Addressing perinatal health inequities in Dutch municipalities: Protocol for the Healthy Pregnancy 4 All-3 programme

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ContentslistsavailableatScienceDirect

Health

Policy

j o u r n al ho me p ag e :w w w . e l s e v i e r . c o m / l o c a t e / h e a l t h p o l

Addressing

perinatal

health

inequities

in

Dutch

municipalities:

Protocol

for

the

Healthy

Pregnancy

4 All-3

programme

Lisa

S. Barsties

a,b,1

_,

_Leonie

_A.

_Daalderop

a,b,∗,1

_,

_Jacqueline

_Lagendijk

a

_,

Frank

van

Steenbergen

b

_,

_Jasper

_V.

_Been

a,c,d

_,

_Loes

_C.M.

_Bertens

a

_,

_Adja

_J.M.

_Waelput

a

_,

Hanneke

van

Zoest

e

_,

_Derk

_Loorbach

b

_,

_Eric

_A.P.

_Steegers

a

a_Department_of_Obstetrics_and_Gynaecology,_Erasmus_MC,_University_Medical_Centre,_PO_Box_2040,₃₀₀₀_CA,_Rotterdam,_the_Netherlands

b_Dutch_Research_Institute_for_Transitions,_Erasmus_University_Rotterdam,_PO_Box_1738,₃₀₀₀_DR,_Rotterdam,_the_Netherlands

c_Department_of_Paediatrics,_Erasmus_MC_–_Sophia_Children’s_Hospital,_University_Medical_Centre_Rotterdam,_PO_Box_2040,₃₀₀₀_CA,_Rotterdam,_the

Netherlands

d_Department_of_Public_Health,_Erasmus_MC,_University_Medical_Centre_Rotterdam,_PO_Box_2040,₃₀₀₀_CA,_Rotterdam,_the_Netherlands

e_Pharos,_The_Dutch_Centre_of_Expertise_on_Health_Disparities,_PO_Box_13318,₃₅₀₇_LH,_Utrecht,_the_Netherlands

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received26June2020

Receivedinrevisedform

13December2020

Accepted22December2020

Keywords:

Perinatalhealthinequities

Healthpolicy

Cross-sectoralcollaborations

Municipalities

a

b

s

t

r

a

c

t

Background:Healthinequitiesarealreadypresentatbirthandaffectindividuals’healthand socioeco-nomicoutcomesacrossthelifecourse.Addressingtheseinequitiesrequiresacross-sectoralapproach, coveringtheﬁrst1,000daysoflife.Webelievethat-intheDutchcontext-municipalgovernmentscanbe themainresponsibleactortodrivesuchanapproach,sincetheyareprimarilyresponsiblefororganising adequatepublichealth.Therefore,weaimtoidentifyanddeveloptransformativechangetowardsthe implementationofperinatalhealthintomunicipalapproachesandpoliciesconcerninghealthinequities. Methods:AtransitionanalysiswillbecombinedwithactionresearchinsixDutchmunicipalities. Inter-viewsandinteractive groupsessionswithprofessionalsandorganisations thatarerelevantforthe institutionalembeddingofperinatalhealthintoapproachesandpoliciesregardinghealthinequities, willbeorganisedineachmunicipality.Asafollow-up,aquestionnairewillbeadministeredamongall participantsoneyearaftercompletionofthegroupsessions.

Discussion:Weexpecttogaininsightsintotheroleofmunicipalitiesinaddressingperinatalhealth inequities,learnmoreabouttheinteractionbetweendifferentkeystakeholders,andidentifybarriers andfacilitatorsforacross-sectoralapproachtoperinatalhealth.Thisknowledgewillservetoinformthe developmentofapproachestoperinatalhealthinequitiesinareaswithrelativelypoorperinatalhealth outcomes,bothintheNetherlandsandabroad.

1. Introduction

Substantialperinatalhealthinequitiesexistbetweenandwithin citiesacrosshigh-incomecountries[1–3]. Theseinequitieshave long-termhealthconsequencesandthereforemajorimplications

∗ Correspondingauthorat:DepartmentofObstetricsandGynaecology,Erasmus

MC,UniversityMedicalCentre,POBox2040,3000CA,Rotterdam,theNetherlands.

E-mailaddresses:l.barsties@erasmusmc.nl(L.S.Barsties),

l.daalderop@erasmusmc.nl(L.A.Daalderop),j.lagendijk.2@erasmusmc.nl

(J.Lagendijk),f.s.vansteenbergen@drift.eur.nl(F.vanSteenbergen),

j.been@erasmusmc.nl(J.V.Been),l.bertens@erasmusmc.nl(L.C.M.Bertens),

a.waelput@erasmusmc.nl(A.J.M.Waelput),h.vanzoest@pharos.nl(H.vanZoest),

loorbach@drift.eur.nl(D.Loorbach),e.a.p.steegers@erasmusmc.nl(E.A.P.Steegers).

1 _Both_authors_contributed_equally_to_this_paper.

forpublichealth [4]. Nexttomedicalriskfactors,accumulation ofnon-medicalriskfactors,suchasaloweducationallevel, psy-chosocialproblems,lackofsocialsupport,alowhouseholdincome, unemployment,andneighbourhooddeprivationunderlieperinatal healthinequities[1,2,5–8].Perinatalhealthchallengesassociated withthesenon-medicalriskfactorsarebeyondthescopeofthe tra-ditionalremitoftheperinatalhealthcaresystemandare,atleast inpart,eitherdirectlyorindirectlyshapedbymunicipalpolicy.

Asthepreconception,prenatal,postpartum,andearlychildhood periods(i.e.theﬁrst1,000daysof life)bear substantial plastic-ity,theseallowforimprovementviaearlyinterventionsthathelp enablethedevelopmentofthefunctionalcapacity ofa childto respondtohealthchallengesthroughoutlife.Interventions dur-ingtheﬁrst1,000daysoflifethataddresstheearly-lifecausesof healthinequitiesrequireaholisticandcross-sectoralapproachto https://doi.org/10.1016/j.healthpol.2020.12.013

Pleasecitethisarticleas:BarstiesLS,etal,AddressingperinatalhealthinequitiesinDutchmunicipalities:ProtocolfortheHealthy Pregnancy4All-3programme,HealthPolicy,https://doi.org/10.1016/j.healthpol.2020.12.013

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healththatappreciatestheinterconnectednessofmedical,social, economic,cultural,andenvironmentalriskfactors.

Such a cross-sectoral approach toperinatalhealth, engaging theentire medical,social, and publichealth carechain, aswell as the national and municipal government has been labelled ‘social obstetrics’. Based on the core ideas of social obstetrics, theReadyforBabyprogramme(2008−2012)wasestablishedto addressperinatalhealthinequitiesinRotterdam,theNetherlands [9].BuildingontheinsightsofReadyforaBaby,theMinistryof Health,Welfare,andSportsubsidisedthenationwideresearch pro-grammeHealthyPregnancy4All(HP4All) [10]. TheﬁrstHP4All programme(2011−2014)emphasisedcollaborationbetweenthe medical, social, and public health sector, as well as municipal governments onpreconception and antenatal care[11,12]. This approachhasbeenextendedtocoverpostpartumcare(i.e. mater-nitycare),PreventiveChildHealthCare,andinterconceptioncare within the second HP4All programme (2014−2017) (Table 1) [13,14].Building ontheknow-howacquiredthroughReadyfor a Baby and HP4All, the Ministryof Health, Welfare, and Sport launchedanationwideactionprogramme entitledSolidStart in 2018. Solid Start supports municipalities in addressing health inequities before, during, and shortly after pregnancy.Through ﬁnancial incentives, participatingmunicipalitiesareencouraged andfacilitatedtobuildacross-sectoralapproachtoperinatalhealth tosupportparents(-to-be)and/oryoungchildrenlivingin precar-iousconditions.

The Readyfora Babyand HP4Allprogrammeshave demon-stratedthepotentialofacross-sectoralapproachtoperinatalhealth tointerruptthenegativecycleofeventsassociatedwithsocialand environmentalrisk factorsamong parents(-to-be)living in pre-cariousconditions.Bothprogrammeshavesparkedawarenessof

theimpactofnon-medicalrisk factorsonperinatalhealth out-comesamongprofessionalsacrossdifferentsectors.Thisresultedin astrongerfocusofnationalandmunicipalpoliciesonpreventive careandhealth measuresearlyinlife,whichcontributedtothe foundationofacross-sectoralapproachtoperinatalhealthinthe Netherlands[15–19].Despitethesepromisingresults,this cross-sectoralapproachis stillnot thestatus quointheNetherlands. Thismightbeexplainedbythefactthatresearchintoperinatal healthinequitiespredominantlyfocuses ontheidentiﬁcationof itscausesandevaluationofsubsequentinterventionswithinthe medicalcaresector.However,perinatalhealthinequitiesoriginate fromarangeofmedical,social,cultural,andenvironmentalfactors [1,2,5–8].Addressingthemrequiresaholisticandcross-sectoral approachbeyondtheboundariesofthemedicalcaresector,aswell asthoseofthe(separate)social,andpublichealthcaresector.We believethat-intheDutchcontext-municipalgovernmentscanbe themainresponsibleactortodrivesuchanapproach,sincetheyare primarilyresponsiblefororganisingadequatepublichealth.Local politiciansandcivilservantsareideallypositionedtocreatesuch anapproach[20].

To better understand the cultural, behavioural, and institu-tionalbarriers fora cross-sectoral approach toperinatal health and toﬁndout how this approach can beimplemented atthe municipallevel,action research– in which research, participa-tion,and action forma simultaneous process– in combination with transition analysis can be a fruitful approach. Transition analysisassemblesdifferentperspectivesonanissueinorderto developanewwayofunderstandingapersistentsocietal prob-lemandidentifyingthedriversbehindthispersistency.Bysharing and discussing a transitionanalysis withkey stakeholders that arestrugglingwithapersistentsocietalproblem,newstrategies

Table1

OverviewofDutchresearchandpolicyprogrammesthatprecededtheHealthyPregnancy4All-3programme.

