Effects of a Nudging Cue Targeting Food Choice in a University Cafeteria: A Field Study.

Many students approaching adulthood often choose high-calorie food products. Concurrently, health interventions applied during this life phase can potentially lead to a healthier lifestyle. Nudge health interventions in experimental cafeteria settings have been found to improve eating behavior effectively, yet research in real-world settings is lacking. Accepting nudges as health interventions impacts nudge effectiveness. The present study applies a pretest-posttest design for a period of three consecutive weeks (no nudge, nudge, no nudge), testing the effectiveness of the so-called Giacometti cue on the number of calories purchased in a real-world cafeteria. Students were exposed to the nudge during the intervention week when entering the cafeteria and when choosing their meals. After purchasing a meal, their choice was recorded, and they completed a questionnaire. The Giacometti cue immediately reduced the number of calories purchased (comparing weeks one and two). After nudge removal, an effect was identified, increasing the number of calories purchased (comparing weeks two and three). Contrary to expectations, higher nudge acceptance resulted in more calories purchased. Neither awareness of the nudge's presence when buying food nor the interaction between acceptance and awareness played a role. We explore potential explanations for the Giacometti cue's effects.

Are You "Nudgeable"? Factors Affecting the Acceptance of Healthy Eating Nudges in a Cafeteria Setting.

Research has identified nudging as a promising and effective tool to improve healthy eating behavior in a cafeteria setting. However, it remains unclear who is and who is not "nudgeable" (susceptible to nudges). An important influencing factor at the individual level is nudge acceptance. While some progress has been made in determining influences on the acceptance of healthy eating nudges, research on how personal characteristics (such as the perception of social norms) affect nudge acceptance remains scarce. We conducted a survey on 1032 university students to assess the acceptance of nine different types of healthy eating nudges in a cafeteria setting with four influential factors (social norms, health-promoting collaboration, responsibility to promote healthy eating, and procrastination). These factors are likely to play a role within a university and a cafeteria setting. The present study showed that key influential factors of nudge acceptance were the perceived responsibility to promote healthy eating and health-promoting collaboration. We also identified three different student clusters with respect to nudge acceptance, demonstrating that not all nudges were accepted equally. In particular, default, salience, and priming nudges were at least moderately accepted regardless of the degree of nudgeability. Our findings provide useful policy implications for nudge development by university, cafeteria, and public health officials. Recommendations are formulated for strengthening the theoretical background of nudge acceptance and the susceptibility to nudges.

Cafeteria Online: Nudges for Healthier Food Choices in a University Cafeteria-A Randomized Online Experiment.

Many people do not consume as much healthy food as recommended. Nudging has been identified as a promising intervention strategy to increase the consumption of healthy food. The present study analyzed the effects of three body shape nudges (thin, thick, or Giacometti artwork) on food ordering and assessed the mediating role of being aware of the nudge. Students (686) and employees (218) of a German university participated in an online experimental study. After randomization, participants visited a realistic online cafeteria and composed a meal for themselves. Under experimental conditions, participants were exposed to one out of three nudges while choosing dishes: (1) thin body shape, (2) thick body shape, and (3) the Giacometti artwork nudge. The Giacometti nudge resulted in more orders for salad among employees. The thin and thick body shape nudges did not change dish orders. Awareness of the nudge mediated the numbers of calories ordered when using the Giacometti or thin body shape nudges. These findings provide useful insights for health interventions in occupational and public health sectors using nudges. Our study contributes to the research on the Giacometti nudge by showing its effectiveness when participants are aware (it is effective under conditions where it is consciously perceived).

External validation of a prediction model on vaginal birth after caesarean in a The Netherlands: a prospective cohort study.

