral approach to perinatal health. This knowledge will serve to inform the development of approaches to perinatal health inequities in areas with relatively poor perinatal health outcomes, both in the Netherlands and abroad.

Prediction of stillbirth: an umbrella review of evaluation of prognostic variables

BACKGROUND

Stillbirth accounts for over 2 million deaths a year worldwide and rates remains stubbornly high. Multivariable prediction models may be key to individualised monitoring, intervention or early birth in pregnancy to prevent stillbirth.

OBJECTIVES

To collate and evaluate systematic reviews of factors associated with stillbirth in order to identify variables relevant to prediction model development.

SEARCH STRATEGY

MEDLINE, Embase, DARE and Cochrane Library databases and reference lists were searched up to November 2019.

SELECTION CRITERIA

We included systematic reviews of association of individual variables with stillbirth without language restriction.

DATA COLLECTION AND ANALYSIS

Abstract screening and data extraction were conducted in duplicate. Methodological quality was assessed using AMSTAR and QUIPS criteria. The evidence supporting association with each variable was graded.

RESULTS

The search identified 1198 citations. Sixty-nine systematic reviews reporting 64 variables were included. The most frequently reported were maternal age (n = 5), body mass index (n = 6) and maternal diabetes (n = 5). Uterine artery Doppler appeared to have the best performance of any single test for stillbirth. The strongest evidence of association was for nulliparity and pre-existing hypertension.

CONCLUSION

We have identified variables relevant to the development of prediction models for stillbirth. Age, parity and prior adverse pregnancy outcomes had a more convincing association than the best performing tests, which were PAPP-A, PlGF and UtAD. The evidence was limited by high heterogeneity and lack of data on intervention bias.

TWEETABLE ABSTRACT

Review shows key predictors for use in developing models predicting stillbirth include age, prior pregnancy outcome and PAPP-A, PLGF and Uterine artery Doppler.

Innovative postnatal risk assessment in preventive child health Care: A study protocol

AIM

To introduce the rationale and design of a postnatal risk assessment study, which will be embedded in Preventive Child Health Care. This study will evaluate: (a) the predictive value of an innovative postnatal risk assessment, meant to assess the risk of growth and developmental problems in young children; and (b) its effectiveness in combination with tailored care pathways.

DESIGN

This study concerns a historically controlled study design and is designed as part of the Healthy Pregnancy 4 All-2 program. We hypothesize that child growth and developmental problems will be reduced in the intervention cohort due to the postnatal risk assessment and corresponding care pathways.

METHODS

The study was approved in August 2016. Children and their parents, visiting well-baby clinics during regular visits, will participate in the intervention (N = 2,650). Additional data of a historical control group (N = 2,650) in the same neighbourhoods will be collected. The intervention, consisting of the risk assessment and its corresponding care pathways, will be executed in the period between birth and 2 months of (corrected) age. The predictive value of the risk assessment and its effectiveness in combination with its corresponding care pathways will be assessed by Preventive Child Health Care nurses and physicians in four Preventive Child Health Care organisations in three municipalities with adverse perinatal outcomes. A total risk score above a predefined threshold, which is based on a weighted risk score, determines structured multidisciplinary consultation.

DISCUSSION

The successful implementation of this innovative postnatal risk assessment including corresponding care pathways has potential for further integration of risk assessment and a family-centred approach in the work process of Preventive Child Health Care nurses and physicians.

IMPACT

This study introduces a systematic approach in postnatal health care which may improve growth and developmental outcomes of children and even future generations.

Visualizing Opportunity Index Data Using a Dashboard Application: A Tool to Communicate Infant Mortality-Based Area Deprivation Index Information

BACKGROUND

An area deprivation index (ADI) is a geographical measure that accounts for socioeconomic factors (e.g., crime, health, and education). The state of Ohio developed an ADI associated with infant mortality: Ohio Opportunity Index (OOI). However, a powerful tool to present this information effectively to stakeholders was needed.

OBJECTIVES

We present a real use-case by documenting the design, development, deployment, and training processes associated with a dashboard solution visualizing ADI data.

METHODS

The Opportunity Index Dashboard (OID) allows for interactive exploration of the OOI and its seven domains-transportation, education, employment, housing, health, access to services, and crime. We used a user-centered design approach involving feedback sessions with stakeholders, who included representatives from project sponsors and subject matter experts. We assessed the usability of the OID based on the effectiveness, efficiency, and satisfaction dimensions. The process of designing, developing, deploying, and training users in regard to the OID is described.

RESULTS

We report feedback provided by stakeholders for the OID categorized by function, content, and aesthetics. The OID has multiple, interactive components: choropleth map displaying OOI scores for a specific census tract, graphs presenting OOI or domain scores between tracts to compare relative positions for tracts, and a sortable table to visualize scores for specific county and census tracts. Changes based on parameter and filter selections are described using a general use-case. In the usability evaluation, the median task completion success rate was 83% and the median system usability score was 68.

CONCLUSION

The OID could assist health care leaders in making decisions that enhance care delivery and policy decision making regarding infant mortality. The dashboard helps communicate deprivation data across domains in a clear and concise manner. Our experience building this dashboard presents a template for developing dashboards that can address other health priorities.

Associations of area-level deprivation with adverse obstetric and perinatal outcomes in Bavaria, Germany: Results from a cross-sectional study

Background

We investigated associations of area-level deprivation with obstetric and perinatal outcomes in a large population-based routine dataset.

Methods

We used the data of n = 827,105 deliveries who were born in hospitals between 2009 to 2016 in Bavaria, Germany. The Bavarian Index of Multiple Deprivation (BIMD) on district level was assigned to each mother by the zip code of her residential address. We calculated odds ratios (ORs) with 95% confidence intervals (CIs) for preterm deliveries, Caesarian sections (CS), stillbirths, small for gestational age (SGA) births and low 5-minute Apgar scores by BIMD quintiles with and without adjustment for potential confounders.

Results

We observed a significantly increased risk for preterm deliveries in mothers from the most deprived compared to the least deprived districts (e.g. OR [95% CI] for highest compared to lowest deprivation quintile: 1.06 [1.03, 1.09]) in adjusted analyses. Increased deprivation was also associated with higher SGA and secondary CS rates, but with lower proportions of stillbirths, primary CS and low Apgar scores. When one large clinic with an unusually high stillbirth rate was excluded, the association of BIMD with stillbirths was attenuated and almost disappeared.

Conclusions

We found that area-level deprivation in Bavaria was positively associated with preterm and SGA births, confirming previous studies. In contrast, the finding of an inverse association between deprivation and both stillbirth rates and low Apgar score came somewhat surprising. However, we conclude that the stillbirths finding is spurious and reflects regional bias due to a clinic which seems to specialize in termination of pregnancies.

Validation of a prognostic model for adverse perinatal health outcomes

There is a strong association between social deprivation and adverse perinatal health outcomes, but related risk factors receive little attention in current antenatal risk selection. To increase awareness of healthcare professionals for these risk factors, a model for antenatal risk surveillance and care was developed in The Netherlands, called the ‘Rotterdam Reproductive Risk Reduction’ (R4U) scorecard. The aim of this study was to validate the R4U-scorecard. This study was conducted using external, prospective data from thirty-two midwifery practices, and fifteen hospitals in The Netherlands. The main outcome measures were the discrimination of the prognostic models for the probability of a pregnant woman developing adverse pregnancy outcomes (babies born preterm or small for gestational age), and calibration. We performed cross-validation and updated the model using statistical re-estimation of all predictors. 1752 participants were included, of whom 282 (16%) had one of the predefined adverse outcomes. The discriminative value of the original scoring system was poor [area under the curve (AUC) of 0.58 (95% CI 0.53–0.64)]. The model showed moderate calibration. The updated R4U-scorecard showed good generalisability to the validation set but did not alter the predictive value [AUC 0.61 (95% CI 0.56–0.66)]. By using external data and by updating the prognostic model, we have provided a comprehensive evaluation of the R4U-scorecard. Further improvement in classification of high-risk pregnancies is important considering the necessity of early risk detection for healthcare professionals to take appropriate actions to prevent these risks from becoming manifest problems.

