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Erschienen in: BMC Pregnancy and Childbirth 1/2017

Open Access 01.12.2017 | Research article

Risk of obstetric anal sphincter injury increases with maternal age irrespective of parity: a population-based register study

verfasst von: Ulla Waldenström, Cecilia Ekéus

Erschienen in: BMC Pregnancy and Childbirth | Ausgabe 1/2017

Abstract

Background

Obstetric anal sphincter injury (OASI) is a rare but serious outcome of vaginal birth. Based on concerns about the increasing number of women who commence childbearing later than previous generation, this study aimed at investigating age-related risk of OASI in women of different parity.

Methods

A population-based register study including 959,559 live singleton vaginal births recorded in the Swedish Medical Birth Register 1999 to 2011. In each parity group risks of OASI at age 25–29 years, 30–34 years, and ≥35 years compared with age < 25 years were investigated by logistic regression analyses, adjusted for year of birth, education, region of birth, smoking, Body Mass Index, infant birthweight and fetal presentation; and in parous women, history of OASI and cesarean section. Additional analyses also adjusted for mediating factors, such as epidural analgesia, episiotomy, and instrumental delivery, and maternal age-related morbidity.

Results

Rates of OASI were 6.6%, 2.3% and 0.9% in first, second and third births respectively. Age-related risk increased from 25-29 years in first births (Adjusted OR 1.66; 95% CI 1.59–1.72) and second births (Adjusted OR 1.78; 95% CI 1.58–2.01), and from 30-34 years in third births (Adjusted OR 1.60; 95% CI 1.00–2.56). In all parity groups the risk was doubled at age ≥ 35 years, compared with the respective reference group of women under 25 years. Adding mediating factors and maternal age-related morbidity only marginally reduced these risk estimates.

Conclusion

Maternal age is an independent risk factor for OASI in first, second and third births. Although age-related risks by parity are relatively similar, more nulliparous than parous women will be exposed to OASI due to the higher baseline rate.
Hinweise

Electronic supplementary material

The online version of this article (https://​doi.​org/​10.​1186/​s12884-017-1473-7) contains supplementary material, which is available to authorized users.

Background

Obstetric anal sphincter injury (OASI), which refers to perineal tears that involve the external and/or internal anal sphincter, is a well-known complication of vaginal birth. Three factors have significantly contributed to the increased attention paid to OASI by clinicians and researchers: the severe consequences in terms of anal incontinence [13]; the increasing incidence in many countries, such as the UK [4, 5], Canada [6], Sweden [7], Norway [8] and Finland [9]; and the variation in the reported rates of OASI from less than 2% [10] to 27% in primiparous and 8.5% in multiparous women when assessed by endoanal ultrasonography [11].
In order to understand and reduce the incidence of OASI extensive research has focused on identification of risk factors, many of which are directly or indirectly associated with one another. To simplify, the risk factors can be classified into three clusters related to the infant, the medical procedures and maternal characteristics. An important infant risk factor is high birthweight [4, 7, 9, 1214], but also large head circumference [8, 15, 16], occiput posterior presentation [7, 15, 16], shoulder dystocia [17], and a long second stage [13, 15, 16, 18, 19]. Procedural risk factors are instrumental vaginal birth [4, 7, 8, 13, 14, 16, 18], and midline episiotomy [7, 20]. Also, birth position [15, 19] and preventive measures applied to the perineum may affect the risk of OASI [2124], whereas findings regarding the association between OASI and epidural pain relief are inconclusive [7, 12, 15, 16, 18, 19]. Important maternal risk factors are nulliparity [8, 12, 14, 15], and in parous women cesarean section in the previous birth [8, 12, 18], or a previous vaginal birth with OASI [13]. Asian [4, 7, 8, 12] and African [4, 7, 8] ethnic background and advanced maternal age [2527] are associated with OASI, and age-related morbidity such as diabetes [8, 12] and gestational diabetes [8] have been reported.
The background for the present study was the need to explore in more depth the association between advanced maternal age and the risk of OASI, based on concerns about the increasing number of women who commence childbearing later than previously. Although epidemiological studies cannot ascertain the causes of OASI, they may provide clues about the mechanisms involved. Biological ageing has been the focus of many studies of adverse pregnancy outcomes [28, 29], but less so in studies of OASI. Maternal age has often been treated as a confounding variable and not as the exposure of interest. Comparison groups have been defined differently, resulting in different conclusions. When maternal age was dichotomized, for instance by comparing women younger and older than 35 years, no associations with OASI were found [15, 19, 25], whereas a continuous increase of OASI by maternal age was reported when dividing age into several categories, with the exception of the oldest group of 40 years and over where findings were inconclusive [4, 8, 1214, 18, 26]. Most studies have either included only primiparous women or all parous women combined. We found no study investigating the association between advanced maternal age in women of different parities. Considering maternal age and parity as two interrelated risk factors that may affect OASI in different ways, it is important to study their combined effect.
The principal aim of the present study was to investigate associations between advanced maternal age and risks of OASI in women’s first, second, and third births in a large population-based cohort. Associations between OASI and other factors, which were regarded as confounding or mediating factors, are also presented.

