Regional variations in childbirth interventions in the Netherlands: A nationwide explorative study

A. E. Seijmonsbergen-Schermers, D. C. Zondag, M. Nieuwenhuijze, T. Van den Akker, C. J. Verhoeven, C. Geerts, F. Schellevis, A. De Jonge

Research output: Contribution to journalArticleAcademicpeer-review

Abstract

Background: Although interventions in childbirth are important in order to prevent neonatal and maternal morbidity and mortality, non-indicated use may cause avoidable harm. Regional variations in intervention rates, which cannot be explained by maternal characteristics, may indicate over- and underuse. The aim of this study is to explore regional variations in childbirth interventions in the Netherlands and their associations with interventions and adverse outcomes, controlled for maternal characteristics. Methods: Childbirth intervention rates were compared between twelve Dutch regions, using data from the national perinatal birth register for 2010-2013. All single childbirths from 37weeks' gestation onwards were included. Primary outcomes were induction and augmentation of labour, pain medication, instrumental birth, caesarean section (prelabour, intrapartum) and paediatric involvement. Secondary outcomes were adverse neonatal and maternal outcomes. Multivariable logistic regression analyses were used to adjust for maternal characteristics. Associations were expressed in Spearman's rank correlation coefficients. Results: Most variation was found for type of pain medication and paediatric involvement. Epidural analgesia rates varied from between 12 and 38% (nulliparous) and from between 5 and 14% (multiparous women). These rates were negatively correlated with rates of other pharmacological pain relief, which varied from between 15 and 43% (nulliparous) and from between 10 and 27% (multiparous). Rates of paediatric involvement varied from between 37 and 60% (nulliparous) and from between 26 and 43% (multiparous). For instrumental vaginal births, rates varied from between 16 and 19% (nulliparous) and from between 3 and 4% (multiparous). For intrapartum caesarean section, the variation was 13-15% and 5-6%, respectively. A positive correlation was found between intervention rates in midwife-led and obstetrician-led care at the onset of labour within the same region. Adverse neonatal and maternal outcomes were not lower in regions with higher intervention rates. Higher augmentation of labour rates correlated with higher rates of severe postpartum haemorrhage. Conclusions: Most variation was found for type of pain medication and paediatric involvement, and least for instrumental vaginal births and intrapartum caesarean sections. Care providers and policy makers should critically audit remarkable variations, since these may be unwarranted. Limited variation for some interventions may indicate consensus for their use. Further research should focus on variations in evidence-based interventions and indications for the use of interventions in childbirth.

Original languageEnglish
Article number192
JournalBMC Pregnancy and Childbirth
Volume18
Issue number1
DOIs
Publication statusPublished - 1 Jun 2018

