How to Make the Hospital an Option Again: Midwives' and Obstetricians' Experiences with a Designated Clinic for Women Who Request Different Care than Recommended in the Guidelines

Abstract

Background: An increasing number of maternity care providers encounter pregnant women who request less care than recommended. A designated outpatient clinic for women who request less care than recommended was set up in Nijmegen, the Netherlands. The clinic's aim is to ensure that women make well-informed choices and arrive at a care plan that is acceptable to all parties. The aim of this study is to make the clinic's approach explicit by examining care providers' experiences who work with or within the clinic.

Methods: qualitative analysis of in-depth interviews with Dutch midwives (n = 6) and obstetricians (n = 4) on their experiences with the outpatient clinic "Maternity Care Outside the Guidelines" in Nijmegen, the Netherlands.

Results: Four main themes were identified: (1) "Trusting mothers, childbirth and colleagues"; (2) "A supportive communication style"; (3) "Continuity of carer"; (4) "Willingness to reconsider responsibility and risk". One overarching theme emerged from the data, which was "Guaranteeing women's autonomy". Mutual trust is a prerequisite for a constructive dialogue about birth plans and can be built and maintained more easily when there is continuity of carer during pregnancy and birth. Discussing birth plans at the clinic was believed to be successful because the care providers listen to women, take them seriously, show empathy and respect their right to refuse care. A change in vision on responsibility and risk is needed to overcome barriers such as providers' fear of adverse outcomes. Taking a more flexible approach towards care outside the guidelines demands courage but is necessary to guarantee women's autonomy.

Key conclusions and implications for practice: In order to fulfil women's needs and to prevent negative choices, care providers should care for women with trust, respect for autonomy, and provide freedom of choice and continuity. Care providers should reflect on and discuss why they are reluctant to support women's wishes that go against their personal values. The structured approach used at this clinic could be helpful to maternity care providers in other contexts, to make them feel less vulnerable when working outside the guidelines.

Keywords: The Netherlands; autonomy; care outside the guidelines; high risk; homebirth; maternity care; personalised care; shared decision making; treatment refusal; woman-centred care.