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Advancing an Evidence-Based Approach to Episiotomy

Posted on May 30, 2017May 30, 2017

By: Sarah Hodin, MPH, CD(DONA), LCCE, National Senior Manager of Maternal Newborn Health Programs, Steward Health Care

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 Outdated clinical guidelines previously recommended the routine use of episiotomy to avoid natural vaginal tearing.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

—

Check out the Maternal Health Task Force (MHTF)’s mini-series, “The Global Epidemic of Unnecessary Cesarean Sections.”
Part 1 | Part 2 | Part 3

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.

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CATEGORIESCATEGORIES: Quality of Maternal Health Care
TOPICSTOPICS: Education Emergency Obstetric and Newborn Care Facility-based Births Health Systems Human Resources for Health Inequities & Inequalities Intrapartum Care Monitoring & Evaluation Obstructed & Prolonged Labor Policy & Advocacy Quality of Care Respectful Maternity Care Social Determinants
GEOGRAPHIESGEOGRAPHIES: China Indonesia Iran Latin America & Caribbean Malaysia Oman Philippines Thailand Tibet United States

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The posts on this blog do not necessarily reflect the views of the Maternal Health Task Force. Our objective is to provide a platform for our Editorial Committee and other experts to post a myriad of data and evidence, as well as opinions/views that exist in the field which will contribute to expanding the maternal health dialogue.
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This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant T76MC00001 and entitled Training Grant in Maternal and Child Health. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.
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