Semiha Denktaş

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).

Evidence-Based Preconceptional Lifestyle Interventions

Although the evidence for the associations between preconceptional risk factors and adverse pregnancy outcomes is extensive, the effectiveness of preconceptional interventions to reduce risk factors and to improve pregnancy outcomes remains partly unclear. The objective of this review is to summarize the available effectiveness of lifestyle interventions prior to pregnancy for women in terms of behavior change and pregnancy outcome. A predefined search strategy was applied in electronic databases, and citation tracking was performed. Study selection was performed by 2 independent reviewers according to predefined criteria for eligibility: The intervention was performed preconceptionally on women regarding alcohol use, smoking, weight, diet/nutrition, physical activity, and folic acid status (fortification and supplementation) to achieve behavior change and/or improve pregnancy outcome. Quality and strength of evidence were assessed by 2 independent reviewers. A total of 4,604 potentially relevant records were identified, of which 44 records met the inclusion criteria. Overall, there is a relatively short list of core interventions for which there is substantial evidence of effectiveness when applied in the preconception period.

Urban perinatal health inequalities

Objective. Large urban areas have higher perinatal mortality rates. In attaining a better understanding, we conducted an analysis on a neighborhood level in Rotterdam, the second largest city of The Netherlands. Methods. Perinatal outcome of all single pregnancies (50,000) was analyzed for the period of 2000–2006. The prevalences of perinatal mortality and perinatal morbidity were determined for every neighborhood. Results. Large perinatal health inequalities exist between neighborhoods in the city of Rotterdam with perinatal mortality rates as high as 37 per 1000 births. The highest risks were observed in deprived neighborhoods. Conclusion. We observed high levels of perinatal health inequalities in the city of Rotterdam which have not been previously described in the Western world. Accumulation of medical risk factors as well as socioeconomic and urban risk factors seems to be a likely contributor.

An Urban Perinatal Health Programme of Strategies to Improve Perinatal Health

Promotion of a healthy pregnancy is a top priority of the health care policy in many European countries. Perinatal mortality is an important indicator of the success of this policy. Recently, it was shown that the Netherlands has relatively high perinatal death rates when compared to other European countries. This is in particular true for large cities where perinatal mortality rates are 20–50% higher than elsewhere. Consequently in the Netherlands, there is heated debate on how to tackle these problems. Without the introduction of measures throughout the entire perinatal health care chain, pregnancy outcomes are difficult to improve. With the support of health care professionals, the City of Rotterdam and the Erasmus University Medical Centre have taken the initiative to develop an urban perinatal health programme called ‘Ready for a Baby’. The main objective of this municipal 10-year programme is to improve perinatal health and to reduce perinatal mortality in all districts to at least the current national average of l0 per 1000. Key elements are the understanding of the mechanisms of the large health differences between women living in deprived and non-deprived urban areas. Risk guided care, orientation towards shared-care and improvement of collaborations between health care professionals shapes the interventions that are being developed. Major attention is given to the development of methods to improve risk-selection before and during pregnancy and methods to reach low-educated and immigrant groups.

Preconception care: an essential preventive strategy to improve children's and women's health.

Reproductive health has improved little in the last few decades. The Netherlands, particularly in large cities, has relatively high perinatal death rates compared with other European countries. Lack of improvement in reproductive outcomes despite improved quality of and better access to prenatal care strongly suggests that prenatal care alone is insufficient. We discuss how preconception care offers new strategies for improving reproductive health, how it usefully connects the life course of the affected individual and many health-care disciplines, and the benefits of combining a top-down policy structure and bottom-up organisation around caregivers. Given the likely benefits and cost savings calculated for the Netherlands, we conclude that failing to facilitate preconception care would reflect a breakdown of both professional and governmental responsibilities.

Bridging Between Professionals in Perinatal Care: Towards Shared Care in The Netherlands

Relatively high perinatal mortality rates in the Netherlands have required a critical assessment of the national obstetric system. Policy evaluations emphasized the need for organizational improvement, in particular closer collaboration between community midwives and obstetric caregivers in hospitals. The leveled care system that is currently in place, in which professionals in midwifery and obstetrics work autonomously, does not fully meet the needs of pregnant women, especially women with an accumulation of non-medical risk factors. This article provides an overview of the advantages of greater interdisciplinary collaboration and the current policy developments in obstetric care in the Netherlands. In line with these developments we present a model for shared care embedded in local ‘obstetric collaborations’. These collaborations are formed by obstetric caregivers of a single hospital and all surrounding community midwives. Through a broad literature search, practical elements from shared care approaches in other fields of medicine that would suit the Dutch obstetric system were selected. These elements, focusing on continuity of care, patient centeredness and interprofessional teamwork form a comprehensive model for a shared care approach. By means of this overview paper and the presented model, we add direction to the current policy debate on the development of obstetrics in the Netherlands. This model will be used as a starting point for the pilot-implementation of a shared care approach in the ‘obstetric collaborations’, using feedback from the field to further improve it.

