title: Variation in referrals to secondary obstetrician-led care among primary midwifery care practices in the Netherlands: a nationwide cohort study.
abstract: BACKGROUND
  The primary aim of this study was to describe the variation in intrapartum referral rates in midwifery practices in the Netherlands. Secondly, we wanted to explore the association between the practice referral rate and a woman's chance of an instrumental birth (caesarean section or vaginal instrumental birth).
  
  
  METHODS
  We performed an observational study, using the Dutch national perinatal database. Low risk births in all primary care midwifery practices over the period 2008-2010 were selected. Intrapartum referral rates were calculated. The referral rate among nulliparous women was used to divide the practices in three tertile groups. In a multilevel logistic regression analysis the association between the referral rate and the chance of an instrumental birth was examined.
  
  
  RESULTS
  The intrapartum referral rate varied from 9.7 to 63.7 percent (mean 37.8; SD 7.0), and for nulliparous women from 13.8 to 78.1 percent (mean 56.8; SD 8.4). The variation occurred predominantly in non-urgent referrals in the first stage of labour. In the practices in the lowest tertile group more nulliparous women had a spontaneous vaginal birth compared to the middle and highest tertile group (T1: 77.3%, T2:73.5%, T3: 72.0%). For multiparous women the spontaneous vaginal birth rate was 97%. Compared to the lowest tertile group the odds ratios for nulliparous women for an instrumental birth were 1.22 (CI 1.16-1.31) and 1.33 (CI 1.25-1.41) in the middle and high tertile groups. This association was no longer significant after controlling for obstetric interventions (pain relief or augmentation).
  
  
  CONCLUSIONS
  The wide variation between referral rates may not be explained by medical factors or client characteristics alone. A high intrapartum referral rate in a midwifery practice is associated with an increased chance of an instrumental birth for nulliparous women, which is mediated by the increased use of obstetric interventions. Midwives should critically evaluate their referral behaviour. A high referral rate may indicate that more interventions are applied than necessary. This may lead to a lower chance of a spontaneous vaginal birth and a higher risk on a PPH. However, a low referral rate should not be achieved at the cost of perinatal safety.
authors.affiliation: KNOV (Royal Dutch Organisation for Midwives), P.O. Box 2001, 3500GA, Utrecht, the Netherlands. 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, 1007MB, Amsterdam, the Netherlands. c.geerts@vumc.nl.
authors.forename: Caroline
authors.initials: C
authors.lastname: Geerts
authors.affiliation: Department of Midwifery Science, AVAG and the EMGO Institute for Health and Care Research, VU University Medical Center, P.O. Box 7057, 1007MB, Amsterdam, the Netherlands. ank.dejonge@vumc.nl.
authors.forename: Ank
authors.initials: A
authors.lastname: de Jonge
authors.affiliation: PRN (the Netherlands Perinatal Registry), P.O. Box 8588, 3503RN, Utrecht, the Netherlands. chukkelhoven@perinatreg.nl.
authors.forename: Chantal W P M
authors.initials: CW
authors.lastname: Hukkelhoven
authors.affiliation: Department of Epidemiology and Biostatistics, VU University Medical Center, P.O. Box 7057, 1007MB, Amsterdam, the Netherlands. jwr.twisk@vumc.nl.
authors.forename: Jos W R
authors.initials: JW
authors.lastname: Twisk
authors.affiliation: Radboud University Nijmegen Medical Centre, Internal postal code 118, P.O. Box 9101, 6500HB, Nijmegen, the Netherlands. Toine.Lagro@radboudumc.nl.
authors.forename: Antoine L M
authors.initials: AL
authors.lastname: Lagro-Janssen
mesh_terms: D000328:Adult; D015331:Cohort Studies; D036861:Delivery, Obstetric / Q000009:adverse effects / Q000379:methods / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D008880:Midwifery; D009426:Netherlands / Q000453:epidemiology; D007744:Obstetric Labor Complications / Q000175:diagnosis / Q000453:epidemiology / Q000517:prevention & control; D010298:Parity; D011247:Pregnancy; D011256:Pregnancy Outcome / Q000453:epidemiology; D011295:Prenatal Care / Q000379:methods / Q000706:statistics & numerical data; D063127:Secondary Health Care / Q000379:methods / Q000706:statistics & numerical data