Variations over time in mode of birth and perinatal outcomes in women with one previous cesarean in the Netherlands: A 20-year population-based study.

BACKGROUND: Globally, cesarean birth rates are rising, and while it can be a lifesaving procedure, cesarean birth is also associated with increased maternal and perinatal risks. This study aims to describe changes over time about the mode of birth and perinatal outcomes in second-pregnancy women with one previous cesarean birth in the Netherlands over the past 20 years. METHODS: We conducted a nationwide, population-based study using the Dutch perinatal registry. The mode of birth (intended vaginal birth after cesarean (VBAC) compared with planned cesarean birth) was assessed in all women with one previous cesarean birth and no prior vaginal birth who gave birth to a term singleton in cephalic presentation between 2000 and 2019 in the Netherlands (n = 143,146). The reported outcomes include the trend of intended VBAC, VBAC success rate, and adverse perinatal outcomes (perinatal mortality up to 7 days, low Apgar score at 5 min, asphyxia, and neonatal intensive care unit admission ≥24 h). RESULTS: Intended VBAC decreased by 21.5% in women with one previous cesarean birth and no prior vaginal birth, from 77.2% in 2000 to 55.7% in 2019, with a marked deceleration from 2009 onwards. The VBAC success rate dropped gradually, from 71.0% to 65.3%, across the same time period. Overall, the cesarean birth rate (planned and unplanned) increased from 45.2% to 63.6%. Adverse perinatal outcomes were higher in women intending VBAC compared with those planning a cesarean birth. Perinatal mortality initially decreased but remained stable from 2009 onwards, with only minimal differences between both modes of birth. CONCLUSIONS: In the Netherlands, the proportion of women intending VBAC after one previous cesarean birth and no prior vaginal birth has decreased markedly. Particularly from 2009 onwards, this decrease was not accompanied by a synchronous reduction in perinatal mortality.

Spontaneous haemoperitoneum in pregnancy: Nationwide surveillance and Delphi audit system.

OBJECTIVE: To evaluate the incidence, diagnostic management strategies and clinical outcomes of women with spontaneous haemoperitoneum in pregnancy (SHiP) and reassess the definition of SHiP. DESIGN: A population-based cohort study using the Netherlands Obstetric Surveillance System (NethOSS). SETTING: Nationwide, the Netherlands. POPULATION: All pregnant women between April 2016 and April 2018. METHODS: This is a case study of SHiP using the monthly registry reports of NethOSS. Complete anonymised case files were obtained. A newly introduced online Delphi audit system (DAS) was used to evaluate each case, to make recommendations on improving the management of SHiP and to propose a new definition of SHiP. MAIN OUTCOME MEASURES: Incidence and outcomes, lessons learned about clinical management and the critical appraisal of the current definition of SHiP. RESULTS: In total, 24 cases were reported. After a Delphi procedure, 14 cases were classified as SHiP. The nationwide incidence was 4.9 per 100 000 births. Endometriosis and conceiving after artificial reproductive techniques were identified as risk factors. No maternal and three perinatal deaths occurred. Based on the DAS, adequate imaging of free intra-abdominal fluid, and identifying and treating women with signs of hypovolemic shock could improve the early detection and management of SHiP. A revised definition of SHiP was proposed, excluding the need for surgical or radiological intervention. CONCLUSIONS: SHiP is a rare and easily misdiagnosed condition that is associated with high perinatal mortality. To improve care, better awareness among healthcare workers is needed. The DAS is a sufficient tool to audit maternal morbidity and mortality.

Lessons learned in cases of late preterm mortality in the Netherlands: Results from nationwide perinatal audits, a mixed method study.

