Infants in the Netherlands born to mothers who have been classified as low risk, are more than twice as likely to die during or shortly after birth than babies born to high risk mothers, finds a study published in the British Medical Journal today.
While the risk remains low the authors are surprised at the results and say "a critical evaluation of the obstetrical care system in the Netherlands is urgently required."
Despite the high level of medical care in the Netherlands, the perinatal mortality rate (death of fetus or new born baby) is one of the highest in Europe, says the study.
The management of childbirth delivery in the Netherlands is divided into two independent systems midwife-led care for low risk pregnancies and obstetrician-led care for high-risk pregnancies. This differs to all other obstetric care systems in the industrial world. Home birth in the low risk group is popular and 22% of this group deliver their babies this way.
The authors, led by Dr Annemieke Evers from the University Medical Center in Utrecht, investigated whether the obstetric care system in the Netherlands contributes to the high perinatal mortality rate.
Evers and colleagues assessed the data of 37,735 births from a region in the middle of the Netherlands covering 13% of the Dutch population. The overall perinatal death rate in the study group was 2.62 per 1,000 babies delivered but this risk more than doubles for infants of low risk pregnant women.
The authors were also concerned to note that this risk more than triples for babies of women who were referred during labour by a midwife to an obstetrician.
The results also show that there was no difference in the admission rate of babies born to low and high risk women to neonatal intensive care units (NICU).
Dr Evers believes this study puts "severe question marks by the supposed effectiveness of the Dutch obstetrical system that is based on risk selection and obstetrical care at two levels." She says "the Dutch system of risk selection in relation to perinatal death at term is not as effective as once thought this implies as well that the high perinatal death in the Netherlands compared to other European countries is among other factors possibly caused by the obstetrical care system itself."
In an accompanying editorial, Mr Derek Tuffnell, Consultant Obstetrician at the Bradford Royal Infirmary, believes women at low risk of complications should be given a choice of having their baby at home or in a midwifery unit.
While Tuffnell acknowledges that Evers' study suggests that the higher rate of perinatal mortality in the Netherlands may be "because women were inappropriately booked for labour care under a midwife," he adds that "risk assessment is an inexact science" and that no birth is without risk.
He says "low risk does not equal no risk, and high risk women who are away from consultant care are a particular risk."
Mr Tuffnell concludes that the study is welcome but it can only provide estimates. He argues that the debate about how to manage low risk and high risk pregnancies will continue and that "women will have to make individual choices."