Inequalities in perinatal and maternal health

Extending Driver's Licenses to Undocumented Immigrants: Comparing Perinatal Outcomes Following This Policy Shift

Research shows that restrictive immigration policies and practices are associated with poor health, but far less is known about the relationship between inclusive immigration policies and health. Using data from the United States natality files, we estimate associations between state laws granting undocumented immigrants access to driver's licenses and perinatal outcomes among 4,047,067 singleton births to Mexican and Central American immigrant birthing people (2008-2021). Fitting multivariable log binomial and linear models, we find that the implementation of a license law is associated with improvements in low birthweight and mean birthweight. Replicating these analyses among U.S.-born non-Hispanic White birthing people, we find no association between the implementation of a license law and birthweight. These findings support the hypothesis that states' extension of legal rights to immigrants improves the health of the next generation.

Associations Between Early-Pregnancy Vitamin D Status and Postpartum Depressive and Anxiety Symptoms

OBJECTIVE

Maternal postpartum depressive and anxiety symptoms are risk factors for subsequent maternal and child mental health problems. Little is known about the potential role of antepartum vitamin D and C-reactive protein (CRP) in the etiology of maternal postpartum affective symptoms. We investigated associations between antepartum vitamin D status and postpartum depressive and anxiety symptoms and whether antepartum CRP mediated these associations.

METHODS

In 2483 participants of the Amsterdam Born Children and their Development prospective cohort, maternal serum vitamin D and CRP were measured at a median of 13 weeks' gestation. Vitamin D status was defined as deficient (≤29.9 nM), insufficient (30-49.9 nM), sufficient (50-79.9 nM), or normal (≥80 nM). Maternal depressive symptoms (Center for Epidemiologic Studies-Depression) and anxiety (State-Trait Anxiety Inventory) were assessed 3 months postpartum.

RESULTS

After adjustments for confounders, vitamin D deficiency was only associated with increased postpartum anxiety symptoms ( B = 0.17, 95% confidence interval [CI] = 0.03-0.30, p = .017) compared to normal vitamin D levels (≥80 nM). In women not taking vitamin D supplementation ( n = 2303), vitamin D deficiency was associated with increased postpartum depressive and anxiety symptoms ( B = 0.14, 95% CI = 0.03-0.28, p = .045; and B = 0.17, 95% CI = 0.03-0.32, p = .015). Antepartum CRP did not mediate these links.

CONCLUSIONS

We found some evidence that antepartum vitamin D deficiency was associated with increased postpartum affective symptoms, especially in women not taking vitamin D supplementation. Clinical trials should determine whether vitamin D supplementation can reduce the risk for postpartum affective disorders.

Identifying psychosocial vulnerabilities in pregnancy: A mixed-method systematic review of the knowledge base of antenatal conversational psychosocial assessment tools

BACKGROUND

Early identification of psychosocial vulnerability among expectant parents through psychosocial assessment is increasingly recommended within maternity care. For routine antenatal assessment, a strong recognition exists regarding conversational assessment tools. However, the knowledge base of conversational tools is limited, inhibiting their clinical use.

OBJECTIVE

Synthesising existing knowledge pertaining to antenatal conversational psychosocial assessment tools, including identifying characteristics, acceptability, performance, effectiveness and unintended consequences.

DESIGN

Mixed-method systematic review based on searches in CINAHL, PubMed, Embase, PsycINFO, Cochrane and Scopus. 20 out of 5394 studies were included and synthesised with a convergent integrated approach using a thematic analysis strategy.

FINDINGS

We identified seven antenatal psychosocial assessment tools that partially or completely utilised a conversational approach. Women's acceptability was high, and tools were generally found to support person-centred communication and the parent-health care professional relationship. Evidence regarding effectiveness and performance of conversational tools was limited. Unintended consequences were found, including some women having negative experiences related to assessment of intimate partner violence, lack of preparation and lack of relevance. High acceptability was reported by health care professionals who considered the tools as valuable and enhancing of identification of vulnerability. Unintended consequences, including lack of time and competencies as well as discomfort when assessment is very sensitive, were reported.

CONCLUSIONS

Evidence regarding conversational tools' effectiveness and performance is limited. More is known about the acceptability of conversational tools, which is generally highly acceptable among women and health care professionals. Some unintended consequences of the use of included conversational tools were identified.

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.

Living in a low socioeconomic status neighbourhood is associated with lower cumulative ongoing pregnancy rate after IVF treatment

RESEARCH QUESTION

Does an association exist between neighbourhood socioeconomic status (SES) and the cumulative rate of ongoing pregnancies after 2.5 years of IVF treatment?

DESIGN

A retrospective observational study involving 2669 couples who underwent IVF or IVF and intracytoplasmic sperm injection treatment between 2006 and 2020. Neighbourhood SES for each couple was determined based on their residential postal code. Subsequently, SES was categorized into low (p80). Multivariable binary logistic regression analyses were conducted, with the cumulative ongoing pregnancy within 2.5 years as the outcome variable. The SES category (reference category: high), female age (reference category: 32-36 years), body mass index (reference category: 23-25 kg/m2), smoking status (yes/no), number of oocytes after the first ovarian stimulation, embryos usable for transfer or cryopreservation after the first cycle, duration of subfertility before treatment and insemination type were used as covariates.

RESULTS

A variation in ongoing pregnancy rates was observed among SES groups after the first fresh embryo transfer. No difference was found in the median number of IVF treatment cycles carried out. The cumulative ongoing pregnancy rates differed significantly between SES groups (low: 44%; medium: 51%; high: 56%; P < 0.001). Low neighbourhood SES was associated with significantly lower odds for achieving an ongoing pregnancy within 2.5 years (OR 0.66, 95% CI 0.52 to 0.84, P < 0.001).

CONCLUSION

Low neighbourhood SES compared with high neighbourhood SES is associated with reducing odds of achieving an ongoing pregnancy within 2.5 years of IVF treatment.

The Equity Impact of Universal Home Visits to Pregnant Women and Their Spouses in Bauchi State, Nigeria: Secondary Analysis From a Cluster Randomised Controlled Trial

BACKGROUND

Socio-economically disadvantaged women have poor maternal health outcomes. Maternal health interventions often fail to reach those who need them most and may exacerbate inequalities. In Bauchi State, Nigeria, a recent cluster randomised controlled trial (CRCT) showed an impressive impact on maternal health outcomes of universal home visits to pregnant women and their spouses. The home visitors shared evidence about local risk factors actionable by households themselves and the program included specific efforts to ensure all households in the intervention areas received visits.

PURPOSE

To examine equity of the intervention implementation and its pro-equity impact.

RESEARCH DESIGN AND STUDY SAMPLE

The overall study was a CRCT in a stepped wedge design, examining outcomes among 15,912 pregnant women.

ANALYSIS

We examined coverage of the home visits (three or more visits) and their impact on maternal health outcomes according to equity factors at community, household, and individual levels.

RESULTS

Disadvantaged pregnant women (living in rural communities, from the poorest households, and without education) were as likely as those less disadvantaged to receive three or more visits. Improvements in maternal knowledge of danger signs and spousal communication, and reductions in heavy work, pregnancy complications, and post-natal sepsis were significantly greater among disadvantaged women according to the same equity factors.

CONCLUSIONS

The universal home visits had equitable coverage, reaching all pregnant women, including those who do not access facility-based services, and had an important pro-equity impact on maternal health.

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.

Effects of psychosocial work factors on preterm birth: systematic review and meta-analysis

OBJECTIVES

Preterm birth is one of the global public health issues that result in high rates of infant mortality and long-term health complications. We sought to explore the association between psychosocial work factors and preterm birth.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

This systematic review and meta-analysis searched relevant literature from electronic databases to explore the association between psychosocial work factors and preterm birth. The methodological quality of the included studies was evaluated through the Joanna Briggs Institute's critical appraisal method. We performed a meta-analysis using a random-effects model to combine odds ratios (ORs) from studies with similar definitions of exposure and outcome. The quality of the evidence was evaluated using the GRADE (Grade of recommendation, Assessment, development, and Evaluation) method to assess.

RESULTS

Ten studies were included, with a total of 92,815 participants. Moderate evidence indicated a positive association between high psychosocial job strain and preterm birth. The result from the meta-analysis supported the statistical significance of this relationship (OR 1.32 [95% CI (1.22-1.44)]).

CONCLUSIONS

Pregnant women who experience high levels of psychosocial job strain are more likely to give birth prematurely. In order to decrease this risk, employers should prioritise creating supportive work environments, government bodies should enact protective policies and regulations, and clinicians should give advice to pregnant working women. Pregnant women should be aware of the risk of preterm birth from psychosocial work factors.

