Dutch Midwives Research Articles

Perspective of obstetric care-providers on being involved in cervical cancer screening during antenatal care in the Netherlands.

The aim of this study was to determine attitude of Dutch midwifes, gynecologists and general practitioners (GPs) towards involvement in antenatal cervical cancer screening (CCS) in the Netherlands. In 2021, Dutch midwives, gynecologists, and GPs were offered a single digital questionnaire assessing perceived feasibility, benefits, and harms of antenatal CCS. A total of 6943 Questionnaires were send and response rate was 18% (N = 1260). Of all respondents, 78% considered antenatal CCS via obstetric care providers feasible. Most respondents (85%) agreed that offering CCS in person can increase motivation to attend. Most midwives (93%) considered that women would feel less encumbered if cervical sampling would be performed by obstetric care providers, rather than by GPs. Results indicate that introduction of antenatal CCS is considered feasible by a majority of Dutch midwifes, gynecologists, and GPs. Considered benefits include improved motivation to attend and reduced test related barriers.

Midwives' work-related fear and anxiety and its impact on their wellbeing and performance. A qualitative study of perceived anxiety in community midwives.

Working with acute situations is usually part of midwifery practice. In the Netherlands the community midwives work in a context where they are mostly the sole decision-makers and policymakers and often do not have the support of a multidisciplinary team during a birth. How Dutch community midwives maintain their emotional hygiene is not known. This study aims to explore how Dutch midwives perceive fear and its influence on their performance. This is a qualitative study with semi-structured interviews of 19 Dutch community midwives between October 2018 and January 2019. Four themes were identified: 1) midwives' perceptions of fear and anxiety, 2) how years of experience affect fear and anxiety, 3) influence of the work content; and 4) implications for performance. Midwives perceived fear in acute situations where maternal and/or fetal complications were imminent. Participants perceived anxiety either as helpful or a hindrance. Awareness of these feelings helps them to regulate whether or not to give in to these feelings. Our findings suggest similar perspectives on fear in Dutch community midwives compared to previous outcomes. In the Netherlands, midwives seem reluctant to talk about fear and anxiety in the profession. The awareness of these emotions occurring while working is essential for the wellbeing of midwives, as well as the importance of knowing how to act on fear and anxiety.

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

ObjectiveInternationally, 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. DesignA 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 participantsWe 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 FindingsData 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 conclusionsA 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 practiceThe 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.

Negotiating Awareness: Dutch Midwives' Experiences of Noninvasive Prenatal Screening Counseling.

Discussion of the topic of noninvasive prenatal screening (NIPS) has become a standard part of Dutch maternity care practice. This means that pregnant women who are contemplating NIPS can receive counseling from their midwife or obstetrician. The aim of this study is to understand the communicative practices and decision-making principles regarding first-tier use of NIPS, as experienced by Dutch midwives. Qualitative analysis of in-depth interviews with Dutch midwives (n = 10) exploring their conversations about NIPS counseling and decision making. Midwives value the autonomy of women in decisions on NIPS. They consider it a midwifery task to assess women's awareness of the risks and implications of using or not using this mode of screening. The optimal level of awareness may differ between women and midwives, creating novel challenges for informed decision making in midwifery communication. Negotiating awareness about NIPS in individual women is a relatively new and complex midwifery task in need of counseling time and skill. NIPS practices call for a reflection on midwifery values in the context of integrated maternity care.

Experiences of Dutch Midwives Regarding the Quality of Care during the COVID-19 Pandemic.

This study assessed how the quality of care during the COVID-19 pandemic has been experienced by Dutch midwives. At the beginning of May 2020, 15 Dutch midwives were interviewed during the first wave of the pandemic. The interviews included questions based on the value-based healthcare framework by Porter. The interviews were transcribed verbatim, coded, and analyzed according to recurrent themes using the directed content analysis approach. Key themes identified included high quality midwifery care, information provision, costs, under/over treatment, interprofessional collaboration, and shared decision making. The quality of midwifery care during the COVID-19 pandemic was experienced to be sufficient, given the challenging circumstances. The midwives experienced the lack of face-to-face check-ups to be problematic. Unclear information and lack of personal protective equipment caused stress and confusion, and they worked an additional 2–4 h per working day. Some pregnant women were hesitant to call or visit them when they thought something was wrong. The midwives perceived some advantages in using video or telephone calls. Considerations for future pandemics include an additional face-to-face check-up between 16 and 27 weeks of pregnancy and one postpartum visit. For post-pandemic care, providing a check-up through telephone or video call could be offered in certain cases.

