Remote patient monitoring in patients with COVID-19 at home: literature review.

BACKGROUND: During the pandemic healthcare providers implemented remote patient monitoring (RPM) for patients suffering from COVID-19. RPM is an interaction between healthcare professionals and patients who are in different locations, in which a certain number of patient's functioning parameters is assessed and followed up for a certain duration of time. By implementing RPM for these patients they obtained to reduce the strain on hospitals and primary care. OBJECTIVE: With this literature review we aim at describing the characteristics of the RPM interventions, reporting on the patients with COVID-19 included in RPM, and providing an overview of outcome variables such as length of stay (LOS), hospital (re)admissions, and mortality. METHODS: A combination of different searches in several database types (traditional databases, trial registers, daily (google) searches and daily Pubmed alerts) were run daily from March 2020 till December 2021. A search update for randomized clinical trials (RCT's) was done in April 2022. RESULTS: The initial search yielded more than 4448 articles (not including daily searches). After deduplication and assessment for eligibility, 241 articles were retained describing 164 telemonitoring studies from 160 centres. None of the 164 studies covering 248,431 included patients reported on the presence of a randomized control group. Studies described a 'prehosp' group (96 studies) with patients who had a suspected or confirmed COVID-19 diagnosis and for whom it was decided not to hospitalize them yet, but closely monitor them at home, or a 'posthosp' group (32 studies) with patients who were monitored at home after hospitalization for COVID-19; 34 studies described both groups, in 2 studies it was unclear. There is a large variety in number of emergency department (ED) visits (0-36% and 0-16%) and no convincing evidence that RPM leads to less or more ED-visits as well as hospital (re)admissions (0-30% and 0-22%) in prehosp and posthosp, respectively. Mortality was generally low, and there is weak to no evidence that RPM is associated with lower mortality. There is neither evidence that RPM shortens previous LOS. A literature update detected three small scale RCT's which could not demonstrate statistically significant differences in these outcomes. Most papers claim savings, however the scientific base for these claims is doubtful. The overall patient experiences with RPM were positive, as patients felt more reassured, although many patients declined RPM for several reasons (eg, technological embarrassment, digital literacy, etc.). CONCLUSIONS: Based on these results, there is no convincing evidence that RPM in COVID-19 patients could avoid ED-visits or hospital (re)admissions, could shorten LOS or reduce mortality, but neither is there evidence that RPM has adverse outcomes. Further research should focus on developing, implementing, and evaluating an RPM framework.

Barriers to the Implementation of Infant- and Family-Centered Developmental Care From Focus Groups With Neonatal Care Providers.

AIM: Although infant- and family-centered developmental care (IFCDC) is scientifically grounded and offered in many hospitals to some extent, it has not yet been universally implemented as the standard of care. In this article, we aim to identify barriers to the implementation of IFCDC in Belgian neonatal care from the perspective of neonatal care providers. METHODS: We conducted 8 online focus groups with 40 healthcare providers working in neonatal care services. An inductive thematic analysis was carried out by means of Nvivo. RESULTS: The focus groups revealed barriers related to contextual, hospital, and neonatal unit characteristics. Barriers found in the hospital and neonatal unit were related to financing, staffing, infrastructure, access to knowledge/information and learning climate, leadership engagement, and relative priority of IFCDC. Contextual barriers were related to peer pressure and partnerships, newborn/parent needs and resources, external policy, and budgetary incentives. CONCLUSION: Three main barriers to IFCDC implementation have been identified. Resources (staffing, financing, and infrastructure) must be available and aligned with IFCDC standards, knowledge and information have to be accessible and continuously updated, and hospital management should support IFCDC implementation to create an enabling climate, including compatibility with the existing workflow, learning opportunities, and priority setting.

Experiences with the implementation of remote monitoring in patients with COVID-19: A qualitative study with patients and healthcare professionals.

