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Purpose: To investigate trends and regional variations in uterotonics dispensed around birth between 2003 and 2018 in Belgium. Methods: Data, including outpatient and inpatient prescriptions were extracted from a nationally representative prescription database. The prevalence of uterotonics dispensed during a period including the 7 days before birth, the delivery day and the 7 days after birth was computed over three 4‐year‐long study periods from 2003 to 2018. The trends between periods and associations between the use of at least one uterotonic and maternal age, region of residence, delivery type and social status were assessed using logistic regression. Results: In total, 31 675 pregnancies were included in the study. The proportion of pregnancies exposed to at least one uterotonic decreased significantly from 92.9% (95%CI, 92.3–93.4) in 2003–2006 to 91.4% (95%CI, 90.7–92.0) in 2015–2018 for vaginal births and from 95.5% (95%CI, 94.5–96.4) to 93.7% (95%CI, 92.6–94.7) for caesarean sections. However, for vaginal births, the proportion of oxytocin increased from 84.5% (95%CI, 83.7–85.2) to 89% (95%CI 88.3–89.7). A significant association was found between uterotonic agent use and maternal age, region of residence, and delivery type. The dispensation of some uterotonic agents differed significantly between the regions. Conclusions: The proportion of pregnancies exposed to at least one uterotonic was high across the study period but decreased slightly between 2003 and 2018. Important variations in uterotonic use between regions highlight the need for improved national guidance. [ABSTRACT FROM AUTHOR]