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Abstract Background Recent research within the context of Obstetrics shows the added value of patient participation in in-hospital patient safety. Notwithstanding these benefits, recent research within an Obstetrics department shows that four different negative effects of patient participation in patient safety have emerged. However, the approach to addressing these negative effects within the perspective of patient participation in patient safety is currently lacking. For this reason, the aim of this study is to generate an overview of actions that could be taken to mitigate the negative effects of patient participation in patient safety within an Obstetrics department. Methods This study was conducted in the Obstetrics Department of a tertiary academic center. An explorative qualitative interview study included sixteen interviews with professionals (N = 8) and patients (N = 8). The actions to mitigate the negative effects of patient participation in patient safety, were analyzed and classified using a deductive approach. Results Eighteen actions were identified that mitigated the negative effects of patient participation in patient safety within an Obstetrics department. These actions were categorized into five themes: ‘structure’, ‘culture’, ‘education’, ‘emotional’, and ‘physical and technology’. These five categories reflect the current approach to improving patient safety which is primarily viewed from the perspective of professionals rather than of patients. Conclusions Most of the identified actions are linked to changing the culture to generate more patient-centered care and change the current reality, which looks predominantly from the perspective of the professionals and too little from that of the patients. Furthermore, none of the suggested actions fit within a sixth anticipated category, namely, ‘politics’. Future research should explore ways to implement a patient-centered care approach based on these actions. By doing so, space, money and time have to be created to elaborate on these actions and integrate them into the organizations’ structure, culture and practices.

Objective Nurses’ and doctors’ health at work is crucial for their overall performance and the quality of care they provide. The Jobs Demands Resources (JD-R) model offers a framework for health at work, encompassing ‘job demands’, ‘job resources’, ‘personal resources’, ‘leadership’, ‘well-being’ and ‘outcomes’. While various instruments exist to measure health, an overview of instruments specifically designed for assessing nurses and doctors health is currently missing. This study provides a comprehensive overview of available health instruments specifically developed and validated for healthcare professionals in hospital care.Design Scoping review.Data sources MEDLINE, Embase and CINAHL.Eligibility criteria Studies assessing the health of nurses and/or doctors in hospitals using or evaluating instruments based on the JD-R model, published between January 2011 and January 2024, excluding student-exclusive samples.Data extraction and synthesis We extracted data on study and sample characteristics, as well as details of the measurement instruments, including main and subconstructs. Instruments were categorised based on the JD-R model domains. Descriptive analysis and data visualisation were performed using Excel and Python.Results We included 1204 studies, reporting 986 unique instruments. We identified 32 comprehensive instruments suitable for broad health screening, measuring four or more of the JD-R model domains. Additionally, we identified instruments focusing on specific domains for targeted screening needs. Furthermore, we present frequently reported instruments assumed to be extensively evaluated, user-friendly, accessible and available in multiple languages.Conclusions Health at work cannot be determined by a single instrument alone, underscoring the multidimensional nature of workplace health. Alternatively, organisations should select instruments based on domains most relevant and applicable to their context. This approach ensures a more comprehensive assessment of health at work.

Besides age, estrogen exposure plays a crucial role in changes in bone density (BD) in women. Premature ovarian insufficiency (POI) and polycystic ovary syndrome (PCOS) are conditions in reproductive-aged women in which the exposure to estrogen is substantially different. Women with a history of preeclampsia (P E) are expected to have normal estrogen exposure. Within the CREw IMAGO study, we investigated if trabecular BD is different in these women because of differences in the duration of estrogen exposure. Trabecular BD was measured in thoracic vertebrae on coronary CT scans. Women with a reduced estrogen exposure (POI) have a lower BD compared to women with an intermediate exposure (PE) (mean difference (MD) −26.8, 95% CI −37.2 to −16.3). Women with a prolonged estrogen exposure (PCOS) have the highest BD (MD 15.0, 95% CI 4.3–25.7). These results support the hypothesis that the duration of estrogen exposure in these women is associated with trabecular BD. Significance statement: Our results suggest that middle-aged women with PCOS have a higher BD and women with POI have a lower BD. We hypothesized that this is due to either a prolonged estrogen exposure, as seen in women with PCOS, or a reduced estrogen exposure, as in women with POI. In the counseling of women with reproductive disorders on long-term health issues, coronary CT provides a unique opportunity to assess both coronary artery calcium score for cardiovascular screening as w ell as trabecular BD.

Objectives To determine whether integrated maternity care is associated with reduced preterm births (PTB) and fewer small-for-gestational-age infants (SGA), and whether its implementation leads to a reduction of secondary care consultations.Design Retrospective study.Setting Integrated maternity care organisation in the southwestern region of the Netherlands.Participants All singleton pregnancies (≥24 weeks) within integrated maternity care organisation Annature between 2015 and 2020.Intervention Implementation of a shared maternity record in primary and secondary care.Methods Data of 20 818 women were derived from patient records and from the Netherlands Perinatal Registry. Intervention was the introduction of integrated maternity care in January 2018. Through multivariate logistic regression and segmented regression analysis we assessed the combined prevalence of SGA and PTB (SGA-PTB) before (2015–2017), and after the intervention (2018–2020). Regional rates were contrasted with nationwide rates (n=782 176).Main outcome measures SGA-PTB prevalence and mean number of secondary care consultations per pregnancy.Results SGA-PTB prevalence declined from 618/3443 (17.9%) in 2015 to 560/3501 (16.0%) in 2017 to 507/3459 (14.7%) in 2020 (p

Abstract Background In the transition towards value-based healthcare, patient-reported outcome and experience measures (PROM and PREM) are recommended by international collaborations and government programs to guide clinical practice and quality improvement. For many conditions, using PROM/PREM over the complete continuum of care requires implementation across care organizations and disciplines. Along PROM/PREM implementation in obstetric care networks (OCN), we aimed to evaluate implementation outcomes and the processes influencing these outcomes in the complex context of care networks across the continuum of perinatal care. Methods Three OCN in the Netherlands implemented PROM/PREM in routine practice, using an internationally developed outcomes set with care professionals and patient advocates. Their aim was to use PROM/PREM results individually to guide patient-specific care decisions and at group-level to improve quality of care. The implementation process was designed following the principles of action research: iteratively planning implementation, action, data generation and reflection to refine subsequent actions, involving both researchers and care professionals. During the one-year implementation period in each OCN, implementation outcomes and processes were evaluated in this mixed-methods study. Data generation (including observation, surveys and focus groups) and analysis were guided by two theoretical implementation frameworks: the Normalization Process Theory and Proctor’s taxonomy for implementation outcomes. Qualitative findings were supplemented with survey data to solidify findings in a broader group of care professionals. Results Care professionals in OCN found the use of PROM/PREM acceptable and appropriate, recognized their benefits and felt facilitated in their patient-centered goals and vision. However, feasibility for daily practice was low, mainly due to IT issues and time constraints. Hence PROM/PREM implementation did not sustain, but strategies for future PROM/PREM implementation were formulated in all OCN. Processes contributing positively to implementation outcomes were internalization (understand the value) and initiation (driven by key-participants), whereas challenges in relational integration (maintain confidence) and reconfiguration (refine activities) affected implementation negatively. Conclusion Although implementation did not sustain, network-broad PROM/PREM use in clinic and quality improvement matched professionals’ motivation. This study provides recommendations to implement PROM/PREM meaningfully in practice in ways that support professionals in their drive towards patient-centered care. In order for PROM/PREM to fulfill their potential for value-based healthcare, our work highlights the need for sustainable IT infrastructures, as well as an iterative approach to refine their complex implementation into local contexts.

Plain language summary High blood pressure (hypertension) in pregnancy can have severe complications for both mother and fetus including loss of life. The outcome of pregnancy for women who develop hypertension during pregnancy can be improved by ensuring optimal quality of care. In this study, we explored the opinions and experiences of women whose pregnancies were affected by hypertension concerning the care they received during their recent admission at different hospitals in Ghana and the challenges they faced. In four major referral hospitals in the Greater Accra Region of Ghana, we interviewed the women and had focus group discussions. Women who were pregnant for 26 weeks up to 34 weeks and had hypertension in pregnancy were invited for inclusion in the study. We conducted in-depth interviews with fifty women and three focus group discussions with 22 women. Most women who participated in the study were between 20 and 30 years old, Akans (ethnicity), married/cohabiting, self-employed and secondary school graduates. The women reported both positive and negative experiences of care during their admission at the hospitals. Examples of positive experiences were receiving good quality of care, satisfaction with care, and adequate counselling from the health workers. Examples of negative experiences were poor communication between the providers and affected women, inappropriate attitudes by the healthcare providers, and disrespectful treatment such as verbal and physical abuse. The major factors in the health system that influenced women’s experiences of care were lack of logistics, substandard professionalism, inefficient national health insurance system and long delays at health facilities prior to receiving treatment. The individual women’s factors that affected the quality of care included financial constraints, psychosocial stress and inadequate knowledge about hypertension during pregnancy. In conclusion, we determined that women with hypertension in pregnancy experience both positive and negative aspects of care and these may be due to challenges associated with the healthcare system, health providers and women themselves. There is the need to ensure optimal quality and respectful maternity care considering the nature of hypertension in pregnancy. These women require dedicated hospital staff with significant experience to improve the quality of care provided to women with hypertension in pregnancy.

