Social deprivation and adverse perinatal outcomes among Western and non-Western pregnant women in a Dutch urban population

Barriers to assessing vulnerability in pregnant women. A cross-sectional survey in Danish general practice

BACKGROUND

Undetected vulnerability in pregnancy contributes to inequality in maternal and perinatal health and is associated with negative birth outcomes and adverse child outcomes. Nationwide reports indicate important barriers to assessing vulnerability among Danish general practitioners.

OBJECTIVE

To explore general practitioners perceived barriers to vulnerability assessment in pregnant women and whether the barriers are associated with practice organization of antenatal care, general practitioner, and practice characteristics.

METHODS

The questionnaire was sent to all Danish general practitioners (N = 3,465). Descriptive statistics described the barriers to assessing vulnerability in pregnant women. Analytical statistics with ordered logistic regression models were used to describe the association between selected barriers to vulnerability assessment and antenatal care organization, and general practitioner and practice characteristics.

RESULTS

760 general practitioners (22%) answered. Barriers to vulnerability assessment were related to lacking routines for addressing vulnerability, lacking attention to and record-keeping on vulnerability indicators, an insufficient overview of vulnerable pregnant women, and perceived insufficient remuneration for antenatal care consultations. Not prioritizing extra time when caring for vulnerable pregnant women was associated with experiencing more barriers. Always prioritizing continuity of care was associated with experiencing fewer barriers. General practitioners of either young age, male gender, or who did not prioritize extra time to care for vulnerable pregnant women experienced more barriers.

CONCLUSION

Barriers to vulnerability assessment among pregnant women do exist in general practice and are associated with organizational characteristics such as lacking prioritization of extra time and continuity in antenatal care consultations. Also, general practitioner characteristics like male gender and relatively young age are associated with barriers to vulnerability assessment.

Stimulating Preconception Care Uptake by Women With a Vulnerable Health Status Through a Mobile Health App (Pregnant Faster): Pilot Feasibility Study

BACKGROUND

A low socioeconomic status is associated with a vulnerable health status (VHS) through the accumulation of health-related risk factors, such as poor lifestyle behaviors (eg, inadequate nutrition, chronic stress, and impaired health literacy). For pregnant women, a VHS translates into a high incidence of adverse pregnancy outcomes and therefore pregnancy-related inequity. We hypothesize that stimulating adequate pregnancy preparation, targeting lifestyle behaviors and preconception care (PCC) uptake, can reduce these inequities and improve the pregnancy outcomes of women with a VHS. A nudge is a behavioral intervention aimed at making healthy choices easier and more attractive and may therefore be a feasible way to stimulate engagement in pregnancy preparation and PCC uptake, especially in women with a VHS. To support adequate pregnancy preparation, we designed a mobile health (mHealth) app, Pregnant Faster, that fits the preferences of women with a VHS and uses nudging to encourage PCC consultation visits and engagement in education on healthy lifestyle behaviors.

OBJECTIVE

This study aimed to test the feasibility of Pregnant Faster by determining usability and user satisfaction, the number of visited PCC consultations, and the course of practical study conduction.

METHODS

Women aged 18-45 years, with low-to-intermediate educational attainment, who were trying to become pregnant within 12 months were included in this open cohort. Recruitment took place through social media, health care professionals, and distribution of flyers and posters from September 2021 until June 2022. Participants used Pregnant Faster daily for 4 weeks, earning coins by reading blogs on pregnancy preparation, filling out a daily questionnaire on healthy lifestyle choices, and registering for a PCC consultation with a midwife. Earned coins could be spent on rewards, such as fruit, mascara, and baby products. Evaluation took place through the mHealth App Usability Questionnaire (MAUQ), an additional interview or questionnaire, and assessment of overall study conduction.

RESULTS

Due to limited inclusions, the inclusion criterion "living in a deprived neighborhood" was dropped. This resulted in the inclusion of 47 women, of whom 39 (83%) completed the intervention. In total, 16 (41%) of 39 participants visited a PCC consultation, with their main motivation being obtaining personalized information. The majority of participants agreed with 16 (88.9%) of 18 statements of the MAUQ, indicating high user satisfaction. The mean rating was 7.7 (SD 1.0) out of 10. Points of improvement included recruitment of the target group, simplification of the log-in system, and automation of manual tasks.

CONCLUSIONS

Nudging women through Pregnant Faster to stimulate pregnancy preparation and PCC uptake has proven feasible, but the inclusion criteria must be revised. A substantial number of PCC consultations were conducted, and this study will therefore be continued with an open cohort of 400 women, aiming to establish the (cost-)effectiveness of an updated version, named Pregnant Faster 2.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/45293.

Deprived areas and adverse perinatal outcome: a systematic review

PURPOSE

This systematic review aimed to assess if women living in deprived areas have worse perinatal outcomes than those residing in high-income areas.

METHODS

Datasets of PubMed, ScienceDirect, CENTRAL, Embase, and Google Scholar were searched for studies comparing perinatal outcomes (preterm birth, small-for-gestational age, and stillbirth) in deprived and non-deprive areas.

RESULTS

A total of 46 studies were included. The systematic review of the literature revealed a higher risk for adverse perinatal outcomes such as preterm birth, small for gestational age, and stillbirth in deprived areas.

CONCLUSION

Deprived areas are associated with adverse perinatal outcomes. More multifactorial studies are needed to assess the weight of each factor that composes the socioeconomic gradient of health in adverse perinatal outcomes.

Maternal Migration Background and Mortality Among Infants Born Extremely Preterm

Importance

Extremely preterm infants require care provided in neonatal intensive care units (NICUs) to survive. In the Netherlands, a decision is made regarding active treatment between 24 weeks 0 days and 25 weeks 6 days after consultation with the parents.

Objective

To investigate the association between maternal migration background and admissions to NICUs and mortality within the first year among extremely preterm infants.

Design, Setting, and Participants

This cross-sectional study linked data of registered births in the Netherlands with household-level income tax records and municipality and mortality registers. Eligible participants were households with live births at 24 weeks 0 days to 25 weeks 6 days gestation between January 1, 2010, and December 31, 2017. Data linkage and analysis was performed from March 1, 2020, to June 30, 2023.

Exposure

Maternal migration background, defined as no migration background vs first- or second-generation migrant mother.

Main Outcomes and Measures

Admissions to NICUs and mortality within the first week, month, and year of life. Logistic regressions were estimated adjusted for year of birth, maternal age, parity, household income, sex, gestational age, multiple births, and small for gestational age. NICU-specific fixed effects were also included.

Results

Among 1405 live births (768 male [54.7%], 546 [38.9%] with maternal migration background), 1243 (88.5%) were admitted to the NICU; 490 of 546 infants (89.7%) born to mothers with a migration background vs 753 of 859 infants (87.7%) born to mothers with no migration background were admitted to NICU (fully adjusted RR, 1.03; 95% CI, 0.99-1.08). A total of 652 live-born infants (46.4%) died within the first year of life. In the fully adjusted model, infants born to mothers with a migration background had lower risk of mortality within the first week (RR, 0.81; 95% CI, 0.66-0.99), month (RR, 0.84; 95% CI, 0.72-0.97), and year of life (RR, 0.85; 95% CI, 0.75-0.96) compared with infants born to mothers with no migration background.

Conclusions

In this nationally representative cross-sectional study, infants born to mothers with a migration background at 24 weeks 0 days to 25 weeks 6 days of gestation in the Netherlands had lower risk of mortality within the first year of life than those born to mothers with no migration background, a result that was unlikely to be explained by mothers from different migration backgrounds attending different NICUs or differential preferences for active obstetric management across migration backgrounds. Further research is needed to understand the underlying mechanisms driving these disparities, including parental preferences for active care of extremely preterm infants.

Current preconception care practice in the Netherlands - An evaluation study among birth care professionals

OBJECTIVE

To evaluate the current practice of preconception care in the Netherlands and the perceptions of birth care professionals concerning preconception care.

