Field Notes

To speak of improving health care delivery is to call for "cultural change." Hospitals are urged to nurture a "culture of safety" with respect to the need for error prevention and reduction, and a "blame-free culture" with respect to the just resolution of medical injuries. Institutions and professions are encouraged to build a "culture of quality improvement," in which QI is understood as a continuous activity and obligation. These are essential goals-ones that recognize that safety and quality improvements cannot operate as discrete entities, but must be integrated into larger systems, which in turn are informed by cultural norms. Change the culture, and you change the system.

No one claims this is easy: "turning the Titanic" is one popular metaphor. To speak of cultural change is to acknowledge that there is an existing culture of health care delivery-many cultures, in fact-that are in need of change. Yet surprisingly often in our zeal for improvement, we forget about this existing culture, how complex it is, and how it has organized itself for survival. Rather than grapple with the values and complexities of this culture and figure out how to graft improvements onto it, we find it easier to imagine we are working with a culture of no culture-a tabula rasa onto which we can inscribe The Truth. Or, if not Truth, then at least slogans.

Cultural change means taking existing culture seriously. It also means understanding culture's powerful role in shaping health policy and making the rules that, among other things, protect the culture. One's goal may not even be cultural change per se, but rather an understanding of how health care delivery works, how health policy comes to be, and why certain improvements have failed to take hold. Yet to forget about culture, or to fail to take it seriously or dismiss it as soft stuff, is-in the argot of computer culture-a permanent fatal error. You'll never get anywhere, and you'll never understand why.

Raymond de Vries' important and wonderfully engrossing new book, A Pleasing Birth: Midwives and Maternity Care in the Netherlands, makes no such mistakes. Throughout this sociological study, de Vries seeks to tell two stories: one about the uniquely "Dutch way" of "getting" babies, and one about how deeply rooted cultural values gave birth to health care policies that maintain, in minutest detail, the "Dutch way." As a social scientist, de Vries is not content with being a mere "detailer," though this book is replete (pregnant?) with all the epidemiological statistics, bar graphs, interview transcripts, and Dutch-language terminology a health policy analyst could wish for. Nor is he willing to be a "tourist," painting broad-stroke comparisons between health outcomes in the Netherlands and other developed nations without sufficient attention to the cultural forces that have shaped them. While careful not to reduce everything to "culture," de Vries concludes: "Any effort to change health care systems-be it to make them more efficient, more just, more compassionate, less costly, or less prone to error-must consider the way culture is implicated in the current organization of care" (p. 212).

So, what is this "Dutch way"? Well into the 1990s (de Vries began his field research in 1994-95), over 30 percent of Dutch women were choosing to give birth at home, attended by midwives or by their own general practitioners (huisarten, which translates literally as "house doctors"-their offices are attached to their homes). No other developed nation comes close to this home-birth rate. In the United States, the United Kingdom, Germany, France, and the Scandinavian nations, the home-birth rate is 1 percent or less; in some nations, it is virtually nonexistent apart from unplanned home deliveries. While midwives are involved in all deliveries in Sweden and Norway, the Netherlands has the reputation as the "Mecca for Midwives" (p. 39), even though midwives there attend only about one third of all births. This reputation is due in part to the remarkable persistence of home birth, and in part to the professional culture of Dutch midwives, who are neither nurses nor lay practitioners...