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Florence Talrich,1,2 Astrid Van Damme,1,2 Hilde LA Bastiaens,3 Jochen Bergs,4 Marlies EB Rijnders,5 Katrien Beeckman1,2,6 1Department of Public Health, Vrije Universiteit Brussel (VUB), Jette, Belgium; 2Department of Nursing and Midwifery Research Group (NUMID), Universitair Ziekenhuis Brussel (UZ Brussel), Jette, Belgium; 3Department Family Medicine and Population Health, Universiteit Antwerpen, Antwerp, Belgium; 4Department of Healthcare, Universiteit Hasselt, Hasselt, Belgium; 5Department of Child Health, TNO, Leiden, the Netherlands; 6Department Nursing and Midwifery, Universiteit Antwerpen, Antwerp, BelgiumCorrespondence: Florence Talrich, Laarbeeklaan 103, Brussel, Jette, 1090, Belgium, Tel +324749853, Email florence.talrich@vub.be

Background Group care (GC) improves the quality of maternity care, stimulates women’s participation in their own care and facilitates growth of women’s social support networks. There is an urgent need to identify and disseminate the best mechanisms for implementing GC in ways that are feasible, context appropriate and sustainable. This protocol presents the aims and methods of an innovative implementation research project entitled Group Care in the first 1000 days (GC_1000), which addresses this need. Aims The aim of GC_1000 is to co-create and disseminate evidence-based implementation strategies and tools to support successful implementation and scale-up of GC in health systems throughout the world, with particular attention to the needs of ‘vulnerable’ populations. Methods By working through five inter-related work packages, each with specific tasks, objectives and deliverables, the global research team will systematically examine and document the implementation and scale-up processes of antenatal and postnatal GC in seven different countries. The GC_1000 project is grounded theoretically in the consolidated framework for implementation research (CFIR), while the process evaluation is guided by ‘Realistic Evaluation’ principles. Data are gathered across all research phases and analysis at each stage is synthesized to develop Context-Intervention-Mechanism-Outcome configurations. Discussion GC_1000 will generate evidence-based knowledge about the integration of complex interventions into diverse health care systems. The 4-year project also will pave the way for sustained implementation of GC, significantly benefitting populations with adverse pregnancy and birthing experiences as well as poor outcomes.

AIM: To evaluate the impact and the possible role of psychological resilience in the COVID-19 pandemic outbreak on healthcare workers' mental and physical well-being in Belgium. DESIGN: This cross-sectional, survey-based study enrolled 1376 healthcare workers across Belgium from 17 April 2020 to 24 April 2020. METHODS: The study sample consisted of direct care workers (nurses and doctors), supporting staff and management staff members. The main outcomes are resilience, distress and somatization. RESULTS: Higher educational level was associated with lower symptoms of distress and somatization. Physicians exhibited the lowest risk of experiencing heightened levels of distress and somatization. Controlling for confounding factors, higher levels of resilience were associated with a 12% reduced chance of increased distress levels and 5% lower chance of increased somatization levels. Our results suggest the potentially buffering role of mental resilience on those working on the frontline during the COVID-19 pandemic outbreak. ispartof: NURSING OPEN vol:9 issue:2 pages:1181-1189 ispartof: location:United States status: published

Background and Objectives Belgian health authorities launched a national platform in 2011 to improve the quality of transfusion practices and blood use in Belgian hospitals. No data were available about the quality of hospital transfusion practice at the national level. Materials and Methods Three consecutive national surveys (2012, 2014 and 2016) were performed in all 111 Belgian hospitals to assess the degree of implementation of standards in four process domains related to red blood cell (RBC) transfusion: general quality aspects, ordering of RBC, electronic traceability and reporting of adverse events. The surveys were part of a methodology based on informing, feedback and benchmarking. Responses to questions were analysed semi-quantitatively, and hospitals could score 10 points on each of the domains. Results The proportion of hospitals scoring below 5 per domain decreased from 16%, 70%, 14% and 11% (2012) to 2%, 17%, 1% and 1% (2016), respectively. Similarly, scores above 7.5 increased from 25%, 1%, 23% and 36% (2012) to 64%, 30%, 68% and 81% (2016), respectively. In 2016, overall quality of transfusion practices, including the four pre-specified domains, improved continuously with an average total score (max = 40) increasing from 24.2 to 30.5 (p = 0.0005). In addition, there was a decrease in the number of distributed and transfused RBC per 1000 population between 2011 and 2019 from 47.0 to 36.5 and 43.5 to 36.1, respectively. Conclusion These data show that the applied methodology was a powerful tool to improve quality of transfusion practices and to optimize utilization of RBC at the national level.

Background Antenatal psychosocial vulnerability is a main concern in today’s perinatal health care setting. Undetected psychosocially vulnerable pregnant women and their unborn child are at risk for unfavourable health outcomes such as poor birth outcomes or mental state. In order to detect potential risks and prevent worse outcomes, timely and accurate detection of antenatal psychosocial vulnerability is necessary. Therefore, this paper aims to develop a screening tool ‘the Born in Brussels Screening Tool (ST)’ aimed at detecting antenatal psychosocial vulnerability. Methods The Born in Brussels ST was developed based on a literature search of existing screening tools measuring antenatal psychosocial vulnerability. Indicators and items (i.e. questions) were evaluated and selected. The assigned points for the answer options were determined based on a survey sent out to caregivers experienced in antenatal (psychosocial) vulnerability. Further refinement of the tool’s content and the assigned points was based on expert panels’ advice. Results The Born in Brussels ST consists of 22 items that focus on 13 indicators: communication, place of birth, residence status, education, occupational status, partner’s occupation, financial situation, housing situation, social support, depression, anxiety, substance use and domestic violence. Based on the 168 caregivers who participated in the survey, assigned points account between 0,5 and 4. Threshold scores of each indicator were associated with adapted care paths. Conclusion Generalied and accurate detection of antenatal psychosocial vulnerability is needed. The brief and practical oriented Born in Brussels ST is a first step that can lead to an adequate and adapted care pathway for vulnerable pregnant women.