Programme Initiator(s) Financier Timeperiod Location Keyapproaches

ReadyforaBaby[9,15] • ErasmusMC

• GGD

Rotterdam-Rijnmonda

Municipalityof

Rotterdam

2008−2012 CityofRotterdam • Healthpromotionthrough

customisedpreconception

care

• Systematicantenatalrisk

assessment(R4Uc₎_with

increasedattentionfor

non-medicalriskfactors

• Interdisciplinary

risk-directedcare

• Establishmentofaprimary

birthcarecentreinthe

ErasmusMC(Rotterdam)

HealthyPregnancy4

All-1[10,18,31]

ErasmusMC MinistryofHealth,

Welfare,andSport

2011−2014 14Dutchmunicipalitiesb_:

Almere,Amsterdam,

Appingedam,Delfzijl,

Enschede,Groningen,Heerlen,

Menterwolde,Nijmegen,

Pekela,Schiedam,TheHague,

Tilburg,Utrecht

• Healthpromotionthrough

customisedpreconception

care

• AntenatalR4Urisk

assessmentfollowedby patient-tailored multidisciplinarycare pathways HealthyPregnancy4 All-2[13,14,32,33]

ErasmusMC MinistryofHealth,

Welfare,andSport

2014−2017 10Dutchmunicipalitiesb_:

Almere,Amsterdam,Arnhem,

Dordrecht,Groningen,

Rotterdam,Schiedam,The

Hague,Tilburg,Utrecht

• Interconceptioncare

throughPreventiveChild

HealthCare

• Structuredriskassessment

duringpregnancyand

customisedmaternitycare

• OptimisingpostnatalR4U

riskassessmentin

PreventiveChildHealthCare

a_GGD_{Rotterdam-Rijnmond}_provides_the_Municipal_Health_Services_for_the_municipality_of_Rotterdam_as_well_as_for_the_surrounding_{municipalities.}

b_All_{municipalities}_were_selected_based_on_their_relatively_poor_perinatal_and_child_health_outcomes.

c_R4U_stands_for_Rotterdam_Reproductive_Risk_Reduction_and_is_a_70-item_score_card,_assessing_risks_for_adverse_pregnancy_and_child_health_outcomes_in_six_domains_(social

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Box1:Sustainabilitytransitions.

Transitionsareradical,non-linear,andstructuralchangesfrom one equilibrium of a complex adaptive societal subsystem (e.g.healthcare,education,mobility)toanother[22].A transi-tionisconceptualisedasachangeinasubsystem’sdominant culture, structures, and practices (i.e. its regime). Regimes are path dependent as actors, policy, and innovation are directedtowardsimprovement,efficiency, andoptimisation. Transitionscholarsstudytheprocessthroughwhichregimes destabilise due to external (societal) pressures and emerg-ingdisruptivesocial,technological,institutional,andeconomic developments[22].

Theexplorativemethodsoftransitionscholarsareguidedby theprincipleof‘(un)sustainability’.Ifthereisevidenceofa per-sistent‘grandsocietalchallenge’[22],suchasperinatalhealth inequitiesbetweenandwithinDutchmunicipalities[23],what arepossiblefuturesandupcominginnovationstoovercome thispersistency?Inotherwords,whatisadesireddirectionto asystemicchange,whoisdrivingthischange,andwhy?

andpathwaysforadesiredtransitioncanbeidentiﬁed.Thistype of analysis enablesacademics to take part in process-oriented research, rather than applyingtraditional descriptive-analytical methods[21].

1.1. HealthyPregnancy4All-3

The HP4All-3 programme (2018–2021) aims to identify the dynamics and mechanisms that might enable a ‘sustainability transition’(Box1)towardsacross-sectoralapproachtoperinatal health.Toachievethis,ourresearchwilltakeplaceinaselected sampleofDutchmunicipalities.Wewillfocusontransformative changewithinlocalpublichealthpolicies,aswehypothesisethat municipalgovernments canplay a centralrole instimulatinga cross-sectoralapproachtoperinatalhealth.

With theuse ofa transitionanalysis, combinedwithaction research, we intend to increase the impact potential of local policies,approaches,andinitiativesthataddressperinatalhealth inequities.Todo so,wewilldevelop alocalaction-agendaina selectedsampleofDutchmunicipalities.Anaction-agendaconsists ofsuggestionsonagreementstobemadeandactionstobetaken. Theresultsofthisresearchwillbeusedtoinforma knowledge dissemination programme onthe need toimplement perinatal healthintomunicipalapproachesandpoliciesconcerninghealth inequities.Theknowledgedisseminationprogrammewillberolled outamongthe156municipalitieswiththehighestshareof dispar-itiesoutofall380Dutchmunicipalities.

TheHP4All-3programmeisacollaborationbetweenthe Eras-musMC,theDutchResearchInstituteforTransitions(DRIFT),and theDutchCentreofExpertiseonHealthDisparities(Pharos).The ErasmusMCandDRIFTareresponsibleforallresearchactivities. InclosecollaborationwiththeErasmusMCandDRIFT,Pharos car-riesouttheknowledgedisseminationprogramme.Bycollaborating withsuchadiversesetofpartners,weaimtoreachallrelevant stakeholdersandinstitutionsindifferentDutchmunicipalitiesand thereby promotetheestablishmentofacross-sectoralapproach toperinatalhealthtoaddresshealthinequitiesfromtheirearliest origins.

