Neighbourhood-related socioeconomic perinatal health inequalities: An illustration of the mediational g-formula and considerations for the big data context.

BACKGROUND: Advances in computing power have enabled the collection, linkage and processing of big data. Big data in conjunction with robust causal inference methods can be used to answer research questions regarding the mechanisms underlying an exposure-outcome relationship. The g-formula is a flexible approach to perform causal mediation analysis that is suited for the big data context. Although this approach has many advantages, it is underused in perinatal epidemiology and didactic explanation for its implementation is still limited. OBJECTIVE: The aim of this was to provide a didactic application of the mediational g-formula by means of perinatal health inequalities research. METHODS: The analytical procedure of the mediational g-formula is illustrated by investigating whether the relationship between neighbourhood socioeconomic status (SES) and small for gestational age (SGA) is mediated by neighbourhood social environment. Data on singleton births that occurred in the Netherlands between 2010 and 2017 (n = 1,217,626) were obtained from the Netherlands Perinatal Registry and linked to sociodemographic national registry data and neighbourhood-level data. The g-formula settings corresponded to a hypothetical improvement in neighbourhood SES from disadvantaged to non-disadvantaged. RESULTS: At the population level, a hypothetical improvement in neighbourhood SES resulted in a 6.3% (95% confidence interval [CI] 5.2, 7.5) relative reduction in the proportion of SGA, that is the total effect. The total effect was decomposed into the natural direct effect (5.6%, 95% CI 5.1, 6.1) and the natural indirect effect (0.7%, 95% CI 0.6, 0.9). In terms of the magnitude of mediation, it was observed the natural indirect effect accounted for 11.4% (95% CI 9.2, 13.6) of the total effect of neighbourhood SES on SGA. CONCLUSIONS: The mediational g-formula is a flexible approach to perform causal mediation analysis that is suited for big data contexts in perinatal health research. Its application can contribute to providing valuable insights for the development of policy and public health interventions.

Creating a sense of urgency and provoking action - An example on the use of heat maps to address perinatal health inequalities.

Health outcomes of mothers and their (unborn) children in the perinatal period, i.e., during pregnancy and shortly after birth, can vary by geographical location. This is often due to differences in exposure to medical and social risk factors. Policies aimed at reducing inequalities in perinatal health can provide significant long-term health benefits, especially for (unborn) children. However, a lack of insight into regional perinatal health inequalities means that perinatal health is not always a priority in policy formulation. Novel methods should be used to draw attention to these inequalities, spark interdisciplinary debate and encourage collaborative initiatives. In this commentary, we propose that the development of heat maps that visualize perinatal health outcomes, and risk factors for those outcomes, could be a valuable tool in doing this. Heat maps are a data visualization technique that uses color variations to emphasize value differences between areas. Visualizing health inequalities could potentially create a sense of urgency among (local) stakeholders to initiate polices aimed at improving perinatal health. We illustrate the targeted use of heat maps with an example from the city of Rotterdam, the Netherlands. Large perinatal health inequalities between neighborhoods were visualized in heat maps by a team from the Erasmus Medical Center to bring these inequalities to the attention of the municipality of Rotterdam. Local collaborative initiatives were set up to reduce perinatal health inequalities. These local initiatives formed the foundation for later national policies, including proposals to online implement heat maps regarding perinatal health topics, that are still ongoing today.

Social determinants of vulnerability in the population of reproductive age: a systematic review.

BACKGROUND: The health of an (unborn) child is largely determined by the health and social determinants of its parents. The extent to which social determinants of parents or prospective parents affect their own health depends partly on their coping or resilience abilities. Inadequate abilities allow negative effects of unfavourable social determinants to prevail, rendering them vulnerable to adverse health outcomes. Addressing these determinants in the reproductive-aged population is therefore a key approach in improving the health of the future generation. This systematic review aims to synthesise evidence on social determinants of vulnerability, i.e., inadequate coping or low resilience, in the general population of reproductive age. METHODS: The databases EMBASE, Medline, PsycINFO, CINAHL, Google Scholar, Web of Science, and Cochrane Library, were systematically searched from database inception to December 2th 2021. Observational studies examining social determinants and demographics in relation to vulnerability among the general population of reproductive age (men and women aged 18-40 years), conducted in a high-income country in Europe or North America, Australia or New Zealand were eligible for inclusion. Relevant data was extracted from each included article and findings were presented in a narrative and tabulated manner. RESULTS: We identified 40,028 unique articles, of which 78 were full text reviewed. Twenty-five studies were included, of which 21 had a cross-sectional study design (84%). Coping was the most frequently assessed outcome measure (n = 17, 68%). Thirty social determinants were identified. Overall, a younger age, lower socioeconomic attainment, lack of connection with the social environment, and adverse life events were associated with inadequate coping or low resilience. CONCLUSIONS: This review shows that certain social determinants are associated with vulnerability in reproductive-aged individuals. Knowing which factors make people more or less vulnerable carries health-related implications. More high-quality research is needed to obtain substantial evidence on the strength of the effect of these social conditions in this stage of life.

