Applied Nursing Research 29 (2016) 131–135

Contents lists available at ScienceDirect

Applied Nursing Research

journalhomepage:www.elsevier.com/locate/apnr

Predictors of routine episiotomy in primigravida women in Oman

Khadija Al-Ghammari, BSc a, Zainab Al-Riyami, BSc a, Moza Al-Moqbali, BSc a,
Fatma Al-Marjabi, BSc a, Basma Al-Mahrouqi, BSc a,
Amal Al-Khatri, BSc a, Esra M. Al-Khasawneh, RN, DNSc b,
a
Final Year Students, College of Nursing, Muscat 123, Sultanate of Oman
b
College of Nursing, Sultan Qaboos University, Muscat 123, Sultanate of Oman

article info abstract

Article history: Purpose: Episiotomy is still the most common surgical procedure performed on women, despite the evidence against its
Received 5 March 2015 routine use. This cross-sectional study was conducted to determine the practice and predictors of routine episiotomy on
Revised 4 May 2015 primigravidae in Oman.
Accepted 9 May 2015 Methods: Demographic data, reasons for and rate of performing routine episiotomies, and perceptions of 269 ob-stetricians,
midwives and nurses from 11 hospitals in Oman regarding the procedure were recorded and analyzed. Results: The rate of
Keywords:
episiotomies was 66%. In terms of performing routine episiotomies (p b 0.05): non-Omanis were 4.49 times more likely than
Episiotomy
Omanis; bachelor's degree-holders were 2.26 more likely than diploma-holders; and regional hospitals were 2.36 times more
Midwifery
Oman likely than tertiary hospitals. The majority perceived episiotomies “reduce spontaneous perineal tearing risk”, “reduce shoulder
Perception dystocia complications”, and allow for “easier suturing”.
Primigravidity Conclusion: The rate of episiotomies was higher than other similar contexts. An urgent intervention is necessary to curb this
excessive practice, and create a culture of evidence-based practice to deal with misleading perceptions.
© 2015 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction
Episiotomy is one of the most common procedures in obstetrics, defined
as a surgical incision of the perineum during the last part of the second stage
of delivery (Enyindah, Fiebai, Anya, & Okpani, 2007). Vaginal tears are
common during childbirth, and midwives and obstetricians may feel
compelled to make a surgical incision to increase the diameter of the vaginal
outlet to facilitate the birth (Kettle, Hills, & Ismail, 2012). Since 1995, all
international organizations such as the World Health Organization (WHO)
have developed guidelines to limit the indiscriminate use of episiotomy,
known as “routine episiotomy”. The WHO states that limiting the use of
episiotomy to strict indications—referred to as “restrictive episiotomy”—has a
number of benefits: less posterior perineal trauma, less need for suturing and
fewer complications (Liljestrand, 2003). The 2006 Practice Bulletin from the
American College of Obstetricians and Gynaecologists did not recommend
the routine use of episiotomy (ACOG, 2006; NICE, 2014). Researchers
reported that the routine use of episiotomy leads to increased risk of anterior
perineal trauma (Liljestrand, 2003).
Obstetricians used to perform episiotomies routinely as it was believed to
hasten the second stage of labor and reduce the risk of spontaneous per-ineal
tearing. The practice of surgical incisions on all women delivering
Corresponding author at: Sultan Qaboos University, P.O. Box 66, Al-Khoud, Muscat 123,
Sultanate of Oman. Tel.: +968 24145401, +968 24145447; fax: +968 24413536.
E-mail address: esra@squ.edu.om (E.M. Al-Khasawneh).
vaginally has no demonstrable benefit for infant or mother, since it can cause
unnecessary pain and may be associated with potential short-term—pain,
hemorrhage and infection—and long-term—dyspareunia, general
incontinence—complications (Carroli & Mignini, 2009).
While the most common recommendation is for restrictive use of
episiotomy—to be performed only when indicated—episiotomy rates around
the world differ considerably. Considerable variations in percent-ages of the
use of routine episiotomy exist between countries, within countries, and even
within the same professional provider group (Carroli & Mignini, 2009;
Graham, Carroli, Davies, & Medves, 2005). In some developed countries
such as the US, episiotomy rates have signifi-cantly declined in the last three
decades—from 60.9% in 1979s to 24.5% in 2004 (Frankman, Wang, Bunker,
& Lowder, 2009; Graham et al., 2005). In the Middle East episiotomy rates
remain high despite the dearth in lit-erature and data. Some descriptive
studies reported high rates of routine episiotomy in Jordan (60%), Lebanon
(62%), and UAE (64%) (Fernandes, Benjamin, & Edwards, 2009). Hong
Kong, Vietnam, Ireland and countries in South America were reported to have
rates around 30% (Graham et al., 2005; Macleod & Murphy, 2008). Changing
the clinical practice from lib-eral to restrictive episiotomy, the prevalence in
Al Wasl Hospital in Dubai reduced from 64% in 2006 to 52.2% in 2007,
which further declined to 22.4% in 2008 (Fernandes et al., 2009).
The Pregnancy & Childbirth Management Guidelines, 2010, adopted by
the Omani Ministry of Health has restricted the use of episiotomy and
specified conditions in which episiotomy becomes necessary, including:
complicated vaginal delivery; scarring from female genital

