See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/338171330

The Woman-Centeredness of Various Dutch Maternity Service Providers

During Antenatal and Postnatal Care

Article · December 2019

DOI: 10.1891/2156-5287.9.2.92

CITATION READS

1 288

4 authors, including:

Yvonne Kuipers Elise van Beeck

Edinburgh Napier University Erasmus MC
65 PUBLICATIONS   338 CITATIONS    13 PUBLICATIONS   111 CITATIONS   

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Woman-centered care View project

CA18211 - Perinatal Mental Health and Birth-Related Trauma: Maximising best practice and optimal outcomes View project

All content following this page was uploaded by Yvonne Kuipers on 04 February 2020.

The user has requested enhancement of the downloaded file.

ID:p0085
ID:p0055

ID:ti0020
ID:TI0015
ID:p0080

The Woman-Centeredness of Various Dutch Maternity

Service Providers During Antenatal and Postnatal Care
Yvonne Fontein-Kuipers, Elise van Beeck, Liesbeth Kammeraat, and
Fleur Rutten

AIMS: To examine the woman-centeredness of maternity care providers from the woman’s perspective.
To investigate the validity and reliability of the Client Centered Care Questionnaire among a childbearing
population.
DESIGN: A cross-sectional study.
METHODS: The self-report Client Centered Care Questionnaire was administered to evaluate women’s
one-on-one antenatal and postnatal care appointments with various Dutch care providers: community
and hospital-based midwives, General Practitioners, (registrar) obstetricians, sonographers, and
maternity care nurses.
RESULTS: Eight-hundred and fifteen completed questionnaires were received. Exploratory and
confirmatory factor analyses provided support for a two-factor model, with an acceptable model fit.
Woman-centeredness of all maternity care providers showed scores above baseline for the neutral value.
Welch ANOVA showed a statistical significant effect of the type of maternity care practitioner in
providing woman-centered care during antenatal and postnatal visits (F(5.8) = 7.79). The Bonferroni post
hoc test showed that women assigned significantly higher woman-centered care scores to
community-based midwives compared with hospital-based midwives (p .011) and compared with
registrars/obstetricians (p < .001).
CONCLUSION: Although overall scores of perceived woman-centeredness indicated a good to excellent
performance of woman-centered care, with significantly higher scores for community-based midwives, it
cannot be assumed that current woman-centered care completely meets the needs of Dutch childbearing
women. The Client Centered Care Questionnaire (CCCQ) is an adequate instrument to measure
woman-centered care in antenatal and postnatal maternity services. Further research regarding
measuring woman-centered care is needed.
KEYWORDS: woman-centered care; client centered care questionnaire; antenatal care; postnatal care

INTRODUCTION (Perined, 2018). Primary care maternity services include

Maternity Care Provision in the Netherlands
Low-risk women in the Netherlands predominantly
receive maternity care provided by the primary care mid-
wife and occasionally by the General Practitioner (GP)
antenatal, intrapartum, and postnatal care. Women
receive care from traditionally organized community
midwives and GP’s, who work in varying team struc-
tures (Fontein, 2010; NIVEL, 2017). Consultation or
referral to obstetric-led care at any point during child-
birth occurs when complications arise or threaten to

