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

BACKGROUND: The 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. METHOD: The 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. RESULTS: Poor 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. CONCLUSION: To improve responsiveness outcomes caregivers should focus on domains in the category 'client orientation'.

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

BACKGROUND: Birth 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. DESIGN: The 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. DISCUSSION: The 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.

Population attributable risks of patient, child and organizational risk factors for perinatal mortality in hospital births.

The main objective of this study was to estimate the contributing role of maternal, child, and organizational risk factors in perinatal mortality by calculating their population attributable risks (PAR). The primary dataset comprised 1,020,749 singleton hospital births from ≥22 weeks' gestation (The Netherlands Perinatal Registry 2000-2008). PARs for single and grouped risk factors were estimated in four stages: (1) creating a duplicate dataset for each PAR analysis in which risk factors of interest were set to the most favorable value (e.g., all women assigned 'Western' for PAR calculation of ethnicity); (2) in the primary dataset an elaborate multilevel logistic regression model was fitted from which (3) the obtained coefficients were used to predict perinatal mortality in each duplicate dataset; (4) PARs were then estimated as the proportional change of predicted- compared to observed perinatal mortality. Additionally, PARs for grouped risk factors were estimated by using sequential values in two orders: after PAR estimation of grouped maternal risk factors, the resulting PARs for grouped child, and grouped organizational factors were estimated, and vice versa. The combined PAR of maternal, child and organizational factors is 94.4 %, i.e., when all factors are set to the most favorable value perinatal mortality is expected to be reduced with 94.4 %. Depending on the order of analysis, the PAR of maternal risk factors varies from 1.4 to 13.1 %, and for child- and organizational factors 58.7-74.0 and 7.3-34.3 %, respectively. In conclusion, the PAR of maternal-, child- and organizational factors combined is 94.4 %. Optimization of organizational factors may achieve a 34.3 % decrease in perinatal mortality.

Validity of a questionnaire measuring the world health organization concept of health system responsiveness with respect to perinatal services in the Dutch obstetric care system.

BACKGROUND: The concept of responsiveness, introduced by the World Health Organization (WHO), addresses non-clinical aspects of health service quality that are relevant regardless of provider, country, health system or health condition. Responsiveness refers to "aspects related to the way individuals are treated and the environment in which they are treated" during health system interactions. This paper assesses the psychometric properties of a newly developed responsiveness questionnaire dedicated to evaluating maternal experiences of perinatal care services, called the Responsiveness in Perinatal and Obstetric Health Care Questionnaire (ReproQ), using the eight-domain WHO concept. METHODS: The ReproQ was developed between October 2009 and February 2010 by adapting the WHO Responsiveness Questionnaire items to the perinatal care context. The psychometric properties of feasibility, construct validity, and discriminative validity were empirically assessed in a sample of Dutch women two weeks post partum. RESULTS: A total of 171 women consented to participation. Feasibility: the interviews lasted between 20 and 40 minutes and the overall missing rate was 8%. Construct validity: mean Cronbach's alphas for the antenatal, birth and postpartum phase were: 0.73 (range 0.57-0.82), 0.84 (range 0.66-0.92), and 0.87 (range 0.62-0.95) respectively. The item-own scale correlations within all phases were considerably higher than most of the item-other scale correlations. Within the antenatal care, birth care and post partum phases, the eight factors explained 69%, 69%, and 76% of variance respectively. Discriminative validity: overall responsiveness mean sum scores were higher for women whose children were not admitted. This confirmed the hypothesis that dissatisfaction with health outcomes is transferred to their judgement on responsiveness of the perinatal services. CONCLUSIONS: The ReproQ interview-based questionnaire demonstrated satisfactory psychometric properties to describe the quality of perinatal care in the Netherlands, with the potential to discriminate between different levels of quality of care. In view of the relatively small sample, further testing and research is recommended.

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.