Assessment of social factors influencing hospitalization cost of US preterm newborns, 2016

Background and objective: Preterm newborn (PTN) care is costly in the US, and the preterm birth (PTB) rate has not seen substantial improvement. PTB remains a significant public health issue because of risks of adverse health outcomes and the associated economic burden. Assessing factors leading to high hospital cost is imperative in order to ease economic burden associated with PTB. Social factors influencing hospitalization cost for PTN have not been studied extensively. This study aims to examine the contributions of hospital type, race/ethnicity, and median household income quartile to the cost of the PTN's initial hospitalization after birth.Materials and methods: Data used in this study originated from the 2016 Healthcare Cost and Utilization Project Kids' Inpatient Database (KID) which provided the most recent national records of pediatric hospitalization in the US. International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes P07.2x and P07.3x were used to identify birth gestational age (GA) in complete weeks. Q00-Q99 codes were used to identify congenital anomalies. Data records reflecting hospitalization of newborns without congenital anomalies were extracted to estimate total cost in 2016. Analysis of factors influencing total cost was performed on the subset of newborns that were in-born and with birth GA from 24 to 36 weeks. Total hospital cost was calculated by multiplying total charges and cost-to-charge ratios. Per-diem cost was calculated by dividing total hospital cost by length of stay. Linear regression modeling was performed using weighted data, and the best model was selected using the Akaike information criteria. Results: Hospitalization cost for PTNs, who constituted 7.6% of all studied newborns, comprised 45% of total newborn hospitalization cost. PTNs in freestanding children's hospitals had significantly higher total cost compared to non-children's teaching and non-teaching hospitals. The cost difference was GA-dependent. The latter two hospital types reported similar cost for PTNs. Although race/ethnicity and median household income quartile were related, the two covariates had independent effects on total hospitalization cost. A model built to assess the roles of covariates in the association between GA and total hospitalization cost found that all three covariates independently affected total cost when controlling for one another, with hospital type also showing an interaction effect with GA.Conclusions: Hospitalization cost is highly influenced by hospital type, race/ethnicity, and median household income quartile. The modifiable aspects of these factors may be further dissected and targeted in order to ease the burden of high hospitalization cost associated with PTB.

Socioeconomic Inequalities in Small-for-Gestational-Age Births Before and During the Economic Crisis: An Ecologic Study of Trends in 13 Spanish Cities

Economic recessions can increase socioeconomic inequalities in health. The objective of this study was to analyze socioeconomic inequalities in small-for-gestational-age (SGA) births before and during the Spanish economic crisis. We conducted an ecological study of trends based on 2 periods before the crisis (1999-2003 and 2004-2008) and another during the crisis (2009-2013). The study population was Spanish women resident in 13 cities who had given birth during 1999-2013. The prevalence of SGA was calculated for each census tract. A hierarchical Bayesian model was used to obtain the prevalence ratio (PR) and 95% credible intervals (CI). We analyzed the association between SGA and socioeconomic deprivation in each period for each city and for 3 age groups. The PR was above 1 and statistically significant for all 3 time periods in most of the 13 cities. The differences in PR between periods were only statistically significant for Madrid (PR = 1.56, 95% CI 1.48-1.65 for 1999-2003; PR = 1.28, 95% CI 1.19-1.38 for 2004-2008) and Barcelona (PR = 0.99, 95% CI 0.87-1.12 for 2004-2008; PR = 1.20, 95% CI 1.05-1.36 for 2009-2013). Socioeconomic inequalities in SGA births in small areas (census tracts) of most Spanish cities studied remained stable before and during the economic crisis.

Neighborhood Privilege, Preterm Delivery, and Related Racial/Ethnic Disparities: An Intergenerational Application of the Index of Concentration at the Extremes

We assessed whether early childhood and adulthood experiences of neighborhood privilege, measured by the Index of Concentration at the Extremes (ICE), were associated with preterm delivery and related racial/ethnic disparities using intergenerationally linked birth records of 379,794 California-born primiparous mothers (born 1982-1997) and their infants (born 1997-2011). ICE measures during early childhood and adulthood approximated racial/ethnic and economic dimensions of neighborhood privilege and disadvantage separately (ICE-income, ICE-race/ethnicity) and in combination (ICE-income + race/ethnicity). Results of our generalized estimating equation models with robust standard errors showed associations for ICE-income and ICE-income + race/ethnicity. For example, ICE-income + race/ethnicity was associated with preterm delivery in both early childhood (relative risk (RR) = 1.12, 95% confidence interval (CI): 1.08, 1.17) and adulthood (RR = 1.07, 95% CI: 1.03, 1.11). Non-Hispanic black and Hispanic women had higher risk of preterm delivery than white women (RR = 1.32, 95% CI: 1.28, 1.37; and RR = 1.11, 95% CI: 1.08, 1.14, respectively, adjusting for individual-level confounders). Adjustment for ICE-income + race/ethnicity at both time periods yielded the greatest declines in disparities (for non-Hispanic black women, RR = 1.23, 95% CI: 1.18, 1.28; for Hispanic women, RR = 1.05, 95% CI: 1.02, 1.09). Findings support independent effects of early childhood and adulthood neighborhood privilege on preterm delivery and related disparities.

Small-Area Factors and Their Impact on Low Birth Weight-Results of a Birth Cohort Study in Bielefeld, Germany

Introduction: The location of residence is a factor possibly contributing to social inequalities and emerging evidence indicates that it already affects perinatal development. The underlying pathways remain unknown; theory-based and hypothesis-driven analyses are lacking. To address these challenges, we aim to establish to what extent small-area characteristics contribute to low birth weight (LBW), independently of individual characteristics. First, we select small-area characteristics based on a conceptual model and measure them. Then, we empirically analyse the impact of these characteristics on LBW. Material and methods: Individual data were provided by the birth cohort study "Health of infants and children in Bielefeld/Germany." The sample consists of 892 eligible women and their infants distributed over 80 statistical districts in Bielefeld. Small-area data were obtained from local noise maps, emission inventory, Google Street View and civil registries. A linear multilevel analysis with a two-level structure (individuals nested within statistical districts) was conducted. Results: The effects of the selected small-area characteristics on LBW are small to non-existent, no significant effects are detected. The differences in proportion of LBW based on marginal effects are small, ranging from zero to 1.1%. Newborns from less aesthetic and subjectively perceived unsafe neighbourhoods tend to have higher proportions of LBW. Discussion: We could not find evidence for negative effects of small-area factors on LBW, but our study confirms that obtaining adequate sample size, reliable measure of exposure and using available data for operationalisation of the small-area context represent the core challenges in this field of research.

Effects of gentrification on health status after Hurricane Katrina

Despite substantial debate about the impacts of gentrification on cities, neighborhoods, and their residents, there is limited evidence to demonstrate the implications of gentrification for health. We examine the impacts of gentrification on several health measures using a unique individual-level longitudinal data set. We employ data from the Resilience in Survivors of Hurricane Katrina (RISK) project, a study of low-income parents, predominantly non-Hispanic Black single mothers, who participated in a New Orleans-based study before and after Hurricane Katrina. After Katrina, all participants were displaced, at least temporarily, from New Orleans, and had little or no control over neighborhood placement immediately following the storm. This near-random displacement after Katrina created a natural experiment. We employ a quasi-experimental intent to treat design to assess the causal effects of gentrification on health in the RISK population. We do not find evidence of significant main effects of being displaced to a gentrified neighborhood on BMI, self-rated health, or psychological distress. The analysis employs a quasi-experimental design and has several additional unique features--homogeneous population, limited selection bias, and longitudinal data collection-- that improve our ability to draw causal conclusions about the relationship between gentrification and health. However, the unique context of displacement by natural disaster may limit the generalizability of our findings to other circumstances or residents experiencing gentrification.