http://dx.doi.org/10.1016/j.apnr.2015.05.002
0897-1897/© 2015 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
132 K. Al-Ghammari et al. / Applied Nursing Research 29 (2016) 131–135
cutting; or poorly healed previous third or fourth degree tears; and fetal
distress. However, observations indicate that routine episiotomy is widely
used, especially for primigravidae.
1.1. Literature review
The current literature demonstrates that avoiding routine episioto-my in
unnecessary conditions improves the health of women, increases the rate of
intact perineum or limits perineal trauma, and reduces post-partum delivery
pain while limiting maternal and neonatal morbidities. A retrospective review
showed consistent evidence demonstrating de-creased value in episiotomy for
prevention of fecal and urinary inconti-nence or pelvic floor relaxation
(Enyindah et al., 2007). A Cochrane meta-analysis concluded that
implementing the policy of restrictive episiotomy appears to have a number of
benefits: hospitals that restrict-ed episiotomies report less posterior perineal
trauma, less suturing and fewer complications (Carroli & Mignini, 2009). In a
study in Iran which compared a restrictive episiotomy group with a routine
group, the rate of maternal short-term complications such as perineum
laceration and pain severity was reported to be less in the restrictive group
than the routine group (Sheikhan et al., 2011). Another experimental study re-
ported that the percentage of intact perineum or first-degree laceration was
seen in 80% of the restrictive group, and pain relief was significantly better in
the restrictive group (p b 0.05) (Shahraki, Aram, Pourkabirian, Khodaee, &
Choupannejad, 2011). The Clinical Practice Obstetrics Com-mittee of Canada
strongly recommends that routine episiotomy is not necessary for assisted
vaginal birth, as it does not reduce and may increase the incidence of maternal
trauma (Cargill et al., 2004). Another study reported that episiotomy at the
first vaginal delivery significantly and in-dependently increased the risk of
repeated episiotomy and spontaneous perineal tears in a subsequent delivery:
23.9% of the women who experi-enced routine episiotomy at a previous
pregnancy, have had an episioto-my at the subsequent delivery and a 23%
increased risk of perineal tears at the subsequent delivery (Lurie, Kedar, Boaz,
Golan, & Sadan, 2013).
A survey of obstetricians practicing in the UK and Ireland demonstrat-ed
that obstetricians' preferences for restrictive or routine episiotomy depended
on the type of delivery: 72% of obstetricians preferred a restric-tive approach
of using episiotomy for vacuum delivery, while 73% pre-ferred a routine
approach for forceps delivery (Macleod & Murphy, 2008).
Our study was conducted in order to identify predictors of the practice of
routine episiotomy among midwives and obstetricians, and to deter-mine the
perception of midwives and obstetrician towards routine episiotomy. Findings
of this study will inform episiotomy practices of healthcare providers in
Oman, since understanding attitudes and factors that contribute to the health
care provider's decision to perform an episiotomy would inform larger scale
studies that would target behavioral change.
2. Methodology
2.1. Design and instrument
A cross-sectional design was utilized for this study. The instrument was
developed by investigators and was internally validated by conducting a pilot
study to test the instrument's reliability, resulting in slight modification of the
questionnaire. The reliability of the instru-ment was 0.73, which was within
acceptable limits. The individual questionnaire items comprised demographic
questions and questions on practice of episiotomy, and respondents' level of
agreement with misinformed perceptions of episiotomy—derived from the
literature— were recorded on a Likert scale. Some of these perceptions
included “performing episiotomy is a safe practice”, “episiotomy facilitates
deliv-ery”, “episiotomy prevents post-partum complications”, and “suturing the
episiotomy is better than suturing a tear”. The practice of episiotomy was
examined by asking three questions: the number of vaginal deliveries
performed within a 7-day period; number of episiotomies
done during the same period; and the reasons for performing or not
performing such episiotomies.
2.2. Sample, sampling procedures and setting
Data were collected from midwives, nurses and obstetricians work-ing in
11 different hospitals in five governorates within Oman. Hospitals were
selected using cluster sampling; five out of nine governorates with the highest
birth rates—Muscat, Al-Batina, Al-Dakhiliyia, Al-Sharqia, and Al-Dahira—
were selected; clustering of hospitals in each governorate was based on rates
of birth. This was based on the assumption that higher rates of birth would
reflect increased use of routine episiotomy. Power calculations indicated that
we required a sample of approximate-ly 91 participants from each governorate
to obtain a power of 80 percent and a significance level of b0.05 with a
medium effect size. According to the sample calculations, the total number of
sample required, keeping attrition rate at 10%, was 265 participants. When
approached, 269 participants consented to take part in the study.
2.3. Data collection
Data were collected over a period of 4 months from April to July 2014.
After obtaining ethical approval from the Sultan Qaboos Universi-ty, as well
as permission from the Omani Ministry of Health and con-cerned hospitals,
the research team approached midwives, nurses and obstetricians to explain
the study purpose. Respondents who consented in writing to be surveyed were
recruited, and were asked to complete the survey questionnaire.
2.4. Data analysis
Data were analyzed through SPSS software version 21 (IBM, 2012). The
demographics of the 269 respondents—including age, nationality, education
level, job title, years of experience and place of work—were compiled as
percentages for each category. The binary variable “Do you use routine
episiotomy for primigravidae?” was used to establish whether or not the
respondent practiced routine episiotomy. This variable was used as a
dependent variable, and Fisher's Exact Test was used to deter-mine whether it
had any significant relationship with any of the demo-graphic variables.
Nationality, education level and place of work were found to have a
significant relationship with the dependent variable, and a backwards
multivariate regression model was applied to examine the extent of each
relationship when adjusted for the significant demo-
graphic variables with odds ratios and significance levels.
The descriptive results for each reason for performing routine episi-otomy
were tabulated for all respondents who said that they perform routine
episiotomies on primigravidae.
The mean was calculated for the level of agreement respondents had with
each perception, with numerical values assigned to “Strongly disagree” (1),
“Disagree” (2), “Agree” (3), “Strongly agree” (4). This was carried out in order
to find the central tendency of each perception, and the extent to which the
overall sample agreed or disagreed with the perception. A mean less than 2.5
would show a tendency to disagree with the perception, while a mean greater
than 2.5 would illustrate some level of agreement.
3. Results
3.1. Socio-demographic data
The socio-demographic results of the survey are presented in Table 1. Of
all the midwives, nurses and obstetricians approached for participation, 269
responded. The majority of the respondents belonged to the 31 to 35 years age
group (31.2%) followed by N40 years (25.3%), 25 to 30 years (24.9%), 36 to
40 years (17.1%) and b25 years (1.5%). Nearly half of the midwives, nurses
and obstetricians were Omani
 K. Al-Ghammari et al. / Applied Nursing Research 29 (2016) 131–135 133

