Birth


This episode offers an insight into the way one’s profession influences one’s approach to research. Those who are not obstetricians will immediately see how insulting and harmful these words are: why should midwives trust those who seek to undermine their authority and diminish their realm of competence? However, from the point of view of an obstetrician – who, as a result of years of experience with high-risk births, has come to believe that birth is an inherently risky event – it makes sense to argue in favour of the hospitalisation of all births and to assume that other maternity care professionals would agree. Indeed, the power of the socialisation experience for both obstetricians and midwives is evident in the fact that the findings of their respective research coincide perfectly with their profession: research done by midwives (and general practitioners) proves the safety of home birth, and research done by obstetricians shows home birth is dangerous.


Note that, when examining the influence of one’s profession on one’s research, we are not saying the same thing as those who suggest that professionals consciously steer research in favour of their own interests. Rather, we assert that professionals ‘see what they know’ and ‘know what they see’ – and, of course, their knowledge and vision are shaped by what they have been taught, their clinical experience and the social expectations for their profession.


Culture


The continued high rate of home birth in the Netherlands has long been a medical and sociological curiosity. It is clear that the Dutch created policies that favoured home birth and midwifery, but why did they decide to encourage the practice in the first place, when all the other countries around them allowed home birth to disappear? Unlike their neighbours, the Dutch live in a culture that ‘fits’ with home birth; they have distinctive cultural ideas about family, the roles of women, heroism, thriftiness and home, which all conspire to support home birth and midwifery. These cultural ideas, together with the social policies based on them, nurtured an environment that continues to allow women to choose – and have easy access to – birth at home.21


This environment and the high number of home births it generates make the Netherlands a perfect laboratory for studies comparing birth at home and in hospital. Furthermore, these cultural ideas influence the way research on home birth is conducted, where it is published and how it is received. In the Netherlands in the 1970s and 1980s, there was a ‘loyal opposition’ to the Dutch maternity care system and its support of home birth. Interestingly, Dutch researchers challenging home birth found it difficult to publish their results in Dutch-language scientific journals, while Dutch researchers whose work supported home birth found it difficult to publish in English-language scientific journals.21


Of


course, researchers on both sides assumed that when their research was rejected it was for ideological reasons, and when it was accepted it was for scientific reasons.22


Culture is not static. Changes in Dutch culture have altered ideas about home birth, which, in turn, has altered the science of home birth and its impact on the public. An increase in media representations of birth originating from outside the Netherlands has made women more open to hospital birth. The culture of obstetric science in the Netherlands has also changed, becoming more international. Nowadays there are only a handful of obstetric scientists willing to defend birth at home, a practice most of their colleagues believe to be an anachronism. In the 1970s, 1980s and 1990s, some of the most respected professors of obstetrics


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were defenders of midwifery and home birth. Today, success in obstetric science is measured in terms of grants, publications and service on professional and national committees, which means the attention of researchers has been turned away from being responsible for a whole system of care towards a more narrowly defined professional success.


Creating Fear – Media, Safety and Place of Birth


Dutch women are becoming more and more fearful of giving birth at home. Public opinion about the safety of home birth started changing drastically after the EURO-PERISTAT reports were published in 2007 and 2010.23,24


In these reports, perinatal mortality in the Netherlands appeared to be relatively high compared with other European countries. Again and again, the media made the claim that the unique Dutch practice of home birth was at the root of this phenomenon, even though only about 35 of the approximately 1,700 perinatal deaths in the country can potentially be related to home birth. Again and again, the media made the claim that the unique Dutch practice of home birth was at the root of this phenomenon, despite research showing no relationship between home birth and excess mortality. Only about 35 of the approximately 1,700 perinatal deaths that occur each year in the Netherlands have a potential relationship to home birth (an estimate based on the total perinatal mortality in the seven-year cohort of women intending a home birth in the study by de Jonge et al.5


Why this distorted reporting? First, citizens of western societies are no longer willing to accept risk, let alone unknown and unexpected risk. The death of a baby is something so unimaginable and threatening that, against what we know to be true, we want to believe that we have the tools to totally eliminate the possibility of it happening. Second, we have a nearly blind faith in technology and medical procedures. ‘Nature’ may be fallible, we believe, but technology will eliminate all dangers, including those associated with pregnancy and birth. The notion that technology may fail, or that it may have unwanted side effects, has yet to enter the public consciousness. Finally, as noted above, controversies and drama are popular with the media, even, surprisingly, with serious journalists. Issues are often presented as black and white and, if there are differing opinions, only one side can be right. It seems that careful investigation, and the articulation of a nuanced opinion, take too much time or trouble.


Unfortunately, the notion that medical procedures can stop babies from dying is easier to demonstrate and can be visualised in more exciting ways than the potential benefits of primary care and home birth. The result has been that home birth and midwives are frequently described as backward and dangerous. They belong to an earlier, less technological era, and therefore they must be the cause of the relatively high rate of perinatal mortality in the Netherlands. Dutch journalists often ignore scientific data that falsify this notion.


In the discussion about safety and place of birth in the Netherlands (and internationally), the burden of proof lies with midwives and much less with obstetricians. The assumption is that the technological care provided by obstetricians can only be beneficial, and that it is thus virtually impossible to refer too many women to obstetric care. Increasingly, Dutch women are, like women elsewhere in the developed world, inclined to choose hospital birth as a way to err on the side of safety. This choice for technology and hospital ignores the potential undesirable side-effects of the medicalisation of birth.


EUROPEAN OBSTETRICS & GYNAECOLOGY SUPPLEMENT


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