Episiotomy Practice and Its Associated Factors in Africa: A Systematic Review and Meta-Analysis

Abstract

BackgroundEpisiotomy, a surgical procedure that enlarges the vaginal opening during childbirth, was common practice until the early 2000s. Other sources, including the World Health Organization (WHO), advocate for the selective use of episiotomy. Episiotomy rates, on the other hand, have remained high in developing countries, while declining in developed countries. As a result, the current study sought to determine the overall prevalence of episiotomy in Africa as well as the risk factors associated with its practice.MethodsArticles were searched in international electronic databases. A standardized Microsoft Excel spreadsheet and STATA software version 14 were used for data extraction and analysis, respectively. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist was used to write this report. A random-effects meta-analysis model was used to determine the pooled prevalence of episiotomy. A heterogeneity test was conducted using I-Squared (I2) statistics. Egger's test and funnel plots were conducted to detect publication bias. Subgroup analysis was also conducted. Association was expressed through a pooled odds ratio (OR) with a 95% Confidence Interval (CI).ResultA total of 21 studies with 40,831 participants were included in the systematic review and meta-analysis. The pooled prevalence of episiotomy practice was 41.7% [95% CI (36.0–47.4), I2 = 99.3%, P < 0.001). Primiparity [OR: 6.796 (95% CI (4.862–9.498)), P < 0.001, I2: 95.1%], medical doctors- assisted delivery [OR: 3.675 (95% CI (2.034–6.640)), P < 0.001, I2: 72.6%], prolonged second stage of labor [OR: 5.539 (95% CI (4.252–7.199)), P < 0.001, I2: 0.0%], using oxytocin [OR: 4.207 (95% CI (3.100–5.709)), P < 0.001, I2: 0.0%], instrument -assisted vaginal delivery [OR: 5.578 (95% CI (4.285–7.260)), P < 0.001, I2: 65.1%], and macrosomia [OR: 5.32 (95% CI (2.738–10.339)), P < 0.001, I2: 95.1%] were factors associated with episiotomy practice.ConclusionIn this review, the prevalence of episiotomy among African parturients was high. A selective episiotomy practice should be implemented to reduce the high episiotomy rates.Systematic Review Registrationhttps://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021293382, identifier: CRD42021293382.

Analysis of Maternal Positions during the Dilation and Expulsive Phase and Their Relationship with Perineal Injuries in Eutocic Deliveries Attended by Midwives

“…A multicenter clinical trial conducted in 2019 observed a 10% rate of perineal intactness in multiparous women, emphasizing the need for a restrictive episiotomy approach to childbirth to reduce perineal trauma. These findings were consistent with several studies in which primiparity was identified as one of the main risk factors associated with episiotomy [21][22][23][24][25][26]. In addition, factors such as fetal weight greater than 4000 g and vacuum extraction have been found to be independent risk factors for both second-degree perineal tears and obstetric anal sphincter injury [21].…”

“…In addition, factors such as fetal weight greater than 4000 g and vacuum extraction have been found to be independent risk factors for both second-degree perineal tears and obstetric anal sphincter injury [21]. Other studies have also identified influential factors for the performance of episiotomy in primiparous women, such as maternal age, maternal body mass index, presence of analgesia, duration of the second stage, estimated birth weight, and perineal stress [22][23][24][25][26]. These findings led us to ask what characteristics are determinant for a higher rate of episiotomy in primiparous women and whether these characteristics justify the difference in numbers compared to multiparous women.…”

Midwives' approach to the prevention and repair of obstetric perineal trauma in Spain

“…This aligns with a 2014 Spanish study, which found an average episiotomy rate of 34.9% among midwives (Hernández‐Martínez et al., 2014 ). These figures are lower than those estimated in developing countries, where they can exceed 40% (Woldegeorgis et al., 2022 ). However, they surpass the rates reported in Western countries, which are documented at 19% (Goueslard et al., 2018 ), 10% (Leclercq et al., 2024 ), and even as low as 2% (Dillon et al., 2021 ).…”

“…where they can exceed 40% (Woldegeorgis et al, 2022). However, they surpass the rates reported in Western countries, which are documented at 19% (Goueslard et al, 2018), 10% (Leclercq et al, 2024), and even as low as 2% (Dillon et al, 2021).…”

Neonatal birth trauma and associated factors in low and middle-income countries: A systematic review and meta-analysis

“…Our finding was congruent with a systematic review and meta-analysis report by Woldegeorgis et al . [ 78 ] that described operative vaginal delivery as a significant contributor to trauma to both the mother and newborn. Moreover, comparative studies in California and Quebec [ 79 ], the Cochrane Database of systematic review [ 80 ], a study in China [ 16 ], Bulgaria [ 81 ], and a retrospective review of operative delivery, in Singapore [ 82 ] identified that forceps or vacuum-assisted vaginal delivery was associated with increased risk of neonatal birth trauma although the risks are generally instrument specific and also affected by correct application and delivery technique as well as complex procedures.…”