41 Defining vulnerability subgroups among pregnant women healthcare needs, but less access to services and lower quality of healthcare. This raises questions about whether current support meets parents’ needs. The main strength of this study is that we linked routinely collected nationwide observational data sources to self-reported data on health, well-being and lifestyle. This offered the opportunity to include data on a wide range of medical and social factors for a large group of pregnant women to better understand vulnerability. While previous studies often had a unidimensional perspective to vulnerability (focussing on single risk factors such as individual SES, or neighbourhood SES on aggregated level), we could unravel the difference between unidimensional and multidimensional types of vulnerability due to our extensive dataset. Another strength is that we included protective factors, while most studies focus primarily on factors that increase the risk of adverse outcomes and less on protective factors that might counteract these effects (18, 19). Unfortunately, data on topics such as nutrition, stress, health literacy, preconception care and adverse childhood experiences were not available, while these factors could provide additional insights into vulnerability. Next, using largest posterior probability to assign women to classes is a limitation, because not all women are fully representative of one class only. Our study was moreover limited by not including the father or woman’s partner, despite growing evidence of their importance in promoting healthy pregnancy, childbirth and child-outcomes. Another limitation relates to the representativeness of the study population due to using the PHM-2016. Compared to all other pregnant women in 2017/2018, women in our study less often had a low income (5% vs 8%), low educational level (8% vs 12%) and migration background (18% vs 32%). Since generally people with higher vulnerability less often participate in research, we assume that the size of the multidimensional vulnerabilityclass is an underestimation. Nevertheless, since we could identify classes of vulnerability and differentiate between single and multidimensional vulnerability, we expect that their characteristics are also applicable beyond the study population. Similar results from our additional analyses strengthen this expectation. Nevertheless, our approach and findings should be validated in other cohorts and countries and until then be interpreted with caution. Our findings can have several implications for practice and research. We believe that screening instruments for vulnerability before and during pregnancy could benefit from including a balanced set of both risk and protective factors. In refining screening instruments, we have to consider the various criteria for responsible screening, such as the availability of associated care or support strategies (41). Greater consciousness among healthcare providers regarding the complexity of vulnerability in terms of risk and protective factors and personal perceptions could enhance the provision of person-centred care and support (6, 40, 42). Multiple studies argue that future strategies should also pay attention to underlying, root causes of vulnerability in policies, laws and governance (3, 15, 43). Advancing health equity requires both individual-level interventions targeted at vulnerable individuals as well as systemic-level change (3, 15, 43). Factors related to housing, education and social security for example, frequently lie upstream of individual lifestyle and behavioural factors modifiable through individual-level interventions. Findings of our study can be input for longitudinal monitoring of vulnerability at population level. Future 2
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