Daily disease severity in patients with COVID-19 admitted to the hospital: The SCODA (severity of coronavirus disease assessment) score.

BACKGROUND: A multitude of diagnostic and predictive algorithms have been designed for COVID-19. However, currently no score can accurately quantify and track day-to-day disease severity in hospitalised patients with COVID-19. We aimed to design such a score to improve pathophysiological insight in COVID-19. METHODS: Development of the Severity of COronavirus Disease Assessment (SCODA) score was based on the 4C Mortality score but patient demographic variables that remain constant during admission were excluded. Instead, parameters associated with breathing and oxygenation were added to reflect the daily condition. The SCODA score was subsequently applied to the BEAT-COVID cohort to describe COVID-19 severity over time and to determine the timing of clinical recovery for each patient, an important marker in pathophysiological studies. The BEAT-COVID study included patients with PCR confirmed COVID-19 who were hospitalized between April 2020 and March 2021 in the Leiden University Medical Center, The Netherlands. RESULTS: The SCODA score consists of 6 clinical and 2 routine lab parameters. 191 patients participated in the BEAT-COVID study. Median age was 66, and 74.4% was male. The modal timepoint at which recovery was clinically initiated occurred on days 8 and 24 since symptom onset for non-ICU and ICU-patients, respectively. CONCLUSIONS: We developed a daily score which can be used to track disease severity of patients admitted due to COVID-19. This score is useful for improving insight in COVID-19 pathophysiology, its clinical course and to evaluate interventions. In a future stage this score can also be used in other (emerging) infectious respiratory diseases.

Trajectories and Determinants of Quality of Life in Dementia with Lewy Bodies and Alzheimer's Disease.

BACKGROUND: Quality of Life (QoL) is an important outcome measure in dementia, particularly in the context of interventions. Research investigating longitudinal QoL in dementia with Lewy bodies (DLB) is currently lacking. OBJECTIVE: To investigate determinants and trajectories of QoL in DLB compared to Alzheimer's disease (AD) and controls. METHODS: QoL was assessed annually in 138 individuals, using the EQ5D-utility-score (0-100) and the health-related Visual Analogue Scale (VAS, 0-100). Twenty-nine DLB patients (age 69±6), 68 AD patients (age 70±6), and 41 controls (age 70±5) were selected from the Dutch Parelsnoer Institute-Neurodegenerative diseases and Amsterdam Dementia Cohort. We examined clinical work-up over time as determinants of QoL, including cognitive tests, neuropsychiatric inventory, Geriatric Depression Scale (GDS), and disability assessment of dementia (DAD). RESULTS: Mixed models showed lower baseline VAS-scores in DLB compared to AD and controls (AD: ß±SE = -7.6±2.8, controls: ß±SE = -7.9±3.0, p < 0.05). An interaction between diagnosis and time since diagnosis indicated steeper decline on VAS-scores for AD patients compared to DLB patients (ß±SE = 2.9±1.5, p < 0.1). EQ5D-utility-scores over time did not differ between groups. Higher GDS and lower DAD-scores were independently associated with lower QoL in dementia patients (GDS: VAS ß±SE = -1.8±0.3, EQ5D-utility ß±SE = -3.7±0.4; DAD: VAS = 0.1±0.0, EQ5D-utility ß±SE = 0.1±0.1, p < 0.05). No associations between cognitive tests and QoL remained in the multivariate model. CONCLUSION: QoL is lower in DLB, while in AD QoL shows steeper decline as the disease advances. Our results indicate that non-cognitive symptoms, more than cognitive symptoms, are highly relevant as they impact QoL.

Exploring health education with midwives, as perceived by pregnant women in primary care: A qualitative study in the Netherlands.

