15 General introduction General aim and research questions The general aim of this thesis is to generate more knowledge about how midwives’ personal and professional factors are related to their clinical decisions about childbirth interventions. This can contribute to reducing unwarranted practice variation in maternity care. The first research question aims to provide more background knowledge about the current regional variation within the Netherlands, after which the other research questions focus on the general aim. The findings of this thesis focus on two different levels for practising midwives: 1) the individual midwife (micro-level) 2) the midwife as part of the collaboration within midwifery practices or maternity care networks (meso-level). On the level of the microlevel, we want to explore how midwives’ attitude, knowledge, and skills influence clinical decisions on the use of interventions. On the meso-level, we want to explore if differences in birth beliefs of maternity care professionals and regional protocols are a factor contributing to practice variation. The following research questions are addressed in this thesis: 1. Which regional variations in childbirth intervention rates exist in the Netherlands, and how are these variations associated to maternal and perinatal outcomes? (meso-level) 2. What experiences, beliefs, and values influences midwives’ attitudes toward childbirth interventions? (micro-level) 3. How do knowledge and skills influence clinical decision-making of midwives on the appropriate use of childbirth interventions? (micro-level) 4. Can the Birth Beliefs Scale be used to measure beliefs towards the nature of birth (medical or natural) among maternity care professionals? (micro and meso-level) 5. What is the variation in regional protocols with regard to recommendations on induction of labour, and do regional protocols contribute to practice variation? (meso-level) Outline of this thesis Following the general introduction to the thesis, chapter 2 describes the regional variation of commonly used childbirth interventions in obstetricianled care in the Netherlands, and how these variations were correlated both to each other and to maternal and perinatal outcomes, adjusted for population characteristics. (Q1) In chapter 3, regional variations and correlations in the Netherlands were also described, but in this chapter for childbirth interventions that are used in both midwife-led and obstetrician-led care. (Q1) 1
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