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. 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.

In Denmark, the cesarean section rate has increased by 49% between 1998 and 2015 and accounts for 21% of all births. Cesarean sections may cause short- as well as long-term consequences for both the mother and the child and impose further risks in future pregnancies. Delaying pregnancy until advanced maternal age at childbirth has been suggested as contributing to the increase. The proportion of women giving birth at 35 years or above increased from 15% (1998) to 21% (2015). Advanced maternal age at childbirth has been found to be related to increased pre-pregnancy morbidity and associated risk factors that may contribute to an increased risk of cesarean section. The aim of this study was to examine the association between advanced maternal age and cesarean section in a Danish population and the influence of demographic, anthropometric, health, and obstetric factors on this association. This study draws on a national population-based cohort study of all Danish births between 1998 and 2015 (N = 1,122,964). Maternal age less than 30 years serves as reference with the following age categories: (30–34 years); (35–39 years), and (40 years and above). The primary outcome was a cesarean section. Multivariate regression models with adjustment for demographic, health, pregnancy, fetal, and obstetric characteristics were performed with the results further stratified by parity. In general, a positive association between advanced maternal age and cesarean section was found. Only minor changes in the risk estimate occurred after adjustment for relevant confounders. In comparison with the reference category, nulliparous women aged 35-39- years had twice the risk for cesarean section (adjusted odds ratio (AOR) 2.18, 95% confidence interval (CI) [2.11–2.26]) whereas for women of 40 years or above, the risk was more than tripled (AOR 3.64, 95% CI [3.41–3.90]). For multiparous women aged 35-39-years the risk was more moderate, but still with an AOR of 1.56, 95% CI [1.53–1.60], and for those 40 years and above, the AOR was 2.02, 95% CI [1.92–2.09]. Overall, cesarean section increased with increasing maternal age. Adjustment for maternal and obstetric risk factors had only a minor influence on the association. The association was stronger in nulliparous women compared to multiparous women. Given the lack of impact of demographic and health risks on the relationship between maternal age and cesarean section, the authors suggest obstetric culture could be added to the list of risk factors for a cesarean. Future research on obstetric culture is recommended as are studies on a possible age-related decrease in the ability to maintain the progression of labor. The study uses depersonalized register data and has been approved by the Danish Data Protection Agency (2015-41-4168).

Objective: The objective of this review was to identify, assess and synthesize the best available evidence on the effects of induction prior to post-term on the mother and fetus. Maternal and fetal outcomes after routine labor induction in low-risk pregnancies at 41+0 to 41+6 gestational weeks (prior to post-term) were compared to routine labor induction at 42+0 to 42+6 gestational weeks (post-term). Introduction: Induction of labor when a pregnancy exceeds 14 days past the estimated due date has long been used as an intervention to prevent adverse fetal and maternal outcomes. Over the last decade, clinical procedures have changed in many countries towards earlier induction. A shift towards earlier inductions may lead to 15–20% more inductions. Given the fact that induction as an intervention can cause harm to both mother and child, it is essential to ensure that the benefits of the change in clinical practice outweigh the harms. Inclusion criteria: This review included studies with participants with expected low-risk deliveries, where both fetus and mother were considered healthy at inclusion and with no known risks besides the potential risk of the ongoing pregnancy. Included studies evaluated induction at 41+1–6 gestational weeks compared to 42+1–6 gestational weeks. Randomized control trials (n = 2), quasi-experimental trials (n = 2), and cohort studies (n = 3) were included. The primary outcomes of interest were cesarean section, instrumental vaginal delivery, low Apgar score (≤ 7/5 min.), and low pH (< 7.10). Secondary outcomes included additional indicators of fetal or maternal wellbeing related to prolonged pregnancy or induction. Methods: The following information sources were searched for published and unpublished studies: PubMed, CINAHL, Embase, Scopus, Swemed+, POPLINE; Cochrane, TRIP; Current Controlled Trials; Web of Science, and, for gray literature: MedNar; Google Scholar, ProQuest Nursing & Allied Health Source, and guidelines from the Royal College of Obstetricians and Gynaecologists, and American College of Obstetricians and Gynecologists, according to the published protocol. In addition, OpenGrey and guidelines from the National Institute for Health and Care Excellence, World Health Organization, and Society of Obstetricians and Gynaecologists of Canada were sought. Included papers were assessed by all three reviewers independently using the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information (JBI SUMARI). The standardized data extraction tool from JBI SUMARI was used. Data were pooled in a statistical meta-analysis model using RevMan 5, when the criteria for meta-analysis were met. Non-pooled results were presented separately. Results: Induction at 41+0–6 gestational weeks compared to 42+0–6 gestational weeks was found to be associated with an increased risk of overall cesarean section (relative risk [RR] = 1.11, 95% confidence interval [CI] 1.09–1.14), cesarean section due to failure to progress (RR = 1.43, 95% CI 1.01–2.01), chorioamnionitis (RR = 1.13, 95% CI 1.05–1.21), labor dystocia (RR = 1.29, 95% CI 1.22–1.37), precipitate labor (RR = 2.75, 95% CI 1.45–5.2), uterine rupture (RR = 1.97, 95% CI 1.54–2.52), pH < 7.10 (RR = 1.9, 95% CI 1.48–2.43), and a decreased risk of oligohydramnios (RR = 0.4, 95% CI 0.24–0.67) and meconium stained amniotic fluid (RR = 0.82, 95% CI 0.75–0.91). Data lacked statistical power to draw conclusions on perinatal death. No differences were seen for postpartum hemorrhage, shoulder dystocia, meconium aspiration, 5-minute Apgar score < 7, or admission to neonatal intensive care unit. A policy of awaiting spontaneous onset of labor until 42+0–6 gestational weeks showed, that approximately 70% went into spontaneous labor. Conclusions: Induction prior to post-term was associated with few beneficial outcomes and several adverse outcomes. This draws attention to possible iatrogenic effects affecting large numbers of low-risk women in contemporary maternity care. According to the World Health Organization, expected benefits from a medical intervention must outweigh potential harms. Hence, our results do not support the widespread use of routine induction prior to post-term (41+0–6 gestational weeks).

