Variation in referrals to secondary obstetrician-led care among primary midwifery care practices in the Netherlands: a nationwide cohort study

Intrapartum time intervals and transfer of nulliparae from community births to maternity care units in Germany

BACKGROUND

Over one-third of nulliparae planning births either at home or in freestanding midwife-led birthing centers (community births) in high-income countries are transferred during labor. Perinatal data are reported each year in Germany for women planning community birth. So far, data sets have not been linked to describe time-related factors associated with nulliparous transfer to hospital.

OBJECTIVES

To describe the prevalence of referral for nulliparae and assess maternal and labor characteristics associated with intrapartum transfer.

METHODS

Perinatal data from 2010 to 2015 were linked (n = 26,115). Women were reviewed with respect to international eligibility criteria for community birth; 1997 women were excluded (7.6%). Descriptive statistics were reported; unadjusted and adjusted odds ratios with 95% confidence intervals (CI) tested the predictive effect of demographic and labor factors on rates of intrapartum transfer.

RESULTS

One in three nulliparous women (30.6%) were transferred to hospital. Compared with community births, transferred women were significantly more likely to experience longer time intervals during labor: from rupture of membranes (ROM) until birth lasting 5 to 18 h (OR 6.05, CI 5.53-6.61) and 19 to 24 h (OR 10.83, CI 9.45-12.41) compared to one to 4 h; and from onset of labor until birth 11 to 24 h (OR 6.72, CI 6.24-7.23) and 25 to 29 h (OR 26.62, CI 22.77-31.11) compared to one to 10 h. When entering all factors into the model, we found the strongest predictors of transfer to be fetal distress, longer time intervals between ROM until birth and onset of labor until birth.

CONCLUSIONS

Nulliparous transfer rates were similar to rates in other high-income countries; 94% of referrals were non-urgent. Time was found to be an independent risk factor for the transfer of nulliparae planning community birth.

Audit and feedback to reduce unwarranted clinical variation at scale: a realist study of implementation strategy mechanisms

BACKGROUND

Unwarranted clinical variation in hospital care includes the underuse, overuse, or misuse of services. Audit and feedback is a common strategy to reduce unwarranted variation, but its effectiveness varies widely across contexts. We aimed to identify implementation strategies, mechanisms, and contextual circumstances contributing to the impact of audit and feedback on unwarranted clinical variation.

METHODS

Realist study examining a state-wide value-based healthcare program implemented between 2017 and 2021 in New South Wales, Australia. Three initiatives within the program included audit and feedback to reduce unwarranted variation in inpatient care for different conditions. Multiple data sources were used to formulate the initial audit and feedback program theory: a systematic review, realist review, program document review, and informal discussions with key program stakeholders. Semi-structured interviews were then conducted with 56 participants to refute, refine, or confirm the initial program theories. Data were analysed retroductively using a context-mechanism-outcome framework for 11 transcripts which were coded into the audit and feedback program theory. The program theory was validated with three expert panels: senior health leaders (n = 19), Agency for Clinical Innovation (n = 11), and Ministry of Health (n = 21) staff.

RESULTS

The program's audit and feedback implementation strategy operated through eight mechanistic processes. The strategy worked well when clinicians (1) felt ownership and buy-in, (2) could make sense of the information provided, (3) were motivated by social influence, and (4) accepted responsibility and accountability for proposed changes. The success of the strategy was constrained when the audit process led to (5) rationalising current practice instead of creating a learning opportunity, (6) perceptions of unfairness and concerns about data integrity, 7) development of improvement plans that were not followed, and (8) perceived intrusions on professional autonomy.

CONCLUSIONS

Audit and feedback strategies may help reduce unwarranted clinical variation in care where there is engagement between auditors and local clinicians, meaningful audit indicators, clear improvement plans, and respect for clinical expertise. We contribute theoretical development for audit and feedback by proposing a Model for Audit and Feedback Implementation at Scale. Recommendations include limiting the number of audit indicators, involving clinical staff and local leaders in feedback, and providing opportunities for reflection.

