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The Perinatal Database of the Netherlands.

OBJECTIVE: In the Netherlands, the Perinatal Database of the Netherlands (Landelijke Verloskunderegistratie, LVR) was set up in 1982 for secondary care obstetric departments on a voluntary participation basis, its main goal being quality monitoring. At the outset of the database, 70% of Dutch obstetric departments participated immediately. This percentage has now increased to almost 100%. How the LVR was set up, its aims, participation, general function and some aspects of the reliability are described in this article. RESULTS: Assessment of the reliability of the data on a number of points found that the frequency of various types of nearly all errors has decreased during the existence of the LVR, with the exception of a complete registration of the first-week mortality. CONCLUSIONS: The quality of the data has improved over the years. More reliable figures for the first-week mortality would be available if the LVR data were linked to those of the Neonatal Database of the Netherlands (Landelijk Neonatale Registratie, LNR), so that the condition of each child is known up to and including 28 days after birth. Improvements in the reliability of other items can be attained by implementing more checks during the data input stage and by making the data more accessible to the gynaecologists, in order to further increase motivation to record the data.

Cesarean Section↗

Indirect costs of back pain in the Netherlands: a comparison of the human capital method with the friction cost method.

In this study we estimated the indirect costs of back pain in 1991 in The Netherlands on the basis of two approaches: the traditionally used human capital method and the more recently developed friction cost method. The indirect costs of illness were defined as the value of production losses of paid labour and related costs to society due to back pain. The results of this study in 1991 in The Netherlands show that the short-term indirect costs estimated by the human capital method were more than three times as high as the indirect costs estimated by the friction cost method (US$ 4.6 billion vs. USS 1.5 billion, respectively). The lower estimate of indirect costs when using the friction cost method is mainly due to the fact that in this method actual production losses are estimated during a relatively short friction period, which is defined as the period needed to restore the initial production level. In contrast with the human capital method, long-term absenteeism and disability do not induce additional costs when applying the friction cost method. Since the friction cost method takes into account that employees can be replaced, we believe that this method produces a more accurate estimate of indirect costs than the human capital method. Notwithstanding the resulting decrease in indirect costs of back pain, these costs are still impressive, representing 0.28% of the GNP in The Netherlands in 1991. As a consequence, but particularly stimulated by structural changes in the Dutch social security system, policies aimed at reducing indirect costs of back pain, increasingly concentrate on the development and evaluation of interventions early after the onset of disease. This is complemented, on the one hand, by the development of clinical guidelines for the management of back pain in primary care and, on the other hand, by governmental policies aimed at reintegration of chronically ill in the labour force.

Adult↗

Cost-of-illness of neck pain in The Netherlands in 1996.

The prevalence of neck pain in the general population ranges from 10 to 15%. The complaints can result in substantial medical consumption, absenteeism from work and disability. In this study we investigated the costs of neck pain in the Netherlands in 1996 to assess the financial burden to society. The study was based on prevalence data. Data sources included national registries, reports of research institutes and health care authorities. Direct health care costs were estimated for hospital care, general practice care and paramedical care. These costs were calculated using fees. Calculation of indirect costs (absenteeism and disability) was based on the Human Capital Method (HCM). As an alternative approach the Friction Cost Method (FCM) was used. The total cost of neck pain in The Netherlands in 1996 was estimated to be US $686 million. The share of these costs was about 1% of total health care expenditures and 0.1 % of the Gross Domestic Product (GDP) in 1996. Direct costs were $160 million (23%). Paramedical care accounted for largest proportion of direct costs (84%). When applying the HCM for calculating indirect costs, these costs amounted to $527 million (77%). The total number of sick days related to neck pain were estimated to be 1.4 million with a total cost of $185.4 million in 1996. Disability for neck pain accounted for the largest proportion (50%) of the total costs related to neck pain in 1996 ($341). When applying the FCM for calculating the indirect costs, these costs were reduced to $96 million. The costs related to neck pain in 1996 in The Netherlands were substantial. Some caution should be taken in interpretation, as a number of assumptions had to be made in order to estimate the total costs. The cost structure shown in this study, with high indirect costs, has also been found in other studies. From an economical point of view it seems to be important to prevent patients from having to take sick leave and disability. One way in achieving this goal is to develop and investigate more effective treatments for acute neck pain, in order to prevent patients developing chronic pain and disability. Another option is to protect chronic patients from sick leave and disability by careful management. Thus, also in the area of direct medical costs, there may be room for cost savings by stimulating and improving cost-efficiency and cost-effectiveness of the (para)medical care. In order to deal with the lack of specific disease information, more detailed information of medical consumption, sick leave and disability is required for future cost analysis.

