antenatal care is important - ucvv · pdf fileantenatal care use in urban areas in two...

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Antenatal care use in urban areas in two European

countries: Predisposing, enabling and pregnancy-

related determinants in Belgium and the

Netherlands

Jana Vanden Broeck, dr Esther Feijen-de Jong, dr Trudy Klomp, prof dr Koen Putman,

prof dr Katrien Beeckman

Antenatal care is important

∎ Role of antenatal care

∎ Physical importance

∎ Prevention – treatment

∎ Psychological importance

∎ Information – preparation

∎ Fetal origins hypothesis (Barker, 2002-2007-2009)

2 Prenatale zorg in Brussel

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Disparities in antenatal care use

titel 3 Andersen and Newman’s Health Behaviour model, 1973

Societal Determinants Health Services System

Technology

Norms

Resources

Organisation

Individual determinants

Health Care Utilisation

Predisposing

Enabling

Need

Type

Purpose

Unit of Analysis


Individual determinants related to inadequate Antenatal care use:

Predisposing: Maternal Age, being single, low educational

level, lack of paid job, foreign ethnic background or origin,

poor language proficiency, lack of support social network, lack

of knowledge HCS, etc

Enabling: absence of health insurance, hospital type, care

provider’s characteristics, etc.

Need component: parity, unplanned pregnancy, previous

preterm birth, discontinuity of care, smoking, etc.

Baker et al, 2012; Feijen de Jong, 2012; Heaman, 2013; Beeckman et al, 2013; Choté et al, 2011 4

Individual determinants

Predisposing

Enabling

Need

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Societal Determinants:

Country specific organisation, eg referral system between health care

providers

Health Services System:

Resources: eg Number of care providers available

Need for comparative research in several countries with varying

antenatal health care arrangements as these might explain

differences in the effects of individual determinants on ANC use

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Societal Determinants Health Services System

Technology

Norms

Resources

Organisation

Measuring antenatal care use

Number of visits

Number of visits in relation to pregnancy

duration: eg APNCU index (Alexander and Kotelchuck, 2001)

Measures including content of care

Content and Timing of Care in Pregnancy tool

(CTP) (Beeckman et al, 2011)

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Health Care Utilisation

Type

Purpose

Unit of Analysis

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Measuring antenatal care use

Content and Timing of Care in Pregnancy tool

Literature relevance interventions in pregnancy

Congruences in (inter)national guidelines for routine care

in pregnancy

CTP reflects a minimal care package

recommended in every pregnancy regardless risk

status or parity

Timing of initiation of care

Number and appropriate timing of three interventions in

pregnancy

(Beeckman et al, 2011)

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U: Ultrasounds BP: Blood Pressure BS: Blood Sample T: Trimester

YES

Prenatale zorg in Brussel 8 21-10-2016

1. Initiation of care before 14 weeks of gestation

NO = Inadequate

2. Number of interventions:

3. Timing of interventions:

Not all interventions occurred according the

time table = Sufficient

All interventions occurred according the time

table = Appropriate

Minimum number per trimester

U BP BS

T1 1 1 1

T2 1 2 0

T3 0 3 1

U BP BS

> 2 en > 6 en > 2 )

U BP BS

(< 4 en < 11 en < 4 )

YES= Inadequate

NO= Intermediate

NO

YES

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Aim of the study

Comparison of Antenatal care utilisation

in Belgium and the Netherlands

Two countries with different health care

system

Netherlands: primary care midwives, women

receive fixed remunerations

Belgium: most women access an obstetrician

directly, payment on a fee-for-service basis

Gain insight in predisposing, enabling

and pregnancy related determinants

titel 9 21-10-2016

Methods

Secondary data analysis

Belgium: prospective observational study in the

Brussels Metropolitan Region

- Recruitment:

Consecutive (April - July 2008);

9 Brussels hospitals;

Inclusion criteria: Women aged >18; speaking (Dutch, French,

English, Turkish or Arabic); reachable by phone; living in the

Brussels Metropolitan Region, no major deseases;

maximum3th visit

- Data Collection:

