Risico besef en thuis bevallen

Open brief aan de Nederlandse verloskundigen

(met daaronder de lezing waarop de brief is gebaseerd)

Rineke van Daalen

September 2017

Beste verloskundigen,

In het buitenland – en niet alleen daar – worden jullie bewonderd. Jullie werken zelfstandig en onafhankelijk. Jullie hebben een goede taakverdeling met gynaecologen: jullie doen de fysiologie, zij de pathologie. Jullie hebben de thuisbevalling onder je hoede – een unicum in een wereld die steeds meer gemedicaliseerd raakt. Maar juist met die thuisbevalling gaat het niet goed. Al een halve eeuw neemt het percentage af: van zo een 80% in de jaren 1950, tot een schamele 13% in 2016. Waar ligt de kritische grens?

Ik schrijf deze brief om jullie een hart onder de riem te steken. Ik ben een socioloog die al vanaf 1980 de geboorten in Nederland volgt en daarover schrijft. Onlangs gaf ik in Nara, Japan, een lezing over de stand van zaken in Nederland. Mijn publiek bestond uit verloskundigen, die het Nederlandse geboortemodel met jaloezie bekijken en die met argusogen volgen hoe zwangerschap en geboorten in Nederland veranderen. Ik had me een tijd niet met bevallingen beziggehouden, moest me van tevoren verdiepen in de nieuwste ontwikkelingen, en daarbij viel me iets op waarvan ik denk dat jullie er iets aan hebben.

Naar mijn idee is het belangrijk dat zelfstandig werkende verloskundigen en de thuisbevalling blijven bestaan. Ik zie het als een waarde, dat ouders zonder medische ingrepen en in hun eigen huis een kind kunnen krijgen, wanneer dat vanuit gezondheidsoogpunt mogelijk is. Ik zie het Nederlandse geboortestelsel als cultureel erfgoed, dat beschermd moet worden. Dat stelsel staat model voor een combinatie van vertrouwen in de natuur voor zover dat kan, en medicalisering wanneer dat nodig is.

De professionele autonomie van verloskundigen is een van de belangrijkste steunpilaren van het Nederlandse stelsel. Hun krachtige positie heeft een lange traditie, die teruggaat op de Wet op de Geneeskunst van 1865. Daarin werden hun autonomie en de taakverdeling met gynaecologen vastgelegd. Zij kregen de zorg voor ‘normale’ zwangerschappen en geboorten toebedeeld, gynaecologen moesten worden ingeschakeld bij pathologie. Een eeuw later werden verloskundigen daarin gesteund door een groot deel van de gynaecologen, waaronder de beroemde G.J. Kloosterman. Als directeur van de Kweekschool voor vroedvrouwen zorgde hij ervoor dat de verloskundigen qua expertise niet bij gynaecologen achterbleven, dat zij op de hoogte bleven van de nieuwste medische inzichten, dat ze ook de prenatale zorg op een hoog niveau konden verrichten, dat ze met de introductie van de poliklinische bevalling toegang kregen tot het ziekenhuis – om daar vrouwen met een ‘normale’ bevalling te kunnen begeleiden als die hun kind liever niet thuis wilden krijgen.

Om zelfstandig mee te kunnen doen gingen verloskundigen zich steeds verder professionaliseren, op gevaar af van overbelasting en van verloochening van hun eigen specialisatie. In de jaren 1970, 1980 moesten ze hun positie verdedigen tegen de gynaecologen die voorstanders waren van verdergaande medicalisering. In die beroepenstrijd stelden vrouwelijke verloskundigen zich tegenover mannelijke gynaecologen op.

Maar tegenwoordig is er iets anders aan de hand, waartegen verloskundigen zich veel slechter kunnen verweren. Mensen zijn risicogevoeliger geworden, en dat besef dat er iets mis kan gaan is een algemeen verschijnsel. Het is aanwezig bij gynaecologen en verloskundigen, bij zwangere vrouwen, hun echtgenoten, en alle omstanders. Vaak gaat dat bewustzijn ook nog eens samen met een verminderd vertrouwen in de deskundigheid van professionals.

