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PubMed2005

CONCOR, an initiative towards a national registry and DNA-bank of patients with congenital heart disease in the Netherlands: rationale, design, and first results.

INTRODUCTION: Survival of patients with congenital heart disease has dramatically improved after surgical repair became available 40 years ago. Instead of a mortality of 85% during childhood following the natural course, over 85% of these infants are now expected to reach adulthood. However, data on long-term outcome is scarce due to the lack of large, national registries. Moreover, little is known about the genetic basis of congenital heart defects. In 2000, the Interuniversity Cardiology Institute of the Netherlands and the Netherlands Heart Foundation have taken the initiative to develop a national registry and DNA-bank of patients with congenital heart disease in the Netherlands named CONCOR. OBJECTIVES: The aims of the CONCOR project are to facilitate investigation of the prevalence and long-term outcome of specific congenital heart defects and their treatment, to develop an efficient organisational structure for the improvement of healthcare for patients with congenital heart disease, and to allow investigation of the molecular basis of congenital heart defects. METHODS: After informed consent, research nurses enter data of participating patients into the CONCOR database using a web application. Data is transferred over the Internet via a secure connection. About 20 ml blood is withdrawn from the patient, and the DNA is isolated and stored. From each participating patient family history on congenital heart disease is obtained. RESULTS: Within two and a half years more than 4200 patients have agreed to participate. More than 99% of the patients that were asked have given their consent to participate in CONCOR. From 60% of these patients DNA has already been obtained. Mean age of the patients included is 34 years; more than 85% of the patients are younger than 45 years. Late complications occur frequently and the incidence increases with advancing age. 18% of the patients are known with supraventricular or ventricular arrhythmias. 2% of the included patients suffered a cerebrovascular accident, 139 (3%) had endocarditis. 6% of the patients has pulmonary hypertension or Eisenmenger syndrome. More than 15% of the patients reported an affected family member with congenital heart disease in the first, second, or third degree. 6% has an affected first-degree relative, and 4% a second-degree relative. Already 10 research projects have started using the CONCOR data and DNA. CONCLUSION: The population of patients with congenital heart disease is young and rapidly growing. Late complications occur frequently and the incidence increases with advances age. The CONCOR registry and DNA-bank facilitates research on prevalence and long-term outcome and allows investigation of the molecular basis of congenital heart disease.

Academies and Institutes↗

PubMed2005

Volume and market share of anti-epileptic drugs in The Netherlands: impact of new drugs.

OBJECTIVE: In the past decade, several new anti-epileptic drugs (AEDs) were introduced in The Netherlands. These new drugs, one of which is lamotrigine, are 6 to 10 times more expensive than conventional anti-convulsants. In 1997, the high cost of lamotrigine, together with a lack of clinical data supporting its superiority over conventional drugs, prompted the Dutch Health Insurance Board to release a guideline in which the use of lamotrigine was restricted to difficult-to-treat patients. Other new drugs that were marketed after 1997 also became subject to this guideline. The utilisation of new AEDs and the cost consequences are the subject of this paper. METHODS: Data from extramurally prescribed AEDs was obtained from the Dutch Drug Information Project, which is a database containing prescriptions for about 5.5 million inhabitants of the Netherlands. This data was used to study the impact of new AEDs on volume and market share of AEDs in the period from 1995 to 2001 in The Netherlands. RESULTS: Between 1995 and 2001, the total volume of AEDs increased by 130%, 60% of which consisted of new AEDs. Gabapentin, lamotrigine and oxcarbazepine were the most frequently prescribed new compounds. The volume share of new AEDs increased from 5% in 1995 to 18% in 2001. The market share amounted to 21.5 million euros in 1995 and rose to 47 million euros in 2001; 80% of this increase was due to the introduction of new AEDs. DISCUSSION: Although in 2001 the volume share of new AEDs was still modest, their introduction has led to a strong increase in the cost. New data is emerging on the effectiveness and cost-benefit sum of the new AEDs; this may change the place in therapy of these drugs. Because of their strong potential to force up cost, the positioning of new AEDs requires further attention.

Anticonvulsants↗

PubMed1993

Low-dose aspirin in pregnancy: changes in patterns of prescription in The Netherlands.