BackgroundWell-being at work can be defined as “creating an environment to promote a state of contentment which allows an employee to flourish and achieve their full potential for the benefit of themselves and their organisation.” In the health care context, well-being at work of nurses and doctors is important for good patient care. Moreover, it is strongly associated with individual- and organization-level consequences. Relevant literature presents models and concepts of physical, mental, and social well-being. This study uses the 6 elements of the job demands-resources (JD-R) model to interpret well-being at work (job demands, job resources, personal resources, leadership, well-being, and outcomes) as part of a Netherlands Federation of University Medical Hospitals program to find ways to improve and monitor health care professionals’ well-being in Dutch hospitals. Many instruments exist to measure well-being at work in terms of population, setting, and other aspects. An overview of available and eligible instruments assessing and monitoring the well-being of nurses and doctors is currently missing. ObjectiveWe will perform a scoping review aiming to provide an overview of validated instruments assessing and monitoring the well-being of nurses and doctors at work. MethodsWe will perform a search of published literature in the following databases: Medline, Embase, and CINAHL. Studies will be eligible if they (1) assess well-being at work of nurses and doctors employed in hospitals; (2) describe an evaluation of an instrument or review an instrument; (3) measure well-being at work or aspects of well-being at work according to the elements of the JD-R model, and (4) were published in English from 2011 onwards. Title/abstract screening according to the eligibility criteria will be followed by full-text screening. Data extraction of included studies will be conducted by 3 reviewers independently. Reviewers will use standardized data extraction forms that include study characteristics, sample characteristics, measurement instrument details, and psychometric properties. The analysis will be descriptive. When synthesizing the data, a distinction will be made between comprehensive instruments and common instruments. ResultsThis scoping review identifies instruments that have been developed and validated for monitoring the well-being of nurses and doctors at work. Studies were searched between September and December 2021 and screened between December 2021 and May 2022. A total of 739 studies were included. ConclusionsTimely screening of well-being at work may be beneficial for individual health care workers, the organization, and patients. There is often a substantial gap and mismatch between employer perceptions of well-being and well-being interventions. It is important to develop and implement suitable interventions adapted to the needs of nurses and doctors and their health or other problems. Well-being screening should be timely to gain insight into these needs and problems. Moreover, to determine the effectiveness of well-being interventions, measurement is mandatory. The results will be critical for organizations to select a monitoring instrument that best fits the needs of employees and organizations. International Registered Report Identifier (IRRID)DERR1-10.2196/43692

AbstractThis study analyses the contribution of system-related factors to maternal mortality in the low-resource setting of Mnazi Mmoja Hospital in Zanzibar, Tanzania. It is a retrospective cohort study including all maternal deaths (MD, n = 139) and maternal near-misses (MNM, n = 122) in Mnazi Mmoja Hospital with sufficient documentation during 2015 to 2018 (MD) and 2017 to 2018 (MNM). The number of admissions and surgical interventions per health care provider on the day of admission and the number of times vital signs were monitored per day were compared between MNM and MD cases using logistic regression. The mean number of times vital signs were monitored per day was associated with reduced odds of mortality (aOR 0.75, 95% CI 0.64–0.89), after adjustment for confounding factors such as severity of illness. The numbers of admissions or surgical procedures per health care provider were not associated with mortality. Concluding, the degree of monitoring of patients with life-threatening complications of pregnancy or childbirth is associated with the risk of mortality independent of the degree of severity. Preventing maternal mortality requires going beyond availability of essential interventions to tackle system-related factors that have a direct impact on the capacity to provide comprehensive care.Impact StatementWhat is already known on this subject? Root cause analyses of maternal deaths have identified many system-related factors, such as availability of health care providers, adequate training, and motivation to sustain high intensity monitoring (Madzimbamuto et al. 2014; Mahmood et al. 2018).What do the results of this study add? This is the first study to attempt to quantify the contribution of these system-related factors by comparing cases of maternal death with cases of maternal near-miss. We show that the degree of monitoring of patients with life-threatening complications is associated with the odds of mortality independent of the degree of severity. Even though this relation should not be regarded as causative, monitoring of vital signs can be seen as reflective of many system-related factors which hamper or facilitate comprehensive care.What are the implications of these findings for clinical practice and/or further research? This study helps increase general understanding of the factors leading to progression from severe disease to death in a high-volume low-income setting.

IntroductionIn recent years, Value-Based Healthcare (VBHC) has been gaining traction, particularly in hospitals. A core VBHC element is patient value, i.e., what matters most to the patient and at what cost can this be delivered. This interpretation of value implies patient engagement in patient–doctor communication. Although patient engagement in direct care in the VBHC setting is well described, patient engagement at the organizational level of improving care has hardly been studied. This systematic review maps current knowledge regarding the intensity and impact of patient engagement in VBHC initiatives. We focus on the organizational level of a continuous patient engagement model.MethodsWe performed a systematic review following PRISMA guidelines using five electronic databases. The search strategy yielded 1,546 records, of which 21 studies were eligible for inclusion. Search terms were VBHC and patient engagement, or similar keywords, and we included only empirical studies in hospitals or transmural settings at the organizational level.ResultsWe found that consultation, using either questionnaires or interviews by researchers, is the most common method to involve patients in VBHC. Higher levels of patient engagement, such as advisory roles, co-design, or collaborative teams are rare. We found no examples of the highest level of patient engagement such as patients co-leading care improvement committees.ConclusionThis study included 21 articles, the majority of which were observational, resulting in a limited quality of evidence. Our review shows that patient engagement at the organizational level in VBHC initiatives still relies on low engagement tools such as questionnaires and interviews. Higher-level engagement tools such as advisory roles and collaborative teams are rarely used. Higher-level engagement offers opportunities to improve healthcare and care pathways through co-design with the people being served. We urge VBHC initiatives to embrace all levels of patient engagement to ensure that patient values find their way to the heart of these initiatives.

BACKGROUND: Severe maternal morbidity has been shown to have specific, long-term effects on health and wellbeing, such as daily functioning and mental health. OBJECTIVE: This study aimed to multidimensionally assess the long-term impact of maternal near-miss complications in Zanzibar. STUDY DESIGN: A prospective cohort study was conducted in Zanzibar's referral hospital. Women with maternal near-miss complications were matched with controls. At 3, 6, and 12 months after hospital discharge, history was taken, blood pressure and haemoglobin levels were measured, and multiple validated questionnaires (WHOQOL-BREF, WHODAS2.0, Patient Health Questionnaire-9, Harvard Trauma Questionnaire-16) were administered assessing experienced quality of life and disability, and screening for depression and posttraumatic stress disorder. RESULTS: We included 223 women after maternal near-miss complications and 213 women controls. There was a high prevalence of hypertension at 6 and 12 months in both groups and significantly higher after a near-miss. The proportion of women with low quality of life, disability, depression, or posttraumatic stress disorder was not significantly different between the 2 groups. A poor outcome for at least 1 of these 3 health domains was more prevalent after a near-miss complication. CONCLUSION: In Zanzibar, women after maternal near-miss complications report similar but slower recovery to control participants in the assessed dimensions. Adaptation of perceptions on and coping mechanisms with daily reality might partly explain this. Hypertension has a high prevalence after childbirth and should be treated adequately to prevent recurrent obstetrical and cardiovascular complications. Blood pressure follow-up for all women who delivered at Mnazi Mmoja Hospital seemed justified.

Abstract Background Unhealthy prenatal lifestyle behaviours are associated with adverse pregnancy outcomes, but little is known about what motivates women to comply with preconceptional lifestyle recommendations or consciously plan their pregnancy. Therefore, the objective of this study is to explore the associations between preconceptional lifestyle behaviours, health beliefs and pregnancy planning among Dutch pregnant women. Methods In this cross-sectional study based on the data of the APROPOS-II study, 1,077 low-risk pregnant women were eligible for inclusion. Preconception lifestyle behaviours and actively preparing for pregnancy were assessed in relation to planned pregnancies (based on the London Measure of Unplanned Pregnancies) and health beliefs (14 statements). The following preconceptional lifestyle behaviours were assessed through a self-administered questionnaire in the first trimester of pregnancy: fruit intake, vegetable intake, caffeine intake, (second-hand)smoking, alcohol intake, folic acid supplement use and exercise. Data were analysed using multivariate logistic regression analyses. Results A total of 921 (85.5%) women in our cohort had a planned pregnancy. However, of these women, 640 (69.5%) adequately used folic acid supplements and 465 (50.5%) women consumed alcohol at any point during pregnancy. Of the women considering themselves ‘healthy enough and not needing preconception care’, 48 (9.1%) women had an adequate vegetable intake, 294 (55.6%) women consumed alcohol at any point during pregnancy and 161 (30.4%) women were either over-or underweight. Conclusion Despite consciously planning their pregnancy, most women did not adhere to preconceptional lifestyle behaviour recommendations. Women’s health beliefs and overestimation of their health status seem to interfere with actively planning and preparing for pregnancy. Findings from our study may encourage the development of prospective health-promoting interventions that focus on health beliefs and actively preparing for pregnancy, to improve preconceptional lifestyle behaviours, thereby optimizing the health of future generations.