Theobjectiveofthisprotocolarticleistointroducethecontext andresearchquestionsoftheHP4All-3programme,aswellasits innovativedesignandresearchmethodsthatweintendtoapplyto addressperinatalhealthinequities.

1.2. Researchquestions

ThecentralresearchquestionposedintheHP4All-3programme is formulated as follows: Which transition dynamics are driv-ingtransformativechangeininstitutionalstructures,culture,and practices, towards the implementation of perinatal health into municipalapproachesand policiesconcerninghealth inequities resultinginacross-sectoralapproachtoperinatalhealth?

Inadditiontothecentralresearchquestion,thefollowing sub-questionswereposed:

1Towhatextentareprofessionalsfromthemedical,social,and publichealthsector,aswellasthemunicipalgovernmentaware oftheconceptofperinatalhealthinequities,thedegreetowhich theseinequitiesexistintheirmunicipality,andtheurgencyto addressthemthroughacross-sectoralapproach?

2Whatisneededtoincreaseawarenessofexistingperinatalhealth inequitiesand theurgency toaddressthem through a cross-sectoralapproachamongprofessionalsfromthemedical,social, andpublichealthsector,aswellasthemunicipalgovernment? 3Whatisneededtoengagemunicipalitiesinactivitiesaimedat

addressinglocalperinatalhealthinequities(e.g.byintroducing policiesthataddresstheseinequities)?

4Whatare theinstitutional facilitatorsand barriers that inﬂu-ence the implementation of perinatal health into municipal approachesandpolicyplansregardinghealthinequities? 5Howcancollaborationbetweendifferentmunicipal

stakehold-ers(e.g.civilservants,aldermen,etc.)andprofessionalsfromthe medical,social,andpublichealthsectorbestimulatedin address-ingperinatalhealthinequities?

6Whichlessonscanbelearnedfrombestpracticesandfront run-ningmunicipalities regarding approaches to reduceperinatal healthinequities?

7Howcanwestrengthenandaccelerateexistinglocalmunicipal approachesaimedataddressingperinatalhealthinequities?

2. Methods

2.1. Studydesign

Inthisstudy,transitionanalysiswillbecombinedwithaction research.Actionresearchisanumbrella-termforvariousresearch processes and methods that try to achieve change in a cer-taincontextand/orsystem.Notwithstandingitsdiversity,action researchalwaysconsistsofthree balancing elements;research, participation,andaction [24]. WefollowBartelsand Wittmayer (2018)whodeﬁneactionresearchas“criticalandrelational pro-cessesthroughwhich researchersandtheirco-inquirersaimto collaborativelyproducescientiﬁcallyandsociallyrelevant knowl-edgeandtransformativeaction”[25].Inourresearchprogramme, action research will be used to guide a process of knowledge co-productionthatcontributestotheabilityoftheinvolved munic-ipalities/participantstocontrolperinatalhealth inequitiesmore effectivelyandtokeepimprovingtheircapacity todosowithin a more sustainableand just environment. Asour researchwill takeplaceinvariousmunicipalities,wewilluseamultiplecase studydesign [26].Weaimtohighlightdifferencesand similari-tiesin(existing)municipalapproaches andpoliciestoperinatal healthinequities.Thecommonalitythatallowsforcomparisonof theparticipatingmunicipalitiesaretherelativelypoorperinatal healthoutcomes,therelativelyhighshareofchildrenlivingin fam-iliesonwelfare,andthelargeproportionofinhabitantswithalow socioeconomicstatus(SES).

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2.2. Identiﬁcationandselectionofparticipatingmunicipalities Action researchis anintensiveand time-consumingprocess. Giventhecapacityofourresearchteam,wewereabletoselectsix Dutchmunicipalitiesascasesforouractionresearch.These munici-palitieswereselectedbasedonanextensivebaselinemeasurement (supplementaryﬁle1)thatwascarriedoutin2018amongthe156 municipalitieswiththehighestshareofdisparitiesoutofall380 Dutchmunicipalities.Thisbaselinemeasurement,whichwaspart ofthetransitionanalysis,consistedofaGooglesearch,adocument analysisandaquantitativeanalysisintomunicipalperinatalhealth outcomes.

We hypothesised that our action research would have the biggestimpactinmunicipalitieswhereinequitiesaregreatest.A policyanalysistowardsimprovementsinperinatalhealthinthe Netherlands showedthat quantiﬁcationofperinatalhealth data createdurgencytoactamongstpoliticians,aldermen,andthe pre-ventivehealthsector[17].Assuch,weexpectthattheurgencyto addressperinatalhealthinequitieswillbestirredupmoreeasilyin municipalitieswithpoorperinatalhealthoutcomescomparedto municipalitieswithbetterperinatalhealthoutcomes.Wetherefore selectedmunicipalitieswithahighincidenceofadverse perina-talhealthoutcomes(i.e.pretermbirthandsmallforgestational age(SGA)),ahighproportionofchildrenlivinginfamilieson wel-fare, and a low municipal SES. Municipalities were considered having a lowSES, when a largeproportionof theirinhabitants are living in an areawitha SES score withinthe lowest quin-tile(detailsarepresentedinsupplementaryﬁle1).Additionally, weconsideredwhethermunicipalitieswerealready implement-ingperinatalhealthintotheirapproachesandpoliciesconcerning healthinequitiesandwhethertheyparticipatedinpreviousHP4All programmes(Table1).

