84 Chapter 3 its variation was limited, suggesting a consensus in the use of AROM among midwives. More research is needed to investigate appropriate rates of AROM (4, 44). Postpartum administration of oxytocin The large regional variation of postpartum oxytocin among low-risk women, that was found in our study, suggests a lack of a national consensus in midwifeled care. As described by the WHO, the administration of oxytocin seems beneficial for reducing the risk of PPH (44, 51). Our study suggests underuse of oxytocin in the Netherlands in some regions. This may be explained by some midwives, particularly in regions with low rates, not being convinced of the benefits of routine oxytocin for low-risk women (52), and they may be concerned about potential side effects that have been highlighted in literature (5). As has been argued before (5), we recommend further research into the use of routine administration of postpartum oxytocin among low-risk women and to develop a national guideline on this issue. Conclusions High rates and large variations were found for intrapartum referral, indicating differences in risk perception between care providers. A correlation was found between intrapartum referral and PPH. More research is required into factors influencing care providers’ decision to refer a woman during labour. Higher rates in the use of episiotomy in the total population and postpartum administration of oxytocin in midwife-led care were found in regions with fewer home births. These were not accompanied by better maternal and neonatal outcomes. It seems that existing evidence for restricted use of episiotomy has not been implemented in clinical practice in the Netherlands and large variations in rates of episiotomy and postpartum administration of oxytocin suggest lack of national consensus with regard to these practices. In the short-term, care providers should reflect on their episiotomy practice and restrict the use of episiotomy to evidence-based indications. In the longerterm, policy makers in midwife-led and obstetrician-led care at the national level should achieve consensus on indications for episiotomy and postpartum administration of oxytocin. Further research is needed to identify the reasons for these differences in intervention rates, to explore ways of reducing possibly avoidable interventions, and acquiring evidence-based consensus on the use of interventions.
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