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OBJECTIVE: To compare rates of adverse perinatal outcomes between planned home births versus planned hospital births. DESIGN: A nationwide cohort study. SETTING: The Netherlands. POPULATION: Low-risk women in midwife-led care at the onset of labour. METHODS: Analysis of national registration data. MAIN OUTCOME MEASURES: Intrapartum and neonatal death, Apgar scores, and admission to a neonatal intensive care unit (NICU) within 28 days of birth. RESULTS: Of the total of 814 979 women, 466 112 had a planned home birth and 276 958 had a planned hospital birth. For 71 909 women, their planned place of birth was unknown. The combined intrapartum and neonatal death rates up to 28 days after birth, including cases with discrepancies in the registration of the moment of death, were: for nulliparous women, 1.02‰ for planned home births versus 1.09‰ for planned hospital births, adjusted odds ratio (aOR) 0.99, 95% confidence interval (95% CI) 0.79-1.24; and for parous women, 0.59‰ versus 0.58‰, aOR 1.16, 95% CI 0.87-1.55. The rates of NICU admissions and low Apgar scores did not significantly differ among nulliparous women (NICU admissions up to 28 days, 3.41‰ versus 3.61‰, aOR 1.05, 95% CI 0.92-1.18). Among parous women the rates of Apgar scores below seven and NICU admissions were significantly lower among planned home births (NICU admissions up to 28 days, 1.36 versus 1.95‰, aOR 0.79, 95% CI 0.66-0.93). CONCLUSIONS: We found no increased risk of adverse perinatal outcomes for planned home births among low-risk women. Our results may only apply to regions where home births are well integrated into the maternity care system.

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BACKGROUND: The 'Hague Protocol' enables professionals at the adult Emergency Department (ED) to detect child abuse based on three parental characteristics: (i) suicide attempt or self-harm, (ii) domestic violence or (iii) substance abuse, and to refer them to the Reporting Centre for Child Abuse and Neglect (RCCAN). This study investigates what had happened to the families three months after this referral. METHOD: ED referrals based on parental characteristics (N = 100) in which child abuse was confirmed after investigation by the RCCAN were analysed. Information was collected regarding type of child abuse, reason for reporting, duration of problems prior to the ED referral, previous involvement of support services or other agencies, re-occurrence of the problems and outcome of the RCCAN monitoring according to professionals and the families. RESULTS: Of the 100 referred cases, 68 families were already known to the RCCAN, the police or family support services, prior to the ED referral. Of the 99 cases where information was available, existing support was continued or intensified in 31, a Child Protection Services (CPS) report had to be made in 24, new support was organized for 27 cases and in 17 cases support was not necessary, because the domestic problems were already resolved. Even though the RCCAN is mandated to monitor all referred families after three months, 31 cases which were referred internally were not followed up. CONCLUSION: Before referral by the ED two thirds of these families were already known to organizations. Monitoring may help provide a better, more sustained service and prevent and resolve domestic problems. A national database could help to link data and to streamline care for victims and families. We recommend a Randomized Controlled Trial to test the effectiveness of this Protocol in combination with the outcomes of the provided family support.

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OBJECTIVE: This study aims to evaluate trends in prevalence of Down syndrome (DS) births in the Netherlands over an 11-year period and how they have been affected by maternal age and introduction of prenatal screening. METHOD: Nationwide data of an 11-year birth cohort (1997-2007) from the Netherlands Perinatal Registry were analyzed. First-trimester combined screening was introduced in 2002, free of charge only for women 36 years of age or older and only on patients' request. Changes in maternal age, prevalence of DS births, and rates of births at <24 weeks (legal limit for termination of pregnancy in the Netherlands) during the study period were evaluated using logistic and linear regression analyses. RESULTS: In total, 1,972,058 births were registered (91% of the births in 1997-2007). Mean prevalence of DS was 14.57 per 10,000 births (95% confidence interval 14.43; 14.73); 85% of DS were live births. No significant trend in overall prevalence of DS births was observed (p = 0.385), in spite of a significant increase of mean maternal age during the same period (p < 0.001). The increased prevalence of DS births at ≥ 24 weeks among women ≥ 36 years of age (p = 0.011) was offset by a significant increase in the proportion of DS births at <24 weeks among women aged <36 years (p = 0.013). CONCLUSION: The proportion of DS births in the Netherlands has not changed during the period 1997-2007.

