Some time ago, Mr. Mitko Popov announced that he had won a case against the St. George Plovdiv University Hospital on his own. The case was under the Access to Public Information Act. The satisfaction of winning against an administration in which the refusal to provide the requested information was written by some legal advisor, signed by a professor, albeit of medical, not legal sciences, and you are a simple goatherd, is great! But what is it about? They refused to say how many of the natural births performed in their hospital involved episiotomy. Women may know better what an episiotomy is: it is, roughly speaking, an incision that is made in order to facilitate natural childbirth. This is by definition. In reality, this incision is abused a lot. Because it is done wherever it is available, but also in the vast majority of cases - where it is not needed! Mitko Popov spoke to FAKTI on the topic.
- Mr. Popov, you recently raised the topic of episiotomies that are performed. What made you want information from hospitals?
- Last summer, my wife was in labor. Even though I took her to the maternity ward of the emergency department of a Burgas hospital at the last minute, when she was already fully dilated, precisely to avoid such interventions and the "donkey sitting", they still performed an episiotomy on her. My wife was unhappy about this, even though she had not been asked. Moreover, she was convinced that it was not necessary and that the birth would have been successful and natural, if only they had shown more patience. Apart from that, as you can guess, there were long-term consequences – she couldn't sit, she had pain every time she went to the toilet, she was visibly bleeding from the stitches, they hadn't explained to her how to care for these stitches, nor when they were expected to heal. It seemed to me like something that could have been avoided. However, it occurred to me that perhaps ours was not an isolated case, and that's why I decided to get official data from the same hospital. At first, they refused to provide them, which showed me even more that there was something there that needed to be revealed. After I did receive them from them, I forwarded them to the Ministry of Health and asked them to change their Medical Standard for Obstetrics. However, they replied that not only did they not know what the average rate of episiotomies in the country was, but also that the data I sent for the hospital in Burgas was not representative. I could not disagree with the latter. Therefore, although according to REGULATION No. 1 of 27.02.2013 for providing medical-statistical information and information about the medical activities of the medical institutions, they should have it, I decided to do this work for them by collecting all the relevant data for them.
- Why did hospitals refuse to tell you how many of the natural births performed at them involved episiotomies...
- I have no idea about these decisions of theirs. At first I thought that among the numbers of episiotomies there were also fictitious numbers submitted for payment by the NHIF, and they would not want to be in the spotlight. Now I think that they simply do not want their low level of professionalism to be revealed. Because in the end, it turns out to be “C-section or episiotomies?“. There seems to be no place for natural childbirth with care for the woman in labor, which does not involve cutting.
- Does the episiotomy procedure make the clinical pathway of childbirth more expensive?
- The episiotomy itself does not seem to make the clinical pathway more expensive. However, the recovery of the episiotomy adds to the cost. This is also reflected in the WHO report from 2018. This is the time for suturing, consumables. They increase accordingly in case of wound complications.
- This is done at the discretion of the doctor. Why do you think this incision is abused?
- At least, this is the conclusion I come to, looking at the data obtained from nearly 60 hospitals. And they indicate that the share of episiotomy is from 0 to 78%. Sound logic shows that there is no single factor that explains such large differences, and hence the working hypothesis is about the abuse of this incision. It is likely that the delivery teams in some facilities are more inclined to this manipulation than others. In addition, as I have already noted, episiotomy repair still costs money and I do not exclude that some of these episiotomy were performed precisely for the purpose of billing.
- You asked the Ministry of Health to change their standard. And what did they tell you…
- Yes, it is precisely because of these large differences that I asked the Ministry to update their standard, thus unifying the practice. In addition, it was preferable to adopt the World Health Organization's recommendation that episiotomies should not be performed in principle. The second time, I already gave them all the collected data and they replied that they would discuss it. However, for me, this is like a dead letter. After all, two months have passed, and there has been no feedback from them.
- And finally, it turns out that there are hospitals that perform 0 (zero) episiotomies, and others over 75%. It's all at the doctor's discretion…
- Yes, this is crazy! Here one can speculate extensively about the reasons - from the age of the women in labor, through their social status, to the workload or level of professionalism of the delivery teams, and why not their health insurance status. However, what are the chances that the hospital will get its money back for an episiotomy if the woman in labor is not insured? But I emphasize that what allows such high rates is the Medical Standard for Obstetrics itself, which states that each team decides for itself whether to perform an episiotomy, and hospitals are not obliged to keep their share within certain limits.
- Why are fewer episiotomies performed in small hospitals?
- This is also a question whose real answer I would like to know myself. Based on the geographical distribution of the small hospitals in question, namely, for example, Chirpan, Levski, Knezha, Nova Zagora, one might think that the social status of the women in labor protects them. These are relatively small places where the anonymity of the teams is nonexistent and perhaps they are aware that if they cause severe discomfort after childbirth in a woman in labor, they may become the subject of revenge, as is sometimes reported in the media. The other possible reason is the relatively young age of childbirth. Perhaps because of this, these women do not need an episiotomy. At the same time, in Burgas, for example, there are apparently many women who give birth young, but the percentage of episiotomies in this city is very high. So age cannot fully explain this phenomenon.
- The World Health Organization has recommended that episiotomies not be performed at all, because…
- The WHO report emphasizes the lack of indisputable data on the effectiveness of episiotomies.