Regional perinatal mortality differences in the Netherlands; care is the question

Preconception lipid profile and the subsequent risk of pregnancy disorders characterized by uteroplacental dysfunction in a multi-ethnic population: the linked HELIUS-PERINED study

BACKGROUND

Unfavorable lipid profile is associated with pregnancy disorders characterized by uteroplacental dysfunction, including hypertensive disorders of pregnancy, preterm birth and fetal growth restriction. None of current tools used to predict the risk of pregnancy complications include lipid levels.

OBJECTIVE(S)

In this study, we examined the association of preconception lipid profile with pregnancy disorders characterized by uteroplacental dysfunction in a multi-ethnic population, aiming to improve the identification of women at high risk for uteroplacental dysfunction using current prediction models.

STUDY DESIGN

We conducted a linkage study combining lipid profile collected in the multi-ethnic HELIUS study (Amsterdam, 2011-2015), linked with national perinatal registry data on pregnancy complications after inclusion until 2019. We included 1177 women of Dutch, South-Asian Surinamese, African Surinamese, Ghanaian, Turkish, and Moroccan origin. Associations were studied using Poisson regression. The discriminative ability was assessed for different pregnancy complications of significantly associated lipid parameters when added to commonly used prediction tools for preeclampsia.

RESULTS

Preconception triglyceride level was associated with prevalence of hypertensive disorders of pregnancy (e^triglyceride level (mmol/L) adjusted prevalence ratio 1.07, 95% CI 1.00 to 1.14). Age-adjusted prevalence of hypertensive disorders of pregnancy was also higher among women with high LDL-C level, high TC/HDL-C or ≥4 adverse lipid parameters, but most of these findings were not statistically significant when adjusted for demographic, lifestyle and medical characteristics. Addition of triglyceride level and other lipid parameters to the NICE guideline criteria and to the EXPECT prediction tool did not improve discriminative ability for hypertensive disorders of pregnancy, preterm birth or fetal growth restriction.

CONCLUSION(S)

Lipid profile did not aid in the identification of women at high risk for pregnancy disorders characterized by uteroplacental dysfunction. Further studies are needed to improve preconception prediction models for hypertensive disorders of pregnancy and other pregnancy disorders characterized by uteroplacental dysfunction using biomarkers or other easily available measurements.

Regional perinatal mortality differences in Indonesia: Evidence from Indonesian demographic health survey

Aim

Perinatal mortality can be used as a reference to assess health status in a country. In Indonesia, none of previous studies specifically discuss the incidence of prenatal mortality by region. The objective of this study was to analyze perinatal mortality difference by region of Indonesia.

Study design

This study used a cross-sectional approach.

Method

The sample in this study was 13,310 women of childbearing age obtained from the Indonesian Demographic Health Survey (IDHS) 2017. The perinatal mortality rate was calculated using data on stillbirths with a gestational duration of seven months or more and early neonatal deaths. Perinatal mortality was analyzed by region using a binary logistic regression statistical test to examine the relationship between perinatal mortality and its factors (socio-demographic factors, individual disease control factors, and maternal factors).

Results

This study shows that the proportion of perinatal mortality in Indonesia is 1.5 % of total births. The highest proportion of perinatal mortality (2.5 %) was in the Papua region, while the lowest proportion (1.3 %) was in the Java region. The results of this study indicated that women in the Maluku Islands had a 1.82 times higher chance of perinatal mortality compared to the Java-Bali region. The causative variable associated with perinatal mortality in the Java-Bali and Papua regions was employment status. The causative variables associated with perinatal mortality in Kalimantan were the quality of antenatal care and delivery assistance. The causative variable associated with perinatal mortality in Nusa Tenggara and Papua was the location of delivery. The causative variable associated with perinatal mortality in Kalimantan, Maluku, and Papua was the mother's age. The causative variable associated with perinatal mortality in the Java-Bali region was parity. The causative variable associated with perinatal mortality in Sumatra was the type of delivery.

Conclusion

This study show that there were disparities in the incidence of perinatal mortality between regions in Indonesia. The government needs to re-adjust the existing strategies to improve health status and focus on community empowerment for women to prevent perinatal mortality.

Maternal Migration Background and Mortality Among Infants Born Extremely Preterm

Importance

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

Objective

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

Design, Setting, and Participants

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

Exposure

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

Main Outcomes and Measures

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

Results

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

Conclusions

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

Exploring the Interrelationships between Public Health, Fiscal Decentralization, and Local Government Debt in China

This paper investigates the interrelationships among local government debt, fiscal decentralization, and public health. The investigation begins by constructing a theoretical model to analyze the inherent connections between these variables. Subsequently, an empirical analysis is conducted using data from China between 2015 and 2021. The findings demonstrate a bidirectional relationship between fiscal decentralization, local government debt, and public health. Specifically, it is observed that an increase in local government debt has adverse effects on both fiscal decentralization and public health, while fiscal decentralization has a positive impact on public health. These insights are consistently validated through rigorous regression methodologies, affirming the robustness and significance of these relationships.

Birth-weight centile at term and school performance at 12 years of age: linked cohort study

OBJECTIVE

Birth weight, fetal growth and placental function influence cognitive development. The gradient of these associations is understudied, especially among those with a birth weight considered appropriate-for-gestational age. The aim of this study was to evaluate the associations between birth-weight centile and intellectual development in term/near-term infants across the entire birth-weight spectrum, in order to provide a basis for better understanding of the long-term implications of fetal growth restriction and reduced placental function.

METHODS

This was a population-based cohort study of 266 440 liveborn singletons from uncomplicated pregnancies, delivered between 36 and 42 weeks of gestation. Perinatal data were obtained from the Dutch Perinatal Registry over the period 2003-2008 and educational data for children aged approximately 12 years were obtained from Statistics Netherlands over the period 2016-2019. Regression analyses were conducted to assess the association of birth-weight centile with school performance. The primary outcomes were mean school performance score, on a scale of 501-550, and proportion of children who reached higher secondary school level.

RESULTS

Mean school performance score increased gradually with increasing birth-weight centile, from 533.6 in the 1st -5th birth-weight-centile group to 536.8 in the 81st -85th birth-weight-centile group. Likewise, the proportion of children at higher secondary school level increased with birth-weight centile, from 43% to 57%. Compared with the 81st -85th birth-weight-centile group, mean school performance score and proportion of children at higher secondary school level were significantly lower in all birth-weight-centile groups below the 80th centile, after adjusting for confounding factors.

CONCLUSIONS

Birth-weight centile is associated positively with school performance at 12 years of age across the entire birth-weight spectrum, well beyond the conventional and arbitrary cut-offs for suspected fetal growth restriction. This underlines the importance of developing better tools to diagnose fetal growth restriction and reduced placental function, and to identify those at risk for associated short- and long-term consequences. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Offspring school performance at age 12 after induction of labor vs non-intervention at term: A linked cohort study

INTRODUCTION

The incidence of induction of labor, for both medical reasons and as an elective procedure, has been rising and a further increase in induction of labor following the ARRIVE trial may be expected. The effects of induction of labor at term on childhood neurodevelopment, however, are not well studied. We aimed to study the influence of elective induction of labor for each week of gestation separately from 37 to 42 weeks on offspring school performance at 12 years of age after uncomplicated pregnancies.

MATERIAL AND METHODS

We performed a population-based study among 226 684 liveborn children from uncomplicated singleton pregnancies, born from 37⁺⁰ to 42⁺⁰  weeks of gestation in cephalic presentation in 2003-2008 (no hypertensive disorders, diabetes or birthweight ≤p5) in the Netherlands. Children with congenital anomalies, of non-white mothers and born after planned cesarean section were excluded. Birth records were linked with national data on school achievement. We compared, using a fetus-at-risk approach and per week of gestation, school performance score and secondary school level at age 12 in those born after induction of labor to those born after non-intervention, ie spontaneous onset of labor in the same week plus all those born at later gestations. Education scores were standardized to a mean of 0 and a standard deviation of 1 and adjusted in the regression analyses.

