A healthy start? Mortality around birth in the Netherlands: trends and causes from an international perspective

Over the last four decades perinatal and infant mortality rates have decreased strongly in all countries of the European Union (EU). The declining trend for the Netherlands, however, has recently levelled off more strongly than for other EU countries and is stronger for perinatal than for infant mortality. Two questions arose: (1) Which risk factors can explain the unfavourable Dutch trends? And (2) How may the present situation be improved? With respect to the first question, four risk factors for perinatal mortality were specifically investigated: age of mother at birth (older and teenage mothers having increased risks), ethnic origin of the mother (most often increased risks), multiple births (increased risks for twins, even higher for larger (3 or more) multiplets) and smoking during pregnancy (increased risk for low birth weight and perinatal mortality). Over the past 25 years the percentage of Dutch children born with an older (35+) mother has increased from 5 to 20%. The average age of Dutch mothers at birth of their first child has increased simultaneously and faster than elsewhere and it is now the highest in the world. In the same period the number of children born to mothers with an ethnic origin has also increased from about 5 to 20 %. Several large Dutch minority groups (Turkish, Moroccan, and Surinam) have increased risks for perinatal mortality. Recently, immigrants and refugees from Eastern Europe, Asia and Africa have added to these groups with increased risks. Although accurate data are lacking, it is likely that this increase has been larger in the Netherlands than in several other EU countries. The number of Dutch children born as (one of) a multiplet rose from 2 % in 1980 to 3.5 % in 2000. Not only the increasing age of the mother, but also the concurrent increase in infertility and its treatments (hormonal and/or IVF) are responsible for the rise in multiplets. The Dutch multiple birthrate is now among the highest in Europe, although not for 'higher' mutliplets. Dutch women in the fertile age are among the most frequent smokers in the EU and Dutch women also are still smoking relatively much during pregnancy (20 %). The pattern of these risk factors could at least partly explain the relatively unfavourable development of the Dutch perinatal mortality rates. Nevertheless, these mortality rates have continued to decrease and other, positive, factors must have been at work as well. These would include improvements in living conditions and healthy lifestyle as well as improvements in prevention, healthcare and medical technology. The counterpart of the declining perinatal mortality rate, however, is the increased number of children that survive with a neurologic or cognitive disability. Dutch health care historically involves a high percentage of homebirths and the Dutch system is also known for its relatively low medical intervention rates. Comparative studies show that the performance of the Dutch system of perinatal care is as good as other European systems. In all countries, however, there remains a certain amount of probably or potentially avoidable perinatal mortality (6, respectively 19 % for the Netherlands). Taking into account the observed pattern and trends in risk factors as well as the relevant aspects of health care and prevention this report points at health policy options to improve health care and prevention during pregnancy and around birth in the Netherlands. Focusing on a multicultural approach to prevention and health care for pregnant women, more attention to quitting smoking during pregnancy, more effective screening before birth and improving the national information collection in this area are major opportunities for Dutch health policy.In Europa zijn de perinatale en zuigelingensterfte de laatste veertig jaar sterk gedaald. Recent was die daling in Nederland echter minder sterk dan in andere Europese landen. Dit rapport analyseert een aantal risicofactoren, die dit zouden kunnen verklaren. Oudere (35+) moeders en moeders van allochtone herkomst hebben een verhoogd risico op sterfte van hun kind rond de geboorte, evenals vrouwen die roken tijdens de zwangerschap en vrouwen die een meerling krijgen. In de afgelopen decennia zijn zowel het aandeel oudere (35+) als allochtone moeders in Nederland gestegen van 5 tot ongeveer 20%. Het aantal meerlingen is daarnaast ongeveer verdubbeld en Nederlandse vrouwen roken nog steeds relatief veel, ook tijdens de zwangerschap. Op deze gebieden lijkt de situatie in Nederland op dit moment ongunstiger dan in andere Europese landen en dit verklaart waarschijnlijk ook de relatief ongunstige trend voor de Nederlandse sterfte rond de geboorte. De perinatale sterfte is echter steeds blijven dalen, ook in Nederland en ondanks de toegenomen risico's. Andere, positieve, factoren zullen daarom ook hun bijdrage hebben gehad. Te denken valt aan gunstiger leefomstandigheden en leefstijlfactoren (bijvoorbeeld voeding) en aan positieve effecten van preventie en van de gezondheidszorg rond de zwangerschap en tijdens en na de geboorte. Hoewel het Nederlandse systeem van zorg rond zwangerschap en geboorte enigszins afwijkt van de systemen in de meeste Europese landen wijzen vergelijkende studies erop dat het Nederlandse systeem even goed is als dat in andere Europese landen. Wel is er in alle landen sprake van waarschijnlijk of mogelijk vermijdbare perinatale sterfte. Verbeteringen in zorg, preventie en leefstijl lijken ook in Nederland mogelijk. Meer aandacht voor een multiculturele benadering van zorg en preventie rond zwangerschap en geboorte, meer aandacht voor stoppen met roken tijdens de zwangerschap, een meer effectieve screening voor de geboorte en het verbeteren van de nationale dataverzameling op dit gebied vormen duidelijke aanknopingspunten voor het Nederlands gezondheidsbeleid