Childbirth in The Netherlands: The midwifery system

 If you live in The Netherlands you have for sure heard the childbirth-related horror stories that circulate among expats. How midwives are very "hippie" and "natural" in their approach. How they promote births at home as if this was the best (and preferable) way, how they will try and convince you to do things in a certain way, sometimes against your wishes. How you might be denied access to an epidural, or instead of being provided with pain-relief options you would be encouraged to "take it" because you can and your body is made for it. I personally heard stories like these from girls I know and I saw a couple of birth videos that made me very scared of such a system. I like to be able to research and then take my own decisions, not to be pushed in one way or another.

When I heard the word midwife (partera in Spanish), what came to mind was an old, wise lady who would come to your place with buckets of boiling water, herbs and plenty of towels. I do believe that during childbirth the most important thing is feeling safe, however that is and whatever that means for each of us. This can mean different things for different women because we are all unique.

I have to say I was quite pleasantly surprised with the whole experience. First of all in The Netherlands, a priori, you do not get to choose the type of care you'll get. If your pregnancy is considered low risk*, you will be followed by a midwife, period. Only in cases where there is a medical reason or risk factor or if a situation arises are you transferred to medical care. Moreover, because it is a social system (for which we'll be eternally grateful), being followed by a midwife does not mean that you will see the same midwife during all your appointments, or even guarantees that you will know who will be there at the moment of birth. The midwives, same as the rest of the medical professionals work in teams and you get cared by whomever is on call at the moment.

The choice you do have is whether you give birth at home or at the hospital. Because of my background and my rational nature I feel a lot safer in a medical environment. I understand people are afraid of the "coldness" of a hospital, but for me it's quite the opposite. Needles, medicines, monitors and an environment full of medically trained, experienced workers suit me best (the relative anonymity of the care was going to be a factor anyway, as there is no personalized care as such over here).  So we chose a midwife practice that only did births at the hospital. I wanted a hospital birth anyway, and we did not really want to deal with the mess at home either; but after reading a few articles we decided it was the safer option for us. Research shows that "among women having their first pregnancy who opted for a home birth, 45% were transferred to hospital before or after delivery". Considering this information and knowing that in case of an emergency the time it would take to get to the hospital in the midst of the birth process could potentially be life threatening or have life altering consequences, we did not want to take any chances.(And yes, things that happen to less than 5% of the population can happen to anyone. Even if you are (or seem) perfectly healthy. Even if there are no signs or risk factors that would pinpoint to such a situation).

To my surprise, in The Netherlands midwifes are trained 3-4 years, at a technical level (HBO), as regulated by the Royal Dutch Organization of midwives (KNOV). (Yes, my mental image of a midwife was quite different from reality). Each and every midwife that cared for us (well, with one exception) was very knowledgeable, kind, nice and always took the time to answer our questions and make us feel comfortable. Even if I ended up being transferred to gynaecological care at the last moment, (though I went back to midwife care for the recovery period), I was quite happy with the care we received. I do have to say that the Dutch system works under very specific premises that are perhaps not transposable to other countries:

a). -first of all, only low-risk pregnancies and births can be handled by midwives. This is ensured by a very carefully thought of selection protocol (triage)* in which high-risk cases are carefully cared for by obstetricians. and, more importantly,
b). -the system considers the distance from a home to a nearby hospital and other conditions in the household (such as whether there are stairs or elevators, the height of the bed, etc.). If certain requirements are not met, you are not allowed to have a home birth, because it should always be possible to get to the hospital in a short period of time. I can not imagine this being possible in a country like Mexico, where distances between places can be quite big and services spread around a large area.

Even if I was reluctant to have to give birth the "Dutch way" (to put it mildly), I am grateful for such a system, and for anyone out there who'll be going through this, I would say:

- don't listen (only) to the scary stories, it's always the loudest voices that make the noise, but they do not necessarily reflect everyone's experience.
-don't be afraid, but do research your options so that you'll find a practice that adapts to your needs and personality, as every midwifery practice has their own philosophy and way of working.

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 <sup>* "The principle idea is that a healthy woman with a healthy pregnancy (low-risk) is best  taken care of by a midwife.  Emphasis is placed on natural processes, with intervention only occurring when a problem arises. In this case, the midwife will consult or refer to an obstetrician.This optimises the risk selection and referral and is formulated  in a dialogue between primary, secondary and tertiary care professionals. A comprehensive list of preexisting,pregnancy-and perinatal-related disorders exists,in which:
 
A. the care of a primary care midwife is considered sufficient (eg. Previous miscarriages, previous premature birth (>33 weeks), cystitis.)
B. an obstetrician should be consulted (eg. Anaemia, Preeclampsia, psychiatric illnesses, hepatitis C).
C. the care definitely has to be shifted to an obstetrician (eg.  Diabetes mellitus, previous C-Section (from the 37thweek of pregnancy), >24 hours of ruptured membranes, meconium-stained liquor, breech birth,multiple birth, third or fourth degree tear.)
 D. the natal care should be given in a hospital but can be supervised by a primary care midwife (eg.
Previous Postpartum Hemorrhague (>1L), previous retained placenta (manually removed)"

Excerpt from the information pamphlet: Midwifery in The Netherlands by Myrte de Geus. 2012. KNOV (Royal Dutch Organization of  Midwives). Available here:
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 Alternative versus conventional institutional settings for birth. Ellen D. Hodnett, Soo Downe, Denis Walsh, Cochrane Pregnancy and Childbirth group.  2012.

Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study. Brocklehurst P. National Perinatal Epidemiology Unit. University of Oxford British Medical Journal 2011; 343 doi: http://dx.doi.org/10.1136/bmj.d7400 BMJ 2011;343:d7400

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