Midwives’ perception of intrapartum risk in England, Belgium and France

The second half of the last century saw remarkable changes in the delivery of maternity care services, with the introduction of antibiotics and safe anaesthesia. This was associated with a continued decrease in maternal and perinatal mortality and some were quick to establish a cause-and-effect relationship. However, this was challenged by statisticians and technological developments have also been challenged later by some, though embraced by others. An initial study of midwives’ practice and perception of risk had demonstrated not only a slight link between higher intrapartum intervention rate and higher perception of risk but also an over-pessimistic evaluation of the chances of normal women to progress normally and an over-optimistic risk perception of the outcomes associated with interventions. Known variations in obstetric practice and caesarean section rates suggested that this study might benefit from replication in other European Union member states. The replication of the initial English study aimed at comparing the intrapartum care provided by midwives in the Belgian Flanders and the French regions of Alsace and Lorraine, as well as their intrapartum risk perception for the outcomes of spontaneous labour of nulliparous women suitable for midwifery-led care. A survey by questionnaire was administered to midwives in England, Belgium and France. In England, the midwives were selected on the basis that they worked in maternity units that made their maternity data available centrally on an annual basis. This enabled the analysis of the level of intrapartum interventions for healthy nulliparous women suitable for midwifery-led care and the subsequent comparison of the level of recommended intrapartum care and risk perception by midwives working in maternity units classified as either “lower” or “higher” intrapartum intervention units. The opportunities to replicate the study in Belgium and France were limited to the survey of midwives’ recommended intrapartum care and perception of risk, without the comparison of the actual intrapartum care and outcomes of the maternity units where they practise. All midwives working in the 11 relevant maternity units in England were surveyed. In Belgium, midwives attending the annual Flemish midwives’ conference were surveyed, whereas in France the collaboration of two midwifery schools meant that all midwives involved in intrapartum care in two regions – Alsace and Lorraine – were surveyed. The computerised St Mary’s Maternity Information System data were subjected to systematic data reduction to analyse the data of healthy Caucasian women at term of a healthy pregnancy and in spontaneous labour. The remaining data were then subjected to descriptive statistics to examine the rate of various intrapartum interventions and to establish an intrapartum score that was used to categorise maternity units as either “lower” or “higher” intrapartum intervention units (Mead and Kornbrot, Midwifery 20(1):61–71, 2004). The midwives’ surveys were subjected to descriptive statistical analysis. Major differences in midwifery practice were observed in the three countries: English midwives were more likely to monitor the maternal condition than French and Belgian midwives but less likely to use continuous electronic fetal monitoring, restrict maternal nutrition or recommend epidural analgesia. They were also generally more pessimistic about women’s ability to progress normally in labour. If the variations in methods of delivery observed in England parallel those of France and Belgium, the midwives in all three countries systematically overestimated the benefits of intrapartum intervention and, in particular, epidural analgesia. There are major differences in midwifery practice and in obstetric outcomes in these three countries. It is unlikely that the practices alone can explain the variations in outcomes and, in particular, the differences in caesarean section rates. More research is necessary to examine how the health care systems, perception of risk and attitudes to risk aversion may affect midwifery and obstetric practices and maternity services outcomes.