65 Regional variations in childbirth interventions and their correlations Introduction Rates of interventions during childbirth have been studied worldwide and large variations between countries have been reported (1). Interventions during childbirth can be crucial in order to prevent neonatal and maternal morbidity and mortality (2) and, therefore, underuse of healthcare services can be an important cause of preventable morbidity and mortality. On the other hand, use without a medical indication may cause avoidable harm, given the risk of adverse effects related to interventions (3-5). Worldwide, rates of most interventions and referrals during childbirth have increased (1, 6, 7), episiotomy being the exception (1, 8). The rate of home births varies worldwide and is low in most high-income countries. For instance, in 2017, the rate of home births was 1% in the USA (9), 0.3% in Australia (10), and 2% in England and Wales (11). The rate of referrals depends on the maternity care system in a country. Alliman et al. (2016) showed a range of intrapartum referral rates from birth centres to hospitals of between 12% and 37% (12), and Blix et al. (2014) a referral rate range from home to hospital of between 10% and 32% (13). Episiotomy rates vary largely, from 5% in Denmark, to 75% in Cyprus (14). In the Netherlands, a variation in intrapartum referral rates among midwifery practices has been shown of between 10% and 64% (15). Since the late twentieth century, referrals during pregnancy and labour have increased continuously. Where in 1999 more than 60% of women received midwife-led care at the onset of labour, this number has decreased to 51% in 2015 (15, 16). The rate of home births has historically been high in the Netherlands. However, the rate of home births declined from 23% in 2000 to 13% in 2015 (15, 16). Episiotomy rates declined from 23% in 2005 to 13% in 2015 in the Netherlands. Variations in the use of interventions between countries may be explained by differences in maternal and perinatal characteristics and perinatal healthcare systems (18). For example, parity, maternal age, ethnicity, and birthweight are associated with the use of episiotomy (19). However, since these factors are likely to be more similar within a specific country, less variation may be expected within a country than between countries (20). If variations persist after adjustment for maternal characteristics, then this may indicate that variations are unwarranted and it may indicate inappropriate use (20, 21). While on one hand characteristics can be associated with interventions, on the other hand interventions can be associated with improved or worsened neonatal and maternal outcomes (2-5). Therefore, intervention rates should be investigated in view of adverse outcomes. Similar neonatal and maternal outcomes between regions together with variations in interventions, is another indicator of unwarranted variation (20, 21). 3
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