The Netherlands, homebirth and the high mortality rate

Homebirth and natural childbirth advocates often approvingly cite the maternity care in the Netherlands. Homebirth rates are the highest in the world (30%, but down considerably and falling every year) and midwives are the mainstay of the system, caring for any woman who does not require the care of a doctor.

What homebirth and natural childbirth advocates fail to realize is that The Netherlands has one the highest perinatal death rate in Europe and a high and rising rate of maternal mortality. Indeed, the Dutch have become so alarmed at the perinatal and neonatal death rates that the government has convened a variety of investigations to determine the cause.

The paper Higher perinatal mortality in The Netherlands than in other European countries: the Peristat-II study, published in a Dutch journal, brought the issue of perinatal mortality into focus:

… In Peristat-II from 22 weeks gestation, after France, The Netherlands had the highest fetal mortality rate (7.0 per 1,000 total number of births). Of all western European countries, The Netherlands had the highest early neonatal mortality rate (3.0 per 1,000 live births). Over the past 5 years the perinatal mortality rate in The Netherlands has dropped from 10.9 to 10.0 per 1,000 total births but this drop has been faster in other countries. CONCLUSION: The Netherlands has a relatively high number of older mothers and multiple pregnancies, but this only partly explains the high Dutch perinatal mortality rate which still ranks unfavourably in the European tables. More research is necessary to gain insight into the prevalence of risk factors for perinatal mortality compared with other European countries. In addition, perinatal health and the quality ofperinatal healthcare deserve a more prominent position in Dutch research programmes.

The government has commissioned researchers at the Erasmus Medical Centre in Rotterdam to oversee the investigation. From the Erasmus MC website:

The Netherlands has a relatively poor position in Europe when it comes to health at the time of birth, in other words, perinatal health. Approximately 10 out of every 1000 children die around the time of birth. In similar other countries this mortality rate can be as much as 30% lower. Of the perinatal deaths in the Netherlands, 70% are stillbirths when counted from the 22nd week of pregnancy. Thirty percent of the perinatal deaths take place in the first week after birth. In Flanders, that is socio-democratically and economically comparable to the Netherlands, the perinatal death rate has been two-thirds of that in the Netherlands for at least 10 years. This means that instead of 1700 cases of perinatal death that occur per year among the 175,000 newborns in the Netherlands, only 1150 cases should occur; an unprecedented large difference. Moreover, within the Netherlands, and particularly in the larger cities such as Rotterdam and The Hague, there are distinct differences between groups of pregnant women.

The ZonMw has commissioned Erasmus MC to carry out the Descriptive study Pregnancy and Childbirth. The aim of the study is to determine knowledge questions and research opportunities to improve the perinatal care in the Netherlands. Aspects studied include patient-related risk factors such as diseases already present, lifestyle and social factors on the one hand and the role of the midwife practices including use of care, risk selection, and quality of care in the Netherlands on the other. The preliminary conclusion is that the unfavorable European position is probably mainly caused by factors in the care system while the differences within the Netherlands and the larger cities are linked to large risk differences between groups on the basis of ethnicity, social deprivation and the neighborhood in which people live. A research agenda has been formulated based on this.

In other words, the government investigation found that one of the main reasons for the high perinatal death rate is the midwife care system including use of care, risk selection, and quality of care.

Not only is perinatal mortality unacceptably high, maternal mortality is high and rising. According to the paper Rise in maternal mortality in the Netherlands, published in the British Journal of Obstetrics and Gynaecology earlier this year:

The overall maternal mortality ratio was 12.1 per 100 000 live births, which was a statistically significant rise compared with the maternal mortality ratio of 9.7 in the period 1983–1992 (OR 1.2, 95% CI 1.0–1.5). The most frequent direct causes were (pre-)eclampsia, thromboembolism, sudden death in pregnancy, sepsis, obstetric haemorrhage and amniotic fluid embolism. The number of indirect deaths also increased, mainly caused by an increase in cardiovascular disorders (OR 2.5, 95% CI 1.4–4.6). Women younger than 20 years and older than 45 years, those with high parity or from nonwestern immigrant populations were at higher risk. Most substandard care was found in women with pre-eclampsia (91%) and in immigrant populations (62%).

Maternal mortality in the Netherlands has increased since 1983–1992. Pre-eclampsia remains the number one cause. Groups at higher risk for complications during pregnancy should be better identified early in pregnancy or before conception, in order to receive preconception advice and more frequent antenatal visits. There is an urgent need for the better education of women and professionals concerning the danger signs, and for the training of professionals in order to improve maternal health care.

In an accompanying commentary, British obstetrician JJ Walker notes that there has been pressure in the UK to adopt the Dutch system of maternity care:

… The fact that there are areas of concern in the Netherlands over rising maternal death ratios, despite their generally high socio-economic profile, as well as the previously documented high level of perinatal mortality, suggests that we should be cautious about moving our pattern of care towards theirs without careful consideration of a potentially adverse effect on maternal and perinatal mortality and morbidity. The UK has improved its safety for both mothers and babies by careful audit and guideline development. Care should be taken not to undo these changes by striving for political correctness.

American homebirth advocates and natural childbirth advocates who point to the Dutch system as a model would do well to heed Dr. Walker’s advice.