Dutch homebirth rate continues to plummet; now only 13%

Percentage decrease concept

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?

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.

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.

  • The Vitaphone Queen

    Off topic, but hey, it’s DUTCH!!!
    https://youtu.be/FsssPTsyXYs
    Let’s all Trust Lead™️!

  • Curious reader

    Of course an obstetrician is going to try to twist the facts about the safety
    Obstetricians love scare-mongering poor women and doing a witch-hunt on innocent midwives (they have a long history of this). Obstetricians undoubtedly wouldn’t tell women that births in obstetric-led hospital unit are associated with greater risks (higher intervention rate such as c-section, episiotomy, instrumental birth, etc.). Also, the NCT is not providing inaccurate information; please check the NICE guidelines (UK).

    P.S., If anyone wants reliable information on home birth safety, etc., check the Birth Place Cohort Study (link: https://www.npeu.ox.ac.uk/birthplace).
    You’d think that a female obstetrician wouldn’t try so hard to mislead fellow women *rolls eyes* (but of course, more hospital births = more money for the obstetrician).

    • Curious reader

      Also, have you ever given much thought on why America, a developed country, has the worst most adverse outcomes and perinatal mortality rates (maternal and neonatal) in the West, when compared to other developed countries? Ever wondered that it’s probably due to its horrifically high c-section and intervention rates?

      This, of course, is hardly spoken about in the media, due to its hidden agenda against normal birth and midwives.

    • Sarah

      Oh dear…

      • The Vitaphone Queen

        Oh! D-d-d-dear!
        – Piglet

    • Nick Sanders

      Why is instrumental birth considered a risk but mortality not?

    • Who?

      So are the numbers Dr T quotes wrong, or do you just not like them?

  • Michael Ray Overby

    Thanks again Dr Amy for having the Nerve to tell the truth.

  • Dr Kitty

    I’m currently emailing NCT about some “concerns” I have about the information on their website.

    For example, they think women need to know that some studies have shown “different feeding behaviour” in neonates whose mothers have epidurals containing Fentanyl- strongly implying breastfeeding difficulties related to epidurals.

    And YET nowhere does the website mention that’s low risk first time mother has double the risk of her baby dying or suffering serious health problems if she chooses home birth over hospital birth.

    It’s *almost* as if there is an overt NCB process over outcome agenda…

    Personally, I think NCB needs to take responsibility for the fact that for every 200 primips their information convinces to deliver at home, one baby who would have been healthily delivered in hospital will suffer death or serious illness. I couldn’t have that on my conscious, apparently they can.

    • Dr Kitty

      And I’ve just got the polite brush off…
      “Thank you so much for raising these concerns…blah blah blah”.

      NCT don’t want to hear it.

      Well, I know which national charity’s services I won’t be advising my patients to avail of…
      After all, I have a professional duty of care, and if I can’t be convinced that NCT is in the best interests of my patients I have a duty to tell them to avoid it.

      • Sarah

        A big problem is that people are having to look more to the likes of the NCT as NHS antenatal class provision is reduced. There were none locally for me to attend when I was pregnant, so I paid for the NCT ones and considered myself fortunate to be able to afford it. There are others like me. If we don’t have this stuff on the NHS, the private and third sectors step in, and they don’t always do a decent job.

        • Lilly de Lure

          You’ve just described my position to a tee – I had my doubts (serious ones) about NCT but didn’t know where else to go for ante-natal classes and signed on. I just made sure I fact checked everything I was told afterwards.

          • Sarah

            There’s nothing else, is there? I made some good pals at mine who I’m still in touch with years on, and we did have both an instructor who kept her woo to herself and an anaesthetist who was one of the preggos taking the class and stepped in for the epidurals part! So it wasn’t too bad. But the organisation itself and some of the practices can be very problematic. There is a LOT of variation in instructors, I think.

            It’s outrageous that the NHS provision is so limited though, it really is. Women living where I did who weren’t able to pay £150 would have got nothing at all- granted, the NCT do some discounts for people on benefits etc but I don’t think they’re especially well publicised.

          • Sarah

            I don’t think I had the energy for fact checking by that stage of the pregnancy but yeah, basically.

    • Eater of Worlds

      NCT?

