Experienced disrespect & abuse during childbirth and associated birth characteristics: a cross-sectional survey in the Netherlands.

BACKGROUND: Experiencing upsetting disrespect and abuse (D&A) during labour and birth negatively affects women's birth experiences. Knowing in what circumstances of birth women experience upsetting situations of D&A can create general awareness and help healthcare providers judge the need for extra attention in their care to help reduce these experiences. However, little is known about how different birth characteristics relate to the experience of D&A. Previous studies showed differences in birth experiences and experienced D&A between primiparous and multiparous women. This study explores, stratified for parity, (1) how often D&A are experienced in the Netherlands and are considered upsetting, and (2) which birth characteristics are associated with these upsetting experiences of D&A. METHODS: For this cross-sectional study, an online questionnaire was set up and disseminated among women over 16 years of age who gave birth in the Netherlands between 2015 and 2020. D&A was divided into seven categories: emotional pressure, unfriendly behaviour/verbal abuse, use of force/physical violence, communication issues, lack of support, lack of consent and discrimination. Stratified for parity, univariable and multivariable logistic regression analyses were performed to examine which birth characteristics were associated with the upsetting experiences of different categories of D&A. RESULTS: Of all 11,520 women included in this study, 45.1% of primiparous and 27.0% of multiparous women reported at least one upsetting experience of D&A. Lack of consent was reported most frequently, followed by communication issues. For both primiparous and multiparous women, especially transfer from midwife-led to obstetrician-led care, giving birth in a hospital, assisted vaginal birth, and unplanned cesarean section were important factors that increased the odds of experiencing upsetting situations of D&A. Among primiparous women, the use of medical pain relief was also associated with upsetting experiences of D&A. CONCLUSION: A significant number of women experience upsetting disrespectful and abusive care during birth, particularly when medical interventions are needed after the onset of labour, when care is transferred during birth, and when birth takes place in a hospital. This study emphasizes the need for improving quality of verbal and non-verbal communication, support and adequate decision-making and consent procedures, especially before, during, and after the situations of birth that are associated with D&A.

Methods of induction of labor in women with obesity: A secondary analysis of two multicenter randomized controlled trials.

INTRODUCTION: Obesity is an increasing public health concern worldwide and can lead to more complications in pregnancy and childbirth. Women with obesity more often require induction of labor for various indications. The aim of this study is to assess which method of induction of labor is safest and most effective in women with obesity. MATERIAL AND METHODS: This is a secondary analysis of two randomized controlled trials about induction of labor. Women with a term singleton pregnancy in cephalic presentation, an unfavorable cervix, intact membranes and without a previous cesarean section were randomly allocated to cervical priming with a Foley catheter or vaginal prostaglandin-E2-gel (PROBAAT-I) or a Foley catheter or oral misoprostol (PROBAAT-II). The inclusion and exclusion criteria for the studies were identical. Induction methods were compared in women with obesity (body mass index ≥30.0). Main outcomes were cesarean section and postpartum hemorrhage (blood loss >1000 mL). RESULTS: A total of 2664 women, were included in the trials, 517 of whom were obese: 254 women with obesity received a Foley catheter, 176 oral misoprostol and 87 prostaglandin E2 (PGE2). A cesarean section was performed in 29.1% of women allocated to Foley vs 22.2% in the misoprostol and 23.0% in the PGE2 groups. Comparisons between groups revealed no statistically significant differences: the relative risk [RR] was 1.31 (95% confidence interval [CI] 0.94-1.84) in the Foley vs misoprostol group and 1.27 (95% CI 0.83-1.95) in the Foley vs PGE2 group. The rates of postpartum hemorrhage were comparable (10.6%, 11.4% and 6.9%, respectively; P = 0.512). In women with obesity, more often a switch to another method occurred in the Foley group, (20.1% vs 6.3% in misoprostol vs 1.1% in the PGE2 group; P < 0.001). The risk of a failed Foley placement was higher in women with obesity than in women without obesity (8.3% vs 3.2%; adjusted odds ratio 3.12, 95% CI 1.65-5.90). CONCLUSIONS: In women with obesity we found a nonsignificant trend towards an increased rate of cesarean sections in the group induced with a Foley catheter compared to oral misoprostol; however, the study lacked power for this subgroup analysis. The finding of a higher risk of failed placement of a Foley catheter in women with obesity can be used in shared decision making.

