Preconception care to improve urban perinatal health
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1 Preconception care to improve urban perinatal health Eric A.P. Steegers, Obstetrics and Prenatal Medicine, Erasmus MC, Rotterdam Rotterdam, December 10, 2009
2 fetal mortality Perinatal mortality early and late neonatal mortality Peristat II, 2008
3 Urban perinatal health
4 Perinatal Mortality Rotterdam Perinatale Sterfte Rotterdam / total western non-western Totaal Autochtoon Allochtoon Totaal Autochtoon Allochtoon Totaal Autochtoon Allochtoon Totaal Autochtoon Allochtoon Rotterdam Deprived districts Other districts Outskirts Rotterdam Stichting Perinatale Registratie Nederland Rotterdam center Rotterdam area
5 Relative risk for perinatal mortality in deprived districts RR 2,00 1,80 1,60 1,40 1,20 1,00 0,80 0,60 0,40 0,20 0,00 western non-western niet-westers westers Rotterdam Rest van Nederland De Graaf et al. Ned Tijdschr Geneesk 2008; 152: 2734 Stichting Perinatale Registratie Nederland
6 Urban perinatal health Rotterdam Not only ethnicity related, but also an issue of urban socio-economic deprivation
7 Perinatal mortality in Rotterdam according to neighbourhoods TOP 5 unfavourable neighbourhoods B A13 E A20 A16 A Waalhaven / rand Charlois 37 B Schieveen 34 C Pernis 24 D Delfshaven 23 E Nieuw Crooswijk 22 D C A A15 uninhabited National average: 10,3
8 Perinatal mortality in Rotterdam in perspective
9 Perinatal morbidity (congenital anomalies, smal for gestational age, prematurity, Apgar 5 min. < 7) per 1000 births, according to neighbourhoods C TOP 5 unfavourable neighbourhoods A Heijplaat 270 A13 A20 A16 B Hoogvliet-Noord 241 C Rijnpoort (HvH) 234 D Tarwewijk 232 E Carnisse 228 A D E B A15 uninhabited Gemiddelde Nederland: 163
10 RIGHT TO A GOOD START Perinatal mortality neccesitates preconception care
11 FOETALE PROGRAMMERING E p i g e n e t i c s oocytes semen embryo quality Environment FIRST TRIMESTER OF PREGNANCY Genetic factors Genetic factors Environment FATHER MOTHER
12 HEALTH IN LATER LIFE FOETAL GROWTH RETARDATION PREGNANCY COMPLICATIONS: CONGENITAL MALFORMATIONS PREECLAMPSIA, PREMATURITY E p i g e n e t i c s oocytes semen embryo quality FOETALE PROGRAMMERING Environment FOETUS PLACENTA MOTHER FIRST TRIMESTER OF PREGNANCY Environment Genetic factors Genetic factors Environment FATHER MOTHER
13 Perinatal mortality Morbidity perinatally and in later adult life
14 HEALTH IN LATER LIFE FOETAL GROWTH RETARDATION PREGNANCY COMPLICATIONS: CONGENITAL MALFORMATIONS PREECLAMPSIA, PREMATURITY FOETALE PROGRAMMERING Environment FOETUS PLACENTA MOTHER FIRST TRIMESTER OF PREGNANCY Environment Genetic factors Genetic factors Environment FATHER MOTHER PRE- AND PERICONCEPTION CARE AND RESEARCH
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16 The womb is not always safe
17 ROTTERDAM STUDY ON GROWTH, DEVELOPMENT AND HEALTH Liv
18 Lifestyle riks
19 Smoking 35% 30% 25% 20% 15% 10% 5% 0% Nederlands Dutch Marokkaans Marocco Turkey Turks Antilliaans Antilles Surinaams- Surinam-Cr Surinam-Hin Surinaams- Cape Kaap verde Islands Creools Hindoestaans Verdiaans
20 Alcohol 60% 50% 40% 30% 20% 10% 0% Nederlands Dutch Marokkaans Marocco Turkey Turks Antilliaans Antilles Surinaams- Surinam-Cr Surinaams- Surinam- Hin Cape Kaap verde Islands Creools Hindoestaans Verdiaans
21 Chlamydia infection 16,0 0 / 0 14,0 12,0 10,0 8,0 6,0 4,0 2,0 0,0 Nederlands Marokkaans en Turks Antilliaans Surinaams Kaap Verdiaans Alleenstaand Lage opleiding Ethnicity SES Rours, Duijts, 2007
22 Chlamydia infection 16,0 0 / 0 14,0 12,0 10,0 8,0 5 x increased risk of prematurity 6,0 4,0 2,0 0,0 Nederlands Marokkaans en Turks Antilliaans Surinaams Kaap Verdiaans Alleenstaand Lage opleiding Ethnicity SES Rours, Duijts, 2007
23 Dietary patterns Principal component analysis (PCA) Mediterranean dietary pattern omega fatty acids unsatured fats B vitamins alcohol vegetable proteins Spina bifida OR 0.3 ( ) SGA OR 0.5 ( ) Western dietary pattern saturated fats animal proteins carbohydrates Clefts OR 1.9 ( ) Dutch dietary pattern carbohydrates animal proteins B vitamins Semen Vujkovic et al., 2007,2008,2009 Oberman-Borst et al., 2009
24 Urban perinatal health % Adverse perinatal outcome 12.6% 20.2% 30.4% Other places Deprived neighbourhoods Distribution of weighted prenatal summary risk scores according to neighbourhood where women prenatally lived Low risk Medium risk High risk score score score S. Timmermans et al. 2009
25 Insufficient prenatal care 40% 35% 30% 25% 20% 15% 10% 5% 0% Nederlands Dutch Marokkaans Marocco Turkey Turks Antilliaans Antilles Surinam-Cr Surinaams- Surinam-Hin Surinaams- Cape Kaap verde Islands Creools Hindoestaans Verdiaans