OBJECTIVE: to explore the experiences, wishes and needs of pregnant women with respect to health education in primary care with midwives. DESIGN: qualitative semi-structured interview study, using thematic analysis and constant comparison. SETTING AND PARTICIPANTS: twenty-two pregnant women in midwife-led primary care, varying in socio-demographic characteristics, weeks of pregnancy and region of residence in the Netherlands, were interviewed between April and December 2013. FINDINGS: women considered midwives to be the designated health caregivers for providing antenatal health education, and generally appreciated the information they had received from their midwives. Some women, however, believed the amount of verbal health information was insufficient; others that there was too much written information. Many women still had questions and expressed uncertainties regarding various health issues, such as weight gain, alcohol, and physical activity. They perceived their health education to be individualised according to their midwives' assessments of the extent of their knowledge, as well as by the questions they asked themselves. A few were concerned that midwives may make incorrect assumptions about the extent of their knowledge. Women also varied in how comfortable they felt about contacting their midwives for questions between antenatal visits. Women felt that important qualities for midwives underlying health education, were making them feel at ease and building a relationship of trust with them. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: health education was highly appreciated by women in general, suggesting that midwives should err on the side of providing too much verbal information, as opposed to too little. A more pro-active approach with information provision may be of value not only to those with a clear desire for more information, but also to those who are unsure of what information they may be missing. As midwives are the principal health care providers throughout pregnancy,they should ideally emphasise their availability for questions between antenatal visits.

Socio-demographic inequalities across a range of health status indicators and health behaviours among pregnant women in prenatal primary care: a cross-sectional study.

BACKGROUND: Suboptimal maternal health conditions (such as obesity, underweight, depression and stress) and health behaviours (such as smoking, alcohol consumption and unhealthy nutrition) during pregnancy have been associated with negative pregnancy outcomes. Our first aim was to give an overview of the self-reported health status and health behaviours of pregnant women under midwife-led primary care in the Netherlands. Our second aim was to identify potential differences in these health status indicators and behaviours according to educational level (as a proxy for socio-economic status) and ethnicity (as a proxy for immigration status). METHODS: Our cross-sectional study (data obtained from the DELIVER multicentre prospective cohort study conducted from September 2009 to March 2011) was based on questionnaires about maternal health and prenatal care, which were completed by 6711 pregnant women. The relationships of education and ethnicity with 13 health status indicators and 10 health behaviours during pregnancy were examined using multilevel multiple logistic regression analyses, adjusted for age, parity, number of weeks pregnant and either education or ethnicity. RESULTS: Lower educated women were especially more likely to smoke (Odds Ratio (OR) 11.3; 95% confidence interval (CI) 7.6- 16.8); have passive smoking exposure (OR 6.9; 95% CI 4.4-11.0); have low health control beliefs (OR 10.4; 95% CI 8.5-12.8); not attend antenatal classes (OR 4.5; 95% CI 3.5-5.8) and not take folic acid supplementation (OR 3.4; 95% CI 2.7-4.4). They were also somewhat more likely to skip breakfast daily, be obese, underweight and depressed or anxious. Non-western women were especially more likely not to take folic acid supplementation (OR 4.5; 95% CI 3.5-5.7); have low health control beliefs (OR 4.1; 95% CI 3.1-5.2) and not to attend antenatal classes (OR 3.3; 95% CI 2.0-5.4). They were also somewhat more likely to have nausea, back pains and passive smoking exposure. CONCLUSIONS: Substantial socio-demographic inequalities persist with respect to many health-related issues in medically low risk pregnancies in the Netherlands. Improved strategies are needed to address the specific needs of socio-demographic groups at higher risk and the structures underlying social inequalities in pregnant women.

Severe Adverse Maternal Outcomes among Women in Midwife-Led versus Obstetrician-Led Care at the Onset of Labour in the Netherlands: A Nationwide Cohort Study.

