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Trends and determinants of the use of episiotomy in a prospective population-based registry from central India

BMC Pregnancy and Childbirth volume 24, Article number: 598 (2024) Cite this article

Abstract

Background

Findings from research and recommendations from the World Health Organization favor restrictive use of episiotomy, but whether this guidance is being followed in India, and factors associated with its use, are not known. This study sought to document trends in use of episiotomy over a five-year period (2014–2018); to examine its relationship to maternal, pregnancy, and health-system characteristics; and to investigate its association with other obstetric interventions.

Methods

We conducted a secondary analysis of data collected by the Maternal Newborn Health Registry, a prospective population-based pregnancy registry established in Central India (Nagpur, Eastern Maharashtra). We examined type of birth and use of episiotomy in vaginal deliveries from 2014 to 2018, as well as maternal and birth characteristics, health systems factors, and concurrent obstetric interventions associations with its use with multivariable Poisson regression models.

Results

During the five-year interval, the rate of episiotomy in vaginal birth rose from 13 to 31% despite a decline in assisted vaginal birth. Associations with episiotomy were found for the following factors: prior birth, multiple gestations, seven or more years of maternal education, higher gestational age, higher birthweight, delivery by an obstetrician (as compared to midwife or general physician), and birth in hospital (as compared to clinic or health center). After adjusting for these factors, year over year rise in episiotomy was significant with an adjusted incidence rate ratio (AIRR) of 1.10 [95% confidence interval (CI) 1.08–1.12; p = 0.002]. We found an association between episiotomy and several other obstetric interventions, with the strongest relationship for maternal treatment with antibiotics (AIRR 4.23, 95% CI 3.12–5.73; p = 0.001).

Conclusions

Episiotomy in this population-based sample from central India steadily rose from 2014 to 2018. This increase over time was observed even after adjusting for patient characteristics, obstetric risk factors, and health system features, such as specialty of the birthing provider. Our findings have important implications for maternal-child health and respectful maternity care given that most women prefer to avoid episiotomy; they also highlight a potential target for antibiotic stewardship as part of global efforts to combat antimicrobial resistance.

Trial Registration

The study was registered at ClinicalTrials.gov under reference number NCT01073475.

Plain English summary

Episiotomy is a surgical procedure to widen the vaginal opening for childbirth. It was once commonly used worldwide. However, because the procedure can cause pain to mothers and place them at risk for infections and serious tears to the vagina—especially when the cut is directly downward—research suggests it should be used sparingly. As such, it is now less often practiced in high-income countries, but whether the same is true in India is not known. To answer this question, we used a large population-based pregnancy registry, the Maternal Newborn Health Registry, from Central India (Nagpur) to assess the frequency of episiotomy use between 2014 and 2018 and if there were certain maternal characteristics, features of the health care system, and other pregnancy interventions that were related with its use. Over this five-year period, the use of episiotomy during vaginal birth rose more than two-fold. It was more often used on women who had never delivered a baby before, were further along in pregnancy, had higher levels of education, had heavier babies, or were carrying more than one baby. Obstetricians were more likely to perform episiotomy than midwives or general physicians and it was more likely to be performed in hospitals than in clinics or primary health centers. This rise during the five-year interval was significant even when accounting for these patient and provider characteristics, suggesting a shift in medical practice. Because this was an observational study more research is needed to determine if the associations we found are causal.

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Background

Episiotomy—the surgical incision of the perineum to enlarge the vaginal outlet at the time of fetal delivery—was once the most common surgical procedure in obstetrics. In 1979, two-thirds of all vaginal deliveries in the United States involved an episiotomy [1, 2]. The theoretical benefits—including prevention of severe perineal injury, faster second stage of labor, and prevention of shoulder dystocia—also led to its routine use in low- and middle-income countries (LMICs) where obstructed labor is a major cause of morbidity and mortality [3,4,5,6]. A large study conducted in the mid-1990s in 13 Latin American countries found a median rate of episiotomy in nulliparous women ranging from 69.2% in Mexico to 96.2% in Ecuador [5, 7]. Similarly, a 2003 study from the Global Network for Women and Children’s Research found that rates among nulliparous women neared 100% in many countries, including India [8].

Despite the theoretical benefits of episiotomy, its true clinical impact remains unclear. There are well documented risks associated with its use, including excessive blood loss, wound dehiscence, infection, short- and long-term perineal pain, and increased risk of severe lacerations in future deliveries [9,10,11,12,13]. Some studies have also found a higher risk of dyspareunia and long-term symptoms related to pelvic floor dysfunction [14]. A Cochrane systematic review on the topic concluded that restrictive use of episiotomy leads to better clinical outcomes—including a decreased incidence of severe (third- and fourth-degree) lacerations—as compared to routine use [6]. In 2018, the World Health Organization (WHO) recommended against its routine/liberal use [15]. While the American College of Obstetrics and Gynecology (ACOG) recognizes its utility in assisted vaginal birth (vacuum or forceps delivery), their guideline states that “current data and clinical opinion suggest that there are insufficient objective evidence-based criteria to recommend episiotomy.” [16].

