Episiotomy practice and perineal outcomes in low risk vaginal deliveries: comparing a hospital attached birth center and delivery suite in Beirut, Lebanon

Abstract

Background: Episiotomy is considered a protective intervention when used selectively rather than routinely. Although current obstetric practice no longer recommends routine episiotomy, data on its use remain limited, particularly in Lebanon.

Objective: This study evaluated the prevalence, predictors, and maternal outcomes of episiotomy in low-risk vaginal deliveries and compared its use between a hospital-attached birth center (BC) and a delivery suite (DS).

Methods: A retrospective observational study was conducted using data from Rafik Hariri University Hospital (RHUH) BC and DS between January 2024 and September 2025. A total of 333 patients were included. Data were analyzed using SPSS v23. Binary logistic regression identified predictors of episiotomy, while associations with maternal outcomes were assessed using risk ratios and number needed to treat.

Results: The episiotomy rate was 28.5%, with no significant difference between BC and DS. Rates were higher among primiparous women. Episiotomy was associated with lower rates of perineal injury overall (NNT = 4 for both parity groups). Among primiparous women, those without episiotomy had significantly higher rates of paraurethral injury (41.2 vs 12.3%, p = 0.011) and first-degree tears (35.3 vs 11.0%). On multivariate logistic regression, independent predictors of episiotomy included primiparity (aOR = 39.18, 95%, CI 18.42–83.33), private patient status (aOR = 21.72, 95%, CI 3.33–141.64), older age (aOR = 0.93, 95% CI: 0.86–0.99), and greater cervical dilation at admission (aOR = 0.74, 95% CI: 0.60–0.91).

Conclusion: Episiotomy use varies by case and remains common in low-risk pregnancies, especially among primiparous women. Predictive and preventive factors associated with its use were identified.

PLAIN LANGUAGE SUMMARY

Episiotomy is a small surgical cut made between the vagina and the anus during childbirth. It is done in order to help the baby pass through more easily. It was once done routinely for almost all women giving birth for the first time, but health organizations now recommend using it only when truly necessary.

This study looked at how often episiotomy was performed at Rafik Hariri University Hospital (RHUH) in Beirut, Lebanon. The hospital has both a midwife-led birth center and a standard delivery suite. We included 333 women with low-risk pregnancies who delivered vaginally between January 2024 and September 2025.

We found that about 1 in about 3 women received an episiotomy. Women giving birth for the first time were much more likely to have one. There was no notable difference in the rates of episiotomy between the birth center and the delivery suite.

Women who had an episiotomy were less likely to experience perineal tearing or injury around the urethra, particularly among first-time mothers.

The study also found that younger age, being a first-time mother, having less cervical dilation on arrival, and being a private patient were the strongest predictors of receiving an episiotomy.

Overall, the episiotomy rate at RHUH is lower than older Lebanese data and lower than most neighboring countries, which can suggest progress toward evidence-based practice. However, the rate remains above the World Health Organization’s recommended level of 10%.

All in all, this study is one of the few to examine episiotomy in Lebanon, which has a large refugee population. The findings of this study can help inform better and more individualized obstetric care.

ARTICLE HIGHLIGHTS

• Episiotomy rate at RHUH (Rafik Hariri University Hospital) was 28.5%. It is indeed lower than regional averages. Nevertheless, it still exceeds the recommended threshold of 10% set by the WHO.

• No statistically significant difference in the rates of episiotomies was observed between hospital attached birth center (27.3%) and the delivery suite (30.2%).

• Primiparous women had significantly higher episiotomy rates in both settings (BC: 82.4; DS: 79.5%) compared to multiparous women (BC: 7.7%; DS: 11.0%).

• Episiotomy was associated with reduced perineal injury rates in both primiparous and multiparous women. There were also statistically significant reductions in first-degree tears and paraurethral injuries among primiparous women

• Independent predictors of episiotomy included primiparity (aOR 39.18), private patient status (aOR 21.72), younger maternal age (aOR 0.93), and lesser cervical dilation at admission (aOR 0.74).

• All in all, our findings support selective rather than routine episiotomy practice, particularly in low-resource and refugee settings.