OBJECTIVES: Discussing the individual probability of a successful vaginal birth after caesarean (VBAC) can support decision making. The aim of this study is to externally validate a prediction model for the probability of a VBAC in a Dutch population. METHODS: In this prospective cohort study in 12 Dutch hospitals, 586 women intending VBAC were included. Inclusion criteria were singleton pregnancies with a cephalic foetal presentation, delivery after 37 weeks and one previous caesarean section (CS) and preference for intending VBAC. The studied prediction model included six predictors: pre-pregnancy body mass index, previous vaginal delivery, previous CS because of non-progressive labour, Caucasian ethnicity, induction of current labour, and estimated foetal weight ≥90th percentile. The discriminative and predictive performance of the model was assessed using receiver operating characteristic curve analysis and calibration plots. RESULTS: The area under the curve was 0.73 (CI 0.69-0.78). The average predicted probability of a VBAC according to the prediction model was 70.3% (range 33-92%). The actual VBAC rate was 71.7%. The calibration plot shows some overestimation for low probabilities of VBAC and an underestimation of high probabilities. CONCLUSIONS: The prediction model showed good performance and was externally validated in a Dutch population. Hence it can be implemented as part of counselling for mode of delivery in women choosing between intended VBAC or planned CS after previous CS.

Neonatal outcomes according to actual delivery mode after planned vaginal delivery in women with a twin pregnancy.

OBJECTIVE: To compare, in women with twin pregnancy with the first twin in cephalic position, neonatal morbidity and mortality rates after actual 1) Vaginal delivery (VD) both twins versus 2) unplanned Cesarean Delivery (CD) of both twins and 3) after VD of twin A and CD of twin B (combined delivery). STUDY DESIGN: We describe a nationwide cohort study of women pregnant with twins who planned to deliver vaginally between 32+0 - 41+6 weeks with the first twin in cephalic position, between 2000-2012 in the Netherlands. We used multivariate logistic regression analysis to compare neonatal morbidity and mortality according to actual mode of delivery, overall, and for preterm and term groups separately. RESULTS: We included 19,723 women of whom 15,785 women (80.0 %) delivered both twins by VD, 2926 (14.6 %) delivered both twins by unplanned CD, and 1012 (5.1 %) women delivered by combined delivery. After unplanned CD of both twins compared to VD more perinatal mortality (1 or more twins affected) was seen (adjusted Odds Ratio (aOR) 2.23 (95 % CI 1.26-4.129)), as was 'Asphyxia related morbidity' (aOR 2.44 (95 % CI 1.80-3.31), 'other morbidity' (aOR 1.34 (95 %CI 1.17-1.54), and 'any morbidity or mortality' (aOR1.39 (95 % CI 1.22-1.58)). Less 'Trauma- related morbidity' after unplanned CD vs. VD (aOR 0.11 (95 % 0.02-0.79)) was seen. After combined delivery vs. VD, more perinatal mortality (aOR 7.75 (95 % CI 4.51-13.34)), more Asphyxia- related morbidity (aOR 6.67 (95 % CI4.91-9.06), 'prematurity related morbidity' (aOR 2.11 (95 % CI 1.59-2.79) 'other morbidity' (aOR 2.01 (95 % CI 1.65-2.46), and 'any morbidity or mortality' (aOR 2.44 (95 % CI 2.04-2.91)) were noted. All outcomes expect 'trauma-associated morbidity' were more increased for twin B as compared to twin A. CONCLUSION: After unplanned CD of both twins vs. VD of both twins, a twofold increase in neonatal mortality is noted. Combined delivery vs. VD of both twins is associated with a sevenfold increase in perinatal mortality and a five-fold increase in asphyxia-related outcomes. Twin A is more affected after unplanned CD of both twins, while twin B is more affected after combined delivery.

The effect of the use of a decision aid with individual risk estimation on the mode of delivery after a caesarean section: A prospective cohort study.

