Knowledge, Attitude and Practice of Brazilian Obstetricians Regarding Episiotomy

Abstract

Objective To determine the prevalence of episiotomy and the factors associated with the knowledge, attitude and practice (KAP) of Brazilian obstetricians in relation to this procedure.

Methods A KAP survey was conducted with obstetricians working in Brazil. An electronic form containing structured questions previously evaluated using the Delphi method was created in Google Docs and sent by e-mail. A multivariate logistic regression was performed to determine the principal factors associated with adequate KAP. For each dependent variable (knowledge, attitude and practice) coded as adequate (1 = yes; 0 = no), a multiple logistic regression model was developed. Binary codes (1 = yes and 0 = no) were assigned to every independent or predictor variables. Prevalence ratios (PRs) and their respective 95% confidence intervals (95%CIs) were calculated as measures of relative risk, at a significance level of 5%.

Results Out of the 13 thousand physicians contacted, 1,163 replied, and 50 respondents were excluded. The mean episiotomy rate reported was of 42%. Knowledge was determined as adequate in 44.5% of the cases, attitude, in 10.9%, and practice, in 26.8% of the cases.

Conclusion Most respondents had inadequate knowledge, attitudes and practices regarding episiotomy. Although some factors such as age, teaching, working in the public sector and attending congresses improved knowledge, attitude and practice, we must recognize that episiotomy rates remain well above what would be considered ideal. Adequate knowledge is more prevalent than adequate attitude or practice, indicating that improving knowledge is crucial but insufficient to change the outlook of episiotomies in Brazil.

Resumo

Objetivo Determinar o nível e os fatores associados a conhecimento, atitude e prática (CAP) dos obstetras brasileiros em relação à episiotomia.

Métodos Foi realizado um estudo de corte transversal do tipo inquérito CAP com obstetras atuantes no território brasileiro. Foi criado um formulário eletrônico com perguntas estruturadas e previamente avaliadas pelo método Delphi, que foi enviado por e-mail pelo sistema Google Docs. Foi realizada uma análise multivariada de regressão logística múltipla para determinação dos principais fatores associados ao conhecimento, à atitude e à prática adequados. Para cada variável dependente (conhecimento, atitude e prática) codificada como adequada (1 = sim; 0 = não) foi construído um modelo de regressão logística múltipla. Todas as variáveis independentes ou preditivas foram codificadas binariamente (1 = sim; 0 = não). As razões de prevalência (RPs) e seus respectivos intervalos de confiança de 95% (ICs95%) foram calculados como medidas do risco relativo, com um nível de significância de 5%.

Resultados Dos 13 mil obstetras contatados, foram obtidas 1.163 respostas, sendo 50 participantes excluídos. A média da taxa de episiotomia relatada foi de 42%. Verificou-se que 44,5% dos médicos tinham conhecimentos adequados, 10,9% tinham atitudes adequadas e 26,8% tinham práticas adequadas.

Conclusão A maioria dos participantes tinha conhecimento, atitudes e práticas inadequadas em relação à episiotomia. Embora alguns fatores como idade, ensino, trabalho no setor público e participação em congressos melhorem o conhecimento, a atitude e a prática, é preciso reconhecer que as taxas de episiotomia permanecem bem acima do que se considera ideal. O conhecimento adequado é mais prevalente do que a atitude ou a prática adequadas, indicando que a melhora do conhecimento é crucial, mas insuficiente para mudar o panorama das episiotomias neste país.

Keywords

episiotomy - health knowledge - attitudes in health - practices in health - obstetrics - delivery - perineum

Palavras-chave

episiotomia - conhecimentos em saúde - atitudes em saúde - práticas em saúde - parto - obstetrícia - períneo

Contributors

All authors participated in the concept and design of the study; analysis and interpretation of data; draft or revision of the manuscript; and they have approved the manuscript as submitted. All authors are responsible for the reported research.