Absenteeism↗

Detection of Echinococcus multilocularis in foxes in The Netherlands.

Echinococcus multilocularis was demonstrated in 5 out of 272 foxes in The Netherlands close to the border with Germany and Belgium. Besides microscopic examination of mucosal scrapings, two different PCR assays were used based on the detection of E. multilocularis DNA in colon content. Two distinct areas in The Netherlands were positive for E. multilocularis. Two positive foxes were found in the northern province of Groningen and three positive foxes were found in the southern province of Limburg. Both PCR assays detected more positive foxes compared to microscopic examination of the intestinal content. This is the first report of E. multilocularis in foxes occurring in The Netherlands.

Animals↗

Epidemiology of Norwalk-like virus infections in cattle in The Netherlands.

"Norwalk-like viruses" (NLVs) are the most common cause of acute non-bacterial gastroenteritis in humans. Cattle may be a reservoir of NLVs although never bovine NLVs have been found in humans. To gain more insight into the epidemiology of NLV, infections in cattle in The Netherlands were studied. Individual faecal samples from a large dairy herd and 243 pooled samples from veal calf farms were analysed for NLV by RT-PCR. Calves under 3 months of age in the dairy herd were sampled three to five times with 3-week intervals, whereas dairy cattle were sampled twice with a 2-month interval. In 31.6% (77/243) of the veal calf farm samples and in 4.2% (13/312) of the individual dairy cattle samples NLV was detected. The mean age of virus positive dairy cattle was 2.5 months. The highest numbers of NLV positive veal calf farms in The Netherlands were found in the regions with the highest number of veal calf farms. NLV infected veal calf farms were detected in every month throughout the study period. Cattle appeared to be hosts of NLVs, and virus shedding was weakly associated with diarrhoea. Complete ORF2 sequences were obtained from two calf NLVs and phylogenetic analyses suggested that these strains belong to a distinct cluster (GGIII/2) in between GGI and GGII NLVs of humans. Overall, genetic variation between strains as determined by sequence analysis of the P1/P2 capsid region was limited to 14.6%. Our data shows that NLV is endemic in the cattle population in The Netherlands and genetically distinct from NLVs in humans.

Animals↗

[Euthanasia and palliative care in the Netherlands].

THE BIRTH OF THE DUTCH LAW: Euthanasia has been recently legalized in the Netherlands (since April 1, 2002). In this Article, we present the various cultural and historical factors that contributed to the law, the guidelines for the procedure and the resulting controversy. THE INTERVENING FACTORS: Internationally, the attitude concerning end of life care are heterogenic and also directly depend on religious and cultural factors. In the Netherlands, the health system promotes the maintenance at home of the terminally ill. However, the financial aspects (private health insurance) interact with the management of these patients. The rules for euthanasia are very strict and a declaration must be registered. Dedicated commissions are organised to control that the rules are applied. The current debate concerns the pertinence of the regulations, the attitude towards handicapped people and children, and the need to develop palliative care. The latter have only recently been developed in the country. The priority is focusing on old peoples' homes. The Netherlands is slow in this regard, but a new draft law is soon to be presented to the Authorities, and will most probably enable the gaps to be bridged.

Adolescent↗

Rising trends in the incidence of and mortality from cutaneous melanoma in the Netherlands: a Northwest to Southeast gradient?

The aim of this study was to determine characteristics of the trends in incidence of and mortality from cutaneous malignant melanoma in The Netherlands. We used incidence data from the Netherlands Cancer Registry since 1989 and the causes of death registry of Statistics Netherlands since 1950. Data were age-adjusted and age-specific rates were calculated. Age-period-cohort modelling was applied to the mortality data. Between 1989 and 1998, age-adjusted incidence rates increased, mainly among those aged 45 years and older. Incidence rates were highest in the North-West and lowest in the South-East. Mortality rates increased in all age-categories, but more so among males than females. For women, an age-period model fitted the data, with decreasing relative risks after 1972. Age-period-cohort models were needed for males. The most likely explanation for the higher incidence is increasing intermittent over-exposure to ultraviolet (UV) radiation. The regional differences in melanoma incidence rates would correspond with host characteristics opportunities for and recreational exposure. Melanomas were detected at earlier stages in females, possibly explaining the flattening out of the female mortality rates.

