Reasons for routine episiotomy: A mixed-methods study in a large maternity hospital in Phnom Penh, Cambodia

Abstract

First documented in 1741, the practice of episiotomy substantially increased worldwide during the 20th century. However, research shows that episiotomy is not effective in reducing severe perineal trauma and may be harmful. Using a mixed-methods approach, we conducted a study in 2013-14 on why obstetricians and midwives in a large maternity hospital in Phnom Penh, Cambodia, still do routine episiotomies. The study included the extent of the practice, based on medical records; a retrospective analysis of the delivery notes of a random sample of 365 patients; and 22 in-depth interviews with obstetricians, midwives and recently delivered women. Of the 365 women, 345 (94.5%, 95% CI: 91.7-96.6) had had an episiotomy. Univariate analysis showed that nulliparous women underwent episiotomy more frequently than multiparous women (OR 7.1, 95% CI 2.0-24.7). The reasons given for this practice by midwives and obstetricians were: fear of perineal tears, the strong belief that Asian women have a shorter and harder perineum than others, lack of time in overcrowded delivery rooms, and the belief that Cambodian women would be able to have a tighter and prettier vagina through this practice. A restrictive episiotomy policy and information for pregnant women about birthing practices through antenatal classes should be implemented as soon as possible.

Factors associated with caesarean sections in Phnom Penh, Cambodia

“…13 Damage during vaginal birth has recently been observed in Phnom Penh where routine episiotomy is practiced in order to "help" women deliver faster. 27 Lumbiganon and colleagues have shown that women often do not know that, when performed without medical justification, this surgical intervention may increase maternal and perinatal morbidity, causing an unnecessary additional health burden. 2 In our study, many women mentioned that they felt a c-section would be safer for their baby and themselves.…”

Risk factors for episiotomy during vaginal childbirth: A retrospective cohort study in Western China

“…Despite the many harms of episiotomy, however, episiotomy remains a very common practice among Chinese populations with reported incidences of 82%, 86%, and 100% in Mainland China, Hong Kong, and Taiwan, respectively, and routine use of episiotomy for nearly all first vaginal births in China . Internationally, there is a wide variation in episiotomy rates, varying from as low as 6.7% (Hawaii) to as high as 94.5% (Cambodia) . There are no valid guidelines for the performance of episiotomy, and the decision of the procedure is based on clinical judgment of the accoucheur attending the delivery.…”

Women’s Involvement in Decision Making: Episiotomy Procedure

“…Episiotomy is the birth interventions that commonly performed to enlarge the perineum during delivery which, may be justified for specific maternal or fetal indications such as poor maternal effort, forceps extraction or fetal distress, however, the routine use of this procedure is being questioned [3,21]. The World Health Organization (WHO) has recommendation to restrict the use of episiotomy procedure in low risk pregnancy, nevertheless, this procedure has remained constant in all countries around the world [5,11] in particular developing countries [3,5,21].…”

“…The World Health Organization (WHO) has recommendation to restrict the use of episiotomy procedure in low risk pregnancy, nevertheless, this procedure has remained constant in all countries around the world [5,11] in particular developing countries [3,5,21].…”

“…The reason for performing episiotomy might be influenced by individual practice patterns [21] or attitudes of the health providers [1,10,14]. On the other hand, it is possible that women's lack of involvement in decision making about the treatment choices [19,22].…”