(Paper in Dutch. This abstract is by Bernike Pasveer.)
The authors argue that the dutch obstetrical system is under pressure: perinatal mortality and morbidity are higher than they used to be (no numbers). They don’t criticize the existence and subsistence of primary care midwives who have specific experience and responsibilities for healthy/low risk pregnancies & deliveries.
There has been little research into the quality of the entire care-chain, so that changes in ’isolated’ elements of the chain take place without knowledge of their gross effect on the quality of care. Example of an isolated change is the training of midwives to change the position of the child when it is in a breech, while there are others (gynaecologists) who are trained to do so already.
The authors argue that the chain would do better to try to reduce the number of referrals during labour, which is (2005) 51% for low-risk nulliparae and 17% of low-risk multiparae. These result in higher percentages of artificial deliveries including caesareans and caesareans in their turn result in complications during pregnancies that follow.
Reasons for the high referral rates: impatient parents, and discontinuous care during the entire delivery. Research has however shown that continuous presence of a ’wise woman’ during the entire delivery reduces the need for pain suppression, and the duration of the delivery itself of almost 2 hours.
In other words: healthy pregnant women need care, not cure. However, home delivery should not be a goal in itself, nor should a hospital (second line) delivery become the alternative to a home delivery (like in Rotterdam and Utrecht where the % of homebirths is as low as 10%): birth centers close to hospital are needed, which would be attractive to immigrants and would empower midwifery.
There is also a need for better care to hospital births - clinically working midwives could play an important role there: these professionals guard the physiological aspects of pregancy, labour and after for women who do have a medical indication, and can thus improve the quality of care considerably - and thus counter the increase of obstetrical interventions.
There is also a need for better care for high-risk deliveries, which take place within and outside office hours whereas gynaecologists are only present 5 days a week during office hours. Dutch research shows that intrapartum and neonatal mortality was 23% higher in the nighttime than in daytime on workdays between 11 pm and 8 am, and in weekends mortality was 7% higher.
Their plea is for a regional concentration of 24/24 care (but they note that this can be consequential for the percentage of homebirths).
Such concentration might also increase the quality of second and third line care: 90% of substandard care with maternal mortality due to pre-eclampsia is an effect of insufficient medical care, too late referral and too late induction of labour. Dutch obstetrics might be too conservative, they conjecture, and the belief in good results of a low-intervention process too high.
Full text paper is available on the link.
An incorrect abstract of this paper was published - and ultimately modified - by Tony Sheldon: "Obstetric care must change if Netherlands is to regain reputation for safe childbirth". BMJ 2008;336:239 (2 February). See record #2199 in this database and CIANE’s letter to BMJ: http://wiki.naissance.asso.fr/index.php?pagename=LetterBmjApril2008
L’article est disponible en texte intégral sur le lien.
Un résumé incorrect de cet article a été publié - puis rectifié - par Tony Sheldon : "Obstetric care must change if Netherlands is to regain reputation for safe childbirth". BMJ 2008;336:239 (2 February). Voir la fiche #2199 dans cette base de données et la lettre du CIANE au BMJ : http://wiki.naissance.asso.fr/index.php?pagename=LetterBmjApril2008
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