Patient versus professional based psychosocial risk factor screening for adverse pregnancy outcomes.

To identify Psychopathology, Psychosocial problems and substance use (PPS) as predictors of adverse pregnancy outcomes, two screen-and-advice instruments were developed: Mind2Care (M2C, self-report) and Rotterdam Reproductive Risk Reduction (R4U, professional's checklist). To decide on the best clinical approach of these risks, the performance of both instruments was compared. Observational study of 164 pregnant women who booked at two midwifery practices in Rotterdam. Women were consecutively screened with M2C and R4U. For referral to tailored care based on specific PPS risks, inter-test agreement of single risks was performed in terms of overall accuracy and positive accuracy (risk present according to both instruments). With univariate regression analysis we explored determinants of poor agreement (<90 %). For triage based on risk accumulation and for detecting women-at-risk for adverse birth outcomes, M2C and R4U sum scores were compared. Overall accuracy of single risks was high (mean 93 %). Positive accuracy was lower (mean 46 %) with poorest accuracy for current psychiatric symptoms. Educational level and ethnicity partly explained poor accuracy (p < 0.05). Overall low PPS prevalence decreased the statistical power. For triage, M2C and R4U sum scores were interchangeable from sum scores of five or more (difference <1 %). The probability of adverse birth outcomes similarly increased with risk accumulation for both instruments, identifying 55-75 % of women-at-risk. The self-report M2C and the professional's R4U checklist seem interchangeable for triage of women-at-risk for PPS or adverse birth outcomes. However, the instruments seem to provide complementary information if used as a guidance to tailored risk-specific care.

Feasibility and reliability of a newly developed antenatal risk score card in routine care.

OBJECTIVE: to study in routine care the feasibility and inter-rater reliability of the Rotterdam Reproductive Risk Reduction risk score card (R4U), a new semi-quantitative score card for use during the antenatal booking visit. The R4U covers clinical and non-clinical psychosocial factors and identifies overall high risk pregnancies, qualifying for intensified antenatal care. DESIGN: a population-based cross-sectional study (feasibility) and a cohort study (inter-rater reliability). SETTING: feasibility was studied in six midwifery practices and two hospitals; the reliability study was performed in one midwifery practice. PARTICIPANTS: 1096 pregnant women in the feasibility study and a subsample of 133 participants in the inter-rater reliability study. MEASUREMENTS: feasibility was expressed as (a) time needed to complete the R4U and (b) the missing rate at the item and client level. For inter-rater reliability (IRR) an independent, blinded, caregiver completed a re-test R4U during a second visit; inter-rater agreement for each item and all domain sum scores were computed. FINDINGS: completion of the R4U took 5 minutes or less in 63%; and between 5 and 10 minutes in another 33%. On the participant level 0.2% of women had >20% missing values (below 4% threshold, P<0.001). One of 77 items had a >10% missing rate. The per item IRR was 100% in 20% of the items, and below the predefined 80% threshold in 13% of the items (n=9). The domain sum scores universally differed less than the predetermined ±15% margin. KEY CONCLUSION: the R4U risk score card is a feasible and reliable instrument. IMPLICATION FOR PRACTICE: the R4U is suitable for the assessment of clinical and non-clinical risks during the antenatal booking visit in a heterogeneous urban setting in routine practice.

An instrument for broadened risk assessment in antenatal health care including non-medical issues.

INTRODUCTION: Growing evidence on the risk contributing role of non-medical factors on pregnancy outcomes urged for a new approach in early antenatal risk selection. The evidence invites to more integration, in particular between the clinical working area and the public health domain. We developed a non-invasive, standardized instrument for comprehensive antenatal risk assessment. The current study presents the application-oriented development of a risk screening instrument for early antenatal detection of risk factors and tailored prevention in an integrated care setting. METHODS: A review of published instruments complemented with evidence from cohort studies. Selection and standardization of risk factors associated with small for gestational age, preterm birth, congenital anomalies and perinatal mortality. Risk factors were weighted to obtain a cumulative risk score. Responses were then connected to corresponding care pathways. A cumulative risk threshold was defined, which can be adapted to the population and the availability of preventive facilities. A score above the threshold implies multidisciplinary consultation between caregivers. RESULTS: The resulting digital score card consisted of 70 items, subdivided into four non-medical and two medical domains. Weighing of risk factors was based on existing evidence. Pilot-evidence from a cohort of 218 pregnancies in a multi-practice urban setting showed a cut-off of 16 points would imply 20% of all pregnant women to be assessed in a multidisciplinary setting. A total of 28 care pathways were defined. CONCLUSION: The resulting score card is a universal risk screening instrument which incorporates recent evidence on non-medical risk factors for adverse pregnancy outcomes and enables systematic risk management in an integrated antenatal health care setting.