Access to this full-text is provided by Springer Nature.
Content available from BMC Pregnancy and Childbirth
This content is subject to copyright. Terms and conditions apply.
R E S E A R C H A R T I C L E Open Access
Women’s characteristics and care outcomes
of caseload midwifery care in the
Netherlands: a retrospective cohort study
Pien Offerhaus
1*
, Suze Jans
2
, Chantal Hukkelhoven
3
, Raymond de Vries
1,4,5
and Marianne Nieuwenhuijze
1
Abstract
Background: The maternity care system in the Netherlands is well known for its support of community-based
midwifery. However, regular midwifery practices typically do not offer caseload midwifery care –one-to-one
continuity of care throughout pregnancy and birth. Because we know very little about the outcomes for women
receiving caseload care in the Netherlands, we compared caseload care with regular midwife-led care, looking at
maternal and perinatal outcomes, including antenatal and intrapartum referrals to secondary (i.e., obstetrician-led)
care.
Methods: We selected 657 women in caseload care and 1954 matched controls (women in regular midwife-led
care) from all women registered in the Dutch Perinatal Registry (Perined) who gave birth in 2015. To be eligible for
selection the women had to be in midwife-led antenatal care beyond 28 gestational weeks. Each woman in
caseload care was matched with three women in regular midwife-led care, using parity, maternal age, background
(Dutch or non-Dutch) and region. These two cohorts were compared for referral rates, mode of birth, and other
maternal and perinatal outcomes.
Results: In caseload midwifery care, 46.9% of women were referred to obstetrician-led care (24.2% antenatally and
22.8% in the intrapartum period). In the matched cohort, 65.7% were referred (37.4% antenatally and 28.3% in the
intrapartum period). In caseload care, 84.0% experienced a spontaneous vaginal birth versus 77.0% in regular
midwife-led care. These patterns were observed for both nulliparous and multiparous women. Women in caseload
care had fewer inductions of labour (13.2% vs 21.0%), more homebirths (39.4% vs 16.1%) and less perineal damage
(intact perineum: 41.3% vs 28.2%). The incidence of perinatal mortality and a low Apgar score was low in both
groups.
Conclusions: We found that when compared to regular midwife-led care, caseload midwifery care in the
Netherlands is associated with a lower referral rate to obstetrician-led care –both antenatally and in the
intrapartum period –and a higher spontaneous vaginal birth rate, with similar perinatal safety. The challenge is to
include this model as part of the current effort to improve the quality of Dutch maternity care, making caseload
care available and affordable for more women.
Keywords: Continuity of care, Caseload midwifery, Primary health care, Birth outcomes
© The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,
which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give
appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if
changes were made. The images or other third party material in this article are included in the article's Creative Commons
licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons
licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain
permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
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 in a credit line to the data.
* Correspondence: p.offerhaus@av-m.nl
1
Research Centre for Midwifery Science, Midwifery Education and Studies
Maastricht, ZUYD University, Universiteitssingel 60, 6229 ER Maastricht, the
Netherlands
Full list of author information is available at the end of the article
Offerhaus et al. BMC Pregnancy and Childbirth (2020) 20:517
https://doi.org/10.1186/s12884-020-03204-3
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Background
A solid evidence base exists for midwife-led continuity
of care (MLCC) models, including caseload midwifery
[1–3]. According to the Cochrane review on this topic,
women in caseload midwifery or other MLCC models of
care are likely to receive fewer interventions, with com-
parable or even better outcomes, compared to women in
shared care models [3]. In this study we define caseload
midwifery care as a MLCC model in which one-to-one
continuity of care throughout pregnancy, childbirth and
the postpartum period is guaranteed by a single midwife,
with backup provided by a partner midwife and in good
collaboration with other professionals. A full-time case-
load midwife typically provides care to approximately
35–45 women per year [3]. The way caseload care is de-
fined and organised varies with the context of the exist-
ing maternity care system. Caseload midwives may be
self-employed or employed by a hospital or a cooper-
ation such as one2one.org in the United Kingdom (UK).
Achieving better continuity of care by implementing
caseload midwifery has gained attention in various coun-
tries and maternity care systems, such as the United
Kingdom [4]; Denmark [5]; Sweden [6], Australia [7]. In
New Zealand, caseload midwifery is the predominant
model of maternity care [8].
Caseload midwifery is not the dominant model in
Dutch maternity care. Most women do not experience
midwife-led continuity of care throughout the antenatal,
natal and postnatal period [9]. Primary care midwives
provide care to the vast majority of women, but if com-
plications arise or are expected, women are referred to
obstetrician-led care and the maternity care team in the
hospital [10,11]. Obstetric interventions such as
pharmaceutical pain relief, induction or augmentation of
labour are only available after a referral to obstetrician-
led care. Although midwives can choose to stay involved
in the care, especially after a referral during labour, these
referrals usually lead to discontinuity of care, giving rise
to less positive experiences [12,13] and loss of sense of
control [14]. Referral rates in the Netherlands have been
rising since the eighties [10,15,16]. Current referral
rates during labour are higher in comparison with pri-
mary midwifery care in the UK [17], without clear bene-
fits for health outcomes [15].
Although primary maternity care in the Netherlands is
midwife-led, relational continuity of care in primary
midwife-led care is limited. Primary care midwives are
mainly self-employed, and practice in teams of three to
five midwives or more [18]. On average, a primary mid-
wifery care practice is involved in the care of 90 to 100
women annually per participating midwife [19]. Mid-
wives typically work in shifts of 24 or 12 h, sharing ante-
natal, natal, and postnatal care for the complete caseload
of the practice with their team. For example, a woman
who is cared for in a practice with a team of three mid-
wives may have seen all three midwives antenatally. Each
midwife in such a practice will give her share of the
antenatal consultations to most of the 300 pregnant
women who attend this practice annually. A woman
who is referred to obstetrician-led care antenatally usu-
ally will not see her own midwife during childbirth. A
woman who is still in primary midwife-led care when
her labour starts, does not know which of the three mid-
wives in the practice will attend her birth. During holi-
days, this could be an unknown substitute midwife.
Altogether, this means that many women cared for in a
group practice –which we will refer to as “regular pri-
mary midwifery care”–do not receive one-to-one con-
tinuity of care.
