The rapid sociodemographic transition that has been ongoing in India has enormously affected our hygiene practices too, most importantly the type of toilets used in our homes. With the onset of globalization we have transitioned from using the traditional Indian toilet(squatting type) to western. The evolving landscape of hygiene practices in India has witnessed a significant shift, particularly in toilet usage, as globalization and urbanization have influenced daily lifestyles. Traditionally, Indian households predominantly used squatting toilets, a posture that aligns closely with human biomechanics. However, the transition to sitting toilets, inspired by Western sanitation infrastructure, has raised questions regarding its long-term implications on health—especially for pregnant women. Squatting is not merely a cultural norm but a physiologically advantageous position that enhances core muscle strength, maintains pelvic floor integrity, and facilitates smoother bowel and urinary functions. In the context of pregnancy and childbirth, the benefits of squatting extend beyond routine activities—it serves as a natural resistance exercise, strengthening abdominal and pelvic muscles, which are crucial during labor. The squatting posture has been associated with improved fetal descent, reduced labor duration, and lower rates of obstetric interventions, making it a topic of clinical interest. Despite these advantages, sitting toilets are increasingly becoming the standard in modern households, raising concerns about their potential impact on maternal health outcomes. Could the reduction in squatting activity contribute to weaker pelvic muscles and more complicated deliveries? This study aims to explore the association between toilet posture and obstetric outcomes among women delivering at Government Medical College (GMC) Anantnag, offering insights into how a seemingly mundane habit may influence maternal well-being.

Study Design A retrospective observational study was conducted in the Department of Obstetrics and Gynecology at Government Medical College (GMC) Anantnag over a period of six months. This study aimed to evaluate the association between toilet type (squatting vs. sitting) and obstetric outcomes among pregnant women delivering at the institution. A retrospective approach was chosen to analyze pre-existing data from hospital records, allowing for the assessment of delivery outcomes without influencing patient behavior. Study Population Inclusion Criteria The study included 400 pregnant women who delivered at GMC Anantnag and met the following criteria: Primipara women (first-time mothers) Gestational age ≥37 weeks (term pregnancy) Singleton pregnancy (one fetus) Vertex presentation (baby’s head facing down) Women delivering either vaginally or via lower segment cesarean section (LSCS) Absence of pelvic floor disorders No high-risk pregnancies requiring planned cesarean sections (e.g., placenta previa, cephalopelvic disproportion) Exclusion Criteria Women were excluded from the study if they had: Multiple pregnancies (twins or more) Breech or transverse fetal presentation Previous cesarean section or uterine surgery Preterm deliveries (<37 weeks) Known pelvic floor disorders Medical complications affecting labor (e.g., severe preeclampsia, gestational diabetes requiring early induction, intrauterine growth restriction with abnormal Doppler findings) Grouping of Participants Participants were divided into two groups based on their predominant toilet type usage throughout pregnancy: Group 1: Squatting Toilet Users (n = 200) – Women who primarily used Indian-style squatting toilets. Group 2: Sitting Toilet Users (n = 200) – Women who primarily used Western-style sitting toilets. Data Collection Data were collected retrospectively from hospital records, including antenatal history, labor progress notes, and delivery records. The following variables were recorded for each participant: 1. Demographic and Maternal Characteristics Age :Gestational age at delivery Residence: (rural/urban) 2. Obstetric Outcomes Mode of delivery (Vaginal delivery, or cesarean section) Induction of labor (Cerviprime or Misoprostol) Duration of labor (first and second stages) Need for episiotomy Incidence of PPH Statistical Analysis Data analysis was performed using SPSS (Statistical Package for the Social Sciences), version 25.0. 1. Descriptive Statistics Mean ± standard deviation (SD) was used for continuous variables such as maternal age, gestational age, and labor duration. Frequency and percentage (%) were used for categorical variables such as mode of delivery and induction rates. 2. Comparative Analysis Chi-square (χ²) test was used to compare categorical variables such as mode of delivery and labor induction rates. Independent t-test was used to compare continuous variables like labor duration and neonatal birth weight. 3. Statistical Significance A p-value < 0.05 was considered statistically significant, indicating a meaningful association between the toilet type and obstetric outcomes. 4. Subgroup Analysis Further analysis was conducted based on maternal BMI and gestational age to assess if these factors influenced the relationship between toilet type and delivery outcomes. Ethical Considerations Approval for the study was obtained from the Institutional Ethical Committee of GMC Anantnag. Since this was a retrospective study, informed consent was waived, but patient data confidentiality was strictly maintained.

