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R E S E A R C H A R T I C L E Open Access
Perineal injuries and birth positions among
2992 women with a low risk pregnancy
who opted for a homebirth
Malin Edqvist
1
, Ellen Blix
2*
, Hanne K. Hegaard
3
, Olöf Ásta Ólafsdottir
4
, Ingegerd Hildingsson
5,6
, Karen Ingversen
7
,
Margareta Mollberg
1
and Helena Lindgren
1,8
Abstract
Background: Whether certain birth positions are associated with perineal injuries and severe perineal trauma (SPT)
is still unclear. The objective of this study was to describe the prevalence of perineal injuries of different severity in
a low-risk population of women who planned to give birth at home and to compare the prevalence of perineal
injuries, SPT and episiotomy in different birth positions in four Nordic countries.
Methods: A population-based prospective cohort study of planned home births in four Nordic countries. To assess
medical outcomes a questionnaire completed after birth by the attending midwife was used. Descriptive statistics,
bivariate analysis and logistic regression were used to analyze the data.
Results: Two thousand nine hundred ninety-two women with planned home births, who birthed spontaneously at
home or after transfer to hospital, between 2008 and 2013 were included. The prevalence of SPT was 0.7 % and the
prevalence of episiotomy was 1.0 %. There were differences between the countries regarding all maternal
characteristics. No association between flexible sacrum positions and sutured perineal injuries was found (OR 1.02;
95 % CI 0.86–1.21) or SPT (OR 0.68; CI 95 % 0.26–1.79). Flexible sacrum positions were associated with fewer
episiotomies (OR 0.20; CI 95 % 0.10–0.54).
Conclusion: A low prevalence of SPT and episiotomy was found among women opting for a home birth in four
Nordic countries. Women used a variety of birth positions and a majority gave birth in flexible sacrum positions. No
associations were found between flexible sacrum positions and SPT. Flexible sacrum positions were associated with
fewer episiotomies.
Keywords: Home birth, Birth positions, Severe perineal trauma, Perineal injuries, Episiotomy, Waterbirth
Background
Perineal injuries and severe perineal trauma involving the
anal sphincter complex (SPT) are associated with short-
and long-term morbidity, such as perineal pain [1, 2], dys-
pareunia [2, 3] and anal incontinence [4]. Both short- and
long-term symptoms have an impact on women’s daily lives
[5] and on women’s quality of life for those with persistent
defects [6]. The prevalence of perineal injuries of all types is
reported to be 77–86 % [7, 8] of which 60 % need to be
sutured [8]. The incidence of SPT in the Nordic countries
(in this article ‘Nordic countries’refers to Norway, Sweden,
Denmark and Iceland) varies from 2.3 % in Norway to
4.2 % in Denmark [9–11] whereas there is no national data
availableregardingtheprevalenceoflesssevereinjuries.
Known risk factors for perineal trauma, including SPT
are primiparity [12, 13], high birth weight [12] and occiput
posterior presentation [14]. Obstetrical factors associated
with SPT are a prolonged second stage [12, 15], instru-
mental delivery [16], episiotomy [17], poor visualization of
the perineum [16], fundal pressure [12], the lithotomy
position [18] and oxytocin augmentation [19]. Few studies
have assessed risk factors for less severe perineal trauma
such as second degree tears but the risk factors appears to
* Correspondence: ellen.blix@hioa.no
2
Research Group: Maternal, Reproductive and Children’s Health, Faculty of
Health Sciences, Oslo and Akershus University College of Applied Sciences,
Oslo, Norway
Full list of author information is available at the end of the article
© 2016 The Author(s). Open Access This 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.
Edqvist et al. BMC Pregnancy and Childbirth (2016) 16:196
DOI 10.1186/s12884-016-0990-0
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
be similar [20]. Home births have been associated with
fewer perineal injuries and SPT compared to hospital
births [21–23].