In response to this evidence and the recommendations from professional societies, the rate of episiotomy has significantly declined in most high-income countries [5, 17, 18]. Less well documented is the recent trend and clinical associations of its use in LMICs. The vast majority of studies identified by a 2019 systematic review and more recent publications—including from India, which accounts for approximately one-fifth of births worldwide—represent data from a single hospital [19,20,21,22,23,24,25]. Understanding representative trends in episiotomy use globally is important given mounting evidence that most women prefer to avoid the procedure; its use without full patient consent is a common example of disrespectful and abusive maternity care that can deter women from seeking facility-based birth, a key strategy to reducing maternal mortality [26, 27].

The Maternal Newborn Health Registry (MNHR) is a large ongoing prospective population-based pregnancy cohort founded to address gaps in global health research [28]. We used data from the Nagpur (Central India) MNHR site to better understand the pattern of episiotomy use. Our goals were to document trends in use of episiotomy over a five-year period (2014–2018) both overall and as a proportion of vaginal deliveries; to examine its relationship to maternal, pregnancy, and health-system characteristics; and to investigate its association with other obstetric interventions.

Methods

Overall study population, setting, and participants

Nagpur is one of eight sites included in the Global Network for Women and Children’s Research funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD). The Global Network’s goal is to conduct research to improve maternal and newborn outcomes in low-resource settings [3, 28, 29]. The MNHR enrolls women as early in pregnancy as possible and collects data on pregnancy outcomes, regardless of birth location, through six weeks (42 days) postpartum. We used observational data of pregnant women and their babies enrolled in the MNHR from 20 geographic clusters served by a central clinic, known as primary health centers (PHCs), located in rural and semi-urban areas of eastern Maharashtra near Nagpur, India. Within each PHC catchment area are multiple smaller clinics where basic maternal and childcare are provided who refer to secondary and tertiary hospitals in both the public and private sector. Each PHC registers 300–500 births yearly with follow-up rates of over 99% for pregnant women and their babies.

Full description of MNHR methodology has been previously published [28]. Briefly, MNHR data is derived from two sources: mothers are interviewed by trained auxiliary nurse midwives using standardized data collection forms and medical officers at the PHCs abstract clinical data from hospital and clinic records, such as facility discharge summaries. Information is gathered on maternal characteristics, including age, parity, educational attainment, and BMI (in kg/m2 taken at the first antenatal visit). Data collection tools also query key pregnancy and birth details, including type of birth (assisted vaginal birth; does not distinguish between forceps and vacuum), use of episiotomy, neonatal birth weight, birth location (hospital versus clinic, including PHCs), type of delivery provider, and gestational age (calculated based on last menstrual period or, when available, from the earliest ultrasound) at birth. For provider type, deliveries in India may be attended by obstetricians, other physicians without specialty training (generalists), or professional midwives (who practice with variable levels of autonomy) [30]. Lastly, data are collected on birthing complications, including postpartum hemorrhage and a combined outcome of obstructed labor, prolonged labor, and failure to progress (henceforth known as obstructed labor) and other medical interventions including maternal treatment with uterotonics (most commonly misoprostol and oxytocin), antibiotics, and blood transfusion—as documented in the medical record [31]. Data from the registry case report forms were entered into a secure electronic database by trained research assistants and verified for accuracy. For more details on the MNHR methodology, definitions, and quality assurance please see prior publications [28].

Approval by Institutional Review Boards/Ethics Committees was obtained prior to initiation of the MNHR, which is registered in ClinicalTrials.gov (NCT01073475). Individual informed consent is also solicited from each study participant. A Data Monitoring Committee appointed by the NICHD oversees the study and reviews it annually.

Inclusion/exclusion criteria

The enrollment diagram for the study is provided in Fig. 1. For this secondary analysis aimed at understanding the use of episiotomy, we limited our sample to women who underwent a facility-based birth with a skilled provider. Exclusion criteria included no documented consent, spontaneous abortion or medical termination of pregnancy, home or unskilled birth, and missing data for the primary outcome of episiotomy. After an examination of trends in mode of birth over the study timeframe in this sample, the remainder of the analysis considered only vaginal deliveries.

