Variation in referrals to secondary obstetrician-led care among primary midwifery care practices in the Netherlands: a nationwide cohort study

Contains fulltext : 154413.pdf (publisher's version ) (Open Access)BACKGROUND: The primary aim of this study was to describe the variation in intrapartum referral rates in midwifery practices in the Netherlands. Secondly, we wanted to explore the association between the practice referral rate and a woman's chance of an instrumental birth (caesarean section or vaginal instrumental birth). METHODS: We performed an observational study, using the Dutch national perinatal database. Low risk births in all primary care midwifery practices over the period 2008-2010 were selected. Intrapartum referral rates were calculated. The referral rate among nulliparous women was used to divide the practices in three tertile groups. In a multilevel logistic regression analysis the association between the referral rate and the chance of an instrumental birth was examined. RESULTS: The intrapartum referral rate varied from 9.7 to 63.7 percent (mean 37.8; SD 7.0), and for nulliparous women from 13.8 to 78.1 percent (mean 56.8; SD 8.4). The variation occurred predominantly in non-urgent referrals in the first stage of labour. In the practices in the lowest tertile group more nulliparous women had a spontaneous vaginal birth compared to the middle and highest tertile group (T1: 77.3%, T2:73.5%, T3: 72.0%). For multiparous women the spontaneous vaginal birth rate was 97%. Compared to the lowest tertile group the odds ratios for nulliparous women for an instrumental birth were 1.22 (CI 1.16-1.31) and 1.33 (CI 1.25-1.41) in the middle and high tertile groups. This association was no longer significant after controlling for obstetric interventions (pain relief or augmentation). CONCLUSIONS: The wide variation between referral rates may not be explained by medical factors or client characteristics alone. A high intrapartum referral rate in a midwifery practice is associated with an increased chance of an instrumental birth for nulliparous women, which is mediated by the increased use of obstetric interventions. Midwives should critically evaluate their referral behaviour. A high referral rate may indicate that more interventions are applied than necessary. This may lead to a lower chance of a spontaneous vaginal birth and a higher risk on a PPH. However, a low referral rate should not be achieved at the cost of perinatal safety

Participatory storylines and their influence on deliberative forums

For all the recent discussion on the virtues and vices of public deliberation, surprisingly little attention has been given to how deliberative procedures actually operate in different policy contexts. This article takes up this task with a specific focus on how deliberative designs such as citizens' juries and consensus conferences interface with their participatory context. The concept of the participatory storyline is developed to describe the competing narratives associated with a policy issue on who constitutes the publicâ€\x9D and how “theyâ€\x9D should be represented and involved in the policy process. An analysis of two Australian cases reveals how existing participatory storylines can productively or destructively influence deliberative forums. The empirical research suggests that a more productive deliberative procedure is one that supports or “speaks toâ€\x9D existing narratives on what constitutes public participation. Under these conditions key policy actors are more likely to engage in the deliberative process and endorse its outcomes. Some suggestions are provided for how practitioners can better anticipate the way a deliberative forum might interface with its participatory context. Copyright Springer Science + Business Media, Inc. 2005