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BackgroundThe age at onset of the association between poverty and poor health is not understood. Our hypothesis was that individuals from highest household income (HI), compared to those with lowest HI, will have increased fetal size in the second and third trimester and birth.Methods.Second and third trimester fetal ultrasound measurements and birth measurements were obtained from eight cohorts. Results were analysed in cross-sectional two-stage individual patient data (IPD) analyses and also a longitudinal one-stage IPD analysis.ResultsThe eight cohorts included 21 714 individuals. In the two-stage (cross-sectional) IPD analysis, individuals from the highest HI category compared with those from the lowest HI category had larger head size at birth (mean difference 0.22 z score (0.07, 0.36)), in the third trimester (0.25 (0.16, 0.33)) and second trimester (0.11 (0.02, 0.19)). Weight was higher at birth in the highest HI category. In the one-stage (longitudinal) IPD analysis which included data from six cohorts (n=11 062), head size was larger (mean difference 0.13 (0.03, 0.23)) for individuals in the highest HI compared with lowest category, and this difference became greater between the second trimester and birth. Similarly, in the one-stage IPD, weight was heavier in second highest HI category compared with the lowest (mean difference 0.10 (0 .00, 0.20)) and the difference widened as pregnancy progressed. Length was not linked to HI category in the longitudinal model.ConclusionsThe association between HI, an index of poverty, and fetal size is already present in the second trimester.

Background Lipids are crucial for fetal growth and development. Maternal lipid concentrations are associated with fetal growth in the second and third trimester of pregnancy and with birth outcomes. However, it is unknown if this association starts early in pregnancy or arises later during fetal development. The aim of this study was to investigate the association between the maternal lipid profile in early pregnancy and embryonic size. Methods We included 1474 women from the Generation R Study, a population based prospective birth cohort. Both embryonic size and the maternal lipid profile were measured between 10 weeks + 1 day and 13 weeks + 6 days gestational age. The maternal lipid profile was defined as total cholesterol, triglycerides (TG), high-density lipoprotein cholesterol (HDL-c), low-density lipoprotein cholesterol (LDL-c), remnant cholesterol, non-high-density (non-HDL-c) lipoprotein cholesterol concentrations and the triglycerides/high-density lipoprotein (TG/HDL-c) ratio. Additionally, maternal glucose concentrations were assessed. Embryonic size was assessed using crown-rump length (CRL) measurements. Associations were studied with linear regression models, adjusted for confounding factors: maternal age, pre-pregnancy body mass index (BMI), parity, educational level, ethnicity, smoking and folic acid supplement use. Results Triglycerides and remnant cholesterol concentrations are positively associated with embryonic size (fully adjusted models, 0.17 SDS CRL: 95% CI 0.03; 0.30, and 0.17 SDS: 95% CI 0.04; 0.31 per 1 MoM increase, respectively). These associations were not present in women with normal weight (triglycerides and remnant cholesterol: fully adjusted model, 0.44 SDS: 95% CI 0.15; 0.72). Associations between maternal lipid concentrations and embryonic size were not attenuated after adjustment for glucose concentrations. Total cholesterol, HDL-c, LDL-c, non-HDL-c concentrations and the TG/HDL-c ratio were not associated with embryonic size. Conclusions Higher triglycerides and remnant cholesterol concentrations in early pregnancy are associated with increased embryonic size, most notably in overweight women. Trial registration The study protocol has been approved by the Medical Ethics Committee of the Erasmus University Medical Centre (Erasmus MC), Rotterdam (MEC-2007-413). Written informed consent was obtained from all participants.

Objectives In the Netherlands, all women are claimed to have equal access to prenatal screening (PS). Prior research demonstrated substantial inequalities in PS uptake associated with socioeconomic status (SES) and ethnic background. The suggested pathway was a lack of intention to participate in PS among these subgroups. We studied the background of inequalities in PS participation, challenging intention heterogeneity as the single explanation. Methods Multivariable logistic regression analyses of the national PS registry, focusing on the four largest cities in the Netherlands (n= 4578, years 2011-2013), stratified by SES. Outcome measures: 1.Any uptake of PS (yes/no) and 2. Uptake (one/two tests) for women who intended to participate in two tests. Determinants included intention, ethnicity, practice and age. Results Of non-Western women 85.7% were screened versus 89.7% of Western women. Intention was an important explanatory factor in all models. However, after correction for intention, ethnicity remained a significant determinant for differences in uptake. Ethnicity and SES also interacted, indicating that non-Western women in low SES areas had the lowest uptake (corrected for intention). Conclusions for Practice SES and ethnicity related inequalities in PS uptake are only partially explained by intention heterogeneity; other pathways, in particular provider-related determinants, may play a role.