Die ontwikkeling wordt versterkt door nieuwe prenatale diagnostische methoden en nieuwe medische interventiemogelijkheden. Risico’s komen eerder aan het licht en kunnen vaker worden voorkomen of behandeld. Die nieuwe prenatale tests maken de scheidslijn tussen ‘normale’ en ‘pathologische’ zwangerschappen en bevallingen vager. Ze werken medicalisering in de hand en ze ondergraven het vertrouwen in de natuur. De scheidslijn tussen wel of niet ‘medisch geïndiceerd’ is altijd omstreden geweest, omdat daar de taakverdeling tussen verloskundigen en gynaecologen in het geding is. Maar deze nieuwe ontwikkeling treft vooral de positie van verloskundigen.

Het vergrote risicobewustzijn, het verminderde vertrouwen in professionals, en de verdere ontwikkeling van prenatale diagnostiek hebben tot gevolg dat zwangere vrouwen meer moeite hebben om zich te oriënteren. Ze wikken en wegen over de vraag wat de beste manier is om een kind te krijgen, welke tests daar wel of niet voor nodig zijn, ze vragen zich af hoeveel medische zorg nodig is om veilig te bevallen, en ze maken daarbij gebruik van het internet. Voor zwangere vrouwen, de meesten leken in de geneeskunst, zijn die zoektochten ingewikkelde exercities die hen in verwarring brengen. Op het internet zijn verschillende en tegenstrijdige inzichten en opvattingen te vinden; vrouwen weten zich niet goed raad met debatten over medische aangelegenheden, ze kunnen de wirwar aan informatie op het internet niet zelf ontwarren.

Hoe kunnen verloskundigen zich in deze nieuwe verhoudingen het beste profileren? Ze zijn van oudsher gewend zich op te werpen als de hoeders van de ‘normale’ geboorten, thuis en in het ziekenhuis. Dat moeten ze zeker blijven doen, maar tegelijkertijd zouden ze naar mijn idee twee andere rollen beter voor het voetlicht kunnen halen. Het zijn rollen die verloskundigen steeds hebben gespeeld maar die complexer en belangrijker zijn geworden, door voortschrijdend medisch inzicht en door voortschrijdende technologie.

De eerste is de rol als poortwachter voor de pathologie. Die rol spelen verloskundigen al, maar door de toename van tests en screeningmethoden is deze rol veranderd en heeft deze een ‘medischer’ karakter gekregen. Verloskundigen bezitten de deskundigheid om zwangere vrouwen bij te staan in hun keuzen. De tweede rol, die ze ook nu al spelen is die van voorlichter aan zwangere vrouwen, voor wie het moeilijker is geworden om zich een weg te banen in de veelheid van informatie die van alle kanten op ze af komt. Een goede gids is daarbij meer dan welkom, en verloskundigen zijn in staat om die gidsfunctie te vervullen.

Verloskundige, poortwachter en gids – deze drie rollen in combinatie met elkaar vormen de exclusieve expertise van verloskundigen. Jullie kunnen je positie versterken door alle drie deze rollen beter te benoemen, te expliciteren en vooral door er trots op te zijn dat jullie over die gecombineerde deskundigheid beschikken. De term ‘verloskundigen’ dekt niet wat jullie doen. Jullie doen veel meer dan dat. Wie verzint een goede benaming die al die rollen bestrijkt?

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Op 19 januari 2018 vormde bovenstaande brief aan de verloskundigen een van de vier perspectieven die ten grondslag lagen aan een discussie op het congres van de Kennispoort Verloskunde, het kennisplatform voor verloskundig onderzoek: https://www.youtube.com/watch?v=hq1jbPI-CB8

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Hieronder volgt de lezing die ik in Nara, Japan, heb gehouden en waarop deze openbrief is gebaseerd.

