An Initiative to Reduce the Episiotomy Rate

Zhang-Rutledge, Kathy; Clark, Steven L.; Denning, Stacie; Timmins, Audra; Dildy, Gary A.; Gandhi, Manisha

doi:10.1097/aog.0000000000002060

Cited by 8 publications

(3 citation statements)

References 13 publications

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“…At the facility level, restrictive episiotomy hospital policies were successful in dramatically decreasing the episiotomy rate in both Nepal [ 64 ] and Hong Kong [ 65 ]. Zhang-Rutledge and colleagues [ 66 ] took a quality improvement approach with success: they used education, performance feedback, and the Hawthorne effect with a significant reduction in the episiotomy rate in a large academic institution. At a programmatic and population level, there is less data to support episiotomy practices specifically.…”

Section: Discussionmentioning

confidence: 99%

Health care workers’ perceptions of episiotomy in the era of respectful maternity care: a qualitative study of an obstetric training program in Mexico

García-Cerde

Torres‐Pereda

Olvera-García

et al. 2021

BMC Pregnancy Childbirth

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Background Episiotomy in Mexico is highly prevalent and often routine - performed in up to 95% of births to primiparous women. The WHO suggests that episiotomy be used in selective cases, with an expected prevalence of 15%. Training programs to date have been unsuccessful in changing this practice. This research aims to understand how and why this practice persists despite shifts in knowledge and attitudes facilitated by the implementation of an obstetric training program. Methods This is a descriptive and interpretative qualitative study. We conducted 53 pre and post-intervention (PRONTO© Program) semi-structured interviews with general physician, gynecologists and nurses (N = 32, 56% women). Thematic analysis was carried out using Atlas-ti© software to iteratively organize codes. Through interpretive triangulation, the team found theoretical saturation and explanatory depth on key analytical categories. Results Themes fell into five major themes surrounding their perceptions of episiotomy: as a preventive measure, as a procedure that resolves problems in the moment, as a practice that gives the clinician control, as a risky practice, and the role of social norms in practicing it. Results show contradictory discourses among professionals. Despite the growing support for the selective use of episiotomy, it remains positively perceived as an effective prophylaxis for the complications of childbirth while maintaining control in the hands of health care providers. Conclusions Perceptions of episiotomy shed light on how and why routine episiotomy persists, and provides insight into the multi-faceted approaches that will be required to affect this harmful obstetrical practice.

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Section: Discussionmentioning

confidence: 99%

Health care workers’ perceptions of episiotomy in the era of respectful maternity care: a qualitative study of an obstetric training program in Mexico

García-Cerde

Torres‐Pereda

Olvera-García

et al. 2021

BMC Pregnancy Childbirth

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“…Some authors have described how a private and confidential feedback from physicians about their own practices can induce a decrease in the use of episiotomy [35, 36]. Ambassadors with communication and training skills may effectively facilitate changes in their teams [37].…”

Section: Discussionmentioning

confidence: 99%

How did episiotomy rates change from 2007 to 2014? Population-based study in France

