" ° ° ' ) ' , " ° ' Midwifery Longman Group UK Ltd 1991

Safest birth attendants: recent Dutch evidence

Marjorie Tew, S M I Damstra-Wijmenga

Analysis o f nat ional pe r ina ta l statistics f r o m Hol land , 1986, d e m o n s t r a t e s tha t fo r all b i r ths a f t e r 32 weeks ' ges ta t ion mor ta l i ty is m u c h lower u n d e r the non- in te rvent ion is t care o f midwives t han u n d e r the in te rven t ion i s t m a n a g e m e n t o f obstetr icians at all levels o f p r e d i c t e d risk. Th is f ind ing conf i rms with grea t au tho r i ty the conclus ions o f all ear l ie r impar t ia l analyses f r o m Bri ta in and o t h e r count r ies which agree in con t r ad i c t i ng the claims on which the organisa t ion o f ma te rn i t y services in mos t d e v e l o p e d count r ies is now based, namely , tha t ch i ldbi r th is m a d e so m u c h safer by the appl ica t ion o f h igh t echno logy that only this op t ion shou ld be p r o v i d e d .

INTRODUCTION

In all economically developed countries except Holland, maternity care has come to be organised so as to give full effect to the theory that childbirth is always safer if it takes place under the management of obstetricians in a hospital provided with the technological equip- ment for carrying out interventions in the natu- ral process. It is a remarkable fact that obstetricians have never at any time had valid evidence to support the theory they have so successfully propagated. It was not based on the results of a randomised controlled trial, for none was ever conducted; and once strong opinions had been implanted among both the providers and the users of the maternity service about its safer management, a randomised controlled trial had ceased to be a feasible or appropriate

Marjorie Tew MA, Research Statistician, Department of Orthopaedic Surgery Nottingham Medical School. S M I Damstra-Wijmenga MD, General Physician Groningen, Holland. Manuscript accepted 7 January 1991 Requests for offprints to MT

instrument for impartial evaluation (Campbell & Macfarlane, 1986; Tew, 1990).

Lacking objective experimental results, evid- ence has to be drawn from actual observed experience and this does not support the obste- tricians' theory. Records from the most reliable British sources (Butler & Bonham. 1963; Cham- berlain et al, 1978; Registrar General, 1969-73) covering the years before the hospitalisation of birth was nearly complete show consistently that rates of perinatal mortality (PNMR) were much higher for births in specialist hospitals where the practice of intervention was common than in non-specialist hospitals or family homes where interventions were uncommon. Even more important was the finding that PNMRs were also higher in hospital for births at every identified level of predicted risk, whether low or high, on account of the mother 's age, her parity, her social class, her obstetric and medical history, or her experience of complications right up to early labour. PNMRs in hospital were higher also in all subgroups of baby birth weight or length of gestation. Conditions or complications where obstetric management possibly reduced the dan- ger must have been too few for the beneficial

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outcome to be reflected in any identified subgroup of risk. Apparent ly such cases were always ou tnumbered by cases where hospital care was less safe (Tew, 1986a; Tew, 1986b).

These accumulating statistical facts, which discredit the obstetricians' theory, were not taken into consideration in the 1960s and 1970s when they should have been used as the basis for policy in the UK. When challenged in the later 1970s and 1980s to refute them, obstetricians could not do so. Instead they dismissed them as out-of-date and no longer relevant, secure in the knowledge that comparisons with the results of non-interventionist care could not be made after near total hospitalisation had been achieved in the UK. Therefore , an unsound theory, with implications on past evidence unfavourable to most mothers and babies but favourable to the profession of obstetrics, would have to go on being accepted for lack of current evidence against which to test it.

However, one source of relevant data remains. In Holland the proport ion of births at home fell continuously f rom 74% in 1958 to 35% in 1979 (Kloosterman, 1978; Kloosterman, 1984), but then the trend halted, so that by 1986 36% of the births were still at home, unlike the experience in other countries where by the 1980s hardly 1% of births were at home. Thus Holland is now the only country where the number of home births remains large enough to permit meaningful comparisons to be made between perinatal mor- tality at home and in hospital.

