Analysis of policy towards improvement of perinatal mortality in the Netherlands (2004–2011)

Embryonic size and growth and adverse birth outcomes: the Rotterdam Periconception Cohort

STUDY QUESTION

Is early embryonic size and growth in the first trimester of pregnancy associated with adverse birth outcomes?

SUMMARY ANSWER

Larger embryonic crown-rump length (CRL) and embryonic volume (EV) are associated with lower odds of adverse birth outcomes, especially small for gestational age (SGA).

WHAT IS ALREADY KNOWN

Preterm birth, SGA, and congenital anomalies are the most prevalent adverse birth outcomes with lifelong health consequences as well as high medical and societal costs. In the late first and second trimesters of pregnancy, fetuses at risk for adverse birth outcomes can be identified using 2-dimensional ultrasonography (US).

STUDY DESIGN, SIZE, DURATION

Between 2009 and 2018, singleton pregnancies were enrolled in this ongoing prospective Rotterdam Periconception Cohort.

PARTICIPANTS/MATERIALS, SETTING, METHODS

This study included 918 pregnant women from a tertiary hospital in the Netherlands. Pregnancy dating was based on either a regular menstrual cycle (for natural pregnancies) or a conception date (for ART pregnancies). CRL and EV were measured using Virtual Reality software on 3-dimensional (3D) ultrasound scans, repeatedly performed around 7, 9, and 11 weeks of gestation. The main outcome measure was adverse birth outcome, defined as the composite of SGA (birth weight <10th percentile), preterm birth (<37th week of gestation), congenital anomalies (Eurocat criteria), stillbirth (>16th week of pregnancy), or early neonatal mortality (≤7 days of life). Reference curves for CRL and EV were constructed. Cross-sectional (CRL/EV <20th percentile at 7, 9, and 11 weeks of gestation) and longitudinal (CRL/EV growth trajectories between 6th and 13th weeks) regression analyses were performed, with adjustments for the participants' educational level, smoking, parity, age, BMI, geographical background, mode of conception, and fetal sex.

MAIN RESULTS AND THE ROLE OF CHANCE

Of the 918 pregnant women included, the median age was 32.3 years, and 404 (44%) pregnancies had been conceived via ART. In 199 (22%) pregnancies, there was an adverse birth outcome. Regression analyses showed that at 7 weeks of gestation onwards, embryos with a CRL <20th percentile had an ∼2-fold increased odds of adverse birth outcome (adjusted odds ratio (aOR) 2.03, 95% CI 1.21-3.39, P = 0.007). Similar associations were found for EV <20th percentile but were not statistically significant. These findings were mainly driven by the strong association between embryonic size and SGA (e.g. 7-week CRL: aOR 2.18 (1.16-4.09), P = 0.02; 9-week EV: aOR 2.09 (1.10-3.97, P = 0.02). Longitudinal growth trajectories of CRL, but not of EV, were associated with adverse birth outcomes. Both CRL and EV growth trajectories were associated with SGA.

LIMITATIONS, REASONS FOR CAUTION

The tertiary hospital population and the availability of sophisticated 3D-ultrasound techniques limit the generalizability of this study to general populations and settings.

WIDER IMPLICATIONS OF THE FINDINGS

Already very early in the first trimester of pregnancy, embryos with increased risks of an adverse birth outcome can be identified by using 3D-US and Virtual Reality. This expands the window of opportunity to enable the development of future interventions to potentially improve pregnancy outcomes and offspring health during their life-course.

STUDY FUNDING/COMPETING INTEREST(S)

This work was funded by the Department of Obstetrics and Gynecology, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands. The authors declare no conflicts of interest.

TRIAL REGISTRATION NUMBER

NL4115.

Differences in Antenatal Care Policies in England, Finland, and the Netherlands: A Framing analysis

BACKGROUND AND PURPOSE

The World Health Organization (WHO) states that good quality antenatal care should strive for both mother and child achieving their best possible health. On a policy level, in Europe these goals are reached with varying approaches. This research offers a fresh look on the underlying assumptions embedded in the ANC policies in three European countries.

