Understanding the perspectives and values of midwives, obstetricians and obstetric registrars regarding episiotomy: qualitative interview study

Abstract

Objectives: Insight into perspectives and values of care providers on episiotomy can be a first step towards reducing variation in its use. We aimed to gain insight into these perspectives and values.

Setting: Maternity care in the Netherlands.

Participants: Midwives, obstetricians and obstetric registrars working in primary, secondary or tertiary care, purposively sampled, based on their perceived episiotomy rate and/or region of work.

Primary and secondary outcome measures: Perspectives and values of care providers which were explored using semistructured in-depth interviews.

Results: The following four themes were identified, using the evidence-based practice-model of Satterfield et al as a framework: 'Care providers' vision on childbirth', 'Discrepancy between restrictive perspective and daily practice', 'Clinical expertise versus literature-based practice' and 'Involvement of women in the decision'. Perspectives, values and practices regarding episiotomy were strongly influenced by care providers' underlying visions on childbirth. Although care providers often emphasised the importance of restrictive episiotomy policy, a discrepancy was found between this vision and the large number of varying indications for episiotomy. Although on one hand care providers cited evidence to support their practice, on the other hand, many based their decision-making to a larger extent on clinical experience. Although most care providers considered women's autonomy to be important, at the moment of deciding on episiotomy, the involvement of women in the decision was perceived as minimal, and real informed consent generally did not take place, neither during labour, nor prenatally. Many care providers belittled episiotomy in their language.

Conclusions: Care providers' underlying vision on episiotomy and childbirth was an important contributor to the large variations in episiotomy usage. Their clinical expertise was a more important component in decision-making on episiotomy than the literature. Women were minimally involved in the decision for performing episiotomy. More research is required to achieve consensus on indications for episiotomy.

Keywords: obstetrics; perinatology; qualitative research.

Figure 1

The revised model on evidence-based practice of Attride-Stirling.