• References

• 1 Jiang H, Qian X, Carroli G, Garner P. Selective versus routine use of episiotomy for vaginal birth. Cochrane Database Syst Rev 2017; 2: CD000081 . Doi: 10.1002/14651858.CD000081.pub3
• 2 Hartmann K, Viswanathan M, Palmieri R, Gartlehner G, Thorp Jr J, Lohr KN. Outcomes of routine episiotomy: a systematic review. JAMA 2005; 293 (17) 2141-2148 . Doi: 10.1001/jama.293.17.2141
• 3 World Health Organization. WHO Recommendations: Intrapartum Care for a Positive Childbirth Experience. Geneva: World Health Organization; 2018
• 4 Waldman R. ACOG Practice Bulletin No. 198: prevention and management of obstetric lacerations at vaginal delivery. Obstet Gynecol 2019; 133 (01) 185 . Doi: 10.1097/AOG.0000000000003041
• 5 Graham ID, Carroli G, Davies C, Medves JM. Episiotomy rates around the world: an update. Birth 2005; 32 (03) 219-223 . Doi: 10.1111/j.0730-7659.2005.00373.x
• 6 Scott JR. Episiotomy and vaginal trauma. Obstet Gynecol Clin North Am 2005; 32 (02) 307-321 , x. Doi: 10.1016/j.ogc.2004.12.001
• 7 Steiner N, Weintraub AY, Wiznitzer A, Sergienko R, Sheiner E. Episiotomy: the final cut?. Arch Gynecol Obstet 2012; 286 (06) 1369-1373 . Doi: 10.1007/s00404-012-2460-x
• 8 Althabe F, Belizán JM, Bergel E. Episiotomy rates in primiparous women in Latin America: hospital based descriptive study. BMJ 2002; 324 (7343): 945-946 . Doi: 10.1136/bmj.324.7343.945
• 9 Lago TDG, Lima LP. Assistência à gestação, ao parto e ao puerpério: diferenciais regionais e desigualdades socioeconômicas. In: Ministério da Saúde. Pesquisa Nacional de Demografia e Saúde da Criança e da Mulher – PNDS 2006. Brasília, DF: Ministério da Saúde; 2009: 151-170
• 10 Lansky S, Lima Friche AA, Silva AA. , et al. Birth in Brazil survey: neonatal mortality, pregnancy and childbirth quality of care. Cad Saude Publica 2014; 30 (Suppl. 01) S1-S15 . Doi: 10.1590/0102-311x00133213
• 11 Frankman EA, Wang L, Bunker CH, Lowder JL. Episiotomy in the United States: has anything changed?. Am J Obstet Gynecol 2009; 200 (05) 573.e1-573.e7 . Doi: 10.1016/j.ajog.2008.11.022
• 12 Reinbold D, Éboue C, Morello R, Lamendour N, Herlicoviez M, Dreyfus M. [From the impact of French guidelines to reduce episiotomy's rate]. J Gynecol Obstet Biol Reprod (Paris) 2012; 41 (01) 62-68 . Doi: 10.1016/j.jgyn.2011.08.006
• 13 Seijmonsbergen-Schermers AE, Geerts CC, Prins M. , et al. The use of episiotomy in a low-risk population in the Netherlands: a secondary analysis. Birth 2013; 40 (04) 247-255 . Doi: 10.1111/birt.12060
• 14 Lappen JR, Gosset DR. Changes in episiotomy practice: evidence-based medicine in action. Expert Rev Obstet Gynecol 2010; 5: 301-309 . Doi: 10.1586/eog.10.21
• 15 East CE, Lau R, Biro MA. Midwives' and doctors' perceptions of their preparation for and practice in managing the perineum in the second stage of labour: a cross-sectional survey. Midwifery 2015; 31 (01) 122-131 . Doi: 10.1016/j.midw.2014.07.002
• 16 Badran IG. Knowledge, attitude and practice, the three pillars of excellence and wisdom: a place in the medical profession. East Mediterr Health J 1995; 1: 8-16
• 17 Hasson F, Keeney S, McKenna H. Research guidelines for the Delphi survey technique. J Adv Nurs 2000; 32 (04) 1008-1015 . Doi: 10.1046/j.1365-2648.2000.t01-1-01567.x
• 18 Likert R. A technique for the measurement of atitudes. Arch Psychol 1932; 22: 1-55
• 19 Ministério da Saúde. Secretaria de Políticas de Saúde. Área Técnica de Saúde da Mulher. Parto, Aborto e Puerpério: Assistência Humanizada à Mulher. Brasília, DF: Ministério da Saúde; 2001
• 20 Ministério da Saúde. Secretaria de Ciência, Tecnologia e Insumos Estratégicos. Departamento de Gestão e Incorporação de Tecnologias em Saúde. Diretrizes Nacionais de Assistência ao Parto Normal. Brasília, DF: Ministério da Saúde; 2017
• 21 Camano L, Souza E. Manual de Orientação FEBRASGO: Assistência ao Parto e Tocurgia. São Paulo, SP: Ponto; 2002
• 22 Federação Brasileira das Associações de Ginecologia e Obstetrícia. Manual de Orientação FEBRASGO: Assistência ao Abortamento, Parto e Puerpério. Rio de Janeiro, RJ: FEBRASGO; 2010