As a result of their preference to provide one-to-one
continuity of care to a smaller number of clients, some
primary care midwives in the Netherlands changed the
way they organized their practices and began to offer
caseload midwifery care. In our ongoing interview study
with these midwives, we are learning more about their
practices and motivation (Offerhaus PM, Jans S, Nieu-
wenhuijze MJ. The perspective of Dutch caseload mid-
wives on their model of care. In preparation). Caseload
midwives may offer extra antenatal consultations, and
usually agree to be present at birth even if a referral is
made and an obstetrician is the lead caregiver. The de-
sire to offer caseload midwifery care seems to emerge
from a personal desire to provide truly woman-centred
care with a more personal and continuous service to
pregnant women [20–23]. Caseload midwifery meets the
need of women in search of a “personal”midwife, some-
times because of a concern that certain wishes will be
denied in the course of regular care [24]. For instance,
some women entrust their care to a caseload midwife
because they prefer a homebirth despite receiving med-
ical advice to birth in an obstetrician-led setting [25].
Apart from these observations, little is known about
caseload midwifery care in the Netherlands. There is no
formal description or definition of caseload midwifery
care in the Dutch setting, and an accurate estimate of
the actual number of caseload midwives does not exist.
Furthermore, the outcomes of this type of care have not
been evaluated. One study suggests that women in small
midwifery practices run by one or two midwives experi-
ence fewer intrapartum referrals and fewer interventions
compared to women in group practices [26]. This study
by Fontein confirms that women in small practices know
their midwife better, are more often accompanied by
their own midwife throughout birth, even when referred
to obstetrician-led care, and are more satisfied with the
care received. However, this study surveyed women in
midwife-led care at the start of labour and did not spe-
cifically address caseload midwifery care or the care
Offerhaus et al. BMC Pregnancy and Childbirth (2020) 20:517 Page 2 of 11
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
given throughout pregnancy and birth. If caseload mid-
wifery care is to be sustained or even expanded within
the Dutch maternity care system, evaluation of this type
of care is essential. The objective of our study is to con-
tribute to this evaluation by describing the outcomes of
caseload midwifery care compared to regular midwife-
led care in the Netherlands in terms of maternal and
perinatal outcomes, and antenatal and intrapartum refer-
rals to obstetrician-led care.
Methods
Study population
The data used in our study came from the Netherlands
Perinatal Registry (Perined). The registry routinely col-
lects and combines data on antenatal, intrapartum and
postnatal care from four separate national registries; one
for primary midwife-led care (LVR1), one for maternity
care by general practitioners (LVR1h), one for
obstetrician-led care (LVR2), and one for neonatal care
(LNR). The Netherlands Perinatal Registry contains data
on approximately 98% of all births in the Netherlands
[16]. We selected all women who gave birth in 2015 and
received antenatal care in a primary midwifery practice
in the Netherlands. Exclusion criteria were birth at a
gestational age under 28 weeks, or an antenatal transfer
to secondary or tertiary care for pregnancy complica-
tions before 28 weeks. In this way we ensured that
women experiencing serious medical problems in early
pregnancy are not included. The study population, being
in primary midwife-led care at 28 weeks of pregnancy, is,
by definition, considered to be low risk.
Identification of caseload women
Caseload midwives throughout the Netherlands were
identified with a snowball method, starting from the
professional network of the first author (PO). All poten-
tial participants were contacted and were included if
their practice description fit the caseload definition [3],
based on a short questionnaire. Midwives working in a
team or as a couple were included only if they offered
24/7 one-to-one continuity of care throughout preg-
nancy and birth. Midwives working according to an
agreed schedule or duty roster and who shared their cli-
ents with their colleagues –a customary arrangement in
regular midwifery practices - were excluded from the
caseload group. Participating caseload midwives gave in-
formed consent and voluntary disclosed their LVR1
practice registration number, to enable the researchers
to anonymously identify caseload clients in the study
population.
Identification of matched controls
Based on personal communication with caseload mid-
wives, we expected their clients to be more often
multiparous, older, with a higher social-economic status
(SES) and more often of a Dutch background, compared
to women in regular care. To reduce confounding and
enhance comparability of characteristics in the study
population, we matched each woman in caseload care to
three women in regular midwife-led care. We used par-
ity (0, 1 or more), maternal age (six categories) and
background (Dutch or non-Dutch) as matching vari-
ables. Since SES is measured on neighborhood level only
in the Perined database, we decided not to use SES as a
matching variable. Because serious regional variation in
maternity care has been described in the Netherlands
[27,28] we also included the postal code (first two out
of four digits) in the matching procedure to minimize
confounding based on these regional differences. Exact
matching was performed randomly using SPSS for Win-
dows, version 22.
Characteristics and outcome variables
The following maternal characteristics were collected
from the database: maternal age; parity; ethnic back-
ground (Dutch or non-Dutch); SES and level of urban-
isation of the neighbourhood in which women were
living were determined using the four digits of the postal
code [29]. The characteristics of birth we collected were:
planned and actual place of birth, gestational age at
birth, birthweight, multiple pregnancy and foetal presen-
tation at birth. To explore whether women in caseload
care may have switched to a caseload midwife at a later
stage after starting their care in another midwifery prac-
tice or a secondary care hospital team [25], we also col-
lected the gestational age at intake in the practice that
recorded the birth.
The primary outcomes of interest were antenatal or
intrapartum referral to obstetrician-led care and mode
of birth (spontaneous vaginal, instrumental vaginal or
caesarean). Other outcomes of interest were inductions
of labour, maternal morbidity (blood loss and perineal
trauma) and perinatal outcomes (perinatal mortality and
Apgar score). In a sub-analysis among low risk women
who were in midwife-led care at the start of labour, we
also observed interventions during childbirth (augmenta-
tion of labour, pharmaceutical pain relief and
episiotomy).
Analysis
All analyses of outcomes are presented separately for
nulliparous and multiparous women. In the main ana-
lysis, we used inferential statistics (Chi square; two-sided
t-test) to compare the outcomes for women in caseload
care and regular care. To capture the differences be-
tween intrapartum care in caseload and regular prac-
tices, we performed an exploratory sub-analysis among
low risk women who started labour in midwife-led care.
Offerhaus et al. BMC Pregnancy and Childbirth (2020) 20:517 Page 3 of 11
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
For this sub-analysis we excluded all women who experi-
enced an antenatal referral after 28 weeks and women
with the following risk factors: gestational age < 37 or >
42 weeks, non-vertex presentation, and multiple preg-
nancy. Given these exclusions, we could no longer use
our matching procedure; for this reason we used only
descriptive statistics (percentages) to illustrate the differ-
ences between the two groups.
