Jehovah's witnesses are a religious society with more than six million members worldwide. For religious reasons, most Jehovah's witnesses refuse transfusion of blood or any of its primary components (red and white blood cells, platelets and plasma), even when red blood cell transfusion could be life saving.

In this nationwide retrospective study, the researchers examined all cases of maternal mortality in the Netherlands between 1983 and 2006, and all cases of serious maternal morbidity between 2004 and 2006.

The authors report that all identified cases of maternal mortality in Jehovah's witnesses during this period were caused by major obstetric haemorrhage. The refusal of red blood cell transfusion was found to be an important factor in the course of events leading to the death of these women. All cases of serious maternal morbidity in Jehovah's witnesses were similarly caused by major obstetric haemorrhage and linked to the refusal of red blood cell transfusion.

While the society of Jehovah's witnesses has issued a clear stance against transfusion of blood or any of its major components, individual members may have different positions on accepting treatment with other blood products such as coagulation factors, or receiving back their own blood collected using a cell-saver. These individual choices can make a big difference in management options in cases of major obstetric haemorrhage. The authors recommend that the exact treatments acceptable to each patient, together with available alternatives, be discussed early in pregnancy.

Professor Jos van Roosmalen, Chairman of the National Maternal Mortality Committee of the Netherlands Society of Obstetrics and Gynaecology, and supervisor of the research, said "In the Netherlands, the overall maternal mortality ratio due to obstetric haemorrhage is extremely low at 0.67 per 100,000 live births. Excellent blood transfusion facilities contribute heavily to this low ratio".

"Jehovah's witnesses, by refusing blood transfusion, expose themselves to a serious risk during childbirth. Our survey has shown a maternal mortality ratio due to obstetric haemorrhage of 68 per 100, 000 live births in this group, a 130 times higher risk than the average."

Professor Philip Steer, BJOG editor-in-chief, said "Major obstetric haemorrhage is one of the main causes of maternal mortality and serious maternal morbidity. It is important for doctors to discuss all risks and available alternatives with patients early in pregnancy, to ensure that both patient and doctor have a clear understanding of the options in the event of an emergency."

"Any hospital treating Jehovah's witnesses should have a clear protocol for obstetric care, and ensure training for staff in the management of obstetric haemorrhage in these patients."


For a more in-depth discussion of Jehovah's witnesses' beliefs about blood transfusion, as well as possible variations in patient choices in relation to the use of plasma derivatives and autologous transfusion, please see Wade P, Blood transfusion refusal in Jehovah's Witnesses, available online at http://dx.doi,org/10.1111/j.1471-0528.2009.02193.x.

A related commentary in the latest BJOG issue has suggested that women who are Jehovah's witnesses may not have typical fertility rates. If this is the case, this may lead to possible variations in the interpretation of the study's results, as risk estimates were based on the assumption that birth rates among Jehovah's witnesses were equivalent to the national average. Please see Oteng-Ntim E, Harrison C, Commentary for BJOG on 'Maternal mortality and serious maternal morbidity in Jehovah's witnesses in the Netherlands', available online at

BJOG: An International Journal of Obstetrics and Gynaecology is owned by the Royal College of Obstetricians and Gynaecologists (RCOG) but is editorially independent and published monthly by Wiley-Blackwell. The journal features original, peer-reviewed, high-quality medical research in all areas of obstetrics and gynaecology worldwide. Please quote 'BJOG' or 'BJOG: An International Journal of Obstetrics and Gynaecology' when referring to the journal and include the website: as a hidden link online.


Van Wolfswinkel M, Zwart J, Schutte J, Dukevot J, Pel M, Van Roosmalen J. Maternal mortality and serious morbidity in Jehovah's witnesses in the Netherlands. BJOG 2009; DOI: 10.1111/j.1471-0528.2009.02191.x.

An abstract of this paper is available at

BJOG: An International Journal of Obstetrics and Gynaecology