Opinions of maternity care professionals and other stakeholders about integration of maternity care: a qualitative study in the Netherlands

The way in which maternity care is organized and by whom maternity care is provided shows substantial variation around the world. In a midwife-led care model “the midwife is the lead professional in the planning, organisation and delivery of care given to a woman from initial booking to the postnatal period” [1], in an obstetrician-led care model the obstetrician is the lead professional and in a shared care model the responsibility for the organisation and delivery of care is shared between different health care professionals. The degree of continuity of care is different in each model. In some models the midwife remains the main caregiver after referral to another care provider, whereas in other models the obstetrician takes over responsibility from the midwife entirely when a risk factor or complication occurs.

Maternity care in the Netherlands is organised in two echelons, midwife-led care and obstetrician-led care (Fig. 1), with professionals in these echelons working alongside and complementary to each other. Primary care midwives work autonomously and are responsible for the care of 85 % of women at the start of antenatal care (www.perinatreg.nl/uploads/150/153/PRN_jaarboek_2013_09122014.pdf). Women at low risk of complications, who are in midwife-led care at the onset of labour, may choose to give birth at home or in a hospital. During pregnancy 30 % of women in the Netherlands who start antenatal care with a primary care midwife, develop a risk factor or complication as listed in the national “List of Obstetric indications” [2], and are subsequently referred to secondary or tertiary obstetrician-led care. Responsibility is then taken over by obstetricians and most care is provided by clinical midwives [3]. A primary care midwife no longer has a formal role in the care of women referred to secondary or tertiary care. Of all women in midwife-led care at onset of labour 23 % is referred (www.perinatreg.nl/uploads/150/153/PRN_jaarboek_2013_09122014.pdf). This means that overall approximately two third of all women in the Netherlands give birth in an obstetrician-led care setting. Only 0.5 % of women give birth assisted by their general practitioner (http://www.nivel.nl/sites/default/files/Cijfers-uit-de-registratie-van-verloskundigen-peiling-jan-2013.pdf). In the Dutch system, a woman may be transported from home to hospital or from one hospital department to another in case of a referral during labour. Obstetric nurses assist both midwives and obstetricians and provide nursing care during labour in a hospital. Maternity care assistants assist the primary care midwives during labour and care for women at home during the first week after birth.

In the current restricted market-driven health care system in the Netherlands the government is responsible for safeguarding public interests. Health insurers play an active role as health care purchasers and as representatives of their clients’ interests (https://www.nivel.nl/en/governance). The insurance company pays the primary care midwife a fixed fee for care during pregnancy, birth and the postpartum period. This in contrast to the payments of maternity care in hospital, which are not transparent and differ considerably between hospitals [4]. However, the payment structure for maternity care is likely to change as the health insurance companies aim to introduce an overall integrated fee for all maternity care which should be divided among care providers involved.

Although the maternity care system in the Netherlands has been an example for other countries such as Canada [5] the system has also been subject of debate both nationally [6], and internationally [7]. A system with two separate echelons has disadvantages such as discontinuity of care as a result of referrals from midwife-led to obstetrician-led care [8]. Discontinuity of care increases the risk of inaccurate communication [9], and may lead to more interventions and less satisfaction among women [10].

Our previous research in the Netherlands showed that the majority of maternity care professionals are in favour of closer collaboration between primary and secondary care professionals to enhance personal continuity of care for women [11] which was defined as “integrated care” [11]. However, views differ widely on how to operationalise integrated care in practice [11]. In order to improve personal continuity of care, earlier research showed that primary care midwives are willing to expand their tasks to continue management of labour for women that are currently referred to an obstetrician once they have acquired the necessary skills. However, no consensus could be reached on the division of responsibilities and tasks [11]. For innovations in maternity care, such as integration of care, gaining insight into the opinions of health professionals and other stakeholders is important. Innovation strategies can then take these opinions into account.

In the “INtegrated CAre System” study (INCAS), we examined facilitating and inhibiting factors for integration of midwife-led and obstetrician-led care during labour amongst maternity care professionals. This study is the fourth sub-study within the INCAS-study (Fig. 1) [11–13]. The aim of this study is to gain insight into the opinions of maternity care professionals and other stakeholders on the integration of midwife-led care and obstetrician-led care and on facilitating and inhibiting factors for the implementation of this care.

