Targeted social care for highly vulnerable pregnant women: protocol of the Mothers of Rotterdam cohort study

Clustering of non-medical risk factors and the association with duration of social care in pregnant women in highly vulnerable circumstances

Pregnancy can be considered a window of opportunity to help pregnant women optimize the circumstances they live in. Within the Mothers of Rotterdam study, pregnant women in highly vulnerable circumstances received standard social care or targeted social care to improve their circumstances. Women in this study had many combinations of non-medical risk factors contributing to their vulnerable circumstances. Here, the aim is to study the association between different combinations of non-medical risk factors and duration of care. Existing non-medical risk factors, assessed with a vulnerability checklist, were clustered using Latent Class Analysis (LCA). Linear regression was used to examine the relationship with duration of social care. The model was adjusted for maternal age, deprived neighbourhood, and type of social care. Four vulnerability classes were identified among 840 women and were labelled complex (9%), educational (24%), social network (12%), and financial vulnerability (55%). In the unadjusted model, all three classes showed a significant longer duration of social care compared to the financial vulnerability class. After adjustment, only the longer duration of care of the social network vulnerability class remained statistically significant. The four identified vulnerability classes illustrate that even within a group of women in highly vulnerable circumstances, subgroups of vulnerability exist. The vulnerability classes were identifiable through different combinations of non-medical risk factors and are all, associated with different durations of social care. These findings help to understand, and plan for, the requirements of social care for women in highly vulnerable circumstances.

Incidence of adverse perinatal outcomes in highly vulnerable pregnant women - the Mothers of Rotterdam study

BACKGROUND

Socioeconomic disadvantaged circumstances are known to affect health outcomes, but during pregnancy it also affects the growth and development of the fetus. This often results in adverse perinatal outcomes and other long lasting effects. Here we refer to pregnant women living in such circumstances as a highly vulnerable population.

OBJECTIVES

To study adverse perinatal outcomes in highly vulnerable pregnant women within the Mothers of Rotterdam (MoR) study and to compare findings to the outcomes of women in the Netherlands as a whole and the city of Rotterdam.

METHODS

Pregnancy and childbirth data from women participating in the MoR study (2015-2019) was requested from their obstetric professional. For comparison, data from the Dutch national birth registry (Perined) were used representing women in the Netherlands and Rotterdam. Main outcome measures were preterm birth (PTB) and small for gestational age (SGA). Secondary outcome measures were perinatal mortality and a low Apgar score. Only singleton viable pregnancies (i.e. birthweight above 500 g or born after 22 + 0 weeks of gestation) were included in this study. Prevalence rates and corresponding 95% confidence intervals (95%CI) were calculated for all outcomes in each group. Direct standardization was used to account for possible differences in case-mix composition between the studied groups.

RESULTS

Data on 346 childbirths within the MoR study were retrieved and compared to 813,755 and 34,009 childbirths in the Netherlands and Rotterdam, respectively. The prevalence of PTB (4.34% (95%CI 2.19-6.48) was lower in the MoR population compared to both the Netherlands (6.21% (95%CI 6.16-6.27)) and Rotterdam (6.39% (95%CI 6.13-6.65)). The prevalence of SGA (21.09% (95% CI 16.80-25.40)) was higher in the MoR population compared to both the Netherlands (10.11% (95%CI 10.04-10.17)) and Rotterdam (13.28% (95%CI 12.92-13.65)). There were no cases of perinatal mortality registered in the MoR population. The prevalence of a low Apgar score (0.87% (95%CI 0.00-1.84)) was lower in the MoR population.

CONCLUSIONS

Our study found unexpected low PTB and high SGA prevalence rates in the MoR population compared to the Netherlands and Rotterdam. Mechanisms through which socioeconomic disadvantaged circumstances affect perinatal health seem to work differently in various strata of vulnerable populations.

Complexity and interplay of faced adversities and perceived health and well-being in highly vulnerable pregnant women-the Mothers of Rotterdam program

BACKGROUND

Living in socially disadvantaged circumstances has a widespread impact on one's physical and mental health. That is why individuals living in this situation are often considered vulnerable. When pregnant, not only the woman's health is affected, but also that of her (unborn) child. It is well accepted that vulnerable populations experience worse (perinatal) health, however, little is known about the lived adversities and health of these vulnerable individuals.

OBJECTIVES

With this article, insights into this group of highly vulnerable pregnant women are provided by describing the adversities these women face and their experienced well-being.

