54 2 CHAPTER 2 The interviews and documents show that efforts to promote the interests of obstetricians by both the first and the second representative were met with resistance from the other SGKL members, including the only other obstetrician in the SGKL, the scientific advisor, whose contribution also aligned more with the ‘conservative’ stance. Furthermore, our participants told us that the disregard of the ‘progressive’ stance in the SGKL was one of the reasons for the first representative to leave the SGKL. According to some of the participants, the GPs in the SGKL felt that the reasoning of the obstetricians’ representatives went against the principles of a gatekeeping system. As one participant explained: ‘[…] The midwife needs the obstetrician’s expertise to assess risks. The obstetrician has to use substantive arguments to convince the midwife that birth in the hospital is required. […] Of course that took long discussions because the obstetrician said: “when I am of the opinion that referral to secondary care is required, referral to secondary care is required.” But that is a misunderstanding of the function of primary care. […]’ (P1) Also, almost all the participants mentioned that some of the SGKL members perceived the obstetricians’ authority as the real cause of the rising referral rates, which was one of the reasons the SGKL was assembled in the first place. According to the participants, the SGKL members reasoned ‘emphasizing the equal position’ of midwives and obstetricians could be part of the solution, because the midwives’ more physiological point of view would counterbalance the more interventionist approach of the obstetricians. One participant told us: ‘[…] It was all about the emancipation of the midwife who participates as an equal force. […] For example, in [the southern province] Limburg the medical indication rate was 80%. [The midwives] needed to be able to be a countervailing power when in certain regions things get completely out of hand. […]’ (P8) Our data show that the midwives’ representatives wished for a stronger position vis-a-vis obstetricians. The interviews reveal that the secretariat ―the chair and the secretary―felt the midwives could not stand their ground against the obstetricians’ representatives in the discussion on the matter. Therefore, driven by their interest in applying the gatekeeping system, the secretariat helped the midwives in the debate. One participant explained: ‘[…] [The secretariat] felt that secondary care is too medical for a primarily physiological process. […] As a result [the secretariat] protected the midwives somewhat because the midwives could not offer sufficient counterbalance against the obstetricians [in the discussion]. […] So [the secretariat] argued for them. [Had it been a different secretariat] it’s possible the midwives would have been defeated. […]’ (P1) Discussion Unexpected alliances and transprofessional coalitions in professional boundary work In our analysis of the negotiations that occurred between the representatives of midwives, general practitioners, and obstetricians in the SGKL regarding the authority over risk assessment and referral in MNC, we found four themes that explained how the SGKL arrived at their decision to grant midwives the authority as gatekeeper. To understand why the SGKL decided in favour of the profession of midwives, we needed to move beyond a merely descriptive account of the SGKL’s work. Using a grounded theory approach, and calling on theories of boundary work and cultural theories of risk, we gained new insights 16 B. Goodarzi et al.