|10. Over-medicalisation of Maternal Care in Developing Countries|
Episiotomy has been practised with increasing frequency within recent years without strong scientific evidence of its effectiveness. A systematic review of six randomized controlled trials comparing the possible beneficial and harmful effects of selective versus routine use of episiotomy has been recently published (Carroli & Belizán 2000). The selective use of episiotomy shows a lower risk of clinically relevant morbidity including posterior perineal trauma (Relative Risk (RR) 0.88, 95% Confidence Interval (CI) 0.84 to 0.92), a reduced need for suturing perineal trauma (RR 0.74, 95% CI 0.71 to 0.77), and fewer healing complications at seven days (RR 0.69, 95% CI 0.56 to 0.85). The only disadvantage shown in the selective use of episiotomy is an increased risk of anterior perineal trauma (RR 1.79, 95% CI 1.55 to 2.07). There was no difference in the incidence of major complications, such as severe vaginal or perineal trauma nor in pain, dyspareunia or urinary incontinence. There is clear evidence to recommend a selective use of episiotomy.
A recent Editorial of the British Medical Journal strongly advocated the need to decrease the use of routine episiotomies in developing countries (Maduma-Butshe et al. 1998). The authors polled 10 midwifes from Ghana, Kenya, Malawi, Nepal, Nigeria, and Zambia, attending courses in Liverpool, England. Most respondents indicated that health professionals perform episiotomies routinely on primiparae to prevent third degree perineal tears. Maduma-Butshe et al. 1998 also cited a study form Botswana, where one in three mothers having a normal delivery had episiotomy. A study from Burkina Faso reported an episiotomy rate of 37% among primiparae (Lorenz et al. 1998). The rate was 46% among primiparae when trained midwives attended the delivery and of 26% among primiparae delivered by auxiliary midwives. A study of all vaginal deliveries performed in 1997 and 1998 at the University of Benin Teaching Hospital, Benin City, Nigeria found episiotomy rates of 46.6% among all deliveries, and of 87.4% among primiparae (Otoide et al. 2000).
High frequencies of episiotomies have been reported in Latin America. Several studies from Argentina showed that episiotomy is routinely performed among primiparae. Eight hospitals from the City of Rosario participated in a randomized controlled trial comparing routine and selective use of episiotomies (Argentine episiotomy Trial Collaborative Group 1993). The episiotomy rate among primiparae was 90.7% in the four control hospitals, compared to 39.5% in the four intervention hospitals. A follow up study performed in one of the intervention hospitals showed that the rate of episiotomies among primiparae increased again after the end of the trial, and reached 65.3% in 1996 (Belizan et al. 1998). Another Argentine study showed that in the Province of Nequen, the episiotomy rate was 45.9% among all vaginal births, with hospital rates ranging from 33.4% to 62.5% (Cravchik et al . 1998). Hospital rates of episiotomies among primiparae ranged from 81.5% to 96.0%, and differences among hospitals were not statistically significant.
The situation might be different in other countries, regions, or hospitals. Women interviewed in a population-based maternal morbidity study from southern India reported that an episiotomy was performed in 9% of deliveries (Bhatia 1995). An episiotomy rate lower than 1% has been reported in a small secondary care facility in Jamaica (Doherty & Cohen 1993). However, a study from the University Hospital of the West Indies showed overall episiotomy rates of 31.5% among low birth weight infants delivered vaginally (The 1990).