Abstract Objective To determine the prevalence of incidental findings (IFs) on coronary computed tomography (CCT) in women aged 45–55 years and previously diagnosed with reproductive disorders such as polycystic ovary syndrome (PCOS), premature ovarian insufficiency (POI) or preeclampsia (PE). Methods A total of 486 middle-aged women with PCOS (n = 101), POI (n = 97) or a history of PE (n = 288) underwent a CCT as part of a prior prospective study. IFs were categorized by their significance (minor, moderate and major). Follow-up information was collected from patients’ records. To investigate the impact of different field of views (FOVs), a subset of scans was analyzed in full FOV and small FOV. Results In 96/486 (19.8%) women, one or more IFs were detected, of which 54/486 (11.1%) were classified as moderate/major and 48/486 (9.9%) required follow-up. A moderate/major IF was detected in 16/101 (15.9%) women with PCOS, 13/97 (13.4%) women with POI and 25/288 (8.7%) women with a history of PE. In 78 women with an IF detected in the full FOV, the IF was still visible in 60 (76.9%) women in the small FOV. In the full FOV, 46 women required follow-up, but using the small FOV this was reduced to 30 women. Conclusion Using CCT as a cardiovascular disease screening tool in women with selected reproductive disorders increases the probability of detecting IFs that can cause anxiety and may generate extra costs, but can also reveal clinically relevant findings. Using a small FOV centered around the heart resulted in a lower prevalence of IFs and required less follow-up.

Abstract Objective To identify neonatal risk for severe adverse perinatal outcomes across birth weight centiles in two Dutch and one international birth weight chart. Background Growth restricted newborns have not reached their intrinsic growth potential in utero and are at risk of perinatal morbidity and mortality. There is no golden standard for the confirmation of the diagnosis of fetal growth restriction after birth. Estimated fetal weight and birth weight below the 10th percentile are generally used as proxy for growth restriction. The choice of birth weight chart influences the specific cut-off by which birth weight is defined as abnormal, thereby triggering clinical management. Ideally, this cut-off should discriminate appropriately between newborns at low and at high risk of severe adverse perinatal outcomes and consequently correctly inform clinical management. Methods This is a secondary analysis of the IUGR Risk Selection (IRIS) study. Newborns (n = 12 953) of women with a low-risk status at the start of pregnancy and that received primary antenatal care in the Netherlands were included. We examined the distribution of severe adverse perinatal outcomes across birth weight centiles for three birth weight charts (Visser, Hoftiezer and INTERGROWTH) by categorizing birth weight centile groups and comparing the prognostic performance for severe adverse perinatal outcomes. Severe adverse perinatal outcomes were defined as a composite of one or more of the following: perinatal death, Apgar score

Objectives To gain insight into the experiences of women with completing and discussing patient-reported outcome measures (PROM) and patient-reported experience measures (PREM), and tailoring their care based on their outcomes.Design A mixed-methods prospective cohort study.Setting Seven obstetric care networks in the Netherlands that implemented a set of patient-centred outcome measures for pregnancy and childbirth (PCB set), published by the International Consortium for Health Outcomes Measurement.Participants All women, receiving the PROM and PREM questionnaires as part of their routine perinatal care, received an invitation for a survey (n=460) and an interview (n=16). The results of the survey were analysed using descriptive statistics; thematic inductive content analysis was applied on the data from open text answers and the interviews.Results More than half of the survey participants (n=255) felt the need to discuss the outcomes of PROM and PREM with their care professionals. The time spent on completing questionnaires and the comprehensiveness of the questions was scored ‘good’ by most of the survey participants. From the interviews, four main themes were identified: content of the PROM and PREM questionnaires, application of these outcomes in perinatal care, discussing PREM and data capture tool. Important facilitators included awareness of health status, receiving personalised care based on their outcomes and the relevance of discussing PREM 6 months post partum. Barriers were found in insufficient information about the goal of PROM and PREM for individual care, technical problems in data capture tools and discrepancy between the questionnaire topics and the care pathway.Conclusions This study showed that women found the PCB set an acceptable and useful instrument for symptom detection and personalised care up until 6 months post partum. This patient evaluation of the PCB set has several implications for practice regarding the questionnaire content, role of care professionals and congruity with care pathways.

Background Patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) can highlight issues that remain unnoticed when using standard clinical quality indicators. However, estimations of the potential power of measuring PROMs and PREMs to identify unrecognised areas suitable for quality improvement are often limited by a lack of reliable real-world data. Here, we report on how the indicator set for PROMs and PREMs that was recently developed by the International Consortium for Health Outcome Measures can change perspectives on quality assessment in women receiving care for pregnancy and childbirth.Methods PROMs and PREMs were captured 6 months after childbirth via an online survey in a single academic maternity unit in the Netherlands between 2018 and 2019. Indicators of abnormality were scored using predefined cut-off values established by a national consensus group. We used regression analysis to identify associations between PROMs, PREMs and healthcare use, and further stratified data to explore the distribution of indicators among relevant patient subgroups.Results Of 2775 questionnaires, 645 were completed and linked to medical health records. Despite only 5% of women reporting overall dissatisfaction with care, suboptimal scores were often found; in birth experience for 32% of the population, and 42% who experienced painful sexual intercourse. Subgroup analysis further revealed associations with relevant indicators of quality of care; inadequate pain relief among women with preterm birth (OR 8.8), pain with sexual intercourse among women undergoing vaginal assisted delivery (OR 2.2) and women living in a deprived area had problematic birth experiences (coefficient −3.2).Conclusion Use of PROMs and PREMs in pregnancy and childbirth care provides new insights on quality of care, resulting in potentially actionable targets for improvement not normally identified with standard clinical quality indicators. Implementation strategies and follow-up are needed to act on these findings.

Introduction: An important aspect of Value-Based Healthcare (VBHC) is providing the full cycle of care for a specific medical condition through interprofessional collaboration. This requires employees from diverse professional backgrounds to interact, but there is limited knowledge on how professionals perceive such interprofessional collaboration. We aimed to provide insight into how different professionals perceive Integrated Practice Unit (IPU) composition and what factors influence the quality of interprofessional collaboration within IPUs. Methods: A survey was administered to employees from different professional backgrounds (medical specialists, nurses, allied health professionals, administrative employees) working in IPUs to assess their perception of the composition of their IPU and the quality of the interactions. Subsequently, semi-structured interviews were conducted to gain a deeper understanding of the findings of the survey. Results: Medical specialists and nurses were most frequently considered to be part of an IPU and indicated that they have high quality interactions. Allied health professionals were less often considered part of the team by all other professional groups and all report low quality interaction with this group. The extent to which a professional group is perceived as a team member depends on their visibility, involvement in the treatment of the patient, and shared interest. Differences in the quality of interprofessional collaboration are influenced by organizational structures, knowledge of each other’s expertise, and by ways of communication. Conclusions: In VBHC, there seems to be a lack of common perception of an IPU’s composition and a failure to always achieve high quality interprofessional collaboration. Given the importance of interprofessional collaboration in VBHC, effort should be invested in achieving a shared understanding and improved collaboration.

Abstract Background While the potential adverse outcomes of prenatal exposure to unhealthy lifestyle are widely evidenced, little is known about these exposures in the periconception period. We investigated the associations between lifestyle behaviours and adverse pregnancy outcomes with a unique distinction between preconceptional- and prenatal lifestyle behaviours. Methods A secondary analysis took place within a prospective multicentre cohort study in the Netherlands, including 3,684 pregnant women. Baseline characteristics and preconceptional and first trimester lifestyle behaviours were assessed through a self-administered questionnaire in the first trimester. Adverse pregnancy outcomes (hypertensive disorders in pregnancy (HDP), small for gestational age (SGA), gestational diabetes (GDM) and spontaneous preterm birth (sPTB)) were reported by healthcare professionals. Data were collected between 2012 and 2014 and analysed using multivariate logistic regression. Results Women who are overweight, and especially obese, have the highest odds of developing any adverse pregnancy outcome (adjusted odds ratio (aOR) 1.61 (95 % Confidence Interval (CI) 1.31–1.99) and aOR 2.85 (95 %CI 2.20–3.68), respectively), particularly HDP and GDM. Women who prenatally continued smoking attained higher odds for SGA (aOR 1.91 (95 %CI 1.05–1.15)) compared to the reference group, but these odds decreased when women prenatally quit smoking (aOR 1.14 (95 %CI 0.59–2.21)). Women who did not use folic acid supplements tended to have a higher odds of developing adverse pregnancy outcomes (aOR 1.28 (95 %CI 0.97–1.69)), while women who prenatally started folic acid supplements did not (aOR 1.01 (95 %CI 0.82–1.25)). Conclusions Our results indicate that smoking cessation, having a normal body mass index (BMI) and initiating folic acid supplements preconceptionally may decrease the risk of adverse pregnancy outcomes. Therefore, intervening as early as the preconception period could benefit the health of future generations.