Perinatal health in Spain during and after the Great Recession: Educational selection into fertility as a protective factor in high unemployment contexts

Higher maternal resources have long been associated with superior birth outcomes. This study analyzes the potentially protective role of maternal educational selection into fertility in adverse macroeconomic contexts. We focus on the case of Spain, a country reaching record-high unemployment levels during the Great Recession starting in 2008. First, we examine whether selection into fertility of more educated mothers took place as province-level unemployment rates rose. Secondly, we assess whether maternal education mitigated the impact of higher unemployment levels on different birth outcomes. The analysis combines register data on the universe of live births with aggregate data on province-level unemployment. We cover the period 2007-2019 to ensure sufficient variability of unemployment rates and perform linear regression and linear probability models with fixed effects to hold constant unobserved heterogeneity across provinces. Findings indicate selection into fertility of mothers with university-level education in times of high unemployment. In addition, while unemployment rates did show an adverse impact on certain birth outcomes -birthweight, the occurrence of low and very low birthweight, and the risk of stillbirth - maternal education mitigated the observed relations. It was itself, moreover, consistently and independently associated with better perinatal health. We thus conclude that fertility selectivity by maternal education cushioned the impact of the adverse economic context derived from the Great Recession through two separate pathways.

Community midwives' perspectives on perinatal care for asylum seekers and refugees in the Netherlands: A survey study

BACKGROUND

The rise of forced migration worldwide compels birth care systems and professionals to respond to the needs of women giving birth in these vulnerable situations. However, little is known about the perspective of midwifery professionals on providing perinatal care for forcibly displaced women. This study aimed to identify challenges and target areas for improvement of community midwifery care for asylum seekers (AS) and refugees with a residence permit (RRP) in the Netherlands.

METHODS

For this cross-sectional study, data were collected through a survey aimed at community care midwives who currently work or who have worked with AS and RRP. We evaluated challenges identified through an inductive thematic analysis of respondents' responses to open-ended questions. Quantitative data from close-ended questions were analyzed descriptively and included aspects related to the quality and organization of perinatal care for these groups.

RESULTS

Respondents generally considered care for AS and RRP to be of lower quality, or at best, equal quality compared to care for the Dutch population, while the workload for midwives caring for these groups was considered higher. The challenges identified were categorized into five main themes, including: 1) interdisciplinary collaboration; 2) communication with clients; 3) continuity of care; 4) psychosocial care; and 5) vulnerabilities among AS and RRP.

CONCLUSIONS

Findings suggest that there is considerable opportunity for improvement in perinatal care for AS and RRP, while also providing direction for future research and interventions. Several concerns raised, especially the availability of professional interpreters and relocations of AS during pregnancy, require urgent consideration at legislative, policy, and practice levels.

The neonatal perspective of paid family medical leave (PFML)

Paid family medical leave (PFML) offers infants, parents, and society at large numerous health and economic benefits. It has been shown to improve neonatal and maternal outcomes, breastfeeding rates, familial relationships, and decrease gender inequalities in the workplace. Though the economic feasibility of PFML has been well established in many countries, the USA lacks a cohesive and comprehensive federal PFML policy. Neonatal healthcare providers play a critical role in impacting neonatal health and should actively advocate for the development and promotion of a federal PFML policy, particularly one that is inclusive of both mothers and fathers and is at least 12 weeks in duration.

‘It's about developing a trustful relationship’: A Realist Evaluation of midwives’ relational competencies and confidence in a Danish antenatal psychosocial screening programme

OBJECTIVE

to explore how contextual conditions influence midwives' relational competencies, ability and confidence to undertake psychosocial assessment of pregnant women and their partners during the first antenatal consultation that identifies expectant parents in vulnerable positions.

DESIGN

a realist evaluation carried out through three phases: 1) development 2) testing and 3) refinement of programme theories. Data was generated through realist interviews and observations.

SETTING

nine community-based and hospital-based midwife clinics in the North Region of Denmark.

INTERVENTION

a dialogue-based psychosocial assessment programme in the the North Region of Denmark was evaluated.

PARTICIPANTS AND DATA

15 midwives were interviewed and 16 observations of midwives undertaking psychosocial assessment during the first antenatal consultation were conducted.

FINDINGS

contextual conditions at multiple levels which supported midwives' relational competencies, autonomy and the power of peer reflection-and thus facilitation of a woman-centred approach and trust-were identified, i.e., being experienced, having interest, organisational prioritisation of peer reflection and flexibility. Where midwives lacked experience, competency development regarding psychosocial assessment, opportunities for peer reflection and autonomy to individualise care for expectant parents in vulnerable positions, the approach to assessment tended to become institution-centred which caused a distant dialogue and instrumental assessment which potentially harmed the midwife-woman/couple relationship.

CONCLUSION

midwives' ability and confidence to undertake psychosocial assessment were affected by whether individual and organisational contextual conditions empowered them to assess and care for expectant parents within a philosophy of woman-centred care. Accordingly, development of trustful midwife-woman/couple relationships - which is essential for disclosure - was achievable. These conditions become fundamental for securing quality of antenatal care for expectant parents in vulnerable positions.

The Experiences of Midwives in Caring for Vulnerable Pregnant Women in The Netherlands: A Qualitative Cross-Sectional Study

Vulnerable pregnant women have an increased risk for preterm birth and perinatal mortality. This study identifies the perspectives, perceived barriers, and perceived facilitators of midwives toward current care for vulnerable pregnant women in the Netherlands. Knowing those perspectives, barriers, and facilitators could help increase quality of care, thereby reducing the risks of preterm birth and perinatal mortality. Midwives working in primary care practices throughout the Netherlands were interviewed. Semi-structured interviews were conducted remotely through a video conference program, audio recorded, transcribed verbatim, and coded based on the theoretical domains framework and concepts derived from the interviews, using NVivo-12. All midwives provided psychosocial care for vulnerable pregnant women, expected positive consequences for those women resulting from that care, considered it their task to identify and refer vulnerable women, and intended to improve the situation for mother and child. The main barriers perceived by midwives were too many organizations being involved, inadequate communication between care providers, lack of time to care for vulnerable women, insufficient financing to provide adequate care, and uncooperative clients. The main facilitators were having care coordinators, treatment guidelines, vulnerability detection tools, their own knowledge about local psychosocial organizations, good communication skills, cooperative clients, consultation with colleagues, and good communication between care providers. The findings suggest that midwives are highly motivated to care for vulnerable women and perceive a multitude of facilitators. However, they also perceive various barriers for providing optimal care. A national guideline on how to care for vulnerable women, local overviews of involved organizations, and proactive midwives who ensure connections between the psychosocial and medical domain could help to overcome these barriers, and therefore, maximize effectiveness of the care for vulnerable pregnant women.

Significant regional inequalities in the prevalence of intellectual disability and trends from 1990 to 2019: a systematic analysis of GBD 2019

AIMS

Policymakers and researchers have little evidence on prevalence rates of intellectual disability (ID) or their changes over time to tailor healthcare interventions. Prevalence rates and trends of ID are especially lacking in regions with lower socio-demographic development. Additionally, the assessment of inequalities in the prevalence of ID across regions with varying socio-demographic development is understudied. This study assessed variations in prevalence rates of ID from 1990 to 2019 and the related inequalities between low and high socio-demographic index (SDI) regions.

METHODS

This study used global data from 1990 to 2019 for individuals with ID from the 2019 Global Burden of Diseases study. Data analyses were performed from September 2021 to January 2022. Prevalence for individuals with ID was extracted by sex, age groups and SDI regions. Annual percentage change (APC) was estimated for each demographic group within SDI regions to assess their prevalence trends over 30 years. Relative and absolute inequalities were calculated between low and high SDI regions for the various age groups.

RESULTS

In 2019, there were 107.62 million (1.74%) individuals with ID, with an APC of -0.80 (-0.88 to -0.72). There was a slightly higher prevalence among males (1.42%) than females (1.37%). The highest prevalence rates were found in the low-middle SDI regions (2.42%) and the lowest prevalence rates were in the high SDI regions (0.33%). There was a large reduction in the prevalence rate between the youngest age group v. the oldest age group in all the SDI regions and at all time points. The relative inequalities between low and high SDI regions increased over three decades.

CONCLUSIONS

While an overall decrease in global prevalence rate for ID was found, relative inequalities continue to increase with lower SDI regions needing more comprehensive support services. The demographic trends indicate a significantly higher mortality rate among those with ID v. the rest of the population. Our study highlights the necessity for policies and interventions targeting lower SDI regions to mobilise resources that better support individuals with ID and achieve sustainable development goals proposed by the United Nations.