How to Make the Hospital an Option Again: Midwives' and Obstetricians' Experiences with a Designated Clinic for Women Who Request Different Care than Recommended in the Guidelines.

Background: An increasing number of maternity care providers encounter pregnant women who request less care than recommended. A designated outpatient clinic for women who request less care than recommended was set up in Nijmegen, the Netherlands. The clinic’s aim is to ensure that women make well-informed choices and arrive at a care plan that is acceptable to all parties. The aim of this study is to make the clinic’s approach explicit by examining care providers’ experiences who work with or within the clinic. Methods: qualitative analysis of in-depth interviews with Dutch midwives (n = 6) and obstetricians (n = 4) on their experiences with the outpatient clinic “Maternity Care Outside the Guidelines” in Nijmegen, the Netherlands. Results: Four main themes were identified: (1) ”Trusting mothers, childbirth and colleagues”; (2) “A supportive communication style”; (3) “Continuity of carer”; (4) “Willingness to reconsider responsibility and risk”. One overarching theme emerged from the data, which was “Guaranteeing women’s autonomy”. Mutual trust is a prerequisite for a constructive dialogue about birth plans and can be built and maintained more easily when there is continuity of carer during pregnancy and birth. Discussing birth plans at the clinic was believed to be successful because the care providers listen to women, take them seriously, show empathy and respect their right to refuse care. A change in vision on responsibility and risk is needed to overcome barriers such as providers’ fear of adverse outcomes. Taking a more flexible approach towards care outside the guidelines demands courage but is necessary to guarantee women’s autonomy. Key conclusions and implications for practice: In order to fulfil women’s needs and to prevent negative choices, care providers should care for women with trust, respect for autonomy, and provide freedom of choice and continuity. Care providers should reflect on and discuss why they are reluctant to support women’s wishes that go against their personal values. The structured approach used at this clinic could be helpful to maternity care providers in other contexts, to make them feel less vulnerable when working outside the guidelines.

What is needed to facilitate healthy dietary behaviours in pregnant women: A qualitative study of Dutch midwives’ perceptions of current versus preferred nutrition communication practices in antenatal care

ObjectiveThe aim of this paper was to explore midwives’ perceptions of current and preferred nutrition communication practices in antenatal care, and to identify what is needed to achieve their preferred practices. DesignA qualitative descriptive design was used. Semi-structured interviews were conducted with twenty Dutch midwives working in primary care or secondary care settings across the Netherlands. To create a positive atmosphere, interviews were based on the principles of Appreciative Inquiry. FindingsOpportunities identified in current practices included midwives’ sense of responsibility, their skills and experience, availability of resources, and group consultations. Barriers were the precarity and lack of prioritization of the topic, and the current focus on food safety (risks). Ideally, midwives envisioned nutrition communication as a continuous trajectory, in which not only reliable and consistent information is provided, but also more personalized and positive communication, to empower pregnant women. Key conclusionsMidwives favour nutrition communication practices characterized by continuity of care and woman-centeredness. Opportunities to realize such practices in antenatal care are the use of innovative tools to support nutrition communication, more sustainable collaborations with dietitians, and better nutrition education for midwives. Implications for practiceMidwives could act as facilitators and gatekeepers in nutrition communication, requiring limited time and expertise from midwives, and empowering pregnant women.

Experiences of Dutch maternity care professionals during the first wave of COVID-19 in a community based maternity care system.

