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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

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

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.

Competing interests: No competing interests

24 June 2013
Ank De Jonge
midwife senior researcher
Jeanette AJM Mesman, Joost J Zwart, Jeroen Van Dillen, Jos Van Roosmalen
Department of Midwifery Science, AVAG and the EMGO Institute of Health and Care Research, VU University Medical Center
Van der Boechorststraat 7, 1081 BT Amsterdam, the Netherlands