Cassie Werber

Writer & journalist

Divided at Birth – Disparity in Dutch maternal healthcare

A new study has revealed that mothers from ethnic minorities have a more difficult – and dangerous – experience of maternal care in the Netherlands. At a particularly sensitive time for immigration policy in the Netherlands, CASSIE WERBER examines why this disparity exists

 Deniz* moved to the Netherlands to marry her Turkish husband, and was not yet able to speak Dutch when the time came to deliver their child.

When she went into labour, it was an unusually quick process and Deniz began to feel strong, frequent contractions. She tried to explain her experience to health workers via translation by her sister-in-law, but they assured her that labour would take some time.

The baby’s heart rate then began to drop, and Deniz was told to move onto her side. She couldn’t; she knew the baby was about to be born.

Panicking, her sister-in-law failed to translate the reason for Deniz’s refusal, and a nurse pushed her onto her side. The baby was born, and Deniz’s cervix ruptured, leading to the onset of heavy bleeding – she had suffered a major obstetric haemorrhage.

Major obstetric haemorrhage (MOH) is one of the most common forms of maternal morbidity, a term which refers to serious complications or illness incurred by a woman during pregnancy or childbirth, or after delivery.

Deniz’s story is not uncommon. Researchers based at the University of Leiden have discovered that women from ethnic minority backgrounds in the Netherlands are not only more likely to die as a result of their pregnancies, but are also more likely to suffer from maternal morbidity and to receive substandard care for such conditions from doctors and midwives.

The study’s findings, published in May in the British-based journal Reproductive Health Matters, is a qualitative assessment of maternal care in the Netherlands which compares the experiences of 50 women – the majority from immigrant backgrounds – who experienced health complications as a result of giving birth.  The women were interviewed to find out their individual stories, and 20 of the interviews were then further assessed by a team of obstetricians.

In 80 percent of these 20 cases, obstetricians judged that “substandard care,” or care which fell below the standard that doctors considered should have been achieved given the circumstances, had played a role in the development of complications.

Ferko Öry, a public health paediatrician at the Netherlands Organisation for Applied Scientific Research (TNO) based in Leiden and one of the study’s authors, says that the research into morbidity was prompted by a 2008 study revealing that in the Netherlands, death as a result of pregnancy or birth was higher amongst women from ethnic minorities. “I had already expected the mortality would be much greater,” says Öry.

But morbidity figures and the findings of substandard care came as more of a shock. “I was surprised because in the Netherlands, there is absolute access to healthcare for everybody. Perhaps with the exception of illegal immigrants, the health system is accessible and good,” Öry says.

These research findings bring together two topics currently creating friction within Dutch society. The status of people from immigrant backgrounds forms a backdrop to much political wrangling. Where and how to give birth, meanwhile, has become a source of debate in a country which has long encouraged home birth – a method currently preferred by 25 percent of Dutch mothers. Recent controversial claims that home birth is less safe than hospital delivery have sparked much media interest. All births considered in the Leiden study in question took place in hospital.

Lack of care

The Leiden study reveals a number of reasons why women from ethnic minority backgrounds were less likely to receive good obstetric care than native Dutch women. Some problems, like those experienced by Deniz, resulted mainly from language barriers and inadequate communication skills.

Save one, all the Turkish women involved in the study had a “socially dependent position,” requiring Dutch-speaking relatives to translate their problems. The study did not find any instance of a professional interpreter being arranged during antenatal check-ups or being present at a birth.

Daily stress factors in the lives of the women and lack of knowledge of danger signs during pregnancy also contributed to inadequate care.

One Bosnian woman suffered an epileptic seizure during labour. Having fled civil war seven years previously, she failed to explain to her midwife that she had had a previous seizure during the bombardment of her village. With little education, she did not know the word for epilepsy.

Lack of patient information was also cited as a problem, but the health community is likely to be most concerned by the finding that health care providers underestimated women’s complaints.

Yasemin, a 35-year-old Turkish woman, felt dizzy and suffered headaches during her pregnancy. These symptoms were attributed to stress by her general practitioner, though she had been referred to an obstetrician three times by her midwife because of hypertension (high blood pressure).

After delivering in hospital she was sent home, where she developed more severe headaches, dizziness and pain. The midwife referred her to the hospital once again, where she had a seizure while waiting to see a doctor. The seizure was due to eclampsia, another of the more common morbidities, which results from high blood pressure associated with pregnancy.

Some of the problems identified in the study may be associated with the lack of education and lower socio-economic status that some ethnic groups – and specifically women from migrant communities – experience in the Netherlands. However, the study found that ethnically diverse women from all non-Dutch backgrounds were subject to more problems.

University-educated Ayumi was 33-years-old and 26 weeks pregnant with twins when she arrived from Japan with her husband.

She complained of headaches and weight gain, and suffered high blood pressure and fluid retention. Concerned, she asked the doctor about her problems and whether a caesarean might be necessary. She was told not to worry.

At 38 weeks and still experiencing symptoms, she was admitted to hospital with pre-eclampsia. Labour was induced, but when it did not progress, a caesarean was performed.

An hour later, Ayumi began bleeding heavily due to uterine atonia, a condition in which the muscles of the womb lose the ability to contract. She was immediately operated on, but when the bleeding could not be stopped a hysterectomy was performed to save her life.

Ayumi now expresses both anger and confusion at the way that she was treated. “They really hated us,” she says of the doctors who treated her. “I had to challenge the doctor. But I was new here. I try to respect the way things are here.”

