191 Summary birth. We compared data across twelve regions and controlled for maternal characteristics such as age, parity, ethnicity, socioeconomic status, and degree of urbanization. We found the largest variations for the type of pain medication and whether a paediatrician was involved within 24 hours after birth, followed by variation in augmentation after a spontaneous onset of labour. Less variation was found for induction of labour and prelabour caesarean sections, and least for instrumental vaginal births and intrapartum caesarean sections. We found similar variation in intervention rates for births in midwife-led care compared to those in obstetrician-led care at the onset of labour in the same region. This correlation suggests that regional medical culture and practices influence decision-making in midwife-led and obstetrician-led care. Higher of lower intervention rates did not lead to differences in rates of adverse neonatal and maternal outcomes. The study highlights the need for critical evaluation of regional differences in childbirth interventions in the Netherlands. Major variations may indicate unwarranted interventions. Variation may be explained to some extent by a difference in the degree of implementation of national guidelines between regions. Further research should therefore focus on variations in evidence based interventions and indications for the use of interventions in childbirth. Chapter 3 In this nationwide retrospective cohort study, we explored variations in childbirth interventions that are used in both midwife- and obstetrician-led care, and in referral rates, place of birth, and care provider. We analysed variations in childbirth interventions across twelve Dutch regions using a national data registry of 614,730 singleton births after 37 weeks’ of gestation (2010–2013). We adjusted for maternal maternal characteristics using multivariable logistic regression. Intrapartum referral rates varied widely for primiparae (55 to 68%) and multiparae (20 to 32%). We found higher rates of postpartum haemorrhage in regions with higher rates of intrapartum referral. Large variations were found in the use of episiotomy and postpartum oxytocin administration. In regions with more home births, an episiotomy was placed less and postpartum oxytocin was administered less often. Remarkable was a northsouth division: northern regions had higher rates of home birth and lower rates of interventions (episiotomy and oxytocin use) than southern regions. Adjustment for maternal characteristics did not change the variations in childbirth interventions, suggesting differences in healthcare professional attitudes towards interventions. The findings highlight the role of the healthcare professional in decisions about the use of interventions. In addition, policy makers and healthcare 9
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