How to Make the Hospital an Option Again: Midwives’ and Obstetricians’ Experiences with a Designated Clinic for Women Who Request Different Care than Recommended in the Guidelines
Abstract
:1. Introduction
2. Materials and Methods
2.1. Research Team and Reflexivity
2.2. Study Design
2.3. Study Population
2.4. Data Collection
2.5. Data Analysis
3. Results
3.1. Trusting Mothers, Childbirth and Colleagues
“People are often distrustful when they enter my room. Because they went through something and don’t just give in. They are often resistant, like ‘I really know what I want this time, what I don’t want and I’m going to fight for it, fight against you. I need to fight because you’re going to try to convince me to consent to recommended care.’ So that’s how the first conversation starts. At that point you’re already a few steps behind.”(Obstetrician 1)
“As long as I can monitor and determine whether intervention is necessary. […] So, when people allow me to monitor, if I can monitor mother and baby, I’m fine with it. […] It hasn’t happened to me yet that I wasn’t allowed to intervene while intervening was crucial. I don’t know why. Maybe, like we discussed before, that I build trust from the beginning on and that people think ‘She will only intervene when it is really necessary’.”(Hospital midwife 1)
“I know caregivers who say: ‘You need to trust me, because I want what’s best for you’. I think that trust is something you need to earn so you need to listen to your patient. Not until she asks about your idea of the situation, only then you will tell her. The chance of her listening to you is so much better than when you immediately start with: ‘I think this is right for you’.”(Caseload midwife 1)
“Trust is built by investing time, the first consultation at the clinic lasts an hour. During this consultation I want to know ‘who is this woman?’ […] It’s not about medical questions, I just want to get an impression of this person. […] Asking her about her vision is important, even if it differs from mine. […] That’s how I start my conversations at the designated clinic.”(Obstetrician 2)
“I would prefer that the care provider who did the whole care process at the clinic, would also attend the birth. And yes, that is logistically difficult and I understand it causes a certain pressure. It would be ideal for me, to have that continuity. Because I think it is sometimes inconvenient to perform an invasive medical procedure, when the woman does not know or trust you yet. For these procedures, a trusting relationship is essential. And you can’t always achieve that in ten minutes.”(Obstetrician 4)
“I trusted her because she could assess risks better than I could. Well, she just immersed herself really well into this specific medical topic. […] Besides, she was just really good in her reasoning, which made me have faith in a good outcome. […] I was not afraid that I would be traumatised myself because I had to conform to her choices. No, I trusted her that if I needed to do a certain intervention, for example give an oxytocin injection, that she would allow me to.”(Community midwife 1)
“She trusted that if I wanted to intervene, I would have a good reason for it. However, trusting me did not mean that she trusted the entire team. So, the difficult thing was that I couldn’t just leave her with anyone. Moreover, I could foresee that some of my colleagues would have a lot of difficulty with her birth plan. I was not sure that her wishes would be respected.”(Obstetrician 1)
“There was no need to intervene in the process because there was continuous foetal monitoring and she (the client) was handling the contractions really well. In the end she had the urge to push […] and her partner said ‘I feel that the baby is coming closer’. I thought: that’s fine, I don’t need to go and check. […] The baby was doing well so I didn’t need to intervene. All that time I sat on my chair and observed.”(Hospital midwife 1)
“It should be more common. That the collaboration is good and pleasant, that the obstetricians trust the community midwives. That we make sensible decisions and really don’t do crazy things.”(Community midwife 1)
3.2. A Supportive Communication Style
“Well, it helps if I understand, so I ask questions so that I can find out why it is so important to… I always try to find the motive behind the request, although some people are very obvious in formulating their question. Whereas other people say: ‘I want to birth at home’, while they actually mean: ‘I had a bad experience in a hospital and I feel like I had no say over my own body and I hope I will have that with a midwife.’”(Caseload midwife 1)
“I think what happens often is that there is non-verbal communication, but no verbal communication. Women see the disturbed faces of care providers, but they are not told what’s going on. This can do a lot of harm […] when care providers are afraid to say what’s going on during birth.”(Community midwife 1)
