Type of deliveries supported by Dutch clinical midwives.

OBJECTIVE: The number of clinical midwives in the Netherlands has substantially increased over the last twenty years, but their role in obstetric care is not clearly defined. Our aim was to identify the type of deliveries that are usually supported by clinical midwives and whether these changed over time. DESIGN, SETTING, AND PARTICIPANTS: National data from the Netherlands Perinatal Registry from the years 2000 to 2016 (n = 2.999.411 deliveries) were used to divide all deliveries into classes using latent class analyses based on delivery characteristics. In the primary analyses, the identified classes, type of hospital, and year of cohort were used to predict deliveries supported by a clinical midwife. In secondary analyses, the same analyses were repeated where the classes were replaced by individual level characteristics of deliveries and stratified by referral during birth. MEASUREMENTS AND FINDINGS: The latent class analyses identified three classes: I. referral during birth; II. Induction of labour; and III. Planned caesarian section. The primary analyses indicated that women in both class I and II were frequently supported by clinical midwives and those in the third class almost never. Therefore, only data from deliveries assigned to class I and II were used in the secondary analyses. The secondary analyses showed that clinical midwives supported deliveries with a great variety in characteristics, such as pain relief and preterm birth. Although the frequency of clinical midwives being involved in the second stage of labour increased over the years, we did not find noticeable changes in their involvement. KEY CONCLUSION AND IMPLICATIONS FOR PRACTICE: Clinical midwives care for women with various types of deliveries with varying degrees of pathology and complexity during second stage of labour. Additional training, taking previously acquired skills and competences into account, is necessary to deal with this complexity for which clinical midwives are not always trained.

Process evaluation of the implementation of scorecard-based antenatal risk assessment, care pathways and interdisciplinary consultation: the Healthy Pregnancy 4 All study.

OBJECTIVE: To evaluate the implementation of a complex intervention in the antenatal healthcare field in 14 Dutch municipalities. The intervention consisted of the implementation of a systematic scorecard-based risk assessment in pregnancy, subsequent patient-tailored care pathways, and consultations of professionals from different medical and social disciplines. METHODS: Saunders's seven-step method was used for the development of a programme implementation monitoring plan, with specific attention to the setting and context of the programme. Data were triangulated from multiple sources, and prespecified criteria were applied to examine the evidence for implementation. RESULTS: Six out of 11 municipalities (54%) met the implementation criteria for the entire risk assessment programme, whereas three municipalities (27%) met the criteria if the three components of implementation were analysed separately. CONCLUSIONS: A process evaluation of implementation of a complex intervention is possible. The results can be used to improve understanding of the associations between specific programme elements and programme outcomes on effectiveness of the intervention. Additionally, the results are important for formative purposes to assess how future implementation of antenatal risk assessment can be improved in comparable contexts.

Effect of culturally competent educational films about prenatal screening on informed decision making of pregnant women in the Netherlands.

OBJECTIVE: To evaluate the effect of a culturally competent educational film (CCEF) on informed decision making (IDM) regarding prenatal screening (PS) in a study population consisting of multicultural pregnant women. METHODS: A cross-sectional study with 262 women in the control group and 117 in the intervention group. All counselled participants received a self-report questionnaire to obtain data on IDM and only the intervention group received the CCEF. Twenty two percent of the study population had an ethnic minority background and 52% had a low or medium educational level. RESULTS: After exposure to the CCEF, knowledge about the Fetal Anomaly Scan (FAS) was significantly increased in ethnic minority women and in 'medium' and 'highly' educated women. Among women in the intervention group who had the intention to participate in FAS, there was an increase of 11% in IDM and a decrease of 12% in uninformed decision making. CONCLUSION: CCEF leads to a significant increase in the level of knowledge in medium and highly educated groups as well as non-western ethnic minority groups. The increase in IDM among intentional participants in the FAS is promising as well. CCEF's are a valuable complement to counseling about PS.

An antenatal prediction model for adverse birth outcomes in an urban population: The contribution of medical and non-medical risks.

OBJECTIVES: in the Netherlands the perinatal mortality rate is high compared to other European countries. Around eighty percent of perinatal mortality cases is preceded by being small for gestational age (SGA), preterm birth and/or having a low Apgar-score at 5 minutes after birth. Current risk detection in pregnancy focusses primarily on medical risks. However, non-medical risk factors may be relevant too. Both non-medical and medical risk factors are incorporated in the Rotterdam Reproductive Risk Reduction (R4U) scorecard. We investigated the associations between R4U risk factors and preterm birth, SGA and a low Apgar score. DESIGN: a prospective cohort study under routine practice conditions. SETTING: six midwifery practices and two hospitals in Rotterdam, the Netherlands. PARTICIPANTS: 836 pregnant women. INTERVENTIONS: the R4U scorecard was filled out at the booking visit. MEASUREMENTS: after birth, the follow-up data on pregnancy outcomes were collected. Multivariate logistic regression was used to fit models for the prediction of any adverse outcome (preterm birth, SGA and/or a low Apgar score), stratified for ethnicity and socio-economic status (SES). FINDINGS: factors predicting any adverse outcome for Western women were smoking during the first trimester and over-the-counter medication. For non-Western women risk factors were teenage pregnancy, advanced maternal age and an obstetric history of SGA. Risk factors for high SES women were low family income, no daily intake of vegetables and a history of preterm birth. For low SES women risk factors appeared to be low family income, non-Western ethnicity, smoking during the first trimester and a history of SGA. KEY CONCLUSIONS: the presence of both medical and non-medical risk factors early in pregnancy predict the occurrence of adverse outcomes at birth. Furthermore the risk profiles for adverse outcomes differed according to SES and ethnicity. IMPLICATIONS FOR PRACTICE: to optimise effective risk selection, both medical and non-medical risk factors should be taken into account in midwifery and obstetric care at the booking visit.

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.

Higher plants as indicators and accumulators of gaseous air pollution.

Some higher plant species or varieties are very sensitive to certain gaseous air pollutants, and the resulting effects show sometimes more or less specific, well-visible and measurable symptoms.On this basis several species and varieties of natural and cultivated plants have been selected to serve as biological indicators for the possible presence of certain air polluting substances. But these indicator plants may also be used for the quantitative determination of the effect intensities of the air pollutants involved.Besides, some plant species or varieties may accumulate certain components of air pollution, without changing these substances, in such a way that after accumulation in the plants these substances may be analyzed physicochemically (qualitatively and quantitatively).Definitions are proposed and examples are given of both indicator and accumulator plants. Also information is displayed on the methods for the use of plants as indicators and accumulators of air pollutants (standardized system of plant cultivation and exposure). Some applications of biomonitoring the effects of air pollution with plants are discussed and illustrated with data from The Netherlands.