INTRODUCTION: This study investigated how patients with COVID-19, telemonitoring (TM) teams, general practitioners (GPs) and primary care nurses in Belgium experienced remote patient monitoring (RPM) in 12 healthcare organizations, in relation to the patients' illness, health, and care needs, perceived quality of care, patient and health system outcomes, and implementation challenges. DESIGN: A qualitative research approach was adopted, including focus group discussions and semi-structured interviews. METHODS: Four different groups of participants were interviewed, that is, patients (n = 17), TM teams (n = 27), GPs (n = 16), and primary care nurses (n = 12). An interview guide was drafted based on a literature review. Interviews were transcribed verbatim, and NVivo was used for managing and analyzing the data. The QUAGOL method was used to guide the data analysis process and was adapted for the purpose of a thematic content analysis. RESULTS: All participants agreed that RPM-reassured patients. The overall perceived value of RPM for individual patients depended on how well the intervention matched with their needs. Patients who did not have the necessary language (Dutch/French speaking) and digital skills, who did not have the right equipment (smartphone or tablet), or who missed the necessary infrastructure (no internet coverage in their region) were often excluded. Remote patient monitoring also reassured healthcare professionals as it gave them information on a disease they had little knowledge about. Professionals involved in RPM experienced a high workload. All TM teams agreed that quality of data was a key factor to ensure an adequate follow-up, but they differed in what they found important. The logistic management of RPM was a challenge because of the contagious character of COVID-19, and the need for an effective information flow between the hospital team and primary care providers. Participants missed clarification about who was accountable for the care for patients in the projects. Primary care nurses and GPs missed access to RPM data. All agreed that the funding they received was not sufficient to cover all the costs associated with RPM. CONCLUSION: Healthcare professionals and patients perceive RPM as valuable and believe that the concept will have its place in the Belgium health system. However, current RPM practice is challenged by many barriers, and the sustainability of RPM implementation is low. CLINICAL RELEVANCE: Remote patient monitoring (RPM) was perceived as a valuable intervention for patients with COVID-19, but there were important concerns about unequal access to care. While the technology for RPM is available, the sustainability of implementation is low because of concerns with data quality, challenging logistics within projects, lack of data integration and communication, and a lack of an overarching guiding framework.

Barriers to Somatic Health Care for Persons With Severe Mental Illness in Belgium: A Qualitative Study of Patients' and Healthcare Professionals' Perspectives.

BACKGROUND: A huge and still growing mortality gap between people with severe mental illness (SMI) and the general population exists. Physical illnesses, mainly cardiovascular diseases, substantially contribute to the high mortality rates in patients with SMI. Disparities in somatic health care access, utilisation, and provision contribute to these poor physical health outcomes. METHODS: A qualitative study, using semi-structured interviews, was set up to explore SMI patients' and healthcare professionals' perspectives on somatic health care in different psychiatric settings of the three Belgian regions (Flanders, Brussels, Wallonia). Interviews were digitally recorded and transcribed prior to qualitative inductive thematic analysis, using Nvivo software. The COnsolidated criteria for REporting Qualitative research (COREQ) were used for reporting methods and findings. RESULTS: Collaboration and information flows between psychiatric healthcare professionals, non-psychiatric healthcare professionals, and persons with SMI were troublesome. This seemed to be mainly due to stigma and prejudice and challenging communication and data transfer. Lack of sufficient training and experience to identify and treat somatic health problems in people with SMI (for psychiatrists and psychiatric nurses) and lack of psychiatric knowledge and feeling or sensitivity for psychiatric patients (for non-psychiatric healthcare professionals) further complicated adequate somatic health care. Finally, optimal somatic follow-up of patients with SMI was hampered by organisational problems (unavailability of equipment, unadapted infrastructure, understaffing, hospital pharmacy issues, and insufficient health promotion/lifestyle interventions), patient-related issues (unawareness of physical problems, non-adherence, need for accompaniment) and financial barriers. CONCLUSION: There is an urgent need for integrated somatic and mental healthcare systems and a cultural change. Psychiatrists and primary care providers continue to consider the mental and physical health of their patients as mutually exclusive responsibilities due to a lack of sufficient training and experience, poor or absent liaison links, time constraints and organisational and financial barriers. Modifying these aspects will improve the quality of somatic health care for these vulnerable patients.

Developing an agency's position with respect to patient involvement in health technology assessment: the importance of the organizational culture.