In Holland, however, the PNMR for hospital births is not a simple reflection of the results of obstetric management , for of the total births there in 1986 only 70% were officially recorded as being under the sole care of obstetricians, while 29% were recorded as being under the sole care of independent midwives. Thus there is a division of control in Dutch hospitals which does not exist in British hospitals.

The Dutch midwife, who does not have a prior qualification in nursing, is trained and recog- nised as an autonomous practitioner, a specialist in normal childbirth, legally permit ted to per- form a few intranatal interventions, including episiotomy and Perineal suturing, but barred

f rom using instruments (Klomp, 1985). The pregnant woman can refer herself directly to a midwife and so long as she remains within certain defined risk criteria, the midwife will undertake complete maternity care with a free choice of conducting the delivery in the woman's home or in hospital, retaining her own control and using only her own permit ted methods. In 1986 11.8% of the midwives' original 'bookings' fell at some stage outside the risk criteria and were transferred to obstetricians' care, but 43% of all births remained under midwives' care, 44% of these being delivered in hospital and 56% at home (SIG, 1987; CBS, 1987). Protection of the midwives' field of care is encouraged by the system of public health insurance, (the Sick Funds) which, unless care is to be given in a teaching hospital, will finance attendance by an obstetrician only when signs of abnormality are present or predicted (Van Teijlingen & McCaf- frey, 1987). A list of medical indications has been developed by leading obstetricians over the last 20 years and has gradually been extended (K10osterman, 1978; Schellekens, 1987), so that the percentage of deliveries per formed by hospi- tal physicians, nearly all obstetricians, increased f rom 28 in 1970 to 45 in 1986.

General practitioners (GPs) in Holland have become much less involved in maternity care over the years, for the Sick Funds will not finance their services in districts where a midwife is in practice. By 1984 GPs at tended only about 15% of deliveries, mostly at home in cases where there was no local midwife or where the cost was covered by private insurance (Van Teijlingen & McCaffrey, 1987). By 1986 their share had fallen fur ther to around 12% of all births or one-third of home births (CBS, 1987).

Of the births in hospital the 29% under midwives care could not be subject to instru- mental interventions, but the remainder under obstetricians' management certainly were. As the percentage of births in hospital increased, so did the rate of operative deliveries: f rom 4.5 % in 1968-69 to 8.3% in 1976-77, with the caesarean section rate rising f rom 1.9% to 3.2% (Klooster- man, 1984). By 1986 the caesarean section rate had reached 6.5% of all births, and 12.1% of t h e births attended by obstetricians, with assisted

MIDWIFERY 57

deliveries making up a further 17.9% (SIG, 1987 Table 10).

For many years the PNMR has regularly been from 5-6 times as high for births in hospital as at home. Analysis of official data published by the Centraal Bureau voor de Statistiek (CBS) has shown that in 1983 the excess was repeated in every subgroup of maternal age and parity (Damstra-Wijmenga, 1986). The official data for 1986 show the same pattern (CBS, 1987) and so corroborate the earlier findings of British data.

The fundamental issue is to establish not just which is the safest place of birth, but which are the safest methods of intranatal care. Since under Dutch organisation the PNMR for hospi- tal births reflects the results partly of interven- tionist intranatal care by obstetricians and partly of low interventionist care by midwives, while the PNMR for home births reflects the results partly of low interventionist care by midwives and partly of possibly more interventionist care by general practitioners, it is much more informa- tive to examine the PNMRs following the care of the different birth attendants. Moreover, since births predicted to be at high risk are directed to obstetricians' care for delivery in hospital, it is necessary to examine how far this excess at predicted high risk explains the eventual excess of mortality.

M E T H O D

S ta t i s t i ca l m a t e r i a l .

