Subscribe to Lemonada Premium for Bonus Content

This week, we travel east to the Netherlands. Here, midwives and “kraamzorgs,” or postnatal maternity aides, help parents during every step of the pregnancy journey. We’ll meet expecting parents trying out a new type of group-based care, hear from an American journalist about the the hands-on postpartum support she received in her own home, and meet a midwife prioritizing maternal care for undocumented immigrants.

Learn more about the Amstermam midwifery practice: https://amstermam.nl/over-ons/

Learn more about the Bijlmermeer Birth Center: https://verloskundigenpraktijkbijlmermeer.nl/en/

Interested in the history of the Bijlmermeer neighborhood? Listen to an episode of 99% Invisible that’s all about it: https://99percentinvisible.org/episode/bijlmer-city-future-part-1/

Look into centering care in the US: https://centeringhealthcare.org/what-we-do/centering-pregnancy

Read more of Dr. Ank de Jonge’s research: https://research.vumc.nl/en/persons/ank-de-jonge

Uncared For is presented by the Commonwealth Fund, a nonprofit foundation making grants to promote an equitable, high-performing health care system. Learn more at CommonwealthFund.org.

SuChin Pak is our host. Muna Danish is our supervising producer. Giulia Hjort is our producer and Rachel Lightner is our producer and audio engineer. Isaura Aceves is our associate producer. Mix help from Kristin Mueller. Music is by Andrea Kristinsdottir. Jackie Danziger is our VP of Narrative Content. Our story consultant is Kaya Henderson. Fact-checking by Naomi Barr. Executive producers are Jessica Cordova Kramer and Stephanie Wittels Wachs.

Follow SuChin on Twitter and Instagram at @suchinpak. Stay up to date with us on Twitter, Facebook and Instagram at @LemonadaMedia.

You can also get premium content and behind the scenes material by subscribing to Lemonada Premium on Apple Podcasts.

Want to become a Lemonada superfan? Join us at https://joinsubtext.com/lemonadasuperfan.

Click this link for a list of current sponsors and discount codes for this and all other Lemonada series: lemonadamedia.com/sponsors.

To follow along with a transcript, go to www.lemonadamedia.com/show/ shortly after the air date.

See omnystudio.com/listener for privacy information.

Transcript

SPEAKERS

Rihanna, Luciana, SuChin Pak, Tracy Brown, Joyce, Speaker 2, Speaker 6, Speaker 7, Speaker 4, Speaker 5, Marta, Speaker 8

SuChin Pak  00:00

By walking around Amsterdam on a summer morning, you may notice something a bit strange. No, it’s not the endless rows of wooden clogs in the shop windows, or the impromptu choir performing beautiful Dutch folk songs on the corner. It feels like everyone here seems really happy. Which may actually be true considering Amsterdam ranks as one of the top cities in the world to live a happy and healthy life. It is among the most bike friendly cities in the world. It’s no stranger to progressive cultural policies. And it’s coffee shops serve a lot more than just coffee. On top of that, it’s home to an incredibly robust system of maternal care. Which our team got to see firsthand when we visited New parents […] and […], just four days after the birth of their daughter, Artemis.

Speaker 2  01:17

The first feeling that kicked in me, the moment I saw her is like, okay, let’s go as fast as possible home to be with three of us.

Rihanna  01:26

And then they asked her like, how did I climb the stairs?

SuChin Pak  01:30

That’s Dutch community midwife, Rihanna Scholten. And folks, she is not joking about those stairs. That couple live in the quintessential Amsterdam home and narrow one bedroom apartment up a comically steep staircase. Not ideal for someone who just gave birth. Rihanna made the trek up to their third floor apartment bright and early this morning to check up on tiny Artemis and her mother Peen.

Rihanna  01:56

How are you doing?

Speaker 4  01:56

Good. It was a right the whole labor because she was in stargazer.

SuChin Pak  02:05

Stargazer, meaning baby Artemis was facing up in the uterus as if looking at the stars. This type of breech makes it more difficult for the baby to come through the pelvis.

Speaker 4  02:15

So I was stuck on five centimeter for six hours. I experienced a bit out of body experience. It was so heavy the contractions. So we chose for the epidural. I got the epidural at 2am. And then at six o’clock, I could push. I felt really respected and we all made the right choices. If she wasn’t a stargazer, it would be way faster birth, and probably didn’t need any medication. But it’s okay. She’s here. She’s also the goddess of them all. Artemis so yeah, you know it Stargazer was meant to be.

