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Severe adverse maternal outcomes among low risk women with planned home versus hospital births in the Netherlands: nationwide cohort study

BMJ 2013; 346 doi: (Published 13 June 2013) Cite this as: BMJ 2013;346:f3263
  1. Ank de Jonge, midwife senior researcher1,
  2. Jeanette A J M Mesman, physician assistant midwife2,
  3. Judith Manniën, senior researcher1,
  4. Joost J Zwart, obstetrician3,
  5. Jeroen van Dillen, obstetrician4,
  6. Jos van Roosmalen, professor25
  1. 1Department of Midwifery Science, AVAG and the EMGO Institute of Health and Care Research, VU University Medical Center, Amsterdam, Netherlands
  2. 2Department of Obstetrics, Leiden University Medical Center, Leiden, Netherlands
  3. 3Deventer Hospital, Deventer, Netherlands
  4. 4Radboud University Nijmegen Medical Center, Nijmegen, Netherlands
  5. 5Department of Medical Humanities, EMGO, VU University Medical Center, Netherlands
  1. Correspondence to: A de Jonge ank.dejonge{at}


Objectives To test the hypothesis that low risk women at the onset of labour with planned home birth have a higher rate of severe acute maternal morbidity than women with planned hospital birth, and to compare the rate of postpartum haemorrhage and manual removal of placenta.

Design Cohort study using a linked dataset.

Setting Information on all cases of severe acute maternal morbidity in the Netherlands collected by the national study into ethnic determinants of maternal morbidity in the netherlands (LEMMoN study), 1 August 2004 to 1 August 2006, merged with data from the Netherlands perinatal register of all births occurring during the same period.

Participants 146 752 low risk women in primary care at the onset of labour.

Main outcome measures Severe acute maternal morbidity (admission to an intensive care unit, eclampsia, blood transfusion of four or more packed cells, and other serious events), postpartum haemorrhage, and manual removal of placenta.

Results Overall, 92 333 (62.9%) women had a planned home birth and 54 419 (37.1%) a planned hospital birth. The rate of severe acute maternal morbidity among planned primary care births was 2.0 per 1000 births. For nulliparous women the rate for planned home versus planned hospital birth was 2.3 versus 3.1 per 1000 births (adjusted odds ratio 0.77, 95% confidence interval 0.56 to 1.06), relative risk reduction 25.7% (95% confidence interval −0.1% to 53.5%), the rate of postpartum haemorrhage was 43.1 versus 43.3 (0.92, 0.85 to 1.00 and 0.5%, −6.8% to 7.9%), and the rate of manual removal of placenta was 29.0 versus 29.8 (0.91, 0.83 to 1.00 and 2.8%, −6.1% to 11.8%). For parous women the rate of severe acute maternal morbidity for planned home versus planned hospital birth was 1.0 versus 2.3 per 1000 births (0.43, 0.29 to 0.63 and 58.3%, 33.2% to 87.5%), the rate of postpartum haemorrhage was 19.6 versus 37.6 (0.50, 0.46 to 0.55 and 47.9%, 41.2% to 54.7%), and the rate of manual removal of placenta was 8.5 versus 19.6 (0.41, 0.36 to 0.47 and 56.9%, 47.9% to 66.3%).

Conclusions Low risk women in primary care at the onset of labour with planned home birth had lower rates of severe acute maternal morbidity, postpartum haemorrhage, and manual removal of placenta than those with planned hospital birth. For parous women these differences were statistically significant. Absolute risks were small in both groups. There was no evidence that planned home birth among low risk women leads to an increased risk of severe adverse maternal outcomes in a maternity care system with well trained midwives and a good referral and transportation system.


  • We thank the Netherlands perinatal registry for the use of the national database.

  • Contributors: AJ conceived the study, wrote the article, and is guarantor of the study. JMe and AJ conducted the analyses. JMa linked the datasets. All authors contributed to interpretation of the data, critically revised earlier drafts of the paper for important intellectual content, and gave final approval of the version to be published. The researchers had access to all the research data.

  • Funding: This study was funded with a career grant (VENI) from ZonMw. The funder had no role in any aspect of the study.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: The ethical committee of VU University Medical Center confirmed that ethical approval was not necessary for this study (reference No 11/399).

  • Data sharing: No additional data available.

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