Towards a universal concept of vulnerability: Broadening the evidence from the elderly to perinatal health using a Delphi approach.

BACKGROUND: The concept 'vulnerability' is prevalent in the public domain, health care, social institutions and multidisciplinary research. Conceptual heterogeneity is present, hampering the creation of a common evidence-base of research achievements and successful policies. Recently an international expert group combined a specific literature review with a 2-stage Delphi procedure, arriving at a seemingly universal concept of vulnerability for the elderly with applications for research instruments. We replicated and extended this study, to generalize this result to health in general, and perinatal health in particular. METHODS: Two independent expert panels (general health, perinatal health) repeated the Delphi-procedure, using an extended and updated literature review to derive statements on the concept and defining pathways of vulnerability. Additional views were collected on research tools. Consensus-by-design was explicitly avoided. Data collection and processing was independent. RESULTS: Both panels showed surprising convergence on the pathways of vulnerability to health/ill-health, and their interaction. The agreed conceptual model describes a dynamic relation between health and ill-health and vulnerability. The 2 key pathways that link to vulnerability, are complementary, but not symmetrical as biological processes of maintaining health or obtaining better health are not reciprocal to recovery, so also not in terms of vulnerability impacts. An individual's degree of vulnerability is the net balance of risk effects and protective and healing factors (socially, biologically and in terms of health literacy and health care access). These factors can for measurement purposes (according to the panels: interview for exploration, checklists for population research) be grouped into 'material resources', 'taking responsibility for one's own health', 'risky activities and behaviors', and 'social support'. Supportive and transforming action can thus be undertaken. CONCLUSION: A universal concept of vulnerability in the context of health was successfully derived after careful replication and extension of an international Delphi study on vulnerability among the elderly.

Personality Traits Predict Meeting the WHO Recommendation of 6 Months' Breastfeeding: A Prospective General Population Cohort Study.

BACKGROUND: Although personality as well as anxiety and depression are recognized as predictors for breastfeeding initiation, evidence of an association of these factors with 6 months' exclusive breastfeeding as recommended by the World Health Organization (WHO) is sparse. PURPOSE: The purpose of this study was to investigate the associations of personality and symptoms of anxiety and depression during and after pregnancy with meeting the WHO recommendation of 6 months' exclusive breastfeeding. METHODS: In their first trimester of pregnancy, 5784 pregnant women were enrolled in Dutch primary obstetric care centers and hospitals, of which 2927 completed the breastfeeding assessments 6 months postpartum. We performed logistic regression analyses to test the associations of "big five" personality traits (NEO Five Factor Inventory), anxiety (State-Trait Anxiety Inventory), and depression (Edinburgh Postnatal Depression Scale) symptom levels during pregnancy and postpartum with meeting the WHO recommendation of 6 months' exclusive breastfeeding. RESULTS: Agreeableness (odds ratio [OR] = 1.18, P = .006) and openness (OR = 1.31, P < .001) were positively associated with meeting the WHO recommendation, whereas extraversion (OR = 0.83, P = .005) and neuroticism (OR = 1.18, P = .006) were negatively associated. After adjustment for both antenatal and postpartum symptom levels of anxiety and depression, the associations of the agreeableness, extraversion, and openness personality traits remained strong and statistically significant (P < .05). IMPLICATIONS FOR PRACTICE: Patient-centered care should take personality into account in an effort to tailor interventions to optimize breastfeeding behavior. IMPLICATIONS FOR RESEARCH: In contrast to earlier findings, personality traits may be of greater importance than symptoms of anxiety and depression for meeting the WHO recommendation of 6 months' exclusive breastfeeding.

The role of structured Antenatal Risk Management (sARM) on experiences with antenatal care by vulnerable clients.

INTRODUCTION: Vulnerable clients (i.e. clients reporting psychopathology, psychosocial problems, or substance use, and/or features of deprivation) represent a challenge in perinatal care, both in term of care process and outcome. Adhering to a structured care process (i.e. structured Antenatal Risk Management [sARM]) has shown to benefit professionals in supporting vulnerable clients, but its effect on client experiences is yet to be determined. As better processes are assumed to benefit outcome, we investigated the relationship between vulnerable clients' experiences with antenatal care in perinatal units adhering to differing degrees of sARM. METHODS: We combined data from two sources: on the client level antenatal collected survey data from which vulnerability status (Mind2Care instrument) and client experiences (ReproQ questionnaire) were derived, and on the unit level interview data from healthcare providers from which the unit degree of sARM was ascertained. RESULTS: A total of N = 1.176 clients from N = 38 units were included in the study. Vulnerable clients with psychosocial problems reported more negative experiences than non-vulnerable clients. In high sARM units, vulnerable clients, regardless of type of problems, reported more negative experiences than non-vulnerable clients. In multiple regression analysis this effect disappeared and only vulnerability defined as psychosocial problems remained predictive for negative experiences. CONCLUSIONS: Vulnerable clients, specifically those with psychosocial problems, present a challenge in perinatal healthcare. Negative appraisal of care might be an unavoidable drawback of adhering to sARM. It also stresses the need for improving caregiver-client expectations and system side improvements.

The prevalence of adverse postnatal outcomes for mother and infant in the Netherlands.

BACKGROUND: In high-income countries delivery usually takes place in a short-stay hospital setting and includes limited specific care after discharge. Perinatal system performance is therefore predominantly expressed in direct terms of delivery outcomes such as preterm birth (PTB), small for gestational age (SGA) or, in case of the mother, perineal rupture and haemorrhage. Additional postnatal complications may emerge, but their incidence is largely unknown. The Dutch obstetric system includes an 8-10 day episode of professional postnatal home maternity care. Our aim was to establish, under routine conditions, the incidence of a comprehensive set of 67 predefined complications and their predictors. A second aim was to address interaction between maternal and child complications. METHODS: The study design was a prospective cohort study of all clients of one large maternity care organization receiving home maternity care in November 2014. We combined maternal background and intrapartum and postnatal characteristics with complication data, routinely recorded by home maternity care assistants. Complication prevalence rates per postnatal day were calculated. Univariate and multivariable logistic regression were used to predict the presence of postnatal complications. RESULTS: Complications occurred throughout the entire episode of home maternity care and prevalence was high, with 55% of all mother-baby pairs experiencing at least one complication (e.g. cracked nipples, >10% weight loss of the baby) and 5% at least one major complication (e.g. mastitis, cyanosis of the baby). Predictive ability of maternal background and intrapartum and postnatal variables on presence of complications was moderate (max. 62.9%), even when a cumulative risk score was used. CONCLUSIONS: The prevalence rates of maternal and neonatal postnatal complications with care as usual in high-income countries was higher than expected. Professional postnatal follow-up is to be considered in order to timely detect and manage emerging complications with minimal delay. Opportunities for risk-guided care should be investigated further. The pattern of complications in low-income countries remains to be established.

Seasonality of depressive symptoms during pregnancy.

Various risk factors have been identified for antepartum depression. This study evaluated seasonal influences on antepartum depressive symptoms. Data of 2,438 pregnant women on current depressive symptoms was obtained from a large-scale cross-sectional study in The Netherlands. Most women were screened during the first trimester. Depressive symptoms were assessed using the Edinburgh Postnatal Depression Scale (EPDS) and dichotomized using ≥ 9 as cut-off score. The seasonal relationship between antepartum depressive symptoms and the month of assessment was estimated by fitting a sinusoidal curve to the data. A total of 323 women (13.2%) scored above cut-off. In the full sample, we found no significant evidence for seasonal influences on depressive symptoms after adjusting for confounders. Additionally, we found that the seasonal influence was obscured by the modification of the effect by current treatment status. In women untreated for psychiatric complaints, we found a minimum of depressive symptomatology in September and a maximum in March. In women treated for psychiatric complaints we found a minimum of depressive symptomatology in December and a maximum in June. Thus, the effects of seasonality are apparent, but opposite in treated and untreated women. However, health professionals should be aware of depressive symptoms the whole year through.

Vulnerable pregnant women in antenatal practice: Caregiver's perception of workload, associated burden and agreement with objective caseload, and the influence of a structured organisation of antenatal risk management.

INTRODUCTION: pregnancy care for vulnerable women is often perceived as a burden by caregivers as vulnerable clients require complex case management, additional time, and more often show adverse perinatal outcomes. Vulnerable clients bring about additional work strain for the caregiver, especially when the workload is high. We define client vulnerability as coexistence of psychopathology, psychosocial problems or substance use, together with features of deprivation. We investigated, as part of a national programme, whether the subjective caregiver's perception of workload and the objective registry-based caseload of vulnerable clients are in agreement, and whether a structured organisation of antenatal risk management reduces the burden associated with the perceived workload, in particular if the objective caseload is high. METHODS: we combined three data sources: (1) at the unit level (i.e. midwifery practice, obstetric unit) interview data from caregivers, from which we derived a) the (subjective) caregiver's perception of workload, b) the associated burden and c) organisational structure of antenatal risk management, (2) at the unit level perinatal registry data, from which we derived a) unit characteristics and b) (objective) unit specific caseload, and (3) at the individual client level survey data collected during the first antenatal visit, from which the prevalence of vulnerable clients was derived. The study area was the South-West Netherlands (2.5 million inhabitants), containing areas with varying degrees of urbanisation and deprivation. FINDINGS: sixteen units had complete data on all measures. Generally, subjective workload and objective caseload were only weakly related, the relation being modified by the organisation of antenatal risk management. If the organisational structure of antenatal risk management was low, the experienced burden was high, even if the objective caseload was low. Highly structured antenatal risk management was associated with a medium to low burden. DISCUSSION: our observational study suggests that even a high caseload can be dealt with by structured antenatal risk management. A change from the current individual case-finding policies towards a more universal screen-like approach may thus benefit both the client and the caregiver.