127 Knowledge and skills used for clinical decision-making on childbirth interventions with other healthcare professionals, such as other midwives, residents and obstetricians. They described how, in discussions, they are comfortable to deal with resistance or disagreement from other healthcare professionals and are prepared to defend their point of view. These midwives saw it as their duty to be the advocate for the woman’s wishes. They reported how it is necessary to be persistent in these discussions to achieve physiological care or the care the pregnant woman desires. During multidisciplinary meetings we are transparent and open. We honestly say what we think and what we want. […] Always as the advocate of the woman. It is very important that you neatly organize the desired healthcare plan for her.’ (Midwife 1) Some midwives who utilize high rates of interventions as part of their clinical practice described how they avoid discussion with healthcare professionals in the hospital, especially with obstetricians. Generally, they conformed to the wishes of the local obstetricians. ‘If someone has an Hb [haemoglobin] of 5.9, then you don’t have to do anything according to the national guidelines. But the obstetrician is not very happy when he gets someone on his operation table with an Hb of 5.9. […] So if it gets towards 6.0, we prescribe iron. Because we know the obstetrician doesn’t like it, you know.’ (Midwife 4) Overall, the results suggest that midwives who utilize low rates of interventions as part of their clinical practice explore women’s options and considerations to a higher extent, using a communication style that balances instrumental and affective communication skills, compared to midwives who utilize high rates of interventions as part of their clinical practice. In addition, the narratives of the midwives suggest that midwives who utilize high rates of interventions are less skilled to engage in discussions with colleague healthcare professionals. Discussion In this qualitative study, we explored how knowledge and skills influence clinical decision-making towards the appropriate use of childbirth interventions. We found that the level of reflection seems to differ among midwives with either a low or high use of childbirth interventions. Midwives who utilize low rates of interventions as part of their clinical practice described how they reflect on previous experiences and the evidence that influence their clinical decision-making. In addition, they seem to use more critical thinking skills during reflective moments as well as a communication style that balances instrumental and affective communication skills in interaction with the woman resulting in more personalized care. This personalized approach to maternity care may help in the pursuit for an appropriate use instead of routine use of interventions and may reduce medicalization in childbirth. 5
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