The difficult process of autonomous choice: using I-poems to understand experiences of abortion-seekers in The Netherlands.

While key barriers to abortion care accessibility have been established, little is known about the experiences of people having abortions in the Netherlands. Stories of individual abortion-seekers can help counteract stereotyping, diminish abortion stigma, and improve accessibility. This study's research question is: What experiences do abortion-seekers in the Netherlands have with abortion care and what new insights can the I-poem method of analysis provide? This qualitative feminist study used transcripts of semi-structured, in-depth interviews with abortion-seekers from previous research to create I-poems. Using a grounded theory method, the I-poems were coded deductively to validate previous findings, and inductively to generate new insights. The I-poems revealed that although abortion-seekers felt autonomous, their decision-making was complicated by doubt concerning their partner's views and/or suitability as a parent, feelings of shame, and a lack of support. The abortion-seekers were often slowed by obstacles in policy and care; waiting caused feelings of fear and panic and routine pre-abortion ultrasounds led to anxiety. They often did not know what to expect from their body or the abortion procedure. I-poems show how autonomous choice in abortion care is socially constructed rather than purely individual. Abortion providers must pay special attention to external factors complicating the decision-making process such as partner discordance (even in stable relationships) and anxiety due to waiting times and routine pre-abortion ultrasound. Future action on normalisation of information provided on all aspects of choosing an abortion is necessary to realise informed choice and reduction of abortion stigma.Plain language summary Abortion is a medical procedure that ends a pregnancy. In some countries, people can easily get an abortion. In others, it is illegal or difficult to access. In the Netherlands, abortion is accessible and legal before 24 weeks of pregnancy and can be performed upon request of the abortion seeker. This policy is often seen as liberal, as it allows people to make their own decisions about their bodies. Still, abortion stigma is present in Dutch society. Stigma around abortion refers to negative attitudes and beliefs that society has towards people who have had abortions or are considering having one.Research by Holten et al7 looked at how easy it is for abortion seekers in the Netherlands to access abortion services. The study highlighted that people in the Netherlands still face barriers to accessing abortion services. For example: the law and regulations regarding abortions and the fact that people had difficulty in talking about their abortion due to stigma.The abovementioned study gives a broad view on challenges in the accessibility of abortion in the Netherlands, but the individual experiences are not portrayed.The goal of this study is to learn about the personal experiences of abortion-seekers in the Netherlands. It aims to understand what it's like for these people to access abortion services and what we can learn from their individual stories by using a method of analysis called I-poem. I-poems are a type of poem created by the researcher by looking for sentences using the first-person pronoun "I" in interview texts. I poems show the personal experience or point of view of the person interviewed. This type of poem is often used to express emotions or share personal stories or observations.This study used interviews with people who have had abortions to create I-poems. The grounded theory method was used to analyse the I-poems in two ways: confirming what was found in previous studies, and also providing new insights from the data.The study found that the people contemplating having an abortion had a hard time making the decision to have an abortion because they had doubts, were worried about what their partner would think, felt ashamed to talk about it with friends and family, and didn't have enough support. They also faced challenges like having to wait for the abortion because of clinic schedules and laws and getting ultrasounds before the procedure, which made them anxious. It was also found that the people contemplating abortion were unsure of what to expect from the abortion procedure and how their body would react, which made the decision even harder.The study concludes that even when people felt in control of their decision, the decision-making process was still difficult. The decision is not just personal, but is also affected by society, partners, and healthcare policies. The waiting time and the ultrasound before the abortion made the process harder, and abortion seekers were not aware of what to expect from the procedure. More information and education on all aspects of having an abortion should be provided to help people to make better informed decisions and reduce the abortion stigma. Further research on experiences of routine ultrasound before abortion in the Netherlands is needed to improve abortion care.

Permeability of abortion care in the Netherlands: a qualitative analysis of women's experiences, health professional perspectives, and the internet resource of Women on Web.