RESULTS

For each gestational age up to 41 weeks, induction of labor was associated with decreased school performance scores compared with non-intervention (at 37 weeks -0.05 SD, 95% confidence interval [CI] -0.10 to -0.01 SD; adjusted for confounding factors). After induction of labor, fewer children reached higher secondary school level (at 38 weeks 48% vs 54%; adjusted odds ratio [aOR] 0.88, 95% CI 0.82-0.94).

CONCLUSIONS

In women with uncomplicated pregnancies at term, consistently, at every week of gestation from 37 to 41 weeks, induction of labor is associated with lower offspring school performance at age 12 and lower secondary school level compared with non-intervention, although residual confounding may remain. These long-term effects of induction of labor should be incorporated in counseling and decision making.

Cardiovascular risk profile after a complicated pregnancy across ethnic groups: The HELIUS study

AIMS

Little is known about how pregnancy complications and cardiovascular disease (CVD) risk are associated, specifically among ethnic minorities. In this study we examined this association in women from six ethnic groups, and the potential value of pregnancy complications as eligibility criterion for CVD risk screening.

METHODS

We conducted a cross-sectional study combining obstetric history from the Dutch perinatal registry with data on cardiovascular risk up to 15 years after pregnancy from the multi-ethnic HELIUS study. We included 2,466 parous women of Dutch, South-Asian Surinamese, African Surinamese, Ghanaian, Turkish and Moroccan origin. Associations were studied across ethnicities and predictive value of pregnancy complications for CVD risk factors above traditional eligibility criteria for CVD risk screening was assessed using Poisson regression.

RESULTS

History of hypertensive disorders of pregnancy and preterm birth were associated with higher prevalence of chronic hypertension and chronic kidney disease across most groups (prevalence ratio 1.6-1.9). Gestational diabetes mellitus was associated with increased type 2 diabetes mellitus risk, particularly in ethnic minority groups (prevalence ratio 4.5-7.7). Associations did not significantly differ across ethnic groups. The prediction models did not improve substantially after adding pregnancy complications to traditional eligibility criteria for CVD risk screening.

CONCLUSION

History of hypertensive disorders of pregnancy, preterm birth and gestational diabetes mellitus is associated with CVD risk factors in parous women, without evidence of a differential association across ethnic groups. However, addition of pregnancy complications to traditional eligibility criteria for CVD risk screening does not substantially improve the prediction of prevalent CVD risk factors.

Stillbirth and neonatal mortality in a subsequent pregnancy following stillbirth: a population-based cohort study

BACKGROUND

A history of stillbirth is a risk factor for recurrent fetal death in a subsequent pregnancy. Reported risks of recurrent fetal death are often not stratified by gestational age. In subsequent pregnancies increased rates of medical interventions are reported without evidence of perinatal benefit. The aim of this study was to estimate gestational-age specific risks of recurrent stillbirth and to evaluate the effect of obstetrical management on perinatal outcome after previous stillbirth.

METHODS

A retrospective cohort study in the Netherlands was designed that included 252.827 women with two consecutive singleton pregnancies (1^st and 2^nd delivery) between 1999 and 2007. Data was obtained from the national Perinatal Registry and analyzed for pregnancy outcomes. Fetal deaths associated with a congenital anomaly were excluded. The primary outcome was the occurrence of stillbirth in the second pregnancy stratified by gestational age. Secondary outcome was the influence of obstetrical management on perinatal outcome in a subsequent pregnancy.

RESULTS

Of 252.827 first pregnancies, 2.058 pregnancies ended in a stillbirth (8.1 per 1000). After adjusting for confounding factors, women with a prior stillbirth have a two-fold higher risk of recurrence (aOR 1.96, 95% CI 1.07-3.60) compared to women with a live birth in their first pregnancy. The highest risk of recurrence occurred in the group of women with a stillbirth in early gestation between 22 and 28 weeks of gestation (a OR 2.25, 95% CI 0.62-8.15), while after 32 weeks the risk decreased. The risk of neonatal death after 34 weeks of gestation is higher in women with a history of stillbirth (aOR 6.48, 95% CI 2.61-16.1) and the risk of neonatal death increases with expectant obstetric management (aOR 10.0, 95% CI 2.43-41.1).

CONCLUSIONS

A history of stillbirth remains an important risk for recurrent stillbirth especially in early gestation (22-28 weeks). Women with a previous stillbirth should be counselled for elective induction in the subsequent pregnancy at 37-38 weeks of gestation to decrease the risk of perinatal death.

Effect of Training Healthcare Providers in Helping Babies Breathe Program on Neonatal Mortality Rates

BACKGROUND

Training in the Helping Babies Breathe (HBB) Program has been associated with a reduction in early neonatal mortality rate (ENMR), the neonatal mortality rate (NMR), and fresh stillbirth rate (FSBR) in low- and middle-income countries (LMICs). This program was implemented in five different healthcare facilities in the Oliver Reginald Tambo (ORT) District, South Africa from September 2015 to December 2020.

OBJECTIVE

To determine and compare the FSBR, ENMR, and NMR between 2015 before initiation of the program (baseline) and subsequent years up to 2020 following the implementation of facility-based training of HBB in five hospitals in ORT District.

METHODS

Records of perinatal statistics from January 2015 to December 2020 were reviewed to calculate FSBR, ENMR, and NMR. Data were collected from the five healthcare facilities which included two district hospitals (Hospital A&B), two regional hospitals (Hospital C&D), and one tertiary hospital (Hospital E). Comparisons were made between pre- (2015) and post- (2016-2020) HBB implementation periods. Differences in changes over time were also assessed using linear regression analysis.

RESULTS

There were 19,275 births in 2015, increasing to 22,192 in 2020 with the majority (55.3%) of births occurring in regional hospitals. There were significant reductions in ENMR (OR-0.78, 95% CI 0.70-0.87) and NMR (OR-0.81, 95% CI 0.73-0.90), but not in FSBR, in the five hospitals combined when comparing the two time periods. Significant reduction was also noted in trends over time in ENMR (r ² = 0.45, p = 0.001) and NMR (r ² = 0.23, p = 0.026), but not in FSBR (r ² = 0.0, p = 0.984) with all hospitals combined. In looking at individual hospitals, Hospital A (r ² = 0.61, p < 0.001) and Hospital E (r ² = 0.19, p = 0.048) showed a significant reduction in ENMR over time, but there were no significant changes in all mortality rates for Hospitals B, C, and D, and for the district or regional hospitals combined.

CONCLUSION

There was an overall reduction of 22% and 19% in ENMR and NMR, respectively, from pre- to post-HBB implementation periods, although there were variations from year to year over the 5-year period and, across hospitals. These differences suggest that there were other factors that affected the perinatal/neonatal outcomes in the hospital sites in addition to the implementation of training in HBB.

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.

Converging or diverging trajectories of mortality under one year of age in the Baltic States: a comparison with the European Union

BACKGROUND

Information about trends in perinatal and child health inequalities is scarce, especially in the Eastern Europe. We analyzed how mortality under 1 year of age has been changing in the Baltic States and the European Union (EU) over 25 years, and what associations occurred between changes in macroeconomic factors and mortality.

METHODS

Data on fetal, neonatal, infant mortality, and macroeconomic factors were extracted from WHO database. Joinpoint regression analysis was performed to analyze time trajectories of mortality over 1990-2014. We also investigated how the changes in health expenditures and Gross Domestic Product (GDP) contributed to the changes in mortality.