SuChin Pak  03:08

peens labor was challenging to say the least. But now that she’s done the hard part, the Dutch maternal care system takes over, and that care is covered through the country’s national health insurance program. During her home visit, Rihanna examines the baby takes out Peen’s stitches, and gives the first time mom a heads up about the physical changes. She’ll be feeling post birth.

Rihanna  03:34

If you’re going to walk around and you feel that your pelvic floor feels heavy, that’s normal in first weeks. But that’s really a sign like okay, just go home and take some rest. And it’s good every afternoon to at least for half an hour or an hour really lay flat. So even if you’re not asleep, lay down completely flat. Everyday for the upcoming I would say two or three weeks.

SuChin Pak  03:59

After imparting a ton of practical advice and answering each and every one of the couple’s questions. Rihanna gives the new family the rundown on how they will be supported going forward.

Rihanna  04:12

You don’t do anything. It’s all coming to you. But this is what you can expect. It will be the GP taking care of you guys. For the upcoming weeks. If there’s something regarding blood loss or your breast or there are topics that you think okay, it’s more useful to talk to me and then of course, feel free to give us a call.

SuChin Pak  04:33

So those cheerful church bells, that cute phrase stargazers so much sweeter than breech the thoughtful care that as Rihanna said is all coming to you. I can’t help but think that if American parents had this kind of support, maybe we’d collectively rank a little higher on the happiness meter too. But what if I told you that the comprehensive, convenient and compassionate health care you just heard in action was only the tip of the iceberg when it comes to Dutch maternal care? Last episode, we learned about how progressive family policies including the legal right to a midwife, or improving birth rates in Germany. Now, we’re spending time in the Netherlands, where long term Postpartum Support is just one of many reasons why the Dutch have earned a spot among the top performing countries for maternal care.

Speaker 5  05:39

We’re spending so much time on building a relationship that people just feel safe.

Speaker 6  05:44

We mostly live in this community. So we see our clients as family members, and that’s the key.

Speaker 7  05:51

So while you’re pregnant, they’re not really fussed about you. But once you have your baby, then they really pay attention.

SuChin Pak  05:58

Today, we’re going to walk a mile in the metaphorical clogs of Dutch birthing people and explore what makes Dutch maternal care such a standout from its high rankings and access to care to the postpartum support role called kraamzorgs that is unique to the Netherlands. This is UNCARED FOR I’m SuChin Pak.

Rihanna  06:28

I think doing good stuff or making good stuff is most of the time quite old fashioned. But I think mostly the old fashioned is higher quality.

SuChin Pak  06:38

In Dutch, the traditional word for midwife translates to a wise woman, a title that Rihanna Scholten definitely lives up to.

Rihanna  06:47

In the past, if somebody builds this table for you how to food that he cut himself and Luke could do 40 years with that, or 50 years, and it was stayed in the family and it was never breaking down. And then nowadays with all the IKEA or what else then after a few years, you just throw it away.

SuChin Pak  07:07

If we’re measuring maternal care on the quality home furniture scale, the US system is definitely closer to an Ikea table than an heirloom. Our model is confusing to navigate, often unreliable and very unstable. But the Netherlands, well, their maternal care model is the intricately carved mahogany table passed down over generations.

Rihanna  07:34

I really think that giving birth is healthy process for a woman, you’re not sick, you don’t need a doctor, you’re healthy and you’re carrying a baby. And that’s it and we’re going to prepare you to keep that healthy process.

SuChin Pak  07:48

Rihanna is a community midwife at Amstermaam. Get it? Amstermaam, a birth center that cares for about 500 pregnant people per year.

Rihanna  07:58

We have three different locations in the middle of the city center, where we’re working with women like healthy pregnant women, because that’s how the system in the Netherlands is that if you’re healthy, you’re just visiting a community midwife.

SuChin Pak  08:11

The maternal care system in the Netherlands is pretty comprehensive. There are multiple lines of care that birthing people can access, which are determined by pregnancy risk level. Community midwives and birth centers are considered the first line of care and are the most commonly accessed form of birth support.

Speaker 8  08:30

In Holland because we have a strong community based system. Many women, if they remain low risk, they may never see a doctor going through pregnancy.

SuChin Pak  08:38

That’s Dr. […] a Dutch midwife and professor of midwifery science. She tells us that midwives actually greatly outnumber OBGYN in the Netherlands.

Speaker 8  08:51

So every woman needs a midwife but not every birthing person needs to an obstetrician.

