67 Regional variations in childbirth interventions and their correlations and maternal outcomes. Knowledge on these correlation will give insight into underlying processes of variations in childbirth interventions, place of birth, and referral, and will help care providers and policy makers to know which variation is large and likely unwarranted and should therefore be the focus of changes in practices and policies with the ultimate aim to improve the quality of maternity care. This article focuses on rates of referral, place of birth, and interventions that are used in both primary midwife-led, and secondary obstetrician-led care. The first aim of this study was to explore which regional variations in intrapartum rates of referral, place of birth, and use of intrapartum interventions, exist for women who gave birth in the Netherlands between 2010 and 2013. Secondly, we aimed to investigate how these variations are correlated to each other. Thirdly, we examined the association between variations, and adverse neonatal and maternal outcomes, adjusted for maternal characteristics. Methods Data collection The methods of this explorative study have been described previously in more detail (23). For this nationwide study, we used data on single births after 37 weeks of gestation. We focused on single births because multiple pregnancies are associated with much higher risks of adverse outcomes and therefore medical interventions are often justified. These data originated from the national register, “Perined”, covering the years 2010 up to 2013 and including 98% of all births in the Netherlands after 24 weeks of gestation (29). Patient records were excluded when data were missing on: postal codes or parity; or when data were missing from the midwifery database of women that received both midwife- and obstetrician-led care. The pitfalls in the use of data based on the national register have been described in a recently published article (30). Selection of variables We used the twelve Dutch administrative provinces as regions. A record of a birth was allocated to a region on the basis of the mother’s residential postal code. All women, in all regions, have access to all types of birth settings and therefore, these regions were comparable. Care processes The following primary outcome variables concerning maternity care processes were examined: the number of women receiving midwife-led care at the onset of their pregnancy, at the onset of labour, and at the time of birth; intrapartum referral to obstetrician-led care, and the planned, and actual place of birth (home, hospital and birth centre midwife-led, hospital obstetrician-led). The onset of labour was defined as the onset of active uterine contractions or rupture of membranes. Intrapartum referral to an obstetrician-led care setting was defined as a referral after the onset of labour and before birth. The planned 3
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