Despite WHO recommending against its routine use, many episiotomies are still performed during childbirth
Having an episiotomy, a surgical cut to the vagina during childbirth, doubles the risk of postpartum haemorrhage (PPH) in women with moderate or severe anaemia, according to new research published in The Lancet Global Health.
The research involved data from over 15,000 women who took part in the WOMAN-2 Trial from 2019-2023. Over a quarter had an episiotomy during childbirth, a procedure where the area between the vagina and anus is surgically cut.
Led by the London School of Hygiene & Tropical Medicine (LSHTM) and centres in Nigeria, Pakistan, Tanzania and Zambia, the study is the first to explore the impacts of episiotomy on PPH in women with anaemia.
The World Health Organization does not recommend the routine use of episiotomy in non-instrumental births, as its risks outweigh potential benefits. Researchers now suggest there is an increased risk of severe bleeding resulting from this procedure, as 40% of PPH cases in women who had an episiotomy in the trial were attributed to tearing - double that of the women who did not.
Women with anaemia already experience PPH sooner after birth, have fewer treatment options, and are at increased risk of life-threatening complications and death. Severe bleeding after childbirth is responsible for about 70,000 maternal deaths every year, almost all in sub-Saharan Africa and South Asia.
This new evidence, which shows that episiotomy is an additional risk for life-threatening bleeding in women with anaemia, could better inform routine practices.
Dr Judith Lieber, Research Fellow at LSHTM and lead author of the paper, said: "Women with anaemia are particularly vulnerable to negative birth outcomes, such as stillbirths, PPH, and death.
"These women cannot afford to bleed more. Our study highlights that practices such as episiotomy, which place mothers with anaemia at even higher risk of severe bleeding, should not be done unless absolutely necessary for the welfare of the mother or baby."
Data also revealed many first-time mothers participating in the trial received an episiotomy - with 81% of women from Pakistan and 63% of women from Nigeria receiving one. First time mothers in Zambia and Tanzania had rates of 29% and 15% respectively. Mothers who had given birth before were less likely to have an episiotomy.
Globally, episiotomy rates vary between countries. For example, rates in first-time mothers in 2022 in France and Sweden were 9% and 10% respectively, and in the UK it was 20% in 2023.
There are various reasons the practice is still routine in some countries, such as the idea it will speed up labour, prevent adverse outcomes, a belief that first time mothers are at high risk of tearing and this will help prevent it, and lack of awareness of evidence and guidelines.
Professor Rizwana Chaudhri, consultant gynaecologist and obstetrician and lead investigator for the WOMAN-2 Trial in Pakistan, said: "Despite evidence that routine episiotomy does not prevent severe tears, it still remains an established practice in many countries, with many clinicians still opting to follow the practices they were taught in training.
"This is the first study to look specifically at episiotomy in women with anaemia. New evidence like this is necessary to advocate for change, especially in countries where episiotomy is still the standard approach."
This study was part of the WOMAN-2 Trial, the first large scale study of women giving birth with moderate or severe anaemia. Researchers now call for better anaemia prevention programmes, including routine screening before and during pregnancy as well as proper management and treatment of anaemia and its routine causes.
Publication
The WOMAN-2 Trial Collaborators. Episiotomy and postpartum haemorrhage in women with moderate or severe anaemia: A cohort analysis of the WOMAN-2 trial. The Lancet Global Health, 2025. DOI: 10.1016/S2214-109X(25)00449-8
Funding
The WOMAN-2 Trial is funded by the Bill & Melinda Gates Foundation (INV-007787) and the Wellcome Trust (WT208870/Z/17/Z).