Objective: Assess improvable care factors in late preterm mortality, defined as death of a child during labour or in the first 28 days thereafter between 32 + 0 and 36 + 6 weeks gestation, in the Netherlands. Design: Perinatal audit has been coordinated and supported at the national level, with selection of nationwide audit themes, and audit sessions are performed at the local level across the country as multidisciplinary meetings with primary and secondary level health care professionals, organised in local perinatal cooperation units. In 2017-2019, late preterm mortality was such a theme. We compiled and systematically categorised all improvable care factors formulated during local audit meetings in a national perinatal audit database. Results: In total, 27 cases were discussed in local perinatal audits and analysed locally and at the national level. Altogether, 52 improvable care factors were identified. Most identified improvable care factors concerned inadequate foetal monitoring by cardiotocography during labour, factors related to care organisation, particularly unclarity around local assigning of responsibilities and work procedures, and poor communication between involved health care professionals especially in transfer of care. Conclusion: Several critical improvable care factors were identified through nationwide perinatal audit of late preterm deaths in the Netherlands.

Trends in perinatal outcomes of women with chronic medical conditions: A 10-year population-based study in the Netherlands.

OBJECTIVE: To gain insight into perinatal outcomes in women with chronic medical conditions, in order to contribute to the optimization of personalized perinatal care. We hypothesize that women with a chronic medical condition have poorer perinatal outcomes than women without a known chronic medical condition. DESIGN: Population-based study using data of the Netherlands Perinatal Registry between 2010-2019. SETTING: Nationwide study in the Netherlands. PARTICIPANTS: Pregnancies of women who were diagnosed with chronic medical conditions by a medical specialist before pregnancy (n=36,835), divided into seven sub-groups and a reference group of pregnancies of women without known chronic medical conditions (n=1,084,623). MEASUREMENTS AND FINDINGS: The primary outcome measure was mode of birth. Secondary outcomes measures were onset of labour, preterm birth, asphyxia, Neonatal Intensive Care Unit (NICU) admission, and perinatal mortality. Spontaneous birth ranged from 45.0% (orthopaedic conditions) to 71.3% (neurological conditions) to 82.6% in the reference group. Assisted vaginal birth, planned caesarean birth, and emergency caesarean birth occurred significantly more in all groups compared to the reference group (p<0.001). Preterm birth was significantly more likely in the studied groups as well as perinatal asphyxia and NICU admission (all p<0.001). Adjusting for mode of birth, parity, age and ethnicity did not change the outcomes for the group of women with chronic medical conditions. Perinatal mortality was seen in all groups but in none of the separate groups significantly more than in the reference group. Descriptive statistics, univariate and multivariable logistic regression analyses were applied. KEY CONCLUSIONS: Women with chronic medical conditions are more likely to experience preterm birth, caesarean births and NICU admission of the new-born. IMPLICATIONS FOR PRACTICE: Knowledge about perinatal outcomes of women with chronic medical conditions is a first step for obstetrics care providers in order to optimize personalized care.

Lessons learned from the perinatal audit of uterine rupture in the Netherlands: A mixed-method study.

Background and Aims: To analyze outcomes of nationwide local audits of uterine rupture to draw lessons for clinical care. Methods: Descriptive cohort study. Critical incident audit sessions within all local perinatal cooperation groups in the Netherlands. Women who sustained uterine rupture between January 1st, 2017 and December 31st, 2019. Main Outcome Measures: Improvable factors, recommendations, and lessons learned for clinical care. Women's case histories were discussed in multidisciplinary perinatal audit sessions. Participants evaluated care against national and local clinical guidelines and common professional standards to identify improvable factors. Cases and outcomes were registered in a nationwide database. Results: One hundred and fourteen women who sustained uterine rupture were discussed in local perinatal audit sessions by 40-60 participants on average: A total of 111 (97%) were multiparous of whom 107 (94%) had given birth by cesarean section in a previous pregnancy. The audit revealed 178 improvable factors and 200 recommendations. Six percent (N = 11) of the improvable factors were identified as very likely and 18% (N = 32) as likely to have a relationship with the outcome or occurrence of uterine rupture. Improvable factors were related to inadequate communication, absent, or unclear documentation, delay in diagnosing the rupture, and suboptimal management of labor. Speak up in case a suspicion arises, escalating care by involving specialist obstetricians, addressing the importance of accurate documentation, and improving training related to fetal monitoring were the most frequent recommendations and should be topics for team (skills and drills) training. Conclusions: Through a nationwide incident audit of uterine rupture, we identified improvable factors related to communication, documentation, and organization of care. Lessons learned include "speaking up," improving the transfer of information and team training are crucial to reduce the incidence of uterine rupture.

