This month I had the pleasure of interviewing Simone Valk, a midwife practicing in Rotterdam, Holland. Simone graciously gave of her time to share a bit about herself, the training of midwives in Holland and the general nature of maternity care in Holland. The differences between our systems of healthcare is quite evident, but I found the differences in philosophy most impressive, and sobering.
This month I had the pleasure of interviewing Simone Valk, a midwife practicing in Rotterdam, Holland. Simone graciously gave of her time to share a bit about herself, the training of midwives in Holland and the general nature of maternity care in Holland. The differences between our systems of healthcare is quite evident, but I found the differences in philosophy most impressive, and sobering. I challenge all readers of this candid exchange to reflect upon the information Simone provides and perhaps glean a bit of philosophical wisdom that may strengthen you as a provider of obstetrical care.
Deborah: Simone, would you please give us an overview of the midwifery educational path in your country?
Simone: We have 3 midwifery schools in the country. They all have the same curriculum and the same exams. They all have 40 students a year. The training takes 4 years (used to be 3). Anyone with a high school diploma on a certain level (the high school system here is widely different from the one in the US) can apply for a place.
Deborah: What is the outcome of the 4 years, is it a college degree?
Simone: More or less. It is not a university degree, but I think in U.S. terms it can be named a college degree.
Deborah: Is this nursing education? Does one have to be a nurse to be a midwife?
Simone: No, you don't have to be a nurse in order to become a midwife. It just so happens every now and then. I have no idea about a percentage, but in my class of 20 students, we had 3 nurses. But a lot of students have done something else before. I remember in my class a social worker, someone who had done 2 years of psychology and a dental hygienist. There is no age limit to the school. The minimum is 19 years. But we had a student last year who started school when she was 41. Any midwife that graduates will be registered by the state. She can work in either a home practice or a hospital that works with midwives. She is entitled to do low risk prenatal care, low risk deliveries and childbed care. Holland is a very small country, with 15 million people living here. It is pretty crowded. Most midwives work in the vincinity of a hospital and most have good working relationships with the ob's and peds there. But it can vary enormously.
Ob's are not supposed to do low risk patients, only high risk. The medium care should be covered in mutual agreement. On paper the system works fine, in practice of course not a 100%, but the variety is wide, depending on the area, local habits and personal tempers.
Deborah: Would you define what is considered "low risk" and "high risk" in your country?
Simone: Low risk is everyone who is healthy. High risk are women, e.g. Diabetes patients, or hypertension patients (without being pregnant). A woman can start as a low risk client and develop problems that make her high risk. A woman with a cs (cesarean section) the previous birth is considered high risk. But someone with a pph is medium risk. [She] should deliver in the hospital but with a midwife. Midwives cannot do vacuums or forceps. We have a long list in which every possible ailment is listed with a grade. "A" means midwife, "B" means consulting, "C" means ob (obstetric) care and "D" means hospital but with a midwife. These lists were made by midwives and ob's and gps (general practitioners). Not everyone sticks 100% to it but generally it works. This list states furthermore that a midwife should sometimes seek advice, that the ob gives the advice but that the midwife decides if she follows it.
Deborah: Tell us now about yourself, how you became a midwife and your own practice situation.
Simone: I am 42 years old, married and mother of 2 girls, ages 11 and 9, and a boy, 8 years old. I live and work in Rotterdam, one of our 4 big cities. (All of these 4 have less than 1 million occupants) I live on the outskirts in a fairly wealthy spot and there I work with 2 other midwives. We have about 350-400 clients a year. This is considered a 2 person practice, but we all 3 like to work part-time. After highschool I had no idea what to do, so I entered a nursing career. Always useful. Well, I liked it enormously. During my weeks on the l&d ward I saw midwives working and then I was hooked. After nursing school I went to midwifery school and I liked that very much. After midwifery school I started on the job I still have. We used to be with 2 midwives, but this area was developing rapidly and there was a babyboom so after 2 years we asked another midwife to join us. Gradually the babyboom has died down a bit (people stay in their house till the children leave) but in the meantime my own kids were born and I like to spend some time with them. From every 3 weeks I work 11 days, and have 10 days off. These 11 days are 4 days in the office, doing prenatals, (well, 2 half and 2 whole days) and 7 days on call, in portions of 48 hours and one of 72 hours. During these days you are responsible for all deliveries and all childbed care. We visit mothers postpartum.
Deborah: Is that a private practice? What is it called? If not, how are you funded?
Simone: No, it is not really private practice. We are paid by either the private insurance company or the general insurance that covers everyone who earns less than a general amount. We just send bills afterwards. We have a contract with 1 general insurance, and because of that contract every general insurance pays us. Deliveries are either at home or in the hospital. We have access to every hospital we care to go to.
Deborah: Is there any sort of accreditation process for hospital privileges?
Simone: No, you start in your practice, send around that you are the new midwife and go and introduce yourself. If a midwife gives a lot of trouble they can take your privileges away, but this is very rare. I am also a member of the complaints committee. Every professional group has to have a possibility for clients to complain without having to go to court directly. So when someone complains about her midwife, anywhere in the country, we read it, send it to the midwife with requests for reaction within 3 weeks. After that we organize a hearing in the town where they come from and talk it over with the client and the midwife and two or three members of the committee. Quite often they all leave this hearing very satisfied. And within 4 weeks the committee decides if the client is right or not and why. If the client is right we can advise the midwife to take some special training. This is really a very interesting job.
