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.
Most participants agreed that client-centred care is a prerequisite for optimal care, which is the aim of integrating midwife-led and obstetrician-led care. To achieve client-centred care participants indicated that clients must be involved in management of care and decision-making. Moreover, good collaboration between primary and secondary care is needed within an organization: the client should experience a smooth transfer from primary to secondary care.
Participants expressed different opinions on the optimal level of client involvement during pregnancy and labour. Opinions varied from freedom of choice for women to limitations prescribed by the professional responsible for medical care, in case of a risk factor.
“But it is about giving a patient all options, including all risks involved of course. But the patient should be allowed to choose. A patient should decide because it is all about the patient. Sometimes it can be different, it may perhaps be better, medically, to choose another option. But a patient may interpret quality of life differently sometimes. Incomprehensible for a medical professional”. (Representative of a Client organisation, interview #11).
Participants mentioned a variety of examples with regard to the degree of client involvement for the place of birth and caregiver. Opinions ranged from believing that clients should have the freedom to choose the place of birth based on informed consent, to the opinion that clients should not have a choice in the place of birth at all. Concerning the choice of caregivers, opinions ranged from ‘clients should have complete freedom in choosing their own caregiver’ to ‘caregivers should decide which caregiver should be involved, as clients cannot be held responsible for medical decisions’.
“I think it’s good to involve the patient but you cannot pass medical responsibility on to the patient. Caregivers must ensure that they can offer a good service. With adequate level of care […]. Trust in the system will then arise”. (Representative of the Dutch College of General Practitioners, interview #2).
Good collaboration between primary and secondary care was said to be a condition for client-centred care. Several participants agreed that it is important to organise multidisciplinary training for maternity care professionals, to improve collaboration in emergency situations and to have knowledge of each other’s competencies and working methods. According to participants, shared training and more involvement in each other’s working environment could improve communication between professionals as well as improve the quality of care.
“Yes, I think that if we talk about training, if we would train multidisciplinary, structurally training the whole chain of professionals, that that could have additional value. Occasionally you can see this happening here and there during the “skills and drills training” but this could be very much extended I think”. (Representative of the Royal Dutch Organisation of Midwives, interview #13).
“We have gained a better understanding of each others profession: by getting to know the other, trust arises in knowledge and skills. It works two ways: physiology when possible and medical interventions when necessary”. (Primary care midwife, online focusgroup #10).
Type of organisation
Respondents had difficulty describing which type of organization would be ideal in order to provide more client-centred care during labour. However a well operating chain of care was mentioned several times: care in which the various partners work together in a birth centre and the client should experience a smooth transfer. Most participants in both the interviews and focus groups held the opinion that all caregivers should work in the same building and that clients who want to give birth in hospital should not have to be moved to a different department or room when a referral is indicated. According to them, the labour ward must be accommodated and equipped to the needs of both the primary care midwife and the obstetrician.
“In that type of care [care with division between primary and secondary care], you are still talking about a primary care birth centre where you only carry out primary care things. I do not think that this is the concept of the future because if a woman needs medical attention, which occurs quite often, one has to lug the patient around to another location in the same hospital. I envisage that our care will eventually merge more and more. […] That there should be no door in between, that you can do the transfer from primary to secondary care totally transparent within one open space”. (Representative Project management organisation in maternity care assistance, interview #10)
One primary care midwife emphasised that the primary care midwifery practices should be part of a larger cooperation to create more efficient collaboration. Participants of one focus group mentioned the need of a team of eight to twelve professionals for the system to function well.
“We have had some discussions to combine the various midwifery practices into one large [primary care] centre. Antenatal clinics on more than one location, shorter routes for consultation or referral. Choice of place of birth and home birth guaranteed. […]. Joint consultations can subsequently be organized more effectively, as well as training etc. There are a lot of advantages to it, except for the bigger scale”. (Primary care midwife, online focus group #2)
A counter argument was that if organisations are too big, this could lead to professionals having many meetings at the expense of care for clients.
