Has the Use of Routine Episiotomy Decreased?
Examination of Episiotomy Rates From 1983 to
2000
Jay Goldberg, MD, David Holtz, MD, Terry Hyslop, PhD, and Jorge E. Tolosa, MD, MS
OBJECTIVE: To determine if practice patterns have been
altered by the large body of literature strongly advocating
the selective use of episiotomy.
METHODS: An electronic audit of the medical procedures
database at Thomas Jefferson University Hospital from
1983 to 2000 was completed. Univariate and multivariable
models were computed using logistic regression models.
RESULTS: Overall episiotomy rates in 34,048 vaginal births
showed a significant reduction from 69.6% in 1983 to 19.4%
in 2000. Significantly decreased risk of episiotomy was seen
based upon year of childbirth (odds ratio [OR] 0.87, 95%
confidence interval [CI] 0.86, 0.87), black race (OR 0.29,
95% CI 0.28, 0.31), and spontaneous vaginal delivery (OR
0.40, 95% CI 0.36, 0.45). Increased association with episiot-
omy was seen in forceps deliveries (OR 4.04, 95% CI 3.46,
4.72), and with third- or fourth-degree lacerations (OR
4.87, 95% CI 4.38, 5.41). In deliveries with known insurance
status, having Medicaid insurance was also associated with
a decreased episiotomy risk (OR 0.59, 95% CI 0.54, 0.64).
CONCLUSION: There was a statistically significant reduc-
tion in the overall episiotomy rate between 1983 and 2000.
White women consistently underwent episiotomy more
frequently than black women even when controlling for
age, parity, insurance status, and operative vaginal deliv-
ery. (Obstet Gynecol 2002;99:395– 400. © 2002 by the
American College of Obstetricians and Gynecologists.)
For most of the 20th century, the routine use of episiot-
omy was believed to have multiple benefits for both
mother and infant. These benefits were believed to in-
clude prevention of pelvic floor damage and its sequelae,
including urinary incontinence, poor wound healing,
From the Department of Obstetrics and Gynecology, Division of Research in
Reproductive Health, and Biostatistics Section, Division of Clinical Pharmacology,
Jefferson Medical College, Philadelphia, Pennsylvania.
The abstract from this paper will be presented at the American College of
Obstetricians and Gynecologists’ Annual Clinical Meeting in Los Angeles, Califor-
nia, May 4 – 8, 2002.
VOL. 99, NO. 3, MARCH 2002
© 2002 by The American College of Obstetricians and Gynecologists. Published by Elsevier Science Inc.
severe lacerations involving the anal sphincter, and fetal
intracranial hemorrhage. Thacker and Banta’s 1983 re-
view of episiotomy literature from 1860 through 1980,
which found few good studies and no evidence of any
benefit, sparked further investigation.1 During the past
20 years, a large body of literature has been published,
which strongly advocates the selective use of episioto-
my.2 Multiple studies during this period were reported
demonstrating that the routine use of episiotomy did not
protect against pelvic relaxation or fetal intracranial
bleeds. Episiotomy actually increased rates of perineal
infection, increased blood loss, increased pain during
healing, negatively affected body image issues and sex-
ual function, and increased incidence of injuries to the
anal sphincter, with subsequent increased risks of incon-
tinence of flatus and fecal material.3
Episiotomy rates widely vary between countries, insti-
tutions, and individuals because of differences in atti-
tudes and training. The Argentine episiotomy trial re-
ported an 83% incidence of episiotomies in 1993.4
Henriksen et al in Denmark found a 37% overall rate of
episiotomy in 1990.5 The range of episiotomy rates in
the United Kingdom’s West Berkshire perineal manage-
ment trial was 14 –96% in primiparas in the early 1980s.6
Shiono et al found the mean episiotomy rate in the
United States to be 62% in 1990.7 Although there are
many cross-sectional epidemiologic reports of episiot-
omy rates, few long-term longitudinal studies of episiot-
omy rates were found. The National Center for Health
Statistics reported episiotomies in 61.1%, 55.6%, 47.2%,
and 39.3% of deliveries in 1985, 1990, 1995, and 1998 in
the United States, respectively.8 Similarly, Graham and
Graham reported a decrease in Canadian episiotomy
rates from 66.8% in 1981/1982 to 37.7% in 1993/1994.9
This study was initiated to examine trends in episiot-
omy rates over the last 20 years to see if practice patterns
had been altered by the large body of literature strongly
advocating the selective use of episiotomy.