OBJECTIVE: To describe patterns of prescription in the Netherlands of low-dose aspirin in pregnancy. DESIGN: Anonymous written inquiry in 1989 and 1991. SUBJECTS: Gynecologists in the Netherlands (619 in 1989 and 618 in 1991), practicing in training and non-training hospitals. MAIN OUTCOME MEASURES: Prescription rates for prevention of pregnancy-induced hypertension and fetal growth retardation, or for intention to treat. RESULTS: The response rates were 52% in 1989 and 58% in 1991, covering approximately 61% and 62%, respectively, of the practicing gynecologists in the Netherlands. The use for prevention increased from 53% to 79% and for therapeutic intentions from 25% to 48%. CONCLUSION: The prescription rate for low-dose aspirin increased markedly from 1989 to 1991, without evidence for its benefit from the literature published in the same time period.

Aspirin↗

PubMedDate not supplied

Dioxin and PCB levels in blood and human milk in relation to living areas in The Netherlands.

Dioxins and polychlorinated biphenyls (PCBs) are ubiquitous toxic compounds in the environment. Negative influences of these compounds on the health status of human beings have been described. Especially susceptible might be the fetus, which is exposed in utero, and the newborn breast-fed infant, since both are exposed to relatively high levels of dioxins and PCBs during a critical period of organ growth and development. We investigated PCB levels in 406 maternal plasma samples as well as PCB and dioxin levels in 172 human milk samples with relation to living area of women living for at least five years in the western industrialized part of the Netherlands or the northern more rural part. The western part was further subdivided into one urban and two highly industrialized areas. After correction for covariates, we found significantly higher levels of PCB 118 in maternal plasma as well as significantly higher levels of the dioxin-TEQ and of ten individual dioxin and PCB congener levels in human milk in the western more industrialized areas of the Netherlands compared to the northern more rural part. We did not find significant differences in planar, mono-ortho or di-ortho PCB-TEQ levels in human milk between all different areas. We conclude that significantly higher levels of a number of dioxin and PCB congeners are found in women living in industrialized areas compared to women living in rural areas in the Netherlands.

Adult↗

PubMed1989

The intake of cadmium in the Kempen, an area in the south of The Netherlands.

In The Netherlands many areas with soil pollution have been detected. The largest polluted area is a zone of 350 km2 in the Kempen, in the south of The Netherlands. This Kempen zone is polluted with heavy metals, especially cadmium (Cd) and zinc (Zn), emitted from metal factories in the Netherlands and in Belgium. Because of the high Cd in soil, vegetables grown in that area contain relatively high Cd concentrations. The Cd uptake by inhabitants of these areas--especially individuals consuming vegetables from their own gardens--therefore is considerably increased. This Cd intake is shown to be higher than the provisionally tolerated weekly uptake of Cd set by the WHO. The role of smoking in Cd intake is discussed.

Cadmium↗

PubMed1994

Intercomparison of calibration procedures for Ir-192 HDR sources in The Netherlands and Belgium.

Thirteen radiotherapy departments in The Netherlands and Belgium participated in an intercomparison of the calibration procedures in use for the quality control of iridium-192 high dose rate sources. A measuring device from 1 of the departments was taken to the 12 other participants, where 1-3 sources were measured by both the local and the visiting physicist's team. Also, 1 192Ir HDR reference source was taken to 7 other--Dutch--departments to serve as a stability check of the measuring device. The results of the local calibration were compared with the values obtained by the visiting team. A mean deviation of +1.3% was found in 19 observations, with values ranging from -0.4% to +3.0%. In total, 16 sources were checked. The measured reference air kerma rate of the available sources was compared with the value stated on the source calibration certificate: the values on the certificate were on the average +1.8% higher than the measured values, ranging from -4.2% to +6.8%. In 1 instance the reference source was also measured by The Netherlands Measurements Institute (NMI), the national standards laboratory in The Netherlands. A good agreement was found between the NMI calibration and the reference air kerma rate determined with the measuring device used in this project.

Belgium↗

PubMed1995

Evaluation and diffusion of excimer laser treatment of myopia in the United States and in The Netherlands.

