BACKGROUND:The organisation of health assessments by preventive health services focusing on children's health and educational performance needs to be improved due to evolving health priorities such as mental health problems, reduced budgets and shortages of physicians and nurses. We studied the impact on the school professionals' perception of access to school health services (SHS) when a triage approach was used for population-based health assessments in primary schools. The triage approach involves pre-assessments by SHS assistants, with only those children in need of follow-up being assessed by a physician or nurse. The triage approach was compared with the usual approach in which all children are assessed by physicians and nurses.METHODS:We conducted a cross-sectional study, comparing school professionals' perceptions of the triage and the usual approach to SHS. The randomly selected school professionals completed digital questionnaires about contact frequency, the approachability of SHS and the appropriateness of support from SHS. School care coordinators and teachers were invited to participate in the study, resulting in a response of 444 (35.7%) professionals from schools working with the triage approach and 320 (44.6%) professionals working with the usual approach.RESULTS:Respondents from schools using the triage approach had more contacts with SHS and were more satisfied with the appropriateness of support from SHS than respondents in the approach-as-usual group. No significant differences were found between the two groups in terms of the perceived approachability of SHS.CONCLUSIONS:School professionals were more positive about access to SHS when a triage approach to routine assessments was in place than when the usual approach was used. Countries with similar population-based SHS systems could benefit from a triage approach which gives physicians and nurses more opportunities to attend schools for consultations and assessments of children on demand.

Objectives A novel triage approach to routine assessments was introduced to improve the efficiency of Preventive Child Healthcare (PCH): PCH assistants carried out pre-assessments of all children and sent the children with suspected health problems to follow-up assessments conducted by a physician or nurse. This two-step approach differed from the usual approach, in which physicians or nurses assessed all children. This study was aimed to examine the impact of triage and task shifting on care for children at risk identified by PCH or parents and schools. Design and participants An observational prospective cohort design was used, with an analysis of the basic registration data from the preventive health assessments for 1897 children aged 5 to 6, and 10 to 11, years from a sample of 41 schools stratified by socioeconomic status, region of PCH service and urbanisation. Setting A comparison was made between two PCH services in the Netherlands that used the triage approach and two PCH services that provided the usual approach. Main outcome measures The primary outcome measures were the referral rates to either additional PCH assessments or external services. The secondary outcome measures were the rates of PCH assessments requested by, for example, parents and schools. Results Overall, a higher referral rate to additional PCH assessments was found for the triage approach than for the usual approach (OR 1.3, 95% CI 1.0 to 1.6), mainly in the age group of 5 to 6 years (OR 1.9, 95% CI 1.3 to 2.7). We found a lower rate of referral to external services in the triage approach (OR 0.4, 95% CI 0.3 to 0.7) and a higher referral rate to PCH assessments on request (OR=4.6, 95% CI 3.0 to 7.0). Conclusions The triage approach provides extra opportunities to deliver PCH assessments and PCH assessments on request for children at risk. Further research is needed into the cost benefits of the triage approach.

Background Triage in Preventive Child Health Care (PCH) assessments could further the efficient use of human resources and budgets and therefore make extra care possible for children with specific needs. We assessed the costs of routine PCH assessments with and without triage for children aged 5/6 years and 10/11 years. In a triage approach, PCH assistants conduct pre-assessments to identify children requiring follow-up assessments by a physician or nurse. In the usual approach, all children are assessed by a physician and an assistant (children aged 5/6 years) or a nurse (children aged 10/11 years). Methods All the direct costs of conducting routine PCH assessments with the triage and usual approach were assessed using a bottom-up micro-costing approach. In four PCH services in the Netherlands, two using triage and two the usual approach, professionals completed questionnaires about time spent on assessments, including time related to non-attendance at assessments, the referral of children and administration. Results The projected costs for PCH professionals working on PCH assessments amounted to €5.2 million per cohort of 100,000 children aged 5/6 years in the triage approach, and €7.6 million in the usual approach. The projected costs in both approaches for children aged 10/11 years were about €4 million per 100,000 children. Conclusion The triage approach to PCH resulted in a projected cost reduction of about one-third, compared with usual practice, for routine assessments by physicians of children aged 5/6 years. There are minimal cost savings in the group of children aged 10/11 years when nurses are involved and so other considerations such as workforce shortages would be required to justify a change to a triage approach. Further research is needed to investigate the differences in costs of care after the completion of the routine assessments.

