What does it take to have a strong and independent profession of midwifery? Lessons from the Netherlands

The Effect of CenteringPregnancy Group Antenatal Care on Maternal, Birth, and Neonatal Outcomes Among Low-Risk Women in the Netherlands: A Stepped-Wedge Cluster Randomized Trial

INTRODUCTION

This study was carried out to assess the effects of participating in CenteringPregnancy (CP) on maternal, birth, and neonatal outcomes among low-risk pregnant women in the Netherlands.

METHODS

A total of 2124 pregnant women in primary care were included in the study. Data were derived from the Dutch national database, Perined, complemented with data from questionnaires completed by pregnant women. A stepwise-wedge design was employed; multilevel intention-to-treat analyses and propensity score matching were the main analytic approaches. Propensity score matching resulted in sample sizes of 305 nulliparous women in both the individual care (IC) and the matched control group (control-IC) and 267 in the CP and control-CP groups. For multiparous women, 354 matches were found for IC and control-IC groups and 152 for CP and control-CP groups. Main outcome measures were maternal, birth, and neonatal outcomes.

RESULTS

Compared with the control-CP group receiving standard antenatal care, nulliparous women participating in CP had a lower risk of maternal hypertensive disorders (odds ratio [OR], 0.53; 95% CI, 0.30-0.93) and for the composite adverse maternal outcome (OR, 0.52; 95% CI, 0.33-0.82). Breastfeeding initiation rates were higher amongst nulliparous (OR, 2.23; 95% CI, 134-3.69) and multiparous women (OR, 1.62; 95% CI, 1.00-2.62) participating in CP compared with women in the control-CP group.

CONCLUSION

Nulliparous women in CP were at lower risk of developing hypertensive disorders during pregnancy and, consequently, at lower risk of having adverse maternal outcomes. The results confirmed our hypothesis that both nulliparous and multiparous women who participated in CP would have higher breastfeeding rates compared with women receiving standard antenatal care.

Midwives' occupational wellbeing and its determinants. A cross-sectional study among newly qualified and experienced Dutch midwives

OBJECTIVE

Internationally, about 40 percent of midwives report symptoms of burnout, with young and inexperienced midwives being most vulnerable. There is a lack of recent research on burnout among Dutch midwives. The aim of this study was to examine the occupational wellbeing and its determinants of newly qualified and inexperienced midwives in the Netherlands. The majority of practicing Dutch midwives are aged under 40, which could lead to premature turnover.

DESIGN

A cross-sectional study was conducted using an online questionnaire that consisted of validated scales measuring job demands, job and personal resources, burnout symptoms and work engagement. The Job Demands-Resources model was used as a theoretical model.

SETTING AND PARTICIPANTS

We recruited Dutch midwives who were actually working in midwifery practice. A total of N=896 midwives participated in this study, representing 28 percent of practicing Dutch midwives.

MEASUREMENTS AND FINDINGS

Data were analysed using regression analysis. Seven percent of Dutch midwives reported burnout symptoms and 19 percent scored high on exhaustion. Determinants of burnout were all measured job demands, except for experience level. Almost 40 percent of midwives showed high work engagement; newly qualified midwives had the highest odds of high work engagement. Master's or PhD-level qualifications and employment status were associated with high work engagement. All measured resources were associated with high work engagement.

KEY CONCLUSIONS

A relatively small percentage of Dutch midwives reported burnout symptoms, the work engagement of Dutch midwives was very high. However, a relatively large number reported symptoms of exhaustion, which is concerning because of the risk of increasing cynicism levels leading to burnout. In contrast to previous international research findings, being young and having less working experience was not related to burnout symptoms of Dutch newly qualified midwives.

IMPLICATIONS FOR PRACTICE

The recognition of job and personal resources for midwives' occupational wellbeing must be considered for a sustainable midwifery workforce. Midwifery Academies need to develop personal resources of their students that will help them in future practice.

Midwives' perceptions of the performance- and transition into practice of newly qualified midwives, a focus group study

PROBLEM

Newly qualified midwives in the Netherlands perceive the adaptation to new responsibilities as difficult due to the autonomous nature of- and required accountability for the work they face in practice.

BACKGROUND

All Dutch newly qualified midwives are accountable for their work from the moment of registration while usually working solistically.

AIM

This paper explores the perceptions of experienced midwives regarding: (1) the performance- and transition into practice of newly qualified midwives, and (2) their supporting role in this transition.

METHODS

The design of this study is qualitative with focus groups. Experienced midwives' perceptions were explored by means of seven semi-structured focus groups (N = 46 participants) with two meetings for each focus group.

