105 Experiences, beliefs, and values influencing midwives’ attitude woman-centeredness and safety. For example, in a critical situation, they did not ask for informed consent before they acted because obtaining informed consent felt as losing time. We explain [in the pregnancy]: “… if you have a lot of blood loss we will administer oxytocin”. They will agree to it. During birth, you also need to obtain informed consent. I find that difficult. Sometimes I just want to administer it. (Midwife 15) Midwives who told us about their difficulties with supporting a woman’s preference when it differed from the national guidelines and local protocols, were more inclined to persuade the woman to follow the midwife’s healthcare management plan. This often included more interventions. Midwives gave examples of situations in which they persuaded or overruled the woman. In their stories, the midwife appeared to be the main subject instead of the woman. I look at what the patient wants. If I find it medically responsible, they can do anything they want to. But if things are not going in the right direction, I will put a stop to it. I try to explain why, and usually, they listen. (Midwife 20) All midwives mentioned that workload sometimes influenced the extent to which they provided woman-centered care and influenced their use of a particular intervention. Notably, midwives with a more wait and see approach described changing their work circumstances to be able to provide care from this approach. They choose to work in smaller teams or in shorter shifts, or even stopped working in a group practice and started working in caseload midwifery to create more time for each woman and experienced a lower workload. Midwives with a more check and control approach talked about the Dutch perinatal care system and the consequences of this system for the workload of a primary care midwife as an entrepreneur. The supportive and directive style From the analysis, two attitudes emerged that influenced midwives’ approach towards perinatal care: a wait and see attitude and a check and control attitude. In the three subthemes, the midwives in our study described what experiences, beliefs, and values influenced their attitude. We summarized this in figure 1. Midwives with a wait and see attitude described a more restricted approach towards interventions than midwives with a more check and control attitude. They described childbirth as a physiologic process that only needs an intervention when pathology occurs or at woman’s request. Experiences of uncomplicated births reinforced trust in the physiologic childbirth. Midwives with this attitude emphasized the importance of collaborating with healthcare 4
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