Assessment, management, and incidence of neonatal jaundice in healthy neonates cared for in primary care: a prospective cohort study.

Jaundice caused by hyperbilirubinaemia is a common phenomenon during the neonatal period. Population-based studies evaluating assessment, management, and incidence of jaundice and need for phototherapy among otherwise healthy neonates are scarce. We prospectively explored these aspects in a primary care setting via assessing care as usual during the control phase of a stepped wedge cluster randomised controlled trial.We conducted a prospective cohort study embedded in the Screening and TreAtment to Reduce Severe Hyperbilirubinaemia in Infants in Primary care (STARSHIP) Trial. Healthy neonates were included in seven primary care birth centres (PCBCs) in the Netherlands between July 2018 and March 2020. Neonates were eligible for inclusion if their gestational age was ≥ 35 weeks, they were admitted in a PCBC for at least  2 days during the first week of life, and if they did not previously receive phototherapy. Outcomes were the findings of visual assessment to detect jaundice, jaundice incidence and management, and the need for phototherapy treatment in the primary care setting.860 neonates were included of whom 608 (71.9%) were visibly jaundiced at some point during admission in the PCBC, with 20 being 'very yellow'. Of the latter, four (20%) did not receive total serum bilirubin (TSB) quantification. TSB levels were not associated with the degree of visible jaundice (p = 0.416). Thirty-one neonates (3.6%) received phototherapy and none received an exchange transfusion. Five neonates did not receive phototherapy despite having a TSB level above phototherapy threshold.Jaundice is common in otherwise healthy neonates cared for in primary care. TSB quantification was not always performed in very jaundiced neonates, and not all neonates received phototherapy when indicated. Quality improvement initiatives are required, including alternative approaches to identifying potentially severe hyperbilirubinaemia.Trial registration: NL6997 (Dutch Trial Register; Old NTR ID 7187), registered 3 May 2018.

Childbirths and the Prevalence of Potential Risk Factors for Adverse Perinatal Outcomes among Asylum Seekers in The Netherlands: A Five-Year Cross-Sectional Study.

This five-year cross-sectional study mapped the prevalence of several known risk factors for adverse perinatal outcomes in asylum-seeking women in The Netherlands. Characteristics of 2831 registered childbirths among residents of asylum seekers centers (ASCs) in The Netherlands from 2016 to 2020 were included. Results showed a high general and teenage birthrate (2.15 and 6.77 times higher compared to the Dutch, respectively). Most mothers were pregnant upon arrival, and the number of births was highest in the second month of stay in ASCs. Another peak in births between 9 and 12 months after arrival suggested that many women became pregnant shortly after arrival in The Netherlands. Furthermore, 69.5 percent of all asylum-seeking women were relocated between ASCs at least once during pregnancy, which compromises continuity of care. The high prevalence of these risk factors in our study population might explain the increased rate of adverse pregnancy outcomes in asylum seekers compared to native women found in earlier studies. Incorporating migration-related indicators in perinatal health registration is key to support future interventions, policies, and research. Ultimately, our findings call for tailored and timely reproductive and perinatal healthcare for refugee women who simultaneously face the challenges of resettlement and pregnancy.

Screening and treatment to reduce severe hyperbilirubinaemia in infants in primary care (STARSHIP): a factorial stepped-wedge cluster randomised controlled trial protocol.

