The paper by De Jonge et al. (2008) illuminates a crucial aspect of decision-making in midwifery care. Their distinction between informed consent, to which healthcare practitioners generally aspire, and informed choice, which is quite a different matter, is well made. The researchers effectively utilize these two approaches to decision-making to distinguish midwives who rely on the medical model in their practice from those who apply a midwifery model.
This study raises certain issues relating to midwifery research and midwifery practice which may bear closer scrutiny. By way of background, I should mention my longstanding admiration for Dutch midwives (Mander 1995). This is based largely on having met Dutch midwives at conferences and meetings. I have been left with the abiding impression that they are powerful women. Their power and status derive from both their historical and their current position in the Dutch healthcare system (Van Teijlingen 1994). Unlike midwives working in the United Kingdom’s (UK) National Health Service (NHS), Dutch midwives function as independent contractors. More akin to UK general practitioners, their practices verge on the entrepreneurial. While this may make them vulnerable in some ways, Dutch midwives are privileged by being protected from any professional competitors by a system known as ‘primaat’.
Another unique privilege enjoyed by the Dutch midwife is the existence and availability to the childbearing woman of the ‘kraamverzorgende’ or maternity home care assistant (MHCA). This person assists the midwife during a home birth and means that most of the ‘nursing and caring tasks’ can be left to the MHCA (Van Teijlingen 1990, p. 361, 1994, p. 117). This author goes on to observe that the MHCA’s presence means that ‘midwives can devote themselves entirely to their obstetric task’ (Van Teijlingen 1994, p. 217). Thus, in combination, ‘primaat’ and the MHCA serve to maximize the status and power of the midwife in Holland. It is these arrangements which have allowed the Dutch midwife to continue to carry the, albeit guttering, home birth torch. Perhaps due to the absence of such midwives this torch is all but extinguished in a large proportion of developed countries.
De Jonge et al. provide a well-detailed account of their study; their discussion of ethical issues, though, is interesting. In this section (p. 349), they state that they paid the participants €20 for attending the focus group; at the time of the data collection this sum equated to approximately £15 or US$30. Although this is clearly not a large sum, that it was paid at all would have benefited from some discussion. The fact that it is mentioned in the ethics section suggests that the researchers realize this, but neglected to elaborate. The researchers may have adopted the view that the participant midwives were, effectively, businesswomen, for whom ‘time is money’; so, for this reason, they probably regard the payment as justified. In spite of this, there should have been some mention of its potential to influence the researcher–participant relationship as well as the possibility of affecting the data (Dickert & Grady 1999).
It may be that one of the reasons why this questionably ethical payment to the participants was not addressed at the planning stage is that the research was not subjected to scrutiny by a research ethics committee. The researchers explain that ‘In the Netherlands ethics approval is not required for this type of study’ (De Jonge et al. 2008, p. 349). Unfortunately, the researchers do not explain the ‘type of study’ which is exempt from ethical scrutiny.
The payment of participants may be regarded as a relatively minor ethical issue, but this point raises questions about the remit and function of ethics committees. One of these questions, which may verge on the heretical, relates to the need for ethical approval and what it is that these committees are assessing. Their remit is widely accepted as the protection of vulnerable individuals and no one would question that protection is needed from the horrors which necessitated the Declaration of Helsinki (1964/96). It may be, though, that these committees may stray outwith their remit of addressing ethical issues. While the functioning of UK ethics committees has been standardized and improved, there remain anxieties about the agendas to which some of the members operate.
My own experience of obtaining ethical approval for a study interviewing (among others) women who had previously relinquished a baby for adoption, showed that the committees’ agendas went far beyond the ethics of the research (Mander 1992). Their criticism of ‘sociological-type research’ (1992, p. 1463) demonstrates the phenomenon which has become known as ‘ethics creep’ (Angell et al. 2008, p. 131). More recently, when ethical approval was declined on the basis of neglecting to consult with one particular ethnic group, it became apparent that some ethics committees are being used as instruments of government policy (HDEC 2005). It may be that this political function of ethics committees was seeking to resolve a form of national guilt complex. The recent study by Angell et al. (2008) clearly demonstrates the extent to which these committees stray from the straight and narrow of research ethics. These researchers showed that a large majority (74%n = 141) of the committees’ letters addressed ‘scientific issues’ relating to methodology. The problems associated with ethics committees are compounded by the hard line adopted by some journal editors (Mchaffie 1998, Thomson 2005).
So, although the study by De Jonge et al. might have been different had ethical approval been a requirement in Holland, it would have been difficult for such scrutiny to improve this generally admirable paper. This study provides a clear picture of the nature of Dutch midwifery practice. The reader learns that the Dutch midwife is a human being, rather than the paragon which we may have been led to believe. The reader is told that a large proportion of the births these midwives attend are in supine positions, that episiotomy and vaginal examination feature in their practice, that back pain or being pregnant affect their practice and that they may use ‘tricks’ (p. 351) to persuade the woman from her desired birthing position. Thus, rather than the rose-tinted spectacle view of Dutch midwifery, which is all too often presented, De Jonge et al. give a realistic representation of what happens, fortunately still quite frequently, in the woman’s home in the Netherlands.