Excimer laser photorefractive keratectomy (PRK) is an experimental treatment to correct myopia (short-sightedness) that is diffusing into use without convincing evidence of safety and efficacy. It has been claimed that PRK may render conventional methods of correcting myopia, such as wearing glasses or contact lenses, obsolete. Since about 25% of the world's population is myopic, the consequences of this technology in terms of benefits, risks, and costs could be truly enormous. The fee for the procedure in various countries such as the United States, the Netherlands, and Australia varies from about US $1500 to US $2250 per eye. In the United States, the Food and Drug Administration, acting as authorized in the Medical Devices Act of 1976, has limited the use of PRK to patients participating in clinical trials. In the Netherlands, in contrast, where medical equipment is not regulated, the method has diffused without controls, although it is not reimbursed by health insurance agencies. The procedure has become controversial in the Netherlands because it is provided privately and has been aggressively and inappropriately promoted. The case illustrates the limitations of health policy concerning technologies provided privately and raises a number of social and political questions.

Diffusion of Innovation↗

PubMed1986

Mental health care and the opposition movement in The Netherlands.

In The Netherlands, there is a more or less recognized movement in the field of mental health care which is referred to as the psychiatric opposition movement or the patients movement. The nucleus of the Dutch movement consists of patients and ex-patients. As far as mental health professionals are participating in the movement, they do so as more or less passive supporters of a movement dominated by patients and ex-patients. This article is dealing with two questions. The first question is how and to what degree the opposition movement in The Netherlands has succeeded in breaking through or at least questioning the closed nature of Dutch mental health care system. The second question will be whether the dilemma between resistance and dependence in the position of patients and ex-patients is visible in the activities of the opposition movement, and whether this dilemma acted as an obstacle to their efforts to influence the mental health care debate in The Netherlands. An effort is being made to answer this question by describing the position of the opposition movement with respect to the Insanity Law and with respect to the organization of mental health care. In conclusion, three stages were found to be crucial in the development of Dutch opposition movement. In the 1970s, the opposition movement appeared to operate within the borders of a closed system in which the medical profession had a high degree of autonomy.(ABSTRACT TRUNCATED AT 250 WORDS)

Attitude of Health Personnel↗

PubMedDate not supplied

The impact of diabetes-related lower-extremity amputations in The Netherlands.

The purpose of this study is to identify the incidence of diabetes-related lower-extremity amputations in the Netherlands. We used discharge records from SIG Health Care Information for every hospitalization for a lower-extremity amputation in all hospitals in the Netherlands in 1992. Age- and gender-specific population figures and diagnosed cases of diabetes were obtained from the Central Bureau of Statistics. Age- and gender-adjusted amputation incidences were identified at four different levels (toe, foot, leg, and thigh). Multiple amputations were analyzed by the highest level. Of all lower-extremity amputations, 1,575 (47%) were in persons with diabetes mellitus. Age- and gender-adjusted lower-extremity amputation rates per 10,000 persons with diabetes by level were the following: toe 12.39, foot 2.42, leg 7.82, thigh 2.54, and total 25.17. People with diabetes were 20.3 times more likely to experience a lower-extremity amputation than people without diabetes. Males were at a significantly higher risk of experiencing an amputation than females. There was a significant increase in the age-specific incidence of amputations as age increased. The most common amputation procedure performed was the toe amputation. There was a significant increase in thigh amputations as age increased, indicating that as people get older they suffer higher levels of amputations. Although the incidence of lower-extremity amputations was lower than previous reports, they still have a serious impact on the health-care system in the Netherlands.

Adult↗

PubMed2006

Translation and validation of the EORTC QLQ-C30 for use among Turkish and Moroccan ethnic minority cancer patients in the Netherlands.

The purpose of this study was to validate the core EORTC quality of life questionnaire, the QLQ-C30 (version 3.0), for use among Turkish and Moroccan cancer patients in the Netherlands. The questionnaire was translated into two oral Moroccan languages , and the existing Turkish version was culturally adapted for use in the Netherlands. Ninety Turkish and 79 Moroccan patients completed the questionnaire. Administration of the questionnaire proved feasible, with low levels of missing questionnaires (4%) and missing items (on average, 1.5-2.4%). With one minor exception, the evidence of convergent validity was strong for all multi-item scales. Internal consistency reliability was above 0.70 for all scales except the cognitive functioning scale in the Turkish sample. The questionnaire was able to distinguish clearly between subgroups formed on the basis of performance status and comorbidity, and was moderately responsive to change over time in performance status. These data support the use of the QLQ-C30 among Turkish and Moroccan cancer patients residing in the Netherlands. Additional studies are needed to confirm the psychometrics of the questionnaire when used among these ethnic minority groups residing in other Western European countries.