FINDINGS

Community-based and hospital-based midwives perceived newly qualified midwives as colleagues who did not oversee all their tasks and responsibilities. They perceived newly qualified midwives as less committed to the practice organisation. Support in community-based practices was informally organised with a lack of orientation. In the hospital-based setting, midwives offered an introduction period in a practical setting, which was formally organised with tasks and responsibilities. Experienced midwives recognised the need to support newly qualified midwives; however, in practice, they faced barriers.

DISCUSSION

The differences in experienced midwives' expectations of newly qualified midwives and reality seemed to depend on the newly qualified midwives' temporary working contracts and -context, rather than the generational differences that experienced midwives mentioned. Dutch midwives prioritised their work with pregnant individuals and the organisation of their practice above supporting newly qualified midwives.

The United Kingdom and the Netherlands maternity care responses to COVID-19: A comparative study

BACKGROUND

The national health care response to coronavirus (COVID-19) has varied between countries. The United Kingdom (UK) and the Netherlands (NL) have comparable maternity and neonatal care systems, and experienced similar numbers of COVID-19 infections, but had different organisational responses to the pandemic. Understanding why and how similarities and differences occurred in these two contexts could inform optimal care in normal circumstances, and during future crises.

AIM

To compare the UK and Dutch COVID-19 maternity and neonatal care responses in three key domains: choice of birthplace, companionship, and families in vulnerable situations.

METHOD

A multi-method study, including documentary analysis of national organisation policy and guidance on COVID-19, and interviews with national and regional stakeholders.

FINDINGS

Both countries had an infection control focus, with less emphasis on the impact of restrictions, especially for families in vulnerable situations. Differences included care providers' fear of contracting COVID-19; the extent to which community- and personalised care was embedded in the care system before the pandemic; and how far multidisciplinary collaboration and service-user involvement were prioritised.

CONCLUSION

We recommend that countries should 1) make a systematic plan for crisis decision-making before a serious event occurs, and that this must include authentic service-user involvement, multidisciplinary collaboration, and protection of staff wellbeing 2) integrate women's and families' values into the maternity and neonatal care system, ensuring equitable inclusion of the most vulnerable and 3) strengthen community provision to ensure system wide resilience to future shocks from pandemics, or other unexpected large-scale events.

Models for midwifery care: A mapping review

INTRODUCTION

According to WHO, midwives are found competent to provide evidencebased and normalcy-facilitating maternity care. Models for midwifery care exist, but seem to be lacking explicit epistemological status, mainly focusing on the practical and organizational level of care delivery. To make the values and attitudes of care visible, it is important to implement care models with explicit epistemological status. The aim of this paper is to identify and gain an overview of publications of theoretical models for midwifery care.

METHODS

A mapping review was conducted with systematic searches in nine databases for studies describing a theoretical model or theory for midwifery care that either did or was intended to impact clinical practice. Eligibility criteria were refined during the selection process.

RESULTS

Six models from six papers originating from different parts of the world were included in the study. The included models were developed using different methodologies and had different philosophical underpinnings and complexity gradients. Some characteristics were common, the most distinctive being the emphasis of the midwife-woman relationship, secondly the focus on woman-centeredness, and thirdly the salutogenic focus in care.

CONCLUSIONS

Overall, scarcity exists regarding theoretical models for midwifery care with explicit epistemological status. Further research is needed in order to develop generic theoretical models with an epistemological status to serve as a knowledge base for midwifery healthcare.

Transforming maternity care: obstetric partnerships as a policy instrument for integration

Increasing continuity in Dutch maternity care is considered pivotal to improve safety and client-centeredness. Closer collaboration between the historically relatively autonomous professionals and organizations in maternity care is deemed conditional to reach this goal, both by maternity care professionals and policy makers. Governmental policy therefore strives for organizational and financial integration. One of the policy measures has been to stimulate interprofessional and interorganizational collaboration through local obstetric partnerships. This study aimed to gain insight into whether this policy measure supported professionals in reaching the policy aim of increasing integration in the maternity care system. We therefore conducted 73 semistructured interviews with maternity care professionals in the region Northwest Netherlands, from 2014 to 2016. Respondents expressed much willingness to intensify interprofessional and interorganizational collaboration and experienced obstetric partnerships as contributing to this. As such, stimulating integration through obstetric partnerships can be considered a suitable policy measure. However, collaborating within the partnerships simultaneously highlighted deep-rooted dividing structures (organizational, educational, legal, financial) in the maternity care system, especially at the systemic level. These were experienced to hinder collaboration, but difficult for the professionals to influence, as they lacked knowledge, skills, resources and mandate. A lack of clear and timely guidance and support from policy, counterbalancing these barriers, limited partnerships' potential to unify professionals and integrate their services.

