title: Episiotomy and obstetric outcomes among women living with type 3 female genital mutilation: a secondary analysis.
abstract: BACKGROUND
  To investigate the association between type of episiotomy and obstetric outcomes among 6,187 women with type 3 Female Genital Mutilation (FGM).
  
  
  METHODS
  We conducted a secondary analysis of women presenting in labor to 28 obstetric centres in Burkina Faso, Ghana, Kenya, Nigeria, Senegal and Sudan between November 2001 and March 2003. Data were analysed using cross tabulations and multivariable logistic regression to determine if type of episiotomy by FGM classification had a significant impact on key maternal outcomes. Our main outcome measures were anal sphincter tears, intrapartum blood loss requiring an intervention, and postpartum haemorrhage.
  
  
  RESULTS
  Type of episiotomy performed varied significantly by FGM status. Among women without FGM, the most common type of episiotomy performed was posterior lateral (25.4 %). The prevalence of the most extensive type of episiotomy, anterior and posterior lateral episiotomy increased with type of FGM. Among women without FGM, 0.4 % had this type of episiotomy. This increased to 0.6 % for women with FGM Types 1, 2 or 4 and to 54.6 % of all women delivering vaginally with FGM Type 3. After adjustment, women with an anterior episiotomy, (AOR = 0.15 95 %; CI 0.06-0.40); posterior lateral episiotomy (AOR = 0.68 95 %; CI 0.50-0.94) or both anterior and posterior lateral episiotomies performed concurrently (AOR = 0.21 95 % CI 0.12-0.36) were all significantly less likely to have anal sphincter tears compared to women without episiotomies. Women with anterior episiotomy (AOR = 0.08; 95%CI 0.02-0.24), posterior lateral episiotomy (AOR = 0.17 95 %; CI 0.05-0.52) and the combination of the two (AOR = 0.04 95 % CI 0.01-0.11) were significantly less likely to have postpartum haemorrhage compared with women who had no episiotomy.
  
  
  CONCLUSIONS
  Among women living with FGM Type 3, episiotomies were protective against anal sphincter tears and postpartum haemorrhage. Further clinical and research is needed to guide clinical practice of when episiotomies should be performed.
authors.affiliation: Department of Reproductive Health and Research, World Health Organization, Avenue Appia 20, 1211, Geneva, Switzerland.|Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR, USA.
authors.forename: Maria I
authors.initials: MI
authors.lastname: Rodriguez
authors.affiliation: Department of Reproductive Health and Research, World Health Organization, Avenue Appia 20, 1211, Geneva, Switzerland.
authors.forename: Armando
authors.initials: A
authors.lastname: Seuc
authors.affiliation: Department of Reproductive Health and Research, World Health Organization, Avenue Appia 20, 1211, Geneva, Switzerland.
authors.forename: Lale
authors.initials: L
authors.lastname: Say
authors.affiliation: Department of Reproductive Health and Research, World Health Organization, Avenue Appia 20, 1211, Geneva, Switzerland. hindinm@who.int.
authors.forename: Michelle J
authors.initials: MJ
authors.lastname: Hindin
mesh_terms: D000328:Adult; D000349:Africa / Q000453:epidemiology; D001003:Anal Canal / Q000293:injuries; D002921:Cicatrix / Q000209:etiology / Q000601:surgery; D019093:Circumcision, Female / Q000009:adverse effects*; D036861:Delivery, Obstetric / Q000379:methods; D004841:Episiotomy / Q000009:adverse effects / Q000379:methods*; D005260:Female; D006470:Hemorrhage / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control; D006801:Humans; D007744:Obstetric Labor Complications / Q000453:epidemiology* / Q000517:prevention & control; D006473:Postpartum Hemorrhage / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control; D011247:Pregnancy; D011256:Pregnancy Outcome / Q000453:epidemiology; D012307:Risk Factors; D012959:Socioeconomic Factors; D055815:Young Adult
keywords: Circumcision; Episiotomy; FGM; Female genital mutilation; Obstetrics