Trends in postpartum hemorrhage and manual removal of the placenta and the association with childbirth interventions: A Dutch nationwide cohort study.

BACKGROUND: Because the cause of increasing rates of postpartum hemorrhage (PPH) and manual placental removal (MROP) is still unknown, we described trends in PPH, MROP, and childbirth interventions and examined factors associated with changes in rates of PPH and MROP. METHODS: This nationwide cohort study used national perinatal registry data from 2000 to 2014 (n = 2,332,005). We included births of women who gave birth to a term singleton child in obstetrician-led care or midwife-led care. Multivariable logistic regression analyses were used to examine associations between characteristics and interventions, and PPH ≥ 1000 mL and MROP. RESULTS: PPH rates increased from 4.3% to 6.6% in obstetrician-led care and from 2.5% to 4.8% in midwife-led care. MROP rates increased from 2.4% to 3.4% and from 1.0% to 1.4%, respectively. A rising trend was found for rates of induction and augmentation of labor, pain medication, and cesarean section, while rates of episiotomy and assisted vaginal birth declined. Adjustments for characteristics and childbirth interventions did not result in large changes in the trends of PPH and MROP. After adjustments for childbirth interventions, in obstetrician-led care, the odds ratio (OR) of PPH in 2014 compared with the reference year 2000 changed from 1.66 (95% CI 1.57-1.76) to 1.64 (1.55-1.73) among nulliparous women and from 1.56 (1.47-1.66) to 1.52 (1.44-1.62) among multiparous women. For MROP, the ORs changed from 1.51 (1.38-1.64) to 1.36 (1.25-1.49) and from 1.56 (1.42-1.71) to 1.45 (1.33-1.59), respectively. CONCLUSIONS: Rising PPH trends were not associated with changes in population characteristics and rising childbirth intervention rates. The rising MROP was to some extent associated with rising intervention rates.

"Hypertension in Pregnancy Intervention Trial At Term" and "Disproportionate Intrauterine Growth Intervention Trial At Term" Studies.

In 2003, in the context of a national research funding program in which obstetric research was prioritized, several perinatal centers took the initiative to jointly submit a number of applications to the subsidy programs of Effectiveness Research and Prevention of ZonMw. This has led to the funding of the Obstetric Consortium with several projects, including the "Hypertension in Pregnancy Intervention Trial At Term" and the "Disproportionate Intrauterine Growth Intervention Trial At Term" studies. The studies showed that induction of labor for hypertension and growth restriction at term was the appropriate management. Subsequent implementation improved maternal and perinatal outcomes.

Association between high levels of comorbid anxiety and depressive symptoms and decreased likelihood of birth without intervention: A longitudinal prospective cohort study.

OBJECTIVE: To assess the association between trajectories of comorbid anxiety and depressive (CAD) symptoms assessed in each pregnancy trimester and physiological birth. DESIGN: Large longitudinal prospective cohort study with recruitment between January 2013 and September 2014. SETTING: Primary care, in the Netherlands. POPULATION: Dutch-speaking pregnant women with gestational age at birth ≥37 weeks, and without multiple pregnancy, severe psychiatric disorder or chronic disease history. METHODS: Pregnancy-specific anxiety and depressive symptoms were measured prospectively in each trimester of pregnancy using the negative affect subscale of the Tilburg Pregnancy Distress Scale and Edinburgh (Postnatal) Depression Scale. Data on physiological birth were obtained from obstetric records. Multivariate growth mixture modelling was performed in MPLUS to determine longitudinal trajectories of CAD symptoms. Multiple logistic regression analysis was used to examine the association between trajectories and physiological birth. MAIN OUTCOME MEASURES: Trajectories of CAD symptoms and physiological birth. RESULTS: Seven trajectories (classes) of CAD symptoms were identified in 1682 women and subsequently merged into three groups: group 1-persistently low levels of symptoms (reference class 1; 79.0%), group 2-intermittently high levels of symptoms (classes 3, 6 and 7; 11.2%), and group 3-persistently high levels of symptoms (classes 2, 4 and 5; 9.8%). Persistently high levels of CAD symptoms (group 3) were associated with a lower likelihood of physiological birth (odds ratio 0.67, 95% confidence interval 0.47-0.95, P = 0.027) compared with the reference group (persistently low levels of symptoms), after adjusting for confounders. CONCLUSIONS: This study is the first showing evidence that persistently high CAD levels, assessed in each pregnancy trimester, are associated with a lower likelihood of physiological birth.

