VALID study: practice VAriation in Labour InDuction

Practice variation in health care is a complex issue that raises questions about quality of care and deserves further investigation. In maternity care in the Netherlands, considerable practice variation has also been observed, for instance in induction of labour (IOL). Practice variation is the extent to which care providers differ in type and frequency of provided care to patients with a similar health status or medical condition. Induction of labour (IOL) is a major intervention in pregnancy that is increasingly being used in the Netherlands. Usually, IOL is recommended in circumstances in which the risks of waiting for the onset of spontaneous labour judged by caregivers to be greater than the risks associated with shortening the duration of pregnancy by induction. Until now, the observed practice variation is not well understood. To determine whether this variation is unwarranted or not, it is important to assess the impact on birth outcomes and to understand the underlying mechanisms of practice variation. The most appropriate level to study practice variation in IOL is at VSV level. A VSV is the multidisciplinary collaborative maternity care network, centred around a hospital and including midwifery care practices and other professionals involved in maternity care. A VSV is considered responsible for the overall regional quality of maternity care. The objectives of the VALID study are to describe practice variation in IOL between VSVs and to explore the different mechanisms that influence decision-making on IOL, how these mechanisms contribute to practice variation, what variation in IOL is unwarranted and how unwarranted practice variation may be reduced. Unwarranted practice variation might mean that some women receive an unnecessary intervention or that others do not receive necessary care. We propose a multi methods study consisting of four parts to examine these objectives. In part 1, we will use data from the national perinatal database Perined to explore practice variation in IOL rates between VSVs and to analyse the associations between IOL rates in VSVs and maternal and neonatal outcomes. In part 2, we will conduct a mixed methods multiple case study using both quantitative and qualitative methods to collect and analyse data from 6 VSVs with different IOL rates. In this phase, we will examine the mechanisms that contribute to practice variation in IOL according to a sociological model of practice variation on the micro-level (mechanisms with impact on interaction professional-client) and the meso-level (mechanisms with impact on practices and organizations). The results from this phase will serve as input for part 3. In part 3, we will use a national expert meeting to determine the degree and type of variation in IOL that is unwarranted. In addition, we will set goals for quality improvement- reducing unwarranted IOL practice variation- for each of the 6 included VSVs. We will align with the existing quality cycle of each VSV. In part 4, we will synthesize the results and place them in a broader context of reducing unwarranted practice variation in maternity care. As general mechanisms that explain variation in IOL, for instance diversity in protocols, might also apply to other clinical topics in the field of maternity care. The results of the project will be disseminated by journals, conferences and websites, and are available for all VSVs in the Netherlands. To support VSVs in quality improvement activities aimed at reducing unwarranted practice variation in IOL or other topics in maternity care, we will develop a toolkit that helps them in gaining insight in their own data and improvement activities, by utilizing their own quality improvement system.