Elsevier

Midwifery

Volume 31, Issue 1, January 2015, Pages 147-154
Midwifery

Feasibility and reliability of a newly developed antenatal risk score card in routine care

https://doi.org/10.1016/j.midw.2014.08.002Get rights and content

Highlights

  • The poor Dutch perinatal outcomes suggest that improved risk assessment is needed.

  • R4U antenatal card addresses clinical and non-clinical risks during history taking.

  • R4U shows excellent feasibility and good inter-rater reliability.

  • The risk accumulation does not support a simple high-/low-risk dichotomy.

  • R4U is a suitable instrument to screen all risks in all pregnant women.

Abstract

Objective

to study in routine care the feasibility and inter-rater reliability of the Rotterdam Reproductive Risk Reduction risk score card (R4U), a new semi-quantitative score card for use during the antenatal booking visit. The R4U covers clinical and non-clinical psychosocial factors and identifies overall high risk pregnancies, qualifying for intensified antenatal care.

Design

a population-based cross-sectional study (feasibility) and a cohort study (inter-rater reliability).

Setting

feasibility was studied in six midwifery practices and two hospitals; the reliability study was performed in one midwifery practice.

Participants

1096 pregnant women in the feasibility study and a subsample of 133 participants in the inter-rater reliability study.

Measurements

feasibility was expressed as (a) time needed to complete the R4U and (b) the missing rate at the item and client level. For inter-rater reliability (IRR) an independent, blinded, caregiver completed a re-test R4U during a second visit; inter-rater agreement for each item and all domain sum scores were computed.

Findings

completion of the R4U took 5 minutes or less in 63%; and between 5 and 10 minutes in another 33%. On the participant level 0.2% of women had >20% missing values (below 4% threshold, P<0.001). One of 77 items had a >10% missing rate. The per item IRR was 100% in 20% of the items, and below the predefined 80% threshold in 13% of the items (n=9). The domain sum scores universally differed less than the predetermined ±15% margin.

Key conclusion

the R4U risk score card is a feasible and reliable instrument.

Implication for practice

the R4U is suitable for the assessment of clinical and non-clinical risks during the antenatal booking visit in a heterogeneous urban setting in routine practice.

Introduction

The Netherlands show a high perinatal mortality rate (nine per 1000 births) compared to other European countries (EURO-PERISTAT Project in Collaboration with SCPE, 2010). Eighty-five per cent of the cases of perinatal mortality are associated with the presence of one or more of the following: congenital anomaly, small for gestation age (SGA, birth weight <P10 adjusted for gestational age), preterm birth (<37 weeks), or low Apgar score (<7, five minutes after birth) (van der Kooy et al., 2011). Under current guidelines 25% of these conditions (excluding low Apgar score) are not recognised prior to the onset of delivery. Hence, there is room for improvement in the current system of antenatal risk assessment (Bonsel et al., 2010).

Enhanced risk assessment can be considered in all trimesters of pregnancy, e.g. by means of the collection of biomarkers and ultrasound measurements in the second and third trimester respectively. Here we focus on improved non-invasive risk assessment in early pregnancy through checklist-wise history taking with a broader than usual scope. Large cohort studies and public health reports revealed an independent contribution of non-clinical perinatal risk factors, particularly in deprived environments where perinatal mortality is high (Kleijer et al., 2005; (Agyemang et al., 2009, Timmermans et al., 2011, Poeran et al., 2013). Low socio-economic status, domestic violence, psychosocial morbidity and, more generally, living in a deprived neighbourhood are examples of evidence-based non-clinical risk factors which add to adverse perinatal outcome (Goedhart et al., 2008, de Graaf et al., 2013). These risks, taken apart of only moderate impact for e.g. SGA or preterm birth, supposedly act through accumulation (Timmermans et al., 2011). Unlike obstetrical and medical risk factors, history taking in routine care only partially covers these non-clinical risk factors, if covering them at all. Their recording also shows high variability. Appropriate coverage of these risks may enhance awareness for cases with a high combined risk load, and induce active prevention in due time.

As part of a regional, currently national public health initiative, aimed at improving birth outcomes in the Dutch urban areas, we developed an antenatal risk score card for universal use in routine care: the so-called ‘Rotterdam Reproductive Risk Reduction for You (R4U)’ (Denktas et al., 2012). The R4U equally assesses clinical and non-clinical risks, thereby allowing the estimation of a cumulative risk profile. It translates results from, in particular, international birth cohort studies into a pragmatic risk score card for perinatal use, the format itself being derived from the existing WIC program in the United States (WIC: Women, Infant and Children Program). After initial piloting we report in this study the feasibility and reliability of this tool as measured under routine care by midwives and obstetricians.

Section snippets

Concept

The R4U risk score card consists of 46 non-clinical and 31 clinical items, conveniently grouped into six domains (Table 2). The left hand side of the R4U form (paper version; see Appendix 5) covers four domains: psychosocial and economic, communication and ethnicity, pregnancy onset, and lifestyle. The right hand side of the form encloses the clinical risk items in the medical (e.g. psychiatry, cardiovascular) and the obstetrical domains.

Response is generally dichotomous (yes/no presence of

Baseline characteristics

Table 1 shows clients׳ characteristics by midwifery practices and hospitals. Overall midwifery clients had a more ‘healthy’ profile: being younger, living less often in a deprived neighbourhood, and less often from non-Western origin. The participating clients in the IRR study showed little difference with the non-participating booking visit clients.

Time to complete the R4U

The time to complete the R4U was <5 minutes in 63% of cases, and 5–10 minutes in 33% of cases. More than 15 minutes to complete the R4U was needed

Discussion

In this study a newly developed antenatal score card that allows a quick uniform screening of 71 clinical and non-medical antenatal risks, showed excellent feasibility and good to excellent inter-rater reliability in an unselected urban population. These results were obtained in eight different care settings and did not show feasibility differences under routine care conditions. On average the sum score of all risks was slightly lower in midwifery practices than in hospitals, which should be

Conflict of interest statement

None of the authors had any conflicts of interest.

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