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

As a psychologist with a professional interest in reproductive health, and being 30 weeks pregnant myself, I have recently been consulting the literature to determine my own birth options. I read the deJonge article (1) with interest and the subsequent correspondence by Teuter with surprise (2).

To begin with, it seems Teuter is unable to count. DeJonge et al. clearly state there were 5 maternal deaths in the study sample, 2 in the home birth category (2/100,000) and 3 in the hospital birth category (6/100,000) (3). Despite this clear and unambiguous statement, Teuter in her blog states “there were 3 maternal deaths attributable to pregnancy in the entire study, 2 in the homebirth group and one in the hospital group for a death rate of 2/1000, 000 in each group” (4) and uses these figures to argue that this paper in fact provides evidence that that home births are unsafe.

As the author of the Skeptical OB http://www.skepticalob.com/ (a clearly undeclared competing interest) it seems that Teuter’s raison d’etre is to rubbish homebirths at every opportunity. Let’s be clear, she is not just questioning the BMJ results, she is doing all she can to discredit them.

The public should be able to have confidence in their physicians. By confidence, I mean that they should expect their care to be based on evidence. Despite the clear and careful work of DeJonge et al, and the rigours of the BMJ peer review process, Teuter is unwilling to consider any alternatives to her own entrenched position. As a member of the public it is worrying to think that my medical care might be determined by a doctor’s personal agenda rather than clinical evidence.

References:

1) de Jonge, A., Mesman, J AJM, Manniën, J., Zwart, J. J. van Dillen, & J. van Roosmalen (2013) Severe adverse maternal outcomes among low risk women with planned home versus hospital births in the Netherlands: nationwide cohort study. British Medical Journal 346. doi: http://dx.doi.org/10.1136/bmj.f3263

2) Tuteur, A. (14th and 25th June 2013) Rapid Response. http://www.bmj.com/content/346/bmj.f3263?tab=responses

3) de Jonge, A., Mesman, J. A. J. M., Manniën, J., Zwart, J. J., van Dillen, J., & van Roosmalen. J., (24th June 2013) Rapid Response. Authors Reply. http://www.bmj.com/content/346/bmj.f3263?tab=responses

4) http://www.skepticalob.com/2013/06/surprise-there-were-homebirth-deaths-...

Dear editor,

We did not mention maternal deaths in our study, but they were included among the women with severe acute maternal morbidity (SAMM). There were two maternal deaths in the planned home birth group (2 per 100,000) and three in the planned hospital birth group (6 per 100,000). The differences between these rates were not statistically significant (Fisher’s exact test, P=0.367).

One woman gave birth at home at 38 weeks gestation in midwife led care and was referred to hospital in the postpartum period by the general practitioner because of signs of HELLP syndrome. She died the following day due to brain haemorrhage. At 37 weeks she had been sent for consultation to hospital because of upper abdominal pain and headache. Her blood pressure was slightly elevated, she had proteinuria but her blood results were normal. She had been referred back to primary care. All cases of maternal death in the Netherlands are audited in a confidential enquiry1. The conclusion of the audit in this case was that the woman should not have been referred back to primary care by the obstetrician and that she should have given birth in secondary care in hospital.

The other four women were referred during labour from primary to secondary care because of meconium stained liquor. One woman suffered from sudden collapse during labour, when she was already in secondary care, and died. Although no definite diagnosis was made at postmortem examination, a cardiac cause appeared to be most likely.

A woman who gave birth spontaneously was discharged after one day. On the fourth day postpartum she was readmitted because of profuse vaginal bleeding and shortness of breath. She had a sudden collapse and died. Postmortem examination showed sinus sagittalis superior thrombosis.

Two women died a few weeks after they gave birth from causes not related to the delivery; one from a severe asthma attack, the other one fell down the stairs, had a skull fracture and died of a subarachnoid haemorrhage.

The most common adverse maternal outcome in our study was postpartum haemorrhage over 1000 mls and by far the most common type of SAMM was major obstetric haemorrhage treated with four or more packed cells. None of these cases resulted in maternal death. Delay during emergency transport from home to hospital played no role in any of the maternal deaths.

(1) Schutte JM, Steegers EA, Schuitemaker NW, Santema JG, de BK, Pel M et al. Rise in maternal mortality in the Netherlands. BJOG 2010; 117(4):399-406.