Awesome! Dutch midwives kill just as many babies in the hospital as at home!

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Talk about making lemonade out of lemons! Only a Dutch midwife could take the fact that the Netherlands has one of the highest perinatal mortality rates in Western Europe and the fact Dutch midwives caring for low risk women (home or hospital) have a higher perinatal death rate than Dutch obstetricians caring for HIGH risk women and turn it into a defense of homebirth.

But those facts are not a defense of homebirth; they are a scathing indictment of Dutch midwifery. Ank de Jonge’s new paper in BJOG tells us the same thing most of her old papers tell us: Dutch midwives provide substandard care.

This is the fourth paper that I know of where de Jonge presents misleading information in an effort to promote homebirth. I could almost feel sorry for her since her efforts serve only to highlight the deficiencies of Dutch midwives.

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.

In 2013 de Jonge in a paper in the journal Midwifery Perinatal mortality rate in the Netherlands compared to other European countries: A secondary analysis of Euro-PERISTAT data that attempted to absolve Dutch midwives, but actually CONFIRMED their poor mortality statistics

Later in 2013 de Jonge published Severe adverse maternal outcomes among low risk women with planned home versus hospital births in the Netherlands: nationwide cohort study. de Jonge found that there were fewer serious maternal complications at homebirth than hospital birth. There was just one teensy, weensy problem. de Jonge left out the mortality rates. Severe maternal morbidity is an appropriate measure of safely ONLY when death rate is zero or nearly zero. If the death rate is not zero, that MUST be taken into account in assessing safety. It was subsequently revealed that the homebirth group had a potentially preventable maternal death while the hospital group had none.

de Jonge’s latest paper is Perinatal mortality and morbidity up to 28 days after birth among 743 070 low-risk planned home and hospital births: a cohort study based on three merged national perinatal databases,  She found:

Of the total of 814 979 women, 466 112 had a planned home birth and 276 958 had a planned hospital birth. For 71 909 women, their planned place of birth was unknown. The combined intrapartum and neonatal death rates up to 28 days after birth, including cases with discrepancies in the registration of the moment of death, were: for nulliparous women, 1.02‰ for planned home births versus 1.09‰ for planned hospital births, adjusted odds ratio (aOR) 0.99, 95% confidence interval (95% CI) 0.79–1.24; and for parous women, 0.59‰ versus 0.58‰, aOR 1.16, 95% CI 0.87–1.55.

And concluded:

We found no increased risk of adverse perinatal outcomes for planned home births among low-risk women. Our results may only apply to regions where home births are well integrated into the maternity care system.

But 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, was careful to leave out the death rates of Dutch obstetricians, though she does acknowledge 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.

de Jonge concludes:

This study did not show increased risks of intrapartum and neonatal mortality, among low-risk women planning a home birth.

That’s true as far as it goes but a more accurate conclusion would be:

This study did not show increased risks of intrapartum and neonatal mortality among low-risk women planning a home birth with a midwife compared compared to low-risk women planning a hospital birth with a midwife. It does, however show an increased risk of intrapartum and neonatal mortality among low risk women in midwifery care compared to HIGH risk women in obstetrical care.

de Jonge didn’t show that homebirth is safe. She showed that Dutch midwives are dangerous.

89 Responses to “Awesome! Dutch midwives kill just as many babies in the hospital as at home!”

    • Young CC Prof
      September 13, 2014 at 12:33 pm #

      Briefly. The conclusion was that the hospital was probably right to let her deliver vaginally because the babies were so tiny and non-viable, and it’s unclear why she died.

      • Susan
        September 13, 2014 at 2:13 pm #

        That’s my initial thought. Obviously, we don’t know the details. Having had the experience of watching a case I knew intimately discussed in news and online once I can say that the discussion may have very little to do with what really happened. It’s something we should keep in mind when discussing these homebirth gone wrong tales too… that the facts we have may have little to do with what really happened.