Objective: Development and validation of a set of quality indicators for vulnerable women during the perinatal period. Design: A three-phase method was used. Phase 1 consisted of a literature review to identify publications for the development of care domains and potential QIs, as well as a quality assessment by the research team. In phase 2 an expert panel assessed the set of concept QIs in a modified three-round Delphi survey. Finally, semi-structured interviews with vulnerable women were conducted as a final quality assessment of a set of indicators (phase 3). Ethical approval was obtained from the ethics committee of the University Hospital Brussels and from the Ethics Committees of all the participating hospitals. Setting: The Flemish Region and the Brussels Capital Region in Belgium. Participants: Healthcare and social care professionals (n = 40) with expertise in the field of perinatal care provision for vulnerable families. Vulnerable women (n = 11) who gave birth in one of the participating hospitals. Findings: The literature review resulted in a set of 49 potential quality indicators in five care domains: access to healthcare, assessment and screening, informal support, formal support and continuity of care. After assessment by the expert panel and vulnerable women, a final set of 21 quality indicators in five care domains was identified. First of all, organisation of care must involve an integrated multidisciplinary approach taking account of financial, administrative and social barriers (care domain 1: access to healthcare). Second, qualitative care includes the timely initiation of care, a general screening of the various aspects of vulnerability (biological, psychological, social and cognitive) and a risk assessment for all women (care domain 2: assessment and screening). Vulnerable women benefit from intensive formal and informal support taking account of individual needs and strengths (care domain 3: formal support; care domain 4: informal support). Finally, continuity of care needs to be guaranteed in line with vulnerable woman's individual needs (care domain 5: continuity of care). Key conclusions and implications for practice: Implementing quality indicators in existing and new care pathways offers an evidence-based approach facilitating an integrated view promoting a healthy start for woman and child. These quality indicators can assist healthcare providers, organisations and governmental agencies to improve the quality of perinatal care for vulnerable women. (C) 2020 Elsevier Ltd. All rights reserved.

Background Continuity of care (COC) is essential for high-quality patient care in the perinatal period. Insights in the effects of COC models on patient outcomes are important to direct perinatal healthcare organization. To our knowledge, no previous review has listed the effects of COC on the physical and mental health of mother and child in the postnatal period. Methods A search was conducted in four databases (PubMed, Web of Knowledge, CENTRAL and CINAHL), from 2000 to 2018. Studies were included if: participants were healthy mothers or newborns with a gestational age between 37–42 weeks; they covered the perinatal period and aimed to measure breastfeeding or any outcome related to the maternal/newborn physical or mental health. At least one of the three COC types (management, informational and relationship) was identified in the intervention. The methodological quality was assessed. Results Ten articles were included. COC is mostly present in the identified care models. The effects of COC on the outcomes of mother and child in the postnatal period seem mostly to be positive, although not always significant. The relation between COC and the outcomes can be influenced by confounding factors, like the socio-economic status of the included population. Interventions with COC during pregnancy appear to be more effective for all the studied outcome factors. Conclusion COC as management, relational and informational continuity starting antenatal has the most impact on the postnatal outcomes of mother and child.

Objectives Currently maternity care organisation is developing worldwide. Therefore insight in the position of the midwife is important. The 'Midwife Profiling Questionnaire′ (MidProQ) measures women’s preferred perinatal care professional and their knowledge of midwives’ legal competences. MidProQ is based on the European legal framework and was tested in a pilot study. This study aims to determine its content and face validity. Study design. A two-phase validation study with a Delphi method questioning content experts (n = 10) on items relevance and clarity as well as its scale and face validity. Further semi-structured interviews were performed with lay experts (n = 10) to evaluate the questionnaire’s clarity, layout, phrasing and wording. Results After round one, most questions (42/47) were considered content valid for relevance and clarity (Item Content Validity Index 0.80–1.00). Scale (Scale Content Validity Index 0.92) and face validity (Face Validity Index 0.89) of the entire instrument was obtained. Five questions were revised until item content (0.83–1.00), scale content (0.92) and face validity (1.00) were appropriate. Lay experts’ suggestions for improving the readability and usability were taken into account. Conclusions We developed a valid instrument to elicit women’s preferred health professional for uncomplicated pregnancy, labour and childbirth and to determine their knowledge about midwives’ legal competences. Our instrument can be valuable in identifying knowledge gaps and improving the knowledge of the general population about the midwifery profession and maternity care. Finally, the MidProQ may improve research in the domain of maternity care culture, scale up midwifery and facilitate a more women-centred care.