Results
We identified 33 midwives that fulfilled the description
of caseload midwifery care. Among them 23 had a LVR1
practice registration number in 2015, individually or to-
gether with other caseload midwives. Six midwives
started practice registration in 2016, and another four
did not provide a practice registration number. These 10
were excluded from the study.
Characteristics of caseload clients
The national database contained the records of 127,818
women in midwife-led care at a gestational age of 28
weeks and beyond. Of these women, we included all 657
women that were registered by caseload midwives in our
study. The matched cohort contained 1954 women in
regular midwifery care. If the matching procedure had
been fully successful, the matched cohort would have
contained 1971 controls. This means we missed 17 con-
trols (0,9%). All cases had at least one exact match.
Women in caseload care were slightly older (mean
31.6 vs 30.4 year) when compared to women in the total
national cohort, they more often had a Dutch back-
ground (79.5% vs 75.6%), and were somewhat more
often nulliparous (48.6% vs 45.8%). These and other
characteristics are shown in Table 1.
After matching for parity, age and background, women
in caseload care showed some differences in other
demographic characteristics with the women in regular
care. They more often lived in a neighbourhood with a
higher SES (24.8% vs 19.6%), more often in an urban
neighbourhood (29.5% vs 18.4%) and less often in a rural
neighbourhood (14.2% vs 23.9%). There were no signifi-
cant differences in mean birthweight, birthweight cat-
egories, small for gestational age (<percentile 5) or large
for gestational age (>percentile 95).
Other characteristics seem to confirm that women in
caseload care are a distinct group. They more often
opted for a home birth (44.5%% vs 20.3%), and more
often had a late intake in the practice (11.4% vs 2.1% at
≥28 weeks), likely an indication of a switch in care pro-
vider during antenatal care. Gestational age at birth was
slightly higher (39.5 vs 39.3 weeks; p-value 0.004), and
more women in caseload care gave birth at or after 42 +
0 weeks (5.2% vs 1.6%). This suggests that they more
often opted for expectant management in case of a
prolonged pregnancy, despite existing recommendations
in the Netherlands [29].
Primary outcomes
Outcomes of women in caseload care were compared to
the matched cohort (Table 2). We found that women in
caseload care were less often referred to obstetrician-led
care (p-value < 0.001). A small majority (53.1%) stayed in
primary midwife-led care without a referral to
obstetrician-led care (nulliparous women: 40.3%; multip-
arous women: 65.2%), compared to 34.3% in the
matched cohort (nulliparous women 23.8%; multiparous
women: 44.2%). The overall referral rate was 46.9% in
the caseload group and 65.7% in the matched cohort. A
lower referral rate was observed both in the antenatal
period and in the intrapartum period, for nulliparous
and for multiparous women. In the antenatal period,
24.2% of women in caseload care experienced a referral
to obstetrician-led care and 22.8% were referred intra-
partum, versus 37.4 and 28.3% in regular care.
Mode of birth also differed between women in case-
load care and in the matched cohort (p-value 0.001).
Women in caseload care more often (84.0% vs 77.0%)
experienced a spontaneous vaginal birth (nulliparous
women: 75.2% vs 68.3%, multiparous women: 92.3% vs
85.0%), and less often (9.4% vs 14.2%) a caesarean sec-
tion (nulliparous women: 13.5% vs 16.0%, multiparous
women: 5.6% vs 12.6%).
Other outcomes
Interventions at the start of labour differed between the
two groups (p-value < 0.001). Women in caseload care
were more likely to experience a spontaneous start of
labour (83.7%) compared to women in regular care
(73.2%). They were less often induced (13.2% vs 21.0%)
and less often had an elective caesarean section (3.0% vs
5.8%). A similar pattern existed for nulliparous and mul-
tiparous women. The place of birth was also different
(p-value 0.001). A larger proportion of women in case-
load care had an out-of-hospital birth (39.4% at home
and 2.1% in a birth centre) compared to women in regu-
lar care (16.1% at home and 1.6% in a birth centre).
More multiparous women than nulliparous women had
an out-of-hospital birth, both in caseload practices and
in regular care. The larger proportion of hospital births
in obstetrician-led care in regular care (66.1% vs 47.5%)
reflects the higher referral rate discussed earlier. A post-
partum haemorrhage (> 1000 ml) occurred in 5.0% (nul-
liparous women 6.9%; multiparous women 3.3%) versus
6.9% in the regular care group (nulliparous women 8.3%;
multiparous women 5.6%). This difference was not sta-
tistically significant (p-value 0.088). Fewer women in
caseload care experienced an episiotomy (16.0% vs
26.4%, p-value < 0.001) and more had an intact
Offerhaus et al. BMC Pregnancy and Childbirth (2020) 20:517 Page 4 of 11
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Table 1 Maternal and pregnancy characteristics of women in primary midwifery care at 28 weeks and beyond
National Caseload practices Matched controls p-value
(caseload vs
matched)
n= 127,818 n= 657 n= 1954
Maternal age na
a
Mean 30.4 (SD 4.6) 31.6 (SD 4.5) 31.4 (SD 4.4)
< 25 13,197 (10.3%) 32 (4.9%) 99 (5.1%)
25–29 41,138 (32.2%) 192 (29.2%) 567 (29.0%)
30–34 49,438 (38.7%) 272 (41.4%) 814 (41.7%)
35–39 20,885 (16.3%) 132 (20.1%) 393 (20.1%)
≥40 3160 (2.5%) 29 (4.4%) 81 (4.1%)
Parity na
a
