Client perspectives of midwifery care in the transition from subfertility to parenthood: a qualitative study in the Netherlands

Figures & data

Table 1. Topic list.

• Fertility history (context of desire to conceive, fertility treatment, gravidity, miscarriages, ectopic pregnancies, abortions)

• Gynecological & obstetric history (parity, details of past pregnancies)

• What was your experience during your period of subfertility?

• What type of care did you require from the primary care midwife or other maternity care providers?

• To what extent do you feel that the care you wanted or received differed from standard midwifery care?

• Do you have any suggestions for primary care midwives or other maternity care providers who are caring for clients with a history of subfertility?

Table 2. Examples of coding process.

Citation	Category	Theme
Helen p. 10: “And what I missed was more attention from them, um, I expected them to ask more questions. They did ask some question, they mentioned that I got pregnant thanks to my ICSI treatment. So you can’t say they ignored it, but I had the feeling that they didn’t pay extra attention to my case.”	Need for understanding of treatment history	Need for understanding of impact of previous history
Ivonne p. 11:“But, um, the ultrasound scan, I felt fine for the first 2 or 3 days after it and I was confident that everything was all right, but by the time the next scan was due I was all stressed out and nervous again.”	Need for early and frequent ultrasound scans and monitoring	Need for care in general

Table 3. Characteristics of interviewees.

Fictional name	Age*	Region of origin	GPA†	Cause of infertility	Type of fertility treatment‡	Duration treatment	Care provider during pregnancy
Anna  Abraham	33 35	Groningen	G1P1	Reduced sperm potency	ICSI five attempts in the cycle and three re-placements	2.5 years	Midwife referred to gynecologist at term
Bertha  Bjorn	31 32	Groningen	G1P0	Early menopause	Seven IUI Six ICSI in own cycle Hyperstimula-tion	4.5 years	Midwife
Catharine	37	Utrecht	G2P1	Cause unknown	1st: 4 IUI, 2 IVF, 1 cryo replacement 2nd: spontaneous	4 years	Midwife referred at 36 weeks Midwife
Didi	34	Overijssel	G2P0A1	Reduced sperm potency	Four ICSI in Zwolle and one ICSI in Germany	4 years	Midwife
Erica	32	Zuid-Holland	G2P2	Cause unknown	1st: 5 IVF, 7IUI, 2 ICSI 2nd: 12 cryos, 1 ICSI	1st: 4 years 2nd: 1.5 years	Midwife Midwife
Fay	38	Utrecht	G2P2†	Male infertility	1^e: TESA premature labour at 23 weeks: 2nd : finish up Cryo , 2 x ICSI	1st: 1.5 years, 2nd	Midwife referred at 23 weeks Gynecologist
Gwen	36	Utrecht	G3P2†A1	Elevated FSH, otherwise unknown	1^e: spontaneous IUFD at 24 weeks due to trisomy 18 2^e: spontaneous 3^e: 7 IUI, 1 ICSI	2nd: 6 months 3rd: 5 years	Midwife referred to gynecologist at 6 months
Helen	34	Overijssel	G2P1A1	Sterilization of husband	1st: PESA, 3 ICSI 2nd: 1 ICSI	2.5 years	Midwife
Ivonne	32	Noord-Brabant	G2P1A1	PCOS Male infertility	1e: 6 ICSI, 3 cryo, 1 IMSI, 1 DI (IUFD 10 week) 2e: 1 DI	4.5	Gynecologist

*At the time of interview.

†G = gravidity, P = parity, A = no. of abortions.

‡Cryo = cryopreservation, DI = donor insemination, ICSI = intracytoplasmic sperm injection, IMSI = intracytoplasmic morphologically selected sperm Injection, IUFD = intrauterine fetal death, IUI = intrauterine insemination, IVF = in vitro fertilization, PCOS = PolyCysteus Ovarium Syndroom, PESA = percutaneous epididymal sperm aspiration, TESE = testicular sperm extraction.

Table 4. Schematic representation of the results.

Client centered midwifery care
1. Normal but not normal: Paradoxical feelings
a. Coping with change from inability to conceive to being pregnant
b. Wish for normal pregnancy
c. Being different from other pregnant women
d. Feeling obliged to enjoy pregnancy
2. Need for understanding of impact of previous history
a. Need for client-oriented care and customized information
b. Need for understanding of treatment history
c. Need to discuss fertility treatment
3. Need for psychosocial care
a. Need for support in postpartum period
b. Emotional support and guidance
c. More attention to reassurance and uncertainty
d. Create opportunities to discuss feelings
4. Need for care in general
a. Need for early and frequent ultrasound scans and monitoring of fetal heart sounds
b. Need to feel the fetus oneself
c. Need for shorter time between consultations
d. Need for extra information
e. Wish for extra consultations, frequent use of fetal heartbeat monitor

Table 5. Normal, but not normal: paradoxical feelings.

Helen p. 7: “This pregnancy is normal – or fairly normal, at least. Now I just want a normal pregnancy. I had a problem, but that’s solved now and I want to get out of the hospital – back to a normal routine where I can have my baby under the care of a normal midwife.”

Bertha p. 6: “The hospital is simply associated with too many memories of drama, stress and sadness. Being under the care of a midwife is a kind of new start without all that baggage: now you can just have your baby like anyone else.”

Helen p. 19, 20: “I didn’t experience this as a normal pregnancy. What it was for me … Look, every woman who has a baby in the normal way assumes that she’s going to have at least one more, or doesn’t give the matter much thought. But I know this is the only one for me.”

Table 6. Understanding the impact of previous history.

Anna p. 15: “ICSI … the topic was never mentioned. She never really asked ‘Gosh, were there any difficult moments or how did the whole thing go?’ I think that was because she knew very little about the whole procedure.”

Bjorn p. 4: “It was one of the most intense period for the two of us .[…] … And, uh, you cannot do much, but you can do it together."

Table 7. Psychosocial support.

Abraham p. 4 “[I] had a reduced sperm quality, but SHE had to undergo all treatments. We stick to the agreement, … yeah, uh, as far as possible … to do it together."

Didi p. 10: “ … Yes, I think you have to listen very carefully to your patient’s needs.”

Fay p. 6: “ … We have to learn to trust.”

Fay p. 9: “ … You have to make sure as a midwife that people get the impression that you’re approachable.”

Ivonne p.14: “ … Well yes, there’s still a lot of stress left over from everything that happened in the past, and I just need to talk about it for a while. About the fact that the pregnancy is quite a stressful period, and that you need to know that your feelings are understood. In fact, I really think that showing understanding is the most important thing.”

Table 8. Care needs in general.

Erica p. 7: “ … Well, I can’t understand … how people can just wait for six weeks without feeling anything at all – apart from the morning sickness, that is. Not feeling any movement or hearing that little heartbeat or anything. I would have needed that reassurance – and there’s nothing to stop you from getting it.”

Gwen p. 11: “ … Well, I must say that I personally appreciated the fact that my midwife let me come more often if I wanted to, or she would ask, well, when would you like to come next? Yes, that was really great, there I was, I could come for a check-up every four weeks at that stage and then she said, when do you want to come? Well, I didn’t want to overdo it so I said in 3 weeks, or 2 weeks maybe. Yes, I really appreciated it as such, the chance to have another little check-up again”.