Dutch homebirth rate continues to fall

Homebirth advocates point to the Netherlands as an example of a country where homebirth is popular and safe, but Dutch women think otherwise. The Dutch homebirth rate, which has been falling for decades, continues its decline.

As reported in Dutch News:

Professor Jan van Lith of Leiden University’s teaching hospital told the paper media reports about the high perinatal death rate in the Netherlands were driving women to chose hospital births. The increase in demand for pain relief is also playing a role, he said.

In other words, Dutch women find the hospital (and obstetrician care) to be safer and more comfortable.

It’s not merely that perinatal death rates in the Netherlands are relatively high. The truly amazing fact is that Dutch midwives caring for low risk patient at home or in the hospital have HIGHER death rates than Dutch obstetricians caring for high risk women in the hospital.

That was the finding of the study Perinatal mortality and severe morbidity in low and high risk term pregnancies in the Netherlands: prospective cohort study published in a November 2010 issue of the British Medical Journal. The study was undertaken to investigate why the Netherlands has one of the highest perinatal mortality rates in Europe. The results of the study were nothing short of astounding:

Of the 60 antepartum stillbirths, 37 occurred in primary care and 23 in secondary care…

Twenty-two intrapartum stillbirths and 14 delivery related neonatal deaths occurred. Infants of pregnant women at low risk had a significantly higher risk of delivery related perinatal death (relative risk 2.33, 1.12 to 4.83), compared with infants of women at high risk whose labour started in secondary care under the supervision of an obstetrician. Infants of women who were referred to secondary care during labour had a 3.66 times higher risk of delivery related perinatal death than did infants of women who started labour in secondary care (relative risk 3.66, 1.58 to 8.46)…

That means that low risk women under the care of a midwife had more than DOUBLE the chance of perinatal death than high risk women being cared for by obstetricians.

This finding puts the results of the Dutch homebirth study into an entirely different light. Homebirth advocates are quick to cite Perinatal mortality and morbidity in a nationwide cohort of 529 688 low-risk planned home and hospital births as evidence that homebirth is safe because mortality rates at midwife attended births were the same whether they took place at home or in the hospital. But as several commentors pointed out at the time, the mortality rate in both locations (approximately 1/1000) was much higher than would have been expected for a low risk birth. For comparison, consider that low risk midwife attended hospital births in the US have a mortality rate of only 0.4/1000.

So what the Dutch homebirth study REALLY showed is that Dutch midwives have higher than expected rates of perinatal mortality at home AND in the hospital. Hardly an endorsement of either homebirth or midwifery.

Interestingly, health insurance companies report that the decrease in homebirth has not increased health care costs because women are willing to pay an out of pocket fee in return for the perceived increase in safety, not to mention the option of effective pain relief in labor.

This ought to be an object less for homebirth advocates. In the country with the highest rate of homebirth in the industrialized world, neither homebirth nor midwifery provides the lowest risk. That is only found in the hospital under the care of obstetricians. Dutch women know this and the popularity of homebirth has declined dramatically as a result.