Contribution of PPS to urban and rural differences in birth outcomes
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......................................................................................................... European Journal of Public Health, Vol. 24, No. 6, 917–923 ß The Author 2014. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved. doi:10.1093/eurpub/cku063 Advance Access published on 26 June 2014
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Contribution of psychopathology, psychosocial problems and substance use to urban and rural differences in birth outcomes Chantal Quispel1,2*, Mijke P. Lambregtse-van den Berg1,3, Eric A.P. Steegers2, Witte J.G. Hoogendijk1, Gouke J. Bonsel2,4
Correspondence: Chantal Quispel, Departments of Psychiatry and Obstetrics & Gynaecology, Erasmus MC, University Medical Centre Rotterdam, Room Wk-221, Rotterdam, The Netherlands, Tel: +3110-7032952, Fax: +3110-7036815, e-mail: [email protected]
Background: Urban residence contributes to disparities in preterm birth (PTB) and birth weight. As urban and rural pregnant populations differ in individual psychopathological, psychosocial and substance use (PPS) risks, we examined the extent to which PTB and birth weight depend on the (accumulative) effect of PPS risk factors and on demographic variation. Methods: Follow-up study from 2010 to 2012 among 689 urban and 348 rural pregnant women. Urbanity was based on the population density per ZIP code. Women completed the validated Mind2Care instrument questionnaire, which includes the Edinburgh Depression Scale, and demographic, obstetric and PPS questions. Pregnancy outcomes were extracted from medical records. With regression analyses we assessed crude and adjusted associations between residence and birth outcomes, adjusted for available confounding or mediating factors. Results: PTB was significantly associated with segregation, maternal age (10% of women
and their newborns worldwide.1,2 Both conditions are leading causes of perinatal and infant mortality,3,4 chronic disease in later life5 and result in high health-care costs.1,6 Among other well-known risks factors, such as pre-eclampsia and ethnicity contributing to adverse birth outcomes,2,6 the influence of geographical disparities is relatively understudied. Regarding geographical disparities in perinatal health, there are contrasting findings on the contribution of urban and rural residence.7–13 In international literature, rural populations generally have the highest prevalence of adverse birth outcomes, of deprivation and of individual risk factors, such as a nonindigenous ethnicity, low socio-economic status and maternal depression.8–10,13,14 Some studies, however, find the opposite, in particular, studies from the Netherlands.7,15 One explanation for the contrasting findings is that they are confounded or mediated by underlying individual risks, as urban and rural populations differ in many respects, e.g. demographic composition and environmental exposures.1,6,16,17 More specific and often co-occurring risk factors concerning psychopathology, psychosocial problems and substance use (PPS) are also associated with PTB and LBW,14,15,18 in particular, in case of risk
accumulation.19 Geographical disparities in PPS risk factors also exist. Therefore, urban–rural disparities in birth outcomes may not only be affected by geographic risks but also by (the accumulation of) PPS risks. The observed perinatal health disparities urge for targeted improvement strategies. Increased insight into the contribution of specific (treatable) risk factors for adverse birth outcomes in combination with screening and subsequent referral to targeted interventions could reduce these disparities. To our knowledge, there are no studies that systematically investigated the (accumulative) effect of PPS risk factors in relation to geographic disparities in birth outcomes. We aimed to investigate the extent to which PTB and birth weight depend on the (accumulative) effect of individual PPS risk factors in urban and rural areas or on geographic and demographic variation.
