Giving birth in the Netherlands

Don't blame it on home births

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The infant mortality rate in the Netherlands remains one of the highest in the European Union, but is this anything to do with home births? Amanda van Mulligen investigates.

The infant mortality rate in the Netherlands is one of the highest in the European Union, with one in 100 babies dying during pregnancy, the birth or shortly after. Only France and Latvia have worse statistics. That is according to the figures released in December 2008 in The European Perinatal Health Report.

In the same survey six years ago, the Netherlands also fared poorly with 10.9 deaths in every 1,000 births, the worst record of the 15 participating EU countries. Whilst the mortality rate here has decreased, it is not declining as fast as in other, comparable EU states.

In response to the two reports, many were quick to point the finger at the Dutch culture of home births.  But research just published in the British Journal of Obstetrics and Gynaecology shows no significant difference in the perinatal mortality rate or incidences of intensive care treatment between home and planned hospital births.

Research by The Netherlands Organisation for Applied Scientific Research (TNO) in Leiden also shows no connection between infant mortality and home births.

Simone Buitendijk, Professor of Maternal and Child Health at TNO says, “In our research, we studied more than half a million women in primary care and compared planned home births with planned hospital births. The number of babies that died or that were admitted to a neonatal intensive care unit was the same in both groups, namely, seven per 1, 000. We conclude that women can safely choose where they want to give birth, provided the maternity care system is well equipped for homebirths.”

So if home births are not to blame for the worrying data trend in the Netherlands, what is?

According to experts in the Dutch health profession, there are a number of factors to look at.  Most notably, this latest report uses statistics from 2004 and four year old data was also used in 2003.

The Dutch government has requested a briefing from the Health Minister, Ab Vink, on the actual state of affairs, as well as an update on the work of the steer group, “Modernisering Verloskunde” (Modernising Obstetrics) set up to reduce infant mortality rates by 2009.

The steer group has focused efforts on education within the high-risk groups, ensuring pre-conception awareness of the risks associated with drinking alcohol, smoking, being overweight and not taking supplements like folic acid and vitamin D during pregnancy.

This latest EU report does not reflect any results contributable to the measures that the government has already taken in the Dutch maternity profession. This includes pay increases for midwives in problem neighbourhoods, accelerated training to combat shortages, and the introduction in 2005 of twenty-week scans, which were previously not standard in the prenatal process in the Netherlands.
Studies predict that the introduction of 20-week scans will result in a four percent reduction in deaths within the timeframe covered by the research, which is from 22 weeks into the pregnancy until four weeks after the birth.

The prior absence of these scans as standard procedure meant that birth defects and hereditary conditions often remained undetected until after the legal gestation period for abortion. In other EU countries, these scans have been standard practice much longer and therefore any critical problems with the foetus discovered much earlier. Most parents faced with life-threatening defects choose for abortion; figures not included in this report.

The ethical and medical decisions taken by Dutch doctors are often quite different to those in other EU countries. Doctors in the Netherlands will generally not undertake intensive treatment for premature babies (24 to 25 weeks) with low survival expectancy. In the 2003 survey, there were 600 more deaths in the Netherlands than the EU average. This is thought to explain 200 of them.

Dr Hens Brouwers, paediatrician from the Wilhelmina Children’s Hospital in Utrecht said in 2004, “In other countries these babies possibly also die, but they fall outside of the statistics”. This is because the deaths occur outside the time parameters of this EU research.

Also considered a significant contributor to the high rate of infant deaths is the relatively high non-western population (allochtonen) within the Netherlands, a group which is overrepresented in the statistics and which fall into the higher-risk category.  The chance of infant death is higher within this population because of the increased risk of diabetes, overweight, high blood pressure and infections. Allochtonen women tend to go to a midwife later in their pregnancy and make less use of kraamzorg. Poor Dutch language skills are also though to play a role. To counteract this, Groen Links Member of Parliament, Tofik Dibi, wants pregnancy care incorporated into the integration exam for immigrants (inburgeringscursussen).

Another prominent factor is that many women in the Netherlands become mothers at the age of 35 or older, which is higher than the EU average. The risks associated with childbirth increase with age, and the augmented use of fertility treatments is notable within this population (2.6 percent of Dutch women conceiving within the research period), leading to an elevated chance of multiple births. In fact, the Netherlands sees a quarter more instances of multiple births than the average in other EU countries.  

