Routine episiotomy in developing countries

More women in developing countries are delivering their babies in hospitals. In Latin America institutional births account for 70% of all deliveries; in Africa, 36%; and in developing countries overall some 40%.¹ What is becoming apparent is that in some countries virtually all the women delivering in hospital will be surgically cut. If they miss out on a caesarean section they will have an episiotomy. For example, Brazil has caesarean section rates of greater than 30%, and Argentina has episiotomy rates of greater than 80% for vaginal births.²,³ Questions about high caesarean sections rates have been raised in the past, but unnecessary episiotomies have not been widely debated.

Obstetricians in the tropics continue to instruct health staff to apply a policy of “avoid tears-do episiotomies” routinely. They may be acting in good faith, but the evidence shows that they are wrong.⁴ Aiming surgically to cut all women delivering vaginally has no demonstrable benefit for the infant or mother but causes the woman unnecessary pain and adverse psychological effects and may cause death.⁵

In England episiotomies were performed on over half of all women delivering in 1980, falling to 37% in 1985. Recently released figures for 1994-5 indicate a further dramatic fall to about 20%.⁶,⁷ Although the older figures may not be strictly comparable with those from 1994-5, the overall trend downwards is clear, and local data support this. For example, in Liverpool Women’s Hospital, in the first half of 1997 episiotomies were performed in 16% of all deliveries and 5% of normal births ( J Neilson, personal communication).

Is this the trend in the world’s poorer countries? We conducted a straw poll of 10 midwives from Zambia, Malawi, Nigeria, Ghana, Kenya, and Nepal attending courses in Liverpool. Our respondents had not considered whether policies of routine episiotomy could do more harm than good and found the review by Carroli et al enlightening.⁴ Most indicated that health professionals performed episiotomies routinely on primigravidas to prevent third degree perineal tears. Some midwives reported that some were performed to allow midwifery and medical students the opportunity to practise the procedure.

We sought to document this anecdotal evidence of high episiotomy rates in developing countries, but data are sparse. A systematic search of Medline and contact with the Royal College of Midwives revealed very little quantitative data. We found a study in Botswana, where 1 in 3 mothers having a normal delivery had an episiotomy.⁸ Another study in Burkina Faso showed that, in primary care facilities, 43% of primigravidas received episiotomies—in a health system that frequently ran out of sutures and antibiotics.⁹ What is particularly worrying is that when health care resources are short episiotomy is more likely to result in complications. This increases the harm done by the procedure, in people who are least able to cope with the increased pain and suffering and least able to afford the prolonged hospitalisation.

The World Health Organisation has taken a clear stand against routine episiotomy, in line with the best available evidence.¹⁰ Convincing obstetricians may be more problematical. Yet this is an important ethical issue for doctors and patients alike. In the West the procedure is usually discussed with women at antenatal clinics. In our experience in developing countries this does not happen. When the procedure is routine it therefore becomes a premeditated surgical procedure carried out without consent from the woman.

It is important that we rapidly compare episiotomy rates between facilities and countries. Such data will guide more informed discussion about the level of unnecessary interventions. It will then be obvious to obstetricians, midwives, and the public whether obstetric practice is based on doing what is best for women, or persisting with policies that do more harm than good.