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

BACKGROUND: 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. METHODS: Qualitative analysis of in-depth interviews with Dutch midwives (n = 10) exploring their conversations about NIPS counseling and decision making. RESULTS: 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. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: 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.

Midwifery students' expectations of and experiences with ethics education: A qualitative study.

BACKGROUND: Instruction in ethics is an essential component of midwifery education. However, the evidence for how midwifery students experience ethics instruction in the classroom and via clinical experience is limited. OBJECTIVE: This study explores midwifery students' perceptions of ethics education and their opinions about essential components of ethics education. DESIGN: This was a qualitative descriptive thematic study, exploring student midwives' experiences of ethics education in their midwifery programs. We conducted focus group interviews with students from three midwifery programs in the United States (U.S.). SETTING: Graduate midwifery educational programs in the United States. PARTICIPANTS: Thirty-nine students from three graduate midwifery programs participated in four focus group discussions. RESULTS: Thematic analysis identified three primary themes and associated subthemes: 1) current experience and identified needs, 2) the preceptor dilemma, with subthemes the critical role of modeling ethics and powerlessness within interprofessional conflicts, and 3) complicated relationships: advocacy, autonomy and choice. Students relied primarily upon clinical preceptors rather than classroom discussion as a significant source of learning ethics content and ethical behavior. Students called for explicit identification of ethics learning when it occurs, particularly midwifery-specific content, as well as increased opportunities for reflection and integration of their experiences. CONCLUSION: This study shows the need for intentional inclusion of midwifery-specific ethics content into the overall midwifery education program content, in both classroom and clinical experiences. Midwifery programs should integrate ethics content in their curricula in a way that complements other midwifery content. This study also demonstrates the key role of clinical preceptors in student ethics learning.

Essential components of midwifery ethics education: results of a Delphi study.

OBJECTIVE: Ethical dilemmas are an inevitable part of a midwife's experience in clinical care. Midwifery educational programs have an obligation to provide students the opportunities to acquire the skills and knowledge to recognize and negotiate ethical dilemmas. Implementation of strategies for imparting ethical competencies and clinical ethics decision-making skills in formal midwifery curricula have been challenging and inconsistent. The purpose of this study was to gather information and opinions from midwifery educators and clinical preceptors about the essential components of ethics education for midwifery students in the United States (U.S.), aiming for consensus on key content, competencies, learning outcomes, and teaching strategies. DESIGN: This is an online Delphi study conducted in three rounds. Round 1 consisted of open-ended questions to explore and identify key content, competencies, learning outcomes, and teaching strategies for midwifery ethics education. In Rounds 2 and 3, experts rated statements on a 1 to 7 Likert scale, with positive consensus defined as 70% or more of the experts scoring ≥6. PARTICIPANTS: The panel included midwifery educators (midwifery program directors, faculty, and clinical preceptors) from the United States. FINDINGS: Of the 12 statements on key content of ethics education, midwives emphasized that content promoting an understanding of shared decision-making is essential for inclusion. Of the statements regarding competencies, learning outcomes, and teaching strategies, 20 of 21 statements met consensus, including those related to shared decision-making and ethical decision-making, as well as attributes such as compassion and courage. Midwives did not agree that an essential teaching strategy includes a validated assessment tool for evaluating students on any component of ethics learning (knowledge, skills, behaviour). KEY CONCLUSIONS: This Delphi study reveals what midwifery educators consider essential components of ethics education for midwifery students, with a particular focus on the professional attributes of shared decision-making. IMPLICATIONS FOR PRACTICE: Initial insights about optimal ways to incorporate the essential ethics education components into midwifery program curricula are provided, and more research is needed.

Paving the way for successful twinning:: Using grounded theory to understand the contribution of twin pairs in twinning collaborations.

