I recently heard some figures about the number of Dutch women who receive spinal puncture anaesthesia when giving birth. The figure would be around 15 percent. This is probably the lowest percentage among all affluent countries. According to the same newspaper article, in Belgium the figure would be 70%, as it is probably also in many other European countries.
The exact figures don’t matter: this post is about the remarkable low percentage of women who receive spinal puncture anaesthesia in the Netherlands. I think these low figures are a scandal. Why? Because in the Netherlands most women have effectively no choice to give birth with effective painkillers. The figures are not low because there is no demand; rather, the figures are low because there are so many barriers, that it is effectively impossible for most women to choose to give birth without suffering immense pain.
The Dutch always praise themselves to be one of the few countries where women can give birth at home, and they have a relative high percentage of women giving birth at home. However, increasingly women give birth in hospitals, but not with the help of gyneacologists, but with midwives only. In the hospital in which my son Aaron was born, the midwives rule on the third floor, whereas the doctors are on the second floor. When I asked what pain relief was available on the third floor, I got the response: “there is a shower.”
The Dutch health care system makes it virtually impossible for healthy women to choose for anaesthetics. Pregnant women are divided in two categories: those who have healthy pregnancies, and those who have a so-called ‘medical indication’, which means that there is an increased risk for some medical problem, or when one knows that there is something non-standard going on (e.g. in case a previous pregnancy was problematic, or if one knows in advance that a C-section will have to be performed).
Why do so few women in the Netherlands have anaesthetics at birth? I can see three reasons. First, women who do not have a ‘medical indication’ have to give birth under the guidance of the midwives. They cannot choose to give birth under a gynaecologist. You can only go to a gynaecologist if you have a medical indication. If a woman receives spinal puncture anaesthesia, she needs to be supervised by an anaesthetist and a gynaecologist, and the midwives lose their authority. Hence it is clearly not in the interest of midwives to have more women who receive anaesthethics when they give birth: it basically means they have less work, and the remaining work is assistant work for a doctor, not work in which they are in controle.
Second, since many women give birth at night, making the option of spinal anaesthethics available to every woman would imply that many more anaesthetists would have to work during the night—something they are not eager to do, especially not wihtou a significant wage increase.
Thirdly, the Dutch health care system is a complicated mixture of private insurance and public subsidies; but it is extremely unlikely that making spinal anaesthethics genuinly available to all women would not imply higher costs for the government. And this at a moment when the health care costs are already increasing rapidely due to an aging population.
So, you probably ask, why don’t women revolt? Surely part of the explanation is that there is a collective action problem. But many Dutch women also ‘buy’ the idea that it is much better for the child and for the delivery process if it is all ‘natural’, that is, without pain killers. Pain relief is simply not discussed in most pregnancy courses, and many midwives de facto refuse to talk about it, or to give objective information to the women who ask questions. Some pregnancy books written by midwives try to glorify the power that women have over the process, and how proud they will feel afterwards. They even go so far to argue that it’s good to suffer pain, since it speeds up the dilatation and would lower the chance for complications. Women should embrace the pain for their own benefit, and for the benefit of their child.
But even the more mainstream books have explanations that stay clear from the political-economy explanation scetched above. They play the culture card. And who are made the bad guys? Here’s my translation of the answer in a mainstream book (Ouders van nu, Zwanger van je eerste kind, p. 216)
The way people give birth differs according to culture. For American women, giving birth is often experienced as the most horrible experience of their life becaus of the pain. Pain relief is then a logical choice. It is possible to regard childbirth as surgery, which implies that one uses pain relief, but it is also possible to see it as a marathon, where you suffer pain, but you constantly try to push your boundaries. Many Dutch women see the pain as an additional effect of the most beautiful experience in their life.
What can one say?