OBJECTIVE: After one previous caesarean section (CS), pregnant women can deliver by elective repeat CS or have a trial of labor which can end in a vaginal birth after caesarean (VBAC) or an unplanned CS. Despite guidelines describing women's rights to make an informed choice, trial of labor and VBAC rates vary greatly worldwide. Many women are inadequately informed due to caregivers' fear of an increase in CS rates in a high VBAC rate setting. We compared counseling with a decision aid (DA) including a prediction model on VBAC to care as usual. We hypothesize that counselling with the DA does not decrease VBAC rates. In addition, we aimed to study the effects on unplanned CS rate, patient involvement in decision-making and elective repeat CS rates. METHODS: We performed a prospective cohort study. From 2012 to 2014, 483 women in six hospitals, where the DA was used (intervention group), were compared with 441 women in six matched hospitals (control group). Women with one previous CS, pregnant of a singleton in cephalic presentation, delivering after 37 weeks 0 days were eligible for inclusion. RESULTS: There was no significant difference in VBAC rates between the intervention (45%) and control group (46%) (adjusted odds ratio 0,92 (95% Confidence interval 0.69-1.23)). In the intervention group more women (42%) chose an elective repeat CS compared to the control group (31%) (adjusted odds ratio 1.6 (95% Confidence interval 1.18-2.17)). Of women choosing trial of labor, in the intervention group 77% delivered vaginally compared to 67% in the control group, resulting in an unplanned CS adjusted odds ratio of 0,57 (0.40-0.82) in the intervention group. In the intervention group, more women reported to be involved in decision-making (98% vs. 68%, P< 0.001). CONCLUSIONS: Implementing a decision aid with a prediction model for risk selection suggests unchanged VBAC rates, but 40% reduction in unplanned CS rates, increase in elective repeat CS and improved patient involvement in decision-making.

[Decrease in foetal and neonatal mortality in the Netherlands; comparison with other Euro-Peristat countries in 2004, 2010 and 2015]. / Afname van foetale en neonatale sterfte in Nederland.

OBJECTIVE: To compare changes in foetal, neonatal and perinatal mortality in the Netherlands in 2015, relative to 2004 and 2010, with changes in other European countries and regions. DESIGN: Descriptive population-wide study. METHOD: Data from 32 European countries and regions within the Euro-Peristat registration area were analysed. These countries and regions were grouped into: the Netherlands, Scandinavia, Western Europe and Eastern Europe. International differences in registration and policies were taken into account by using rates from 28 weeks gestation for foetal mortality and for 24 weeks gestation and beyond for neonatal mortality. Ranking was based on individual countries and regions. RESULTS: Foetal mortality decreased by 24% in the Netherlands, from 2.9 per 1,000 births in 2010 to 2.2 per 1,000 births in 2015; neonatal mortality decreased by 9%, from 2.2 to 2.0 per 1,000 live births. Perinatal mortality (the sum of foetal mortality and neonatal mortality) decreased by 18% from 5.1 to 4.2 per 1,000 births. The Netherlands moved from the 18th place in the European ranking in 2004 to the 10th place in 2015. CONCLUSION: Foetal, neonatal and perinatal mortality in the Netherlands decreased in 2015 when compared with 2004 and 2010. The country's position in the European ranking also improved. Explanations for this decrease are related to changes in the areas of organisation of care, population and risk factors. When mortality rates in other European countries and regions - particularly Scandinavia - are considered there is room for further improvement.

Systematic literature review on which maternal alcohol behaviours are related to fetal alcohol spectrum disorders (FASD).

OBJECTIVES: Fetal alcohol spectrum disorders (FASD) is a worldwide problem. Maternal alcohol consumption is an important risk factor for FASD. It remains unknown which alcohol consumption patterns most strongly predict FASD. The objective of this study was to identify these. DESIGN: Systematic literature review. METHODS: We searched in PubMed, PsychINFO, PsycARTICLES, ERIC, CINAHL, Embase and MEDLINE up to August 2018. The query consisted of keywords and their synonyms related to FASD, pregnancy and behaviour. Studies were excluded when not published in English, were reviews or involved non-human subjects. Substantial heterogeneity precluded aggregation or meta-analysis of the data. Instead, data were qualitatively inspected. RESULTS: In total, 21 studies were eligible for further data analysis. All studies that measured both maternal alcohol drinking behaviours and FASD reported retrospective data on maternal drinking patterns, employing both continuous and categorical measures and exhibiting substantial heterogeneity in measures of alcohol consumption (eg, timing of exposure, quantification of alcohol measure and definition of a standard drink). Study quality improved over time and appeared higher for studies based on active case ascertainment, especially when conducted in schools and when behaviour was assessed through interviews. CONCLUSIONS: We aimed to identify specific maternal drinking behaviour(s) related to FASD. The state of the literature precludes such conclusions. Evidence-based preventive measures necessitate identifying which prenatal alcohol drinking behaviour(s) are most in need of intervention. Therefore, we formulate three recommendations for future research. First, future studies can optimise the value of the collected dataset through specifying measurements and reporting of maternal drinking behaviours and avoiding categorised measures (nominal or ordinal) whenever possible. Second, samples should not be selected based on FASD status, but instead, FASD status as well as maternal alcohol consumption should both be measured in a general population sample. Finally, we provide 10 reporting guidelines for FASD research.