Based ontheﬁndingsofthebaseline measurement,we ﬁrst selected municipalities that belong to (1) the highest quintile regardingtheincidenceofadverseperinatalhealthoutcomes,(2) thehighestquintileregardingchildrenlivinginfamiliesonwelfare, and(3)thelowestquintileregardingmunicipalSES.Thisresulted in a selectionof 20 municipalities.We thenselected sixout of the20municipalitiestorepresentvariationinthelevelof activ-ityconcerningapproachestoperinatalhealthinequities,size,and location.Ofthesesix,fourmunicipalitieswerealready activein addressingperinatalhealthinequitiesand/orparticipatedin previ-ousHP4Allprogrammesandtwomunicipalitieswerenot.Seventy thousandinhabitantswasusedasacut-off formunicipalitiesto beconsideredlarge.Threeofthesixmunicipalitieshadlessthan 70,000inhabitantsandthreehadmorethan70,000inhabitants. Finally, the selectedsix municipalities had tobe spread across thecountry.Accordingly,thefollowingDutchmunicipalitieswere invited toparticipate inouraction research: Delfzijl,Enschede, TheHague, Vlissingen,Landgraaf,and Heerlen(seeFig.1foran overviewoftheirlocationwithintheNetherlands).Allsix munici-palitiesarewillingtoparticipateinourresearch.

2.3. Datacollection

TheHP4All-3programmeisbasedonactionresearch,an itera-tiveprocess,inwhichtheoryandactionareinterlinkedbyreflection [24].Asmentioned,actionresearchconsistsofthreebalancing ele-ment:research,participation,andaction.Regardingourrolesas (action)researchers,itwasabalancingactofconstantlyswitching betweenbeingachangeagent,knowledgebroker,reflective sci-entist,self-reflexivescientist,andprocessfacilitator.Variousyet complementing typesofexpertisewithintheHP4All-3research teamfacilitatedthisprocess.Wewillstartouractionresearchwith conductingatransitionanalysistogatherknowledgeandtheories onthepersistentsocietalproblematstake(i.e.perinatalhealth

inequities)andtoidentifypossibledriversbehindthispersistency. Thisknowledgewillbeusedina participatoryresearchsetting. Researchersand participantswill collaborativelyreflect on and analysethefindingsofthetransitionanalysis,while simultane-ouslyformulatingatheoryorhypothesisabouthowtoaddressthis problem.Additionally,concreteactionsareidentifiedtoactively tackleperinatalhealthinequities.Togothroughthesesteps,we willconductinterviewsandinteractivegroupsessionswithvarious relevantstakeholders.

2.3.1. Sampling-interviews

Theaimofourresearchprogrammeistoacceleratethe institu-tionalembeddingofacross-sectoralapproachtoperinatalhealth. Todoso,wewanttostimulatecollaborationbetween profession-alswithvaryingbackgrounds,motives,andcompetencesthatcan collectivelyaddressthevarietyofinterconnectedmedical,social, economic,cultural,andenvironmentalriskfactorsthatunderlie perinatalhealthinequities.

Fortheinterviews,wewillemploypurposivesampling[27], selectingprofessionalswhocanprovidethegreatestinsightinto factorsthateitherhinderorfacilitatethisinstitutionalembedding, suchas1)municipalstructures,2)approachestoperinatalhealth inequities(ifexisting),and3)relevantfutureplans/ideas.We pre-speciﬁedalistofkeystakeholdersforacross-sectoralapproachto perinatalhealth(supplementaryﬁle2)whomweintendto inter-view(correspondingsectorbetweenbrackets):

• Aldermanfromtheﬁeld ofyouthorpublichealth (municipal government);

• Civilservantfromtheﬁeldofyouthorpublichealth(municipal government);

• Civilservantfromtheﬁeldofworkandincomeorsocietalsupport (municipalgovernment);

• Professionalfromalocalmultidisciplinaryneighbourhoodteam (supportteamfor inhabitantsofa speciﬁcneighbourhood)or anotherrelevantwelfareorganisation(socialsector);

• EmployeeofthelocalPreventiveChildHealthCareorganisation (publichealthsector);

• Obstetricprofessional,suchasamidwifefromalocalmidwifery practiceorobstetricianfromthenearesthospital(medical sec-tor);

• Professionalfroma localmaternitycareorganisation(medical sector);

• Generalpractitioner(GP)fromalocalGPpracticeand/or paedia-tricianfromthenearesthospital(medicalsector).

