- Email: [email protected]
The profession of midwife in the Netherlands
Midwifery (1987)3, 178 186
© Longman Group UK Ltd 1987
Midwifery
The profession of m i d w i f e in the Netherlands Edwin van Teijlingen and Peter McCaffery
Community midwives in the Netherlands have a greater degree of autonomy in relation to the medical profession than do midwives in most countries. They are independent practitioners having full responsibility for providing continuous care for healthy women who are pregnant, and for conducting ante-natal assessments to ensure that those women with pathology are referred to hospital specialists. The midwives attend over 40% of all deliveries, more than half of which take place in the mother's home (the remainder being short-stay hospital births). General Practitioners (GPs) are precluded by health-insurance regulations from receiving payment for maternity care, except in rural areas where no community midwife is available. Midwives are assisted in home deliveries by maternity home helps, who also take on household tasks for mothers during the first few days. This service is used by more than two-thirds of all mothers, since it is also available after a hospital birth. Its availability helps to explain the continuing high percentage of home confinements in the Netherlands (36%). The Dutch system, giving midwives a high degree of responsibility and of financial independence, can give rise to tensions between midwives and obstetricians, but limits unnecessary medicalisation of childbirth.
INTRODUCTION This paper addresses the independent position of community midwives in the Netherlands. They are independent in both a medical and a financial sense, and this independence affects their attitudes towards their job, towards their clients and towards the place of confinement. It also has consequences for the midwives' relations with the other professions in the field of the maternity s e r Edwin van Teijlingen MA, Postgraduate student Peter i c C a f f e r y MA, DPhil, Lecturer Sociology Department, Aberdeen University, Old Aberdeen AB9 2TY
Manuscriptaccepted6 May 1987 (Reprint requests to PMcC).
178
vices. The Dutch way oforganising the maternity services has, of course, its own particular shortcomings.
DUTCH MATERNITY SERVICES Midwives in the Netherlands are in many ways in the same position as midwives in Britain. They work in a similar medical environment. The Dutch health services are financed by a public health insurance scheme, the Sick Funds, which covers the 70% of the population earning less than £14000p.a. (about 49 150 guilders). The remainder of the population are covered by private insurance companies. In both countries the basic philosophy behind
MIDWIFERY
the maternity services is that pregnancy is a normal event, generally involving regular physical assessments and counselling. O n l y if something during the course of the pregnancy goes wrong, or is expected to go wrong, is the pregnancy regarded as pathological. T h e main differences between the two services are to be found in the organisational structure. In the Netherlands normal deliveries can take place at home or in hospital, as the w o m a n prefers. In hospital it will be a 'short-stay delivery', similar to the 'domino birth' in Britain ( = D O M i c i l i a r y midwifery IN and Out) (Fry 1985). If the w o m a n opts for a short-stay delivery, she is obliged to pay a delivery room charge of about £120 {about 400 guilders) to the Sick Funds (Butter & Lapre 1986). 'At risk' women will be delivered in hospital. W o m e n who have given birth in hospital on medical (or social) grounds do not have to pay the delivery room charge, precisely because they are referred to hospital by doctors. About 50% of births take place in hospital following referral on medical or social grounds. Approximately equal numbers of births occur at home, in hospital on a short-stay basis and in hospital on a longer-stay basis--a ratio which has been tMrly stable over the last 6 years (CBS 1983; 1985a; 1985b). A w o m a n can in principle opt either to ask her general practitioner to provide maternity care, or go to a midwife or obstetrician, who will then be responsible for antenatal care, delivery and postnatal care. There are two main factors which serve to limit the choices of pregnant women. The first is financial. T h e Sick Funds will not reimburse the t~es for a GP if there is a midwife practising in the region, or for an obstetrician if the w o m a n has a normal pregnancy. Secondly, there are medical considerations. A w o m a n who is classified as being 'at risk' will normally be supervised by an obstetrician in a hospital, since the law forbids an independent midwife to attend her. For these women with a high-risk pregnancy the Sick Funds will, of course, reimburse the fees for an obstetrician. The standard of maternity care in the Netherlands is high. T h e figures for perinatal mortality Ere the same as in England and Wales, and in
179
Scotland (9.8 per 1000 births in 1985), although some people stress the fact that perinatal mortality rates are better in certain other industrial countries (Hoogendoorn 1986).
Midwives The midwife is one of the main figures in the organisation of the Dutch maternity services. In contrast with their British counterparts, Dutch midwives are not nurses, but autonomous 'obstetrical' practitioners. They spend 3 years in training at one of the country's three Colleges of Midwifery. These are in Amsterdam, R o t t e r d a m and Heerlen. T h e training is geared largely to childbirth, but also to identit}Ang high-risk women during antenatal care. Currently there is a shortage of places in the training schools for the n u m b e r of prospective students in the Netherlands. T h e income of most midwives consists of the fees they receive both t?om the Sick Funds and from private health-insurance companies. This means that they are financially independent. T h e y are self-employed, rather than salaried employees of a hospital, health centre or Sick Fund. T h e y are not regarded as part of the strictly medical services, and, in general, do not operate from a hospital, but from a private practice (which is the midwife's own house) or group practice. Doctors are also financially independent; in general, they receive their income in the same way as midwives. GPs also operate from a private practice or group practice. By contrast, obstetricians see people in hospitals. T h e head of the School of Midwit~ry in Amsterdam, M s J . Klomp, an obstetrician with a law degree, has written about the legal position of midwives in the Netherlands. She 'translates' the legal terms into the everyday reality of midwitkry, as follows: Antenatal care: midwives (a) are only allowed to deal with pregnant women, (b) should limit themselves to pregnancy-related phenomena, (c) m a y do preventive blood tests, (d) should give advice on a suitable diet, and (e) m a y alter the baby's position in the womb by external manipulation (Klomp 1985). Natal/inlrapartum care: midwives are allowed to
180
MIDWIFERY
HOSPITAL DELI'fERIES
C'/.)
100" L
95.
~
A
~
.
O
D
q
L
~
L
~
'
m
m
L
~
D
~
i fS
8O,
j=
°j. S°
60
/ /i
/
/
s.t
s/ ~,/. t"S" .i °
~S~
i
w
i
i;0
w
•
|
•
•
"f5
•
•
|
•
•
80
w
85
YEAR
.....
SCOTLAND - ENGLAND &
......
