57 Predicting population-level vulnerability among pregnant women INTRODUCTION A strong foundation during the first thousand days of life, which span from conception till a child’s second birthday, can positively impact health and development in later life and across generations (1, 2). Adverse experiences and exposures can influence the health of parents themselves, but can also be transmitted to their children, which, as these children grown into adulthood and potentially become parents themselves, leads to new cycles of adversity (2). In order to prevent health inequities and break the intergenerational cycle, it is important to recognize and address vulnerability during the first thousand days (1-3). This is also a focus in the Dutch nationwide action program Solid Start (in Dutch: Kansrijke Start) (4). The concept of vulnerability is often used to describe subgroups with increased risks to adverse health outcomes or limited access to healthcare. In short, vulnerability encompasses a multifaceted and dynamic process in which diverse stressors at the individual or contextual level can serve as risk factors, whereas protective factors have the potential to mitigate or prevent vulnerability (5-9). Examples of risk factors encompass unemployment or stress, while examples of protective factors include a strong social network or effective coping skills. The concept of vulnerability and its scope has garnered increasing attention among providers and policymakers who strive to enhance the provision of care and support during the first thousand days of life (4, 9, 10). In daily care, a common understanding between professionals from the medical and social sector on the characteristics of high-risk individuals can foster mutual understanding and improve cross-sectoral collaboration (9). At national and local policy levels, drawing attention to the prevalence, geographical distributions and trends in vulnerability can support policy monitoring and prioritization. These insights not only foster a sense of urgency, but also enhance the conversation between different stakeholders, and facilitate vision formulation and intervention prioritization (11). This study extends our prior research to predict population-level vulnerability among pregnant women. Our previous study highlighted the significance of considering both risk and protective factors, particularly in the context of adverse outcomes (12). Through Latent Class Analysis (a data-driven technique to identify subgroups with similar characteristics), we identified five groups of pregnant women with different social risk and protective factors to vulnerability prior to pregnancy. Women in the ‘multidimensional vulnerability’- group shared multiple risk factors across several domains (e.g. psychosocial, medical, and socioeconomic), lacked protective factors and were most at risk of adverse outcomes such as premature birth and caesarean section. Having risk factors in a single domain (e.g. socioeconomic) was not necessarily associated with adverse outcomes. This study utilized both routinely collected observational data and self-reported data on health, wellbeing and lifestyle of the Public Health Monitor 2016 (PHM-2016) to predict multidimensional vulnerability (12). Using the PHM-2016 resulted in a subset of the total Dutch pregnant population. Hence, the prevalence of multidimensional vulnerability across the entire population of pregnant women at a national level remains unknown, and it is unclear 3
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