Women who choose home birth are a selected and
highly motivated population. Generally they are multipar-
ous, are older, and tend to have a higher socioeconomic
status [24]. Fewer are smokers and overweight, which can
be viewed as indicators of health [25]. The prevalence of
planned home birth varies in the Nordic countries. In
Sweden and Norway it is 0.06 % and 0.019 % respectively,
while home birth is more common in Denmark and
Iceland with 1.5–1.8 % [26]. It is not known whether the
observed benefit of opting for a home birth with regard to
SPT and perineal injuries is due to differences in midwif-
ery practice, the selected population of women or other
factors, such as birth position. Midwifery care measures at
home to prevent perineal injuries include getting to know
the woman before the onset of labor, following the physio-
logical process of birth and letting her choose the position
for birth [27]. Furthermore some of the obstetrical risk
factors of SPT are not present in the home birth setting,
such as instrumental delivery, the lithotomy position for
birth, and oxytocin augmentation since the woman will be
transferred to hospital in the event of an emergency or
slow progress of labor. Waterbirth on the other hand is
common in this setting [28]; in some studies it is associ-
ated with SPT and perineal injuries [23, 29] but not in
others [30].
There is still controversy around whether upright or
recumbent birth positions are beneficial or harmful with
regard to SPT as well as less severe perineal injuries.
Giving birth in the lateral and all-fours position has been
associated with a higher prevalence of intact perineum
[31–33] but this is not found in the meta-analysis by
Gupta et al. [34]. Upright birth positions occur more
often within certain birth settings, such as birth centers
and at home [28]. Upright birth positions in Western
obstetrics may be defined as positions in which a line
connecting the center of a woman’s third and fifth verte-
brae is more vertical than horizontal [34, 35]. According
to this definition sitting, squatting, the birth-seat, kneel-
ing and standing are defined as upright positions,
whereas lateral and all-fours, semi-recumbent and the
lithotomy position are considered supine positions [34],
although they are different and may facilitate or hinder
physiological birth.
Another possible definition is to classify birth positions
in which the body weight is on or off the sacrum. Posi-
tions that take the weight off the sacrum and allow the
pelvic outlet to expand might be favorable to facilitating
spontaneous birth [36]. Birth positions that take the
weight off the sacrum and could be categorized as flex-
ible sacrum positions are kneeling, standing, all-fours,
lateral position, squatting and giving birth on the birth
seat. On the other hand all the positions where the
woman is sitting or lying on her back, such as the supine
and the semi-recumbent position put weight on the
sacrum and could be categorized as non-flexible sacrum
positions. The evidence as to the impact of upright birth
and flexible sacrum positions on perineal outcomes re-
mains inconclusive [36] and has to our knowledge not
been tested in the home birth setting. Since home births
are seldom recorded in the registers in the Nordic coun-
tries, the prevalence of perineal injuries, SPT, episiotomy
and birth positions for women opting for a home birth
is not known.
The objective of this study is to describe the preva-
lence of perineal injuries of different severity in a low-
risk population of women who planned to give birth at
home in four Nordic countries and to compare the
prevalence of perineal injuries, SPT and episiotomy in
flexible and non-flexible birth positions.
Method
Design and study sample
This is a prospective cohort study collecting data from
planned home births in Norway, Denmark, Sweden and
Iceland between 2008 and 2013. All midwives attending
home births were asked to recruit their clients to the
study. The women were given information about the
study during pregnancy, and signed a form agreeing to
participate. The method and data collection has been de-
scribed previously by Blix et al. [37]
Data collection
The data collection lasted from January 1
st
2008 to
December 31
st
2012 in Norway, in Sweden from January
1
st
2009 to December 31
st
2013, in Denmark from March
1
st
2010 to May 15
th
2013 and in Iceland from January 1
st
2010 to December 31
st
2013.
The questionnaire included information about women’s
background characteristics (country of residence, age, par-
ity, marital status, Body Mass Index, tobacco use) (Table 1)
and was completed by the attending midwife 1 week after
the birth. The questionnaire also contained information
about place of birth (home, during transfer, hospital) and
birth outcome related to the woman [37]. All births that
were planned to take place at home and started at home
are included in the cohort irrespective of where the baby
actually was born, at home or after transfer to the hospital.