Methods

The study was based on data from the Swedish Medical Birth Register (MBR), which includes more than 98% of all births in Sweden, and is validated annually against the National Population Register, using the mother’s and infant’s unique personal identification numbers [30, 31]. Starting at the first antenatal visit, information is prospectively collected during pregnancy and delivery, using standardized records. We included live singleton vaginal births at term (≥37 weeks of gestation), recorded in the MBR from 1999 to 2011. Consequently, a majority of women contributed with information about all their births, some only provided information about their last birth at the beginning of the study period (1999), and others only provided information about their first birth at the end of the period (2011).
From 1999 to 2011, the total number of births in Sweden was 1,301,134. We excluded parity 4 and above (6.0%), multiple births (2.9%), stillbirths (0.3%), preterm births (<37 weeks: 6.2%), cesarean sections (17.2%), and pregnancies without maternal identification number (0.01%), leaving 956,559 pregnancies in the final sample.
The outcome variable was obstetric anal sphincter injury (OASI). Cases were reported by the midwife or the obstetrician using a checkbox in the case notes and/or the notified ICD-10 code (International Classification of Diseases, version 10) for sphincter injury: O702, O702C, O702D, O702X (grade III, which involves the anal sphincter complex) and O703 (grade IV, which extends to the mucosa).
The exposure variable of interest was maternal age when giving birth to the first, second and third infant. In each parity group, maternal age younger than 25 years was used as the reference, and compared with 25–29 years, 30–34 years, and 35 years and over. The rationale for choosing the youngest women as the reference was the assumption that young age would be the most optimal in terms of the elasticity of perineal tissue, and that many studies have reported the lowest OASI rates in the youngest age group [4, 8, 12, 14, 26].
The principal analyses were adjusted for possible confounding factors, including year of birth, education, region of birth, smoking, BMI, infant birthweight and fetal presentation, and in parous women, also history of OASI and history of cesarean section in the previous birth. Information about smoking (dichotomized as daily smoking vs. non-daily smoking), and maternal height and weight were recorded at the first antenatal visit (commonly at 8–12 weeks of gestation). Body Mass Index (BMI) was calculated (weight in kilograms/height in square metres) and categorized according to the World Health Organization as: underweight (BMI <18.5 kg/m2), normal weight (BMI 18.5–24.9 kg/m2), overweight (BMI 25.0–29.9 kg/m2), and obese (BMI ≥30.0 kg/m2). Infant birthweight and fetal presentation were recorded shortly after the birth. The Swedish Register of Total Population provided information about the mother’s country of birth (categorized as Sweden, Asia, Africa and Other). Level of education (Elementary school or less, High school, and College or university) was obtained by linkage to the Swedish Education Register. History of OASI and cesarean section was based on information about these outcomes from the previous birth in the dataset.
Additional analyses also included potentially mediating factors, such as epidural analgesia, episiotomy and instrumental vaginal birth (vacuum extraction and forceps), and maternal age-related morbidity (diabetes, gestational diabetes, pregestational hypertension, preeclampsia). Data on maternal diseases were retrieved from the MBR: pregestational diabetes (insulin-dependent or noninsulin-dependent; ICD-9 codes 250 and 648A; ICD-10 codes E10-E14 and O240-O243), gestational diabetes (ICD-9 code 648 W; ICD-10 code O244), pregestational hypertension (self-reported by check box at first antenatal visit or by ICD-9 codes 401–405, 642C and 642H; or by ICD-10 codes 110–115, O10 and O11) and preeclampsia (including eclampsia; ICD-9 codes 642E-642G; ICD-10 codes O14 and O15).
