Every year, around 10,000 UK women who give birth for the first time sustain a severe third- or fourth-degree tear that damages the anal sphincter. Half of these women who have another vaginal birth will develop anal incontinence—the involuntary leakage of stool or gas—over their lifetime, a condition that profoundly affects quality of life. Yet the national guidance advising many of them to opt for a caesarean section next time is based on expert opinion, not robust research, and no studies have asked women what they actually want or need to make that decision. This project will follow up women who had such a tear, using bowel symptom questionnaires to identify long-term risk factors—including irritable bowel syndrome—and conduct in-depth interviews with women and healthcare professionals about how birth choices are made. The results will be synthesised with patient groups to produce practical recommendations, a visual information summary, and a patient video to support informed decision-making. If successful, the research could end the current variation in care and give women the evidence they need to choose their next birth with confidence, rather than uncertainty.
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Background: Anal incontinence (AI) is the involuntary passage of solid/liquid stool or flatus(12) and a life-changing complication of obstetric anal sphincter injury (OASI). OASI affects 6% primiparous births, approximately 10,000 UK women* per year(13,14). Half of women (range 38.9%-64.5%) who have had an OASI and another vaginal birth develop AI over their lifetime(15-21). Recent evidence suggest the presence of irritable bowel syndrome (IBS) results in worse quality-of-life after OASI(22). OASI impacts birth choice; up to 83.6% women are advised to deliver subsequently by caesarean (CS)(23,24). Concerns revolve around developing new/worsening AI, which profoundly affects quality-of-life(24-28). However, national guidance is based on expert opinion rather than well-designed research studies, causing practice variation and variable access to anorectal investigations(29,30). My systematic review demonstrates low evidence quality and no overall evidence of benefit for CS over vaginal birth to prevent AI after OASI(31). There is not enough evidence to support informed decision-making for mode of birth after OASI. More research is required, specifically to advise asymptomatic women regarding long-term AI risk. Other factors influence decisions, such as previous experience(32,33). No studies have previously explored women's perspectives. Research question: To support women making mode of birth choices after OASI; what are the factors that contribute to long-term AI, and what information do women and healthcare professionals (HCP) need to support informed decision-making? Aims: To identify factors contributing to the development of long-term AI after OASI, including IBS To identify and explore the factors influencing women's mode of birth decision-making after OASI To synthesise information and make practice recommendations Objectives: To establish predictors of long-term AI after OASI, and the impact of IBS on AI symptoms, via a large database and follow-up questionnaire study To explore the factors influencing mode of birth decision-making via detailed semi-structured interviews with women and HCP To present information incorporating women's preferences on optimal content, format, and timing for mode of birth discussion to focus groups of women and HCP Methods: I will perform a convergent parallel mixed-methods study(34) consisting of three work packages WP1-2 will be completed in parallel with synthesis of results prior to WP3. In WP1, I will perform a long-term follow-up study of women with OASI in our institution using electronic validated bowel symptom questionnaires, and investigate associations between factors influencing AI. In WP2, I will undertake in depth semi-structured interviews with women planning future birth after OASI and HCP. I will perform Framework Analysis. I will synthesise quantitative and qualitative data. In WP3, I will present information synthesis to separate focus groups with women and HCP and codevelop outputs with my PPIE group. Outputs: Recommendations for clinical practice Visual information summary and patient video to support birth choice Preliminary data for decision-aid for mode of birth after OASI PPIE is integral to this project; a funded advisory group of women with lived experience influence all aspects and will codevelop outputs. Dissemination: A tailor-made strategy will widely distribute project findings to academics, HCP and women through my network of local and national patient and medical groups.
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