154 Chapter 7 regional protocols within MCNs (14). In general, protocols are more contextspecific than guidelines and describe the ‘who’, ‘what’, ‘when’, and ‘how’ of medical practice provided in a given region. Box 1 – maternity care in the Netherlands In the Netherlands, primary care midwives provide care to women with a low-risk pregnancy as independent healthcare professionals and are able to make autonomous decisions with the woman about childbirth interventions or referral to obstetrician-led care (37). Indications for a referral from midwife-led to obstetrician-led care are described in the obstetric indication list of 2003 and in national multidisciplinary guidelines (38). In obstetrician-led care, hospital-based midwives and obstetricians provide care after referral and can provide childbirth interventions such as augmentation of labor, analgesia, and instrumental birth (37). Primary care midwives, obstetricians, and other disciplines such as pediatricians and maternity care assistants collaborate regionally in maternity care networks (MCNs) (13, 14). 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 urbanization 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 (14). Previous research on regional protocols for perinatal care in Dutch hospitals showed a lack of standardization (15–17). Not all hospitals had protocols on similar topics, and there was a wide variation in developmental methodology and content. It seemed unclear to health professionals what the purpose and content of a protocol should be and how to formulate recommendations that reflect the quality of the supporting evidence (15,17). There is also no clarity on how regional protocols relate to national guidelines. Development of clinical practice guidelines was started to reduce practice variation and methodological clarity exists on how to develop them in accordance with the AGREE recommendations, however, no guidance exists on the development procedure or content of regional protocols. The lack of guidance makes it possible that regional protocols are a potential factor for practice variation. In this study, we focused on guidelines and protocols with recommendations on induction of labor (IOL). IOL is an intervention in perinatal care that is used for various indications (18). Despite national guidelines recommending situations in which IOL is appropriate care, there are large regional differences in the use of this intervention in the Netherlands, with percentages ranging
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