Adult↗

Accuracy and completeness of the registration of childhood leukaemia in The Netherlands, 1989-1992.

In the Netherlands, childhood leukaemia is recorded by the Dutch Childhood Leukaemia Study Group (DCLSG, set up in 1972) and by nine regional cancer registries which together form the Netherlands Cancer Registry (NCR, set up in 1989). The data files from the incidence years 1989-1992 of the two registries were linked in order to evaluate accuracy and completeness and to calculate and equalise the incidence rates for childhood leukaemia in The Netherlands. Unlinked records or records with disagreements (birth date, sex, type of leukaemia and incidence date) were checked by the DCLSG and by the regional cancer registries. The DCLSG recorded 431 cases of childhood leukaemia, while the NCR recorded 434 cases. After record linkage and review of the cases, it was concluded the 445 records should have been recorded as childhood leukaemia. The NCR had recorded 425 of the 445 correct cases (95.5%), but had missed 20 cases (4.5%). The DCLSG had recorded 431 of the 445 correct cases (96.9%) and had missed 14 cases (3.1%). In addition, the NCR had recorded 9 cases incorrectly as childhood leukaemia. Part of the disagreement was caused by differences in coding rules (definition of non-Hodgkin's lymphoma (NHL) and the myelodysplastic syndrome versus leukaemia). It could be concluded that the quality and completeness of the two registries was very high. Regular comparison of the recorded data will help to reveal the inherently problematic disagreement between definitions and coding.

Adolescent↗

Trends in treatment and long-term survival of thyroid cancer in southeastern Netherlands, 1960-1992.

Thyroid cancer (TC), comprising less than 1% of all cancers in the Netherlands, has a good prognosis in general. Controversy still remains on the extent of surgical treatment and the indication for additional Iodine-131 (131I) therapy in the management of differentiated TC. The aim of this study was to describe (changes in) the treatment of TC and to determine independent prognostic factors for crude and relative survival of differentiated TC diagnosed in general hospitals. This population-based, retrospective study was based on data from the Eindhoven Cancer Registry, Comprehensive Cancer Centre South (I.K.Z.), Eindhoven, the Netherlands. Data were collected on all 343 TC patients diagnosed from 1 January 1960 to 31 December 1992. All available information on treatment (initial and additional) and survival (on 1 April 1994) were recorded. Initial surgical treatment was defined as limited or extended. Multivariate analysis of crude and relative survival to determine prognostic factors for differentiated TC was performed. Mean follow-up was 7.6 years. The proportion of patients with differentiated TC increased from 60% in 1960-1972 to 84% in 1985-1992. TC patients were treated in all hospitals in the region, approximately 2-4/year. Ninety per cent of all TC patients initially underwent surgical treatment; the extended procedures increasing from 27% in 1960-1974 to 61% in 1985-1992. 131I was also administered increasingly (from 18-44%) to patients with differentiated TC. The relative 5, 10 and 20 year survival rates for all TC were 80, 75 and 75%, respectively. In the first 5 years after diagnosis the crude death ratio was higher with the rise of age and for the follicular type and after 5 years for males and advanced disease. After inclusion of surgical treatment into the model, the estimates of the other death ratios did not change. Patients treated with 131I did better only during the first 5 years. Although the prognosis for TC patients treated in general hospitals in Southeastern Netherlands was similar to that found for patients treated in referral centres, concentration of treatment should be considered.

Adult↗

Intrauterine insemination in The Netherlands.

The aim of this retrospective study was to assess the results of intrauterine insemination (IUI) in The Netherlands, using data from 2003 taken from hospital annual reports and reports from individual gynaecologists. By extrapolation, the total number of IUI cycles performed that year nationwide, and the related outcomes, was estimated. IUI was performed in 91 of the country's 101 hospitals. Of these, 58 (64%) registered their IUI results and performed 19,846 IUI cycles. The mean pregnancy rate per cycle was 9.0% and the ongoing pregnancy rate per cycle was 7.3%. Multiple pregnancies occurred in 9.5% of the ongoing pregnancies. Extrapolation of the data suggested that approximately 28,500 IUI cycles were performed, of which approximately 2000 resulted in an ongoing pregnancy. The number of multiple pregnancies following IUI was estimated to be 180 (9.0%). According to the national IVF registry, 9761 IVF cycles were started in 2003, resulting in 2,028 ongoing pregnancies (20.8% per cycle) and 439 twin pregnancies (21.6% per ongoing pregnancy). In conclusion, the pregnancy rate per IUI cycle in The Netherlands (9.0%) was comparable with that reported in the international literature (8.7%). The contribution made by IUI to the number of multiple pregnancies in The Netherlands was much smaller than the contribution made by IVF.

