A positive experience of the perinatal period is significant for women in midwifery care. The literature on women’s experiences of the care in this period is extensive. However, a clear overview of the dimensions important for women’s experiences is lacking. Consequently, care providers and researchers may ignore aspects significant to women’s experience. In this short communication, we present a framework identifying the dimensions relevant for women’s experiences of the perinatal period.
DOCUMENT
Introduction This study aims to explore maternal and perinatal outcomes of migrant women in Iceland. Material and methods This prospective population-based cohort study included women who gave birth to a singleton in Iceland between 1997 and 2018, comprising a total of 92 403 births. Migrant women were defined as women with citizenship other than Icelandic, including refugees and asylum seekers, and categorized into three groups, based on their country of citizenship Human Development Index score. The effect of country of citizenship was estimated. The main outcome measures were onset of labor, augmentation, epidural, perineum support, episiotomy, mode of birth, obstetric anal sphincter injury, postpartum hemorrhage, preterm birth, a 5-minute Apgar <7, neonatal intensive care unit admission and perinatal mortality. Odds ratios (ORs) and 95% confidence intervals (CIs) for maternal and perinatal outcomes were calculated using logistic regression models. Results A total of 8158 migrant women gave birth during the study period: 4401 primiparous and 3757 multiparous. Overall, migrant women had higher adjusted ORs (aORs) for episiotomy (primiparas: aOR 1.43, 95% CI 1.26–1.61; multiparas: 1.39, 95% CI 1.21–1.60) and instrumental births (primiparas: 1.14, 95% CI 1.02–1.27, multiparas: 1.41, 95% CI 1.16–1.72) and lower aORs of induction of labor (primiparas: 0.88, 95% CI 0.79–0.98; multiparas: 0.74, 95% CI 0.66–0.83), compared with Icelandic women. Migrant women from countries with a high Human Development Index score (≥0.900) had similar or better outcomes compared with Icelandic women, whereas migrant women from countries with a lower Human Development Index score than that of Iceland (<0.900) had additionally increased odds of maternal and perinatal complications and interventions, such as emergency cesarean and postpartum hemorrhage. Conclusions Women’s citizenship and country of citizenship Human Development Index scores are significantly associated with a range of maternal and perinatal complications and interventions, such as episiotomy and instrumental birth. The results indicate the need for further exploration of whether Icelandic perinatal healthcare services meet the care needs of migrant women.
DOCUMENT
Introduction: Shared decision-making is considered to be a key aspect of woman-centered care and a strategy to improve communication, respect, and satisfaction. This scoping review identified studies that used a shared decision-making support strategy as the primary intervention in the context of perinatal care. Methods: A literature search of PubMed, CINAHL, Cochrane Library, PsycINFO, and SCOPUS databases was completed for English-language studies conducted from January 2000 through November 2019 that examined the impact of a shared decision-making support strategy on a perinatal decision (such as choice of mode of birth after prior cesarean birth). Studies that only examined the use of a decision aid were excluded. Nine studies met inclusion criteria and were examined for the nature of the shared decision-making intervention as well as outcome measures such as decisional evaluation, including decisional conflict, decisional regret, and certainty. Results: The 9 included studies were heterogeneous with regard to shared decision-making interventions and measured outcomes and were performed in different countries and in a variety of perinatal situations, such as women facing the choice of mode of birth after prior cesarean birth. The impact of a shared decision-making intervention on women’s perception of shared decision-making and on their experiences of the decision-making process were mixed. There may be a decrease in decisional conflict and regret related to feeling informed, but no change in decisional certainty. Discussion: Despite the call to increase the use of shared decision-making in perinatal care, there are few studies that have examined the effects of a shared decision-making support strategy. Further studies that include antepartum and intrapartum settings, which include common perinatal decisions such as induction of labor, are needed. In addition, clear guidance and strategies for successfully integrating shared decision-making and practice recommendations would help women and health care providers navigate these complex decisions.
DOCUMENT
Background: Empowerment is expected to have a beneficial effect on a woman’s well-being during the perinatal period and her readiness to face the challenges of motherhood. In the literature on pregnancy and childbirth, empowerment is used widely in different contexts, with different connotations and often without a definition, thus indicating a lack of clarity of what is actually meant by the concept. Objective: To report an analysis of the concept of women’s empowerment in the context of the perinatal period. Methods: We used the concept analysis framework of Walker and Avant to analyse the concept of women’s empowerment during pregnancy and childbirth. In July 2018, we did a systematic search in EBSCOhost, including the database MEDLINE, CINAHL, PsycINFO, PsycARTICLES and SocINDEX, using keywords: empower, women, childbirth and their synonyms. All selected papers were analysed for definitions of empowerment, defining attributes, antecedents and consequences. Results: Ninety-seven scientific papers from all continents were included in the analysis. Defining attributes, antecedents, consequences and empirical referents are discussed, and a model case as well as related and contrary cases are presented. Conclusion: Attributes, external and internal to the woman, were identified. Both types of attributes need to be considered within the broader socio-cultural-economic-political landscape of the individual woman, in conjunction with a woman’s belief in herself and her meaningful interconnectedness with carers. Relevance: This study resulted in an understanding of empowerment in the context of pregnancy and childbirth that can be used in research and for the development of interventions preparing women for childbirth and their subsequent transition to motherhood.
