160 Chapter 7 3.3. Development procedure regional protocols Five of the six MCNs described a comparable development procedure. Their regional protocols were developed by a multidisciplinary panel of healthcare providers. Subsequently, a draft version was presented for feedback to their colleagues. In four out of five MCNs, all colleagues were consulted to approve the final protocol. In one other MCN approval was done by a specially mandated committee. The sixth MCN described a different procedure. A mandated multidisciplinary workgroup formulated specific statements on care based on a review of national and international guidelines and other relevant literature. The other care professionals in this MCN were subsequently asked to react to these statements, and based on these reactions the final recommendations were formulated by the working group and published. None of the MCNs described the participation of women in the development procedure of a regional protocol. 3.4 Recommendations in regional protocols We observed variations between MCNs in the use of national guidelines in their protocols. However, we did not observe a clear relationship between the extent to which national guidelines were used in regional protocols and the overall AGREE II score of the national guidelines. Two MCNs used the national guidelines as the main source for their protocols and included recommendations from the national guideline in their regional protocols (Table 4). The protocols of these two MCNs followed the national guidelines quite precisely. One of these MCNs belonged to the high IOL group and the other to the low IOL group. Two other MCNs, also one high and one low IOL MCN, developed regional protocols and formulated recommendations based on self-collected evidence, such as data from the Dutch national perinatal register, individual studies, documents from the Dutch Association of Midwives, and international and national guidelines. The last two MCNs used both these strategies for developing protocols, depending on the topic. Self-developed recommendations varied in several ways. Based on the variation in these recommendations, a possible relationship between the regional protocols and a high or low percentage of IOL appeared. Firstly, protocols from MCNs with a high percentage of IOLs described additional risk factors compared to national guidelines, often expanding the group eligible for IOLs. Factors such as advanced maternal age, smoking, or maternal body mass index >40 kg/m2 were described as indicators to induce labor at 41 weeks gestation instead of considering expectant management. Secondly, cut-off values or definitions were defined differently in MCNs compared to national guidelines. For example, some protocols of MCNs with a high percentage of IOL recommended IOL in cases of suspected fetal macrosomia, based on a specific and rather strict cut-off value at the fetal growth scan (f.e. the 75th percentile). Other MCNs with a low percentage of IOL stated no specific cut-off value at the growth scan for the management of suspected fetal macrosomia and indicated continuing midwife-led care until referral
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