Severe neonatal hyperbilirubinaemia: lessons learnt from a national perinatal audit.

OBJECTIVES: To describe characteristics of neonates with severe neonatal hyperbilirubinaemia (SNH) and to gain more insight in improvable factors that may have contributed to the development of SNH. DESIGN AND SETTING: Descriptive study, based on national Dutch perinatal audit data on SNH from 2017 to 2019. PATIENTS: Neonates, born ≥35 weeks of gestation and without antenatally known severe blood group incompatibility, who developed hyperbilirubinaemia above the exchange transfusion threshold. MAIN OUTCOME MEASURES: Characteristics of neonates having SNH and corresponding improvable factors. RESULTS: During the 3-year period, 109 neonates met the eligibility criteria. ABO antagonism was the most frequent cause (43%). All neonates received intensive phototherapy and 30 neonates (28%) received an exchange transfusion. Improvable factors were mainly related to lack of knowledge, poor adherence to the national hyperbilirubinaemia guideline, and to incomplete documentation and insufficient communication of the a priori hyperbilirubinaemia risk assessment among healthcare providers. A priori risk assessment, a key recommendation in the national hyperbilirubinaemia guideline, was documented in only six neonates (6%). CONCLUSIONS: SNH remains a serious threat to neonatal health in the Netherlands. ABO antagonism frequently underlies SNH. Lack of compliance to the national guideline including insufficient a priori hyperbilirubinaemia risk assessment, and communication among healthcare providers are important improvable factors. Implementation of universal bilirubin screening and better documentation of the risk of hyperbilirubinaemia may enhance early recognition of potentially dangerous neonatal jaundice.

Change in Lifestyle Behaviors After Preconception Care: A Prospective Cohort Study.

PURPOSE: To evaluate the effects of preconception care (PCC) consultations by change in lifestyle behaviors. SETTING AND INTERVENTION: Women in deprived neighborhoods of 14 Dutch municipalities were encouraged to visit a general practitioner or midwife for PCC. SAMPLE: The study included women aged 18 to 41 years who had a PCC consultation. DESIGN: In this community-based prospective cohort study, we assessed initiation of folic acid supplementation, cessation of smoking, alcohol consumption, and illicit drug use. MEASURES: Self-reported and biomarker data on behavioral changes were obtained at baseline and 3 months later. ANALYSIS: The changes in prevalence were assessed with the McNemar test. RESULTS: Of the 259 included participants, paired analyses were available in 177 participants for self-reported outcomes and in 82 for biomarker outcomes. Baseline self-reported prevalence of no folic acid use was 36%, smoking 12%, weekly alcohol use 22%, and binge drinking 17%. Significant changes in prevalence toward better lifestyle during follow-up were seen for folic acid use (both self-reported, P < .001; and biomarker-confirmed, P = .008) and for self-reported binge drinking (P = .007). CONCLUSION: Our study suggests that PCC contributes to initiation of folic acid supplementation and cessation of binge drinking in women who intend to become pregnant. Although based on a small sample, the study adds to the limited body of evidence regarding the benefits of PCC in improving periconception health.

Identifying the Needs for a Web-Based Postpartum Platform Among Parents of Newborns and Health Care Professionals: Qualitative Focus Group Study.

