97 Experiences, beliefs, and values influencing midwives’ attitude Introduction The rates of childbirth interventions have shown a steady increase in the last decades (1). For example, in 2000 a caesarean birth was performed on 12.1% of all births worldwide. This number almost doubled in 2015, where the caesarean birth rate was 21.1% (2). Interventions during pregnancy, childbirth, and the postpartum period can prevent both perinatal morbidity and mortality. Inadequate access to timely childbirth interventions jeopardizes positive birth outcomes (3). Conversely, medicalization of normal antenatal, natal, and postnatal care by using unnecessary interventions has negative consequences and seems an even larger problem worldwide (3,4). Childbirth interventions have the potential to harm women, physically and mentally, and their newborns, and therefore unnecessary use should be avoided (5,6). In addition, overuse of childbirth interventions leads to higher health costs (7). Worldwide, the Netherlands is known for its low intervention rates and high rates of home births. In this country, childbirth has long been defined as a physiologic process where the woman can choose to give birth at home or in a hospital under the care of a midwife (8). Dutch midwives are supposed to be the guardians of physiology and advocate for non-intervention in physiologic childbirth (9). Two thirds of the midwives work in community group practices with 2-5 midwives as independent health professionals paid by insurance companies. They provide antenatal, natal and postnatal care to healthy women registered in this practice, who can choose to give birth with their midwife at home or in the hospital (10). Dutch primary care midwives are an integrated part of the Dutch perinatal care system and collaborate with one or more hospitals in their region (10). The other third of the midwives are employed by hospitals and take care of women with complicated pregnancies or births under the supervision of obstetricians. Almost 90% of pregnant women start antenatal care in midwife-led primary care (11). Midwives refer women to obstetrician-led care when risks of adverse outcomes increase or complications arise (12). Criteria for referral are described in the obstetric indication list of 2003, however, every primary care midwife has the autonomy to refer to obstetrician-led care at any point in care. In addition, primary care midwives can make autonomous decisions together with the woman to perform certain childbirth interventions such as artificial rupture of membranes, episiotomy, and postpartum administration of oxytocin. During the past decades, a rise in childbirth interventions has been described in the Netherlands (13). Additionally, large variations in childbirth interventions are described between regions in the Netherlands and between Dutch primary midwifery practices, without differences in neonatal or maternal outcomes (12-14). These variations cannot be explained by variation in populations’ characteristics and it remains unclear why a group of autonomous midwives in the same small country shows such a wide variation in use of childbirth interventions (12,13). Previous research showed a positive correlation between 4
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