“And of course it will be very nice for the College of Perinatal Care to soon be able to say how well everyone is collaborating regionally, but what we see is that it mainly consists of managerial meetings of people who have never seen a postpartum woman before or it has been a long time ago”. (Representative of the Dutch Organisation for Maternity Care Assistants, interview #6)
Continuity of care
It was a commonly held view by both maternity caregivers and stakeholders, that continuity of care during labour is important for women in an integrated care system. Although in the current system the primary care midwife only cares for women at low-risk of complications, several participants of both echelons, indicated that primary care midwives should also be the main caregivers after referral during labour so women continue to have the same caregiver. A primary care midwife who already provides this type of care said the following:
“We conduct regular client satisfaction surveys which show that pregnant women have difficulty with the large number of midwives in our practice … with regards to birth, our pregnant women don’t know any better other than that the midwife will assist them to give birth, and that she has both primary and secondary care responsibilities.” (Primary care midwife, online focus group #10).
Some participants made a distinction between low, moderate and high-risk indications. The following examples of moderate risk indications were given: meconium stained amniotic fluid, need for medical pain relief, prolonged rupture of membranes and a previous caesarean section. Participants stated that primary care midwives could continue to take care of women in labour also when moderate risk situations occur, if necessary after consulting or under supervision of a clinical midwife or obstetrician, leading to a more integrated way of working.
“I think that you will have to let the ordinary [primary care] midwives support physiology as much as possible and that they will really try their best to really assist people. More nitrous oxide and water injections etc. Doing everything that’s possible with regard to pain relief in primary care. Then the midwife will accompany women and finish things [labours] that are expected to end fairly soon. Meconium, induction of labour and so on…” (Representative of Midwifery cooperation, interview #17).
“Maybe formally the obstetrician will remain responsible but the midwife continues to provide care. And more training will be given with regards to surveillance and pathology (Representative of project management organisation in maternity Care Assistance Organisation, interview #10).
Other participants preferred to adhere to the current system in which the obstetrician takes over the responsibility of care when a moderate or high risk occurs and the primary care midwife assists low risk women remaining skilled in physiological birth. It was noted that the transfer of care must be ‘seamless’ which should be supported by a joint electronic record system and shared protocols.
According to the majority of participants integration of care will lead to task shifting for all maternity care professionals. This should involve extra training for professionals taking over certain tasks as a condition to obtain new competencies. An example of task shifting is when the “maternity care assistant”, who currently assists the primary care midwife at home during labour would continue to provide assistance to women after referral to hospital. This would mean a shift of tasks from the obstetric nurse to the maternity care assistant for moderate-risk women.
“I think the maternity care assistant will also have more tasks in the field of risk identification and more coordination with the midwife, and of course providing assistance during labour. […] The maternity care assistant will receive more training in these things and will become more like the obstetric nurse. If the maternity care assistant will be better trained, I think that hospitals will make more use of maternity care assistants during a hospital birth assisted by a primary care midwife”. (Representative of a Health insurance company, interview #8).
Some midwives mentioned the need for specific competencies such as the ability to interpret continuous electronic fetal heart rate monitoring (EFM). Other participants, however, argued that the primary care midwife should not carry out interventions such as EFM because they would not perform these often enough to guarantee good quality of care.
“We work with primary care midwives, and they interpret EFM, you know it is all relative and of course it is possible if you have been trained. But I doubt that it is efficient […] you need enough cases and a lot of practice to be good at the secondary care tasks. […] It is about volume of practice. I do not agree with midwives who say they can do both primary and secondary care. We obstetricians have to specialize. Within our team of obstetricians, six of the seventeen have obstetrics as their main field of practise. We try and have one of these six available during every shift. I don’t agree with a midwife saying: “we can all do the same”. Acknowledge what you’re not so good at, and have someone else do that”. (Obstetrician, face-to-face focus group #1).
Participants agree that training is required if tasks are shifted to other professionals.
Several participants agreed that it is necessary to upgrade midwifery training to an academic level, to be capable of performing more specialised tasks and conducting research. However, some participants prefer to maintain midwifery at a higher professional education level, as they are afraid that upgrading midwifery to a university Master level will be at the expense of hands-on experience of student midwives.
