Dutch midwives struggle to avoid accountability for high perinatal death rate

Who me

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.

  • IT

    Dr. Amy does not seem to be aware of what confidence intervals are. On the odds ratio graphs you are showing only the scores with confidence intervals (the thin black lines extending from the data points) that do not cross the line corresponding to 1 (or the Dutch score) are different from the Dutch score. So in the first graph, all the countries in the pink portion of the graph have scores that are not (statistically) significantly different from the Dutch score. So the Netherlands could be #7 on the list. In the second graph again 9 countries have either scores that are higher or statistically the same as that of the Dutch. So in this graph the Netherlands could be #10 on the list. It is not as bad as Dr. Amy is describing.

    • Young CC Prof

      Could be #7, but not likely. The confidence intervals don’t overlap that far. And if you really want to use the data that way, they could also be #3 on both lists, rather than #3 and #6.

      We know what the confidence intervals mean, and I don’t find the “It might not be quite as bad as it looks” argument terribly compelling.

  • Hannah
    • Becky05

      Now watch people blame it on the epidural, instead of the neglect. :/

  • My daughter’s second pregnancy, like mine, was a lot less dramatic than her first. Both in trouble the first time with early onset Pre-e, we were both quite boring until later the second time. Nobody took any chances with me, but my daughter met the new breed of midwives both times. She was cherished and cossetted by the young women who attended the first part of her labour – assured she didn’t really need the epi she wanted, and that the mec she was leaking was not significant. I was getting very twitchy indeed until the shift changed and the old-school midwife appeared. She was wonderful, if a bit taken by surprise by the very rapid arrival of an infant who at term was not in as great condition as my first, premature grandchild. It ended OK, happily. Didn’t improve my view of NCB style midwives.

  • Dr Kitty

    Low risk is not no risk. Rare is not impossible.
    Until October 2012 UHG hadn’t had a maternal death in 17 years.
    Then Savita Halappanavar died.

    Is UHG safer or more dangerous now than it was in September? Would you have your baby there tomorrow?

    Any physical condition which increases your chance of dying is NOT safe.
    Obstetrics is a specialty where you hope for the best, but plan for the worst.

    Midwifery and NCB seem to forget about the ” plan for the worst” bit.

    • The Bofa on the Sofa

      Is UHG safer or more dangerous now than it was in September? Would you have your baby there tomorrow?

      This is a really interesting comment in light of recent events.

      With the bombs going off at the Boston Marathon yesterday, there is the question of whither the London Marathon this week. It is going on as before, but the question is, would you run in it?

      Mike Greenberg, on ESPN radio of all people, pointed out the following: in fact, the London marathon this year is likely to be far safer than it was last year due to yesterday. The only difference is our level of awareness.

  • Eyerollin

    The trouble with “low risk” – I began my pregnancy as “low risk”. My weigh was good, I was young (in my early 20s), no diabetes, no high blood pressure. I had no significant complications, the baby was growing fine – up until the last 2 weeks when I went overdue, stayed in prodromal labor, and suddenly developed pre-eclampsia.
    Everything was FINE till then. But then we almost died but for the timely intervention of the hospital staff. I have long term health problems due to the pre-e but he came out fine. I shudder when reading some of these stories because if I’d been with a midwife they probably would have blathered on about “variations of normal” until I dropped dead.

  • Bystander

    Just thinking out loud here:

    Perhaps the way to explain ‘low’ and ‘high’ risk is in terms of a cliff overlooking a pounding, shark-infested sea. The consequence of going over the cliff edge is always dire; risk is how close to that edge you are. The problem is that the weather is foggy and so we have only an approximate idea of where that edge is… And the ground is crumbly. No matter how far away the cliff seems, the risk is never zero, and conversely some teetering on the edge will be just fine. If you do go over, gravity won’t pull any less, the waves aren’t going to be kinder and the sharks aren’t any less hungry for all that you were originally at lower risk.

    Risk is a prediction of the probability of bad things happening, not a measure of how bad those things are. Woe betide anyone using it as a justification for complacency.

    • The trouble is, the conviction that it won’t happen to you is built into pregnancy. Maybe it has to be, or no-one would embark on such a preposterous exercise.

      My twin sister didn’t make it. My mother was quite ill .And I grew up with that, and in a world where childbirth and its consequences were commonly discussed. Not long before I became pregnant my healthy, low risk niece suffered an intra-uterine death,(preventable) and it was ghastly. Admitted to hospital at 29 weeks, I still didn’t really get it. Things were different, somehow, it would all be OK. I did by the end – largely because of watching my daughter’s heartbeat plummet and stutter – something no instinct or symptom could have told me. It doesn’t happen, it can’t, it is too horrible to contemplate. When it does happen, it must be down to some fundamental difference in those women.

