163 The contribution of regional protocols on practice variation in induction of labor 3.5 Other observations Regional protocols varied in the way they described different care options for women and the involvement of women in the final decision about care options, including IOL. Some regional protocols did not mention women in their protocols, and other regional protocols, all from MCNs with low percentages of IOL, described women as the final decision maker. These protocols explicitly described that woman’s preferences should be explored and that the woman should be allowed to decide on treatment. The provision of information was most frequently described in protocols on reduced fetal movements. Protocols from MCNs with high and low percentages of IOL were equally likely to mention ‘personalized care’ and ‘treatment based on counseling’, without further specification of the content of this care. Recommendations for counseling were regularly described in protocols for late term pregnancy and large-for-gestational age. However, the protocols were limited in their specifications. We observed differences in the writing style used in the MCNs. In one MCN, a prescriptive writing style was observed, including strict cut-off values for interventions and prescriptive instructions on what to do if a woman requested care different from the regional protocol. Discussion In this critical document analysis, we found a large variation between regional protocols, which suggests that regional protocols may contribute to the current practice variation in IOL in the Netherlands. Some MCNs followed the recommendations of the national guidelines for all topics, other MCNs developed their own recommendations, and some MCNs used both these strategies depending on the topic. When developing their own recommendations, MCNs added additional risk factors, care options, and specific cut-off values. It appears that MCNs with a low percentage of IOL were more likely to describe additional options where women could stay in midwife-led primary care and to describe the involvement of women in decision-making. MCNs with a high percentage of IOL seemed to describe more indications for interventions such as ultrasound or fetal monitoring, and more indications or stricter cut-off values for IOL compared with MCNS with a low percentage of IOL. Causality could not be proven on the basis of this study, but these results suggest that regional protocols from regions with a high percentage of IOL indicate more situations in which IOL is recommended. Both groups were equally likely to mention ‘personalized care’ and ‘treatment based on counseling’. No clear relationship was observed between the AGREE scores of the national guidelines and the extent to which the regional protocols complied with national recommendations. 7
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