We read with interest the article by Frankman et al, who reported the significant decreases in episiotomy rates between 1979–2004 in the United States. Are pregnant women in the United States satisfied with the trends in episiotomy?

The same tendency may be observed in Japan. In our institution (approximately 1500 vaginal deliveries per year), for example, the rates of episiotomy with spontaneous and operative vaginal delivery were 70% and 96%, respectively, in 1988, and they were 29% ( P < .01 vs 1988 by χ ² test) and 94% (not significant), respectively, in 2008. One reason, which may be the same as in the United States, was that midline episiotomy and assisted vaginal delivery have been reported to be independent risk factors for severe perineal laceration after vaginal delivery in Japanese patients. The other reason may be maternal demands for the “humanization” of obstetric care in Japan. Although the incidence of perineal laceration that requires suturing after low-risk deliveries in our institution is more than 85%, delivery without episiotomy seems be associated with the increased odds of high maternal satisfaction. Although further studies may be needed to define the benefits and risks of episiotomy, we also recommend the policy in the article.