DOCUMENT
Background: Post-term pregnancy, a pregnancy exceeding 294 days or 42 completed weeks, is associated with increased perinatal morbidity and mortality and is considered a high-risk condition which requires specialist surveillance and induction of labour. However, there is uncertainty on the policy concerning the timing of induction for post-term pregnancy or impending post-term pregnancy, leading to practice variation between caregivers. Previous studies on induction at or beyond 41 weeks versus expectant management showed different results on perinatal outcome though conclusions in meta-analyses show a preference for induction at 41 weeks. However, interpretation of the results is hampered by the limited sample size of most trials and the heterogeneity in design. Most control groups had a policy of awaiting spontaneous onset of labour that went far beyond 42 weeks, which does not reflect usual care in The Netherlands where induction of labour at 42 weeks is the regular policy. Thus leaving the question unanswered if induction at 41 weeks results in better perinatal outcomes than expectant management until 42 weeks. Methods/design: In this study we compare a policy of labour induction at 41 + 0/+1 weeks with a policy of expectant management until 42 weeks in obstetrical low risk women without contra-indications for expectant management until 42 weeks and a singleton pregnancy in cephalic position. We will perform a multicenter randomised controlled clinical trial. Our primary outcome will be a composite outcome of perinatal mortality and neonatal morbidity. Secondary outcomes will be maternal outcomes as mode of delivery (operative vaginal delivery and Caesarean section), need for analgesia and postpartum haemorrhage (≥1000 ml). Maternal preferences, satisfaction, wellbeing, pain and anxiety will be assessed alongside the trial. Discussion: his study will provide evidence for the management of pregnant women reaching a gestational age of 41 weeks.
MULTIFILE
Background: The maternity care system in the Netherlands is well known for its support of community-based midwifery. However, regular midwifery practices typically do not offer caseload midwifery care – one-to-one continuity of care throughout pregnancy and birth. Because we know very little about the outcomes for women receiving caseload care in the Netherlands, we compared caseload care with regular midwife-led care, looking at maternal and perinatal outcomes, including antenatal and intrapartum referrals to secondary (i.e., obstetrician-led) care. Methods: We selected 657 women in caseload care and 1954 matched controls (women in regular midwife-led care) from all women registered in the Dutch Perinatal Registry (Perined) who gave birth in 2015. To be eligible for selection the women had to be in midwife-led antenatal care beyond 28 gestational weeks. Each woman in caseload care was matched with three women in regular midwife-led care, using parity, maternal age, background (Dutch or non-Dutch) and region. These two cohorts were compared for referral rates, mode of birth, and other maternal and perinatal outcomes. Results: In caseload midwifery care, 46.9% of women were referred to obstetrician-led care (24.2% antenatally and 22.8% in the intrapartum period). In the matched cohort, 65.7% were referred (37.4% antenatally and 28.3% in the intrapartum period). In caseload care, 84.0% experienced a spontaneous vaginal birth versus 77.0% in regular midwife-led care. These patterns were observed for both nulliparous and multiparous women. Women in caseload care had fewer inductions of labour (13.2% vs 21.0%), more homebirths (39.4% vs 16.1%) and less perineal damage (intact perineum: 41.3% vs 28.2%). The incidence of perinatal mortality and a low Apgar score was low in both groups. Conclusions: We found that when compared to regular midwife-led care, caseload midwifery care in the Netherlands is associated with a lower referral rate to obstetrician-led care – both antenatally and in the intrapartum period – and a higher spontaneous vaginal birth rate, with similar perinatal safety. The challenge is to include this model as part of the current effort to improve the quality of Dutch maternity care, making caseload care available and affordable for more women.
