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

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.

Keywords: Birth complications; Episiotomy; India; Vaginal birth.

Fig. 1

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

Fig. 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

Fig. 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)