To carry out this investigation, the present authors were privileged to be given, by the CBS, unpublished computer print-outs of raw detailed data which supplemented the official published data on births and stillbirths (CBS, 1987). The detailed data cross-classified the stillbirths and also 1st week deaths with maternal age, parity, gestation, place of birth and birth attendant, midwife or physician. The latter description covers both general practitioners and obstetricians, but the physicians who con- duct home deliveries are nearly always general practitioners and those who deliver in hospital are nearly always obstetricians, and these identi- ties have been assumed.

When births and perinatal deaths are regis- tered, the age and parity of the mother are recorded. Data f rom all these sources are brought together to give the specific PNMRs shown in Table 1. For all birth attendants together the PNMRs in the highest risk groups of age or parity are less than twice the PNMRs in the lowest risk groups. The variance between PNMRs is much wider when the risk variables are birth weight or fetal gestation, so that an excess proport ion in the higher risk groups of these might be more effective in explaining the excess overall mortality in hospital under obste- tricians' care. In Holland birth weight is not recorded when births and perinatal deaths are registered. Length of gestation is recorded only with the registration of perinatal deaths, not with births. The recorded data are available by place of birth, but without the denominators relating to births, specific PNMRs in gestational subgroups cannot be calculated.

This gap in vital information can now effectively be filled by data derived from a new information system - the National Obstetrics Registration (LVR) - 'set up to register nation- wide data on obstetric care. The system was developed in close cooperation with the Dutch Society for Obstetrics and Gynaecology (NVOG), the Dutch Organisation of Midwives (NOV) and the Health Inspection (GHI)' (SIG, 1985). Participation is voluntary and has increased since the inception of the scheme. Registration covered 68% of deliveries for which obstetricians (described as 2nd line maternity care) were responsible in 1982 and 82% in 1986. Participation by midwives (described as 1st line care) started in 1985 and by 1986 registrations covered 70% of independent midwives. Partici- pation by general practitioners had not been arranged by 1986. Nevertheless, though incomplete, the statistics they publish are judged by the LVR to give a representative picture of many aspects of perinatal experience in Holland (SIG, 1987).

In particular, they show the proportion of births having care by independent midwives and by obstetricians with gestations of very short (<33 weeks), short (33-36 weeks), and normal (>36 weeks) length. The proportions in these

58 MIDWIFERY

three gestational subgroups were respectively for midwives 0.002, 0.016, and 0.980, with 0.002 unknown, and for obstetricians 0.037, 0.094, and 0.863, with 0.006 unknown (corresponding data are obviously not available for general practitioners). These proport ions can be applied with considerable confidence to the official data on births to form denominators for the recorded perinatal deaths and give the specific mortality rates shown in Table 2.

The material of this study covers all the births in Holland in 1986. Since the mortality rates are not derived f rom a sample of the population, no statistical test needs to be applied to establish with what confidence differences between rates apply to the whole Dutch population. They apply with complete confidence. Only in the sense that the births in Holland represent a sample of all births taking place in countries practising Western-style obstetrics is it appro- priate to calculate the confidence with which differences found between rates can be accepted as universally valid.

Statistical significance was determined by the X 2 test. Because both the numbers of births and the differences in most rates were so large, the X 2 values obtained denote an extremely high pro-

bability that differences are real and universaly applicable.

FINDINGS

As shown in Table 1, the PNMR for all births is found to be higher for doctors in hospital (18.9) than for doctors at home (4.5), which is in turn higher than for midwives in hospital (2.1), which is in turn higher than for midwives at home (1.0). Between each of the three consecutive pairs compared, the difference in PNMRs is signifi- cant at such a high level as to indicate virtual certainty (p being far less than 0.0005, derived f rom ×2 values (with degree of freedom) of 227.8, 25.4 and 15.6 respectively). The lower and upper confidence intervals mark a range very close to the actual difference between the rates compared.