Fig. 1
figure 1

Enrollment diagram. The study reflects data from the Maternal Newborn Health Registry in Nagpur, India from 2014–2018

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Statistical analysis

We computed summary statistics (e.g., proportions) for mode of birth and use of episiotomy by study year among all births and among the subset of vaginal deliveries. Significance in trends over time were examined using the Cochrane-Armitage test. We obtained unadjusted incidence rate ratios (IRR) and adjusted IRRs (AIRR) with 95% confidence intervals (CIs) from Poisson regression models to assess the relationship of the maternal and pregnancy characteristics with episiotomy using generalized estimating equations to account for clustering of women within PHCs (Table 1). We excluded 16 cases with extreme values for BMI indicative of data error from this analysis. We built two adjusted models. The first (Fig. 2) included maternal, neonatal, and health system characteristics found to be associated with episiotomy in the prior research. Most variables were considered as categorical, except for year of birth which was considered continuous. For example, maternal age was dichotomized as < 25 or ≥ 25 years and gestational age was classified as < 37 weeks, 37–38 weeks, 39–41 weeks, and ≥ 42 weeks. [32]The second model (Table 2) examined associations between labor complications and concurrent maternal interventions queried by the MNHR and episiotomy and was adjusted for those variables found to be significant in the first model. We used Benjamini-Hochberg (BH) procedure to control for the false discovery rate. Statistical significance was set at a two-sided p-value of < 0.05. All analyses were conducted using Stata (StataCorp 2018 release 14.2, College Station, Texas, USA).

Table 1 Maternal, pregnancy, and newborn characteristics and association with use of episiotomy. Data presented represent women who underwent skilled facility-based vaginal delivery from 2014–2018 and excludes participants with missing data for the primary outcome of episiotomy. Poisson regression models were used to account for clustering by primary health center
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Fig. 2
figure 2

Trends in mode of delivery and episiotomy use in a population-based cohort from Central India. Data shown here represent births from the population-based Maternal Newborn Health Registry from Nagpur, India from 2014–2018 by (a) mode of delivery (b) use of episiotomy among all births and the subset of vaginal births and (c) overall use of episiotomy and by parity from 2014–2018. This analysis is limited to facility-based births attended by a skilled provider and excludes women who did not provide informed consent, spontaneous abortions and medically terminated pregnancies, and those missing the primary outcomes of episiotomy

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Table 2 Association of complications and other interventions peri-birth with Use of Episiotomy. Results of analysis including Poisson regression models of all facility-based skilled vaginal deliveries from the 2014–2018 Maternal Newborn Health Registry conducted in Nagpur, India
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Results

Of the 43,359 women screened for participation in the MNHR from 2014 to 2018, 91.8% (n = 39,789) met our inclusion criteria (Fig. 1). During the study period from 2014 to 2018, the proportion of births by Cesarean birth rose from 23.8 to 37.3% with a concordant decrease in spontaneous (73.0–63%) and assisted (3.2–0.2%) vaginal birth (Fig. 3; p < 0.001 for all trends). While the overall incidence of episiotomy in live births increased 9% (from 10 to 19%) during the five-year study period, as a proportion of vaginal deliveries the frequency of episiotomy rose 2.3-fold from 13 to 31% (Fig. 2b; p < 0.001 for all trends). Episiotomy was more commonly used on primiparous women as compared to multiparous across all years of the study, though a similar symmetric rise by year was observed in both groups (Fig. 2c; p < 0.001 for all trends).

Fig. 3
figure 3

Adjusted regression model of relationship between episiotomy and maternal, pregnancy, and health system characteristics. Forest plot of adjusted incident rate ratios for Poisson regression model. Overall p-values were generated for each variable; the Benjamini-Hochburg method for multiple comparisons was used to determine significance using a two-sided p < 0.05. Adjusted model adjusts for year of birth, maternal age (< 25 years vs. ≥ 25 years), maternal parity (primiparous vs. multiparous), use of assisted vaginal birth, multiple gestations, gestational age (< 37 weeks, 37–38 weeks, 39–41 weeks, ≥ 42 weeks), maternal education (no schooling, 1–6 years, 7–12 years, or > 12 years), maternal body weight index (underweight, healthy weight, overweight, obese), birthweight (extremely low birth weight, very low birth weight, low birth weight, normal birth weight, macrosomia), type of birth provider (obstetrician, non-obstetrician physician, and midwife), and birth location (hospital or clinic/PHC)

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Among the 27,614 women who had a vaginal birth, a total of 6,862 (24.8%) underwent episiotomy (Fig. 1). The distribution of characteristics of women who delivered vaginally with and without episiotomy are shown in Table 1. Most mothers included in our sample had 7–12 years of formal education, a mean age of 23.9 years (standard deviation 0.018), and had a low BMI (mean BMI 19.4, standard deviation 2.84). In both sub-groups most births were singleton deliveries (99.3%) at 37 weeks or more (89.8%) with a low prevalence of neonates weighting over 4,000 g (0.14%).