OBJECTIVE: To test the hypothesis that it is possible to select a group of low risk women who can start labour in midwife-led care without having increased rates of severe adverse maternal outcomes compared to women who start labour in secondary care. DESIGN AND METHODS: We conducted a nationwide cohort study in the Netherlands, using data from 223 739 women with a singleton pregnancy between 37 and 42 weeks gestation without a previous caesarean section, with spontaneous onset of labour and a child in cephalic presentation. Information on all cases of severe acute maternal morbidity collected by the national study into ethnic determinants of maternal morbidity in the Netherlands (LEMMoN study), 1 August 2004 to 1 August 2006, was merged with data from the Netherlands Perinatal Registry of all births occurring during the same period. Our primary outcome was severe acute maternal morbidity (SAMM, i.e. admission to an intensive care unit, uterine rupture, eclampsia or severe HELLP, major obstetric haemorrhage, and other serious events). Secondary outcomes were postpartum haemorrhage and manual removal of placenta. RESULTS: Nulliparous and parous women who started labour in midwife-led care had lower rates of SAMM, postpartum haemorrhage and manual removal of placenta compared to women who started labour in secondary care. For SAMM the adjusted odds ratio's and 95% confidence intervals were for nulliparous women: 0.57 (0.45 to 0.71) and for parous women 0.47 (0.36 to 0.62). CONCLUSIONS: Our results suggest that it is possible to identify a group of women at low risk of obstetric complications who may benefit from midwife-led care. Women can be reassured that we found no evidence that midwife-led care at the onset of labour is unsafe for women in a maternity care system with a well developed risk selection and referral system.

Explanatory factors for first and second-generation non-western women's inadequate prenatal care utilisation: a prospective cohort study.

BACKGROUND: Little research into non-western women's prenatal care utilisation in industrialised western countries has taken generational differences into account. In this study we examined non-western women's prenatal care utilisation and its explanatory factors according to generational status. METHODS: Data from 3300 women participating in a prospective cohort of primary midwifery care clients (i.e. women with no complications or no increased risk for complications during pregnancy, childbirth and the puerperium who receive maternity care by autonomous midwives) in the Netherlands (the DELIVER study) was used. Gestational age at entry and the total number of prenatal visits were aggregated into an index. The extent to which potential factors explained non-western women's prenatal care utilisation was assessed by means of blockwise logistic regression analyses and percentage changes in odds ratios. RESULTS: The unadjusted odds of first and second-generation non-western women making inadequate use of prenatal care were 3.26 and 1.96 times greater than for native Dutch women. For the first generation, sociocultural factors explained 43% of inadequate prenatal care utilisation, socioeconomic factors explained 33% and demographic and pregnancy factors explained 29%. For the second generation, sociocultural factors explained 66% of inadequate prenatal care utilisation. CONCLUSION: Irrespective of generation, strategies to improve utilisation should focus on those with the following sociocultural characteristics (not speaking Dutch at home, no partner or a first-generation non-Dutch partner). For the first generation, strategies should also focus on those with the following demographic, pregnancy and socioeconomic characteristics (aged ≤ 19 or ≥ 36, unplanned pregnancies, poor obstetric histories (extra-uterine pregnancy, molar pregnancy or abortion), a low educational level, below average net household income and no supplementary insurance.

Antenatal counselling for congenital anomaly tests: pregnant Muslim Moroccan women's preferences.

OBJECTIVE: to gain insight into pregnant Muslim Moroccan women's preferences regarding the content of and approach to antenatal counselling for anomaly screening. DESIGN: qualitative study using in-depth interviews. SETTING: participants were recruited from one midwifery practice in a medium-sized city near Amsterdam. PARTICIPANTS: 12 pregnant Muslim Moroccan women who live in an area with a high density of immigrants. DATA COLLECTION AND DATA ANALYSES: we conducted open interviews after the cut-off date for the 20 week fetal anomaly scan and used techniques from the thematic analysis approach described by Braun and Clarke (2006). FINDINGS: pregnant Muslim Moroccan women's preferences towards counselling could be summarised in three main findings. Firstly, pregnant Muslim Moroccan women underlined the importance of accurate and detailed information about the tests procedures and the anomalies that could be detected. Secondly, pregnant Muslim Moroccan women preferred counsellors to initiate discussions about moral topics and its relationship with the women's religious beliefs and values to facilitate an informed choice about whether or not to participate in the screening tests. Thirdly, pregnant Muslim Moroccan women preferred a counsellor who respects and treats them as an individual who has an Islamic background. The counsellor should have practical knowledge of Islamic rulings that are relevant to the anomaly tests. KEY CONCLUSIONS: pregnant Muslim Moroccan women preferred to be accurately informed about antenatal anomaly tests and to be asked about their individual views on life by a counsellor who has genuine interest in the individual client and applied knowledge of Islamic beliefs regarding the value of life. IMPLICATIONS FOR PRACTICE: counsellors should explore clients' moral values about quality of life and termination and its relationship with religious beliefs. Counsellors should know about Islamic rulings related to antenatal anomaly screening.

