176 Chapter 8 so that in future research the relationship between professionals’ beliefs about birth and the use of interventions can be explored. Our validation study showed that the Birth Beliefs Scale is a valid instrument to measure birth beliefs among maternity care professionals. Natural and medical birth beliefs differed between community midwives, hospital-based midwives, and obstetricians. Community midwives had the highest scores on the natural birth beliefs scale, followed by hospital-based midwives, and obstetricians showed the lowest score. For the medical birth beliefs scale an inverse scoring pattern was seen, with the highest score for obstetricians, followed by hospital-based midwives and the lowest scores for community midwives. These differences in birth beliefs were seen between maternity care professionals in all MCNs, however, beliefs did not explain practice variation between MCNs. Reflection on the findings In our nationwide studies, we found major regional variation for use of most childbirth interventions after correction for population characteristics, without significant differences in regional perinatal morbidity and mortality rates (Chapters 2 and 3). Some practice variation in childbirth interventions is to be expected when care is adapted to medical conditions or to woman’s preferences (2,6). However, the large regional variation we observed can indicate unwarranted variation in Dutch maternity care. Sutherland and Levesque designed a framework which can be used to assess whether the variation is warranted or unwarranted (2). According to this framework causes of unwarranted variation can be found in 1) lack of evidence-based care (evidence); 2) differences in the availability of healthcare resources (capacity); and/or 3) care providers offering care based on the beliefs and personal interests (agency) (2). When variation cannot be explained by medical conditions, population characteristics or patient preferences and occurs despite strong evidence-based recommendations, it is defined as unwarranted (7,8). In other words, when patients conditions or preferences are considered in the process of clinical decision-making, variation can occur, but is warranted. We reflect on the findings of this thesis using part of the framework described by Sutherland and Levesque (2). In line with the first cause of the framework, we discuss how evidence-based care is part of midwifery care in the development of guidelines and regional protocols, and how regional collaboration affects evidence based care. The second cause of the framework, reflection on differences in the availability of healthcare resources (capacity), was not part of our studies and goes beyond the scope of this thesis. It can be subject for future research. In line with the third cause of the framework ‘agency’, we explore how reflective practice can help to gain insight into midwives’ beliefs and attitudes and the influence on their clinical decisions about the use of interventions. Woman-centredness was found in our study (chapter 4) to be part of midwives’ attitudes and also to influence clinical decision-
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