~
N~I"HER.~
Fig. 1 Percentage hospital deliveries in England and Wales, Scotland and the Netherlands (CBS 1978, 1983, 1985a, 1986a; OPCS 1985, 1987; SHHD 1986)
MIDWIFERY
take full responsibility for n o r m a l deliveries. T h e y can do episiotomies, a n d can stitch an episiotomy or a m i n o r tear, with or without local anaesthetics. I t is u p to the midwife to j u d g e whether an assisted delivery is necessary, in which case the midwife is obliged to call for a doctor. T h e Sick F u n d s ' rules allow them to bypass the G P in that case a n d go straight to an obstetrician. I f in an e m e r g e n c y the doctor or ambuJance seems likely to arrive too late, the midwife is allowed to intervene m a n u a l l y , but m a y not use obstetrical instruments. Postnatal care: midwives take care of the medical well-being of m o t h e r a n d baby, as long as no abnormalities occur. Again, as soon as problems are identified, the w o m a n must be referred to a doctor. A n t e n a t a l , natal a n d p o s t n a t a l care can be provided by different people. For instance, the midwife m a y u n d e r t a k e the a n t e n a t a l care, but m a y then have to refer the w o m a n to hospital d u r i n g labour, in which case the obstetrician takes over. I f after 2 or 3 days the w o m a n is sent home, the midwife continues with the p o s t n a t a l care. A n y o t h e r c o m b i n a t i o n of the three parts of p r e g n a n c y care is possible, t h o u g h continuity of care is r e g a r d e d as very i m p o r t a n t . G r e a t etibrts are m a d e to keep interruptions in continuous care to an absolute minimum." Midwives a t t e n d h o m e a n d hospital deliveries without supervision; however, on the whole they are not allowed to u n d e r t a k e assisted deliveries, unless an e m e r g e n c y occurs, or the w o m a n refuses to be referred to a d o c t o r (CBS 1986b). T h e limitations on w h a t midwives are allowed to do are connected with the legal obligation that all other a b n o r m a l i t i e s must be referred to a doctor. Some w o m e n retuse to go to a doctor a n d dem a n d to continue u n d e r the care of a midwife. This creates an a w k w a r d situation for the midwit~, who is c a u g h t b e t w e e n loyalty towards the w o m a n , her own m e d i c a l knowledge, a n d the law. A c c o r d i n g to K l o m p (1985), there is no universal solution to this p r o b l e m . She recommends that a midwife confronted with this situation should keep a record o f the opinions she has offered, a n d o f the discussion with the w o m a n a n d the reasons why the w o m a n refuses to be ret~rred to a doctor.
181
Maternity home helps I t m a y a p p e a r t h a t the i n d e p e n d e n t midwife in the Netherlands, when she is involved at all, has sole responsibility for m a t e r n i t y care. This is not the case. D u r i n g a short-stay hospital delivery she will be assisted b y (general) hospital nurses. A n d d u r i n g a h o m e birth she is usually assisted by a m a t e r n i t y h o m e help, who also assists the G P during a home confnement. M a t e r n i t y h o m e helps are the second key elem e n t in the D u t c h system. Like midwives, they are not trained as nurses. T h e y are engaged to look after the m o t h e r and b a b y tbr a p p r o x i m a t e l y 8 days tbllowing the birth. Currently, this occurs in over 70% of all births. Parents have to p a y a fee which varies from £ 4 a d a y tbr p a r t time h o m e help to £ 1 2 a d a y for full-time home help. T h e Sick F u n d s or private insurance companies p a y the rest of the costs which v a r y between £ 2 5 and £ 7 0 a d a y (Samuel 1986). M a t e r n i t y h o m e helps c a r r y out general household tasks, while also keeping an eye on the health of m o t h e r a n d child, and giving p r a c t i c a l advice on child care to the parents. M a t e r n i t y h o m e help t r a i n i n g consists of 4 months of formal training a n d a y e a r working u n d e r the g r a d u a l l y declining supervision of an experienced m a t e r nity home help. T h e i r residential training o f 4 months consists of learning: 1. H o w to assist a midwife at a home confinement. 2. H o w to recognise symptoms of b a d h e a l t h in the m o t h e r and baby. 3. H o w to look after a b a b y and other toddlers. 4. H o u s e k e e p i n g skills. 5. H o w to convey to parents various kinds of p r a c t i c a l advice e.g. a b o u t feeding the b a b y a n d c h a n g i n g nappies, a n d infbrmation concerning the b a b y ' s general health needs and so on (Van de Voorde; Dickhoff, personal communications). C o n t i n u i t y of care is r e g a r d e d as i m p o r t a n t . T h e m a t e r n i t y h o m e help organisations have a policy of ensuring that the same m a t e r n i t y h o m e help stays with a f a m i l y / m o t h e r a n d child for a b o u t 8 days.
182
MIDWIFERY
Due to cuts in the health services, radical changes are planned in the training of maternity home helps from 1988. Their specific training course is to be combined with the training for general home help (gezinszorg), caring for old people (bejaardenzorg), caring for children (kinderzorg) and caring for mentally handicapped people (zwakzinnigenzorg) (Rotterdams Nieuwsblad, 14 August 1986).
Social distance There is a substantial literature about the problem of social distance between doctors and patients in Britain (Steele & Morton 1978). Communication problems between patients and members of the medical profession, related to the social distance between the two groups, occur less frequently between midwives and pregnant women in the Netherlands (de H a a n & I m p e 1983). It is often easier for a w o m a n to ask questions of a midwife than of a doctor. Midwives are not regarded as doctors. T h e y do not wear uniforms during consultations and generally not during deliveries. T h e relationship is often less formal. I f the social distance between midwife and mother tends to be less than that which separates most women from members of the medical profession, the point often applies with even more force in the case of the maternity home help. She stays with the mother for about a week, usually 8 hours a day, pertbrming the tasks the w o m a n would otherwise be undertaking. There is virtually no question of social barriers in such a situation. As one obstetrician has remarked: "It is much easier for a w o m a n to ask a maternity home help when she can have sex again with her partner than it is to ask a doctor' (van Alten, personal communication).
Maternity services and financial constraints Nearly all Dutch obstetricians, GPs and midwives are entrepreneurs, whose income is ati~cted by their n u m b e r of patients. Their income m a y be affected by the medical decisions they make, especially when such decisions involve the refer-
ral of a client to another practitioner. While this may not be a strong influence, it can be a background factor in some decisions. In the Netherlands the three professions are in competition for a limited n u m b e r of deliveries to be attended. Although the competition is not entirely controlled by market forces, since there are too m a n y other influences at work for this description to be applicable, some notion of competitive feelings exists. T h e relatively low figure for GP deliveries is ultimately due to a 1941 Sick Fund Act, whose provisions have already been mentioned. T h e Sick Funds will not reimburse a GP's fee for a delivery if there is a midwife practising in that particular region. Since the Sick Funds cover over 70% of the population and there are midwives practising in all urban and m a n y rural areas, not very m a n y women can opt for a delivery attended by a GP. T h e Act protects midwives by guaranteeing them business, and limits the competition between them and GPs. GPs do attend deliveries of privately insured women whose private health insurance c o m p a n y will reimburse the GP's fee, and of those who pay the fee personally. In addition, some births in large cities are attended by GPs because no previous arrangements have been made. Competition between obstetricians and midwives, however, is often more intense. M a n y midwives complain that obstetricians seldom retkr a w o m a n back to them if she has once been sent to hospital for a consultation. Midwives sometimes say: "Every w o m a n referred to a obstetrician for a check-up means a patient lost' (Berendrecht & De Kroes-Suverijn, personal communication). Even if the obstetrician cannot find anything wrong s/he m a y well offer to oversee the remainder of the pregnancy. There are both financial and psychological reasons for this. Like the midwilh, the obstetrician is usually a self-employed person, and receives a fee for each patient from the Sick Funds or a private health insurance company. And if the midwife has referred a w o m a n as being 'at-risk', the obstetrician will tend to work from the assumption that this assessment is wellfounded. Even without having absolute certainty, it is satyr in a professional sense for the
MIDWIFERY obstetrician to keep an eye on the w o m a n , just in case. I n such a situation the obstetrician fills out a medical i n d i c a t i o n form to m a k e sure the Sick Funds will p a y the fees. T h e woman, a l r e a d y slightly worried because she has been required to consult an obstetrician, usually accepts this offer with relief, p a r t i c u l a r l y if it is backed up with arguments such as: 'Since you are here a n y w a y . . . ' or ' Y o u r notes are here now' or ' I t ' s better for your b a b y if you stay u n d e r my supervision'. I n this w a y the midwife can lose, perhaps unnecessarily, a customer to a p r a c t i t i o n e r higher up in the medical hierarchy. Obstetricians, on the other hand, sometimes c o m p l a i n t h a t midwives keep women too long under their supervision, resulting in too m a n y last-minute transfers. I n this situation the obstetrician m a y not have time for a thorough review of the w o m a n ' s medical history, the progress o f the p r e g n a n c y and so on. T h e opposite, however, is also known to occur. C o - o p e r a t i o n between midwives and obstetricians can be carried to extremes. Some w o m e n who clearly fall u n d e r the definition o f ' h i g h - r i s k ' in the N e t h e r l a n d s m i g h t not be referred by the midwife till the 28th week of pregnancy. T h e Sick F u n d pays a full a n t e n a t a l and confinement fee to the midwife if s/he has p r o v i d e d the a n t e n a t a l care up to week 28. A d d i t i o n a l l y , the obstetrician then receives the confinement fee for the actual delivery a t t e n d e d . T h e Sick F u n d s try to m o n i t o r the n u m b e r of 'unnecessary' referrals and the n u m b e r of d o u b l e p a y m e n t s of delivery fees. T h e y c a r r y out checks to limit i n a p p r o p r i a t e medical indications, a n d scrutinise the returns sent in by midwives with a p r o p o r t i o n a l l y high n u m b e r of certain medical indications, a n d by those with m a n y late referrals (after the 28th week).