SuChin Pak  08:56

I just want to reiterate that every birthing person needs a midwife, but not all of them need a doctor. That’s definitely not the norm here in the US. In fact, it’s reversed. Every pregnant person in our country gets an OB, but very few get a midwife. In the Netherlands, there’s something else especially unique about how babies are brought into the world.

Speaker 8  09:23

We’re known for that in the world to where women can choose to give birth at home as well.

SuChin Pak  09:28

The Netherlands has the highest rate of home births in the EU just over 16% of all births. And out of the clients that Rihanna sees at Amstermaam, that percentage is even higher

Rihanna  09:40

from all the labors that we do complete. So where we really end the care by having a baby in our hands. It’s 50/50. So we have 50% homebirths.

SuChin Pak  09:53

From an American perspective, this might seem like kind of an unconventional approach. After all in the US only a little over 1% of all births are home births. But Professor […] says a lot of thought is put into ensuring the pregnant person and baby are safe.

Speaker 8  10:12

We have midwives who are well-trained to do home births. We have good guidelines on when we think it’s safe to give birth at home or not. And we have a very good ambulance support system. So if you need to get to hospital in an emergency, you can get there quickly.

SuChin Pak  10:29

The Dutch embrace homebirth not just because of tradition, but also because they have evidence that this long standing custom leads to good results.

Speaker 8  10:39

We’ve had several studies in the Netherlands showing that the outcomes are comparable to if women choose hospital birth. And in fact, they have a lower rate of interventions. So it’s considered quite safe.

SuChin Pak  10:53

Interventions meaning procedures like C-sections, induce labor, and administering of antibiotics, all of which can be lifesaving in many circumstances. But research shows that routine use of interventions can lead to increased risk of complications. The American system has been widely criticized for being too intervention focused since the 1970s there has been a 500% increase in C-sections in the US. This over medicalization of the birth process is actually something that contributes to our high maternal mortality rate, which feels sort of ironic since these interventions are meant to be done in the name of safety. And research shows that high income countries with the lowest intervention rates, lowest costs and best outcomes have good old fashioned midwifery led care, like you find at Amstermaam.

Rihanna  11:49

And that’s what I think as a community midwife. Like that’s my goal to help somebody to give birth with as less interventions that are possible with a good outcome. To go back to the table. You can do all kinds of different stuff on the table, but sometimes it tables just a good table.

SuChin Pak  12:08

A good table is worth keeping. Just like a good tradition is worth continuing. While the Dutch commitment to tradition plays a large role in what makes their system so successful. Rihanna and other community midwives also look for new ways to problem solve and improve care.

Rihanna  12:25

We see that women are quite lonely in their motherhood in the first weeks, and they’re finding out everything by themselves. And like every day or almost every day, there’s a baby born in our practice, and the same thing repeats. So we’ve been thinking already for a few years what to do about that. And then we really think that Centering Pregnancy is a solution for that.

SuChin Pak  12:50

Centering Pregnancy is a type of care where small groups of pregnant people meet with a midwife to learn together and support each other. But this model actually originated in the US. A Connecticut based midwife developed it when she noticed that throughout her tireless days of back to back 10 to 15 minute appointments, she was answering the same questions over and over. While the centering model of care is pretty niche in the US, as is midwifery care in general, this new approach took off in the Netherlands. Currently, more than 100 midwifery practices in the Netherlands have successfully implemented this model. We wanted to see for ourselves what this type of care looks like. So we met up with Rihanna at the Amsterdam East location. Walking through the front door of the birth center, you’re hit with a warm wave of what can be only described as comfiness. Aside from a small exam room tucked in the back, you wouldn’t know this is a place where healthcare is delivered. There’s a small kitchenette for making coffee or tea couches and beanbag chairs. And in the center of the room is a large circle of about a dozen chairs. So okay, I’ll come walking. It’s only half an hour. Packed in this comfy space are about a dozen very pregnant people. As more people file in a cluster forms around a table with a blood pressure cuff.

Rihanna  14:28

They always check their blood pressure themselves. That’s also part of it that they really know what it is about.

SuChin Pak  14:35

One of the fundamentals of the Centering Pregnancy model is encouraging pregnant people to take more of a hands on role in their care process. Each person measures their own blood pressure, registers their weight and maintains their own medical files. While everyone is taking their blood pressure, Rihanna pulls people back to the exam room. One by one for a quick checkup.

SuChin Pak  15:07

Rihanna greets a woman named Marta who is 28 weeks pregnant.

Marta  15:10

I’m Marta. I’m 42 years old. And I’m Italian. But I live in Netherlands since six years now. Yes.