Wewillsearchthewebsitesoftheparticipatingmunicipalities, localhospitals,midwiferypractices,maternitycareorganisations, GPpractices,welfareorganisations,etc.toidentifypotentially eli-gibleinterviewrespondents.Additionally,wewillapplysnowball samplingby askingparticipantswhom we already interviewed aboutotherpotentiallyeligibleparticipantsinadditiontoour pre-speciﬁedlistofkeystakeholders[28].Weintendtoconducteight to12interviewsineachparticipatingmunicipalitytogather infor-mationonwhatiscurrentlybeingdonewithinandacrossdifferent sectorstoaddressperinatalhealthinequities.

AllinterviewswillbeconductedbymembersoftheHP4All-3 researchteam,usingasemi-structuredapproach.Eachinterview willbeconductedbytwointerviewers(alternatelyLSB,LAD,and FS),face-to-faceorbytelephone.Aninterviewprotocol (supple-mentaryﬁle3)wasdevelopedandtestedinadvancetoguidethe interviews.Duringtheinterviews,therewillbetimefor partici-pantstoshareextrainformationwhichtheyconsiderrelevantto ourtopic[29].Allinterviewswillbeaudio-recordedandwilllast aboutonehour.

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Fig.1.Geographicallocationoftheparticipatingmunicipalities.

Legend:Circlesindicatemunicipalitieswithlessthan70,000inhabitantsandsquaresindicatemunicipalitieswithmorethan70,000inhabitants.Municipalitiesthatare

alreadyactiveinaddressingperinatalhealthinequalitiesarebluecolouredandmunicipalitiesthatarenotyetactiveareorangecoloured.

FromJanuary1,2021,themunicipalityofDelfzijlwillmergewithtwoneighbouringmunicipalities,AppingedamandLoppersum,intothemunicipalityEemsdelta.Therefore,

wedecidedtoincludeAppingedamandLoppersuminadditiontoDelfzijl.Wewillexaminethesethreemunicipalitiesasonecase.(Forinterpretationofthereferencesto

colourinthisﬁgurelegend,thereaderisreferredtothewebversionofthisarticle.)

2.3.2. Sampling–interactivegroupsessions

Aftercompletionoftheinterviews,wewillorganisetwo suc-cessiveinteractivegroupsessionswithineachmunicipality.These groupsessionswillfocus onhowtodevelop oracceleratelocal approaches and policies concerningperinatal health inequities. Eachsessionwilllastthreehoursandwillbeaudio-recorded. Pro-fessionalsworkinginthemedical,social,orpublichealthsector or for themunicipalgovernmentwill beinvited toboth group sessions.Wewillapplypurposivesampling,aimingtoinvite indi-viduals of whom we expect that they can contribute valuable insights,questions,andideastoagroupdiscussionconcerningthe institutionalembeddingofacross-sectoralapproachtoperinatal health. Interviewees who meetthese criteria willbeinvited to participateinthegroupsessions.Additionally,stakeholderswho cancontributevaluableinsightsaccordingtoparticipantsofthe ﬁrstgroupsession,willbeinvitedtojointhesecondgroup ses-sion.Wewillusethemethodologyoftransitionmanagementto guidethegroupsessions[30].Acentralmethodintransition man-agement aresmall-scale groupsessions,so-called ‘arenas’,with key stakeholdersfromdifferentbackgrounds,who holdvarying perspectivesonperinatalhealthinequities.Duringthesearenas, participantscollectivelygothroughaparticipatoryprocessof1) problem structuring,2)envisioning, 3) agenda-building,and 4)

developingaction-orientedexperiments.Betweentenand20 par-ticipantswillparticipateinthesesessions,astosafeguardspacefor personalinteractionandexchange.

Duringtheﬁrstgroupsession,wewillpresenttheﬁndingsof ourtransitionanalysis.Thisincludeslocalperinatalhealth out-comesfortheperiod2013–2017(freelyaccessibleonthewebpage

www.waarstaatjegemeente.nl), findings fromtheGoogle search and documentanalysis, aswell asinsights that we willgather duringtheinterviews.Theseinsightswillbeusedtoinform par-ticipantsabout:1)thecurrent orientationof localstakeholders towardsperinatalhealthinequities,2)localapproachesand poli-ciesaimedataddressingperinatalhealthinequities(ifexisting), and3)localchallengestobuildacross-sectoralapproachto peri-natalhealth.Subsequently,participantswillworkinsmallgroups (threetofiveparticipantseach)todefinefuturesystemicchanges thatareneededwithintheirmunicipalitytoovercomeperinatal healthinequities.Theideasofthesesmallgroupswillbeshared duringaplenarydiscussionattheendofthemeeting.

Inthetimebetweenthetwogroupsessions,theresearchteam willsynthesisetheproposedfuturesystemicchangesinto approx-imatelyﬁvelocalkeychangesforeachparticipatingmunicipality. Inthesecondgroupsession,wewillpresentanddiscussthesekey changesto/withtheparticipantstovalidatethem.Subsequently,

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using thefive key systemic changes, participants will work in smallgroupstoidentifytangibleactionstoaddressperinatalhealth inequitiesonboththeshort-(withinoneyear)andmedium-term (onetofiveyears).Next,prioritisationoftheidentifiedactionswill takeplaceduringaplenaryexercise,whichwillresultinthe for-mationofalocalaction-agenda.Lastly,participantswilldiscussin plenarywhichstepsneedtobetakeninthemonthsfollowingthe groupsessions.Additionally,theywillidentifywhichstakeholders areresponsiblefortheimplementationoftheaction-agenda.