Medical practitioners in the maternity services O f the three groups of professionals who work in the field of obstetrics in the Netherlands, midwives a n d GPs c a r r y out n o r m a l deliveries at home a n d in hospital and m a k e the 'high-risk/ low-risk' selection, while obstetricians take care
183
Table 1 Deliveries in the Netherlands 1984, by type of professional care (CBS 1985a, pp 1-2). Professional care
Hospital (%)
Home (%)
All births (%)
Doctor only Doctor and midwife Midwife only Unknown
44.3 00.6 18.9 00.1
12.5 00.1 23.4 00.0
56.8 00.7 42.4 00.1
Total
63.9
36.1
100.0
of the rest of the d e l i v e r i e s - - m o s t l y w o m e n with a b n o r m a l i t i e s in hospital. GPs are responsible fbr a p p r o x i m a t e l y 15% of all deliveries in the Netherlands, the m a j o r i t y of which are h o m e births. Midwives a t t e n d 4 2 % of all deliveries, 5 5 % of which are home births, while obstetricians take responsibility for a n o t h e r 4 2 % , all in hospital (CBS 1985a). Unfortunately, the official statistics on births in the N e t h e r l a n d s tail to m a k e a n y distinction between doctors who are GPs a n d doctors who are obstetricians. I n i n t e r p r e t i n g T a b l e 1, it is necessary to b e a r in m i n d that a small p r o p o r t i o n (about 4 % ) of hospital deliveries are attended by GPs. T h e division of the total a m o u n t of work between the three prot~ssions has c h a n g e d over the years. M i d w i v e s have m a i n t a i n e d their position, even increasing the percentage of births they a t t e n d over the last few years, while GPs have been left with a smaller a n d smaller share of a diminishing total n u m b e r of births over the last 30 years. Overall, however, it is the obstetricians who have m a d e the most substantial gains. I t is not only that a t t e n d a n c e percentages are differently d i v i d e d than they were I0 or 20 years ago, b u t also t h a t the m a r k e t itself is shrinking. T h e n u m b e r of live births has d r o p p e d li'om 254319 in 1964, to 187633 in 1974, a n d 175472 in'1984 (CBS 1985b; 1985c).
Working relationships between the three professions Midwives are not officially entitled to refer w o m e n to specialists. T h e y are obliged to send ,any p r o b l e m case to a GP. A l t h o u g h the G P will generally not do deliveries personally, it is for
184
MIDWIFERY
h i m / h e r to m a k e the referral, even if in practice this means only r u b b e r - s t a m p i n g the decision to refer. This does not, of course, a p p l y to emergency (last-minute) transfers during labour: in such a case, a midwife is allowed to by-pass the GP. T h e n a t u r e of the relationship between midwives a n d local GPs varies: in rural areas they compete with one another, while in u r b a n areas most GPs do not do deliveries, b u t refer the e x p e c t a n t mothers to the midwives. I n an u r b a n area, a w o m a n will generally go first to a GP, and will then be referred to a midwife. A l t h o u g h m a n y midwives complain a b o u t obstetricians in general, on the grounds that a midwif~ whose client goes to see a consultant rarely sees that w o m a n again, they seem to have a reasonably good relationship with the obstetrician they deal with personally. Moreover, there are examples o f o r g a n i s a t i o n s where obstetricians work with a positively helpful attitude towards i n d e p e n d e n t midwives. F o r example, Keirse describes good c o - o p e r a t i o n in Leiden between prim a r y a n t e n a t a l care and secondary a n t e n a t a l care (Keirse 1982).
Quality of care GPs are family doctors; delivering babies is not something they n o r m a l l y specialise in. H a l f of the GPs do not u n d e r t a k e any deliveries at all. T h e r e m a i n i n g h a l f do less t h a n 20 deliveries per y e a r on average (Butter & L a p r e 1986). T h e midwives are the specialists in n o r m a l childbirth. T h e m a j o r i t y of t h e m deliver between 100 and 200 babies a y e a r (Klinkert 1980). Obstetricians, as specialists, are responsible for women with abnormalities. These are the p r e g n a n t w o m e n with a higher risk, referred to t h e m by midwives and GPs. T h e y a t t e n d a fair n u m b e r of n o r m a l d e l i v e r i e ~ e n o u g h , most obstetricians say, to enable them to stay a w a r e of the norm. I n the end, m a n y w o m e n with high-risk pregnancies which are classified as needing hospital confinem e n t turn out to have n o r m a l deliveries. T h e a d e q u a c y of the referral system is the focus of much attention. Some 20 years ago the Sick F u n d s asked Professor Kloosterman, at that
time Professor of G y n a e c o l o g y a n d Obstetrics in A m s t e r d a m , to provide them with a list of all the medical indications for referring a p r e g n a n t w o m a n to an obstetrician (see Keirse 1982). T h e request was m a d e on financial/administrative grounds. I n cases of low-risk pregnancies they would reimburse only the midwife's or the G P ' s fee. O n l y in instances of high-risk pregnancies would they reimburse the fee of an obstetrician. L a t e r this so-called ' K l o o s t e r m a n list' was p u b lished in the m a i n D u t c h textbook on obstetrics, and b e c a m e the accepted medical guidelines for midwives a n d GPs. T o d a y the list is reviewed by leading obstetricians for every new edition of the textbook (Kloo~terman 1985). It is often r e g a r d e d as a d i s a d v a n t a g e that p r e g n a n t w o m e n in the Netherlands who are u n d e r the care of a midwife never see an obstetrician. M a n y people have argued that there should be the possibility o f consulting an obstetrician at least once d u r i n g every pregnancy, without the actual referral of the w o m a n from the midwife to the obstetrician. It is a r g u e d t h a t by doing so, the chance of late transfers m i g h t be avoided. However, transfer risks do not p o i n t unequivocally to hospital delivery for all. A l t h o u g h e v e r y b o d y argues that an e m e r g e n c y transtkr to hospital d u r i n g l a b o u r is something which should be avoided, some see it as a risk which is acceptable in a small c o u n t r y with a good r o a d network and a m b u l a n c e service (Van 't Oor, personal c o m m u n i c a t i o n ) , a n d a reliable referral process. T h e D u t c h policy regarding the m a t e r n i t y services is formed and guided by issues related to the home versus hospital debate. T h e Ministry of H e a l t h considers arguments for home deliveries as well as those for hospital deliveries. G o v e r n m e n t reports, such as Sikkel's, refer to m o r b i d i t y rates a n d psycho-social factors: for example, the involvement of the tRmily in the birth as an event, and the formation of a bond between m o t h e r and child (Sikkel 1979).
