In international debates about birthing practices, the Netherlands is often portrayed as the ‘homebirth paradise’ – a country where most children are born at home, placed in the arms of happy mothers who are assisted by capable, supportive and understanding midwives. How accurate is this portrayal?
For many mothers, giving birth at home without too much medical interference, analgesia and in familiar surroundings is almost impossible to attain – except in the Netherlands, where it is allegedly standard practice. Even though the high rate of homebirth in the Netherlands is often considered inspiring and worth emulating, Dutch practices have not always been scrutinised in great detail. A closer look would reveal that giving birth at home has recently received considerable criticism because it is seen as the main culprit for the relatively high Dutch perinatal mortality rate; one of the highest in Europe. Today, in the Netherlands, many people think that the practice of giving birth at home puts young lives at risk unnecessarily. In this article, I will give an overview of the public debate about ‘baby mortality’ in the Netherlands – how it has been presented in the media and how non-medically trained people think about it. It should be emphasised that many mothers, mothersto-be, physicians and midwives hold highly nuanced opinions – yet when they are covered in the media, these nuances tend to disappear. The opinions presented here are not universally shared, but they have been highly visible and have shaped the debate.
The Netherlands has a problem
It all started in 2003, when a major European study showed that perinatal mortality rates in the Netherlands were among the highest in Europe (10.5 per 1000 births, or just over one per cent, or around 1700 babies, every year). After initial disbelief, denial (mostly by politicians) and criticism of the study’s methodology (by physicians), it was concluded that ‘the Netherlands has a problem’. ‘Only when we were confronted with international monitoring figures did it become clear that our cherished feeling of complacency had been unjustified. ‘The shock was great,’ as two researchers later described this moment. Could it be that the treasured practice of homebirth was to blame (around 30 per cent of women intend to deliver at home, attended by a midwife). A number of outspoken obstetricians and gynaecologists surely believed this and did not hesitate to present their opinions to the media. Midwives quickly rebutted their claims, pointing to the increasing and unnecessary medicalisation of childbirth as the cause of the problem. After all, they argued, a baby is not a problem or a disease, but a wonderful little creature best received lovingly into the world in one’s natural surroundings.
Initially, physicians and other commentators suggested that a number of not entirely unexpected conditions were to blame: Dutch women give birth relatively late in life; not all of them give up smoking and drinking while pregnant; there is a relatively high number of immigrant women who do not frequently consult physicians and report to midwives very late in their pregnancy; and there are issues related to poverty and social disadvantage. Perinatal mortality rates and other complications during and after delivery are certainly higher in poor and disadvantaged neighbourhoods. The city of Rotterdam organised more maternal healthcare in such neighbourhoods – to good effect. Nevertheless, even though all these factors are of importance, they are not sufficient to explain the differences in perinatal mortality rates in Europe. Even when they all are corrected for, the Dutch still have a problem.
Sniping between midwives and obstetricians
As presented by the media, which covered it widely, the debate on the high Dutch perinatal mortality rate became highly polarised. It often turned into finger-pointing and mutual recrimination between midwives (at one point branded as the ‘midwife mafia’) and obstetricians, with the voices of a few worried mothers-to-be mixed in. Not surprisingly, it was partly inspired by professional rivalry. Midwives and obstetricians conducted surveys and studies to buttress their views, published these in their own journals, wrote articles for the newspapers’ opinion pages and appeared on current events shows to present their viewpoints and rebut those of others. However, more than just professional rivalry is at stake. Both groups operate from an entirely different philosophy. Midwives consider giving birth an entirely natural process that constitutes a high point in a woman’s life. Giving birth is a celebration of life that best takes place in one’s natural surroundings without men in white coats interfering and disempowering them. Obstetricians, on the contrary, view the process of giving birth as inherently perilous and fraught with dangers, which require quick medical intervention that can best be provided by highly trained and specialised medical professionals.
The media followed the debate about giving birth in the Netherlands closely (every new medical study and government initiative is now covered extensively) and Labour politician Khadija Arib continued to bring the matter to the attention of parliament. Leading obstetricians blamed the archaic and ill-informed practices of midwives, who, according to them, are insufficiently trained to recognise complications during childbirth early enough. In the Netherlands, midwives make an early selection of women whose pregnancy is associated with one or more risk factors; these women are referred to obstetricians. In 2000, about 30 per cent of women opted to give birth at home and were screened as low risk. Yet, more than 30 per cent of these women were transferred to the hospital during their delivery (for first deliveries this number rises to 40–50 per cent) because of complications. Obstetricians argued that risk factors had not been recognised. It became clear the detection of risk factors should be improved – even though it was not clear how this could be accomplished.