A qualitative study on how Muslim women of Moroccan descent approach antenatal anomaly screening.

OBJECTIVE: to extend the knowledge on Muslim women's approach of antenatal anomaly screening. DESIGN: qualitative interview study with pregnant Muslim women from Moroccan origin. SETTING: one midwifery practice in a medium-sized city near Amsterdam participated in the study. PARTICIPANTS: twelve pregnant Muslim women who live in a high density immigrant area and who attended primary midwives for antenatal care were included in the study. DATA COLLECTION AND DATA ANALYSES: we conducted open interviews with pregnant Moroccan Muslim women for the purpose of studying how they made decisions about antenatal anomaly screening. We used a thematic analysis approach. FINDINGS: women experienced the combined test as 'a test' that could identify potentially anomalous infants, and could result in being offered termination of the pregnancy; a fact that resulted in their extensive deliberations and hesitation about the test uptake. Only two women had the combined test. Conversely, women opted for the Fetal Anomaly Scan and saw it as 'only an ultrasound to see the baby'. Above all, women emphasised that whether or not to participate in antenatal anomaly tests was their own, individual decision as ultimately they were accountable for their choices. All women, including nulliparous women, viewed becoming pregnant as the point of becoming a mother - and considered antenatal screening through the lens of motherhood. KEY CONCLUSIONS: motherhood was the lens through which the decision to participate in antenatal anomaly screening was approached. Religious beliefs influenced values on termination and disability and were influential in the deliberations for antenatal testing. Combined test but not Fetal Anomaly Scan was considered to be a antenatal screening test. IMPLICATIONS FOR PRACTICE: counsellors should have knowledge of the different Islamic beliefs about - the latest possible day for - termination and an awareness that Muslim women make their own conscious choices, also beyond Islamic rulings.

Factors affecting the uptake of prenatal screening tests for congenital anomalies; a multicentre prospective cohort study.

BACKGROUND: Two prenatal screening tests for congenital anomalies are offered to all pregnant women in the Netherlands on an opt-in basis: the Combined Test (CT) for Down syndrome at twelve weeks, and the Fetal Anomaly Scan (FAS) at around twenty weeks. The CT is free for women who are 36 or older; the FAS is free for all women. We investigated factors associated with the CT and FAS uptake. METHOD: This study is part of the DELIVER study that evaluated primary care midwifery in the Netherlands. Associations between the women's characteristics and the CT and FAS uptake were measured using multivariate and multilevel logistic regression analyses. RESULTS: Of 5216 participants, 23% had the CT and 90% had the FAS, with uptake rates ranging from 4% to 48% and 62% to 98% respectively between practices. Age (OR: 2.71), income (OR: 1.38), ethnicity (OR: 1.37), being Protestant (OR: 0.25), multiparous (OR: 0.64) and living in the east of the country (OR: 0.31) were associated with CT uptake; education (OR: 1.26), income (OR: 1.66), being Protestant (OR: 0.37) or Muslim (OR: 0.31) and being multiparous (OR: 0.74) were associated with FAS uptake. Among western women with a non-Dutch background, first generation (OR: 2.91), age (OR: 2.00), income (OR: 1.97), being Protestant (OR: 0.32) and living in the east (OR: 0.44) were associated with CT uptake; being Catholic (OR: 0.27), Protestant (OR: 0.13) were associated with FAS uptake. Among non- western women with a non-Dutch background, age (OR: 1.73), income (OR: 1.97) and lacking proficiency in Dutch (OR: 2.18) were associated with CT uptake; higher education (OR: 1.47), being Muslim (OR: 0.37) and first generation (OR: 0.27) were associated with FAS uptake. CONCLUSION: The uptake of the CT and FAS varied widely between practices. Income, parity and being Protestant were associated with uptake of both tests; ethnicity, age and living in the east were associated with CT uptake, and education and being Muslim with FAS uptake. These findings help to explain some differences between women choosing or declining early and late screening, but not the large variation in test uptake among practices, nor between the Netherlands and other countries.

