May 12th, 2013

Dutch homework

I've been working on this all week; it is completely out of hand. The actual assignment was to research the vocabulary associated with thuis bevallen and zwangerschappen in general in the Netherlands -- there are some recent controversies associated with relatively higher perinatal mortality rates in the Netherlands than other Eurozone countries. Also, there was a study that got a lot of mileage out of claiming that second line (under obstetrician care) mothers had fewer bad events (perinatal mortality, NICU admission, etc.) than first line (under midwifery care).

I have a theory about why the Netherlands has a _comparatively_ (all of the European countries in question have a lower rate than the US, as near as I can tell) high perinatal mortality rate: they only recently put together nationwide screening for trisomy, and honestly, it is terrible. I say this as a person who went to some effort to avoid screening for trisomy (not entirely successfully, I might add) -- but I would be pretty annoyed to learn that you had to pay for a quad screen (say -- they use a different test in the Netherlands, what we might call a first trimester down's test, that checks for hcg and PAPP-A in the blood, and then an ultrasound for nuchal transparency) if you were under 36 at 14 weeks or whatever. Predictably, median age for actually participating in screening is ever so slightly above 36: women under 36 are NOT being screened for trisomy in the Netherlands at anything like the rates that they are ... in all the comparator countries for PNMR purposes. The effects are basically what you would expect.

They are doing audits of perinatal deaths, so more data is seeping out about what is going on, and they are (yay) focusing on things that are changeable (mom developed high blood pressure during the pregnancy. Did anyone notice? What did they do about it? The baby stopped/slowed growing after xx weeks. Was this detected? What was done?), but it's turning out to be incredibly hard to determine whether genetic testing is being done on the intrapartum deaths -- at all. You would think that might be helpful information, no? I mean, if you didn't bother to catch it early on, you could at least establish whether it might have been a contributor to the outcome, since we've known since the late 1980s/early 1990s that countries which actively screen for things and make selective termination very accessible have _very_ different PNMR than countries which ... don't. I don't have a horse in the "which is better" race, other than to note that proposing to medicalize all births because of a high PNMR that you think might be attributable to using midwives is probably overkill, if the difference that would make a difference in your numbers is a bloodtest, an extra ultrasound and a couple rounds of informed consent/counseling.

Given that this is an entire country full of Dutch people, I predict they'll continue to do what they're doing (they actually had a _law_ against putting together a screening program for stuff like trisomy -- that was passed in 1996! They didn't roll out their nationwide screening program until 2007) far longer than I think is called for, and then they'll implement something extremely cheap, efficient and optional. I bet they'll authorize widespread use of the first cheap and readily available maternal bloodtest for trisomy -- we're sort of expecting to have one within the next few years/decade.