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Management of late-term pregnancy in midwifery- and obstetrician-led care., Background: Since there is no consensus regarding the optimal management in late-term pregnancies (≥41.0 weeks), we explored the variety of management strategies in late-term pregnancy in the Netherlands to identify the magnitude of this variety and the attitude towards late-term pregnancy., Methods: Two nationwide surveys amongst all midwifery practices (midwifery-led care) and all hospitals with an obstetric unit (obstetrician-led care) were performed with questions on timing, frequency and content of consultations/surveillance in late-term pregnancy and on timing of induction. Propositions about late-term pregnancy were assessed using Likert scale questions., Results: The response rate was 40% (203/511) in midwifery-led care and 92% (80/87) in obstetrician-led care. All obstetric units made regional protocols with their collaborating midwifery practices about management in late-term pregnancy. Most midwifery-led care practices (93%) refer low-risk women at least once for consultation in obstetrician-led care in late-term pregnancy. The content of consultations varies among hospitals. Membrane sweeping is performed more in midwifery-led care compared to obstetrician-led care (90% vs 31%, p < 0.001). Consultation at 41 weeks should be standard care according to 47% of midwifery-led care practices and 83% of obstetrician-led care units (p < 0.001). Induction of labour at 41.0 weeks is offered less often to women in midwifery-led care in comparison to obstetrician-led care (3% vs 21%, p < 0.001)., Conclusions: Substantial practice variation exists within and between midwifery-and obstetrician-led care in the Netherlands regarding timing, frequency and content of antenatal monitoring in late-term pregnancy and timing of labour induction. An evidence based interdisciplinary guideline will contribute to a higher level of uniformity in the management in late- term pregnancies.

Background: At present, the maternity care system in the Netherlands is being reorganized into an integrated model of care, shifting the focus of midwives to include increasing numbers of births in hospital settings and clients with medium risk profiles. In light of these changes, it is useful for midwives to have a tool which may help them in reflecting upon care practices that promote physiological childbirth practices. The Optimality Index-US is an evidence based tool, designed to measure optimal perinatal care processes and outcomes. It has been validated for use in the United States (OI-US), United Kingdom (OI-UK) and Turkey (OI-TR). The objective of this study was to adapt the OI-US for the Dutch maternity care setting (OI-NL)., Methods: Translation and back translation were applied to create the OI-NL. A panel of maternity care experts (n = 10) provided input for face validation items in the OI-NL. Assessment of inter-rater reliability and ease of use was also conducted. Following this, the OI-NL was used prospectively to collect data on 266 women who commenced intrapartum care under the responsibility of a midwife. Twice groups were compared, based on parity and on care-setting at birth. Mean scores between these groups, corrected for perinatal background factors were assessed for discriminant validity., Results: Face validity was established for OI-NL on the basis of expert input. Discriminant validity was confirmed by conducting multiple regressions analyses for parity (β = 6.21, P = 0.00) and for care-setting (β = 12.1, p = 0.00). Inter-rater reliability was 98%, with one item (Apgar score) sensitive to scoring differences., Conclusion: OI-NL is a valid and reliable tool for use in the Dutch maternity care setting. In addition to its value for assessing evidence-based maternity care processes and outcomes, there is potential for use for learning and reflection. Against the backdrop of a changing maternity care system, and due to the specificity of its items OI-NL may be of value as a tool for detecting subtle changes indicative of escalating medicalization of childbirth in the Netherlands.

