Psychological distress during pregnancy and adverse maternal and perinatal health outcomes: The role of socioeconomic status.

OBJECTIVE: To study the contribution of socioeconomic status (SES) to the prevalence of psychological distress during pregnancy, and to investigate the association between psychological distress and maternal and perinatal health among different SES groups. METHODS: This study was embedded in the Generation R study. Multiple self-reported questionnaires were used to measure psychological distress. Prevalence differences between SES groups were tested with the χ2 test. Linear and logistic regression analyses were used to examine the associations between psychological distress and maternal and perinatal health outcomes. RESULTS: Women of low SES experience symptoms of psychopathology distress 4.5 times as often and symptoms of stress 2.5 times as often as women with of high SES. Women of low SES experiencing symptoms of psychopathology are at greater risk of delivering preterm. We also found associations between psychological distress and adverse perinatal health outcomes among women of middle and high SES. CONCLUSION: The present study shows that the associations between SES, psychological distress, and maternal and perinatal health are complex, but do exist. To provide a better understanding of these associations, it is important to include mental health information in the standard national data collection on pregnant women, as this allows population-based studies.

Patient-reported outcome and experience measures for quality improvement in pregnancy and childbirth care: a retrospective cohort study.

BACKGROUND: Patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) can highlight issues that remain unnoticed when using standard clinical quality indicators. However, estimations of the potential power of measuring PROMs and PREMs to identify unrecognised areas suitable for quality improvement are often limited by a lack of reliable real-world data. Here, we report on how the indicator set for PROMs and PREMs that was recently developed by the International Consortium for Health Outcome Measures can change perspectives on quality assessment in women receiving care for pregnancy and childbirth. METHODS: PROMs and PREMs were captured 6 months after childbirth via an online survey in a single academic maternity unit in the Netherlands between 2018 and 2019. Indicators of abnormality were scored using predefined cut-off values established by a national consensus group. We used regression analysis to identify associations between PROMs, PREMs and healthcare use, and further stratified data to explore the distribution of indicators among relevant patient subgroups. RESULTS: Of 2775 questionnaires, 645 were completed and linked to medical health records. Despite only 5% of women reporting overall dissatisfaction with care, suboptimal scores were often found; in birth experience for 32% of the population, and 42% who experienced painful sexual intercourse. Subgroup analysis further revealed associations with relevant indicators of quality of care; inadequate pain relief among women with preterm birth (OR 8.8), pain with sexual intercourse among women undergoing vaginal assisted delivery (OR 2.2) and women living in a deprived area had problematic birth experiences (coefficient -3.2). CONCLUSION: Use of PROMs and PREMs in pregnancy and childbirth care provides new insights on quality of care, resulting in potentially actionable targets for improvement not normally identified with standard clinical quality indicators. Implementation strategies and follow-up are needed to act on these findings.

Exposure to outdoor residential noise during pregnancy, embryonic size, fetal growth, and birth outcomes.

INTRODUCTION: Previous literature suggested that noise exposure during pregnancy was not associated with adverse birth outcomes. However, no studies evaluated the association between noise exposure and embryonic and fetal growth, or mutually assessed other urban environmental exposures such as traffic-related air pollution or natural spaces. METHODS: We included 7947 pregnant women from the Generation R Study, the Netherlands. We estimated total (road traffic, aircraft, railway, and industry), road traffic, and railway noise at the participants' home addresses during pregnancy using environmental noise maps. We estimated traffic-related air pollution using land-use regression models, greenness within a 300 m buffer using the normalized difference vegetation index, and distance to blue spaces using topographical maps at the home addresses. Embryonic size (crown-rump length) and fetal growth parameters (head circumference, femur length, and estimated fetal weight) were measured by ultrasound at several gestational ages. Information on neonatal anthropometrics at birth (head circumference, length, and weight) and adverse birth outcomes (preterm birth, low birth weight, and small for gestational age) were retrieved from medical records. RESULTS: Higher total noise exposure during pregnancy was associated with larger crown-rump length (0.07 SDS [95%CI 0.00 to 0.14]). No association was found with fetal growth parameters, neonatal anthropometrics, and adverse birth outcomes. Similar results were observed for road traffic noise exposure, while railway noise exposure was not associated with any of the outcomes. Traffic-related air pollution was not associated with crown-rump length. Total noise exposure mediated 15% of the association between exposure to greenness and smaller crown-rump length. No association was observed between distance to blue spaces and total noise exposure. CONCLUSION: Exposure to outdoor residential noise during pregnancy was associated with larger embryonic size. Moreover, a reduction of total noise exposure during pregnancy partially mediated the association between exposure to greenness and smaller embryonic size. Additional research is warranted to confirm and further understand these novel findings.

