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The nation of Holland consistently has among the finest statistics for mother and baby health in the world. Holland is a model for us to follow.

Contrary to popular misconception, Holland has a widely diverse population, with as many as 23 languages spoken at prenatal clinics. Many immigrants to Holland come from societies where women have little education, economic power or freedom of choice. These women would be at higher risk for developing complications in birth. Yet Holland has consistently fine statistics in maternity care, and mother-infant and child-family health.

Like several other Northern European countries, Holland has a national policy that guarantees every woman a midwife from the beginning of pregnancy through the first year after birth. In Holland 30-40% of births still take place in the home under the care of a midwife. This is because home birth with skilled midwives has been proven to be safe and cost-effective in the long run. Obstetricians and hospitals are reserved for women and babies at risk for developing complications in birth.

Access to health care

A second important feature is that a community-based team of primary care practitioners has the responsibility of seeing that every child and family have the healthcare and social services they need to maintain good health. This team consists of a family physician and includes a midwife and social worker. Any one of them can initiate hospitalization or call a specialist physician such as an obstetrician or neonatologist when a baby's condition necessitates that response.

When the home birth rate dropped to 30% in the 1970's because more and more women began seeking obstetricians (a direct result of the impact of American obstetric practices infiltrating world health), the government recognized it as a dangerous and costly trend. A multi-disciplinary commission was formed to evaluate maternity care and make recommendations.

Balance of power

The national health policy of Holland had always recognized the importance of maintaining a balance of power between family physicians, sub-specialist physicians, and midwives, with each profession needing to be independent in order for the team to work.

Before the commission, family physicians had slowly been phased out of attending home births in favor of midwives, leaving a power imbalance toward hospital based physicians (OB's, natalogists, peri and neo). Midwives, who earned less money than obstetricians and were beginning to have less prestige with the public, needed special support. Otherwise, the government recognized, obstetricians and perinatologists would soon take over, resulting in a loss of normal birth and the runaway costs associated with routine hospitalization for birth and unnecessary procedures and interventions.

Current policy in Holland assures that any woman who has a complicated pregnancy or birth has guaranteed care by physicians in a hospital. Because every Dutch adult is required to have some form of health insurance there is no direct cost to a family when a woman or baby needs a physician or hospital care.

Midwife as gatekeeper

Any woman has the option of choosing to be cared for by an obstetrician and birth in a hospital. However, if she has no medical indication for her choice, then she is responsible for paying for the privilege. In addition, every midwife has guaranteed hospital privileges. Because the midwife is the gatekeeper (for maternity care in the neighborhood), she is responsible for all physician referrals, and helps insure that physicians do not abuse either technology or their patients, by doing unnecessary procedures.

This has kept Holland's cesarean rate well below 10%, despite the eagerness of obstetricians to perform more cesareans. Holland's maternal and infant health statistics constantly rank among the highest in the world. Note: For decades Holland's cesarean rate was below 4%; increasing pressure to "modernize" has brought rising rates of intervention.

Postpartum care

A third important component of Dutch maternal—infant care—is that every mother is offered postpartum doula care at minimal cost. From two to eight hours a day (depending on the family's need or the woman's preference) a doula comes to the house, and cares for the mother, helps with breastfeeding, does house keeping, runs errands, and cares for siblings. Doulas in Holland have special training as a profession, keep records on the family's health, report to the midwife, and play a crucial role in maintaining high quality care, with the support of government subsidy. This is because they have been found cost effective.

Contrary to what U.S. medical organizations lead us to believe, Holland has shown that it is possible to identify those women at risk for developing complications during labor and predict the vast majority of serious problems with a high degree of accuracy. Only 20-30% of all birthing women fall into this category, and most of them do not develop any complication. The remaining 70-80% can safely birth at home or in a birth center.

Effective system

A midwifery-based maternity child health care system does not train more specialist physicians and than is needed. It utilizes them and hospitals as important adjunct service for those mothers and babies who are likely to benefit from medical treatment. In such a system midwives, obstetricians and neonatal pediatricians are colleagues who respect and support each other.

Holland, along with Denmark, Sweden, and Britain, supports at least 9 months of breastfeeding in addition to a complete system of paid maternity leave. Mothers who work are allowed time off to breastfeed their baby during the day. Despite the initial cost of such a complete well-integrated maternal-child-family system, Holland has proven the long term benefits of such a policy. This is probably the best model today for us to look towards.

My thoughts to follow.
valancystirling: (Default)
Something that has particularly struck me recently is the thought that perhaps the average person believes that homebirth is something that anyone can choose under any circumstances. The Pang study cited by ACOG apparently seeks to perpetuate this misconception for its own charming reasons about which I shall not speculate in this post. I seek to give insight into the true nature of homebirth, and the process by which homebirth is achieved.

Apparently it is not commonly known that midwives screen prospective homebirth clients. There are a number of factors they look at in deciding who is a good candidate and who is better off in a hospital. These reasons include the following and probably others specific to a midwife's own experience and comfort level.

There are certain health factors that may make home delivery unwise. We screen for these possibilities by first asking questions about the client's health, reviewing their health history and blood work results, and then watching carefully for any problems throughout the prenatal period. Below are guidelines for our practice; these may be adapted to particular situations according to our judgment and experience.

Definite contraindications to homebirth

Placenta previa
Breech presentation
Multiple gestation
Blood disorders
Drug dependency
Delivery before 36 weeks gestation
Previous classical (vertical) uterine incision
Other serious health problems, such as epilepsy, tuberculosis, renal disease, cardiovascular disease, AIDS
Possible contraindications to homebirth

Sexually-transmitted diseases
Abnormal fetal growth
Poor nutritional status
Psychological problems
Active herpes eruptions at time of labor

Should your pregnancy fall outside the parameters for a safe homebirth, we will refer you back into medical care. Should you so desire, we will be happy to continue to support you in the role of a doula (childbirth assistant) as you plan your hospital birth.

Complications which MAY require transport to hospital during labor, birth or postpartum

Irregular, depressed or accelerated fetal heart rate
Thick meconium staining
Prolonged lack of progress in labor
Elevated maternal temperature
Poor infant response after birth
Infant abnormalities
Retained placenta
Extensive perineal or cervical lacerations
Maternal hemorrhage


Although, I have to clarify, multiple babies does not necessarily rule you out for homebirth. Many midwives are comfortable delivering twins and some will even do triplets. Doctors have standardised many birth scenarios, and as such have generally made it uncommon practice to do vaginal breech deliveries, or vaginal multiple deliveries. I read some stats on this recently and am trying to remember where. But just because most doctors choose to preemptively perform c-sections on these potentially complicated birth scenarios does not mean that multiples or breech babies HAVE to be c-sections. Probably in a lot of cases a c-section is a good idea, but it's not across the board mandatory, though I suspect many doctors might feel uncomfortable outside their standardised comfort zone.

It's also important to note that while midwives can detect many of these risk factors at the beginning of a pregnancy, several can pop up at any time during the pregnancy, including during labor, and the midwife is responsible for judging for the entire pregnancy whether or not the status of her client has changed. Pre-eclampsia, placenta previa, and preterm labor are examples of issues that could develop later in the pregnancy and which a midwife would recognize to eliminate homebirth as a reasonable and safe option for a given client.


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December 2010

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