Exploring psychosocial vulnerability among Dutch pregnant women: a register study.

In the Netherlands adverse perinatal outcomes are also associated with non-medical factors which vary across geographical locations. This study analyses the presence of non-medical vulnerabilities in pregnant women in two regions with high numbers of psychosocial adversity using the same definition for vulnerability in both regions. A register study was performed in 2 regions. Files from women in midwife-led care were analyzed using a standardized case report form addressing non-medical vulnerability based on the Rotterdam definition for vulnerability: measurement A in Groningen (n = 500), measurement B in South-Limburg (n = 538). Only in South-Limburg a second measurement was done after implementing an identification tool for vulnerability (C (n = 375)). In both regions about 10% of pregnant women had one or more urgent vulnerabilities and almost all of these women had an accumulation of several urgent and non-urgent vulnerabilities. Another 10% of women had an accumulation of three or more non-urgent vulnerabilities. This study showed that by using the Rotterdam definition of vulnerability in both regions about 20% of pregnant women seem to live in such a vulnerable situation that they may need psychosocial support. The definition seems a good tool to determine vulnerability. However, without considering protective factors it is difficult to establish precisely women's vulnerability. Research should reveal whether relevant women receive support and whether this approach contributes to better perinatal and child outcomes.

The contribution of birth plans to shared decision-making from the perspectives of women, their partners and their healthcare providers.

BACKGROUND: The birth plan is a document expressing a pregnant woman's childbirth preferences, enabling communication of expectations and facilitating discussions among women, their partners, and healthcare providers for key birthing decisions. There has been limited research on the role of birth plans in shared decision-making (SDM). Our study aims to explore how the use of birth plans can contribute to SDM from women's, partners, and healthcare providers' perspectives. METHODS: We conducted in-depth interviews with women, their partners, and their healthcare providers. We used a thematic analysis to identify themes and subthemes. Furthermore, we created a grounded theory about the role of birth plans as a tool in SDM. RESULTS: Three main themes were created: ''Creating a birth plan", ''Getting all on board" and ''Birth plans in the daily practice of decision-making". Most women, partners, and healthcare providers agreed that birth plans can facilitate communication and SDM. Women and their partners viewed the birth plan as a tool to prepare for birth. Most healthcare providers mentioned the birth plan as a tool to get to know the women, their partners, and their preferences. Barriers are the attitude of healthcare providers toward birth plans, such as their evident resistance to the birth plan itself or to certain preferences. Another barrier is the assumption women and their partners may have that these plans can accurately predict the childbirth experience, enhancing the chance of a disappointing, negative experience. Some healthcare providers view birth plans as barriers to SDM. CONCLUSION: The use of a birth plan seems to promote women's, partners', and healthcare providers' involvement in the birth process, and seems suitable to facilitate SDM. Further research is required to explore strategies for overcoming barriers, including healthcare providers' attitudes toward birth plans and the expectations of women and their partners regarding their role.

The impact of severe perinatal events on maternity care providers: a scoping review.

BACKGROUND: Severe events during the perinatal period can be experienced as traumatic by pregnant women, their partners or others who are closely involved. This includes maternity care providers who can be affected by being involved in or observing these events. This may have an impact on their personal well-being and professional practice, influencing quality of care. The aim of this study is to map research investigating the impact of severe events during the perinatal period on maternity care providers, and how these experiences affect their well-being and professional practice. METHOD: A scoping review following the manual of the Joanna Briggs Institute was undertaken. The electronic bibliographic databases included PubMed/MEDLINE, CINAHL, PsycINFO, PsycARTICLES, SocINDEX, Cochrane, Scopus, Web of Science and databases for grey literature. Records passing the two-stage screening process were assessed, and their reference lists hand searched. We included primary research papers that presented data from maternity care professionals on the impact of severe perinatal traumatic events. A descriptive content analysis and synthesis was undertaken. RESULTS: Following a detailed systematic search and screening of 1,611 records, 57 papers were included in the scoping review. Results of the analysis identified four categories, which highlighted the impact of traumatic perinatal events on maternity care providers, mainly midwives, obstetricians and nurses: Traumatic events, Impact of traumatic events on care providers, Changes in care providers' practice and Support for care providers; each including several subcategories. CONCLUSION: The impact of traumatic perinatal events on maternity care providers ranged from severe negative responses where care providers moved position or resigned from their employment in maternity care, to responses where they felt they became a better clinician. However, a substantial number appeared to be negatively affected by traumatic events without getting adequate support. Given the shortage of maternity staff and the importance of a sustainable workforce for effective maternity care, the impact of traumatic perinatal events requires serious consideration in maintaining their wellbeing and positive engagement when conducting their profession. Future research should explore which maternity care providers are mostly at risk for the impact of traumatic events and which interventions can contribute to prevention.

