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08-10/04 2016

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Midwifery in the Netherlands

Koninklijke Nederlandse
Organisatie van Verloskundigen

The Royal Dutch Organisation of Midwives

2014

Midwifery in the Netherlands

2015
The Netherlands is not only famous for its tulips and windmills, its maternity
system is just as outstanding. The Dutch tradition of a free choice of place of
birth including home birth is quite unique in the western world.
This leaflet will provide you with lots of information about the Dutch maternity
and midwifery system, and touches upon some of the challenges we face.
Facts
Inhabitants
Active midwives
Active Ob/Gyns
Total Fertility Rate
Maternal age at birth of 1st child
Maternal age at birth 17 years
Live Births
Home birth
Birth in primary care
Referral primips (37 wks) during birth
Referral multips (37 wks) during birth
Induction of birth
Caesarean section
Vaginal birth after caesarean (VBAC)
Epidural pain relief (1st stage of birth)
Maternal mortality
Perinatal mortality (22.0 wks-7 days)
Foetal mortality (22.0 wks)
Foetal mortality (37.0 wks)
Neonatal mortality (1-7 days)
Neonatal mortality (1-28 days)
Infant mortality (0-5 years)
Women who start with breast feeding
Women who breast feed 6 months pp

16,909,016 (March 15, CBS)

2980, 29% work in a hospital (14, Nivel)
775 (10, CBS)
1.68 (13, CBS)
29.4 years average (13, CBS)
0.1% (13, PRN)
171,341 (13, CBS) primips 45,2% (13, PRN)
15.9% (13, PRN) 20.8% (10-12, CBS) 23.4%
(08-10, CBS) 29.4% (05-07, CBS)
28.6% (13, PRN) 32.8% (08, PRN)
62.3%, (13, PRN, table 9.1.2 )
26.2% (13, PRN, table 9.1.2 )
21.8% (13, PRN) 15.5% (08, PRN)
16.4%, 79.8% in case of breech (13, PRN)
54% (02-03, NVOG)
18.4% (13) 11.3% (08) 6.2% (04) (PRN)
4.7/100,000 live births (13, PRN, table 6.1)
7.6/1000 births (13, PRN table 7.1.2)
4.9/1000 births (13, PRN, table 7.2.2)
1.1/1000 births (13, PRN, table 7.2.2)
2.7/1000 live births (13, PRN, table 7.3.2)
3.1/1000 live births (13, PRN, table 7.3.3)
0.8/1000 live births (13, CBS)
75% (10, TNO)
18% (exclusive BF 10, TNO)

(Please find the mentioned figures at the following websites: CBS, Nivel, PRN, TNO.)

Structure
In the Netherlands, maternity care is organised in a so called primary, secondary
and tertiary care model. The primary care, for low-risk women, is formed by
midwives and GPs. GPs are responsible for only about 0.5% of all births, mainly
in rural areas with a low population density (11, Nivel). The secondary care consists
of obstetricians and specialised clinical midwives in general hospitals and the
tertiary care comprises obstetricians in academic hospitals.
Risk selection, a clear distribution of tasks and a close mutual co-operation
between these different strata forms the strength of the Dutch system.
The principle idea is that a healthy woman with a healthy pregnancy (low-risk) is
best taken care of by a midwife. This minimises her chances of receiving an
unnecessary intervention of any kind, gives her a high standard of care and is
furthermore very cost-effective.
The midwife guiding a
woman through her
pregnancy, birth and
postnatal period is
autonomous in her
actions and decisions.
Emphasis is placed on natural processes, with intervention only occurring when a
problem arises. In this case, the midwife will consult or refer to an obstetrician.
Obstetric and Midwifery Manual
Since 1959 a comprehensive list of pre-existing, pregnancy- and perinatal-related
disorders has existed, in which:
A the care of a primary care midwife is considered sufficient
B an obstetrician should be consulted
C the care definitely has to be shifted to an obstetrician
D the natal care should be given in a hospital but can be supervised by a
primary care midwife
This manual, called the VIL, optimises the risk selection and referral and is
formulated in a dialogue between primary, secondary and tertiary care
professionals. It should be noted, however, that the manual is a guideline, and
health professionals have the option to make autonomous decisions.

