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\title{Rates of obstetric anal sphincter injuries among immigrant women}



\author[1]{Marie-Louise Marschalek}%
\affil[1]{Affiliation not available}%


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  \date{May 18, 2024}


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Rates of obstetric anal sphincter injuries among immigrant women

Marie-Louise Marschalek

Klinik Floridsdorf, Vienna, Austria

Linked article: This is a mini commentary on Sorbye et al.

The Norwegian-wide cohort study by Sorbye et al addresses the question
of whether the maternal region of origin and birthplace have an
influence on the risk of obstetric anal sphincter injury (BJOG 2021).

Obstetric anal sphincter injuries (OASI), as a complication of vaginal
delivery, are associated with potential long-term complications such as
anal and fecal incontinence, perineal pain, sexual dysfunction and
increased rates of caesarean section in subsequent deliveries.
Established risk factors for OASI are high birthweight, operative
vaginal delivery and prolonged second stage of labor.

When it comes to ethnicity as a risk factor, retrospective studies
suggest Asian women are at increased risk for OASI (Brown J et al. Aust
N Z J Obstet Gynaecol. 2018;58(1):79-85.). However, it has remained
unclear whether the biological or the migration factor is the cause.

Maternal origin, immigrant status and duration of residence have been
the subject of many studies, in order to identify risks of various
adverse obstetric outcomes, with known increased risk of both giving
birth to small for gestational age fetuses, and preterm delivery (Urquia
et al. BJOG 2010 Apr;117(5):591-601.)

The present study analyzed a 9-year comprehensive data set from birth
registries, and concluded that, compared to Norwegian women, women from
South Asia were most likely to experience OASI, with an aOR of 2.24,
followed by women from Southeast/East Asian/Pacific and Sub-Saharan
Africa. Furthermore, the authors found newly arrived migrant women to be
at highest risk for OASI.

Migrant women are exposed to a new physical and social environment, with
limited language competence a significant factor in preventing social
integration, resulting in limited health literacy and sub-optimal care
after migration.

Language skills are particularly significant in OASI cases, being
important for collaboration between the woman and birth attendant during
delivery. Interestingly, a difference was found regarding whether the
partner was Norwegian-born or foreign-born, indicating that good
communication at giving birth was important. The inference is that an
understanding of the birth process and an explanation of the
difficulties that might arise is an advantage. Undoubtedly educating
women during pregnancy itself about OASI risks is of value.

Sorbye et al do not address the topic of perineal laceration protection
techniques, experience of birth attendants or birth position. As studies
have identified certain positions, such as the lithotomy position, to be
a risk factor for OASI, whilst others, such as the lateral position, are
considered to be protective, this information would have been
interesting.

In other nationwide studies the incidence of OASI is shown to have
increased, explained by improved awareness, diagnostic recognition and
documentation (Andrews V et al. BJOG. 2006;113:195-200.). However, in
this and another recent study, the incidence has decreased in Norway and
Sweden, possibly due to implemented perineal protection programs for
midwives/physicians (Gyhagen et al. Acta Obstet Gynecol Scand. 2021 Aug
25).

Sorbye and colleagues highlight the influence of environmental factors
on OASI, which in theory could be preventable, and confirm that there
are migration specific factors. Hence, the vulnerable group of migrant
women need special attention and care in order to reduce morbidity.

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