Gestational age and socio-demographic factors associated with school performance at the age of 12 years, a population-based study.

BACKGROUND: Gestational age is positively associated with cognitive development, but socio-demographic factors also influence school performance. Previous studies suggested possible interaction, putting children with low socio-economic status (SES) at increased risk of the negative effects of prematurity. OBJECTIVES: To investigate the association between gestational age in weeks, socio-demographic characteristics, and school performance at the age of 12 years among children in regular primary education. METHODS: Population-based cohort study among liveborn singletons (N = 860,332) born in the Netherlands in 1999-2006 at 25-42 weeks' gestation, with school performance from 2011 to 2019. Regression analyses were conducted investigating the association of gestational age and sociodemographic factors with school performance and possible interaction. RESULTS: School performance increased with gestational age up to 40 weeks. This pattern was evident across socio-demographic strata. Children born at 25 weeks had -0.57 SD (95% confidence interval -0.79, -0.35) lower school performance z-scores and lower secondary school level compared to 40 weeks. Low maternal education, low maternal age, and non-European origin were strongly associated with lower school performance. Being born third or later and low socioeconomic status (SES) were also associated with lower school performance, but differences were smaller than among other factors. When born preterm, children from mothers with low education level, low or high age, low SES or children born third or later were at higher risk for lower school performance compared to children of mothers with intermediate education level, aged 25-29 years, with intermediate SES or first borns (evidence of interaction). CONCLUSIONS: Higher gestational age is associated with better school performance at the age of 12 years along the entire spectrum of gestational age, beyond the cut-off of preterm birth and across socio-demographic differences. Children in socially or economically disadvantaged situations might be more vulnerable to the negative impact of preterm birth. Other important factors in school performance are maternal education, maternal age, ethnicity, birth order and SES. Results should be interpreted with caution due to differential loss to follow-up.

Does induction of labor at 41 weeks (early, mid or late) improve birth outcomes in low-risk pregnancy? A nationwide propensity score-matched study.

INTRODUCTION: This study aimed to assess whether induction of labor at 41 weeks of gestation improved perinatal outcomes in a low-risk pregnancy compared with expectant management. MATERIAL AND METHODS: Registry-based national cohort study in The Netherlands. The study population comprised 239 971 low-risk singleton pregnancies from 2010 to 2019, with birth occurring from 41+0 to 42+0 weeks. We used propensity score matching to compare induction of labor in three 2-day groups to expectant management, and further conducted separate analyses by parity. The main outcome measures were stillbirth, perinatal mortality, 5-min Apgar <4 and <7, neonatal intensive care unit (NICU) admissions ≥24 h, and emergency cesarean section rate. RESULTS: Compared with expectant management, induction of labor at 41+0 to 41+1 weeks resulted in reduced stillbirths (adjusted odds ratio [aOR] 0.15, 95% confidence interval [CI] 0.05-0.51) in both nulliparous and multiparous women. Induction of labor increased 5-min Apgar score <7 (aOR 1.30, 95% CI 1.09-1.55) and NICU admissions ≥24 h (aOR 2.12, 95% CI 1.53-2.92), particularly in nulliparous women, and increased the cesarean section rate (aOR 1.42, 95% CI 1.34-1.51). At 41+2-41+3 weeks, induction of labor reduced perinatal mortality (aOR 0.13, 95% CI 0.04-0.43) in both nulliparous and multiparous women. The rate of 5-min Apgar score <7 was increased (aOR 1.26, 95% CI 1.06-1.50), reaching significance in multiparous women. The cesarean section rate increased (aOR 1.57, 95% CI 1.48-1.67) in both nulliparous and multiparous women. Induction of labor at 41+4 to 41+5 weeks reduced stillbirths (aOR 0.30, 95% CI 0.10-0.93). Induction of labor increased rates of 5-min Apgar score <4 (aOR 1.61, 95% CI 1.01-2.56) and NICU admissions ≥24 h (aOR 1.52, 95% CI 1.08-2.13) in nulliparous women. Cesarean section rate was increased (aOR 1.47, 95% CI 1.38-1.57) in nulliparous and multiparous women. CONCLUSIONS: At 41+2 to 41+3 weeks, induction of labor reduced perinatal mortality, and in all 2-day groups at 41 weeks, it reduced stillbirths, compared with expectant management. Low 5-min Apgar score (<7 and <4) and NICU admissions ≥24 h occurred more often with induction of labor, especially in nulliparous women. Induction of labor in all 2-day groups coincided with elevated cesarean section rates in nulliparous and multiparous women. These findings pertaining to the choice of induction of labor vs expectant management should be discussed when counseling women at 41 weeks of gestation.