Household income, fetal size and birth weight: an analysis of eight populations.

BACKGROUND: The age at onset of the association between poverty and poor health is not understood. Our hypothesis was that individuals from highest household income (HI), compared to those with lowest HI, will have increased fetal size in the second and third trimester and birth. METHODS: Second and third trimester fetal ultrasound measurements and birth measurements were obtained from eight cohorts. Results were analysed in cross-sectional two-stage individual patient data (IPD) analyses and also a longitudinal one-stage IPD analysis. RESULTS: The eight cohorts included 21 714 individuals. In the two-stage (cross-sectional) IPD analysis, individuals from the highest HI category compared with those from the lowest HI category had larger head size at birth (mean difference 0.22 z score (0.07, 0.36)), in the third trimester (0.25 (0.16, 0.33)) and second trimester (0.11 (0.02, 0.19)). Weight was higher at birth in the highest HI category. In the one-stage (longitudinal) IPD analysis which included data from six cohorts (n=11 062), head size was larger (mean difference 0.13 (0.03, 0.23)) for individuals in the highest HI compared with lowest category, and this difference became greater between the second trimester and birth. Similarly, in the one-stage IPD, weight was heavier in second highest HI category compared with the lowest (mean difference 0.10 (0 .00, 0.20)) and the difference widened as pregnancy progressed. Length was not linked to HI category in the longitudinal model. CONCLUSIONS: The association between HI, an index of poverty, and fetal size is already present in the second trimester.

Maternal lipid profile in pregnancy and embryonic size: a population-based prospective cohort study.

BACKGROUND: Lipids are crucial for fetal growth and development. Maternal lipid concentrations are associated with fetal growth in the second and third trimester of pregnancy and with birth outcomes. However, it is unknown if this association starts early in pregnancy or arises later during fetal development. The aim of this study was to investigate the association between the maternal lipid profile in early pregnancy and embryonic size. METHODS: We included 1474 women from the Generation R Study, a population based prospective birth cohort. Both embryonic size and the maternal lipid profile were measured between 10 weeks + 1 day and 13 weeks + 6 days gestational age. The maternal lipid profile was defined as total cholesterol, triglycerides (TG), high-density lipoprotein cholesterol (HDL-c), low-density lipoprotein cholesterol (LDL-c), remnant cholesterol, non-high-density (non-HDL-c) lipoprotein cholesterol concentrations and the triglycerides/high-density lipoprotein (TG/HDL-c) ratio. Additionally, maternal glucose concentrations were assessed. Embryonic size was assessed using crown-rump length (CRL) measurements. Associations were studied with linear regression models, adjusted for confounding factors: maternal age, pre-pregnancy body mass index (BMI), parity, educational level, ethnicity, smoking and folic acid supplement use. RESULTS: Triglycerides and remnant cholesterol concentrations are positively associated with embryonic size (fully adjusted models, 0.17 SDS CRL: 95% CI 0.03; 0.30, and 0.17 SDS: 95% CI 0.04; 0.31 per 1 MoM increase, respectively). These associations were not present in women with normal weight (triglycerides and remnant cholesterol: fully adjusted model, 0.44 SDS: 95% CI 0.15; 0.72). Associations between maternal lipid concentrations and embryonic size were not attenuated after adjustment for glucose concentrations. Total cholesterol, HDL-c, LDL-c, non-HDL-c concentrations and the TG/HDL-c ratio were not associated with embryonic size. CONCLUSIONS: Higher triglycerides and remnant cholesterol concentrations in early pregnancy are associated with increased embryonic size, most notably in overweight women. TRIAL REGISTRATION: The study protocol has been approved by the Medical Ethics Committee of the Erasmus University Medical Centre (Erasmus MC), Rotterdam (MEC-2007-413). Written informed consent was obtained from all participants.