A comparison of the Fear of Childbirth Scale with the Tilburg Pregnancy Distress Scale to identify childbirth-related fear in a sample of Dutch pregnant women: a diagnostic accuracy comparative cross-sectional study

BACKGROUND

Because of the considerable negative effects of women's childbirth-related anxiety, fear and worries, and the time constraints that midwives perceive to assess women's antenatal emotional wellbeing, it is important that midwives can identify women with a more severe fear of birth with an easy to administer, validated tool.

OBJECTIVE

To investigate the ability of the two-item Fear of Childbirth Scale (FOBS) to discriminate between pregnant women with and without birth-related fear, compared with the 16-item Tilburg Pregnancy Distress Scale (TPDS).

METHODS

A diagnostic accuracy comparative cross-sectional study was performed, comparing two screening tests. Sensitivity, specificity, positive and negative predictive values and accuracy and discriminant property of the FOBS were determined and compared with the TPDS and with the negative affect 11-items TPDS (TPDS-NA) subscale. The TPDS and TPDS-NA were treated as reference standard to establish the discriminative potential of the FOBS for the presence or absence of antenatal birth-related fear.

PARTICIPANTS

A sample of 396 Dutch women with uncomplicated pregnancies.

RESULTS

When compared with the 16-items TPDS, the FOBS showed a higher specificity (95%) than sensitivity (70%) to detect fear of childbirth. The FOBS items had a good predictive ability for fear and worries about the forthcoming birth (79%) and a conclusive ability for negative case-finding (92%). The FOBS showed good accuracy (89%). The FOBS discriminated women who were or were not classified as being fearful according to the TPDS (AUC .86). When compared with the 11 items TPDS-NA subscale, the FOBS validity and accuracy decreased: sensitivity: 51%; specificity 92%; positive predictive ability 65%; negative predictive ability 88%; accuracy 83%; AUC .82.

CONCLUSION

When compared with the 16-items TPDS, the two-item FOBS shows to be an accurate tool for identifying the presence of antenatal birth-related fear in a sample of Dutch women with uncomplicated pregnancies.

The initiation of Dutch newly qualified hospital-based midwives in practice, a qualitative study

In the Netherlands, a percentage of newly qualified midwives start work in maternity care as a hospital-based midwife, although prepared particularly for working autonomously in the community.

AIM

This study aimed to explore newly qualified Dutch midwives' perceptions of their job demands and resources during their initiation to hospital-based practice.

DESIGN

We conducted a qualitative study with semi structured interviews using the Job Demands-Resources model as theoretical framework.

METHODS

Twenty-one newly qualified midwives working as hospital-based midwives in the Netherlands were interviewed individually between January and July 2018. Transcripts were analyzed using thematic content analysis.

FINDINGS

High workload, becoming a team member, learning additional medical procedures and job insecurity were perceived demands. Participants experienced the variety of the work, the teamwork, social support, working with women, and employment conditions as job resources. Openness for new experiences, sociability, calmness and accuracy were experienced as personal resources, and perfectionism, self-criticism, and fear of failure as personal demands.

CONCLUSION

Initiation to hospital-based practice requires from newly qualified midwives adaptation to new tasks: working with women in medium and high-risk care, managing tasks, as well as often receiving training in additional medical skills. Sociability helps newly qualified midwives in becoming a member of a multidisciplinary team; neuroticism and perfectionism hinders them in their work. Clear expectations and a settling-in period may help newly qualified midwives to adapt to practice. The initiation phase could be better supported by preparing student midwives for working in a hospital setting and helping manage expectations about the settling-in period.

Are midwives in the Netherlands satisfied with their jobs? A systematic examination of satisfaction levels among hospital and primary-care midwives in the Netherlands

Background

Job satisfaction is generally considered to be an important element of work quality and workplace relations. Little is known about levels of job satisfaction among hospital and primary-care midwives in the Netherlands. Proposed changes to the maternity care system in the Netherlands should consider how the working conditions of midwives affect their job satisfaction.

Aim

We aimed to measure and compare job satisfaction among hospital and primary-care midwives in the Netherlands.

Methods

Online survey of all practising midwives in the Netherlands using a validated measure of job satisfaction (the Leiden Quality of Work Questionnaire) to analyze the attitudes of hospital and primary-care midwives about their work. Descriptive and inferential statistics were used to assess differences between the two groups.

Results

Approximately one in six of all practising midwives in the Netherlands responded to our survey (hospital midwives n = 103, primary-care midwives n = 405). All midwives in our survey were satisfied with their work (n = 508). However, significant differences emerged between hospital and primary-care midwives in terms of what was most important to them in relation to their job satisfaction. For hospital midwives, the most significant domains were: working hours per week, workplace agreements, and total years of experience. For primary-care midwives, social support at work, work demands, job autonomy, and the influence of work on their private life were most significant.

