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

Abstract

Background: 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.

Conclusions: 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.

Fig 1. Intercountry variation of onset of labour in 2013 (%).

(A) Nulliparous women. (B) Multiparous women. BEL, Belgium; CHL, Chile; CS, cesarean section; DNK, Denmark; ENG, England; FIN, Finland; HESSE, the state of Hesse (Germany); IRL, Ireland; ISL, Iceland; MLT, Malta; NLD, the Netherlands; NOR, Norway; SWE, Sweden; USA, United States of America.

Fig 2. Intercountry variation of mode of birth in 2013 (%).

(A) Nulliparous women. (B) Multiparous women. BEL, Belgium; CHL, Chile; DNK, Denmark; ENG, England; FIN, Finland; HESSE, the state of Hesse (Germany); IRL, Ireland; ISL, Iceland; MLT, Malta; NLD, the Netherlands; NOR, Norway; SWE, Sweden; USA, United States of America.

Fig 3. Intercountry variation of interventions to stimulate uterine contractions in 2013 (%).

(A) Nulliparous women. (B) Multiparous women. AROM, artificial rupture of membranes; BEL, Belgium; CHL, Chile; DNK, Denmark; ENG, England; FIN, Finland; HESSE, the state of Hesse (Germany); IRL, Ireland; ISL, Iceland; MLT, Malta; NLD, the Netherlands; NOR, Norway; SWE, Sweden; USA, United States of America.

Fig 4. Intercountry variation of pain medication during labour in 2013 (%).

(A) Nulliparous women. (B) Multiparous women. BEL, Belgium; CHL, Chile; DNK, Denmark; ENG, England; FIN, Finland; HESSE, the state of Hesse (Germany); IRL, Ireland; ISL, Iceland; MLT, Malta; NLD, the Netherlands; NOR, Norway; SWE, Sweden; USA, United States of America.

Fig 5. Intercountry variation of episiotomy and OASI in 2013 (%).BEL, Belgium; CHL, Chile; DNK, Denmark; ENG, England; FIN, Finland; HESSE, the state of Hesse (Germany); IRL, Ireland; ISL, Iceland; OASI, obstetric anal sphincter injury; MLT, Malta; NLD, the Netherlands; NOR, Norway; SWE, Sweden; USA, United States of America.

Fig 6. Interventions among multiparous women with a correlation with the incidence of births at ≥42 weeks’ gestation.

(A) Negative correlation. (B) Positive correlation. CS, cesarean section.

Fig 7. Interventions among nulliparous women with a correlation with emergency CS.

CS, cesarean section.