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Misleading interpretation of the Dutch paper on childbirth

To : Sharon Davies
Letters editor
British Medical Journal

18 April, 2008

Re: article ID: 336/7638/0


I am writing to you as a spokesperson of CIANE (Collectif interassociatif autour de la naissance), the prominent coalition of childbirth associations in France. To our surprise, we recently heard French obstetricians claiming that, in 2005, 51% of Dutch women who had begun giving birth at home were refered to hospitals due to unexpected problems during labour. Doctors used this assertion to enforce a dominant belief that home birth should be banned because of its cost and high risk.

Since this bizarre statement was refering to BMJ, we read Tony Sheldon's paper from which this information had been extracted: "Obstetric care must change if Netherlands is to regain reputation for safe childbirth". BMJ 2008;336:239, doi: 10.1136/bmj.39472.657384.DB. The original paper we downloaded on 27 February contained the following paragraph: ''"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."'' This paragraph was also displayed on the free-access presentation of the paper.

In reality, Tony Sheldon had misunderstood Visser & Steegers' original paper in Dutch ("Beter baren." Medisch Contact 63, 3, 18 januari 2008, p. 96-99):

The accurate translation of the "51% statement" is:

''"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 ''{the 51% is NOT the aggregated percentage for all deliveries - translator's note}''. These result in higher percentages of artificial deliveries including caesareans, and caesareans in turn result in complications during pregnancies that follow."''

Back to the BMJ website, a few days later we noticed that both Sheldon's paper and its presentation had been corrected. However, the editorial by Tony Delamothe ( "What counts?" BMJ 2008;336, doi:10.1136/bmj.39476.584005.47) still contains the same misleading statement:
''"It turns out that half the women who choose home births are transferred to hospital during labour because of unexpected problems."''

Given that the topic of home birth is a highly controversial one in France, we would very much appreciate that you publish a clarification of this point.

Besides, a fair account of Visser & Steegers' paper still needs to be published. We were disappointed to notice that Tony Sheldon's paper, supposedly an extended abstract of the Dutch paper, concentrates on a few specific issues and pays little attention to aspects that may sound less conventional with respect to obstetrics as it is practiced in many countries. For example, it overlooked the fact that, for the Dutch authors, increasing the rate of hospital birth was not a desirable goal...

The following are quotes from our translated abstract:

''"These (referrals) 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 discontinuated care during the whole delivery. However, research has shown that the continuous presence of a 'wise woman' during the entire delivery decreases the need for pain suppression, and further reduces the duration of labour by almost 2 hours."''

''"In other words, healthy pregnant women need care, not cure. It remains that home birth should not be a goal in itself, nor should a hospital (second line) delivery become the alternative to a home birth (as is the case in Rotterdam and Utrecht with a percentage of home births as low as 10%): birth centers close to hospital are required, which would be attractive to immigrants and would empower midwifery."''

We do expect from the BMJ a fair account of what is published in other countries, considering its worldwide audience and authority.

Looking forward to hearing from you soon.

With warm regards

Madeleine Akrich, PhD

Collectif interassociatif autour de la naissance

Competing interests:
None declared

Note (29 avril 2008)

Nous avons reçu hier une réponse de Tony Delamothe qui confirme qu'il a dû y avoir une erreur de traduction, erreur que l'on retrouve sur le site anglophone DutchNews : http://www.dutchnews.nl/news/archives/2008/01/hospital_baby_deaths_much_high.php. Toutefois, notre traduction « precise » du passage sur les 51% et 17% n'est peut-être pas correcte car il peut s'agir d'AAD et non de l'ensemble des accouchements. Nous allons vérifier. Cela n'enlève rien à l'argument puisque l'erreur que nous avons signalée consistait à appliquer le taux de 51% à l'ensemble des parturientes alors qu'il s'agit seulement des primipares. Pour les multipares le taux de transfert est de 17%, ce qui à notre avis reste trop élevé, mais Visser & Steegers expliquent plus loin que cela a à voir avec l'impatience des parents et l'absence de la présence d'une sage-femme (voire d'une doula) pendant toute la durée de l'accouchement.

We received Tony Delamothe's reply yesterday, agreeing that there must have been a mistake in the translation. However the same misleading statement is found on the DutchNews website : http://www.dutchnews.nl/news/archives/2008/01/hospital_baby_deaths_much_high.php. Further, he pointed out that our "precise" translation might not be so precise because the 51% transfer rate seems to apply to homebirths, not to births in general. We will check it with the translator. This does not solve the argument, though, since the error we had pointed out consists in applying this 51% transfer rate to all women whereas it only concerns nulliparious women. Multiparious women have a 17% transfer rate, which in our view is still too high. Visser & Steegers further explain that this has to do with parents' impatience and the absence of continuous care (by a midwife or a doula) during the whole birth.

