Risks of homebirths: latest Dutch research published today

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This article was in today's Volkskrant
www.volkskrant.nl/vk/nl/2672/Wetenschap-Gezondheid/article/detail/1044490/2010/11/03/Babysterfte-hoog-door-falend-systeem.dhtml

it is in Dutch but summarises an article published in the British Medical Journal.

AMSTERDAM - Women who get prenatal care from midwives face more risk than women who get obstetric care from the start.When women start their giving birth with a midwife, they have two times more chance that their baby dies then if they had given birth with an obstetrician.

If a woman during a homebirth have to go to hospital or is passed from midwife to obstetrician, then the chance that her baby dies is four times as much.

This has become clear from research from the University Medic Centre (UMC) Utrecht that has been published today in the British Medical Journal. The Netherlands has been facing years of relatively high infant mortality. The new figures demonstrate the shortfalls of its system. The Netherlands has one of the highest levels of infant mortality, approximately 1 in 100 babies dies at/around birth. Only France and Latvia have worse figures.

Gobsmacked.

"Research from the Netherlands - which has a high rate of home births - found no difference in death rates of either mothers or babies in 530,000 births".
Study reported by BBC, which was set up to look at high levels of babes dying whilst or just after giving birth. It found no risk posed by homebirth to non-risk mums-to-be.

Ditto what others said- if any woman is passed in an emergency from a midwife to an obstretician, the risk is of course multiplied. That's just the very definition of an emergency.

AP - me too. Lovely lovely midwife who gave me fantastic care and kept in touch to make sure I was OK after DS2's eventful arrival into the world (nothing to do with birth btw, long story...).

I have received nothing but excellent healthcare generally in the Netherlands. I also know their practice is very 'evidence-based' so all research is very carefully interpreted.

You are right that it is easier to get a hospital birth in the cities now :) It is still bad in some of the regions though.
There's a massive campaign and public debate that's been going on in the Netherlands because of the high mortality rates and anti pain relief attitudes - there is a writer and campaigner called Heleen van Royen who wrote a best seller -The Happy Housewife - about a woman driven insane by the agony of childbirth. It provoked an outcry and people started calling for reform. Here's a quote from her interview "The midwives say the pain is good for bonding with your child. It's medieval." The Netherlands has one of the leading centres for the study of post traumatic stress disorder after childbirth at Utrecht.
There was a study comparing Netherlands and Belgium which has a much respectful system maternity system ( you can have a homebirth, hospital birth, epidural, or whatever you want) and surprise surprise the Belgium system came out better! But that?s the answer isn?t it? Women want different things and a good maternity service reflects that.

Sorry I have posted the reply further on (Sunday 7th). You are right though, it is easier to get a hospital birth now - certainly in the cities.

BTABODS - I'm not in one of the big Randstad cities though... I'm in a provincial backwater 5 miles from the German border - the Dutch equivalent of the Norfolk Broads!

I do find it somewhat ironic though that mn (to me) is full of lentil-weaving yoghurt-knitting medal-wearers who voluntarily turn their backs on pain relief and instead "visualise a perfect pain-free birth" - yet when NL hb prefers it as standard it's "barbaric".

I must admit, I wasn't overly thrilled at not being give painkillers at home, however, because my birth was going to be at home I was going to have a glass of wine in the bath, wander around and take things at my own pace. At any point during the hb process, I still could've asked for a transfer.

Everyone should be entitled to choose the type of birth they wish for whether it be at home and all natural or a fully medicalised, doped to the eyeballs type of birth.

What I found difficult was to actually choose tbh. With my first, I asked midwife for advice and all I got was "up to you".

I suppose what I wanted was someone to tell me which was the safest, quickest and most painfree type of birth.

Unfortunately no one can tell you that in advance. All types of childbirth carries risks for mother and baby. Right from the full on natural to the elective c section.

I don't think there is a "best type of birth" - only a best birth for you and that means you have to make your own informed choices.

In that respect it would be nice to get more information than just the basics on types of birth while you're a first timer in antenatal. It have been great to chat to more mums about their types of birth before hand.

I did talk to friends and neighbours who recommended anything from elective c section to home birth.

