Radical Doula

An interesting article in Women’s Enews today about the persisting prevalence of episiotomies, despite a medical study from two years ago which proves that there is NO MEDICAL BENEFIT.

The article points out that the procedure (which involves making an incision in the perineum, the area between the vagina and the anus, during labor) continues to be employed in one-quarter of births. It was previously thought that making a surgical incision was preferable to the possibility of a natural tear during delivery, and the practice became widely employed by the 1940s with the rational being that subsequent stitching would be easier, as well as avoiding side effects like pelvic floor dysfunctions. It also helps to speed up the pushing phase of labor, by widening the vaginal opening for the baby to exit.

The study cited by this article, which reviewed over 50 years worth of data and research on the use of episiotomy came to these conclusions:

The JAMA researchers found that the benefits traditionally attributed to routine episiotomy do not exist. They also found that episiotomy actually increases the risk of severe tearing, pain with intercourse, incontinence and other pelvic problems following delivery. Based on these findings, the researchers called for an end to the procedure, except when the health of the fetus is at risk.

This is a huge step forward in recognizing something that midwives have known for a long time–this intervention is unnecessary and actually harmful in many cases. I witnessed the detrimental effects of episiotomy firsthand while observing in an Ecuadorian maternity ward. The doctors (actually medical students) there told me that while they knew that it was counter-indicated to perform routine episiotomies, they continued to do it anyway, for ALL women who labored at their maternity. One woman who I accompanied during her labor, whose pushing stage only lasted maybe 30 minutes, then required almost an hour and a half of stitching for the episiotomy she was given.

The article goes on to explain why there hasn’t been a more significant decrease in the use of the procedure in the two years since the study was released–the difficulty of educating older doctors.

A study published last year in the Journal of Reproductive Medicine showed that physicians in practice 15 years or more perform episiotomies 50 percent more often than those in practice less than 15 years. “I can’t wait for the doctors who do routine episiotomies to fall out by attrition,” says Hoskins. “That’s too long to wait.”

This is similar to the reason why in places like Ecuador, they are still employing old standards of episiotomy indications. In many foreign countries, particularly in Latin America, they follow the American College of Obstetrics and Gynecology Guidelines. They use the US curriculum for teaching their students, and rely on the research and developments that come out of the practice in the US. The problem is, it can take a significant amount of time for these things to filter down, particularly to the level of public maternity practice in Ecuador. The accountability in those countries is not the same, and there is often times a stark difference between private maternity care and the services offered to low-income people in public hospitals.