Development of the Conversational Health Literacy Assessment Tool for maternity care (CHAT-maternity-care): participatory action research.

BACKGROUND: Limited health literacy in (expectant) parents is associated with adverse health outcomes. Maternity care providers often experience difficulties assessing (expectant) parents' level of health literacy. The aim was to develop, evaluate, and iteratively adapt a conversational tool that supports maternity care providers in estimating (expectant) parents' health literacy. METHODS: In this participatory action research study, we developed a conversational tool for estimating the health literacy of (expectant) parents based on the Conversational Health Literacy Assessment Tool for general care, which in turn was based on the Health Literacy Questionnaire. We used a thorough iterative process including different maternity care providers, (expectant) parents, and a panel of experts. This expert panel comprised representatives from knowledge institutions, professional associations, and care providers with whom midwives and maternity care assistants work closely. Testing, evaluation and adjustment took place in consecutive rounds and was conducted in the Netherlands between 2019 and 2022. RESULTS: The conversational tool 'CHAT-maternity-care' covers four key domains: (1) supportive relationship with care providers; (2) supportive relationship within parents' personal network; (3) health information access and comprehension; (4) current health behaviour and health promotion. Each domain contains multiple example questions and example observations. Participants contributed to make the example questions and example observations accessible and usable for daily practice. The CHAT-maternity-care supports maternity care providers in estimating (expectant) parents' health literacy during routine conversations with them, increased maternity care providers' awareness of health literacy and helped them to identify where attention is necessary regarding (expectant) parents' health literacy. CONCLUSIONS: The CHAT-maternity-care is a promising conversational tool to estimate (expectant) parents' health literacy. It covers the relevant constructs of health literacy from both the Conversational Health Literacy Assessment Tool and Health Literacy Questionnaire, applied to maternity care. A preliminary evaluation of the use revealed positive feedback. Further testing and evaluation of the CHAT-maternity-care is required with a larger and more diverse population, including more (expectant) parents, to determine the effectiveness, perceived barriers, and perceived facilitators for implementation.

Traumatic birth and childbirth-related post-traumatic stress disorder: International expert consensus recommendations for practice, policy, and research.

BACKGROUND: Research suggests 1 in 3 births are experienced as psychologically traumatic and about 4% of women and 1% of their partners develop post-traumatic stress disorder (PTSD) as a result. AIM: To provide expert consensus recommendations for practice, policy, and research and theory. METHOD: Two consultations (n = 65 and n = 43) with an international group of expert researchers and clinicians from 33 countries involved in COST Action CA18211; three meetings with CA18211 group leaders and stakeholders; followed by review and feedback from people with lived experience and CA18211 members (n = 238). FINDINGS: Recommendations for practice include that care for women and birth partners must be given in ways that minimise negative birth experiences. This includes respecting women's rights before, during, and after childbirth; and preventing maltreatment and obstetric violence. Principles of trauma-informed care need to be integrated across maternity settings. Recommendations for policy include that national and international guidelines are needed to increase awareness of perinatal mental health problems, including traumatic birth and childbirth-related PTSD, and outline evidence-based, practical strategies for detection, prevention, and treatment. Recommendations for research and theory include that birth needs to be understood through a neuro-biopsychosocial framework. Longitudinal studies with representative and global samples are warranted; and research on prevention, intervention and cost to society is essential. CONCLUSION: Implementation of these recommendations could potentially reduce traumatic births and childbirth-related PTSD worldwide and improve outcomes for women and families. Recommendations should ideally be incorporated into a comprehensive, holistic approach to mental health support for all involved in the childbirth process.