METHODS

We have developed a digital questionnaire and conducted a cross-sectional study by distributing the questionnaire among 102 organisations: 90 primary care midwifery practices and obstetric departments of 12 hospitals in the Southwest region of the Netherlands between December 2020 and March 2021. One birth care professional per organization was asked to complete the questionnaire. Descriptive statistics were used to present the results.

FINDINGS

Respondents of eighty-three organisations (81.4 %) filled in the questionnaire, of whom 74 respondents were independent primary care midwives and 9 respondents were obstetricians. Preconception care mostly consisted of an individual consultation in which personalized health and lifestyle advice was given. Among the respondents, 44.4 % reported that the organization had a preconception care protocol. The way in which the consultation was carried out, as well as the health and lifestyle related questions asked, differed between respondents. More than 85 % of the respondents inquire about the following possible risk factors for complications: maternal illnesses, obstetric history, folic acid supplement intake, alcohol intake, smoking, substance abuse, hereditary disease, prescription medication, dietary habits, overweight, and birth defects in the family. The respondents acknowledged that preconception care should be offered to all couples who wish to become pregnant, as opposed to offering preconception care only to those with an increased risk of complications. Still, respondents do not receive many questions regarding the preconception period or requests for preconception care consultations.

KEY CONCLUSION

Birth care professionals acknowledge the need for preconception care for all couples. In the Netherlands, preconception care consists mostly of an individual consultation with recommendations for health and lifestyle advice. However, the identification of risk factors varies between birth care professionals and less than half of the respondents indicate that they have a protocol available in their practice. Furthermore, the demand of parents-to-be for preconception care is low. More research, that includes more obstetricians, is necessary to investigate if there is a difference between the care provided by primary care midwives and obstetricians.

IMPLICATIONS FOR PRACTICE

To increase the awareness and uptake of preconception care, it would be prudent to emphasize its importance to parents-to-be and professionals, and actively promote the use of widespread, standardized protocols for birth care professionals.

Stimulating the Uptake of Preconception Care by Women With a Vulnerable Health Status Through mHealth App-Based Nudging (Pregnant Faster): Cocreation Design and Protocol for a Cohort Study

BACKGROUND

Women with a low socioeconomic status often have a vulnerable health status due to an accumulation of health-deteriorating factors such as poor lifestyle behaviors, including inadequate nutrition, mental stressors, and impaired health literacy and agency, which puts them at an unnecessary high risk of adverse pregnancy outcomes. Adequately preparing for pregnancy through preconception care (PCC) uptake and lifestyle improvement can improve these outcomes. We hypothesize that nudging is a successful way of encouraging engagement in PCC. A nudge is a behavioral intervention that changes choice behavior through influencing incentives. The mobile health (mHealth) app-based loyalty program Pregnant Faster aims to reward women in an ethically justified way and nudges to engage in pregnancy preparation by visiting a PCC consultation.

OBJECTIVE

Here, we first describe the process of the cocreation of the mHealth app Pregnant Faster that aims to increase engagement in pregnancy preparation by women with a vulnerable health status. Second, we describe the cohort study design to assess the feasibility of Pregnant Faster.

METHODS

The content of the app is based on the eHealth lifestyle coaching program Smarter Pregnancy, which has proven to be effective in ameliorating preconceptional lifestyle behaviors (folic acid, vegetables, fruits, smoking, and alcohol) and an interview study pertaining to the preferences of the target group with regard to an mHealth app stimulating PCC uptake. For moral guidance on the design, an ethical framework was developed based on the bioethical principles of Beauchamp and Childress. The app was further developed through iterative cocreation with the target group and health care providers. For 4 weeks, participants will engage with Pregnant Faster, during which opportunities will arise to earn coins such as reading informative blogs and registering for a PCC consultation. Coins can be spent on small fun rewards, such as folic acid, fruits, and mascara. Pregnant Faster's feasibility will be tested in a study including 40 women aged 18 to 45 years, who are preconceptional or <8 weeks pregnant, with a low educational level, and living in a deprived neighborhood. The latter 2 factors will serve as a proxy of a low socioeconomic status. Recruitment will take place through flyers, social media, and health care practices. After finalization, participants will evaluate the app through the "mHealth App Usability Questionnaire" and additional interviews or questionnaires.

RESULTS

Results are expected to be published by December 2023.

CONCLUSIONS

Pregnant Faster has been designed through iterative cocreation with the target group and health care professionals. With the designed study, we will test Pregnant Faster's feasibility. If overall user satisfaction and PCC uptake is achieved, the app will be further developed and the cohort will be continued with an additional 400 inclusions to establish effectiveness.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/45293.

Association between social vulnerability profiles, prenatal care use and pregnancy outcomes

BACKGROUND

Evaluating social vulnerability is a challenging task. Indeed, former studies demonstrated an association between geographical social deprivation indicators, administrative indicators, and poor pregnancy outcomes.

OBJECTIVE

To evaluate the association between social vulnerability profiles, prenatal care use (PCU) and poor pregnancy outcomes (Preterm birth (PTB: <37 gestational weeks (GW)), small for gestational age (SGA), stillbirth, medical abortion, and late miscarriage).

METHODS

Retrospective single center study between January 2020 and December 2021. A total of 7643 women who delivered a singleton after 14 GW in a tertiary care maternity unit were included. Multiple component analysis (MCA) was used to assess the associations between the following social vulnerabilities: social isolation, poor or insecure housing conditions, not work-related household income, absence of standard health insurance, recent immigration, linguistic barrier, history of violence, severe dependency, psychologic vulnerability, addictions, and psychiatric disease. Hierarchical clustering on principal component (HCPC) from the MCA was used to classify patients into similar social vulnerability profiles. Associations between social vulnerability profiles and poor pregnancy outcomes were tested using multiple logistic regression or Poisson regression when appropriate.

RESULTS

The HCPC analysis revealed 5 different social vulnerability profiles. Profile 1 included the lowest rates of vulnerability and was used as a reference. After adjustment for maternal characteristics and medical factors, profiles 2 to 5 were independently associated with inadequate PCU (highest risk for profile 5, aOR = 3.14, 95%CI[2.33-4.18]), PTB (highest risk for profile 2, aOR = 4.64, 95%CI[3.80-5.66]) and SGA status (highest risk for profile 5, aOR = 1.60, 95%CI[1.20-2.10]). Profile 2 was the only profile associated with late miscarriage (adjusted incidence rate ratio (aIRR) = 7.39, 95%CI[4.17-13.19]). Profiles 2 and 4 were independently associated with stillbirth (highest association for profile 2 (aIRR = 10.9, 95%CI[6.11-19.99]) and medical abortion (highest association for profile 2 (aIRR = 12.65, 95%CI[5.96-28.49]).

CONCLUSIONS

This study unveiled 5 clinically relevant social vulnerability profiles with different risk levels of inadequate PCU and poor pregnancy outcomes. A personalized patient management according to their profile could offer better pregnancy management and reduce adverse outcomes.

Use of pregnancy personalised follow-up in case of maternal social vulnerability to reduce prematurity and neonatal morbidity

BACKGROUND

Social deprivation is a major risk factor of adverse pregnancy outcomes. Yet, there is few studies evaluating interventions aiming at reducing the impact of social vulnerability on pregnancy outcomes.

OBJECTIVE

To compare pregnancy outcomes between patients that received personalized pregnancy follow-up (PPFU) to address social vulnerability versus standard care.

METHODS

Retrospective comparative cohort in a single institution between 2020 and 2021. A total of 3958 women with social vulnerability that delivered a singleton after 14 gestational weeks were included, within which 686 patients had a PPFU. Social vulnerability was defined by the presence of at least one of the following characteristics: social isolation, poor or insecure housing conditions, no work-related household income, and absence of standard health insurance (these four variables were combined as a social deprivation index (SDI)), recent immigration (< 12 month), interpersonal violence during pregnancy, being handicaped or minor, addiction during pregnancy. Maternal characteristics and pregnancy outcomes were compared between patients that received PPFU versus standard care. The associations between poor pregnancy outcomes (premature birth before 37 gestational weeks (GW), premature birth before 34 GW, small for gestational age (SGA) and PPFU were tested using multivariate logistic regression and propensity score matching.

