209 Appendices give direction to regional protocols, leaving only context-specific factors such as ’who’ and ’how ’ to be specified in a regional protocol (7). To be effective, guidelines should create room for women’s preferences and should also describe where evidence is lacking. In addition, national associations such as the Federatie van Medisch Specialisten (FMS), Koninklije Nederlandse Organisatie van Verloskundigen (KNOV) and Nederlandse Vereniging voor Obstetrie en Gynaecologie (NVOG), need to ensure that guidelines are still up to date or need to be revised. It appears that most maternity care professionals do not know the difference between a guideline and a protocol adequately. National associations and bachelor programmes can be of help to educate (future) maternity care professionals about the differences between national guidelines and regional protocols and the risk of too much standardisation of care. Reflective practitioners have the skills to interpret the evidence and can have a role in the development of regional protocols creating awareness for not evidence-based care. Supporting MCNs in the development of regional protocols can avoid random use of study results in regional protocols and give room to women’s preferences, which supports personalised care and decrease unwarranted practice variation. These protocols should clarify which treatments are evidence-based and which are less or not evidence-based. Our results show that not all midwives have sufficient knowledge and skills of a reflective practitioner to provide care adapted to the personal context of women (chapter 5). These knowledge and skills can be trained to midwives. A large systematic review investigated what matters to childbearing women based on their beliefs, expectations, and values (8). The outcomes of this review were used for the recommendations in the intrapartum guideline of the World Health Organisation (9). The review showed that most healthy women want a positive birth experience and prefer a physiological labour and birth. When women’s preferences are taken into account through personalised care, it is expected that this on average will result in less medicalisation (8). In other words, personalised care can reduce the unnecessary use of interventions that can potentially harm women and their newborns and increase healthcare costs. Scientific relevance Overall in medicine, practice variation in interventions can be explained by a sociological model that describes factors that interact with practice variation at macro-, meso-, and micro-level (10). As far as we know, this is the first time that the sociological model is used for maternity care. Based on the results of this thesis, we found that the model is useful to extend knowledge about factors interacting with practice variation in maternity care at the meso- and micro-level. The investigation of factors on micro-level has added indepth knowledge about the clinical decisions midwives make in the use of interventions. This knowledge shows that the maternity care professional has
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