Adult↗

PubMed2004

Heart failure clinics in the Netherlands in 2003.

PURPOSE: Heart failure (HF) care in the Netherlands is going through a lot of changes. Nurses have increasingly important roles in providing optimal care for these chronically ill patients. In this study, we describe the current number of HF management programs and the role of the nurses in these programs. METHOD: Data were collected by a national survey as part of a European HF clinic survey of the UNITE study group of the Working Group on Cardiovascular Nursing between February and March 2003 to 142 hospitals in the Netherlands. RESULTS: In 60% of the hospital locations, there is a HF management program. Most of the programs are organized as HF outpatient clinics. In all HF programs, cardiologists and nurses are involved. Other health care providers involved are, amongst others, general practitioners (29%), dieticians (59%), physical therapists (47%), social workers (30%) and psychologists (17%). All programs offer follow-up after discharge from the hospitals and in most of the programs patients have increased access to a health care provider. Behavioural interventions (68%), psychosocial counselling (64%), patient education (88%) and support of the informal caregivers (59%) are important components. In 90% of the programs (restricted), physical examination is the responsibility of the HF nurse and in 65% of the programs nurses are involved in optimizing medical treatment. Financial support and education of HF nurses is still unstructured and diverse. CONCLUSION: There is a rise in the number of HF programs in the Netherlands. There is diversity in content and intensity of these programs and the role of the nurse is not clearly defined yet. Research and discussion on the subject of optimal effective HF care and the role of the HF nurse is still needed.

Heart Failure↗

PubMedDate not supplied

Availability, content and quality of local guidelines for the assessment of suicide attempters in university and general hospitals in the Netherlands.

OBJECTIVE: This study was performed to investigate the availability, content and quality of local guidelines for the assessment of suicide attempters in the Netherlands. METHOD: All university and general hospitals in the Netherlands were asked to provide their local guidelines. Published national guidelines and the Appraisal of Guidelines for Research and Education (AGREE) instrument were used to evaluate the content and quality of the local guidelines. RESULTS: Eighty-eight hospitals (90.7%) responded; 34 (38.6%) reported that they used local guidelines. Twenty-seven guidelines were submitted for evaluation. Most of the guidelines were more than 5 years old and had not been updated recently. The contents of the guidelines differed. Criteria addressing patient safety, staff attitude toward patients, reassessment of nonalert patients, relevant stressors, involvement of significant others and aftercare were found in less than 50% of the guidelines. Although psychiatric consultation was incorporated in almost 80%, the psychiatrist's tasks were specified infrequently. The guidelines seldom required monitoring of staff compliance. Only in the AGREE domain "clarity and presentation" was the mean score above 60% of the maximum. According to the instructions for the AGREE instrument, 10 (37.0%) of the 27 guidelines were recommended (with provisos or alterations) and 1 was strongly recommended for use in practice. CONCLUSIONS: In the Netherlands, a minority of hospitals reported use of local guidelines for the assessment of suicide attempters. When available, the guidelines were mostly not based on international standards, their contents varied greatly and their quality was unsatisfactory.

Attitude↗

PubMed2006

Detection of noroviruses in shellfish in the Netherlands.

Shellfish from oyster farms in the Netherlands and imported from other European countries were examined for viral contamination. A method that allows sequence matching between noroviruses from human cases and shellfish was used. The samples of shellfish (n = 42) were analyzed using a semi-nested RT-PCR that had been optimized for detection of norovirus in shellfish (SR primer sets). In addition, a different genome region was targeted using a second primer set which is routinely used for diagnosis of norovirus infection in humans (JV12Y/JV13I). To improve the detection limit for this RT-PCR a semi-nested test format was developed (NV primer sets). One of 21 oyster samples (4.8%) from Dutch farms was norovirus positive, whereas norovirus was detected in 1 out of 8 oyster samples (12.5%) and 5 out of 13 mussel samples (38.5%) collected directly after importation in the Netherlands. RNA from samples associated with an outbreak of gastro-enteritis in the Netherlands in 2001 was re-analyzed using the NV primer sets. At least one identical sequence (142/142 nt) was found in three fecal and in two oyster samples related to this outbreak. Further surveillance of norovirus by detection and typing of viruses from patients with gastroenteritis and shellfish is warranted to clarify the causes of future outbreaks.

