Neonate. * Evidence ofgrowth retardation or prematurity, cyanosis, congenital anomaly. Conditions for home delivery. * No contraindications as above; singleton.
GENERAL PRACTICE
Organising midwifery led care in the Netherlands Christina Oppenheimer The growing pressure for changes in the care available for pregnant women at low risk found a voice in the report on maternity services from the House of Commons Health Committee published in February 1992. The demand for greater autonomy and responsibility by midwives and the need to rationalise medical working practices in the light of changes in junior doctors' hours adds urgency to the need to find ways of instituting change while maintaining safety. A visit to the Netherlands allowed first hand evaluation of aspects ofthe Dutch model of maternity care of relevance to establishing midwifery led care for women with uncomplicated pregnancies in the United Kingdom.
The second report on maternity services from the House of Commons Health Committee took evidence from many professional and lay sources.' Among the conclusions was that "there is a strong desire among and the women for continuity of care and carer majority of them regard midwives as the group best placed to provide this."' Melia et al surveyed 1807 women and found that 65% regarded continuity of midwifery care and familiarity with the midwife at delivery as important.2 The joint statement by the Royal College of Obstetricians and Gynaecologists, Royal College of Midwives, and Royal College of General Practitioners reiterates the need for integrated care, avoidance of duplication, and the need for midwives to have identifiable case loads.3 The reply from the Royal College of Obstetricians and Gynaecologists to the health committee report supports the concept of "low risk" midwifery units within hospitals.4 The new NHS and the market oriented ethos also provide some dilemmas-competition rather than cooperation. Jenkins warns that any agency providing continuity of care at a competitive rate could in theory receive a contract from a trust or a fundholder in general practice.' The Netherlands, unique among industrialised countries for providing midwifery led care, was frequently cited in the health committee report as a model to follow. I and a senior midwifery colleague visited hospitals, midwifery practices, and family homes to examine the practical and organisational aspects of the Dutch system of maternity care. The Netherlands has about 200 000 deliveries a year, 43% of which are conducted independently by midwives, 14% by general practitioners, and 43% by obstetricians.6 The basic organisation of care is different from that in the United Kingdom. A newly pregnant woman consults either a general practitioner or a midwifery practice and is assessed by the risk criteria described below and referred to the sole care of midwife, general practitioner, or obstetrician. About 80% of midwives work in independent practices run as businesses and are answerable to but not employed by the national health management hierarchy. The remaining 20% provide care in hospitals. Their independent position is protected by law in that a .
Department ofObstetrics and Gynaecology, Clinical Sciences Building, Leicester Royal Infirmary, Leicester LE2 7LX Christina Oppenheimer, senior registrar
BMJ 1993;307:1400-2
1400
.
.
Indications for specialist obstetric care in the Netherlands, 1959 At booking * Medical history-epilepsy, multiple sclerosis, diabetes, etc * Gynaecological history-habitual abortion; previous injury or operation to uterus or vagina such as cone biopsy of cervix, prolapse repair, myomectomy * Obstetric history-perinatal loss, premature delivery, growth retardation, postpartum haemorrhage of 1000 ml or more, third degree tear, caesarean section, etc * Primigravidas over 35 * Involuntary infertility of more than three years * Severe hypertension or presence of other symptoms or signs Antenatal complications * First trimester-haemorrhage, trophoblastic disease, ectopic pregnancy, etc * Second and third trimesters-pre-eclampsia, antepartum haemorrhage, premature rupture of membranes, growth retardation, etc In labour * Malpresentation, meconium staining of liquor, fetal distress, poor progress, etc * Requirement for injectable or other analgesia * Third stage complications-retained placenta, postpartum haemorrhage, third degree tear, etc
Puerperium * Vulval haematoma, urinary retention, psychosis, thrombosis Neonate * Evidence of growth retardation or prematurity, cyanosis, congenital anomaly
Conditions for home delivery * No contraindications as above; singleton pregnancy; cephalic presentation * Easy access to hospital * Specific domestic circumstances-running water, adequate heating, ambulance access, adequate hygiene and privacy woman is not reimbursed for care by anyone other than a midwife if she is in the low risk category. The midwives consult but are not answerable to their