RESULTS

The reduction of fetal, neonatal and infant mortality in the Baltic countries led to convergence with the EU. In Estonia this process was the fastest, and then the rates tended to diverge. The strongest effect in reduction of neonatal mortality was related to the annual increase in health expenditure and GDP which had occurred in the same year, and a decrease in fetal mortality associated with an increase in health expenditure and GDP in the 4th and 5th year, respectively, following the initial change.

CONCLUSIONS

These findings outlined convergences and divergences in mortality under 1 year of age in the Baltic States compared with the patterns of the EU. Our data highlighted a need to define health policy directions aimed at the implementation of effective intervention modalities addressing reduction of risks in prenatal and early life.

Spatial pattern of perinatal mortality and its determinants in Ethiopia: Data from Ethiopian Demographic and Health Survey 2016

BACKGROUND

The perinatal mortality rate in Ethiopia is among the highest in Sub Saharan Africa. The aim of this study was to identify the spatial patterns and determinants of perinatal mortality in the country using a national representative 2016 Ethiopia Demographic and Health Survey (EDHS) data.

METHODS

The analysis was completed utilizing data from 2016 Ethiopian Demographic and Health Survey. This data captured the information of 5 years preceding the survey period. A total of 7230 women who at delivered at seven or more months gestational age nested within 622 enumeration areas (EAs) were used. Statistical analysis was performed by using STATA version 14.1, by considering the hierarchical nature of the data. Multilevel logistic regression models were fitted to identify community and individual-level factors associated with perinatal mortality. ArcGIS version 10.1 was used for spatial analysis. Moran's, I statistics fitted to identify global autocorrelation and local autocorrelation was identified using SatSCan version 9.6.

RESULTS

The spatial distribution of perinatal mortality in Ethiopia revealed a clustering pattern. The global Moran's I value was 0.047 with p-value <0.001. Perinatal mortality was positively associated with the maternal age, being from rural residence, history of terminating a pregnancy, and place of delivery, while negatively associated with partners' educational level, higher wealth index, longer birth interval, female being head of household and the number of antenatal care (ANC) follow up.

CONCLUSIONS

In Ethiopia, the perinatal mortality is high and had spatial variations across the country. Strengthening partner's education, family planning for longer birth interval, ANC, and delivery services are essential to reduce perinatal mortality and achieve sustainable development goals in Ethiopia. Disparities in perinatal mortality rates should be addressed alongside efforts to address inequities in maternal and neonatal healthcare services all over the country.

Circulating pregnancy hormone relaxin as a first trimester biomarker for preeclampsia

OBJECTIVE

Preeclampsia, a multi-system hypertensive disorder, is associated with perturbations in the maternal cardiovascular system during early pregnancy. The corpus luteal hormone relaxin, a potent vasodilator, may contribute to physiological circulatory changes especially in early gestation when circulating levels are highest. This study investigated whether first trimester circulating relaxin may be a suitable biomarker for the early prediction of preeclampsia.

METHODS

Relaxin was initially measured in first-trimester samples of women who developed late-onset preeclamptic (LO-PE; delivery ≥ 34 weeks; n = 33) and uncomplicated pregnancies (n = 25) in Pittsburgh, USA. Subsequently, to expand the group numbers, relaxin was measured in women who developed LO-PE (n = 95), early-onset preeclamptic (EO-PE; delivery < 34 weeks; n = 57), and uncomplicated pregnancies (n = 469) in Utrecht, the Netherlands.

RESULTS

In the Pittsburgh subjects, low relaxin levels (lowest centile: <p10) showed an adjusted odds ratio (OR) of 5.29 (95%CI 1.10-25.5) for LO-PE. In the Utrecht population, low relaxin levels (<p10) demonstrated adjusted ORs of 1.45 (95%CI 0.54-3.90) and 2.03 (95%CI 1.06-3.88) for EO-PE and LO-PE respectively, the latter increasing to an adjusted OR of 3.18 (95%CI 1.41-7.20) when newborn weight was < 10%. Serum relaxin concentrations slightly improved the detection rate of a previously derived prediction model for LO-PE from 42.5% to 45.1% at a fixed 10% false-positive rate.

CONCLUSION

Relaxin shows little improvement in the performance of first trimester prediction models, which does not support its clinical implementation as a biomarker. Although this study was only correlational, the results point to a possible pathophysiologic role for low relaxin levels in pregnancies that later develop LO-PE.

Persisting inequalities in birth outcomes related to neighbourhood deprivation

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Perinatal Mortality and Associated Factors Among Antenatal Care Attended Pregnant Mothers at Public Hospitals in Gamo Zone, Southern Ethiopia

Introduction: Perinatal mortality is the death of a baby between 28 weeks of gestation onwards and before the first 7 days of life. According to WHO, Ethiopia is one of the most commonly noticed country in the world in considering perinatal mortality rate. The overall perinatal mortality rate in Ethiopia was around 66-124 per 1,000 births. Objective: To determine the magnitude of perinatal mortality and associated factors among mothers who attended antenatal care at public hospitals in Gamo Zone, Southern Ethiopia. Methods: A cross-sectional study was conducted at Arba Minch General Hospital and Chencha District Hospital antenatal care attended by pregnant mothers from the 1st of February to the 28th of March 2019, among the mothers enrolled at ANC clinic from the 1st of January to the 30th of December 2018 using a simple random sampling method for the pre-determined 1,820 records. Both bivariate and multivariable logistic regression analysis was conducted. Variables which had a p-value <0.25 in bivariate analysis were considered as a candidate variable for multivariable analysis and variables which had a P-value <0.05 in multivariable analysis were declared as statically significant. Results: The prevalence of perinatal mortality was 12.6% (95% CI: 11.80, 13.40) and grand multiparity (AOR: 7.40; 95% CI: 2.77, 20.26), having one antenatal visit (AOR: 4.40; 95% CI: 1.64, 11.91), spontaneous vaginal delivery (AOR: 0.36; 95% CI: 0.16, 0.82), being pre-term (AOR: 6.78; 95% CI: 2.41, 19.09), birth weight <2,500 gram (AOR: 3.10; 95% CI: 1.48, 6.46), maternal ever hemoglobin level <10 gm/dl (AOR: 4.04; 95% CI: 1.91, 8.57), and pre-partum onset of pregnancy induced hypertension (AOR: 4.01; 95% CI: 2.01, 6.08) were statistically significant in the multivariable logistic regression model. Conclusion: The magnitude of perinatal mortality was high as compared with the Ethiopian Health and Demographic Survey report 2016 and high parity, low in number of antenatal care visits, low gestational age, low birth weight, low maternal hemoglobin level, and pre-partum onset of pregnancy induced hypertension were independent factors which increase the perinatal mortality while spontaneous vaginal delivery reduces the mortality risk. Therefore; the community should be educated to reduce the number of instance of births. In addition; the health care professionals should emphasize on the care provided for the newborns having low birth weight and use spontaneous vaginal delivery as much as possible.

Association between fetal sex, birthweight percentile and adverse pregnancy outcome

Introduction

The objective was to evaluate the association between fetal sex and adverse pregnancy outcome, while correcting for fetal growth and gestational age at delivery.