Some examples:
A Previous miscarriages, previous premature birth (>33 weeks), cystitis.
B Anaemia, PIH, psychiatric illnesses, hepatitis C.
C Diabetes mellitus, previous CS (from the 37th week of pregnancy), >24 hours
of ruptured membranes, meconium-stained liquor, breech birth, multiple birth,
third or fourth degree tear.
D Previous PPH (>1L), previous retained placenta (manually removed).
The manual is currently being updated by midwives, GPs, obstetricians and
government authorities. The current version dates from 2003, and an update is
expected in 2015. Unfortunately, there is not an English translation of the
manual available. The Dutch version can be found here.
Education
There are three academies for
midwifery in the Netherlands, in
Amsterdam (our capital)with a
second location in Groningen,
Rotterdam and Maastricht. The
first one also has a satellite in
Groningen, in the north of the
Netherlands. These academies are
all part of universities for applied
sciences:
Copyright: AVAG

Midwifery Academy Amsterdam and Groningen

(Amsterdam university of applied sciences)

Midwifery Academy Maastricht

(Zuyd University)

Midwifery Academy Rotterdam

(Rotterdam University of applied sciences)

The midwifery training is a four year fulltime

direct entry education which eventually leads
to a Bachelor of Science degree. The total
study load is 240 ECTS and equals nearly
6800 hours of education. Altogether, a
minimum of 100 ECTS are spend on

Dutch midwives have not

been trained as nurses! A
Dutch nurse cannot work as
a midwife and vice versa.

internships in primary care (minimal 60 ECTS) and in secondary/tertiary care.

The rest of the time is spend on theory, skills training and the bachelor thesis.
The internships are spread equally over these four years. Students are primarily
trained to become independent midwives in primary and secondary care.
190 Students enrol each year nationwide. They have had an extensive assessment
which selects the best candidates. Around four times more candidates apply for
the course than places are available.
The tuition fee is set by the government and is 1951,- for Dutch students
for the year 2015-2016.
Students from abroad may be accepted when they are proficient in Dutch (NT2,
level 2) and after their diplomas have been assessed by participation in an
extensive assessment procedure.
Since there are many Dutch midwifery students that need placements for their
training, it is difficult to arrange an internship for foreign student midwives. For
more information please contact the KNOV at info@knov.nl.
Nuffic, a Dutch institute for international cooperation in higher
education, launched a website for foreign students with lots of
information.
University level?
To maintain the strong autonomous position of Dutch midwives and the high
level of care for low-risk women, it is important that midwives are empowered by
being academically trained to a high standard. Attempts to bring the midwifery
training to a master of science is still in progress.
Advanced education
A Dutch midwife who wants to continue her education has the following
options:
European master of science in midwifery (Midwifery Academy Maastricht)
This master prepares midwives to work in the field of research and management.
Master physician assistant (HRO, Rotterdam)
Clinical midwife (UMC, Utrecht)

These two Masters educate midwives to work in a hospital. They must have
employment in a hospital before they can enroll.
Teacher in midwifery, first degree (VU, Amsterdam)

Dutch midwifery research

Almost 4% of all Dutch midwives have completed a master in midwifery science.
So far, twenty midwives have acquired a PhD in midwifery science and several
midwives are working on their PhD thesis.
Two academies,
Amsterdam/Groningen and
Maastricht, have already employed a

professor in midwifery Science. Eileen

Hutton from Canada and Raymond de
Vries from The United States both strengthen the field of Midwifery Science in
the Netherlands.
The Royal Dutch Organisation of Midwives, the KNOV, has initiated a special
Midwifery Science Board in 2011. It will stimulate evidence based midwifery by
providing talented midwives with a PhD scholarship and by supporting efforts to
bring the midwifery training to degree level.
Copyright: AVAG and AVM

