Regional variations in childbirth interventions in the Netherlands: a nationwide explorative study.

BACKGROUND: Although interventions in childbirth are important in order to prevent neonatal and maternal morbidity and mortality, non-indicated use may cause avoidable harm. Regional variations in intervention rates, which cannot be explained by maternal characteristics, may indicate over- and underuse. The aim of this study is to explore regional variations in childbirth interventions in the Netherlands and their associations with interventions and adverse outcomes, controlled for maternal characteristics. METHODS: Childbirth intervention rates were compared between twelve Dutch regions, using data from the national perinatal birth register for 2010-2013. All single childbirths from 37 weeks' gestation onwards were included. Primary outcomes were induction and augmentation of labour, pain medication, instrumental birth, caesarean section (prelabour, intrapartum) and paediatric involvement. Secondary outcomes were adverse neonatal and maternal outcomes. Multivariable logistic regression analyses were used to adjust for maternal characteristics. Associations were expressed in Spearman's rank correlation coefficients. RESULTS: Most variation was found for type of pain medication and paediatric involvement. Epidural analgesia rates varied from between 12 and 38% (nulliparous) and from between 5 and 14% (multiparous women). These rates were negatively correlated with rates of other pharmacological pain relief, which varied from between 15 and 43% (nulliparous) and from between 10 and 27% (multiparous). Rates of paediatric involvement varied from between 37 and 60% (nulliparous) and from between 26 and 43% (multiparous). For instrumental vaginal births, rates varied from between 16 and 19% (nulliparous) and from between 3 and 4% (multiparous). For intrapartum caesarean section, the variation was 13-15% and 5-6%, respectively. A positive correlation was found between intervention rates in midwife-led and obstetrician-led care at the onset of labour within the same region. Adverse neonatal and maternal outcomes were not lower in regions with higher intervention rates. Higher augmentation of labour rates correlated with higher rates of severe postpartum haemorrhage. CONCLUSIONS: Most variation was found for type of pain medication and paediatric involvement, and least for instrumental vaginal births and intrapartum caesarean sections. Care providers and policy makers should critically audit remarkable variations, since these may be unwarranted. Limited variation for some interventions may indicate consensus for their use. Further research should focus on variations in evidence-based interventions and indications for the use of interventions in childbirth.

The use of episiotomy in a low-risk population in the Netherlands: a secondary analysis.

BACKGROUND: To examine the episiotomy incidence and determinants and outcomes associated with its use in primary care midwifery practices. METHODS: Secondary analysis of two prospective cohort studies (n = 3,404). RESULTS: The episiotomy incidence was 10.8 percent (20.9% for nulliparous and 6.3% for parous women). Episiotomy was associated with prolonged second stage of labor (adj. OR 12.09 [95% CI 6.0-24.2] for nulliparous and adj. OR 2.79 [1.7-4.6] for parous women) and hospital birth (adj. OR 1.75 [1.2-2.5] for parous women). Compared with episiotomy, perineal tears were associated with a lower rate of postpartum hemorrhage in parous women (adj. OR 0.58 [0.4-0.9]). Fewer women with perineal tears reported perineal discomfort (adj. OR 0.35 [0.2-0.6] for nulliparous and adj. OR 0.22 [0.1-0.3] for parous women). Among nulliparous women episiotomy was performed most frequently for prolonged second stage of labor (38.8%) and among parous women for history of episiotomy or prevention of major perineal trauma (21.1%). CONCLUSIONS: The incidence of episiotomy is high compared with some low-risk settings in other Western countries. Episiotomy was associated with higher rates of adverse maternal outcomes. Restricted use of episiotomy is likely to be beneficial for women.