BACKGROUND: Twinning collaborations, where two groups - from educational institutions, hospitals or towns - work together cross-culturally on joint goals, are increasingly common worldwide. Pairing up individuals, so-called twin pairs, is thought to contribute to successful collaboration in twinning projects, but as yet, there is no empirical evidence or theory that offers insight into the value of the pair relationship for twinning. AIM: To explore the contribution of one-to-one relationships between twins to twinning projects, as exemplified in projects between Dutch and Moroccan, and Dutch and Sierra Leone midwives. METHODS: We conducted thirteen in-depth interviews with midwives from two twinning collaborations. Interviews were transcribed and analysed using an iterative, grounded theory process, yielding a theoretical understanding of one-to-one twinning relationships for twinning collaborations. FINDINGS: Participant comments fell into four substantive categories: 1) Being named a twin, 2) moving beyond culture to the personal level, 3) searching for common ground to engage, 4) going above and beyond the twinning collaboration. Their interplay demonstrates the value of twin pairs in paving the way for successful twinning. DISCUSSION: A complex combination of contextual inequities, personality, and cultural differences affect the twin relationship. Trusting relationships promote effective collaboration, however, as 'trust' cannot be mandated, it must be built by coaching twins in personal flexibility and (cultural) communication. CONCLUSION: By offering original insights into the ways twinning relationships are built, our research explores how twin pairs can enhance the success of twinning projects.

Perinatal factors related to pregnancy and childbirth satisfaction: a prospective cohort study.

BACKGROUND: Satisfaction of pregnancy and childbirth is an important quality measure of maternity care. Satisfaction questionnaires generally result in high scores. However, it has been argued that dissatisfaction relies on a different construct. In response to a worldwide call for obstetric care that is more woman-centered, we identified and described the contributors to suboptimal satisfaction with pregnancy and childbirth. METHODS: A prospective subcohort of 739 women from a larger cohort (Expect Study I, n = 2614) received a pregnancy and childbirth satisfaction questionnaire. Scores were transformed to a binary outcome whereby a score <100 points corresponded with less satisfied women. We performed a multiple logistic regression analysis to define independent perinatal factors related to suboptimal satisfaction. RESULTS: Decreased perceived personal well-being, antenatal anxiety, and obstetrician-led care during labor were all independently associated with suboptimal pregnancy and childbirth satisfaction. No difference in satisfaction was found between antenatal care led by a midwife or an obstetrician, but midwife-led antenatal care reduced the odds of suboptimal satisfaction compared to women who were transferred to an obstetrician in the antenatal period. Antenatal anxiety was experienced by 25% of all women and is associated with decreased satisfaction scores. DISCUSSION: Screening and treatment of women suffering from anxiety might improve pregnancy and childbirth satisfaction, but further research is necessary. Women's birthing experience may improve by reducing unnecessary secondary obstetric care.

The paradoxes of communication and collaboration in maternity care: A video-reflexivity study with professionals and parents.

BACKGROUND: Research on maternity care often focuses on factors that prevent good communication and collaboration and rarely includes important stakeholders - parents - as co-researchers. To understand how professionals and parents in Dutch maternity care accomplish constructive communication and collaboration, we examined their interactions in the clinic, looking for "good practice". METHODS: We used the video-reflexive ethnographic method in 9 midwifery practices and 2 obstetric units. FINDINGS: We conducted 16 meetings where participants reflected on video recordings of their clinical interactions. We found that informal strategies facilitate communication and collaboration: "talk work" - small talk and humour - and "work beyond words" - familiarity, use of sight, touch, sound, and non-verbal gestures. When using these strategies, participants noted that it is important to be sensitive to context, to the values and feelings of others, and to the timing of care. Our analysis of their ways of being sensitive shows that good communication and collaboration involves "paradoxical care", e.g., concurrent acts of "regulated spontaneity" and "informal formalities". DISCUSSION: Acknowledging and reinforcing paradoxical care skills will help caregivers develop the competencies needed to address the changing demands of health care. The video-reflexive ethnographic method offers an innovative approach to studying everyday work, focusing on informal and implicit aspects of practice and providing a bottom up approach, integrating researchers, professionals and parents. CONCLUSION: Good communication and collaboration in maternity care involves "paradoxical care" requiring social sensitivity and self-reflection, skills that should be included as part of professional training.

Evaluating the effect of an educational intervention on student midwife self-efficacy for their role as physiological childbirth advocates.