      • Lilly de Lure

        National Childbirth Trust – it’s a British organisation that in theory supports and provides information for women throughout pregnancy and whilst looking after babies through to toddlerhood. It runs classes taken in late pregnancy for women who are all due at the same time and a lot of women take them as a means of getting to know other local women going through pregnancy/birth/baby stages at the same time as themselves. The classes are famously woo-prone (when I went Dick Grantly-Reed’s theories were treated like Holy Writ and whilst hours were spent on teaching us the ins and outs of how to breast feed (although not how to spot a starving baby – we were just told that “cluster feeding” was normal and healthy and should be persevered through) not a word was said about how to use formula, just a grudging admission that on rare occasions some women might need it but since the majority would not they weren’t going to talk about it further) and were skewered by Dara O-Briain in the below routine:

        https://www.youtube.com/watch?v=khfJ-HB12Z0

        I can confirm that the routine is a pretty fair portrait of the classes (at least the ones I attended) and we did indeed get the line “a tear heals better than a cut”.

        • Sue

          Brilliant!

        • Roadstergal

          That Dara O’Briain routine should be required watching for UK expectant mothers. 😀

          • The Vitaphone Queen

            Love him!

    • Michael Ray Overby

      Process Over Outcome is Precisely It. However Debug Cycles are for HardWare SoftWare & FirmWare, NOT for Birthing New Humans. Bc you’re gonna Have To Kill during Each, & Every One. We know this in MoDi Twins. We are Fully Stuck on 36/6, Never Later, for Delivery Timing because of Losses. IUF Deaths, At or Very Near Term. (“Term” now has less meaning to us, as we have found out Empirically where that really is for our Pairs & express accordingly…)

      We wouldn’t know otherwise, & the World has come up around us, in Agreement! That feels Really Nice too. Why do we Advocate like we do for Selective Intrauterine Growth Restriction SIUGR (Expectant Management, nearly Always) BC Too Damn Many were Getting Killed by the only So Called treatment for it, Placental Laser! (70%, now it’s 4.7%). These fools are Far Too Cavalier with Human Lives, trying to bring a Centuries-Old Process up to 21st Century Specification, & It Just Can’t Do It!

      NEVER start with Process & try to get Process Adoption via Social Engineering. You’re Fucking Doomed, on Multiple Levels, if you do that shit. ALWAYS start Where They Are Dying & try to Control Those Deaths. DON’T ever start with something Known Dangerous & try to Suck the Danger Out, & attempt Advertising based on Nostalgia to Sell It. MoDi offers Multiple Ample Opportunities within this Domain. Alterations to Extant Best Processes focused on the aforementioned OUTCOMES have borne positive results…

  • Roadstergal

    At what point does ‘disingenuous’ turn into ‘malicious’?
    The midwives are twisting the data in an attempt to convince women to make decisions that objectively have a higher risk of death..

  • EllenL

    This study, the coverage, and even the comments are a breath
    of fresh air in the home vs. hospital birth discussion. It’s great that more Dutch women are choosing to protect their babies and themselves, and have effective pain relief available.

    What is the value of tradition compared to saving a baby’s
    life? Or preventing unnecessary suffering? The Dutch are getting it right.

    • EmbraceYourInnerCrone

      I like the demotivators despair.com line on Tradition: Just because you’ve always done it that way doesn’t mean it’s not incredibly stupid.

      But then I’m a cranky cave troll…

      • MaineJen

        “Meetings: None of us is as dumb as all of us.”

        • EmbraceYourInnerCrone

          AH yes one of my favorites! followed by: “Teamwork :A few harmless flakes working together can unleash an avalanche of destruction.” They really are brilliant

    • Jenny Ruff

      Was it the pain relief or was it a couple of well publicised legal actions in 2010 (attributed to the Natural birth lobby but not always right)? That’s what it often is and the point is, that if you are in familiar surroundings rather then a clinical hospital environment you may feel less pain because of that. And things go wrong in hospital too! But everyone is covered there… But to be fair I was glad of my epidural, even though it resulted in a horrible forceps delivery.

      • Heidi

        Saying things go wrong in the hospital is the equivalent of saying people die in car crashes wearing their seatbelt. Even most car crashes fatalities the dead people were seatbelted because more people wear seatbelts than don’t. That still doesn’t change the fact that you are much more likely to die not wearing your seatbelt and more likely to survive wearing your seatbelt.

      • Bombshellrisa

        Pain is pain, transmitted via the same nerves and path no matter where you are. A stab wound or crushed limb would hurt just as much at home as it would anywhere else.

  • Azuran

    OT – I can’t make up my mind about something and would like opinions.
    Tomorrow is my mother’s 50th birthday. As such, her husband is preparing a huge surprise party/dinner. The whole family is going to be there and lots of friends (he’s expecting like 60 people).
    However, going to my mom is a 7-8hour drive (depending on traffic and road condition.) and then driving back another 7-8h on Sunday.
    But right now I’m at 36w+2. Everything is going fine and I have no complication of any kind so far, but It seems reckless to me to go so far away on such a trip so late in a pregnancy.
    I’ve been stressing over this for a week now and keep changing my mind every single day….

