Preconception care to improve urban perinatal health Eric A.P. Steegers, Obstetrics and Prenatal Medicine, Erasmus MC, Rotterdam Rotterdam, December 10, 2009
fetal mortality Perinatal mortality early and late neonatal mortality Peristat II, 2008
Urban perinatal health
Perinatal Mortality 2002-2006 Rotterdam Perinatale Sterfte Rotterdam 2002-2006 0 / 00 16 14 12 total western non-western 10 8 6 4 2 0 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
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
Urban perinatal health 2002-2006 Rotterdam Not only ethnicity related, but also an issue of urban socio-economic deprivation
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
Perinatal mortality in Rotterdam in perspective
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
RIGHT TO A GOOD START Perinatal mortality neccesitates preconception care
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
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
Perinatal mortality Morbidity perinatally and in later adult life
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
The womb is not always safe
ROTTERDAM STUDY ON GROWTH, DEVELOPMENT AND HEALTH Liv
Lifestyle riks
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
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
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
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
Dietary patterns Principal component analysis (PCA) Mediterranean dietary pattern omega fatty acids unsatured fats B vitamins alcohol vegetable proteins Spina bifida OR 0.3 (0.1-0.9) SGA OR 0.5 (0.2 0.6) Western dietary pattern saturated fats animal proteins carbohydrates Clefts OR 1.9 (1.2-2.9) Dutch dietary pattern carbohydrates animal proteins B vitamins Semen 37.10 6-62.10 6 Vujkovic et al., 2007,2008,2009 Oberman-Borst et al., 2009
Urban perinatal health % 50 45 40 35 30 25 20 15 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 10 5 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Low risk Medium risk High risk score score score S. Timmermans et al. 2009
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
Perinatal public health One in six babies an unhealthy start
City-council / municipality as a partner to improve perinatal health Doing things better, Doing better things 0907
Municipal perinatal mortality programme Rotterdam 18 juni 2008 Preconception care Antenatal care Delivery Maternity care Child care Programmestructure, education, information, research, monitoring & evaluation
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
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
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?
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?
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
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
Zwangerwijzer.nl Preconceptiewijzer.nl public midwife, GP, obstetrician
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
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!
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
Outpatient clinic for lifestyle risks WOMEN ** ** % volgens ADH 100 90 80 70 60 50 40 30 20 10 0 GZW MANMEN ** First visit Second visit, 2 months Brood Margarine Groente Fruit ** Vlees Vis
Fertiltity, pregnancy and birth at the center of the continuity of human life FETAL PROGRAMMING CONCEPTION BIRTH 1 3 5 10 20 40 80 Chronic diseases Cardiovascular diseases Diabetes mellitus Congenital malformations Subfertility Miscarriages Low birthweight Maternal diseases
FETAL PROGRAMMING Key role of CONCEPTION and therefore BIRTH 1 3 great 5 10 20 opportunities 40 80 for- preconception care and research Chronical diseases Cardiovascular diseases Diabetes mellitus Congenital malformations Subfertility Miscarriages Low birthweight Maternal diseases