Maternal hypertensive disorders in pregnancy and early childhood cardiometabolic risk factors: The Generation R Study.

The objective of this study was to determine the associations between hypertensive disorders of pregnancy and early childhood cardiometabolic risk factors in the offspring. Therefore, 7794 women from the Generation Rotterdam Study were included, an ongoing population-based prospective birth cohort. Women with a hypertensive disorder of pregnancy were classified as such when they were affected by pregnancy induced hypertension, pre-eclampsia or the haemolysis, elevated liver enzymes and low platelet count (HELLP) syndrome during pregnancy. Early childhood cardiometabolic risk factors were defined as the body mass index at the age of 2, 6, 12, 36 months and 6 years. Additionally, it included systolic blood pressure, diastolic blood pressure, total fat mass, cholesterol, triglycerides, insulin and clustering of cardiometabolic risk factors at 6 years of age. Sex-specific differences in the associations between hypertensive disorders and early childhood cardiometabolic risk factors were investigated. Maternal hypertensive disorders of pregnancy were inversely associated with childhood body mass index at 12 months (confounder model: -0.15 SD, 95% CI -0.27; -0.03) and childhood triglyceride at 6 years of age (confounder model: -0.28 SD, 95% CI -0.45; -0.10). For the association with triglycerides, this was only present in girls. Maternal hypertensive disorders of pregnancy were not associated with childhood body mass index at 2, 6 and 36 months. No associations were observed between maternal hypertensive disorders of pregnancy and systolic blood pressure, diastolic blood pressure, body mass index, fat mass index and cholesterol levels at 6 years of age. Our findings do not support an independent and consistent association between maternal hypertensive disorders of pregnancy and early childhood cardiometabolic risk factors in their offspring. However, this does not rule out possible longer term effects of maternal hypertensive disorders of pregnancy on offspring cardiometabolic health.

Association between neighbourhood deprivation, fetal growth, small-for-gestational age and preterm birth: a population-based prospective cohort study.

OBJECTIVE: To study the associations between neighbourhood deprivation and fetal growth, including growth in the first trimester, and adverse pregnancy outcomes. DESIGN: Prospective cohort study. SETTING: The Netherlands, Rotterdam. PARTICIPANTS: 8617 live singleton births from the Generation R cohort study. EXPOSITION: Living in a deprived neighbourhood. MAIN OUTCOME MEASURES: Fetal growth trajectories of head circumference, weight and length. SECONDARY OUTCOMES MEASURES: Small-for-gestational age (SGA) and preterm birth (PTB). RESULTS: Neighbourhood deprivation was not associated with first trimester growth. However, a higher neighbourhood status score (less deprivation) was associated with increased fetal growth in the second and third trimesters (eg, estimated fetal weight; adjusted regression coefficient 0.04, 95% CI 0.02 to 0.06). Less deprivation was also associated with decreased odds of SGA (adjusted OR 0.91, 95% CI 0.86 to 0.97, p=0.01) and PTB (adjusted OR 0.89, 95% CI 0.82 to 0.96, p=0.01). CONCLUSIONS: We found an association between neighbourhood deprivation and fetal growth in the second and third trimester pregnancy, but not with first trimester growth. Less neighbourhood deprivation is associated with lower odds of adverse pregnancy outcomes. The associations remained after adjustment for individual-level risk factors. This supports the hypothesis that living in a deprived neighbourhood acts as an independent risk factor for fetal growth and adverse pregnancy outcomes, above and beyond individual risk factors.