INTRODUCTION: Jaundice caused by hyperbilirubinaemia is a physiological phenomenon in the neonatal period. However, severe hyperbilirubinaemia, when left untreated, may cause kernicterus, a severe condition resulting in lifelong neurological disabilities. Although commonly applied, visual inspection is ineffective in identifying severe hyperbilirubinaemia. We aim to investigate whether among babies cared for in primary care: (1) transcutaneous bilirubin (TcB) screening can help reduce severe hyperbilirubinaemia and (2) primary care-based (versus hospital-based) phototherapy can help reduce hospital admissions. METHODS AND ANALYSIS: A factorial stepped-wedge cluster randomised controlled trial will be conducted in seven Dutch primary care birth centres (PCBC). Neonates born after 35 weeks of gestation and cared for at a participating PCBC for at least 2 days within the first week of life are eligible, provided they have not received phototherapy before. According to the stepped-wedge design, following a phase of 'usual care' (visual assessment and selective total serum bilirubin (TSB) quantification), either daily TcB measurement or, if indicated, phototherapy in the PCBC will be implemented (phase II). In phase III, both interventions will be evaluated in each PCBC. We aim to include 5500 neonates over 3 years.Primary outcomes are assessed at 14 days of life: (1) the proportion of neonates having experienced severe hyperbilirubinaemia (for the TcB screening intervention), defined as a TSB above the mean of the phototherapy and the exchange transfusion threshold and (2) the proportion of neonates having required hospital admission for hyperbilirubinaemia treatment (for the phototherapy intervention in primary care). ETHICS AND DISSEMINATION: This study has been approved by the Medical Research Ethics Committee of the Erasmus MC Rotterdam, the Netherlands (MEC-2017-473). Written parental informed consent will be obtained. Results from this study will be published in peer-reviewed journals and presented at (inter)national meetings. TRIAL REGISTRATION NUMBER: NTR7187.

[Planned location for delivery; no relationship with maternal or neonatal morbidity]. / Geplande locatie van bevalling.

OBJECTIVE: To compare maternal and neonatal outcomes of planned primary-care birth-centre deliveries with those of planned home deliveries and planned outpatient deliveries. DESIGN: Retrospective cohort study. METHOD: We used data collected in the period February 2009 to November 2013 from 4 community midwife practices attached to the Sophia birth centre (GCS), which is attached to the Erasmus MC academic hospital in Rotterdam, The Netherlands. We included women with low-risk pregnancies for whom primary-care midwives were responsible at the start of the delivery. Pregnant women were stratified according to planned location of delivery (home, outpatient or GCS). The most important outcome measures were: medical intervention during the delivery, and maternal or neonatal morbidity. We used 'propensity score matching' to correct for confounding factors. RESULTS: We included a total of 6185 pregnant women in our study. After propensity score matching, no statistically significant difference was seen in the total number of medical interventions during pregnancy, total maternal morbidity and total neonatal morbidity between pregnant women with planned home deliveries and those with planned GCS deliveries. (Medical interventions 13.6% and 12.4%, respectively; p-value 0.56. Maternal morbidity 4.9% and 5.7%, respectively; p-value 0.53. Neonatal morbidity 6.8% and 5.4%, respectively; p-value 0.31.) Similar results were seen when we compared pregnant women with planned outpatient deliveries with pregnant women with planned deliveries in the GCS. CONCLUSION: In women with low-risk pregnancies the planned location for delivery does not seem to be related to either the number of medical interventions during pregnancy or to maternal or neonatal morbidity. The GCS seems, therefore, to be an appropriate location for these women to deliver, but this should be confirmed by further studies.

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.

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.

Different settings of place of midwife-led birth: evaluation of a midwife-led birth centre.