Knowledge and acceptability of Chlamydia trachomatis screening among pregnant women and their partners; a cross-sectional study.

BACKGROUND: Chlamydia trachomatis infections in pregnancy can cause maternal disease, adverse pregnancy outcomes and neonatal disease, which is why chlamydia screening during pregnancy has been advocated. The effectiveness of a screening program depends on the knowledge of health care professionals, women and partners and the acceptability for screening of the target population. We assessed the knowledge of chlamydia infection among pregnant women and their partners in the Netherlands, their attitudes towards testing, and their experiences of being offered a chlamydia test. In addition, we evaluated the association between participants' background characteristics and knowledge of chlamydia. METHODS: Pregnant women aged ≤ 30 years and their partners (regardless of their age) attending one of the participating primary midwifery care practices in the Netherlands were invited to participate. All participants completed a questionnaire, pregnant women provided a vaginal swab and partners provided a urine sample to test for C. trachomatis. RESULTS: In total, 383 pregnant women and 282 partners participated in the study of whom 1.9% women and 2.6% partners tested chlamydia positive. Participants had high levels of awareness (92.8%) of chlamydial infection. They were knowledgeable about the risk of chlamydia infection; median knowledge score was 9.0 out of 12.0. Lower knowledge scores were found among partners (p-value <0.001), younger aged (p-value 0.02), non-western origin (p-value <0.001), low educational level (p-value <0.001), and no history of sexually transmitted infections (p-value <0.001). In total, 78% of respondents indicated that when pregnant women are tested for chlamydia, their partners should also be tested; 54% believed that all women should routinely be tested. Pregnant women more often indicated than partners that testing partners for chlamydial infection was not necessary (p-value <0.001). The majority of pregnant women (56.2%) and partners (59.2%) felt satisfied by being offered the test during antenatal care. CONCLUSION: Pregnant women and their partners were knowledgeable about chlamydial infection, found testing, both pregnant women and their partners, for chlamydia acceptable and not stigmatizing.

Prenatal screening for congenital anomalies: exploring midwives' perceptions of counseling clients with religious backgrounds.

BACKGROUND: In the Netherlands, prenatal screening follows an opting in system and comprises two non-invasive tests: the combined test to screen for trisomy 21 at 12 weeks of gestation and the fetal anomaly scan to detect structural anomalies at 20 weeks. Midwives counsel about prenatal screening tests for congenital anomalies and they are increasingly having to counsel women from religious backgrounds beyond their experience. This study assessed midwives' perceptions and practices regarding taking client's religious backgrounds into account during counseling. As Islam is the commonest non-western religion, we were particularly interested in midwives' knowledge of whether pregnancy termination is allowed in Islam. METHODS: This exploratory study is part of the DELIVER study, which evaluated primary care midwifery in The Netherlands between September 2009 and January 2011. A questionnaire was sent to all 108 midwives of the twenty practices participating in the study. RESULTS: Of 98 respondents (response rate 92%), 68 (69%) said they took account of the client's religion. The two main reasons for not doing so were that religion was considered irrelevant in the decision-making process and that it should be up to clients to initiate such discussions. Midwives' own religious backgrounds were independent of whether they paid attention to the clients' religious backgrounds. Eighty midwives (82%) said they did not counsel Muslim women differently from other women. Although midwives with relatively many Muslim clients had more knowledge of Islamic attitudes to terminating pregnancy in general than midwives with relatively fewer Muslim clients, the specific knowledge of termination regarding trisomy 21 and other congenital anomalies was limited in both groups. CONCLUSION: While many midwives took client's religion into account, few knew much about Islamic beliefs on prenatal screening for congenital anomalies. Midwives identified a need for additional education. To meet the needs of the changing client population, counselors need more knowledge of religious opinions about the termination of pregnancy and the skills to approach religious issues with clients.

What information do Dutch midwives give clients about toxoplasmosis, listeriosis and cytomegalovirus prevention? An exploratory study of videotaped consultations.