Validation of a prognostic model for adverse perinatal health outcomes.

There is a strong association between social deprivation and adverse perinatal health outcomes, but related risk factors receive little attention in current antenatal risk selection. To increase awareness of healthcare professionals for these risk factors, a model for antenatal risk surveillance and care was developed in The Netherlands, called the 'Rotterdam Reproductive Risk Reduction' (R4U) scorecard. The aim of this study was to validate the R4U-scorecard. This study was conducted using external, prospective data from thirty-two midwifery practices, and fifteen hospitals in The Netherlands. The main outcome measures were the discrimination of the prognostic models for the probability of a pregnant woman developing adverse pregnancy outcomes (babies born preterm or small for gestational age), and calibration. We performed cross-validation and updated the model using statistical re-estimation of all predictors. 1752 participants were included, of whom 282 (16%) had one of the predefined adverse outcomes. The discriminative value of the original scoring system was poor [area under the curve (AUC) of 0.58 (95% CI 0.53-0.64)]. The model showed moderate calibration. The updated R4U-scorecard showed good generalisability to the validation set but did not alter the predictive value [AUC 0.61 (95% CI 0.56-0.66)]. By using external data and by updating the prognostic model, we have provided a comprehensive evaluation of the R4U-scorecard. Further improvement in classification of high-risk pregnancies is important considering the necessity of early risk detection for healthcare professionals to take appropriate actions to prevent these risks from becoming manifest problems.

Satisfaction with obstetric care in a population of low-educated native Dutch and non-western minority women. Focus group research.

BACKGROUND: Low-educated native Dutch and non-western minority women have inadequate access to obstetric care. Moreover, the care they receive lacks responsiveness to their needs and cultural competences. Gaining a deeper understanding of their experiences and satisfaction with antenatal, birthing and maternity care will help to adjust healthcare responsiveness to meet their needs during pregnancy, childbirth and the postpartum period. METHODS: We combined the World Health Organization conceptual framework of healthcare responsiveness with focus group research to measure satisfaction with antenatal, birthing and maternity care of women with a low-educated native Dutch and non-western ethnic background. RESULTS: From September 2011 until December 2013, 106 women were recruited for 20 focus group sessions. Eighty-five percent of the women had a non-western immigrant background and 89% a low or intermediate educational attainment. The study population was mostly positive about the provided care during the antenatal phase. They were less positive about the other two phases of care. Moreover, the obstetric healthcare systems' responsiveness in all phases of care (antenatal, birthing and maternity) did not meet these women's needs. The 'respect for persons' domains 'autonomy', 'communication' and 'dignity' and the 'client orientation' domain 'prompt attention' were judged most negatively. CONCLUSIONS: The study findings give contextual meaning and starting points for improvement of responsiveness in the provision of obstetric care within a multi-ethnic women's population.

Inequalities in uptake of prenatal screening according to ethnicity and socio-economic status in the four largest cities of the Netherlands (2011-2013).

OBJECTIVES: In the Netherlands, all women are claimed to have equal access to prenatal screening (PS). Prior research demonstrated substantial inequalities in PS uptake associated with socioeconomic status (SES) and ethnic background. The suggested pathway was a lack of intention to participate in PS among these subgroups. We studied the background of inequalities in PS participation, challenging intention heterogeneity as the single explanation. METHODS: Multivariable logistic regression analyses of the national PS registry, focusing on the four largest cities in the Netherlands (n = 4578, years 2011-2013), stratified by SES. OUTCOME MEASURES: (1) any uptake of PS (yes/no) and (2) uptake (one/two tests) for women who intended to participate in two tests. Determinants included intention, ethnicity, practice, and age. RESULTS: Of non-Western women, 85.7% were screened versus 89.7% of Western women. Intention was an important explanatory factor in all models. However, after correction for intention, ethnicity remained a significant determinant for differences in uptake. Ethnicity and SES also interacted, indicating that non-Western women in low SES areas had the lowest uptake (corrected for intention). CONCLUSIONS FOR PRACTICE: Socioeconomic status and ethnicity related inequalities in PS uptake are only partially explained by intention heterogeneity; other pathways, in particular provider-related determinants, may play a role. © 2017 John Wiley & Sons, Ltd.

