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The Dutch Obstetrical System
Vanguard of the Future in Maternity Care
Raymond De Vries, Therese A. Wiegers, Beatrijs Smulders, and Edwin van Teijlingen
The German poet Heinrich Heine is reported to have said, "When the world comes to an end, I shall go to Holland, for everything there happens fifty years later." For some, this Dutch "quaintness" explains the unusual system of obstetric care found in the Netherlands, a system where nearly one-third of births occur at home and where midwives have a degree of professional independence unrivaled by midwives in any other country. Heine's observation about the Netherlands suggests that the unique Dutch way of birth is a vestige from a bygone era—a credible conclusion if you believe that humans are helpless in the face of technology. But the stubborn persistence of midwifery and home birth in the Netherlands, in spite of the declaration of medical professionals elsewhere that midwife-attended birth at home is a dangerous anachronism, forces us to conclude that Dutch obstetrics can be the vanguard of the future.
The singularity of the Dutch maternity care system has made it a model for all those who seek to slow or reverse the march toward the medicalization of birth found in the developed world (Van Teijlingen et al. 2004). For birth activists, the Netherlands has become the destination for inspiration and for instruction on how to reorganize birth in their home countries. The uniqueness of the system, coupled with the desire of short-term visitors to find what they are looking for, has resulted in mischaracterizations of the Dutch way of birth. For example, Mehl-Madrona and Mehl-Madrona (1993: 1) claimed that "over 70% of births [in the Netherlands] are still attended by midwives." In fact, in the early 1990s midwives accompanied about half of all births in the Netherlands (see Table 1.1). As far back as 1910, the first year a breakdown by caregiver is available, midwives in the Netherlands attended 57.7 percent of all births, and at no point since did they attend more than 60 percent of births. Midwives do attend over 70 percent of the births that occur at home. It is likely the authors heard this statistic and somehow assumed that the 70 percent figure applied to all Dutch births. In her ethnographically based discussion of the lessons of Dutch obstetrics for Americans, Rothman (1993: 201) sets the scene by discussing windmills, tulips, bicycles, and Rembrandt, giving an over-romanticized picture of Dutch midwifery and society. Her description of the Netherlands as a "Mecca for midwives" and the home of noninterventive obstetrics makes it difficult to believe that Dutch midwives once argued for the right to wield forceps (see Marland 1995: 328) or that they are beginning to outfit their offices with the apparatus for sonograms (see Pasveer and Akrich 2001).
Even the Dutch misrepresent their obstetric system. For example, Expecting, an annual special issue on pregnancy and birth of a Dutch parenting magazine, states that "in the Netherlands about 70% of babies are born at home, without complication or unusual interventions" (Schiet 1994: 112). In the early 1960s, this was the case (72.6 percent of births were at home in 1960), but throughout the last decades of the twentieth century, the percent of births at home continued to decline. By 1994, the date of the article in Expecting, the home birth rate was just over 30 percent.
Although we count ourselves among the champions of the way obstetrics is organized and accomplished in the Netherlands, we believe that the Dutch system can serve as a model only if we see it clearly, with its strengths and its flaws, and with its ties to the structure and culture of Dutch society. To that end, we offer a description of the Dutch way of birth that includes (1) stories and statistics that paint a picture of the players and outcomes of the system; (2) accounts of the history of midwifery and its place in the organization of medical care; and (3) explanations of the ways obstetrics in the Netherlands expresses the culture of that country.
SEEING MATERNITY CARE IN THE NETHERLANDS
Too often descriptions of the Dutch way of birth are limited to statistical portrayals of caregivers and outcomes; even though these are clearly necessary, they exclude the voices of midwives and the women and families they serve, and they fail to convey what occurs in the homes, polyclinics, and hospitals of the Netherlands. In the following pages, we provide a statistical picture of the Dutch way of birth, interspersed with stories of births that reveal what birth in the Netherlands feels like and how it is valued.
We open with a story told by a Dutch mother that illustrates the features of maternity care in the Netherlands much admired by non-Netherlanders:
My second pregnancy was not as exciting as my first. I was often tired and had many colds. [My labor began when] I felt a weak contraction, and then a while later, another small one. I decided to go to bed nice and early. If I could get to sleep, maybe the contractions would stop. That did not work. I was definitely having contractions, so I went with my big bare belly and stood in front of the gas heater. That felt great! The contractions became stronger and more regular, and we called the midwife.