METHODS

A framing analysis was conducted to publicly available ANC policies on uncomplicated pregnancies in Finland, England, and the Netherlands. Analysis was guided by van Hulst and Yanowa and included the following phases: a) Sense-making, b) Selecting, naming, and categorizing and c) Storytelling.

MAIN FINDINGS

Findings of this study demonstrate how ANC is organized with distinct frames. The Finnish ANC policies emphasized equity in care and instead of focusing on women, the ANC focused on the family. In England the pregnant woman was central, and it is seen as her responsibility to understand the ANC protocols. The ANC in the Netherlands focused on the pregnant woman's pregnancy experience and freedom.

CONCLUSION

The three studied countries had individual priorities and values guiding ANC provision. Despite each country being in line with the WHO ANC recommendations, areas requiring improvement should not be overlooked.

A realist synthesis to develop an explanatory model of how policy instruments impact child and maternal health outcomes

BACKGROUND

Child and maternal health, a key marker of overall health system performance, is a policy priority area by the World Health Organization and the United Nations, including the Sustainable Development Goals. Previous realist work has linked child and maternal health outcomes to globalization, political tradition, and the welfare state. It is important to explore the role of other key policy-related factors. This paper presents a realist synthesis, categorising policy instruments according to the established NATO model, to develop an explanatory model of how policy instruments impact child and maternal health outcomes.

METHODS

A systematic literature search was conducted to identify studies assessing the relationships between policy instruments and child and maternal health outcomes. Data were analysed using a realist framework. The first stage of the realist analysis process was to generate micro-theoretical initial programme theories for use in the theory adjudication process. Proposed theories were then adjudicated iteratively to produce a set of final programme theories.

FINDINGS

From a total of 43,415 unique records, 632 records proceeded to full-text screening and 138 papers were included in the review. Evidence from 132 studies was available to address this research question. Studies were published from 1995 to 2021; 76% assessed a single country, and 81% analysed data at the ecological level. Eighty-eight initial candidate programme theories were generated. Following theory adjudication, five final programme theories were supported. According to the NATO model, these were related to treasure, organisation, authority-treasure, and treasure-organisation instrument types.

CONCLUSIONS

This paper presents a realist synthesis to develop an explanatory model of how policy instruments impact child and maternal health outcomes from a large, systematically identified international body of evidence. Five final programme theories were supported, showing how policy instruments play an important yet context-dependent role in influencing child and maternal health outcomes.

Impact of the EURO-PERISTAT Reports on obstetric management: a difference-in-regression-discontinuity analysis

BACKGROUND

Population health monitoring, such as perinatal mortality and morbidity rankings published by the European Perinatal Health (EURO-PERISTAT) reports may influence obstetric care providers' decision-making and professional behaviour. We investigated short-term changes in the obstetric management of singleton term deliveries in the Netherlands following publication of the EURO-PERISTAT reports in 2003, 2008 and 2013.

METHODS

We used a quasi-experimental difference-in-regression-discontinuity approach. National perinatal registry data (2001-15) was used to compare obstetric management at delivery in four time windows (1, 2, 3 and 5 months) surrounding publication of each EURO-PERISTAT report.

RESULTS

The 2003 EURO-PERISTAT report was associated with higher relative risks (RRs) for an assisted vaginal delivery across all time windows [RR (95% CI): 1 month: 1.23 (1.05-1.45), 2 months: 1.15 (1.02-1.30), 3 months: 1.21 (1.09-1.33) and 5 months: 1.21 (1.11-1.31)]. The 2008 report was associated with lower RRs for an assisted vaginal delivery at the 3- and 5-month time windows [0.86 (0.77-0.96) and 0.88 (0.81-0.96)]. Publication of the 2013 report was associated with higher RRs for a planned caesarean section across all time windows [1 month: 1.23 (1.00-1.52), 2 months: 1.26 (1.09-1.45), 3 months: 1.26 (1.12-1.42) and 5 months: 1.19(1.09-1.31)] and lower RRs for an assisted vaginal delivery at the 2-, 3- and 5-month time windows [0.85 (0.73-0.98), 0.83 (0.74-0.94) and 0.88 (0.80-0.97)].

CONCLUSIONS

This study showed that quasi-experimental study designs, such as the difference-in-regression-discontinuity approach, are useful to unravel the impact of population health monitoring on decision-making and professional behaviour of healthcare providers. A better understanding of the contribution of health monitoring to the behaviour of healthcare providers can help guide improvements within the (perinatal) healthcare chain.

Decrease in perinatal mortality after closure of obstetric services in a community hospital in Amsterdam, The Netherlands. A retrospective cohort study

OBJECTIVE

To assess differences in adverse maternal and neonatal outcomes before and after closure of a secondary obstetric care unit of a community hospital in an urban district.

STUDY DESIGN

Retrospective cohort study using aggregated data from National Perinatal Registry of the Netherlands (PERINED) in the very urban region of Amsterdam, consisting of data of five secondary and two tertiary hospitals. We assessed maternal and neonatal outcomes in singleton hospital births between 24⁺⁰ weeks of gestational age (GA) up to 42⁺⁶ weeks. Data of 78.613 births were stratified in two groups: before closure (years 2012-2015) and after closure (2016-2019).

RESULTS

Perinatal mortality decreased significantly from 0.84 % to 0.63 % (p = 0.0009). The adjusted odds ratio (aOR) of the closure on perinatal mortality was 0.73 (95 % CI 0.62-0.87). Both antepartum death (0.46 % vs 0.36 %, p = 0.02) and early neonatal death (0.38 % vs 0.28 %, p = 0.015) declined after closure of the hospital. The number of preterm births decreased significantly (8.7 % vs 8.1 %, p=<0.007) as well as number of neonates with congenital abnormalities (3.2 % vs2.2 %, p=<0.0001). APGAR < 7 after 5 min increased (2.3 % vs 2.5 %, p = 0.04). There was no significant difference in SGA or NICU admission. Postpartum hemorrhage increased significantly from 7.7 % to 8.2 % (p=<0.003). Perinatal mortality from 32 weeks onwards was not significantly different after closure 0.29 % to 0.27 %.

CONCLUSIONS

After closure of an obstetric unit in a community hospital in Amsterdam, there was a significant decrease in perinatal, intrapartum and early neonatal mortality in neonates born from 24⁺⁰ onwards. The mortality decrease coincides with a reduction of preterm deliveries. The increasing trend in asphyxia and postpartum hemorrhage is of concern.. Centralization of care and increasing birth volume per hospital may lead to improvement of quality of care. A broad integrated, multidisciplinary maternity healthcare system linked with the social domain can achieve health gains in maternity care for all women.

The effect of a locally tailored intervention on the uptake of preconception care in the Netherlands: a stepped-wedge cluster randomized trial (APROPOS-II study)

BACKGROUND

The preconception period provides a window of opportunity for interventions aiming to reduce unhealthy lifestyle behaviours and their negative effect on pregnancy outcomes. This study aimed to assess the effectiveness of a locally tailored preconception care (PCC) intervention in a hybrid-II effectiveness implementation design.

METHODS

A stepped-wedge cluster randomized controlled trial was performed in four Dutch municipalities. The intervention contained a social marketing strategy aiming to improve the uptake (prospective parents) and the provision (healthcare providers) of PCC. Prospective parents participated by administering a questionnaire in early pregnancy recalling their preconceptional behaviours. Experiences of healthcare providers were also evaluated through questionnaires. The composite primary outcome was adherence to at least three out of four preconceptional lifestyle recommendations (early initiation of folic acid supplements, healthy nutrition, no smoking or alcohol use). Secondary outcomes were preconceptional lifestyle behaviour change, (online) reach of the intervention and improved knowledge among healthcare providers.

RESULTS

A total of 850 women and 154 men participated in the control phase and 213 women and 39 men in the intervention phase. The composite primary outcome significantly improved among women participating in the municipality where the reach of the intervention was highest (Relative Risk (RR) 1.57 (95% Confidence Interval (CI) 1.11-2.22). Among women, vegetable intake had significantly improved in the intervention phase (RR 1.82 (95%CI 1.14-2.91)). The aimed online reach- and engagement rate of the intervention was achieved most of the time. Also, after the intervention, more healthcare providers were aware of PCC-risk factors (54.5% vs. 47.7%; p = 0.040) and more healthcare providers considered it easier to start a conversation about PCC (75.0% vs. 47.9%; p = 0.030).