BACKGROUND: During the turbulent postpartum period, there is an urgent need by parents for support and information regarding the care for their infant. In the Netherlands, professional support is provided during the first 8 days postpartum and for a maximum of 8 hours a day. This care is delivered by maternity care assistants (MCAs). Despite the availability of this extensive care, a majority of women prefer to make use of a lesser amount of postpartum care. After this period, access to care is less obvious. Where parents are automatically offered care in the first 8 days after birth, they must request care in the period thereafter. To compensate for a possible gap in information transfer, electronic health (eHealth) can be a valuable, easily accessible addition to regular care. OBJECTIVE: We explored the needs and preferred content by new parents and health care professionals of a web-based platform dedicated to the postpartum period and identified barriers and facilitators for using such a platform. METHODS: We conducted 3 semistructured focus groups among (1) parents of newborns, (2) MCAs, and (3) clinicians and administrators in maternity care. A topic list based on a framework designed for innovation processes was used. Thematic content analysis was applied. RESULTS: In the focus group for parents, 5 mothers and 1 male partner participated. A total of 6 MCAs participated in the second focus group. A total of 5 clinicians and 2 administrators-a member of a stakeholder party and a manager of a maternity care organization-participated in the third focus group. All user groups underlined that a platform focusing on the postpartum period was missing in current care, especially by parents experiencing a gap following the intensive care ending after the first week of childbirth. Parents indicated that they would perceive a postpartum platform as a proper source of reliable information on topics regarding breastfeeding, growth, and developmental milestones, but also as a tool to support them in seeking care with appropriate professionals. They also emphasized the need to receive personalized information and the opportunity to ask questions via the platform. MCAs acknowledged added value of providing additional information on topics that they address during the early postpartum period. MCAs as well as clinicians and administrators would guide parents to such a platform for additional support. All user groups experienced disadvantages of using an authentication procedure and filling out extra questionnaires to receive tailored information. CONCLUSIONS: Our research shows that parents of newborns, MCAs, and clinicians and administrators foresee the additional value of a web-based postpartum platform for at least the whole postpartum period. The platform should be easily accessible and personalized. Content on the platform should contain information regarding breastfeeding, growth, and developmental milestones. A chat function with professionals could be considered as an option.

Results of a Dutch national and subsequent international expert meeting on interconception care.

Introduction: The potential value of preconception care and interconception care is increasingly acknowledged, but delivery is generally uncommon. Reaching women for interconception care is potentially easier than for preconception care, however the concept is still unfamiliar. Expert consensus could facilitate guidelines, policies and subsequent implementation. A national and subsequent international expert meeting were organized to discuss the term, definition, content, relevant target groups, and ways to reach target groups for interconception care.Methods: We performed a literature study to develop propositions for discussion in a national expert meeting in the Netherlands in October 2015. The outcomes of this meeting were discussed during an international congress on preconception care in Sweden in February 2016. Both meetings were recorded, transcribed and subsequently reviewed by participants.Results: The experts argued that the term, definition, and content for interconception care should be in line with preconception care. They discussed that the target group for interconception care should be "all women who have been pregnant and could be pregnant in the future and their (possible) partners". In addition, they opted that any healthcare provider having contact with the target group should reach out and make every encounter a potential opportunity to promote interconception care.Discussion: Expert discussions led to a description of the term, definition, content, and relevant target groups for interconception care. Opportunities to reach the target group were identified, but should be further developed and evaluated in policies and guidelines to determine the optimal way to deliver interconception care.

Systematic Development of Materials for Inviting Low Health-Literate Individuals to Participate in Preconception Counseling.

In this study we aimed to systematically analyze problems in the recruitment of women with low health literacy for preconception counseling and to adapt and evaluate written invitations for this group. In a problem analysis (stage 1) we used structured interviews (n = 72) to assess comprehension of the initial invitations, perception of perinatal risks, attitude and intention to participate in preconception counseling. These outcomes were used to adapt the invitation. The adapted flyer was pretested in interviews (n = 16) (stage 2) and evaluated in structured interviews among a new group of women (n = 67) (stage 3). Differences between women in stages 1 and 3 regarding comprehension, risk perception, attitude and intention to participate in counseling were analyzed by linear regression analysis and chi-square tests. Women in stage 3 (who read the adapted flyer) had a more positive attitude towards participation in preconception counselling and a better understanding of how to apply for a consultation than women in stage 1 (who read the initial invitations). No differences were found in intention to participate in preconception counseling and risk perception. Systematic adaptation of written invitations can improve the recruitment of low health-literate women for preconception counselling. Further research should gain insight into additional strategies to reach and inform this group.