PURPOSE: To test third stage management of labor for low-risk women comparing routine prophylactic intramuscular oxytocin management versus modified expectant management. STUDY DESIGN: Randomized controlled multicenter trial in primary care midwifery practice. MAJOR FINDINGS: 32.4% of women in the prophylactic intramuscular oxytocin management group had blood loss of 500 mL or more versus 44.2% in the modified expectant management group, relative risk (RR) 0.61, 95% confidence interval (CI) [0.50, 0.74]. The percentage of women experiencing postpartum hemorrhage (PPH) defined as more than 1,000 mL blood loss was 6.3% in the prophylactic intramuscular oxytocin management group versus 11.9% in the modified expectant management group (RR 0.50, 95% CI [0.36, 0.71]). The type of management showed no significant differences between the two groups in clinically relevant indicators of women’s short-term health such as the number of referrals, treatment given, hemoglobin level 36 hours postpartum, and breastfeeding rates after 1 week. Medium-term health such as hemoglobin level at 6 weeks postpartum, women’s perceptions of tiredness, and breastfeeding rates at 3 months after birth also showed no differences between the two groups. CONCLUSION: Third stage management by means of routine prophylactic intramuscular oxytocin reduced the risk of postpartum hemorrhage in a group of childbearing women at low risk of complications in primary midwifery care compared to modified expectant third stage management, but there was no evidence this was associated with a reduction in clinically relevant adverse health outcomes.

Recent decades have seen a sharp increase in the number of female PhD graduates in the Netherlands. Currently, the share of females among newly graduated PhDs is almost on par with that of males. A considerable body of scientific studies has investigated the role of gender in the academic workplace. However, the role of gender in the careers of all PhD graduates, including those outside academia, has been studied less. In this study, we investigate gender differences in type of job, occupation, career perception and research performance of recent PhDs. The study is based on a survey of persons who obtained a PhD from one of five Dutch universities between 2008 and early 2012. We show that gender differences in post-PhD careers are non-existent in some aspects studied, but there are small differences in other aspects, such as sector of employment, type of contract, involvement in teaching and management, and career perception. In contrast, male and female PhDs differ sharply on two factors. The first is field of PhD, females being heavily underrepresented in engineering and the natural sciences. The second is part-time employment, females being much more likely to work part-time than males, especially if they work in the Netherlands. In later career stages, the combination of the small and large differences can be presumed to affect the career progression of female PhDs through cumulative disadvantage.

BACKGROUND: We investigated the detection of health problems in preventive child health care (PCH) by a novel triage approach for routine health assessments. In the triage approach, all children were preassessed by a physician’s assistant, and only those in need of follow-up were assessed by a PCH physician or nurse. In the traditional approach, all children were assessed by a PCH physician or nurse. METHODS: A prospective cohort design was used with data on routine assessments of 1897 children aged 5 to 6 and 10 to 11 years. Primary outcomes were the detection of overweight, visual disorders, and psychosocial problems, with type of approach (traditional vs triage) as independent variable. To assess the severity of health problems, BMI, Snellen, Strengths and Difficulties Questionnaire, and Child Behavior Checklist, scores were compared for both approaches in subgroups of children with overweight, visual disorders, or psychosocial problems. RESULTS: No significant differences were found between the approaches in terms of the detection of incident cases of overweight, visual disorders, and psychosocial problems. Significantly higher Strengths and Difficulties Questionnaire scores were found in the subgroup with psychosocial problems when the triage approach was used. Marginal differences between the approaches were found for severity of overweight in the subgroup of overweight children. CONCLUSIONS: A novel triage approach to PCH resulting in less involvement of physicians and nurses in routine assessments appears to detect health problems as effectively as the traditional approach in place. More research is needed to determine the long-term outcomes of the 2 approaches.

