Wednesday, September 30, 2015

How the Dutch do Birth

How the Dutch do Birth
        We can learn a lot if we look to the Dutch regarding birth matters. And I’m not referring to our hospital births here in the USA. I’m referring to our home birth system. Or rather, lack thereof. While most other developed countries have home birth rates at roughly 1%, the Netherlands boasts the highest rate in the developed world, with nearly 20% of births taking place at home with a midwife in attendance.1 The Dutch have it down. Their system works like a well-oiled machine. And though their birth philosophy is rooted in the same faith that you will see around the world for midwifery-led care, a belief in the normal, physiological process of birth, unlike our chaotic American home birth system, the Dutch leave very little to chance. (Update March 1, 2017 - home birth rate in the Netherlands is now at 13%)
Midwives and Systems
        The Dutch have only one type of midwife. To become a midwife in the Netherlands is a very competitive process where only the best candidates are accepted into the midwifery programs. Approximately four times the number of candidates accepted will apply.2
        The Dutch midwifery program is offered through three applied science universities. It is a four year, full-time program. Once a midwife graduates, she can officially use her title, verloskundige, and begin working as a midwife. Her name will also be added to a publicly accessible register. Are you wondering if your Dutch midwife is the real thing or just a charlatan? Anyone can access the register to look up the name of a midwife to verify.2
        A Dutch midwife who attends home births can also attend births in a hospital. They can reserve a room if their client wishes, for whatever reason, to give birth at a local hospital. The same transfer protocols apply as if it were a home birth: if the woman becomes high risk (“secondary care”) at any point of pregnancy or birth, the home birth midwife hands the care of the woman over to an obstetrician or to a hospital-based midwife (a hospital-based midwife in the Netherlands has earned a master’s degree).
       The Dutch midwifery system is externally monitored by a government agency, the Health Care Inspectorate. Every birth and outcome is tracked. Even the title for midwife (“verloskundige”) is legally protected.2
       Depending on the type of midwife a woman chooses in the US, the education requirements vary. A midwife certified through the American Midwifery Certification Board (AMCB) must earn at least a master’s degree in midwifery. AMCB-certified midwives have either earned the title Certified Nurse Midwife (CNM) or Certified Midwife (CM). Our CNMs are some of the most highly trained and educated midwives in the world, many of whom have earned a doctoral degree. AMCB-certified midwives are the only midwives in the US that are eligible to work in a hospital.
A midwife certified through the North American Registry of Midwives (NARM) has no education requirements beyond a high school diploma (which was not a requirement prior to 2012). One popular route to earning certification from NARM is the Portfolio Evaluation Process (PEP). The PEP is an apprenticeship. The student midwife follows the preceptor midwife for a minimum of 55 births (and prenatal appointments leading up to the births). Once the apprenticeship is complete, the student midwife may sit for the NARM exam. NARM-certified midwives are called Certified Professional Midwives (CPM). In some states, home birth midwives can be licensed through the state earning the title Licensed Midwife (LM) or Licensed Direct-Entry Midwife (LDM) by taking the NARM entrance exam and attending a midwifery school (requirements may vary by state). These midwifery schools, however, are not part of our formal college/university system. Only one midwifery designation is recognized in all 50 states: the CNM. The other designations are only recognized in certain states (CM, CPM, LM, LDM).
Home birth outcomes in the US are not tracked (except on a volunteer basis). Midwifery laws and regulations vary from state to state with loopholes and inconsistencies abundant. Some states have little to no regulations at all. And unfortunately, the title “midwife” is not legally protected in the USA as it is in the Netherlands (and Canada, also). Want to call yourself a midwife, set up a website for your business with fake reviews and fabricate a training/experience history? Go for it. No one can stop you.
Strict Criteria for Selection and Risking Out
        In the Netherlands, home birth is for women who are truly low risk. Women in this low risk category are considered to be in “primary care.” If a woman is at an increased risk for complications, they are in “secondary care.”3  Only women in primary care have the option to give birth at home. In primary care, regardless of place, the prenatal care and birth will likely be handled by a midwife. Women in secondary care are under the care of an obstetrician for a hospital birth. Breech, VBAC (vaginal birth after cesarean) and multiple birth (twins, triplets, etc) are more obvious reasons for a woman to be in secondary care, however, other examples of secondary care might surprise you: meconium in fluid, more than 24 hours since rupture of membranes (water breaking) and pregnancy reaching 42 weeks gestation, to name a few. 2,3,4
       The list of complications and/or conditions that designates a woman in the secondary care category is extensive and specific. The guidelines were written as a collaborative effort between the Royal Dutch Organisation of Midwives (KNOV),  the National Association of General Practitioners (LHV) and the Dutch Association for Obstetrics and Gynaecology (NVOG).2,4
On the flip side, in the home birth community in the USA, it’s a bit of a free-for-all. High risk home births such as twins, breech, VBAC and postdates are not uncommon in the USA5 and are often romanticized by the home birth community, describing them not as “high risk” but instead as “variations of normal.” While some home birth midwives may insist on screening measures (such as ultrasounds or gestational diabetes testing) to ensure her clients remain low risk, other midwives may actually discourage women from any testing or ultrasounds at all.
While the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) have written committee opinions on planned home birth, which include guidelines for appropriate protocols and client selection criteria6,7, the American College of Nurse-Midwives (ACNM), National Association of Certified Professional Midwives (NACPM) and the Midwives Alliance of North America (MANA) do not promote any such guidelines.
Emergency Supplies and Insurance
        When a Dutch midwife attends a birth, she must bring her emergency supplies. The emergency and monitoring supplies are not optional. Items such as oxygen, blood pressure cuff, medications (Pitocin for postpartum hemorrhage, for example), suturing items and a handheld fetal heart rate monitor will be with the midwife at each birth. Dutch midwives also have an assistant present with them at each birth. These maternity assistants, called kraamverzorgster, are trained in CPR and neonatal resuscitation and stay after the birth to monitor and assist the mother after the midwife has left. Side note: Regardless of place of birth or type of attendant, the kraamverzorgster helps the mother and baby for a total of 40 hours over the course of eight days after the birth and reports back to the care provider. How nice would that be!