The results of the unadjusted regression models examining maternal and pregnancy characteristics are shown in in Table 1 and the results of the adjusted model in the Forest plot displayed in Fig. 2. In the multivariable model, episiotomy was significantly more likely in women with multiple gestations (AIRR 1.74, 95% CI 1.38–2.21), higher levels of education (7–12 years AIRR 1.23, 95% CI 1.09–1.38); > 12 years AIRR 1.28, 95% CI 1.13–1.46), births between 37 and 41 weeks (37–38 weeks AIRR 1.10, 95% CI 1.02–1.20 and 39–41 weeks AIRR 1.20, 95% CI 1.10–1.30, respectively), and larger neonates (normal birth weight AIRR 5.03 95% CI 2.74–9.23 and macrosomia AIRR 6.63 95% CI 3.10–14.16). Primiparous women were more likely to undergo episiotomy compared to multiparous (AIRR 1.36 95% CI 1.27–1.45), while the risk was lower for the minority of women who underwent assisted vaginal birth (AIRR 0.0.78, 95% CI 0.62–0.97).

With regards to health system factors, women who gave birth in hospitals were significantly more likely to receive an episiotomy than those who delivered in clinics and PHCs (AIRR 1.22, 95% CI 1.15–1.30). Furthermore, women were 23% less likely to undergo this intervention if delivered by a general physician (AIRR 0.76, 95% CI 0.71–0.82) and 18% less likely if delivered by a nurse midwife (AIRR 0.82, 95% CI 0.77–0.88) as compared to those delivered by an obstetrician. The relative risk of episiotomy increased over the study timeframe even when adjusting for other variables (birth year AIRR 1.10, 95% CI 1.08–1.13). The findings of the adjusted analysis are summarized in the Forest plot (Fig. 2).

There was a significant relationship between episiotomy and obstructed labor in both the unadjusted and adjusted analyses (IRR 1.58 95% CI 1.34–1.86 and AIRR 1.29 95% CI 1.12–1.48, respectively). There was a statistically significant association between episiotomy and receipt of antibiotics (AIRR 4.23, 95% CI 3.12–5.73), uterotonics (AIRR 1.60, 95% CI 1.43–1.79), and blood transfusion (AIRR 1.61, 95% CI 1.32–1.95) as compared to women who did not receive antibiotics, uterotonics, and blood transfusion, respectively (Table 2).

We found no significant relationship between obstructed labor, birth location, or delivery provider and year of birth in both unadjusted models and those adjusted for episiotomy.

Discussion

In this analysis of facility-based births from a prospective population-based pregnancy registry in Central India based on 20 catchment areas (PHCs) we found that the use of episiotomy in vaginal birth more than doubled, from 13 to 31%, between 2014 and 2018. While the average episiotomy rate of 24.9% over this five-year interval is lower as compared to the estimated incidence of 45% in India from a 2003 study, it represents a rapid rise and is notably higher than the 10% threshold that the WHO stated is “a good goal to pursue.” [8, 17, 18, 33] However, the true ideal rate of episiotomy remains unknown and may be even lower [34].

One important strength of our study is that MNHR data reflects deliveries in both public and private hospitals and clinics across urban and rural areas. As such, it provides a reliable picture of episiotomy incidence as compared to estimates derived from a single type of health facility, which can provide biased estimates if extrapolated to the population level. For example, a recent study from 18 academic hospitals in India’s capital New Delhi found that episiotomy was used in 63.4% of vaginal deliveries, much higher than the average from MNHR data published here [21].

Similar to prior research, we found that primiparous mothers, regardless of age, were at higher risk for episiotomy [19, 35]. Other significant maternal or pregnancy characteristics in the adjusted analysis included higher gestational age, multiple gestations, and higher fetal weight. Interestingly, while assisted vaginal birth is a more accepted indication for episiotomy—to facilitate placement of a vacuum or forceps—we found it was less likely to be used in these births though the p-value did not meet the pre-specified cut-off [13, 36,37,38]. The overall low rates of assisted vaginal delivery point to an opportunity to improve provider training in a technique that can prevent cesarean delivery. We also found an association between episiotomy and obstructed/prolonged labor even when adjusting for use of assisted vaginal birth and maternal characteristics, which could indicate its use as an intervention for obstructed/prolonged labor. While episiotomy has been shown to improve outcomes for obstructed/prolonged labor in women with female genital mutilation, this cultural practice is not common in the population we studied [39].

Because evidence strongly favors restrictive use of episiotomy, the fact that we found a year over year rise in episiotomy even when adjusting for patient characteristics is concerning. [6] Prior research has shown that provider type was the strongest predictor of episiotomy use in first vaginal birth, more so than patient demographic and obstetric factors [35]. Our study found that provider type (physician versus midwife), physician specialty (obstetrician versus generalist), and facility type were associated with episiotomy use. However, the annual rise in episiotomy rate was still significant when adjusting for these health system features. From this we hypothesize that the most likely explanation is a shift in practice toward a more interventionalist approach to maternity care, which is supported by the concurrent rise in cesarean birth over the same timeframe. As this theory cannot be confirmed based on our data, further research is needed including qualitative exploration of this phenomenon. Our data show that in 2018 over one-third of all births were surgical, a trend that is seen across most LMICs [32, 40, 41]. The WHO has recently highlighted the global rise in cesarean birth without medical indication and the need for effective interventions to address the overmedicalization of childbirth and the resulting iatrogenic harm [42,43,44]. Parallel efforts to reduce the overuse of episiotomy are likely needed, including testing which strategies are most effective at changing provider behavior.

