Risk and the politics of boundary work: preserving autonomous midwifery in the Netherlands

Midwives’ position in maternal and newborn care (MNC) in the Netherlands is unique:
unlike many other countries, they have retained the authority over risk assessment and
referral. We studied why and how midwives formally gained their position as gatekeepers,
a role formally granted in 1987 by the Study Group for the Revision of the
Kloosterman List (SGKL), a group of representatives from all professions and organisations
involved in Dutch MNC. We analysed the minutes of the SGKL’s meetings
and conducted interviews with eight key-informants who were involved in the SGKL’s
decision process. We used theories of professional boundary work and cultural theories
of risk to analyse the negotiations regarding the authority over risk assessment and
referral in MNC that occurred between the representatives of midwives, general
practitioners, and obstetricians in the SGKL. Our study offers new insights into
professional boundary demarcation and the contest for control of risk management
that occur at the political level of MNC. We show that beliefs regarding risks
associated with childbirth and concern with the protection of professional interests
can differ not only between but also within professions that seek to police and extend
their boundaries. Negotiations are shaped by a dynamic interaction between these
beliefs and interests, creating the possibility for otherwise unexpected transprofessional
coalitions and redefining boundaries in unexpected ways. Our findings offer the
possibility to view disputes in MNC as occurring between beliefs and interests, instead
of between professional groups. These insights can reframe policy discussions in MNC
and point to the need for further analysis of the boundary work that occurs in political
and regulatory arenas.