Conclusion

Although midwives were generally satisfied, differences emerged in the key predictors of job satisfaction between hospital and primary-care midwives. These differences could be of importance when planning workforce needs and should be taken into consideration by policymakers in the Netherlands and elsewhere when planning new models of care.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4454-x) contains supplementary material, which is available to authorized users.

How good is collaboration between maternity service providers in the Netherlands?

AIMS

To examine the experiences of inter-professional collaboration of maternity service providers in the Netherlands and to identify potential enhancing and inhibiting factors for inter-professional collaboration within maternity care in the Netherlands.

BACKGROUND

Good collaboration between health care professionals is a key element of safe, effective care, but creating a collaborative culture can be challenging. Good collaboration requires, among other things, negotiating different professional orientations and the organizational constraints of hierarchies and scheduling. Good collaboration is especially important in maternity care. In the Netherlands, suboptimal collaboration has been cited as a significant factor in maternal deaths and in adverse incidents occurring in hospitals during evenings, nights, and weekends. In spite of its importance for effective maternity care, little is known about the nature and quality of collaboration between maternity care professionals. In order to fill this gap, we examined the inter-professional collaboration within multi-disciplinary teams (MDTs) providing maternity services in the Netherlands.

METHODS

Online survey of MDTs (consisting of hospital and PCMs, doctors, and carers) involved in the provision of maternity services in the Netherlands. We used a validated measure of collaboration (the Leiden Quality of Work Questionnaire) to analyze the attitudes of those involved in the provision of maternity services about multi-disciplinary collaboration in their work. We used descriptive and inferential statistics to assess differences between the groups.

RESULTS

40% of all respondents were not satisfied with collaboration within their MDT. Overall, mean collaboration scores (MCS) were low. We found significant differences in MCS between professional groups. Midwives - community and hospital based - were pessimistic about collaboration in future models of maternity care.

DISCUSSION

In the Netherlands, collaboration in maternity care is less than optimal. Poor collaboration is associated with negative consequences for patient safety and quality of care. Strategies to address suboptimal collaboration exist; however, no one-size-fits-all approach is identified in the literature.

CONCLUSION

Suboptimal collaboration exists within the midwifery model of care in the Netherlands and the relationship between care providers is under pressure. This could affect patient safety and quality of care, according to the literature.

PRÉCIS

This paper presents an in-depth examination of the nature of, and attitudes about, collaboration between members of the MDT involved in the provision of maternity services in the Netherlands.

Sharing special birth stories. An explorative study of online childbirth narratives

BACKGROUND

Increasingly, pregnant women, as active online media users, incorporate media driven values on childbirth that may not agree with professional midwifery values. In Dutch midwifery practice, online searching for other women's stories is often discouraged. However, online birth stories attract women as a means to learn from one another's experiences of childbirth.

AIM

This study aims to explore Dutch women's use of an online social media platform (Instagram) to represent childbirth by analyzing their narrative strategies.

METHOD

A collection of 110 Instagram-linked childbirth narratives (2015-2017) were analyzed applying an approach of interpretative repertoires.

FINDINGS

The Dutch women in this study linked birth stories on their Instagram accounts that represented impactful experiences of childbirth. In their narratives, three interconnected repertoires are played out: sharing your story, going into details, and doing it yourself. This study highlights that narrative details of the online birth stories illustrate the physical and procedural obstacles that women overcame in giving birth.

DISCUSSION

Reporting their emotional experiences in detail, women's online sharing of birth stories puts a focus on their personal preferences and decision making, and may ease the way for medical interventions. Without giving explicit advice, personal online birth stories could be instrumental in reformulating the standards of what childbirth is, or should be, like.

CONCLUSION

Social media networks allow women to exchange stories that structure narrating women's childbirth experiences and offer a structure for the lived or future experiences of others. This may have an impact on women's decision-making during pregnancy and childbirth.

Perceived job demands and resources of newly qualified midwives working in primary care settings in The Netherlands

OBJECTIVE

The objective of this study is to identify perceived job demands and job resources of newly qualified midwives (NQMs), working in primary midwifery care during their first years in practice.

DESIGN/SETTING

A qualitative study, with semi-structured group interviews was conducted. Midwives working less than three years in primary midwifery care in the Netherlands were invited to join a focus group interview.

