Regional variations in childbirth interventions and their correlations with adverse outcomes, birthplace and care provider: A nationwide explorative study

Background

Variations in childbirth interventions may indicate inappropriate use. Most variation studies are limited by the lack of adjustments for maternal characteristics and do not investigate variations in adverse outcomes. This study aims to explore regional variations in the Netherlands and their correlations with referral rates, birthplace, interventions, and adverse outcomes, adjusted for maternal characteristics.

Methods

In this nationwide retrospective cohort study, using a national data register, intervention rates were analysed between twelve regions among single childbirths after 37 weeks’ gestation in 2010–2013 (n = 614,730). These were adjusted for maternal characteristics using multivariable logistic regression. Primary outcomes were intrapartum referral, birthplace, and interventions used in midwife- and obstetrician-led care. Correlations both between primary outcomes and between adverse outcomes were calculated with Spearman’s rank correlations.

Findings

Intrapartum referral rates varied between 55–68% (nulliparous) and 20–32% (multiparous women), with a negative correlation with receiving midwife-led care at the onset of labour in two-thirds of the regions. Regions with higher referral rates had higher rates of severe postpartum haemorrhages. Rates of home birth varied between 6–16% (nulliparous) and 16–31% (multiparous), and was negatively correlated with episiotomy and postpartum oxytocin rates. Among midwife-led births, episiotomy rates varied between 14–42% (nulliparous) and 3–13% (multiparous) and in obstetrician-led births from 46–67% and 14–28% respectively. Rates of postpartum oxytocin varied between 59–88% (nulliparous) and 50–85% (multiparous) and artificial rupture of membranes between 43–52% and 54–61% respectively. A north-south gradient was visible with regard to birthplace, episiotomy, and oxytocin.

Conclusions

Our study suggests that attitudes towards interventions vary, independent of maternal characteristics. Care providers and policy makers need to be aware of reducing unwarranted variation in birthplace, episiotomy and the postpartum use of oxytocin. Further research is needed to identify explanations and explore ways to reduce unwarranted intervention rates.

Mode of birth and medical interventions among women at low risk of complications: A cross-national comparison of birth settings in England and the Netherlands

OBJECTIVES

To compare mode of birth and medical interventions between broadly equivalent birth settings in England and the Netherlands.

METHODS

Data were combined from the Birthplace study in England (from April 2008 to April 2010) and the National Perinatal Register in the Netherlands (2009). Low risk women in England planning birth at home (16,470) or in freestanding midwifery units (11,133) were compared with Dutch women with planned home births (40,468). Low risk English women with births planned in alongside midwifery units (16,418) or obstetric units (19,096) were compared with Dutch women with planned midwife-led hospital births (37,887).

RESULTS

CS rates varied across planned births settings from 6.5% to 15.5% among nulliparous and 0.6% to 5.1% among multiparous women. CS rates were higher among low risk nulliparous and multiparous English women planning obstetric unit births compared to Dutch women planning midwife-led hospital births (adjusted (adj) OR 1.89 (95% CI 1.64 to 2.18) and 3.66 (2.90 to 4.63) respectively). Instrumental vaginal birth rates varied from 10.7% to 22.5% for nulliparous and from 0.9% to 5.7% for multiparous women. Rates were lower in the English comparison groups apart from planned births in obstetric units. Transfer, augmentation and episiotomy rates were much lower in England compared to the Netherlands for all midwife-led groups. In most comparisons, epidural rates were higher among English groups.

CONCLUSIONS

When considering maternal outcomes, findings confirm advantages of giving birth in midwife-led settings for low risk women. Further research is needed into strategies to decrease rates of medical intervention in obstetric units in England and to reduce rates of avoidable transfer, episiotomy and augmentation of labour in the Netherlands.

Pregnancy related anxiety and general anxious or depressed mood and the choice for birth setting: a secondary data-analysis of the DELIVER study

Background

In several developed countries women with a low risk of complications during pregnancy and childbirth can make choices regarding place of birth. In the Netherlands, these women receive midwife-led care and can choose between a home or hospital birth. The declining rate of midwife-led home births alongside the recent debate on safety of home births in the Netherlands, however, suggest an association of choice of birth place with psychological factors related to safety and risk perception. In this study associations of pregnancy related anxiety and general anxious or depressed mood with (changes in) planned place of birth were explored in low risk women in midwife-led care until the start of labour.