To compare the incidence of perinatal mortality and morbidity between planned home versus planned hospital births among low-risk women in midwife-led care at the onset of labour.A nationwide cohort study.Retrospective analysis of data from 3 nationwide registries over the years 2000-2009. Main outcome measures were intrapartum and neonatal death, Apgar scores and NICU admission within 28 days after birth.Of the total of 814,858 women, 466,041 (57.2%) had planned home birth and 276,908 (34.0) had planned hospital birth. For 71,909 women (8.8%) the planned place of birth was unknown. Combined intrapartum and neonatal death rates up to 28 days were 1.02‰ for planned home versus 1.09‰ for planned hospital births for primiparous women (adjusted OR: 0.99; 95%-CI: 0.79-1.24), and 0.59‰ versus 0.58‰ for multiparous women (adjusted OR: 1.16; 95%-CI 0.87-1.55). Children of multiparous women with a planned hospital birth had a significantly lower rate of Apgar scores < 7 (adjusted OR: 0.77; 95%-CI: 0,69-0,86) and a significantly higher rate of NICU admissions within 28 days (adjusted OR: 0.79; 95%-CI: 0.66-0.93). For children of primiparous women, we found no differences.We found no increased risk of adverse perinatal outcomes for planned home births among low risk women. Our results may only apply to regions where homebirths are well integrated into the maternity care system.

Objective To test the hypothesis that it is possible to select a group of low risk women who can start labour in midwife-led care without having increased rates of severe adverse maternal outcomes compared to women who start labour in secondary care. Design and Methods We conducted a nationwide cohort study in the Netherlands, using data from 223 739 women with a singleton pregnancy between 37 and 42 weeks gestation without a previous caesarean section, with spontaneous onset of labour and a child in cephalic presentation. Information on all cases of severe acute maternal morbidity collected by the national study into ethnic determinants of maternal morbidity in the Netherlands (LEMMoN study), 1 August 2004 to 1 August 2006, was merged with data from the Netherlands Perinatal Registry of all births occurring during the same period. Our primary outcome was severe acute maternal morbidity (SAMM, i.e. admission to an intensive care unit, uterine rupture, eclampsia or severe HELLP, major obstetric haemorrhage, and other serious events). Secondary outcomes were postpartum haemorrhage and manual removal of placenta. Results Nulliparous and parous women who started labour in midwife-led care had lower rates of SAMM, postpartum haemorrhage and manual removal of placenta compared to women who started labour in secondary care. For SAMM the adjusted odds ratio’s and 95% confidence intervals were for nulliparous women: 0.57 (0.45 to 0.71) and for parous women 0.47 (0.36 to 0.62). Conclusions Our results suggest that it is possible to identify a group of women at low risk of obstetric complications who may benefit from midwife-led care. Women can be reassured that we found no evidence that midwife-led care at the onset of labour is unsafe for women in a maternity care system with a well developed risk selection and referral system.

