Associations with perineal trauma during childbirth at home and in health facilities in indigenous municipalities in southern Mexico: a cross-sectional cluster survey

Associations with perineal trauma during childbirth at home and in health facilities in... Background: Episiotomy and perineal tears remain common in vaginal deliveries. This study estimated the frequency of and factors associated with perineal tears, episiotomies, and postnatal infections among women in two predominantly indigenous municipalities in southern Mexico, where traditional midwives play an important role in women’shealth. Methods: A cross-sectional study contacted women who gave birth in the previous three years. An administered questionnaire asked about place of delivery, birthing position, birth attendant, episiotomy, perineal tears, and wound infection after delivery. Cluster adjusted bivariate and then multivariate analysis examined factors potentially associated with self-reported perineal trauma (episiotomy and/or perineal tear). Key informant interviews sought insights into some of the findings. Results: Among women with a vaginal delivery, 71% (876/1238) of indigenous women and 18% (36/197) of non- indigenous women delivered at home. Some 17% (247/1416) of women overall, and 33% (171/525) of those delivering in a health facility, reported an episiotomy during delivery. Among 171 women reporting an episiotomy in a health facility, 30% (52) also reported a perineal tear. Overall, 13% (190/1412) of women reported they had a perineal tear during delivery, 17% (86/515) of those delivering in a health facility and 12% (104/897) of those delivering at home. A quarter of the women had self-reported perineal trauma during their last delivery, 38% (196/511) of those delivering in a health facility and 18% (160/893) of those delivering at home. In bivariate analysis, indigenous ethnicity, home delivery, upright posture in labour, and delivery by a traditional midwife were associated with a lower risk of perineal trauma, while primiparas had a higher risk. In the final multivariate model, delivery by a traditional midwife was protective (ORa 0.41, 95%CIca 0.32–0.54) and primiparity was a risk factor (ORa 2.01, 95%CIca 1.5–2.68) for perineal trauma. Women suggested that fear of bad treatment and being cut made them unwilling to deliver in health facilities. Conclusions: The rate of perineal trauma among women giving birth in indigenous communities could be reduced by efforts to decrease the use of episiotomies in health facilities, and by opening a dialogue with traditional midwives to increase their interaction with formal health services. Keywords: Perineal tears, Episiotomy, Perineal trauma, Traditional midwife, Indigenous communities * Correspondence: sparedes@ciet.org Centro de Investigación de Enfermedades Tropicales (CIET), Universidad Autónoma de Guerrero, Av. Pino s / n, Colonia El Roble, C.P.38640 Acapulco, Guerrero, Mexico Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This 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. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. de Jesús-García et al. BMC Pregnancy and Childbirth (2018) 18:198 Page 2 of 8 Background The questionnaire documented age at the time of the More than 30 years ago, the World Health Organisation last delivery, education, language, parity, and socioeco- recommended against routine episiotomy in uncompli- nomic status. It asked about where the delivery took cated vaginal deliveries [1]. Despite this, rates of episiot- place, who assisted the delivery, and the woman’s pos- omy, especially among primiparous women, have ition during labour and delivery. Each woman reported remained very high in some regions and countries [2, 3], whether she had a perineal tear or episiotomy during including countries in Latin America [4]. This is prob- delivery, and if any perineal wound became infected, in ably related to a continuing belief that episiotomy response to the following questions: Did you have a tear prevents severe perineal tears, especially among primipa- in your vagina when you had your delivery? Did the doc- ras [5]. Analysis from a multi-country study in mainly tor cut your vagina when you had your delivery? Was low income countries estimated rates of severe (3rd and the wound infected – was there pus coming from the 4th degree) perineal tears of between 0.1 and 1.4%, with wound? We also asked women about the size of the the rate in Mexico relatively high at 0.9% [6]. Reported baby, in terms of being bigger, the same size, or smaller risk factors for severe perineal tears include primiparity, than other babies in their community. We attempted to high birthweight, instrumental delivery, and episiotomy collect information about actual birth weight but more [6, 7]. Both perineal tears and episiotomies can have than half of the women did not know. important complications, including infection [8, 9], dys- Double data entry with validation minimised keystroke pareunia [10], urinary [11] and anal incontinence [12]. errors. Analysis relied on CIETmap, a windows interface According to the National Population Council, in for the R programming language [19]. We defined “peri- Mexico in 2014, 95% of deliveries were assisted by a neal trauma” as a self-reported episiotomy, a self-reported doctor, 3% were assisted by a professional midwife or a perineal tear, or both. We examined associations with the traditional midwife, and 3% by a nurse or other person. outcome of perineal trauma, in bivariate and then multi- In Guerrero, 84% of deliveries were assisted by a doctor, variate analysis, using the Mantel-Haenszel procedure 9% by a professional midwife or a traditional midwife, [20]. Multivariate analysis began with a saturated model and 4% by some other person. [13]. Most rural deliveries including the variables significantly associated with the attended by traditional midwives take place at the outcome in bivariate analysis, removing the least signifi- woman’s house [14]. Other studies have reported that in cant associations one by one, until only variables associ- Mexican states with a high proportion of indigenous ated with the outcome at the 95% confidence level populations like Chiapas and Oaxaca, more than half of remained. We report associations as odds ratios (OR) with all births are attended by traditional midwives [15, 16]. 95% confidence intervals adjusted for the effect of cluster- In Xochistlahuaca and Tlacoachistlahuaca municipalities ing (95% CIca) using the Lamothe method [21]. of Guerrero state, 92 and 78% of the populations respect- After preliminary analysis of the survey findings, ively are indigenous [17], mainly from the ethnic groups three of the researchers returned to the communities Na Savi (Mixteco) and Nancue Ñomndaa (Amuzgo). Only and carried out open interviews with key informants, five of the 116 communities in Xochistlahuaca have health to hear their views and experiences about some of centres; a hospital in the municipal capital provides sec- the emerging issues. They interviewed two women ondary care for the 28,000 residents. In Tlacoachistlahuaca, who had recently given birth, two pregnant women, with 21,000 residents, seven of 53 communities have med- four traditional midwives (one of them a male), three ical facilities. husbands of women who had given birth or were Using baseline data from a study of neonatal survival, pregnant, eight health workers from health centres, cultural safety and traditional midwifery, we analysed the community basic hospitals and the regional general frequency of perineal tearing, episiotomy, and perineal hospital, and five health service managers and plan- infection, and examined the factors