Goueslard

Cottenet

Roussot

et al. 2018

BMC Pregnancy Childbirth

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BackgroundSince the 2000s, selective episiotomy has been systematically recommended worldwide. In France, the recommended episiotomy rate in vaginal deliveries is less than 30%. The aims of this study were to describe the evolution of episiotomy rates between 2007 and 2014, especially for vaginal deliveries without instrumental assistance and to assess individual characteristics and birth environment factors associated with episiotomy.MethodsThis population-based study included all hospital discharge abstracts for all deliveries in France from 2007 to 2014. The use of episiotomy in vaginal deliveries was identified by one code in the French Common Classification of Medical Procedures. The episiotomy rate per department and its evolution is described from 2007 to 2014. A mixed model was used to assess associations with episiotomy for non-operative vaginal deliveries and the risk factors related to the women’s characteristics and the birth environment.ResultsThere were approximately 540,000 non-operative vaginal deliveries per year, in the study period. The national episiotomy rate for vaginal deliveries overall significantly decreased from 26.7% in 2007 to 19.9% in 2014. For non-operative deliveries, this rate fell from 21.1% to 14.1%. For the latter, the use of episiotomy was significantly associated with breech vaginal delivery (aOR = 1.27 [1.23–1.30]), epidural analgesia (aOR = 1.45 [1.43–1.47]), non-reassuring fetal heart rate (aOR = 1.47 [1.47–1.49]), and giving birth for the first time (aOR = 3.85 [3.84–4.00]).ConclusionsThe episiotomy rate decreased throughout France, for vaginal deliveries overall and for non-operative vaginal deliveries. This decrease is probably due to proactive changes in practices to restrict the number of episiotomies, which should be performed only if beneficial to the mother and the infant.Electronic supplementary materialThe online version of this article (10.1186/s12884-018-1747-8) contains supplementary material, which is available to authorized users.

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“…The rate of restrictive episiotomy recommended by the WHO does not exceed 10%. 6 47 concluded that education, operative feedback and the Hawthorne effect were associated with a decrease in rates of episiotomy (from 7.2% to less than 5%). As far as our hospital is concerned, episiotomy was routinely performed before 2016 and the rate of episiotomy has significantly decreased to 25%-35% recently after adopting a publicity policy of personal episiotomy rate.…”

Section: Obstacles To Reducing the Rate Of Episiotomymentioning

confidence: 99%

Knowledge, attitude and experience of episiotomy practice among obstetricians and midwives: a cross-sectional study from China

Yang

Bai

2021

BMJ Open

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ObjectiveEpisiotomy is still performed widely by obstetricians and midwives in some Chinese maternity units, but the reasons are unknown. This study aims to determine the knowledge, attitude and experience towards the practice of episiotomy among obstetricians and midwives in China’s public hospitals and consider strategies to reduce its practice.MethodsA cross-sectional web survey using a self-administered questionnaire was conducted among obstetricians and midwives in 90 public hospitals in Henan Province, China.Results900 (82.21%) participants completed the questionnaire. Average knowledge level (4.15, SD=1.10) on complications and overuse was identified among participants. Episiotomy was performed more frequently in secondary hospitals than in tertiary hospitals (p<0.05). Senior clinicians were more likely to perform episiotomy than younger ones (p<0.05). Almost half of the clinicians (42.11%) considered the current rate of episiotomy (45%) to be right or too low. The most common reason for performing episiotomy identified by obstetricians (83.94%) and midwives (79.69%) was to reduce third-degree or fourth-degree perineal laceration. Both obstetricians (80.29%) and midwives (82.57%) agreed that the most significant obstacle to reducing the rate of episiotomy was lack of training on reducing perineal tears.ConclusionIn sum, episiotomy was driven by previous training, practitioners’ experience and local norms rather than the latest medical evidence. Clinicians in secondary hospitals and senior clinicians are key training targets. It is urgent to improve current clinical policies and surgical procedure guidelines for obstetricians and midwives regarding episiotomy.

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An Initiative to Reduce the Episiotomy Rate

Abstract: Education, performance feedback, and the Hawthorne effect were associated with a reduction in the episiotomy rate in a large academic institution without a reduction in the rate of operative vaginal delivery or an increase in the rate of third- and fourth-degree lacerations.

Cited by 8 publications

References 13 publications

Health care workers’ perceptions of episiotomy in the era of respectful maternity care: a qualitative study of an obstetric training program in Mexico

Health care workers’ perceptions of episiotomy in the era of respectful maternity care: a qualitative study of an obstetric training program in Mexico

How did episiotomy rates change from 2007 to 2014? Population-based study in France

Knowledge, attitude and experience of episiotomy practice among obstetricians and midwives: a cross-sectional study from China

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