27 Defining vulnerability subgroups among pregnant women INTRODUCTION The first thousand days of life, from preconception to the child’s second birthday, are crucial to children’s further physical, mental and social development. This critical and sensitive period is an important determinant of health and well-being in adulthood, as supported by the well-evidenced Developmental Origins of Health and Disease (DOHaD) concept (1, 2). The DOHaD concept explains how experiences and exposures during early life, such as stress and nutrition, influence susceptibility to disease in later life and across generations, arguably through epigenetic mechanisms of foetal programming (1, 2). Because of this intergenerational aspect, parents are the central focus to improve child health and advance health equity (3). To indicate subgroups of parents and their unborn or newborn children who are at higher risk of poor health or have lower access to healthcare, the concept of vulnerability is often used (4-6). Vulnerability reflects a complex and dynamic process. Simplified, various stressors at individual or contextual level (e.g. unemployment or living in a deprived neighbourhood) can act as risk factors to vulnerability, while protective factors (e.g. stable social network) might reduce or prevent vulnerability (4, 5, 7, 8). Whether the presence of risk factors increases vulnerability and thereby hinder achieving one’s optimal health potential depends on the balance and interaction between risk and protective factors (4, 8). While research on perinatal health has traditionally focussed on risk factors of a medical nature, there is now indisputable evidence for direct and indirect influences of social factors as well (9-14). The social, economic, cultural and environmental living conditions (i.e. social determinants of health) that shape parents’ and children’s daily experiences and thereby influence their health and development, are embedded in larger systems and structures such as policies and laws (3, 15). There is an international growing professional and political focus on early detection of vulnerability during the first thousand days and development of effective strategies to improve parental health and well-being (3, 16). For instance in the Netherlands, the government launched a nationwide ‘Solid Start’-programme in 2018 with the aim of providing each child the best start in life by strengthening collaboration between medical and social services, with a specific focus on families in vulnerable situations (16). Detecting vulnerability during pregnancy with the preventive purpose of countering suboptimal child health is challenging and can benefit from in-depth knowledge into vulnerability. However, currently, little is known about the combination of different risk and protective factors to vulnerability and its influence on health outcomes. There seems to be few studies that consider protective factors to vulnerability and there is limited insight into clustering and underlying interactions, while it is recognized that especially the co-existence of risk factors can lead to adverse birth outcomes (11, 17, 18). Previous studies frequently explored the association between a limited number of predetermined, single risk factors 2
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