Differences in perinatal morbidity and mortality on the neighbourhood level in Dutch municipalities: a population based cohort study.
BACKGROUND
In a national perinatal health programme, we observed striking heterogeneity in the explanation of the most prominent risks across municipalities. Therefore we explored the separate contribution of several socio-demographic risks on perinatal health inequalities between municipalities and neighbourhoods. The study aims to identify perinatal health inequalities on the neighbourhood level across the selected municipalities, and to objectify the contribution of socio-demographic risk factors on pregnancy outcomes in each municipality by the application of the population attributable risk concept.


METHODS
Population based cohort study (2000-2008). Perinatal outcomes of 352,407 single pregnancies from 15 municipalities were analysed. Odds ratios and population attributable risks were calculated. Main outcomes were combined perinatal morbidity (small-for-gestational age, preterm birth, congenital anomalies, and low Apgar score), and perinatal mortality.


RESULTS
Perinatal health inequalities existed on both the municipal and the neighbourhood level. In municipalities, combined perinatal morbidity ranged from 17.3 to 23.6%, and perinatal mortality ranges from 10.1 to 15.4‰. Considerable differences in low socio-economic status between municipalities were apparent, with prevalences ranging from 14.4 to 82.5%. In seven municipalities, significant differences between neighbourhoods existed for perinatal morbidity (adjusted OR ranging from 1.33 to 2.38) and for perinatal mortality (adjusted OR ranging from 2.06 to 5.59). For some municipalities, socio-demographic risk factors were s a strong predictor for the observed inequalities, but in other municipalities these factors were very weak predictors. If all socio-demographic determinants were set to the most favourable value in a predictive model, combined perinatal morbidity would decrease with 15 to 39% in these municipalities.


CONCLUSIONS
Substantial differences in perinatal morbidity and mortality between municipalities and neighbourhoods exist. Different patterns of inequality suggest differences in etiology. Policy makers and healthcare professionals need to be informed about their local perinatal health profiles in order to introduce antenatal healthcare tailored to the individual and neighbourhood environment.
Department of Obstetrics and Gynecology, Division of Obstetrics & Prenatal Medicine, Erasmus MC, PO Box 2040, 3000 CA, Rotterdam, The Netherlands. a.a.vos@erasmusmc.nl.
Amber A
AA
Vos
Department of Obstetrics and Gynecology, Division of Obstetrics & Prenatal Medicine, Erasmus MC, PO Box 2040, 3000 CA, Rotterdam, The Netherlands. denktas@euc.eur.nl.|Department of Social Sciences, Erasmus University College, Erasmus University Rotterdam, PO Box 1738, 3000, DR, Rotterdam, The Netherlands. denktas@euc.eur.nl.
Semiha
S
Denktaş
Department of Public Health, Erasmus University Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands. g.borsboom@erasmusmc.nl.
Gerard J J M
GJ
Borsboom
Department of Obstetrics and Gynecology, Division of Obstetrics & Prenatal Medicine, Erasmus MC, PO Box 2040, 3000 CA, Rotterdam, The Netherlands. g.bonsel@erasmusmc.nl.|Department of Public Health, Erasmus University Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands. g.bonsel@erasmusmc.nl.
Gouke J
GJ
Bonsel
Department of Obstetrics and Gynecology, Division of Obstetrics & Prenatal Medicine, Erasmus MC, PO Box 2040, 3000 CA, Rotterdam, The Netherlands. e.a.p.steegers@erasmusmc.nl.
Eric A P
EA
Steegers
D000328:Adult; D002947:Cities; D015331:Cohort Studies; D005260:Female; D005865:Gestational Age; D019538:Health Care Surveys; D054624:Health Status Disparities; D006801:Humans; D015994:Incidence; D007223:Infant; D007226:Infant Mortality; D007231:Infant, Newborn; D008427:Maternal Health Services / Q000458:organization & administration*; D009426:Netherlands; D054238:Perinatal Mortality; D011204:Poverty Areas; D011247:Pregnancy; D018873:Pregnancy Rate; D047928:Premature Birth / Q000453:epidemiology; D011787:Quality of Health Care; D018570:Risk Assessment; D012959:Socioeconomic Factors; D014504:Urban Health / Q000706:statistics & numerical data; D055815:Young Adult