Antenatal cardiotocography in primary midwife-led care: Women's satisfaction

BACKGROUND

In the Netherlands, antenatal cardiotocography (aCTG), used to assess fetal well-being, is performed in obstetrician-led care. To improve continuity of care, an innovation project was designed wherein primary care midwives perform aCTGs for specific indications. The aim of this study was to examine the satisfaction and experiences of pregnant women who received an aCTG in primary midwife-led care and explore which factors were associated with high satisfaction.

METHODS

Data were collected through a self-administered questionnaire based on the Consumer Quality Index. The primary outcome was general satisfaction on a 10-point scale, with a score above nine indicating participants were "highly satisfied".

RESULTS

In total, 1227 women were included in the analysis. The study showed a mean general satisfaction score of 9.2. Most women were highly satisfied with receiving an aCTG in primary midwife-led care (77.4%). On the Consumer Quality Index, the mean satisfaction level varied from 3.98 (SD ± 0.11) for the subscale "client satisfaction" to 3.87 (SD ± 0.32) for the subscale "information provision" on a 4-point scale. Women at between 33 and 36 weeks' gestation were more likely to be highly satisfied (adjusted OR [aOR] = 3.35). Compared with a completely comfortable position during the aCTG, a mostly comfortable or somewhat comfortable level had decreased odds of being associated with a ranking of highly satisfied (aOR 0.24 and 0.19, respectively).

CONCLUSIONS

This study shows that pregnant women are satisfied with having an aCTG in midwife-led care. Providing aCTG in midwife-led care can increase access to continuity of care.

Knowledge and skills used for clinical decision-making on childbirth interventions: A qualitative study among midwives in the Netherlands

INTRODUCTION

Appropriate use of interventions in maternity care is a worldwide issue. Midwifery-led models of care are associated with more efficient use of resources, fewer medical interventions, and improved outcomes. However, the use of interventions varies considerably between midwives. The aim of this study was to explore how knowledge and skills influence clinical decision-making of midwives on the appropriate use of childbirth interventions.

METHODS

A qualitative study using in-depth interviews with 20 primary care midwives was performed in June 2019. Participants’ clinical experience varied in the use of interventions. The interviews combined a narrative approach with a semi-structured question route. Data were analyzed using deductive content analysis.

RESULTS

‘Knowledge’, ‘Critical thinking skills’, and ‘Communication skills’ influenced midwives’ clinical decision-making towards childbirth interventions. Midwives obtained their knowledge through the formal education program and extended their knowledge by reflecting on experiences and evidence. Midwives with a low use of interventions seem to have a higher level of reflective skills, including reflection-in-action. These midwives used a more balanced communication style with instrumental and affective communication skills in interaction with women, and have more skills to engage in discussions during collaboration with other professionals, and thus personalizing their care.

CONCLUSIONS

Midwives with a low use of interventions seemed to have the knowledge and skills of a reflective practitioner, leading to more personalized care compared to standardized care as defined in protocols. Learning through reflectivity, critical thinking skills, and instrumental and affective communication skills, need to be stimulated and trained to pursue appropriate, personalized use of interventions.

Modelling the cost of place of birth: a pathway analysis

BACKGROUND

In New South Wales (NSW), Australia there are three settings available for women at low risk of complications to give birth: home, birth centre and hospital. Between 2000 and 2012, 93.6% of babies were planned to be born in hospital, 6.0% in a birth centre and 0.4% at home. Availability of alternative birth settings is limited and the cost of providing birth at home or in a birth centre from the perspective of the health system is unknown.

OBJECTIVES

The objective of this study was to model the cost of the trajectories of women who planned to give birth at home, in a birth centre or in a hospital from the public sector perspective.

METHODS

This was a population-based study using linked datasets from NSW, Australia. Women included met the following selection criteria: 37-41 completed weeks of pregnancy, spontaneous onset of labour, and singleton pregnancy at low risk of complications. We used a decision tree framework to depict the trajectories of these women and Australian Refined-Diagnosis Related Groups (AR-DRGs) were applied to each trajectory to estimate the cost of birth. A scenario analysis was undertaken to model the cost for 30 000 women in one year.

FINDINGS

496 387 women were included in the dataset. Twelve potential outcome pathways were identified and each pathway was costed using AR-DRGs. An overall cost was also calculated by place of birth: $AUD4802 for homebirth, $AUD4979 for a birth centre birth and $AUD5463 for a hospital birth.

