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Giving Birth In the Netherlands
 Women have long searched for a pleasing birth, a birth with a minimum of fear and pain, in the company of supportive family, friends, and caregivers, a birth that ends with a healthy mother and baby gazing into each other's eyes. For women in the Netherlands, such a birth is defined as one at home under the care of a midwife. We are a country known for it’s liberal approach to many things such as drugs, prostitution, and euthanasia, but it is government support for midwife-attended home birth is actually its most radical policy: every other modern nation regards birth as too risky to occur outside a hospital setting but we take entirely the opposite view for all but high risk births.
Dutch Qualifications & Midwife Power.
Most Dutch midwives are RN’s first and then go onto be midwives with a with year degree course. We are now being encouraged to become more scientific with a post graduate year being added to our three-year training course, I have just started mine.
Such is the power of the midwife that the specialist doctor who coerces a woman into having a hospital birth against her wishes will no longer receive referrals. The obstetrician who is not "woman-friendly" is ostracised by the midwives, and is only reconnected to their system when he asks what can he do to ensure that he receives referrals. If a midwife is in town, then, by law, she is given precedence over the GP as the birth attendee. This level of authority has come about through the 1865 Act of the Practice of Medicine in which the profession of midwifery was defined and protected. We can make life hell for doctors if we feel they are not doing their jobs.
Midwife vs Doctor
 The ‘mid’ in ‘midwife’ originates from the German word, ‘mit’, meaning ‘with’. A midwife is literally the woman who is with the wife for the birthing of her child.
In Holland we midwives strongly feel that when women let go of their midwives, they are letting go of womanhood, and turning their backs on a tradition that respects and values her womanhood and the infant she brings into the world. She is relinquishing responsibility and control of her own life-process that is also part of the cycle of renewal and regeneration of the community to which she belongs. Most of all, she loses an essential support system that helps to bring gestation to fruition, that nurtures mother and child both before, during and long after birthing and contributes to family bonding at a time when those family bonds are under most strain.
Conversely, as the woman places herself in the hands of the medical doctor, she becomes a passive instrument of reproduction, to be invaded and probed by an increasing armoury of other instruments, to be mutilated in the name of efficiency and progress. Her ‘labour’ turns painful and unproductive until it becomes an illness that has to be treated. She is rendered unconscious while the child is wrenched from her birth canal with forceps, or straight from her cut-open womb. Mother and ‘new-born’ are registered in the official statistics, and, except for further medical tests and interventions, abandoned to their own devices. The demand of pharmaceutical companies for every more outrageous profits, and of doctors for every more status and power has fuelled this unhappy state of medicalisation. Extensive studies here have shown that for low and medium risk births mother and infant stand a much better chance of survival at home, medical intervention in these birth causes more problems than it solves.
The single most important factor in the Dutch way of pregnancy and birth is the ethos that regards pregnancy and childbirth as normal physiological processes, NOT a medical one, though it can become one.
Holland is the one country in Europe where the autonomous profession of the midwife has survived intact. Nationally one third of babies are home-births, here in the southern province of Limburg it is now 47%. Midwives are part of the primary healthcare system, we have the authority to decide which women can have a home birth, which women can deliver in short stay hospitals known as a "polyclinics" attended by midwives and which women must be referred to a specialist. We have a well organised maternity home care system that facilitates continuity of home births, and careful screening systems for high-risk pregnancy. The result of this way of birth is a peri-natal mortality rate (PRM) of 2.4 in women having first babies in hospital, compared with a PMR of only 1.2 in women having first-time babies at home.