Design and outline of the Healthy Pregnancy 4 All study

BackgroundPromotion 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/designA 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.DiscussionOptimal 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.

The Association of Neighborhood Social Capital and Ethnic (Minority) Density with Pregnancy Outcomes in the Netherlands

Background Perinatal morbidity rates are relatively high in the Netherlands, and significant inequalities in perinatal morbidity and mortality can be found across neighborhoods. In socioeconomically deprived areas, ‘Western’ women are particularly at risk for adverse birth outcomes. Almost all studies to date have explained the disparities in terms of individual determinants of birth outcomes. This study examines the influence of neighborhood contextual characteristics on birth weight (adjusted for gestational age) and preterm birth. We focused on the influence of neighborhood social capital – measured as informal socializing and social connections between neighbors – as well as ethnic (minority) density. Methods Data on birth weight and prematurity were obtained from the Perinatal Registration Netherlands 2000–2008 dataset, containing 97% of all pregnancies. Neighborhood-level measurements were obtained from three different sources, comprising both survey and registration data. We included 3.422 neighborhoods and 1.527.565 pregnancies for the birth weight analysis and 1.549.285 pregnancies for the premature birth analysis. Linear and logistic multilevel regression was performed to assess the associations of individual and neighborhood level variables with birth weight and preterm birth. Results We found modest but significant neighborhood effects on birth weight and preterm births. The effect of ethnic (minority) density was stronger than that of neighborhood social capital. Moreover, ethnic (minority) density was associated with higher birth weight for infants of non-Western ethnic minority women compared to Western women (15 grams; 95% CI: 12,4/17,5) as well as reduced risk for prematurity (OR 0.97; CI 0,95/0,99). Conclusions Our results indicate that neighborhood contexts are associated with birth weight and preterm birth in the Netherlands. Moreover, ethnic (minority) density seems to be a protective factor for non-Western ethnic minority women, but not for Western women. This helps explain the increased risk of Western women in deprived neighborhoods for adverse birth outcomes found in previous studies.

The Dutch national summit on preconception care: a summary of definitions, evidence and recommendations.

In conclusion, a consensus was achieved on the majority of the key elements of PCC, including the definition, the categorisation, institutes and health care professionals which should play a role in reaching target groups, the content and delivery and the need for development of evidence-based risk assessment instruments. These elements give further insight in what should be resolved in order to enlarge the scale at which PCC is delivered. Furthermore, these can be used as starting points for policymakers and other relevant actors that take responsibility to develop implementation strategies for PCC. In order to develop a tailored PCC programme, the needs of specific populations should be known and resources should be in line with setting specific characteristics. This consensus paper is based on current evidence. Biannual update on the evidence of preconception risk factors and management is recommended to keep the debate going. This debate is necessary to hold the commitment amongst the broad scope of professionals in the curative setting and the public health care setting to collaborate regarding PCC.

Effectiveness of general preconception care accompanied by a recruitment approach: protocol of a community-based cohort study (the Healthy Pregnancy 4 All study)

Introduction Promotion of healthy pregnancies has gained high priority in the Netherlands because of the relative unfavourable perinatal outcomes. In response, a nationwide study Healthy Pregnancy 4 All (HP4ALL) has been initiated. One of the substudies within HP4ALL focuses on preconception care (PCC). PCC is an opportunity to detect and eliminate risk factors before conception to optimise health before organogenesis and placentation. The main objectives of the PCC substudy are (1) to assess the effectiveness of a recruitment strategy for the PCC health services and (2) to assess the effectiveness of individual PCC consultations. Methods/analysis Prospective cohort study in neighbourhoods of 14 municipalities with perinatal mortality and morbidity rates exceeding the nations average. The theoretical framework of the PCC substudy is based on Andersens model of healthcare utilisation (a model that evaluates the utilisation of healthcare services from a sociological perspective). Women aged 18 up to and including 41 years are targeted for utilisation of the PCC health service by a four armed recruitment strategy. The PCC health service consists of an individual PCC consultation consisting of (1) initial risk assessment and risk management and (2) a follow-up consultation to assess adherence to the management plan. The primary outcomes regarding the effectiveness of consultations is behavioural change regarding folic acid supplementation, smoking cessation, cessation of alcohol consumption and illicit substance use. The primary outcome regarding the effectiveness of the recruitment strategy is the number of women successfully recruited and the outreach in terms of which population is reached in comparison to the approached population. Data collection consists of registration in the database of women that enrol for a visit to the individual PCC consultations (women successfully recruited), and preconsultation and postconsultation measurements among the included study population (by questionnaires, anthropometric measurements and biomarkers). Sample size calculation resulted in a sample size of n=839 women. Ethics and dissemination Approval for this study has been obtained from the Medical Ethical Committee of the Erasmus Medical Center of Rotterdam (MEC 2012-425). Results will be published and presented at international conferences.