CONCLUSION

The findings from this study provides some clarity into the financial saving of offering more options to women seeking an alternative to giving birth in hospital. Given the relatively lower rates of complex intervention and neonatal outcomes associated with women at low risk of complications, we can assume the cost of providing them with homebirth and birth centre options could be cost-effective.

Health system redesign for maternal and newborn survival: rethinking care models to close the global equity gap

Large disparities in maternal and neonatal mortality exist between low- and high-income countries. Mothers and babies continue to die at high rates in many countries despite substantial increases in facility birth. One reason for this may be the current design of health systems in most low-income countries where, unlike in high-income countries, a substantial proportion of births occur in primary care facilities that cannot offer definitive care for complications. We argue that the current inequity in care for childbirth is a global double standard that limits progress on maternal and newborn survival. We propose that health systems need to be redesigned to shift all deliveries to hospitals or other advanced care facilities to bring care in line with global best practice. Health system redesign will require investing in high-quality hospitals with excellent midwifery and obstetric care, boosting quality of primary care clinics for antenatal, postnatal, and newborn care, decreasing access and financial barriers, and mobilizing populations to demand high-quality care. Redesign is a structural reform that is contingent on political leadership that envisions a health system designed to deliver high-quality, respectful care to all women giving birth. Getting redesign right will require focused investments, local design and adaptation, and robust evaluation.

Can a simple assessment of fear of childbirth in pregnant women predict requests and use of non-urgent obstetric interventions during labour?

OBJECTIVE

To examine whether the Wijma Delivery Expectation Questionnaire (W-DEQ-A) and the one-item Fear of Childbirth-Postpartum-Visual Analogue Scale (FOCP-VAS) - measuring high FOC - are useful tools in predicting requested and received non-urgent obstetric interventions in pregnant women.

DESIGN

A prospective cohort study.

POPULATION AND SETTING

Self-selected pregnant women from midwifery care settings (n=401).

METHODS

W-DEQ-A and FOCP-VAS were assessed at two timepoints in pregnancy. Measures of non-urgent obstetric interventions which were derived from medical files were: induction of labour, epidural analgesia, augmentation with oxytocin due to failure to progress and self-requested caesarean section. Hierarchical logistics regression models were used.

MAIN OUTCOME MEASURES

The change in the Nagelkerke R² was examined for three models predicting two outcome measures: (1) explicitly requested non-urgent obstetric interventions during pregnancy and (2) received non-urgent obstetric interventions during labour. The first model only included participants' characteristics, the second model also included FOCP-VAS ≥5, and in the third model the W-DEQ-A ≥66 was added.

RESULTS

High FOC measured with FOCP-VAS≥5 predicted requested (pseudo-R²=0.33, X²=59.82, P<0.001) and received non-urgent obstetric interventions (pseudo-R²=0.19, X²=32.81, P<0.001) better than high FOC measured with W-DEQ-A≥66.

CONCLUSION

This study is the first evaluating self-reported FOC and postpartum based on VAS (subjective outcome) in relation to actual pregnancy and childbirth outcomes derived from medical files (objective outcome). Non-urgent obstetric interventions could already be predicted in the first half of pregnancy by means of a simple FOC assessment with the one-item FOCP-VAS. Implementing this easy to use one-item screening tool in midwifery care is suggested.

Detailed registration of care in midwifery practices in the Netherlands: an opportunity for research within a healthy pregnant population

Background

Research in maternity care is often conducted in mixed low and high-risk or solely high-risk populations. This limits generalizability to the low-risk population of pregnant women receiving care from Dutch midwives. To address this limitation, 24 midwifery practices in the Netherlands bring together routinely collected data from medical records of pregnant women and their offspring in the VeCaS database. This database offers possibilities for research of physiological pregnancy and childbirth. This study explores if the pregnant women in VeCaS are a representative sample for the national population of women who receive primary midwife-led care in the Netherlands.

Methods

In VeCaS we selected a low risk population in midwife-led care who gave birth in 2015. We compared population characteristics and birth outcomes in this study cohort with a similarly defined national cohort, using Chi Square and two side t-test statistics. Additionally, we describe some birth outcomes and lifestyle factors.