Losing ground. Dutch home birth in trouble

Rineke van Daalen

rineke@rinekevandaalen.nl

Nara 1 August 2017

1

The Dutch Model: An Anomaly

Seen from an international perspective, the Dutch birth model is an anomaly. People from other countries are amazed, they are inspired by the system or they abhor it. Take for example the amazement of Barbara Katz Rothman, an American sociologist who did a lot of work in the field of birth and maternity, reproduction, medical sociology. She dedicated her working life to research and writing books, and at least as important she is a lifelong activist in the home birth movement, trying to persuade people into home birth.

In 1993 she wrote a lovely article in the reader edited by Eva Abraham- van der Mark Successfull Home Birth and Midwifery: The Dutch Model: ‘Going Dutch. Lessons for Americans’ the article is called (Katz Rothman 1993). In this article she describes how she came to the Netherlands because she wanted to see a home birth. In her words, this is one of the occasions where you can find the heart and the soul of the Netherlands, comparable to the tulip fields or the Rijksmuseum showing Rembrandt. Katz Rothman is a phenomenal writer and she gives a very lively image of the events that follow. The small residence where she arrives. ‘Laundry in the stairwell, the barking dog, the young woman with a tattooed arm, her boyfriend looking nervous, and her pacing mother.’ There, upstairs, is the place where she expects to experience the Dutch birth model. For her ‘the goal, the proof, the argument’,the ultimate evidence of ‘Yes we can’.

But she doesn’t get a demonstration of a home birth. The birth Katz Rothman describes, there in the small dwelling upstairs, is not progressing quickly enough, and the whole family, Katz Rothman and the midwife included, are transferred to hospital. There the baby is born, even with a Caesarean section, carried out by an obstetrician. But at the transfer Katz Rothman is more than amazed: she didn’t see any anger or hostility with the hospital staff, no reproaches of irresponsibility; the midwife, together with the woman, made the decision to go to the hospital, the midwife transferred the woman, and after that she left the hospital. Katz Rothman saw how trust between professionals functioned as the foundation of the birth system.

For Katz Rothman this experience seemed to be even more instructive than a home birth: the transfer to the hospital ending in a Caesarean section gave her even more insight in the working of the Dutch system, in the working of the division between ‘normal birth’ and ‘pathological birth’.

In the Netherlands having your baby at home in case of ‘normal birth’ is part of a long and valued tradition, but it is exactly this tradition that is gradually fading away. The home birth doesn’t flourish anymore and it is worthwhile to read Barbara Katz Rothman and Gerrit-Jan Kloosterman, the famous obstetrician who strongly supported the position of midwives in the Netherlands, about the future of home birth and midwifery in Succesful Home Birth and Midwifery (Katz Rothman 1993; Van Daalen & Van Goor 1993). Katz Rothman and Kloosterman saw the obstetricians as a threat of the Dutch model, because of their disposition toward medicalization, their warnings about the dangers of home birth, and their skeptic attitude toward the methods of midwives. Besides, Katz Rothman was worried about the future of feminism and what it would mean for midwifery. Births are no longer a ‘gendered battleground’, a place where feminist groups have to fight male dominance. Obstetricians more often are feminine as well. She also expected that reproductive technologies, in particular prenatal diagnosis, with its new prenatal screening possibilities, would encourage further medicalization, not only of birth but also of pregnancy. Kloosterman mentioned other worries – that high flats with twenty stories, and traffic jams would make home birth more hazardous, that the attitude of midwives would change. And indeed, a new-style-midwife has appeared. A midwife who has a partner and children, for whom group practices and the regular working hours of hospitals proved to be a way out for those with young children. Midwives are no longer able to act as the former stand-by, one-and-only professional for the pregnant woman.

Both Katz Rothman and Kloosterman pointed to the unification of Europe as a threat to home birth. Rereading the article, I realised I’d forgotten this point of concern, but with hindsight I think that they are right. And not only internationalization processes at a European scale are relevant, mondial processess are involved as well. Take for example the immigration from countries from all over the world into the Netherlands. Immigrants coming to the Netherlands do not know the tradition of home birth and see it as obsolete folklore, a remnant of the past, something for poor people.

I will explore the causes of the decline of the home birth, focussing on two pillars of the Dutch system: the position of the empowered autonomous midwife, and the cultural definition of birth as a normal life event, not as an illness. My argument will be that these pillars are shattering.