Pregnancies of nulliparous women (1st births), para 1 (2nd births), and para 2 (3rd births) were analyzed separately. Rates of OASI were calculated for each age category and parity group, and also for each of the potentially confounding and mediating factors. The associations between maternal age and OASI were investigated in logistic regression analyses. First, analyses were adjusted for year of birth (Model 1). The principal analyses in Model 2 were also adjusted for mother’s education, region of birth, smoking, BMI, infant birthweight and fetal presentation; and in parous women, also for OASI and cesarean section in the previous pregnancy. Finally, the potentially mediating factors and age-related morbidity were added (Model 3).
In the total sample, missing data were low except for BMI (11.3%) and history of previous OASI and cesarean section (11.1% in second births and 11.7% in third births) (Table 1). Missing data on BMI (maternal weight and height) was substantially explained by the time-point when this information was included in the Medical Birth Register. Missing data on history of previous OASI and cesarean section were related to how the study sample was defined; with information missing in parous women who had their previous birth prior to the onset of the data collection in 1999. We therefore assessed that the missing values in these three variables were likely to be nearly at random (MAR) and thus meeting the criteria for multiple imputation [32]. Imputations were conducted in SPSS Version 22, in three separate datasets including first, second and third births respectively. The SPSS “Automatic” imputation method was used (Type of imputation model: Logistic Regression), and 15 imputations were performed. The imputed variable in the dataset of first births was BMI, in the dataset of second births, BMI and history of OASI and cesarean section in the first birth, and in the dataset of third births, BMI and history of OASI and cesarean section in the second birth. The variables used in the imputation procedure included the outcome variable (OASI), and all the exposure variables listed in Table 1 (except parity). A comparison between the principal findings in Model 2 (based on imputation of missing data on BMI, and history of OASI and cesarean section) and corresponding findings based on complete case analyses are presented in a (Additional file 1: Table S1).
Table 1
Variables analyzed, and rates of obstetric anal sphincter injury (OASI) in each variable category: singleton, live, term, vaginal 1st, 2nd and 3rd births, Sweden 1999–2011
Variables
1st births
2nd births
3rd births
Prevalence of variables
Rates of OASI
Prevalence of variables
Rates of OASI
Prevalence of variables
Rates of OASI
n (436670)
%
(%)
n (379787)
%
(%)
n (140102)
%
(%)
Maternal age (years)
  < 25
111,828
25.6
4.1
38,677
10.2
1.0
5232
3.7
0.4
 25–29
163,471
37.4
6.9
117,498
30.9
2.0
29,102
20.8
0.6
 30–34
121,833
27.9
8.0
153,263
40.4
2.7
57,036
40.7
0.8
  ≥ 35
39,538
9.1
7.8
70,349
18.5
3.0
48,732
34.8
1.1
Year of birth
 1999–2004
185,654
42.5
7.0
161,407
42.5
2.5
62,560
44.7
1.0
 2005–2011
251,016
57.5
6.3
218,380
57.5
2.2
77,542
55.3
0.8
Education
 Elementary: ≤ 9 years
43,820
10.0
4.2
35,170
9.3
1.6
19,189
13.7
0.7
 High school
175,631
40.2
6.0
163,317
43.0
2.2
63,376
45.2
0.8
 College or university
205,730
47.1
7.6
174,711
46.0
2.6
54,505
38.9
1.0
 Missing
11,489
2.6
 
