165 The contribution of regional protocols on practice variation in induction of labor and professional expertise is important in addition to knowledge of the client’s clinical condition and previous practices. Healthcare providers need to be aware of their directing role in medical practice performed. It appears healthcare providers also need support in interpreting evidence and in shared decision-making (28,29). For healthcare providers, guidelines and guideline developers represent a new authority that makes evidence available for use and makes recommendations that must be followed. As a result, healthcare providers become ‘evidence users’, rather than reviewing and applying the available evidence themselves and developing a (self)critical attitude (30). Too much standardization in regional protocols through additional risk factors and strict cut-off values may result in different management of certain obstetric problems in neighboring MCNs with similar populations. This can also be a reason for practice variation between different MCNs. Research has shown that the clinical decision-making of healthcare providers is influenced by several factors, such as geographical and organizational factors (1,31). Over-standardization of protocols can make it difficult to align protocols across regions. It can also lead to confusion among healthcare professionals providing care in different regions, possibly leading to more unwarranted practice variation. Patient preferences One factor in good evidence-based practice is whether patient’s individual preferences are taken into account (12,26). Shared decision-making is fundamental to maternity care and is a collaborative process between the healthcare professional and the patient to make healthcare decisions using respectful communication (26,32). Our analysis showed that the role of women’s choice in clinical decision-making was not always described in regional protocols. Counseling seemed to be described in cases where there is a lack of good evidence, or where the available evidence gives room for equivalent care options. Regions with a lower percentage of IOL appeared to be more likely to describe women having a choice or making the final decision. This may indicate that these regions are more attentive towards involving women in the decision-making process. Previous research has shown that most women receiving maternity care prefer physiological labor and birth (33). Increasing women’s involvement in clinical decision-making could therefore lead to less medicalization. Following patients’ preferences is a source of justified variation and appears to reduce practice variation between hospitals and simultaneously increase variation within hospitals (34). Women’s preferences should be described as a factor to be considered in clinical decision-making as a standard in regional protocols. Attention should also be given to evaluating how these preferences are managed in practice and whether healthcare professionals have sufficient skills to support women’s active participation and involvement in maternity care. 7
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