Childbirth considerations when Asian and South Asian ethnicity

Australia’s ethnicity mix has been changing. This is having an impact on pregnancy management.

In the past there were very few people of Asian and South Asian ethnicity living in Australia. Over more recent years there has been considerable immigration from Asian and South Asian countries to Australia. The Australian Bureau of Statistics survey in 2023 reported 30.7% of Australia’s population were born overseas. England, India, China, and New Zealand were the most popular countries of birth of people living in Australia and born overseas. Those born in India recorded the largest increase since 2013. Women from Asian and South Asian countries have been shown in many medical studies to have a higher incidence of postpartum haemorrhage (PPH) and severe birth canal trauma.

There also have been changes in pregnancy and childbirth management practices since I started as a specialist obstetrician doctor. For instance, Caesarean section deliveries were in the past done less frequently, and vaginal deliveries were the preferred option for 90% of pregnant women. As well, there were in the past longer labours, less epidurals, more difficult vaginal deliveries including more forceps deliveries. But despite this I recall PPHs, and third- and fourth-degree perineal tears were not common. In the past vacuum deliveries were done infrequently as vacuum cups were less reliable. I recall in the past doing a lot of Kielland’s rotational forceps deliveries. Kielland’s use often resulted in nasty vaginal tears, which could extend the length of the vagina and which were a challenge repairing. I do not recall excessive bleeding and PPH issues with these significant vaginal wall tears. I always did (and still do) episiotomies with forceps use. I do not recall many third-degree perineal tears. I do not recall having any 3c third-degree tears and I know I did not have any no fourth-degree perineal tears, either following forceps use or with a spontaneous vaginal delivery. I had infrequent PPHs.

Now Caesarean section deliveries are more common. In seconds stage labour they are commonly done if a spontaneous vaginal delivery will not happen, and it is likely to be difficult operative delivery. Vacuum cups are more dependable. If an operative vaginal delivery is needed, I choose a vacuum cup as it is less traumatic for the mother’s birth canal. I only do forceps deliveries if the vacuum cup does not work. As I very rarely do Kielland’s forceps deliveries. I do not see the associated significant vaginal tears.

Two patients who delivered 19 months apart had significant vaginal wall tearing that caused PPHs. The first was an Indian ethnicity woman and the second was of Sri Lanka ethnicity. On both occasions there was significant bleeding from vaginal wall tearing after traction with a vacuum cup attached to baby’s scalp and with descent of the baby’s head. Both had episiotomies and neither had perineal tearing. But the ethnicity similarity and the surprise significant vaginal wall tearing with considerable vaginal wall bleeding resulting in PPHs prompted me to do a literature such on the topic. This is the background to this article. I was already aware of the increased risk of maternal birth canal trauma with a vaginal delivery if Asian or South Asian ethnicity before this literature search, but doing this search has helped reinforce the correct management approach when a patient is of Asian or South Asian ethnicity.

I have also noticed a differences between the SAN Hospital and Norwest Private Hospital. In more recent years I have had more PPH’s at Norwest Private Hospital. I have safely delivered many thousands of women at the SAN over several decades without many PPH’s. The PPH incidence difference between the hospitals is despite my providing the same management approaches and the same quality of care in both hospitals.

The incidence of PPHs and vaginal tearing with PPHs I suspect reflects to ethnic population demographics differences between the two hospitals. I have far more South Asian patients booking for confinement at Norwest Private Hospital than the SAN Hospital. I provide the same management in both hospitals and the two hospitals are similar in management. I have not had an increase in major perineal trauma at either hospital, which I suspects reflects my awareness of the increased risk in Asians and South Asians and my appropriate management. I have a very low incidence of perineal tears involving the anal sphincter.

After a 2012 review of 2,890 medical articles the authors of a medical report concluded Asian ethnicity has been identified as a significant risk factor for severe perineal trauma during vaginal birth (1).

As well, many studies have shown there is higher incidence of postpartum haemorrhage (PPH) in women of South Asian ethnicity with childbirth (2), (3), (4), (5).

It is reported in June 2024 that in India PPH has an incidence of approximately 12% of deliveries (6). In 2007 it was reported PPH had an incidence of 4% – 6% in New South Wales, Australia (7).

