Maternal hypertensive disorders in pregnancy and early childhood cardiometabolic risk factors:The Generation R Study

The objective of this study was to determine the associations between hypertensive disorders of pregnancy and early childhood cardiometabolic risk factors in the offspring. Therefore, 7794 women from the Generation Rotterdam Study were included, an ongoing population-based prospective birth cohort. Women with a hypertensive disorder of pregnancy were classified as such when they were affected by pregnancy induced hypertension, pre-eclampsia or the haemolysis, elevated liver enzymes and low platelet count (HELLP) syndrome during pregnancy. Early childhood cardiometabolic risk factors were defined as the body mass index at the age of 2, 6, 12, 36 months and 6 years. Additionally, it included systolic blood pressure, diastolic blood pressure, total fat mass, cholesterol, triglycerides, insulin and clustering of cardiometabolic risk factors at 6 years of age. Sex-specific differences in the associations between hypertensive disorders and early childhood cardiometabolic risk factors were investigated. Maternal hypertensive disorders of pregnancy were inversely associated with childhood body mass index at 12 months (confounder model: -0.15 SD, 95% CI -0.27; -0.03) and childhood triglyceride at 6 years of age (confounder model: -0.28 SD, 95% CI -0.45; -0.10). For the association with triglycerides, this was only present in girls. Maternal hypertensive disorders of pregnancy were not associated with childhood body mass index at 2, 6 and 36 months. No associations were observed between maternal hypertensive disorders of pregnancy and systolic blood pressure, diastolic blood pressure, body mass index, fat mass index and cholesterol levels at 6 years of age. Our findings do not support an independent and consistent association between maternal hypertensive disorders of pregnancy and early childhood cardiometabolic risk factors in their offspring. However, this does not rule out possible longer term effects of maternal hypertensive disorders of pregnancy on offspring cardiometabolic health

Association between neighbourhood deprivation, fetal growth, small-for-gestational age and preterm birth: a population-based prospective cohort study

Objective To study the associations between neighbourhood deprivation and fetal growth, including growth in the first trimester, and adverse pregnancy outcomes. Design Prospective cohort study. Setting The Netherlands, Rotterdam. Participants 8617 live singleton births from the Generation R cohort study. Exposition Living in a deprived neighbourhood. Main outcome measures Fetal growth trajectories of head circumference, weight and length. Secondary outcomes measures Small-for-gestational age (SGA) and preterm birth (PTB). Results Neighbourhood deprivation was not associated with first trimester growth. However, a higher neighbourhood status score (less deprivation) was associated with increased fetal growth in the second and third trimesters (eg, estimated fetal weight; adjusted regression coefficient 0.04, 95% CI 0.02 to 0.06). Less deprivation was also associated with decreased odds of SGA (adjusted OR 0.91, 95% CI 0.86 to 0.97, p=0.01) and PTB (adjusted OR 0.89, 95% CI 0.82 to 0.96, p=0.01). Conclusions We found an association between neighbourhood deprivation and fetal growth in the second and third trimester pregnancy, but not with first trimester growth. Less neighbourhood deprivation is associated with lower odds of adverse pregnancy outcomes. The associations remained after adjustment for individual-level risk factors. This supports the hypothesis that living in a deprived neighbourhood acts as an independent risk factor for fetal growth and adverse pregnancy outcomes, above and beyond individual risk factors

Psychological distress during pregnancy and adverse maternal and perinatal health outcomes: The role of socioeconomic status

Objective: To study the contribution of socioeconomic status (SES) to the prevalence of psychological distress during pregnancy, and to investigate the association between psychological distress and maternal and perinatal health among different SES groups. Methods: This study was embedded in the Generation R study. Multiple self-reported questionnaires were used to measure psychological distress. Prevalence differences between SES groups were tested with the χ2 test. Linear and logistic regression analyses were used to examine the associations between psychological distress and maternal and perinatal health outcomes. Results: Women of low SES experience symptoms of psychopathology distress 4.5 times as often and symptoms of stress 2.5 times as often as women with of high SES. Women of low SES experiencing symptoms of psychopathology are at greater risk of delivering preterm. We also found associations between psychological distress and adverse perinatal health outcomes among women of middle and high SES. Conclusion: The present study shows that the associations between SES, psychological distress, and maternal and perinatal health are complex, but do exist. To provide a better understanding of these associations, it is important to include mental health information in the standard national data collection on pregnant women, as this allows population-based studies

The Association of Ethnic Minority Density with Late Entry into Antenatal Care in the Netherlands

In the Netherlands, non-Western ethnic minority women make their first antenatal visit later than native Dutch women. Timely entry into antenatal care is important as it provides the opportunity for prenatal screening and the detection of risk factors for adverse pregnancy outcomes. In this study we explored whether women's timely entry is influenced by their neighborhood. Moreover, we assessed whether ethnic minority density (the proportion of ethnic minorities in a neighborhood) influences Western and non-Western ethnic minority women's chances of timely entry into care differently. We hypothesized that ethnic minority density has a protective effect against non-Western women's late entry into care. Data on time of entry into care and other individual-level characteristics were obtained from the Netherlands Perinatal Registry (2000-2008; 97% of all pregnancies). We derived neighborhood-level data from three other national databases. We included 1,137,741 pregnancies of women who started care under supervision of a community midwife in 3422 neighborhoods. Multi-level logistic regression was used to assess the associations of individual and neighborhood-level determinants with entry into antenatal care before and after 14 weeks of gestation. We found that neighborhood characteristics influence timely entry above and beyond individual characteristics. Ethnic minority density was associated with a higher risk of late entry into antenatal care. However, our analysis showed that for non-Western women, living in high ethnic minority density areas is less detrimental to their risk of late entry than for Western women. This means that a higher proportion of ethnic minority residents has a protective effect on non-Western women's chances of timely entry into care. Our results suggest that strategies to improve timely entry into care could seek to create change at the neighborhood level in order to target individuals likely of entering care too late

Geographical, Ethnic and Socio-Economic Differences in Utilization of Obstetric Care in the Netherlands.