American Figures
I tried to find figures for the USA for comparison and I have to say that I hope the figures I have found are wrong. In one study 2,092 home births and 2,092 hospital births revealed that the hospital group having six times higher foetal distress rate. Maternal haemorrhage were three times higher. Limp, unresponsive new-borns arrived three times more often. Thirty permanent birth injuries were caused by doctors along with lacerations to the mothers, neonatal infections, forceps deliveries caesarean sections and nine times more episiotomies. There was no difference in PMR between hospital births and home births. Research also reveals that unnecessary interventions have been linked with birth trauma and interferes with mother and child bonding. I also saw that in the United States, between 50% and 80% of women giving birth for the first time are given episiotomy and that is a horrific rate. If any specialist here was having rates between 25% and 40% midwives would be knocking on the door of the regulatory body asking them to examine that doctors qualifications, so I am hoping that those figure are a misprint. I also saw there are 870,000 caesareans per year in the United States. A study by the US Public Citizen Research Group involving 906,000 cases estimated that half of these were unnecessary, resulting in 142 avoidable maternal deaths. When midwives rather than obstetricians attend births, caesarean rates drop to less than half the national average. Indeed, in one New York hospital, midwives were actually criticised for their caesarean rate of 12.9%, well below the city’s average of 23.1% how insane is that ! If the 50% of unnecessary caesareans were avoided American hospitals would lose $1.billion in revenue a year, and this goes a long, long way to explaining these figures. In Holland, it is about 10 per cent with an epidural rate of only six per cent of deliveries. What is most interesting is that no Dutch study has EVER shown that C-section result in fewer brain damaged babies, only studies funded by drug companies have ever come to this conclusion. The private health companies that provide facilities and health insurance in Holland have the profit margins they can make limited by law, this removes much of the greed and push for unnecessary medical interventions.
Home Birth
 A home, natural childbirth is something that many women all over the world want, which is to experience birthing as free of fear and pain as possible.
As I am military midwife my system of work is a little different to the civilian midwife who are independent, although many work in group practices. We are both seen as a separate profession with equal status to a GP or an obstetrician and our judgement is respected.
Last night I was attending a birth. The mother was a 38 years old French lady who had had one child 5 years previously. That birth had been complicated, resulting in a forceps birth after an episiotomy while in hospital. Careful questioning of her early in her pregnancy left me with the impression that most of the problems of her last birth were the result of too much intervention due to excessive clock watching by her obestrician and that she certainly should be able to have the home birth she wanted this time. We do a thorough risk assessment of the client's past and present medical and obstetric history. It is the midwife who acts as gatekeeper, deciding - with reference to the bible that is the Dutch Obstetric Manual - who needs a hospital referral during pregnancy and childbirth. It is integral to Dutch culture that pregnancy and birth are normal events that can take place at home, unless complications occur. We don't ask people where they want to give birth because in the end, nature decides for you and you don't have a choice. The safest place is where there will be the least intervention, because each intervention carries risks for mother and baby and as a midwife I am most definitely not in the business of putting either at risk.
Last night, as usual, I attended when my mother in labour called me. I checked that all was well, give advice and reassurance to both parents, made sure her little boy was ok and understood what was going on (I had spoken to him many times before and explained with his parents what he would see as his mother gave birth to his little brother) and told her I would return when she was is 8cm dilated. This is an approach that can seem shockingly relaxed to those who are not used to it, but it really does work because as a midwife you put a lot of work into building trust between you, it is crucial. There is no pressure on us to listen constantly to the baby's heartbeat, nor is there a need, since we are working with a select group of women whom we know very well.
During pregnancy my most important role is education of the family and especially the mother. Education about her body, about pregnancy and birth and how to best help her own body work through it all. We midwives have to do a lot to persuade clients that babies do not pop out in an hour - as they seem to on television soaps - and that a long and possibly painful labour will do no harm to mother or child in most cases.
The most important role for the midwife during the birth is to ensure that the woman is not disturbed, so that the physiology of labour can work as well as possible.
Dutch women, unlike many of their British and American counterparts, do not expect to be given drugs to ease the pain of labor. Epidurals are used only in caesarean deliveries, and gas and air is unknown here. This sounds harsh but most pain comes directly from fear, and using education and support we can allay most of those fears. We also show them how their own body can help deal with pain. In the relaxed atmosphere of home births I find it is very common for ladies to experience an orgasm as the baby’s head descends the birth canal. Mixed as it is between contractions I suspect it is often missed and so is probably even more common.
We know women can handle pain and that they need pain and they know that if the pain is abnormal, pethidine will be administered. But midwives cannot give pethidine, so a transfer to hospital will be necessary, which tends to discourage its use because women, once started with a home delivery, will fight like wild cats to stay at home.
