To the Editors:

We carefully read the work by Sagi-Dain et al. [1], a randomized clinical trial (RCT) asking whether it is time to abandon episiotomy. We congratulate the authors for choosing this theme, we have followed EPITRIAL since the publication of its interim analysis [2]. Routine episiotomy should not be performed, but whether any episiotomy is needed is questioned by the current literature [3]. However, we would like to question some points. First, when the interim analysis was published and the final sample size was estimated in 6,006 pregnant women, the authors stated that a multicenter study would be carried out [2]. In the present study, only one hospital randomized 692 participants. It was not clear why the plan for a multicenter study was abandoned and the study stopped. This may explain why the rate of severe perineal lacerations was not statistically significant. This undermines the final analysis, which concludes that “reduced episiotomy rates were not associated with higher rates of severe perineal tears.” It is curious that within the interventionist paradigm, the statement is formulated in this sense. The systematic review comparing selective episiotomy versus non-episiotomy for severe perineal trauma had a similar conclusion, i.e., that “no RCT was able to confirm the benefit of non-performance of episiotomies in the non-episiotomy arm” [4]. The “reversal of the burden of proof” for the physiological is typically characterized. Second, although episiotomy rates are statistically different in the two groups (19.6% versus 29.8%), these rates were very high in the “non-episiotomy” group and cannot be accepted as a practice of not performing an episiotomy. In our study [5], we did not find any differences between the two groups, but this was because the study was conducted at a time when the use of episiotomy had already been greatly reduced in our hospital; thus, we found only 1.7% in each group. A rate of 20% episiotomies deserves reflection, and every effort must be made to reduce this rate to close to zero, which is our current clinical practice. There is no sense in carrying out episiotomy with the indication of “fetal distress.” Although it has become a scientific convention to recommend that “new RCTs including a larger number of participants have to be carried out,” it is time to stop investigations by mutilating women’s perineums. Thus, the question in the title of this interesting article could very easily be removed, as it is definitely time to abandon episiotomy use.