SuChin Pak  15:29

Marta’s face looks concerned as Rihanna begins moving a Doppler device over her belly to check the baby’s heartbeat.

Marta  15:38

The things that worry me constantly is because even if I don’t think I am, but I am a bit old. Oh my god, I cannot say that. But yes.

SuChin Pak  15:52

In the US Marta’s pregnancy would be labeled as advanced maternal age. As someone who is older than 35. Not too long ago, doctors refer to these as geriatric pregnancies. These pregnancies are considered high risk, even though the majority results in healthy babies. But here in the Netherlands, Marta is considered low enough risk to stay in the first line of care at Amstermaam, with just a few extra tests performed here and there. For example, last session, Rihanna had Marta get a blood sugar test for gestational diabetes, which came back normal.

Rihanna  16:31

35 to 140 beats per minute, which is a normal frequency being normal as ever. It’s very good. Very well. According to plan.

SuChin Pak  16:43

Marta is relieved to hear that our baby’s heartbeat is sounding normal, which is at once both a relief and empowering.

Rihanna  16:51

When it’s positive, and everything is fine. So oh my god, yes, I’m strong and do it.

SuChin Pak  17:00

Because all the participants are close enough in their stages of pregnancy. They have a lot of similar questions. So while she briefly examines each person, Rihanna jots down these common questions, and gathers a group in a circle for the part of the session she called the waiting room.

Rihanna  17:18

I’m going to first do the waiting room. So with the topics that I want to discuss to give some more information or answer your questions about the estanza I think you can tell about that better than I can. So do you want to share why I asked you to write this down.

SuChin Pak  17:42

Rihanna asks a group member to share about her experience with […] or abdominal muscle separation, which can begin in the second trimester and is fairly common by the end of pregnancy. The diathesis diagnosis was frustrating for her because she feels healthiest when regularly working out. So Rihanna asked her to share some of the pregnancy adapted and midwife approved strength training exercises she’s been trying out. Rihanna also add some everyday practical advice for coping with […]

Rihanna  18:23

So also where you’re coming out of your bed or these kind of things. First, turn to your side, like help yourself with your hands. If you’re carrying your groceries, don’t pick them up like this, but do it like this. So act like an old lady with a miniskirt. My role is basically to let the group have all the knowledge on the surface. And so I’m really trying to ask a lot of questions trying to give some inspiring information that they can go on with

SuChin Pak  19:11

There are 10, 2 hours session in the Centering Pregnancy program. The final ten session is actually after the babies are born. So the new parents have a built in network of support that Rihanna says goes on long after the final session.

Rihanna  19:27

They’re all in WhatsApp group and they’re sharing they also have such a big lack of sleep and your baby also crying more. I read that it’s normal between two and eight weeks babies are crying the most and of course it’s so my information that I also have but it’s impossible to share all my knowledge with everybody so it’s nice when they share with each other.

SuChin Pak  19:49

Midwifery expert Dr. […]

Speaker 8  19:53

It really helps to give some peer support and that helps women to be more confident and learn more from each other than you would want to learn from a midwife.

SuChin Pak  20:04

Dr. […] says that in her years studying Dutch Midwifery, the most notable change she’s seen is in its progression towards integrated care, like Rihanna’s centering program, where the medical checkups are combined with interactive learning and peer support

Speaker 8  20:22

That’s been going on for a while now. And people are experimenting and doing that in different ways. Because everybody always wants to improve outcomes.

SuChin Pak  20:31

And the outcomes do improve with Centering Pregnancy. The research shows less preterm births and lower rates of hypertensive disorders. And centering care has a positive impact on improving healthy behaviors postpartum too, like more healthy eating and physical activity after pregnancy, which Rihanna has seen firsthand.

Rihanna  20:54

There are two people living here on the west shore dock. And then they’re having a walk every day, because they both had the goal, like I need to walk at least 8000 steps a day to have a good recovery. So they’re just ringing each other doorbell in the evening, and they’re having a walk. And that’s something that I never can like, there’s no way to facilitate this in another way than doing the Centering Pregnancy. The taking care of each other, so that it gives a feeling I’m not on my own, I don’t have to do everything alone. And they realize it a bit during the pregnancy, but especially after.