DOCUMENT
Pregnancy and early parenthood mark a transformative period where women become caregivers and assume a new role with new responsibilities. While often portrayed positively, the transition to motherhood can be overwhelming. This is especially true for women living in adverse circumstances, presenting substantial difficulties such as providing a nurturing home environment under unsafe conditions or cooking healthy food with insufficient resources. Women in these adverse situations face multiple challenges across various domains, affecting both social and economic positions, as well as health and mental well-being. Low income, unemployment, single parenthood, and living in a deprived neighbourhood increase chronic stress, negatively impacting health. People experiencing chronic stress often have diminished resources to cope with stressful situations, frequently resulting in unhealthy behaviour. These circumstances create a negative cycle where socio-economic circumstances influence health and well-being, subsequently affecting their economic potential. Furthermore, stress and decreased self-sufficiency can impair competent parenting and healthy parent-child relationships. Insufficient family resources limit nutrition, stimulation, and time for childcare, hindering all essential requirements for healthy child development. This downward spiral results in the intergenerational transmission of adversity, already during pregnancy and early life. This thesis focuses on the specific population of pregnant women, mothers, and young children living in circumstances characterized by multiple medical and social risk factors for an unhealthy pregnancy or early life. Rather than using a term like ‘vulnerable’ to indicate these women and families, a term that diminishes the strength present in these families, within this thesis I will refer to these families as a priority population. A population that deserves priority regarding the allocation of attention, time and resources of medical and social care. This thesis aims to provide insight into this priority population by examining the problems, adversities and challenges faced by pregnant women and mothers of young children. Additionally, it describes the caregiving capacities of these mothers. Most data presented within this thesis is collected within Rotterdam. More specifically, within the Mothers of Rotterdam program, regular social care, or through birth professionals. Using various research methods, from quantitative analyses of large datasets to qualitative approaches with detailed information, this thesis combines different perspectives and sources to provide a comprehensive overview of the topic. Previously, the Developmental Origins of Health and Disease paradigm has described how adverse pregnancy exposures have lasting developmental effects. Prenatal stress exposure can impact perinatal morbidity, premature birth, low birth weight, and increase risks for future health problems. These children more often report unhealthy behaviours and suboptimal (mental) health in later life. In Chapter 2 I present findings on this phenomenon through a large, nationwide registry study on the socio-economic determinants of healthcare costs in early life. Data from three Dutch national registries covering 480,471 children born between 2011-2014 were combined to investigate relationships between individual- (monthly household income) and contextual-level (neighbourhood deprivation) of socio-economic status and perinatal morbidity (being born preterm and/or small for gestational age) on healthcare costs in early life (0-3 years of age). This study revealed children from lower-income households and from more deprived neighbourhoods to have notably higher healthcare costs. Although perinatal morbidity accounted for higher expenses, both income and neighbourhood deprivation independently contributed to higher healthcare costs. This suggests either increased ill-health or inadequate healthcare utilization in this low socio economic population. Understanding this mechanism is crucial for developing adequate, targeted policies to minimize differences in healthcare costs and optimize health and healthcare use. The early postpartum period is a highly suitable period for improving health outcomes among mothers and their newborns, for example through maternity care assistants that provide care directly after birth and subsequent days. Although in the Netherlands, 95% of all postpartum women receive at least some amount of postpartum care, utilisation of postpartum care is lower in the priority population. A situation that is particularly undesirable given that these women may benefit most from this preventive and supportive care. In Chapter 3 I explore the experiences, facilitators and barriers to postpartum care utilization through an analysis of 23 in-depth interviews with pregnant and postpartum women living in adverse circumstances in Rotterdam. Through a grounded theory approach, postpartum care utilization was conceptualized as influenced by information