The organisation of midwifery care in the Netherlands

Chapter 1 Introduction In the introductory chapter, chapter 1, a sketch is given how the current practice of primary care midwives in the Netherland is changing. Like all health care, the maternity care in the Netherlands is organised in echelons, with a strict role division between primary, secondary and tertiary care. In primary care, midwife-led care is provided to healthy women with uncomplicated pregnancies throughout their pregnancy, labour and six-weeks post partum, by independent, autonomous midwives. These primary care midwives have a gate keeping role: in case of complications, or if the woman requests a form of pain relief that can only be given in secondary care, the woman is referred to obstetricians and clinical midwives in a hospital (secondary care), or an academic referral centre (tertiary care). However, Dutch maternity care is in motion. At present, there is a dialogue on the reorganization of the maternity care system in the Netherlands. This dialogue centres on the need to integrate care more effectively between the various maternity care providers. This may lead to major changes in the organisation of midwifery care. This thesis focuses on the organisation of midwifery care in the Netherlands and on views regarding changes to the organisation. Furthermore, this thesis seeks and identifies components of care organisation, which are likely to be conditional for successful collaborative midwifery practice in the future.Chapter 2 through 5 identifies and describes maternity care from a human resources and work content perspective, using data from the DELIVER study. The purpose was to assess the situation in the field of maternity care provision in the Netherlands in 2010, linking this with developments within the midwifery profession and maternity care. Chapters 2 and 3 are primarily concerned with how midwives experience their profession, in terms of job satisfaction and intention-to-leave the current position. Chapters 4 and 5 describe the job content and professional cooperation of midwives with other health professionals. Chapter 6 gives perspectives on the care organisation from student midwives with experiences in primary, secondary and tertiary maternity care; in order to understand new professionals’ perspectives on potential changes and priorities of midwives within that change.Chapter 2 An explorative study of factors contributing to the job satisfaction of primary care midwives Chapter 2 describes an exploratory qualitative study among 99 primary care midwives to gain insight of how primary care midwives in the Netherlands feel about their work. Also, factors associated with primary care midwives’ job satisfaction and areas for improvement are identified. This study indicates that in 2010 83% of the participating primary care midwives were satisfied or very satisfied with their job in the current echelon system. The factors positively associated with their job satisfaction are their direct contact with clients, the supportive cooperation and teamwork with immediate colleagues, the organisation of and innovation within their practice group and the independence, autonomy, freedom, variety and opportunities that they experienced in their work. Regarding improvements, the midwives desire a reduction in non-clientrelated activities, such as paperwork and meetings. They want a lower level of work pressure, and a reduced case-load in order to have more time to devote to individual clients’ needs. Participants see that cooperation with other partners in the healthcare system can also be improved. Factors associated with job satisfaction and improvement are important in the discussion how the organization of Dutch maternity care can be improved. The advice is to do more in-depth research in a larger study population, including solo- and duo-practices, and to support the qualitative findings with quantitative data.Chapter 3 Career plans of primary care midwives in the Netherlands and their intentions to leave the current job. Chapter 3 describes the career plans of 98 primary care midwives and their intentions to leave their current job. The results of the study show that, on the subject of the career plans, three quarters of the midwives want to be (or remain) self-employed practitioners in private practice in five years’ time, with full range of midwifery care. Of the participants, 32.7% primary care midwives had in the past year an intention to leave their current job. This study shows the absence of job satisfaction, and being in the age-group between 30 and 45 to be associated in primary care midwives’ intention to leave their job. The generally high level of job satisfaction indicates that midwives generally enjoy their work in the primary care in the current Dutch system (midwife-led care by independent, autonomous primary care midwives).Chapter 4 Work and workload of Dutch primary care midwives in 2010 Chapter 4 describes the results of a study among 99 primary care midwives and 319 midwifery practices to re-assess the work and workload of primary care midwives in the Netherlands. Primary care midwives actually work on average 32.6 hours per week and approximately 67% of their working time (almost 22 hours per week) was spent on client-related activities. On average a midwife is on-call for 39 hours a week and almost 13 of the 32.6 hours of work take place during on-call-hours. This means that the total hours that an average midwife is involved in her work (either actually working or on-call) is almost 59 hours a week. Compared to 2004 the number of hours an average midwife actually works, increase by 4 hours (from 29 to 32.6 hours) while the total number of hours an average midwife is involved with her work decreases by 6 hours (from 65 to 59 hours). In 2010, compared to 2001-2004, the midwives spend proportionally less time on direct client care (67% vs. 73%), although in actual number of hours this did not change much (22 vs. 21). In 2009 the average workload of a midwife was 99 clients at booking, 56 at the start of labour, 33 at childbirth, and 90 clients in postpartum care. All in all, the primary care midwives worked on average more hours in 2010 than they did in 2004 or 2001, but spent these extra hours increasingly on non-client-related activities.Chapter 5 Collaboration of midwives in primary care midwifery practices with other maternity care providers Chapter 5 provides insight into the professional working relations of primary care midwives in the Netherlands. This study indicates that satisfaction experienced by primary care midwives when collaborating with the different maternity care providers varies within and between primary and secondary/ tertiary care. Interactions with non-physicians (clinical midwives and MCA(O)) are ranked consistently higher on satisfaction compared with interactions with physicians (GPs, obstetricians and paediatricians). Midwives with more work experience were more satisfied with their collaboration with GPs. Midwives from the southern region of the Netherlands were more satisfied with collaboration with GPs and obstetricians. Compared to the urban areas, in the rural or mixed areas the midwives were more satisfied regarding their collaboration with MCA(O) s and clinical midwives. Midwives from non-Dutch origin were less satisfied with the collaboration with paediatricians. No relations were found between the overall mean satisfaction of collaboration and work-related and personal characteristics and attitude towards work. In conclusion, inter-professionals relations in maternity care in the Netherlands can be enhanced, especially in the primary care midwives’ interactions with physicians and with maternity care providers in the northern and central part of the Netherlands, and in urban areas. Future exploratory or deductive research may provide additional insight in the collaborative practice in everyday work setting. Chapter 6 Student midwives’ perceptions on the organisation of maternity care and alternative maternity care models in the Netherlands - a qualitative study Chapter 6 looks at new developments within the midwifery profession and maternity care and explores 18 student midwifes’ perceptions on the organisation of midwifery care and alternative maternity care systems. Students feel that inevitably there will be a change in the organisation of maternity care, and they are open to change. Participants indicate that good collaboration between professions, including a shared system of maternity notes and guidelines, and mutual trust and respect arre important aspects of any new model. They indicate that client-centred care and safeguarding of the physiological, normalcy approach to pregnancy and birth should be maintained in any new model. Students express worries that the role of midwives in intrapartum care could become redundant, and thus they are motivated to take on new roles and competencies, so they can ensure their own role in intrapartum care. It can be important to involve students’ views in the discussion, because they are the future maternity care providers. A survey among the whole population of final year students midwives in the Netherlands is recommended.Chapter 7 summarizes and discusses the main finding of this thesis, and addresses its methodological considerations and the implications for practice, education and future research. This thesis focuses on the organisation of midwifery care in the Netherlands and on views regarding changes to the organisation of midwifery care. All in all, the high level of job satisfaction indicates that primary care midwives in the Netherlands generally enjoy their work in the current echelon system: midwife-led care by independent, autonomous primary care midwives. Despite the uncertainties about the future of maternity care, the majority of midwives intend to stay in primary care. Ongoing monitoring of and focussing on job satisfaction, as important predictor of midwives’ intention to leave the current job, will be important in the future. On the other hand, the midwives perceive high work pressure. The balance between non-client-related activities, such as administrative tasks, meetings, and direct client care can be improved. Essential components which are likely to be conditional for successful collaborative midwifery practice in the future are formulated, like good collaboration, respectful communication, sharing information and activities with other maternity care providers. Client centred care and safeguard the physiological, normalcy approach to pregnancy and birth should be maintained in any maternity care model. Midwives can play central role here, because of the functions of primary midwifery care, such as first contact, comprehensiveness and coordination, and the person and population health-focused view and the physiological, normalcy approach to pregnancy and birth. Next to the current echelon system and the proposed shared care between primary and secondary care -vertical integration-, one can envision other alternative maternity care models, such shared care within primary care -horizontal integration-, group antenatal care, maternity care professionals active in the community as well as in the hospital, or expansion of primary care midwives’ responsibilities and competencies to supervising medium-risk pregnancies and births. The perspectives and preferences of all relevant stakeholders, including midwives, student midwives and clients, should be taken into consideration regarding any changes to the maternity care model