During the COVID-19 pandemic the organization of maternity care changed drastically; this study into the experiences of maternity care professionals with these changes provides suggestions for the organization of care during and after pandemics. An online survey among Dutch midwives, obstetricians and obstetric residents. Multinomial logistic regression analyses were used to investigate associations between the respondents' characteristics and answers. Reported advantages of the changes were fewer prenatal and postpartum consultations (50.1%). The necessity and safety of medical interventions and ultrasounds were considered more critically (75.9%); 14.8% of community midwives stated they referred fewer women to the hospital for decreased fetal movements, whereas 64.2% of the respondents working in hospital-based care experienced fewer consultations for this indication. Respondents felt that women had more confidence in giving birth at home (57.5%). Homebirths seemed to have increased according to 38.5% of the community midwives and 65.3% of the respondents working in hospital-based care. Respondents appreciated the shift to more digital consultations rather than face-to-face consultations. Mentioned disadvantages were that women had appointments alone, (71.1%) and that the community midwife was not allowed to join a woman to obstetric-led care during labour and subsequently stay with her (56.8%). Fewer postpartum visits by family and friends led to more tranquility (59.8%). Overall, however, 48.0% of the respondents felt that the safety of maternity care was compromised due to policy changes. Maternity care professionals were positive about the decrease in routine care and the increased confidence of women in home birth, but also felt that safety in maternity care was sometimes compromised. According to the respondents in a future crisis situation it should be possible for community midwives to continue to deliver a personal handover after the referral of women to the hospital, and to stay with them.

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

BackgroundResearch 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.MethodsIn 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.ResultsMidwifery 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.ConclusionsThe 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.

Optimizing Low-Socioeconomic Status Pregnant Women's Dietary Intake in the Netherlands: Protocol for a Mixed-Methods Study.

BackgroundAlthough the importance of maternal nutrition is evident, adherence to dietary guidelines is limited in pregnant women, especially in those with a low socioeconomic status. Promotion of a healthy diet in midwifery practice is promising. As prenatal diet affects both maternal and child health, pregnant women are open to dietary changes during this critical transition, and midwives are their first and most important source of information. Unfortunately, nutrition communication by Dutch midwives is limited.ObjectiveThe objective of this study is to optimize the dietary intake of low–socioeconomic status pregnant women by contributing to the further development and adjustment of a tool or toolbox to support midwives in providing nutrition communication.MethodsThis interdisciplinary, mixed methods study includes 2 phases, in which quantitative and qualitative research are complementary. In phase 1, we will conduct a literature study and interviews to gain insight into midwives’ knowledge, needs, and practice. We will obtain data on the dietary intake of low–socioeconomic status pregnant women and factors influencing this intake from another literature study, an interviewer-administered meal-based food frequency questionnaire, and qualitative interviews with pregnant women. We will identify the availability of suitable tools to improve pregnant women’s dietary intake from the literature, interviews, focus groups, and expert meetings. In phase 2, we shall adapt an existing tool or develop a new tool(box), depending on the results of phase 1, and implement it in 5 midwifery practices. Ultimately, a process evaluation will provide insight into barriers and facilitating factors playing a role in the implementation of the tool(box).ResultsThe main outcome of this study will be a tool(box) to optimize the dietary intake of Dutch pregnant women. We anticipate that the developed or adjusted tool(s) will be available in February 2020. After we implement the tool(s) and evaluate the implementation process, the final results should be available by February 2021.ConclusionsThis study is scientifically and socially relevant, as we will study low–socioeconomic status pregnant women’s contextual dietary intake in-depth from an ecological perspective on health. The results obtained will lead to recommendations for multidisciplinary strategies to promote a healthy maternal dietary intake in low–socioeconomic status populations.International Registered Report Identifier (IRRID)DERR1-10.2196/14796

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. AimThis study aimed to explore newly qualified Dutch midwives' perceptions of their job demands and resources during their initiation to hospital-based practice. DesignWe conducted a qualitative study with semi structured interviews using the Job Demands-Resources model as theoretical framework. MethodsTwenty-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. FindingsHigh 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. ConclusionInitiation 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.

Addressing a need. Holistic midwifery in the Netherlands: A qualitative analysis.