INTRODUCTION: Midwifery education that strengthens self-efficacy can support student midwives in their role as advocates for a physiological approach to childbirth. METHODS: To assess the effect of an educational intervention on self-efficacy, a pre- and post-intervention survey was administered to a control group and an intervention group of third year student midwives. The General Self-Efficacy Scale (GSES) was supplemented with midwifery-related self-efficacy questions related to behaviour in home and hospital settings, the communication of evidence, and ability to challenge practice. RESULTS: Student midwives exposed to midwifery education designed to strengthen self-efficacy demonstrated significantly higher levels of general self-efficacy (p = .001) when contrasted to a control cohort. These students also showed significantly higher levels of self-efficacy in advocating for physiological childbirth (p = .029). There was a non-significant increase in self-efficacy in the hospital setting in the intervention group, a finding that suggests that education may ameliorate the effect of hospital settings on midwifery practice. DISCUSSION: In spite of the small size of the study population, education that focuses on strengthening student midwife self-efficacy shows promise.

Women's characteristics and care outcomes of caseload midwifery care in the Netherlands: a retrospective cohort study.

BACKGROUND: The maternity care system in the Netherlands is well known for its support of community-based midwifery. However, regular midwifery practices typically do not offer caseload midwifery care - one-to-one continuity of care throughout pregnancy and birth. Because we know very little about the outcomes for women receiving caseload care in the Netherlands, we compared caseload care with regular midwife-led care, looking at maternal and perinatal outcomes, including antenatal and intrapartum referrals to secondary (i.e., obstetrician-led) care. METHODS: We selected 657 women in caseload care and 1954 matched controls (women in regular midwife-led care) from all women registered in the Dutch Perinatal Registry (Perined) who gave birth in 2015. To be eligible for selection the women had to be in midwife-led antenatal care beyond 28 gestational weeks. Each woman in caseload care was matched with three women in regular midwife-led care, using parity, maternal age, background (Dutch or non-Dutch) and region. These two cohorts were compared for referral rates, mode of birth, and other maternal and perinatal outcomes. RESULTS: In caseload midwifery care, 46.9% of women were referred to obstetrician-led care (24.2% antenatally and 22.8% in the intrapartum period). In the matched cohort, 65.7% were referred (37.4% antenatally and 28.3% in the intrapartum period). In caseload care, 84.0% experienced a spontaneous vaginal birth versus 77.0% in regular midwife-led care. These patterns were observed for both nulliparous and multiparous women. Women in caseload care had fewer inductions of labour (13.2% vs 21.0%), more homebirths (39.4% vs 16.1%) and less perineal damage (intact perineum: 41.3% vs 28.2%). The incidence of perinatal mortality and a low Apgar score was low in both groups. CONCLUSIONS: We found that when compared to regular midwife-led care, caseload midwifery care in the Netherlands is associated with a lower referral rate to obstetrician-led care - both antenatally and in the intrapartum period - and a higher spontaneous vaginal birth rate, with similar perinatal safety. The challenge is to include this model as part of the current effort to improve the quality of Dutch maternity care, making caseload care available and affordable for more women.

"I'm sure we talked about it": Midwives experiences of ethics education and ethical dilemmas, a qualitative study.

AIM: Midwives are expected to identify and help resolve ethics problems that arise in practice, skills that are presumed to be taught in midwifery educational programs. In this study, we explore how midwives recognize ethical dilemmas in clinical practice and examine the sources of their ethics education. METHODS: We conducted semi-structured, individual interviews with midwives from throughout the United States (U.S.) (n=15). Transcripts of the interviews were analysed using an iterative process to identify themes and subthemes. FINDINGS: Midwives described a range of professional ethical dilemmas, including challenges related to negotiating strained interprofessional relationships and protecting or promoting autonomy for women. Ethical dilemmas were identified by the theme of unease, a sense of distress that was expressed in three subthemes: uncertainty of action, compromise in action, and reflecting on action. Learning about ethics and ethical dilemmas occurred, for the most part, outside of the classroom, with the majority of participants reporting that their midwifery program did not confer the skills to identify and resolve ethical challenges. CONCLUSION: Midwives in this study reported a range of ethical challenges and minimal classroom education related to ethics. Midwifery educators should consider the purposeful and explicit inclusion of midwifery-specific ethics content in their curricula and in interprofessional ethics education. Reflection and self-awareness of bias were identified as key components of understanding ethical frameworks. As clinical preceptors were identified as a key source of ethics learning, midwifery educators should consider ways to support preceptors in building their skills as role models and ethics educators.

