Integrated cross-sectoral collaboration for pregnant women and (expectant) parents in a vulnerable situation: the Solid Start Integrated Approach in South Limburg, the Netherlands

South Limburg is one of the regions in the Netherlands that has faced health and participation disadvantages for many years. Residents of South Limburg live shorter lives and live fewer years in good health [1]. An important explanatory factor is the lower educational level and socioeconomic status of the population [1, 2]. Often, this disadvantage begins early in life and is accompanied by increased risks of preterm birth, low birth weight, and health and developmental issues in children [3, 4].

Despite steady progress over the years, the number of children born preterm and/or with low birth weight remains higher in South Limburg compared with other parts of the Netherlands. This issue was recognized not only by maternity care professionals (such as midwives, obstetricians, and pediatricians), but, since 2018, also by municipalities based on regional and municipal data on preterm birth and/or low birth weight. As the first region in the Netherlands, South Limburg formed a Solid Start Regional Coalition (hereafter “Regional Coalition”) at the end of 2018. This coalition consists of partners in the medical, social, and public health sectors (see Appendix 1 in the digital supplementary content) and its shared ambition is to provide more children with a solid start to life. This ambition was also included in the Regional Health Policy 2020–2023 of the sixteen South Limburg municipalities. In this policy, the Solid Start action program is one of the phases of the multiyear, regional program Breaking the Trend (Trendbreuk), which aims to reduce South Limburg’s health gap compared to the Netherlands with 25% by 2030 [5]. In line with the national Solid Start action program, regional collaboration was further expanded in the following years. This has been made possible by the partners’ own contributions in the form of human resources and with external sources of funding. The Dutch Healthy and Active Living Agreement (Gezond en Actief Leven Akkoord) and financial arrangements from the government provided further policy and financial support for the Solid Start approach from 2023 onwards.

The focus is on Solid Start, which spans from preconception to the child’s second year of life. A key goal of Solid Start in South Limburg is to strengthen the regional collaboration between partners in the medical, social, and public health sectors regarding early identification of psychosocial risks and provide tailored support to pregnant women, parents, and expectant parents in vulnerable situations.

In South Limburg, the risk of vulnerability is elevated among (potential) parents [6]. In line with the definition of the Erasmus Medical Center in Rotterdam, the Netherlands and the municipality of Rotterdam [7], South Limburg defines vulnerability as an imbalance between risk factors and protective factors (see Fig. 1). Tab. 1 provides an overview of possible vulnerabilities and protective factors, based on previous research [7, 8]. The definition categorizes vulnerability into four groups: self-reliant, potentially vulnerable, vulnerable, and highly vulnerable [7]. Although the focus in the Rotterdam definition is on the pregnant woman, in the Solid Start Integrated Approach South Limburg, we use a broader interpretation that includes her partner and the postpregnancy phase.

To strengthen the regional collaboration, initiatives were launched to bring professionals in the medical, social, and public health sectors together to improve screening, referral, and support for the target group. From 2019 onwards, grants from the Province of Limburg and the Dutch funding agency Netherlands Organization for Health Research and Development (ZonMw) were used to invest in network meetings, knowledge-sharing sessions, and meetings between professionals, managers, and directors of the three sectors to get to know each other, explore ambitions and interests, establish collaboration agreements, and identify promising ideas. In two research projects, new practices were developed that were implemented (see Box 1). Additionally, investments were made in scaling-up and ensuring sustainability of the interventions VoorZorg, Supportive Parenting (Stevig Ouderschap), and Pregnant Not Now! (Nu Niet Zwanger) in South Limburg. Inspired by an approach from another part of the Netherlands (Good Start—Opportunity for the Peat Colonies; Goede Start—Kans voor de Veenkoloniën), in 2022, the Regional Coalition proposed to integrate the developed tools, initiatives, and collaboration agreements more cohesively into a regional Solid Start Integrated Approach South Limburg (hereafter: Integrated Approach) (see Fig. 2; [9]).

The goals of the Integrated Approach are:

The Integrated Approach is centered around the aforementioned definition of vulnerability (see Tab. 1 and Fig. 1; [7, 8]). Depending on the degree of vulnerability, various options for support are offered. The Integrated Approach outlines the pathway from early identification of vulnerabilities to tailored support. Concrete working agreements and related forms are described in the Solid Start South Limburg Manual. The key components of the Integrated Approach are described below.

At the beginning of 2023, the sixteen municipalities of South Limburg, the two maternity care networks (Verloskundige Samenwerkingsverbanden), and the YHC approved the Integrated Approach, thereby committing themselves to collaborate in providing appropriate care and support to pregnant women, parents, and expectant parents in vulnerable situations. This support at the strategic/executive level marked a major milestone and was a prerequisite for further implementation of the Integrated Approach throughout the region. Municipalities, the maternity care sector, and the YHC became responsible for its implementation. Together with the Public Health Service South Limburg and the University of Midwifery Education & Studies (AVMU) in Maastricht, the Netherlands, they formed a working group (see Appendix 1 in the digital supplementary content), which was given the following assignments:

To support the implementation of the Integrated Approach, the working group developed a regional implementation plan. Three Solid Start project leaders will facilitate and support the implementation, also at the municipal level. The initial step in the implementation in 2023 was informing the stakeholders involved about the practices of the Integrated Approach through presentations at the Solid Start Local Coalition meetings, meetings between doctors and YHC nurses, and team meetings of social workers, youth care providers, and mental health professionals, among others. Additionally, all midwifery practices in South Limburg were visited in person, and meetings were held with hospitals in the region. This provided insight into the opportunities and challenges of integrating the Integrated Approach into existing professional and organizational practices. In 2024, these conversations continued with, among others, subregional GP organizations. In addition, implementation plans are being developed for each organization or professional group.