1. Introduction

It is undeniable that the main goal in clinical practice is to optimize patient care. From this perspective, physicians are constantly striving to improve health outcomes [1]. This is especially the case in the field of obstetrics and gynecology. Indeed, episiotomy, a perineal incision performed during the second stage of labor, was regarded as a protective measure. Historically, it was extensively performed as a routine standard procedure. However, the World Health Organization (WHO) and American College of Obstetricians and Gynecologists (ACOG) advise against its routine use, and only when benefits outweigh possible risks [2].

Circumstances that impel toward opting for an episiotomy include non-reassuring fetal status, atypical fetal presentations, the need for an operative vaginal delivery, and the risk for a severe perineal tear occurring mainly in primiparous females.

It is mainly achieved by performing a mediolateral perineal incision, as evidenced by previous studies [3]. To elaborate, perineal lacerations are of four degrees. A first-degree tear involves the perineal skin only, a second-degree tear involves the perineal muscles but not the anal sphincter, a third-degree tear involves the anal sphincter complex, and a fourth-degree tear involves the anal sphincter complex and anal mucosa. Perineal tears, especially third and fourth degree lacerations known as Obstetric Anal Sphincter Injury (OASI), could collectively lead to short- and long-term postpartum adverse outcomes such as urinary and/or fecal incontinence and dyspareunia. Opting for an episiotomy prevents severe natural trauma from occurring in the perineal area [4,5].

Regarding the benefit-to-risk ratio of interventions applied to promote perineal care in Lebanon, current literature is insufficient and remains far from being conclusive [6]. As the available data reported from Lebanese health centers may no longer be current, new updates on episiotomy practice are required.

To expand the scope of Lebanese obstetrical practice, this study aims to report and assess factors affecting the likelihood of episiotomy performance in low-risk pregnancies as well as the respective postpartum outcomes. In particular, this study evaluates episiotomy in a hybrid care model. It also frames it in the context of low-resources settings, which are further burdened by high refugee rates.

2. Methods

This study is a retrospective observational study in the Obstetrics and Gynecology Department at Rafik Hariri University Hospital (RHUH), Beirut. RHUH is a Lebanese tertiary hospital that has the only hospital-attached BC in Lebanon in addition to its DS. It is important to note that midwives in the RHUH BC do not perform episiotomies, as they are done by the obstetrician if needed. As for the DS, it involves obstetricians, midwives, and residents. Data from both the DS and BC between January 2024 and September 2025 was collected from written hospital records and subsequently entered into an electronic data sheet. Collected data included demographic patient characteristics, gravidity, parity, abortions, gestational age, episiotomy status, cervical dilation at presentation, past medical and surgical history, and several fetal and maternal outcomes (APGAR score, NICU, perineal injury, paraurethral injury, bleeding after delivery, etc.). Primiparity was defined for women after the studied delivery, and so the term “nulliparous” was not used. Patient sources are defined as: “out-patient department” (OPD) which follow up and attends the outpatient clinics in the hospital RHUH, “out” patients from public health care (PHC) or Médecins Sans Frontières (MSF); and “private”. Blood loss was estimated visually, and standard childbirth blood loss was considered 400 mL. Institutional Review Board (IRB) approval was obtained, and informed consent was not needed since data was collected from retrospective medical records anonymously.

Inclusion criteria in this study met the following criteria: (1) singleton pregnancy, (2) vertex presentation, (3) term gestation (≥37 weeks), (4) low-risk pregnancy without maternal or fetal complications, and (5) vaginal delivery at RHUH between January 2024 and September 2025. Exclusion criteria included shoulder dystocia, operative vaginal delivery (vacuum/forceps), non-reassuring fetal heart rate tracing, twin or multiple gestations, abnormal fetal presentations, preterm labor (<37 weeks), vulvar varicosities, severe fetal anomalies, and any other high-risk pregnancies that required emergent obstetric intervention (Figure 1).

Figure 1.

Inclusion and exclusion criteria for study population.

*Low-risk pregnancies were defined as term singleton vertex pregnancies without maternal or fetal complications that required operative or emergent obstetric intervention.

The final sample consisted of 333 from 485 patients admitted to BC.

