Homebirth advocates in the US, the UK, Canada and elsewhere have long considered the Netherlands to be a paradise of homebirth midwifery. They haven’t been paying attention; Dutch perinatal death rates were found to be among the highest in Western Europe and Dutch mothers have been abandoning homebirth in droves.
When I started Homebirth Debate, the predecessor to this blog, almost 11 years ago, the Dutch homebirth rate was 30%. By 2015 it had dropped to 13%. Why such a precipitous drop in a relatively short time?
[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]US midwives cite the Netherlands experience as proving the safety and desirability of homebirth at the same time that Dutch women are deciding the opposite.[/pullquote]
From Dutch News:
According to the Dutch association of gynaecologists NVOG the fall in home births is connected with an increase in the demand for pain relief which cannot be administered at home.
Dutch women are apparently deciding that the comfort of pain relief in labor is more important to them than the comforts of home.
In addition:
More ‘honest’ information also contributed to home births becoming less popular. ‘Time was when having your baby at home was the norm. But now women are told that this isn’t always the best option. Half of women who choose a home birth end up in hospital,’ NVOG chair Jan van Lith told the paper.
The honest information was obtained from a number of papers that showed that the perinatal mortality rate at low risk homebirth was higher than at high risk hospital birth. The findings led the authors to conclude:
We found that the perinatal death rate of normal term infants was higher in the low risk group than in the high risk group, so the Dutch system of risk selection in relation to perinatal death at term is not as effective as was once thought. This also implies that the high perinatal death rate in the Netherlands compared with other European countries may be caused by the obstetric care system itself, among other factors. A critical evaluation of the obstetric care system in the Netherlands is thus urgently needed.
An economic analysis published several years later demonstrated that falling homebirth rates were associated with improved perinatal outcomes:
Historical data show that 7-day (28-day) mortality declined from 4.25 (5.35) deaths per 1,000 births in 1980–1985 to 2.42 (3.18) deaths in 2005-2009, while the share of hospital births increased from 61.25 percent to 72.06 percent. In addition, using a decomposition … we find that most of the mortality decline between 2000–2008 comes from newborns over 2,500 grams, who are more likely to be low-risk and thus eligible for home births.
Indeed:
Back-of-the-envelope calculations suggest that the rise in hospital births explains roughly 46– 49 percent of the reduction in infant mortality in the Netherlands between 1980 and 2009.
Not surprisingly, that’s not how Dutch midwives, who highly value the opportunity to act autonomously at home, see it. They too were interviewed for the Dutch News article:
Midwife association KNOV chair Mieke Beentjes thinks the problem lies with women being given the wrong information. ‘In 2010 baby mortality in the Netherlands was the subject of much heated debate and at the time an unjustified link was made with home births. The effect of that is still noticeable,’ Beentjes told the paper.
The wrong information? Beentjes almost certainly believes that the right information comes from a series of papers by midwife Ank de Jonge, such as this one, that claim to show that homebirth with a midwife in the Netherlands is as safe as hospital birth with a midwife.
But as I have noted in the past, the combined intrapartum/neonatal death rates for both groups was higher than would be expected for a group of low risk women in midwifery care. Indeed, it is higher than the intpartum/neonatal death rate of 0.74/1000 (nullips) and 0.46 (multips) previously reported for high risk patients under the care of Dutch obstetricians.
De Jonge, of course, has been careful to leave out the death rates of Dutch obstetricians, though she has acknowledged that previous studies have shown midwifery mortality rates for babies of low risk women to be higher than those of obstetricians caring for high risk women.
So women who informed of the risks of homebirth are NOT being given the wrong information; they are being given all the relevant information and are choosing accordingly.
How ironic then that US, UK, Canadian and other midwives point to the Netherlands experience as proving the safety and desirability of homebirth at the same time that Dutch women are deciding the opposite.