INTERNATIONAL JOURNAL OF CHILDBIRTH Volume 9 Issue 2, 2019

© 2019 Springer Publishing Company, LLC www.springerpub.com
92
Pdf_Folio:92

http://dx.doi.org/10.1891/2156-5287.9.2.92

ID:p0090
ID:ti0025
ID:p0095
The Woman-Centeredness of Various Dutch Maternity Service Providers Fontein-Kuipers et al.
arise or when medical interventions are needed. Thirty-
six percent of childbearing women are being referred
during pregnancy from primary care to an obstetric
unit and 21% of women during labor and birth (Per-
ined, 2018). Obstetric-led antenatal, intrapartum, and
postnatal care is being provided by (registrar) obste-
tricians and hospital-based midwives. Obstetric ultra-
sound scans (early pregnancy/ dating scan, 20-weeks
fetal anomaly scan, fetal growth, fetal lie, and placenta
localization) are most often performed by certified sono-
graphers, although scans can also be carried out by
community and hospital-based midwives and (registrar)
obstetricians. Maternity care assistants support women
and their families with their new born babies during the
first week postpartum in postnatal wards as well as in
the home situation; preceded by a home visit during the
third trimester of pregnancy. Thirty percent of Dutch
childbearing women receive intrapartum midwife-led or
GP-led midwifery care, either at home, in a birth center
or the low-risk hospital birth-unit, while 70% of Dutch
women give birth in an obstetric secondary or tertiary
care maternity unit, receiving intrapartum obstetric-led
care (Perined, 2018).
Woman-Centered Care
Dutch childbearing women have articulated their need
for woman-centered care (Baas et al., 2017), which has
been recognized as a marker of quality in maternity
services (De Labrusse, Remaelt, & MacLennan, 2016).
Woman-centered care is a philosophy and a pragmatic
framework for midwifery care. Woman-centered care is
defined as “a philosophy and a consciously chosen tool
for the care management of the childbearing woman,
where the collaborative relationship between the woman
—as an individual human being—and the midwife—as
an individual and professional—is shaped through co-
humanity and interaction; recognizing and respecting
one another’s respective fields of expertise. Woman-
centered care has a dual and equal focus on the woman’s
individual experience, meaning and manageability of
childbearing and childbirth, as well as on health and
wellbeing of mother and child. Woman-centered care
has a reciprocal character but fluctuates in equality and
locus of control” (Fontein-Kuipers, de Groot, & van
Staa, 2018, p. 8). This implies that in woman-centered
care the woman’s social, emotional, physical, and
cultural needs and values as well as her experiential
knowledge meet the midwife’s professional knowledge,
expertise, and values. In woman-centered care health
and birth outcomes are regarded as equally important as
Pdf_Folio:93
93
the woman’s subjective experiences (Fontein-Kuipers,
de Groot, et al., 2018). Woman-centered care is associ-
ated with de-medicalization of maternity care, person-
alization, humanization, and physiology of childbirth
(Berg, Ólafsdóttir, & Lundgren, 2012; Fontein-Kuipers,
de Groot, et al., 2018). It has also been recognized that
woman-centered care is authentic to midwifery whereby
midwives are appointed as exclusive executors of the care
concept (Morgan, 2015). Moreover, woman-centered
care is associated with the biopsychosocial rather than
with the medical model of care (Fontein-Kuipers, de
Groot, et al., 2018). Midwives identify themselves with
a biopsychosocial model of care while medical practi-
tioners adhere to a medical model. These models are
differentiated by the levels of the medical competence
hierarchy, that is, the decision authority and complex-
ity of interventions, control of technology, and the
categorization of normal/physiology and nonnormal/
pathology (Dekker, Bergström, Amer-Wåhlin, &
Cilliers, 2013). Therefore, different practitioners in the
maternity care system and different care settings are
likely to hold different perspectives, interpretations, and
ideations on what woman-centered care is —anticipat-
ing differences in the articulation of woman-centered
care among maternity care professionals (Hunter et al.,
2017). Aspects such as humanization, personalization,
and de-medicalization are important to all childbearing
women and should be standard practice, irrespective
of care provider —as women are entitled to access a
healthcare system that provides equal opportunity for
all (World Health Organization, 2015). Importantly,
woman-centeredness will emphasize the responsiveness
of maternity services to childbearing women’s needs
(Baas et al., 2017). Yet, the possible differences between
various maternity care providers in providing woman-
centered care have never been studied. In this study, we
aimed to examine to what extent pregnant and postpar-
tum women perceive woman-centered care provided
by the different maternity care practitioners in Dutch
maternity care services.
There are instruments that measure women’s per-
ceived respect and perceived autonomy in decision-
making (Vedam, Stoll, Martin, et al., 2017; Vedam, Stoll,
Rubashkin, et al., 2017) but there is a lack of valid instru-
ments with which to measure the performance of prac-
titioners’ woman-centeredness in maternity care. The
Woman Centered Care Scale (WCCS) has been devel-
oped and piloted for use in Australian midwifery educa-
tion but not for the evaluation of practitioners (Brady,
Bogossian, & Gibbons, 2017). Currently the Client Cen-
tered Care Questionnaire (CCCQ) (de Witte, Schoot,
 94
ID:p0100
ID:p0105
ID:TI0030
ID:ti0035
ID:p0110
ID:ti0040
ID:p0115
The Woman-Centeredness of Various Dutch Maternity Service Providers Fontein-Kuipers et al.
& Proot, 2006; Muntinga, Mokkink, Knol, Nijpels, &
Jansen, 2014) is being used to measure woman-centered
care in Dutch maternity care services (Fontein-Kuipers,
Romeijn, Zwijnenberg, Eekhof, & van Staa, 2018). It
can be hypothesized that because woman-centered care
derives from the concept client-centered care (Fontein-
Kuipers, de Groot, et al., 2018), this instrument might
be fit to measure the concept of woman-centered care.
Therefore, the second aim of this study was to investigate
if the CCCQ is a valid and reliable instrument to evalu-
ate women’s perceptions of the care providers’ woman-
centeredness during antenatal and postnatal care.
METHODS
We conducted a cross-sectional study among women
receiving maternity care in the Netherlands and collected
data during the antenatal and postnatal care period (up
to 6 weeks postpartum) using an online questionnaire.
Pregnant and postpartum women, ≥ 18 years of age
with good command of the Dutch language, living in
the Netherlands and receiving either community-based
care, hospital-based obstetric-led care, and/or shared
care (involving a combination of both) were found to be
eligible. There were no restrictions for parity, ethnicity,
or socio-economic status. Women with severe pathology
(e.g., cancer, neurodegenerative illnesses) were excluded.
The data were collected between September 2016 and
October 2018 as part of the “I See You” project, a woman-
centered care education and research project (Fontein-
Kuipers, Romeijn, et al., 2018). After each antenatal
and postnatal visit, the woman evaluated the woman-
centeredness of the maternity care provider involved,
either the community-based midwife, the hospital-based
midwife, the (registrar)obstetrician, the GP, the obstetric
sonographer and/or the maternity care consultant, usu-
ally a nurse. In this study we included women that had
evaluated at least one antenatal or postnatal visit up to 6
weeks postpartum.
Measures
We collected women’s socio-demographic factors and
birth details. We collected partial postcodes iden-
tifying the participants’ regions of habituation. We
measured woman-centered care from the woman’s per-
spective, using the self-report CCCQ, evaluating a one-
on-one contact between the woman and her caregiver.
The 15-item CCCQ was originally developed and val-
idated for use among adults receiving home care (de
Pdf_Folio:94
Witte et al., 2006; Muntinga et al., 2014). Each item was
scored on a 5-point Likert-type scale, ranging from “1”
(totally disagree) to “5” (totally agree) (Example item: I
can tell that the care provider takes my personal wishes into
account). The total CCCQ score ranged from 15 to 75
and expressed care receivers’ perceptions of practition-
ers’ woman-centered care delivery (de Witte et al., 2006;
Muntinga et al., 2014). Validation of the original CCCQ
showed a bifactor model with unequal loadings and good
internal consistency (𝛼.88) (Muntinga et al., 2014).
Analysis
We calculated descriptive statistics for participants’
demographic details, personal characteristics, and birth
details. Before analyzing the CCCQ, we removed the
postcodes from the dataset to remain anonymity of the
practitioners being evaluated. We calculated Cronbach’s
alpha (𝛼) to measure internal consistency of the CCCQ
scale items. We performed an exploratory factor analy-
sis (EFA), based on the unequal loadings of the origi-
nal scale (Muntinga et al., 2014)—to establish the factor
construct of the CCCQ items (Field, 2013). As advised
by Köberich and Farin (2015), confirmatory factor anal-
ysis (CFA) was subsequently performed to test the sta-
bility of the CCCQ’s factor structures found with EFA.
The comparative fit index (CFI), the goodness of fit index
(GFI), and the root mean square error of approximation
(RMSEA) were used to evaluate model fit. A GFI of ≥
0.80 in combination with a CFI of ≥ 0.80 and a RMSEA
of ≤ 0.06 were considered as indicators of adequate fit of
a model (Byrne, 2010).
We summed the scores of the CCCQ and calcu-
lated a mean total score per maternity care provider
group. We transformed the 5-point Likert scores to a 10-
point ranking scale and dichotomized the outcome vari-
able into “high” (scores 8 to 10) and “less than high”
(scores 1–7). The dichotomous scores are based on the
Dutch school system—thus providing implied meaning
—where 8 or above indicated a good to excellent perfor-
mance and a 7 or less a moderate or bad performance
(Nuffic, 2018). We used the CCCQ set with the 5-point
Likert scale to compare the sample scores of maternity
care providers. Firstly, we performed the Kruskal-Wallis
test, to examine if at least one sample mean was differ-
ent from the mean of at least one other group. When
significance in differences was shown, we performed
a Welch’s ANOVA with Bonferroni correction, allow-
ing heterogeneity of variance between groups (Field,
2013). Data entry and analysis were performed using the
 95
ID:p0130
ID:p0120