provided by the maternity care assistant; perceived parenting self-efficacy; and support provided by their social network. Although information during pregnancy was often perceived as inadequate, information during the postpartum period was highly valued, especially when tailored to specific needs. Women experienced increased self-efficacy through postpartum care, facilitating continued utilization of care. Women with more support from their social network asked the maternity care assistants to focus on specialized care for mother and newborn, while their network handled household tasks. Finally, the connection between mother and the maternity care assistant significantly impacted women’s experience and continued use of service across all themes. These findings highlight the need for improved information provision, tailoring care to individual self-efficacy levels, and engaging social networks in the care process, with consideration for the connection between mother and maternity care assistant. Although the above mentioned elements are crucial for postpartum care provided by maternity care assistants, they are not reserved exclusively for this type of care. Another example of care founded on these elements is the Mothers of Rotterdam program, which I describe in Chapter 4. The Mothers of Rotterdam program is an innovative social care initiative for pregnant women and mothers living in adverse circumstances. Developed in response to Rotterdam’s elevated rates of perinatal mortality and morbidity, child poverty, and welfare dependency, the program integrates medical and social care during pregnancy and two years postpartum. The program provides intensive, accessible, and holistic support, delivered by social work professionals with support of third-year college students in Social Work and Applied Psychology. The support from students increases the workforce, enabling intensive long-term support for families. Furthermore, students are perceived as less threatening, reducing distrust and enabling a stronger connection between women and care providers. Structured into four phases, the program first focuses on reducing acute stress during pregnancy, then creating a safe environment in the child’s first year, promoting child development and expanding the mother’s social participation in the second year, and finally transitioning to independent functioning of the family. Throughout these phases, the program addresses health and care, housing, finances, and child development simultaneously, working to break intergenerational transmission of adversity. In Chapter 5 I present the research protocol for the evaluation of the Mothers of Rotterdam program, comparing it to care as usual, through a prospective cohort study. Data collection occurs at nine timepoints from pregnancy until after care completion, using questionnaires, developmental assessments, video and photo observations and registry data from various medical and social care registries. Primary outcomes include child development and maternal mental health. With a target of 1200 participants, the study aims to detect meaningful differences between both approaches. Subsequently, in Chapter 6 I summarize information on 919 women referred to either the Mother of Rotterdam program or care as usual. More specifically, information is provided on faced adversities and experienced well-being. Heat map methodology showed women to face a multitude of adversities, across several life domains, mostly related to social functioning, health and finances. Furthermore, two clusters of women emerged: one with women facing mostly financial problems, whereas the second cluster of women faced a complex interplay of difficulties across multiple life domains. Additionally, women and social care providers differed in their perception of stress, anxiety and depression experienced by these women. Together, these findings highlight the need for a personalized, holistic care approach that addresses problems on multiple life domains simultaneously and a careful, joint assessment of health and mental well-being. As described above, problems, adversities and challenges faced by these women not only impact their own health and well-being, but can also impair competent parenting and healthy parent-child relationships. Therefore, I explore in Chapter 7 the caregiving capacities of 83 women included in the Mothers of Rotterdam study. Through video-observations of daily tasks (feeding, bathing, changing) overall, emotional and instrumental caregiving capacity was assessed. Video observations were made around six weeks postpartum in the home of mother and child, supplemented with information on psychological symptoms, self sufficiency, adversity, living conditions and mental health. Analyses showed overall, emotional and instrumental caregiving to be all below adequate caregiving quality, with emotional caregiving to be especially low. Surprisingly, few indicators of adversity significantly associated with caregiving quality, and counterintuitively, mothers in unsafe environments