nationals. The vast majority (74.8%) of the non-Omanis were Indian Table 2
nationals. The data collection was distributed as 49.8% from tertiary hos- Factors which showed an association with performing routine episiotomy.
pitals, 41.3% from regional hospitals and 8.9% from primary health cen-ters. Adjusted OR of performing 95% CI
Among the participants, 83.6% were midwives, 13.4% were nurses who were routine episiotomy
practicing as midwives and 2.6% were obstetricians. Slightly more than half Nationality
of the respondents had a diploma in nursing or midwifery, 16.5% had post Omani 1
basic midwifery and advanced diploma in nursing and mid-wifery, 26.4% had Non-Omani 4.49 (2.13–9.45)
a bachelor of nursing and midwifery, while 3.5% were postgraduate Education level
Diploma 1
obstetricians. Twenty-six percent of respondents claimed to perform Post-basic/advanced diploma 2.28 (0.87–5.91)
episiotomy routinely for primigravid mothers. Six hundred and forty-two Bachelor's degree 2.26 (1.09–4.66)
episiotomies were conducted within 7 days, of which 426 (66.0%) involved Postgraduate 0.19 (0.02–1.77)
episiotomies. Fifteen percent read scientific articles relat-ed to episiotomy Place of work
Tertiary hospital 1
over a period of 6 months, and 75% of the respondents had perused articles
Regional hospital 2.36 (1.21–4.59)
relevant to episiotomy in the previous 6 years. Primary health center 0.27 (0.05–1.32)
p b 0.05.
3.2. Regression analysis