  1. attitude devant
    September 12, 2014 at 11:29 am #

    I have been thinking about this all day (meaning the last 24 hours). This is amazing. What we have here is a time-honored tradition that is demonstrably harmful to the larger population, that the larger population now finds inadequate (if we are to take the comments of Nederlanders below as truth), and the people who continue to advocate for it are the only group who benefits from it: the midwives. Just jaw-dropping. Astounding.

    Casting about for parallel examples in public health and safety: suppose you had a culture where most water was from privately owned wells, the use of which was shared by small towns, and suppose that some were contaminated with, say vibrio cholerae. And the scientific types would be recommending that the water supply be switched to a water treatment plant, but the owners of the wells would be upset because they make their living off charging people to draw from the wells. So they might have a campaign to talk about how homey and traditional these wells are and to show that in winter, people weren’t dying from cholera, so….. Would people allow this?

    Or suppose it’s the early age of aviation, and everyone is used to learning how to fly in fairly haphazard ways, and someone starts an airline. The pilots can be drawn from the early risk-taking barnstormers or from people who have undergone rigorous training and testing and follow strict protocols. And within a short time, it’s clear that the barnstormers crash more often and more people die riding with them than with the professionally trained pilots. To make matters worse, the barnstormers’ risk-taking puts the planes flown by the pros in troulbe because of their behavior, so everyone is at peril. But the barnstormers are so historic! So quaint! Would anyone think this was acceptable?

    At what point does this stop? Because I can’t think of a single other situation where this kind of disparity in outcomes would be allowed to stand. Is it something special about women’s health and babies’ well-being that leads people to shrug and say, “It’s been our way, we’re not going to change it”?

    • delicate white.
      September 12, 2014 at 10:30 pm #

      I think its misogyny. They don’t think women’s health is worth protecting.

      • September 13, 2014 at 2:56 am #

        The Dutch believe that the pain is better for women, is empowering, is good for the bonding.It’s getting better though: if you want a hospital birth, the insurance will now pay for it. And if you want an epidural, it will be considered medically necessary and the insurance will pay for that as well. I’m writing a book about giving birth in the Netherlands and talked to a doula, who expressed her concern that in the future, every pregnant woman in the Netherlands will get a team instead of a midwife. I thought it’d be a good thing though.

        • SporkParade
          September 13, 2014 at 6:06 am #

          Let us know once you’ve published it! I’m thinking of becoming a doula precisely because I think there need to be more labor support people who are fans of medicalized birth, who are dedicated to giving accurate information and letting women decide.

          • September 13, 2014 at 6:15 am #

            Precisely! I want to write a guide to navigating the Dutch system for my fellow expats, but it can take me a while until it’s done, but thank you so much for your interest! Besides, I had a doula and a birth plan in the Netherlands for that very reason: I wanted my wish for pain relief, if needed, to be respected, and the doula was a great help! And accurate information is very important because many doulas favour natural birth and often try to persuade their clients to change their mind and forgo pain relief. My doula was surprised that my son was born alert and crying even though I had a shot of pethidine! She expected him to be high and sleepy!

          • September 13, 2014 at 6:16 am #

            If you’re interested in this topic, try ” A pleasing birth” by Pieter de Vrees. He’s very fond of the Dutch system and Duthc midwives but does a good job of describing the system.

          • Young CC Prof
            September 13, 2014 at 10:08 am #

            Excellent! I’d love to be a doula, but dropping everything to attend a labor doesn’t fit my life right now. Maybe later when my son is older.

    • fiftyfifty1
      September 13, 2014 at 8:16 am #

      “they might have a campaign to talk about how homey and traditional these wells are ”

      Oh you mustn’t forget to say how the people have grown hale, hearty (not to mention blond) for generations on the well water.

      • fiftyfifty1
        September 13, 2014 at 8:18 am #

        eta: because a spoon full of flattery (and even perhaps subtle xenophobia) makes the medicine go down!

  2. Ines
    September 12, 2014 at 4:07 am #

    The root cause of the failure of the Dutch maternity system is the underlying paradigm that “pregnancy is not a disease’.
    The whole organization is geared towards the assumption that risk is low by default, testing is unnecessary until proven otherwise, and the low tech option is always the better one.
    Dutch midwives are very proud of this ‘unique’ outlook on pregnancy. They attach great moral superiority to avoiding ultrasounds, prenatal testing and hospital birth for ‘low risk’ women.
    The Netherlands are what happens when the collective delusion of “birth is not dangerous” that we see so often in home birth midwives is allowed to permeate the mainstream.

