Variations in use of childbirth interventions in 13 high-income countries: A multinational cross-sectional study

Autoři: Anna E. Seijmonsbergen-Schermers aff001;  Thomas van den Akker aff002;  Eva Rydahl aff004;  Katrien Beeckman aff005;  Annick Bogaerts aff006;  Lorena Binfa aff008;  Lucy Frith aff009;  Mechthild M. Gross aff010;  Björn Misselwitz aff011;  Berglind Hálfdánsdóttir aff012;  Deirdre Daly aff013;  Paul Corcoran aff014;  Jean Calleja-Agius aff015;  Neville Calleja aff016;  Miriam Gatt aff016;  Anne Britt Vika Nilsen aff018;  Eugene Declercq aff019;  Mika Gissler aff020;  Anna Heino aff020;  Helena Lindgren aff022;  Ank de Jonge aff001
Působiště autorů: Department of Midwifery Science, AVAG, Amsterdam Public Health research institute, Amsterdam UMC, location VUmc, Amsterdam, the Netherlands aff001;  Department of Obstetrics, Leiden University Medical Center, Leiden, the Netherlands aff002;  Athena Institute, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands aff003;  University College Copenhagen, Department of Midwifery, Copenhagen NV, Denmark aff004;  Nursing and Midwifery Research unit, faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium aff005;  Department of Development and Regeneration KU Leuven, University of Leuven, Leuven, Belgium aff006;  Faculty of Medicine and Health Sciences, Centre for Research and Innovation in Care (CRIC), University of Antwerp, Belgium aff007;  Department of Women´s and Newborn Health Promotion-School of Midwifery, Faculty of Medicine, University of Chile, Santiago, Chile aff008;  Department of Health Services Research, The University of Liverpool, Liverpool, United Kingdom aff009;  Midwifery Research and Education Unit, Department of Obstetrics, Gynaecology and Reproductive Medicine, Hannover Medical School, Hannover, Germany aff010;  Institute of Quality Assurance Hesse, Eschborn, Germany aff011;  Midwifery Programme, Faculty of Nursing, School of Health Sciences, University of Iceland, Reykjavík, Iceland aff012;  School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland aff013;  National Perinatal Epidemiology Centre, Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland aff014;  Department of Anatomy, Faculty of Medicine and Surgery, University of Malta, Tal-Qroqq, Msida, Malta aff015;  Directorate for Health Information and Research, Gwardamangia, Malta aff016;  Department of Public Health Department, Faculty of Medicine and Surgery, University of Malta, Tal-Qroqq, Msida, Malta aff017;  Western Norway University of Applied Sciences (HVL), Department of Health and Caring Sciences, Bergen, Norway aff018;  Boston University School of Public Health, Boston, United States of America aff019;  THL Finnish Institute for Health and Welfare, Information Services Department, Helsinki, Finland aff020;  Karolinska Institute, Department of Neurobiology, Care Sciences and Society, Huddinge, Sweden aff021;  Department of Women’s and Children’s Health, Karolinska Institutet, Solna, Sweden aff022
Vyšlo v časopise: Variations in use of childbirth interventions in 13 high-income countries: A multinational cross-sectional study. PLoS Med 17(5): e32767. doi:10.1371/journal.pmed.1003103
Kategorie: Research Article
doi: 10.1371/journal.pmed.1003103



Variations in intervention rates, without subsequent reductions in adverse outcomes, can indicate overuse. We studied variations in and associations between commonly used childbirth interventions and adverse outcomes, adjusted for population characteristics.

Methods and findings

In this multinational cross-sectional study, existing data on 4,729,307 singleton births at ≥37 weeks in 2013 from Finland, Sweden, Norway, Denmark, Iceland, Ireland, England, the Netherlands, Belgium, Germany (Hesse), Malta, the United States, and Chile were used to describe variations in childbirth interventions and outcomes. Numbers of births ranged from 3,987 for Iceland to 3,500,397 for the USA. Crude data were analysed in the Netherlands, or analysed data were shared with the principal investigator. Strict variable definitions were used and information on data quality was collected. Intervention rates were described for each country and stratified by parity. Uni- and multivariable analyses were performed, adjusted for population characteristics, and associations between rates of interventions, population characteristics, and outcomes were assessed using Spearman’s rank correlation coefficients. Considerable intercountry variations were found for all interventions, despite adjustments for population characteristics. Adjustments for ethnicity and body mass index changed odds ratios for augmentation of labour and episiotomy. Largest variations were found for augmentation of labour, pain relief, episiotomy, instrumental birth, and cesarean section (CS). Percentages of births at ≥42 weeks varied from 0.1% to 6.7%. Rates among nulliparous versus multiparous women varied from 56% to 80% versus 51% to 82% for spontaneous onset of labour; 14% to 36% versus 8% to 28% for induction of labour; 3% to 13% versus 7% to 26% for prelabour CS; 16% to 48% versus 12% to 50% for overall CS; 22% to 71% versus 7% to 38% for augmentation of labour; 50% to 93% versus 25% to 86% for any intrapartum pain relief, 19% to 83% versus 10% to 64% for epidural anaesthesia; 6% to 68% versus 2% to 30% for episiotomy in vaginal births; 3% to 30% versus 1% to 7% for instrumental vaginal births; and 42% to 70% versus 50% to 84% for spontaneous vaginal births. Countries with higher rates of births at ≥42 weeks had higher rates of births with a spontaneous onset (rho = 0.82 for nulliparous/rho = 0.83 for multiparous women) and instrumental (rho = 0.67) and spontaneous (rho = 0.66) vaginal births among multiparous women and lower rates of induction of labour (rho = −0.71/−0.66), prelabour CS (rho = −0.61/−0.65), overall CS (rho = −0.61/−0.67), and episiotomy (multiparous: rho = −0.67). Variation in CS rates was mainly due to prelabour CS (rho = 0.96). Countries with higher rates of births with a spontaneous onset had lower rates of emergency CS (nulliparous: rho = −0.62) and higher rates of spontaneous vaginal births (multiparous: rho = 0.70). Prelabour and emergency CS were positively correlated (nulliparous: rho = 0.74). Higher rates of obstetric anal sphincter injury following vaginal birth were found in countries with higher rates of spontaneous birth (nulliparous: rho = 0.65). In countries with higher rates of epidural anaesthesia (nulliparous) and spontaneous births (multiparous), higher rates of Apgar score < 7 were found (rhos = 0.64). No statistically significant variation was found for perinatal mortality. Main limitations were varying quality of data and missing information.


Considerable intercountry variations were found for all interventions, even after adjusting for population characteristics, indicating overuse of interventions in some countries. Multivariable analyses are essential when comparing intercountry rates. Implementation of evidence-based guidelines is crucial in optimising intervention use and improving quality of maternity care worldwide.

Klíčová slova:

Anesthesia – Birth – Birth rates – Epidural block – Iceland – Labor and delivery – Netherlands – Malta


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