MEDIA PENELITIAN DAN
PENGEMBANGAN KESEHATAN
Vol 35 No 3.
September 2025
e-ISSN: 2338-3445
p-ISSN: 0853-9987
ANALYSIS OF FACTORS CAUSING EPIOSTOMY IN THE BIRTH
PROCESS: SCOPING REVIEW
Analisis Faktor yang Memengaruhi Tindakan Episiotomy pada Ibu Bersalin:
Scoping Review Dea Ayu Sartika1.
Farida Kartini1 Universitas Aisyiyah Yogyakarta.
Yogyakarta.
Indonesia *Email: deaayu.
sartika@gmail.
ABSTRAK
Episiotomi merupakan tindakan insisi perineum yang umum dilakukan dalam proses persalinan, namun praktik ini masih menuai kontroversi.
Sejak tahun 1996, sebagian besar literatur menyimpulkan bahwa episiotomi rutin tidak diperlukan dan bahkan berisiko meningkatkan kejadian laserasi perineum derajat tiga atau empat.
Meskipun Organisasi Kesehatan Dunia (WHO) telah merekomendasikan pembatasan praktik episiotomi rutin sejak 1990-an, kenyataannya tindakan ini masih sering dilakukan, terutama di negara berkembang, termasuk Indonesia.
Scoping review ini bertujuan untuk menganalisis faktor yang mendasari tindakan episiotomi pada ibu bersalin.
Scoping review menggunakan PRISMA-ScR Ceklist.
Pencarian database dari Pubmed.
Scopus.
Wiley Online Library, dan Science Direct.
dengan kata kunci pencarian AuFactorAy AND AuindicationAy OR AuepisiotomyAy OR AulacerationAy OR Aurupture perineumAy.
Kriteria inklusi yang digunakan meliputi artikel orisinal yang membahas topik relevan serta artikel yang diterbitkan dalam lima tahun terakhir, yaitu antara tahun 2018 hingga 2023.
Sebanyak 18 artikel terpilih dianalisis menggunakan checklist dari Joanna Briggs Institute (JBI) melalui proses Critical Appraisal.
Tinjauan ini menghasilkan sub tema tehadap faktor yang berhubungan dengan tindakan episiotomy yaitu jarak kelahiran.
BMI ibu, gawat janin, berat lahir, paritas, kehamilan ganda.
Perineum pendek, perineum kaku, kala II lama.
TFU >32 cm, penggunaan oksitosin, dan persalinan instrumen.
Dapat disimpulkan bahwa paritas dan berat janin yang paling banyak ditemukan dalam kasus episiotomy.
Temuan ini memiliki implikasi penting bagi praktik klinis dan kebijakan pelayanan kebidanan, khususnya dalam mengembangkan panduan pengambilan keputusan berbasis bukti yang lebih selektif dan rasional terkait tindakan episiotomi, guna meminimalkan risiko komplikasi serta meningkatkan keselamatan ibu dan bayi.
Kata kunci: episiotomy, faktor, indikasi, robekan perineum, scoping review
ABSTRACT
Episiotomy is a common perineal incision during labor, but the practice remains Since 1996, most literature has concluded that routine episiotomy is unnecessary and even risks increasing the incidence of third or fourth degree perineal Although the World Health Organization (WHO) has recommended limiting the practice of routine episiotomy since the 1990s, it is still frequently performed, especially in developing countries, including Indonesia.
This scoping review aims to analyze the factors underlying episiotomy in laboring women.
The scoping review used the PRISMA-ScR Checklist.
Database searches from Pubmed.
Scopus.
Wiley Online Library, and Science Direct.
with the search keywords AuFactorAy AND AuindicationAy OR AuepisiotomyAy OR AulacerationAy OR Auperineal ruptureAy.
The inclusion criteria used included original articles addressing relevant topics and articles published within the last five years, i.
between 2018 and 2023.
A total of 18 selected articles were analyzed using the Joanna Briggs Institute (JBI) checklist through the Critical Appraisal process.
This review produced sub-themes on factors associated with episiotomy, namely birth spacing, maternal BMI, fetal distress, birth weight, parity, multiple pregnancy, short perineum, stiff perineum, prolonged second stage.
TFU >32 cm, oxytocin use, and https://doi.
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MEDIA PENELITIAN DAN
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Vol 35 No 3.
