10 Chapter 1 conditions, population characteristics or patient preferences and occurs despite strong evidence-based recommendations, it is defined as unwarranted (9,11). Unwarranted variation is a problem because it contributes to inequalities in the availability and use of health services. As a result, interventions in childbirth may be used inappropriately, with interventions used too little and too late on the one hand, and interventions used too much and too soon on the other hand (1). Explaining practice variation Practice variation can be explained by a sociological model that describes factors that interact with practice variation at macro-, meso-, and micro-level (12) (Figure 1). Figure 1. Theoretical model for the explanation of medical practice variation (de Jong et al, 2015) Although the model describes mechanisms on different levels, these levels are not isolated but are interrelated with each other. Organisational arrangements at meso-level can, for example, influence individual choices made at microlevel. We will provide further insight into practice variation in maternity care by describing the factors at the different levels of the sociological framework. Within this description we will also link elements of Sutherland’s analytical framework about warranted and unwarranted practice variation (8). Practice variation in maternity care: macro-level The organisation of maternity care in the Netherlands is based on the principle that pregnancy, childbirth, and postpartum care are physiological processes. If risk factors are present, they are identified in time to be monitored and to prevent or treat the pathology they may cause (13). Emphasis is placed on early prevention. Uncomplicated pregnancies of healthy women are cared for by community midwives. Community midwives are autonomous
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