and those with more problematic life domains showed higher caregiving capacities in some areas. These findings suggest mothers in adverse circumstances might compensate through caregiving, or that inadequate caregiving relates to overall circumstances rather than specific indicators. The research underscores the importance of early intervention, particularly for emotional caregiving aspects, as adequate caregiving can protect against the negative impact of adversity. In the final chapter, Chapter 8, I discuss the main findings of this thesis and implications for practice, policy and research. In this chapter, I address the ability to be adaptable in the face of adversity; characteristics and adversities within this priority population; the intergenerational transmission of adversity; the use and misuse of (health)care, including ill-health, more (inadequate) use of healthcare services, and the healthcare system itself; the importance of social support; and mutual trust as crucial element for successful care and support for this priority population. Recommendations for policy and practice focus on building trust, investing in a shared perspective and equal partnership between the family and (social) care provider, strengthening social support, working from a positive attitude, intervening as early as possible and utilizing pregnancy as a window of opportunity for support and intervention. Furthermore, I give a number of recommendations for research in this priority population. Personally, a key realization has been that by focusing on the adversities, we reduce these women to the problems they face, not considering the potential they have. Zwangerschap en het vroege ouderschap markeert een periode waar vrouwen in verzorgers veranderen en een nieuwe rol met nieuwe verantwoordelijkheden op zich nemen. Hoewel het moederschap vaak positief wordt voorgesteld, kan deze overgang overweldigend zijn. Dit geldt vooral voor vrouwen die in uitdagende omstandigheden leven, wanneer de omgeving onveilig is en middelen schaars, is het moeilijk om kinderen een warme, stimulerende thuisomgeving te bieden en van gezond voedsel te voorzien. Vrouwen die leven onder deze ongunstige omstandigheden worden geconfronteerd met meerdere uitdagingen op verschillende gebieden, die zowel de sociale en economische positie, als de gezondheid en het mentale welzijn beïnvloeden. Een laag inkomen, werkloosheid, alleenstaand ouderschap en het leven in achterstandswijken verhogen de chronische stress en hebben een negatieve invloed op de gezondheid. Mensen die chronisch stress ervaren zijn vaak minder goed in staat om met stressvolle situaties om te gaan, wat vaak resulteert in ongezond gedrag. Zo creëren deze omstandigheden een negatieve cyclus waarin sociaaleconomische omstandigheden de gezondheid en het welzijn beïnvloeden, wat vervolgens weer van invloed is op hun economisch potentieel. Bovendien kunnen stress en verminderde zelfredzaamheid een nadelige invloed hebben op competent ouderschap en gezonde ouder-kindrelaties. Onvoldoende middelen in het gezin hebben een weerslag op voeding, stimulatie en tijd voor opvoeding en verzorging, waardoor alle essentiële elementen voor een gezonde ontwikkeling van kinderen worden belemmerd. Deze neerwaartse spiraal resulteert in de overdracht tegenslag van generatie op generatie, al tijdens de zwangerschap en de eerste levensjaren. Dit proefschrift richt zich op de specifieke populatie van zwangere vrouwen, moeders en jonge kinderen die leven in omstandigheden die worden gekenmerkt door meerdere medische en sociale risicofactoren voor een ongezonde zwangerschap of het vroege leven. In plaats van een term als ‘kwetsbaar’ te gebruiken om deze vrouwen en gezinnen te beschrijven, een term die afbreuk doet aan de kracht van deze gezinnen, zal ik in dit proefschrift naar deze gezinnen verwijzen als een prioriteitspopulatie. Een populatie die prioriteit verdient met betrekking tot de verdeling van aandacht, tijd en middelen van de medische en sociale zorg en hulpverlening. Dit proefschrift beoogt inzicht te geven in deze prioriteitspopulatie door de problemen, tegenslagen en uitdagingen te onderzoeken waarmee zwangere vrouwen en moeders van jonge kinderen worden geconfronteerd. Daarnaast worden de ouderschapscapaciteiten van deze moeders beschreven. De meeste gegevens in dit proefschrift zijn verzameld in Rotterdam. Meer specifiek binnen het programma Moeders van Rotterdam, reguliere ondersteuning door de wijkteams of bij geboorteprofessionals. Door gebruik te maken van verschillende onderzoeksmethoden, van kwalitatieve analyses van grote datasets tot kwalitatieve benaderingen met gedetailleerde informatie, combineert dit proefschrift verschillende perspectieven en bronnen om een uitgebreid overzicht van het onderwerp te geven. Het model van de ‘Ontwikkelingsoorsprong van gezondheid en ziekte’ heeft eerder beschreven hoe nadelige blootstellingen tijdens de zwangerschap blijvend van invloed is op de ontwikkeling. Blootstelling aan prenatale stress kan invloed hebben op perinatale