174 Chapter 8 General discussion Practice variation is known for various childbirth interventions in maternity care. A number of factors such as organisational structures, regulations and population characteristics have been shown in research as potential explanations for this variation (1–4). This thesis contributes to further insight into a number of these factors. It describes exploratory research on the variation in childbirth interventions in the Netherlands and generates further knowledge about how personal and professional factors are related to midwives’ clinical decisions about the use of childbirth interventions. We performed a variety of studies to answer five research questions. In this final chapter, the main findings of this PhD project are presented. Followed by a reflection on these findings, consideration of the methodological strengths and limitations, discussion about implications for practice and suggestions for further research. Main findings Two chapters of this thesis present a comprehensive overview of existing regional variation in the Netherlands. We found major regional variation for most childbirth interventions, which persisted after adjusting for population characteristics (Chapter 2 and 3). Perinatal mortality and morbidity rates did not vary significantly between regions. This practice variation can be an indicator of unwarranted variation, potentially leading to avoidable harm, inequalities in quality of care, and higher costs. Within the same region, intervention rates in midwife-led and obstetrician-led care were positively correlated, showing similar higher or lower use of different interventions, such as episiotomy and artificial rupture of membranes. Practice variation in maternity care is a topic involving different mechanisms at micro-, meso- and macrolevel. In this thesis, we focused on studying how personal and professional factors influence midwives’ clinical-decisions about the use of interventions in childbirth. We chose to focus on primary care midwives working in the Netherlands, because as autonomous professionals they make clinical decisions about the use of childbirth interventions on a day-to-day basis, including referrals to obstetrician-led care. Factors at the micro-level of the individual midwife and at the meso-level of collaboration in a maternity care network were examined. Insights from our studies can help to develop effective strategies to improve clinical decision-making and possibly contribute to reducing unwarranted practice variation in maternity care. At the micro level, we focussed on attitudes, knowledge and skills of the individual midwife, working in primary midwife-led care, using the ASE-model. The ASE-model explains behaviour by linking attitude, social norms and selfefficacy with behavioural intention and actual behaviour. Two distinct attitudes towards interventions were identified (Chapter 4). Midwives with an attitude oriented to ‘wait and see’, who displayed a more supportive style of behaviour
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