(missing: 2) 0 58,608 (45.8%) 319 (48.6%) 940 (48.1%)
1 46,010 (36.0%) 240 (36.5%) 722 (36.9%)
≥2 23,198 (18.1%) 98 (14.9%) 292 (14.9%)
Background na
a
Dutch 96,589 (75.6%) 522 (79.5%) 1555 (79.6%)
Non Dutch 31,229 (24.4%) 135 (20.5%) 399 (20.4%)
SES 0.019
b
(missing 574) 1 (low) 41,146 (32.3%) 237 (36.7%) 757 (39.0%)
2 (intermediate) 55,949 (44.0%) 248 (38.4%) 802 (41.4%)
3 (high) 30,149 (23.7%) 160 (24.8%) 380 (19.6%)
Urbanisation < 0.001
b
(missing 206) Very urban 31,693 (24.8%) 184 (28.1%) 539 (27.6%)
Urban 32,707 (25.6%) 193 (29.5%) 360 (18.4%)
Semi-urban 23,989 (18.8%) 65 (9.9%) 253 (13.0%)
Rural 21,991 (17.2%) 93 (14.2%) 467 (23.9%)
Very Rural 17,232 (13.5%) 119 (18.2%) 333 (17.1%)
Gestational age at intake in practice < 0.001
b
(missing 1206) ≤12 112,767 (89.1%) 480 (73.2%) 1770 (90.6%)
13–27 10,578 (8.4%) 101 (15.4%) 131 (6.7%)
28–36 2763 (2.2%) 57 (8.7%) 37 (1.9%)
≥37 wk 506 (0.4%) 18 (2.7%) 3 (0.2%)
Antenatally planned place of birth < 0.001
b
(missing 3269) home 27,111 (21.8%) 291 (44.5%) 387 (20.3%)
birthcentre 12,666 (10.2%) 28 (4.3%) 87 (4.6%)
hospital 70,322 (56.5%) 272 (41.6%) 1177 (61.6%)
undecided 14,450 (11.6%) 63 (9.6%) 259 (13.6%)
Gestational age at birth in weeks < 0.001
b
(missing 1432) <37
0
5121 (4.1%) 20 (3.1%) 80 (4.1%)
37–41
6
119,429 (94.5%) 601 (91.8%) 1829 (94.2%)
≥42
0
1836 (1.5%) 34 (5.2%) 32 (1.6%)
Mean 39.3 (SD 1.5) 39.5 (SD 1.6) 39.3 (SD 1.5) 0.004
c
Birthweight (gram)
(missing 796) Mean 3469 (SD 513) 3.495 (SD 499) 3.475 (SD 508) 0.382
c
SGA (<p5) 4575 (3.6%) 26 (4.0%) 61 (3.1%) 0.302
b
LGA (>p95) 5765 (4.5%) 26 (4.0%) 82 (4.2%) 0.790
b
Offerhaus et al. BMC Pregnancy and Childbirth (2020) 20:517 Page 5 of 11
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
perineum (41.3% vs 28.2%; p-value < 0.001). There was
no significant difference in 3rd or 4th degree perineal
ruptures (2.4% vs 2.8%; p-value 0.687). Nulliparous
women were more likely to experience perineal damage
compared to multiparous women, both in the caseload
group and in the matched cohort.
Unfavourable perinatal outcomes were rare in both
groups. Perinatal mortality occurred in one case (0.2%)
in the caseload group and in seven cases (0.4%) in the
matched cohort. A low Apgar score (< 7 at 5 min) was
registered in 8 cases (1.2%) in the caseload group and in
35 cases (1.8%) in the matched cohort. These differences
were not statistically significant.
Sub-analysis: intrapartum care
In a sub-analysis we analysed births of women who had
no antenatal referral to obstetrician-led care, describing
births attended by a primary care midwife in caseload
care (n= 496) and births from the regular care group
(n= 1214). We excluded 39 (7.9%) births with a known
risk factor (23 pregnancies ≥42 weeks) from the caseload
group and 73 (6.0%; 7 pregnancies ≥42 weeks) from the
regular care group (see Fig. 1for a flowchart). As a result
of this selection of women without known risk factors at
the start of term labour, the groups are no longer
matched and the results should be interpreted with
caution.
Results are displayed in Table 3. In this sub-analysis
the lower intrapartum referral rate in caseload care
among nulliparous women (42.6% vs 63.0%) and multip-
arous women (13.3% vs 25.7%) is largely explained by a
lower referral rate in the first stage of labour: 24.1% vs
44.4% for nulliparous women and 11.2% vs 19.8% for
multiparous women. Both nulliparous and multiparous
women in caseload care experienced fewer interventions
during labour, and more often had a spontaneous vagi-
nal birth. As in the main analysis, maternal morbidity
was lower in the caseload group.
Discussion
Our study shows that in the Netherlands, when com-
pared with regular midwife-led care, caseload midwife-
led care was associated with considerably fewer referrals
to obstetrician-led care –both antenatally and in the
intrapartum period –and with more spontaneous vagi-
nal births. These results were found for both nulliparous
and multiparous women. Furthermore, we observed
fewer interventions during labour and birth and less ma-
ternal morbidity in caseload midwifery care. The inci-
dence of perinatal mortality or a low Apgar score were
low in both groups.
Methodological considerations
The main challenge in this comparison of results from
caseload care and regular midwife-led care is the com-
parability of women in both groups. Women were in-
cluded when in primary care at 28 weeks gestation and
are therefore likely to have a relatively low risk profile.
Several factors may still cause differences in risk profiles,
although our matching procedure successfully mini-
mized confounding by parity, age, or background. To
control for regional variation in interventions we added
the first two digits of the postal code in the matching
procedure. Because our measure for SES and
urbanization both are based on the postal code as well,
we chose not to match on these variables. Based on the
somewhat higher SES in the caseload group compared
to the matched controls in regular care, a slightly more
favorable risk profile cannot be ruled out. We could also
not describe, nor control for, risk factors such as obesity,
smoking or other life style factors since these are not re-
liably registered in the Perined database. On the other
hand, we observed no important differences in preterm
births, mean birthweight, and SGA (<p5) between the
national cohort, the caseload group and the matched co-
hort. Therefore, we assume that the risk profiles of the
caseload group and the matched cohort are not very dif-
ferent and do not lead to important bias.