    • EmbraceYourInnerCrone

      Personally I think you are better off not going. It will be hard to miss the party but that’s a long drive at 36 weeks. If you go into labor at your destination, you would have to deliver in an unfamiliar hospital with an OB you don’t know. If you went into labor on the way there or the way back, you would have to find a hospital…

    • myrewyn

      I wouldn’t go. A 7-8 hour drive is just as bad as a cross country flight and you’re well past when that would be recommended. Not only do you risk going into labor either on the road or in an unfamiliar city, the ride itself is bound to be uncomfortable. I just did a 9 hour flight at about 26 weeks pregnant and it was miserable having to sit so long.

    • J.B.

      I didn’t mind a 4 hour drive each way at 36 weeks pregnant, but that is a long trip. I’m sure she will be more than happy to celebrate again once your little one gets here. Also, my own experience of having my mother around with a newborn is that she was very protective of me, wanting me to get as much sleep as possible.

    • The Bofa on the Sofa

      I can’t make up my mind about something and would like opinions.
      Tomorrow is my mother’s 50th birthday.

      Whoa, your mom is about my age?

      But to your question:
      The week before my wife was scheduled for c-section with our second, we went to a local favorite festival of ours, about 2 hours away. Not far or anything, and not a problem, but even doing that we took a slightly longer route that always kept a hospital relatively nearby. If we had taken our usual route, we would have been too far from a hospital for comfort for a while. And that was only a 2 hour trip.

      As others have said, you are probably best to decline. I would hope that everyone would understand that there is a risk for you to travel, and they would not ask you to take a risk with which you are uncomfortable.

      Be sure to offer to skype to participate, but that’s just too far to go in person.

      • Azuran

        XD Yea, I get that a lot about my parent’s age. People tend to have kids really early in my family. At 27, I’m comparatively very old to be having my first child.
        You should see the face people do when they meet my 66 years old grandmother.

        • Tigger_the_Wing

          Same here, I became a grandmother at 44. My fifteen-year-old grandsons are unique amongst their friends in having had four great-grandparents until they were ten. They still have two.

        • LaMont

          As another 27-year-old I just want to say I’m *super* jealous of anyone whose life is in *any* way collected enough to be substantially thinking about the future. What I mean to say, ultimately, is *Congratulations!* and have a lovely Skype session into the party 🙂

      • Sean Jungian

        Her mom is YOUNGER than me! 😀

        • The Bofa on the Sofa

          I don’t remember how old your kids are, if any. I have young’ns (although they are getting older)

          • Sean Jungian

            I have a now-15-year old 🙂 But STILL!!

        • Who?

          Me too.

          FWIW, Azuran, I’d tell my daughter or a daughter in law that while we’d love to see her, it sounds like a good time to stay home. And you could skype in, or call for a long chat the day before, or similar.

    • Empress of the Iguana People

      It *is* a long and, at 8 months along, usually pretty damned uncomfortable trip. Obviously, I don’t know your mom, but mine wouldn’t have expected me to make such a trip this far along. You’re essentially talking about 2 full days journey with almost no down time between.

      • BeatriceC

        I’m only a few years younger than your mom. If one of my step-daughters or future daughters-in-law was in the same position as you, I’d hope that they put their own safety above an admittedly “big occasion” party. Also, I’d spend the entire time you were driving worrying and fretting about you and wouldn’t be able to enjoy myself as much. It stinks to miss such an occasion, but it’s probably better to stay home. Perhaps you could FaceTime or Skype for a little bit to be there electronically?

        • Empress of the Iguana People

          Or rather Azuran’s. My mom would have been 62. 😉

          • BeatriceC

            Gaaahhhhhhh! This is why I shouldn’t respond while distracted. Though MrC is 63, so sometimes I feel like I’ve got a toe in both age groups.

        • KeeperOfTheBooks

          Yes!! At a friend’s wedding recently, the groom arranged for one of his friends to set up a Skype feed for groom’s across-the-country-and-in-poor-health great grandma so that she could watch her great grandson get married. She was happy as could be about it, to say the least.

    • AnnaPDE

      I’m pretty unconcerned about some long distance drives, but I’d look if there’s a flight that could cut the travel time down. Just so much nicer than a pregnant road trip.

    • Merrie

      I wouldn’t. I’d be worried about going into labor; my mom would be worried about me; the trip would be long and uncomfortable and I’d lose valuable rest time and be stressed out and exhausted when I went back to work. Just not worth it. If it were only two or three hours that would be a different story.

  • Daleth

    Fantastic news.