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RESEARCH ARTICLE Open Access

Developing quality indicators forassessing quality of birth centrecare: a mixed- methods studyInge C. Boesveld1* , Marieke A. A. Hermus2, Hanneke J. de Graaf3, Marit Hitzert3, Karin M. van der Pal-de Bruin2,Raymond G. de Vries4, Arie Franx5 and Therese A. Wiegers6

Abstract

Background: Birth centres are described as settings where women with uncomplicated pregnancies can give birthin a home-like environment assisted by midwives and maternity care assistants. If complications arise or threaten,the woman is referred to a maternity unit of a hospital where an obstetrician will take over responsibility. In the lastdecade, a number of new birth centres have been established in the Netherlands, based on the assumption thatbirth centres provide better quality of care since they offer a better opportunity for more integrated care than theexisting system with independent primary and secondary care providers. At present, there is no evidence forthis assumption. The Dutch Birth Centre Study is designed to present evidence-based recommendations fororganization and functioning of future birth centres in the Netherlands. A necessary first step in this evaluation isthe development of indicators for measuring the quality of the care delivered in birth centres in the Netherlands.The aim of this study is to identify a comprehensive set of structure and process indicators to assess quality of birthcentre care.

Methods: We used mixed methods to develop a set of structure and process quality indicators for evaluating birthcentre care. Beginning with a literature review, we developed an exhaustive list of determinants. We then used aDelphi study to narrow this list, calling on experts to rate the determinants for relevance and feasibility. Amultidisciplinary expert panel of 63 experts, directly or indirectly involved with birth centre care, was invited toparticipate.

Results: A panel of 42 experts completed two Delphi rounds rating determinants of the quality of birth centre carebased on their relevance (to the setting) and feasibility (of use). A set of 30 determinants for structure and processquality indicators was identified to assess the quality of birth centre care in the Netherlands.

Conclusions: We identified 30 determinants for structure and process quality indicators concerning birth centrecare. This set will be validated during the evaluation of birth centres in the Dutch Birth Centre Study.

Keywords: Quality indicators, Birthing centres, Structure and process assessment, Delphi method, The Netherlands

* Correspondence: [email protected] van Es Institute (Netherlands Expert Centre Integrated Primary Care),Wisselweg 33, 1314 CB Almere, Almere, NetherlandsFull list of author information is available at the end of the article

© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Boesveld et al. BMC Pregnancy and Childbirth (2017) 17:259 DOI 10.1186/s12884-017-1439-9

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BackgroundInternationally, birth centres are described as settingswhere women with uncomplicated pregnancies can givebirth in a home-like environment. In the Netherlands,women with uncomplicated pregnancies can choosewhere they want to give birth: at home, in a birth centreor in a hospital [1]. At any location, community mid-wives are responsible for care during labour and birth aslong as it stays uncomplicated. When additional medicalassistance is required, the women will receive specialistcare under responsibility of an obstetrician at an obstet-ric unit. Birth care in a birth centre is provided by com-munity midwives, assisted by maternity care assistants.The community midwife accompanies the woman to thecentre when labour has started. A maternity care assist-ant assists the midwife during labour and birth and pro-vides postnatal care to the woman and new-born. Mostbirth centres do not have a permanent staff of midwivesand maternity care assistants. They are only present atthe centre when accompanying a woman in labour.Birth centres have been present in the Netherlands

since the nineteenth century [2], but not until the year2000 did the number of these centres begin to growconsiderably. This appeared to be a reaction to a severeshortage of maternity care providers, especially primarycare midwives and maternity care assistants but also ob-stetric nurses in hospitals. Birth centres were seen as asolution, because they reduce the pressure on hospitalmaternity wards by providing women who do not wantto give birth at home with a safe and home-like alterna-tive. And because birth centres allow midwives tosupervise multiple births simultaneously, they also re-duce the pressure on community midwives. These birthcentres were typically built right next to, or within, thewalls of a hospital. However, most of them disappearedagain when the problem of the shortage of maternitycare providers was alleviated by a dropping birth ratefollowing the millennium baby boom.In recent years perceptions about the safety of the ma-

ternity care system in the Netherlands began to change.An important cause for this was the publication of theEuro-Peristat data, alarming the Netherlands because ofits relatively high perinatal mortality compared to otherEuropean countries [3]. It was suggested that this mightbe related to the strict division between primary and sec-ondary care in the Dutch maternity care system [4–7].The basic feature of this system is that for healthywomen community midwives or general practioners arethe responsible care providers (primary care), and forwomen with pre-existing and emerging pathology obste-tricians are the responsible care providers (secondarycare) [8]. Media attention given to the Euro-Peristat dataand the report from a special committee set up by theMinister of Health (Steering Group “Pregnancy and

