Episiotomy and postpartum haemorrhage in women with moderate or severe anaemia: a cohort analysis of data from the WOMAN-2 trial

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BACKGROUND: Women with anaemia have a higher risk of postpartum haemorrhage than those without anaemia. We examined the association between episiotomy and postpartum haemorrhage in women with moderate or severe anaemia. METHODS: We conducted a cohort analysis using data from the World Maternal Antifibrinolytic-2 (WOMAN-2) trial. Women with moderate or severe anaemia who were giving birth vaginally were recruited from 34 hospitals in Nigeria, Pakistan, Tanzania, and Zambia. On arrival at hospital, the participants' haemoglobin concentration was measured with a validated point-of-care haemoglobin test. Moderate anaemia was defined as a haemoglobin concentration of 70-99 g/L and severe anaemia as a haemoglobin concentration lower than 70 g/L. Episiotomy was defined as any perineal incision during delivery. Women were excluded from the WOMAN-2 trial if they were younger than 18 years and lacked consent from a guardian, had a known allergy to the trial intervention, had an indication or contraindication to the intervention, or were diagnosed with postpartum haemorrhage before the umbilical cord was clamped. The primary outcome was a clinical diagnosis of postpartum haemorrhage (estimated blood loss ≥500 mL or any blood loss causing haemodynamic instability), and the secondary outcome was calculated postpartum haemorrhage (estimated from peripartum change in haemoglobin concentration). We modelled the outcomes with multilevel logistic regression, adjusting for confounders with inverse probability of treatment weighting. FINDINGS: Between Aug 24, 2019, and Sept 19, 2023, 4355 (28·9%) of the 15 068 women recruited to the WOMAN-2 trial had an episiotomy. In primiparous women who had non-instrumental births, the incidence of episiotomy was 81·1% in Pakistan (2703 of 3335), 63·3% (307 of 485) in Nigeria, 28·5% (69 of 242) in Zambia, and 15·1% (111 of 735) in Tanzania. Clinically diagnosed postpartum haemorrhage occurred in 1034 (6·9%) of 15 066 participants, and calculated postpartum haemorrhage occurred in 1417 (9·5%) of 14 863. After adjustment for confounders, episiotomy was associated with clinically diagnosed postpartum haemorrhage (odds ratio 1·88, 95% CI 1·33-2·66) and calculated postpartum haemorrhage (1·63, 1·14-2·34). INTERPRETATION: Although WHO recommends against the routine use of episiotomy, many first-time mothers were given this procedure. Episiotomy might increase the risk of postpartum haemorrhage in women with moderate or severe anaemia. As anaemia is known to worsen the life-threatening complications of postpartum haemorrhage, the risks of routine episiotomy could be even greater in women with anaemia. FUNDING: Wellcome and the Bill & Melinda Gates Foundation. TRANSLATIONS: For the Swahili, Urdu, Yoruba, Hausa and Igbo translations of the abstract see Supplementary Materials section.

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