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ABSTRACT: Abstract Objective: To evaluate whether maternal ethnicity affects perinatal mortality by week of gestation from 39 weeks onwards. Study design: In this cohort study, we used data from the nationwide Netherlands Perinatal Registry from 1999 until 2008. All singleton infants born between 39+0 and 42+6 weeks of gestation without congenital anomalies were included. We used crude and multivariate logistic regression analyses with white Europeans as the reference to calculate the adjusted odds ratios (aOR) of South Asian, African and Mediterranean women. The main outcome measure was perinatal mortality (antepartum and intrapartum/neonatal mortality within 7 days after birth). Results: We studied 1,092,255 singleton deliveries. Perinatal mortality occurred in 2315 infants (2.1‰). There was interaction between gestational age and ethnicity (P<0.0001). In week 40 (40+0-40+6) South Asian (aOR 1.9; 95% CI 1.1-3.4) and Mediterranean (aOR 1.3; 95% CI 1.04-1.7) women had an increased risk of perinatal mortality. The perinatal mortality risk became greater in week 41 for South Asian (aOR 4.5 95% CI 2.8-7.2), African (aOR 2.2; 95%CI 1.4-3.4) and Mediterranean (aOR 2.2; 95% CI 1.8-2.9) women, especially among small for gestational age infants. Conclusion: With increasing gestational age beyond 39 weeks, perinatal mortality risk increases more strongly among South Asian, African and Mediterranean women compared to European whites.
Journal of Perinatal Medicine 01/2013; · 1.70 Impact Factor
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ABSTRACT: To study the effect of district on perinatal mortality in Amsterdam, the Netherlands, taking into account various risk factors including ethnicity and social economic status (SES).
Cohort study.
The investigation related to 73,661 singleton births in Amsterdam, Diemen and Ouder-Amstel recorded in the Netherlands Perinatal Registry over the years 2000-2006. Logistic regression analysis was used to determine if perinatal mortality differed by district, taking into account various risk factors.
Each year in Amsterdam an average of 10,525 singleton children were born of whom 114 infants died (10.8 per 1,000 births (‰)). National perinatal mortality was 9.9 ‰. In three districts, perinatal mortality was 1.5-2 times higher than the national average: Zuidoost (21‰), Slotervaart (14‰) and Zeeburg (14‰). However, mortality in the districts of ZuiderAmstel (5‰), Oud-Zuid (7‰), Centrum and Osdorp (8‰) was 20-50% lower. The high risk of perinatal mortality in the Zuidoost district (odds ratio: 2.1; 95% CI: 1.9-2.6) was explained by the high prevalence of women with higher risk factors; African or South Asian Surinamese ethnicity, low SES and preterm birth. The effects of parity and ethnicity on perinatal mortality differed by district. In Zeeburg increased effect for higher parity and for Turkish/Moroccan ethnicity was seen. In Slotervaart the perinatal mortality risk was increased (odds ratio: 1.8; 95% CI: 1.3-2.5), but this was not explained by the risk factors studied.
Amsterdam had districts with both highly elevated and reduced perinatal mortality rates. The prevalence of risk factors differed by district and the effects of ethnicity and parity were not homogenous. Therefore, tailored policy and research by district is necessary.
Nederlands tijdschrift voor geneeskunde 01/2011; 155:A3130.
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ABSTRACT: To explore the feasibility of a national perinatal audit organization.
Validation study.
Three regions in the Netherlands.
228 cases of perinatal mortality.
Narratives of perinatal mortality cases were assessed by a panel of representatives of all perinatal care provider groups. 123 cases were assessed twice. Consensus was defined as 75% agreement. For the chance corrected agreement Cohen's kappa statistic was used.
Consensus and the chance corrected agreement on three cause of death classifications. The presence or absence of substandard factors (SSF) with the care provider, the organization of care and the relation of the SSF with perinatal death.
Consensus rates and chance corrected agreement for three cause of death classifications ranged from 92 to 96% and kappa 0.87 to kappa 0.93 (very good agreement), with comparable confidence intervals and similar values in the validation subset of 123 cases. On the presence of SSF at the level of the care provider consensus and chance corrected agreement was 68% and kappa 0.53 (moderate), with comparable values in the subset of 123 cases. Consensus for the relation between SSF at the level of the care provider and perinatal death was 81.4% and kappa 0.68 (good).
Perinatal audit on a national level with relatively large audit groups with many different care providers is feasible.
Acta Obstetricia Et Gynecologica Scandinavica 09/2010; 89(9):1168-73. · 1.77 Impact Factor
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ABSTRACT: The European PERISTAT-1 study showed that, in 1999, perinatal mortality, especially fetal mortality, was substantially higher in The Netherlands than in other European countries. The aim of this study was to analyse the recent trend in Dutch perinatal mortality and the influence of risk factors.
