American Birthing

Americans attempt to control their environment in every possible way they can, and prepare for the worst possible scenario just in case. From terrorism to flu season to food poisoning outbreaks, we seem paralyzed by the thought that something “might” go wrong.  I am not sure from where this fear stems, but I also have no doubt that corporate interests and politicians play a role in financially maximizing the vulnerability we have as humans to feel secure.

I had never stopped to think about how irrational and anxiety-driven we truly are in this country until I began investigating our birthing practices.  I remember talking to a woman once, in my local community, who was planning a homebirth and I kept thinking, how irresponsible of this mother- what if something goes wrong? However, when I came to understand the process of giving birth and comparing our practices to other cultures in the world, my whole perspective changed.  For the remainder of this article, I will describe the current model of maternal care in The Netherlands.  I hope to deconstruct the image that many people have of maternity care and birthing in this country by providing a counter-example.  In the next articles that I write, I will describe the problems with our current system and steps that need to be taken to ameliorate the situation.

The basic premise of maternity care in The Netherlands is that pregnancy and birth are fundamentally normal and physiologic processes.  About one third (>30%) of women in The Netherlands give birth in their home; this rate is less than 1% in America (1).  Contrary to popular belief in America, the high home birth rate does not make The Netherlands an unsafe place for women to deliver babies.  In fact, the infant mortality rate in The Netherlands is significantly lower than the United States (1).

Additionally, less than 28% of women in The Netherlands receive some form of pain medications, which is considerably lower than the whopping 86% in America (2). In the Netherlands, women with low-risk pregnancies who have a home birth have outcomes that are similar to, or better than, the outcomes of hospital births (1)

The midwife in The Netherlands has considerable autonomy.  Nearly 80% of all Dutch women begin their care with a midwife; they are only transferred to an obstetrician if the midwife determines that the woman has a high-risk profile (3).  In areas where the need for midwives exceeds the supply, general practitioners take over the role of the midwife (3).  There is a “List of Obstetric Indications” that describes the indications of a pregnant woman or her fetus where an obstetric would be necessary or recommended.  However, even with this list available, the midwife generally has the freedom to decide whether a referral is actually needed.  There are only a few cases (~8% of all births) where the midwife does not have the autonomy to determine if an obstetrician is required (3).

Once a woman has seen her midwife or GP, she determines whether her place of birth will be in the hospital, home, or a birthing center.  The primary role of the midwife is to help empower the woman in the choice that she makes.  Whereas many midwives in the US struggle to find hospitals to accommodate them, the Dutch model not only provides space for midwives in hospitals, but also depends on midwives to make the system functional.  The midwife acts as an advocate even for the women who have slightly elevated risks and who are referred to a gynecologist.  If a midwife believes a gynecologist is not treating patients well and discourages them from home births, she will cease referring her patients to that particular gynecologist.  Eventually, that particular gynecologist might perceive a decrease in the number of clients they receive, which will serve as an incentive for them to be more accommodating and change their current style (4).

The midwife-directed model in The Netherlands is made possible by three significant factors: 1) government sponsorship and support; 2) extensive training of midwives; 3) quick and efficient hospital transfers in the event of an emergency.  With respect to the first factor, the government encourages home births and assists in setting limits to the authority of the obstetrician.  Public health campaigns and dialog discussing methods to encourage home births occur frequently in The Netherlands (4).  This is a practice almost unheard of in the US.  With respect to training, midwives spend 5 years in secondary school, followed by 4 years in midwifery school (1).  The training is extensive and comprehensive because this career path holds considerable authority and autonomy in The Netherlands.  Finally, with respect to hospital transfers, The Netherlands is structured in a way that all women are within 20 minutes drive to a hospital (1).  An ambulance service is only 45 minutes from the moment of reporting to the moment of arrival in a hospital, and approximately 85% of the urgent obstetric referrals arrived in the hospital within half hour after reporting (5).  The time that it takes to transport a woman from her home to the hospital is roughly equal to the time it takes to mobilize the necessary specialists in the hospital (5).

Devries (2001) states: When you ask Dutch women and men why they prefer birth at home to birth in the hospital they will often reply that home birth is more gezellig. Gezelligheid is often translated as “coziness” (note Gouds- blom’s translation above); however, there is no single English word that captures the full meaning of the term. Cozy comes close, but gezellig also implies warmth, affection, contentment, enjoyment, happiness, sociability, snugness, and security. For the Dutch, birth at home is gezellig in a way that birth in a hospital can never be. (4)


(1) Johnson, T.R., Callister, L.C., Freeborn, D.S., Beckstrand, R.L., Huender, K. (2007). Dutch Women’s Percpetions of Childbirth. MCN, 32(3), 170-177.

(2) Wiegers, T.A. (2009). The quality of maternity care services as experienced by women in the Netherlands. BMC Pregnancy and Childbirth, 9-18.

(3) Amelink-Verburg, M.P. Buitendijk, S.E. (2010). Pregnancy and labour in the Durch maternity care system: what is normal? The role division between midwives and obstetricians. Journal of Midwifery and Women’s Health, 55, 216-225.

(4) DeVries, R. (2001). Midwifery in the Netherlands: Vestige or vanguard? Medical Anthropology, 20, (4), 277-311.

(5) Amelink-Verburg, M.P., Verloove-Vanhorick, S.P., Hakkenberg, R.M.A., Veldhuijzen, I.M.E., Gravenhorst, J.B., Buitendijk, S.E. (2008). Evaluation of 280,000 cases in Dutch midwifery practices: a descriptive study. BJOG, 115: 570-578.


About The Author

Hanieh Razzaghi

Hanieh Razzaghi was born in Tehran, Iran and moved to the United States with her family when she was two years old. She grew up in Pennsylvania and attended Penn State University where she received a Bachelors Degree in Biobehavioral Health. She then went on to receive a Masters in Public Health at Yale University. Most of her work since graduation has been focused on research related to health care in the United States. Hanieh is currently a stay-at-home mom to her daughter recently born in November of 2009 and her research and blogging interests have expanded to include child health and development. She works part-time from home as a Research Project Manager and she is also studying to become a birth educator and breastfeeding counselor.

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10 2010

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  1. Nabeela #

    In some states in the USA, it is illegal to have a homebirth. I watched my Catholic neighbor go through an underground network of midwives so she could deliver at home. It was like she was negotiating a drug deal, and the fact is the woman just wanted to have her baby at home!
    Countries with socialized medicine are concerned with keeping costs down, and midwives are a great way to do this. In countries with no socialized medicine and where the power institutions are only interested in achieving wealth for physicians (like the AMA), midwifery is vilified and outlawed. Power will keep its wealth for as long as possible unless the citizens educate themselves AND take action.
    Study after study has shown that women with home birth deliveries are safe, the women have greater satisfaction, and there is a much lower rate of C-sections. THe fact that your OB doesn’t want to talk about it says a lot about the USA medical profession: deny the facts if it hurts your pocketbook.


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