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AIM: To examine the association between semi-sitting and sitting position at the time of birth and perineal damage amongst low-risk women in primary care. BACKGROUND: Evidence on the association between birthing positions and perineal trauma is not conclusive. Most studies did not distinguish between positions during the second stage of labour and position at the time of birth. Therefore, although birthing positions do not seem to affect the overall perineal trauma rate, an increase in trauma with upright position for birthing cannot be ruled out. METHODS: Secondary analysis was performed on data from a large trial. This trial was conducted amongst primary care midwifery practices in the Netherlands. A total of 1646 women were included who had a spontaneous, vaginal delivery. Perineal outcomes were compared between women in recumbent, semi-sitting and sitting position. Logistic regression analysis was used to examine the effects of these positions after controlling for other factors. FINDINGS: No significant differences were found in intact perineum rates between the position groups. Women in sitting position were less likely to have an episiotomy and more likely to have a perineal tear than women in recumbent position. After controlling for other factors, the odds ratios (OR) were 0.29 [95% confidence interval (CI): 0.16-0.54] and 1.83 (95% CI: 1.22-2.73) respectively. Women in semi-sitting position were more likely to have a labial tear than women in recumbent position (OR: 1.43, 95% CI: 1.00-2.04). CONCLUSION: A semi-sitting or sitting birthing position does not need to be discouraged to prevent perineal damage. Women should be encouraged to use positions that are most comfortable to them.

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OBJECTIVE: To compare perinatal mortality and severe perinatal morbidity between planned home and planned hospital births, among low-risk women who started their labour in primary care. DESIGN: A nationwide cohort study. SETTING: The entire Netherlands. POPULATION: A total of 529,688 low-risk women who were in primary midwife-led care at the onset of labour. Of these, 321,307 (60.7%) intended to give birth at home, 163,261 (30.8%) planned to give birth in hospital and for 45,120 (8.5%), the intended place of birth was unknown. METHODS: Analysis of national perinatal and neonatal registration data, over a period of 7 years. Logistic regression analysis was used to control for differences in baseline characteristics. MAIN OUTCOME MEASURES: Intrapartum death, intrapartum and neonatal death within 24 hours after birth, intrapartum and neonatal death within 7 days and neonatal admission to an intensive care unit. RESULTS: No significant differences were found between planned home and planned hospital birth (adjusted relative risks and 95% confidence intervals: intrapartum death 0.97 (0.69 to 1.37), intrapartum death and neonatal death during the first 24 hours 1.02 (0.77 to 1.36), intrapartum death and neonatal death up to 7 days 1.00 (0.78 to 1.27), admission to neonatal intensive care unit 1.00 (0.86 to 1.16). CONCLUSIONS: This study shows that planning a home birth does not increase the risks of perinatal mortality and severe perinatal morbidity among low-risk women, provided the maternity care system facilitates this choice through the availability of well-trained midwives and through a good transportation and referral system.