A study in USA in 2015 reported the rate of severe perineal lacerations as 2.6% overall but was 8.2% among Asian women (8).

Medical literature studies consistently report a higher incidence of severe birth canal trauma with childbirth in women of South Asian and Asian ethnicities. There also are many medical literature recommendations that South Asian and Asian ethnicities is an independent risk factor for OASIS (third- and fourth-degree perineal tearing) and that delivery management should take this into consideration.

A medical report from a hospital in Mumbai, India of 144 women with PPHs found vaginal lacerations in 40.27% (9). Another study in from a hospital in Maharashtra, India reported 9.9% of PPHs were due to trauma of the genital tract. It found that 54.96% traumatic PPHs required vaginal or cervical exploration and in those cases surgical repair was done in operating theatre (10). Another study from a hospital in Ahmednagar, India reported birth canal trauma caused 10% of all PPHs (11).  In a Pakistan study trauma to the genital tract accounted for 29.4% of PPHs (12).

A medical study published in 2024 reports: “Obstetrical anal sphincter injury is more frequent among Asian versus white birthing individuals in multiple high-income, non-Asian countries. Qualitative and quantitative research to elucidate underlying causal mechanisms responsible for this relationship are warranted (13).”

An Australian study of 32,653 vaginal births (14) reported that nulliparous women born in South Asian and Southeast/East Asia countries were 2.6 and 2.1 times more likely to sustain an anal sphincter injury than Australian/New Zealand women, respectively. Parous women born in South Asian and Southeast/East Asia countries were 2.4 and 2.0 times more likely to sustain an anal sphincter injury than Australian/New Zealand women, respectively. The authors comment: “There are ethnic differences in the rates of anal sphincter injury not fully explained by known risk factors for such trauma” .

The authors commented: “It has been suggested that anatomical differences may underlie different anal sphincter injury rates between ethnicities. Pelvimetry studies have shown that South Asian women have a smaller pelvic inclination than other women, resulting in a more horizontal pelvis. It has been suggested that this may alter the direction of expulsive forces normally directed anteriorly, towards a more posterior aspect, thereby increasing the risk for perineal damage. Racial differences in perineal muscle support have also been identified. Asian women may have better perineal muscle strength than Australian-born women, as evidenced by less pelvic organ mobility. Racial differences in skin thickness and resistance to mechanical stretch have also been reported such that Asian skin is more susceptible to tearing than stretching.”

That “Asian skin is more susceptible to tearing than stretching” would help explain why in Asian and South Asian women there a greater likelihood of both severe perineal and severe vaginal wall tearing in second stage labour. The significant incidence of PPHs due to vaginal wall trauma in India suggests that vaginal wall tearing in women of South Asian ethnicity is more likely to result in significant bleeding. In contrast, the severe vaginal wall tearing I often encountered with the use of Kielland forceps in the past only very occasionally caused significant bleeding.

The increases incidence in severe perineal tearing and in vaginal tearing in women of Asian and South Asian ethnicity logically is because of skin differences between ethnicities and a greater likelihood for Asian and South Asian women’s vagina and perineal skin to tear rather than stretch with vaginal childbirth. This increased tearing is more likely to result in excessive bleeding and a greater likelihood of PPH.

The majority of PPHs in all studies were due to uterine atony – the uterus not contracting well after delivery. It is a concern with all ethnicities but appears to be a higher incidence in Asian and South Asian countries.

What management measures may help?

• If you are a pregnant woman of Asian or South Asian ethnicity this article is to help you be informed but not alarmed.
• While there is increased risk with childbirth Asian and South Asian ethnicity women, most Asian and South Asian women do not have PPHs and do not sustain major vaginal or perineal trauma with vaginal childbirth.
• Make sure your obstetrician or public hospital staff are aware of the potential issues, and so plan and put in place measures that may help avoid the complications.
• Some Asian and South Asian women may elect to have a Caesarean section delivery, to avoid the vaginal delivery risk. I have never had a major PPH with a Caesarean section.
• Warm hot compresses on the perineum when pushing in second stage have been suggested to help.
• The EPINO use in late pregnancy is not of agreed proven value, but its use may help.
• Avoiding more difficult operative vaginal deliveries.
• Early induction of labour to avoid the baby getting too big.
• An episiotomy will minimise the risks of significant perineal trauma. While not recommended as a routine, an episiotomy should be done if it looks like there will be significant perineal tearing.
• Slow controlled delivery of baby’s head by an experienced accoucheur. This will help gradually stretch the vaginal introitus and so help minimise the likelihood of tearing.