    • SporkParade
      September 12, 2014 at 5:27 am #

      So this is a failure specific to the Dutch maternity system? I hope to God it is, since I’m not too far away from giving birth in a different country’s midwife-based maternity system. Although maybe it’s not quite fair to describe it that way, since the midwives only do the delivery, not the prenatal care, which is handled by OB-GYNs.

      • September 12, 2014 at 7:08 am #

        The NL have a healthcare system that differs greatly from other countries. What you describe is pretty typical, but your care is usually done by the OB (although in countries like Great Britain it could be done by midwives).In the NL, not only do midwives do delivery, they also decide who gets to see an OB.

        • Joy
          September 12, 2014 at 6:37 pm #

          As far as I am aware, the midwives in the UK decide who gets to see an OB. I never saw an OB, or the same midwife twice for that matter.

          • September 13, 2014 at 3:17 am #

            Thanks, Joy, yes the UK system is similar to the Dutch one. You get to see a midwife in an independent practice, and if there is more than 1 midwife, you will get to know them all because they don’t know who will be at the birth.

          • Joy
            September 13, 2014 at 7:02 am #

            Well, in most places in the UK you get one named midwife. I didn’t really get to know all of the midwives, so much as I would show up for my appointment, and it would be someone different each time. But then, they often didn’t have any appointments at my GP’s so I had to travel all over to get one anyway. I don’t think any of the midwives I saw do births in the hospital. You have midwives who do your appointments while pregnant and then there are ones who do births. At least in my area. So no matter what I wouldn’t have known who was at the birth. So much more personal than a mean old American OB.

        • delicate white.
          September 12, 2014 at 10:32 pm #

          That is terrible! They are so biased against women seeing an OB! When really it should be a right!

          • September 13, 2014 at 3:19 am #

            I agree. The reason is that they don’t want to overschedule the OB who are only for emergencies, c sections etc. So if all is fine, the midwife should be OK and if there’s something wrong, she will transfer you to OB care. But the midwives get paid depending on how much of the pregnancy and birth they covered, so they may not be so willing to do the transfer.

      • September 13, 2014 at 2:43 am #

        The key, IMO, is working in a collaborative relationship with OBs, not a confrontational one. Here in Israel (and in the UK when I was there, 40 years ago) we function(ed)as a team, with very clear parameters on our standards of practice. OBs in Israel do the antenatal care, which midwives did in the UK, but in L&D they are essentially on-call and midwives have considerable, but not total autonomy. Works well.

    • September 12, 2014 at 5:34 am #

      not only that, but you get “punished” by complications by getting dumped onto an OB, which means that not only are you anxoius that something is happening to your baby, but you also get to see new people and that is after the midwives tell you all the “horrible” things that happen if the birth becomes medicalized.

    • araikwao
      September 12, 2014 at 6:24 am #

      Avoiding US and prenatal testng is encouraged amongst the majority, then? Yikes..

      • September 13, 2014 at 3:12 am #

        no, not really it isn’t. They do ultrasounds, as I mentioned in a comment above. It’s more that they see some interventions as necessary and others as useless and their reasons are rather arbitrary. They for example are very concerned about the triple test for Down syndrome, to give you the choice of aborting before 16 weeks or so. Also, a lot depends on the history a woman had: someone who has no history of anything, will be convinved to have the most natural birth possible, when there were complications at a previous pregnancy, they may get transfered to a doctor depending on the problem. It seems this system is erally great for two kinds of women: 1) totally low risk pregnancies when the woman wants a natural birth 2) really bad problems, (like losing a baby), then the care is aparently amazing as well (from what I heard from women who actually did lose their babies). Anything in between, it’s harder because your problems may feel “not big enough” for the midwives to take you seriously or transfer you, and you don’t feel supported if you want more tests.