ID:ti0060
ID:ti0045

ID:p0135
ID:TI0050

ID:p0165
ID:ti0055
ID:p0145
ID:t0165
ID:t0155
ID:t0095

ID:t0115

ID:ti0065
ID:t0025

ID:t0065
ID:t0075
ID:t0015

ID:p0170
ID:t0175
ID:t0005

ID:t0145
ID:t0105

ID:t0185
ID:t0195
ID:t0085
ID:t0055

ID:t0125
ID:t0135
ID:t0045
ID:t0035
ID:p0140

The Woman-Centeredness of Various Dutch Maternity Service Providers Fontein-Kuipers et al.

Statistical Package for the Social Sciences (SPSS) version TABLE 1. Characteristics Women (n = 131)
25.0 and Analysis of Moment Structures (AMOS) ver- N/%
sion 25.
Ethnicity
Dutch 108/82.4%
Ethical Considerations Other western 10/7.6%
Nonwestern 13/9.9%
This study received ethical clearance from the Scientific Relationship
Research Ethics Committee Rotterdam (TWOR) (Proto- Partnered 124/94.7
col Ref No. T2016-72). Women participated voluntarily Living apart 4/3.1
and signed a consent form. Single 3/2.3
Education levelsa
Low level 2/1.5
RESULTS
Medium level 11/8.4
High level 99/75.6
We received 815 completed questionnaires from 131 Academic level 19/14.5
pregnant women and 100 postnatal women, including Professional status
the births of 101 neonates. The postnatal women orig- Fulltime job 34/26.0
inated from the antenatal sample. All women reported Part-time job 77/58.8
on individual antenatal and postnatal visits. No par- Job seeking/no occupation 14/10.6
ticipants received Centering Pregnancy. That is, group- Student 6/4.6
based antenatal care. Women completed a mean of 6.06 Primipara 46/35.1
(±2.95; range 1–14) questionnaires covering the antena- Multipara 85/64.6
tal and postpartum periods. We analyzed 650 antenatal a Low = elementary, prevocational secondary education; Medium =
questionnaires (first trimester: n = 80; second trimester: secondary education preparing for higher education or university; High =
n = 245; third trimester: n = 324) and 165 postnatal ques- Bachelor-equivalent; Academic = university.
tionnaires.

