Katrien Beeckman

Determinants of the number of antenatal visits in a metropolitan region

BackgroundAntenatal care has a positive effect on pregnancy, both clinically and psychologically, but consensus about the optimal number of antenatal visits is lacking. This study aims to provide insight into the dynamics of the number of antenatal visits a woman receives. Independent effects of predisposing, enabling and pregnancy-related determinants are examined.MethodsWomen were recruited in nine clinical centres in the Brussels Metropolitan region. Antenatal care use was measured prospectively. A Poisson regression model was applied to measure the independent effect of individual determinants on the number of antenatal visits.ResultsData on antenatal care trajectories in 333 women were collected. The multivariate analyses showed that women with a Maghreb or Turkish origin had 14% fewer visits compared with European (EU15) women. More highly educated women had 22% more visits compared with those with a low education. Women with a high income had 14% more antenatal visits compared with those with a low income. Fewer antenatal visits were observed in multiparae (15%), women initiating care after 14 weeks of gestation (31%), women without medical risks during the pregnancy (12%) and in women with a continuity of care index of 50% or more (12%). More visits were observed in delivering after week 37 (22% increase).ConclusionsPredisposing and enabling factors have to be considered when antenatal care programmes are evaluated in a metropolitan area. Variations in the number of antenatal visits show that socially vulnerable women are more at risk of having fewer visits.

Predisposing, enabling and pregnancy-related determinants of late initiation of prenatal care.

Prenatal care is important for the health and wellbeing of women and their babies. There is international consensus that prenatal care should begin in the first trimester. This study aims to analyze the effects of predisposing, enabling and pregnancy-related determinants of late prenatal care initiation. In this prospective observational study, 333 women were recruited consecutively at the beginning of their prenatal care trajectory. Data was collected on the timing of the first prenatal visit and on socio-demographic and pregnancy-related characteristics, using a semi-structured interview. A multivariate binominal logistic regression was applied to analyze independent effects on late initiation of prenatal care. Bivariately late initiation of care was associated with being inactive on the labor market, non-European origin, not having lived in Belgium since birth, low income, receiving welfare benefits, not having a regular obstetrician and experiencing difficulties getting a first appointment. When adjusting for all determinants, our multivariate analyses showed that late initiation was associated with non-European origin, low income and not having a regular obstetrician. This study shows that late initiation of prenatal care is associated with predisposing and enabling determinants. In order to ensure timely initiation of care, policy-makers should focus on encouraging women to have a regular prenatal care provider before pregnancy and taking steps in lowering out-of-pocket fees for low-income women. Future research is needed to examine whether these determinants are associated with initiation of care only or whether they play a role in the pregnancy follow-up as well.

Predictive social factors in relation to preterm birth in a metropolitan region

Objective. Preterm birth is an important indicator of neonatal wellbeing. Infants born preterm are at higher risk for severe morbidity and mortality. Apart from medical risk factors, social factors are also associated with preterm birth. This study aims to provide knowledge on factors which have a predictive role in relation to preterm birth. Design. Cross‐sectional population study. Setting. The Brussels metropolitan region. Population. Women who gave birth in the Brussels metropolitan region in 2004. In total, 8,586 birth registration forms were reviewed for this study. Main outcome measures. Associations between educational level, occupation, marital status, age, and origin with preterm birth (<37 weeks). Methods. After bivariate analyses, significant correlations were explored in a stepwise logistic regression model. Odds ratios (OR) were calculated for each of the significant characteristics in the final model. Results. The risk of preterm birth was found to be associated with age, origin, and marital status. After controlling for confounding factors, the two most important social risk factors for preterm birth were being a teenage mother (OR 2.15, 95% CI: 1.31–3.53) or single mother (OR 1.49, 95% CI: 1.17–1.91). Conclusions. Being a teenage or single mother are important social risk factors for preterm birth. We hypothesize that the increased risk is related to prenatal care trajectories. To obtain a better understanding of preterm birth occurrences, further research should focus on mapping these trajectories and specifically targeting the most vulnerable groups.

Assessing the performance of maternity care in Europe: a critical exploration of tools and indicators