In the face-to-face focus group more discussion and interaction was observed compared to the online focus groups. More comments were made during the discussion with the mixed health professionals by the obstetricians compared to the midwives. The number of reactions on the online forum was 52 responses for the primary care midwives and 46 responses for clinical midwives.

From the interviews and focus group discussions three main themes of integrating maternity care were identified. The first theme was client-centred care with the sub-theme client involvement, collaboration and the type of organisation. The second theme was continuity of care and the third theme was task shifting between professionals with the sub-theme midwifery training.

Facilitating and inhibiting factors for the implementation of integrated care were also identified: the payment structure and professional autonomy. Saturation was reached after seventeen interviews.

The aim of this study was to gain insight into the opinions of maternity care professionals and other stakeholders on the integration of midwife-led care and obstetrician-led care and on facilitating and inhibiting factors for the implementation of this care. For most professionals it appeared to be difficult to envisage a system, which does not yet exist and to think “out of the box”. Nonetheless, client-centred care and continuity of care for women were found to be important characteristics of an integrated maternity care system by participants. Opinions differed regarding the optimal maternity care organisation model. Participants indicated that inhibiting factors for integrating maternity care are the payment structure and fear of losing autonomy.

In this study we explored the relevant topics for our maternity care model, which is in the process of change. Other studies have not explicitly explored opinions regarding integrated care at both professional and management level. The combination of interviews and focus groups enhances trustworthiness of findings, making the results more robust. The interviews and focus groups generated a broad range of opinions regarding integrated care, giving a realistic impression of opinions in the whole field [14] at both professional and management level. The stakeholders were asked not to give their personal opinion but that of the organisation they represented. We realise that this was sometimes difficult for participants. The advantage of bringing together a diverse group of professionals for our face-to-face focusgroup was that it maximized exploration of different perspectives. However, hierarchy may have affected individual participants [18]. Since obstetricians made more comments compared to the midwives during the face-to-face focusgroup, this may have been the case in this study causing overestimation of the weight of themes. Because the interviews were carried out by telephone and two focus groups were carried out online, it was not possible to observe body language of the participants. The fact that interaction amongst participants in the online focus groups was limited may have been the result of participants not meeting face-to-face. This could also have been the result of not being able to supervise the discussions 24 h a day and respond to participants immediately.

The current restricted market-driven health care system in the Netherlands might strengthen the individual interests of professionals, instead of stimulating collaboration between professionals to achieve optimal care (http://www.nza.nl/104107/139830/465987/Advies_Bekostiging_-integrale-_zorg_rondom_zwangerschap_en_geboorte.pdf). If a woman is referred to the obstetrician during pregnancy, remuneration could be the “trigger” to keep her in obstetrician-led care and vice versa, finances could “trigger” midwives to take care of women longer than they would if finances did not play a part. Participants in our study and in the study of Avery et al. [19] recognize the “finance driven competition for clients” and agree that this must be changed in a modified system, as this does not help to achieve optimal care for clients. However, opinions differ with regards to the design of a new payment structure from an integrated tariff to separate tariffs for each professional group, which could be nationally or regionally determined. Participants agree that health insurance companies should not be allowed to have a major role in determining care policy. To support a decision on the best maternity care system and one that is economically feasible, the Dutch Healthcare Authority (NZA) has stimulated experiments in pilot regions, which are currently being carried out (http://incas2.nl/INCAS-2/).

Participants in our study state that the two separate echelons, which currently exist, may have disadvantages with regards to continuity of care. In countries such as Canada (http://www.canadianmidwives.org/DATA/DOCUMENT/CAM_ENG_Midwifery_Care_Normal_Birth_FINAL_Nov_2010.pdf) and New Zealand [20] midwives move between primary and secondary care settings leading to more personal continuity of care for women. All participants in this study mentioned that personal continuity of care for women is important. This is consistent with earlier findings showing that there is consensus among professionals to minimize the number of professionals involved during labour [13] clients appreciate the continuity of care given by a primary care midwife after referral [21], and clients rate the quality of care higher if they know their care provider prior to going into labour [22]. In our study participants pointed out that this can be achieved if the primary care midwife could remain the caregiver for women with a moderate risk indication, with or without consulting a clinical midwife or obstetrician. However, to realise continuity of care, task shifting is needed but this in itself can be seen as an inhibiting factor for integrating care. Both this study and prior research [11] show a lack of agreement among maternity care professionals with regard to task shifting.

