Change in primary midwife-led care in the Netherlands in 2000­2008: A descriptive study of caesarean sections and other interventions among 807,437 low-risk births.

OBJECTIVE: to study whether an increase in intrapartum referrals in primary midwife-led care births in the Netherlands is accompanied by an increase in caesarean sections. DESIGN: nationwide descriptive study. SETTING: The Netherlands Perinatal Registry. PARTICIPANTS: 807,437 births of nine year cohorts of women with low risk pregnancies in primary midwife-led care at the onset of labour between 2000 and 2008. MEASUREMENTS: primary outcome is the caesarean section rate. Vaginal instrumental childbirth, augmentation with oxytocin, and pharmacological pain relief are secondary outcomes. Trends in outcomes are described. We used logistic regression to explore whether changes in the planned place of birth and other maternal characteristics were associated with the caesarean section rate. FINDINGS: the caesarean section rate increased from 6.2 to 8.3 per cent for nulliparous and from 0.8 to 1.1 per cent for multiparous women. After controlling for maternal characteristics the year by year increase in the caesarean section rate was still significant for nulliparous women (adj OR 1.03; 95% CI 1.02­1.03). The vaginal instrumental birth declined from 18.2 to 17.4 per cent for nulliparous women (multiparous women: 1.7­1.5 per cent). Augmentation of labour and/or pharmacological pain relief increased from 23.1 to 38.1 per cent for nulliparous women and from 5.4 to 9.6 per cent for multiparous women. CONCLUSION: the rise in augmentation of labour, pharmacological pain relief and electronic fetal monitoring in the period 2000­2008 among women in primary midwife-led care was accompanied by an increase in caesarean section rate for nulliparous women. The vaginal instrumental deliveries declined for both nulliparous and multiparous women. IMPLICATIONS FOR PRACTICE: primary care midwives should evaluate whether they can strengthen the opportunities for nulliparous women to achieve a physiological birth, without augmentation or pharmacological pain relief. If such interventions are considered necessary to achieve a spontaneous vaginal birth, the current disadvantage of discontinuity of care should be reduced. In a more integrated care system, women could receive continuous care and support from their own primary care midwife, as long as only supportive interventions are needed.

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.

Persisting rise in referrals during labor in primary midwife-led care in the Netherlands.

BACKGROUND: There are concerns about the Dutch maternity care system, characterized by a strict role division between primary and secondary care. The objective of this study was to describe trends in referrals and in perinatal outcomes among labors that started in primary midwife-led care. METHODS: We performed a descriptive study of all 789,795 labors that started in primary midwife-led care during 2000 to 2008 in The Netherlands. Referrals to obstetrician-led care or pediatrician were classified as urgent or nonurgent. Perinatal safety was described by perinatal mortality (intrapartum or neonatal 0-7 days), admission to neonatal intensive care unit 0-7 days, and Apgar score < 7 at 5 minutes. RESULTS: The proportion of referrals during labor or after birth declined from 52.6 to 42.6 percent for nulliparous women and from 83.2 to 76.7 percent for multiparous women. Especially nonurgent referrals during the first stage increased, for nulliparous women from 28.7 to 40.7 percent and for multiparous women from 10.5 to 16.5 percent. Referrals were less frequent in planned home births. Perinatal mortality was 0.9 per thousand births for nulliparous women, and 0.6 per thousand for multiparous women. A low Apgar score was registered in 8.6 per thousand births for nulliparous women, and 4.1 per thousand for multiparous women. CONCLUSIONS: There was a considerable rise in nonurgent referrals to obstetrician-led care in primary midwife-led care during labor. Perinatal safety did not improve significantly over time. The persisting rise in referrals challenges the sustainability of the current strict role division between primary and secondary maternity care in The Netherlands.

Are there inequalities in choice of birthing position? Sociodemographic and labour factors associated with the supine position during the second stage of labour.

OBJECTIVE: to establish which factors are associated with birthing positions throughout the second stage of labour and at the time of birth. DESIGN: retrospective cohort study. SETTING: primary care midwifery practices in the Netherlands. PARTICIPANTS: 665 low-risk women who received midwife-led care. MEASUREMENTS AND FINDINGS: a postal questionnaire was sent to women 3-4 years after birth. The number of women who remained in the supine position throughout the second stage varied between midwifery practices, ranging from 31.3% to 95.9% (p<0.001). The majority of women pushed and gave birth in the supine position. For positions used throughout the second stage of labour, a stepwise forward logistic regression analysis was used to examine effects controlled for other factors. Women aged 36 years and highly educated women were less likely to use the supine pushing position alone [odds ratio (OR) 0.54, 95% confidence intervals (CI) 0.31-0.94; OR 0.40, 95% CI 0.21-0.73, respectively]. Women who pushed for longer than 60 minutes and who were referred during the second stage of labour were also less likely to use the supine position alone (OR 0.32, 95% CI 0.16-0.64; OR 0.44, 95% CI 0.23-0.86, respectively). Bivariate analyses were conducted for effects on position at the time of birth. Age 36 years, higher education and homebirth were associated with giving birth in a non-supine position. KEY CONCLUSIONS: the finding that highly educated and older women were more likely to use non-supine birthing positions suggests inequalities in position choice. Although the Dutch maternity care system empowers women to choose their own place of birth, many may not be encouraged to make choices in birthing positions. IMPLICATIONS FOR PRACTICE: education of women, midwives, obstetricians and perhaps the public in general is necessary to make alternatives to the supine position a logical option for all women. Future studies need to establish midwife, clinical and other factors that have an effect on women's choice of birthing positions, and identify strategies that empower women to make their own choices.

Women's positions during the second stage of labour: views of primary care midwives.

AIM: This paper is a report of a study to explore the views of midwives on women's positions during the second stage of labour. BACKGROUND: Many authors recommend encouraging women to use positions that are most comfortable to them. Others advocate encouragement of non-supine positions, because offering 'choice' is not enough to reverse the strong cultural norm of giving birth in the supine position. Midwives' views on women's positions have rarely been explored. METHOD: Six focus groups were conducted in 2006-2007 with a purposive sample of 31 midwives. The data were interpreted using Thachuk's models of informed consent and informed choice. FINDINGS: The models were useful in distinguishing between two different approaches of midwives to women's positions during labour. When giving informed consent, midwives implicitly or explicitly ask a woman's consent for what they themselves prefer. When offering informed choice, a woman's preference is the starting point, but midwives will suggest other options if this is in the woman's interest. Obstetric factors and working conditions are reasons to deviate from women's preferences. CONCLUSIONS: To give women an informed choice about birthing positions, midwives need to give them information during pregnancy and discuss their position preferences. Women should be prepared for the unpredictability of their feelings in labour and for obstetric factors that may interfere with their choice of position. Equipment for non-supine births should be more midwife-friendly. In addition, midwives and students need to be able to gain experience in assisting births in non-supine positions.