If you are interested in midwifery science in the Netherlands, there are several
research initiatives that can provide you with more information:
Year index midwifery research 2014
Kennispoort Midwifery
Midwifery Research Network
Consortium for womens health and reproductivity studies
Netherlands institute for health services research (NIVEL)

Midwifery Science (Midwifery Academy Amsterdam and Groningen)

Studies in progress
Academic Collaborative Centre (Midwifery Academy Rotterdam)
Studies in progress
Midwifery Science (Midwifery Academy Maastricht)
Studies in progress
Registration of perinatal data
All maternity caregivers; midwives, GPs, obstetricians and paediatricians, register
their antenatal, natal and postnatal care and results. 96% of all births are
registered in this system (08, PRN). The data are collected and analysed by the
PRN, the Dutch perinatal registration, which is a governmental institute.
Obtaining data
If you want to obtain data about healthcare, midwifery and obstetrics in the
Netherlands, you can consult several organisations:
EuroStat (European Commission)
National Public Health Compass (Ministry of Health)
Netherlands institute for health services research (NIVEL)
The Health Council of the Netherlands
The Netherlands Perinatal Registry (PRN), info@perinatreg.nl
StatLine (Central Bureau for Statistics)
Registration as a midwife
After finishing her education, a Dutch midwife is obliged to register in a
nationwide register for health professionals before she can actually work as a
midwife. The cost for this registration is 85,-.
Her title, verloskundige, is legally protected.
This so called BIG-register is open to the
public. A midwife needs to renew her
registration every five years. The most
important requirement for on-going registration
is a minimum amount of hours spent working as a midwife (2080 hours in five
years).
KNOV

The Royal Dutch Organisation of Midwives, the KNOV, originates from a

merging (1975) of several Dutch midwifery organisations. The oldest of these
was founded in 1898! Currently, the KNOV has 3300 members. These are
primary and secondary care midwives, midwifery students, midwifery scientists,
midwifery teachers and retired midwives. They are organised in so called circles
(Kringen), geographically spread throughout our country.

The KNOV has a board of six people which develops future policies. The
president of the board is midwife Linda Rentes. The KNOV bureau executes
these policies, there are about 40 employees working at the headquarters.
The KNOV is engaged in several activities:
It strengthens the position of midwives and midwifery by advocacy
and lobbyism.
It improves the quality of midwives and midwifery practices. The
KNOV offers schooling, it has developed several instruments for
measuring quality and it supervises the quality register for midwives.
The KNOV develops guidelines for midwifery care, often in
cooperation with other professionals, such as GPs and obstetricians.
The KNOV publishes a magazine for midwives with a mix of
midwifery science and current midwifery affairs.
The KNOV hosts an independent complaints committee where
clients of midwives can turn to.
Recently, our national midwifery organisation KNOV released a vision statement
about midwifery care in the Netherlands. Key issues are:
The freedom of choice for low-risk women for the location of birth.
Putting the woman in the centre and organising all maternity care
around her and her family.
Ensuring that every woman has a midwife, some will need an
obstetrician as well.
A continuum of care for each woman, integrating midwifery and
specialist care.
The midwife of the future is an academically trained midwife to
maintain her autonomous position.

Quality regulation
The KNOV has initiated a quality register for
midwives in 2006. Registration is not compulsory, but
around 80% of all midwives have registered so far.
To maintain her registration, a midwife has to have a
portfolio showing a minimum of 200 hours of training
and additional education over a period of five years.
The KNOV has also initiated a register for midwives who have advanced training
and experience in external cephalic version of the foetus (ECV). Nearly 100
midwives have registered so far. To maintain her registration, a midwife has to
perform a minimum of ten ECVs per year.
The quality of Dutch midwifery is also externally monitored by a government
authority, the Health Care Inspectorate.
Working in the Netherlands
Midwives from abroad who are interested in practicing midwifery in the
Netherlands should be able to communicate in Dutch (NT2, level 2). Their
diplomas will be required to be assessed by the ministry of health, this procedure
is free of charge but requires quite a lot of paperwork. Depending on
competencies and experience, it may be necessary to follow an additional course,
which gives an introduction into Dutch midwifery. The midwifery academy of
choice will offer the candidate a customized program.
If a midwife from abroad wants to work in the field of education, research or
management, it is not necessary to register with the ministry of health.
Some midwives from abroad create their own employment as a doula or as a
childbirth educator for expats.
The KNOV organises a yearly Dutch Midwifery Tour to give midwives
from abroad an introduction to the Dutch midwifery system. The next
Tour is scheduled for May 2015. Please contact the KNOV for further
information, info@knov.nl.
Midwifery practices
There are 518 primary care,
independent midwifery

