14 Chapter 1 As individual decision-making in maternity care is achieved through interaction between the woman and the midwife, the woman is also a factor influencing practice variation (36,40). Woman’s values and preferences influence the decision to perform interventions, and therefore influence with the clinical decisions of a midwife. Research on shared decision-making found that the introduction of shared decision-making increases the amount of different treatments. In other words, through the interaction with the woman variation within hospitals increased (41). In the Netherlands, community midwives are professionals who make autonomous decisions about childbirth interventions or referrals to obstetrician-led care (13). Although Dutch midwifery educational programmes are similar and based on physiology, there is a wide variation in intrapartum referral rates between midwives and midwifery practices (7). Similar to previous research among physicians, it is likely that midwives’ beliefs about treatment and clinical decisions also vary widely (42). However, it is not known how midwives’ beliefs and other personal and professional factors influence clinical decision-making when deciding on the use of interventions or referrals. Problem statement and knowledge gaps Internationally, the interventions used in childbirth vary widely, and there is evidence to suggest that this applies to the Netherlands. Practice variation can be an indicator of unwarranted variation, which can lead to avoidable harm, inequalities in quality of care, and high costs. Regional variation in the Netherlands has not been studied extensively. Possible patterns in intervention rates can provide useful insights, for example whether all intervention rates are higher in certain regions or whether it is a selection of intervention rates that are higher or lower. Therefore, correlations between intervention rates in different regions, adjusted for population characteristics, should be investigated to better understand practice variation in the Netherlands. Different mechanisms that influence practice variation can be understood by the sociological model of de Jong et al (12). To our knowledge, this model has not been used in maternity care. By using this model, we expect to gain knowledge about practice variation in maternity care at meso- and micro-level. As practice variation is a large topic, not all factors can be studied. For this thesis, we focused on the role of midwives and their clinical decisions about the use of interventions. There are indications that the use of interventions varies between midwives and we want to explore what causes this variation. Therefore, we explored how midwives’ personal and professional factors influence their clinical decisions about interventions in childbirth and consequently influence practice variation in maternity care.
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