Episiotomies speed births at risk to moms
It’s a surgical cut made during childbirth that doctors have been officially warned for more than a decade does more harm to women than good.
Mothers who receive episiotomies – an incision at the vaginal opening to create more room as a baby’s head appears – are more likely to suffer severe complications than if they had been allowed to tear naturally.
National guidelines since 2006 have called for limiting the procedure to emergencies, such as when a baby’s shoulders get stuck. Although there is no national consensus on how frequently the procedure should be used, a leading hospital safety group recommends that the cuts should occur in no more than 5% of vaginal deliveries.
A USA TODAY analysis of hospital billing data finds dozens of hospitals in eight states with episiotomy rates of 20% or higher, some nearly double that.
At the 553 hospitals analyzed, nearly 240,000 women were cut over four years. Those with the highest rates of episiotomies included major medical centers in big cities, midsize hospitals in metropolitan suburbs and small facilities in rural communities. Washington had the lowest statewide rate: 3.8% during the time period studied. In New York and Nevada, rates were more than 11%.
Experts blamed high rates on outdated medical practices and a desire to speed up the time it takes to deliver babies. Where hospitals have educated doctors and tracked their use of episiotomy, rates have dropped dramatically.
“I cannot imagine what on earth is going on with a hospital that has a 20% to 30% episiotomy rate,” said Dr. Steven Clark, a professor at Baylor College of Medicine. “There’s not an excuse for a rate anywhere close to that.”
At NewYork-Presbyterian Queens, a 535-bed teaching hospital in Flushing, nearly 40% of women who delivered vaginally from 2014 to 2017 – and whose babies didn’t have shoulder complications – received episiotomies. The hospital’s rate was the highest among hospitals studied by USA TODAY – almost eight times the recommended rate.
Other outliers included Thomas Memorial Hospital in South Charleston, West Virginia, at nearly 37% and Hialeah Hospital near Miami at 36%. At Dallas Regional Medical Center, which touts the “newest medical equipment” at its women’s center, the episiotomy rate was 31%. At Summerlin Hospital Medical Center, one of Las Vegas’ biggest birthing centers, it was about 22%.
Though doctors decide whether to make the cuts, Cindy Pearson, executive director of the National Women’s Health Network, said hospitals have had more than a decade to get doctors to reduce their use of episiotomies.
“Every person who goes into a hospital for any procedure has the right to expect the hospital will not put them at unnecessary risk,” Pearson said. “These hospitals that still have outrageously high rates, they’re to blame.”
Of 30 hospitals contacted by USA TODAY, only three agreed to be interviewed about why their rates have been so high. Some, such as NewYork-Presbyterian Queens issued vague statements. “NewYork-Presbyterian is deeply committed to reducing obstetric maternal mortality and morbidity,” its written response said.
Hialeah Hospital’s operator, Tenet Healthcare, said, “There are many factors that might influence a practitioner’s decision to perform an episiotomy during a delivery. We are committed to delivering safe, highquality, patient-centered care.”
Other hospitals sent emails saying their rates were now lower but declined to share numbers; or they blamed their patients’ health for their frequency of episiotomy use.
The hospitals USA TODAY examined were in Florida, Nevada, New York, Rhode Island, Texas, Vermont, Washington and West Virginia. Though USA TODAY sought patient billing data from all states, many declined to release it, sought to charge exorbitant fees or imposed restrictions that rendered it useless.
The injuries women suffer from episiotomy complications can last years, and there is little scientific evidence of the procedure’s benefits. The American College of Obstetricians and Gynecologists has issued bulletins to doctors since 2006 calling for the procedure to be used sparingly.
Noting that doctors have used episiotomies to expedite delivery when a baby’s heart rate signaled trouble, when a baby’s shoulders got stuck or when the mother appeared likely to suffer a laceration during delivery, the organization warned these uses were based more on opinion and belief than on science.
“Current data and clinical opinion suggest that there are insufficient objective evidence-based criteria to recommend episiotomy, and especially routine use of episiotomy, and that clinical judgment remains the best guide for use of this procedure,” the 2006 bulletin said.
Some episiotomy injuries are physical – deep and painful lacerations that require surgical repair. Wounds become infected or break down and heal slowly. Sex can become painful.
Emilee Strezinski still finds it difficult to talk about the delivery of her first child in 2011, when she was 21. As she labored for hours at a hospital in rural Ohio, her baby wasn’t coming out.
“You could hear the scissors,” Strezinski said, recalling the moment the doctor began cutting. “Since it had gotten toward the end of my pain medication, that last cut, I believe it was number five ... that’s when I felt it, and I remember screaming.”
Strezinski and her husband alleged in a legal action that the doctor never discussed the risks or benefits of the procedure. Strezinski suffered a severe tear into her anus from the episiotomy – and still needed an emergency C-section to deliver her daughter.
Episiotomies date back 300 years in medical literature. Beginning in the 1920s, doctors were taught episiotomies should be routine, to protect women from a wide range of childbirth harms.
It was thought that a surgical cut would be more precise, easier to repair and cause less injury than a natural tear; doctors believed episiotomies would protect a woman’s pelvic floor muscles, which support her bladder, uterus and rectum.
“Our studies over the years have disproven that,” said Dr. Barbara Levy, vice president for health policy at the American College of Obstetricians and Gynecologists.
Dr. Sara Cichowski, an assistant OB/GYN professor at the University of New Mexico who reviewed the latest studies to help write the American College of Obstetricians and Gynecologists’ most recent guidelines, said women often have little chance to make an informed choice.
“It will be cut quickly while someone is pushing,” she said. “I don’t think many mothers in that situation would say: ‘Wait a second, what’s going on?’ ”
Allison Snyder, who had to have surgical repairs to address her incontinence, said there was no time to ask questions during her episiotomy in 2013. “It happened so fast,” she said.
Snyder, who was 27 at the time, said she ended up with a laceration into her rectum that wasn’t fully repaired after the delivery.
“I could feel air moving from my rectum to my vagina,” she said. Even as her symptoms worsened, she said, “no one was taking me seriously.”
A decade after the first national practice bulletins warned doctors about episiotomies, more than 35% of women delivering vaginally at Richmond University Medical Center in Staten Island, New York, still received them during 2014-17.
“I think not every physician modernizes their practice equally,” said Dr. Michael Moretti, chairman of the hospital’s OB/GYN department. “Not all physicians in the country read the literature as religiously as we would like.”
By coupling education with a spotlight on individual doctors’ performances, however, the Staten Island hospital has led to dramatic change.
“We instituted a peer review process of reviewing all physicians’ episiotomy rates on a monthly basis, discussing them openly in a monthly conference,” Moretti said.
During 2018, the hospital’s rate dropped to 19%.