September 2025 e-ISSN: 2338-3445 p-ISSN: 0853-9987 instrument delivery.
It can be concluded that parity and fetal weight are most commonly found in cases of episiotomy.
These findings have important implications for clinical practice and midwifery service policy, especially in developing evidence-based decisionmaking guidelines that are more selective and rational regarding episiotomy, in order to minimize the risk of complications and improve the safety of mothers and babies.
Keywords: episiotomy, factor, indication, perineal tear, scoping review
INTRODUCTION
Episiotomy is an incision in the perineum that has been widely practiced since the 1920s, initially as a prophylactic procedure to prevent spontaneous lacerations in the birth canal and reduce maternal and infant morbidity.
Although routine prophylactic episiotomies were performed in the 1980s to mid-1990s, concerns about potential complications associated with episiotomies arose during this period.
Since 1996, a large body of literature has concluded that routine episiotomy is unnecessary and may even increase the risk of 3rd or 4th degree perineal laceration.
The World Health Organization (WHO) and other professional societies have recommended restrictions on routine episiotomy since the 1990s, although less than ideal episiotomy rates are recommended.
Despite this, episiotomies are still widely practiced, especially in developing countries like Indonesia.
Data shows that approximately 80% of deliveries in Indonesia still involve episiotomies, a figure significantly higher than global recommendations.
The leading causes of death are hemorrhage .
,330 case.
, hypertension .
,100 case.
, and circulatory system disorders .
Postpartum hemorrhage is the leading cause of 40% of maternal deaths in Indonesia.
The birth canal is the second cause of bleeding after uterine atony which occurs in almost all first deliveries and not infrequently in subsequent deliveries.
The results of the recording indicate that almost all or up to 80% of the birth process in Indonesia is followed by an episiotomy.
The problem found is the still low health of women caused by the high maternal mortality rate during pregnancy, childbirth and postpartum, as well as the still low quality of life of women both in terms of health and economic capacity.
Postpartum hemorrhage is bleeding that occurs within 24 hours of delivery.
This bleeding is caused by uterine atony, retained placenta, retained placenta, and tears in the birth canal.
One cause of this bleeding is perineal tears or lacerations of the birth canal, which occur in 4-5% of cases, and this is the most common cause during childbirth.
The results of hospital research on patient data collected through medical records in 2010-2011 showed that the incidence of perineal rupture was 141 people.
Of the 141 mothers who experienced perineal rupture, based on parity, the most were primiparas, namely 88 people .
64%), based on birth intervals, the most were 2-3 years, namely 27 people .
95%), and the most common infant weight was > 3500 grams, namely 66 people .
81%).
These findings suggest that various factors, including maternal, fetal, and procedural factors, can influence the decision to perform an episiotomy.
Given the high prevalence of episiotomy and its risk of complications, it is important to identify the factors influencing its use.
This scoping review explores these factors to support more selective, evidence-based clinical policies, with the aim of improving delivery care quality and reducing unnecessary episiotomies.
METHODS
This study is a scoping review study compiled based on the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Review.
This design is used to map the available literature, identify knowledge gaps, clarify concepts, and evaluate the extent to which the topic has been This study focuses on the synthesis of scientific evidence from various https://doi.
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MEDIA PENELITIAN DAN
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September 2025 e-ISSN: 2338-3445 p-ISSN: 0853-9987 relevant studies regarding factors influencing episiotomy in childbirth.
The subjects in this study were scientific articles discussing episiotomy, including risk factors, indications, and implementation.
A total of 18 articles were analyzed, selected through a systematic selection process based on inclusion and exclusion criteria.
The articles came from several countries, namely Ethiopia, the USA.
France.
Iran.
Egypt.
Spain.
China.
Uganda, and Poland.
The sampling technique was carried out through a purposive article search using four electronic databases, namely PubMed.
Scopus.
Wiley Online Library, and ScienceDirect, with the keywords: "factor" AND "indication" OR "episiotomy" OR "laceration" OR "perineal rupture".
This search was conducted between November 2024 and February 2025.
Inclusion criteria included original articles published in the last five years .
9Ae2.
, available in full-text, in English, and directly discussing topics related to episiotomy.
Review articles, articles irrelevant to the study focus, paid articles that are not freely accessible, and articles without full-text were excluded from the analysis.
The review focus was determined using the PCC (Population.