      Your cliff edge is there. How you factor in those who rush headlong towards it and DON’T fall, I don’t know.

  • fiftyfifty1

    Can anyone from the Netherlands comment on how important homebirthing or natural birth ideology is to a Dutch self-concept? I realize I’m not expressing myself well. It’s that I have read commentary in the past from Dutch midwives saying something along the lines of that Dutch women don’t want interventions and are proud not to need them and that homebirth is part of the national identity for Dutch women. Is this true or is this just a bunch of propaganda/wishful thinking on the part of Dutch midwives?

    • Laural

      My impression (limited to my friendship with one single Dutch family- so take with a grain of salt!!!) is that the NCB philosophy is very well melded with Dutch culture.
      I definitely think that faced with a lot of recent statistics and criticism many people are questioning some of those beliefs and values; I do imagine that the population will demand better results from their health care system.

    • Marfoe

      After living in NL for 7 years, I agree with Laural. Home/natural birth seems to be the social ideal here. Besides, the Dutch mistrust pain relief in general -many are proud of getting dental work done without any. I’d also say that the levels of social normalization of quack medicine are quite high. Pregnancy and labour aren’t an exception.
      But things seem to be changing, since the percentage of home births goes steadily down every year. On the news, we regularly hear that is because more and more women want an epidural. Isn’t safety a more probable, obvious reason? It’s like the Dutch media doesn’t want to even suggest that home birth is not safe.

    • Marfoe

      Here’s the link to the official statistics on percentage of home vs. hospital birth in NL: http://www.cbs.nl/en-GB/menu/themas/gezondheid-welzijn/publicaties/artikelen/archief/2011/2011-3383-wm.htm?Languageswitch=on

  • CSM

    Midwives must be well-trained and well-integrated in order to provide care. I do believe that midwifery as well as family medicine are appropriate options for low-risk maternity care. Two words: education and integration.

    Canadian midwifery is infested with influences of the well-known nutcases – I shall not speak their names… Ideology as such is not a problem in itself for people who are educated enough to laugh off the ridiculous and continue with what is known to be true. However, ideology gives roots where there’s lack of academic knowledge, an abundance of bias, or plain ignorance. And ignorance is aplenty. I have seen midwives who order BPPs without knowing how to interpret them, who have absolutely no idea what congenital heart defects there are and what they sound like, who believe in woo wholeheartedly, who take on high risk patients in order to keep the ideology going.

    What normal physician would want to collaborate respectfully with a midwife who is, frankly, an embarrassment? So guess what, instead of going back to the books, the embarrassments start whining about the traditional power imbalance and indulge in new levels of hatred towards knowledge and modern medicine, further degrading the profession. Forgive my bitterness, but as an insider who has not been brainwashed by Ina May and the gang, I am able to apply critical thinking to what I have come across so far.

    • Dr Kitty

      Interesting fact about medic-legal responsibility in the UK.

      If I refer to someone with appropriate skills and expertise, they take on responsibility for care and I am no longer responsible for any adverse outcome under their watch.

      If they do not have appropriate skills, expertise I am delegating care to them and retain responsibility for their cock ups.

      It is up to ME to decide if they have the skills before I put them in charge of my patient. You can see why I might be uncomfortable recommending an independent midwife without malpractice insurance.

      Even if I didn’t attend a HB, by recommending a private midwife I might be on the hook if she screwed up and it could be argued she didn’t have the required expertise.
      This is not what “collaborative care” means.

      • CSM

        This is one of the reasons MWs here in Canada got licensed – because the OBs were tired of being screwed over by having to clean up the mess. Although, now that we have hospital privileges and a malpractice insurance, it still doesn’t guarantee that the unfortunate OB who ends up being involved in a botched homebirth attempt doesn’t get into legal trouble if there’s a bad outcome. Now add the widespread MW attitude of ‘we know better than OBs’ and you get the idea why the so-called ‘professional collaboration’ is lukewarm here, at best. Here’s an example. MWs here have a professional guideline committee. It consists of several midwives; none have a background in either medicine or biostats, apart from the crappy 2 month course we sat through as students, where the instructor (also a MW) had very little idea of what she was talking about. I swear, the USMLE Step 1 lecture material on inferential stats would be insurmountable for most of them.. So anyway, the MWs hand pick and review studies available on a subject and come up with their own set of guidelines, often different from those recommended by the society of OBGYNs. The guidelines get reviewed by other MWs, get approved and voila! get to guide management of real patients across the province. Just like that! And the funniest part is that MWs argue that their guidelines are more ‘evidence based’ than the standard of care. I’m speaking out of sheer frustration because I have come across such unmovable slabs of plain stupid presented with such breathtaking confidence that the best I can do to prevent brain cells dying a painful death is to walk away and pretend like it doesn’t exist..The MW college claims us to be ‘evidence-based’, what rubbish. This blog is a great venting place, by the way. I would like to have a Canadian version of it but I doubt I can get enough supporters.

