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Practice variation in induction of labor: A critical document analysis on the contribution of regional protocols
Dirkje C Zondag1, Pien M Offerhaus2, Judit K J Keulen2
1CAPHRI, Maastricht University, Maastricht, the Netherlands.
Rationale:
Despite national guidelines with recommendations on induction of labor (IOL), large variation in the use of this intervention exists between regions in the Netherlands. Guidelines are translated into protocols, which give a contextual description of medical practice provided in a given region. Possibly, protocols developed by regional multidisciplinary maternity care networks (MCNs) contribute to the regional variation in IOL.
Aims And Objectives:
The aim of this study was to assess the variation between regional protocols and national guidelines regarding recommendations on IOL and the extent to which this contributes to practice variation.
Method:
We performed a systematic document analysis using the Ready materials, Extract data, Analyze, Distil (READ) approach. National guidelines (n = 4) and regional protocols (n = 18) from six MCNs on topics linked to IOL were assessed between October 2021 and April 2022. An analytical framework was used to extract data for the comparison of regional protocols.
Results:
Some MCNs followed all the recommendations of national guidelines in their regional protocols, others developed their own recommendations, and for some this varied per topic. When developing their own recommendations, MCNs with a high percentage of IOL added additional risk factors and stricter cut-off values. In contrast, MCNs with a low percentage of IOL added more care options for continuing midwife-led care. No clear relationship was observed between the Appraisal of Guidelines for Research & Evaluation (AGREE) scores of the national guidelines and the extent to which regional protocols complied with the recommendations.
Conclusion:
The translation of national guidelines to regional protocols seemed arbitrary and not very systematic. To reduce unwarranted practice variation in the use of IOL, guidance is needed to better align regional protocols with national guidelines, while including appropriate contextual factors and allowing women's preferences. Additionally, healthcare providers should be trained in practicing evidence-based medicine instead of using evidence.
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