Article on Dutch model of care

I found this when hunting about on homebirth. It's pretty long, so i'll just cut and paste a few bits to illustrate the tone of it.

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

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

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

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

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

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

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

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

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

This attitude towards pain is crucial to the way birth is handled in Holland by the midwife and the obstetrician. It is well understood that if a drug is given for the pain it will harm the baby and we tell women this very clearly.

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It really is an amazing insight. Dutch women are not OFFERED epidural and thus don't NEED epidural, unless they have to be sectioned. Very interesting and inspiring. There's a wonderful birth story later on about an american woman birthing in the Netherlands and her journey without epidural (which she calls for at one point).

Bec

So, has anyone had time to check this out yet?

Any thoughts?

It amazes me how frank this system is, that people are informed how dangerous drugs during labour can be (i mean, it is true, nothing, even entonox, is completely harmless), how women all just know labour is normal and how the midwife leaving them between establishment of active labour and commencement of pushing gives women confidence. It seems to me Dutch women are truly empowered in birth, they are not told they need medical help when they do not, and they are not offered things they don't need. It seems so much more useful somehow, not to be given choices over things you don't need when it's hard to make ANY decisions. Even i, at home, was offered (and took) entonox which i wouldn't have asked for and really could have coped without.

Bx

this is great!
i think it shoud be put in the pg section so all the (newly pg ones) have some thing to think about!!
and i just wish it was like it here!!

I didn't see this when you originally posted Bec - i think it's amazing how different the care of pregnancy and birth is between two seemingly similar countries (socio-economically speaking) - it really is something that the governmernt needs to address over here (and possibly in the UK - not sure how bad it is over there!) - there needs to be a shift in seeing birth as a natural progression of pregnancy and not an illness that needs to be medicalised!

I wonder how old the article is, Bec?

the article was from 1999

I find this really interesting. A friend of mine has just returned from the netherlands to Aust to have her bub because she was so underwhealmed with the care that she was receiving over there. I really should ask her what in particular it was about her care that she wasn't happy with but I figure that it must have been quite serious to make her come home.

I have two aquaintances Taffy who went back to the US to have their bubs from the Netherlands because they felt the system was barbaric - the women aren't offered pain relief routinely at home and depending on whether they have midwife or Ob care in hospital they might not be offered it then either. A German friend told me yesterday that as far as she knows the model is basically the same - epidural is still only offered for surgery, never for vaginal birth. THey use local for episiotomies, but they don't give the mother systemic pain relief for the normal sensations of labour. THe thing is though, Dutch women don't EXPECT pain relief, they don't think they'll need it, they aren't brought up to think it is unbearably painful and so for them it isn't. I think it's so interesting how perceptions of things are so deeply culturally routed.

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The obstetricians were silenced as it was shown that much of their research supporting hospital births was of very poor quality, when it was clear that the system of screening and birth in Holland was in fact outstanding.

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WOW! The same could definitely be said of the studies our governments act on in maternity and obstetrics, but these are not discredited - why?

I just find the whole Dutch system is so HONEST. Women aren't told they won't be able to cope with pain or birth, women aren't forced to have uneccesary medical involvement. In America, especially because of medical insurance paying for everything, Obs push every possible intervention onto women because of money - it is TRUE that all drugs given in labour increase risk to baby and mother and the Dutch system makes everyone properly aware of this and reminds them if they ask (when i homebirthed i had MORPHINE in my fridge - imagine having to go to see an Ob just to have a shot of pethidine!) but it's not talked about because we don't want to make people feel bad for using drugs during labour. But that is so unfair because we basically mislead women - we tell them their whole lives they WILL need pain relief and then when they predictably do we gloss over the risks and so often it's the women and their families who are left picking up the pieces of having had a traumatic birth or injured mum or baby.

In the netherlands it seems birth is treated as a private family event which a trained person helps with and not a medical event family members can witness.

BG the UK homebirth rate is 1% - a far cry from the Dutch 40%! And to be in that 1% you do have to fight for it. I wouldn't be too worried next time, because i've already homebirthed once and have "proved" myself in their eyes, but for a first-time mum having a first-time homebirth it was pretty stressful having to "convince" strangers i could do it. Ridiculous.

I like the idea of having the option of having a GP do the birth at home too - birth is so normalised. It's medical but like a cold might be, only minor medical assistance might be needed, it will take care of itself. Matrernal and infant mortality rates are SO low in the Netherlands, way lower than Aus and the UK and way WAY lower than in America (where the rate ROSE last year!). HOwever this system seems, it works great!