Participants labeled “Self-determination.” CFA was conducted on the

Women had a mean age of 29.7 (±4.94; range 18–40)
years and received care from independent midwives
practicing in 85 different community practices and an
unknown number of hospitals in north/mid, west, cen-
tral, and south/west regions of the Netherlands, includ-
ing all levels of urbanization. The women’s personal
details are shown in Table 1 and the birth details are
shown in Table 2. Thirty-one women were lost to follow-
up due to fetal loss.
CCCQ Reliability, Validity, and Goodness-of-Fit
Cronbach’s Alpha showed good internal consistency
(𝛼.93). The underlying structure of the CCCQ was
explored utilizing EFA and CFA. Preliminary analysis
confirmed the factorability of the data set (KMO .96;
Bartlett’s test of sphericity p < .001). EFA revealed two
factors with Eigenvalues over 1, explaining a total of
58.82% of the variance. Reflecting the item content,
Factor 1 (33.68% of variance) was labelled “Participa-
tion in care” and Factor 2 (25.14% of variance) was
Pdf_Folio:95
two-factor solution obtained from EFA. CFA revealed a
range of fit statistics: GFI .92; CFI .91; and RMSEA .07,
showing reasonable model fit (Byrne, 2010).
CCCQ Scores
Women most often evaluated the woman-centeredness
of the community midwife and least often of the
maternity care consultant. Women’s scores of per-
ceived woman-centeredness of the various maternity
care providers, were on average above the neutral score
with the highest score for community-based midwives
and the lowest score for hospital-based midwives. This
applied to both the original CCCQ 1 to 5 scores
as to the transformed 1 to 10 scores. Nearly three
quarters of the scores indicated a good to excellent
performance of all practitioners; the community-based
midwives had the fewest scores indicating moderate or
bad performance (Table 3). Kruskal-Wallis test showed
significant differences between the groups of maternity
care providers (H30.13, df = 5, p < .001). Welch ANOVA
showed a significant effect of the type of maternity
 96
ID:p0160
ID:p0195
ID:p0155
ID:t0205
ID:t0220
ID:t0265
ID:t0280
ID:t0295
ID:t0355
ID:t0400
ID:t0415
ID:t0250
ID:t0325
ID:t0340
ID:t0370
ID:t0235
ID:t0310
ID:t0385
ID:p0150
ID:TI0070
The Woman-Centeredness of Various Dutch Maternity Service Providers Fontein-Kuipers et al.

TABLE 2. Birth Details (n = 100 Births/ 101 Neonates) care providers being evaluated —indicating perceived
Mean ± SD N /%
high levels of woman-centeredness of all maternity
(range) care providers —we observed statistically significant
differences between community-based midwives,
Mode of birth
hospital-based midwives, and (registrar)obstetricians.
SVD 87/87
We realize that the observed mean differences between
Instrumental birth 3/3
(ventouse) practitioners in our study are small. Women overall
Cesarean section 10/10 assigned high scores to all maternity care practitioners’
Place of birth 17/17 woman-centeredness. A high rating of care seems not
Home unusual for studies on birthing experiences (Baas et al.,
Birth center 9/9 2017) nor for the CCCQ (Bosman, Bours, Engels, & de
Low-risk birth- 15/15 Witte, 2008). We tried to adjust for this phenomenon
unit (hospital) with calculating dichotomous scores to explicate the
Obstetric-unit 59/59 level of performance within and between groups, to bet-
(hospital) ter interpret the clinical relevance of the findings. There
Referrala during 25/25
might be reasons for the observed differences in practi-
pregnancy
(including
tioners’ woman-centeredness. Firstly, the scores’ differ-
consultation) ences can be an effect of variation among practitioners in
Referrala during 21/21 interpretation of the philosophy of woman-centered care
birth and/or in recognizing and providing practice consistent
Male neonates 51/50.5 with the underlying philosophy (Fontein-Kuipers, de
Female neonates 50/49.5 Groot, van Beeck, van Hooft, & van Staa, 2019). In our
Birthweight in 3,431 ±482.2 study, women-centeredness of community-based mid-
grams (2,143– wives received the highest scores of all maternity care
4,500)
providers while women-centeredness of hospital-based
Apgar score 1 8.9 ±.83
midwives had the lowest scores. Woman-centered care
minute (4–10)
is recognized to fit a biopsychosocial model (Fontein-
Apgar score 5 9.9 ±.46
minutes (7–10) Kuipers, de Groot, et al., 2018). Community-based
midwives might lean to a biopsychosocial model of
Note. SVD = spontaneous vaginal delivery.
a Transfer from primary care to obstetric-led care (consultation: visit to care where hospital-based practitioners might adhere
[registrar] obstetrician without transfer of care). more to a medical model of care (Goodarzi et al., 2018;
Hunter et al., 2017). The biopsychosocial model has the
potential to enhance communication and collabora-
tion between care receiver and care provider (Edozien,
care provider in providing woman-centered care during
2015) and is therefore more likely to meet the needs
antenatal and postnatal visits for the CCCQ scores on a
of Dutch childbearing women (Baas, Erwich, Wiegers,
5-point Likert score (F(5.8) = 7.79, p < .001). Bonferroni
de Cock, & Hutton, 2015). Communication and part-
post hoc test showed that women perceived significantly
nership between the woman and the midwife are,
higher woman-centeredness of community-based mid-
however, also recognized as important and professional
wives compared with hospital-based midwives (p .011)
features of the midwifery profession (Halldorsdottir
and compared with (registrar)obstetricians (p < .001)
& Karlsdottir, 2011), suggesting that midwives and
(Table 4).
women want similar things regarding collaboration
and communication. The focus of communication
and collaboration in medical obstetrics is rather on
DISCUSSION
between-healthcare practitioners’ (team) level than on
an individual medical practitioner-woman level (Dekker
To the best of our knowledge, this is the first study to et al., 2013). Community-based midwifery practice
examine and compare the woman-centeredness of dif- is associated with a higher level of personalized care
ferent maternity care providers from the perspective of and continuity of care provider opposed to hospital-
the childbearing woman. Although our study showed based care; aspects that are known to contribute to
scores above the neutral value for all the maternity
Pdf_Folio:96
women’s satisfaction with maternity care (Baas et al.,
 97
ID:p0180

ID:p0190
ID:p0190
ID:t0640
ID:t0465

ID:t0605
ID:t0535
ID:t0430

ID:t0690
ID:t0500

ID:p0185
ID:t0570
ID:p0175

ID:t0725
ID:t0740

ID:t0755
ID:t0710
ID:t0455

ID:t0490

ID:t0525

ID:t0560

ID:t0595

ID:t0630

ID:t0680

ID:p0200

The Woman-Centeredness of Various Dutch Maternity Service Providers Fontein-Kuipers et al.