The Lancet Series on violence against women and girls, while providing a global perspective on the subject and exploring possible preventive measures, fails to place enough emphasis on the extent to which violence affects the children of these women.1García-Moreno C Hegarty K Lucas d'Oliveira AF Koziol-MacLain J Colombini M Feder G The health-systems response to violence against women.Lancet. 2015; 385: 1567-1579Summary Full Text Full Text PDF PubMed Scopus (325) Google Scholar According to our experience, many women admit that they have been victims of intimate partner violence only when it has been established that their children have been abused. When a mother is a victim of intimate partner violence her children are at a great risk of both physical and psychological abuse. In the Netherlands being a witness of intimate violence has recently been classified as a form of child abuse. Women who are victims of intimate partner violence regularly attend hospital Emergency Departments but often do not reveal the cause of their injuries. However, experienced staff should be able to explore this issue in a sensitive, safe manner. In 2008, we introduced a programme (Hague Protocol) aimed at patients attending the Emergency Departments for injuries suspected to result from intimate partner violence.2Diderich HM Fekkes M Verkerk PH et al.A new protocol for screening adults presenting with their own medical problems at the Emergency Department to identify children at high risk for maltreatment.Child Abuse Negl. 2013; 37: 1122-1131Crossref PubMed Scopus (30) Google Scholar They are asked whether they are responsible for the care of children. If this is the case, a voluntary community child welfare agency subsequently contacts the family within 2 weeks to discuss the problem and organise the necessary support. This programme has been rolled out over the whole of the Netherlands. Worries that this might lead to avoidance of the Emergency Departments were proved to be unfounded.3Diderich HM Fekkes M Dechesne M Buitendijk SE Oudesluys-Murphy AM Detecting child abuse based on parental characteristics: Does The Hague Protocol cause parents to avoid the Emergency Department?.Int Emerg Nurs. 2014; (published online Sept 19.)https://doi.org/10.1016/j.ienj.2014.09.004Summary Full Text Full Text PDF PubMed Scopus (6) Google Scholar Health systems can help women and children who are victims of violence. We declare no competing interests. Prevention of violence against women and girls: what does the evidence say?In this Series paper, we review evidence for interventions to reduce the prevalence and incidence of violence against women and girls. Our reviewed studies cover a broad range of intervention models, and many forms of violence—ie, intimate partner violence, non-partner sexual assault, female genital mutilation, and child marriage. Evidence is highly skewed towards that from studies from high-income countries, with these evaluations mainly focusing on responses to violence. This evidence suggests that women-centred, advocacy, and home-visitation programmes can reduce a woman's risk of further victimisation, with less conclusive evidence for the preventive effect of programmes for perpetrators. Full-Text PDF The health-systems response to violence against womenHealth systems have a crucial role in a multisector response to violence against women. Some countries have guidelines or protocols articulating this role and health-care workers are trained in some settings, but generally system development and implementation have been slow to progress. Substantial system and behavioural barriers exist, especially in low-income and middle-income countries. Violence against women was identified as a health priority in 2013 guidelines published by WHO and the 67th World Health Assembly resolution on strengthening the role of the health system in addressing violence, particularly against women and girls. Full-Text PDF From work with men and boys to changes of social norms and reduction of inequities in gender relations: a conceptual shift in prevention of violence against women and girlsViolence perpetrated by and against men and boys is a major public health problem. Although individual men's use of violence differs, engagement of all men and boys in action to prevent violence against women and girls is essential. We discuss why this engagement approach is theoretically important and how prevention interventions have developed from treating men simply as perpetrators of violence against women and girls or as allies of women in its prevention, to approaches that seek to transform the relations, social norms, and systems that sustain gender inequality and violence. Full-Text PDF

Infertility treatments are difficult to understand, and doubly so for migrants because of religious and language factors.Previous studies showed that religion plays an important role in infertility care for Muslim couples that doctors do not always understand.The data presented here come from two exploratory studies that aimed to identify the main problems with infertility care for Turkish and Moroccan couples living in the Netherlands.In the first study, 105 Turkish, Moroccan and Dutch men and women were interviewed.In the second study, twenty general practitioners, gynaecologists and andrologists were interviewed by telephone.Additionally, three gynaecologists were interviewed in Morocco.A thematic analysis was conducted of the qualitative data.Almost all migrants had experienced problems with infertility treatments because they felt insecure about what was allowed by their religion.Moroccan men in particular doubt whether Dutch doctors are sufficiently acquainted with Islam and so they turn to Morocco for information and advice.Men stick to the rules and their agency is to follow the dictates of their religion.Women seem willing to be more flexible about the rules and navigate their agency.Doctors assumed that they took the religion of their patients into account, but they were not always fully aware of the importance of religious prohibitions.Others failed to take into account the agency of their patients.Conclusion: The situation in a new country challenges couples to shape their own agency in respect of reproductive treatment.Doctors are not always aware of the importance of religious doctrine about infertility treatment.

