Episiotomy rates drop in France without increasing sphincter injuries

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Reduced episiotomy rates have occurred in France without an increase in obstetric anal sphincter injury (OASI) following a 2005 policy, according to a recent study published in PLOS Medicine.¹

While episiotomy is performed to reduce the risk of OASI, it has been linked to severe maternal complications including dyspareunia, postpartum hemorrhage, infection, urinary retention, post-traumatic stress disorder, and anxiety.² In 2005, recommendations were published to aim for a mediolateral episiotomy prevalence of under 30% of deliveries.¹

According to investigators, “the French national population-based perinatal surveys… provide an opportunity to investigate how this restrictive policy has been implemented in France over a decade.” The study was conducted to determine changes in episiotomy and OASI rates from 2010 to 2021.

Data was obtained from the National Perinatal Surveys, which include all births after 21 weeks’ gestation from maternity units in France. The first set of data was collected from face-to-face interviews between mothers and midwives during the postpartum stay.

Maternal health and obstetric care data was obtained from medical records. Information about the organization of a maternity unit was also reported by the unit’s head. Participants included women with a live vaginal delivery in France recorded in the 2010, 2016, or 2021 Enquête Nationale Périnatale.

Episiotomy was the primary outcome of the analysis, reported as a dichotomized variable. OASI was the secondary outcome, based on Royal College of Obstetricians and Gynecologists classification and French guidelines.

Maternal covariates included age, socioeconomic status, body mass index (BMI), and country of birth. Delivery covariates included birthweight, analgesia, and suspicion of fetal macrosomia. Finally, organization covariates included health care provider qualification and status of the maternity unit.

Compared to women in 2010, those in 2021 had increased BMI, level of education, prevalence of suspected fetal macrosomia, and age at delivery. Delivery in private maternity hospitals was also less common in 2021 vs 2010. While the rate of instrumental deliveries remained stable, vacuum deliveries became more common.

A significant decrease in overall episiotomy rates was reported, at 25.8% in 2010, 20.1% in 2016, and 8.3% in 2021. After adjustments for maternal and obstetric covariates, the adjusted relative risk (aRR) of episiotomy decreased by 22% from 2010 to 2016, and by 67% form 2010 to 2021.

All observed groups reported decreased in the aRR for episiotomy. However, the most significant decrease was in multiparous women with a singleton spontaneous delivery at 37 weeks of amenorrhea or later, with an aRR of 0.20. This was followed by those with multiple pregnancy with an aRR of 0.06.

Nulliparous women with a singleton forceps delivery at 37 weeks of amenorrhea or later reported the lowest decrease in the episiotomy rate, with an aRR of 0.67. Decreases occurred regardless of maternity unit status and the number of deliveries per year in the maternity unit.

Increases in OASI rates were observed over time, at 0.7%, 0.9%, and 1% in 2010, 2016, and 2021. After adjusting for maternal and maternity unit characteristics, these increases were no longer significant, with an aRR of 1.24.

In the subgroup analysis, OASI rates significantly increased in nulliparous women with a singleton, cephalic, at term, spatula delivery, from 2.6% in 2010 to 9.6% in 2021. In nulliparous women with a singleton forceps delivery at 37 weeks of amenorrhea or later, a non-statistically significant increase was observed.

These results indicated decreased episiotomy rates without a significant increase in overall OASI rates. Investigators concluded the findings “suggest that episiotomy use can be safely reduced for spontaneous vaginal deliveries.”

References

1. Houlbracq R, Le Ray C, Blondel B, Lelong N, Alice Chantry A, Desplanches T. Episiotomies and obstetric anal sphincter injuries following a restrictive episiotomy policy in France: An analysis of the 2010, 2016, and 2021 National Perinatal Surveys. PLOS Medicine. 2025. doi:10.1371/journal.pmed.1004501
2. He S, Jiang H, Qian X, Garner P. Women’s experience of episiotomy: a qualitative study from China. BMJ Open. 2020;10(7):e033354. doi:10.1136/bmjopen-2019-033354