TABLE 3. CCCQ Scores per Care Provider

Maternity Care N/% Visits Average N Visits/ CCCQ Mean ± SD (Range) N/% 8–10 (High)/ 1–7
Provider Woman (Moderate or Less)
Community-based 591/72.5 4.8 4.2 ±.57 (1–5)a 440(74.5)/151(25.5)
midwife
8.04 ±1.2 (5–10)b
Hospital-based 25/3.1 1.9 3.79 ±.66 (2.5–5)a 12(48)/13(52)
midwife
7.16 ±1.3 (5–10)b
(Registrar) 85/10.4 1.9 3.85 ±.79 (1.3–5)a 43(50.5)/42(49.5)
obstetrician
7.22 ±1.6 (3–10)b
Midwifery-active 19/2.3 2.7 3.99 ±.78 (1.3–4.8)a 7(36.8)/12(63.2)
GP
7.32 ±1.3 (3–9)b
Ultrasonographer 89/11 1 4.09 ±.67 (1.5–5)a 57(64)/32(36)
7.78 ±1.4 (4–10)b
Maternity care 6/.7 1 4.17 ±.25 (3.8–4.5)a 4(67)/2(33)
consultant
7.38 ±.75 (7–9)b
TOTAL 815/100 2.2 4.14 ±.62 (1–5)a 584(71.7)/231(28.3)
7.95 ±1.3 (2–10)b
a Original CCCQ 5-point Likert scale. b Transformed CCCQ 10-point ranking.

