Perinatal mortality - system related and environmental factors

In The Netherlands perinatal mortality rates exceed the European average. On a second geographic level of comparison, i.e., within The Netherlands, adverse perinatal outcome rates are much higher in the four largest cities (‘G4’, i.e., Amsterdam, Rotterdam, The Hague, Utrecht). Again, on a third level, i.e., within the G4-cities, adverse perinatal outcomes are overrepresented in socially deprived areas on the borough- and neighbourhood level. For long, population factors such as the high age of mothers at first childbirth, the high prevalence of multiple pregnancies (as a consequence of either assisted reproduction or high maternal age), and the increasing prevalence of non-Western pregnant women were held responsible for the high perinatal mortality. However, these explanations were challenged as perinatal mortality remains high in analyses after exclusion of these risk groups. Recent studies have thus addressed the potential role of other factors, in particular healthcare related factors and geographic (e.g., neighbourhood, environment) factors. Healthcare related factors put forward the unique system of Dutch obstetric care with independently practicing community midwives, travel time to hospital13, and organisational characteristics of hospitals. Candidate environmental factors are physical factors (e.g., air pollution and ambient noise pollution17), and aggregate social factors like urban deprivatio

Perinatale gezondheid in Rotterdam; nulmeting periode 2000-2007

Inleiding Rotterdam heeft binnen Nederland een relatief hoog perinataal sterftecijfer. Onder perinatale sterfte verstaan we sterfte vanaf 22 weken zwangerschapsduur tot en met de eerste 7 dagen na de geboorte. Dit bleek reeds in 2008 toen De Graaf et al. beschreven dat vrouwen in de vier grote steden een sterk verhoogde kans hebben op perinatale sterfte en daarmee samenhangende perinatale ziekte. De belangrijkste vier perinatale ziekten, die vaak voorlopers zijn van perinatale sterfte, zijn aangeboren afwijkingen, vroeggeboorte, laag geboortegewicht gelet op de zwangerschapsduur, en een lage Apgar score (een slechte start bij de geboorte). In vervolg op de bevindingen voor Rotterdam is in 2008 het Aanvalsplan Perinatale Sterfte Rotterdam van start gegaan. Dit is een meerjarig programma waarin de Gemeente Rotterdam in samenwerking met het Erasmus MC en de GGD Rotterdam Rijnmond tot doel heeft de perinatale sterfte en perinatale ziekte binnen Rotterdam te verminderen. Een eerste stap hierbij is het nauwkeurig in kaart brengen van perinatale ziekten en sterfte, en de factoren die mogelijk hiervoor verantwoordelijk zijn. Deze factoren kunnen gebonden zijn aan zwangeren zelf, met hun omgeving te maken hebben of met de zorg te maken hebben

Geographical, ethnic and socio-economic differences in utilization of obstetric care in the netherlands

Background All women in the Netherlands should have equal access to obstetric care. However, utilization of care is shaped by demand and supply factors. Demand is increased in high risk groups (non-Western women, low socio-economic status (SES)), and supply is influenced by availability of hospital facilities (hospital density). To explore the dynamics of obstetric care utilization we investigated the joint association of hospital density and individual characteristics with prototype obstetric interventions. Methods A logistic multi-level model was fitted on retrospective data from the Netherlands Perinatal Registry (years 2000-2008, 1.532.441 singleton pregnancies). In this analysis, the first level comprised individual maternal characteristics, the second of neighbourhood SES and hospital density. The four outcome variables were: referral during pregnancy, elective caesarean section (term and post-term breech pregnancies), induction of labour (term and post-term pregnancies), and birth setting in assumed low-risk pregnancies. Results Higher hospital density is not associated with more obstetric interventions. Adjusted for maternal characteristics and hospital density, living in low SES neighbourhoods, and non- Western ethnicity were generally associated with a lower probability of interventions. For example, non-Western women had considerably lower odds for induction of labour in all geographical areas, with strongest effects in the more rural areas (non-Western women: OR 0.78, 95% CI 0.77-0.80, p<0.001). Conclusion Our results suggest inequalities in obstetric care utilization in the Netherlands, and more specifically a relative underservice to the deprived, independent of level of supply

Blood Transfusions in Total Hip and Knee Arthroplasty: An Analysis of Outcomes

Background. Various studies have raised concern of worse outcomes in patients receiving blood transfusions perioperatively compared to those who do not. In this study we attempted to determine the proportion of perioperative complications in the orthopedic population attributable to the use of a blood transfusion. Methods. Data from 400 hospitals in the United States were used to identify patients undergoing total hip or knee arthroplasty (THA and TKA) from 2006 to 2010. Patient and health care demographics, as well as comorbidities and perioperative outcomes were compared. Multivariable logistic regression models were fitted to determine associations between transfusion, age, and comorbidities and various perioperative outcomes. Population attributable fraction (PAF) was determined to measure the proportion of outcome attributable to transfusion and other risk factors. Results. Of 530,089 patients, 18.93% received a blood transfusion during their hospitalization. Patients requiring blood transfusion were significantly older and showed a higher comorbidity burden. In addition, these patients had significantly higher rates of major complications and a longer length of hospitalization. The logistic regression models showed that transfused patients were more likely to have adverse health outcomes than nontransfused patients. However, patients who were older or had preexisting diseases carried a higher risk than use of a transfusion for these outcomes. The need for a blood transfusion explained 9.51% (95% CI 9.12–9.90) of all major complications. Conclusions. Advanced age and high comorbidity may be responsible for a higher proportion of adverse outcomes in THA and TKA patients than blood transfusions

Design and outline of the healthy pregnancy 4 all study

Background: Promotion of healthy pregnancies has gained high priority in the Netherlands because of the relatively unfavourable perinatal health outcomes. In response a nationwide study Healthy Pregnancy 4 All was initiated. This study combines public health and epidemiologic research to evaluate the effectiveness of two obstetric interventions before and during pregnancy: (1) programmatic preconception care (PCC) and (2) systematic antenatal risk assessment (including both medical and non-medical risk factors) followed by patient-tailored multidisciplinary care pathways. In this paper we present an overview of the study setting and outlines. We describe the selection of geographical areas and introduce the design and outline of the preconception care and the antenatal risk assessment studies.Methods/design: A thorough analysis was performed to identify geographical areas in which adverse perinatal outcomes were high. These areas were regarded as eligible for either or both sub-studies as we hypothesised studies to have maximal effect there. This selection of municipalities was based on multiple criteria relevant to either the preconception care intervention or the antenatal risk assessment intervention, or to both. The preconception care intervention was designed as a prospective community-based cohort study. The antenatal risk assessment intervention was designed as a cluster randomised controlled trial - where municipalities are randomly allocated to intervention and control.Discussion: Optimal linkage is sought between curative and preventive care, public health, government, and social welfare organisations. To our knowledge, this is the first study in which these elements are combined

Anesthesia, Outcomes, and Public Health: Changing Health Care While "Asleep"

More than 50 million surgical procedures are performed annually in the United States, with perioperative complications and related long-term adverse outcomes profoundly affecting the nation's health. A growing number of studies recognize that type of anesthesia, a main determinant of perioperative care, is associated with perioperative morbidity and mortality. Emerging data suggest, for example, that anesthesia may be a determinant of cancer recurrence after surgery. Further research is needed to elucidate the impact of anesthesia-related factors on short- and long-term health outcomes. Progress in this area of medicine and its public-health consequences will depend largely on the interest of the public, researchers, and health care policy makers