43 2 RISK AND THE POLITICS OF BOUNDARY WORK twentieth century GPs attended about 1/3 (Abraham– van der Mark, 1996, pp. 31–32) of the home births and they had the authority to use medical interventions outside the hospital. Only if the GP was unwilling or unable to provide the necessary care were women transferred to the hospital (Abraham – van der Mark, 1996, Chapter 2; Drenth, 1998; Ziekenfondsraad, 1982). Over the course of the early twentieth century, the use of hospital birth gradually increased from 1,8% in 1900 (van Daalen, 1988, p. 417) to 8,3% in 1932 (Drenth, 1998, p. 39). In an attempt to regulate the referral rates, in 1941 the Health Insurance Decree1 was introduced by the occupying Germans, giving midwives the prerogative2 in care for uncomplicated birth (Departement van Sociale Zaken, 1941). According to this decree, these births were only remunerated if they had taken place under the care of a midwife, thus at home, because attendance of a doctor ―the GP or the obstetrician ―was seen as medically unnecessary. As such, this decree limited the GPs’ and obstetricians’ jurisdiction (Abraham– van der Mark, 1996, Chapter 2; de Vries, 2005, Chapter 2). To maintain this decree, as of 1957 the Health Insurance Funds3 started using the lists of medical indications as criteria for granting remunerations (Hacke, 1957; Somers, 1971b; 1971a). As a result, throughout the 1960’s and 1970’s different lists were used, causing confusion and variation in practice (Ministerie van Volksgezondheid en Milieuhygiëne, 1981; Van de Koogh, Kloosterman, & Somers, 1972). Despite the Health Insurance Funds’ attempts to regulate referrals, the hospital birth rate rose further from 23,9% in 1955 to 31,5% in 1965 (van Daalen, 1988, p. 421). Several factors contributed to this trend, such as increasing medical possibilities, an increasing number of women requesting hospital based birth, a shortage of midwives and a decreasing number of GPs practicing midwifery (Centrale Raad voor de Volksgezondheid, 1972 annex 1; Werkgroep Geneeskundige Hoofdinspectie, 1969, pp. 5–8). At the same time, the Netherlands dropped in international ranking of perinatal mortality, instigating a debate about the safety of Dutch MNC system (Centrale Raad voor de Volksgezondheid, 1972, pp. 5–10; De Haas – Posthuma, 1962). These developments, together with a declining birth rate (Treffers, 2008), fuelled the competition between midwives, obstetricians and GPs. However, the domains they were competing for differed. Whereas the competition between midwives and obstetricians was based on the line between physiology and pathology, midwives and GPs competed over the physiological domain ― care for healthy pregnant women outside the hospital (Drenth, 1998; Klinkert, 1980). In other developed countries care for pregnancy and birth gradually shifted to the hospital, and home birth, along with the independent community midwife, all but disappeared (Donnison, 1988). In the Netherlands, the Ministry of Health noted a wider trend of hospitalisation in healthcare and was concerned about unnecessary medicalisation and rising health care expenses. As early as 1974, the Ministry sought to turn the tide by reorganizing the national healthcare system into echelons using a strong system of primary care, with GPs serving as gatekeeper to secondary care (Hendriks, 1974). This gatekeeper approach was also recommended for MNC by multiple advisory bodies. They were convinced that to reduce and prevent unnecessary referrals, midwives should be authorized to attend uncomplicated births in the hospital and to directly refer to the obstetrician (Centrale Raad voor de Volksgezondheid, 1972; 1977; Werkgroep Geneeskundige Hoofdinspectie, 1969). Obstetricians, however, varied in their stance towards these views (Instituut Geschiedenis der Geneeskunde Nijmegen, 1981). Based on perceptions about risks associated with pregnancy and birth and the need to manage those risks, some expressed support for these advisory bodies’ Health, Risk & Society 5