103 Experiences, beliefs, and values influencing midwives’ attitude These midwives described that they performed more interventions then recommended in the national standard due to this feeling of authority. I sometimes think: “what does the obstetrician think about it [care management]?”. That is on my mind when I don’t achieve a certain result within a certain time. (Midwife 7) Other midwives experienced local protocols as restrictive and they often felt obligated to follow them, as this was mutually agreed at a local level. They felt internally conflicted between conforming to the local agreements, and their view on how much value the intervention added. Midwives in our study did not mention any internal conflict about the national guidelines, only about the local protocols. The standard offering of OGTT for risk factors is something I feel compelled to do because those are the agreements. But, I’d rather not do it because I don’t support this regional management. I feel compelled from the outside . . . (Midwife 9) In our study, most midwives strived for collaboration based on equality with obstetric care providers. Nevertheless, midwives reported experiencing a difficult relationship with obstetricians and hospital-based midwives due to the different perceptions over what constituted the minimum necessary care for low-risk women. Midwives described how they succeed in defending their physiologic statements in regional collaboration sessions. As a result, the regional protocol included fewer mandatory interventions than had been requested by obstetrician-led care providers. In our region, the postpartum hemorrhage protocol stagnated for a long time. In the end, we managed to cancel the obligation to administer oxytocin by default. So yes, we fight . . . it feels now and then a bit like fighting, but that ultimately helps to ensure that you don’t have to justify yourself for everything every time. (Midwife 10) Trust and fear Trust and fear seemed to be important factors in directing midwives’ attitudes towards the use of interventions. Midwives in our study mentioned that their experiences influenced their fear for complications. They described how experiencing uncomplicated situations boosted their trust in physiologic childbirth, and made them feel more restrained towards the use of interventions. 4
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