Deborah: Do you have "in-house" OB's, for sections and complications?
Simone: The hospitals have 1 ob on call, and an in-house resident for the simple work at nights. The ob will come to the hospital when called, and so does the ped. The hospital we work with has no formal ob training, they have a lot of residents who want to go to the third world and want to have some ob experience and some surgical routine. Most stay 6-24 mos. So we have a teaching job, very informal and not paid, but still a teaching job.
Deborah: What is the philosophy of birth in Holland, both among providers and the women? What is the general relationship between obstetric physicians and midwives?
Simone: The birth philosophy in Holland in general is that pregnancy is not a disease, but a special phase in life. And birth is also viewed as a normal process. Painful, but well worth the effort. Epidurals are still unusual (I clearly remember the anesthesiologist muttering one night: Jesus, my wife did without, what is getting into them these days) birth classes are widely offered, but a lot of folks feel they can do without, or just go to it because they hope to meet a nice friend. Ob's on the whole will get along when someone wants a homebirth and get her the address of a midwife. I don't know if you read my hectic start of the new year. Well, that ob was behaving untypical. Yesterday night I had another breech, almost complete at home and totally undetected before. So I told the mother, sorry we go the hospital now. Well, the ob was very relaxed. Her contractions had completely stopped by the time we arrived at the hospital, but when I said that she had good contractions at home in the dark in her easy chair, he switched off the lights, told her to get as comfortable as possible, take all the time she felt she might need and just sat there with me and the resident chewing the fat a bit with this couple. In the hall he had told me that he wanted the resident to do the breech, guy never had done one and he had to teach him something, but he promised me to do it easy, no episiotomy if he could help it. So I negotiated about not clamping the cord and he agreed to 3 minutes, well, not bad either. After an hour or so she had good contractions, srom and delivered in 10 minutes with a tiny episiotomy that I think I would have done too. Well, later I was thinking of you, thinking that this was really a good example of dutch obstetrics. In general, I think you can say that midwives may tend to be a bit on the medical side, considering from an American midwives point of view, but that obs are midwife friendly and may be less medical or aggressive than their American counterparts.
The relationships between obs and midwives are generally nice. It helps to be in a big city with hospitals to choose from. If the ob will not cooperate we can easily pick another hospital. In smaller towns with often one hospital it might be a bit more difficult for the midwives because the ob's are calling the shots. But in general they appreciate one another and they work well together. The thing is that if we had no homebirths any longer the hospitals would be totally clogged. The biggest l&d ward in Holland is here in Rotterdam and they have 2400 deliveries a year. And they cannot handle more. There is just no money to have everyone deliver in the hospital.
At the moment there is a lot of political arguing to get all medical specialists in paid emloyment, so they don't benefit from having more clients. I don't know if this will really happen, but is interesting just to think about it. As in all countries, healthcare costs are rising and rising and they have to cut it down somehow.
Most obs I know are very easygoing, will let you do breeches etc with them in attendance, or msf with them somewhere around. But that can vary widely. Here in Rotterdam working relations are nice.
Deborah: What about postpartum care?
Simone: At home a doula from the center assists and stays with the family for the first 8 days. She teaches the mother all about babycare, receives visitors, cooks meals, cleans the house etc. In case of problems she calls us. We take care of stitches and PKU testing. After 8 days we are generally finished and the district nurse takes over. We see the mother at a 6 weeks pp visit for the last time.
Deborah: What is your viewpoint regarding maternity care in the United States? Especially midwifery? How are we viewed by OBs and midwives in Holland?
Simone: My viewpoint of maternity care in the US has been largely coloured by this List (referring to a professional midwife listserve she belongs to). The midwives I meet on this list are so skilled and well informed, seem to have the last research on the tip of their tongues. I am really impressed. Before I was a member of this list I had no idea that there were so many midwives in the US, and I had no idea that some have to work almost illegal. I knew that the US has a lot of OB's and there is a general understanding here that in the US everyone has an epidural, that ob's deliver the baby rather than the mother, that there is good care for people who can afford it, and that there mortality rates are a shame for the richest country in the world. Also people here assume that in the US everyone is ready to sue her doctor, which makes dr very defensive and insurance almost impossible. I can remember having read somewhere that there is a bumpersticker for ob's that says: let lawyers deliver the baby.
The midwives here that have met midwives in the US appreciate them. And when I tell ob's something about US midwives they look at me as if I had dug up a very rare new species.
Deborah: What is the one thing that Holland's system could improve upon? And what is the very best thing about it?
Simone: Money here is very tight. Where not indeed? But the government is making cuts everywhere. They are cutting doula service now, and we need them so very much. District nurses baby care services ditto. And the government should spend much more on efforts to educate the public about the safety and the advantages of home deliveries.
The best thing about it is that it is based on: you get what you need, rather than you get what you can afford. That is the heritage of many years of socialism.
Deborah: Simone, this has been wonderful. I think that all of us involved in maternity care whether it is here in the U.S. or anywhere else in the world will benefit from what we have learned from you. Thank you so much for your time and candor. It is greatly appreciated. Best of luck to all your current and future endeavors.