        Not so in the USA. Emergency supplies and birth assistants are optional and in certain states, it is illegal for non-nurse midwives to carry items such as oxygen or any medications. So some midwives just don’t bring them.
        And finally, Dutch midwives carry insurance. This is a requirement. Insurance is important for a variety of reasons but one reason in particular is in the case of birth injury. If a baby is injured – neurologically and/or physically – lifelong care may be needed and it can be expensive. Parents should be able to have compensation, especially if the injury was due to care provider negligence. In the USA, most home birth midwives do not carry insurance. Carrying insurance costs money, of course, which is one reason for a midwife to avoid it. But it also means the midwife’s scope would very likely be limited to low risk births only, as insurers know higher risk home births are too risky.
        Given all of these huge systemic differences, it should come as no surprise that home birth outcomes in the Netherlands are better than those in the USA.
        Let’s compare the safety by looking at outcomes in both countries. In 2014, the Midwives Alliance of North America (MANA) released a study on the outcomes of over 16,000 planned home births. The data was submitted by midwives on a volunteer basis. Using the 2014 MANA study8 as our reference for home birth outcomes in the USA and the 2009 Dutch home birth study3 for our reference for home births in the Netherlands, we are able to get a very good look at outcomes. Please note: in both studies, we are looking at planned, midwife attended home births; outcomes listed below exclude: accidental home births, lethal anomalies and antepartum stillbirths (death of the baby in utero, prior to labor).
The intrapartum mortality rate comparison is particularly worrisome. Intrapartum mortality refers to the death of the baby during labor, meaning the baby was confirmed to be alive at the onset of labor but was born not breathing and was unable to be resuscitated. The intrapartum mortality rate for babies born at home in the USA is 1.30/1000 versus 0.31/1000 for babies born at home in the Netherlands. Speaking in terms of relative risk, this means a baby born at home with a midwife in the USA is 4 times more likely to die during birth than a baby born at home in the Netherlands.
Looking at combined intrapartum plus early neonatal mortality rates (early neonatal death means the baby was born alive but died sometime in the first seven days), a baby is three times more likely to die at a home birth in the USA with a mortality rate of 1.71/1000 versus only 0.64/1000 babies dying in the Netherlands.
        Let’s give a little context to what these numbers mean: for every 10,000 babies born at home in the Netherlands, only 6-7 babies will die; for every 10,000 babies born at home in the USA, 17-18 babies will die. That is an excess of 10-12 babies that die per 10,000 births. According to the CDC Wonder Database9, in 2013 (the most recent year available) in the USA there were over 40,000 births that took place in a non-hospital setting (home or freestanding birth center) with a midwife in attendance, which means, within a single year, 40-48 babies died who would have lived in a safer home birth system like that of the Netherlands.
        Part of the increased mortality is likely due to the higher risk births that take place at home in the USA. But unfortunately, even when looking at outcomes for only low risk women, the mortality rate in the USA is still over twice as high (1.26/1000 for USA compared to 0.64/1000 for Netherlands).
Now, the Netherlands is a small country. One might argue that a hospital is likely closer to a woman giving birth in the Netherlands because they may not have as many home births in rural areas as we do. However, there are home births that take place on islands in the Netherlands where they have no access to hospitals except to go to the mainland. And also, the country is very densely populated. Anyone in a large metropolitan US city knows that going even a quarter mile can sometimes take 30-45 minutes in traffic. And the Netherlands has some of the worst traffic congestion in all of Europe.
        Some home birth proponents have asserted that the poor outcomes in the 2014 MANA study were due to the small percent of uncertified midwives who submitted data for the MANA dataset, though data mostly came from Certified Professional Midwives and Licensed Midwives. You might wonder if those uncertified midwives are responsible for the increased mortality rates. However, the outcomes from the 2014 MANA study are identical to outcomes from the CPM2000 study10, a study which consisted of only CPMs.
        While the Dutch have their own political battles for home birth versus hospital birth, where the debate of which is safer continues to this day, we can certainly learn from the Dutch and strive to emulate a home birth system that works just as well in the USA. Though it would take a lot to get there, any little bit would help.
We already know that home birth in the USA is riskier than hospital birth. We have learned this lesson over and over:
The 2014 MANA home birth study8 - results: a baby is 3-6 times more likely to die at a planned, midwife-attended home birth than in a USA hospital.
The 2014 American Journal of Obstetrics and Gynecology (AJOG) term neonatal deaths study11 - results: a baby is 2-4 times more likely to die at a planned, midwife-attended home birth than in a USA hospital.
The 2014 AJOG HIE study12 - results: a baby born at home is 16.9 times more likely to have neonatal hypoxic-ischemic encephalopathy (HIE; brain damage) necessitating cooling treatment than a baby born in a hospital.
The 2013 AJOG Apgar study13 - results: risk of 5-minute APGAR of zero is 10-19 times higher for babies born at a planned, midwife-attended home birth than in a USA hospital.
The 2013 AJOG perinatal outcomes study14 - results: risk of neonatal seizure is 3 times higher for babies born at a planned, midwife-attended home birth than in a USA hospital.
The 2005 British Medical Journal (“CPM2000”) study9 - results: neonatal death rate is 3 times higher for babies born at a planned, midwife-attended home birth than in a USA hospital.
        The facts are clear: having a home birth in the USA comes with an alarmingly increased risk of infant death and serious neurological harm. But what we know now is that it’s not just about the location of being at home, away from the life-saving technology and staff available in a hospital. It’s about our home birth system being so disorganized and lax that babies born at home in the USA are more likely to die than babies at home in other countries like the Netherlands. American home birth midwives are either purposely ignoring red flags (for the sake of an ideology or to give a woman full autonomy, care provider ethics be damned) or because they lack the competence and skill to recognize and manage complications.
It’s time for our midwifery organizations to wake up. Women deserve to have access to midwifery care where the bare minimum of training and education is the same across the board. We need higher standards. We need a uniform system. We need consistent guidelines for which women should be risked out of home birth and consistent transfer protocols from home to hospital. We need a better home birth system for women. And we needed it yesterday.


