Living in a deprived region is acknowledged as an important risk factor for adverse birth outcomes, such as preterm birth and small-for-gestational age birth [
3,
6,
7]. In deprived regions the prevalence of risk factors, single or in combination, is higher than in non-deprived regions [
8,
9]. Not only medical risks, but also non-medical risk factors are involved, often related to poverty, such as low socioeconomic status, substance abuse including smoking, and psychological distress [
9].
Since 2008, in response to the awareness about the high prevalence of adverse perinatal outcomes in the Netherlands, much effort has been invested into improving perinatal health [
10]. This has led to research and policy programs that aim to increase attention for risk assessment and risk reduction before and during pregnancy. One such program, ‘Ready for a Baby’ (2008–2012), was initiated with the aim to improve perinatal health in Rotterdam, the second largest city in the Netherlands, especially in its deprived neighbourhoods [
11,
12]. Strengthening of the inter-professional collaboration between curative and the public health professionals and reaching-out to a more vulnerable population, consisting of low-educated and/or immigrant groups, were the stepping stones to reach this goal.
In 2011, building on the insights of the ‘Ready for a Baby’ program, we launched the Healthy Pregnancy 4 All (HP4All-1) program in 14 municipalities that had higher rates of adverse perinatal outcomes than the national average [
4]. The HP4All-1 program focused on: a) the implementation of preconception care via different recruitment strategies, and b) the introduction of systematic antenatal risk assessment (considering both medical and non-medical risk factors) with the antenatal Rotterdam Reproductive Risk Reduction (R4U) scorecard, followed by tailored multidisciplinary care pathways [
13,
14]. Again, optimal linkage between the curative and the public health domain was sought on preconception, prenatal and perinatal care.
Since 2014, this approach has been extended to cover postpartum care, early childhood care and interconception care in the Healthy Pregnancy for All 2 (HP4All-2) program.
HP4All-2 program
The HP4All-2 program focuses on creating a continuum of risk selection, followed by tailored (multidisciplinary) care pathways, from the preconception and prenatal period towards the postpartum and early childhood period. The rationale for this focus is that certain risk factors before and during pregnancy, such as neighbourhoods and individual social characteristics, often continue to exist after delivery, affecting both maternal and offspring health [
6,
15]. Moreover, perinatal health status in itself is an important determinant of child health and health in later life [
1]. For example, high birth weight is positively associated with childhood overweight and low birth weight is negatively associated with developmental outcomes [
16,
17]. To translate this knowledge into practice, comprehensive care beyond the boundaries of the separate social and medical domains of care is needed in the preconception, prenatal, postpartum and early childhood period [
18].
Therefore, HP4All-2 aims to introduce integrated, risk-guided care, beyond separate domains of antenatal care, maternity care and Preventive Child Health Care (PCHC). In the Netherlands, professional maternity care is provided at home by maternity care assistants, who have completed a specialisation of ‘personal health care assistant’ at the level of secondary vocational education and are being supervised by community midwives [
19]. PCHC organizations promote children’s health up to the age of 19 years by providing immunisations, monitoring growth and development, offering health advice, and referring to specialised care if needed [
20,
21].
Maternity care and PCHC are used as the main settings for three risk assessment interventions that are studied within the HP4All-2 program. These three intervention studies are being implemented in ten municipalities that agreed to participate in one or more of the studies (Table
1).
Table 1
An overview of the participation of municipalities in the HP4All-2 program, and its studies
Amsterdamd
| | X | X |
Rotterdamd
| X | X | X |
Den Haagd
| | | X |
Utrechtd
| X | | |
Tilburgd
| | | X |
Groningend
| X | | X |
Almered
| X | | X |
Arnhem | X | | |
Dordrecht | | X | |
Schiedamd
| X | | X |
Aim This study aims to timely plan customised maternity care to the individual needs of women at high risk for adverse pregnancy and child outcomes.
Rationale Previous research indicates that high risk women benefit more from intensive postpartum care than women with low risks [
22,
23]. This yields the need for a structured risk assessment during pregnancy in conjunction with custom fit maternity care.
Study Design This study is a cluster randomised controlled trial in six municipalities in the Netherlands. Within a municipality, two clusters are formed in the same geographical area; one intervention and one control cluster. Two municipalities were merged together to account for enough participants, resulting in a total number of 10 clusters. A cluster may consist of one or more maternity care organisations. The intervention under study is a systematic risk assessment during pregnancy of medical and non-medical risk factors for adverse maternal and child outcomes, in conjunction with client-tailored care during pregnancy and the postpartum period. In the control clusters this systematic risk assessment is introduced during pregnancy as well, yet is followed by conventional maternity care during pregnancy and in the postpartum period. All pregnant women cared for by participating maternity care organisations, who have a scheduled home visit during pregnancy, are invited to take part in the trial.
