RESUMO
BACKGROUND: Dutch maternity care is based on the principle that pregnancy and childbirth are physiological processes. However, the last decade an increase of intra-partum referrals to obstetric-led care has been observed. Most of these referrals are among nulliparous women, non-urgent and occur during the first stage of labour. The increase in referrals seems not associated with better perinatal outcomes. OBJECTIVE: Gain understanding of underlying factors in the decision-making process prior to referral to obstetric-led care among midwives attending childbirth in midwifery-led care. METHOD: A qualitative study based on in-depth interviews with Dutch midwives (n=10) working in midwifery-led care. We performed a thematic analysis based on the hypothetico-deductive and the intuitive-humanist theory. RESULTS: Midwives mentioned knowledge as the basis of a reasoned decision. This included both theoretical knowledge, and knowledge from clinical experience. Influences of others, like the needs and wishes of labouring women were another factor influencing the decision-making, especially in non-urgent situations. Under subjective factors, the fear of being held responsible for professional choices emerged. KEY CONCLUSION: The decision-making process during childbirth is multi-factorial. The women's needs and wishes are recognized as of great influence on the decision-making process during childbirth, which is not included as a factor in the hypothetico-deductive or the intuitive-humanist theory. IMPLICATION FOR PRACTICE: The influence of women's needs and wishes should be part of models about the intra-partum decision-making process. Midwives should find strategies to support women to make well-informed choices that include adequate information on the consequences of medicalisation in obstetric-led care.