175 General discussion toward the use of interventions, and midwives with an attitude orientated to ‘check and control’, who displayed a more directive style of behaviour toward the use of interventions. Midwives’ attitudes were shaped by their experiences of collaboration with other healthcare professionals, their trust and fear in the process of pregnancy and birth, and their views on woman-centeredness. Midwives showed a tendency towards either one of these attitudes, however, certain circumstances such as client preferences or recent cases could elicit midwives to use the other style of behaviour. It appeared that midwives with a ‘wait and see’ attitude showed more skills of a reflective practitioner compared to midwives with a ‘check and control’ attitude (Chapter 5). Midwives with an attitude orientated to ‘wait and see’ demonstrated a higher level of reflective skills, used a more balanced communication style in interaction with women, and have more skills to engage in discussions during collaboration with other professionals, thereby personalising their care. This personalised approach to maternity care could help to promote appropriate rather than routine use of interventions and may contribute to reduce the medicalisation of childbirth. The positive correlation between intervention rates in midwife-led care and obstetrician-led care within the same region (Chapters 2 and 3), suggests that variations are not merely individual. Therefore, we explored two factors at meso-level that potentially contribute to practice variation. First, we performed a systematic document analysis of regional protocols of maternity care networks (MCNs), advising on use of induction of labour as a childbirth intervention for various complications during pregnancy (Chapter 7). As previous research on protocols for perinatal care in Dutch hospitals showed a lack of standardization (4), regional protocols of MCNs can be one of the factors on meso-level that contribute to practice variation. Our analysis showed a large variation of recommendations in regional protocols, which suggests that regional protocols may contribute to the current practice variation in induction of labour in the Netherlands. We observed MCNs that adhered to the recommendations set in national guidelines in their regional protocols, other MCNs developed their own recommendations, and for some MCNs this varied per topic. When formulating their own recommendations, regions with a high percentage of induction of labour added additional risk factors and stricter cut-off values for use of induction as an intervention. Conversely, regions with a low percentage of induction of labour offered more opportunities to continue midwife-led care. Additionally, in regions with a low percentage of induction of labour, protocols described more often that woman’s preferences should be explored and that the woman is the final decision-maker in using the intervention. Secondly, we evaluated if the Birth Beliefs Scale can be used to measure beliefs about birth among maternity care professionals (Chapter 6). The Birth Beliefs Scale has been validated for pregnant women (5). We explored if this scale can also be used for maternity care professionals to assess their beliefs, 8
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