BackgroundThis paper critically reviews published tools and indicators currently used to measure maternity care performance within Europe, focusing particularly on whether and how current approaches enable systematic appraisal of processes of minimal (or non-) intervention in support of physiological or “normal birth”. The work formed part of COST Actions IS0907: “Childbirth Cultures, Concerns, and Consequences: Creating a dynamic EU framework for optimal maternity care” (2011-2014) and IS1405: Building Intrapartum Research Through Health - an interdisciplinary whole system approach to understanding and contextualising physiological labour and birth (BIRTH) (2014-). The Actions included the sharing of country experiences with the aim of promoting salutogenic approaches to maternity care.MethodsA structured literature search was conducted of material published between 2005 and 2013, incorporating research databases, published documents in english in peer-reviewed international journals and indicator databases which measured aspects of health care at a national and pan-national level. Given its emergence from two COST Actions the work, inevitably, focused on Europe, but findings may be relevant to other countries and regions.ResultsA total of 388 indicators were identified, as well as seven tools specifically designed for capturing aspects of maternity care. Intrapartum care was the most frequently measured feature, through the application of process and outcome indicators. Postnatal and neonatal care of mother and baby were the least appraised areas. An over-riding focus on the quantification of technical intervention and adverse or undesirable outcomes was identified. Vaginal birth (no instruments) was occasionally cited as an indicator; besides this measurement few of the 388 indicators were found to be assessing non-intervention or “good” or positive outcomes more generally.ConclusionsThe tools and indicators identified largely enable measurement of technical interventions and undesirable health (or pathological medical) outcomes. A physiological birth generally necessitates few, or no, interventions, yet most of the indicators presently applied fail to capture (a) this phenomenon, and (b) the relationship between different forms and processes of care, mode of birth and good or positive outcomes. A need was identified for indicators which capture non-intervention, reflecting the reality that most births are low-risk, requiring few, if any, technical medical procedures.

Predictors of late initiation for prenatal care in a metropolitan region in Belgium. A cohort study

OBJECTIVES Timely initiation of prenatal care (PNC) in the first pregnancy trimester allows prevention, identification and treatment of risk factors. However, not all women initiate PNC timely, especially women in a deprived situation. The aim of this study was to measure the prevalence of late initiation, defined as initiation after 14 weeks of gestational age. Secondly the authors wanted to identify predictors for late PNC onset. STUDY DESIGN Observational cohort study. METHODS Pregnant women (n = 1750) were recruited in all four hospitals in Ghent (Belgium), a metropolitan region. A socio-economic deprivation ranking was measured by using a General Deprivation Index (GDI), which consists of six criteria to assess a socio-economic situation as deprived. A univariate analysis and a forward conditional multivariate logistic regression model were used analysing the association between deprivation and the likelihood to initiate PNC late. RESULTS 1115 women were included of whom 6.1% (n = 68) initiated PNC late. A foreign maternal country of birth (OR 2.10; 95% CI 1.15-3.83) and a total GDI ≥3 (OR 4.40; 95% CI 2.36-8.21) were good predictors for late initiation. More specifically, the GDI criteria education (OR 4.02; 95% CI 2.00-8.08) and unemployment (OR 2.40; 95% CI 1.17-4.90) were significantly associated with higher likelihood for late initiation. CONCLUSIONS A small group of women initiates PNC late. Vulnerable groups, at risk for late initiation can be identified through assessing their deprivation status. Priority for additional support should be given to women with low educational attainment or women in uncertain employment situations.

Inter-professional Perinatal Simulation training: A valuable educational model to improve competencies amongst student midwives in Brussels, Belgium

Simulation training is a powerful and evidence-based teaching method for students and healthcare professionals. The described educational model of Inter-professional Perinatal Simulation training is the result of a collaborative project with the Erasmus University College Brussels, the Medical School of the Vrije Universiteit Brussel (VUB) and the University Hospital Brussels. This model enhances student midwives to acquire competencies in all fields of midwifery according to national and European legislation and to the International Confederation of Midwives Global Standards for Midwifery Education. In our educational program, simulation training enhanced the achievement of decision-making and inter-professional communication competences.

Vaginal birth after caesarean versus elective repeat caesarean delivery after one previous caesarean section: a cost-effectiveness analysis in four European countries

BackgroundThe OptiBIRTH study incorporates a multicentre cluster randomised trial in 15 hospital sites across three European countries. The trial was designed to test a complex intervention aimed at improving vaginal birth after caesarean section (VBAC) rates through increasing women’s involvement in their care. Prior to developing a robust standardised model to conduct the health economic analysis, an analysis of a hypothetical cohort was performed to estimate the costs and health effects of VBAC compared to elective repeat caesarean delivery (ERCD) for low-risk women in four European countries.MethodsA decision-analytic model was developed to estimate the costs and the health effects, measured using Quality Adjusted Life Years (QALYs), of VBAC compared with ERCD. A cost-effectiveness analysis for the period from confirmation of pregnancy to 6 weeks postpartum was performed for short-term consequences and during lifetime for long-term consequences, based on a hypothetical cohort of 100,000 pregnant women in each of four different countries; Belgium, Germany, Ireland and Italy. A societal perspective was adopted. Where possible, transition probabilities, costs and health effects were adapted from national data obtained from the respective countries. Country-specific thresholds were used to determine the cost-effectiveness of VBAC compared to ERCD. Deterministic and probabilistic sensitivity analyses were conducted to examine the uncertainty of model assumptions.ResultsWithin a 6-week time horizon, VBAC resulted in a reduction in costs, ranging from €3,334,052 (Germany) to €66,162,379 (Ireland), and gains in QALYs ranging from 6399 (Italy) to 7561 (Germany) per 100,000 women birthing in each country. Compared to ERCD, VBAC is the dominant strategy in all four countries. Applying a lifetime horizon, VBAC is dominant compared to ERCD in all countries except for Germany (probabilistic analysis, ICER: €8609/QALY). In conclusion, compared to ERCD, VBAC remains cost-effective when using a lifetime time.ConclusionsIn all four countries, VBAC was cost-effective compared to ERCD for low-risk women. This is important for health service managers, economists and policy makers concerned with maximising health benefits within limited and constrained resources.

