153 The contribution of regional protocols on practice variation in induction of labor Introduction Practice variation in health care is gaining attention as a topic in research. Variation in medical practice has been described since the 1930s and variations are seen in diagnoses, contact frequencies, referral rates to more specialized care, and the number of interventions (1). Variation in itself is not remarkable, because medical conditions and patients’ preferences vary. If variation cannot be explained by medical conditions or patient preferences, and there are compelling evidence-based recommendations, practice variation is unwarranted (2,3). Unwarranted practice variation is potentially harmful because it can lead to underuse or overuse of interventions, unequal access to good quality care, and higher healthcare costs (2,4). To understand the causes of medical practice variation, a sociological model of practice variation has been developed (1,5). This model distinguishes three levels 1) micro-level: mechanisms that influence the interaction and decisionmaking process between the healthcare provider and the patient, such as the provider’s attitude and self-efficacy and the patient’s attitude and preferences, 2) meso-level: mechanisms that influence practices and organizations, such as regional protocols and regional culture, and 3) macro-level: mechanisms at the (inter)national levels, such as national guidelines and health care systems. Limiting practice variation was one of the reasons why health professionals began to develop clinical practice guidelines. The first guidelines included recommendations based on expert consensus (6,7). Later, evidence-based medicine (EBM) was introduced as a counter-movement to authority-based medicine (8). In EBM, a clinical decision for each individual patient is made by integrating clinical expertise with the best available evidence and the patient preferences (8). The AGREE Collaboration recognized the importance of high-quality evidence-based guidelines internationally and developed the AGREE instrument to assess the quality of clinical practice guidelines (9). A systematic literature search is the basis of a guideline, this combined with clinical expertise, patient preferences, and consideration of cost-effectiveness, results in recommendations for optimal care for patients and care providers (10,11). Until recently, guidelines for maternity care in the Netherlands were mainly developed monodisciplinary by the professional organizations of obstetricians, midwives, and pediatricians separately (12). More and more, these guidelines are being developed on a multidisciplinary basis using standardized procedures described by the Dutch Federation of medical specialists (12). Multidisciplinary guideline development is important because several disciplines are involved in maternity care and often provide care for the same pregnant woman (Box 1). Regionally, primary care midwives, obstetricians, and other disciplines such as pediatricians and maternity care assistants collaborate in maternity care networks (MCNs) (13,14). Collaboration in MCNs has intensified over the last decade and has stimulated the development of 7
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