179 General discussion midwifery care, such as increasing rates of referral to obstetrician-led care, require a critical evaluation of the statement that Dutch midwives ‘guard physiology’. Midwives need to reflect on their clinical decision-making and whether it is influenced by their personal values and beliefs (28). Reflective practice has been used in midwifery education for several decades. However, there are different interpretations of the concept of reflective practice and it is known to be prone to oversimplification in practice settings (29,30). The Model of Holistic Reflection for the Bachelor of Midwifery program has been developed as an educational tool to support midwifery students to require reflective and critical thinking skills (31). Embedding this model into Dutch educational programs will help student midwives to develop into critically reflective and reflexive practitioners, who demonstrate self-awareness and the ability to discuss. Midwives can be helped to understand their own practice through the use of reflection on action during peer review meetings with colleagues, which helps to make sense of their experiences and identify patterns in practice (30). Nevertheless, midwives need to go beyond reflection on action and should also include reflection in action as part of their practice (32). This makes reflective practice an active process of doing rather than just thinking, offering the opportunity to change actions as they unfold. Genuine reflection is challenging because it requires time, effort and a willingness to question your actions, underlying beliefs and values (33). Reflective models, such as the Model of Holistic Reflection, can promote deeper reflection instead of an uncritical and descriptive cause-and-effect analysis of experience also for graduated midwives (31). Overall, it seems that midwives with a more wait and see attitude are more likely to have the skills of a reflective practitioner. This enables them to provide more personalised care and the use of childbirth interventions appropriate for that situation. Because midwifery practice is dynamic, and the effectiveness and application of interventions depend on the context, midwives need critical thinking skills to examine this (9,29,30). The context of midwifery practice depends on a number of factors, including the preferences of the patient, the expertise and experience of the midwife, and the regional setting. The balance will therefore vary from one individual situation to another. Context-based care consequently introduces greater uncertainty for the healthcare professional, as each decision requires a new weighing of elements (9). It seems that familiarity with and accurate interpretation of the scientific literature and guidelines enables them to contextualise the literature and deviate from established protocols. This results in a more nuanced approach that is responsive to patient preferences, addresses uncertainty, and consequently reduces unwarranted interventions. 8
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