30 Chapter 2 Regional variations Table 2 describes the intervention rates by region in subgroups stratified by parity, and table 4 the crude and adjusted ORs with confidence intervals, on which figures 2-7 are based. Most variation was found for the type of pain medication during labour (figures 2a and 2b), with epidural analgesia rates varying from between 12.3% to 37.5% in nulliparous and from between 4.6% to 13.8% in multiparous women, and rates of other pharmacological pain relief varying from between 14.8% to 43.0% in nulliparous and from between 9.8% to 26.8% in multiparous women without prelabour CS (table 2). The variation of pain medication was similar for women in midwife-led compared to those in obstetrician-led care within the same region, with ρ = 0.97 (table 5), but rates were lower for women in midwife-led care. Generally, lower rates of other pharmacological pain relief were found in regions with higher rates of epidural analgesia, and vice versa. The correlation coefficient was ρ = - 0.61 for women in midwife-led care and ρ = - 0.68 in obstetrician-led care (table 6). There were no significant correlations between the use of pain medication and augmentation of labour, intrapartum oxytocin use, instrumental vaginal birth, intrapartum CS, or spontaneous vaginal birth (table 7). As can be seen from figure 3, considerable variation was found for the involvement of a paediatrician in the first 24 hours after birth, with rates varying from between 36.9% to 60.3% for nulliparous and from between 25.6% to 42.7% for multiparous women (table 2). Figure 4 shows maps with variations of spontaneous birth rates, CS rates, and rates of intrapartum oxytocin between regions. Rates of intrapartum oxytocin, used for induction or augmentation of labour, were found of between 55.1% and 66.5% for nulliparous and of between 39.7% and 51.7% for multiparous women (table 2), and varied significantly across regions (figure 4c). Rates of augmentation after a spontaneous onset of labour varied across regions from between 33.5% to 48.4% for nulliparous and from between 12.4% to 22.6% for multiparous women (table 2). Instrumental vaginal birth rates were lower (ρ = - 0.61) and spontaneous vaginal birth rates were higher (ρ = 0.66; table 7) in regions where rates of augmentation of labour were higher. Variations in augmentation of labour are shown in figure 5. Less variation was found for induction of labour, instrumental vaginal birth, and prelabour and intrapartum CS. Rates of prelabour CS were found of between 3.6% and 5.8% for all nulliparous and of between 5.8% and 9.8% for all multiparous women, and induction of labour rates of between 18.0% and 26.2% for all nulliparous and of between 16.6% and 25.4% for all multiparous women (table 2). Figure 6 illustrates the ORs of prelabour CS and induction of labour. Regions with higher rates of prelabour CS had higher rates of intrapartum CS as well (ρ = 0.67), and lower rates of spontaneous vaginal births (ρ = - 0.62; table 7).
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