Saturday, March 15, 2014

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.


 * "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:
 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: BMJ 2011;343:d7400


Images via: here, here, here, here, here and here


  1. Pues me encantó este post. Mucha información importante y que utilizaré, lo sé. Yo conozco a varias personas muy cercanas que han tenido a su bebé/s en casa con partera en México y les ha ido muy bien. Yo creo que depende de los cuidados previos, aunque croe que lo más sensato es hospital con partera. En San Miguel de Allende había una "universidad" par parteras, es o era una carrera de 3 años con información médica y muy seria, por un momento quise ir a estudiarla, antes de la maestría. Y en los estudios salen muy bien calificadas en la atención al parto al lado de médicos/as, y enfermeras/os obstétricas. Ahora me pregunto, ¿qué número de parteros habrá? Abrazos y a Ju y saluda a "the boy"

    1. Graicas! Wow, la verdad yo no me animaría a tener al bebé en casa. Yo estaba rodeada de gente experta: la ginecóloga, una estudiante interna de medicina, Mark, y 2 enfermeras... aún así fue una sensación tan rara, no sabía lo que me pasaba. Es decir, sabía perfectamente lo que me pasaba, pero es verdaderamente extraño sentir como la naturaleza toma el mando y tu pierdes todo control. En casa, sola... no, no podría. Pero cada quien, tengo amigas que lo han hecho y tan felices, precisamente porque es donde se sienten más cómodas, tranquilas, relajadas.

      También creo que lo más seguro es estar en un hospital con partera (o en otra modalidad de las que existen aquí. en un hotel para partos, que esta casi pegado a un hospital, donde estas en una recámara como en tu casa, con calma, sólo con la partera, en un ambiente digamos más acogedor, pero sabiendo que ahi al lado estan los doctores por si acaso, pero ese servicio era muy caro).

      Discutiendo sobre el tema con una pareja mexicano-holandesa que querían tener un parto en casa en México me quedé intrigada con el tema de las parteras /comadronas me puse a investigar. Encontré algunos artículos sobre el tema (te pongo los enlaces abajo). En México hay desde 1996 únicamente 2 escuelas profesionales de partería, CASA en San Miguel de Allende que es parte de una organización civil y tiene su propio hospital; y en Guerrero (Tlapa) hay otra escuela desde hace poco, que es pública. Sólo muy recientemente se ha reconocido como carrera técnica, y en general no son muy aceptadas / conocidas aun por el sistema de salud tradicional porque la profesión como tal apenas está empezando. (Lo que hay es la tradición milenaria en zonas rurales de la Tlamatquiticitl, nombre que recibían las mujeres que asistían a los partos entre los aztecas. Era una mujer sabia, considerada sacerdotisa por sus múltiples funciones en beneficio de la salud y estabilidad de la familia.)

      Cito de un artículo:"Los métodos para atender a la mujer embarazada se dividen en dos corrientes: la Organización Mundial de la Salud propone la que se designa como 'atención calificada del parto': todos los embarazos deben ser atendidos por personal calificado y en hospitales. Es decir, por cada mujer embarazada, debe haber un médico. Ésta es la estrategia que México sigue."

      Aqui un articulo de el Universal

      Aqui otro sobre la capacitación de las parteras en México

      Y aqui otro articulo en Quo; 10 datos sobre las parteras en México

  2. A todas estas, y porque siempre me ha pasado por la mente que estos holandeses prefieren eso de que "el cuerpo se cura solo" antes de ir a un hospital por lo de las gruesas cuentas que hay que pagar luego de ese lujo, cómo va con uds eso? El seguro asume el parto en el hospital? Tienen que pagar extra?

    1. El seguro asume todos los gastos, únicamente pagamos lo correspondiente al "propio riesgo" en mi caso (ya que Yulia hasta los 18 años esta cubierta al 100%).

      Y yo estuve hospitalizada 4 días (en reposo), después 2 días tras el parto, luego Yu estuvo en el hospital 3 semanas (primero en incubadoras, luego en el departamento de pediatría) y su última semana en el hospital estuve yo con ella en una recámara sola.

      La verdad es que como extranjeros, acostumbrados a un trato distinto, tendemos a criticar mucho el sistema de salud holandés (yo la primera), que sí, es muy conservador, (eso de que no te den antibióticos ni aunque te estes muriendo, y que lo curen todo con paracetamol tampoco lo comprendo, ni que para TODO tengas que pasar primero por el médico general nadamás para que te redirija al especialista), pero la verdad es que son eficientes y después de vivir esto y del excelente trato que tuvimos, no puedo quejarme. Por supuesto que este sistema se basa en detallados análisis riesgo-beneficio para asegurarse que no se gaste ni un quinto de más que no sea el necesario, pero la verdad es que son excelentes médicos y es un alivio y un agradecimiento enorme saber que un sistema así existe.

  3. We have socialized medicine too and in our case, I chose the midwife partly because the same care provider is with us for all of our appointments and 6 weeks after birth, whereas my OBGYN was on call at the hospital and likely wouldn't have been there. I completely agree with you that the most important thing is that the woman (and partner) feel as comfortable and confident with their care provider as possible.

    I am so glad you still are finding the time to post after Yu's arrival. I miss the blogs I get attached to and disappear when baby arrives. I'm glad you are still here :)

    p.s. Those are some gorgeous photos you posted along with the post.

    1. Yeah, I understand. I think if we could have had a choice for a more personalized care, I would have loved it. And knowing what I know now, and how wrong my mental image / prejudices towards midwifery were (to be honest I had no idea what a midwife *really* is), I think it is a good option. But yes, the most important thing is to feel safe.

      Weirdly, magically... call it serendipity or synchronicity I did know the obgyn that was there during Yu's birth, and it was just a coincidence that she was on call at that moment, and that I had seen her 2 weeks before (and loved her). It was such a heaven sent to have someone familiar that was also so nice to us all the time.

      I do want to continue blogging, it is just hard to get organized, hence the slower posting and late commenting, but I feel like I have so much to say and mostly I also want to write things down not to forget it. The relationships and friendships we have built through the connections made via this internet ramblings have been so so valuable and important that I could not just disappear... and I get you on missing people. (Thanks for such a sweet comment!)

      (And yeah, I wanted to find pictures that reflected what was going on in my mind when I was so afraid of home births and midwives)

  4. Guauuu. Pues como tu creo que prefiero estar en un hospital, igual en italia no he escuchado que lo tengas en casa, sobre todo siendo el primero y sin saber que tienes que hacer o que esperarte.
    El sistema de salud holandes es diferente y bastante avanzado en esas cosas, por lo de paracetamolo me hace recordar de la eacuela porque asi se curaba todo aunque hay veces que se nwcesita.
    Un saludo enorme.


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