6589
1.7
 
3032
2.2
 
Country/region of birth
 Sweden
357,730
81.9
6.6
309,967
81.6
2.4
107,752
76.9
0.9
 Asia
33,177
7.6
7.4
28,907
7.6
2.3
14,270
10.2
0.9
 Africa
7163
1.6
9.0
7171
1.9
3.1
4807
3.4
1.2
 Other
38,600
8.8
5.6
33,742
8.9
1.9
13,273
9.5
0.7
Smoking in early pregnancy
 No
381,092
87.3
6.8
335,534
88.3
2.4
119,673
85.4
0.9
 Yes
33,734
7.7
3.9
25,689
6.8
1.4
13,573
9.7
0.6
 Missing
21,844
5.0
 
18,564
4.9
 
6856
4.9
 
BMI
 Low: <18.5
12,152
2.8
6.4
7824
2.1
2.1
2015
1.4
0.4
 Normal weight: 18.5–24.9
260,128
59.6
6.5
210,403
55.4
2.2
71,198
50.8
0.9
 Overweight: 25–29.9
83,185
19.0
6.8
84,411
22.2
2.5
34,887
24.9
0.9
 Obese: ≥ 30
31,333
7.2
6.2
35,013
9.2
2.6
15,749
11.2
0.8
 Missing
49,872
11.4
 
42,136
11.1
 
16,253
11.6
 
Infant birthweight (g)
  < 3000
52,966
12.1
2.7
26,046
6.9
0.9
9447
6.7
0.3
 3000–3499
163,269
37.4
4.5
111,404
29.3
1.3
38,161
27.2
0.4
 3500–3999
157,192
36.0
7.5
150,736
39.7
2.3
54,542
38.9
0.8
 4000–4499
53,342
12.2
11.9
73,289
19.3
3.7
29,503
21.1
1.3
  ≥ 4500
8818
2.0
18.0
17,538
4.6
5.9
8168
5.8
2.6
 Missing
1083
0.2
 
774
0.2
 
281
0.2
 
Presentation
 Occiput anterior
407,784
93.4
6.4
354,776
93.4
2.3
130,554
93.2
0.8
 Occiput posterior
14,355
3.3
10.8
12,375
3.3
4.0
4645
3.3
1.5
 Breech
1405
0.3
4.3
978
0.3
1.6
327
0.2
0.6
 Other
13,126
3.0
6.9
11,658
3.1
2.6
4576
3.3
1.3
Diabetes
 No
435,364
99.7
6.6
378,146
99.6
2.3
139,359
99.5
0.9
 Yes
1306
0.3
8.7
1641
0.4
5.0
743
0.5
1.5
Gestational diabetes
 No
433,683
99.3
6.6
376,826
99.2
2.3
138,580
98.9
0.9
 Yes
2987
0.7
8.1
2961
0.8
3.3
1522
1.1
1.0
Pregestational hypertension
 No
434,666
99.5
6.6
377,874
99.5
2.3
139,239
99.4
0.9
 Yes
2004
0.5
7.0
1913
0.5
2.1
863
0.6
0.9
Preeclampsia
 No
423,794
97.1
6.6
375,404
98.8
2.3
138,380
98.8
0.9
 Yes
12,876
2.9
6.2
4383
1.2
2.3
1722
1.2
0.9
Epidural analgesia
 No
234,246
53.6
6.1
308,153
81.1
2.0
121,796
86.9
0.8
 Yes
202,424
46.4
7.1
71,634
18.9
3.6
18,306
13.1
1.1
Episiotomy
 No
376,486
86.2
6.2
363,439
95.7
2.2
137,265
98.0
0.8
 Yes
60,184
13.8
8.6
16,348
4.3
5.6
2837
2.0
2.5
Vacum extraction or forceps
 No
362,249
83.0
5.0
364,529
96.0
2.0
136,860
97.7
0.8
 Yes
74,421
17.0
14.4
15,258
4.0
10.6
3242
2.3
4.3
Second births only
History of OASI in 1st pregnancy
 No
   
