You might all be interested to read this article from the Daily Telegraph, hope I'm allowed to post it!
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Tuesday 28 January 2003t an
Women
Home births without hazards
(Filed: 24/01/2003)
Fewer caesareans and greater power for midwives... we could learn much from the Dutch, says Barbara Lantin
'It gave me a good start'
With one complicated birth behind her, Deborah Abrahams, 38, was determined to have her second child at home. Her wish was granted without the slightest fuss, and Flo arrived safely last November - in Amsterdam.
Deborah Abrahams gave birth to Flo at home. 'It was a totally different experience. It gave me a great feeling of strength'
Had Deborah and her husband Michael Blass - both British theatre directors - been living in Britain, their chances of achieving a home birth for Flo would have been minimal. The proportion of home births in this country has plummeted from 36 per cent in 1958 to two per cent today. In Holland, about 32 per cent of babies are born at home.
Nor is that the only difference in obstetric practice between the two countries: the caesarean rate has steadily climbed in Britain to 21.5 per cent, while in Holland, it is about 10 per cent. In Holland, an epidural is used in only six per cent of deliveries, compared with 24 per cent here.
Post-natal care is vastly different, too. Every new Dutch mother is entitled to a kraamverzorgster, a maternity assistant who stays for up to eight hours a day for eight days to help with the baby. The cost of this service - about £1,000 - is paid by the state or by health insurance.
The overall impression I gained from a recent whistle-stop tour of Amsterdam maternity services was that childbirth is much less medicalised. The Dutch system is based on a highly refined process of risk assessment carried out by the midwife on the client's past and present medical and obstetric history. It is the midwife who acts as gatekeeper, deciding - with reference to the bible that is the Dutch Obstetric Manual - who needs a hospital referral during pregnancy and childbirth.
"It is integral to Dutch culture that pregnancy and birth are normal events that can take place at home, unless complications occur," says Beatrijs Smulders, a midwife who runs a busy group practice in Amsterdam.
"We don't ask people where they want to give birth. In the end, nature decides for you and you don't have a choice. The safest place is where there will be the least intervention, because each intervention carries risks for mother and baby."
The role of the midwife in Holland is very different from that of her British counterpart. Here, most midwives are hospital-based NHS employees. In Holland, they are independent, although many work in group practices.
"We are seen as a separate profession with equal status to a GP or an obstetrician," says Sue Thompson, a British midwife who is working in Amsterdam. "Our judgment is respected."
Dr Maria Pel, a gynaecologist at the Academic Medical Centre in Amsterdam, agrees. "The important thing is for professionals to respect their own limits," she says. "For example, I am not interested in doing a normal vaginal delivery and I will not do it as well as a midwife because I will probably perform an episiotomy [a cut to enlarge the vaginal opening] too early."
Dutch midwives attend when their client in labour calls them. They check that all is well, give advice and aim to return when the woman is 8cm dilated, an approach that can seem shockingly relaxed to those who are not used to it.
Trust between client and midwife is crucial. "There is no pressure on us to listen constantly to the baby's heartbeat, nor is there a need, since we are working with a select group of women whom we know," says Smulders.
"The most important role for the midwife during the birth is to ensure that the woman is not disturbed, so that the physiology of labour can work as well as possible."
Dutch women, unlike many of their British counterparts, do not expect to be given drugs to ease the pain of labour. Epidurals are used only in caesarean deliveries, and gas and air is unknown.
"We know women can handle pain and that they need pain," says Smulders. "And they know that if the pain is abnormal, pethidine will be administered. But midwives cannot give pethidine, so a transfer to hospital will be necessary, which tends to discourage its use."
About a third of women who plan home births are transferred to hospital in labour. Because Holland is a relatively small country with good roads, if an ambulance is necessary, it will arrive swiftly and the journey to hospital will normally take no more than 15 minutes.
British women are anxious that if complications occur during a home birth, they will not be able to reach a hospital in time - fears that are usually unfounded, says Rick Porter, consultant obstetrician at the Royal United Hospitals, Bath.
"The things that go wrong in a vast majority of cases, particularly with first babies, do so slowly or with plenty of warning, so you have time to make your transfer," he says. Bath and its surroundings have one of the highest rates of non-obstetric births in Britain: 34 per cent take place at home or in low-tech, midwife-led community units. "There was a feeling in the Fifties and again in the Seventies and Eighties that birth was dangerous and should be treated as a medical event," says Mr Porter. "People thought that the only way to have a safe birth was surrounded by machines in a hospital, although there wasn't a huge amount of evidence to support this view. Nobody has demonstrated that it is any less safe in a community unit, though they have tried again and again to do so."
Holland has no litigation culture, and the care of brain-damaged children is paid for, not from insurance claims, but by the state. This may be one reason why the Dutch are slower to reach for the scalpel and perform caesareans.
"The cost to a healthcare trust of carrying out 2,000 deliveries a year is about £4 million - the size of one large settlement," says Mr Porter. "These big claims are going to influence the way people think. However, we have not been able to demonstrate that we have fewer brain-injured children as a result of performing more caesareans."
Some British hospitals - notably in Truro and Shrewsbury - have demonstrated that caesarean rates can be kept down without compromising safety. A small number of midwife-led units have embraced the concept of non-managed births in comfortable, low-tech surroundings.
Some midwives do try to persuade clients that babies do not pop out in an hour - as they seem to on television soaps - and that a long and possibly painful labour will do no harm to mother or child.
Perhaps the tide that brought us the medicalisation of childbirth may be slowly turning.
'It gave me a good start'
For the first five days after her second daughter, Flo, was born, Deborah Abrahams stayed in bed, resting and feeding. This luxury was made possible by the presence of a maternity assistant paid for by the state.
Holland has 6,000 kraamverzorgsters, who spend up to eight hours a day for the first eight days with mothers and newborns. They also assist at home births. Their primary postnatal duties are to help with feeding, bathing and other aspects of baby care, but they also do light household chores and look after other children in the family.
"I know I would have been much more tempted to get out of bed and do the washing if I had not had a maternity assistant," says Deborah, who arrived in Amsterdam on a coach from London with her husband, Michael, 13 years ago.
"In the first few days, she looked after me, checking how far my womb had gone down and giving me lots of advice about the baby. She showed me how to bath Flo, using the strange vertical baths they have here. Then she started organising the washing, folding the clothes and making me lunch.
"It gave me a really good start. I was able to get my energy back, so that I could enjoy Flo instead of feeling completely washed out from the birth."
Deborah and Michael's first child, Daisy, was born in hospital after complications in labour. "Having Flo was a totally different experience. It gave me a great feeling of strength. Afterwards, I thought: if I can do that, I can do anything. It was amazing."
12 November 2002: A question of choice? [insurance for caesareans]
19 July 2002: Scarred for life? Not these mums [caesarean birth scars]
29 October 2001: Why more babies are taking the short cut [increase of caesareans]
25 May 2001: Men give birth to a new career [male midwives]
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