CONCLUSION D u t c h midwives have a certain professional independence, because of their financial i n d e p e n d ence. T h e i r training is separate from nursing
MIDWIFERY
training, a n d is geared towards n o r m a l birth a n d the high-risk versus low-risk selection. H o m e births are m a i n l y facilitated in the Netherlands by the existence of i n d e p e n d e n t midwives a n d m a t e r n i t y home helps. T h e relatively short distances between most homes and the nearest hospital, the good roads and provision of a m b u l a n c e services, also play a role. T h e three types of practitioners in the field of obstetrics (including GPs in so far as they do deliveries) are in competition with one a n o t h e r for clients. Midwives are protected by Sick F u n d s ' regulations which prevent m a n y pregn a n t w o m e n from opting for G P delivery. Obstetricians attend the high-risk women, and, in general, the GPs only attend deliveries in rural areas where no midwives practise. Midwives tend to complain of losing childbearing w o m e n unnecessarily to obstetricians. This may h a p p e n because of the 'business' competition between the financially i n d e p e n d e n t midwives a n d obstetricians. Each childbearing w o m a n represents a part of their income. Sick F u n d s regulations concerning the financing of the m a t e r n i t y services have a great impact on the organisation of those servic.es. These rules keep midwives i n d e p e n d e n t , limit the n u m b e r of deliveries attended by GPs, a n d indirectly limit the unnecessary hospitalisation of child birth. It is often regarded as a disadvantage that p r e g n a n t w o m e n who are u n d e r the care of a midwife never see an obstetrician in the Netherlands. M a n y people have argued that there should be an o p p o r t u n i t y to consult an obstetrician at least once d u r i n g every pregnancy, without the actual referral of the w o m a n from the midwife to the obstetrician. Whereas in Britain every pregnancy is considered to be potentially dangerous, as it is generally accepted by those working in the m a t e r n i t y services that a p r e g n a n c y is only normal in retrospect, in the Netherlands a clear distinction is made between w o m e n with a n o r m a l or abnormal pregnancy. T h e D u t c h midwives are u n d e r a legal obligation to identify a n d refer (potential) abnormalities, while retaining full responsibility for those with a n o r m a l pregnancy. I n contrast to Britain there is a tbrmal selection process which is part of the s t a n d a r d procedure. Thus, in the
185
Netherlands, the general principle of going to the doctor only when you are ill applies to p r e g n a n t w o m e n also. Moreover, women with a low-risk p r e g n a n c y do not have to go to hospital either. Even if they choose to have a short-stay hospital delivery they do not tend to regard themselves as o r d i n a r y patients, partly because they have to pay the delivery room charge. For p r e g n a n t women, the current p a t t e r n of organisation in the Netherlands allows continuity of care. A w o m a n deals with individuals rather t h a n institutions. It also gives the w o m a n a certain power as a client: since most medical practitioners are private entrepreneurs, she is able to say: 'I do not agree with your opinions or your methods, so I am going to a n o t h e r midwife or a n o t h e r obstetrician'. As a result, the attitude of midwives is very much one of doing what the w o m a n wants. O n e midwife put it this way: 'I do not care how a w o m a n wants to give birth, even if it is s t a n d i n g on her head, as long as I think it is safe for the baby. At the end of the day, I a m responsible for the health of the b a b y ' (Berendrecht, personal communication).
References Butter I, Lapre R 1986 Obstetrical care in the Netherlands: manpower substitution and differentialcosts. International Journal of Heahh Planning and Management 1:89 110 CBS (Centraal Bureau voor de Statistiek) 1978 pp 75 & 114. Perinatale Sterfte. Staatsuitgeverij,The Hague CBS 1983Vademecum GezondheidsstatistiekenNederland 1981 p 65. Staatsuitgeverij,The Hague CBS 1985aVademecum gezondheidsstatistiekenNederland 1983 p 69. Staatsuitgeverij,The Hague CBS 1985bGeborenen naar aard verloskundigehulp en plaats van geboortc 1984pp 1-3. Staatsuitgeverij,The Hague CBS 1985c 1899 1984VijfentachtigJaren Statistiekin Tijdreeksen, p 36. Staatsuitgeverij,The Hague CBS 1986a Maandbericht gezondheidsstatistiek,Jaargang 5 No. 9, pp 34-35. Staatsuitgeverij,The Hague CBS 1986bDiagnose-StatistiekZiekenhuizen1983 pp27 28. Staatsuitgcverij, The Hague de Haan H, Impe M van 1983 Hoe Bevalt Nederland? Het Spectrum, Utrecht FryJ 1985 Under-use of midwivesand others. Update: 401 Hoogendorn D 1986 Indrukwekkendeen tegelijk teleurstellendedaling van de perinatale sterfte in Nederland. Nedcrlands Tijdschriftvoor Geneeskunde130: 1436-1440
186
MIDWIFERY
Keirsc M J N C 1982 Interaction between primary and secondary antenatal care, with particular reference to the Netherlands. In: Enkin M & Chahners I (eds) Effectiveness and Satisfaction in Antenatal Care. Heinemann, London pp 222-233 KtinkertJ J 1980 Verloskundigen en Artscn, verledefl en heden van enkele professionele beroepen in de gezondheidszorg, Stafleu's Wetenschappelijke Uitgeversmaatschappij B V, Alphen aid Rijn, p 78 Kloosterman G J 1985 De Voortplanting van de Mcns. Leerboek voor Obstetric en Gynaecologie, 7th ed. Centen, Wcesp KlompJ 1985 De wettelijke bevoegheid van de verloskundige, Nederlands Tijdschrift voor Geneeskunde 129:2125-2128 Office of Population Censuses and Surveys 1985, Birth Statistics, Series FM1, Nos 12 & 13, OPCS, London Office of Population Censuses & Surveys 1987. 1985
Mortality Statistics: Perinatal and Infant, Series DH3 No 18. OPCS, London Rottcrdams Nicuwsblad, 14 August 1986, Kraamzorg gaat met de tijd mee Registrar General Scotland 1986, Annual Report 1985. HMSO, London Samuel A C M 1986 Kraamzorg verleend door de kraamcentra in het jaar 1984, Dutch Ministry of Health (Ministcrie van Welzijn, Volksgezondheid en Cultuur, Geneeskundige Hoofdinspectic v/d Volksgezondheid, Afdeling Moederschapszorg), Leidschendam, pp5 30 Sikkel A 1979 De Vcrloskundige Organisatie in Nederland (Verslag Werkgroep Verloskundige Organisatie), Ministerie van Volksgezondheid cn Milieuhygiene, Leidschendam, p 5 Steele S & Morton D 1978 A consumer based study to improve the treatment of patients in hospitals. King's Fund Project Paper No. 2. HMSO, London
© Longman Group UK Ltd 1987
Midwifery
The profession of m i d w i f e in the Netherlands Edwin van Teijlingen and Peter McCaffery
Community midwives in the Netherlands have a greater degree of autonomy in relation to the medical profession than do midwives in most countries. They are independent practitioners having full responsibility for providing continuous care for healthy women who are pregnant, and for conducting ante-natal assessments to ensure that those women with pathology are referred to hospital specialists. The midwives attend over 40% of all deliveries, more than half of which take place in the mother's home (the remainder being short-stay hospital births). General Practitioners (GPs) are precluded by health-insurance regulations from receiving payment for maternity care, except in rural areas where no community midwife is available. Midwives are assisted in home deliveries by maternity home helps, who also take on household tasks for mothers during the first few days. This service is used by more than two-thirds of all mothers, since it is also available after a hospital birth. Its availability helps to explain the continuing high percentage of home confinements in the Netherlands (36%). The Dutch system, giving midwives a high degree of responsibility and of financial independence, can give rise to tensions between midwives and obstetricians, but limits unnecessary medicalisation of childbirth.