In each subgroup of parity and of maternal age, the same gradient in PNMRs obtains with one slight exception in the case of the oldest mothers. As between obstetricians and all mid- wives, the differences in PNMRs in every subgroup are significant at levels greater than p<0.000001.

Table 1 Perinatal mortality rates/10O0 births by.birth attendant, place of birth and risk factors, Holland 1986

(Number of births in brackets)

Obstetricians/ General Midwives Risk Gynaecologists Practitioners Factor Hospital Home Hospital

All births 18.9 (83351) 4.5 (21653) 2.1 (34874)

Midwives

Home

1.0 (44676)

Parity 0 20.2 (41861) 5.9 (6088) 1.7 (17429) 1 & 2 16.5 (36739) 3.8 (13064) 2.6 (15532) 3 & over 26.1 (4751) 4.4 (2501) 1.6 (1913)

Maternal age <20 20.9 (1816) 4.8 (208) 2,2 (1366) 20--24 23.3(15902) 4.0 (3718) 1.8 (8411) 25-29 17.8 (35104) 3.9 (9959) 2.3 (14640) 30-34 17.8(22741) 4.9 (6090) 2.0 (8198) >34 18.1 (7788) 6.6 (1678) 3.1 (2259)

1.5 (15031) 0.8 (26472) 0.6 (3173)

1.5 (661) 1.4 (8254) 0.7 (21105) 1.1 (12227) 3.7 (2429)

For significance levels of differences see text

Sources: CBS Monthly Bulletin of Population and Health Statistics 87:11 Table 1 and CBS computer print-outs of stillbirths and 1st week deaths. Not included are the 610 births attended by both physician and midwife and the 409 without known attendant.

MIDWIFERY 59

Table 2 Perinatal mortality rates/1000 births by birth attendant, place of birth and length of gestation, Holland 1986 (Number of births in brackets)

99% Confidence Weeks of Obstetricians Midwives Significance Intervals gestation Hospital Hospital and Home of difference for the difference

All gestations 18.9 (83351) 1.5 (79550) p < 0.000001 16.1 to 18.7 <33 185.5 (3084) 169.8 (159) p < 0.60* - 7 1 . 0 t o 102.3 33-36 46.4 (7835) 12.6 (1273) p < 0.00001 23.5to 44.1 >36 8.1 (71932) 0.8 (77958) p < 0.000001 6.4to 8.2 Not known 130.0 (500) 75.5 (159) p < 0.10" - 15 .4 to 124.4

* Not significant

Sources: CBS Monthly Bulletin of Population and Health Statistics 87:11 Table 1 and CBS computer print-outs of stillbirths and 1st week deaths. Not included are the 610 births attended by both physician and midwife and the 409 wi thout known attendant. Proportional distribution by gestation: SlG (Dutch Information Centre for the Health Care Services) 1987 5 jaar L VR 1982-6 obstetr ic ians- Table 7; midwives - page 4 (see text for details).

The National Obstetrics Registration data which show the proport ion of births under midwives' care in gestational subgroups do not distinguish place of delivery. The proport ions in hospital and at home may not be the same since midwives, following protocol, succeed in rushing most cases of suspected p remature labour to hospital in order to transfer the mother to obstetricians' care, so that more of the births at very short and short gestations remaining under midwives' care may take place in hospital, before the transfer is completed, than at home. There- fore, the more reliable comparison at specific gestations has to be between obstetricians and all midwives, wherever delivering, as in Table 2.

For births at <33 weeks' gestation the PNMR was higher for obstetricians (185.5) than for midwives (169.9) but this difference falls far below the conventional level of statistical signifi- cance; it might very well have happened by chance. Moreover, a higher PNMR would be expected if the obstetricians' group included a greater proport ion of births at the very shortest, most dangerous, gestations. This possibility cannot be confirmed from the available data, but it can be calculated f rom the CBS unpublished computer print-outs that the proport ion of deaths at less than 28 weeks' gestation was greater in the obstetricians' than in the midwives' group.

