Evaluation of 280,000 Cases in Dutch Midwifery Practices : A Descriptive Study

Over the past decade, an estimated 30% of Dutch infants have been born at home. Care in early pregnancy is delivered primarily by independently practicing midwives, and in the absence of complications, this continues into the postpartum period. This descriptive study, based on a database covering 95% of midwifery care and 80% of all Dutch pregnancies in the years 2001-2003, was an attempt to determine the frequency and outcome of pregnancies referred intrapartum from primary to secondary care. The study population consisted of 280,097 low-risk women who, at the outset of labor, were solely cared for by a primary-level midwife with the intent to deliver either at home (62% of evaluable cases) or in hospital (29%). More than two-thirds of women in this study (68.1%) completed childbirth under the exclusive care of a midwife. Another 28.3% were referred to secondary care without urgency, and 3.6% were referred urgently. The chief indications for urgent referral were fetal distress and postpartum hemorrhage. Neonatal factors were implicated in 0.4% of cases. Nearly three-fourths of nonurgent referrals were made during the first stage of labor. Women who had planned home delivery were referred to secondary care less often than those planning hospital delivery (29.3% vs. 37.2%). In the overall study population, the mean 5-minute Apgar score was 9.7 and the peripartum neonatal mortality rate was 0.05%. No maternal deaths were recorded. Adverse neonatal outcomes were most prevalent in urgently referred cases and next most frequent in nonurgent referrals. These findings suggest than a system of obstetrical care based on risk assignment by midwives can work well. Further study will be needed to learn whether outcomes would improve with earlier referrals, or whether some referrals in the present series were unnecessary.