Material and methods

Data from the Netherlands Perinatal Registry (1999‐2010) were used. The study population comprised all white European women with a singleton delivery between 25⁺⁰ and 42⁺⁶ weeks of gestation. Fetuses with structural or chromosomal abnormalities were excluded. Outcomes were antepartum death, intrapartum/neonatal death (from onset of labor until 28 days after birth), perinatal death (antepartum death or intrapartum/neonatal death), a composite of neonatal morbidity (including infant respiratory distress syndrome, sepsis, necrotizing enterocolitis, meconium aspiration, persistent pulmonary hypertension of the newborn, periventricular leukomalacia, Apgar score <7 at 5 minutes, and intracranial hemorrhage) and a composite adverse neonatal outcome (perinatal death or neonatal morbidity). Outcomes were expressed stratified by birthweight percentile (<p10 [small for gestation], p10‐90 [normal weight], >p90 [large for gestation]) and gestational age at delivery (25⁺⁰‐27⁺⁶, 28⁺⁰‐31⁺⁶, 32⁺⁰‐36⁺⁶, 37⁺⁰‐42⁺⁶ weeks). The association between fetal sex and outcome was assessed using the fetus at risk approach.

Results

We studied 1 742 831 pregnant women. We found no increased risk of antepartum, intrapartum/neonatal and perinatal death in normal weight and large‐for‐gestation males born after 28⁺⁰ weeks compared with females. We found an increased risk of antepartum death among small‐for‐gestation males born after 28⁺⁰ weeks (relative risk [RR] 1.16‐1.40). All males born after 32⁺⁰ weeks of gestation suffered more neonatal morbidity than females regardless of birthweight percentile (RR 1.07‐1.34). Infant respiratory distress syndrome, sepsis, persistent pulmonary hypertension of the newborn, Apgar score <7 at 5 minutes, and intracranial hemorrhage all occurred more often in males than in females.

Conclusions

Small‐for‐gestation males have an increased risk of antepartum death and all males born after 32⁺⁰ weeks of gestation have an increased risk of neonatal morbidity compared with females. In contrast to findings in previous studies we found no increased risk of antepartum, intrapartum/neonatal or perinatal death in normal weight and large‐for‐gestation males born after 28+0 weeks.

Sentinel Amenable Mortality: A New Way to Assess the Quality of Healthcare by Examining Causes of Premature Death for Which Highly Efficacious Medical Interventions Are Available

BACKGROUND

Amenable mortality, or premature deaths that could be prevented with medical care, is a proven indicator for assessing healthcare quality when adapted to a country or region's specific healthcare context. This concept is currently used to evaluate the performance of national and international healthcare systems. However, the levels of efficacy and effectiveness determined using this indicator can vary greatly depending on the causes of death that are included. We introduce a new approach by identifying a subgroup of causes for which there are available treatments with a high level of efficacy. These causes should be considered sentinel events to help identify limitations in the effectiveness and quality of health provision.

METHODS

We conducted an extensive literature review using a list of amenable causes of death compiled by Spanish researchers. We complemented this approach by assessing the time trends of amenable mortality in two high-income countries that have a similar quality of healthcare but very different systems of provision, namely, Spain and the United States. This enabled us to identify different levels of efficacy of medical interventions (high, medium, and low). We consulted a group of medical experts and combined this information to help make the final classification of sentinel amenable causes of death.

RESULTS

Sentinel amenable mortality includes causes such as surgical conditions, thyroid diseases, and asthma. The remaining amenable causes of death either have a higher complexity in terms of the disease or need more effective medical interventions or preventative measures to guarantee early detection and adherence to treatment. These included cardiovascular diseases, diabetes, hypertension, all amenable cancers, and some infectious diseases such as pneumonia, influenza, and tuberculosis.

CONCLUSIONS

Sentinel amenable mortality could act as a good sentinel indicator to identify major deficiencies in healthcare quality and provision and detect inequalities across populations.

Regional variations in childbirth interventions in the Netherlands: a nationwide explorative study

BACKGROUND

Although interventions in childbirth are important in order to prevent neonatal and maternal morbidity and mortality, non-indicated use may cause avoidable harm. Regional variations in intervention rates, which cannot be explained by maternal characteristics, may indicate over- and underuse. The aim of this study is to explore regional variations in childbirth interventions in the Netherlands and their associations with interventions and adverse outcomes, controlled for maternal characteristics.

METHODS

Childbirth intervention rates were compared between twelve Dutch regions, using data from the national perinatal birth register for 2010-2013. All single childbirths from 37 weeks' gestation onwards were included. Primary outcomes were induction and augmentation of labour, pain medication, instrumental birth, caesarean section (prelabour, intrapartum) and paediatric involvement. Secondary outcomes were adverse neonatal and maternal outcomes. Multivariable logistic regression analyses were used to adjust for maternal characteristics. Associations were expressed in Spearman's rank correlation coefficients.

RESULTS

Most variation was found for type of pain medication and paediatric involvement. Epidural analgesia rates varied from between 12 and 38% (nulliparous) and from between 5 and 14% (multiparous women). These rates were negatively correlated with rates of other pharmacological pain relief, which varied from between 15 and 43% (nulliparous) and from between 10 and 27% (multiparous). Rates of paediatric involvement varied from between 37 and 60% (nulliparous) and from between 26 and 43% (multiparous). For instrumental vaginal births, rates varied from between 16 and 19% (nulliparous) and from between 3 and 4% (multiparous). For intrapartum caesarean section, the variation was 13-15% and 5-6%, respectively. A positive correlation was found between intervention rates in midwife-led and obstetrician-led care at the onset of labour within the same region. Adverse neonatal and maternal outcomes were not lower in regions with higher intervention rates. Higher augmentation of labour rates correlated with higher rates of severe postpartum haemorrhage.

CONCLUSIONS

Most variation was found for type of pain medication and paediatric involvement, and least for instrumental vaginal births and intrapartum caesarean sections. Care providers and policy makers should critically audit remarkable variations, since these may be unwarranted. Limited variation for some interventions may indicate consensus for their use. Further research should focus on variations in evidence-based interventions and indications for the use of interventions in childbirth.

Older mothers and increased impact of prenatal screening: stable livebirth prevalence of trisomy 21 in the Netherlands for the period 2000-2013

In the Netherlands, there is no registry system regarding the livebirth prevalence of trisomy 21 (T21). In 2007, a national screening programme was introduced for all pregnant women, which may have changed the livebirth prevalence of T21. The aim of this study is to analyse trends in factors that influence livebirth prevalence of T21 and to estimate the livebirth prevalence of T21 for the period of 2000–2013. National data sets were used on the following: (1) livebirths according to maternal age and (2) prenatal testing and termination of pregnancy (ToP) following diagnosis of T21. These data are combined in a model that uses maternal age-specific risk on T21 and correction factors for natural foetal loss to assess livebirth prevalence of T21. The proportion of mothers aged ≥ 36 years has increased from 12.2% in 2000 to 16.6% in 2009, to gradually decrease afterwards to 15.2% in 2013. The number of invasive tests performed adjusted for total livebirths decreased (5.9% in 2000 vs. 3.2% in 2013) with 0.18% a year (95% CI: −0.21 to −0.15; p   < 0.001). Following invasive testing, a higher proportion of foetuses was diagnosed with T21 (1.6% in 2000 vs. 4.8% in 2013) with a significant increase of 0.22% a year (95% CI: 0.18–0.26; p < 0.001). The proportion of ToP subsequent to T21 diagnosis was on average 85.7%, with no clear time trend. This resulted in a stable T21 livebirth prevalence of 13.6 per 10,000 livebirths (regression coefficient −0.025 (95% CI: −0.126 to 0.77; p = 0.60).

Client satisfaction and transfers across care levels of women with uncomplicated pregnancies at the onset of labor

OBJECTIVE

to compare the client satisfaction of women with uncomplicated pregnancies at the onset of labor who were transferred across care levels during childbirth and women who were not transferred across care levels in the Dutch perinatal healthcare system, and-if there are differences-to identify the variables that may explain them.

METHODS

the research entailed a population-based study of women with uncomplicated pregnancies at the onset of labor living in the catchment area of a Dutch Neonatal Intensive Care Unit (NICU) in the eastern part of the Netherlands who gave birth between April 2014 and September 2014. Respondents completed a validated questionnaire (n = 842; mean age 30.7 years). Client satisfaction, measured on a 10-point scale, was assessed within 12 weeks after childbirth.