At gestations of 33-36 weeks the PNMR was very significantly higher for obstetricians (46.4)

than for midwives (12.6) and within this group the proport ion of deaths at 33 and 34 weeks' gestation was greater in the midwives' groups, so there is no reason to suspect that the excess PNMR for obstetricians was due to an excess of births at the shorter gestations. At gestations >36 weeks, 93.3% of total births and nearly half of them under obstetricians' care, the PNMR was ten times higher for obstetricians (8.1) than for midwives (0.8), an extremely significant excess (Table 2).

DISCUSSION

This analysis of recent Dutch data demonstrates that for the 98.2% of babies born after 32 weeks' gestation mortality is nearly 12 times lower if the birth takes place under midwives' care in hospi- tal or at home (PNMR 1.0) than under obstetri- cians' care in hospital (PNMR 11.9). For the most immature babies there seems to be little difference in their chances of survival wherever the birth takes place or whoever attends. Thus the Dutch results fail to confirm the popular belief that birth in hospital is made safer for these babies by the high technology of salvage facilities which are immediately available to obstetricians and neonatologists there. But it was only for this small minority of births (1.8%) that the evidence left any doubt that birth is very

6 0 MIDWIFERY

much safer under the low interventionist super- vision of midwives.

Perinatal outcome is determined by two, or possibly three, factors: the pre-delivery risk status of the baby, the nature of maternity and neonatal care, and perhaps also the setting in which delivery takes place. The pre-delivery risk status of the baby is influenced by certain bio- logical and social characteristics of the mother, which in turn influence the likelihood of her developing complications in pregnancy or labour leading to adverse outcomes, the most serious of which for the baby is being born preterm, immature and of low weight. The risk of delivering preterm is greater than average for socially and economically deprived mothers (Newton & Hunt, 1984), as is their risk of lower than average health status.

Since obstetricians claim that their methods of care are safer than those of midwives, they have to argue that the babies they deliver are at much higher than average pre-delivery risk. Dutch midwives are not allowed to 'book' for care women with adverse medical conditions or obstetric experience and have to transfer women who develop significant complications in preg- nancy. The 'booking' restriction does not extend to socially and economically deprived mothers, though delivery may not take place in homes which lack basic facilities (Kloosterman, 1978). Only obstetricians who work in teaching hospi- tals are financed to care for women not predicted to be at high risk, so unless obstetric care overcomes the risk (which obstetric propaganda implies it can), it would be expected that this higher average pre-delivery risk status would be reflected in a higher PNMR for babies under obstetricians' care. There is, however, no gen- erally accepted system for quantifying cumula- tive predicted risk status, and none is ever applied to routine records to set against the recorded mortality data. In the absence of such measurement, the analyst has to apply know- ledge from other sources to estimate the scale of the extra pre-delivery risk faced by obstetricians and whether the PNMR under their care could legitimately be 12 times higher than under midwives' care.

In cases of intrauterine death, which is not influenced by intranatal care of any kind, risk has become certainty, but an excess of these cases could not be the explanation for the Dutch obstetricians' excess PNMR. The stillbirth rate/ 1000 births was 11.6 for hospital obstetricians and 0.6 for all midwives (CBS, 1987). I f half of the stillbirths delivered by obstetricians were intrauterine deaths and none of those delivered by midwives were, which is unlikely, the obstetri- cians' stillbirth rate for intranatal deaths would be 5.8 against midwives' 0.6, still a difference virtually certain to be real.

Also unaffected by intranatal care are deaths due to congenital malformation. Data are not available to show whether these make up a greater proportion of the births under obstetri- cians' than midwives' care, but the overall inci- dence of such deaths is low in Holland and any plausible excess under obstetricians' care is unlikely to explain more than a very small part of their excess PNMR.

