80 Chapter 3 Fig 7. Interregional variation in Artificial rupture of membranes in midwife-led care at onset of labour Discussion This study is a first step towards understanding the appropriate use of interventions in childbirth, as was recommended in a Lancet series on Midwifery (2). Most variation was found in the use of episiotomy and postpartum administration of oxytocin in women receiving midwife-led care at the time of birth. These intervention can be applied in both home and hospital births, but lower rates were found in regions with more home births. Although there was a correlation between episiotomy use in midwife-led care and episiotomy use in obstetrician-led care, the variation between regions in episiotomy rates was greater for women receiving midwife-led care. A finding we believe to be significant was the negative correlation that was found in two-thirds of the regions between the number of women in midwife-led care at the onset of labour and intrapartum referral rates. The only correlation that we found with adverse neonatal and maternal outcomes was between intrapartum referral and PPH; there were higher rates of PPH in regions with more intrapartum referrals, which did not include referrals after birth. Significantly, in our study, no correlation was found between the regional adjusted ORs for episiotomy, and third or fourth degree rupture. Limitations and strengths A limitation of this study is the absence, or low quality of other relevant data in the register such as the maternal body mass index, congenital disorders, and history of obstetric complications. However, adjustments for maternal
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