associated with peri- ners. We audio-recorded the interviews. For the pur- neal trauma [18]. pose of this analysis, we reviewed the responses relevant to perineal trauma and to women’suse of Methods different types of services for pregnancy and delivery. A cross-sectional study included a random sample of Thestudy wasapprovedbythe Ethics Committee of 20 communities from a list of 169 communities in Centro de Investigación de Enfermedades Tropicales the two municipalities, stratified by ethnicity and (CIET), at the Universidad Autónoma de Guerrero in access to health services, each with approximately 100 Mexico. Before each interview, the interviewer sought homes. Health promoters and local indigenous stu- oral informed consent from the respondent. For re- dents who speak the indigenous language adminis- spondents under the age of 16, their parents or legal tered a questionnaire to all women who reported guardians gave oral informed consent for them to births within the last three years. participate. de Jesús-García et al. BMC Pregnancy and Childbirth (2018) 18:198 Page 3 of 8 Results Overall, 13% (190/1412) of women reported they had a We surveyed 1636 women, 720 in Xochistlahuaca and perineal tear during their last delivery, 17% (86/515) of 916 in Tlacoachistlahuaca. Of these, 48% (783/1636) those who delivered in health facilities and 12% (104/ reported Ñomndaa as their mother tongue, 34% (563/ 897) of those who delivered at home (Table 1). 1636) Na savi, and 18% (290/1636) Spanish; 47% (770/ A quarter of the women had self-reported perineal 1636) of them said they could speak Spanish. More than trauma (episiotomy and/or perineal tear) during their one half of the women delivered at home (56%, 923/ last delivery, about one third of those who delivered in a 1636), 30% (493/1636) at the hospital, 8% (123/1636) in health facility and one fifth of those who delivered at a health centre and 6% (90/1636) in a private clinic. home (Table 1). Table 2 shows the results of bivariate Most (79%, 446/563) of na savi women and more than analysis of factors potentially associated with reported half (55%, 430/783) of ñomndaa women gave birth at perineal trauma. Aboriginal women, those who delivered home, compared with only 12% (36/290) of mestizo at home, those who had an upright position during (non-indigenous) women (p < 0.0001). A quarter (26%, labour, and those assisted at delivery by a traditional 181/706) of deliveries in health facilities were by caesar- midwife were significantly less likely to report perineal ean section. These 181 deliveries are not included in the trauma. Primiparas were significantly more likely to analysis of perineal trauma. report perineal trauma. Younger women were more Table 1 shows the characteristics of the 1455 women likely to report perineal trauma, but this association was with vaginal deliveries, in health facilities or at home. not statistically significant at the 5% level. Women Overall, about two-thirds (923/1455) of these women reporting larger babies were not more likely to report delivered at home. Nearly three quarters (71%, 876/ perineal trauma. 1238) of indigenous women delivered at home, while In the multivariate analysis, we included in the initial four out of five of the mestizo women (82%, 161/197) model all the variables shown in Table 2, except for ethni- delivered in a health facility. One in five women was city, which was strongly co-linear with place of delivery and primiparous (21%, 310/1450) and 55% (172/310) of these birth attendant. Table 3 shows the final model from the delivered in a health facility, while only 31% (358/1140) multivariate analysis. Two variables remained independ- of multiparous women delivered in a health facility. Al- ently associated with the outcome of self-reported perineal most all physician-assisted deliveries and three-quarters trauma. A woman whose delivery was assisted by a trad- of nurse-assisted deliveries were in a health facility, while itional midwife had less than half the risk of reporting peri- all deliveries assisted by a traditional midwife were at neal trauma compared with a woman whose delivery was home. Women reported 151 home deliveries as being assisted byadoctorornurse.Aprimiparawas twiceas assisted by a relative; some of these relatives were also likely to report perineal trauma compared with a multipara. traditional midwives, but we are unable to say how many. The position for labour and delivery was reported Infections of perineal wounds by 1434 women. Most women delivering at home Overall, 19% of women who reported perineal trauma reported an upright position during labour, while nearly (an episiotomy or a tear or both) reported that the all who delivered in a health facility reported lying down wound became infected, as judged by the presence of during labour. pus coming from the wound (Table 1). Among women reporting a perineal wound, those who delivered at Perineal trauma home were more likely to report that the wound became Overall, 17% (247/1416) of women reported they had an infected, compared with those who delivered in a health episiotomy during delivery (with or without a perineal facility, but the difference was not significant at the 5% tear), 33% (171/525) of those who delivered in a health level (OR 1.90, 95% CIca 0.87–4.14). Considering all facility and 9% (76/891) of those who delivered at home. women with vaginal deliveries, 5% (44/878) who deliv- It is likely that most of the 76 women who self-reported ered at home reported an infected perineal wound, an episiotomy during home delivery had in fact experi- compared with 6% who delivered in a health facility (31/ enced a perineal tear (Table 1). 510); the difference was not significant at the 5% level Among those 171 women who delivered in a health facil- (OR 0.80, 95% CIca 0.43–1.48). Given the small number ity and reported an episiotomy, 52 (30%) also reported of reported infections in our sample, we were not having a perineal tear. Among health facility deliveries, a able to examine further potential associations with primipara was more likely to have an episiotomy than a this outcome. multipara (OR 2.31, 95% CIca 1.53–3.50). Some 34% (117/ 343) of women who delivered in public hospitals reported Views of key informants an episiotomy, as did 24% (29/119) who delivered in health Some participants described bad experiences in health centres, and 42% (25/59) who delivered in private clinics. facilities. de Jesús-García et al. BMC Pregnancy and Childbirth (2018) 18:198 Page 4 of 8 Table 1 Characteristics of 1455 women with vaginal deliveries in the last three years Characteristics Delivered in health Delivered at home All deliveries facility (532) (923) (1455) n (%) n (%) n (%) Ethnic group Aboriginal 362 (69) 876 (96) 1238 (86) Mestizo 161 (31) 36 (4) 197 (14) Age at delivery 14 to 19 years old 66 (12) 111 (12) 177 (12) 20 to 49 years old 466 (88) 811 (88) 1277 (88) Able to read Spanish Yes 365 (69) 330 (36) 695 (48) No 166 (31) 588 (64) 754 (52) Civil status Married/co-habiting 502 (95) 888 (97) 1390 (97) Single 26 (5) 24 (3) 50 (3) Parity Primipara 172 (32) 138 (15) 310 (21) Multipara 358 (68) 782 (85) 1140 (79) Who attended delivery Physician 460 (86) 20 (2) 480 (33) Nurse 59 (11) 17 (2) 76 (5) Health promotor 8 (2) – 8 (0.5) Traditional midwife – 643 (70) 643 (44) Relative – 151 (16) 151 (10) Nobody – 86 (10) 86 (6) Position during labour and delivery Upright/semi-upright 40 (8) 760 (83) 800 (56) Horizontal 482 (92) 152 (17) 634 (44) Reported perineal tear Yes 86 (17) 104 (12) 190 (14) No 429 (83) 793 (88) 1222 (86) Reported episiotomy Yes 171 (33) 76 (9) 247 (17) No 354 (67) 815 (91) 1169 (83) Reported perineal trauma (tear and/or