For all the preterm births, births before 37 weeks' gestation which made up 6.7% of the total, the PNMR was nearly three times as high under obstetricians' care (85.7) as under mid- wives' care (30.0). Apart from congenital malfor- mation, the overriding cause of death in preterm babies is their very immaturity. To explain their excess mortality under obstetricians' care would require either that these babies suffered also an excess of some very dangerous natural condition which babies under midwives' care escaped, or that non-interventionist intranatal care is more protective of these fragile lives. Since the lethal predicting condition, additional to and indepen- dent of immaturity, has never been identified, far less shown to afflict disproportionately often the babies selected for obstetricians' care, the second explanation, relating to the treatment received, is more probably the correct one.

Most births, 93.3% of them, were not preterm. Whatever were the high-risk conditions and dangerous complications before delivery which were diagnosed as r~,eeding care by obstetricians they obviously did not usually cause preterm birth. The British Perinatal Mortality Survey of 1958 (Butler & Bonham, 1963) found that over- all the PNMR for babies born to mothers with a

MIDWIFERY 61

history of previous ' toxaemia', an tepar tum haemorrhage or caesarean section was 1.5 times as high as when these conditions were absent; the corresponding ratios in cases of previous abor- tion, ectopic pregnancy, p remature live birth or perinatal death ranged between 1.5 and 3. Babies whose mother had severe ' toxaemia' in the current pregnancy had a PNMR less than 2.5 times that of mothers who remained normoten- sive. Babies of the small propor t ion of mothers (6%) who suffered any form of bleeding in pregnancy had a PNMR 4 times that when no bleeding occurred. Moreover, if obstetric care is indeed effective in making high risk conditions safer, these margins should have narrowed since 1958.

In many of these complications the increased risk is precisely that they will lead to a pre te rm birth, so for the affected pregnancies Which nevertheless go to term the chance of higher mortality is less. In 1986 Dutch obstetricians delivered nearly as many term births as did midwives. The average pre-delivery risk status of term births could not have been very much higher under obstetricians' than midwives' care and would be little raised by the inclusion of serious spontaneous emergencies in labour, for these, like complications of any kind in a basically healthy population, befall a very small propor- tion of total births. Though unlikely, excess risk might conceivably have been high enough to account for a threefold or, at a stretch, a fourfold discrepancy between obstetricians' and mid- wives' PNMRs; it could not have been nearly high enough to account for the tenfold discrep- ancy actually experienced. In the light of these results, it is incredible that obstetricians' care reduced the predicted dangers. Indeed, their higher PNMRs at all identified grades of predic- ted risk except perhaps shortest gestation support the contrary hypothesis, that obstetri- cians' care actually provokes and adds to the dangers.

This contrary hypothesis is supported by the findings of a study (Van Alten et al, 1989; Eskes, 1989) in which 8055 Dutch babies were initially 'booked' for midwife delivery but 1430 of them were transferred during pregnancy to obstetri- cians' care on account of diagnosed compli-

cations. Congenital malformation was not listed as a frequent reason for transfer or cause of perinatal death, whether the births were trans- ferred or not. T h e most frequent complications leading to t ransfer were ' toxaemia', post- maturity and suspected disproportion. Obstetri- cians' antenatal and intranatal care apparently did little to avert the predicted dangers, for this t ransferred group had a PNMR of 51.7, com- pared with 1.3 for the babies who remained throughout under midwives' care, a discrepancy far too wide to be plausibly explained by the extra dangers of the complications. Likewise, rates of neonatal morbidity, as measured by first week admissions to the paediatric department , were far higher among survivors in this transfer- red group (26.3%) than among survivors follow- ing midwives? care only (3.8%) (Van Alten et al, 1989; Eskes, 1989). It had earlier been found in British surveys that the incidence of breathing difficulties was much higher among babies born in hospital under obstetric care than elsewhere under the care of midwives and general prac- titioners (Chamberlain et al, 1975; Klein et al, 1983). The risk of infection is also much higher for the hospital born babies.