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OBJECTIVE: To assess the trends and patterns of referral from midwives to obstetricians within the Dutch maternity care system from 1988 to 2004, and the differences in referral patterns between nulliparous and parous women. DESIGN: A descriptive study. SETTING: The Dutch midwifery database (LVR1), which monitored 74% (1988) to 94% (2004) of all midwifery care in the Netherlands between 1988 and 2004. POPULATION: A total of 1 977 006 pregnancies, attended by a primary care level midwife. METHODS: The indications for referral from midwifery to obstetric care were classified into fifteen groups (eight antepartum, six intrapartum and one postpartum). The trends in referrals of these indications were analysed by general linear models. MAIN OUTCOME MEASURES: Trends in the percentage of antepartum, intrapartum and postpartum referrals from midwifery care to obstetric care; trends in the specific indications for referral; contribution of different groups of the indications to the trend. RESULTS: From 1988 to 2004 an increase of 14.5% (from 36.9 to 51.4%) occurred in referrals from primary midwifery care to secondary obstetric care either during pregnancy, childbirth or in the postpartum period. The timing of the referrals was as follows: antepartum +9.0%, intrapartum +5.2% and postpartum +0.3%. In parous women, the increase in referrals was greater (+16.6%) than in nulliparous women (+12.3%) (P = 0.001). The commonest indications for referrals in nulliparous women were anticipated or evident complications due to 'failure to progress in the first or second stage' and 'fetal distress'. Parous women were most commonly referred for anticipated or evident complications due to 'medical history' and 'fetal distress'. In nulliparous women, 52% of the increase in referrals was related to the need of pain relief and occurrence of meconium-stained amniotic fluid; in parous women, 54% of the increase in referrals was related to the general medical and obstetrical history of the women, particularly previous caesarean section, and the occurrence of meconium-stained amniotic fluid. CONCLUSIONS: During a 17-year period, there was a continuous increase in the referral rate from midwives to obstetricians. Previous caesarean section, requirement for pain relief and the presence of meconium-stained amniotic fluid were the main contributors to the changes in referral rates. Primary prevention of caesarean section and antenatal preparation for childbirth are important interventions in the maintenance of primary obstetric care for low-risk pregnant women.

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AIMS: Information about risk factors and preventive measures given before conception is estimated to prevent 15-35% of adverse pregnancy outcomes. We aimed to identify women's motives for not responding to an invitation for preconception counseling (PCC) from their general practitioner. METHODS: A purposive sample of 11 women who did not respond to an invitation for PCC and who became pregnant within 1 year was interviewed. RESULTS: Three key themes influencing nonresponse emerged from the data: perceived knowledge, perceived lack of risk and a misunderstanding of the aim of PCC. CONCLUSION: For successful future implementation of PCC, a more tailored approach may be necessary for certain (groups of) women, addressing the reasons why women do not consider themselves part of the target group for PCC.

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OBJECTIVE: To assess the nature and outcome of intrapartum referrals from primary to secondary care within the Dutch obstetric system. DESIGN: Descriptive study. SETTING: Dutch midwifery database (LVR1), covering 95% of all midwifery care and 80% of all Dutch pregnancies (2001-03). POPULATION: Low-risk women (280,097) under exclusive care of a primary level midwife at the start of labour either with intention to deliver at home or with a personal preference to deliver in hospital under care of a primary level midwife. METHODS: Women were classified into three categories (no referral, urgent referral and referral without urgency) and were related to maternal characteristics and to neonatal outcomes. MAIN OUTCOME MEASURES: Distribution of referral categories, main reasons for urgent referral, Apgar score at 5 minutes, perinatal death within 24 hours and referral to a paediatrician within 24 hours. RESULTS: In our study, 68.1% of the women completed childbirth under exclusive care of a midwife, 3.6% were referred on an urgency basis and 28.3% were referred without urgency. Of all referrals, 11.2% were on an urgency basis. The main reasons for urgent referrals were fetal distress and postpartum haemorrhage. The nonurgent referrals predominantly took place during the first stage of labour (73.6% of all referrals). Women who had planned a home delivery were referred less frequently than women who had planned a hospital delivery: 29.3 and 37.2%, respectively (P < 0.001). On average, the mean Apgar score at 5 minutes was high (9.72%) and the peripartum neonatal mortality was low (0.05%) in the total study group. No maternal deaths occurred. Adverse neonatal outcomes occurred most frequently in the urgent referral group, followed by the group of referrals without urgency and the nonreferred group. CONCLUSIONS: Risk selection is a crucial element of the Dutch obstetric system and continues into the postpartum period. The system results in a relatively small percentage of intrapartum urgent referrals and in overall satisfactory neonatal outcomes in deliveries led by primary level midwives.

