Episiotomies are painful, risky and not routinely recommended; Dozens of hospitals do too many
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.
That’s why 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.
But a USA today analysis of hospital billing data finds dozens of hospitals with episiotomy rates of 20% or higher, some of them nearly double that.
More:Secret data shows hospital episiotomy rates
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, mid-sized hospitals in metropolitan suburbs and small facilities in rural communities. Washington State had the lowest statewide rate: Just 3.8% during the time period studied. In New York and Nevada, statewide 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Experts blamed high rates on outdated medical practices and a desire to speed up the time it takes to deliver babies.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 20-30% episiotomy rate,” said Dr. Steven Clark, a professor at Baylor College of Medicine, who has published research on methods for reducing episiotomy rates. “There’s not an excuse for a rate anywhere close to that.”
More:Several Brevard hospitals lacking in patient safety, new report says
At NewYork-Presbyterian Queens, a 535-bed teaching hospital in Flushing, New York, nearly 40% of women who delivered vaginally from 2014 to 2017 – and whose babies didn’t have the shoulder complication – 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 –which has six labor and delivery rooms across the river from the state capital – at nearly 37%, and Hialeah Hospital near Miami at 36%. At Dallas Regional Medical Center, which touts its women’s center as having the “newest medical equipment,” the episiotomy rate was 31%. At Summerlin Hospital Medical Center, one of Las Vegas’ biggest birthing centers, it was about 22%.
While individual 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, like NewYork-Presbyterian Queens issued vague statements.
“NewYork-Presbyterian is deeply committed to reducing obstetric maternal mortality and morbidity,” their written response said.
Hialeah Hospital’s operator, Tenet Healthcare, said only: "There are many factors that might influence a practitioner’s decision to perform an episiotomy during a delivery. We are committed to delivering safe, high-quality, patient-centered care. "
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, in a 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.
Experts said such explanations make no sense.
“What you often find in these high episiotomy hospitals are cultures of excuse,” Clark said.
Doctors and hospitals want to believe they are doing the right thing, he said, and they excuse their performance by believing that their patients are somehow different than the patients of those who perform better.
The hospitals USA TODAY examined were in Florida, Nevada, New York, Rhode Island, Texas, Vermont, Washington and West Virginia. While 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.
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 new analysis of episiotomies is yet another example of how childbirth care at hospitals varies dramatically – and how data kept secret could inform women’s healthcare decisions.
“Episiotomy should have been solved a long time ago,” Pearson said. “I believe if there were consumer-led efforts to have mandates for full disclosure by hospitals of a variety of outcomes, and also frequency of procedures … you wouldn’t have these outliers because it would have come to light so much earlier.”
Women are injured severely
The injuries women suffer from episiotomy complications can last years and there is little scientific evidence of its benefits. That’s why the American College of Obstetricians and Gynecologists has issued bulletins to doctors since 2006 calling for the procedure to be used sparingly.
While noting that doctors have used episiotomies to expedite delivery in cases where a baby’s heart rate signals trouble, when a baby’s shoulders get stuck or when the mother appears likely to suffer a laceration during delivery, the organization warned these uses were based more on opinion and belief than on science.
“Current data and clinical opinion suggest that there are insufficient objective evidence-based criteria to recommend episiotomy, and especially routine use of episiotomy, and that clinical judgment remains the best guide for use of this procedure,” the 2006 bulletin said.
Some episiotomy injuries are physical – deep and painful lacerations that tear so far they require surgical repair. Wounds become infected or break down and heal slowly. Sex can become painful.
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.
The injuries also can be psychological, affecting women’s views of their bodies and decisions about whether to have more children.
Emilee Strezinski still finds it difficult to talk about the delivery of her first child in 2011, when she was 21. As she labored for hours at a hospital in rural Ohio, her baby wasn’t coming out.
“You could hear the scissors,” Strezinski said, recalling the moment the doctor began cutting. “Since it had gotten toward the end of my pain medication, that last cut, I believe it was number five... that’s when I felt it and I remember screaming.”
The doctor never discussed with Strezinski or her husband the risks or benefits of her undergoing the procedure, they would later allege as part of legal action. Strezinski suffered a severe tear into her anus from the episiotomy – and then still ended up needing an emergency C-section to deliver her daughter.
To heal from the episiotomy she drove twice a week to a specialist in a larger town 40 miles away.
“I ended up having to do physical therapy, which was odd and very uncomfortable for a young girl. It was degrading,” she said. “It affected my sex life, my personal life, just a lot of stuff I wouldn’t have thought could have happened.”
Strezinski sued both the doctor and hospital; in court records they denied wrongdoing. The case was resolved, court records show, but details of the settlement are confidential.
Why change is so hard
Episiotomies date back 300 years in medical literature. 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 that 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.
Change has happened slowly, Levy said, because many doctors were trained to make the cuts.
“It’s so difficult to get people who grew up with a certain mindset to change that mindset,” she said.