Aims/hypothesis: Detection and management of gestational diabetes mellitus (GDM) are crucial to reduce the risk of pregnancy-related complications for both mother and child. In 2013, the WHO adopted new diagnostic criteria for GDM to improve pregnancy outcomes. However, the evidence supporting these criteria is limited. Consequently, these new criteria have not yet been endorsed in the Netherlands. The aim of this study was to determine the impact of these criteria on the number of GDM diagnoses and pregnancy outcomes., Methods: Data were available from 10,642 women who underwent a 75 g OGTT because of risk factors or signs suggestive of GDM. Women were treated if diagnosed with GDM according to the WHO 1999 criteria. Data on pregnancy outcomes were obtained from extensive chart reviews from 4,431 women and were compared between women with normal glucose tolerance (NGT) and women classified into the following groups: (1) GDM according to WHO 1999 criteria; (2) GDM according to WHO 2013 criteria; (3) GDM according to WHO 2013 fasting glucose threshold, but not WHO 1999 criteria; and (4) GDM according to WHO 1999 2 h plasma glucose threshold (2HG), but not WHO 2013 criteria., Results: Applying the new WHO 2013 criteria would have increased the number of diagnoses by 45% (32% vs 22%) in this population of women at higher risk for GDM. In comparison with women with NGT, women classified as having GDM based only on the WHO 2013 threshold for fasting glucose, who were not treated for GDM, were more likely to have been obese (46.1% vs 28.1%, p < 0.001) and hypertensive (3.3% vs 1.2%, p < 0.001) before pregnancy, and to have had higher rates of gestational hypertension (7.8% vs 4.9%, p = 0.003), planned Caesarean section (10.3% vs 6.5%, p = 0.001) and induction of labour (34.8% vs 28.0%, p = 0.001). In addition, their neonates were more likely to have had an Apgar score <7 at 5 min (4.4% vs 2.6%, p = 0.015) and to have been admitted to the Neonatology Department (15.0% vs 11.1%, p = 0.004). The number of large for gestational age (LGA) neonates was not significantly different between the two groups. Women potentially missed owing to the higher 2HG threshold set by WHO 2013 had similar pregnancy outcomes to women with NGT. These women were all treated for GDM with diet and 20.5% received additional insulin., Conclusions/interpretation: Applying the WHO 2013 criteria will have a major impact on the number of GDM diagnoses. Using the fasting glucose threshold set by WHO 2013 identifies a group of women with an increased risk of adverse outcomes compared with women with NGT. We therefore support the use of a lower fasting glucose threshold in the Dutch national guideline for GDM diagnosis. However, adopting the WHO 2013 criteria with a higher 2HG threshold would exclude women in whom treatment for GDM seems to be effective.

Objectives: To assess the effect of implementation of a newly developed e-learning module on the quality of cervical-length measurements., Methods: With the introduction of cervical-length (CL) measurement in a research setting, a CL measurement e-learning module (CLEM) was developed with the purpose to enhance the knowledge and skills of experienced ultrasonographers. CLEM was designed specifically for ultrasonographers who perform ultrasound in a general obstetrical practice but who do not regularly perform CL measurements. CLEM consists of five theoretical questions and three caliper-placement tests to learn the CL measurement technique. The quality of the CL measurements of CLEM participants was compared with images of non-participants using a CL measurement image score (CIS), defined as the sum of six items which assess the quality of the image. Each CLEM participant submitted five CL images and the images of non-CLEM participants were selected randomly from an ultrasound database., Results: The CIS of the CLEM participants (n = 61) were significantly higher than those of non-CLEM participants (n = 23) (164.9 vs 155.6, respectively; P = 0.03). Visualization of the internal os and positioning of the calipers on the internal and external ora were found to have significantly higher CIS among the CLEM participants than among the non-CLEM participants (P = 0.001 and P < 0.001, respectively)., Conclusions: Introducing CLEM may improve the quality of CL measurements obtained by trained and untrained sonographers., (Copyright © 2014 ISUOG. Published by John Wiley & Sons Ltd.)