Highlights from 2010 research
From a midwife: ‘Epidural anaesthetic and pain medication on indication is fine, for someone who really cannot cope, but I have a lot of problems with giving it on demand. There is a range of side effects. It happens that women are offered pain medication at a bad moment (during labour), they take it, but a few are rather upset about it afterwards.’
From a new mother: ‘What struck me was the way homebirth has been greatly encouraged over the past ten years, and I wonder if that is a cost-containing exercise. It is currently considered normal to give birth at home and the GP and midwife encourage this. During my labour I had the same midwife until I was taken to hospital – my labour lasted 28 hours, of those 21 were at home. The midwife did her first check with me at 2pm, the last one at 2am, in the meantime I could reach her by phone. I was rather taken aback when I found out how normal it is these days to ask for pain medication during delivery. I always thought that that only happened when complications occurred, but it turns out that you can get what you ask for, during delivery or ahead of time.’
Doctors nowhere to be found after hours
Even though it was acknowledged there was a problem, little was done during the next five years. In 2008, the debate flared up again. This time, obstetricians bore the brunt of criticism after it became clear the perinatal mortality rate of women who give birth in hospitals increases by 23 per cent after hours and seven per cent during the weekend. This is not hard to explain: it is almost impossible to find medical specialists in hospitals after hours, leaving mothers who encounter problems during delivery high and dry (for example, no caesareans can be conducted or epidurals administered). The residents who are on call are often hesitant to contact specialists after hours and, when they are called, it takes some time for them to get to the hospital (not surprisingly, it takes even more time to fully staff an operating theatre). The absent obstetrician rather than the ignorant midwife was now blamed for the high baby mortality rates in the Netherlands. In addition, it was also claimed that obstetricians had too much of a wait-and-see attitude both towards preterm babies as well as towards babies that are overdue. Obstetricians were generally hesitant to intervene, preferring to let nature take its course, with, at times, disastrous consequences.
In the summer of 2008, a number of leading advocates of homebirth found that a significant number of young mothers (16.5 per cent) were dissatisfied with their birth experience looking back after three years, a rate almost double that of other developed nations. It did not matter very much whether these mothers had given birth at home or in the hospital. The interviews these researchers had conducted provided a bleak image of blunt obstetricians, insensitive assistants and overly pressured midwives. They were particularly dismayed by these findings because, for years, international delegations had visited the Netherlands to admire its obstetrics system. Two of the researchers stated that the Low Countries could no longer be portrayed as a model for others. Midwives were not happy either. The time that a midwife would attend the birth process from first contraction to delivery is long since gone; these days, they frantically cycle between deliveries which, not surprisingly, decreases the quality of care they can give to each future mother. Mothers, midwives and obstetricians were not happy. In the portrayals provided by the media, it appeared that strife, dissatisfaction and unhappiness reigned in the former homebirth paradise.
To make matters worse, it turned out, through a replication of the large European study of 2003, which had been the source of all concerns, that hardly any improvements had been made during the previous five years. The Netherlands still had the same problem as it had had five years before. The Minister of Health, in a quick reaction, urged hospitals to make around-the-clock services available that are within easy reach of the whole population. Others suggested building birth centres next to hospitals so that specialist help would always be close at hand. Still, today, little progress has been made.
During the second part of 2009, two current affairs programs gave attention to the debate featuring several prominent obstetricians and parents who had lost their babies during delivery. The Dutch system of homebirth, late referrals to the hospital and the absence of around-the-clock specialist delivery care were blamed. The physicians featured in these programs advocated that all deliveries should take place in specialised hospitals with around-the-clock specialist care only. Or they could take place in special birth centres to be built next to hospitals. New research demonstrated that women who were transferred to the hospital after delivery had started at home encountered the greatest number of complications. They were most unhappy about their birth experience afterwards as well. Many pregnant women who intended to give birth at home became worried. Research indicating homebirth was not unnecessarily risky was mostly ignored. A committee appointed by the Minister for Health recommended pregnant women be better informed, midwives and obstetricians should cooperate better and a select number of hospitals should provide specialist care 24 hours a day. Women should not deliver at home when there are any risks.
Transfer from midwife to obstetrician the problem
In the second quarter of 2010, the results of a large research project commissioned by the Ministry of Health were published. It concluded that the chances of an adverse outcome increase dramatically for women who were transferred to a hospital during delivery. In addition, the researchers noted that 25 per cent of risk factors had not been recognised by midwives, who are responsible for screening for them. Deficiencies in the organisation of care were thought to be responsible: in particular, the lack of communication, coordination and cooperation between midwives and obstetricians. Later that year, a study claimed that babies of women classified as low risk and starting care under the supervision of a midwife, had a higher rate of perinatal death and the same rate of admission to a neonatal intensive care unit when compared to babies of high risk women starting labour under the care of obstetricians. When a woman was transferred from home to the hospital during her delivery, perimortality rates increased almost fourfold. Both studies intensified the public debate.
