Episiotomies still common despite global recommendations to restrict use

Episiotomy is often called the unkindest cut of all. The procedure involves cutting the skin and muscles of the perineal area, the tissue between a woman's vagina and anus, while she is giving birth. It was once thought to be less painful and damaging than allowing the tissue to tear naturally. It was also thought to prevent urinary incontinence later in life.

Over the last two decades, a large body of evidence has overturned that view. Clinical trials have repeatedly shown that many women fare better without episiotomy because the natural tears they suffer are often less severe than the surgery. But a new worldwide study by Dr. Ian Graham, Associate Professor in the School of Nursing and Epidemiology and Department of Community Medicine at the University of Ottawa, shows that health care providers have been slow to change their ways. Dr. Graham is also a Senior Scientist in the Clinical Epidemiology Program at the OHRI.

Dr. Graham's data shows high rates of episiotomy, with the highest rates (often approaching 100% for first pregnancies) found in parts of South and Central America and Asia. The lowest overall rates are found in Sweden (9.7%), New Zealand (11%) and Denmark (12%). In Canada, the overall rate is 24%, ranging from 3% in Nunavut to 31% in Quebec. The United States has an overall rate of 33% while some European countries, including Spain, Italy, and Turkey, have overall rates above 50%.

It is difficult to know how high is too high for episiotomy rates, because the surgery can help hasten some difficult labors. Some studies have suggested that a rate above 30% cannot be justified, while others have suggested rates of 10-20% to be appropriate.

"Episiotomy is one of those practices that became routine in obstetrics based on lots of theory and virtually no evidence that it was beneficial," says Dr. Graham. "Now decades later there is an accumulation of studies showing the practice is actually not beneficial, and in some cases can even be harmful, yet the operation continues to be performed liberally in many parts of the world. This is a prime example of some health care providers not keeping up-to-date with the literature. Women should be talking to their health care providers about this."

Obstetricians are welcoming the survey. Dr. Mark Walker is an obstetrician at The Ottawa Hospital, a scientist at the OHRI, and an Assistant Professor of Obstetrics and Gynecology at the University of Ottawa.

"Randomized controlled trials have demonstrated that women who have episiotomies tend to have more tissue tears, more pain, more stitches, and a longer recovery time after childbirth," says Dr. Walker. "Although episiotomy can speed delivery, it should only be used when obstetrically indicated as when the health of the mother or child is at risk."

The study is published in the September issue of Birth: Issues in Perinatal Care.