190 Chapter 9 Summary Chapter 1 | Introduction Internationally, the interventions used in childbirth vary widely, and there is evidence to suggest that this is also the case in the Netherlands. Interventions in childbirth are useful in certain circumstances to prevent perinatal morbidity and mortality. Some practice variation in childbirth interventions is to be expected, as care is adapted to medical conditions or the woman’s preferences. However, practice variation can also be an indicator of unwarranted variation, which can lead to avoidable harm, inequalities in quality of care, and high costs. Practice variation can be explained by a sociological model that describes factors that interact with practice variation at macro-, meso-, and micro-level. In this thesis, we focus on mechanisms in maternity care that can help explain practice variation at the meso and micro level. The meso-level, refers to regional collaboration in maternity care networks (MCNs), where community midwives, hospital-based midwives, obstetricians, and other disciplines such as paediatricians and maternity care assistants are collectively responsible for the quality of maternity care in that region. Collaboration in MCNs can be challenging because professionals with different expertise and paradigms need to align and should agree on recommendations in regional protocols. The micro-level describes the interaction between the woman and the maternity care professional to achieve individual decision-making. Decisionmaking at the micro-level appears to be influenced by the attitude of the healthcare professional. There are indications that the use of interventions varies between midwives and we want to explore what causes this variation. Therefore, the general aim of this thesis is to generate more knowledge about how midwives’ personal and professional factors are related to their clinical decisions about childbirth interventions. This can contribute to reducing unwarranted practice variation in maternity care. Chapter 2 In this chapter we explored regional variations in childbirth interventions performed in obstetrician-led care in the Netherlands and their associations with interventions and adverse outcomes, controlled for population characteristics. We performed a register-based study and analyzed data from the Dutch national perinatal register (Perined) from 2010 to 2013, including all singleton births from 37 weeks of gestation onwards. The following interventions were examined: induction and augmentation of labor, pain medication, instrumental vaginal birth, cesarean section, and pediatric involvement after
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