    • fiftyfifty1
      September 12, 2014 at 10:51 am #

      ” They attach great moral superiority to avoiding ultrasounds, prenatal testing and hospital birth for ‘low risk’ women. ”
      Seems to me that they also attach moral superiority to being low risk and not needing intervention in and of itself. As in Dutch women are hale hearty and sensible unlike those other hysterical and weak women from Other Nations.

    • September 13, 2014 at 3:04 am #

      Actually, you do get ultrasounds here. 3 during pregnancy is common. I had one at 8 weeks to determine whether there really is a baby in there, one at 12 weeks (to see if the baby was fine and growing properly), one at 20 weeks (the measuerements etc done at a special ultrasound centre), one at 30 weeks (an optional one because I was afraid that the baby will be too big and one at 36 weeks (to see if the baby is head down). Additionally, before 12 weks they asked me whether I wanted to do the triple test and check the baby for example for Down syndrome. I also had 2 blood tests (but they don’t check for toxoplasmosis here etc). With my second pregnancy, they also did urine checks but somehow said that it’s not supported by science and only do it when the blood pressure goes up. Which is a pity because you can tell a lot from a urine test, not only whether there is a risk of preeclampsia. They have no problem getting you into hospital, but prefer if they come to your house first. I know women who actually went to the hospital and didn’t call their midwives until they arrived at the hospital. After birth, if all goes well, you can go home really quickly (like after a few hours) and then you have the most amazing post partum care at your own home (think nurse/miwdife/cleaning lady/cook/childminder all rolled into one. It’s not as bad as it sounds, and I think it’s getting better.

  3. Young CC Prof
    September 11, 2014 at 9:37 pm #

    I have several possible takeaways:

    1) If you are having a baby under midwife care in the NL, you might as well have a home birth because you won’t get proper care in the hospital.

    2) If you are having a baby in the NL, do anything you can to get bumped to OB care.

    3) Don’t have a baby in the Netherlands if you can avoid it.

    • September 12, 2014 at 7:11 am #

      1) I tried and they transfered me to the hospital at first sight of trouble (meconium in the water). And I am so grateful for this. 2) if you’re not Dutch that may be easier to do since many expat women call their GP first and are given the choice between a doctor and midwife. 3) My experiences from having a baby in Germany were even worse than in the NL but then the birth was also much harder than the one I had here. and it would probably have been even worse to give birth in my native Poland. That being said, I wuld have preferred to have a doctor for my delivieries here.

  4. Kazia
    September 11, 2014 at 6:48 pm #

    I think I just made enemies in one of my classes by saying lay midwives aren’t qualified to be midwives. l can be rather… pig head, I guess. Oh well!

    • DoulaGuest
      September 11, 2014 at 7:18 pm #

      Working towards my CNM right now (in nursing school!), and I’ve run across the same with friends in midwifery and nursing school on the midwifery path. I say if that’s your though, then do you even respect your own credential?

      • Kazia
        September 11, 2014 at 9:56 pm #

        I’m in a child development class (my minor), and according to my professor, a lot of child development majors go on to be midwives (no way in hell would I let any of them anywhere near my nether regions). The professor is very pro-NCB, and reccomended we watch “The Business of Being Born.” I didn’t particularly like her before, but it was still disappointing.

        And she said some very snide things about scheduled elective c-sections too. I don’t want to piss her off too much, so I’ll be keeping my head down.

        • Young CC Prof
          September 11, 2014 at 10:01 pm #

          I firmly believe that a lectern is not a soap box. Your professor is not cool.

          • Kazia
            September 11, 2014 at 10:22 pm #

            I agree. It’s one thing to express your opinion, but it’s not okay to shame others in the process.

          • Dr Jay
            September 11, 2014 at 10:51 pm #

            It’s even worse when you use your position to promote an opinion that has no basis in fact. Unless she’s a professor of Ob/Gyn she should shut her yap.

        • Life Tip
          September 12, 2014 at 12:08 am #

          If you fill out professor evaluations at the end of the semester, I would absolutely bring that up. Not cool at all.