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.

Creating Guardians of Physiologic Birth: The Development of an Educational Initiative for Student Midwives in the Netherlands.

Women want positive birth experiences with high quality maternity care that is neither too much, too soon, nor too little, too late. Research confirms the effectiveness of midwifery care, and the midwifery approach to birth as physiologic may counter the upward trend of the unnecessary medicalization of birth. The role of guardian of physiologic birth is seen as central to midwifery practice; however, medical hegemony has led to the subordination of midwives, which inhibits them in fulfilling the role as guardian of physiologic birth. Learning to become powerful advocates of physiologic birth creates midwives able to speak up for effective, evidence-based maternity care and challenge the unnecessary use of obstetric intervention. Midwifery education has a role to fulfil in molding midwives who are able to assume this role. This brief report describes the development of an educational prototype aimed at increasing student midwife agency as an advocate of physiologic birth. This was done using rapid prototyping (RP) methodology, in which important stakeholders gave input and feedback during the educational design and development process. Input from stakeholders led to the inclusion of persuasive communication strategies and discussion and debate as teaching methodologies in order to increase student midwife agency to argue for physiologic birth. Reflective evidence-based practice, using the Optimality Index-Netherlands, allowed students to reflect on their practice while providing a framework for discussion. Working with the RP methodology allowed for the development of a prototype that reflected the needs of midwifery stakeholders and was mindful of material and human resources.

"A powerful midwifery vision": Dutch student midwives' educational needs as advocates of physiological childbirth.

BACKGROUND: In order to internalize the midwifery philosophy of care and to learn how to advocate for physiological childbirth, student midwives in the Netherlands need learning experiences that expose them to physiological childbirth practices. Increased hospital births, wide variation in non-urgent referrals and escalating interventions impact on learning opportunities for physiological childbirth. Midwifery educators need to find ways to support student agency in becoming advocates of physiological childbirth. OBJECTIVE: To gather students' opinions of what they need to become advocates of physiological childbirth. METHODS: Focus groups with student midwives (n=37), examining attitudes regarding what educational programs must do to support physiological childbirth advocacy. RESULTS: Students reported feelings of personal power when the midwifery philosophy of care is internalized and expressed in practice. Students also identified dilemmas associated with supporting woman-centered care and promoting physiological childbirth. Perceived hierarchy in clinical settings causes difficulties, leading students to practice in accordance with the norms of midwife preceptors. Students are supported in the internalization and realization of the midwifery philosophy of care, including physiological childbirth, if they are exposed to positive examples of care in practice and have opportunities to discuss and reflect on these in the classroom. KEY CONCLUSION: Midwifery education should focus on strategies that include navigating dilemmas in practice and helping students to express the midwifery philosophy of care in communication with other professionals and with women. Preceptors need to be supported in allowing student midwives opportunities to realize the midwifery philosophy of care, also when this differs from preceptor practice.

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 (ß = 6.21, P = 0.00) and for care-setting (ß = 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.

From equity to power: Critical Success Factors for Twinning between midwives, a Delphi study.

AIMS: To gain consensus for Critical Success Factors associated with Twinning in Midwifery. BACKGROUND: International publications identify midwifery as important for improving maternity care worldwide. Midwifery is a team effort where midwives play a key role. Yet their power to take on this role is often lacking. Twinning has garnered potential to develop power in professionals, however, its success varies because implementation is not always optimal. Critical Success Factors have demonstrated positive results in the managerial context and can be helpful to build effective Twinning relationships. DESIGN: We approached 56 midwife Twinning experts from 19 countries to participate in three Delphi rounds between 2016 - 2017. METHODS: In round 1, experts gave input through an open ended questionnaire and this was analysed to formulate Critical Success Factors statements that were scored on a 1-7 Likert scale aiming to gain consensus in rounds 2 and 3. These statements were operationalized for practical use such as a check list in planning, monitoring and evaluation in the field. FINDINGS: Thirty-three experts from 14 countries took part in all three Delphi rounds, producing 58 initial statements. This resulted in 25 Critical Success Factors covering issues of management, communication, commitment and values, most focus on equity. CONCLUSION: The Critical Success Factors formulated represent the necessary ingredients for successful Twinning by providing a practical implementation framework and promote further research into the effect of Twinning. Findings show that making equity explicit in Twinning may contribute towards the power of midwives to take on their identified key role.

