123 Knowledge and skills used for clinical decision-making on childbirth interventions information with the woman and her partner, is sufficiently embedded in their study program. ‘If you don’t learn during your placement to discuss in an open way, and also mention the benefits of giving birth at home [….], you will hear that once during the study program, I hope, but it will not become normal in your way of working and giving information.’ (Midwife 10) 3.1.2 Deepening the knowledge base Midwives in our study described how, over time, experience and reflection deepened their knowledge. 3.1.2.1 Learning through experience A second source of knowledge was knowledge acquired through practical experience by working as a midwife. Midwives in the study spoke about how their experiences with a cascade of interventions after administration of epidural analgesia, a fetal growth scan, or the diagnosis of gestational diabetes, deepens their understanding of the consequences of using interventions. ‘Especially by epidural analgesia. An IV is placed, followed by a catheter, an electrode on the head of the baby, laying down in the bed; the hospital’s “total package”. It all causes a lot of misery…’ (Midwife 2) In particular, midwives from the group that utilize low rates of childbirth interventions as part of their clinical practice spoke about the added value of knowledge from experience. Because of this knowledge, they gained confidence in the natural process of birth, and became more restrained in using interventions. Most midwives from the group that utilize low rates of childbirth interventions as part of their clinical practice reported that their experiences create the possibility to tailor the use of interventions to the individual situation, instead of following standardized recommendations suggested by national guidelines or local protocols. ‘The longer you work, the easier it becomes to feel free in decisionmaking, and to decide what is best in each situation.’ (Midwife 12) 3.1.2.2 Reflection on evidence Some midwives working in practices with a low use of childbirth interventions described situations in which they critically reflect on their own clinical decision-making. These midwives mentioned scientific literature they read and interpret to make clinical decisions regarding childbirth interventions in situations where no guideline or consensus exists. 5
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