INTRODUCTION This paper addresses the independent position of community midwives in the Netherlands. They are independent in both a medical and a financial sense, and this independence affects their attitudes towards their job, towards their clients and towards the place of confinement. It also has consequences for the midwives' relations with the other professions in the field of the maternity s e r Edwin van Teijlingen MA, Postgraduate student Peter i c C a f f e r y MA, DPhil, Lecturer Sociology Department, Aberdeen University, Old Aberdeen AB9 2TY
Manuscriptaccepted6 May 1987 (Reprint requests to PMcC).
178
vices. The Dutch way oforganising the maternity services has, of course, its own particular shortcomings.
DUTCH MATERNITY SERVICES Midwives in the Netherlands are in many ways in the same position as midwives in Britain. They work in a similar medical environment. The Dutch health services are financed by a public health insurance scheme, the Sick Funds, which covers the 70% of the population earning less than £14000p.a. (about 49 150 guilders). The remainder of the population are covered by private insurance companies. In both countries the basic philosophy behind
MIDWIFERY
the maternity services is that pregnancy is a normal event, generally involving regular physical assessments and counselling. O n l y if something during the course of the pregnancy goes wrong, or is expected to go wrong, is the pregnancy regarded as pathological. T h e main differences between the two services are to be found in the organisational structure. In the Netherlands normal deliveries can take place at home or in hospital, as the w o m a n prefers. In hospital it will be a 'short-stay delivery', similar to the 'domino birth' in Britain ( = D O M i c i l i a r y midwifery IN and Out) (Fry 1985). If the w o m a n opts for a short-stay delivery, she is obliged to pay a delivery room charge of about £120 {about 400 guilders) to the Sick Funds (Butter & Lapre 1986). 'At risk' women will be delivered in hospital. W o m e n who have given birth in hospital on medical (or social) grounds do not have to pay the delivery room charge, precisely because they are referred to hospital by doctors. About 50% of births take place in hospital following referral on medical or social grounds. Approximately equal numbers of births occur at home, in hospital on a short-stay basis and in hospital on a longer-stay basis--a ratio which has been tMrly stable over the last 6 years (CBS 1983; 1985a; 1985b). A w o m a n can in principle opt either to ask her general practitioner to provide maternity care, or go to a midwife or obstetrician, who will then be responsible for antenatal care, delivery and postnatal care. There are two main factors which serve to limit the choices of pregnant women. The first is financial. T h e Sick Funds will not reimburse the t~es for a GP if there is a midwife practising in the region, or for an obstetrician if the w o m a n has a normal pregnancy. Secondly, there are medical considerations. A w o m a n who is classified as being 'at risk' will normally be supervised by an obstetrician in a hospital, since the law forbids an independent midwife to attend her. For these women with a high-risk pregnancy the Sick Funds will, of course, reimburse the fees for an obstetrician. The standard of maternity care in the Netherlands is high. T h e figures for perinatal mortality Ere the same as in England and Wales, and in
179
Scotland (9.8 per 1000 births in 1985), although some people stress the fact that perinatal mortality rates are better in certain other industrial countries (Hoogendoorn 1986).
Midwives The midwife is one of the main figures in the organisation of the Dutch maternity services. In contrast with their British counterparts, Dutch midwives are not nurses, but autonomous 'obstetrical' practitioners. They spend 3 years in training at one of the country's three Colleges of Midwifery. These are in Amsterdam, R o t t e r d a m and Heerlen. T h e training is geared largely to childbirth, but also to identit}Ang high-risk women during antenatal care. Currently there is a shortage of places in the training schools for the n u m b e r of prospective students in the Netherlands. T h e income of most midwives consists of the fees they receive both t?om the Sick Funds and from private health-insurance companies. This means that they are financially independent. T h e y are self-employed, rather than salaried employees of a hospital, health centre or Sick Fund. T h e y are not regarded as part of the strictly medical services, and, in general, do not operate from a hospital, but from a private practice (which is the midwife's own house) or group practice. Doctors are also financially independent; in general, they receive their income in the same way as midwives. GPs also operate from a private practice or group practice. By contrast, obstetricians see people in hospitals. T h e head of the School of Midwit~ry in Amsterdam, M s J . Klomp, an obstetrician with a law degree, has written about the legal position of midwives in the Netherlands. She 'translates' the legal terms into the everyday reality of midwitkry, as follows: Antenatal care: midwives (a) are only allowed to deal with pregnant women, (b) should limit themselves to pregnancy-related phenomena, (c) m a y do preventive blood tests, (d) should give advice on a suitable diet, and (e) m a y alter the baby's position in the womb by external manipulation (Klomp 1985). Natal/inlrapartum care: midwives are allowed to
180
MIDWIFERY
HOSPITAL DELI'fERIES
C'/.)
100" L
95.
~
A
~
.
O
D
q
L
~
L
~
'
m
m
L
~
D
~
i fS
8O,
j=
°j. S°
60
/ /i
/
/
s.t
s/ ~,/. t"S" .i °
~S~
i
w
i
i;0
w
•
|
•
•
"f5
•
•
|
•
•
80
w
85
YEAR
.....
SCOTLAND - ENGLAND &
......