Introduction: We aimed to assess the number of "missed cases" in the detection of child abuse based on the Hague Protocol. This protocol considers 3 parental characteristics of ED adult patients to identify child abuse: (1) domestic violence, (2) intoxication, and (3) suicide attempt or auto-mutilation.Methods: This study focuses on parents whose children should have been referred to the Reporting Centre for Child Abuse and Neglect (RCCAN) in the Hague, the Netherlands, according to the guidelines of the Hague Protocol. Data were collected from all referrals by the Medical Centre Haaglanden (Medisch Centrum Haaglanden) to the RCCAN in the Hague between July 1 and December 31, 2011. The hospital's database was searched to determine whether the parents had visited the emergency department in the 12 months before their child's referral to the RCCAN.Results: Eight missed cases out of 120 cases were found. The reasons for not referring were as follows: forgetting to ask about children and assuming that it was not necessary to refer children if parents indicated that they were already receiving some form of family support.Discussion: Barriers to identifying missing cases could be relatively easy to overcome. Regular training of emergency nurses and an automated alert in the electronic health record to prompt clinicians and emergency nurses may help prevent cases being missed in the future.

Inspectorates have been criticized for assessing compliance with the rules rather than outcomes for children. In the Netherlands, inspectorates have developed a ‘journey tool’ to reconstruct children's travels through all the organizations providing care. Using document analysis and semi-structured interviews, we evaluated how inspectors use this tool in practice. We applied an ontological theoretical framework to the coordination of care to analyse 24 journeys through care organizations, including a selection of six journeys in further detail. Our analysis shows that up until now, inspectors used only one form of coordination, the creation of a hierarchy, resulting in one problem definition. However, in complex care practices, children have multiple and often incompatible problems so that one coherent problem definition cannot be made. We show that ‘patchwork’, a form of coordination that allows discrepancies enables inspectors to reflect on complex care practices and evaluate options to improve outcomes for children.

To determine the critical facilitating and impeding factors underlying successful implementation of a method to detect child abuse based on parental rather than child characteristics known as the Hague Protocol. The original implementation region of the protocol (The Hague) was compared to a new implementation region (Friesland), using analysis of referrals, focus group interviews (n=6) at the Emergency departments (ED) and at the Reporting Centers for Child abuse and Neglect (RCCAN) as well as questionnaires (n=76) at the EDs. Implementation of the Hague Protocol substantially increased the number of referrals to the RCCAN in both regions. In Friesland, the new implementation region, the number of referrals increased from 2 out of 92,464 patients (three per 100,000) to 108 out of 167,037 patients (62 per 100,000). However in Friesland, child abuse was confirmed in a substantially lower percentage of cases relative to the initial implementation region (62% vs. 91%, respectively). Follow-up analyses suggest that this lower positive predictive value may be due to the lack of training for RCCAN professionals concerning the Hague Protocol. The focus group interviews and questionnaires point to time limitations as the main impediment for implementation, whereas an implementation coach has been mentioned as the most important facilitating factor for success. The Hague Protocol can be used to detect child abuse beyond the initial implementation region. However, training is essential in order to assure a consistent evaluation by the RCCAN.

The Hague Protocol considers three parental characteristics of Emergency Department adult patients to identify child abuse: (a) domestic violence, (b) intoxication, and (c) suicide attempt or auto mutilation. This study investigated whether additional parental characteristics could be included to improve the chance of detection. Using a nested case-control design, we compared parents identified as child abusers who were missed by the Protocol with a matched group of nonabusing parents. The parental characteristics used were, among others, all physical injuries possibly resulting from domestic violence, psychological, or mental complaints that might indicate elevated domestic stress levels and the number of Emergency Department visits during the previous year. None of the characteristics were statistically significantly associated with child abuse. The Hague Protocol will not be improved by adding one or more of the characteristics that were investigated.

