Women’s Involvement in Decision Making: Episiotomy Procedure

Background: Involving patient in decision making for their care can enhance satisfaction and promote health outcomes in particular in the nursing fields. As The World Health Organization Principles of Perinatal Care has recommended that care should involve women in decision making. This principle strongly endorses for improving effective perinatal care. Decision making regard to treatment options is a concept that has increased widespread appeals to healthcare providers and users in recent year. Evidently, patient involvement in decision making has not always been implemented in clinical practice in particular during intrapartum period. Objective: The aim of this study was to investigate the involvement of women in decision making on episiotomy procedure during labor. Methods: A descriptive quantitative approach was conducted using selfadministered survey questionnaires in two government hospitals, Bangkok, Thailand. Participating hospitals were identified by convenience and remained anonymous. The Participant, eligible women included those who have reached 37 to 42 weeks of gestation, experienced vaginal birth, have a live baby, and admitted in the postpartum units. An appropriate sample size was assigned based on a 95 percent confidence level. A sample size was drawn from two hospitals based on a binomial probability distribution. There were 400 postpartum women participated in this study. Anonymous patient’s data were analyzed using frequencies and percentages. Results: The results revealed that 80% of all women experienced episiotomy. The finding demonstrated that decision making on having this procedure made by health care providers and relatives 73.8%, 3.2%, respectively. 23% of them had a chance to make a decision on having episiotomy. There were 23.8% of women received information about risks and benefits of episiotomy procedure and 76.2% did not get information. Conclusion: The findings of this study demonstrated that women have less opportunity to make a decision on having episiotomy during labor and received less information about this procedure. Therefore, health care providers should be clearly discussed about risks and benefits of episiotomy before performing the procedure. The factors influencing patient involvement in decision making should be investigated to promote good experiences of women during delivery and increase satisfaction toward their care.


Introduction
Patient involvement in decision making regarding the treatment options is a concept that has increased widespread in recent years. Previous research studies found that giving patient an opportunity to participate in decision making regarding treatment choices could increase the satisfaction toward their care [6,8,9] as well as increase the quality of care [16]. However, patient involvement in decision making has not always been implemented in clinical practice [15,18]. In maternity field, many research studies demonstrated that most of health care providers have been providing unnecessary birth interventions in low risk pregnant women without their involvement in decision making [7,25]. Finally, the women have to accept all negative or positive health outcomes following the birth interventions; episiotomy, for instant [23].
Episiotomy is the birth interventions that commonly performed to enlarge the perineum during delivery which, may be justified for specific maternal or fetal indications such as poor maternal effort, forceps extraction or fetal distress, however, the routine use of this procedure is being questioned [3,21]. The World Health Organization (WHO) has recommendation to restrict the use of episiotomy procedure in low risk pregnancy, nevertheless, this procedure has remained constant in all countries around the world [5,11] in particular developing countries [3,5,21].
The reason for performing episiotomy might be influenced by individual practice patterns [21] or attitudes of the health providers [1,10,14]. On the other hand, it is possible that women's lack of involvement in decision making about the treatment choices [19,22]. A descriptive cross-sectional study conducted by Oweis to explore the women's perception regarding childbirth experience in term of induction and episiotomy procedures, t h e results revealed that most of women were not satisfied with care that they received during labour. They reported that they had less involvement in decision making about their care [18].
Many research studies found that sharing information about risks and benefits of birth intervention by healthcare providers and giving patients to involve in decision making about treatment choices could increase satisfaction and good health outcomes [20,26]. In Thailand, there is limited research study regarding the women's involvement in decision making on their care during intrapartum period. Therefore, this research was aim to investigate the involvement of women in decision making on episiotomy procedure during labor.

