108 Chapter 4 accessible in obstetric-led care and women are referred if wanting or needing one (10,15). Still, our study shows that the attitude towards childbirth interventions is influenced by various factors even though the midwife has the autonomy to make her own decisions together with the woman. These findings can make midwives from both countries aware of the significant influence of their attitude on the way they practice midwifery. Influencing factors on the attitude did not depend on the work setting of the midwife, whereby the results of this study probably also apply to midwives working in a hospital. Changes in Dutch midwifery care According to social science, different responses to risk are seen depending on the perception of an individual or group (33). Childbirth in the Netherlands has long been defined as a physiologic process under the care of a midwife (8). Educational programs in the Netherlands still teach student midwives the basic attitude that pregnancy and childbirth are physiologic processes needing minimal interventions (34). However, studies on referral rates among Dutch midwives show a movement towards medicalization of midwifery care in the Netherlands (14). It appears, that some midwives can better retain their basic physiologic attitude compared to colleagues. For example, this study provided insight into different coping mechanisms of midwives according to fear of complications resulting in variation in application of interventions. In recent years, there has been a call in the Netherlands to provide more woman-centered care and the term ‘watchful attendance’ has been introduced (35). Watchful attendance is a combination of continuous support, clinical assessment, and responsiveness (35). Midwives perform regular clinical checks integrated into the whole dynamic of care. Many benefits of care with watchful attendance have been described (36), however, midwives’ motivation and individual skills are of great influence whether and how this care is provided (35,37). In addition, discussion continues that the current official workload is too high to effectuate woman-centered care in all its aspects (38). The number of midwives per 100,000 women in the Netherlands is only 31.1, making it one of the five western countries with the lowest number of midwives (39). In our study, midwives who wanted to provide woman-centered care made changes in their practice towards working in smaller teams or started working as a case load midwife, expecting a reduction in salary. Limitations and strengths Our sample of twenty midwives resulted in a wide variety of participants and information about experiences, beliefs, and values. This study included only midwives working in primary care, so its results cannot be generalized to those working in the hospital setting. Several steps were taken to minimize bias, such as using an interview guide, member checks, and interviewing the midwives by people unknown to them. The researchers were aware they had preconceived ideas, knowledge, and understanding that possibly influenced
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