Prior research has identified a number of maternal risks of episiotomy, such as obstetric anal sphincter injury [9, 12, 13]. We found that women who underwent episiotomy were over four times more likely to be exposed to antibiotics. While antibiotics may be indicated for third or fourth-degree lacerations, universal prophylaxis for all episiotomies is not recommended [16, 45]. Potential risks of antibiotic exposure include Clostridium difficile infection, development of multi-drug resistant organisms, and serious allergic reaction [16, 45,46,47,48]. Given the important clinical implications of global emerging antibiotic resistance, this association merits further investigation to establish a causal link and to understand provider reasoning (given the lack of evidence to support this practice) such that appropriate mitigation efforts can be put in place [49,50,51]. We also found an association between episiotomy and maternal blood transfusion—plausibly a direct effect of increased bleeding from the incision—similar to findings from other LMICs [6]. Prior research has documented high rates of prenatal anemia among women in Nagpur, India, which may explain the need for blood transfusion despite a low incidence of postpartum hemorrhage in our sample [32].

It is important to note the limitations of our analysis. First, we were unable to distinguish whether the episiotomy performed was midline or mediolateral and lacked data on severity of perineal tears. As evidence suggest the mediolateral episiotomy is associated with fewer complications, our analysis would be more robust if this information was available in the MNHR database [52]. Second, the indication for episiotomy is not recorded in the MNHR, which limits our ability to comment on specific clinical rationale for its use. Third, given the large size and diversity of India we cannot extrapolate these findings to the country as a whole. Fourth, our data did not include provider gender which has been shown to significantly influence use of episiotomy [53]. Fifth, given the cross-sectional nature of the data we can only comment on the association between episiotomy and patient characteristics, health systems features, and other medical treatments, thus additional research is critical to establish causal links and further elucidate drivers. Examining neonatal outcomes when episiotomy is used could also help to clarify the full risk-benefit equation of this intervention.

Conclusions

Despite increasing pressure by professional societies to abandon routine use of episiotomy in vaginal birth, we found that its use is becoming more popular in Nagpur, Central India. This rise could not be explained by shifts in patient demographics, obstetric risk factors, or features of the health care system known to influence its use. The increasing popularity of episiotomy without definitive medical benefit has important clinical consequences, as well as implications for patient-centered respectful maternity care. Future research should focus on strategies to de-implement episiotomy, which have the potential to reveal effective approaches to addressing other examples of the overmedicalization of childbirth such as the concurrent rise in cesarean birth.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

ACOG:

American College of Obstetrics and Gynecology

AIRR:

Adjusted incidence rate ratio

BH:

Benjamini-Hochberg

CI:

Confidence interval

IRB:

Institutional review board

IRR:

Incidence rate ratio

LMICs:

Low- and middle-income countries

MNHR:

Maternal Newborn Health Registry

NICHD:

National Institute of Child Health and Human Development

PHC:

Primary health center

WHO:

World Health Organization

References

  1. Frankman EA, Wang L, Bunker CH, Lowder JL. Episiotomy in the United States: has anything changed? Am J Obstet Gynecol. 2009;200(5):573. e1-573.e7.

    Article  Google Scholar 

  2. Thacker SB, Banta HD. Benefits and risks of episiotomy: an interpretative review of the English language literature, 1860–1980. Vol. 38, Obstetrical & gynecological survey. Baltimore:; 1983. pp. 322–38.

  3. Harrison MS, Ali S, Pasha O, Saleem S, Althabe F, Berrueta M, et al. A prospective population-based study of maternal, fetal, and neonatal outcomes in the setting of prolonged labor, obstructed labor and failure to progress in low- and middle-income countries. Reprod Health. 2015;12(Suppl 2):S9.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Berkowitz L, Foust-Wright C, UpToDate. Waltham MA, Editors CJ, Lockwood K, Eckler, editors. ; 2020 [cited 2021 Oct 12]. Approach to episiotomy. https://www.uptodate.com/contents/approach-to-episiotomy?search=episiotomy&source=search_result&selectedTitle=1~62&usage_type=default&display_rank=1#references

  5. Graham ID, Carroli G, Davies C, Medves JM. Episiotomy rates around the world: an update. Birth. 2005;32(3):219–23.

    Article  PubMed  Google Scholar 

  6. Jiang H, Qian X, Carroli G, Garner P. Selective versus routine use of episiotomy for vaginal birth. Cochrane Database Syst Reviews. 2017;2017:2.