Despite a relatively permissive abortion law, women in the Netherlands encounter difficulties in accessing abortion care. Little is known about their experiences. This study explores women's experiences with (online) abortion services and relevant health professionals' experiences delivering care, with the goal of identifying key barriers encountered by abortion-seekers in the Netherlands. An exploratory qualitative research design with a constructivist approach and an abbreviated grounded theory method was used. Interviews with 20 women who had had an abortion and 14 health professionals who provide abortion care, and 200 emails of women seeking abortion care through the non-governmental organisation Women on Web, were coded inductively and deductively (using the Candidacy Framework) thereby generating themes. Abortion-seekers faced barriers including: (i) burden of taboo, (ii) vulnerability (emotional, financial, and social), (iii) health professional evaluation and (iv) disempowerment and distress. The overarching theme was women's lack of autonomy in access to abortion care. The key barriers to abortion access in the Netherlands are the institutionalisation of taboo in abortion law and care, complex candidacy regulations, lack of permeability for certain marginalised groups, and women's inability to speak openly about abortion. To increase the permeability of abortion care, and thereby women's autonomy, legislators and policy-makers must trust women to make their own reproductive decisions and avoid actions that stigmatise abortion and hinder access to care, while actively developing systemic support for vulnerable groups.

Towards a better understanding of risk selection in maternal and newborn care: A systematic scoping review.

Globally, millions of women and their children suffer due to preventable morbidity and mortality, associated with both underuse and overuse of maternal and newborn care. An effective system of risk selection that differentiates between what care should be provided and who should provide it is a global necessity to ensure women and children receive appropriate care, at the right place and the right time. Poor conceptualization of risk selection impedes evaluation and comparison of models of risk selection across various settings, which is necessary to improve maternal and newborn care. We conducted a scoping review to enhance the understanding of risk selection in maternal and newborn care. We included 210 papers, published over the past four decades, originating from 24 countries. Using inductive thematic analysis, we identified three main dimensions of risk selection: (1) risk selection as an organisational measure to optimally align women's and children's needs and resources, (2) risk selection as a practice to detect and assess risk and to make decisions about the delivery of care, and (3) risk selection as a tool to ensure safe care. We found that these three dimensions have three themes in common: risk selection (1) is viewed as both requiring and providing regulation, (2) has a provider centred focus and (3) aims to avoid underuse of care. Due to the methodological challenges of contextual diversity, the concept of risk selection needs clear indicators that capture the complexity of care to make cross-setting evaluation and comparison of risk selection possible. Moreover, a comprehensive understanding of risk selection needs to consider access disparity, women's needs, and unnecessary medicalization.

Left powerless: A qualitative social media content analysis of the Dutch #breakthesilence campaign on negative and traumatic experiences of labour and birth.

INTRODUCTION: Disrespect and abuse during labour and birth are increasingly reported all over the world. In 2016, a Dutch client organization initiated an online campaign, #genoeggezwegen (#breakthesilence) which encouraged women to share negative and traumatic maternity care experiences. This study aimed (1) to determine what types of disrespect and abuse were described in #genoeggezwegen and (2) to gain a more detailed understanding of these experiences. METHODS: A qualitative social media content analysis was carried out in two phases. (1) A deductive coding procedure was carried out to identify types of disrespect and abuse, using Bohren et al.'s existing typology of mistreatment during childbirth. (2) A separate, inductive coding procedure was performed to gain further understanding of the data. RESULTS: 438 #genoeggezwegen stories were included. Based on the typology of mistreatment during childbirth, it was found that situations of ineffective communication, loss of autonomy and lack of informed consent and confidentiality were most often described. The inductive analysis revealed five major themes: ''lack of informed consent"; ''not being taken seriously and not being listened to"; ''lack of compassion"; ''use of force"; and ''short and long term consequences". "Left powerless" was identified as an overarching theme that occurred throughout all five main themes. CONCLUSION: This study gives insight into the negative and traumatic maternity care experiences of Dutch women participating in the #genoeggezwegen campaign. This may indicate that disrespect and abuse during labour and birth do happen in the Netherlands, although the current study gives no insight into prevalence. The findings of this study may increase awareness amongst maternity care providers and the community of the existence of disrespect and abuse in Dutch maternity care, and encourage joint effort on improving care both individually and systemically/institutionally.

'She convinced me'- partner involvement in choosing a high risk birth setting against medical advice in the Netherlands: A qualitative analysis.