Bx

And the way they manage their litigation (or lack of) seems brilliant to me too. IMO many decisions/opinions OBs make/have is coloured by the risk of litigation.

I have a Dutch friend who was telling me this when she was out here at xmas...

She also said that after seeing what birth is like on tv, she was coming here to have her baboes!!! Not sure she really meant it, but she wanta an epi!!!

Many Nordic countries have tis sort of an attitude. I think the whole of the "Allied" countries could take a huge lesson from this sort of care for future generations, not to mention the generous parental leave and employer sponsored childcare options as a recognition that we need more people to have children to care for us in our old age!!!!

We have a pretty decent baby bonus/child care supplement here, and a one year maternity leave, but the birth rate is still pretty low - 1.7 children per woman, if I'm not mistaken. Well below replacement.
Anyways, about the Dutch thing - my midwife said that the Dutch women (children of immigrants, not born in Holland) in their practice seem to have a much better attitude towards labour and birth than many of the others in their practice. And my midwife herself had a Dutch doctor, who, 25 years ago, allowed her to have a homebirth here, which he attended (as a GP) and allowed her children to be present. That would have been totally unheard of at that time! I wondered if it is because the Dutch are typically bigger people (no worries - I'm Dutch myself;)) and maybe have a little less trouble with labour? Just a thought. I know that the size of the woman isn't everything in labour, but I wondered if that might be a factor. Or maybe we're just a wonderfully enlightened bunch of people. :p
Where I live here in Ontario, the hospital doesn't offer epidurals either - only if you are going to need a c-section, or high forceps. Some women travel to the next big city to deliver because of that.

"In the netherlands it seems birth is treated as a private family event which a trained person helps with and not a medical event family members can witness"
What a concept! Now if only THAT would catch on here!

I dunno Cricket....

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Where I live here in Ontario, the hospital doesn't offer epidurals either - only if you are going to need a c-section, or high forceps.

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That sounds like a pretty amazing step to me! I think it's down to attitude really. I think if you grow up your whole life thinking birth is a normal event that can happen at home most of the time you don't go LOOKING for medical intervention. I know so many women who are genuinely frightened of birth and really think the chance of them dying is very high without a doctor being there. That's a terrible crime we've committed against women, as a society, to make them doubt the perfection of their bodies.

Bec

Great thread Bec. I read something once about how Middle Eastern (I think it was) women who had immigrated over here birthed without intervention because they knew they could do it and it was just the way it was done back 'home'. It's interesting that it comes down to one's perception of labour and labour pain which dictates how your labour will turn out....generally speaking that is. I mean, do women even think about how birth was done from the start of time when there were no epis etc?? We aint' changed since then but our mind certainly has!

Thanks Hoob! Obviously, it's not always a case of mind over matter - but I'd say that mostly it is!!

It's funny Cat, I think that about a lot of parenting - breastfeeding, cloth nappies, drug-free birth - what do people think used to happen even 50 years ago?! I agree that formula's brilliant if you can't breastfeed, disposables are good, um, if your washing machine's broken, drugs are great if a medical situation arises - but I wonder if these things weren't options, whether we would think that we needed them?
Like, for a trivial example, sometimes I have to get out of bed at night cos I NEEEEEED an icy pole, but it never happens when I know there's none in the freezer. Only when I know icy poles are an option! Or like, when a little kid knows there's choccy biscuits - they might never usually ask for/have choccy biscuits, but once they know it's an option - nothing else will do! (told you it was trivial!)

I think, for me, giving birth in a Family Birthing Centre, made birth perhaps a bit more like the Dutch model of care (going back to my roots, hehe). There wasn't the option of strong drugs, and it never occurred to me to ask for them. It's not that I wanted drugs, but resisted the urge to ask - I actually never once thought - 'I need pain relief in the form of drugs'.

So yeah...I wonder, if drugs weren't routinely offered, and not recommended, weren't seen as such an integral part of birth - how many women would birth without drugs - and birth just as well, if not better?

ETA: By the way, I've heard that people with a Dutch heritage are really awesome, like, super people. Just passing it on.

