Inequity in postpartum healthcare provision at home and its association with subsequent healthcare expenditure.

BACKGROUND: Provision of postpartum care can support new families in adapting to a new situation. We aimed to determine whether various determinants of socioeconomic status (SES) were associated with utilization of postpartum care. In addition, to stress the relevance of increasing postpartum care uptake among low SES-groups, an assessment of the potential (cost-)effectiveness of postpartum care is required. METHODS: National retrospective cohort study using linked routinely collected healthcare data from all registered singleton deliveries (2010-13) in the Netherlands. Small-for-gestational age and preterm babies were excluded. The associations between SES and postpartum care uptake, and between uptake and health care expenditure were studied using multivariable regression analyses. RESULTS: Of all 569 921 deliveries included, 1.2% did not receive postpartum care. Among women who did receive care, care duration was below the recommended minimum of 24 h in 15.3%. All indicators of low SES were independently associated with a lack in care uptake. Extremes of maternal age, single parenthood and being of non-Dutch origin were associated with reduced uptake independent of SES determinants. No uptake of postpartum care was associated with maternal healthcare expenses in the highest quartile: aOR 1.34 (95% CI 1.10-1.67). Uptake below the recommended amount was associated with higher maternal and infant healthcare expenses: aOR 1.09 (95% CI 1.03-1.18) and aOR 1.20 (95% CI 1.13-1.27), respectively. CONCLUSION: Although uptake was generally high, low SES women less often received postpartum care, this being associated with higher subsequent healthcare expenses. Strategies to effectively reduce these substantial inequities in early life are urgently needed.

Ethnic disparities in maternal obesity and weight gain during pregnancy. The Generation R Study.

OBJECTIVE: To examine ethnic disparities in maternal prepregnancy obesity and gestational weight gain, and to examine to which extent these differences can be explained by socio-demographic, lifestyle and pregnancy related characteristics. METHODS: In a multi-ethnic population-based prospective cohort study among 6444 pregnant women in Rotterdam, the Netherlands, maternal anthropometrics were repeatedly measured throughout pregnancy. Ethnicity, socio-demographic, lifestyle and pregnancy related characteristics were assessed by physical examinations and questionnaires. RESULTS: The prevalence of prepregnancy overweight and obesity was 23.1% among Dutch-origin women. Statistically higher prevalences were observed among Dutch Antillean-origin (40.8%), Moroccan-origin (49.9%), Surinamese-Creole-origin (38.6%) and Turkish-origin (41.1%) women (all p-values <0.05). Only Dutch Antillean-origin, Moroccan-origin, Surinamese-Creole-origin and Turkish-origin women had higher risks of maternal prepregnancy overweight and obesity as compared to Dutch-origin women (p-values <0.05). Socio-demographic and lifestyle related characteristics explained up to 45% of the ethnic differences in body mass index. Compared to Dutch-origin women, total gestational weight gain was lower in all ethnic minority groups, except for Cape Verdean-origin and Surinamese-Creole-origin women (p-values <0.05). Lifestyle and pregnancy related characteristics explained up to 33% and 40% of these associations, respectively. The largest ethnic differences in gestational weight gain were observed in late pregnancy. CONCLUSION: We observed moderate ethnic differences in maternal prepregnancy overweight, obesity and gestational weight gain. Socio-demographic, lifestyle and pregnancy related characteristics partly explained these differences. Whether these differences also lead to ethnic differences in maternal and childhood outcomes should be further studied.

Early origins of ethnic disparities in cardiovascular risk factors.

