Racial/Ethnic Differences in Perineal Lacerations in a Diverse Urban Healthcare System

Differences in maternal and perinatal outcomes between Dutch and non-Western women in a midwife-led care setting: a retrospective cohort study

BACKGROUND

Previous research has shown that genetics and maternal medical, sociodemographic, lifestyle and psychosocial factors affect maternal and perinatal outcomes. Substantial research has been done on ethnic differences and maternal and perinatal outcomes in hospital settings. To our knowledge there are no studies about the associations between ethnicity and maternal and perinatal outcomes in a midwife-led care setting among low-risk women. Therefore, our study aimed to investigate possible ethnic associations between non-Western and Dutch women, and maternal and perinatal outcomes in a midwife-led care setting.

METHODS

A retrospective cohort study was performed of low-risk pregnant women (n = 977) in midwife-led care. Data was collected from a medium-sized midwifery practice in an urban region near Amsterdam, the Netherlands. Regression analyses were performed to examine the effect of ethnicity on maternal and perinatal outcomes. Outcomes of interest were gestational age, mode of birth, perineal status, postpartum hemorrhage, birthweight, perinatal death and low Apgar score. Associations were corrected for deprived areas, body mass index (BMI), parity and maternal educational level. Potential effect modification for prenatal referral to obstetrician and parity were assessed.

RESULTS

The study included 977 women, of whom 483 were non-Western, and 494 were Dutch. Regarding characteristics, compared to Dutch women, non-Western women were more likely to be multiparous (respectively 58.6% versus 49.2%; p = 0.003), live in a deprived area (34.0% versus 8.1%; p < 0.001), have limited formal education (medium: 46.0% versus 49.2%; low: 15.6% versus 7.4%; p < 0.001), have a higher BMI (overweight: 28.6% versus 22.9%; obese: 14.9% versus 12.0%; p = 0.045), make inadequate/intermediate use of prenatal care (7.2% versus 2.4%, p < 0.001) and suffer from gestational diabetes (17.2% versus 9.9%, p < 0.001). Whereas Dutch women were more likely to suffer from psychosocial problems during and/or before pregnancy (34.8% versus 23.0%, p < 0.001) and drink alcohol during pregnancy (5.9% versus 1.9%, p = 0.001). Regarding maternal and perinatal outcomes, non-Western women had increased odds of perineal laceration (OR 1.59, 95%CI 1.14-2.21) and decreased odds of high birthweight (0.50, 95%CI 0.29-0.84). The mode of birth differed by ethnicity. The interaction of prenatal referral and ethnicity was significant for the mode of birth. Therefore, for mode of birth the groups were stratified by prenatal referral (yes/no). In the prenatally referred group (n = 474), non-Western ethnicity was significantly associated with decreased odds of cesarean Sect. (0.63, 0.40-0.98). No other associations were significantly associated with ethnicity.

CONCLUSIONS

Maternal and perinatal outcomes differed between low-risk non-Western and Dutch women in a midwife-led care setting. Among non-Western women, perineal laceration occurred more often, and fewer children with high birthweight were born. In the prenatally referred group, women of non-Western ethnicity had decreased odds of cesarean section. Gestational age and postpartum hemorrhage were not significantly associated with ethnicity.

Maternal origin matters: Country of birth as a risk factor for obstetric anal sphincter injuries

OBJECTIVE

Obstetric anal sphincter injuries (OASIS) are severe complications to vaginal births with potential long-term consequences. Maternal origin has been proposed to affect the overall risk, but the association and underlying explanation are uncertain. The objective was to assess the association between maternal country of birth and OASIS.

METHODS

A Swedish nationwide cohort study including singleton term vaginal births during 2005-2016. Data were extracted from the Swedish Medical Birth Registry and Statistics Sweden. Modified Poisson regression analyses were performed to obtain crude and adjusted risk ratios (RRs). Adjustments were made in four cumulative steps. Sub-analyses were performed to investigate the risk of OASIS associated with female genital circumcision (FGC).

RESULTS

In all, 988 804 births were included. The rate of OASIS in Swedish-born women was 3.5%. Women from East/Southeast Asia had an increased risk of OASIS (adjusted RR [aRR] 1.71, 95% confidence interval [CI] 1.60-1.83), as did women born in Sub-Saharan Africa (aRR 1.60, 95% CI 1.49-1.72). The risk remained significantly increased also after adjustment for maternal height. By contrast, women from South/Central America had a decreased risk of OASIS (aRR 0.65, 95% CI 0.56-0.76). FGC was associated with an increased risk of OASIS (aRR 3.05, 95% CI 2.60-3.58). Episiotomy appeared to have an overall protective effect (aRR 0.95, 95% CI 0.92-0.98), but not significantly more protective among women with female genital mutilation.

