Sunday, January 06, 2008

Dutch midwifery

Homebirth advocates often tout the Netherlands as an example homebirth midwifery in action. They don't realize that Dutch midwifery is nothing like American homebirth midwifery.

A fundamental assumption of American homebirth midwifery is that birth is "not an illness" and complications are rare; neither hospital backup nor emergency transport is arranged in advance. In contrast, the Dutch system assumes that a significant number of high risk situations will develop in advance and during the actual birth. Therefore, strenuous efforts are made to identify potential complications and transfer care to obstetricians. Since it is assumed that serious complications will during attempted homebirths, an elaborate system for transfer of care and physical transfer of the patient to the hospital has been developed.

In a book chapter entitled Challenging Normality: Dutch Obstetric Science, Raymond De Vries explores the Dutch midwifery system. De Vries is a medical sociologist and a strong proponent of the Dutch system. Nonetheless, he chides American midwifery advocates for misunderstanding and misrepresenting the system.
Perhaps because of its peculiarity, the maternal care system of the Netherlands is often misrepresented... [M]any articles about birth in the Netherlands written by non-Netherlanders contain errors of fact and tone. For example, Mehl-Madrona and Mehl-Madrona, writing in 1993, claim that "over 70 percent of births are still attended by midwives." In fact, midwives attended about 46 percent of births in both 1992 and 1993... [A]t no point in the twentieth century did they attend more than 60 percent of overall Dutch births... In her ethnographically based discussion of the lessons of Dutch obstetrics for Americans, Rothman sets the scene by discussing windmills, tulips, bicycles and Rembrandt, giving her readers over-romanticized pictures of Dutch midwifery and Dutch society. Her description of the Netherlands as a "Mecca for Midwives" and the home of noninterventive obstetrics makes it difficult to believe that Dutch midwives once argued for the right to wield forceps or that Dutch midwives are beginning to outfit their offices with the apparatus for sonograms.
The care of pregnant women in the Netherlands is divided between midwives, obstetricians and general practitioners. Dutch midwifery is highly regulated.
The preference for primary care in Dutch obstetrics rests on a generally accepted screening system for identifying "physiological" and "pathological" pregnancies. The "obstetric indications list"... defines the conditions that require midwives and general practitioners to refer their clients to specialists. The list allows the Dutch to avoid the assumption made in most other industrialized countries that all births are potentially high risk and, therefore, must be monitored by specialists.
However, implicit within the guidelines is the understanding that many births can and will become high risk and that provision must be made for quick efficient transfer of care. Moreover, although the midwife makes the determination of need for referral, the required indications have been clearly spelled out.

A recent paper in the BJOG describes the system in greater detail. According to Evaluation of 280 000 cases in Dutch midwifery practices: a descriptive study:
The Dutch obstetric system is well known for its relatively large percentage of planned home deliveries. Approximately 30% of Dutch babies are born at home. This percentage has remained stable over the past 10 years.

The possibility of giving birth at home stems from the organisational model of midwifery care in The Netherlands. A distinction is being made between women with a low risk of pathology and those with a high risk. Early in pregnancy, women enter into the system at the primary care level. Early pregnancy care is primarily being delivered by an independently practising midwife ... If complications occur or threaten to occur, the midwife refers the woman to an obstetrician at the secondary or tertiary care level. Therefore, the woman no longer has the choice of a home birth...

The agreements for collaboration between the professional groups have been specified in the Verloskundig Vademecum (Obstetric Manual). This document includes a list of obstetric indications for referral from primary to secondary care, based on best evidence or on consensus.
The Dutch are particularly cognizant of the need for timely transfer if an emergency should occur during an attempted homebirth. An elaborate transfer strategy has been developed:
A possible disadvantage of referral during home delivery is the time lost in travel to the hospital. The Netherlands is a very densely populated country where the average distance to hospital is relatively short... A local study (Amsterdam) showed that 85% of the urgent obstetric referrals arrived in the hospital within half an hour
after the reporting. We estimate that the time it takes a woman to get to the hospital from her home is, in the majority of women, roughly equal to the time it takes to mobilise the necessary specialists in the hospital. In emergencies at home, the midwife will be able to apply certain remedies themself, such as the administration of an intravenous infusion or the provision of basic life support.
Another substantive difference between Dutch midwifery and American homebirth midwifery is that Dutch midwives are trained in a 4 year program that prepares them to practice in the hospital or in the home. Indeed, women who qualify for midwifery care can pick where they wish to be delivered and they will be delivered by the same midwife regardless of place. Dutch midwives are trained in recognizing and managing complications. American direct entry midwives have little training and no experiencing in recognizing and managing complications.

If the Dutch midwifery system were transplanted to the US, the rate of homebirths would rise, but the women who are currently certified as DEMs would not be qualified to work in the system. They would need years of training to be competent to provide the level of care (in hospital and home) that the Dutch expect. The American DEM philosophy of assuming that complications will not occur will go by the wayside. A strict system of monitoring for risk factors would be introduced and care transferred to obstetricians if those risk factors were identified. The Dutch midwifery system offers care that is highly regulated, depends on risk identification and employs midwives who are medically trained.


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