Continuous care during labor by maternity care assistants in the Netherlands vs care-as-usual: a randomized controlled trial.

BACKGROUND: Continuous support during labor has many benefits including lower use of obstetrical interventions. However, implementation remains limited. Insights into birth outcomes and peripartum costs are essential to assess whether continuous care by a maternity care assistant is a potentially (cost) effective program to provide for all women. OBJECTIVE: Continuous care during labor, provided by maternity care assistants, will reduce the use of epidural analgesia and peripartum costs owing to a reduction in interventions. STUDY DESIGN: This was a randomized controlled trial comparing continuous support during labor (intervention group) with care-as-usual (control group) with prespecified intention-to-treat and per-protocol analyses. The primary outcome was epidural analgesia use. The secondary outcomes were use of other analgesia, referrals from midwife- to obstetrician-led care, modes of birth, hospital stay, sense of control (evaluated with the Labor Agentry Scale), maternal and neonatal adverse outcomes and peripartum costs. Data were collected using questionnaires. Anticipating incomplete adherence to providing continuous care, both intention-to-treat and per-protocol analyses were planned. Peripartum costs were estimated using a healthcare perspective. Mean costs per woman and cost differences between the intervention and control group were calculated. RESULTS: The population consisted of 1076 women with 54 exclusions and 30 discontinuations, leaving 992 women to be analyzed (515 continuous care and 477 care-as-usual). Intention-to-treat analyses showed statistically nonsignificant differences between the intervention and control group for epidural use (relative risk, 0.88; 95% confidence interval, 0.74-1.04; P=.14) and peripartum costs (mean difference, € 185.83; 95% confidence interval, -€ 204.22 to € 624.54). Per-protocol analyses showed statistically significant decreases in epidural analgesia (relative risk, 0.64; 95% confidence interval, 0.48-0.84; P=.001), other analgesia (relative risk, 0.59; 95% confidence interval, 0.37-0.94; P=.02), cesarean deliveries (relative risk, 0.53; 95% confidence interval, 0.29-0.95; P=.03) and increase in spontaneous vaginal births (relative risk, 1.09; 95% confidence interval, 1.01-1.18; P=.001) in the intervention group, but difference in total peripartum costs remained statistically nonsignificant (mean difference, € 246.55; 95% confidence interval, -€ 539.14 to € 13.50). CONCLUSION: If the provision of continuous care given by maternity care assistants during labor can be secured, continuous care leads to more vaginal births and less epidural use, pain medication, and cesarean deliveries while not leading to a difference in peripartum costs compared with care-as-usual.

Health literate-sensitive shared decision-making in maternity care: needs for support among maternity care professionals in the Netherlands.

BACKGROUND: Shared decision-making (SDM) in maternity care is challenging when clients have insufficient health literacy (HL) skills. This study gained insight in how professionals apply HL-sensitive SDM in Dutch maternity care and their needs for support therein. METHODS: Maternity care professionals (n = 30) completed a survey on SDM and the role of HL. Midwives (n = 13) were observed during simulated conversations discussing pain relief options and interviewed afterwards. The client-actors were instructed to portrait specific inadequate HL skills. Observation items focused on adapting communication to HL, and SDM (OPTION-5). RESULTS: In the survey, professionals indicated experiencing most challenges when estimating clients' information comprehension. Observations showed that most midwives created choice awareness and informed clients about options, whereas exploring preferences and actual decision-making together with clients were observed less frequently. Their perceived HL-related obstacles and needs for support related to clients' information comprehension. In the interviews, midwives reported putting much effort into explaining available options in maternity care, but also that decisions about pain relief are often postponed until the moment of labour. CONCLUSION: Professionals' self-reported needs focus on clients' information comprehension. However, observations indicate that it is not the stage of informing, but rather value clarification and actual decision-making that need improvement in HL-sensitive SDM.