episiotomy) Yes 196 (38) 160 (18) 356 (25) No 315 (62) 733 (82) 1048 (75) Reported infection of perineal wound Yes 28 (15) 39 (24) 67 (19) No 165 (85) 121 (76) 286 (81) 76 women who delivered at home reported having an episiotomy, although 59 of them were assisted in their delivery by a traditional midwife and only 7 by a doctor or nurse. It is extremely unlikely that the traditional midwife performed an episiotomy, so probably these women in fact had a perineal tear which they reported as an episiotomy (18 of them also reported a perineal tear) “When I did not push hard enough, the staff told Some women go to health facilities because of the me they would put a condom into my vagina so monetary incentive (pregnant women get a monthly that I would not get pregnant again. They told me allowance that they can only claim if they are to push and then they cut my part. I wish I had attending the health facility). been accompanied (delivered) by the traditional midwife – then things would have been much “If we don’t go, we don’t receive the money, that’s better” (Woman who had recently delivered). why we go to the hospital”. A patient explained that they don’t like to go to the Health workers considered that women should deliver hospital for delivery; they prefer to deliver at home in health facilities, but that ignorance sometimes pre- assisted by the traditional midwife. vented them doing so. “In the health centre the delivery is rushed – “We tell them that they should come here to deliver, it’s not the same as having the baby at it won’t cost them anything, and they will have a clean home”. delivery, without complications.” (A staff physician). de Jesús-García et al. BMC Pregnancy and Childbirth (2018) 18:198 Page 5 of 8 Table 2 Bivariate associations with self-reported perineal trauma Factor With trauma Without trauma OR 95% CIca n (%) n (%) Ethnicity Aboriginal 255 (21) 942 (79) 0.28 0.18–0.43 Mestizo 94 (49) 97 (51) Age at delivery 14–19 years old 57 (32) 120 (68) 1.48 0.96–2.3 20–49 years old 310 (24) 967 (76) Place of delivery Home 162 (18) 761 (82) 0.34 0.21–0.56 Health facility 205 (39) 327 (61) Parity Primiparae 120 (39) 190 (61) 2.31 1.76–3.03 Multipara 245 (21) 895 (79) Position in labour Upright 138 (17) 662 (83) 0.38 0.24–0.61 Horizontal 224 (35) 410 (65) Size of baby Bigger than average 96 (24) 302 (76) 0.92 0.70–1.19 Average or smaller 251 (26) 723 (74) Birth attendant Traditional midwife 126 (19) 530 (81) 0.38 0.22–0.65 Doctor/nurse 210 (39) 333 (61) Bold font indicates associations significant at the 5% level OR Odds ratio, 95% CIca Cluster adjusted 95% confidence intervals This excludes the few women who were assisted at delivery by a relative or by nobody “They don’t know, they are not used to getting care “If you don’t do something, there can be a tear. We from health facilities” (A staff obstetrician). make an episiotomy to avoid tears.” (A staff obstetrician). Some health workers accepted that women might have other reasons for not attending health facilities, A health personnel expressed her belief that being such as being scolded when they attended, or having indigenous is a risk factor for delivery complications. embarrassing examinations. “Yes, being indigenous is itself a risk factor for “The women feel embarrassed by being examined by delivery complications, because of their culture, the the doctor in the lithotomy position.” (A staff nurse). myths and beliefs they have, and because of the difficulty of communication.” (A staff physician). An obstetrician described the steps he believed neces- sary to prevent infections during delivery, which might well be objectionable to women. Discussion We found that women delivered by traditional midwives “The patient should come into the delivery room were less likely to have self-reported perineal trauma naked, and then we provide her with a hospital gown. than those delivered by doctors or nurses, and this asso- Shaving the perineum is routine for all women ciation remained when other potential risk factors for delivering here”. (A staff obstetrician). perineal trauma were taken into account. Women deliv- ered at home by traditional midwives did not have the Another made clear that he believed episiotomy was trauma of episiotomies, and they also had lower rates of necessary to avoid perineal tears. perineal tears. Delivery in health facilities increased the risk of perineal trauma among the women in our study. Our finding of less perineal trauma among women Table 3 Final model of multivariate analysis of factors delivered by traditional midwives is compatible with associated with self-reported perineal trauma (n = 1196) other studies. In Yucatan, Mexico, 10% of women who Factor ORna ORa 95% CIca delivered in hospital had perineal tears, compared with Delivery assisted by traditional midwife 0.38 0.41 0.32–0.54 only 6% of those who delivered at home assisted by a traditional midwife [22]. Although in a very different Primipara 2.31 2.01 1.5–2.68 context, a study from the United Kingdom found that ORna Unadjusted odds ratio, ORa Adjusted odds ratio, 95% CIca Cluster adjusted 95% confidence intervals of ORa women delivered by professional midwives working de Jesús-García et al. BMC Pregnancy and Childbirth (2018) 18:198 Page 6 of 8 independently, were more likely to have an intact peri- chopped” without warning. Interviews with health neum than those delivered within the National Health workers confirmed that they considered women should Service system [23] and a study in Austria reported deliver in health facilities, but also exposed beliefs and fewer episiotomies and less perineal trauma when care practices that might well discourage women from doing was led by professional midwives rather than by obstetri- so. Our study covered municipalities of predominantly cians [24]. indigenous populations with a particular world view re- In our study, although women who laboured and garding pregnancy, childbirth and postpartum, with a delivered in an upright or semi-upright position had preference for home delivery assisted by a traditional lower rates of perineal trauma, this association did not midwife, similar to other indigenous groups in Mexico remain in multivariate analysis. There is still debate [14, 16]. about the benefits and risks of an upright posture during In rural Mexico, traditional midwives play an import- labour; a recent update of a Cochrane review of trials of ant role in the care of pregnant women and can be an different postures in second stage labour concluded that important link between the health care services and an upright posture in labour reduced episiotomies but communities. The strong social and cultural identifica- possibly carried an increased risk of second degree peri- tion between indigenous women and their traditional neal tears [25]. midwives is a good argument to consider incorporation One third of the women in our study who delivered in of traditional midwives into health services in remote a health facility reported an episiotomy. This episiotomy areas [28]. In our study sites, where just over half the rate is lower than in countries of South East Asia, where deliveries took place at home assisted by a traditional a study found an overall rate of 65%, ranging from 47% midwife, key informant interviews indicated that trad- in Malaysia to 91% in Thailand [3]. It is similar to a rate itional midwives encouraged pregnant women also to of 25% reported from a study of hospital discharge attend health facilities for antenatal care, and are inter- records in the USA [26]. Routine episiotomy is still prac- ested in cooperating with official health services. For tised in some countries in the persisting belief that it many