Decreasing trend in preterm birth and perinatal mortality, do disparities also decline?

BACKGROUND: In the Netherlands, several initiatives started after the publication of the PERISTAT findings that showed the perinatal mortality risk was higher than in other European countries. The objective of this study is 1) to report recent trends in perinatal mortality and in intermediate risk groups (preterm birth, congenital anomalies and small for gestational age (SGA)), 2) describing perinatal mortality risk among children born preterm, with congenital anomalies or SGA, and born in maternal high risk groups (parity, age, ethnicity and socio-economic status (SES)). METHODS: A nationwide cohort study in the Netherlands among 996,423 singleton births in 2010-2015 with a gestational age between 24.0 and 42.6 weeks. Trend tests, univariate and multivariable logistic regression analyses were used. We did separate analyses for gestational age subgroups and line of care. RESULTS: The perinatal mortality rate was 5.0 per 1000 and it decreased significantly from 5.6 in 2010 to 4.6 per 1000 in 2015. Preterm birth significantly declined (6.1% in 2010 to 5.6% in 2015). Analysis by gestational age groups showed that the largest decline in perinatal mortality of 32% was seen at 24-27 weeks of gestation where the risk declined from 497 to 339 per 1000. At term, the decline was 23% from 2.2 to 1.7 per 1000. The smallest decline was 3% between 32 and 36 weeks. In children with preterm birth, congenital anomalies or SGA, the perinatal mortality risk significantly declined. Main risk factors for perinatal mortality were African ethnicity (adjusted odds ratio (aOR) 2.1 95%CI [1.9-2.4]), maternal age ≥ 40 years (aOR1.9 95%CI [1.7-2.2]) and parity 2+ (aOR 1.4 95%CI [1.3-1.5]). Among the (post)term born neonates, there was no significant decline in perinatal mortality in women with low age, low or high SES, non-Western ethnicity and among women who started or delivered under primary care. CONCLUSIONS: There is a decline in preterm birth and in perinatal mortality between 2010 and 2015. The decline in perinatal mortality is both in stillbirths and in neonatal mortality, most prominently among 24-27 weeks and among (post)term births. A possible future target could be deliveries among 32-36 weeks, women with high maternal age or non-Western ethnicity.

Intrapartum epidural analgesia and low Apgar score among singleton infants born at term: A propensity score matched study.

INTRODUCTION: The associations of epidural analgesia and low Apgar score found in the Swedish Registry might be a result of confounding by indication. The objective of this study was to assess the possible effect of intrapartum epidural analgesia on low Apgar score and neonatal intensive care unit (NICU) admission in term born singletons with propensity score matching. MATERIAL AND METHODS: This was a propensity score matched study (n = 257 872) conducted in a national cohort of 715 449 term live born singletons without congenital anomalies in the Netherlands. Mothers with prelabor cesarean section were excluded. Main outcome measures were 5-minute Apgar score <7, 5-minute Apgar score <4 and admission to a NICU for at least 24 hours. First, an analysis of the underlying risk factors for low Apgar score <7 was performed. Multivariable analyses were applied to assess the effect of the main risk factor, intrapartum epidural analgesia, on low Apgar score to adjust the results for confounding factors. Second, a propensity score matched analysis on the main risk factors for epidural analgesia was applied. By propensity score matching the (confounding) characteristics of the women who received epidural analgesia with the characteristics of the control women without epidural analgesia, the effect of possible confounding by indication is minimized. RESULTS: Intrapartum epidural analgesia was performed in 128 936 women (18%). Apgar score <7 was present in 1.0%, Apgar score <4 in .2% and NICU admission in .4% of the deliveries. The strongest risk factor for Apgar score <7 was epidural analgesia (adjusted odds ratio [aOR] 1.9, 95% confidence interval [CI] 1.8-2.0). The propensity score matched adjusted analysis of women with epidural analgesia showed significant adverse neonatal outcomes: aOR 1.8 (95% CI 1.7-1.9) for AS <7, aOR 1.6 (95% CI 1.4-1.9) for AS <4 and aOR 1.7 (95% CI 1.6-1.9) for NICU admission. The results of epidural analgesia on AS <7 were also significantly increased for spontaneous start of labor (aOR 2.0, 95% CI 1.8-2.1) and for spontaneous delivery. CONCLUSIONS: Intrapartum epidural analgesia at term is strongly associated with low Apgar score and more NICU admissions, especially in spontaneous deliveries. This association needs further research and awareness.