Female↗

Nurse-managed heart failure programmes in the Netherlands.

Heart failure (HF) care in Europe is going through a lot of changes. Nurses have increasingly important roles in providing optimal care for these chronically ill patients in the Netherlands. The first steps to organise HF nurses have been taken and an overview of HF management programmes in Netherlands has been recently made available. A descriptive study was performed consisting of: (1) a screening phase in which all hospitals (n=109) and 105 home care organisations were approached by telephone to assess availability of HF management programmes and (2) a questionnaires in which content and organisation of the programmes were described. At the moment, the majority of all the hospitals (75%) have, or are currently developing a HF management programme. In 19 home care organisations (18%) a programme was available and 3 organisations had concrete plans to start on short notice. Components of HF programmes differ considerably, with follow-up after discharge from the hospital as the most often reported component. Other components of programmes include patient education, increased access to health care professionals and adjusting medication. Exercise programmes are not often available. Organisational aspects in regard to setting, financing and staffing also differ between various programmes. It was concluded that there is a considerable increase in the number of HF management programmes in the Netherlands, both hospital based and home based. A lot of questions in regard to the most optimal content and the organisation of HF management programmes remain unanswered.

Aged↗

An eighteenth-century medical-meteorological society in the Netherlands: an investigation of early organization, instrumentation and quantification. Part 2.

Scholarship has offered a range of judgements of the Correspondentie Sociëteit. In their recent study of the Netherlands at the start of the nineteenth century, Joost Kloek and Wijnand Mijnhardt characterize the efforts of the Correspondentie Sociëteit as a 'temporary milestone' in 'medical involvement with society'. According to them, this involvement arose after 1750, after university-trained medical doctors had reoriented themselves towards empiricism as a working method. They claim that this resulted in a preventative medical programme starting in about 1770; this process made a significant contribution to increased professional feeling and professional respect of the medical class. Far more negative in his assessment was Harry Snelders, who in 1981 conducted a general investigation of the Verhandelingen of the Correspondentie Sociëteit. He concluded that 'in the end the Sociëteit left us with little more than many particulars about the number of births and deaths in many places in the country, which illnesses people died from, some meteorological observations and an overview of the many contributors'. Also rather negative in his judgement was Frank Huisman, who in 1997 investigated the medical records of the Groningen section of the Correspondentie Sociëteit. Although Huisman underlined the importance of the Correspondentie Sociëteit in the process of the emancipation of the medical class, he also concluded that in the medical field scarcely any insight had been obtained into dominant illnesses. According to Huisman, the medical publications of the Correspondentie Sociëteit 'do not contain an expected level of abstraction, on the contrary they were very casuistic and contained many lists without any form of interpretation'. He judged that the medical doctors of the Correspondentie Sociëteit were no more than 'defective empiricists', because they never explicitly explained the transition from empirical material to theory. In Huisman's opinion, 'the correctness of the ideas adopted was indisputable, so that measurements could never have led to a modification, let alone a rejection, of the theory'. The question arises as to whether this is a useful way of making historical judgements. From a historical viewpoint, processes and efforts rather than results are most important, and innovations with respect to the institution's contemporary practices are to be assessed. If the Correspondentie Sociëteit is examined from such a perspective, then the result is rather positive, at least for the society's meteorological aspect. In the meteorological section of the Verhandelingen attention was mostly devoted to the set-up, methodology and recording of observations. This is hardly surprising, because in this field organized and systematic work was something very new in the Netherlands; members of the Correspondentie Sociëteit had to discover this effectively at first hand. There was no previous expertise on which to rely. The Correspondentie Sociëteit was the first in the Netherlands to genuinely organize scientific research. Moreover, contributors to the society performed much work. During a period of just over ten years the society published eleven volumes with almost five thousand pages of printed observations, about one-third of which was concerned with meteorology. Although these volumes were indeed partly descriptive, this does not mean that a higher level of abstraction was not the aim. For example, in his report about the weather during the years from 1779 to 1781, Van der Weyde sought to draw thoroughly analytical conclusions and even provided methodological arguments. According to Van der Weyde, the body of knowledge formed 'one large structure' which would only progress when many investigators worked on it together. Various types of natural knowledge needed to be distinguished. Meteorological knowledge could only be deduced from observation. Van der Weyde held that reliable natural knowledge was generated in three stages: first, collection and description of the phenomena; then the more difficult step of deriving inferences or patterns from these observations; the third step, the most difficult, to find an underlying theory or explanation. This step could only be taken after much preliminary work had been done. Van der Weyde considered Van Swinden's work on the magnetic needle to be an example of the first phase, that of describing phenomena. An example of the second phase, the derivation of inferences, was

