Johanna P. de Graaf

Inequalities in perinatal and maternal health.

Purpose of review To describe inequalities in perinatal and maternal mortality, and morbidity from an international high-income country perspective. Measures of inequalities are socioeconomic status, ethnic background, and living area. Recent findings Despite decreasing overall perinatal and maternal mortality in high-income countries, perinatal and maternal health inequalities persist. Inequalities in fetal, neonatal, and maternal adverse outcome relate to specific groups of risk factors. They commonly have a background in so-called structural risk factors, that is low level of education and income, being a migrant and living in disadvantaged areas. Structural risk factors therefore drive inequalities, and simultaneously represent the common perspective to judge perinatal and maternal health gaps. The effect of risk factors is further magnified in urban areas through risk accumulation. As mother and child share their background, neonatal, and maternal adverse health outcome patterns coincide, resulting in similar inequalities and similar epidemiological trends. The structural background explains the difficulty of improving this. Summary Inequalities in perinatal and maternal outcome persist in women from lower socioeconomic groups, from specific ethnic groups, and from those living in deprived areas. In view of the lifelong consequences, these marked social disparities pose an important challenge for the political decision makers and the healthcare system.

Planned home compared with planned hospital births in the Netherlands: Intrapartum and early neonatal death in low-risk pregnancies

To the Editor: We congratulate van der Kooy et al on their report comparing delivery-related perinatal mortality between planned home and planned hospital births in the Netherlands.1 The study is an important and timely contribution to the literature on this topic. The results confirm the low absolute delivery-related perinatal mortality rate associated with planned home birth compared with planned hospital birth under the care of licensed midwives. However, the methods lead us to suspect that, in reality, the rate is likely to be higher than presented. Retrospectively excluding women prospectively planning home or hospital birth under the care of a midwife at labor onset reduced the obstetric risk of the entire cohort, thereby reducing the risk of delivery-related perinatal death. The subgroup excluded from the perfect guideline analysis included women with risk factors not necessarily predictable during the prenatal or intrapartum course but requiring transfer to hospital care. Dutch women planning home birth but requiring intrapartum transfer to the hospital experience the highest odds of delivery-related perinatal death.2 Moreover, a recent U.K. study demonstrated that perinatal mortality commonly is associated with women and their midwives proceeding with planned home birth despite recognizing one or more preexisting or late-developing contraindications, raising further questions about these exclusions.3 Although the authors’ approach generated the desired “low-risk” cohort, it likely did not yield a reality-based estimate of delivery-related perinatal mortality.4 Another concern arises from the lack of a comparison group of low-risk or high-risk pregnancies entering labor under in-hospital physician care. A recent report from Utrecht, Netherlands, shows significantly increased deliveryrelated perinatal mortality rates among low-risk women entering labor at home or in the hospital under the care of midwives compared with those of highrisk women entering labor in the hospital under the care of physicians.2 The authors note the absence of this comparison but not the important clinical and interpretive limitations conveyed by this exclusion.2 Finally, although the authors carefully summarize and reference criticisms of our prior publication, we would like to correct their oversight of neglecting to reference our responses and the journal editor’s note describing the postpublication review by three experts who independently affirmed our methods and confirmed our results (Wax JR, Pinette MG, Lucas FL. Reply to letter to the editor [letter-reply]. Am J Obstet Gynecol 2011;204:e18–20).

Living in deprived urban districts increases perinatal health inequalities

Objective: Analyses of the effects of place of residence, socioeconomic status and ethnicity on perinatal mortality and morbidity in the Netherlands. Methods: Epidemiological analysis of all singleton deliveries > 22 gestational weeks (871,889 live born and 5927 stillborn) from the Dutch National Perinatal Registry 2002–2006. Multiple logistic regression analysis was used to determine whether place of residence (deprived neighborhood, or not) contributed to the adverse perinatal outcome (defined as perinatal mortality, preterm birth, small for gestational age, congenital abnormalities or Apgar score <7, 5 min after birth), additional to individual pregnancy characteristics, demographic characteristics, ethnic background and socioeconomic class. Results: Incidence of adverse perinatal outcome was 16.7%. After adjustment the excess risk for perinatal mortality in deprived districts was 21%, for preterm birth 16%, for small-for-gestational age 11%, and for Apgar score <7 after 5 min 11%. Conclusions: Perinatal inequalities appear impressive in both urban and nonurban areas, with a significant additive risk of living in a deprived neighborhood. Excess risk for perinatal mortality generally outranges that for morbidity, suggesting both an etiological and prognostic pathway for neighborhood effects. A distinct pattern exists for congenital anomalies, for which first trimester adverse selection effects may be responsible.