Childbirth”) [9] may have attributed to a change in theattitudes and behaviour of Dutch women and their careproviders with an increasing number of women choos-ing, or being referred to, a hospital to give birth [10]: in2000 30.3% of all births took place at home but this fellto 13.1% in 2015 [11]. More and more healthy womenare opting for a hospital birth because they do not feelsafe at home, or are asking for referral to receive treat-ment (i.e. pain medication) that cannot be provided inprimary care [12]. Birth centres can be seen as an oppor-tunity to keep these healthy women away from the clin-ical setting, to provide a safe and home-like alternative,but to be close enough to a hospital to be able to takethem in quickly when referral is warranted. In theirreport, the Steering Group recommended more integra-tion in maternity care, by improved cooperation betweenprimary and secondary care and the introduction ofbirth centres with close links to hospitals. They also rec-ommended further research on the added value of birthcentres [8]. In recent years, following these recommen-dations, a number of new birth centres have beenestablished in the Netherlands, based on the assumptionthat birth centres provide better quality of care – asmeasured by perinatal and maternal outcomes – sincethey offer a better opportunity for more integrated carethan the existing system with independent primary andsecondary care providers [13]. At present, there is noevidence for this assumption because there is no reliableway to measure degree and quality of integration incare provision. The Dutch Birth Centre Study isdesigned to present evidence-based recommendationsfor organization and functioning of future birth cen-tres in the Netherlands, based on careful assessmentof existing birth centres [14]. A necessary first step inthis process is development of indicators for measur-ing the quality of the care delivered in birth centresin the Netherlands.Although formulated in 1990, the definition of quality

of care provided by the Institute of Medicine (IOM) isstill widely accepted: “quality of care is the degree towhich health services for individuals and populationsincrease the likelihood of desired health outcomes andare consistent with current professional knowledge” [15].Usually three dimensions of quality of care are distin-guished: structure (the capacity to provide high qualitycare), process, and outcome [16]. Measures of thesethree dimensions are called indicators. To assess qualityof care, indicators should be developed for the seven do-mains of quality identified by the IOM: effectiveness,safety, timeliness, efficiency, equity, accessibility andpatient-centeredness [17]. Internationally, standards forbirth centres are available and can provide a tool formeasuring the quality of service provided to childbearingfamilies in birth centres [18, 19], but these standards

Boesveld et al. BMC Pregnancy and Childbirth (2017) 17:259 Page 2 of 13

must be adjusted for specific settings of these centres, inour case, the unique maternity care system in theNetherlands. A number of outcome quality indicatorsare available to assess birth centre care (i.e. perinatal andmaternal mortality and morbidity) [20–27], but structureand process indicators, specifically developed for birthcentre care, are scarce.In this article we describe a set of determinants for

structure and process indicators for assessing the qualityof birth centre care and we explain the approach weused to develop this set. We only describe the deve-lopment of determinants for structure and processindicators, because a newly validated Optimality Index(OI-NL2015) and a Composite Adverse Outcome Score(CAOS) were used to evaluate outcomes of birth centrecare [3].

MethodsStudy designIn order to develop a comprehensive set of structureand process quality indicators to evaluate birth centrecare, we used mixed methods. Three phases werefollowed in the development process: 1) identification ofexisting quality indicators in birth care, 2) translatingthese structure and process indicators into determinants,3) determinant selection by Delphi consultation. Thestudy was conducted in the first half of 2013 as part ofthe Dutch Birth Centre Study [3].

1. Identification of existing quality indicators inbirth care

In the first phase of the study, we used various sourcesto find existing quality indicators in birth care. Webegan with an Internet search for documents fromDutch Institutes that had developed quality indicatorsfor maternity care. Documents that described the (devel-opment of ) quality indicators by midwives, obstetriciansand maternity care assistants were obtained. Next, wereviewed international scientific literature about birthcentres in order to identify existing quality indicators.We searched PubMed and the Cochrane Library usingthe Mesh terms: “birthing centres”, “quality indicator”,“health care” and search terms “quality” and “birthcentre”. We used references from these articles to findother relevant articles and documents related to qualityindicators in maternity care.