SuChin Pak  21:30

It sounds like to me, instead of going to your checkup in a doctor’s office, you go to what feels like a cozy club for pregnant people, led by a birthing expert. imagine just how helpful it is to be in a room with people experiencing similar things as you the stress, the isolation, the fear of having a baby, and being able to talk about it together with a midwife there to guide you through it. Yes, these communities do exist in the US, but they’re not always run by the people who are actually delivering your baby. And you often have to find these groups on your own. They’re not built directly into the care model. Now, think about the impact of care like this on black birthing people, for example, who statistically have worse health care experiences, have a resource like this could support them in a way a doctor’s office never could. Like the progressive family policies we discussed in Germany, the Dutch system supports the well-being of an entire society. But what stands out most is that it manages to take the onus off the pregnant person and put it on the larger system. Coming up, we’ll speak with an American journalist who experience the whole package in the Netherlands firsthand. That’s after the break.

Tracy Brown  23:10

When I was first pregnant, I went to my GP I thought that’s what you do. And he was really confused that I was even talking to him about it. He thought I wanted to terminate or I thought I was having difficulty getting pregnant. Then he realized no, you’re happy, you are pregnant. You need a midwife. You don’t need a doctor.

SuChin Pak  23:30

That’s Tracy Brown and American writer and editor living in Amsterdam with her husband and three kids. When Tracy got pregnant with her first child, Liam, she was a little taken aback by the way the Netherlands did maternal care.

Tracy Brown  23:45

I felt largely ignored. No one in the medical community of the Netherlands cared that I was pregnant. It’s not a big freakin deal. You’re pregnant. A lot of people are pregnant people have been pregnant for millennia, and we know how to do it.

SuChin Pak  24:02

And the first point person in the pregnancy process is your midwife.

Tracy Brown  24:06

I went to one practice, where there are six on rotation because you don’t know who’s going to be on call when you go into labor. So they want you to have an experience with each of them. You meet them, they measure you they talk to they get a sense of how you are feeling psychologically.

SuChin Pak  24:24

part of these conversations with her midwives were about her age. Tracy was 38 when she first got pregnant, and initially she thought this would be a big deal to them, because in the US, it definitely would be but her midwives surprised her.

Tracy Brown  24:38

It was addressed, but it was addressed in a way that there’s no problem

SuChin Pak  24:42

just like her midwives anticipated. Tracy didn’t experience any complications at all. She stayed low risk, which meant that she was able to continue receiving care from her first line midwives. And this sort of care gave Tracy that peace of mind to have a less stressful pregnancy.

Tracy Brown  25:00

And it was so laid back that I thought initially no, no, I need more structure to this. But I got used to that pretty quickly. I thought, if you’re telling me it’s fine, then maybe I can just deal with the rest of my life for the next nine months and enjoy not being a mom until I am one. And just it made me really calm. Let me enjoy being pregnant and let me plan other aspects of my life like my work and my house. And let me focus on things that were really more important to prepare me for having a baby.

SuChin Pak  25:39

Part of these preparations came as a package in the mail, free of charge from her insurance company. You might be thinking insurance company free. Yeah, those are two words you basically never hear in the same sentence in the US. Tracy was surprised too.

Tracy Brown  25:56

So they send you a box that gives you all the stuff that you need for homebirth with things like a bedsheet like surfboard size, sort of maxi pads or something to cut the umbilical cord, basic hygienic stuff for the baby, a little stuffed animal, like a little pair of pajamas, just this is what we need it for, like on a mountain having a baby.

SuChin Pak  26:21

The […] pocket or maternity package, as it’s called, has every item you could ever think of for home births and after care. But the support doesn’t stop there. integrated into their maternal care is a postnatal maternity aid or kraamzorg, as they’re called in Dutch.

Tracy Brown  26:40

So they begin when you’re still pregnant, the kraamzorg comes into your world. And it can feel kind of judgmental, but it’s really its guidance. If you have the right mindset. It’s just really helpful.

SuChin Pak  26:54

Tracy first met her kraamzorg Pauline about a month before the birth of her son. And her first interaction with her was a little intimidating, because she felt like she was being grilled on just how prepared she was for a newborn.

Tracy Brown  27:08

Okay, what’s the nursery set up? Where’s the bed? Where will the baby go? Where will you be? What are they going to wear? What equipment do you have what you need, and they give you a long list.

SuChin Pak  27:17

So when the first contraction hit, Tracy felt well prepared and the baby’s stuffed department. Yes, she and her husband had just moved and yes, almost everything they owned was packed away in boxes. But with the maternity package and kraamzorg on deck, they felt confident everything would be okay.

Tracy Brown  27:35

with my baby’s bedroom set up. And we had one adult bed that was here, but we had no other furniture. But I called the midwife and she wasn’t fast. And she came and she said actually, you’re not screaming, you don’t sound like you’re that far along. So let’s just give it a few more hours. And a few hours later, I called her again. I’m like no, really I think we’re good. And she arrived with a little birthing stool on her bicycle.