Aftercompletionofthetwogroupsessions,theresearchteam will draw upseparate reports for each of thesix participating municipalities.Thesereportswillsummariserelevantinsightsfrom thebaselinemeasurement,theinterviews,thegroupsessions,and theaction-agenda.Thereportswillbesharedwithallparticipants oftheinterviewsandgroupsessions,inordertofuelandguide futureactionsaimedataddressinglocalperinatalhealthinequities. ParticipatingmunicipalitieswillbesupportedbyPharosuntilthe end oftheresearchprogrammetostrengthenand expandlocal actionsandactivitiesdirectedtowardsacross-sectoralapproach toperinatalhealth.

Asafollow-upontheactionresearchprocess,aquestionnaire (seesupplementaryﬁle4foradraftversion)willbeadministered approximatelyoneyearaftercompletionofthegroupsessions.This questionnairewillbedistributedviae-mailamongallinterviewees andparticipantsofthegroupsessions,inordertoprovideinsights into:

1 Theactionstakenintheperiodaftertheformationofthe action-agenda.Weareinparticularinterestedinthehow,what,and why,theeffectoftheactionstaken,aswellastheextenttowhich differentstakeholdersaresatisﬁedwiththeactionstaken; 2 Theextent to which sustainablecross-sectoral collaborations

havebeenandarebeingbuilt,aswellastheextenttowhichthe differentstakeholdersaresatisﬁedwiththesecollaborations; 3 Theextenttowhichperinatalhealthhasbeenorisplannedto

beimplementedinlocalapproachesandpolicyplansaimedat addressinghealthinequities.

Towards theend oftheHP4All-3programme aclosing sym-posiumwillbeorganisedinwhich theresearchteamwillshare keyﬁndingsoftheHP4All-3researchprogrammewith stakehold-ers that are, orcouldbe, involved in a cross-sectoralapproach toperinatalhealth.Thesymposiumwillbeaccessibleforall rel-evant stakeholdersfromthe156Dutchmunicipalitieswiththe highestshareofdisparities.Thissymposiumalsooffersthe pos-sibilityforprofessionalsfromtheparticipatingmunicipalitiesto shareinsightsandlearnfromeachother’sexperiences,struggles, andaction-agendas.

2.4. Studytimeline

Theidentiﬁcationandselectionofthesixparticipating munic-ipalities took place between June 2018 and January 2019. The interviewsandgroupsessionstookplacebetweenFebruaryand December 2019.All action-agendas are aimedto be drawn up betweenJanuaryandMay2020.Thequestionnairewillbe admin-isteredinSeptember/October2020.Theclosingsymposiumwillbe organisedinMarch2021.

2.5. Analyses

Allinterviewsandgroupsessionswillbetranscribedbyan inde-pendentorganisation(TiptopGlobal,www.tiptopglobal.com).The transcripts willbechecked bytwo researchersof theHP4All-3 team(LSB,LAD).Aftertranscription,allinterviewsandgroup ses-sionswillbeanalysedbasedonexistingtheories,elementsofthe

researchquestions,andtheinterviewprotocol.Allanalyseswillbe undertakenbytworesearchers(LSB,LAD).Codes,themes,and sub-themeswillbeusedtoanswertheresearchquestions.Allanalyses willbeperformedinATLAS.ti.

3. Discussion

TheaimoftheHP4All-3programmeistoinvestigatewhich tran-sitiondynamicsaredrivingtransformativechangeininstitutional structures,culture,and practicestostrengthenand acceleratea cross-sectoralapproachtoperinatalhealthinDutchmunicipalities. Sixmunicipalitieswithrelativelypoorperinatalhealthoutcomes, ahighproportionofchildrenlivinginfamiliesonwelfare,anda lowmunicipalSESwereapproachedandhaveagreedto partici-pate.TheHP4All-3programmewillprovideinsightinto:(1)the necessaryfuturesystemicchangesininstitutionalstructures, cul-tures,andpractisestoovercomeperinatalhealthinequities,(2)the variousrolesthatmunicipalitiesare,orcouldbe,playingin address-ingperinatalhealth inequities,and(3) how localcross-sectoral approachestoperinatalhealthcanbebuiltand/orstrengthened. Together,theseinsightswillleadtoadiversesetofdriversand barrierstoinstitutionaliseacross-sectoralapproachtoperinatal healthinDutchmunicipalities.Finally,ourresearchwillprovide knowledgeondifferencesandsimilaritiesbetweenurbanandrural municipalitiesregardingapproachesandpoliciesaimedat address-ingperinatalhealthinequities.

