ACCES FOR INDEPENDENT MIDWIVES TO THE FLEMISH HOSIPITALS Katelijne De Koster Midwife Master of Management and Policy in HC-Services

Background Independent Midwives rarely allowed in hospitals Continuity of care provision at risk Controverse about home birth Toegang van de zelfstandige vroedvrouw tot de Vlaamse ziekenhuizen 2 december 2018

Aims of the study/ Research aims Current state of art in Flanders with regard to the accessibility of independent midwives to the hospitals Variation in motives allowing independent midwives Barrières for access Opportunities provided/given/available Toegang van de zelfstandige vroedvrouw tot de Vlaamse ziekenhuizen 2 december 2018

Literature search Historical overview Evolution of the profession Influence of the medical profession Toegang van de zelfstandige vroedvrouw tot de Vlaamse ziekenhuizen 2 december 2018

Literature search Conclusion Evolution from tradition to ‘profession’ Influence of medical profession on health care professions Society Authonomy of the midwife Legal competences <-> reality Midwife in search for … Toegang van de zelfstandige vroedvrouw tot de Vlaamse ziekenhuizen 2 december 2018

Quantitative study + follow up of labour at home County Medical Commission (visa to midwives) 2009: 183 (FL), 76 (W), 49 (Br), 26 (Bu) = 334 visa RIZIV: 2005-2008 + obstetric pre and postnatal care + follow up of labour at home = home birth: status quo SPE 2009: 665 home births in Flanders (1.6%) (2010: 626), (2011: 549) Toegang van de zelfstandige vroedvrouw tot de Vlaamse ziekenhuizen 2 december 2018

Questionnaire maternity wards Questionnaire about collaboration Hospitals – Independent midwives Written questionnaire Head midwives 68 maternity wards in Flanders and Brussels Toegang van de zelfstandige vroedvrouw tot de Vlaamse ziekenhuizen 2 december 2018

Questionnaire maternity wards Response rate 46 Hospitals (67.6%) Collaboration agreement Oral: 23 H Written: 19 H Internal Regulations: 14 H Financial agreements: 2 H Toegang van de zelfstandige vroedvrouw tot de Vlaamse ziekenhuizen 2 december 2018

Results Collaboration with independent midwives Prenatal: 17 Partus: 19 Postpartum: 35 None: 10 Toegang van de zelfstandige vroedvrouw tot de Vlaamse ziekenhuizen 2 december 2018

Results Prenatal collaboration with independent midwives 17/46 hospitals Toegang van de zelfstandige vroedvrouw tot de Vlaamse ziekenhuizen 2 december 2018

Results Collaboration with independent midwives during delivery 19 46 Labour and delivery at home In hospital when risk situation 14 73.7% 30,4% Reference of pregnant women to the hospital for labour and delivery. 13 68.4% 28,2% Reference of pregnant women to the hospital for labour and delivery Independent midwife can accompany without payment 11 57.9% 23,9% Autonomous performance of labour and delivery in the hospitals for clientele 8 42.1% 17,3% Labour at home Autonomous performence of delivery in hospital 7 36.8% 15,2% Other (2 doulas, 1 together with general practitioner performing deliveries) 3 15.8% 6,5% Reference of pregnant women for labour and delivery to the hospital Indepent midwives can join to support and receive a payment (assistence delivery). 2 10.5% 4,3% Toegang van de zelfstandige vroedvrouw tot de Vlaamse ziekenhuizen 2 december 2018

Results Collaboration with independent midwives in postpartum 35/46 hospitals Toegang van de zelfstandige vroedvrouw tot de Vlaamse ziekenhuizen 2 december 2018

Hospital visions about collaboration with IM POSSIBLE IMPOSSIBLE Solution for shorthening lenght of stay No need for collaboration Continuation/integration hospital management into home care Opposite view Follow-up breastfeeding at home IM does not respect the hospital rules Independent midwives bring clients to the hospital No need for extra clients Provision of answer to the care needs by the midwife IM is concurrent Monitoring of first en second line care Toegang van de zelfstandige vroedvrouw tot de Vlaamse ziekenhuizen 2 december 2018