Outcomes Primary outcome is maternal empowerment assessed between day 6 and 14 postpartum. Secondary outcome measures include maternal health outcomes, maternal health behaviour and health care utilisation in the first months postpartum. In addition, we will assess the determinants of successful implementation by questionnaires addressed to managers of maternity care organisations and to maternity care assistants.
Aim This study aims to identify and reduce the risk of growth and developmental problems in children before the age of 18 months, during their postnatal visits to the PCHC centre.
Rationale Within PCHC centres, care is provided to all children and families free of charge, with population coverage of 95% during the first year of life. Therefore, it seems to be the ideal setting for early risk screening and indicating appropriate care for vulnerable families at risk of adverse child health outcomes. To ensure structured risk assessment, the ‘postnatal R4U’ has been developed (comparable to the ‘antenatal R4U’ [
13]). This risk assessment instrument scores both medical and non-medical risk factors and combines information already documented by the PCHC, obstetric data and newly screened items. All items of the ‘postnatal R4U’ are based on an extensive literature search and expert consultations by focus group interviews. In summary, the items were categorised into six domains: the social [
24‐
26], ethnicity [
17,
27], care status [
28], lifestyle [
29‐
31], obstetric [
32,
33] and medical domains [
34,
35].
Study design In this prospective cohort study, the ‘postnatal R4U’ is introduced in the participating PCHC centres in three municipalities. All children aged zero to 8 weeks old will be assessed with this instrument and, in case of detected risks, integrated care pathways will be offered to reduce the detected risks. A historical control group of children in the same four-digit postal code area will be constructed for comparison of the study outcomes.
Outcomes Primary outcomes are growth problems (defined as overweight, obesity and catch-up growth) and developmental problems in children until the age of 18 months. Developmental problems will be assessed using the ‘Van Wiechen Scheme’, a Dutch instrument for monitoring motor, language, cognitive and psychosocial development which is routinely applied from birth onward at visits to the PCHC centre [
36].
Aim This study aims to implement and evaluate interconception care in PCHC centres.
Rationale Interconception care, also referred to as preconception care between pregnancies, aims to facilitate optimal preparation for pregnancy and minimise risk factors for an adverse pregnancy outcome. Delivery of interconception care is still uncommon [
37]. A valuable opportunity to deliver interconception care can be through PCHC centres, since almost all parents and their young children visit PCHC centres regularly for routine well-child visits [
38].
Study Design In this prospective cohort study, interconception care is implemented in participating PCHC centres in seven municipalities. PCHC professionals are instructed to inform women about the possibility of an interconception care consultation in case of a (future) pregnancy wish. They discuss this possibility with women who attend for a routine visit at their child’s age of 6 months. Subsequently, women can make an appointment for a separate interconception care consultation. In three municipalities women are offered this consultation by the PCHC centre, in the other four municipalities they are referred to local midwives or general practitioners. Decisions on which approach was applied, were made in mutual agreement with stakeholders within the municipalities.
Professionals are requested to record each time they discuss the possibility of an interconception care consultation with women, as well as when they provide the actual consultation.
Outcomes Primary outcome is the effectiveness of the implementation of interconception care in PCHC, measured as the proportion of eligible women who were informed about an interconception care consultation. Secondary outcomes include determinants of the implementation, effectiveness and utilisation of interconception care, studied by surveying women with a (future) pregnancy wish and PCHC professionals.
The HP4All-2 program is currently implementing these studies, aiming to target municipalities with a relatively disadvantageous position on perinatal and child health outcomes. In 2014 we presented data on regional perinatal health outcomes in the Netherlands during the period 2000–2008, based on which municipalities were invited to participate in the HP4All-1 program [
4]. To delineate the recent position of the ten currently participating municipalities relative to other regions in the Netherlands, we now present the municipal and regional prevalence of perinatal mortality and morbidity over the period 2009–2014. Additionally, given the focus of the HP4All-2 program on postnatal care in continuum with antenatal care, proxies for socioeconomic risk factors for adverse child health are included in our analyses, being the prevalence of children living in deprived neighbourhoods and of children living in families on welfare over the period 2009–2012.