Intrapartum and neonatal mortality in low-risk term women in midwife-led care and obstetrician-led care at the onset of labor: A national matched cohort study.

INTRODUCTION: Midwife-led models of care have been the subject of debate for many years. We conducted a study to compare intrapartum and neonatal mortality rates in midwife-led (primary) vs obstetrician-led (secondary) care at the onset of labor in low-risk term women. MATERIAL AND METHODS: We performed an unmatched and a propensity score matched cohort study using data from the national perinatal audit registry (PAN) and from the national perinatal registry (PERINED) of the Netherlands. We included women with singleton pregnancies (without congenital anomalies or antepartum fetal death) who gave birth at term between 2010 and 2012. We excluded the following major risk factors: non-vertex position of the fetus, previous cesarean birth, hypertension, diabetes mellitus, prolonged rupture of membranes (≥24 hours), vaginal bleeding in the second half of pregnancy, nonspontaneous start of labor and post-term pregnancy (≥42 weeks). The primary outcome was intrapartum or neonatal mortality up to 28 days after birth. Secondary outcome measures were mode of delivery and a 5-minute Apgar score <7. RESULTS: We included 259 211 women. There were 100/206 642 (0.48‰) intrapartum and neonatal deaths in the midwife group and 23/52 569 (0.44‰) in the obstetrician group (odds ratio [OR] 1.11, 95% CI 0.70-1.74). Propensity score matched analysis showed mortality rates of 0.49‰ (26/52 569) among women in midwife-led care and 0.44‰ (23/52 569) for women in obstetrician-led care (OR 1.13, 95% CI 0.65-1.98). In the midwife group there were significantly lower rates of vaginal instrumental deliveries (8.4% vs 13.0%; matched OR 0.65, 95% CI 0.62-0.67) and intrapartum cesarean sections (2.6% vs 8.2%; matched OR 0.32, 95% CI 0.30-0.34), and fewer neonates with low Apgar scores (<7 after 5 minutes) (0.69% vs 1.11%; matched OR 0.61, 95% CI 0.53-0.69). CONCLUSIONS: Among low-risk term women, there were comparable intrapartum and neonatal mortality rates for women starting labor in midwife-led vs obstetrician-led care, with lower intervention rates and fewer low Apgar scores in the midwife group.

Small for gestational age and perinatal mortality at term: An audit in a Dutch national cohort study.

OBJECTIVE: To assess the underlying risk factors for perinatal mortality in term born small for gestational age infants. STUDY DESIGN: We performed a population based nationwide cohort study in the Netherlands of 465,532 term born infants from January 2010 to January 2013. Logistic regression analyses were performed. Also audit results were studied for detailed care information. RESULTS: We studied 162 small for gestational age infants who died in the perinatal period. Risk factors were: gestational age at 37completed weeks (adjusted Odds Ratio (aOR) 2.6, 95% Confidence Interval (CI) 1.6-4.3), male gender (aOR 1.4, 95% CI 1.01-1.9), South Asian ethnicity (aOR 3.6, 95% CI 1.6-8.4), African (aOR 3.5, 95% CI 1.9-6.5) and other non-Western ethnicity (aOR 1.9, CI 1.2-3.1). At 37 completed weeks gestation audit results showed that 26% of the women smoked, 91% were boys and in all but one case death occurred before birth. In 61% of all deceased SGA infants born at 37 completed weeks gestation referral from primary care by independent midwives to the obstetrician took place because of antepartum death before labor. CONCLUSIONS: Gestational age of 37 completed weeks, male gender, South Asian, African or other non-Western ethnicity and smoking are associated with perinatal mortality in SGA infants. These risk factors concern the complete term population starting at 37 weeks or even earlier. Therefore, it is of utmost importance to develop accurate diagnostic tests to screen for SGA before 36 weeks gestation to prevent perinatal mortality at term in SGA infants.