obstetric colleagues. Both general practitioners and midwives are qualified and licensed for care of normal pregnancy and labour. Practices are small and personalised care is possible. Thus the basic philosophy of the Dutch system holds that the midwife or general practitioner cares for normal pregnancies, freeing the obstetrician to provide care for women who have
BMJ voLuME 307
27 NOVEMBER 1993
specific medical or obstetric indications. The more detailed aspects of organisation underpinning this are as follows. Philosophy of care Firstly, selection of women into low or high risk with midwifery or consultant led care is based on officially approved criteria for specialist care antenatally, in labour, and in the puerperium.7 The original criteria were published in 1959 after agreement between medical advisers of insurance companies and Professor Kloosterman (insurance companies, both state and private, provide reimbursement of fees for care, and source of insurance depends on income). Professor Kloosterman, the father figure of the present Dutch system of obstetric care, wrote in 1978 that "in The Netherlands the principle is still adhered to that in humans also, pregnancy and parturition are essentially normal events which, as a rule, only require careful control examinations and counselling, and medical intervention only if this is specially indicated."8 A revised list published in 1987 remains under discussion because of criticism of the scientific foundation of some of the new criteria by the Dutch Society of Obstetrics and Gynaecology. In Britain better ways of assessing risk are being explored at the medical audit unit of the Royal College of Obstetricians and Gynaecologists.4 Generally accepted criteria applied locally would help in altering the emphasis in care for women at low risk. The effectiveness of the risk criteria in the Netherlands is discussed below. Secondly, all midwifery training is by direct entry after A level equivalents in chemistry, biology, and English language and lasts three years. There is a strong element of basic sciences in the curriculum, and there is emphasis on independent practice and decision making during training. In contrast with Britain, however, there is no statutory requirement for midwives to attend refresher courses. Midwives are assisted by general nurses in hospital and by maternity aids at home. The maternity aid system underpins the domiciliary midwifery system and the ability to discharge women without complications from hospital within 12 hours of delivery. Matemity aids receive an 18 month practical and theoretical training. They assist the midwife and mother in labour, care for the mother and baby, and undertake household duties for up to eight hours a day for eight days postnatally. The midwife visits for consultation only. The role of the general practitioner is limited in BMJ
VOLUME
307
27 NOVEMBER1993
maternity services in the Netherlands. Only those working in an area with no midwifery practice undertake antenatal care and look after women in labour and during the postnatal period. In the United Kingdom Kielty has emphasised the need for an alteration in emphasis of training for the general practitioner obstetric list so that more motivated general practitioners take an active and enthusiastic role in all aspects ofmaternity care.9 Campbell et al also noted the importance of training in allowing a more meaningful role.'0 Van der Slikke emphasises that "cooperation between providers of primary and secondary care is an essential prerequisite to the functioning of the Dutch system" (J W Van der Slikke, personal communication, 1991). Official policy has a major effect on this interaction as does using remuneration to uphold the regulations ofprovision ofcare."I A striking feature of the Dutch system is the low level of litigation. Discussion with obstetricians and midwives in the Netherlands suggests that a major factor in this- is the continuity of care and personal care First hand observation during consultations revealed an enviable rapport between women and her carers. There is pressure to alter the emphasis of care for healthy pregnant women at low risk of complications, and there must be data either to support new systems or to justify resistance to change. In both countries research has been carried out into the effects of different systems of care, and some projects are under way. Satisfing and safe care Obviously the two main issues to be considered are, firstly, the effectiveness of antenatal categorisation, and, secondly, the ability of the system to provide satisfying and safe care. In the Netherlands attempts have been made to examine the problem from early on. In 1961 Breyer and Stolk studied 3724 cases of stillbirth registered at the central bureau of statistics.'2 In over half of these cases there was an indication for hospital delivery but 29% of deliveries occurred at home. The authors concluded that the system of selection, then only two years old, was not applied correctly. This issue was subsequently dealt with. Smits described a prospective regional study of the incidence of low birth weight and prematurity and decided that the selection system for the early detection of risk factors in pregnancy and labour was not used optimally by midwives, family doctors, and obstetricians alike.'3 Probably the best known study is