2

The empowered midwife and the normal birth

The foundation of the strong position of midwives dates back to the Health Law of 1865 (Wet op de Uitoefening der Geneeskunst). In this law the legal competences and qualifications of different medical professionals in the Netherlands were established. The professional tasks of midwives, were also regulated: they didn’t become subordinate to doctors, they didn’t have to work as nurses, as paramedical personnel. Their work was defined as complementary to that of obstetricians. They had to act in cases of normal birth, the obstetricians in case of pathology. These professions should work together, side by side.

Later, some physicians wanted to create a division of labor between themselves and midwives, along lines of wealth. They wanted to attend to rich patients, while midwives should look after the poor ones. But the doctors didn’t succeed: midwives remained the attendants of women who were healthy and expected to have a normal birth. Speaking about the second half of the twentieth century, Gerrit-Jan Kloosterman remembers in Successful Home Birth how indignant rich people could be when he referred them to a midwife. It is interesting to see, that today the same objections are uttered by immigrants in the Netherlands. At the playground where I am often together with my grandchildren a man from Romania, told me he was very angry that it was not self-evident his wife would have their baby in hospital. He saw this as an example of discrimination against them as immigrants.

In the 1960s the obstetrician Kloosterman became the director of the School for Midwives in Amsterdam, one of the three schools in the Netherlands. He thought the distance between midwifery and obstetric science, and the medical world in general, was too big. He saw the isolated position of midwives as a danger for their profession, and he was afraid that this isolation could make them look like second-rate professionals. He therefore brought about the integration of the School for Midwives in a large hospital, where cooperation between midwives, obstetricians, but also surgeons and pediatricians could guarantee that they worked at a top level.

For Americans like Katz Rothman this close cooperation is difficult to understand, but in my opinion it is one of the foundations of the Dutch birth model. The tasks and the qualifications of the midwives were from time to time adapted and upgraded to the newest medical insights. When prenatal care became important, midwives too received the right to care for a pregnant woman. They became qualified to do some blood tests and prenatal screening tests, and they also received the permission to repair a tear in a perineum. Only if they expected pathology they should send the woman to the specialist.

This refers to the foundation of the Dutch birth system: the distinction between physiological and pathological pregnancies and births. Birth is seen as a normal life event, not as an illness. Trust in nature is the basis of these ideas, medicalization was only justified in case of medical necessity. That means that pregnant women first of all visit the midwife, who has to determine which women are at risk. These women have to see the obstetrician who can send them back to the midwife in case birth is nevertheless expected to be normal. This division of labor between midwives and obstetricians is sanctioned by the government.

Midwives acquired the monopoly over normal birth, also because of their lower costs, and they were indicated as the gatekeepers for referring pregnant women to obstetricians. Births attended by an obstetrician were only remunerated in case of pathology. For this reason health insurance companies asked for clear directives to regulate the screening between physiological and pathological pregnancies and births. In 1973 Kloosterman compiled a list with medical indications, a selection instrument that became known as the ‘Kloosterman-list’, revised several times in the course of the years. This list has always been a battleground, because it determines the division of labor between midwives and obstetricians.

This has also consequences for the place of birth: obstetricians only work in hospitals, which means that a referral to an obstetrician also implies a referral to a hospital. In the case of physiological pregnancies and births, pregnant women are attended by midwives and they can choose themselves between a home birth or a short-time hospital birth – which was introduced in 1965.

Good and smooth relations between midwives and obstetricians or other specialists are necessary conditions for the functioning of this system, as the example of Katz Rothman demonstrates. For a long time, advanced medical possibilities, high-standard medical facilities, together with more financial security and good welfare facilities parallelled a peace of mind about the Dutch birth model. Midwives had much support among obstetricians, but this support is gradually diminishing.

