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.


METHODS
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.
a Department of Obstetrics and Gynecology , University of Insubria , Varese , Italy and.
Antonella
A
Cromi
b Research Center in Epidemiology and Preventive Medicine, Insubria University , Varese , Italy.
Matteo
M
Bonzini
a Department of Obstetrics and Gynecology , University of Insubria , Varese , Italy and.
Stefano
S
Uccella
a Department of Obstetrics and Gynecology , University of Insubria , Varese , Italy and.
Maurizio
M
Serati
a Department of Obstetrics and Gynecology , University of Insubria , Varese , Italy and.
Giorgio
G
Bogani
a Department of Obstetrics and Gynecology , University of Insubria , Varese , Italy and.
Nadia
N
Pozzo
a Department of Obstetrics and Gynecology , University of Insubria , Varese , Italy and.
Fabio
F
Ghezzi
D000328:Adult; D004841:Episiotomy / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D007558:Italy; D016015:Logistic Models; D008880:Midwifery; D057184:Practice Patterns, Nurses' / Q000706:statistics & numerical data*; D011247:Pregnancy; D011446:Prospective Studies; D018570:Risk Assessment; D012307:Risk Factors
Clinician; episiotomy; genital tract trauma; midwife; provider; risk model