FINDINGS

of the 842 respondents, 277 women experienced a transfer of care during childbirth, and 565 women were not transferred. The client satisfaction of women who were transferred across care levels (mean 8.04; SD 1.4) was significantly lower (p<0.001) than that of women who were not transferred across care levels (mean 8.78; SD 0.9). Seven variables together explained 93.2% of the difference in client satisfaction. Explanatory pregnancy and childbirth variables were perceived health problems for the mother and medical interventions during childbirth. Explanatory clients' experiences with the care process variables were respect, prompt attention, quality of basic amenities, social consideration, and choice and continuity.

CONCLUSION

women were highly satisfied with the care they received, although transfers across care levels during childbirth were associated with substantially lower client satisfaction. The differences in client satisfaction between transferred and non-transferred women can largely be explained by pregnancy and childbirth characteristics, and by clients' experiences with the care process.

Spatial Analysis of China Province-level Perinatal Mortality

BACKGROUND

Using spatial analysis tools to determine the spatial patterns of China province-level perinatal mortality and using spatial econometric model to examine the impacts of health care resources and different socio-economic factors on perinatal mortality.

METHODS

The Global Moran's I index is used to examine whether the spatial autocorrelation exists in selected regions and Moran's I scatter plot to examine the spatial clustering among regions. Spatial econometric models are used to investigate the spatial relationships between perinatal mortality and contributing factors.

RESULTS

The overall Moran's I index indicates that perinatal mortality displays positive spatial autocorrelation. Moran's I scatter plot analysis implies that there is a significant clustering of mortality in both high-rate regions and low-rate regions. The spatial econometric models analyses confirm the existence of a direct link between perinatal mortality and health care resources, socio-economic factors.

CONCLUSIONS

Since a positive spatial autocorrelation has been detected in China province-level perinatal mortality, the upgrading of regional economic development and medical service level will affect the mortality not only in region itself but also its adjacent regions.

Social equity in perinatal survival: a case-control study at hospitals in Kigali, Rwanda

AIM

Rwanda has invested heavily in improving maternal and child health, but knowledge is limited regarding social equity in perinatal survival. We analysed whether perinatal mortality risks differed between social groups in hospitals in the country's capital.

METHODS

A case-control study was carried out on singleton births aged at least 22 weeks of gestation and born in district or tertiary referral hospitals in Kigali from July 2013 to May 2014. Perinatal deaths were recorded as they occurred, with the next two surviving neonates born in the same hospital selected as controls. Conditional logistic regression was used to determine social determinants of perinatal death after adjustments for potential confounders.

RESULTS

We analysed 234 perinatal deaths and 468 controls. Rural residence was linked to an increased risk of perinatal death (OR = 3.31, 95% CI 1.43-7.61), but maternal education or household asset score levels were not. Having no health insurance (OR = 2.11, 95% CI 0.91-4.89) was associated with an increased risk of perinatal death, compared to having community health insurance.

CONCLUSION

Living in a rural area and having no health insurance were associated with an increased risk of perinatal mortality rates in the Rwandan capital, but maternal education and household assets were not.

Disparities in Infant Mortality Due to Congenital Anomalies on Guam

In the 1970's and 1980's, there were large inter-village disparities in infant mortality due to congenital anomalies on Guam. A village-level analysis was conducted to determine if these disparities can be explained by behavioral (ie, median age of village females, village fertility ratio), structural (ie, population density, persons per household, single mother households per village, married females per village), and environmental (ie, living in a village where Agent Orange (AO) spraying was conducted) factors. Village-level data for live births and infant mortality due to congenital anomalies (1970-1989) was collected from Guam's Office of Vital Statistics. Data on median age of village females, village fertility ratio, population density, persons per household, single mother households, and married females were obtained from the 1980 US Census. Estimates of village-level AO use were provided through personal communications, and villages were dichotomized into AO and non-AO spray areas. Village location was classified by usual residence of the mother. Linear regression was used to determine associations between infant mortality due to congenital anomalies and the behavioral, structural, and environmental factors. The association between AO spray area and infant mortality due to congenital anomalies was statistically significant under univariable (B [95%CI] = 1.88 [0.64,3.11], P = .005) and multivariable conditions (B [95%CI] = 2.02 [0.08,3.96], P = .042). These results suggest that infants born to mothers whose usual residence was in an AO spray area on Guam are at an increased risk of mortality due to congenital anomalies. Further studies using individual-level data are needed to validate these results.

Environmental and socio-economic determinants of infant mortality in Poland: an ecological study

BACKGROUND

Health status of infants is related to the general state of health of women of child-bearing age; however, women's occupational environment and socio-economic conditions also seem to play an important role. The aim of the present ecological study was to assess the relationship between occupational environment, industrial pollution, socio-economic status and infant mortality in Poland.

METHODS

Data on infant mortality and environmental and socio-economic characteristics for the 66 sub-regions of Poland for the years 2005-2011 were used in the analysis. Factor analysis was used to extract the most important factors explaining total variance among the 23 studied exposures. Generalized Estimating Equations model was used to evaluate the link between infant mortality and the studied extracted factors.

RESULTS

Marked variation for infant mortality and the characteristics of industrialization was observed among the 66 sub-regions of Poland. Four extracted factors: "poor working environment", "urbanization and employment in the service sector", "industrial pollution", "economic wealth" accounted for 77.3% of cumulative variance between the studied exposures. In the multivariate regression analysis, an increase in factor "poor working environment" of 1 SD was related to an increase in infant mortality of 40 (95% CI: 28-53) per 100,000 live births. Additionally, an increase in factor "industrial pollution" of 1 SD was associated with an increase in infant mortality of 16 (95% CI: 2-30) per 100,000 live births. The factors "urbanization and employment in the service sector" and "economic wealth" were not significantly related to infant mortality.

CONCLUSION

The study findings suggested that, at the population level, infant mortality was associated with an industrial environment. Strategies to improve working conditions and reduce industrial pollution might contribute to a reduction in infant mortality in Poland.

Comparison of Perinatal Outcome of Preterm Births Starting in Primary Care versus Secondary Care in Netherlands: A Retrospective Analysis of Nationwide Collected Data

Introduction. In Netherlands, the obstetric care system is divided into primary and secondary care by risk level of the pregnancy. We assessed the incidence of preterm birth according to level of care and the association between level of care at time of labor onset and delivery and adverse perinatal outcome. Methods. Singleton pregnancies recorded in Netherlands Perinatal Registry between 1999 and 2007, with spontaneous birth between 25(+0) and 36(+6) weeks, were included. Three groups were compared: (1) labor onset and delivery in primary care; (2) labor onset in primary care and delivery in secondary care; (3) labor onset and delivery in secondary care. Multivariable logistic regression analyses were performed to calculate the risk of perinatal mortality and Apgar score ≤4. Results. Of all preterm deliveries, 42% had labor onset and 7.9% had also delivery in primary care. Women with labor onset between 34(+0) and 36(+6) weeks who were referred before delivery to secondary care had the lowest risk of perinatal mortality (aOR 0.49 (0.30-0.79)). Risk of perinatal mortality (aOR 1.65; 95% CI 1.20-2.27) and low Apgar score (aOR 1.95; 95% CI 1.53-2.48) were significantly increased in preterm home delivery. Conclusion. Referral before delivery is associated with improved perinatal outcome in the occurrence of preterm labor onset in primary care.