1. Is Asian ethnicity an independent risk factor for severe perineal trauma in childbirth? A systematic review of the literature. Janet Wheeler, Deborah Davis, Margaret Fry, Pat Brodie, Caroline S.E. Homer. Women and Birth Volume 25, Issue 3, September 2012, Pages 107-113.
2. Risk of postpartum haemorrhage is associated with ethnicity: A cohort study of 981,801 births in England. Jennifer Jardine, Ipek Gurol-Urganci, Tina Harris, Jane Hawdon, Dharmintra Pasupathy, Jan van der Meulen, Kate Walker, the NMPA Project Team. BJOG 09 December 2021.
3. Epidemiology of postpartum haemorrhage: a systematic review. Guillermo Carroli, Cristina Cuesta MSc, Edgardo Abalos MD, A. Metin Gulmezoglu MD Best Practice & Research Clinical Obstetrics & Gynaecology Volume 22, Issue 6, December 2008, Pages 999-1012
4. Factors Associated With Postpartum Hemorrhage With Vaginal Birth Combs, C. Andrew MD, Murphy, Edward L. MD, Laros, Russell K. Jr MD Obstetrics & Gynecology 77(1):p 69-76, January 1991.
5. Prevalence and risk factors of severe obstetric haemorrhage I Al-Zirqi, S Vangen, L Forsen, B Stray-Pedersen BJOG 11 August 2008
6. Postpartum Hemorrhage: Enhancing Outcomes for Mothers by Effective Management Madhuri Patel, The Journal of Obstetrics and Gynecology of India (May–June 2024) 74(3):191–195
7. Postpartum haemorrhage occurrence and recurrence: a population-based study Jane B Ford, Christine L Roberts, Jane C Bell, Charles S Algert, Jonathan M Morris Med J Aust 2007 Oct 1;187(7):391-3
8. Racial/ethnic variations in perineal length and association with perineal lacerations: a prospective cohort study. Amanda Yeaton-Massey, Luchin Wong, Teresa N. Sparks, Stephanie J. Handler, Michelle R. Meyer, Jesus M. Granados. The Journal of Maternal-Fetal & Neonatal Medicine Volume 28, 2015 – Issue 3.
9. Lower Genital Tract Injuries during Multiparous Vaginal Delivery in Tertiary Hospital of Western India: An Observational Study Padmaja N Kumbhar, Padmaja Samant Journal of South Asian Federation of Obstetrics and Gynaecology 31 October 2023.
10. Clinical study of post partum haemorrhage from a teaching hospital in Maharashtra, India. Shankarrao Chavan, International Journal of Reproduction, Contraception, Obstetrics and Gynecology Vol. 6 No. 6 (2017): June 2017.
11. Clinical Evaluation of Post-Partum Haemorrhage at Tertiary Care Hospital Kuldeep Wagh International Journal of Medical Science and Education pISSN- 2348 4438 eISSN-2349- 3208
12. An audit of primary post-partum haemorrhage. Shamshad Bibi, Nargis Danish, Anisa Fawad, Muhammad Jamil J Ayub Med Coll Abbottabad 2007 Oct-Dec;19(4):102-6.
13. Asian-White disparities in obstetric anal sphincter injury: a systematic review and meta-analysis. Meejin Park, Susitha Wanigaratne, Rohan D’Souza, Roxana Geoffrion, Sarah Williams, Giulia M. Muraca AJOG Global Reports Volume 4, Issue 1, February 2024.
14. Maternal Asian ethnicity and the risk of anal sphincter injury. Miranda Davies-Tuck, Mary-Anne Biro, Joanne Mockler, Lynne Stewart, Euan M Wallace, Christine East A C TA Obstetricia et Gynecologica 12 December 2014.