How (not) to create value based integrated maternity care: Lessons from the Netherlands

What encourages (or discourages) health policymakers to create systems of integrated care? The answer to this important question can be found by looking at Dutch maternity care. Health care officials in several countries are struggling to achieve the “triple aim” in maternity care: to maximize health and satisfaction while minimizing costs. These policymakers often look to the Netherlands, with its well-organized system of referral between primary and specialist care, as a successful model of integrated maternity care that delivers on each of the triple aims. In spite of this favorable attention, Dutch policymakers have been pushing to create “integrale verloskunde zorg” – integrated maternity care – replacing the current system with one that gives obstetricians a more prominent role. This development gives us the opportunity to look more closely at the factors that promote and hinder the creation of integrated care systems. In the case of the Netherlands, the push toward (more) integrated maternity care is the result of an uneasy relationship between midwives and obstetricians, unsound science, critical reports in the media, and the differential political power of the professions. Interprofessional competition: For most of the twentieth century, Dutch midwives and obstetricians had a cooperative relationship, defined and regulated by an “indications list” that determined who was responsible for which types of care. In the 1980s, efforts to revise that list created tension between the two professions, with each group seeking to protect and/or extend their jurisdiction. The shift from collaboration to competition moved the conversation away from what must to done to deliver the most effective maternity care, to efforts to promote the value of the services of one profession over the other. Unsound science: Interprofessional competition has led to the production of unsound science. Rather than collaborative research, where obstetricians and midwives work together to identify the most effective ways to deliver care, there has been a spate of research offering “scientific” evidence for the superiority of each profession’s approach: research done by obstetricians typically shows that the current, integrated system is failing, while research done by midwives shows the success and value of the current system. Media attention: In the contest between midwifery and obstetric science, the media in the Netherlands have sided with the obstetricians. Stories of harm to mothers and babies capture the attention of the public and are more interesting than stories of the success of integrated care. Political power: Midwives have less political power and less access to policymakers in the government and the insurance industry. Their efforts to support and improve the current system have been less persuasive with the Ministry of Health and the Zorginstituut Nederland (ZN – the overseer of the health insurance system) than those of the obstetricians, who are succeeding in increasing their role in maternity care. This analysis of the (dis)integration of Dutch maternity care sheds important light on the factors that move health systems toward, and away from, integrated care. If the value of integrated care is to be realized we must understand these factors.