Regional practice variation in induction of labor in the Netherlands: Does it matter? A multilevel analysis of the association between induction rates and perinatal and maternal outcomes.

BACKGROUND: Practice variation in healthcare is a complex issue. We focused on practice variation in induction of labor between maternity care networks in the Netherlands. These collaborations of hospitals and midwifery practices are jointly responsible for providing high-quality maternity care. We explored the association between induction rates and maternal and perinatal outcomes. METHODS: In a retrospective population-based cohort study, we included records of 184,422 women who had a singleton, vertex birth of their first child after a gestation of at least 37 weeks in the years 2016-2018. We calculated induction rates for each maternity care network. We divided networks in induction rate categories: lowest (Q1), moderate (Q2-3) and highest quartile (Q4). We explored the association of these categories with unplanned caesarean sections, unfavorable maternal outcomes and adverse perinatal outcomes using descriptive statistics and multilevel logistic regression analysis corrected for population characteristics. FINDINGS: The induction rate ranged from 14.3% to 41.1% (mean 24.4%, SD 5.3). Women in Q1 had fewer unplanned caesarean sections (Q1: 10.2%, Q2-3: 12.1%; Q4: 12.8%), less unfavorable maternal outcomes (Q1: 33.8%; Q2-3: 35.7%; Q4: 36.3%) and less adverse perinatal outcomes (Q1: 1.0%; Q2-3: 1.1%; Q4: 1.3%). The multilevel analysis showed a lower unplanned caesarean section rate in Q1 in comparison with reference category Q2-3 (OR 0.83; p = .009). The unplanned caesarean section rate in Q4 was similar to the reference category. No significant associations with unfavorable maternal or adverse perinatal outcomes were observed. CONCLUSION: Practice variation in labor induction is high in Dutch maternity care networks, with limited association with maternal outcomes and no association with perinatal outcomes. Networks with low induction rates had lower unplanned caesarean section rates compared to networks with moderate rates. Further in-depth research is necessary to understand the mechanisms that contribute to practice variation and the observed association with unplanned caesarean sections.

Measuring women's empowerment during the perinatal period in high income countries: A scoping review of instruments used.

Empowerment is acknowledged as a process facilitating those who are less powerful to be engaged in their problem identification, decision making and actions to gain control over their life. This is an important goal for women during the perinatal period in their transition to motherhood. A concept analysis of women's empowerment during the perinatal period found that psychological and social dimensions play a role in women's perinatal empowerment and identified several defining attributes. The aim of this study was to identify robust validated instruments that measure all the attributes of women's empowerment during the perinatal period. We did a scoping review of scientific literature following the methodology of the JBI Reviewer's Manual. We searched the database MEDLINE, CINAHL, PsycINFO, PsycARTICLES and SocINDEX and selected papers meeting the inclusion criteria. Instruments measuring empowerment or related concepts were identified in the selected papers. Two authors independently cross referenced the items of each instrument against the defining attributes for empowerment. Our search resulted in 9771 unique hits of which 36 papers were finally included. Studies were from various countries with a wide variety of aims, demographics of cohorts and timepoints across the perinatal period. Twenty-one different instruments were used to measure empowerment, of which 11 were validated among women during the perinatal period. However, no identified instrument was developed specifically for women during the perinatal period or included all the dimensions of empowerment and the defining attributes. There is a need for a theoretically sound valid and reliable instrument measuring all the dimensions of empowerment of women during the perinatal period. Once developed this instrument needs testing with a broad range of women. Results from such a study will inform the development of appropriate interventions that have a coherent theoretical basis and are empirically informed to enhance women's empowerment during the perinatal period.

Women's Birth Beliefs During Pregnancy and Postpartum in the Netherlands: A Quantitative Cross-Sectional Study.