TABLE 4. Post hoc Bonferroni practitioners have been evaluated by the women in
Mean Dif- 95%
our study. We did not collect characteristics of the
ference Confidence maternity care providers. Therefore, we do not know
Interval whether commitment to a certain care model, practi-
Community- Hospital-based .42* .056 to .794
tioners’ ages, and years of practice experience affected
based midwife midwife the scores. Moreover, we are aware that practices vary
(Registrar) .37** .165 to .584 in organization (Fontein, 2010), which could also have
obstetrician affected the results of the study. It can be advised for
GP .22 −.194 to .648 future similar research to collect more information
Ultra- .12 −.077 to .334 about the practitioners and to examine the associa-
sonographer tion of characteristics of maternity care providers with
Maternity care .05 −.688 to .795 woman-centeredness, to better understand the observed
consultant
differences in our study.
Note. GP = General Practitioner. Our sample was small and included more multi-
*p < .05. **p < .001.
parous than primiparas women, which possibly influ-
enced the findings as previous experiences are likely to
influence perspectives of current antenatal maternity
2017; Forster et al., 2016; McPherson, Roqué-Sanchez, care experiences (Baron et al., 2017). This might rep-
Legget, Fuertes, & Segarra, 2016)—contributing to the resent a type-two error resulting from limited power
explanation of perceived high woman-centeredness to consider parity as an influencing variable. Future
scores of community midwives. Furthermore, commit- research including more primiparas women is needed
ment to the philosophy of woman-centeredness and to further explore this phenomenon. The women in
providing care accordingly, are influenced by profes- our study did not fully represent Dutch childbear-
sional development and maturity (Brady et al., 2017; ing women as our sample included not only fewer
Fontein-Kuipers et al., 2019). Due to anonymity, we primiparas women but also fewer women with non-
also do not know how many individual different care
Pdf_Folio:97
Dutch backgrounds, fewer births via caesarean section
 98
ID:p0205
ID:p0215
ID:p0210
The Woman-Centeredness of Various Dutch Maternity Service Providers Fontein-Kuipers et al.
and more women with high levels of education when
compared to the general Dutch childbearing popu-
lation (Statistics Netherlands, 2016: Perined, 2018).
Our findings are therefore only generalizable to sim-
ilar childbearing populations as presented in this
study. Future research should consider to look at the
determinants, that is, women’s socio-demographic and
personal characteristics, that influence women’s percep-
tions of woman-centered care in a larger sample of
women.
Women in our study most often evaluated the
community-based midwife and our data included far
more antenatal than postnatal care evaluations as well
as that the antenatal trimesters were not equally dis-
tributed. This does, however completely reflect the
routine care pathway of antenatal and postnatal care
(National Institue for Health and Care Excellence, 2015,
2018; Perined, 2018). It could be that women’s preg-
nancy mindset influenced the findings as the various
trimesters of pregnancy are associated with different
pregnancy mindsets that subsequently demonstrate dif-
ferent attitudes toward pregnancy and care (Haddrill,
Jones, Mitchell, & Anumba, 2014). Different attitudes
during different trimesters of pregnancy might have
possibly affected the factorial model fit of the CCCQ.
It might be of worth to repeat factor analysis for the
respective trimesters to validate its use and goodness
of fit for each trimester. Also, it has to be noted that
the women in our sample completed on average six
questionnaires, each time reporting on the same items.
After numerous times of completing the questionnaire,
women might have viewed this exertion as a “tick
box” exercise, which could have influenced the relia-
bility of the findings. The fact that women evaluated
the community-based midwife most often compared to
other care providers, could also have caused bias. Dutch
childbearing women, most often, receive care from the
community-based midwife (Perined, 2018). This sug-
gests that women are likely to feel more comfortable with
these midwives, which could have caused a halo effect.
However, because most community-midwives work in
group practices (NIVEL, 2017), women will not always
meet the same midwife during consultations (Fontein,
2010). Although in some cases participants rated mul-
tiple visits of community-based midwives, that is, mid-
wives from one practice, it is very likely that these were
different midwives. It is known that individual mid-
wives practice differently and hold different perspec-
tives (Thompson, Nieuwenhuijze, Budé, de Vries, & Kane
Low, 2018) and therefore the multiple ratings did not
necessarily cause bias.
Pdf_Folio:98
Similar to the validation of the original CCCQ, we
found a bifactorial model. Both factors “participation
in care” and “self-determination” depend on the level
that a woman retains control over the participation in
the care process, the level the woman is aware of her
own interests and preferences to participate in decision-
making and to advocate for herself (Haddrill et al., 2014;
Hunter et al., 2017). The women in our study had overall
high levels of education, which is known to be a predic-
tor for active participation in care (Florin, Ehrenberg, &
Ehnfors, 2008; Haddrill et al., 2014), which might have
influenced the findings. The WCCS identified four inter-
connected core concepts of woman-centered care (Brady
et al., 2017). Three WCCS core concepts: individual-
ity, self-determination, and shared-power (Brady et al.,
2017) seem to correspond with our two factors participa-
tion in care and self-determination, acknowledging the
model fit of the CCCQ used in our study. The CCCQ
seems to be of merit to measure woman-centered care
among a childbearing population. Further research is
needed to assess the utility of the CCCQ as an instrument
to evaluate practitioner’s woman-centeredness in recog-
nizing and providing practice consistent with the under-
lying philosophy of woman-centered care.
The overall results underpin the need for education
on woman-centered care and support in professional
development of the various maternity care providers
regarding their woman-centeredness. The dichotomous
scores in particular, indicate that education should be
focused on the encouragement of practitioners to main-
tain, improve, and fine-tune their woman-centered per-
formance. It seems pivotal to embed woman-centered
care in the curricula of all maternity practitioners’ edu-
cation programs or to include it in lifelong learning
programs of maternity care providers. It can be rec-
ommended to discuss the topic in an interprofessional
learning environment that includes the community-
based midwife, to overcome the imbalance between the
various practitioners in their approach and provision
of woman-centered care (George, MacDonnell, Nimma-
gadda, Murphy, & Dollase, 2015). We identified partici-
pation in care and self-determination as the two CCCQ
factors. Participation in care and self-determination
include communication, listening skills, willingness to
compromise, and mutual goal setting (Vahdat, Hamze-
hgardeshi, Hessam, & Hamzehgardeshi, 2014). These
elements can be obtained through education and profes-
sional development (Hunter et al., 2017; Poitras, Maltais,
Bestard-Denommé, Stewart, & Florin, 2018) and thus
require specific attention during education and lifelong
learning.

