144 6 CHAPTER 6 16 | GOODARZI et al. included in this study, international guidelines do not recommend routine neonatal referral to the pediatrician.29–31 For MSAF, Dutch national guidelines differ. The guideline of the professional association of obstetricians (2011) recommends 8h of observation, based on a Dutch study.32 The guidelines of the professional association of midwives (2015)33 are based on the guideline of the United Kingdom's National Institute for Health Care and Excellence (NICE),31 which differentiates between nonsignificant and significant MSAF, and recommends anobservationperiod of 2 and 12h, respectively. Neither the obstetricians’ nor the midwives’ guidelines explicitly recommend pediatric involvement. Variation in guidelines leaves room for recommendations in protocols based on professionals' beliefs and interests.4,5,26,28,34,35 Interprofessional differences in attitudes, beliefs, and interests may explain the differences in neonatal referral thresholds between obstetric and neonatal departments. Most studies on interprofessional differences in maternal and newborn care focus on differences between obstetricians and midwives, indicating differences in provider attitudes, beliefs, and interests.36–40 Little is known about the differences in attitudes, beliefs, and interests between obstetricians and pediatricians. Geurtzen and colleagues (2016) studied Dutch obstetricians' and neonatologists' treatment decisions for the extremely premature neonate. They found disagreement in preferred treatment decisions between obstetricians and neonatologists, contributing to considerable variation within one hospital.28 The differences in the threshold for neonatal referral to the pediatrician between regions found in this study may also be explained by local availability of resources.2,3 For example, Offerhaus and colleagues (2013) found no association between referral rates for people with healthy pregnancies and perinatal outcomes in the Netherlands in the years 2000–2008. However, they did find a small rise in NICU admissions. According to these researchers, this may be associated with the improved NICU availability in the Netherlands since 2006.41 4.2 | Enhancing effective health care: toward the implementation of multidisciplinary, evidence-based guidelines To reduce unwarranted variation in local protocols, we recommend evidence-based, international, multidisciplinary guidelines to support national guideline and local protocol development. Research on unanswered questions and gaps in evidence is necessary to inform these guidelines. Where evidence is lacking, guidelines should include consensus-based recommendations to reduce local provider preference and supply-based care. These guidelines should also include recommendations against the use of specific practices where these are contraindicated.35 For example, for MSAF, the international31,42 and national32,33 guidelines, and many protocols included in our study, contained a recommendation against routine intrapartum and postpartum nasal or oral suction. If international guidelines differ or cannot easily be applied because of differences in population characteristics, we recommend multidisciplinary national guidelines. Attention should be paid to guideline implementation. If local protocols deviate from guidelines because of specific local circumstances, this should be well described. Uniformity in guidelines and protocols will offer clear standards for care evaluations, which can lead to a reduction of underuse or overuse of care and reduce care disparity because of unwarranted variation in care. 4.3 | Strengths and limitations To our knowledge, this is the first nationwide study exploring variation in local hospital protocols for neonatal referral to the pediatrician within and between obstetric and neonatal departments as a possible determinant contributing to unwarranted variation in neonatal referral. More than half of the obstetric and neonatology departments in the Netherlands participated in this study, providing us with 420 protocols. This enabled detailed examination of a large variety of protocols in neonatal care. Our study has some limitations. We were unable to study differences between smaller geographical areas because of the limited number of departments per province that provided information. More research is necessary to better understand regional variation in protocols. The missing protocols from departments that did not respond or declined participation may have biased the study's outcomes. Also, not all participating departments sent us all six requested protocols. This may have biased our sample. Eleven obstetric and eleven neonatology departments were located in the same hospital, enabling us to study intrahospital variation. However, these departments cannot be considered independent of one other, which may have affected the multivariable analyses. 4.4 | Conclusions This study provides insight into variation in local hospital protocols for neonatal referral to the pediatrician as a determinant of unwarranted variation in care. Comparison of these protocols showed unexplained large variation in recommendations for care. We found differences in recommendations for type of referral, admission, screening/ 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