Methodology
A descriptive quantitative approach was conducted using self-administered survey questionnaires with postpartum women in two government hospitals, Bangkok, Thailand. Eligible women included those who have reached 37 to 42 weeks of gestation, experienced vaginal birth, have a live baby, and admitted in the postpartum units. After delivered for two days, all postpartum women who have no complications after delivery would ask to participate in the study because at this time they would be feeling well enough to answer the questionnaire. An appropriate sample size was assigned based on a 95 percent confidence level. A sample size was drawn from two hospitals based on a binomial probability distribution. There were 400 postpartum women participated in this study. Anonymous patient's data were analyzed using frequencies and percentages.
Ethical Considerations Ethics approvals were obtained from the hospital settings prior to conduct the research.
Participant information sheet and informed consent were distributed to the participants to read and signed before participating in research study. It was clearly stated that participation in the study was voluntary; they could refuse to participate and free to withdraw from the research at any time. Their refusal or withdrawal to participate would not affect any treatment in any way.
Participants were informed their responses would be kept confidential; no individual to be identified in the study, and only grouped data would be analyzed and presented. Table 1 presents demographic characteristics of women who participated in the study. Most participants were 20 to 29 years old. There were two hundred and eight women (52%) completed high school education, 95 women (23.8%) had primary school level, 58 (14.5%) and 39 (9.8%) of all graduated diploma and higher than bachelor degree, respectively. The majority of the women in the study were married (94.5%), only 5% versus 0.5% were separated, widowed or divorced, respectively. Most of the women were attended general antenatal care (83%), and 6% were did not receiving antenatal care during their pregnancy period. The study found that there were three hundred and twenty women (80%) experienced episiotomy.  Table 2 demonstrates the person who involved in decision making on episiotomy procedure. The study found that two hundred ninety five women (73.8%) reported the decision making on episiotomy procedure was made by health care providers. There were ninety two women (23%) had a chance to make decision on having episiotomy. Only thirteen women (3.2%) reported the decision making was made by husband and relatives.  Table 3 presents the information sharing between health care providers and the women on the topic of risks and benefit of episiotomy procedure. The finding pointed out that three hundred and five women (76.2%) did not receive information.

Discussion
The findings of this study demonstrated that the rate of episiotomy still high in clinical practice in the government hospitals in Thailand. Similar to the studied of Trinh and team found that the rate of episiotomy in Vietnamese women was 29.9% compared with 15.1% in Australia [27]. It clearly seen that decision making from this study has been done by health care providers as same as others health care settings [14,20]. Although previous study found that the effective of decision making during intrapartum period involved both health care providers and patients [17], however, some patients lacked of a chance to make decision to receive or refuse the intervention during intrapartum period [4]. Therefore, providing an opportunity for the patients to share their needs would be increased satisfaction.
Health care providers are the key person to encourage the patients to share about health problems and give them information regarding the risks and benefits of the treatment options. In doing this, the patients can gain more understanding about treatment choices and able to involve in decision making toward their care [25]. Previous research studies have focused that effective communication between health care providers and patients could increase better health outcomes as well as satisfaction [12,23]. During intrapartum period, the information regarding risks and benefits of birth interventions need to be clearly discussed with the women because it can help them to gain more understanding and having a chance to involve in decision making about their care [25]. However, in the real practice, most of the women lacked of an opportunity to know about the advantages and disadvantages of birth intervention that they received [20]. Surprisingly, some of health care providers have been performing unnecessary birth interventions because they afraid of involvement in adverse patient's health outcomes [14].

Conclusion and Recommendation
The women have less opportunity to receive information on the risks and benefits of episiotomy. Patient involvement in decision making regarding episiotomy procedure appeared low in clinical practice. Therefore, health care providers should provide adequate information for patients regard to the risks and benefits of each intervention and encourage them to involve in decision making toward their care. Patient involvement in decision making about treatment options in particular episiotomy procedure should be implemented in clinical practice to promote patient satisfaction and good health outcomes. On the other hand, patients should speak out and sharing their health problems with health care providers. In doing this, it can helps to increase satisfaction both health care providers and patients.