Therese A. Wiegers, PhD.

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2. Structure of this presentation Perinatal care in international perspective Birth in the Netherlands The importance of continuity in maternity care Professionals involved in maternity care The maternity care crisis in 1999/2000 Organisation and workload in midwifery

3. Infant mortality rate, deaths per 1,000 live births in 1970 and 2004 (* = 2003)

4. Cesarean section ratein 1990 and latest available year

5. Number of midwives per 100,000 inhabitants in European countries in 2003

6. Number of births in the Netherlands since 1965

7. Percentage of home births in the Netherlandssince 1965

13. General practitioners and their role in maternity care Percentage of GPs Contribution of GPs in providing maternity/ maternity/obstetric obstetric care: care: 1998: 15% 10% (including) 8% (excluding referral during labour/birth) 2000: 11% 6% (including) 5% (excluding referral during labour/birth) 2002: 6% 4% (including) 3% (excluding referral during labour/birth)

15. 2000:Threats to the Dutch system of maternity care Shortage of midwives and of maternity care assistants Shortage of GPs providing maternity care Closing of maternity wards Change of attitude towards workload Increasing referral rates A number of recent developments are threatening to change the Dutch system of maternity care. First of all, on all levels of health care there is a shortage of personnel, on medical as well as on nursing staff, resulting in waiting lists for patients who need surgery, for patients who need home help and for many others. There is also a shortage of midwives, while the number of births has increased unexpectedly. But because a waiting list in maternity care is not possible, the workload of midwives has increased considerably over the last few years. Moreover, the shortage of maternity care assistants increases the workload of midwives even further. Secondly, the attitude of many workers in health care, as elsewhere in society, has changed. People no longer want to be available 24 hours a day, 7 days a week. They want to spend more time with their family and friends and as midwifery is almost completely a female profession, this is felt even stronger among midwives than among other health care professionals. Among general practitioners, men and women, this means that many of them no longer want to provide maternity, especially intrapartum care, because it cannot be scheduled and it interferes too much with their daily routine. Thirdly, patient, clients, have become consumers of health care. They are more involved, they want to be informed, they want to participate in decisions about the care they need, which means that health care workers have to spend more time with them, again increasing their workload. Fourthly, hospitals have been reorganizing almost continually during the last few years, sometimes relocating obstetric and paediatric staff, resulting in the closing of maternity wards. This means that midwives and general practitioners have to travel further with their clients to reach a hospital in case of complications during labour. Therefore they will be more often inclined to opt for a hospital birth in stead of a home birth. Finally, the referral rates during pregnancy and during labour have increased significantly, as shown in the previous figure. A number of recent developments are threatening to change the Dutch system of maternity care. First of all, on all levels of health care there is a shortage of personnel, on medical as well as on nursing staff, resulting in waiting lists for patients who need surgery, for patients who need home help and for many others. There is also a shortage of midwives, while the number of births has increased unexpectedly. But because a waiting list in maternity care is not possible, the workload of midwives has increased considerably over the last few years. Moreover, the shortage of maternity care assistants increases the workload of midwives even further. Secondly, the attitude of many workers in health care, as elsewhere in society, has changed. People no longer want to be available 24 hours a day, 7 days a week. They want to spend more time with their family and friends and as midwifery is almost completely a female profession, this is felt even stronger among midwives than among other health care professionals. Among general practitioners, men and women, this means that many of them no longer want to provide maternity, especially intrapartum care, because it cannot be scheduled and it interferes too much with their daily routine. Thirdly, patient, clients, have become consumers of health care. They are more involved, they want to be informed, they want to participate in decisions about the care they need, which means that health care workers have to spend more time with them, again increasing their workload. Fourthly, hospitals have been reorganizing almost continually during the last few years, sometimes relocating obstetric and paediatric staff, resulting in the closing of maternity wards. This means that midwives and general practitioners have to travel further with their clients to reach a hospital in case of complications during labour. Therefore they will be more often inclined to opt for a hospital birth in stead of a home birth. Finally, the referral rates during pregnancy and during labour have increased significantly, as shown in the previous figure.