sterfte, vroeggeboorte, laag geboortegewicht en een verhoogd risico op toekomstige gezondheidsproblemen. Deze kinderen melden op latere leeftijd vaker ongezond gedrag en een suboptimale (geestelijke) gezondheid. In Hoofdstuk 2 presenteer ik resultaten over dit fenomeen aan de hand van een groot, landelijk registeronderzoek naar de sociaaleconomische determinanten van zorgkosten op jonge leeftijd. Gegevens van drie Nederlandse nationale registers werden gecombineerd om relaties te onderzoeken tussen de individuele- (maandelijks huishoudinkomen) en contextuele (achterstandswijk) sociaaleconomische status en perinatale morbiditeit (te vroeg en/of te klein geboren) op zorgkosten in het vroege leven (0-3 jaar) bij 480.471 kinderen geboren tussen 2011-2014. Uit dit onderzoek bleek dat kinderen uit huishoudens met een lager inkomen en uit meer achtergestelde buurten significant hogere zorgkosten hadden. Hoewel perinatale morbiditeit verantwoordelijk was voor hogere kosten, droegen zowel inkomen als achterstandswijk onafhankelijk bij aan hogere zorgkosten. Dit suggereert ofwel een verhoogde slechte gezondheid of onvoldoende gebruik van gezondheidszorg in deze lage sociaaleconomische populatie. Het begrijpen van dit mechanisme is cruciaal voor het ontwikkelen van adequaat, gericht beleid om de verschillen in zorgkosten te minimaliseren en de gezondheid en het gebruik van gezondheidszorg te optimaliseren. De periode vlak na de bevalling is een zeer geschikt moment voor het verbeteren van de gezondheidsuitkomsten bij moeders en hun pasgeborenen, bijvoorbeeld door de kraamzorg die geboden wordt direct na de geboorte en de dagen daarna. Hoewel in Nederland 95% van alle vrouwen na de bevalling ten minste enige mate van kraamzorg ontvangt, is het gebruik van kraamzorg in de prioriteitspopulatie lager. Een situatie die vooral onwenselijk is omdat juist deze vrouwen het meeste baat kunnen hebben bij deze preventieve en ondersteunende zorg. In Hoofdstuk 3 verken ik de ervaringen, bevorderende factoren en barrières voor het gebruik van kraamzorg door een analyse te maken van 23 diepte-interviews met zwangere en onlangs bevallen vrouwen uit Rotterdam die te maken hebben met moeilijke omstandigheden. Vanuit een ‘grounded-theory’-benadering werd beschreven dat het gebruik van kraamzorg beïnvloed wordt door de informatie gegeven door de kraamverzorgende, ervaren zelfredzaamheid op het gebied van ouderschap en de sten vanuit het sociale netwerk. Hoewel de gegeven informatie tijdens de zwangerschap vaak als ontoereikend werd ervaren, werd de informatie tijdens de kraamperiode zeer gewaardeerd, vooral wanneer deze was afgestemd op hun specifieke behoeften. Vrouwen ervoeren een toegenomen zelfredzaamheid in de kraamperiode, waardoor ze ook gebruik bleven maken van de kraamzorg. Vrouwen met meer steun van hun sociale netwerk vroegen de kraamverzorgenden zich te richten op de gespecialiseerde zorg voor moeder en kind, terwijl hun netwerk de huishoudelijke taken op zich nam. Tot slot had de band tussen de moeder en de kraamverzorgende bij alle thema’s een significante invloed op de ervaring van vrouwen en het verdere gebruik van kraamzorg. Deze bevinden benadrukken de noodzaak van betere informatievoorziening, het afstemmen van de zorg op het niveau van de individuele zelfredzaamheid en het betrekken van sociale netwerken bij het zorgproces, met aandacht voor de band tussen moeder en kraamverzorgende. Hoewel bovenstaande elementen cruciaal zijn voor kraamzorg zijn ze niet uitsluitend voorbehouden aan dit type zorg. Een ander voorbeeld van zorg gebaseerd op deze elementen in het programma Moeders van Rotterdam, dat ik beschrijf in Hoofdstuk 4. Moeders van Rotterdam is een innovatief initiatief op het gebied van maatschappelijke zorg voor zwangere vrouwen en moeders die onder ongunstige omstandigheden leven. Het programma is ontwikkeld als reactie op de hoge percentages perinatale sterfte en morbiditeit, armoede en afhankelijkheid van uitkeringen in gezinnen met kinderen in Rotterdam, waarbij medische en sociale zorg en ondersteuning tijdens de zwangerschap en twee jaar na de bevalling wordt geïntegreerd. Het programma biedt intensieve, toegankelijke en holistische ondersteuning door maatschappelijk werkers, ondersteund door derdejaars studenten maatschappelijk werk en toegepaste psychologie. De ondersteuning vanuit studenten vergroot het personeelsbestand, waardoor intensieve, lange-termijn ondersteuning voor gezinnen mogelijk wordt. Bovendien worden de studenten door de vrouwen als minder bedreigend ervaren, waardoor het wantrouwen afneemt en er een sterkere band ontstaat tussen (toekomstige) moeders en hulpverleners. Verdeeld over vier fasen richt het programma zich eerst op het verminderen van acute stress tijdens de zwangerschap, vervolgens op het creëren van een veilige omgeving in het eerste jaar van het kind, het bevorderen van de ontwikkeling van het kind en het uitbreiden van de sociale participatie van de moeder in het tweede jaar, en tot slot op de overgang naar het zelfstandig functioneren van het