Perinatal and maternal health inequalities: effects of places of residence and delivery

In the Netherlands, perinatal mortality has declined substantially since 1920, although the rate of decline seemed to have levelled off from 1978 onwards. Last decades the decline was as not as steep as in other European countries. As a consequence the Netherlands dropped from a number two position in 1960 to one at the bottom in 2004 in the ranking of the European countries according to perinatal mortality rate. The same stagnating trend is observed for maternal mortality. We may expect that in the Netherlands, an egalitarian prosperous society with universal access to education and (perinatal) health care, health inequalities by area of residence will be limited. But geographical health differences in the Netherlands are persistent, and extend to perinatal health. Hence in the Netherlands, both the general level of perinatal mortality and its geographical distribution deserve attention. New evidence has emerged on (a) factors that may be responsible, among which factors related to obstetric care provision, and on (b) the interrelationships between these individual, geographic, and care-related, factors. This thesis aims to capture the origin of, in particular, the inequalities in perinatal- and maternal outcomes in the Netherlands in relation to socio-economic and ethnic factors, to the area of residence, and to care-related factors in terms of setting and organization. The studies, reported in this thesis, address the following questions: 1. To what extent do ethnic, socioeconomic and geographic related differences exist in adverse perinatal and maternal outcomes in the Netherlands? How are ethnic and socio-economic effects, if existent, related? 2. Do perinatal adverse outcomes in the Netherlands differ according to time of birth (day, evening, night), and hospital-organisational aspects such as the annual number of deliveries (volume) and staffing during and outside office hours? 3. Is intrapartum and early neonatal death different between planned home and planned hospital births in the Netherlands, for assumed low risk women starting delivery under supervision of a community midwife? 4. Can a scavenging system for nitrous oxide-sedation during labour be safe used in a midwifery-led birth centre

Perinatale uitkomsten in de vier grote steden en de prachtwijken in Nederland

__Doel:__ Het verband tussen woonwijk, etniciteit en ongunstige perinatale uitkomsten analyseren bij zwangeren in de 4 grootste steden (Amsterdam, Rotterdam, Den Haag en Utrecht; G4) en in de rest van Nederland. __Opzet:__ Descriptief, retrospectief. __Methode:__ De perinatale uitkomst van 877.816 eenlingzwangerschappen in Nederland in de periode 2002-2006, vastgelegd in de Perinatale Registratie Nederland, werd geanalyseerd op etniciteit van de zwangere (westers of niet-westers) en op woonwijk (achterstandswijk (‘prachtwijk’) of niet) in de G4-steden en daarbuiten. Een ongunstige perinatale uitkomst was gedefinieerd als perinatale sterfte, congenitale afwijkingen, dysmaturiteit, vroeggeboorte, een apgar-score na 5 minuten < 7 en/of opname op een neonatale intensivecareunit. __Resultaten:__ Het perinatale sterftecijfer was in de G4-steden hoger dan in de rest van Nederland (11,1 versus 9,3‰; p < 0,001; 95%-BI van het verschil: 1,2-2,4‰). Hetzelfde gold voor het totaal van ongunstige perinatale uitkomsten (154,9 versus 138,9‰). In de G4-steden was de perinatale sterfte in de groep niet-westerse vrouwen hoger dan in de groep westerse vrouwen (13,2 versus 9,5‰). Het wonen in een prachtwijk gaat gepaard met een hogere perinatale sterfte dan in een niet-prachtwijk (13,5 versus 9,3‰). De relatieve risico’s van het wonen in een prachtwijk zijn groter bij westerse dan bij niet-westerse vrouwen. __Conclusie:__ Vrouwen in de G4-steden hebben een sterk verhoogde kans op een ongunstige perinatale uitkomst. Wonen in een prachtwijk vormt een nog groter risico, vooral voor westerse zwangeren. Deze bevindingen zijn van belang voor het vaststellen van nieuwe strategieën ter

Validity of a questionnaire measuring the world health organization concept of health system responsiveness with respect to perinatal services in the Dutch obstetric care system