practices in the Netherlands (14, Nivel). Most primary care Dutch midwives work
in group practices, often with two or three colleagues. Together they provide care
for hundreds of women each year. They often have their own premises and offer
prenatal clinics during the week. Each practice has a midwife on call 24/7, with
each midwifes shift normally lasting for 24 hours. During this shift, a midwife
combines both postnatal visits at home and natal care, at home or in hospital. If
she cannot visit
a client in labour because she is assisting another client, she will call a colleague
from her own or a neighbouring practice to attend to her client.
4.9% of primary care Dutch midwives have a solo practice (14, Nivel). Often they
have an agreement with a neighbouring practice to occasionally cover for them in
order to allow them to have some time off. To enable them to take holidays, they
usually wont accept new clients for a certain period each year.
15.7% of all active midwives are locums (14, Nivel). These are mostly midwives
who have just finished their education. 29.3% of all active midwives work in a
hospital under the supervision of an obstetrician (14, Nivel). They are called clinical
There is a Dutch institute for health services research, NIVEL, which
publishes a yearly report about Dutch midwives. Email address:
receptie@nivel.nl.
midwives.
Finances and insurances
Every midwifery practice has several contracts with different health care insurers.
Everybody in the Netherlands is obliged to insure oneself for standard care;
midwifery care is included. The standard insurance for an adult is partly received
through taxes. Additional to this the individual
Midwives obtain the
costs are around 1100,- plus an income
following amounts for
related contribution of up to 500 per year.
their given care (2015):
Children are covered free of charge until the
Antenatal 472,37
age of eighteen.
Natal 513,56
Practices have a free choice in how to arrange
Postnatal 285,31
antenatal care. Often they will see their clients
Total: 1271,24
around ten to twelve times, each consultation
lasting for 10 to 45 minutes. Some practices
These amounts are yearly
incorporate a home visit at around 35 weeks
adjusted by the Dutch
Healthcare Authority.

of pregnancy, which is a recommendation from the government but comes

without financial compensation for now.
If care is only given for part of the pregnancy, due, for example, to miscarriage,
change of midwife or referral to secondary care, only that part of the pregnancy
can be claimed under the health insurance. There are fixed prices for several
durations of care.
The price for natal care is always the same, no matter how long the birth takes or
whether the woman stays under the care of a midwife or is referred to an
obstetrician. Natal care starts when the membranes rupture or if a woman has
contractions.
There is an additional
The financial compensation given for
budget for clients with
postnatal care is also always the same, no
poor socio-economic
matter whether the midwife visits the client
backgrounds. Whether the
only once or several times. A visit is often
midwife can claim this
scheduled every other day for seven or eight
extra amount (23%) is
days after birth and takes between fifteen
based on the zip code of
minutes and one hour to complete. The
the client.
midwife works closely together with a
maternity assistant during the postnatal period.
If a midwife works fulltime, she will take care of the antenatal, natal and
postnatal care of approximately 105 women annually.
As an independent midwife, you need to have indemnity insurance. For about
500 annually you are insured for claims up to 2,500,000. It is easy to get such
insurance, though you need an agency to arrange it for you. It is very rare to get
confronted with a claim, as Dutch judges are very reluctant on this matter.
Many midwives also choose to have invalidity insurance in case they are sick.
Independent midwives are obliged to contribute to a retirement fund for
midwives, which is quite a unique situation in the Netherlands.
Ultrasound scans and antenatal testing
Every low-risk woman is offered two
ultrasound scans; one in the first term to
set a due date and one anomaly scan at
twenty weeks. There needs to be a medical
indication to have additional ultrasound
scans. The scans are sometimes made by

