83 Regional variations in childbirth interventions and their correlations - underlying social history and various developments in attitudes towards interventions during childbirth over time and culture (37, 38, 41). Variations are not merely individual, since care providers are influenced by the culture of their working environment (42). Similar variations in rates of episiotomy between women in midwife-led care versus those in obstetrician-led care, within the same region, may be explained by a number of factors including: the impact of regional guidelines; comparable attitudes towards interventions during childbirth; and the influence different care providers have upon each other with regard to which care strategies are preferred within a region (37, 38, 42). Considerable variation between regions with regard to rates of intrapartum referrals, episiotomy and postpartum administration of oxytocin, particularly in midwife-led care, may indicate lack of national consensus about indications for these practices. Further research into the factors which may influence the clinical practice behaviours mentioned above is needed to identify the underlying causes, attitudes towards interventions during childbirth, and the perception of risk (41). Episiotomy The routine use of episiotomy is not recommended in recent literature (43) or by the World Health Organization (WHO) (44), because it can lead to physical problems such as a lower pelvic floor muscle strength, dyspareunia and perineal pain (3). The WHO recommends restricting episiotomy in normal labour to a rate of ten per cent (44), but there are no national guidelines on indications for episiotomy in the Netherlands. An episiotomy rate of 60% for all nulliparous women, found in one of the regions, suggests that this intervention is not performed in a restrictive manner (43). Since rates of adverse neonatal and maternal outcomes in regions with high episiotomy rates were not lower, such major variation might indicate that episiotomy has been overused in some regions. This warrants further investigation. In our study, a correlation between the regional adjusted ORs for episiotomy, and third or fourth degree perineal tears was not found. In addition, regional variation in performing an episiotomy was considerably larger than the variation in severe perineal tears. An episiotomy is often performed to prevent severe perineal tears (43, 45). However, literature supports other methods to reduce the rate of third or fourth degree tears which do not have adverse effects (46-48). Artificial rupture of membranes AROM may reduce the length of time of labour (4) and it might, therefore, decrease the need for augmentation of labour with oxytocin (4). On the other hand, some concerns about possible adverse effects have been suggested (4, 49). The WHO states there should be a valid reason for the artificial rupturing of the membranes in normal labour (44), but there are no national guidelines on indications for AROM in the Netherlands. The average incidence of AROM in our study (47% for nulliparous and 57% for multiparous women in midwifeled care at the onset of labour) was relatively high compared to for instance Germany, where the incidence is 34% and 42% respectively (50). However, 3
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