320,913
84.5
2.0
   
 Yes
   
16,531
4.4
7.3
   
 Missing
   
42,343
11.1
    
History of cesarean section 1st pregnancy
 No
   
312,869
82.4
1.6
   
 Yes
   
24,575
6.5
10.3
   
 Missing
   
42,343
11.1
    
Third births only
History of OASI in 2nd pregnancy
 No
      
121,980
87.1
0.7
 Yes
      
1688
1.2
7.6
 Missing
      
16,434
11.7
 
History of cesarean section 2nd pregnancy
 No
      
121,305
86.6
0.7
 Yes
      
2363
1.7
2.4
 Missing
      
16,434
11.7
 

Results

The rates of OASI in live singleton vaginal births at term were 6.6% in first births, 2.3% in second births, and 0.9% in third births, and increased by maternal age in all parity groups (Table 1). The one exception was in the oldest nulliparae who had about the same rate of OASI as the previous age group of 30–34 years. The incidence of OASI decreased from the first to the second half of the observation period. Table 1 also shows differences in maternal characteristics between the parity groups, which is most obvious in third births where low education, being born in Africa or Asia, smoking, and overweight/obesity were more common than in first and second births. These characteristics were most pronounced in women who had their third birth at young age, that is in the reference group of 25 years and younger (elementary school or less 55%; not born in Sweden 45%; smoking 22%, overweight/obesity 44%). The mediating factors epidural analgesia, episiotomy and instrumental vaginal delivery also differed significantly between the parity groups, with the highest rates in first births and the lowest in third births.
The risk of OASI, expressed as adjusted Odds Ratios, increased almost continuously by maternal age, from the youngest to the oldest, irrespective of parity (Table 2: Model 2). Exceptions were the oldest women (≥35 years) with a first birth, who were at similar risk as the 30–34 year olds, and the 25–29 year olds with a third birth who were at the same risk as the younger reference group. The principal findings in Table 2 (Model 2) are also illustrated in Fig. 1. The associations between maternal age and OASI were very similar to those obtained when data were analysed by complete cases (Additional file 1: Table S1: Model 2 analysed by imputed and complete cases).
Table 2
Risk of OASI in first, second and third live, singleton, vaginal births at term
Variables
 
1st births1
  
2nd births2
  
3rd births2
 
Model 1
Model 2
Model 3
Model 1
Model 2
Model 3
Model 1
Model 2
Model 3
n = 436,670
(n = 412,442)
(n = 412,442)
n = 379,787
(n = 350,986)
(n = 350,982)
(n = 140,102)
(n = 128,668)
(n = 128,668)
Adj OR (95% CI)
Adj OR (95% CI)
Adj OR (95% CI)
Adj OR (95% CI)
Adj OR (95% CI)
Adj OR (95% CI)
Adj OR (95% CI)
Adj OR (95% CI)
Adj OR (95% CI)
Maternal age (years)
  < 25
1
1
1
1
1
1
1
1
1
 25–29
1.75 (1.69–1.82)
1.66 (1.59–1.72)
1.56 (1.50–1.62)
2.05 (1.83–2.29)
1.78 (1.58–2.01)
1.73 (1.53–1.95)
1.29 (0.83–1.99)
1.09 (0.67–1.77)
1.07 (0.66–1.73)
 30–34
2.05 (1.98–2.13)
1.94 (1.86–2.02)
1.74 (1.67–1.81)
2.84 (2.55–3.16)
2.30 (2.04–2.59)
2.18 (1.93–2.46)
1.90 (1.25–2.89)
1.60 (1.00–2.56)
1.51 (0.94–2.42)
  ≥ 35
2.01 (1.92–2.11)
1.95 (1.85–2.05)
1.64 (1.56–1.73)
3.18 (2.84–3.55)
2.54 (2.24–2.87)
2.32 (2.05–2.63)
2.64 (1.74–4.01)
2.16 (1.34–3.46)
1.97 (1.23–3.16)
Year of delivery
 1999–2004
1
1
1
1
1
1
1
1
1
 2005–2011
0.88 (0.86–0.90)
0.89 (0.87–0.91)
0.88 (0.86–0.90)
0.88 (0.84–0.91)
0.85 (0.82–0.89)
0.85 (0.81–0.89)
0.77 (0.68–0.86)
0.79 (0.70–0.89)
0.80 (0.71–0.90)
Education
 Elementary: 9 ≤ years
 
0.83 (0.78–0.87)
0.84 (0.79–0.89)
 
0.92 (0.83–1.02)
0.92 (0.84–1.02)
 
1.02 (0.83–1.26)
1.01 (0.82–1.25)
 High school
 
1
1
 
1
1
 
1
1
 College or university
 
1.08 (1.05–1.12)
1.10 (1.07–1.13)
 
1.01 (0.96–1.06)
1.03 (0.98–1.08)
 
0.97 (0.85–1.11)
0.97 (0.85–1.11)
Country/Region of birth
 Sweden
 
1
1
 
1
1
 
1
1
 Asia
 
1.66 (1.58–1.74)
1.58 (1.50–1.65)
 
1.40 (1.28–1.54)
1.36 (1.24–1.49)
 
1.43 (1.15–1.78)
1.40 (1.13–1.74)
 Africa
 
2.01 (1.85–2.20)
1.96 (1.79–2.14)
 
1.76 (1.50–2.06)
1.71 (1.45–2.00)
 
2.14 (1.58–2.88)
2.05 (1.52–2.77)
 Other
 
0.93 (0.89–0.97)
0.93 (0.88–0.97)
 