Nexttothesepromisingresultsthatwillbegatheredthrough theHP4All-3 programme,there aresomelimitationsthatmerit discussion.First,althoughwehaveincludedadiversesetof stake-holdersinourresearch,thereareseveralgroupsthataremissing. Forinstance,wedidnotincludeparents(-to-be),localcommunity organisations,and informal networksin ourresearch.We have chosentofocusonstakeholdersdirectlyinvolvedinthe institu-tionalembeddingofacross-sectoralapproachtoperinatalhealth. ThischoicestemsfromtheexperiencesofthepreviousHP4All pro-grammes.Theseprogrammeshaveshowedhowtime-consuming andchallengingitistoestablishcollaborationsbetweendifferent sectorsandprofessions.Therefore,westartedwithacoresetof pro-fessionalsthataredirectlyinvolvedintheinstitutionalembedding asastartingpointtoestablishacross-sectoralapproachtoperinatal health.Whenthereisasolidcollaborationestablishedbetweenthis coresetofprofessionals,itispossibletoenrichthecross-sectoral approachwithperspectivesfromtheaforementioned stakehold-ers.Second,alimitationoftheresearchdesignisitsrelativeshort time span. Thetransition towards a cross-sectoral approach to perinatalhealthrequiresmultipletransformationsininstitutional structures,culture,andpractices,whichwillnotbeaccomplished inthetimeavailableforourresearchprogramme.Asocietal tran-sitioncouldtakedecades.AstheHP4All-3programmelaststhree years,anin-depthmonitoringofsuchtransformationscouldnotbe integratedinourresearchdesign.However,thetransitiontowards across-sectoralapproachtoperinatalhealthhasbeenstudiedsince 2010.BuildingontheinsightsofamongotherstheHP4All pro-grammes,thenational programme SolidStart waslaunchedby theMinistryofHealth,Welfare,andSportin2018.WithinSolid Start,municipalitiesthatwishtoparticipatereceivesupportand guidanceinimplementingexistingapproacheswhich areaimed ataddressinghealthinequitiesbefore,duringandafterpregnancy. This,aswellasthesupportprovidedbyPharostostrengthenand expandmunicipalactivities,ensuresthatthetransitionisfurther guided.In addition, weaimto monitorshortterm transforma-tionswithaquestionnaireoneyearaftercompletionoftheaction research.Wewillalsoorganiseaclosingsymposiumtoevaluate transformationswithintheparticipatingmunicipalities.Itwould beinteresting tofollowsomemunicipalitiesmore upcloseand

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(collaboratively) monitortheirtransitionprocess inthecoming years.

4. Conclusion/Policyrecommendations

Toconclude,theHP4All-3programmecanserveasanexample forothercountrieswithpersistent(perinatal)healthinequities.The designdescribedinthisprotocolcanbeusedbyothercountries toshapeacross-sectoralapproachto(perinatal)healthinequities, bothnationally,regionally,orlocally.Ourﬁndingswillthereforebe ofaddedvalueforinstitutionalactorsworkingforthenationalor municipalgovernment,aswellasinstitutionalactorsworkingin themedical,social,orpublichealthsector,bothintheNetherlands andabroad.

Our research approach along withknowledge dissemination acrossa largesetofDutchmunicipalitiescancontributetothe development of (inter)national action-agendas directed at sus-tainable approaches to (perinatal) health inequities. This will contributetoenablingchildrentodevelopintohealthycitizenswho canliveindependentlyandparticipateinsociety.

CRediTauthorshipcontributionstatement

LisaS.Barsties:Methodology,Investigation,Writing-original draft, Project administration. Leonie A. Daalderop: Methodol-ogy,Investigation,Writing-originaldraft,Projectadministration.

JacquelineLagendijk:Writing-originaldraft,Supervision.Frank vanSteenbergen:Conceptualisation,Methodology,Investigation, Writing -originaldraft,Supervision,Fundingacquisition.Jasper V.Been:Conceptualisation,Writing-review&editing, Supervi-sion,Fundingacquisition.LoesC.M.Bertens:Writing-review& editing.AdjaJ.M.Waelput:Conceptualisation,Methodology, Writ-ing-review&editing,Supervision,Fundingacquisition.Hanneke vanZoest:Conceptualisation,Writing-review&editing, Fund-ingacquisition.DerkLoorbach:Conceptualisation,Methodology, Writing-review&editing,Supervision,Fundingacquisition.Eric A.P.Steegers:Conceptualisation,Methodology,Writing-review& editing,Supervision,Fundingacquisition.

DeclarationofCompetingInterest

Theauthorsreportnodeclarationsofinterest.

Acknowledgements

The HealthyPregnancy4 All-3programme is funded bythe DutchMinistry ofHealth, Welfare andSport,The Hague [grant number326481];JasperV.Beenissupportedbyfellowshipsofthe ErasmusUniversityMedicalCentreandtheNetherlandsLung Foun-dation(4.2.14.063JO).Thefunderhadnoroleinthedesignofthe study,writingofthemanuscript,andthedecisiontosubmitthe manuscriptforpublication.

AppendixA. Supplementarydata

Supplementarymaterialrelatedtothisarticlecanbefound,in theonlineversion,atdoi:https://doi.org/10.1016/j.healthpol.2020. 12.013.

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