The Place of Birth The Dutch Midwifery System

On the same subject Birth Midwifery

by Beatrijs Smulders
		As an independent midwife she plays a leading role not only in the development of midwifery and modern obstetrics in the Netherlands, but also in the preservation of the Dutch birth system. She has been a prominent speaker at many national and international conferences and a successful author of several best sellers.

Dutch midwifery care is unique in the world. Our country has a totally different culture and system that allows Dutch midwives to work as they do and this is not because our midwives or obstetricians are very different from elsewhere but because our approach enables women to get the best of both worlds. The system prevents midwives and obstetricians from behaving in ways that are bad for women and demands the best from all of us.

In Holland, midwives are totally autonomous. How have we achieved this status? What are the problems we have faced and what of the future?

A brief history

In the beginning of the 1970s, the homebirth rate was around 70%. During that decade there was a staggering decline in the percentage of homebirth in Holland and by the late 70s when I graduated from midwifery school, it stood at 35%. The reason for this decline was twofold: the midwives themselves and their status as professionals, and the training needs of medical and nursing students. In those days being a midwife was very hard work and the pay was low, forcing the midwife to carry a large caseload in order to survive. A law had also been passed that required nurses and doctors to observe 15 births during their training and this created a problem as there were not enough births occurring in hospitals to meet the needs of these students. To remedy this situation is was decided that midwives should have access to the hospitals so they could bring the women in to give birth. This pleased the midwives as it improved their status and they could see more clients and thus earn more money. This trend continued and it was with a shock that we realised that by the end of the 70s the rate of homebirth had halved and was at a very low level.

The younger midwives were particularly alarmed. When I completed my training, Professor Kloosterman, who spoke at my graduation ceremony, said that it was "5 minutes to midnight" for midwifery in Holland and that it could go either way: following the international community by medicalising birth with total hospitalisation for birth, or by choosing to keep the Dutch midwifery system, Through retaining the system of prenatal screening that ensures the wonderful autonomy of independent midwifery. His words had a huge impact on my colleagues and I and it inspired us all to take action to stop this decline in homebirths. We became aware that having a certain percentage of homebirths influences the whole system. Through screening and selecting women for homebirth during pregnancy, midwives are then able to work with a group of very healthy women whom they can protect from unnecessary medicalisation. This means that the statistics for birth in Holland are always going to be good, not because of homebirth itself, but because the screening process identifies those women with problems in advance. The remainder go on to have very normal births with midwives, and this is reflected in the results: low induction and Caesarean section rates and a low incidence of epidurals (Entonox doesn't exist). This is the strength of the Dutch birth system.

For us the decade of the 1980s was a time of battle, struggle and controversy. As midwives we were very militant because we had to protect homebirth, and we produced books and videos and sought publicity everywhere. We decided that we wanted to change our image from being that of very hardworking worn-out midwives that lack the time to update our skills or undertake necessary research (or even record our results). We didn't want to feel burnt-out any more, so we worked at the political level to increase our income so we could attend fewer births and be properly recognised for our services (midwives have always been paid by the Government health system or by private health insurance companies).

At this time, the Active Birth movement in the UK and Michel Odent's ideas also helped by giving us some new ideas and by incorporating these into our practice we were able to show that we were keeping up with modern, woman-friendly ideas - we were emancipating women from being in bed to sitting up or squatting to give birth. These ideas also freed up midwifery thinking and helped us to become less rigid in accepting ideas from abroad.

There was a big need for research to support our practice, so a number of studies were undertaken by obstetricians to show the value of the work done by midwives - we didn't do this work ourselves because we had little time and few skills in this area. Many obstetricians, of course, really favoured 100% hospital births so they did their own research to try and show that homebirth was dangerous.

The 1990s brought a new way of thinking. The obstetricians were silenced as it was shown that much of their research supporting hospital births was of very poor quality, when it was clear that the system of screening and birth in Holland was in fact outstanding. Births in hospital showed a much higher rate of perinatal mortality, as would be expected and proved that the system of identifying those at risk in the pregnancy was working properly.

A national database was established, overseen by a committee of obstetricians and midwives and this has been collecting data for the past 15 years. This has enabled women to be followed through their pregnancy and if a transfer to an obstetrician becomes necessary the woman's details are immediately available.

That all this has been achieved is a miracle, and the slide towards hospital birth has been halted. In the 80s the rate of homebirth went up again to 35-38% and there was much celebrating amongst midwives when these results were announced.

