182 Chapter 8 interventions, it appears that there should be more focus on midwives as reflective practitioners. The skills of a reflective practitioner will probably help to provide more personalised care, which can help in the appropriate use of interventions and can contribute to reduce unwarranted practice variation in maternity care. In order to raise awareness among midwives about their role in the use of interventions, the findings of this thesis will be disseminated with the help of the Dutch Association of Midwives (KNOV) and the Dutch Master in Midwifery. Midwives can be trained to provide personalised care and integration of this training in the current quality register will be explored. For student midwives, education in critical thinking skills and an advanced level of interpretation of the scientific literature need to be part of the bachelor curriculum (45). Models such as the Model of Holistic Reflection can be used to embed reflection in the educational programme. Midwives with a Master’s degree can add value to the midwifery profession, for example by using their advanced competencies in the development of national guidelines or regional protocols. In addition, they can act as role models for practice or mentors for bachelor midwives. It is necessary that the Dutch Associations of Midwives and of Obstetricians as well as the federation of MCNs anticipate on the need for clarity on the difference between national guidelines and regional protocols. Both national guidelines and regional protocols should allow room for patient’s preferences and the expertise and experiences of the healthcare professional, avoiding undesirable standardisation. The professional associations can contribute to supporting MCNs in the development of regional protocols through the federation of MCNs, as the development of regional protocols occurs in MCNs and this organisation is affiliated to almost all networks. Implications for future research This thesis contributes knowledge about how personal and professional factors relate to midwives’ clinical decisions about childbirth interventions. We have focused on a number of factors on micro- and meso-level, but predicting human behaviour is complex and depends on different elements of an integrative framework. Future research should therefore focus on more factors, such as social norms, barriers and stimuli that influence midwives in their process to come from intention to actual behaviour. Research is also needed on possible factors influencing attitudes. For example, years of work experience have been described as both stimulating and inhibiting factor in the provision of personalised and low-intervention care (46–48). Our studies were also ambiguous about whether years of work experience had a stimulating or an inhibiting effect on beliefs towards the use of interventions. Research is needed to investigate the influence of contextual factors and culture in MCNs during the process of developing regional protocols and execution of care. In light of the conclusions reached in this thesis, it is our
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