2.1. Data analysis

Analysis was conducted using Statistical Package for the Social Sciences (SPSS) V23. Qualitative variables were represented using frequencies and percentages, and their associations were tested using the chi-square and Fisher’s exact test. Quantitative variables were represented using means and standard deviations. Multiple binary logistic regression55 was done to determine risk factors for episiotomy. Adjusted odds ratios (aOR), relative risk (RR), and number needed to treat (NNT) were calculated for different associations. Statistical significance was set at a p-value < 0.05.

Variables were selected based on their clinical relevance to episiotomy as established in prior literature, as well as statistical significance in univariate analyses (p < 0.05). The final model included age, patient source (OPD, private, out), primiparity, and cervical dilation at admission.

Perineal injuries were classified according to the standard four-degree system. Indeed, first-degree tears involve the perineal skin and/or vaginal mucosa only. In parallel, second-degree tears further extend into the perineal muscles, yet they spare the anal sphincter. In contrast, third-degree tears involve the anal sphincter (internal or external). Finally, fourth degree tears extend through the anal sphincter into the anorectal mucosa.

On another level, paraurethral injury was defined as any laceration that involves the periurethral, anterior vaginal, vestibular, clitoral, or labial tissue.

Postpartum hemorrhage was defined as estimated blood loss which exceeds 500 mL.

Neonatal outcomes included APGAR score at five minutes (with a score ≥7 considered reassuring) and admission to the Neonatal Intensive Care Unit (NICU).

3. Results

Our sample consisted of 333 total women across BC and transfer to DS for induction or augmentation of labor. The respective characteristics of patients are described in Table 1. Of all the women in our study, only 28.5% had an episiotomy. The rates of episiotomy in DS and BC according to primiparity are reported in Table 2. There was no statistically significant difference in the total rate of episiotomy between the BC (27.3%) and DS (30.2%). Furthermore, in the BC group the rate of episiotomy in primiparous women was 82.4% compared to only 7.7% in multiparous women (p-value < 0.001). A similar association was found in the DS group, where the rate of episiotomy in primiparous women was significantly greater than in multiparous women (79.5 and 11.0%, respectively, p-value < 0.001). Overall, primiparous women had a 10.75 times higher risk of episiotomy, compared to multiparous women in the BC (95%, CI = 5.98–19.23) and a 7.25 times higher risk in the DS (95%, CI = 4.05–12.99).

Table 1.

Sample characteristics.

		Mean +/−SD
Age		26 +/−6
Gravida		3 +/−2
Para		3 +/−2
Aborta		1 +/−1
		Count (Column N%)
Primiparity	No	243 (73.0%)
	Yes	90 (27.0%)
Nationality	Bangladeshi	11 (3.3%)
	Ethiopian	11 (3.3%)
	Indian	1 (0.3%)
	Lebanese	39 (11.7%)
	Sri Lankan	1 (0.3%)
	Sudanese	8 (2.4%)
	Syrian	261 (78.4%)
	Palestinian	1 (0.3%)
Residence	City	63 (18.9%)
	Rural	270 (81.1%)
Source	opd	148 (44.4%)
	Private	9 (2.7%)
	Out	176 (52.9)
DS or BC	BC birth center	194 (58.3%)
	DS delivery suite	139 (41.7%)
Episiotomy	No	238 (71.5%)
	Yes	95 (28.5%)

Table 2.

Episiotomy rate according to primiparity in DS and BC.

				Episiotomy
				No	Yes
				Count (row N%)	Count (row N%)
DS or BC	Birth center	Primiparity	No	132 (92.3%)	11 (7.7%)
			Yes	9 (17.6%)	42 (82.4%)
			Total	141 (72.7%)	53 (27.3%)
	Delivery suite	Primiparity	No	89 (89%)	11 (11%)
			Yes	8 (20.5%)	31 (79.5%)
			Total	97 (69.8%)	42 (30.2%)

On another level, the outcomes of episiotomy results were grouped across primiparous and multiparous women and are shown in Table 2. In both groups, perineal injury was more common in women who did not undergo an episiotomy compared to those who did (p-value = 0.014 in multiparous and p-value = 0.003 in primiparous). When looking at the different degrees of perineal injury, the same association was found in both groups with respect to first-, second-, and third- degree perineal injuries. However, the results were only statistically significant for the first-degree injuries. Moreover, the rate of paraurethral injury in women who had an episiotomy was found to be significantly lower than in those who did not. This was specially significant in the primiparous group (p value = 0.011). To note, no significant association was found in the multiparous group. Additionally, no significant associations were found between episiotomy status among primiparous and multiparous groups and the following outcomes: cervical injury, fetal NICU entry, APGAR score of 7 or higher, and bleeding after delivery. The number needed to treat (NNT) for an episiotomy to prevent one perineal injury was 4 in both primiparous and multiparous women.