Abstract Background To evaluate the indications for admission and mortality rates of women of reproductive age admitted to a tertiary Intensive Care Unit (ICU) and to compare the outcomes of obstetric and non-obstetric admissions. Methods A retrospective cohort study was performed, including all women aged 17–41 years admitted to a level 3 ICU in the Netherlands, between January 1, 2000 and January 1, 2016. Primary outcome was indication for admission and mortality. Mortality, length of stay (LOS), need for mechanical ventilation and APACHE II score were compared between obstetric and non-obstetric admissions. The obstetric group was further analyzed for maternal and perinatal outcomes. Results 3461 women (median age 32 years) were included, with an overall mortality rate of 13.3%. The obstetric group consisted of 265 women (7.7%). The non-obstetric group (n = 3196) was admitted most often for cardiovascular disease (19.6%), followed by oncologic disease (15%). Mortality was the highest in women with oncologic disease (23.9%). The obstetric group had lower mortality compared to the non-obstetric group (4.9% vs. 14%, p

Abstract Background Worldwide, hypertensive disorders in pregnancy (HDPs) complicate between 5 and 10% of pregnancies. Sub-Saharan Africa (SSA) is disproportionately affected by a high burden of HDPs and chronic kidney disease (CKD). Despite mounting evidence associating HDPs with the development of CKD, data from SSA are scarce. Methods Women with HDPs (n = 410) and normotensive women (n = 78) were recruited at delivery and prospectively followed-up at 9 weeks, 6 months and 1 year postpartum. Serum creatinine was measured at all time points and the estimated glomerular filtration rates (eGFR) using CKD-Epidemiology equation determined. CKD was defined as decreased eGFR

Introduction: Patient-reported outcome and experience measures (PROM and PREM) are used to guide individual care and quality improvement (QI). QI with patient-reported data is preferably organized around patients, which is challenging across organisations. We aimed to investigate network-broad learning for QI with outcome data. Methods: In three obstetric care networks using individual-level PROM/PREM, a learning strategy for cyclic QI based on aggregated outcome data was developed, implemented and evaluated. The strategy included clinical, patient-reported, and professional-reported data; together translated into cases for interprofessional discussion. This study’s data generation (including focus groups, surveys, observations) and analysis were guided by a theoretical model for network collaboration. Results: The learning sessions identified opportunities and actions to improve quality and continuity of perinatal care. Professionals valued the data (especially patient-reported) combined with in-dept interprofessional discussion. Main challenges were professionals’ time constraints, data infrastructure, and embedding improvement actions. Network-readiness for QI depended on trustful collaboration through connectivity and consensual leadership. Joint QI required information exchange and support including time and resources. Conclusions: Current fragmented healthcare organization poses barriers for network-broad QI with outcome data, but also offers opportunities for learning strategies. Furthermore, joint learning could improve collaboration to catalyse the journey towards integrated, value-based care.

Abstract Background Improvement in the accuracy of identifying women who are at risk to develop gestational diabetes mellitus (GDM) is warranted, since timely diagnosis and treatment improves the outcomes of this common pregnancy disorder. Although prognostic models for GDM are externally validated and outperform current risk factor based selective approaches, there is little known about the impact of such models in day-to-day obstetric care. Methods A prognostic model was implemented as a directive clinical prediction rule, classifying women as low- or high-risk for GDM, with subsequent distinctive care pathways including selective midpregnancy testing for GDM in high-risk women in a prospective multicenter birth cohort comprising 1073 pregnant women without pre-existing diabetes and 60 obstetric healthcare professionals included in nine independent midwifery practices and three hospitals in the Netherlands (effectiveness-implementation hybrid type 2 study). Model performance (c-statistic) and implementation outcomes (acceptability, adoption, appropriateness, feasibility, fidelity, penetration, sustainability) were evaluated after 6 months by indicators and implementation instruments (NoMAD; MIDI). Results The adherence to the prognostic model (c-statistic 0.85 (95%CI 0.81–0.90)) was 95% (n = 1021). Healthcare professionals scored 3.7 (IQR 3.3–4.0) on implementation instruments on a 5-point Likert scale. Important facilitators were knowledge, willingness and confidence to use the model, client cooperation and opportunities for reconfiguration. Identified barriers mostly related to operational and organizational issues. Regardless of risk-status, pregnant women appreciated first-trimester information on GDM risk-status and lifestyle advice to achieve risk reduction, respectively 89% (n = 556) and 90% (n = 564)). Conclusions The prognostic model was successfully implemented and well received by healthcare professionals and pregnant women. Prognostic models should be recommended for adoption in guidelines.

Abstract Background To improve their quality, healthcare systems are increasingly focused on value delivered to patients. For perinatal care, the International Consortium for Health Outcomes Measurement (ICHOM) proposed a patient-centred outcome set with both clinical and patient-reported measures for pregnancy and childbirth (PCB set). This study aimed to identify factors that affect the implementation of the PCB set at the pre-implementation stage, using the consolidated framework for implementation research (CFIR). Methods In this qualitative study, we conducted semi-structured interviews amongst a purposive sample of key stakeholders within an obstetric care network (OCN): 1) patients, 2) perinatal care professionals involved in the full cycle of perinatal care, and 3) policy makers, including hospital managers, administrative staff and health care insurers. While the CFIR guided data capture and structuring, thematic analysis revealed overarching themes that best reflected the barriers and facilitators from different stakeholder perspectives. Within these overarching themes, the CFIR constructs were maintained. Results Interviews were conducted with 6 patients, 16 professionals and 5 policy makers. Thematic analysis supported by the CFIR framework identified four main themes: the instrument and its implementation process, use in individual patient care, use in quality improvement, and the context of the OCN. Important barriers included professional workload, data reliability, and interprofessional and interorganizational collaboration. Potential facilitators were the PCB set’s direct value in individual care, interprofessional feedback and education, and aligning with existing systems. Prominent variations between stakeholder groups included the expected patient burden, the level of use, transparency of outcomes and the degree of integrated care. Conclusions This study clarified critical factors that affect successful implementation of the PCB set in perinatal care. Practice recommendations, suggested at multiple levels, can enable structural patient-centred care improvement and may unite stakeholders towards integrated birth care.

BackgroundThe International Consortium for Health Outcomes Measurement has published a set of patient-centered outcome measures for pregnancy and childbirth (PCB set), including patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs). To establish value-based pregnancy and childbirth care, the PCB set was implemented in the Netherlands, using the outcomes on the patient level for shared decision-making and on an aggregated level for quality improvement. ObjectiveThis study aims to report first outcomes, experiences, and practice insights of implementing the PCB set in clinical practice. MethodsIn total, 7 obstetric care networks across the Netherlands, each consisting of 1 or 2 hospitals and multiple community midwifery practices (ranging in number from 2 to 18), implemented the PROM and PREM domains of the PCB set as part of clinical routine. This observational study included all women participating in the clinical project. PROMs and PREMs were assessed with questionnaires at 5 time points: 2 during pregnancy and 3 post partum. Clinical threshold values (alerts) supported care professionals interpreting the answers, indicating possibly alarming outcomes per domain. Data collection took place from February 2020 to September 2021. Data analysis included missing (pattern) analysis, sum scores, alert rates, and sensitivity analysis. ResultsIn total, 1923 questionnaires were collected across the 5 time points: 816 (42.43%) at T1 (first trimester), 793 (41.23%) at T2 (early third trimester), 125 (6.5%) at T3 (maternity week), 170 (8.84%) at T4 (6 weeks post partum), and 19 (1%) at T5 (6 months post partum). Of these, 84% (1615/1923) were filled out completely. Missing items per domain ranged from 0% to 13%, with the highest missing rates for depression, pain with intercourse, and experience with pain relief at birth. No notable missing patterns were found. For the PROM domains, relatively high alert rates were found both in pregnancy and post partum for incontinence (469/1798, 26.08%), pain with intercourse (229/1005, 22.79%), breastfeeding self-efficacy (175/765, 22.88%), and mother-child bonding (122/288, 42.36%). Regarding the PREM domains, the highest alert rates were found for birth experience (37/170, 21.76%), shared decision-making (101/982, 10.29%), and discussing pain relief ante partum (310/793, 39.09%). Some domains showed very little clinical variation; for example, role of the mother and satisfaction with care. ConclusionsThe PCB set is a useful tool to assess patient-reported outcomes and experiences that need to be addressed over the whole course of pregnancy and childbirth. Our results provide opportunities to improve and personalize perinatal care. Furthermore, we could propose several recommendations regarding methods and timeline of measurements based on our findings. This study supports the implementation of the PCB set in clinical practice, thereby advancing the transformation toward patient-centered, value-based health care for pregnancy and childbirth.