BACKGROUND: In recent years, the Dutch have begun to question the safety and efficacy of theirmaternity care system. Particular concerns have been raised about the quality of care in hospital - settings. One way to address concerns regarding quality and efficacy of care is by the introduction and use of evidence-based protocols for practice. The primary aims of this study are to (a) describe the availability and diffusion of protocols in Dutch maternity hospitals, (b) systematically assess the - methodological quality of these protocols, and (c) consider the content of the protocols in relation to the best evidence for practice.METHODS: A mailed and Internet questionnaire to all hospitals with maternity facilities in the - Netherlands inquiring about the availability, content, and methodological quality of protocols for three situations: hypertensive conditions of pregnancy, fetal surveillance, and postpartum hemorrhage. All protocols were systematically assessed twice. We first assessed the methodological quality of the - protocol using the Appraisal of Guidelines Research and Evaluation (AGREE) framework, and we then evaluated protocol content using a framework we developed for this purpose. Protocols were scored using a Likert-type scale.RESULTS: There were 53% (N = 48) of all maternity hospitals in the Netherlands that responded. The methodological quality of protocols we evaluated was poor. Using the AGREE framework, 70% of fetal surveillance protocols could not be recommended. Only 1 protocol from 1 hospital scored strongly recommend. Confusion regarding the definition of a protocol and what it should contain were common problems. There was a general paucity of evidence in the protocols assessed.DISCUSSION: Protocols may not be widely available in Dutch maternity hospitals. Where they are available, the quality is poor. There is no national strategy for coordination, implementation, and - dissemination of evidence-based protocols. Because centralization, uniformity, and interprofessional collaboration are known to improve adherence, it would be prudent for maternity care professions to develop and disseminate protocols based on best evidence.

BACKGROUND:The coverage of preventive health assessments for children is pivotal to the system of preventive health screening. A novel method of triage was introduced in the Preventive Youth Health Care (PYHC) system in the Netherlands with an associated shift of tasks of professionals. Doctor's assistants carried out pre-assessments to identify children in need of follow-up assessment, whereas in the traditional approach all children would have been screened by a doctor or nurse. The accessibility and care delivery of this new PYHC system was studied.METHODS:The new triage approach was compared to the traditional approach in 780 children undergoing PYHC assessment with the use of an observational retrospective study design. Outcomes were attendance of assessment appointments (accessibility of care) and referral of children to either extra PYHC assessment or external specialised care (delivery of preventive care). PYHC registry data were analysed. In two regions of the Netherlands, 390 children five to six years of age were randomly selected from the PYHC registries according to the socio-economic strata of the schools they attended.RESULTS:When the triage and traditional approaches to PYHC were compared, we found similar attendance rates for assessment appointments, namely about 90%. As expected, 100% of the children in the traditional group were assessed by a PYHC doctor compared to 46% of the children in the triage group. Significantly fewer children were referred for extra PYHC assessment or for treatment by an external specialised care giver when a triage as opposed to the traditional assessment approach was used (19.6% vs. 45.9%).CONCLUSIONS:The novel triage approach for preventive health assessment shows equal accessibility, but a different delivery of preventive care. A beneficial effect of the adoption of the triage approach is the opportunity to provide more attention from doctors and nurses to children at risk of health problems. However, lower referral rates of the triage approach may be explained by an under-identification of children with health problems. Further research is needed to document the health outcomes and the possible reduction of health care costs with a triage approach compared to traditional PYHC care.

OBJECTIVES:The Hague Protocol is used by professionals at the adult Emergency Departments (ED) in The Netherlands to detect child abuse based on three parental characteristics: (1) domestic violence, (2) substance abuse or (3) suicide attempt or self-harm. After detection, a referral is made to the Reporting Center for Child Abuse and Neglect (RCCAN). This study investigates whether implementing this Protocol will lead parents to avoid medical care.METHOD:We compared the number of patients (for whom the Protocol applied) who attended the ED prior to implementation with those attending after implementation. We conducted telephone interviews (n = 14) with parents whose children were referred to the RCCAN to investigate their experience with the procedure.RESULTS:We found no decline in the number of patients, included in the Protocol, visiting the ED during the 4 year implementation period (2008-2011). Most parents (n = 10 of the 14 interviewed) were positive and stated that they would, if necessary, re-attend the ED with the same complaints in the future.CONCLUSION:ED nurses and doctors referring children based on parental characteristics do not have to fear losing these families as patients.