Addressing perinatal health inequities in Dutch municipalities: Protocol for the Healthy Pregnancy 4 All-3 programme.

BACKGROUND: Health inequities are already present at birth and affect individuals' health and socioeconomic outcomes across the life course. Addressing these inequities requires a cross-sectoral approach, covering the first 1,000 days of life. We believe that - in the Dutch context - municipal governments can be the main responsible actor to drive such an approach, since they are primarily responsible for organising adequate public health. Therefore, we aim to identify and develop transformative change towards the implementation of perinatal health into municipal approaches and policies concerning health inequities. METHODS: A transition analysis will be combined with action research in six Dutch municipalities. Interviews and interactive group sessions with professionals and organisations that are relevant for the institutional embedding of perinatal health into approaches and policies regarding health inequities, will be organised in each municipality. As a follow-up, a questionnaire will be administered among all participants one year after completion of the group sessions. DISCUSSION: We expect to gain insights into the role of municipalities in addressing perinatal health inequities, learn more about the interaction between different key stakeholders, and identify barriers and facilitators for a cross-sectoral approach to perinatal health. This knowledge will serve to inform the development of approaches to perinatal health inequities in areas with relatively poor perinatal health outcomes, both in the Netherlands and abroad.

[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.

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.

Small for gestational age and perinatal mortality at term: An audit in a Dutch national cohort study.

OBJECTIVE: To assess the underlying risk factors for perinatal mortality in term born small for gestational age infants. STUDY DESIGN: We performed a population based nationwide cohort study in the Netherlands of 465,532 term born infants from January 2010 to January 2013. Logistic regression analyses were performed. Also audit results were studied for detailed care information. RESULTS: We studied 162 small for gestational age infants who died in the perinatal period. Risk factors were: gestational age at 37completed weeks (adjusted Odds Ratio (aOR) 2.6, 95% Confidence Interval (CI) 1.6-4.3), male gender (aOR 1.4, 95% CI 1.01-1.9), South Asian ethnicity (aOR 3.6, 95% CI 1.6-8.4), African (aOR 3.5, 95% CI 1.9-6.5) and other non-Western ethnicity (aOR 1.9, CI 1.2-3.1). At 37 completed weeks gestation audit results showed that 26% of the women smoked, 91% were boys and in all but one case death occurred before birth. In 61% of all deceased SGA infants born at 37 completed weeks gestation referral from primary care by independent midwives to the obstetrician took place because of antepartum death before labor. CONCLUSIONS: Gestational age of 37 completed weeks, male gender, South Asian, African or other non-Western ethnicity and smoking are associated with perinatal mortality in SGA infants. These risk factors concern the complete term population starting at 37 weeks or even earlier. Therefore, it is of utmost importance to develop accurate diagnostic tests to screen for SGA before 36 weeks gestation to prevent perinatal mortality at term in SGA infants.

Assessment and care for non-medical risk factors in current antenatal health care.

OBJECTIVE: this study aims to identify current practice in risk assessment, current antenatal policy and referral possibilities for non-medical risk factors (lifestyle and social risk factors), and to explore the satisfaction among obstetric caregivers in their collaboration with non-obstetrical caregivers. DESIGN: cross-sectional study SETTING: Dutch antenatal care system PARTICIPANTS: community midwives from 139 midwifery practices and gynaecologists, hospital-based midwives, and trainees in obstetrics from 38 hospitals. MEASUREMENTS AND FINDINGS: results were analysed with χ(2) tests and unpaired t-tests. Caregivers universally screened upon lifestyle risk factors (e.g. smoking or drug use), whereas the screening for social risk factors (e.g. social support) was highly variable. As national guidelines are absent, local protocols were reported to be used for screening on non-medical risk factors in more than 40%. Caregivers stated multidisciplinary protocols to be a prerequisite for assessment of non-medical risk factors. Only 22% of the caregivers used predefined criteria to define when patients should be discussed multidisciplinary. CONCLUSION: despite their relevance, non-medical risk factors remain an underexposed topic in antenatal risk factor screening in both the community and hospital-based care setting. Implications for practice Structural antenatal risk assessment for non-medical risk factors with subsequent consultation opportunities is advocated, preferably based on a multidisciplinary guideline.

