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Maternal Health Care in the Netherlands: A Right for Some

At the start of the presentation "Maternal mortality: A human rights violation," Professor Jos van Roosmalen, a specialist in maternal mortality and severe maternal morbidity warns us, “ These images will shock you.” He proceeds to show us gruesome images of women who faced complications and died in childbirth in different countries around the world. We see the usual suspects, Somalia, Ethiopia and mostly Sub Saharan Africa. We are surprised when he points to a picture of Amsterdam,  “There is a great difference in mortality rates between women who lives in Amsterdam South – a wealthy district- and women who lives in Amsterdam South-East, a poor district where many ethnic minorities live. The fact that we see this should alarm us!”  

With 99% of maternal deaths occurring in developing countries, it is too often assumed that maternal mortality is not a problem in wealthier countries. However despite The Netherlands’ lower maternal mortality rate of 12.1 per 100 000 live births, women from ethnic minorities within The Netherlands have a maternal mortality rate three times higher than native white Dutch women. These avoidable deaths represent human rights violations against women; a violation of women's rights to life, health, equality and nondiscrimination. This paper examines why there is a widening gap in maternal mortality among ethnic populations in The Netherlands and why there have not been sufficient efforts to reduce this gap.

Population Demography of the Netherlands In terms of Mortality

Overall The Netherlands has had a relatively large ethnic minority. About 10% of the population in The Netherlands is of non-Western origin with the largest groups being Turkish, Moroccan, Surinamese and Antillean/Aruban immigrant groups. Recent studies have shown that non-western ethnic minorities in general face a higher risk of maternal mortality than native Dutch. However even among the ethnic minorities, differences in maternal mortality exist. Turkish people and Moroccans generally benefit from lower risks of maternal mortality compared to immigrants of African descent like Antilleans, Surinamese and Somalian who have the highest mortality rates. While this is a complex issue since there are overall higher mortality rates due to the ethnic composition of these migrants, mortality levels are influenced by a series of factors and activities of which health care is a part.

Health care system in The Netherlands: Affordability and Accessibility

The Netherlands appears to have one of the most comprehensive health systems, offering universal health coverage for all its citizens and legal migrants. Every citizen in The Netherlands is legally obligated to pay about 110 euro per month for health insurance. This insurance covers basic health care needs. This includes primary medical care provided by a general practitioner, dental care for those below 18 years old, hospital stay, midwifery care and after delivery care. For those citizens and legal permanent residents who are unemployed or who earn below 35.059 (single) or 51.691 (for married couples), the Dutch government offers them 70 euros per month to cover their health care costs and they pay 40 euros per month. In addition to the monthly amount, everyone pays about 250 euros per year for what is termed ‘own risk’. This means, if someone frequently uses health care facilities, they will have to pay an initial 250 euros as a personal contribution.  

While the health care system seems inclusive, affordability can be an issue for some patients. Several health care services like after delivery care require a personal contribution. If you do not use health care services that require this additional contribution, the health insurance company can reimburse the full amount or part of it. Patients with low socioeconomic status, who cannot afford to pay the additional amount often, do not utilize these health services in order to receive this money back. If a patient knows that a certain procedure, medication or any other medical help will require an additional amount beyond their basic health insurance, they will sometimes decline the service.  In particular for maternal health care, every woman is insured for prenatal and delivery and after delivery care. However for after delivery care (10-14 days after birth), one pays an additional personal contribution of 35 euros per day therefore spending at minimum 350 euros. Many immigrant women might therefore reject the after delivery care assistance since it seems to be an unnecessary financial burden especially because they can often request extended family members to help take care of the baby. However this deprives the mother of the care of a trained professional who can check on her to ensure she is recovering well. Professor Koos van der Velden, professor of Public Health at the department of Primary and community Care Radboud University thinks after delivery care is important and the affordability issue needs to be tackled. He says, “There is a lower rate of post delivery care among ethnic minorities which can be problematic since complications may not be seen in time. The lower rate might be due to financial impediments and charging for post delivery care should stop for low income women.” Almost all indicators of health are related to socio-economic class. Migrants often have a lower socioeconomic class and the extra costs within the health care system might hinder certain people from fully utilizing the services.

Health care costs are however only a small part of the picture. Sub-optimal quality of services also contribute to ethnic disparities in mortality. In the 2010 research article, “Indirect Maternal Mortality Increases in The Netherlands,” it was found that substandard care was often present in 53% of the non-indigenous maternal deaths versus 26% in the indigenous group. Substandard care was defined as all care factors which may have resulted in low standards of care and which had a probable negative influence on the chain of events leading directly to death. Substandard care could be the fault of any person involved in the care of pregnant women or that of the pregnant woman herself. Sarah, an immigrant from Ghana described to us complications in her third pregnancy that the doctor did not take seriously.  

“Even though my baby was not due for a few days, I could feel her coming. I was dilated. I tried to tell the midwife but she told me it was fine and to go back home. I insisted on staying and asked them if I could use their shower. I was afraid to leave the hospital because I was sure the baby was coming. When I was in the shower, my water broke and I realized the water contained baby feces. Alarmed I called the midwife who then took me seriously.”  

