Strategies to Reduce Perinatal Health Inequalities

Abstract Promotion of healthy pregnancies has gained high priority in the Netherlands because of the relatively unfavorable perinatal outcomes compared to surrounding countries which was confirmed by two consecutive European reports on perinatal health. Additionally, large inequalities were observed within the Netherlands. Poor perinatal outcomes seemed to be more prevalent in deprived areas and were often associated with socio-economic and ethnic minority related risk factors such as low-income or less integration into society. Research revealed that in 85% of all cases mortality was preceded by perinatal morbidity (e.g. preterm birth, small-for-gestational age, suboptimal start or congenital anomalies), also known as Big 4 morbidities. In addition, it was demonstrated that non-medical risk factors (social and lifestyle risk factors) had an equally high impact of perinatal outcomes when compared to medical and obstetrical risk factors, and that the accumulation of these risk factors could even further harm the chances of a good pregnancy outcome. Non-medical risk factors and risk accumulation were especially observed in deprived areas. This information made perinatal mortality an important political and social issue, which led to many national and local initiatives in the Dutch antenatal healthcare field. In this thesis, the aim was threefold: 1) to evaluate initiatives that were implemented to improve perinatal morbidity and mortality rates in the Netherlands, 2) to investigate the influence of neighbourhood deprivation on perinatal outcomes, and 3) to investigate the contribution of (the assessment of ) non-medical risk factors. Our results were therefore presented and summarized in three parts

Differences in perinatal morbidity and mortality on the neighbourhood level in Dutch municipalities: A population based cohort study

Background: In a national perinatal health programme, we observed striking heterogeneity in the explanation of the most prominen

An instrument for broadened risk assessment in antenatal health care including non-medical issues.

Growing evidence on the risk contributing role of non-medical factors on pregnancy outcomes urged for a new approach in early antenatal risk selection. The evidence invites to more integration, in particular between the clinical working area and the public health domain. We developed a non-invasive, standardized instrument for comprehensive antenatal risk assessment. The current study presents the application-oriented development of a risk screening instrument for early antenatal detection of risk factors and tailored prevention in an integrated care setting. A review of published instruments complemented with evidence from cohort studies. Selection and standardization of risk factors associated with small for gestational age, preterm birth, congenital anomalies and perinatal mortality. Risk factors were weighted to obtain a cumulative risk score. Responses were then connected to corresponding care pathways. A cumulative risk threshold was defined, which can be adapted to the population and the availability of preventive facilities. A score above the threshold implies multidisciplinary consultation between caregivers. The resulting digital score card consisted of 70 items, subdivided into four non-medical and two medical domains. Weighing of risk factors was based on existing evidence. Pilot-evidence from a cohort of 218 pregnancies in a multi-practice urban setting showed a cut-off of 16 points would imply 20% of all pregnant women to be assessed in a multidisciplinary setting. A total of 28 care pathways were defined. The resulting score card is a universal risk screening instrument which incorporates recent evidence on non-medical risk factors for adverse pregnancy outcomes and enables systematic risk management in an integrated antenatal health care setting

Effectiveness of score card-based antenatal risk selection, care pathways, and multidisciplinary consultation in the Healthy Pregnancy 4 All study (HP4ALL): Study protocol for a cluster randomized controlled trial

Background: Promotion of healthy pregnancies has gained high priority in the Netherlands because of relatively unfavorable perinatal outcomes. In response, a nationwide study, 'Healthy Pregnancy 4 All' (HP4ALL), has been initiated. Part of this study involves systematic and broadened antenatal risk assessment (the Risk Assessment substudy). Risk selection in current clinical practice is mainly based on medical risk factors. Despite the increasing evidence for the influence of nonmedical risk factors (social status, lifestyle or ethnicity) on perinatal outcomes, these risk factors remain highly unexposed. Systematic risk selection, combined with customized care pathways to reduce or treat detected risks, and regular and structured consultation between community midwives, gynecologists and other care providers such as social workers, is part of this study. Methods/Design: Neighborhoods in 14 municipalities with adverse perinatal outcomes above national and municipal averages are selected for participation. The study concerns a cluster randomized controlled trial. Municipalities are randomly allocated to intervention (n = 3,500 pregnant women) and control groups (n = 3,500 pregnant women). The intervention consists of systematic risk selection with th

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)

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

Assessment and care for non-medical risk factors in current antenatal health care

Objective: this study aims to identify current practice in risk assessment, current antenatal policy and referral possibilities for non-medical risk factors (lifestyle and social risk factors), and to explore the satisfaction among obstetric caregivers in their collaboration with non-obstetrical caregivers. Design: cross-sectional study. Setting: Dutch antenatal care system. Participants: community midwives from 139 midwifery practices and gynaecologists, hospital-based midwives, and trainees in obstetrics from 38 hospitals. Measurements and findings: results were analysed with χ2 tests and unpaired t-tests. Caregivers universally screened upon lifestyle risk factors (e.g. smoking or drug use), whereas the screening for social risk factors (e.g. social support) was highly variable. As national guidelines are absent, local protocols were reported to be used for screening on non-medical risk factors in more than 40%. Caregivers stated multidisciplinary protocols to be a prerequisite for assessment of non-medical risk factors. Only 22% of the caregivers used predefined criteria to define when patients should be discussed multidisciplinary. Conclusion: despite their relevance, non-medical risk factors remain an underexposed topic in antenatal risk factor screening in both the community and hospital-based care setting. Implications for practice Structural antenatal risk assessment for non-medical risk factors with subsequent consultation opportunities is advocated, preferably based on a multidisciplinary guideline

ラミナリアジャポニカに含まれるフコキサンチンとフコイダンの生活習慣病予防活性に関する研究

博士（学術）神戸大