OBJECTIVES: The objective of this study was to map the PI culture at KCE in the context of the development of organization-wide supported position statements about PI. METHODS: A nominal group technique was used to measure the PI culture at KCE. Arguments for and against PI and conditions for PI in different phases of the HTA process were collected. A literature review and interviews fed the draft position statements, for which support was assessed by means of a two-round Delphi process. RESULTS: Arguments in favor of PI in HTA related to the relevance of the scope, expertise with data collection, bringing in fresh ideas for study design, access to survey participants, validation of data analyses, adherence to recommendations. Disadvantages and risks included the lack of scientific knowledge of involved patients, resources requirements, conflicts of interest, and heterogeneity within patient populations. Conditions for meaningful PI referred to measures mitigating the identified disadvantages. Eighteen position statements supported by KCE could be formulated. CONCLUSION: The KCE culture seems predominantly positive toward PI, although attitudes vary between HTA researchers. KCE recognizes the potential value of PI in HTA, but considers the level of involvement to be contingent on the topic and phase in the HTA process.

The view of severely burned patients and healthcare professionals on the blind spots in the aftercare process: a qualitative study.

BACKGROUND: In most Western countries burn centres have been developed to provide acute and critical care for patients with severe burn injuries. Nowadays, those patients have a realistic chance of survival. However severe burn injuries do have a devastating effect on all aspects of a person's life. Therefore a well-organized and specialized aftercare system is needed to enable burn patients to live with a major bodily change. The aim of this study is to identify the problems and unmet care needs of patients with severe burn injuries throughout the aftercare process, both from patient and health care professional perspectives in Belgium. METHODS: By means of face-to-face interviews (n = 40) with individual patients, responsible physicians and patient organizations, current experiences with the aftercare process were explored. Additionally, allied healthcare professionals (n = 17) were interviewed in focus groups. RESULTS: Belgian burn patients indicate they would benefit from a more integrated aftercare process. Quality of care is often not structurally embedded, but depends on the good intentions of local health professionals. Most burn centres do not have a written discharge protocol including an individual patient-centred care plan, accessible to all caregivers involved. Patients reported discontinuity of care: nurses working at general wards or rehabilitation units are not specifically trained for burn injuries, which sometimes leads to mistakes or contradictory information transmission. Also professionals providing home care are often not trained for the care of burn injuries. Some have to be instructed by the patient, others go to the burn centre to learn the right skills. Finally, patients themselves underestimate the chronic character of burn injuries, especially at the beginning of the care process. CONCLUSIONS: The variability in aftercare processes and structures, as well as the failure to implement locally developed best-practices on a wider scale emphasize the need for a comprehensive network, which can initiate transversal activities such as the development of discharge protocols, common guidelines, and quality criteria.

Acceptability and Perceived Benefits and Risks of Public and Patient Involvement in Health Care Policy: A Delphi Survey in Belgian Stakeholders.

BACKGROUND: In systems with public health insurance, coverage decisions should reflect social values. Deliberation among stakeholders could achieve this goal, but rarely involves patients and citizens directly. OBJECTIVES: This study aimed at evaluating the acceptability, and the perceived benefits and risks, of public and patient involvement (PPI) in coverage decision making to Belgian stakeholders. METHODS: A two-round Delphi survey was conducted among all stakeholder groups. The survey was constructed on the basis of interviews with 10 key stakeholders and a review of the literature on participation models. Consensus was defined as 65% or more of the respondents agreeing with a statement and less than 15% disagreeing. Eighty stakeholders participated in both rounds. They were defined as the Delphi panel. RESULTS: Belgian stakeholders are open toward PPI in coverage decision processes. Benefits are expected to exceed risks. The preferred model for involvement is to consult citizens or patients, within the existing decision-making structures and at specific milestones in the process. Consulting citizens and patients is a higher level of involvement than merely informing them and a lower level than letting them participate actively. Consultation involves asking nonbinding advice on (parts of) the decision problem. According to the Delphi panel, the benefits of PPI could be increasing awareness among members of the general public and patients about the challenges and costs of health care, and enriched decision processes with expertise by experience from patients. Potential risks include subjectivity, insufficient resources to participate and weigh on the process, difficulties in finding effective ways to express a collective opinion, the risk of manipulation, and lobbying or power games of other stakeholders. CONCLUSIONS: PPI in coverage decision-making processes is acceptable to Belgian stakeholders, be it in different ways for different types of decisions. Benefits are expected to outweigh risks.

Work-family conflict, health services and medication use among dual-income couples in Europe.

