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.

Vaginal Birth After Cesarean: Views of Women From Countries With High VBAC Rates.

Despite the consequences for women's health, a repeat cesarean section (CS) birth after a previous CS is common in Western countries. Vaginal Birth After Cesarean (VBAC) is recommended for most women, yet VBAC rates are decreasing and vary across maternity organizations and countries. We investigated women's views on factors of importance for improving the rate of VBAC in countries where VBAC rates are high. We interviewed 22 women who had experienced VBAC in Finland, the Netherlands, and Sweden. We used content analysis, which revealed five categories: receiving information from supportive clinicians, receiving professional support from a calm and confident midwife/obstetrician during childbirth, knowing the advantages of VBAC, letting go of the previous childbirth in preparation for the new birth, and viewing VBAC as the first alternative for all involved when no complications are present. These findings reflect not only women's needs but also sociocultural factors influencing their views on VBAC.

The effect of gestational weight gain on likelihood of referral to obstetric care for women eligible for primary, midwife-led care after antenatal booking.

OBJECTIVE: to examine the effect of gestational weight gain (GWG) on likelihood of referral from midwife-led to obstetrician-led care during pregnancy and childbirth for women in primary care at the outset of their pregnancy. DESIGN: secondary analysis of data from a prospective cohort study. SETTING: Dutch midwife-led practices. PARTICIPANTS: a cohort of 1288 women of Northern European descent, with uncomplicated, singleton pregnancy at antenatal booking who consequently were eligible for primary, midwife-led care. MEASUREMENTS: because of the absence of an established GWG guideline in the Netherlands, we compared the effect of inadequate and excessive GWG according to two GWG guidelines: the criterion traditionally used, which is based on knowledge of the physiological components of GWG, advising 10-15kg as a normal GWG irrespective of a woman׳s BMI category, and the 2009 Institute of Medicine recommendations (IOMr) on GWG, which provide BMI related advice. Outcome measures were: number of women referred from midwife-led to obstetrician-led care during pregnancy and during childbirth; indications of referral and birth outcomes. FINDINGS: GWG above traditional criteria (Tc; >15kg between 12 and 36 weeks) was associated with increased odds for referral during childbirth (adjusted odds ratio (aOR) 1.88; 95% confidence interval (CI) 1.22-2.90), but had no effect on referral during pregnancy (aOR .86; 95% CI .57-1.30). No associations were established between GWG below Tc (<10kg) and referral during pregnancy (aOR 1.08; 95% CI .78-1.50) or childbirth (aOR 1.08; 95% CI .74-1.56). No associations were found between GWG below and above the IOMr and referral during pregnancy (below IOMr: aOR 1.01; 95% CI .71-1.45; above IOMr: aOR .89; 95% CI .61-1.28) or childbirth (below IOMr: aOR .85; 95% CI .57-1.25; above IOMr: aOR 1.09; 95% CI .73-1.63). With regard to the effect of GWG according to both recommendations on indications for referral and birth outcomes, GWG above Tc was associated with higher rates of referral for hypertensive disorders (aOR 1.91; 95% CI 1.04-3.50) and for meconium stained liquor (aOR 2.22; CI 1.33-3.71) after adjusting for BMI and parity. CONCLUSIONS: GWG above Tc - irrespective of BMI category - was associated with doubled odds of referral to specialist care during childbirth. GWG below or above IOMR and GWG below TC were not associated with adverse obstetric outcomes in women who were eligible for primary care at the outset of their pregnancy. IMPLICATIONS FOR PRACTICE: weight gain <15kg between 12 and 36 weeks is advised for women in all BMI categories in this population. It is important to validate GWG guidelines in a target population before implementing them.

Women-centred interventions to increase vaginal birth after caesarean section (VBAC): A systematic review.