gezin. Gedurende deze fases richt het programma zich gelijktijdig op gezondheid en zorg, huisvesting, financiën en de ontwikkeling van het kind, om zo de intergenerationele overdracht van tegenslag te doorbreken. In Hoofdstuk 5 presenteer ik het onderzoeksprotocol voor de evaluatie van het Moeders van Rotterdam programma, waarbij binnen een prospectieve cohortstudie een vergelijking wordt gemaakt met reguliere ondersteuning vanuit het wijkteam. Dataverzameling vindt plaats op negen tijdstippen vanaf de zwangerschap tot na afloop van de zorg, waarbij gebruik gemaakt wordt van vragenlijsten, ontwikkelingstaken, video- en foto-observaties en registratiegegevens uit verschillende medische en sociale registraties. De primaire uitkomsten zijn de ontwikkeling van het kind en de geestelijke gezondheid van de moeder. Met een doelstelling van 1200 deelnemers wil het onderzoek betekenisvolle verschillen tussen beide vormen van zorg en ondersteuning detecteren. Vervolgens vat ik in Hoofdstuk 6 informatie samen over 919 vrouwen die zijn doorverwezen naar Moeders van Rotterdam of naar reguliere zorg. Meer specifiek wordt informatie gegeven over tegenslagen en ervaren welzijn. ‘Heat map’ methodologie toonde aan dat vrouwen te maken hadden met een veelheid aan uitdagingen, op verschillende levensdomeinen, meestal gerelateerd aan sociaal functioneren, gezondheid en financiën. Verder kwamen er twee clusters van vrouwen naar voren: één cluster met vrouwen die vooral financiële problemen hadden, terwijl het tweede cluster van vrouwen te maken had met een complex samenspel van uitdagingen om meerdere levensdomeinen. Bovendien verschilden vrouwen en hulpverleners in hun perceptie van stress, angst en depressie ervaren door deze vrouwen. Tezamen benadrukken deze bevindingen de noodzaak van een gepersonaliseerde, holistische zorgaanpak die problemen op meerdere levensdomeinen tegelijk aanpakt, evenals een zorgvuldige, gezamenlijke beoordeling van gezondheid en mentaal welzijn. Zoals hierboven beschreven hebben de problemen, tegenslagen en uitdagingen waar deze vrouwen mee te maken hebben niet alleen invloed op hun eigen gezondheid en welzijn, maar kunnen ze ook een belemmering vormen voor competent ouderschap en gezonde ouder-kind relaties. Daarom verken ik in Hoofdstuk 7 de ouderschapscapaciteiten van 83 vrouwen uit het Moeders van Rotterdam onderzoek. Door middel van video-observaties van dagelijkse verzorgingstaken (voeden, in bad doen, verschonen) werd de gehele, emotionele en instrumentele ouderschapscapaciteiten beoordeeld. De video-observaties vonden plaats rond zes weken na de bevalling bij moeder en kind thuis en werd aangevuld met informatie over psychologische symptomen, zelfredzaamheid, uitdagingen, leefomstandigheden en mentale gezondheid. Analyses toonden aan dat zowel de gehele, emotionele als instrumentele ouderschapscapaciteiten onder de maat waren, waarbij vooral de emotionele ouderschapscapaciteiten laag waren. Verrassend genoeg waren er maar weinig indicatoren wijzend op uitdagingen die significant samenhingen met de kwaliteit van de verzorging, en contra-intuïtief toonden moeders in onveilige omgevingen en moeders met meer problematische levensdomeinen betere ouderschapscapaciteiten op sommige gebieden. Deze bevindingen suggereren dat moeders in moeilijke omstandigheden dit zouden kunnen compenseren in de verzorging, of dat inadequate ouderschapscapaciteiten eerder verband houden met algemene omstandigheden dan met specifieke indicatoren. Het onderzoek onderstreept het belang van vroegtijdige interventie, in het bijzonder voor emotionele ouderschapscapaciteiten, omdat adequaat ouderschap kan beschermen tegen de negatieve impact van problemen en uitdagingen. In het laatste Hoofdstuk, Hoofdstuk 8, bespreek ik de belangrijkste bevindingen van dit proefschrift en de implicaties voor praktijk, beleid en onderzoek. In dit Hoofdstuk ga ik in op het vermogen om zich aan te passen in het licht van tegenslag; kenmerken en uitdagingen binnen deze prioriteitspopulatie; de intergenerationele overdracht van tegenslag; het (verkeerd) gebruik van (gezondheids)zorg, inclusief slechte gezondheid, meer (inadequaat) gebruik van gezondheidszorg en het zorgsysteem zelf; het belang van sociale steun; en wederzijds vertrouwen als cruciaal element voor succesvolle zorg en ondersteuning voor deze prioriteitspopulatie. Aanbevelingen voor beleid en praktijk richten zich op het opbouwen van vertrouwen, het investeren in een gedeeld perspectief en gelijkwaardig partnerschap tussen het gezin en de (sociale) zorgverlener, het versterken van sociale steun, het werken vanuit een positieve houding, zo vroeg mogelijk interveniëren en het benutten van de zwangerschap als een unieke kans voor ondersteuning en interventie. Verder geef ik een aantal aanbevelingen voor onderzoek in deze prioriteitspopulatie. Persoonlijk heb ik me beseft dat door ons te richten op de tegenslagen en uitdagingen, we deze vrouwen reduceren tot de problemen waarmee ze geconfronteerd worden en dat we daardoor niet kijken naar het potentieel dat ze hebben.
