Advancing an Evidence-Based Approach to Episiotomy
Episiotomies—incisions made between the vagina and anus during childbirth—have long been a topic of debate among clinicians, researchers and advocates. Outdated clinical guidelines previously recommended the routine use of episiotomy to avoid natural vaginal tearing. Over the past two decades, a growing body of literature and increased advocacy efforts have led to a general consensus that episiotomy should not be conducted as a standard practice. Nevertheless, in many parts of the world, the majority of women still undergo episiotomy during childbirth.
Current state of the evidence
Episiotomy can be protective for women under certain circumstances. For example, a study based on data from several facilities in sub-Saharan Africa concluded that episiotomy was protective against anal sphincter tears and postpartum hemorrhage among women who had undergone type 3 female genital mutilation. However, used inappropriately, it can be detrimental to women’s health.
A recent Cochrane systematic review examining the evidence on selective versus routine episiotomies for vaginal birth concluded:
“Overall, the findings show that selective use of episiotomy in women (where a normal delivery without forceps is anticipated) means that fewer women have severe perineal trauma. Thus the rationale for conducting routine episiotomies to prevent severe perineal trauma is not justified by current evidence, and we could not identify any benefits of routine episiotomy for the baby or the mother.”
Despite this recommendation, health workers sometimes encounter institutional barriers that pressure them to perform the procedure. Fear of a woman developing a third or fourth degree perineal tear and a lack of proper training can also contribute to high episiotomy rates.
Global trends and disparities
The data on global episiotomy use are limited, especially in countries with weak health information systems. However, a paper from the 2016 Lancet Maternal Health Series reported prevalence estimates for several middle-income countries based on the most recent available data:
| Country | Episiotomy rate (year) |
| China | 44.9% (2002) |
| India | 45.0% (2003) |
| Indonesia | 53.5% (2005) |
| Iran | 79.2% (2012) |
| Malaysia | 46.0% (2005) |
| Philippines | 63.7% (2005) |
| Thailand | 91.8% (2005) |
| South Africa | 63.3% (2003) |
High episiotomy rates have been reported elsewhere, such as in Oman, Tibet and in several countries in Central and South America.
In settings where episiotomy rates have declined over time, socioeconomic, geographic and racial disparities persist. In the United States, for example, the national episiotomy rate decreased from 25% in 2004 to 14% in 2012. However, episiotomies are more common among white women compared to black women, among women with private insurance compared to those with Medicaid and in urban hospitals compared to rural ones. Other research has found that certain types of health care providers are more likely than others to perform episiotomy.
The way forward
While episiotomy can be beneficial in some cases, extremely high rates in many settings across the globe indicate overuse. Additional research to estimate the ideal population-level rate may help countries and facilities adjust their practices according to a specific evidence-based target.
When an episiotomy is necessary, it is crucial that the procedure be performed in a way that maximizes outcomes for the mother and infant. Some research has found variation in episiotomy technique, which may be a result of inconsistent international practice guidelines.
Ensuring that women are involved in the decision-making process in the event that an episiotomy might be needed is also critical. Performing an episiotomy—or any other intervention—without a woman’s informed consent is a violation of her right to respectful maternity care. Addressing the non-evidence-based use of episiotomy is key to improving maternal health and women’s birthing experiences worldwide.
Key papers
Selective versus routine use of episiotomy for vaginal birth
Cochrane Database of Systematic Reviews | February 2017
Episiotomy rates around the world: An update
Birth | August 2005
Outcomes of routine episiotomy: A systematic review
Journal of the American Medical Association | May 2005
Routine vs selective episiotomy: A randomised controlled trial
The Lancet | December 1993
Practice bulletin no. 165: Prevention and management of obstetric lacerations at vaginal delivery
Obstetrics & Gynecology | July 2016
—
Watch the webcast from “Too Much Too Soon: Addressing Over-Intervention in Maternity Care,” a discussion that took place in April 2017 as part of the Advancing Dialogue in Maternal Health Series.
Subscribe to receive new MHTF blog posts in your inbox.