RESULTS

After adjustment on SDI, maternal age, parity, body mass index, maternal origin and both high medical and obstetrical risk level before pregnancy, PPFU was an independent protective factor of premature birth before 37 gestational weeks (GW) (aOR = 0.63, 95%CI[0.46-0.86]). The result was similar for premature birth before 34 GW (aOR = 0.53, 95%CI [0.34-0.79]). There was no association between PPFU and SGA (aOR = 1.06, 95%CI [0.86 - 1.30]). Propensity score adjusted (PSa) OR for PPFU using the same variables unveiled similar results, PSaOR = 0.63, 95%CI[0.46-0.86] for premature birth before 37 GW, PSaOR = 0.52, 95%CI [0.34-0.78] for premature birth before 34 GW and PSaOR = 1.07, 95%CI [0.86 - 1.33] for SGA.

CONCLUSIONS

This work suggests that PPFU improves pregnancy outcomes and emphasizes that the detection of social vulnerability during pregnancy is a major health issue.

Antenatal Care and Health Behavior of Pregnant Women—An Evaluation of the Survey of Neonates in Pomerania

Background. The German maternity guidelines require regular medical checkup (MC) during pregnancy as a measure of prevention. Socioeconomic factors such as education, profession, income and origin, but also age and parity may influence the preventive and health behavior of pregnant women. The aim was to investigate the influence of these factors on the participation rate in MC of pregnant women. Method. The current analysis is based on the prospective population-based birth cohort study Survey of Neonates in Pomerania, which was conducted in Western Pomerania, Germany. The data of 4092 pregnant women from 2004 to 2008 were analyzed regarding the antenatal care and health behavior. Up to 12 MC were regularly offered; participation in 10 MC is defined as standard screening according to maternity guidelines. Results. Women participated in the first preventive MC on average in the 10th (±3.8 SD) week of pregnancy. 1343 (34.2%) women participated in standard screening and 2039 (51.9%) took a screening above standard. 547 (13.92%) women participated in less than the 10 standard MCs. In addition, about one-third of the pregnancies investigated in this study were unplanned. Bivariate analyses showed an association between better antenatal care behavior and higher maternal age, stabile partnerships and mother born in Germany, p < 0.05. On the contrary antenatal care below standard were more often found by women with unplanned pregnancies, less educational women and women with lower equivalent income, p < 0.001. Health behaviors also influenced antenatal care. Whereas the risk of antenatal care below standard increased by smoking during pregnancy (RRR 1.64; 95% CI 1.25, 2.14) and alcohol consumption (RRR 1.31; 95% CI 1.01, 1.69), supplementation intake was associated with decreased risk (iodine—RRR 0.66; 95% CI 0.53, 0.81; folic acid—RRR 0.56; 95% CI 0.44, 0.72). The health behavior of pregnant women also differs according to their social status. Higher maternal income was negatively correlated with smoking during pregnancy (OR 0.2; 95% CI 0.15, 0.24), but positively associated with alcohol consumption during pregnancy (OR 1.3; 95% CI 1.15, 1.48) and lower pre-pregnancy BMI (Coef. = 0.083, p < 0.001). Lower maternal education was positively correlated with smoking during pregnancy (OR 59.0; 95% CI 28.68, 121.23). Conclusions. Prenatal care according to maternity guidelines is well established with a high participation rate in MC during pregnancy of more than 85%. However, targeted preventive measures may address younger age, socioeconomic status and health-damaging behaviors (smoking, drinking) of the pregnant women because these factors were associated with antenatal care below standard.

Patients' experiences with an obstetric telephone triage system: A qualitative study

BACKGROUND

Telephone Triage Systems aim to provide a uniform and practical system for healthcare professionals in order to prioritize urgency of care. A disadvantage of telephone triage system could be that the conversations are experienced as less personal, as it uses a uniform procedure for every patient. Therefore, aside from the clinical relevance, patient expectations, experiences and satisfaction were studied.

OBJECTIVE

The purpose of this study is to explore patients' experiences with obstetric telephone triage.

METHODS

A descriptive, qualitative design to explore experiences after triage with Dutch Obstetric Telephone Triage System. Participants, recruited from two Dutch hospitals, were pregnant women who received triage by telephone. Semi-structured interviews were held. The following topics were discussed: expectations before triage, experiences with triage, waiting time, information and communication, approach of healthcare professional, and quality of treatment. Data were analyzed using open, axial and selective coding.

RESULTS

Overall, the participants experienced the telephone conversation as satisfactory. This was due to the perceived professionalism with high accessibility and perceived reassurance. The approach of the professional was experienced as friendly and empathetic. Participants suggested that triage services could be improved by looking specifically at information provision. Explaining in advance how the service works can be helpful to create more awareness and to align better with expectations.

CONCLUSION

Participants reported that they could tell their own story and most participants realized that the professional asked extra questions in order to quantify the seriousness of the complaints. The level of involvement in the next steps of their care episode experienced by respondents lead us to conclude that the professional intended patient-centered care.

PRACTICE IMPLICATIONS

Improving the provision of information during waiting times and about the accessibility of the service can increase the quality of obstetric triage care. Patient involvement is necessary to increase trust and to meet the needs of the patient.

Association between preterm births and socioeconomic development: analysis of national data

Background

The increasing prevalence of preterm birth, which is a global phenomenon, is attributable to the increased medical indications, artificial gestations, and some socioeconomic factors. This study was conducted to identify whether development and equality indices are associated with the incidence of preterm birth, specifically, spontaneous and elective preterm births.

Methods

This retrospective observational study comprised an analysis of data on live births from 2019 in Brazil and on socioeconomic indices that were derived from census information in 2017. Data were summarised using absolute and relative frequencies. Spearman’s correlation was used to determine the correlation between socioeconomic factors and the preterm birth rate. Multiple beta regression analysis was performed to determine the best model of socioeconomic covariates and preterm birth rate. The significance level was set at 5%.

Results

In 2019 in Brazil, the preterm birth rate was 11.03%, of which 58% and 42% were spontaneous and elective deliveries, respectively. For all preterm births, Spearman’s correlation varied from ρ = 0.4 for the Gini Index and ρ =  − 0.24 for illiteracy. The best fit modelled the spontaneous preterm birth fraction as a negative function of the Human Development Index (HDI). The best-fit model considered the expected elective preterm birth fraction as a positive function of the HDI and as a negative function of the Gini Index, which was used as a precision parameter.

Conclusions

We observed a reduction in the fraction of spontaneous preterm births; however, the distribution was not uniform in the territory: higher rates of spontaneous preterm birth were noticed in the north, northeast, and mid-west regions. Thus, areas with lower education levels and inequal income distribution have a higher proportion of spontaneous preterm birth. The fraction of elective preterm birth was positively associated with more advantaged indices of socioeconomic status.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-14376-2.

Classification of Deprivation Indices That Applied to Detect Health Inequality: A Scoping Review

INTRODUCTION

Many studies around the world are undertaken to establish the association between deprivation and public health indicators. Both separate indicators (e.g., income, education, occupation, public security and social support) and complex models (indices) include several indicators. Deprivation indices are actively used in public health since the mid 1980s. There is currently no clear classification of indices.

METHODS

In the current review, data related to deprivation indices are combined and analyzed in order to create a taxonomy of indices based on the results obtained. The search was carried out using two bibliographic databases. After conducting a full-text review of the articles and searching and adding relevant articles from the bibliography, and articles that were already known to the authors, sixty studies describing the use of sixty deprivation indices in seventeen countries were included in the narrative synthesis, resulting in development of a taxonomy of indices. When creating the taxonomy, an integrative approach was used that allows integrating new classes and sub-classes in the event that new information appears.