SuChin Pak  27:59

A birthing stool and a bicycle doesn’t get any more Dutch than that. Although Tracy had planned on delivering her baby at home, There ended up being one small complication, […] aspiration her baby had breathed in a mixture of its first feces and amniotic fluid. This can happen when the fetus is stressed during labor, and can lead to severe illness or even death of a newborn. Luckily, Tracy was transferred to the hospital and given the support she and her baby needed.

Tracy Brown  28:33

My midwife eventually had to go, and I was left with the OB. But he was brilliant. And he maintain the same tone of autonomy. He said, you’re doing this, you’re doing all of this. I’m just here, I’m just watching what you’re doing this. And that kind of assurance, that kind of respect, that we’re not just getting you out of this room because we need to have another patient in but you are delivering your baby by yourself. I’m just here.

SuChin Pak  29:07

For Tracy, this sort of care felt really empowering.

Tracy Brown  29:12

The autonomy of the mother is crucial to the process. And that is what they really emphasize. And you need to have that confidence from the get go. And if you don’t, they will guide you through how to do it. And that’s the role.

SuChin Pak  29:27

Let’s try to understand what this really means. When it comes to birth Dutch providers see the pregnant person as the expert on their own body. They only intervene if it’s medically necessary. And this builds confidence that continues on into the postnatal phase with the kraamzorg.

Tracy Brown  29:47

So my baby was born in hospital. I went home at like six in the morning and she came to my house at 8.

SuChin Pak  29:55

Pauline continued to check on Tracy and help her out. And this took some good It used to for Tracy,

Tracy Brown  30:02

The first time it was really awkward. And I was kind of getting up and showering, like I felt like I had a social worker in my house, assessing me, you know?

SuChin Pak  30:11

For 8 to 10 days straight, depending on your need, kraamzorg at your house doing all the things you can’t or don’t want to think about. And this care is included in every Dutch person’s basic health insurance package. The only extra cost may be a small co-payment of about $5 per hour.

Tracy Brown  30:31

And she’s sort of the contact to the GP and to the midwife. So she has to report back how long recovering how the baby’s doing. So they are monitoring the baby, but in a very personal way. And her job is to kind of run errands, do whatever you need to have done so that you can rest.

SuChin Pak  30:49

By the way, these errands can include things like bringing older kids to school, walking the dog or doing the grocery shopping.

Tracy Brown  30:58

I live here with no family around me. So I don’t have my big sister to come help me or my mother to come and help me with my baby. So this kind of help is actually really appreciated.

SuChin Pak  31:13

In addition to keeping the house in order and checking on mom’s recovery, and baby’s growth, the kraamzorg is also there for emotional support.

Tracy Brown  31:21

She would say things like tomorrow, you might feel really depressed. Because tomorrow, your milk will come in and you’re going to wake up and it’s going to feel different and just be prepared for that. And it’s normal. It’s okay. Like all kinds of just big sister kind of advice.

SuChin Pak  31:40

And all of this big sister advice from a birth expert is crucial considering how delicate the postnatal period is.

Tracy Brown  31:48

It’s like the dashboard has been completely rearranged and you’re just flying down the highway. And that’s a very unsafe place to just leave someone.

SuChin Pak  31:58

Because while birth is a physical transformation, it’s just as much a psychological one. In the US postpartum depression affects one out of seven new moms, but it’s often not diagnosed or treated. Many people just get a generic survey with questions like have you been anxious or worried for no good reason. This feels like the absolute bare minimum, given the fact that having a baby is definitely not an easy thing to prepare yourself for.

Tracy Brown  32:28

And that’s mostly what the crumbs org is doing. They’re also doing the medical stuff. But I think they’re mostly looking at you psychologically, and helping you adjust and adapt and feel like you’re rocking it even if you feel like you’re not.

SuChin Pak  32:44

Hearing Tracy’s story, it makes sense that the Netherlands is among the top performing countries for maternal care, GPs, midwives, and kraamzorgs ensure healthy babies are born to equally healthy moms who birth with dignity and autonomy. And all of these puzzle pieces work together seamlessly to keep them healthy, long term. A crucial part of this comes down to mental health. In the US about 40% of new parents don’t attend postpartum visits. And attendance rates are especially low for people with limited resources. What this means is that lots of people aren’t getting the mental health support they might need.

