The article titled, Perineal Injury in Nulliparous Women Giving Birth at a Community Hospital: Reduced Risk in Births Attended by Certified Nurse-Midwives, was prepared by Maureen Browne et al., who conducted a study to ascertain the difference in rates of perineal injury suffered by nulliparous women under the care of obstetricians and those attended by certified nurse-midwives (CNMs) at a community hospital in the US. Perineal injury during birth is closely related to both temporary and lasting maternal morbidities that include sexual dysfunction, postpartum perineal pain, and deferred time to resume sexual intercourse. Postpartum depression (PPD) is also related to perineal ache and sexual complications. For example, one study found that women who suffered from both sexual problems and perineal pain nine months after delivery were also likely to develop PDD (Browne, Jacobs, Lahiff & Miller, 2010, p.243).
In a US study that used the National Hospital Discharge Survey data (between 1979 and 2004), it was discovered that 3.4% of all women who experienced an impulsive vaginal birth had a harsh perineal laceration. This percentage has not declined since 1979. The same study also revealed that the rate of episiotomy associated with vaginal births declined from 60.8% in 1979 to about 24.4% in 2004. Nonetheless, several women still experience perineal aches and its consequence up to date. Thus, Maureen Browne et al. conducted a study to find out the link between the occurrence and severity of perineal pain and the nature of birth attendants in impulsive natural births of nulliparous women who visited a US community hospital. The study also examined both impulsive lacerations and episiotomies (Browne, Jacobs, Lahiff & Miller, 2010, p.243).
Methods
The study used a sample of 2819 nulliparous women derived from the peri-natal database of Marin General Hospital, found in California. The database holds peri-natal data for births at sampled healthcare institutions in California. The ultimate study population was made up of 2819 nulliparous women who had experienced an impulsive natural birth of a live child in cephalic presentation with a developmental age of at least 36 completed weeks. The study used only women who had been attended to by either a CNM or an obstetrician. The core exposure was the type of attendant-CNM or obstetrician. The key outcome variables were: spontaneous perineal laceration; episiotomy; and intact perineum (Browne, Jacobs, Lahiff & Miller, 2010, p.244). The spontaneous perineal injury was categorized as an injury independent of episiotomy. Those women whose medical records revealed that they suffered secondary episiotomy and perineal laceration were categorized as victims of episiotomy (Browne, Jacobs, Lahiff & Miller, 2010, p.245).
The study also analyzed the link between the type of birth assistant and episiotomy in relation to secondary laceration; the link between the type of birth helper and episiotomy in addition to the third or fourth-degree laceration vis-Ã -vis no injury; and the link between the kind of birth assistant and episiotomy minus a third or fourth-degree laceration vis-Ã -vis no injury. Given that maternal age, oxy-toxin administration, epidural anesthesia; type of medical insurance; ethnic background; and macrosomia are prospective independent risk factors for episiotomy and perineal laceration. The researchers referred to these six factors as the six potential confounders. All data analyses were done in STATA. In addition, the study used a multivariate logistic regression model to approximate ORs to evaluate obstetricians with CNMS, altering for the six potential confounders (Browne, Jacobs, Lahiff & Miller, 2010, p.245).
Results
The study found major disparities with respect to the attributes of women between helpers’ types. Women served by CNMs were Hispanic, younger, had public insurance, and received epidural anesthesia less often than women under obstetrician care. The occurrence and degree of perineal injury as a result of both episiotomy use and impulsive lacerations were notably higher among women attending obstetrician. With respect to impulsive perineal lacerations, women who gave birth under the care of obstetricians were 1.81 times more likely to experience impulsive minor laceration against no injury compared to women who delivered under CNMs care (1.32-2.47). Women who were delivered under the obstetrician were 2.28 times likely to have a major impulsive laceration against no injury, in comparison to women served by CNMs (Browne, Jacobs, Lahiff & Miller, 2010, p.245).
With respect to episiotomy, women who delivered under obstetrician care were 2.93 more likely to experience episiotomy with or without second-degree laceration without any injury in comparison to those under CNMS care (2.0-4.28). Women served by obstetricians were 2.86 more likely to have an episiotomy versus an impulsive second-degree laceration in comparison to those under the CNMs care. Amongst all women who experienced episiotomy, 11.9% suffered either a third or fourth-degree extension (Browne, Jacobs, Lahiff & Miller, 2010, p.246).
The limitations and strengths of the study
There are a number of studies done to assess the link between the type of attendant and perineal outcomes for women who delivered spontaneously. For example, Bodner-Adler et al. conducted a retrospective study with reported similar findings. One of the limitations of this study is that the population used only nulliparous women. On the other hand, Bodner-Adler’s study used both nulliparous and multiparous women. This study also did not utilize information about the years of practice of the attendants as evidence indicates that women are bound to experience less perineal injury under the care of an experienced attendant. However, one of the study’s strengths is that it used six potential confounders: maternal age, oxy-toxin administration; epidural anesthesia; type of medical insurance; ethnic background; and macrosomia as control variables. On the other hand, the study done by Bodner-Adler used maternal age as the only control variable. In addition, a number of similar studies done recently controlled for one or two prospective confounders, for example, ethnic background, maternal age, or health insurance. Nevertheless, none of these studies used all the six potential confounders except research done by Browne et al. also one of the strengths of this study is that it used a bigger sample of women and retrieved data from only one healthcare institution for a period of six years (Browne, Jacobs, Lahiff & Miller, 2010, p.246).
The conclusions derived from this study have a significant impact on the well-being of expectant mothers (Renaud, 2007, p.197). Brown et al. concluded that expectant women need to be given information on the variation in perineal injury by assistant type to help them make informed choices. The study also recommended that women will benefit immensely if clinician shares their knowledge and experience concerning research-based outcomes (Browne, Jacobs, Lahiff & Miller, 2010, p.246). Thus, clinicians need to engage women in meaningful discourses to enable them to make wise decisions (Penney & Wellard, 2007, p.34). The study done by Browne et al. has a significant impact on society since childbirth holds a prominent place in all cultures and communities around the world (Weel, Velden & Lagro-Janssen, 2009, p.1149).
References
Browne, M., Jacobs, M., Lahiff, M., & Miller, S. (2010). Perineal Injury in Nulliparous Women Giving Birth at a Community Hospital: Reduced Risk in Births Attended by Certified Nurse-Midwives. Journal of Midwifery Women’s Health, 55, 243-249.
Penney. W., & Wellard, S.J. (2007). Hearing what other older consumers say about participation in their care. International Journal of Nursing Practice, 13(1), 16-68.
Renaud, M.T. (2007). We are mothers too: Childbearing experiences of lesbian families. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 36(2), 190-199.
Weel, C., Velden, K & Lagro-Janssen, T. (2009). Home births revisited: the continuing search for better evidence. International Journal of Obstetrics and Gynecology, 116, 1149-1150.