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Abstract
OBJECTIVE To determine whether women treated by older physicians are more likely to undergo episiotomy. DATA SOURCES/STUDY SETTING Hospital discharge data from Pennsylvania for the period 1994 to 2010. STUDY DESIGN We examined the impact of the year in which physicians started delivering babies (a proxy for age) in Pennsylvania on episiotomy rates using a linear probability model with hospital fixed effects. DATA COLLECTION/EXTRACTION METHODS Using diagnosis and procedure codes, we identified women delivering vaginally (N = 1 658 327) and determined the proportion who had an episiotomy. PRINCIPAL FINDINGS The average physician-level episiotomy rate declined from 54 percent in 1994 to 13 percent in 2010. Rates declined among older and younger physicians, but, at any point in time, women treated by older physicians were more likely to have an episiotomy. A 10-year difference in physician age is associated with a 6 percentage point increase in episiotomy rates. CONCLUSIONS Results indicate that older physicians, who entered practice when episiotomy was common, were slow to adjust their practices in response to evidence showing that routine episiotomy is unnecessary.
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Affiliation(s)
- David H. Howard
- Department of Health Policy and ManagementEmory UniversityAtlantaGeorgia
| | - Jason Hockenberry
- Department of Health Policy and ManagementEmory UniversityAtlantaGeorgia
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Clesse C, Lighezzolo-Alnot J, De Lavergne S, Hamlin S, Scheffler M. Factors related to episiotomy practice: an evidence-based medicine systematic review. J OBSTET GYNAECOL 2019; 39:737-747. [DOI: 10.1080/01443615.2019.1581741] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- Christophe Clesse
- Interpsy Laboratory (EA4432), Université de Lorraine, Nancy, France
- Hospital Centre of Jury-les-Metz – Route d’Ars Laquenexy, Jury-Lesmetz, France
- Polyclinic Majorelle, Nancy, France
| | | | | | | | - Michèle Scheffler
- Polyclinic Majorelle, Nancy, France
- Cabinet de Gynécologie Médicale et Obstétrique, Nancy, France
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An Initiative to Reduce the Episiotomy Rate: Association of Feedback and the Hawthorne Effect With Leapfrog Goals. Obstet Gynecol 2017; 130:146-150. [PMID: 28594760 DOI: 10.1097/aog.0000000000002060] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess the association of education, performance feedback, and the Hawthorne effect with a reduction in the episiotomy rate in a large academic institution. METHODS We describe a prospective observational study of a project conducted between March 2012 and February 2017 to assist clinicians in meeting the Leapfrog Group (www.leapfroggroup.org) target rates for episiotomy. Phases of this project included preintervention (phase 1, March 2012 to April 2014), education and provision of collective department episiotomy rates (phase 2, May 2014 to December 2014), ongoing education with emphasis on a revised Leapfrog target rate (phase 3, January 2015 to February 2016), and provision of individual episiotomy rates to practitioners on a monthly basis (phase 4, March 2016 to February 2017). We analyzed the department episiotomy rates before, during, and after these efforts. Cases of shoulder dystocia were excluded from this analysis. Statistical analysis was performed using a two-tailed Student t test and χ test with P<.05 considered significant. RESULTS During the study period 1,176 episiotomies were performed in 16,441 vaginal deliveries (7.2%). In phase 2 (2,352 vaginal deliveries), there was a nonsignificant drop in the episiotomy rate with education alone (9.0-8.2%, P=.21). In phase 3 (4,379 vaginal deliveries), the episiotomy rate demonstrated an additional, significant drop to 5.9% (P<.001), but this reduction did not reach the new Leapfrog goal of 5%. In phase 4 (3,160 vaginal deliveries), the hospital episiotomy rate again dropped significantly from 5.9% to 4.37% (P=.007) and met the target rate of 5%. This reduction was sustained over a 12-month time period. During this same time period, the rate of operative vaginal delivery among vaginal births increased (4.5-5.4%, P=.003) and there was no significant change in the rates of third- and fourth-degree perineal laceration (3.8-3.3%, P=.19). CONCLUSION Education, performance feedback, and the Hawthorne effect were associated with a reduction in the episiotomy rate in a large academic institution without a reduction in the rate of operative vaginal delivery or an increase in the rate of third- and fourth-degree lacerations.
