Our research in southern Alberta found that low-risk delivery patients were more likely (P < .01) to undergo episiotomy in the regional study hospital (13%) than in the rural hospitals included (4%). Despite decreased accessibility to cesarean section and no specialist obstetric or pediatric support—factors which we thought might predispose a rural practitioner to performing episiotomy in an effort to hasten delivery—our study shows that rural FPs performed episiotomy less frequently than regional practitioners did in these study settings.
Episiotomy rates in both southern Alberta settings were lower than the most recent published national (23.8% in 2001 and 20.7% in 2006)1,20
and provincial (15.5% in 2004)13
statistics, although the regional centre episiotomy rate of 13% was similar to the rate of 12.9% reported in the Maternity Experiences Survey for Alberta.20
Available literature on low-risk deliveries from 1997 to 1998 shows similar episiotomy rates to the national and provincial data: episiotomy rates for low-risk deliveries in Alberta were 19.2% for low-volume and 17.3% for high-volume FP delivery providers,18
while a study of deliveries in one Canadian hospital found rates of 22.7% and 19.1%.19
The 1997 publication of the first Cochrane review that recommended against routine episiotomy4
might help account for the low episiotomy rates observed in our study of centres in southern Alberta (13% for regional and 4% for rural deliveries) compared with earlier studies.1,13
The 2004 Society of Obstetricians and Gynaecologists of Canada Guideline on Operative Vaginal Birth also discouraged routine episiotomy even with instrumented delivery.9
On subgroup analysis, our data showed that episiotomy rates of regional FPs did not differ significantly from those of their rural counterparts (2% vs 4%, P
= .51). The episiotomy rate for women treated by regional OBs (21%), however, does compare with the national1,20
and provincial averages.13
The higher episiotomy rate among OBs cannot be attributed to instrumentation in our study, as rates did not differ between FPs and OBs, in contrast to studies that show correlation of higher episiotomy rates with instrumentation and higher instrumentation rates by OBs.16,17
Another finding that differed significantly between regional and rural deliveries was the rate of epidural analgesia (37% regional vs 19% rural, P = .02). This was not unexpected, as more anesthetists are available in the regional site to provide the services. We were surprised that fewer inductions or augmentations were performed regionally (33% vs 66% rural, P < .01), and that nonreassuring fetal status was recorded more frequently in the regional hospital (27% vs 10% of rural deliveries, P < .01). Unfortunately the information we collected from the charts was insufficiently detailed to enable us to identify the reason for either of these differences.
Strengths of this research include that all low-risk vaginal deliveries at rural sites were reviewed. Patients delivering in regional and rural settings did not appear to differ in maternal and infant demographic characteristics, suggesting that the regional sample was indeed comparable to the rural population. In addition, the regional charts included the patients of 18 physicians, and the rural deliveries were done by 19 FPs. The physicians were also from a variety of backgrounds.
The main limitation of this study was its design. The study was restricted to 4 FP practice settings in southern Alberta: 1 regional and 3 rural hospitals. Therefore, we cannot comment on the generalizability of our findings.
Further limitations relate to the retrospective chart review: definition of cases relied on data collected for clinical purposes21
; therefore, identification of truly eligible cases is less accurate than in a prospective study, and data are less likely to be complete without the ability to seek clarification.21
Reporting error is also possible, as data entry into delivery records was undertaken by various medical providers. We attempted to manage these concerns by using a standardized database to collect data and having close collaboration between data abstracters to ensure data consistency.
A further unexpected limitation was that there were fewer episiotomies than expected in our study. As a result, detailed analyses of delivery and provider characteristics that contributed to differing episiotomy rates in different locations were not possible.
Owing to researcher manpower, only 10% of estimated eligible regional deliveries were reviewed, introducing the possibility of sampling bias in the regional sample. The potential for bias was reduced by random sampling of regional records by the records department independent of the researchers.
In our study, both rural and regional practitioners in southern Alberta performed episiotomy less frequently than provincial and national rates, thus demonstrating a “restrictive” use of the procedure in keeping with current evidence-based guidelines.4,9
Rural practitioners should be reassured that practice in a rural facility does not increase the likelihood of performing episiotomy, despite limited cesarean section availability or OB backup. Regional OBs performed episiotomy with around 5 times the frequency of FPs, a difference that is not accounted for by instrumentation alone.
Our small study raises a number of research questions for further detailed research. Larger prospective studies are needed to examine possible differences between FP and OB obstetric practice (eg, the differences between training or philosophy of FPs and OBs).16,22
Larger prospective studies would also allow detailed examination of maternal and pregnancy characteristics that might affect episiotomy and perineal tear rates.