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Implementation of an integrated care system for women during labour: bridging the gap between primary and secondary care. A problem analysis. (INCAS study)



1.      Background

Integrating primary midwifery and secondary midwifery and obstetric care during labour fulfils an urgently felt societal need to reduce infant deaths, improve birth outcomes and womenís experiences and to reduce unnecessary medical interventions and health care costs.

Currently, the percentage of referrals during labour from primary to secondary care is rising. Disadvantages of referrals during labour are that women who have been referred during labour look back more negatively on their birth, that vital information may get lost during handover, and that there is no continuity of support during labour. Continuous support is associated with fewer instrumental deliveries, less pain relief and more satisfaction among women. However, most referrals are for indications that only imply a moderate increase in risk, for instance prolonged rupture of membranes, meconium stained liquor, request for pain relief or failure to progress in labour. These indications lead to routine interventions such as continuous foetal monitoring, pain relief or augmentation of labour.


2.      Objectives

a.       Main objective

We aim to conduct an in-depth problem analysis of facilitators and barriers for implementation of an integrated system of care for women in labour, with the aim to develop an implementation strategy.


b.      Specific objectives

The objectives of the proposed study are:

- To identify characteristics of the optimal model for integration of care in the Netherlands

- To examine the facilitators and barriers of integrating primary and secondary care during  labour, in particular for women who develop moderate risk factors.
- To design an implementation strategy to integrate primary and secondary care during labour.

    In a subsequent study, we can implement and evaluate this new strategy and conduct an economic evaluation. If successful, this will revolutionize maternity care as we know it in the Netherlands.


    3.      Methods

    a. Study design

    The INCAS study comprises a systematic analysis of determinants of innovation using a combination of quantitative and qualitative methods.


    b. Study population

    The health care innovation of integrating midwifery and obstetric care is primarily aimed at women in labour who currently receive primary care (for which the primary care midwife is responsible) as well as secondary care (for which the obstetrician is responsible).

    In the proposed study, we will carry out a problem analysis for which we will focus on health professionals involved in the care of pregnant women as well as other stakeholders.


    c. The study consists of four sub-studies


    • Mapping of current referrals during labour and their subsequent management and outcomes. Baseline data from patient records will be collected retrospectively from six hospitals.
    • A Delphi study to identify characteristics of the optimal model for integration of care, in which obstetricians, midwives and obstetrics & gynecology nurses participate.
    • A qualitative survey (focus groups and interviews) among professionals and other stakeholders to identify  facilitators and barriers to integration of midwifery and obstetric care Next, a quantitative survey among a large random sample of midwives and obstetricians in the country will be conducted to assess which determinants are most important. 
    • Finally, an implementation strategy will be developed. This strategy will be evaluated in a subsequent study.


    4.      Projectleaders and collaborations

    Dr. Ank de Jonge, midwife / senior researcher, AVAG, EMGO/VumC, Afdeling Midwifery Science, ank.dejonge@vumc.nl; 020-4448196


    Prof Ben Willem Mol, gynaecoloog/ hoogleraar klinische evaluatiestudies in obstetrie, gynaecologie en fertiliteit, AMC, b.w.mol@amc.uva.nl


    Prof Eileen Hutton, verloskundige/hoogleraar,  AVAG, EMGO/VumC, Afdeling Midwifery Science, huttone@mcmaster.ca


    Dr Judith ManniŽn, senior researcher/ epidemiologist, AVAG, EMGO/VumC, Afdeling Midwifery Science, j.mannien@vumc.nl; 020-4448406


    Hilde Perdok-van Oostveen, midwife / researcher, AVAG, EMGO/VumC, Afdeling Midwifery Science h.perdok@vumc.nl; 020-4449987