Tracy Brown  33:27

Having someone kind of just check in in your own environment and see how you’re conducting yourself and what your life demands of you. It’s not just that you have a baby, you also have a job. You also have maybe other children or an older parent that you’re looking after. All of that is part of the demands this baby’s going to put on your whole system. And they’re there to watch that.

SuChin Pak  33:52

After the break, we’ll head out of the city center to Amsterdam southeast where we’ll dig into culturally centered care. Before the break we heard from parents and providers in the Amsterdam city center, but now we’re heading 15 minutes southeast to a neighborhood called Billmer. Since the 60s, this neighborhood has been home to many immigrant communities. Nowadays, there’s about 140 different nationalities represented, including many immigrants from African South American and Caribbean countries. And we’re here to meet another midwife who helps deliver their babies.

Luciana  34:43

I’m missionaries and I work now 17 years in a clinical setting and also for 17 years in the realm of mu

SuChin Pak  34:53

Luciana is a clinical midwife. She splits her time between a birth center known as the Belmar and one of the country’s leading hospitals, the Amsterdam University Medical Center or AMC for short. That’s where we met her.

Luciana  35:08

This is one of the biggest one in Amsterdam. And we also have the […]. But the maternity ward is only here at the AMC.

SuChin Pak  35:17

The AMC is what’s known as a third line hospital or one where OBs and clinical midwives handle mostly high risk births. It’s a particularly swanky hospital with a pretty extensive food court, a Starbucks, a library and a museum dedicated to anatomical oddities, just in case you get bored while your partner is in labor. Here’s Luciana giving us a tour of the AMC maternity ward.

Luciana  35:43

This is one of our rooms, not the biggest one. But here we do deliveries. And most of the time, it’s also warm here because it’s better to deliver in a warm room than also for mother.

SuChin Pak  36:01

Clinical midwives, like Luciana are becoming more common in the Netherlands. But what makes Luciana especially valuable is that she has a foot in both worlds, the AMC Hospital and the neighborhood birth center.

Luciana  36:15

I like to do both because I like the medical setting. But I also want to be in a normal setting. And when you are only working in the hospital, you’re forgetting that it’s also can be low risk normal birth and that women can do it with less stress and less intervention. Yes, that’s my goal.

SuChin Pak  36:37

This less stress, less interventions mentality is what’s made the relationship between the AMC and the birth center work so well. Because staff know one another and have a go to middlemen like Luciana. They’re more efficient at communicating about when a hospital transfer is needed. The AMC is only a seven minute drive from the birth center. And while that’s mostly a plus it can also mean emergency phone calls and extra work for the already busy Luciana.

Luciana  37:11

I also work for other practice. How many weeks are you pregnant? Baby your stomach. Okay. Are you losing blood sweetie? Wait time can you be at cryonics so I can check you over there. Okay, 12:50. I’m sorry. And then, very often, women who speaking English from Hana or Africa, they don’t speak in Dutch, and this woman who doesn’t have a family doctor, so I didn’t check it, but I think she’s not registered. So I need to see her.

SuChin Pak  38:09

By not registered, Luciana means undocumented, and these sorts of calls are routine for her. In one day, Luciana gets about 10 phone calls like this one. And the majority are from pregnant African immigrants who learned about the birth center through word of mouth.

Luciana  38:27

A couple of practice doesn’t take women who are not registered, or they are asking money for it. So women are not coming. So in you see that our practice, it doesn’t matter. If you don’t have money or anything, come to the practice and don’t worry about the money.

SuChin Pak  38:48

Don’t worry about the money. Again, not something you’d ever hear in the US. As an undocumented immigrant in the US, you wouldn’t be eligible for public insurance. And while emergency Medicaid covers limited care for labor and delivery, additional care varies state by state, and it typically excludes postpartum care. But in the Netherlands, the Bill Maher birth center treats everybody equally regardless of their insurance or immigration status. The center has the flexibility to not ask for payment because of a special type of insurance offered by the Dutch government that covers the cost of checkups and homebirths. Still, this example of health equity is particularly crucial in a community that is up to three times more likely to die from pregnancy related causes than their non-migrant counterparts.

Joyce  39:42

I saw the importance as an African nurse to educate my own people about the importance of the maternity care.

SuChin Pak  39:52

This is Joyce […] a kraamzorg at the Billmer birth center. When Joyce isn’t working at Bill Maher. She’s running her own postnatal care organization called Joy crumbs. org, which she started specifically to serve undocumented migrants.

Joyce  40:09

I started working for them because they didn’t know that they have the same rights as all Dutch women. Some also coming from Africa and having somebody that they can relate to brought more trust into the health care system.