Objective: To compare synthetic oxytocin infusion regimens used during labour, calculate the International Units (IU) escalation rate and total amount of IU infused over eight hours. Design: Observational study. Setting: Twelve countries, eleven European and South Africa. Sample: National, regional or institutional-level regimens on oxytocin for induction and augmentation labour Methods: Data on oxytocin IU dose, infusion fluid amount, start dose, escalation rate and maximum dose were collected. Values for each regimen were converted to IU in 1000ml diluent. One IU corresponded to 1.67μg for doses provided in grams/micrograms. IU hourly dose increase rates were based on escalation frequency. Cumulative doses and total IU amount infused were calculated by adding the dose administered for each previous hour. Main Outcome Measures Oxytocin IU dose infused. Results: Data were obtained on 21 regimens used in 12 countries. Details on the start dose, escalation interval, escalation rate and maximum dose infused were available from 16 regimens. Starting rates varied from 0.06 IU/hour to 0.90 IU/hour, and the maximum dose rate varied from 0.90 IU/hour to 3.60 IU/hour. The total amount of IU oxytocin infused, estimated over eight hours, ranged from 2.38 IU to 27.00 IU, a variation of 24.62 IU and an 11-fold difference. Conclusion: Current variations in oxytocin regimens for induction and augmentation of labour are inexplicable. It is crucial that the appropriate minimum infusion regimen is administered because synthetic oxytocin is a potentially harmful medication with serious consequences for women and babies when inappropriately used. Estimating the total amount of oxytocin IU received by labouring women, alongside the institution’s mode of birth and neonatal outcomes, may deepen our understanding and be the way forward to identifying the optimal infusion regimen. This study is part of the EU COST Action IS1405 "Building Intrapartum Research Through Health—An interdisciplinary whole system approach to understanding and contextualising physiological labour and birth".

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To assess the beneficial and harmful effects of pharmacological interventions for the prevention of pain during endotracheal suctioning in mechanically ventilated neonates. Pharmacological interventions will be compared to no intervention or standard care, or to non‐pharmacological interventions.

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To assess the beneficial and harmful effects of pharmacological interventions for the prevention of pain during endotracheal suctioning in mechanically ventilated neonates. Pharmacological interventions will be compared to no intervention or standard care, or to non‐pharmacological interventions.

Der Artikel wurde innerhalb des EU-Projekts OptiBIRTH erstellt., This is the peer reviewed version of the following article: [Haunberger, S, Rüegger, C, Baumgartner, E. Experiences with a psychosocial screening instrument (S‐FIRST) to identify the psychosocial support needs of parents of children suffering from cancer. Psycho‐Oncology. 2019; 28: 1025‐ 1032.], which has been published in final form at https://doi.org/10.1002/pon.5045. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions., Objective: To perform a health economic analysis of an intervention designed to increase rates of vaginal birth after caesarean, compared with usual care. Design: Economic analysis alongside the cluster-randomised OptiBIRTH trial (Optimising childbirth by increasing vaginal birth after caesarean section (VBAC) through enhanced women-centred care). Setting: Fifteen maternity units in three European countries - Germany (five), Ireland (five), and Italy (five) - with relatively low VBAC rates. Population: Pregnant women with a history of one previous lower-segment caesarean section; sites were randomised (3:2) to intervention or control. Methods: A cost-utility analysis from both societal and health-services perspectives, using a decision tree. Main Outcome Measures: Costs and resource use per woman and infant were compared between the control and intervention group by country, from pregnancy recognition until 3 months postpartum. Based on the caesarean section rates, and maternal and neonatal morbidities and mortality, the incremental cost-utility ratios were calculated per country. Results: The mean difference in costs per quality-adjusted life years (QALYs) gained from a societal perspective between the intervention and the control group, using a probabilistic sensitivity analysis, was: €263 (95% CI €258-268) and 0.008 QALYs (95% CI 0.008-0.009 QALYs) for Germany, €456 (95% CI €448-464) and 0.052 QALYs (95% CI 0.051-0.053 QALYs) for Ireland, and €1174 (95% CI €1170-1178) and 0.006 QALYs (95% CI 0.005-0.007 QALYs) for Italy. The incremental cost-utility ratios were €33,741/QALY for Germany, €8785/QALY for Ireland, and €214,318/QALY for Italy, with a 51% probability of being cost-effective for Germany, 92% for Ireland, and 15% for Italy. Conclusion: The OptiBIRTH intervention was likely to be cost-effective in Ireland and Germany.

Introduction: Clinical placements are an integral part of midwifery education and are crucial for achieving professional competencies. Although students’ experiences on placements have been shown to play a meaningful role in their learning, they have received scant attention in the literature. The aim of this paper is to describe the learning experiences of final-year student midwives in labor wards within the Brussels metropolitan region, Belgium. Methods: A qualitative exploratory study was conducted using two focus groups (N=20). Data analysis included: transcription of audio recordings, thematic content analysis with coding into recurrent and common themes, and broader categories. Discussions among researchers were incorporated in all phases of the analysis for integrity and data fit. Results: Data analysis identified the following categories as determining student learning experiences in labor wards: 1) managing opportunities, 2) being supported, and 3) dealing with the environment. Overall, respondents were positive and enthusiastic about their learning experiences, although some felt tense and unprepared. Students expressed concerns about differences in learning opportunities between placements and found it challenging to achieve all competencies. Student learning experiences were enhanced when they had placements for longer periods with the same supportive mentors. Conclusions: Factors related to students’ functioning, the healthcare professional, midwifery education and hospital environment affected their learning in labor wards. The combination of a more persevered preparation of students and mentors, together with a student-centered organization of placements, is crucial to create a positive learning experience for midwifery students in labor wards. ispartof: European Journal of Midwifery vol:3 pages:1-8 ispartof: location:Greece status: published