          • Kazia
            September 12, 2014 at 12:21 am #

            Anonymous evaluations are mandatory for every class. I’ll defintely bring that up.

        • delicate white.
          September 12, 2014 at 10:37 pm #

          I believe the root of all evil is people believing they have entitlement to dictate what another person can do with their bodies. I do not want to be a mother but if I did I would schedule an elective c-section no question. I have anxiety and I know I could not handle waiting for my water to break and going through labour. I would feel humiliated. The decision to have an elective c-section is an extremely personal one and no one should ever be looked down on for it. We should start looking down on home birth as a society, because it is so dangerous.

  5. CanDoc
    September 11, 2014 at 6:38 pm #

    Nulliparous women have a 1% chance of a DEAD BABY with Dutch midwives? ONE PERCENT. That’s HIGHER than the reported risk of of dead baby with a *VBAC* (which is about 0.01-0.25%, depending.) Chilling.

    • Amy Tuteur, MD
      September 11, 2014 at 7:09 pm #

      Not 1%, but 1/1000. If you look closely at the percent sign, it has two zeros in the denominator, not one.

      • Amazed
        September 11, 2014 at 7:15 pm #

        Wow, I didn’t see it. Thanks!

        Once again, the 3 times higher risk is rearing its ugly head.

        I do realize it isn’t really comparing likes with likes. Hospital birth in the USA and homebirth in the Netherlands cannot be compared. Still, American low-risk hospital birth has a mortality of 3-6/1000, right?

        Weird how consistent the threefold risk is.

        • attitude devant
          September 11, 2014 at 8:50 pm #

          It is a remarkably robust finding!!!

        • Young CC Prof
          September 11, 2014 at 9:48 pm #

          Neonatal mortality for term full-weight babies is 0.3 for hospital midwives, 0.6 for hospital OBs. (Lower, as it should be, since the midwives are delivering low-risk babies.)

          Intrapartum mortality, also included in the latest de Jong study, is not specifically tracked in the US. However, 0.1 per thousand is probably a reasonable estimate. (Keep in mind total term stillbirths are less than 1 per thousand in the USA.)

  6. moto_librarian
    September 11, 2014 at 2:31 pm #

    I seriously question the credentials of whomever peer-reviewed this paper. To fail to compare mortality rates between midwives and OBs seems to be a huge error, and I cannot believe that it was overlooked.

    I know, I know…it was peer-reviewed by people with the agenda to promote home birth. I still expect better than this though.

    • Dr Jay
      September 11, 2014 at 10:55 pm #

      You wouldn’t *believe* the politics that go into who gets published and what they can say. My boss is probably the world expert on pelvic floor trauma, and he recently had a study rejected from the local rag because he referred to the patients as “nullips” and not “clients” or some other fool thing. You could tell the reviewer was a MW (and a not too clever one at that) and was being deliberately obstructive as no one here wants anyone to talk about the damage that is done to the pelvic floor in child birth!

      • Siri
        September 11, 2014 at 11:44 pm #

        Actually it would make quite a good term of abuse – ‘you bloody nullip’!

      • delicate white.
        September 12, 2014 at 10:39 pm #

        Can you tell me more about damage to the pelvic floor in childbirth? Can it be avoided by elective c-section?

        • fiftyfifty1
          September 13, 2014 at 8:11 am #

          Here’s a good book to read that goes in depth and lays out both the pros and cons of planning a CS. There is a lot on the pelvic floor:
          Choosing Cesarean: A Natural Birth Choice
          authors Hull and Murphy.

        • Poogles
          September 18, 2014 at 8:02 pm #

          “Can you tell me more about damage to the pelvic floor in childbirth? Can it be avoided by elective c-section?”

          In a very general sense, you cannot expect it to be completely avoided by pre-labor CS because some pelvic floor damage can be caused just by being pregnant. However – you’re very likely to have less damage with a pre-labor CS than a vaginal delivery, and if you’re lucky enough you could avoid all damage.

          I also second fiftyfifty’s suggestion – a great book that covers the topic in great detail.

