Birth-Related Perineal Trauma in Low- and Middle-Income Countries: A Systematic Review and Meta-analysis

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Abstract

Introduction Birth-related perineal trauma (BPT) is a common consequence of vaginal births. When poorly managed, BPT can result in increased morbidity and mortality due to infections, haemorrhage, and incontinence. This review aims to collect data on rates of BPT in low- and middle-income countries (LMICs), through a systematic review and meta-analysis. Methods The following databases were searched: Medline, Embase, Latin American and Caribbean Health Sciences Literature (LILACs), and the World Health Organization (WHO) regional databases, from 2004 to 2016. Cross-sectional data on the proportion of vaginal births that resulted in episiotomy, second degree tears or obstetric anal sphincter injuries (OASI) were extracted from studies carried out in LMICs by two independent reviewers. Estimates were meta-analysed using a random effects model; results were presented by type of BPT, parity, and mode of birth. Results Of the 1182 citations reviewed, 74 studies providing data on 334,054 births in 41 countries were included. Five studies reported outcomes of births in the community. In LMICs, the overall rates of BPT were 46% (95% CI 36–55%), 24% (95% CI 17–32%), and 1.4% (95% CI 1.2–1.7%) for episiotomies, second degree tears, and OASI, respectively. Studies were highly heterogeneous with respect to study design and population. The overall reporting quality was inadequate. Discussion Compared to high-income settings, episiotomy rates are high in LMIC medical facilities. There is an urgent need to improve reporting of BPT in LMICs particularly with regards to births taking in community settings.

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Most cited references 96

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Critical appraisal of the health research literature: prevalence or incidence of a health problem.

James Stratford, Anna L. Chambers, J. Roberts … (1997)

This article identifies and discusses criteria that can be used by health professionals to critically appraise research articles that estimate the prevalence or incidence of a disease or health problem. These guidelines will help determine the validity and usefulness of such community assessment studies. The criteria relate to the validity of the study methods (design, sampling frame, sample size, outcome measures, measurement and response rate), interpretation of the results and applicability of the findings. The research question "What is the prevalence of dementia in Canada?" is used as an example for this paper.

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60 Million non-facility births: who can deliver in community settings to reduce intrapartum-related deaths?

Gary Darmstadt, Anne C C Lee, Simon Cousens … (2009)

For the world's 60 million non-facility births, addressing who is currently attending these births and what effect they have on birth outcomes is a key starting point toward improving care during childbirth. We present a systematic review of evidence for the effect of community-based cadres-community-based skilled birth attendants (SBAs), trained traditional birth attendants (TBAs), and community health workers (CHWs)-in improving perinatal and intrapartum-related outcomes. The evidence for providing skilled birth attendance in the community is low quality, consisting of primarily before-and-after and quasi-experimental studies, with a pooled 12% reduction in all cause perinatal mortality (PMR) and a 22%-47% reduction in intrapartum-related neonatal mortality (IPR-NMR). Low/moderate quality evidence suggests that TBA training may improve linkages with facilities and improve perinatal outcomes. A randomized controlled trial (RCT) of TBA training showed a 30% reduction in PMR, and a meta-analysis demonstrated an 11% reduction in IPR-NMR. There is moderate evidence that CHWs have a positive impact on perinatal-neonatal outcomes. Meta-analysis of CHW packages (2 cluster randomized controlled trials, 2 quasi-experimental studies) showed a 28% reduction in PMR and a 36% reduction in early neonatal mortality rate; one quasi-experimental study showed a 42% reduction in IPR-NMR. Skilled childbirth care is recommended for all pregnant women, and community strategies need to be linked to prompt, high-quality emergency obstetric care. CHWs may play a promising role in providing pregnancy and childbirth care, mobilizing communities, and improving perinatal outcomes in low-income settings. While the role of the TBA is still controversial, strategies emphasizing partnerships with the health system should be further considered. Innovative community-based strategies combined with health systems strengthening may improve childbirth care for the rural poor, help reduce gross inequities in maternal and newborn survival and stillbirth rates, and provide an effective transition to higher coverage for facility births.

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Episiotomy for vaginal birth.