Birth positions were assessed according to type of position
at the moment when the baby was born. Eight different
positions were predefined. The positions that aim at
expanding the pelvic outlet and taking weight off the
sacrum are defined as flexible sacrum positions in this
study. Birth positions were dichotomized into two groups:
flexible or non-flexible sacrum positions. Positions that
take the weight off the sacrum are: kneeling, standing, all-
Edqvist et al. BMC Pregnancy and Childbirth (2016) 16:196 Page 2 of 8
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fours, squatting, the birth seat and lateral. Positions de-
fined as non-flexible are semi-recumbent, lithotomy and
supine positions. Perineal injuries were reported as su-
tured injury or not, episiotomy and SPT. A non-sutured
injury includes no tear at all, small abrasions or minor in-
juries, which the midwife considered did not require su-
turing. A variable was created to capture total recorded
perineal injuries, where SPT, episiotomy and sutured in-
juries were included.
Analysis
Descriptive statistics, Chi
2
and ANOVA tests were used
to present the background characteristics and compare
data between the Nordic countries. The outcome vari-
ables were sutured perineal and vaginal injuries, SPT,
episiotomies and total posterior trauma. Crude and ad-
justed odds ratios with a 95 % confidence interval were
calculated between the outcome variables and flexible
sacrum positions. Potential confounders were adjusted
for using logistic regression. The IBM SPSS software
package version 22.0 was employed for the data analysis.
Results
For the purpose of this study, a selected sample of 2992
of the original cohort of 3068 women with a planned
home birth was included. A total of 76 women who had
a caesarean section or an instrumental delivery after
transfer to hospital were excluded. Instrumental deliver-
ies were excluded since they are performed in a supine
or recumbent birth position. Of the 2992 women, 2796
(93.4 %) successfully gave birth at home and 196 (6.6 %)
gave birth spontaneously after transfer to the hospital.
The most common reason for transfer was slow progress
of labor.
Table 1 shows the background characteristics of the
2992 women included in this study. The majority of the
Table 1 Socio-demographic background
Total Norway Sweden Denmark Iceland Chi
2
test
N= 2992 N= 468 N= 438 N= 1799 N= 287 p-value
n(%) n (%) n (%) n (%) n (%)
Age groups <0.001
<25 years 202 (6.8) 26 (5.6) 24 (5.5) 119 (6.6) 33 (11.5)
25-34 years 1923 (64.3) 295 (63.0) 234 (53.4) 1188 (66.0) 206 (72.0)
>35 years 850 (28.4) 145 (31.0) 177 (40.4) 481 (26.7) 47 (16.4)
Missing 17 (0.6) 2 (0.4) 3 (0.7) 11 (0.6) 1 (0.3)
Marital status <0.001
Married/cohabit 2918 (97.5) 449 (95.7) 407 (92.9) 1779 (98.9) 284 (99.0)
Not married/cohabit 51 (1.7) 17 (3.6) 13 (3.0) 20 (1.1) 1 (0.3)
Missing 23 (0.8) 3 (0.6) 18 (4.1) 0 2 (0.7)
Tobacco use <0.001
Yes 198 (6.6) 16 (3.4) 5 (1.1) 167 (9.3) 10 (3.5)
No 2735 (91.4) 450 (96.2) 425 (97.0) 1587 (88.2) 273 (95.1)
Missing 59 (2.0) 2 (0.4) 8 (1.8) 45 (2.5) 4 (1.4)
Number of children 0.004
First baby 524 (17.5) 80 (17.1) 70 (16.0) 313 (17.4) 61 (21.3)
One previous child 1257 (42.0) 175 (37.4) 208 (47.5) 753 (41.9) 121 (42.2)
Two previous children 828 (27.7) 137 (29.3) 113 (25.8) 494 (27.5) 84 (29.3)
Three or more previous children 322 (10.8) 74 (15.8) 46 (10.5) 182 (10.1) 20 (7.0)
Missing 61 (2.0) 2 (0.4) 1 (0.2) 57 (3.2) 1 (0.3)
Body Mass Index (BMI), mean (SD)
BMI-groups 0.001
<18.5 101 (3.4) 16 (3.4) 16 (4.7) 60 (3.3) 9 (3.1)
18,5-24.9 1943 (64.9) 289 (61.8) 260 (59.4) 1220 (67.8) 174 (60.6)
25.0-29.9 516 (17.2) 87 (18.6) 51 (11.6) 323 (18.0) 55 (19.9)
>30 196 (6.6) 25 (5.3) 17 (3.9) 116 (6.4) 38 (13.2)
Missing 236 (7.9) 51 (10.9) 94 (21.5) 80 (4.4) 11 (3.8)
Edqvist et al. BMC Pregnancy and Childbirth (2016) 16:196 Page 3 of 8
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planned home births in this study occurred in Denmark
(n= 1799), followed by Norway (n= 468), Sweden (n=
438) and Iceland (n= 287). The mean age for the total
sample was 32 years (range 18–47). There were signifi-
cant differences between the countries regarding all ma-
ternal characteristics. The Icelandic mothers were the
youngest and the Swedish mothers were the oldest. The
highest proportion of planned home births for women
expecting their first baby occurred in Iceland (21.7 %)
and in Denmark (18.5 %). Most women irrespective of
country were married or cohabiting, did not smoke and
were expecting their second baby. Among the multipar-
ous women in the cohort, 140 (4.7 %) women attempted
a planned home birth after a caesarean section (VBAC).
