Proefschrift

44 2 CHAPTER 2 recommendations (Kloosterman, 1970), while others believed the solution to rising referral rates and disappointing perinatal mortality rates was to centralize MNC in the hospital (Seelen, 1970). The Ministry of Health endorsed the advisory bodies’ recommendations (Eerste Kamer der Staten-Generaal, 1978; Veder-Smit, 1980) stating ‘unnecessary medical interventions’ were as problematic as ‘intervening too late’ (Eerste Kamer der Staten-Generaal, 1978, p. 2). Some believed the obstetricians’ authority to determine the medical indications for remuneration created a financial incentive, resulting in overuse of medical indications and rising referral rates (Eerste Kamer der Staten-Generaal, 1978, p. 3; Subcommissie Ziekenfondsverzekering Werkgroep Onderzoek Kostenstijging, 1964, pp. 11, 66). The advisory bodies, above all, emphasized the importance of better collaboration between midwives, obstetricians and GPs. They held the belief that a medical indication list developed cooperatively by maternity care professionals would be used more uniformly, reducing referral rates (Centrale Raad voor de Volksgezondheid, 1972; 1977; Werkgroep Bijstelling Kloostermanlijst, 1985; Werkgroep Geneeskundige Hoofdinspectie, 1969). In 1979, after joint consultation in the Committee on the Organisation of Maternal and Newborn Care,4 the professions and organisations involved in MNC expressed their support for the advisory bodies’ recommendations (Werkgroep Verloskundige Organisatie, 1979). As an effect of this broad support, the Study Group for the Revision of the Kloosterman List5 (hereafter, SGKL) ―a diverse group of representatives from all professions and organisations involved in MNC ―was created in 1983 by the Health Insurance Council6 to update the list of medical indications (Ziekenfondsraad, 1982, p. 6). However, in almost four years the SGKL did more than revise the indication list: they also designated the midwife as the gatekeeper to specialist care. This policy ― giving midwives the authority over risk assessment and referral ―was an exception to events in other developed countries, where midwives were losing jurisdiction. The existing competition over risk assessment and referral in Dutch MNC could thus be seen as rooted in a history of boundary work between midwives and obstetricians in which the language of risk was used to demarcate professional boundaries. In the SGKL, for the first time in Dutch MNC history, the meaning and role of risk in defining the division of labour were negotiated by all professions involved in MNC, re-assigning jurisdictions over risk. The contemporary division of labour between midwives and obstetricians, where jurisdiction over risk assessment and referral is in the hands of midwives, is the result of the work of the SGKL. As such, a richer understanding the SGKL’s work will be a useful guide for the current efforts to understand and, where necessary, reform Dutch MNC. The insights gained from our study can also inform policies elsewhere, especially given the current call for the implementation of midwifeled models of care (Homer, 2016; Renfrew et al., 2014; Sandall et al., 2016); an approach that is recommended by the World Health Organization (2018) and is gaining traction around the world, including in England, Scotland and Australia (Homer, 2016; The Royal College of Midwives, 2016; The Scottisch Government, 2017). Methods Study design To understand how and why the SGKL decided to grant midwives the role of gatekeeper in MNC, we studied their work in the period from 1983 to 1987. We used a socio-historical approach, guided by the method of grounded theory (Allotey, 2011; 6 B. Goodarzi et al.

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