    Google Scholar 

  7. Althabe F, Belizán JM, Bergel E. Episiotomy rates in primiparous women in Latin America: Hospital based descriptive study. Br Med J. 2002;324(7343):945–6.

    Article  Google Scholar 

  8. Kropp N, Hartwell T, Althabe F. Episiotomy rates from eleven developing countries. Int J Gynecol Obstet. 2005;91(2):157–9.

    Article  CAS  Google Scholar 

  9. Shmueli A, Gabbay Benziv R, Hiersch L, Ashwal E, Aviram R, Yogev Y, et al. Episiotomy–risk factors and outcomes. J Maternal-Fetal Neonatal Med. 2017;30(3):251–6.

    Article  Google Scholar 

  10. Pergialiotis V, Vlachos D, Protopapas A, Pappa K, Vlachos G. Risk factors for severe perineal lacerations during childbirth. Int J Gynecol Obstet. 2014;125(1):6–14.

    Article  Google Scholar 

  11. Frigerio M, Mastrolia SA, Spelzini F, Manodoro S, Yohay D, Weintraub AY. Long-term effects of episiotomy on urinary incontinence and pelvic organ prolapse: a systematic review. Arch Gynecol Obstet. 2019;299(2):317–25.

    Article  PubMed  Google Scholar 

  12. Lacross A, Groff M, Smaldone A. Obstetric anal sphincter injury and anal incontinence following vaginal birth: a systematic review and meta-analysis. J Midwifery Womens Health. 2015;60(1):37–47.

    Article  PubMed  Google Scholar 

  13. Frenette P, Crawford S, Schulz J, Ospina MB. Impact of Episiotomy during Operative Vaginal Delivery on Obstetrical Anal Sphincter injuries. J Obstet Gynecol Can. 2019;41(12):1734–41.

    Article  Google Scholar 

  14. Handa VL, Blomquist JL, McDermott KC, Friedman S, Muñoz A. Pelvic floor disorders after vaginal birth: Effect of episiotomy, perineal laceration, and operative birth. Obstet Gynecol. 2012;119(2):233–9.

    Article  PubMed  PubMed Central  Google Scholar 

  15. World Health Organization. WHO recommendation on Episiotomy Policy. WHO Reproductive Health Libr. 2018;February:1–10.

    Google Scholar 

  16. The American College of Obstetricians and Gynecologists. Prevention and Management of Obstetric lacerations at Vaginal Delivery. ACOG Pract Bull 198 Obstet Gynecol. 2018;132(3):e87–102.

    Google Scholar 

  17. Kozhimannil KB, Karaca-Mandic P, Blauer-Peterson CJ, Shah NT, Snowden JM. Uptake and utilization of practice guidelines in hospitals in the United States: the case of routine episiotomy. Jt Comm J Qual Patient Saf. 2017;43(1):41–8.

    PubMed  Google Scholar 

  18. Mandelbaum A, Rudasil S, Aguayo E, Chan E, Sanaiha Y, Cohen J, et al. National Trends in Utilization of Episiotomy and Factors Associated with high-utilization centers in the United States. J Womens Health Dev. 2021;04(03):82–94.

    Article  Google Scholar 

  19. Aguiar BM, da Silva TPR, Pereira SL, Sousa AMM, Guerra RB, de Souza KV, et al. Factors associated with the performance of episiotomy. Rev Bras Enferm. 2020;73(Suppl 4):e20190899.

    Article  PubMed  Google Scholar 

  20. Woretaw E, Teshome M, Alene M. Episiotomy practice and associated factors among mothers who gave birth at public health facilities in Metema district, northwest Ethiopia. Reprod Health. 2021;18(1):1–11.

    Article  Google Scholar 

  21. Singh S, Thakur T, Chandhiok N, Dhillon BS. Pattern of episiotomy use & its immediate complications among vaginal deliveries in 18 tertiary care hospitals in India. Indian J Med Res. 2016;143(April):474–80.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Obioha KC, Ugwu EO, Obi SN, Dim CC, Oguanuo TC. Prevalence and predictors of urinary/anal incontinence after vaginal delivery: prospective study of Nigerian women. Int Urogynecol J. 2015;26(9):1347–54.

    Article  PubMed  Google Scholar 

  23. Moghadam MF, Shamsi A, Moro FH. The prevalence of post-traumatic stress disorder among women with normal vaginal delivery in Zahedan city. Archives Psychiatry Psychother. 2015;17(1):15–9.

    Article  Google Scholar 

  24. Egbe TO, Omeichu A, Halle-Ekane GE, Tchente CN, Egbe EN, Oury JF. Prevalence and outcome of teenage hospital births at the buea health district, South West Region, Cameroon. Reprod Health. 2015;12(1):1–10.

