Analysis of the coordination of care during pregnancy and perinatal period.

The Peristat I and II studies, based on data from 1999 and 2004, showed that the Netherlands had almost the highest perinatal mortality (11.4 and 10.0 per thousand in Europe (Evers 2010). In the period 2001-2008 perinatal mortality in the Netherlands declined with 23% (PRN Jaarboeken). Of perinatal deaths, 85% concern congenital abnormalities, premature delivery, low birth weight and low Apgar score. Especially when two of the circumstances are present, the risk of perinatal mortality is high. Prevention of perinatal death requires, among others, optimal collaboration of primary, secondary and tertiary care. This demands agreement on standards for quality, registration, responsibilities, giving account, communication and transparency (Stuurgroep Zwangerschap en Geboorte 2009, Bonsel 2010). Because of the slower decline of perinatal mortality in the Netherlands in comparison to surrounding countries, the Dutch government stimulates investigations into care-related causes of perinatal death (Leeman 2007). This has resulted in the implementation of a perinatal audit scheme in 2010: a monthly regional audit and an annual national audit. The regional audit is performed by professionals who are involved in the provision of care and who can prompt improvements in the regional service provision, the national audit by experts that focus on special issues or subgroups of perinatal mortality. The national audit triggers adjustment of national guidelines, training and education. In addition to evaluation of care patterns in pregnancies that resulted in perinatal death, attention is needed for substandard care factors that are associated with morbidity rather than death (non-fatal cases). In addition, identification and dissemination of good practices are important to reinforce professionals and improve care practices. The active involvement of the client can also contribute to optimisation of the care during pregnancy and childbirth. By listening carefully to the expectations, wishes and fears of the pregnant woman and her partner, interaction between professionals and the client can probably be improved and, if appropriate, care can be tailored. It is expected that this approach will make it easier to address non-medical risk factors like unhealthy life style and no-show (Stuurgroep Zwangerschap en Geboorte 2009, Manant 2011, Overgaard 2012). The main objective of this study is to improve quality of obstetric and perinatal care in Overijssel and Noord-Flevoland by focussing on the coordination and transfer of care. We aim to achieve this by: 1) identification of risk factors for morbidity, related to coordination and transfer of care, 2) development of preventive actions to improve coordination and transfer of care, 3) further development and implementation of methods that involve patients’ perceptions in the evaluation of obstetric and perinatal care, and 4) implementation of interventions following the identified points for improvement. The research questions will be answered through Action Research (Lewin 1946; O'Brien 2001; McNiff 2002). The study comprises 3 parts: A. In the first year, a baseline measurement on the current provision of perinatal care experienced by parents (400 in Twente and 400 in the Zwolle area) one month after the delivery. The questionnaire is based on validated questionnaires concerning risk screening (e.g. R4U) and client experiences (CQ index). In the fourth year, this measurement is repeated in another group of 800 parents. Main topics are: medical-biological, psycho-social, behavioural and care-related risk factors (coordination and transfer of care) for morbidity. B. In total 200 pregnant women (100 in Twente, 100 in the Zwolle area) and their partners are followed from the moment that the pregnancy is confirmed (obstetrician) till one month after delivery. The objective is to measure quality of care (coordination and transfer of care) prospectively through data collection in the pregnant women and their partners and the professionals involved during transfer from primary to secondary and tertiary care, to maternity care and youth health care. C. Forty case discussion in 8 interdisciplinary care meetings (comparable with regional perinatal audit meetings) specifically on coordination and transfer of care. The yield of these case discussions is measured through the identified points of improvement and proposed preventive interventions. Cases are selected from the 200 pregnancies that were followed in part B. Inclusion criteria are: 1) cases who unexpectedly had to be transferred from primary to secondary and tertiary care, and/or 2) clients with negative experiences in transfer of care (obstetric, maternity and/or youth health care). Finally, because the risk of perinatal mortality and morbidity is relatively high in women in underprivileged situations, results of this research in groups of clients with a different socio-economic status will be compared.