Birth place preferences and women's expectations and experiences regarding duration and pain of labor.

INTRODUCTION: We know a great deal about how childbirth is affected by setting; we know less about how the experience of birth is shaped by the attitudes women bring with them to the birthing room. In order to better understand how women frame childbirth, we examined the relationship between birth place preference and expectations and experiences regarding duration of labor and labor pain in healthy nulliparous women. METHODS: A prospective cohort study (2007-2011) of 454 women who preferred a home birth (n = 179), a midwife-led hospital birth (n = 133) or an obstetrician-led hospital birth (n = 142) in the Netherlands. Data were collected using three questionnaires (before 20 weeks gestation, 32 weeks gestation and 6 weeks postpartum) and medical records. Analyses were performed according to the initial preferred place of birth. RESULTS: Women who preferred a home birth were significantly less likely to be worried about the duration of labor (OR 0.5, 95%CI 0.2-0.9) and were less likely to expect difficulties with coping with pain (OR 0.4, 95%CI 0.2-0.8) compared with women who preferred an obstetrician-led birth. We found no significant differences in postpartum accounts of duration of labor. When compared to women who preferred an obstetrician-led birth, women who preferred a home birth were significantly less likely to experience labor pain as unpleasant (OR 0.3, 95%CI 0.1-0.7). Women who preferred a midwife-led birth - either home or hospital - were more likely to report that it was not possible to make their own choices regarding pain relief compared to women who preferred obstetrician-led care (OR 4.3, 95%CI 1.9-9.8 resp. 3.4, 95%CI 1.5-7.7). Compared to women who preferred a midwife-led hospital birth, women who preferred a home birth had an increased likelihood of being dissatisfied about the management of pain relief (OR 2.5, 95%CI 1.1-6.0). DISCUSSION: Our findings suggest a more natural orientation toward birth with the acceptance of labor pain as part of giving birth in women with a preference for a home birth. Knowledge about women's expectations and experiences will help caregivers to prepare women for childbirth and will equip them to advise women on birth settings that fit their cognitive frame.

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.

Typology of birth centres in the Netherlands using the Rainbow model of integrated care: results of the Dutch Birth Centre Study.

BACKGROUND: The goal of integrated care is to offer a continuum of care that crosses the boundaries of public health, primary, secondary, and tertiary care. Integrated care is increasingly promoted for people with complex needs and has also recently been promoted in maternity care systems to improve the quality of care. Especially when located near an obstetric unit, birth centres are considered to be ideal settings for the realization of integrated care. At present, however, we know very little about the degree of integration in these centres and we do not know if increased levels of integration improve the quality of the care delivered. The Dutch Birth Centre Study is designed to evaluate birth centres and their contribution to the Dutch maternity care system. The aim of this particular sub-study is to classify birth centres in clusters with similar characteristics based on integration profiles, to support the evaluation of birth centre care. METHODS: This study is based on the Rainbow Model of Integrated Care. We used a survey followed by qualitative interviews in 23 birth centres in the Netherlands to determine which integration profiles can be distinguished and to describe their discriminating characteristics. Cluster analysis was used to classify the birth centres. RESULTS: Birth centres were classified into three clusters: 1)"Mono-disciplinary-oriented birth centres" (n = 10): which are mainly owned by primary care organizations and established as physical facilities to provide an alternative birthplace for low risk births; 2) "Multi-disciplinary-oriented birth centres" (n = 6): which are mainly multi-disciplinary oriented and can be regarded as facilities to give birth, with a focus on integrated birth care; 3) "Mixed Cluster of birth centres" (n = 7): which have a range of organizational forms that differentiate them from centres in the other clusters. CONCLUSION: We identified a recognizable classification, with similar characteristics between birth centres in the clusters. The results of this study can be used to relate integration profiles of birth centres to quality of care, costs, and perinatal outcomes. This assessment makes it possible to develop recommendations with regard to the type and degree of integration of Dutch birth centres in the future.

