My thoughts to follow.
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.
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.
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.