Health in Preconception, Pregnancy and Postpartum Global Alliance: International Network Preconception Research Priorities for the Prevention of Maternal Obesity and Related Pregnancy and Long-Term Complications

The preconception period is a key public health and clinical opportunity for obesity prevention. This paper describes the development of international preconception priorities to guide research and translation activities for maternal obesity prevention and improve clinical pregnancy outcomes. Stakeholders of international standing in preconception and pregnancy health formed the multidisciplinary Health in Preconception, Pregnancy, and Postpartum (HiPPP) Global Alliance. The Alliance undertook a priority setting process including three rounds of priority ranking and facilitated group discussion using Modified Delphi and Nominal Group Techniques to determine key research areas. Initial priority areas were based on a systematic review of international and national clinical practice guidelines, World Health Organization recommendations on preconception and pregnancy care, and consumer and expert input from HiPPP members. Five preconception research priorities and four overarching principles were identified. The priorities were: healthy diet and nutrition; weight management; physical activity; planned pregnancy; and physical, mental and psychosocial health. The principles were: operating in the context of broader preconception/antenatal priorities; social determinants; family health; and cultural considerations. These priorities provide a road map to progress research and translation activities in preconception health with future efforts required to advance evidence-translation and implementation to impact clinical outcomes.

Neighborhood Physical Disorder and Adverse Pregnancy Outcomes among Women in Chicago: a Cross-Sectional Analysis of Electronic Health Record Data

Adverse pregnancy outcomes increase infants' risk for mortality and future health problems. Neighborhood physical disorder may contribute to adverse pregnancy outcomes by increasing maternal chronic stress. Google Street View technology presents a novel method for assessing neighborhood physical disorder but has not been previously examined in the context of birth outcomes. In this cross-sectional study, trained raters used Google's Street View imagery to virtually audit a randomly sampled block within each Chicago census tract (n = 809) for nine indicators of physical disorder. We used an item-response theory model and spatial interpolation to calculate tract-level neighborhood physical disorder scores across Chicago. We linked these data with geocoded electronic health record data from a large, academic women's hospital in Chicago (2015-2017, n = 14,309 births). We used three-level hierarchical Poisson regression to estimate prevalence ratios for the associations of neighborhood physical disorder with preterm birth (overall and spontaneous), small for gestational age (SGA), and hypertensive disorder of pregnancy (HDP). After adjustment for maternal sociodemographics, multiparity, and season of birth, living in a neighborhood with high physical disorder was associated with higher prevalence of PTB, SGA, and HDP (prevalence ratios and 95% confidence intervals 1.21 (1.06, 1.39) for PTB, 1.13 (1.01, 1.37) for SGA, and 1.23 (1.07, 1.42) for HDP). Adjustment for neighborhood poverty and maternal health conditions (e.g., hypertension, diabetes, asthma, substance use) attenuated associations. Results suggest that an adverse neighborhood physical environment may contribute to adverse pregnancy outcomes. However, future work is needed to disentangle the unique contribution of physical disorder from other characteristics of disadvantaged neighborhoods.

The Impact of Neighbourhood Deprivation on Embryonic Growth Trajectories: Rotterdam Periconception Cohort

Background: Neighbourhood deprivation is a risk factor for impaired health and adverse pregnancy outcomes. We investigated whether living in a deprived neighbourhood is associated with embryonic growth. Methods: From the Predict cohort, we studied 566 women who underwent repeated first trimester ultrasound examinations. Crown rump length (CRL; n = 1707) and embryonic volume (EV; n = 1462) were measured using three-dimensional techniques. Neighbourhood deprivation was assessed using the neighbourhood status scores (NSS) of the Dutch Social Cultural Planning office. A high NSS represents a non-deprived neighbourhood. Associations between the NSS and embryonic growth were investigated using linear mixed models. Adjustment was performed for individual-level factors: maternal age, geographic origin, educational level, BMI, folic acid supplement use, fruit and vegetable intake, alcohol use and smoking habits. Results: The NSS was negatively associated with embryonic growth: a higher score (a less deprived neighbourhood) was associated with a smaller CRL and EV; adjusted β: −0.025 (95% CI −0.046, −0.003) and adjusted β: −0.015 (95% CI −0.026, −0.003). At 11 weeks of pregnancy, we observed a 0.55 cm³ smaller EV (7.65 cm³ vs. 7.10 cm³) and 1.08 mm smaller CRL (43.14 mm vs. 42.06 mm) in the highest compared to the lowest category. Conclusion: In deprived neighbourhoods, embryos are larger than in non-deprived neighbourhoods.

Neighbourhood Income and Risk of Having an Infant With Concomitant Preterm Birth and Severe Small for Gestational Age Birth Weight

OBJECTIVE

Socioeconomic position gradients have been individually demonstrated for preterm birth (PTB) at <37 weeks gestation and severe small for gestational age birth weight at <5th percentile (SGA). It is not known how neighbourhood income is related to the combination of PTB and severe SGA, a state reflective of greater placental dysfunction and higher risk of neonatal morbidity and mortality than PTB or severe SGA alone.

METHODS

This population-based study comprised all 1 367 656 singleton live births in Ontario from 2002 to 2011. Multinomial logistic regression was used to estimate the odds of PTB with severe SGA, PTB without severe SGA, and severe SGA without PTB, compared with neither PTB nor severe SGA, in relation to neighbourhood income quintile (Q). The highest income quintile, Q5, served as the exposure referent. Adjusted odds ratios (aORs) were adjusted for maternal age at delivery, parity, marital status, and world region of birth (Canadian Task Force Classification II-2).

RESULTS

Relative to women residing in Q5 (2.3 per 1000), the rate of PTB with severe SGA was highest among those in Q1 (3.6 per 1000), with an aOR of 1.34 (95% confidence interval [CI] 1.20-1.50). The corresponding aORs were 1.23 (95% CI 1.09-1.37) for Q2, 1.14 (95% CI 1.02-1.28) for Q3, and 1.06 (95% CI 0.95-1.20) for Q4. Less pronounced aORs were seen for each individual outcome of PTB and severe SGA.

CONCLUSION

Women residing in the lowest-income areas are at highest risk of having a fetus born too small and too soon. Future research should focus on identifying those women most predisposed to combined PTB and severe SGA.

Non-medical determinants of perinatal health: protocol for a systematic review with meta-analysis

INTRODUCTION

Research focusing on the associations between non-medical determinants and unfavourable perinatal health outcomes is increasing. Despite increasing knowledge on this theme, it still remains unclear to what extent social, environmental and lifestyle factors contribute to these unfavourable outcomes. Therefore, we aim to provide a systematic review, preferably with meta-analysis, in order to provide insight into the associations between non-medical determinants and perinatal mortality, preterm birth and being small for gestational age (SGA).