“I think that you mainly need hands at the bedside and if every midwife is academically educated, I think a lot of power will be lost at the bedside; maybe that is not quite the right word [bedside], in care. […] I think that you disqualify yourself as well by saying that you need an academic education. That would mean that you don’t do it [provide care] well enough at the moment. I do think that they do very well at the moment [provide care]. Rather, you must believe in your own strength, like: we do it our way, and the obstetrician complements that and vice versa”. (Representative of the Ministry of Health, interview #5).
Facilitating and inhibiting factors
From the interviews and focus group discussions facilitating and inhibiting factors for the implementation of integrated care were identified. Two factors were found to be most important: the payment structure and professional autonomy.
Some participants indicated that the payment structure is a sensitive subject. Participants expressed their concern that in a different payment structure, cost savings could occur which could possibly lead to a reduction in income for health professionals. These concerns may be the cause of resistance to the development of a new funding system.
“Yes, money, we avoided that a little bit up until now. Yes, but everyone avoids it and at a certain moment you will have to address the issue”. (Obstetrician, face-to-face focus group #1)
“Those are things [money] with which people are less willing to take risks. And that starting point makes that it remains a sensitive subject”. (Representative of Midwifery cooperation, interview #9)
A few participants considered the current financial structure as a threat because referrals from primary care to secondary care or vice versa may be “finance-driven”.
“At the College of Perinatal Care we are already in favour of an integral payment structure, stemming from the thought that the current system sometimes has incentives for midwives and obstetricians to keep a woman in their care or, say, not return her [to the original caregiver.] It would be better if those incentives no longer existed and that you might have an incentive to collaborate”. (Representative of the National collaborating organisation for perinatal care, interview #12)
In addition, participants indicated that the influence of health insurance companies should be limited so that optimal care for women can be provided without financial hindrance.
“Our common goal should be: to give the best care without any form of personal interest or financial drive”. (Representative of the Dutch Society for Obstetrics and Gynaecology, interview #18)
Opinions on how a new payment structure should be defined differed among participants. A fair distribution of money between care providers based on the actual work performed was said to be important.
Participants of both the focus groups and interviews indicated the importance of professionals functioning as a team.
“Both midwives and obstetricians are trained to function autonomously but I hope we can change that into functioning as a team”. (Obstetrician, face-to-face focus group #1).
“I think all professionals involved in maternity care are responsible together […] I don’t think you have to lose your own identity”. (Representative of the Royal Dutch Organisation of Midwives, interview #13).
Professionals are concerned about the loss of autonomy if an integrated care system would be implemented. Most professionals would like to collaborate but wish to remain autonomous when making decisions and in the way they organise their practice.
“I notice that the Royal Dutch Organisation of Midwives is very frightened of losing part of the autonomy, where it concerns primary care…[…] on the other hand there is a tendency for obstetricians, to say; “if 80 % of women will be in our care sooner or later, let us be in the lead. We can then decide what can be delegated to the midwife”. For midwives that would be the unacceptable” (Representative Project management organisation in maternity care assistance, interview #10)
Several stakeholders and professionals mentioned that the existing domain struggle between primary and secondary care could be a bottleneck for integration of care. According to participants a joint vision should be formulated and multidisciplinary protocols should be developed, as this would be of benefit to women. Others indicated that it is necessary to formulate the professional organisations’ vision first before making multidisciplinary protocols.
“You know, the vision of the Royal Dutch Organisation is that in an ideal world we will do all this [making of protocols] together. But it seemed better to us [the KNOV] to first have our own ideas on paper: how we think it should be done. Subsequently, of course you have to talk to your collaborative partners and I understand that the Dutch Society for Obstetrics and Gynaecology will do something similar”. (Representative of the Royal Dutch Organisation of Midwives, interview #13).
General characteristics of integrated care
Besides the main themes, participants mentioned the following characteristics of integrated care: a joint electronic client record system for all maternity caregivers, the use of pathways and multidisciplinary protocols supporting a consistent and unequivocal management of care in primary and secondary care for women, mutual respect among professionals, intakes for pregnant women jointly by midwives and obstetricians, a buddy system between obstetricians and midwifery practices for more collaborative work and consultations by obstetricians in midwifery practises as opposed to consultations after referral to hospital.