years, researchers have called for the development prevents severe perineal tears, especially among primipa- of working linkages with traditional midwives to reduce ras [5]. This is despite a body of evidence to the con- the work load of government medical services while trary. A systematic review of trials of selective versus showing respect for indigenous cultures [29]. Our results routine episiotomy, recently updated, found less risk of suggest that increased cooperation with traditional mid- severe perineal trauma when episiotomies were wives could reduce the rates of perineal trauma during performed only when necessary, and concluded that rou- delivery and the associated complications. tine episiotomy to prevent severe perineal tears is not justified and has no benefits for the mother or the baby Limitations [27]. One third of the women in our study who reported We relied on women’s self-reports of having an episiot- an episiotomy in a health facility also reported a perineal omy or a perineal tear, for deliveries up to three years tear. A previous study of women delivering in Acapulco’s previously and did not have any means of verifying their General Hospital found that 20% of women who reports. However, a study among women living in slum reported having an episiotomy during vaginal delivery areas of Dhaka, Bangladesh, reported 82% agreement also reported a perineal tear [10]. between the post-partum physical findings of physicians In our study, primiparas were significantly more likely and maternal reporting of perineal tears [30]. As shown to have self-reported perineal trauma compared with in Table 1, some women in our study who delivered at multiparas and this association persisted in multivariate home assisted by a traditional midwife reported an episi- analysis. This was largely because primiparas delivering otomy, when probably they experienced a perineal tear. in a health facility were more than twice as likely to have Women judged that they had perineal tearing mainly be- an episiotomy compared with multiparas. Our key cause of the associated pain, as well as the subsequent informant interviews with health workers suggested that presence of a wound, with or without infection, and this is because doctors perform episiotomies more rou- because of what the person assisting the delivery told tinely among primiparas, in the belief it will prevent them. We have no reason to believe that traditional mid- perineal tearing. wives were less likely than health workers in a facility to Concerns about the way women are treated when they tell women if they had suffered perineal trauma. Women deliver in local health facilities, including high rates of delivering in a health facility may have been less aware episiotomy, might discourage women from delivering of tears because of the use of analgesia in this setting. there. Key informants in our study communities We did not ask women about analgesia during their last described bad experiences in health care facilities, in- delivery. Despite uncertainty about the frequency of cluding one woman who described having her “part perineal trauma based only on women’s self-reporting, de Jesús-García et al. BMC Pregnancy and Childbirth (2018) 18:198 Page 7 of 8 we believe the analysis of the factors related to the under the age of 16, their parents or legal guardians gave oral informed consent for them to participate. trauma is valid. We were not able to examine whether women with Competing interests high birth weight babies were more likely to have peri- The authors declare that they have no competing interests. neal trauma because more than half the women did not know the birth weight of their baby; there was no associ- Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in ation between self-reported large babies and perineal published maps and institutional affiliations. trauma. We did not ask women about the duration of labour, another potential risk factor for perineal trauma. Author details Centro de Investigación de Enfermedades Tropicales (CIET), Universidad We defined infection of the perineal wound based on Autónoma de Guerrero, Av. Pino s / n, Colonia El Roble, C.P.38640 Acapulco, women’s self-report of pus coming from the wound. 2 Guerrero, Mexico. CIETinternational, 511 Avenue of the Americas #132, New There was a higher rate of infections among home deliv- York, USA. Department of Family Medicine, McGill University, 5858 Chemin de la Côte-des-Neiges, Montreal, Canada. eries, although the difference was not statistically signifi- cant. The relatively small number of infections reported Received: 24 February 2017 Accepted: 20 May 2018 by the women in our sample meant we could not ana- lyse the factors related to infections. References 1. World Health Organization. Appropriate technology for birth. Lancet. 1985;2: Conclusions 436–7. 2. Graham ID, Carroli G, Davies C, Medves JM. 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Rev Panam Salud Publica. 2008;23(1):44–51. colleagues who accompanied us in fieldwork: Alba Meneses Rentería, David Gasga 11. Rockner G. Urinary incontinence after perineal trauma at childbirth. Scand J Salinas, Miguel Flores Moreno, Alejandro Balanzar Martinez, and Jorge Laucirica. Caring Sci. 1990;4:169–72. 12. Abbott D, Atere-Roberts N, Williams A, Oteng-Ntim E, Chappell LC. Obstetric Funding anal sphincter injury. BMJ. 2010;341:c3414. https://doi.org/10.1136/bmj.c3414. The study was funded by the UBS Optimus Foundation. The Foundation 13. Encuesta Nacional de la Dinámica Demográfica 2014, Consejo Nacional de played no part in the design of the study and collection, analysis, and Población, Instituto Nacional de Estadística y Geografía. México. 2015. interpretation of data and in writing the manuscript. México, DF. Boletín de prensa núm. 271/15 available from: http://www.inegi. org.mx/saladeprensa/boletines/2015/especiales/especiales2015_07_1.pdf. Availability of data and materials Accessed 18 Dec 2017. The datasets used and/or analysed during the current study are available 14. Argüello-Avendaño HE, Mateo-González A. Parteras tradicionales y parto from the corresponding author on reasonable request. medicalizado, ¿un conflicto del pasado? Evolución del discurso de los organismos internacionales en los últimos veinte años. Revista LiminaR. Authors’ contributions Estudios Sociales y Humanísticos. 2014;12(2):13–29. NA, SPS and AJG designed the study. AJG, RSS and GVG conducted the field 15. Braine T. Mexico’s midwives enter the mainstream. Bull World Health Organ. work. AJG, RSS, BMSG, SPS and GVG analysed and interpreted the data. SPS, 2008;86(4):244. AJG and RJL wrote the draft manuscript. NA provided technical oversight 16. Sánchez Pérez HJ, Ochoa Díaz López H, Navarro i Giné A, Martín Mateo M. and contributed to the final manuscript. AC analysed and interpreted the La atención del parto en Chiapas, México: ¿dónde y quién los atiende. data and contributed to the final manuscript. All authors read and approved Salud Publica Mex. 1998;40:494–502. the final manuscript. 17. Tascon Mendoza J A, Solís Cervantes G R. Situación de salud de los pueblos indígenas y perspectivas de una atención intercultural. En Estado del desarrollo Ethics approval and consent to participate económico y social de los pueblos indígenas de Guerrero. Programa The study was approved by the Ethics Committee of Tropical Diseases Universitario México Nación Multicultural. UNAM. México, D.F. 2009. Research Centre (CIET), at the Autonomous University of Guerrero, Mexico. 