In the 1970s, advocates of demedicalising pregnancy and birth 'discovered' Dutch maternity care. The Netherlands presented an attractive model because its maternity care system was characterised by a strong and independent profession of midwifery, close co-operation between obstetricians and midwives, a very high rate of births at home, little use of caesarean section, and morbidity and mortality statistics that were among the best in the developed world. Over the course of the following 40 years much has changed in the Netherlands. Although the home birth rate remains quite high when compared to other modern countries, it is half of what it was in the 1970s. Midwifery is still an independent medical profession, but a move toward 'integrated care' threatens to bring midwives into hospitals under the direction of medical specialists, more women are interested in medical pain relief, and there is a growing concern that current, albeit slight, increases in rates of intervention in physiological births foreshadow the end of the unique approach to birth in the Netherlands. The story of Dutch maternity care thus offers an ideal opportunity to examine the social, organisational, and cultural factors that work to support, and to diminish, the independent practice of midwifery in high-resource countries. We may wish to believe that providing ample and convincing evidence of the value of midwifery care will be enough to promote more and better use of midwifery, but the lessons from the Netherlands make clear that an array of social forces play a critical role determining the place of midwives in the health care system and how the care they provide is deployed.

Objective: to describe the incidence and characteristics of patient safety incidents in midwifery-led care for low-risk pregnant women.Design: multi-method study.Setting: 20 midwifery practices in the Netherlands; 1,000 patient records.Population: low-risk pregnant women.Methods: prospective incident reporting by midwives during 2 weeks; questionnaire on safety culture and retrospective content analysis of 1,000 patient records in 2009.Main outcome measures: incidence, type, impact and causes of safety incidents.Results: in the 1,000 patient records involving 14,888 contacts, 86 safety incidents were found with 25 of these having a noticeable effect on the patient. Low-risk pregnant women in midwifery care had a probability of 8.6% for a safety incident (95% CI 4.8-14.4). In 9 safety incidents, temporary monitoring of the mother and/or child was necessary. In another 6 safety incidents, reviewers reported psychological distress for the patient. Hospital admission followed from 1 incident. No safety incidents were associated with mortality or permanent harm. The majority of incidents found in the patient records concerned treatment and organisational factors.Conclusions: a low prevalence of patient safety incidents was found in midwifery care for low-risk pregnant women. This first systematic study of patient safety in midwifery adds to the base of evidence regarding the safety of midwifery-led care for low-risk women. Nevertheless, some areas for improvement were found. Improvement of patient safety should address the better adherence to practice guidelines for patient risk assessment, better implementation of interventions for known lifestyle risk factors and better availability of midwives during birthing care. (C) 2011 Elsevier Ltd. All rights reserved.

Background: This study aimed to perform a structural analysis of determinants of risk of critical incidents in care for women with a low risk profile at the start of pregnancy with a view on improving patient safety.Methods: We included 71 critical incidents in primary midwifery care and subsequent hospital care in case of referral after 36 weeks of pregnancy that were related to substandard care and for that reason were reported to the Health Care Inspectorate in The Netherlands in 36 months (n = 357). We performed a case-by-case analysis, using a previously validated instrument which covered five broad domains: healthcare organization, communication between healthcare providers, patient risk factors, clinical management, and clinical outcomes.Results: Determinants that were associated with risk concerned healthcare organization (n = 20 incidents), communication about treatment procedures (n = 39), referral processes (n = 19), risk assessment by telephone triage (n = 10), and clinical management in an out of hours setting (n = 19). The 71 critical incidents included three cases of maternal death, eight cases of severe maternal morbidity, 42 perinatal deaths and 12 critical incidents with severe morbidity for the child. Suboptimal prenatal risk assessment, a delay in availability of health care providers in urgent situations, miscommunication about treatment between care providers, and miscommunication with patients in situations with a language barrier were associated with safety risks.Conclusions: Systematic analysis of critical incidents improves insight in determinants of safety risk. The wide variety of determinants of risk of critical incidents implies that there is no single intervention to improve patient safety in the care for pregnant women with initially a low risk profile.