Home births: let the gynaecologist decide

Midwives are not competent enough to assess the risks surrounding childbirth. Let gynaecologists decide, write Kenneth Watson and Rob Kottenhagen.

The German poet Heinrich Heine once said that if the end of the world came he would go to the Netherlands because there everything happened fifty years later. This comment seems a fitting one for another anachronistic Dutch phenomenon: the home birth. Everywhere in the affluent West the safety of mother and child is paramount and hospital births are the norm. The empirical evidence is that every birth carries unforeseen risks and those risks are carefully weighed.

The Netherlands is the odd one out in Europe. It is the only country which allows independent midwives to play Russian roulette with the lives of mothers and babies. How much longer is this situation going to continue? Impressive statistics give the impression that home births are medically safe and the midwives’ association KNOV never ceases to emphasise the ability of midwives to assess the risk of a complicated birth correctly.

Medicalising a natural process

Worried gynaecologists who do not agree and know better are being shamelessly accused of wanting to medicalise a perfectly natural process. Pregnant women are always being told what a pleasant and safe experience a home birth is. They are seldom aware of the fact that in the last five years one in five women had their pleasant experience interrupted only to be rushed into hospital with all speed to have the baby there, often to avoid birth defects caused by a lack of oxygen. Neither do they realise that the Netherlands has one of the highest numbers of baby deaths shortly before and after birth in Europe.

One of the main causes undoubtedly is that the risk assessment carried out by midwives is woefully inadequate. According to the Erasmus Medical Centre (EMC) this is the reason that 30% of women with a higher risk of complications continue to start giving birth at home with an independent midwife in attendance while a hospital birth would have been medically appropriate. In 2010, the Utrecht university medical centre (UMCU) published a report which said that a delivery started at home with a midwife in attendance carries four times the risk of the baby dying than a planned hospital delivery.

Those who want to maintain home births as a cornerstone of our obstetrical care at all cost criticised the report but its core results were subsequently confirmed by independent research by Tilburg University in 2013. Home births are not that nice and not that safe.

Midwives’ mistakes

Independent midwives don’t always keep to the guidelines and professional norms set by the association of midwives. In June 2013 one midwife was convicted by the regional medical board RTA in Amsterdam for almost letting a mother bleed to death while the baby died shortly after birth as a result of a severe lack of oxygen. The board ruled she could never work as a midwife again. But on April 24 the central medical board CTG took the incomprehensible step of reinstating her.

It is high time to move the goal posts in obstetrical care and put the lives of mothers and babies first. Gynaecologists are better trained in the pathology of childbirth so why not give them the ultimate word in deciding whether or not it is really safe for women to have their baby at home attended by a midwife. It will save lives and prevent much unnecessary grief. Better safe than sorry.

Kenneth Watson is a PhD student at the Institute for Healthcare Policy & Management at Erasmus University. Rob Kottenhagen is a senior lecturer at the Institute.

This article was published earlier in the Volkskrant

(On May 7, we corrected the spelling of Kottenhagen)