The vast majority (85 %) of these planned VBAC home
births occurred in Denmark.
The prevalence of SPT was 0.7 % for the total study
population, 2.3 % among primiparas and 0.3 % among
multiparas (Table 2). The only risk factors for SPT found
in this study were primiparity (adj OR 9.90; CI 95 %
3.63–26.98) and birth weight > 4000 g (adj OR 2.87; CI
95 % 1.07–7.75) (Table 4). The overall prevalence of
sutured injuries was 41.5 % (Table 2). When stratifying
for parity, 60.9 % of the primiparous women had injuries
considered as needing sutures and so did 36.8 % of the
multiparous women. The prevalence of episiotomy was
1.0 %. The women who were transferred to hospital were
more likely to have an episiotomy (OR 3.98; CI 95 %
1.72–9.22) (Table 4).
Women gave birth in a variety of positions (Table 3).
The majority (65.2 %) used flexible sacrum positions.
Kneeling was the most frequently used birth position of
the flexible sacrum positions regardless of parity
(24.6 %). However for primiparous women semi-
recumbent, which is considered as a non-flexible sacrum
position was the most common position for birth
(29.6 %), followed by kneeling (19.1 %) (Table 3). The
prevalence of waterbirth was 31.8 % (Table 2) but varied
in the four countries. Almost half of the Icelandic
women in this cohort gave birth in water (48.1 %) com-
pared to only 6.6 % in Sweden. No association between
flexible sacrum positions and sutured injuries was found
(OR 1.02; CI 95 % 0.86–1.21) or between flexible sacrum
positions and SPT (OR 0.68; CI 95 % 0.26–1.79). Flexible
sacrum positions were associated with fewer episioto-
mies after adjusting for potential confounders (primipar-
ity, birth weight, transfer before birth and waterbirth)
(OR 0.20; CI 95 % 0.10–0.54) (Table 4).