Lastly, a multivariate binary logistic regression model was developed to determine predictors of episiotomy (Table 3). The model was significant (p value < 0.001) with a sensitivity of 78.9% and a specificity of 92.4%. It had a Nagelkerke (pseudo) R² of 0.61, meaning 61% of the variance in our outcome variable was accounted for by the predictors in our model. Age, patient source, primiparity, and cervical dilation were included in the final model as significant predictors (Table 4). Older age and greater cervical dilation at presentation were protective against episiotomy, whereas primiparity and private patient status were risk factors for episiotomy.

Table 3.

Rates of maternal and fetal outcomes according to episiotomy status stratified by parity.

		Primiparity
		No		Yes
		Episiotomy		Episiotomy
		No	Yes	No	Yes
		Count (column N%)	Count (column N%)	Count (column N%)	Count (column N%)
Perineal injury	No	157 (71.0%)	21 (95.5%)	8 (47.1%)	61 (83.6%)
	1st degree	46 (20.8%)	0 (0.0%)	6 (35.3%)	8 (11.0%)
	2nd degree	18 (8.1%)	1 (4.5%)	2 (11.8%)	4 (5.5%)
	3rd degree	0 (0.0%)	0 (0.0%)	1 (5.9%)	0 (0.0%)
Paraurethral injury	No	207 (93.7%)	20 (90.9%)	10 (58.8%)	64 (87.7%)
	Yes	14 (6.3%)	2 (9.1%)	7 (41.2%)	9 (12.3%)
Cervical injury	No	209 (94.6%)	22 (100%)	15 (88.2%)	68 (93.2%)
	Yes	12 (5.4%)	0 (0.0%)	2 (11.8%)	5 (6.8%)
NICU Di	No	217 (98.2%)	21 (95.5%)	17 (100%)	72 (98.6%)
	Yes	4 (1.8%)	1 (4.5%)	0 (0.0%)	1 (1.4%)
APGAR 7 and above	No	2 (0.9%)	1 (4.5%)	0 (0.0%)	4 (5.5%)
	Yes	219 (99.1%)	21 (95.5%)	17 (100%)	69 (94.5%)

Table 4.

Multivariate regression of outcome (episiotomy) with other covariates.

	Coefficient	p-value	Adjusted or	95% C.I.
Age	−0.077	0.030	0.926	0.863–0.992
Cervical dilation	−0.301	0.005	0.740	0.601–0.913
Source		0.001
Private	3.078	0.001	21.722	3.331–141.64
Out	−0.445	0.233	0.641	0.309–1.332
Primiparity	3.668	0.000	39.177	18.419–83.329

4. Discussion

The rate of episiotomy in Lebanon is marginally covered in the existing body of literature with very few studies tackling it. In a study dating back to 2,000, a semi-structured questionnaire showed that the rate of episiotomy was at least 30% in more than 33 of the 39 hospitals in Lebanon [7]. In a second study, the average episiotomy rate between 2009 and 2014 in an anonymous hospital was 73.3% [6].

Our study found the episiotomy rate in RHUH to be 28.5%, which is lower than the previously known rates. This persistent gap between the observed rates and WHO recommendations most likely stems from the absence of institutionally standardized, evidence-based guidelines for selective episiotomy in Lebanon. It can also be reflective of provider discretion when it comes to episiotomy practice.

Of interest, the rate found in our study nearly equated to half the average episiotomy rate in Gulf Council Countries (GCC), which is 52%. Looking into the rates of individual countries, the rate of episiotomy was 36.4% in Saudi Arabia in 2015, 34.6% in the UAE in 2006, 39.9% in Oman in 2015, 73.9% in Iraq in 2019, 60% in Qatar in 2008, and 28.7% in Palestine between March 2015 and 2016 [8,9]. These findings are all higher than the rate found in our study, albeit with significant variability. As for countries outside the Middle East, our rate was lower than countries such as Turkey (74.2%) and Ethiopia (42.75%) but higher than more developed countries like the United States (24.5%), Hong Kong (27%), and France (19.9%) [10,11]. It is also worth noting that the recommended episiotomy rate by the World Health Organization (WHO) is 10% [12]. From this perspective, while it is true that our findings are lower than multiple nations, it still exceeds the WHO recommendation. This result might stem from the absence of clear indications and guidelines for selective episiotomy.