Methods Data were obtained from the validated Mind2Care screen-andadvice instrument (M2C, formerly known as the GyPsy instrument),20 including the Edinburgh Depression Scale (EDS),21 and a set of risk factors for psychiatric disorders during pregnancy, including substance use, demographic, obstetric and psychosocial factors. M2C was specifically developed by the Erasmus Medical
Downloaded from http://eurpub.oxfordjournals.org/ at University of California, San Francisco on December 14, 2014
1 Department of Psychiatry, Erasmus Medical Centre Rotterdam, Rotterdam, The Netherlands 2 Division of Obstetrics & Prenatal Medicine, Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands 3 Department of Child and Adolescent Psychiatry, Erasmus Medical Centre Rotterdam, Rotterdam, The Netherlands 4 Department of Public Health, Erasmus Medical Centre Rotterdam, Rotterdam, The Netherlands
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European Journal of Public Health
Center as a tool for screening and the subsequent treatment allocation for PPS risks during pregnancy, as these often escape detection.22 In Rotterdam, one of the major cities in the Netherlands, M2C was implemented from June 2010 to June 2012, in three midwifery practices and a general hospital. All pregnant women with a booking visit at these clinics were approached for this study. The midwifery practices were located in a severely deprived, a less deprived and a non-deprived area. The hospital served a severely deprived area. Together, 40% of all urban Rotterdam pregnant women were served by a participating practice. In Meppel, a small rural city, M2C was implemented from April 2012 to May 2012 in four midwifery practices and the local general hospital. All pregnant women residing in this city and the adjacent rural agricultural area who attended the clinics during the study period were approached for this study. All participating women completed the M2C questionnaire on a personal digital assistant before their pregnancy check-up, as part of routine practice. In total, 1076 (88%) of the 1230 eligible women were screened with M2C (figure 1). Of these, 11% refused participation and 1% was excluded owing to a language barrier. M2C data were complete for 1037 women (96%), as data on residence or 10 M2C questions were missing for 39 women. Postpartum, follow-up information and birth outcomes were extracted from medical records. Birth outcomes were unavailable for 25% of women (n = 259). Main reasons included miscarriage or pregnancy termination (4%), referral outside the study region (4%) and lack of consent for follow-up (13%). Outcomes of 778 women were analysed. Women with incomplete data on birth outcomes were more often of rural residence, non-Western ethnicity and low educational level compared with women with complete data (42 vs. 31%, 33 vs. 23% and 28 vs. 21%; P < 0.05; data available on request). Study approval was obtained from the medical ethical board of the Erasmus University Medical Center Rotterdam [MEC-2013162]. Birth outcomes included PTB (
917
......................................................................................................... European Journal of Public Health, Vol. 24, No. 6, 917–923 ß The Author 2014. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved. doi:10.1093/eurpub/cku063 Advance Access published on 26 June 2014
.........................................................................................................
Contribution of psychopathology, psychosocial problems and substance use to urban and rural differences in birth outcomes Chantal Quispel1,2*, Mijke P. Lambregtse-van den Berg1,3, Eric A.P. Steegers2, Witte J.G. Hoogendijk1, Gouke J. Bonsel2,4
Correspondence: Chantal Quispel, Departments of Psychiatry and Obstetrics & Gynaecology, Erasmus MC, University Medical Centre Rotterdam, Room Wk-221, Rotterdam, The Netherlands, Tel: +3110-7032952, Fax: +3110-7036815, e-mail: [email protected]
Background: Urban residence contributes to disparities in preterm birth (PTB) and birth weight. As urban and rural pregnant populations differ in individual psychopathological, psychosocial and substance use (PPS) risks, we examined the extent to which PTB and birth weight depend on the (accumulative) effect of PPS risk factors and on demographic variation. Methods: Follow-up study from 2010 to 2012 among 689 urban and 348 rural pregnant women. Urbanity was based on the population density per ZIP code. Women completed the validated Mind2Care instrument questionnaire, which includes the Edinburgh Depression Scale, and demographic, obstetric and PPS questions. Pregnancy outcomes were extracted from medical records. With regression analyses we assessed crude and adjusted associations between residence and birth outcomes, adjusted for available confounding or mediating factors. Results: PTB was significantly associated with segregation, maternal age (10% of women