Table 2 Birth outcomes
Total Primiparas Multiparas
a
Missing
N= 2992 N= 524 N= 2422 N= 46 (1.5)
n (%) n (%) n (%)
Birth weight
<2999 g 134 (4.5) 44 (8.4) 88 (3.6)
3000-3999 g 2029 (67.8) 392 (74.8) 1609 (66.4)
4000-4499 g 607 (20.3) 55 (10.5) 541 (22.3)
>4500 g 143 (4.8) 15 (2.9) 127 (5.2)
Missing 79 (2.6) 18 (3.4) 57 (2.4)
Sutured injury
Yes 1242 (41.5) 319 (60.9) 891 (36.8)
No 1709 (57.1) 196 (37.4) 1499 (61.9)
Missing 41 (1.4) 9 (1.7) 32 (1.3)
OASIS
Yes 21 (0.7) 12 (2.3) 7 (0.3)
No 2937 (98.2) 501 (95.6) 2392 (98.8)
Missing 34 (1.1) 11 (2.1) 23 (0.9)
Episiotomy
Yes 31 (1.0) 23 (4.4) 7 (0.3)
No 2926 (97.8) 493 (94.1) 2388 (98.6)
Missing 35 (1.2) 8 (1.5) 27 (1.1)
Total perineal injury
Yes 1276 (42.6) 342 (65.3) 899 (37.1)
No 1669 (55.8) 174 (33.2) 1484 (61.3)
Missing 47 (1.6) 8 (1.5) 39 (1.6)
a
141 women with one previous CS, 3 women with 2 previous CS
Table 3 Birth positions, waterbirth and flexible sacrum positions
stratified by parity
Total Primiparas Multiparas Missing
Total N= 2992 N= 524 N= 2422 N= 46 (1.5)
n (%) n (%) n (%) n (%)
Birth position
Semi-recumbent 687 (23.0) 155 (29.6) 516 (21.3)
Supine 238 (8.0) 49 (9.4) 185 (7.6)
Lateral 420 (14.0) 64 (12.2) 351 (14.5)
Birth seat/squatting 251 (8.4) 62 (11.8) 187 (7.7)
All-fours 326 (10.9) 45 (8.6) 278 (11.5)
Kneeling 737 (24.6) 100 (19.1) 629 (26.0)
Standing 216 (7.2) 24 (4.6) 190 (7.8)
Missing 117 (3.9) 25 (4.8) 86 (3.6)
Flexible sacrum
a
Yes 1950 (65.2) 295 (56.3) 1635 (67.5)
No 925 (30.9) 204 (38.9) 701 (28.9)
Missing 117 (3.9) 25 (4.8) 86 (3.6)
Waterbirth
Yes 952 (31.8) 186 (35.5) 755 (31.2)
No 2031 (67.9) 336 (64.1) 1660 (68.5)
Missing 9 (0.3) 2 (0.4) 7 (0.3)
a
kneeling, all-fours, standing, squatting, birth seat, lateral
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Table 4 Risk factors for different types of perineal trauma
OASIS Episiotomy Sutured injury Total perineal trauma
Crude OR Adjusted OR Crude OR Adjusted OR Crude OR Adjusted OR Crude OR Adjusted OR
Primiparity
d
8.19 (3.21–20.89) 9.90 (3.63–26.98)
c
15.92 (6.79–37.30) 10.84 (4.28–27.45)
c
2.74 (2.25–3.33) 3.07 (2.48–3.81)
c
3.25 (2.66–3.97) 3.60 (2.89–4.49)
c
Birthweight > 4000 g
d
1.93 (0.79–4.75) 2.87 (1.07–7.75)
a
0.75 (0.31–1.85) 1.58 (0.59–4.18) 1.30 (1.10–1.54) 1.48 (1.24–1.77)
c
1.32 (1.11–1.56) 1.53 (1.28–1.83)
c
Transfer before birth 2.42 (0.71–8.30) 0.46 (0.06–3.59) 11.02 (5.31–22.84) 3.98 (1.72–9.22)
b
1.33 (0.99–1.79) 0.91 (0.65–1.28) 1.60 (1.19–2.15) 1.01 (0.71–1.42)
Country 1.19 (0.70–2.03) 1.07 (0.60–1.90) 1.28 (0.82–2.01) 1.27 (0.78–2.09) 1.45 (1.32–1.58) 1.42 (1.29–1.56)
c
1.47 (1.34–1.61) 1.44 (1.31–1.59)
c
Flexible sacrum positions
e
0.71 (0.29–1.75) 0.68 (0.26–1.79) 0.20 (0.10–0.44) 0.20 (0.10-0.54)
b
0.89 (0.76–1.04) 1.02 (0.86–1.21) 0.84 (0.71–0.98) 0.96 (0.81–1.14)
Waterbirth 1.30 (0.54–3.16) 0.99 (0.36–2.73) 0.41 (0.16–1.06) 0.36 (0.13–1.03) 1.19 (1.02–1.39) 1.01 (0.85–1.20) 1.19 (1.02–1.39) 1.01 (0.85–1.21)
a
< 0.05
b
< 0.01
c
< 0.001
d
adjusted for birthweight, transfer, flexile sacrum positions, waterbirth, country
e
adjusted for parity, birthweight, transfer, waterbirth
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Discussion
The major finding of this study is a low prevalence of
SPT and episiotomy which did not differ between the
countries. The women in this cohort used a variety of
birth positions and one third of them gave birth in
water. No association was found between flexible sacrum
positions and SPT or sutured injuries. Episiotomy was
associated with giving birth in a non-flexible sacrum
position.