Concept.
Contex.
framework as recommended by the Joanna Briggs Institute .
Furthermore, the selected articles were analyzed and evaluated for quality using the Joanna Briggs Institute (JBI) critical appraisal checklist to ensure data validity and reliability.
Identifying research questions This study used the Population.
Concept, and Context (PCC) framework to find articles, establish inclusion and exclusion criteria, and identify relevant outcomes.
This scoping review aimed to analyze the factors underlying episiotomy in women giving birth.
This analysis used the PCC (Population.
Concept.
Contex.
framework, where the population studied was women giving birth, the concept discussed was the factors influencing the decision to perform an episiotomy, and the context was the labor process.
Identifying relevant studies The article search strategy was developed according to the research questions and Researchers used inclusion criteria that included original articles published within the last five years .
Articles that did not meet the inclusion criteria, such as review articles, irrelevant articles, articles not available in full text, or paid articles, were excluded from the search.
In identifying relevant studies, researchers used several databases.
The databases used were Pubmed.
Scopus.
Wiley Online Library, and Science Direct.
Article searches used several strategies such as the use of keywords and Boolean operators (OR.
AND.
NOT).
The keywords used in the article search were "factor" AND "indication" OR "episiotomy" OR "laceration" OR "perineal rupture".
The obtained articles were entered into Mendeley to assist in article selection including titles, abstracts, and reading the full Then, a critical appraisal was conducted to assess the quality of the selected articles using the Joanna Briggs Institute checklist.
The Joanna Briggs Institute checklist was chosen because the JBI provides a complete critical appraisal checklist for all research study designs.
Selecting study results Identifying the literature that has been obtained using the PRISMA Flowchart with the aim of describing the literature identification process in detail and transparently.
From the results of searching for articles in 4 databases used 72 articles from PubMed.
Scopus 276 articles.
Science Direct 52 articles, and Wiley Online Library 159 articles, the next step is to enter the articles into the Mendeley software then 46 duplicate articles are obtained, after removing duplicate articles the researcher filters the title and abstract, conducts a scoping review by reading the research publication as a whole to determine the eligibility of the research article.
The article search process can be seen in the PRISMA Flowchart as follows:
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Identification MEDIA PENELITIAN DAN PENGEMBANGAN KESEHATAN Vol 35 No 3.
September 2025 Articles identified through database search:
PubMed .
= .
Scopus .
= .
Science Direct .
= .
Wiley Online Library .
Screening Filtered articles .
= .
Included Complete articles deemed eligible .
= .
e-ISSN: 2338-3445 p-ISSN: 0853-9987 Duplicate Articles removed .
= .
Articles excluded .
= .
Irrelevant articles = 361 Articles not in English and/or Indonesian = 11 Articles not full text = 61 Review articles = 31 Articles excluded because they did not meet the objectives of the scooping review .
= .
Articles included in the scoping review study .
= Figure 1.
PRISMA Flow chart Data Charting At this stage, the selected articles are numbered A1-A18, then entered into a table that can explain: article title, author, year of publication, country name, research objectives, type of research, data collection method, number of respondents, and research results.
RESULT
The charting data is explained in the following table 1:
Title and Author Restrictive Southeast Asian (Thailan.
Table1.
Scoping Study Article Types of Population and Data Collection Sample RCT Population:
3006 Multicenter pregnant randomized women aged 18 years controlled trial.
and above, gestational Established in Ou37 Sampling technique: hospitals randomization two adjusted for study hospitals location and maternal Thailand.
Results A restrictive episiotomy maintains a more intact perineum in multiparas, but increases the risk of vaginal lacerations in increasing the need for The risks of postpartum hemorrhage, neonatal intensive care https://doi.
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MEDIA PENELITIAN DAN
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Vol 35 No 3.
September 2025 Types of ive cohort Title and Author Incidence of Obstetric Lacerations Episiotomy Following Labiaplasty (United State.
Impact of Episiotomy During Operative Vaginal Delivery on Obstetrical Anal Sphincter Injuries.
(Canad.
ive cohort Randomized Clinical Trial of an Aquatic Physical Exercise Program During Pregnancy (Spai.
RCT The between perineal size (Ira.
Crosectional Population and Sample Seventy patients had labiaplasty, while 33 Sampling with a retrospective 56,070 vaginal deliveries met the inclusion criteria.
these, 14,665 .
were assisted with forceps and 37,576 .