Objectives: Women who have had a caesarean section may have a preference for birth mode during their subsequent pregnancy, either 'vaginal birth after caesarean' (VBAC) or 'elective repeat caesarean section' (ERCS). A mismatch between the preferred and actual birth mode may result in an impaired postnatal Health Related Quality of Life (HRQoL). This study examined the associations between antenatal birth mode preferences, the actual birth mode and postnatal HRQoL in women with one previous caesarean section in three European countries. Design: Prospective longitudinal survey, as a part of a cluster randomised trial (OptiBIRTH) Setting: Fifteen maternity units in three European countries: Germany (5), Ireland (5) and Italy (5). Participants: Women (≥ aged 18 years) living in Germany, Ireland and Italy with one previous caesarean section. The sample consisted of 862 women with complete antenatal and postpartum data. Measurements: Women's preference for birth mode after one previous caesarean section was assessed at inclusion to the trial, and HRQoL was assessed antenatally and at three months postpartum using the Short-Form Six-Dimension health survey. Based on women's preferences and actual birth mode six groups were determined: "match VBAC-VBAC" (preference for vaginal birth, actual mode of birth vaginal birth), "match ERCS-ERCS" (preference for caesarean section, actual mode of birth elective repeat caesarean section), "match ERCS-EMCS" (preference for caesarean section, actual mode of birth emergency repeat caesarean section), "mismatch VBAC-ERCS" (preference for vaginal birth, actual mode of birth elective repeat caesarean section), "mismatch VBAC-EMCS" (preference for vaginal birth, actual mode of birth emergency repeat caesarean section) and "no preference". Associations between the preferred and actual birth mode were examined using univariate and multivariate analyses. Findings: Women with preference for vaginal birth but who gave birth by elective repeat caesarean section (mismatch VBAC-ERCS) had a lower postnatal HRQoL compared to women with a preference for vaginal birth who actually had a birth vaginally (match VBAC-VBAC, p = 0.02). Poor antenatal HRQoL scores (p < 0.01) and maternal readmission postpartum (p = 0.03) are cofounding factors for poorer postnatal HRQoL scores. Key Conclusions: The results show that women with a preference for a vaginal birth who gave birth by an elective repeat caesarean section had a significantly lower HRQoL at three months postnatal. The long-term consequences and psychological health of women who do not achieve a vaginal birth after caesarean require further consideration and research. Implications for Practice: Attention should be given to the long-term impact of a mismatch in preferred and actual mode on the psychological health of women

BACKGROUND: The publication of the World Health Organization (WHO) recommendations on antenatal care in 2016 introduced the perspective of women as a necessary component of clinical guidelines in maternity care. WHO highlights the crucial role played by evidence-based recommendations in promoting and supporting normal birth processes and a positive experience of pregnancy. This paper aims to explore and critically appraise recommendations of national antenatal care guidelines across European countries in comparison with the WHO guideline.METHODS: We collected guidelines from country partners of the EU CO ST Action IS1405. Components of the documents structure and main recommendations within and between them were compared and contrasted with the WHO guideline on antenatal care with a particular interest in exploring whether and how women’s experience was included in the recommendations.RESULTS: Eight out of eleven countries had a single national guideline on antenatal care while three countries did not. National guidelines mostly focused on care of healthy women with a straightforward pregnancy. The level of concordance between the national and the WHO recommendations varied along a continuum from almost total concordance to almost total dissonance. Women’s views and experiences were accounted for in some guidelines, but mostly not placed at the same level of importance as clinical items.CONCLUSIONS: Findings outline convergences and divergences with the WHO recommendations. They highlight the need for considering women’s views more in the development of evidence-based recommendations and in practice for positive impacts on perinatal health at a global level, and on the experiences of each family.(Cite this article as: Iannuzzi L, Branchini L, Clausen JA, Ruiz-Berdún D, Gillen P, Healy M, et al. Optimal outcomes and women’s positive pregnancy experience: a comparison between the World Health Organization guideline and recommendations in European national antenatal care guidelines.

Introduction There are growing concerns about the increase in rates of commonly used childbirth interventions. When indicated, childbirth interventions are crucial for preventing maternal and perinatal morbidity and mortality, but their routine use in healthy women and children leads to avoidable maternal and neonatal harm. Establishing ideal rates of interventions can be challenging. This study aims to describe the range of variations in the use of commonly used childbirth interventions in high-income countries around the world, and in outcomes in nulliparous and multiparous women. Methods and analysis This multinational cross-sectional study will use data from births in 2013 with national population data or representative samples of the population of pregnant women in high-income countries. Data from women who gave birth to a single child from 37 weeks gestation onwards will be included and the results will be presented for nulliparous and multiparous women separately. Anonymised individual level data will be analysed. Primary outcomes are rates of commonly used childbirth interventions, including induction and/or augmentation of labour, intrapartum antibiotics, epidural and pharmacological pain relief, episiotomy in vaginal births, instrument-assisted birth (vacuum or forceps), caesarean section and use of oxytocin postpartum. Secondary outcomes are maternal and perinatal mortality, Apgar score below 7 at 5 min, postpartum haemorrhage and obstetric anal sphincter injury. Univariable and multivariable logistic regression analyses will be conducted to investigate variations among countries, adjusted for maternal age, body mass index, gestational weight gain, ethnic background, socioeconomic status and infant birth weight. The overall mean rates will be considered as a reference category, weighted for the size of the study population per country. Ethics and dissemination The Medical Ethics Review Committee of VU University Medical Center Amsterdam confirmed that an official approval of this study was not required. Results will be disseminated at national and international conferences and published in peer-reviewed journals., The study was developed during a meeting with COST-members (European Cooperation in Science and Technology). These meetings are funded by the COST Action IS1405 ‘BIRTH’ (European Cooperation in Science and Technology). There is no other external funding for this study.