OBJECTIVES: The claimed advantages of home deliveries, including fewer medical interventions, are potentially counter balanced by the small additional risk on perinatal adverse outcome compared to hospital deliveries in low risk women. Homelike birth centres have been proposed a new setting for low risk women combining the advantages of home and hospital, resulting in lower intervention rates with equal safety. This paper addresses whether the introduction of a midwife-led birth centre adjacent to the hospital combines the advantages of home and hospital deliveries. Additionally, we investigate whether the introduction of a midwife-led birth centre leads to a different risk selection of women planning their delivery either at home, at the hospital or at the birth centre. METHODS: Anonymized data, between January 2007 and June 2012, was collected from the four participating midwife practices. Women (n = 5558) were categorized according to intended place of birth. Women's characteristics and pregnancy outcomes were compared between the period before and after its introduction using Chi square and Fisher's Exact tests. Direct and indirect standardized rates were calculated for different outcomes [(1) intrapartum and neonatal mortality (<24 h), (2) composite outcome of neonatal morbidities, (3) composite outcome of maternal morbidities, and (4) medical intervention], taking the period before introduction as reference. RESULTS: After the introduction of the birth centre a different risk selection was observed. Women's characteristics were most unfavourable for intended birth centre births. Additionally, an higher neonatal risk load was seen within these women. After its introduction neonatal morbidities decreased (5.0 vs. 3.8 %) and maternal morbidities decreased (8.3 vs. 7.3 %). Interventions were about equal. Direct and indirect standardization provided similar results. CONCLUSION: Neonatal morbidity and maternal morbidity tended to decrease, while overall intervention rates were unaffected. The introduction of the midwife-led birth centre seems to benefit the outcome of midwife-led deliveries. We interpret this change by the redistribution of the higher risk women among the low risk population intending birth at the birth centre instead of home.

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.

Does centralisation of acute obstetric care reduce intrapartum and first-week mortality? An empirical study of over 1 million births in the Netherlands.

In this hypothetical analysis with retrospective cohort data (1,160,708 hospital births) we estimated outcome of centralisation of acute obstetric care, i.e., closure of 10 hospitals (out of 99) in The Netherlands. The main outcome was predicted intrapartum and first-week mortality (further referred to as neonatal mortality) for several subgroups of patients affected by two centralisation scenarios: (1) closure of the 10 smallest hospitals; (2) closure of the 10 smallest hospitals, but avoiding adjacent closures. Predictions followed from regression coefficients from a multilevel logistic regression model. Scenario 1 resulted in doubled travel time, and 10% increased mortality (210 [0.34%] to 231 [0.38%] cases). Scenario 2 showed less effect on mortality (268 [0.33%] to 259 [0.32%] cases) and travel time. Heterogeneity in hospital organisational features caused simultaneous improvement and deterioration of predicted neonatal mortality. Consequences vary for subgroups. We demonstrate that (in The Netherlands) centralisation of acute obstetric care according to the 'closure-of-the-smallest-rule' yields suboptimal outcomes. In order to develop an optimal strategy one would need to consider all positive and negative effects, e.g., organisational heterogeneity of closing and surviving hospitals, differential effects for patient subgroups, increased travel time, and financial aspects. The provided framework may be beneficial for other countries considering centralisation of acute obstetric care.

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.

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

OBJECTIVE: The purpose of our study was to compare the intrapartum and early neonatal mortality rate of planned home birth with planned hospital birth in community midwife-led deliveries after case mix adjustment. METHODS: The perinatal outcome of 679,952 low-risk women was obtained from the Netherlands Perinatal Registry (2000-2007). This group represents all women who had a choice between home and hospital birth. Two different analyses were performed: natural prospective approach (intention-to-treat-like analysis) and perfect guideline approach (per-protocol-like analysis). Unadjusted and adjusted odds ratios (ORs) were calculated. Case mix was based on the presence of at least one of the following: congenital abnormalities, small for gestational age, preterm birth, or low Apgar score. We also investigated the potential risk role of intended place of birth. Multivariate stepwise logistic regression was used to investigate the potential risk role of intended place of birth. RESULTS: Intrapartum and neonatal death at 0-7 days was observed in 0.15% of planned home compared with 0.18% in planned hospital births (crude relative risk 0.80, 95% confidence interval [CI] 0.71-0.91). After case mix adjustment, the relation is reversed, showing nonsignificant increased mortality risk of home birth (OR 1.05, 95% CI 0.91-1.21). In certain subgroups, additional mortality may arise at home if risk conditions emerge at birth (up to 20% increase). CONCLUSION: Home birth, under routine conditions, is generally not associated with increased intrapartum and early neonatal death, yet in subgroups, additional risk cannot be excluded.