16. Measures taken to preserve the Dutch system of maternity care Increased capacity of midwifery schools Increased income for midwives Reduction of midwifery �case load� Extra courses for maternity care assistants The threats to the Dutch system of maternity care have been taken seriously and the government has taken steps to preserve it. First of all, the capacity of the three midwifery schools in the Netherlands has been increased from a total of 120 students in 1999 to a maximum of 240 students 2001. The fees for midwifery care have been raised and the standard practice size for a full-time working midwife is reduced from 150 to 120 births a year. The shortage of maternity care assistants is dealt with by providing short-term courses for those interested in working in maternity care. This means that within a few years time the shortage of midwives and of maternity care assistants will be resolved and with that the workload will be reduced to acceptable levels. However, other developments still threaten the system: There is no solution yet for the diminishing numbers of GPs who are prepared to provide maternity care. The problem here is that GPs provide maternity care in regions with a very low population density, where a midwife would not be able to maintain a viable practice. When this GP stops practicing maternity care, there is for pregnant women no other choice than to go to a gynaecologist and give birth in hospital. The scaling-up of gynaegologic/obstetric and paediatric units in hospitals continues, which may lead to a further reduction in maternity wards; In some regions temporary �birth centres� were established to deal with the problems in midwifery practices. But temporary may become permanent and home birth may disappear completely in those regions. Finally, there is no answer yet to the increased referral rates for pregnant and labouring women because the cause is not clear. Is it because the women themselves no longer accept prolonged labour and demand to be referred to an obstetrician? Is it because midwives are unsure about their own skills? The final question in this debate is: what would be the best for women, what do they want from a maternity care system and in what way can the maternity care system contribute to the empowerment of women? The threats to the Dutch system of maternity care have been taken seriously and the government has taken steps to preserve it. First of all, the capacity of the three midwifery schools in the Netherlands has been increased from a total of 120 students in 1999 to a maximum of 240 students 2001. The fees for midwifery care have been raised and the standard practice size for a full-time working midwife is reduced from 150 to 120 births a year. The shortage of maternity care assistants is dealt with by providing short-term courses for those interested in working in maternity care. This means that within a few years time the shortage of midwives and of maternity care assistants will be resolved and with that the workload will be reduced to acceptable levels. However, other developments still threaten the system: There is no solution yet for the diminishing numbers of GPs who are prepared to provide maternity care. The problem here is that GPs provide maternity care in regions with a very low population density, where a midwife would not be able to maintain a viable practice. When this GP stops practicing maternity care, there is for pregnant women no other choice than to go to a gynaecologist and give birth in hospital. The scaling-up of gynaegologic/obstetric and paediatric units in hospitals continues, which may lead to a further reduction in maternity wards; In some regions temporary �birth centres� were established to deal with the problems in midwifery practices. But temporary may become permanent and home birth may disappear completely in those regions. Finally, there is no answer yet to the increased referral rates for pregnant and labouring women because the cause is not clear. Is it because the women themselves no longer accept prolonged labour and demand to be referred to an obstetrician? Is it because midwives are unsure about their own skills? The final question in this debate is: what would be the best for women, what do they want from a maternity care system and in what way can the maternity care system contribute to the empowerment of women?

17. Study design Midwives: 24-hour diary during three weeks Questionnaires Clients: Questionnaires Labour force planning: GPs, hospital-based midwives, student-midwives

18. Range in actual working hours of primary care midwives

19. Overlap between on-call-hours and working hours of midwives

20. Average time midwives spend on different aspects of their work 2004 2003 2002 2001 Average working hours per week 28,9 u 29,6u 28,8u 29,7u Client-related work 72,3% 71,6% 77,1% 74,5% non-client-related work 27,7% 28,4% 22,9% 25,5% time spend on parturition 18,7% 19,3% 20,1% 20,7% other activities 81,3% 80,7% 79,9% 79,3%

21. Time spend on direct client carein minutes 2004 2003 2002 2001 1 booking visit 36,3 34,3 34,7 32,9 11 prenatal check-ups 170,5 168,3 167,2 150,7 1 check-up + ultrasound 19,9 18,1 18,7 17,5 parturition 278,5 227,9 223,9 192,7 5 (6) postnatal visits 189,5 188,0 192,5 190,8 1 concluding contact 16,9 15,8 15,6 16,4 Total 711,6 652,4 652,6 601,0 In hours: 11h52m 10h52m 10h53m 10h01m

22. Conclusions Increasing number of practicing midwives Reduced workload Unchanged average number of working hours Reduced average number of on-call-hours Increased proportion of non-client related activities Increased actual time per client More midwives, fewer clients per midwife, more time per client