MEASUREMENTS AND FINDINGS

Five focus group interviews were with 31 participants. Interviews were transcribed and analyzed. Data were analyzed thematically by using the different characteristics of the Job Demands Resources model. Working as a locum midwife is demanding for Dutch NQMs, due to a large number of working hours in different practices and a lack of job security. Decision-making and adapting to local guidelines and collaborations demand a high cognitive load. These aspects of the work context negatively impact NQMs' work and private life. Working with clients and working autonomously motivates the newly graduates. Support from colleagues and peers are important job resources, although colleagues are also experienced as a job demand, due to their role as employer. Strictness in boundaries, flexibility and sense of perspective are NQMs' personal resources. On the other hand, NQMs perceived perfectionism and the urge to prove oneself as personal demands.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Dutch NQMs' first years in primary midwifery care are perceived as highly demanding. In primary care, NQMs usually work as locum midwives, self-employed and in different practices. Working in different practices requires not only working with different client populations and autonomous decision-making, but also requires adaptation to different local working arrangements. Building adequate support systems might help NQMs finding a balance between work and private life by having experienced midwives available as mentors. Furthermore, training and coaching of NQMs help them to become aware of their personal resources and demands and to help them strengthen their personal resources. Improving NQMs' working position through secure employments require changes in the organization of maternity care in the Netherlands.

An approach to assessing the quality of birth centres results of the Dutch birth centre study

OBJECTIVE

to determine the usability of a recently developed set of 30 structure and process birth centre quality indicators.

DESIGN

an explorative study using mixed-methods including literature, a survey, interviews and observations. The study is part of the Dutch Birth Centre Study. We first determined the measurability of birth centre quality indicators by describing them in detail. Next, we assessed the birth centres in the Netherlands according to these indicators using data derived from the Dutch Birth Centre General Questionnaire, the Dutch Birth Centre Integration Questionnaire, interviews, and policy documents.

SETTING AND PARTICIPANTS

representatives of 23 birth centres in the Netherlands.

MEASUREMENTS AND FINDINGS

28 of the 30 quality indicators could be used to assess birth centres in the Netherlands, one had no optimal value defined, another could not be scored because the information was not available. Each quality indicator could be scored 0 or 1. Differences between birth centres were shown: the scores ranged from 7 to 22. Some of the quality indicators can be combined or made more specific so that they are easier to assess. Some quality indicators need adaptation because they are only applicable for some birth centres (e.g. only for freestanding or alongside birth centres).

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

28 of the 30 quality indicators are usable to assess structure and process quality of birth centres. With the findings of this study the set of structure and process quality indicators for birth centres in the Netherlands can be reduced to 22 indicators. This set of quality indicators can contribute to the development of a quality system for birth centres. Further research is necessary to formulate standards or minimum quality requirements for birth centres and to improve the set of birth centre quality indicators.

Interprofessional collaboration among care professionals in obstetrical care: are perceptions aligned?

BACKGROUND

In an obstetrical team, obstetricians, midwives and nurses work together in a dynamic and complex care setting. Different professional cultures can be a barrier for effective interprofessional collaboration. Although the different professional cultures in obstetrical care are well known, little is understood about discrepancies in mutual perceptions of collaboration. Similar perceptions of collaboration are important to ensure patient safety. We aimed to understand how different care professionals in an obstetrical team assess interprofessional collaboration in order to gain insight into the extent to which their perceptions are aligned.

METHODS

This cross-sectional study was performed in the north-western region of the Netherlands. Care professionals from five hospitals and surrounding primary-care midwifery practices were surveyed. The respondents consisted of four groups of care professionals: obstetricians (n=74), hospital-based midwives known as clinical midwives (n=42), nurses (n=154) and primary-care midwives (n=109). The overall response rate was 80.8%. We used the Interprofessional Collaboration Measurement Scale (IPCMS) to assess perceived interprofessional collaboration. The IPCMS distinguishes three subscales: communication, accommodation and isolation. Data were analysed using non-parametrical tests.

RESULTS

Overall, ratings of interprofessional collaboration were good. Obstetricians rated their collaboration with clinical midwives, nurses and primary-care midwives more positively than these three groups rated the collaboration with obstetricians. Discrepancies in mutual perceptions were most apparent in the isolation subscale, which is about sharing opinions, discussing new practices and respecting each other.

CONCLUSION

We found relevant discrepancies in mutual perceptions of collaboration in obstetrical care in the Netherlands. Obstetrical care is currently being reorganised to enable more integrated care, which will have consequences for interprofessional collaboration. The findings of this study indicate opportunities for improvement especially in terms of perceived isolation.

Collaboration of midwives in primary care midwifery practices with other maternity care providers

BACKGROUND

Inter-professional collaboration is considered essential in effective maternity care. National projects are being undertaken to enhance inter-professional relationships and improve communication between all maternity care providers in order to improve the quality of maternity care in the Netherlands. However, little is known about primary care midwives' satisfaction with collaboration with other maternity care providers, such as general practitioners, maternity care assistance organisations (MCAO), maternity care assistants (MCA), obstetricians, clinical midwives and paediatricians. More insight is needed into the professional working relations of primary care midwives in the Netherlands before major changes are made OBJECTIVE: To assess how satisfied primary care midwives are with collaboration with other maternity care providers and to assess the relationship between their 'satisfaction with collaboration' and personal and work-related characteristics of the midwives, their attitudes towards their work and collaboration characteristics (accessibility). The aim of this study was to provide insight into the professional working relations of primary care midwives in the Netherlands.