METHODS AND ANALYSIS

Observational studies performed in European countries studying the associations between non-medical determinants and unfavourable perinatal health outcomes will be included. Primary outcomes of interest are perinatal mortality, preterm birth and SGA. To retrieve potential eligible articles, a systematic literature search was performed in the following online databases on 5 October 2018: MEDLINE, Embase, Web of Science, Cochrane and Google Scholar. Additionally, a reference list check and citation search will be performed. Data of the included articles will be extracted using a standardised and piloted data extraction form. Risk of bias will be assessed using the Newcastle-Ottawa Scale. The study selection and data extraction process will be performed by two reviewers independently. Disagreements will be resolved through discussion with a third reviewer. The pooled effects will be calculated separately for each association found between one of the outcome measures and the non-medical determinants using a random effects model. Heterogeneity of the studies will be assessed using the I² statistic.

ETHICS AND DISSEMINATION

No ethical approval is necessary for a systematic review with meta-analysis. The findings will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42018056105.

Are socioeconomic inequalities in the incidence of small-for-gestational-age birth narrowing? Findings from a population-based cohort in the South of England

OBJECTIVES

To investigate socioeconomic inequalities, using maternal educational attainment, maternal and partner employment status, and lone motherhood indicators, in the risk of small-for-gestational-age (SGA) births, their time trend, potential mediation by maternal smoking and body mass index, and effect modification by parity.

DESIGN

Population-based birth cohort using routine antenatal healthcare data.

SETTING

Babies born at University Hospital Southampton, UK, between 2004 and 2016.

PARTICIPANTS

65 909 singleton live births born to mothers aged ≥18 years between 24-week and 42-week gestation.

MAIN OUTCOME MEASURES

SGA (birth weight <10th percentile for others born at the same number of completed weeks compared with 2013/2014 within England and Wales).

RESULTS

Babies born to mothers educated up to secondary school level (adjusted OR (aOR) 1.32, 99% CI 1.19 to 1.47), who were unemployed (aOR 1.27, 99% CI 1.16 to 1.38) or with unemployed partners (aOR 1.27, 99% CI 1.13 to 1.43), were at greater risk of being SGA. There was no statistically significant change in the magnitude of this risk difference by these indicators over time between 2004 and 2016, as estimated by linear interactions with year of birth. Babies born to lone mothers were not at higher risk compared with partnered mothers after adjusting for maternal smoking (aOR 1.05, 99% CI 0.93 to 1.20). The inverse association between maternal educational attainment and SGA risk appeared greater in multiparous (aOR 1.40, 99% CI 1.10 to 1.77) compared with primiparous women (aOR 1.28, 99% CI 1.12 to 1.47), and the reverse was true for maternal and partner's unemployment where the association was stronger in primiparous women.

CONCLUSIONS

Socioeconomic inequalities in SGA risk by educational attainment and employment status are not narrowing over time, with differences in association strength by parity. The greater SGA risk in lone mothers was potentially explained by maternal smoking. Preventive interventions should target socially disadvantaged women, including preconception and postpartum smoking cessation to reduce SGA risk.

Anxiety, depression, and birth outcomes in a cohort of unmedicated women

BACKGROUND

Even though most of the systematic reviews suggest that depression and anxiety are related to poor neonatal outcomes, it is not yet clear whether a dose-response effect exists.

AIM

The aim of the present study is to evaluate the amount of depressive and anxiety symptoms in a cohort of pregnant women and its effect on their newborns.

METHODS

Two hundred ninety-nine women were assessed for anxiety and depressive disorders and anxious and depressive symptoms at near monthly intervals throughout pregnancy. At the time of delivery, we collected the newborns' gestational age, birth weight and the Apgar score at 1 and 5 min.

RESULTS

Sixty-seven women were diagnosed as depressed and 43 had an anxious disorder. After controlling for confounding variables only the overall levels of anxiety during pregnancy were negatively associated with birth weight (B = -5.76; 95% CI = -10.96, -2.81), suggesting the existence of a "dose-response" effect. The birth outcomes in mildly depressed pregnant women were similar to those of nondepressed women.

CONCLUSION

Anxiety symptoms, beyond a categorical diagnosis, are associated with low birth weight and should be recognized and properly treated during pregnancy.

Communication barriers in maternity care of allophone migrants: Experiences of women, healthcare professionals, and intercultural interpreters

Aim

To describe communication barriers faced by allophone migrant women in maternity care provision from the perspectives of migrant women, healthcare professionals, and intercultural interpreters.

Background

Perinatal health inequality of migrant women hinges on barriers to services, with a major barrier being language. Their care is often also perceived as demanding due to conflicting values or complex situations. Potentially divergent perceptions of users and providers may hinder efficient communication.

Design

Qualitative explorative study.

Methods

A convenience sample of 36 participants was recruited in the German speaking region of Switzerland. The sample consisted of four Albanian and six Tigrinya speaking women, 22 healthcare professionals and four intercultural interpreters (March–June 2016) who participated in three focus group discussions and seven semi‐structured interviews. Audio recordings of the discussions and interviews were transcribed and thematically analysed.

Results

The analysis revealed three main themes: the challenge of understanding each other's world, communication breakdowns and imposed health services. Without interpretation communication was reduced to a bare minimum and thus insufficient to adequately inform women about treatment and address their expectations and needs.

Conclusion

A primary step in dismantling barriers is guaranteed intercultural interpreting services. Additionally, healthcare professionals need to continuously develop and reflect on their transcultural communication. Institutions must enable professionals to respond flexibly to allophone women's needs and to offer care options that are safe and in accordance to their cultural values.

Impact

Our results give the foundation of tenable care of allophonic women and emphasize the importance of linguistic understanding in care quality.

Reducing growth and developmental problems in children: Development of an innovative postnatal risk assessment

Introduction

Globally, awareness of the relevance of both medical and non-medical risk factors influencing growth and development of children has been increasing. The aim of our study was to develop an innovative postnatal risk assessment to be used by the Preventive Child Healthcare (PCHC) to identify at an early stage children at risk for growth (catch-up growth, overweight and obesity) and developmental problems (such as motor, cognitive, psychosocial and language/ speech problems).

Methods

We used the first four steps of the Intervention Mapping process. Step 1: Review of the literature and focus group discussions. Step 2: Identification of program objectives on how to develop and implement a risk assessment in PCHC daily practice. Step 3: Application of the ASE model to initiate behavioral change in the target group. Step 4: Development of the postnatal R4U and a program plan for the implementation in PCHC organizations.

Results

Subsequently in 2015, the 41 item postnatal R4U (the postnatal Rotterdam Reproduction Risk Reduction checklist) was developed according to steps one until four of the Intervention Mapping process and was implemented in four PCHC organizations.

Conclusions

It was feasible to design and implement a postnatal risk assessment identifying both medical and non-medical risks for growth and developmental problems, using the Intervention Mapping process.

Poor mothers, unhealthy children: the transmission of health inequalities in the INMA study, Spain

BACKGROUND

The health of pregnant women and their fetuses are especially sensitive to socioeconomic conditions. This study analyzes the impact of maternal socioeconomic status (SES), evaluated by occupation and maternal education level, in preterm births (PTBs) and in small for gestational age (SGA) fetuses, considering the effect of the potential mediating factors on the SES and birth outcomes.

METHODS

A total of 2497 mother/newborn dyads from the INMA-Spain project were studied. We examined maternal occupation and education in relation to PTB and SGA along with covariate data, using logistic regression analysis. Adjusted models for each of the outcome variables in relation to SES indicators were estimated, considering potential mediating factors.

RESULTS

About 4.7% of babies were PTB and 9.7% SGA. Full adjusted logistic regression models showed similar odds ratio (OR) for SGA in both SES indicators. Manual working women or without university studies had higher risk of SGA than their counterpart groups (OR = 1.39% CI = 1.03-1.88 and OR = 1.39% CI = 1.00-2.00, respectively). Likewise, mothers with a manual occupation were at more risk of PTB than those with a non-manual occupation (OR = 1.74 95% CI = 1.13-2.74), but there was no association between education and PTB. Smoking, pre-pregnancy BMI and underweight gain during pregnancy were significantly associated to SGA births. The mother's age, presence of complications and overweight gain during pregnancy were related to PTB.

