Gaps in Knowledge and Diagnostic Practice for Obstetric Anal Sphincter Injuries: A Multicountry Cross-Sectional Survey of Maternity Care Providers
A multicountry survey of 530 maternity care providers across seven Middle Eastern countries reveals significant gaps in knowledge and diagnostic practices regarding obstetric anal sphincter injuries, highlighting that while structured training and guidelines improve awareness of clinically unrecognised injuries, overreliance on digital rectal examination as a sufficient detection method remains a critical barrier to optimal care.
Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer
When a baby is born through the vagina, the muscles that control the anus can sometimes tear. This type of injury, known as an obstetric anal sphincter injury, is a serious complication that can lead to long-term problems with bowel control. The damage is not always obvious to the naked eye. Sometimes the tear is hidden deep inside, or the muscles are stretched so subtly that a standard visual check misses it entirely. Because these injuries can go unnoticed at the moment of birth, they are not always repaired correctly, leaving women to deal with unexpected pain or incontinence years later. To prevent this, doctors and midwives are trained to look closely and feel for these tears using a finger examination, a procedure called a digital rectal examination. However, knowing how to perform the exam is only part of the puzzle; the person doing the exam must also understand that even a careful check can miss a hidden injury, and they need to know exactly what kind of damage they are looking for.
A recent study set out to see how well maternity care providers across the Middle East understand these hidden injuries and how they check for them. Researchers from several countries surveyed 530 doctors, midwives, and nurses who work in hospitals in Bahrain, Egypt, Jordan, Kuwait, Lebanon, Saudi Arabia, and the United Arab Emirates. They asked these professionals about their training, what they know about classifying these tears, and how they decide whether an injury is present. The goal was to find out if there were gaps in their knowledge that might be putting patients at risk. The researchers were particularly interested in whether providers realized that a tear could exist even if the initial exam looked normal.
The results revealed a significant disconnect between what providers do and what they know. While most of the surveyed professionals reported using the finger examination after a vaginal birth, a large majority of them believed that this single check was enough to find every tear. In fact, nearly 61 percent of respondents thought this examination alone was sufficient to detect the injury. This belief is problematic because medical evidence shows that these exams can miss damage, especially to the internal muscles. The study found that only about 37 percent of the providers were familiar with a specific system used to classify the severity of these tears, and only about 30 percent were aware that these injuries could remain hidden during a routine check. Among those who said they knew about hidden injuries, fewer than half could actually explain what the term meant in their own words, suggesting that many had heard the phrase but did not truly understand the concept.
The study also looked at what factors helped providers understand these risks. Those who had more than seven years of experience, who had access to specific training on the topic, or who worked in hospitals with clear written guidelines were more likely to be aware that injuries could be missed. Interestingly, the more confident a provider felt in their ability to find the injury with a finger exam, the more likely they were to understand that the exam could still miss something. This suggests that true confidence comes from understanding the limits of the tool, not just from using it often. On the other hand, those who believed the finger exam was a perfect, all-sufficient tool were actually less likely to know that hidden injuries exist. This indicates that over-reliance on a single method can blind a provider to the possibility of a missed diagnosis.
The researchers concluded that the problem is not just about whether an exam is performed, but about the quality of the knowledge behind it. Many providers are doing the physical check, but they may not have the training to interpret the results correctly or to recognize when the check might have failed to find a problem. The study suggests that improving care requires more than just telling staff to perform the exam; it requires structured education that teaches them how to recognize the limits of their own assessment. By understanding that a normal-looking exam does not guarantee a normal result, and by having access to clear guidelines and specialized training, maternity care providers can better identify these hidden injuries and ensure women receive the care they need to avoid long-term complications.
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