RESULTS

In the review, 68% (41/60) of indices were classified as socio-economic, 7% (4/60) of indices as material deprivation, 5% (3/60) of indices as environmental deprivation and 20% (12/60) as multidimensional indices.

CONCLUSIONS

The data stimulates the use of a competent approach, and will help researchers and public health specialist in resolving conflicts or inconsistencies that arise during the construction and use of indices.

Association Between Income and Perinatal Mortality in the Netherlands Across Gestational Age

Importance

The association between household income and perinatal health outcomes has been understudied. Examining disparities in perinatal mortality within strata of gestational age and before and after adjusting for birth weight centile can reveal how the income gradient is associated with gestational age, birth weight, and perinatal mortality.

Objectives

To investigate the association between household income and perinatal mortality, separately by gestational age strata and time of death, and the potential role of birth weight centile in mediating this association.

Design, Setting, and Participants

This cross-sectional study used individually linked data of all registered births in the Netherlands with household-level income tax records. Singletons born between January 1, 2004, and December 31, 2016, at 24 weeks to 41 weeks 6 days of gestation with complete information on birth outcomes and maternal characteristics were studied. Data analysis was performed from March 1, 2018, to August 30, 2021.

Exposures

Household income rank (adjusted for household size).

Main Outcomes and Measures

Perinatal mortality, stillbirth (at ≥24 weeks of gestation), and early neonatal mortality (at ≤7 days after birth). Disparities were expressed as bottom-to-top ratios of projected mortality among newborns with the poorest 1% of households vs those with the richest 1% of households. Generalized additive models stratified by gestational age categories, adjusted for potential confounding by maternal age at birth, maternal ethnicity, parity, sex, and year of birth, were used. Birth weight centile was included as a potential mediator.

Results

Among 2 036 431 singletons in this study (1 043 999 [51.3%] males; 1 496 579 [73.5%] with mother of Dutch ethnicity), 121 010 (5.9%) were born before 37 weeks of gestation, and 8720 (4.3 deaths per 1000) died during the perinatal period. Higher household income was positively associated with higher rates of perinatal survival, with an unadjusted bottom-to-top ratio of 2.18 (95% CI, 1.87-2.56). The bottom-to-top ratio decreased to 1.30 (95% CI, 1.22-1.39) after adjustment for potential confounding factors and inclusion of birth weight centile as a possible mediator. The fully adjusted ratios were lower for stillbirths (1.27; 95% CI, 1.20-1.36) than for early neonatal deaths (1.35; 95% CI, 1.14-1.66). Inequalities in perinatal mortality were found for newborns at greater than 26 weeks of gestation but not between 24 and 26 weeks of gestation (fully adjusted bottom-to-top ratio, 0.89; 95% CI, 0.77-1.04).

Conclusions and Relevance

The results of this large nationally representative cross-sectional study suggest that a large part of the increased risk of perinatal mortality among low-income women is mediated via a lower birth weight centile. The absence of disparities at very low gestational ages suggests that income-related risk factors for perinatal mortality are less prominent at very low gestational ages. Further research should aim to understand which factors associated with preterm birth and lower birth weight can reduce inequalities in perinatal mortality.

A prospective population-based multicentre study on the impact of maternal body mass index on adverse pregnancy outcomes: Focus on normal weight

Background

Maternal body mass index (BMI) below or above the reference interval (18.5–24.9 kg/m²) is associated with adverse pregnancy outcomes. Whether BMI exerts an effect within the reference interval is unclear. Therefore, we assessed the association between adverse pregnancy outcomes and BMI, in particular within the reference interval, in a general unselected pregnant population.

Methods

Data was extracted from a prospective population-based multicentre cohort (Risk Estimation for PrEgnancy Complications to provide Tailored care (RESPECT) study) conducted between December 2012 to January 2014. BMI was studied in categories (I: <18.5, II: 18.5–19.9, III: 20.0–22.9, IV: 23.0–24.9, V: 25.0–27.4, VI: 27.5–29.9, VII: >30.0 kg/m²) and as a continuous variable within the reference interval. Adverse pregnancy outcomes were defined as composite endpoints for maternal, neonatal or any pregnancy complication, and for adverse pregnancy outcomes individually. Linear trends were assessed using linear-by-linear association analysis and (adjusted) relative risks by regression analysis.

Results

The median BMI of the 3671 included women was 23.2 kg/m² (IQR 21.1–26.2). Adverse pregnancy outcomes were reported in 1256 (34.2%). Linear associations were observed between BMI categories and all three composite endpoints, and individually for pregnancy-induced hypertension (PIH), preeclampsia, gestational diabetes mellitus (GDM), large-for-gestational-age (LGA) neonates; but not for small-for-gestational-age neonates and preterm birth. Within the reference interval, BMI was associated with the composite maternal endpoint, PIH, GDM and LGA, with adjusted relative risks of 1.15 (95%CI 1.06–1.26), 1.12 (95%CI 1.00–1.26), 1.31 (95%CI 1.11–1.55) and 1.09 (95%CI 1.01–1.17).

Conclusions

Graded increase in maternal BMI appears to be an indicator of risk for adverse pregnancy outcomes even among women with a BMI within the reference interval. The extent to which BMI directly contributes to the increased risk in this group should be evaluated in order to determine strategies most valuable for promoting safety and long-term health for mothers and their offspring.

Inequity in postpartum healthcare provision at home and its association with subsequent healthcare expenditure

Background

Provision of postpartum care can support new families in adapting to a new situation. We aimed to determine whether various determinants of socioeconomic status (SES) were associated with utilization of postpartum care. In addition, to stress the relevance of increasing postpartum care uptake among low SES-groups, an assessment of the potential (cost-)effectiveness of postpartum care is required.

Methods

National retrospective cohort study using linked routinely collected healthcare data from all registered singleton deliveries (2010–13) in the Netherlands. Small-for-gestational age and preterm babies were excluded. The associations between SES and postpartum care uptake, and between uptake and health care expenditure were studied using multivariable regression analyses.

Results

Of all 569 921 deliveries included, 1.2% did not receive postpartum care. Among women who did receive care, care duration was below the recommended minimum of 24 h in 15.3%. All indicators of low SES were independently associated with a lack in care uptake. Extremes of maternal age, single parenthood and being of non-Dutch origin were associated with reduced uptake independent of SES determinants. No uptake of postpartum care was associated with maternal healthcare expenses in the highest quartile: aOR 1.34 (95% CI 1.10–1.67). Uptake below the recommended amount was associated with higher maternal and infant healthcare expenses: aOR 1.09 (95% CI 1.03–1.18) and aOR 1.20 (95% CI 1.13–1.27), respectively.

Conclusion

Although uptake was generally high, low SES women less often received postpartum care, this being associated with higher subsequent healthcare expenses. Strategies to effectively reduce these substantial inequities in early life are urgently needed.

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.

Joint contribution of socioeconomic circumstances and ethnic group to variations in preterm birth, neonatal mortality and infant mortality in England and Wales: a population-based retrospective cohort study using routine data from 2006 to 2012

OBJECTIVES

This study aimed to describe the variation in risks of adverse birth outcomes across ethnic groups and socioeconomic circumstances, and to explore the evidence of mediation by socioeconomic circumstances of the effect of ethnicity on birth outcomes.

SETTING

England and Wales.

PARTICIPANTS

The data came from the 4.6 million singleton live births between 2006 and 2012.

EXPOSURE

The main exposure was ethnic group. Socioeconomic circumstances, the hypothesised mediator, were measured using the Index of Multiple Deprivation (IMD), an area-level measure of deprivation, based on the mother's place of residence.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcomes were birth outcomes, namely: neonatal death, infant death and preterm birth. We estimated the slope and relative indices of inequality to describe differences in birth outcomes across IMD, and the proportion of the variance in birth outcomes across ethnic groups attributable to IMD. We investigated mediation by IMD on birth outcomes across ethnic groups using structural equation modelling.

