From 1980 to 2009, the Dutch maintained a homebirth rate of 30–35%. Between 2009 and 2012, that rate fell to 23% (and the Dutch cesarean rate rose from 12% to 16%). While this homebirth rate remains remarkably high compared to other developed nations, the steep and recent decline is nevertheless a troubling development. Not only is the turn toward hospital birth overloading the obstetric departments in Dutch hospitals, more importantly, it is threatening the widely admired autonomy of Dutch midwives. The reasons for this decline in homebirths in the Netherlands are many and varied; we will address the most salient ones.
Reason #1: Culture Change
The turn away from homebirth is not the result of the restructuring of the health care system. Although the government adopted a more market-based approach to health care in 2006 (who.int/health_financing/documents/dp_e_07_3-new_dutch_healthinsurance.pdf), policy with regard to place of birth has not changed in any significant way in the past half-decade. Rather, it is cultural change that is driving the move from home to hospital.
The German poet Heinrich Heine is purported to have said, “If the world should end, I will move to the Netherlands, because everything there happens 50 years later.” Some believe that this pattern of Dutch conservatism is now playing its course in maternity care—that the Netherlands has finally arrived where most countries were in the mid-20th century. Formerly a nation of farmers, fishermen and traders characterized by the saying, “Just be normal, that is already crazy enough,” the Dutch are becoming just as technocratic as the rest of us. A new generation of Dutch women includes many who are convinced of the benefits of hospital birth (including epidurals) and a new generation of Dutch midwives includes many who want to work on shift in hospitals for the regular hours and the regular pay.
Two changes, both of which have to do with women’s roles in the labor market, have been particularly important: increasing numbers of mothers working in paid labor (cbs.nl/nl-NL/menu/themas/arbeid-sociale-zekerheid/cijfers/extra/werkende-moeders.htm) and the movement of midwives from solo to group practices, with 79.5% of all practices consisting of three or more midwives (NIVEL 2011).
As women move away from homemaker to paid labor, the idea of a cozy birth in their home no longer fits easily into their lives—better to birth in a hospital where pain relief is available and where someone else can do all the preparation, care and clean up. Meanwhile, midwives—members of a historically overworked profession—have been seeking (reasonably) to have more predictable lives, making group practice or salaried work in a hospital a logical choice. Independent, autonomous Dutch midwives who specialize in homebirth have always been overworked. Their current normpraktijk (the number of births a midwife must attend in order to earn her full salary) is 105 per year—quite a lot, but down significantly from the 160 they were required to attend in the 1990s. (A midwife can choose to limit her caseload if she is willing to accept a lower salary, but most are not.) Group practice does, in fact, make a midwife’s life more predictable, but it disrupts the relationship between caregiver and client, breaking the intimate connection between a pregnant woman and her midwife that used to be a strong point of homebirth.
Reason #2: Media Sensationalism
These cultural trends away from home and toward hospital birth were accelerated by media reports summarizing epidemiological and clinical studies of the performance of the Dutch maternity care system. In 2008, Peristat reported that the perinatal mortality rate (PNMR) in the Netherlands (10.2/1000) was twice as high as the surrounding countries in Europe; higher, in fact, than all the other countries that participated in the study with the exception of France. Two years later, a study done in the Utrecht area concluded that the infants of healthy women who began their labors with midwives “had a significantly higher risk of delivery-related perinatal death than did infants of pregnant women at high risk whose labour started in secondary care under the supervision of an obstetrician” (Evers et al. 2010).
In both of these cases, the media, not known for handling the nuances of scientific studies and statistical analyses, published sensational stories making the unsubstantiated link between these results and the relatively high rates of homebirth in the Netherlands. Headlines around the country criticized the “medieval” Dutch system, blaming the observed high PNMR on homebirth. The media failed to note that France, where nearly all births are in the hospital, had higher mortality rates, or that different countries in the Peristat study used different gestational ages for defining mortality (from 22 to 28 weeks gestation), or that the Utrecht study authors used mismatched data sets to draw their conclusions.
Researchers in Amsterdam tried to reproduce the Utrecht study, but soon discovered that the forms reporting where labor began were inconsistent and untrustworthy. Nevertheless, one of the researchers reported in the Dutch medical journal Medisch Contact that it seemed that his team was finding the same thing as was found in Utrecht. Other members of the team were upset that their colleague came to this preliminary and unjustified conclusion. (The research team is now painstakingly reviewing each case by hand and their study has not yet been published.)
