title: Variation in intrapartum referral rates in primary midwifery care in the Netherlands: a discrete choice experiment.
abstract: OBJECTIVE
  in midwife-led care models of maternity care, midwives are responsible for intrapartum referrals to the obstetrician or obstetric unit, in order to give their clients access to secondary obstetric care. This study explores the influence of risk perception, policy on routine labour management, and other midwife related factors on intrapartum referral decisions of Dutch midwives.
  
  
  METHODS
  a questionnaire was used, in which a referral decision was asked in 14 early labour scenarios (Discrete Choice Experiment or DCE). The scenarios varied in woman characteristics (BMI, gestational age, the preferred birth location, adequate support by a partner, language problems and coping) and in clinical labour characteristics (cervical dilatation, estimated head-to-cervix pressure, and descent of the head).
  
  
  METHODS
  primary care midwives in the Netherlands.
  
  
  METHODS
  a systematic random selection of 243 practicing primary care midwives. The response rate was 48 per cent (117/243).
  
  
  METHODS
  the Impact Factor of the characteristics in the DCE was calculated using a conjoint analysis. The number of intrapartum referrals to secondary obstetric care in the 14 scenarios of the DCE was calculated as the individual referral score. Risk perception was assessed by respondents׳ estimates of the probability of eight birth outcomes. The associations between midwives׳ policy on management of physiological labour, personal characteristics, workload in the practice, number of midwives in the practice, and referral score were explored.
  
  
  RESULTS
  the estimated head-to-cervix pressure and descent of the head had the largest impact on referral decisions in the DCE. The median referral score was five (range 0-14). Estimates of probability on birth outcomes were predominantly overestimating actual risks. Factors significantly associated with a high referral score were: a low estimated probability of a spontaneous vaginal birth (p=0.007), adhering to the active management policy Proactive Support of Labour (PSOL) (p=0.047), and a practice situated in a rural area or small city (p=0.016).
  
  
  CONCLUSIONS
  there is considerable variation in referral decisions among midwives that cannot be explained by woman characteristics or clinical factors in early labour. A realistic perception of the possibility of a spontaneous vaginal birth and adhering to expectant management can contribute to the prevention of unwarranted medicalisation of physiological childbirth.
  
  
  CONCLUSIONS
  awareness of variation in referrals and the associated midwife-related factors can stimulate midwives to reflect on their referral behavior. To diminish unwarranted variation, high quality research on the optimal management of a physiological first stage of labour should be performed.
authors: KNOV (Royal Dutch Organisation for Midwives), P.O. Box 2001, 3500GA Utrecht, The Netherlands. Electronic address: pofferhaus@knov.nl.
authors: Pien M
authors: PM
authors: Offerhaus
authors: TNO Life Style, P.O. Box 2215, 2301 CE Leiden, The Netherlands. Electronic address: wilma.otten@tno.nl.
authors: Wilma
authors: W
authors: Otten
authors: Midwifery Academy Amsterdam Groningen (AVAG), Louwesweg 6, 1066EC Amsterdam, The Netherlands. Electronic address: Jolanda.Boxem@inholland.nl.
authors: Jolanda C G
authors: JC
authors: Boxem-Tiemessen
authors: Department of Midwifery Science, AVAG and the EMGO Institute for Health and Care Research, VU University Medical Center, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands. Electronic address: ank.dejonge@vumc.nl.
authors: Ank
authors: A
authors: de Jonge
authors: TNO Child Health, P.O. Box 2215, 2301 CE Leiden, The Netherlands. Electronic address: Karin.vanderpal@tno.nl.
authors: Karin M
authors: KM
authors: van der Pal-de Bruin
authors: Faculty of Social Sciences, Radboud University, P.O. Box 9104, 6500 HE Nijmegen, The Netherlands. Electronic address: p.scheepers@maw.ru.nl.
authors: Peer L H
authors: PL
authors: Scheepers
authors: Radboud University Nijmegen Medical Centre, Internal Postal Code 118, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands. Electronic address: Toine.Lagro@radboudumc.nl.
authors: Antoine L M
authors: AL
authors: Lagro-Janssen
mesh_terms: D000328:Adult; D036861:Delivery, Obstetric / Q000379:methods; D005260:Female; D006305:Health Status Indicators; D006801:Humans; D008880:Midwifery / Q000379:methods*; D009426:Netherlands; D007744:Obstetric Labor Complications / Q000628:therapy*; D009774:Obstetrics; D011247:Pregnancy; D011320:Primary Health Care / Q000706:statistics & numerical data; D012017:Referral and Consultation / Q000706:statistics & numerical data*
keywords: Early labour; Midwifery; Practice variation; Referral; Risk perception