Patterns in primary midwife-led care in the Netherlands. Trends and variation intrapartum referrals.

Abstract

Summary This thesis describes and analyses labours of healthy women in primary midwife-led care in the years 2000-2008. During the study period the intrapartum referral rate from primary midwife-led care to secondary obstetrician-led care increased. As primary care midwives have to hand over care in case of such a referral, this resulted in more discontinuity of care for women. Non-urgent referral reasons such as request for pain relief and a perceived lack of progress explained this rise. The trend in referrals was accompanied by an increase in pharmacological pain relief during labour, augmentation of labour and continuous fetal monitoring. For nulliparous women the unplanned caesarean section rate also increased. At the same time, the incidence of intrapartum and neonatal mortality and low Apgar scores remained low, as can be expected in a low risk cohort. Midwifery practices showed considerable variation in intrapartum referral rates. Midwives appeared to differ in decision making during labour. Variation in risk perception and in protocols may contribute to this variation. The collaboration with the hospital team may also be important, as it is known that hospitals also show variation in obstetric interventions. The changes reflect an improved availability of pain relief, but also more fragmentation of care. Moreover, the increased use of interventions is accompanied with an increased risk of maternal morbidity. Although midwife-led primary care for low risk women results in a high level of spontaneous vaginal births and good perinatal results, there is room for improvement. Better continuity of care and higher chances of a physiological birth can be achieved without major changes in the current Dutch maternity care model. Improving continuity of care for women may also be achieved by extending primary midwife-led care in non-urgent situations. This is only achieved with good inter-professional collaboration with the hospital team. In the Netherlands, not only perinatal safety nee attention, tention should also be given to optimalisation of the possibilities for healthy women to have a normal birth. To improve quality of maternity care for healthy women, Om optimale kwaliteit van de verloskundige zorg aan vrouwen met een normale zwangerschap te realiseren is het belangrijk dat de kansen op een normale bevalling worden geoptimaliseerd, en dat niet alleen wordt gelet op het terugdringen van babysterfte. Dit kan gerealiseerd worden binnen de eerste lijn, zonder grote veranderingen in de organisatie van de verloskundige zorg in Nederland. Wel kan de taak van de eerstelijns verloskundige eventueel worden uitgebreid om de continuïteit van zorg tijdens de bevalling te verbeteren. Net als in andere Europese landen, kan zij dan de begeleiding van haar cliënten langer voortzetten als behandelingen zoals pijnbestrijding nodig zijn in niet-urgente situaties.