RESULTS

Neonatal mortality, infant mortality and preterm birth risks were 2.1 per 1000, 3.2 per 1000 and 5.6%, respectively. Babies in the most deprived areas had 47%-129% greater risk of adverse birth outcomes than those in the least deprived areas. Minority ethnic babies had 48%-138% greater risk of adverse birth outcomes compared with white British babies. Up to a third of the variance in birth outcomes across ethnic groups was attributable to differences in IMD, and there was strong statistical evidence of an indirect effect through IMD in the effect of ethnicity on birth outcomes.

CONCLUSION

There is evidence that socioeconomic circumstances could be contributing to the differences in birth outcomes across ethnic groups.

Satisfaction with obstetric care in a population of low-educated native Dutch and non-western minority women. Focus group research

Background

Low-educated native Dutch and non-western minority women have inadequate access to obstetric care. Moreover, the care they receive lacks responsiveness to their needs and cultural competences. Gaining a deeper understanding of their experiences and satisfaction with antenatal, birthing and maternity care will help to adjust healthcare responsiveness to meet their needs during pregnancy, childbirth and the postpartum period.

Methods

We combined the World Health Organization conceptual framework of healthcare responsiveness with focus group research to measure satisfaction with antenatal, birthing and maternity care of women with a low-educated native Dutch and non-western ethnic background.

Results

From September 2011 until December 2013, 106 women were recruited for 20 focus group sessions. Eighty-five percent of the women had a non-western immigrant background and 89% a low or intermediate educational attainment. The study population was mostly positive about the provided care during the antenatal phase. They were less positive about the other two phases of care. Moreover, the obstetric healthcare systems’ responsiveness in all phases of care (antenatal, birthing and maternity) did not meet these women’s needs. The ‘respect for persons’ domains ‘autonomy’, ‘communication’ and ‘dignity’ and the ‘client orientation’ domain ‘prompt attention’ were judged most negatively.

Conclusions

The study findings give contextual meaning and starting points for improvement of responsiveness in the provision of obstetric care within a multi-ethnic women’s population.

Travel Time to Hospital for Childbirth: Comparing Calculated Versus Reported Travel Times in France

Objectives Timely access to health care is critical in obstetrics. Yet obtaining reliable estimates of travel times to hospital for childbirth poses methodological challenges. We compared two measures of travel time, self-reported and calculated, to assess concordance and to identify determinants of long travel time to hospital for childbirth. Methods Data came from the 2010 French National Perinatal Survey, a national representative sample of births (N = 14 681). We compared both travel time measures by maternal, maternity unit and geographic characteristics in rural, peri-urban and urban areas. Logistic regression models were used to study factors associated with reported and calculated times ≥30 min. Cohen's kappa coefficients were also calculated to estimate the agreement between reported and calculated times according to women's characteristics. Results In urban areas, the proportion of women with travel times ≥30 min was higher when reported rather than calculated times were used (11.0 vs. 3.6%). Longer reported times were associated with non-French nationality [adjusted odds ratio (aOR) 1.3 (95% CI 1.0-1.7)] and inadequate prenatal care [aOR 1.5 (95% CI 1.2-2.0)], but not for calculated times. Concordance between the two measures was higher in peri-urban and rural areas (52.4 vs. 52.3% for rural areas). Delivery in a specialised level 2 or 3 maternity unit was a principal determinant of long reported and measured times in peri-urban and rural areas. Conclusions for Practice The level of agreement between reported and calculated times varies according to geographic context. Poor measurement of travel time in urban areas may mask problems in accessibility.

Preconception counselling for low health literate women: an exploration of determinants in the Netherlands

Background

Women from lower socioeconomic groups tend to be at greater risk of adverse perinatal outcomes, but are less likely to participate in preconception counselling compared to higher socioeconomic groups. This could be partly because of their limited skills to assess, understand and use health related information in ways that promote and maintain good health (health literacy skills). In this study we explored determinants of participation in preconception counselling among women with low health literacy in The Netherlands.

Methods

Potential determinants of participation in preconception counselling were derived from the literature, and mapped onto a theoretical framework, which was tested for perceived relevance and completeness in an expert review (n = 20). The framework was used to prepare face-to-face interviews with women with low health literacy and a wish to conceive (n = 139). In the interviews we explored preconception counselling awareness, knowledge, considerations, subjective norms, self-efficacy, attitude, and intention. Linear regression analyses were used to test associations with intention to participate in preconception counselling.

Results

Most women (75%) were unaware of the concept of preconception counselling and the provision of counselling, even if they lived in areas where written invitations had been disseminated. Common considerations for participation were: preparation for pregnancy; perceived lack of information; and problems in a previous pregnancy. Considerations not to participate were mostly related to perceived sufficient knowledge and perceived low risk of perinatal problems. Respondents generally had a positive attitude towards participation in preconception counselling for themselves, and 41% reported that they would participate in preconception counselling.

Conclusion

Women with low health literacy were generally unaware of the concept and provision of preconception counselling, but seemed to be interested in participation. Further research should investigate how to effectively reach and inform this group about preconception counselling. This knowledge is essential for evidence-based development of interventions to increase the accessibility and understanding of preconception counselling.

Electronic supplementary material

The online version of this article (10.1186/s12978-018-0617-1) contains supplementary material, which is available to authorized users.

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.

Human Development Index (HDI) of the maternal country of origin as a predictor of perinatal outcomes - a longitudinal study conducted in Spain

Background

In an era of worldwide population displacement, recent studies have identified strong associations between social situations and perinatal outcomes among immigrants. Little is known about the effect of maternal social background on pregnancy outcomes. The Human Development Index (HDI) assesses the following dimensions of human development: life expectancy, education level and income. The objective of our study was to determine if maternal HDI may be used to identify women at increased odds of poor pregnancy outcomes.

Methods

We conducted a longitudinal population-based study in a tertiary centre in Madrid, Spain. The outcome variables were maternal and perinatal/antenatal mortality, preeclampsia (PE), low birth weight (LBW), gestational diabetes mellitus (GDM), preterm delivery (PTD) before 37 and 34 gestational weeks, abnormal cardiotocography (CTG) during delivery, C-section (CS) due to abnormal CTG, pH < 7.10 at birth, Apgar at 5 min ≤ 7, and resuscitation type ≥3. We performed multivariate logistic regression analyses adjusted for potential confounding variables to evaluate the associations between maternal HDI and perinatal outcomes.

Results

In total, 38,719 singleton infants who were born in our maternity ward between 2010 and 2016 and had perinatal outcome data available were included in this study. The neonates of women from medium/low HDI countries had significantly lower odds of low birth weight (LBW) than their very high HDI country counterparts (OR 0.63, 95% CI 0.55–0.72). However, the odds of PTD before 37 gestational weeks and PE were higher in the medium/low HDI group than the very high HDI group (OR 1.26, 95% CI 1.04–1.53; OR 1.35, 95% CI 1.02–1.79, respectively). Poorer neonatal outcomes were identified in the medium/low HDI group than the very high HDI group, including greater odds of abnormal CTG, CS due to abnormal CTG and Apgar 2 ≤ 7 (p < 0.05).

Conclusions

Our findings suggest that the infants of mothers from medium/low HDI had lower odds of LBW but higher odds of PTD, PE and poor neonatal outcomes. These results support the hypothesis that maternal HDI can be used to understand the impact of maternal origin on pregnancy outcomes. Further studies are needed to confirm its validity.

Correlation between preconception maternal non-occupational exposure to interior decoration or oil paint odour and average birth weight of neonates: findings from a nationwide cohort study in China's rural areas

BACKGROUND

Birth weight is a critical indicator of neonatal health and foretells people's health in adolescence and even adulthood. Some researchers have warned against the adverse effects on babies' birth weight of exposure to pollutants in interior decoration or oil paint by odour intake. This study evaluated the effects of maternal exposure to such factors before conception on the birth weights of neonates.

METHODS

Data on 213 461 cases in this study were from the database of the free National Pre-pregnancy Checkups Project. Defined as 'exposed' were those women exposed to oil paint odour or interior decoration at home or in the workplace within 6 months before their pregnancy. The study focused on revealing the correlation between such exposure and the birth weight of the neonates of these women, especially the incidence of macrosomia and low birth weight (LBW). Statistical analysis was conducted using the Kruskal-Wallis H test, the Mann-Whitney U test and logistic regression.