When grouped by delivery setting, a rate of 27.3% was found in the BC and 30.2% in the DC. On the contrary, according to a study about midwife lead care, births attended by midwives in stand-alone birth centers had lower episiotomy rates than those in hospital settings (12.7% compared to 28.7%) [13]. The difference between both settings in our study was not pronounced and was not statistically significant. This can be attributed to the BC being hospital-attached and the frequent involvement of obstetricians, which may alter the midwife practice in the BC. Rates were further stratified according to parity. The rate of episiotomy in primiparas was significantly greater in both the BC (82.4%) and DS (79.5%) compared to the rates in multiparas in these settings (7.7 and 11% respectively). A similar study in Ethiopia also showed a significant difference between the rates in primiparas and multiparas, 61.45 and 30.47% respectively [11]. Another study in Saudi Arabia also showed this significant difference in rates, with 87.6% of primiparas having episiotomies opposed to only 16.1% of multiparas [14]. This finding might stem from longer second stages of labor, tighter perineal tissue, or instrumental deliveries in primiparas compared to multiparas.

Perineal tears are a common complication that occurs during childbirth, with rates reaching 90% in primiparas and 70% in multiparas. A perineal tear is an injury to the area between the vagina and the anus. Perineal tears are classified into 4 degrees. First-degree tears, which are small and affect only the skin. Second-degree tears, which involve the skin and the muscle but spare the anal sphincter. Third-degree tears tend to extend to the anal sphincter. Lastly, fourth-degree tears go all the way to the anorectal mucosa [5,15]. These tears were evaluated as outcomes with respect to episiotomy status in our study. In multiparous women who had an episiotomy, the percentages of perineal injuries were as follows: 95.5% had no injury, 0% had 1st-degree injury, 4.5% had 2nd-degree injury and 0% had 3rd-degree injury which is lower than the group that did not have an episiotomy. Moreover, primiparous women who had an episiotomy were also less likely to have perineal tears with 83.6% having no tears compared to 47.1% for women who did not undergo episiotomy. In addition, 11% had 1st degree tear compared with 35.3, 5.5% had 2nd degree lacerations compared with 11.8, and 0% had 3rd degree laceration compared to 5.9%. This shows that women who had episiotomy were less likely to have perineal laceration irrespective of being primiparous or multiparous. To reiterate, our results were only statistically significant for first-degree injuries, which are generally self-limiting and associated with minimal long-term morbidity. The absence of significant reductions in second- and third-degree tears further reinforces the selective approach. These findings are in line with the existing body of literature. Indeed, performing selective episiotomy has been shown to decrease the risk of lacerations compared to performing routine or not performing episiotomies [16]. In contrast, other studies showed that episiotomy increases the rate of first- and second-degree lacerations and has no effect on more severe tears [17]. The existing evidence on the matter is also confounding, as a decreased rate of episiotomy was not associated with higher rates of lacerations [18]. As a matter of fact, it is safe to say that the protective outcome of episiotomy against perineal laceration remains unclear. Therefore, the need to adopt a selective episiotomy becomes more prominent. There is also an increasing need to establish objective guidelines to benefit from the advantages of episiotomy.

Moreover, paraurethral tear is a broad term that encompasses a wide range of injuries surrounding the urethra, including anterior vaginal, periurethral, vestibular, clitoral, and labial damage. Such complications are often underdiagnosed [19]. Additionally, higher rates of paraurethral injuries were reported among deliveries without an episiotomy, which exposed women to a pricking pain in well innervated areas [19]. Our results further support this aspect of episiotomy. Indeed, lower rates of paraurethral injuries in primiparas who received a perineal incision were detected.

Episiotomy is deemed a surgical procedure, with certain predictors contributing to its prevalence among various groups. Maternal age, a previously studied predictor in the literature, has had controversial results. A study in Singapore suggested that older women are more prone to receive an episiotomy due to reduced perineal elasticity [20]. In contrast, our findings suggest older maternal age as a protective characteristic, which aligns with other studies in the literature [21].