0.95 (0.87–1.03)
0.95 (0.87–1.04)
 
0.92 (0.73–1.17)
0.94 (0.74–1.18)
Smoking in early pregnancy
 No
 
1
1
 
1
1
 
1
1
 Yes
 
0.81 (0.76–0.86)
0.81 (0.76–0.86)
 
0.88 (0.78–0.98)
0.87 (0.77–0.97)
 
0.96 (0.75–1.22)
0.93 (0.73–1.18)
BMI
 Low: <18.5
 
1.23 (1.14–1.33)
1.22 (1.13–1.31)
 
1.28 (1.08–1.52)
1.28 (1.08–1.51)
 
0.71 (0.35–1.43)
0.71 (0.35–1.44)
 Normal weight: 18.5–24.9
1
1
 
1
1
 
1
1
 Overweight: 25–29.9
 
0.96 (0.93–0.99)
0.95 (0.92–0.99)
 
1.00 (0.94–1.05)
0.99 (0.94–1.05)
 
0.92 (0.80–1.06)
0.92 (0.80–1.06)
 Obese: ≥ 30
 
0.90 (0.85–0.94)
0.90 (0.86–0.95)
 
0.96 (0.89–1.03)
0.96 (0.89–1.04)
 
0.79 (0.65–0.97)
0.79 (0.64–0.97)
Infant birthweight (g)
  < 3000
 
1
1
 
1
1
 
1
1
 3000–3499
 
1.70 (1.61–1.81)
1.69 (1.60–1.80)
 
1.45 (1.25–1.67)
1.44 (1.25–1.67)
 
1.02 (0.68–1.53)
1.02 (0.68–1.54)
 3500–3999
 
2.98 (2.81–3.16)
2.88 (2.72–3.05)
 
2.53 (2.20–2.91)
2.50 (2.17–2.87)
 
2.40 (1.64–3.51)
2.38 (1.62–3.48)
 4000–4499
 
5.08 (4.78–5.40)
4.69 (4.41–4.98)
 
4.25 (3.69–4.90)
4.09 (3.55–4.72)
 
3.97 (2.70–5.83)
3.84 (2.61–5.65)
  ≥ 4500
 
8.51 (7.86–9.20)
7.62 (7.04–8.25)
 
7.39 (6.34–8.61)
7.01 (6.01–8.17)
 
8.17 (5.48–12.16)
7.70 (5.16–11.49)
Presentation
 Occiput anterior
 
1
1
 
1
1
 
1
1
 Occiput posterior
 
1.89 (1.78–2.00)
1.43 (1.35–1.51)
 
1.92 (1.74–2.12)
1.59 (1.44–1.76)
 
2.00 (1.55–2.59)
1.58 (1.22–2.06)
 Breech
 
0.87 (0.76–0.99)
1.06 (0.93–1.22)
 
1.20 (0.72–2.02)
1.26 (0.75–2.12)
 
1.34 (0.33–5.40)
1.34 (0.33–5.42)
 Other
 
1.11 (1.04–1.18)
1.03 (0.97–1.11)
 
1.24 (1.09–1.41)
1.22 (1.07–1.38)
 
1.72 (1.30–2.28)
1.70 (1.29–2.25)
History of OASI in 1st pregnancy3
 No
    
1
1
   
 Yes
    
4.38 (4.08–4.70)
4.38 (4.09–4.70)
   
History of cesarean section 1st pregnancy3
 No
    
1
1
   
 Yes
    
7.14 (6.77–7.53)
5.46 (5.14–5.80)
   
History of OASI in 2nd pregnancy4
 No
       
1
1
 Yes
       
8.92 (7.28–10.90)
8.62 (7.01–10.61)
History of cesarean section 2nd pregnancy4
 No
       
1
1
 Yes
       
3.29 (2.45–4.41)
2.93 (2.18–3.95)
Diabetes
 No
  
1
  
1
  
1
 Yes
  
0.98 (0.79–1.21)
  
1.35 (1.04–1.73)
  
0.98 (0.48–2.02)
Epidural analgesia
 No
  
1
  
1
  
1
 Yes
  
0.93 (0.90–0.95)
  
1.09 (1.03–1.15)
  
1.10 (0.93–1.29)
Episiotomy
 No
  
1
  
1
  
1
 Yes
  
0.89 (0.87–0.92)
  