RESULTS

The birth weight of babies from mothers non-occupationally exposed to such settings averaged 3465 g (range 3150-3650 g), whereas the birth weight of those from mothers free of such exposure averaged 3300 g (range 3000-3600g). Maternal exposure preconception to interior decoration or oil paint odour reduced the incidence of LBW in their babies (p=0.003, OR 0.749, 95% CI 0.617 to 0.909). Such exposure may also augment the probability of macrosomia (p<0.001, OR 1.297, 95% CI 1.133 to 1.484).

CONCLUSION

Maternal exposure to interior decoration or oil paint odour preconception may increase the average birth weight of neonates, as well as the incidence of macrosomia.

Effect of planned place of birth on obstetric interventions and maternal outcomes among low-risk women: a cohort study in the Netherlands

BACKGROUND

The use of interventions in childbirth has increased the past decades. There is concern that some women might receive more interventions than they really need. For low-risk women, midwife-led birth settings may be of importance as a counterbalance towards the increasing rate of interventions. The effect of planned place of birth on interventions in the Netherlands is not yet clear. This study aims to give insight into differences in obstetric interventions and maternal outcomes for planned home versus planned hospital birth among women in midwife-led care.

METHODS

Women from twenty practices across the Netherlands were included in 2009 and 2010. Of these, 3495 were low-risk and in midwife-led care at the onset of labour. Information about planned place of birth and outcomes, including instrumental birth (caesarean section, vacuum or forceps birth), labour augmentation, episiotomy, oxytocin in third stage, postpartum haemorrhage >1000 ml and perineal damage, came from the national midwife-led care perinatal database, and a postpartum questionnaire.

RESULTS

Women who planned home birth more often had spontaneous birth (nulliparous women aOR 1.38, 95 % CI 1.08-1.76, parous women aOR 2.29, 95 % CI 1.21-4.36) and less often episiotomy (nulliparous women aOR 0.73, 0.58-0.91, parous women aOR 0.47, 0.33-0.68) and use of oxytocin in the third stage (nulliparous women aOR 0.58, 0.42-0.80, parous women aOR 0.47, 0.37-0.60) compared to women who planned hospital birth. Nulliparous women more often had anal sphincter damage (aOR 1.75, 1.01-3.03), but the difference was not statistically significant if women who had caesarean sections were excluded. Parous women less often had labour augmentation (aOR 0.55, 0.36-0.82) and more often an intact perineum (aOR 1.65, 1.34-2.03). There were no differences in rates of vacuum/forceps birth, unplanned caesarean section and postpartum haemorrhage >1000 ml.

CONCLUSIONS

Women who planned home birth were more likely to give birth spontaneously and had fewer medical interventions.

Vulnerable pregnant women in antenatal practice: Caregiver's perception of workload, associated burden and agreement with objective caseload, and the influence of a structured organisation of antenatal risk management

INTRODUCTION

pregnancy care for vulnerable women is often perceived as a burden by caregivers as vulnerable clients require complex case management, additional time, and more often show adverse perinatal outcomes. Vulnerable clients bring about additional work strain for the caregiver, especially when the workload is high. We define client vulnerability as coexistence of psychopathology, psychosocial problems or substance use, together with features of deprivation. We investigated, as part of a national programme, whether the subjective caregiver's perception of workload and the objective registry-based caseload of vulnerable clients are in agreement, and whether a structured organisation of antenatal risk management reduces the burden associated with the perceived workload, in particular if the objective caseload is high.

METHODS

we combined three data sources: (1) at the unit level (i.e. midwifery practice, obstetric unit) interview data from caregivers, from which we derived a) the (subjective) caregiver's perception of workload, b) the associated burden and c) organisational structure of antenatal risk management, (2) at the unit level perinatal registry data, from which we derived a) unit characteristics and b) (objective) unit specific caseload, and (3) at the individual client level survey data collected during the first antenatal visit, from which the prevalence of vulnerable clients was derived. The study area was the South-West Netherlands (2.5 million inhabitants), containing areas with varying degrees of urbanisation and deprivation.

FINDINGS

sixteen units had complete data on all measures. Generally, subjective workload and objective caseload were only weakly related, the relation being modified by the organisation of antenatal risk management. If the organisational structure of antenatal risk management was low, the experienced burden was high, even if the objective caseload was low. Highly structured antenatal risk management was associated with a medium to low burden.

DISCUSSION

our observational study suggests that even a high caseload can be dealt with by structured antenatal risk management. A change from the current individual case-finding policies towards a more universal screen-like approach may thus benefit both the client and the caregiver.

Geographical, Ethnic and Socio-Economic Differences in Utilization of Obstetric Care in the Netherlands

Background

All women in the Netherlands should have equal access to obstetric care. However, utilization of care is shaped by demand and supply factors. Demand is increased in high risk groups (non-Western women, low socio-economic status (SES)), and supply is influenced by availability of hospital facilities (hospital density). To explore the dynamics of obstetric care utilization we investigated the joint association of hospital density and individual characteristics with prototype obstetric interventions.

Methods

A logistic multi-level model was fitted on retrospective data from the Netherlands Perinatal Registry (years 2000–2008, 1.532.441 singleton pregnancies). In this analysis, the first level comprised individual maternal characteristics, the second of neighbourhood SES and hospital density. The four outcome variables were: referral during pregnancy, elective caesarean section (term and post-term breech pregnancies), induction of labour (term and post-term pregnancies), and birth setting in assumed low-risk pregnancies.

Results

Higher hospital density is not associated with more obstetric interventions. Adjusted for maternal characteristics and hospital density, living in low SES neighbourhoods, and non-Western ethnicity were generally associated with a lower probability of interventions. For example, non-Western women had considerably lower odds for induction of labour in all geographical areas, with strongest effects in the more rural areas (non-Western women: OR 0.78, 95% CI 0.77–0.80, p<0.001).

Conclusion

Our results suggest inequalities in obstetric care utilization in the Netherlands, and more specifically a relative underservice to the deprived, independent of level of supply.

New index of social deprivation during pregnancy: results from a national study in France

OBJECTIVES

To identify precariousness markers in pregnant women that differ from the usual socioeconomic variables.

METHODS

Data were obtained from the National Perinatal Survey, a representative sample of women giving birth in France in 2010. From six indicators of social vulnerability, four were selected by multiple correspondence analysis. The first axis of this analysis was used, characterised by the following contributory variables: receiving RSA (Revenu de Solidarité Active) allowance; benefitting from the CMU (Couverture Maladie Universelle) system (French social security) or not being insured; not living in own accommodation; and not living with a partner. These four variables were summed to create a deprivation index.

RESULTS

This index was strongly associated with social maternal characteristics and correctly identified women who were socially vulnerable. Furthermore, it was highly related to the psychosocial context, access to care, behaviours during pregnancy, and pregnancy outcomes. These associations remained significant after adjustment for social variables: compared with no deprivation (no factors), a high level of deprivation (≥3 factors) was associated with late prenatal care (OR 5.8, 95% CI 4.6 to 7.2) and small for gestational age (OR 1.5, 95% CI 1.1 to 1.9).

CONCLUSIONS

This index of social deprivation was associated with health issues and behaviours during pregnancy, even after adjustment for social variables, revealing a dimension not measured by the usual variables. Moreover, it is simple to use and easily reproducible.

Caught in the middle? How women deal with conflicting pregnancy-advice from health professionals and their social networks

OBJECTIVE

to investigate how pregnant women deal with conflicting advice from their social networks and their caregivers and how this influenced their pregnancy-related behaviours.

DESIGN AND METHODS

a qualitative study based on face-to-face interviews and focus-groups. We applied an inductive analysis technique closely following the 'Gioia method'.

SETTING

impoverished neighbourhoods in Rotterdam, the Netherlands.