Visualization of contractions: Evaluation of a new experience design concept to enhance the childbirth experience.

BACKGROUND: The purpose of this study was to develop and evaluate an innovative design proposition intended to help enhance the childbirth experience. The innovation consists of a smartphone application for birth preparation during pregnancy with information and coaching, in addition to a wall projection at the labor ward that visualizes the progress of labor based on uterine monitoring data. METHODS: We conducted a randomized controlled clinical pilot study. Singleton pregnant people pursuing a vaginal birth were recruited between 28 and 32 weeks of gestation and allocated to the intervention group (mobile application during the third trimester and wall projection at the labor ward) or to care as usual. Childbirth expectations and experiences were measured with validated questionnaires, which were completed at 32 and 36 weeks of gestation, immediately after birth, and at 4 weeks postpartum. Quantitative outcomes were analyzed and feedback about the proposition was evaluated using qualitative methods. RESULTS: The qualitative feedback from patients was largely positive; however, we could not detect any significant differences between the intervention and control groups about fear of childbirth and other outcome measures. CONCLUSION: In this pilot study, we evaluated a new experience design proposition for pregnancy and childbirth. This study generated data that will help to further improve and evaluate similar innovations in the future. This application may facilitate participatory care, promoting active involvement of parents in the healthcare processes of pregnancy and childbirth.

Antenatal cardiotocography in primary midwife-led care: Women's satisfaction.

BACKGROUND: In the Netherlands, antenatal cardiotocography (aCTG), used to assess fetal well-being, is performed in obstetrician-led care. To improve continuity of care, an innovation project was designed wherein primary care midwives perform aCTGs for specific indications. The aim of this study was to examine the satisfaction and experiences of pregnant women who received an aCTG in primary midwife-led care and explore which factors were associated with high satisfaction. METHODS: Data were collected through a self-administered questionnaire based on the Consumer Quality Index. The primary outcome was general satisfaction on a 10-point scale, with a score above nine indicating participants were "highly satisfied". RESULTS: In total, 1227 women were included in the analysis. The study showed a mean general satisfaction score of 9.2. Most women were highly satisfied with receiving an aCTG in primary midwife-led care (77.4%). On the Consumer Quality Index, the mean satisfaction level varied from 3.98 (SD ± 0.11) for the subscale "client satisfaction" to 3.87 (SD ± 0.32) for the subscale "information provision" on a 4-point scale. Women at between 33 and 36 weeks' gestation were more likely to be highly satisfied (adjusted OR [aOR] = 3.35). Compared with a completely comfortable position during the aCTG, a mostly comfortable or somewhat comfortable level had decreased odds of being associated with a ranking of highly satisfied (aOR 0.24 and 0.19, respectively). CONCLUSIONS: This study shows that pregnant women are satisfied with having an aCTG in midwife-led care. Providing aCTG in midwife-led care can increase access to continuity of care.

More home births during the COVID-19 pandemic in the Netherlands.