  • Marfoe

    I live in the Netherlands and gave birth to my first baby a few months ago. While my experience has been positive overall, I am absolutely not impressed with the Dutch system. As far as I know, it’s only possible to be under the care of an OB if your pregnancy is assessed as high risk. I wasn’t, so I received all of my prenatal care from midwives. And the point is that it isn’t much: in the Netherlands, for instance, only two ultrasounds (8 and 20 weeks) are recommended -I insisted on another one at the end, and had to arrange it myself somewhere else. Low risk pregnancies are mostly left alone, so I guess the chances of complications going undetected are considerable.

    Giving birth at home with one of those midwives would have been seriously terrifying to me. I managed to deliver in a big, big hospital in Amsterdam with midwives and OBs, thanks to my determination to get an epidural. (In smaller hospitals, it isn’t available at all or only during office hours.) Let me tell you that it took quite some planning and a lot of assertiveness. One of the arguments I had to hear against the epidural says a lot about the mentality here: “But if you get an epidural, then you and the baby will have to monitored during the whole delivery!” (That’s a winning argument, isn’t it?)

    • Expat in Germany

      Maybe the problem starts with the prenatal care and payment incentives structure. In Germany, the doc does the prenatal care and a hospital midwife on call does the delivery. I got an ultrasound almost every month and BP, blood and urine tests at every appointment. The doc gives a recommendation to the hospital for whatever sort of delivery is needed, and they take it from there. I had CEFM for all 3 labors. They get a 30 minute trace when you arrive and then let you go walk for a while if you aren’t close to delivery. When you are ready to push or if you get an epidural, you put the belt back on. You can stand and walk around with the CEFM belt as long as you don’t have an epidural. In general, the midwives think the epidural is good so that the mom doesn’t give up trying and so that emergency interventions can be done more quickly. They did not, however, provide a dense epidural. I was still in a lot of pain for the labors with epidurals. I was not a screaming mess, though. It wasn’t a perfect system. I did show up once when they were understaffed and I didn’t get checked out in a timely manner. The baby came quickly.

      • Marfoe

        The prenatal care is completely different over here in the Netherlands -and insufficient in my opinion. I only got to see an OB when I visited the big hospital in Amsterdam to get “approved” for an epidural beforehand, and she just reviewed my file. In all, I think I got 2 blood tests and 1 urine test. I did get my BP checked and they listened to my baby’s heartbeat in every visit, but that was it. Dutch midwives usually go with you to the hospital and deliver your baby (or collaborate with the hospital team). However, my midwives wouldn’t come with me because the hospital was “too far.” In Amsterdam, I got a midwive and an OB and it was fine.

        • Expat in Germany

          http://www.quag.de/content/english.htm here is a link to German home birth statistics for 2000 – 2004. They did not do a comparison to in hospital birth, probably because the perinatal death rate was 1.6/1000. Not great.

          • Expat in Germany

            3 times higher than the 0.45/1000 reported for all births. Woo knows no boundaries.

          • Eddie

            This rough factor of three seems to be remarkably consistent across different data sets. I bet there is something to that. If we could pool all of these statistics and get a break down of precisely how things went wrong, we’d be even better able to make a case for, “These are the specific things that go wrong in home birth, their rates, the chance that immediate medical intervention would have saved the baby” (and so on).

            In fact, the only places where the factor is much larger than three seems to be in America where lay (by which I mean non-Nurse) midwives are allowed.

      • Isramommy

        The German system sounds very similar to the Israeli system. Prenatal care is with an ob/gyn. Lots of screening/tests- standard is an early dating scan, nucal test, two anatomy scans, late term growth scan, and bio-physical profile every other day if you’re over due- plus monthly and then weekly nurses’ checks for weight, bp, and urine. Delivery is with an on-call nurse midwife and/or an ob if needed (labor wards are staffed by both). Epidurals are readily available and supported by most midwives. I think most women do get monitored all through labor unless they choose not to. I’m very impressed this type of maternity care model.

    • That’s frightening. I can’t believe women in the first world have to do that to get pain relief, I know people like to say that American Health care stinks because we have to pay for it, but at least we get epidurals if we want them.