Methods

Data (n = 2854 low risk women in midwife-led care at the onset of labour) were selected from the prospective multicenter DELIVER study. Women completed the Pregnancy Related Anxiety Questionnaire-Revised (PRAQ-R) to assess pregnancy related anxiety and the EuroQol-6D (EQ-6D) for an anxious and/or depressed mood.

Results

A high PRAQ-R score was associated with planned hospital birth in nulliparous (aOR 1.92; 95% CI 1.32–2.81) and parous women (aOR 2.08; 95% CI 1.55–2.80). An anxious or depressed mood was associated with planned hospital birth (aOR 1.58; 95% CI 1.20–2.08) and with being undecided (aOR 1.99; 95% CI 1.23–2.99) in parous women only. The majority of women did not change their planned place of birth. Changing from an initially planned home birth to a hospital birth later in pregnancy was, however, associated with becoming anxious or depressed after 35 weeks gestation in nulliparous women (aOR 4.17; 95% CI 1.35–12.89) and with pregnancy related anxiety at 20 weeks gestation in parous women (aOR 3.91; 95% CI 1.32–11.61).

Conclusion

Low risk women who planned hospital birth (or who were undecided) more often reported pregnancy related anxiety or an anxious or depressed mood. Women who changed from home to hospital birth during pregnancy more often reported pregnancy related anxiety or an anxious or depressed mood in late pregnancy. Anxiety should be adequately addressed in the process of informed decision-making regarding planned place of birth in low risk women.

Perinatal mortality and morbidity up to 28 days after birth among 743 070 low-risk planned home and hospital births: a cohort study based on three merged national perinatal databases

OBJECTIVE

To compare rates of adverse perinatal outcomes between planned home births versus planned hospital births.

DESIGN

A nationwide cohort study.

SETTING

The Netherlands.

POPULATION

Low-risk women in midwife-led care at the onset of labour.

METHODS

Analysis of national registration data.

MAIN OUTCOME MEASURES

Intrapartum and neonatal death, Apgar scores, and admission to a neonatal intensive care unit (NICU) within 28 days of birth.

RESULTS

Of the total of 814 979 women, 466 112 had a planned home birth and 276 958 had a planned hospital birth. For 71 909 women, their planned place of birth was unknown. The combined intrapartum and neonatal death rates up to 28 days after birth, including cases with discrepancies in the registration of the moment of death, were: for nulliparous women, 1.02‰ for planned home births versus 1.09‰ for planned hospital births, adjusted odds ratio (aOR) 0.99, 95% confidence interval (95% CI) 0.79-1.24; and for parous women, 0.59‰ versus 0.58‰, aOR 1.16, 95% CI 0.87-1.55. The rates of NICU admissions and low Apgar scores did not significantly differ among nulliparous women (NICU admissions up to 28 days, 3.41‰ versus 3.61‰, aOR 1.05, 95% CI 0.92-1.18). Among parous women the rates of Apgar scores below seven and NICU admissions were significantly lower among planned home births (NICU admissions up to 28 days, 1.36 versus 1.95‰, aOR 0.79, 95% CI 0.66-0.93).

CONCLUSIONS

We found no increased risk of adverse perinatal outcomes for planned home births among low-risk women. Our results may only apply to regions where home births are well integrated into the maternity care system.

Effect of physical activity on vascular characteristics in young children

BACKGROUND

Physical activity has long been proposed as an important modifiable cardiovascular risk factor in adults. We assessed whether physical activity already has an effect on childhood vasculature.

METHODS

In the Wheezing-Illnesses-Study-in-Leidsche-Rijn birth cohort, we performed vascular ultrasound to measure carotid intima-media thickness (cIMT) and functional properties (distensibility, elastic modulus) at 5 and 8 years of age. Child typical physical activities were inquired using a questionnaire completed by parents. Linear regression was used with physical activity level, expressed as a standardized value of time-weighted metabolic equivalent (MET) as the independent variable and vascular properties as dependent variables with further confounder adjustment and evaluation for possible body mass index and sex effect modifications.

RESULTS

In 595 5-year-old children and in 237 of those who had reached the age of 8 years, we did not find statistically significant associations between total time-weighted MET and each vascular parameter, neither in pooled nor stratified analysis. However, sport activities were associated with thinner cIMT (-3.20 µm/SD, 95% CI -6.34, -0.22, p = 0.04) at 5 years of age; a similar pattern was seen for organized sport. This effect was strongest in children in the highest body mass index tertile (-5.38 µm/SD, 95% CI -10.54, -0.19, p = 0.04). At the age of 8 years, higher sport level tended to be associated with higher vascular distensibility (2.64 × 10(3) kPa/SD, 95% CI -0.18, 5.45, p = 0.07) although this was not statistically significant.