BACKGROUND: Not much is known about the ethnic differences in cardiovascular risk factors during childhood in European countries. We examined the ethnic differences in childhood cardiovascular risk factors in the Netherlands. METHODS: In a multi-ethnic population-based prospective cohort study, we measured blood pressure, left ventricular mass, and levels of cholesterol, triglyceride and insulin at the median age of 6.2years. RESULTS: As compared to Dutch children, Cape Verdean and Turkish children had a higher blood pressure, whereas Cape Verdean, Surinamese-Creole and Turkish children had higher total-cholesterol levels (p-values<0.05). Turkish children had higher triglyceride levels, but lower insulin levels than Dutch children (p-values<0.05). As compared to Dutch children, only Turkish children had an increased risk of clustering of cardiovascular risk factors (odds ratio: 2.45 (95% confidence interval 1.18, 3.37)). Parental pre-pregnancy factors explained up to 50% of the ethnic differences in childhood risk factors. In addition to these factors, pregnancy and childhood factors and childhood BMI explained up to 50%, 12.5% and 61.1%, respectively. CONCLUSIONS: Our results suggest that compared to Dutch children, Cape Verdean, Surinamese-Creole and Turkish children have an adverse cardiovascular profile. These differences are largely explained by parental pre-pregnancy factors, pregnancy factors and childhood BMI.

Low and high birth weight and the risk of child attention problems.

OBJECTIVE: To study the prospective association between birth weight and attention problems and to explore the role of maternal body mass index (BMI) in this association. STUDY DESIGN: In 6015 children of a population-based cohort (Rotterdam, The Netherlands, 2001-2005), information on birth weight was collected and gestational age-adjusted SDS were calculated. At age 6 years, parents assessed attention problems with the Child Behavior Checklist. We used linear regression to study the association of birth weight with attention problem score and examined the modification of this association by maternal early pregnancy BMI. RESULTS: The observed association between birth weight and attention problem score was curvilinear (adjusted ß per birth weight SDS(2): 0.02, 95% CI 0.00; 0.03, P = .008); the turning point equals 3.6 kg at term. In analyses of the extreme tails of the birth weight distribution, the associations with attention problem score disappeared after adjustment for socioeconomic confounders. Maternal early pregnancy BMI moderated the association of child birth weight with attention problem score (P interaction = .007, with curvilinear term in model). CONCLUSIONS: Higher birth weight was related to less attention problems but from a birth weight of about 3.6 kg or more, a higher birth weight did not reduce the risk of attention problems any further. However, in children of obese mothers (BMI >30 kg/m(2)), high birth weight may increase the risk of attention problems.

Ethnic differences in antenatal care use in a large multi-ethnic urban population in the Netherlands.

OBJECTIVE: to determine differences in antenatal care use between the native population and different ethnic minority groups in the Netherlands. DESIGN: the Generation R Study is a multi-ethnic population-based prospective cohort study. SETTING: seven midwife practices participating in the Generation R Study conducted in the city of Rotterdam. PARTICIPANTS: in total 2093 pregnant women with a Dutch, Moroccan, Turkish, Cape Verdean, Antillean, Surinamese-Creole and Surinamese-Hindustani background were included in this study. MEASUREMENTS: to assess adequate antenatal care use, we constructed an index, including two indicators; gestational age at first visit and total number of antenatal care visits. Logistic regression analysis was used to assess differences in adequate antenatal care use between different ethnic groups and a Dutch reference group, taking into account differences in maternal age, gravidity and parity. FINDINGS: overall, the percentages of women making adequate use are higher in nulliparae than in multiparae, except in Dutch women where no differences are present. Except for the Surinamese-Hindustani, all women from ethnic minority groups make less adequate use as compared to the native Dutch women, especially because of late entry in antenatal care. When taking into account potential explanatory factors such as maternal age, gravidity and parity, differences remain significant, except for Cape-Verdian women. Dutch-Antillean, Moroccan and Surinamese-Creole women exhibit most inadequate use of antenatal care. KEY CONCLUSIONS: this study shows that there are ethnic differences in the frequency of adequate use of antenatal care, which cannot be attributed to differences in maternal age, gravidity and parity. Future research is necessary to investigate whether these differences can be explained by socio-economic and cultural factors. IMPLICATIONS FOR PRACTISE: clinicians should inform primiparous women, and especially those from ethnic minority groups, on the importance of timely antenatal care entry.

Indirect maternal mortality increases in the Netherlands.

