Too many women get episiotomy in childbirth: study

By Amy Norton

NEW YORK (Reuters Health) – Many women worldwide continue
to undergo a painful procedure during childbirth that experts
say should be used only in limited circumstances, a new study
shows.

The procedure, called episiotomy, involves making an
incision to enlarge the vaginal opening during childbirth.
Episiotomies were once performed routinely in the U.S. and
elsewhere, in part because doctors believed it helped prevent
vaginal tearing that can occur during delivery.

But in many countries, rates of episiotomy have fallen
sharply since the 1980s, after mounting evidence began to show
no benefit from routinely performing the procedure. The
incision takes weeks to heal, during which time walking, using
the bathroom and even sitting can be painful. At worst,
episiotomy can lead to a laceration in the anal sphincter, a
difficult-to-repair tear that can cause long-term incontinence.

Though episiotomy is necessary in some cases to ensure a
safe delivery, a range of professional medical organizations
now agree that it should be used sparingly — in cases of fetal
or maternal distress, for instance.

There is, however, no agreement on what constitutes an
acceptable rate of episiotomy. And in the new study, Canadian
researchers found that rates vary widely from country to
country, among regions within the same country, and even among
providers in the same medical network.

Episiotomy rates are generally highest in Asia and Central
and South America, while they are lowest in English-speaking
countries and some European nations, the researchers report in
the medical journal Birth.

Sweden had the lowest rate, at less than 10 percent of
vaginal births in 1999-2000. In contrast, it’s estimated that
in Guatemala and Taiwan, all first-time mothers who delivered
vaginally received an episiotomy.

In Western Europe, episiotomy rates for all vaginal
deliveries ranged from 13 percent in England, in 2002-2003, to
87 percent in Spain, in 1995.

In the U.S., episiotomies were performed in one third of
vaginal deliveries in 2000, the researchers found. But, as in
Canada and other countries, the rate varied according to
region; it was highest in the Northeast, at 38 percent, and
lowest in the West, at 27 percent.

Exactly why episiotomy rates vary so widely among nations
is unclear, the study’s lead author, Dr. Ian D. Graham of the
University of Ottawa, told Reuters Health.

Cultural ideas about women and about childbirth, such as
the notion that it should be treated as a medical condition,
could be at work, according to the researcher. In developing
countries, he added, high episiotomy rates could also be the
result of doctors “importing” a Western-style medical
intervention because they see it as “more progressive” than
traditional, low-tech births.

The fact that episiotomy rates vary substantially within
countries — and, according to a number of international
studies, within single institutions — is surprising, according
to Graham.

“It does mean that the reasons for doing the episiotomies
must be related to differences in the providers’ attitudes and
practices,” he said.

In English-speaking countries, Graham noted, doctors should
by now be well aware of guidelines calling for restricted use
of episiotomy.

So, he said, women should ask their providers about their
personal attitudes toward the procedure to ensure that those
beliefs match their own.

SOURCE: Birth, September 2005.