If the water of the baby in the womb is contaminated with feces then it could be very dangerous for the baby and mother. Similarly a pregnant Surinamese lady complained of not being listened to, 

“You don’t get the feeling that they are taking you seriously or listening. It is kind of like a factory. They examine you and you are out. There is lack of personal interest about how you are doing and how the pregnancy is going.”  The attitudes of health professionals might stem from preconceptions doctors have about these ethnic minorities. As Prof. van Roosmalen explains, ‘’Doctors have several thoughts about immigrants before they talk to them. They assume they will not understand so they treat them differently and sometimes the doctors will not really listen to them.’’ These attitudes could easily result in substandard care, overlooking complications that might endanger the lives of pregnant mothers. 

It is also important to take into account other barriers to healthcare accessibility for ethnic migrant populations. Immigrant women usually do not understand how the health system works in The Netherlands nor do they understand why regular check up is important. Prof. van Roosmalen refers to this as  ‘health illiteracy.’ Ms. Maria Pel, a gynecologist at the Academic Medical Centre (AMC) in Amsterdam agrees, “They have no network in the health care system and no knowledge about where to go. Network and knowledge are very important. I came from a doctor’s family, which provided me with a broad network. I knew very well where to go for which health issue.’’ It is problematic when women do not know where they should go particularly to access prenatal care or understand why it is important to go for these prenatal checkups. Ms. Pel elaborates, “I had a patient from West-Africa, whom I was trying to convince to do the prenatal screening on genetic diseases. I tried everything to explain why this screening was important, but she didn’t understand it.” As Prof. van der Velden emphasizes, “You might think of it as a problem primarily of demand.  Most native Dutch women start prenatal care at 10 weeks and most ethnic minorities start at 16 weeks. I met a midwife from Suriname who explained to me that in most families in Suriname, you do not go before you are 16 weeks.  There is therefore a higher probability that problems in pregnancy will not be detected in time.”  Since ethnic groups are often at a higher risk for complications during pregnancy, lack of understanding of healthcare system can hinder women from accessing prenatal health care where some possible complications can be identified early in pregnancy or before conception, in order to mitigate the risk of maternal mortality. 

In addition to cultural barriers, communication barriers impede migrant women from fully accessing these needed health services. A Ghanaian woman we interviewed complained that she was never understood. “When I go to the doctor, they don’t understand my English. I am Ghanaian and the way we speak is different.  Now that my daughter is a bit older, I take her along to translate.” In her case there were no interpreters however hospitals often have a ‘translation telephone line’. The problem is they are rarely used. Ms. J.G. Jorna, a midwife at the Academic Medical Center Amsterdam agrees, “Language and culture are big problems. We do not understand each other. For the African women, sometimes they don’t understand the questions we ask them. For example if we ask if someone in the family died during pregnancy, they don’t talk about it. So we don’t know for sure if they have told us everything because sometimes its language and sometimes its culture and sometimes it is both.” Communication between the mother and health care providers is necessary so as to provide important information about the patient’s health history, their lifestyle and their family background and reduce possible complications.

It is important to note that even within ethnic minorities, illegal immigrants are more adversely affected. The lack of legal documentation often prevents them from accessing health care. While everyone living in the Netherlands including illegal immigrants is entitled to free emergency health care and this includes maternal care, illegal immigrants are afraid of being reported to the police and will often only seek help when things get complicated. As a result, they miss out on vital prenatal care. Ms. J.G. Jorna highlights this, “ When they are illegal, they are afraid to go to a government building like AMC. They think we will report them to the police. They also think because they are illegal, they have to pay so they come very late in pregnancy. They have usually missed critical tests and are already 7 months pregnant with a disease. If we could treat them before, we could have better results.”  

Why inequalities in Maternal Mortality Rates have not been tackled:

All the people we spoke to were not surprised to learn about this inequality in maternal mortality rates. After all what is written above is nothing new. As early as the 1970’s, researchers found disparities in maternal mortality rates among immigrant populations and native Dutch women in the Amsterdam. At the time, they were not sure if it applied to the rest of The Netherlands. However numerous studies confirmed this with the most recent in May 2011 carried out by professors at Leiden University Medical Centre. Why then has nothing substantial been done to tackle these inequalities? Prof. Anton Kunst, an epidemiologist argues, “There is a general recognition of these disparities in maternal health and there are small individual initiatives being carried out by different municipalities and hospitals however there has not been a huge integrated program to tackle the problem especially because of the political environment.” The heated political climate in The Netherlands concerning migrants rights and the rise of anti-immigrant sentiments means no one seems particularly interested in addressing issues that only seem to pertain to migrant populations. As Prof. van Roosmalen sums it up, “ People think immigrants do not have problems but that they are a problem.’’ As a result, funding for research on possible solutions is not as easy to come by. Prof. Kunst elaborates, “In public health, even though we do recognize there are huge differences in mortality, it is difficult to pay attention to it. We hesitate to focus on ethnic inequalities and prefer to address broader social inequalities. Ethnic inequalities are only addressed when it comes to infectious diseases.” In other words such research is justifiable when it threatens the health of the entire population. 