The Integrated Approach Implementation Working Group evaluates the implementation process, identifies barriers and facilitators, and proposes improvements to enhance the implementation and upscaling in South Limburg (such as for the digital psychosocial questionnaire and the Solid Start Multidisciplinary Consultation). The findings from the research projects are helpful in this regard.

Primary care midwives in South Limburg prefer a broad conversation instrument to identify women in a vulnerable situation rather than a validated screening instrument (such as Mind2Care, R4U, ALPHA-NL). Research conducted among ten midwifery practices indicates that the developed digital psychosocial questionnaire provides midwives with a comprehensive overview of pregnant women in vulnerable situations, allowing more time for discussing challenges and wishes. Pregnant women are generally willing to complete the questionnaire [10]. The research also reveals success factors for collaboration between midwives and YHC professionals, including personal contact and clear working agreements, a shared framework and definition of vulnerability (which fosters collaboration and a common language), well-defined roles, tasks, and responsibilities, interprofessional training, and adequate time and funding [8, 10]. Implementing the Solid Start Multidisciplinary Consultation in three pilot municipalities (Kerkrade, Landgraaf, and Vaals) has demonstrated that these multidisciplinary consultations better align support with the needs of families, which they also perceive as valuable.

At the same time, registration data show that the reach of the Solid Start Multidisciplinary Consultation and prenatal home visit of YHC remains low: The number of reported cases falls short of expectations based on the percentage of families and expectant families in a vulnerable situation. One of the explanations mentioned are varying degrees of engagement and knowledge among professional groups and their members regarding the Integrated Approach or parts thereof. Implementing and integrating new working practices require time and financial resources, and this is hampered by the fact that organizations and professional groups are bound by sector-specific legislation, funding, structures, and policies.

The initial findings of the research projects highlight areas for improvement. While professionals generally have a positive view of the Integrated Approach, there is also interest in expanding the Integrated Approach to encompass the entire Solid Start target group, focusing not only on perinatal care, but also on parents of children aged 0–2 years. In this age group, screening could be performed by early childhood education and care organizations, GPs, social workers, YHC providers, or mental health professionals.

Another area for improvement is the involvement of the target group in the development of the Integrated Approach. While some families have been interviewed about their experiences with the care and support provided, it remains difficult to engage families in participating in interviews through professionals. This may be because of reluctance among professionals, due to concerns about overburdening families or fear of compromising the relationship of trust between them and the client or patient.

Based on the development and evaluation of the Solid Start Integrated Approach in South Limburg, some important lessons learned are worth mentioning.

First, it is crucial to invest sufficient time in building relationships, understanding each other’s interests, and exploring opportunities for collaboration. This process can be initiated and facilitated by, for instance, Solid Start project leaders and members of the Regional Coalition. From the start, all relevant parties in the medical, social, and public health sectors should be involved in the various phases of development, decision-making, and implementation.

Second, securing the commitment of all participating parties in the medical, social, and public health sectors to adhere to the Integrated Approach is essential. While achieving integrated cross-sectoral collaboration within Solid Start is possible, it remains complex and time-consuming. As a result of governmental policy (Healthy and Active Living Agreement), structural financial resources are available for Solid Start, but these are insufficient. Therefore, municipalities and health insurance companies must also contribute financially, for example by facilitating extra time for professionals.

Third, developing the Integrated Approach in co-creation with the professionals responsible for its implementation is vital, allowing for aligning the approach as closely as possible with their existing daily practices. Involving the target group in this process is equally important. In South Limburg, families have been approached through professionals and were found willing to talk about their experiences with care or support. However, this approach has been insufficient to structurally engage the target group in the development and implementation of the Integrated Approach.

Fourth, paying attention to sustainable implementation is important, as well as monitoring the impact of working according the Integrated Approach and assigning the responsibility for the content of the Integrated Approach, preparation of an implementation plan, and monitoring to a multidisciplinary working group. Practice-based research helps to support further development and implementation.

Future plans for sustainable implementation of the Integrated Approach in South Limburg must, among other things, ensure that all professionals are aware of and apply the practices and agreements of the Integrated Approach. To achieve this, informational and educational strategies are used, such as regional (network) meetings, work visits, and a website containing all relevant information and contact details for professionals. Efforts are also focused on professional and interprofessional development (e-learning, peer consultation) to ensure adequate identification of vulnerabilities and overcome barriers (hesitance to act) when weighing vulnerabilities and protective factors, as well as providing social support. Finally, efforts are underway, in collaboration with municipalities and health insurance companies, to secure appropriate funding to cover the additional time required to work according to the Integrated Approach.

In South Limburg, a shared ambition exists to ensure a Solid Start for all children, which arises from a broad understanding of the need to jointly address health inequalities. Thanks to the efforts and enthusiasm of the professionals involved, along with commitment from all stakeholders, regional collaboration agreements have been made across the medical, social, and public health sectors: the Solid Start Integrated Approach. The regional program Breaking the Trend South Limburg and various research projects have been key drivers of this progress. Sustainable implementation of cross-sectoral collaboration in the chain of care requires ongoing monitoring of opportunities, challenges, and the impact of collaboration and implementation. Based on these insights, appropriate implementation strategies must be selected to ensure that the Integrated Approach is structurally embedded in the practices of professionals and organizations.