Geographical, Ethnic and Socio-Economic Differences in Utilization of Obstetric Care in the Netherlands.

BACKGROUND: All women in the Netherlands should have equal access to obstetric care. However, utilization of care is shaped by demand and supply factors. Demand is increased in high risk groups (non-Western women, low socio-economic status (SES)), and supply is influenced by availability of hospital facilities (hospital density). To explore the dynamics of obstetric care utilization we investigated the joint association of hospital density and individual characteristics with prototype obstetric interventions. METHODS: A logistic multi-level model was fitted on retrospective data from the Netherlands Perinatal Registry (years 2000-2008, 1.532.441 singleton pregnancies). In this analysis, the first level comprised individual maternal characteristics, the second of neighbourhood SES and hospital density. The four outcome variables were: referral during pregnancy, elective caesarean section (term and post-term breech pregnancies), induction of labour (term and post-term pregnancies), and birth setting in assumed low-risk pregnancies. RESULTS: Higher hospital density is not associated with more obstetric interventions. Adjusted for maternal characteristics and hospital density, living in low SES neighbourhoods, and non-Western ethnicity were generally associated with a lower probability of interventions. For example, non-Western women had considerably lower odds for induction of labour in all geographical areas, with strongest effects in the more rural areas (non-Western women: OR 0.78, 95% CI 0.77-0.80, p<0.001). CONCLUSION: Our results suggest inequalities in obstetric care utilization in the Netherlands, and more specifically a relative underservice to the deprived, independent of level of supply.

The association of ethnic minority density with late entry into antenatal care in the Netherlands.

In the Netherlands, non-Western ethnic minority women make their first antenatal visit later than native Dutch women. Timely entry into antenatal care is important as it provides the opportunity for prenatal screening and the detection of risk factors for adverse pregnancy outcomes. In this study we explored whether women's timely entry is influenced by their neighborhood. Moreover, we assessed whether ethnic minority density (the proportion of ethnic minorities in a neighborhood) influences Western and non-Western ethnic minority women's chances of timely entry into care differently. We hypothesized that ethnic minority density has a protective effect against non-Western women's late entry into care. Data on time of entry into care and other individual-level characteristics were obtained from the Netherlands Perinatal Registry (2000-2008; 97% of all pregnancies). We derived neighborhood-level data from three other national databases. We included 1,137,741 pregnancies of women who started care under supervision of a community midwife in 3422 neighborhoods. Multi-level logistic regression was used to assess the associations of individual and neighborhood-level determinants with entry into antenatal care before and after 14 weeks of gestation. We found that neighborhood characteristics influence timely entry above and beyond individual characteristics. Ethnic minority density was associated with a higher risk of late entry into antenatal care. However, our analysis showed that for non-Western women, living in high ethnic minority density areas is less detrimental to their risk of late entry than for Western women. This means that a higher proportion of ethnic minority residents has a protective effect on non-Western women's chances of timely entry into care. Our results suggest that strategies to improve timely entry into care could seek to create change at the neighborhood level in order to target individuals likely of entering care too late.

Deprived neighborhoods and adverse perinatal outcome: a systematic review and meta-analysis.