Background: The importance of effective clinical teaching for the quality of future patient care is globally understood. Due to recent changes in graduate medical education, new tools are needed to provide faculty with reliable and individualized feedback on their teaching qualities. This study validates two instruments underlying the System for Evaluation of Teaching Qualities (SETQ) aimed at measuring and improving the teaching qualities of obstetrics and gynecology faculty., Methods and Findings: This cross-sectional multi-center questionnaire study was set in seven general teaching hospitals and two academic medical centers in the Netherlands. Seventy-seven residents and 114 faculty were invited to complete the SETQ instruments in the duration of one month from September 2008 to September 2009. To assess reliability and validity of the instruments, we used exploratory factor analysis, inter-item correlation, reliability coefficient alpha and inter-scale correlations. We also compared composite scales from factor analysis to global ratings. Finally, the number of residents' evaluations needed per faculty for reliable assessments was calculated. A total of 613 evaluations were completed by 66 residents (85.7% response rate). 99 faculty (86.8% response rate) participated in self-evaluation. Factor analysis yielded five scales with high reliability (Cronbach's alpha for residents' and faculty): learning climate (0.86 and 0.75), professional attitude (0.89 and 0.81), communication of learning goals (0.89 and 0.82), evaluation of residents (0.87 and 0.79) and feedback (0.87 and 0.86). Item-total, inter-scale and scale-global rating correlation coefficients were significant (P<0.01). Four to six residents' evaluations are needed per faculty (reliability coefficient 0.60-0.80)., Conclusions: Both SETQ instruments were found reliable and valid for evaluating teaching qualities of obstetrics and gynecology faculty. Future research should examine improvement of teaching qualities when using SETQ.

Introduction: In the Dutch maternity care system, the role division between independently practising midwives (who take care of normal pregnancy and childbirth) and obstetricians (who care for pathologic pregnancy and childbirth) has been established in the so-called "List of Obstetric Indications"(LOI). The LOI designates the most appropriate care provider for women with defined medical or obstetric conditions., Methods: This descriptive study analysed the evolution of the concept of "normality" by comparing the development and the contents of the consecutive versions of the LOI from 1958 onwards. The results were related to data from available Dutch national databases concerning maternity care., Results: The number of conditions defined in the successive lists increased from 39 in 1958 to 143 in 2003. In the course of time, the nature and the content of many indications changed, as did the assignment to the most appropriate care provider. The basic assumptions of the Dutch maternity care system remained stable: the conviction that pregnancy and childbirth fundamentally are physiologic processes, the strong position of the independently practising midwife, and the choice between home or hospital birth for low-risk women. Nevertheless, the odds of the obstetrician being involved in the birth process increased from 24.7% in 1964 to 59.4% in 2002, whereas the role of the primary care provider decreased correspondingly., Discussion: Multidisciplinary research is urgently needed to better determine the risk status and the optimal type of care and care provider for each individual woman in her specific situation, taking into account the risk of both under- and over-treatment. Safely keeping women in primary care could be considered one of a midwife's interventions, just as a referral to secondary care may be. The art of midwifery and risk selection is to balance both interventions, in order to end up with the optimal result for mother and child., (Copyright (c) 2010 American College of Nurse-Midwives. Published by Elsevier Inc. All rights reserved.)

Progesterone treatment has proven to be effective in preventing recurrent preterm birth. The use of progesterone varies widely between different obstetric clinics in the Netherlands. The study aimed to identify factors that hamper or facilitate the use of progesterone to create an implementation strategy. A Web-based survey was developed containing questions on sociopolitical factors, organizational factors, knowledge, and attitude. This survey was spread among 212 gynecologists, 203 midwives, and 130 women with a recent preterm birth. Response rates were 46% for gynecologists, 57% for midwives, and 78% for patients. Twenty-five percent of gynecologists were prescribing progesterone, 21% of midwives would recommend progesterone, and 54% of patients were willing to undergo treatment in future pregnancies. Specific factors hampering implementation for gynecologists were working in nonteaching hospitals and absence of progesterone treatment in local protocols. For midwives and patients, unfamiliarity with progesterone was the most notable finding. The major reason for failure of implementation of progesterone treatment to prevent recurrent preterm birth is absence of this treatment in protocols and lack of familiarity with this treatment in midwives and patients. This may be overcome through adjustment of clinical protocols on regional and national levels., (Thieme Medical Publishers.)

At the request of the State Secretary of the Dutch Ministry of Health, Welfare and Sport a national multidisciplinary workgroup developed an evidence-based practice guideline for the management of pregnant women with an imminent preterm delivery after a pregnancy of less than 26 weeks duration and for extremely preterm neonates. Active care measures are advised for neonates from a gestational age of 24 0/7 weeks onwards, unless there are serious arguments that justify a conservative management. In cases of imminent preterm delivery, intrauterine transport to a perinatological care centre is advised from a gestational age of 23 4/7 weeks onwards. In cases of imminent preterm delivery, glucocorticoids to enhance fetal lung maturity should be administered from a gestational age of 23 5/7 weeks onwards. From a gestational age of 24 0/7 weeks onwards a caesarean section may be considered if the fetal condition during spontaneous labour justifies this.