2. Translating indicators into determinantsIn the second phase we translated the structure andprocess indicators that we had identified into determi-nants (or topics): elements that identify the nature of theindicator. We used a framework based on the sevendomains of quality according to the IOM (effectiveness,safety, timeliness, efficiency, equity, accessibility and

patient-centeredness.) We added an eighth domain,“Law on the Accessibility of Healthcare Facilities”, be-cause of obligations placed on healthcare facilities by thislaw in the Netherlands. The research group used theirexperience to add topics that were missing in the result-ing list. No outcome indicators were included. We thencreated a questionnaire that members of an expert panelcould complete in a minimum amount of time in orderto maximize our response rate.

3. Determinant selection by Delphi consultationWe initiated an online Delphi study with the goal ofobtaining consensus among a group of experts. Theonline Delphi technique is an anonymously structuredapproach, in which information is gathered from a groupof participants through a number of Delphi rounds. Theweb-based anonymous nature of the Delphi techniqueensures that a single individual cannot dominate theconsensus formation. Moreover all participants areequally able to change their opinion in the course of theprocess [28, 29]. Our Delphi study consisted of twoonline questionnaires.

ParticipantsWe selected participants for the expert panel from theResearch Advisory Group of the Dutch Birth CentreStudy [3], participants of former panels of developingindicators for maternity care in the Netherlands, profes-sionals from different disciplines who are working withor in a birth centre with several years of experience,representatives of health insurance companies, policy-makers, clients and advisors in birth care. Of the careproviders, only experts who are actually involved in birth(centre) care were invited and all health care disciplinesrelated to birth (centre) care were represented. We in-cluded professionals in our heterogeneous expert panel:(11 (community and clinical) midwives, 2 general practi-tioners, 5 maternity care assistants, 6 obstetricians, 4paediatricians, 5 obstetrics and gynaecology nurse spe-cialists, 7 managers from birth centres, 5 representativesfrom health insurance companies, 3 representatives fromclients and 15 other experts (i.e. policymakers, advisorsand research experts). We limited the number of partici-pating clients, because their view on quality of birthcentre care is examined in another part of the study [3].

Rating determinants by experts: First Delphi roundIn May 2013, we sent a link to an online questionnaireby e-mail to the expert panel. The experts wereinstructed to rate the determinants on relevance (to thesetting) and feasibility (of use) and, if necessary, tocomment on them. Each determinant was rated on aseven-point Likert scale (1 = not at all relevant/feasible;4 = neutral; 7 = very much relevant/feasible). Finally,


experts were encouraged to suggest additional relevantsubjects that should be taken into consideration in theassessment of the quality of birth centre care. All ratingsfrom the first Delphi round were analysed in Excel anddistributions of scores were presented in median scoresfor each determinant. We considered determinants witha median score of ≥6 with agreement to be relevant andfeasible to collect and accepted these immediately.Agreement was defined when 80% or more of the ratingswere within a range of three (i.e. 5–6-7 of 4–5-6).Determinants that scored with a median score of ≤2were rejected. Median scores of >3 and <6 with agree-ment or ≥6 without agreement were discussed again inthe second Delphi round. Furthermore, all the com-ments on determinants from the first round wereanalysed and the descriptions of determinants were re-phrased in cases of ambiguity. All proposed newdeterminants from the first round were categorized in

domains. New determinants were coded and two re-searchers of our research group decided, using a consen-sus method, which determinants should be submitted inthe second round. Items the research group already haddecided to include in the overall study (i.e. professionalexperiences and topics related to integration) were notincluded in the second round.

Rating determinants by experts: Second Delphi roundIn the second Delphi round, the experts were informedabout the median scores on relevance and feasibility ofthe total expert group, their own scores and the com-ments of the respondents regarding determinants forwhich no consensus was reached in the first round. Theywere instructed to re-consider their rating of the deter-minants presented in the first round as well as to rateand comment on the new elements the same way as inthe first round. This was done to allow experts to revise

Fig. 1 Flowchart selection process indicators quality birth centres


Table 1 Selected determinants per domain

Determinant Type ofindicator

Rating on: Median scoreLikert scale

Consensus (%) Conclusionround 1

Conclusionround 2

(1–7) (80%consensus)

(80%consensus)

Domain: effectiveness

Written agreements on care aspects(i.e. by hospital care, obstetricians)

Structure Relevance 7 100 Include

Feasible 6 87,5

Structural evaluation of the care providedin the birth centre

Structure Relevance 7 93,7 Include

Feasible 6 83,4

Maternity care assistant present duringlaboura

Process Relevance 6 87,5 Include

Feasible 6,5 79,2

(Integrated) ICT system with hospitaland midwifery practices

Structure Relevanceround 1

6 75 Submit again

Feasible round1

5 54,3

Relevanceround 2

6 90,5 Include

Feasible round2

6 76,2

Domain: safety

Facilities at a birth centre in relation toemergency care (i.e. CPR resuscitation)