Implementation of external cephalic version in the Netherlands: a retrospective cohort study

BACKGROUND

External cephalic version (ECV) reduces the rate of elective cesarean sections as a result of breech presentation. Several studies have shown that not all eligible women undergo an ECV attempt. The aim of this study was to evaluate the implementation of ECV in the Netherlands and to explain variation in implementation rates with hospital characteristics and individual factors.

METHODS

We invited 40 hospitals to participate in this retrospective cohort study. We reviewed hospital charts for all singleton breech deliveries from 36 weeks' gestation and onwards between January 2008 and December 2009. We documented whether an ECV attempt was performed, reasons for not performing an attempt, mode of delivery, and hospital characteristics.

RESULTS

We included 4,770 women from 36 hospitals. ECV was performed in 2,443 women (62.2% of eligible women, range 8.2-83.6% in different hospitals). Implementation rates were higher in teaching hospitals, hospitals with special office hours for ECV, larger obstetric units, and hospitals located in larger cities. Suboptimal implementation was mainly caused by health care providers who did not offer ECV.

CONCLUSION

ECV implementation rates vary widely among hospitals. Suboptimal implementation is mostly caused by the care provider not offering the treatment and secondly due to women not opting for the offered attempt. A prerequisite for designing a proper implementation strategy is a detailed understanding of the exact reasons for not offering and not opting for ECV.

Birth weight ratio as an alternative to birth weight percentile to express infant weight in research and clinical practice: a nationwide cohort study

Objective. To compare birth weight ratio and birth weight percentile to express infant weight when assessing pregnancy outcome. Study Design. We performed a national cohort study. Birth weight ratio was calculated as the observed birth weight divided by the median birth weight for gestational age. The discriminative ability of birth weight ratio and birth weight percentile to identify infants at risk of perinatal death (fetal death and neonatal death) or adverse pregnancy outcome (perinatal death + severe neonatal morbidity) was compared using the area under the curve. Outcomes were expressed stratified by gestational age at delivery separate for birth weight ratio and birth weight percentile. Results. We studied 1,299,244 pregnant women, with an overall perinatal death rate of 0.62%. Birth weight ratio and birth weight percentile have equivalent overall discriminative performance for perinatal death and adverse perinatal outcome. In late preterm infants (33(+0)-36(+6) weeks), birth weight ratio has better discriminative ability than birth weight percentile for perinatal death (0.68 versus 0.63, P  0.01) or adverse pregnancy outcome (0.67 versus 0.60, P < 0.001). Conclusion. Birth weight ratio is a potentially valuable instrument to identify infants at risk of perinatal death and adverse pregnancy outcome and provides several advantages for use in research and clinical practice. Moreover, it allows comparison of groups with different average birth weights.

EXPRESS study shows significant regional differences in 1-year outcome of extremely preterm infants in Sweden

Aim

The aim of this study was to investigate differences in mortality up to 1 year of age in extremely preterm infants (before 27 weeks) born in seven Swedish healthcare regions.

Methods

National prospective observational study of consecutively born, extremely preterm infants in Sweden 2004–2007. Mortality was compared between regions. Crude and adjusted odds ratios and 95% CI were calculated.

Results

Among 844 foetuses alive at mother's admission for delivery, regional differences were identified in perinatal mortality for the total group (22–26 weeks) and in the stillbirth and perinatal and 365-day mortality rates for the subgroup born at 22–24 weeks. Among 707 infants born alive, regional differences were found both in mortality before 12 h and in the 365-day mortality rate for the subgroup (22–24 weeks) and for the total group (22–26 weeks). The mortality rates were consistently lower in two healthcare regions. There were no differences in the 365-day mortality rate for infants alive at 12 h or for infants born at 25 weeks. Neonatal morbidity rates among survivors were not higher in regions with better survival rates. Perinatal practices varied between regions.

Conclusion

Mortality rates in extremely preterm infants varied considerably between Swedish healthcare regions in the first year after birth, particularly between the most immature infants.

Unemployment and stillbirth risk among foreign-born and Spanish pregnant women in Spain, 2007-2010: a multilevel analysis study

We describe stillbirth and unemployment rates by autonomous region in Spain and analyse whether women who gave birth in regions with high unemployment rates were more likely to have a stillborn. We designed a multilevel population-based observational study of births from 2007 to 2010. We defined stillbirth as the outcome, individual maternal socioeconomic and pregnancy-related characteristics as covariates, and maternal autonomous region of residence as the contextual covariate. We used mixed-logistic regression models to account for differences across regions. In total, 1,920,235 singleton births and 5,560 stillbirths were included in the study. Women residing in autonomous regions with the highest rates of unemployment had a two-times-greater chance of delivering a stillborn (adjusted OR 2.60; 95 % CI 2.08-3.21). The region where women resided explained 14 % of the total individual differences in the risk of delivering a stillborn. The odds of stillbirth were 1.82 (95 % CI 1.62-2.05) times higher for African-born women than for Spanish-born women and 1.90 (95 % CI 1.68-2.15) times higher for women with low educational attainment than for women with higher education. In conclusion, regional disparities in stillbirth rates in Spain in the period 2007-2010 were mainly associated with mothers who had low levels of education, were African-born, and lived in regions with higher unemployment.

Perinatal health inequalities and accessibility of maternity services in a rural French region: closing maternity units in Burgundy

Maternity unit closures in France have increased travel time for pregnant women in rural areas. We assessed the impact of travel time to the closest unit on perinatal outcomes and care in Burgundy using multilevel analyses of data on deliveries from 2000 to 2009. A travel time of 30min or more increased risks of fetal heart rate anomalies, meconium-stained amniotic fluid, out-of-hospital births, and pregnancy hospitalizations; a positive but non-significant gradient existed between travel time and perinatal mortality. The effects of long travel distances on perinatal outcomes and care should be factored into closure decisions.

Maternal education and risk of offspring death; changing patterns from 16 weeks of gestation until one year after birth

BACKGROUND

The social disparity in perinatal mortality may vary by the age of the offspring. We studied offspring mortality from pregnancy week 16 until 1 year after birth by maternal educational level.

METHODS

We included all births in Norwegian women during the years 1999-2004 (n = 297 663). The Medical Birth Registry of Norway was linked to the Norwegian Education Registry to obtain individual information on maternal education at the time of delivery. Information on infant mortality was obtained by linkage to the Norwegian Central Person Registry.

RESULTS

In pregnancy weeks 37 through 43 and in the first week after birth, there was little difference in offspring mortality by maternal education. Before pregnancy week 37, the excess offspring mortality associated with compulsory school only was >60% using university/college education as the reference. During the 2nd through 12th month after birth, the excess mortality was 132% in offspring of mothers with compulsory school only.

CONCLUSION

The social disparity in offspring mortality was lowest in pregnancies at term and in the first week after birth. In this period, all women living in Norway and their infants use the public health care service extensively. Our results may suggest that health care that is equally available to all citizens, reduces social disparities in mortality.

Recurrence of small-for-gestational-age pregnancy: analysis of first and subsequent singleton pregnancies in The Netherlands

OBJECTIVE

Small-for-gestational-age (SGA) neonates are at increased risk of adverse pregnancy outcome. Our objective was to study the recurrence rate of SGA in subsequent pregnancies.

STUDY DESIGN

A prospective national cohort study of all women with a structurally normal first and subsequent singleton pregnancy from 1999-2007. SGA was defined as birthweight <5th percentile for gestation. We compared the incidence and recurrence rate of SGA for women in total and with and without a hypertensive disorder (HTD) in their first pregnancy. Moreover, we assessed the association between gestational age at first delivery and SGA recurrence.

