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


1. Woods R. Long-term trends in fetal mortality: implications for developing countries. Bull World Health Organ. 2008;86(6):460–6. doi: 10.2471/BLT.07.043471 18568275

2. Miller S, Abalos E, Chamillard M, Ciapponi A, Colaci D, Comande D, et al. Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide. Lancet. 2016;388(10056):2176–92. doi: 10.1016/S0140-6736(16)31472-6 27642019

3. The Lancet Ending Preventable Stillbirths study group. Ending preventable stillbirths. The Lancet [Internet]. 2016 [cited 2019 Jul 15]. Available from:

4. Brownlee S, Chalkidou K, Doust J, Elshaug AG, Glasziou P, Heath I, et al. Evidence for overuse of medical services around the world. Lancet. 2017;390(10090):156–68. doi: 10.1016/S0140-6736(16)32585-5 28077234

5. Gibbons L, Belizán J, Lauer J, Betrán A, Merialdi M, Althabe F. The Global Numbers and Costs of Additionally Needed and Unnecessary Caesarean Sections Performed per Year: Overuse as a Barrier to Universal Coverage. World Health Report Background Paper. 2010;30:1–31.

6. Gray M, Jani A. Promoting Triple Value Healthcare in Countries with Universal Healthcare. Healthc Pap. 2016;15(3):42–8. 27009586

7. EURO-PERISTAT Project with SCPE and EUROCAT. European Perinatal Health Report. Health and care of pregnant women and babies in Europe in 2010. EURO-PERISTAT; 2013.

8. Notzon FC. International differences in the use of obstetric interventions. JAMA. 1990;263(24):3286–91. 2348539

9. Blondel B, Alexander S, Bjarnadottir RI, Gissler M, Langhoff-Roos J, Novak-Antolic Z, et al. Variations in rates of severe perineal tears and episiotomies in 20 European countries: a study based on routine national data in Euro-Peristat Project. Acta Obstet Gynecol Scand. 2016;95(7):746–54. doi: 10.1111/aogs.12894 26958827

10. Betran AP, Merialdi M, Lauer JA, Bing-Shun W, Thomas J, Van LP, et al. Rates of caesarean section: analysis of global, regional and national estimates. Paediatr Perinat Epidemiol. 2007;21(2):98–113. doi: 10.1111/j.1365-3016.2007.00786.x 17302638

11. Seijmonsbergen-Schermers A, van den Akker T, Beeckman K, Bogaerts A, Barros M, Janssen P, et al. Variations in childbirth interventions in high-income countries: protocol for a multinational cross-sectional study. BMJ Open. 2018;8(1):e017993. doi: 10.1136/bmjopen-2017-017993 29326182

12. EU Birth Research Project. A COST Action website detailing research into birth practices. Information about the EU Birth Research Project. 2018 [cited 2019 Jul 15]. Available from:

13. Sultan AH, Thakar R. Lower genital tract and anal sphincter trauma. Best Pract Res Clin Obstet Gynaecol. 2002;16(1):99–115. doi: 10.1053/beog.2002.0258 11866500

14. Van Buuren S, Groothuid-Oudshoorn K. Multivariate Imputation by Chained Equations in R. Journal of Statistical Software. 2001;45(3):1–67.

15. The BMJ. 11. Correlation and regression. The BMJ [Internet]. 2018 [2019 Jul 15]. Available from:

16. Gissler M, Mohangoo AD, Blondel B, Chalmers J, Macfarlane A, Gaizauskiene A, et al. Perinatal health monitoring in Europe: results from the EURO-PERISTAT project. Inform Health Soc Care. 2010;35(2):64–79. doi: 10.3109/17538157.2010.492923 20726736

17. EURO-PERISTAT. Euro-Peristat list of indicators, updated 2012. [cited 2019 Jul 15]. Available from:

18. Zeitlin J, Wildman K, Breart G, Alexander S, Barros H, Blondel B, et al. Selecting an indicator set for monitoring and evaluating perinatal health in Europe: criteria, methods and results from the PERISTAT project. Eur J Obstet Gynecol Reprod Biol. 2003;111 Suppl 1:S5–s14.