0029-7844/02/$22.00 395
PII S0029-7844(01)01756-2
Table 1. Multivariable Logistic Regression Models of Episiotomy Performed During Childbirth Over the Period 1983–2000
(n ⫽ 34,048)
Factor Category n OR Robust 95% CI Robust P
Year of childbirth 0.87 0.86, 0.87 ⬍.001
Race of mother White 13,759 Referent
Black 16,956 0.29 0.28, 0.31 ⬍.001
Asian 833 0.71 0.60, 0.84 ⬍.001
Hispanic 392 0.54 0.43, 0.68 ⬍.001
Other 2108 0.66 0.59, 0.74 ⬍.001
Mother’s age at childbirth (y)
ⱕ21 6451 Referent
22–34 22,241 0.48 0.45, 0.51 ⬍.001
ⱖ35 5356 0.43 0.39, 0.47 ⬍.001
Spontaneous vaginal delivery No 6140 Referent
Yes 27,908 0.40 0.36, 0.45 ⬍.001
Forceps No 30,310 Referent
Yes 3738 4.04 3.46, 4.72 ⬍.001
Third and fourth-degree laceration No 30,561 Referent
Yes 3487 4.87 4.38, 5.41 ⬍.001
Large for gestational age No 33,869 Referent
Yes 179 1.21 0.86, 1.71 .28
Small for gestational age No 33,671 Referent
Yes 377 0.96 0.76, 1.21 .71
OR ⫽ odds ratio; CI ⫽ confidence interval.

MATERIALS AND METHODS extracted based on International Classification of Dis-

This study received approval by the Internal Review
Board of Thomas Jefferson University Hospital. An
electronic audit of the medical procedures database at
Thomas Jefferson University Hospital from 1983 to
2000 was completed, and all records on childbirth were
eases, 9th Revision, codes. This database also included
some limited information on maternal demographics,
such as age and ethnicity. Race was categorized as white,
black, Asian, Hispanic, or other. Other, as listed in
Tables 1 and 2, were mostly patients having no racial

Table 2. Multivariable Logistic Regression Model of Episiotomy Performed During Childbirth Over the Period 1990 –2000,
in Multiparous Subgroup (n ⫽ 4075)
Factor Category n OR Robust 95% CI Robust P
Year of childbirth 0.80 0.78, 0.82 ⬍.001
Race of mother White 1565 Referent
Black 2159 0.21 0.17, 0.26 ⬍.001
Asian 146 0.72 0.50, 1.05 .09
Hispanic 64 0.59 0.32, 1.11 .10
Other 141 0.83 0.56, 1.23 .35
Mother’s age at childbirth (y)
⬍21 768 Referent
22–34 2629 0.41 0.33, 0.51 ⬍.001
ⱖ35 678 0.43 0.32, 0.58 ⬍.001
Medicaid status No 2187 Referent
Yes 1888 0.67 0.55, 0.83 ⬍.001
Spontaneous vaginal delivery No 491 Referent
Yes 3584 0.39 0.28, 0.54 ⬍.001
Forceps No 3831 Referent
Yes 244 3.69 2.27, 6.00 ⬍.001
Third and fourth degree laceration No 3785 Referent
Yes 290 4.35 3.09, 6.12 ⬍.001
Large for gestational age No 4037 Referent
Yes 38 1.81 0.75, 4.36 .18
Small for gestational age No 4032 Referent
Yes 43 1.62 0.79, 3.34 .19
Abbreviations as in Table 1.

396 Goldberg et al Episiotomy Rates OBSTETRICS & GYNECOLOGY

designation. Procedure codes were used to determine
which births involved episiotomy, spontaneous vaginal
delivery (SVD), cesarean, forceps, or vacuum assistance.
We eliminated births involving cesarean, so that the
remaining data are for vaginal births only (n ⫽ 34,048).
