Promoting selective use of episiotomy

19 July, 2018

Two related papers, with thanks to Sahar Hassan and Public Health in Arab World forum.

'The overall episiotomy rate [in 6 Palestinian goivernment hospitals] was 28.7%: 78.8% for women with first vaginal birth (range 56.6%–86.0%) and 5.9% for parous women (range 1.0%–9.5%). The most common indications for episiotomy were ‘primiparity’ in the first vaginal birth group (69.9%) and ‘protecting the perineum’ in the parous group (59.5%). The least common indications were prolonged second stage (1.5%) and fetal distress (6.9%), respectively.' Episiotomy practice in six Palestinian hospitals: a population-based cohort study among singleton vaginal births


CITATION: Impact of animated instruction on tablets and hands-on training in applying bimanual perineal support on episiotomy rates: an intervention study Zimmo, K.M., Laine, K., Fosse, E. et al. Int Urogynecol J (2018).


Introduction and hypothesis: In Palestine, episiotomy is frequently used among primiparous women. This study assesses the effect of training birth attendants in applying bimanual perineal support during delivery by either animated instruction on tablets or hands-on training on episiotomy rates among primiparous women.

Methods: An interventional cohort study was performed from 15 October 2015 to 31 January 2017, including all primiparous women with singletons and noninstrumental vaginal deliveries at six Palestinian hospitals. Intervention 1 (animated instructions on tablets) was conducted in Hospitals 1, 2, 3, and 4. Intervention 2 (bedside hands-on training) was applied in Hospitals 1 and 2 only. Hospitals 5 and 6 did not receive interventions. Differences in episiotomy rates in intervention and nonintervention hospitals were assessed before and after the interventions and presented as p values using chi-square test, and odds ratios (OR) with 95% confidence intervals (CI). Differences in the demographic and obstetric characteristics were presented as p values using the Kruskal–Wallis test.

Results: Of 46,709 women, 12,841 were included. The overall episiotomy rate in the intervention hospitals did not change significantly after intervention 1, from 63.1 to 62.1% (OR?=?0.96, 95% CI 0.84–1.08), but did so after intervention 2, from 61.1 to 38.1% (OR?=?0.39, 95% CI 0.33–0.47). Rates after Intervention 2 changed from 65.0 to 47.3% (OR?=?0.52, 95% CI 0.40–0.67) in Hospital 1 and from 39.4 to 25.1% (OR?=?0.49, 95% CI 0.35–0.68) in Hospital 2.

Conclusions: Hands-on training of bimanual perineal support during delivery of primiparous women was significantly more effective in reducing episiotomy rates than animated instruction videos alone.


How does this compare with other countries? Are HIFA members aware of other research to promote selective episiotomy?

Best wishes, Neil

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HIFA profile: Neil Pakenham-Walsh is coordinator of the HIFA global health campaign (Healthcare Information For All - ), a global community with more than 18,000 members in 177 countries, interacting on five global forums in three languages. He also currently chairs the Dgroups Foundation (, which supports 800 communities of practice on international development, health and social justice. Twitter: @hifa_org FB: