Introduction
Dutch perinatal care system | |
Antenatal care in The Netherlands is based on the concept that pregnancy, childbirth, and the postpartum period are fundamentally physiologic processes. Obstetric risk selection is performed by community midwives or obstetricians and is based on the ‘List of Obstetric Indications’ (LOI), which specifies manifest conditions that define a low, medium, or high-risk pregnancy. An obstetrician will care for women with a high-risk pregnancy whereas a community midwife may provide care to women with a low or a medium risk. Based on the LOI approximately 30% of all pregnant women are considered to have a low risk throughout their pregnancy and delivery. In 2015, 13.1% of all births in the Netherlands were home births. In case of an uncomplicated institutional delivery the mother will usually be discharged home within a few hours. Regardless of the risk indication based on the LOI, the community midwife will be responsible for care of the mother when discharged home during the postpartum period. Maternity care is provided by maternity care assistants (MCAs) and will start at home, or – less frequently – in a primary care birth center, under supervision of the community midwife. Following delivery, a MCA visits and supports the family at home on a daily basis for the first eight to ten consecutive days. Initially maternity care covers six to eight hours a day but this is tapered off towards the end of the care period. If a mother is hospitalized after delivery for a longer duration, the provided care by MCAs is reduced. However, based on specific indications (see Table 2) the care provision by MCAs may be expanded. |
Maternity care organizations | |
There are around 120 maternity care organizations in the Netherlands that function as independent enterprises. Women can sign up during pregnancy with any maternity care organization that provides care in their neighborhood. On average, 95% of all women make use of some amount of maternity care. During pregnancy a MCA will assess a woman’s expected care requirements during a scheduled home visit around 25–37 weeks of gestation. For primiparous women this intake is scheduled as a home visit, whereas for multiparous women this intake is conducted per telephone. Compensation from health insurers to maternity care organizations differs according to this policy. The intensity of care provision during the postpartum period is based on the indications denoted in the Dutch national indication protocol (abbreviated by LIP in Dutch). Examples of indications that add to the intensity of care are: not being physically self-sufficient, having a psychological illness, and having other children under the age of four years. An example of an indication that will downscale the intensity of care is planning to bottle feed rather than breastfeed the newborn. The minimum volume of care at home is set at 24 h over eight days, the recommended volume is set at 49 h, and its maximum amount is set at 80 h, depending on specific indications, spread out over eight to ten days. Maternity care is covered by the general health care insurance (which is mandatory for every Dutch inhabitant) with exception of an out-of-pocket payment of €4.30 per hour (2017). |
Methods
Study setting
Eligibility criteria
Criteria for maternity care organizations
Criteria for health care professionals
Exclusion criteria for maternity care organizations
Inclusion criteria participants
Exclusion criteria participants
Intervention
Intervention at the level of the participant
Aspects relevant to both intervention and control arms
Intervention on the level of the MCA and the level of maternity organizations
Control situation
Outcomes
Primary outcome
Outcomes | Postpartum period | |
Early (1–2 weeks after childbirth) | Late (6–12 weeks after childbirth) | |
Primary |
Maternal empowerment
| |
Definition | Low empowerment score (no/yes) defined as a score beneath the 20th centile within the control group | |
Assessment | Maternal Empowerment Questionnaire (MEQ). Overall scoring based on the median score across the following four domains; “Looking after yourself”, “My baby”, “My family”, “The future”. Values per question: 1 “Never” 2 “Sometimes”, 3 “Usually”, and 4 “Always”. | |
Secondary |
Maternal health related quality of life
|
Maternal depression (postnatal depression)
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Definition | Continuous outcome ranging from zero (dead) to one (full health). | Dichotomous outcome based on the sum score: “No” sum score < 13 and “Yes” sum score > 12. |
Assessment | 5-level EQ-5D (EQ-5D-5 L). Each dimension within the questionnaire has 5 levels: 1 “no problems”, 2 “slight problems”, 3 “moderate problems”, 4 “severe problems”, and 5 “extreme problems”. Resulting in health profiles ranging from “11,111” through “55,555”. Continuous score calculated with the obtained profiles of the questionnaire with the validated EQ-5D-5 L calculator. | Edinburgh Postnatal Depression Scale (EPDS). Ten item scale. Responses are scored 0, 1, 2 and 3 based on the seriousness of the symptom. Range 0–30. |
Maternal perceived health
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Maternal health care utilization
| |
Definition | Continuous outcome ranging from zero (the worst health possible) to 100 (the best health possible). | Categorical outcome: “No additional care”, “One visit to the A and E department, GP, or GP out-of-hours service”, “Multiple visits”, and “Admission in a hospital” |
Assessment | EuroQol-visual analogue scales (EQ-VAS) represented by a 20 cm vertical scale. | Q1: Since your baby was born, have you had any symptoms for which you have been to the accident and emergency (A and E) department, GP or out-of-hours GP service? |
Q2: Have you been admitted to hospital since your baby was born? | ||
Neonatal health care utilization
| ||
Definition | Categorical outcome ranging from: “No additional care”, “One visit to the A and E department, GP, or GP out-of-hours service”, “Multiple visits”, and “Admission in a hospital” | |
Assessment | Q1: Have you been to the accident and emergency (A and E) department, GP or out-of-hours GP service for your baby since he or she was born? | |
Q2: Has your baby been admitted to hospital since he or she was born? | ||
Maternal cigarette use
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Maternal cigarette use
| |
Definition | Dichotomous outcome (no/yes): “Yes” defined as any usage | Dichotomous outcome (no/yes): “Yes” defined as any usage |
Assessment | Q: Do you smoke? | Q: Do you smoke? |
Maternal alcohol use
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Maternal alcohol use
| |
Definition | Dichotomous outcome (no/yes): “Yes” defined as any usage | Dichotomous outcome (no/yes): “Yes” defined as any usage |
Assessment | Q: Do you drink alcohol? | Q: Do you drink alcohol? |
Maternal drugs use
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Maternal drugs use
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Definition | Dichotomous outcome (no/yes): “Yes” defined as any usage | Dichotomous outcome (no/yes): “Yes” defined as any usage |
Assessment | Q: Do you use drugs? Marijuana, hash and weed are drugs too. | Q: Do you use drugs? Marijuana, hash and weed are drugs too. |