Results

Midwifery practices contributing to VeCaS are spread over the Netherlands, although the western region is underrepresented. For population characteristics, the VeCaS cohort is similar to the national cohort in maternal age (mean 30.4 years) and parity (nulliparous women: 47.1% versus 45.9%). Less often, women in the VeCaS cohort have a non-Dutch background (15.7% vs 24.4%), a higher SES (9.9% vs 23.7%) and live in an urbanised surrounding (4.9% vs 24.8%). Birth outcomes were similar to the national cohort, most women gave birth at term (94.9% vs 94.5% between 37 + ⁰–41+ ⁶ weeks), started labour spontaneously (74.5% vs 75.5%) and had a spontaneous vaginal birth (77.4% vs 77.6%), 16.9% had a home birth. Furthermore, 61.1% had a normal pre-pregnancy BMI, and 81.0% did not smoke in pregnancy.

Conclusions

The VeCaS database contains data of a population that is mostly comparable to the national population in primary midwife-led care in the Netherlands. Therefore, the VeCaS database is suitable for research in a healthy pregnant population and is valuable to improve knowledge of the physiological course of pregnancy and birth. Representativeness of maternal characteristics may be improved by including midwifery practices from the urbanised western region in the Netherlands.

Towards a better understanding of risk selection in maternal and newborn care: A systematic scoping review

Globally, millions of women and their children suffer due to preventable morbidity and mortality, associated with both underuse and overuse of maternal and newborn care. An effective system of risk selection that differentiates between what care should be provided and who should provide it is a global necessity to ensure women and children receive appropriate care, at the right place and the right time. Poor conceptualization of risk selection impedes evaluation and comparison of models of risk selection across various settings, which is necessary to improve maternal and newborn care. We conducted a scoping review to enhance the understanding of risk selection in maternal and newborn care. We included 210 papers, published over the past four decades, originating from 24 countries. Using inductive thematic analysis, we identified three main dimensions of risk selection: (1) risk selection as an organisational measure to optimally align women's and children's needs and resources, (2) risk selection as a practice to detect and assess risk and to make decisions about the delivery of care, and (3) risk selection as a tool to ensure safe care. We found that these three dimensions have three themes in common: risk selection (1) is viewed as both requiring and providing regulation, (2) has a provider centred focus and (3) aims to avoid underuse of care. Due to the methodological challenges of contextual diversity, the concept of risk selection needs clear indicators that capture the complexity of care to make cross-setting evaluation and comparison of risk selection possible. Moreover, a comprehensive understanding of risk selection needs to consider access disparity, women's needs, and unnecessary medicalization.

Unwarranted clinical variation in health care: Definitions and proposal of an analytic framework

RATIONALE, AIMS, AND OBJECTIVES

Unwarranted clinical variation is a topic of heightened interest in health care systems around the world. While there are many publications and reports on clinical variation, few studies are conceptually grounded in a theoretical model. This study describes the empirical foundations of the field and proposes an analytic framework.

METHOD

Structured construct mapping of published empirical studies which explicitly address unwarranted clinical variation.

RESULTS

A total of 190 studies were classified in terms of three key dimensions: perspective (assessing variation across geographical areas or across providers); criteria for assessment (measuring absolute variation against a standard, or relative variation within a comparator group); and object of analysis (using process, structure/resource, or outcome metrics).

CONCLUSION

Consideration of the results of the mapping exercise-together with a review of adjustment, explanatory and stratification variables, and the factors associated with residual variation-informed the development of an analytic framework. This framework highlights the role that agency and motivation, evidence and judgement, and personal and organizational capacity play in clinical decision making and reveals key facets that distinguish warranted from unwarranted clinical variation. From a measurement perspective, it underlines the need for careful consideration of attribution, aggregation, models of care, and temporality in any assessment.

Regional variations in childbirth interventions and their correlations with adverse outcomes, birthplace and care provider: A nationwide explorative study

Background

Variations in childbirth interventions may indicate inappropriate use. Most variation studies are limited by the lack of adjustments for maternal characteristics and do not investigate variations in adverse outcomes. This study aims to explore regional variations in the Netherlands and their correlations with referral rates, birthplace, interventions, and adverse outcomes, adjusted for maternal characteristics.