Understanding Fetal Heart Rate Patterns That May Predict Antenatal and Intrapartum Neural Injury.

Electronic fetal heart rate (FHR) monitoring is widely used to assess fetal well-being throughout pregnancy and labor. Both antenatal and intrapartum FHR monitoring are associated with a high negative predictive value and a very poor positive predictive value. This in part reflects the physiological resilience of the healthy fetus and the remarkable effectiveness of fetal adaptations to even severe challenges. In this way, the majority of "abnormal" FHR patterns in fact reflect a fetus' appropriate adaptive responses to adverse in utero conditions. Understanding the physiology of these adaptations, how they are reflected in the FHR trace and in what conditions they can fail is therefore critical to appreciating both the potential uses and limitations of electronic FHR monitoring.

The peripheral chemoreflex: indefatigable guardian of fetal physiological adaptation to labour.

The fetus is consistently exposed to repeated periods of impaired oxygen (hypoxaemia) and nutrient supply in labour. This is balanced by the healthy fetus's remarkable anaerobic tolerance and impressive ability to mount protective adaptations to hypoxaemia. The most important mediator of fetal adaptations to brief repeated hypoxaemia is the peripheral chemoreflex, a rapid reflex response to acute falls in arterial oxygen tension. The overwhelming majority of fetuses are able to respond to repeated uterine contractions without developing hypotension or hypoxic-ischaemic injury. In contrast, fetuses who are either exposed to severe hypoxaemia, for example during uterine hyperstimulation, or enter labour with reduced anaerobic reserve (e.g. as shown by severe fetal growth restriction) are at increased risk of developing intermittent hypotension and cerebral hypoperfusion. It is remarkable to note that when fetuses develop hypotension during such repeated severe hypoxaemia, it is not mediated by impaired reflex adaptation, but by failure to maintain combined ventricular output, likely due to a combination of exhaustion of myocardial glycogen and evolving myocardial injury. The chemoreflex is suppressed by relatively long periods of severe hypoxaemia of 1.5-2 min, longer than the typical contraction. Even in this setting, the peripheral chemoreflex is consistently reactivated between contractions. These findings demonstrate that the peripheral chemoreflex is an indefatigable guardian of fetal adaptation to labour.

Birth place preferences and women's expectations and experiences regarding duration and pain of labor.

INTRODUCTION: We know a great deal about how childbirth is affected by setting; we know less about how the experience of birth is shaped by the attitudes women bring with them to the birthing room. In order to better understand how women frame childbirth, we examined the relationship between birth place preference and expectations and experiences regarding duration of labor and labor pain in healthy nulliparous women. METHODS: A prospective cohort study (2007-2011) of 454 women who preferred a home birth (n = 179), a midwife-led hospital birth (n = 133) or an obstetrician-led hospital birth (n = 142) in the Netherlands. Data were collected using three questionnaires (before 20 weeks gestation, 32 weeks gestation and 6 weeks postpartum) and medical records. Analyses were performed according to the initial preferred place of birth. RESULTS: Women who preferred a home birth were significantly less likely to be worried about the duration of labor (OR 0.5, 95%CI 0.2-0.9) and were less likely to expect difficulties with coping with pain (OR 0.4, 95%CI 0.2-0.8) compared with women who preferred an obstetrician-led birth. We found no significant differences in postpartum accounts of duration of labor. When compared to women who preferred an obstetrician-led birth, women who preferred a home birth were significantly less likely to experience labor pain as unpleasant (OR 0.3, 95%CI 0.1-0.7). Women who preferred a midwife-led birth - either home or hospital - were more likely to report that it was not possible to make their own choices regarding pain relief compared to women who preferred obstetrician-led care (OR 4.3, 95%CI 1.9-9.8 resp. 3.4, 95%CI 1.5-7.7). Compared to women who preferred a midwife-led hospital birth, women who preferred a home birth had an increased likelihood of being dissatisfied about the management of pain relief (OR 2.5, 95%CI 1.1-6.0). DISCUSSION: Our findings suggest a more natural orientation toward birth with the acceptance of labor pain as part of giving birth in women with a preference for a home birth. Knowledge about women's expectations and experiences will help caregivers to prepare women for childbirth and will equip them to advise women on birth settings that fit their cognitive frame.

Comparison of planned caesarean delivery and planned vaginal delivery in women with a twin pregnancy: A nation wide cohort study.

OBJECTIVE: To compare, in women with twin pregnancy with the first twin in cephalic position, neonatal morbidity and mortality rates after planned caesarean delivery (CD) versus planned vaginal delivery (VD). STUDY DESIGN: A nationwide cohort study on women pregnant with twins and the first child in cephalic position, who delivered between 32 + 0-41 + 0 weeks between 2000 and 2012 in the Netherlands, using multivariate logistic regression analysis to compare neonatal morbidity and mortality according to planned delivery mode, and looking at subgroups 32 + 0-36 + 6 and 37 + 0-41 + 0 weeks. RESULTS: We included 21,107 women, of whom 1384 (6.6%) had a planned CD. Of the 19,723 women (93.4%) who had a planned VD, 19.7% delivered by intrapartum CD. We found no significant differences in 'any mortality' (aOR planned CD vs. planned VD 1.34 (95% CI 0.63-2.60)), the outcome 'Apgar score (AS) < 4 or death within 28 days' (aOR 1.28 (95% CI 0.77-2.11) or asphyxia-related morbidity (aOR 0.57 (95% CI 0.32-1.03)). After planned CD more prematurity-related morbidity (aOR 1.55 (95% CI 1.21-1.98)), other morbidity (aOR 1.50 (95% CI 1.26-1.78)) and 'any morbidity or mortality' (aOR 1.41 (95% CI 1.20-1.66) was noted. Trauma-associated morbidity was absent after planned CD and occurred 45 times (0.2%) after planned VD. Before 36 + 6 weeks, planned CD resulted in more perinatal mortality (aOR 2.10 (95% CI 0.92-4.76)), while asphyxia-related morbidity did not differ (aOR 0.80 (95% CI 0.41-1.54). Planned CD resulted in more 'any morbidity or mortality' (aOR 1.52 (95% CI 1.25-1.84)), 'AS < 4 or death within 28 days' (aOR 1.77 (95% CI 1.02-3.09)), prematurity-related morbidity (aOR 1.73 (95% CI 1.34-2.23)), and 'other morbidity' (aOR 1.56 (95% CI 1.28-1.90)). After 37 weeks, no significance differences in mortality, 'any morbidity or mortality <28 days' (aOR 0.96 (95% CI 1 (0.67-1.38)), or 'AS < 4 or death within 28 days' (aOR 0.41 (95% CI (0.10-1.70)) were found. There was less asphyxia-related morbidity after planned CD (aOR 0.24 (95% CI 0.06-1.002)). CONCLUSION: Planned VD results in comparable neonatal outcomes as planned CD for twin pregnancy with the first twin in cephalic position, even with a low intrapartum CD rate of 19.7%. At term, a planned CD may result in less asphyxia- and trauma-related outcomes.

Retrospective study of the effect of remifentanil use during labor on fetal heart rate patterns.

OBJECTIVE: To investigate possible associations between remifentanil and the appearance of sinusoidal heart rate patterns in fetuses, and neonatal outcomes. METHODS: The present retrospective cohort study included data from patients at over 37 weeks of singleton or multiple pregnancies attending Zuyderland Medical Center, Sittard, the Netherlands, in labor between June 1, and August 31, 2015. Patient data were stratified by whether remifentanil was administered during delivery (remifentanil group) or not (control group), and fetal heart rate tracings were reviewed to identify sinusoidal heart rate patterns. The neonatal outcomes compared were 5-minute Apgar scores and umbilical artery pH. RESULTS: There were 119 patients included in the study; 60 in the remifentanil group and 59 in the control group. Tracings from 20 (33%) patients in the remifentanil group exhibited a sinusoidal heart rate pattern after remifentanil administration, compared with 5 (8%) patients in the control group (P=0.001). The median time before the onset of sinusoidal patterns after remifentanil administration was 12 minutes. No adverse neonatal outcomes were recorded in either group. CONCLUSION: Remifentanil use during labor was associated with the occurrence of sinusoidal heart rate patterns in the fetus; this was not associated with adverse neonatal outcomes.

External Validation Study of First Trimester Obstetric Prediction Models (Expect Study I): Research Protocol and Population Characteristics.

BACKGROUND: A number of first-trimester prediction models addressing important obstetric outcomes have been published. However, most models have not been externally validated. External validation is essential before implementing a prediction model in clinical practice. OBJECTIVE: The objective of this paper is to describe the design of a study to externally validate existing first trimester obstetric prediction models, based upon maternal characteristics and standard measurements (eg, blood pressure), for the risk of pre-eclampsia (PE), gestational diabetes mellitus (GDM), spontaneous preterm birth (PTB), small-for-gestational-age (SGA) infants, and large-for-gestational-age (LGA) infants among Dutch pregnant women (Expect Study I). The results of a pilot study on the feasibility and acceptability of the recruitment process and the comprehensibility of the Pregnancy Questionnaire 1 are also reported. METHODS: A multicenter prospective cohort study was performed in The Netherlands between July 1, 2013 and December 31, 2015. First trimester obstetric prediction models were systematically selected from the literature. Predictor variables were measured by the Web-based Pregnancy Questionnaire 1 and pregnancy outcomes were established using the Postpartum Questionnaire 1 and medical records. Information about maternal health-related quality of life, costs, and satisfaction with Dutch obstetric care was collected from a subsample of women. A pilot study was carried out before the official start of inclusion. External validity of the models will be evaluated by assessing discrimination and calibration. RESULTS: Based on the pilot study, minor improvements were made to the recruitment process and online Pregnancy Questionnaire 1. The validation cohort consists of 2614 women. Data analysis of the external validation study is in progress. CONCLUSIONS: This study will offer insight into the generalizability of existing, non-invasive first trimester prediction models for various obstetric outcomes in a Dutch obstetric population. An impact study for the evaluation of the best obstetric prediction models in the Dutch setting with respect to their effect on clinical outcomes, costs, and quality of life-Expect Study II-is being planned. TRIAL REGISTRATION: Netherlands Trial Registry (NTR): NTR4143; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4143 (Archived by WebCite at http://www.webcitation.org/6t8ijtpd9).

Identification of barriers and facilitators for optimal cesarean section care: perspective of professionals.

BACKGROUND: The cesarean section (CS) rate has increased over recent decades with poor guideline adherence as a possible cause. The objective of this study was to explore barriers and facilitators for delivering optimal care as described in clinical practice guidelines. METHODS: Key recommendations from evidence-based guidelines were used as a base to explore barriers and facilitators for delivering optimal CS care in The Netherlands. Both focus group and telephone interviews among 29 different obstetrical professionals were performed. Transcripts from the interviews were analysed. Barriers and facilitators were identified and categorised in six domains according to the framework developed by Grol: the guideline recommendations (I), the professional (II), the patient (III), the social context (IV), the organizational context (V) and the financial/legislation context (VI). RESULTS: Most barriers were found in the professional and organizational domain. Barriers mentioned by healthcare professionals were disagreement with specific guideline recommendations, and hesitation to allow women to be part of the decision making process. Other barriers are lack of adequately trained personal staff, lack of collaboration between professionals, and lack of technical equipment. CONCLUSIONS: Clear facilitators and barriers for guideline adherence were identified in all domains. Several barriers may be addressed by using decision aids on mode of birth or prediction models to individualise care in women in whom both planned vaginal birth and CS are equal options. In women with an intended vaginal birth, adequate staffing and the availability of both fetal blood sampling and epidural analgesia are important.

Lower perinatal mortality in preterm born twins than in singletons: a nationwide study from The Netherlands.

BACKGROUND: Twin pregnancies are at increased risk for perinatal morbidity and death because of many factors that include a high incidence of preterm delivery. Compared with singleton pregnancies, overall perinatal risk of death is higher in twin pregnancies; however, for the preterm period, the perinatal mortality rate has been reported to be lower in twins. OBJECTIVE: The purpose of this study was to compare perinatal mortality rates in relation to gestational age at birth between singleton and twin pregnancies, taking into account socioeconomic status, fetal sex, and parity. STUDY DESIGN: We studied perinatal mortality rates according to gestational age at birth in 1,502,120 singletons pregnancies and 51,658 twin pregnancies without congenital malformations who were delivered between 2002 and 2010 after 28 weeks of gestation. Data were collected from the nationwide Netherlands Perinatal Registry. RESULTS: Overall the perinatal mortality rate in twin pregnancies (6.6/1000 infants) was higher than in singleton pregnancies (4.1/1000 infants). However, in the preterm period, the perinatal mortality rate in twin pregnancies was substantially lower than in singleton pregnancies (10.4 per 1000 infants as compared with 34.5 per 1000 infants, respectively) for infants who were born at <37 weeks of gestation; this held especially for antepartum deaths. After 39 weeks of gestation, the perinatal mortality rate was higher in twin pregnancies. Differences in parity, fetal sex, and socioeconomic status did not explain the observed differences in outcome. CONCLUSION: Overall the perinatal mortality rate was higher in twin pregnancies than in singleton pregnancies, which is most likely caused by the high preterm birth rate in twins and not by a higher mortality rate for gestation, apart from term pregnancies. During the preterm period, the antepartum mortality rate was much lower in twin pregnancies than in singleton pregnancies. We suggest that this might be partially due to a closer monitoring of twin pregnancies, which indirectly suggests a need for closer surveillance of singleton pregnancies.

Practice variation of vaginal birth after cesarean and the influence of risk factors at patient level: a retrospective cohort study.

INTRODUCTION: Large practice variation exists in mode of delivery after cesarean section, suggesting variation in implementation of contemporary guidelines. We aim to evaluate this practice variation and to what extent this can be explained by risk factors at patient level. MATERIAL AND METHODS: This retrospective cohort study was performed among 17 Dutch hospitals in 2010. Women with one prior cesarean section without a contraindication for a trial of labor were included. We used multivariate logistic regression analysis to develop models for risk factor adjustments. One model was derived to adjust the elective repeat cesarean section rates; a second model to adjust vaginal birth after cesarean rates. Standardized rates of elective repeat cesarean section and vaginal birth after cesarean per hospital were compared. Pseudo-R2 measures were calculated to estimate the percentage of practice variation explained by the models. Secondary outcomes were differences in practice variation between hospital types and the correlation between standardized elective repeat cesarean section and vaginal birth after cesarean rates. RESULTS: In all, 1068 women had a history of cesarean section, of whom 71% were eligible for inclusion. A total of 515 women (67%) had a trial of labor, of whom 72% delivered vaginally. The elective repeat cesarean section rate at hospital level ranged from 6 to 54% (mean 29.8, standard deviation 11.8%). Vaginal birth after cesarean rates ranged from 50 to 90% (mean 71.8%, standard deviation 11.1%). More than 85% of this practice variation could not be explained by risk factors at patient level. CONCLUSION: A large practice variation exists in elective repeat cesarean section and vaginal birth after cesarean rates that can only partially be explained by risk factors at patient level.

Epidural analgesia during labour, routinely or on request: a cost-effectiveness analysis.

OBJECTIVE: To assess the cost-effectiveness of routine labour epidural analgesia (EA), from a societal perspective, as compared with labour analgesia on request. STUDY DESIGN: Women delivering of a singleton in cephalic presentation beyond 36+0 weeks' gestation were randomly allocated to routine labour EA or analgesia on request in one university and one non-university teaching hospital in the Netherlands. Costs included all medical, non-medical and indirect costs from randomisation to 6 weeks postpartum. Effectiveness was defined as a non-operative, spontaneous vaginal delivery without EA-related maternal adverse effects. Incremental cost-effectiveness ratio (ICER) was defined as the ratio of the difference in costs and the difference in effectiveness between both groups. Data were analysed according to intention to treat and divided into a base case analysis and a sensitivity analysis. RESULTS: Total delivery costs in the routine EA group (n=233) were higher than in the labour on request group (n=255) (difference -€ 322, 95% CI -€ 60 to € 355) due to more medication costs (including EA), a longer stay in the labour ward, and more operations including caesarean sections. Total postpartum hospital costs in the routine EA group were lower (difference -€ 344, 95% CI -€ 1338 to € 621) mainly due to less neonatal admissions (difference -€ 472, 95% CI -€ 1297 to € 331), whereas total postpartum home and others costs were comparable (difference -€ 20, 95% CI -€ 267 to € 248, and -€ 1, 95% CI -€ 67 to € 284, respectively). As a result, the overall mean costs per woman were comparable between the routine EA group and the analgesia on request group (€ 8.708 and € 8.710, respectively, mean difference -€ 2, 95% CI -€ 1.012 to € 916). Routine labour EA resulted in more deliveries with maternal adverse effects, nevertheless the ICER remained low (€ 8; bootstrap 95% CI -€ 6.120 to € 8.659). The cost-effectiveness acceptability curve indicated a low probability that routine EA is cost-effective. CONCLUSION: Routine labour EA generates comparable costs as analgesia on request, but results in more operative deliveries and more EA-related maternal adverse effects. Based on cost-effectiveness, no preference can be given to routine labour EA as compared with analgesia on request.

Declines in stillbirth and neonatal mortality rates in Europe between 2004 and 2010: results from the Euro-Peristat project.

BACKGROUND: Stillbirth and neonatal mortality rates declined in Europe between 2004 and 2010. We hypothesised that declines might be greater for countries with higher mortality in 2004 and disproportionally affect very preterm infants at highest risk. METHODS: Data about live births, stillbirths and neonatal deaths by gestational age (GA) were collected using a common protocol by the Euro-Peristat project in 2004 and 2010. We analysed stillbirths at ≥28 weeks GA in 22 countries and live births ≥24 weeks GA for neonatal mortality in 18 countries. Per cent changes over time were assessed by calculating risk ratios (RR) for stillbirth, neonatal mortality and preterm birth rates in 2010 vs 2004. We used meta-analysis techniques to derive pooled RR using random-effects models overall, by GA subgroups and by mortality level in 2004. RESULTS: Between 2004 and 2010, stillbirths declined by 17% (95% CI 10% to 23%), with a range from 1% to 39% by country. Neonatal mortality declined by 29% (95% CI 23% to 35%) with a range from 9% to 67%. Preterm birth rates did not change: 0% (95% CI -3% to 3%). Mortality declines were of a similar magnitude at all GA; mortality levels in 2004 were not associated with RRs. CONCLUSIONS: Stillbirths and neonatal deaths declined at all gestational ages in countries with both high and low levels of mortality in 2004. These results raise questions about how low-mortality countries achieve continued declines and highlight the importance of improving care across the GA spectrum.