Temporal trends in the incidence of and associations between the risk factors for obstetrical anal sphincter injuries

Abstract

Obstetrical anal sphincter injuries are an important complication of vaginal deliveries that may result in short- and long-term pelvic floor morbidity and a diminished quality of life in young, healthy women. The prevalence of obstetrical anal sphincter injuries ranges from 0.1% to 8.7%. Over recent years, there seems to be a trend of increasing occurrence of obstetrical anal sphincter injuries worldwide. It is unclear why the rates are rising. Previous studies have examined the effect of different risk factors on the prevalence of obstetrical anal sphincter injuries. The change in the incidence of some risk factors for obstetrical anal sphincter injuries can partially explain the overall increase in obstetrical anal sphincter injuries. There is no previous study that explored the impact of the changes of individual risk factors over time on the risk for obstetrical anal sphincter injuries. The main aim of this study was to examine the temporal trends in the prevalence and odds ratio of the major risk factors known to be associated with obstetrical anal sphincter injuries in the period from 1988 to2016. This was a retrospective cohort study that included all women who underwent vaginal deliveries between 1988 and 2016 at a tertiary university medical center. The time intervals were divided into 4 periods (1988-1997, 1998-2007, 2008-2016, and the total time from 1988 to 2016) and the incidence of each risk factor was calculated for each time period. Correlation models and regression analysis were performed to examine the association between obstetrical anal sphincter injuries and the different risk factors over time. Furthermore, the trends in the odds ratios of the important risk factors over the time periods were evaluated using a multivariate regression analysis in which the primiparous women were separated from the multiparous women. During the study period, there were 295,668 vaginal deliveries. Of these, 591 women were diagnosed with obstetrical anal sphincter injuries (0.2%). The significant risk factors for obstetrical anal sphincter injuries (P<.05) in the multivariable analysis were the following: primiparity, vaginal birth after cesarean delivery, vacuum extraction, and a birthweight of >4 kg. There was a significant (P<.05) increase in the incidence over the study period for the following risk factors: primiparity, vaginal birth after cesarean delivery, and vacuum extraction. No change was found in the incidence of the risk factor of a birthweight of >4 kg. In addition, we found a strengthening of the association between vaginal birth after cesarean delivery and macrosomia with obstetrical anal sphincter injuries, as opposed to a decline in the relative contribution of vacuum extraction to the overall risk for obstetrical anal sphincter injuries. Moreover, we found that obstetrical anal sphincter injuries among primiparous women increased 7-fold over the study period but was unchanged among multiparous women. We have shown significant (P<.05) temporal trends in the incidence and odds ratio of some of the known risk factors for obstetrical anal sphincter injuries. A better understanding of the changes in the incidence and specific contribution of important risk factors for obstetrical anal sphincter injuries may explain, in part, the worldwide increase in the prevalence of this important and detrimental complication of vaginal birth.