Episiotomy Rates Declining but Remain Varied

January 22, 2015

Nonmedical factors seem to be driving the use of episiotomies, and there remains a wide variation in episiotomy rates in hospitals nationwide.

Episiotomy rates are on the decline, as physicians appear to be following the recommendation to restrict the use of the once-common procedure.

From 2006 to 2012, the episiotomy rate dropped from 17.3% to 11.6%, according to Alexander M. Friedman, MD, of the Columbia University College of Physicians and Surgeons, New York, and colleagues, who published their findings in a research letter in JAMA earlier this month. They also noted that the decline represented a significant fall from 2004, when estimates indicate episiotomy was performed in 25% of vaginal deliveries in the United States. However, despite the overall decrease, there remains a wide variation in episiotomy rates at US hospitals.

Factors associated with episiotomy use include:

- White ethnicity.
- Commercial insurance.
- Urban, nonteaching hospital.
- Nulliparous status.
- Prolonged second stage of labor.
- Suspected macrosomia.

Still, among the 10% of hospitals that used the procedure most frequently, the average adjusted rate for episiotomy use was 34.1%. Among the 10% of hospitals that used the procedure the least, the adjusted rate was 2.5%. Teaching hospitals and rurally located hospitals were associated with less use of the procedure, the authors reported.

"These observations suggest non-medical factors are related to use of episiotomy," write the authors, suggesting that new research should focus on better understanding the reason behind the stark differences in the procedure’s use.

In conducting the analysis, the researchers relied on the Perspective database, which includes more than 500 hospitals, to identify women who underwent a vaginal delivery from 2006 to 2012.

In raw numbers, the analysis included 2,261,070 women who were hospitalized for a vaginal delivery, with 325,193 (or 14.4%) having an episiotomy. The data also allowed the authors to observe several demographic characteristics about the women who underwent the procedure. More white women had an episiotomy than black women, and 17.2% of the women having the procedure were insured with commercial insurance, versus 11.2% who were covered by Medicaid.