Human Rights in Childbirth: Panel 6

Panel 6:

Cases on the Edge: 
Controversial Birth Choices in the Netherlands

Panelists:

• Monique Severijns: mother, Netherlands
• Arie Franx: professors of obstetrics & gynecology, Netherlands
• Rebekka Visser: midwife, Netherlands
• Robert Kottenhagen: professor of law & ethics, Netherlands
• Wilma Duijst: forensic doctor and criminal law researcher, Netherlands
• Joke Meulmeester: Chairperson, VVAK, Netherlands
• Sandra Bruin (moderator): mother, Netherlands

The panel began with Monique Severijns telling the story of why she chose a (repeat) cesarean. From how she began her presentation, I expected this would be about choosing a primary elective cesarean with no medical indication. Instead, it was a story of a traumatic first birth that ended in cesarean and in her decision to choose a gentle, empowered cesarean the second time around. Her presentation spoke volumes about the normality of VBAC in the Netherlands, since she framed her choice as such a radical, controversial one in need of defending. Very different from the US, where most women in her situation a) would not see her choice as controversial at all and b) would not even have the choice not to have a repeat cesarean.

Next, Arie Franx spoke about controversies surrounding elective cesarean section (ECS) and "risky" home births. He noted that an OB who performs an ECS may be violating the Hippocratic Oath. He was the co-author of the 2011 Dutch obstetric guidelines, which noted that "term vaginal birth is a fact of nature and does not require consent." ECS is rare in the Netherlands; there were 69 performed in 2006 and 233 in 2011. Next, he addressed "risky" home births (twins, breeches, and VBAC). The Dutch maternity care system is based on a triage risk strategy, with 1st, 2nd, and 3rd lines of care based on the level of complication and complexity. The last of my notes reads, "He strongly disapproves of this." I think I was referring to his disapproval of "risky" home birth, but my notes aren't entirely clear.

Rebekka Visser, a Dutch midwife, explained why she attends breeches & VBACs at home. She gradually learned to respect and understand undisturbed birth. Over time, she started doing less and less during births. Now a primary interest of hers is understanding and promoting physiological birth. She argued that we shouldn't use the Dutch obstetric guidelines as the low or as a tool to coerce women. Rather, use them as a starting point for disucssion and keep care individualized. In her letter to the conference, she argued strongly that birth is a human rights issue and that "women themselves are the best advocates for their babies' interests. Period." During her time as a midwife, she has seen childbirth empower women, but she has also seen it inflict lifelong damage to a woman "if authority is taken away from her." 

Robert Kottenhagen, a law professor, addressed ethics & the legal status of the unborn. He noted that is most cases surrounding disagreements about home birth, "there is not a mother-fetus conflict at all, but a mother-doctor conflict." He examined the Dutch Civil code and the Abortion ACt of 1981 and concluded that under Dutch law, the unborn fetus does have some legal protection, but how far the fetus' rights may go when put into conflict with the mother's is unclear. Currently, "a doctor can act against the will of the mother to prevent severe damage or death of the unborn," according to the Royal Dutch Medical Association. However, these situations are fairly limited in scope. He concluded by noting that most often, there is not a mother-fetus conflict at all, but a mother-doctor conflict. "If the relationship between patient and doctor could be improved in such cases," he wrote in his letter to the conference, "the legal fight would probably be over."

Wilma Duijst, a forensic physician and law researcher, noted that her conclusions differ from Kottenhagen's. By law, a Dutch midwife cannot abandon a woman at home who refuses transfer or treatment. She advised against using coercion or threats on pregnant or laboring women.

Joke Meulmeester, who works at the Advice and Reporting Center for Child Abuse (AMK) and is chairperson of the VVAK (Association for Child Abuse Counselors), noted that controversial birth choices rarely initiate investigations within her agency. She can think of only 1 case in his agency's history. In her letter to the conference, she commented, "Most reported cases around birth are the outcome of a multi-problem situation, with either serious medical and social problems." She noted that respect and communication are important. (As a side note, she had a home birth in the US in 1980).

Joke noted that the Dutch Obstetric Indication List or VIL (Verloskundige Indicatielijst) is a guideline, not a law. The VIL is a list of obstetric indications for risk selection to the appropriate care provider & birth location. The Netherlands has contradictory Supreme Court decisions about how binding medical guidelines are. In one legal case, medical guidelines were enforced, but in another they were not.

Some notes from the post-panel discussion:

• Raymond de Vries noted how a "society makes you desire the very things it limits you to." Fascinating. 
• We have created a culture of blame by dichotomizing choices and by standardizing choices and care.
• Why, if we grant rights to the fetus, does it make us so flippant about the rights of the mother? In other situations we'd never imagine doing such things to other (non-pregnant) people.

If you were present at Panel 6 and have anything else to add, please share in the comments section!
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