Home births in high risk pregnancies and unassisted childbirth seem to be increasing in the Netherlands. There is a lack of qualitative data on women's partners' involvement in these choices in the Dutch maternity care system, where integrated midwifery care and home birth are regular options in low risk pregnancies. The majority of available literature focuses on the women's motivations, while the partner's influence on these decisions is much less well understood. We aimed to examine partners' involvement in the decision to birth outside the system, in order to provide medical professionals with insight and recommendations regarding their interactions with these partners in the outpatient clinic. An exploratory qualitative research design with a constructivist approach and a grounded theory method were used. In-depth interviews were performed with twenty-one partners on their involvement in the decision to go against medical advice in choosing a high risk childbirth setting. Open, axial and selective coding of the interview data was done in order to generate themes. Four main themes were found: 1) Talking it through, 2) A shared vision, 3) Defending our views, and 4) Doing it together. One overarching theme emerged that covered all other themes: 'She convinced me'. These data show that the idea to choose a high risk birth setting almost invariably originated with the women, who did most of the research online, filtered the information and convinced the partners of the merit of their plans. Once the partners were convinced, they took a very active and supportive role in defending the plan to the outside world, as well as in preparing for the birth. Maternity care providers can use these findings in cases where there is a discrepancy between the wishes of the woman and the advice of the professional, so they can attempt to involve partners actively during consultations in pregnancy. That will ensure that partners also receive information on all options, risks and benefits of possible birth choices, and that they are truly in support of a final plan.

Addressing a need. Holistic midwifery in the Netherlands: A qualitative analysis.

The Netherlands has a maternity care system with integrated midwifery care, including the option of home birth for low risk women. A small group of Dutch (holistic) midwives is willing to assist women in high risk pregnancies during a home birth against medical advice. We examined holistic midwives' motivations and way of practice, in order to provide other maternity care professionals with insight into the way they work and to improve professional relationships between all care providers in the field. An exploratory qualitative research design with a constructivist approach and a grounded theory method were used. We performed in-depth interviews with twenty-four holistic midwives on their motivations for working outside their professional boundaries. Open, axial and selective coding of the interview data was done in order to generate themes. We held a focus group for a member check of the findings. Four main themes were found: 1) The regular system is failing women, 2) The relationship as basis for empowerment, 3) Delivering client centered care in the current system is demanding, and 4) Future directions. One core theme emerged that covered all other themes: Addressing a need. Holistic midwives explained that many of their clients had no other choice than to choose a home birth in a high risk pregnancy because they felt let down by the regular system of maternity care. Holistic midwives appear to deliver an important service. They provide continuity of care and succeed in establishing a relationship with their clients built on trust and mutual respect, truly putting their clients' needs first. Some women feel let down by the regular system, and holistic midwives may be the last resort before those women choose to deliver unattended by any medical professional. Maternity care providers should consider working with holistic midwives in the interest of good patient care.

When the Hospital Is No Longer an Option: A Multiple Case Study of Defining Moments for Women Choosing Home Birth in High-Risk Pregnancies in The Netherlands.

Some women in a high-risk pregnancy go against medical advice and choose to birth at home with a "holistic" midwife. In this exploratory multiple case study, grounded theory and triangulation were employed to examine 10 cases. The women, their partners, and (regular and holistic) health care professionals were interviewed in an attempt to determine whether there was a pattern to their experiences. Two propositions emerged. The dominant one was a trajectory of trauma, self-education, concern about paternalism, and conflict leading to a negative choice for holistic care. The rival proposition was a path of trust and positive choice for holistic care without conflict. We discuss these two propositions and make suggestions for professionals for building a trusting relationship using continuity of care, true shared decision making, and an alternative risk discourse to achieve the goal of making women perceive the hospital as safe again.

Less or more? Maternal requests that go against medical advice.

