How long ago did you write your thesis “The Place to Be”, about home birth in Holland?
I wrote it a year ago and last year I had my defense for my PhD. That was in May 2018.
I have a few questions about home birth in Holland. Why is home birth so much more common and popular in Holland than anywhere else in the developed world?
Well that’s interesting because I always discuss that with my students: Why is homebirth so popular in the Netherlands, although the number of home births is decreasing.
In the Netherlands we always had a very strong vision separating births without complications from those with complications.
It was written into law in 1895 that normal birth should be done by midwives, and birth with complications should be done by medical doctors.
I think that’s very important because that law made midwives a strong profession, where midwives were the ones who were doing home births. So in other countries, where there was no law supporting midwives, I think a lot of births were done in the end by doctors and hospitals, whereas we had the law on our side that we should care for women without any complications.
Besides this law supporting midwives position, it’s the Dutch culture which we call a “down to earth” culture.
Yes, but also the Dutch culture of being at home with your family. We have a professor of midwifery science here, who is actually from the States, Prof. Raymond de Vries. He is a professor in the University of Michigan’s Department of Learning Health Sciences and the Department of Obstetrics and Gynecology, as well as co-director of the Center for Bioethics and Social Sciences in Medicine at U of M. Dr. De Vries is also a visiting professor at the CAPHRI School for Public Health and Primary Care, University of Maastricht, the Netherlands. I think you know that from Ank De Jonge. He’s one of my teachers when I was working on my PhD, so I talked a lot with him. He said the difference between the United States and Holland is you have tiny homes and live close to your family.
In the Dutch culture, not for the last 20 years but before that, it was very normal to give birth at home. It is changing now, actually.
I saw that home birth statistics for Holland has gone down recently, and I saw in your thesis that you had linked the reason to a study that was done a few years ago where they found perinatal outcomes for women and babies in the Netherlands was worse than in other European countries. It was blamed on the Dutch tradition of home birth, because home birth is such a big part of the maternity services.
So how do you explain those statistics? I know that other studies showed that home birth in Holland was safe and you have a very strong maternity care system, so I’m wondering how you would explain that study.
Well the first numbers were from 2004. It was the first time that results were published comparing European data. This data showed that the Netherlands was not doing well on perinatal mortality. Everyone was pointing to our system because what was different between the Netherlands and other countries is we have a lot of home births. So what was happening was that before we really looked at what’s going on and what the numbers were telling us, everybody was already pointing at our home birth system. So we did the research again (re-analysis) in 2008 and there was a new report with the same data, so we looked more in detail at what was happening here, and we saw that it was very difficult to compare all European countries because of the difference in registration level. We have quite a good registration level in the Netherlands, but for all other countries: when are you registering a perinatal mortality? From how many weeks til how many weeks after birth? So there was quite a lot of difference when registering the data. We also saw differences between the population.
The mean age for when women have their first baby is quite high in the Netherlands compared to other countries, but that doesn’t really explain all the numbers. The Netherlands had a different approach to premature birth. In Germany, for instance, they are actively taking care for babies that are born from 24 weeks gestation, whereas in the Netherlands, we have a more conservative approach in case of a very premature neonate. There are so many problems with morbidity and neurologic development with very premature babies, so that was also a difference between European countries, because are you keeping babies alive with high morbidity rates later on, or choosing not to give treatment for very premature babies. So I think it’s a combination of culture, a combination of population, and a combination of how we are registering all the data. What is very interesting about the study is we were not the highest rate of perinatal mortality. The highest number was in France. And France is a country where birth is highly medicalized. Everyone gives birth in hospitals there, so I think it’s very complex.
On the other hand, I think it was a good moment to reflect on our maternity care system. Until that moment we always said, ‘Oh we’re doing so well in the Netherlands with a high home birth rate and very good numbers.’ Now we are thinking, ‘Is that really the point?’ So what is happening since 2008 is that there are a lot of changes in maternity care in the Netherlands. We are going to more integrated care, more collaboration with all the different care providers, but also with the goal to preserve the different choices of place for birth. We are not outlawing home birth, as far as I know, although I can’t see in the future.
We had some problems with those studies but I think it is also a good point that you can be critical and reflect on your own maternity care system. The latest European data from 2015 shows that the neonatal mortality rate in the Netherlands have gone down. Recent studies also show no connection between infant mortality and home births.
Women who choose to have a home birth in Holland, what would their reasons be, and how would they resolve any fear that they have?
Well I think the reasons people have for giving birth at home are different. I think that the most important issue is they want to feel safe in their own environment. And a lot of women think, ‘Well my mother did it, my grandmother did it, so why should it be a problem for me?’
If the numbers are decreasing, that’s a problem, for in thirty years the question is: Did their mothers and grandmothers give birth at home? But now you see a lot of women who say, ‘Ok I was born at home.’ That’s a factor.
I also think a lot of women don’t want to be in a hospital because of the interventions, and the strange environment.
But if you look at studies on home birth from other countries, like New Zealand or the United States or Canada, you see some women who really don’t want to give birth in hospital for a number of reasons, and that’s not a very strong reason here for most women. Women prefer to stay home but if there’s something wrong, they’re ok with going to the hospital. So that sentiment is not so very strong in the Netherlands.
Yes, and you also have that the midwives who will come to your home, they will also transfer you to the hospital and stay with you and care for you in the hospital, so that’s also a big positive.
At this moment it is only true for women who have an uncomplicated birth. So if you decide to give birth in hospital without complications, then your own midwife is going with you, but if there is something happening, like meconium stained fluid, or a problem with the baby’s heartbeat, or slow progress in labor, then the care is transferred to another health care provider. That is something we can work on. Most of the time it’s a clinical midwife, so that’s a positive point because they are trained together, so clinical midwives have the same background as primary care midwives so they understand each other. But I think we can work on continuity of care in case there is some complication, sometimes a very slight complication, or if they just ask for pain medication.
I think your strength is that when someone comes into the hospital from a home birth setting, it is not looked down upon. In the United States, many hospital doctors and nurses don’t really trust home birth midwives.
It is very true. We are very lucky with our system. Because it is arranged by law, we have a very strong position for the midwife within the system. We are used to a system where you are transported from home to hospital. That’s normal.
Yes, that’s a big strength.
Another question I had was regarding congenital defects that were not known about prior to birth. Is that found to be a problem at home births?
No. most of the time people know before they give birth that there may be an anomaly with the child from the ultrasound. So it’s not a problem. Otherwise, midwives are well trained to deal with problems with the neonate after birth.
Are you a practicing home birth midwife?
I did practice as a home birth midwife, but now I’m a lecturer training midwives. I worked as a home birth midwife and then as a clinical midwife, so I worked in both settings.
What’s very important to realize in the Netherlands is that the infrastructure is very important. We are a very small country, so women in the Netherlands are within 30 minutes of a hospital. 30 minutes is a long distance. Most women are even within 15 minutes, so that’s quite a difference if you compare to other countries where women may be an hour or two hours to the nearest hospital or birth clinic. And sometimes we forget in Holland that if we have a hemorrhage postpartum, within 30 minutes we are in a hospital. So I think that’s also part of the system. I’m very curious how our future will develop with home birth. Hopefully we will be stable at this 13%, because I train student midwives and they have problems doing home births within their education. The the rate has dropped from 30-13%, which means they don’t see as many home births during their training period as I had during my training period. I think that’s very important as you need to be skilled, and you need to believe in the system and feel comfortable doing home births. Hopefully we can keep it at this number, and hopefully the number will go up again. But birth in the whole world is more medicalized, and I think we should make an effort not to medicalize birth as much as we do now. We will try. We will do our best.