45 Regional variations in childbirth interventions in the Netherlands achieving a low intervention rate should not be an aim in itself (10, 57). It is not possible to identify the optimal rate of interventions based on this study. An essential element in improving quality of care, is that care providers critically audit remarkably high and low rates (10, 58). This study intends to contribute to this debate. Following national guidelines and using the recommendations of the WHO might help in achieving the optimal use of interventions (15-17, 23, 58). On the other hand, differences in regional guidelines and in adherence to national guidelines may explain a part of the large variation in type of pain medication and involvement of a paediatrician. Use of epidural analgesia for women with a single fetus in cephalic position after 37 weeks’ gestation, has almost tripled between 2000 and 2009 in the Netherlands (from 7.7% to 21.9%) (59). In 2008, a multidisciplinary guideline on pain medication was published, in which adequate pain relief upon request for all women during labour was advised, with epidural analgesia as the most effective method for pain relief. Two randomized controlled trials showed that women were more satisfied with epidural analgesia compared to patient-controlled remifentanil (60, 61), but access to pain medication should not be at the expense of continuous support, which can reduce the need for pain medication (22). The large variation in rates of pain medication suggests different degrees of implementation of evidence and national guidelines, leading to disparity in accessibility to pain medication. Furthermore, the absence of a national guideline on when a paediatrician needs to be involved after birth and differences in accessibility may explain a part of the large variation in the rates of paediatric involvement, leading to differences in care and costs. Further research is required to examine which medical and non-medical factors may explain the large variations in pain medication and involvement of a paediatrician. Clinical practice is influenced by characteristics of the care provider, such as age, educational background, perceptions of risks, and views on childbirth (62-66). Culture within the work environment may encourage care providers to take similar decisions, and variations are therefore not merely individual (67). Differences in perceptions and attitudes may result in differences in local practice and guidelines. The fact that variations were found between regions, even after adjustments for maternal characteristics, suggests that there may be cultural differences between regions, reflected in differences in the views of care providers on childbirth (63, 68, 69). The large variation, in particular for pain medication and involvement of a paediatrician, cannot be explained by clinical variations only. Similarities in variations in interventions that were found between women in midwife-led and obstetrician-led care, suggest similar practice by midwives and obstetricians within regions. These similarities existed in interventions with minor variation as well as in those with considerable variation. The results of this study call for implementation of evidence-based interventions, and for investigation into indications for the use of interventions in childbirth (10). The Robson Classification System 2
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