A nationwide retrospective cohort study of 1,246,440 singleton births in 2000-2006 in The Netherlands. The source data were available from three linked registries: the midwifery registry, the obstetrics registry and the neonatology/paediatrics registry. The outcome measure was perinatal mortality (fetal and early neonatal mortality). The trend was studied with and without risk adjustment. Five clinical distinct groups with different perinatal mortality risks were used to gain further insight.
Perinatal mortality among singletons declined from 10.5 to 9.1 per 1000 total births in the period 2000-2006. This trend remained significant after full adjustment (odds ratio 0.97; 95% CI 0.96 to 0.98) and was present in both fetal and neonatal mortality. The decline was most prominent among births complicated by congenital anomalies, among premature births (32.0-36.6 weeks) and among term births. Home births showed the lowest mortality risk.
Dutch perinatal mortality declined steadily over this period, which could not be explained by changes in known risk factors including high maternal age and non-western ethnicity. The decline was present in all risk groups except in very premature births. The mortality level is still high compared with European standards.
Journal of epidemiology and community health 06/2009; 63(9):761-5. · 3.04 Impact Factor
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ABSTRACT: Perinatal mortality is an important indicator of health. European comparisons of perinatal mortality show an unfavourable position for the Netherlands. Our objective was to study regional variation in perinatal mortality within the Netherlands and to identify possible explanatory factors for the found differences.
Our study population comprised of all singleton births (904,003) derived from the Netherlands Perinatal Registry for the period 2000-2004. Perinatal mortality including stillbirth from 22+0 weeks gestation and early neonatal death (0-6 days) was our main outcome measure. Differences in perinatal mortality were calculated between 4 distinct geographical regions North-East-South-West. We tried to explain regional differences by adjustment for the demographic factors maternal age, parity and ethnicity and by socio-economic status and urbanisation degree using logistic modelling. In addition, regional differences in mode of delivery and risk selection were analysed as health care factors. Finally, perinatal mortality was analysed among five distinct clinical risk groups based on the mediating risk factors gestational age and congenital anomalies.
Overall perinatal mortality was 10.1 per 1,000 total births over the period 2000-2004. Perinatal mortality was elevated in the northern region (11.2 per 1,000 total births). Perinatal mortality in the eastern, western and southern region was 10.2, 10.1 and 9.6 per 1,000 total births respectively. Adjustment for demographic factors increased the perinatal mortality risk in the northern region (odds ratio 1.20, 95% CI 1.12-1.28, compared to reference western region), subsequent adjustment for socio-economic status and urbanisation explained a small part of the elevated risk (odds ratio 1.11, 95% CI 1.03-1.20). Risk group analysis showed that regional differences were absent among very preterm births (22+0 - 25+6 weeks gestation) and most prominent among births from 32+0 gestation weeks onwards and among children with severe congenital anomalies. Among term births (>or= 37+0 weeks) regional mortality differences were largest for births in women transferred from low to high risk during delivery.
Regional differences in perinatal mortality exist in the Netherlands. These differences could not be explained by demographic or socio-economic factors, however clinical risk group analysis showed indications for a role of health care factors.
BMC Public Health 05/2009; 9:102. · 2.00 Impact Factor
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ABSTRACT: To investigate the feasibility of nationwide perinatal mortality audits in the Netherlands.
Over a one-year period, data for all cases of perinatal mortality were collected. Six perinatal audit panels of professionals within perinatal care investigated and classified causes of death and identified the presence of substandard care factors (SSF).
Out of 22,189 newborns, 228 cases of perinatal mortality were audited. Placental pathology, congenital anomalies and preterm birth were the main causes of perinatal death. SSF by caregivers were identified in 72 cases (32 %). Almost 20% of the cases were not reported.
In the Netherlands, perinatal audit is well supported by all groups of caregivers. It reveals usable facts and findings for the quality assessment of perinatal care. This audit showed that in 9% of the cases perinatal death was related to SSF and potentially avoidable. However, immediate reporting of cases of perinatal death apart from regular registration in the perinatal database proved to be inaccurate. Once a nationwide audit program is realized, in which data from the different caregivers will be collected in a single database instead of collection by linkage afterwards, this problem should be solved. Local audits will start from 2009. These audits will assess mortality cases within their respective areas and may initiate adjustments for perinatal care and optimize the quality of care and inter-professional collaboration. Yearly nationwide audits will focus on specific items (e.g. term or post-term deliveries) and may well offer an opportunity for the development or adjustment of national guidelines.
