Claims data show episiotomy on the decline

Analysis of data from more than 2.2 million vaginal deliveries shows that episiotomy declined between 2006 and 2012 and nonmedical factors may have been at play. The findings were published in a Research Letter in JAMA.

The deliveries were identified in an insurance claims database by researchers from Columbia University College of Physicians and Surgeons. More than 500 hospitals or 15% of hospitalizations nationally are reflected in the Perspective database. Of the 2,261,070 vaginal deliveries represented in the analysis, 325,193 included episiotomy.

Between 2006 and 2012, the authors found, rates of the procedure declined from 17.3% to 11.6% (95% CI, 17.2%-17.4% vs 95% CI, 11.5%-11.7%). Episiotomy was more common among white women than among black women (15.7%; 95% CI, 15.6%-15.8% vs 7.9%; 95% CI, 7.8%-8.0%; P<.001) and among those with commercial insurance versus Medicaid (17.2%; 95% CI, 17.1%-17.3% vs 11.2%; 95% CI, 11.1%-11.3%; P<.001).

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Deliveries with accepted indications for episiotomy, such as shoulder dystocia, fetal distress, and fetal heart rate abnormalities, were excluded from the analysis. The researchers used multivariable mixed-effects log-linear models and a generalized linear mixed model to calculate between-hospital variation in the procedure. Hospital rates of episiotomy were highly variable, with a mean adjusted rate of 34.1% among the 10% of institutions that performed the procedure most frequently, compared with 2.5% among the 10% that performed it least frequently.

Adoption of the American College of Obstetricians and Gynecologists’ 2006 recommendation to limit routine episiotomy, the authors said, may have triggered the decline but they also cited insurance, race, rurality, and hospital teaching status as playing a role. Among the limitations of their analysis, they noted, were the possibility that billing data did not capture all episiotomies and that the sample may not be representative of all hospitals in the United States. 

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