The prevalence of SPT and episiotomy in this study is
in line with previous research [21, 24, 38] and adds to
the growing body of evidence regarding positive mater-
nal outcomes and low levels of intervention for women
with low risk choosing to give birth outside the hospital.
Furthermore, the prevalence of SPT and episiotomy in
this study did not differ between the countries, which is
interesting considering the observed differences between
the Nordic countries (2.3 to 4.2 %) [9–11]. Stating what
prevalence of SPT should be considered to indicate good
quality of care is problematic and has been discussed
[39]. A low prevalence of SPT could be due to successful
interventions during the second stage. On the other
hand when midwives and obstetricians focus on assess-
ment and classifying perineal injuries, the detection rate
of SPT often increases [39, 40]. A prevalence between
1.0 and 3.9 % has been suggested to be a realistic target
in high-risk units [39] but what rate is reasonable in a
low-risk setting is not known. A lower prevalence of
SPT could be expected in a low-risk setting such as
home birth where fewer of the obstetrical interventions
associated with SPT are present. Stedenfeldt et al. (2014)
have shown that the greatest reduction in sphincter in-
juries after an educational program for midwives and ob-
stetricians took place among low risk-births (i.e., second
child, birth weight <4000 g and spontaneous birth with
the baby in the occiput anterior position) [41].
The women in this study used a variety of birth posi-
tions and the majority used flexible sacrum positions. A
recent review of the literature reports physical and psy-
chological benefits for women when they give birth in
an upright position of their choice [42] but the position
assumed by women during birth is influenced by several
complex factors. Upright birth positions occur more
often within certain birth settings, such as birth centers
and home [28, 29]. The midwife’s preference [43] as well
as cultural values may influence the position for birth
[34, 42]. It is not possible in this study to determine
whether midwives influenced the position for birth but
the variation in positions used suggests that women had
the opportunity to choose position themselves. Although
the number of SPT in this study was low, with only 21
detected cases, no generalizations can be drawn. How-
ever, none of the birth positions used –supine, upright
or flexible sacrum positions –was associated with SPT
which is in line with meta-analyses of the subject [34].
This indicates that midwives were skilled in attending
women in different birth positions and it is also in line
with the current evidence suggesting that women should
be encouraged to give birth in the position most com-
fortable for them [34].
Flexible sacrum positions were associated with fewer
episiotomies. To our knowledge and according to the
midwifery literature [44, 45], midwives are taught to per-
form an episiotomy in the lithotomy or semi-recumbent
position. This could imply that this finding is con-
founded by indication. If a midwife finds it necessary to
perform an episiotomy, she will ask the woman to
change position from a flexible sacrum position to a
non-flexible sacrum position (semi-recumbent or su-
pine). However, when looking at which birth position
women had when the episiotomy was cut, 9 (30.0 %) of
the 30 episiotomies were performed in a position other
than the semi-recumbent or supine: 7 in the lateral pos-
ition, 1 in squatting and 1 in the all-fours position. Five
of the episiotomies were performed in water.
One limitation of this study is the lack of information
regarding midwifery practices during the second stage to
prevent perineal injuries, as well as midwives’experience
and training in assessing and suturing perineal injuries.
There is evidence that perineal injuries are often mis-
classified [46] by both midwives and obstetricians. A sec-
ond examiner and educational workshops have been
shown to improve diagnosis and the appropriate classifi-
cation of perineal trauma [46, 47]. Information regarding
whether a rectal examination has been performed would
be of value in further studies.