the midwife herself in her own practice, otherwise the woman is referred to a
primary care ultrasound centre.
If there is a higher risk for congenital anomalies, the twenty week anomaly scan is
performed in a hospital that has a specific license for antenatal testing.
Currently there is a lively debate about whether or not an extra scan around thirty
weeks would reduce perinatal morbidity and mortality by detecting intra uterine
growth retardation. Research is being done on this matter.
Each pregnant woman is informed about the combination test, which calculates
her risk of being pregnant with a Downs, Edwards or Pataus syndrome baby.
They have to pay for this test themselves. The cost is around 160,- and some
insurance companies will cover this expense. The screening is performed at the
same primary care centre where the low-risk pregnant woman goes for her
ultrasound scans. In cases of a result with a risk higher than 1:200, the client is
subsequently offered a non invasive prenatal test (NIPT), a chorionic villi
sampling or an amniocentesis. These antenatal tests are always performed in a
hospital that has a specific licence for this purpose. The costs are completely
covered by the standard health care insurance.
If the foetus suffers from a medical condition from which it will certainly die
during or shortly after birth, or if it will be seriously handicapped, the parents
have a choice to terminate the pregnancy until 24 weeks.
Choice of home or hospital birth
Low-risk women may choose
whether to give birth at home
or in a hospital (outpatient
clinic). This free choice for the
place of birth is almost unique
in the (western) world and is an
important pillar of the Dutch
maternity system.
If a woman chooses a home
Copyright: AVAG

birth, her primary care midwife

will attend her birth, aided by a maternity assistant. The insurance company
usually provide a maternity box, which contains bed protectors, maternity pads,

gauze and sterilizing alcohol amongst other necessities. The midwife will bring
her own equipment, which always includes a neonatal resuscitation set and
oxygen. If complications arise, the midwife will refer to an obstetrician or
paediatrician. Every hospital in the Netherlands accepts these referrals from
primary care midwives. A midwife will use an ambulance for transport in high
risk situations. On average this ambulance will reach the client in just ten minutes
(11, Gezondheidsraad).

The most common reason to refer a woman during birth is a wish for medicinal
pain relief (17.3% of all referrals), followed by meconium stained liquor (17.1%),
slow progress during first stage of labour (13.2%) and slow progress during
second stage of labour (8.1%) (13, PRN, table 9.3.2).
If a low-risk woman opts for an outpatient birth she has to pay the hospital
around 325,-. Some health insurances will cover this expense. Her birth is
attended by the same primary care midwife that attended her pregnancy and
would give her natal care at home. The midwife is assisted by an (obstetric) nurse
who is employed by the hospital. Some hospitals employ maternity assistants for
this purpose. Usually, women will leave the hospital a couple of hours after birth.
Women who have an increased obstetrical risk give birth in hospital, without
extra costs to themselves. A secondary or tertiary care professional will attend
them during birth. This is either a clinical midwife, a general doctor or an
obstetrician in training. They will call upon an obstetrician if a serious
complication arises.
There has been an extensive cohort study about the safety of Dutch planned
home birth versus planned outpatient hospital birth, which included nearly
530,000 low-risk women. It showed that a planned home birth was just as safe as
a planned outpatient hospital birth. It was published in the BJOG.
Pain relief
Dutch midwives minimise the need for medicinal pain relief by offering honest
information during pregnancy and a high quality of continuous support during
birth.
Currently, there are only a few birth centres where gas and air pain relief is
available, which can be administered under the supervision of a primary care
midwife. Since it is necessary for health reasons to have an adequate system of
ventilation, such pain relief can only be available in a hospital or birth centre and
not at home.