METHODS

Our descriptive cross-sectional study is part of the DELIVER study. Ninety nine midwives completed a written questionnaire in May 2010. A Friedman ANOVA test assessed differences in satisfaction with collaboration with six groups of maternity care providers. Bivariate analyses were carried out to assess the relationship between satisfaction with collaboration and personal and work-related characteristics of the midwives, their attitudes towards their work and collaboration characteristics.

RESULTS

Satisfaction experienced by primary care midwives when collaborating with the different maternity care providers varies within and between primary and secondary/tertiary care. Interactions with non-physicians (clinical midwives and MCA(O)) are ranked consistently higher on satisfaction compared with interactions with physicians (GPs, obstetricians and paediatricians). Midwives with more work experience were more satisfied with their collaboration with GPs. Midwives from the southern region of the Netherlands were more satisfied with collaboration with GPs and obstetricians. Compared to the urban areas, in the rural or mixed areas the midwives were more satisfied regarding their collaboration with MCA(O)s and clinical midwives. Midwives from non-Dutch origin were less satisfied with the collaboration with paediatricians. No relations were found between the overall mean satisfaction of collaboration and work-related and personal characteristics and attitude towards work.

CONCLUSIONS

Inter-professionals relations in maternity care in the Netherlands can be enhanced, especially the primary care midwives' interactions with physicians and with maternity care providers in the northern and central part of the Netherlands, and in urban areas. Future exploratory or deductive research may provide additional insight in the collaborative practice in everyday work setting.

Student midwives' perceptions on the organisation of maternity care and alternative maternity care models in the Netherlands - a qualitative study

BACKGROUND

A major change in the organisation of maternity care in the Netherlands is under consideration, going from an echelon system where midwives provide primary care in the community and refer to obstetricians for secondary and tertiary care, to a more integrated maternity care system involving midwives and obstetricians at all care levels. Student midwives are the future maternity care providers and they may be entering into a changing maternity care system, so inclusion of their views in the discussion is relevant. This study aimed to explore student midwives' perceptions on the current organisation of maternity care and alternative maternity care models, including integrated care.

METHODS

This qualitative study was based on the interpretivist/constructivist paradigm, using a grounded theory design. Interviews and focus groups with 18 female final year student midwives of the Midwifery Academy Amsterdam Groningen (AVAG) were held on the basis of a topic list, then later transcribed, coded and analysed.

RESULTS

Students felt that inevitably there will be a change in the organisation of maternity care, and they were open to change. Participants indicated that good collaboration between professions, including a shared system of maternity notes and guidelines, and mutual trust and respect were important aspects of any alternative model. The students indicated that client-centered care and the safeguarding of the physiological, normalcy approach to pregnancy and birth should be maintained in any alternative model. Students expressed worries that the role of midwives in intrapartum care could become redundant, and thus they are motivated to take on new roles and competencies, so they can ensure their own role in intrapartum care.

CONCLUSIONS

Final year student midwives recognise that change in the organisation of maternity care is inevitable and have an open attitude towards changes if they include good collaboration, client-centred care and safeguards for normal physiological birth. The graduating midwives are motivated to undertake an expanded intrapartum skill set. It can be important to involve students' views in the discussion, because they are the future maternity care providers.

Perceptions of labour pain management of Dutch primary care midwives: a focus group study

BACKGROUND

Labour pain is a major concern for women, their partners and maternity health care professionals. However, little is known about Dutch midwives' perceptions of working with women experiencing labour pain. The aim of this study was to explore midwives' perceptions of supporting women in dealing with pain during labour.

METHODS

We conducted a qualitative focus group study with four focus groups, including a total of 23 midwives from 23 midwifery practices across the country. Purposive sampling was used to select the practices. The constant comparison method of Glaser and Straus (1967, ren. 1995) was used to gain an understanding of midwives' perceptions regarding labour pain management.

RESULTS

We found two main themes. The first theme concerned the midwives' experienced professional role conflict, which was reflected in their approach of labour pain management along a spectrum from "working with pain" to a "pain relief" approach. The second theme identified situational factors, including time constraints; discontinuity of care; role of the partner; and various cultural influences, that altered the context in which care was provided and how midwives saw their professional role.

CONCLUSION

Midwives felt challenged by the need to balance their professional attitude towards normal birth and labour pain, which favours working with pain, with the shift in society towards a wider acceptance of pharmacological pain management during labour. This shift compelled them to redefine their professional identity.

