A gap in rates of episiotomy still exists between Asia and Europe

We investigated the knowledge, attitude and experience of episiotomy among a representative sample of midwives and obstetricians in Chinese public hospitals for the first time, aiming to collect information and remedy the current situation. Nine hundred participants completed the questionnaire. An average level of knowledge on complications and overuse was identified among participants. Episiotomy was performed more frequently in secondary hospitals than in tertiary hospitals. Senior clinicians were more likely to perform episiotomy than younger ones. Almost half of the clinicians considered the current rate of episiotomy to be right or too low. The most common reason for performing episiotomy identified by obstetricians and midwives was reducing third-degree or fourth-degree perineal laceration. Both obstetricians and midwives agreed that the most significant obstacle to reducing the rate of episiotomy was lack of training on reducing perineal tears.

The rates of episiotomy are still very high in Asian nations, such as 86% in Vietnam,27 60% in India14 and 94.5% in Cambodia.12 China had been considered to have a high rate of episiotomy for a long time. When referring to high rates of episiotomy, China is often cited as an example, with an episiotomy rate of around 80%.13 31 36 After restrictive episiotomy was urged by the Chinese Medical Association in 20169 and the China Maternal and Child Health Association in 2019,37 the rate of episiotomy had significantly decreased to 45% in China. The knowledge level on episiotomy complications among participants was higher than Vietnam and Jordan as well.27 34 However, a gap in rates of episiotomy still exists between China and Europe,10 11 which is our target and impetus for improvement. It is generally believed that Asian women had shorter perineum length than Caucasians, putting them at a higher risk of perineal injury.38 However, it is proven that the increased risk only applied to Asian-born women who deliver in Western countries and that Asian women in an Asian setting had a lower risk.39 A prospective study among Chinese women reported a similar mean perineal length to that reported for other populations, and restrictive episiotomy was generalised to Chinese women without compromising perineal safety.32 Considering the lack of training and the different culture in China, it may be unrealistic to expect a decrease in the rate of episiotomy to 10% in the short term, as recommended by WHO.6 However, efforts have been made to protect the perineum instead of performing routine episiotomy within hospitals in China. A slow birth and stretched perineum are fundamental to preventing third-degree or fourth-degree tears. Hands-off techniques, perineal massage and warm compress are widely used by midwives in China, helping reduce the number of episiotomies, according to a Cochrane review.40 Freedom position labour and birth and immersion in water during the first and second stage of labour appear to have contributed to perineum stretching in Chinese hospitals. A Cochrane review showed similar results, where fewer episiotomies were performed when birth is delivered in upright, stool or squatting position compared with supine position.41 42 A randomised controlled trial (RCT) in Spain43 also showed that the alternative birth model significantly reduced the number of episiotomy compared with the traditional birth model.

Complicated reasons for performing routine episiotomy

Medical practices are largely socially determined. In addition to physiological reasons, a deeper problem is the backward operation system of medical malpractice. In case of severe perineal tears caused by the absence of an episiotomy, the hospital may assume all the responsibilities in a lawsuit. Therefore, to avoid unexpected situations in China, public hospitals have a tacit understanding to implement episiotomy for vaginal birth. Third-degree or fourth-degree laceration is one of the sensitive quality evaluation indexes of obstetric care across China.44 Midwives with third-degree or fourth-degree tears medical records will be incorporated into the files, which may hinder future promotion. As shown in table 2, compared with spontaneous vaginal laceration, almost all obstetricians and midwives believed that episiotomy could reduce the risk of third-degree and fourth-degree perineal laceration, which was the best reason for using this approach. However, evidence suggested that, rather than providing a preventive effect, episiotomy results in severe perineal lacerations.45 Selective episiotomy may result in 30% fewer women experiencing third-degree or fourth-degree tears than routine episiotomy (8 RCTs, 5375 women).2 Midline episiotomy even was a powerful risk factor for third-degree and fourth-degree perineal lacerations. Moreover, routine episiotomy reduces early risk of perineal laceration but increases future risk. Women who had an episiotomy had a doubled risk of second-degree laceration in subsequent vaginal delivery compared with those without an episiotomy, which may be due to the decrease in pelvic floor muscle strength caused by the previous episiotomy.12 It is imperative to reduce the rate of episiotomy among nulliparas in the context of the two-child policy. A considerable number of obstetricians and midwives chose episiotomies to prevent neonatal distress. When the fetus is at risk during childbirth, any procedure seems to be allowed, even if it is potentially harmful to the mother. We found a similar result in another episiotomy survey46: 95% of patients were able to accept episiotomy performed to prevent neonatal distress, compared with 82% to prevent third or fourth tears, suggesting that women were more likely to protect their children than themselves. However, as decreases in fetal heart rate are more detected rather than real neonatal distress, we are concerned about the overuse of episiotomy by midwives claiming to involve fetal distresss and more use episiotomy.