1.04 (0.96–1.13)
  
1.34 (1.01–1.77)
Vacuum extraction or forceps
 No
  
1
  
1
  
1
 Yes
  
2.87 (2.80–2.95)
  
2.82 (2.63–3.02)
  
4.07 (3.33–4.99)
Adjusted Odds Ratio (OR) with 95% Confidence Interval (CI) in three different models: all variables included in the respective model presented
1Multiple imputation of missing values in BMI
2Multiple imputation of missing values in BMI, OASI in previous birth, and cesarean section in previous birth
3Only second births
4Only third births
The following factors included in Model 3 were not statistically significant in any of the three parity groups, and are not shown in the table: pregestational hypertension, gestational diabetes and preeclampsia
When the mediating factors (epidural analgesia, episiotomy, instrumental delivery) and maternal age-related morbidity (diabetes, pregestational hypertension, gestational diabetes, preeclampsia) were added in Model 3, only minor reductions of the risk estimates were found, and these did not alter the general findings.
Table 2 also shows the independent effect of other risk factors for OASI, the strongest of which were infant birth weight of ≥4000 g, history of OASI, and history of cesarean section. Factors that increased the risk in a similar way in all three parity groups were, besides infant birth weight, occiput posterior presentation, African and Asian region of birth, and instrumental vaginal delivery.

Discussion

This study showed that the risk of OASI in live singleton vaginal births at term increased by maternal age in first, second and third births. The association between increasing maternal age and OASI is supported by studies in which the age distribution is divided into four categories or more [4, 1214, 16, 26], whereas only two age categories may have concealed the effect [15, 19, 25]. The rates of OASI differed between first, second and third births, indicating that information about parity is important, not only when comparing incidences of OASI in different settings, but also when discussing the effect of maternal age in individual cases. Even though the aged-related risk of OASI was approximately doubled at age 30 and older in both first and second births, compared with the respective reference group aged <25 years, the proportion of women who experienced an OASI was greater in first births due to the higher prevalence at baseline (4.1% and 1.0% at age < 25 years in first and second births respectively, Table 1).
We further explored the finding that risk of OASI at age 35 and older in first births did not continue to increase but was the same as in the previous age category (Fig. 1). Several other studies have reported that the risk of OASI in first births did not increase in the oldest women, mostly defined as 40 years and older [4, 14, 18, 26]. We speculate that one explanation could be that the oldest nulliparae who had a vaginal birth were more low-risk, compared with the oldest women having their second or third vaginal birth, because many having a first birth in this age category were delivered by cesarean section (CS rates at age ≥ 35 years were 30% in 1st births, 21% in 2nd births, and 17% in 3rd births). Infant birthweight of ≥4000 g was a strong risk factor for OASI, and this factor was less prevalent in the oldest nulliparae with a vaginal birth compared with those delivered by CS (birth weight ≥ 4000 g in vaginal birth versus CS at age ≥ 35: 1st births 14% vs. 23%; 2nd births 24% vs. 24%; 3rd births 27% vs. 20%). Although analyses were adjusted for infant birthweight, this outcome could have been associated with other unmeasured confounding, such as prolonged labour.
In third births, the age-related risk of OASI commenced at higher age than in first and second births, and we cannot exclude that this finding was also related to unmeasured confounding. The reference group, with which all other age groups were compared, included only 3.7% of third births, and constituted a very selected group of women with high rates of low education, non-Swedish background, smoking and high BMI. This selection of women may be explained by the fact that having a third child before the age of 25 years is uncommon in Sweden where two children has long been the norm [33, 34]. However, since the end of the 1990s it has become more popular to have a third child, and this trend has primarily involved highly educated women and high income earners [35]. Consequently, third births included a more heterogeneous group of women in terms of socioeconomic background and lifestyle, both factors associated with OASI.
The physiological mechanism explaining why rates of OASI are much lower in multiparous than primiparous women may primarily be related to more resilient anatomical structures, after having been stretched during the first birth. The selection of women who have more than one child may also be a consideration, since OASI in the first birth may be a reason for not having more children. This makes multiparous women more low risk in relation to OASI, which was illustrated in the present study with a history of OASI being least common in third births.
The physiological mechanisms explaining the independent effect of maternal age on the risk of OASI seem more complex. Although we know that ageing occurs in all of the body’s cells, tissues and organs from an early age, the physiological effect of ageing on the connective and muscular tissues in the perineal region during childbirth is poorly researched. One effect of ageing which could possibly affect blood circulation in the perineum is the early onset of sclerotic lesions [36]. Of all the measures taken to reduce rates of OASI, such as manual support to reduce pressure on the perineum [37, 38], injection of hyaluronidase to affect perineal connective tissue [39, 40], application of oil [41] and antenatal massage [42, 43] to increase elasticity in the perineum, only application of warm packs to increase blood circulation in the perineum [44] has been effective. Whether perineal warm packs are more effective at advanced age has not, however, been investigated. Our finding that smoking decreased the risk of OASI was confusing, considering that smoking has been described as an ageing accelerator, which exhausts cellular defense and repair functions [45]. Norwegian [8] and Finnish [18] cohort studies have also reported a lower risk of OASI in smokers, and Räisänen and colleagues suggested that “smoking may interfere with collagen synthesis and connective tissue properties, and thus modify the OASI risk by an, as yet, unknown mechanism.” (page7).
This study shows that giving birth for the first time at a young age could reduce the risk of OASI, with maternal age under 25 years being most optimal. However, to change the current trend in modern societies of parenthood often starting after the age of 30, is probably not the most effective or feasible way of achieving a reduction in the incidence of OASI at a population level. The most important step is to decrease the adverse effects of OASI by effective diagnosis, followed by effective treatment. Faltin and colleagues [46] showed in a randomized controlled trial of primiparous women without a clinically evident anal sphincter tear that endoanal ultrasound examination of the perineum after childbirth increased the detection rate of OASI to 5.6%, and that immediate repair decreased the risk of severe fecal incontinence 3 months after birth from 8.7% in the control group to 3.3% in the intervention group. A systematic review of seven observational studies reported a reduction of OASI after the introduction of a manual support technique originating from Finland [24]. The level of evidence in the included studies was, however, too low to recommend implementation in clinical settings.
The strengths of this study include the high quality of data in the Swedish Medical Birth Register, with a low percentage of missing cases (<2%), and the possibility of taking important confounding factors into account. Including history of OASI and cesarean section in the analyses of second and third births was particularly important considering the strong associations between these variables and OASI. Still, residual confounding may be a problem, and information was not available on important confounders, such as length of second stage labour, inter-delivery interval and female genital mutilation. Another limitation was that the proportion of missing values was relatively high in relation to BMI and history of OASI and cesarean section. The missing values in these variables were assumed to be close to random which justified multiple imputation. The findings presented in this study differed little from those obtained by complete case analyses, and none of the conclusions was altered.

