Delivering babies in a time of transition in Tula, Russia.

OBJECTIVE: To investigate the provision of maternal services in the Tula region of Russia, with an emphasis on variations in practice. METHOD: The study was set in Tula Oblast. Data sources included an obstetric information database detailing all Tula deliveries in 2000 (n = 11,123) and structured interviews with the heads of maternity facilities and hospital maternity departments. RESULTS: Caesarean-section rates varied from 3.3-37%; episiotomy from 9-80%; and amniocentesis from 0-51%. As fertility rates fell since the 1980s, increasing numbers of women were hospitalized for 'pathological pregnancy' in an attempt to preserve infrastructure. CONCLUSION: Over-medicalization arises in a system typified by excess capacity and large numbers of specialists. Some practice variations were correlated with characteristics of mothers, but others derive from systems structures such as equipment availability. Improvements in practice will require addressing these structural elements and steering the clinical culture towards evidence-based medicine, rather than simply writing new decrees.