Assessing and addressing vulnerability in pregnancy: General practitioners perceived barriers and facilitators - a qualitative interview study

Background

Vulnerability due to low psychosocial resources increases among women in the fertile age. Undetected vulnerability in pregnancy is a major contributor to inequality in maternal and perinatal health and constitutes a risk of maternal depression, adverse birth outcomes,—i.e. preterm birth, low birth weight, and adverse outcomes in childhood such as attachment disorders. General practitioners (GPs) have a broad understanding of indicators of vulnerability in pregnancy. However, less than 25% of pregnant women with severe vulnerability are identified in Danish general practice. The aim was to explore GPs’ perceived barriers and facilitators for assessing and addressing vulnerability among pregnant women.

Methods

A qualitative study with semi-structured focus group interviews with twenty GPs from urban and rural areas throughout the Region of Southern Denmark. A mixed inductive and deductive analytic strategy was applied, structured according to the Theoretical Domains Framework (TDF).

Results

Five themes emerged covering twelve TDF domains: (I)knowledge and attention, (II)professional confidence, (III)incentives, (IV)working conditions and (V)behavioral regulations. Prominent barriers to assessment were lack of continuity of care and trust in the doctor-patient relation. Other barriers were inattention to indicators of vulnerability, time limits, unavailable information on patients’ social support needs from cross-sectoral collaborators, and lack of reimbursement for the use of extra time. Fear of damaging the doctor-patient relation, ethical dilemmas and time limits were barriers to addressing vulnerability. Facilitators were increased attention on vulnerability, professionalism and a strong and trustful doctor-patient relation. Behavioral regulations ensuring continuity of care and extra time for history taking enabled assessing and addressing vulnerability, especially when a strong doctor-patient relation was absent.

Conclusions

The TDF disclosed several barriers, especially in the absence of a strong doctor-patient relation. A behavior change intervention of restructuring the organization of antenatal care in general practice might reduce the GPs’ barriers to assessing and addressing vulnerability in pregnancy. The findings may serve as a guide for commissioners and policymakers of antenatal care on the GPs’ support needs when providing antenatal care to vulnerable pregnant women.

Facilitators and barriers to seeking and engaging with antenatal care in high-income countries: A meta-synthesis of qualitative research

Inadequate attendance to antenatal care has been associated with negative maternal and fetal outcomes, including stillbirth. This study aimed to identify facilitators and barriers to antenatal care attendance. A systematic search was conducted in March 2019 and updated in January 2021. Qualitative studies involving pregnant or post-partum women up to 12 months from high-income countries that provided data about facilitators and barriers to antenatal care attendance were sought. Meta-ethnography was used to inform this meta-synthesis. Fifteen studies were included in the analysis. Findings indicate that inadequate antenatal care attendance is influenced at different levels. Aspects like sociodemographic factors, difficulties navigating the health system, administrative delays, lack of flexibility and tailored care, constant change of carer and communication issues also act as barriers. These issues affect women's access to knowledge and the formation of women's beliefs and feelings towards seeking care. On the contrary, having a positive attitude towards the pregnancy, encountering empathetic healthcare professionals and availing of social support acted as facilitators. The reasons why women seek or delay attending antenatal care are multifactorial and can be explained using the Social Determinants of Health Framework. Any response needs to be taken across all levels of influence and not just focused on the individual. A better understanding of the barriers and facilitators to antenatal care might contribute to informing intervention or policy development addressing this issue.

Global variations in the burden of SARS-CoV-2 infection and its outcomes in pregnant women by geographical region and country’s income status: a meta-analysis

Introduction

The prevalence of COVID-19 and its impact varied between countries and regions. Pregnant women are at high risk of COVID-19 complications compared with non-pregnant women. The magnitude of variations, if any, in SARS-CoV-2 infection rates and its health outcomes among pregnant women by geographical regions and country’s income level is not known.

Methods

We performed a random-effects meta-analysis as part of the ongoing PregCOV-19 living systematic review (December 2019 to April 2021). We included cohort studies on pregnant women with COVID-19 reporting maternal (mortality, intensive care admission and preterm birth) and offspring (mortality, stillbirth, neonatal intensive care admission) outcomes and grouped them by World Bank geographical region and income level. We reported results as proportions with 95% confidence intervals (CI).

Results

We included 311 studies (2 003 724 pregnant women, 57 countries). The rates of SARS-CoV-2 infection in pregnant women varied significantly by region (p<0.001) and income level (p<0.001), with the highest rates observed in Latin America and the Caribbean (19%, 95% CI 12% to 27%; 13 studies, 38 748 women) and lower-middle-income countries (13%, 95% CI 6% to 23%; 25 studies, 100 080 women). We found significant differences in maternal and offspring outcomes by region and income level. Lower-middle-income countries reported significantly higher rates of maternal mortality (0.68%, 95% CI 0.24% to 1.27%; 3 studies, 31 136 women), intensive care admission (4.53%, 95% CI 2.57% to 6.91%; 54 studies, 23 420 women) and stillbirths (1.09%, 95% CI 0.48% to 1.88%; 41 studies, 4724 women) than high-income countries. COVID-19 complications disproportionately affected South Asia, which had the highest maternal mortality rate (0.88%, 95% CI 0.16% to 1.95%; 17 studies, 2023 women); Latin America and the Caribbean had the highest stillbirth rates (1.97%, 95% CI 0.9% to 3.33%; 10 studies, 1750 women).

Conclusion

The rates of SARS-CoV-2 infection in pregnant women vary globally, and its health outcomes mirror the COVID-19 burden and global maternal and offspring inequalities.

PROSPERO registration number

CRD42020178076.

Perinatal Health Inequalities in the Industrial Region of Estonia: A Birth Registry-Based Study

Despite the increasing number of studies on industrially contaminated sites (ICS) and their health effects, there are very few studies on perinatal health outcomes in ICSs. In the present study, we examined the perinatal health inequalities by comparing adverse birth outcomes (ABOs) in the oil shale industry region of Ida-Viru County in Estonia with national-level figures and investigated the effects of maternal environmental and sociodemographic factors. Based on the 208,313 birth records from 2004-2018, Ida-Viru ICS has a birth weight 124.5 g lower than the average of 3544 g in Estonia. A higher prevalence of preterm birth (4.3%) and low birth weight (4.8%) in Ida-Viru ICS is found compared to 3.3% on both indicators at the national level. Multiple logistic regression analysis shows the statistically significant association of ABOs with fine particle (PM_2.5) air pollution, mother's ethnicity, and education throughout Estonia. However, in Ida-Viru ICS, the ABOs odds are remarkably higher in these characteristics except for the mother's ethnicity. Furthermore, the ABOs are associated with the residential proximity to ICS. Thus, the Ida-Viru ICS has unequally higher odds of adverse perinatal health across the environmental and sociodemographic factors. In addition to reducing the air pollutants, policy actions on social disparities are vital to address the country's unjustly higher perinatal health inequalities, especially in the Ida-Viru ICS.

Neonatal Outcomes of Mothers With a Disability

OBJECTIVES

To assess the risk of neonatal complications among women with a disability.

METHODS

This population-based cohort study comprised all hospital singleton livebirths in Ontario, Canada from 2003 to 2018. Newborns of women with a physical (N = 144 187), sensory (N = 44 988), intellectual or developmental (N = 2207), or ≥2 disabilities (N = 8823) were each compared with 1 593 354 newborns of women without a disability. Outcomes were preterm birth <37 and <34 weeks, small for gestational age birth weight (SGA), large for gestational age birth weight, neonatal morbidity, and mortality, neonatal abstinence syndrome (NAS), and NICU admission. Relative risks were adjusted for social, health, and health care characteristics.

RESULTS

Risks for neonatal complications were elevated among newborns of women with disabilities compared with those without disabilities. Adjusted relative risks were especially high for newborns of women with an intellectual or developmental disability, including preterm birth <37 weeks (1.37, 95% confidence interval 1.19-1.58), SGA (1.37, 1.24-1.59), neonatal morbidity (1.42, 1.27-1.60), NAS (1.53, 1.12-2.08), and NICU admission (1.53, 1.40-1.67). The same was seen for newborns of women with ≥2 disabilities, including preterm birth <37 weeks (1.48, 1.39-1.59), SGA (1.13, 1.07-1.20), neonatal morbidity (1.28, 1.20-1.36), NAS (1.87, 1.57-2.23), and NICU admission (1.35, 1.29-1.42).

CONCLUSIONS

There is a mild to moderate elevated risk for complications among newborns of women with disabilities. These women may need adapted and enhanced preconception and prenatal care, and their newborns may require extra support after birth.

Interventions for vulnerable pregnant women: Factors influencing culturally appropriate implementation according to health professionals: A qualitative study

Background

Proper implementation of interventions by health professionals has a critical effect on their effectiveness and the quality of care provided, especially in the case of vulnerable pregnant women. It is important, therefore, to assess the implementation of interventions in care settings to serve as input to improve implementation.

Objective

The aim of this study is to identify factors that influence the implementation of interventions for vulnerable pregnant women in the North of the Netherlands from the perspective of health professionals. In this region, an intergenerational transfer of poverty is apparent, leading to many health problems and the transfer of unhealthy lifestyles and the associated diseases to subsequent generations.