Women's Suggestions for Improving Midwifery Care in The Netherlands

BACKGROUND

The experience of the care a woman receives during pregnancy and childbirth has an immediate and long-lasting effect on her well being. The involvement of patients and clients in health care has increased over the last decades. The Dutch maternity care system offers an excellent opportunity to explore and involve women's suggestions for the improvement of midwifery care in the current maternity care model.

METHODS

This qualitative study is part of the "DELIVER" study. Clients were recruited from 20 midwifery practices. Purposive sampling was used to select the practices. The clients received up to three questionnaires, in which they could respond to the question; "Do you have any suggestions on how your midwife could improve his/her provision of care?" The answers were analyzed with a qualitative thematic content analysis, using the software program MAXQDA.

RESULTS

Altogether, 3,499 answers were provided. One overarching concept emerged: clients' desire for individualized care. Within this concept, suggestions could be clustered around 1) provider characteristics: interpersonal skills, communication, and competence, and 2) service characteristics: content and quantity of care, guidance and support, continuity of care provider, continuity of care, information, and coordination of care.

CONCLUSIONS

Informed by the suggestions of women, care to women and their families could be improved by the following: 1) more continuity of the care provider during the prenatal, natal, and postnatal periods, 2) more information and information specifically tailored for the person, 3) client-centered communication, and 4) a personal approach with 5) enough time spent per client.

Intrapartum referral from primary to secondary care in the Netherlands: a retrospective cohort study on management of labor and outcomes

BACKGROUND

In the Dutch maternity care system, primary care midwives provide care to low-risk women and refer to obstetricians if risks or complications occur. We examined reasons for referral, management of labor, and maternal and neonatal outcomes among women who were referred during labor.

METHODS

In a retrospective cohort study, descriptive analyses were performed on data obtained from patient records. Six purposively chosen hospitals in The Netherlands participated in the study from June 2011 to February 2012. The study population included 600 pregnant women who were referred during labor from primary to secondary care.

MAIN OUTCOME MEASURES

Reasons for referral, interventions after referral, mode of delivery, and maternal and neonatal outcomes.

RESULTS

Of women who were referred during labor, three out of four women were referred for moderate risk indications: request for pain relief (30.5%), meconium-stained liquor (25.3%), failure to progress during first stage of labor (14.0%), and prolonged ruptured membranes without contractions (12.5%). Of all women, 65.7 percent had a spontaneous vaginal delivery and 59.7 percent received some kind of pain relief. Acute referral, meaning fetal distress, occurred in 5.5 percent. Of the newborns, 2.7 percent had an Apgar score of 7 or less after 5 minutes and 1.2 percent had an umbilical cord pH < 7.05. Postpartum complications occurred among 11.0 percent of women.

CONCLUSION

Women who are referred during labor have a high probability of spontaneous vaginal delivery. To improve continuity of care and satisfaction for this group of women, management of labor could be continued by trained primary care midwives.

Career plans of primary care midwives in the Netherlands and their intentions to leave the current job

BACKGROUND

In labour market policy and planning, it is important to understand the motivations of people to continue in their current job or to seek other employment. Over the last decade, besides the increasingly medical approach to pregnancy and childbirth and decreasing home births, there were additional dramatic changes and pressures on primary care midwives and midwifery care. Therefore, it is important to re-evaluate the career plans of primary care midwives and their intentions to leave their current job.

METHODS

All 108 primary care midwives of 20 selected midwifery care practices in the Netherlands were invited to fill out a written questionnaire with questions regarding career plans and intentions to leave. Bivariate analyses were carried out to compare career plans and work-related and personal characteristics and attitudes towards work among the group of midwives who indicated that they intended to leave their current job (ITL group) and those who indicated they had no intention to leave (NITL group). Significant predictors of ITL were included in the multiple binary logistic regression with 'intention to leave' as the dependent variable.

RESULTS

In 2010, 32.7% of the 98 participating primary care midwives surveyed had considered an intention to leave their current type of job in the past year. Fewer ITL midwives wanted to be a self-employed practitioner with the full range of primary care tasks and work full-time. Significant predictors of the primary care midwives' intention to leave included a lower overall score on the job satisfaction scale (OR = 0.18; 95% CI = 0.06-0.58; p = 0.004) and being between 30 and 45 years old (OR = 2.69; 95% CI = 1.04-7.0; p = 0.041).

CONCLUSION

Our study shows that, despite significant changes in the reproductive, maternal and newborn health service delivery that impact on independent midwifery practice, the majority of primary care midwives intended to stay in primary care. The absence of job satisfaction, and being in the age group between 30 and 45 years old, is associated with primary care midwives' intention to leave their current job. Ongoing monitoring will be important in the future.