Structured questionaires: beginning and end; diary

Selfregistration of each visit, structured

Follow-up: bimonthly telephone call


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Methods

Secondary data analysis

Netherlands: Data Primary care Delivery

- Recruitment:

purposive sampling of 20 midwifery practices spread over the

country,

consecutive inclusion of all women attending the practice

between 2009-2010, eligible when understanding Dutch,

English, Turkish or Arabic

- Data collection:

two questionnaires on demographics and ultrasound scans

(begin and end),

data on ANC was extracted from the electronic records

(Mannien et al, 2012)

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Methods: Pooled dataset

- Adult women

- Residing an urban

region

- Low-risk onset of

pregnancy

N= 632 out of

7907

Whole sample

N=333

titel 12 * Exact matching on household income, occupation and educational level, Hot Deck method was used

Random matched *

sample n= 321 from

each study

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Methods

Individual determinants available in both

studies

Predisposing: age, marital status, educational

level, occupational status and current

nationality, education of partner, current

nationality of partner, country of residence

Enabling: equivalent income, health insurance

cover, additional health insurance cover

Need/pregnancy related: parity, wish for

pregnancy planned pregnacy, continuity of

care, attendance of antenatal informtion

classes

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Methods

Statistical analysis

Descriptive statistics

Comparison of study population in both

datasets: Chi² - analysis

Logisitic ordinal regression analyses,

likelihood of having a better care trajectory

(higher CTP classification) while controlling of

the remaining significant characteristics.

Proportional odds assumption

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Results, predisposing characteristics

Brussels Metropolitan Region The Netherlands

(N = 321) (N = 321) Chi2

N (column %) N (column %) (p-value)

Age (years) < =20 4 (1.2) 4 (1.2) 1.000

21-35 264 (82.2) 264 (82.2)

> 35 53 (16.5) 53 (16.5)

Marital status Co-habiting or married 291 (90.7) 313 (97.5) .000

Single 30 (9.3) 8 (2.5)

Educational level Up to secondary 188 (58.6) 188 (58.6) 1.000

Tertiary 133 (41.4) 133 (41.4)

Occupational status Employed 149 (46.4) 270 (84.1) .000

Unemployed 172 (53.6) 51 (15.9)

Nationality Belgian/Dutch 184 (57.3) 291 (90.7) .000

All other nationalities 137 (42.7) 30 (9.3)

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(N = 321) (N = 321) Chi2


Educational level partner No partner 30 (9.3) 8 (2.5) .001

Up to secondary 163 (50.8) 171 (53.3)

Tertiary 128 (39.9) 142 (44.2)

Nationality of the partner

No partner 30 (9.3) 8 (2.5) .000

Belgian/Dutch 170 (53.0) 271 (84.4)

All other nationalities 121 (37.7) 42 (13.1)

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Results, enabling characteristics


(N = 321) (N = 321) Chi2


Equivalent incomea Low 92 (28.7) 20 (6.2) .000

Moderate 151 (47.0) 300 (93.5)

High 78 (24.3) 1 (0.3)

Health insurance coverage

Yes 302 (94.1) 321 (100.0) .000

No 19 (5.9) 0 (0.0)

Additional health insurance coverage

Yes 151 (47.0) 280 (87.2) .000

No 170 (53.0) 41 (12.8)

a∑ incomes in the household/(1 + (x*0.5) + (y*0.3)) (x: number of adults living in the same household, y: number of children under the age

of 18 years living in the same household [modified OECD scale] 17

Results, pregnancy related

characteristics


(N = 321) (N = 321) Chi2


Parity Primiparae 121 (37.7) 163 (50.8) .001

Multiparae 200 (62.3) 158 (49.2)

Wish for pregnancyb Wanted pregnancy 308 (96.3) 320 (99.7) .002

Unwanted pregnancy 12 (3.8) 1 (0.3)

Planned pregnancy Yes 250 (77.9) 262 (81.6) .239

No 71 (22.1) 59 (18.4)

COCc < 50 % 238 (74.1) 225 (70.1) .253

> =50 % 83 (25.9) 96 (29.9)

Attending antenatal information courses

Yes 71 (22.1) 167 (52.0) .000

No 250 (77.9) 154 (48.0)

Continuity of Care index: COC=∑n 2 j −n/n(n−1) 18 21-10-2016

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Results

titel 19 21-10-2016

9,7 5,6

8,1

6,2

36,8

29,9

45,5

58,3

B RUS S ELS METRO PO LITA N REG IO N URB A N D UTCH REG IO NS

ANTENATAL CARE USE (CTP)

