title: Geographical, Ethnic and Socio-Economic Differences in Utilization of Obstetric Care in the Netherlands.
abstract: BACKGROUND
  All women in the Netherlands should have equal access to obstetric care. However, utilization of care is shaped by demand and supply factors. Demand is increased in high risk groups (non-Western women, low socio-economic status (SES)), and supply is influenced by availability of hospital facilities (hospital density). To explore the dynamics of obstetric care utilization we investigated the joint association of hospital density and individual characteristics with prototype obstetric interventions.
  
  
  METHODS
  A logistic multi-level model was fitted on retrospective data from the Netherlands Perinatal Registry (years 2000-2008, 1.532.441 singleton pregnancies). In this analysis, the first level comprised individual maternal characteristics, the second of neighbourhood SES and hospital density. The four outcome variables were: referral during pregnancy, elective caesarean section (term and post-term breech pregnancies), induction of labour (term and post-term pregnancies), and birth setting in assumed low-risk pregnancies.
  
  
  RESULTS
  Higher hospital density is not associated with more obstetric interventions. Adjusted for maternal characteristics and hospital density, living in low SES neighbourhoods, and non-Western ethnicity were generally associated with a lower probability of interventions. For example, non-Western women had considerably lower odds for induction of labour in all geographical areas, with strongest effects in the more rural areas (non-Western women: OR 0.78, 95% CI 0.77-0.80, p<0.001).
  
  
  CONCLUSIONS
  Our results suggest inequalities in obstetric care utilization in the Netherlands, and more specifically a relative underservice to the deprived, independent of level of supply.
authors.affiliation: Department of Obstetrics and Gynaecology, Division of Obstetrics and Prenatal Medicine, Erasmus University Medical Centre, Rotterdam, the Netherlands.
authors.forename: Anke G
authors.initials: AG
authors.lastname: Posthumus
authors.affiliation: Department of Public Health, Erasmus University Medical Centre, Rotterdam, The Netherlands.
authors.forename: Gerard J
authors.initials: GJ
authors.lastname: Borsboom
authors.affiliation: Department of Healthcare Policy and Research, Division of Biostatistics and Epidemiology, Weill Cornell Medical College, New York, United States of America.
authors.forename: Jashvant
authors.initials: J
authors.lastname: Poeran
authors.affiliation: Department of Obstetrics and Gynaecology, Division of Obstetrics and Prenatal Medicine, Erasmus University Medical Centre, Rotterdam, the Netherlands.
authors.forename: Eric A P
authors.initials: EA
authors.lastname: Steegers
authors.affiliation: Department of Obstetrics and Gynaecology, Division of Obstetrics and Prenatal Medicine, Erasmus University Medical Centre, Rotterdam, the Netherlands.|Department of Public Health, Erasmus University Medical Centre, Rotterdam, The Netherlands.
authors.forename: Gouke J
authors.initials: GJ
authors.lastname: Bonsel
mesh_terms: D000328:Adult; D005260:Female; D006297:Health Services Accessibility; D006801:Humans; D007743:Labor, Obstetric; D008875:Middle Aged; D009426:Netherlands / Q000453:epidemiology / Q000208:ethnology; D009774:Obstetrics / Q000706:statistics & numerical data*; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D018743:Perinatal Care; D011247:Pregnancy; D012017:Referral and Consultation; D012042:Registries; D012111:Residence Characteristics; D012189:Retrospective Studies; D012959:Socioeconomic Factors; D055815:Young Adult