Table 1 Maternal and pregnancy characteristics of women in primary midwifery care at 28 weeks and beyond (Continued)
National Caseload practices Matched controls p-value
(caseload vs
matched)
n= 127,818 n= 657 n= 1954
Birthweight Categories 0.424
b
< 2500 4267 (3.3%) 12 (1.8%) 52 (2.7%)
2500–4500 120,844 (94.7%) 630 (96.0%) 1863 (95.3%)
> 4500 2459 (1.9%) 14 (2.1%) 35 (1.8%)
Multiple pregnancy 135 (0.1%) 1 (0.2%) 3 (0.2%)
Non-vertex presentation at birth breech 3881 (3.0%) 15 (2.3%) 58 (3.0%)
other / unknown 2746 (2.1%) 8 (1.2%) 42 (2.1%)
a
not applicable, matching variable
b
Chi Square
c
Two-sided t-test
Offerhaus et al. BMC Pregnancy and Childbirth (2020) 20:517 Page 6 of 11
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Nevertheless, women in caseload care may be differ-
ent from women in regular care in other important
ways that cannot easily be assessed. The observed
characteristics confirm that women in caseload care
are a distinct group, with a higher than average mo-
tivation for a physiological birth, including homebirth
and expectant management in prolonged pregnancy
beyond 42 gestational weeks. Seeking the care of a
caseload midwife may be a part of this inclination
[25]. It is not possible to assess to what extent these
preferences resulted in continuation of primary care
or opting for homebirths in situations that usually
lead to referral to secondary care in the hospital. We
did find a slightly higher percentage of women with
known risk factors- mainly gestational age ≥42 weeks
- in the caseload group. Altogether, the lower referral
and intervention rate we found will at least partly be
a result of specific preferences among this group of
women.
The study is too small for a reliable comparison in
perinatal mortality or serious perinatal morbidity,
since these outcomes are rare. At the same time, our
results do not suggest that perinatal safety is compro-
mised in caseload care: percentages of both perinatal
mortality and low Apgar scores in the caseload and
control groups in the caseload and control groups
Table 2 Outcomes for women in caseload midwifery care and regular midwifery care
All women p-value Chi square Nulliparous women Multiparous women
Caseload
practices
Matched
cohort
Caseload
practices
Matched
cohort
Caseload
practices
Matched
cohort
n= 657 n= 1954 n= 319 n= 940 n= 338 n= 1014
Referrals < 0.001
no referral 347 53.1% 666 34.3% 128 40.3% 222 23.8% 219 65.2% 444 44.2%
antenatal 158 24.2% 725 37.4% 77 24.2% 328 35.1% 81 24.1% 397 39.5%
intrapartum 149 22.8% 548 28.3% 113 35.5% 384 41.1% 36 10.7% 164 16.3%
(missing: 18)
Mode of birth 0.001
spontaneous vaginal 552 84.0% 1492 77.0% 240 75.2% 636 68.3% 312 92.3% 856 85.0%
vaginal instrumental 43 6.5% 170 8.8% 36 11.3% 146 15.7% 7 2.1% 24 2.4%
caesarean section 62 9.4% 276 14.2% 43 13.5% 149 16.0% 19 5.6% 127 12.6%
(missing: 16)
Start of labour < 0.001
Spontaneous 550 83.7% 1431 73.2% 263 82.4% 709 75.4% 287 84.90% 722 71.2%
Induction 87 13.2% 410 21.0% 47 14.8% 187 19.9% 40 11.8% 223 22.0%
amniotomy only 19 2.9% 78 4.0% 6 1.9% 27 2.9% 13 3.80% 51 5.0%
hormonal/foley/oxytocin 68 10.4% 332 17.0% 41 12.9% 160 17.0% 27 8.00% 172 17.0%
Caesarean section 20 3.0% 113 5.8% 9 2.8% 44 4.7% 11 3.30% 69 6.8%
Actual place of birth < 0.001
home 259 39.4% 314 16.1% 92 28.8% 95 10.1% 167 49.4% 219 21.6%
birthcentre 14 2.1% 31 1.6% 6 1.9% 12 1.3% 8 2.4% 19 1.9%
hospital (primary care) 72 11.0% 318 16.3% 28 8.8% 113 12.0% 44 13.0% 205 20.2%
hospital (secondary care) 312 47.5% 1291 66.1% 193 60.5% 720 76.6% 119 35.2% 571 56.3%
Maternal outcomes
PPH > 1000 ml 33 5.0% 135 6.9% 0.088 22 6.9% 78 8.3% 11 3.3% 57 5.6%
intact perineum (vaginal births) 246 41.3% 468 28.2% < 0.001 85 30.8% 164 21.0% 161 50.5% 304 34.5%
Episiotomy (vaginal births) 95 16.0% 438 26.4% < 0.001 74 26.8% 336 43.0% 21 6.6% 102 11.6%
3rd/4th perineal tear (vaginal births) 14 2.4% 47 2.8% 0.687 12 4.3% 35 4.5% 2 0.6% 12 1.4%
Perinatal outcomes
Perinatal mortality 1 0.2% 7 0.4% 0.408 1 0.3% 5 0.5% 0 –2 0.2%
Apgar 5 min < 7 8 1.2% 35 1.8% 0.318 6 1.9% 21 2.2% 2 0.6% 14 1.4%
Offerhaus et al. BMC Pregnancy and Childbirth (2020) 20:517 Page 7 of 11
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Table 3 Outcomes in caseload and regular care for women who started labour in primary care (37–42 wk, singleton, vertex)
Nulliparous women Multiparous women
Caseload practices Regular midwife-led care Caseload practices Regular midwife-led care
n= 216 n= 565 n= 241 n= 576
No intrapartum referral 124 57.4% 209 37.0% 209 86.7% 428 74.3%
Intrapartum referral 92 42.6% 356 63.0% 32 13.3% 148 25.7%
1st stage 52 24.1% 251 44.4% 27 11.2% 114 19.8%
2nd stage 21 9.7% 63 11.2% 3 1.2% 7 1.2%
other/ unclear 19 8.8% 42 7.4% 2 0.8% 27 4.7%
Interventions during labour
amniotomy 61 28.2% 236 42.7% 61 25.4% 289 50.8%
augmentation 51 23.8% 215 38.4% 12 5.0% 60 10.5%
pharmaceutical pain relief 42 20.8% 193 35.4% 9 3.8% 48 8.5%
episiotomy 40 18.5% 220 38.9% 8 3.3% 48 8.3%
Mode of birth
spontaneous 181 83.8% 425 75.9% 234 97.1% 555 96.7%
vaginal instrumental 21 9.7% 93 16.6% 3 1.2% 11 1.9%
caesarean section 14 6.5% 42 7.5% 4 1.4% 8 1.4%
Maternal outcomes
PPH > 1000 cc 15 6.9% 40 7.1% 8 3.3% 27 4.7%
Perineum intact (vaginal births only) 67 33.2% 109 21.0% 122 51.5% 201 35.5%
3rd/4th perineal tear (vaginal births only) 9 4.5% 24 4.6% 1 0.4% 7 1.2%
Fig. 1 Flowchart exclusions for sub-analysis ‘midwife-led care at start of labour’
Offerhaus et al. BMC Pregnancy and Childbirth (2020) 20:517 Page 8 of 11
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
were similar. In a larger, preferably prospective, study
it would be interesting to analyze perinatal results
with the possibility to control for several risk factors
including maternal lifestyle and to audit cases with
severe perinatal morbidity or mortality.
