Martine Eskes

Travel time from home to hospital and adverse perinatal outcomes in women at term in the Netherlands

Please cite this paper as: Ravelli A, Jager K, de Groot M, Erwich J, Rijninks‐van Driel G, Tromp M, Eskes M, Abu‐Hanna A, Mol B. Travel time from home to hospital and adverse perinatal outcomes in women at term in the Netherlands. BJOG 2011;118:457–465.

Regional perinatal mortality differences in the Netherlands; care is the question

BackgroundPerinatal mortality is an important indicator of health. European comparisons of perinatal mortality show an unfavourable position for the Netherlands. Our objective was to study regional variation in perinatal mortality within the Netherlands and to identify possible explanatory factors for the found differences.MethodsOur study population comprised of all singleton births (904,003) derived from the Netherlands Perinatal Registry for the period 2000–2004. Perinatal mortality including stillbirth from 22+0 weeks gestation and early neonatal death (0–6 days) was our main outcome measure. Differences in perinatal mortality were calculated between 4 distinct geographical regions North-East-South-West. We tried to explain regional differences by adjustment for the demographic factors maternal age, parity and ethnicity and by socio-economic status and urbanisation degree using logistic modelling. In addition, regional differences in mode of delivery and risk selection were analysed as health care factors. Finally, perinatal mortality was analysed among five distinct clinical risk groups based on the mediating risk factors gestational age and congenital anomalies.ResultsOverall perinatal mortality was 10.1 per 1,000 total births over the period 2000–2004. Perinatal mortality was elevated in the northern region (11.2 per 1,000 total births). Perinatal mortality in the eastern, western and southern region was 10.2, 10.1 and 9.6 per 1,000 total births respectively. Adjustment for demographic factors increased the perinatal mortality risk in the northern region (odds ratio 1.20, 95% CI 1.12–1.28, compared to reference western region), subsequent adjustment for socio-economic status and urbanisation explained a small part of the elevated risk (odds ratio 1.11, 95% CI 1.03–1.20). Risk group analysis showed that regional differences were absent among very preterm births (22+0 – 25+6 weeks gestation) and most prominent among births from 32+0 gestation weeks onwards and among children with severe congenital anomalies. Among term births (≥ 37+0 weeks) regional mortality differences were largest for births in women transferred from low to high risk during delivery.ConclusionRegional differences in perinatal mortality exist in the Netherlands. These differences could not be explained by demographic or socio-economic factors, however clinical risk group analysis showed indications for a role of health care factors.

Vaginal birth after caesarean section in a population with a low overall caesarean section rate

OBJECTIVE To determine the clinical outcome of vaginal birth after caesarean section (VBAC) in a Dutch population with a low overall caesarean section (CS) rate of 6.5%. STUDY DESIGN Prospective population based cohort study of 252 patients with a previous caesarean section (CS). Outcome parameters were trial of labour (TOL), success rate and VBAC rate. RESULTS The TOL rate in the study cohort was 73%, success rate 77%, VBAC rate 56%. The reason for the previous CS influenced success rate. Complications, morbidity and mortality were not different between elective, emergency CS and TOL group, except for a higher incidence of haemorrhage more than 500 ml in the elective CS compared to the TOL group (29% versus 17%, relative risk (RR) 1.74 (1.15--2.34)). CONCLUSIONS In this Dutch study the success rate is comparable to rate in US study reports. Increase of the VBAC rate can mainly be achieved by increasing the number of women attempting TOL.

Bad experience, good birthing: Dutch low-risk pregnant women with a history of sexual abuse

Objective. The long-term effects on women in childbirth with a history of sexual abuse have only been studied to a limited degree. We estimated the prevalence of lifetime experience among low-risk pregnant women (non-clinical) in the Netherlands as well as the association with (1) psycho-social outcomes, and (2) the birth process. Methods. Study of 625 randomly selected low-risk pregnant women. At 20–24 weeks gestation, participants completed a questionnaire covering socio-demographic variables, sexual attitude, and psychological determinants. Midwives recorded details of the birth process. Results. Nearly one-in-nine (11.2%) women had experienced sexual abuse. They were on average younger, more likely to smoke, and had lower household income. They reported more conflicting feelings about sex than women who did not report a history of abuse ( p = 0.02). Multiparous women with a history of sexual abuse reported more emotional distress ( p = 0.037), more internal beliefs concerning health ( p = 0.004), and they were also more likely to suffer pelvic pain ( p = 0.045). Sexually-abused women reported higher levels of autonomy ( p =<0.001). Referral rates to secondary care were equal. Sexually-abused women were less likely to receive episiotomies ( p < 0.005). Conclusion. Little difference was observed in major birth-related technical interventions between women with and without a history of sexual abuse.