CONCLUSION

The mother's socioeconomic disadvantage was consistently associated with birth outcomes giving rise to intergenerational transmission of health inequalities. Reducing inequalities requires eliminating the upstream causes of poverty itself.

Influence of the Urban Exposome on Birth Weight

BACKGROUND

The exposome is defined as the totality of environmental exposures from conception onwards. It calls for providing a holistic view of environmental exposures and their effects on human health by evaluating multiple environmental exposures simultaneously during critical periods of life.

OBJECTIVE

We evaluated the association of the urban exposome with birth weight.

METHODS

We estimated exposure to the urban exposome, including the built environment, air pollution, road traffic noise, meteorology, natural space, and road traffic (corresponding to 24 environmental indicators and 60 exposures) for nearly 32,000 pregnant women from six European birth cohorts. To evaluate associations with either continuous birth weight or term low birth weight (TLBW) risk, we primarily relied on the Deletion-Substitution-Addition (DSA) algorithm, which is an extension of the stepwise variable selection method. Second, we used an exposure-by-exposure exposome-wide association studies (ExWAS) method accounting for multiple hypotheses testing to report associations not adjusted for coexposures.

RESULTS

The most consistent statistically significant associations were observed between increasing green space exposure estimated as Normalized Difference Vegetation Index (NDVI) and increased birth weight and decreased TLBW risk. Furthermore, we observed statistically significant associations among presence of public bus line, land use Shannon's Evenness Index, and traffic density and birth weight in our DSA analysis.

CONCLUSION

This investigation is the first large urban exposome study of birth weight that tests many environmental urban exposures. It confirmed previously reported associations for NDVI and generated new hypotheses for a number of built-environment exposures. https://doi.org/10.1289/EHP3971.

Combined environmental and social exposures during pregnancy and associations with neonatal size and body composition: the Healthy Start study

BACKGROUND

Prenatal environmental and social exposures have been associated with decreased birth weight. However, the effects of combined exposures in these domains are not fully understood. Here we assessed multi-domain exposures for participants in the Healthy Start study (Denver, CO) and tested associations with neonatal size and body composition.

METHODS

In separate linear regression models, we tested associations between neonatal outcomes and three indices for exposures. Two indices were developed to describe exposures to environmental hazards (ENV) and social determinants of health (SOC). A third index combined exposures in both domains (CE = ENV/10 × SOC/10). Index scores were assigned to mothers based on address at enrollment. Birth weight and length were measured at delivery, and weight-for-length z-scores were calculated using a reference distribution. Percent fat mass was obtained by air displacement plethysmography.

RESULTS

Complete data were available for 897 (64%) participants. Median (range) ENV, SOC, and CE values were 31.9 (7.1-63.2), 36.0 (2.8-75.0), and 10.9 (0.4-45.7), respectively. After adjusting for potential confounders, 10-point increases in SOC and CE were associated with 27.7 g (95%CI: 12.4 - 42.9 g) and 56.3 g (19.4 - 93.2 g) decreases in birth weight, respectively. SOC and CE were also associated with decreases in % fat mass.

CONCLUSIONS

Combined exposures during pregnancy were associated with lower birth weight and % fat mass. Evidence of a potential synergistic effect between ENV and SOC suggests a need to more fully consider neighborhood exposures when assessing neonatal outcomes.

Neighborhood deprivation and adverse perinatal outcomes in Sweden: A population-based register study

INTRODUCTION

Neighborhood deprivation has been associated with adverse perinatal outcomes but it is unclear to what extent maternal and social risk factors explain the association and how a stressful environment per se contributes.

MATERIAL AND METHODS

A population-based register study including 218 030 deliveries in Sweden between January 2013 and July 2017 was conducted. Exposure was living in a deprived or severely deprived area defined by the National Operations Department of the Swedish Police Authority. Adverse perinatal outcomes included preterm births, small-for-gestational-age births and stillbirths. A propensity score-based method was used to control for individual baseline characteristics. Associations were investigated with logistic regression analyses and risk estimates are presented as crude (OR) and adjusted odds ratio (aOR) with 95% confidence interval (CI).

RESULTS

Living in a deprived neighborhood in Sweden was associated with extremely preterm births (deprived area OR 1.50, 95% CI 1.07-2.11, severely deprived OR 1.90, 95% CI 1.40-2.58), small-for-gestational-age birth (deprived OR 1.45, 95% CI 1.31-1.60, severely deprived OR 1.85, 95% CI 1.69-2.03) and stillbirth (deprived OR 1.62, 95% CI 1.17-2.26, severely deprived OR 1.56, 95% CI 1.11-2.19). After accounting for individual maternal and social risk factors, the risk of small for gestational age in severely deprived areas remained (aOR 1.45, 95% CI, 1.19-1.75).

CONCLUSIONS

The contextual effect of living in a deprived neighborhood on the risk of extremely preterm births, small-for-gestational-age births and stillbirths was to a high extent explained by individual factors of women residing in exposed areas, yet remained for small-for-gestational-age births in severely deprived areas after adjustment for maternal and social risk factors.

The DESiGN trial (DEtection of Small for Gestational age Neonate), evaluating the effect of the Growth Assessment Protocol (GAP): study protocol for a randomised controlled trial

Background

Stillbirth rates in the United Kingdom (UK) are amongst the highest of all developed nations. The association between small-for-gestational-age (SGA) foetuses and stillbirth is well established, and observational studies suggest that improved antenatal detection of SGA babies may halve the stillbirth rate. The Growth Assessment Protocol (GAP) describes a complex intervention that includes risk assessment for SGA and screening using customised fundal-height growth charts. Increased detection of SGA from the use of GAP has been implicated in the reduction of stillbirth rates by 22%, in observational studies of UK regions where GAP uptake was high. This study will be the first randomised controlled trial examining the clinical efficacy, health economics and implementation of the GAP programme in the antenatal detection of SGA.

Methods/design

In this randomised controlled trial, clusters comprising a maternity unit (or National Health Service Trust) were randomised to either implementation of the GAP programme, or standard care. The primary outcome is the rate of antenatal ultrasound detection of SGA in infants found to be SGA at birth by both population and customised standards, as this is recognised as being the group with highest risk for perinatal morbidity and mortality. Secondary outcomes include antenatal detection of SGA by population centiles, antenatal detection of SGA by customised centiles, short-term maternal and neonatal outcomes, resource use and economic consequences, and a process evaluation of GAP implementation. Qualitative interviews will be performed to assess facilitators and barriers to implementation of GAP.

Discussion

This study will be the first to provide data and outcomes from a randomised controlled trial investigating the potential difference between the GAP programme compared to standard care for antenatal ultrasound detection of SGA infants. Accurate information on the performance and service provision requirements of the GAP protocol has the potential to inform national policy decisions on methods to reduce the rate of stillbirth.

Trial registration

Primary registry and trial identifying number: ISRCTN 67698474. Registered on 2 November 2016.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3242-6) contains supplementary material, which is available to authorized users.

Area-level deprivation and preterm birth: results from a national, commercially-insured population

BACKGROUND

Area-level deprivation is associated with multiple adverse birth outcomes. Few studies have examined the mediating pathways through which area-level deprivation affects these outcomes. The objective of this study was to investigate the association between area-level deprivation and preterm birth, and examine the mediating effects of maternal medical, behavioural, and psychosocial factors.

