Social Obstetrics: Addressing inequalities in perinatal healthcare

Research with the aim to investigate the effectiveness of preventive strategies. These strategies were implemented during different phases in reproductive healthcare, to reduce adverse perinatal health outcomes and low empowerment particularly among women with a low socioeconomic status and their offsprin

Inequity in postpartum healthcare provision at home and its association with subsequent healthcare expenditure

BACKGROUND: Provision of postpartum care can support new families in adapting to a new situation. We aimed to determine whether various determinants of socioeconomic status (SES) were associated with utilization of postpartum care. In addition, to stress the relevance of increasing postpartum care uptake among low SES-groups, an assessment of the potential (cost-)effectiveness of postpartum care is required. METHODS: National retrospective cohort study using linked routinely collected healthcare data from all registered singleton deliveries (2010-13) in the Netherlands. Small-for-gestational age and preterm babies were excluded. The associations between SES and postpartum care uptake, and between uptake and health care expenditure were studied using multivariable regression analyses. RESULTS: Of all 569 921 deliveries included, 1.2% did not receive postpartum care. Among women who did receive care, care duration was below the recommended minimum of 24 h in 15.3%. All indicators of low SES were independently associated with a lack in care uptake. Extremes of maternal age, single parenthood and being of non-Dutch origin were associated with reduced uptake independent of SES determinants. No uptake of postpartum care was associated with maternal healthcare expenses in the highest quartile: aOR 1.34 (95% CI 1.10-1.67). Uptake below the recommended amount was associated with higher maternal and infant healthcare expenses: aOR 1.09 (95% CI 1.03-1.18) and aOR 1.20 (95% CI 1.13-1.27), respectively. CONCLUSION: Although uptake was generally high, low SES women less often received postpartum care, this being associated with higher subsequent healthcare expenses. Strategies to effectively reduce these substantial inequities in early life are urgently needed

An innovative postnatal risk assessment and corresponding care pathways in Preventive Child Healthcare

Aims This study aims to evaluate the effectiveness of an innovative postnatal risk assessment (the postnatal Rotterdam Reproductive Risk Reduction checklist: R4U) and corresponding care pathways in Preventive Child Healthcare (PCHC), along with PCHC professional satisfaction. Design Four PCHC organizations located in three municipalities with a higher adverse perinatal outcome than the national average were selected for participation. The study concerns a historically controlled study design. Methods The study enrolled participants from September 2016 until December 2017. The historical cohort existed of children born in previous years from 2008 until 2016. The outcome measure was defined as catch-up growth: more than 0.67 standard deviation score weight for height increase in the first 6 months of life. PCHC professional opinion was assessed with a digital survey. Results After the inclusion period, 1,953 children were included in the intervention cohort and 7,436 children in the historical cohort. Catch-up growth was significantly less common in the intervention cohort; 14.9% versus 19.5% in the historical cohort (p < 0.001). A regression sensitivity analysis, using matching, showed an odds ratio of 0.957 (95% CI 0.938-0.976) for the intervention cohort. In the survey, 74 PCHC physicians and nurses participated; most of them were neutral concerning the benefits of the postnatal R4U. Conclusion This study shows that the implementation of a novel postnatal risk assessment including in PCHC is feasible and effective. Final efforts to ensure a widespread implementation should be taken. Impact PCHC offers a unique opportunity to recognize and address risk factors for growth and development in children and to implement care pathways. Effective and widely implemented risk assessments in antenatal and PCHC are scarce. To our knowledge, this kind of evidence-based postnatal risk assessment has not been implemented in PCHC before and seizes the opportunity to prevent catch-up growth and its long-term effects

Antenatal non-medical risk assessment and care pathways to improve pregnancy outcomes: a cluster randomised controlled trial

