By nature, the Dutch are a nation of sailors, with an adventurous spirit and a love for taking the lead and entrepreneuring. Wherever they go, the Dutch tend to make themselves heard and count, for better or for worse. It comes with a strong sense of independence, a desire to make their own free choices. This is exactly what we find in the world renowned Dutch maternity system, with its free choice of place of birth, its homebirths and its unique system of “kraamzorg”, an extended postnatal care service. But to quote Bob Dylan, “the times they are a changin”, and a balance between independence and collaboration, between devision and integration, between free choice and best choice and between physiology and the health benefit of interventions is sought.
Dutch Midwifery Platform "Without Borders"
The current balancing act in Dutch birth care is not an easy one. In this process we can benefit and learn from looking beyond our own borders. That is why the Royal Dutch Organisation of Midwives (KNOV) has a special platform “Without Borders”. It aims to connect the Dutch midwifery community with the international one and to exchange all the inspiration, ideas and energy that come from abroad. Last monday, the members of the platform “Without Borders” gathered for their biannual meeting, this time at the University of Midwifery Education & Studies (AVMU) in the city of Maastricht. The focus of the day was on physiology and what we can learn about it from other countries.
Physiology across borders
Marianne Nieuwenhuijze, lecturer in midwifery at the AVMU, gave us the highlights of the 2016 Normal Birth Conference in Sydney and the inspiration she took home from there. For instance, she introduced us to “Birth By The Numbers”, a project started by Eugene Declerq, professor in Community Health Sciences in Boston. The website provides an online platform where data from all over the world are collected and put in a uniform format so that it gives an accurate, up-to-date insight into childbirth practices and outcomes. I also highly recommend that you check the other keynote speakers’ videos on the conference website. Thanks to Marianne’s update, an interesting debate arose. One of the topics was how we go about standard interventions like continuous CTG monitoring, the moment of cutting the cord, active management of the third phase with oxytocin, and routinely administering vitamin K. Do we see our protocols and directives (which are sometimes evidence based but more often consensus based) as recommendations or as strict instructions on how to manage situations as a midwife? Shouldn't we facilitate choice by informing our clients about the pro and cons instead of expecting them to just follow the path of care we set out for them?
As an intermezzo, a lady of the Female Health Company introduced the female condom FC2. The giggling in the room probably indicates that even among us midwives, this product is not yet a household name. The FC2 is made of a nitrile polymer (non-latex) sheath of 17 centimeters, it contains an outer ring and a polyurethane inner ring and is covered with a silicone-based lubricant (which is spermicide, preservative, paraben and gluten free). Even though I understand the potential of this product, I have my reservations, which I might discuss some other time.
Inspiration from Canada
A very interesting presentation was given by midwife Else Vooijs. In 2015, she visited Canada with a small group of Dutch midwives, for a crash course in midwifery the Ontario way. In the past, Canada found inspiration in the Dutch system when introducing and establishing midwifery care in their country. Now the Canadian system can spice up our thoughts on the role and place of midwifery. Unlike in The Netherlands, in the province of Ontario there is no distinction between a clinical midwife and an independently practicing midwife. In Canada, they are actually two in one, the midwife can do home deliveries as well as follow up labour in hospitals. Even in case of meconium stained liquor, induction of labour or an epidural, she remains the leading midwife until she makes the diagnosis that high risk became pathology and demands supervision by a gynaecologist. It is clear that the Canadian interpretation of physiology is different than ours. High risk is not yet considered a pathology. This means that the midwife plays a bigger role in diagnostics than in the Dutch system in which medical and obstetric risk situations are listed in the “List of Obstetric Indications”, which tells you to which care provider your client needs to be referred. For instance, in Canada, a midwife is allowed to start antibiotic therapy at home, which allows even women who tested positive on the Group B strep bacteria to have a home delivery.
The Canadian interpretation of the midwife’s role seemed to find a willing ear with the midwives in Maastricht. In Canada, the midwifery care model is deeply rooted in a grassroots movement of women which gives them a powerful voice in debates on development of care and the role of midwives. Such a natural symbiosis gives both women and midwives a powerful voice in the path of care and in the development of birth care. In this respect, important lessons can be drawn from a recent campaign of Stichting Geboortebeweging, which brought to the fore a sometimes painful image of how women perceive the birth care they received. Even though it is sometimes a challenge to represent the voices and wishes of all women, their feedback is essential in learning how to make them the focal point of our work.
Last but not least, Franka Cadée presented the outcomes and experiences of the Twin2twin project of the KNOV and the organisation Midwives4mothers. For those who are new to the concept, twinning is “a cross-cultural, reciprocal process where two groups of people work together to achieve joint goals” (Cadée, 2016). Twin2twin is a form of twinning in which individuals are matched, on the basis of equality, in order to learn from one another, to build bridges between cultures and to strengthen their power as a midwife and as a midwifery organisation. Each Dutch midwife was matched to a colleague in Morocco or Sierra Leone and worked with her “twin” on a small-scale project to improve maternal health. By running both projects, a Dutch team of researchers could gain experience with this form of twinning and was able to develop the method further. During the 2017 ICM conference in Toronto, the T2T mobile app will be launched which will allow others to learn about the method.
Maybe “the times they are a changin”, but if we respond to the call of the new coordinator of the “Without Borders” platform, Liselotte Kweekel, to humanize birth care, then I am looking forward to those times and hope to be part of that “wind of change”.
De Geus, M. & Kweekel, L. (2012). Twin2twin, Midwives Empower Midwives, an inspirational step-by-step-guide. KNOV.
Amelink-Verburg, M. P. & Buitendijk, S.E. (2010). Pregnancy and labour in the Dutch maternity care system: what is normal? The role division between midwives and obstetricians. J Midwifery Womens Health, 55(3):216-25. doi: 10.1016/j.jmwh.2010.01.001. See: https://www.ncbi.nlm.nih.gov/pubmed/20434081
Cadée, F., et al. (2013). ‘Twin2twin’ an innovative method of empowering midwives to strengthen their professional midwifery organisations. Midwifery 29 (2013) 1145–1150.