Background: The concept of responsiveness, introduced by the World Health Organization (WHO), addresses non-clinical aspects of health service quality that are relevant regardless of provider, country, health system or health condition. Responsiveness refers to "aspects related to the way individuals are treated and the environment in which they are treated" during health system interactions. This paper assesses the psychometric properties of a newly developed responsiveness questionnaire dedicated to evaluating maternal experiences of perinatal care services, called the Responsiveness in Perinatal and Obstetric Health Care Questionnaire (ReproQ), using the eight-domain WHO concept. Methods: The ReproQ was developed between October 2009 and February 2010 by adapting the WHO Responsiveness Questionnaire items to the perinatal care context. The psychometric properties of feasibility, construct validity, and discriminative validity were empirically assessed in a sample of Dutch women two weeks post partum. Results: A total of 171 women consented to participation. Feasibility: the interviews lasted between 20 and 40 minutes and the overall missing rate was 8%. Construct validity: mean Cronbach's alphas for the antenatal, birth and postpartum phase were: 0.73 (range 0.57-0.82), 0.84 (range 0.66-0.92), and 0.87 (range 0.62-0.95) respectively. The item-own scale correlations within all phases were considerably higher than most of the item-other scale correlations. Within the antenatal care, birth care and post partum phases, the eight factors explained 69%, 69%, and 76% of variance respectively. Discriminative validity: overall responsiveness mean sum scores were higher for women whose children were not admitted. This confirmed the hypothesis that dissatisfaction with health outcomes is transferred to their judgement on responsiveness of the perinatal services. Conclusions: The ReproQ interview-based questionnaire demonstrated satisfactory psychometric properties to describe the quality of perinatal care in the Netherlands, with the potential to discriminate between different levels of quality of care. In view of the relatively small sample, further testing and research is recommended

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

Introduction: Social vulnerability is known to be related to ill health. When a pregnant woman is socially vulnerable, the ill health does not only affect herself, but also the health and development of her (unborn) child. To optimise care for highly vulnerable pregnant women, in Rotterdam, a holistic programme was developed in close collaboration between the university hospital, the local government and a non-profit organisation. This programme aims to organise social and medical care from pregnancy until the second birthday of the child, while targeting adult and child issues simultaneously. In 2014, a pilot in the municipality of Rotterdam demonstrated the significance of this holistic approach for highly vulnerable pregnant women. In the Mothers of Rotterdam' study, we aim to prospectively evaluate the effectiveness of the holistic approach, referred to as targeted social care. Methods and analysis: The Mothers of Rotterdam study is a pragmatic prospective cohort study planning to include 1200 highly vulnerable pregnant women for the comparison between targeted social care and care as usual. Effectiveness will be compared on the following outcomes: (1) child development (does the child show adaptive development at year 1?) and (2) maternal mental health (is maternal distress reduced at the end of the social care programme?). Propensity scores will be used to correct for baseline differences between both social care programmes. Ethics and dissemination: The prospective cohort study was approved by the Erasmus Medical Centre Ethics Committee (ref. no. MEC-2016-012) and the first results of the study are expected to be available in the second half of 2019 through publication in peer-reviewed international journals. Trial registration number NTR6271; Pre-results

Quality of perinatal care services from the user's perspective: A Dutch study applies the World Health Organization's responsiveness concept

Background: The concept of responsiveness was introduced by the World Health Organization (WHO) to address non-clinical aspects of service quality in an internationally comparable way. Responsiveness is defined as aspects of the way individuals are treated and the environment in which they are treated during health system interactions. The aim of this study is to assess responsiveness outcomes, their importance and factors influencing responsiveness outcomes during the antenatal and delivery phases of perinatal care. Method: The Responsiveness in Perinatal and Obstetric Health Care Questionnaire was developed in 2009/10 based on the eight-domain WHO concept and the World Health Survey questionnaire. After ethical approval, a total of 171 women, who were 2 weeks postpartum, were recruited from three primary care midwifery practices in Rotterdam, the Netherlands, using face-to-face interviews. We dichotomized the original five ordinal response categories for responsiveness attainment as 'poor' and good responsiveness and analyzed the ranking of the domain performance and importance according to frequency scores. We used a series of independent variables related to health services and users' personal background characteristics in multiple logistic regression analyses to explain responsiveness. Results: Poor responsiveness outcomes ranged from 5.9% to 31.7% for

Prospective observational cohort study of oesophagogastric cancer patients (POCOP): A Dutch nationwide cohort

Experimentele farmacotherapi