Journal of Midwifery & Women’s Health www.jmwh.org Original Research Differences in Quality of Antenatal Care Provided by Midwives to Low-Risk Pregnant Dutch Women in Different Ethnic Groups Anushka Chot´ e, PhD, Christianne de Groot, MD, PhD, Ken Redekop, PhD, Renske Hoefman, MSc, Gerrit Koopmans, PhD, Vincent Jaddoe, MD, PhD, Albert Hofman, MD, PhD, Eric Steegers, MD, PhD, Margo Trappenburg, MD, PhD, Johan Mackenbach, MD, PhD, Marleen Foets, PhD Introduction: The objective of this study was to evaluate whether differences existed in the adherence to the Dutch national guidelines regarding basic antenatal care by Dutch midwives for low-risk women of different ethnic groups. Methods: This was an observational study using data from electronic antenatal charts of 7 midwife practices (23 midwives), participating in the Generation R Study. The Generation R Study is a multiethnic, population-based, prospective, cohort study that is investigating the growth, development, and health of urban children from fetal life until young adulthood. The study is conducted in Rotterdam, The Netherlands. The antenatal charts of 2093 low-risk pregnant women with an expected birthing date in 2002 through 2004 were used to determine the mean quality of antenatal care scores for 7 ethnic groups. These scores reflected the degree of adherence to the guidelines regarding 10 tests and examinations. Results: Few differences between ethnic groups were found in adherence to the guidelines that addressed the obstetric-technical quality of antenatal care. This finding applied more to nulliparous than to multiparous women. Adherence to guidelines was not always better in the antenatal care provided to native Dutch multiparous women when compared to other ethnic groups. Midwives adhered well to the guidelines regarding most tests. For all women, irrespective of ethnic background, hemoglobin was not measured as often as recommended, and this was especially the case for Moroccan, Surinamese-Creole, and Dutch-Antillean multiparous women. Discussion: The poorer adherence regarding screening for hemoglobin needs further investigation, as women with African or Mediterranean heritage are more at risk for hemoglobinopathies. However, in general, midwives adhered well to the clinical guidelines regarding most tests irrespective of the ethnic background of the pregnant women. When differences were present, these were not systematically less favorable for non-Dutch pregnant women. J Midwifery Womens Health 2012;57:461–468 c  2012 by the American College of Nurse-Midwives. Keywords : adherence, antenatal care, ethnicity, guidelines, quality of care INTRODUCTION Pregnancy outcomes are traditionally considered as outcome indicators of the quality of antenatal (and maternal) care. 1,2 A recent study by Handler et al 3 found that lower quality of antenatal care, as measured by a decreased degree of adher- ence by caregivers to the recommended content of antenatal care, was significantly associated with lower birth weight and preterm birth. Pregnancy outcomes are usually worse in mi- nority ethnic groups. 4 The purpose of this study was to inves- tigate whether differences exist in the quality of care received by women from different ethnic groups. BACKGROUND In Western societies, the risk of adverse pregnancy outcomes, including perinatal and maternal mortality, preterm birth, and low birth weight, is higher among ethnic minority and migrant women when compared to that of the native popu- lation. 4-7 This raises the question of whether there are ethnic differences in the quality of the antenatal care provided. Address correspondence to Anushka Chot´ e, Erasmus University Rot- terdam, PO Box 1738, 3000 DR, Rotterdam, The Netherlands. E-mail: chote@bmg.eur.nl Studies that address the quality of antenatal care often fo- cus on quantifiable measures, especially the timing of initia- tion of antenatal care, and subsequent adherence to the rec- ommended number of visits by the pregnant women. 8,9 Even in countries where antenatal care is available to all pregnant women, migrant women enter antenatal care later than native women. This is true even when gravidity, parity, and mater- nal age are controlled for. 9 Studies that investigate the con- tent and quality of antenatal care often make use of maternal reports. 10-13 These studies usually focus on variables such as overall satisfaction, experiences of time spent obtaining ante- natal care, provider continuity of care, or respect and commu- nication problems. Other studies have evaluated the quality of antenatal care by assessing how well care providers adhere to established guidelines for specific services, especially with respect to health education such as smoking cessation. 14 Studies that ad- dress adherence to the technical aspects of antenatal care are uncommon. Existing studies that do assess the technical qual- ity of care usually are confined to specific screening for prena- tal syphilis, 15 group B streptococcal carrier status, 16 sexually transmitted infections, 17 and infectious diseases in general. 18 Few studies have been performed that take into account all technical procedures included in antenatal guidelines. 19-21 1526-9523/09/$36.00 doi:10.1111/j.1542-2011.2012.00169.x c  2012 by the American College of Nurse-Midwives 461