CONCLUSION Questionnaire Collaboration provides an added value with regard to care and customer relation Opposite view and competition are key elements to not cooperate Delivery with IM in Hospital is rather exceptional Toegang van de zelfstandige vroedvrouw tot de Vlaamse ziekenhuizen 2 december 2018

Qualitative research/study In dept-interviews (23) Exploitory talk with a group of IM Topiclist with questions 6 hospitals: 3 open, 3 closed (head)midwife of the delivery room, (head)obstetrician, middle management Strenght Research on the field + collaboration Restrictions Only 6 H, 23 interviews, choice of Hospitals Further research is recommended Toegang van de zelfstandige vroedvrouw tot de Vlaamse ziekenhuizen 2 december 2018

Results OPEN HOSPITALS CLOSED Doctors and MW: VISION ABOUT HOME BIRTH Doctors and MW: Positive if respect of certain guidelines Doctors and MW Not so positive: Hosptial is safest place EDUCATION More practice More experience want more practice, experience, improved knowledge about medical and nursing courses VISION ABOUT CARE Hospital MW finds partner in IM MW shares the vision with the IM but wants the Hospital MWto ensure the physiologie Toegang van de zelfstandige vroedvrouw tot de Vlaamse ziekenhuizen 2 december 2018

Results OPEN HOSPITALS CLOSED MW: positive about IM PERCEPTION OF IM MW: positive about IM D: only positive about IM they are collaborating with A: IM does not perform enough deliveries TRUST IN IM IM need to be willing to be integrate A: trusts only the MW from the hospital HOSPITAL POLICY Internal regulation is made after consultation and communication with the D and MW of the Hospital Policy of hospital is incompatibel with polciy of the IM Toegang van de zelfstandige vroedvrouw tot de Vlaamse ziekenhuizen 2 december 2018

Results OPEN HOSPITALS CLOSED JURIDICAL Included in internal agreement between H en IM Use of obstetric indication list D en MW feel Co-responsable = important motivation to refuse IM RESPONSIBILITY Well known because of Internal regulation and a good communication with the D and MW of the Hospital The delivery room is ownership/area of the MW of the hospital FINANCIAL D give advice free of charge IM and D are concurrents Toegang van de zelfstandige vroedvrouw tot de Vlaamse ziekenhuizen 2 december 2018

SWOT- analyses STRENGHT (+) WEAKNESS (-) Care demand from the patient Independent midwifery practice is too small Innovative Training: theory and practice Positive results from open hospitals Alternative vision of obstetric care OPPORTUNITIES (+) TREATS (-) Headmidwife in hospital = facilitator Financing model of obstetric care IM stimulates physiology in hospitals Physiology comes into contact with medical interventions in hosptial Model of cooperation versus competition model Fear of the hosptial midwife to be held legally responsible Toegang van de zelfstandige vroedvrouw tot de Vlaamse ziekenhuizen 2 december 2018

Professional organisations Recommendations Independent midwives Pioniers Proof themselves Apply the law correctly with respect of ethical code The will to collaborate with MW of hospital Influence of the hospital culture Support of physiology Professional organisations Stimulate contact and communication between obstetricians/MW Stimulate collaboration between MW Facilitate access to hospitals for IM Toegang van de zelfstandige vroedvrouw tot de Vlaamse ziekenhuizen 2 december 2018

Recommendations Government Education FOD Figures and numbers !!! Competent <-> authorized Extra criteria before starting an independent practice? RIZIV Model of concurrention <-> collaboration Care trajectories, importance of outcome Education Content and duration of the training, higher competences Toegang van de zelfstandige vroedvrouw tot de Vlaamse ziekenhuizen 2 december 2018

THANKS FOR YOUR ATTENTION! ANY QUESTIONS? Toegang van de zelfstandige vroedvrouw tot de Vlaamse ziekenhuizen 2 december 2018