BACKGROUND: The aim of this observational study was to examine whether the course of pregnancy and birth and accompanying outcomes among low-risk pregnant women changed in the COVID-19 pandemic compared to the prepandemic period. METHODS: We analyzed data from the Dutch Midwifery Case Registration System (VeCaS). Differences in the course of pregnancy and birth, and accompanying maternal and neonatal outcomes, were calculated between women pregnant during the initial months of the COVID-19 pandemic (March 1 to August 3, 2020) and the prepandemic period (March 1-August 3, 2019). We also conducted a stratified analysis by parity. RESULTS: We included 5913 low-risk pregnant women of whom 2963 (50.1%) were pregnant during the first surge of the COVID-19 pandemic, and 2950 (49.9%) in the prepandemic period. During the COVID-19 pandemic, more women desired and had a home birth. More women used pain medication and fewer had an episiotomy in the COVID-19 period than prior. Multiparous women had a higher suspected rate of fetal growth restriction during COVID; however, the actual rate of small for gestational age infants was not significantly increased. We observed no differences for onset and augmentation of labor or for mode of birth, though the rate of vaginal births increased. CONCLUSIONS: During the COVID-19 pandemic, there was a higher rate of planned and actual home birth, and suspected growth restriction and a lower rate of episiotomy among low-risk pregnant women in the Netherlands.

Disrespect and abuse during labour and birth amongst 12,239 women in the Netherlands: a national survey.

BACKGROUND: Women experience disrespect and abuse during labour and birth all over the world. While the gravity of many forms of disrespect and abuse is evident, some of its more subtle forms may not always be experienced as upsetting by women. This study examines (1) how often women experience disrespect and abuse during labour and birth in the Netherlands and (2) how frequently they consider such experiences upsetting. We also examine (3) which respondent characteristics (age, ethnicity, educational level and parity) are associated with those experiences of disrespect and abuse that are upsetting, and (4) the associations between upsetting experiences of disrespect and abuse, and women's labour and birth experiences. METHODS: Women who gave birth up to five years ago were recruited through social media platforms to participate in an online survey. The survey consisted of 37 questions about experiences of disrespect and abuse divided into seven categories, dichotomised in (1) not experienced, or experienced but not considered upsetting (2) experienced and considered upsetting. A multivariable logistic regression analysis was performed to examine associated characteristics with upsetting experiences of disrespect and abuse. A Chi-square test was used to investigate the association between upsetting experiences of disrespect and abuse and overall birth experience. RESULTS: 13,359 respondents started the questionnaire, of whom 12,239 met the inclusion and exclusion criteria. Disrespect and abuse in terms of 'lack of choices' (39.8%) was reported most, followed by 'lack of communication' (29.9%), 'lack of support' (21.3%) and 'harsh or rough treatment/physical violence' (21.1%). Large variation was found in how frequently certain types of disrespect and abuse were considered upsetting, with 36.3% of women experiencing at least one situation of disrespect and abuse as upsetting. Primiparity and a migrant background were risk factors for experiencing upsetting disrespect and abuse in all categories. Experiencing more categories of upsetting disrespect and abuse was found to be associated with a more negative birth experience. CONCLUSIONS: Disrespectful and abusive experiences during labour and birth are reported regularly in the Netherlands, and are often (but not always) experienced as upsetting. This emphasizes an urgent need to implement respectful maternity care, even in high income countries.

Disrespect and abuse during labour and birth is a globally recognized phenomenon and has been linked to traumatic birth experiences and PTSD. In our study, we investigated how often women experience disrespect and abuse during labour and birth in the Netherlands and what proportion of these experiences was found to be upsetting. We also looked at risk factors for experiencing upsetting disrespect and abuse and to what extent upsetting disrespect and abuse influences the overall labour and birth experience.We conducted an online survey, with 12,239 respondents included in the analysis. We found a large variation in how frequently certain types of disrespect and abuse were considered upsetting, with 36.3% of women experiencing at least one situation of disrespect and abuse as upsetting. More subtle forms of disrespect and abuse, such as lack of choice, communication or support, were most prevalent and often considered upsetting. Giving birth for the first time and having a migrant background were risk factors for experiencing upsetting disrespect and abuse. Upsetting disrespect and abuse was found to have a strong impact on the overall labour and birth experience; with every additional experienced category of upsetting disrespect and abuse, the number of (very) positive labour and birth experiences decreases and the number of very negative ones increases.Although disrespect and abuse is a complex issue and its measurement subjective, this study shows that there is still a long way to go before achieving optimal respectful maternity care for all women, even in high income countries.

Psychosocial and peripartum determinants of postpartum depression: Findings from a prospective population-based cohort. The ABCD study.