History, 18th Century↗

Population-based Toxoplasma seroprevalence study in The Netherlands.

During 1995--1996 a population-based seroprevalence study was conducted in The Netherlands. Risk factors were established for postnatally acquired toxoplasmosis. The results were compared with a study conducted during 1987-1988 in pregnant women in the Southwest of The Netherlands in order to estimate the change in seroprevalence. In total, 7521 sera were tested and the national seroprevalence was 40.5 % (95 % CI 37.5-43.4). Living in the Northwest, having professional contact with animals, living in a moderately urbanized area, being divorced or widowed, being born outside The Netherlands, frequent gardening and owning a cat were independently associated with Toxoplasma seropositivity. Risk factors like eating undercooked meat could not be studied. The seroprevalence among women aged 15-49 years was 10 % lower (35.2 %, 95 % CI 32.9-38.6) in the study of 1995-1996, compared to the Toxoplasma study of 1987--1988 (45.8 %, 95 % CI 45.2-46.3). The steepest rise in seroprevalence still occurred among the subjects aged 25-44 years.

Adolescent↗

Identification of a common mutation (R245H) in Sanfilippo A patients from The Netherlands.

We have identified a common mutation (R245H) in the sulphamidase gene of Sanfilippo syndrome type A (mucopolysaccharidosis type IIIA, MPS IIIA) patients from The Netherlands. Allele-specific oligonucleotide hybridization was used to determine the incidence of this mutation in 45 unrelated MPS IIIA patients from different regions of The Netherlands. R245H was present in 51 alleles, representing 56.7% of the total allelic population. Of 39 patients, for whom we have uniform clinical details, 13 MPS IIIA patients who were homozygous for this common mutation had a more uniform but severe clinical phenotype than the remaining 21 or 5 patients, containing respectively one or no R245H alleles. The R245H allele had a higher prevalence in western rather than eastern regions of The Netherlands.

Adolescent↗

Fluoroquinolone use and the change in incidence of tendon ruptures in the Netherlands.

INTRODUCTION: Shortly after their introduction, fluoroquinolones were associated with reports of tendinitis and tendon rupture. During the past years, the number of reports has risen, possibly because of an increased use of fluoroquinolones. In this study, we describe the use of fluoroquinolones in the Dutch community and the possible public health effects of an association between fluoroquinolone use and tendon ruptures. METHODS: In the PHARMO drug database we identified all prescriptions for fluoroquinolones in the period 1991-1996. The incidence of fluoroquinolone use was expressed as the number of fluoroquinolone episodes per 1000 inhabitants in one year, and extrapolated to the Dutch population after standardisation on age and gender. The annual incidence of non-traumatic tendon ruptures in the period 1991-1996 was calculated with data from the nation-wide hospital registry. The expected number of fluoroquinolone attributable tendon ruptures was calculated on the basis of the use of fluoroquinolones, the number of non-traumatic tendon ruptures and an assumed relative risk of 1.5-10. RESULTS: In 1996, approximately 251,000 patients experienced 318,000 episodes of fluoroquinolone use in the Netherlands. Females used more often fluoroquinolones than males, and the number of episodes increased exponentially with age. In the period 1991 through 1996, the absolute number of fluoroquinolone episodes increased by 160%, from 122,000 to 318,000. The absolute number of hospitalised tendon ruptures increased with 28%, from 768 in 1991 to 984 in 1996. Assuming a relative risk of 1.5 to 10.0, 1 to 15 tendon ruptures could be attributed to fluoroquinolone use in 1996. Only 7% of the observed increase could be attributed to the increased use of fluoroquinolones. If the total increase of hospitalised non-traumatic tendon ruptures would be attributable to the increase in fluoroquinolone use, this would mean that the risk of non traumatic tendon ruptures to fluoroquinolones would be more than 250 times the risk during non-use. CONCLUSION: In the Netherlands, a large simultaneous increase in non-traumatic tendon ruptures and fluoroquinolone use was observed in the period between 1991 to 1996. Assuming a relative risk of 1.5 to 10.0 for tendon ruptures during fluoroquinolone use, only 0.5 to 7% of the increase in non-traumatic tendon ruptures could be attributed to the increased fluoroquinolone use. The increase in the incidence of non-traumatic hospitalised tendon ruptures in the Netherlands is not likely to be explained solely by the increased use of fluoroquinolones.

