Table 1: Place of Birth in the Netherlands Since 1994 (as Percentages of all Births)
1994–1996 1998–2000 2001–2003 2004–2006 2005–2007 2006–2008 2007–2009 2008–2010
34.1 31.9 31.6 29.4 28.4 23.9 23.4
65.8 67.9 67.8 70.2 71.4 75.6 75.3
Hospital births include births occurring in outpatient clinics located within hospitals and attended by midwives. The 95 % confidence level for all years is ±3.3 %. The figures come from a Dutch national survey. Source: CBS Statline, 2012.29
accounts that enumerate the risks of home birth and celebrate the safety of hospital birth are gradually altering Dutch public opinion.
The effect of this attack on home birth in the Netherlands can be seen in Table 1: in the 17 years between 1994 and 2010, the home birth rate dropped by a third, from 34.1 to 23.4 % of all births. Although not all of this decline can be blamed on the misuse of science, questionable research emphasising the dangerousness of home birth and associated publicity campaigns have been important engines driving healthy women with physiological pregnancies to give birth in hospital.
In an effort to more fully understand this new role played by the Netherlands in the debate over the place of birth, we examine the quality of the body of recent research that is putting home birth under pressure. Closer examination of these studies makes it clear that this research lacks rigour, yet it is finding its way into the most prestigious medical journals. Their design, analyses and conclusions are heavily influenced by gender, professional interests and cultural assumptions hiding behind claims of objectivity. In other parts of the developed world, as home birth re-emerges, we are seeing a similar pattern of ‘scientific’ assault on the practice. It is important that we understand how this research questioning the safety of home birth and the popular media reports derived from it are shaped by a variety of social factors. This is where the Netherlands has become a new and valuable model for those interested in home birth.
The Strange Science of Home Birth The 2 November 2010 issue of the British Medical Journal (BMJ) included an article, ‘Perinatal mortality and severe morbidity in low and high risk term pregnancies in the Netherlands: prospective cohort study’, authored by a group of researchers from the Utrecht area in the Netherlands.9
midwife-led home births and midwife-led clinic births – the results questioned all births attended by midwives, including home births.
Needless to say, these findings came as a shock to Dutch maternity care-givers. Media accounts of the research – with eye-catching headlines such as “Obstetric system in the Netherlands is failing”, “The obstetric system is to blame for baby deaths”, “Child deaths two times higher with midwives in attendance” – caused widespread concern about the continued use of home as a place of birth.
We now know that the data used in this study are questionable. The researchers combined data on births in and around the Utrecht area taken from the Perinatal Registry Netherlands (PRN) – a national database assembled from reports from midwives, obstetricians and paediatricians – with prospective data on perinatal death and NICU admissions collected from midwife practices in the same area. There are several problems with this method:
• the study is not prospective as the authors claim – the data for the denominator used to calculate the rates were taken from retrospective data;
the data sources do not match – the PRN data came from postal codes of midwife practices, ignoring the fact that midwives work across postal codes, and thus the denominators for calculating rates of adverse events for midwives are artificially decreased (inflating the size of the rate);10
• the PRN does not include a variable for where labour begins (i.e., in primary or secondary care) – the researchers compared the form used in primary care, which indicates when a woman was referred, and the form used in secondary care, which indicates when care was started, and in many cases these records do not match.
Furthermore, recent data from the Perinatal Audit Netherlands11 contradict the findings of the study by Evers et al.,9
rates of intrapartum or neonatal deaths among women who start care in the second-line setting.
The article by Evers et al.9 illustrates several of the strange features characteristic of the science of home birth.
• First, the science of home birth ‘proves’ that home birth is safe but conversely also ‘proves’ that it is dangerous. The study by Evers et al.9
came on the heels of two studies published in 2009 by de Jonge and Janssen et al.12
that came to the opposite conclusion.
The rather surprising finding of this research by Evers et al. was that “Infants of pregnant women at low risk whose labour started in primary care under the supervision of a midwife in the Netherlands had a higher risk of delivery related perinatal death and the same risk of admission to the NICU [neonatal intensive care unit] compared with infants of pregnant women at high risk whose labour started in secondary care under the supervision of an obstetrician”. The pillar on which the Dutch maternity care system rests is the proper selection of women for first- or second-line care. This research was a direct challenge to that pillar and thus to the entire system. Even though the study did not examine the safety of home birth as such – first-line births can also occur in outpatient clinics located within hospitals, and no distinction was made between
These studies, one of which was also conducted in the Netherlands, showed that women expecting a physiological birth were equally safe at home and in hospital. Earlier in 2010, Wax and colleagues13
birth that, agreeing with Evers et al.,9
had published a meta-analysis of the safety of home showed that home birth
increased the risk of neonatal death by a factor of two or three.
• Second, those who demonstrate the dangerousness of home birth have an easier time publishing in journals with high impact factors. The study by Evers et al.9
was published in the BMJ and the study
by Wax et al.13 in the American Journal of Obstetrics and Gynecology. The study by de Jonge et al.5
was published in the
BJOG, after it had been rejected by the BMJ, which, according to the lead author, refused the article not for reasons of quality (it had had good reviews) but because it offered “nothing new”. The study by Janssen et al.12
Association Journal. This pattern – i.e., the relegation of articles EUROPEAN OBSTETRICS & GYNAECOLOGY SUPPLEMENT
was published in the Canadian Medical
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