98 CHAPTER 4 The indicator set covers the following topics: poverty, psychological/psychiatric problems, stress, smoking, cumulation of risk factors, preconception care, low literacy, socioeconomic status, premature birth, intellectual disability, and child abuse and neglect. The first four topics are presented in the indicator set for all three phases (preconception, pregnancy and after birth). In general, the social determinants of health (7, 28) are represented in the indicator set (e.g. debts, low literacy and living in a neighbourhood with a low liveability score). Specific clinical aspects that belong to one group of care providers (e.g. caesarean section, a child’s hearing) are less present. Nonetheless, the indicator set reflects both medical and social care, which aligns with the aims of the Solid Start program. In comparison to the indicators used in the current national Solid Start monitor (Appendix 4), there is some overlap (e.g. debts during pregnancy, preterm birth and low birth weight for gestational age) but also differences. For instance, the national monitor also includes indicators such as ‘the percentage of municipalities that implemented the program ‘Not Pregnant Now’’. These differences are arguably caused by the different purposes of both indicator sets. The indicators in the national monitor can be used to monitor and evaluate the nationwide implementation of the program, and to monitor health outcomes of parents and children on a national level. As the implementation and health outcomes vary between municipalities, the indicator set of the local monitor aims to enhance the conversation between policymakers, managers, professionals and other stakeholders about the local situation and developments in order to prioritize interventions and policies at a local level. A development agenda was made with indicators and topics that lacked data in nationwide data sources or a clear operationalization. Among others, the topics and indicators on the development agenda were related to stress, unwanted or unintended pregnancy, (quitting) smoking before pregnancy, loneliness, early detection, secure bonding, and child abuse or neglect. Multiple indicators related to stress were prioritized: stress due to finances, stress during pregnancy and stress with parenting. There is growing scientific evidence that stress during pregnancy or parenting has long- and short-term consequences for children’s health and development (14, 29, 30). The multidimensional concept of stress (31) may require different indicators. It seems, therefore, valuable to explore which topics of the development agenda should be prioritized to be incorporated in routine registries for the purpose of local monitoring. There are, to the best of our knowledge, no other studies that used a Delphi technique to identify indicators for local monitoring of the full first thousand days (approach). There are, however, several previous studies that sought to describe indicators for aspects of the first thousand days, including antenatal care (32), obstetrical care (33), children’s health (34), birth centre care (35), and maternal and newborn health (36) or care (25) during pregnancy, childbirth and the postpartum period. Next to that, we found several programs in other countries that were focused to the first thousand days, but the aims, scope and keydesign elements of the programs and their evaluation differ (37-41). These programs were often not directly comparable to the Dutch Solid Start program and not (yet) focused on supporting monitoring on a local level. Consequently, a comparison between our indicator set and indicators in the aforementioned studies is hampered, with the exception of a
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