Integrating interconception care in preventive child health care services: The Healthy Pregnancy 4 All program.

BACKGROUND: Most parents with young children pay routine visits to Well-Baby Clinics, or so-called Preventive Child Health Care (PCHC) services. This offers a unique opportunity to promote and deliver interconception care. This study aimed to integrate such care and perform an implementation evaluation. METHODS: In seven Dutch municipalities, PCHC professionals were instructed to discuss the possibility of an interconception care consultation during each routine six-months well-baby visit. The primary outcome of this study was coverage of the intervention, quantified as the proportion of visits during which women were informed about interconception care. Secondary outcomes included adoption, fidelity, feasibility, appropriateness, acceptability and effectiveness of the intervention, studied by surveying PCHC professionals and women considering becoming pregnant. RESULTS: The possibility of interconception care was discussed during 29% (n = 1,849) of all visits, and 60% of the PCHC physicians adopted the promotion of interconception care by regularly informing women. About half of the PCHC professionals and most women judged integration of interconception care in PCHC appropriate and acceptable. Estimated feasibility was poor, since 13% of the professionals judged future integration in daily practice as probable. The uptake of interconception care consultations was low (n = 4 consultations). CONCLUSIONS: Promotion of interconception care was achieved in approximately one-third of the routine PCHC consultations and appeared promising with regards to adoption, appropriateness and acceptability. However, concerns on feasibility and uptake of interconception care consultations in daily practice remain. Suggestions for improvement may include further integration of interconception care health promotion in routine PCHC consultations, while allocating sufficient resources.

[Decrease in foetal and neonatal mortality in the Netherlands; comparison with other Euro-Peristat countries in 2004, 2010 and 2015]. / Afname van foetale en neonatale sterfte in Nederland.

OBJECTIVE: To compare changes in foetal, neonatal and perinatal mortality in the Netherlands in 2015, relative to 2004 and 2010, with changes in other European countries and regions. DESIGN: Descriptive population-wide study. METHOD: Data from 32 European countries and regions within the Euro-Peristat registration area were analysed. These countries and regions were grouped into: the Netherlands, Scandinavia, Western Europe and Eastern Europe. International differences in registration and policies were taken into account by using rates from 28 weeks gestation for foetal mortality and for 24 weeks gestation and beyond for neonatal mortality. Ranking was based on individual countries and regions. RESULTS: Foetal mortality decreased by 24% in the Netherlands, from 2.9 per 1,000 births in 2010 to 2.2 per 1,000 births in 2015; neonatal mortality decreased by 9%, from 2.2 to 2.0 per 1,000 live births. Perinatal mortality (the sum of foetal mortality and neonatal mortality) decreased by 18% from 5.1 to 4.2 per 1,000 births. The Netherlands moved from the 18th place in the European ranking in 2004 to the 10th place in 2015. CONCLUSION: Foetal, neonatal and perinatal mortality in the Netherlands decreased in 2015 when compared with 2004 and 2010. The country's position in the European ranking also improved. Explanations for this decrease are related to changes in the areas of organisation of care, population and risk factors. When mortality rates in other European countries and regions - particularly Scandinavia - are considered there is room for further improvement.

Handover of care and of information by community midwives, maternity care assistants and Preventive Child Healthcare professionals, a qualitative study.