OBJECTIVE: To assess information provided by midwives about methods to prevent toxoplasmosis, listeriosis and cytomegalovirus, and whether the amount of provided information varied according to clients' and midwives' characteristics. METHODS: Intake consultations with 229 clients in four midwifery practices were videotaped between August 2010 and April 2011. Videotaped intake consultations, where infectious disease prevention were discussed, were evaluated, using a specifically designed nine-item scoring tool. Midwives and clients filled in a questionnaire about their background characteristics. Multilevel linear regression analysis was performed to establish associations between the amount of information provided and clients' and midwives' characteristics. RESULTS: In total 172 consultations with fifteen midwives were suitable for analyses. Information about not eating raw or undercooked meat and not consuming unpasteurized dairy products was provided most often. Information about not sharing eating utensils with small children and thoroughly reheating all ready-to-eat foods were rarely provided. More information was provided when the client was a primigravidae or the consultation lasted longer than 50min. CONCLUSION: Information on infectious disease prevention given to pregnant women by primary care midwives was insufficient; especially for cytomegalovirus prevention. PRACTICE IMPLICATIONS: A guideline for professionals on preventable infectious diseases may be useful to inform pregnant women properly.

Maternal cytomegalovirus infection prevention: the role of Dutch primary care midwives.

OBJECTIVE: to assess the knowledge of cytomegalovirus (CMV) infection among Dutch primary care midwives, and clinical approaches to informing women about CMV. DESIGN: cross-sectional study, using self-administered questionnaires. PARTICIPANTS: 330 Dutch primary care midwives. SETTING: primary midwifery care practices across the Netherlands. MAIN OUTCOME: Midwives' knowledge of CMV transmission routes and maternal symptoms, and clinical practice behaviours regarding CMV, the information typically provided or reasons for not informing pregnant women about CMV. FINDINGS: the overall median knowledge score was 8.0 out of a maximum possible score of 13.0. Of all participants, 10.6% reported always informing pregnant women about CMV infection prevention and 41.0% reported never informing pregnant women. The main reason indicated for not informing pregnant women was lack of knowledge about preventive methods (45.7%). CONCLUSION: Dutch primary care midwives have limited knowledge of CMV infection. Improvement in providing education to pregnant women about strategies to prevent CMV is necessary.

"Being flexible and creative": a qualitative study on maternity care assistants' experiences with non-Western immigrant women.

BACKGROUND: Several studies conducted in developed countries have explored postnatal care professionals' experiences with non-western women. These studies reported different cultural practices, lack of knowledge of the maternity care system, communication difficulties, and the important role of the baby's grandmother as care-giver in the postnatal period. However, not much attention has been paid in existing literature to postnatal care professionals' approaches to these issues. Our main objective was to gain insight into how Dutch postnatal care providers--'maternity care assistants' (MCA)--address issues encountered when providing care for non-western women. METHODS: A generic qualitative research approach was used. Two researchers interviewed fifteen MCAs individually, analysing the interview material separately and then comparing and discussing their results. Analytical codes were organised into main themes and subthemes. RESULTS: MCAs perceive caring for non-western women as interesting and challenging, but sometimes difficult too. To guarantee the health and safety of mother and baby, they have adopted flexible and creative approaches to address issues concerning traditional practices, socioeconomic status and communication. Furthermore, they employ several other strategies to establish relationships with non-western clients and their families, improve women's knowledge of the maternity care system and give health education. CONCLUSION: Provision of postnatal care to non-western clients may require special skills and measures. The quality of care for non-western clients might be improved by including these skills in education and retraining programmes for postnatal care providers on top of factual knowledge about traditional practices.

Chlamydia trachomatis infection during pregnancy: knowledge, test practices, and attitudes of Dutch midwives.