Feasible 7 97,9

Joint (interdisciplinary) emergency caretraining


Feasible 6 87,5

Agreements with ambulance service andnearest hospital about urgent referrals


Feasible 6 77

Domain: timeliness

Necessary transport time from birthcentre to hospital

Process Relevance 7 100 Include

Feasible 7 96

In case of referral from the birth centredurante partu: required time betweendecision to refer and treatment inhospital


Feasible 6 81,3

Domain: efficiency

In case of referral from the birth centredurante partu: guaranteed access to thehospital with which agreements weremade


Feasible 6 87,6

Distance between birth centre andhospital


Feasible 7 96

Cooperation with (almost) all relevantorganizations in the region (such asmidwifery practices and maternity careassistance organisations)


Feasible 6 81,3

Protocols on care aspects Structure Relevance 7 87,5 Include

Feasible 6,5 81,3

Participation of birth centre in localmaternity care consultation andcooperation group (VSV)


Feasible 6 81,3

Indoor connection between birth centreand hospital


Feasible 7 96


Table 1 Selected determinants per domain (Continued)

Joint use of an electronic patient record Structure Relevanceround 1

6 87,6 Submit again

Feasibleround 1

6 66,7

Relevanceround 2

6 95,2 Include

Feasibleround 2

6 85,7

System of quality improvement(i.e. accreditation)


6 70,9 Submit again

Feasibleround 1

5 56,3

Relevanceround 2

6 85,7 DecisionResearchgroup: include

Feasibleround 2

5 80,9

Multidisciplinary education as result offormulated points of improvement fromperinatal audit

Process Relevanceround 2

6 90,5 New in round2

Include

Feasibleround 2

6 83,3

Domain: equity

Care pathways formulated with chainpartners


Feasible 6 79,2

Birth centre has vision of birth care Structure Relevance 7 91,8 Include

Feasible 6 75

Formal partnership agreement with chainpartners


Feasible 7 81,3

Admission agreement for professionalswho use birth care facilities at the birthcentre


6 69,3 Submit again

Feasibleround 1

7 75,5

Relevanceround 2

6 81 Include

Feasibleround 2

7 85,7

Domain: accessibility

24 /7 telephone accessibility birth centre Process Relevance 7 100 Include

Feasible 7 98

Physical access to birthing centre forclients (i.e. parking)


Feasible 6 78

Physical access to birthing centre formidwives and maternity care assistants(e.g. parking)


Feasible 6 80

Domain: patient-centeredness

Facilities at a birth centre in relation topain management (i.e. nitrous oxide)


Feasible 6 83,7

Continuous presence of a healthcareprovider during laboura


Feasible 6 81,3

Structural research on client experiences Structure Relevance 7 98 Include

Feasible 6 85,5


their opinion of the first round while considering theratings and comments provided by the other membersof the expert panel. The link to the personalized onlinequestionnaire was sent by email 10 days after the firstround. Again, the median scores and the degree ofagreement were calculated. Only scores ≥6 with agree-ment were adopted into the list. Determinants withscores for relevance ≥6 with agreement, but feasibilitybetween 3 and 6 were presented to the research groupfor a final decision.

ResultsFigure 1 shows the total process that led to theselection of structure and process quality indicators ofbirth centres, and the number of determinants(topics) at each step.

Identification of existing quality indicators in birth careTwo hundred fifteen indicators were derived from Dutchsources, 145 from international literature. We eliminatedduplication and excluded all outcome indicators. Indica-tors that clearly do not determine quality of care in abirth centre (because it is clear that this kind of caredoes not occur in birth centres, i.e. caesarean section)were also excluded from this list. Finally 66 structureand process indicators were identified.

Translating indicators into determinantsThese 66 literature-based indicators were divided intoseven themes matching the seven domains of qualityaccording to the United States Institute of Medicine(IOM). The research group added a domain “Law Acces-sibility of Healthcare Facilities”. In these eight domains,22 topics were identified, because several indicators ap-peared to relate to the same topic, albeit with differentwordings. The research group added another 13 topicsthat they missed, based on their experience. After thisprocess, the topics were formulated as 35 determinantsto be included in the first questionnaire for the onlineDelphi panel.

