51 2 RISK AND THE POLITICS OF BOUNDARY WORK referral was a waste of money. […] [Therefore GPs] and their scientific society worked very hard to substantiate [the GP’s position as gatekeeper]. Eventually research from [the universities in] Maastricht and Utrecht was published that showed that selection in primary care enhanced the effectiveness of secondary care. […]’ (P3) One participant explained that although GPs would be giving up some of their jurisdiction, support for midwives as gatekeeper would strengthen the overall position of primary care. ‘[…] Yes, [the GPs] consented because – and that is the politics of it all – if primary care doesn’t work as one…Before you know it the internists starts telling you when to refer a patient. […] So that is when the primary care professionals joined forces. […]’ (P6) Underrepresentation of one of the two schools of obstetricians An interesting aspect of the SGKL’s negotiations was that the obstetricians’ representative agreed to give midwives the authority to do risk assessment and referral, even though 1) this would limit the obstetricians’ jurisdiction, and 2) the professional association of obstetricians rejected this decision (Associated document no. 60). Our analysis revealed several reasons for this. Diverging beliefs and interests: the two schools in Dutch obstetrics Our participants indicated that the obstetricians’ representative consented to give midwives authority over risk assessment and referral because it harmonized with this representative’s personal professional beliefs and interests. Our participants went on to explain that some obstetricians had differing beliefs and interests, and this group felt insufficiently represented in the SGKL. These observations help to explain why the obstetricians’ professional association rejected the final report of the SGKL. Our participants identified two ‘schools’ in Dutch obstetrics. These ‘schools’ had opposing beliefs about the risks associated with pregnancy and birth, and contrasting ideas about obstetricians’ position, power, and income within the organisation of MNC. ‘[…] One group is conservative [in terms of medical interventions], pro-midwife, pro-hands off, in most cases has no financial interest and is distrustful of new technology. And the other group is entirely the opposite. […] And each group was convinced that they were right and that the other group was, by definition, wrong. […]’ (P5) ‘[…] Two schools existed in “obstetrician land”. Those who held midwives in high regard and said: “not every woman needs hospital care”, and those who said: “come on, safety first demands that all women must be cared for in the hospital”. […]’ (P1) The participants who described these two groups always did so in relation to the professors and the universities that represented either school. They spoke specifically about a geographical north-south division, caused by the location of the universities; the ‘conservatives’ in the north―mainly Leiden, Utrecht, and the AmsterdamMedical Centre―under the lead of Professors de Snoo and Kloosterman, and the ‘progressives’ in the south ―mainly Rotterdam, Maastricht, Nijmegen and VU University Amsterdam ―under the lead of Professors Stolte and Eskes. All of our participants mentioned the tension between these two groups. One participant said: Health, Risk & Society 13
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