RESULTS

We studied 259,481 pregnant women, of whom 12,943 women (5.0%) had an SGA neonate in their first pregnancy. The risk of SGA in the second pregnancy was higher in women with a previous SGA neonate than for women without a previous SGA neonate (23% vs 3.4%; adjusted odds ratio, 8.1; 95% confidence interval, 7.8-8.5) and present in both women with and without an HTD in pregnancy. In women without an HTD, the increased recurrence risk was independent of the gestational age at delivery in the index pregnancy; whereas in women with an HTD, this recurrence risk was increased only when the woman with the index delivery delivered at >32 weeks' gestation.

CONCLUSION

Women with SGA in their first pregnancy have a strongly increased risk of SGA in the subsequent pregnancy and first pregnancy SGA delivers a significant contribution to the total number of second pregnancy SGA cases.

Regional variation in late preterm births in North Carolina

Late preterm (LPT) neonates (34 0/7th-36 6/7th weeks' gestation) account for 70% of all premature births in the United States. LPT neonates have a higher morbidity and mortality risk than term neonates. LPT birth rates vary across geographic regions. Unwarranted variation is variation in medical care that cannot be explained by sociodemographic or medical risk factors; it represents differences in health system performance, including provider practice variation. The purpose of this study is to identify regional variation in LPT births in North Carolina that cannot be explained by sociodemographic or medical/obstetric risk factors. We searched the NC State Center for Health Statistics linked birth-death certificate database for all singleton term and LPT neonates born between 1999 and 2006. We used multivariable logistic regression analysis to control for socio-demographic and medical/obstetric risk factors. The main outcome was the percent of LPT birth in each of the six perinatal regions in North Carolina. We identified 884,304 neonates; 66,218 (7.5%) were LPT. After multivariable logistic regression, regions 2 (7.0%) and 6 (6.6%) had the highest adjusted percent of LPT birth. Analysis of a statewide birth cohort demonstrates regional variation in the incidence of LPT births among NC's perinatal regions after adjustment for sociodemographic and medical risk factors. We speculate that provider practice variation might explain some of the remaining difference. This is an area where policy changes and quality improvement efforts can help reduce variation, and potentially decrease LPT births.

Development of a prognostic model for predicting spontaneous singleton preterm birth

OBJECTIVE

To develop and validate a prognostic model for prediction of spontaneous preterm birth.

STUDY DESIGN

Prospective cohort study using data of the nationwide perinatal registry in The Netherlands. We studied 1,524,058 singleton pregnancies between 1999 and 2007. We developed a multiple logistic regression model to estimate the risk of spontaneous preterm birth based on maternal and pregnancy characteristics. We used bootstrapping techniques to internally validate our model. Discrimination (AUC), accuracy (Brier score) and calibration (calibration graphs and Hosmer-Lemeshow C-statistic) were used to assess the model's predictive performance. Our primary outcome measure was spontaneous preterm birth at <37 completed weeks.

RESULTS

Spontaneous preterm birth occurred in 57,796 (3.8%) pregnancies. The final model included 13 variables for predicting preterm birth. The predicted probabilities ranged from 0.01 to 0.71 (IQR 0.02-0.04). The model had an area under the receiver operator characteristic curve (AUC) of 0.63 (95% CI 0.63-0.63), the Brier score was 0.04 (95% CI 0.04-0.04) and the Hosmer Lemeshow C-statistic was significant (p<0.0001). The calibration graph showed overprediction at higher values of predicted probability. The positive predictive value was 26% (95% CI 20-33%) for the 0.4 probability cut-off point.

CONCLUSIONS

The model's discrimination was fair and it had modest calibration. Previous preterm birth, drug abuse and vaginal bleeding in the first half of pregnancy were the most important predictors for spontaneous preterm birth. Although not applicable in clinical practice yet, this model is a next step towards early prediction of spontaneous preterm birth that enables caregivers to start preventive therapy in women at higher risk.

Healthcare inequalities in paediatric respiratory diseases

Identifying that health inequalities exist is not enough; nor does the knowledge that a patient has a high-risk genotype or comes from a higher risk socioeconomic background does not, by itself, help the patient. To thoroughly examine the origins of health disparities, a broad view of environmental and molecular influences must be included. As these factors are identified, it is important to focus on interventions that can change outcomes for patients. Tools for education, community involvement, literacy, and environmental safety need to be developed, tested and disseminated. The basic science of health disparities must move forward in a coordinated fashion by structuring research that is an integrated effort between basic sciences, clinical medicine and include all traditionally underserved communities. Only through these collaborations can we hope to eliminate health inequalities in the future.

Neonatal morbidity in term neonates is related to gestational age at birth and level of care

AIMS

The objective of this study was to assess whether the incidence of neonatal morbidity of neonates born at term and admitted to a neonatal intensive care unit (NICU) differs by gestational age and level of care.

METHODS

This is a 5-year retrospective cohort study of singleton term births admitted to the NICU of the VU University Medical Center with a gestational age ≥37+0 weeks.

RESULTS

In total, 497 neonates were included in the study. The incidence of neonates born with an arterial cord blood pH<7.10, neonatal asphyxia, and meconium aspiration syndrome increased with advancing gestational age. The incidence of secondary cesarean section and operative vaginal delivery also increased with advancing gestational age. Neonatal death occurred in 29 (5.84%) of the 497 cases; 27 (93%) of 29 were due to asphyxia. Seventeen (34%) of the 50 neonates born in primary care were admitted for asphyxia. Eight (47%) of these 17 neonates died.

CONCLUSIONS

Neonatal morbidity in term neonates is related to gestational age at birth. Since asphyxia is an important cause of both morbidity and mortality in term neonates, it is important to clearly define and include asphyxia in future perinatal audits.

[Short-term complications of late preterm infants]

INTRODUCTION

Late preterm infants, born at 34-36(+6) weeks gestation, are physiologically more immature than term infants. As a consequence, they have an increased risk of morbidity and mortality. Since health outcomes in prematurity may change depending on local factors we have proposed determine the short-term medical problems of these infants in our hospital.

PATIENTS AND METHODS

A retrospective observational study was carried out on all newborn ≥ 34 weeks gestation admitted to Virgen del Rocio hospital from May 2005 to December 2008. We divided this cohort into late preterm (34-36(+6) weeks, n=769) and term (37-41(+6) weeks, n=1460) groups. We compared mortality and morbidity data between the 2 groups.

RESULTS

Late preterm group was associated with assisted reproduction, twin pregnancy, caesarean delivery and preeclampsia during pregnancy. The risk of hospitalization was six times greater in these infants and neonatal intensive care admissions were twice as common. The hospital stay was double in this group. Neonatal respiratory morbidity and jaundice were greater in the preterm group. The use of surfactant, oxygen and respiratory support (CPAP and CMV) was also higher. There were no significant differences in hypoglycaemia and neonatal mortality between both groups.

CONCLUSIONS

Late preterm infants represent a well-defined risk group for developing complications and should be available the necessary resources should be made available for their special care.

Trends in preterm birth: singleton and multiple pregnancies in the Netherlands, 2000-2007

OBJECTIVE

Several studies have reported increasing trends in preterm birth in developed countries, mainly attributable to an increase in medically indicated preterm births. Our aim was to describe trends in preterm birth among singleton and multiple pregnancies in the Netherlands.

DESIGN

Prospective cohort study.

SETTING

Nationwide study.

POPULATION

We studied 1,451,246 pregnant women from 2000 to 2007.

METHODS

We assessed trends in preterm birth. We subdivided preterm birth into spontaneous preterm birth after premature prelabour rupture of membranes (pPROM), medically indicated preterm birth and spontaneous preterm birth without pPROM. We performed analyses separately for singletons and multiples.

MAIN OUTCOME MEASURES

The primary outcome was preterm birth, defined as birth before 37 weeks of gestation, with very preterm birth (<32 weeks of gestation) being a secondary outcome.

