RESUMEN
BACKGROUND: Midwife-led continuity of carer (MLCC) improves health outcomes and increases pregnant women's satisfaction. Working in smaller teams in community midwifery practices is one of the ways to promote continuity of carer. AIM: To gain insight into the experiences of Dutch community midwives regarding working in smaller teams, by identifying motivators and barriers. METHODS: A qualitative study was conducted using individual, semi-structured interviews (n=9). The sample was purposively selected. The interviews were analysed using the Abbreviated Grounded Theory. FINDINGS: Four themes were identified: 1) Ideal implementation of working in smaller teams, 2) Best care for pregnant women, 3) Conflicts with the current maternity care system, 4) Personal interests of the midwife. The core concept connecting all themes was midwives' experiences of an 'inner conflict' regarding working in smaller teams. CONCLUSION: A strong motivation for working in smaller teams is the wish to provide the best care for pregnant women through offering more continuity of carer. The structure of maternity care, financially and organisationally, acts as a barrier in the transition to working in smaller teams. How community midwives manage these motivators and barriers depends on their personal interests, vision, and personal life. The balance between the motivators and barriers can create an inner conflict among the midwives. This inner conflict encompasses an ethical issue: what is the best care and what is it worth? A discussion within the professional group concerning the practical and ethical aspects of working in smaller teams is needed to find ways to reduce the inner conflict of community midwives who wish to work in smaller teams, thereby promoting the implementation of MLCC.
RESUMEN
BACKGROUND: Episiotomy at the time of vaginal birth can result in short- and long-term complications for women. Therefore, it is important to study factors that influence the occurrence of episiotomy. AIM: To examine to what extent the individual factors of clinical midwives in the same working conditions contribute to variations in episiotomy. METHODS: A retrospective cohort study was performed at a secondary care hospital in Amsterdam, the Netherlands, using data from women who were assisted by a clinical midwife during birth in 2016. The clinical midwives filled out a questionnaire to determine individual factors. The predictive value of the individual factors of the clinical midwives was examined in a multiple logistic regression model on episiotomy. RESULTS: A total of 1302 births attended by 27 midwives were included. The mean episiotomy rate was 12.7%, with a range from 3.2% to 30.8% among midwives (p = 0.001). When stratified for parity, within the primipara group there was a significant variation in episiotomy among midwives with a range from 7.9% to 47.8% (p = 0.006). No significant variation was found in the occurrence of third/fourth degree tears or intact perineum. There was a significant difference in episiotomy for maternal indication among midwives (p = 0.041). Predictors for an episiotomy were number of years since graduation and place of bachelor education of the clinical midwife. CONCLUSION: This study shows that individual factors of clinical midwives influence the rate of episiotomy. Predictors for an episiotomy were the number of years since graduation and place of bachelor education. This shows that continuous training of clinical midwives could contribute to reducing the number of unnecessary episiotomies. Since suspected fetal distress is the only evidence based indication to perform an episiotomy, there is room for improvement given the variation in the number of episiotomies performed for maternal indication.