More about mothers

While such findings might be expected to antagonise the medical profession, Öry says that the response has in fact been positive. He attributes this in part to the high rate of participation in the study.

“We had 100 percent coverage of participation of all Dutch obstetricians, which is very, very exceptional,” Öry says. “I think the reaction was very positive because everybody participated, and then you are also interested in the study.”

It did not all go smoothly, he admits. “There was of course a small shock about the findings, especially the diagnosis and treatment of eclampsia.”

The 2008 study reported 6.2 cases of eclampsia per 10,000 deliveries, prompting the authors to call the figure “worrying” and suggest more research into the reasons behind eclampsia’s prevalence.

The May 2011 study is significant because it concentrates on the health and well-being of mothers, says Jos van Roosmalen, another co-author and professor in the Department of Obstetrics at Leiden University Medical Centre.

Van Roosmalen, who had returned from Tanzania the day before our interview and spends about 20 percent of his time in Africa, said that his experience of the extreme conditions on that continent have influenced his approach to maternity care in the developed world.

“In our countries here, the emphasis lies on the health of the baby,” he says, citing Western medicine’s concentration on saving the lives of ever-more premature babies as one example of that trend.

“When I came back [from Africa] to the Netherlands I thought, we in the Western world almost completely forget about maternal issues related to obstetrics. We are so busy with the babies that we forget about the health of the women. I always wanted to describe the price women pay – also in the so-called Western and developed world – with regard to getting babies.”

Concentration on the child rather than the mother has led to a prolonged process of finding the funding for such studies as that published in Reproductive Health Matters, says Van Roosmalen. At the moment, this paper represents one of a suite of about 30 publications based on the Leiden research.

Another breakthrough came in July 2010 with the establishment of the International Network of Obstetric Survey Systems (INOSS) in Oxford, England.

INOSS’s mission, according to its website, is to “improve the care given to women, their babies and their families, by advancing knowledge and contributing to the evidence base about serious, rare disorders in pregnancy including near-miss events, through international co-operation and collaborative working.” (A near-miss refers to extreme maternal morbidity in which a woman comes close to death but survives).

Van Roosmalen points out that, since some of the conditions associated with morbidity are rare, sufficient evidence for effective studies can only be achieved through such international collaboration. The group will next meet in Leiden in November 2011.

Global goals

While the Dutch researchers sound a hopeful note for the future of global obstetric care, there are still obstacles to overcome. Marge Berer, editor of Reproductive Health Matters and a long-time campaigner for women’s sexual and reproductive rights, says that global organisations are not yet engaging with the complex and multidimensional problem of morbidity.

“Because maternal morbidity is so difficult to measure, and because there are so many different kinds, it’s not being counted,” Berer says. There are global estimates, with some suggesting that 10 or 15 times the number of women experience maternal morbidity as die from pregnancy-related causes.

But in low-income countries, says Berer, “much of it goes untreated. It can lead to a death if it’s not taken care of, but more commonly it can cause chronic problems that go on and on forever. For example if a women gets a tear during delivery and she’s stitched up badly, she can suffer from pain during sex for the rest of her life. And nothing may ever be done about it.”

The fifth of the Millennium Development Goals (MDGs) is concerned with maternal health, but it measures only a very limited set of factors, says Berer. As one example, the number of “skilled birth attendants” is recorded, but without clear checks on how such skills are defined, which can lead to the diversion of resources and incomplete, rushed training.

“What they do measure and what they don’t measure are both problems,” says Berer of the MDGs, pointing out that maternal morbidity is not being prioritised precisely because it falls outside the official goals.

The developing world is of course seeing the worst of both maternal mortality and morbidity. Van Roosmalen says that there are some worrying trends suggesting that practices from the developed world, such as a greater prevalence of caesarean section, may be having an adverse effect on health care in developing countries.

He recently witnessed a hysterectomy performed on an 18-year-old Malawian girl after a caesarean birth resulted in infection, while it also failed to save her baby.

The future for this woman is bleak – but is also frightening for many who have to go through childbirth again and again in conditions which Van Roosmalen says “dehumanise” them.

“Women’s rights are threatened, even violated,” in many instances during the process of birth, he says, especially in the developing world.

“In many places, women are not allowed to take anyone with them into the labour room, so they deliver on their own, in a room where 10 or 20 other women are also delivering.”

He would like to see things change. When might that happen? “When women themselves stand up and say okay, the way we are treated when we come to deliver in our health institutions is inhumane, and we do not accept it any longer.”

Given his experience of such appalling birth conditions, I wonder if Van Roosmalen finds it difficult to choose to devote his time to the problems in the Netherlands.

“It is easy to say that the problems in deprived areas of the world are 10 or maybe 100 times more prevalent than in our situation and that we should not bother about it here,” he says. There is a political agenda that tries to find incendiary advantage in such issues. “We talk about ‘some immigrants having more problems,’ which sometimes is translated by more populist politicians into ‘immigrants are the problem’,” he says.

What matters is helping people who need it; and that can be anywhere. “Our societies tend to ignore that women suffer from childbirth,” says van Roosmalen.

“The Dutch pride themselves on having one of the best pregnancy care services in the world,” says Berer, “and they do, there’s no doubt that they do. But this study shows that not everybody is getting the very best treatment out of that service.”

*Women’s names have been changed to preserve patient confidentiality.

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