The Dutch Birth Centre Study: study design of a programmatic evaluation of the effect of birth centre care in the Netherlands

BackgroundBirth centres are regarded as settings where women with uncomplicated pregnancies can give birth, assisted by a midwife and a maternity care assistant. In case of (threatening) complications referral to a maternity unit of a hospital is necessary. In the last decade up to 20 different birth centres have been instituted in the Netherlands. This increase in birth centres is attributed to various reasons such as a safe and easy accessible place of birth, organizational efficiency in integration of care and direct access to obstetric hospital care if needed, and better use of maternity care assistance. Birth centres are assumed to offer increased integration and quality of care and thus to contribute to better perinatal and maternal outcomes. So far there is no evidence for this assumption as no previous studies of birth centres have been carried out in the Netherlands.DesignThe aims are 1) Identification of birth centres and measuring integration of organization and care 2) Measuring the quality of birth centre care 3) Effects of introducing a birth centre on regional quality and provision of care 4) Cost-effectiveness analysis 5) In depth longitudinal analysis of the organization and processes in birth centres.Different qualitative and quantitative methods will be used in the different sub studies. The design is a multi-centre, multi-method study, including surveys, interviews, observations, and analysis of registration data and documents.DiscussionThe results of this study will enable users of maternity care, professionals, policy makers and health care financers to make an informed choice about the kind of birth location that is appropriate for their needs and wishes.

Experiences of women who planned birth in a birth centre compared to alternative planned places of birth. Results of the Dutch Birth Centre Study

OBJECTIVE to assess the experiences with maternity care of women who planned birth in a birth centre and to compare them to alternative planned places of birth, by using the responsiveness concept of the World Health Organization. DESIGN this study is a cross-sectional study using the ReproQ questionnaire filled out eight to ten weeks after birth. The primary outcome was responsiveness of birth care. Secondary outcomes included overall grades for birth care and experiences with the birth centre services. Regression analyses were performed to compare experiences among the planned places of birth. The study is part of the Dutch Birth Centre Study. SETTING the women were recruited by 82 midwifery practices in the Netherlands, within the study period 1 August 2013 and 31 December 2013. PARTICIPANTS a total of 2162 women gave written consent to receive the questionnaire and 1181 (54.6%) women completed the questionnaire. MEASUREMENTS AND FINDINGS women who planned to give birth at a birth centre: (1) had similar experiences as the women who planned to give birth in a hospital receiving care of a community midwife. (2) had significantly less favourable experiences than the women who planned to give birth at home. Differences during birth were seen on the domains dignity (OR=1.58, 95% CI=1.09-2.27) and autonomy (OR=1.77, 95% CI=1.25-2.51), during the postpartum period on the domains social considerations (OR=1.54, 95% CI=1.06-2.25) and choice and continuity (OR=1.43, 95% CI=1.00-2.03). (3) had significantly better experiences than the women who planned to give birth in a hospital under supervision of an obstetrician. Differences during birth were seen on the domains dignity (OR=0.51, 95% CI=0.31-0.81), autonomy (OR=0.59, 95% CI=0.35-1.00), confidentiality (OR=0.57, 95% CI=0.36-0.92) and social considerations (OR=0.47, 95% CI=0.28-0.79). During the postpartum period differences were seen on the domains dignity (OR=0.61, 95% CI=0.38-0.98), autonomy (OR=0.52, 95% CI=0.31-0.85) and basic amenities (OR=0.52, 95% CI=0.30-0.88). More than 80% of the women who received care in a birth centre rated the facilities, the moment of arrival/departure and the continuity in the birth centre as good. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE in the last decades, many birth centres have been established in different countries, including the United Kingdom, Australia, Sweden and the Netherlands. For women who do not want to give birth at home a birth centre is a good choice: it leads to similar experiences as a planned hospital birth. Emphasis should be placed on ways to improve autonomy and prompt attention for women who plan to give birth in a birth centre as well as on the improvement of care in case of a referral.

