Surgical slice speeds births, risky for moms
Though doctors cautioned about cutting, practice is common at several hospitals
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 of them 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Experts blamed high rates on outdated medical practices and a desire to speed up the time it takes to deliver babies.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 2030% 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.
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.
Thomas Memorial Hospital’s statement pointed to the poor health of the West Virginia mothers it serves, their lack of prenatal care and the state’s opioid epidemic. The hospital didn’t respond to questions about how opioid addiction or prenatal care increase the need for episiotomies.
“What you often find in these highepisiotomy hospitals are cultures of excuse,” Clark said.
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.
Women injured severely
In March, USA TODAY revealed rates of severe childbirth complications at nearly 1,000 hospitals in 13 states. The work identified 120 hospitals where women giving birth were more than twice as likely to have had blood transfusions, hysterectomies, heart attacks, strokes and other indicators of deliveries that could turn deadly.
USA TODAY’s analysis of episiotomies is another example of how childbirth care at hospitals varies dramatically – and how data kept secret could inform women’s health care decisions.
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.
Studies indicate that women who receive episiotomies are at four -times the risk of suffering severe lacerations into their anal sphincter than women whose doctors don’t cut them during a vaginal delivery.
Emilee Strezinski suffered a severe tear into her anus from an episiotomy and still ended up needing an emergency C-section to deliver her first child in 2011 in rural Ohio.
“You could hear the scissors . ... That last cut, I believe it was number five ... that’s when I felt it, and I remember screaming,” she said.
To heal from the episiotomy, she drove twice a week to a specialist in a larger town 40 miles away. “It affected
“Every person who goes into a hospital for any procedure has the right to expect the hospital will not put them at unnecessary risk.” Cindy Pearson National Women’s Health Network
my sex life, my personal life, just a lot of stuff I wouldn’t have thought could have happened,” she said.
Strezinski sued both the doctor and hospital; in court records, they denied wrongdoing. The case was settled, but details are confidential.
Why change is so hard
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 – and possibly reduce risks of incontinence later in life.
“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.
“It’s so difficult to get people who grew up with a certain mindset to change that mindset,” she said.
In some emergency circumstances when a baby needs to be delivered quickly, Levy said, an episiotomy can be a lifesaving procedure that is less risky than a Cesarean section delivery, which is a major surgery.
“I think what has to happen is a shared decision-making conversation between the woman and her delivering health care professional,” Levy said. Ideally, that conversation should occur before the emergency arises, she added.
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.”
At the urging of a friend, she demanded additional testing. Only then was the hole discovered.
Hospitals move the needle
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 2014-2017. “I think not every physician modernizes their practice equally,” said Dr. Michael Moretti, chairman of the hospital’s OB/GYN department.
U.S. doctors are given wide latitude to practice medicine according to their clinical judgments. Even the national bulletins give doctors leeway.
Coupling education with a spotlight on individual doctors’ performances 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. “This kind of peer pressure was particularly valuable in changing physician behavior.”
During 2018, the hospital’s rate dropped to 19%, he said, and it fell lower during the first months of this year.
Studies going back decades have found that people will change their behavior when they know their actions are being watched. Called the Hawthorne effect, it can be a powerful influence in stopping unnecessary episiotomies, according to a study in 2017 by Dr. Clark and a team at Texas Children’s Hospital Pavilion for Women in Houston.
This large, urban medical center reduced its episiotomy rate from 9% in 2012 to less than 5% in 2017 through education and sharing data monthly.
“What we found was the value of feedback,” Clark said.
Excuses disappear, he said, when data is broken down by doctor, allowing them to see how they compare to colleagues caring for the same kinds of patients in the same hospital.
The nonprofit Leapfrog Group, founded by employers and others who pay for health care, set 5% as the target episiotomy rate based on the rarity of sound reasons for its use, along with the group’s own observation that many hospitals have safely achieved rates of less than 3%, said Dr. Elliott Main, chairman of the Leapfrog panel.
Since 2012, Leapfrog annually asks hospitals about safety and quality issues, including episiotomy rates – information it posts on its website. Only about 1,300 of the nation’s approximately 2,400 maternity hospitals disclosed their episiotomy rates.
Many of the hospitals with the highest episiotomy rates in USA TODAY’s analysis are among those that declined to respond to Leapfrog.