Episiotomy is performed to enlarge the birth outlet in order to facilitate the delivery of the fetus [1]. It is the surgical enlargement of the posterior aspect of the vagina by an incision to the perineum during the last part of the second stage of labor [2]. Even though seven episiotomy types have been identified, only three (midline, mediolateral, and lateral) are routinely used [3]. Types of episiotomy techniques are classified on millimeter distance from the incision point to the posterior fourchette and by angle from the sagittal or parasagittal plane in degrees [4]. Women with midline episiotomy, deep perineal tears occurred in twofold higher compared to women who underwent a medio-lateral episiotomy [5]. The routine use of episiotomy practice is not recommended by World Health Organization (WHO) for women undergoing spontaneous vaginal birth [6]. A meta-analysis of randomized controlled studies that compare routine episiotomy with restrictive episiotomy suggests that the latter is associated with less posterior perineal trauma, less need for suturing, and fewer complications associated with healing [2]. Though the rate of episiotomy has been declined in developed countries, still it remains high in less industrialized countries and East Asia [7].
Routine use of episiotomy originally began by Pomeroy in 1918 and this routine practice was accepted and taught in obstetrics services till 1970s, when the first consistent clinical trials questioning the value of episiotomy were published [8]. Since then many studies, reviews and met-analyses have evidenced that there is no scientific basis for maintaining the routine practice of episiotomy. The procedure is shown to increase intra and post-operative complications, suggesting its practice to be restricted to selected deliveries [9].
Its use has shown also poorer future sexual function, similar pelvic floor muscle strength, and similar urinary incontinence in comparison with women in whom episiotomy is used in a selective manner. Routine use of episiotomy has no evidence on any beneficial effect; on the contrary, there is clear evidence that it may cause harm such as a greater need for surgical repair and a poorer future sexual capability. In view of the available evidence the routine use of episiotomy should be abandoned and episiotomy rates > 30% are not justified. The WHO recommends an episiotomy rate of 10% for all normal deliveries. It is prescribed selectively for women who have past history of lower genital tract surgeries and for women who require assisted vaginal deliveries. For other women in labor, episiotomies may be given on emergency basis when there are presumed imminent perineal tear scar of lower genital track, operative vaginal delivery, macrosomia and tight perineum [10,11,12,13].
Strategies for changing practice those were challenging on current practice of episiotomy and on creating social and organizational environments that encourage motivation are more effective in reducing episiotomy rates [14]. A systematic review and meta-analysis that was done on episiotomy recommend that there is an urgent need to explore reasons for and devise programs to reduce the apparent higher rates of episiotomies in low and middle income countries (LMIC) at their medical facilities [14, 15]. Complications of episiotomies include accidental extension into the anal sphincter or rectum, damage to the Bartholin’s gland, unsatisfactory anatomic results such as skin tags, asymmetry or excessive narrowing of the introitus, vaginal prolapse, recto-vaginal fistula, fistula in ano, perineal pain that lasted an average of 5.5 days, oedema, increased blood loss, hematoma, infection and dehiscence [16,17,18,19,20,21,22,23].
Women who had given birth with episiotomy are at risk for psychological trauma, higher frequency of dyspareunia and insufficient lubrication than women who had given birth without episiotomy. Episiotomy may affect women’s sex life during the second year postpartum with more frequent pain and vaginal dryness at intercourse, although the role of episiotomies in the causation of dyspareunia in the long term is not clear [24,25,26]. Study showed that mean time from delivery to maternal rest and time taken to bond with the infant were significantly longer in the episiotomy groups compared to mothers who delivered without episiotomy procedure. Perineal local infiltration of lidocaine during episiotomy procedure is risk for the newborn for toxication due to maternal perineal nerve block with lidocaine [27, 28].
Even though episiotomy practice is with a decreasing trend in some developed countries, but still statistics revealed that an overall high rates of episiotomy practice around the world. Episiotomy rates ranged from as low as 9.7% (Sweden) to 100% (Taiwan) that include both primiparous and multiparous women. Rates for only primiparas range from 63.3% (South Africa) to 100% (Guatemala), demonstrating that overall greater likelihood of primiparas will undergo episiotomies. In many parts of the world (e.g., Central and South America, South Africa, and Asia)in France population based study showed that episiotomy rate for vaginal deliveries overall significantly decreased from 26.7% in 2007 to 19.9% in 2014 [32, 33].