1. Participant Characteristics The study included 400 women, with 100% of rural women using squatting toilets, while 60% of urban women used sitting type of toilet. This distribution reflects the cultural and infrastructural variations among rural and urban populations. 2. Mode of Delivery | Mode of Delivery | Squatting Toilet Users (n=200) | Sitting Toilet Users (n=200) | |-------------------|--------------------------------|-------------------------------| | Vaginal Delivery | 144 (72%) | 113 (56.5%) | | Cesarean Section | 56 (28%) | 87(43.5%) | The higher rate of vaginal delivery among squatting toilet users (70%) compared to sitting toilet users (55%) suggests that squatting may enhance pelvic floor strength and facilitate natural childbirth. This finding aligns with Gupta et al. (2017), who reported that squatting improves pelvic floor tone, reducing the need for cesarean sections. 3. Induction of Labor | Induction Method | Squatting Toilet Users (n=76) | Sitting Toilet Users (n=112) | |-------------------|--------------------------------|-------------------------------| | Cerviprime | 64 (84.2%)| 93 (78.7%)| | Misoprostol | 12(15.8%) | 19 (21.3%)| The higher frequency of labor induction in sitting toilet users may indicate weaker pelvic floor muscles, necessitating medical intervention. This observation is consistent with Bortolini et al. (2020), who found that squatting exercises during pregnancy reduce the need for labor induction. 4. Labor Duration | Labor Stage | Squatting Toilet Users | Sitting Toilet Users | |------------|------------------------|----------------------| | First Stage (Mean) | 6.5 ± 1.2 hours | 7.0 ± 1.5 hours | | Second Stage (Mean) | 45 ± 10 minutes | 60 ± 15 minutes | The significantly shorter second stage of labor in squatting toilet users (45 minutes) compared to sitting toilet users (60 minutes) suggests that squatting may enhance the efficiency of the birthing process. This finding is supported by WHO (2021) recommendations, which advocate for upright positions, including squatting, during labor to promote physiological birth. Page 04 5. Maternal Outcomes Squatting toilet users had fewer episiotomies, while postpartum hemorrhage rates were comparable in both groups. The reduced incidence of need for episiotomy in squatting toilet users highlights the protective effect of squatting on maternal tissues during delivery. Variable Squatting Toilet Users (n=200) Sitting Toilet Users (n=200) Statistical Significance (p-value) Mode of Delivery Vaginal Delivery 144 (72%) 113 (56.5%) <0.05 (Significant) Cesarean Section 56 (28%) 87 (43.5%) <0.05 (Significant) Labor Induction Induced Cases 76 (38%) 112 (56%) <0.05 (Significant) Cerviprime Used 64 (84.2%) 93 (78.7%) NS (Not Significant) Misoprostol Used 12 (15.8%) 19 (21.3%) NS (Not Significant) Labor Duration First Stage (Mean) 6.5 ± 1.2 hours 7.0 ± 1.5 hours <0.05 (Significant) Second Stage (Mean) 45 ± 10 minutes 60 ± 15 minutes <0.05 (Significant) Maternal Outcomes Episiotomy 102 (70.83%) 108 (95.5%) <0.05 (Significant) Postpartum Hemorrhage (PPH) 10 (5%) 12 (6%) NS (Not Significant)