Methods

We used a qualitative research design. Semi-structured interviews with 39 health professionals were conducted between February 2019 and April 2020. To analyse the findings, the MIDI (Measurement Instrument for Determinants of Innovations) was used, an instrument designed to identify what determinants influence the actual use of a new or existing innovation.

Results

We found two themes that influence the implementation of interventions: 1. The attitude of health professionals towards vulnerable pregnant women: stereotyped remarks and words expressing the homogenization of vulnerable pregnant women. 2. A theme related to the MIDI determinants, under which we added six determinants.

Conclusion

Our research showed that many factors influence the implementation of interventions for vulnerable pregnant women, making the optimal implementation of interventions very complex. We highlight the need to challenge stereotypical views and attitudes towards specific groups in order to provide relation-centred care, which is extremely important to provide culturally appropriate care. Health professionals need to reflect on their own significant influence on access to and the use of care by vulnerable groups. They hold the key to creating partnerships with women to obtain the best health for mothers and their babies.

Experiences and needs of women in vulnerable situations receiving additional interventions in maternity care: a qualitative study

BACKGROUND

Tailoring an intervention to the needs and wishes of pregnant women in vulnerable situations (e.g., socioeconomic disadvantages) can reduce the risk of adverse outcomes and empower these women. A relatively high percentage of pregnant women in the North of the Netherlands are considered vulnerable to adverse pregnancy outcomes because of their low socioeconomic status and the intergenerational transmission of poverty. In order to improve perinatal and maternal health, next to standard prenatal care, various interventions for pregnant women in vulnerable situations have been developed. We do not know to what extent these additional interventions suit the needs of (pregnant) women. Therefore, the aim of this study is to gain insight into the experiences and needs of women in vulnerable situations who receive additional maternity care interventions in the Northern Netherlands.

METHODS

Qualitative research was performed. We used a phenomenological framework, which is geared towards understanding people's experiences in the context of their everyday lives. In-depth semi-structured interviews were conducted with 17 pregnant women in vulnerable situations living in the Northern Netherlands. A thematic analysis was carried out.

RESULTS

We found three themes that reflect the experiences and needs of pregnant women in vulnerable situations in relation to the intervention they receive. These themes relate to the care provided by health professionals, to the impact of being offered an intervention, and to practical issues related to receiving an additional intervention. We found that the needs of pregnant women in vulnerable situations who received an additional maternity care intervention varied. This variation in needs was mainly related to practical issues. Women also expressed common needs, namely the desire to have control over their situation, the wish to receive tailor-made information about the intervention, and the wish for the intervention to be specifically tailored to their circumstances.

CONCLUSIONS

Living in vulnerable situations and being offered additional care evoked diverse reactions and emotions from pregnant women. We recommend that health professionals ensure open and clear communication with women, that they ensure continuity of care and relationship-centered care, and that they become aware of the process of stigmatization of women in vulnerable situations.

Social determinants of vulnerability in the population of reproductive age: a systematic review

Background

The health of an (unborn) child is largely determined by the health and social determinants of its parents. The extent to which social determinants of parents or prospective parents affect their own health depends partly on their coping or resilience abilities. Inadequate abilities allow negative effects of unfavourable social determinants to prevail, rendering them vulnerable to adverse health outcomes. Addressing these determinants in the reproductive-aged population is therefore a key approach in improving the health of the future generation. This systematic review aims to synthesise evidence on social determinants of vulnerability, i.e., inadequate coping or low resilience, in the general population of reproductive age.

Methods

The databases EMBASE, Medline, PsycINFO, CINAHL, Google Scholar, Web of Science, and Cochrane Library, were systematically searched from database inception to December 2th 2021.

Observational studies examining social determinants and demographics in relation to vulnerability among the general population of reproductive age (men and women aged 18-40 years), conducted in a high-income country in Europe or North America, Australia or New Zealand were eligible for inclusion. Relevant data was extracted from each included article and findings were presented in a narrative and tabulated manner.

Results

We identified 40,028 unique articles, of which 78 were full text reviewed. Twenty-five studies were included, of which 21 had a cross-sectional study design (84%). Coping was the most frequently assessed outcome measure (n = 17, 68%). Thirty social determinants were identified. Overall, a younger age, lower socioeconomic attainment, lack of connection with the social environment, and adverse life events were associated with inadequate coping or low resilience.

Conclusions

This review shows that certain social determinants are associated with vulnerability in reproductive-aged individuals. Knowing which factors make people more or less vulnerable carries health-related implications. More high-quality research is needed to obtain substantial evidence on the strength of the effect of these social conditions in this stage of life.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13651-6.

A Community Prenatal Intervention in Social Nutrition: Evaluating the Impact on Pregnancy and Birthweight Outcomes

This study aims to assess the associations between structural features of the Montreal Diet Dispensary’s social nutrition intervention and pregnancy (i.e., anemia, gestational diabetes mellitus (GDM), gestational weight gain (GWG), hypertension) and birthweight outcomes (i.e., small- or large-for-gestational-age) among pregnant women, most of them recent immigrants. The study consists of a secondary analysis of the digital client database of the Montreal Diet Dispensary (n = 2925). Logistic regressions were used to estimate the odds of pregnancy and birthweight outcomes, depending on structural features of the intervention. Pregnant women who attended a welcoming group session presented lower odds of GDM and anemia compared to those who did not attend. A longer duration of intervention was also associated with lower odds of GDM and anemia. Each additional appointment with a dietitian was associated with higher odds of excessive GWG and lower odds of insufficient GWG only among women with a pre-pregnancy BMI lower than 25 kg/m². This study emphasizes the importance of providing nutritional services early in pregnancy to reduce the risk of GDM and anemia. It also stresses the importance of using appropriate nutritional guidelines to avoid increasing the risk of excessive GWG.

The WOMBS Framework: A review and new theoretical model for investigating pregnancy-related weight stigma and its intergenerational implications

As the growing weight stigma literature has developed, one critically relevant and vulnerable population has received little consideration-pregnant and postpartum women. Because weight fluctuations are inherent to this life phase, and rates of prepregnancy overweight and obesity are already high, this gap is problematic. More recently, however, there has been a rising interest in pregnancy-related weight stigma and its consequences. This paper therefore sought to (a) review the emerging research on pregnancy-related weight stigma phenomenology and (b) integrate this existing evidence to present a novel theoretical framework for studying pregnancy-related weight stigma. The Weight gain, Obesity, Maternal-child Biobehavioral pathways, and Stigma (WOMBS) Framework proposes psychophysiological mechanisms linking pregnancy-related weight stigmatization to increased risk of weight gain and, in turn, downstream childhood obesity risk. This WOMBS Framework highlights pregnant and postpartum women as a theoretically unique at-risk population for whom this social stigma engages maternal physiology and transfers obesity risk to the child via social and physiological mechanisms. The WOMBS Framework provides a novel and useful tool to guide the emerging pregnancy-related weight stigma research and, ultimately, support stigma-reduction efforts in this critical context.

Association between neighbourhood deprivation, fetal growth, small-for-gestational age and preterm birth: a population-based prospective cohort study

OBJECTIVE

To study the associations between neighbourhood deprivation and fetal growth, including growth in the first trimester, and adverse pregnancy outcomes.

DESIGN

Prospective cohort study.

SETTING

The Netherlands, Rotterdam.

PARTICIPANTS

8617 live singleton births from the Generation R cohort study.

EXPOSITION

Living in a deprived neighbourhood.

MAIN OUTCOME MEASURES

Fetal growth trajectories of head circumference, weight and length.

SECONDARY OUTCOMES MEASURES

Small-for-gestational age (SGA) and preterm birth (PTB).

RESULTS

Neighbourhood deprivation was not associated with first trimester growth. However, a higher neighbourhood status score (less deprivation) was associated with increased fetal growth in the second and third trimesters (eg, estimated fetal weight; adjusted regression coefficient 0.04, 95% CI 0.02 to 0.06). Less deprivation was also associated with decreased odds of SGA (adjusted OR 0.91, 95% CI 0.86 to 0.97, p=0.01) and PTB (adjusted OR 0.89, 95% CI 0.82 to 0.96, p=0.01).

CONCLUSIONS

We found an association between neighbourhood deprivation and fetal growth in the second and third trimester pregnancy, but not with first trimester growth. Less neighbourhood deprivation is associated with lower odds of adverse pregnancy outcomes. The associations remained after adjustment for individual-level risk factors. This supports the hypothesis that living in a deprived neighbourhood acts as an independent risk factor for fetal growth and adverse pregnancy outcomes, above and beyond individual risk factors.

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.