~
N~I"HER.~
Fig. 1 Percentage hospital deliveries in England and Wales, Scotland and the Netherlands (CBS 1978, 1983, 1985a, 1986a; OPCS 1985, 1987; SHHD 1986)
MIDWIFERY
take full responsibility for n o r m a l deliveries. T h e y can do episiotomies, a n d can stitch an episiotomy or a m i n o r tear, with or without local anaesthetics. I t is u p to the midwife to j u d g e whether an assisted delivery is necessary, in which case the midwife is obliged to call for a doctor. T h e Sick F u n d s ' rules allow them to bypass the G P in that case a n d go straight to an obstetrician. I f in an e m e r g e n c y the doctor or ambuJance seems likely to arrive too late, the midwife is allowed to intervene m a n u a l l y , but m a y not use obstetrical instruments. Postnatal care: midwives take care of the medical well-being of m o t h e r a n d baby, as long as no abnormalities occur. Again, as soon as problems are identified, the w o m a n must be referred to a doctor. A n t e n a t a l , natal a n d p o s t n a t a l care can be provided by different people. For instance, the midwife m a y u n d e r t a k e the a n t e n a t a l care, but m a y then have to refer the w o m a n to hospital d u r i n g labour, in which case the obstetrician takes over. I f after 2 or 3 days the w o m a n is sent home, the midwife continues with the p o s t n a t a l care. A n y o t h e r c o m b i n a t i o n of the three parts of p r e g n a n c y care is possible, t h o u g h continuity of care is r e g a r d e d as very i m p o r t a n t . G r e a t etibrts are m a d e to keep interruptions in continuous care to an absolute minimum." Midwives a t t e n d h o m e a n d hospital deliveries without supervision; however, on the whole they are not allowed to u n d e r t a k e assisted deliveries, unless an e m e r g e n c y occurs, or the w o m a n refuses to be referred to a d o c t o r (CBS 1986b). T h e limitations on w h a t midwives are allowed to do are connected with the legal obligation that all other a b n o r m a l i t i e s must be referred to a doctor. Some w o m e n retuse to go to a doctor a n d dem a n d to continue u n d e r the care of a midwife. This creates an a w k w a r d situation for the midwit~, who is c a u g h t b e t w e e n loyalty towards the w o m a n , her own m e d i c a l knowledge, a n d the law. A c c o r d i n g to K l o m p (1985), there is no universal solution to this p r o b l e m . She recommends that a midwife confronted with this situation should keep a record o f the opinions she has offered, a n d o f the discussion with the w o m a n a n d the reasons why the w o m a n refuses to be ret~rred to a doctor.
181
Maternity home helps I t m a y a p p e a r t h a t the i n d e p e n d e n t midwife in the Netherlands, when she is involved at all, has sole responsibility for m a t e r n i t y care. This is not the case. D u r i n g a short-stay hospital delivery she will be assisted b y (general) hospital nurses. A n d d u r i n g a h o m e birth she is usually assisted by a m a t e r n i t y h o m e help, who also assists the G P during a home confnement. M a t e r n i t y h o m e helps are the second key elem e n t in the D u t c h system. Like midwives, they are not trained as nurses. T h e y are engaged to look after the m o t h e r and b a b y tbr a p p r o x i m a t e l y 8 days tbllowing the birth. Currently, this occurs in over 70% of all births. Parents have to p a y a fee which varies from £ 4 a d a y tbr p a r t time h o m e help to £ 1 2 a d a y for full-time home help. T h e Sick F u n d s or private insurance companies p a y the rest of the costs which v a r y between £ 2 5 and £ 7 0 a d a y (Samuel 1986). M a t e r n i t y h o m e helps c a r r y out general household tasks, while also keeping an eye on the health of m o t h e r a n d child, and giving p r a c t i c a l advice on child care to the parents. M a t e r n i t y h o m e help t r a i n i n g consists of 4 months of formal training a n d a y e a r working u n d e r the g r a d u a l l y declining supervision of an experienced m a t e r nity home help. T h e i r residential training o f 4 months consists of learning: 1. H o w to assist a midwife at a home confinement. 2. H o w to recognise symptoms of b a d h e a l t h in the m o t h e r and baby. 3. H o w to look after a b a b y and other toddlers. 4. H o u s e k e e p i n g skills. 5. H o w to convey to parents various kinds of p r a c t i c a l advice e.g. a b o u t feeding the b a b y a n d c h a n g i n g nappies, a n d infbrmation concerning the b a b y ' s general health needs and so on (Van de Voorde; Dickhoff, personal communications). C o n t i n u i t y of care is r e g a r d e d as i m p o r t a n t . T h e m a t e r n i t y h o m e help organisations have a policy of ensuring that the same m a t e r n i t y h o m e help stays with a f a m i l y / m o t h e r a n d child for a b o u t 8 days.
182
MIDWIFERY
Due to cuts in the health services, radical changes are planned in the training of maternity home helps from 1988. Their specific training course is to be combined with the training for general home help (gezinszorg), caring for old people (bejaardenzorg), caring for children (kinderzorg) and caring for mentally handicapped people (zwakzinnigenzorg) (Rotterdams Nieuwsblad, 14 August 1986).
Social distance There is a substantial literature about the problem of social distance between doctors and patients in Britain (Steele & Morton 1978). Communication problems between patients and members of the medical profession, related to the social distance between the two groups, occur less frequently between midwives and pregnant women in the Netherlands (de H a a n & I m p e 1983). It is often easier for a w o m a n to ask questions of a midwife than of a doctor. Midwives are not regarded as doctors. T h e y do not wear uniforms during consultations and generally not during deliveries. T h e relationship is often less formal. I f the social distance between midwife and mother tends to be less than that which separates most women from members of the medical profession, the point often applies with even more force in the case of the maternity home help. She stays with the mother for about a week, usually 8 hours a day, pertbrming the tasks the w o m a n would otherwise be undertaking. There is virtually no question of social barriers in such a situation. As one obstetrician has remarked: "It is much easier for a w o m a n to ask a maternity home help when she can have sex again with her partner than it is to ask a doctor' (van Alten, personal communication).
Maternity services and financial constraints Nearly all Dutch obstetricians, GPs and midwives are entrepreneurs, whose income is ati~cted by their n u m b e r of patients. Their income m a y be affected by the medical decisions they make, especially when such decisions involve the refer-
ral of a client to another practitioner. While this may not be a strong influence, it can be a background factor in some decisions. In the Netherlands the three professions are in competition for a limited n u m b e r of deliveries to be attended. Although the competition is not entirely controlled by market forces, since there are too m a n y other influences at work for this description to be applicable, some notion of competitive feelings exists. T h e relatively low figure for GP deliveries is ultimately due to a 1941 Sick Fund Act, whose provisions have already been mentioned. T h e Sick Funds will not reimburse a GP's fee for a delivery if there is a midwife practising in that particular region. Since the Sick Funds cover over 70% of the population and there are midwives practising in all urban and m a n y rural areas, not very m a n y women can opt for a delivery attended by a GP. T h e Act protects midwives by guaranteeing them business, and limits the competition between them and GPs. GPs do attend deliveries of privately insured women whose private health insurance c o m p a n y will reimburse the GP's fee, and of those who pay the fee personally. In addition, some births in large cities are attended by GPs because no previous arrangements have been made. Competition between obstetricians and midwives, however, is often more intense. M a n y midwives complain that obstetricians seldom retkr a w o m a n back to them if she has once been sent to hospital for a consultation. Midwives sometimes say: "Every w o m a n referred to a obstetrician for a check-up means a patient lost' (Berendrecht & De Kroes-Suverijn, personal communication). Even if the obstetrician cannot find anything wrong s/he m a y well offer to oversee the remainder of the pregnancy. There are both financial and psychological reasons for this. Like the midwilh, the obstetrician is usually a self-employed person, and receives a fee for each patient from the Sick Funds or a private health insurance company. And if the midwife has referred a w o m a n as being 'at-risk', the obstetrician will tend to work from the assumption that this assessment is wellfounded. Even without having absolute certainty, it is satyr in a professional sense for the
MIDWIFERY obstetrician to keep an eye on the w o m a n , just in case. I n such a situation the obstetrician fills out a medical i n d i c a t i o n form to m a k e sure the Sick Funds will p a y the fees. T h e woman, a l r e a d y slightly worried because she has been required to consult an obstetrician, usually accepts this offer with relief, p a r t i c u l a r l y if it is backed up with arguments such as: 'Since you are here a n y w a y . . . ' or ' Y o u r notes are here now' or ' I t ' s better for your b a b y if you stay u n d e r my supervision'. I n this w a y the midwife can lose, perhaps unnecessarily, a customer to a p r a c t i t i o n e r higher up in the medical hierarchy. Obstetricians, on the other hand, sometimes c o m p l a i n t h a t midwives keep women too long under their supervision, resulting in too m a n y last-minute transfers. I n this situation the obstetrician m a y not have time for a thorough review of the w o m a n ' s medical history, the progress o f the p r e g n a n c y and so on. T h e opposite, however, is also known to occur. C o - o p e r a t i o n between midwives and obstetricians can be carried to extremes. Some w o m e n who clearly fall u n d e r the definition o f ' h i g h - r i s k ' in the N e t h e r l a n d s m i g h t not be referred by the midwife till the 28th week of pregnancy. T h e Sick F u n d pays a full a n t e n a t a l and confinement fee to the midwife if s/he has p r o v i d e d the a n t e n a t a l care up to week 28. A d d i t i o n a l l y , the obstetrician then receives the confinement fee for the actual delivery a t t e n d e d . T h e Sick F u n d s try to m o n i t o r the n u m b e r of 'unnecessary' referrals and the n u m b e r of d o u b l e p a y m e n t s of delivery fees. T h e y c a r r y out checks to limit i n a p p r o p r i a t e medical indications, a n d scrutinise the returns sent in by midwives with a p r o p o r t i o n a l l y high n u m b e r of certain medical indications, a n d by those with m a n y late referrals (after the 28th week).