• 23 Wyatt JC, Paterson-Brown S, Johanson R, Altman DG, Bradburn MJ, Fisk NM. Randomised trial of educational visits to enhance use of systematic reviews in 25 obstetric units. BMJ 1998; 317 (7165): 1041-1046 . Doi: 10.1136/bmj.317.7165.1041
• 24 Elliott JH, Turner T, Clavisi O. , et al. Living systematic reviews: an emerging opportunity to narrow the evidence-practice gap. PLoS Med 2014; 11 (02) e1001603 . Doi: 10.1371/journal.pmed.1001603
• 25 Trinh AT, Khambalia A, Ampt A, Morris JM, Roberts CL. Episiotomy rate in Vietnamese-born women in Australia: support for a change in obstetric practice in Viet Nam. Bull World Health Organ 2013; 91 (05) 350-356 . Doi: 10.2471/BLT.12.114314
• 26 Ahmed HM. Midwives' clinical reasons for performing episiotomies in the Kurdistan region: are they evidence-based?. Sultan Qaboos Univ Med J 2014; 14 (03) e369-e374
• 27 Klein MC, Liston R, Fraser WD. , et al; Maternity Care Research Group. Attitudes of the new generation of Canadian obstetricians: how do they differ from their predecessors?. Birth 2011; 38 (02) 129-139 . Doi: 10.1111/j.1523-536X.2010.00462.x
• 28 Harrison RF, Brennan M, North PM, Reed JV, Wickham EA. Is routine episiotomy necessary?. Br Med J (Clin Res Ed) 1984; 288 (6435): 1971-1975 . Doi: 10.1136/bmj.288.6435.1971
• 29 Dannecker C, Hillemanns P, Strauss A, Hasbargen U, Hepp H, Anthuber C. Episiotomy and perineal tears presumed to be imminent: randomized controlled trial. Acta Obstet Gynecol Scand 2004; 83 (04) 364-368 . Doi: 10.1111/j.0001-6349.2004.00366.x
• 30 Sleep J, Grant A, Garcia J, Elbourne D, Spencer J, Chalmers I. West Berkshire perineal management trial. Br Med J (Clin Res Ed) 1984; 289 (6445): 587-590 . Doi: 10.1136/bmj.289.6445.587
• 31 Argentine Episiotomy Trial Collaborative Group. Routine vs selective episiotomy: a randomised controlled trial. Lancet 1993; 342 (8886-8887): 1517-1518 . Doi: 10.1016/S0140-6736(05)80085-6
• 32 Amorim MM, Franca-Neto AH, Leal NV, Melo FO, Maia SB, Alves JN. Is it possible to never perform episiotomy during vaginal delivery?. Obstet Gynecol 2014; 123: 38S . Doi: 10.1097/01.AOG.0000447314.51968.54
• 33 M Amorim M, Coutinho IC, Melo I, Katz L. Selective episiotomy vs. implementation of a non-episiotomy protocol: a randomized clinical trial. Reprod Health 2017; 14 (01) 55 . Doi: 10.1186/s12978-017-0315-4
• 34 Diniz SG. Que valores escolhemos nesse ritual?. Rev Estud Fem 2002; 10: 523-527 . Doi: 10.1590/S0104-026X2002000200023
• 35 Howden NL, Weber AM, Meyn LA. Episiotomy use among residents and faculty compared with private practitioners. Obstet Gynecol 2004; 103 (01) 114-118 . Doi: 10.1097/01.AOG.0000103997.83468.70
• 36 Mostofian F, Ruban C, Simunovic N, Bhandari M. Changing physician behavior: what works?. Am J Manag Care 2015; 21 (01) 75-84
• 37 Carmo Leal Md, Pereira APE, Domingues RMSM. , et al. Obstetric interventions during labor and childbirth in Brazilian low-risk women. Cad Saude Publica 2014; 30 (Suppl. 01) S1-S16 . Doi: 10.1590/0102-311X00151513
• 38 Davis-Floyd RE. Birth as an American Rite of Passage. 2nd ed. Berkeley, CA: University of California Press; 2004
• 39 Diniz D, Penalva J, Faúndes A, Rosas C. [Anencephaly: the magnitude of the judicial authorization among medical doctors in Brazil]. Cien Saude Colet 2009; 14 (Suppl. 01) 1619-1624 . Doi: 10.1590/s1413-81232009000800035
• 40 Braga GC, Clementino STP, Luz PFN, Scavuzzi A, Noronha Neto C, Amorim MM. Risk factors for episiotomy: a case-control stud. Rev Assoc Med Bras 2014; 60: 465-472 . Doi: 10.1590/1806-9282.60.05.015
• 41 Souza JP, Pileggi-Castro C. On labor and childbirth: the importance of quaternary prevention. Cad Saude Publica 2014; 30 (Suppl. 01) S1-S3 . Doi: 10.1590/0102-311xpe02s114
• 42 Norman AH, Tesser CD. [Quaternary prevention in primary care: a necessity for the Brazilian Unified National Health System]. Cad Saude Publica 2009; 25 (09) 2012-2020 . Doi: 10.1590/s0102-311x2009000900015