  • The Computer Ate My Nym

    Of course, once again, mortality is only the tip of the iceberg. The daughter of a friend of mine had a child in the Netherlands. She was allowed to continue in the second stage too long and the child was born with a learning disorder. The child is getting excellent pediatric care and special schooling and will likely do well, but none of the extra care she is getting should ever have been necessary.

  • Susan

    Is there data about low risk births with OB’s in the Netherlands or are the women always cared for by midwives? Is there data that we can look at about home v hospital birth in there? It’s disturbing that high risk moms with OBs have better outcomes than low risk moms with midwives. I’d like to see the data about hospital birth with midwives. If it doesn’t compare with our CNMs I wonder if they should be looking at their midwifery education?

    • Becky05

      Low risk women are only cared for by midwives. OBs only care for women who were risked out of midwifery care.

  • moto_librarian

    Someone has already said this on another thread, but this study is further proof that low-risk is a label that can only be applied retroactively. NCBers have held up the Netherlands and the UK as “proof” of the safety of both homebirth and midwifery. Knowing that the perinatal mortality rate remains three times higher with careful screening guidelines and well-trained midwives should give everyone pause.

    I believe that CNMs can play an important role in women’s healthcare in the United States (and other countries), but only when they work as part of an integrated team that includes obstetricians and perinatologists. I was comfortable with my own CNMs because they did have professional relationships with other medical professionals, were quick to refer and/or consult when a problem was detected, and only delivered babies in the hospital. I have no hesitation in recommending my CNMs to other expectant parents because I have witnessed their level of professionalism and their commitment to evidence-based care through my own two pregnancies and deliveries. Sadly, I have seen a number of women complaining that these CNMs are “med-wives” who place too many restrictions on women (like recommending inductions at 41 weeks, requiring CEFM during a VBAC attempt, etc.).

    • Expat in Germany

      CNM type midwives deliver babies in Germany (in hospital) and Germany is one of the best performers on the charts above. The docs do the prenatal care and only enter the delivery room when things get complicated.

      • Expat in Germany

        CEFM is central to how they provide care.

      • RosaInBerlin

        Given the parallels between the German and Dutch systems (i.e. with midwives dealing with the majority of hospital births), I’m also quite curious as to why Germany’s stats seem to be so much better.

        • Expat in Germany

          In the Netherlands, the prenatal care is done by midwives and that is a big difference. One could also speculate about cultural differences amongst the midwives.. Different attitudes about NCB.

          • RosaInBerlin

            Yeah, these are the factors that occurred to me too. I do suspect that the tide may be turning in favor of homebirth/birth center birth, in some circles at least. I personally know of one case of each from within my direct network of friends/acquaintances.

          • Expat in Germany

            One of my kid’s friends was born at home and my husband’s ex girlfriend tried for a homebirth but got risked out. She recommended a very *alternative* birth education class prior my first labor. Orgasmic birth, good pain, and all of that. It was at a free standing birth center that I seriously considered using. I’m glad I didn’t because my son wouldn’t have survived it. Given the class I took, I wasn’t that surprised when the hospital midwife stuck an acupuncture needle in my hand when I arrived. I wasn’t a believer, though, so it didn’t do anything for my teeth rattling posterior labor.

          • Expat in Germany

            She only got risked out at 42 weeks. She was 42 years old and the amniotic fluid was low and green. The woo is strong with her and she found a midwife who was willing to push the envelope pretty far. Her pre natal care doc was finally able to talk some sense into her and get her to go to the hospital for a c section but not until she disappeared for a week in her winnabego (wohnmobile) to think it all over. He wanted to induce at 40 weeks. instead, she got a csection at 42 weeks with a 5 pound baby. IUGR?

          • RosaInBerlin

            The homebirth case I know about ended up being an unintended unassisted birth after the midwife did not show. Luckily for everyone involved, it all turned out fine. I’m not quite sure they are aware of the sheer size of the bullet they dodged.

          • fiftyfifty1

            This happened in Germany or where?

          • Expat in Germany

            In Germany. Therè is a woo counterculture here too.

          • Lisa from NY

            “The woo is strong with her and she found a midwife who was willing to push the envelope pretty far.”

            Redefining “low-risk”.

          • There seems to be some rather impressive birth centres dedicated to natural in some London hospitals, and as far as I can tell they are very popular. An ideal compromise – if it wasn’t for midwives keener on proving the superiority of natural and their own record for low intervention/better ways. Natural is LOVELY when it is…errr…natural. Pursuing it as an ideal seems rather unwise if it leads to interventions being demonised. Intervene, terrible concept. To come between….popularly interpreted as coming between mother and bliss, mother and child. How about between mother and various degrees of grief?

