129 Birth. 2022;00:1–19. | 1 Received: 23 June 2022 | Revised: 23 October 2022 | Accepted: 27 October 2022 DOI: 10.1111/birt.12690 O R I G I NA L A RT I C L E (Un)warranted variation in local hospital protocols for neonatal referral to the pediatrician: An explorative study in the Netherlands Bahareh Goodarzi RM, MSc1,2,3,4 | Anna Seijmonsbergen-Schermers RM, PhD1,2,3,4 | Doug Cronie DM, PhD5 | Henriëtte van Laerhoven MD, PhD6 | Thomas van den Akker MD, PhD7,8,9 | Anton H. van KaamMD, PhD9,10 | Ank de Jonge RM, PhD1,2,4,10 This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes. © 2022 The Authors. Birth published by Wiley Periodicals LLC. 1Department of Midwifery Science, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands 2Midwifery Academy Amsterdam Groningen, Amsterdam, The Netherlands 3Amsterdam Public Health, Quality of Care, Amsterdam, The Netherlands 4Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands 5Rotterdam University of Applied Sciences, Institute of Healthcare, Rotterdam, The Netherlands 6Department of Pediatrics, OLVG, Amsterdam, The Netherlands 7Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, The Netherlands 8Athena Institute, VU University, Amsterdam, The Netherlands 9Department of neonatology, Emma Children's Hospital, University of Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands 10Amsterdam Reproduction and Development, Amsterdam, The Netherlands Abstract Background: Studies indicate unwarranted variation in a wide range of neonatal care practices, contributing to preventable morbidity and mortality. Unwarranted variation is the result of complex interactions and multiple determinants. One of the determinants contributing to unwarranted variation in care may be variation in local hospital protocols. The purpose of this study was to examine variation in the content of obstetric and neonatal protocols for six common indications for neonatal referral to the pediatrician: large for gestational age/macrosomia, small for gestational age/fetal growth restriction, meconium-stained amniotic fluid, vacuum extraction, forceps extraction, and cesarean birth. Methods: We conducted a nationwide cross-sectional study examining protocols for neonatal referral to the pediatrician in the obstetric and neonatal departments of all Dutch hospitals. Variation in protocols was analyzed between regions, between neonatal and obstetrics departments located in the same hospital, and within neonatal and obstetrics departments. Results: There was considerable variation in protocols between regions, between neonatal and obstetrics departments, and within neonatal and obstetrics departments. The results of this study showed considerable variation in recommendations for type of referral, admission, screening/diagnostic tests, treatment, and discharge. Furthermore, results generally showed lower referral thresholds in neonatal departments compared with obstetric departments, and higher referral thresholds in the eastern region of the Netherlands. We also found variation in local hospital protocols, which could not be explained by population characteristics but which may be explained by varying recommendations in existing national and international guidelines and/or lack of adherence to these guidelines. 1523536x, 0, Downloaded from by Vrije Universiteit Amsterdam, Wiley Online Library on [14/11/2022]. See the Terms and Conditions ( on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License