There are also pilots researching the use of sterile water injections to use as pain
relief in primary care, these could also be administered during a birth at home. It
is expected that our Minister of Health will soon give her formal approval to
primary care midwives to administer sterile water injections.
Medicinal pain relief is generally used in prolonged labour. When a woman is in
need of medicinal pain relief, an obstetrician is consulted. Depending on the
situation, a choice is made for minor pain relief or epidural analgesia.

In general there are three types of medicinal pain relief used in the Netherlands,
all of which are administered in hospital:
Epidural analgesia This type of pain relief is always administered by an
anaesthesiologist. Sometimes this
specialist will come to the delivery
room, in other hospitals the woman is
brought to the operation complex. The
Dutch association of anaesthesiologists
agreed on the 24/7 availability of
epidural pain relief for women in labour
a few years ago. A woman who has an
epidural is always under the
responsibility of an obstetrician.
Pethidine i.m. An obstetrician can prescribe pethidine, sometimes combined
with sleeping medication. A nurse gives the woman the medicine and it depends
on the hospital protocol whether the primary care midwife will continue the care
immediately, after four hours, or that the woman gives birth under the
responsibility of the obstetrician.
Remifentanil PCA i.v. This medication is given in a couple of Dutch
hospitals. There have been some incidents of maternal breathing problems and
that is the main reason that other hospitals dont offer it at all or only offer it in a
research setting. When remifentanil is given, the responsibility for the delivery is
always shifted to an obstetrician.
Maternity services

During a home birth, the midwife is assisted by a maternity assistant,

kraamverzorgster in Dutch. She supports the mother during her labour, assists
the midwife at birth, takes care of the mother and her baby and tidies up the
delivery room.
For the eight days following the birth, she will attend to the care of the mother
and the newborn. She performs medical checks, supports breast feeding, gives
information, takes care of light household chores, prepares meals and takes care
of other children if necessary.
Obviously she is not only of great significance for the new parents and their
baby, but also for the midwife!
Every mother is entitled to 49 hours of this
type of maternity care, 24 hours being the
legal minimum. The amount of hours is
calculated individually, depending on factors
such as hospital stay, choice for breast
feeding and health problems.
The basic health care insurance covers the
expenses for the maternity assistant, apart
from 4,10 per hour which the parents have
to pay themselves. Sometimes the health
care insurance will also cover these costs, if
the parents have paid for additional
coverage.
The maternity assistant has completed a
vocational education and training for three
years. She is an employee at a maternity care
Copyright: De Waarden
organisation or she can be self-employed.
Maternity leave
Dutch working women have a minimum of sixteen weeks of maternity leave. A
woman can choose to start her leave at 34 or 36 weeks of her pregnancy, but not
later. She always has a minimum of ten weeks of maternity leave after birth. So if
she gives birth beyond her due date, she sometimes gets seventeen or even
eighteen weeks of paid leave.
If a woman is self-employed, the government will pay her a minimum wage for
sixteen weeks. Often, these women (many midwives!) have an invalidity
insurance which covers her income during maternity leave.

When a breastfeeding mother resumes work, she is entitled for nine months after
birth to use up to a quarter of her working hours to nurse the baby or to express
breast milk. The employer has to provide her with a separate room for this
purpose or has to allow her to visit her baby.
Fathers receive two days of paid leave and three days of unpaid leave, the
day of birth excluded.

