Open access Original research BMJ Open: first published as 10.1136/bmjopen-2019-033354 on 19 July 2020. Downloaded from Women’s experience of episiotomy: a qualitative study from China Siyuan He ,1,2 Hong Jiang,1,2,3 Xu Qian,1,2,3 Paul Garner4 To cite: He S, Jiang H, Qian X, ABSTRACT Strengths and limitations of this study et al. Women’s experience Objective To describe women’s experience of episiotomy of episiotomy: a qualitative in urban China. ► This study is one of a few qualitative studies to study from China. BMJ Open Design This is a semistructured, indepth interview with 2020;10:e033354. doi:10.1136/ explore women’s experience of episiotomy after women after episiotomy. We analysed transcriptions using bmjopen-2019-033354 childbirth. thematic analysis in Chinese. Emerging themes were ► The study identified an effect of episiotomy de- ► Prepublication history and debated in English to finalise interpretation. scribed in Chinese as a ‘psychological shadow’, and additional material for this Setting Two community health centres and four hospitals that societal norms meant women felt they were ex- paper are available online. To in Shanghai, China. pected to suffer alone and not complain. view these files, please visit Participants Purposive sampling of 30 postpartum the journal online (http:// dx. doi. ► We interviewed women at different times after epi- women who had experienced episiotomy; 25 were org/ 10. 1136/ bmjopen- 2019- siotomy and were not able to evaluate whether their primiparous and 4 had deliveries by forceps. We 033354). perceptions changed over time. interviewed health providers to complement the data. SH and HJ contributed equally. Results We identified four main themes: (1) women’s views of the procedure vary considerably; (2) pain SH and HJ are joint first authors. interferes with daily life for weeks; (3) long- term anxiety for example, 53.2% in Chile9 (from hospital is a consequence for some, described as a ‘psychological 10 Received 31 July 2019 records), 73% from a hospital in Lebanon shadow’; and (4) societal norms assume women will not Revised 03 April 2020 and 92% from a hospital in Cambodia.11 complain. Accepted 03 June 2020 Pushback from consumers in the early Conclusion Women receive little information in advance about episiotomy, yet the procedure has a wide range of 1990s may have contributed to the decline in physical and psychological consequences. This includes routine episiotomy in the UK, but in general long- term anxiety about the damage done to them as recommendations for episiotomy have been women. set up mainly from the health provider’s medical standpoint, with little reference to the http://bmjopen.bmj.com/ views or preferences of women. A Cochrane INTRODUCTION review in 2017 pointed out that trials inad- Doctors introduced episiotomy as a surgical equately considered women’s preferences, procedure in the 1950s to reduce the risk views on the procedures or the outcomes that of severe perineal tear, shorten delivery and are important to them.3 prevent damage to the pelvic floor.1 However, More recently, the WHO recognised the the procedure can cause pain in the imme- need for a ‘positive childbirth experience’,4 on October 2, 2021 by guest. Protected copyright. © Author(s) (or their diate postpartum period, the wound can which corresponds to the new Global Strategy employer(s)) 2020. Re- use become infected, and the scar can cause for Women’s, Children’s and Adolescents’ permitted under CC BY. long- term dyspareunia. Indeed, the benefits Health (2016–2030). With an increase in Published by BMJ. of routine episiotomy have been contested.2 emphasis on women-centred outcomes in 1 School of Public Health, Fudan This balance between benefits and harms clinical decision making, women’s experi- University, Shanghai, China 2Global Health Institute, Fudan has been evaluated in randomised controlled ence of episiotomy is highly relevant. University, Shanghai, China trials. These are summarised in a Cochrane In China, episiotomy used to be a routine 12 13 3National Health Commission review which shows that there is no evidence practice for vaginal delivery. In the last Key Laboratory of Health that routine episiotomy has the benefits orig- decade, hospital data reported rates of Technology Assessment, Fudan inally assumed and that more restricted use 47.4%–84.7%,14–17 and some multicentre University, Shanghai, China 4 results in fewer women experiencing severe studies reported hospital rates from 41.2% Centre for Evidence Synthesis 3 18 19 in Global Health, Department perineal or vaginal trauma. to 69.7%. For China, where there were 20 of Clinical Sciences, Liverpool International institutions and professional 17.23 million births in 2016, there could School of Tropical Medicine, societies now recommend episiotomy only be as many as 7.33 million episiotomies a Liverpool, UK when there is a clear clinical indication.4–7 year (given a vaginal birth rate of 61.0% and 8 Correspondence to Practices in most European countries show an episiotomy rate of 69.7% among vaginal 18 Professor Xu Qian; rates