According to the Peristat II study, based on data from 2004, The Netherlands has almost the highest perinatal mortality rate in Europe. In 2006 perinatal mortality in The Netherlands was also higher than in the Flemish part of its neighbouring country Belgium (10.40 per thousand versus 7.76 per thousand). The difference in perinatal mortality between Flanders and The Netherlands cannot be explained by the risk factors analysed in the Peristat study, nor by the Dutch system of home deliveries. It is more likely that the attitude of Dutch professionals is too expectative, based on too much confidence in a non-intervention policy. Since the Peristat I publication many measures have been taken in The Netherlands in order to improve the quality of perinatal care. The most important are the start of the perinatal audit preparations, better prenatal screening and the introduction of preconception care.

Objective: Comparison of perinatal mortality in The Netherlands with that in other European countries (Peristat-II), and with data collected 5 years previously (Peristat-I)., Design: Descriptive study., Method: Indicators ofperinatal mortality which were developed for Peristat-I were used again in Peristat-II. Data on perinatal mortality in 2004 were delivered by 26 European countries. The Dutch data originated from national registers of midwives and gynaecologists and the National Neonatology Register., Results: In Peristat-I, from 22 weeks gestation, The Netherlands had the highest fetal mortality rate (7.4 per 1,000 total number of births). Furthermore, after Greece, The Netherlands had the highest early neonatal mortality rate (3.5 per 1,000 live births). In Peristat-II from 22 weeks gestation, after France, The Netherlands had the highest fetal mortality rate (7.0 per 1,000 total number of births). Of all western European countries, The Netherlands had the highest early neonatal mortality rate (3.0 per 1,000 live births). Over the past 5 years the perinatal mortality rate in The Netherlands has dropped from 10.9 to 10.0 per 1,000 total births but this drop has been faster in other countries., Conclusion: The Netherlands has a relatively high number of older mothers and multiple pregnancies, but this only partly explains the high Dutch perinatal mortality rate which still ranks unfavourably in the European tables. More research is necessary to gain insight into the prevalence of risk factors for perinatal mortality compared with other European countries. In addition, perinatal health and the quality ofperinatal healthcare deserve a more prominent position in Dutch research programmes.

--In 2007, the Dutch Society for Obstetrics and Gynaecology issued a revised version of the 1999 guideline on recurrent miscarriage. --The new guideline was developed according to the principles of evidence-based guideline development and includes levels of evidence. --The guideline contains recommendations for effective diagnosis and treatment and explicitly mentions certain diagnostic tests and treatments that should be avoided. --After a thorough investigation of a couples'-history, the type of diagnostic tests that should be offered to the couple can be determined. Patients with a low risk of having cytogenetic abnormalities or thrombophilia may be excluded from parental karyotyping and thrombophilia screening, respectively. --Women with confirmed antiphospholipid antibody syndrome should be offered anticoagulation treatment before and during subsequent pregnancies. --Effective therapy for unexplained recurrent miscarriage is lacking. However, the probability of a successful future pregnancy is high. This probability can be estimated based on the number of previous miscarriages and maternal age.