3

Three cracks in the birth system

The short-stay hospital birth

No strangers at the bed – that statement is characteristic of the closed domestic family which was for a long time characteristic of Dutch family life. In the twentieth century this ideal of domesticity was also implemented in the arrangements created by the welfare state, which promoted home birth and the independent midwife. But from 1965 short-stay hospital births in cases of normality and attended by midwives, (in the Netherlands called ‘policlinical births’) were introduced and these were also remunerated by insurance companies. In an article about the rise of the hospital birth I argued that the short-stay hospital delivery was an important factor in the accelerated increase of hospital births. ‘Policlinical births’ offered the combination of the ‘safety of the hospital’ and the ‘cozyness of the home’. The result was a quick increase in hospital births, with and without a medical indication: from 22,1% in 1950, to 27.4% in 1960, to 42.7% in 1970, to 64.6% in 1980 (Van Daalen 1988). This increase can be interpreted as the first crack in the traditional birth system.

In 2015 only 13,1% of the births takes place at home, 2,4% in a birth centre, while 13% of the births is a short-stay hospital birth. That means that 29% of the women has a ‘normal birth’, under responsibility of a midwife; and 71% is medically indicated and is attended by an obstetrician in hospital (Jaarboek Zorg 2015).

In the 1970s and 1980s some obstetricians began to criticize the possibility of home birth, and this is the starting point of ‘a birth movement’, a cooperation between feminists and active midwives, supported by the majority of obstetricians, with well known names like Kloosterman. This movement supported home birth and the autonomy of midwives, and defended the traditional Dutch birth model, with its trust in nature and its resistance to medicalization.

The strength of the system was that it was organized on a foundation of traditions while it was adapted to the modernity of the welfare state of those days. There were good prenatal care provisions, a good selection system for pathological cases, legally recognized independent and certified midwives, maternity care assistants – helping after birth, supporting the mother in breastfeeding, helping in the household, regulating visits. At that time the image of home birth changed from a traditional custom and a self-evident remnant from the past into a modern practice, especially suitable for autonomous and independent mothers-to-be. Feminists sided with midwives against male gynaecologists, emphasizing their common female status and their shared emancipatory struggle. But the hospital births continued to grow.

The perinatal mortality shock

In 1960 The Netherlands had the fourth place in perinatal mortality rate on a range of 15 European countries. That made a defense of the system redundant. But the Dutch perinatal mortality rates didn’t decline as quickly as elsewhere in Europe. In 1996 the place of The Netherlands even had fallen back to the eleventh position (Garssen & Van der Meulen 2004). This fact gave much commotion in the media, and the news was presented as highly alarming. There were critical sounds that the statistical evidence was not sound, that definitions of perinatal mortality in different countries didn’t correspond and that these were not comparable (in the Netherlands defined as mortality during pregnancy from 22 weeks, birth and the first period after birth 28 days after birth). Some people were opposed to the idea that home birth or the quality of the work of midwives were the cause of the relatively slow decline of perinatal mortality. Kloosterman for example saw an explanation in the earlier lower mortality level. He pointed to the fact that between 1963 and 1978 the number of home births didn’t decline, while perinatal mortality continued to go down from 12,5 in 1963 to 9% in 1978 (Van Daalen & Van Goor 1993). Other causes were also mentioned, eg the increase of the average age of primiparae, women who give birth for the first time, or the increasing frequency of twins.

Since that time the relative position of The Netherlands has improved somewhat, and in 2010 the Netherlands reached a middle position within Europe, with a rate of 5,1 per 1000¹.

But despite this improvement and despite the critical comments, the opponents of home birth and a strong midwifery used the perinatal mortality rates to defend their case. They presented these data as a proof that home birth was too risky. And many women believed that they were right. Media gave sensational stories about the anachronistic Dutch customs around birth, which were presented as unworthy of a modern country. Public anxiety didn’t disappear, and the effects of this discussion were extensive. Home birth lost its self-evidence.