Abstract Background This study aims to explore the stories of three women from Zanzibar, Tanzania, who survived life-threatening obstetric complications. Their narratives will increase understanding of the individual and community-level burden masked behind the statistics of maternal morbidity and mortality in Tanzania. In line with a recent systematic review of women-centred, qualitative maternal morbidity research, this study will contribute to guidance of local and global maternal health agendas. Methods This two-phased qualitative study was conducted in July-August 2017 and July-August 2018, and involved three key informants, who were recruited from a maternal near-miss cohort in May 2017 in Mnazi Mmoja Hospital, Zanzibar. The used methods were participant observation, interviews (informal, unstructured and semi-structured), participatory methods and focus group discussions. Data analysis relied primarily on grounded theory, leading to a theoretical model, which was validated repeatedly by the informants and within the study team. The findings were then positioned in the existing literature. Approval was granted by Zanzibar’s Medical Ethical Research Committee (reference number: ZAMREC/0002/JUN/17). Results The impact of severe maternal morbidity was found to be multi-dimensional and to extend beyond hospital discharge and thus institutionalized care. Four key areas impacted by maternal morbidities emerged, namely (1) social, (2) sexual and reproductive, (3) psychological, and (4) economic well-being. Conclusions This study showed how three women’s lives and livelihoods were profoundly impacted by the severe obstetric complications they had survived, even up to 16 months later. These impacts took a toll on their physical, social, economic, sexual and psychological well-being, and affected family and community members alike. These findings advocate for a holistic, dignified, patient value-based approach to the necessary improvement of maternal health care in low-income settings. Furthermore, it emphasizes the need for strategies to be directed not only towards quality of care during pregnancy and delivery, but also towards support after obstetric complications.

Abstract Background The majority of the world’s perinatal deaths occur in low- and middle-income countries. A substantial proportion occurs intrapartum and is avoidable with better care. At a low-resource tertiary hospital, this study assessed the quality of intrapartum care and adherence to locally-tailored clinical guidelines. Methods A non-participatory, structured, direct observation study was held at Mnazi Mmoja Hospital, Zanzibar, Tanzania, between October and November 2016. Women in active labour were followed and structure, processes of labour care and outcomes of care systematically recorded. Descriptive analyses were performed on the labour observations and compared to local guidelines and supplemented by qualitative findings. A Poisson regression analysis assessed factors affecting foetal heart rate monitoring (FHRM) guidelines adherence. Results 161 labouring women were observed. The nurse/midwife-to-labouring-women ratio of 1:4, resulted in doctors providing a significant part of intrapartum monitoring. Care during labour and two-thirds of deliveries was provided in a one-room labour ward with shared beds. Screening for privacy and communication of examination findings were done in 50 and 34%, respectively. For the majority, there was delayed recognition of labour progress and insufficient support in second stage of labour. While FHRM was generally performed suboptimally with a median interval of 105 (interquartile range 57–160) minutes, occurrence of an intrapartum risk event (non-reassuring FHR, oxytocin use or poor progress) increased assessment frequency significantly (rate ratio 1.32 (CI 1.09–1.58)). Conclusions Neither international nor locally-adapted standards of intrapartum routine care were optimally achieved. This was most likely due to a grossly inadequate capacity of birth attendants; without whom innovative interventions at birth are unlikely to succeed. This calls for international and local stakeholders to address the root causes of unsafe intrafacility care in low-resource settings, including the number of skilled birth attendants required for safe and respectful births.

Abstract Background In a previous feasibility study (APROPOS) in a single municipality of the Netherlands, we showed that a locally tailored preconception care (PCC) approach has the potential to positively affect preconceptional lifestyle behaviours. Therefore, we designed a second study (APROPOS-II) to obtain a more robust body of evidence: a larger group of respondents, more municipalities, randomization, and a more comprehensive set of (clinical) outcomes. The aim of this study is to assess the effectiveness and the implementation process of a local PCC-approach on preconceptional lifestyle behaviours, health outcomes and the reach of PCC among prospective parents and healthcare providers. Methods This study is an effectiveness-implementation hybrid type 2 trial. This involves a stepped-wedge cluster randomized controlled trial design aiming to include over 2000 future parents from six municipalities in the Netherlands. The intervention has a dual-track approach, focusing on both the uptake of PCC among future parents and the provision of PCC by healthcare providers. The PCC-approach consists of 1) a social marketing strategy directed towards prospective parent(s) and 2) a local care pathway to improve interdisciplinary collaboration. Data will be collected before and after the introduction of the intervention through questionnaires and medical records in each of the participating municipalities. The primary outcome of this study is change in lifestyle behaviours (e.g. folic acid use, smoking and alcohol use). Secondary outcomes are pregnancy outcomes (e.g. miscarriage, preterm birth, gestational diabetes) and the uptake of PCC. Moreover, a process evaluation will be performed, providing information on the efficacy, feasibility, barriers and facilitators regarding the implementation of the intervention. Discussion The APROPOS-II study introduces a locally tailored PCC-approach in six municipalities in the Netherlands that will contribute to the body of evidence regarding the effectiveness of PCC and its implementation. If this intervention has a positive effect on lifestyle behaviour changes, leading to improved pregnancy outcomes and the future health of prospective parents and their offspring, it could subsequently be upscaled to (inter)national implementation. Trial registration Dutch Trial register: NL7784 (Registered June 6th, 2019).

Summary: Background: Most pregnancy-related deaths in low and middle income countries occur around the time of birth and are avoidable with timely care. This study aimed to develop a prognostic model to identify women at risk of intrapartum-related perinatal deaths in low-resourced settings, by (1) external validation of an existing prediction model, and subsequently (2) development of a novel model. Methods: A prospective cohort study was conducted among pregnant women who presented consecutively for delivery at the maternity unit of Zanzibar's tertiary hospital, Mnazi Mmoja Hospital, the Republic of Tanzania between October 2017 and May 2018. Candidate predictors of perinatal deaths included maternal and foetal characteristics obtained from routine history and physical examination at the time of admission to the labour ward. The outcomes were intrapartum stillbirths and neonatal death before hospital discharge. An existing stillbirth prediction model with six predictors from Nigeria was applied to the Zanzibar cohort to assess its discrimination and calibration performance. Subsequently, a new prediction model was developed using multivariable logistic regression. Model performance was evaluated through internal validation and corrected for overfitting using bootstrapping methods. Findings: 5747 mother-baby pairs were analysed. The existing model showed poor discrimination performance (c-statistic 0·57). The new model included 15 clinical predictors and showed promising discriminative and calibration performance after internal validation (optimism adjusted c-statistic of 0·78, optimism adjusted calibration slope =0·94). Interpretation: The new model consisted of predictors easily obtained through history-taking and physical examination at the time of admission to the labour ward. It had good performance in predicting risk of perinatal death in women admitted in labour wards. Therefore, it has the potential to assist skilled birth attendance to triage women for appropriate management during labour. Before routine implementation, external validation and usefulness should be determined in future studies. Funding: The study received funding from Laerdal Foundation, Otto Kranendonk Fund and UMC Global Health Fellowship. TD acknowledges financial support from the Netherlands Organisation for Health Research and Development (grant 91617050).

Hypertensive disorders in pregnancy (HDP) and cardiometabolic and kidney diseases are rising in low- and middle-income countries (LMICs). While HDP are risk factors for cardiometabolic and kidney diseases, cost-effective, scalable strategies for screening and prevention in women with a history of HDP are lacking. Existing guidelines and recommendations require adaptation to LMIC settings. This article aims to generate consensus-based recommendations for the prevention and screening of cardiometabolic and kidney diseases tailored for implementation in LMICs. We conducted a systematic review of guidelines and recommendations for prevention and screening strategies for cardiometabolic and chronic kidney diseases following HDP. We searched PubMed/Medline, Embase and Cochrane Library for relevant articles and guidelines published from 2010 to 2021 from both high-income countries (HICs) and LMICs. No other filters were applied. References of included articles were also assessed for eligibility. Findings were synthesized narratively. The summary of guiding recommendations was subjected to two rounds of Delphi consensus surveys with experts experienced in LMIC settings. Fifty-four articles and 9 guidelines were identified, of which 25 were included. Thirty-five clinical recommendations were synthesized from these and classified into six domains: identification of women with HDP (4 recommendations), timing of first counseling and provision of health education (2 recommendations), structure and care setting (12 recommendations), information and communication needs (5 recommendations), cardiometabolic biomarkers (8 recommendations) and biomarkers thresholds (4 recommendations). The Delphi panel reached consensus on 33 final recommendations. These recommendations for health workers in LMICs provide practical and scalable approaches for effective screening and prevention of cardiometabolic disease following HDP. Monitoring and evaluation of implementation of these recommendations provide opportunities for reducing the escalating burden of noncommunicable diseases in LMICs.

