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