OBJECTIVE: To assess causes, trends, and substandard care in indirect maternal mortality in the Netherlands. DESIGN: Confidential enquiry into causes of maternal death. SETTING: Nationwide in the Netherlands. POPULATION: A total of 2,557,208 live births. METHODS: Data analysis of indirect maternal deaths in the period 1993-2005. MAIN OUTCOME MEASURES: Indirect maternal mortality. RESULTS: Of the study subjects, 97 were classified as indirect deaths, representing a maternal mortality ratio of 3.3/100,000 live births, a significant increase compared to the preceding enquiry in the period 1983-1992 (MMR 2.4, OR 1.5, 95%CI 1.0-2.1). The percentage of cases not directly reported to the Maternal Mortality Committee decreased from 15 to 5%. Cardiovascular disorders were the leading cause of indirect maternal mortality, followed by cerebrovascular disorders. Vascular dissection (n = 19) was the most frequent specified cause of death. Risk factors were advanced maternal age, non-indigenous origin (Surinam and Dutch Antilles), and medical health risks before pregnancy. Substandard care was present in 35%, mainly being misjudgment of the severity of the condition and delay in initiating therapy. CONCLUSION: The rise of mortality due to indirect causes is considered a reflection of the change in risk profile of women of childbearing age and the result of demographic alterations concerning ethnicity and maternal age. The identification of high risk groups, preferably by programs of preconception care, should lead to improved care for these women, with a multidisciplinary approach when needed.

Ethnic differences in informed decision-making about prenatal screening for Down's syndrome.

BACKGROUND: The aim of this study was to assess ethnic variations in informed decision-making about prenatal screening for Down's syndrome and to examine the contribution of background and decision-making variables. METHODS: Pregnant women of Dutch, Turkish and Surinamese origin were recruited between 2006 and 2008 from community midwifery or obstetrical practices in The Netherlands. Each woman was personally interviewed 3 weeks (mean) after booking for prenatal care. Knowledge, attitude and participation in prenatal screening were assessed following the 'Multidimensional Measure of Informed Choice' that has been developed and applied in the UK. RESULTS: In total, 71% of the Dutch women were classified as informed decision-makers, compared with 5% of the Turkish and 26% of the Surinamese women. Differences between Surinamese and Dutch women could largely be attributed to differences in educational level and age. Differences between Dutch and Turkish women could mainly be attributed to differences in language skills and gender emancipation. CONCLUSION: Women from ethnic minority groups less often made an informed decision whether or not to participate in prenatal screening. Interventions to decrease these ethnic differences should first of all be aimed at overcoming language barriers and increasing comprehension among women with a low education level. To further develop diversity-sensitive strategies for counselling, it should be investigated how women from different ethnic backgrounds value informed decision-making in prenatal screening, what decision-relevant knowledge they need and what they take into account when considering participation in prenatal screening.

Ethnic differences in considerations whether or not to participate in prenatal screening for Down syndrome.

OBJECTIVE: To evaluate ethnic differences in considerations whether or not to participate in prenatal screening for Down syndrome and to relate these to differences in participation. METHOD: The study population consisted of 270 pregnant women from Dutch, Turkish and Surinamese (African and South Asian) ethnic origin, attending midwifery or obstetrical practices in the Netherlands. Women were interviewed after booking for prenatal care. Considerations were assessed by one open-ended question and 18 statements that were derived from focus group interviews. Actual participation was assessed several months later. RESULTS: Women from ethnic minorities were less likely to participate in prenatal screening, which could be attributed to differences in age and religious identity. They more often reported acceptance of 'what God gives', low risk of having a child with Down syndrome and costs of screening as considerations not to participate in prenatal screening. They also reported many considerations in favour of participation, which did not differ from those of Dutch women but were less often consistent with actual participation in screening. CONCLUSIONS: Women from ethnic minorities should not be stereotyped as being uninterested in prenatal screening, but should be better informed about the consequences of prenatal screening and Down syndrome.

Information about prenatal screening for Down syndrome: ethnic differences in knowledge.

