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Résumé (français)
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Un article de Gerard Visser et Eric Steegers dans le journal de l’association néerlandaise de médecine (Medisch Contact 2008;63:96-9) [Voir fiche 2200 dans cette base] signale qu’aux Pays-Bas les bébés meurent plus la nuit qu’en journée (la nuit, pas de gynéco, anesthésiste, pédiatre en permanence dans ces hôpitaux). La demande concerne la présence 24h sur 24 de gynécos à la maternité, 7 jours sur 7 (mortalité plus forte le week-end).
Ensuite, il est question de la remise en cause de tout le système, notamment de l’AAD tel qu’on le pratique. On demande aux sages-femmes d’êtres présentes plus longtemps au domicile [mais pas d’arrêter leur pratique].
Les Pays-Bas auraient le 2e moins bon chiffre d’Europe en matière de mortalité périnatale (3.5 pour 1000 naissances), toutes naissances et lieux de naissance confondus.
Selon l’auteur, on compterait « 51% de transferts lors d’un AAD pour problème de progression du travail ou gestion de la douleur par anesthésie ». [Cette donnée ne figure pas dans l’article de Visser & Steegers. il s’agit en réalité du taux de transfert pour les seules primipares. Il est de 17% pour les multipares (année 2005). Voir la lettre du CIANE au BMJ : http://wiki.naissance.asso.fr/index.php?pagename=LetterBmjApril2008]
Les associations de sages-femmes disent que les statistiques sont alarmantes mais que les Pays-Bas peuvent être fiers de leur système d’obstétrique, et qu’elles encouragent surtout les femmes à avoir un enfant plus jeunes.
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Abstract (English)
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The number of deaths of babies during childbirth in Dutch hospitals is considerably higher at night than during daytime, claim two leading clinicians writing in the journal of the Dutch Medical Association (Medisch Contact 2008;63:96-9). [See record #2200 in this database]
A lack of 24 hour cover by gynaecologists could be to blame, say the authors, Gerard Visser and Eric Steegers, heads of the obstetric departments of, respectively, the Utrecht university medical centre and the Erasmus university medical centre in Rotterdam. They write that the figures elicit a "strong suspicion" that obstetric departments are less safe outside normal working hours.
However, they argue that the whole chain of obstetric care, including the Netherlands’ strong tradition of home births, needs to be scrutinised. Dutch obstetric care must "dare to make choices" and challenge "conservatism" if the country is to regain its leading position on perinatal deaths. The number of perinatal deaths in the Netherlands is 3.5 per 1000 births, the second highest in Europe.
Their article cites figures from the Dutch Foundation for Perinatal Registration covering 380 000 hospital births from 2000 to 2004. During weekdays the number of intrapartum and neonatal deaths was 23% higher between 11 pm and 8 am than during the daytime. At weekends the number of such deaths was 7% higher than during weekdays.
The professors say that, although gynaecologists have the final responsibility for patients, they are present on obstetric wards only during normal working hours, five days a week, before handing over to junior doctors.
Gynaecologists, they argue, are needed to interpret the monitoring of fetal heart rate or to avoid complications such as with the uterus or placenta, especially where women have a history of caesarean section. Such situations, they write, may require swift action not just from a gynaecologist but also from an anaesthetist, a paediatrician, and the operating theatre team. Professor Visser said, "If you are there you act proactively. The moment you are home you are reacting: first there is a problem, and then they phone you. Most caesarean sections should be carried out within 30 minutes. That should be possible, but if you need an anaesthesiologist [and] a paediatrician, it can take longer.
"Do we want to pay for a healthcare system that has the same quality over 24 hours? If not, then we will not share the improvements seen in other countries."
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[The following was found in an earlier version.]
They also pinpoint the need for midwives to be present for longer during home births. Although women who choose home births are deemed to be at low risk of complications, 51% are referred to hospital during labour because of difficulties in managing pain or a lack of progress with the delivery. [Wrong: see remarks] The Dutch Association of Obstetrics and Gynaecology said that, together with other professional bodies, it is now studying data covering the whole chain of obstetric care. The Dutch junior doctors’ organisation is opposed to gynaecologists being present on wards 24 hours a day, as this would remove an important part of training.