Association of neighbourhood socioeconomic trajectories with preterm birth and small-for-gestational-age in the Netherlands: a nationwide population-based study

BACKGROUND

Adverse birth outcomes have serious health consequences, not only during infancy but throughout the entire life course. Most evidence linking neighbourhood socioeconomic status (SES) to birth outcomes is based on cross-sectional SES measures, which do not reflect neighbourhoods' dynamic nature. We investigated the association between neighbourhood SES trajectories and adverse birth outcomes, i.e. preterm birth and being small-for-gestational-age (SGA), for births occurring in the Netherlands between 2003 and 2017.

METHODS

We linked individual-level data from the Dutch perinatal registry to the Netherlands Institute for Social Research neighbourhood SES scores. Based on changes in their SES across four-year periods, neighbourhoods were categorised into seven trajectories. To investigate the association between neighbourhood SES trajectories and birth outcomes we used adjusted multilevel logistic regression models.

FINDINGS

Data on 2 334 036 singleton births were available for analysis. Women living in stable low-SES neighbourhoods had higher odds of preterm birth (OR[95%CI]= 1·12[1·07-1·17]) and SGA (OR[95%CI]= 1·19[1·15-1·23]), compared to those in high SES areas. Higher odds of preterm birth (OR[95%CI]= 1·12[1·05-1·20]) and SGA (OR[95%CI]=1·12[1·06-1·18]) were also observed for those living in areas declining to low SES. Women living in a neighbourhood where SES improved from low to medium showed higher odds of preterm birth (OR[95%CI]= 1·09[1·02-1·18]), but not of SGA (OR[95%CI]= 1·04[0.98-1·10]). The odds of preterm or SGA birth in other areas were comparable to those seen in high SES areas.

INTERPRETATION

In the Netherlands, disadvantaged neighbourhood SES trajectories were associated with higher odds of adverse birth outcomes. Longitudinal neighbourhood SES measures should also be taken into account when selecting a target population for public health interventions.

FUNDING

Erasmus Initiative Smarter Choices for Better Health.

The risk of preterm birth in combinations of socioeconomic position and mental health conditions in different age groups: a Danish nationwide register-based cohort study

Background

Inequality in preterm birth is a world-wide challenge that has proved difficult for maternity care services to meet. Reducing the inequality requires identification of pregnant women at particularly high risk of preterm birth in order to target interventions. Therefore, the aim was to estimate the risk of preterm birth in women with different combinations of socioeconomic position, mental health conditions, and age.

Methods

In this nationwide register-based cohort study, we included all first-time mothers that gave birth to a singleton liveborn infant in Denmark between 2000 and 2016. The absolute and relative risk of preterm birth (< 37 weeks of gestation) was examined in different combinations of educational level (high, intermediate, and low) and mental health conditions (no, minor, and moderate/severe) in three age strata (≤23, 24–30, and ≥ 31 years). We estimated the relative risk using Poisson regression with a robust error variance. As additive interaction can help identify subgroups where limited resources can be of best use, we measured the attributable proportion to assess the risk that is due to interaction of the different exposures.

Results

Of the 415,523 included first-time mothers, 6.3% gave birth prematurely. The risk of preterm birth increased with decreasing educational level and increasing severity of mental health conditions in all age strata, but most in women aged ≥31 years. The highest absolute risk was 12.9% [95% CI: 11.2;14.8%] in women aged ≥31 years with low education and moderate/severe mental health conditions resulting in a relative risk of 2.23 [95% CI: 1.93–2.58] compared to the unexposed reference group in that age strata. We found positive additive interaction between low education and mental health conditions in women aged 24–30 and ≥ 31 years and between age ≥ 31 years and combinations of mental health conditions and educational levels.

Conclusion

The inequality in preterm birth increased with increasing age. To reduce inequality in preterm birth focused attention on women with higher age further combined with lower educational levels and mental health conditions is essential.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-04138-0.

Evidence of disparities in the provision of the maternal postpartum 6-week check in primary care in England, 2015-2018: an observational study using the Clinical Practice Research Datalink (CPRD)

Background

A maternal postpartum 6-week check (SWC) with a general practitioner (GP) is now considered an essential service in England, a recent policy change intended to improve women’s health. We aimed to provide an up-to-date snapshot of the prevalence of SWC prior to the policy change as a baseline, and to explore factors associated with having a late or no check.

Methods

We conducted a cohort study using primary care records in England (Clinical Practice Research Datalink (CPRD)). 34 337 women who gave birth between 1 July 2015 and 30 June 2018 and had ≥12 weeks of follow-up post partum were identified in the CPRD Pregnancy Register. The proportion who had evidence of an SWC with a GP was calculated, and regression analysis was used to assess the association between women’s characteristics and risks of a late or no check.

Results

Sixty-two per cent (95% CI 58% to 67%) of women had an SWC recorded at their GP practice within 12 weeks post partum, another 27% had other consultations. Forty per cent had an SWC at the recommended 6–8 weeks, 2% earlier and 20% later. A late or no check was more common among younger women, mothers of preterm babies or those registered in more deprived areas.

Conclusions

Nearly 40% of women did not have a postpartum SWC recorded. Provision or uptake was not equitable; younger women and those in more deprived areas were less likely to have a record of such check, suggesting postpartum care in general practice may be missing some women who need it most.

Insight into the process of postpartum care utilisation and in-home support among vulnerable women in the Netherlands: an in-depth qualitative exploration

OBJECTIVE

To gain insight into the process of postpartum care utilisation and in-home support among vulnerable women.

DESIGN, METHOD, PARTICIPANTS AND SETTING

A qualitative interview study was conducted among 23 pregnant and postpartum vulnerable women in the Netherlands, following a grounded theory approach. Women were determined as vulnerable by their healthcare providers. Theoretical sampling of participants was applied and was alternated by data analysis to include information-rich cases until saturation was achieved.

RESULTS

A conceptual framework of postpartum care utilisation was generated consisting of three phases: pregnancy, early postpartum period and late postpartum period. Within these phases, information provision, parenting self-efficacy and social network were identified as overarching themes. Perceived inadequate information on content of postpartum care posed a major barrier to forming realistic expectations during pregnancy and hindered its utilisation. Low self-efficacy facilitated postpartum care utilisation. All women experienced increased self-efficacy during and after postpartum care. Support from a social network influenced expectations regarding the added value of postpartum care during pregnancy, and lowered actual utilisation during the postpartum period. The costs of postpartum care and the role of the maternity care assistant acted as general barriers or facilitators influencing the three overarching themes and therefore postpartum care utilisation indirectly.

CONCLUSIONS

Our findings suggest that postpartum care utilisation among vulnerable women may be improved by considering the particular phase and relevant themes applying to individual women, and adapt care accordingly. We recommend to provide comprehensive, understandable information and to emphasise the gains of postpartum care in improving self-efficacy for vulnerable women. Moreover, involving a woman's social network in postpartum care may add value to this care for this population.

Risk of adverse perinatal outcomes in infants born to mothers with mental health conditions

INTRODUCTION

Maternal mental health conditions have been shown to affect perinatal outcomes negatively. However, knowledge on the impact of different types and severities of maternal mental health conditions is needed. The objective of this study was to determine the association between maternal mental health status and perinatal health outcomes in the infant.

MATERIAL AND METHODS

This register-based cohort study included all live-born infants in Denmark born between 2000 and 2016. Exposed infants were grouped based on whether the mothers received mental health care in primary care settings only (minor conditions) or required specialized psychiatric intervention (moderate-severe conditions) within 12 months before childbirth. Modified Poisson regression analyses were applied to produce adjusted risk ratios (aRRs) for each perinatal outcome of interest. The primary outcomes were neonatal mortality, 5-minute Apgar scores <7 and <4 and newborn hospital admission during the neonatal period. Secondary outcomes included several neonatal morbidities such as respiratory distress syndrome and abstinence syndrome.

RESULTS

A total of 952 071 infants were included in the analysis; 4.0% had mothers with minor mental health conditions and 2.9% had mothers with moderate-severe conditions. The risk of neonatal death in exposed infants was aRR 1.08 (95% CI 0.93-1.27) for minor mental health conditions and aRR 0.93 (95% CI 0.78-1.11) for moderate-severe conditions. Both exposure groups had increased risks of 5-minute Apgar scores <7 (minor: aRR 1.28, 95% CI 1.16-1.41; moderate-severe: aRR 1.49, 95% CI 1.34-1.66); 5-minute Apgar scores <4 (minor: aRR 1.10, 95% CI 0.93-1.30; moderate-severe: aRR 1.18, 95% CI 0.98-1.43), and hospital admission during the neonatal period (minor: aRR 1.20, 95% CI 1.17-1.23; moderate-severe: aRR 1.22, 95% CI 1.19-1.26) along with several neonatal morbidities. An explicit high risk was seen for abstinence syndrome (minor: aRR 10.30, 95% CI 8.40-12.63; moderate-severe: aRR 12.13, 95% CI 10.17-15.67).