18. Neonatal survival, cultural safety and traditional midwifery in All participants gave oral informed consent to participate. For respondents indigenous communities of Guerrero State, Mexico. ISRCTN80090228 de Jesús-García et al. BMC Pregnancy and Childbirth (2018) 18:198 Page 8 of 8 DOI https://doi.org/10.1186/ISRCTN80090228. Available at: http://www. controlled-trials.com/ISRCTN80090228?q=&filters=recruitmentCountry: Mexico,conditionCategory:Pregnancy%20and%20Childbirth&sort= relevance&offset=4&totalResults=4&page=1&pageSize=10&searchType= basic-search. 19. Andersson N, Mitchell S. Epidemiological geomatics in evaluation of mine risk education in Afghanistan: introducing population weighted raster maps. Int J Health Geogr. 2006;5:1. 20. Mantel N, Haenszel W. Statistical aspects of the analysis of data from retrospective studies of disease. J Natl Cancer Inst. 1959;222:719–48. 21. Andersson N, Lamothe G. Clustering and meso-level variables in cross- sectional surveys: an example of food aid during the Bosnian crisis. BMC Health Serv Res. 2011;11(Suppl 2):S15. 22. Méndez González RM, Cervera Montejano MD. Comparación de la atención del parto normal en los sistemas hospitalario y tradicional. Salud Publica Mex. 2002;44:129–36. 23. Symon A, Winter C, Inkster M, Donnan PT. Outcomes for births booked under an independent midwife and births in NHS maternity units: matched comparison study. BMJ. 2009;338:b2060. 24. Bodner-Adler B, Kimberger O, Griebaum J, Husslein P, Bodner K. A ten-year study of midwife-led care at an Austrian tertiary care center: a retrospective analysis with special consideration of perineal trauma. BMC Pregnancy Childbirth. 2017;17(1):357. https://doi.org/10.1186/s12884-017-1544-9. 25. Gupta JK, Sood A, Hofmeyr GJ, Vogel JP. Position in the second stage of labour for women without epidural anaesthesia. Cochrane Database Syst Rev. 2017;5:CD002006. https://doi.org/10.1002/14651858.CD002006.pub4. 26. Frankman EA, Wang L, Bunker CH, Lowder JL. Episiotomy in the United States: has anything changed? Am J Obstet Gynecol. 2009;200(5):573. e571–77 27. Jiang H, Qian X, Carroli G, Garner P. Selective versus routine use of episiotomy for vaginal birth. Cochrane Database Syst Rev. 2017;2:CD000081. https://doi.org/10.1002/14651858.CD000081.pub3. 28. Cameron M, Andersson N, McDowell I, Ledogar RJ. Culturally safe epidemiology: oxymoron or scientific imperative. Pimatisiwin. 2010;8(2):89–116. 29. Castañeda Camey X. Embarazo, parto y puerperio: conceptos y prácticas de las parteras en el estado de Morelos. Salud Publica Mex. 1992;34:528–32. 30. Fronczak N, Antelman G, Moran AC, Caulfield LE, Baqui AH. Delivery-related complications and early postpartum morbidity in Dhaka, Bangladesh. Int J Gynaecol Obstet. 2005;91(3):271–8. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png BMC Pregnancy and Childbirth Springer Journals

Associations with perineal trauma during childbirth at home and in health facilities in indigenous municipalities in southern Mexico: a cross-sectional cluster survey

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Abstract

Background: Episiotomy and perineal tears remain common in vaginal deliveries. This study estimated the frequency of and factors associated with perineal tears, episiotomies, and postnatal infections among women in two predominantly indigenous municipalities in southern Mexico, where traditional midwives play an important role in women’shealth. Methods: A cross-sectional study contacted women who gave birth in the previous three years. An administered questionnaire asked about place of delivery, birthing position, birth attendant, episiotomy, perineal tears, and wound infection after delivery. Cluster adjusted bivariate and then multivariate analysis examined factors potentially associated with self-reported perineal trauma (episiotomy and/or perineal tear). Key informant interviews sought insights into some of the findings. Results: Among women with a vaginal delivery, 71% (876/1238) of indigenous women and 18% (36/197) of non- indigenous women delivered at home. Some 17% (247/1416) of women overall, and 33% (171/525) of those delivering in a health facility, reported an episiotomy during delivery. Among 171 women reporting an episiotomy in a health facility, 30% (52) also reported a perineal tear. Overall, 13% (190/1412) of women reported they had a perineal tear during delivery, 17% (86/515) of those delivering in a health facility and 12% (104/897) of those delivering at home. A quarter of the women had self-reported perineal trauma during their last delivery, 38% (196/511) of those delivering in a health facility and 18% (160/893) of those delivering at home. In bivariate analysis, indigenous ethnicity, home delivery, upright posture in labour, and delivery by a traditional midwife were associated with a lower risk of perineal trauma, while primiparas had a higher risk. In the final multivariate model, delivery by a traditional midwife was protective (ORa 0.41, 95%CIca 0.32–0.54) and primiparity was a risk factor (ORa 2.01, 95%CIca 1.5–2.68) for perineal trauma. Women suggested that fear of bad treatment and being cut made them unwilling to deliver in health facilities. Conclusions: The rate of perineal trauma among women giving birth in indigenous communities could be reduced by efforts to decrease the use of episiotomies in health facilities, and by opening a dialogue with traditional midwives to increase their interaction with formal health services. Keywords: Perineal tears, Episiotomy, Perineal trauma, Traditional midwife, Indigenous communities * Correspondence: sparedes@ciet.org Centro de Investigación de Enfermedades Tropicales (CIET), Universidad Autónoma de Guerrero, Av. Pino s / n, Colonia El Roble, C.P.38640 Acapulco, Guerrero, Mexico Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This 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. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. de Jesús-García et al. BMC Pregnancy and Childbirth (2018) 18:198 Page 2 of 8 Background The questionnaire documented age at the time of the More than 30 years ago, the World Health Organisation last delivery, education, language, parity, and socioeco- recommended against routine episiotomy in uncompli- nomic status. It asked about where the delivery took cated vaginal deliveries [1]. Despite this, rates of episiot- place, who assisted the delivery, and the woman’s pos- omy, especially among primiparous women, have ition during labour and delivery. Each woman reported remained very high in some regions and countries [2, 3], whether she had a perineal tear or episiotomy during including countries in Latin America [4]. This is prob- delivery, and if any perineal wound became infected, in ably related to a continuing belief that episiotomy response to the following questions: Did you have a tear prevents severe perineal tears, especially among primipa- in your vagina when you had your delivery? Did the doc- ras [5]. Analysis from a multi-country study in mainly tor cut your vagina when you had your delivery? Was low income countries estimated rates of severe (3rd and the wound infected – was there pus coming from the 4th degree) perineal tears of between 0.1 and 1.4%, with wound? We also asked women about the size of the the rate in Mexico relatively high at 0.9% [6]. Reported baby, in terms of being bigger, the same size, or smaller risk factors for severe perineal tears include primiparity, than other babies in their community. We attempted to high birthweight, instrumental delivery, and episiotomy collect information about actual birth weight but more [6, 7]. Both perineal tears and episiotomies can have than half of the women did not know. important complications, including infection [8, 9], dys- Double data entry with validation minimised keystroke pareunia [10], urinary [11] and anal incontinence [12]. errors. Analysis relied on