Objective: Identification of determinants affecting the outcome of external cephalic version (ECV) in breech presentation, and investigation of the impact of ECV--performed according to a standardized protocol in an outpatient clinic--on the mode of delivery., Design: Retrospective analysis., Method: In 2003 a standardized protocol of ECV was developed in the outpatient clinic for obstetrics of the Catharina Hospital in Eindhoven, the Netherlands; it was tested in 'version office visits'. Obstetric characteristics of all pregnant women who underwent attempts of ECV in the clinic from January 2004 until June 2006 during these sessions, and the subsequent births, were analysed. 85% of all ECVs were performed by the same hospital midwife and gynaecologist, in accordance with the protocol., Results: ECV was successful in 96 of 209 pregnant women (46%). In 1 pregnant woman an emergency caesarean section was performed after ECV because of partial abruptio placentae. Nulliparity, incomplete breech presentation and low birth weight of the baby were associated with a lower success rate of ECV in this study. In the group with a successful ECV the percentage of caesarean deliveries was substantially lower (9 versus 83%; odds ratio: 0.21; 95% CI: 0.09-0.51)., Conclusion: A regular team consisting of a hospital midwife and a gynaecologist working according to a standardized protocol for ECV in a case of breech presentation proved successful: the number of term breech presentations substantially diminished and therefore the percentage of caesarean sections was lower in the group in which ECV had been successful. This could have considerable impact on health care in the Netherlands in terms of reduced maternal morbidity and cost savings.

Objective: Evaluation of policy and treatment of deliveries at the limits of viability in the Netherlands and resulting survival figures., Design: Cohort study., Method: Within the framework of the European 'Models of organising access to intensive care for very preterm births in Europe' (MOSAIC) study, data was collected on all 512 births in 2003 (terminations excluded) following 22-31 weeks gestation in the catchment areas of the perinatal centres in Nijmegen and Utrecht, the Netherlands., Results: Gynaecologists and neonatologists practised a reserved policy for the active treatment of pregnancies under 25 weeks (5/77; 6%); all infants died. At 25 weeks, an active obstetric policy was used in one quarter of pregnancies, but none of the infants survived. Even at 26 weeks pregnancy, the obstetric policy was reserved and the mortality relatively high (9/31; 29%). From the neonatal deaths, 86 out of 92 (93%) were preceded by a decision either not to start or to discontinue treatment., Conclusion: Dutch obstetricians and neonatologists practised a reserved policy at the limits of neonatal viability. There is more need for active antenatal transfer to perinatal centres for those at the lower limit of neonatal viability to enable well-balanced decisions to take place. The parents' wishes should always be taken into account.

The guideline for referral to perinatology centres in cases of imminent preterm birth at 24-26 weeks gestation, is poorly adhered to by Dutch gynaecologists. Unfortunately, the guideline can be interpreted in various ways and the reasons for non-adherence remain unclear. In addition, no measures were taken to implement the guideline when it was published. This means that the usefulness of the finding that the guideline is poorly adhered to is limited.

In the field of obstetrics, important clinical questions have been addressed by multicentre randomised trials, but only a limited number of such trials have been carried out in the Netherlands. Implementation of the results is hampered because the organisation of Dutch obstetric practice differs from that abroad. In view of this, all ten Dutch perinatal centres and more than 30 non-academic hospitals initiated 6 randomised trials with the aim of improving their quality and power, as well as the subsequent implementation of the trial results. Clinical questions that were addressed included: (a) whether or not labour should be induced in women with foetal growth retardation at term; (b) whether or not labour should be induced in women with preeclampsia or pregnancy-induced hypertension at term; (c) whether or not labour should be induced in women with ruptured membranes at term; (d) which form of foetal surveillance is most effective in women with a high-risk pregnancy at or near term; (e) which form of foetal surveillance is most effective in women with growth retardation at 26 to 32 weeks; and (f) whether premature delivery during a multiple pregnancy can be effectively prevented by prophylactic administration of progesterone.

Background: Guidelines aim to improve clinical practice but are not self-implementing. Insight into barriers to physician guideline adherence is crucial for development of effective implementation strategies. The study aim was to identify barriers to physician adherence to an intrauterine insemination (IUI) guideline of the Dutch Society of Obstetrics and Gynaecology., Methods: We conducted a cross-sectional survey among all Dutch gynaecologists, residents and fertility physicians (n = 860), using written questionnaires that were based on information obtained in focus group discussions. We investigated barriers related to physicians' knowledge and attitudes, and external barriers., Results: The response rate was 65%. We used 344 questionnaires for analysis. Physicians' knowledge was adequate, with a median unfamiliarity rate with each of the 31 key guideline recommendations of 12%. Physicians' attitudes were generally positive, especially regarding guideline development and quality. Important attitude-related barriers included physicians' lack of self-efficacy regarding physician-patient communication and poor outcome expectancy. External barriers were mostly related to specific patient characteristics and associated with higher age of physicians and fewer consultations for fertility problems per week., Conclusions: Multiple barriers impede physician adherence to subfertility guidelines, mainly physicians' lack of self-efficacy and low outcome expectancy. Both physicians and patients play an important role in future implementation interventions to optimize subfertility care.

