Associations between Socio-Economic Status and Unfavorable Social Indicators of Child Wellbeing; a Neighbourhood Level Data Design.

BACKGROUND: Living in deprivation is related to ill health. Differences in health outcomes between neighbourhoods may be attributed to neighbourhood socio-economic status (SES). Additional to differences in health, neighbourhood differences in child wellbeing could also be attributed to neighbourhood SES. Therefore, we aimed to investigate the association between neighbourhood deprivation, and social indicators of child wellbeing. METHODS: Aggregated data from 3565 neighbourhoods in 390 municipalities in the Netherlands were eligible for analysis. Neighbourhood SES scores and neighbourhood data on social indicators of child wellbeing were used to perform repeated measurements, with one year measurement intervals, over a period of 11 years. Linear mixed models were used to estimate the associations between SES score and the proportion of unfavorable social indicators of child wellbeing. RESULTS: After adjustment for year, population size, and clustering within neighbourhoods and within a municipality, neighbourhood SES was inversely associated with the proportion of 'children living in families on welfare' (estimates with two cubic splines: -3.59 [CI: -3.99; -3.19], and -3.00 [CI: -3.33; -2.67]), 'delinquent youth' (estimate -0.26 [CI: -0.30; -0.23]) and 'unemployed youth' (estimates with four cubic splines: -0.41 [CI: -0.57; -0.25], -0.58 [CI: -0.73; -0.43], -1.35 [-1.70; -1.01], and -0.96 [1.24; -0.70]). CONCLUSIONS: In this study using repeated measurements, a lower neighbourhood SES was significantly associated with a higher prevalence of unfavorable social indicators of child wellbeing. This contributes to the body of evidence that neighbourhood SES is strongly related to child health and a child's ability to reach its full potential in later life. Future studies should consist of larger longitudinal datasets, potentially across countries, and should attempt to take the interpersonal variation into account with more individual-level data on SES and outcomes.

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.

Risk-guided maternity care to enhance maternal empowerment postpartum: A cluster randomized controlled trial.

OBJECTIVE: To investigate whether a structured inquiry during pregnancy of medical factors and social factors associated with low socioeconomic status, and subsequent patient-centred maternity care could increase maternal empowerment. DESIGN: Cluster-randomised controlled trial. SETTING: This study was conducted among pregnant women in selected urban areas in the Netherlands. This study was part of the nationwide Healthy Pregnancy 4 All-2 programme. POPULATION: Pregnant women listed at one of the sixteen participating maternity care organisations between July 1, 2015, and Dec 31, 2016. METHODS: All practices were instructed to provide a systematic risk assessment during pregnancy. Practices were randomly allocated to continue usual care (seven practices), or to provide a patient-centred, risk-guided approach to addressing any risks (nine practices) identified via the risk assessment during pregnancy. MAIN OUTCOME MEASURES: Low postpartum maternal empowerment score. RESULTS: We recruited 1579 participants; 879 participants in the intervention arm, and 700 participants in the control arm. The prevalence of one or more risk factors during pregnancy was similar between the two arms: 40% and 39%, respectively. In our intention-to-treat analysis, the intervention resulted in a significant reduction in the odds of having a low empowerment score [i.e. the primary outcome; adjusted OR 0.69 ((95% CI 0.47; 0.99), P 0.046)]. CONCLUSIONS: Implementation of additional risk assessment addressing both medical and social factors and subsequent tailored preventive strategies into maternity care reduced the incidence of low maternal empowerment during the postpartum period. Introducing this approach in routine maternity care may help reduce early adversity during the postpartum period.

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.

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.

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.

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.

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.

Facilitators and Barriers for Successful Implementation of Interconception Care in Preventive Child Health Care Services in the Netherlands.

Objectives Successful implementation of preconception and interconception care contributes to optimizing pregnancy outcomes. While interconception care to new mothers could potentially be provided by Preventive Child Health Care services, this care is currently not routinely available in the Netherlands. The purpose of this study was to identify facilitators and barriers for implementation of interconception care in Preventive Child Health Care services. Methods We organized four focus groups in which Preventive Child Health Care physicians and nurses, related health care professionals and policymakers participated. A semi-structured interview approach was used to guide the discussion. The transcribed discussions were analyzed. Results All four groups agreed that several facilitators are present, such as the unique position to reach women and the expertise in preventive health care. Identified barriers include unfamiliarity with interconception care among patients and health care providers, as well as lack of consensus about the concept of interconception care and how it should be organized. A broad educational campaign, local adaptation, and general agreement or a guideline for standard procedures were recognized as important for future implementation. Conclusions for practice This study identifies potentially important facilitators and barriers for the implementation of interconception care in Preventive Child Health Care services or comparable pediatric settings. These factors should be considered and strategies developed to achieve successful implementation of interconception care.

Reversal of rivaroxaban and dabigatran by prothrombin complex concentrate: a randomized, placebo-controlled, crossover study in healthy subjects.

BACKGROUND: Rivaroxaban and dabigatran are new oral anticoagulants that specifically inhibit factor Xa and thrombin, respectively. Clinical studies on the prevention and treatment of venous and arterial thromboembolism show promising results. A major disadvantage of these anticoagulants is the absence of an antidote in case of serious bleeding or when an emergency intervention needs immediate correction of coagulation. This study evaluated the potential of prothrombin complex concentrate (PCC) to reverse the anticoagulant effect of these drugs. METHODS AND RESULTS: In a randomized, double-blind, placebo-controlled study, 12 healthy male volunteers received rivaroxaban 20 mg twice daily (n=6) or dabigatran 150 mg twice daily (n=6) for 2½ days, followed by either a single bolus of 50 IU/kg PCC (Cofact) or a similar volume of saline. After a washout period, this procedure was repeated with the other anticoagulant treatment. Rivaroxaban induced a significant prolongation of the prothrombin time (15.8±1.3 versus 12.3±0.7 seconds at baseline; P<0.001) that was immediately and completely reversed by PCC (12.8±1.0; P<0.001). The endogenous thrombin potential was inhibited by rivaroxaban (51±22%; baseline, 92±22%; P=0.002) and normalized with PCC (114±26%; P<0.001), whereas saline had no effect. Dabigatran increased the activated partial thromboplastin time, ecarin clotting time (ECT), and thrombin time. Administration of PCC did not restore these coagulation tests. CONCLUSION: Prothrombin complex concentrate immediately and completely reverses the anticoagulant effect of rivaroxaban in healthy subjects but has no influence on the anticoagulant action of dabigatran at the PCC dose used in this study. Clinical Trial Registration- URL: http://www.trialregister.nl. Unique identifier: NTR2272.

New anticoagulants: moving on from scientific results to clinical implementation.

Vitamin K antagonists (VKA) are the only registered oral anticoagulants for the treatment of venous thromboembolism (VTE). VKA have an unpredictable and highly variable effect on coagulation, with a high risk of under- and over-treatment. Novel anticoagulants, such as dabigatran and rivaroxaban, could be a very welcome replacement for VKA, as they show a predictable anticoagulant effect. Results of several phase II and III studies have shown the efficacy and safety of dabigatran and rivaroxaban in the prophylaxis and treatment of VTE, and for the prevention of stroke in atrial fibrillation. It remains to be shown whether these new anticoagulants have the same safety profile in daily clinical practice, where more vulnerable patients will be treated. Lack of information on the proper monitoring method or antidote in case of bleeding may also hinder the translation from science to clinical practice.