119 Knowledge and skills used for clinical decision-making on childbirth interventions 2.2 Setting In the Netherlands, low-risk pregnant women can choose to give birth at home, in a birth centre, or in hospital under the supervision of their independent midwife. Women will not receive interventions such as epidural analgesia, augmentation, or continuous fetal monitoring while in primary midwife-led care. If a woman wants these interventions or if they become necessary, a referral to obstetrician-led care is indicated. Therefore, referral to obstetrician-led care is seen as an intervention in this study. Criteria for referral are described in the List of Obstetric Indications (9). 2.3 Participants Participants were purposive sampled and included midwives from midwifery practices with either a low- or a high use of childbirth interventions in order to explore differences between these two groups. The definition of low- or high use of childbirth interventions is based on literature describing variations in childbirth interventions (14, 19). For the purpose of this study we used data from the Dutch national perinatal register Perined to identify midwifery practices with a high or a low intervention rate (https://www.perined.nl/). Practices in the group with a low intervention rate had a combination of three factors: low referral rate (<35th percentile), a high homebirth rate (>65th percentile), and a low episiotomy rate (<35th percentile). Practices considered as having a high use of interventions had the combination of: a high referral rate (>65th percentile), a low homebirth rate (<35th percentile) and a high episiotomy rate (>65th percentile). We invited midwives from 46 midwifery practices, 23 for each category (low and high use of interventions), taking into account geographical locations and practice sizes to include various types of practices throughout the Netherlands. We intended to interview one midwife per practice. We send a reminder two weeks after the invitation. 2.4 Data collection Before the interviews, we distributed a short questionnaire to collect the participants’ demographic characteristics. The face-to-face interviews were conducted in June 2019 by four interviewers with a midwifery background, and without a personal relationship with the participants. It was unknown for the interviewers to which of the two categories the participant belonged. The first two interviews of each interviewer were observed by another member of the research team to ensure validity, consistency and enhance quality across each of the interviews. After the first four interviews, the research team made small adjustments to the semi-structured question route, in order to reinforce the narrative approach. The interviews were audio-recorded and transcribed verbatim for analysis. Each participant received a transcription of the interview for a member-check. We anonymized and encrypted the transcripts, together with field notes, the data were safely stored and only accessible for the research team. 5
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