“I see myself as a guide. To provide information, and not just present it to her and say: ‘OK, this is it and make your decision.’ I think supporting her in making decisions is important. For example, I say: ‘You’re choosing this, but looking at what I know of you, this choice doesn’t seem to fit you altogether. Is this really the right choice for you? Does it fit your way of thinking and living, because to me it doesn’t match.’”(Obstetrician 1)
“Yes… what is a shared decision? A real shared decision does not exist of course. Because, imagine someone is pregnant and she does not want the baby and the partner does not agree, or the other way around, you can’t keep half of the baby. You keep it or you don’t keep it. It’s a ‘yes’ or a ‘no’. So, in the end there’s one person who decides. And that is the one who can say ‘yes’ or ‘no’. And that’s her (the woman).”(Obstetrician 1)
3.3. Continuity of Carer
“I think for many pregnant women continuity of carer is important. I think there are some women who find it less important, but if you know each other well it’s easier to sense what the woman needs during birth. (…) Knowing each other helps… to act better if you get into a situation. So, I think it contributes to a healthy birth. […] So, I think it really contributes to good outcomes, for mother and child.”(Community midwife 1)
“In the end, giving birth is about that people can shut their minds down and let their bodies do the work. And we, modern people are taught to think a lot and we are less used to listening to our body, our belly. Mutual trust can help women to trust their bodies, that they feel like they are able to do it on their own. And yes, you can give them some tools for that and one of these tools is continuity of carer.”(Caseload midwife 1)
“A vaginal birth after a caesarean with continuous electronic foetal monitoring attended by a community midwife… that’s fine. I think there are more indications […] that I would feel capable to be responsible for. Such as meconium-stained liquor or […] attending births of GBS-positive women who receive intravenous antibiotic prophylaxis. I completely support that.”(Caseload midwife 2)
“Well, I think, I don’t think you necessarily need to have one care provider in order to achieve personalised care, because we also don’t do that in our practice. […] So, we (midwives in the practice) […] have weekly meetings, and then for example, the client we talked about now, is discussed. Like ‘what is her wish’ and then everyone is informed. So, I don’t think continuity (of carer) is necessary.”(Community midwife 2)
3.4. Willingness to Reconsider Responsibility and Risk
“Things would be easy […] if women would completely conform […]. It makes everything more complex and beautiful that women make their own decisions. Being able to make your own decisions as a woman is really important. I think it’s a good development because giving birth is a rather intense life-event, and that’s something you should have complete control over. And with good information you can make choices that fit you. I don’t think that every woman fits in the same protocol.”(Community midwife 1)
“My main goal in a consultation is that patients make a well-considered choice when they have all the available information […] And that we finally arrive at a care plan that she supports, regardless of the outcome, that she doesn’t regret afterwards. […] Whether that’s inside or outside the protocol. […] And if the outcome turns out to be bad, she’s able to say: ‘It is what it is because I chose this consciously’.”(Obstetrician 1)
“I think it’s important to fulfil my medical responsibilities… Yes, I don’t want to cross my own limits. So, when someone has certain wishes and I am medically responsible for this birth, I can be held accountable afterwards. For instance, by a disciplinary judge. […] No continuous electronic foetal monitoring is no option for me. And often, if you discuss that with people, they are fine with it. They appreciate that you are willing to look at their wishes and see to which extent they are possible.”(Obstetrician 4)
“Well, of course, as a result of all these guidelines and—if I look at 27 years ago when I started as a midwife… back then, women with meconium-stained liquor just birthed at home. I was less anxious than I am now—if you want to call it anxious—I think I’m more careful these days. It has something to do with guidelines and perinatal audits where you need to justify your actions.”(Community midwife 3)
“I believe in freedom of choice. […] And to have a pregnancy outcome… I don’t just look at the medical outcomes, the woman’s birth experience is just as important. In my eyes, a birth experience is positive when there’s trust and freedom of choice.”(Obstetrician 2)
“I’ve been a midwife for nine years now and I’ve grown as a person. If I had to do this while I was recently graduated, I may not have done this, because I would have been afraid of… trouble, I think. Now I’m able to… I understand… I can empathise better with clients.”(Community midwife 2)