Current debate
In a global context, care for women and infants in the Netherlands is safe and
well organised. However, Dutch maternity care is undergoing major changes in
the last few years. Investment in better integrated team work is one of them.
Evidenced based practise another. However, where the national policy is to
invest in primary health care in the community an opposite direction seems to be
taking place in maternal health. Concentration of hospitals and an increase in
medicalisation directly affect the choice of care and carer for (pregnant) women
without a significant improvement in the outcome of birth or increased
satisfaction by women [Sandel ea Cochrane review 2013] [de Jonge ea BJOG. 2014] [Brockelhurst ea
2012]. The number of women giving birth with a community midwife is decreasing
[ZN monitor 11-12-13] while overwhelming evidence points towards a continuity of
care model and the empowering effect of a midwife for women, both physically
and psychologically [Lancet Midwifery series 14] [de Jonge et al. BMC Pregnancy and Childbirth
2014][van Haaren Birth 2014] ] [Maassen ea 08]. The focus within society and the Press for
the dangers of childbirth has had an effect on women and health care
professionals, an indication of this is the rise of hospital births and an increase in
requests for epidural anaesthesia [Christiaens Midwifery 2012] [de Vries Midwifery2014]. At the
same time 82% of women want to keep the possibility of the choice of home
birth [TNS NIPO 13]. Within this challenging context the KNOV and her members
strive towards keeping pregnancy normal and safe by investing in evidence based
integrated team work so that all women can receive continuity of care from a
midwife plus the additional care of a specialist (obstetrician) when necessary.
International affairs

The Netherlands is a country with a long history of

autonomous, independent midwifery. This makes it
an ideal location for international organisations in
this field.
ICM, the International
Confederation of Midwives, has its
headquarters in The Hague, our
administrative capital.
EMA, the European Midwives Association, is based at the
KNOV in Utrecht.
Safe Motherhood
Dutch midwives are actively involved in Safe
Motherhood through their charity midwives4mothers
(m4m). This organisation helps to reduce maternal and
infant mortality by empowering midwives in developing
countries. Over the last years, they have built an intense
collaboration with the midwifery association of Sierra
Leone (SLMA) through their twin2twin project. 25
Dutch midwives were paired with 25 colleagues from Sierra Leone and
exchanged knowledge and experiences. This successful project has been
completed in 2012.
Currently, there is a successful twin2twin project with the midwifery association
of Morocco (AMSF), which will be concluded in 2016. Stay informed by Twitter
and Facebook.
If you want to learn more about the unique twin2twin method to empower
midwives, developed by KNOV and Midwives4Mothers, please read the
informative and practical twin2twin guide.

Do you have any question?

Please contact the KNOV at info@knov.nl

Author: Myrte de Geus & Franka Cade
Editor: Franka Cade
Second edition, KNOV, March 2015
This information leaflet is carefully composed and produced by the KNOV.
Every effort is made to ensure that the information is correct. The content of
this leaflet may only be reproduced or published with the prior written consent
of the KNOV. The KNOV assumes that the information in this leaflet will be
used correctly and under the sole responsibility of the user.
Royal Dutch Organisation of Midwives

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2011-2016 Pubed, Wiley Online Library, Medline, HEALLink. - : skin to skin contact, kangaroo
care exclusive breastfeeding, initiation of breastfeeding.
: SSC
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2012, Iqbal M 2011) (Stevens 2014, Cuze 2012, Velandia 2012)
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2014) SSC

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Aghdas, Karimi, Khadivzadeh Talat, and Bagheri Sepideh. Effect of

