Texas Children’s Hospital in Houston is reporting continued success with a program that reduced the rate of episiotomies from 9.11% of births to 3.44%. The hospital used a five-step approach that focused on publicizing the rate of episiotomies and encouraging physicians to improve their individual rates. The hospital’s experience is an example of how some quality improvement efforts may take time to implement, but can produce long-lasting results.

Episiotomies have been targeted for reduction by the American College of Obstetricians and Gynecologists.1 In 2015, the Leapfrog Group set a target rate of 5% or lower for these procedures. A 2018 report by Castlight and Leapfrog on maternity care revealed the average rate of episiotomies at hospitals was 7.8% in 2017.2

“While routine episiotomies were common for many years — ostensibly to prevent tears during delivery — recent studies have found that more selective use of this procedure may result in 30% fewer women experiencing severe perineal/vaginal trauma — including tears, pelvic floor defects, and loss of bladder or bowel control,” the report authors wrote.2

Texas Children’s effort to reduce episiotomies started as far back as 2012 when its Pavilion for Women opened. Hospital leaders saw the opening of the pavilion as an opportunity to improve quality of care for women, with episiotomies a primary target for reform, says Manisha Gandhi, MD, maternal fetal medicine clinic chief. At that time, Leapfrog called for a episiotomy rate of 12% or lower. Texas Children’s was at 9%. Nonetheless, leaders wanted to cut the rate further.

“We knew we could tell people to stop doing episiotomies because there was an increased risk with episiotomies. We had to devise a way to do it so that physicians could feel they were reducing unnecessary episiotomies but still had the ability to do the procedure when necessary,” Gandhi says.

Data Gathered for Baseline

The hospital established guidelines for the use of episiotomies and began collecting monthly data on the procedure for benchmarking. Those rates were not made public or provided to physicians. In 2014, monthly rates were revealed at monthly staff meetings, and leaders encouraged fewer procedures. In 2015 and 2016, as data reporting continued in monthly meetings, leaders emphasized Leapfrog’s 5% target. In 2016 and 2017, the hospital began providing each physician with his or her individual episiotomy rate each month, with a comparison to the department rate.

“If a department was 7% and you were at 9%, the idea was that you should look at why you’re doing more of these and whether that’s justified,” Gandhi says. “If your individual rate is lower than the department rate, there could be a discussion about what you are doing differently and what others might learn from your experience.”

From 2017 and continuing today, Texas Children’s reports quarterly on the individual episiotomy rates of all physicians, allowing for peer-to-peer comparisons.

Hawthorne Effect in Play

Individual rates began to decline after clinicians saw how their rates compared to the department average. Gandhi says this is an example of the “Hawthorne effect,” in which subjects change their behavior for the better when they know they are under observation. The natural competitive spirit of physicians also plays a role.

“We all compare ourselves to each other. We all very much want to meet the standard of care. Providing individual data and comparing it to what your peers are doing can be very powerful,” Gandhi says. “It’s a nice complement to system changes when you have people committed to doing it as a group. You’re giving them information as individuals, but it really leads to a response as a group.”

The hospital’s cumulative episiotomy rate fell to 3.44% by November 2017. Today, that rate holds steady. Administrators continue issuing quarterly reports about episiotomies so peers may continue comparing their numbers. Gandhi argues this is necessary because, under the Hawthorne effect theory, subjects may revert to previous negative behavior if they believe no one is regularly watching them perform the new, desired method anymore.

(Editor’s Note: There has been much speculation about the integrity of the data and methodologies used in the experiment conducted in the 1920s and 1930s that led to the term “Hawthorne effect,” first coined in the 1950s. In the decades since, many investigators have suggested alternative theories and called for more research.3)

Data Collection, Analysis Team Required

The biggest challenge for a hospital interested in replicating this success could be the heavy demand for statistical analysis, according to Gandhi. Texas Children’s employs a strong team of data specialists.

“If a hospital has to do this on its own without a strong data infrastructure of a health system to back them up, I could see data collection and interpretation being the challenge,” Gandhi cautions.

The long-term success of the effort is at least partly attributable to how leaders moved deliberately, carrying out the improvement plan in multiple phases over several years.

“Any time you’re making big changes — and if there is no acute rush to change it immediately — you’ll see more success with an approach that gives people time to learn about the issue, understand the concerns, understand where the recommendations are coming from, and give people time to get to it,” Gandhi says. “We’re continuing with the reports because it is clear that if you’re getting feedback on your performance, you are more likely to change your practice and work to maintain an acceptable rate.”


  1. Committee on Practice Bulletins-Obstetrics. ACOG Practice Bulletin No. 198: Prevention and management of obstetric lacerations at vaginal delivery. Obstet Gynecol 2018;132:e87-e102.
  2. Castlight, The Leapfrog Group. Maternity care. Data by hospital on nationally reported metrics. 2018.
  3. McCambridge J, Witton J, Elbourne DR. Systematic review of the Hawthorne effect: New concepts are needed to study research participation effects. J Clin Epidemiol 2014;67:267-277.


  • Manisha Gandhi, MD, Maternal Fetal Medicine Clinic Chief, Texas Children’s Hospital, Houston. Phone: (832) 826-4636.