Editor—In their editorial Maduma-Butshe et al discussed the need to abandon the routine use of episiotomy in developing countries.1
The use of episiotomy is a paradigmatic example of the many interventions that are introduced into clinical practice without scientific evidence and found after well performed research to be not only unjustified but also possibly harmful.2 In addition, once an intervention has been established in clinical practice it is not easily abandoned, even when strong scientific evidence shows its uselessness and harmfulness.
We have presented the results of our study on episiotomy3 and the reviews about it2,4 many times, but clinicians have often remained sceptical and expressed little desire for change.
The table shows the trend in the use of episiotomy in one of the hospitals where the Argentine episiotomy trial was performed (Maternidad Martin, Rosario, Argentina).3 Overall rates of episiotomy changed from 47.9% before the trial to 28.4% four years after completion of the trial. However, the decrease in the rate of episiotomy was observed predominately in multiparous women, with little change in nulliparous women. During the trial nulliparous women had an episiotomy rate of 39.5%, but rates in daily practice increased to 82%; four years after the end of the study and an intense dissemination of the results, rates were nearly double those obtained during the trial.
There is no obvious way to change a practice that has strong evidence against it once the practice has been implemented. The challenge is now to look for and test strategies to obtain such a change for routine episiotomy.
Table.
Episiotomy rates in one hospital in Rosario, Argentina, before, during, and after episiotomy trial.3 Values are percentages (proportions)
| Parity | 1990 | Trial, 1991-2
|
1993 | 1994 | 1995 | 1996 | |
|---|---|---|---|---|---|---|---|
| Intervention* | Control | ||||||
| 0 | 92.2 (273/296) | 39.5 (307/777) | 90.7 (706/778) | 82.4 (210/255) | 67.6 (226/334) | 71.3 (751/1053) | 65.3 (760/1164) |
| ⩾1 | 28.9 (199/689) | 16.3 (87/531) | 70.4 (366/520) | 21.0 (88/418) | 14.8 (142/960) | 15.6 (442/2841) | 13.4 (389/2896) |
| All | 47.9 (472/985) | 30.1 (394/1308) | 82.6 (1072/1298) | 44.3 (298/673) | 29.1 (368/1264) | 30.6 (1193/3894) | 28.5 (1149/4033) |
Selective use of episiotomy.
References
- 1.Maduma-Butshe A, Dyall A, Garner P. Routine episiotomy in developing countries. BMJ. 1998;316:1179–1180. doi: 10.1136/bmj.316.7139.1179. . (18 April.) [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Lede R, Belizán JM, Carroli G. Is routine use of episiotomy justified? Am J Obstet Gynecol. 1996;174:1399–1402. doi: 10.1016/s0002-9378(96)70579-3. [DOI] [PubMed] [Google Scholar]
- 3.Argentine Episiotomy Trial Collaborative Group. Routine vs selective episiotomy: a randomised controlled trial. Lancet. 1993;342:1517–1518. [PubMed] [Google Scholar]
- 4.Carroli G, Belizán JM, Stamp G. Episiotomy policies in vaginal births. In: Pregnancy and childbirth module of the Cochrane database of systematic reviews. Cochrane Library. Oxford: Update Software, 1997.