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

Abstract

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.

Episiotomy Practice and Its Associated Factors in Africa: A Systematic Review and Meta-Analysis

“…Similarly, the episiotomy rate in all vaginal deliveries in the United States fell from 60.9% in 1979 to 24.5% in 2004 ( 89 ), and the rate in Hong Kong fell from 73% in 2003 to 27% in 2008 ( 86 ). In contrast, the pooled estimate for episiotomy practice, in all vaginal deliveries, in this meta-analysis was lower than in a study conducted in India, where 63.4% ( 90 ), Oman, 66% ( 27 ), Portugal, 72.9% in 2010 ( 20 ), Mexico City, 77.2% ( 25 ), Turkey, 93.3% ( 91 ), Phnom Penh, Cambodia, 94.5% ( 28 ), and Taiwan, 100% ( 23 ), which may suggest liberal use in these countries.…”

“…Reported rates of episiotomies vary greatly from one country to another across the globe. The lowest rate (1%) of episiotomy was reported in Sweden, whereas the highest (100%) was reported in Taiwan among primiparous parturients (23) (20,(23)(24)(25)(26)(27)(28). In addition, significant number of women undergone episiotomy in Asian countries, 42-98% (23,29,30).…”

“…Furthermore, despite the standard recommendations that corroborate judicious use of episiotomy, increasing and variable patterns have been reported in Mexico: 41.8% in the state of Oaxaca and 77.2% in Mexico City ( 8 , 25 , 31 ). A sharp decline in episiotomy rates was reported in some countries like Turkey (93.3% in primipara women and 30.2% in multipara women in 2013) (1), France (18.6% from 2013 to 2017) (2), China (85.50% in 2003 to 41.7% in nulliparae and 21.5% in multiparae from 2015 to 2016) (3), the United States of America (20.3% in 2002 to 9.4% 2011 (4).…”

Reasons for performing episiotomy during ectopic deliveries: An integrative literature review

“…Some studies have shown that fetal distress is one of the main reasons for performing an episiotomy 21 , which is consistent with several other findings 22,23,24 . In the Seijmonsbergen-Schermers et al study 21 , fetal macrosomia and other physical characteristics were criteria for performing episiotomy.…”

Implementation and evaluation of the WHO maternity care model: a convergent parallel mixed-methods study protocol

“…The literature review did not yield any studies that dealt with all the components of the 2018 WHO intrapartum care model. Moreover, few qualitative studies were conducted on this subject, most of which were not comprehensive and discussed only some components of this model such as respectful maternal care and continuity of care ( 22 – 24 ). In line with the population policies of the Iranian government and the promotion of intrapartum care, this study on the 2018 WHO intrapartum care model is expected to lead to an increase in women's positive experiences of labor and their desire for giving birth to another child through normal vaginal delivery and also to reduce the rate of unnecessary cesarean sections.…”