Antenatal prediction of neonatal mortality in very premature infants.

OBJECTIVE: To develop a prognostic model for antenatal prediction of neonatal mortality in infants threatening to be born very preterm (<32 weeks). STUDY DESIGN: Nationwide cohort study in The Netherlands between 1999 and 2007. We studied 8500 singletons born between 25(+0) and 31(+6) weeks of gestation where fetus was alive at birth without congenital anomalies. We developed a multiple logistic regression model to estimate the risk of neonatal mortality within 28 days after birth, based on characteristics that are known before birth. We used bootstrapping techniques for internal validation. Discrimination (AUC), accuracy (Brier score) and calibration (graph, c-statistics) were used to assess the model's predictive performance. RESULTS: Neonatal mortality occurred in 766 (90 per 1000) live births. The final model consisted of seven variables. Predictors were low gestational age, no antental corticosteroids, male gender, maternal age ≥35 years, Caucasian ethnicity, non-cephalic presentation and non-3rd level of hospital. The predicted probabilities ranged from 0.003 to 0.697 (IQR 0.02-0.11). The model had an AUC of 0.83, the Brier score was 0.065. The calibration graph showed good calibration, and the test for the Hosmer Lemeshow c-statistic showed no lack of fit (p=0.43). CONCLUSIONS: Neonatal mortality can be predicted for very preterm births based on the antenatal factors gestational age, antental corticosteroids, fetal gender, maternal age, ethnicity, presentation and level of hospital. This model can be helpful in antenatal counseling.

Term perinatal mortality audit in the Netherlands 2010-2012: a population-based cohort study.

OBJECTIVE: To assess the implementation and first results of a term perinatal internal audit by a standardised method. DESIGN: Population-based cohort study. SETTING: All 90 Dutch hospitals with obstetric/paediatric departments linked to community practices of midwives, general practitioners in their attachment areas, organised in perinatal cooperation groups (PCG). POPULATION: The population consisted of 943 registered term perinatal deaths occurring in 2010-2012 with detailed information, including 707 cases with completed audit results. MAIN OUTCOME MEASURES: Participation in the audit, perinatal death classification, identification of substandard factors (SSF), SSF in relation to death, conclusive recommendations for quality improvement in perinatal care and antepartum risk selection at the start of labour. RESULTS: After the introduction of the perinatal audit in 2010, all PCGs participated. They organised 645 audit sessions, with an average of 31 healthcare professionals per session. Of all 1102 term perinatal deaths (2.3/1000) data were registered for 86% (943) and standardised anonymised audit results for 64% (707). In 53% of the cases at least one SSF was identified. Non-compliance to guidelines (35%) and deviation from usual professional care (41%) were the most frequent SSF. There was a (very) probable relation between the SSF and perinatal death for 8% of all cases. This declined over the years: from 10% (n=23) in 2010 to 5% (n=10) in 2012 (p=0.060). Simultaneously term perinatal mortality decreased from 2.3 to 2.0/1000 births (p<0.00001). Possibilities for improvement were identified in the organisation of care (35%), guidelines or usual care (19%) and in documentation (15%). More pregnancies were antepartum selected as high risk, 70% in 2010 and 84% in 2012 (p=0.0001). CONCLUSIONS: The perinatal audit is implemented nationwide in all obstetrical units in the Netherlands in a short time period. It is possible that the audit contributed to the decrease in term perinatal mortality.

Ethnic disparities in perinatal mortality at 40 and 41 weeks of gestation.

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.

[Differences in perinatal mortality between districts of Amsterdam]. / Perinatale sterfteverschillen in Amsterdam.