and their newborns worldwide.1,2 Both conditions are leading causes of perinatal and infant mortality,3,4 chronic disease in later life5 and result in high health-care costs.1,6 Among other well-known risks factors, such as pre-eclampsia and ethnicity contributing to adverse birth outcomes,2,6 the influence of geographical disparities is relatively understudied. Regarding geographical disparities in perinatal health, there are contrasting findings on the contribution of urban and rural residence.7–13 In international literature, rural populations generally have the highest prevalence of adverse birth outcomes, of deprivation and of individual risk factors, such as a nonindigenous ethnicity, low socio-economic status and maternal depression.8–10,13,14 Some studies, however, find the opposite, in particular, studies from the Netherlands.7,15 One explanation for the contrasting findings is that they are confounded or mediated by underlying individual risks, as urban and rural populations differ in many respects, e.g. demographic composition and environmental exposures.1,6,16,17 More specific and often co-occurring risk factors concerning psychopathology, psychosocial problems and substance use (PPS) are also associated with PTB and LBW,14,15,18 in particular, in case of risk
accumulation.19 Geographical disparities in PPS risk factors also exist. Therefore, urban–rural disparities in birth outcomes may not only be affected by geographic risks but also by (the accumulation of) PPS risks. The observed perinatal health disparities urge for targeted improvement strategies. Increased insight into the contribution of specific (treatable) risk factors for adverse birth outcomes in combination with screening and subsequent referral to targeted interventions could reduce these disparities. To our knowledge, there are no studies that systematically investigated the (accumulative) effect of PPS risk factors in relation to geographic disparities in birth outcomes. We aimed to investigate the extent to which PTB and birth weight depend on the (accumulative) effect of individual PPS risk factors in urban and rural areas or on geographic and demographic variation.
Methods Data were obtained from the validated Mind2Care screen-andadvice instrument (M2C, formerly known as the GyPsy instrument),20 including the Edinburgh Depression Scale (EDS),21 and a set of risk factors for psychiatric disorders during pregnancy, including substance use, demographic, obstetric and psychosocial factors. M2C was specifically developed by the Erasmus Medical
Downloaded from http://eurpub.oxfordjournals.org/ at University of California, San Francisco on December 14, 2014
1 Department of Psychiatry, Erasmus Medical Centre Rotterdam, Rotterdam, The Netherlands 2 Division of Obstetrics & Prenatal Medicine, Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands 3 Department of Child and Adolescent Psychiatry, Erasmus Medical Centre Rotterdam, Rotterdam, The Netherlands 4 Department of Public Health, Erasmus Medical Centre Rotterdam, Rotterdam, The Netherlands
918
European Journal of Public Health
Center as a tool for screening and the subsequent treatment allocation for PPS risks during pregnancy, as these often escape detection.22 In Rotterdam, one of the major cities in the Netherlands, M2C was implemented from June 2010 to June 2012, in three midwifery practices and a general hospital. All pregnant women with a booking visit at these clinics were approached for this study. The midwifery practices were located in a severely deprived, a less deprived and a non-deprived area. The hospital served a severely deprived area. Together, 40% of all urban Rotterdam pregnant women were served by a participating practice. In Meppel, a small rural city, M2C was implemented from April 2012 to May 2012 in four midwifery practices and the local general hospital. All pregnant women residing in this city and the adjacent rural agricultural area who attended the clinics during the study period were approached for this study. All participating women completed the M2C questionnaire on a personal digital assistant before their pregnancy check-up, as part of routine practice. In total, 1076 (88%) of the 1230 eligible women were screened with M2C (figure 1). Of these, 11% refused participation and 1% was excluded owing to a language barrier. M2C data were complete for 1037 women (96%), as data on residence or 10 M2C questions were missing for 39 women. Postpartum, follow-up information and birth outcomes were extracted from medical records. Birth outcomes were unavailable for 25% of women (n = 259). Main reasons included miscarriage or pregnancy termination (4%), referral outside the study region (4%) and lack of consent for follow-up (13%). Outcomes of 778 women were analysed. Women with incomplete data on birth outcomes were more often of rural residence, non-Western ethnicity and low educational level compared with women with complete data (42 vs. 31%, 33 vs. 23% and 28 vs. 21%; P < 0.05; data available on request). Study approval was obtained from the medical ethical board of the Erasmus University Medical Center Rotterdam [MEC-2013162]. Birth outcomes included PTB (
