183 General discussion hope that MCNs will be provided with the necessary support to develop context-based protocols that align with national guidelines. Instruments or implementation strategies to support MCNs in the development of regional protocols should be the subject of further research and development. The development and implementation of a training program to obtain the knowledge and skills of a reflective practitioner is an interesting and relevant topic for implementation research. Final conclusion We have shown that midwives’ attitudes, knowledge and skills differ and are influencing factors on practice variation at the micro-level. More attention for the skills as a reflective practitioner could contribute to a more personalised approach in clinical decision-making towards childbirth interventions. At the meso-level, midwives can use these skills in the context of MCNs for effective interdisciplinary collaboration and the development of regional protocols. Together with guidance on how to translate national guidelines into regional protocols. This can provide opportunities for more personalised care and a reduction of unwarranted practice variation. We have shown that midwives have an important role in clinical-decision making and can make a difference in the use of interventions, and therefore to women’s experiences of childbirth. Finding a balance between too little too late and too much too soon, requires a midwife that finds a balance between evidence, expertise and women’s preferences in order to proves personalised care with appropriate interventions. 8
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