Changes in Episiotomy Practice: Evidence-based Medicine in Action

Justin R Lappen; Dana R Gossett

Disclosures

Expert Rev of Obstet Gynecol. 2010;5(3):301-309. 

In This Article

Why Don't Doctors Follow Guidelines?

The challenges of obtaining high-quality data to direct evidence-based care have been greater in obstetrics than in many other medical disciplines. For many years, all women were excluded from the majority of research studies owing to concerns about negative effects on pregnancy or developing fetuses. While this general ban has been reversed, it remains difficult to conduct prospective research in obstetrics for multiple reasons. First, any study of clinical practices must consider whether it is ethical to proceed if there may be increased risk to an unborn child. Second, pregnant women themselves may be more reluctant than other patient populations to participate in prospective clinical research for much the same reasons. Finally, since obstetrics generally has lagged behind other disciplines in its efforts to have standardized, outcomes-based practices, there may be greater cultural barriers among obstetricians to changing practices based on new data.

In 1993, a Canadian study of low-risk deliveries over a 4-year period found that some trends in obstetric practice reflected current recommendations (including, in this case, a small decrease in episiotomy rates), and others, such as increased rates of induction and electronic fetal monitoring, were not based on current evidence.[44]

In 1995, Michel Klein described physician beliefs regarding episiotomy during an attempted prospective randomized trial of episiotomy.[45] In this publication, the authors note that those physicians who regarded episiotomy 'very favorably' performed more interventions to expedite delivery, and were also less likely to assign patients to a study arm. These doctors had difficulty limiting episiotomy use when patients were randomized to 'restricted use' of episiotomy. The authors concluded that physician beliefs influence not only clinical practice but also compliance with research protocols.

In 1998, a questionnaire mailed to family physicians and obstetricians found that only 40% felt that evidence-based medicine was "very applicable to obstetric practice".[46] Concerning comments from this survey included "obstetrics requires manual dexterity more than science", "evidence-based medicine ignores clinical experience", and that following guidelines could result in "erosion of physician autonomy". These views were described as obstacles to the adoption of evidence-based practices, and the authors recommended emphasis of critical analysis of the literature as part of medical education.

The following year, Cabana and colleagues published a review of reasons that physicians fail to change their practices in the face of new evidence or published clinical guidelines.[47] They found multiple types of barriers to practice change, including lack of awareness or familiarity with current recommendations, lack of agreement with the recommendations, lack of self-efficacy to make practice changes, inertia and external barriers to practice change. Of those physicians who did not agree with the practice recommendations, a variety of reasons were cited. Some physicians felt the evidence did not support the guidelines, some felt the recommendations were like a 'cookbook' or reduced physician autonomy, or did not apply to their patient population. Finally, some physicians had a "lack of outcome expectancy", or did not believe that making the recommended practice changes would improve clinical outcomes. While the authors provide a "differential diagnosis" of reasons that physicians fail to adopt new practices, they did not provide any recommendations for how to address these various barriers.

In addition, recent data from Greece highlight another potential reason for the delay in acceptance of evidence-based practice guidelines by obstetricians: differences in healthcare delivery systems and cultural approaches to care on provider practice patterns. In 2009, Grigoriadis et al. published survey results regarding the use of episiotomy and technique for perineal lacerations among obstetricians in Greece.[48] This study found that 51% of providers performed routine episiotomy for spontaneous vaginal deliveries, 89% performed episiotomy for operative vaginal delivery, and that lateral and mediolateral episiotomy were equally common. The authors note that the evidence for restrictive episiotomy use reflects North American and European data. They comment that the differences in the healthcare systems, provider and patient expectations, and the medical and cultural approaches to peripartum care may influence the perceived clinical efficacy and the acceptance and implementation of new evidence-based guidelines.

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