Can perineal tears and obstetric anal sphincter injuries in Palestine be prevented? A study of two different interventions.

The Palestinian perineum and birth complication study a collaboration between Oslo University hospital (OUH), the Palestinian Ministry of Health, Birzeit university and the University of Oslo (UiO); and has been organized by the Intervention center at OUH Rikshospitalet. Three Palestinian specialists in obstetrics and gynaecology, Dr Kaled Zimmo and Dr Mohammed Zimmo from Gaza plus Dr Hadeel Ali from Ramallah in the West Bank, collected during the time period between March 1st, 2015 until April 30th, 2017 the largest database on maternal-child health in Palestine so far. The study included three governmental hospitals in Gaza and three in the West bank and comprises information on 75 000 women giving birth in the study hospitals. In his study, Dr Kaled Zimmo has explored episiotomy practice in Palestine. Episiotomy involves cutting muscles in the perineum to provide better space conditions when the child is born. This is the most common surgical procedure at birth but can cause injuries and should therefore not be done routinely in all births. In his thesis Dr Zimmo studied the level of knowledge of Palestinian obstetricians and midwives before and after expert training in the diagnosis and treatment of birth tears (perineal tears) and mapped current episiotomy practices in Palestine. In addition, he investigated the effects of the different interventions developed to prevent episiotomy, by using a two-handed support technique of perineum. This doctoral work shows that in Palestine, episiotomy is performed routinely on women who give birth vaginally for the first time. Moreover, the positive effect of training in episiotomy practices, diagnostics and treatment of perineal injuries was clearly demonstrated, as well as the use of interventions reducing the incidences of episiotomy. Dr Mohamed Zimmo studied the use of Caesarean section (CS) in Palestine. CS is one of the world's most common surgical procedures. The operation may have unfortunate short- and long-term consequences for both mother and child. The incidence of caesarean section varies from country to country, but also from hospital to hospital in the same country. In order to understand possible causes of alarming increase globally in the occurrence of caesarean section, it is important to identify which women are at the highest risk. In his study, Dr. Zimmo showed large variations between hospitals in Palestine in prevalence of CS. Previous CS or IVF was associated with higher prevalence of CS but could not, however, explain the differences between the hospitals. Approximately 60 percent of the variation in prevalence could be explained by differences given indication for CS. More than 40 percent of CS were performed on women who have previously had CS, while 12 percent had twin pregnancies and 8 percent had premature births (< 37 weeks of gestational age). As a result of Dr Mohammed Zimmos work, measures should be taken by Health Authorities in Palestine to increasing the proportion of normal births after CS and to reduce antenatal CS for twin births and preterm births. Dr Hadeel Ali studied severe birth tears in Palestine. Severe perineal tears (obstetric anal sphincter injuries, OASIS) is a complication of vaginal birth and causes damage of the anal close muscle with or without damage to the rectum. OASIS can cause abdominal pain, trouble having sex, or can cause loss of control of air and stool. To diagnose and repair OASIS immediately after childbirth will reduce negative consequences, but prevention is the optimal strategy. Perineal tears have overall been neglected in Palestine based on a belief that they rarely occur. In her thesis, Hadeel Ali and co-workers have examined the effects of various training methods for the improvement of diagnosing and preventing perineal tears at six governmental hospitals in Palestine. The quality of episiotomy, clipping intended to expand the vaginal opening at birth, was also investigated. Ali and co-workers found that the discovery of perineal tears increased after midwives and physicians received theoretical and practical training in correct diagnosis and repair. In addition, it was documented that the quality of episiotomy was so poor that it contributed to an increased risk of tears. After training in the correct execution of the cutting and, and in use of the bimanual support technique to protect the perineum by animated instructions as well as bedside hands-on training, the result showed that animation alone reduced the occurrence of OASIS by 50 percent. When additionally combined with individual bedside hands-on training, the incidence of the OASIS was reduced by another 50 percent. The main findings suggest that the incidence of OASIS can be effectively prevented using various training methods. The methods described above are now applied in Palestinian hospitals in the West Bank and in Gaza.

a. Outcome: Birth complication that has been neglected in Palestine. Systematic training of birth attendants in OASIS diagnosis and prevention has resulted in a remarkable improvement in OASIS detection and reduction. Impact: Improving the quality of obstetric care and reduce morbidity associated with OASIS. Structured training to become mandatory for midwifes and doctors. b. Outcome: Variations in rates of cesarean section between hospitals. Need to increase the proportion of normal births after caesarean section and reducing the number of caesarean sections. Impact: Improve and standardize maternal care, and training in diagnose of indication of cs. c. Outcome: Observed high and routinely performed episiotomy rates in Palestine. Demonstrated the effectiveness of training to optimize episiotomy. Impact: Episiotomy practice in Palestine not in line with international guidelines. Episiotomy among women giving first time birth vaginally should be reduced and, conducted correctly.

The main aim is to reduce the incidence of perineal tears during vaginal delivery in Palestine, introducing a new support technique of perineum. Norwegian intervention studies have shown that the incidence of obstetric anal sphincter injuries (OASIS) can be reduced by 40-70% by improving hands-on delivering techniques. The reduction was achieved by educating all staff on the delivery unit, implementing a new hands-on delivering technique. Some previous research has shown that non-interactive training by a nimated instructions or videos? in emergency obstetric care, might be equally effective as conventional interactive hands-on training. However,the effectiveness of mHealth training compared to conventional training programs remains to be assessed properly . By performing a multicentre intervention study, we will explore the effect of interactive hands-on training? on the incidence of perineal tears. Likewise we will study effect of non-interactive training by animated instructions. Three hospitals on the W est Bank (WB) and three in Gaza have accepted to participate. We will also investigate whether health personnel?s attitudes towards training methods influence the results. Intervention1 (6 months): Education in diagnosis and repair and implementation of s ystem to register data. Observation1 (6 months): Data-registration baseline. Intervention2 (6 months): One hospital in Gaza and one in the WB will receive ?interactive bedside training in hands-on manual perineal protection? for two weeks, whereas two oth er hospitals will have ?non-interactive training in hands-on manual perineal protection? by animated instructions on smartphones. The control units will be another two hospitals without training during the study period. Observation 2 (12 months): There wi ll be a 12 month observational period where all data is collected. Post-study intervention (6 months): Control hospitals will be offered bed-side interactive training in the same technique.