INTRODUCTION: Women and care providers increasingly regard childbirth as a medical process, resulting in high use of medical interventions, which could negatively affect a woman's childbirth experience. Women's birth beliefs may be key to understanding the decisions they make and the acceptance of medical interventions in childbirth. In this study we explore women's beliefs about birth as a natural and medical process and the factors that are associated with women's birth beliefs. METHODS: Data were obtained from a cross-sectional survey of women living in the Netherlands asking them about their experiences during pregnancy and childbirth, including their beliefs about birth as a natural and medical process. RESULTS: A total of 3494 women were included in this study. Mean scores of natural birth beliefs ranged between 3.73 and 4.01 points, and medical birth belief scores ranged between 2.92 and 3.12 points. There were significant but very small changes between prenatal and postnatal birth beliefs. Regression analyses showed that (previous) childbirth experiences were the most consistent predictor of women's birth beliefs. DISCUSSION: Women's high scores on natural birth beliefs and lower scores on medical birth beliefs correspond with the philosophy of Dutch perinatal care that considers pregnancy and childbirth to be natural processes. Perinatal care providers must be aware of women's birth beliefs and recognize that they as professionals influence women's birth beliefs. They make an important contribution to women's perinatal experiences, which affects both women's natural and medical birth beliefs.

The natural pattern of birth timing and gestational age in the U.S. compared to England, and the Netherlands.

OBJECTIVE: To examine cross-national differences in gestational age over time in the U.S. and across three wealthy countries in 2020 as well as examine patterns of birth timing by hour of the day in home and spontaneous vaginal hospital births in the three countries. METHODS: We did a comparative cohort analysis with data on gestational age and the timing of birth from the United States, England and the Netherlands, comparing hospital and home births. For overall gestational age comparisons, we drew on national birth cohorts from the U.S. (1990, 2014 & 2020), the Netherlands (2014 & 2020) and England (2020). Birth timing data was drawn from national data from the U.S. (2014 & 2020), the Netherlands (2014) and from a large representative sample from England (2008-10). We compared timing of births by hour of the day in hospital and home births in all three countries. RESULTS: The U.S. overall mean gestational age distribution, based on last menstrual period, decreased by more than half a week between 1990 (39.1 weeks) and 2020 (38.5 weeks). The 2020 U.S. gestational age distribution (76% births prior to 40 weeks) was distinct from England (60%) and the Netherlands (56%). The gestational age distribution and timing of home births was comparable in the three countries. Home births peaked in early morning between 2:00 am and 5:00 am. In England and the Netherlands, hospital spontaneous vaginal births showed a generally similar timing pattern to home births. In the U.S., the pattern was reversed with a prolonged peak of spontaneous vaginal hospital births between 8:00 am to 5:00 pm. CONCLUSIONS: The findings suggest organizational priorities can potentially disturb natural patterns of gestation and birth timing with a potential to improve U.S. perinatal outcomes with organizational models that more closely resemble those of England and the Netherlands.

The role of birth plans for shared decision-making around birth choices of pregnant women in maternity care: A scoping review.

BACKGROUND: Birth plans can be used to facilitate shared decision-making in childbirth. A birth plan is a document reflecting women's preferences for birth, which they discuss with their maternity care provider. AIM: This scoping review aims to synthesize current findings on the role of birth plans for shared decision-making around birth choices of pregnant women in maternity care. METHODS: We conducted a scoping review using the Joanna Briggs Institute three-step search strategy in multiple databases PubMed, EMBASE, CINAHL, Web of Science, PsycINFO. We synthesized the results using a metasynthesis approach to identify themes and subthemes. RESULTS: From the 21 articles included, five themes were identified: birth plan as a tool for shared decision-making, autonomy, sense of control, professionalism of the care provider, and trust. Primarily, midwives seemed to use birth plans to explore and facilitate women's choices around birth. Other healthcare providers involved in studies were obstetricians and nurses. The interrelationship between care providers and women, the attitude of care providers and women towards each other and the birth plan, and how providers and women use the birth plan influence shared decision-making. DISCUSSION AND CONCLUSION: Birth plans can facilitate shared decision-making, and women's sense of autonomy and control before, during, and after giving birth. When discussing the birth plan, exploring different scenarios may help women prepare for unforeseen circumstances. This will likely facilitate shared decision-making even if the birth process is not unfolding as hoped for.