Variation in intrapartum referral rates in primary midwifery care in the Netherlands: a discrete choice experiment

OBJECTIVE

in midwife-led care models of maternity care, midwives are responsible for intrapartum referrals to the obstetrician or obstetric unit, in order to give their clients access to secondary obstetric care. This study explores the influence of risk perception, policy on routine labour management, and other midwife related factors on intrapartum referral decisions of Dutch midwives.

DESIGN

a questionnaire was used, in which a referral decision was asked in 14 early labour scenarios (Discrete Choice Experiment or DCE). The scenarios varied in woman characteristics (BMI, gestational age, the preferred birth location, adequate support by a partner, language problems and coping) and in clinical labour characteristics (cervical dilatation, estimated head-to-cervix pressure, and descent of the head).

SETTING

primary care midwives in the Netherlands.

PARTICIPANTS

a systematic random selection of 243 practicing primary care midwives. The response rate was 48 per cent (117/243).

MEASUREMENTS

the Impact Factor of the characteristics in the DCE was calculated using a conjoint analysis. The number of intrapartum referrals to secondary obstetric care in the 14 scenarios of the DCE was calculated as the individual referral score. Risk perception was assessed by respondents׳ estimates of the probability of eight birth outcomes. The associations between midwives׳ policy on management of physiological labour, personal characteristics, workload in the practice, number of midwives in the practice, and referral score were explored.

FINDINGS

the estimated head-to-cervix pressure and descent of the head had the largest impact on referral decisions in the DCE. The median referral score was five (range 0-14). Estimates of probability on birth outcomes were predominantly overestimating actual risks. Factors significantly associated with a high referral score were: a low estimated probability of a spontaneous vaginal birth (p=0.007), adhering to the active management policy Proactive Support of Labour (PSOL) (p=0.047), and a practice situated in a rural area or small city (p=0.016).

KEY CONCLUSIONS

there is considerable variation in referral decisions among midwives that cannot be explained by woman characteristics or clinical factors in early labour. A realistic perception of the possibility of a spontaneous vaginal birth and adhering to expectant management can contribute to the prevention of unwarranted medicalisation of physiological childbirth.

IMPLICATIONS FOR PRACTICE

awareness of variation in referrals and the associated midwife-related factors can stimulate midwives to reflect on their referral behavior. To diminish unwarranted variation, high quality research on the optimal management of a physiological first stage of labour should be performed.

Down syndrome screening information in midwifery practices in the Netherlands: Strategies to integrate biomedical information

The aim of this qualitative study was to analyse counselling with regard to prenatal screening in midwifery consultations in the Netherlands where a national prenatal screening programme has only existed since 2007, after years of social and political debates. The methodology is based on in situ observations of 25 counselling consultations in four midwifery practices in two main cities in the Netherlands. The results of this study show that, since midwives are obliged to offer information on Down syndrome screening to all pregnant women (2007), they have to deal with the communication of medical screening information using biostatistical concepts to explain risks, calculations, probabilities and chromosomal anomalies. In order to avoid the risk of medicalization of their consultation, midwives develop strategies that allow them to integrate this new biomedical discourse while maintaining their low medicalized approach of midwife-led care. One of their main strategies is to switch from 'alarming' biomedical messages to 'reassuring words' in order to manage the anxiety induced by the information and to keep the control over their low medicalized consultation. They also tend to distance themselves from the obligation to talk about screening. The way midwives handle these counselling consultations allows them to respect their obligation to propose information, and to remain faithful to their struggle to protect the natural process of pregnancy as well as their professional autonomy.

Eliciting preferences for key attributes of intrapartum care in the Netherlands

BACKGROUND

As part of the move toward "patient-centered care," women's preferences with regard to maternity services have become increasingly important to policy makers. To realize optimal patient-centered care, knowledge of patients' preferences is essential. The aim of our study was to assess the strength and relative importance of women's preferences for different aspects of intrapartum care in The Netherlands, where women have easy access to both home and hospital birth.

METHODS

A discrete choice experiment was conducted at 16 weeks of gestation as part of a Dutch multicenter, prospective cohort study from 2007 to 2011 of low-risk, nulliparous women. Responses were analyzed per intended place of birth group: midwifery-led home (n = 191) and hospital birth (n = 152) and obstetric-led hospital birth (n = 188).

RESULTS

We analyzed 562 questionnaires. Women in all groups preferred the possibility of influencing decision making and pain-relief treatment during birth and no co-payment for childbirth. Women with an intended home birth preferred a home-like birth setting with the assistance of a midwife and transport during birth in case of complications. Type of birth setting and transport during birth were not considered important to women with an intended midwifery- or obstetric-led hospital birth.

CONCLUSION

Policies aimed at the improvement of maternity care must take into account women's preferences for the possibility of pain-relief treatment and the fact that all women desire a high level of involvement in decision making. Furthermore, efforts to change maternity care systems must consider how to counter the culturally embedded nature of women's preferences.