The rate of episiotomy use declined from 17.3% to 11.6% from 2006 to 2012, according to claims data from 510 U.S. hospitals.

The drop in the procedure’s frequency follows guidance advising against its widespread use. In 2006, the American Congress of Obstetricians and Gynecologists recommended against routine episiotomy, and in 2008 the National Quality Forum stated that limiting routine episiotomy was important to patient safety, noting the increased risks of pain, laceration, and anal incontinence associated with the procedure.

Dr. Alexander M. Friedman and his colleagues at Columbia University in New York, analyzed claims in an insurance database that included 2,261,070 women hospitalized for a vaginal delivery from 2006 to 2012. The sample did not include cases of shoulder dystocia, fetal distress, or fetal heart rate abnormalities, since these complications can be considered indications for episiotomy. A total of 325,193 of these women had an episiotomy during the 7-year period, according to the analysis published in JAMA on Jan. 13 ( JAMA 2015;313:197-9 ).

The rate of episiotomy use varied widely among hospitals. It was 34.1% among the approximately 50 hospitals that used the procedure the most often, compared with 2.5% in the 50 hospitals that used the procedure the least.

The variation appears to be due to nonmedical factors, the authors wrote. For instance, the rate of episiotomy was nearly twice as high among white women (15.7%) as among black women (7.9%). Similarly, women with commercial insurance were more likely to undergo the procedure than those with Medicaid insurance.

“Further strategies are needed to enhance adherence to evidence-based recommendations,” Dr. Friedman and his colleagues wrote.


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