OBJECTIVES: This study aims to summarize evidence on the relation between neighborhood deprivation and the risks for preterm birth, small-for-gestational age, and stillbirth. DESIGN: The design was a systematic review and meta-analysis. MAIN OUTCOME MEASURES: The main outcome measures included studies that directly compared the risk of living in the most deprived neighborhood quintile with least deprived quintile for at least one perinatal outcome of interest (preterm delivery, small-for-gestational age and stillbirth). METHODS: Study selection was based on a search of Medline, Embase and Web of Science for articles published up to April 2012, reference list screening, and email contact with authors. Data on study characteristics, outcome measures, and quality were extracted by two independent investigators. Random-effects meta-analysis was performed to estimate unadjusted and adjusted summary odds ratios with the associated 95% confidence intervals. RESULTS: We identified 2863 articles, of which 24 were included in a systematic review. A meta-analysis (n = 7 studies, including 2 579 032 pregnancies) assessed the risk of adverse perinatal outcomes by comparing the most deprived neighborhood quintile with the least deprived quintile. Compared with the least deprived quintile, odds ratios for adverse perinatal outcomes in the most deprived neighborhood quintile were significantly increased for preterm delivery (odds ratio 1.23, 95% confidence interval 1.18-1.28), small-for-gestational age (odds ratio 1.31, 95% confidence interval 1.28-1.34), and stillbirth (odds ratio 1.33, 95% confidence interval 1.21-1.45). CONCLUSIONS: Living in a deprived neighborhood is associated with preterm birth, small-for-gestational age and stillbirth.

Improving interprofessional coordination in Dutch midwifery and obstetrics: a qualitative study.

BACKGROUND: Coordination between the autonomous professional groups in midwifery and obstetrics is a key debate in the Netherlands. At the same time, it remains unclear what the current coordination challenges are. METHODS: To examine coordination challenges that might present a barrier to delivering optimal care, we conducted a qualitative field study focusing on midwifery and obstetric professional's perception of coordination and on their routines. We undertook 40 interviews with 13 community midwives, 8 hospital-based midwives and 19 obstetricians (including two resident obstetricians), and conducted non-participatory observations at the worksite of these professional groups. RESULTS: We identified challenges in terms of fragmented organizational structures, different perspectives on antenatal health and inadequate interprofessional communication. These challenges limited professionals' coordinating capacity and thereby decreased their ability to provide optimal care. We also found that pregnant women needed to compensate for suboptimal coordination between community midwives and secondary caregivers by taking on an active role in facilitating communication between these professionals. CONCLUSIONS: The communicative role that pregnant women play within coordination processes underlines the urgency to improve coordination. We recommend increasing multidisciplinary meetings and training, revising the financial reimbursement system, implementing a shared maternity notes system and decreasing the expertise gap between providers and clients. In the literature, communication by clients in support of coordination has been largely ignored. We suggest that studies include client communication as part of the coordination process.

Adverse drug reaction-related admissions in paediatrics, a prospective single-centre study.

OBJECTIVE: To investigate the incidence and characteristics of hospital admissions related to adverse drug events in the paediatric setting. DESIGN: Prospective single-centre study. SETTING: A secondary and tertiary paediatric care centre. PARTICIPANTS: A total of 683 acutely admitted patients, aged 0-18 year. All acutely admitted patients, using medication before admission, were prospectively screened for possible Adverse Drug Reactions (ADR)-related admission with a trigger list. Included cases were analysed with the Naranjo score for the assessment of causality. MAIN OUTCOME MEASURES: This research explored the incidence of ADR-related admissions and investigated the relation between ADR and the licensing status of the medicines, as well as the severity and potential to prevent the ADRs. RESULTS: A total of 683 patients were admitted acutely during the study period, 47 of them were exposed to cancer chemotherapy. Fifteen patients not exposed to chemotherapy (2.4%) were admitted due to an ADR. Five of these 15 ADRs (33%) were caused by unlicensed or off-label used drugs. Thirty-two patients exposed to chemotherapy (68.1%) were admitted due to an ADR; 27 of these (84%) were caused by unlicensed or off-label used drugs. CONCLUSIONS: In conclusion, this study shows that ADR-related hospital admissions occur more frequently in the paediatric population compared with adults, and more frequently in patients exposed to cancer chemotherapy. No relation was found between the unlicensed and off-label used drugs and the incidence of ADRs.