Combination pressure or work-life imbalance is linked to adverse health. However, it remains unclear how work-family conflict is related to healthcare utilisation. Does work-family conflict function as a barrier or as a facilitator in relation to the use of health services and prescription medication? Lack of time may prevent people from visiting a doctor when they feel unwell. However, combination pressure can also be expected to intensify the use of health services, as the need for a quick fix is prioritised. Further, do women and men differ in their susceptibility to medicalisation and time pressure resulting from work-life imbalance? This article investigates the use of health services and prescription medication of dual-income couples with children, based on data from 23 countries in the European Social Survey round 2 (N(women) = 3755; N(men) = 3142). It was found that medical services and prescription medications are used more frequently in dual-income couples experiencing work-to-family spillover, but for women only this is irrespective of their self-reported health. Family-to-work spillover does not result in increased health service or medication use for either men or women. While women opt for a medical response to work-life imbalance, men's reluctance to seek formal health support is confirmed.

Trends in the medicalisation of childbirth in Flanders and the Netherlands.

OBJECTIVE: in this paper we offer new insights about the medicalisation of childbirth by closely examining the trends in obstetric intervention rates in Flanders and the Netherlands and by considering the influence of contextual factors - including the organisation of the medical system, professional guidelines, and cultural ideas - on the way maternity care is delivered. DESIGN: a comparative study using perinatal statistics from the National Perinatal Databases of the Netherlands and Flanders and historical and qualitative data about the organisation and culture of maternity care in each country. SETTING AND PARTICIPANTS: in the Netherlands data are gathered from practices of the participating midwives, general practitioners and obstetricians. In Flanders the registration of data takes place in Flemish maternity units and independent midwifery practices. MEASUREMENTS AND FINDINGS: in the Netherlands the home birth rate is still by far the highest in Europe and some interventions (e.g. caesarean section and epidural) are among the lowest. However, some perinatal statistics - such as in the use of epidural analgesia during labour - suggest an increasingly medical approach to birth in the Netherlands. Other trends in the Netherlands include an increasing use of inductions and augmentation in labour, and a decreasing number of births in primary care. The practice of home birth is being challenged by critical discussions in the popular media and 'scientific' debates among professionals. In Flanders, there have been some efforts to reduce medicalisation of childbirth, focussed on specific interventions such as induction and episiotomy. KEY CONCLUSIONS: in recent years the obstetric intervention rates in Belgium and the Netherlands are slowly converging. IMPLICATIONS FOR PRACTICE: because the lives of women, midwives, and obstetricians (among others) are significantly affected by patterns of medicalisation and de-medicalisation, it is important that we understand the drivers of the medicalising process.

Pregnant women's fear of childbirth in midwife- and obstetrician-led care in Belgium and the Netherlands: test of the medicalization hypothesis.

Fear of childbirth has gained importance in the context of increasing medicalization of childbirth. Belgian and Dutch societies are very similar but differ with regard to the organization of maternity care. The Dutch have a high percentage of home births and low medical intervention rates. In contrast, home births in Belgium are rarer, and the medical model is more widely used. By comparing the Belgian and Dutch maternity care models, the association between fear of childbirth and medicalization can be explored. For this study an antenatal questionnaire was completed by 833 women at 30 weeks of pregnancy. Fear of childbirth was measured by a shortened Dutch version of the Childbirth Attitudes Questionnaire. A four-dimensional model with baby-related, pain and injuries-related, general and personal control-related, and medical interventions and hospital care-related fear, fitted well in both countries. Multiple regression analysis showed no country differences, except that Belgian women in midwife-led care were more fearful of medical interventions and hospital care than the Dutch. For the other dimensions, both Belgian and Dutch women receiving midwifery care reported less fear compared to those in obstetric antenatal care. Hence, irrespective of the maternity care model, antenatal care providers are crucial in preventing fear of childbirth.

Pain acceptance and personal control in pain relief in two maternity care models: a cross-national comparison of Belgium and the Netherlands.

