Jacqueline Lagendijk

The overarching aim of this thesis was to investigate the effectiveness of preventive strategies, implemented during different phases in reproductive healthcare, to reduce adverse perinatal health outcomes and low empowerment particularly among women with a low socioeconomic status and their offspring.

In part one the effectiveness of different strategies to improve neonatal health outcomes was described along with a validation study of the R4U-scorecard.

The results of the ‘Ready for a Baby’ programme that ran from 2009 to 2012 in Rotterdam are presented in chapter 2. In this study, the influence of an urban perinatal health programme in Rotterdam on perinatal health outcomes was evaluated by a difference in difference approach, an analytical technique for natural experiment evaluation in an observational setting. The difference in difference analysis could not demonstrate that the introduction of the programme influenced trends in perinatal mortality, preterm birth, or small-for-gestational age birth in the post-intervention years in the intervention group.

In chapter 3 the results of the national C-RCT embedded in the ‘Healthy Pregnancy 4 All-1’ programme are described. The implementation of an extended risk assessment during pregnancy, and subsequent institution of care pathways and multidisciplinary consultations, showed to be feasible. The traditional risk assessment during pregnancy, mainly focussing on apparent medical risk factors, shifted towards the first trimester and created a larger window of opportunity for prevention. However, the intervention did not decrease the incidence of adverse neonatal health outcomes at birth.

Chapter 4 consists of a comprehensive evaluation of the ‘Rotterdam Reproductive Risk Reduction’ (R4U) scorecard, used in the ‘Healthy Pregnancy 4 All-1’ programme. An updated R4U-scorecard was presented that can be used in the first trimester of pregnancy to estimate the risk of adverse neonatal health outcomes. By updating the model we increased the sensitivity of the scorecard by 11%. This improved classification of high-risk pregnancies is especially important considering the feasible function of the R4U-scorecard as a diagnostic tool guiding clinicians into taking appropriate preventive follow-up actions.

In part two the current degree of inequalities in care provision and child health outcomes were reported. Furthermore, the effectiveness of extending the application of preventive strategies from pregnancy towards the postpartum period and early childhood was evaluated.

Chapter 5 presents the protocol for the “Healthy Pregnancy 4 All-2” programme. The results presented in this chapter underlie the considerable variation between geographical areas within the Netherlands for perinatal mortality and morbidity, and the prevalence of children living in deprived neighbourhoods and children living in families on welfare. The results of this study also suggest associations between adverse perinatal health and socio-economic disadvantage of children, hereby reinforcing the importance of extending the continuum for risk selection and tailored care pathways from preconception and antenatal care towards postpartum care, early childhood care, and interconception care.

In chapter 6 the existing inequity in postpartum care provision in the Netherlands is presented using a national population-based retrospective cohort study with routinely collected healthcare data. The results illustrated that women of low socioeconomic status are much less likely to receive postpartum care, and that low uptake of postpartum care was associated with higher health care expenditure after childbirth. Furthermore, the results of this study showed that substantial inequities in postpartum care provision exist according to immigration status.

The protocol for a pragmatic C-RCT embedded in the ‘Healthy Pregnancy 4 All-2’ programme is presented in chapter 7. Six urban municipalities and twelve independent maternity care organisations participated in this study that evaluates the effectiveness of a complex intervention to promote maternal empowerment in the postpartum period. The intervention under study consisted of a structured risk assessment during pregnancy, focussing on identifying non-medical risk factors for adverse maternal and neonatal health outcomes. Consecutive risk-guided tailored care was instituted throughout pregnancy and the postpartum period.

Chapter 8 presents the results of the study described in chapter 7. The implementation of the structured risk assessment during pregnancy followed by client-tailored maternity care showed to reduce the incidence of low maternal empowerment during the postpartum period. This large-scale randomised trial was the first to amend routine maternity care with tailored care and to evaluate its effectiveness. Moving forward to early identification of women at risk along with tailored, risk-reducing strategies that decrease the odds of having a low empowerment score might minimise early adversity and existing inequalities in postpartum care.