Hi Ank, thank you for speaking with me.
I wanted to speak to you to get insight into why and how homebirth is so common and popular.
Have you ever been to the United States?
I have been, but not everywhere, of course. We have contact with midwives there.
How do you meet midwives here?
There’s a sociologist, a professor here, Raymond De Vries, do you know him? He writes a lot about the organization of maternity care. The midwifery world is quite small so we have conferences together. We had a conference in Michigan last year so we know some.
Is Raymond De Vries Dutch?
Yes, his ancestors are Dutch. He’s American but he has lived in Holland, on and off, so he speaks Dutch quite well, but he works in Michigan now.
What’s his position?
He’s a professor in sociology, I think. Raymond De Vries, wrote a book which is called “A Pleasing Birth”, about birth in Holland.
Are you a professor?
I’m an associate professor so most of my time is spent on research and I still practice 6 days a month in primary care.
How did you get started as a midwife? Why did you become a midwife?
I was a nurse to begin with many years ago, and then I worked in Britain for a bit. I wanted to learn something again and I was looking for something I could do in the community because I don’t like hospitals very much. Then it occurred to me that midwifery in Holland takes place in the community most of the time, and I was living in UK with an Australian woman who was doing the course in midwifery, and she was really keen. So she got me into it and I was trained in Britain. I qualified in ’94, so that is how I got into it. It’s not like I dreamt about it as a child, because I didn’t really know much about it.
How does midwifery differ between Great Britain and Holland?
The biggest difference is that in Holland we still have quite a dichotomized system with independent midwives in primary care to take care of low risk women. As soon as a risk factor occurs, and it could be as small as somebody wanting pain relief or having meconium stained liquor (fluid), then we refer to obstetrician led care in hospitals where very often clinical midwives provide the care, but under the responsibility of obstetricians.
Of course in the UK it’s one system, although community midwives, you could say, are independent in a way, but they are still part of the same trust, so you still have the same joint protocols. In Holland we are moving towards more integrated care, because we know that our system is very good as long as you don’t have any complications, but as soon as you have any risk factor then you lose continuity of care, because we then transfer to a different system of care, and nobody’s very happy with that, so we’re trying to change that.
Midwifery care in Great Britain is so commonplace, and I know that in Great Britain the homebirth rate is 2-3% and in Holland it’s 30%, what would you say the reason for the difference is?
Well actually it’s dropping in Holland. The latest figure is just above 12%, it’s really dropping. It had been around 30% for a long time.
Why is it dropping?
Well let me first say why we have homebirths. A lot has been written about it. I think part of it is our culture, we love doing things at home. We meet each other at home, we eat together at home, and sometimes we die at home, whereas British people meet each other in the pub, so it’s also a cultural thing. As Raymond De Vries describes, it may have something to do with thriftiness; It’s cheaper to do things at home. The insurance system is such that if you give birth in hospital without a medical indication, you have to pay a few hundred euros. Although it doesn’t appear that most women choose homebirth to save money, because actually most women who give birth at home are from a relatively higher social class, but it does send out a message that homebirth is normal. Women need to have a medical indication for their hospital care to be fully funded, which strengthens homebirth.
The homebirth rate in Holland is dropping, possibly due to a lot of bad press in Holland about our system. A study showed our perinatal mortality rate to be high.
I did see that study, and I didn’t know how to read that. It didn’t really fit in with everything else I read about Holland.
Yes the particular one from Evers where it appeared that babies were more likely to die if you were cared for in primary care. We’ve written about that. There were some methodology issues with that paper so we repeated that study actually, and the numbers were different, but still that study’s been used a lot and has been picked up by the media big time. It really discouraged primary care, and in particular homebirth, even though the study wasn’t about homebirth. So we’ve had a lot of bad press over the last decade or so, so that hasn’t helped; It has decreased confidence among people in homebirth. I’m still practicing as a midwife, and I find I have people who I would call typical ‘homebirthers’ now questioning whether it’s safe, and if the women feel it’s safe, then the family doesn’t think so. So we have the same lack of confidence other countries have had for a long time.
Another factor of course is women want pain medication, and we have no pain medication at home apart from shower or massage or a bath. That’s about it, so if you want anything medical you need to go to hospital or birth center, and that plays a role as well.
In Holland, midwives come prepared to a homebirth; They bring all their stuff. In case of an emergency, the ambulance knows what to do. Women get to hospital in time, and I think people forget that. If you look at other countries, if you read between the lines, about 1 in 200 or so babies are born before arrival, so that’s quite a number. Women in England, or other countries, give birth on the car park, or in a taxi, or wherever; Whereas in Holland, if a woman gives birth fast, a midwife can be with her usually in time, or at least in time for the placenta, and have all of her equipment with her. So that’s an added benefit of having a homebirth system. Women always start at home in Holland, so if someone goes into labor, even if they want to give birth in hospital, they always call the midwife. The midwife then comes to the house, assesses the situation, and then if they’re not in labor, they have a cup of tea, reassures them, makes a plan with them, and discusses when she’ll come back. This is contrast to in another country having a hospital birth, you go to the hospital, you’re sent home because you’re too early, you go back again, then sent home again. You don’t have that in Holland. Midwives will come to your house as often as needed, and then go with you to the hospital if you want to give birth there, and then continue your care there. So it’s not only about giving birth at home, it’s a whole system where you can be at home as long as you’re comfortable at home, so even if you want to give birth in hospital, you can be at home and then go to hospital when labor is progressing, or you can change your mind. In Holland, you don’t have to choose before your birth. I have to ask what you intend to do, but you can easily change your mind, because everyone starts birth at home. You can see how you feel, and if you feel like I’m not going anywhere, let’s stay here, that’s fine. We’ve got stuff with us and the initial stages are exactly the same wherever you want to give birth. So that means if you suddenly go too fast or you don’t want to move, you can just give birth. If you wanted to give birth at home and you decide you want medication, or you don’t like it (at home), then you can still go to hospital. The system gives you a lot of flexibility.
