The issue: High infant mortality is a medical and social problem

Text: George van Hal / Photography: Levien Willemse

Ten in one thousand babies in the Netherlands die during pregnancy: much more than in other European countries. And in Rotterdam the situation is even worse. In certain districts the mortality rate is even three to four times higher than the already high national average. Frightening statistics in the opinion of Prof Eric Steegers of the Erasmus MC. Fortunately in his view something can be done about this.

Why is it that the infant mortality rate in the Netherlands is so high? “In the Netherlands, ten babies die for every thousand pregnancies, while that figure in Scandinavian countries is six. You have to make a distinction between various types of mortality in this regard. First there is the death of unborn infants, the so called foetal deaths. Furthermore, there is the mortality during delivery and finally, mortality during the first week after delivery is also included in the statistics. From this it is apparent that foetal deaths in particular are very high in the Netherlands; almost twice as high as in Belgium.
A major portion of these deaths are due to infants who did not grow sufficiently. If you catch this in time, childbirth can be induced - for example through a caesarean section. Controls are not very good in this respect here in the Netherlands, however, and these infants often die, while they have a very good chance of survival starting from weeks 32 – 34. And monitoring this is not very difficult. A growth ultrasound around week thirty provides sufficient information for this. This is a much more commonly used procedure abroad, because expectant mothers there visit a gynaecologist.”

Should expectant mothers therefore visit the gynaecologist more often? “It is a frequent enough occurrence that women at risk visit a midwife, while they should really undergo a medical examination. However, there are also women who unnecessarily visit a gynaecologist for every examination, while everything is perfectly in order. Midwives as well as gynaecologists must play a role during pregnancy, but you must not be afraid to change the form in which this happens. It is awful, but professional interests currently play a dominant role. In the Netherlands, financing is focused on the type of social worker the parent visits. From a financial perspective, it should therefore not make any difference as to whether the patient visits a gynaecologist or a midwife.”

Why is the problem in Rotterdam so serious?
“Infant mortality is higher in Rotterdam, The Hague and Utrecht than in the rest of the Netherlands; this is therefore primarily a large city problem. Analysing the situation in further detail, it turns out that the problem lies in the disadvantaged districts. The statistics there are shocking. In some districts the mortality rates are as much as three to four times higher.
But as sad as infant mortality is – and it is absolutely a huge tragedy – it is only the tip of the iceberg. Children in disadvantaged districts also have a poorer start. In some districts, the probability of illness for the newborn is more than 30 percent higher than the national average. There are more premature births and many infants weigh too little. Furthermore, there are also infants who at birth simply perform ‘poorly’ physically and, for example, have breathing or heart problems. A poor start like this often has permanent consequences. Children's development slows down, on the social level as well as in terms of intelligence, and at a later age they are more often afflicted by disorders such as heart and vascular diseases or diabetes. Pregnancy therefore is not an isolated event: it is of vital importance to society. A healthy pregnancy is the starting point for a healthy new generation. This is why the Erasmus MC in collaboration with the Area Health Authority (GGD) has initiated a € 1.5 million plan (‘Ready for a Child’), to properly manage the various healthcare phases related to a pregnancy.

Is there any hope for the struggle against the problems in disadvantaged districts? “We are demonstrating that this is possible in Rotterdam. First of all we are providing pre-conception care, still before pregnancy. Things in the first ten to twelve weeks – when a woman often barely knows that she is pregnant – are already critical at that stage. Smoking during pregnancy, the use of alcohol, drugs, unhealthy eating habits, all of these influence the development of the embryo and the growth of the placenta. Especially smoking combined with failure to take folic acid constitutes a significant risk factor. And in the disadvantaged districts many such factors are at play.
The Generation R research showed that there are significant differences in the growth of embryos in the first ten to twelve weeks. The probability that embryos of inferior weight during this period result in a birth of inferior weight is three times higher. After delivery such infants still grow substantially and that is a precursor of obesity at a later age. This is why it is necessary to provide healthcare services prior to the pregnancy as well. You can then prepare a programme during a sort of ‘intake interview’. Once you are pregnant it is very difficult to stop smoking, but if you are still planning to become pregnant it is much easier to take time for this.
The second step is to provide better supervision during the pregnancy itself. Women must start their visits earlier and they must also be able to deliver their child safely. For example, in a disadvantaged district you should not want to have your baby at home. A birthing centre like the centre we have constructed here on the roof of the Sophia Children’s hospital is a much better place.
Finally, after delivery everything must be in order as well. It is apparent that 80 percent of women in disadvantaged districts does not receive any maternity care. This is shocking. Furthermore, the aftercare must better match the first visit to the consultation bureau.”