However in a highly developed country like The Netherlands, high rates of maternal mortality among ethnic minorities should be alarming. It is well known that the mortality rate is a strong predictor of the quality of care. If we know that the maternal mortality rate is three times higher among Surinamese and Antillean women compared to the Dutch, we can assume that the quality of care for this minority group is highly substandard. From a human rights perspective, this issue needs to be addressed very carefully. At what point do these lives matter? Are they any less valuable than those of native Dutch women or of any human being for that matter?  At what point does the government step in and recognize that something needs to be done? 

The people we interviewed believe that with more integration and with more time, the health services will adapt to the needs of these immigrant groups. As Prof. Kunst argues, “I think it will improve. With more research and more integration, society will become more familiar with these problems. Health insurance companies over time will recognize it as an important market.” When we ask about those people that will migrate to the Netherlands and face the same challenges, he responds, “If we believe our current political climate, I think people hope they will not be let in anymore.” However how much can we rely on a gradual recognition of the importance of these groups by a public that still holds anti immigrant sentiments or by health insurance companies that are not necessarily concerned with social justice?  At the moment we have unsatisfactory answers to these questions. 

What needs to be done?

To improve maternal health care for the immigrant women in The Netherlands, the government should be more proactive and below are a few recommendations.

The government should implement a broad national educational program focused on the special needs of ethnic minorities. Cultural differences, socioeconomic status and language barriers need to be taken into account.  Prof. van der Velden recommends, “I think you have to be proactive and start educating them while they are in school about what to do when pregnant.” This is particularly important since there is sex education in schools but very little about how important it is to visit the hospital when pregnant. The government should also implement a more targeted education outreach campaign to communities that may have more ethnic migrants and who often might not be aware of how the health care system works in the Netherlands. Ms. J.G. Jorna, a midwife agrees, “ I think we have to be more conscious to make sure they understand and they can come to us. For example every week, the Amsterdam Medical Center has a radio host from Ghana who provides information about the health care system to let them know what we can do for them. We have translations in English, and Moroccan.” Such education initiatives that take into account cultural differences, and language barriers promote timely demand for health services, which can reduce rates of maternal mortality.

Furthermore the government should provide young doctors with culturally competent education during their medical school. During the interviews we learned of several doctors’ negative attitude towards patients that were immigrants. Most of the physicians are unfamiliar with the patient's culture and they do not know how to handle the language barrier. Moreover, they have prejudices towards their patients, which may strongly affect health outcomes. Physicians should be trained on how to manage problems that may arise because of the cultural barrier between the physician and the patient. As Prof. van Roosmalen says, “ Doctors should see these kind of patients as a challenge and not as a burden.”

Finally the government should invest in research. Not much has been researched on effective ways to reduce maternal mortality among ethnic minorities, which is necessary in order to reduce the health inequalities. Government should provide more funds for doing research in this field. Learning more about these factors will enable health authorities to adjust the healthcare system in ways that would reduce ethnic inequalities in health.

The Dutch health care system is known as one of the more accessible and highly qualitative health care systems in the world. However having a universal health care system is not enough. One must examine what barriers to accessibility exist for immigrant populations and how well it serves these populations. What these great disparities in maternal mortality rates reveal is that not everyone in The Netherlands has equal access to health care even though it is a fundamental right.  As Ms. Jorna reminds us, “ We have to take care of all people living in Holland.”



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Accessible at: http://onlinelibrary.wiley.com/doi/10.1111/bjo.2010.117.issue-4/issuetoc

Waelput, A.J.M. Achterberg, P.W. “Ethniciteit en zorg rondom zwangerschap en een verkening van Nederlandse onderzoek.” RIVM rapport (2004/2007)
Accessible at: http://www.rivm.nl/bibliotheek/rapporten/270032004.pdf

College voor zorgverzekeringen; http://www.cvz.nl

Belastingdienst; http://www.belastingdienst.nl/wps/wcm/connect/bldcontentnl/belastingdienst/prive/toeslagen/informatie_over_toeslagen/zorgtoeslag/kan_ik_zorgtoeslag_krijgen/kan_ik_zorgtoeslag_krijgen

Stribu.I, Kunst. AE, Bos.V, Mackenbach. JP. “Differences in avoidable mortality between migrants and the native Dutch in the Netherlands.” Bio Med Central Public Health (2006) 


Maria, Pel. Gynecologist at Academic Medical Centre, University of Amsterdam. June 19, 2012 

J.Roosmalen. A specialist in maternal mortality and severe maternal morbidity and Professor at Leiden University Medical Centre. June 19, 2012

J.G.Jorna. Midwife at Academic Medical Centre, University of Amsterdam. June 20, 2012

Anton, Kunst. Associate Professor bij Department of Public Health, AMC, University of Amsterdam. June 21 2012

Koos, van der Velde. Professor of Public Health at the department of Primary and community Care at the Radboud Medical Centre, University Nijmegen, June 21, 2012

Immigrant women in Hollendrecht. Interviews conducted June 19, 2012

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HIA Program:

Netherlands Netherlands 2012


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