BACKGROUND: Postpartum depression is prevalent and concerns a serious health problem for women and their families. The current large-scale birth cohort study investigated: (1) the associations of various potential determinants of postpartum depression using a multidimensional approach, and (2) the individual contribution of obstetric and perinatal determinants and pregnancy-specific anxiety to the risk of postpartum depression. METHODS: This study was based on a large-scale birth cohort study in Amsterdam, the Netherlands (ABCD-study). In 5109 women depressive symptoms were assessed using the Center for Epidemiologic Studies Depression Scale (cut-off ≥16 indicating high risk of postpartum depression). Determinants were assessed using self-report or perinatal registries. RESULTS: In the final multivariable model, other-Western and non-Western ethnic background, increased antepartum depressive symptoms, increased antepartum anxiety, increased pregnancy-specific anxiety, being unemployed, poor sleep quality, unwanted pregnancy, abuse, multiparity, and congenital abnormality were all independently related to an increased risk of postpartum depression. The strongest risk factors for postpartum depression were antepartum depressive symptoms (adjusted odds ratio (AOR) = 3.86, 95% confidence interval (CI) 3.02-4.92), having a baby with a congenital abnormality (AOR = 2.33, 95% CI 1.46-3.73), and abuse (AOR = 1.95, 95% CI 1.02-3.73). The final model accounted for 24.5% of the variance. LIMITATIONS: Our dataset did not provide information on social support or maternal and family history of depression. Next to these determinants, future research should include biological factors. CONCLUSIONS: The determinants identified provide opportunities for the development of multidimensional early screening and early intervention strategies for women with an increased risk of postpartum depression.

Centralisation of acute obstetric care in the Netherlands: a qualitative study to explore the experiences of stakeholders with adaptations in organisation of care.

BACKGROUND: In the past decade, acute obstetric care (AOC) has become centralised in many high-income countries. In this qualitative study, we explored how stakeholders in maternity care perceived and experienced adaptations in the organisation of maternity care in areas in the Netherlands where AOC was centralised. METHODS: A heterogenic group of fifteen maternity care stakeholders, including patients, were purposively selected for semi-structured interviews. An inductive thematic analysis was used. RESULTS: Three main themes were identified: (1) lack of involvement. (2) the process of making adaptations in the organisation of maternity care. (3) maintaining quality of care. Stakeholders in this study were highly motivated to maintain a high quality of maternity care and therefore made adaptations at several organisational levels. However, they felt a lack of involvement during the planning of centralisation of AOC and highlighted the importance of a collaborative process when making adaptations after centralisation of AOC. CONCLUSIONS: Regions with AOC centralisation plans should invest time and money in change management, encourage early involvement of all maternity care stakeholders and acknowledge centralisation of AOC as a professional life event with associated emotions, including a feeling of unsafety.

Effectiveness of a guided ACT-based self-help resilience training for depressive symptoms during pregnancy: Study protocol of a randomized controlled trial embedded in a prospective cohort.

BACKGROUND: During pregnancy, about 10 to 20% of women experience depressive symptoms. Subclinical depression increases the risk of peripartum depression, maternal neuro-endocrine dysregulations, and adverse birth and infant outcomes. Current treatments often comprise face-to-face psychological or pharmacological treatments that may be too intensive for women with subclinical depression leading to drop-out and moderate effectiveness. Therefore, easily accessible, resilience enhancing and less stigmatizing interventions are needed to prevent the development of clinical depression. This paper describes the protocol of a prospective cohort study with an embedded randomized controlled trial (RCT) that aims to improve mental resilience in a sample of pregnant women through a self-help program based on the principles of Acceptance and Commitment Therapy (ACT). Maternal and offspring correlates of the trajectories of peripartum depressive symptoms will also be studied. METHODS: Pregnant women (≥ 18 years) receiving care in Dutch midwifery practices will participate in a prospective cohort study (n ~ 3500). Between 12 and 18 weeks of pregnancy, all women will be screened for depression with the Edinburgh Postnatal Depression Scale (EPDS). Women with an EPDS score ≥ 11 will be evaluated with a structured clinical interview. Participants with subclinical depression (n = 290) will be randomized to a 9-week guided self-help ACT-training or to care as usual (CAU). Primary outcomes (depressive symptoms and resilience) and secondary outcomes (e.g. anxiety and PTSD, bonding, infant development) will be collected via online questionnaires at four prospective assessments around 20 weeks and 30 weeks gestation and at 6 weeks and 4 months postpartum. Maternal hair cortisol concentrations will be assessed in a subsample of women with a range of depressive symptoms (n = 300). The intervention's feasibility will be assessed through qualitative interviews in a subsample of participants (n = 20). DISCUSSION: This is the first study to assess the effectiveness of an easy to administer intervention strategy to prevent adverse mental health effects through enhancing resilience in pregnant women with antepartum depressive symptomatology. This longitudinal study will provide insights into trajectories of peripartum depressive symptoms in relation to resilience, maternal cortisol, psychological outcomes, and infant developmental milestones. TRIAL REGISTRATION: Netherlands Trial Register (NTR), NL7499 . Registered 5 February 2019.