While our study has certain methodological limitations
–e.g. self-selection –our results are supported by high
quality studies of caseload midwifery care. For instance,
randomized trials [1,2,30,31] showed no differences in
neonatal outcomes such as low Apgar scores or admis-
sion to neonatal intensive care. A meta-analysis showed
a higher spontaneous vaginal birth rate in caseload mid-
wifery care [3]. Observational studies of caseload mid-
wifery in various settings consistently show fewer
interventions during childbirth, without compromising
perinatal safety [32–35].
Continuity of care: empowering women for childbirth
We were not able to assess the level of one-to-one
continuity of care in the caseload group because this
information is not available in the Perined database.
However, we are confident that the majority of the
caseload clients received a high level of continuity of
care throughout pregnancy and childbirth. In the in-
clusion procedure, participating midwives confirmed
that they remained involved in the care when ante-
natal obstetric consultation or referral was needed,
and all offered continuity of care during labour, even
when there was an intrapartum referral. Most of them
also inform women of this service on their practice
website. Fontein [26] observed a similar pattern in
practices with one or two midwives, where continuity
of care was higher, and the midwife-woman relation-
ship was experienced more positively when compared
to group practices.
A recent meta-synthesis of 13 qualitative articles
examining women’s perspectives on continuity of care
models confirms the importance of such relationships
for women, concluding that ‘the midwife–woman rela-
tionship is the vehicle through which trust is built, per-
sonalised care is provided, and the woman feels
empowered’[36]. Fontein et al. describe this type of rela-
tionship as a key feature of woman-centered care [37].
Such relationships are more likely to evolve in continuity
models than in fragmented care offered in busy institu-
tions or by large midwifery teams [38]. Indeed, caseload
midwives in the Netherlands report that they offer this
kind of woman-centered care [20–23] in order to
strengthen women and give them more control in the
care process [39]. Our data suggest that a strong
woman-centered model of care –with the midwife in a
supporting and facilitating role –results in more control
by women themselves and a more optimal, less medical-
ized pregnancy and birth process, with no compromise
in perinatal safety. Improving woman-centeredness is an
important point in the quality improvement agenda for
maternity care in the Netherlands [40]. Based on our re-
sults, finding ways to implement caseload midwifery on
a larger scale should be considered.
Conclusion
Our study found that caseload midwifery care in the
Netherlands is associated with a lower referral rate to
obstetrician-led care –both antenatally and in the
intrapartum period –and more spontaneous vaginal
births compared to regular midwife-led care, without
any indications that perinatal safety is compromised.
Our findings are in line with the growing body of evi-
dence on the importance of continuity of midwife-led
care [3,41]. A larger scale prospective study is
needed to provide more definitive evidence on peri-
natal and maternal outcomes of caseload care and to
provide insights in the lower referral rate to
obstetrician-led care and in the cost-effectiveness of
the caseload model in the context of Dutch maternity
care. Such a study should also examine women’sper-
spectives on this model of care in the Netherlands. If
the results of a larger study mirror our findings, the
challenge will be to make this model available and af-
fordable for more women in the Netherlands.
Abbreviations
LNR: Landelijke Neonatale Registratie (National Neonatal Registry);
LVR: Landelijke Verloskundige Registratie (National Perinatal Registry);
MLCC: Midwife-Led Continuity of Care; SES: Social-economic status;
UK: United Kingdom
Acknowledgements
We acknowledge the caseload midwives for their consent for the analysis
with their data. We thank Sonja Roosma for her help in preparing the data
and the matching procedure, and we thank Perined for their support in
working with the database. We thank the KNOV Scientific Committee for the
opportunity to work on this project.
Authors’contributions
All authors (PO, SJ, CH, RdV, MN) contributed to the conception and design
of the study. PO, CH performed the statistical analysis. All authors were
involved in the interpretation of the data and results. PO and SJ drafted the
manuscript. All authors read and approved the final manuscript.
Funding
This study is performed as part of a fellowship program followed by the first
author (PO). The fellowship is funded by the KNOV (Royal Dutch
Organization of Midwives), and approved by the KNOV Scientific Committee.
The KNOV nor the KNOV Scientific Committee had any role in performing
the study or in writing the manuscript.
Availability of data and materials
The data that support the findings of this study are available from Perined
but restrictions apply to the availability of these data, which were used
under license for the current study, and so are not publicly available. Data
are however available from the first author upon reasonable request and
with permission of Perined.
Ethics approval and consent to participate
Participating midwives gave written informed consent for the anonymous
use of their LVR1 practice registration numbers, thereby conforming to
Offerhaus et al. BMC Pregnancy and Childbirth (2020) 20:517 Page 9 of 11
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
privacy regulations of the Perined registry who gave permission for the use
of the database for this analysis. Because of its non-invasive nature, this type
of research does not require further ethical approval in the Netherlands.
Consent for publication
Not applicable.
Competing interests
One of the authors, dr. M. Nieuwenhuijze, is a member of the editorial board
of BMC Pregnancy and Childbirth.
Author details
1
Research Centre for Midwifery Science, Midwifery Education and Studies
Maastricht, ZUYD University, Universiteitssingel 60, 6229 ER Maastricht, the
Netherlands.
2
TNO, Department of Child Health, Schipholweg 77, 2316 ZL
Leiden, The Netherlands.
3
Perined, Mercatorlaan 1200, 3528 BL Utrecht, the
Netherlands.
4
CAPHRI (School for Public Health and Primary Care), Maastricht
University, PO Box 616, 6200 MD Maastricht, the Netherlands.
5
Center for
Bioethics and Social Sciences in Medicine, University of Michigan Medical
School, 2800 Plymouth Road, Building 14, CBSSM, Ann Arbor, MI 48109-2800,
USA.