INTRODUCTION: Handover of care has been internationally acknowledged as an important aspect in patient safety. Families who are vulnerable due to low socio-economic status, a language barrier or poor health skills, benefit especially from a decent handover of care from one healthcare professional to another. The handover from primary midwifery care and maternity care to Preventive Child Healthcare (PCHC) is not always successful, especially not in case of vulnerable families. AIM: Obtaining insight in and providing recommendations for the proces of handover of information by primary midwifery care, maternity care and PCHC in the Netherlands. METHODS: A qualitative research through semi-structured interviews was conducted. Community midwives, maternity care nurses and PCHC nurses from three municipalities in the Netherlands were invited for interviews with two researchers. The interviews took place from February to April 2017. The qualitative data was analyzed using NVivo11 software (QSR International). RESULTS: A total of 18 interviews took place in three different municipalities with representatives of the three professions involved with the handover of care and of information concerning antenatal, postnatal and child healthcare: six community midwives, six maternity care assistants and six PCHC nurses. All those interviewed emphasized the importance of good information transfer in order to provide optimum care, especially when problems within the family ar present. In order to improve care, a large number of healthcare professionals prefered a fully digitized handover of information, providing the privacy of the client is warrented and the system works efficiently. To provide high quality care, it is considered desirable that healthcare workers get to know each other and more peer agreements are prepared. The 'obstetric collaborative network' or another structured meeting was considered most suitable for this exchange. CONCLUSION: This study shows that the handover of care and of information between professionals in the fields of antenatal, postnatal and child healthcare is gaining awareness, but a more rigorous chain of care and collaboration between these disciplines is desired. Digitizing seems important to improve the handover of information.

The effect of a preconception care outreach strategy: the Healthy Pregnancy 4 All study.

BACKGROUND: Preconception care has been acknowledged as an intervention to reduce perinatal mortality and morbidity. However, utilization of preconception care is low because of low awareness of availability and benefits of the service. An outreach strategy was employed to promote uptake of preconception care consultations. Its effect on the uptake of preconception care consultations was evaluated within the Healthy Pregnancy 4 All study. METHODS: We conducted a community-based intervention study. The outreach strategy for preconception care consultations included four approaches: (1) letters from municipal health services; (2) letters from general practitioners; (3) information leaflets by preventive child healthcare services and (4) encouragement by peer health educators. The target population was set as women aged 18 to 41 years in 14 Dutch municipalities with relatively high perinatal morbidity and mortality rates. We evaluated the effect of the outreach strategy by analyzing uptake of preconception care consultations between February 2013 and December 2014. Registration data of applications for preconception care as well as participant questionnaires were obtained for analysis. RESULTS: The outreach strategy led to 587 applications for preconception care consultations. The majority of applications (n = 424; 72%) were prompted by the invitation letters (132,129) from the municipalities and general practitioners. The effect of the municipal letter seemed to fade out after 3 months. CONCLUSIONS: Outreach strategies amongst the general population promote uptake of preconception care consultations, although on a small scale and with a temporary effect.

Preconception counselling for low health literate women: an exploration of determinants in the Netherlands.

BACKGROUND: Women from lower socioeconomic groups tend to be at greater risk of adverse perinatal outcomes, but are less likely to participate in preconception counselling compared to higher socioeconomic groups. This could be partly because of their limited skills to assess, understand and use health related information in ways that promote and maintain good health (health literacy skills). In this study we explored determinants of participation in preconception counselling among women with low health literacy in The Netherlands. METHODS: Potential determinants of participation in preconception counselling were derived from the literature, and mapped onto a theoretical framework, which was tested for perceived relevance and completeness in an expert review (n = 20). The framework was used to prepare face-to-face interviews with women with low health literacy and a wish to conceive (n = 139). In the interviews we explored preconception counselling awareness, knowledge, considerations, subjective norms, self-efficacy, attitude, and intention. Linear regression analyses were used to test associations with intention to participate in preconception counselling. RESULTS: Most women (75%) were unaware of the concept of preconception counselling and the provision of counselling, even if they lived in areas where written invitations had been disseminated. Common considerations for participation were: preparation for pregnancy; perceived lack of information; and problems in a previous pregnancy. Considerations not to participate were mostly related to perceived sufficient knowledge and perceived low risk of perinatal problems. Respondents generally had a positive attitude towards participation in preconception counselling for themselves, and 41% reported that they would participate in preconception counselling. CONCLUSION: Women with low health literacy were generally unaware of the concept and provision of preconception counselling, but seemed to be interested in participation. Further research should investigate how to effectively reach and inform this group about preconception counselling. This knowledge is essential for evidence-based development of interventions to increase the accessibility and understanding of preconception counselling.

[Preconception care in 2018; still too many missed opportunities]. / Preconceptiezorg anno 2018.