Targeted social care for highly vulnerable pregnant women: protocol of the Mothers of Rotterdam cohort study

Introduction Social vulnerability is known to be related to ill health. When a pregnant woman is socially vulnerable, the ill health does not only affect herself, but also the health and development of her (unborn) child. To optimise care for highly vulnerable pregnant women, in Rotterdam, a holistic programme was developed in close collaboration between the university hospital, the local government and a non-profit organisation. This programme aims to organise social and medical care from pregnancy until the second birthday of the child, while targeting adult and child issues simultaneously. In 2014, a pilot in the municipality of Rotterdam demonstrated the significance of this holistic approach for highly vulnerable pregnant women. In the ‘Mothers of Rotterdam’ study, we aim to prospectively evaluate the effectiveness of the holistic approach, referred to as targeted social care. Methods and analysis The Mothers of Rotterdam study is a pragmatic prospective cohort study planning to include 1200 highly vulnerable pregnant women for the comparison between targeted social care and care as usual. Effectiveness will be compared on the following outcomes: (1) child development (does the child show adaptive development at year 1?) and (2) maternal mental health (is maternal distress reduced at the end of the social care programme?). Propensity scores will be used to correct for baseline differences between both social care programmes. Ethics and dissemination The prospective cohort study was approved by the Erasmus Medical Centre Ethics Committee (ref. no. MEC-2016–012) and the first results of the study are expected to be available in the second half of 2019 through publication in peer-reviewed international journals. Trial registration number NTR6271; Pre-results.

Quality improvement opportunities for handover practices in birth centres: A case study from a process perspective

RATIONALE, AIMS AND OBJECTIVES Handovers within and between health care settings are known to affect quality of care. Health care organizations, struggle how to guarantee best care during handovers. The aim of this paper is to evaluate handover practices in Dutch birth centres from a process perspective, to identify obstacles and opportunities for quality improvements. METHODS This case study in 7 Dutch birth centres was undertaken from a process perspective by conducting observations and using process mapping. This study is part of the Dutch Birth Centre Study. RESULTS Solutions to obstacles during handovers from a birth centre to a hospital were identified in at least 1 of the 7 birth centres. Four of the centres had agreements with a hospital for client support when a caregiver in a birth centre was absent. Face-to-face communication during handover was observed in 6 of the 7 centres. An electronic health record was noted in 1 centre; joint training of acute situations was available in 2 centres with 3 centres indicating that this was not compulsory. Continuity of caregiver was present in 4 birth centres with postpartum care available in 3 centres. CONCLUSIONS Ensuring quality during handovers requires a case-specific process approach. This study reveals distinctive aspects during handovers, concrete obstacles, and potential solutions for quality improvements in inter-organizational networks, transferrable to birth centres in other countries as well.

Quality of perinatal care services from the user's perspective: a Dutch study applies the World Health Organization's responsiveness concept

BackgroundThe concept of responsiveness was introduced by the World Health Organization (WHO) to address non-clinical aspects of service quality in an internationally comparable way. Responsiveness is defined as aspects of the way individuals are treated and the environment in which they are treated during health system interactions.The aim of this study is to assess responsiveness outcomes, their importance and factors influencing responsiveness outcomes during the antenatal and delivery phases of perinatal care.MethodThe Responsiveness in Perinatal and Obstetric Health Care Questionnaire was developed in 2009/10 based on the eight-domain WHO concept and the World Health Survey questionnaire. After ethical approval, a total of 171 women, who were 2 weeks postpartum, were recruited from three primary care midwifery practices in Rotterdam, the Netherlands, using face-to-face interviews. We dichotomized the original five ordinal response categories for responsiveness attainment as ‘poor’ and good responsiveness and analyzed the ranking of the domain performance and importance according to frequency scores. We used a series of independent variables related to health services and users’ personal background characteristics in multiple logistic regression analyses to explain responsiveness.ResultsPoor responsiveness outcomes ranged from 5.9% to 31.7% for the antenatal phase and from 9.7% to 27.1% for the delivery phase. Overall for both phases, ‘respect for persons’ (Autonomy, Dignity, Communication and Confidentiality) domains performed better and were judged to be more important than ‘client orientation’ domains (Choice and Continuity, Prompt Attention, Quality of Basic Amenities, Social Consideration). On the whole, responsiveness was explained more by health-care and health related issues than personal characteristics.ConclusionTo improve responsiveness outcomes caregivers should focus on domains in the category ‘client orientation’.