This paper focuses on the individual perspective, as opposed to the institutional or operational one, towards the Fundamental Principles and their underpinning humanitarian values. It demonstrates the added value of this perspective, which goes beyond addressing challenges regarding the Fundamental Principles' understanding and application. By making the Principles and values come alive in peoples' behaviour, the individual perspective also enables Red Cross and Red Crescent staff and volunteers to inspire a change of mindset and behaviour towards a culture of non-violence and peace. Two tools created to this purpose, as well as their impact, are presented: (i) the Seven Skills for Seven Principles (747) framework, which unpacks the high-level Principles into more concrete and tangible components, values and intra- and interpersonal skills; and (ii) the Youth as Agents of Behavioural Change (YABC) initiative, which, using a non-cognitive learning approach, fosters a personal connection towards the Principles and increases participants' ability to role-model them.

OBJECTIVES: Measuring of antenatal care utilisation is important from a public health perspective. The Content and Timing of care in Pregnancy tool (CTP) focuses on the care process and includes aspects on quality of care. The aim of the study is to gain insight in the applicability of the CTP tool across Europe. METHODS: National guidelines for routine antenatal care were examined, analysing the degree to which the four items in the CTP tool were included in these guidelines. RESULTS: From the 30 countries, 22 had a national guideline for routine antenatal care. The CTP tool is applicable in over 60% of the European countries with a national guideline. CONCLUSIONS: The CTP tool can be used to measure antenatal care delivery in Europe. The tool is useful to evaluate the care process, focusing on rates of interventions as the closest approximation to the delivery of health care, with a focus on content of visits rather than simply the number of visits. Together with indicators measuring structure and outcome of health care, conclusions about the quality of care can be made.

Background: How a woman gives birth can affect her health- related quality of life (HRQoL). This study explored HRQoL at 3 months postpartum in women with a history of one previous cesarean in three European countries. Methods: A prospective longitudinal survey, embedded within a cluster randomized trial in three countries, exploring women’s postnatal HRQoL up to 3 months postpartum. The Short- Form Six- Dimensions (SF- 6D) was used to measure HRQoL, and multivariate analyses were used to examine the relationship with mode of birth. Results: Complete data were available from 880 women. Women with a spontaneous vaginal birth had the highest HRQoL scores, whereas women with an emergency repeat cesarean (P = .01) had the lowest. Postnatal readmission of the mother (P = .03), having public health insurance (P = .04) and a low antenatal HRQoL score (P < .01), contributes to poorer HRQoL scores. More specifically, women with a spontaneous vaginal birth had significantly higher HRQoL scores on the vitality dimension compared with women with an emergency repeat cesarean (P = .04). Conclusions: In women with low- risk factors, repeat cesareans result in a poorer HRQoL compared with vaginal birth. When there are no contraindications for vaginal birth, women with a history of one previous cesarean should be encouraged to give birth vaginally rather than have an elective repeat cesarean.

Background Simulation training is a powerful and evidence-based teaching method in healthcare. It allows students to develop essential competences that are often difficult to achieve during internships. High-Fidelity Perinatal Simulation exposes them to real-life scenarios in a safe environment. Although student midwives’ experiences need to be considered to make the simulation training work, these have been overlooked so far. Aim To explore the experiences of last-year student midwives with High-Fidelity Perinatal Simulation training. Methods A qualitative descriptive study, using three focus group conversations with last-year student midwives (n = 24). Audio tapes were transcribed and a thematic content analysis was performed. The entire data set was coded according to recurrent or common themes. To achieve investigator triangulation and confirm themes, discussions among the researchers was incorporated in the analysis. Findings Students found High-Fidelity Perinatal Simulation training to be a positive learning method that increased both their competence and confidence. Their experiences varied over the different phases of the High-Fidelity Perinatal Simulation training. Although uncertainty, tension, confusion and disappointment were experienced throughout the simulation trajectory, they reported that this did not affect their learning and confidence-building. Conclusion As High-Fidelity Perinatal Simulation training constitutes a helpful learning experience in midwifery education, it could have a positive influence on maternal and neonatal outcomes. In the long term, it could therefore enhance the midwifery profession in several ways. The present study is an important first step in opening up the debate about the pedagogical use of High-Fidelity Perinatal Simulation training within midwifery education.

