Childbirth Acquired Perineal Trauma (CHAPTER) study: A cohort study investigating health outcomes after childbirth-related perineal trauma

Introduction
Childbirth-related perineal trauma (CRPT) is the most common complication of vaginal birth, yet its associations with mental health and other health outcomes remain poorly described. This study examined the annual incidence of recorded CRPT by tear degree and investigated its association with mental health and other health outcomes.

Material and Methods
We conducted a retrospective cohort study using Clinical Practice Research Datalink Aurum primary care data linked with Hospital Episode Statistics, including women aged ≥16 years who had given birth vaginally between 1st January 2005 and 31st December 2019. Exposure was defined as recorded CRPT of any degree including episiotomy. Annual incidence of CRPT was calculated as a percentage of all births. Cox proportional hazards regression models compared short-, medium-, and long-term (<1 year, 1–5 years, and >5 years post-childbirth) outcomes between women with and without CRPT. We conducted subgroup analyses by degree of tear and in women with spontaneous vertex births, and a sensitivity analysis restricted to first birth.

Results
Incidence of recorded CRPT increased from 43.4% to 48.8% between 2005 and 2019. Compared to women without CRPT, those with CRPT had a higher risk of anxiety (aHR 1.19, 95%CI 1.17, 1.22) or depression (aHR 1.23, 95%CI 1.21, 1.25) within 1 year postpartum, with elevated risks persisting beyond 5 years and across all degrees of tear. Women with 1st/2nd degree tears or episiotomy had a higher hazard of post-traumatic stress disorder 1–5 years postpartum. CRPT was associated with increased hazard of urinary incontinence, dyspareunia, reduced libido, vaginal discharge, general and perineal pain, and prolapse in all follow-up periods. Fecal incontinence was increased in women with episiotomy or 3rd/4th degree tears, persisting long-term for severe tears. CRPT was associated with 32% higher risk of antibiotic prescription compared to no CRPT (OR 1.32, 95%CI 1.30, 1.33) within 6 weeks postpartum.

Conclusions
Recorded CRPT was associated with increased risks of diagnosed anxiety and depression in short-, medium- and long-term post-childbirth, irrespective of tear severity, as well as higher risks of other adverse outcomes, including urinary incontinence, pain, and sexual dysfunction. Addressing CRPT should be prioritized to improve women's health and well-being.