The Netherlands has a maternity care system with integrated midwifery care, including the option of home birth for low risk women. A small group of Dutch (holistic) midwives is willing to assist women in high risk pregnancies during a home birth against medical advice. We examined holistic midwives’ motivations and way of practice, in order to provide other maternity care professionals with insight into the way they work and to improve professional relationships between all care providers in the field. An exploratory qualitative research design with a constructivist approach and a grounded theory method were used. We performed in-depth interviews with twenty-four holistic midwives on their motivations for working outside their professional boundaries. Open, axial and selective coding of the interview data was done in order to generate themes. We held a focus group for a member check of the findings. Four main themes were found: 1) The regular system is failing women, 2) The relationship as basis for empowerment, 3) Delivering client centered care in the current system is demanding, and 4) Future directions. One core theme emerged that covered all other themes: Addressing a need. Holistic midwives explained that many of their clients had no other choice than to choose a home birth in a high risk pregnancy because they felt let down by the regular system of maternity care. Holistic midwives appear to deliver an important service. They provide continuity of care and succeed in establishing a relationship with their clients built on trust and mutual respect, truly putting their clients’ needs first. Some women feel let down by the regular system, and holistic midwives may be the last resort before those women choose to deliver unattended by any medical professional. Maternity care providers should consider working with holistic midwives in the interest of good patient care.

Proactive behaviour in midwifery practice: A qualitative overview based on midwives’ perspectives

BackgroundMidwifery practice is in the process of continuing developments and contemporary working conditions asking for proactive behaviour, which could increase work-efficiency, job satisfaction, commitment and coping attitudes towards stress resistance. This study aims to provide an in depth exploration of midwives’ perceptions of facilitators and/or barriers of proactive behaviour in midwifery practice. MethodsA qualitative descriptive study, using individual semi-structured interviews, was undertaken within a sample of 102 Flemish and Dutch midwives who were interviewed from September to December 2017 using a four-item topic-list. ResultsSix influencing factors emerged from the data consisted of the causal, contextual and conditional factors faced by the midwives in order to show proactive behaviour in midwifery practice. Midwives elaborated the need for team consultations, a safe organizational culture, an appreciative midwifery leader and an attitude of lifelong learning. Furthermore, midwives are looking for a way to deal with both challenges in healthcare and the competitive societal system. ConclusionThis inductive study confirmed, supported and expanded previous deductive research and provided additional insights of proactive behaviour in midwifery. Providing midwives with knowledge of the influencing factors, required to successfully effecting proactive behaviour in midwifery, this study has subsequently merit for future research in the transfer of recommendation in daily midwifery practice, education and policymaking.

Traumatic Experiences and the Midwifery Profession: A Cross-Sectional Study Among Dutch Midwives.

IntroductionTraumatic events that occur in a clinical setting can have long‐lasting adverse effects on persons who are affected, including health care providers. This study investigated the prevalence of work‐related traumatic events, posttraumatic stress disorder (PTSD), anxiety, and depression among Dutch midwives. Additionally, differences between midwives working in primary care (independently assisting births at home and in birthing centers) and midwives working in secondary or tertiary care (hospital setting) were examined. Finally, this study investigated the support midwives would like to receive after experiencing a work‐related adverse event.MethodsA descriptive, cross‐sectional online survey of Dutch midwives was conducted. The respondents completed a questionnaire about demographic and work‐related events, as well as the Trauma Screening Questionnaire and the Hospital Anxiety and Depression Scale.ResultsThe estimated response rate was 23%, with 691 questionnaires eligible for analysis. Thirteen percent of respondents reported having experienced at least one work‐related traumatic event. Among these, 17% screened positive for PTSD, revealing an estimated PTSD prevalence of 2% among Dutch midwives. Clinically relevant anxiety symptoms were reported by 14% of the respondents, significantly more often among midwives working in primary care (P = .014). Depressive symptoms were reported by 7% of the respondents. The desired strategies to cope with an adverse event were peer support by direct colleagues (79%), professional support from a coach or psychologist (30%), multidisciplinary peer support (28%), and support from midwives who are not direct coworkers (17%).DiscussionDutch midwives are at risk of experiencing work‐related stressful or traumatic events that might lead to PTSD, anxiety, or depression. Midwives working in primary care reported higher levels of anxiety compared with their colleagues working in a clinical setting (secondary or tertiary care). Most midwives preferred peer support with direct colleagues after an adverse event, and some could have profited from easier access to seeking professional help. It could be speculated that midwives would benefit from increased awareness about work‐related traumatic events as well as implementation of standardized guidelines regarding support after a traumatic event.