METHODS

Highly vulnerable women were recruited when referred to tailored social care during pregnancy. Being highly vulnerable was defined as facing at least three different adversities divided over two or more life-domains. The heat map method was used to assess the interplay between adversities from the different life domains. Demographics and results from the baseline questionnaires on self-sufficiency and perceived health and well-being were presented.

RESULTS

Nine hundred nineteen pregnant women were referred to social care (2016-2020). Overall, women had a median of six adversities, distributed over four life-domains. The heat map revealed a large variety in lived adversities, which originated from two parental clusters, one dominated by financial adversities and the other by a the combination of a broad range of adversities. The perceived health was moderate, and 25-34% experienced moderate to severe levels of depression, anxiety or stress. This did not differ between the two parental clusters.

CONCLUSIONS

This study shows that highly vulnerable pregnant women deal with multiple adversities affecting not only their social and economic position but also their health and well-being.

Early Maternal Caregiving Capacities in Highly Vulnerable, Multi-Problem Families

Caregiving capacities may be an important link between multi-problem circumstances and adverse child development. This study aims to assess caregiving capacities and their correlations in highly vulnerable, multi-problem families in Rotterdam, the Netherlands. Caregiving capacity (overall, emotional and instrumental) was prospectively assessed in 83 highly vulnerable women using video-observations of daily caregiving tasks, six week postpartum. Supporting data were collected at three time points: at inclusion, six weeks after inclusion and six weeks postpartum, and these included psychological symptoms, self-sufficiency, problematic life domains, home environment, income, depression, anxiety and stress. Pregnancy- and delivery-related information was collected from obstetric care professionals. Maternal caregiving scores averaged below adequate quality. Mothers living in an unsafe home environment (B = 0.62) and mothers with more problematic life domains (≤3 domains, B = 0.32) showed significantly higher instrumental caregiving capacities. Other variables were not related to caregiving capacities. Caregiving capacity in this highly vulnerable population was below adequate quality. However, in most cases there was no significant association between caregiving and the variables related to vulnerability. This means that a potential association between vulnerability and caregiving capacities might be driven by the interaction between several problems, rather than the type or number of problems.

"Who am I to say?" Dutch care providers' evaluation of psychosocial vulnerability in pregnant women

Maternity care increasingly focuses on evaluating psychosocial vulnerability during pregnancy. Research and nationwide (public health) programs, both in the USA and Europe, led to the development of new protocols and screening instruments for care providers to systematically screen for psychosocial vulnerability in pregnant women. However, standardised screening for vulnerability is complex since it requires discussion of sensitive issues. Women may fear stigmatisation and may have limited trust in their care providers or the health system. Our study contributes to the growing field of client-facing risk work by exploring care providers' interpretations and evaluation of psychosocial vulnerability in pregnant women. Drawing on semi-structured interviews with Dutch maternity care providers, we explore how they conceptualise risk and vulnerability and identify 'vulnerable pregnant women' in their practices. We find that care providers conceptualise 'vulnerability' as primarily based on risk, which contributes to an imbalanced focus on individual mothers, rather than on both parents and the social context. Our findings highlight care providers' concerns around 'care avoidance', seen as a risk factor affecting 'vulnerability' during pregnancy and as a possible consequence of risk screening. The care providers we interviewed employ "in between-strategies" based on intuition, emotion, and trust to skillfully attend to the risk that comes with risk work, in terms of its potential impact on relationships of trust and open communication. We conclude that 'vulnerability' should be understood as a multi-layered, situated and relational concept rather than simply as an epidemiological category. Since a trusting relationship between pregnant women and care providers is crucial for the evaluation of vulnerability, we reflect critically on the risk of standardised perinatal psychosocial risk evaluations. Policy should recognise providers' "in between-strategies" to embed epidemiological understandings of risk in the context of everyday risk work.

Health Agency and Perfectionism: The Case of Perinatal Health Inequalities

Poor pregnancy outcomes and inequalities in these outcomes remain a major challenge, even in prosperous societies that have high-quality health care and public health policy in place. In this article, we propose that justice demands the improvement of what we call the ‘health agency’ of parents-to-be as part of a response to these poor outcomes. We take health agency to have three aspects: (i) the capacity to form health-goals one has reason to value, (ii) the control one perceives to have over achieving those health-goals and (iii) the freedom(s) one has to achieve those health-goals. We will moreover argue that this demand of justice can be best based on a perfectionist rather than neutralist method of justification. Subsequently, we will argue that perfectionist policy may be paternalistic but not wrongfully paternalistic. This leads us to conclude that perfectionism should be adopted to inform and justify public health policy that is aimed at improving health agency in general and counteracting poor pregnancy outcomes and inequalities in perinatal health outcomes in particular.

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.