ACOG 2009: Steep Decline in Episiotomy Rates Credited to Research, Peer Pressure

Richard Hyer

May 08, 2009

May 8, 2009 (Chicago, Illinois) — A study of 10-year episiotomy trends among different practice groups at Brigham and Women's Hospital in Boston, Massachusetts, found a substantial reduction in episiotomy rates across patient and provider groups, owing to factors as varied as local peer pressure and response to significant research. Patient preference and other factors also contributed.

These findings were presented here at the American College of Obstetricians and Gynecologists (ACOG) 57th Annual Clinical Meeting by the study's lead author, Cynthia Johnson, MD, MPH, assistant professor at Brigham and Women's Hospital. Dr. Johnson discussed her results with Medscape Ob/Gyn & Women's Health.

"We had hoped to look at episiotomy rates and relate them to important research articles and to possible policies to see if these changed the rate of episiotomy. But in fact there were many, many factors, including peer pressure and residents (the younger doctors wouldn't let the doctors cut an episiotomy). Clearly, the [Hartmann] article in JAMA in 2005 also had an effect [JAMA. 2005;4;293:2141-2148]. Everyone dropped to the same range," Dr. Johnson said.

This study was designed to review 10-year (1997 to 2006) episiotomy trends among different practice groups at a large urban teaching hospital, and to examine the effect of hospital-policy recommendations and well-publicized outcome research on the procedure.

The study gathered data from 5 practice groups at Brigham and Women's Hospital (BWH): BWH certified nurse midwives (CNMs) (n = 29); BWH physicians (n = 44); Harvard Vanguard Medical Associates CNMs (n = 24); Harvard Vanguard Medical Associates physicians (n = 35); and private-practice physicians (n = 62). Harvard Vanguard is the former health maintenance organization of Harvard, and is now a multispecialty group practice.

The study population was 61,268 women with a singleton vertex fetus at a gestational age of 36 weeks or more. For greatest accuracy, episiotomy rates were culled from an intrapartum electronic database. Results were stratified by parity and by practice type, with the 3 major practice groups being hospital-based, multispecialty, and private practice. The data were also stratified by clinician type (obstetrician vs CNM) and by the clinician's sex. Of the 141 physicians, 40 were male and 101 female; all 53 CNMs were female.

In 1997, episiotomies were performed in over 30% of deliveries, but the decline had already begun. This was accelerated by various factors. In 2001, the hospital adopted the performance-management tool known as the Balanced Scorecard. In 2002, the obstetric chiefs made reducing episiotomy a priority. In 2005, the Hartmann article was published, recommending against routine episiotomies, and suggesting that the rate be less than 15%. A 50% decrease in episiotomies followed at BWH.

By 2006, the national rate of episiotomy was 9%, and at BWH it had fallen to 6%.

Dr. Johnson reviewed the data stratified by parity and provider and noted that midwives performed the fewest episiotomies. Sex stratification showed a higher rate of episiotomy throughout the 10-year period by male physicians than by female physicians. However, Dr. Johnson noted that select female physicians performed high rates (>60%) of episiotomies.

The study concluded that local peer pressure and response to significant research, in particular the Hartmann study, contributed to the substantial reduction in rates of episiotomy across patient and provider groups over the 10-year period.

It recognized several other contributing factors, including long-standing CNM service in hospital-based practice, and the addition of CNMs to Harvard Vanguard Medical Associates in 1990. Institution of the Balanced Scorecard was a factor, as was the gradual retirement of older obstetricians trained in routine episiotomy. Younger residents avoid episiotomy, she observed. Dr. Johnson also recognized the obstetric chiefs' making episiotomy a priority in 2002 and noted that labor and delivery nurses were educated about the procedure.

She pointed out that women giving birth also increasingly refused episiotomy.

"We have an intuition that medicine changes over time with change in standards and with peer pressure," Kurt L. Barnhart, MD, MSCE, moderator and member of ACOG's Committee on Scientific Program, told Medscape Ob/Gyn & Women's Health. Dr. Barnhart is director of women's health research at the University of Pennsylvania in Bryn Mawr, and also served as director, with Janice L. Bacon, MD, of the Papers on Clinical and Basic Investigation session.

"Papers like this confirm that there are secular trends in medicine, and often for the better. So it's important for these studies to be done, to demonstrate something, even though we think it's intuitive, Dr. Barnhart said. "We all thought that episiotomies were probably not necessary, but you can't just suggest change, you'd like to measure that that change has actually occurred. This paper very nicely demonstrates that evidence-based medicine, and talking about a problem, results in change."

This research project was supported by Dr. Johnson, who pursued it in the course of receiving an MPH from Boston University School of Public Health. Dr. Johnson has disclosed no relevant financial relationships.

American College of Obstetricians and Gynecologists (ACOG) 57th Annual Clinical Meeting: Papers on Current Clinical and Basic Investigation. Presented May 5, 2009.


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