193 Summary optional choices. Midwives with reflective skills, critical thinking skills, and the skills to discuss about care seem to make more personalised decisions about interventions rather than following standardised procedures. We concluded from these findings that midwives with a low use of interventions seemed to have the knowledge and skills of a reflective practitioner, leading to more personalised care compared to standardised care as defined in protocols. Learning through reflectivity, critical thinking skills, and instrumental and affective communication skills, need to be stimulated and trained to pursue appropriate, personalised use of interventions. Chapter 6 We analyzed variation between regional protocols, and variation between regional protocols and national guidelines regarding recommendations for induction of labour (IOL). Additionally, we explored the extent to which national guidelines were used in regional protocols and whether this was related to the quality of the national guidelines. The research explored how regional maternity care networks (MCNs) translate national guidelines into protocols and how these variations may contribute to practice variation. Using a systematic document analysis, we compared four national guidelines with eighteen regional protocols from six different MCNs. The study applied the READ approach (Ready materials, Extract data, Analyze, Distil) to analyze the content of these protocols. Additionally, the AGREE II instrument was used to assess the quality of national guidelines, while a analytical framework was developed to evaluate regional protocols. Our analysis showed a large variation of recommendations in regional protocols, which suggests that regional protocols may contribute to the current practice variation in IOL in the Netherlands. We observed MCNs that adhered to the recommendations set in national guidelines in their regional protocols, other MCNs developed their own recommendations, and for some MCNs this varied per topic. When formulating their own recommendations, regions with a high percentage of IOL added additional risk factors and stricter cut-off values for use of induction as an intervention. Conversely, regions with a low percentage of IOL offered more opportunities to continue midwife-led care. Additionally, in regions with a low percentage of IOL, protocols described more often that woman’s preferences should be explored and that the woman is the final decision-maker in using the intervention. This study illustrates that the translation of national guidelines to regional protocols seemed arbitrary and not very systematic. There seems to be a need for guidance to help healthcare professionals translate national guidelines into regional protocols, while including appropriate contextual factors and allowing women’s preferences to ensure that protocols do not lead to overstandardisation. 9
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