Animals↗

PubMed2005

Molecular epidemiology of hepatitis A in Noord-Brabant, The Netherlands.

BACKGROUND: Previous studies on the molecular epidemiology of hepatitis A virus (HAV) in Amsterdam, The Netherlands, show that subgenotype 1A is mainly seen among homosexual men practising anonymous oral-anal sex in saunas and darkrooms, while subgenotype 1B is usually detected among children originating from Morocco, and subgenotype 3A is mostly found among travellers to Pakistan. OBJECTIVE: We studied the genotype distribution in a more rural area of The Netherlands, Noord-Brabant, and compared it with Amsterdam. STUDY DESIGN: We collected blood and feces samples from 34 HAV IgM(+) individuals who were reported from August 2001-March 2003 at the Municipal Health Service (MHS) Heart for Brabant (Brabant). We also collected feces samples from nine household contacts of whom the HAV IgM status was not known. HAV RNA was isolated and subsequently amplified by reverse transcriptase polymerase chain reaction (RT-PCR) at the VP1-P2a and the VP3-VP1 region, sequenced and analysed. RESULTS AND CONCLUSIONS: In most cases, relations between risk groups and HAV subgenotypes in Noord-Brabant were similar to those in Amsterdam. Next to genotypes 1 and 3 we also detected a genotype 2/7 strain in a Noord-Brabant case. Also, in contrast to the Amsterdam study, sporadic transmission occurred among various risk groups. Children involved in a school-related outbreak were infected with strains identical to one that was previously isolated from a man who has sex with men (MSM). Also, Dutch patients having no epidemiological link with Turkish or Moroccan children harboured strains imported from high-endemic countries. Furthermore, we report a special case in which HAV may be causally involved in meningitis. The results of this study show that the molecular epidemiology of HAV in The Netherlands can be more complicated than previously anticipated and that HAV phylogenetic studies can provide important information for the design of appropriate public health measures.

Adolescent↗

PubMed2005

A national prospective study on childhood celiac disease in the Netherlands 1993-2000: an increasing recognition and a changing clinical picture.

OBJECTIVES: To investigate prospectively whether the incidence of diagnosed celiac disease (CD) is increasing in the Netherlands and whether the clinical presentation is changing. STUDY DESIGN: All newly diagnosed cases of CD throughout the Netherlands were registered prospectively from 1993 to 2000. The clinical picture was compared with that noted in our former study (1975-1990). RESULTS: The overall incidence rate of CD was 0.81/1000 live births, with a linear increase from 1993 to 2000. There was a significant increase in the number of subjects with partial villous atrophy of the small bowel mucosa. The clinical presentation has changed significantly: abdominal distention, chronic diarrhea, and failure to thrive are less common, and more children presented with weight < P10, abdominal pain, and lassitude. The median age at diagnosis also increased. CONCLUSION: The recognition of childhood CD in the Netherlands has increased significantly during the last few years, and the clinical picture has changed as well. Our data may indicate an increasing awareness of the Dutch doctors working in Child Public Health, general practitioners, and pediatricians to recognize more subtle expressions of the disease.

Celiac Disease↗

PubMed2026

Lineage dynamics of invasive Escherichia coli isolates in the Netherlands from 1975 to 2021: a retrospective longitudinal genomic analysis.

