82 Chapter 3 women, found varying episiotomy rates of between 5% to 24% (34). A variation of between 1% and 34% was found for episiotomy rates in non-instrumental births across many regions in France, in a study including national data (35). A result in our study which we believe to be significant is the north-south divide within the country. In northern regions, rates of home births were higher and rates of episiotomy in the total population and postpartum oxytocin administration in midwife-led care were lower. It is unlikely that this can be entirely explained by the different risk profiles of low-risk women giving birth at home, compared to low-risk women giving birth in a hospital or a birth centre. Fewer intrapartum referrals to obstetrician-led care might be expected in regions with fewer women in midwife-led care at the onset of labour because women with higher risks may already have been referred earlier during their pregnancy. Yet, our results showed the opposite for twothirds of all regions. These findings may be explained by regional policies oriented towards obstetrician-led care, or by the preferences of women which may require more referrals. In regions with higher referral rates, PPH rates were higher as well, which may be explained by the association that was found between the augmentation of labour and PPH in our previous publication (23). Offerhaus et al. (2015) described a similar correlation (15). Previous studies showed non-urgent referrals, such as meconium-stained amniotic fluid, need for pain medication and/or delay in progress of first stage of labour, being the main reasons for intrapartum referrals in the Netherlands (15, 36). Our findings of varying rates of intrapartum referral, which may be correlated with higher PPH rates requires further investigation, before any conclusions in terms of policy with regard to augmentation of labour may be drawn. Several important bodies, such as the WHO, and the series on Caesarean section and Midwifery in the Lancet, have called for action to reduce the inappropriate use of medical interventions in maternity care. Large regional variation that is not explained by differences in maternal characteristics may be unwarranted. There is a lack of literature on regional variations in interventions, related to place of birth and other care processes. It is important to give more insight in the existing variation to care providers and policy makers, to motivate for reflection on their practice policies, on remarkable high or low rates, and on possible causes of variation. This study is therefore an important step in the reduction of unwarranted variation. Possible explanations of variations in referrals and interventions Many studies have investigated midwives’ and obstetricians’ perceptions of risk and uncertainty surrounding clinical practice behaviours. They showed that perceived higher risk or uncertainty is associated with higher rates of interventions (37-39) and intrapartum referrals (40). Care providers’ perceptions of risk or uncertainty may also have an impact upon the preferences of childbearing women. Perceptions among care providers may vary due to differences in education - in particular between different countries
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