Smoking is also cited as a contributor to the poor statistics, with 13.4 percent of Dutch women continuing to smoke during their pregnancy.

None of these factors in isolation can explain the alarming statistics facing the Dutch maternity profession, but the most recent research seems to lay the discussion about the dangers of home births in the Netherlands to rest. However, there is still further research to do and actions to take to restore the faith in the Dutch maternity system.


Amanda van Mulligen / Expatica

Amanda van Mulligen, British born, moved to The Netherlands in 2000 and runs The Writing Well, an English language writing and translation business. She is married to a Dutchman and has one son. Amanda writes about life as an expatriate in Holland as well as travel articles on her website
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15 Comments To This Article

  • Joe posted:

    on 30th June 2009, 16:49:10 - Reply

    The Dutch medical system is an insult to modern medicine. Not only is the infant mortality here highest of any first world country, it is higher than the poorest countries in Europe. They pride themselves on the opinion that child birth is not a medical procedure here, so it takes place at home, assisted only by barely trained midwifes, without even the presence of an OB/GYN or a medical professional of any kind. You will not believe the hatchet job these midwifes do on an episiotomy and stitches until you have seen it. The baby momma, tricked into allowing a Dutch birth by their deceitful pregnancy classes, had to be rushed to a private clinic in Belgium to have it fixed.
    Besides the high infant mortality, this (together with pollution) could also explain the exceptionally high prevalence of birth defects and brain damage so obvious in this country.
    To receive any kind of medical attention, one first needs to beg for approval from a so called housearts, generally barely trained and without a medical degree, wearing plain clothes and holding office in a spare room in their home. I have had numerous life threatening medical emergencies that I have been forced to self diagnose using the internet, and self medicate using online pharmacies, because the standard verdict from the housearts is always "take a paracetamol, it will go away by itself".
  • matt posted:

    on 16th June 2009, 21:24:45 - Reply

    The simple answer is that the Dutch health care system is poor quality. The Dutch need to accept this, speak up, and demand better service. Only when they demand it, will it happen. Expats are a lost voice. Thatr is at least until the international organizations and corporations start moving away - and I know from friends that many international organizations are considering it due to the difficulty of recruiting good staff willing to live with the poor medical services.
    I am an expat and every single one of my expat friends have personally encountered an example of botched medical service, including me. Luckily mine was minor. Many of my Dutch friends have, in private, confessed that most of them have experience a botch as well. Any wonder then why anyone with any money (like all of the ambassadors here) has all of their medical services performed in Switzerland, France or the US?
    It is a mark of maturity when a people can admit that something in their society is wrong and speak up. I am sure that every country thinks it is number one in everything and feels a need to defend their system. Many, many things in the Netherlands show that the Dutch have quite a lot to be very rightly proud of. I hope they can swallow their pride and admit this one thing is broken, and move on to improve it. They will benefit from that when expat (and Dutch) are more willing to stay and contribute their skills and knowledge.
  • Ada posted:

    on 3rd June 2009, 22:33:25 - Reply

    I have just had an incredible experience in Bronovo hospital, shortly because I am still very weak: on 18th of May I have had an ultrasound performed by one gynecologist at Bronovo: she said that I was having a natural miscarriage. On 28th of May I fainted and went to ER at Bronovo hospital, having unbearable pain in my abdomen, the ER sent me directly to gynecology, another doctor performed an ultrasound, and told me that I have no gyneco problem. Because meantime my blood pressure dropped to 70/43 and I was in pain ER sent me to an internist that performed an abdominal ultrasound and.. I had a ruptured ectopic pregnancy, one of my Fallopian tubes was broken and I have lost 2 and 1/2 liters of blood, so almost died. They performed and emergency surgery and God saved my life.
    But my question is: what kind of medical system is this one, where two experienced doctors misdiagnosed an ectopic pregnancy?
  • Voodoo Doll posted:

