12 Chapter 1 Regional care should be designed as integrated care for pregnant women, respecting patient preferences and the specific expertise and autonomy of different healthcare professionals (13). Collaboration in MCNs can be challenging because professionals with different expertise and paradigms need to align (20). Particularly between the disciplines of community midwives and obstetricians, there are examples of each discipline having concerns about the other’s professional perspective on birth and its impact on birth outcomes. Midwives have concerns about the medicalisation of childbirth, while obstetricians have expressed concerns that an overemphasis on physiological childbirth might overlook risks to mothers and their newborns (21). Another challenge is to ensure equality between the different disciplines. Relationships between midwives and obstetricians seem to be influenced by the history of maternity care. Historically, the midwifery profession has been predominantly female and has fewer years of training than obstetricians (22). This hierarchy is also reflected in the experienced collaboration between midwives and obstetricians in MCNs. Midwives perceive an imbalance of power in their professional relationship with obstetricians and are cautious about collaborating with obstetricians (23–25). International research has shown that the culture of maternity units has an influence on the intervention rates (26–28). Individual professionals working in the same maternity unit have comparable intervention rates, but the intervention rates between maternity units differ. Evidence suggests that intervention rates in Dutch maternity care are influenced by the culture of a midwifery practice or an MCN (7). Healthcare professionals’ birth beliefs are a factor that contributes to attitudes and clinical decisions about interventions, and are therefore part of the culture (29). However, it is unclear how these beliefs influence clinical decision making on interventions. Hospital protocols in other disciplines have shown that hospital culture is reflected in recommendations for treatment or interventions (19,30). It is possible that a similar mechanism applies to maternity care, with regional culture reflected in regional protocols formulated by MCNs. Practice variation in maternity care: micro-level The third level of the sociological model on practice variation - the micro level - describes the interaction between the woman and the maternity care professional to achieve individual decision-making (12). At this level, the professional applies their theoretical knowledge and professional experience to individual situations. Preferably, the values and preferences of the individual woman are explored through shared decision-making, creating a conversation about clinical characteristics and woman’s preferences. Decision-making at the micro-level appears to be influenced by the attitude of the healthcare professional (29). To study attitudes, intentions, and other factors that influence behaviour theories on human behaviour are used. Underlying reasons why
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