Continuity of care is an important and distinct aspect of childbirth experience: findings of a survey evaluating experienced continuity of care, experienced quality of care and women's perception of labor.

BACKGROUND: To compare experienced continuity of care among women who received midwife-led versus obstetrician-led care. Secondly, to compare experienced continuity of care with a. experienced quality of care during labor and b. perception of labor. METHODS: We conducted a questionnaire survey in a region in the Netherlands in 2014 among 790 women after they gave birth. To measure experienced continuity of care, the Nijmegen Continuity Questionnaire was used. Quality of care during labor was measured with the Pregnancy and Childbirth Questionnaire, and to measure perception of labor we used the Childbirth Perception Scale. RESULTS: Three hundred twenty five women consented to participate (41%). Of these, 187 women completed the relevant questions in the online questionnaire. 136 (73%) women were in midwife-led care at the onset of labor, 15 (8%) were in obstetrician-led care throughout pregnancy and 36 (19%) were referred to obstetrician-led care during pregnancy. Experienced personal and team continuity of care during pregnancy were higher for women in midwife-led care compared to those in obstetrician-led care at the onset of labor. Experienced continuity of care was moderately correlated with experienced quality of care although not significantly so in all subgroups. A weak negative correlation was found between experienced personal continuity of care by the midwife and perception of labor. CONCLUSION: This study suggests that experienced continuity of care depends on the care context and is significantly higher for women who are in midwife-led compared to obstetrician-led care during labor. It will be a challenge to maintain the high level of experienced continuity of care in an integrated maternity care system. Experienced continuity of care seems to be a distinctive concept that should not be confused with experienced quality of care or perception of labor and should be considered as a complementary aspect of quality of care.

Pharmacological pain relief and fear of childbirth in low risk women; secondary analysis of the RAVEL study.

BACKGROUND: Fear of childbirth may reduce the womens' pain tolerance during labour and may have impact on the mother-infant interaction. We aimed to assess (1) the association between fear of childbirth antepartum and subsequent request for pharmacological pain relief, and (2) the association between the used method of pain relief and experienced fear of childbirth as reported postpartum in low risk labouring women. METHODS: Secondary analysis of the RAVEL study, a randomised controlled trial comparing remifentanil patient controlled analgesia (PCA) and epidural analgesia to relieve labour pain. The RAVEL study included 409 pregnant women at low risk for obstetric complications at 18 midwifery practices and six hospitals in The Netherlands (NTR 3687). We measured fear of childbirth antepartum and experienced fear of childbirth reported postpartum, using the Wijma Delivery Expectancy/Experience Questionnaire. RESULTS: Women with fear of childbirth antepartum more frequently requested pain relief compared to women without fear of childbirth antepartum, but this association did not reach statistical significance (adjusted odds ratio (aOR2.0; 95% confidence interval (CI) 0.8-4.6). Women who received epidural analgesia more frequently reported fear of childbirth postpartum compared to women who did not receive epidural analgesia (aOR3.5; CI 1.5-8.2), while the association between remifentanil-PCA and fear of childbirth postpartum was not statistically significant (aOR1.7; CI 0.7-4.3). CONCLUSIONS: Women with fear of childbirth antepartum more frequently requested pain relief compared to women without fear of childbirth antepartum, but this association was not statistically significant. Women who received pharmacological pain relief more frequently reported that they had experienced fear of childbirth during labour compared to women who did not receive pain relief. Based on our data epidural analgesia with continuous infusion does not seem to be preferable over remifentanil-PCA as method of pain relief when considering fear of childbirth postpartum. TRIAL REGISTRATION: Netherlands Trial Register 3687 ; Register date: 5 Nov 2012.

