***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: OBJECTIVE : To compare the outcomes of the current practice of liberally or routinely employing episiotomy to prevent perineal tears and pelvic floor relaxation ( control group ) to a policy of restricting episiotomy use to specific fetal and maternal indications ( experimental group ) . DESIGN : A r and omized controlled trial ( RCT ) . SETTING : Three university hospitals in Montreal . SUBJECTS : Seven hundred three low-risk women enrolled at 30 to 34 weeks of gestation were r and omized late in labor to the design ated trial arm , by parity , and followed up to 3 months postpartum . MAIN OUTCOME MEASURES : Antepartum and postpartum information on perineal trauma and pain , pelvic floor symptoms ( urinary incontinence ) , and sexual activity was collected through the use of st and ard question naires ; pelvic floor function was measured by electromyographic ( EMG ) perineometry . RESULTS : Restricting episiotomy use in primiparous women was associated with similar sutured perineal trauma to the liberal or routine approach . Multiparous women in the restricted episiotomy group more often gave birth with an intact perineum ( 31 % compared with 19 % , odds ratio ( OR ) = 1.85 , 95 % confidence interval ( CI ) = 1.09 to 3.16 ) . All but one 3rd/4th-degree perineal tear was associated with median episiotomy ( 46 of 47 in primiparous women and 6 of 6 among multiparous women ) . No difference between trial groups was found in postpartum perineal pain , antepartum and 3-month postpartum EMG perineometry , and urinary and pelvic floor symptoms . CONCLUSIONS : We found no evidence that liberal or routine use of episiotomy prevents perineal trauma or pelvic floor relaxation . Virtually all severe perineal trauma was associated with median episiotomy . Restriction of episiotomy use among multiparous women result ed in significantly more intact perineums and less perineal suturing Episiotomy is a widely-done intervention in childbirth , regardless of poor scientific evidence of its benefits . This r and omised controlled trial compares selective with routine use of a mediolateral episiotomy for women having first and second deliveries in 8 public maternity units in Argentina . 2606 women participated ; 1555 were nulliparous ( 778 in the selective group and 777 in the routine group ) and 1051 primiparous ( 520 in the selective group and 531 in the routine group ) . The two interventions compared were selective ( limited to specified maternal or fetal indications ) , and routine episiotomy ( following the hospital 's previous policy ) . Episiotomy was done in 30.1 % of deliveries in the selective , and 82.6 % in the routine group . The main outcome measure was severe perineal trauma . Severe perineal trauma was uncommon in both groups but was slightly less frequent in the selective group ( 1.2 % vs 1.5 % ) . Anterior perineal trauma was more common in the selective group but posterior perineal surgical repair , perineal pain , healing complications , and dehiscence were all less frequent in the selective group . Routine  episiotomy should be ab and oned and episiotomy rates above 30 % can not be justified Women who had participated in a r and omised controlled trial of policies  of  restricted ( 10 % ) versus liberal ( 51 % ) episiotomy during spontaneous vaginal delivery were recontacted by postal question naire three years after delivery . Altogether 674 out of 1000 responded , and there was no evidence of a differential response rate between the two trial groups . Similar numbers of women in the two groups reported further deliveries , almost all of which had been vaginal and spontaneous . Fewer women allocated to restrictive use of episiotomy required perineal suturing after subsequent delivery , but this difference was not significant . Pain during sexual intercourse and incontinence of urine were equally reported in the two groups . The similarity in incontinence rates persisted when severity , type of incontinence , and subsequent deliveries were taken into account . Liberal use of episiotomy does not seem to prevent urinary incontinence or increase long term dyspareunia One thous and women were allocated at r and om to one of two perineal management policies , both intended to minimise trauma during spontaneous vaginal delivery . In one the aim was to restrict episiotomy to fetal indications ; in the other the operation was to be used more liberally to prevent perineal tears . The result ant episiotomy rates were 10 % and 51 % respectively . An intact perineum was more common among those allocated to the restrictive policy . This group experienced more perineal and labial tears , however , and included four of the five cases of severe trauma . There were no significant differences between the two groups either in neonatal state or in maternal pain and urinary symptoms 10 days and three months post partum . Women allocated to the restrictive policy were more likely to have resumed sexual intercourse within a month after delivery . These findings provide little support either for liberal use of episiotomy or for cl aims that reduced use of the operation decreases postpartum morbidity OBJECTIVE : To evaluate the effect of mediolateral episiotomy on puerperal pelvic floor strength and dysfunction ( urinary and anal incontinence , genital prolapse ) . METHODS : Five hundred nineteen primiparous women were enrolled 3 months after vaginal delivery . Puerperae were divided in 2 groups : group A ( 254 women ) comprised the women who received mediolateral episiotomy  and group B ( 265 women ) the women with intact perineum and first- and second-degree spontaneous perineal lacerations . Each woman was question ed about urogynecological symptoms and examined by digital test , vaginal perineometry , and uroflowmetric stop test score . Data were subjected to Student t test and Fisher exact test to assess , respectively , the difference between the mean values and the proportions within the sub population s. Using a simple logistic regression model to test an estimate of relative risk , we expressed the odds ratios of the variables considered with respect to the control population ( group B ) . RESULTS : No significant difference was found with regard to the incidence of urinary and anal incontinence and genital prolapse , whereas dyspareunia and perineal pain were significantly higher in the episiotomy group ( 7.9 % versus 3.4 % , P = .026 ; 6.7 % versus 2.3 % , P = .014 , respectively ) . Episiotomy was associated with significantly lower values , both in digital test ( 2.2 versus 2.6 ; P < .001 ) and in vaginal manometry ( 12.2 versus 13.8 cm water ; P < .001 ) , but not in uroflowmetric stop test . CONCLUSION : Mediolateral episiotomy does not protect against urinary and anal incontinence and genital prolapse and is associated with a lower pelvic floor muscle strength compared with spontaneous perineal lacerations and with more dyspareunia and perineal pain . LEVEL OF EVIDENCE : OBJECTIVE In 1999 , three r and omized controlled trials concluded that high-dose chemotherapy followed by autologous hematopoietic stem cell transplantation ( HDC/HCT ) is no better than conventional chemotherapy for women with breast cancer . This study documents the impact of the trials on use of HDC/HCT and describes how hospitals reacted to the trials . DATA SOURCE We used patient-level data on 15,847 HDC/HCTs reported to the Center for International Blood and Marrow Transplant Research between 1994 and 2005 . STUDY DESIGN We report trends in total HDC/HCT procedure volume , compare the time to hospitals ' exit from the HDC/HCT market between research and non research hospitals , and document trends in hospital-specific volumes in the 2 years before exit . PRINCIPAL FINDINGS HDC/HCT volume declined from 3,108 in 1998 to 1,363 the year after trial results were released . In 2002 , only 76 procedures were performed . Teaching hospitals and the hospitals that participated in the trials were no slower to discontinue the procedure compared with nonteaching , nonparticipating hospitals . At the hospital level , volume declined steadily in the months before ab and onment . CONCLUSION The results suggest that comparative effectiveness research studies that report negative results can reduce spending , but specialists may be reluctant to relinquish cutting-edge technologies 
    Output:
    
Mixed effects models estimated negative correlation between cross-time and cross-hospital variations in episiotomy rates , indicating reduced cross-hospital variation over time .
Conclusions Our results suggested that there has been a gradual decline in episiotomy rates over the period 2003–2008 , and that synthesis of evidence showing harms from routine episiotomy had limited impact on practice patterns in the case of episiotomy .