RESULTS

The risk of preterm birth was 7.7% and the risk of very preterm birth was 1.3%. In singleton pregnancies, the preterm birth risk decreased significantly from 6.4% to 6.0% (P < 0.0001), mainly as a result of the decrease in spontaneous preterm birth without pPROM (3.6-3.1%, P < 0.0001). In multiple pregnancies, the preterm birth risk increased significantly (47.3-47.7%, P = 0.047), mainly as a result of medically indicated preterm birth, which increased from 15.0% to 17.9% (P < 0.0001).

CONCLUSION

In the Netherlands, the preterm birth risk in singleton pregnancies decreased significantly over the years. The trend of increasing preterm birth risk reported in other countries was only observed in (medically indicated) preterm birth in multiple pregnancies.

Modeling geographic risk of complex congenital heart defects in Eastern Wisconsin

BACKGROUND

Geographic variation may be an indicator of risk factors for birth defects. This study models the geographic distribution of three complex congenital heart defects (CHDs) in eastern Wisconsin, and evaluates effects of demographic census variables linked to geographic location.

METHODS

Cases of Hypoplastic Left Heart Syndrome (HLHS), Tetralogy of Fallot (TOF) and d-Transposition of the Great Arteries (d-TGAs) born between1995 and 2004 were identified from three medical centers serving eastern Wisconsin. Case diagnoses were assigned by a pediatric cardiologist using echocardiographic records. Births by ZIP code were obtained from the State of Wisconsin. ZIP Code demographic variables were derived from 2000 census data. Numbers of cardiac defects by ZIP code were modeled using cluster analysis and Poisson generalized additive models (GAMs) for spatial coordinates including all and white only cases (excluding trisomies). GAM analyses were repeated adjusting for census variables.

RESULTS

Four hundred forty-eight cases were ascertained. A significant south-to-north spatial gradient for HLHS, TOF, and combined CHDs, but not d-TGAs was identified. This gradient remained significant when census variables were included in the model for the full sample. In the analysis excluding non-white cases, findings were the same for TOF, combined CHDs, and d-TGAs. However, the geographic gradient for HLHS was not significant in the adjusted model.

CONCLUSIONS

A south-to-north gradient was apparent for two of three complex CHDs in eastern Wisconsin. For white cases, demographic variation seems to explain some of this spatial gradient in HLHS. Further studies are needed to confirm demographic and other risk factors underlying this geographic gradient.

Travel time from home to hospital and adverse perinatal outcomes in women at term in the Netherlands

OBJECTIVE

To study the effect of travel time, at the start or during labour, from home to hospital on mortality and adverse outcomes in pregnant women at term in primary and secondary care.

DESIGN

Population-based cohort study from 2000 up to and including 2006.

SETTING

The Netherlands Perinatal Registry.

POPULATION

A total of 751,926 singleton term hospital births.

METHODS

We assessed the impact of travel time by car, calculated from the postal code of the woman's residence to the 99 maternity units, on neonatal outcome. Logistic regression modelling with adjustments for gestational age, maternal age, parity, ethnicity, socio-economic status, urbanisation, tertiary care centres and volume of the hospital was used.

MAIN OUTCOME MEASURES

Mortality (intrapartum, and early and late neonatal mortality) and adverse neonatal outcomes (mortality, Apgar <4 and/or admission to a neonatal intensive care unit).

RESULTS

The mortality was 1.5 per 1000 births, and adverse outcomes occurred in 6.0 per 1000 births. There was a positive relationship between longer travel time (≥20 minutes) and total mortality (OR 1.17, 95% CI 1.002-1.36), neonatal mortality within 24 hours (OR 1.51, 95% CI 1.13-2.02) and with adverse outcomes (OR 1.27, 95% CI 1.17-1.38). In addition to travel time, both delivery at 37 weeks of gestation (OR 2.23, 95% CI 1.81-2.73) or 41 weeks of gestation (OR 1.52, 95% CI 1.29-1.80) increased the risk of mortality.

CONCLUSIONS

A travel time from home to hospital of 20 minutes or more by car is associated with an increased risk of mortality and adverse outcomes in women at term in the Netherlands. These findings should be considered in plans for the centralisation of obstetric care.

Pain acceptance and personal control in pain relief in two maternity care models: a cross-national comparison of Belgium and the Netherlands

BACKGROUND

A cross-national comparison of Belgian and Dutch childbearing women allows us to gain insight into the relative importance of pain acceptance and personal control in pain relief in 2 maternity care models. Although Belgium and the Netherlands are neighbouring countries sharing the same language, political system and geography, they are characterised by a different organisation of health care, particularly in maternity care. In Belgium the medical risks of childbirth are emphasised but neutralised by a strong belief in the merits of the medical model. Labour pain is perceived as a needless inconvenience easily resolved by means of pain medication. In the Netherlands the midwifery model of care defines childbirth as a normal physiological process and family event. Labour pain is perceived as an ally in the birth process.

METHODS

Women were invited to participate in the study by independent midwives and obstetricians during antenatal visits in 2004-2005. Two questionnaires were filled out by 611 women, one at 30 weeks of pregnancy and one within the first 2 weeks after childbirth either at home or in a hospital. However, only women having a hospital birth without obstetric intervention (N = 327) were included in this analysis. A logistic regression analysis has been performed.

RESULTS

Labour pain acceptance and personal control in pain relief render pain medication use during labour less likely, especially if they occur together. Apart from this general result, we also find large country differences. Dutch women with a normal hospital birth are six times less likely to use pain medication during labour, compared to their Belgian counterparts. This country difference cannot be explained by labour pain acceptance, since - in contrast to our working hypothesis - Dutch and Belgian women giving birth in a hospital setting are characterised by a similar labour pain acceptance. Our findings suggest that personal control in pain relief can partially explain the country differences in coping with labour pain. For Dutch women we find that the use of pain medication is lowest if women experience control over the reception of pain medication and have a positive attitude towards labour pain. In Belgium however, not personal control over the use of pain relief predicts the use of pain medication, but negative attitudes towards labour.

CONCLUSIONS

Apart from individual level determinants, such as length of labour or pain acceptance, our findings suggest that the maternity care context is of major importance in the study of the management of labour pain. The pain medication use in Belgian hospital maternity care is high and is very sensitive to negative attitudes towards labour pain. In the Netherlands, on the contrary, pain medication use is already low. This can partially be explained by a low degree of personal control in pain relief, especially when co-occurring with positive pain attitudes.

Predictive value of definitely abnormal general movements in the general population

AIM

Definitely abnormal general movements in populations of high-risk infants predict serious neurodevelopmental impairment. This study aimed to assess predictive values of definitely abnormal general movements at 3 months for serious neurodevelopmental impairment in a representative sample of the general population.

METHOD

A prospective cohort study of 455 3-month-old infants was performed (241 females, 214 males; mean birthweight 3452g, SD 604g; mean gestational age 39.4wks, SD 1.96; n=32 born preterm). At enrolment, general movement quality was assessed by means of video recording. At 4 years, all participants were reassessed by well-baby health clinicians; if serious neurodevelopmental impairment was identified, clinical records were reviewed. Predictive values of definitely abnormal general movement quality for major neurodevelopmental impairment were calculated.

RESULTS

Five children were diagnosed as having a major neurodevelopmental disorder with serious implications for daily life, including three children with cerebral palsy (CP). Three out of the five had shown definitely abnormal general movements; they had lesions involving the periventricular white matter. Two children did not show definitely abnormal general movements; one had unilateral spastic CP due to a cortical lesion and the other had ataxia due to cerebellar atrophy. The positive predictive value of definitely abnormal general movements for major neurodevelopmental impairment was 18/100, and for CP it was 12/100. Negative predictive values approached 100%.

INTERPRETATION

The good predictive value of general movement assessment in high-risk populations cannot be generalized to the general population.