Obstacles to reducing the rate of episiotomy

The rate of restrictive episiotomy recommended by the WHO does not exceed 10%.6 However, 42.11% of participants still thought that the current episiotomy rate (45%) was about right or too low, far from the current evidence-based medicine. Obstetricians and midwives believed that lack of training on perineal tear prevention was the most common obstacle to reducing the rate of episiotomy, which indicated that clinicians needed continuing education. In 2015, a standardised training base for midwives was established to conduct standardised and systematic training of midwives in China, but seats for each batch were limited. Therefore, we recommend that, under experienced supervision, compulsory education and training programmes be formally implemented as early as possible in obstetric clinical training. Besides, we also need other methods to help clinicians keep the habit of restrictive episiotomy. Zhang-Rutledge et al 47 concluded that education, operative feedback and the Hawthorne effect were associated with a decrease in rates of episiotomy (from 7.2% to less than 5%). As far as our hospital is concerned, episiotomy was routinely performed before 2016 and the rate of episiotomy has significantly decreased to 25%–35% recently after adopting a publicity policy of personal episiotomy rate. Meanwhile, regular reviews could remind participants to maintain behavioural changes during weekly staff meetings. The second common obstacle reported by obstetricians and midwives was the lack of time to wait for the perineum to stretch. It is partly due to an emergency requiring saving neonatal lives, such as those with neonatal distress and cord prolapse, or an emergency requiring shortening the second stage of labour, such as maternal heart disease or eclampsia, or thick or swollen perineal body tissue. Furthermore, it seems that overwhelmed delivery rooms and shortage of time lead to overmedicalised delivery, suggesting an expansion in the scale of birthing facilities and healthcare providers during birth. Prior studies showed that lack of time was a reason for cutting the perineum in order to hasten delivery by birth attendants, given the high number of women in the labour ward.28 Instrument-assisted stretching using an inflatable silicon ball with a pressure display hand pump gradually stretches the vagina and the perineum in late pregnancy. The stretching is performed via widening the hiatus in the axial plane, similar to what happens during perineal massage. de Freitas et al conducted a pilot study to explore the effects of perineal preparation techniques on tissue extensibility and muscle strength.48 They concluded that the techniques increased extensibility without altering the strength of the pelvic floor muscle, which may provide us with a new idea to facilitate perineum stretching. A third of midwives reported that women were expecting an episiotomy. In fact, because delivery is complicated and urgent, midwives often lead the decision-making process of episiotomy. Out of concern for maternal and neonatal health, a woman said she would not reject the midwives’ advice. In general, women had little knowledge about episiotomy and were not well informed; some did not even know what had been done until after the episiotomy.49 Instead of expectation, the effect of episiotomy was described in Chinese as a ‘psychological shadow’ of postpartum sexual life and the next childbirth, which are societal norms that meant women are expected to suffer alone and not complain.50

As shown in tables 5 and 6, the episiotomy practice at different hospital levels showed difference. Compared with secondary hospitals, the rate of episiotomy in tertiary hospitals was lower, and the knowledge level of obstetricians and midwives was higher, probably as a result of staff qualification being higher and standardised training being disseminated with the latest evidence-based medicine in tertiary hospitals. However, the maternity and child health hospitals are secondary hospitals in most regions of China, which need standardised midwifery training. Senior midwives were more likely to use episiotomy than the young, probably attributed to senior midwives treating more high-risk cases, while there was a small difference between senior and young midwives in terms of using caesarean section, induction and operative vaginal delivery, which implies these differences were not driven by patient risk factors.51 The literature indicated that the age gap of every 10 years among obstetricians caused a 6% increase in episiotomy rate. We have reason to believe that older obstetricians are less likely to persist and be aware of evidence-based medicine. Klein et al 52 found that obstetricians with a higher episiotomy rate had a higher caesarean delivery rate, which was associated with personal overmedical style. If practice is constrained by the persistence of beliefs, it is difficult for obstetricians to abandon outdated operations as well as implement new midwifery technologies. Many medical specialty societies have started requiring physicians to recertify every 10 years. Since 2011, societies have paid bonuses to physicians who pass ‘maintenance of certification’ examinations, which provide older physicians with an opportunity to identify mismatches between practice patterns and current evidence.

Limitations

Our study has several limitations. First, we only investigated the knowledge, attitude and experience towards episiotomy. Perineal suturing was not studied since knowledge on perineal suturing involves numerous areas of evaluation, materials selection, operation points and so on. Second, the paper is a cross-sectional study rather than a prospective cohort study, which restricts the ability to infer a causal relationship between attitudes and episiotomy practice. Third, the questionnaire is anonymous, without knowledge of the names of the participants who come from 90 hospitals of diverse cities, and other medical records were not available due to patient privacy, which hinders finding individual medical record reviews and exploring the effects of knowledge, attitude and experience of delivery service.