BACKGROUND: A cross-national comparison of Belgian and Dutch childbearing women allows us to gain insight into the relative importance of pain acceptance and personal control in pain relief in 2 maternity care models. Although Belgium and the Netherlands are neighbouring countries sharing the same language, political system and geography, they are characterised by a different organisation of health care, particularly in maternity care. In Belgium the medical risks of childbirth are emphasised but neutralised by a strong belief in the merits of the medical model. Labour pain is perceived as a needless inconvenience easily resolved by means of pain medication. In the Netherlands the midwifery model of care defines childbirth as a normal physiological process and family event. Labour pain is perceived as an ally in the birth process. METHODS: Women were invited to participate in the study by independent midwives and obstetricians during antenatal visits in 2004-2005. Two questionnaires were filled out by 611 women, one at 30 weeks of pregnancy and one within the first 2 weeks after childbirth either at home or in a hospital. However, only women having a hospital birth without obstetric intervention (N = 327) were included in this analysis. A logistic regression analysis has been performed. RESULTS: Labour pain acceptance and personal control in pain relief render pain medication use during labour less likely, especially if they occur together. Apart from this general result, we also find large country differences. Dutch women with a normal hospital birth are six times less likely to use pain medication during labour, compared to their Belgian counterparts. This country difference cannot be explained by labour pain acceptance, since - in contrast to our working hypothesis - Dutch and Belgian women giving birth in a hospital setting are characterised by a similar labour pain acceptance. Our findings suggest that personal control in pain relief can partially explain the country differences in coping with labour pain. For Dutch women we find that the use of pain medication is lowest if women experience control over the reception of pain medication and have a positive attitude towards labour pain. In Belgium however, not personal control over the use of pain relief predicts the use of pain medication, but negative attitudes towards labour. CONCLUSIONS: Apart from individual level determinants, such as length of labour or pain acceptance, our findings suggest that the maternity care context is of major importance in the study of the management of labour pain. The pain medication use in Belgian hospital maternity care is high and is very sensitive to negative attitudes towards labour pain. In the Netherlands, on the contrary, pain medication use is already low. This can partially be explained by a low degree of personal control in pain relief, especially when co-occurring with positive pain attitudes.

Mental health in a gendered context: Gendered community effect on depression and problem drinking.

Socio-economic features of a community influence people's health. However, not all inhabitants are affected similarly. The present study explores gendered contextual effects on problem drinking and depression with the differential exposure, vulnerability and expression hypotheses of the social stress model in mind. Analyses are based on the pooled data of the Belgian Health Interview Survey 2001 and 2004 (N=21.367 respondents, N=589 municipalities). Results reveal that living in an area with high unemployment is more detrimental for women in terms of depression, but has the same impact on men and women when problem drinking is the outcome.

Place of birth and satisfaction with childbirth in Belgium and the Netherlands.

OBJECTIVE: to gain insight into the association between satisfaction with childbirth and place of birth, in the context of two maternity-care systems, in Belgium and the Netherlands. The Belgian and Dutch societies have many similarities but differ in the organisation of maternity care. The Dutch way of giving birth is well known for its high percentage of home births and its low medical intervention rate. In contrast, home births in Belgium are uncommon and the medical model is taken for granted. DESIGN: quantitative, comparative study using questionnaires to assess satisfaction with childbirth. SETTING: hospitals and independent midwifery practices in two comparable cities in Belgium and the Netherlands. PARTICIPANTS: two questionnaires were completed by 611 women, one at 30 weeks of pregnancy and one within the first 2 weeks after childbirth, at home or in hospital. The women were invited to participate in the study by independent midwives and obstetricians during prenatal visits between 2004 and 2005. MEASUREMENTS AND FINDINGS: satisfaction with childbirth was measured by the Mackey Satisfaction with Childbirth Rating Scale, which takes into account the multi-dimensional nature of the concept. An analysis of variance with two fixed factors, planned place of birth and maternity-care system, shows that women who had planned for a home birth were more satisfied than women who had planned for a hospital birth. This was true in every subdimension of satisfaction. Belgian women were more satisfied with childbirth than their northern neighbours, in every subdimension. The higher satisfaction scores of the Belgian women accounted for both home and hospital births. KEY CONCLUSIONS: women who had planned a home birth were the most satisfied (in both countries), but Belgian women had higher satisfaction scores than Dutch women. This is paradoxical because a non-medical home context has a beneficial effect on satisfaction, whereas the Dutch non-interventionist approach in maternity care does not yield the same effect. IMPLICATIONS FOR PRACTICE: medicalisation critics may be right about the iatrogenic effects of the medical approach on an individual level, but other social forces operate on the level of maternity-care systems.

Part-time hospitalisation and stigma experiences: a study in contemporary psychiatric hospitals.

BACKGROUND: Because numerous studies have revealed the negative consequences of stigmatisation, this study explores the determinants of stigma experiences. In particular, it examines whether or not part-time hospitalisation in contemporary psychiatric hospitals is associated with less stigma experiences than full-time hospitalisation. METHODS: Survey data on 378 clients of 42 wards from 8 psychiatric hospitals are used to compare full-time clients, part-time clients and clients receiving part-time care as aftercare on three dimensions of stigma experiences, while controlling for symptoms, diagnosis and clients' background characteristics. RESULTS: The results reveal that part-time clients without previous full-time hospitalisation report less social rejection than clients who receive full-time hospitalisation. In contrast, clients receiving part-time treatment as aftercare do not differ significantly from full-time clients concerning social rejection. No significant results for the other stigma dimensions were found. CONCLUSION: Concerning social rejection, immediate part-time hospitalisation could be recommended as a means of destigmatisation for clients of contemporary psychiatric hospitals.

Assessment of social psychological determinants of satisfaction with childbirth in a cross-national perspective.

BACKGROUND: The fulfilment of expectations, labour pain, personal control and self-efficacy determine the postpartum evaluation of birth. However, researchers have seldom considered the multiple determinants in one analysis. To explore to what extent the results can be generalised between countries, we analyse data of Belgian and Dutch women. Although Belgium and the Netherlands share the same language, geography and political system and have a common history, their health care systems diverge. The Belgian maternity care system corresponds to the ideal type of the medical model, whereas the Dutch system approaches the midwifery model. In this paper we examine multiple determinants, the fulfilment of expectations, labour pain, personal control and self-efficacy, for their association with satisfaction with childbirth in a cross-national perspective. METHODS: Two questionnaires were filled out by 605 women, one at 30 weeks of pregnancy and one within the first 2 weeks after childbirth either at home or in a hospital. Of these, 560 questionnaires were usable for analysis. Women were invited to participate in the study by independent midwives and obstetricians during antenatal visits in 2004-2005. Satisfaction with childbirth was measured by the Mackey Satisfaction with Childbirth Rating Scale, which takes into account the multidimensional nature of the concept. Labour pain was rated retrospectively using Visual Analogue Scales. Personal control was assessed with the Wijma Delivery Expectancy/Experience Questionnaire and Pearlin and Schooler's mastery scale. A hierarchical linear analysis was performed. RESULTS: Satisfaction with childbirth benefited most consistently from the fulfilment of expectations. In addition, the experience of personal control buffered the lowering impact of labour pain. Women with high self-efficacy showed more satisfaction with self-, midwife- and physician-related aspects of the birth experience. CONCLUSION: Our findings focus the attention toward personal control, self-efficacy and expectations about childbirth. This study confirms the multidimensionality of childbirth satisfaction and demonstrates that different factors predict the various dimensions of satisfaction. The model applies to both Belgian and Dutch women. Cross-national comparative research should further assess the dependence of the determinants of childbirth satisfaction on the organisation of maternity care.

Does a referral from home to hospital affect satisfaction with childbirth? A cross-national comparison.

BACKGROUND: The Belgian and Dutch societies present many similarities but differ with regard to the organisation of maternity care. The Dutch way of giving birth is well known for its high percentage of home births and its low medical intervention rate. In contrast, home births in Belgium are uncommon and the medical model is taken for granted. Dutch and Belgian maternity care systems are compared with regard to the influence of being referred to specialist care during pregnancy or intrapartum while planning for a home birth. We expect that a referral will result in lower satisfaction with childbirth, especially in Belgium. METHODS: Two questionnaires were filled out by 605 women, one at 30 weeks of pregnancy and one within the first two weeks after childbirth, either at home or in a hospital. Of these, 563 questionnaires were usable for analysis. Women were invited to participate in the study by independent midwives and obstetricians during antenatal visits in 2004-2005. Satisfaction with childbirth was measured by the Mackey Satisfaction with Childbirth Rating Scale, which takes into account the multidimensional nature of the concept. RESULTS: Belgian women are more satisfied than Dutch women and home births are more satisfying than hospital births. Women who are referred to the hospital while planning for a home birth are less satisfied than women who planned to give birth in hospital and did. A referral has a greater negative impact on satisfaction for Dutch women. CONCLUSION: There is no reason to believe Dutch women receive hospital care of lesser quality than Belgian women in case of a referral. Belgian and Dutch attach different meaning to being referred, resulting in a different evaluation of childbirth. In the Dutch maternity care system home births lead to higher satisfaction, but once a referral to the hospital is necessary satisfaction drops and ends up lower than satisfaction with hospital births that were planned in advance. We need to understand more about referral processes and how women experience them.