Births involving both forceps and vacuum (n ⫽ 338)
were also not included because we believed that this
small number of deliveries was very different from other
operative deliveries. Rates were determined by comput-
ing the total number of episiotomies performed divided
by the total number of vaginal births, not including the
small number with both vacuum and forceps, in each of
the calendar years in the study database.
Univariate analyses of the association of episiotomy
status with clinical characteristics was completed based
on univariate logistic regression models and generalized
estimating equations (GEE) techniques. GEE is used to
adjust standard errors for the clustering of multiple
childbirths within mothers.10 Multivariable analyses of
the association of episiotomy status with clinical charac-
teristics were also completed. The multivariable models
were computed using logistic regression models with
GEE methods to adjust for clustering of births within
mothers. Possible covariates considered in these models
were: year of childbirth, race, maternal age, SVD, for-
ceps, large for gestational age, small for gestational age,
third- or fourth-degree laceration, and whether the pa-
tient had private or Medicaid insurance. Because of the
statistical linear relationship between SVD, forceps, and
vacuum-assisted delivery, only two of these can simulta-
neously be considered in models. Because there was
minimal information on insurance status before 1990, all
analyses that include insurance status are based on births
occurring in 1990 and beyond (n ⫽ 18,138).
Because parity and gravidity were not available, we
selected the subgroup of mothers having more than one
vaginal delivery during the period of the study at
Thomas Jefferson University Hospital. Every delivery
after the initial delivery within our database for an
individual woman was assigned to a multiparous sub-
group. SAS statistical software 8.0 (SAS Institute Inc.,
Cary, NC) was used for data management and descrip-
tive analyses. STATA statistical software 7.0 (Stata
Corp., College Station, TX) was used for univariate and
multivariable logistic regression GEE models.
RESULTS
We examined 34,048 vaginal births between 1983 and
2000 at Thomas Jefferson University Hospital in Phila-
delphia. The cumulative percentage of patients classified
as white, black, Asian, Hispanic, or other were 40.5%,
49%, 2.5%, 1.2%, and 6.8%, respectively. Episiotomy
VOL. 99, NO. 3, MARCH 2002
rates were calculated for all vaginal deliveries, overall,
and by maternal race, and for forceps and vacuum-
assisted deliveries. Overall episiotomy rates showed a
significant reduction from 69.6% in 1983 to 19.4% in
2000. White women’s episiotomy rates declined from
79% to 32.1%, whereas black women’s rates decreased
from 60.5% to 11.2%. Figure 1 illustrates this decrease in
episiotomy rates for vaginal deliveries overall (solid
line), for blacks (large dashed lines), and for whites
(small dashed lines). These two groups represent the
largest racial populations studied. Cumulatively, episiot-
omy was performed in 43.3%, 71.7%, and 90% of SVD,
vacuum-assisted, and forceps deliveries, respectively.
Figure 2 shows parallel decreasing episiotomy rate
trends for overall vaginal deliveries and SVDs, some
decrease since 1993 for episiotomy use in forceps deliv-
eries, and an unchanged rate in vacuum- assisted deliv-
eries. A total of 19.8% of vaginal deliveries used forceps
in 1983, decreasing yearly to a nadir of 6.5% in 1991,
then increasing to 11.7% in 2000, whereas 2.5% of
vaginal deliveries were vacuum assisted in 1983, increas-
ing yearly to a peak of 12.6% in 1991, then decreasing to
1.2% in 2000. Deliveries over the 18 years surveyed
involved over 100 attending physicians and over 200
resident physicians, but only the attending physician
could be identified by the database. Twenty of the at-
tendings were responsible for 55.7% of the deliveries
surveyed.
A univariate analysis of the association of episiotomy
with clinical characteristics was performed. Decreased
episiotomy rates were significantly associated with non-
white race of the mother (63.8% for whites versus 39.4%
for blacks, 47.2% for Asians, and 40.6% for Hispanics,
P ⬍ .001), if the mother was on Medicaid insurance
(28.4% versus 47.4%, P ⬍ .001), SVDs (43.3% versus
82.8%, P ⬍ .001), in patients older than 21 years (49.1%
for patients 22–34 and 49.9% for patients older than 34
versus 55.4% for age less than 21, P ⬍ .001), and if the
infant was small for gestational age (41.6% versus 50.5%,
P ⬍ .001). Large-for-gestational-age deliveries were asso-
ciated with a nonsignificant decrease in episiotomy rate
(50.5% versus 45.2%, P ⫽ .09). Women having a third-
or fourth-degree perineal laceration were significantly
more likely to have received an episiotomy (85.4% ver-
sus 46.5%, P ⬍ .001).