CIETmap, a windows interface According to the National Population Council, in for the R programming language [19]. We defined “peri- Mexico in 2014, 95% of deliveries were assisted by a neal trauma” as a self-reported episiotomy, a self-reported doctor, 3% were assisted by a professional midwife or a perineal tear, or both. We examined associations with the traditional midwife, and 3% by a nurse or other person. outcome of perineal trauma, in bivariate and then multi- In Guerrero, 84% of deliveries were assisted by a doctor, variate analysis, using the Mantel-Haenszel procedure 9% by a professional midwife or a traditional midwife, [20]. Multivariate analysis began with a saturated model and 4% by some other person. [13]. Most rural deliveries including the variables significantly associated with the attended by traditional midwives take place at the outcome in bivariate analysis, removing the least signifi- woman’s house [14]. Other studies have reported that in cant associations one by one, until only variables associ- Mexican states with a high proportion of indigenous ated with the outcome at the 95% confidence level populations like Chiapas and Oaxaca, more than half of remained. We report associations as odds ratios (OR) with all births are attended by traditional midwives [15, 16]. 95% confidence intervals adjusted for the effect of cluster- In Xochistlahuaca and Tlacoachistlahuaca municipalities ing (95% CIca) using the Lamothe method [21]. of Guerrero state, 92 and 78% of the populations respect- After preliminary analysis of the survey findings, ively are indigenous [17], mainly from the ethnic groups three of the researchers returned to the communities Na Savi (Mixteco) and Nancue Ñomndaa (Amuzgo). Only and carried out open interviews with key informants, five of the 116 communities in Xochistlahuaca have health to hear their views and experiences about some of centres; a hospital in the municipal capital provides sec- the emerging issues. They interviewed two women ondary care for the 28,000 residents. In Tlacoachistlahuaca, who had recently given birth, two pregnant women, with 21,000 residents, seven of 53 communities have med- four traditional midwives (one of them a male), three ical facilities. husbands of women who had given birth or were Using baseline data from a study of neonatal survival, pregnant, eight health workers from health centres, cultural safety and traditional midwifery, we analysed the community basic hospitals and the regional general frequency of perineal tearing, episiotomy, and perineal hospital, and five health service managers and plan- infection, and examined the factors associated with peri- ners. We audio-recorded the interviews. For the pur- neal trauma [18]. pose of this analysis, we reviewed the responses relevant to perineal trauma and to women’suse of Methods different types of services for pregnancy and delivery. A cross-sectional study included a random sample of Thestudy wasapprovedbythe Ethics Committee of 20 communities from a list of 169 communities in Centro de Investigación de Enfermedades Tropicales the two municipalities, stratified by ethnicity and (CIET), at the Universidad Autónoma de Guerrero in access to health services, each with approximately 100 Mexico. Before each interview, the interviewer sought homes. Health promoters and local indigenous stu- oral informed consent from the respondent. For re- dents who speak the indigenous language adminis- spondents under the age of 16, their parents or legal tered a questionnaire to all women who reported guardians gave oral informed consent for them to births within the last three years. participate. de Jesús-García et al. BMC Pregnancy and Childbirth (2018) 18:198 Page 3 of 8 Results Overall, 13% (190/1412) of women reported they had a We surveyed 1636 women, 720 in Xochistlahuaca and perineal tear during their last delivery, 17% (86/515) of 916 in Tlacoachistlahuaca. Of these, 48% (783/1636) those who delivered in health facilities and 12% (104/ reported Ñomndaa as their mother tongue, 34% (563/ 897) of those who delivered at home (Table 1). 1636) Na savi, and 18% (290/1636) Spanish; 47% (770/ A quarter of the women had self-reported perineal 1636) of them said they could speak Spanish. More than trauma (episiotomy and/or perineal tear) during their one half of the women delivered at home (56%, 923/ last delivery, about one third of those who delivered in a 1636), 30% (493/1636) at the hospital, 8% (123/1636) in health facility and one fifth of those who delivered at a health centre and 6% (90/1636) in a private clinic. home (Table 1). Table 2 shows the results of bivariate Most (79%, 446/563) of na savi women and more than analysis of factors potentially associated with reported half (55%, 430/783) of ñomndaa women gave birth at perineal trauma. Aboriginal women, those who delivered home, compared with only 12% (36/290) of mestizo at home, those who had an upright position during (non-indigenous) women (p < 0.0001). A quarter (26%, labour, and those assisted at delivery by a traditional 181/706) of deliveries in health facilities were by caesar- midwife were significantly less likely to report perineal ean section. These 181 deliveries are not included in the trauma. Primiparas were significantly more likely to analysis of perineal trauma. report perineal trauma. Younger women were more Table 1 shows the characteristics of the 1455 women likely to report perineal trauma, but this association was with vaginal deliveries, in health facilities or at home. not statistically significant at the 5% level. Women Overall, about two-thirds (923/1455) of these women reporting larger babies were not more likely to report delivered at home. Nearly three quarters (71%, 876/ perineal trauma. 1238) of indigenous women delivered at home, while In the multivariate analysis, we included in the initial four out of five of the mestizo women (82%, 161/197) model all the variables shown in Table 2, except for ethni- delivered in a health facility. One in five women was city, which was strongly co-linear with place of delivery and primiparous (21%, 310/1450) and 55% (172/310) of these birth attendant. Table 3 shows the final model from the delivered in a health facility, while only 31% (358/1140) multivariate analysis. Two variables remained independ- of multiparous women delivered in a health facility. Al- ently associated with the outcome of self-reported perineal most all physician-assisted deliveries and three-quarters trauma. A woman whose delivery was assisted by a trad- of nurse-assisted deliveries were in a health facility, while itional midwife had less than half the risk of reporting peri- all deliveries assisted by a traditional midwife were at neal trauma compared with a woman whose delivery was home. Women reported 151 home deliveries as being assisted byadoctorornurse.Aprimiparawas twiceas assisted by a relative; some of these relatives were also likely to report perineal trauma compared with a multipara. traditional midwives, but we are unable to say how many. The position for labour and delivery was reported Infections of perineal wounds by 1434 women. Most women delivering at home Overall, 19% of women who reported perineal trauma reported an upright position during labour, while nearly (an episiotomy or a tear or both) reported that the all who delivered in a health facility reported lying down wound became infected, as judged by the presence of during labour. pus coming from the wound (Table 1). Among women reporting a perineal wound, those who delivered at Perineal trauma home were more likely to report that the wound became Overall, 17% (247/1416) of women reported they had an infected, compared with those who delivered in a health episiotomy during delivery (with or without a perineal facility, but the difference was not significant at the 5% tear), 33% (171/525) of those who delivered in a health level (OR 1.90, 95% CIca 0.87–4.14). Considering all facility and 9% (76/891) of those who delivered at home. women with vaginal deliveries, 5% (44/878) who deliv- It is likely that most of the 76 women who self-reported ered at home reported an infected perineal wound, an episiotomy during home delivery had in fact experi- compared with 6% who delivered in a health facility (31/ enced a perineal tear (Table 1). 