Progressive cervical dilation, a proposition that has been thoroughly tested in recent work, could be a potential element that preserves women from perineal incisions. Our results, consistent with findings in a Turkish study, suggest that greater dilation is associated with fewer rates of episiotomy [22]. When it comes to addressing the risk factors, primiparity and private patient status were determined. As stated in the literature, episiotomy is highly frequent in primiparas [22]. Additionally, previous studies have demonstrated that attending a private obstetrician can increase the risk of episiotomy by seven-fold. All in all, these predictors denote how complex the variables that drive episiotomy are.

5. Strengths

This study carries several notable strengths. First, it is among the very few studies to examine episiotomy practice and perineal outcomes in Lebanon, which is underrepresented in the obstetric literature. Second, the study focuses on low-risk vaginal deliveries. Accordingly, it increases internal validity by reducing heterogeneity. Finally, this study contributes data from a low-resource, refugee-burden settings, which is often marginalized and often underrepresented in the literature.

6. Limitation

It is true that this research has contributed significant insight into the existing body of literature, especially in low-resource settings such as RHUH in Lebanon. Nonetheless, multiple limitations have to be noted. The retrospective nature of the study and reliance on medical record data may introduce information bias and limit the ability to control for all potential confounders. The limited sample size of this study may have restricted the analysis of some parameters. This is mainly due to the absence of data on third- and fourth-degree lacerations. In addition, it is worth noting that data on manual perineal protection techniques used during delivery (hands-on vs. hands-poised) were not systematically documented in our medical records and, therefore, could not be analyzed. Future studies could study this aspect, especially since it can have an impact on perineal outcomes. Additionally, it should not be overlooked that this study only takes place in a single center in Lebanon. Therefore, its findings are not necessarily generalizable to the wider population. Future multi-institutional studies could help in addressing this gap. Furthermore, multiple variables such as duration of the second stage of labor, fetal birth weight, and analgesia use were not available.

7. Conclusion

All in all, episiotomy in the context of low-risk vaginal deliveries remains prevalent. This is especially the case among primiparous women. Certain maternal factors were found to be predictive of episiotomy use. While associations between episiotomy and reduced perineal injury were observed, these findings must be interpreted with caution. Indeed, since our study has a retrospective observational design, it has potential for residual confounding. These results do not establish causality. They should inform rather than replace clinical judgment.

That being said, our findings provide insight into the Lebanese context. They also reinforce current recommendations that advocate for selective episiotomy practice rather than routine application.

Author contributions

Kariman Ghazal: Conceptualization; Methodology; Supervision; Project administration; Writing – review & editing; Final approval. Christopher Massaad: Methodology; Formal analysis; Validation; Writing – review & editing. Mohammed Zaatari: Data curation; Investigation; Writing – original draft; Visualization. Georges Yared: Supervision; Writing – review; Visualization. Manal Dahrouj: Investigation; Data curation; Validation. Abdullah Kadhim: Data curation; Investigation; Resources. Ahmad Sabbagh: Investigation; Writing – review & editing. Issam Hijazi: Investigation; Validation; Resources. Julia Ftouny: Data curation; Investigation; Writing – review & editing. Charlotte Al Hajjar: Supervision; Writing – review; Visualization.

Disclosure statement

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Institutional Review Board statement

Ethical approval for this study was granted by Dr. Muhammad Al-Zahtari, the authorized representative responsible for ethical oversight at Rafik Hariri University Hospital (RHUH). Due to the ongoing administrative disruptions related to the prolonged healthcare and institutional crisis in Lebanon, a formal written reference number could not be issued at the time of approval. Nevertheless, the study was reviewed and approved in accordance with institutional ethical standards and the principles of the Declaration of Helsinki. All data were collected retrospectively from anonymized medical records, and no direct patient identifiers were accessed.

Informed consent statement

Given the retrospective nature of the study and the use of fully anonymized data, the requirement for informed consent was waived.

Care checklist statement

This manuscript was developed following the CARE guidelines to ensure transparent and complete reporting.

Data availability statement

The data supporting the findings of this study are available from the corresponding author upon reasonable request.