157 The contribution of regional protocols on practice variation in induction of labor 2.4 Regional protocols 2.4.1. Search and selection Regional protocols from the six participating MCNs were collected for indepth content analysis and assessment. They were collected between 1 October 2021 and 15 April 2022 from the MCN websites and by contacting the MCNs. Regional protocols were eligible if they described recommended care related to IOL for the topics shoulder dystocia, large-for-gestational-age or macrosomia, reduced fetal movements, elective induction of labor, or late term pregnancy (≥41 weeks). 2.4.2. Analytical framework Because the AGREE II instrument was developed specifically for guidelines, it contains elements that are applicable to national guidelines. Regional protocols have a different structure and include different elements, which makes the AGREE II instrument not suitable for analyzing regional protocols. An analytical framework (S1 Appendix. Analytical framework for analyzing regional protocols.) was developed for this study, based on the domains of the AGREE II instrument (22) and complemented with items for critical document analysis (21). A first version was pilot tested on the regional protocols for late term pregnancy and adjusted for data extraction to meet the purpose of this study. The analytical framework consisted of questions about the development procedure such as scope and target population. Other questions focused on the content of the regional protocols, with questions about relevant recommendations, supporting evidence for the recommendations, clarity of presentation, applicability, and general impression. The first author answered the questions of the analytical framework for each protocol based on the information given in the protocol. Subsequently, the second author monitored the answers given and these were discussed together for the final assessment. 2.5 Analysis The collected data resulted in an extensive dataset, which we analyzed by systematically answering the questions of the analytical framework for each MCN and reasoning what effect the described care might have on IOL rates. The different MCNs were then compared to see if the outcomes differed and if there was a relationship between the outcomes of the analysis and whether the MCN had a high or low IOL rate. In accordance with the READ method, we also took a holistic view of all documents to see what variation there was within and between the documents (21). The scores of the AGREE II instrument were compared with the recommendations of the regional protocols to see if there was a relationship between the score and the extent to which national guidelines were used in the regional protocols. To increase the validity of our findings, we discussed them in detail with the research team and checked them in the original data before drawing conclusions. 7
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