SuChin Pak  40:25

over the 25 years that Joyce has been working as a maternity nurse, she’s learned a lot about the delicate balancing act of multicultural care.

Joyce  40:35

In the beginning, we were bringing the Dutch system to the African community and they didn’t want that. We’re bringing the Dutch system to the Spanish community. And they didn’t want that, until we realized that we have to find a balance. And the balance is that we learned the Dutch way from school, but on practice is different.

SuChin Pak  40:54

In practice, a large part of Joyce’s job is about culturally centered care, a kind of care that pays attention to a patient’s background and empowers them when they’ve just experienced this major life shift.

Joyce  41:07

Our idea of coming actually to their homes is to help them take care of the baby themselves. And knowing that, after childbirth, you need rest, warmth and hygiene to recover from the pregnancy and the birth, the system chooses to come to you.

SuChin Pak  41:22

Years of working and culturally centered care have made it clear to Joyce that there isn’t any benefit in imposing the Dutch weigh on her clients. She wants him to feel that they can embrace their own traditions while taking care of their newborns. But this is sometimes easier said than done. In practice, it’s hard work keeping tabs on the 140 or so nationalities living in the Billmer neighborhood. So when Joyce is making home visits, there’s a lot of memory work involved. For example, which culture has which tradition.

Joyce  41:57

which culture must not walk barefooted in the house when you give birth, which culture must take water first before eating breakfast. With cultural tradition within the Surinamese community must first seek their local drink before they bind their belly.

SuChin Pak  42:14

Joyce keeps all of these cultural traditions in mind when she provides support to parents. One thing that makes this job easier though, she lives in the neighborhood, she serves like most of the birth center staff.

Joyce  42:28

So we understand each other. And we see our clients as family members. And that’s the key. Because we do meet them at school with our children. Also, we made them access swimming pools, we meet them at the market. So everywhere we go, we meet our clients. So it’s better. You treat them as family. Afterwards, we see them grow. We see them on the street. Before you know they’re taller than us like this lady changed your diaper. When you were you know you did this and I did.

SuChin Pak  43:03

So much of what Joyce does is about building trust, by listening and valuing the cultural differences of her community. And that’s a huge part of Rihanna and Luciana is work as midwives too, the home visits, the group care being available for an emergency call. They seem to know that relationships are key to their work, and the system is actually set up to allow those relationships to thrive. And then there’s the radical idea that birth is well normal. There’s something so powerful about that, because it means that you can embrace it, rather than worry and analyze it for every possible worst case scenario. We know that the US views birth from a medical perspective. And while it’s helpful for those births that are complicated or high risk, for low risk pregnancies, we might end up doing more harm than good. So while I don’t think we all need to be rushing to give birth at home, what we can do is rethink how we look at birth in the first place.

Tracy Brown  44:04

I felt more engaged with it in this system because I felt more empowered. And I felt more autonomy and I felt like I was given space to really think about how I felt about it.

SuChin Pak  44:16

Tracy’s experience giving birth felt radical in a way and very mundane and others. And that’s exactly the type of experience that midwives like Rihanna hoped for.

Rihanna  44:27

Because I think if you have a healthy pregnancy and a healthy birth as a mum, it’s life changing to have that experience.

SuChin Pak  44:46

We’ve now been to Germany and the Netherlands on our maternal care world tour. And while both countries are outperforming the US, there are other health care systems out there that don’t make the top 10 list, but they’re still seeing an impressive outcomes. One of these countries is Costa Rica, where the emphasis is on community and rural health. Next week, we’ll head to Costa Rica and meet the community health workers who literally climb mountains to deliver quality care.

CREDITS  45:38

UNCARED FOR is a production of Lemonada Media. I’m your host SuChin Pak. Muna Danish is our supervising producer. Giulia Hjort is our producer. And Rachel Lightner is our producer and audio engineer. Isaura Aceves is our associate producer. Mix help from Kristin Mueller. Music is by Andí Kristinsdóttir, Jackie Danziger is our VP of narrative content. A story consultant is Kaya Henderson. Fact checking by Naomi Barr. Executive Producers are Jessica Cordova Kramer and Stephanie Wittels Wachs. This season of Uncared For is created in partnership with the Commonwealth Fund. There’s more UNCARED FOR with Lemonada Premium subscribers get exclusive access to bonus content, like interviews with health experts, midwives and doulas. Subscribe now in Apple podcasts, follow UNCARED FOR wherever you get your podcasts or listen ad free on Amazon music with your Prime membership.