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

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

An innovative postnatal risk assessment and corresponding care pathways in Preventive Child Healthcare.

AIMS: This study aims to evaluate the effectiveness of an innovative postnatal risk assessment (the postnatal Rotterdam Reproductive Risk Reduction checklist: R4U) and corresponding care pathways in Preventive Child Healthcare (PCHC), along with PCHC professional satisfaction. DESIGN: Four PCHC organizations located in three municipalities with a higher adverse perinatal outcome than the national average were selected for participation. The study concerns a historically controlled study design. METHODS: The study enrolled participants from September 2016 until December 2017. The historical cohort existed of children born in previous years from 2008 until 2016. The outcome measure was defined as catch-up growth: more than 0.67 standard deviation score weight for height increase in the first 6 months of life. PCHC professional opinion was assessed with a digital survey. RESULTS: After the inclusion period, 1,953 children were included in the intervention cohort and 7,436 children in the historical cohort. Catch-up growth was significantly less common in the intervention cohort; 14.9% versus 19.5% in the historical cohort (p < 0.001). A regression sensitivity analysis, using matching, showed an odds ratio of 0.957 (95% CI 0.938-0.976) for the intervention cohort. In the survey, 74 PCHC physicians and nurses participated; most of them were neutral concerning the benefits of the postnatal R4U. CONCLUSION: This study shows that the implementation of a novel postnatal risk assessment including in PCHC is feasible and effective. Final efforts to ensure a widespread implementation should be taken. IMPACT: PCHC offers a unique opportunity to recognize and address risk factors for growth and development in children and to implement care pathways. Effective and widely implemented risk assessments in antenatal and PCHC are scarce. To our knowledge, this kind of evidence-based postnatal risk assessment has not been implemented in PCHC before and seizes the opportunity to prevent catch-up growth and its long-term effects.

Insight into the process of postpartum care utilisation and in-home support among vulnerable women in the Netherlands: an in-depth qualitative exploration.

OBJECTIVE: To gain insight into the process of postpartum care utilisation and in-home support among vulnerable women. DESIGN, METHOD, PARTICIPANTS AND SETTING: A qualitative interview study was conducted among 23 pregnant and postpartum vulnerable women in the Netherlands, following a grounded theory approach. Women were determined as vulnerable by their healthcare providers. Theoretical sampling of participants was applied and was alternated by data analysis to include information-rich cases until saturation was achieved. RESULTS: A conceptual framework of postpartum care utilisation was generated consisting of three phases: pregnancy, early postpartum period and late postpartum period. Within these phases, information provision, parenting self-efficacy and social network were identified as overarching themes. Perceived inadequate information on content of postpartum care posed a major barrier to forming realistic expectations during pregnancy and hindered its utilisation. Low self-efficacy facilitated postpartum care utilisation. All women experienced increased self-efficacy during and after postpartum care. Support from a social network influenced expectations regarding the added value of postpartum care during pregnancy, and lowered actual utilisation during the postpartum period. The costs of postpartum care and the role of the maternity care assistant acted as general barriers or facilitators influencing the three overarching themes and therefore postpartum care utilisation indirectly. CONCLUSIONS: Our findings suggest that postpartum care utilisation among vulnerable women may be improved by considering the particular phase and relevant themes applying to individual women, and adapt care accordingly. We recommend to provide comprehensive, understandable information and to emphasise the gains of postpartum care in improving self-efficacy for vulnerable women. Moreover, involving a woman's social network in postpartum care may add value to this care for this population.

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.

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.

Validation of a prognostic model for adverse perinatal health outcomes.

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

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.

Did an urban perinatal health programme in Rotterdam, the Netherlands, reduce adverse perinatal outcomes? Register-based retrospective cohort study.