Objective To evaluate the effect of a culturally competent educational film (CCEF) on informed decision making (IDM) regarding prenatal screening (PS) in a study population consisting of multicultural pregnant women. Methods A cross-sectional study with 262 women in the control group and 117 in the intervention group. All counselled participants received a self-report questionnaire to obtain data on IDM and only the intervention group received the CCEF. Twenty two percent of the study population had an ethnic minority background and 52% had a low or medium educational level. Results After exposure to the CCEF, knowledge about the Fetal Anomaly Scan (FAS) was significantly increased in ethnic minority women and in ‘medium’ and ‘highly’ educated women. Among women in the intervention group who had the intention to participate in FAS, there was an increase of 11% in IDM and a decrease of 12% in uninformed decision making. Conclusion CCEF leads to a significant increase in the level of knowledge in medium and highly educated groups as well as non-western ethnic minority groups. The increase in IDM among intentional participants in the FAS is promising as well. CCEF’s are a valuable complement to counseling about PS.

BackgroundLow-educated native Dutch and non-western minority women have inadequate access to obstetric care. Moreover, the care they receive lacks responsiveness to their needs and cultural competences. Gaining a deeper understanding of their experiences and satisfaction with antenatal, birthing and maternity care will help to adjust healthcare responsiveness to meet their needs during pregnancy, childbirth and the postpartum period.MethodsWe combined the World Health Organization conceptual framework of healthcare responsiveness with focus group research to measure satisfaction with antenatal, birthing and maternity care of women with a low-educated native Dutch and non-western ethnic background.ResultsFrom September 2011 until December 2013, 106 women were recruited for 20 focus group sessions. Eighty-five percent of the women had a non-western immigrant background and 89% a low or intermediate educational attainment. The study population was mostly positive about the provided care during the antenatal phase. They were less positive about the other two phases of care. Moreover, the obstetric healthcare systems' responsiveness in all phases of care (antenatal, birthing and maternity) did not meet these women's needs. The 'respect for persons' domains 'autonomy', 'communication' and 'dignity' and the 'client orientation' domain 'prompt attention' were judged most negatively.ConclusionsThe study findings give contextual meaning and starting points for improvement of responsiveness in the provision of obstetric care within a multi-ethnic women's population.

Objectives: in the Netherlands the perinatal mortality rate is high compared to other European countries. Around eighty percent of perinatal mortality cases is preceded by being small for gestational age (SGA), preterm birth and/or having a low Apgar-score at 5 minutes after birth. Current risk detection in pregnancy focusses primarily on medical risks. However, non-medical risk factors may be relevant too. Both non-medical and medical risk factors are incorporated in the Rotterdam Reproductive Risk Reduction (R4U) scorecard. We investigated the associations between R4U risk factors and preterm birth, SGA and a low Apgar score. Design: a prospective cohort study under routine practice conditions. Setting: six midwifery practices and two hospitals in Rotterdam, the Netherlands. Participants: 836 pregnant women. Interventions: the R4U scorecard was filled out at the booking visit. Measurements: after birth, the follow-up data on pregnancy outcomes were collected. Multivariate logistic regression was used to fit models for the prediction of any adverse outcome (preterm birth, SGA and/or a low Apgar score), stratified for ethnicity and socio-economic status (SES). Findings: factors predicting any adverse outcome for Western women were smoking during the first trimester and over-the-counter medication. For non-Western women risk factors were teenage pregnancy, advanced maternal age and an obstetric history of SGA. Risk factors for high SES women were low family income, no daily intake of vegetables and a history of preterm birth. For low SES women risk factors appeared to be low family income, non-Western ethnicity, smoking during the first trimester and a history of SGA. Key conclusions: the presence of both medical and non-medical risk factors early in pregnancy predict the occurrence of adverse outcomes at birth. Furthermore the risk profiles for adverse outcomes differed according to SES and ethnicity. Implications for practice: to optimise effective risk selection, both medical and non-medical risk factors should be taken into account in midwifery and obstetric care at the booking visit. (C) 2016 Published by Elsevier Ltd.