19. Reproductive Maternal and Child Health European Regional office World Health Organization. Definitions and indicators in family planning maternal & child health and reproductive health. Used in the WHO regional office for Europe. 2001 [cited 2019 Jul 15]. Available from:

20. EURO-PERISTAT. EURO-PERISTAT indicators of perinatal health 2018 [2019 Jul 15]. Available from:

21. Bouvier-Colle MH, Mohangoo AD, Gissler M, Novak-Antolic Z, Vutuc C, Szamotulska K, et al. What about the mothers? An analysis of maternal mortality and morbidity in perinatal health surveillance systems in Europe. BJOG. 2012;119(7):880–9. doi: 10.1111/j.1471-0528.2012.03330.x 22571748

22. Deneux-Tharaux C, Berg C, Bouvier-Colle MH, Gissler M, Harper M, Nannini A, et al. Underreporting of pregnancy-related mortality in the United States and Europe. Obstet Gynecol. 2005;106(4):684–92. doi: 10.1097/01.AOG.0000174580.24281.e6 16199622

23. Sauvegrain P, Chantry AA, Chiesa-Dubruille C, Keita H, Goffinet F, Deneux-Tharaux C. Monitoring quality of obstetric care from hospital discharge databases: A Delphi survey to propose a new set of indicators based on maternal health outcomes. PLoS ONE. 2019;14(2):e0211955. doi: 10.1371/journal.pone.0211955 30753232

24. Schaap T, Bloemenkamp K, Deneux-Tharaux C, Knight M, Langhoff-Roos J, Sullivan E, et al. Defining definitions: a Delphi study to develop a core outcome set for conditions of severe maternal morbidity. BJOG. 2019;126(3):394–401. doi: 10.1111/1471-0528.14833 28755459

25. Lain SJ, Roberts CL, Hadfield RM, Bell JC, Morris JM. How accurate is the reporting of obstetric haemorrhage in hospital discharge data? A validation study. Aust N Z J Obstet Gynaecol. 2008;48(5):481–4. doi: 10.1111/j.1479-828X.2008.00910.x 19032664

26. O'Donnell CP, Kamlin CO, Davis PG, Carlin JB, Morley CJ. Interobserver variability of the 5-minute Apgar score. J Pediatr. 2006;149(4):486–9. doi: 10.1016/j.jpeds.2006.05.040 17011319

27. Sioutis D, Thakar R, Sultan AH. Overdiagnosis and rising rate of obstetric anal sphincter injuries (OASIS): time for reappraisal. Ultrasound Obstet Gynecol. 2017;50(5):642–7. doi: 10.1002/uog.17306 27643513

28. Ginath S, Mizrachi Y, Bar J, Condrea A, Kovo M. Obstetric Anal Sphincter Injuries (OASIs) in Israel: A Review of the Incidence and Risk Factors. Rambam Maimonides Med J. 2017;8(2).

29. Aasheim V, Nilsen ABV, Reinar LM, Lukasse M. Perineal techniques during the second stage of labour for reducing perineal trauma. Cochrane Database Syst Rev. 2017;6:CD006672. doi: 10.1002/14651858.CD006672.pub3 28608597

30. Anim-Somuah M, Smyth RM, Cyna AM, Cuthbert A. Epidural versus non-epidural or no analgesia for pain management in labour. Cochrane Database Syst Rev. 2018;5:Cd000331.

31. Tornell S, Ekeus C, Hultin M, Hakansson S, Thunberg J, Hogberg U. Low Apgar score, neonatal encephalopathy and epidural analgesia during labour: a Swedish registry-based study. Acta Anaesthesiol Scand. 2015;59(4):486–95. doi: 10.1111/aas.12477 25683882

32. Hincz P, Podciechowskil L, Grzesiak M, Horzelski W, Wilczyflski J. Epidural analgesia during labor: a retrospective cohort study on its effects on labour, delivery and neonatal outcome. Ginekol Pol. 2014;85(12):923–8. 25669061

33. Fagerberg MC, Marsal K, Kallen K. Neonatal outcome after trial of labor or elective cesarean section in relation to the indication for the previous cesarean delivery. Acta Obstet Gynecol Scand. 2013;92(10):1151–8. doi: 10.1111/aogs.12202 23782390

34. Kupari M, Talola N, Luukkaala T, Tihtonen K. Does an increased cesarean section rate improve neonatal outcome in term pregnancies? Arch Gynecol Obstet. 2016;294(1):41–6. doi: 10.1007/s00404-015-3942-4 26573011

35. Plevani C, Incerti M, Del Sorbo D, Pintucci A, Vergani P, Merlino L, et al. Cesarean delivery rates and obstetric culture—an Italian register-based study. Acta Obstet Gynecol Scand. 2017;96(3):359–65. doi: 10.1111/aogs.13063 27869984

36. Davis G, Fleming T, Ford K, Mouawad MR, Ludlow J. Caesarean section at full cervical dilatation. Aust N Z J Obstet Gynaecol. 2015;55(6):565–71. doi: 10.1111/ajo.12374 26223774

37. Reschovsky JD, Rich EC, Lake TK. Factors Contributing to Variations in Physicians' Use of Evidence at The Point of Care: A Conceptual Model. J Gen Intern Med. 2015;30 Suppl 3:S555–61.