OBJECTIVE: to evaluate the effectiveness of women-centred interventions during pregnancy and birth to increase rates of vaginal birth after caesarean. DESIGN: we searched bibliographic databases for randomised trials or cluster randomised trials on women-centred interventions during pregnancy and birth designed to increase VBAC rates in women with at least one previous caesarean section. Comparator groups included standard or usual care or an alternative treatment aimed at increasing VBAC rates. The methodological quality of included studies was assessed independently by two authors using the Effective Public Health Practice Project quality assessment tool. Outcome data were extracted independently from each included study by two review authors. FINDINGS: in total, 821 citations were identified and screened by title and abstract; 806 were excluded and full text of 15 assessed. Of these, 12 were excluded leaving three papers included in the review. Two studies evaluated the effectiveness of decision aids for mode of birth and one evaluated the effectiveness of an antenatal education programme. The findings demonstrate that neither the use of decision aids nor information/education of women have a significant effect on VBAC rates. Nevertheless, decision-aids significantly decrease women's decisional conflict about mode of birth, and information programmes significantly increase their knowledge about the risks and benefits of possible modes of birth. KEY CONCLUSIONS: few studies evaluated women-centred interventions designed to improve VBAC rates, and all interventions were applied in pregnancy only, none during the birth. There is an urgent need to develop and evaluate the effectiveness of all types of women-centred interventions during pregnancy and birth, designed to improve VBAC rates. IMPLICATIONS FOR PRACTICE: decision-aids and information programmes during pregnancy should be provided for women as, even though they do not affect the rate of VBAC, they decrease women's decisional conflict and increase their knowledge about possible modes of birth.

Clinician-centred interventions to increase vaginal birth after caesarean section (VBAC): a systematic review.

BACKGROUND: The number of caesarean sections (CS) is increasing globally, and repeat CS after a previous CS is a significant contributor to the overall CS rate. Vaginal birth after caesarean (VBAC) can be seen as a real and viable option for most women with previous CS. To achieve success, however, women need the support of their clinicians (obstetricians and midwives). The aim of this study was to evaluate clinician-centred interventions designed to increase the rate of VBAC. METHODS: The bibliographic databases of The Cochrane Library, PubMed, PsychINFO and CINAHL were searched for randomised controlled trials, including cluster randomised trials that evaluated the effectiveness of any intervention targeted directly at clinicians aimed at increasing VBAC rates. Included studies were appraised independently by two reviewers. Data were extracted independently by three reviewers. The quality of the included studies was assessed using the quality assessment tool, 'Effective Public Health Practice Project'. The primary outcome measure was VBAC rates. RESULTS: 238 citations were screened, 255 were excluded by title and abstract. 11 full-text papers were reviewed; eight were excluded, resulting in three included papers. One study evaluated the effectiveness of antepartum x-ray pelvimetry (XRP) in 306 women with one previous CS. One study evaluated the effects of external peer review on CS birth in 45 hospitals, and the third evaluated opinion leader education and audit and feedback in 16 hospitals. The use of external peer review, audit and feedback had no significant effect on VBAC rates. An educational strategy delivered by an opinion leader significantly increased VBAC rates. The use of XRP significantly increased CS rates. CONCLUSIONS: This systematic review indicates that few studies have evaluated the effects of clinician-centred interventions on VBAC rates, and interventions are of varying types which limited the ability to meta-analyse data. A further limitation is that the included studies were performed during the late 1980s-1990s. An opinion leader educational strategy confers benefit for increasing VBAC rates. This strategy should be further studied in different maternity care settings and with professionals other than physicians only.

Patterns of gestational weight gain in healthy, low-risk pregnant women without co-morbidities.

BACKGROUND: little is known of the impact of gestational weight gain (GWG) in relation to Body Mass Index (BMI) classification on perinatal outcomes in healthy pregnant women without co-morbidities. As a first step, the prevalence of obesity and the distribution of GWG in relation to the Institute of Medicine (IOM) 2009 guidelines for GWG were examined. METHODS: data from a prospective cohort study of - a priori - low risk, pregnant women from five midwife-led practices (n=1449) were analysed. Weight was measured at 12, 24 and 36 weeks. FINDINGS: at 12 weeks, 1.4% of the women were underweight, 53.8% had a normal weight, 29.6% were overweight, and 15.1% were obese according to the WHO classification of BMI. In our study population, 60% of the women did not meet the IOM recommendations: 33.4% had insufficient GWG and 26.7% gained too much weight. Although BMI was negatively correlated to total GWG (p<.001), overweight and obese women class I had a significant higher risk of exceeding the IOM guidelines. Normal weight women had a significantly higher risk of gaining less weight than recommended. Obese women classes II and III were at risk in both over- and undergaining. CONCLUSIONS: our data showed that the majority of women were unable to stay within recommended GWG ranges without additional interventions. The effects on pregnancy and health outcomes of falling out the IOM guidelines remain unclear for - a priori - low risk women. Since interventions to control GWG would have considerable impact on women and caregivers, harms and benefits should be well-considered before implementation.