KARACHI: A multi-country study recently published in an international journal has linked episiotomy — an obstetric procedure routinely carried out in many developing countries, including Pakistan — with an increased risk for life-threatening bleeding in women with anaemia.
Led by the London School of Hygiene & Tropical Medicine (LSHTM) and centres in Nigeria, Pakistan, Tanzania and Zambia, the study –– Episiotomy and postpartum haemorrhage (PPH) in women with moderate or severe anaemia: a cohort analysis of data from the WOMAN-2 Trial –– is the first to explore the impacts of episiotomy on women with anaemia.
According to the study published in the Lancet Global Health, having an episiotomy –– a surgical cut that widens the vaginal opening during childbirth –– doubles the risk of PPH (severe bleeding after childbirth) in women with moderate or severe anaemia.
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.
The World Health Organisation 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 per cent of the PPH cases in women who had an episiotomy in the trial were attributed to tearing — double that of the women who did not.
Episiotomy doubles the risk of severe bleeding, says research published in Lancet Global Health
According to the study, women with anaemia already experience PPH sooner after birth, have fewer treatment options, and are at increased risk of life-threatening complications and even death.
Severe bleeding after childbirth is responsible for about 70,000 maternal deaths every year, almost all in sub-Saharan Africa and South Asia.
Prof Rizwana Chaudhri, lead investigator for the WOMAN-2 Trial in Pakistan, currently associated with Shifa Tameer-e-Millat University, Islamabad, says: “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,” she adds.
‘Women cannot afford to bleed more’
Data also revealed many first-time mothers participating in the trial received an episiotomy — with 81 per cent of women from Pakistan and 63 per cent of women from Nigeria receiving one. First-time mothers in Zambia and Tanzania had rates of 29 per cent and 15 per cent respectively.
Mothers who had given birth before were less likely to have an episiotomy.
Globally, the study says, episiotomy rates vary between countries. For example, rates in first-time mothers in 2022 in France and Sweden were 9 per cent and 10 per cent respectively, and in the UK it was 20 per cent in 2023.
“Our study showed that over 80 per cent of first-time mothers in Pakistan were given an episiotomy, despite the WHO recommending against routine episiotomy for the past 30 years. This practice is probably doing more harm than good,” says Dr Judith Lieber, Research Fellow at LSHTM and lead author of the paper.
“This finding is especially worrying because women who took part in the study were all anaemic, so already vulnerable to negative birth outcomes like stillbirths, PPH, and death. These women cannot afford to bleed more.”
She emphasised that episiotomy, which places 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.
Over 80pc anaemic mothers
Explaining why episiotomy is still being routinely practiced, Prof Shabeen Naz Masood representing the Society of Obstetricians and Gynaecologists of Pakistan, said the key reason is unfounded fears that not doing so would lead to larger perineal (vaginal) tears that would be difficult to handle and stitch and the belief that an incision would heal better than a natural tear.
“Although modern obstetric supports judicious use of episiotomy, almost all women in Pakistan receive episiotomy at childbirth.”
Talking about maternal health challenges, she said over 80 per cent pregnant women in Pakistan suffer from anaemia, though government figures put the prevalence of the blood disorder in pregnancy at 50 per cent.
“Despite progress, we lose 27 mothers every day to largely preventable causes, including PPH (the chief cause) followed by hypertension and infections.”
Endorsing the study’s findings, Dr Masood underscored the need for selective episiotomy, stressing that the procedure should be performed only when medically necessary, such as in cases of fetal distress. Otherwise, it could lead to unaccounted blood loss, resulting in health complications.
The study was part of the WOMAN-2 Trial — which assessed the effect of early tranexamic acid administration on mortality, hysterectomy and other morbidities in women with PPH — carried out during the period between Aug, 2019 and Sep, 2023.
Published in Dawn, March 15th, 2026