          • fiftyfifty1

            “Natural is LOVELY when it is…errr…natural.”
            Isn’t that the case though? There is not much that is more heartwarming than witnessing a birth that goes very very well. No need for interventions, labor that can be described more as “hard work” and not torture, healthy mom and baby and no tearing, no complications. If I could clone and guarantee this experience I would die a very happy (and rich) woman.

        • Expat in Germany

          Also, home birth and free standing birth center birth is pretty rare in Germany.

        • I’m not sure they are all that parallel – as far as I can gather up to now the Dutch hospital obstetrics were not wonderful or easily accessed. Anaesthetists do 9 til 5 (I read yesterday) epis have never been much used (unlike the UK, where they WERE very popular but are now discouraged in favour of “natural”) and a different culture to Germany. It isn’t a move back to homebirth, it is more like the UK was in the 50s and 60s – and the start of a move away from it maybe. From stoic obedience and conformity to NCB without what I consider to be the sane bit of good hospital care in between.

    • The Bofa on the Sofa

      Someone has already said this on another thread, but this study is further proof that low-risk is a label that can only be applied retroactively.

      I disagree with this comment, btw. It’s not that the low-risk groups aren’t lower risk than the high risk groups, it is that the “low-risk” isn’t all that low-risk. All childbirth ends up being relatively risky, I’ve explained that many times. Even the supposed “low-risk” births are far more risky than things that we could consider unimaginably dangerous normally (drunk driving, for example).

      The so-called “low-risk” pregnancies are absolutely lower risk than the high risk pregnancies, in that low-risk pregnancies are less likely to have complications. That what lower risk means, and it is true. However, low-risk is NOT “no risk” and even with “low risk” pregnancies, the chance of problem is far too high to be messing around with it.

      • moto_librarian

        Well, I guess that my point is that we need to get away from describing pregnancies as low risk since it can only be diagnosed after the pregnancy and birth are over. It is becoming clear that even well-trained midwives operating within their scope of practice have a higher perinatal mortality rate. Perhaps in some cases, they are lulled into a false sense of security if a woman in her care has met the criteria for a “low risk” pregnancy. We also know that even a well-trained midwife has fewer options for diagnosing and treating a problem with the baby, particularly when presiding over a homebirth. I think that we need to do a better job of identifying and articulating the risks associated with giving birth period.

        • Hannah

          “Well, I guess that my point is that we need to get away from describing pregnancies as low risk since it can only be diagnosed after the pregnancy and birth are over. ”

          Risk is prospective by definition. On the other hand it also has a range of ultimate outcomes built in, by definition.

          • fiftyfifty1

            “Risk is prospective by definition. On the other hand it also has a range of ultimate outcomes built in, by definition.”
            These are very important points. This is what risk means. In my experience the general population has a very very hard time understanding this. Here are 3 important ways they misinterpret the term “Low Risk”.
            1. Something bad could happen to me but it would be a mild (low) thing if it did happen because I am “low risk”. It couldn’t be one of the truly dangerous outcomes which are reserved for high risk patients.
            2.Something bad cannot happen to me unless I become High Risk first. As long as I stay Low Risk bad things can’t happen.
            3. If you had a bad outcome after all, your care provider must have been wrong about you being low risk. They misdiagnosed you.
            Back before modern obstetrics, woman had a real understanding of the risks of childbirth because they knew real women who had had bad pregnancy outcomes despite being healthy. But now that intuitive understanding of the danger is gone and has been replaced by scientific terminology that can be hard to grasp.
            This is where I think anecdotes are important. This, in my experience, is what resonates best with most patients. Anybody else have other ideas about a way to express Risk especially for those with low to moderate science literacy?

          • auntbea

            The same bad things happen to low-risk people as to high risk people. Just not to as many of them.

          • Eddie

            I think your #3 (If you had a bad outcome after all, your care provider must have been wrong about you being low risk. They misdiagnosed you) is a common misunderstanding. A lot of people misunderstand “science” as something that is all-powerful in some ways, as if it is possible to really identify, beforehand, all the people to whom bad things can occur.

            While the story is more complicated than this summary, last fall in Italy, some earthquake researchers were convicted for failing to predict an earthquake. Medicine faces the same dilemma on a daily basis.

          • fiftyfifty1

            And the opposite: “If you have a good outcome even though your care provider labeled you as “high risk”, then your care provider was wrong about your risk status. You were misdiagnosed.”
            How to combat this I don’t really know. Trying to make women understand that “the risk really does apply to you, yes YOU!” makes this misunderstanding grow even deeper roots when all goes well in the end.