BACKGROUND: Chlamydia trachomatis infection in pregnancy may lead to adverse pregnancy outcomes. In the Netherlands, testing for C. trachomatis is based on risk assessment. We assessed midwives' knowledge, test practices, assessment of risk behavior, and attitudes regarding testing for C. trachomatis infection during pregnancy. We evaluated the association between midwives' characteristics and their knowledge of C. trachomatis infection in terms of symptomatology and outcomes. METHODS: This was a cross-sectional study among primary care midwives in the Netherlands. Between September and November 2011, midwives from all Dutch primary care midwifery practices were invited to complete a questionnaire about C. trachomatis infection. RESULTS: Of the 518 midwives invited to participate in this study, 331 (63.9%) responded. The overall median knowledge score for questions about symptomatology and outcomes was 10 out of a maximum score of 15. The median knowledge score was higher among midwives in urban areas. In total, 239 (72.2%) midwives reported testing pregnant women for C. trachomatis. The primary reason for testing was a request by the woman herself (96.2%), followed by symptoms of infection (89.1%), risk behavior (59.3%), and risk factors for infection (7.3%). Almost 25% of midwives showed positive attitudes towards universal screening for C. trachomatis. CONCLUSIONS: Midwives were knowledgeable about symptoms of infection, but less about outcomes. Midwives test pregnant women for C. trachomatis mainly on the women's request. Otherwise, testing is based on symptoms of infection rather than on known risk factors. This may contribute to under-diagnosis and under-treatment, leading to maternal, perinatal, and neonatal morbidity.

The role of religion in decision-making on antenatal screening of congenital anomalies: a qualitative study amongst Muslim Turkish origin immigrants.

OBJECTIVE: to explore what role religious beliefs of pregnant Muslim women play in their decision-making on antenatal screening, particularly regarding congenital abnormalities and termination, and whether their interpretations of the religious doctrines correspond to the main sources of Islam. DESIGN: qualitative pilot study using in-depth interviews with pregnant Muslim women. SETTING: one midwifery practice in a medium-sized city near Amsterdam participated in the study. PARTICIPANTS: 10 pregnant Muslim women of Turkish origin who live in a high density immigrant area and who attended primary midwives for antenatal care were included in the study. DATA COLLECTION AND DATA ANALYSIS: to explore the role of religion in decision-making on antenatal screening tests, a topic list was constructed, including four subjects: being a (practising) Muslim, the view on unborn life, the view on disabled life and the view on termination. To analyse the interviews, open and axial coding based on the Grounded Theory was used and descriptive and analytical themes were identified and interpreted. FINDINGS: all 10 interviewees stated that their faith played a role in their decision-making on antenatal screening, specific to the combined test. They did not consider congenital anomalies as a problem and did not consider termination to be an option in case of a disabled fetus. However, the Islamic jurisprudence considers that termination is allowed if the fetus has serious abnormalities, but only before 19 weeks plus one day of gestation. KEY CONCLUSIONS: religious convictions play a role regarding antenatal screening in pregnant Muslim women of Turkish origin. The interviewees did not consider a termination in case of an affected child. Women were unaware that within Islamic tradition there is the possibility of termination if a fetus has serious anomalies. Incomplete knowledge of religious doctrines may be influencing both decisions of antenatal screening and diagnostic tests uptake and of terminating a pregnancy for fetuses with serious anomalies. IMPLICATIONS FOR PRACTISE: counsellors should be aware of the role of religious beliefs in the decision-making process on antenatal screening tests.

What do midwives need to know about approaches of women towards labour pain management? A qualitative interview study into expectations of management of labour pain for pregnant women receiving midwife-led care in the Netherlands.

OBJECTIVE: to investigate factors important to women receiving midwife-led care with regard to their expectations for management of labour pain. DESIGN: semi-structured ante partum interviews and analyses using constant comparison method. PARTICIPANTS: fifteen pregnant women between 36 and 40 weeks gestation receiving midwife-led care. SETTING: five midwifery practices across the Netherlands between June 2009 and July 2010. MAIN OUTCOME: women's expectations regarding management of labour pain. RESULTS: we found three major themes to be important in women's expectations for management of labour pain: preparation, support and control and decision-making. In regards to all these themes, three distinct approaches towards women's planning for pain management in labour were identified: the 'pragmatic natural', the 'deliberately uninformed' and the 'planned pain relief' approach. CONCLUSION: midwives need to recognise that women take different approaches to pain management in labour in order to adapt care to the individual woman.

Factors associated with not using folic acid supplements preconceptionally.

