Experts involved in a major multinational study have warned that episiotomy, a common childbirth procedure traditionally used to prevent severe tearing during delivery, may inadvertently increase the risk of life-threatening bleeding in women with anaemia.
The research, based on data from more than 15,000 women across Nigeria, Pakistan, Tanzania and Zambia, found that women with moderate or severe anaemia who underwent an episiotomy were almost twice as likely to experience postpartum haemorrhage compared with those who did not.
Postpartum haemorrhage, excessive bleeding after childbirth, remains one of the leading causes of maternal deaths worldwide and is particularly deadly in low-resource settings where anaemia is widespread.
The study, conducted by the WOMAN-2 Trial Collaborators, analysed deliveries between 2019 and 2023 and found that nearly three in every 10 women received an episiotomy.
An episiotomy is a surgical incision made in the area between the vagina and the anus during childbirth to enlarge the vaginal opening and facilitate the baby’s delivery. Once routinely performed to speed up labour and prevent severe tearing, the procedure is not recommended for routine use by the World Health Organization.
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Despite WHO guidance, the researchers found that episiotomy remains common among first-time mothers in some countries.
In Pakistan, 81 per cent of first-time mothers who had uncomplicated vaginal births received an episiotomy, while the rate in Nigeria was 63 per cent. The figures were considerably lower in Zambia and Tanzania.
After adjusting for factors that could influence outcomes, the researchers found that episiotomy was associated with an 88 per cent increase in the odds of clinically diagnosed postpartum haemorrhage.
The study also revealed that about four in every 10 postpartum haemorrhage cases among women who underwent an episiotomy involved tearing as a contributing cause of the bleeding.
Lead investigators warned that the consequences could be particularly severe for women with anaemia, who already have a reduced capacity to tolerate blood loss during childbirth.
Anaemia affects millions of pregnant women worldwide and is especially prevalent in Nigeria and other parts of sub-Saharan Africa. Women with the condition face a significantly higher risk of complications and death when postpartum haemorrhage occurs.
The researchers estimated that if episiotomy were used only when medically necessary, up to 22 per cent of postpartum haemorrhage cases among first-time mothers in Pakistan and 14 per cent in Nigeria could potentially be prevented.
While the study does not establish a direct cause-and-effect relationship between episiotomy and postpartum haemorrhage, the researchers said the findings add to growing evidence that routine use of the procedure may expose women to avoidable risks.
They called for greater adherence to WHO recommendations and further research into why episiotomy rates remain high in some countries despite evidence showing limited benefits.
The researchers also noted that reducing unnecessary episiotomies could be an important step towards lowering maternal deaths and improving childbirth outcomes, particularly among women living with anaemia.
“Our study showed that episiotomy might increase the risk of postpartum haemorrhage in women with moderate or severe anaemia. The risks of routine episiotomy may be even greater for women who are highly vulnerable to haemorrhage and its life-threatening complications,” they wrote.
According to the researchers, anaemia affects a large proportion of pregnant women, and avoiding unnecessary procedures that may increase the risk of bleeding could help save lives and strengthen efforts to reduce maternal mortality in Nigeria, which accounts for one of the world’s highest burdens of maternal deaths.
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