A study on the quality of primary obstetric care in uncomplicated pregnancies carried out by means of a checklist revealed substandard factors in perinatal care in 71 out of 72 pregnancies. However there are many objections to the quality-control procedure. Some items on the original checklist had to be abandoned due to lack of evidence. In other items definitions and circumstances had not been properly considered and in some cases the patient's own wishes were responsible for a change in policy. The quality of the care delivered cannot be judged only by counting items on a checklist, but requires careful consideration of the situation and of the circumstances that led to the choices in perinatal care.

Objective: Analysis of the effects of population-based determinants (maternal age, parity, multiple pregnancy and ethnicity) and of professional and organisational factors (conservative management in case of early preterm birth, the policy on prenatal screening and the Dutch obstetric-care system in general) on perinatal mortality., Design: Population-based prospective cohort study., Method: In a regional cohort (Zaanstreek) of 8031 pregnancies in the period 1990-1994 data were prospectively collected in an electronic database by deliverers of primary and secondary care. Analysis focussed on the effect on perinatal mortality of maternal age, parity, multiple pregnancy, ethnicity and professional and organisational factors (the policy in case of early preterm birth, the policy on prenatal screening and the Dutch obstetric-care system in general). Perinatal mortality was defined as mortality from a gestational age of 22 weeks until 28 days post partum., Results: The perinatal mortality in the Zaanstreek was 12.6/1000. Increasing the gestational age to 28 weeks decreased the perinatal mortality by 29%. The perinatal mortality in this cohort was significantly affected by parity, multiple pregnancy and maternal age (relative risk: 2.8), but not by ethnicity if corrected for the previous factors. Conservative management in case of early preterm birth and a restrictive screening policy for lethal birth defects were associated with an increase in perinatal mortality. In 31 of 92 singleton pregnancies followed by perinatal mortality, a relationship to substandard care was established. In 7 cases this relationship was probable and in 1 case the midwife was responsible., Conclusion: Given the magnitude of their effects, both independently and via interaction, stratification for maternal age, parity, multiple pregnancy and ethnicity must precede any interpretation and comparison of perinatal mortality rates. Although clinical policy played a modest role, a negative role of the organisation of obstetric care was unlikely in this cohort. A definitive judgement as to the quality of perinatal care would require extension of the evaluation to at least the entire first year of life in connection with the morbidity. The most favourable effects can be expected from stimulatory measures directed at lowering the age at first pregnancy.

The Dutch College of General Practitioners' (NHG) guideline on hormonal contraception does not follow the WHO criteria for the use of oral contraceptives in contrast to the guideline of the Dutch Society of Obstetrics and Gynaecology. Contrary to the WHO criteria, the NHG guideline considers a blood-pressure measurement before starting with an oral contraceptive to be unnecessary. It also considers no form of migraine to be a contraindication for oral contraceptives. The NHG guideline further disclaims the (slightly) increased risk of developing breast cancer in women using oral contraceptives. It advises initiation of oral-contraceptive use two weeks postpartum in non-breastfeeding women and six weeks postpartum in breastfeeding women, instead of the three weeks and six months, respectively, indicated in the WHO guideline. Lastly, the NHG guideline is too optimistic as to the reliability of oral-contraceptive use, as no distinction is made between efficacy and effectiveness. Such discrepancies between two Dutch guidelines can be detrimental to women's health care. The WHO criteria for contraceptive use may be a valuable tool to overcome differences of opinion so as to achieve a badly needed full consensus.