Background: Hypertensive disorders in pregnancy (HDPs) are associated with lifelong cardiovascular disease risk. Persistent postpartum hypertension in HDPs could suggest progression to chronic hypertension. This phenomenon has not been well examined in low- and middle-income countries (LIMCs), and most previous follow-ups typically last for maximally six weeks postpartum. We assessed the prevalence of persistent hypertension up to one year in women with HDPs in a low resource setting and determined associated risk factors. Methodology: A prospective cohort study of women conducted at eight tertiary health care facilities in seven states of Nigeria. Four hundred and ten women with any HDP were enrolled within 24 hours of delivery and followed up at intervals until one year postpartum. Descriptive statistics were performed to express the participants’ characteristics. Univariable and multivariable logistic regressions were conducted to identify associated risk factors. Results: Of the 410 women enrolled, 278 were followed up to one year after delivery (follow-up rate 68%). Among women diagnosed with gestational hypertension and pre-eclampsia/eclampsia, 22.3% (95% CI; 8.3–36.3) and 62.1% (95% CI; 52.5–71.9), respectively, had persistent hypertension at six months and this remained similar at one year 22.3% (95% CI; 5.6–54.4) and 61.2% (95% CI; 40.6–77.8). Maternal age and body mass index were significant risk factors for persistent hypertension at one year [aORs = 1.07/year (95% CI; 1.02–1.13) and 1.06/kg/m2 (95% CI; 1.01–1.10)], respectively. Conclusion: This study showed a substantial prevalence of persistent hypertension beyond puerperium. Health systems in LMICs need to be organized to anticipate and maintain postpartum monitoring until blood pressure is normalized, or women referred or discharged to family physicians as appropriate. In particular, attention should be given to women who are obese, and or of higher maternal age.

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

Objective: To perform an external validation of all published prognostic models for first-trimester prediction of the risk of developing preeclampsia (PE). Methods: Women

Introduction Tackling substandard maternity care in health facilities requires engaging women’s perspectives in strategies to improve outcomes. This study aims to provide insights in the perspectives of women with severe maternal morbidity on preparedness, access and quality of care in Zanzibar’s referral hospital.Methods In a prospective cohort from April 2017 to December 2018, we performed semistructured interviews with women who experienced maternal near-miss complications and matched controls. These focused on sociodemographic and obstetric characteristics, perceived accessibility to and quality of facility care with 15 domains, scored on a one-to-five scale. Participants’ comments and answers to open questions were employed to illustrate quantitative outcomes. Zanzibar’s Medical Research and Ethics Committee approved the study (ZAMREC/0002/JUN/17).Results We included 174 cases and 151 controls. Compared with controls, patients with a near-miss had less formal education (p=0.049), perceived their wealth as poor (p=0.002) and had a stillbirth more often (p

BackgroundMaternal body mass index (BMI) below or above the reference interval (18.5-24.9 kg/m2) is associated with adverse pregnancy outcomes. Whether BMI exerts an effect within the reference interval is unclear. Therefore, we assessed the association between adverse pregnancy outcomes and BMI, in particular within the reference interval, in a general unselected pregnant population.MethodsData was extracted from a prospective population-based multicentre cohort (Risk Estimation for PrEgnancy Complications to provide Tailored care (RESPECT) study) conducted between December 2012 to January 2014. BMI was studied in categories (I: 30.0 kg/m2) and as a continuous variable within the reference interval. Adverse pregnancy outcomes were defined as composite endpoints for maternal, neonatal or any pregnancy complication, and for adverse pregnancy outcomes individually. Linear trends were assessed using linear-by-linear association analysis and (adjusted) relative risks by regression analysis.ResultsThe median BMI of the 3671 included women was 23.2 kg/m2 (IQR 21.1-26.2). Adverse pregnancy outcomes were reported in 1256 (34.2%). Linear associations were observed between BMI categories and all three composite endpoints, and individually for pregnancy-induced hypertension (PIH), preeclampsia, gestational diabetes mellitus (GDM), large-for-gestational-age (LGA) neonates; but not for small-for-gestational-age neonates and preterm birth. Within the reference interval, BMI was associated with the composite maternal endpoint, PIH, GDM and LGA, with adjusted relative risks of 1.15 (95%CI 1.06-1.26), 1.12 (95%CI 1.00-1.26), 1.31 (95%CI 1.11-1.55) and 1.09 (95%CI 1.01-1.17).ConclusionsGraded increase in maternal BMI appears to be an indicator of risk for adverse pregnancy outcomes even among women with a BMI within the reference interval. The extent to which BMI directly contributes to the increased risk in this group should be evaluated in order to determine strategies most valuable for promoting safety and long-term health for mothers and their offspring.

Hypertensive disorders in pregnancy (HDPs) are a leading cause of maternal morbidity and mortality. Available guidelines for their postpartum management are expected to be optimally utilized. This study aimed to determine adherence to guidelines in selected Nigerian tertiary hospitals. It was nested in a cohort of women with HDPs who delivered in eight facilities between October 2017 and June 2018. Nine weeks after delivery, their cases were evaluated on prespecified indicators and supplemented with interviews. The level of adherence to the guidelines was determined using descriptive analyses, including frequencies, percentages, means, and standard deviations, as well as charts. Of the 366 participants, 33 (9%), 75 (20%), 200 (55%), and 58 (16%) had chronic hypertension, gestational hypertension, preeclampsia, and eclampsia, respectively. Only about a third had their blood pressure measured between postpartum days three and five. Similarly, a third of those with persistent hypertension (≥140/90 mmHg) were not on antihypertensive medications within the first week postpartum. In addition, 37% and 42% of participants were not counseled on contraceptives and early subsequent antenatal visits, respectively. Among those with preeclampsia/eclampsia, 93% were not offered postpartum screening for thromboprophylaxis. Although all women with preeclampsia/eclampsia remained hypertensive two weeks after discharge, only 24% had medical reviews. Overall, only 58% and 44% of indicators were adhered to among all HDPs and preeclampsia/eclampsia-specific indicators, respectively. Level of adherence to guidelines on postpartum management of HDPs in Nigerian tertiary hospitals is poor. It is recommended that institutionalization of guidelines be prioritized and linked to the entire continuum from preconception through longer term postpartum care.

Abstract Given all its systemic adaptive requirements, pregnancy shares several features with physical exercise. In this pilot study, we aimed to assess the physiological response to submaximal cardiopulmonary exercise testing (CPET) in early pregnancy. In 20 healthy, pregnant women (

Abstract Background and Aims Patient‐reported outcome and experience measures (PROM and PREM) can facilitate shared decision making and hold potential to improve healthcare quality. However, their adoption in perinatal care is still limited. The International Consortium for Health Outcomes Measurement (ICHOM) developed a Pregnancy and Childbirth (PCB) outcome set, including PROM and PREM questionnaires. We studied the feasibility to use these PROMs/PREMs in Dutch perinatal care, addressing both women's and professionals' perspective. Methods Patients and professionals in primary and hospital care participated. Women under care at one of five timepoints for PROM/PREM collection of the PCB set (2 during pregnancy, 3 postpartum) were e‐mailed a questionnaire and discussed their answers with their obstetric professional the next regular visit. Compliance was recorded. After discussing the PROMs/PREMs, usability and experience were assessed with separate surveys amongst women and professionals. Results Of 26 women approached, 21 completed and discussed their PROM/PREM questionnaire. Mean questionnaire completion rate was 97%. Average reported time completing the questionnaires was 10 minutes; most women (90%) stated this was acceptable. Women preferred completing questionnaires digitally and discuss their answers with an obstetric professional rather than other care professionals, also 6 months postpartum. Over half of women agreed PROMs/PREMs supported shared decision making (58%), ability to raise issues (60%), and patient‐clinician relationship (52%). Six professionals participated: two obstetricians, two clinical midwives, and two community midwives. Most professionals experienced sufficient time to discuss the responses, except at 6 months postpartum. They knew what items to discuss but did not always feel responsible to act upon them. Professionals agreed PROMs/PREMs supported symptom detection and personalized care. Conclusions Patients and obstetric professionals consider the PCB set a feasible instrument for PROM/PREM assessment, with good compliance, acceptability and usability. Important determinants of successful implementation are a well‐equipped ICT‐tool, agreements regarding professionals' responsibilities and how outcomes are discussed or acted upon.

Abstract Background Value-based health care aims to optimize the balance of patient outcomes and health care costs. To improve value in perinatal care using this strategy, standard outcomes must first be defined. The objective of this work was to define a minimum, internationally appropriate set of outcome measures for evaluating and improving perinatal care with a focus on outcomes that matter to women and their families. Methods An interdisciplinary and international Working Group was assembled. Existing literature and current measurement initiatives were reviewed. Serial guided discussions and validation surveys provided consumer input. A series of nine teleconferences, incorporating a modified Delphi process, were held to reach consensus on the proposed Standard Set. Results The Working Group selected 24 outcome measures to evaluate care during pregnancy and up to 6 months postpartum. These include clinical outcomes such as maternal and neonatal mortality and morbidity, stillbirth, preterm birth, birth injury and patient-reported outcome measures (PROMs) that assess health-related quality of life (HRQoL), mental health, mother-infant bonding, confidence and success with breastfeeding, incontinence, and satisfaction with care and birth experience. To support analysis of these outcome measures, pertinent baseline characteristics and risk factor metrics were also defined. Conclusions We propose a set of outcome measures for evaluating the care that women and infants receive during pregnancy and the postpartum period. While validation and refinement via pilot implementation projects are needed, we view this as an important initial step towards value-based improvements in care.