I asked for a water birth but ended up with a fully medicalised long labour followed by an emergency c section. This was exactly what I didn't want. I would have been better off with an elective section (brow presentation missed during labour so lots of pushing with no result).

God another witch-hunt
The US has the most technocratic, medicalised system in the world and they spend more money on "birth" than any other country.
It has the second worst mortality rate in the world and its maternal mortality rate ranks 40 something after some African countries.
I saw US led "research" earlier this year "stating" that homebirths worldwide were risky. I was like this as I read it.

Great post, skandi
"Everyone should be entitled to choose the type of birth they wish for whether it be at home and all natural or a fully medicalised, doped to the eyeballs type of birth."

That's what I was tryingto say ut didn't say it as well as you:)

"Belgium which has a much respectful system maternity system"

From what I've heard most women in Belgium have highly medicalised births and episiotomy is the norm.

Am I right in thinking that women in the Netherlands have far less antenatal screening than women do in the UK? Sure that has something to do with the higher mortality figures.

titty You have to be joking about antenatal screening! I am consistently shocked at the lack of care I read about on mn...

1. First appointment at 7 weeks (get to know you)
2. 9 weeks - bloods taken
3. 10 weeks - first scan
4. 14 weeks - regular check-up (could've had NF tests at this point but I declined)
5. 18 weeks - regular check-up
6. 20 week scan
7. 22 weeks - regular check-up
8. 26 weeks - regular check-up
9. 28 weeks - growth scan

10. 30 weeks - regular check-up 11. 33 weeks - regular check-up 12. 36 weeks - regular check-up (admitted to hospital that day)

Would've been weekly after 36 weeks.

And, as previously stated, the same midwife each and every time.

Should've added that from (and including) the 26 week scan I had my wee tested for sugars & proteins each and every time.

AP agree again. And you get the SAME with a second pregnancy - and al subsequent None of this "oh you've done it before so we'll see you less" business.

My midwife could also carry out scans, and I even had my dating and anomaly scans with her. Had she seen anything I would have been sent to the main hospital in Utrecht to see a consultant. The care was exemplary.

And we could discuss "kraamzorg" but then we're really getting off the point!

Yes, I had my dating scan with my midwife - anomoly scan was done elsewhere but still in the neighbourhood. Got to hear the hb every time too which was great.

Oh god yes, kraamzorg - I thought I'd hate it and actually sent them off home early the first day. By the end of the week I'd negotiated them to stay more days!

I do worry about how information gets out there though. Last year there was a woman on mn who was "scared" of moving to NL because she had a SN child and had heard that NL has legalised euthanasia... she seemed to be under the impression she'd nip in to the doctor to get a prescription for penicillin and come home with a corpse instead. :(

tittybangbang - I don't know who you are talking to but Belgium is one of the best countries in Europe for giving a woman the choice of high quality care in hospital or out of it.

In Flanders there are birthing houses, and several sets of independent midwives including the Bolle Buik who are highly experienced in home and water births. Maybe my experience is a statistical anomaly but I know 9 woman who have had home births including a GP and a midwife.

And if you want a hospitalised birth or if you have to have one, then the hospitals are great.

It does shock me when I see on MN women in the UK who are virtually ignored for much of their subsequent pregnancies or if they are overdue.

In Belgium I was having daily scans because I was nearly a week overdue.

I loved the way the kraamzorg lady cleaned my bathroom and changed my sheets! And made breakfast out of nothing in my kitchen. I honestly don't know how they do that...

They arrived one morning and I went to the loo, pulled down my pyjama bottoms and there was a "blood explosion" - I burst in to tears and they just showered me then popped me in to bed. I woke up to a spotless bathroom - I dread to think how I'd have felt if I'd had to get down on my hands & knees to fix all of that. Amazing ladies!

Undutchable - just hours after giving birth, my krammzorg lady was sorting out my wardrobe, showing me how to fold fitted sheets! I still haven't got a clue how to fold them! My house has never been so tidy as when she was here. And she made us food - her stoofvlees with beer was delicious.

having lived in US, UK and holland maybe i can provide my "reading" of the data.

