Anita Ravelli

Immigrants in the Netherlands: Equal access for equal needs?

OBJECTIVE This paper examines whether equal utilisation of health care services for first generation immigrant groups has been achieved in the Netherlands. DESIGN Survey data were linked to an insurance register concerning people aged 16–64. Ethnic differences in the use of a broad range of health care services were examined in this group, with and without adjustment for health status and socioeconomic status, using logistic regression. SETTING Publicly insured population in Amsterdam, the Netherlands. PARTICIPANTS 1422 people from the indigenous population, and 378 people from the four largest immigrant groups in the Netherlands—that is, the Surinamese, the Netherlands Antilleans, and the Turkish and Moroccan. MAIN OUTCOME MEASURES General practitioner service use (past two months), prescription drug use (past three months), outpatient specialist contact (past two months), hospital admission (past year), physiotherapist contact (past two months) and contact with other paramedics (past year). MAIN RESULTS Ethnicity was found to be associated with the use of health care after controlling for health status as an indicator for need. The use of general practitioner care and the use of prescribed drugs was increased among people from Surinam, Turkey and Morocco as compared with the indigenous population. Compared with the indigenous group with corresponding health status, the use of all other more specialised services was relatively low among Turkish and Moroccan people. Among the Surinamese population, the use of more specialised care was highly similar to that found in the Dutch population after differences in need were controlled for. Among people from the Netherlands Antilles, we observed a relatively high use of hospital services in combination with underuse of general practitioner services. The lower socioeconomic status of immigrant groups explained most of the increased use of the general practitioner and prescribed drugs, but could not account for the lower use of the more specialised services. CONCLUSIONS The results indicate that the utilisation of more specialised health care is lower for immigrant groups in the Netherlands, particularly for Turkish and Moroccan people and to a lesser extent, people from the Netherlands Antilles. Although underuse of more specialised services is also present among the lower socioeconomic groups in the Netherlands, the analyses indicate that this only partly explains the lower utilisation of these services among immigrant groups. This suggests that ethnic background in itself may account for patterns of consumption, potentially because of limited access.

Infant feeding and adult glucose tolerance, lipid profile, blood pressure, and obesity

BACKGROUND It is generally accepted that breast feeding has a beneficial effect on the health of infants and young children. Recently, a few studies have shown that the method of infant feeding is also associated with cardiovascular disease and its risk factors in adult life. AIMS To examine the association between the method of infant feeding in the first weeks after birth and glucose tolerance, plasma lipid profile, blood pressure, and body mass in adults aged 48–53 years. METHODS Subjects born at term between 1 November 1943 and 28 February 1947 in the Wilhelmina Gasthuis in Amsterdam around the time of a severe period of famine (late November 1944 to early May 1945). For 625 subjects, information was available about infant feeding at the time of discharge from hospital (on average 10.4 days after birth), and at least one blood sample after an overnight fast. RESULTS Subjects who were bottle fed had a higher mean 120 minute plasma glucose concentration after a standard oral glucose tolerance test than those who were exclusively breast fed. They also had a higher plasma low density lipoprotein (LDL) cholesterol concentration, a lower high density lipoprotein (HDL) cholesterol concentration, and a higher LDL/HDL ratio. Systolic blood pressure and body mass index were not affected by the method of infant feeding. CONCLUSIONS Exclusive breast feeding seems to have a protective effect against some risk factors for cardiovascular disease in later life.

Blood pressure in adults after prenatal exposure to famine.

BACKGROUND Many studies have shown that low birth weight is associated with high blood pressure. The composition of the diet of pregnant women has also been found to affect blood pressure in their children. We assessed the effect of prenatal exposure to the Dutch famine of 1944-1945, during which the caloric intake from protein, fat and carbohydrate was proportionally reduced, on blood pressures in adults now aged about 50 years. METHODS AND RESULTS We measured blood pressures at home and in the clinic among people born at term in one hospital in Amsterdam, The Netherlands, between November 1 1943 and February 28 1947, for whom we had detailed birth records. Blood pressures of people exposed to famine during late (n = 120), mid-(n = 109) or early gestation (n = 68) were compared with those of people born in the year before or conceived in the year after the famine (unexposed subjects, n = 442). No effect of prenatal exposure on systolic and diastolic blood pressure was observed. The mean systolic blood pressure taken in the clinic in those exposed in late gestation, and adjusted for sex and age, was 1.3 mmHg higher than in the unexposed group (95% confidence interval -1.9 to 4.4). The mean systolic blood pressure differed by -0.6 mmHg (95% confidence interval -3.9 to 2.7) for those exposed in mid-gestation and -1.7 mmHg (95% confidence interval -5.6 to 2.2) for those exposed in early gestation. People who were small at birth had higher blood pressures. A 1 kg increase in birth weight was associated with a decrease of 2.7 mmHg (95% confidence interval 0.3 to 5.1) in systolic blood pressure. Analyses of blood pressures measured at home gave similar results. CONCLUSION High blood pressure was not linked to prenatal exposure to a balanced reduction of macronutrients in the maternal diet. However, it was linked to reduced fetal growth. We postulate that it might be the composition rather than the quantity of a pregnant womans diet that affects her childs blood pressure in later life.