9%) were vacuumassisted.
Episiotomies were performed in 17,824 .
%) The A total of 129 pregnant women .
ontrol group [CG] A 64.
exercise group [EG] A Sampling random sampling women were referred to Fatemieh Hospital in Hamadan singleton pregnancies, first stage of labor, and gestational age of 37 weeks or more, of whom 372 participated.
The technique used was purposive sampling.
Data Collection Results Interview The rate of vaginal delivery is lower in women who had children Episiotomy in vaginal delivery is lower in women who had children compared to women who had children before Questionnaire Episiotomy in forceps or increases the risk of laceration in vacuum and OASIS in forceps in women with a history of vaginal delivery, but is protective in forceps for vaginal primiparas.
The intervention was an aquatic (Study of Water Gymnastics During Pregnancy SWEP Metho.
Questionnaire Women in the EG had a greater rate of intact perineum than those in the CG .
dds ratio [OR] = 13.
54, 95% confidence [CI] .
After adjusting for infant birth weight, the effect of the intervention on intact perineum was OR 8.
% CI .
The mean gestational age was 39.
10A1.
weeks, and the newborn 37A42.
39 g.
episiotomy, and 5.
The average perineal size 99A0.
There significant relationship between perineal body https://doi.
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e-ISSN: 2338-3445
p-ISSN: 0853-9987
MEDIA PENELITIAN DAN
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Vol 35 No 3.
September 2025 Title and Author Types of Population and Sample Data Collection Magnitude Episiotomy Associated Factors among Mothers Who Gave Birth in Arba Minch General Hospital.
Southern Ethiopia:
Observation-Based Cross-Sectional Study (Ethiopi.
Crosectional The sample size of this study was 410.
The sampling technique Questionnaire A nationwide crosectional survey of episiotomy practice in China (Chin.
Crosectional Survey Perineal and training reduces perineal trauma in older than 35 years: a (Egyp.
RCT The vaginal delivery with Retrospec tive cohort Hospitals with at least 1,000 deliveries per year were eligible for randomly selected six weeks within a year for facilities with 6,000 or more deliveries per year, or ten weeks for facilities with fewer than 6,000 deliveries per year, for data The first group .
was taught to perform massage and pelvic floor muscle massage.
training and received a PFD The second group .
= .
received only the prevention education The sampling technique used was purposive sampling.
A sample size of 500 women in each group was sufficient to detect The Questionnaire Questionnaire Results size, episiotomy, and neonatal birth weight.
primiparous women with a gestational age of 37 to delivery, the perineum was shorter, increases the likelihood of an episiotomy.
The highest incidence of episiotomy was found in women with secondary education, birth weight Ou3000 g, primipara, housewives, and body mass index < 25 kg/m2 The episiotomy rate in vaginal births was 41.
multiparas in China.
Factors associated with episiotomy included prepregnancy BMI, maternal disease, and Unindicated mediolateral episiotomy increased the risk of third- and fourthdegree lacerations.
Perineal massage can reduce episiotomy and perineal laceration rates.
Perineal tear rates are significantly higher in obese women, and those with a higher BMI are more likely to have The results showed that mothers who underwent episiotomy were more likely to be younger, primiparous, and babies with macrosomia and https://doi.
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September 2025 Title and Author soft cup (Israe.
A10 Types of Population and Sample sampling in the context cohort study.
All mothers who gave birth naturally at the Gondar Community Health Center were sampled using random sampling techniques.
total of 411 participants were included in the All 411 women who gave birth vaginally participated in this e-ISSN: 2338-3445 p-ISSN: 0853-9987 Data Collection fetal weight >4000 g had a higher tendency to undergo episiotomy.
Factors Associated Episiotomy Practices in Gondar City at Public Health Facility Northwest Ethiopia: A Crosectional Study (Ethiopi.
Factors associated practices in Bahirdar City.
Ethiopia:
cross-sectional study (Ethiopi.
Crosectional A12 Episiotomy practice mothers who gave birth at public health facilities in Metema Ethiopia (Ethiopi.
Crosectional All 410 mothers who gave birth normally were recruited using Allocate proportionally to health facilities A13 Episiotomy practices France:
epidemiology and risk (Franc.
