Voor wie het nog niet wist, de WOZ-waarde in een wijk is een goede voorspeller voor het risico op perinatale sterfte of ziekte. De afzonderlijke publicaties van Hanneke de Graaf over de correlatie tussen wonen in een achterstandswijk en perinatale uitkomsten, hebben al veel stof doen opwaaien. Een greep uit de opvallendste resultaten: In Nederland vindt 6% van de geboorten plaats in achterstandswijken, terwijl dit percentage in grote steden als Rotterdam maar liefst 46% bedraagt. Ook na correctie voor effecten als leeftijd van de moeder, pariteit, comorbiditeit en etniciteit, bedraagt het extra risico op perinatale sterfte 21%, als gevolg van het wonen in een achterstandswijk. Wat betreft perinatale ziekte is er een extra risico op vroeggeboorte van 16%, op foetale groeivertraging van 11% en op een lage Apgar-score van 11%. Ook de maternale sterfte is fors hoger in achterstandswijken, vooral in de grote steden: 10,8 per 100.000 landelijk versus circa 20 in Rotterdam en Den Haag.


In the Netherlands, perinatal mortality has declined substantially since 1920, although the rate of decline seemed to have levelled off from 1978 onwards. Last decades the decline was as not as steep as in other European countries. As a consequence the Netherlands dropped from a number two position in 1960 to one at the bottom in 2004 in the ranking of the European countries according to perinatal mortality rate. The same stagnating trend is observed for maternal mortality.

We may expect that in the Netherlands, an egalitarian prosperous society with universal access to education and (perinatal) health care, health inequalities by area of residence will be limited. But geographical health differences in the Netherlands are persistent, and extend to perinatal health.

Hence in the Netherlands, both the general level of perinatal mortality and its geographical distribution deserve attention. New evidence has emerged on (a) factors that may be responsible, among which factors related to obstetric care provision, and on (b) the interrelationships between these individual, geographic, and care-related, factors.

This thesis aims to capture the origin of, in particular, the inequalities in perinatal- and maternal outcomes in the Netherlands in relation to socio-economic and ethnic factors, to the area of residence, and to care-related factors in terms of setting and organization.

The studies, reported in this thesis, address the following questions:

  1. To what extent do ethnic, socioeconomic and geographic related differences exist in adverse perinatal and maternal outcomes in the Netherlands? How are ethnic and socio-economic effects, if existent, related?
  2. Do perinatal adverse outcomes in the Netherlands differ according to time of birth (day, evening, night), and hospital-organisational aspects such as the annual number of deliveries (volume) and staffing during and outside office hours?
  3. Is intrapartum and early neonatal death different between planned home and planned hospital births in the Netherlands, for assumed low risk women starting delivery under supervision of a community midwife?
  4. Can a scavenging system for nitrous oxide-sedation during labour be safe used in a midwifery-led birth centre?