Quit-smoking counselling in Dutch midwifery practices: Barriers to the implementation of national guidelines

ObjectiveAlthough smoking during pregnancy can have severe health consequences for the (unborn) child, 9% of Dutch pregnant women smoke at any time during their pregnancy. Midwives in the Netherlands are a responsible party in the provision of quit-smoking counselling for pregnant women by means of the 7-step `V-MIS' intervention, but in practice the implementation appears to be suboptimal. The purpose of the present study was to assess the provision of quit-smoking counselling by midwives, and to clarify the nature and extent of any existing barriers and needs in the provision of quit-smoking counselling in Dutch midwifery settings. MethodsAn online questionnaire to the target population of Dutch midwives (N ≈ 3150) was set out in the spring of 2016. The questionnaire included items on the provision of quit-smoking counselling for pregnant women, and on possible barriers and needs regarding the provision of this counselling. Descriptive statistics were used to analyse weighed data from 135 midwives representative for the Dutch setting in terms of age, function, and region. ResultsEighty-one percent of the midwives inquire about smoking profile (V-MIS step 1) but only 10% go through all the V-MIS counselling steps (i.e. up to discussing postnatal passive smoking and smoke free breastfeeding, step 7). Although 74% of the midwives regard it as their task to provide quit-smoking guidance to pregnant women, 77% perceive referral to a professional as a useful strategy (mostly to the GP; 74%). For 61% of the midwives, their clients' lack of motivation undermines the provision of quit-smoking counselling. Other hindering factors are the perceived lack of free brochures (54%), simple tools or gadgets (51%), and financial consequences for the midwife (37%) and/or the client (22%). ConclusionThe smoking cessation intervention strategy currently imposed in Dutch midwifery practices (V-MIS) is being used by midwives, however its implementation may considerably benefit from strengthening skills in motivational interviewing techniques, provision of supporting materials, and structural embedding of GP referral. Based on the study's findings, practical recommendations are made to facilitate the provision of quit-smoking counselling in (international) midwifery settings.

How (not) to create value based integrated maternity care: Lessons from the Netherlands

What encourages (or discourages) health policymakers to create systems of integrated care? The answer to this important question can be found by looking at Dutch maternity care. Health care officials in several countries are struggling to achieve the “triple aim” in maternity care: to maximize health and satisfaction while minimizing costs. These policymakers often look to the Netherlands, with its well-organized system of referral between primary and specialist care, as a successful model of integrated maternity care that delivers on each of the triple aims. In spite of this favorable attention, Dutch policymakers have been pushing to create “integrale verloskunde zorg” – integrated maternity care – replacing the current system with one that gives obstetricians a more prominent role. This development gives us the opportunity to look more closely at the factors that promote and hinder the creation of integrated care systems. In the case of the Netherlands, the push toward (more) integrated maternity care is the result of an uneasy relationship between midwives and obstetricians, unsound science, critical reports in the media, and the differential political power of the professions. Interprofessional competition: For most of the twentieth century, Dutch midwives and obstetricians had a cooperative relationship, defined and regulated by an “indications list” that determined who was responsible for which types of care. In the 1980s, efforts to revise that list created tension between the two professions, with each group seeking to protect and/or extend their jurisdiction. The shift from collaboration to competition moved the conversation away from what must to done to deliver the most effective maternity care, to efforts to promote the value of the services of one profession over the other. Unsound science: Interprofessional competition has led to the production of unsound science. Rather than collaborative research, where obstetricians and midwives work together to identify the most effective ways to deliver care, there has been a spate of research offering “scientific” evidence for the superiority of each profession’s approach: research done by obstetricians typically shows that the current, integrated system is failing, while research done by midwives shows the success and value of the current system. Media attention: In the contest between midwifery and obstetric science, the media in the Netherlands have sided with the obstetricians. Stories of harm to mothers and babies capture the attention of the public and are more interesting than stories of the success of integrated care. Political power: Midwives have less political power and less access to policymakers in the government and the insurance industry. Their efforts to support and improve the current system have been less persuasive with the Ministry of Health and the Zorginstituut Nederland (ZN – the overseer of the health insurance system) than those of the obstetricians, who are succeeding in increasing their role in maternity care. This analysis of the (dis)integration of Dutch maternity care sheds important light on the factors that move health systems toward, and away from, integrated care. If the value of integrated care is to be realized we must understand these factors.

