66 Chapter 3 A first step in addressing possible inappropriate use of interventions is to examine regional variations of intrapartum interventions within a country (20). Regional variation would not be expected in a relatively small country such as the Netherlands without regional differences in the maternity healthcare system. In the Dutch maternity care system, low-risk women start antenatal care in midwife-led primary care. Midwives refer women to obstetricianled care when risks of adverse outcomes increase or complications arise. Interventions such as episiotomy, artificial rupture of membranes (AROM), and postpartum administration of oxytocin are used in both midwife-led and obstetrician-led care settings (22). Box 1 cites the description of the maternity care system in the Netherlands from our previous publication on regional variations in the Netherlands (23). Box 1: The maternity care system in the Netherlands (23) In the Netherlands, there are no regional differences in the maternity healthcare system. Low-risk women start antenatal care in midwife-led primary care. These women are cared for by independent midwives who attend home births, low-risk hospital births, and births in alongside and free-standing birth centres. The Dutch Birth Centre Study showed that health outcomes, experiences, and costs for low-risk women are similar for planned birth in a birth centre and planned birth in a hospital, both supervised by a primary care midwife (24, 25). Midwives refer women to obstetrician-led care when risks of adverse outcomes increase or complications arise. Criteria for referral from midwife-led to obstetrician-led care have been laid out in the obstetric indication list of 2003. Interventions in childbirth such as induction and augmentation of labour, pain medication, instrumental birth, and CS, are only available in an obstetrician-led care setting (22, 25). These intrapartum interventions may be used for women in midwife-led care at the onset of labour after referral to obstetrician-led care. Interventions such as episiotomy, artificial rupture of membranes (AROM), and postpartum administration of oxytocin are used in both midwife-led and obstetrician-led care settings (22). The Steering Committee ‘Pregnancy and birth’ recommended in 2009 more integration in maternity care between midwife-led and obstetrician-led care, which led to several regional initiatives to change the organisation of care, but there was not one uniform, national model (27). The decreased rate of midwife-led births in the Netherlands corresponded with an increased use of interventions on the national level (15, 28). A previous article described regional variations in rates of induction and augmentation of labour, pain medication, caesarean section, and involvement of paediatrician in the first 24 h after birth (23). Little information is available as to how regional variations in rates of referral, place of birth, and interventions during childbirth, relate to each other, nor how they might relate to adverse neonatal
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