26 Perinatal public health One in six babies an unhealthy start
27 City-council / municipality as a partner to improve perinatal health Doing things better, Doing better things 0907
28 Municipal perinatal mortality programme Rotterdam 18 juni 2008 Preconception care Antenatal care Delivery Maternity care Child care Programmestructure, education, information, research, monitoring & evaluation
29 Municipal perinatal mortality programme Rotterdam 18 juni 2008 Preconception care Antenatal care Delivery Maternity care Child care Risk prevention, better and innovative care, improved chain of midwifery, obstetric neonatal and child care
30 Preconception care; target populations General population (general individual preconception care) All couples planning pregnancy Cooperation community care High-risk populations (specialist individual preconception care) Complicated obstetrical histories, chronic diseases, maternal congenital anomalies, transplantions, medication, some immigrant populations University and peripheral hospitals Coordinating role of the obstetrician
31 A woman who intends to become pregnant should consult a midwife or general practitionar Preconception care and ethnicity 50% 45% 40% 35% respo ons 30% 25% 20% 15% 10% 5% 0% No Only if problems Dutch Yes etniciteit Only if problems Immigrants? No Yes?
32 A woman who intends to become pregnant should take folic acid supplements Folic acid and ethnicity 60% 50% re espons 40% 30% 20% 10% 0% Dutch etniciteit immigrants No Yes? No Yes?
33 Pilotstudy preconception care in the deprived district North in Rotterdam: - To reach all ethnic and social-economic groups - To offer both preconception care and social services
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35 Preconception care Risk analysis/inventarisation Health information and advise Intervention Counseling - medical history - obstetrical history - infections - birth defects Information to improve basic health: heriditary diseases in family - avoidance of occupation - intoxications - quality of nutrition - harmfull medication - smoking - specific infections use of medication nutritional recommendations alcohol - prenatal screening and diagnosis drugs - importance of timely prenatal care - folic acid suppletion - treatment of infections - vaccinations - refraining from smoking - improvement of nutritional intake - reduction of overweight Specialist preconception care
36 Zwangerwijzer.nl Preconceptiewijzer.nl public midwife, GP, obstetrician
37 Preconception care; target populations General population (general individual preconception care) All couples planning pregnancy Cooperation community care and peripheral hospitals High-risk populations (specialist individual preconception care) Complicated obstetrical histories, chronic diseases, maternal congenital anomalies, transplantions, medication, some immigrant populations University and peripheral hospitals Coordinating role of the obstetrician
38 Preconception care Risk analysis/inventarisation Health information and advise Intervention Counseling PC in a high risk population: - influence of chronic diseases on the course of pregnancy - influence of pregnancy on the course of the disease - risks of surgical interventions - risks of medication - recurrence risks and implications for health in later life if complicated obstetrical history - clear management plan!
39 Erasmus MC outpatient clinic for specialist preconception care Own initiative or Referral - referral letter internal external 1st visit - medical history - description of specific problem - to gain additional information of doctors involved 2 months - consultation of other specialities - search of literature - additional diagnostic procedures 2nd visit - to draw up a preconceptional, ante- and postnatal management plan - written report (for both files and couple) - archiving Follow up of pregnancy outcome
40 Outpatient clinic for lifestyle risks WOMEN ** ** % volgens ADH GZW MANMEN ** First visit Second visit, 2 months Brood Margarine Groente Fruit ** Vlees Vis
41 Fertiltity, pregnancy and birth at the center of the continuity of human life FETAL PROGRAMMING CONCEPTION BIRTH Chronic diseases Cardiovascular diseases Diabetes mellitus Congenital malformations Subfertility Miscarriages Low birthweight Maternal diseases
42 FETAL PROGRAMMING Key role of CONCEPTION and therefore BIRTH 1 3 great opportunities for- preconception care and research Chronical diseases Cardiovascular diseases Diabetes mellitus Congenital malformations Subfertility Miscarriages Low birthweight Maternal diseases
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