Abstract Background Screening for, diagnosis and management of intrauterine growth restriction (IUGR) is often performed in multidisciplinary collaboration. However, variation in screening methods, diagnosis and management of IUGR may lead to confusion. In the Netherlands two monodisciplinary guidelines on IUGR do not fully align. To facilitate effective collaboration between different professionals in perinatal care, we undertook a Delphi study with uniform recommendations as our primary result, focusing on issues that are not aligned or for which specifications are lacking in the current guidelines. Methods We conducted a Delphi study in three rounds. A purposively sampled selection of 56 panellists participated: 27 representing midwife-led care and 29 obstetrician-led care. Consensus was defined as agreement between the professional groups on the same answer and among at least 70% of the panellists within groups. Results Per round 51 or 52 (91% - 93%) panellists responded. This has led to consensus on 27 issues, leading to four consensus based recommendations on screening for IUGR in midwife-led care and eight consensus based recommendations on diagnosis and eight on management in obstetrician-led care. The multidisciplinary project group decided on four additional recommendations as no consensus was reached by the panel. No recommendations could be made about induction of labour versus expectant monitoring, nor about the choice for a primary caesarean section. Conclusions We reached consensus on recommendations for care for IUGR within a multidisciplinary panel. These will be implemented in a study on the effectiveness and cost-effectiveness of routine third trimester ultrasound for monitoring fetal growth. Research is needed to evaluate the effects of implementation of these recommendations on perinatal outcomes. Trial registration NTR4367 .

Abstract Background Reproductive disorders, such as polycystic ovary syndrome (PCOS), primary ovarian insufficiency (POI) and hypertensive pregnancy disorders (HPD) like pre-eclampsia (PE), are associated with an increased risk of cardiovascular disease (CVD). Detection of early signs of cardiovascular disease (CVD), as well as identification of risk factors among women of reproductive age which improve cardiovascular risk prediction, is a challenge and current models might underestimate long-term health risks. The aim of this study is to assess cardiovascular disease in patients with a history of a reproductive disorder by low-dose computed tomography (CT). Methods Women of 45 - 55 years, who experienced a reproductive disorder (PCOS, POI, HPD), are invited to participate in this multicenter, prospective, cohort study. Women will be recruited after regular cardiovascular screening, including assessment of classical cardiovascular risk factors. CT of the coronary arteries (both coronary artery calcium scoring (CACS), and contrast-enhanced coronary CT angiography (CCTA)) and carotid siphon calcium scoring (CSC) is planned in 300 women with HPD and 300 women with PCOS or POI. In addition, arterial stiffness (non-invasive pulse wave velocity (PWV)) measurement and cell-based biomarkers (inflammatory circulating cells) will be obtained. Discussion Initial inclusion is focused on women of 45 - 55 years. However, the age range (40 - 45 years and/or ≥ 55 years) and group composition may be adjusted based on the findings of the interim analysis. Participants can potentially benefit from information obtained in this study concerning their current cardiovascular health and expected future risk of cardiovascular events. The results of this study will provide insights in the development of CVD in women with a history of reproductive disorders. Ultimately, this study may lead to improved cardiovascular prediction models and will provide an opportunity for timely adjustment of preventive strategies. Limitations of this study include the possibility of overdiagnosis and the average radiation dose of 3.5 mSv during coronary and carotid siphon CT, although the increased lifetime malignancy risk is negligible. Trial registration Netherlands Trial Register, NTR5531 . Date registered: October 21st, 2015.

Abstract Background Birth centres are described as settings where women with uncomplicated pregnancies can give birth in a home-like environment assisted by midwives and maternity care assistants. If complications arise or threaten, the woman is referred to a maternity unit of a hospital where an obstetrician will take over responsibility. In the last decade, a number of new birth centres have been established in the Netherlands, based on the assumption that birth centres provide better quality of care since they offer a better opportunity for more integrated care than the existing system with independent primary and secondary care providers. At present, there is no evidence for this assumption. The Dutch Birth Centre Study is designed to present evidence-based recommendations for organization and functioning of future birth centres in the Netherlands. A necessary first step in this evaluation is the development of indicators for measuring the quality of the care delivered in birth centres in the Netherlands. The aim of this study is to identify a comprehensive set of structure and process indicators to assess quality of birth centre care. Methods We used mixed methods to develop a set of structure and process quality indicators for evaluating birth centre care. Beginning with a literature review, we developed an exhaustive list of determinants. We then used a Delphi study to narrow this list, calling on experts to rate the determinants for relevance and feasibility. A multidisciplinary expert panel of 63 experts, directly or indirectly involved with birth centre care, was invited to participate. Results A panel of 42 experts completed two Delphi rounds rating determinants of the quality of birth centre care based on their relevance (to the setting) and feasibility (of use). A set of 30 determinants for structure and process quality indicators was identified to assess the quality of birth centre care in the Netherlands. Conclusions We identified 30 determinants for structure and process quality indicators concerning birth centre care. This set will be validated during the evaluation of birth centres in the Dutch Birth Centre Study.

Abstract Background The goal of integrated care is to offer a continuum of care that crosses the boundaries of public health, primary, secondary, and tertiary care. Integrated care is increasingly promoted for people with complex needs and has also recently been promoted in maternity care systems to improve the quality of care. Especially when located near an obstetric unit, birth centres are considered to be ideal settings for the realization of integrated care. At present, however, we know very little about the degree of integration in these centres and we do not know if increased levels of integration improve the quality of the care delivered. The Dutch Birth Centre Study is designed to evaluate birth centres and their contribution to the Dutch maternity care system. The aim of this particular sub-study is to classify birth centres in clusters with similar characteristics based on integration profiles, to support the evaluation of birth centre care. Methods This study is based on the Rainbow Model of Integrated Care. We used a survey followed by qualitative interviews in 23 birth centres in the Netherlands to determine which integration profiles can be distinguished and to describe their discriminating characteristics. Cluster analysis was used to classify the birth centres. Results Birth centres were classified into three clusters: 1)“Mono-disciplinary-oriented birth centres” (n = 10): which are mainly owned by primary care organizations and established as physical facilities to provide an alternative birthplace for low risk births; 2) “Multi-disciplinary-oriented birth centres” (n = 6): which are mainly multi-disciplinary oriented and can be regarded as facilities to give birth, with a focus on integrated birth care; 3) “Mixed Cluster of birth centres” (n = 7): which have a range of organizational forms that differentiate them from centres in the other clusters. Conclusion We identified a recognizable classification, with similar characteristics between birth centres in the clusters. The results of this study can be used to relate integration profiles of birth centres to quality of care, costs, and perinatal outcomes. This assessment makes it possible to develop recommendations with regard to the type and degree of integration of Dutch birth centres in the future.

BackgroundThe aim of this study was to evaluate whether soluble frizzled-related protein 4 (sFRP4) concentration in the first trimester of pregnancy is individually, or in combination with Leptin, Chemerin and/or Adiponectin, associated with the development of gestational diabetes (GDM).MethodsIn a nested case-control study, 50 women with GDM who spontaneously conceived and delivered a live-born infant were matched with a total of 100 uncomplicated singleton control pregnancies based on body mass index (± 2 kg/m2), gestational age at sampling (exact day) and maternal age (± 2 years). In serum samples, obtained between 70-90 days gestational age, sFRP4, Chemerin, Leptin and Adiponectin concentrations were determined by ELISA. Statistical comparisons were performed using univariate and multi-variate logistic regression analysis after logarithmic transformation of the concentrations. Discrimination of the models was assessed by the area under the curve (AUC).ResultsFirst trimester sFRP4 concentrations were significantly increased in GDM cases (2.04 vs 1.93 ng/ml; pConclusionIn the first trimester of pregnancy, a multi-marker model with sFRP4, Leptin, Chemerin and Adiponectin is associated with the development of GDM. Therefore, this panel seems to be an interesting candidate to further evaluate for prediction of GDM in a prospective study.

