Jan Nijhuis and Raymond de Vries Jan Nijhuis and Raymond de Vries Sacha Ruland

Childbirth: Home versus hospital delivery

In Body
Written by  Graziella Runchina Tuesday, 23 October 2012 14:52

The topic of home births always makes for heated discussion. Are we better off giving birth at home, or in hospital? While some women will swear by the hospital birth, others want nothing more than to deliver their child at home. And there are no clear answers from an academic perspective, either. We asked Jan Nijhuis, professor of Obstetrics at Maastricht University, and Raymond de Vries, professor of Midwifery Science at the University of Midwifery Education and Studies (AVMU), for their views.

The debate on home birth erupted again last year, and it was mainly the opponents who could be heard. In a highly developed country like the Netherlands, they said, that something as backwards as home birth still exists could only be the work of the “home birth mafia”: midwives whose main goal is to line their own pockets. “Mafia is a strong word”, says Nijhuis. “But it’s true that midwives have a great deal of autonomy here compared to most other countries. My view is that a pregnant woman has to have the free choice to give birth where she wants. If that’s with a gynaecologist in the hospital, then that has to be possible.”

“And that’s where the shoe pinches”, adds De Vries. “There’s also such a thing as a ‘hospital birth mafia’ and now the media seems to be encouraging it. The newspapers publish so many wrong articles about the dangers of giving birth at home that it creates unnecessary anxiety among pregnant women. Yes, of course I agree with my colleague that women have to have a free choice, but that choice should be based on the right information and not on the fear caused by unscientific information reported in the media.”
 

Hell of a job

With these home birth fears, the Netherlands may well be en route to an American-style situation. De Vries comes from the US, and two of his three children were born at home there. “It was a hell of a job, trying to find a midwife who would be willing to do a home birth”, he says. “In the US fewer than 1% of all births take place at home. That’s the other extreme, compared to the Netherlands. Though I don’t entirely agree with Professor Nijhuis that a healthy woman should have the choice to give birth with a gynaecologist in the hospital – that is, the American system. I think that’s a waste of talent. In my view, gynaecologists have other things to do than lead healthy deliveries.”


Fully and correctly informed

The key issue here, both men think, is that pregnant women need to be fully and correctly informed about all the pros and cons of giving birth both at home and in the hospital. “Home births have been the norm in the Netherlands for years because there’s a hint of romance about it”, says Nijhuis. “In fact, more than half of women end up being rushed to hospital for their first delivery, but this was not widely known for a long time. Historically, we’ve kept women ignorant in this area; no honest information has been given for years. As a result, three years after delivering their first child almost a quarter of women are dissatisfied with how things went, because they assumed the birth would take place at home.”

“Yes,” answers De Vries, “but the same proportion – a quarter – of the new mothers who are outpatients but then find themselves referred to the gynaecologist are also dissatisfied. That’s to be expected if your plans fall through.”
 

Netherlands: model country

“If you’re a healthy pregnant woman, then a home birth is the best option”, says De Vries, a staunch home birth advocate. “Hospital deliveries are more likely to end up being caesareans, with all the complications that may entail for mother, child and potential future deliveries. Healthy pregnant women should also be well informed of the risk of unnecessary intervention if a delivery begins in hospital. In the US, hospital deliveries are the most normal thing in the world. Almost all babies are born in hospital and in around 34% of cases these end up being caesareans. In a country like Brazil as many as 70% of babies are delivered by caesarean.”

These are extremes, of course – but the other end of the spectrum is the full romanticising of home births, as in the Netherlands. “Once upon a time, the idea was that pain would be good for the bond between mother and child”, says Nijhuis. “Which is nonsense. A good bond doesn’t depend on pain during childbirth. And any woman who decides beforehand that she’ll want an epidural during labour will have to go to the hospital anyway.”

“But,” De Vries hastens to add, “there’s also such a thing as the romanticising of hospital births, with the idea that the hospital is the safest place for all women to give birth. This is just scientifically not true. So it’s just like in the US, though there they often have unnecessary interventions, something that we should not aspire to in the Netherlands. Far from being backwards, I see the Dutch system – with its midwives who can work independently – as being very progressive. At least, that’s how many countries view the Dutch approach to childbirth. It’s seen as a model country in this area.”
 

High infant mortality

What about infant mortality rates, which are significantly higher in the Netherlands than in neighbouring countries? Is this due to the high number of home births? Nijhuis: “Studies show that the relatively high infant mortality in the Netherlands is not caused by the large number of planned home births; after all, the mortality rates among women who go into labour on time is already low, and also not all hospitals are 100% open 24 hours a day. So healthy pregnant women can choose their own place of delivery. To that end, home birth is a very safe option. If that’s not possible for whatever reason, more’s the pity. In any event, what we all have to stop doing is giving women the feeling that they’ve failed if their delivery ends up taking place in the hospital with medical intervention. That sentiment is deeply rooted in our country.”

This is “a bad thing”, De Vries agrees. “We also have to reassure these women, let them know that they’ve done well – under any circumstances, wherever they end up giving birth. The point is that home birth is a safe option and we have to protect the freedom of women who choose it. The preconditions, of course, are a good healthcare system and an integrated referral system. Here in the Netherlands, there are enough skilled midwives who can assess the suitability of a home birth. So healthy Dutch women should have no qualms opting for a home birth.”
 
 

Jan Nijhuis (1952) specialises in obstetrics and prenatal diagnostics. His research focuses on foetal monitoring and foetal behaviour, with the aim of gaining a better understanding of how the foetus ‘feels’ and ensuring that fewer children are born with a lack of oxygen. He has been professor of Obstetrics at the Maastricht academic hospital since 1999, and head of the Department of Obstetrics and Gynaecology at the Maastricht University Medical Centre since 2006. Nijhuis also advocates at a national level for quality improvements in obstetric care.
 
Raymond de Vries (1951) works at the University of Midwifery Education and Studies (AVMU), appointed by Hogeschool Zuyd. These institutions collaborate closely on the academisation of the midwifery knowledge domain. De Vries works at the AVMU for several months per year, but is now spending a full year in Maastricht while on sabbatical leave from the University of Michigan (Ann Arbor).  

 

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