Other researchers, before and after the Utrecht study, have found that neither homebirth nor transports from home to hospital explain the high PNMR. The de Jonge study (2009) reviewed hundreds of thousands of births and found no difference in perinatal mortality between home and hospital. Other studies pointed to the real reasons for the Dutch PNMR, showing that these deaths were largely occurring in planned hospital births for reasons like socio-economic disparity (worse outcomes for immigrants) and changes in the health of the population. (See, e.g., De Graff et al. 2008; Tromp et al. 2009)
But the media damage had been done. Both pregnant women and midwives got scared. Homebirth rates dropped steadily, and midwives’ referral rates to gynecologists (the Dutch use the term gynecologist to describe the medical specialist who provides care at “pathological” births) for primips under their prenatal care rose to 60% and to almost 50% for primip referrals for birth (13% for multips) (Rafael van Crimpen, Director of the Academy for Midwifery in Maastricht, av-m.nl/avm/symposia-amp-congressen#.UHZzisXZbqU).
Reason #3: OB Embarrassment
It seems that at least some Dutch gynecologists are embarrassed by the persistence of homebirth in the Netherlands. The older generation of Dutch gynecologists (many of whom were not fond of high-tech approaches to birth) who were proud of the high homebirth rate and worked hard to support midwives and normal, physiologic birth (including the renowned Dr. Kloosterman) have, for the most part, retired or died—a huge loss for Dutch midwives. The younger gynecologists, traveling to international conferences, are tired of getting criticized for their “premodern” birth system and eager to catch up with the latest technologies.
Reason #4: Community Hospital Closings
In an effort to promote more cost efficiency, the Dutch government has been closing many small maternity hospitals in communities around the country, which is part of a larger move toward marketing Dutch health care that began in 2006 in an effort to use market forces to hold down rising costs. (Unfortunately, costs have continued to rise and the Netherlands now has the distinction of having the highest per capita health costs in Europe; see zorgvisie.nl/nederland-een-van-de-landen-met-de-hoogste-zorgkosten-zvs014917w/.)
Many women in the Netherlands believe that it is not legal to give birth at home if the home is more than 30 minutes away from a hospital. That isn’t actually true—it is a guideline, not a law, but many parents think it is the law (and midwives act as if it were a law even if they know better). So when a local community maternity hospital is closed, women think they must give birth in the large tertiary care hospital even if they wanted to birth at home. Even if the mother is aware that she still has the right to a homebirth, she might not be able to find a midwife to attend her, because some midwives are not willing to take the risk of a longer distance to the hospital, especially in rural areas, nor to risk a negative reaction from gynecologists for taking on such a birth.
Reason #5: Rising Referral Rate
Hermine Hayes-Klein, a lawyer and the organizer of the recent (June 2012) conference in The Hague on human rights in childbirth, notes that midwives’ rising rates of referral of their clients to doctors during both pregnancy and labor stem from an ever-increasing list of indications. She writes:
This is the weakest point of current Dutch midwifery: the media can say, “50% of homebirths end up in the hospital!” And the public has the impression that this is because birth is so dangerous and unpredictable. But the studies show (Marianne Amelink-Verburg’s thesis is a priceless resource for all things Dutch midwifery) that, as the rates of referral have increased, the reasons for referral have shifted. In Kloosterman’s time, referrals were more likely to be made for reasons like postpartum hemorrhage or fetal distress, etc. The rate of referral has risen with the increase of a new set of reasons; during pregnancy, that includes “medical history” (previous cesarean, which occurs with greater frequency as the cesarean rate rises); during labor, significant referral increases have occurred for failure to progress and “needs pain relief.” Dutch midwifery student leader Marjolein Faber (2012) homes in on this issue, pointing out that what’s needed in those “needs pain relief” moments is an aspect of midwifery care that is left out of Dutch midwifery education and has to do with intimacy/love/warmth, etc. (Hayes-Klein, personal communication)
Both the Midwifery Academies and the Royal College of Midwives in the Netherlands (KNOV) see midwifery primarily as a medical profession that focuses on detecting variations of normal and actual abnormalities, and referring care accordingly (verloskunde-academie.nl/VerloskundeStuderen/detail/HBO-Bachelor-verloskunde; knov.nl/knov/waar-staan-wij-voor/missie-en-visie/). They tend to downplay the multidisciplinary supportive health care provider role of the midwife, which focuses on improving neonatal and maternal health in both the short and long terms. The current Dutch midwifery system (of big group practices and high caseloads) and the educational programs (more focused on research and evidence-based medicine than on non-medical midwifery skills) do not leave much space to create and build the intimate relationship between mother and midwife that is beneficial during childbirth.