I believe that in UK home birth is safer, given how bad the NHS is.... at least they won t kill your baby with MRSA (recently happened at a hospital in London were 6 babies died of it) or stitch you up in the wrong way

I'm sure that in the US is at least a much better experience to give birth at home given how much they stuff you with medical treatments that you don't need just to make money on you.

As in Holland the healthcare is actually really good and they go very mild on medication, i believe it is much safer and more pleasant than homebirth !

A response to the research:

"Too early to question effectiveness of Dutch maternity care system
Ank De Jonge, senior midwife researcher Ben Willem Mol, Birgit Y Van der Goes, Jan G Nijhuis, Joris A Van der Post, Simone E Buitendijk
Midwifery Science, AVAG and the EMGO Institute for Health and Care Research, VU University Medical C
With interest we read the study from Evers et al. on perinatal mortality and morbidity in the Utrecht region, one of the 12 provinces in the Netherlands. This is the first study ever to show a higher mortality rate among births that started in primary care compared with secondary care. We have concerns about the methods used.

First, although the title suggests that this is a prospective cohort study, the entire population at risk has been defined retrospectively and was based on postal codes of the catchment area of one university hospital. All intrapartum and neonatal deaths were included from hospitals and midwifery practices within this area, but potentially not all births. Midwives in practices at the periphery of the catchment area will also care for many women in neighbouring regions. These births have not been included in the study, unless the baby died. This will artificially inflate mortality rates in midwifery practices.

Second, the study was conducted in only one region in the Netherlands. The intrapartum and neonatal mortality rate was twice as high as in recent national studies among women in primary care at the onset of labour (1.39 versus 0.65 and 0.52 per 1000)1;2. Although classification bias and underreporting may have played a role in these retrospective studies, it is unlikely that half of all deaths would have been missed. In another prospective study of perinatal mortality cases only 3.5% additional cases were found as compared to national registration data 3.

Strikingly, in Evers' study 67% of all babies that died during labour were born in primary care. This means that either the midwife noticed fetal distress too late to refer a woman because the birth was imminent or a deceased baby was born so fast that the midwife arrived too late to a woman's home. It is very surprising that these situations were much more common than referral before birth. In Amelink's national study, only 5% of intrapartum deaths were among births that took place in primary care 1. This discrepancy suggests that the study sample may be rather different from the national population.

Given the limitations of the study, the conclusion that labour starting in primary care carries a higher risk of delivery related perinatal death compared to labour starting in secondary care is premature from a scientific point of view. The authors correctly state that "their findings are unexpected and deserve further evaluation". Previous audit studies did not find that features of the Dutch maternity care system were related to preventable perinatal deaths 3;4. The results of Evers' study call for an urgent review of all mortality cases in the audit study announced by the authors. In addition, perinatal outcomes in other regions need to be examined. Ideally, a large national prospective cohort study should be conducted. The suggestion that "the obstetric care system in the Netherlands possibly contributes to the high perinatal mortality rate" can not be made based on these data alone.

(1) Amelink-Verburg MP, Verloove-Vanhorick SP, Hakkenberg RM, Veldhuijzen IM, Bennebroek GJ, Buitendijk SE. Evaluation of 280,000 cases in Dutch midwifery practices: a descriptive study. BJOG 2008; 115(5):570- 578.

(2) De Jonge A, Van der Goes BY, Ravelli AC, Amelink-Verburg MP, Mol BW, Nijhuis JG et al. Perinatal mortality and morbidity in a nationwide cohort of 529,688 low-risk planned home and hospital births. BJOG 2009; 116(9):1177-1184.

(3) Wolleswinkel-van den Bosch JH, Vredevoogd CB, Borkent-Polet M, van EJ, Fetter WP, Lagro-Janssen TL et al. Substandard factors in perinatal care in The Netherlands: a regional audit of perinatal deaths. Acta Obstet Gynecol Scand 2002; 81(1):17-24.

(4) Bais JM, Eskes M, Bonsel GJ. [The determinants of the high Dutch perinatal mortality in a complete regional cohort, 1990-1994]. Ned Tijdschr Geneeskd 2004; 148(38):1873-1878.

Competing interests: None declared