Luciano E Mignini, Guillermo Carroli (2009)

Episiotomy is done to prevent severe perineal tears, but its routine use has been questioned. The relative effects of midline compared with midlateral episiotomy are unclear. The objective of this review was to assess the effects of restrictive use of episiotomy compared with routine episiotomy during vaginal birth. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (March 2008). Randomized trials comparing restrictive use of episiotomy with routine use of episiotomy; restrictive use of mediolateral episiotomy versus routine mediolateral episiotomy; restrictive use of midline episiotomy versus routine midline episiotomy; and use of midline episiotomy versus mediolateral episiotomy. The two review authors independently assessed trial quality and extracted the data. We included eight studies (5541 women). In the routine episiotomy group, 75.15% (2035/2708) of women had episiotomies, while the rate in the restrictive episiotomy group was 28.40% (776/2733). Compared with routine use, restrictive episiotomy resulted in less severe perineal trauma (relative risk (RR) 0.67, 95% confidence interval (CI) 0.49 to 0.91), less suturing (RR 0.71, 95% CI 0.61 to 0.81) and fewer healing complications (RR 0.69, 95% CI 0.56 to 0.85). Restrictive episiotomy was associated with more anterior perineal trauma (RR 1.84, 95% CI 1.61 to 2.10). There was no difference in severe vaginal/perineal trauma (RR 0.92, 95% CI 0.72 to 1.18); dyspareunia (RR 1.02, 95% CI 0.90 to 1.16); urinary incontinence (RR 0.98, 95% CI 0.79 to 1.20) or several pain measures. Results for restrictive versus routine mediolateral versus midline episiotomy were similar to the overall comparison. Restrictive episiotomy policies appear to have a number of benefits compared to policies based on routine episiotomy. There is less posterior perineal trauma, less suturing and fewer complications, no difference for most pain measures and severe vaginal or perineal trauma, but there was an increased risk of anterior perineal trauma with restrictive episiotomy.

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Contributors

Magda Aguiar:

ORCID: http://orcid.org/0000-0002-7966-6897

magda.aguiar@ubc.ca

Semira Manaseki-Holland: s.manasekiholland@bham.ac.uk

Journal

Journal ID (nlm-ta): Matern Child Health J

Journal ID (iso-abbrev): Matern Child Health J

Title: Maternal and Child Health Journal

Publisher: Springer US (New York )

ISSN (Print): 1092-7875

ISSN (Electronic): 1573-6628

Publication date (Electronic): 26 March 2019

Publication date PMC-release: 26 March 2019

Publication date (Print): 2019

Volume: 23

Issue: 8

Pages: 1048-1070

Affiliations

[1 ]ISNI 0000 0004 1936 7486, GRID grid.6572.6, Institute of Applied Health Research, , University of Birmingham, ; Birmingham, UK

[2 ]ISNI 0000 0004 1936 7486, GRID grid.6572.6, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, , University of Birmingham, ; Birmingham, UK

[3 ]ISNI 0000 0001 0679 8269, GRID grid.189530.6, Present Address: Department of Nursing and Midwifery, Institute of Health & Society, , University of Worcester, ; Worcester, UK

[4 ]ISNI 0000 0001 2288 9830, GRID grid.17091.3e, Faculty of Pharmaceutical Sciences, University of British Columbia, ; Vancouver, BC Canada

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Magda Aguiar http://orcid.org/0000-0002-7966-6897

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Publisher ID: 2732

DOI: 10.1007/s10995-019-02732-5

PMC ID: 6606670

PubMed ID: 30915627

SO-VID: 64bd7e16-4cfd-44dc-946c-c8d35827b3ec

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Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

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ScienceOpen disciplines: Obstetrics & Gynecology

Keywords: episiotomy,oasi,birth-related perineal trauma,systematic review,lmics

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ScienceOpen disciplines: Obstetrics & Gynecology

Keywords: episiotomy, oasi, birth-related perineal trauma, systematic review, lmics

Birth-Related Perineal Trauma in Low- and Middle-Income Countries: A Systematic Review and Meta-analysis

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Most cited references 96

Critical appraisal of the health research literature: prevalence or incidence of a health problem.

60 Million non-facility births: who can deliver in community settings to reduce intrapartum-related deaths?

Episiotomy for vaginal birth.

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