Hans van den Heuvel

PREGNANCY AND CHILDBIRTH CARE IN THE NETHERLANDS In the Netherlands approximately 170.000 children are born annually. 1 The majority of these children is born healthy. However, around 14% of babies do not have the best possible start of life. 2,3 Amongst others, the increase of unhealthy life style, obesity, and advanced maternal age result in an increase of complications in pregnancy. These predisposing factors may lead to hypertension, fetal growth restriction, (gestational) diabetes or preterm birth. Furthermore, complications in pregnancy are known to subsequently affect long term maternal health as well as health of the offspring. 4 To diagnose and monitor pregnancy complications, frequent surveillance of both maternal and fetal condition is recommended. Antenatal care for such high-risk pregnancies in The Netherlands is concentrated in secondary and tertiary care hospitals, after referral from primary care midwifes. Around 10% of women develop a hypertensive disorder of pregnancy, such as preeclampsia. The International Society for the Study of Hypertension in Pregnancy has recently published their latest classification and discerns chronic hypertension (hypertension diagnosed <20 weeks of gestation), gestational hypertension (arising de novo after 20 weeks of gestation) and preeclampsia (gestational hypertension, combined with one or more of the following: proteinuria, uteroplacental dysfunction, or other signs of maternal organ dysfunction), see Table 1. 5 Hypertension in pregnancy is associated with maternal risks such as preeclampsia, severe hypertension, organ failure, seizures, stroke and mortality. Perinatal complications of hypertensive disorders of pregnancy include fetal growth restriction, perinatal asphyxia, placental abruption, preterm delivery, and subsequent neonatal respiratory distress and admission to intensive care. Risk factors for the development of preeclampsia in pregnancy include prior preeclampsia, chronic hypertension, pregestational diabetes mellitus, obesity (BMI>30), and assisted reproduction. 5 For pregnant women at higher risk of complications, the frequency of antenatal visits may vary from 2 weeks up to 3 times a week. 6 Especially those with uncontrolled hypertension or antihypertensive medication use will visit the hospital more frequently. During these visits focus is onmaternal parameters as blood pressure, symptoms, weight, and urine or blood analysis. The fetal condition can be evaluated using ultrasound assessment of growth, Doppler velocity of uterine-placental flow, fetal movements and cardiotocography. The latter is used to determine fetal heart rate patterns and its variability. These recurrent visits for risk assessment, either planned or unplanned, interfere with daily life and can be burdensome for the pregnant patient and her support system. Due to the distance from home to hospital, these visits result in more travel time and parking costs compared to primary care visits. Additionally, antenatal visits may lead to considerable work absence of both women and partners. Furthermore, pregnancy complications can cause stress and anxiety. CHAPTER 1 8