Schools of thought: the force behind the preservation of the autonomous midwife in the Netherlands

Globally, the power struggle between obstetricians and midwives has been won long ago by obstetricians, resulting in the marginalization and hospitalization of the profession of midwifery. In the Netherlands however, the... [ view full abstract ]

Globally, the power struggle between obstetricians and midwives has been won long ago by obstetricians, resulting in the marginalization and hospitalization of the profession of midwifery. In the Netherlands however, the midwife’s autonomy has been preserved. In the Dutch maternal and newborn care system the midwife is responsible for risk assessment, and decides when referral to specialist care is necessary. This system is praised internationally because it is believed to minimize unnecessary medical interventions in the Netherlands. The divergent historical development of the midwife’s profession in the Netherlands is a widely discussed topic. Many researchers provide an overview of the historical events that have encouraged the Dutch system and the midwife’s position within it. However, the forces behind these events are unknown.

In the Netherlands, the power struggle between obstetricians and midwives has intensified as a result of recent research on perinatal mortality, referral rates and inter-practice variation. The position of the midwife in the Dutch maternal and newborn care system is now up for debate and a new “shared care” model is being implemented to greater or lesser extent. For instance, in some regions obstetricians are now routinely involved in assessment and referral process to specialist care. These changes are being reinforced in newly written regulations. It is noteworthy that these developments in the Netherlands run counter to a turn in international policy that is emphasizing midwife-led care.

To make sound decisions regarding the midwife’s position in the Dutch maternal and newborn care system, we need to better understand the social, cultural and political forces at work in the history of the Dutch system. To this purpose, we studied the drivers of the decisions of the Study Group Revision Kloosterman List (WBK) in the period 1983-1987, initiated by the Sick Fund to review the rising referral rates. This Study Group – made up of representatives of the professional organizations of midwives, obstetricians, and general practitioners – gave official recognition to the gatekeeper role that, until then had been ascribed to the midwife by tradition. In order to study the forces behind this decision, we conducted an extensive literature review, interviewed eight key players who were involved in the WBK’s decision-making process, and analyzed archival data about the Study Group’s work. The preliminary results indicate the existence of two schools of thought in Dutch maternal and newborn care: the ‘conservative’ school that supported a physiological approach to pregnancy and birth that was pro-midwife, pro-hands off, distrustful of technology, and the ‘progressive’ school with the opposite point of view. Furthermore, these schools did not only have ideological differences, they also had different financial interests. The driver behind the WBK’s decisions seems to be an overrepresentation of the point of view of the conservative school among representatives to the WBK. This overrepresentation led to a consensus-based maternal and newborn care system wherein the midwife is positioned as an autonomous gatekeeper to secondary care. This position, however, was not supported by obstetricians in the progressive school.