Conclusions

Our study suggests that advanced maternal age is an independent risk factor for OASI irrespective of parity. When discussing young people’s life plans, this information could be added to other information about the potential risks associated with postponing parenthood to age 30 and later. For the clinician who assists women during labour, increased attention should be paid to older women, especially nulliparae, in order to ascertain the status of the perineum and optimise prompt treatment when OASI is diagnosed.

Acknowledgements

The authors thank all the women, midwives and obstetricians who provided data for this study by completing the antenatal, intrapartum and postpartum records on which the Swedish National Medical Birth Register is based.

Funding

No extra external funding was sought for this study. It was undertaken within the remit of our academic appointments.

Availability of data and materials

Access to the data in this study is regulated by regulations of The National Board of Health and Welfare in Sweden as indicated below.
The study was approved by the Regional Ethics Review Board in Stockholm, Stockholm (2013/731–31/1). This is a register study based on data from the Swedish Medical Birth Register (MBR). The National Board of Health and Welfare in Sweden, which is responsible for the MBR, assesses the researchers’ application after ethical approval has been obtained from the Regional Ethics Review Board, and then delivers the anonymous data to the researchers.
Individual consent is not required since data is anonymised when delivered to the researchers.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

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Open AccessThis 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.
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Metadaten
Titel
Risk of obstetric anal sphincter injury increases with maternal age irrespective of parity: a population-based register study
verfasst von
Ulla Waldenström
Cecilia Ekéus
Publikationsdatum
01.12.2017
Verlag
BioMed Central
Erschienen in
BMC Pregnancy and Childbirth / Ausgabe 1/2017
Elektronische ISSN: 1471-2393
DOI
https://doi.org/10.1186/s12884-017-1473-7

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