Objectives. This study aims to summarize evidence on the relation between neighborhood deprivation and the risks for preterm birth, small-for-gestational age, and stillbirth. Design. The design was a systematic review and meta-analysis. Main outcome measures. The main outcome measures included studies that directly compared the risk of living in the most deprived neighborhood quintile with least deprived quintile for at least one perinatal outcome of interest (preterm delivery, small-for-gestational age and stillbirth). Methods. Study selection was based on a search of Medline, Embase and Web of Science for articles published up to April 2012, reference list screening, and email contact with authors. Data on study characteristics, outcome measures, and quality were extracted by two independent investigators. Random-effects meta-analysis was performed to estimate unadjusted and adjusted summary odds ratios with the associated 95% confidence intervals. Results. We identified 2863 articles, of which 24 were included in a systematic review. A meta-analysis (n = 7 studies, including 2 579 032 pregnancies) assessed the risk of adverse perinatal outcomes by comparing the most deprived neighborhood quintile with the least deprived quintile. Compared with the least deprived quintile, odds ratios for adverse perinatal outcomes in the most deprived neighborhood quintile were significantly increased for preterm delivery (odds ratio 1.23, 95% confidence interval 1.18-1.28), small-for-gestational age (odds ratio 1.31, 95% confidence interval 1.28-1.34), and stillbirth (odds ratio 1.33, 95% confidence interval 1.21-1.45). Conclusions. Living in a deprived neighborhood is associated with preterm birth, small-for-gestational age and stillbirth.

Introduction Embryonic development is under the constant influence of the intrauterine environment. This environment is determined not only by genetic factors, but also by maternal health conditions. A strong association between hypertensive disorders (pre-eclampsia and pregnancy induced hypertension) and both intrauterine growth restriction and low birth weight have been described. However, these associations are mainly limited to second and third trimester foetal growth parameters and birth weight. The association between these hypertensive disorders of pregnancy and first trimester growth parameters have not been investigated yet. Objective/hypothesis In line with the findings on second and third trimester foetal growth, we hypothesize that embryonic (first trimester) growth is reduced in women with pregnancies complicated by hypertensive disorders. Methods Within a large population-based cohort in Rotterdam, The Netherlands, we assessed whether there is an association between maternal hypertensive disorders in pregnancy (both pregnancy induced hypertension and preeclampsia) and embryonic growth, defined as crown-rump-length (CRL) and embryonic volume (EV) using logistic regression analysis. Embryonic volume was measured using 3D ultrasound and virtual reality techniques, which enabled us to take this accurate parameter for embryonic growth into account. Results We included 1631 pregnancies in the analysis. In our first crude model, CRL has a statistically significant association with hypertensive disorders in pregnancy (p = 0.042). This accounts for a decrease of −0.22 SD CRL in women with a pregnancy complicated by a hypertensive disorder, compared to women without a hypertensive disorder. Discussion Our preliminary results suggest that embryonic (first trimester) growth is associated with hypertensive disorders in pregnancy. Additional analysis in which we adjust for confounding factors are currently being conducted. These will clarify the pathway through which embryonic growth is impaired. Moreover, the association with embryonic volume is being analysed, since this is a more accurate parameter for embryonic growth compared to the crown-rump-length.

Introduction Embryonic development is affected by multiple parental lifestyle factors and environmental exposures. Neighbourhood deprivation is associated with lower birth weight and higher preterm birth rates. However, the effects of living in a deprived neighbourhood on embryonic and foetal growth have not been explored yet. Hypothesis We hypothesized that living in a deprived neighbourhood is negatively associated with embryonic and foetal growth. Therefore, our objective was to assess the association between neighbourhood deprivation and embryonic and foetal growth parameters. Methods We evaluated the association between living in a deprived neighbourhood and embryonic and foetal growth parameters in 1614 mothers with a reliable first day of last menstrual period and a regular menstrual cycle. Foetal measurements included crown rump length (CRL), head circumference (HC), femur length (FL), biparietal diameter (BPD), abdominal circumference (AC) and estimated foetal weight (EFW). Results A total of 1614 pregnant women were included. Most were of Western ethnicity (70.7%) and nulliparous (59.0%). Almost every pregnancy was spontaneously conceived (95.7%). The score for neighbourhood deprivation is determined for all 4-digit zip codes and takes income, education and employment into account. A low score represents a deprived neighbourhood. Using linear mixed models, we found a statistically significant association between the neighbourhood deprivation score and FL (adjusted β −1.06 [95% CI: −1.98, −0.15]) and EFW (adjusted β −0.96 [95% CI: −1.89, −0.04]), but not with CRL, HC, AC and BPD. Discussion This population-based study shows that residing in a deprived neighbourhood is statistically associated with some, but not all, foetal growth parameters. Possibly, foetal growth parameters have different degrees of receptivity to external factors such neighbourhood deprivation. The effects we found remained above and beyond individual SES, for which we adjusted. This suggests a separate neighbourhood level effect on embryonic and foetal growth.