During the 1990s the rate of homebirth fell again - a very depressing outcome. This was partly because GP's who were doing 17-19% of homebirths at the start of the 90s were doing fewer by the end of that decade - around 6%. This has affected the overall rate of homebirth. At the same time, midwives are doing more homebirths than before so perhaps the reduced involvement of GPs will prove a good thing as this removes a source of competition. The Dutch Government has always supported midwifery. The law says that if a midwife is working in a town where there is also a GP offering maternity care, the midwife will be paid in preference to the GP, and if he does assist at a homebirth, the woman must pay him herself. This really helps the midwife and it is likely that this will force GPs out of the maternity scene altogether. There are moves to change this law and this is a great concern since if a young enthusiastic GP does decide he wants to offer maternity care and the women use his services, the risk is that after a few years if he then wants to stop providing this aspect of care, there may not be any midwife to step in and provide for the women. In recognition of this potential outcome, the Dutch Government has consistently supported the midwife through laws passed in 1943 that ensure that poorer people can always be guaranteed good care.

Birth in Holland

The population of Holland is 15 million, and the annual number of births is around 74,500. Of the total number of births, 46% are attended by midwives, 8% by GPs and 46% are assisted by obstetricians.

There are 1422 registered midwives at present, of which 70% are in independent practice, 15% work as replacement midwives (for those on holiday or leave etc) and 15% work in the hospital clinics, mostly supervising students involved in training as midwives or doctors. Some midwives have now decided to specialise in high risk care and they work closely with obstetricians.

The homebirth rate has fluctuated: In 1997 31% of births took place at home and in 1998 this rose to 32.4%. In Amsterdam, the rate has risen from 18% in 1995 to 26% in 1998. In Rotterdam, the rate has risen from 19% in 1995 to 25% in 1998.

The national Caesarean section rate has risen from 8.5% in 1993 to 9.5% in 1997. Forceps/vacuum rates have remained steady: 7.7% in 1993 and 7.8% in 1997. The rate for epidurals is 6% with this form of pain relief only being used for Caesareans. The perinatal mortality rate in 1997 was 8.1 per 1000 births.

Cultural differences in Holland

In Holland midwives have belonged to the medical profession since 1972, along with GPs, dentists, pharmacists and obstetricians. Midwifery training has always been of a very high standard, with very strict criteria for entry into the College, including high academic achievement and being of good character and behaviour. These criteria have created a body of women who were strong and intelligent and this is reflected in the Dutch word for "midwife" which translates to mean "wise woman".

There is no tradition of litigation in Holland and this has been a major influence on the provision and development of our maternity care. The laws are such that if a client is unhappy with the care received from a doctor or midwife, she can attend a special committee, comprising midwives, obstetricians and GPs, who will review the case and the medical evidence. Financial compensation is not a consideration and usually if a mistake has been made this is acknowledged as something that does occasionally happen and the midwife or doctor will receive a warning. After three warnings court proceedings may be commenced. This approach is made possible because of the social support system in Holland, which provides fully for parents who have a handicapped child through the national insurance system and other community facilities. There is no need to sue the doctor or midwife to obtain money to pay for this care. This is a very ethical approach to the provision of maternity services and brings out the best in both the professional care givers and the community as a whole.

Life is centred around the home in Holland. Your home is your castle and the family are all important. The average age of a woman having their first child is 29 years and women tend to have a career first, moving on to motherhood at a later age. Long maternity leave is common and most women then take up part time work to accommodate their family's needs. This shows the level of emancipation in Holland - a woman can have both babies and a career when the children are young. Women who return to work in their 40s have the benefit of skills gained from caring from a family and there is still time to reach a peak position in their field. Many children have been present at births and this helps to bind the family together and reduce fears around birth.

The Birth Centre Amsterdam

Our Birth Centre was set up in 1992. It comprises two groups of four midwives, running their own business and caring for around 800 women per year (in 1998 the midwives cared for 795 women - 495 primips and 300 multips). During pregnancy around 20% are referred on to a doctor and a further 15% are referred during birth. The main reasons for referral during pregnancy are high blood pressure, post maturity (more than 42 weeks), breech, multiple birth, preterm birth, IUGR and bleeding. During labour the main reasons for referral are lack of progress in second stage, slow progress in first stage, meconium stained liquor and long term rupture of membranes without contractions.

It can be argued that midwives tend to refer during labour far to quickly. Since the midwife will get paid whether or not she refers, there is an incentive to refer quickly (perhaps for social reasons of her own) rather than take the time to wait. Referral is also easy - the midwife is treated very well in hospitals because she brings in the money and provides clients for the obstetricians (the doctor and hospital will also be paid if the midwife refers a client). Some doctors therefore woo the midwife and look after her as a peer. Consultations are on a joint basis and the doctor will often defer to the midwife and ask her advice. This collegiate atmosphere encourages dialogue and sharpens the practices of both the doctors and midwives in contrast to the adversarial interactions often seen in other countries.

One outcome of this approach is that doctors who are not "woman friendly" tend to be ostracised by the midwives, who blacklist those who do not measure up. As a result, hospital funding can be severely affected and this stimulates change. Money is thus used to make people behave properly and midwives are very powerful, taking their clients to those hospitals and doctors which give the best care. This is made easier by the fact that most cities have a choice of doctors and hospitals available. There is also an excellent ambulance system and although this is often cited as a reason for the safety of homebirth in Holland (not born out by the facts) it is true that if an ambulance is called it will arrive in minutes. They are very familiar with homebirth and midwifery and provide the necessary back up without fuss. Since midwives don't carry drips, this is the main service that they provide.

