Societal Valorisation of New Knowledge to Improve Perinatal Health: Time to Act.

Academics have a public duty to use their research to promote improvements in patient care and health. Here, we argue that there is an imperative to translate recent compelling evidence demonstrating the importance of the periconceptional period in determining the health of future generations, into improvements in pregnancy-related care and perinatal health. Taking this action has the potential to interrupt cycles of deprivation and to reduce inequalities in health. These are among the biggest challenges in health care today. It has been known for three decades that maternal exposures influence fetal growth and development by programming of the health of the newborn. These changes persist into later life, and also affect health in the next generation, one example being the ongoing effects of undernutrition in those born or conceived during the Dutch Hunger Winter. It has become increasingly apparent that maternal characteristics not only affect fetal growth but also gametogenesis and embryonic development with lasting impact on health at birth and during childhood. Periconceptional paternal influences on sexspecific fetal growth and long-term health of the offspring are also beginning to be seen. The periconceptional period is therefore one of the most critical periods in the life course, initiating epigenetic programming determining perinatal health and wellbeing for generations to come. Perinatal health outcomes differ widely between countries, but even within high-income countries large differences in perinatal health outcomes exist. Perinatal mortality – as tip of the iceberg of perinatal morbidity – is an indicator of perinatal health. In cities like Rotterdam in the Netherlands, perinatal mortality in neighbourhoods ranges between 2 and 34 per 1000 births. Between 2006 and 2013 in Southampton in the UK, perinatal mortality across electoral wards ranged from 4‰ to 13‰, and an eightfold difference is observed in infant mortality rates across municipalities of Massachusetts, USA. Disparities in perinatal health outcomes are known to be related not only to differences in obstetric and medical risk factors but also to lifestyle, education, working conditions, experience of violence, geography and socioeconomic status of couples. Effects of poverty and deprivation on perinatal health are substantial and are seen across all immigrant and native European and US communities. Even after adjustment for determinants such as socioeconomic status, age, parity, race and ethnicity there remain increased risks associated with living in deprived neighbourhoods for perinatal mortality (20%), preterm delivery (16%) and fetal growth restriction (11%). Risk accumulation involving decreased literacy, lack of access to social facilities, health care, and support as well as exposure to urban environmental stressors including crime, noise, physical insecurity, inadequate housing, air pollution, and unemployment may also play a role. These factors provide a compelling case for the provision of new, comprehensive pregnancy-related care. As long ago as 1963, the WHO was calling for attention to those aspects of personal and community life, which have an impact on reproductive, perinatal and child health. This shift requires general practitioners, obstetricians and community midwifes to include routine assessment of non-medical risks such as those related to poverty as part of the process of risk analysis already carried out at the booking. To maximise benefits, there should be an equivalent mechanism for conducting such a risk assessment at some point prior to conception for couples. Analogous with the opportunity map of societal investment in health created by Correspondence: Eric A. P. Steegers, Department of Obstetrics and Gynecology, Erasmus MC, University Medical Center, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands. E-mail: [email protected] Commentary doi: 10.1111/ppe.12275 201