By Dr Judith Lieber, Assistant Professor at the London School of Hygiene & Tropical Medicine and Head of the I’M WOMAN Trial, and Professor Rizwana Chaudhri, obstetrician & gynaecologist, and Head of the WOMAN Trials in Pakistan
On World PPH Day, we highlight the evidence shaping clinical decisions that improve respectful maternity care and save mothers’ lives.
Dr Judith Lieber: What the evidence tells us
Maternal deaths rarely result from a single event. They are often caused by a combination of risks and complications – anaemia, an incision, a tear, a delayed diagnosis, or a lack of treatment. Some of this is out of an obstetrician or midwife’s hands; some not.
Recent research from the WOMAN Trials team has explored two aspects of maternity care that deserve greater attention: the use of episiotomy and the limited availability of pain relief during labour.
Our research included women with moderate or severe anaemia giving birth vaginally in hospitals in Nigeria, Pakistan, Tanzania and Zambia. Overall, 29% had an episiotomy, a surgical cut to the vagina during childbirth. Among first-time mothers, that figure was over 80% in Pakistan and 60% in Nigeria. Episiotomy was associated with almost twice the risk of PPH.
The WHO recommend against routine episiotomy because high-quality trials show that it increases severe perineal tearing and does not benefit the mother or infant in any other way. Restricting the procedure to the rare occasion in which it is clinically needed could potentially prevent cases of PPH, particularly in anaemic women.
When a woman goes into labour with a reduced capacity to tolerate blood loss, an incision or tear can have serious consequences. Preventing these may help to stop the buildup of risk factors into a life-threatening emergency.
Clinical practices can change. A decade ago, researchers in Thailand undertook the largest ever trial of episiotomy in response to shockingly high rates of episiotomy (over 90% in some hospitals).
This trial showed that a restrictive approach to episiotomy did not increase severe tearing for women, and in fact, likely reduced tearing. A study of one of the trial hospitals showed episiotomy use dropped rapidly after the trial results were published in 2020, as did the rate of severe tears.
The WOMAN-2 Trial data show that only 12% of women received pharmacological pain relief during labour. Women who received it were less likely to experience PPH. While the observational nature of the evidence means this must be interpreted cautiously, there are plausible biological mechanisms for this relationship. Adrenaline worsens bleeding by increasing the breakdown of blood clots. Pain relief could limit bleeding by reducing the adrenaline stress response to fear and physical trauma during childbirth.
Regardless of its relationship with PPH, pain relief matters. It can reduce stress and improve a woman’s experience of childbirth. A safe birth is about more than survival, it also includes avoiding unnecessary pain and trauma and supporting recovery.
Professor Rizwana Chaudhri: The realities of clinical practice
As a practising obstetrician in Pakistan, I have seen the scale at which episiotomy is used, particularly during first births. It is often performed because clinicians believe it will prevent serious tearing or will speed up delivery.
There are circumstances in which an episiotomy is necessary. There can be no single rule for every woman or every delivery.
However, this new evidence has made us think more carefully. It was widely shared and discussed through clinical networks in Pakistan. Clinicians are open to reconsidering routine practice. Within my own team, we have asked staff to avoid episiotomy wherever possible and to consider whether it is genuinely necessary for each woman.
An episiotomy should never become an automatic response to a busy labour ward or a woman’s distress. It should have a clear clinical justification and be performed with informed consent and adequate local anaesthetic.
Pain management is a major challenge in Pakistan. Epidural services are generally unavailable in public hospitals because they require specialist staff and close monitoring. Opioids can be difficult to access, and clinicians may be concerned about subsequent respiratory problems in newborns, particularly where staff are not available to manage complications. Supplies of suitable medical gases do not get replenished once they run out.
These are genuine health-system constraints. But they should not result in women’s pain simply being ignored. I do not accept that women should be left screaming in pain because a labour ward is busy. Nor do I accept that an episiotomy be carried out in the hope of making a delivery quicker for the clinician performing it.
Clinicians should offer the most appropriate pain-management options available in their settings. And collectively, clinicians, researchers and policy makers all need to work towards strengthening health systems and not accepting women’s pain, as pain relief options are available for other surgeries.
Local anaesthetic should always be used when an episiotomy is performed. Junior clinicians must be taught when and how to administer anaesthetics and episiotomies correctly and effectively. Respectful communication is also essential, including explaining what is happening, seeking consent, and listening to women’s needs.
We also need better data to understand the impact of these clinical changes. In many hospitals, records are incomplete. Sharing evidence and experiences from other countries can help maintain momentum and encourage professional leadership while local monitoring systems are strengthened.
A shared call for action
This World PPH Day, our message to clinicians, professional bodies and health systems is practical:
- end routine episiotomy,
- provide appropriate pain-management options, where available,
- embed informed consent and respectful communication in clinical training,
- and strengthen the prevention and treatment of anaemia among all women of reproductive age.
By bringing together research and practice, we can reduce avoidable harm, improve women’s experiences of childbirth, and save lives.