Received: 4 June 2019 Accepted: 21 August 2020
References
1. McLachlan HL, Forster DA, Davey MA, Farrell T, Gold L, Biro MA, Albers L,
Flood M, Oats J, Waldenström U. Effects of continuity of care by a primary
midwife (caseload midwifery) on caesarean section rates in women of low
obstetric risk: the COSMOS randomised controlled trial. Br J Obstet
Gynaecol. 2012;119(12):1483–92.
2. Tracy SK, Hartz DL, Tracy MB, Allen J, Forti A, Hall B, White J, Lainchbury A,
Stapleton H, Beckmann M, et al. Caseload midwifery care versus standard
maternity care for women of any risk: M@NGO, a randomised controlled
trial. Lancet (London, England). 2013;382(9906):1723–32.
3. Sandall J, Soltani H, Gates S, Shennan A, Devane D. Midwife-led continuity
models versus other models of care for childbearing women. Cochrane
Database Syst Rev. 2016;4:Cd004667.
4. National Maternity Review: Better Births: Improving outcomes of maternity
services in England. NHS; 2016.
5. Burau V, Overgaard C. Caseload midwifery as organisational change: the
interplay between professional and organisational projects in Denmark.
BMC Pregnancy Childbirth. 2015;15:121.
6. Hildingsson I, Rubertsson C, Karlstrom A, Haines H. Caseload midwifery for
women with fear of birth is a feasible option. Sex Reprod Healthc. 2018;16:
50–5.
7. Dawson K, McLachlan H, Newton M, Forster D. Implementing caseload
midwifery: exploring the views of maternity managers in Australia - a
national cross-sectional survey. Women Birth. 2016;29(3):214–22.
8. Gunn GAM-CJ, Susan JC, Macgreggor HM, Claire DH. Midwifery practice
arrangements which sustain caseloading Lead Maternity Carer midwives in
New Zealand. New Zealand Coll Midwives J. 2015;51:7.
9. Wiegers TA. The quality of maternity care services as experienced by
women in the Netherlands. BMC Pregnancy Childbirth. 2009;9(1):18.
10. Amelink-Verburg MP, Rijnders MEB, Buitendijk S. A trend analysis in referrals
during pregnancy and labour in Dutch midwifery care 1988-2004. Br J
Obstet Gynaecol. 2009;116:923–32.
11. CVZ. Verloskundig vademecum. Eindrapport van de Commissie Verloskunde
van het College voor Zorgverzekeringen. [Obstetrical manual Final report of
the Obstetric working Group of the National Health Insurance Board CVZ].
Diemen: CVZ; 2003.
12. Rijnders M, Baston H, Schonbeck Y, van der Pal K, Prins M, Green J,
Buitendijk S. Perinatal factors related to negative or positive recall of birth
experience in women 3 years postpartum in the Netherlands. Birth
(Berkeley, Calif). 2008;35(2):107–16.
13. Hitzert M, Hermus MA, Scheerhagen M, Boesveld IC, Wiegers TA, van den
Akker-van Marle ME, van Dommelen P, van der Pal-de Bruin KM, de Graaf
JP. Experiences of women who planned birth in a birth Centre compared
to alternative planned places of birth. Results of the Dutch birth Centre
study. Midwifery. 2016;40:70–8.
14. Geerts C, Klomp T, Lagro-Janssen A, Twisk J, van Dillen J, de Jonge A. Birth
setting, transfer and maternal sense of control: results from the DELIVER
study. BMC Pregnancy Childbirth. 2014;14(1):27.
15. Offerhaus PM, Hukkelhoven CWPM, de Jonge A, van der Pal-de Bruin K,
Scheepers PLH, Lagro-Janssen ALM. Persisting rise in referrals during labor
in primary midwife-led care in the Netherlands. Birth (Berkeley, Calif). 2013;
40(3):192–201.
16. Perined. Perinatal care in the Netherlands 2017. Utrecht; 2019. Available at
https://www.perined.nl/publicaties1/publicaties/jaarboeken. Accessed 28
May 2019.
17. de Jonge A, Peters L, Geerts CC, van Roosmalen JJM, Twisk JWR,
Brocklehurst P, Hollowell J. Mode of birth and medical interventions among
women at low risk of complications: a cross-national comparison of birth
settings in England and the Netherlands. PLoS One. 2017;12(7):e0180846.
18. Kenens RJB, Batenburg R, Kasteleijn A. Cijfers uit de registratie van
verloskundigen: peiling 2016. Data from the registration of midwives:
census 2016. Utrecht: NIVEL; 2017.
19. Wiegers TA, Warmelink JC, Spelten ER, Klomp T, Hutton EK. Work and workload
of Dutch primary care midwives in 2010. Midwifery. 2014;30(9):991–7.
20. ten Berge M. Caseload verloskunde of ‘working apart together’. [Caseload
midwifery or ‘working apart together’]. Tijdschrift voor Verloskundigen. 2008;
33(6):4.
21. Visser R. Caseload werken! Working caseload. In: Blog Vroedvrouw en
Radicaal; 2010. Available at https://vroedvrouwenradicaal-rebekka.blogspot.
com/search?q=caseload. Accessed 31 May 2019.
22. Oudshoorn TK. Gré: Zo behouden we de menselijke maat in geboortezorg.
[On keeping the human dimension in maternity care]. Tijdschrift voor
Verloskundigen. 2016;06:2.
23. Verbeek A. Tegen de stroom in: caseload verloskunde in opkomst. [Against
the stream: upcoming caseload midwifery]. Tijdschrift voor Verloskundigen.
2017;42(2):4.
24. Offerhaus P. Caseload midwifery: a new option for Dutch midwives and
their clients. In: Normal labour & Birth Conference. Cumbria: Grange-Over-
Sands; 2017.
25. Hollander M, de Miranda E, van Dillen J, de Graaf I, Vandenbussche F,
Holten L. Women’s motivations for choosing a high risk birth setting against
medical advice in the Netherlands: a qualitative analysis. BMC Pregnancy
Childbirth. 2017;17(1):423.
26. Fontein Y. The comparison of birth outcomes and birth experiences of low-
risk women in different sized midwifery practices in the Netherlands.
Women Birth. 2010;23(3):103–10.
27. RIVM. Zorgbalans 2014. De prestaties van de Nederlandse gezondheidszorg.
Hoofdstuk 2 Zorg rond de geboorte. [Balance of care. The performance of
Dutch Healthcare. Chapter 2: Maternity care]. Bilthoven: RIVM; 2014.