Indications for specialist obstetric care in the Netherlands, 1987 Still under discussion between health department, funding bodies, and Dutch Society of Obstetricians and Gynaecologists Basic indications are the same as in 1959 but a "medium risk" category is suggested in which care may be provided by primary care giver (midwife or general practitioner) but obstetrician must be consulted (rather than total care by either primary or secondary care provider) and hospital delivery advised. Among groups for which this intermediate care is proposed are: * Women with a previous postpartum haemorrhage or retained placenta * Women who have had a caesarean section for nonrecurrent cause * Women,with previous placental abruption * Women with infertility * Nulliparous women over the age of 35
1401
the Wormerveer study.'4 Almost 8000 women booked consecutivelybetween 1969 and 1983 at an independent midwifery practice in Wormerveer, a suburb near Amsterdam, were studied. The women gave birth to 8055 children. Of those booked for midwifery care, 17-1% were later referred for specialist care in pregnancy. The 82-9% who started labour under the care of the midwife were the selected low risk group and 8% of these were referred for specialist care in labour. The overall perinatal mortality was 11 1/1000; for those delivered by midwives it was 2-3/1000 and for those referred in labour 11/1000. The highest rate was in the group referred during pregnancy from low risk care; this was 51-7/1000. Of the 89 perinatal deaths, 29 (about 33%) were judged to have avoidable factors. This is similar to contemporary regional studies in the United Kingdom.'5 Of these 29 cases, 12 concemed the skill of the obstetrician, seven the skill of the paediatrician, and seven the skill of the midwife (M Eskes et al, intemational conference on primary care obstetrics and perinatal health, Den Bosch, 1991). Hoogendoom documented a slower decline in perinatal mortality in the Netherlands compared with other European countries and advocated a shift in emphasis from home to hospital.'6 He did not, however, comment on the need for change away from midwifery led care or to "high tech" care. Indeed, the Dutch perinatal mortality now rates sixth in Europe, but the rate in deliveries by midwives is 0 9/1000. There is concem that registration of perinatal deaths in the Netherlands is voluntary, and underreporting has been documented.'7 Most important research is based on local data collection and not national figures. Numerous studies have also been published on variables within perinatal morbidity. In the Wormerveer study the rate of neonatal seizure within 48 hours of delivery compared favourably with that of contemporary studies in Britain and Ireland. Berghs studied prospectively over 1000 women at low risk and showed that by detailed neurological examination of the neonate by the Prechtl method in the first week of life there was no difference between the 62% cared for throughout by a midwife, the 12% by a general practitioner, and the 26% by an obstetrician.'8 The only significant difference was in the rate of instrumental delivery. There is little information on "consumer satisfaction" in the Netherlands or the United Kingdom. Kleiverda et al investigated motives and background variables in relation to home or hospital confinement.'9 Control over events, emotional support, and anxiety about unnecessary intervention were all important and are currently issues of public interest in Britain.
Current progress An initiative in contemporary data collection in the Zaanstreek region, north west of Amsterdam, began in 1990. This documents interaction between providers of primary and secondary care and outcome of pregnancies booked under their care. All relevant information about women booking at three midwifery practices associated with one district general hospital is entered on a specially designed software system. Data are available on 1500 women each year and preliminary findings were presented at a conference on primary obstetric care in Den Bosch, including data on care provider, consultations and transfers, birth weight, perinatal morbidity, and mortality (D M R Van der Borden et al, international conference on primary care obstetrics and perinatal health, Den Bosch, 1991). Systems of midwifery led care within a hospital setting with ready access to specialist care (seamless care) are being developed in the United Kingdom. These are being studied in Aberdeen and Leicester and 1402
