Experts: Too Many Episiotomies in U.S.

A study looking at episiotomy rates around the world shows that a third of American women get episiotomies during childbirth. Experts tell WebMD that's too many.

Researchers reported that rates of episiotomy -- cutting of the skin between the vagina and anus to ease delivery -- varied greatly from country to country.

South and Central America had some of the highest episiotomy rates. According to government figures compiled by the researchers, these rates ranged from 65 percent in Argentina to close to 100 percent in Guatemala.

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No Clear Pattern

Rates in other parts of the world ranged from a low of 9.7 percent in Sweden to close to 100 percent in Taiwan. China, Spain, South Africa, and Turkey also reported extremely high episiotomy rates, ranging from 63 percent to almost 90 percent.

Researcher Ian D. Graham, PhD, of the University of Ottawa, says no clear pattern emerged to explain why some countries embrace routine episiotomies while others do not.

He suggested, however, that there may be a bias toward an interventional, Westernized approach to childbirth in countries where episiotomy rates were high.

"It may be an issue of trying to emulate what is perceived as the best that Western medicine has to offer," he says.

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Rates in U.S. Too High

Among English-speaking countries, the U.S. had the highest episiotomy rate, varying greatly from region to region.

One in three mothers who delivered vaginally in the U.S. from 1995 to 2003 had episiotomies. Just under 40 percent of women delivering in the Northwest got them, compared to 27 percent of women living in Western states.

Childbirth practices researcher Katherine Hartmann, MD, PhD, estimates that close to 1 million unnecessary episiotomies are performed in the U.S. each year. She says episiotomies are probably medically warranted in fewer than 10 percent of cases.

Hartmann is director of the Center for Women's Health Research at the University of North Carolina in Chapel Hill.

"It is hard to imagine that most centers couldn't get well below 15 percent if episiotomies were only done when medically necessary," she tells WebMD.

In a review of studies evaluating routine episiotomy outcomes published in May of this year, Hartmann and colleagues found no evidence that the practice helped women avoid severe tears, improved long-term sexual function, or helped prevent childbirth-related incontinence.

The study appeared in The Journal of the American Medical Association and was supported by the American College of Gynecology (ACOG).

ACOG opposes routine episiotomy, noting in its guidelines that the practice may lead to an increased risk for severe tearing and may delay the ability to resume sexual activity after childbirth.

"Not only were we not achieving the ends that we had hoped for with routine episiotomy, but the evidence suggested that it might be causing harm in some cases," Hartmann says. "With an episiotomy a woman will always need stitches. Women who don't have the procedure may end up needing stitches, but they may not."

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Talk to Your Doctor

Episiotomy rates in the U.S. have been dropping steadily over the past several decades and are now about half what they were in the early 1980s.

But all the experts interviewed by WebMD agreed that too many of the procedures are still being done, and that pregnant women should discuss the issue with their doctor long before delivery if they are concerned.

"It is important to frame the question in the right way," says ob-gyn Iffath Hoskins, MD, of Brooklyn's Lutheran Medical Center.

"Instead of saying, 'I don't want an episiotomy,' ask what (your doctor's) policy and practice is. If he or she tells you that they do them in appropriate circumstances and they do a good job of explaining what those circumstances are, I wouldn't nitpick."

On the other hand, if your doctor doesn't have a good answer or says that they do them routinely, it is important to know this, Hoskins adds.

Hartmann says she is hopeful that rates will continue to come down as more and more women have this discussion with their doctors, in the same way that they began to question the medical need for so many hysterectomies several decades ago.

"This is nothing new to people who make health policy, and it does seem that patients are beginning to tune in to the debate and make their feelings known," she says.

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By Salynn Boyles, reviewed by Michael W. Smith, MD

SOURCES: Graham, I., Birth, September 2005; vol 32: pp 219-223. Ian Graham, PhD, associate professor, School of Nursing, University of Ottawa; associate director, Clinical Epidemiology Program, Ottawa Health Research Institute, Ottawa, Ontario. Iffath Hoskins, MD, chief and residency director, department of obstetrics and gynecology, Lutheran Medical Center, New York. Katherine Hartmann, MD, PhD, director, Center for Women's Health Research, University of North Carolina, Chapel Hill. The Journal of the American Medical Association, May 4, 2004.