Rates of episiotomy – a surgical procedure performed to aid the delivery of a baby – fell between 2006 and 2012, according to researchers. The decline comes following the recommendations of various experts for restricted use of the obstetric procedure.
Episiotomy was estimated to be performed in around a quarter of vaginal deliveries in the US in 2004. The procedure involves making an incision in the perineum to enlarge the vaginal opening.
According to the American Pregnancy Association (APA), doctors could opt to perform an episiotomy if the baby’s head is too large for the vaginal opening, the mother needs a forceps- or vacuum-assisted delivery or if the baby is in the breech position.
However, the procedure has its risks. Evidence has shown that episiotomy can increase the risk of pain, laceration and anal incontinence for women giving birth.
Due to the risks of the procedure and the unclear benefits of routine utilization, the American Congress of Obstetricians and Gynecologists and the National Quality Forum recommended restricting use of episiotomy.
These recommendations were made in 2006 and 2008 respectively. While previous studies had shown decreasing use of the procedure in the 1990s, it has not been known whether these evidence-based recommendations have had any further impact on utilization rates.
For the study, published in JAMA, researchers identified women who underwent vaginal delivery from 2006-2012. Information was obtained using the Perspective database which contains data from over 510 hospitals, covering approximately 15% of hospitalizations in the US.
Dr. Alexander Friedman of Columbia University College of Physicians and Surgeons, New York, and colleagues examined data for 2,261,070 women who visited hospital for a vaginal delivery. A total of 325,193 (14.4%) underwent episiotomy.
The researchers noted a fall in the rate of episiotomy from 2006-2012. The rate of utilization fell from 17.3% in 2006 to 11.6% in 2012.
A number of factors were linked with differing rates of the procedure. A total of 15.7% of white women received episiotomy, compared with 7.9% of black women. Equally, patients with commercial insurance (17.2%) were more likely to receive episiotomy than patients with Medicaid insurance (11.2%).
Hospitals situated in a rural location or teaching hospitals were also associated with lower rates of episiotomy.
While the study shows that episiotomy rates have indeed fallen since recommendations were made, the researchers are left with a new conundrum, finding that there was a significant variation in episiotomy rates across different hospital sites.
For the 10% of hospitals where episiotomy was most frequently performed, the average rate of use was 34.1%. In contrast, in the 10% of hospitals where the procedure was least performed, the average rate of use was 2.5%.
“These observations suggest non-medical factors are related to use of episiotomy,” write the authors. Further research will be needed in order for an explanation to be found for this result.
The Mayo Clinic recommend discussing any thoughts or concerns about episiotomy with health care providers during prenatal check-ups and once labor has begun. Episiotomy is still a useful procedure in certain circumstances and may well be the best option to ensure a healthy delivery for both mother and child.
Variation in procedure rates from hospital to hospital have not just been observed with episiotomies. In October, Medical News Today reported on a study finding that hospital variation in Cesarean section deliveries was not explained by women’s medical conditions.