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OBJECTIVE: Comparison of perinatal mortality in The Netherlands with that in other European countries (Peristat-II), and with data collected 5 years previously (Peristat-I). DESIGN: Descriptive study. METHOD: Indicators ofperinatal mortality which were developed for Peristat-I were used again in Peristat-II. Data on perinatal mortality in 2004 were delivered by 26 European countries. The Dutch data originated from national registers of midwives and gynaecologists and the National Neonatology Register. RESULTS: In Peristat-I, from 22 weeks gestation, The Netherlands had the highest fetal mortality rate (7.4 per 1,000 total number of births). Furthermore, after Greece, The Netherlands had the highest early neonatal mortality rate (3.5 per 1,000 live births). In Peristat-II from 22 weeks gestation, after France, The Netherlands had the highest fetal mortality rate (7.0 per 1,000 total number of births). Of all western European countries, The Netherlands had the highest early neonatal mortality rate (3.0 per 1,000 live births). Over the past 5 years the perinatal mortality rate in The Netherlands has dropped from 10.9 to 10.0 per 1,000 total births but this drop has been faster in other countries. CONCLUSION: The Netherlands has a relatively high number of older mothers and multiple pregnancies, but this only partly explains the high Dutch perinatal mortality rate which still ranks unfavourably in the European tables. More research is necessary to gain insight into the prevalence of risk factors for perinatal mortality compared with other European countries. In addition, perinatal health and the quality ofperinatal healthcare deserve a more prominent position in Dutch research programmes.

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OBJECTIVE: To compare the difference in neonatal mortality and morbidity between breech and cephalic presentations at term. METHODS: This was a retrospective matched cohort study in two centers between July 1998 and April 2000, including all breech deliveries between 37(+0) and 41(+6) weeks, except cases with multiple gestations and antepartum intrauterine deaths. All breech presentations were matched with two cephalic presentations. Onset of labor and route of delivery were recorded, and neonatal data were categorized into variables belonging to serious morbidity or moderate morbidity. RESULTS: One thousand one hundred and nineteen deliveries were included. Three hundred and seventy-three babies were in breech position and 746 in cephalic position. The gestational age and birth weight of the babies in the breech group were lower than in the cephalic group (p < 0.001). Congenital abnormalities occurred more often in the breech group (p < 0.005). An elective cesarean section was performed in 23.3% of breech presentations versus 3.5% of cephalic presentations (p < 0.001). Emergency cesarean sections were done in 29.2% of breech presentations versus 8.8% of cephalic presentations (p < 0.001). Children born in breech presentation had lower Apgar scores after 1 minute (p < 0.0001), but 5-minute Apgar scores were the same in both groups (p = 0.22). Children born in breech presentation received significantly more resuscitation than children born in cephalic presentation (p < 0.001). In both groups no perinatal mortality occurred. No differences were observed in percentages of children with serious or moderate neonatal morbidity between the breech and cephalic lies. CONCLUSIONS: Although the numbers are small, this study shows that the conservative (vaginal) approach in selected fetuses in breech position can be safely pursued with neonatal results similar to fetuses in cephalic presentation.