An important consequence of the high referral rate due to the increasing “need for pain relief” and “failure to progress” is that it deprives both midwifery students and today’s young midwives of experience of and exposure to the variations of normal childbirth and homebirth.
With their current educational policies, the midwifery academies do not guarantee this exposure, as Dutch midwifery students need to attend only eight homebirths out of a total of 60 births in order to graduate. Many students end up having much more experience in the hospital/medical setting than at home. Thus, it is not surprising that valuable midwifery knowledge is gradually lost, while lack of out-of-hospital experience is likely to further increase the referral rate and result in a vicious cycle as the homebirth rate continues to decrease.
New, Positive Developments: Ongoing Desire for Homebirth, and the Rise of Doulas and Birth Centers
All is not lost! Het Ouderschap, a Dutch parenting association, questioned 1000 mothers about their experiences before, during and after childbirth. Although this was not a scientific study (parents were asked to respond to a survey on a website), 80% of their respondents wanted to preserve the unique freedom of choice for place of birth that is found in the Netherlands and a significant majority (60%) of the mothers preferred homebirth if they are given a choice (as a result of a desire to be accompanied by the same trusted person throughout birth). Only 11% would prefer a hospital birth under the supervision of a gynecologist.
It is important to point out that the attitude of Dutch midwives toward homebirth is and has long been very different from that of American homebirth midwives, who go to the home when called, often early in labor, and settle in for the duration. For Dutch midwives, this is molly-coddling, not part of the “just be normal” culture of the Netherlands. Dutch homebirth midwives with busy practices expect their clients to get along on their own during early labor; when called, they stop by to check in, then proceed with their multitude of daily pre- and postnatal exams, expecting the mother to simply “get on with it” and call them when birth is imminent.
Yet a new generation of Dutch homebirthers, perhaps influenced by films and stories of homebirth in the United States and elsewhere, are no longer content to “just be normal”—they want to be molly-coddled!
There have been two responses to this new demand. In some places, the Dutch have started to train the kraamverzorgende—women who are trained to take care of the family after birth and whose care, up to 40 hours spread over eight days, is covered by insurance (Zwart 2002)—as doulas who can go to the home when labor begins and simply be with the laboring mom until it’s time to call the midwife. In other places midwives themselves offer this more attentive care, but charge an additional fee for this service (since it necessarily limits the size of their case load).
Neither solution is ideal. The use of kraamverzorgende as labor doulas is still in an early stage. Many mothers have not met these doulas in advance and are not sure they really want them around. Furthermore, the midwife herself has to call the doula while the mother is in early labor at home, and many midwives (unused to this new possibility) do not make that call, so the couple is left alone until the midwife has time to come and stay with them. The “private midwife” concept is attractive, but is a choice limited to women with resources enough to pay for the special service.
Another new development in the Netherlands is the construction of birth centers around the country to fill the gap created by the closing of so many small community maternity hospitals. The idea here is to create a space for the protection of physiological birth, a place that will appeal to women who no longer wish to birth at home or believe they can’t because they are too far away from a hospital, and that will avoid the temptation to intervene so prevalent in hospital birth (BECG 2011).
Most of the new birth centers are located inside or very near to the large hospitals, and they are, for the most part, staffed only by autonomous homebirth midwives (not by midwives used only to working in hospital, who are generally not as independent-minded nor as supportive of physiological birth as midwives who regularly attend homebirths). Yet if the hospital is overcrowded (as many often are due to the recent drop in homebirth rates), the birth center near or inside the hospital can’t admit new clients because there is no room to receive transfers from birth center to hospital—another new problem in need of a solution, which will probably entail the construction of larger hospitals or the expansion of existing ones. Dutch gynecologists admit freely that if homebirth in their country vanished tomorrow, the hospitals would be completely overwhelmed.
Changes in Dutch Midwifery Education and Robbie’s Talks at the Midwifery Programs
In tandem with all the above, Dutch midwifery education, long held apart in four-year vocational schools for midwives under the supervision of the Ministry of Health, has recently been moved into Hogescholen, under the supervision of the Ministry of Education. Hogescholen are best understood as technical universities that educate accountants, physiotherapists, social workers and the like. Graduates receive a bachelor’s degree. The effort here is to upgrade midwifery education—the faculty at each of the four schools includes a “midwifery science” research group, intent on doing research that supports physiologic birth—and to generate PhDs capable of promoting and protecting independent midwifery (DeVries et al. 2011). Some midwifery students and faculty feel that in the move to the Hogescholen, focus on the hands-on skills and physical intimacy with laboring mothers has been lost (as Hermine mentioned above).