Second message (19 mai 2008)

Dear Tony Delamothe,

We sorted out pending translation issues with our Dutch colleague. You are right that the word "homebirth" was missing in our English version of the "51% statement", which now read as follows:

This action of midwives aims at reducing the number of breeches and therewith the number of caesareans. But in that case it seems to be more effective to reduce the number of referrals durante partu: in 2005, 51 percent nulliparae and 17 percent multiparae that were supposed to deliver at home, were referred durante partu because of insufficient dilation or expulsion, tiredness, meconium in the water, the need for sedation and pain suppression et caetera (data Stichting Perinatale Registratie Nederland).1 It seems that Dutch nullipara are less and less able to deliver 'normally'.

It remains that our major concern with the summary in your editorial "What counts" (and in the Dutch News paper you cited) is the wrong assertion "half the women..." may apply to the entire population of home births wheras it only concerns nulliparae. For multiparae the transfer rate is only 17%. This is the specific point that we beg you to rectify in a next issue, as this interpretation is being misused by influent people trying to eradicate the practice of home birth in France.

As to Sheldon's paper, we are enclosing the version received by one of your subscribers and circulated on professional discussion lists. Indeed the last two paragraphs have been removed from the paper version (because of lack of space?) but these are the ones currently quoted and commented by professional caregivers!

We do share Visser & Steegers' concern about high transfer rates in low-risk births. As suggested in their paper, bad rates point at the detrimental effect of discontinuity of care, rather than at unforeseen serious complications. In their words, "healthy pregnant women need care, not cure."

Besides, the transfer rates of home births seem to be rising in the Netherlands. They were 40% and 9% for nulliparae and multiparae respectively in 2002. It is also significant that these rates were even higher from polyclinics to hospital: 43% and 19% respectively, as deducted from the enclosed graphs. (The leftmost bars indicate home and polyclinic births and the central ones indicate transfers from home and from polyclinics.)

Midwives comment that they feel more under pressure to accelerate labour when working closer to "the machines". This observation remains consistent with the conclusions of Wiegers and colleagues comparing midwifery practice at home and in hospitals: Outcome of planned home and planned hospital births in low risk pregnancies: prospective study in midwifery practices in the Netherlands (TA. Wiegers, MJNC. Keirse, J. van der Zee, GAH. Berghs). BMJ 1996;313:1309-1313


Continuity of care is a crucial issue for midwife-attended birth. Some women are not moving to hospitals because they are in danger, but because they feel unsafe if left on ther own. This was Visser & Steegers' major contention, which indeed deserves being discussed. We regret that a distorted interpretation of an excerpt is being used to support the claim that home birth per se is 'dangerous'.

With warm regards

Madeleine Akrich, PhD
Bernard Bel, PhD
Collectif interassociatif autour de la naissance

Date: Mon, 6 Oct 2008 09:04:08 +0530
To: Tony Delamothe
From: Bernard Bel
Subject: Re: CIANE's letter to CMJ (3d posting)

Dear Tony Delamothe,

We have not heard from you since we sent the enclosed additional information regarding your editorial on homebirth in the Netherlands. The erronous statement remains unchanged on your website:

Before raising the issue in another renowned medical journal, we look forward to receiving BMJ's final statement on this controversy.

With best regards

Bernard Bel, PhD
Collectif interassociatif autour de la naissance

To: Bernard Bel
Cc: Beverley Beech, CIANE, Madeleine Akrich, Sharon Davies
Subject: Re: CIANE's letter to CMJ (3d posting)
From: Tony Delamothe
Date: Mon, 6 Oct 2008 16:28:14 +0100

My colleague posted a correction in July to Tony Sheldon's original new story

See: http://www.bmj.com/cgi/content/full/336/7638/239

The intentions was that my editor's choice was also to be corrected at the same time - but it hasn't been, for which I apologise. I'll try to sort that out in the next day or so.

Tony Delamothe
deputy editor


Correction for Sheldon, BMJ 336 (7638) 239.

Published 9 July 2008, doi:10.1136/bmj.a706
Cite this as: BMJ 2008;337:a706


Obstetric care must change if Netherlands is to regain reputation for safe childbirth

Some confusion in translation resulted in an error in the full text (online) version of this News article by Tony Sheldon published in February (BMJ2008;336:239 doi: 10.1136/bmj.39472.657384.DB). In the third paragraph from the end, we wrongly said: "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." In fact, the 51% refers to women who have not given birth before and who then choose a home birth. In the original research on which this assertion is based, 51% of women who had not given birth before and who were supposed to give birth at home were referred during labour because of complications; the corresponding referral figure for women who had given birth before was 17%.


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