PARTICIPANTS

40 women who were pregnant, or had given birth within the last 12 months. 12 women were Native Dutch, 16 had a Moroccan background, and 12 had a Turkish background.

FINDINGS

all women faced a misalignment of advice by health professionals and social networks. For the native Dutch respondents, this misalignment did not seem to present a challenge. They had a strongly articulated preference for the advice of health professionals, and did not fear any social consequences for openly following their advice. For the women with a Turkish/Moroccan background, however, this discrepancy in advice presented a dilemma. Following one piece of advice seemed to exclude also following the other one, which would possibly entail social consequences. These women employed one of the three strategies to deal with this dilemma: a) avoiding the dilemma (secretly not following the advice of one side), b) embracing the dilemma (combining conflicting advice), and c) resolving the dilemma (communicating between both sides).

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

we argue that the currently popular interventions geared towards increasing the health literacy of non-Western ethnic minority pregnant women and improving communication between ethnic minority clients and caregivers are not sufficient, and might even exacerbate the dilemma some pregnant women face. As an alternative, we recommend involving not only caregivers but also women's social network in intervention efforts. Interventions could aim to increase the negotiation capacity of the target group, but also to increase the health literacy of the members of their social network to enable the circulation of 'new' information within a rather homogeneous, tight-knit network.

An antenatal prediction model for adverse birth outcomes in an urban population: The contribution of medical and non-medical risks

OBJECTIVES

in the Netherlands the perinatal mortality rate is high compared to other European countries. Around eighty percent of perinatal mortality cases is preceded by being small for gestational age (SGA), preterm birth and/or having a low Apgar-score at 5 minutes after birth. Current risk detection in pregnancy focusses primarily on medical risks. However, non-medical risk factors may be relevant too. Both non-medical and medical risk factors are incorporated in the Rotterdam Reproductive Risk Reduction (R4U) scorecard. We investigated the associations between R4U risk factors and preterm birth, SGA and a low Apgar score.

DESIGN

a prospective cohort study under routine practice conditions.

SETTING

six midwifery practices and two hospitals in Rotterdam, the Netherlands.

PARTICIPANTS

836 pregnant women.

INTERVENTIONS

the R4U scorecard was filled out at the booking visit.

MEASUREMENTS

after birth, the follow-up data on pregnancy outcomes were collected. Multivariate logistic regression was used to fit models for the prediction of any adverse outcome (preterm birth, SGA and/or a low Apgar score), stratified for ethnicity and socio-economic status (SES).

FINDINGS

factors predicting any adverse outcome for Western women were smoking during the first trimester and over-the-counter medication. For non-Western women risk factors were teenage pregnancy, advanced maternal age and an obstetric history of SGA. Risk factors for high SES women were low family income, no daily intake of vegetables and a history of preterm birth. For low SES women risk factors appeared to be low family income, non-Western ethnicity, smoking during the first trimester and a history of SGA.

KEY CONCLUSIONS

the presence of both medical and non-medical risk factors early in pregnancy predict the occurrence of adverse outcomes at birth. Furthermore the risk profiles for adverse outcomes differed according to SES and ethnicity.

IMPLICATIONS FOR PRACTICE

to optimise effective risk selection, both medical and non-medical risk factors should be taken into account in midwifery and obstetric care at the booking visit.

Stillbirth and congenital anomalies in migrants in Europe

The risk of giving birth to a stillborn child or a child with severe congenital anomaly is higher for women who have immigrated to Europe as compared to the majority population in the receiving country. The literature, however, reveals great differences between migrant groups, even within migrants from low-income countries, although there is no clear pattern regarding refugee or non-refugee status. This heterogeneity argues against a particular migration-related explanation. There are social disparities in stillbirth risk worldwide, and it has been suggested that the demonstrated ethnic disparity is a result of the socioeconomic disadvantage most migrants face. Consanguinity has been considered as another cause for the increased stillbirth risk and the high risk of congenital anomaly observed in many migrant groups. Utilization and quality of care during pregnancy and childbirth is the third major aspect. All three factors seem to contribute to stillbirth risk, and they should be considered in clinical practice and public health.

Socio-demographic inequalities across a range of health status indicators and health behaviours among pregnant women in prenatal primary care: a cross-sectional study

Background

Suboptimal maternal health conditions (such as obesity, underweight, depression and stress) and health behaviours (such as smoking, alcohol consumption and unhealthy nutrition) during pregnancy have been associated with negative pregnancy outcomes. Our first aim was to give an overview of the self-reported health status and health behaviours of pregnant women under midwife-led primary care in the Netherlands. Our second aim was to identify potential differences in these health status indicators and behaviours according to educational level (as a proxy for socio-economic status) and ethnicity (as a proxy for immigration status).

Methods

Our cross-sectional study (data obtained from the DELIVER multicentre prospective cohort study conducted from September 2009 to March 2011) was based on questionnaires about maternal health and prenatal care, which were completed by 6711 pregnant women. The relationships of education and ethnicity with 13 health status indicators and 10 health behaviours during pregnancy were examined using multilevel multiple logistic regression analyses, adjusted for age, parity, number of weeks pregnant and either education or ethnicity.

Results

Lower educated women were especially more likely to smoke (Odds Ratio (OR) 11.3; 95 % confidence interval (CI) 7.6– 16.8); have passive smoking exposure (OR 6.9; 95 % CI 4.4–11.0); have low health control beliefs (OR 10.4; 95 % CI 8.5–12.8); not attend antenatal classes (OR 4.5; 95 % CI 3.5–5.8) and not take folic acid supplementation (OR 3.4; 95 % CI 2.7–4.4). They were also somewhat more likely to skip breakfast daily, be obese, underweight and depressed or anxious. Non-western women were especially more likely not to take folic acid supplementation (OR 4.5; 95 % CI 3.5–5.7); have low health control beliefs (OR 4.1; 95 % CI 3.1–5.2) and not to attend antenatal classes (OR 3.3; 95 % CI 2.0–5.4). They were also somewhat more likely to have nausea, back pains and passive smoking exposure.

Conclusions

Substantial socio-demographic inequalities persist with respect to many health-related issues in medically low risk pregnancies in the Netherlands. Improved strategies are needed to address the specific needs of socio-demographic groups at higher risk and the structures underlying social inequalities in pregnant women.

Differences in perinatal morbidity and mortality on the neighbourhood level in Dutch municipalities: a population based cohort study

BACKGROUND

In a national perinatal health programme, we observed striking heterogeneity in the explanation of the most prominent risks across municipalities. Therefore we explored the separate contribution of several socio-demographic risks on perinatal health inequalities between municipalities and neighbourhoods. The study aims to identify perinatal health inequalities on the neighbourhood level across the selected municipalities, and to objectify the contribution of socio-demographic risk factors on pregnancy outcomes in each municipality by the application of the population attributable risk concept.

METHODS

Population based cohort study (2000-2008). Perinatal outcomes of 352,407 single pregnancies from 15 municipalities were analysed. Odds ratios and population attributable risks were calculated. Main outcomes were combined perinatal morbidity (small-for-gestational age, preterm birth, congenital anomalies, and low Apgar score), and perinatal mortality.

RESULTS

Perinatal health inequalities existed on both the municipal and the neighbourhood level. In municipalities, combined perinatal morbidity ranged from 17.3 to 23.6%, and perinatal mortality ranges from 10.1 to 15.4‰. Considerable differences in low socio-economic status between municipalities were apparent, with prevalences ranging from 14.4 to 82.5%. In seven municipalities, significant differences between neighbourhoods existed for perinatal morbidity (adjusted OR ranging from 1.33 to 2.38) and for perinatal mortality (adjusted OR ranging from 2.06 to 5.59). For some municipalities, socio-demographic risk factors were s a strong predictor for the observed inequalities, but in other municipalities these factors were very weak predictors. If all socio-demographic determinants were set to the most favourable value in a predictive model, combined perinatal morbidity would decrease with 15 to 39% in these municipalities.

CONCLUSIONS

Substantial differences in perinatal morbidity and mortality between municipalities and neighbourhoods exist. Different patterns of inequality suggest differences in etiology. Policy makers and healthcare professionals need to be informed about their local perinatal health profiles in order to introduce antenatal healthcare tailored to the individual and neighbourhood environment.

The association of ethnic minority density with late entry into antenatal care in the Netherlands

In the Netherlands, non-Western ethnic minority women make their first antenatal visit later than native Dutch women. Timely entry into antenatal care is important as it provides the opportunity for prenatal screening and the detection of risk factors for adverse pregnancy outcomes. In this study we explored whether women's timely entry is influenced by their neighborhood. Moreover, we assessed whether ethnic minority density (the proportion of ethnic minorities in a neighborhood) influences Western and non-Western ethnic minority women's chances of timely entry into care differently. We hypothesized that ethnic minority density has a protective effect against non-Western women's late entry into care. Data on time of entry into care and other individual-level characteristics were obtained from the Netherlands Perinatal Registry (2000-2008; 97% of all pregnancies). We derived neighborhood-level data from three other national databases. We included 1,137,741 pregnancies of women who started care under supervision of a community midwife in 3422 neighborhoods. Multi-level logistic regression was used to assess the associations of individual and neighborhood-level determinants with entry into antenatal care before and after 14 weeks of gestation. We found that neighborhood characteristics influence timely entry above and beyond individual characteristics. Ethnic minority density was associated with a higher risk of late entry into antenatal care. However, our analysis showed that for non-Western women, living in high ethnic minority density areas is less detrimental to their risk of late entry than for Western women. This means that a higher proportion of ethnic minority residents has a protective effect on non-Western women's chances of timely entry into care. Our results suggest that strategies to improve timely entry into care could seek to create change at the neighborhood level in order to target individuals likely of entering care too late.

Design and outline of the Healthy Pregnancy 4 All study

Background

Promotion of healthy pregnancies has gained high priority in the Netherlands because of the relatively unfavourable perinatal health outcomes. In response a nationwide study Healthy Pregnancy 4 All was initiated. This study combines public health and epidemiologic research to evaluate the effectiveness of two obstetric interventions before and during pregnancy: (1) programmatic preconception care (PCC) and (2) systematic antenatal risk assessment (including both medical and non-medical risk factors) followed by patient-tailored multidisciplinary care pathways. In this paper we present an overview of the study setting and outlines. We describe the selection of geographical areas and introduce the design and outline of the preconception care and the antenatal risk assessment studies.

Methods/design

A thorough analysis was performed to identify geographical areas in which adverse perinatal outcomes were high. These areas were regarded as eligible for either or both sub-studies as we hypothesised studies to have maximal effect there. This selection of municipalities was based on multiple criteria relevant to either the preconception care intervention or the antenatal risk assessment intervention, or to both. The preconception care intervention was designed as a prospective community-based cohort study. The antenatal risk assessment intervention was designed as a cluster randomised controlled trial – where municipalities are randomly allocated to intervention and control.

Discussion

Optimal linkage is sought between curative and preventive care, public health, government, and social welfare organisations. To our knowledge, this is the first study in which these elements are combined.

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

OBJECTIVES

This study aims to summarize evidence on the relation between neighborhood deprivation and the risks for preterm birth, small-for-gestational age, and stillbirth.

DESIGN

The design was a systematic review and meta-analysis.

MAIN OUTCOME MEASURES

The main outcome measures included studies that directly compared the risk of living in the most deprived neighborhood quintile with least deprived quintile for at least one perinatal outcome of interest (preterm delivery, small-for-gestational age and stillbirth).

METHODS

Study selection was based on a search of Medline, Embase and Web of Science for articles published up to April 2012, reference list screening, and email contact with authors. Data on study characteristics, outcome measures, and quality were extracted by two independent investigators. Random-effects meta-analysis was performed to estimate unadjusted and adjusted summary odds ratios with the associated 95% confidence intervals.

RESULTS

We identified 2863 articles, of which 24 were included in a systematic review. A meta-analysis (n = 7 studies, including 2 579 032 pregnancies) assessed the risk of adverse perinatal outcomes by comparing the most deprived neighborhood quintile with the least deprived quintile. Compared with the least deprived quintile, odds ratios for adverse perinatal outcomes in the most deprived neighborhood quintile were significantly increased for preterm delivery (odds ratio 1.23, 95% confidence interval 1.18-1.28), small-for-gestational age (odds ratio 1.31, 95% confidence interval 1.28-1.34), and stillbirth (odds ratio 1.33, 95% confidence interval 1.21-1.45).

CONCLUSIONS

Living in a deprived neighborhood is associated with preterm birth, small-for-gestational age and stillbirth.

The association of neighborhood social capital and ethnic (minority) density with pregnancy outcomes in the Netherlands

BACKGROUND

Perinatal morbidity rates are relatively high in the Netherlands, and significant inequalities in perinatal morbidity and mortality can be found across neighborhoods. In socioeconomically deprived areas, 'Western' women are particularly at risk for adverse birth outcomes. Almost all studies to date have explained the disparities in terms of individual determinants of birth outcomes. This study examines the influence of neighborhood contextual characteristics on birth weight (adjusted for gestational age) and preterm birth. We focused on the influence of neighborhood social capital--measured as informal socializing and social connections between neighbors--as well as ethnic (minority) density.

METHODS

Data on birth weight and prematurity were obtained from the Perinatal Registration Netherlands 2000-2008 dataset, containing 97% of all pregnancies. Neighborhood-level measurements were obtained from three different sources, comprising both survey and registration data. We included 3.422 neighborhoods and 1.527.565 pregnancies for the birth weight analysis and 1.549.285 pregnancies for the premature birth analysis. Linear and logistic multilevel regression was performed to assess the associations of individual and neighborhood level variables with birth weight and preterm birth.

RESULTS

We found modest but significant neighborhood effects on birth weight and preterm births. The effect of ethnic (minority) density was stronger than that of neighborhood social capital. Moreover, ethnic (minority) density was associated with higher birth weight for infants of non-Western ethnic minority women compared to Western women (15 grams; 95% CI: 12,4/17,5) as well as reduced risk for prematurity (OR 0.97; CI 0,95/0,99).

CONCLUSIONS

Our results indicate that neighborhood contexts are associated with birth weight and preterm birth in the Netherlands. Moreover, ethnic (minority) density seems to be a protective factor for non-Western ethnic minority women, but not for Western women. This helps explain the increased risk of Western women in deprived neighborhoods for adverse birth outcomes found in previous studies.

Where does distance matter? Distance to the closest maternity unit and risk of foetal and neonatal mortality in France

Background: The number of maternity units has declined in France, raising concerns about the possible impact of increasing travel distances on perinatal health outcomes. We investigated impact of distance to closest maternity unit on perinatal mortality. Methods: Data from the French National Vital Statistics Registry were used to construct foetal and neonatal mortality rates over 2001–08 by distance from mother’s municipality of residence and the closest municipality with a maternity unit. Data from French neonatal mortality certificates were used to compute neonatal death rates after out-of-hospital birth. Relative risks by distance were estimated, adjusting for individual and municipal-level characteristics. Results: Seven percent of births occurred to women residing at ≥30 km from a maternity unit and 1% at ≥45 km. Foetal and neonatal mortality rates were highest for women living at <5 km from a maternity unit. For foetal mortality, rates increased at ≥45 km compared with 5–45 km. In adjusted models, long distance to a maternity unit had no impact on overall mortality but women living closer to a maternity unit had a higher risk of neonatal mortality. Neonatal deaths associated with out-of-hospital birth were rare but more frequent at longer distances. At the municipal-level, higher percentages of unemployment and foreign-born residents were associated with increased mortality. Conclusion: Overall mortality was not associated with living far from a maternity unit. Mortality was elevated in municipalities with social risk factors and located closest to a maternity unit, reflecting the location of maternity units in deprived areas with risk factors for poor outcome.