CONCLUSIONS

Sport activity may have beneficial effects on arteries of young children, particularly those with higher relative body weight.

Birth setting, transfer and maternal sense of control: results from the DELIVER study

BACKGROUND

In the Netherlands, low risk women receive midwife-led care and can choose to give birth at home or in hospital. There is concern that transfer of care during labour from midwife-led care to an obstetrician-led unit leads to negative birth experiences, in particular among those with planned home birth. In this study we compared sense of control, which is a major attribute of the childbirth experience, for women planning home compared to women planning hospital birth under midwife-led care. In particular, we studied sense of control among women who were transferred to obstetric-led care during labour according to planned place of birth: home versus hospital.

METHODS

We used data from the prospective multicentre DELIVER (Data EersteLIjns VERloskunde) cohort-study, conducted in 2009 and 2010 in the Netherlands. Sense of control during labour was assessed 6 weeks after birth, using the short version of the Labour Agentry Scale (LAS-11). A higher LAS-11 score indicates a higher feeling of control. We considered a difference of a minimum of 5.5 points as clinically relevant.

RESULTS

Nulliparous- and parous women who planned a home birth had a 2.6 (95% CI 1.0, 4.3) and a 3.0 (1.6, 4.4) higher LAS score during first stage of labour respectively and during second stage a higher score of 2.8 (0.9, 4.7) and 2.3 (0.6, 4.0), compared with women who planned a hospital birth. Overall, women who were transferred experienced a lower sense of control than women who were not transferred. Parous women who planned a home birth and who were transferred had a 4.3 (0.2, 8.4) higher LAS score in 2nd stage, compared to those who planned a hospital birth and who were transferred.

CONCLUSION

We found no clinically relevant differences in feelings of control among women who planned a home or hospital birth. Transfer of care during labour lowered feelings of control, but feelings of control were similar for transferred women who planned a home or hospital birth.As far as their expected sense of control is concerned, low risk women should be encouraged to give birth at the location of their preference.

The use of episiotomy in a low-risk population in the Netherlands: a secondary analysis

BACKGROUND

To examine the episiotomy incidence and determinants and outcomes associated with its use in primary care midwifery practices.

METHODS

Secondary analysis of two prospective cohort studies (n = 3,404).

RESULTS

The episiotomy incidence was 10.8 percent (20.9% for nulliparous and 6.3% for parous women). Episiotomy was associated with prolonged second stage of labor (adj. OR 12.09 [95% CI 6.0-24.2] for nulliparous and adj. OR 2.79 [1.7-4.6] for parous women) and hospital birth (adj. OR 1.75 [1.2-2.5] for parous women). Compared with episiotomy, perineal tears were associated with a lower rate of postpartum hemorrhage in parous women (adj. OR 0.58 [0.4-0.9]). Fewer women with perineal tears reported perineal discomfort (adj. OR 0.35 [0.2-0.6] for nulliparous and adj. OR 0.22 [0.1-0.3] for parous women). Among nulliparous women episiotomy was performed most frequently for prolonged second stage of labor (38.8%) and among parous women for history of episiotomy or prevention of major perineal trauma (21.1%).

CONCLUSIONS

The incidence of episiotomy is high compared with some low-risk settings in other Western countries. Episiotomy was associated with higher rates of adverse maternal outcomes. Restricted use of episiotomy is likely to be beneficial for women.

Body fat distribution and early arterial changes in healthy 5-year-old children

BACKGROUND

It is unknown at what age overweight starts to takes its toll on the vasculature. We studied the relation between body size measures and vascular characteristics in healthy 5-year-old children.

METHODS

In 306 5-year-old children from an on-going birth cohort, body size characteristics were measured, including sonographic measurement of abdominal fat. Ultrasonographic measurements of the carotid artery were performed to obtain intima-media thickness (CIMT), arterial wall distensibility, and elastic modulus (EM).

RESULTS

Increased body-weight was related to thicker CIMT (linear regression coefficient 2.25 μm/kg; P = 0.003), increased EM (2.73 kPa/kg; P = 0.01), and lower distensibility (-1.23 MPa(-1)/kg; P = 0.03). Similar relations were found for increased BMI with CIMT and EM. Increased intra-abdominal fat was related to thicker CIMT (9.19 μm/cm; P = 0.02), and increased waist circumference with thicker CIMT (2.17 μm/cm; P = 0.02), lower distensibility (-1.70 MPa(-1)/cm; P = 0.01), and higher EM (2.77 kPa/cm; P = 0.02), independent of BMI.