Retrospec tive cohort A total of 584 vaginal performed in French hospitals, including 28 Sampling technique:
total sampling Collecting individual data in a standardized diagnosed and then coded.
A14
Prevalence primiparous women in Mulago national Uganda (Ugand.
Crosectional 249 participants were recruited on the first day postpartum after meeting the criteria.
The technique used was Questionnaire A15 To Determine the Affecting Factors of Performing Episiotomy Women Delivering Vaginally in King Crosectional All mothers who gave birth vaginally.
The Questionnaire A11 Crosectional Results Questionnaire The episiotomy was 52.
and factors significantly primipara, fetal distress, and fetal weight.
Questionnaire Primipara, second stage of labor, use of oxytocin, birth weight >4000 grams The episiotomy was 44.
Maternal age 25-35 years, birth spacing <2 years, and use of oxytocin were factors significantly associated with episiotomy.
Among non-operative analgesia, fetal distress, dystocia, fetal weight, breech delivery, and multiple pregnancy are The episiotomy is 73%, long second stage of labor, gestational age above >37 weeks are factors The results showed that 132 primiparas, 66 stiff perineums, and 63 fetal distress had a significant relationship with the incidence of episiotomy.
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A16
A17
A18
Title and Author Salman Armed Forces Western Region Hospital (KSAFWRH) (Saudi Arabi.
Risk (OASIS) and the role retrospective series (German.
Magnitude Episiotomy Associated Factors among Mothers Who Gave Birth in Arba Minch General Hospital.
Southern Ethiopia:
Observation-Based Cross-Sectional Study (Ethiopi.
Episiotomy Medical Indications Vaginal BirthAiRetrospective Analysis Risk Factors Determining the Performance of This Procedure (Polan.
Types of Case Crosectional Case Population and Sample Data Collection Results A total of 42,626 patients were included in the study.
The case group consisted of patients with OASIS, and the control group consisted of patients without signs of OASIS on the day of delivery.
The technique used was a casecontrol study.
Mothers who gave birth at Arba Minch General Hospital.
Using random sampling techniques Collected using a digital obstetric The main factors of OASIS are nulliparous.
TFU height >32 cm, birth weight >3500 gr.
Questionnaire Factors associated with women with secondary education, women with college degrees, birth
>3000
primipara, and BMI <25 kg/m2.
The consisted of patients who had undergone episiotomy and the control group consisted of patients without The casecontrol study.
Patient records from Saint Sophi Hospital Warsaw database of all Risk episiotomy include the use of oxytocin and a long second stage of After data mapping, journal quality was assessed through critical appraisal, assessing potential methodological bias or systematic errors in the research so that reviewers could consider the findings.
The articles were assessed using the Journal of Critical Review (JBI), a freely available critical review tool, based on the assessment of 18 articles, 12 of which received a B grade and six of which received an A grade.
Figure 2.
Analysis Based on Article Value https://doi.
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MEDIA PENELITIAN DAN
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September 2025 Theme Factors Table 4.
Mapping Sub-theme Birth spacing 12
BMI 6 7 9 17
Fetal distress 10 13 15 Birth weight 4 6 8 9 10 11 13 16 17 Parity 1 2 5 6 7 10 15 17 Multiple pregnancy 13 Short Perineum 5 Stiff perineum 15 Long stage II 14 18 TFU >32 cm 16 Use of oxytocin 11 12 18 Instrumented workforce 3 11 13 16 The mapping in Table 4 shows that episiotomy is influenced by various factors, including maternal factors .
uch as BMI, parity, perineal lengt.
, pregnancy conditions .
aby weight, multiple gestation.
TFU), and medical interventions .
xytocin use, instrumental procedure.
These data support the need for a selective approach to episiotomy, taking into account the individual conditions of both mother and baby.
Geographic characteristics of the results A systematic search yielded 18 articles published between 2018-2023, originating from several countries, namely Ethiopia.
USA.
France.
Iran.
Egypt.
Spain.
China, and Uganda.
6%6%
Ethiopia
USA
arab saudi Figure 3.
Analysis by Country Type Based on the 18 selected articles, there were 6 articles of research conducted in developed countries and 12 articles in developing countries.
Characteristics based on research design case control Figure 4.
Analysis by Research Type Based on the 9 selected articles, they were grouped based on their research design, namely quantitative research with cross-sectional studies .