CONCLUSIONS

Infants of mothers with moderate-severe and minor mental health conditions were at increased risks of multiple adverse perinatal outcomes. Effective supportive interventions to improve outcomes in both groups are needed.

General practitioners' perceived indicators of vulnerability in pregnancy- A qualitative interview study

Objective

To explore general practitioners’ (GPs’) perceived indicators of vulnerability among pregnant women in primary care.

Design

A qualitative study with semi-structured in-depth focus group interviews.

Setting

General practices located in a mixture of urban, semi-urban and rural practices throughout the Region of Southern Denmark

Subjects

Twenty GPs.

Main outcome measures

Through qualitative analysis with systematic text condensation of the interview data, the following themes emerged: (1) obvious indicators of vulnerability—i.e. somatic or psychological illnesses, or complex social problems and 2) intangible indicators of vulnerability – i.e. identification depended on the GPs’ gut-feeling.

From the GPs’ perspective, the concept of vulnerability in pregnancy were perceived as the net result of risk factors and available individual and social resources, with a psychosocial etiology as the dominant framework.

Conclusions

The GPs demonstrated a broad variety of perceived indicators of vulnerability in pregnancy; most importantly, the GPs were aware of a group of pregnant women with intangible vulnerability mainly representing low resilience. Despite not fitting into the GPs' perceived concept of vulnerability, the GPs had a strong gut feeling that these women might be vulnerable. Misjudging the resources of pregnant women due to their physical appearance could delay the GPs’ identification of vulnerability. Future studies should explore the challenges GPs experiences when assessing vulnerability among pregnant women.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01439-3.

Risk factors of ocular morbidity among under-five years old children in Khartoum State- Sudan- 2020

BACKGROUND AND AIMS

Visual impairment in early childhood can significantly affect the development of visual, motor, and cognitive function and potentially lead to long-term adverse psychosocial consequences. This study aimed to identify the risk factors of ocular morbidity among under 5-year old children in Khartoum State, Sudan.

METHODS

A cross-sectional study was conducted in three tertiary eye care hospitals in Khartoum State, Sudan. The study included 391 children under the age of 5 years. The parent(s) were interviewed using a precoded, pretested, closed-ended questionnaire that included questions regarding socio-demographic profile and possible risk factors. Data were analyzed using Statistical Package for the Social Sciences (version 21.0). A P-value of less than .05 was regarded as significant.

RESULTS

There was a significant association between participants with diabetes mellitus and poor vision (P-value <.001). Two-thirds of participants (57%) with visual impairment had mothers, who reportedly attended antenatal care services regularly (P-value .001), revealing a significant statistical association. Maternal diseases, specifically diabetes, was identified as a risk factor for poor visual acuity in their offspring (P-value <.001). A significant relation was revealed between family history of eye disease and the degree of relationship to the affected participant (P-value <.001). There was an association between watching TV and current visual acuity (P-value <.001); as well as using mobile phones and current visual acuity (P-value <.001). Multilinear analysis revealed the stronger influence of TV watching rather than the use of mobile phones (P-value <.001).

CONCLUSIONS

Diabetes, diabetic mothers, a family history of ocular morbidity, watching television, and using mobile phones emerged as significant risk factors of ocular morbidity among children under the age of 5 years in this study. Many of these risk factors are either modifiable or controllable ocular morbidities among under-five children can be reduced with suitable interventions.

Supportive encounters during pregnancy and the postnatal period: An ethnographic study of care experiences of parents in a vulnerable position

BACKGROUND

Pregnant women and partners with psychological and/or social challenges are exposed to adverse health outcomes. It is therefore recommended that they receive targeted maternity care services. The relationship between parents and professionals is key to help parents engage with services and experience them as supportive. However, more knowledge is needed on parents' care experiences during encounters with professionals to further understand when and how these are experienced as supportive.

OBJECTIVES

This study aimed at identifying the key elements of supportive care practices by exploring how parents in vulnerable positions experience their relationship and encounters with the professionals involved in their pregnancy and postnatal care.

DESIGN

Ethnographic fieldwork was conducted in a Danish municipality, including 50 semi-structured interviews with parents and 51 field visits during parent-professional encounters, including informal interviews and participant observation. Using a purposive recruitment strategy, 26 women and 13 men were recruited, who varied in age, socioeconomic background and vulnerability factors. COREQ reporting guidelines were used.

RESULTS

The analysis identified five themes: (a) Having a voice: Feeling listened to, (b) Being met with empathy: Feeling understood, (c) Worthy of attention: Feeling taken seriously, (d) On equal terms: Feeling like a normal family and (e) Moving in the right direction: Feeling reassured.

CONCLUSION

Positive care experiences facilitate engagement with services and professionals as this contribute to parents feeling included, respected and safe. Conversely, negative care experiences leave parents feeling excluded, judged and anxious, potentially reinforcing and adding to existing feelings of anxiety and stigma. This requires that professionals have good communication skills and are able to approach parents in an open and non-judgmental way.

RELEVANCE TO CLINICAL PRACTICE

Understanding the significance of supportive care practices is paramount for health visitors, midwives and other professionals involved in providing for parents in vulnerable positions during pregnancy and the postnatal period.

Placental weight in first generation migrant mothers in Germany. Do the length of stay, acculturation or migrant status play a role?

INTRODUCTION

Migration status affects perinatal outcomes. A small placenta is associated with placental dysfunction and poor outcomes. Placental weight and perinatal outcomes are influenced by migrant status, the length of stay and the level of acculturation in the host country. Our aim was to compare placental weight in first generation immigrants to native non-immigrants in a teaching hospital in Berlin. The influence of migrant status, the length of stay and the level of acculturation on placental weight was also ascertained.

METHODS

At the Charité University Hospital in Berlin Germany between January 2011 and January 2012, 1373 non-migrant and 1243 first generation migrants were included. Data collection was by means of a standardized questionnaire. The level of acculturation was based on the Frankfurter Acculturation Questionnaire (Frankfurter Akkulturationsfragebogen-FRAKK). Demographic parameters such as age, maternal weight, country of origin, parity, anemia, diabetes, hypertension, smoking and neonatal outcomes including neonatal weight, placental weight were measured.

RESULTS

We found no difference in mean placenta weight when comparing first generation women with a migration background to women of the native population (608 g vs 597 g, p-value 0.41). There was also no difference in placental weight when assessed by the length of stay and degree of acculturation in the host country.

DISCUSSION

While first generation migrant women have increased perinatal complications, there is no influence of migrant status, length of stay and the degree of acculturation on placenta weight. Pregnancy outcomes maybe be more dependent on factors such as the access to adequate maternal care.

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.

Fit to conceive? Representations of preconception health in the UK press

The period before conception is increasingly claimed to be of critical importance for pregnancy and birth outcomes, prompting calls for public health advice and interventions to be targeted at women before rather than during pregnancy. Drawing on Foucault’s concepts of governmentality and technologies of the self, this article explores the implications of preconception health messages for women of reproductive age. Following a critical discursive analysis of 57 UK newspaper articles, three dominant representations of preconception health were identified: preconception health as optimizing fertility, as determining infant health, and as point of intervention. I suggest that these representations reflect neoliberal health agendas, positioning women as in control of and responsible for their fertility, the health of their future children, future generations, and of the wider population, all through careful self-policing of their lifestyles. In this way, “good” preconception health is emphasized as an increasingly important form of health citizenship. Furthermore, the analysis highlights the gendered nature of these expectations, with a disproportionate focus on the potential impact of women’s preconception health. Few challenges to these dominant messages were identified, and concerns are raised about the potential impacts on the autonomy and subjectivities of women of reproductive age, regardless of pregnancy intentions.

The risks of advancing parental age on neonatal morbidity and mortality are U- or J-shaped for both maternal and paternal ages

BACKGROUND

The biologic implications of delayed parenthood have been blamed for a major public health crisis in the United States, that includes high rates of neonatal morbidity and mortality (NMM). The objective of this study was to evaluate the risk of parent age on NMM and to provide results that can serve as a starting point for more specific mediation modeling.

METHODS

Data containing approximately 15,000,000 birth records were obtained from the United States Natality database for the years 2014 to 2018. A Bayesian modeling approach was used to estimate the both the total effect and the risk adjusted for confounding between parent ages and for mediation by chromosomal disorders including Down syndrome. Outcomes included intra-hospital death and nine measures of neonatal morbidity.