Cite this

@article{dbb3dee57f414ec29147a87a97e33d77,
title = "Regional variations in childbirth interventions in the Netherlands: A nationwide explorative study",
abstract = "Background: Although interventions in childbirth are important in order to prevent neonatal and maternal morbidity and mortality, non-indicated use may cause avoidable harm. Regional variations in intervention rates, which cannot be explained by maternal characteristics, may indicate over- and underuse. The aim of this study is to explore regional variations in childbirth interventions in the Netherlands and their associations with interventions and adverse outcomes, controlled for maternal characteristics. Methods: Childbirth intervention rates were compared between twelve Dutch regions, using data from the national perinatal birth register for 2010-2013. All single childbirths from 37weeks' gestation onwards were included. Primary outcomes were induction and augmentation of labour, pain medication, instrumental birth, caesarean section (prelabour, intrapartum) and paediatric involvement. Secondary outcomes were adverse neonatal and maternal outcomes. Multivariable logistic regression analyses were used to adjust for maternal characteristics. Associations were expressed in Spearman's rank correlation coefficients. Results: Most variation was found for type of pain medication and paediatric involvement. Epidural analgesia rates varied from between 12 and 38{\%} (nulliparous) and from between 5 and 14{\%} (multiparous women). These rates were negatively correlated with rates of other pharmacological pain relief, which varied from between 15 and 43{\%} (nulliparous) and from between 10 and 27{\%} (multiparous). Rates of paediatric involvement varied from between 37 and 60{\%} (nulliparous) and from between 26 and 43{\%} (multiparous). For instrumental vaginal births, rates varied from between 16 and 19{\%} (nulliparous) and from between 3 and 4{\%} (multiparous). For intrapartum caesarean section, the variation was 13-15{\%} and 5-6{\%}, respectively. A positive correlation was found between intervention rates in midwife-led and obstetrician-led care at the onset of labour within the same region. Adverse neonatal and maternal outcomes were not lower in regions with higher intervention rates. Higher augmentation of labour rates correlated with higher rates of severe postpartum haemorrhage. Conclusions: Most variation was found for type of pain medication and paediatric involvement, and least for instrumental vaginal births and intrapartum caesarean sections. Care providers and policy makers should critically audit remarkable variations, since these may be unwarranted. Limited variation for some interventions may indicate consensus for their use. Further research should focus on variations in evidence-based interventions and indications for the use of interventions in childbirth.",
keywords = "Caesarean section, Childbirth, Induction, Interventions, Obstetric, Outcomes, Pain relief, Regional, Variations",
author = "Seijmonsbergen-Schermers, {A. E.} and Zondag, {D. C.} and M. Nieuwenhuijze and {Van den Akker}, T. and Verhoeven, {C. J.} and C. Geerts and F. Schellevis and {De Jonge}, A.",
year = "2018",
month = "6",
day = "1",
doi = "10.1186/s12884-018-1795-0",
language = "English",
volume = "18",
journal = "BMC Pregnancy and Childbirth",
issn = "1471-2393",
publisher = "BioMed Central",
number = "1",

}

Regional variations in childbirth interventions in the Netherlands : A nationwide explorative study. / Seijmonsbergen-Schermers, A. E.; Zondag, D. C.; Nieuwenhuijze, M.; Van den Akker, T.; Verhoeven, C. J.; Geerts, C.; Schellevis, F.; De Jonge, A.

In: BMC Pregnancy and Childbirth, Vol. 18, No. 1, 192, 01.06.2018.

Research output: Contribution to journalArticleAcademicpeer-review

TY - JOUR

T1 - Regional variations in childbirth interventions in the Netherlands

T2 - A nationwide explorative study

AU - Seijmonsbergen-Schermers, A. E.

AU - Zondag, D. C.

AU - Nieuwenhuijze, M.

AU - Van den Akker, T.

AU - Verhoeven, C. J.

AU - Geerts, C.

AU - Schellevis, F.

AU - De Jonge, A.