Women's decision-making autonomy in Dutch maternity care.

BACKGROUND: A positive childbirth experience is an important outcome of maternity care. A significant component of a positive birth experience is the ability to exercise autonomy in decision-making. In this study, we explore women's reports of their autonomy during conversations about their care with maternity care practitioners during pregnancy and childbirth. METHOD: Data were obtained from a cross-sectional survey of women living in The Netherlands that asked about their experiences during pregnancy and childbirth, including their role in conversations concerning decisions about their care. RESULTS: A total of 3494 women were included in this study. Most women scored high on autonomy in decision-making conversations. During the latter stage of pregnancy (32+ weeks) and in childbirth, women reported significantly lower levels of autonomy in their care conversations with obstetricians as compared with midwives. Linear regression analyses showed that women's perception of personal treatment increased women's reported autonomy in their conversations with both midwives and obstetricians. Almost half (49.1%) of the women who had at least one intervention during birth reported pressure to accept or submit to that intervention. This was indicated by 48.3% of women with induced labor, 47.3% who had an instrumental vaginal birth, 45.2% whose labor was augmented, and 41.9% of women who had a cesarean birth. CONCLUSIONS: In general, women's sense of autonomy in decision-making conversations during prenatal care and birth is high, but there is room for improvement, and this appeared most notably in conversations with obstetricians. Women's sense of autonomy can be enhanced with personal treatment, including shared decision-making and the avoidance of pressuring women to accept interventions.

Integrating women's voices in quality improvement for maternity care: A qualitative study.

INTRODUCTION: Improving the quality of maternity care is high on the national agenda in the Netherlands. One aspect gaining significant attention is integrating women's experiences - as users of maternity care - in this quality improvement. The aim of this study was to gain deeper insights into how maternity care professionals in Dutch Maternity Care Collaborations integrate women's voices into quality improvement as part of integrated maternity care and what role midwives can have in this. METHODS: This was a descriptive qualitative study, using semi-structured individual interviews and content analysis for an in-depth exploration of maternity care professionals' experiences and opinions on integrating women's voices in quality improvement. Participants were twelve maternity care professionals involved in quality improvement activities from eight Dutch Maternity Care Collaborations. RESULTS: Four themes emerged: 'Quality improvement based on women's voices is still in its infancy' and was experienced as an important but challenging topic; 'Collecting women's voices' was conducted, but needed more facilitation; Using women's voices' was hindered by a lack of expertise and a structured feedback and feedforward system; and 'Ensuring listening to women's voices' and integrating them in quality improvement required further facilitation. CONCLUSIONS: Care professionals emphasized that listening to women's voices for quality improvement is important but challenging due to the lack of expertise, organizational structure, time, and financial resources. A feasible implementation strategy including concrete support is recommended by maternity care professionals to boost action.

Knowledge and skills used for clinical decision-making on childbirth interventions: A qualitative study among midwives in the Netherlands.

INTRODUCTION: Appropriate use of interventions in maternity care is a worldwide issue. Midwifery-led models of care are associated with more efficient use of resources, fewer medical interventions, and improved outcomes. However, the use of interventions varies considerably between midwives. The aim of this study was to explore how knowledge and skills influence clinical decision-making of midwives on the appropriate use of childbirth interventions. METHODS: A qualitative study using in-depth interviews with 20 primary care midwives was performed in June 2019. Participants' clinical experience varied in the use of interventions. The interviews combined a narrative approach with a semi-structured question route. Data were analyzed using deductive content analysis. RESULTS: 'Knowledge', 'Critical thinking skills', and 'Communication skills' influenced midwives' clinical decision-making towards childbirth interventions. Midwives obtained their knowledge through the formal education program and extended their knowledge by reflecting on experiences and evidence. Midwives with a low use of interventions seem to have a higher level of reflective skills, including reflection-in-action. These midwives used a more balanced communication style with instrumental and affective communication skills in interaction with women, and have more skills to engage in discussions during collaboration with other professionals, and thus personalizing their care. CONCLUSIONS: Midwives with a low use of interventions seemed to have the knowledge and skills of a reflective practitioner, leading to more personalized care compared to standardized care as defined in protocols. Learning through reflectivity, critical thinking skills, and instrumental and affective communication skills, need to be stimulated and trained to pursue appropriate, personalized use of interventions.

