Regional practice variation in induction of labor in the Netherlands: Does it matter? A multilevel analysis of the association between induction rates and perinatal and maternal outcomes

Abstract

Background Practice variation in healthcare is a complex issue. We focused on practice variation in induction of labor between maternity care networks in the Netherlands. These collaborations of hospitals and midwifery practices are jointly responsible for providing high-quality maternity care. We explored the association between induction rates and maternal and perinatal outcomes. Methods In a retrospective population-based cohort study, we included records of 184,422 women who had a singleton, vertex birth of their first child after a gestation of at least 37 weeks in the years 2016–2018. We calculated induction rates for each maternity care network. We divided networks in induction rate categories: lowest (Q1), moderate (Q2-3) and highest quartile (Q4). We explored the association of these categories with unplanned caesarean sections, unfavorable maternal outcomes and adverse perinatal outcomes using descriptive statistics and multilevel logistic regression analysis corrected for population characteristics. Findings The induction rate ranged from 14.3% to 41.1% (mean 24.4%, SD 5.3). Women in Q1 had fewer unplanned caesarean sections (Q1: 10.2%, Q2-3: 12.1%; Q4: 12.8%), less unfavorable maternal outcomes (Q1: 33.8%; Q2-3: 35.7%; Q4: 36.3%) and less adverse perinatal outcomes (Q1: 1.0%; Q2-3: 1.1%; Q4: 1.3%). The multilevel analysis showed a lower unplanned caesarean section rate in Q1 in comparison with reference category Q2-3 (OR 0.83; p = .009). The unplanned caesarean section rate in Q4 was similar to the reference category. No significant associations with unfavorable maternal or adverse perinatal outcomes were observed. Conclusion Practice variation in labor induction is high in Dutch maternity care networks, with limited association with maternal outcomes and no association with perinatal outcomes. Networks with low induction rates had lower unplanned caesarean section rates compared to networks with moderate rates. Further in-depth research is necessary to understand the mechanisms that contribute to practice variation and the observed association with unplanned caesarean sections.

Shroud waving self-determination: A qualitative analysis of the moral and epistemic dimensions of obstetric violence in the Netherlands

“…This particular discussion was about the fact that the mother did not want to be induced when recommended by the guidelines. Note that induction rates in the Netherlands are highly dependent on the region in the Netherlands, ranging from 14.3% to 41.1% [ 42 ]. The mother was additionally considered high risk due to a high BMI, so they wanted her to birth in the hospital while she wanted to give birth at home.…”

In-Depth Analysis of Caesarean Section Rate in the Largest Secondary Care-Level Maternity Hospital in Latvia

“…Within Group 2, 75.8% (198/261) were women with induced labour. The CS rate for nulliparous women with induced labour varied in previous studies from 10.2% to 38.7% [28][29][30] depending on gestational age at the time of induction, labour management, national guidelines and traditions, and other factors. The CS rate in the RMH for this subgroup was not outstanding (24.9%), while nulliparous women with term singleton pregnancy and spontaneous labour onset or induced labour made the same absolute contribution to the overall CS rate -3.4% each.…”

Editorial: Approaches to, and the implications of, timing of birth

“…Indeed, in both uncomplicated and complicated pregnancies at term, in randomised controlled trials induction appears to consistently increase the opportunities to give birth vaginally (2)(3)(4)(5), albeit that this may not be the only outcome of value to women and their context. It is important to notice that in observational studies, such as registry-based studies, it seems the other way around: in regions with low induction of labour rates, also fewer unplanned Caesareans were observed (6). This apparent contradiction requires ongoing investigation and is a source of debate amongst the editors.…”