181 General discussion Reflection on the methodological strengths and limitations of this thesis A strength of this thesis is that used the sociological model for explaining practice variation by de Jonge et al (14) (Chapter 1: figure 1), which provides knowledge about factors interacting on micro and meso-level for midwives. The use of this model has ensured a broader view on factors influencing practice variation, also investigating the role of midwives within the interdisciplinary collaboration of MCNs. On meso-level, we gained knowledge about the influence of regional protocols and differences in maternity care professionals’ birth beliefs. In the document analysis, we focused on protocols with recommendations on induction of labour. However, we expect that the findings of this study are also applicable to other topics in maternity care. Due to time and resources limitations, we were unable to investigate other factors that have been identified to influence medical practice variation, including staff capacity, the structure of collaboration and the effective application of protocols (2,11,14). In our qualitative studies, we used the ASE-model to investigate which factors influence individual midwives’ intention to use interventions or not (42–44). We gained in-depth knowledge of the experiences, beliefs and values that underpin their attitudes, and how knowledge and skills influence midwives’ intentions to come to actual behaviour. The ASE-model is internationally used in behavioural science studies and known as the Theory of Planned Behaviour. Over time, this theory has been replaced by The Reasoned Action Approach, which provides a more integrative framework for predicting human behaviour (44). As in our studies, multiple factors such as context and time are taken into account, making the outcomes of our studies more in line with the Reasoned Action Approach. Considering multiple factors is a strength because it gives more in-depth insight into the underlying motivations that influence midwives’ decisions to perform or refrain from performing childbirth interventions. The results of our studies allow us to formulate hypotheses about the influence of specific factors on the decision to use interventions. However, it is not possible to describe the precise effect on intervention rates, as we did not investigate actual behaviour. We identified knowledge and skills that (future) midwives need to become reflective practitioners with the aim to reduce unwarranted interventions. However, we did not study the actual interaction between midwives and women during decision-making. Patient involvement in shared decisionmaking represents another potential element that affects practice variation in maternity care (36). Therefore, research is needed to investigate the interaction with women during decision-making and the impact on practice variation in maternity care. Implications for practice Given what we and others have learned regarding the influence of personal and professional factors on midwives’ clinical decisions about the use of childbirth 8
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