  7. fiftyfifty1
    September 11, 2014 at 1:26 pm #

    I would also love to be able to see the stillbirth rates. These can make up a big part of perinatal mortality rates and a large percentage of stillbirths are avoidable with excellent prenatal care. A vital part of this prenatal care is timely inductions including *routine* inductions for going over the due date. But too many midwives (both lay midwives and highly trained midwives) have a laissez-faire attitude where “babies aren’t library books, they don’t have due dates”.

    • atmtx
      September 11, 2014 at 2:16 pm #

      A library book will also be fine when you forget about it on the floorboard of your car for a month. Can’t say the same about a baby.

      • Siri
        September 11, 2014 at 11:46 pm #

        Plus you can take it back and swap it for a more enjoyable one. A baby you’re stuck with forever!

        • An Actual Attorney
          September 12, 2014 at 6:35 am #

          And if you accidentally destroy a library book, you can quickly replace it with one from Amazon.

          • Siri
            September 13, 2014 at 6:27 am #

            For a baby, you have to go to Craigslist.

          • araikwao
            September 13, 2014 at 7:45 am #

            Ah, so you can get more than just their milk there, it’s quite the one stop shop!

    • Dr Jay
      September 11, 2014 at 10:57 pm #

      Exactly. I had a colleague tell me the other day that they are thinking of pushing IOL for post dates back to “get the CS rate down.” No concern re: increase in SB rates (especially for older mothers) and no insight into the fact that a move like this will likely INCREASE the CS rate.

      • Young CC Prof
        September 11, 2014 at 11:08 pm #

        Actually, in the USA, they’ve recently opened a controlled trial of automatic 39-week induction, to see what happens to stillbirth rates, neonatal morbidity, and c-section and other labor complication rates.

        If they find better outcomes AND lower c-section rates, will NCB’s collective head explode? Only 2 years until we find out!

        • Siri
          September 11, 2014 at 11:45 pm #

          But you’ve got to be a bloody nullip to take part (see above), so how will they recruit?!

        • Amy
          September 12, 2014 at 11:43 am #

          I just read a birth story a day or so ago… I believe it was my due date group on Baby Bump. This woman said that her dr with her last child WOULD NOT induce her till 42 weeks! I guess she came out OK, I don’t remember any negative outcomes.

          But how do you tell women to trust their OB’s when there are OB’s like this?

          • Jenny_from_da_Bloc
            September 12, 2014 at 9:58 pm #

            My OB and I had a conversation about induction/cs today at my appt. She said she will induce any of her patient’s who ask to be induced as long as they are 39 wks. She also said she will perform MRCS if a patient wants a CS even if it is her first baby. She also does VBACs as long as the patient is a good candidate. Her exact words were, “My job is to deliver babies safely and make sure everybody comes out alive. My job is not to tell you how to give birth, that is your choice. But I do make sure all my patient’s understand the risks of every decision especially if they are making bad choices.” She then asked me, ” So, what day are we having.this baby? Does 10/3 sound like a good day for a c-section?”

          • Dr Jay
            September 13, 2014 at 3:39 am #

            That’s how I practice, too. If you’re old enough to get pregnant, you’re old enough to decide what you want to do to get that child out. I won’t help you do something overtly dangerous or stupid, but as long as you understand the risks, I don’t mind how you deliver/give birth.

          • Poogles
            September 18, 2014 at 2:21 pm #

            “She also said she will perform MRCS if a patient wants a CS even if it is her first baby.”

            I see you’re in Ohio…any chance it’s Central Ohio and/or you can tell me your OB’s name? (Looking for an OB who is MRCS friendly 🙂 )

          • Jenny_from_da_Bloc
            September 18, 2014 at 7:58 pm #

            I’m in SW Ohio and my OB is Dr. Egbert. I live less than 1.5 hours from Columbus if that helps. My husband’s cousin lives in Columbus and had a MRCS about 6 months ago, I will find out that OBs name for you too.

          • Poogles
            September 18, 2014 at 9:28 pm #

            Oh awesome! Thank you!