In some emergency circumstances where 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 healthcare professional,” Levy said. “There are women who would choose a Cesarean birth over perineal laceration and episiotomy.”
Ideally, that conversation should occur before the emergency arises, she added.
Dr. Sara Cichowski, an assistant OB/GYN professor at the University of New Mexico who reviewed the latest studies to help write the American College of Obstetricians and Gynecologists’ most recent guidelines, said women often have little chance to make an informed choice.
“It will be cut quickly while someone is pushing,” she said. “I don’t think many mothers in that situation would say: ‘Wait a second, what’s going on?’ ”
Once in the delivery room, if the situation isn’t really urgent, Cichowski said studies have found that the use of warm compresses can reduce how much a woman tears during birth. She said women might also ask whether there is anything they can do to push more effectively.
Allison Snyder, who had to have surgical repairs to address her incontinence, said there was no time to ask questions during her 2013 episiotomy.
“It happened so fast,” Snyder said. She remembers her surprised husband saying to the midwife who handled her hospital delivery: “What did you just do?”
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 says she demanded additional testing. Only then was the hole discovered.
Snyder said it hadn’t occurred to her to ask about episiotomies during prenatal appointments.
“It’s such an outdated practice, I didn’t think I needed to bring it up,” said Snyder, a pharmacist in North Carolina. She advises other pregnant women: “Go in prepared with questions you want answered, even the gross stuff, the uncomfortable stuff. That’s their job to talk to you.”
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. “Not all physicians in the country read the literature as religiously as we would like.”
U.S. doctors are given wide latitude to practice medicine according to their clinical judgments. Even the national bulletins give doctors leeway.
By coupling education with a spotlight on individual doctors’ performances, however, the Staten Island hospital 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 had dropped to 19%, he said, and it fell even lower during the first few 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 2017 study by Dr. Steven Clark and other researchers at Texas Children’s Hospital Pavilion for Women in Houston.
This large, urban medical center reduced its episiotomy rate from 9% in 2012 to below 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.
Hospitals across the state of Washington also rely on education and shared data. In addition to the state’s low 3.8% rate during 2014-2017, many of the state’s major birthing centers had rates of 2% to 3%.
“This is something we’ve worked on really hard and the rate is lower even than what you saw,” said Cassie Sauer, president of the Washington State Hospital Association. In late 2018, she said, the statewide episiotomy rate fell to 2.2%.
It wasn’t always that way. Since 2012 – when the statewide rate was about 7% and some hospitals had rates up to 40% – the association has emphasized episiotomy prevention during education events and by collecting and sharing data across all delivery hospitals.
“Providers really respond well to data, especially if they trust the data,” said Dr. Dale Reisner, who has helped lead those efforts as medical director for OB/GYN quality and safety for Swedish Health Services.
Reports are distributed to hospitals showing how they measure up. And the episiotomy rates for individual hospitals are public on the association’s Washington Hospital Quality website.
Data routinely kept secret
Studies based on data that keeps hospital names confidential indicate episiotomy rates have been dropping nationally. In 1979 the procedure was performed in nearly two-thirds of deliveries. By 2000, use had dropped to one-third and, in 2012, about 12% of mothers across the country were cut.
But nationwide rates obscure what’s happening at individual hospitals. And it’s difficult for women to find out whether their hospital or doctor is practicing outdated medicine.
There is no national requirement that hospitals publicly disclose their episiotomy rates – or other measures related to maternal safety. And there is no publicly available national data on doctors' episiotomy rates.
The federal Centers for Medicare and Medicaid Services requires hospitals to disclose their rates of a wide range of medical complications on its Hospital Compare website. But for childbirth, the government website includes only how often babies are delivered early by choice, which can lead to complications from prematurity.
The agency requires no public reporting on childbirth safety measures, such as how often women experience severe complications, receive prompt treatment for emergencies, or have C-sections or episiotomies.
The federal agency “is working to identify potential further actions to better measure and reduce severe maternal morbidity, including maternal mortality, as well as to reduce disparities by race and geography,” the agency said in a statement to USA TODAY. It did not explain what those actions might be or provide any timeline.
Citing USA TODAY’s ongoing investigation, both Democrat and Republican leadership of the House Committee on Energy and Commerce sent a letter to the federal agency last month seeking a briefing on potential reporting requirements and coverage improvements to reduce what it called the nation’s high rate of maternal deaths and injuries.
The Leapfrog Group, a nonprofit founded by major employers and others who pay for healthcare, has set 5% as the target episiotomy rate based on the rarity of sound reasons for its use, along with the nonprofit’s own observation that many hospitals have safely achieved rates of less than 3%, said Dr. Elliott Main, chairman of the Leapfrog panel and national expert on childbirth safety.
Since 2012, Leapfrog annually asks hospitals about a variety of safety and quality issues, including their episiotomy rates – information it posts on its website. Only about 1,300 of the nation’s approximately 2,400 hospitals that provide maternity services disclosed data on 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.
Contributing: Christopher Schnaars
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