How do these steps translate into actual practice? “First, we started up the website (Pregnancy Guide) in collaboration with the Erfocentrum (the Dutch national genetic resource and information centre), where women can inform themselves about pregnancy and health. Furthermore we started up (Pre-conception Guide), a website for social workers, because it turned out that there were no protocols for what to do in case of chronic afflictions. In the past, when someone with a serious congenital heart condition wanted to become pregnant, we told them it would be better not to do that. Today, it is possible, but pregnancy is paired with a major increase in blood volume and that represents a major assault on the condition of your heart. Furthermore, medication must be adjusted because you cannot simply continue to take just any kind of medication during pregnancy. In addition, adjustments are required if the mother requires anaesthesia. Today such adjustments are all too often not made. When a mother then suddenly comes to the hospital with serious problems in the middle of the night, no one then exactly knows what to do. And there are many other problem illnesses as well: diabetes, people who have had transplants, people with Crohn's disease, etc. This is why we now have developed guidelines for such situations. In addition to our websites, we also have two new consultations at our policlinic. One focuses on medical risks; during this consultation we prepare a plan for the pregnancy. The other is entirely focused on lifestyle risks. Everyone who visits our clinic must schedule an appointment with this service and this appears to be a big success. After two months the future parents – including the men –start to eat demonstrably better. People are more susceptible to advice during the period in which they want to become pregnant and that is good for overall health.

How important is that: healthy eating habits during pregnancy? “Poor eating habits appear to have a major impact on the probability of having a child with abnormalities. Someone with a healthy Mediterranean diet – with vegetables and olive oil – for example, appears to have 70 percent less chance of having a child with spina bifida. Similarly someone with – what I’ll call a ‘McDonald’s diet’ – has a threefold higher chance of having a child with a harelip.”

Are you able to properly reach people in problem districts? “Here in Rotterdam we are fairly successful in reaching people in target groups. Groups of Turkish and Moroccan women regularly meet at some sort of Tupperware parties to share all kinds of information about pregnancy and becoming pregnant. It is so successful that you now also see men coming together to talk about this. Indeed, this is not just an ethnic issue. The risks are also particularly related to issues experienced by disadvantaged groups.”

It is therefore not only a medical problem? “No, very definitely not. It is also a social-welfare problem. These things must be resolved if you want to limit infant mortality rates and create healthier generations. In other words, you can no longer say: ‘How unfortunate that you are living under such bad conditions, but that’s not my problem.’ Only by tackling the whole is it possible to resolve this.”

Thursday, April 29th 2010 (week 17).

The issue is a section in Erasmus Magazine, the opinion and information magazine of Erasmus University Rotterdam, in which an EUR-academic responds to a current-social issue.

Eric A.P. Steegers (1961) completed his medical examinations and doctoral studies at the Catholic University of Nijmegen. After completing his education in obstetrics and gynaecology he first became a staff member and later senior university lecturer at the St Radboud University Medical Centre in Nijmegen. He started working for the Erasmus MC in Rotterdam in 2001. In 2004 he became professor of Obstetrics and Prenatal Care. He is involved in various research projects, such as research into the causes of ‘suboptimal pregnancy outcomes’ and tries to apply these findings in the form of healthcare innovations.