The blurring of normality and pathology

In recent years the expansion of prenatal care, in particular the increase of prenatal screening and the emphasis on preventive medicine, have made the always contested demarcation line between normality and pathology more diffuse. Continuing medicalization of pregnancy has undermined the ideas that existed in the Netherlands about a good ‘natural’ birth. As more and more risks during pregnancy are identified as suitable for treatment, this aspect of the progress in medical science and technology has raised awareness of all the possible risks concerning birth. The technological imperative, having to give the best care that is technically possible became more and more important as a general guideline (Compare: Guillemin & Holmstrom 1986: 130, 268). Screenings have become normal routines, pain relief is no longer taboo.

If pregnancy or birth become labeled as pathological, obstetricians are the ones who determine the birth trajectory. But in the case of ‘normal’ birth, parents have more to choose, and as prenatal screenings are expanding pregnant women have to make more medicine related choices. They have not only to choose between home and hospital, but they also must make up their mind about prenatal screenings and diagnostics – blood tests, genetic tests, the frequency of ultra sound examination. Besides that, they have to decide about associated issues, like pain relief or birthing position – horizontally, vertically, in a bath.

While in former times the instructions and advices of professional attendants, mostly midwives, were the most important source of information of pregnant women, today the worldwide web gives access to information about state of the art knowledge of pregnancy and birth, about diagnostics and medical interventions. But it is difficult to find your way when searching for such knowledge. Mothers-to-be see that medical knowledge is constantly changing and that it is always disputed, as is characteristic of science. It is difficult for them as lay-persons in medicine to assess the information they can find. But whatever this information tells them, they surely will become more aware of dangers and risks. Just like professionals, pregnant mothers have to deal with different kinds of insecurities. I interviewed one young mother who forbade herself to search on the internet, because she became obsessed and confused about the overload of information. That confusion makes it more difficult to decide about issues like place of delivery, with the result that they tend to choose for what they consider to be the safe side, and many of them see hospitals as the safe side.

4

Recent trends

In order to investigate the causes of perinatal mortality, from 2010 perinatal audits are organized, regularly at a national level.² Within two years all hospitals in the country providing obstetric/paediatric care together with their surrounding midwifery practices participate in such perinatal audits. Nurses, midwives, obstetricians, paediatrics discuss case by case the steps taken by the different professionals before the death of a baby.

The so called ‘substandard factors’ which they find are very diverse. Not following the instructions and the protocols is mentioned, miscommunication between professionals at the transfer from one professional to the other one, for example when the pregnant women moves to another place. The conclusions of the audits thus far is that professionals should be more alert during preconception, pregnancy and birth. Prenatal care and the supervision of birth should be more intense and more interventionist, with more medical tests, more ultrasounds and more measurements of the growth of the foetus. Most of the proposed measures are routine procedures in neigboring countries. Pregnant women should be better informed about a diversity of risks, eg the risk for primiparae of having to move from home to hospital during birth, the risk of waiting too long to induce birth with babies who are overdue, the risk of an unhealthy life style, the risk of not recognizing problems of the fetus in utero, such as growth delay of the fetus. Despite these warnings the possibility of home birth as such is not dismissed, and the autonomy of parents-to-be is respected, also if they prefer home birth attended by a midwife.

These perinatal audits are based on cooperation between professionals and that is also the government policy. The intention is that in the future midwives and obstetricians will work together within collective associations and collectively financed. This policy is founded on the expectation that joint action will lower the perinatal mortality rate. For each woman one professional will act as a coordinator, which should improve the communication. Midwives – and also maternity care assistants – however experience such a cooperation as a threat of their autonomy and as promoting medicalization.

Doubt about the ‘Dutch model’ has grown, the normality of birth has become disputed, while the awareness that something can go wrong has increased. The risks of pregnancy and birth are emphasized, the balance in the perception of trust and risk has been disturbed. In this constellation the position of midwives has become more contested than ever. Their reaction and that of outsiders has been a call for more and more professionalization. The result is that midwives are caught in a web of obligations, of more and more tasks and responsibilities – coaching the lifestyle of pregnant women, performing more tests and screenings. Their professional position is besieged, trapped in-between obstetricians and assertive knowledgeable mothers-to-be.

