23 Regional variations in childbirth interventions in the Netherlands Introduction The rates of interventions in childbirth vary worldwide (1-4) and have fluctuated over the years (1, 4-7). Induction of labour and caesarean section (CS) rates have shown a steady increase since the 1970s (1, 4, 6, 8, 9), which raised concerns (10). Interventions in childbirth are important in order to prevent neonatal and maternal morbidity and mortality. However, use without a medical indication may cause avoidable harm (2, 11-14). The World Health Organization (WHO) recommends limited use of interventions during childbirth (15). Induction and augmentation of labour should only be performed on medical indication (16, 17). However, there are concerns about poor adherence to this recommendation in a significant number of women with uncomplicated pregnancies (16-19). Epidural analgesia is the most effective method for pain medication during labour (20), but is associated with a higher risk of instrumental birth, oxytocin use, maternal fever, urinary retention and complications, such as post-dural puncture headache (20, 21). The decision for pain medication is ultimately based on women’s choice. There is some evidence that continuous support of labour might reduce the need for pain medication (22). Furthermore, the WHO states that CS rates higher than ten percent at population level are not associated with reductions in maternal, neonatal and infant mortality rates (23). Variations in intervention rates between high-income countries may be explained by culture and history, differences in population characteristics, maternity care systems, and national guidelines (12, 15, 24-26). Clinical guidelines have been used for a long time to harmonise and rationalise the use of interventions within countries, and to improve outcomes (27, 28). Nevertheless, studies comparing regions within countries like England, Ireland, Canada and Germany, have found substantial variations in rates of induction of labour, epidural analgesia, continuous fetal electronic monitoring, episiotomy, instrumental birth, and CS (29-33). Additionally, Dutch studies have reported variations in rates between hospitals, of induction and augmentation of labour, administration of sedation and analgesics, episiotomy, instrumental birth, and CS (34, 35). Regional variations in intervention rates, which cannot be explained by maternal characteristics, may indicate over- and underuse (36). This is especially true in a relatively small country without regional differences in the maternity healthcare system. The aim of this study was therefore to explore which regional variations in intervention rates in childbirth exist, and how these variations are associated both to each other, and to adverse neonatal and maternal outcomes. These are explored for single childbirths from 37 weeks of gestation onwards in midwife- or obstetrician-led care in the Netherlands, and controlled for maternal characteristics. 2
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