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Views of student midwives on the organisation of midwifery care and new maternity care models, including integrated care, in the Netherlands.” A qualitative study

Catja Warmelink(psychologist, lecturer, PhD student, 2 kids)

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City of Groningen

Since 1469

Since 2001

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Program

1. The current Dutch maternity care system2. Objective and methods of our study3. Data- analysis4. Results5. Validation measures6. Discussion7. Take home message

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The Dutch maternity care system

• Echelon-system with a strict role division between primary and secondary care

• The primary care midwife plays a key role

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The Dutch maternity care system

• Challenges, such as– relatively high perinatal mortality (Euro-peristat, 2013)

– organizational and coordination challenges (Schölmerich, 2014; Van der Lee, 2014)

– considerable rise in non-urgent referrals (Offerhaus, 2013; Perdok, 2014)

– decreasing home-births (The Netherlands Perinatal Registry, 2002, 2014)

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The Dutch maternity care system

• Reorganization to a more integrated maternity care system? (Schippers, 2014, de Vries, 2014).

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Objective and methods

• Objective: to explore student midwives’ perceptions on the organisation of midwifery care and (new) maternity care systems.

• Paradigm: interpretivist/constructivist (Boeije, 2008)

• Setting: Midwifery Academy Amsterdam Groningen • Participants: final year student midwives– 18 students in 10 individual interviews (7 in A’dam; 3

in Groningen) and 2 focus-groups (Groningen)• Design: constant comparison/grounded theory (Baarda, 2015)

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Data- analysis: Example of coding process1st level Fragment

2nd level Labelling

3rd levelCategory

4th levelTheme

“The media… that so much negative emphasis is placed on home births and that pregnant women now even find it more attractive to just (go to the hospital) #7

bad press shift toward medicalization

Society:Pressure to change

Change is in-evitable

“...a healthcare system that centres on the client, but then a self-determining client who also has confidence in herself again, and I think that the primary midwife has a great deal of expertise for restoring this confidence.” #4

client centered empowerment

Essential com-ponents

OK, if..

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Results

1. Change is inevitable, because ..

• Decline in numbers of home births• Shift towards medicalization• Bad press (media coverage)• Resentment and 'professional territorialism' • Pressure from government and health insurance

 

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Results

1. Change is inevitable, because ..

“…because it has also been a bit of a trend in other countries, where you see that pregnancy and birth are much more medicalised. So I can imagine that the same is going to happen here, too.” #1

“Very often I have the feeling that the gynaecologist thinks ‘you want to be autonomous, well you can just look after yourself then!’ And if you want to discuss something with this person, ...they first want to see the client and once they’ve seen the client, they basically already take over the whole thing”. #fg1

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Results

2. Change is OK, if….

• Good collaboration, mutual trust and respect• Client-centered care, empowerment• Preservation of physiology• Shared maternity notes system, guidelines, protocols• Emergency assistance accessible

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Results -

2. Change is OK, if….

“But sure, if it’s proven that the client could get better care from, um, that other system, integral care, then I would ... yes ... change, let’s say” #3

“Perinatal mortality in the Netherlands ... could also simply be reduced through better communication and better collaboration” #8

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Results

3. Change is OK, but…

• Don’t throw the baby out with the bathwater• Students are interested in:– Learning new skills

• Prescribing birth control • cardiotocography (CTG)• vacuum extraction {or ventouse}

– Supervising “medium risk” pregnancies and births• meconium-stained liquor, previous Caesarean, pain relief• Obese women, thyroid problems, diabetic patients

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Results

3. Change is OK, but…

“in other healthcare areas … integral care is indeed applied... but the big difference is ... if you’re pregnant, then you’re not ill. You’re quite simply healthy and so why should you have to go into hospital? And then you don’t need all kinds of healthcare providers... (and so) integral healthcare and midwifery might not really be the right match. #3

“So I think, yes, progress is always good of course... I just wonder whether it’s worth radically changing the whole system right now”. #1

“The more skills and actions you give up, then at a certain moment the less remains of your own professional profile. So maybe we should actually make sure we take on more tasks.” #fg1

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Validation measures

• Triangulation• Negative case analysis• Audit trial(logbook)• Peer debriefing (collegues)• Member checking (people involved)• COREQ (Tong, et al. 2007) • ‘Thick description’

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Discussion

The current Dutch maternity care system: vanguard or vestige?

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Take home message

• According to the students there will be a change in organisation of maternity care.

• Students are provisionally accepting of change

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Take home message

“Well, I think that a new generation of midwifery students will be less weighed down by all those years of conflict that’s been ongoing between primary, secondary and tertiary healthcare providers, so I hope that they’ll, er, approach things in a fresher way and can also play a role in making this more usual but ... erm ... in consultation and amicability, but sure, it will take a few years to overcome the old resentment, I think “ #2

“gynaecologists need midwives and midwives need gynaecologists. So it should then basically ... turn out OK”. #5

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Questions?

GRMA go raibh maith agat as ag éisteacht