        • Ash
          September 12, 2014 at 11:17 pm #

          dog bless the study teams on this trial. 6000 pts as enrollment goal, 2 years to enroll, and some of the sites aren’t up and running yet. I suspect they won’t be able to enroll 6000 by the time the funding cycle ends.

          • Young CC Prof
            September 13, 2014 at 10:12 am #

            Even if they fall a bit short, they should still be able to measure things like c-section rate and NICU admission rate. They won’t be able to measure perinatal death.

            Heck, even 6,000 low-risk women will probably not be enough for that, the expected number of deaths is 3.

      • Anonymous
        September 13, 2014 at 7:52 am #

        In the UK, induction after 41 weeks REDUCES the CS rate. Something to think on.

  8. Amy M
    September 11, 2014 at 1:10 pm #

    So these 4 studies and all the data collected, show that homebirth (always with a midwife) is not as safe as hospital birth, period. Of course, that’s in the Netherlands, and outcomes may be different in Sweden or wherever. Is it at all possible to compare these data with the Birthplace study that we were all discussing in the last post?

    If the numbers differ in the UK, that homebirth with a midwife IS safer than high-risk hospital birth with an OB, could it mean UK midwives are better trained? Or that high-risk OBs are not as well trained in the UK? Or that a given set of complications is more likely in the Netherlands than the UK? Or is there just no way to compare?

    • Mariana Baca
      September 11, 2014 at 2:25 pm #

      could also be that the system is more rigid in the Netherlands, so transferring from being “low risk” to “high risk” is more difficult/has a higher barrier of entry, and midwives are left to take care of women better suited for OB care for cost savings or bureaucracy.

    • attitude devant
      September 11, 2014 at 2:44 pm #

      Well, as we said before, with the Birthplace study, the protocols for risking out were MUCH stricter than the protocols used in general. So there’s that. Additionally, they had some kind of expedited transport system in place. On Dr. Amy’s Fed Up page she links to a story about delays in obstetrical transport in the Netherlands due to inadequate numbers of OB units. So if things go south, you may not get to the hospital fast. But what is REALLY the shocker here is that in the Netherlands midwifery care, in or out of the hospital, is an independent risk factor for a bad outcome.

      • Sue
        September 12, 2014 at 5:21 am #

        Right, AD – the Birthplace study had not only a tight risk-out regime, but also a 40% transfer rate – and there was still a 3x excess mortality in the babies of first-timers. They didn’t even report morbidity like hypoxic injury.

      • Hannah
        September 13, 2014 at 6:09 pm #

        I’ve said this before, but it’s worth repeating. The reason that the Birthplace study didn’t match the protocols used “in the wild” in the UK, is because there aren’t any fixed protocols as such. If you insist on having a homebirth, in theory you have the right to have someone come to attend you although the counselling you receive will be very different if you’re a multip with a pristine medical and obstetric history compared to a breech, twin, VBAC. Nevertheless if you are in the minority, albeit non-trivial, of multips with a pristine history in the UK, or someone who cares for one, it’s still useful information, in as far as it goes, that you can have a homebirth without significant increase in risks and perhaps some benefits in terms of lower unplanned caesarean rate. If you fall outside the studied group then it’s not relevant to you although that’s not to say it’s never abused in that way.

  9. September 11, 2014 at 12:59 pm #

    Good grief.. I’m glad I won’t have any more children.

  10. Mel
    September 11, 2014 at 12:41 pm #

    “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.”

    That’s a freaking terrifying sentence. Some problems that friends/family have had that were high risk and ended up with healthy babies thanks to careful prenatal care and monitoring: mono/mono twins, mono/di twins with TTTS, short cervix (measured in mm at 20 weeks gestation, bicornate uterus and lots of preeclampsia cases.

    If healthy, low-risk women are losing more babies with midwives than women with terrifying, dangerous prenatal conditions under the care of an OB – RUN AWAY FROM THE MIDWIVES.

    • Turkey Sandwich
      September 11, 2014 at 2:48 pm #

      You say that as if we get a choice! You cannot opt in to OB care in the NL.

      • atmtx
        September 11, 2014 at 3:03 pm #

        And that seriously sucks. I’m so sorry.