Experiences, Beliefs, and Values Influencing Midwives' Attitudes Toward the Use of Childbirth Interventions.

INTRODUCTION: Intervention rates in perinatal care vary between and within countries, without populations' characteristics as a full explanation. Research suggests that one factor in this variation might be the attitudes of perinatal health care providers. Systematic knowledge on the background of midwives' attitudes and how this influences the use of interventions is limited. The study aim was to to explore experiences, beliefs, and values that influence midwives' attitudes toward interventions in perinatal care. METHODS: A qualitative study using in-depth interviews with primary care midwives (n = 20) in the Netherlands. The interviews were performed in June 2019 and combined a narrative approach with a semistructured interview guide. Inductive content analysis was applied. RESULTS: We identified 2 main themes: attitudes toward interventions and influences on midwives' attitudes. The midwives in our study described their attitudes toward interventions as oriented to either wait and see or check and control. Care based on wait and see displayed a more supportive style of behavior, and care based on check and control appeared to display a more directive style of behavior. In the theme of influences on midwives' attitudes, 3 subthemes emerged: experiences in collaboration, trust and fear, and woman-centeredness. DISCUSSION: Midwives with a wait and see attitude seem to have a more restricted approach toward interventions compared with midwives with a check and control attitude. Midwives need to be aware how their experiences, beliefs, and values shape their attitudes toward use of interventions. This awareness could be a first step toward the reduction of unwarranted interventions.

Women's view on shared decision making and autonomy in childbirth: cohort study of Belgian women.

BACKGROUND: Health care providers have an important role to share evidence based information and empower patients to make informed choices. Previous studies indicate that shared decision making in pregnancy and childbirth may have an important impact on a woman's birth experience. In Flemish social media, a large number of women expressed their concern about their birth experience, where they felt loss of control and limited possibilities to make their own choices. The aim of this study is to explore autonomy and shared decision making in the Flemish population. METHODS: This is a cross-sectional, non-interventional study to explore the birth experience of Flemish women. A self-assembled questionnaire was used to collect data, including the Pregnancy and Childbirth Questionnaire (PCQ), the Labor Agentry Scale (LAS), the Mothers Autonomy Decision Making Scale (MADM), the 9-item Shared Decision Making Questionnaire (SDM-Q9) and four questions on preparation for childbirth. Women who gave birth two to 12 months ago were recruited by means of social media in the Flemish area (Northern part of Belgium). Linear mixed-effect modelling with backwards variable selection was applied to examine relations with autonomy in decision making. RESULTS: In total, 1029 mothers participated in this study of which 617 filled out the survey completely. In general, mothers experienced moderate autonomy in decision-making, both with an obstetrician and with a midwife with an average on the MADM score of respectively 18.5 (± 7.2) and 29.4 (±10.4) out of 42. The linear mixed-effects model showed a relationship between autonomy in decision-making (MADM) for the type of healthcare provider (p < 0.001), the level of self-control during labour and birth (LAS) (p = 0.003), the level of perceived quality of care (PCQ) (p < 0.001), having epidural analgesia during childbirth (p = 0.026) and feeling to have received sufficient information about the normal course of childbirth (p < 0.001). CONCLUSIONS: Childbearing women in Flanders experience moderate levels of autonomy in decision- making with their health care providers, where lower autonomy was observed for obstetricians compared to midwives. Future research should focus more on why differences occur between obstetrics and midwives in terms of autonomy and shared decision-making as perceived by the mother.