Good preconception care does not only benefit the health of the mother to be and her child during pregnancy, but also their health in later life. In the Netherlands, preconception care is not standard care. Preconception care aims to prevent biomedical, behavioural and social risks by taking steps before conception to reduce the likelihood of these risks materialising. It also helps mothers to be to make informed reproductive choices. Caregivers and the public are not aware enough of the extent in which the first 10 weeks of pregnancy affect the health of the infant and of the child later in life. Nowadays, antenatal care often starts around 8 weeks of pregnancy, by which time it is too late to influence potential risks since embryonic development and placentation start immediately after conception. Therefore, all young men and women need to be offered preconception care.

The Usability and Effectiveness of Mobile Health Technology-Based Lifestyle and Medical Intervention Apps Supporting Health Care During Pregnancy: Systematic Review.

BACKGROUND: A growing number of mobile health (mHealth) technology-based apps are being developed for personal lifestyle and medical health care support, of which several apps are related to pregnancy. Evidence on usability and effectiveness is limited but crucial for successful implementation. OBJECTIVE: This study aimed to evaluate the usability, that is, feasibility and acceptability, as well as effectiveness of mHealth lifestyle and medical apps to support health care during pregnancy in high-income countries. Feasibility was defined as the actual use, interest, intention, and continued use; perceived suitability; and ability of users to carry out the activities of the app. Acceptability was assessed by user satisfaction, appreciation, and the recommendation of the app to others. METHODS: We performed a systematic review searching the following electronic databases for studies on mHealth technology-based apps in maternal health care in developed countries: EMBASE, MEDLINE Epub (Ovid), Cochrane Library, Web of Science, and Google Scholar. All included studies were scored on quality, using the ErasmusAGE Quality Score or the consolidated criteria for reporting qualitative research. Main outcome measures were usability and effectiveness of mHealth lifestyle and medical health care support apps related to pregnancy. All studies were screened by 2 reviewers individually, and the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement were followed. RESULTS: Our search identified 4204 titles and abstracts, of which 2487 original studies remained after removing duplicates. We performed full-text screening of 217 studies, of which 29 were included in our study. In total, 19 out of 29 studies reported on mHealth apps to adopt healthy lifestyles and 10 out of 29 studies to support medical care. The lifestyle apps evaluated in 19 studies reported on usability and effectiveness: 10 studies reported positive on acceptability, and 14 studies reported on feasibility with positive results except one study. In total, 4 out of 19 studies evaluating effectiveness showed significant results on weight gain restriction during pregnancy, intake of vegetables and fruits, and smoking cessation. The 10 studies on medical mHealth apps involved asthma care, diabetic treatment, and encouraging vaccination. Only one study on diabetic treatment reported on acceptability with a positive user satisfaction. In total, 9 out of 10 studies reported on effectiveness. Moreover, the power of most studies was inadequate to show significant effects. CONCLUSIONS: Most studies on mHealth apps to support lifestyle and medical care for high-income countries reveal the usability of these apps to reduce gestational weight gain, increase intakes of vegetables and fruit, to quit smoking cessation, and to support health care for prevention of asthma and infections during pregnancy. In general, the evidence on effectiveness of these apps is limited and needs further investigation before implementation in medical health care.

Perceptions of pregnancy preparation in women with a low to intermediate educational attainment: A qualitative study.

OBJECTIVE: in the promotion of periconceptional health, appropriate attention has to be given to the perceptions of those who are most vulnerable, such as women with a relatively low socioeconomic status based on their educational attainment. The aim of this study was to explore these women's perceptions of pregnancy preparation and the role they attribute to healthcare professionals. DESIGN: we conducted semi-structured interviews with women with a low to intermediate educational attainment and with a desire to conceive, of which a subgroup had experience with preconception care. Thematic content analysis was applied on the interview transcripts. FINDINGS: the final sample consisted of 28 women. We identified four themes of pregnancy preparation perceptions: (i)"How to prepare for pregnancy?", which included health promotion and seeking healthcare; (ii) "Why prepare for pregnancy?", which mostly related to fertility and health concerns; (iii) "Barriers and facilitators regarding pregnancy preparation", such as having limited control over becoming pregnant as well as the health of the unborn; (iv) "The added value of preconception care", reported by women who had visited a consultation, which consisted mainly of reassurance and receiving information. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: the attained insights into the perceptions of women with a low to intermediate education are valuable for adapting the provision of preconception care to their views. We recommend the proactive offering of preconception care, including information on fertility, to stimulate adequate preparation for pregnancy and contribute to improving perinatal health among women who are socioeconomically more vulnerable.

