Why focus on preventing third and fourth degree tears?

During October and November 2016, Women’s Healthcare Australasia (WHA) consulted with a range of member groups  to seek their advice on their highest priority problem. Consideration was then given to the use of a  collaborative improvement approach to address the issue. Based on input from member hospitals a work decision was then made to run a Collaborative that would focus on reducing harm from third and fourth degree perineal tears.

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There is clear evidence that some Women's Healthcare Australasia WHA member hospitals are succeeding in minimising this harm to women, and that their success is not simply the under reporting of harm.  WHA is keen to facilitate sharing of learning to assist all member hospitals to minimise this harm to women.

Approximately 73% of women giving birth vaginally experience varying degrees of tear in Australia (AIHW, 2015a). While grazes, first and second degree tears of the anterior vaginal wall are usually associated with little to no morbidity for women, third and fourth degree tears, involving  injury to the posterior vaginal wall, muscles or anal sphincter, can present an array of physical and psychological morbidities for women many months or years after childbirth (Frohlich & Kettle, 2015).

During 2014, 3.1% (n=6,365) of women having a vaginal birth in Australia experienced a third or fourth degree tear (AIHW, 2016). Women’s Healthcare Australasia (WHA) data shown below indicates a consistent increase in the number of women experiencing a third or fourth perineal degree tear.  This rising rate of harm from tears is occurring despite a declining vaginal birth rate.  

There is also considerable variation in rates of third and fourth degree tears among WHA member hospitals. This variation is not specific to different service capabilities, as illustrated in the 2015/16 Benchmarking Maternity Care report below. Hospitals supporting more than 500 births per annum participating in the WHA Benchmarking Maternity Care program for 2016/17 reported rates of third and fourth degree tear ranging between 1.3% and 5.6%, with an average of 3.86%.  For hospitals supporting fewer than 500 births per annum the rates varied from 0% to 10%, with an average of 2.51%. Rates of third and fourth degree tear also vary by level of maternity care. Level 1-5 hospitals report an average rate of 3.37%, and level 6 (tertiary) hospitals report an average of 3.86%.

References 

Australian Institute of Health and Welfare (AIHW). (2015). Mothers and babies. Canberra: AIHA. Retrieved from https://www.aihw.gov.au/reports-statistics/populat...

Australian Institute of Health and Welfare (AIHW). (2018). Procedures data cubes. Retrieved from AIHW: https://www.aihw.gov.au/reports/hospitals/procedur...

Frohlich, J., & Kettle, C. (2015). Perineal care. Retrieved from BMJ Best Practice: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4356152/

Women's Healthcare Australasia (WHA). (2016). Benchmarking maternity care data 2015-16 [unpublished]. Canberra: Women's Healthcare Australasia.