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BACKGROUND: Preconception counselling (PCC) can reduce adverse pregnancy outcome by addressing risk factors prior to pregnancy. This study explores whether anxiety is induced in women either by the offer of PCC or by participation with GP-initiated PCC. METHODS: Randomised trial of usual care versus GP-initiated PCC for women aged 18-40, in 54 GP practices in the Netherlands. Women completed the six-item Spielberger State Trait Anxiety Inventory (STAI) before PCC (STAI-1) and after (STAI-2). After pregnancy women completed a STAI focusing on the first trimester of pregnancy (STAI-3). RESULTS: The mean STAI-1-score (n = 466) was 36.4 (95% CI 35.4-37.3). Following PCC there was an average decrease of 3.6 points in anxiety-levels (95% CI, 2.4-4.8). Mean scores of the STAI-3 were 38.5 (95% CI 37.7-39.3) in the control group (n = 1090) and 38.7 (95% CI 37.9-39.5) in the intervention group (n = 1186). CONCLUSION: PCC from one's own GP reduced anxiety after participation, without leading to an increase in anxiety among the intervention group during pregnancy. We therefore conclude that GPs can offer PCC to the general population without fear of causing anxiety.

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OBJECTIVES: In the Netherlands, approximately one-third of births are planned home births, mostly supervised by a midwife. The relationship between maternal demographic factors and home births supervised by midwives was examined. DESIGN: Cross-sectional study. Setting Dutch national perinatal registries of the year 2000. POPULATION: All women starting their pregnancy care under the supervision of a midwife, because these women have the possibility of having a planned home birth. METHODS: The possible groups of birth were as follows: planned home birth or short stay hospital birth, both under the supervision of a midwife, or hospital birth under the supervision of an obstetrician after referral from the midwife during pregnancy or birth. The studied demographic factors were maternal age, parity, ethnicity and degree of urbanisation. Probabilities of having a planned home birth were calculated for women with different demographic profiles. MAIN OUTCOME MEASURE: Place of birth. RESULTS: In all age groups, the planned home birth percentage in primiparous women was lower than in multiparous women (23.5%vs 42.8%). A low home birth percentage was observed in women younger than 25 years. Dutch and non-Dutch women showed almost similar percentages of obstetrician-supervised hospital births but large differences in percentage of planned home births (36.5%vs 17.3%). Fewer home births were observed in large cities (30.5%) compared with small cities (35.7%) and rural areas (35.8%). CONCLUSIONS: This study demonstrates a clear relationship between maternal demographic factors and the place of birth and type of caregiver and therefore the probability of a planned home birth.

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Congenital malformations are among the major causes of perinatal mortality and morbidity at present. Research into the ethnic diversity of congenital malformations can form a basis both for aetiological studies and for health care advice and planning. This study compared the overall prevalence of congenital malformations, the prevalence in different organ systems and of several specific malformations between different maternal ethnic groups in the Netherlands using a 5-year national birth cohort (1996-2000) containing 881 800 births. Maternal ethnic groups considered were Dutch; Mediterranean (Moroccan/Turkish); other European; Black; Hindu and Asian. Mediterranean women had a 20% higher risk of having a child with a congenital malformation than Dutch women (age-adjusted OR = 1.21 [95% CI 1.16, 1.27]). They showed an increased risk of malformations in several organ systems such as the central nervous system and sensory organs, the urogenital system and skin and abdominal wall. Further, they had an increased risk of the group of chromosomal malformations/multiple malformations/syndromes. For the specific group of multiple malformations the maternal age adjusted OR was 1.80 [95% CI 1.47, 2.20]. The Black group showed a significantly increased risk of skeletal and muscular malformations (age adjusted OR = 1.76 [95% CI 1.53, 2.02]) with a sixfold increased risk of polydactyly compared with the Dutch group. For Mediterranean women, the largest and fastest growing group of immigrants in the Netherlands, this study demonstrated an increased risk of congenital malformations.