I think we think we need what we're opffered yes. Several people said to me when i was planning a homebirth "Why do you think they let women birth in hospitals if it is so safe to do it at home?" and when i told them the facts about cost, about control and about standardisation of care they just went blank and said "Yeah, sure or maybe it's DANGEROUS!". Because they've been told it is. I know so many women told afterwards "it's a good job you were here! You might have died at home!", in several cases the women who had difficulty had medical inductions at EDD+4-10, epidurals, deep transverse arrest and high forceps deliveries and then a big bleed from haematoma's inside. HOW THE HECK WOULD THAT HAPPEN AT HOME!? But we don't question doctors. THere is this holiness around the medical ranks still, which is a closed community to so many. My GP i have just now i love because if i do some reading and come in to talk about my thyroid or whatever he always says, "you have more time for specific research than me, what have you got to tell me" and that is SO rare. So many doctor's attitude is "who here went to medical school?" When my mum was having her ablation (burning of faulty nerve paths in the heart) done before having her pacemaker fitted she was awake and sedated (they have to make you cough during the procedure so they can check they haven't punctured a lung) and was in agony everytime they used the ablation tool to burn. Her heartrate was sky-high, she was white, clammy, shaking, moaning at the exact moment of the burn (she couldn't see the controls to see when they were doing it) and afterwards went into medical shock and yet every time she told the surgeon she was in pain he said "EU guidelines state this is a non-painful procedure"!

The medical model is failing women and babies because there is too much emphasis on what one can do to treat a set of symptoms or conditions and NOT enough on what is appropriate for an individual. FOr instance women who are given pitocin to hurry along a normal but slow labour. Baby is not distressed, mum is doing ok and has a lot of options for pain-relief and care, WHY are we risking their wellbeing to hasten things for no reason?

Hospitals and the medical model there can and does save lives, but so so many women are unneccessarily injured with treatment they do not need whether they want it or not. It seems with every new drug there is a new condition to treat.

Bx

You've hit the nail on the head Nelle. Stats at places which don't offer an epidural at the door have great outcomes and less intervention.

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ETA: By the way, I've heard that people with a Dutch heritage are really awesome, like, super people. Just passing it on.

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Oh, I think I've heard that too, Nelle. ;)

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T

I think, for me, giving birth in a Family Birthing Centre, made birth perhaps a bit more like the Dutch model of care (going back to my roots, hehe). There wasn't the option of strong drugs, and it never occurred to me to ask for them. It's not that I wanted drugs, but resisted the urge to ask - I actually never once thought - 'I need pain relief in the form of drugs'.

So yeah...I wonder, if drugs weren't routinely offered, and not recommended, weren't seen as such an integral part of birth - how many women would birth without drugs - and birth just as well, if not better?

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I had a similar experience in a Family Birth Centre, but I do remember thinking that pain relief would be great - thinking, oh gee, wouldn't an epidural be nice right now! - even though I've never had one, and I had put in my birth plan that I didn't want one, and the whole idea of having to go up to the hospital wasn't an option for me. I did NOT want to birth in a hospital, and so the epidural just wasn't available, so I didn't ask for it.

I'm sure if I'd have been in a hospital situation, I would have had one. And probably more intervention as well - as it was I narrowly avoided a episiotomy (sp?) and vacuum because I'd been pushing so long... again, the threat of going to the hospital just made me try a bit harder, and lo and behold, he was born then and there, with no pain relief.

I wouldn't deny the relief to women who need it, but like others have mentioned, it's as if we expect that we can't do it on our own. I truly think that if we let women know how possible it is to birth more naturally, many more would feel they could do it.

Great article, and really highlights how the attitudes to homebirth are cultural, and that information about it really needs to make it into the public eye a lot more here in Australia.

I truly believe the vast majority of birthing work takes place in our minds, if your attitude is right, then you are setting yourself up for the best possible experience.

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She also said that after seeing what birth is like on tv, she was coming here to have her baboes!!! Not sure she really meant it, but she wanta an epi!!!

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Exactly! When have you ever seen a birth or birth-scenario in TV or a in a movie where the woman is calm, supported, confident? It's almost always a case of "ooh, I think I'm in labour" followed by a mercy-dash straight to the hospital where the heroic doctor states grimly "we gotta get this baby out or we're gonna lose them both", all amid much screaming and moaning and people yelling "STAT!". (ok, that was very soap opera-ish but you get the idea)

Now, I'm not saying that emergency situations don't occur. Of course they do. But the problem here is that, these days, many women's only experience of birth comes from what they have seen on TV/movies. There was a time when women were present at their sister's/friend's/cousin's birth and when women talked more about the realities of birth and it wasn't such a scary thing. In fact, birth was seen as the perfectly normal, beautiful process that it is.

So next time you are talking to a pregnant woman, tell her about an awesome birth-experience that you know of, whether it be your own or someone else's. Surely we all know at least one great story??...

(hmm, stepping off soap-box now... :rolleyes: )