    Article  Google Scholar 

  25. Worku SA, Mitku YMGSA. Episiotomy practice and its associated factor among women who gave birth at public health institutions of akaki kality in Addis Ababa, Ethiopia. Clin Mother Child Health. 2019;16(2):318.

    Google Scholar 

  26. Rosen HE, Lynam PF, Carr C, Reis V, Ricca J, Bazant ES, et al. Direct observation of respectful maternity care in five countries: a cross-sectional study of health facilities in East and Southern Africa. BMC Pregnancy Childbirth. 2015;15(1):306.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Bohren MA, Hunter EC, Munthe-Kaas HM, Souza JP, Vogel JP, Gülmezoglu AM. Facilitators and barriers to facility-based delivery in low- and middle-income countries: a qualitative evidence synthesis. Reprod Health. 2014;11(1):71.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Bose CL, Bauserman M, Goldenberg RL, Goudar SS, McClure EM, Pasha O et al. The Global Network Maternal Newborn Health Registry: a multi-national, community-based registry of pregnancy outcomes. Reprod Health [Internet]. 2015;12 Suppl 2(Suppl 2):S1. http://www.ncbi.nlm.nih.gov/pubmed/26063166

  29. Harrison M, Saleem S, Ali S, Pasha O, Chomba E, Carlo W, et al. A prospective, Population-based study of trends in Operative Vaginal Delivery compared to Cesarean Delivery Rates in Low- and Middle-Income Countries, 2010–2016. Am J Perinatol. 2018;1(212):2010–6.

    Google Scholar 

  30. Mayra K, Padmadas SS, Matthews Z. Challenges and needed reforms in midwifery and nursing regulatory systems in India: implications for education and practice. PLoS ONE. 2021;16(5 May).

  31. Harrison MS, Ali S, Pasha O, Saleem S, Althabe F, Berrueta M et al. A prospective population-based study of maternal, fetal, and neonatal outcomes in the setting of prolonged labor, obstructed labor and failure to progress in low- and middle-income countries. Reprod Health [Internet]. 2015;12 Suppl 2(Suppl 2):S9. /pmc/articles/PMC4464213/?report = abstract

  32. Patel A, Pusdekar YV, Prakash AA, Simmons E, Waikar M, Rao SR, et al. Trends and determinants of increasing caesarean sections from 2010 to 2013 in a prospective population-based registry in eastern rural Maharashtra, India. BMJ Open. 2019;9(8):e024654.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Guide P. Care in normal birth: a practical guide. Birth. 1997;24(2):121–3.

    Article  Google Scholar 

  34. Amorim MM, Coutinho IC, Melo I, Katz L. Selective episiotomy vs. implementation of a non-episiotomy protocol: a randomized clinical trial. Reprod Health. 2017;14(1):1–10.

    Google Scholar 

  35. Robinson JN, Norwitz ER, Cohen AP, Lieberman E. Predictors of episiotomy use at first spontaneous vaginal delivery. Obstet Gynecol. 2000;96(2):214–8.

    CAS  PubMed  Google Scholar 

  36. Royal College of Obstetricians. & Gynaecologists. Operative vaginal delivery. Green-top Guideline No.26. 2011.

  37. Dillon SJ, Nelson DB, Spong CY, McIntire DD. Forceps and episiotomy: do they go hand in hand or should they go their separate ways? Am J Obstet Gynecol MFM. 2021;3(4):100370.

    Article  PubMed  Google Scholar 

  38. De Leeuw JW, De Wit C, Kuijken JPJA, Bruinse HW. Mediolateral episiotomy reduces the risk for anal sphincter injury during operative vaginal delivery. BJOG. 2008;115(1):104–8.

    Article  PubMed  Google Scholar 

  39. Rodriguez MI, Seuc A, Say L, Hindin MJ. Episiotomy and obstetric outcomes among women living with type 3 female genital mutilation: a secondary analysis. Reprod Health. 2016;13(1):1–7.

    Article  Google Scholar 

  40. Harrison MS, Pasha O, Saleem S, Ali S, Chomba E, Carlo WA, et al. A prospective study of maternal, fetal and neonatal outcomes in the setting of cesarean section in low- and middle-income countries. Acta Obstet Gynecol Scand. 2017;96(4):410–20.

    Article  PubMed  Google Scholar 

  41. Betran AP, Ye J, Moller AB, Souza JP, Zhang J. Trends and projections of caesarean section rates: global and regional estimates. BMJ Glob Health. 2021;6(6):1–8.

    Article  Google Scholar 

  42. World Health Organization. Non-clinical interventions to reduce unneccessary caesarean sections. World Health Organisation. Geneva, Switzerland; 2018.

  43. Chen I, Opiyo N, Tavender E, Mortazhejri S, Rader T, Petkovic J et al. Non-clinical interventions for reducing unnecessary caesarean section. Cochrane Database Syst Reviews. 2018;2018(9).