Come On! Using intervention mapping to help healthy pregnant women achieve healthy weight gain.

OBJECTIVE: Gaining too much or too little weight in pregnancy (according to Institute of Medicine (IOM) guidelines) negatively affects both mother and child, but many women find it difficult to manage their gestational weight gain (GWG). Here we describe the use of the intervention mapping protocol to design 'Come On!', an intervention to promote adequate GWG among healthy pregnant women. DESIGN: We used the six steps of intervention mapping: (i) needs assessment; (ii) formulation of change objectives; (iii) selection of theory-based methods and practical strategies; (iv) development of the intervention programme; (v) development of an adoption and implementation plan; and (vi) development of an evaluation plan. A consortium of users and related professionals guided the process of development. RESULTS: As a result of the needs assessment, two goals for the intervention were formulated: (i) helping healthy pregnant women to stay within the IOM guidelines for GWG; and (ii) getting midwives to adequately support the efforts of healthy pregnant women to gain weight within the IOM guidelines. To reach these goals, change objectives and determinants influencing the change objectives were formulated. Theories used were the Transtheoretical Model, Social Cognitive Theory and the Elaboration Likelihood Model. Practical strategies to use the theories were the foundation for the development of 'Come On!', a comprehensive programme that included a tailored Internet programme for pregnant women, training for midwives, an information card for midwives, and a scheduled discussion between the midwife and the pregnant woman during pregnancy. The programme was pre-tested and evaluated in an effect study.

Exploring Dutch midwives' attitudes to promoting physiological childbirth: A qualitative study.

OBJECTIVE: to describe Dutch midwives' attitudes toward, and motivations for, the promotion of physiological childbirth and to identify factors associated with those attitudes and motivations. DESIGN: exploratory, qualitative design using focus groups. SETTING: The Netherlands. PARTICIPANTS: hospital- and community-based midwives. FINDINGS: four themes emerged: physiological birth as a continuum, navigating the settings, woman-centeredness and competence and confidence. Midwives view the safeguarding and promotion of physiological childbirth as central to their role. They define physiological childbirth along a continuum that is related to the context of their practice. Hospital culture is seen as an inhibitor of practices that promote physiological birth. Midwives believe that woman-centred ways of working and challenging practices that are not evidence-based will promote physiological childbirth. KEY CONCLUSIONS: in order to become competent and confident practitioners of physiological childbirth midwives need to be aware of the factors that inhibit and encourage practices that support this way of giving birth. IMPLICATIONS FOR PRACTICE: midwives should consciously employ strategies that promote physiological birth in both home and hospital settings. Midwifery education and midwifery science research should focus on developing strategies that support midwives in this endeavor.

The effect of Wazzup Mama?! An antenatal intervention to prevent or reduce maternal distress in pregnancy.

We evaluated the effect of the intervention WazzUp Mama?! on antenatal maternal distress in a non-randomized pre-post study including healthy women in 17 Dutch midwifery practices. The control group (n = 215) received antenatal care-as-usual. The experimental group (n = 218) received the intervention. Data were collected at the first and third trimester of pregnancy. Maternal distress (MD) was measured with the Edinburgh Depression Scale (EDS), State-Trait Anxiety Inventory (STAI), and Pregnancy-Related Anxiety Questionnaire (PRAQ). We used multivariate repeated-measure analysis to examine the across time changes and ANCOVA was used to examine the differences between the two groups. In the control group, mean EDS, STAI, and MD scores significantly increased from first to third trimester of pregnancy, mean PRAQ scores increased, but not significantly, the proportion of scores above cut-off level of EDS, STAI, and PRAQ significantly increased from first to third trimester, and the proportion of MD scores above cut-off level increased, but not significantly. Within the experimental group, the mean STAI, PRAQ, and MD scores significantly decreased from first to third trimester, the EDS mean scores decreased but not significantly, proportions of scores above cut-off level for PRAQ and MD significantly decreased from first to third trimester of pregnancy, the proportions of EDS and STAI scores above cut-off level decreased but not significantly. There was a moderate significant positive effect of WazzUP Mama?! on the MD scores (F(1.43) = 27.05, p < 0.001, d = 0.5). The results provide support for the effectiveness of the intervention WazzUp Mama?!