collection of data continues.20 Such alternative systems should be developed, supported, and evaluated. Obstetricians are being asked to relinquish basic care for healthy pregnant women and the time seems ripe for negotiation. The pressures cannot be avoided, and to do so would merely make the most radical elements more powerful. Unproved (and possibly cheaper) working practices could be instigated. We are all making attempts to ensure that cooperation not confrontation occurs. We must ensure that any change is assessed by adequate data collection, as in the Leicester and Zaanstreek studies. There are as many problems in the Dutch system of maternity care as in our own. The major features and philosophies of the Dutch system, however, have something to teach usnationally agreed criteria of risk, training and support of midwives in more independent methods, and good communication and confidence between providers of primary and secondary care. Perhaps we can achieve not only low perinatal and maternal mortality and morbidity but also less dissatisfaction among consumers, more job satisfaction among midwives, and more rational working for obstetric staff. I thank Professor Treffers and Dr M Pel at AMC Amsterdam, Professor T Eskes and Dr R Thijssen at Nijmegen, Professor M Keirse at Leiden, Dr J van der Slikke in Zaandam, hospital staff and midwifery practices in Nieuwegen, and midwives A Limburg, G Rosendaal, and B Smulders for their help, kindness, and information during the visit. The visit was made possible by a quality travel award from Trent Regional Health Authority and included Miss M Stockwell, senior midwife, Mrs V Westbrook, nursing auxiliary, and Mrs J Short, community midwifery team leader. 1 House of Commons Health Committee. Maternity services. London: HMSO, 1992. (Second report.) 2 Melia RJW, Swan AV, Morgan M, Wolfe CDA. Consumers' views of the matemity services: implications for medical audit and planning. Br J Obstet Gynaecol 1991;98:1307-8. 3 Simmons S, Brain M, Waine C. Maternity care in the new NHS-a joint approach. London: Royal College of Obstetricians and Gynaecologists, Royal College of Midwives, and Royal College of General Practitioners, 1992. 4 Royal College of Obstetricians and Gynaecologists. Complete response to the report of the House of Commons health committee on maternity services. London: Royal College of Obstetricians and Gynaecologists, 1992. 5 Jenkins R. Maternity services after 1992. In: Charnberlain G, Zander L, eds. Pregnancy carefor the 1990s. Camforth: Parthenon, 1992:166. 6 Treffers PE, Eskes M, Kleiverda G, van Alten D. Home births and minimal medical interventions.JAMA 1990;264:2206-8. 7 Keirse MJNC. Interaction between primary and secondary antenatal care with particular reference to the Netherlands. In: Enkin M, Chalmers I, eds. Effectiveness and satisfaction in antenatal care. London: Spastics Intemational Medical Publication, William Heinemann Medical Books, 1982:222-33. 8 Kloosterman GJ. De Netherlandse verloskunde orp op de tweesprong. Ned Tijdschr Geneeskd 1978;122:1 161-71. 9 Kielty P. General practitioner participation in policy making. In: Chamberlain G, Zander L, eds. Pregnancy care for the 1990s. Carnforth: Parthenon, 1992:77. 10 Campbell R, Macfarlane A, Cavenagh S. Choice and chance in low risk maternity care. BMJ 1991;303:1487-8. 11 Keirse MJNC. Interaction between primary and secondary care in pregnancy and childbirth. In: Chalmers I, Enkin M, Keirse MJNC, eds. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989:200. 12 Breyer HBG, Stolk JG. Enkele beschouwingen naar aanleiding van een onderzoek over doodgeboorte in her jaar 1961 in Nederland. Ned Tijdschr Geneeskd 1971;115:1638-46. (English abstract.) 13 Smits F. The efficacy of the selection system of obstetrical care [PhD thesis]. Nijmegen: University of Nijmegen, 1975. (In Dutch, French abstract.) 14 Van Alten D, Eskes M, Treffers PE. Midwifery in the Netherlands. The Wormerveer study: selection, model of delivery, perinatal mortality and infant morbidity. BrJ Obstet Gynaecol 1989;96:656-62. 15 Van Alten D, Eskes M, Treffers PE. Midwifery in the Netherlands. BMJ 1992;305:1 155. 16 Hoogendoom D. Impressive but still disappointing decrease in perinatal mortality in the Netherlands. Ned Ti)dschr Geneeskd 1986;130:1436-40. 17 Doombos JPR, Nordbeck HJ, Treffers PE. The reliability of perinatal mortality statistics in the Netherlands. Am J Obstet Gynecol 1987;156: 1183-7. 18 Berghs G. The normal pregnancy: labour and management. A prospective study of 1034 normal pregnancies in primary and secondary obstetric care measured by neurological outcome of the newbom. [PhD thesis.] Nijmegen: University of Nijmegen, 1988. (In Dutch, English summary.) 19 Kleiverda G, Steer AM, Andersen I, Treffers PE, Everaerd W. Place of delivery in the Netherlands: matemal motives and background variables related to preferences for home or hospital confinement. Eur J Obstet Gynecol Reprod Biol 1990;35:1-9. 20 MacVicar J, Dobbie G, Owen-Johnstone L, Jagger C, Hopkins M, Kennedy J. Simulated home delivery in hospital: a randomised controlled trial. Br Jf Obstet Gynaecol 1993;100:316-23. (Accepted 22 September 1993)
BMJ VOLUME 307
27 NOVEMBER 1993