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Piccoli GB, Cabiddu G, Attini R, Gerbino M, Todeschini P, Perrino ML, Manzione AM, Piredda GB, Gnappi E, Caputo F, Montagnino G, Bellizzi V, Di Loreto P, Martino F, Montanaro D, Rossini M, Castellino S, Biolcati M, Fassio F, Loi V, Parisi S, Versino E, Pani A, Todros T. Pregnancy outcomes after kidney graft in Italy: are the changes over time the result of different therapies or of different policies? A nationwide survey (1978–2013). Nephrol Dial Transplant 2016; 31:1957-1965. [DOI: 10.1093/ndt/gfw232] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Escuriet R, Pueyo MJ, Perez-Botella M, Espada X, Salgado I, Gómez A, Biescas H, Espiga I, White J, Fernandez R, Fusté J, Ortún V. Cross-sectional study comparing public and private hospitals in Catalonia: is the practice of routine episiotomy changing? BMC Health Serv Res 2015; 15:95. [PMID: 25889079 PMCID: PMC4365515 DOI: 10.1186/s12913-015-0753-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Accepted: 02/17/2015] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND In Spain, the Strategy for Assistance in Normal Childbirth (SANC) promoted a model of care, which respects the physiological birth process and discards unnecessary routine interventions, such as episiotomies. We evaluated the rate of episiotomy use and perineal trauma as indicators of how selective introduction of the SANC initiative has impacted childbirth outcomes in hospitals of Catalonia. METHODS Cross-sectional study of all singleton vaginal term deliveries without instrument registered in the Minimum Basic Data Set (MBDS) of Catalonia in 2007, 2010 and 2012. Hospitals were divided into types according to funding (public or private), and four strata were differentiated according to volume of births attended. Episiotomies and perineal injury were considered dependent variables. The relationship between qualitative variables was analysed using the chi-squared test, and Student's t-test was used for quantitative variables. Comparison of proportions was performed on the two hospital groups between 2007 and 2012 using a Z-test. Logistic regression models were used to analyse the relationship between episiotomy or severe perineal damage and maternal age, volume of births and hospital type, obtaining odds ratios (OR) and 95% confidence intervals (CI). RESULTS The majority of normal singleton term deliveries were attended in public hospitals, where maternal age was lower than for women attended in private hospitals. Analysis revealed a statistically significant (P < 0.001) decreasing trend in episiotomy use in Catalonia for both hospital types. Private hospitals appeared to be associated with increased episiotomy rate in 2007 (OR = 1.099, CI: 1,057-1,142), 2010 (OR = 1.528, CI: 1,472-1,587) and 2012 (OR = 1.459, CI: 1,383-1,540), and a lower rate of severe perineal trauma in 2007 (OR = 0.164, CI: 0.095-0.283), 2010 (OR = 0.16, CI: 0.110-0.232) and 2012 (OR = 0.19, CI: 0.107-0.336). Regarding severe perineal injury, when independent variables were adjusted, maternal age ceased to have a significant correlation in 2012 (OR = 0.994, CI: 0.970-1.018). CONCLUSIONS Episiotomy procedures during normal singleton vaginal term deliveries in Catalonia has decreased steadily since 2007. Study results show a stable incidence trend below 1% for severe perineal trauma over the study period.
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Affiliation(s)
- Ramón Escuriet
- Directorate-General for Health Planning and Research, Ministry of Health of the Government of Catalonia, Barcelona, Spain.
- Department of Experimental and Health Sciences, Universitat Pompeu Fabra (UPF), Barcelona, Spain.
- Consorci Sanitari Integral, Hospital General de l'Hospitalet, L'Hospitalet de Llobregat, Barcelona, Spain.
| | - María J Pueyo
- Directorate-General for Health Planning and Research, Ministry of Health of the Government of Catalonia, Barcelona, Spain.
| | - Mercedes Perez-Botella
- University of Central Lancashire, School of Health, Midwifery, Neonatal and Sexual Health Division, Preston, UK.
| | - Xavi Espada
- Institut Català de la Salut, Unitat Atenció a la Salut Sexual i Reproductiva, Granollers, Spain.
- Fundació Hospital Asil de Granollers, Granollers, Spain.
| | - Isabel Salgado
- Consorci Sanitari Integral, Hospital General de l'Hospitalet, L'Hospitalet de Llobregat, Barcelona, Spain.
| | - Analía Gómez
- Consorci Sanitari Integral, Hospital General de l'Hospitalet, L'Hospitalet de Llobregat, Barcelona, Spain.
| | - Herminia Biescas
- Directorate-General for Health Planning and Research, Ministry of Health of the Government of Catalonia, Barcelona, Spain.
| | - Isabel Espiga
- Women's Health Observatory, Subdirectorate for Quality and Cohesion, Ministry of Health, Social Services and Equality, Madrid, Spain.
| | - Joanna White
- Centre for Research in Anthropology (CRIA-IUL), Lisbon, Portugal.
- Visiting Fellow, King's College, London, UK.
| | - Rosa Fernandez
- Public Health Agency of Catalonia, Maternal and Infant Health Programme, Government of Catalonia, Barcelona, Spain.
| | - Josep Fusté
- The Union, Health and Social Entities Association, Barcelona, Spain.
| | - Vicente Ortún
- Universitat Pompeu Fabra (UPF), Faculty of Economic and Business Sciences, Barcelona, Spain.
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