Methods

In this nationwide retrospective cohort study, using a national data register, intervention rates were analysed between twelve regions among single childbirths after 37 weeks’ gestation in 2010–2013 (n = 614,730). These were adjusted for maternal characteristics using multivariable logistic regression. Primary outcomes were intrapartum referral, birthplace, and interventions used in midwife- and obstetrician-led care. Correlations both between primary outcomes and between adverse outcomes were calculated with Spearman’s rank correlations.

Findings

Intrapartum referral rates varied between 55–68% (nulliparous) and 20–32% (multiparous women), with a negative correlation with receiving midwife-led care at the onset of labour in two-thirds of the regions. Regions with higher referral rates had higher rates of severe postpartum haemorrhages. Rates of home birth varied between 6–16% (nulliparous) and 16–31% (multiparous), and was negatively correlated with episiotomy and postpartum oxytocin rates. Among midwife-led births, episiotomy rates varied between 14–42% (nulliparous) and 3–13% (multiparous) and in obstetrician-led births from 46–67% and 14–28% respectively. Rates of postpartum oxytocin varied between 59–88% (nulliparous) and 50–85% (multiparous) and artificial rupture of membranes between 43–52% and 54–61% respectively. A north-south gradient was visible with regard to birthplace, episiotomy, and oxytocin.

Conclusions

Our study suggests that attitudes towards interventions vary, independent of maternal characteristics. Care providers and policy makers need to be aware of reducing unwarranted variation in birthplace, episiotomy and the postpartum use of oxytocin. Further research is needed to identify explanations and explore ways to reduce unwarranted intervention rates.

Women-centered care: Implementation of CenteringPregnancy® in The Netherlands

INTRODUCTION

In response to a relatively high perinatal mortality rate in The Netherlands, the Dutch Health Ministry recommended changes to maternity care, opening a pathway toward more integrated woman-centered services. Because of its potential to positively influence risk factors for adverse pregnancy outcomes, CenteringPregnancy (CP) group prenatal care was implemented.

METHODS

We performed a retrospective cohort study (n = 2318) and survey on women's experiences (n = 222) in eight primary care midwifery practices to investigate outcome differences between CP and traditional individual prenatal care. Data from the period 2011-2013 were analyzed.

RESULTS

Primiparous and multiparous CP women attended more prenatal care visits compared with women who received individual care (adjusted odds ratio [aOR] 1.23 [95% confidence interval [CI] 1.18-1.29] and 1.29 [1.21-1.36]). Fewer primiparous CP women used pain relief during labor (0.56 [0.43-0.73]), and they initiated breastfeeding more often (1.74 [1.15-2.62]). Women participating in CP were more likely to feel that their wishes with respect to medication use (69.1% vs 54.4%, P = 0.039), physical activities (72.8% vs 52.5%, P = 0.008), and relaxation exercises (67.9% vs 35.6%, P ≤ 0.001) were listened to by care providers. They also felt more supported to actively participate in their care (89.6% vs 68.5%, P = 0.001) and felt more able to voice opinions about care (92.7% vs 73.9%, P = 0.002).

CONCLUSIONS

The CP model is a good approach aligning with Dutch policy calling for women-centered care and responding to the needs of pregnant women. This study supports CP scale-up in The Netherlands and adds to the pool of international knowledge about CP implementation.

The influence of individual provider characteristics and attitudes on caesarean section decision-making: a global review

Caesarean section (CS) rates have risen worldwide in the past two decades, particularly in middle and high-income countries. In addition to changing maternal and health system factors, there is growing evidence that provider factors may contribute to rising unnecessary caesareans. The aim of this review was to assess the evidence for the association between individual provider characteristics, attitudes towards CS and decision-making for CS. A search was conducted in May 2018 in PubMed and Web of Science with 23 papers included in our final review. Our results show that higher anxiety scores and more favourable opinions of CS were associated with increased likelihood of performing CS. These findings highlight a need for appropriate interventions to target provider attitudes towards CS to reduce unnecessary procedures.