Medical practitioners in the maternity services O f the three groups of professionals who work in the field of obstetrics in the Netherlands, midwives a n d GPs c a r r y out n o r m a l deliveries at home a n d in hospital and m a k e the 'high-risk/ low-risk' selection, while obstetricians take care
183
Table 1 Deliveries in the Netherlands 1984, by type of professional care (CBS 1985a, pp 1-2). Professional care
Hospital (%)
Home (%)
All births (%)
Doctor only Doctor and midwife Midwife only Unknown
44.3 00.6 18.9 00.1
12.5 00.1 23.4 00.0
56.8 00.7 42.4 00.1
Total
63.9
36.1
100.0
of the rest of the d e l i v e r i e s - - m o s t l y w o m e n with a b n o r m a l i t i e s in hospital. GPs are responsible fbr a p p r o x i m a t e l y 15% of all deliveries in the Netherlands, the m a j o r i t y of which are h o m e births. Midwives a t t e n d 4 2 % of all deliveries, 5 5 % of which are home births, while obstetricians take responsibility for a n o t h e r 4 2 % , all in hospital (CBS 1985a). Unfortunately, the official statistics on births in the N e t h e r l a n d s tail to m a k e a n y distinction between doctors who are GPs a n d doctors who are obstetricians. I n i n t e r p r e t i n g T a b l e 1, it is necessary to b e a r in m i n d that a small p r o p o r t i o n (about 4 % ) of hospital deliveries are attended by GPs. T h e division of the total a m o u n t of work between the three prot~ssions has c h a n g e d over the years. M i d w i v e s have m a i n t a i n e d their position, even increasing the percentage of births they a t t e n d over the last few years, while GPs have been left with a smaller a n d smaller share of a diminishing total n u m b e r of births over the last 30 years. Overall, however, it is the obstetricians who have m a d e the most substantial gains. I t is not only that a t t e n d a n c e percentages are differently d i v i d e d than they were I0 or 20 years ago, b u t also t h a t the m a r k e t itself is shrinking. T h e n u m b e r of live births has d r o p p e d li'om 254319 in 1964, to 187633 in 1974, a n d 175472 in'1984 (CBS 1985b; 1985c).
Working relationships between the three professions Midwives are not officially entitled to refer w o m e n to specialists. T h e y are obliged to send ,any p r o b l e m case to a GP. A l t h o u g h the G P will generally not do deliveries personally, it is for
184
MIDWIFERY
h i m / h e r to m a k e the referral, even if in practice this means only r u b b e r - s t a m p i n g the decision to refer. This does not, of course, a p p l y to emergency (last-minute) transfers during labour: in such a case, a midwife is allowed to by-pass the GP. T h e n a t u r e of the relationship between midwives a n d local GPs varies: in rural areas they compete with one another, while in u r b a n areas most GPs do not do deliveries, b u t refer the e x p e c t a n t mothers to the midwives. I n an u r b a n area, a w o m a n will generally go first to a GP, and will then be referred to a midwife. A l t h o u g h m a n y midwives complain a b o u t obstetricians in general, on the grounds that a midwif~ whose client goes to see a consultant rarely sees that w o m a n again, they seem to have a reasonably good relationship with the obstetrician they deal with personally. Moreover, there are examples o f o r g a n i s a t i o n s where obstetricians work with a positively helpful attitude towards i n d e p e n d e n t midwives. F o r example, Keirse describes good c o - o p e r a t i o n in Leiden between prim a r y a n t e n a t a l care and secondary a n t e n a t a l care (Keirse 1982).
Quality of care GPs are family doctors; delivering babies is not something they n o r m a l l y specialise in. H a l f of the GPs do not u n d e r t a k e any deliveries at all. T h e r e m a i n i n g h a l f do less t h a n 20 deliveries per y e a r on average (Butter & L a p r e 1986). T h e midwives are the specialists in n o r m a l childbirth. T h e m a j o r i t y of t h e m deliver between 100 and 200 babies a y e a r (Klinkert 1980). Obstetricians, as specialists, are responsible for women with abnormalities. These are the p r e g n a n t w o m e n with a higher risk, referred to t h e m by midwives and GPs. T h e y a t t e n d a fair n u m b e r of n o r m a l d e l i v e r i e ~ e n o u g h , most obstetricians say, to enable them to stay a w a r e of the norm. I n the end, m a n y w o m e n with high-risk pregnancies which are classified as needing hospital confinem e n t turn out to have n o r m a l deliveries. T h e a d e q u a c y of the referral system is the focus of much attention. Some 20 years ago the Sick F u n d s asked Professor Kloosterman, at that
time Professor of G y n a e c o l o g y a n d Obstetrics in A m s t e r d a m , to provide them with a list of all the medical indications for referring a p r e g n a n t w o m a n to an obstetrician (see Keirse 1982). T h e request was m a d e on financial/administrative grounds. I n cases of low-risk pregnancies they would reimburse only the midwife's or the G P ' s fee. O n l y in instances of high-risk pregnancies would they reimburse the fee of an obstetrician. L a t e r this so-called ' K l o o s t e r m a n list' was p u b lished in the m a i n D u t c h textbook on obstetrics, and b e c a m e the accepted medical guidelines for midwives a n d GPs. T o d a y the list is reviewed by leading obstetricians for every new edition of the textbook (Kloo~terman 1985). It is often r e g a r d e d as a d i s a d v a n t a g e that p r e g n a n t w o m e n in the Netherlands who are u n d e r the care of a midwife never see an obstetrician. M a n y people have argued that there should be the possibility o f consulting an obstetrician at least once d u r i n g every pregnancy, without the actual referral of the w o m a n from the midwife to the obstetrician. It is a r g u e d t h a t by doing so, the chance of late transfers m i g h t be avoided. However, transfer risks do not p o i n t unequivocally to hospital delivery for all. A l t h o u g h e v e r y b o d y argues that an e m e r g e n c y transtkr to hospital d u r i n g l a b o u r is something which should be avoided, some see it as a risk which is acceptable in a small c o u n t r y with a good r o a d network and a m b u l a n c e service (Van 't Oor, personal c o m m u n i c a t i o n ) , a n d a reliable referral process. T h e D u t c h policy regarding the m a t e r n i t y services is formed and guided by issues related to the home versus hospital debate. T h e Ministry of H e a l t h considers arguments for home deliveries as well as those for hospital deliveries. G o v e r n m e n t reports, such as Sikkel's, refer to m o r b i d i t y rates a n d psycho-social factors: for example, the involvement of the tRmily in the birth as an event, and the formation of a bond between m o t h e r and child (Sikkel 1979).
