Associations with perineal trauma during childbirth at home and in health facilities in indigenous municipalities in southern Mexico: a cross-sectional cluster survey

Background: Episiotomy and perineal tears remain common in vaginal deliveries. This study estimated the frequency of and factors associated with perineal tears, episiotomies, and postnatal infections among women in two predominantly indigenous municipalities in southern Mexico, where traditional midwives play an important role in women's health. Methods: A cross-sectional study contacted women who gave birth in the previous three years. An administered questionnaire asked about place of delivery, birthing position, birth attendant, episiotomy, perineal tears, and wound infection after delivery. Cluster adjusted bivariate and then multivariate analysis examined factors potentially associated with self-reported perineal trauma (episiotomy and/or perineal tear). Key informant interviews sought insights into some of the findings. Results: Among women with a vaginal delivery, 71% (876/1238) of indigenous women and 18% (36/197) of nonindigenous women delivered at home. Some 17% (247/1416) of women overall, and 33% (171/525) of those delivering in a health facility, reported an episiotomy during delivery. Among 171 women reporting an episiotomy in a health facility, 30% (52) also reported a perineal tear. Overall, 13% (190/1412) of women reported they had a perineal tear during delivery, 17% (86/515) of those delivering in a health facility and 12% (104/897) of those delivering at home. A quarter of the women had self-reported perineal trauma during their last delivery, 38% (196/511) of those delivering in a health facility and 18% (160/893) of those delivering at home. In bivariate analysis, indigenous ethnicity, home delivery, upright posture in labour, and delivery by a traditional midwife were associated with a lower risk of perineal trauma, while primiparas had a higher risk. In the final multivariate model, delivery by a traditional midwife was protective (ORa 0.41, 95% CIca 0.32-0.54) and primiparity was a risk factor (ORa 2.01, 95% CIca 1.5-2.68) for perineal trauma. Women suggested that fear of bad treatment and being cut made them unwilling to deliver in health facilities. Conclusions: The rate of perineal trauma among women giving birth in indigenous communities could be reduced by efforts to decrease the use of episiotomies in health facilities, and by opening a dialogue with traditional midwives to increase their interaction with formal health services.