Effectiveness of general preconception care accompanied by a recruitment approach: protocol of a community-based cohort study (the Healthy Pregnancy 4 All study).

INTRODUCTION: Promotion of healthy pregnancies has gained high priority in the Netherlands because of the relative unfavourable perinatal outcomes. In response, a nationwide study Healthy Pregnancy 4 All (HP4ALL) has been initiated. One of the substudies within HP4ALL focuses on preconception care (PCC). PCC is an opportunity to detect and eliminate risk factors before conception to optimise health before organogenesis and placentation. The main objectives of the PCC substudy are (1) to assess the effectiveness of a recruitment strategy for the PCC health services and (2) to assess the effectiveness of individual PCC consultations. METHODS/ANALYSIS: Prospective cohort study in neighbourhoods of 14 municipalities with perinatal mortality and morbidity rates exceeding the nation's average. The theoretical framework of the PCC substudy is based on Andersen's model of healthcare utilisation (a model that evaluates the utilisation of healthcare services from a sociological perspective). Women aged 18 up to and including 41 years are targeted for utilisation of the PCC health service by a four armed recruitment strategy. The PCC health service consists of an individual PCC consultation consisting of (1) initial risk assessment and risk management and (2) a follow-up consultation to assess adherence to the management plan. The primary outcomes regarding the effectiveness of consultations is behavioural change regarding folic acid supplementation, smoking cessation, cessation of alcohol consumption and illicit substance use. The primary outcome regarding the effectiveness of the recruitment strategy is the number of women successfully recruited and the outreach in terms of which population is reached in comparison to the approached population. Data collection consists of registration in the database of women that enrol for a visit to the individual PCC consultations (women successfully recruited), and preconsultation and postconsultation measurements among the included study population (by questionnaires, anthropometric measurements and biomarkers). Sample size calculation resulted in a sample size of n=839 women. ETHICS AND DISSEMINATION: Approval for this study has been obtained from the Medical Ethical Committee of the Erasmus Medical Center of Rotterdam (MEC 2012-425). Results will be published and presented at international conferences.

Effectiveness of score card-based antenatal risk selection, care pathways, and multidisciplinary consultation in the Healthy Pregnancy 4 All study (HP4ALL): study protocol for a cluster randomized controlled trial.

BACKGROUND: Promotion of healthy pregnancies has gained high priority in the Netherlands because of relatively unfavorable perinatal outcomes. In response, a nationwide study, 'Healthy Pregnancy 4 All' (HP4ALL), has been initiated. Part of this study involves systematic and broadened antenatal risk assessment (the Risk Assessment substudy). Risk selection in current clinical practice is mainly based on medical risk factors. Despite the increasing evidence for the influence of nonmedical risk factors (social status, lifestyle or ethnicity) on perinatal outcomes, these risk factors remain highly unexposed. Systematic risk selection, combined with customized care pathways to reduce or treat detected risks, and regular and structured consultation between community midwives, gynecologists and other care providers such as social workers, is part of this study. METHODS/DESIGN: Neighborhoods in 14 municipalities with adverse perinatal outcomes above national and municipal averages are selected for participation. The study concerns a cluster randomized controlled trial. Municipalities are randomly allocated to intervention (n = 3,500 pregnant women) and control groups (n = 3,500 pregnant women). The intervention consists of systematic risk selection with the Rotterdam Reproductive Risk Reduction (R4U) score card in pregnant women at the booking visit, and referral to corresponding care pathways. A risk score, based on weighed risk factors derived from the R4U, above a predefined threshold determines structured multidisciplinary consultation. Primary outcomes of this trial are dysmaturity (birth weight < p10), prematurity (birth <37 weeks), and efficacy of implementation. DISCUSSION: The 'HP4ALL' study introduces a systematic approach in antenatal health care that may improve perinatal outcomes and, thereby, affect future health status of a new generation in the Netherlands. TRIAL REGISTRATION: Dutch Trial Registry ( NTR-3367) on 20 March 2012.

Design and outline of the Healthy Pregnancy 4 All study.

