117 Knowledge and skills used for clinical decision-making on childbirth interventions Introduction The appropriate use of interventions in maternity care has attracted considerable international attention (1, 2). It appears that medicalisation of pregnancy and birth has negative consequences for women and babies, and results in higher health costs (2, 3). Therefore, medicalisation of maternity care has become a contentious issue worldwide. There is a growing body of evidence that care provided by midwives results in fewer medical interventions, and increased satisfaction with the birthing experience without differences in adverse perinatal outcomes (4). Regarding the appropriate use of interventions, using as little interventions as possible is not a purpose in itself, the purpose is to have the optimal balance between childbirth interventions and perinatal and maternal outcomes (3, 4, 5). Midwifery care provided by primary care midwives in the Netherlands attracts attention internationally, because of the high number of homebirths and the autonomy of midwives (6). Two third of Dutch midwives work as independent healthcare professionals in primary care, and are able to make, together with women, autonomous decisions about childbirth interventions or referral to obstetrician-led care (7). Around 87% of the Dutch pregnant women start their prenatal care in primary midwifery care, however, during pregnancy and birth a large percentage of women is referred to obstetrician-led care (8). The referral percentage for nulliparous women is around 74% and 55% for multiparous women (8). For a long time, the leading principle of maternity care in the Netherlands has been that pregnancy and birth are physiological and normal processes (9). Research exploring the background of midwives’ attitudes towards childbirth also suggests a common belief among Dutch midwives that pregnancy and childbirth are physiological processes and unnecessary use of interventions should be avoided (10, 11). Despite the fact that midwives seem to have a joint intention to promote physiological childbirth, different behaviours are seen towards clinical decision-making, resulting in variations in use of childbirth interventions including variations in referrals from midwife-led care to obstetrician-led care (12, 13, 14). Theories on human behaviour, such as the Attitude, Social norms, Self-efficacy model (ASE-model), are relevant for studying intention and factors influencing behaviour in human beings (15, 16). The ASE-model explains behaviour by linking attitude, social norms and self-efficacy with behavioural intention and actual behaviour. In addition to these three determinants of behavioural intention, factors such as ‘knowledge and skills’ and ‘barriers and facilitators’ also play a role in explaining behaviour. Earlier studies in the Netherlands on determinants of intention and behaviour towards clinical decision-making during childbirth, showed the influence of differences in midwives’ risk perception, work-experience, workload, setting (home or hospital), interaction 5
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