A Pleasing Birth: Midwives and Maternity Care in the Netherlands

Vries, Raymond De
Stanford University Press, Stanford, CA

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Cover of book This is a rewarding book to read. Its argument proceeds at more than one level. The author's previous work was focused on maternity care in the USA, and in particular, on the obstacles faced by midwives in gaining acceptance as professionals with a valuable contribution to make. De Vries is of Dutch descent, and not surprisingly, he was drawn to the task of describing, explaining and accounting for the unique pattern of maternity care that prevails in the Netherlands. His book gives an excellent description of how that system works, but it has more than this to offer.

De Vries draws extensively on interviews with midwives and obstetricians who had experienced the events and social processes that gave rise to the current arrangements. He supplements these oral narratives with written historical material, for the purpose of enabling the reader to form a view of the forces at work in the creation of a setup that is unparalleled in the industrialised world, in that about 30% of births take place in the mother's own home. How is this to be explained? It is the outcome of conscious efforts to preserve what was best in the older way of birth, before anxiety to guard against risk led other countries to take the path of medicalising pregnancy and childbirth.

Readers acquainted with the story of these efforts will be aware of the important role that was played by one eminent obstetrician, Kloosterman, who advocated the preservation of an independent midwifery profession. It is a measure of the thoroughness with which De Vries has investigated this topic that he has unearthed the fact that in the early 1960s, even Kloosterman believed it was inevitable that midwives in the Netherlands would have to lose their autonomy, becoming subordinates in a hospital-based system that would require them to train first as nurses (p.64). Only a series of unforeseen contingencies like a temporary shortage of state funding for the restructuring of midwifery training prevented a policy along these lines, conceived on the British model, from being implemented. But somehow, by the early 1970s, a more questioning attitude to the authority of high-tech obstetrics had taken root and manifested itself in a major policy reversal. Instead of assuming that only someone experienced in handling difficult labours could be relied upon to distinguish between high-risk pregnancies and low-risk ones, Dutch policy-makers adopted the view that this crucial part of the decision-making process could safely be entrusted to midwives with the proviso that a set of standardised guidelines could be formulated for discriminating between different levels of risk.

For those who have only a passing interest in the conundrum of how the Dutch maternity-care system came to be so different from every other, the highly detailed account which De Vries offers of the ins and outs of the negotiations that shaped it might be in danger of seeming excessively lengthy. But this is where the multi-layered character of the book becomes relevant. This is not simply a book about maternity care. It is also about a more general question: how should we set about analysing the pressures that cause this or that set of health-care policies to take shape, in any national context? De Vries claims to throw light on this basic question by reflecting on what is involved in providing a sociological analysis of the Dutch debates about the role of midwives. In a nutshell, his argument is that tracing the political processes will only take us so far. We need, in addition, to pay attention to the cultural presuppositions that give extra resonance to some proposals and less to others.

Though conscious that sociologists are often critical of culturalist 'explanations', De Vries presents a strong case for saying that we need to think in terms not only of decision-making structures but of cultural traditions as well. Admittedly, the procedures whereby social policies are arrived at in the Netherlands are exceptional in giving a chance for all interested parties to make a significant contribution. But that alone does not suffice to account for the unusual outcome in this instance: distinctively Dutch attitudes to the family and the home, to pain, to heroics and to value for money all played their part.

Peter McCaffery
University of Aberdeen