There was a time when episiotomy -- a surgical incision made in a woman's perineum -- was a routine part of childbirth in the United States, believed to help prevent the vaginal tears that can occur as babies emerge.
But with the procedure leading to complications, including infection and even potential incontinence, doctors began stepping back from it in the 1990s. And promising new figures released this week suggest that rates have continued to fall after several major healthcare organizations in the mid 2000s spoke out against its routine use.
In a short research letter published in the Journal of the American Medical Association, a team of researchers with Columbia University looked at claims of women who had vaginal deliveries at more than 500 United States hospitals between 2006 and 2012.
During that time, episiotomy rates dropped from 17.3 percent in 2006 to 11.6 percent in 2012.
Though the researchers are not sure what led to the decrease, they hypothesized that their findings "possibly" reflect recommendations of groups such as the American College of Obstetricians and Gynecologists, which in 2006 urged restricted use of the procedure.
"The best available data do not support the liberal or routine use of episiotomy," the group wrote at the time, noting that in 2002, episiotomies were performed in roughly one-quarter of all vaginal births. There is a place for episiotomy, ACOG added, but it should be limited to difficult deliveries or to avoid severe lacerations in the laboring woman, for example.
"When birth is happening and we're seeing that extensive vaginal tearing is likely to occur, perhaps we might perform an episiotomy to prevent it," echoed Sharon Wiener, a certified nurse-midwife and professor in the division of maternal-fetal medicine at the University of California, San Francisco.
"If the baby is in a very abnormal position, [a woman] has been crowning for a very long time and the baby needs to be delivered more quickly," she continued, "these are conditions when it might be warranted. Otherwise, if it's just standard fare, it's absolutely not."
Wiener credits the drop in episiotomy to better research highlighting the associated risks, as well as what she believes is a broader emphasis on evidence-based practices in medicine in general.
But the authors of the new study suggest that non-medical factors may exert their own influence on who undergoes episiotomy. White women were more likely than black women to have one, they found, as were those with commercial insurance versus Medicaid.
The study also revealed significant variation in rates among hospitals. In the 10 percent of hospitals that used the procedure most often, the average rate was 34.1, whereas in the 10 percent of hospitals that used episiotomy the least, the average rate was 2.5 percent.
An "ideal" rate of episiotomy, the researchers point out, has not been established.
"I think if we're looking at the rate being down to 25 percent [of vaginal births] in 2002, which is down from 60 percent in the 1980s, and now this [suggests] it's 11 percent, that suggests we're making great strides," said Dr. Mary Rosser, an OB-GYN and attending physician with Montefiore Medical Center in New York. She predicted that the rate would continue to fall as more good, systematic review studies emerge.
Rosser also urged women to talk to their doctors and midwives about episiotomy. "All of this information needs to be discussed during pregnancy, so women and their partners have a good talk with their providers about what they think about routine versus restricted use," she said.