Regional variations in childbirth interventions in the Netherlands: a nationwide explorative study

BACKGROUND

Although interventions in childbirth are important in order to prevent neonatal and maternal morbidity and mortality, non-indicated use may cause avoidable harm. Regional variations in intervention rates, which cannot be explained by maternal characteristics, may indicate over- and underuse. The aim of this study is to explore regional variations in childbirth interventions in the Netherlands and their associations with interventions and adverse outcomes, controlled for maternal characteristics.

METHODS

Childbirth intervention rates were compared between twelve Dutch regions, using data from the national perinatal birth register for 2010-2013. All single childbirths from 37 weeks' gestation onwards were included. Primary outcomes were induction and augmentation of labour, pain medication, instrumental birth, caesarean section (prelabour, intrapartum) and paediatric involvement. Secondary outcomes were adverse neonatal and maternal outcomes. Multivariable logistic regression analyses were used to adjust for maternal characteristics. Associations were expressed in Spearman's rank correlation coefficients.

RESULTS

Most variation was found for type of pain medication and paediatric involvement. Epidural analgesia rates varied from between 12 and 38% (nulliparous) and from between 5 and 14% (multiparous women). These rates were negatively correlated with rates of other pharmacological pain relief, which varied from between 15 and 43% (nulliparous) and from between 10 and 27% (multiparous). Rates of paediatric involvement varied from between 37 and 60% (nulliparous) and from between 26 and 43% (multiparous). For instrumental vaginal births, rates varied from between 16 and 19% (nulliparous) and from between 3 and 4% (multiparous). For intrapartum caesarean section, the variation was 13-15% and 5-6%, respectively. A positive correlation was found between intervention rates in midwife-led and obstetrician-led care at the onset of labour within the same region. Adverse neonatal and maternal outcomes were not lower in regions with higher intervention rates. Higher augmentation of labour rates correlated with higher rates of severe postpartum haemorrhage.

CONCLUSIONS

Most variation was found for type of pain medication and paediatric involvement, and least for instrumental vaginal births and intrapartum caesarean sections. Care providers and policy makers should critically audit remarkable variations, since these may be unwarranted. Limited variation for some interventions may indicate consensus for their use. Further research should focus on variations in evidence-based interventions and indications for the use of interventions in childbirth.

Creating an Optimality Index - Netherlands: a validation study

BACKGROUND

At present, the maternity care system in the Netherlands is being reorganized into an integrated model of care, shifting the focus of midwives to include increasing numbers of births in hospital settings and clients with medium risk profiles. In light of these changes, it is useful for midwives to have a tool which may help them in reflecting upon care practices that promote physiological childbirth practices. The Optimality Index-US is an evidence based tool, designed to measure optimal perinatal care processes and outcomes. It has been validated for use in the United States (OI-US), United Kingdom (OI-UK) and Turkey (OI-TR). The objective of this study was to adapt the OI-US for the Dutch maternity care setting (OI-NL).

METHODS

Translation and back translation were applied to create the OI-NL. A panel of maternity care experts (n = 10) provided input for face validation items in the OI-NL. Assessment of inter-rater reliability and ease of use was also conducted. Following this, the OI-NL was used prospectively to collect data on 266 women who commenced intrapartum care under the responsibility of a midwife. Twice groups were compared, based on parity and on care-setting at birth. Mean scores between these groups, corrected for perinatal background factors were assessed for discriminant validity.

RESULTS

Face validity was established for OI-NL on the basis of expert input. Discriminant validity was confirmed by conducting multiple regressions analyses for parity (β = 6.21, P = 0.00) and for care-setting (β = 12.1, p = 0.00). Inter-rater reliability was 98%, with one item (Apgar score) sensitive to scoring differences.

CONCLUSION

OI-NL is a valid and reliable tool for use in the Dutch maternity care setting. In addition to its value for assessing evidence-based maternity care processes and outcomes, there is potential for use for learning and reflection. Against the backdrop of a changing maternity care system, and due to the specificity of its items OI-NL may be of value as a tool for detecting subtle changes indicative of escalating medicalization of childbirth in the Netherlands.

Less or more? Maternal requests that go against medical advice

PROBLEM AND BACKGROUND

This study explores the experiences of Dutch midwives and gynaecologists with pregnant women who request more, less or no care during pregnancy and/or childbirth.

