11 General introduction health professionals, usually working in independent practices. They attend home births, uncomplicated hospital births and births in birth centres, and are capable to make autonomous decisions together with the woman about childbirth interventions or the intervention of referral to obstetrician-led care (14). Indications for referral from midwife-led to obstetrician-led care are described in the obstetric indication list of 2003 and multidisciplinary guidelines (15). Midwives are allowed to perform certain interventions, such as artificial rupture of membranes or episiotomies, while other interventions are restricted to obstetrician-led care. There hospital-based midwives and obstetricians provide care for women with specific risk factors or complications and more childbirth interventions are available, such as augmentation of labour, analgesia, and instrumental birth (14). The organisational context can be the basis of practice variation through organisational structures, regulations, population characteristics or resource constraints that influence clinical decision-making (8). The organisation of maternity care in the Netherlands differs from other high-income countries because of the division between midwife-led and obstetrician-led care. This may contribute to practice variation at the macro level: the high rate of home births in the Netherlands compared to rates in other countries (16). In this thesis, we focus on mechanisms that can help explain practice variation at the meso and micro level. We will therefore explain the mechanisms at these levels in more detail. Practice variation in maternity care: meso-level In the Netherlands, community midwives, hospital-based midwives, obstetricians, and other disciplines such as paediatricians and maternity care assistants collaborate regionally in maternity care networks (MCNs) (17,18). An MCN is usually situated around one hospital and the midwifery practices in the same region. The number of professionals involved varies from about 30 to 120, depending on the number of births and the level of urbanisation in the region. Professionals in an MCN are collectively responsible for the quality of maternity care in that region and are expected to continually evaluate perinatal outcomes and women’s experiences in order to improve the quality and efficiency of their care (18). Collaboration in MCNs has intensified over time and has stimulated the development of regional protocols within the networks (18). In general, protocols are more context-specific and describe the ‘who’, and ‘how’ of medical practice provided in a given region, while national guidelines describe the ‘what’ and ‘when’ based on available evidence. The quality of collaboration between the different disciplines in an MCN is an important issue in relation to practice variation at the meso-level. Good collaboration encourages to make joint agreements and to reflect on care between healthcare professionals in the same midwifery practice or MCN (8,19). However, multidisciplinary collaboration also comes with challenges. 1
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