title: Change in primary midwife-led care in the Netherlands in 2000-2008: a descriptive study of caesarean sections and other interventions among 789,795 low risk births.
abstract: OBJECTIVE
  to study whether an increase in intrapartum referrals in primary midwife-led care births in the Netherlands is accompanied by an increase in caesarean sections.
  
  
  METHODS
  nationwide descriptive study.
  
  
  METHODS
  the Netherlands Perinatal Registry.
  
  
  METHODS
  789,795 births of nine year cohorts of women with low risk pregnancies in primary midwife-led care at the onset of labour between 2000 and 2008.
  
  
  METHODS
  primary outcome is the caesarean section rate. Vaginal instrumental delivery, augmentation with oxytocin, and pharmacological pain relief are secondary outcomes. Trends in outcomes are described. We used logistic regression to explore whether changes in the planned place of birth and other maternal characteristics influenced the caesarean section rate.
  
  
  RESULTS
  the caesarean section rate did not increase and was 5.5 per cent (range 4.9-6.3 per cent) for nulliparous women, and 1.0 per cent (range 0.8-1.1 per cent) for multiparous women. After controlling for the decline in planned home births and other maternal characteristics no increase in the caesarean section rate was found. The vaginal instrumental birth rate showed no increase, and was 18.1 per cent (range 17.9-18.5 per cent) for nulliparous women and 1.5 per cent (range 1.4-1.7 per cent) for multiparous women. Augmentation of labour and/or pharmacological pain relief increased from 24.0 to 38.8 per cent for nulliparous women, and from 5.4 to 10.0 per cent for multiparous women.
  
  
  CONCLUSIONS
  the rise in intrapartum referrals was not accompanied by an increase in caesarean section rate over the period 2000-2008. Despite a considerable rise in the use of pain relief and augmentation, the rate of spontaneous vaginal birth remained high for low risk women who started labour in primary midwife-led care.
  
  
  CONCLUSIONS
  the current strict role division between primary care midwives and the obstetrician-led team increasingly results in a change in care provider during labour. In a more integrated care system, more women can receive continuous support of labour from their own primary care midwife, as long as only supportive interventions are needed.
authors.affiliation: KNOV (Royal Dutch Organisation for Midwives), P.O. Box 2001, 3500 GA Utrecht, The Netherlands. Electronic address: pofferhaus@knov.nl.
authors.forename: Pien M
authors.initials: PM
authors.lastname: Offerhaus
authors.affiliation: Department of Midwifery Science, AVAG and the EMGO Institute for Health and Care Research, VU University Medical Center, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands. Electronic address: ank.dejonge@vumc.nl.
authors.forename: Ank
authors.initials: A
authors.lastname: de Jonge
authors.affiliation: TNO Child Health, P.O. Box 2215, 2301 CE Leiden, The Netherlands. Electronic address: Karin.vanderpal@tno.nl.
authors.forename: Karin M
authors.initials: KM
authors.lastname: van der Pal-de Bruin
authors.affiliation: The Netherlands Perinatal Registry, P.O. Box 8588, 3503 RN Utrecht, The Netherlands. Electronic address: chukkelhoven@perinatreg.nl.
authors.forename: Chantal W P M
authors.initials: CW
authors.lastname: Hukkelhoven
authors.affiliation: Faculty of Social Sciences, Radboud University, P.O. Box 9104, 6500 HE Nijmegen, The Netherlands. Electronic address: p.scheepers@maw.ru.nl.
authors.forename: Peer L H
authors.initials: PL
authors.lastname: Scheepers
authors.affiliation: Radboud University Nijmegen Medical Centre, Internal Postal Code 118, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands. Electronic address: A.Lagro-Janssen@elg.umcn.nl.
authors.forename: Antoine L M
authors.initials: AL
authors.lastname: Lagro-Janssen
mesh_terms: D002585:Cesarean Section / Q000401:mortality / Q000706:statistics & numerical data*; D036861:Delivery, Obstetric / Q000639:trends*; D005260:Female; D006801:Humans; D009321:Natural Childbirth / Q000401:mortality / Q000706:statistics & numerical data*; D009426:Netherlands / Q000453:epidemiology; D036801:Parturition; D011247:Pregnancy; D059017:Primary Care Nursing / Q000401:mortality / Q000706:statistics & numerical data*; D012306:Risk
keywords: Home birth; Maternity care; Midwifery; Obstetrical interventions