Antenatal care use in urban areas in two European countries: Predisposing, enabling and pregnancy-related determinants in Belgium and the Netherlands.

BackgroundExamining determinants of antenatal care (ANC) is important to stimulate equitable distribution of ANC across Europe. This study (1) compares ANC utilisation in Belgium and the Netherlands and (2) identifies predisposing, enabling and pregnancy-related determinants.MethodsSecondary data analysis is performed using data from Belgium, and the Netherlands. The content and timing of care during pregnancy (CTP) tool measured ANC use. Non-parametric tests and ordinal logistic regression are performed to gain insight in the determinants of health care use.ResultsDutch women receive appropriate ANC more often than Belgian women. Multivariate analysis showed that lower education, unemployment, lower continuity of care and non-attendance of antenatal classes are associated with a lower likelihood of having more appropriate ANC.ConclusionsPredisposing and pregnancy related variables are most important to influence the content and timing of ANC, irrespective of the country women live in. Lower health literacy in socially vulnerable women might explain the predisposing determinants of health care use in both countries. Stimulating accessibility to antenatal courses or organising public education are recommendations for practice. Regarding pregnancy-related determinants, improving continuity of care can optimise ANC use in both countries.

Variations in childbirth interventions in high-income countries: protocol for a multinational cross-sectional study

Introduction There are growing concerns about the increase in rates of commonly used childbirth interventions. When indicated, childbirth interventions are crucial for preventing maternal and perinatal morbidity and mortality, but their routine use in healthy women and children leads to avoidable maternal and neonatal harm. Establishing ideal rates of interventions can be challenging. This study aims to describe the range of variations in the use of commonly used childbirth interventions in high-income countries around the world, and in outcomes in nulliparous and multiparous women. Methods and analysis This multinational cross-sectional study will use data from births in 2013 with national population data or representative samples of the population of pregnant women in high-income countries. Data from women who gave birth to a single child from 37 weeks gestation onwards will be included and the results will be presented for nulliparous and multiparous women separately. Anonymised individual level data will be analysed. Primary outcomes are rates of commonly used childbirth interventions, including induction and/or augmentation of labour, intrapartum antibiotics, epidural and pharmacological pain relief, episiotomy in vaginal births, instrument-assisted birth (vacuum or forceps), caesarean section and use of oxytocin postpartum. Secondary outcomes are maternal and perinatal mortality, Apgar score below 7 at 5 min, postpartum haemorrhage and obstetric anal sphincter injury. Univariable and multivariable logistic regression analyses will be conducted to investigate variations among countries, adjusted for maternal age, body mass index, gestational weight gain, ethnic background, socioeconomic status and infant birth weight. The overall mean rates will be considered as a reference category, weighted for the size of the study population per country. Ethics and dissemination The Medical Ethics Review Committee of VU University Medical Center Amsterdam confirmed that an official approval of this study was not required. Results will be disseminated at national and international conferences and published in peer-reviewed journals.

Measuring antenatal care use in Europe: is the content and timing of care in pregnancy tool applicable?

ObjectivesMeasuring of antenatal care utilisation is important from a public health perspective. The Content and Timing of care in Pregnancy tool (CTP) focuses on the care process and includes aspects on quality of care. The aim of the study is to gain insight in the applicability of the CTP tool across Europe.MethodsNational guidelines for routine antenatal care were examined, analysing the degree to which the four items in the CTP tool were included in these guidelines.ResultsFrom the 30 countries, 22 had a national guideline for routine antenatal care. The CTP tool is applicable in over 60% of the European countries with a national guideline.ConclusionsThe CTP tool can be used to measure antenatal care delivery in Europe. The tool is useful to evaluate the care process, focusing on rates of interventions as the closest approximation to the delivery of health care, with a focus on content of visits rather than simply the number of visits. Together with indicators measuring structure and outcome of health care, conclusions about the quality of care can be made.