CONCLUSION D u t c h midwives have a certain professional independence, because of their financial i n d e p e n d ence. T h e i r training is separate from nursing
MIDWIFERY
training, a n d is geared towards n o r m a l birth a n d the high-risk versus low-risk selection. H o m e births are m a i n l y facilitated in the Netherlands by the existence of i n d e p e n d e n t midwives a n d m a t e r n i t y home helps. T h e relatively short distances between most homes and the nearest hospital, the good roads and provision of a m b u l a n c e services, also play a role. T h e three types of practitioners in the field of obstetrics (including GPs in so far as they do deliveries) are in competition with one a n o t h e r for clients. Midwives are protected by Sick F u n d s ' regulations which prevent m a n y pregn a n t w o m e n from opting for G P delivery. Obstetricians attend the high-risk women, and, in general, the GPs only attend deliveries in rural areas where no midwives practise. Midwives tend to complain of losing childbearing w o m e n unnecessarily to obstetricians. This may h a p p e n because of the 'business' competition between the financially i n d e p e n d e n t midwives a n d obstetricians. Each childbearing w o m a n represents a part of their income. Sick F u n d s regulations concerning the financing of the m a t e r n i t y services have a great impact on the organisation of those servic.es. These rules keep midwives i n d e p e n d e n t , limit the n u m b e r of deliveries attended by GPs, a n d indirectly limit the unnecessary hospitalisation of child birth. It is often regarded as a disadvantage that p r e g n a n t w o m e n who are u n d e r the care of a midwife never see an obstetrician in the Netherlands. M a n y people have argued that there should be an o p p o r t u n i t y to consult an obstetrician at least once d u r i n g every pregnancy, without the actual referral of the w o m a n from the midwife to the obstetrician. Whereas in Britain every pregnancy is considered to be potentially dangerous, as it is generally accepted by those working in the m a t e r n i t y services that a p r e g n a n c y is only normal in retrospect, in the Netherlands a clear distinction is made between w o m e n with a n o r m a l or abnormal pregnancy. T h e D u t c h midwives are u n d e r a legal obligation to identify a n d refer (potential) abnormalities, while retaining full responsibility for those with a n o r m a l pregnancy. I n contrast to Britain there is a tbrmal selection process which is part of the s t a n d a r d procedure. Thus, in the
185
Netherlands, the general principle of going to the doctor only when you are ill applies to p r e g n a n t w o m e n also. Moreover, women with a low-risk p r e g n a n c y do not have to go to hospital either. Even if they choose to have a short-stay hospital delivery they do not tend to regard themselves as o r d i n a r y patients, partly because they have to pay the delivery room charge. For p r e g n a n t women, the current p a t t e r n of organisation in the Netherlands allows continuity of care. A w o m a n deals with individuals rather t h a n institutions. It also gives the w o m a n a certain power as a client: since most medical practitioners are private entrepreneurs, she is able to say: 'I do not agree with your opinions or your methods, so I am going to a n o t h e r midwife or a n o t h e r obstetrician'. As a result, the attitude of midwives is very much one of doing what the w o m a n wants. O n e midwife put it this way: 'I do not care how a w o m a n wants to give birth, even if it is s t a n d i n g on her head, as long as I think it is safe for the baby. At the end of the day, I a m responsible for the health of the b a b y ' (Berendrecht, personal communication).
References Butter I, Lapre R 1986 Obstetrical care in the Netherlands: manpower substitution and differentialcosts. International Journal of Heahh Planning and Management 1:89 110 CBS (Centraal Bureau voor de Statistiek) 1978 pp 75 & 114. Perinatale Sterfte. Staatsuitgeverij,The Hague CBS 1983Vademecum GezondheidsstatistiekenNederland 1981 p 65. Staatsuitgeverij,The Hague CBS 1985aVademecum gezondheidsstatistiekenNederland 1983 p 69. Staatsuitgeverij,The Hague CBS 1985bGeborenen naar aard verloskundigehulp en plaats van geboortc 1984pp 1-3. Staatsuitgeverij,The Hague CBS 1985c 1899 1984VijfentachtigJaren Statistiekin Tijdreeksen, p 36. Staatsuitgeverij,The Hague CBS 1986a Maandbericht gezondheidsstatistiek,Jaargang 5 No. 9, pp 34-35. Staatsuitgeverij,The Hague CBS 1986bDiagnose-StatistiekZiekenhuizen1983 pp27 28. Staatsuitgcverij, The Hague de Haan H, Impe M van 1983 Hoe Bevalt Nederland? Het Spectrum, Utrecht FryJ 1985 Under-use of midwivesand others. Update: 401 Hoogendorn D 1986 Indrukwekkendeen tegelijk teleurstellendedaling van de perinatale sterfte in Nederland. Nedcrlands Tijdschriftvoor Geneeskunde130: 1436-1440
186
MIDWIFERY
Keirsc M J N C 1982 Interaction between primary and secondary antenatal care, with particular reference to the Netherlands. In: Enkin M & Chahners I (eds) Effectiveness and Satisfaction in Antenatal Care. Heinemann, London pp 222-233 KtinkertJ J 1980 Verloskundigen en Artscn, verledefl en heden van enkele professionele beroepen in de gezondheidszorg, Stafleu's Wetenschappelijke Uitgeversmaatschappij B V, Alphen aid Rijn, p 78 Kloosterman G J 1985 De Voortplanting van de Mcns. Leerboek voor Obstetric en Gynaecologie, 7th ed. Centen, Wcesp KlompJ 1985 De wettelijke bevoegheid van de verloskundige, Nederlands Tijdschrift voor Geneeskunde 129:2125-2128 Office of Population Censuses and Surveys 1985, Birth Statistics, Series FM1, Nos 12 & 13, OPCS, London Office of Population Censuses & Surveys 1987. 1985
Mortality Statistics: Perinatal and Infant, Series DH3 No 18. OPCS, London Rottcrdams Nicuwsblad, 14 August 1986, Kraamzorg gaat met de tijd mee Registrar General Scotland 1986, Annual Report 1985. HMSO, London Samuel A C M 1986 Kraamzorg verleend door de kraamcentra in het jaar 1984, Dutch Ministry of Health (Ministcrie van Welzijn, Volksgezondheid en Cultuur, Geneeskundige Hoofdinspectic v/d Volksgezondheid, Afdeling Moederschapszorg), Leidschendam, pp5 30 Sikkel A 1979 De Vcrloskundige Organisatie in Nederland (Verslag Werkgroep Verloskundige Organisatie), Ministerie van Volksgezondheid cn Milieuhygiene, Leidschendam, p 5 Steele S & Morton D 1978 A consumer based study to improve the treatment of patients in hospitals. King's Fund Project Paper No. 2. HMSO, London