The benefits of risk-based maternal care

In the 2000s, it emerged that the infant mortality rate in the Netherlands was much higher than in other Western European countries. This troubling statistic led to various initiatives to improve maternal care, including the Expect study in the Limburg region. The project is special because it focuses on early pregnancy, says gynaecologist Liesbeth Scheepers, one of the project leaders together with epidemiologist Luc Smits. 'In the past, maternal health care providers only intervened if complications arose. The Expect calculator allows us to make an early risk assessment and to subsequently provide maternal care tailored to each individual risk profile. People used to assume that first pregnancies in particular would usually go well, but you can’t know that in advance.'

Predictive models

As Luc Smits, professor of Clinical Epidemiology and Risk-Based Care, explains, 'The first research phase produced two predictive models that provided reliable risk assessments for two complications: pre-eclampsia and gestational diabetes. These complications can cause babies to be born too small or prematurely or can lead to infant mortality.' In a trial, these predictive models were incorporated into the Expect calculator and applied in a large number of obstetric and gynaecological centres in Limburg.

'We can assess the risk of pregnancy complications for each pregnant woman', says Scheepers. 'We recommend people with an increased risk of complications to take precautions, such as taking aspirin to help prevent pre-eclampsia, or we give them dietary advice. We follow the principle of shared decision making. The pregnant woman has the last word. If she says, 'Never mind', it’s OK too.'

Fewer complications

The results of the trial are now available. 'The implementation of the Expect calculator shows a 44 per cent reduction in serious first-time pregnancy complications', says Smits. 'This is an annual reduction of 88 babies in Limburg who die, are admitted to neonatal intensive care units or have other adverse birth outcomes.' This may prevent serious long-term consequences, adds Scheepers. 'A difficult start in life can cause lifelong disabilities or developmental disorders.'

Risk-based maternal care also proved to be very cost-effective. 'This is because it’s more focused', explains Smits. 'We provide more care where we have to and less care where we can.' The implementation resulted in an average cost saving of 2700 euros per pregnancy, amounting to an annual saving of 22 million euros for the Limburg region.

Support

The implementation exceeded the researchers’ expectations. It can be difficult to apply new knowledge in practice, says Smits. 'Getting behind a new policy and modifying your own behaviour is a complex process for health care providers and patients alike. It worked out well in this project.'

Moreover, health care providers in the Netherlands tend to take a conservative approach to maternal care, says Scheepers. Your average midwife is of the opinion that pregnancy is generally healthy. 'That’s why we didn’t want to be too directive and made sure to involve them closely in the study and developing the care pathways. We also emphasised that risk assessment will remain a primary health care service provided by midwives.' Smits adds, 'The fact that we didn’t try to impose policy on primary health care providers helped build acceptance and support.'

Joint effort

The researchers feel a sense of pride whenever they talk about the Expect study. 'Not just because of the wonderful results', says Smits, 'but also because it was a joint effort of more than a hundred health care providers, researchers and patients to improve maternal care. Important partners participated, such as the University of Midwifery Education & Studies (AVMU) and the department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), which considered the financial aspects of the project.' The collaboration between Scheepers, a gynaecologist at the Academic Hospital Maastricht (MUMC+), and CAPHRI’s Smits is a beautiful example of interdisciplinary collaboration. 'We wouldn’t have got anywhere without each other', says Smits.

Uniform care pathways

The Expect study has paved the way for improved maternal care, healthy lifestyle education and cooperation between maternal health care providers and researchers in Limburg. The uniform care pathways also help reduce inequality in maternal care. According to Scheepers, 'A midwife in one city in Limburg will give the same advice as a midwife in another city in the region.' Smits adds, 'This degree of uniformity and cooperation between gynaecologists and midwives is unique. You won’t find it anywhere else in the Netherlands.'

Two new challenges await. 'The results of this study are wonderful', says Smits. 'It deserves to be rolled out across the Netherlands.' Another line of research will focus on qualitative improvement of the predictive model. 'We want to find out why not all midwives participated in the study or failed to do what they should have done. We also want to find out what pregnant women do with our advice. What are motivating factors for them? This research will make further improvement of the implementation possible.'

More information:
www.zwangerinlimburg.nl

Text: Hans van Vinkeveen
Translation: Emdash