The contrary hypothesis has already been supported by analyses of British data, in particu- lar by the publication in 1985 of hitherto undis- closed findings of the British Births survey of 1970. These were that at every level of predicted risk, as measured by a comprehensive risk score constructed by the obstetricians concerned, PNMRs were highest for births in obstetric hospitals (Tew, 1985). The recent results in Holland, as earlier in Britain, cast serious doubt on the advantage for most babies of being passed f rom the less interventionist care of the midwife or general practitioner with a record of lower mortality to the more interventionist care of the obstetrician with a record of much higher mor- tality.

Tha t the PNMRs in total and in certain risk groups are significantly higher for midwives delivering in hospital than at home may possibly be due to their selection for hospital delivery of women with predicted problems, though proto- col would have required the earlier transfer of such women to obstetricians' care. But the true

62 MIDWIFERY

explanation may well lie in the effect of the setting itself.

The physical environment and ordered routines of hospital, in other contexts associated with suffering, danger and death, are often reported as inspiring feelings of apprehension and tension in mothers to whom they are unfa- miliar, emotions which are antagonistic to easy, relaxed childbirth. How much this happens has not been measured, but in so far as it does, it constitutes a further reason prejudicing perina- tal outcome. The very low PNMRs for home births in Holland, even for those in so-called high risk groups, may reflect, not only the competence of the midwife, but also the benefi- cial effect of emotional security for the mother in a relaxed familiar setting. Results give no support to the belief, popular in Britain, that the 15 000 first babies delivered in their unequipped homes with a PNMR of 1.5 would have fared better if they had joined the 42 000 delivered in hospital with the technological equipment and obstetric staff ready to cope with all emergencies and a PNMR of 20.2. Nor is it demonstrated that most preterm babies really benefit from being rushed to hospital for delivery with the high technology facilities there.

A study in Amsterdam hospitals found appreciable under-reporting of perinatal deaths to the Centraal Bureau voor de Statistiek, largely due to differing interpretations of required procedure in cases of babies with very short gestation (Doornbos et al, 1987). I f such under- reporting occurs in all Dutch hospitals, as has been suggested (Keirse, 1984), this would accen- tuate the disparities shown here, unless there was as much or more under-report ing after home births.

It is obvious from the analysis of results by birth attendant why perinatal mortality is in nearly all cases so much lower for home than for hospital births. It is demonstrated that, except possibly for the extremely immature babies, high technology can rarely make birth safer, whether the predicted risk is high or low. This is the conclusion reached by all previous analyses of British data (Tew, 1985; Tew, 1986a, Campbell & Macfarlane, 1987), of New Zealand national data (Rosenblatt et al, 1985), of Finnish regional

data (Hemminki, 1985), and of specific studies in other countries such as the US (Mehl, 1978). The conclusion has been accepted by the World Health Organization which recommends that the contribution of modern technology to childbirth should be reduced (WHO, 1985).

In an editorial in The Lancet (Lancet, 1986) it was acknowledged that in the light of the accu- mulated British evidence neither the lack of safety of birth at home nor iEhe greater safety of birth in hospital had been proved, a judgement contrary to established medical claims. The results from Holland in 1986 now point to the strong probability that birth at home is indeed the safer option and that, despite all the techno- logical innovations, the claim for the greater safety of birth in hospital cannot be sustained.

I f promoting the welfare of mothers and babies is its paramount concern, the maternity service needs urgent re-organisation to take account of the unanimous conclusions from worldwide experience and to reverse the policy of withdrawing low technology options for

childbirth.

Acknowledgement The authors are greatly indebted to the Centraal Bureau voor de Statistiek for providing computer print-outs of the detailed data of perinatal deaths for 1986 and making possible the analysis presented here.

Some of the material in this article has already been published in Safer Childbirth ? A Critical History of Maternity Care by Marjorie Tew, 1990, Chapman and Hall, London.

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