Provider contribution to an episiotomy risk model

OBJECTIVE: The extent to which the observed variation in episiotomy rates can be attributed to individual practitioners is not known. We sought to analyze the contribution of the attending midwife to a risk model for episiotomy. STUDY DESIGN: We prospectively collected data on 736 consecutive vaginal deliveries in nulliparas at a tertiary maternity hospital. The study measures the impact of the attending midwife on the decision to perform an episiotomy, controlling for a host of patient and clinical characteristics. Midwife effect is evaluated in terms of its overall contribution to the explanatory power of logistic regression model. RESULTS: The overall rate of episiotomy in primiparas was 40.6%. Individual midwife episiotomy rate ranged from 5.6% to 73.9% (p < 0.0001). After controlling for confounding factors with logistic regression, maternal age ≥35 years (OR 1.61, 95%CI: 1.02-2.52), vacuum extraction (OR 26.88, 95%CI: 2.57-280.7), fundal pressure (OR 62.90, 95%CI: 18.39-214.98), second-stage duration (OR 2.24, 95%CI: 1.53-3.28), and the individual midwife were all associated with episiotomy use. The midwife attending the birth and fundal pressure provided the greatest explanatory power of the model. CONCLUSIONS: The attending provider adds a significant independent effect to the episiotomy risk model. This has implications for both practice and research in this clinical area.