Another rule governing midwifery states that a midwife may not undertake the care of a woman who lives more than a half hour away from her home, so that the midwife can attend quickly if needed.

Messages for women

In talking to women we no longer promote homebirth as safe but rather say that the safest place to give birth is where there will be the least intervention, since each intervention in birth carries risks for the mother and baby. This means that it is not necessary to defend yourself as a midwife since you are just concerned about achieving maximum safety for mother and child. Every woman understands this message, which is so logical. Therefore we do not talk about the place of birth, which can be confusing and instead say that where to give birth will be decided during the labour when the woman will feel what she wants to do as part of the birth process.

During the pregnancy we don't give the woman a lot of detailed information (a midwife would see an average of 26 - 28 women during a prenatal clinic), since women just want to basically know that the baby is growing well, she is healthy and there is nothing to be concerned about. There are meetings at 36 weeks where practical issues about this birth, such as when to call the midwife and how the labour will be managed are discussed. We explain that we will attend as soon as she calls, assess the situation and check the baby, make suggestions about comfort etc and then we will leave, aiming to come back at 8 cms. There is no pressure on us to listen constantly top the baby's heartbeat, nor is there a need, since we are working with a selected group of women whom we know and whom have had excellent care during the pregnancy. The most important role for the midwife during the birth is to ensure that the woman is not being disturbed, so that the physiology of labour can work as well as possible. Individual assessment is vital, and of course, some women will need the midwife to stay all the time for the birth to go well.

Another very important message is about the pain of labour. We know that women can handle the pain and that they need the pain. It is a measure of the trust and confidence in the midwife that if the pain is abnormal some pethidine will be administered. Pethidine is not called "pain relief" but rather a "labour de-inhibitor" as it enables the women to sleep a little so that she can handle the pain better. Midwives are not able to give pethidine and a transfer to the hospital will be necessary so that it can be given by the doctor. This also discourages its use.

This attitude towards pain is crucial to the way birth is handled in Holland by the midwife and the obstetrician. It is well understood that if a drug is given for the pain it will harm the baby and we tell women this very clearly. It is a different way of thinking, especially for women from a different cultural background, well illustrated by this story:

Many American women come to Holland to give birth, especially if they have Dutch partners. One midwife (Astrid Limburg) assisted an American woman who, at 36 weeks, came to live in a hotel in Amsterdam to await the birth of her baby. The woman said "I want to give birth in the Dutch way, so please help me Astrid, especially if I am in pain as I want to do it like the women do here". Astrid answered that they would "go Dutch" as she wished.

Labour started and the woman called her midwife to come. Despite her loud screaming (the whole hotel was getting involved!) she was only 1 cm dilated. She said "I'm sorry, I was mistaken about this whole Dutch thing - I want my epidural!". Astrid got her moving, into the shower and made several suggestions about getting more comfortable. The woman's partner was also feeling very sorry for himself. After a time, Astrid said "I am going to leave now" and the woman was horrified, shouting "it is criminal to leave me!" However, the reply was "well, we are going Dutch now and I always leave at this point. You are doing well, everything is fine. This is how millions of Dutch women do it and you can too". She also suggested that the father should go off for a walk in the park.

Four hours later the partner called and when Astrid arrived she found the woman fully dilated. She gave birth a half hour later to a beautiful boy. The next morning during the postnatal visit, the woman described the birth as the most extraordinary experience, telling Astrid that after she and her partner had left, she stood under the shower and thought that since the midwife had gone she must be OK. This gave her enormous confidence, so she forgot the midwife and focused instead on the labour. She was completely taken by surprise when she wanted to push.

This story illustrates our basic philosophy to pain and the role of the midwife at birth. It is important to give strong messages to women and of course, the system in Holland totally supports us in this way.

Another way we promote homebirth is to say that at home women labour better and that the decision on whether to stay there or go to the hospital will be made as the labour develops. In this way women get the best of both worlds and if a transfer to hospital is necessary then the obstetrician comes specially (he's not always at the hospital) so that the woman receives special attention from the doctor. He then gets on with the necessary treatment because his special skills are really required.

The Dutch midwife also works with a professional assistant, the maternity aide nurse, who acts as an assistant to the midwife during the labour and then stays on with the family afterwards to take care of the family. She charts the daily observations of mother and baby, helps the mother with her breastfeeding and undertakes the household chores. Her training takes 18 months, and she is paid by the government. The midwife visits every second day, up to 5 or 6 visits as needed, knowing that the woman and her family will be professionally cared for during the first week by the maternity aide nurse. It provides a wonderful combination of carers and is integral to Dutch maternity care.

This paper was presented at the Future Birth: The Place to be Born Conference, Australia, February 1999 for Birth International PO Box 366 Camperdown NSW 1450.