    on 26th May 2009, 12:14:18 - Reply

    I completely agree with you Gift, the dutch health care system is relaying on luck and statistics... it is much cheaper to do this thant to have more proactive care such as physical exams.
    The blameing of a group of people is offensive and the way they state it with out any real way to check the facts makes me apprehensive.
    Even if indeed it were true that the majority of babies who die are ethnic minorities how does that make it okay??? Simple instructions and education in a native languge would help and isolation of the group certinally does not help.
    I had my baby here and I got good care because I insisted on a doctor not a midwife... if you want to talk to me about it private message me on this site and I might be able to give you good advice. Oh I do here Bronovo is a very good hospital so that is good. My hospital was so so..
    write me an email if you choose and I would be happy to share my experiences with you.
    Good luck and happy pregnancy and baby!
  • Gift posted:

    on 26th May 2009, 11:25:06 - Reply

    I am worried because I am having my baby in Bronovo in the next few weeks and i feel I cannot afford relying on the luck of getting a good doctor or midwife to hve a healthy baby. I have been attending a midwife practice that has four midwives and having met all the four, I see and feel a clear difference in care and I hope not reflection on competence. I realise that there is so much reliance on machines and test results that one can go through the whole pregnancy without ever getting any actual physical exam and no wonder that some of the potential causes of death could be missed. The problem is that the Dutch themselves seem to be ok with this kind of care and thats why it goes on, but something has to to be done to improve the death rate apart from blaming different groups of people
  • Voodoo Doll posted:

    on 24th May 2009, 11:49:31 - Reply

    I want to retract the statement I made on a earlier post it was a mistake I stated and I quote “Dutch do not have equal training”. This can be misinterpreted, I should have said that the quality of care is not equal depending on where you go and who you see, where you live etc… Sorry for the confusion.
    Deej is right comparisons are subjective at best and not fair or sometimes relevant if you do not say what you are comparing to. In fact, I wish not to really compare but see things that could be fixed or made better by what I have seen in other health care systems. Like for instance emergency medical care.
    I have had a lot of experience with the medical system here, some good some very bad. The World Health Organization gave NL bad marks for communication and access along with the high infant mortality rate. I tend to agree these are the problem areas in the NL system amongst others.
    What is upsetting to me is that is appears that once again the NL explanation for a problem is put on the foreigners’ and even if lets say for the sake of argument that it is only non-ethnic Dutch whose babies are dying why is it not being taken care of with some real action instead of a blame game. The problem is a wealthy, modern country has a high infant mortality rate and why are they not doing more about it.
    What is even more appalling is the response by the Dutch rarely is backed up by real facts and figures usually some random stats are thrown around and it is a defensive response. I would like to see them state what they are going to do about the issue and see more proactive work done instead of reactive. In addition, the response of blaming it on non-ethnic Dutch is really going towards a feeling of discrimination. Blame all the bad things on the minorities…
  • oyvind posted:

    on 14th May 2009, 11:54:21 - Reply

    I think we can conclude the following

    1. It's riskier to give birth in the Netherlands than other 1st world countries.
    2. It is equally unsafe to give birth at home and in the hospital.
    3. Because we're in a small and densly populated country you always have a hospital nearby, it means you don't gain much in time by actually being in the hospital in the event of complications.
    4. The Dutch medical professionals on average have lower standards than their foreign colleagues.

    I think several posts touches on possible reasons, but it starts with a question of whether the right people ends up admitted to medical school.

    Admissions to med. school is lottery based, which means the lucky winners get to become doctors, whereas in other countries the brightest people with the highest grades are admitted. Lack of specialists, mimimum risk of lawsuits and repercussions of errors and the laissez faire attitude of Dutch practitioners also don't help.
  • Voodoo Doll posted:

    on 13th May 2009, 14:59:45 - Reply

    I agree with you lightdancer, these stories always say how the dutch are so happy and the ones I talk to are not so happy. I wonder too where they get these numbers, people etc.
    I think it comes down cost. These so called shortages are due to budget restrictions. A family memeber of mine waited 3 years to get help for her medical problme . It was always the same story, waiting list due to shortages of specialist. I asked is there a shortage due to not enough people going to school in the medical field or is this a budget issue. I was told point blank by a person in the field it was a budget issue.
    It is all about cost.
    I don't disagree that home births can be a safe thing, but how they pratice OBGYN care here is not very good across the board. It is a gamble if you will get a good midwife, kraamzorg etc. If you get lucky things can go well but if you are unlucky things can go very wrong and lives can be lost.
    One should not have to only hope for luck to have healthy babies and moms.
    Remember statistics are so easy to manipulate and people tend to belive them without question.
  • woland posted:

    on 13th May 2009, 14:56:10 - Reply

    I have friends who recently had problems with the birth of their daughter. They said the medical system is terrible for the simple reason is based on computer's charts and suggestions. Those guys that study for so long cannot make decisions on their own. Although the evidence is pretty clear they totally ignore it if the computer says otherwise. How good do you think is that for your health? Do you dare to let your life in their hands?
  • lightdancer posted:

    on 13th May 2009, 12:58:48 - Reply

    Maybe it is also about the desire for a goedkoop. Home births may cost less than hospital stays.

    Not too long ago, I read something about Nederlanders commenting on their health care system. The report may actually have been an expat article. said Nederlanders are happy with the system and with their doctors.

    According to the many Nederlanders I have worked with in my alternative health care bedrijf...this is really not the case at all. So where do they get these numbers?
  • Voodoo Doll posted:

    on 13th May 2009, 12:05:45 - Reply

    I find it also interesting that they same Dutch home births are safe. I think the term is should be safe according to stats.
    Dutch do not have equal training and I wonder about the so called midwife training. I agree there are good doctors, nurses and midwifes but there are too many bad ones.
    They really don't want people to worry about homebirths and blame it could it be because homebirths mean less bed to fill in the hospital and they quite often have bed shortages, could it be it is CHEAP??? Money over life....
  • Nada posted:

    on 13th May 2009, 11:51:48 - Reply

    Great to read that the Dutch health system is better than the French one again. The "health report" lotery continue. Last time, another pretended "European something" organization reported the the Dutch was the best in 2008. What's next ?
    What to say to the GP, when the anwser is always "it is normal" ... you are to crawl with your big belly with contractions if you do not have 2euro coin to get the rolling chair in front the Bronovo Hospital to reach the 5th floor! During the presentation organized by Bronovo was "Don't forget your coin!" huge laugh from the audience.
    Dear expat, get your international insurance and go to Germany, Belgium or France to get your treatment if you don't want to have the anwser "It is normal"
  • mirne posted:

    on 13th May 2009, 11:50:14 - Reply

    As already noted in some of the replies above, there are some factual inaccuracies in this article. Hopefully these will be clarified and corrected ASAP.

    I am a Dutch-Australian living in the Netherlands. I have had two children and buried them both. One was still-born at 28 weeks (in Australia) and no reason for her death was ever found. I was healthy and so was she. My second child was born in the Netherlands at term. He was healthy also. I was healthy also. He died unexpected at age 7 weeks.

    During my pregnancies I did not smoke, I did not drink alcohol, I did not eat any of the "listeria" dangerous foods. I did all the right things. I did not have high blood pressure. My health was excellent. I had monitored pregnancies.

    However, the Dutch medical system was (to my expectation) poorly equipped to handle such pregnancies as mine - ie. pregnancies with my history. The doctors and nurses we encountered were unsympathetic and completely uncaring.

    This article does not mention that babies die for NO REASON. As was the case with my first born child. Her death had NOTHING to do with my age, my health, her health, our ethnicity, our language skills (or lack thereof - I speak perfect English and Dutch). This baby simply died. As do many others around the world -- for no reason AT ALL.

    Based on my experiences, as well as those of my husband (who is now also crippled as a result of Dutch medical negligence), I believe I am quite justified in saying that I have no confidence in the Dutch medical system at all.
  • Voodoo Doll posted:

    on 13th May 2009, 11:24:09 - Reply

    Of course they will put some of the blame on teh Allochtonen but this is baseless and deflecting from the problem. In my country we have many people who are immigrants and so does many other EU nations that are doing a better job at infant mortality rates.
    I don't trust the Dutch to care eaither...
  • Voodoo Doll posted:

    on 13th May 2009, 11:21:23 - Reply

    I cannot help but state that the unavailability of emergency surgical staff and care after midnight and until 7am is not a leading cause of this issue. Why is it not mentioned??? Is it because they don't really want to change it?