CONCLUSION

The intervention showed some tentative positive effects on lifestyle behaviours among prospective parents. Primarily on vegetable intake and the knowledge and competence of healthcare providers. The results of this study contribute to the evidence regarding successfully implementing PCC-interventions to optimize the health of prospective parents and future generations.

TRIAL REGISTRATION

Dutch Trial Register: NL7784 (Registered 06/06/2019).

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.

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.

Persisting inequalities in birth outcomes related to neighbourhood deprivation

INTRODUCTION

Health inequalities can be observed in early life as unfavourable birth outcomes. Evidence indicates that neighbourhood socioeconomic circumstances influence health. However, studies looking into temporal trends in inequalities in birth outcomes including neighbourhood socioeconomic conditions are scarce. The aim of this work was to study how inequalities in three different key birth outcomes have changed over time across different strata of neighbourhood deprivation.

METHODS

Nationwide time trends ecological study with area-level deprivation in quintiles as exposure. The study population consisted of registered singleton births in the Netherlands 2003-2017 between 24 and 41 weeks of gestation. Outcomes used were perinatal mortality, premature birth and small for gestational age (SGA). Absolute rates for all birth outcomes were calculated per deprivation quintile. Time trends in birth outcomes were examined using logistic regression models. To investigate relative inequalities, rate ratios for all outcomes were calculated per deprivation quintile.

RESULTS

The prevalence of all unfavourable birth outcomes decreased over time: from 7.2 to 4.1 per 1000 births for perinatal mortality, from 61.8 to 55.6 for premature birth, and from 121.9 to 109.2 for SGA. Inequalities in all birth outcomes have decreased in absolute terms, and the decline was largest in the most deprived quintile. Time trend analyses confirmed the overall decreasing time trends for all outcomes, which were significantly steeper for the most deprived quintile. In relative terms however, inequalities remained fairly constant.

CONCLUSION

In absolute terms, inequalities in birth outcomes by neighbourhood deprivation in the Netherlands decreased between 2003 and 2017. However, relative inequalities remained persistent.

[Models for public health policy analysis reported in scientific publications]

OBJECTIVE

To summarize public health policy models reported in studies published between 2002-2017.

METHOD

Using MesH vocabulary, we systematically searched articles in English, Spanish and Portuguese in the PubMed, Scielo, Jstor, ProQuest and Google Scholar data-bases. The quality of the articles was assessed using the tool for understanding a qualitative study by CASPe.

RESULTS

A higher proportion of scientific studies were conducted in the African continent. The policies relating to health care were most frequently investigated. Walt and Gilson's model and Kingdon's multiple streams framework were more frequently reported.

CONCLUSIONS

The articles set out the public policy analysis model, but not the approach to guide it. A more robust theoretical body needs to be built to enable discussion about the approaches and models for the analysis of public policies. Its distinction is relevant, since it can order methodological proposals for the study of policies.

The effect of a preconception care outreach strategy: the Healthy Pregnancy 4 All study

Background

Preconception care has been acknowledged as an intervention to reduce perinatal mortality and morbidity. However, utilization of preconception care is low because of low awareness of availability and benefits of the service. An outreach strategy was employed to promote uptake of preconception care consultations. Its effect on the uptake of preconception care consultations was evaluated within the Healthy Pregnancy 4 All study.

Methods

We conducted a community-based intervention study. The outreach strategy for preconception care consultations included four approaches: (1) letters from municipal health services; (2) letters from general practitioners; (3) information leaflets by preventive child healthcare services and (4) encouragement by peer health educators. The target population was set as women aged 18 to 41 years in 14 Dutch municipalities with relatively high perinatal morbidity and mortality rates. We evaluated the effect of the outreach strategy by analyzing uptake of preconception care consultations between February 2013 and December 2014. Registration data of applications for preconception care as well as participant questionnaires were obtained for analysis.