OBJECTIVES The OptiBIRTH study incorporates a multicentre cluster randomised trial in 15 sites across three European countries. The trial was designed to test a complex intervention aimed at improving vaginal birth after caesarean section (VBAC) rates through increasing women’s involvement in their care. In preparation for conducting the health economic analysis part of the OptiBIRTH study, an analysis of a hypothetical cohort was performed to estimate the costs and health effects of VBAC compared to elective repeat caesarean delivery (ERCD) for low-risk women in four European countries. METHODS A decision-analytic model was developed to estimate the costs and the health effects, measured using Quality Adjusted Life Years (QALYs), of VBAC compared with ERCD. A cost-utility analysis for the period from confirmation of pregnancy to 6 weeks postpartum was performed for a hypothetical cohort of 100,000 pregnant women in each of four different countries; Belgium, Germany, Ireland and Italy adopted a societal perspective. Where possible, transition probabilities, costs and health effects were adapted from data obtained from the respective countries, and country-specific thresholds were used to determine the cost-effectiveness of VBAC compared to ERCD. Deterministic and probabilistic sensitivity analyses were conducted to examine the uncertainty of model assumptions. RESULTS VBAC was a dominant strategy compared to ERCD and resulted in a reduction in costs, ranging from €14,851,642 (Germany) to €87,695,173 (Ireland), and gains in QALYs ranging from 6129 (Italy) to 7325 (Germany) per 100,000 women birthing in each country. The ICER results differed from €-1,975/QALY (Germany), €-2,446/QALY (Belgium), €-3,345/QALY (Italy) to €-13,971/QALY (Ireland). CONCLUSIONS In all four countries, VBAC was associated with costs savings and gains in QALYs compared to ERCD for low-risk women. This is important for health service managers, economists and policy makers concerned with maximising health benefits within limited and constrained resources.

Background: Examining determinants of antenatal care (ANC) is important to stimulate equitable distribution of ANC across Europe. This study (1) compares ANC utilisation in Belgium and the Netherlands and (2) identifies predisposing, enabling and pregnancy-related determinants. Methods: Secondary data analysis is performed using data from Belgium, and the Netherlands. The content and timing of care during pregnancy (CTP) tool measured ANC use. Non-parametric tests and ordinal logistic regression are performed to gain insight in the determinants of health care use. Results: Dutch women receive appropriate ANC more often than Belgian women. Multivariate analysis showed that lower education, unemployment, lower continuity of care and non-attendance of antenatal classes are associated with a lower likelihood of having more appropriate ANC. Conclusions: Predisposing and pregnancy related variables are most important to influence the content and timing of ANC, irrespective of the country women live in. Lower health literacy in socially vulnerable women might explain the predisposing determinants of health care use in both countries. Stimulating accessibility to antenatal courses or organising public education are recommendations for practice. Regarding pregnancy-related determinants, improving continuity of care can optimise ANC use in both countries.

Objective to explore women's preferences with regard to their preferred health professional during labour and childbirth in case of an uncomplicated pregnancy, and to gain insight into women's knowledge of the legal competences of midwives. Design a descriptive observational study. Setting Brussels metropolitan region, Belgium. Participants women in their reproductive age, living in the Brussels metropolitan region, with Dutch or French as their first language ( n =830). Measurements a ten-item standardized questionnaire'Midwife Profiling Questionnaire' (MidProQ) was developed to determine which health professional respondents would prefer to assist them during labour and childbirth if there were no complications and to assess their knowledge about midwives' legal competences during pregnancy, labour and childbirth. Descriptive statistics were used to report the findings. To identify relationships between the socio-demographic variables of the women and her preferences, knowledge and opinion Chi² analysis were used. Findings For 68.0% of the participants in an uncomplicated labour ( n =564) and 66.3% of the participants with an uncomplicated childbirth ( n =550), a midwife is the preferred health professional. Brussels women prefer an obstetrician in an uncomplicated labour ( n =730, 88%) and for uncomplicated childbirth ( n =756, 91.1%). Only 20.2% of the respondents ( n =168) consider midwives to play a central role in an uncomplicated pregnancy. The knowledge of Brussels women about midwives' legal competences during pregnancy, labour and childbirth is rather poor, especially in youngsters and women who have never given birth. Key conclusions In general, for Brussels women, midwives are not the first preferred health professional for an uncomplicated labour or for childbirth, and they do not consider midwives to play a central role in an uncomplicated pregnancy. The legal competences of midwives are not known very well, especially by youngsters and women who have never given birth. The Belgian medical model of maternity care and women's experiences affect their preferences and knowledge about the legal competences of midwives and their opinion about the central health professional in an uncomplicated pregnancy. Implications for practice To enhance more women-centred care and initiate change in the current maternity care culture in Belgium, public education, structural changes in maternity services and strategies to inspire public opinion to initiate cultural change are suggested. Involvement of midwifery organisations, other health professionals in maternity services and policy-makers with women's groups and potential service users is key.

Aim To report an analysis of the concept of proactive behaviour and apply the findings to midwifery. Background Proactive behaviour is a universal phenomenon generalizable to multiple professions. The purpose of this work was to establish a link with midwifery. Design Concept analysis by Walker and Avant's method. Data sources Literature was searched in PubMed, ERIC, NARCIS, Emerald and reference lists of related journal articles with a timeline of 1990 – April 2015 in the period of November 2014 – June 2015. Next key words were combined by the use of Boolean operators: ‘proactive behaviour’, ‘midwifery’, ‘midwife’, ‘proactivity’ and ‘proactive’. Fifteen studies were included. Methods A focused review of scientific publications in midwifery, health care, healthcare education and social sciences, which highlighted the concept of proactive behaviour. Results In the studied literature, several attributes of proactive behaviour were cited. These attributes were narrowed by applying it on a midwifery model case, borderline case and contrary case. Related concepts were elaborated and distinguished of the concept of proactive behaviour in midwifery. Proactive behaviour is triggered by different individual and contextual antecedents and has consequences at multiple levels. Conclusion A midwife who behaves proactive would not look at changes as a boundary, persistently improves things she experienced as wrong, anticipates future barriers and looks for viable alternatives to carry out her work as efficiently and effectively as possible. Various individual and/or contextual antecedents trigger proactive behaviour in midwifery, and this behaviour could cause multiple future benefits for the constant evolving reproductive health care.