Acta Obstetricia Et Gynecologica Scandinavica 01/2009; 88(11):1201-8. · 1.77 Impact Factor
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ABSTRACT: OBJECTIVE: a national study of midwives' perceptions of women's decision-making in the technical interventions in the birth process. DESIGN: questionnaire survey of women and their midwives. Midwives completed a maternity record for each woman in the study after the birth, and the women completed a demographic questionnaire at to 20-24 weeks gestation. SETTING: a stratified sample of 25 Dutch midwifery practices based on rural or urban location. Each of these 25 independent practices agreed to approach 25 eligible consecutive pregnant women on a randomly assigned day. PARTICIPANTS: in total 637 women were invited and 625 participated (response rate 98%). FINDINGS AND KEY CONCLUSIONS: midwives reported that they had a large influence in the decision to refer a woman to an obstetrician, but far and far less so when it comes to decisions around taking pharmaceutical pain relief. Midwives felt women had least say in the decision around augmentation of labour and most in the decision to sweep the membranes, whilst obstetricians had most input in the decision around primary induction of labour and least in the decision to refer from primary to secondary care. Our analysis indicated that midwives saw younger women (29 and younger) as having more influence in the decision-making process than old ones. Our analysis suggests there might be a tension between midwives own professional ideology and their non-interventionist focus and women's choice, which leads to an increase in medicalisation of childbirth.
Midwifery 10/2007; 23(3):279-86. · 1.78 Impact Factor
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ABSTRACT: The long-term effects on women in childbirth with a history of sexual abuse have only been studied to a limited degree. We estimated the prevalence of lifetime experience among low-risk pregnant women (non-clinical) in The Netherlands as well as the association with (1) psycho-social outcomes, and (2) the birth process.
Study of 625 randomly selected low-risk pregnant women. At 20-24 weeks gestation, participants completed a questionnaire covering socio-demographic variables, sexual attitude, and psychological determinants. Midwives recorded details of the birth process.
Nearly one-in-nine (11.2%) women had experienced sexual abuse. They were on average younger, more likely to smoke, and had lower household income. They reported more conflicting feelings about sex than women who did not report a history of abuse (p = 0.02). Multiparous women with a history of sexual abuse reported more emotional distress (p = 0.037), more internal beliefs concerning health (p = 0.004), and they were also more likely to suffer pelvic pain (p = 0.045). Sexually-abused women reported higher levels of autonomy (p = < 0.001). Referral rates to secondary care were equal. Sexually-abused women were less likely to receive episiotomies (p < 0.005).
Little difference was observed in major birth-related technical interventions between women with and without a history of sexual abuse.
Journal of Psychosomatic Obstetrics & Gynecology 03/2006; 27(1):59-66. · 1.39 Impact Factor
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ABSTRACT: To evaluate the performance of abdominal palpation as a screening test for intrauterine growth retardation (IUGR) in a low risk population, under standard practice conditions.
Population based observational study of 6318 consecutive low risk singleton pregnancies. The Dutch obstetric system distinguishes low from high risk pregnancies. In the low risk group abdominal palpation as a screening test is performed by midwives. If a complication, like IUGR, during prenatal care is assessed, the women is referred to a consulted obstetrician. Ultrasound is performed by the consulted obstetrician. In case of sustained suspicion the women is selected as high risk. Outcome parameters: severe small for gestational age (SGA) birthweight below 2.3rd centile, all SGA birthweight below 10th centile, operative delivery, neonatal morbidity and perinatal mortality. Screening value of abdominal palpation, abdominal palpation combined with ultrasound, and the performance of high risk selection was assessed by conventional performance measures.
Abdominal palpation as a screening test for IUGR is of limited value: the observed sensitivities were 28% for severe SGA and 21% for SGA p < or = 10, respectively. After ultrasound in case of sustained suspicion, the sensitivity in detection of severe SGA was 25% and positive predictive value (PPV) 16%. In detection of SGA p < or = 10 sensitivity was 15% and PPV 55%, which means 45% were false positives. The sensitivity of the Dutch obstetric system in selection of high risk pregnancies in detection of severe SGA was 53%, in detection of SGA p < or = 10 was 37%. Perinatal mortality was 0.9% (57/6318) and 32% of these cases were SGA. Six cases of fetal death were unrecognised during prenatal care (0.09%) and seem preventable. The prevalence of a 5 min Apgar Score < or = 7 was significantly higher in the SGA infants if SGA was defined as p < or = 10.
The diagnostic performance of abdominal palpation as a screening test for IUGR detection in a low risk population is disappointing. However, various stratagems such as routine ultrasound do not improve detection rate or perinatal morbidity and mortality.
