Contributor(s)Spitz, Bernard; U0013436; ; ; ;
Sermeus, Walter; U0010801; ; ; ;
Thomson, Ann; U0039634; ; ; ;
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AbstractThe way maternity care is organised varies considerably around the world. In Flanders, Belgium, maternity care is predominantly obstetric-led care whereby the obstetrician is the primary care provider and women give birth in hospital. This model of care has several implications for the stakeholders, but not all stakeholders are routinely involved in research on maternity care.The aim of this study was to explore the views of seven groups of stakeholders on maternity care by addressing the following research questions: what are the views on maternity care in Flanders that are held by midwives, obstetricians, student midwives at the beginning of their education, student midwives at the end of their education, nurse directors, nulligravid women and mothers? Eventually, the different views were matched in order to visualize similarities and differences.A qualitative hermeneutic phenomenological method, based on van Manen s approach was used consistently to study all research questions, thus enabling comparison. Data were collected by means of in-depth face-to-face interviews and focus groups and quality enhancement strategies were used to obtain trustworthiness of the findings. In total, 100 persons participated in this study and over all studies, 37 themes and 24 subthemes emerged from the data.The midwives held a woman-centred ideology and perceived current maternity care as very medicalised. Ideal maternity care is seen as woman-centred care with no unnecessary interventions, in which women can make an informed choice and there is continuity of care. Ideally there should be a cultural change and maternity care should be supported by management and education. They also expressed a wish for more equality between midwives and obstetricians and between hospital and independent midwives. Being equal partners with obstetricians implied that midwives would have the autonomy for normal childbirth. Respect and trust were considered to be the cornerstones of the working relationship. For commencing student midwives, midwifery was a well-considered choice. They had a realistic view on maternity care and the role of the midwife in the current Belgian context. They saw a midwife as a caring person who held a lot of responsibility. They were aware of the hierarchy in current maternity care and the fact that most deliveries were conducted by the obstetricians. Furthermore they expressed a preference for normality and they used the opinion and experience of their own mother to build their personal view. For the student midwives at the end of their education midwifery was also a well-considered choice. They saw the midwife as a coach for women and made a distinction between hospitals and caregivers based upon style of care and professional relations.The obstetricians found current maternity care to be situated within a medicalised context whereby care was also driven by other factors apart from the individual needs of women. Current maternity care was considered to be safe care based upon mortality rates. However, they expressed concern towards unnecessary interventions carried out by colleague obstetricians, as these were believed to jeopardise safety. Furthermore, information and informed choice, or the lack hereof, appeared to play an important role in current maternity care. The obstetricians thought midwives were the ideal caregivers to provide perinatal education and information and they should therefore be routinely involved in antenatal care. For the nurse directors, the quality of maternity care was primordial. They saw their own role as staying within budget , but without compromising on quality of care. They set the limits of care while they gave the professionals the autonomy to define practice. The maternity unit was considered to be just another unit in the hospital with aspects that were both generic and specific. Furthermore they believed a difference could be seen between the nurses and midwives working in their hospital, with the latter being an all-round professional who is very motivated and well educated. The staffing norm was judged dated and insufficient. Nulligravid women already had views and expectations on pregnancy and childbirth. These women used stories from other women and reality TV as their primary source of information. The experience of their own mother had a major influence on their own expectations. There appeared to be a self-sustaining system in which the current culture of childbirth was passed on to the next generation. Although not actively seeking for information, these women perceived a lack of knowledge and a need for information to be given preconceptionally. Mothers looked back upon their childbirth experience as happy days and having a healthy baby and being healthy themselves was very important. They relied on the caregivers to provide adequate care and make decisions, as well as on their own instinct. They found it important that care was adjusted to their personal needs. The women s experiences with the labour and delivery ward were closely linked with the caregivers whereas they described their postnatal stay as a hotel-like stay. The obstetricians were the key figures for the mothers who felt very safe under their care. Although they had not met the midwives before their labour and delivery, they bonded quickly with them. Midwives were described as warm, sensitive and caring. The views of the seven groups were then matched through a meta-synthesis based on the method of Noblit and Hare and eight themes were identified: (1) Safety is priority in maternity care, (2) Maternity care should be woman-centred, (3) the leading role of the obstetrician, (4) the supporting role of the midwife, (5) the information paradox: too little or too much?,(6) Childbirth (and) culture (7) From the unknown to happy days and (8) co-existing ideologies.This is the first study which looked in-depth at maternity care for different perspectives. Some of these perspectives had not been explored before. It became apparent from themeta-synthesis that the perspectives complemented each other and only slight divergences were found. An important overall finding is that ideology appears to determine maternity care since different ideologies are not merely a different way of thinking; they also result in differences in practice and in differences as to how caregivers encounter each other and women.Based upon the findings from this qualitative study, it is recommended that efforts are made to reduce the number of unnecessary interventions, the fee for service financing system, postnatal hospital stay and the free enrolment of student midwives are re-evaluated, woman-centred care is enhanced, the feasibility of midwife-led care is explored, midwives are made more visible in society, student midwives are put in contact with all aspects of midwifery practice and lastly future research looks into the relationship between ideology and obstetric care and relations in care.
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