146 Chapter 6 An interesting finding is the difference between community and hospitalbased midwives. Our results showed that hospital-based midwives’ scores on the BBS-Nat and the BBS-Med subscales were intermediate between the scores of community midwives and obstetricians, being a distinct group. All midwives educated in the Netherlands follow the same bachelor program, regardless of their later choice of workplace (23). Our findings suggest that beliefs are influenced by the work setting. This is consistent with previous research showing that healthcare professionals adapt their practice to their colleagues and local circumstances, also including managerial demands (24–26). More specifically for maternity care, Thompson et al (20) described the hospital culture as a barrier to practices that promote physiological birth. The influence of the hospital culture can be an explanation for the BBSprofessional scores of hospital-based midwives. When community midwives make the transition to work as hospital-based midwives, their beliefs may be influenced by this culture and a higher incidence of pathology, creating a distinct group with intermediate BBS-professional scores. Another explanation can be that not all student midwives have the same beliefs at the end of their midwifery training, as described by Feijen- de Jong et al (23). It is possible that student midwives with beliefs more supportive of a medical approach are more inclined to choose to work in a hospital setting. Association of beliefs with type of MCN and work experience In our study, we found clear differences between the different disciplines of professionals, and only small effects on the BBS-Nat subscale for the two types of MCN. Therefore, we cannot conclude that professional’s birth beliefs contribute to regional practice variation. Previous research has shown that variation in intervention rates appears to be dependent on regional culture (4,13). Since beliefs are a factor in the attitudes of maternity care professionals, but not the only factor to actual behaviour toward childbirth interventions, the 11-item BBS is probably limited to discriminate between differences in regional culture (10). An instrument that also considers other influencing factors, such as communication skills and collaboration, would probably be more appropriate to measure differences in regional culture (27). According to years of work experience, there was a small decrease in BBS-Nat score with more years of work experience for community midwives in both types of MCNs. A small increase in BBS-Nat score was seen in both types of MCNs for hospital-based midwives and obstetricians with more years of work experience. As a result, total scores on the BBS-Nat of the different disciplines were less divergent when years of work experience increased. An Australian study among midwives and obstetricians also found an influence of years of work experience on the beliefs and attitudes of maternity care professionals, but was inconclusive about whether there was an effect on medical or natural beliefs about childbirth (12). Further research is needed to investigate the association between beliefs and work experience.
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