The time and again upgrading of their tasks and qualifications, is seen as a necessary condition for remaining on stage, but at the same time this will involve more medicalization, associated with more risk awareness, less self-confidence and less trust in nature. One indication of their heightened risk awareness is the increase of durante partu transfers to hospital. In order to be competent colleagues who are able to cooperate with obstetricians they try to professionalize more, but they are in danger of being overburdened. In the meantime their specific qualities as attendants in a normal birth situation are underrated.

5

Interpretation: mental struggles

Medicalization and internationalization, in particular competition between countries concerning mortality rates, have influenced the practices and the ideas around birth in the Netherlands and home birth is losing ground. The fears of Katz Rothman and Kloosterman were grounded, but both of them pointed in 1993 to technology oriented obstetricians as the possible evildoers. In her recent book, A bun in the oven. How the food and birth movements resist industrialization (2016), Katz Rothman also points to ‘capitalism’, ‘medicalization’, the ‘industrialization of birth’ as causes of the commodification of babies and of the efficiency in hospitals. She writes: ‘Babies are not products. They are relationships’ (Katz Rothman 2016: 227).

She is right, but blaming the systems is a reifying way of explaining the recent developments. It obscures the fact that mothers-to-be and professionals are the agents in this story, interacting together, having their own ideas and feelings, their own ambivalences. Such changes in mentality are the real threat to the Dutch birth system. The choice is not between technology or humanity, as is for example suggested in the French film Sage femme (2017), ‘midwife’ in English. Modernity doesn’t have to exclude humanity, midwifery can go together with technology. It is a mystification to draw a line between old-fashioned considerate midwives and obstetricians using cutting edge technology. Indeed, there are battles between professionals going on, but just as important are the mental battles of pregnant women and of professionals, each of them struggling to search for the best way to act, entangled in knowledge which is always disputed, hesitating about the choices between different insights, worried by a growing awareness of risk.

In the Netherlands women, midwives and obstetricians have become more risk conscious, while trust in the basic assumptions of the Dutch model has diminished– like ‘pregnancy and having a baby are natural phenomena, not illnesses’, ‘nature knows best’, ‘a conservative, non-interventionist medical approach can prevent the negative side-effects of medicalization’. These changes in assumptions erode the thinking and feeling around pregnancy and birth in the Netherlands.

That means that it has become more difficult to reach a situation of trust. Trust presupposes confidence, which according to Georg Simmel is based on a mixture of knowledge and ignorance. When people give an interpretation of a situation, they are always confronted with uncertainties. Some things they know, other things they don’t know. In trying to overcome their lack of knowledge, they need a willingness to suspend their doubts and their anxieties. That is the only way in which they are able to formulate expectations of what is about to happen. So situations of trust presuppose a leap from people’s often intuitive interpretations into expectations for-the-time-being, suspending contradictions and ignorance (Möllering 2001).

In the case of pregnancy and birth, people today are more knowledgeable than ever. They know more and they are better informed about risks; concerning their own health they have more options of screening and control. Their knowledge has increased and the domain of their ignorance has become smaller. But at the same time new uncertainties have developed. Pregnant women are continuously confronted with uncertainties about where normality ends and pathology begins. It is difficult for them to orient themselves in the ocean of information, to judge contradictory views of professions, to interpret their own experiences, and to combine it with common sense knowledge from family and friends.

At one end of the continuum, women see pregnancy and birth as a kind of dangerous illness, in need of medical supervision. They listen to medical professionals, by preference to obstetricians, and they rather go to hospital, having confidence in the newest technology. At the other end of the continuum there is a small number of pregnant women who prefers ‘freebirth’. They see pregnancy and birth as natural processes, and as empowering experiences. They want to be in charge themselves, taking decisions and taking risks as they please. In the middle of the continuum one may find the majority of pregnant women, searching for information, puzzling together the right strategy.

Simmel’s concept of ‘weak inductive knowledge’ is particularly adequate to characterize the state of knowledgeability of these women: it is hard to articulate expectations. They are confronted with new knowledge and new techniques, which cause new uncertainties while pertinent knowledge is lacking. It has not become easier to bridge the gap between interpretation and expectation. Now the traditional trust balance in the relations between pregnant women, midwives and obstetricians has lost its self-evidence, it has become more difficult to acquire an adequate overview of the broad field of pregnancy and birth, to know all the possible alternatives with their advantages and disadvantages.

