Interventions and Strategies for Reducing Episiotomy Rates Globally: A Systematic Review

Episiotomy is still commonly practiced during childbirth worldwide, despite decades of scientific evidence that indicates no justification for its routine use. Routine episiotomy is associated with increased risk of serious maternal morbidity and no improvements in neonatal outcomes. We sought to analyze this gap between evidence-based knowledge and implementation surrounding reducing episiotomy practice. We systematically reviewed the literature to identify practices that have resulted in a change in episiotomy rates.

We searched three databases (PubMed/MEDLINE, CINAHL Complete, Embase) using key words and subject headings with no time restriction. Any studies published in English and reporting an original empirical analysis in any global, regional, or country-specific context that examined practice changes that were implemented and reported episiotomy as an outcome were included in our review. Studies were excluded if they only reported on trends or changes in episiotomy rates without examining the specific practices implemented. We sought to identify practices that resulted in a change in episiotomy rates, rather than to evaluate or compare the effectiveness of these practices.

Search results returned 1265 records; 40 papers met the inclusion criteria for a full review. Twenty-five papers were included in our final analysis. All included studies documented a decrease in episiotomy rates, with 21 studies reporting a statistically significant reduction. Most studies were mixed interventions, often a combination of an educational intervention and audit and feedback.

Specific practice changes have been shown to effectively decrease the incidence of episiotomy. The findings from our review provide actionable insights for implementing evidence-based interventions to improve obstetric care. Prioritizing respectful birthing practices and reducing the routine use of episiotomy are critical steps toward addressing obstetric violence and promoting equitable, patient-centered maternity care globally.