The capacity of mid-pregnancy cervical length to predict preterm birth in low-risk women: a national cohort study.

INTRODUCTION: We investigated the predictive capacity of mid-trimester cervical length (CL) measurement for spontaneous and iatrogenic preterm birth. MATERIAL AND METHODS: We performed a prospective observational cohort study in nulliparous women and low-risk multiparous women with a singleton pregnancy between 16(+0) and 21(+6) weeks of gestation. We assessed the prognostic capacity of transvaginally measured mid-trimester CL for spontaneous and iatrogenic preterm birth (<37 weeks) using likelihood ratios (LR) and receiver-operating-characteristic analysis. We calculated numbers needed to screen to prevent one preterm birth assuming different treatment effects. Main outcome measures were preterm birth <32, <34 and <37 weeks. RESULTS: We studied 11,943 women, of whom 666 (5.6%) delivered preterm: 464 (3.9%) spontaneous and 202 (1.7%) iatrogenic. Mean CL was 44.1 mm (SD 7.8 mm). In nulliparous women, the LRs for spontaneous preterm birth varied between 27 (95% CI 7.7-95) for a CL ≤ 20 mm, and 2.0 (95% CI 1.6-2.5) for a CL between 30 and 35 mm. For low-risk multiparous women, these LRs were 37 (95% CI 7.5-182) and 1.5 (95% CI 0.97-2.2), respectively. Using a cut-off for CL ≤ 30 mm, 28 (6.0%) of 464 women with spontaneous preterm birth were identified. The number needed to screen to prevent one case of preterm birth was 618 in nulliparous women and 1417 for low-risk multiparous women (40% treatment effect, cut-off 30 mm). CONCLUSION: In women at low risk of preterm birth, CL predicts spontaneous preterm birth. However, its isolated use as a screening tool has limited value due to low sensitivity.

Preventing Preterm Birth with Progesterone in Women with a Short Cervical Length from a Low-Risk Population: A Multicenter Double-Blind Placebo-Controlled Randomized Trial.

OBJECTIVE: The objective of this study was to evaluate the effectiveness of vaginal progesterone in reducing adverse neonatal outcome due to preterm birth (PTB) in low-risk pregnant women with a short cervical length (CL). STUDY DESIGN: Women with a singleton pregnancy without a history of PTB underwent CL measurement at 18 to 22 weeks. Women with a CL ≤ 30 mm received vaginal progesterone or placebo. Primary outcome was adverse neonatal outcome, defined as a composite of respiratory distress syndrome, bronchopulmonary dysplasia, intracerebral hemorrhage > grade II, necrotizing enterocolitis > stage 1, proven sepsis, or death before discharge. Secondary outcomes included time to delivery, PTB before 32, 34, and 37 weeks of gestation. Analysis was by intention to treat. RESULTS: Between 2009 and 2013, 20,234 women were screened. A CL of 30 mm or less was seen in 375 women (1.8%). In 151 women, a CL ≤ 30 mm was confirmed with a second measurement and 80 of these women agreed to participate in the trial. We randomly allocated 41 women to progesterone and 39 to placebo. Adverse neonatal outcomes occurred in two (5.0%) women in the progesterone and in four (11%) women in the control group (relative risk [RR], 0.47; 95% confidence interval [CI], 0.09-2.4). The use of progesterone resulted in a nonsignificant reduction of PTB < 32 weeks (2.0 vs. 8.0%; RR, 0.33; 95% CI, 0.04-3.0) and < 34 weeks (7.0 vs. 10%; RR, 0.73; 95% CI, 0.18-3.1) but not on PTB < 37 weeks (15 vs. 13%; RR, 1.2; 95% CI, 0.39-3.5). CONCLUSION: In women with a short cervix, who are otherwise low risk, we could not show a significant benefit of progesterone in reducing adverse neonatal outcome and PTB.