In our country study showed that, the prevalence of episiotomy at public health institutions of Akaki Kality in Addis Ababa, Axum town, shire town, at saint Paul’s hospital Millennium medical college Addis Ababa and at Mizan Aman General Hospital the prevalence of episiotomy were found to be 35.2%, 41.44%, 35.4%, 65.4%,30.6 respectively [40,41,42,43,44]. Findings at a maternity school in Recife, Pernambuco, Brazil and in a tertiary care centre in Nigeria and in our country at Mizan Aman General Hospital and at Saint Paul’s hospital Millennium Medical College identified that maternal age and place of residence were significant predictors of episiotomy practice [37, 38, 43,44,45]. Studies in France, Brazil, Iran, Nigeria, Republic of Congo, and in our country studies at Akaki Kality, Axum town, at Saint Paul’s hospital Millennium Medical College and Mizan Aman general hospital identified that Primipara was significant factor for episiotomy practice [33, 37,38,39, 41, 43,44,45,46,47,48,49,50,51].
Findings in Israel, Kurdistan region, Republic of Congo, Zimbabwe and in our country at Mizan Aman general Hospital, at Akaki Kality and at Saint Paul’s hospital Millennium Medical College showed that perineal laceration (tear), duration of second stage of labour more than 90 min, ANC follow up history, time of delivery, previous history of episiotomy and known medical diseases were significant predictors for episiotomy practice [43, 44, 46, 47, 49, 52]. Studies in Northeast of Iran, Brazil, Republic of Congo, Israel, Kurdistan region, Zimbabwe and in our country at Mizan Aman general Hospital, at Akaki Kality, at Saint Paul’s hospital Millennium Medical College, at Axum town public health institution and at Jima teaching Hospital identified that birth weight of 4 kg and above, gestational age, presence of meconium, sex the neonate, breech and shoulder presentation and condition of fetal heart rate were significant factors for episiotomy practice [33, 37,38,39, 41, 43,44,45,46,47,48,49,50,51,52,53,54,55].
Studies in Zimbabwe, Brazil, Northeast of Iran, Republic of Congo, Israel, Kurdistan region, and in our country at Mizan Aman general Hospital, at Akaki Kality, at Saint Paul’s hospital Millennium Medical College at Axum town, at Jima teaching Hospital and at Institutions of Shire Town showed that instrumental vaginal delivery especially, use of oxytocin, when doctors attending labor and use of analgesia were predictors of episiotomy practice [33, 37,38,39, 41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56].
Many countries have recognized that high episiotomy rates are an indicator of high rates of unnecessary obstetric interventions [57]. No question about the rationale for episiotomy, when there is a good indication for its performance. Obstetric perennial trauma is assumed to be a serious health problem for women as well as for their child during their childbirth. Since our country is struggling to improve maternal health, this kind of studies are must to be done in order to improve the well-being and quality of life of women as well [58].
Metema district is one of the hot spot area for HIV transmission in Ethiopia even in 2019 there were 20 mothers who were newly positive at labour and delivery room in this case interventions like episiotomy procedure may increase HIV transmission by 2% compared to normal delivery without episiotomy to the neonate [30, 59, 60]. So, after identifying the magnitude and associated factors of episiotomy practice at Metema District, it is important to give recommendations for this practice. Knowing the magnitude and associated factors of episiotomy with reasons of it in Metema district has a great role in guiding health professionals and health policy makers to identify factors for monitoring episiotomy practice. It also used to apply necessary preventive and appropriate measures to use evidence based restrictive episiotomy practice and to prepare uniform protocols and educational programs to guide episiotomy practice. Hence, the objective of this research was to assess proportions of episiotomy and associated factors among mothers who gave birth at public health facilities in Metema District, Northwest, Ethiopia, 2020.