2. Royal Dutch Organisation of Midwives, KNOV, Second edition, March 2015.  

3.  de Jonge, A., van der Goes, B., Ravelli, A., Amelink-Verburg, M., Mol, B., Nijhuis, J., Gravenhorst, J. B. and Buitendijk, S. (2009), Perinatal mortality and morbidity in a nationwide cohort of 529 688 low-risk planned home and hospital births. BJOG: An International Journal of Obstetrics & Gynaecology, 116: 1177–1184. doi: 10.1111/j.1471-0528.2009.02175.x

4. Obstetric Manual, Final report of the Obstetric Working Group of the National Health Insurance Board of the Netherlands (abridged version)

5. Grünebaum A, McCullough LB, Brent RL, et al. Perinatal risks of planned home births in the United States. Am J Obstet Gynecol 2015;212:350.e1-6.

6. Planned home birth. Committee Opinion No. 476. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;117:425–8

7. American Academy of Pediatrics Policy Statement on Planned Home Birth, Committee on Fetus and Newborn Pediatrics. Vol. 131 No. 5 May 1, 2013 pp. 1016 -1020

8.  Cheyney, M., Bovbjerg, M., Everson, C., Gordon, W., Hannibal, D. and Vedam, S. (2014), "Outcomes of Care for 16,924 Planned Home Births in the United States: The Midwives Alliance of North America Statistics Project, 2004 to 2009." Journal of Midwifery & Women’s Health, 59: 17–27. doi: 10.1111/jmwh.12172

9. CDC Wonder: Live Births

11. 57: Term neonatal deaths resulting from home births: an increasing trend, Grunebaum, Amos et al. American Journal of Obstetrics & Gynecology , Volume 210 , Issue 1 , S38

American Journal of Obstetrics & Gynecology , Volume 210 , Issue 1 , S251

13. Grünebaum A, McCullough LB, Sapra KJ, et al. Apgar score of 0 at 5 minutes and neonatal seizures or serious neurologic dysfunction in relation to birth setting. Am J Obstet Gynecol 2013;209:323.e1-6.

14. Cheng YW, Snowden JM, King TL, et al. Selected perinatal outcomes associated with planned home births in the United States. Am J Obstet Gynecol 2013;209:325.e1-8.

Special thanks to Dutch midwife Franka Cadée for answering my many questions about midwifery in the Netherlands!


  1. How does the home birth intrapartum and perinatal death rates in the Netherlands compare to those same rates for a matched population of hospital births?

    1. According to the de Jonge study above, the rates are similar. You can see the break down here in Tables 2 and 3: