Understanding the perspectives and values of midwives, obstetricians and obstetric registrars regarding episiotomy: qualitative interview study

Abstract

ObjectivesInsight into perspectives and values of care providers on episiotomy can be a first step towards reducing variation in its use. We aimed to gain insight into these perspectives and values.SettingMaternity care in the Netherlands.ParticipantsMidwives, obstetricians and obstetric registrars working in primary, secondary or tertiary care, purposively sampled, based on their perceived episiotomy rate and/or region of work.Primary and secondary outcome measuresPerspectives and values of care providers which were explored using semistructured in-depth interviews.ResultsThe following four themes were identified, using the evidence-based practice-model of Satterfield et al as a framework: ‘Care providers’ vision on childbirth’, ‘Discrepancy between restrictive perspective and daily practice’, ‘Clinical expertise versus literature-based practice’ and ‘Involvement of women in the decision’. Perspectives, values and practices regarding episiotomy were strongly influenced by care providers’ underlying visions on childbirth. Although care providers often emphasised the importance of restrictive episiotomy policy, a discrepancy was found between this vision and the large number of varying indications for episiotomy. Although on one hand care providers cited evidence to support their practice, on the other hand, many based their decision-making to a larger extent on clinical experience. Although most care providers considered women’s autonomy to be important, at the moment of deciding on episiotomy, the involvement of women in the decision was perceived as minimal, and real informed consent generally did not take place, neither during labour, nor prenatally. Many care providers belittled episiotomy in their language.ConclusionsCare providers’ underlying vision on episiotomy and childbirth was an important contributor to the large variations in episiotomy usage. Their clinical expertise was a more important component in decision-making on episiotomy than the literature. Women were minimally involved in the decision for performing episiotomy. More research is required to achieve consensus on indications for episiotomy.

The ethics of consent during labour and birth: episiotomies

“…It is difficult to imagine that 43%8 of women who had an episiotomy in a high-resource setting would report not having explicitly consented to this procedure, if care providers were genuinely convinced that consent for this procedure was (always) required. Indeed, care providers actively express doubt about the need for gaining consent, and experience challenges in obtaining it 17 56. Nonetheless we argue that, yes, consent is necessary for all types of episiotomies, under all circumstances, and that all women, regardless of personal characteristics or cultural background, are entitled to it.…”

“…Care providers frequently express surprise that consent should be necessary 17. They cite, among others, the trusting relationship as grounding the permissibility of these procedures, and the diminished ability or desire of labouring women to engage in elaborate communication 17. Indeed, there is some evidence that not all women want to give consent for every procedure 13 18.…”

Influence of the maternity unit and region of delivery on episiotomy practice in France: a nationwide population‐based study

“…Gachon et al advanced these hypotheses in 2019 in a publication assessing inter‐practitioner variability in episiotomy use among 389 members of the CNGOF 25 . A qualitative study published in 2020 concluded that care providers' underlying vision on episiotomy and childbirth was an important contributor to the large variations in episiotomy usage 26 . Their clinical expertise was a more important component in decision‐making in episiotomy compared with the literature.…”

Informed consent in episiotomy: Co‐analysis with midwives and distillation of best practice

“…Despite assessment for episiotomy being a component of the OASI‐CB, the discussion guide does not cover the potential situations where an episiotomy may be offered, or the potential risks, benefits, or alternative options. This leaves the content of the conversation dependent on the practice experience and knowledge of the midwife 12 …”