          • The Bofa on the Sofa

            And the opposite: “If you have a good outcome even though your care provider labeled you as “high risk”, then your care provider was wrong about your risk status. You were misdiagnosed.”

            Grrrrr………

            I hate this one, of course. It’s the basis of my typical comment about drunk driving. Just because you don’t die in a drunk driving car wreck doesn’t mean drunk driving is a good idea.

            Jeebus, even Russian Roullette only has a 1/6 chance of being fatal (or a heart attack).

            Of course, we see the same thing here all the time. Anyone makes some generalization comment, and you can pretty much guarantee that someone will jump in with, “It isn’t always like that…yadda yadda yadda”

            It drives me up the wall, personally.

          • pam

            This is it, so few people truly understand the concept of risk…i.e. the probability of a certain consequence happening (to you in this case). In the safety field that I work in we have to constantly remind people that if there is a chance of an incident happening once in 100 years, that does NOT mean that it can only happen 100 years from now, it can happen tomorrow, or the next day or any day in the next 100 years…. As low risk does not mean no risk, you could be the 1 in 10 000 that has a bad outcome.

          • Eddie

            I used to live in a flood zone. That is defined in the US as meaning a 1% chance of flood in any given year. We experienced two 100-year floods less than ten years apart. People definitely do not understand the concept of risk. I understood what I was living in, but so many neighbors had no real understanding. They thought, simplified, that this meant floods happened once per hundred years. Nope.

          • fiftyfifty1

            Yes this seems to be a variation of the mistake people make when thinking about the gender of their babies: “I have had 2 boys already so the next one is more likely to be a girl”.

          • The Bofa on the Sofa

            n my experience the general population has a very Anybody else have other ideas about a way to express Risk especially for those with low to moderate science literacy?

            I struggle trying to explain it to people as well, but in a very different sense.

            Do sports analogies work? Upsets happen. Sometimes, they are monumental upsets. Any given Sunday and all that. An upset is when the expected outcome did not occur. Do you want your child to be the victim of an upset victory by an underdog?

            (then again, I’m not quite the right person to ask – I live my life under a paradigm of phase space theory – to me, EVERYTHING in life is a matter of degree, and all of phase space is accessible, it’s just that some regions are more likely to be accessed than others – I have to run, but when I get back, I’ll dig up my Eyring quote)

          • The Bofa on the Sofa

            “… A system …(passes) … from one state of equilibrium to another … by means of all possible intermediate paths, but the path most economical of energy will be the more often traveled.”

            Henry Eyring, 1945

            The key term in here is the bolded part – “more often travelled” which is not the same as _always_ travelled.

          • fiftyfifty1

            Off topic: can you give me a concrete example of what Eyring meant by that? I am thinking about things melting around here as we still have a lot of snow to melt. Most of it melts. And then evaporates (if summer comes which I still have hope it might). But some of the snow sublimates. Is this an appropriate example?

          • The Bofa on the Sofa

            Well, Eyring was specifically focusing moreso on the microscopic details of a transformation at the molecular level (particularly how the atoms are moving), but from a broader sense, yeah, this covers the flavor of it. You have two equilibrium states (snow and vapor) and you have defined two paths. The challenge in this example is to determine which path is more “economical in energy.” It’s hard, and is a temperature dependent issue, but that is the type of thing you would think about from a phase space theory POV. So the question you’d consider is, at a given temperature, how much snow sublimes directly and how much melts/evaporates? At very cold temperatures, it’s almost all sublimation. However, when it is very warm, it’s mostly by melting.

          • auntbea

            What is a phase space?

          • Eddie

            Wikipedia reference is here: http://en.wikipedia.org/wiki/Phase_space but it is heavy reading.

            A quick overview is that phase space is an abstract multi-dimensional “space” where every possible independent variable of motion is represented by a dimension. Within a phase space, you can map out every single possible configuration of a physical system. Many parts of physics use phase space heavily, such as quantum physics and thermodynamics (particularly statistics mechanics).

            A simple example of phase space is an undriven pendulum that can only move side to side. This pendulum really has two independent parameters — its angle of displacement from vertical and the velocity with which it is moving.These are independent because you can start the pendulum at a given point with or without giving it a kick. The graph of these two independent variables is the phase space of this system. Once the pendulum is set into motion, you can plot the velocity and displacement over time on a two-dimensional graph. In the simple case you’ll get an oval.

            I don’t know if this helps. But basically, phase space allows you to map out every single possible configuration of a system and then follow transitions of the system from one state to another state. It’s an incredibly useful abstraction.

          • The Bofa on the Sofa

            One way to think about it is “places where things CAN go” or, in terms of events, things that CAN happen. The basis of phase space theory is basically that everything is possible, but some things are just more likely to occur than others.