BACKGROUND: Escherichia coli is a common cause of invasive infections such as bloodstream and cerebrospinal fluid infections in neonates. Strains positive for the K1 capsule are considered the most common cause of such neonatal invasive infections. This assumption of K1 dominance, and indeed the population genomics of E coli causing invasive infections in general is largely unstudied. We aimed to provide a comprehensive characterisation of this pathogen population using a longitudinal isolate collection. METHODS: In this analysis we report the findings of the SENTINEL study, a longitudinal genomic analysis of 1790 invasive E coli isolates collected mainly from newborns in the Netherlands between 1975 and 2021 by the Netherlands Reference Laboratory for Bacterial Meningitis, Amsterdam University Medical Centre, Amsterdam, Netherlands. The dataset included all bacterial strains cultured from cerebrospinal fluid or blood in cases of (clinical) bacterial meningitis (1976 to 1980). In 1981 the criteria were expanded to include neonates (aged ≤4 weeks) with E coli sepsis, and from July, 2016 all infants younger than 1 year with E coli sepsis were included. All isolates were sequenced using either the HiSeq 2500 or HiSeq 4000 platforms (Illumina, San Diego, CA, USA). We confirmed species and identified sequence types (STs), detected antimicrobial resistance genes, virulence genes, and the presence of K1 capsule, and characterised the dynamics of these factors over time. FINDINGS: Our data show a highly dynamic bacterial population that is entirely unaffected by antimicrobial resistance determinants. Key pathogen population fluctuations include the complete disappearance of the dominant lineage ST567 and the swapping of dominant ST95 clones from a single serotype O18:H7 clone to two distinct serotype O1:H7 clones, with changes in virulence factors including major fimbrial adhesins. These findings, combined with only 58·8% (1053 of 1790) prevalence in K1-expressing isolates in the entire study population, point to host-pathogen interaction and immune selection pressures as key drivers of bacterial population dynamics in this largely antimicrobial-naive population. INTERPRETATION: Our data show the vital need for ongoing genomic surveillance of microbial pathogen populations to guide appropriate intervention strategies. Additionally, genomic insights of a pathogen population from one specific disease syndrome or patient population cannot always be generalised across other cohorts. FUNDING: Wellcome Antimicrobial and Antimicrobial Resistance Doctoral Training Programme and the National Institute for Health and Care Research Birmingham Biomedical Research Centre.

Netherlands↗

PubMed2006

HRT use in 2001 and 2004 in The Netherlands--a world of difference.

OBJECTIVE: Did the publication of the Women Health Initiative (WHI) trial in 2002 and the Million Women Study (MWS) in 2003 lead to changes in prescription rates of hormone replacement therapy (HRT). Therefore, we compare the prescribing of HRT in 2004 (after) with that of 2001 (before the publications) in The Netherlands. METHOD: Community pharmacy dispensing data from a population of approximately 500,000 patients in The Netherlands. Women aged 40-74 years to whom at least one HRT prescription was dispensed in 2001 or 2004 were included. Annual prevalences of HRT in 2001 and 2004 and the percentage change (2004 versus 2001) were calculated for overall HRT (excluding vaginal products) and per HRT category (combined estrogens and progestagens, estrogens only, tibolon and vaginal preparations) and age category. RESULTS: In 2001, 5.64% of the women aged 40-74 used HRT and this percentage declined to 2.39 in 2004. The use of vaginal products among these women did not change, 1.76% in 2001 and 1.65% in 2004. The percentage change was highest in the opposed HRT group (66% decrease) and in women aged 50-54 (64.4% decrease). In 2004, compared with 2001, the proportion of long-term users (>3 year) increased with 12.7%. CONCLUSIONS: In The Netherlands, after publication of the WHI study and the MWS the prescribing of HRT fell dramatically whereas the prescribing of vaginal products did not change. Future patterns of HRT use should be monitored to know whether this decrease will be sustained.

Adult↗

PubMed2005

Guidelines on anaemia: effect on primary-care midwives in The Netherlands.

OBJECTIVE: To assess the adherence and perceived barriers for implementation of a clinical-practice guideline on anaemia, which was the first national guideline for primary-care midwifery in The Netherlands. DESIGN: Cross-sectional survey study. SETTING: Primary-care midwifery in The Netherlands. PARTICIPANTS: 160 midwives (60% response rate). MEASUREMENTS: Questionnaire on the knowledge of, and attitudes and self-reported adherence to, 14 key recommendations in the guideline; attitudes to guidelines in general; and perceived barriers to implementation. FINDINGS: The number of midwives agreeing with and adhering to specific recommendations varied between 29 and 90%. Most midwives had a positive attitude to the guidelines. The most relevant general barriers were related to the behaviour of general practitioners and obstetricians (32% of the midwives reported this). Larger numbers of midwives mentioned barriers to specific aspects of the guideline, particularly alternative iron supplementation or dietary supplements (59%), and not prescribing iron supplementation if haemoglobin was low but mean corpuscular volume was normal (49%). KEY CONCLUSIONS: The guideline on anaemia was well received by primary-care midwives in The Netherlands, but implementation of specific recommendations needs further attention. IMPLICATIONS FOR PRACTICE: The study provides evidence for the national organisation of midwives to continue with the development and implementation of clinical guidelines.

Adult↗