European Journal of Obstetrics & Gynecology and Reproductive Biology 11/2004; 116(2):164-9. · 1.97 Impact Factor
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ABSTRACT: To determine the incidence and risk factors for standard and severe postpartum haemorrhage (PPH) in vaginally delivering nulliparous women, before and after risk stratification.
A population-based cohort study in an unselected cohort nulliparous women (N = 3464) in 'The Zaanstreek' district, The Netherlands. Risk stratification is part of routine care, where midwives cover all obstetrical care for women with low risk pregnancies.
The incidence of standard PPH (> or = 500 ml) and severe PPH (> or = 1000 ml) were 19 and 4.2%, respectively. A retained placenta occurred in 1.8%. These data show consistently slightly higher values as compared to studies in literature. The most important risk factors for standard and severe PPH were related to an abnormal third stage of labour-third stage > or = 30 min and retained placenta (in severe PPH: odds ratio (OR) 14.1, 95% confidence interval (CI) 10.4-19.1). High birth weight and perineal damage were less important, but independent, significant risk factors. In the low risk group (N = 1416), incidence of severe PPH was 4.0%. Independent risk factors for severe PPH were third stage > or = 30 min (incidence 7.1%, OR 3.6) and retained placenta (incidence 1.2%, OR 21.6). In 25% of the women with a prolonged third stage (> or = 30 min), third stage was complicated due to retained placenta and/or severe PPH (1.8% of the low risk group).
The incidence of PPH in nulliparous women in this cohort was on average higher than published data, while the most important risk factors for standard and severe PPH, even after risk stratification, were the same. A prolonged third stage of labour has to be considered as abnormal, requiring specific action.
European Journal of Obstetrics & Gynecology and Reproductive Biology 09/2004; 115(2):166-72. · 1.97 Impact Factor
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ABSTRACT: A home confinement with midwifery care is still an integral part of Dutch maternity care. It has been argued that the existence of home birth itself influences the course of the birth process positively, which is why obstetric interventions are low in comparison with neighboring countries. This study examined the impact of women's intended place of birth (home or hospital) and the course of pregnancy and labor when attended by midwives.
This is a prospective study of 625 low-risk pregnant women, gestation 20 to 24 weeks, enrolled in 25 independently working midwifery practices. The course of labor was measured by the frequency of interventions by midwives and obstetricians.
A more non-technological approach to childbirth was observed within the women opting for a home birth compared with the women opting for a hospital birth. Data showed a relationship between interventions and planned birth site: sweeping membranes and amniotomy by midwives were more likely to be conducted in women opting for a home birth. Multiparas opting for hospital birth were more likely to experience consultations and referrals. Within the group of multiparas referred for obstetrician care, women intending to have a home birth experienced fewer interventions (e.g., induction, augmentation, pharmacologic pain relief, assisted delivery, cesarean section) compared with those who had opted for a hospital birth.
A large proportion of women desire a home birth. The impact of that choice demonstrated a smoother course of the birth process, compared with women who desired to deliver in the hospital, as measured by fewer obstetric interventions. We suggest that psychological factors (expectation and perceptions) influence both a woman's decision of birthplace and the actual birth process.
Birth 04/2004; 31(1):28-33. · 2.18 Impact Factor
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ABSTRACT: Background: A home confinement with midwifery care is still an integral part of Dutch maternity care. It has been argued that the existence of home birth itself influences the course of the birth process positively, which is why obstetric interventions are low in comparison with neighboring countries. This study examined the impact of women's intended place of birth (home or hospital) and the course of pregnancy and labor when attended by midwives. Methods: This is a prospective study of 625 low-risk pregnant women, gestation 20 to 24 weeks, enrolled in 25 independently working midwifery practices. The course of labor was measured by the frequency of interventions by midwives and obstetricians. Results: Amore nontechnological approach to childbirth was observed within the women opting for a home birth compared with the women opting for a hospital birth. Data showed a relationship between interventions and planned birth site: sweeping membranes and amniotomy by midwives were more likely to be conducted in women opting for a home birth. Multiparas opting for hospital birth were more likely to experience consultations and referrals. Within the group of multiparas referred for obstetrician care, women intending to have a home birth experienced fewer interventions (e.g., induction, augmentation, pharmacologic pain relief, assisted delivery, cesarean section) compared with those who had opted for a hospital birth. Conclusions: A large proportion of women desire a home birth. The impact of that choice demonstrated a smoother course of the birth process, compared with women who desired to deliver in the hospital, as measured by fewer obstetric interventions. We suggest that psychological factors (expectation and perceptions) influence both a woman's decision of birthplace and the actual birth process. (BIRTH 31:1 March 2004)
Birth 03/2004; 31(1):28 - 33. · 2.18 Impact Factor