OBJECTIVES: To study the effect of an urban perinatal health programme in Rotterdam, the Netherlands, on perinatal outcomes. DESIGN: A retrospective cohort study with difference-in-differences analysis using individual-level perinatal outcome data from the Dutch Perinatal Registry 2003-2014 linked to Central Bureau of Statistics data of migration background and individual disposable household income. INTERVENTION: The programme consisted of perinatal health promotion, risk selection and risk-guided pregnancy care, and a new primary care child birth centre. The programme was implemented during 2009-2012. PRIMARY OUTCOME MEASURES: We compared trends in perinatal mortality, preterm delivery and small-for-gestational-age births between targeted urban neighbourhoods in Rotterdam (n=61 415) and all other urban neighbourhoods in the Netherlands (n=881 202). The effect of the programme was modelled as a change in trend of each perinatal outcome in the treatment group post intervention compared with the control population from January 2010 onwards. All analyses were adjusted for maternal age, parity, ethnicity and individual-level low socioeconomic status (SES). We also conducted a stratified analysis by SES. RESULTS: During 2003-2014, downward trends in perinatal mortality (adjusted OR (aOR) 0.9439 per year, 95% CI 0.9362 to 0.9517), preterm birth (aOR 0.9970 per year, 95% CI 0.9944 to 0.9997) and small-for-gestational-age births (aOR 0.9809 per year, 95% CI 0.9787 to 0.9831) in the entire study population were observed. No demonstrable changes in these trends were found in the intervention group after the programme had started. The stratified analyses by SES showed no changes in trends post intervention in both strata either. CONCLUSIONS: The programme had no demonstrable effects on perinatal outcomes. The intervention may not have reached a sufficient proportion of the population or has provided too little contrast to the widespread attention for inequalities in pregnancy outcomes occurring simultaneously in the Netherlands.

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.

Antenatal non-medical risk assessment and care pathways to improve pregnancy outcomes: a cluster randomised controlled trial.

Social deprivation negatively affects health outcomes but receives little attention in obstetric risk selection. We investigated whether a combination of (1) risk assessment focused on non-medical risk factors, lifestyle factors, and medical risk factors, with (2) subsequent institution of risk-specific care pathways, and (3) multidisciplinary consultation between care providers from the curative and the public health sector reduced adverse pregnancy outcomes among women in selected urban areas in the Netherlands. We conducted a cluster randomised controlled trial in 14 urban municipalities across the Netherlands. Prior to the randomisation, municipalities were ranked and paired according to their expected proportion of pregnant women at risk for adverse outcomes at birth. The primary outcome was delivery of a preterm and/or small for gestational age (SGA) baby, analysed with multilevel mixed-effects logistic regression analysis adjusting for clustering and individual baseline characteristics. A total of 33 community midwife practices and nine hospitals participated throughout the study. Data from 4302 participants was included in the Intention To Treat (ITT) analysis. The intervention had no demonstrable impact on the primary outcome: adjusted odds ratio (aOR) 1.17 (95% CI 0.84-1.63). Among the secondary outcomes, the intervention improved the detection of threatening preterm delivery and fetal growth restriction during pregnancy [aOR 1.27 (95% CI 1.01-1.61)]. Implementation of additional non-medical risk assessment and preventive strategies into general practices is feasible but did not decrease the incidence of preterm and/or SGA birth in the index pregnancy in deprived urban areas.Trial registration Netherlands National Trial Register (NTR-3367).

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.

The impact of early- and late-onset preeclampsia on umbilical cord blood cell populations.

Pregnancies complicated by preeclampsia (PE) are characterised by an enhanced maternal and fetal inflammatory response with increased numbers of leukocytes in maternal peripheral blood. The impact of PE on newborn umbilical cord blood cell (UCBC) populations however, has been scarcely studied. We hypothesise that PE deranges fetal haematopoiesis and subsequently UCBC populations. Therefore, the objective of this study was to investigate newborn umbilical cord blood cell populations in early- (EOPE) and late-onset PE (LOPE). A secondary cohort analysis in The Rotterdam Periconceptional Cohort was conducted comprising 23 PE cases, including 11 EOPE and 12 LOPE, and 195 controls, including 153 uncomplicated and 23 fetal growth restriction- and 19 preterm birth complicated controls. UCBC counts and differentials were quantified by flow cytometry and analysed as main outcome measures. Multivariable regression analysis revealed associations of EOPE with decreased leucocyte- (monocytes, neutrophils, eosinophils, immature granulocytes) and thrombocyte counts and increased NRBC counts (all p<0.05). EOPE remained associated with neutrophil- (ß-0.92, 95%CI -1.27,-0.57, p<0.001) and NRBC counts (ß1.11, 95%CI 0.27,1.95, p=0.010) after adjustment for gestational age and birth weight. LOPE did not reveal any significant association. We conclude that derangements of fetal haematopoiesis, in particular of neutrophil- and NRBC counts, are associated with EOPE only, with a potential impact for future health of the offspring. This heterogeneity in UCBC should be considered as confounder in epigenetic association studies examining EOPE.