National perinatal audit, a feasible initiative for the Netherlands!? A validation study

Objective. To explore the feasibility of a national perinatal audit organization. Design. Validation study. Setting. Three regions in the Netherlands. Population. 228 cases of perinatal mortality. Methods. Narratives of perinatal mortality cases were assessed by a panel of representatives of all perinatal care provider groups. 123 cases were assessed twice. Consensus was defined as 75% agreement. For the chance corrected agreement Cohens kappa statistic was used. Main outcome measures. Consensus and the chance corrected agreement on three cause of death classifications. The presence or absence of substandard factors (SSF) with the care provider, the organization of care and the relation of the SSF with perinatal death. Results. Consensus rates and chance corrected agreement for three cause of death classifications ranged from 92 to 96% and κ 0.87 to κ 0.93 (very good agreement), with comparable confidence intervals and similar values in the validation subset of 123 cases. On the presence of SSF at the level of the care provider consensus and chance corrected agreement was 68% and κ 0.53 (moderate), with comparable values in the subset of 123 cases. Consensus for the relation between SSF at the level of the care provider and perinatal death was 81.4% and κ 0.68 (good). Conclusion. Perinatal audit on a national level with relatively large audit groups with many different care providers is feasible.

Ethnic disparities in perinatal mortality at 40 and 41 weeks of gestation

Abstract Objective: To evaluate whether maternal ethnicity affects perinatal mortality by week of gestation from 39 weeks onwards. Study design: In this cohort study, we used data from the nationwide Netherlands Perinatal Registry from 1999 until 2008. All singleton infants born between 39+0 and 42+6 weeks of gestation without congenital anomalies were included. We used crude and multivariate logistic regression analyses with white Europeans as the reference to calculate the adjusted odds ratios (aOR) of South Asian, African and Mediterranean women. The main outcome measure was perinatal mortality (antepartum and intrapartum/neonatal mortality within 7 days after birth). Results: We studied 1,092,255 singleton deliveries. Perinatal mortality occurred in 2315 infants (2.1‰). There was interaction between gestational age and ethnicity (P<0.0001). In week 40 (40+0–40+6) South Asian (aOR 1.9; 95% CI 1.1–3.4) and Mediterranean (aOR 1.3; 95% CI 1.04–1.7) women had an increased risk of perinatal mortality. The perinatal mortality risk became greater in week 41 for South Asian (aOR 4.5 95% CI 2.8–7.2), African (aOR 2.2; 95%CI 1.4–3.4) and Mediterranean (aOR 2.2; 95% CI 1.8–2.9) women, especially among small for gestational age infants. Conclusion: With increasing gestational age beyond 39 weeks, perinatal mortality risk increases more strongly among South Asian, African and Mediterranean women compared to European whites.

Antenatal prediction of neonatal mortality in very premature infants

OBJECTIVE To develop a prognostic model for antenatal prediction of neonatal mortality in infants threatening to be born very preterm (<32 weeks). STUDY DESIGN Nationwide cohort study in The Netherlands between 1999 and 2007. We studied 8500 singletons born between 25(+0) and 31(+6) weeks of gestation where fetus was alive at birth without congenital anomalies. We developed a multiple logistic regression model to estimate the risk of neonatal mortality within 28 days after birth, based on characteristics that are known before birth. We used bootstrapping techniques for internal validation. Discrimination (AUC), accuracy (Brier score) and calibration (graph, c-statistics) were used to assess the models predictive performance. RESULTS Neonatal mortality occurred in 766 (90 per 1000) live births. The final model consisted of seven variables. Predictors were low gestational age, no antental corticosteroids, male gender, maternal age ≥35 years, Caucasian ethnicity, non-cephalic presentation and non-3rd level of hospital. The predicted probabilities ranged from 0.003 to 0.697 (IQR 0.02-0.11). The model had an AUC of 0.83, the Brier score was 0.065. The calibration graph showed good calibration, and the test for the Hosmer Lemeshow c-statistic showed no lack of fit (p=0.43). CONCLUSIONS Neonatal mortality can be predicted for very preterm births based on the antenatal factors gestational age, antental corticosteroids, fetal gender, maternal age, ethnicity, presentation and level of hospital. This model can be helpful in antenatal counseling.

Small for gestational age and perinatal mortality at term: An audit in a Dutch national cohort study

OBJECTIVE To assess the underlying risk factors for perinatal mortality in term born small for gestational age infants. STUDY DESIGN We performed a population based nationwide cohort study in the Netherlands of 465,532 term born infants from January 2010 to January 2013. Logistic regression analyses were performed. Also audit results were studied for detailed care information. RESULTS We studied 162 small for gestational age infants who died in the perinatal period. Risk factors were: gestational age at 37completed weeks (adjusted Odds Ratio (aOR) 2.6, 95% Confidence Interval (CI) 1.6-4.3), male gender (aOR 1.4, 95% CI 1.01-1.9), South Asian ethnicity (aOR 3.6, 95% CI 1.6-8.4), African (aOR 3.5, 95% CI 1.9-6.5) and other non-Western ethnicity (aOR 1.9, CI 1.2-3.1). At 37 completed weeks gestation audit results showed that 26% of the women smoked, 91% were boys and in all but one case death occurred before birth. In 61% of all deceased SGA infants born at 37 completed weeks gestation referral from primary care by independent midwives to the obstetrician took place because of antepartum death before labor. CONCLUSIONS Gestational age of 37 completed weeks, male gender, South Asian, African or other non-Western ethnicity and smoking are associated with perinatal mortality in SGA infants. These risk factors concern the complete term population starting at 37 weeks or even earlier. Therefore, it is of utmost importance to develop accurate diagnostic tests to screen for SGA before 36 weeks gestation to prevent perinatal mortality at term in SGA infants.