The regression analysis is presented in Table 2, and showed that non- p b 0.05). Those who worked in a regional hospital were more than twice as
Omanis were nearly 4.5 times more likely than Omanis to say that they likely (OR = 2.36, p b 0.05) as those who worked in a tertiary hospital (OR =
perform routine episiotomy on primigravidae (OR = 4.49, p b 0.05). While 1.00, p b 0.05) to perform routine episiotomy.
the results were not significant for every category of ed-ucation when
compared to a diploma (OR = 1.00, p b 0.05), the OR for respondents with a 3.3. Reasons for performing routine episiotomy
bachelor's degree was significant (OR = 2.26,
The descriptive results of all the reasons as provided by participants who
Table 1 said “yes” to performing routine episiotomy, further divided ac-cording to
Socio-demographic characteristics of survey participants. nationality, are presented in Table 3. The results were elabo-rated according
to nationality of the respondents, since this variable was found to have a
N = 269 n (%)
significant association with performing routine episiot-omy on primigravidae.
Age
Overall, a large majority of such participants be-lieved that routine
b25 4 (1.5)
25–30 67 (24.9) episiotomies were needed in order to “prevent complications”. While the
31–35 84 (31.2) prevalence for most reasons was comparable for overall and non-Omanis, a
36–40 46 (17.1) greater percentage of non-Omanis be-lieved that episiotomies were needed to
N40 68 (25.3) “prevent tears” (78.0%) than the overall sample (69.0%). However, fewer
Nationality
Omani 133 (49.4)
non-Omanis believed that episiotomy is a “common practice” (8.0%) and
Non-Omanis 136 (50.6) “saves time” (12.0%).
Bangladesh (1.8)
British (0.9) 3.4. Perception of the health care providers towards routine episiotomy
Egyptian (1.8)
among primigravid women
Indian (74.8)
Iranian (0.9)
Malaysian (6.3) As shown in Table 4, nearly half of the respondents (47.5%) reported that
Nigerian (2.7) the routine episiotomy to primigravid mothers is considered as a safe practice
Filipino (4.5) and speeds up the second stage of labor (46%). Most of them agreed with the
Tanzanian (0.9)
Tunisian (5.4)
perception that routine episiotomy will prevent perineal tear (63%) and pelvic
Education† floor dysfunction (39%). Nearly one-third agreed and strongly agreed that
Diploma 124 (53.7) episiotomy prevents urinary and fecal incontinence (34%) and fetal distress
Post-basic midwifery/advanced diploma in nursing and midwifery 38 (16.5) (31%). They perceive that an episiotomy reduces maternal distress (25%) and
Bachelor in nursing and midwifery 61 (26.4)
helps in the reduc-tion of complications encountered during shoulder dystocia
Postgraduate 8 (3.5)
Years of experience‡
(68%). They also perceive that routine episiotomy in primigravidae reduces
b1 15 (6.6)
1–10 141 (61.8)
11–20 47 (20.6)
21–30 25 (11.0) Table 3
Job title§ Reasons provided by participants who perform routine episiotomy on primigravidae, ac-cording
Midwife 224 (83.9) to nationality.
Staff nurse 36 (13.5)
Reasons Overall Omanis Non-Omanis
Obstetrician 7 (2.6)
(%) (%) (%)
Place of work
N = 71 n = 21 n = 50
Tertiary hospital 134 (49.8)
Regional hospital 111 (41.3) To prevent complications 80.3 76.2 82.0
Primary health center 24 (8.9) Recommended for all primigravida 29.6 19.0 34.0
Do you perform episiotomy as routine on primigravidae? To save time 15.5 23.8 12.0
Yes 71 (26.4) Suturing episiotomy better than 46.5 38.1 50.0
No 198 (73.6) suturing vaginal tear
Primigravida deliveries performed in last 7 days 642 Facilitate delivery 49.3 57.1 46.0
Routine episiotomies performed on primigravida in last 7 days 426 (66) Common practice 12.7 23.8 8.0
To prevent lacerations 40.8 42.9 40.0
Missing cases
† To prevent tears 69.0 47.6 78.0
38
‡ Prophylactic 19.7 23.8 18.0
41
Others 15.5 23.8 10.2
§ 2
134 K. Al-Ghammari et al. / Applied Nursing Research 29 (2016) 131–135