OBJECTIVE: 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). DESIGN: Cohort study. METHOD: 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. RESULTS: 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. CONCLUSION: 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.

[Differences between Dutch provinces in perinatal mortality and travel time to hospital]. / Provinciale verschillen in perinatale sterfte en reistijd tot ziekenhuis.

OBJECTIVE: To investigate differences in perinatal mortality between Dutch provinces and to determine the significance of risk factors including travel time from home to the hospital during labour. DESIGN: Cohort study. METHOD: The study was based on 1,242,725 singleton births in 2000-2006 as recorded in the Netherlands Perinatal Registry. The influence of province on perinatal mortality was estimated, with logistic regression analysis adjusting for risk factors (age, parity, ethnicity, socioeconomic status) and care factors such as start of antenatal care and travel time. RESULTS: The perinatal mortality rate in the Netherlands was 9.9 per 1000 births. The provinces with the highest mortality rates were Friesland (11.3‰), Groningen (11.1‰), Zeeland (10.6‰) and Flevoland (10.4‰). Noord-Brabant (9.2‰) and Limburg (9.2‰) had the lowest mortality rates. These differences were significantly higher for Friesland (odds ratio: 1.16; 95%-CI: 1.05-1.28) and Groningen (odds ratio: 1.13; 95%-CI: 1.02-1.26). Starting late with perinatal care, at 18 weeks of gestation or later was an important risk factor (adjusted odds ratio 1.8; 95%-CI: 1.7-1.8). Low socio-economic status could partly be associated with the higher mortality risk in Groningen. Longer travel time (≥ 20 minutes) was an independent risk factor associated with perinatal mortality. On average 19% of the women travelled ≥ 20 minutes to the hospital. In the provinces Groningen, Friesland, Flevoland and Zeeland these percentages ranged between 32 and 36%. The adjusted odds ratio of travel time was 1.7 (95%-CI 1.6-1.7). CONCLUSION: The perinatal mortality differs per province. This can be explained by longer travel time to the hospital during labour. Late start of perinatal care and low socio-economic status also affect the mortality rate. These risk factors need to be taken into account during registration, investigation, audit and obstetric policy.

National perinatal audit, a feasible initiative for the Netherlands!? A validation study.

OBJECTIVE: To explore the feasibility of a national perinatal audit organization. DESIGN: Validation study. SETTING: Three regions in the Netherlands. POPULATION: 228 cases of perinatal mortality. METHODS: 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. MAIN OUTCOME MEASURES: 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. RESULTS: 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). CONCLUSION: Perinatal audit on a national level with relatively large audit groups with many different care providers is feasible.

The Dutch Perinatal Audit Project: a feasibility study for nationwide perinatal audit in the Netherlands.

OBJECTIVE: To investigate the feasibility of nationwide perinatal mortality audits in the Netherlands. STUDY DESIGN: 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). RESULTS: 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. CONCLUSIONS: 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.

Regional perinatal mortality differences in the Netherlands; care is the question.

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSION: 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.

Dutch women's decision-making in pregnancy and labour as seen through the eyes of their midwives.

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.

Bad experience, good birthing: Dutch low-risk pregnant women with a history of sexual abuse.

OBJECTIVE: 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. METHODS: 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. RESULTS: 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). CONCLUSION: Little difference was observed in major birth-related technical interventions between women with and without a history of sexual abuse.

Effectiveness of detection of intrauterine growth retardation by abdominal palpation as screening test in a low risk population: an observational study.

OBJECTIVE: 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. STUDY DESIGN: 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. RESULTS: 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. CONCLUSIONS: 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.

Postpartum haemorrhage in nulliparous women: incidence and risk factors in low and high risk women. A Dutch population-based cohort study on standard (> or = 500 ml) and severe (> or = 1000 ml) postpartum haemorrhage.

OBJECTIVE: To determine the incidence and risk factors for standard and severe postpartum haemorrhage (PPH) in vaginally delivering nulliparous women, before and after risk stratification. STUDY DESIGN: 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. RESULTS: 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). CONCLUSIONS: 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.

Does a pregnant woman's intended place of birth influence her attitudes toward and occurrence of obstetric interventions?

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: 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. 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.