OBJECTIVE: Neural tube defects are among the most common birth defects worldwide. Folic acid intake from one month before to three months after conception reduces the likelihood of neural tube defects by at least 50%. Since 1995, several campaigns have been organised in the Netherlands which resulted in 51% of pregnant women using folic acid supplements during the entire recommended period in the northern part of the Netherlands in 2005. Our research question was to gain insight into the current prevalence and factors associated with inadequate pregnancy-related use of folic acid supplements. DESIGN: Data from the DELIVER study were used, which is a population-based cohort study. SETTING: Twenty midwifery practices across the Netherlands in 2009 and 2010. SUBJECTS: In total 5975 pregnant women completed a questionnaire covering items on sociodemographic and lifestyle factors, including folic acid intake. RESULTS: Of our study population, 55·5% (3318/5975) used folic acid supplements before conception. Several sociodemographic and lifestyle factors were associated with no preconception use of folic acid, of which non-Western ethnicity and not having a partner had the largest effect size. CONCLUSIONS: In the Netherlands, the folic acid intake before conception is suboptimal and has not improved over recent years. Fortification of staple foods with folic acid should be reconsidered as it would provide a more effective means of ensuring an adequate intake, especially for those groups of women who are unlikely to plan their pregnancies or to receive or respond to health promotion messages.

Socio-demographic and lifestyle-related characteristics associated with self-reported any, daily and occasional smoking during pregnancy.

Smoking during pregnancy is a risk factor for various adverse birth outcomes. In order to develop effective interventions, insight is needed into the characteristics associated with pregnant women who smoke. Unknown is whether these characteristics differ for women who smoke daily and women who smoke occasionally. Our study sample, drawn from the DELIVER study (Sept 2009-March 2011), consisted of 6107 pregnant women in primary care in the Netherlands who were up to 34 weeks pregnant. The associations of thirteen socio-demographic or lifestyle-related characteristics with 'any smoking', 'daily smoking' and 'occasional smoking' during pregnancy were tested using multiple binary logistic regression with general estimating equations (GEE). Characteristics most strongly associated with any smoking were low education (OR 10.3; 95% confidence interval (CI) 7.0-15.4), being of Turkish ethnicity (OR 3.9; 95%CI 2.3-6.7) and having no partner (OR 3.7; 95%CI 2.3-6.0). Women of Dutch ethnicity were three times more likely to smoke than those from Dutch-speaking Caribbean countries and non-religious women were much more likely to smoke than religious women. Low education was markedly more strongly associated with daily smoking than with occasional smoking (OR 20.3; 95%CI 13.2-31.3 versus OR 6.0; 95%CI 3.4-10.5). Daily smokers were more likely to be associated with other unfavorable lifestyle-related characteristics, such as not taking folic acid, being underweight, and having had an unplanned pregnancy. There is still much potential for health gain with respect to smoking during pregnancy in the Netherlands. Daily and occasional smokers appear to differ in characteristics, and therefore possibly require different interventions.

"A mixture of positive and negative feelings": a qualitative study of primary care midwives' experiences with non-western clients living in the Netherlands.

BACKGROUND: Non-western women living in the Netherlands are diverse in origin, which implies diversity in their needs and expectations for midwifery care. Furthermore, it has also been shown that non-western women make suboptimal use of prenatal care. Midwives may therefore face difficulties when caring for these clients. OBJECTIVE: The main objective of our study was to explore Dutch primary care midwives' experiences with non-western clients. METHODS: A qualitative design was used. Thirteen midwives were interviewed individually and 8 participated in a focus group. All interviews were transcribed and analysed by two researchers who compared and discussed their results. Analytical codes were organised into subthemes and main themes. RESULTS: Midwives perceived ethnic diversity as both difficult and interesting. Caring for these women was perceived as demanding, but also rewarding. They experienced a variety of difficulties when caring for these women: communication problems, suboptimal health literacy, socioeconomic problems, lack of knowledge of the maternity care system, pressure from the family and a strong preference for physicians. In spite of these difficulties, midwives aim for optimal care by being alert and proactive, taking these women by the hand and making use of alternative resources. CONCLUSION: Provision of care to non-western clients can be difficult and may require additional measures. These problems and measures should be included in midwifery education programmes as well as training programmes for midwives.