Determinant selection by Delphi consultationThe questionnaire in the first Delphi round was com-pleted by 48 experts (response rate of 76%). 42 of themalso completed the questionnaire in the second round(response rate of 88%). During the first round, 24 of the35 determinants were accepted for inclusion, none wererejected right away, leaving 11 topics without consensus.22 experts mentioned 52 new topics they missed in thequestionnaire. These topics were labelled and catego-rized, after which two researchers of our research groupdecided, based on consensus, that 8 of them would beincluded in the second Delphi round. In the secondround, the 11 topics from the first round on which noconsensus was reached and the 8 new topics were pre-sented to the expert panel. This resulted in the accept-ance of another five determinants and the rejection of13 determinants. One determinant was presented to theresearch group because of low feasibility according tothe experts. The research group accepted this determin-ant, so finally 30 determinants resulted from the Delphiconsultation. Table 1 shows the selected determinantsper IOM quality domain. Table 2 shows all determinantsincluded in the Delphi procedure with the number orrated scores on the Likert Scale.

DiscussionIn this study, part of the Dutch Birth Centre Study, weidentified a set of 30 determinants, to be translated into30 structure and process quality indicators that can beused to assess the quality of birth centre care in theNetherlands. The new developed determinants are de-rived from existing quality indicators in maternity carein the Netherlands (used to measure quality of care bymidwives, obstetricians and maternity care assistants)and indicators derived from international documentsconcerning birth centre care. The experts selected 5determinants that are used by Laws in the research oncharacteristics and practices of birth centres in Australia[20] and 4 determinants derived from Dutch existingquality indicators. They also selected 3 determinantswhich were formulated in a quality framework of birthcentre care, proposed by the Royal Dutch Organization

Table 1 Selected determinants per domain (Continued)

Focusing on the patients(i.e. use individual birth plan)


Feasible 6 83,4

Participation and representation of clientsin organisation (i.e. in the board)


6 85,7 New in round2

Include

Feasibleround 2

6 78,6

aThese determinants appear similar but are different: ‘Continuous presence of a healthcare provider during labour’ refers to continuous support of labour (notleaving alone the woman in labour). ‘Maternity care assistant present during labour’ refers to the presence of assistance of the midwife during childbirth. In theNetherlands, the midwife attends birth of low risk women, regardless the location (at home, in a birth centre or in a hospital) and is assisted by a maternity careassistant. Sometimes, it happens that the maternity care assistant is too late present at the childbirth to assist the midwife adequately. This determinant refers tothis aspect


Table

2Allde

term

inantsinclud

edin

theDelph

i-procedu

re

Scores

LikertScale(N)

Determinant

Dom

aina

Ratin

gon

:1

23

45

67

Dono

tknow

Total(N)

Med

ian

Con

sensus

(%)

Con

clusionroun

d1

(80%

consen

sus)

Con

clusionroun

d2

(80%

consen

sus)

Ado

pted

afterfirstroun

d

Necessary

transporttim

efro

mbirth

centre

toho

spital

3Relevance

313

3450

7100

Includ

e

Feasible

24

1430

507

96

24/7

teleph

oneaccessibility

birthcentre

6Relevance

26

4250

7100

Includ

e

Feasible

13

1036

507

98

Facilitiesat

abirthcentre

inrelatio

nto

pain

managem

ent(i.e.nitrou

soxide)

7Relevance

11

22

1217

1449

6100

Includ

e

Feasible

13

35

1422

149

683,7

Writtenagreem

entson

care

aspe

cts

(i.e.by

hospitalcare,ob

stetricians)

1Relevance

417

2748

7100

Includ

e

Feasible

11

24

1820

248

687,5

Incase

ofreferralfro

mthebirthcentre

durantepartu:gu

aranteed

access

tothe

hospitalw

ithwhich

agreem

entswere

made

4Relevance

39

3648

7100

Includ

e

Feasible

14

912

211

486

87,6

Distancebe

tweenbirthcentre

and

hospital

4Relevance

17

1527

507

98Includ

e

Feasible

21

1433

507

96

Con

tinuo

uspresen

ceof

ahe

althcare

provider

durin

glabo

ur7

Relevance

16

1427

487

98Includ

e

Feasible

15

312

1413

486

81,3

Structuralresearch

onclient

expe

riences

7Relevance

12

1827

487

98Includ

e

Feasible

12

43

1523

486

85,5

Physicalaccess

tobirthing

centre

for

clients(i.e.parking)