METHODS

All Dutch midwives and (trainee) gynaecologists were invited to fill out a questionnaire specifically designed for the purposes of this study. Holistic midwives were analysed separately from regular community midwives.

FINDINGS

Most maternity care providers in the Netherlands receive requests for less care than recommended at least once a year. The most frequently maternal requests were declining testing for gestational diabetes (66.3%), opting for a home birth in case of a high risk pregnancy (65.3%), and declining foetal monitoring during labour (39.6%). Holistic midwives are more convinced of an increasing demand for less care than community midwives (73.1% vs. 35.2%, p=<0.001). More community midwives than hospital staff reported to have declined one or more request for less care than recommended (48.6% vs. 27.9%, p=<0.001). The majority of hospital staff also receive at least one request for an elective caesarean section every year.

DISCUSSION AND CONCLUSION

Requests for more and less care than indicated during pregnancy and childbirth are equally prevalent in this study. However, a request for less care is more likely to be declined than a request for more care. Counselling women who disagree with their care provider demands time. In case of requests for less care, second best care should be considered.

Women's motivations for choosing a high risk birth setting against medical advice in the Netherlands: a qualitative analysis

BACKGROUND

Home births in high risk pregnancies and unassisted childbirth seem to be increasing in the Netherlands. Until now there were no qualitative data on women's motivations for these choices in the Dutch maternity care system where integrated midwifery care and home birth are regular options in low risk pregnancies. We aimed to examine women's motivations for birthing outside the system in order to provide medical professionals with insight and recommendations regarding their interactions with women who have birth wishes that go against medical advice.

METHODS

An exploratory qualitative research design with a constructivist approach and a grounded theory method were used. In-depth interviews were performed with 28 women on their motivations for going against medical advice in choosing a high risk childbirth setting. Open, axial and selective coding of the interview data was done in order to generate themes. A focus group was held for a member check of the findings.

RESULTS

Four main themes were found: 1) Discrepancy in the definition of superior knowledge, 2) Need for autonomy and trust in the birth process, 3) Conflict during negotiation of the birth plan, and 4) Search for different care. One overarching theme emerged that covered all other themes: Fear. This theme refers both to the participants' fear (of interventions and negative consequences of their choices) and to the providers' fear (of a bad outcome). Where for some women it was a positive choice, for the majority of women in this study the choice for a home birth in a high risk pregnancy or an unassisted childbirth was a negative one. Negative choices were due to previous or current negative experiences with maternity care and/or conflict surrounding the birth plan.

CONCLUSIONS

The main goal of working with women whose birthing choices do not align with medical advice should not be to coerce them into the framework of protocols and guidelines but to prevent negative choices. Recommendations for maternity caregivers can be summarized as: 1) Rethink risk discourse, 2) Respect a woman's trust in the birth process and her autonomous choice, 3) Have a flexible approach to negotiating the birth plan using the model of shared decision making, 4) Be aware of alternative delivery care providers and other sources of information used by women, and 5) Provide maternity care without spreading or using fear.

Differences in optimality index between planned place of birth in a birth centre and alternative planned places of birth, a nationwide prospective cohort study in The Netherlands: results of the Dutch Birth Centre Study

OBJECTIVES

To compare the Optimality Index of planned birth in a birth centre with planned birth in a hospital and planned home birth for low-risk term pregnant women who start labour under the responsibility of a community midwife.

DESIGN

Prospective cohort study.

SETTING

Low-risk pregnant women under care of a community midwife and living in a region with one of the 21 participating Dutch birth centres or in a region with the possibility for midwife-led hospital birth. Home birth was commonly available in all regions included in the study.

PARTICIPANTS

3455 low-risk term pregnant women (1686 nulliparous and 1769 multiparous) who gave birth between 1 July 2013 and 31 December 2013: 1668 planned birth centre births, 701 planned midwife-led hospital births and 1086 planned home births.

MAIN OUTCOME MEASUREMENTS

The Optimality IndexNL-2015, a tool to measure 'maximum outcome with minimal intervention', was assessed by planned place of birth being a birth centre, a hospital setting or at home. Also, a composite maternal and perinatal adverse outcome score was calculated for the different planned places of birth.

