The gentlebirth.org website is provided courtesy of
Ronnie Falcao, LM MS, a homebirth midwife in Mountain View, CA

Episiotomy Trials

[from ob-gyn-l]

For all that RCTs are worth (and that is a lot), the ability to influence a clinician's practice by showing 'the evidence' is futile when faced with the bigger influence discussed in this letter. Sometimes, "To truly understand one must unburden oneself from the yoke of rationality" Zan Blue

I believe therefore I practise

REFERENCES AND NOTES

Should one take account of practitioners' beliefs when attempting to influence clinical practice? A recent report by Klein and colleagues 1) answers this question with a resounding yes. These researchers analysed physicians' beliefs concerning episiotomy, and their behaviour and patient outcome, during a randomised controlled trial of episiotomy. (2) The purpose of this analysis was to explore some physicians' poor compliance with the trial protocol. During the trial, a third of the physicians did not change their use of episiotomy as required by the protocol and continued to use episiotomy almost 90 percent of the time in both arms of the trial (one arm required restriction of episiotomy to fetal and maternal indications while the other required the more liberal or routine use of the operation).

After the trial ended but before the results were released, Klein et al surveyed doctors who had participated and conducted a post-hoc analysis of the trial data. They divided them into quartiles based on the strength of the views that they held about episiotomy. The clinicians were categorised as having either very favourable, favourable, unfavourable, or very unfavourable beliefs about episiotomy. The researchers then compared the use of obstetric practices and subsequent patient outcomes of each of these groups of clinicians.

Whilst characteristics of the women attended by each category of clinician were similar (e.g., in terms of parity, age, height, weight gain, baby's birth weight), doctors with more favourable views of episiotomy were less likely to randomise women into the trial and more likely to justify the exclusion of women from the trial on the grounds of "fetal distress" or caesarean section than were their colleagues with very unfavourable views of episiotomy. Once a woman was randomised into the trial, these same doctors also had more difficulty limiting the use of episiotomy in the restricted arm of the trial. Compared with their colleagues with very unfavourable views of episiotomy, they were more likely to perform episiotomy when the protocol called for avoiding one, because they perceived the fetus to be distress or thought the perineum was unable to distend or was about to tear. Furthermore, women attended by these clinicians received more oxytocin augmentations of labour and had shorter labours than women attended by doctors with very unfavourable views of episiotomy. Klein et al. concluded that physicians with more favourable views of episiotomy were more likely to consider apparently normal labour as abnormal and, in accord with this perspective, were also more likely to intervene in the birth process and use techniques to expedite labour.

One could argue that the findings of Klein et al. are of limited generalisability because the experimental design of randomised controlled trials runs counter to usual autonomous clinical decision-making and is therefore an anathema to the human spirit. (3) However, over the past century, one of the many factors that has been instrumental in influencing the use of episiotomy has been clinicians' beliefs. For example, during the late 1800s, physicians' beliefs effectively discouraged the acceptance of a "new" maternity practice-elective episiotomy. The liberal use of episiotomy advocated by numerous doctors during the latter decades of the 19th century was largely rejected because elective episiotomy went against the then prevailing obstetric belief in the "natural law" of the perineum, according to which Nature ensured the proper distension of the perineum during childbirth, making the use of perineal incision unnecessary in the vast majority of births.

During the 20th century, routine use of episiotomy in the USA and liberal use of episiotomy in the UK eventually came about, but only after a radical shift in the obstetric belief systems of both countries. In the USA, the routine use of episiotomy, which became popular beginning in late 1930s, did so after obstetricians succeeded in recasting childbirth from a normal process that was thought to require very little intervention to a more pathological process that was believed to necessitate prophylactic intervention to diminish or prevent fetal and maternal damage. In the UK, the shift that removed some of the longstanding philosophical barriers to the more liberal use of episiotomy was the acceptance of "active management of labour" during the 1970s, the underlying principle being the superiority of obstetric intervention over physiological processes.

Finally, the history of episiotomy reveals that clinicians do not always possess the same beliefs, and that competing belief systems can encourage and support change by offering philosophical justification for challenging existing practices. This has been the case with the questioning of the liberal use of episiotomy by midwives and general and family medicine practitioners on both sides of the Atlantic. These groups' belief in birth as an essentially physiological process not requiring routine surgical intervention has been central to their challenging of routine episiotomy.

Proposed changes in practice are much more likely to succeed when they are compatible with existing beliefs. Conversely, belief systems at odds with a proposed change may discourage clinicians from seriously considering adopting the practice. When this occurs, it may be reasonable and necessary to modify the belief system to make it more congruent with the proposed change. Despite the growing interest in strategies to influence practitioner performance, (4-6) clinicians' beliefs are not explicitly or systematically receiving the attention they deserve. Policy makers and healthcare researchers, both those conducting randomised controlled trials and those interested in research transfer, should pay attention to this area. If they do not, we should not be surprised when the results of efforts to influence doctors' behaviour remain disappointing.

References

1. Klein MC, Kaczorowski J, Robbins JM, et al. Physicians' beliefs and behaviour during a randomized controlled trial of episiotomy: consequences for women in their care. Can Med Assoc J 1995; 153: 769-79.
2. Klein MC, Gauthier RJ, Jorgenson SH, et al. Does episiotomy prevent perineal trauma and pelvic floor relaxation? Online J Curr Clin Trials 1992; July 1 (doc 10).
3. Schulz KF. Editorial: Unbiased research and the human spirit: the challenges of randomized controlled trials. Can Med Assoc J 1995; 153: 783-86.
4. Oxman A, Thomson MA, Davis D, Haynes RB. No magic bullets: a systematic review of 102 trials of interventions to improve professional practice. Can Med Assoc J 1995; 153: 1423-31.
5. Davis D, Thomson MA, Oxman A, Haynes RB. Changing physician performance: a systematic review of the effect of continuing medical education strategies. JAMA 1995; 274: 700-05.
6. Grimshaw J, Freemantle N, Wallace S, et al. Developing and implementing clinical practice guidelines. Qual Health Care 1995; 4: 55-64.