      • Kesiana
        September 11, 2014 at 6:05 pm #

        What?! So what ARE your care choices??

        • Ines
          September 12, 2014 at 3:42 am #

          Simple: you cannot see an OB until your midwife says you can.

          • Amy M
            September 12, 2014 at 7:57 am #

            What do they do if a baby dies on their watch?

          • MaineJen
            September 12, 2014 at 1:36 pm #

            I’ll bet you are ridiculed if you want pain relief, too. That is just not right…

        • Turkey Sandwich
          September 12, 2014 at 3:07 pm #

          tl;dr version: there are few choices, but that doesn’t automatically mean bad care

          I was able to choose my practice and give preference on which hospital I delivered in, but even that wasn’t a given. Don’t get me wrong-during my second pregnancy I received fantastic care. Plenty of tests and several ultrasounds. When I needed emotional support due to some issues related to the pregnancy, I got, it no questions asked. I got referrals to specialist therapists and extra appointments. If I expressed concern about anything, it was immediately further investigated. Despite all this I am able to look critically at the system and see its flaws. I do think women should get more choice in their care than they do, and this archaic belief that we should avoid pain relief at all costs needs to go sooner rather than later.

          Strangely though, in the US I had even less choice than I did here. Being uninsured in a rural area leaves much to be desired, after all. I think this sometimes (not always!) gets overlooked in these discussions. Where I lived, there was one midwife in town who would see me (there was an OB in the practice, but it was quite well known in town he wouldn’t see medicade/uninsured patients unless absolutely necessary), one hospital with no bells nor whistles, and I couldn’t afford pain relief even if I wanted it (I ended up delivering in the NL anyway). Maybe a screwed up perspective, but at least I’m not in debt and got to pick a practice that suited my needs.

          • Young CC Prof
            September 12, 2014 at 3:16 pm #

            Oh yes, in the US, you may not have many choices unless you have money or good insurance. And the special problems of delivering rural health care are rare in most of Europe, though not in Australia.

    • atmtx
      September 11, 2014 at 3:02 pm #

      This is what I really don’t get. If you have unfettered access to the person with more knowledge, then why don’t you go to them? I certainly didn’t need an OB, but you bet I went to one. If I’m paying the same price (actually less, with my insurance), I want the best.

      And if home is safer than the hospital, then why don’t people planning hospital births have transfer plans in place to go home if there’s a problem? Why do all people planning a homebirth and hell, all birth center websites I’ve seen, tout their close proximity to hospitals?

  11. Mel
    September 11, 2014 at 12:36 pm #

    If at first you don’t succeed, redefine your control group until you do! That’s the first rule of responsible science, right?

    • Dr Kitty
      September 12, 2014 at 5:21 am #

      I’m waiting for the study that says
      “Homebirth is as safe as hospital care for white, married, university educated women with no prior medical history who live within 500m of a level 2 NICU. Our authors are hopeful the same result can be replicated in their next study population in rural Mississippi.”

      That’s really what we’ve got from most of these studies. “Homebirth is safe in very specific situations, therefore, logically it should be safe in most conditions”.

      • Amy M
        September 12, 2014 at 7:59 am #

        Like SCUBA diving. Most people can learn to dive and have a safe dive, but asthmatics and COPD sufferers are not allowed. As individuals they might be fine, but the overall risk is greater. So, it would be wrong to say “EVERYONE in the whole world can SCUBA dive. It’s as safe or safer than taking a shower!”

      • Young CC Prof
        September 12, 2014 at 8:19 am #

        Yup. The results of the UK Birthplace study weren’t as good as US hospital birth, but they weren’t radically worse.

        That study is CONSTANTLY used to justify home birth in the USA, undertaken with none of those safety measures.

      • fiftyfifty1
        September 12, 2014 at 8:28 am #

        “That’s really what we’ve got from most of these studies. “Homebirth is safe in very specific situations,”

        And I don’t even think we really even have that. I think what we actually have is “An *ultra* low risk population can have outcomes at home that match those of a regular low risk population in hospital”

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