RESULTS

For paternal age, seven NMM (preterm birth, very preterm birth, low Apgar score, treatment with antibiotics, treatment with surfactant, prolonged ventilation, intra-hospital death) had U-shaped risk patterns, two NMM (small for gestational age, admission to neonatal intensive care) had J-shaped risk patterns, one NMM (seizures) was not significantly related to paternal age. For maternal age, three NMM (low Apgar score, treatment with antibiotics and intra-hospital death) had U-shaped risk patterns, four NMM (preterm delivery, very preterm delivery, admission to neonatal intensive care, treatment with surfactant) had J-shaped risk patterns, one NMM (small for gestational age) had a risk declining with age, one NMM (prolonged ventilation) had a risk increasing with age and one NMM (seizures) was not significantly related to maternal age.

CONCLUSIONS

Both advancing maternal and paternal ages had U- or J-shaped risk patterns for neonatal morbidity and mortality.

Barriers and associated factors for adequate antenatal care among Afghan women in Iran; findings from a community-based survey

BACKGROUND

Almost a third of Afghan women living in Iran are at childbearing age. Antenatal care (ANC) is an inextricable part of healthy pregnancy and could prevent the adverse birth outcomes. Almost 97% of Iranian expectant women are receiving adequate ANC (4 or more visits). However, the situation for pregnant Afghan women is unclear. Some studies indicated low access to ANC among Afghan women. In the present study, we aimed to explore the sociodemographic factors and potential barriers associated with adequate ANC among Afghan women in Iran.

METHODS

A cross sectional study was conducted between June 2019 and August 2019. Using time location sampling (TLS), we recruited 424 Afghan women aged 18-45 years old at three health centers in south region of Tehran. The data were collected on sociodemographic characteristics and the reported reasons for inadequate ANC using a questionnaire and analyzed applying bivariate, and multivariate analyses. Factor analysis was performed to reduce the number of potential reasons for inadequate ANC in order to improve the precision of regression analysis.

RESULTS

Almost a third of Afghan women in this study had adequate ANC (≥ 8 visits). The women in older age group, those with higher education and family income, women with longer length of stay, those of legal status were more likely to have adequate ANC. In multivariate analysis, the poor knowledge and attitude toward ANC (AOR = 0.06; 95% CI [0.03-0.15]), the poor quality of services (AOR = 0.17 95% CI [0.07-0.41]); and to some extent, the difficulties in access (AOR = 0.33; 95% CI [0.11-1.00]) were the main obstacles toward adequate ANC among the study population.

CONCLUSION

Our study emphasized the important role of the personal knowledge and attitude toward ANC with adequate antenatal care among Afghan women in Iran. This could be addressed by well-oriented interventions and health education for Afghan women. The collaboration between central government with international agencies should be directed toward enhancing the social support, promoting the awareness and knowledge, and expanding the safety net services to improve the access and quality care among Afghan women in Iran.

Towards an integrated perinatal care pathway for vulnerable women: The development and validation of quality indicators

OBJECTIVE

Development and validation of a set of quality indicators for vulnerable women during the perinatal period.

DESIGN

A three-phase method was used. Phase 1 consisted of a literature review to identify publications for the development of care domains and potential QIs, as well as a quality assessment by the research team. In phase 2 an expert panel assessed the set of concept QIs in a modified three-round Delphi survey. Finally, semi-structured interviews with vulnerable women were conducted as a final quality assessment of a set of indicators (phase 3). Ethical approval was obtained from the ethics committee of the University Hospital Brussels and from the Ethics Committees of all the participating hospitals.

SETTING

The Flemish Region and the Brussels Capital Region in Belgium.

PARTICIPANTS

Healthcare and social care professionals (n = 40) with expertise in the field of perinatal care provision for vulnerable families. Vulnerable women (n = 11) who gave birth in one of the participating hospitals.

FINDINGS

The literature review resulted in a set of 49 potential quality indicators in five care domains: access to healthcare, assessment and screening, informal support, formal support and continuity of care. After assessment by the expert panel and vulnerable women, a final set of 21 quality indicators in five care domains was identified. First of all, organisation of care must involve an integrated multidisciplinary approach taking account of financial, administrative and social barriers (care domain 1: access to healthcare). Second, qualitative care includes the timely initiation of care, a general screening of the various aspects of vulnerability (biological, psychological, social and cognitive) and a risk assessment for all women (care domain 2: assessment and screening). Vulnerable women benefit from intensive formal and informal support taking account of individual needs and strengths (care domain 3: formal support; care domain 4: informal support). Finally, continuity of care needs to be guaranteed in line with vulnerable woman's individual needs (care domain 5: continuity of care).

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Implementing quality indicators in existing and new care pathways offers an evidence-based approach facilitating an integrated view promoting a healthy start for woman and child. These quality indicators can assist healthcare providers, organisations and governmental agencies to improve the quality of perinatal care for vulnerable women.

Fuzzy cognitive mapping and soft models of indigenous knowledge on maternal health in Guerrero, Mexico

Background

Effective health care requires services that are responsive to local needs and contexts. Achieving this in indigenous settings implies communication between traditional and conventional medicine perspectives. Adequate interaction is especially relevant for maternal health because cultural practices have a notable role during pregnancy, childbirth and the postpartum period. Our work with indigenous communities in the Mexican state of Guerrero used fuzzy cognitive mapping to identify actionable factors for maternal health from the perspective of traditional midwives.

Methods

We worked with twenty-nine indigenous women and men whose communities recognized them as traditional midwives. A group session for each ethnicity explored risks and protective factors for maternal health among the Me’phaa and Nancue ñomndaa midwives. Participants mapped factors associated with maternal health and weighted the influence of each factor on others. Transitive closure summarized the overall influence of each node with all other factors in the map. Using categories set in discussions with the midwives, the authors condensed the relationships with thematic analysis. The composite map combined categories in the Me’phaa and the Nancue ñomndaa maps.

Results

Traditional midwives in this setting attend to pregnant women’s physical, mental, and spiritual conditions and the corresponding conditions of their offspring and family. The maps described a complex web of cultural interpretations of disease – “frío” (cold or coldness of the womb), “espanto” (fright), and “coraje” (anger) – abandonment of traditional practices of self-care, women’s mental health, and gender violence as influential risk factors. Protective factors included increased male involvement in maternal health (having a caring, working, and loving husband), receiving support from traditional healers, following protective rituals, and better nutrition.

Conclusions

The maps offer a visual language to present and to discuss indigenous knowledge and to incorporate participant voices into research and decision making. Factors with higher perceived influence in the eyes of the indigenous groups could be a starting point for additional research. Contrasting these maps with other stakeholder views can inform theories of change and support co-design of culturally appropriate interventions.

The impact of periconceptional maternal lifestyle on clinical features and biomarkers of placental development and function: a systematic review

BACKGROUND

Worldwide, placenta-related complications contribute to adverse pregnancy outcomes, such as pre-eclampsia, fetal growth restriction and preterm birth, with implications for the future health of mothers and offspring. The placenta develops in the periconception period and forms the interface between mother and embryo/fetus. An unhealthy periconceptional maternal lifestyle, such as smoking, alcohol and under- and over-nutrition, can detrimentally influence placental development and function.

OBJECTIVE AND RATIONALE

The impact of maternal lifestyle on placental health is largely unknown. Therefore, we aim to summarize the evidence of the impact of periconceptional maternal lifestyle on clinical features and biomarkers of placental development and function throughout pregnancy.

SEARCH METHODS

A comprehensive search in Medline, Embase, Pubmed, The Cochrane Library Web of Science and Google Scholar was conducted. The search strategy included keywords related to the maternal lifestyle, smoking, alcohol, caffeine, nutrition (including folic acid supplement intake) and body weight. For placental markers throughout pregnancy, keywords related to ultrasound imaging, serum biomarkers and histological characteristics were used. We included randomized controlled trials and observational studies published between January 2000 and March 2017 and restricted the analysis to singleton pregnancies and maternal periconceptional lifestyle. Methodological quality was scored using the ErasmusAGE tool. A protocol of this systematic review has been registered in PROSPERO International prospective register of systematic reviews (PROSPERO 2016:CRD42016045596).

OUTCOMES

Of 2593 unique citations found, 82 studies were included. The median quality score was 5 (range: 0-10). The findings revealed that maternal smoking was associated with lower first-trimester placental vascularization flow indices, higher second- and third-trimester resistance of the uterine and umbilical arteries and lower resistance of the middle cerebral artery. Although a negative impact of smoking on placental weight was expected, this was less clear. Alcohol use was associated with a lower placental weight. One study described higher second- and third-trimester placental growth factor (PlGF) levels after periconceptional alcohol use. None of the studies looked at caffeine intake. Adequate nutrition in the first trimester, periconceptional folic acid supplement intake and strong adherence to a Mediterranean diet, were all associated with a lower resistance of the uterine and umbilical arteries in the second and third trimester. A low caloric intake resulted in a lower placental weight, length, breadth, thickness, area and volume. Higher maternal body weight was associated with a larger placenta measured by ultrasound in the second and third trimester of pregnancy or weighed at birth. In addition, higher maternal body weight was associated with decreased PlGF-levels.