, cohort studies .
, and RCTs .
DISCUSSION
https://doi.
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MEDIA PENELITIAN DAN
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Vol 35 No 3.
September 2025 e-ISSN: 2338-3445 p-ISSN: 0853-9987 Based on the results of a review involving 18 relevant articles, several articles discussed themes that were factors related to episiotomy procedures.
explained in several sub-themes, namely birth spacing, maternal BMI, fetal distress, birth weight, parity, multiple pregnancy, short perineum, stiff perineum, long second stage.
TFU >32 cm, use of oxytocin, and instrumental delivery.
An episiotomy, a surgical procedure that involves cutting the perineum to widen the birth canal, is often performed in high-risk While once considered a routine procedure, its use is now under greater scrutiny, with evidence suggesting it is not always necessary and may carry risks.
Episiotomy is still often used as a preventative measure to reduce further perineal tearing or other complications.
One factor influencing the decision to have an episiotomy is short birth spacing, meaning births occurring less than two years after the previous birth.
Research shows that short birth spacing increases the risk of weakening the mother's reproductive organs, making the perineum more susceptible to tearing.
A study.
revealed that mothers with short birth intervals have a higher risk of experiencing perineal tears, so episiotomy is considered a preventive measure.
Body mass index (BMI) is also closely linked to the likelihood of requiring an Mothers with a high BMI, which can lead to obesity, are more susceptible to severe perineal tears.
The perineal tissue in obese women is less able to stretch, increasing the risk of deep tears.
Data shows that approximately 52% of mothers with a higher BMI are more likely to give birth with an episiotomy.
Excess weight also affects the elasticity of the perineal tissue, making an episiotomy an option to prevent further Fetal distress and multiple pregnancies are also important factors.
A distressed or multiple pregnancy often results in prolonged labor, especially in the second stage.
If not treated promptly, this condition can be life-threatening for the fetus.
In these cases, an episiotomy is performed to expedite labor and reduce the risk of fatal complications for the fetus.
Several studies have shown that.
, showing that episiotomy is effective in reducing the risk of fetal death or other complications that endanger the mother.
A birth weight of >4000 grams and a length of >32 cm increase the risk of episiotomy due to the potential for perineal tearing or distortion.
Parity also plays a role, with primiparas and mothers with short or stiff perineums being more likely to require an The use of oxytocin, which can trigger strong contractions and affect fetal well-being, also increases the likelihood of an episiotomy.
A study at Saint Sophia Hospital showed that the use of oxytocin during the second stage of labor significantly increased the risk of episiotomy (OR = 6.
95% CI: 4.
76Ae7.
Instrumental deliveries, such as vacuum or forceps, often require an episiotomy to widen the birth canal and facilitate safe instrument use, while reducing the risk of severe perineal tears.
The decision to episiotomy is influenced by clinical factors such as birth spacing, maternal BMI, fetal distress, birth weight, parity, multiple gestation, short or rigid perineum, prolonged second stage of labor, oxytocin use, and instrumental delivery.
This study comprehensively mapped these factors from 18 articles, providing a basis for more selective practice.
Weaknesses include reliance on secondary data and limited study Implications include improved clinical practice, maternal education, and opportunities for further research on non-episiotomy techniques and their long-term impact on maternal health.
CONCLUSION
Factors influencing the decision to perform an episiotomy include birth spacing, maternal body mass index (BMI), fetal distress, birth weight, parity, multiple gestation, short or rigid perineum, prolonged second stage of labor, uterine fundal height (FFU) >32 cm, oxytocin use, and instrumental delivery.
These factors increase the risk of perineal tears and labor complications, and therefore, episiotomy is often considered a https://doi.
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MEDIA PENELITIAN DAN
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September 2025 e-ISSN: 2338-3445 p-ISSN: 0853-9987 preventative measure.
Health care providers need to be more selective, guided by clear medical indications, and educate pregnant women about risk factors and prevention, including optimal prenatal care and perineal exercises.
Evidence-based guidelines are needed to ensure episiotomy is performed only when necessary.
Future research is recommended to compare the effectiveness of non-episiotomy methods, such as alternative birth techniques or perineal exercises, and to conduct longitudinal studies to assess their long-term impact.
Examining other factors, such as genetics and prepregnancy health, also has the potential to provide more effective prevention strategies.
REFERENCES