The midwives organisation described the statistics as alarming but said that the Netherlands should be proud of its system of obstetrics. It said it welcomes any review while emphasising the need to encourage women to give birth at a younger age.
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Comments :
| Ce que je trouve intéressant dans l’article :
- les auteurs s’élèvent contre la tendance abusive du transfert des primipares qui du coup entraîne trop de gestes dont les césariennes qui elles-mêmes vont entraîner des complications pour les futures grossesses. Les raisons de ce transfert sont l’impatience des jeunes parents et le fait que la présence de la sage-femme est intermittente. Il suffirait qu’il y ait quelqu’un en continu (pas forcément d’ailleurs une sage-femme) pour améliorer les choses. Les femmes ont besoin qu’on prenne soin d’elles et pas qu’on les soigne.
- par ailleurs, ils préconisent l’ouverture de maisons de naissance à proximité des hôpitaux dans les grands centres urbains où peu d’accouchements à domicile, en particulier parce que les femmes immigrées veulent accoucher à l’hôpital : le rapport que j’ai sur les Pays-Bas montre que globalement la répartition entre accouchement à domicile et accouchement "polyclinique" (c’est-à-dire pôle physiologique avec sage-femme libérale) est inverse dans les deux ensembles femmes néerlandaises (29% maison, 9% pôle physio) et femmes non néerlandaises (13% maison, et 26% pôles physio)
- ils préconisent une plus grande place prise par les sages-femmes en milieu hospitalier afin de garantir plus de respect de la physiologie
- enfin, ils préconisent plus d’encadrement pour les naissances à risque.
Voir discussion : http://wiki.naissance.asso.fr/index.php?pagename=StatistiquesPaysBas
(Madeleine Akrich)
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The following is an abstract of Visser & Steeger’s original paper in Dutch, by Bernike Pasveer. [See record #2200 in this database]
The authors argue that the dutch obstetrical system is under pressure: perinatal mortality and morbidity are higher than they used to be (no numbers). They don’t criticize the existence and subsistence of primary care midwives who have specific experience and responsibilities for healthy/low risk pregnancies & deliveries.
There has been little research into the quality of the entire care-chain, so that changes in ’isolated’ elements of the chain take place without knowledge of their gross effect on the quality of care. Example of an isolated change is the training of midwives to change the position of the child when it is in a breech, while there are others (gynaecologists) who are trained to do so already.
The authors argue that the chain would do better to try to reduce the number of referrals during labour, which is (2005) 51% for low-risk nulliparae and 17% of low-risk multiparae [Note that the 51% is NOT the aggregated percentage for all deliveries! See CIANE’s letter to BMJ: http://wiki.naissance.asso.fr/index.php?pagename=LetterBmjApril2008]. These result in higher percentages of artificial deliveries including caesareans and caesareans in their turn result in complications during pregnancies that follow.
Reasons for the high referral rates: impatient parents, and discontinuous care during the entire delivery. Research has however shown that continuous presence of a ’wise woman’ during the entire delivery reduces the need for pain suppression, and the duration of the delivery itself of almost 2 hours.
In other words: healthy pregnant women need care, not cure. However, home delivery should not be a goal in itself, nor should a hospital (second line) delivery become the alternative to a home delivery (like in Rotterdam and Utrecht where the percentage of homebirths is as low as 10%): birth centers close to hospital are needed, which would be attractive to immigrants and would empower midwifery.
There is also a need for better care to hospital births - clinically working midwives could play an important role there: these professionals guard the physiological aspects of pregancy, labour and after for women who do have a medical indication, and can thus improve the quality of care considerably - and thus counter the increase of obstetrical interventions.
There is also a need for better care for high-risk deliveries, which take place within and outside office hours whereas gynaecologists are only present 5 days a week during office hours. Dutch research shows that intrapartum and neonatal mortality was 23% higher in the nighttime than in daytime on workdays between 11pm and 8 am, and in weekends mortality was 7% higher.
Their plea is for a regional concentration of 24/24 care [but they note that this can be consequential for the percentage of homebirths].
Such concentration might also increase the quality of second and third line care: 90% of substandard care with maternal mortality due to pre-eclampsia is an effect of insufficient medical care, too late referral and too late induction of labour. Dutch obstetrics might be too conservative, they conjecture, and the belief in good results of a low-intervention process too high.
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