Introduction The importance of cardiovascular health in relation to pregnancy outcome is increasingly acknowledged. Women who develop certain pregnancy complications, in particular preeclampsia, are at higher risk for future cardiovascular disease. Independent of its outcome, pregnancy requires a substantial adaptive response of the maternal cardiovascular system. In the Hemodynamic Adaptation to Pregnancy and Placenta-related Outcome (HAPPO) study, we aim to examine longitudinal maternal haemodynamic adaptation to pregnancy from the preconception period onwards. We hypothesise that women who will develop adverse pregnancy outcomes have impaired cardiovascular health before conception, leading to haemodynamic maladaptation to pregnancy and diminished uteroplacental vascular development.Methods and analysis In this prospective cohort study embedded in the Rotterdam periconception cohort, 200 women with a history of placenta-related pregnancy complications (high-risk group) and 100 women with an uncomplicated obstetric history (low-risk group) will be included. At five moments (preconception, first, second and third trimester and postdelivery), women will undergo an extensive examination of the macrocirculatory and microcirculatory system and uteroplacental vascular development. The main outcome measures are differences in maternal haemodynamic adaptation to pregnancy between women with and without placenta-related pregnancy complications. In a multivariate linear mixed model, the relationship between maternal haemodynamic adaptive parameters, (utero)placental vascularisation indices and clinical outcomes (occurrence of pregnancy complications, embryonic and fetal growth trajectories, miscarriage rate, gestational age at delivery, birth weight) will be studied. Subgroup analysis will be performed to study baseline and trajectory differences between high-risk and low-risk women, independent of subsequent pregnancy outcome.Ethics and dissemination This study protocol was approved by the Medical Ethics Committee of the Erasmus MC, Rotterdam, the Netherlands (MEC 2018–150). Results will be disseminated to the medical community by publications in peer-reviewed journals and presentations at scientific congresses. Also, patient associations will be informed and the public will be informed by dissemination through (social) media.Trial registration number NL7394 (www.trialregister.nl)

Background The aim of the ReproQuestionnaire (ReproQ) is to measure the client’s experience with maternity care, following WHO’s responsiveness model. To support quality improvement, ReproQ should be able to discriminate best from worst organisational units. Methods We sent questionnaires to 27,487 third-trimester pregnant women (response 31%) and to 37,230 women 6 weeks after childbirth (response 39%). For analysis we first summarized the ReproQ domain scores into three summary scores: total score (all eight domains), personal score (four personal domains), and setting score (four setting domains). Second, we estimated the proportion of variance across perinatal units attributable to the ‘actual’ difference across perinatal units using intraclass correlation coefficients (ICCs). Third, we assessed the ability of ReproQ to discriminate between perinatal units based on both a statistical approach using multilevel regression analyses, and a relevance approach based on the minimally important difference (MID). Finally, we compared the domain scores of the best and underperforming units. Results ICCs ranged between 0.004 and 0.025 for the summary scores, and between 0.002 and 0.125 for the individual domains. ReproQ was able to identify the best and worst performing units with both the statistical and relevance approach. The statistical approach was able to identify four underperforming units during childbirth (total score), while the relevance approach identified 10 underperforming units. Conclusions ReproQ, a valid and efficient measure of client experiences in maternity care, has the ability to discriminate well across perinatal units, and is suitable for benchmarking under routine conditions.

Introduction Pregnant women faced with complications of pregnancy often require long-term hospital admission for maternal and/or fetal monitoring. Antenatal admissions cause a burden to patients as well as hospital resources and costs. A telemonitoring platform connected to wireless cardiotocography (CTG) and automated blood pressure (BP) devices can be used for telemonitoring in pregnancy. Home telemonitoring might improve autonomy and reduce admissions and thus costs. The aim of this study is to compare the effects on patient safety, satisfaction and cost-effectiveness of hospital care versus telemonitoring (HOTEL) as an obstetric care strategy in high-risk pregnancies requiring daily monitoring.Methods and analysis The HOTEL trial is an ongoing multicentre randomised controlled clinical trial with a non-inferiority design. Eligible pregnant women are >26+0 weeks of singleton gestation requiring monitoring because of pre-eclampsia (hypertension with proteinuria), fetal growth restriction, preterm rupture of membranes without contractions, recurrent reduced fetal movements or an intrauterine fetal death in a previous pregnancy.Randomisation takes place between traditional hospitalisation (planned n=208) versus telemonitoring (planned n=208) until delivery. Telemonitoring at home is facilitated with Sense4Baby CTG devices, Microlife BP monitor and daily telephone calls with an obstetric healthcare professional as well as weekly hospital visits.Primary outcome is a composite of adverse perinatal outcome, defined as perinatal mortality, 5 min Apgar

Introduction In women with gestational diabetes mellitus (GDM) requiring pharmacotherapy, insulin was the established first-line treatment. More recently, oral glucose lowering drugs (OGLDs) have gained popularity as a patient-friendly, less expensive and safe alternative. Monotherapy with metformin or glibenclamide (glyburide) is incorporated in several international guidelines. In women who do not reach sufficient glucose control with OGLD monotherapy, usually insulin is added, either with or without continuation of OGLDs. No reliable data from clinical trials, however, are available on the effectiveness of a treatment strategy using all three agents, metformin, glibenclamide and insulin, in a stepwise approach, compared with insulin-only therapy for improving pregnancy outcomes. In this trial, we aim to assess the clinical effectiveness, cost-effectiveness and patient experience of a stepwise combined OGLD treatment protocol, compared with conventional insulin-based therapy for GDM.Methods The SUGAR-DIP trial is an open-label, multicentre randomised controlled non-inferiority trial. Participants are women with GDM who do not reach target glycaemic control with modification of diet, between 16 and 34 weeks of gestation. Participants will be randomised to either treatment with OGLDs, starting with metformin and supplemented as needed with glibenclamide, or randomised to treatment with insulin. In women who do not reach target glycaemic control with combined metformin and glibenclamide, glibenclamide will be substituted with insulin, while continuing metformin. The primary outcome will be the incidence of large-for-gestational-age infants (birth weight >90th percentile). Secondary outcome measures are maternal diabetes-related endpoints, obstetric complications, neonatal complications and cost-effectiveness analysis. Outcomes will be analysed according to the intention-to-treat principle.Ethics and dissemination The study protocol was approved by the Ethics Committee of the Utrecht University Medical Centre. Approval by the boards of management for all participating hospitals will be obtained. Trial results will be submitted for publication in peer-reviewed journals.Trial registration number NTR6134; Pre-results.

ObjectiveTo evaluate the validity of WHO's near-miss approach in a low-resource, high maternal mortality setting.DesignProspective cohort study.SettingMnazi Mmoja Hospital, the main referral hospital of Zanzibar, Tanzania, from 1 April 2017 until 31 December 2018.PopulationAll women, pregnant or until 42 days after the end of pregnancy, admitted at Mnazi Mmoja Hospital, the tertiary referral hospital in Zanzibar.MethodsCases of maternal morbidity and mortality were evaluated according to WHO's near-miss approach. The approach's performance was determined by calculating its accuracy through sensitivity, specificity and positive and negative likelihood ratios. The approach's validity was assessed with Pearson's correlation coefficient between the number of organ dysfunction markers and risk of mortality.Main outcomes measuresCorrelation between number of organ dysfunction markers and risk of mortality, sensitivity and specificity.Results26,842 women were included. There were 335 with a severe maternal outcome: 256 maternal near-miss cases and 79 maternal deaths. No signs of organ dysfunction were documented in only 4 of the 79 cases of maternal death. The number of organ dysfunction markers was highly correlated to the risk of mortality with Pearson's correlation coefficient of 0.89.ConclusionsWHO's near-miss approach adequately identifies women at high risk of maternal mortality in Zanzibar's referral hospital. There is a strong correlation between the number of markers of organ dysfunction and mortality risk.

Introduction: Preeclampsia (PE) represents a hypertensive pregnancy disorder that is associated with increased cardiovascular disease (CVD) risk. This increased risk has been attributed to accelerated atherosclerosis, with inflammation being a major contributor. Neutrophils play an important role in the onset and progression of atherosclerosis and have been associated with vascular damage in the placenta as well as the chronic inflammatory state in women with PE. We therefore investigated whether circulating neutrophil numbers or reactivity were associated with the presence and severity of subclinical atherosclerosis in women with a history of PE. Methods: Women aged 45−60 years with a 10 to 20 years earlier history of early onset preeclampsia (delivery 0 AU) or stenosis, categorized as absent (0%), minimal to mild (>0 and 0). Total white blood cell count and neutrophil counts were not associated with the presence of subclinical CAD or with a positive CAC score. When assessing the presence of the chemokine receptors CXCR4 and CXCR2, we observed a slight decrease of neutrophil CXCR2 expression in women with CAC (median MFI 22.0 [interquartile range (IQR) 20.2−23.8]) compared to women without CAC (23.8 [IQR 21.6−25.6], p = 0.02). We observed no differences regarding neutrophil CXCR4 expression. In addition, expression of the early activity marker CD35 was slightly lower on neutrophils of women with subclinical CAD (median MFI 1.6 [IQR 1.5−1.9] compared to 1.9 [IQR 1.7−2.1] in women without CAD, p = 0.02). However, for all findings, statistical significance disappeared after adjustment for multiple testing. Conclusion: Our findings indicate that neutrophil counts and (re)activity are not directly associated with silent CAD disease burden and as such are not suitable as biomarkers to predict the presence of subclinical CAD in a high-risk population of women with a history of preeclampsia.