Effects of prenatal exposure to the Dutch famine on adult disease in later life: an overview

Chronic diseases are the main public health problem in Western countries. There are indications that these diseases originate in the womb. It is thought that undernutrition of the fetus during critical periods of development would lead to adaptations in the structure and physiology of the fetal body, and thereby increase the risk of diseases in later life. The Dutch famine--though a historical disaster--provides a unique opportunity to study effects of undernutrition during gestation in humans. This thesis describes the effects of prenatal exposure to the Dutch famine on health in later life. We found indications that undernutrition during gestation affects health in later life. The effects on undernutrition, however, depend upon its timing during gestation and the organs and systems developing during that critical time window. Furthermore, our findings suggest that maternal malnutrition during gestation may permanently affect adult health without affecting the size of the baby at birth. This may imply that adaptations that enable the fetus to continue to grow may nevertheless have adverse consequences of improved nutrition of pregnant women will be underestimated if these are solely based on the size of the baby at birth. Little is known about what an adequate diet for pregnant women might be. In general, women are especially receptive to advice about diet and lifestyle before and during a pregnancy. This should be exploited to improve the health of future generations.

Maternal nutrition during gestation and blood pressure in later life.

Objective To assess the link between maternal diet during pregnancy and blood pressure of the offspring. Design Follow-up study. Setting A university hospital in Amsterdam, The Netherlands. Participants People born at term as singletons between November 1943 and February 1947. Main outcome measure Blood pressure at adult age. Results Adult blood pressure was not associated with protein, carbohydrate or fat intake during any period of gestation. We found, however, after adjustment for sex that the systolic blood pressure decreased by 0.6 mmHg (0.1–1.1) for every 1% increase in protein/carbohydrate ratio in the third trimester. This association was present both in people who had been exposed to the famine during gestation as well as in those who had not been exposed. The association between protein/carbohydrate ratio in the third trimester and adult blood pressure was furthermore independent of maternal weight gain and final weight, and birth weight [increase for every 1% increase in protein/carbohydrate ratio 0.6 mmHg (0.0–1.2)]. Adjustment for adult characteristics such as body mass index, smoking and socio-economic status did not affect the observed association appreciably [adjusted increase 0.5 mmHg (0.0–1.0)]. Conclusion Adult blood pressure seems to be affected by small variations in the balance of macro-nutrients in the maternal diet during gestation rather than by relatively large variations in the absolute amounts.

Prediction of Mortality in Very Premature Infants: A Systematic Review of Prediction Models

Context Being born very preterm is associated with elevated risk for neonatal mortality. The aim of this review is to give an overview of prediction models for mortality in very premature infants, assess their quality, identify important predictor variables, and provide recommendations for development of future models. Methods Studies were included which reported the predictive performance of a model for mortality in a very preterm or very low birth weight population, and classified as development, validation, or impact studies. For each development study, we recorded the population, variables, aim, predictive performance of the model, and the number of times each model had been validated. Reporting quality criteria and minimum methodological criteria were established and assessed for development studies. Results We identified 41 development studies and 18 validation studies. In addition to gestational age and birth weight, eight variables frequently predicted survival: being of average size for gestational age, female gender, non-white ethnicity, absence of serious congenital malformations, use of antenatal steroids, higher 5-minute Apgar score, normal temperature on admission, and better respiratory status. Twelve studies met our methodological criteria, three of which have been externally validated. Low reporting scores were seen in reporting of performance measures, internal and external validation, and handling of missing data. Conclusions Multivariate models can predict mortality better than birth weight or gestational age alone in very preterm infants. There are validated prediction models for classification and case-mix adjustment. Additional research is needed in validation and impact studies of existing models, and in prediction of mortality in the clinically important subgroup of infants where age and weight alone give only an equivocal prognosis.