Table 4
Perception of respondents regarding routine episiotomy for primigravidae.

Perceptions Strongly agree % Agree % Disagree % Strongly disagree %

Performing routine episiotomy for primi gravidas is considered as a safe practice. 12.6 34.9 33.8 18.6
Routine episiotomy in primi gravidas speeds up the second stage of labor. 8.2 37.5 42.4 11.9
Routine episiotomy in primi gravidas reduces the risk of spontaneous perineal tearing of 2nd and 3rd degree. 24.9 37.9 27.5 9.7
Routine episiotomy in primi gravidas prevents subsequent pelvic floor dysfunction. 10.4 28.6 47.6 13.4
Routine episiotomy in primi gravidas prevents urinary and fecal incontinence. 10.0 23.8 52.4 13.8
Routine episiotomy in primi gravidas helps to prevent fetal distress. 8.9 22.3 48.3 20.4
Routine episiotomy in primi gravidas helps to prevent maternal distress. 7.1 17.8 55.8 19.3
Routine episiotomy in primi gravidas help to reduce the complications encountered during shoulder dystocia. 23.8 44.6 20.8 10.8
Routine episiotomy in primi gravidas reduces labor pain 0.4 5.2 46.8 47.6
Routine episiotomy in primi gravidas reduces the bleeding rather tearing. 4.1 23.8 43.5 28.6
Routine episiotomy in primi gravidas will help in easy suturing rather tear. 20.4 47.6 21.9 10.0
Routine episiotomy in primi gravidas can prevent the mother to go for instrumental delivery. 7.4 14.1 51.3 27.1

