title: Cross-sectional study comparing public and private hospitals in Catalonia: is the practice of routine episiotomy changing?
abstract: BACKGROUND
  In Spain, the Strategy for Assistance in Normal Childbirth (SANC) promoted a model of care, which respects the physiological birth process and discards unnecessary routine interventions, such as episiotomies. We evaluated the rate of episiotomy use and perineal trauma as indicators of how selective introduction of the SANC initiative has impacted childbirth outcomes in hospitals of Catalonia.
  
  
  METHODS
  Cross-sectional study of all singleton vaginal term deliveries without instrument registered in the Minimum Basic Data Set (MBDS) of Catalonia in 2007, 2010 and 2012. Hospitals were divided into types according to funding (public or private), and four strata were differentiated according to volume of births attended. Episiotomies and perineal injury were considered dependent variables. The relationship between qualitative variables was analysed using the chi-squared test, and Student's t-test was used for quantitative variables. Comparison of proportions was performed on the two hospital groups between 2007 and 2012 using a Z-test. Logistic regression models were used to analyse the relationship between episiotomy or severe perineal damage and maternal age, volume of births and hospital type, obtaining odds ratios (OR) and 95% confidence intervals (CI).
  
  
  RESULTS
  The majority of normal singleton term deliveries were attended in public hospitals, where maternal age was lower than for women attended in private hospitals. Analysis revealed a statistically significant (P < 0.001) decreasing trend in episiotomy use in Catalonia for both hospital types. Private hospitals appeared to be associated with increased episiotomy rate in 2007 (OR = 1.099, CI: 1,057-1,142), 2010 (OR = 1.528, CI: 1,472-1,587) and 2012 (OR = 1.459, CI: 1,383-1,540), and a lower rate of severe perineal trauma in 2007 (OR = 0.164, CI: 0.095-0.283), 2010 (OR = 0.16, CI: 0.110-0.232) and 2012 (OR = 0.19, CI: 0.107-0.336). Regarding severe perineal injury, when independent variables were adjusted, maternal age ceased to have a significant correlation in 2012 (OR = 0.994, CI: 0.970-1.018).
  
  
  CONCLUSIONS
  Episiotomy procedures during normal singleton vaginal term deliveries in Catalonia has decreased steadily since 2007. Study results show a stable incidence trend below 1% for severe perineal trauma over the study period.
authors.affiliation: Directorate-General for Health Planning and Research, Ministry of Health of the Government of Catalonia, Barcelona, Spain. rescuriet@catsalut.cat.|Department of Experimental and Health Sciences, Universitat Pompeu Fabra (UPF), Barcelona, Spain. rescuriet@catsalut.cat.|Consorci Sanitari Integral, Hospital General de l'Hospitalet, L'Hospitalet de Llobregat, Barcelona, Spain. rescuriet@catsalut.cat.
authors.forename: Ramón
authors.initials: R
authors.lastname: Escuriet
authors.affiliation: Directorate-General for Health Planning and Research, Ministry of Health of the Government of Catalonia, Barcelona, Spain. mjpueyo@catsalut.cat.
authors.forename: María J
authors.initials: MJ
authors.lastname: Pueyo
authors.affiliation: University of Central Lancashire, School of Health, Midwifery, Neonatal and Sexual Health Division, Preston, UK. MPerez-Botella1@uclan.ac.uk.
authors.forename: Mercedes
authors.initials: M
authors.lastname: Perez-Botella
authors.affiliation: Institut Català de la Salut, Unitat Atenció a la Salut Sexual i Reproductiva, Granollers, Spain. xespada.ics@gencat.cat.|Fundació Hospital Asil de Granollers, Granollers, Spain. xespada.ics@gencat.cat.
authors.forename: Xavi
authors.initials: X
authors.lastname: Espada
authors.affiliation: Consorci Sanitari Integral, Hospital General de l'Hospitalet, L'Hospitalet de Llobregat, Barcelona, Spain. isabel.Salgado@sanitatintegral.org.
authors.forename: Isabel
authors.initials: I
authors.lastname: Salgado
authors.affiliation: Consorci Sanitari Integral, Hospital General de l'Hospitalet, L'Hospitalet de Llobregat, Barcelona, Spain. analiagomez2@yahoo.es.
authors.forename: Analía
authors.initials: A
authors.lastname: Gómez
authors.affiliation: Directorate-General for Health Planning and Research, Ministry of Health of the Government of Catalonia, Barcelona, Spain. hbiescas@catsalut.cat.
authors.forename: Herminia
authors.initials: H
authors.lastname: Biescas
authors.affiliation: Women's Health Observatory, Subdirectorate for Quality and Cohesion, Ministry of Health, Social Services and Equality, Madrid, Spain. iespiga@msssi.es.
authors.forename: Isabel
authors.initials: I
authors.lastname: Espiga
authors.affiliation: Centre for Research in Anthropology (CRIA-IUL), Lisbon, Portugal. jowhite67@yahoo.co.uk.|Visiting Fellow, King's College, London, UK. jowhite67@yahoo.co.uk.
authors.forename: Joanna
authors.initials: J
authors.lastname: White
authors.affiliation: Public Health Agency of Catalonia, Maternal and Infant Health Programme, Government of Catalonia, Barcelona, Spain. rosa.fernandezb@gencat.cat.
authors.forename: Rosa
authors.initials: R
authors.lastname: Fernandez
authors.affiliation: The Union, Health and Social Entities Association, Barcelona, Spain. josepfuste@uch.cat.
authors.forename: Josep
authors.initials: J
authors.lastname: Fusté
authors.affiliation: Universitat Pompeu Fabra (UPF), Faculty of Economic and Business Sciences, Barcelona, Spain. vicente.ortun@upf.edu.
authors.forename: Vicente
authors.initials: V
authors.lastname: Ortún
mesh_terms: D000328:Adult; D003430:Cross-Sectional Studies; D036861:Delivery, Obstetric; D004841:Episiotomy; D005260:Female; D016304:Hospitals, Private; D006779:Hospitals, Public; D006801:Humans; D016015:Logistic Models; D008423:Maternal Age; D007744:Obstetric Labor Complications / Q000209:etiology; D016017:Odds Ratio; D010502:Perineum / Q000601:surgery; D010818:Practice Patterns, Physicians'; D011247:Pregnancy; D012307:Risk Factors; D013030:Spain; D055815:Young Adult