PY - 2018/6/1

Y1 - 2018/6/1

N2 - Background: Although interventions in childbirth are important in order to prevent neonatal and maternal morbidity and mortality, non-indicated use may cause avoidable harm. Regional variations in intervention rates, which cannot be explained by maternal characteristics, may indicate over- and underuse. The aim of this study is to explore regional variations in childbirth interventions in the Netherlands and their associations with interventions and adverse outcomes, controlled for maternal characteristics. Methods: Childbirth intervention rates were compared between twelve Dutch regions, using data from the national perinatal birth register for 2010-2013. All single childbirths from 37weeks' gestation onwards were included. Primary outcomes were induction and augmentation of labour, pain medication, instrumental birth, caesarean section (prelabour, intrapartum) and paediatric involvement. Secondary outcomes were adverse neonatal and maternal outcomes. Multivariable logistic regression analyses were used to adjust for maternal characteristics. Associations were expressed in Spearman's rank correlation coefficients. Results: Most variation was found for type of pain medication and paediatric involvement. Epidural analgesia rates varied from between 12 and 38% (nulliparous) and from between 5 and 14% (multiparous women). These rates were negatively correlated with rates of other pharmacological pain relief, which varied from between 15 and 43% (nulliparous) and from between 10 and 27% (multiparous). Rates of paediatric involvement varied from between 37 and 60% (nulliparous) and from between 26 and 43% (multiparous). For instrumental vaginal births, rates varied from between 16 and 19% (nulliparous) and from between 3 and 4% (multiparous). For intrapartum caesarean section, the variation was 13-15% and 5-6%, respectively. A positive correlation was found between intervention rates in midwife-led and obstetrician-led care at the onset of labour within the same region. Adverse neonatal and maternal outcomes were not lower in regions with higher intervention rates. Higher augmentation of labour rates correlated with higher rates of severe postpartum haemorrhage. Conclusions: Most variation was found for type of pain medication and paediatric involvement, and least for instrumental vaginal births and intrapartum caesarean sections. Care providers and policy makers should critically audit remarkable variations, since these may be unwarranted. Limited variation for some interventions may indicate consensus for their use. Further research should focus on variations in evidence-based interventions and indications for the use of interventions in childbirth.

AB - Background: Although interventions in childbirth are important in order to prevent neonatal and maternal morbidity and mortality, non-indicated use may cause avoidable harm. Regional variations in intervention rates, which cannot be explained by maternal characteristics, may indicate over- and underuse. The aim of this study is to explore regional variations in childbirth interventions in the Netherlands and their associations with interventions and adverse outcomes, controlled for maternal characteristics. Methods: Childbirth intervention rates were compared between twelve Dutch regions, using data from the national perinatal birth register for 2010-2013. All single childbirths from 37weeks' gestation onwards were included. Primary outcomes were induction and augmentation of labour, pain medication, instrumental birth, caesarean section (prelabour, intrapartum) and paediatric involvement. Secondary outcomes were adverse neonatal and maternal outcomes. Multivariable logistic regression analyses were used to adjust for maternal characteristics. Associations were expressed in Spearman's rank correlation coefficients. Results: Most variation was found for type of pain medication and paediatric involvement. Epidural analgesia rates varied from between 12 and 38% (nulliparous) and from between 5 and 14% (multiparous women). These rates were negatively correlated with rates of other pharmacological pain relief, which varied from between 15 and 43% (nulliparous) and from between 10 and 27% (multiparous). Rates of paediatric involvement varied from between 37 and 60% (nulliparous) and from between 26 and 43% (multiparous). For instrumental vaginal births, rates varied from between 16 and 19% (nulliparous) and from between 3 and 4% (multiparous). For intrapartum caesarean section, the variation was 13-15% and 5-6%, respectively. A positive correlation was found between intervention rates in midwife-led and obstetrician-led care at the onset of labour within the same region. Adverse neonatal and maternal outcomes were not lower in regions with higher intervention rates. Higher augmentation of labour rates correlated with higher rates of severe postpartum haemorrhage. Conclusions: Most variation was found for type of pain medication and paediatric involvement, and least for instrumental vaginal births and intrapartum caesarean sections. Care providers and policy makers should critically audit remarkable variations, since these may be unwarranted. Limited variation for some interventions may indicate consensus for their use. Further research should focus on variations in evidence-based interventions and indications for the use of interventions in childbirth.

KW - Caesarean section

KW - Childbirth

KW - Induction

KW - Interventions

KW - Obstetric

KW - Outcomes

KW - Pain relief

KW - Regional

KW - Variations

UR - http://www.scopus.com/inward/record.url?scp=85047898975&partnerID=8YFLogxK

U2 - 10.1186/s12884-018-1795-0

DO - 10.1186/s12884-018-1795-0

M3 - Article

VL - 18

JO - BMC Pregnancy and Childbirth

JF - BMC Pregnancy and Childbirth

SN - 1471-2393

IS - 1

M1 - 192

ER -