The prevalence of episiotomy in France dropped significantly since the adoption of restrictive guidelines in 2005, decreasing from 25.8% in 2010 to 8.3% in 2021, according to findings from a recent cohort study.
Researchers analyzed data from the 2010, 2016, and 2021 National Perinatal Surveys, covering 29,750 women who had vaginal deliveries. They published their findings in PLOS Medicine.
The study, reported by Raphaele Houlbracq, of Université Paris Cité, Center of Research in Epidemiology and StatisticS/CRESS/Obstetrical Perinatal and Pediatric Epidemiology, INSERM, INRAE, and colleagues, found that reductions in episiotomy rates were observed across all obstetric classification groups, with decreases ranging from 33% in nulliparous term cephalic singleton deliveries with forceps (Group 2a) to 94% in women with multiple pregnancies (Group 7). Adjusted risk ratios (aRR) confirmed the decline was significant across all groups (P < .001).
Despite this decline, the prevalence of obstetric anal sphincter injuries (OASI) increased in specific subgroups. Among nulliparous women undergoing spatula-assisted deliveries (Group 2b), OASI prevalence rose from 2.6% in 2010 to 9.6% in 2021 (aRR = 3.69, 95% confidence interval [CI] = 1.50–9.09). Similarly, OASI prevalence in forceps-assisted deliveries (Group 2a) increased from 3.2% in 2010 to 5.7% in 2021, although this rise was not statistically significant (aRR = 1.78, 95% CI = 0.81–3.90).
The overall prevalence of OASI remained low, rising slightly from 0.7% in 2010 to 1.0% in 2021, with no statistically significant difference after adjustments (aRR = 1.24, 95% CI = 0.91–1.68).
The study highlights that the restrictive episiotomy policy has successfully reduced the procedure's prevalence without a corresponding increase in OASI for the general population. However, the findings raise concerns about increased OASI risk in certain instrumental delivery contexts.
"Episiotomy could be safely reduced for spontaneous vaginal deliveries to comply with international guidelines and women’s requests... further research is needed to predict the optimal rate of episiotomy for instrumental deliveries," wrote the study authors.
The researchers acknowledged several study limitations, including the inability to account for all potential confounding factors and insufficient event counts in some subgroups. Nevertheless, they emphasized the need for targeted research on episiotomy rates and their impact on specific delivery scenarios.
Several authors reported ties to Novo Nordisk, including research and medical writing assistance (Drs. Houlbracq, Le Ray, Blondel, and Desplanches). Full disclosures are detailed in the study.