Social deprivation negatively affects health outcomes but receives little attention in obstetric risk selection. We investigated whether a combination of (1) risk assessment focused on non-medical risk factors, lifestyle factors, and medical risk factors, with (2) subsequent institution of risk-specific care pathways, and (3) multidisciplinary consultation between care providers from the curative and the public health sector reduced adverse pregnancy outcomes among women in selected urban areas in the Netherlands. We conducted a cluster randomised controlled trial in 14 urban municipalities across the Netherlands. Prior to the randomisation, municipalities were ranked and paired according to their expected proportion of pregnant women at risk for adverse outcomes at birth. The primary outcome was delivery of a preterm and/or small for gestational age (SGA) baby, analysed with multilevel mixed-effects logistic regression analysis adjusting for clustering and individual baseline characteristics. A total of 33 community midwife practices and nine hospitals participated throughout the study. Data from 4302 participants was included in the Intention To Treat (ITT) analysis. The intervention had no demonstrable impact on the primary outcome: adjusted odds ratio (aOR) 1.17 (95% CI 0.84–1.63). Among the secondary outcomes, the intervention improved the detection of threatening preterm delivery and fetal growth restriction during pregnancy [aOR 1.27 (95% CI 1.01–1.61)]. Implementation of additional non-medical risk assessment and preventive strategies into general practices is feasible but did not decrease the incidence of preterm and/or SGA birth in the index pregnancy in deprived urban areas. Trial registration Netherlands National Trial Register (NTR-3367)

Integrating interconception care in preventive child health care services:The Healthy Pregnancy 4 All program

BackgroundMost parents with young children pay routine visits to Well-Baby Clinics, or so-called Preventive Child Health Care (PCHC) services. This offers a unique opportunity to promote and deliver interconception care. This study aimed to integrate such care and perform an implementation evaluation.MethodsIn seven Dutch municipalities, PCHC professionals were instructed to discuss the possibility of an interconception care consultation during each routine six-months well-baby visit. The primary outcome of this study was coverage of the intervention, quantified as the proportion of visits during which women were informed about interconception care. Secondary outcomes included adoption, fidelity, feasibility, appropriateness, acceptability and effectiveness of the intervention, studied by surveying PCHC professionals and women considering becoming pregnant.ResultsThe possibility of interconception care was discussed during 29% (n = 1,849) of all visits, and 60% of the PCHC physicians adopted the promotion of interconception care by regularly informing women. About half of the PCHC professionals and most women judged integration of interconception care in PCHC appropriate and acceptable. Estimated feasibility was poor, since 13% of the professionals judged future integration in daily practice as probable. The uptake of interconception care consultations was low (n = 4 consultations).ConclusionsPromotion of interconception care was achieved in approximately one-third of the routine PCHC consultations and appeared promising with regards to adoption, appropriateness and acceptability. However, concerns on feasibility and uptake of interconception care consultations in daily practice remain. Suggestions for improvement may include further integration of interconception care health promotion in routine PCHC consultations, while allocating sufficient resources

Did an urban perinatal health programme in Rotterdam, the Netherlands, reduce adverse perinatal outcomes? Register-based retrospective cohort study

OBJECTIVES: To study the effect of an urban perinatal health programme in Rotterdam, the Netherlands, on perinatal outcomes. DESIGN: A retrospective cohort study with difference-in-differences analysis using individual-level perinatal outcome data from the Dutch Perinatal Registry 2003-2014 linked to Central Bureau of Statistics data of migration background and individual disposable household income. INTERVENTION: The programme consisted of perinatal health promotion, risk selection and risk-guided pregnancy care, and a new primary care child birth centre. The programme was implemented during 2009-2012. PRIMARY OUTCOME MEASURES: We compared trends in perinatal mortality, preterm delivery and small-for-gestational-age births between targeted urban neighbourhoods in Rotterdam (n=61 415) and all other urban neighbourhoods in the Netherlands (n=881 202). The effect of the programme was modelled as a change in trend of each perinatal outcome in the treatment group post intervention compared with the control population from January 2010 onwards. All analyses were adjusted for maternal age, parity, ethnicity and individual-level low socioeconomic status (SES). We also conducted a stratified analysis by SES. RESULTS: During 2003-2014, downward trends in perinatal mortality (adjusted OR (aOR) 0.9439 per year, 95% CI 0.9362 to 0.9517), preterm birth (aOR 0.9970 per year, 95% CI 0.9944 to 0.9997) and small-for-gestational-age births (aOR 0.9809 per year, 95% CI 0.9787 to 0.9831) in the entire study population were observed. No demonstrable changes in these trends were found in the intervention group after the prog

