You will be presented with a collection of medical randomized controlled trial (RCT) reports addressing a shared clinical question -- for instance, the efficacy of a medical intervention on a disease or condition. Given the titles and abstracts of these reports, your task is to generate the conclusion of the systematic review article synthesizing the key findings. Your conclusion should be a few sentences long. In your response, include only the conclusion and no other text. The RCT reports are below.



Title 1:
[Does episiotomy prevent perineal trauma and pelvic floor relaxation?].
Abstract 1:
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


Title 2:
Routine vs selective episiotomy: a randomised controlled trial
Abstract 2:
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


Title 3:
West Berkshire perineal management trial: three year follow up.
Abstract 3:
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


Title 4:
West Berkshire perineal management trial.
Abstract 4:
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


Title 5:
The Effects of Mediolateral Episiotomy on Pelvic Floor Function After Vaginal Delivery
Abstract 5:
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 :


Title 6:
Abandonment of high-dose chemotherapy/hematopoietic cell transplants for breast cancer following negative trial results.
Abstract 6:
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
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 .