Adult↗

Prevention of suicides in Penal Institutions in The Netherlands.

As in other countries, suicides are a matter of great concern in The Netherlands. This article addresses suicide-prevention measures in prisons in The Netherlands. It focuses primarily on screening, monitoring, incapacitation, psychological support, and transferal to specialized institutions. In addition, it asks which practices are common, which can be improved, and the limitations of certain strategies. Relatively speaking, The Netherlands does not appear to be doing too badly in terms of preventive measures, although there is room for improvement.

Adult↗

Defaulting from tuberculosis treatment in The Netherlands: rates, risk factors and trend in the period 1993-1997.

The aim of this study was to assess the rate of defaulting from treatment among tuberculosis patients diagnosed in the Netherlands in the period 1993-1997, whether risk groups for defaulting can be identified at the start of treatment and the trend of defaulting over time. The Netherlands Tuberculosis Register provided data on all patients diagnosed in the Netherlands during the period 1993-1997. Defaulting probabilities were determined using Kaplan-Meier survival analysis and risk factors were identified with Cox's proportional hazard analysis. Of 7,529 patients with reported treatment outcome, 718 (10%) defaulted or left the country within 1 yr after starting treatment. Defaulting probabilities were 9% (95% confidence interval (CI) 8-10%) among 5,256 patients in low-risk groups, 17% (95% CI 14-19%) among 1,437 asylum seekers and 29% (95% CI 24-34%) among 836 patients in other high-risk groups (other recent immigrants, illegal immigrants, the homeless, prisoners and nationals from Eastern Europe). Defaulting probabilities decreased over time from 12% in 1993 to 7% in 1997. Risk groups for defaulting can be recognized at the start of treatment. The decreasing defaulting probabilities were probably due in part to shortening treatment from 9 to 6 months and improved follow-up of asylum seekers. However, additional measures are needed to reduce defaulting among the homeless, recent immigrants, illegal immigrants and prisoners.

Adult↗

Substandard factors in perinatal care in The Netherlands: a regional audit of perinatal deaths.

BACKGROUND: To determine: 1) whether substandard factors were present in cases of perinatal death, and to what extent another course of action might have resulted in a better outcome, and 2) whether there were differences in the frequency of substandard factors by level of care, particularly between midwives and gynecologists/obstetricians and between home and hospital births. METHODS: Population-based perinatal audit, with explicit evidence-based audit criteria. SETTING: The northern part of the province of South-Holland in The Netherlands. All levels of perinatal care (primary, secondary and tertiary care, and home and hospital births) were included. CASES: Three hundred and forty-two cases of perinatal mortality (24 weeks of pregnancy--28 days after birth). MAIN OUTCOME MEASURES: Scores by a Dutch and a European audit panel. Score 0: no substandard factors identified; score 1, 2 or 3: one or more substandard factors identified, which were unlikely (1), possibly (2) or probably (3) related to the perinatal death. RESULTS: In 25% of the perinatal deaths (95% Confidence Interval: 20-30%) a substandard factor was identified that according to the Dutch panel was possibly or probably related to the perinatal death. These were mainly maternal/social factors (10% of all perinatal deaths; most frequent substandard factor: smoking during pregnancy), and antenatal care factors (10% of all perinatal deaths; most frequent substandard factor: detection of intra-uterine growth retardation). We did not find statistically significant differences in scores between midwives and gynecologists/obstetricians or between home and hospital births. The European panel identified more substandard factors, but these were again equally distributed by level of care. CONCLUSIONS: Perinatal deaths might be partly preventable in The Netherlands. There is no evidence that the frequency of substandard factors is related to specific aspects of the perinatal care system in The Netherlands.

Europe↗