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In the Peristat-project, a European collaborative study, a set of indicators has been defined for monitoring perinatal health outcomes. For a group of 10 core indicators, with variables for subgroup analysis, national registry data from 15 European member states were collected and compared. The Netherlands was found to have the highest perinatal mortality in Europe: the foetal and neonatal mortality amounted to 7.4 and 3.5 per 1000 births, respectively. European countries differ in registration practices. Some countries do not register perinatal deaths occurring before a duration of amenorrhoea of 28 weeks. Therefore, the Peristat mortality data should be compared with 28 weeks of gestation as a cut-off point. With this cut-off point, The Netherlands has the second highest perinatal mortality. A number of factors may have contributed to this relatively high mortality, such as differences in registration practices, the profile of the Dutch childbearing population and the characteristics of Dutch perinatal care. The Netherlands has a relatively high proportion of older mothers, multiple births and mothers belonging to an ethnic minority. Also, Dutch neonatologists are known to be conservative in their treatment of premature newborns, which reduces their chances of survival. There is also less prenatal screening for congenital abnormalities in The Netherlands than in many other European countries. Further analysis of the Dutch data, as well as continued monitoring at the European level, can serve as a basis for future policy decisions to enhance the health of Dutch mothers and newborns.

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BACKGROUND: Specific subgroups of people planning IVF might be at risk of having more psychological or health-related problems. Identification of subgroups at risk may better enable allocation of appropriate counselling. METHODS: A group of 425 men and 447 women planning to undergo IVF treatment filled out a questionnaire. Four domains of health-related quality of life were measured, namely perceived emotional, physical, cognitive and social functioning. RESULTS: Young men and women (aged 21-30 years) planning IVF had more short-term social and emotional problems than people of the same age group in the general population. No substantial differences were found in cognitive and physical functioning for all age groups of men nor women planning IVF compared with the general population. A high level of irrational parenthood cognitions substantially accounted for a less optimal score on all the different domains of quality of life. These cognitions ('needing a child in order to live a happy life') were especially prevalent among younger women. CONCLUSIONS: Patients with high levels of irrational parenthood cognitions are at risk of a less optimal quality of life. A short cognitive counselling therapy is advised for patients with high levels of these cognitions.

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BACKGROUND: The percentage of children born after IVF will continue to increase due to demographic changes such as increasing maternal age and new developments in assisted reproduction techniques. IVF conceptions may carry an increased risk of congenital malformations. METHODS: We compared overall and specific congenital malformation rates calculated for IVF children (n = 4224) and naturally conceived children (n = 314 605), using records from the same Dutch national database for the years 1995 and 1996 and controlling for confounding maternal factors. RESULTS: The overall crude odds ratio (OR) for the risk of any malformation for IVF children compared with naturally conceived children was 1.20 [95% confidence interval (CI): 1.01-1.43]. After correction for differences in maternal age, parity and ethnicity between the IVF and control population the OR was 1.03 (95% CI: 0.86-1.23). The crude OR for IVF children appeared higher for the cardiovascular organ system and for several specific minor congenital malformations. However, these could be chance findings due to comparison of many malformation categories or may result from remaining differences in ascertaining malformations between IVF and naturally conceived children. CONCLUSIONS: The small increase in overall congenital malformations observed in the IVF children appears to be attributable to differences in maternal characteristics and not to any aspect of the IVF procedure.

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In the 'Overview of the role of antibiotics in curtailing labour and early delivery' (ORACLE I)-trial in women with premature rupture of membranes, the use of erythromycin was found to be associated with a decrease in the primary composite outcome (neonatal death, chronic lung disease or major cerebral abnormality on ultrasound; p = 0.08) and in single adverse neonatal outcomes (p = 0.02) when compared to placebo. The positive results were more significant in the singleton group (p = 0.02 for the composite outcome), while no effects were found in twin pregnancies. The combination of amoxycillin and clavulanic acid, with or without erythromycin, was associated with some improvements in outcome, but was also accompanied by a higher rate of neonatal necrotising enterocolitis. Another trial (ORACLE II) found no effects of antibiotic use in women with premature labour with intact membranes. Although both trials were of good quality, the stratification into singleton and twin pregnancies should have been done more consistently. Because premature rupture of membranes in singleton pregnancies is more likely to be associated with a pre-existing infection than in multiple pregnancies, the potential benefit of treatment with antibiotics is larger in singleton pregnancies.

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