Simulation training is a powerful and evidence-based teaching method for students and healthcare professionals. The described educational model of Inter-professional Perinatal Simulation training is the result of a collaborative project with the Erasmus University College Brussels, the Medical School of the Vrije Universiteit Brussel (VUB) and the University Hospital Brussels. This model enhances student midwives to acquire competencies in all fields of midwifery according to national and European legislation and to the International Confederation of Midwives Global Standards for Midwifery Education. In our educational program, simulation training enhanced the achievement of decision-making and inter-professional communication competences.

BACKGROUND: Antenatal care can play an important role in the prevention of preterm birth. Evaluation of antenatal care is usually based on the number of visits rather than the content of care, using tools such as the Adequacy of Prenatal Care Use index. This article presents an analysis of the relation between specific elements of antenatal care and the risk of preterm birth compared with considering the number of visits only. METHODS: A prospective cohort study was conducted in the Brussels Metropolitan Region. In all, 333 women were consecutively recruited at the beginning of their antenatal care trajectory and followed until birth. Information on timing and content for every visit was recorded by structured interview. A new tool was developed to measure the antenatal care trajectory, which included Content and Timing of care in Pregnancy (CTP). Odds ratios (OR) (adjusted and unadjusted) for preterm birth were calculated for the Adequacy of Prenatal Care Use and CTP model. RESULTS: The number of visits alone was not associated with preterm birth. In contrast, a significant association was found between the content and timing of care and preterm birth. Compared with the CTP lowest ('inadequate') category, women in the CTP 'sufficient' (OR 0.30; 95% CI 0.09-0.94) and CTP 'appropriate' (OR 0.21; 95% CI 0.06-0.68) category had a lower risk. CONCLUSIONS: This study suggests that measurement of the content and timing of care of antenatal care using the new CTP tool is a better assessment of the risk of preterm birth than assessment of the number of antenatal visits alone.

OBJECTIVE: Preterm birth is an important indicator of neonatal wellbeing. Infants born preterm are at higher risk for severe morbidity and mortality. Apart from medical risk factors, social factors are also associated with preterm birth. This study aims to provide knowledge on factors which have a predictive role in relation to preterm birth. DESIGN: Cross-sectional population study. SETTING: The Brussels metropolitan region. POPULATION: Women who gave birth in the Brussels metropolitan region in 2004. In total, 8,586 birth registration forms were reviewed for this study. MAIN OUTCOME MEASURES: Associations between educational level, occupation, marital status, age, and origin with preterm birth (

Objectives Timely initiation of prenatal care (PNC) in the first pregnancy trimester allows prevention, identification and treatment of risk factors. However, not all women initiate PNC timely, especially women in a deprived situation. The aim of this study was to measure the prevalence of late initiation, defined as initiation after 14 weeks of gestational age. Secondly the authors wanted to identify predictors for late PNC onset. Study design Observational cohort study. Methods Pregnant women ( n = 1750) were recruited in all four hospitals in Ghent (Belgium), a metropolitan region. A socio-economic deprivation ranking was measured by using a General Deprivation Index (GDI), which consists of six criteria to assess a socio-economic situation as deprived. A univariate analysis and a forward conditional multivariate logistic regression model were used analysing the association between deprivation and the likelihood to initiate PNC late. Results 1115 women were included of whom 6.1% ( n = 68) initiated PNC late. A foreign maternal country of birth (OR 2.10; 95% CI 1.15–3.83) and a total GDI ≥3 (OR 4.40; 95% CI 2.36–8.21) were good predictors for late initiation. More specifically, the GDI criteria education (OR 4.02; 95% CI 2.00–8.08) and unemployment (OR 2.40; 95% CI 1.17–4.90) were significantly associated with higher likelihood for late initiation. Conclusions A small group of women initiates PNC late. Vulnerable groups, at risk for late initiation can be identified through assessing their deprivation status. Priority for additional support should be given to women with low educational attainment or women in uncertain employment situations.

Introduction BeQuinT (Belgian Quality in Transfusion), une plateforme mise en place par le service public federal de sante publique a organise 3 enquetes nationales (2012–2014–2016) ayant pour but de dresser une carte et determiner l’evolution dans le temps de la qualite de la politique transfusionnelle dans les hopitaux belges relatives a differents champs d’application : la « Transfusion en general », la « Prescription », la « Tracabilite » et le « Rapportage ». Methodologie Tous les hopitaux belges avec un comite de transfusion ont ete invites a remplir l’enquete en ligne ; c’etait la condition sine qua non du financement de la fonction d’hemovigilance. La distribution et les tendances des scores par champ d’application et pour la totalite de l’enquete ont ete examines et un benchmarking anonymise pour les 4 champs d’application a ete calcule. En juin 2013, 2015, 2017, les resultats ont ete presentes aux presidents des comites de transfusion, ainsi que les points a ameliorer, pour aider les comites de transfusion a orienter leur politique transfusionnelle et pour etablir les priorites de la politique de BeQuinT. Resultats Entre la 1 re et la 3 e enquete, les scores medians sont plus eleves dans tous les champs d’application ; l’augmentation des scores est significative ( p re et la 3 e enquetes est significative ( p = 0,005). Nous pouvons donc conclure a une amelioration significative de la qualite transfusionnelle entre 2012 et 2016.