This search for a new balance in trust relations is completely in line with the contemporary preoccupation with things that might go wrong, which Ulrich Beck and Anthony Giddens see as a characteristic of the modern ‘risk society’ (Beck, 1992; Giddens 2001). Risk assessment has become an important technique of living in a modern world, especially so when matters of health are concerned. In the case of birth in The Netherlands new medical possibilities enable people to see more risks, which undermines the long-established trust in nature and in the naturalness of births. Modern risk awareness goes together with trust in medical supervision and medical advancement. More risks become perceptible, which feeds feelings of insecurity about home birth and about midwives and their way of working. This is an ever reinforcing process, a kind of loop.

Discussion: what about home birth?

At this moment home birth in the Netherlands is for the happy few, whose pregnancy and birth are not medically indicated. They can enjoy the luxury of staying at home, in their own bed and bath, with their own family and friends. It is important to cherish home birth as one of the alternatives to have your baby. Not only for women who prefer a home birth, but also to protect home birth as a valued cultural heritage, and as a demonstration that healthy pregnancies and births do not have to go together with medical interventions and hospitalization.

But home birth only will have a future if the position of midwives, as one of the pillars of the Dutch model, is strengthened. For a long time the professionalization of midwives has been connected to the professionalization of obstetricians. This mechanism enabled midwives to keep up with the state of the art of medical science, and not to become second-rate professionals. But today the oppposite effect is reached. Midwives are overloaded with obligations and responsibilities, while their specific professional qualities tend to become invisible. Their first quality is their capability to attend in case of normal birth, at home or in hospital. But midwives are also specialized in other professional tasks, which are underrated, which are often neglected and are seldom articulated. They have also a role as counselor and as gatekeeper for obstetricians. In giving prenatal care, they have to function as a guide for pregnant women looking for information and knowledge; and they have to decide if a woman needs extra attention of a medical specialist. The progress of medical knowledge and medical screening techniques has changed these aspects of their work. Their roles as counselor and as gatekeeper have become more important and more encompassing. The professionalism of both of these roles should be recognized as something to cherish and to be proud of.

Medical progress makes that we have to live with insecurities about which we were ignorant in the past. We have to find new ways of doing that. Different strategies are used to close the trust-gap. The first one is based on the professional logic, as described by Eliot Freidson (Freidson 2001). Here, knowledge, training and experience are the foundations of trust and of professional acting, of innovation and creativity. Externally imposed rules are supposed to stand in the way of a professional approach. Each client or patient has to be observed with a fresh eye, recognizing the specifics of each separate case; routine procedures are not sufficient. Therefore professionals should have ‘discretionary power’, a certain freedom to take decisions, following their own professional rationality. Such ‘discretion’ assumes being committed, being morally involved in one’s work, and being trusted. These are attitudes in which failure in work is not seen as the result of willful neglect.

Today this model of professionalism is observable in the perinatal audits in the Netherlands, but it is combined with promoting ‘transparancy and accountability’, the magic words of today. Protocols and standardization are seen as methods to control the acting of professionals, but these methods are characteristic for the distrustful way professionals are regarded today. In this strategy trust as a self-evident trait of the relations between professionals and their clients/patients is in danger to be lost.

Offering discretionary power to midwives and obstetricians presupposes that they are well trained, that they know enough and that they have sufficient experience. If all these conditions are fulfilled, the growing awareness of risk doesn’t have to go together with a decrease of trust in the capabilities of both midwives and obstetricians. There is another condition which should be fulfilled: the blurring of normality and pathology has made it necessary to reconsider the differentiation between the tasks and qualifications of midwives and obstetricians. Such rethinking should take the independent and autonomous professional position of midwives as its starting point. Midwives are no obstetricians-light, nor are they the assistants of obstetricians. They are attenders of normal birth, they are counselors of pregnant women and they are the gatekeepers of pathology.

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