Results

The outreach strategy led to 587 applications for preconception care consultations. The majority of applications (n = 424; 72%) were prompted by the invitation letters (132,129) from the municipalities and general practitioners. The effect of the municipal letter seemed to fade out after 3 months.

Conclusions

Outreach strategies amongst the general population promote uptake of preconception care consultations, although on a small scale and with a temporary effect.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-3882-y) contains supplementary material, which is available to authorized users.

Barriers in the Uptake and Delivery of Preconception Care: Exploring the Views of Care Providers

Objectives To examine health care professionals’ views of their role and responsibilities in providing preconception care and identify barriers that affect the delivery and uptake of preconception care. Methods Twenty health care professionals who provide preconception care on a regular basis were interviewed using semi-structured interviews. Results We interviewed twelve community midwives, three General Practitioners, three obstetricians, one cardiologist specialized in congenital heart diseases and one gastroenterologist.We identified four barriers affecting the uptake and delivery of preconception care (PCC): (1) lack of a comprehensive preconception care program; (2) limited awareness of most future parents about the benefits of preconception care, hesitance of GP’s about the necessity and effectiveness of PCC; (3) poor coordination and organization of preconception care; (4) conflicting views of health care professionals on pregnancy, reproductive autonomy of patients and professional responsibility. Conclusion We have identified four barriers in the uptake and delivery of preconception care. Our findings support the timely implementation of a comprehensive program of PCC (already advocated by the Health Council of the Netherlands) and increasing awareness and knowledge of PCC from care providers and future parents. We emphasize the need for further research on how organizational barriers lead to suboptimal PCC and how interdisciplinary collaboration and referral can lead to optimally tailored intervention approaches.

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.

Process evaluation of the implementation of scorecard-based antenatal risk assessment, care pathways and interdisciplinary consultation: the Healthy Pregnancy 4 All study

OBJECTIVE

To evaluate the implementation of a complex intervention in the antenatal healthcare field in 14 Dutch municipalities. The intervention consisted of the implementation of a systematic scorecard-based risk assessment in pregnancy, subsequent patient-tailored care pathways, and consultations of professionals from different medical and social disciplines.

METHODS

Saunders's seven-step method was used for the development of a programme implementation monitoring plan, with specific attention to the setting and context of the programme. Data were triangulated from multiple sources, and prespecified criteria were applied to examine the evidence for implementation.

RESULTS

Six out of 11 municipalities (54%) met the implementation criteria for the entire risk assessment programme, whereas three municipalities (27%) met the criteria if the three components of implementation were analysed separately.

CONCLUSIONS

A process evaluation of implementation of a complex intervention is possible. The results can be used to improve understanding of the associations between specific programme elements and programme outcomes on effectiveness of the intervention. Additionally, the results are important for formative purposes to assess how future implementation of antenatal risk assessment can be improved in comparable contexts.

Developing social marketed individual preconception care consultations: Which consumer preferences should it meet?

Aims

Preconception care (PCC) is care that aims to improve the health of offspring by addressing risk factors in the pre‐pregnancy period. Consultations are recognized as a method to promote perinatal health. However, prospective parents underutilize PCC services. Uptake can improve if delivery approaches satisfy consumer preferences. Aim of this study was to identify preferences of women (consumers) as a first step to social marketed individual PCC consultations.

Methods

In depth, semi‐structured interviews were performed to identify women's views regarding the four components of the social marketing model: product (individual PCC consultation), place (setting), promotion (how women are made aware of the product) and price (costs). Participants were recruited from general practices and a midwife's practice. Content analysis was performed by systematic coding with NVIVO software.

Results

The 39 participants reflected a multiethnic intermediately educated population. Product: Many participants had little knowledge of the need and the benefits of the product. Regarding the content of PCC, they wish to address fertility concerns and social aspects of parenthood. PCC was seen as an informing and coaching service with a predominant role for health‐care professionals. Place: the general practitioner and midwife setting was the most mentioned setting. Promotion: A professional led promotion approach was preferred. Price: Introduction of a fee for PCC consultations will make people reconsider their need for a consultation and could exclude vulnerable patients from utilization.

Conclusion

This study provides consumer orientated data to design a social marketed delivery approach for individual PCC consultations.