‘Such a waste’ – conflicting communicative roles of Dutch midwifery students in childbirth decision making

ObjectiveIn the Netherlands, the place of birth, birthing position, and pain relief are subject to preference-sensitive decisions of women, after counseling by their midwife. Dutch midwives are responsible for providing information and advice to guide pregnant women in such decisions. In this study we investigate how midwifery students, who are simultaneously committed to midwifery values and influenced by media culture, approach such preference-oriented communication in midwifery care. Design and settingIn-depth interviews and a focus group with seventeen Dutch midwifery students were conducted and analyzed applying a grounded theory approach. FindingsStudent midwives are confronted with women who prefer a medical (“safe”) and pain-free (“comfortable”) birth. Such preferences reveal culturally induced priorities that form a threat to the bond of trust between midwives and women throughout the childbirth continuum. This development is felt personally by midwifery students, as an impact on each individual physiological birth, as well as professionally, as a threat to the midwifery values they acquire in their education. The interviews revealed that students have adopted distinctive communicative strategies to respond to media-driven values in childbearing women: Take Time and Listen; Counsel Neutral Information; and Safeguard from Negative Impact. Key conclusions and implicationsNon-confrontational communication strategies allow midwifery students to build a trusting relationship with women, but the strategies are in part contradictory. Students experience inner tension due to decision outcomes that conflict with their midwifery values. Consequences for midwifery education are discussed.

Influencing factors in midwives’ decision-making during childbirth: A qualitative study in the Netherlands

BackgroundDutch maternity care is based on the principle that pregnancy and childbirth are physiological processes. However, the last decade an increase of intra-partum referrals to obstetric-led care has been observed. Most of these referrals are among nulliparous women, non-urgent and occur during the first stage of labour. The increase in referrals seems not associated with better perinatal outcomes. ObjectiveGain understanding of underlying factors in the decision-making process prior to referral to obstetric-led care among midwives attending childbirth in midwifery-led care. MethodA qualitative study based on in-depth interviews with Dutch midwives (n=10) working in midwifery-led care. We performed a thematic analysis based on the hypothetico-deductive and the intuitive-humanist theory. ResultsMidwives mentioned knowledge as the basis of a reasoned decision. This included both theoretical knowledge, and knowledge from clinical experience. Influences of others, like the needs and wishes of labouring women were another factor influencing the decision-making, especially in non-urgent situations. Under subjective factors, the fear of being held responsible for professional choices emerged. Key conclusionThe decision-making process during childbirth is multi-factorial. The women’s needs and wishes are recognized as of great influence on the decision-making process during childbirth, which is not included as a factor in the hypothetico-deductive or the intuitive-humanist theory. Implication for practiceThe influence of women’s needs and wishes should be part of models about the intra-partum decision-making process. Midwives should find strategies to support women to make well-informed choices that include adequate information on the consequences of medicalisation in obstetric-led care.

Less or more? Maternal requests that go against medical advice

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

Introduction of non-invasive prenatal testing as a first-tier aneuploidy screening test: A survey among Dutch midwives about their role as counsellors

In 2014, non-invasive prenatal testing (NIPT) for trisomies 21, 18 and 13 was added to the Dutch prenatal screening program as part of the TRIDENT study. Most (85%) pregnant Dutch women are counselled for prenatal aneuploidy screening by primary care midwives. This will remain when NIPT is implemented as a first-tier screening test. We therefore investigated midwife counsellors’: 1) Knowledge about NIPT; 2) Attitudes towards NIPT as first-tier screening test; and 3) Experiences with informing clients about NIPT. Between April-June 2015, an online questionnaire to assess knowledge about NIPT, attitudes towards NIPT, and experiences with NIPT was completed by 436 Dutch primary care midwives. We found that 59% midwives answered ≥7 of 8 knowledge questions correctly. Continuing professional education attendance and more positive attitudes towards prenatal screening for Down syndrome were positively associated with the total knowledge score (β = 0.261; p = 0.007 and β = 0.204; p = 0.015, respectively). The majority (67%) were in favor of replacing First trimester Combined Test with NIPT, although 41% preferred to maintain a nuchal translucency measurement alongside NIPT. We conclude that midwives demonstrated solid knowledge about NIPT that may still be improved in some areas. Dutch midwives overwhelmingly support the integration of NIPT as a first-tier screening test.