Public opinion started to shift away from women who like to give birth at home, ‘surrounded by cats, lit candles, doing contractiondances… with Norah Jones as background music and a skippy ball for pain relief.’ Instead, as newspaper editorials put it: ‘The typical Dutch system with midwives and home-deliveries is bankrupt’ and ‘Don’t try this at home’. The few voices disputing these conclusions were hardly heard. In response to the new consensus favouring hospital births, it was demonstrated that the rate of caesareans among women giving birth there was markedly higher, which could cause problems during their second delivery. When these were taken into account, would specialist care still appear better?
In December 2010, a forum consisting of 20 health professionals informed parliament on ways to improve things. Integration of delivery care and around-the-clock availability of specialist care were the main recommendations. One physician explicitly urged them not to conduct any further research, since the problems were already very well known. They had been known for years and it was time to take action.
Nothing new in 2011
Giving birth at home appears to be falling out of favour in the Netherlands. The number of women opting for hospital births is increasing (from 70 per cent ten years ago to 75 per cent today), even though women classified as low-risk are required to pay additional fees. Many hospitals are building birthing suites to meet the demand and an increasing number of midwives are now working in hospitals. The main reason is the extensive negative publicity related to homebirth and the availability of pain relief in hospitals. For a long time, both midwives and physicians discouraged pharmaceutical pain relief during labour. Dutch feminists have called for the right of women to pain relief, in particular epidurals, and questioned ‘the ideology of natural delivery and the positive meaning attached by midwives to women’s capacity to deal with pain without pharmacological support.’ Following a 2008 ministerial directive, women should receive pain relief on request; no longer is the decision in the hands of the physician only.
Midwives and obstetricians continue to be on somewhat less than friendly terms. Both associations of midwives and gynaecologists have developed and presented plans for improvement. The Minister of Health has again expressed her commitment to change. A few scholars from North America who recently received appointments at Dutch universities admonished against drawing hasty conclusions. The increasing medicalisation of childbirth there, which is, paradoxically, now held up as example for the Dutch healthcare system to emulate, is not without its problems either (as the increasing rate of caesareans indicates). At the same time, an almost puritan approach to delivery care was expressed by an MP who decried the scandal of pregnant women having ultrasounds ‘just for fun’. One ultrasound is standard; a second scan has to be paid for or demanded by a physician. One could be inclined to conclude that Dutch approaches to pregnancy and birth have not yet taken full advantage of the technological developments of the last 50 years. An emphasis on cutting healthcare costs is partly responsible for this.
Things still don’t look good in the former homebirth paradise. During the last few years, the Dutch healthcare system has received rather negative media coverage in which sub-standard care, malpractice, inept reactions to crises, lack of communication and coordination between specialists, fraudulent behaviour by suppliers and self-enrichment by top administrators have been central. Policies promoting the influence of market forces to reduce the cost of healthcare have not had the expected effects. The sorry state of healthcare in the Netherlands today does not provide an ideal context for the improvement of delivery care. Successive Ministers of Health have long favoured homebirth and delivery care by midwives because it was cheap. The initiatives of the current (Liberal) and previous (Labour) Ministers of Health have thus far been disappointing. In the Netherlands, giving birth at home increasingly appears as an archaic procedure, once supported by an overly idealistic belief in the benign powers of nature. Although a great number of recommendations has been made and many plans developed, the amount of actual change thus far is disappointing. The Netherlands is the homebirth paradise no more and few international delegations will be visiting the Low Countries to see how delivery care is organised there.
References are available from the author upon request.
The Royal Dutch Organisation of Midwives (KNOV): http://www.knov.nl
The Dutch Association of Obstetricians and Gynaecologists (NVOG): http://www.nvog.nl
Dossier perinatal death of Medisch Contact, a medical weekly magazine published by the KNMG, the Royal Dutch Society of Physicians: http://medischcontact.artsennet.nl/Dossiers/Alle-dossiers-1/Perinatale-sterfte.htm
Dossier perinatal death of the Nederlands Tijdschrift voor Geneeskunde [Dutch Medical Journal]: http://www.ntvg.nl/dossier/perinatale-sterfte
Newspaper articles can easily be found at http://www.volkskrant.nl and http://www.nrc.nl
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