Homing in on the Dutch birth debate

Interested in home birth, hospital birth or Medicare-funded private midwifery care? Questions or comments? Email Melissa Maimann or call 0400 418 448. I'm reading a fantastic book at the moment, "Proactive Support of Labor" which speaks of the very issues raised in the article below. I think there are some very valid points that we need to consider as we reform maternity care in Australia.

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With the highest rate of home births in Europe, the Netherlands also has the highest rate of death among newborns, so how safe are home births?

DUTCH MOTHER Petra de Haan delivered three of her four sons at home, doing what generations of women before her in the Netherlands had done, gritting her teeth while “mother nature” took its course.

Stoic and strong, typical of women in her northern province of Friesland, she describes how home births were always part of “our culture, as natural as breastfeeding, decided on without any discussion, we believed it was the right way, the only way”.

Looking back now she realises that her first delivery ... could have gone horribly wrong. “The labour went on much too long. I lost a lot of blood, the baby’s head was so big. But there was no indication of that beforehand as no echogram was done, you only had one in exceptional circumstances in Holland ... ”

Ultrasounds are not routine in the Netherlands; even if they were, a 19-week scan would not accurately predict a baby's weight at birth. In fact, there's no truly accurate way to predict a baby's size before birth. It's often a matter of awaiting labour and seeing how it goes.

That was 22 years ago and Petra ... remembers the great contrast between her first and second home births.

“It all went so well the second time, I was pottering around in labour, drinking a cup of tea at my kitchen table, in my own familiar surroundings, much better than in a hospital full of bright lights, noise and sick people.”

... the birth of her third, Jesse, who weighed over 10lb, was “awful”, with extensive cutting, loss of blood and stitches afterwards on that same bed in the family living room. Her fourth and youngest son, Ydwer (12), was born with a heart condition in hospital.

With the highest modern rate of home births in Europe, the Dutch are held up as an example to other countries ... whenever it is suggested that more women would choose to give birth at home if the appropriate infrastructure was in place.

There is growing evidence, however, to show that Dutch women are falling out of love with home births and fast. Only a few decades ago, more than half of all women ... deemed “low risk”, were having their babies at home, assisted by a midwife ... But the rate of home births has dropped dramatically to 24 per cent ...

A number of reasons are given for the decline. Women are waiting until they are older to start families, increasing complications, immigrant mothers often prefer hospital birth, while less healthy lifestyles, including obesity and smoking, remove others from the “low- risk” category suitable for home births. Some doctors say women are choosing hospital birth because they want a full range of pain relief and quicker deliveries.

Champions of home birth ... are blaming negative media reports, which have raised questions about the safety of home births with “scare stories” and “muddled statistics”.

The powerful Dutch pro-home birth lobby and critics of the traditional system are at loggerheads. The figures, nevertheless, are disturbing. Last year, there were 1,700 still births and deaths among newborn babies, giving the Netherlands, among Europe’s highest rates, double that of Flanders (Dutch speaking Flanders across the border). Everyone agrees the figure is much too high.

The Health Ministry, which has long prided itself on the high quality of health and medical care in the Netherlands, has described as “worrying” the fact that the rate of death among newborn babies is higher than in other European countries.

To the public, this wrangling between the midwives’ sector, who operate independently within the system, and leading obstetricians and gynaecologists, who want more “intervention” and “medicalisation”, begs the question, who is right – are home births really that safe in Holland?

Prof Simone Buitendijk, head of the child health programme ... declares: “Yes, they are safe, even if we totally abolished them we wouldn’t make a small dent in the mortality statistics. It is about choice and it would be really sad if choice disappears.”

She believes there is a real risk of that now happening in Holland ... “The negative media coverage will influence some women and persuade them to have their babies in hospital instead of at home out of fear.” In her view, for low-risk women, not in danger of having complications, “home birth is the best possible way of being properly in control”.

“Midwives in the Netherlands offer an excellent level of care and are key to risk referral because they ensure that those opting to give birth at home fall into the low-risk category.”

Prof GHA Visser, a leading obstetrician at Utrecht Medical, is among a group of senior specialists who have criticised the system, claiming that intervention is too slow and the country has “fallen asleep on the job”.

He claims that midwives often neglect to inform many women wanting home births that there is a strong likelihood they will end up being taken to hospital after labour starts.

“Over 50 per cent of first-time deliveries end up in hospital, in rare cases there are tragic circumstances and the baby dies. We know midwives do a very good job, but there is this mentality among GPs as well that intervention should be avoided and the traditional philosophy goes on.

“The fact is that not all pregnancies are normal, and symptoms and warning signs are missed, the midwives are clinging on to a culture which used to work well but clearly has shortcomings also,” he says.

“... It’s a question of better co-operation between first- and second-line care givers.”

An independent inquiry has been launched into why the Dutch have one of the highest perinatal mortality rates compared with the rest of Europe. The big question is whether that will vindicate the Netherlands’ unique home births system.

Some believe there is no going back and more and more women will end up in hospital, with an increase in epidurals and Caesarean sections, even for those in the low-risk category, increasing the risk of maternal mortality in the process.

Petra de Haan is watching developments with interest. Like many other women in the Netherlands she believes childbirth should be as natural as possible, that the pain helps in the bonding process with the newborn infant, but she wonders whether tomorrow’s Dutch mothers will share that view.

Melissa Maimann, Essential Birth Consulting 0400 418 448