Potential improvement of pregnancy outcome through prenatal small for gestational age detection. [correction].

OBJECTIVE: To assess differences in mode of delivery and pregnancy outcome between prenatally detected and nonprenatally detected small for gestational age (SGA) neonates born at term. STUDY DESIGN: We performed a retrospective multicenter cohort study. All singleton infants, born SGA in cephalic position between 36(0/7) and 41(0/7) weeks gestation, were classified as either prenatally detected SGA or nonprenatally detected SGA. With propensity score matching we created groups with comparable baseline characteristics. We compared these groups for composite adverse perinatal outcome, labor induction, and cesarean section rates. RESULTS: We included 718 SGA infants, of whom 555 (77%) were not prenatally detected. Composite adverse neonatal outcome did not differ statistically significant between the matched prenatally detected and the nonprenatally detected group (5.5 vs. 7.4%, odds ratio [OR] 0.74, 95% confidence interval [CI]: 0.30-1.8). However, perinatal mortality only occurred in the nonprenatally detected group (1.8% [3/163] in the matched cohort, 1.3% [7/555] in the complete cohort). In the propensity matched prenatally detected SGA group both induction of labor (57 vs. 9%, OR 14.0, 95% CI: 7.4-26.2) and cesarean sections (20 vs. 8%, OR 2.9, 95% CI: 1.5-5.8) were more often performed compared with the nonprenatally detected SGA group. CONCLUSION: Prenatal SGA detection at term allows timely induction of labor and cesarean sections thus potentially preventing stillbirth.

Decline in home births associated with faster increase in trend of postpartum haemorrhage and manual removal of the placenta.

In this study we explored the relationship between home birth rates and increasing rates of postpartum haemorrhage (PPH) and manual removal of the placenta (MROP). Data were used from the Dutch national perinatal registry (2000-2014) of women in midwife-led care. Adjusting for place of birth flattened the increasing trends of PPH and MROP. By adjusting for place of birth, the rising trend of MROP among multiparous women disappeared. This suggests that if home birth rates had not declined, PPH and MROP rates might not have increased as much. This study supports policies of enabling women to choose home births.

Antenatal cardiotocography in primary midwife-led care: a budget impact analysis.

OBJECTIVES: In many countries, the healthcare sector is dealing with important challenges such as increased demand for healthcare services, capacity problems in hospitals and rising healthcare costs. Therefore, one of the aims of the Dutch government is to move care from in-hospital to out-of-hospital care settings. An example of an innovation where care is moved from a more specialised setting to a less specialised setting is the performance of an antenatal cardiotocography (aCTG) in primary midwife-led care. The aim of this study was to assess the budget impact of implementing aCTG for healthy pregnant women in midwife-led care compared with usual obstetrician-led care in the Netherlands. METHODS: A budget impact analysis was conducted to estimate the actual costs and reimbursement of aCTG performed in midwife-led care and obstetrician-led care (ie, base-case analysis) from the Dutch healthcare perspective. Epidemiological and healthcare utilisation data describing both care pathways were obtained from a prospective cohort, survey and national databases. Different implementation rates of aCTG in midwife-led care were explored. A probabilistic sensitivity analysis was conducted to estimate the uncertainty surrounding the budget impact estimates. RESULTS: Shifting aCTG from obstetrician-led care to midwife-led-care would increase actual costs with €311 763 (97.5% CI €188 574 to €426 072) and €1 247 052 (97.5% CI €754 296 to €1 704 290) for implementation rates of 25% and 100%, respectively, while it would decrease reimbursement with -€7 538 335 (97.5% CI -€10 302 306 to -€4 559 661) and -€30 153 342 (97.5% CI -€41 209 225 to -€18 238 645) for implementation rates of 25% and 100%, respectively. The sensitivity analysis results were consistent with those of the main analysis. CONCLUSIONS: From the Dutch healthcare perspective, we estimated that implementing aCTG in midwife-led care may increase the associated actual costs. At the same time, it might lower the healthcare reimbursement.