Another limitation is that midwives in four different
countries entered the data. However, using the same
protocol limits the classification bias. Midwives who as-
sist women at home births are usually employed within
the health care system and are used to recording this
type of data, which is similar to the data entered in hos-
pital records. The strength of this study is that the ma-
jority of women opting for a home birth and all the
midwives assisting with home births on a regular basis
in Norway, Sweden, Denmark and Iceland were identi-
fied and agreed to participate in this study. According to
Blix et al. [48] the original cohort of 3068 women is sug-
gested to cover 80–90 % of the planned home births in
the four Nordic countries.
It is important to evaluate perineal outcome in relation
to birth setting, since perineal injuries are associated
with short- and long-term morbidity for women [49].
Home births in Norway, Sweden, Denmark and Iceland
are not always registered and it is not possible to access
the data specific to this study from the medical birth
registers. The population studied consists of healthy
women, giving birth without many of the interventions
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associated with modern obstetrics. Further studies are
needed to assess long-term consequences of childbirth,
such as urinary incontinence, dyspareunia, anal incon-
tinence and the prevalence of prolapse in women giving
birth at home. It would be of interest to study the im-
pact of physiological birth on the pelvic floor in this
group of women since they receive low levels of obstet-
ric interventions.
Conclusion
A low prevalence of SPT and episiotomy was found
among women opting for a home birth in four Nordic
countries. Women used a variety of birth positions and a
majority gave birth in flexible sacrum positions. No asso-
ciations were found between flexible sacrum position
and SPT. Further studies are needed to assess the long-
term consequences related to perineal injuries for
women giving birth at home.
Acknowledgements
The authors want to thank all the women who participated in this study,
and Anette S. Huitfeldt and Ásrún Ösp Jónsdottir for collecting data in
Norway and Iceland.
Avaliability of the dataset: Please contact the corresponding author.
Funding
The study was funded by the Northern Norway Regional Health Authority,
the Swedish Council for Working Life and Social Research, the Danish
Association of Midwives’Research Fund, Aase and Ejnar Danielsen’s Fund,
Denmark, the Icelandic Association of Midwives’Research Fund and Oslo
and Akershus University College for Applied Sciences, Norway.
Authors’contribution
HL, EB and ÓÁÓ initiated and designed the study together with Hanne
Kjærgaard, who passed away in December 2013. KI, HL, EB and ÓÁÓ carried
out the data collection. ME analyzed the data and wrote the manuscript. ME,
HL, IH, EB, HKH, ÓÁÓ, MM and KI participated in interpretation of results and
participated in the writing process. ME, HL, IH, EB, HKH, ÓÁÓ, MM and KI
read and approved the final manuscript.
Competing interests
The authors declare that they have no competing interests.
Ethical approval
The study was approved separately in each of the participating countries, by
the Regional Committee for Medical and Health Research Ethics (REC North)
(200704605–5) in Norway, by the Regional Committee at Karolinska Institutet
(2009/147-31) in Sweden, by The Capital Region Committee on Health
Research Ethics (H-3-2014-FSP71) in Denmark, and by The National Bioethics
Committee (No. 11–031) in Iceland. All women participating in this study
were given written information and consented to participate. They were
informed of the possibility to withdraw their consent at any time without
any consequences regarding care during pregnancy, birth and the postnatal
period.
Author details
1
Institute of Health and Care Sciences, The Sahlgrenska Academy, University
of Gothenburg, Arvid Wallgrens backe hus 1, Box (PO) 457405 30
Gothenburg, Sweden.
2
Research Group: Maternal, Reproductive and
Children’s Health, Faculty of Health Sciences, Oslo and Akershus University
College of Applied Sciences, Oslo, Norway.
3
Research Unit, Women’s and
Children’s Health, Juliane Marie Center for Women, Children and
Reproduction, Copenhagen University Hospital, Rigshospitalet, Copenhagen,
Denmark.
4
Department of Midwifery, Faculty of Nursing, University of Iceland,
Reykjavík, Iceland.
5
Department of Nursing, Mid Sweden University, Sundsvall,
Sweden.
6
Department of Women’s and Children’s Health, Uppsala University,
Uppsala, Sweden.
7
Homebirth Association Sealand, Copenhagen, Denmark.
8
Department of Women’s and Children’s Health, Karolinska Institute,
Stockholm, Sweden.
Received: 7 February 2016 Accepted: 23 July 2016
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