            Here is a sports example: suppose the local Pop Warner football team is playing a pro team. Now, you’d say that of course the pro team is going to win, right? However, there is a possibility that just as the nfl team kicks off, an earthquake could hit and all of the members of the NFL team are swallowed into the earth, and they have to forfeit the game.

            In this event, there are two outcomes possible (either team winning), however, one is much more likely than the other. That’s a phase space theory perspective.

            Of course, it’s pretty trivial in this type of extreme case, but consider a more realistic case, such as two pro football teams. When they play, one team or the other is almost certainly to win (there are ties in the NFL, of course), but what does that mean? Phase space theory gives you a means for interpreting that in a descriptive manner. Phase space theory tells us that the most likely outcome will be the better team winning, but how likely depends on the probability of the team winning, and for teams that are very close, that outcome doesn’t mean a lot. For example, in the NFL, if a team beats an opponent on the road, and then plays them again later in the season, the chance that they will beat them again, this time at home, is only like 70%. Turn it around, and a team that beats an opponent at home and plays them on the road, the chance of winning is only 50/50. Home wins tell us nothing about who is better. Also, regardless of the game or outcome, after about 8 weeks, it means absolutely nothing.

            Similarly the NCAA basketball tournament is completely an exercise in phase space theory. Every team has a chance to win every game, and so every possible outcome is possible. Some are just more likely than others.

            Another implication of phase space theory is that, given enough samples, unlikely events not only can happen, they MUST happen. If an underdog has only a 1% chance of pulling off an upset, and that would be a very serious upset, if you look at any single game, you generally won’t see it. However, if you have 1000 of these games, you will expect to see 10 or so such upsets occur. According to phase space theory, if you are not seeing these types of upsets occur, then you have mis-interpreted the chances of it occurring.

          • auntbea

            Oh. Why don’t you just call that the universe of cases like normal people?

          • The Bofa on the Sofa

            Because by treating it as an n-dimensional space, you can describe motion through it by using vectors (and, in fact, the paths that are followed are called “trajectories”). At that point, you can basically utilize Newton’s laws of motion to describe it.

      • Eddie

        You’re right. Maybe it’s better to refer to “high risk” and “lower risk.” When you say “low risk” it makes it sound safe, and as we’re learning, it’s not really “low risk.”

        • Or “high risk” and “higher risk”?

          • The Bofa on the Sofa

            Nah, I think we can use “high risk” and “not as high risk”

        • It is obvious that most assume that low risk means “I am healthy and there is nothing obvious indicating any potential problem.” Which would be fine if our knowledge of birth was perfect, but it isn’t. I have mentioned before an article I came across called “The high risk baby in the low risk mother” – which can be where many of the problems come from. Our ability to be precise about the size of the baby, the state of the placenta is still imperfect. Knowing which baby will easily tolerate the stresses of labour and which one won’t, knowing what happens in a baby’s brain in those crucial last weeks – it is still very imprecise. The miracle is that it works out fine as often as it does. The tragedies are those that strike unpredictably at low risk mothers – and hospital obstetrics and modern science have done a lot to reduce them. The hubris of rejecting that baffles me.

          • The Bofa on the Sofa

            All that’s true, but it’s not a problem with the terminology of low-risk. All you have said can be true, and it still is consistent with the pregnancy being low risk.

            Risk is about probability, and the likelyhood of a problem. It is absolutely the case that those who are classified as low risk, as in”there is nothing obvious indicating any potential problem” are less likely to encounter problems than those who have risk indicators. That’s what makes them low risk, relative to the general pool. But as I pointed out, the problem is when it comes to pregnancy, low risk isn’t all that low compared to what we normally consider acceptable in our lives.

          • Lisa from NY

            Midwives are more willing to gamble the life of the baby, so they translate “low-risk” more loosely than a doctor would.

          • fiftyfifty1

            What a great article title. For my second, in retrospect, it was a case of “The low risk baby in the low risk mother but with a high risk placenta”. A lot has to go right.

        • Sue

          I have an interest in this area because I work in a specialty that is all about assessing risk. And believe me, when we urge someone with chest pain or abdominal pain to stay for a full evaluation “just in case of a life-threatening cause”, the actual risk of death is very low, and yet people don;t want to tolerate the risk because there is no culture of “natural” or Heroism for risking your wellbeing in those circumstances. (and there isn’t even a second human being involved!)

      • Lisa from NY

        A pregnant woman with no history and large weight gain would be classified as low-risk by a midwife and high-risk by a doctor, because of probable shoulder dystocia.