The influence of counseling on the mode of breech birth: A single-center observational prospective study in The Netherlands.

OBJECTIVE: women in the Netherlands, with a fetus in breech presentation, are thoroughly counseled to make an informed choice for the mode of delivery. The aim of this study was to assess the influence of counseling techniques on women's choices for the mode of delivery and subsequently to compare fetal and maternal outcomes of vaginal breech birth versus planned caesarean section. STUDY DESIGN: we performed an observational prospective study. Data on breech deliveries were prospectively collected. We used ANOVA to identify variables influencing women's choice for the mode of delivery. SETTING: the obstetric department of the Red Cross Hospital in Beverwijk, the Netherlands. PARTICIPANTS: women with a singleton gestation (>37 + 0 weeks) and a fetus in breech presentation were included. MEASUREMENTS AND FINDINGS: between January 2007 and December 2015 364 women were included. Counseling technique (p =<0.001) and maternal education (p = 0.046) were significantly associated with the choice of mode of delivery. Of all included women 33% (N = 119) opted for a vaginal breech delivery and 52% (N = 190) opted for a planned cesarean section. 15% (N = 55) were unexpected breeches. Of the planned vaginal delivery group 66% (N = 79) delivered vaginal, whereas 99.5% (N = 189) of the women in the planned cesarean section group underwent a planned cesarean section. There were no significant differences in maternal and neonatal outcomes. KEY CONCLUSIONS: women's choice on the mode of delivery and the eventual modus partus of fetuses in breech presentation is strongly influenced by the counseling technique. Vaginal breech birth in low-risk women is a safe option without long term morbidity in neonates. IMPLICATIONS FOR PRACTICE: counselors should be aware of their influence on women's choice for mode of delivery in breech presentation. Counseling should be done using evidence based information.

Geographical differences in perinatal health and child welfare in the Netherlands: rationale for the healthy pregnancy 4 all-2 program.

BACKGROUND: Geographical inequalities in perinatal health and child welfare require attention. To improve the identification, and care, of mothers and young children at risk of adverse health outcomes, the HP4All-2 program was developed. The program consists of three studies, focusing on creating a continuum for risk selection and tailored care pathways from preconception and antenatal care towards 1) postpartum care, 2) early childhood care, as well as 3) interconception care. The program has been implemented in ten municipalities in the Netherlands, aiming to target communities with a relatively disadvantageous position with regard to perinatal and child health outcomes. To delineate the position of the ten participating municipalities, we present municipal and regional differences in the prevalence of perinatal mortality, perinatal morbidity, children living in deprived neighbourhoods, and children living in families on welfare. METHODS: Data on all singleton births in the Netherlands between 2009 and 2014 were analysed for the prevalence of perinatal mortality and morbidity. In addition, national data on children living in deprived neighbourhoods and children living in families on welfare between 2009 and 2012 were analysed. The prevalence of these outcomes were calculated and ranked for 62 geographical areas, the 50 largest municipalities and the 12 provinces, to determine the position of the municipalities that participate in HP4All-2. RESULTS: Considerable geographical differences were present for all four outcomes. The municipalities that participate in HP4All-2 are among the 25 municipalities with the highest prevalence of perinatal mortality, perinatal morbidity, children living in deprived neighbourhoods, or children in families on welfare. CONCLUSION: This study illustrates geographical differences in perinatal health and/or child welfare outcomes and demonstrates that the HP4All-2 program targets municipalities with a relative unfavourable position. By targeting these municipalities, the program is expected to contribute most to improving the care for young children and their mothers at risk, and hence to reducing their risks and health inequalities.