The first multivariable model of episiotomy is pre-
sented in Table 1. This model includes year of childbirth
plus all the factors from the univariate analysis except
Medicaid status, which was not available until 1990.
This table shows a statistically significant reduction in
risk of episiotomy with increasing year of birth and
maternal age greater than 21. Black race showed the
most dramatic risk reduction (odds ratio [OR] 0.29, 95%
Goldberg et al Episiotomy Rates 397
Figure 1. Episiotomy rates (%) in vaginal deliveries overall and by race of mother.
Goldberg. Episiotomy Rates. Obstet Gynecol 2002.
confidence interval [CI] 0.28, 0.31), with less significant
reductions for Asians (OR 0.71, 95% CI 0.60, 0.84) and
Hispanics (OR 0.54, 95% CI 0.43, 0.68). Significant
positive association with episiotomy was found in
women delivered with forceps and with those who expe-
rienced third- or fourth-degree perineal laceration.
A multivariable logistic regression model including
insurance information is constructed on the subset of
data occurring from 1990 to 2000, 18,138 vaginal births.
This model shows that controlling for insurance status,
the factors still significantly associated with a decreased
risk of episiotomy include increasing year of childbirth
(OR 0.82, 95% CI 0.81, 0.83), black race (OR 0.31, 95%
CI 0.28, 0.34), Asian race (OR 0.78, 95% CI 0.65, 0.93),
Hispanic race (OR 0.61, 95% CI 0.47, 0.80), maternal
age 22–34 years (OR 0.49, 95% CI 0.45, 0.54), age
greater than 35 years (OR 0.45, 95% CI 0.40, 0.51), and
SVD (OR 0.34, 95% CI 0.30, 0.39). Receiving Medicaid
insurance was also associated with a decreased episiot-
omy risk (OR 0.59, 95% CI 0.54, 0.64). Increased asso-
ciation with episiotomy was seen in forceps deliveries
(OR 3.53, 95% CI 2.90, 4.28), and with third- or fourth-
degree lacerations (OR 3.92, 95% CI 3.44, 4.47). Non-
significant changes in episiotomy risk were seen in the
women who delivered large-for-gestational-age (OR
1.13, 95% CI 0.77, 1.66) or small-for-gestational-age
infants (OR 1.05, 95% CI 0.77, 1.43).
398 Goldberg et al Episiotomy Rates
To try to control for parity, we selected the subset of
births known to be from multiparous women. A multi-
variable logistic regression model with GEE is presented
for this subgroup in Table 2. The model is based on 4075
multiparous births from 1990 to 2000 to enable the
inclusion of insurance status in this model. Although
there is some loss of power in the smaller covariate
categories, the general magnitude and trend of the ORs
remain the same as in the previous models.
DISCUSSION
Although the use of selective episiotomy is advocated in
the literature, there is little evidence on whether the
practice of performing episiotomies has actually de-
creased or not over the last 20 years. We found a
statistically significant reduction in the overall episiot-
omy rate between 1983 and 2000 from 69.6% to 19.4%.
The OR of 0.87 per year of childbirth in Table 1 reflects
a statistically significant reduction in episiotomy rates per
year from 1983 through 2000. This change in practice
pattern may be largely due to the impact of a growing
body of literature against routine episiotomy, including
that derived from randomized controlled trials. Addi-
tionally, improved patient education and participation in
decision making and changes in use of forceps and
vacuum assistance probably play a role in reducing the
OBSTETRICS & GYNECOLOGY
Figure 2. Episiotomy rates (%) in vaginal deliveries overall, spontaneous vaginal deliveries (SVD), forceps, and vacuum-
assisted deliveries (VAD).
Goldberg. Episiotomy Rates. Obstet Gynecol 2002.
overall number of episiotomies. No specific policy or
educational initiative regarding episiotomy was imple-
mented during the study period.
We also found that white women consistently under-
went episiotomy more frequently than black women. It
was initially hypothesized that the difference between
races in episiotomy rates may have been due to differ-
ences in parity, prenatal care, or in the number of oper-
ative vaginal deliveries. Episiotomies remained signifi-
cantly greater in white patients, however, despite
multivariable logistic regression analysis controlling for
these possible confounding factors. Socioeconomic and
racial differences have been reported for obstetric prac-
tices and procedure rates, including cesarean delivery,
epidural use, and episiotomy, with higher socioeconomic
status increasing the risk for intervention. Hueston re-
ported white race as a predictor for episiotomy (OR 2.02,
CI 1.66, 2.46). He hypothesized that the increased epi-
siotomy rate could represent a marker for patient expec-
tations or perceived threat of a malpractice suit.11
Howard et al’s study similarly found an increased epi-
siotomy rate (34.8% versus 22.3%, P ⫽ .003) in white
patients compared with black patients.12 It also showed
that black primiparas were less likely to deliver with
second-degree or greater vaginal lacerations and more
VOL. 99, NO. 3, MARCH 2002
likely to deliver with their perineums intact, supporting
anecdotal reports of lower vaginal laceration rates in
black women.12 Physician perception of differing risks of
severe spontaneous lacerations between racial groups
may also factor into white women undergoing episiot-
omy more often in a misguided attempt to prevent this. It
may also simply be a marker of the arbitrary and non-
scientific nature employed by the physician in determin-
ing which patients need an episiotomy.
Our study is retrospective, and it is limited by a
database unable to supply information on nulliparity,
epidural usage, specific infant weight, and insurance
information before 1990. Secondary analyses of the mul-
tiparous subgroup were used to attempt to control for
parity as best possible in assessing our results. Even in
the multiparous subgroup, the association of episiotomy
with race remained consistent. Physician turnover dur-
ing the 18 years studied may have affected episiotomy
rates; however, given that 55.7% of the deliveries were
performed by 20 physicians, it is unlikely that practices
of a few would have significantly affected the results.
Our findings of a decreasing rate of episiotomy be-
tween 1983 and 2000 agrees with national trends.8 Al-
though our overall episiotomy rates appear lower than
national rates, the proportion of black women in our
Goldberg et al Episiotomy Rates 399
population is larger than national demographics. Further
investigation is needed to examine trends in episiotomy
rates among other academic institutions and community
and rural hospitals in different geographic areas.
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3. Wooley RJ. Benefits and risks of episiotomy: A review of
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4. Argentine Episiotomy Trial Collaborative Group. Routine
vs. selective episiotomy: A randomized controlled trial.
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mers I. West Berkshire perineal management trial. BMJ
Clin Res Ed 1984;289:587–90.
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7. Shiono P, Klebanoff M, Christopher J. Midline episioto-
mies: More harm than good? Obstet Gynecol 1990;75:
765.
8. Curtin SC, Martin JA. Preliminary data for 1999. National
vital statistics reports. Vol. 48, No. 14. Hyattsville, MD:
National Center for Health Statistics, 2000.
9. Graham ID, Graham DF. Episiotomy counts: Trends and
prevalence in Canada, 1981/1982 to 1993/1994. Birth
1997;24:141–7.
10. Zeger SL, Liang KY, Albert PS. Models for longitudinal
data: A generalized estimating equation approach. Biomet-
rics 1988;44:1049 – 60.
11. Hueston WJ. Factors associated with the use of episiotomy
during vaginal delivery. Obstet Gynecol 1996;87:1001–5.
12. Howard D, Davies PS, DeLancey JOL, Small Y. Differ-
ences in perineal lacerations in black and white primiparas.
Obstet Gynecol 2000;96:622– 4.
Address reprint requests to: Jay Goldberg, MD, Thomas Jef-
ferson University, Jefferson Medical College, Department of
Obstetrics and Gynecology, 834 Chestnut Street, Suite 400,
Philadelphia, PA 19107; E-mail: jay.goldberg@mail.tju.edu.
Received July 23, 2001. Received in revised form November 1, 2001.
Accepted November 9, 2001.
OBSTETRICS & GYNECOLOGY