METHODS

We conducted a retrospective cohort study using national, commercial health insurance claims data from 2011, obtained from the Health Care Cost Institute. Area-level deprivation was derived from principal components methods using ZIP code-level data. Multilevel structural equation modeling was used to examine mediating effects.

RESULTS

In total, 138,487 women with a live singleton birth residing in 14,577 ZIP codes throughout the United States were included. Overall, 5.7% of women had a preterm birth. In fully adjusted generalized estimation equation models, compared to women in the lowest quartile of area-level deprivation, odds of preterm birth increased by 9.6% among women in the second highest quartile (odds ratio (OR) 1.096; 95% confidence interval (CI) 1.021, 1.176), by 11.3% in the third highest quartile (OR 1.113; 95% CI 1.035, 1.195), and by 24.9% in the highest quartile (OR 1.249; 95% CI 1.165, 1.339). Hypertension and infection moderately mediated this association.

CONCLUSIONS

Even among commercially-insured women, area-level deprivation was associated with increased risk of preterm birth. Similar to individual socioeconomic status, area-level deprivation does not have a threshold effect. Implementation of policies to reduce area-level deprivation, and the screening and treatment of maternal mediators may be associated with a lower risk of preterm birth.

Client-tailored maternity care to increase maternal empowerment: cluster randomized controlled trial protocol; the healthy pregnancy 4 All-2 program

Background

The postpartum period is an important period for preventive strategies as common maternal and child health risks may become manifest. Women with a lower socioeconomic status tend to have lower maternal empowerment. Increasing their risks of adverse maternal and child health outcomes. This study aims to assess the effectiveness of a primary care level intervention. Delivered to maternity care assistants, aiming to increase maternal empowerment postpartum.

Methods

This study is part of the Dutch nationwide “Healthy Pregnancy 4 All-2” (HP4All-2) program, which aims to identify vulnerable mothers and young children at risk of adverse health outcomes, and subsequently improve their care. This program targets women from deprived neighborhoods.

A pragmatic cluster randomized controlled trial will be undertaken in 12 maternity care organizations. Maternity care organizations in urban municipalities (i.e. the clusters) will be randomized to either a systematic risk assessment during pregnancy with emphasis on identification of non-medical risk factors for adverse maternal and neonatal health outcomes, and subsequent adaptation of care towards a client-tailored approach during pregnancy and the postpartum period, or solely the systematic risk assessment. The primary outcome is the prevalence of a low maternal empowerment score postpartum. Secondary maternal outcomes cover health-related quality of life, postnatal depression, smoking, alcohol consumption, illicit drug use. Finally, maternal and neonatal health care utilization postpartum are recorded. All outcomes will be analyzed according to the intention-to-treat principle, using multi-level mixed effects models.

Discussion

The study will contribute to evidence regarding the effectiveness of client-tailored, risk-based maternity care to increase maternal empowerment postpartum.

Trial registration

Netherlands Trial Registry (NTR) 6311, registered 03-27-2017.

Racial Disparities in Adverse Pregnancy Outcomes and Psychosocial Stress

OBJECTIVE

To assess the relationships between self-reported psychosocial stress and preterm birth, hypertensive disease of pregnancy, and small-for-gestational-age (SGA) birth and to assess the extent to which these relationships account for racial and ethnic disparities in these adverse outcomes.

METHODS

Self-reported measures of psychosocial stress (perceived stress, depression, racism, anxiety, resilience, and social support) were collected during pregnancy among a racially and ethnically diverse cohort of women enrolled in a prospective observational study of nulliparous women with singleton pregnancies, from eight clinical sites across the United States, between October 2010 and May 2014. The associations of preterm birth, hypertensive disease of pregnancy, and SGA birth with the self-reported measures of psychosocial stress as well as with race and ethnicity were evaluated.

RESULTS

The study included 9,470 women (60.4% non-Hispanic white, 13.8% non-Hispanic black, 16.7% Hispanic, 4.0% Asian, and 5.0% other). Non-Hispanic black women were significantly more likely to experience any preterm birth, hypertensive disease of pregnancy, and SGA birth than were non-Hispanic white women (12.2% vs 8.0%, 16.7% vs 13.4%, and 17.2% vs 8.6%, respectively; P<.05 for all). After adjusting for potentially confounding factors, including the six different psychosocial factors singly and in combination, non-Hispanic black women continued to be at greater risk of any preterm birth and SGA birth compared with non-Hispanic white women.

CONCLUSION

Among a large and geographically diverse cohort of nulliparous women with singleton gestations, non-Hispanic black women are most likely to experience preterm birth, hypertensive disease of pregnancy, and SGA birth. These disparities were not materially altered for preterm birth or SGA birth by adjustment for demographic differences and did not appear to be explained by differences in self-reported psychosocial factors.

Life-course neighbourhood opportunity and racial-ethnic disparities in risk of preterm birth

BACKGROUND

Neighbourhood opportunity, measured by poverty, income and deprivation, has been associated with preterm birth, however little is known about the contribution of early-life and life-course neighbourhood opportunity to preterm birth risk and racial-ethnic disparities. We examined maternal early-life and adult neighbourhood opportunity in relation to risk of preterm birth and racial-ethnic disparities in a population-based cohort of women under age 30.

METHODS

We linked census tract poverty data to 2 generations of California births from 1982-2011 for 403 315 white, black, or Latina mothers-infant pairs. We estimated the risk of preterm birth, and risk difference (RD) comparing low opportunity (≥20% poverty) in early life or adulthood to high opportunity using targeted maximum likelihood estimation.

RESULTS

At each time point, low opportunity was related to increased preterm birth risk compared to higher opportunity neighbourhoods for white, black and Latina mothers (RDs 0.3-0.7%). Compared to high opportunity at both time points, risk differences were generally highest for sustained low opportunity (RD 1.5, 1.3, and 0.7% for white, black and Latina mothers, respectively); risk was elevated with downward mobility (RD 0.7, 1.3, and 0.4% for white, black and Latina mothers, respectively), and with upward mobility only among black mothers (RD 1.2%). The black-white preterm birth disparity was reduced by 22% under high life-course opportunity.

CONCLUSIONS

Early-life and sustained exposure to residential poverty is related to increased PTB risk, particularly among black women, and may partially explain persistent black-white disparities.

Using a Clustering Approach to Investigate Socio-Environmental Inequality in Preterm Birth-A Study Conducted at Fine Spatial Scale in Paris (France)

Background & Objectives: Today, to support public policies aiming to tackle environmental and health inequality, identification and monitoring of the spatial pattern of adverse birth outcomes are crucial. Spatial identification of the more vulnerable population to air pollution may orient health interventions. In this context, the objective of this study is to investigate the geographical distribution of the risk of preterm birth (PTB, gestational age ≤36 weeks) at the census block level in in city of Paris, France. We also aimed to assess the implication of neighborhood characteristics including air pollution and socio-economic deprivation. Material & Methods: Newborn health data are available from the first birth certificate registered by the Maternal and Child Care department of Paris. All PTB from January 2008 to December 2011 were geocoded at the mother residential census block. Each census block was assigned a socioeconomic deprivation level and annual average ambient concentrations of NO₂. A spatial clustering approach was used to investigate the spatial distribution of PTB. Results: Our results highlight that PTB is non-randomly spatially distributed, with a cluster of high risk in the northeastern area of Paris (RR = 1.15; p = 0.06). After adjustment for socio-economic deprivation and NO₂ concentrations, this cluster becomes not statistically significant or shifts suggesting that these characteristics explain the spatial distribution of PTB; further, their combination shows an interaction in comparison with SES or NO₂ levels alone. Conclusions: Our results may inform the decision makers about the areas where public health efforts should be strengthened to tackle the risk of PTB and to choose the most appropriate and specific community-oriented health interventions.