The system in Holland is very strong. That part of the system in Holland is very strong. I even talked to an obstetrician last week who said the same, women should stay at home as long as they can because we know from all the literature it is better for them. And of course, even if they want to have the actual birth in hospital, it’s so great that someone can be at your home during the initial stages. It’s very stressful to know when you should move to hospital, especially if you’ve had a quick birth before. Women get very nervous. Here you don’t have to be. You call the midwife and she’ll be at your place, which is great.
Quite frequently, especially with second or more babies, women plan to give birth in hospital but then end up at home, and then they are happy because that means it usually went very smoothly. One time, I remember that I had a birth with a lady from Morocco or Turkey, and usually ethnic minority women are more likely to want to give birth in hospital, because they come from countries where homebirth is not that safe, and they feel that they’re now they are in a rich country and they want the benefits of a hospital. One lady was too quick, and she gave birth at home. The husband was so surprised when he saw me bringing in all the stuff we carry, and he said, ‘Oh, but you’ve got everything with you, then we might as well stay at home.’ Which made me realize we should inform women more about all the equipment that we bring. We carry oxygen, we carry all the tools for the birth, we can do an episiotomy, we can suture. People sometimes don’t realize that we’ve got all the things with us. There’s sometimes so much misunderstanding, they think we only come with a screwdriver or something.
You do episiotomies?
Yes we can do an episiotomy. We can suture them, we can give oxygen.
How often do you do episiotomies?
Well, that’s a painful question. In Holland we do them quite often in primary care. We’ve published about that, and we’ve compared Britain and Holland, for example, and we’ve found more episiotomies in Holland than in Britain, so that’s something we should work on in Holland. We really have to do fewer of them, so it shows that it doesn’t mean if you have a homebirth system, that you do fewer interventions. We still do interventions quite often. Also, quite a few women in Holland when they give birth at home, lie on their back to give birth. It is not often the case in countries like U.S. If you give birth at home it often is part of a whole physiologic birth philosophy where you also give birth upright. It’s not the case in Holland. You may still lie down on your back, still get your membranes ruptured (water broken), and not always is it necessary.
What’s the c-section rate in Holland?
The c-section rate now is between 16-17%. We are one of the lowest, together with the Scandinavian countries.
The homebirth rate in the Scandinavian countries is not as high as in Holland. Iceland is doing reasonably well with 2%, I think. I don’t think the other countries are very high, for example in Norway or Sweden. Actually, in Sweden you have more unplanned homebirths than planned homebirths.
We have published a lot on homebirth. We did the largest studies on homebirth, because we have the most homebirths in the Western world, and I find we don’t see any difference in perinatal outcomes, and better maternal outcomes even, for planned homebirths compared to planned hospital birth. Sometimes people take that and say, ‘Oh, see, homebirth is safe,’ and then apply it to other systems. We are always careful in our conclusions to say that what we find is in a context of well-trained midwives, a good referral system and a competent transportation system, and in that context we see good outcomes. I think you have to be careful when translating it to systems where either people are not well trained, or you have a problem with transport, or your hospital is completely hostile to homebirth. In these situations you may have different outcomes. You see that actually in the U.S., you have a study from Oregon, showing poorbirth outcomes for planned homebirths or planned birth center births, which included all out of hospital births. The poor outcomes may be attributed to lay midwives and unsupervised homebirths. When you don’t have good guidelines, then the outcomes may not be as good.
I heard about the Oregon study, but they said planned homebirths was just a subset of the study, with all out of hospital births lumped together. So midwives are saying it is not actually a good study. On the other hand, a lot of midwives blamed the poor outcomes on lay midwives who have minimal education.
There’s a lot of variation in the U.S., with different levels of midwives and no consistent quality, so that makes it more difficult to interpret. I’m saying this because in Holland we are always close to a hospital. We’ve got a system that’s prepared for homebirth. It’s a very different thing when you’re in the U.S. somewhere, hours away from a hospital that’s hostile to even receive you. I think that is the reason why you have to sometimes be careful when interpreting research study findings.
When the Oregon study came out, I was invited to an online panel from the New England Journal of Medicine, where it was published. It was actually very interesting. We had an online discussion with obstetricians from the U.S. and they were saying that they looked at countries like U.K. and Holland, and they said, ‘Look, we can see in these countries that it can be safe to plan your birth at home. We know in the U.S., even though we tell women that they should give birth in hospital, some of them don’t, so why don’t we stop pressuring them and just set up a system that’s safe for them to choose homebirth if they want to. So at least treat them with respect when they are referred, as well as make sure there are guidelines for homebirth.’ And I think that’s a very good development. There’s a lot to be done.
Yes, the United States has a lot to learn.
What we’re looking at, if we push the boundaries a little bit, because what we find is low risk in Holland has been defined so strictly that we refer so many women to obstetrician care, so that undermines the benefits of our system. I think what most people feel is that because when we refer, most of our women are looked after by clinical midwives who are our colleagues, so if they can do it, why can’t we give primary care, so I think there we need to move and change, and I think for that and for many reasons, we need university trained midwife, but that’s what we need to do here.
From what I gather, there’s a lot of disagreement among midwives in the U.S. about what’s the best. Some people say you need university training, and some say it’s a hands on vocation that you learn in practice. So I think there are differences in opinion, as always. It’s a sensitive issue, I gather.
ACOG I think, has issued more nuanced viewpoints on the matter. They would still prefer women give birth in the hospital, but if they choose to have a homebirth, they should at least provide safe care. So there’s definitely a change in perspective in the U.S.