41 2 RISK AND THE POLITICS OF BOUNDARY WORK that have since been questioned ―(de Jonge, Baron, Westerneng, Twisk, & Hutton, 2013; Wiegerinck et al., 2015) ―together with increasing rates of referral from midwife-led to obstetrician-led care (Offerhaus, 2015) have been used to challenge the ability of midwives to serve as gatekeepers (Bonsel, Birnie, Denktaş, Steegers, & Poeran, 2010; Oei & Derks, 2015). This has opened the door to claims supporting the routine involvement of obstetricians in the risk assessment and referral process (Smith, Wagener, van de Laar, & van Dillen, 2016). The professional association of midwives and supporters of a more physiological view of pregnancy and birth have responded by drawing attention to the evidence that shows the value of midwife-led models of care (Renfrew et al., 2014; Sandall, Soltani, Gates, Shennan, & Devane, 2016), and expressing concern that the loss of midwives as gatekeepers will result in over-medicalisation of pregnancy and birth (Bos, 2016; de Jonge et al., 2015; de Jonge, Jans, & Perdok, 2012; Koninklijke Nederlandse Organisatie van Verloskundigen, 2014). Referring to the constrained position of midwives in other developed countries, some see the current developments in the Dutch MNC as ‘a historical turning point’ (de Vries, 2014) where the unique system of autonomous midwifery care outside the hospital is in danger of disappearing (van Daalen, 2017). The purpose of this study is to understand the current competition between midwives and obstetricians for authority over risk management in the Netherlands. We locate the situation in its historical context and use theories of professional jurisdiction and cultural theories of risk to study the factors that led to the current – and now challenged – division of labour: why and how did midwives gain their authority over risk assessment and referral to specialist care? The competition for professional jurisdiction and the role of risk According to Abbott (1988), professional groups compete with each other in an attempt to defend their territory. They carve out occupational jurisdiction to legitimise their existence. They demarcate professional boundaries by asserting their specific knowledge and expertise and by emphasizing the limitations of other professions. Jurisdictions are not self-evident and lines of demarcation need to be actively negotiated and claimed, a process also referred to as ‘boundary work’ (Gieryn, 1983). Professional boundaries are socially and culturally constructed. As de Vries, Dingwall, and Orfali (2009, p. 2) denote: ‘History teaches us that occupations change along with changes in the division of labor and shifts in the kinds of work that society needs done. Some occupations disappear […]. Some occupations are created by new technologies and new fads and fashions […].’ Responding to contextual change, professions engage in boundary work in an attempt to extend their occupational jurisdiction, or to monopolize professional authority (Abbott, 1988; Lamont & Molnár, 2002; Martin, Currie, & Finn, 2009; Nancarrow & Borthwick, 2005). Seen as boundary work, midwives and obstetricians in the Netherlands have been, and remain, in competition for jurisdiction over the assessment and management of risk in childbirth. Social and cultural theorists of risk (Lupton, 2013; Tansey & O’Riordan, 1999), including Douglas (1992), see risk as a means to organise human relations in modern society. In contrast to the techno-scientific understanding of risk (Lupton, 2013, Chapters 1 & 2), Douglas states that risk is not ‘a straightforward consequence of the dangers inherent in the physical situation’, but a product of ‘shared beliefs and values’ among groups in society, and those shared beliefs and values differ between groups (Douglas & Wildavsky, 1982, pp. 193–194). Historically, with the rise of the risk discourse in society, the understanding of danger changed from a natural and unpredictable event, to a controllable and avoidable Health, Risk & Society 3