This study aimed to explore the impact of toilet type (squatting vs. sitting) on obstetric outcomes in pregnant women delivering at GMC Anantnag. The results indicate that women who primarily used squatting toilets experienced more favorable obstetric outcomes compared to those who used sitting toilets. Specifically, squatting toilet users had a higher rate of spontaneous vaginal deliveries (72% vs. 56.5%), shorter second-stage labor durations (45 minutes vs. 60 minutes), and fewer episiotomies. Additionally, the need for labor induction was significantly lower in the squatting toilet group (38% vs. 56%), suggesting that squatting may contribute to stronger pelvic floor muscles, enhancing the efficiency of labor and reducing the need for medical interventions. The findings of this study are consistent with existing literature that suggests squatting posture has a positive impact on pelvic floor strength and overall labor outcomes. Gupta et al. (2017) emphasized the role of squatting in improving pelvic floor tone, which can reduce the likelihood of complications and the need for caesarean sections. Similarly, Bortolini et al. (2020) found that squatting exercises during pregnancy significantly reduced the rates of labor induction, supporting the results observed in this study. One of the key findings of this study is the shorter duration of the second stage of labor in squatting toilet users. This is in line with the recommendations from the World Health Organization (2021), which advocate for upright positions, including squatting, during labor to facilitate a more efficient and physiological birth process. Squatting opens up the pelvis and helps in the descent of the baby, which likely explains the reduced duration of the second stage of labor observed in the squatting toilet group. This reduced labor duration is a significant benefit, as prolonged labor can lead to complications such as fetal distress and increased need for medical interventions like forceps or caesarean sections. Page 05 The study also highlights the lower incidence of episiotomy in squatting toilet users. This finding is important because episiotomy, although a common intervention during childbirth, carries risks such as infection, delayed healing, and increased postpartum pain. A reduced need for episiotomy suggests that squatting positions may help in maintaining the integrity of the perineum during delivery. This observation aligns with previous research that suggests squatting helps to control the rate of fetal descent, allowing the perineum more time to stretch naturally, thereby reducing the need for surgical intervention. However, some limitations should be considered when interpreting these results. The study design was retrospective, relying on hospital records for data collection. As such, there may be inherent biases in the data, such as incomplete or inaccurate reporting of certain outcomes. Furthermore, while the study provides useful insights into the association between toilet type and obstetric outcomes, it does not establish causality. Randomized controlled trials or prospective cohort studies would be necessary to definitively determine whether squatting posture directly influences labor outcomes. Additionally, the study population was limited to women delivering at GMC Anantnag, which may not be fully representative of the broader population of pregnant women in different regions of India or elsewhere.

This study suggests that the type of toilet used by pregnant women may play a significant role in influencing labor outcomes. Women who predominantly used squatting toilets demonstrated better obstetric outcomes, including higher rates of spontaneous vaginal delivery, shorter labor duration, , compared to women who used sitting toilets. The findings support the hypothesis that squatting posture may strengthen the pelvic floor and promote more efficient labor progression. While these results are promising, further research is needed to confirm the long-term implications of toilet posture on maternal health. Specifically, prospective studies with larger sample sizes and multi-center designs are required to establish stronger evidence for the observed associations and to explore potential mechanisms behind these outcomes. Additionally, research should investigate the broader effects of squatting exercises on pelvic floor health and how these benefits can be incorporated into prenatal care programs. In light of the increasing adoption of sitting toilets in urban areas, it is essential for healthcare providers to educate pregnant women about the potential advantages of squatting positions and pelvic floor exercises during pregnancy. Encouraging women to adopt practices that strengthen pelvic floor muscles may help improve their labor experiences and reduce the need for medical interventions. Public health campaigns could also emphasize the benefits of traditional squatting practices, particularly for women in rural areas who may have better access to squatting toilets.

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