  44. Betrán AP, Temmerman M, Kingdon C, Mohiddin A, Opiyo N, Torloni MR, et al. Interventions to reduce unnecessary caesarean sections in healthy women and babies. Lancet. 2018;392(10155):1358–68.

    Article  PubMed  Google Scholar 

  45. Berhan Y, Kirba S, Gebre A. Still No Substantial Evidence to Use Prophylactic Antibiotic at Operative Vaginal Delivery: Systematic Review and Meta-Analysis. Obstet Gynecol Int. 2020;2020.

  46. Brown KA, Khanafer N, Daneman N, Fisman DN. Meta-analysis of antibiotics and the risk of community-associated Clostridium difficile infection. Antimicrob Agents Chemother. 2013;57(5):2326–32.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  47. Tamma PD, Avdic E, Li DX, Dzintars K, Cosgrove SE. Association of adverse events with antibiotic use in hospitalized patients. JAMA Intern Med. 2017;177(9):1308–15.

    Article  PubMed  PubMed Central  Google Scholar 

  48. Llor C, Bjerrum L. Antimicrobial resistance: risk associated with antibiotic overuse and initiatives to reduce the problem. Ther Adv Drug Saf. 2014;5(6):229–41.

    Article  PubMed  PubMed Central  Google Scholar 

  49. Ahmad M, Khan AU. Global economic impact of antibiotic resistance: a review. J Glob Antimicrob Resist. 2019;19:313–6.

    Article  PubMed  Google Scholar 

  50. Murray CJ, Ikuta KS, Sharara F, Swetschinski L, Robles Aguilar G, Gray A, et al. Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. Lancet. 2022;399(10325):629–55.

    Article  CAS  Google Scholar 

  51. Laxminarayan R. The overlooked pandemic of antimicrobial resistance. Lancet. 2022;399(10325):606–7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  52. Sooklim R, Thinkhamrop J, Lumbiganon P, Prasertcharoensuk W, Pattamadilok J, Seekorn K, et al. The outcomes of midline versus medio-lateral episiotomy. Reprod Health. 2007;4:1–5.

    Article  Google Scholar 

  53. Yee LM, Miller ES. Association of obstetrician gender with obstetric interventions and outcomes. Obstet Gynecol. 2018;132(1):79–84.

    Article  PubMed  PubMed Central  Google Scholar 

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Acknowledgements

We would like to recognize the auxiliary nurse midwives who collect the MNHR data, the Registry Administrators at each PHC, and the women and families who contribute to the database. In addition, the MNHR would not be possible without the support of RTI International.

Funding

This project was funded by grants U01HD058322 and U01HD078439 from the Eunice Kennedy Shriver National Institute of Child Health and Human Development of the US National Institutes of Health.

Author information

Author notes

  1. Patricia L. Hibberd, Archana B. Patel Co-senior authors.

Authors and Affiliations

  1. Boston University Chobanian & Avedisian School of Medicine, 850 Albany Street Dowling 5th floor, Boston, MA, 02118, USA

    Kirsten E. Austad & Patricia L. Hibberd

  2. Boston University School of Public Health, Boston, MA, USA

    Sowmya R. Rao & Patricia L. Hibberd

  3. Datta Meghe Institute of Medical Sciences, Sawangi, India

    Archana B. Patel

  4. Lata Medical Research Foundation, Nagpur, India

    Archana B. Patel

  5. Evans Center for Implementation & Improvement Science (CIIS), Boston University, Boston, MA, USA

    Kirsten E. Austad

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  1. Kirsten E. Austad
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  2. Sowmya R. Rao
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  3. Patricia L. Hibberd
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  4. Archana B. Patel
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Contributions

KA, PH, and AP conceived of and designed the study. KA, SR, PH, and AP contributed to the statistical analysis plan. KA conducted the analysis and wrote the first draft of the manuscript, which was revised by SR, PH, and AP. All authors read, revised, and approved the final manuscript.

Corresponding author

Correspondence to Kirsten E. Austad.

Ethics declarations

Ethics approval and consent to participate

The MNHR study in Nagpur, India was reviewed and approved by the Lata Medical Research Foundation Institutional Review Board (FWA00012971) and the Partners Human Research Committee, Boston, MA. A Data Monitoring Committee appointed by NICHD reviews the MNH Registry data at least annually. The study was registered at ClinicalTrials.gov (NCT01073475). Research was conduct in concordance with the Declaration of Helsinki. Pregnant women intending to deliver in the study communities or affiliated hospitals were informed about the study and invited to participate in the MNHR if they consented and signed the IRB approved informed consent form.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

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Austad, K.E., Rao, S.R., Hibberd, P.L. et al. Trends and determinants of the use of episiotomy in a prospective population-based registry from central India. BMC Pregnancy Childbirth 24, 598 (2024). https://doi.org/10.1186/s12884-024-06762-y

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BMC Pregnancy and Childbirth

ISSN: 1471-2393

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