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

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