More home births during the COVID-19 pandemic in the Netherlands.

BACKGROUND: The aim of this observational study was to examine whether the course of pregnancy and birth and accompanying outcomes among low-risk pregnant women changed in the COVID-19 pandemic compared to the prepandemic period. METHODS: We analyzed data from the Dutch Midwifery Case Registration System (VeCaS). Differences in the course of pregnancy and birth, and accompanying maternal and neonatal outcomes, were calculated between women pregnant during the initial months of the COVID-19 pandemic (March 1 to August 3, 2020) and the prepandemic period (March 1-August 3, 2019). We also conducted a stratified analysis by parity. RESULTS: We included 5913 low-risk pregnant women of whom 2963 (50.1%) were pregnant during the first surge of the COVID-19 pandemic, and 2950 (49.9%) in the prepandemic period. During the COVID-19 pandemic, more women desired and had a home birth. More women used pain medication and fewer had an episiotomy in the COVID-19 period than prior. Multiparous women had a higher suspected rate of fetal growth restriction during COVID; however, the actual rate of small for gestational age infants was not significantly increased. We observed no differences for onset and augmentation of labor or for mode of birth, though the rate of vaginal births increased. CONCLUSIONS: During the COVID-19 pandemic, there was a higher rate of planned and actual home birth, and suspected growth restriction and a lower rate of episiotomy among low-risk pregnant women in the Netherlands.

The effects of COVID-19 restrictions and other perinatal factors on women's sense of control during childbirth: a prospective cohort study.

BACKGROUND: Restrictions around childbirth, introduced during the COVID-19 pandemic in 2020, could decrease maternal feelings of control during birth. The aim of this study was to compare the sense of control of women who gave birth during the COVID-19 pandemic with women who gave birth before COVID-19. The secondary objective was to identify other factors independently associated with women's sense of control during birth. METHODS: A prospective cohort study, in a sub-cohort of 504 women from a larger cohort (Continuous Care Trial (CCT), n = 992), was conducted. Sense of control was measured by the Labor Agentry Scale (LAS). Perinatal factors independently associated with women's sense of control during birth were identified using multiple linear regression. RESULTS: Giving birth during the COVID-19 pandemic did not influence women's sense of control during birth. Factors statistically significantly related to women's sense of control were Dutch ethnic background (ß 4.787, 95%-CI 1.319 to 8.254), antenatal worry (ß - 4.049, 95%-CI -7.516 to -.581), antenatal anxiety (ß - 4.677, 95%-CI -7.751 to 1.603) and analgesics during birth (ß - 3.672, 95%-CI -6.269 to -1.075). CONCLUSIONS: Despite the introduction of restrictions, birth during the COVID-19 pandemic was not associated with a decrease of women's sense of control.

Sources of information used by women during pregnancy and the perceived quality.

BACKGROUND: Access to reliable information is critical to women's experience and wellbeing during pregnancy and childbirth. In our information-rich society, women are exposed to a wide range of information sources. The primary objective of this study was to explore women's use of information sources during pregnancy and to examine the perceived usefulness and trustworthiness of these sources. METHOD: A quantitative cross-sectional study of Dutch women's experiences with various information sources during pregnancy, including professional (e.g. healthcare system), and informal sources, divided into conventional (e.g. family or peers) and digital sources (e.g. websites or apps). Exploratory backward stepwise multiple regression was performed to identify associations between the perceived quality of information sources and personal characteristics. RESULTS: A total of 1922 pregnant women were included in this study. The most commonly used information sources were midwives (91.5%), family or friends (79.3%), websites (77.9%), and apps (61%). More than 80% of women found professional information sources trustworthy and useful, while digital sources were perceived as less trustworthy and useful. Personal factors explain only a small part of the variation in the perceived quality of information sources. CONCLUSION: Even though digital sources are perceived as less trustworthy and useful than professional and conventional sources, they are among the most commonly used sources of information for pregnant women. To meet the information needs of the contemporary generation of pregnant women it is essential that professionals help in the development of digital information sources.