CONCLUSIONS

Country of birth plays an important role in the risk of OASIS. Women from East/Southeast Asia and Sub-Saharan Africa are at significantly increased risk as compared with Swedish-born women, whereas women from South/Central America are at lower risk. FGC is also a significant risk factor for OASIS.

Asian-White disparities in obstetric anal sphincter injury: a systematic review and meta-analysis

OBJECTIVE

Obstetrical anal sphincter injury describes a severe injury to the perineum and perianal muscles after birth. Obstetrical anal sphincter injury occurs in approximately 4.4% of vaginal births in the United States; however, racial and ethnic inequities in the incidence of obstetrical anal sphincter injury have been shown in several high-income countries. Specifically, an increased risk of obstetrical anal sphincter injury in individuals who identify as Asian vs those who identify as White has been documented among residents of the United States, Australia, Canada, Western Europe, and the Scandinavian countries. The high rates of obstetrical anal sphincter injury among the Asian diaspora in these countries are higher than obstetrical anal sphincter injury rates reported among Asian populations residing in Asia. A systematic review and meta-analysis of studies in high-income, non-Asian countries was conducted to further evaluate this relationship.

DATA SOURCES

MEDLINE, Ovid, Embase, EmCare, and the Cochrane databases were searched from inception to March 2023 for original research studies.

STUDY ELIGIBILITY CRITERIA

Observational studies using keywords and controlled vocabulary terms related to race, ethnicity and obstetrical anal sphincter injury. All observational studies, including cross-sectional, case-control, and cohort were included. 2 reviewers followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and the Meta-analysis of Observational Studies in Epidemiology recommendations.

METHODS

Meta-analysis was performed using RevMan (version 5.4; Cochrane Collaboration, London, United Kingdom) for dichotomous data using the random effects model and the odds ratios as effect measures with 95% confidence intervals. Subgroup analysis was performed among Asian subgroups. The risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal tools. Meta-regression was used to determine sources of between-study heterogeneity.

Results

A total of 27 studies conducted in 7 countries met the inclusion criteria encompassing 2,337,803 individuals. The pooled incidence of obstetrical anal sphincter injury was higher among Asian individuals than White individuals (pooled odds ratio, 1.64; 95% confidence interval, 1.48-1.80). Subgroup analyses showed that obstetrical anal sphincter injury rates were highest among South Asians and among population-based vs hospital-based studies. Meta-regression showed that moderate heterogeneity remained even after accounting for differences in studies by types of Asian subgroups included, study year, mode of delivery included, and study setting.

Conclusion

Obstetrical anal sphincter injury is more frequent among Asian versus white birthing individuals in multiple high-income, non-Asian countries. Qualitative and quantitative research to elucidate underlying causal mechanisms responsible for this relationship are warranted.

Obstetrical Soft Tissue Trauma during Spontaneous Vaginal Birth in the Romanian Adolescent Population-Multicentric Comparative Study with Adult Population

Romania is a country with high rates of adolescent births, associating scarce comprehensive obstetrical management with this specific population. This research aims to assess soft tissue trauma after vaginal birth in teenage mothers compared to their adult counterparts. A retrospective case-control study was conducted for one year in two hospitals. All vaginal deliveries were considered; the age cut-off value was considered at 20 years old for case and control groups. Lacerations were divided into three subgroups, considering the involved anatomical region; group I: labial and periurethral lacerations, group II: vaginal and perineal lacerations, and group III: cervical lacerations. There were 1498 women included in the study: 298 young mothers and 1200 adults. Teenagers were more likely to have an episiotomy during vaginal delivery compared to adult women: 56% versus 26.7% (p = 0.00, Pearson Chi-square) and a 1.89 times increased risk for developing additional group II lacerations: p = 0.01, Pearson Chi-square test with Bonferroni correction: OR = 1.89, 95% CI: 1.18–3.02. Group II lacerations were the most frequent type of birth trauma in both study groups. Fetal weight ≥4000 g was associated with a two times higher risk for vaginal and perineal lacerations when age criterion was not considered (OR = 1.98, 95% CI: 1.13–3.47, p = 0.01). The incidence of group I and II lacerations increased with age: from 0% and 9.1% between 10 and 14 years old to 6% and 26.2% between 18 and 19 years old. All groups of lacerations were more often identified in the case group, compared to the adult group. Fetal macrosomia and spontaneously ruptured membranes at admission could not be documented as risk factors for obstetrical injury in young mothers. Episiotomy performed in teenagers was not a protective procedure for group II lacerations.