38. Hoxha I, Syrogiannouli L, Luta X, Tal K, Goodman DC, da Costa BR, et al. Caesarean sections and for-profit status of hospitals: systematic review and meta-analysis. BMJ Open. 2017;7(2):e013670. doi: 10.1136/bmjopen-2016-013670 28213600

39. Healy S, Humphreys E, Kennedy C. Midwives' and obstetricians' perceptions of risk and its impact on clinical practice and decision-making in labour: An integrative review. Women Birth. 2016;29(2):107–16. doi: 10.1016/j.wombi.2015.08.010 26363668

40. Mead MM, Kornbrot D. The influence of maternity units' intrapartum intervention rates and midwives' risk perception for women suitable for midwifery-led care. Midwifery. 2004;20(1):61–71. doi: 10.1016/S0266-6138(03)00054-8 15020028

41. Cromi A, Bonzini M, Uccella S, Serati M, Bogani G, Pozzo N, et al. Provider contribution to an episiotomy risk model. J Matern Fetal Neonatal Med. 2015;28(18):2201–6. doi: 10.3109/14767058.2014.982087 25380033

42. Toohill J, Sidebotham M, Gamble J, Fenwick J, Creedy DK. Factors influencing midwives' use of an evidenced based Normal Birth Guideline. Women Birth. 2017;30(5):415–23. doi: 10.1016/j.wombi.2017.03.008 28434673

43. Carolan-Olah M, Kruger G, Garvey-Graham A. Midwives' experiences of the factors that facilitate normal birth among low risk women at a public hospital in Australia. Midwifery. 2015;31(1):112–21. doi: 10.1016/j.midw.2014.07.003 25132098

44. Zinsser LA, Stoll K, Gross MM. Midwives' attitudes towards supporting normal labour and birth—A cross-sectional study in South Germany. Midwifery. 2016;39:98–102. doi: 10.1016/j.midw.2016.05.006 27321726

45. Laine K, Gissler M, Pirhonen J. Changing incidence of anal sphincter tears in four Nordic countries through the last decades. Eur J Obstet Gynecol Reprod Biol. 2009;146(1):71–5. doi: 10.1016/j.ejogrb.2009.04.033 19482405

46. Macfarlane AJ, Blondel B, Mohangoo AD, Cuttini M, Nijhuis J, Novak Z, et al. Wide differences in mode of delivery within Europe: risk-stratified analyses of aggregated routine data from the Euro-Peristat study. BJOG. 2016;123(4):559–68. doi: 10.1111/1471-0528.13284 25753683

47. Seijmonsbergen-Schermers AE, Zondag DC, Nieuwenhuijze M, Van den Akker T, Verhoeven C, Geerts C, et al. Regional Variations in Interventions in Childbirth in the Netherlands: a nationwide study. BMC Pregnancy Childbirth. 2018;18(192). doi: 10.1186/s12884-017-1653-5

48. Seijmonsbergen-Schermers AE, Zondag DC, Nieuwenhuijze M, Van den Akker T, Verhoeven C, Geerts C, et al. Regional variations in childbirth interventions and their correlations with adverse outcomes, birthplace and care provider: a nationwide explorative study. PLoS ONE 2020;15(3):e0229488. doi: 10.1371/journal.pone.0229488 32134957

49. World Health Organization. WHO recommendations: Intrapartum care for a positive childbirth experience. Geneva: World Health Organization; 2018.

50. Betran AP, Temmerman M, Kingdon C, Mohiddin A, Opiyo N, Torloni MR, et al. Interventions to reduce unnecessary caesarean sections in healthy women and babies. Lancet. 2018;392(10155):1358–68. doi: 10.1016/S0140-6736(18)31927-5 30322586

51. Boerma T, Ronsmans C, Melesse DY, Barros AJD, Barros FC, Juan L, et al. Global epidemiology of use of and disparities in caesarean sections. Lancet. 2018;392(10155):1341–8. doi: 10.1016/S0140-6736(18)31928-7 30322584

52. Sandall J, Tribe RM, Avery L, Mola G, Visser GH, Homer CS, et al. Short-term and long-term effects of caesarean section on the health of women and children. Lancet. 2018;392(10155):1349–57. doi: 10.1016/S0140-6736(18)31930-5 30322585

53. Vogel JP, Betran AP, Vindevoghel N, Souza JP, Torloni MR, Zhang J, et al. Use of the Robson classification to assess caesarean section trends in 21 countries: a secondary analysis of two WHO multicountry surveys. Lancet Glob Health. 2015;3(5):e260–70. doi: 10.1016/S2214-109X(15)70094-X 25866355

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