Background: When examining risk factors for inadequate antenatal care, the assessment of antenatal care hardly considers the content and timing of interventions during pregnancy. This study aims to provide information about the importance of predisposing, enabling and pregnancy-related determinants on the received content and timing of antenatal care. Methods: In the Brussels Metropolitan Region, 333 women were consecutively recruited at the beginning of their pregnancies. Antenatal care use was recorded prospectively. A classification system measuring the content and timing of care during pregnancy (CTP) divided the women into four categories. Ordinal regression analyses were applied to define unadjusted and adjusted odds ratios (ORs), measuring the effect of different determinants on being assigned to a higher CTP category. Results: A total of 10.2% of the women had an inadequate, 8.4% an intermediate, 36% a sufficient and 45.3% an appropriate antenatal care trajectory. Adjusted ORs showed a lower likelihood of being assigned to a higher CTP category for lower educated women (OR: 0.58; 95% CI 0.37–0.92), women of Maghreb origin (OR: 0.38; 95% CI 0.22–0.66) and women with a higher discontinuity of care (OR: 0.56; 95% CI 0.34–0.90). Conclusions: When controlling for confounders, no enabling determinants were found that affect the content and timing of care in pregnancy. Although antenatal care is equally available to all women, predisposing and pregnancy-related factors were related to the likelihood of completing an appropriate antenatal care trajectory. Besides stimulating knowledge about the importance of antenatal care in less-educated and Maghreb women, supporting continuity of care during pregnancy might result in higher levels of received antenatal care.

\ud Background: Current measures of antenatal care use are limited to initiation of care and number of visits. This\ud study aimed to describe the development and application of a tool to assess the adequacy of the content and\ud timing of antenatal care.\ud Methods: The Content and Timing of care in Pregnancy (CTP) tool was developed based on clinical relevance for\ud ongoing antenatal care and recommendations in national and international guidelines. The tool reflects minimal\ud care recommended in every pregnancy, regardless of parity or risk status. CTP measures timing of initiation of care,\ud content of care (number of blood pressure readings, blood tests and ultrasound scans) and whether the\ud interventions were received at an appropriate time. Antenatal care trajectories for 333 pregnant women were then\ud described using a standard tool (the APNCU index), that measures the quantity of care only, and the new CTP tool.\ud Both tools categorise care into 4 categories, from ‘Inadequate’ (both tools) to ‘Adequate plus’ (APNCU) or\ud ‘Appropriate’ (CTP). Participants recorded the timing and content of their antenatal care prospectively using diaries.\ud Analysis included an examination of similarities and differences in categorisation of care episodes between the\ud tools.\ud Results: According to the CTP tool, the care trajectory of 10,2% of the women was classified as inadequate, 8,4%\ud as intermediate, 36% as sufficient and 45,3% as appropriate. The assessment of quality of care differed significantly\ud between the two tools. Seventeen care trajectories classified as ‘Adequate’ or ‘Adequate plus’ by the APNCU were\ud deemed ‘Inadequate’ by the CTP. This suggests that, despite a high number of visits, these women did not receive\ud the minimal recommended content and timing of care.\ud Conclusions: The CTP tool provides a more detailed assessment of the adequacy of antenatal care than the\ud current standard index. However, guidelines for the content of antenatal care vary, and the tool does not at the\ud moment grade over-use of interventions as ‘Inappropriate’. Further work needs to be done to refine the content\ud items prior to larger scale testing of the impact of the new measure.

Background Antenatal care has a positive effect on pregnancy, both clinically and psychologically, but consensus about the optimal number of antenatal visits is lacking. This study aims to provide insight into the dynamics of the number of antenatal visits a woman receives. Independent effects of predisposing, enabling and pregnancy-related determinants are examined. Methods Women were recruited in nine clinical centres in the Brussels Metropolitan region. Antenatal care use was measured prospectively. A Poisson regression model was applied to measure the independent effect of individual determinants on the number of antenatal visits. Results Data on antenatal care trajectories in 333 women were collected. The multivariate analyses showed that women with a Maghreb or Turkish origin had 14% fewer visits compared with European (EU15) women. More highly educated women had 22% more visits compared with those with a low education. Women with a high income had 14% more antenatal visits compared with those with a low income. Fewer antenatal visits were observed in multiparae (15%), women initiating care after 14 weeks of gestation (31%), women without medical risks during the pregnancy (12%) and in women with a continuity of care index of 50% or more (12%). More visits were observed in delivering after week 37 (22% increase). Conclusions Predisposing and enabling factors have to be considered when antenatal care programmes are evaluated in a metropolitan area. Variations in the number of antenatal visits show that socially vulnerable women are more at risk of having fewer visits.

People from lower socio-economic classes are confronted with several barriers that impede their access to health care. An important, though often forgotten barrier is embedded in the care-relationship. Differences in the social environment of health care workers and poor complicate the care-relationship. By means of in-depth interviews and focus groups with health care workers in the fields of primary and secondary antenatal and postnatal care and diabetes care we mapped their perception of poverty and of their care-relationship with intergenerational poor. Our results show that health care workers perceive the causes of poverty mainly on the individual level. When asked about the basic conditions for a good care-relationship health care workers stress the presence of trust and a fundamental attitude of relational equivalence, authenticity and respect. This ideal image has a stressfull relationship with the framework of individual guilt that puts the responsibility for a good care-relationship, at least partly, with the poor. Based on these results an educational program for health care workers has been developed.