First came the assistant and then the midwife. My friend Jetske came with a big bouquet of fragrant lilies. My neighbor, Otto, happened to come by and asked if he could stay. Sure, why not? Between contractions I was able to relax, and when another came, I was able to handle it easily. I felt like an old hand at this. Gradually the contractions became more frequent and intense, and I suddenly recalled how vicious some contractions can be.
I began to feel irritated and impatient. I had had enough of this; I wanted no more. Soon came the urge to push, but I had to keep these strong contractions at a distance, I had to puff them away. But they were so powerful I had to go along with them, and when I did I found that I enjoyed them. The midwife broke the membranes. And then, an enormous relief, my second child arrived, a beautiful little girl with dark hair, Rosa.
She lay next to me safe and warm, softly groaning as if gradually recovering from her journey. When everyone had gone and Frans, my husband, was sleeping on the sofa and Swaan, my little daughter, was in her bed, and Rosa [was] in my arms, the room changed into an island of rest, the center of the universe.
From the point of view of the midwife, the Dutch way of birth has additional advantages. One of us, Beatrijs Smulders, is a practicing midwife in the Netherlands, and in this chapter she reflects on her work to complete our picture of midwifery in her home country. In this story Beatrijs describes the "deep feeling of emancipation" that accompanies birth at home:
A good birth strengthens the self-image of the birthing woman at a deep, non-rational level. A system in which women do the delivery themselves emancipates women. Often women say after the delivery, "After this I can do anything!" or "Because I was forced to rely on myself during the delivery, I learned all of a sudden to trust myself."
This is well illustrated by the story of a professor, whose pregnancy at the age of 43 was unexpected and unwanted. She never had the desire to have children. She had, in fact, achieved everything that a woman could achieve in a "man's world." She was a university professor, had written bestsellers, and was on several important policy committees. And then this, totally unexpected! At her prenatal visits she was often confused, not knowing whether to be happy or grief stricken. She worked harder than ever, and she wanted to return to work as soon as possible after the delivery. She was not looking forward to the birth. This cool-headed woman preferred to go to hospital with plenty of pain relief. She questioned why we midwives were so keen on the use of water—being under the shower or in the bath during contractions. To her that seemed totally ridiculous. Her mind was made up and I promised to respect her wishes.
But during the pregnancy she changed—she followed a parent-craft course, attended an antenatal education evening and during the last checkup she suggested that "the first few centimeters dilation I'll stay at home, and well, the pain relief can come at the end."
Her delivery started slowly. She found it extremely difficult to put aside the troubling thoughts that filled her head and to give in to her contractions, to her body. When she finally let go, the delivery went unbelievably fast. She insisted on staying at home, and even hopped into the "damned" bath. She dilated fully and within an hour she had a beautiful son in her arms.
Six weeks later she came for her postpartum check-up. She was a very different person: in one arm her son breastfeeding, in the other a big bunch of roses. When I asked her to reflect on her birth she glowed and said: "For years I have fought to make it in a man's world. Even though I succeeded something essential was missing. Now that I have had a baby, I know what that is. At a very deep level I was always unsure about myself; now something fundamental has changed. Rationally I can't put my finger on it, but bodily, intuitively, I have a new self-esteem that I had never experienced before, and as a result I am certain that everything will become easier for me."
This is the kind of reason that makes it so crucial that we in the Netherlands must hold onto a maternity care system that allows women, as much as possible, to make their own decisions and take control over pregnancy and birth, a system where women can choose their own midwife and take things into their own hands.
These narrative pictures of birth naturally lead to questions about the broader dimensions and the trends in the Dutch way of birth. Here is where statistics can help. Tables 1.1 and 1.2 present the most-requested information about midwifery and birth in the Netherlands: the extent of home birth and the role of midwives in birth.
These tables are unsurprising and surprising at the same time. We are unsurprised to learn that the rates of home birth and midwifery involvement in birth are much, much higher than those found in the United States. In the United States there are very few births at home, and midwives are involved in less than 10 percent of births (Martin et al. 2005). But many will be surprised to see that the percentage of births at home in the Netherlands has dropped dramatically in the past four decades, and that—compared to Scandinavian countries where midwives attend nearly all births—Dutch midwives accompany fewer than half of all births.
Of course, the inevitable question that arises in the minds of those first learning about the Dutch way of birth is, is it safe? The answer to this question is found by looking at infant mortality rates in several countries. Table 1.3 shows that the Netherlands has rates lower than those in the United States, similar to those in the United Kingdom and Canada, and higher than those found in Sweden.