I place no restriction on mother’s movement during labour, unless there is a pressing medical need to do so. I leave her to decide her birthing position, standing, squatting, on all fours, reclining, or even going through any number of these! We try and provide any birth furniture that has been requested such as a birthing stool or rocker. I have delivered babies in the shower, in a bath, in a pool, in living rooms, bedrooms and even in the garden. Last night’s delivery was in the living room, by candle light for the most part. Many home birth parents find candle light to be relaxing so I never argue about it as long as they are all safely placed. I have bought on of those head band torches that outdoor sports people use with a bright krypton bulb for these births!
Marie gave birth to a little boy at 02.13 after 5 hours in labour. With her during the birthing was her husband, her little boy, her two sisters, her father and her best friend.
Families
 We encourage families to attend a birth, especially sibling no matter what their age. Many families hold a ‘Birthing Party’, and personally speaking I love to see the generations of a family seeing a new generation into the world. The largest number of spectators at a birth that I have had was 14, thank heavens they had a very large living room. Why shouldn’t birth be a joyous celebration with the mother and baby as the fulcrum of love and attention? Some families, an increasing number in fact, have taken to taking the placenta and burying it in the garden and then planting a sapling over it, a rather good idea in these eco aware days.
When I told a visiting English nurse that we worked liked this she was outraged. When I asked why she stated that she thought it wrong for toddlers to be there because it would ‘traumatise’ them, and older children in their pre-teens and teens would see their mother’s ‘private parts’ (how silly of a Nurse to use the terms ‘private parts’ – talk about repressed upbringing !) and that this is in some way sexual ! I did not know whether to laugh or cry. Small children are not traumatised by birth when you explain and involve them in the whole pregnancy, most just want to be of some help to their mother and display an intense curiosity. One little manoeuvre I call “ Peering under the hood” happens when mum is squatting and baby is crowning the little one get close to the floor and look closely under their mother for the first glimpse of their new brother/sister, it always provides a moment of laughter! To worry about older children seeing their mother’s ‘private parts’ just display’s a total lack of maturity thought, and an unhealthy attitude to the natural body – who on earth would see a vulva during birth and think of sex for heavens sake.
I am in no doubt that women who have their family and friends in on the birth benefit from it mentally and physically. Girlfriends seem to be taking an increasingly important role in those families which are fragmented by divorce or distance. I am sure that this help women bond to each other at a much deeper level.
Post Natal Care
Post-natal care is vastly different, too. Every new Dutch mother is entitled to a kraamverzorgster, a maternity assistant who stays for up to eight hours a day for eight days to help with the baby. The cost of this service - approx E1,800 - is paid by the state or by health insurance.
Holland has 6,000 kraamverzorgsters, who spend up to eight hours a day for the first eight days with mothers and newborns. They also assist at home births. Their primary postnatal duties are to help with feeding, bathing and other aspects of baby care, but they also do light household chores and look after other children in the family. I love having them around at a birth, and the best ones are those who emanate a aura of calm even when rushing around, because calmness is infectious and helpful. They are especially valuable where little siblings are watching the birth as is the norm here
Mothers are more tempted to get out of bed and do the washing if they do not have a kraamverzorgsters. The kraamverzorgsters look after the mother, checking how far their womb has gone down and giving me lots of advice about the baby. Though few have any sort of medical qualification I always take any call from one seriously when they phone about a new mother and/or baby, they are people with good common sense. They show how to bath baby, and many are experienced breast feeders themselves and a great with giving good solid advice on breastfeeding, some are even wet nurses – a nearly forgotten art these days. Most are very organized ladies and will sort out the washing, folding the clothes and making meals. In short they give a family a really good start. Letting mother recharge after the birth and allowing mum and dad to just enjoy those amazing first days.
If Things Go Wrong
The things that go wrong in a vast majority of cases, particularly with first babies, do so slowly or with plenty of warning, so you have time to make your transfer. People in just about every other European country think that the only way to have a safe birth is to be surrounded by machines in a hospital, although there isn't a huge amount of evidence to support this view. Nobody has demonstrated that it is any less safe in a community system, though they have tried again and again to do so. I personally believe the Dutch system shows the lies, distortions and manipulation of biased research data for what they are.
Holland has no litigation culture, and the care of brain-damaged children is paid for, not from insurance claims, but by the state. This may be one reason why the Dutch are slower to reach for the scalpel and perform caesareans.
I hope I have been able to give you a glimpse of the Dutch way of birth. If you have any questions please do mail me and I will respond as quickly as work will allow
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