ID:p0220
ID:ti0080
ID:TI0075
The Woman-Centeredness of Various Dutch Maternity Service Providers Fontein-Kuipers et al.
CONCLUSION
We found differences in the woman-centeredness of
different maternity care providers from the perspec-
tive of the childbearing woman, showing significant
higher scores for the community-based midwife.
Although overall women’s scores of perceived woman-
centeredness were high, it can be assumed that the
evaluated provided woman-centered care meets the
woman-centered care needs of Dutch childbearing
women. Future research that includes information about
practitioners’ characteristics and can provide more
understanding of woman-centeredness of maternity care
providers. A research focus on the possible influence of
parity on women’s perception on the caregivers’ woman-
centeredness is recommended. The CCCQ proved to be
an adequate instrument to measure women’s percep-
tion of antenatal and postnatal woman-centered care
but further research regarding its utility in the different
trimesters of pregnancy is needed. The results need to
be interpreted considering the limitations of the study.
Education for maternity care providers of woman-
centered care and further research are warranted,
specifically research that focuses on characteristics, that
is, the determinants, that influence either the practi-
tioners’ provision of woman-centered care or women’s
perception of the practitioner’s woman-centeredness.
REFERENCES
Baas, C., Erwich, J., Wiegers, T., de Cock, T., & Hutton,
E. (2015). Women’s suggestions for improving mid-
wifery care in the Netherlands. Birth, 42(4), 369–378.
doi:10.1111/birt.12185
Baas, C., Wiegers, T., de Cock, P., Erwich, J. J., Spelten, E. R.,
de Boer, M. R., & Hutton, E. K. (2017). Client-related
factors associated with a “less than good” experience
of midwifery care during childbirth in the Netherlands.
Birth, 44(1), 58–66. doi:10.1111/birt.12266
Baron, R., Heesterbeek, Q., Manniën, J., Hutton, E., Brug, J., &
Westerman, M. (2017). Exploring health education with
midwives, as perceived by pregnant women in primary
care: A qualitative study in the Netherlands. Midwifery,
46, 37–44. doi:10.1016/j.midw.2017.01.012
Berg, M., Ólafsdóttir, A., & Lundgren, I. (2012). A midwifery
model of woman-centred childbirth care - in Swedish
and Iceland care settings. Sexual & Reproductive Health-
care, 3, 79–87. doi:10.1016/j.srhc.2012.03.001
Pdf_Folio:99
99
Bosman, R., Bours, G., Engels, J., & de Witte, L. (2008).
Client-centred care perceived by clients of two
homecare agencies: A questionnaire survey. Inter-
national Journal of Nursing Studies, 45(4), 518–525.
doi:10.1016/j.ijnurstu.2006.12.002
Brady, S., Bogossian, F., & Gibbons, K. (2017). Devel-
opment and piloting the Woman Centred Care
Scale (WCCS). Women and Birth, 30(3), 220–226.
doi:10.1016/j.wombi.2016.10.010
Byrne, B. (2010). Structural equation modeling with AMOS:
Basic concepts, applications, and programming (2nd ed.).
New York, NY: Routledge/Taylor & Francis Group.
De Labrusse, C., Ramelet, A., & Maclennan, J. (2016). Patient
centered care in maternity services: A critical appraisal
and synthesis of the literature. Women’s Health Issues,
26(1), 100–109. doi:10.1016/j.whi.2015.09.003
de Witte, L., Schoot, T., & Proot, I. (2006). Develop-
ment of the client-centred care questionnaire. Jour-
nal of Advanced Nursing, 56, 62–68. doi:10.1111/j.1365-
2648.2006.03980.x
Dekker, S., Bergström, J., Amer-Wåhlin, I., & Cilliers, P. (2013).
Complicated, complex, and compliant: Best practice in
obstetrics. Cognition, Technology & Work, 15, 189–195.
doi:10.1007/s10111-011-0211-6
Edozien, L. (2015). Beyond biology: The biopsychosocial
model and its application in obstetrics and gynaecology.
BJOG, 1, 900–903. doi:10.1111/1471-0528.13328
Field, A. (2013). Discovering statistics using IBM SPSS statistics
(4th ed.). London, England: Sage.
Florin, J., Ehrenberg, A., & Ehnfors, M. (2008). Clinical
decision‐making: Predictors of patient participation in
nursing care. Journal of Advanced Nursing, 17(21), 2934–
2944. doi:10.1111/j.1365-2702.2008.02328.x
Fontein-Kuipers, Y., de Groot, R., & van Staa, A. (2018).
Woman-centered care 2.0: Bringing the concept into
focus. European Journal of Midwifery, 2(5), 1–12.
doi:10.18332/ejm/91492
Fontein-Kuipers, Y., de Groot, R., van Beeck, E., van Hooft,
S., & van Staa, A. (2019). Dutch midwives’ views
on and experiences with woman-centred care – A
Q-methodology study. Women and Birth, 32(6), e567–
e575. doi:10.1016/j.wombi.2019.01.003
Fontein-Kuipers, Y., Romeijn, E., Zwijnenberg, A., Eekhof, W.,
& van Staa, A. (2018). ISeeYou’: A woman-centred care
education and research project in Dutch bachelor mid-
wifery education. Health Education Journal, 77(8), 899–
914. doi:10.1177/0017896918784618
Fontein, Y. (2010). The comparison of birth outcomes and
birth experiences of low-risk women in different sized
midwifery practices in the Netherlands. Women and
Birth, 23(3), 103–110. doi:10.1016/j.wombi.2010.01.002
 100
ID:p0225
The Woman-Centeredness of Various Dutch Maternity Service Providers Fontein-Kuipers et al.
Forster, D., McLachlan, H., Davey, M., Biro, M. A., Farrell,
T., Gold, L., . . . Waldenström, U. (2016). Continu-
ity of care by a primary midwife (caseload midwifery)
increases women’s satisfaction with antenatal, intra-
partum and postpartum care: Results from the COS-
MOS randomised controlled trial. BMC Pregnancy &
Childbirth, 16, 28. doi:10.1186/s12884-016-0798-y
George, P., MacDonnell, C., Nimmagadda, J., Murphy, J., &
Dollase, R. (2015). Designing interprofessional educa-
tion curriculum using multiple conceptual frameworks.
Annals of Behavioral Science and Medical Education,
21(1), 9–13. doi:10.1007/BF03355303
Goodarzi, B., Holten, L., van El, C., de Vries, R., Franx, A.,
& Houwaart, E. (2018). Risk and the politics of bound-
ary work: Preserving autonomous midwifery in the
Netherlands. Health, Risk & Society, 20(708), 379–407.
doi:10.1080/13698575.2018.1558182
Haddrill, R., Jones, G., Mitchell, C., & Anumba, D. (2014).
Understanding delayed access to antenatal care: A qual-
itative interview study. BMC Pregnancy and Childbirth,
14, 207. doi:10.1186/1471-2393-14-207
Halldorsdottir, S., & Karlsdottir, S. I. (2011). The primacy of the
good midwife in midwifery services: An evolving the-
ory of professionalism in midwifery. Scandinavian Jour-
nal of Caring Sciences, 25, 806–817. doi:10.1111/j.1471-
6712.2011.00886.x
Hunter, A., Devane, D., Houghton, C., Grealish, A., Tully,
A., & Smith, V. (2017). Women-centred care during
pregnancy and birth in Ireland: Thematic analysis of
women’s and clinicians’ experiences. BMC Pregnancy
and Childbirth, 17(1), 322. doi:10.1186/s12884-017-
1521-3
Köberich, S., & Farin, E. (2015). A systematic review of
instruments measuring patients’ perceptions of patient-
centred nursing care. Nursing Inquiry, 22(2), 106–120.
doi:10.1111/nin.12078
McPherson, I., Roqué-Sanchez, M., Legget, B., Fuertes, F., &
Segarra, I. (2016). A systematic review of the relation-
ship factor between women and health professionals
within the multivariant analysis of maternal satisfaction.
Midwifery, 41, 68–78. doi:10.1016/j.midw.2016.08.003
Morgan, L. (2015). Conceptualizing woman-centred care in
Midwifery. Canadian Journal of Midwifery Research and
Practice, 14(1), 8–15.
Muntinga, M., Mokkink, L., Knol, D., Nijpels, G., & Jansen, A.
(2014). Measurement properties of the Client-centered
Care Questionnaire (CCCQ): Factor structure, reliabil-
ity and validity of a questionnaire to assess self-reported
client-centeredness of home care services in a popula-
tion of frail, older people. Quality Life of Research, 23,
2063–2072. doi:10.1007/s11136-014-0650-7
Pdf_Folio:100
National Institute for Health and Care Excellence. (2015).
Postnatal care. Quality standard [QS37]. London,
England: Author.
National Institue for Health and Care Excellence (2018).
Antenatal care for uncomplicated pregnancies. Clinical
guideline [CG62]. London, England: Author.
NIVEL. (2017). Registered data from Dutch midwives. Poll
2016. Utrecht, Netherlands: Author.
Nuffic. (2018). Education system the Netherlands. The Dutch
education system described. Version 5. The Hague,
Netherlands: Author.
Perined. (2018). Perinatal care in the Netherlands 2016.
Utrecht, Netherlands: Author.
Poitras, M., Maltais, M., Bestard-Denommé, L., Stewart, M.,
& Florin, M. (2018). What are the effective elements
in patient-centered and multimorbidity care? A scop-
ing review. BMC Health Services Research, 18, 446.
doi:10.1186/s12913-018-3213-8
Statistics Netherlands. (2016). Trends in the Netherlands. The
Hague, Netherlands: Centraal Bureau voor de Statistiek.
Thompson, S., Nieuwenhuijze, M., Budé, L., de Vries, R., &
Kane Low, L. (2018). Creating an optimality index –
Netherlands: A validation study. BMC Pregnancy &
Childbirth, 18, 100. doi:10.1186/s12884-018-1735-z
Vahdat, S., Hamzehgardeshi, L., Hessam, S., & Hamze-
hgardeshi, Z. (2014). Patient involvement in health care
decision making: A review. Iranian Red Crescent Medi-
cal Journal, 16(1), e12454. doi:10.5812/ircmj.12454
Vedam, S., Stoll, K., Martin, K., Rubashkin, N., Partridge,
S., Thordarson, D.Changing Childbirth in BC Steering
Council. (2017). The Mother’s Autonomy in Decision
Making (MADM) scale: Patient-led development and
psychometric testing of a new instrument to evaluate
experience of maternity care. BC Steering Council, 12(2),
e0171804. doi:10.1371/journal.pone.0171804
Vedam, S., Stoll, K., Rubashkin, N., Martin, K., Miller-
Vedam, Z., Hayes-Klein, H.CCinBC Steering Coun-
cil. (2017). The Mothers on Respect (MOR) index:
Measuring quality, safety, and human rights in
childbirth. SSM - Population Health, 3, 201–210.
doi:10.1016/j.ssmph.2017.01.005
World Health Organization. (2015). Health and human rights,
fact sheet no. 323. Geneva, Switzerland: Author.
Disclosure. The authors have no relevant financial interest or
affiliations with any commercial interests related to the subjects
discussed within this article.
 101
ID:p0230
ID:p0230
ID:p0235

