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National Trends in Utilization of Episiotomy and Factors Associated with High-Utilization Centers in the United States

Author(s): Ava D Mandelbaum, Sarah E Rudasil, Esteban Aguayo, Elaine Chan, Yas Sanaiha, Joshua G Cohen, Peyman Benharash

Background: Restrictive use of episiotomy has been recommended given potential risks of routine use. However, recent trends in episiotomy utilization and disparities in its use have not been examined at the national level in the United States. The present study aimed to characterize trends in episiotomy use and examine factors associated with high utilization.

Methods: The National Inpatient Sample database was queried to identify vaginal deliveries between 2005 and 2016. Patients were stratified based on ICD codes specifying episiotomy. Hospitals were classified as low, medium, and high utilization centers based on the annual number of episiotomies per delivery. Multivariable regressions were used to assess factors associated with episiotomy and high utilization centers.

Results: Of 32,975,144 vaginal delivery related hospitalizations, 12.9% underwent an episiotomy. Rates of episiotomy decreased from 19.5% in 2005 to 5.3% in 2016 (P<0.001). Episiotomy was associated with younger age (AOR= 0.96, P<0.001), lower Elixhauser Comorbidity Index (AOR= 0.79, P<0.001), Asian race (AOR= 1.81, P<0.001), private insurance (AOR= 1.32, P<0.001), highest income quartile (AOR= 1.15, P<0.001), as well as third- and fourth-degree perineal lacerations (AOR= 2.10, P<0.001). High utilization centers were more likely to be urban, non-teaching institutions (AOR=3.54, P<0.001) with high-delivery volume (AOR=13.52, P<0.001) and large bed capacity (AOR=1.24, P<0.001).

Conclusions: National rates of episiotomy decreased significantly between 2005 and 2016. Several sociodemographic and hospital-level factors were associated with variation in utilization. Further study of targeted interventions through educational programs and quality benchmarks are needed to better define when episiotomy should be used in obstetrics.

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