have fallen. However, episiotomy rates in births). Although the Chinese national xqian@ shmu. edu. cn vaginal births are still high in some countries, obstetric guideline has recommended He S, et al. BMJ Open 2020;10:e033354. doi:10.1136/bmjopen-2019-033354 1 Open access restrictive use of episiotomy since 2016, it has not been BMJ Open: first published as 10.1136/bmjopen-2019-033354 on 19 July 2020. Downloaded from Box 1 Interview guide implemented.21 We found no data in the published English literature ► What is your experience after episiotomy, from the childbirth to on the experience of episiotomy in women in China, and postpartum period? (Probe: discomfort, pain, swelling) we therefore carried out this study. Through this qualita- ► Did episiotomy impact on your daily life? How? (Probe: walking, sit- tive study, we aimed to describe women’s experience of ting, breast feeding, baby care, sexual life, medication, mood) episiotomy in urban China. ► How did you deal with your suffering or problems? (Probe: medical services usage) ► Are there some long- lasting effects of episiotomy you have noticed? METHODS If yes, what are they? Approach, setting and sampling strategy We used standard qualitative methods with semistructured, indepth individual interviews. The details of the methods written informed consent was obtained from each were reported according to the Standards for Reporting participant. Qualitative Research checklist (see online supplementary file 1).22 We conducted the study in Shanghai (popula- Patient and public involvement tion of 24.2 million in 2016). The city has had a policy of When designing the study, we invited a few women to give routine episiotomy from 1999, with rates around 35.8%– us feedback on the approach and the questions to ask. 86.67% from 2011 to 2014, and the restrictive use of episi- We collected women’s comments on the public internet 23–25 otomy was recommended in 2015. Community health forum and interviewed four women about the research centres hold pregnancy registration and information to topic before we designed the interview guide. This prelim- allow home visits in the postnatal period for clients in inary work led to several revisions to the interview guide. their catchment area, while clinical services for childbirth are provided by higher level hospitals, and episiotomy Data collection practices vary between hospitals. Compared with general We approached women by accompanying health staff hospitals, maternal and child health (MCH) hospitals are during postpartum home visits or when women brought more likely to adopt restrictive episiotomy policy since their children for child health check- up in community their midwives are experienced and well trained, and health centres between September 2017 and March women at these settings tend to be at low risk. We used 2018. We used an interview guide based on the litera- the two community health centres where we had worked ture and our research group discussions (Box 1).29–31 We previously and thus the staff were familiar with us: one in also reviewed women’s comments on the public internet Pudong District, east of Shanghai (1459 pregnant women forum to improve the design of the interview guide and registered in 2017), and one in Xuhui District, west of piloted the interview guide with four postpartum women. http://bmjopen.bmj.com/ Shanghai (775 pregnant women registered in 2017). The piloted data were also included in our analysis as We used purposive sampling strategy, seeking women these were consistent with the main sample. Interviews over 18 years old who had undergone an episiotomy in were conducted in private rooms in the community their last birth. We recruited women from three different health centres, hospitals and interviewees’ homes, and postpartum periods (within 2 weeks, no more than 6 all women provided signed consents. Interviews were in months, and 6 months or more after childbirth); we also Chinese and recorded with permission. Health providers took account of the types of hospitals to ensure a mix of were recommended by relevant administrators and were experiences. Women being invited for this study delivered invited to this study. They were interviewed at a private on October 2, 2021 by guest. Protected copyright. in various types of hospitals, including municipal MCH room in their workplaces. hospital, tertiary general hospital, district MCH hospital and secondary general hospital. Experienced healthcare Data analysis providers who had over 3 years of work experience in Medical master’s students transcribed the interviews, and maternal health area were recruited to confirm women’s one of the interviewers (SH) checked them for accuracy. symptoms and help to better understand women’s views We used NVivo V.8.0 (QSR) software for thematic anal- and reflections. Two or three healthcare providers from ysis.32 33 Two researchers (SH and YC) read all the tran- each type of hospitals were involved in this study and their scripts and coded the data to identify the reoccurring characteristics are shown in online supplementary file 2.