CONCLUSION

For the first time it is demonstrated that increased general body mass and particularly waist circumference and intra-abdominal fat are related to thicker and stiffer arteries already early in life.

Parental smoking and vascular damage in their 5-year-old children

BACKGROUND

The relation between smoke exposure in early life, the prenatal period in particular, and the vascular development of young children is largely unknown.

METHODS

Data from the birth cohort participating in the WHISTLER-Cardio study were used to relate the smoking of parents during pregnancy to subsequent vascular properties in their children. In 259 participating children who turned 5 years of age, parental smoking data were updated and children's carotid artery intima-media thickness (CIMT) and arterial wall distensibility were measured by using ultrasonography.

RESULTS

Children of mothers who had smoked throughout pregnancy had 18.8 μm thicker CIMT (95% confidence interval [CI] 1.1, 36.5, P = .04) and 15% lower distensibility (95% CI -0.3, -0.02, P = .02) after adjustment for child's age, maternal age, gender, and breastfeeding. The associations were not found in children of mothers who had not smoked in pregnancy but had smoked thereafter. The associations were strongest if both parents had smoked during pregnancy, with 27.7 μm thicker CIMT (95% CI 0.2, 55.3) and 21% lower distensibility (95% CI -0.4, -0.03).

CONCLUSION

Exposure of children to parental tobacco smoke during pregnancy affects their arterial structure and function in early life.

The association between breastfeeding and the cardiovascular system in early childhood

BACKGROUND

Breastfeeding is suggested to have beneficial effects on children's health and future health status. However, its cardiovascular effects in childhood and possibly later in life remain largely unclear.

OBJECTIVE

The aim of the present study was to determine the cardiovascular effects of exclusive breastfeeding in early childhood.

DESIGN

We used the ongoing WHeezing Illnesses STudy LEidsche Rijn (WHISTLER) birth cohort to obtain data on infant feeding. In the first 306 children who were 5 y of age, ultrasonographic measurements of the carotid artery were performed to obtain carotid intima-media thickness (CIMT), distensibility, and elastic modulus.

RESULTS

At 5 y of age, children who had been exclusively breastfed in infancy for 3 to 6 mo had a CIMT that was 21.1 μm greater than that of exclusively formula-fed children (95% CI: 5.0, 37.2 μm; P = 0.01, adjusted for confounders). CIMT was not significantly different between children exclusively breastfed for either <3 or >6 mo and formula-fed children. In addition, no significant differences in carotid stiffness were observed between groups.

CONCLUSIONS

The duration of exclusive breastfeeding in infancy is related to properties of the carotid arterial wall at the age of 5 y, as shown by the greater CIMT in children who were exclusively breastfed for 3 to 6 mo. This relation was independent of early growth in infancy and current cardiovascular disease risk factors. The choice of infant feeding appears to have an effect on the vascular system already in early childhood.

Tobacco smoke exposure of pregnant mothers and blood pressure in their newborns: results from the wheezing illnesses study Leidsche Rijn birth cohort

There is evidence to suggest that exposure of pregnant women to tobacco smoke is related to higher childhood blood pressure in their offspring. It is not well known whether this association is set in utero or by shared postnatal environments. The objective of this study was to assess the association between tobacco smoke exposure of pregnant mothers and blood pressure and heart rate of their newborns. In an unselected birth cohort, blood pressure and heart rate were measured in 456 infants at approximately 2 months of age. Smoking exposure of mothers in pregnancy was obtained by questionnaire. Of 456 mothers whose infants had blood pressure measured, 363 (79.6%) were not exposed to tobacco smoke in pregnancy, 63 (13.8%) did not smoke in pregnancy but were exposed by others, and 30 (6.6%) smoked. Infant offspring of mothers who had smoked during pregnancy had 5.4 mm Hg (95% CI: 1.2 to 9.7; P=0.01) higher systolic blood pressure levels than offspring of mothers who were not exposed to tobacco smoke in pregnancy, taking account of birth weight, infant age, gender, nutrition, and age of mother. No associations were found between maternal exposure to tobacco smoke in pregnancy and diastolic blood pressure. A positive association between maternal exposure to tobacco smoke and heart rate was largely explained by confounding. It can be concluded that maternal exposure to tobacco smoke in pregnancy has a substantial increasing effect on systolic blood pressure in early infancy.