6Relevance

26

1626

507

96Includ

e

Feasible

12

72

1324

150

678

Carepathwaysform

ulated

with

chain

partne

rs5

Relevance

17

1821

148

695,9

Includ

e

Feasible

18

714

171

486

79,2

Facilitiesat

abirthcentre

inrelatio

nto

emerge

ncycare

(i.e.CPR

resuscitatio

n)2

Relevance

24

1132

497

95,9

Includ

e

Feasible

110

371

497

97,9

Incase

ofreferralfro

mthebirthcentre

durantepartu:requ

iredtim

ebe

tween

decision

toreferandtreatm

entin

hospital

3Relevance

13

1231

148

795,9

Includ

e

Feasible

33

910

203

486

81,3

Joint(interdisciplinary)em

erge

ncycare

training

2Relevance

27

1722

486

95,8

Includ

e

Feasible

15

719

1648

687,5


Table

2Allde

term

inantsinclud

edin

theDelph

i-procedu

re(Con

tinued)

Structuralevaluatio

nof

thecare

provided

inthebirthcentre

1Relevance

21

1628

148

793,7

Includ

e

Feasible

24

818

142

486

83,4

Physicalaccess

tobirthing

centre

for

midwives

andmaternity

care

assistants

(e.g.p

arking

)

6Relevance

49

1720

506

92Includ

e

Feasible

12

63

1522

150

680

Birthcentre

hasvision

ofbirthcare

5Relevance

13

315

2648

791,8

Includ

e

Feasible

14

75

1120

486

75

Coo

peratio

nwith

(alm

ost)allrelevant

organizatio

nsin

theregion

(suchas

midwifery

practices

andmaternity

care

assistance

organisatio

ns)

4Relevance

11

34

1623

486

89,5

Includ

e

Feasible

21

68

1417

486

81,3

Agreemen

tswith

ambu

lanceserviceand

nearestho

spitalabo

uturge

ntreferrals

2Relevance

23

49

3048

789,6

Includ

e

Feasible

11

84

1023

148

677

Focusing

onthepatients(i.e.useof

individu

albirthplan)

7Relevance

42

2417

148

689,6

Includ

e

Feasible

24

1413

132

486

83,4

Maternity

care

assistantpresen

tdu

ring

labo

ur1

Relevance

24

712

2348

687,5

Includ

e

Feasible

22

52

1224

148

6,5

79,2

Protocolson

care

aspe

cts

4Relevance

21

23

1029

148

787,5

Includ

e

Feasible

31

43

1224

148

6,5

81,3

Participationof

birthcentre

inlocal

maternity

care

consultatio

nand

coop

erationgrou

p(VSV)

4Relevance

25

110

3048

785,4

Includ

e

Feasible

11

63

1323

148

681,3

Indo

orconn

ectio

nbe

tweenbirthcentre

andho

spital

4Relevance

21

58

1123

506

84Includ

e

Feasible

22

1333

507

96

Form

alpartne

rshipagreem

entwith

chain

partne

rs5

Relevance

21

55

1520

486

83,4

Includ

e

Feasible

11

73

1026

487

81,3

Ado

pted

aftersecond

roun

d

Jointuseof

anelectron

icpatient

record

4Relevanceroun

d1

63

1920

486

87,6

Subm

itagain

Feasibleroun

d1

12

38

58

192

486

66,7

Relevanceroun

d2

11

120

1942

695,2

Includ

e

Feasibleroun

d2

12

35

1615

426

85,7

(Integrated

)ICTsystem

with

hospitaland

midwifery

practices

1Relevanceroun

d1

19

317

162

486

75Subm

itagain

Feasibleroun

d1

13

412

39

142

485

54,3

Relevanceroun

d2

36

1913

142

690,5

Includ

e

Feasibleroun

d2

12

510

139

242

676,2


Table

2Allde

term

inantsinclud

edin

theDelph

i-procedu

re(Con

tinued)

System

ofqu

ality

improvem

ent

(i.e.accred

itatio

n)4

Relevanceroun

d1

110

812

143

486

70,9

Subm

itagain

Feasibleroun

d1

21

17

911

116

485

56,3

Relevanceroun

d2

14

816

121

426

85,7

decision

Research

grou

p:includ

eFeasibleroun

d2

21

315

109

242

580,9

Adm

ission

agreem

entforprofession

als

who

usebirthcare

facilitiesat

thebirth

centre

5Relevanceroun

d1

13

46

1018

749

669,3

Subm

itagain

Feasibleroun

d1

13

38

268

497

75,5

Relevanceroun

d2

11

34

1317

342

681

Includ

e

Feasibleroun

d2

57

291

427

85,7

Multid

isciplinaryed

ucationas

resultof

form

ulated

pointsof

improvem

entfro

mpe

rinatalaudit

4Relevanceroun

d2

13

117

2042

690,5

Includ

e

Feasibleroun

d2

15

316

161

426

83,3

Participationandrepresen

tatio

nof

clients

inorganisatio

n(i.e.in

thebo

ard)

