Dutch abandon home birth

A recent article informs us that:

RISK OF DEATH INDUCES DUTCH WOMEN TO ABANDON HOME BIRTHS

It goes on to say that in the last 10 years, the percentage of Dutch women who are giving birth in hospitals has risen from 37% to 75%. They state that reasons for this include:

  • concern at the disproportionally high baby death rate in home birth
  • the rising popularity of epidurals, a pain relief option in labour which is only available in hospitals.
  • The Dutch system of home births has been promoted as one which other countries should emulate, including New Zealand. However, last year a large study found that the perinatal death rate was greater in low risk women who were cared for by midwives than in higher risk women who were cared for by obstetricians. The researchers concluded that the Dutch system of risk selection is not as effective as was once thought.

    I have read the study that has been referred to above. The study concludes that:

    The main finding of this study is that the Dutch obstetric system that is based on risk selection and obstetric care at two levels may not be as effective as was once thought. The Dutch obstetric system itself possibly contributes to the high perinatal mortality compared with most European countries. We found that delivery-related perinatal death was significantly higher among low risk pregnancies in midwife supervised primary care than among high risk pregnancies in obstetrician supervised secondary care.

    The Dutch system relies on a risk assessment. Women are either in primary care or secondary care. Women who are in primary care have midwifery care and they have the option of home birth or hospital birth. The Netherlands currently has a 22% homebirth rate. Women with risk-associated pregnancies have obstetric (secondary) care and give birth in hospital. They might have issues such as high blood pressure, diabetes, twins, a previous caesarean and so on. Overall, 49.5% women remain in primary care at the start oaf labour, and 35% women remain in primary care throughout labour and birth. 65% women either start their pregnancy in secondary care or are transferred to secondary care at some stage in their pregnancy or labour. It is a system that has worked well for many years.

    However, the study has found that the intrapartum (labour and birth) death rate among term babies without congenital malformations (birth defects) was as follows:

  • For babies who started labour in primary (midwifery) care: 0.96/1000
  • For babies who started labour in secondary (obstetric) care: 0.24/1000
  • For births that took place in primary care: 0.91/1000
  • For births that took place in secondary care: 0.45/1000
  • For births that were referred from primary care to secondary care in labour: 1.09/1000
  • Babies of women who were referred from a midwife to an obstetrician during labour had a 3.66 times higher risk of delivery-related perinatal death than did infants of women who started labour supervised by an obstetrician.

    The study concludes that:

    The obstetric care system in the Netherlands may contribute to the high perinatal mortality

    and:

    the Dutch system of risk selection in relation to perinatal death at term is not as effective as was once thought.

    I suggest that there is another major issue involved that has been ignored in the above suggestion. In the Netherlands, midwives book 105 women per year. You read that correctly. While in Australia, midwives care for around 20-40 women per year, in the Netherlands it's a huge caseload of 105 women per year. Therefore it is impossible for the midwife to personally attend every labour for the duration. Instead, there is a system in place where the women are cared for by a Kraamverzorgenden who stays with the woman during labour and for the first week after the baby is born. This person does not perform any midwifery care but provides support to the woman. The midwife pops in and out every two or four hours to examine the woman and perhaps listen to the baby's heart beat - I say "perhaps" because there is no official guideline in The Netherlands that this ought to be attended at any specified interval. Hence the midwives check the baby's heart beat as and when they choose. Acknowledging that the midwife does not sit with each women in labour, it's plausible that the baby's heart beat would only be checked every two or four hours. The standard of care for the UK and Australia is that the baby's heart beat should be checked every 15 minutes in labour and after every contraction in the second stage of labour when the baby is being born. This is identified in the article:

    Of major concern is the fact that the highest mortality was among the infants of women who were referred from primary care to secondary care during labour because of an apparent complication. Hypothetically, this high mortality could have several causes ... diagnosis in primary care can be delayed because the midwife is not always present during the first stage of labour and fetal heart beats are often checked only every two to four hours.

    I am interested in why this fundamental issue has not been addressed; rather, a complete review of a system that is in place in other countries - successfully - has been called for?

    Visit my website to explore home birth, hospital birth and Medicare-funded private midwifery care.