In the Dutch College of General Practitioners' (NHG) practice guideline on the menopause (which also covers hormone therapy), menopausal transition is considered as a physiological life process with inconveniences which can generally be settled by providing information, while leaving hormonal treatment for women who experience serious restrictions in their daily life as a consequence of vasomotor flushes or urogenital atrophy. In those cases, the guideline says, hormonal treatment should not be given for longer than three to six months, after which it should be stopped until a relapse arises. However, it usually takes at least six months of oestrogen replacement therapy to restore urogenital atrophy as well as for the woman to recover from its discomforts such as dyspareunia. Dosages of oestrogens in different hormonal therapies should be 50% or 25% of those advocated in the guideline, as the lowest effective dosage of oestrogen is sufficient. More generally, a woman affected by menopausal inconveniences is not a patient. She deserves to decide for herself whether or not she is willing to use hormone replacement therapy, and if so, she should be allowed to decide on the duration of hormone treatment. The physician should provide adequate information and benevolent supervision.

Objective: To inventory the functioning and the results of obstetrics in the West-Frisian islands in 1995 and 1996., Design: Retrospective., Method: With enquiry forms information was gathered from the six GP practices in the West Frisian islands concerning the course and results of every pregnancy with a delivery between 1 January 1995 and 31 December 1996. Of emergency transfers during labour and in the postpartum period the time span between moment of applying for a transport and arrival at the hospital ashore was noted. Results were compared with those for the total province of Friesland and the national Dutch results., Results: Of the 253 women 23 (9%) had a primary indication for hospital delivery under care of a gynaecologist. During pregnancy 52 patients (21%) were directed for hospital delivery. 23 (9%) of the 178 patients awaiting the home delivery were referred during labour and 155 women (61%) delivered at home. After delivery 3 patients were admitted. The median time span in emergency transfers was 77.5 min (range: 60-105) with transport by boat and 65 min (55-120) with transport by heli. The island people delivered at home in 61% compared with 37% in Friesland in 1996 and 31% in the Netherlands in 1993, had a hospital delivery under care of a gynaecologist in 39% compared with 56% in Friesland and 58% in the Netherlands in 1996, had a caesarean section in 6% compared with 10% in Friesland and the Netherlands in 1996. There were two foetal mortalities and one neonatal mortality., Conclusion: In comparison with the national data the island obstetrics is characterized by a higher home delivery rate, less specialist involvement and a lower caesarean section rate.

Objective: To determine if the birth prevalence data on congenital malformations in the national perinatal registries, the Landelijke Verloskunde Registratie (LVR) (National Obstetrical Registry) and the Landelijke Neonatologie Registratie (LNR) (National Neonatological Registry), can be combined into one nationwide database, and if so to determine the validity of this database., Design: Descriptive., Setting: TNO Prevention and Health, Leiden, the Netherlands., Methods: Investigation of the registered number of congenital malformations in the LVR/LNR, the amount of overlapping and the possibility of combining the LVR and LNR into one nationwide database. The validity of this database was evaluated by comparing the total number of registered children with the total number expected in the Netherlands. Furthermore the total number of children registered in the nationwide database was compared with children registered by the European registration of congenital anomalies and twins (EUROCAT) in the Northern Netherlands., Results: The LVR and LNR were mostly complementary with respect to the registration of congenital anomalies and could be combined to one nationwide database. For sixteen important diagnoses this nationwide database contained approximately 87% of the total number expected in the Netherlands. Comparing this database with the data of EUROCAT in the Northern Netherlands showed that one-third of these congenital malformations (n = 229 in 217 children) were registered in both systems, while 99 (43%) were only registered by EUROCAT and 50 (22%) only by the nationwide database., Conclusion: It was possible to create a nationwide database, which can supplement the regional EUROCAT data with nationwide data on sixteen important diagnoses of congenital malformations.

Analysis of national perinatal statistics from Holland, 1986, demonstrates that for all births after 32 weeks' gestation mortality is much lower under the non-interventionist care of midwives than under the interventionist management of obstetricians at all levels of predicted risk. This finding confirms with great authority the conclusions of all earlier impartial analyses from Britain and other countries which agree in contradicting the claims on which the organisation of maternity services in most developed countries is now based, namely, that childbirth is made so much safer by the application of high technology that only this option should be provided.