7Relevanceroun

d2

15

1214

1042

685,7

Includ

e

Feasibleroun

d2

17

79

171

426

78,6

Rejected

afterroun

d2

Opp

ortunitiesto

stay

inthebirthcentre

aftergiving

birth

7Relevanceroun

d1

22

415

911

649

571,4

Subm

itagain

Feasibleroun

d1

11

35

613

191

496

77,5

Relevanceroun

d2

24

57

109

542

561,9

Reject

Feasibleroun

d2

34

314

1842

683,3

Legalentity

(i.e.foun

datio

n,association)

8Relevanceroun

d1

22

516

78

45

494

57,2

Subm

itagain

Feasibleroun

d1

11

82

1021

649

667,4

Relevanceroun

d2

33

120

36

24

424

57,1

Reject

Feasibleroun

d2

54

1119

342

680.9

Inde

pend

entsupe

rvisorybo

ard

8Relevanceroun

d1

22

27

613

133

486

66,7

Subm

itagain

Feasibleroun

d1

22

73

1220

248

673

Relevanceroun

d2

11

65

1711

142

678,6

Reject

Feasibleroun

d2

17

217

141

426

78,6

Multid

isciplinarycompo

sitio

nof

the

boardof

thebirthcentre

(e.g.m

idwives,

maternity

care

organizatio

nandho

spital)

4Relevanceroun

d1

31

24

1011

1748

679,1

Subm

itagain

Feasibleroun

d1

11

55

828

487

85,4

Relevanceroun

d2

11

16

518

1042

678,6

Reject

Feasibleroun

d2

32

928

427

92,7

Publicationof

annu

alrepo

rt8

Relevanceroun

d1

21

89

1414

486

77,2

Subm

itagain

Feasibleroun

d1

24

214

252

497

85,5

Relevanceroun

d2

18

714

1242

678,6

Reject

Feasibleroun

d2

67

281

427

83,4


Table

2Allde

term

inantsinclud

edin

theDelph

i-procedu

re(Con

tinued)

Num

berof

births

andpo

stpartum

stays

that

occurpe

ryear

inthebirthcentre

4Relevance

22

26

713

1648

675

subm

itagain

Feasible

12

515

2548

793,8

Relevanceroun

d2

21

65

217

426

78,6

Reject

Feasibleroun

d2

18

3342

797,6

Facilitiesat

abirthcentre

inrelatio

nto

stay

(i.e.po

ssibilitiesforfather

tostay

overnigh

t,privateshow

erand/or

toiletin

room

,bath)

7Relevanceroun

d1

24

410

1316

496

79,6

Subm

itagain

Feasibleroun

d1

16

610

2649

785,7

Relevanceroun

d2

14

48

1213

426

78,7

Reject

Feasibleroun

d2

11

48

271

427

92,8

24hpresen

ceof

acaregiverin

birth

centre

(maternity

care

assistantor

midwife)

2Relevanceroun

d2

33

24

413

121

426

69.1

Reject

Feasibleroun

d2

12

12

28

242

427

80,9

Inde

pend

entor

freestand

ingsettingwith

aho

me-like,no

n-clinicalatmosph

ere

6Relevanceroun

d2

41

88

79

542

4,5

54,7

Reject

Feasibleroun

d2

22

56

1413

426

78,6

Detailedbu

sine

ssplan

forthebirthcentre

4Relevanceroun

d2

21

87

156

342

5,5

71,4

Reject

Feasibleroun

d2

14

415

171

426

85,7

Participationof

thebirthcentre

inscientificresearch

1Relevanceroun

d2

13

1014

67

142

571,4

Reject

Feasibleroun

d2

17

812

131

426

78,6

Transfer

from

birthing

room

toa

reside

nceroom

whe

nthemothe

rof

newly-bornchild

wants/can/hasto

stay

a(partof

her)childbe

dpe

riod;

7Relevanceroun

d2

23

114

68

26

424

50Reject

Feasibleroun

d2

11

17

59

126

425,5

50

Staffin

thebirthcentre

mirrorsthe

popu

latio

nthat

(may)usethebirthcentre

7Relevanceroun

d2

93

413

43

24

424

50Reject

Feasibleroun

d2

44

112

310

53

424

38,1

a Descriptio

nof

Dom

ains:

1:Effectiven

ess

2:Safety

3:Timeliness

4:Efficiency

5:Eq

uity

6:Accessibility

7:Pa

tient-cen

teredn

ess

8:Law

onaccessibility

ofhe

alth

care

facilities


of Midwives (KNOV). Ten selected determinants areused by different organizations to assess quality of care(e.g. maternity care assistance, emergency care) [30–34].Finally, 7 new determinants were selected by the experts.The final set of indicators will be included in the on-going study to evaluate birth centre care in theNetherlands.