Another measure of the outcome of maternity care is the proportion of births that are accomplished surgically. The cesarean section (CS) rates for the United States show a gradual increase from 23.5 percent in 1995 to 29.1 percent in 2004, a steady increase over the past fifteen years: in 2004 nearly one in three women in the United States was delivered surgically. The CS rate in the Netherlands nearly doubled in the same period, from 7.5 percent in 1990 to 13.8 percent in 2004, but it is still less than half the rate in the United States.
Maternity care in the Netherlands is remarkable for its degree of cooperation between caregivers at different levels and locations in the system. Those who attend home births in other nations often find that hospital-based caregivers are reluctant to offer support to home birth mothers and are prone to scolding women whose care is transferred to the hospital (De Vries 1996; Davis-Floyd 2003). In the Netherlands the transition from home to hospital is much smoother—so smooth that some worry about overreliance on backup care and consequent overuse of the hospital.
Rothman describes a typical transfer from home to hospital. She is an American sociologist who went to the Netherlands to take a look at its much-discussed maternity care system; as she says, "It is kind of a rite of passage for the childbirth aficionado." But instead of witnessing a calm and cozy affair, she got to see what happens when a home birth mom is transferred to the care of a gynecologist:
The labor was not progressing, and the midwife became concerned. Perhaps bladder pressure was a problem. She tried a catheter, change of position, more time, more changes. Then the decision to move to the hospital: helping the woman slip some clothes on, all of us helping her maneuver down [the] stairs, placing her in the car next to her boyfriend, waving goodbye to the worried grandmother-to-be, jumping in the car with the midwife, and the two cars going off to the hospital. I remember holding the hospital door open for the midwife, carrying one of her bags while she carried another, with the birth stool tucked under her arm. There was a friendly welcome at the entrance, and a warmer welcome from the nurse on duty. A brief exchange of information, and the nurse set things up the way the midwife liked them—an experienced team comfortably working together. More time, more changes of position. I found myself alone with the laboring woman, who was stretched out on a padded table, crying in a Dutch that even I could understand, "I want to go to sleep, let me sleep." Reassuring her (in English—who knows what a laboring woman understands of a language she studied in high school?), but aiming for the right tone of compassion and assurance, I said the midwife would be right back, "She's coming, she'll be right here." Then finally the consultation ... the obstetrician coming in, conferring with the midwife, briefly examining the woman, and agreeing to do a Caesarean section ... the goodbyes, and the midwife assuring the woman and the boyfriend that things were now okay. She said she would see them tomorrow, and off we went. (Rothman 1993: 206)
Rothman was both surprised and pleased with the easy transfer of care from midwife to specialist, which is unlike the situation she observed in the United States, where women transferred from home to hospital are often subject to lectures and harsh treatment from obstetricians and nursing staff (see Davis-Floyd 2003 for examples).
Beatrijs reflects on how the setting of birth influences the midwife's attitude toward the event:
The midwife knows two kinds of fear: the fear of making a mistake and the fear of the immensity of the occasion. The first fear is not something to really worry about. If you have the skills, you will know exactly what to do in each situation, and when you should or should not intervene. The rules are clear, and with increasing experience, you learn to trust your judgment.
The second fear is much more present at home than in the hospital. In the hospital, equipment helps you to allay fear. You can hide behind the technology. Listening with a big imposing CTG [cardiotocograph, electronic fetal monitor] machine is no more efficient than listening with a little wooden Pinard, but the former mystifies. It impresses your audience, and it seems to remove the fear in the midwife. The institution radiates the ultimate control. At home there is nothing to mystify. The woman does it herself, with your support. You try to disturb this process as little as possible, so you listen with your Pinard or Doppler. Strange as it may sound, at home you feel much more that the baby floats between heaven and earth, that a new life is on its way.
The art of the midwife is to never act on the basis of fear. You must learn not to identify with fear. You experience your feelings and let them pass over like clouds, until the sky is blue again. That's when you act. When you act out of fear, there is the risk that you medicalize. Before you know it, you have sent a woman to an obstetrician or to hospital unnecessarily.
Excerpted from Birth Models That Work by Robbie Davis-Floyd, Lesley Barclay, Betty-Anne Daviss, Jan Tritten. Copyright © 2009 The Regents of the University of California. Excerpted by permission of UNIVERSITY OF CALIFORNIA PRESS.
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