DOCUMENT
At the beginning of the twenty first century obesity entered Dutch maternity care as a ‘new illness’ challenging maternity care professionals in providing optimal care for women with higher BMI’s. International research revealed that obese women had more perinatal problems than normal weight women. However, the effect of higher BMIs on perinatal outcomes had never been studied in women eligible for midwife-led primary care at the outset of their pregnancy. In the context of the Dutch maternity care system, it was not clear if obesity should be treated as a high-risk situation always requiring obstetrician-led care or as a condition that may lead to problems that could be detected in a timely manner in midwife-led care using the usual risk assessment tools. With the increased attention on obesity in maternity care there was also increased interest in GWG. Regarding GWG in the Netherlands, the effect of insufficient or excessive GWG on perinatal outcomes had never been studied and there were no validated guidelines for GWG. A midwife’s care for the individual woman in the context of the Dutch maternity care system - characterised by ‘midwife-led care if possible, obstetrician-led care if needed’ - is hampered by the lack of national multidisciplinary consensus regarding obesity and weight gain. Obesity has not yet been included in the OIL and local protocols contain varying recommendations. To enable sound clinical decisions and to offer optimal individual care for pregnant women in the Netherlands more insights in weight and weight gain in relation to perinatal outcomes are required. With this thesis the author intends to contribute to the body of knowledge on weight and weight gain to enhance optimal midwife-led primary care for the individual woman and to guide midwives’ clinical decision-making.
DOCUMENT
Background The caesarean delivery (CD) rate has risen in most countries over the last decades, but it remains relatively low in the Netherlands. Our objective was to analyse the trends of CD rates in various subgroups of women between 2000 and 2010, and identify the practice pattern that is attributable to the relative stability of the Dutch CD rate. Methods A total of 1,935,959 women from the nationwide Perinatal Registry of the Netherlands were included. Women were categorized into ten groups based on the modified CD classification scheme. Trends of CD rates in each group were described. Results The overall CD rate increased slightly from 14.0% in 2000–2001 to 16.7% in 2010. Fetal, early and late neonatal mortality rates decreased by 40–50% from 0.53%, 0.21%, 0.04% in 2000–2001 to 0.29%, 0.12%, 0.02% in 2010, respectively. During this period, the prevalence of non-vertex presentation decreased from 6.7% to 5.3%, even though the CD rate in this group was high. The nulliparous women with spontaneous onset of labor at term and a singleton child in vertex presentation had a CD rate of 9.9%, and 64.7% of multiparouswomen with at least one previous uterine scar and a singleton child in vertex presentation had a trial of labor and the success rate of vaginal delivery was 45.9%. Conclusions The Dutch experience indicates that external cephalic version for breech presentation, keeping the CD rate low in nulliparous women and encouraging a trial of labor in multiparous women with a previous scar, could help to keep the overall CD rate steady
MULTIFILE
Background: In 2009, the Steering Committee for Pregnancy and Childbirth in the Netherlands recommended the implementation of continuous care during labor in order to improve perinatal outcomes. However, in current care, routine maternity caregivers are unable to provide this type of care, resulting in an implementation rate of less than 30%. Maternity care assistants (MCAs), who already play a nursing role in low risk births in the second stage of labor and in homecare during the postnatal period, might be able to fill this gap. In this study, we aim to explore the (cost) effectiveness of adding MCAs to routine first- and second-line maternity care, with the idea that these MCAs would offer continuous care to women during labor. Methods: A randomized controlled trial (RCT) will be performed comparing continuous care (CC) with care-as-usual (CAU). All women intending to have a vaginal birth, who have an understanding of the Dutch language and are > 18 years of age, will be eligible for inclusion. The intervention consists of the provision of continuous care by a trained MCA from the moment the supervising maternity caregiver establishes that labor has started. The primary outcome will be use of epidural analgesia (EA). Our secondary outcomes will be referrals from primary care to secondary care, caesarean delivery, instrumental delivery, adverse outcomes associated with epidural (fever, augmentation of labor, prolonged labor, postpartum hemorrhage, duration of postpartum stay in hospital for mother and/or newborn), women’s satisfaction with the birth experience, cost-effectiveness, and a budget impact analysis. Cost effectiveness will be calculated by QALY per prevented EA based on the utility index from the EQ-5D and the usage of healthcare services. A standardized sensitivity analysis will be carried out to quantify the outcome in addition to a budget impact analysis. In order to show a reduction from 25 to 17% in the primary outcome (alpha 0.05 and bèta 0.20), taking into account an extra 10% sample size for multi-level analysis and an attrition rate of 10%, 2 × 496 women will be needed (n = 992). Discussion: We expect that adding MCAs to the routine maternity care team will result in a decrease in the use of epidural analgesia and subsequent costs without a reduction in patient satisfaction. It will therefore be a costeffective intervention. Trial registration: Trial Registration: Netherlands Trial Register, NL8065. Registered 3 October 2019 - Retrospectively registered.
DOCUMENT