RESULTS

There were no differences in Optimality Index NL-2015 for pregnant women who planned to give birth in a birth centre compared with women who planned to give birth in a hospital. Although effect sizes were small, women who planned to give birth at home had a higher Optimality Index NL-2015 than women who planned to give birth in a birth centre. The differences were larger for multiparous than for nulliparous women.

CONCLUSION

The Optimality Index NL-2015 for women with planned birth centre births was comparable with planned midwife-led hospital births. Women with planned home births had a higher Optimality Index NL-2015, that is, a higher sum score of evidence-based items with an optimal value than women with planned birth centre births.

Factors influencing the clinical decision-making of midwives: a qualitative study

Background

Although midwives make clinical decisions that have an impact on the health and well-being of mothers and babies, little is known about how they make those decisions. Wide variation in intrapartum decisions to refer women to obstetrician-led care suggests that midwives’ decisions are based on more than the evidence based medicine (EBM) model – i.e. clinical evidence, midwife’s expertise, and woman’s values - alone. With this study we aimed to explore the factors that influence clinical decision-making of midwives who work independently.

Methods

We used a qualitative approach, conducting in-depth interviews with a purposive sample of 11 Dutch primary care midwives. Data collection took place between May and September 2015. The interviews were semi-structured, using written vignettes to solicit midwives’ clinical decision-making processes (Think Aloud method). We performed thematic analysis on the transcripts.

Results

We identified five themes that influenced clinical decision-making: the pregnant woman as a whole person, sources of knowledge, the midwife as a whole person, the collaboration between maternity care professionals, and the organisation of care. Regarding the midwife, her decisions were shaped not only by her experience, intuition, and personal circumstances, but also by her attitudes about physiology, woman-centredness, shared decision-making, and collaboration with other professionals. The nature of the local collaboration between maternity care professionals and locally-developed protocols dominated midwives’ clinical decision-making. When midwives and obstetricians had different philosophies of care and different practice styles, their collaborative efforts were challenged.

Conclusion

Midwives’ clinical decision-making is a more varied and complex process than the EBM framework suggests. If midwives are to succeed in their role as promoters and protectors of physiological pregnancy and birth, they need to understand how clinical decisions in a multidisciplinary context are actually made.

Effect of planned place of birth on obstetric interventions and maternal outcomes among low-risk women: a cohort study in the Netherlands

BACKGROUND

The use of interventions in childbirth has increased the past decades. There is concern that some women might receive more interventions than they really need. For low-risk women, midwife-led birth settings may be of importance as a counterbalance towards the increasing rate of interventions. The effect of planned place of birth on interventions in the Netherlands is not yet clear. This study aims to give insight into differences in obstetric interventions and maternal outcomes for planned home versus planned hospital birth among women in midwife-led care.

METHODS

Women from twenty practices across the Netherlands were included in 2009 and 2010. Of these, 3495 were low-risk and in midwife-led care at the onset of labour. Information about planned place of birth and outcomes, including instrumental birth (caesarean section, vacuum or forceps birth), labour augmentation, episiotomy, oxytocin in third stage, postpartum haemorrhage >1000 ml and perineal damage, came from the national midwife-led care perinatal database, and a postpartum questionnaire.

RESULTS

Women who planned home birth more often had spontaneous birth (nulliparous women aOR 1.38, 95 % CI 1.08-1.76, parous women aOR 2.29, 95 % CI 1.21-4.36) and less often episiotomy (nulliparous women aOR 0.73, 0.58-0.91, parous women aOR 0.47, 0.33-0.68) and use of oxytocin in the third stage (nulliparous women aOR 0.58, 0.42-0.80, parous women aOR 0.47, 0.37-0.60) compared to women who planned hospital birth. Nulliparous women more often had anal sphincter damage (aOR 1.75, 1.01-3.03), but the difference was not statistically significant if women who had caesarean sections were excluded. Parous women less often had labour augmentation (aOR 0.55, 0.36-0.82) and more often an intact perineum (aOR 1.65, 1.34-2.03). There were no differences in rates of vacuum/forceps birth, unplanned caesarean section and postpartum haemorrhage >1000 ml.

CONCLUSIONS

Women who planned home birth were more likely to give birth spontaneously and had fewer medical interventions.