Objective To evaluate the implementation of a complex intervention in the antenatal healthcare field in 14 Dutch municipalities. The intervention consisted of the implementation of a systematic scorecard-based risk assessment in pregnancy, subsequent patient-tailored care pathways, and consultations of professionals from different medical and social disciplines. Methods Saunders's seven-step method was used for the development of a programme implementation monitoring plan, with specific attention to the setting and context of the programme. Data were triangulated from multiple sources, and prespecified criteria were applied to examine the evidence for implementation. Results Six out of 11 municipalities (54%) met the implementation criteria for the entire risk assessment programme, whereas three municipalities (27%) met the criteria if the three components of implementation were analysed separately. Conclusions A process evaluation of implementation of a complex intervention is possible. The results can be used to improve understanding of the associations between specific programme elements and programme outcomes on effectiveness of the intervention. Additionally, the results are important for formative purposes to assess how future implementation of antenatal risk assessment can be improved in comparable contexts.

Background: Coordination between the autonomous professional groups in midwifery and obstetrics is a key debate in the Netherlands. At the same time, it remains unclear what the current coordination challenges are. Methods: To examine coordination challenges that might present a barrier to delivering optimal care, we conducted a qualitative field study focusing on midwifery and obstetric professional's perception of coordination and on their routines. We undertook 40 interviews with 13 community midwives, 8 hospital-based midwives and 19 obstetricians (including two resident obstetricians), and conducted non-participatory observations at the worksite of these professional groups. Results: We identified challenges in terms of fragmented organizational structures, different perspectives on antenatal health and inadequate interprofessional communication. These challenges limited professionals' coordinating capacity and thereby decreased their ability to provide optimal care. We also found that pregnant women needed to compensate for suboptimal coordination between community midwives and secondary caregivers by taking on an active role in facilitating communication between these professionals. Conclusions: The communicative role that pregnant women play within coordination processes underlines the urgency to improve coordination. We recommend increasing multidisciplinary meetings and training, revising the financial reimbursement system, implementing a shared maternity notes system and decreasing the expertise gap between providers and clients. In the literature, communication by clients in support of coordination has been largely ignored. We suggest that studies include client communication as part of the coordination process. © 2014 Schölmerich et al.; licensee BioMed Central Ltd.

Background Relatively high perinatal mortality rates have led to a critical assessment of the organization of care in The Netherlands. Policy recommendations emphasize the need for improved coordination between community midwives and obstetric caregivers in hospitals. As such, coordination between the autonomous professional groups in midwifery and obstetrics has become a key debate. However, it remains unclear what the current coordination challenges are. This study focuses on community midwives’ and obstetric caregivers’ perception of coordination …

Background Pregnant women in deprived neighbourhoods experience more adverse perinatal and maternal outcomes. Higher prevalence of individual risk factors and environmental risks are at the base. Inequalities in health care provision may increase rather than reduce this disadvantage at onset. We investigated the presence of adverse perinatal health care inequalities according to neigh-bourhood deprivation. Methods A subset of care indicators was selected to judge relative undertreatment. These indicators covered different stages …

Relatively high perinatal mortality rates in the Netherlands have required a critical assessment of the national obstetric system. Policy evaluations emphasized the need for organizational improvement, in particular closer collaboration between community midwives and obstetric caregivers in hospitals. The leveled care system that is currently in place, in which professionals in midwifery and obstetrics work autonomously, does not fully meet the needs of pregnant women, especially women with an accumulation of non-medical risk factors. This article provides an overview of the advantages of greater interdisciplinary collaboration and the current policy developments in obstetric care in the Netherlands. In line with these developments we present a model for shared care embedded in local 'obstetric collaborations'. These collaborations are formed by obstetric caregivers of a single hospital and all surrounding community midwives. Through a broad literature search, practical elements from shared care approaches in other fields of medicine that would suit the Dutch obstetric system were selected. These elements, focusing on continuity of care, patient centeredness and interprofessional teamwork form a comprehensive model for a shared care approach. By means of this overview paper and the presented model, we add direction to the current policy debate on the development of obstetrics in the Netherlands. This model will be used as a starting point for the pilot-implementation of a shared care approach in the 'obstetric collaborations', using feedback from the field to further improve it. © Springer Science+Business Media New York 2012.