Participants in our study mentioned client-centred care as an important basis for a maternity care model. However, it remains unclear how patient preferences should be balanced with physicians’ opinion [23]. In line with this, our study shows that tension exists between professionals related to the level of client involvement in maternity care, which ranges from the opinion that all decisions should be made by the client to the other extreme that the professional decides what is best for the client. Our results are in accordance with literature [24] showing that opinions of maternity care experts are divided with regards to the amount of professional advice that should be given to women. Our suggestion is that professionals in the Netherlands give more information specifically tailored to each individual woman and move to a model of Shared Decision Making (SDM) which has been shown to have a positive impact on the childbirth experience [25]. SDM is defined as “an approach where the clinician and client share the best available evidence when faced with the task of making decisions, and where the client is supported to consider options, to achieve informed preferences” [26]. Open and respectful communication between women and care professionals will help practitioners in SDM [24]. As well as supporting the client, a common orientation towards the client is beneficial for the success of interdisciplinary teams [27].

Different regions in the Netherlands already have experience with some form of “integrated care”. For example, in one region, the primary care midwife continues to care for women with moderate risk indications during birth [28]. Midwives in our study indicated that although the workload was high in this region, work satisfaction was even greater and satisfaction among clients was very high compared to other regions. In contrast, obstetricians in our study held the opinion that further specialisation is needed among all professionals to increase volume of practice and ensure optimal quality of care. However, literature shows that professionals might best serve the client by providing continuity of care [21] and having common goals and visions among professionals [29].

The current training of midwives and obstetricians is completely separate in the Netherlands. However, participants indicated that some combined education for maternity care professionals would be better to share ideas and broaden their horizon. The importance of interprofessional training is widely accepted [19, 30] and can help develop professional competence, a joint attitude towards the client, interprofessional respect [27] and better teamwork, which could improve quality of care for women.

In contrast to countries such as Canada and New Zealand (http://www.canadianmidwives.org/midwifery-education.html; https://www.midwife.org.nz/education) where midwifery training leads to a university degree, midwifery education in the Netherlands is at higher professional education level. Several participants agreed that it is necessary to upgrade midwifery training in the Netherlands. A few participants were sceptical about this, as they fear that the “practical hands-on midwifery” could disappear. However, general practitioners in the Netherlands have a history of upgrading their level of practice from a Bachelor to a Master’s Degree. This change in academic education has enabled them to support their clinical practice with scientific evidence [31], which strengthened the profession. Currently, the Midwifery Academies are developing a new curriculum at Master’s Level (www.verloskunde-academie.nl/academisering/). Training at academic level will enable the midwife to be a strong advocate for clients by translating scientific evidence in a way that enables pregnant women and their partners to make the choices that are right for them. An academic partner for obstetricians could facilitate the integration of maternity care.

Autonomy is considered to be very important by midwives and obstetricians because they do not want to lose control and independence in their clinical decision-making. In the current maternity care system collaboration already exists between the two professions although they are autonomous in making decisions regarding the management of care. Midwives and obstetricians in this study and professionals in our previous Delphi study [11] expressed fear of losing this autonomy if maternity care is integrated. This is complicated by the fact that professionals disagree about role boundaries [11, 29]. In addition, deep-seated philosophical differences about childbirth generate tensions [32]. In this study participants agreed that to improve good collaborative practice between midwives and obstetricians, respect and accountability are essential as well as clearly identified responsibilities for the different professionals. In the UK, stricter delineation of the boundaries between midwifery and obstetrics increased the confidence and professional visibility of midwives but left doctors feeling excluded and undervalued [33]. In order to achieve good collaborative practice, instead of mainly focussing on autonomy, the skills and qualities that form the basis of “professional courtesy” need to be recognised in one another [32].

Since the start of the data collection in this study, several regions in the Netherlands have already initiated some form of integrated care but a lot of regional variation does exist. A follow-up study is on-going in which these regions will be valuated in terms of clinical outcomes, experiences of women and professionals and costs. By comparing outcomes and experiences between regions, lessons can be learned about the optimal model of integrated care.

Maternity care professionals and other stakeholders who participated in this study indicated that the optimal maternity care system should be client-centred, provide continuity of care for women during labour and birth and include a shift of responsibilities between health care providers. However, opinions differed with regard to the optimal maternity care organisation model, which could complicate the implementation of integrated care.

Important factors for a successful implementation of integrated maternity care are an appropriate payment structure and maintenance of the autonomy of professionals. These factors need to be addressed when implementing an integrated maternity care system.