Small for gestational age and perinatal mortality at term: An audit in a Dutch national cohort study

OBJECTIVE

To assess the underlying risk factors for perinatal mortality in term born small for gestational age infants.

STUDY DESIGN

We performed a population based nationwide cohort study in the Netherlands of 465,532 term born infants from January 2010 to January 2013. Logistic regression analyses were performed. Also audit results were studied for detailed care information.

RESULTS

We studied 162 small for gestational age infants who died in the perinatal period. Risk factors were: gestational age at 37completed weeks (adjusted Odds Ratio (aOR) 2.6, 95% Confidence Interval (CI) 1.6-4.3), male gender (aOR 1.4, 95% CI 1.01-1.9), South Asian ethnicity (aOR 3.6, 95% CI 1.6-8.4), African (aOR 3.5, 95% CI 1.9-6.5) and other non-Western ethnicity (aOR 1.9, CI 1.2-3.1). At 37 completed weeks gestation audit results showed that 26% of the women smoked, 91% were boys and in all but one case death occurred before birth. In 61% of all deceased SGA infants born at 37 completed weeks gestation referral from primary care by independent midwives to the obstetrician took place because of antepartum death before labor.

CONCLUSIONS

Gestational age of 37 completed weeks, male gender, South Asian, African or other non-Western ethnicity and smoking are associated with perinatal mortality in SGA infants. These risk factors concern the complete term population starting at 37 weeks or even earlier. Therefore, it is of utmost importance to develop accurate diagnostic tests to screen for SGA before 36 weeks gestation to prevent perinatal mortality at term in SGA infants.

Antenatal non-medical risk assessment and care pathways to improve pregnancy outcomes: a cluster randomised controlled trial

Social deprivation negatively affects health outcomes but receives little attention in obstetric risk selection. We investigated whether a combination of (1) risk assessment focused on non-medical risk factors, lifestyle factors, and medical risk factors, with (2) subsequent institution of risk-specific care pathways, and (3) multidisciplinary consultation between care providers from the curative and the public health sector reduced adverse pregnancy outcomes among women in selected urban areas in the Netherlands. We conducted a cluster randomised controlled trial in 14 urban municipalities across the Netherlands. Prior to the randomisation, municipalities were ranked and paired according to their expected proportion of pregnant women at risk for adverse outcomes at birth. The primary outcome was delivery of a preterm and/or small for gestational age (SGA) baby, analysed with multilevel mixed-effects logistic regression analysis adjusting for clustering and individual baseline characteristics. A total of 33 community midwife practices and nine hospitals participated throughout the study. Data from 4302 participants was included in the Intention To Treat (ITT) analysis. The intervention had no demonstrable impact on the primary outcome: adjusted odds ratio (aOR) 1.17 (95% CI 0.84–1.63). Among the secondary outcomes, the intervention improved the detection of threatening preterm delivery and fetal growth restriction during pregnancy [aOR 1.27 (95% CI 1.01–1.61)]. Implementation of additional non-medical risk assessment and preventive strategies into general practices is feasible but did not decrease the incidence of preterm and/or SGA birth in the index pregnancy in deprived urban areas.

Trial registration Netherlands National Trial Register (NTR-3367).

Targeted social care for highly vulnerable pregnant women: protocol of the Mothers of Rotterdam cohort study

INTRODUCTION

Social vulnerability is known to be related to ill health. When a pregnant woman is socially vulnerable, the ill health does not only affect herself, but also the health and development of her (unborn) child. To optimise care for highly vulnerable pregnant women, in Rotterdam, a holistic programme was developed in close collaboration between the university hospital, the local government and a non-profit organisation. This programme aims to organise social and medical care from pregnancy until the second birthday of the child, while targeting adult and child issues simultaneously. In 2014, a pilot in the municipality of Rotterdam demonstrated the significance of this holistic approach for highly vulnerable pregnant women. In the 'Mothers of Rotterdam' study, we aim to prospectively evaluate the effectiveness of the holistic approach, referred to as targeted social care.

METHODS AND ANALYSIS

The Mothers of Rotterdam study is a pragmatic prospective cohort study planning to include 1200 highly vulnerable pregnant women for the comparison between targeted social care and care as usual. Effectiveness will be compared on the following outcomes: (1) child development (does the child show adaptive development at year 1?) and (2) maternal mental health (is maternal distress reduced at the end of the social care programme?). Propensity scores will be used to correct for baseline differences between both social care programmes.

ETHICS AND DISSEMINATION

The prospective cohort study was approved by the Erasmus Medical Centre Ethics Committee (ref. no. MEC-2016-012) and the first results of the study are expected to be available in the second half of 2019 through publication in peer-reviewed international journals.

TRIAL REGISTRATION NUMBER

NTR6271; Pre-results.

Associations of neighbourhood crime with adverse pregnancy outcomes among women in Chicago: analysis of electronic health records from 2009 to 2013

BACKGROUND

Adverse pregnancy outcomes are associated with higher cardiovascular disease risk among mothers and future health problems of offspring. Neighbourhood crime may contribute to adverse pregnancy outcomes by increasing chronic stress, yet the association has been relatively understudied.

METHODS

Electronic health records from 34 383 singleton births at a single hospital in Chicago (2009-2013) were geocoded and linked to 1-year rates of police-recorded crime at the neighbourhood (Chicago community area) level. Crimes included homicide, assault/battery, criminal offences and incivilities. Cross-sectional associations of total neighbourhood crime rates with hypertensive disease of pregnancy (HDP: pre-eclampsia/gestational hypertension), preterm birth (PTB), spontaneous preterm birth (sPTB) and small-for-gestational-age (SGA) birth were assessed using multilevel logistic regression with community-area random intercepts. Models controlled for maternal and infant characteristics and neighbourhood poverty. We then assessed associations between individual crime categories and all outcomes.

RESULTS

Total neighbourhood crime rates ranged from 11.6 to 303.5 incidents per 1000 persons per year (mean: 61.5, SD: 40.3). A 1-SD higher total neighbourhood crime rate was associated with higher odds of HDP (OR: 1.06, 95% CI 1.00 to 1.13), PTB (OR: 1.09, 95% CI 1.03 to 1.15), sPTB (OR: 1.09, 95% CI 1.03 to 1.16) and SGA (OR: 1.05, 95% CI 1.01 to 1.10) in fully adjusted models. Associations were generally consistent across crime categories, although only assault/battery and incivilities were associated with HDP.

CONCLUSIONS

Higher neighbourhood crime rates were associated with small but significant increases in the odds of adverse pregnancy outcomes. Interventions that cultivate safer neighbourhoods may be a promising approach for improving pregnancy outcomes.

Socioeconomic disadvantage and altered corticostriatal circuitry in urban youth

Socioeconomic disadvantage (SED) experienced in early life is linked to a range of risk behaviors and diseases. Neuroimaging research indicates that this association is mediated by functional changes in corticostriatal reward systems that modulate goal-directed behavior, reward evaluation, and affective processing. Existing research has focused largely on adults and within-household measures as an index of SED, despite evidence that broader community-level SED (e.g., neighborhood poverty levels) has significant and sometimes distinct effects on development and health outcomes. Here, we test effects of both household- and community-level SED on resting-state functional connectivity (rsFC) of the ventral striatum (VS) in 100 racially and economically diverse children and adolescents (ages 6-17). We observed unique effects of household income and community SED on VS circuitry such that higher community SED was associated with reduced rsFC between the VS and an anterior region of the medial prefrontal cortex (mPFC), whereas lower household income was associated with increased rsFC between the VS and the cerebellum, inferior temporal lobe, and lateral prefrontal cortex. Lower VS-mPFC rsFC was also associated with higher self-reported anxiety symptomology, and rsFC mediated the link between community SED and anxiety. These results indicate unique effects of community-level SED on corticostriatal reward circuitry that can be detected in early life, which carries implications for future interventions and targeted therapies. In addition, our findings raise intriguing questions about the distinct pathways through which specific sources of SED can affect brain and emotional development.