BACKGROUND: Promotion of healthy pregnancies has gained high priority in the Netherlands because of the relatively unfavourable perinatal health outcomes. In response a nationwide study Healthy Pregnancy 4 All was initiated. This study combines public health and epidemiologic research to evaluate the effectiveness of two obstetric interventions before and during pregnancy: (1) programmatic preconception care (PCC) and (2) systematic antenatal risk assessment (including both medical and non-medical risk factors) followed by patient-tailored multidisciplinary care pathways. In this paper we present an overview of the study setting and outlines. We describe the selection of geographical areas and introduce the design and outline of the preconception care and the antenatal risk assessment studies. METHODS/DESIGN: A thorough analysis was performed to identify geographical areas in which adverse perinatal outcomes were high. These areas were regarded as eligible for either or both sub-studies as we hypothesised studies to have maximal effect there. This selection of municipalities was based on multiple criteria relevant to either the preconception care intervention or the antenatal risk assessment intervention, or to both. The preconception care intervention was designed as a prospective community-based cohort study. The antenatal risk assessment intervention was designed as a cluster randomised controlled trial - where municipalities are randomly allocated to intervention and control. DISCUSSION: Optimal linkage is sought between curative and preventive care, public health, government, and social welfare organisations. To our knowledge, this is the first study in which these elements are combined.

[Decline in foetal and neonatal mortality in the Netherlands: comparison with other Euro-Peristat countries between 2004 and 2010]. / Afname van foetale en neonatale sterfte in Nederland: vergelijking met andere Euro-Peristat-landen in 2004 en 2010.

OBJECTIVE: To compare the change in foetal and neonatal mortality in the Netherlands between 2004 and 2010 with the change in other European countries. DESIGN: Descriptive, population-based study. METHOD: Data from the Euro-Peristat project on foetal and neonatal mortality in European countries were analysed for changes between 2004 and 2010. The Netherlands was compared with 26 other European countries and regions. International differences in registration and policy were taken into account using figures on foetal mortality starting at 28 weeks of pregnancy and neonatal mortality starting at 24 weeks of pregnancy. RESULTS: Foetal mortality in the Netherlands declined by 33%, from 4.3 per 1000 births in 2004 to 2.9 per 1000 births in 2010 while neonatal mortality declined by 21%, from 2.8 per 1000 live births in 2004 to 2.2 per 1000 live births in 2010. Perinatal mortality (the sum of foetal mortality and neonatal mortality) declined by 27%, from 7.0 to 5.1 per 1000. In the European ranking, the Netherlands shifted from 23rd to 13th place for foetal mortality; it remained the same for neonatal mortality (15th of 22 countries) and virtually the same for perinatal mortality (from 15th to 13th of 22 countries). CONCLUSIONS: Both foetal mortality at 28+ weeks and neonatal mortality at 24+ weeks declined in the Netherlands between 2004 and 2010. However, the relatively unfavourable position of the Netherlands in the European ranking for foetal and neonatal mortality improved only for foetal mortality. In that respect, the Netherlands holds an average position.

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.

Term perinatal mortality audit in the Netherlands 2010-2012: a population-based cohort study.

OBJECTIVE: To assess the implementation and first results of a term perinatal internal audit by a standardised method. DESIGN: Population-based cohort study. SETTING: All 90 Dutch hospitals with obstetric/paediatric departments linked to community practices of midwives, general practitioners in their attachment areas, organised in perinatal cooperation groups (PCG). POPULATION: The population consisted of 943 registered term perinatal deaths occurring in 2010-2012 with detailed information, including 707 cases with completed audit results. MAIN OUTCOME MEASURES: Participation in the audit, perinatal death classification, identification of substandard factors (SSF), SSF in relation to death, conclusive recommendations for quality improvement in perinatal care and antepartum risk selection at the start of labour. RESULTS: After the introduction of the perinatal audit in 2010, all PCGs participated. They organised 645 audit sessions, with an average of 31 healthcare professionals per session. Of all 1102 term perinatal deaths (2.3/1000) data were registered for 86% (943) and standardised anonymised audit results for 64% (707). In 53% of the cases at least one SSF was identified. Non-compliance to guidelines (35%) and deviation from usual professional care (41%) were the most frequent SSF. There was a (very) probable relation between the SSF and perinatal death for 8% of all cases. This declined over the years: from 10% (n=23) in 2010 to 5% (n=10) in 2012 (p=0.060). Simultaneously term perinatal mortality decreased from 2.3 to 2.0/1000 births (p<0.00001). Possibilities for improvement were identified in the organisation of care (35%), guidelines or usual care (19%) and in documentation (15%). More pregnancies were antepartum selected as high risk, 70% in 2010 and 84% in 2012 (p=0.0001). CONCLUSIONS: The perinatal audit is implemented nationwide in all obstetrical units in the Netherlands in a short time period. It is possible that the audit contributed to the decrease in term perinatal mortality.