28. Seijmonsbergen-Schermers AE, Zondag DC, Nieuwenhuijze M, Van den
Akker T, Verhoeven CJ, Geerts C, Schellevis F, De Jonge A. Regional
variations in childbirth interventions in the Netherlands: a nationwide
explorative study. BMC Pregnancy Childbirth. 2018;18(1):192.
29. van Andel WG, T.; Faqiri, F. SCP Statusscores 2014. Den Haag: SCP; 2016.
30. Turnbull D, Holmes A, Shields N, Cheyne H, Twaddle S, Gilmour WH, et al.
Randomised, controlled trial of efficacy of midwife-managed care. Lancet
(London, England). 1996;348(9022):213–8.
31. North Staffordshire Changing Childbirth Research Team. A randomised
study of midwifery caseload care and traditional ‘shared-care’. Midwifery.
2000;16(4):295–302.
32. Benjamin Y, Walsh D, Taub N. A comparison of partnership caseload
midwifery care with conventional team midwifery care: labour and birth
outcomes. Midwifery. 2001;17(3):234–40.
33. Tracy SK, Welsh A, Hall B, Hartz D, Lainchbury A, Bisits A, et al. Caseload
midwifery compared to standard or private obstetric care for first time
mothers in a public teaching hospital in Australia: a cross sectional study of
cost and birth outcomes. BMC Pregnancy Childbirth. 2014;14:46.
34. Jepsen I, Juul S, Foureur MJ, Sorensen EE, Nohr EA. Labour outcomes in
caseload midwifery and standard care: a register-based cohort study. BMC
Pregnancy Childbirth. 2018;18(1):481.
35. Maimburg RD. Homebirth organised in a caseload midwifery model with
affiliation to a Danish university hospital - a descriptive study. Sex Reprod
Healthcare. 2018;16:82–5.
36. Perriman N, Davis DL, Ferguson S. What women value in the midwifery
continuity of care model: a systematic review with meta-synthesis.
Midwifery. 2018;62:220–9.
Offerhaus et al. BMC Pregnancy and Childbirth (2020) 20:517 Page 10 of 11
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
37. Fontein-Kuipers Y, de Groot R, van Staa A. Woman-centered care 2.0:
Bringing the concept into focus. Eur J Midwifery. 2018;2:1–2.
38. Finlay S, Sandall J. “Someone’s rooting for you”: continuity, advocacy and
street-level bureaucracy in UK maternal healthcare. Soc Sci Med (1982).
2009;69(8):1228–35.
39. Zeeman K. Bouwen aan vertrouwen. [Building trust]. Tijdschrift voor
Verloskundigen. 2017;41(1):3.
40. CPZ. Agenda voor de geboortezorg 2018-2022. Integrale geboortezorg:
samen bevalt beter. [Maternity care agenda 2018–2022. Integrated
maternity care: births better together]. Utrecht: College Perinatale Zorg
(CPZ); 2017.
41. Sandall J. The contribution of continuity of midwifery care to high quality
maternity care. London: the Royal College of Midwives; 2017. p. 11.
Publisher’sNote
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Offerhaus et al. BMC Pregnancy and Childbirth (2020) 20:517 Page 11 of 11
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
1.
2.
3.
4.
5.
6.
Terms and Conditions
Springer Nature journal content, brought to you courtesy of Springer Nature Customer Service Center GmbH (“Springer Nature”).
Springer Nature supports a reasonable amount of sharing of research papers by authors, subscribers and authorised users (“Users”), for small-
scale personal, non-commercial use provided that all copyright, trade and service marks and other proprietary notices are maintained. By
accessing, sharing, receiving or otherwise using the Springer Nature journal content you agree to these terms of use (“Terms”). For these
purposes, Springer Nature considers academic use (by researchers and students) to be non-commercial.
These Terms are supplementary and will apply in addition to any applicable website terms and conditions, a relevant site licence or a personal
subscription. These Terms will prevail over any conflict or ambiguity with regards to the relevant terms, a site licence or a personal subscription
(to the extent of the conflict or ambiguity only). For Creative Commons-licensed articles, the terms of the Creative Commons license used will
apply.
We collect and use personal data to provide access to the Springer Nature journal content. We may also use these personal data internally within
ResearchGate and Springer Nature and as agreed share it, in an anonymised way, for purposes of tracking, analysis and reporting. We will not
otherwise disclose your personal data outside the ResearchGate or the Springer Nature group of companies unless we have your permission as
detailed in the Privacy Policy.
While Users may use the Springer Nature journal content for small scale, personal non-commercial use, it is important to note that Users may
not:
use such content for the purpose of providing other users with access on a regular or large scale basis or as a means to circumvent access
control;
use such content where to do so would be considered a criminal or statutory offence in any jurisdiction, or gives rise to civil liability, or is
otherwise unlawful;
falsely or misleadingly imply or suggest endorsement, approval , sponsorship, or association unless explicitly agreed to by Springer Nature in
writing;
use bots or other automated methods to access the content or redirect messages
override any security feature or exclusionary protocol; or
share the content in order to create substitute for Springer Nature products or services or a systematic database of Springer Nature journal
content.
In line with the restriction against commercial use, Springer Nature does not permit the creation of a product or service that creates revenue,
royalties, rent or income from our content or its inclusion as part of a paid for service or for other commercial gain. Springer Nature journal
content cannot be used for inter-library loans and librarians may not upload Springer Nature journal content on a large scale into their, or any
other, institutional repository.
These terms of use are reviewed regularly and may be amended at any time. Springer Nature is not obligated to publish any information or
content on this website and may remove it or features or functionality at our sole discretion, at any time with or without notice. Springer Nature
may revoke this licence to you at any time and remove access to any copies of the Springer Nature journal content which have been saved.
To the fullest extent permitted by law, Springer Nature makes no warranties, representations or guarantees to Users, either express or implied
with respect to the Springer nature journal content and all parties disclaim and waive any implied warranties or warranties imposed by law,
including merchantability or fitness for any particular purpose.
Please note that these rights do not automatically extend to content, data or other material published by Springer Nature that may be licensed
from third parties.
If you would like to use or distribute our Springer Nature journal content to a wider audience or on a regular basis or in any other manner not
expressly permitted by these Terms, please contact Springer Nature at
onlineservice@springernature.com
Content uploaded by Pien M Offerhaus
Author content
All content in this area was uploaded by Pien M Offerhaus on Sep 11, 2020
Content may be subject to copyright.