WIDER IMPLICATIONS

Evidence of the impact of periconceptional maternal lifestyle on placental health was demonstrated. However, due to poorly defined lifestyle exposures and time windows of investigation, unstandardized measurements of placenta-related outcomes and small sample sizes of the included studies, a cautious interpretation of the effect estimates is indicated. We suggest that future research should focus more on physiological consequences of unhealthy lifestyle during the critical periconception window. Moreover, we foresee that new evidence will support the development of lifestyle interventions to improve the health of mothers and their offspring from the earliest moment in life.

Preconceptional diet quality is associated with birth outcomes among low socioeconomic status minority women in a high-income country

PURPOSE

Studies of the association between maternal nutrition and birth outcomes have investigated differing nutrients, maternal socioeconomic conditions, and timing within the reproductive cycle; and have produced inconsistent results. We evaluated the association of preconceptional maternal dietary intake with birth outcomes among low socioeconomic status ethnic minority women in a high-income country.

METHODS

In this prospective cohort study, habitual preconceptional dietary intake was assessed among pregnant Bedouin Arab women in Israel (n = 384), using a short culturally specific, targeted food frequency questionnaire. Multiple nutrients (protein, lysine, calcium, iron, zinc, folate, omega-3 fatty acids) were evaluated simultaneously via a diet quality score derived from principal component analysis. Multivariable logistic regression was used to test associations between the diet quality score and a composite adverse birth outcomes variable, including preterm birth, low birth weight and small for gestational age.

RESULTS

Sixty-nine women (18%) had adverse birth outcomes. Women with low preconceptional diet quality scores had low intakes of nutrient-rich plant foods, bioavailable micronutrients, and complete proteins. In multivariable analysis, a woman at the 10th percentile of the diet quality score had a 2.97 higher odds (95% CI 1.28-6.86) of an adverse birth outcome than a woman at the 90th percentile.

CONCLUSION

Low diet quality during the preconceptional period was associated with adverse birth outcomes among low socioeconomic status minority women in a high-income country. The results have implications for the development of appropriate intervention strategies to prevent adverse birth outcomes, and the promotion of adequate nutrition throughout the child-bearing years.

Intimate partner violence and perinatal health: a systematic review

BACKGROUND

Physical, psychological and sexual intimate partner violence (IPV) has been described in the literature as different types of IPV experienced by women during pregnancy all over the world.

OBJECTIVES

To review and summarise systematically the empirical evidence on the links between IPV during pregnancy and the perinatal health of mothers and fetuses/neonates.

SEARCH STRATEGY

MEDLINE (Ovid), CINAHL, Embase, Nursing@ovid (Ovid) and LILACS were searched (2008-2018).

SELECTION CRITERIA

Observational studies that examined perinatal health outcomes (i.e. pre-term birth, low birthweight, miscarriage, perinatal death and premature rupture of membranes) in pregnant women exposed to IPV.

DATA COLLECTION AND ANALYSIS

Information on study characteristics, type of IPV measured, study design, methodological quality and outcome variable extracted.

RESULTS

Fifty studies were included. Twenty-nine analysed undifferentiated IPV (n = 25 489), 34 included physical IPV (n = 7333), 22 analysed psychological IPV (n = 7833) and 18 examined sexual IPV (n = 2388). Fifteen studies were from Asia, 12 from North America and Oceania, and 12 from Central and South America. The studies examined the association between IPV and 39 different perinatal health outcomes. The most frequent outcomes reported were pre-term birth (50%), low birthweight (46%), miscarriage (30%), perinatal death (20%) and premature rupture of membranes (20%). A significant association with perinatal health outcomes was reported by 12 of the studies analysing undifferentiated IPV, 18 physical IPV, six psychological IPV and two sexual IPV.

CONCLUSIONS

The relation between IPV and perinatal health outcomes can be seen in different epidemiological designs and countries. In all, 39 different outcomes were identified and 29 were associated with IPV.

TWEETABLE ABSTRACT

A variety of poor perinatal health outcomes are associated with psychological, physical and sexual IPV.

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

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

The Cumulative Risk of Chemical and Nonchemical Exposures on Birth Outcomes in Healthy Women: The Fetal Growth Study

Metals, stress, and sociodemographics are commonly studied separately for their effects on birth outcomes, yet often jointly contribute to adverse outcomes. This study analyzes two methods for measuring cumulative risk to understand how maternal chemical and nonchemical stressors may contribute to small for gestational age (SGA). SGA was calculated using sex-specific fetal growth curves for infants of pregnant mothers (n = 2562) enrolled in the National Institute of Child Health and Human Development (NICHD) Fetal Growth Study. The exposures (maternal lead, mercury, cadmium, Cohen's perceived stress, Edinburgh depression scores, race/ethnicity, income, and education) were grouped into three domains: metals, psychosocial stress, and sociodemographics. In Method 1 we created cumulative risk scores using tertiles. Method 2 employed weighted quantile sum (WQS) regression. For each method, logistic models were built with three exposure domains individually and race/ethnicity, adjusting for age, parity, pregnancy weight gain, and marital status. The adjusted effect of overall cumulative risk with three domains, was also modeled using each method. Sociodemographics was the only exposure associated with SGA in unadjusted models ((odds ratio) OR: 1.35, 95% (confidence interval) CI: 1.08, 1.68). The three cumulative variables in adjusted models were not significant individually, but the overall index was associated with SGA (OR: 1.17, 95% CI: 1.02, 1.35). In the WQS model, only the sociodemographics domain was significantly associated with SGA. Sociodemographics tended to be the strongest risk factor for SGA in both risk score and WQS models.

Women-centered care: Implementation of CenteringPregnancy® in The Netherlands

INTRODUCTION

In response to a relatively high perinatal mortality rate in The Netherlands, the Dutch Health Ministry recommended changes to maternity care, opening a pathway toward more integrated woman-centered services. Because of its potential to positively influence risk factors for adverse pregnancy outcomes, CenteringPregnancy (CP) group prenatal care was implemented.

METHODS

We performed a retrospective cohort study (n = 2318) and survey on women's experiences (n = 222) in eight primary care midwifery practices to investigate outcome differences between CP and traditional individual prenatal care. Data from the period 2011-2013 were analyzed.

RESULTS

Primiparous and multiparous CP women attended more prenatal care visits compared with women who received individual care (adjusted odds ratio [aOR] 1.23 [95% confidence interval [CI] 1.18-1.29] and 1.29 [1.21-1.36]). Fewer primiparous CP women used pain relief during labor (0.56 [0.43-0.73]), and they initiated breastfeeding more often (1.74 [1.15-2.62]). Women participating in CP were more likely to feel that their wishes with respect to medication use (69.1% vs 54.4%, P = 0.039), physical activities (72.8% vs 52.5%, P = 0.008), and relaxation exercises (67.9% vs 35.6%, P ≤ 0.001) were listened to by care providers. They also felt more supported to actively participate in their care (89.6% vs 68.5%, P = 0.001) and felt more able to voice opinions about care (92.7% vs 73.9%, P = 0.002).

CONCLUSIONS

The CP model is a good approach aligning with Dutch policy calling for women-centered care and responding to the needs of pregnant women. This study supports CP scale-up in The Netherlands and adds to the pool of international knowledge about CP implementation.

Associations of Maternal Cell-Phone Use During Pregnancy With Pregnancy Duration and Fetal Growth in 4 Birth Cohorts

Results from studies evaluating potential effects of prenatal exposure to radio-frequency electromagnetic fields from cell phones on birth outcomes have been inconsistent. Using data on 55,507 pregnant women and their children from Denmark (1996-2002), the Netherlands (2003-2004), Spain (2003-2008), and South Korea (2006-2011), we explored whether maternal cell-phone use was associated with pregnancy duration and fetal growth. On the basis of self-reported number of cell-phone calls per day, exposure was grouped as none, low (referent), intermediate, or high. We examined pregnancy duration (gestational age at birth, preterm/postterm birth), fetal growth (birth weight ratio, small/large size for gestational age), and birth weight variables (birth weight, low/high birth weight) and meta-analyzed cohort-specific estimates. The intermediate exposure group had a higher risk of giving birth at a lower gestational age (hazard ratio = 1.04, 95% confidence interval: 1.01, 1.07), and exposure-response relationships were found for shorter pregnancy duration (P < 0.001) and preterm birth (P = 0.003). We observed no association with fetal growth or birth weight. Maternal cell-phone use during pregnancy may be associated with shorter pregnancy duration and increased risk of preterm birth, but these results should be interpreted with caution, since they may reflect stress during pregnancy or other residual confounding rather than a direct effect of cell-phone exposure.

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

Aim

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

Background

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

Design

Qualitative explorative study.

Methods

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

Results

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

Conclusion

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

Impact

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