Dutch midwives struggle to avoid accountability for high perinatal death rate

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Ank de Jonge thought that she had succeeded in showing that homebirth in the Netherlands is safe. She was the lead author on the paper Perinatal mortality and morbidity in a nationwide cohort of 529 688 low-risk planned home and hospital births back in 2009. The study showed that homebirth with a midwife in the Netherlands is as safe as hospital birth with a midwife. That triumph was very short lived.

A subsequent study, Perinatal mortality and severe morbidity in low and high risk term pregnancies in the Netherlands: prospective cohort study, was a stunning indictment of Dutch midwives. The study was undertaken to determine why the Netherlands has one of the worst perinatal mortality rates in Western Europe and the results were unexpected, to say the least.

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.

…[T]he Dutch obstetric care system is based on the assumptions that pregnant women and women in labour can be divided into a low risk group and a high risk group, that the first group of women can be supervised by a midwife (primary care) and the second group by an obstetrician (secondary care), and that women in the primary care group can deliver at home or in hospital with their own midwife… 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.

The validity of these observations have been acknowledged by Dutch midwives:

In 2011 Dutch midwifery is under a microscope. Maternity care in general in The Netherlands has come under scrutiny by governments, media, the public and care providers themselves after two consecutive European Perinatal Statistical Reports ranked The Netherlands among those with the highest rates of perinatal and neonatal mortality compared to other members of the
European Union (and Norway)…

… We have learned that infants born to women of low risk whose labour started in primary care with midwives had higher rates of perinatal death associated with delivery compared to those beginning labour in secondary care…

Obviously, the next step is to determine why Dutch midwives have unacceptably high rates of perinatal mortality, both at home and in the hospital. But some midwives, de Jonge among them, are still struggling to avoid responsibility for the terrible perinatal mortality rates, let alone improve them. de Jonge’s latest effort is a paper in the journal Midwifery Perinatal mortality rate in the Netherlands compared to other European countries: A secondary analysis of Euro-PERISTAT data.

The conclusion is bizarrely disconnected from the actual findings of the paper. The findings of the study do NOT absolve Dutch midwives and does not address homebirth in any way. Regardless, de Jonge inexplicably concludes that the findings mean that no changes in homebirth policy is necessary.

How did de Jonge analyze her data and what did she find? de Jonge, like many Dutch midwives, has suddenly discovered that perinatal mortality rates consist of premature babies as well as term babies. Reasoning that premature babies are cared for by doctors, de Jonge set out to show that the poor perinatal mortality rate of the Netherlands can be ascribed to poor care of premature babies. That’s not what she found.

Microsoft Word - Figure 2 high resolution

As you can see from the chart, the Netherlands has one of the worst perinatal mortality rates in Western Europe (All mortality rates are expressed as compared to the Dutch perinatal mortality rate.) Only Latvia and France have higher rates.

What happens when you break the data down by gestational age and compare mortality rates for term pregnancies?

Microsoft Word - Figure 3 high resolution

After restricting the analysis to term births, de Jonge found that the Netherlands has one of the worst perinatal mortality rates in Western Europe, although now they have the sixth worst rate, instead of the third worst rate.

In other words, de Jonge CONFIRMED that there is a serious problem with perinatal mortality in the Netherlands including the perinatal mortality rate at term. She CONFIRMED that there is significant evidence that Dutch midwives bear responsibility for the Netherlands poor perinatal mortality rate. But, bizarrely, that’s not what she concludes. She writes:

The relatively high perinatal mortality rate in the Netherlands is driven more by extremely preterm births than births at term. Although the PERISTAT data cannot be used to show that the Dutch maternity care system is safe, neither should they be used to argue that the system is unsafe. The PERISTAT data alone do not support changes to the Dutch maternity care system that reduce the possibility for women to choose a home birth while benefits of these changes are uncertain.

Of course the PERISTAT data can be used to show that the Dutch maternity system is not nearly as safe as it could be. Absent demonstrating that the population of Dutch pregnant women differs substantially from that of pregnant women in other European countries, that is the inevitable conclusion. And although perinatal mortality at term is “less terrible” than perinatal mortality overall, that is hardly a defense of Dutch midwifery. We already know that the reason that Dutch perinatal mortality at term is as high as it is because Dutch midwives caring for low risk women have higher perinatal mortality rates than Dutch obstetricians caring for high risk women.

In fact, we know from the BMJ study cited above that the perinatal mortality rate of Dutch midwives is more than double that of Dutch obstetricians. If the perinatal mortality rate of Dutch obstetricians (caring for HIGH risk women) was compared to the rest of Europe, Dutch obstetricians would have the second lowest rate in Western Europe!

de Jonge has CONFIRMED the poor perinatal mortality ranking of the Netherlands. She has CONFIRMED that Dutch midwives have poor perinatal mortality rates. She CONFIRMED that the data DO support changes to the Dutch maternity care system. She NEVER LOOKED at homebirth, and therefore she cannot draw ANY conclusions about Dutch homebirth, let alone the conclusion that homebirth is safe.

Most importantly, in my view de Jonge CONFIRMED that Dutch midwives refuse to accept accountability for their poor perinatal mortality rates. They are not the among the best in Europe. They are among the worst. The sooner they acknowledge reality, the sooner they can start making the improvements that are needed to save babies’ lives.