Objectives: For many years, routine elective induction of labour at gestational week (GW) 42+0 has been recommended in Denmark. In 2011, a more proactive protocol was introduced aimed at reducing stillbirths, and practice changed into earlier routine induction, i.e. between 41+3 and 41+5 GW. The present study evaluates a national change in induction of labour regime. The trend of maternal and neonatal consequences are monitored in the preintervention period (2000–2010) compared with the postintervention period (2012–2016).Design: A national retrospective register-based cohort study.Setting: Denmark.Participants: All births in Denmark 41+3 to 45+0 GWs between 2000 and 2016 (N = 152 887).Outcome measures: Primary outcomes: stillbirths, perinatal death, and low Apgar scores. Additional outcomes: birth interventions and maternal outcomes.Results: For the primary outcomes, no differences in stillbirths, perinatal death, and low Apgar scores were found comparing the preintervention and postintervention period. Of additional outcomes, the trend changed significantly postintervention concerning use of augmentation of labour, epidural analgesia, induction of labour and uterine rupture (all p<0.05). There was no significant change in the trend for caesarean section and instrumental birth. Most notable for clinical practice was the increase in induction of labour from 41% to 65% (p<0.01) at 41+3 weeks during 2011 as well as the rare occurrence of uterine ruptures (from 2.6 to 4.2 per thousand, p<0.02).Conclusions: Evaluation of a more proactive regimen recommending induction of labour from GW 41+3 compared with 42+0 using national register data found no differences in neonatal outcomes including stillbirth. The number of women with induced labour increased significantly.

Current labour practices have seen an acceleration in interventions to either initiate, monitor, accelerate, or terminate the physiological process of pregnancy and childbirth. This study aimed to describe and analyse the use of interventions in childbirth in Denmark over almost two decades (2000-2017). We also examined the extent to which contemporary care adheres to current international recommendations towards restricted use of interventions. A national retrospective Danish register-based cohort study including all nulliparous women with term births with singleton pregnancy and a foetus in cephalic between the years 2000 and 2017 (n = 380,326 births). Multivariate regression analyses with adjustment for change in population were performed. Induction of labour, epidural analgesia, and augmentation of labour. Between 2000/2001 and 2016/2017, the prevalence increased for induction of labour from 5.1% to 22.8%, AOR 4.84, 95% CI [4.61-5.10], epidural analgesia from 10.5% to 34.3% (AOR 4.10, 95% CI [3.95-4.26]), and augmentation of labour decreased slightly from 40.1% to 39.3% (AOR 0.84, 95% CI [0.81-0.86]). Having more than one of the three mentioned interventions increased from 12.8% in to 30.9%. The number of interventions increased during the study period as well as the number of interventions in each woman. As interventions may interfere in physiological labour and carry the risk of potential short- and long-term consequences, the findings call for a careful re-evaluation of contemporary maternity care with a "first, do no harm" perspective.

Introduction There are growing concerns about the increase in rates of commonly used childbirth interventions. When indicated, childbirth interventions are crucial for preventing maternal and perinatal morbidity and mortality, but their routine use in healthy women and children leads to avoidable maternal and neonatal harm. Establishing ideal rates of interventions can be challenging. This study aims to describe the range of variations in the use of commonly used childbirth interventions in high-income countries around the world, and in outcomes in nulliparous and multiparous women. Methods and analysis This multinational cross-sectional study will use data from births in 2013 with national population data or representative samples of the population of pregnant women in high-income countries. Data from women who gave birth to a single child from 37 weeks gestation onwards will be included and the results will be presented for nulliparous and multiparous women separately. Anonymised individual level data will be analysed. Primary outcomes are rates of commonly used childbirth interventions, including induction and/or augmentation of labour, intrapartum antibiotics, epidural and pharmacological pain relief, episiotomy in vaginal births, instrument-assisted birth (vacuum or forceps), caesarean section and use of oxytocin postpartum. Secondary outcomes are maternal and perinatal mortality, Apgar score below 7 at 5 min, postpartum haemorrhage and obstetric anal sphincter injury. Univariable and multivariable logistic regression analyses will be conducted to investigate variations among countries, adjusted for maternal age, body mass index, gestational weight gain, ethnic background, socioeconomic status and infant birth weight. The overall mean rates will be considered as a reference category, weighted for the size of the study population per country. Ethics and dissemination The Medical Ethics Review Committee of VU University Medical Center Amsterdam confirmed that an official approval of this study was not required. Results will be disseminated at national and international conferences and published in peer-reviewed journals.