Inadequate Intermediate Sufficient Appropriate

p = 0,009, Chi² test

Results

Relation between study sample

characteristics and antenatal care

utilisation

Chi² test

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Antenatal care utilisation classified by the CTP tool P value

Inadequate Intermediate Sufficient Appropriate χ2 test

(N = 49) (N = 46) (N = 214) (N = 333)

N (row %) N (row %) N (row %) N (row %)

Age (years) ≤20 0 0 6 (75.0) 2 (25.0) 0.32(a)

21–35 41 (7.8) 40 (7.6) 172 (32.6) 275 (52.1)

>35 8 (7.5) 6 (5.7) 36 (34.0) 56 (52.8)

Marital status Co-habiting or married

44 (7.3) 45 (7.5) 197 (32.6) 318 (52.6) 0.14(a)

Single 5 (13.2) 1 (2.6) 17 (44.7) 15 (39.5)

Educational level Employed 20 (4.8) 26 (6.2) 120 (28.6) 253 (60.4) <0.001

Unemployed 29 (13.0) 20 (9.0) 94 (42.2) 80 (35.9)

Occupational status

Up to secondary 35 (9.3) 33 (8.8) 139 (37.0) 169 (44.9) <0.001

Tertiary 14 (5.3) 13 (4.9) 75 (28.2) 164 (61.7)





(N = 49) (N = 46) (N = 214) (N = 333)


Nationality Belgian/Dutch 29 (6.1) 36 (7.6) 149 (31.4) 261 (54.9) 0.009

All other nationalities

20 (12.0) 10 (6.0) 65 (38.9) 72 (43.1)

Educational level partner

No partner 5 (13.2) 1 (2.6) 17 (44.7) 15 (39.5) <0.001

Up to secondary 33 (9.9) 30 (9.0) 120 (35.9) 151 (45.2)

Tertiary 11 (4.1) 15 (5.6) 77 (28.5) 167 (61.9)

Nationality of the partner

No partner 5 (13.2) 1 (2.6) 17 (44.7) 15 (39.5) 0.003

Belgian/Dutch 27 (6.1) 29 (6.6) 133 (30.2) 252 (57.1)

All other nationalities

17 (10.4) 16 (9.8) 64 (39.3) 66 (40.5)

Region Brussels Metropolitan

31 (9.7) 26 (8.1) 118 (36.8) 146 (45.5) 0.009

Urban Dutch regions

18 (5.6) 20 (6.2) 96 (29.9) 187 (58.3) Continuity of Care index: COC=∑n 2 j −n/n(n−1) 22 21-10-2016

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Results, enabling characteristics



(N = 49) (N = 46) (N = 214) (N = 333)


Equivalent incomea

Low 17 (15.2) 9 (8.0) 51 (45.5) 35 (31.3) <0.001

Moderate 29 (6.4) 33 (7.3) 141 (31.3) 248 (55.0)

High 3 (3.8) 4 (5.1) 22 (27.8) 50 (63.3)

Health insurance coverage

Yes 46 (7.4) 46 (7.4) 202 (32.4) 329 (52.8) 0.008

No 3 (15.8) 0 (0.0) 12 (63.2) 4 (21.1)

Additional health insurance coverage

Yes 24 (5.6) 29 (6.7) 130 (30.2) 248 (57.5) <0.001

No 25 (11.8) 17 (8.1) 84 (39.8) 85 (40.3)


Results, pregnancy related

characteristics



(N = 49) (N = 46) (N = 214) (N = 333)


Parity Primiparae 19 (6.7) 16 (5.6) 84 (29.6) 165 (58.1) 0.042

Multiparae 30 (8.4) 30 (8.4) 130 (36.3) 168 (46.9)

Wish for pregnancyb

Wanted pregnancy 49 (7.8) 44 (7.0) 210 (33.4) 325 (51.8) 0.51(a)

Unwanted pregnancy

0 (0.0) 2 (15.4) 4 (30.8) 7 (53.8)

Planned pregnancy

Yes 35 (6.8) 34 (6.6) 161 (31.4) 282 (55.1) 0.013

No 14 (10.8) 12 (9.2) 53 (40.8) 51 (39.2)

COCc <50 % 42 (9.1) 39 (7.8) 158 (34.1) 227 (49.0) 0.041

≥50 % 7 (3.9) 10 (5.6) 56 (31.3) 106 (59.2)