labor pain (6%) and reduces the bleeding (28%), helps in easy suturing than
tear (68%) and helps avoid instrument-assisted delivery (22%).
These results are also illustrated in Fig. 1 by the central tendencies of each
perception. While the majority of respondents tended to disagree with most of
the misinformed perceptions, they did agree with the re-duction of risk in
spontaneous perineal tearing, the reduction of compli-cations associated with
shoulder dystocia, as well as the ease of suturing an episiotomy rather than
suturing a tear.
4. Discussion
The rate of episiotomy is on the decline in developed countries but
remains high in developing countries. The WHO has insisted on performing
episiotomy only when necessary, and the evidence demon-strates strongly that
episiotomies are associated with complications later on in women's lives. In
this context, the present study researched the practice and frequency of
episiotomy, as well as the perceptions held regarding routine episiotomy
among healthcare providers in Oman. The episiotomy rate in this study was
66%, which is very high when compared with studies conducted in similar
contexts (Fernandes et al., 2009). This study shows that midwives and
obstetri-cians are still practicing episiotomy invariably regardless of
indications, and that there is a lack of awareness among healthcare providers
re-garding the consequences of episiotomy in later age among women. Even
though those who agreed with the misleading perceptions were in the
minority, they still make up an uncomfortably large minority.
likely as locals to perform routine episiotomies, but a qualitative study needs
to be undertaken before any nuanced conclusion can be reached regarding this
result, since the reasons for non-Omanis performing routine episiotomies as
determined by this survey were more or less representative of the overall
sample. Respondents who had a diploma or a bachelor's degree were most
likely to perform routine episiotomies on primigravidae. Respondents who
worked in tertiary or regional hospitals were also most likely to perform
routine episiotomies. The high degree of association between these factors and
its significance makes a compelling case for a qualitative study to ascertain
what intervention steps are required in order to inform practice in Omani
healthcare settings.
It is crucial that healthcare providers provide care based on evidence.
There is a dire and urgent need for staff development and continuing
education, as well as the necessity for hospitals to upgrade practices based on
upcoming scientific research.
The survey showed that only 15% of the respondents were updated on the
most recent literature regarding episiotomies. Even though most of the
respondents reported reading articles about episiotomy in the previous 6 years,
there were still 25% of the respondents who had not read anything at all in this
duration. This makes for an alarming situation, since a quarter of the
respondents are far from implementing anything resembling evidence-based
practice. The design of our current study limits further exploration of whether
age, experience or other factors are relevant to the respondents' awareness of
updated sci-entific literature.

The results from our study illustrate that the significant predictors of The public, especially women also should be informed about episiot-
routine episiotomy performed on primigravidae are nationality, level of omies, and it should be a regular practice to obtain consent from the mother
education and place of work. Expatriates are more than four times as before performing an episiotomy, along with indicating the

Fig. 1. Tendency of agreement with perceptions.

 K. Al-Ghammari et al. / Applied Nursing Research 29 (2016) 131–135
reason. Despite evidence from randomized trials, the use of episiotomy has
remained unacceptably high in some countries, and there is an urgent need to
take a critical look at these practices. A high rate of episiotomy subjects
women to unnecessary risks and unnecessary suffering.
In this study, we found that a large number of healthcare providers had
misleading perceptions towards episiotomy. This is very clear in the
perception statements “episiotomy is a routine procedure”; “routine
episiotomy will prevent perineal tear”; and “helps in easy suturing than
suturing a tear”. The extent of agreement with these perceptions dem-onstrates
that there is a lack of knowledge on episiotomy and evidence-based practice.
Midwives and obstetricians need to have ongoing training and up-dates
regarding changes in practice. Women about to deliver should be aware of
episiotomy as a procedure, including their right to make an informed choice.
On the flip side, it is the duty of the healthcare pro-vider to obtain informed
consent from women who are about to deliver, while ensuring that indications
and evidence are mentioned if and when episiotomy becomes absolutely
necessary. Women need care, and women's health is central in representing a
nation's overall health. Midwives and obstetricians need to employ current
research, statistical data and quality measurements as a tool and guide for
providing quality care.
Conflicts of interest
The authors declare no conflicts of interest.
Acknowledgements
This study was funded by the Faculty-mentored Undergraduate Re-search
Award Programme (FURAP) of the Research Council in Oman. We are
grateful to the Research Council and to Dr. Vidya Seshan for her
contributions and support.
135
We would also like to thank all the participating healthcare profes-sionals
for their patience and co-operation in the survey study.
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