“Medically… I don’t always think it’s sensible. But if you look at absolute risks […] and you say: ‘I had a previous caesarean and I really want to birth at home with my midwife’, then the risk of something dramatic is really small. The chances things turn out well are really big. Weighing risks is difficult. […] I don’t know what my risk is of me getting involved in a car crash or a plane crash or die during childbirth. So, what does this 0.5 percent risk tell me? I have no idea.”(Obstetrician 3)
“Sometimes it’s complicated to discuss everything with five midwives. We’ve talked this case through many times. ‘What’s your personal limit?’ ‘What’s yours?’ ‘How do we do this then?’ ‘What do you accept?’ ‘What not?’ ‘What do we do when a woman with a previous caesarean needs continuous support when at the same time there is a homebirth?’ All that kind of stuff. Well, it’s inconvenient sometimes.”(Community midwife 3)
“You know, it costs a lot of time. I doubt if that is necessary. […] Because you want something that’s different from the guideline. And to which extent can I, as a midwife, care for this woman? […] I think, if you’ve said ten times ‘previous caesarean section, this woman wants to birth in the hospital with her own community midwife, the foetal heart pattern is interpreted by us (medical personnel) and the woman gets intravenous access’. Well, then you can say after five times, it went well so this is our new policy.”(Community midwife 3)
3.5. Core Theme: Guaranteeing Women’s Autonomy
“It is important that women make their own decisions, because it’s their own body and their own child. I don’t think that it only involves pregnancy, birth and the puerperium, but I think as long as you have children, you are the one to decide how to raise them and how you manage your health and theirs.”(Community midwife 1)
“Personalised care is about giving time and attention. […] Really empowering women. […] I think it’s very important that people feel empowered and think about things… how birth can turn out. I always say: ‘Even if it ends in a caesarean section, you can end up feeling good about it when you felt involved in decisions that were made. You don’t have to become traumatised then.’ This is a shortcoming of our regular system; women turn to me because they didn’t feel involved in decision-making during their previous birth.”(Caseload midwife 2)
“It’s about your view on your profession. A lot of people […] are educated—not explicitly—with the idea of ‘a patient has a problem and you need to fix it’. And when something happens, you decide which interventions you’re going to do. In my opinion, this idea is outdated. I don’t think all birth plans are sensible. But for me it is easier to accept these birth plans when I think that it’s not my decision, it’s not my body and it’s not my child.”(Obstetrician 1)
“Everyone says ‘the patient is central’. I question that. […] The protocol is central. And care providers constantly talk about how we practise woman-centred care. I actually think that in the Netherlands we practise midwife- and obstetrician-centred care. […] That is what we do, we think it’s in the patients’ interest, we do it with the best intentions. That’s the reason why change is so hard, because everyone thinks that this is the best way to do it.”(Caseload midwife 1)
4. Discussion
4.1. Achieving Mutual Trust through a Supportive Communication Style
4.2. How Trust, Medicalisation, Freedom of Choice and Negative Choices Are Related
4.3. Continuity of Carer
4.4. Risk and Responsibility
4.5. A Structured Approach
4.6. Autonomy
4.7. Strengths and Limitations
4.8. Implications for Practice
4.9. Directions for Future Research
5. Conclusions
Supplementary Materials
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
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Opdam, F.; Dillen, J.v.; Vries, M.d.; Hollander, M. How to Make the Hospital an Option Again: Midwives’ and Obstetricians’ Experiences with a Designated Clinic for Women Who Request Different Care than Recommended in the Guidelines. Int. J. Environ. Res. Public Health 2021, 18, 11627. https://doi.org/10.3390/ijerph182111627
Opdam F, Dillen Jv, Vries Md, Hollander M. How to Make the Hospital an Option Again: Midwives’ and Obstetricians’ Experiences with a Designated Clinic for Women Who Request Different Care than Recommended in the Guidelines. International Journal of Environmental Research and Public Health. 2021; 18(21):11627. https://doi.org/10.3390/ijerph182111627
Chicago/Turabian StyleOpdam, Floor, Jeroen van Dillen, Marieke de Vries, and Martine Hollander. 2021. "How to Make the Hospital an Option Again: Midwives’ and Obstetricians’ Experiences with a Designated Clinic for Women Who Request Different Care than Recommended in the Guidelines" International Journal of Environmental Research and Public Health 18, no. 21: 11627. https://doi.org/10.3390/ijerph182111627