177 General discussion making, we therefore discuss how woman-centredness might influence the use of interventions. Evidence in guidelines and protocols (cause 1) The development and utilisation of healthcare guidelines is beneficial when practice variation is the consequence of subjectivity, bias, and uncertainty. In that case, guidelines can indicate what care is the best for a specific group (9). Ultimately, a national guideline is the leading document that provides evidence and recommendations for care based on an up-to-date systematic literature analyses of available evidence: the ‘what’ and ‘when’. (10,11). However, good quality of care is more than what is proven in studies. A guideline should therefore provide room for patients’ preferences and the expertise and experiences of the healthcare professional (12). The use of such a guideline is likely to result in warranted practice variation, as patients have different preferences and taking these into account in clinical decision making will result in different treatments. As described in the report ‘No evidence without context – About the illusion of evidence-based practice in healthcare’, guidelines should give direction to regional protocols, leaving the specific implementation to that region, with description of the ‘who’ and ‘how’ (9). National guidelines and regional protocols provide an opportunity for the detailed description of medical practice based on evidence, however, they should not promote undesirable standardisation of care (9). Some MCNs in our research had the tendency to add additional risk factors and stricter cut-off values in their regional protocols providing more indications for interventions compared to the national guidelines. These additional risk factors and stricter cut-off values were recommendations that did not become evident after a systematic exploration of the literature by the guideline or protocol developers. Based on these findings, there seems to be a need for maternity care professionals to have a better understanding of the differences between national guidelines and regional protocols. By making these differences clearer, professionals are likely to better understand the scientific rationale for recommendations. Hopefully, they will be more inclined to use the recommendations of the national guidelines during clinical decision-making, rather than describing additional risk factors and stricter cut-off values, without good scientific evidence. As the latter will limit the scope for patient preferences and healthcare professional expertise and experiences, resulting in strict, standardised protocols. Too much standardisation in regional protocols can decrease the existing room for patients’ preferences and other contextual factors, such as living circumstances of women and the structure of healthcare practices. Offering care in accordance with these protocols will make it more difficult to personalise care and possibly increase unwarranted interventions (13–15). 8
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