25 Regional variations in childbirth interventions in the Netherlands The following interventions were examined as the primary outcomes: induction of labour; augmentation after a spontaneous onset of labour; intrapartum oxytocin use; epidural analgesia; other pharmacological pain relief; instrumental vaginal birth; CS (prelabour, intrapartum); and involvement of a paediatrician in the first 24 hours after birth. Births from 42 weeks onwards were not excluded, because they may explain variation in particularly induction of labour rates, and they may reflect different policies between regions. Artificial rupture of membranes before a spontaneous onset of labour was defined as induction of labour, and administration of oxytocin to stimulate uterine contractions after spontaneously ruptured membranes as augmentation. A CS after spontaneously ruptured membranes was defined as intrapartum CS. Intrapartum oxytocin includes the use of oxytocin for induction or for augmentation of labour, but not oxytocin use in the third stage of labour. Women with a prelabour CS were excluded from the analyses on pain medication. Women with an intrapartum CS and an epidural, are classified as epidural analgesia for labour pain, since epidural analgesia is generally not used for caesarean sections without prior epidural analgesia for labour pain. In Perined ‘other pharmacological pain relief’ is specified as: sedatives; nonopioid analgesics; and opioid analgesics without further details. The most common opioid analgesics are pethidine injections, sometimes combined with a sedative such as promethazine, and patient-controlled remifentanil (45). In some births, epidural analgesia and other pharmacological methods for pain medication were both used, and therefore, the percentages could not be added up (45). Neonatal and maternal outcomes The secondary neonatal and maternal outcomes were: antepartum and intrapartum stillbirth; neonatal mortality; Apgar score below 7 at 5 minutes; third or fourth degree perineal tear among vaginal births; and postpartum haemorrhage (PPH) of 1000 ml or more. Antepartum stillbirths with births beyond 37 weeks were included, since this may influence intervention rates. Neonatal mortality was defined as neonatal death up to 7 days. Antepartum and intrapartum stillbirths were excluded from the analyses on Apgar score. Women who gave birth by CS were excluded from the analyses on third or fourth degree perineal tear. Maternal and neonatal characteristics The following maternal and neonatal characteristics were included as independent variables or potential confounders (29, 30, 32, 46-49): parity (nulliparous, multiparous); care setting at the onset of labour (midwife-led, obstetrician-led), maternal age (<20, 20-24, 25-29, 30-34, 35-39, ≥40 years); ethnic background (Dutch, non-Dutch); degree of urbanisation (urban, intermediate, rural); socioeconomic status (high, medium, low); gestational age (37+0 - 37+6, 38+0 - 40+6, 41+0 - 41+6, ≥42 weeks); and birth weight (<2.3rd, <10th, >90th, >97.7th percentile). Ethnic background was reported by the care provider and was defined as Dutch or non-Dutch, because of 2
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