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.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.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).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

Inequalities in uptake of prenatal screening according to ethnicity and socio-economic status in the four largest cities of the Netherlands (2011-2013)

OBJECTIVES: In the Netherlands, all women are claimed to have equal access to prenatal screening (PS). Prior research demonstrated substantial inequalities in PS uptake associated with socioeconomic status (SES) and ethnic background. The suggested pathway was a lack of intention to participate in PS among these subgroups. We studied the background of inequalities in PS participation, challenging intention heterogeneity as the single explanation. METHODS: Multivariable logistic regression analyses of the national PS registry, focusing on the four largest cities in the Netherlands (n = 4578, years 2011-2013), stratified by SES. OUTCOME MEASURES: (1) any uptake of PS (yes/no) and (2) uptake (one/two tests) for women who intended to participate in two tests. Determinants included intention, ethnicity, practice, and age. RESULTS: Of non-Western women, 85.7% were screened versus 89.7% of Western women. Intention was an important explanatory factor in all models. However, after correction for intention, ethnicity remained a significant determinant for differences in uptake. Ethnicity and SES also interacted, indicating that non-Western women in low SES areas had the lowest uptake (corrected for intention). CONCLUSIONS FOR PRACTICE: Socioeconomic status and ethnicity related inequalities in PS uptake are only partially explained by intention heterogeneity; other pathways, in particular provider-related determinants, may play a role. © 2017 John Wiley & Sons, Ltd

Maternal lipid profile in pregnancy and embryonic size: a population-based prospective cohort study

Background: Lipids are crucial for fetal growth and development. Maternal lipid concentrations are associated with fetal growth in the second and third trimester of pregnancy and with birth outcomes. However, it is unknown if this association starts early in pregnancy or arises later during fetal development. The aim of this study was to investigate the association between the maternal lipid profile in early pregnancy and embryonic size. Methods: We included 1474 women from the Generation R Study, a population based prospective birth cohort. Both embryonic size and the maternal lipid profile were measured between 10 weeks + 1 day and 13 weeks + 6 days gestational age. The maternal lipid profile was defined as total cholesterol, triglycerides (TG), high-density lipoprotein cholesterol (HDL-c), low-density lipoprotein cholesterol (LDL-c), remnant cholesterol, non-high-density (non-HDL-c) lipoprotein cholesterol concentrations and the triglycerides/high-density lipoprotein (TG/HDL-c) ratio. Additionally, maternal glucose concentrations were assessed. Embryonic size was assessed using crown-rump length (CRL) measurements. Associations were studied with linear regression models, adjusted for confounding factors: maternal age, pre-pregnancy body mass index (BMI), parity, educational level, ethnicity, smoking and folic acid supplement use. Results: Triglycerides and remnant cholesterol concentrations are positively associated with embryonic size (fully adjusted models, 0.17 SDS CRL: 95% CI 0.03; 0.30, and 0.17 SDS: 95% CI 0.04; 0.31 per 1 MoM increase, respectively). These associations were not present in women with normal weight (triglycerides and remnant cholesterol: fully adjusted model, 0.44 SDS: 95% CI 0.15; 0.72). Associations between maternal lipid concentrations and embryonic size were not attenuated after adjustment for glucose concentrations. Total cholesterol, HDL-c, LDL-c, non-HDL-c concentrations and the TG/HDL-c ratio were not associated with embryonic size. Conclusions: Higher triglycerides and remnant cholesterol concentrations in early pregnancy are associated with increased embryonic size, most notably in overweight women. Trial registration: The study protocol has been approved by the Medical Ethics Committee of the Erasmus University Medical Centre (Erasmus MC), Rotterdam (MEC-2007-413). Written informed consent was obtained from all participants

Multilevel logistic regression models of ethnic minority density and other individual and neighborhood characteristics on late entry into care (after 14 weeks of gestation).

<p>(Odds ratios, 95% confidence intervals in parentheses).</p><p><i>n = number of pregnancies; nb = number of neighborhoods; significance (p-value)</i>:</p><p>*<i>p≤0</i>.<i>05</i></p><p>**<i>p≤0</i>.<i>01</i></p><p>***<i>p≤0</i>.<i>001</i>.</p><p>Multilevel logistic regression models of ethnic minority density and other individual and neighborhood characteristics on late entry into care (after 14 weeks of gestation).</p

Detailed description of neighborhood level variables included in the multilevel model.

<p>Detailed description of neighborhood level variables included in the multilevel model.</p

Descriptive statistics of individual variables and time of entry into care.

<p>(Source: Perinatal Registration Netherlands, 2000–2008).</p><p>Descriptive statistics of individual variables and time of entry into care.</p