PROBLEM AND BACKGROUND: This study explores the experiences of Dutch midwives and gynaecologists with pregnant women who request more, less or no care during pregnancy and/or childbirth. METHODS: All Dutch midwives and (trainee) gynaecologists were invited to fill out a questionnaire specifically designed for the purposes of this study. Holistic midwives were analysed separately from regular community midwives. FINDINGS: Most maternity care providers in the Netherlands receive requests for less care than recommended at least once a year. The most frequently maternal requests were declining testing for gestational diabetes (66.3%), opting for a home birth in case of a high risk pregnancy (65.3%), and declining foetal monitoring during labour (39.6%). Holistic midwives are more convinced of an increasing demand for less care than community midwives (73.1% vs. 35.2%, p=<0.001). More community midwives than hospital staff reported to have declined one or more request for less care than recommended (48.6% vs. 27.9%, p=<0.001). The majority of hospital staff also receive at least one request for an elective caesarean section every year. DISCUSSION AND CONCLUSION: Requests for more and less care than indicated during pregnancy and childbirth are equally prevalent in this study. However, a request for less care is more likely to be declined than a request for more care. Counselling women who disagree with their care provider demands time. In case of requests for less care, second best care should be considered.

Women's motivations for choosing a high risk birth setting against medical advice in the Netherlands: a qualitative analysis.

BACKGROUND: Home births in high risk pregnancies and unassisted childbirth seem to be increasing in the Netherlands. Until now there were no qualitative data on women's motivations for these choices in the Dutch maternity care system where integrated midwifery care and home birth are regular options in low risk pregnancies. We aimed to examine women's motivations for birthing outside the system in order to provide medical professionals with insight and recommendations regarding their interactions with women who have birth wishes that go against medical advice. METHODS: An exploratory qualitative research design with a constructivist approach and a grounded theory method were used. In-depth interviews were performed with 28 women on their motivations for going against medical advice in choosing a high risk childbirth setting. Open, axial and selective coding of the interview data was done in order to generate themes. A focus group was held for a member check of the findings. RESULTS: Four main themes were found: 1) Discrepancy in the definition of superior knowledge, 2) Need for autonomy and trust in the birth process, 3) Conflict during negotiation of the birth plan, and 4) Search for different care. One overarching theme emerged that covered all other themes: Fear. This theme refers both to the participants' fear (of interventions and negative consequences of their choices) and to the providers' fear (of a bad outcome). Where for some women it was a positive choice, for the majority of women in this study the choice for a home birth in a high risk pregnancy or an unassisted childbirth was a negative one. Negative choices were due to previous or current negative experiences with maternity care and/or conflict surrounding the birth plan. CONCLUSIONS: The main goal of working with women whose birthing choices do not align with medical advice should not be to coerce them into the framework of protocols and guidelines but to prevent negative choices. Recommendations for maternity caregivers can be summarized as: 1) Rethink risk discourse, 2) Respect a woman's trust in the birth process and her autonomous choice, 3) Have a flexible approach to negotiating the birth plan using the model of shared decision making, 4) Be aware of alternative delivery care providers and other sources of information used by women, and 5) Provide maternity care without spreading or using fear.

Women׳s motivations for having unassisted childbirth or high-risk homebirth: An exploration of the literature on 'birthing outside the system'.

OBJECTIVE: to identify and analyze literature exploring women׳s motivations to 'birth outside the system'. DESIGN: scoping review and thematic analysis of (mostly) qualitative studies. FINDINGS: fifteen studies of women choosing an unassisted birth, homebirth in countries where homebirth was not integrated into the maternity care system, or a midwife-attended high-risk homebirth were identified from Sweden, USA, Australia, Canada and Finland. Five main themes emerged as the most important factors: (1) resisting the biomedical model of birth by trusting intuition, (2) challenging the dominant discourse on risk by considering the hospital as a dangerous place, (3) feeling that true autonomous choice is only possible at home, (4) perceiving birth as an intimate or religious experience, and (5) taking responsibility as a reflection of true control over decision-making. KEY CONCLUSIONS: concerns over consent, intervention and loss of the birthing experience may be driving women away from formal healthcare. There is a lack of fit between the health needs of pregnant women and the current system of maternity care. Biomedical and alternative ׳outside the system׳ discourses on authoritative knowledge, risk, autonomy and responsibility must be negotiated to find a common ground wherein a dialogue can take place between client and health professional. IMPLICATIONS FOR PRACTICE: more research is needed to explore the scope of the phenomenon of women birthing outside the system and the experiences of midwives and obstetricians in the care of such women. This knowledge can be used to improve the maternity care system, so that fewer women will choose to withdraw from it.