Background Psychological aspects of labor and birth have received little attention within maternity care service planning or clinical practice. The aim of this paper is to propose a model demonstrating how neurohormonal processes, in particular oxytocinergic mechanisms, not only control the physiological aspects of labor and birth, but also contribute to the subjective psychological experiences of birth. In addition, sensory information from the uterus as well as the external environment might influence these neurohormonal processes thereby influencing the progress of labor and the experience of birth. Methodology In this new model of childbirth, we integrated the findings from two previous systematic reviews, one on maternal plasma levels of oxytocin during physiological childbirth and one meta-synthesis of women´s subjective experiences of physiological childbirth. Findings The neurobiological processes induced by the release of endogenous oxytocin during birth influence maternal behaviour and feelings in connection with birth in order to facilitate birth. The psychological experiences during birth may promote an optimal transition to motherhood. The spontaneous altered state of consciousness, that some women experience, may well be a hallmark of physiological childbirth in humans. The data also highlights the crucial role of one-to-one support during labor and birth. The physiological importance of social support to reduce labor stress and pain necessitates a reconsideration of many aspects of modern maternity care. Conclusion By listening to women’s experiences and by observing women during childbirth, factors that contribute to an optimized process of labor, such as the mothers’ wellbeing and feelings of safety, may be identified. These observations support the integrative role of endogenous oxytocin in coordinating the neuroendocrine, psychological and physiological aspects of labor and birth, including oxytocin mediated. decrease of pain, fear and stress, support the need for midwifery one-to-one support in labour as well as the need for maternity care that optimizes the function of these neuroendocrine processes even when birth interventions are used. Women and their partners would benefit from understanding the crucial role that endogenous oxytocin plays in the psychological and neuroendocrinological process of labor.
Background: The maternity care system in the Netherlands is well known for its support of community-based midwifery. However, regular midwifery practices typically do not offer caseload midwifery care – one-to-one continuity of care throughout pregnancy and birth. Because we know very little about the outcomes for women receiving caseload care in the Netherlands, we compared caseload care with regular midwife-led care, looking at maternal and perinatal outcomes, including antenatal and intrapartum referrals to secondary (i.e., obstetrician-led) care. Methods: We selected 657 women in caseload care and 1954 matched controls (women in regular midwife-led care) from all women registered in the Dutch Perinatal Registry (Perined) who gave birth in 2015. To be eligible for selection the women had to be in midwife-led antenatal care beyond 28 gestational weeks. Each woman in caseload care was matched with three women in regular midwife-led care, using parity, maternal age, background (Dutch or non-Dutch) and region. These two cohorts were compared for referral rates, mode of birth, and other maternal and perinatal outcomes. Results: In caseload midwifery care, 46.9% of women were referred to obstetrician-led care (24.2% antenatally and 22.8% in the intrapartum period). In the matched cohort, 65.7% were referred (37.4% antenatally and 28.3% in the intrapartum period). In caseload care, 84.0% experienced a spontaneous vaginal birth versus 77.0% in regular midwife-led care. These patterns were observed for both nulliparous and multiparous women. Women in caseload care had fewer inductions of labour (13.2% vs 21.0%), more homebirths (39.4% vs 16.1%) and less perineal damage (intact perineum: 41.3% vs 28.2%). The incidence of perinatal mortality and a low Apgar score was low in both groups. Conclusions: We found that when compared to regular midwife-led care, caseload midwifery care in the Netherlands is associated with a lower referral rate to obstetrician-led care – both antenatally and in the intrapartum period – and a higher spontaneous vaginal birth rate, with similar perinatal safety. The challenge is to include this model as part of the current effort to improve the quality of Dutch maternity care, making caseload care available and affordable for more women.
At the beginning of the twenty first century obesity entered Dutch maternity care as a ‘new illness’ challenging maternity care professionals in providing optimal care for women with higher BMI’s. International research revealed that obese women had more perinatal problems than normal weight women. However, the effect of higher BMIs on perinatal outcomes had never been studied in women eligible for midwife-led primary care at the outset of their pregnancy. In the context of the Dutch maternity care system, it was not clear if obesity should be treated as a high-risk situation always requiring obstetrician-led care or as a condition that may lead to problems that could be detected in a timely manner in midwife-led care using the usual risk assessment tools. With the increased attention on obesity in maternity care there was also increased interest in GWG. Regarding GWG in the Netherlands, the effect of insufficient or excessive GWG on perinatal outcomes had never been studied and there were no validated guidelines for GWG. A midwife’s care for the individual woman in the context of the Dutch maternity care system - characterised by ‘midwife-led care if possible, obstetrician-led care if needed’ - is hampered by the lack of national multidisciplinary consensus regarding obesity and weight gain. Obesity has not yet been included in the OIL and local protocols contain varying recommendations. To enable sound clinical decisions and to offer optimal individual care for pregnant women in the Netherlands more insights in weight and weight gain in relation to perinatal outcomes are required. With this thesis the author intends to contribute to the body of knowledge on weight and weight gain to enhance optimal midwife-led primary care for the individual woman and to guide midwives’ clinical decision-making.