510); the difference was not significant at the 5% level Among those 171 women who delivered in a health facil- (OR 0.80, 95% CIca 0.43–1.48). Given the small number ity and reported an episiotomy, 52 (30%) also reported of reported infections in our sample, we were not having a perineal tear. Among health facility deliveries, a able to examine further potential associations with primipara was more likely to have an episiotomy than a this outcome. multipara (OR 2.31, 95% CIca 1.53–3.50). Some 34% (117/ 343) of women who delivered in public hospitals reported Views of key informants an episiotomy, as did 24% (29/119) who delivered in health Some participants described bad experiences in health centres, and 42% (25/59) who delivered in private clinics. facilities. de Jesús-García et al. BMC Pregnancy and Childbirth (2018) 18:198 Page 4 of 8 Table 1 Characteristics of 1455 women with vaginal deliveries in the last three years Characteristics Delivered in health Delivered at home All deliveries facility (532) (923) (1455) n (%) n (%) n (%) Ethnic group Aboriginal 362 (69) 876 (96) 1238 (86) Mestizo 161 (31) 36 (4) 197 (14) Age at delivery 14 to 19 years old 66 (12) 111 (12) 177 (12) 20 to 49 years old 466 (88) 811 (88) 1277 (88) Able to read Spanish Yes 365 (69) 330 (36) 695 (48) No 166 (31) 588 (64) 754 (52) Civil status Married/co-habiting 502 (95) 888 (97) 1390 (97) Single 26 (5) 24 (3) 50 (3) Parity Primipara 172 (32) 138 (15) 310 (21) Multipara 358 (68) 782 (85) 1140 (79) Who attended delivery Physician 460 (86) 20 (2) 480 (33) Nurse 59 (11) 17 (2) 76 (5) Health promotor 8 (2) – 8 (0.5) Traditional midwife – 643 (70) 643 (44) Relative – 151 (16) 151 (10) Nobody – 86 (10) 86 (6) Position during labour and delivery Upright/semi-upright 40 (8) 760 (83) 800 (56) Horizontal 482 (92) 152 (17) 634 (44) Reported perineal tear Yes 86 (17) 104 (12) 190 (14) No 429 (83) 793 (88) 1222 (86) Reported episiotomy Yes 171 (33) 76 (9) 247 (17) No 354 (67) 815 (91) 1169 (83) Reported perineal trauma (tear and/or episiotomy) Yes 196 (38) 160 (18) 356 (25) No 315 (62) 733 (82) 1048 (75) Reported infection of perineal wound Yes 28 (15) 39 (24) 67 (19) No 165 (85) 121 (76) 286 (81) 76 women who delivered at home reported having an episiotomy, although 59 of them were assisted in their delivery by a traditional midwife and only 7 by a doctor or nurse. It is extremely unlikely that the traditional midwife performed an episiotomy, so probably these women in fact had a perineal tear which they reported as an episiotomy (18 of them also reported a perineal tear) “When I did not push hard enough, the staff told Some women go to health facilities because of the me they would put a condom into my vagina so monetary incentive (pregnant women get a monthly that I would not get pregnant again. They told me allowance that they can only claim if they are to push and then they cut my part. I wish I had attending the health facility). been accompanied (delivered) by the traditional midwife – then things would have been much “If we don’t go, we don’t receive the money, that’s better” (Woman who had recently delivered). why we go to the hospital”. A patient explained that they don’t like to go to the Health workers considered that women should deliver hospital for delivery; they prefer to deliver at home in health facilities, but that ignorance sometimes pre- assisted by the traditional midwife. vented them doing so. “In the health centre the delivery is rushed – “We tell them that they should come here to deliver, it’s not the same as having the baby at it won’t cost them anything, and they will have a clean home”. delivery, without complications.” (A staff physician). de Jesús-García et al. BMC Pregnancy and Childbirth (2018) 18:198 Page 5 of 8 Table 2 Bivariate associations with self-reported perineal trauma Factor With trauma Without trauma OR 95% CIca n (%) n (%) Ethnicity Aboriginal 255 (21) 942 (79) 0.28 0.18–0.43 Mestizo 94 (49) 97 (51) Age at delivery 14–19 years old 57 (32) 120 (68) 1.48 0.96–2.3 20–49 years old 310 (24) 967 (76) Place of delivery Home 162 (18) 761 (82) 0.34 0.21–0.56 Health facility 205 (39) 327 (61) Parity Primiparae 120 (39) 190 (61) 2.31 1.76–3.03 Multipara 245 (21) 895 (79) Position in labour Upright 138 (17) 662 (83) 0.38 0.24–0.61 Horizontal 224 (35) 410 (65) Size of baby Bigger than average 96 (24) 302 (76) 0.92 0.70–1.19 Average or smaller 251 (26) 723 (74) Birth attendant Traditional midwife 126 (19) 530 (81) 0.38 0.22–0.65 Doctor/nurse 210 (39) 333 (61) Bold font indicates associations significant at the 5% level OR Odds ratio, 95% CIca Cluster adjusted 95% confidence intervals This excludes the few women who were assisted at delivery by a relative or by nobody “They don’t know, they are not used to getting care “If you don’t do something, there can be a tear. We from health facilities” (A staff obstetrician). make an episiotomy to avoid tears.” (A staff obstetrician). Some health workers accepted that women might have other reasons for not attending health facilities, A health personnel expressed her belief that being such as being scolded when they attended, or having indigenous is a risk factor for delivery complications. embarrassing examinations. “Yes, being indigenous is itself a risk factor for “The women feel embarrassed by being examined by delivery complications, because of their culture, the the doctor in the lithotomy position.” (A staff nurse). myths and beliefs they have, and because of the difficulty of communication.” (A staff physician). An obstetrician described the steps he believed neces- sary to prevent infections during delivery, which might well be objectionable to women. Discussion We found that women delivered by traditional midwives “The patient should come into the delivery room were less likely to have self-reported perineal trauma naked, and then we provide her with a hospital gown. than those delivered by doctors or nurses, and this asso- Shaving the perineum is routine for all women ciation remained when other potential risk factors for delivering here”. (A staff obstetrician). perineal trauma were taken into account. Women deliv- ered at home by traditional midwives did not have the Another made clear that he believed episiotomy was trauma of episiotomies, and they also had lower rates of necessary to avoid perineal tears. perineal tears. Delivery in health facilities increased the risk of perineal trauma among the women in our study. Our finding of less perineal trauma among women Table 3 Final model of multivariate analysis of factors delivered by traditional midwives is compatible with associated with self-reported perineal trauma (n = 1196) other studies. In Yucatan, Mexico, 10% of women who Factor ORna ORa 95% CIca delivered in hospital had perineal tears, compared with Delivery assisted by traditional midwife 0.38 0.41 0.32–0.54 only 6% of those who delivered at home assisted by a traditional midwife [22]. Although in a very different Primipara 2.31 2.01 1.5–2.68 context, a study from the United Kingdom found that ORna Unadjusted odds ratio, ORa Adjusted odds