Attending antenatal information courses

Yes 11 (4.6) 7 (2.9) 72 (30.3) 148 (62.2) <0.001

No 38 (9.4) 39 (9.7) 142 (35.1) 185 (45.8)


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Results

Relation between study sample

characteristics and antenatal care

utilisation

Ordinal regression analyses, adjusted OR for

being assigned into a higher CTP category

titel 25 21-10-2016

62,2

45,8

59,2

49

58,3

45,5

61,7

44,9

52,6

35,9

A N T E N A T A L C L A S S E S

N O A N T E N A T A L C L A S S E S

C O C > = 5 0 %

C O C < 5 0 %

U R B A N D U T C H R E G I O N S

B R U S S E L S M E T R O P O L I T A N

T E R T I A R Y E D U C A T I O N

U P T O S E C O N D A R Y E D U C A T I O N

E M P L O Y E D

U N E M P L O Y E D

PERCENTAGE OF WOMEN IN THE CTP APPROPRIATE GROUP

AdjOR 0,60 (0,43-0,82)

AdjOR 0,90 (0,64-1,26)

AdjOR 0,67 (0,47-0,94)

Results

titel 26 21-10-2016

AdjOR 0,45 (0,34-0,70)

AdjOR 0,60 (0,42-0,84)

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Discussion

Urban Dutch women more appropriate ANC ~

women from Brussels Metropolitan Region

Multivariate analysis do not indicate region itself

as determinant of ANC use

Adequate content and timing of ANC is associated

with higher educational level, employed status,

higher continuity of care and attendance of

antenatal classes

titel 27 21-10-2016

Most important determinants of ANC

Educational level

General health knowledge (Chote et al, 2012)

Health literacy (Chote et al, 2012)

Kwoledge and skills aquired through

education (Solar et al, 2005)

better access to information

receptiveness to health education messages

Enables access and communication with care

providers

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Most important determinants of ANC

Employment

Social network more extented? (Deri, 2005; Lin, 1999)

Information and encouragement might

stimulate ANC use (Deri, 2005; Lin, 1999)

Continuity of care provider

Positive effect on ANC use, irrespective of type

of caregiver

Attenting antenatal information classes

Non-attenders, less convinced of imporatance

and need for ANC (Murphy, 2010)

Non-attenders, often from vulnerable groups

(Fabian et al, 2004)

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No enabling determinant

None of the enabling determinants were

retained in final model

Income does not play a role

Universal coverage, including ANC in BE and

NL, might be explaination

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Study limitations

Variables needed to be equally

operationalised

Missing of Origin or Ethnicity !

Important in original studies as well as international

literature

More variables on health care system =

valuable

Main care provider, reimbursement system

Women that do not seek care are not

included

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Tackling inequalities in ANC use

Universal covarage seems insufficient to

offset disparities in ANC use in both

countries (Simoes et al, 2006)

The focus on educational level and

employement status as structural aspects of

society have a low mutability in the

promotion of equal access (cfr. Andersen, 1994)

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Tackling inequalities in ANC use

Better investments are

- Promotion of health literacy (Parker et al, 2003)

- Promotion of knowledge on health care system (Parker et al, 2003)

through the educational sytem:

primary - secundary school, integration courses

- Training of health professionals: communication skills to

adapt to health literacy level of the patient (Parker et al, 2003)

- Stimulation of continuity in maternal health care models

- Promotion of antenatal classes, eg free to vulnerable women

titel 33 21-10-2016

Midwifery in international perspective

Migration and Poverty

Migration, important determinant of ANC use in the original

studies

Non-western women have double the risk to receive inadequate

ANC compared to Western Non-Dutch or Native Dutch women

(adjOR 2,05 (95%CI 1,48-2,85)) (Feijen-de Jong et al, 2015)

Maghreb Women have less than half the chance of having an

appropriate care trajectory compared to Belgian women or

women with another origin (adjOR 0,38 (95%CI 0,22-0,66))


Employment status and educational level are determinanst of

ANC use

More important than the country a women lives in

Unemployment and low educational level contribute to poverty

titel 34 21-10-2016

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Thank you for your attention

Published in BMC Health Services Research, (2016) 16:337

21-10-2016 35

[email protected]

mailto:[email protected]



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