  • I have a hard time understanding why at a time of high health vulnerability we are willing to accept lower levels of care (midwifery) instead of demanding universal access to the highest standard of care (obstetrics). That does not mean every appointment needs to be with an obstetrician – but rather that obstetricians should be over-seeing every patient and that there should be no reluctance to refer care.

    • AmyM

      My impression is that women in the Netherlands have become aware of the discrepancy in safety based on provider and try to get under OB care. I know nothing about the Netherlands–do they have a similar health care system to the NHS? If so, I imagine their version of it is 1)trying to save money and 2)there may be a shortage of available OBs. Of course I agree with you–every woman should have access to an OB, but I think it is not entirely up to the women.

    • LukesCook

      Money. Babies are being born all the time, and there’s no acceptable way to pressure people into having fewer of them (as you could theoretically do with heart attacks, by encouraging better diet, less smoking, etc). It’s an easy and obvious target for cost-cutting. Policy makers very much want to believe evidence that appears to show that they can spend less without any obvious repercussions. The Dutch are, of course, famously…thrifty.

      • Sullivan ThePoop

        And Happy. Is it related?

        • LukesCook

          Could be. They’re also rich (compared to other Europeans) and have the reputation of smoking a lot of pot.

    • Becky05

      Well, because there’s some benefits to the different style of care. Midwives aren’t just OBs-lite, they also have more training in emotional and physical support of women during pregnancy. They have a different role and different knowledge, not just less. Midwives absolutely can be an important and useful part of the maternity care system.

      • Eddie

        I agree with everything you say. The big problems seem to occur where the midwives try to replace the OB rather than coordinate care with.

  • WordSpinner

    I wonder if the Netherlands is what happens when NCB/homebirth ideologies infect medically-trained widwives, who then refuse to do interventions or transfer care when necessary because “birth is natural” and “birth is as safe as life gets”. If that’s so, we need to nip it in the bud here, because it has a demonstrable cost in lives.

    Seriously–if you can’t get a better record than your collegues dealing with all the high-risk patients, you need to seriously reconsider what you are doing!

    • Olga Mecking

      Interesting that you should say that because I gave birth in the NL twice and both times was transfered for meconium when my waters broke. They seemed to be very quick to transfer me to the hospital. Also, already some women complain about birth becoming “medicalized” also in the Netherlands which means that maybe, just maybe, the situation may improve. Luckily, both of my children born here were healthy and well. I didn’t mind seeing a midwife. However, when there is a complication (even a mimnor one), it’s not only stress because there is possibly something wrong with the baby, but also stress because you get to meet totally new doctors and midwives and it may come as a shock. I for example felt ditched by the midwives, as if I was punished for having a complication… this is why I wanted a doula and it was great support. Still, the system is far from perfect- I wish to see more choice in who’s going to care for moms and their babies when they’re still in the belly…

    • auntbea

      A colleague had a miscarriage in the Netherlands and the OB refused to give her pain meds because “it’s supposed to hurt.” WTF, Netherlands?

      • Eddie

        Where my wife gave birth to our older children in Europe (a poor country not doing well on the charts above), there is no pain treatment during pregnancy, at all, period, unless you are rich. My sister-in-law delivered most recently only four years ago and management of pain was not an option for her. No epidural. No narcotics. Nothing. They also did not allow her husband in the delivery room, at all.

    • Amy Tuteur, MD

      “I wonder if the Netherlands is what happens when NCB/homebirth
      ideologies infect medically-trained midwives, who then refuse to do
      interventions or transfer care when necessary because “birth is natural”

      I suspect you are exactly right. After all, this is what we see in the UK as well.

      It’s
      not that midwives can’t tell the difference between low risk and high
      risk. The problem is that they are trying to increase market share by
      pretending that high risk IS low risk. The entire midwifery campaign to
      “normalize birth” is about midwife self interest and babies are dying as
      a result.

      • The Bofa on the Sofa

        It’snot that midwives can’t tell the difference between what doctors classify as low risk and high
        risk.

        Text added

        Remember that midwives DENY there is even a difference to tell apart in the first place.

      • LukesCook

        I’ve yet to see a persuasive reason to choose a midwife over an OB at all, ever, other than cost.

        • Eddie

          I have to agree completely. With my wife, I would be completely happy working with midwives and an OB, where the midwives provide a lot of the routine care and the OB does the heavy lifting, medically speaking. Similar to the dental model where I spent more time with the hygienist but the dentist is always there as well. And they work together as a team and subscribe to the same medical theories. No woo. No alternative dentistry. 🙂

          But give me an either/or choice and I will choose the OB without having to even think about it. The risk of not choosing the OB is just not worth it.