immediate and continuous motherinfant skin-to-skin contact on
breastfeeding self-efficacy of primiparous women: A randomised
control trial. Women and Birth 27.1 (2014): 37-40.
Atkins, Jamie, Grace Frederick, and Ellen Lintemuth. Promoting Early
Skin-to-Skin Contact and Its Effect on Breastfeeding. (2012).
Beiranvand, Sh, F. Valizadeh, and R. Hosseinabadi. The effect of skinto-skin contact of mother and newborns on breastfeeding status in
full-term newborns after cesarean delivery. Modern Care Journal 10.4
(2014): 288-295.
Bhatt, Darshna. Early Skin-to-Skin Contact in the Delivery Room Leads
to An Increase in Exclusive Breastfeeding During the Newborn Hospital
Stay. 2013 AAP National Conference and Exhibition. American Academy
of Pediatrics, 2013.
Cantrill, Ruth M., et al. Effective suckling in relation to naked maternalinfant body contact in the first hour of life: an observation study. BMC
pregnancy and childbirth 14.1 (2014): 20.
Chiou, Shu-Ti, et al. Early Skin-to-Skin Contact, Rooming-in, and
Breastfeeding: A Comparison of the 2004 and 2011 National Surveys in
Taiwan. Birth 41.1 (2014): 33-38.
Conroy, Caitlin C., and Barbara H. Cottrell. The Influence of Skin-to-Skin
Contact after Cesarean on Breastfeeding Rates, Infant Feeding Responses,
and Maternal Satisfaction. Journal of Obstetric, Gynecologic, & Neonatal
Nursing 44.s1 (2015): S61-S62.
Cuze, Anamarija, and Irena Zakarija-Grkovic. Impact ofbirthskin-toskin contact between mother-infant pairs on breastfeeding practices
during the first 6 months of life. 4th ABM Regional European Meeting.
2012.
Essa, Rasha Mohamed, and Nemat Ismail Abdel Aziz Ismail. Effect of
early maternal/newborn skin-to-skin contact after birth on the duration
of third stage of labor and initiation of breastfeeding. Journal of
Nursing Education and Practice 5.4 (2015): p98.
Hughes, Kimberly N., et al. Using Skin-to-Skin Contact to Increase
Exclusive Breastfeeding at a Military Medical Center. Nursing for

43

womens health 19.6 (2016): 478-489.

Iqbal M, Jamal M, Khan N. Effect of motherinfant early skin to skin
contact on Joshi, S. The effect of birth kangaroo care on maternal and
neonatal outcome: A randomized, controlled trial. Sinhgad e Journal of
Nursing 2.2 (2012): 13-17.
Mellin, Pamela S., et al. Does Skin-to-Skin Contact at Birth Really Make
a Difference in Exclusive Breastfeeding Rates at Discharge?. Journal
of Obstetric, Gynecologic, & Neonatal Nursing 41.s1 (2012): S141-S142.
Moore, Elizabeth R., et al. Early skin-to-skin contact for mothers and
their healthy newborn infants. Cochrane Database Syst Rev 5 (2012).
Physicians and Surgeons Pakistan 2011;21(10):6015.
Ruxer, Deborah J., et al. The Impact of Increased Skin-to-Skin Contact
With the Mother in Breastfeeding Neonates on Exclusive Breastfeeding
at 4 and 8 Weeks Postpartum. Clinical Lactation 6.2 (2015): 75-80.
Srivastava, S., et al. Effect of very early skin to skin contact on success
at breastfeeding and preventing early hypothermia in neonates.
Indian journal of public health 58.1 (2014): 22.
Stevens, Jeni, et al. Immediate or early skin-to-skin contact after a
Caesarean section: a review of the literature. Maternal & child nutrition
10.4 (2014): 456-473.
Strobel, Hayden. Skin-to-skin contact and its impact on exclusive
breastfeeding upon discharge. (2015).
Stuetz, Wolfgang, Francois H. Nosten, and Rose McGready. High
initiation and long duration of breastfeeding despite absence of
early skin-to-skin contact in Karen refugees on the Thai-Myanmar
border: a mixed methods study. (2012).
Velandia, Marianne. Parent-infant skin-to-skin contact studies: Parentinfant interaction and oxytocin levels during skin-to-skin contact after
Cesarean section and mother-infant skin-to-skin contact as treatment
for breastfeeding problems. (2012).
World Health Organization. Evidence for the ten steps to successful
breastfeeding. (1998).


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1. The importance of the mother archetype in our days Hungary. TheSle F. Psychiatr Hung. 2015;30(4):356-62.
Hungarian.
2. The family myth: its deconstruction and replacement with a balanced humanized narrative. Kradin R. J Anal
Psychol. 2009 Apr;54(2):217-32. doi: 10.1111/j 1468-5922.2009.01771.x.
3. Parents attitudes about children: associations with parental life histories and child-rearing quality. Daggett J.,
OBrien M., Zanolli K., Peyton V., J Fam Psychol. 2000 Jun;14(2):187-99.

44


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