208 Appendices Impact Paragraph This paragraph reflects on the achieved and expected scientific and societal impact of the results of this thesis. Impact on use of childbirth interventions Our research contributes to the body of knowledge about practice variation in the Netherlands. In our nationwide studies, we found large regional variation in the use of most childbirth interventions after correction for population characteristics, without significant differences in regional perinatal morbidity and mortality rates (chapter 2 and 3). As indicated in international research, the overuse of interventions during maternity care can result in medicalisation of physiological pregnancy and childbirth (1,2). This unnecessary use of interventions can harm women and their newborns, and can increase healthcare costs (3). Based on our findings, it seems that there is an overuse of childbirth interventions in the Netherlands and that the risks of medicalisation also apply to maternity care in this country. Our work has provided new insights into how personal and professional factors influence midwives’ clinical-decisions about the use of interventions in childbirth. These findings can help midwives to reflect on their care. Critical reflection can help to determine whether midwives are providing medicalised care influenced by their attitudes. Midwives can contribute to reducing the medicalisation of maternity care, if they are capable of critical reflection on their provided care and take ownership of their influence on clinical decisions about the use of interventions in childbirth. With these skills, midwives can contribute to prevent ineffective or unnecessary care. This is in line with the ‘Passende zorg’ programme the Dutch government has launched to improve the quality of care, increase health benefits and avoid unnecessary costs. This programme investigates care in different specialities, including maternity care (4). Care is evaluated in this programme by the ministry of Health together with healthcare professionals and patients. The aim is to come up with specific arrangements for transformation of care, that can actually be implemented and make care more appropriate for patients. In the Netherlands, maternity care is organised regionally in collaborating networks with community midwives, obstetricians, and other disciplines, such as paediatricians and maternity care assistants (5,6). These so-called maternity care networks (MCNs) are usually situated around one hospital and the midwifery practices in the same region. The outcomes of this thesis show that support for MCNs is necessary to improve the quality of maternity care (chapter 7). We observed that the translation of national guidelines to regional protocols is arbitrary and not very systematic. A high-quality national programme on guideline development can support MCNs. Basically, national guidelines provide a systematic literature review and evidence-based recommendations on ‘what’ and ‘when’ certain care is needed. Guidelines
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