40 CHAPTER 2 Our study showed that multidimensional vulnerability leads to experiencing worse outcomes compared to vulnerability on a single domain or no vulnerabilities. This indicates the importance of co-existence or clustering of multiple risk factors (such as no income, high healthcare expenditures and feelings of loneliness) in increasing the probability of adverse outcomes for mother and child. Our findings strengthen results from previous studies that aimed to explain differences in adverse outcomes by interrelated individual or contextual risk factors (10, 11, 17). Previous LCA studies also led to classes of pregnant women with different health behaviours, psychosocial or socioeconomic characteristics that show differences in outcomes, although these studies included less factors and domains, and other populations in comparison to our study (17, 32, 33). The findings do not inform us on how risk factors interplay and lead to adverse health outcomes. The syndemic model provides a perspective on this interplay by describing how co-occurring health adversities are fuelled by different social and contextual factors that interact and increase the health burden of both mental and physical illness (34). This suggests the need to combine social and medical care and support, instead of focussing on the separate domains to combat multidimensional vulnerability. We found that women with socioeconomic vulnerability generally did not experience worse outcomes. This finding is not in congruence with previous research indicating that adverse perinatal health outcomes are more prevalent among women with a low socioeconomic status (SES) (9, 10, 14). Previous studies often focussed on a limited number of risk factors or domains, or used more traditional (regression) techniques to study the relation between SES and outcomes. However, as the impact of risk factors can depend on other factors, it is important to step away from traditional independent ‘ceteris paribus’ linear effect assumption of social determinants. Therefore, we used LCA as analytical approach that considers the combination of both risk and protective factors, allowing a more comprehensive approach to study vulnerability. Protective factors (e.g. social support) can act as positive exposures or buffering mechanisms that promote resilience and improve health (3, 8, 35, 36). This indicates the importance of acknowledging both strengths and challenges in families to create a supportive environment for early development (37). Additionally, low SES may not necessarily be a risk factor for adverse outcomes unless it coincides with other hardships. The relation between SES and health can be described by processes such as social causation (adverse conditions of poverty impact health through, for example, stress and food insecurity) and health selection (people with worse physical or mental health outcomes fall into poverty through, for example, stigma, health expenditures and lower productivity) (38). This increases the importance for healthcare professionals to understand different domains of vulnerability and tailor the need for support to the individual (39, 40). Our findings reveal a difference in care utilization patterns. The ‘healthy and socioeconomically stable’ class was most likely to receive early antenatal care and postpartum care (at home). This corresponds to findings of Grabovschi et al. (6) in their scoping review into vulnerability. People with higher vulnerability levels (i.e. multiple vulnerability aspects) have higher
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