Results from simulated data sets: probabilistic record linkage outperforms deterministic record linkage

OBJECTIVE To gain insight into the performance of deterministic record linkage (DRL) vs. probabilistic record linkage (PRL) strategies under different conditions by varying the frequency of registration errors and the amount of discriminating power. STUDY DESIGN AND SETTING A simulation study in which data characteristics were varied to create a range of realistic linkage scenarios. For each scenario, we compared the number of misclassifications (number of false nonlinks and false links) made by the different linking strategies: deterministic full, deterministic N-1, and probabilistic. RESULTS The full deterministic strategy produced the lowest number of false positive links but at the expense of missing considerable numbers of matches dependent on the error rate of the linking variables. The probabilistic strategy outperformed the deterministic strategy (full or N-1) across all scenarios. A deterministic strategy can match the performance of a probabilistic approach providing that the decision about which disagreements should be tolerated is made correctly. This requires a priori knowledge about the quality of all linking variables, whereas this information is inherently generated by a probabilistic strategy. CONCLUSION PRL is more flexible and provides data about the quality of the linkage process that in turn can minimize the degree of linking errors, given the data provided.

Plasma fibrinogen and factor VII concentrations in adults after prenatal exposure to famine

To assess the effect of maternal malnutrition during different stages of gestation on plasma concentrations of fibrinogen and factor VII, we investigated 725 people, aged 50 years, born around the time of the Dutch famine 1944–5. After adjustment for sex, plasma fibrinogen concentrations differed by −0·01 g/l (95% confidence interval, −0·14–0·11) in those exposed in late gestation, by −0·03 g/l (−0·16–0·11) in those exposed in mid gestation, and by 0·13 g/l (−0·03–0·30) in those exposed in early gestation, compared with non‐exposed people (those born before and those conceived after the famine pooled together). Plasma factor VII concentrations differed by 0·4% (−5·4% to 6·6%) in those exposed to famine in late gestation, by 1·5% (−4·6% to 8·1%) in those exposed in mid gestation, and by −11·8% (−18·4% to −4·8%) in those exposed in early gestation, compared with non‐exposed people. Size at birth was not associated with plasma concentrations of fibrinogen or factor VII. Our finding that factor VII concentrations were significantly lower in people whose mothers had been exposed to famine in early pregnancy suggests that liver function may be affected by undernutrition in early gestation.

Timing of prenatal starvation in women and birth weight in their first and second born offspring : the Dutch famine birth cohort study

OBJECTIVES To examine the long-term effects of severe in utero maternal undernutrition on offspring birth weight. STUDY DESIGN Birth weights were analyzed of 575 first born and 454 second born offspring of 683 women born in Amsterdam, the Netherlands, at the time of a severe famine at the end of World War II. In utero maternal undernutrition was defined separately for each pregnancy trimester by an average daily nutrition ration (supplied to the grandmother) of less than 1000 calories in that trimester of pregnancy. RESULTS Compared to controls, birth weights of first born infants of women prenatally exposed in the first trimester of pregnancy were 73 g heavier (95% CI: -64, 210), and birth weights of second born infants were 96 g lighter (95% CI: -249, 58). Birth weights of infants of women exposed in the second or third trimester were much closer to controls. CONCLUSIONS A substantial (200 g or more) impact of severe in utero maternal undernutrition on OBW can be ruled out. There may, however, be parity specific, moderate (50-100 g) effects of maternal undernutrition early in pregnancy on OBW. This suggestion requires confirmation in other populations.

Maternal characteristics largely explain poor pregnancy outcome after hyperemesis gravidarum

OBJECTIVE To describe the characteristics of women who suffer from hyperemesis gravidarum, and explore the independent effect of hyperemesis gravidarum on pregnancy outcome. STUDY DESIGN In The Netherlands Perinatal Registry, we used all data on singleton pregnancies of at least 24 weeks and 500 g without congenital anomalies in the years 2000-2006. We examined the characteristics of women who suffered from hyperemesis gravidarum and their children. RESULTS Women who suffered from hyperemesis gravidarum were slightly younger; more often primiparous, of lower socio-economic status, of non-Western descent and substance abusers; had more often conceived through assisted reproduction techniques and more often had pre-existing hypertension, diabetes mellitus and psychiatric diseases than women who did not suffer from hyperemesis gravidarum. Also, their pregnancies were more often complicated by hypertension and diabetes and they more often carried a female fetus. Pregnancies complicated by hyperemesis gravidarum significantly more often had an adverse outcome (prematurity or birth weight below the 10th percentile). The increased risk of adverse pregnancy outcomes after hyperemesis gravidarum was largely explained by the differences in maternal characteristics (crude OR 1.22 (95% CI 1.10-1.36), adjusted OR was 1.07 (95% CI 0.95-1.19)). CONCLUSION Hyperemesis gravidarum is associated with adverse pregnancy outcomes. This is largely explained by differences in maternal characteristics. Given the impact of the early environment on later health (which is independent of size at birth), studies that aim to assess the long-term consequences of hyperemesis gravidarum need to be given high priority.