StrengthA strength of the development of this set of determi-nants for indicators is that it is developed in collabor-ation with all parties involved in birth centre care, and isbased on consensus. Therefore it can be expected thatall professionals in the field will accept assessing thequality of birth centre care using this set of indicators.

LimitationsWe are aware that the set of determinants for indicatorswe developed has its limitations. Firstly, to assess care ingeneral, structure, process and outcome indicatorsshould be used. However, because there are already alarge number of quality indicators to assess outcomes ofbirth centre care, this set contains only structure andprocess indicators [35]. The expert panel chose 19 struc-ture and 11 process indicators to asses birth centre care.For the same reason the set we developed does not in-clude indicators of women’s experiences of care, becausethey can be regarded as outcome indicators [36].Thirdly, this set only consists of determinants for indica-tors. The process for developing structure and processquality indicators for birth centres still needs to bedescribed. Also, we do not yet know whether this set ofdeterminants for indicators will be able to differentiatebetween birth centres or not. It has yet to prove itselfin practice: the Dutch National Birth Centre Studywill be the first to use these indicators to assess thequality of care.Finally, although our study was focused on Dutch birth

centres, we expect that this set of determinants forindicators will be applicable in other settings where birthcentres are used.

ConclusionsWe used an online Delphi-method to develop a list ofthirty determinants for structure and process indicatorsto measure quality of birth centre care. We will describethe process for developing quality indicators from thesedeterminants and evaluation of the validity and reliabil-ity of these indicators as part of the Dutch Birth CentreStudy in a later paper. It is important to underscore thatindicators are part of an on-going cycle of qualityimprovement. Indicators should never be static. Changesin evidence or clinical relevance, a consistently highperformance or a low variation in achievement, new

developments and demographic changes in the popu-lation of childbearing women, all may be criteria forremoving an indicator or adding a new one in afuture list of determinants for quality indicators forbirth centre care.

AbbreviationsIOM: Institute of Medicine; KNOV: Royal Dutch Organization of Midwives;ZonMw: the Netherlands Organisation for Health Research and DevelopmentZonMw

AcknowledgementsThe authors gratefully acknowledge the other members of the Project Group‘Birth Centre Study’ for their input in the project. The authors would like tothank the members of the Expert panel for their time and energy spent in thepanel. We are also grateful for the helpful comments of Theo Haitjema andÖmer Aydogan for their useful comments on the draft version of this article.

FundingThis study was funded by ZonMw (the Netherlands Organisation for HealthResearch and Development (ZonMw) in the context of the research programPregnancy and Childbirth, [grant no. 50–50,200–98-102].The authors declare that the funding body had no role in the design of thestudy, collection, analysis and interpretation of data and writing themanuscript.

Availability of data and materialsThe dataset supporting the conclusions of this article is included within thearticle (and its additional file).

Authors’ contributionsAll authors contributed to the design, interpretation of data, drafting andediting of the manuscript. IB collected the data; IB and TW analysed thedata. All authors have read and approved the final manuscript.

Ethics approval and consent to participateDesign and planning of the study were presented to the Medical EthicsCommittee of the UMCU (University Medical Centre Utrecht) who confirmedthat an official ethical approval of this study is not required.

Consent for publicationNot applicable.

Competing interestsThis study was funded by ZonMw (the Netherlands Organisation for HealthResearch and Development (ZonMw) in the context of the research programPregnancy and Childbirth, [grant no. 50–50,200–98-102]. The authors declarethat they have no competing interests.

Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.

Author details1Jan van Es Institute (Netherlands Expert Centre Integrated Primary Care),Wisselweg 33, 1314 CB Almere, Almere, Netherlands. 2Department of ChildHealth, TNO, PO Box 2215 2301, CE Leiden, Leiden, Netherlands.3Department of Obstetrics and Gynaecology, Erasmus University MedicalCentre, PO Box 2014 3000, CA Rotterdam, Rotterdam, Netherlands.4Academie Verloskunde Maastricht/Zuyd University, CAPHRI School for PublicHealth and Primary Care, PO Box 616 6200, MD Maastricht, Maastricht,Netherlands. 5Division Woman and Baby, University Medical Centre Utrecht,PO Box 85500 3508, GA Utrecht, Utrecht, Netherlands. 6NIVEL (NetherlandsInstitute for Health Services Research), PO Box 1568 3500, Utrecht, BN,Netherlands.


Received: 26 February 2016 Accepted: 27 July 2017

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