11 General introduction Despite accumulating evidence regarding the determinants of poor health, health inequities in birth outcomes seem to have persisted (48) and may even be widening in certain populations and for specific health outcomes (49, 50). These considerations of equity are also very important in investing in early life. The concept of vulnerability in early life Thousands of parents and children in high-income countries are exposed to adverse conditions such as poverty, violence, inadequate nutrition, substance abuse, and stress. This means that many face an increased risk or susceptibility to adverse health outcomes or decreased well-being, or they experience a lower access to care. Recent literature often uses the concept of ‘vulnerability’ when referring to these (future) parents and their newborn or unborn children (51-54), but terms such as ‘disadvantaged’, ‘deprivation’ or ‘frailty’ are also common in the scientific literature. There are diverse and heterogeneous definitions and understanding of the concept of vulnerability around pregnancy. For example, de Groot and colleagues (2019) defined vulnerability as “a dynamic state that reflects converging effects of a set of interacting and amplifying personal and environmental factors” (p. 12), which increases a person’s susceptibility to ill health and hamper their recovery (53). Scheele and colleagues (2020) referred to pregnant vulnerable women as being “threatened by physical, psychological, cognitive and/or social risk factors in combination with lack of adequate support and/ or adequate coping skills” (p. 4) (54). Various stakeholders in the city of Rotterdam (2020) explained how “vulnerability arises from an imbalance between risk factors and protective factors” (55). Their definition of vulnerability includes a distinction between highly vulnerable women for whom the risk factors require immediate action (e.g. domestic violence) and vulnerable women who have one or more risk factors (e.g. unhealthy lifestyle factors, unemployment) and insufficient protective factors (e.g. supportive social network, stable home situation). The Dutch national organization for midwives (Dutch abbreviation: KNOV) described how vulnerable pregnant women face several challenging circumstances, emphasizing different risk factors (56). Briscoe, Lavender and McGowan (57) described vulnerability in three main attributes: threat, barrier and repair. Whether potential biological, psychosocial or sociological threats lead to vulnerability, depends on both the existing recovery systems available (e.g. warm supporting relationships), as well as barriers that may impede access to healthcare (e.g. stigmatization, lack of compassion). Taken together, most definitions of vulnerability acknowledge that vulnerability encompasses a dynamic, contextualized and complex process involving the interplay of risk and protective factors at different levels or life domains (51, 53-55, 58). In simplified terms, several stressors at either the individual or contextual level can function as risk factors contributing to vulnerability, whereas protective factors have the potential to diminish or prevent vulnerability. Whether risk factors increase vulnerability and hinder people from achieving their full potential, depends on the co-occurrence and balance of risk factors and protective factors (53, 55). 1
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