Upon learning this news at the June conference in The Hague, and with the enthusiastic and efficient help of Marjolein Faber who is co-authoring this article, Robbie spent a week in the Netherlands in early September 2012 to speak at the midwifery departments in Amsterdam, Rotterdam and Maastricht in order to do her best to issue a wake-up call to students and faculty. The talk she gave at all three schools was “Daughter of Time: The Postmodern Midwife.” Her main point was that the Dutch system was never a premodern vestige of the past, but rather a postmodern vanguard of the future that birth activists around the world have long looked to as the best model in the world and therefore should be preserved for the future, not abandoned because of its connections to the past.
When you are in the middle of living, studying and teaching, it is often hard to step back and take an overview. An outsider like Robbie can provide that overview, and it did seem that both students and faculty heard her message. The feedback was great—apparently, they did feel inspired to preserve their system! (For that moment at least. We all need to do our best to help them.)
The REDTENT Events: Creating a Shift in Midwifery Education
Robbie’s lectures were part of the REDTENT Events that Marjolein started to organize in 2011. Marjolein is a midwifery student who consciously chose to leave medical school in order to become a midwife. Attending several extra-curricular lectures and workshops on how to support the normal physiology of birth broadened her midwifery knowledge and solidified her holistic personal views on midwifery and health care in general. Realizing that this valuable knowledge was not being taught at the midwifery academies and that most students couldn’t attend such workshops due to financial and time restrictions, she started organizing events that were relatively short and affordable. She envisioned starting a dialogue between the different midwifery professionals, clients and students on an equal level.
The REDTENT Events mission is to broaden and deepen knowledge about physiological birth by bringing together everyone who is active and interested in midwifery care. Whether you’re a student or teacher, midwife or doctor, doula or nurse, pregnant woman or father-to-be, everyone is welcome. The events are about sharing each other’s experiences, knowledge, wisdom and questions. The students are invited to introduce topics in which they are interested and feel are being neglected in their formal training. This empowers them by giving them a voice in their path of becoming a midwife.
The topics covered at these events have included waterbirth, shoulder dystocia, homeopathy, human rights in childbirth, hypnotherapy, birthing positions and midwifing death—all these and more have been addressed. The monthly events inspire many attendees. Marjolein is currently expanding the REDTENT Events not only to include all midwifery academies across the country, but also to build bridges towards the medical establishment. This grassroots foundation is at the foreground of a shift in Dutch midwifery education, which will hopefully facilitate much-needed change in the Dutch midwifery system as a whole.
A New Birth Movement in the Netherlands
During her week giving talks in the Netherlands (September 2012), Robbie was delighted to be invited to speak at a meeting in Amsterdam of a relatively new Dutch group called The Birth Movement. The group has around 500 members (including many senior and student midwives, doulas, and activists) who are dedicated to preserving the best of the Dutch system and taking it forward. Fascinatingly, the talk they wanted Robbie to give to them was on “Renegade Midwives.” Robbie had mentioned that phenomenon in passing during her student/faculty talks, and some midwives (having never heard the term before) immediately glommed onto it and identified themselves as renegades (a midwife who puts the interests and desires of the woman above those of the profession) and wanted to know more about American renegade midwives!
The Good News
So, dear Midwifery Today readers, we urge you all to track new developments in the Netherlands and to do anything you can to support Dutch midwives and mothers. The good news is very good: a cesarean rate of 16% (yet rising), a homebirth rate of 23.4%, epidurals still the exception rather than the norm (9.8% in 2008, now rising yet slowly), induction levels still extremely low (15.5% in 2008, again rising yet slowly) and the PMNR has decreased to 9.2/1000 (calculated from 22 weeks) and 4.8/1000 (calculated from 28 weeks) (Stichting Perinatale Registratie Nederland 2011). In short, the Dutch obstetric system is still vastly better at supporting normal, physiologic birth than those in all other developed countries, so there is lots of hope for the preservation and improvement of this long-standing exemplary model!
Our thanks to Hermine Hayes-Klein, Thea van Tuyl and Laura van Deth for their very helpful improvements to this update.
Dear MT readers, if any of you have suggestions for improvements to this article, please e-mail them to Robbie at firstname.lastname@example.org.
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