Group-based multicomponent treatment to reduce depressive symptoms in women with co-morbid psychiatric and psychosocial problems during pregnancy: A randomized controlled trial

BACKGROUND

Depressive symptoms in pregnant women, which are common and debilitating, are often co-morbid with other mental disorders (e.g. anxiety and personality disorders), and related to low socioeconomic status (SES). This situation may hamper treatment outcome, which has often been neglected in previous studies on the treatment of depression during pregnancy. We developed a new group-based multicomponent treatment (GMT) comprising cognitive behavioral therapy, psycho-education and body-oriented therapy and compared the effect on depressive symptoms with individual counseling (treatment as usual, TAU) in a heterogeneous group of pregnant women with co-morbid mental disorders and/or low SES.

METHODS

An outpatient sample from a university hospital of 158 pregnant women who met DSM-IV criteria for mental disorders were included and 99 participants were randomized to GMT or TAU from January 2010 until January 2013. The Edinburgh Depression Scale (EDS) was used at baseline, every 5 weeks during pregnancy and as the primary outcome measure of depressive symptoms at 6 weeks postpartum. Secondary outcome measures included the clinician-reported Hamilton Depression Rating Scale (HDRS), obstetric outcomes and a 'Patient Satisfaction' questionnaire.

RESULTS

155 participants were included the intention-to-treat (ITT)-analysis. GMT was not superior above TAU according to estimated EDS (β = 0.13, CI = - 0.46-0.71, p = 0.67) and HDRS scores (β = - 0.39, CI = - 0.82-0.05, p = 0.08) at 6 weeks postpartum. There were no differences in secondary outcomes between the GMT and TAU, nor between the randomized condition and patient-preference condition.

LIMITATIONS

The ability to detect an effect of GMT may have been limited by sample size, missing data and the ceiling effect of TAU.

CONCLUSIONS

GMT is an acceptable treatment for a heterogeneous group of pregnant women with depressive symptoms and co-morbid mental disorders and/or low SES, but not superior to TAU. Further research should focus on understanding and treating co-morbid disorders and psychosocial problems during pregnancy.

CLINICAL TRIALS REGISTRATION

Dutch trial registry, www.trialregister.nl under reference number: NTR3015.

Perceptions of pregnancy preparation in women with a low to intermediate educational attainment: A qualitative study

OBJECTIVE

in the promotion of periconceptional health, appropriate attention has to be given to the perceptions of those who are most vulnerable, such as women with a relatively low socioeconomic status based on their educational attainment. The aim of this study was to explore these women's perceptions of pregnancy preparation and the role they attribute to healthcare professionals.

DESIGN

we conducted semi-structured interviews with women with a low to intermediate educational attainment and with a desire to conceive, of which a subgroup had experience with preconception care. Thematic content analysis was applied on the interview transcripts.

FINDINGS

the final sample consisted of 28 women. We identified four themes of pregnancy preparation perceptions: (i)"How to prepare for pregnancy?", which included health promotion and seeking healthcare; (ii) "Why prepare for pregnancy?", which mostly related to fertility and health concerns; (iii) "Barriers and facilitators regarding pregnancy preparation", such as having limited control over becoming pregnant as well as the health of the unborn; (iv) "The added value of preconception care", reported by women who had visited a consultation, which consisted mainly of reassurance and receiving information.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

the attained insights into the perceptions of women with a low to intermediate education are valuable for adapting the provision of preconception care to their views. We recommend the proactive offering of preconception care, including information on fertility, to stimulate adequate preparation for pregnancy and contribute to improving perinatal health among women who are socioeconomically more vulnerable.

Dark shadow of the long white cloud: Neighborhood safety is associated with self-rated health and cortisol during pregnancy in Auckland, Aotearoa/New Zealand

Auckland, Aotearoa/New Zealand is a culturally and ethnically diverse city. Despite popular global conceptions regarding its utopian nature, the lived experience for many individuals in Auckland attests to the substantial social, economic, and health inequalities that exist there. In particular, rapidly rising home prices constrain housing decisions and force individuals to live in less desirable neighborhoods, with potential impacts on individual health. One of the pathways through which adverse neighborhood conditions could impact health is through alterations in the functioning of the hypothalamic pituitary adrenal (HPA)-axis, which regulates the physiological stress response. This paper evaluates the relationship between perceived neighborhood safety, self-rated health, and cortisol, an end product of HPA-axis activation, among women in late pregnancy. Pregnant women living in neighborhoods where they were concerned about safety of their property had poorer self-rated health and elevated morning cortisol, even after adjusting for maternal age, material deprivation, and ethnicity. However, fear of personal safety was unrelated to self-rated health and cortisol. These results suggest that maternal health in pregnancy is sensitive to perceptions regarding neighborhood safety. Such findings are important since higher cortisol levels in pregnancy could not only influence maternal health, but also the health and development of women's children.

Getting Under the Skin: Children's Health Disparities as Embodiment of Social Class

Social class gradients in children's health and development are ubiquitous across time and geography. The authors develop a conceptual framework relating three actions of class-material allocation, salient group identity, and inter-group conflict-to the reproduction of class-based disparities in child health. A core proposition is that the actions of class stratification create variation in children's mesosystems and microsystems in distinct locations in the ecology of everyday life. Variation in mesosystems (e.g., health care, neighborhoods) and microsystems (e.g., family structure, housing) become manifest in a wide variety of specific experiences and environments that produce the behavioral and biological antecedents to health and disease among children. The framework is explored via a review of theoretical and empirical contributions from multiple disciplines and high-priority areas for future research are highlighted.

Geographical differences in perinatal health and child welfare in the Netherlands: rationale for the healthy pregnancy 4 all-2 program

Background

Geographical inequalities in perinatal health and child welfare require attention. To improve the identification, and care, of mothers and young children at risk of adverse health outcomes, the HP4All-2 program was developed. The program consists of three studies, focusing on creating a continuum for risk selection and tailored care pathways from preconception and antenatal care towards 1) postpartum care, 2) early childhood care, as well as 3) interconception care. The program has been implemented in ten municipalities in the Netherlands, aiming to target communities with a relatively disadvantageous position with regard to perinatal and child health outcomes. To delineate the position of the ten participating municipalities, we present municipal and regional differences in the prevalence of perinatal mortality, perinatal morbidity, children living in deprived neighbourhoods, and children living in families on welfare.

Methods

Data on all singleton births in the Netherlands between 2009 and 2014 were analysed for the prevalence of perinatal mortality and morbidity. In addition, national data on children living in deprived neighbourhoods and children living in families on welfare between 2009 and 2012 were analysed. The prevalence of these outcomes were calculated and ranked for 62 geographical areas, the 50 largest municipalities and the 12 provinces, to determine the position of the municipalities that participate in HP4All-2.

Results

Considerable geographical differences were present for all four outcomes. The municipalities that participate in HP4All-2 are among the 25 municipalities with the highest prevalence of perinatal mortality, perinatal morbidity, children living in deprived neighbourhoods, or children in families on welfare.

Conclusion

This study illustrates geographical differences in perinatal health and/or child welfare outcomes and demonstrates that the HP4All-2 program targets municipalities with a relative unfavourable position. By targeting these municipalities, the program is expected to contribute most to improving the care for young children and their mothers at risk, and hence to reducing their risks and health inequalities.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-017-1425-2) contains supplementary material, which is available to authorized users.