ID:p0245
ID:p0240

The Woman-Centeredness of Various Dutch Maternity Service Providers Fontein-Kuipers et al.

Funding. This research did not receive any specific grant from Elise van Beeck, MSc, Researcher, School of Midwifery/
funding agencies in the public, commercial, or not-for-profit Research Centre Innovations in Care, Rotterdam University of
sectors. Applied Sciences, Rotterdam, Netherlands.

Correspondence regarding this article should be directed to Liesbeth Kammeraat, BSc, RN, Student midwife, School of
Yvonne Fontein-Kuipers, PhD, RM, Associate Professor Mid- Midwifery, Rotterdam University of Applied Sciences, Rotter-
wifery, Rotterdam University of Applied Sciences, Institute dam, Netherlands.
for Healthcare, Research Centre Innovations in Care and
School of Midwifery Education, Rochussenstraat 198, 3015 EK Fleur Rutten, BSc Student midwife, School of Midwifery,
Rotterdam, Netherlands. E-mail: j.a.c.a.fontein-kuipers@hr.nl. Rotterdam University of Applied Sciences, Rotterdam, Nether-
lands.
Yvonne Fontein-Kuipers, PhD, RM, Associate Professor Mid-
wifery, School of Midwifery/ Research Centre Innovations in
Care, Rotterdam University of Applied Sciences, Rotterdam,
Netherlands.

Pdf_Folio:101
View publication stats