Validation of a prognostic model for adverse perinatal health outcomes

There is a strong association between social deprivation and adverse perinatal health outcomes, but related risk factors receive little attention in current antenatal risk selection. To increase awareness of healthcare professionals for these risk factors, a model for antenatal risk surveillance and care was developed in The Netherlands, called the 'Rotterdam Reproductive Risk Reduction' (R4U) scorecard. The aim of this study was to validate the R4U-scorecard. This study was conducted using external, prospective data from thirty-two midwifery practices, and fifteen hospitals in The Netherlands. The main outcome measures were the discrimination of the prognostic models for the probability of a pregnant woman developing adverse pregnancy outcomes (babies born preterm or small for gestational age), and calibration. We performed cross-validation and updated the model using statistical re-estimation of all predictors. 1752 participants were included, of whom 282 (16%) had one of the predefined adverse outcomes. The discriminative value of the original scoring system was poor [area under the curve (AUC) of 0.58 (95% CI 0.53-0.64)]. The model showed moderate calibration. The updated R4U-scorecard showed good generalisability to the validation set but did not alter the predictive value [AUC 0.61 (95% CI 0.56-0.66)]. By using external data and by updating the prognostic model, we have provided a comprehensive evaluation of the R4U-scorecard. Further improvement in classification of high-risk pregnancies is important considering the necessity of early risk detection for healthcare professionals to take appropriate actions to prevent these risks from becoming manifest problems

Risk-guided maternity care to enhance maternal empowerment postpartum: A cluster randomized controlled trial

Objective To investigate whether a structured inquiry during pregnancy of medical factors and social factors associated with low socioeconomic status, and subsequent patient-centred maternity care could increase maternal empowerment. Design Cluster-randomised controlled trial. Setting This study was conducted among pregnant women in selected urban areas in the Netherlands. This study was part of the nationwide Healthy Pregnancy 4 All-2 programme. Population Pregnant women listed at one of the sixteen participating maternity care organisations between July 1, 2015, and Dec 31, 2016. Methods All practices were instructed to provide a systematic risk assessment during pregnancy. Practices were randomly allocated to continue usual care (seven practices), or to provide a patient-centred, risk-guided approach to addressing any risks (nine practices) identified via the risk assessment during pregnancy. Results We recruited 1579 participants; 879 participants in the intervention arm, and 700 participants in the control arm. The prevalence of one or more risk factors during pregnancy was similar between the two arms: 40% and 39%, respectively. In our intention-to-treat analysis, the intervention resulted in a significant reduction in the odds of having a low empowerment score [i.e. the primary outcome; adjusted OR 0.69 ((95% CI 0.47; 0.99), P 0.046)]. Conclusions Implementation of addition

Geographical differences in perinatal health and child welfare in the Netherlands: Rationale for the healthy pregnancy 4 all-2 program

Background: Geographical inequalities in perinatal health and child welfare require attention. To improve the identification, and care, of mothers and young children at risk of adverse health outcomes, the HP4All-2 program was developed. The program consists of three studies, focusing on creating a continuum for risk selection and tailored care pathways from preconception and antenatal care towards 1) postpart

Integrating interconception care in preventive child health care services: The Healthy Pregnancy 4 All program

Background Most parents with young children pay routine visits to Well-Baby Clinics, or so-called Preventive Child Health Care (PCHC) services. This offers a unique opportunity to promote and deliver interconception care. This study aimed to integrate such care and perform an implementation evaluation. Methods In seven Dutch municipalities, PCHC professionals were instructed to discuss the possibility of an interconception care consultation during each routine six-months well-baby visit. The primary outcome of this study was coverage of the intervention, quantified as the proportion of visits during which women were informed about interconception care. Secondary outcomes included adoption, fidelity, feasibility, appropriateness, acceptability and effectiveness of the intervention, studied by surveying PCHC professionals and women considering becoming pregnant. Results The possibility of interconception care was discussed during 29% (n = 1,849) of all visits, and 60% of the PCHC physicians adopted the promotion of interconception care by regularly informing women. About half of the PCHC professionals and most women judged integration of interconception care in PCHC appropriate and acceptable. Estimated feasibility was poor, since 13% of the professionals judged future integration in daily practice as probable. The uptake of interconception care consultations was low (n = 4 consultations). Conclusions Promotion of interconception care was achieved in approximately one-third of the routine PCHC consultations and appeared promising with regards to adoption, appropriateness and acceptability. However, concerns on feasibility and uptake of interconception care consultations in daily practice remain. Suggestions for improvement may include further integration of interconception care health promotion in routine PCHC consultations, while allocating sufficient resources