ratio, 95% CIca Cluster adjusted 95% confidence intervals of ORa women delivered by professional midwives working de Jesús-García et al. BMC Pregnancy and Childbirth (2018) 18:198 Page 6 of 8 independently, were more likely to have an intact peri- chopped” without warning. Interviews with health neum than those delivered within the National Health workers confirmed that they considered women should Service system [23] and a study in Austria reported deliver in health facilities, but also exposed beliefs and fewer episiotomies and less perineal trauma when care practices that might well discourage women from doing was led by professional midwives rather than by obstetri- so. Our study covered municipalities of predominantly cians [24]. indigenous populations with a particular world view re- In our study, although women who laboured and garding pregnancy, childbirth and postpartum, with a delivered in an upright or semi-upright position had preference for home delivery assisted by a traditional lower rates of perineal trauma, this association did not midwife, similar to other indigenous groups in Mexico remain in multivariate analysis. There is still debate [14, 16]. about the benefits and risks of an upright posture during In rural Mexico, traditional midwives play an import- labour; a recent update of a Cochrane review of trials of ant role in the care of pregnant women and can be an different postures in second stage labour concluded that important link between the health care services and an upright posture in labour reduced episiotomies but communities. The strong social and cultural identifica- possibly carried an increased risk of second degree peri- tion between indigenous women and their traditional neal tears [25]. midwives is a good argument to consider incorporation One third of the women in our study who delivered in of traditional midwives into health services in remote a health facility reported an episiotomy. This episiotomy areas [28]. In our study sites, where just over half the rate is lower than in countries of South East Asia, where deliveries took place at home assisted by a traditional a study found an overall rate of 65%, ranging from 47% midwife, key informant interviews indicated that trad- in Malaysia to 91% in Thailand [3]. It is similar to a rate itional midwives encouraged pregnant women also to of 25% reported from a study of hospital discharge attend health facilities for antenatal care, and are inter- records in the USA [26]. Routine episiotomy is still prac- ested in cooperating with official health services. For tised in some countries in the persisting belief that it many years, researchers have called for the development prevents severe perineal tears, especially among primipa- of working linkages with traditional midwives to reduce ras [5]. This is despite a body of evidence to the con- the work load of government medical services while trary. A systematic review of trials of selective versus showing respect for indigenous cultures [29]. Our results routine episiotomy, recently updated, found less risk of suggest that increased cooperation with traditional mid- severe perineal trauma when episiotomies were wives could reduce the rates of perineal trauma during performed only when necessary, and concluded that rou- delivery and the associated complications. tine episiotomy to prevent severe perineal tears is not justified and has no benefits for the mother or the baby Limitations [27]. One third of the women in our study who reported We relied on women’s self-reports of having an episiot- an episiotomy in a health facility also reported a perineal omy or a perineal tear, for deliveries up to three years tear. A previous study of women delivering in Acapulco’s previously and did not have any means of verifying their General Hospital found that 20% of women who reports. However, a study among women living in slum reported having an episiotomy during vaginal delivery areas of Dhaka, Bangladesh, reported 82% agreement also reported a perineal tear [10]. between the post-partum physical findings of physicians In our study, primiparas were significantly more likely and maternal reporting of perineal tears [30]. As shown to have self-reported perineal trauma compared with in Table 1, some women in our study who delivered at multiparas and this association persisted in multivariate home assisted by a traditional midwife reported an episi- analysis. This was largely because primiparas delivering otomy, when probably they experienced a perineal tear. in a health facility were more than twice as likely to have Women judged that they had perineal tearing mainly be- an episiotomy compared with multiparas. Our key cause of the associated pain, as well as the subsequent informant interviews with health workers suggested that presence of a wound, with or without infection, and this is because doctors perform episiotomies more rou- because of what the person assisting the delivery told tinely among primiparas, in the belief it will prevent them. We have no reason to believe that traditional mid- perineal tearing. wives were less likely than health workers in a facility to Concerns about the way women are treated when they tell women if they had suffered perineal trauma. Women deliver in local health facilities, including high rates of delivering in a health facility may have been less aware episiotomy, might discourage women from delivering of tears because of the use of analgesia in this setting. there. Key informants in our study communities We did not ask women about analgesia during their last described bad experiences in health care facilities, in- delivery. Despite uncertainty about the frequency of cluding one woman who described having her “part perineal trauma based only on women’s self-reporting, de Jesús-García et al. BMC Pregnancy and Childbirth (2018) 18:198 Page 7 of 8 we believe the analysis of the factors related to the under the age of 16, their parents or legal guardians gave oral informed consent for them to participate. trauma is valid. We were not able to examine whether women with Competing interests high birth weight babies were more likely to have peri- The authors declare that they have no competing interests. neal trauma because more than half the women did not know the birth weight of their baby; there was no associ- Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in ation between self-reported large babies and perineal published maps and institutional affiliations. trauma. We did not ask women about the duration of labour, another potential risk factor for perineal trauma. Author details Centro de Investigación de Enfermedades Tropicales (CIET), Universidad We defined infection of the perineal wound based on Autónoma de Guerrero, Av. Pino s / n, Colonia El Roble, C.P.38640 Acapulco, women’s self-report of pus coming from the wound. 2 Guerrero, Mexico. CIETinternational, 511 Avenue of the Americas #132, New There was a higher rate of infections among home deliv- York, USA. Department of Family Medicine, McGill University, 5858 Chemin de la Côte-des-Neiges, Montreal, Canada. eries, although the difference was not statistically signifi- cant. The relatively small number of infections reported Received: 24 February 2017 Accepted: 20 May 2018 by the women in our sample meant we could not ana- lyse the factors related to infections. References 1. World Health Organization. Appropriate technology for birth. Lancet. 1985;2: Conclusions 436–7. 2. Graham ID, Carroli G, Davies C, Medves JM. 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BMC Pregnancy and ChildbirthSpringer Journals

Published: May 31, 2018

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