OBJECTIVE: To evaluate the provision of information about prenatal screening for Down syndrome to women of Dutch, Turkish and Surinamese origins, and to examine the effects of this provision on ethnic differences in knowledge about Down syndrome and prenatal screening. METHODS: The study population consisted of 105 Dutch, 100 Turkish and 65 Surinamese pregnant women attending midwifery or obstetrical practices in The Netherlands. Each woman was personally interviewed for 3 weeks (mean) after booking for prenatal care. RESULTS: Most women reported to have received oral and/or written information about prenatal screening by their midwife or obstetrician at booking for prenatal care. Turkish and Surinamese women less often read the information than Dutch women, more often reported difficulties in understanding the information, and had less knowledge about Down syndrome, prenatal screening and amniocentesis. Language skills and educational level contributed most to the explanation of these ethnic variations. CONCLUSION: Although most Dutch, Turkish and Surinamese women reported to have received information from their midwife or obstetrician, ethnic differences in knowledge about Down syndrome and prenatal screening are substantial. PRACTICE IMPLICATIONS: Interventions to improve the provision of information to women from ethnic minority groups should especially be aimed at overcoming language barriers, and targeting information to the women's abilities to comprehend the information about prenatal screening for Down syndrome.

Smoking during pregnancy in ethnic populations: the Generation R study.

Patterns and correlates of maternal smoking could differ according to ethnic background, and these differences might have consequences for intervention strategies. In the Generation R study, we examined patterns of smoking during pregnancy and the associations of socioeconomic (educational level), demographic (maternal age, marital status, generational status, parity) and lifestyle (alcohol consumption, partner smoking) correlates with smoking during pregnancy in 5,748 women of Dutch, Turkish, Moroccan, Surinamese-Hindustani, Surinamese-Creole, Capeverdean and Antillean ethnic background. Smoking rates before pregnancy were highest in the Turkish group (43.7%) and lowest in the Moroccan group (7.0%). Compared with Dutch women (24.1%), Turkish and Moroccan women were less likely to quit smoking before pregnancy (17.0% and 5.9%, respectively; p<.001). Turkish and Moroccan women (72.0% and 70.6%, respectively) were more likely to continue smoking during pregnancy compared to Dutch women (58.6%, p<.001). Lower education was associated with smoking during pregnancy only in the Dutch group. No significant association of education with smoking was seen in the non-Dutch groups. Second-generation (i.e., foreign-born) Turkish and Capeverdean women were more likely to smoke during pregnancy compared with first-generation women. Partner smoking was associated with smoking during pregnancy in all ethnic groups except for Surinamese-Creole and Antillean. Maternal alcohol consumption was associated with smoking during pregnancy in all ethnic groups except for Capeverdean. Smoking rates and correlates of smoking during pregnancy varied by ethnic background. These observations should be considered when designing maternal smoking prevention and intervention strategies.

Ethnic differences in determinants of participation and non-participation in prenatal screening for Down syndrome: a theoretical framework.

OBJECTIVE: To develop a theoretical framework for analysing ethnic differences in determinants of participation and non-participation in prenatal screening for Down syndrome. METHODS: We applied Weinstein's Precaution Adoption Process (PAP) Model to the decision of whether or not to participate in prenatal screening for Down syndrome. The prenatal screening stage model was specified by reviewing the empirical literature and by data from seven focus group interviews with Dutch, Turkish and Surinamese pregnant women in the Netherlands. RESULTS: We identified 11 empirical studies on ethnic differences in determinants of participation and non-participation in prenatal screening for Down syndrome. The focus group interviews showed that almost all stages and determinants in the stage model were relevant in women's decision-making process. However, there were ethnic variations in the relevance of determinants, such as beliefs about personal consequences of having a child with Down syndrome or cultural and religious norms. DISCUSSION: The prenatal screening stage model can be applied as a framework to describe the decision-making process of pregnant women from different ethnic backgrounds. It provides scope for developing culturally sensitive, tailored methods to guide pregnant women towards informed decision-making on participation or non-participation in prenatal screening for Down syndrome.