Caesarean section and anal incontinence in women after obstetric anal sphincter injury: A systematic review and meta‐analysis

Abstract

AbstractBackgroundApproximately 50% women who give birth after obstetric anal sphincter injury (OASI) develop anal incontinence (AI) over their lifetime.ObjectiveTo evaluate current evidence for a protective benefit of planned caesarean section (CS) to prevent AI after OASI.Search StrategyMEDLINE/PubMed, Embase 1974–2024, CINAHL and Cochrane to 7 February 2024 (PROSPERO CRD42022372442).Selection CriteriaAll studies reporting outcomes after OASI and a subsequent birth, by any mode.Data Collection and AnalysisEighty‐six of 2646 screened studies met inclusion criteria, with nine studies suitable to meta‐analyse the primary outcome of ‘adjusted AI’ after OASI and subsequent birth. Subgroups: short‐term AI, long‐term AI, AI in asymptomatic women. Secondary outcomes: total AI, quality of life, satisfaction/regret, solid/liquid/flatal incontinence, faecal urgency, AI in women with and without subsequent birth, change in AI pre‐ to post‐ subsequent birth.Main ResultsThere was no evidence of a difference in adjusted AI after subsequent vaginal birth compared with CS after OASI across all time periods (OR = 0.92, 95% CI 0.72–1.20; 9 studies, 2104 participants, I2 = 0% p = 0.58), for subgroup analyses or secondary outcomes. There was no evidence of a difference in AI in women with or without subsequent birth (OR = 1.00 95% CI 0.65–1.54; 10 studies, 970 participants, I2 = 35% p = 0.99), or pre‐ to post‐ subsequent birth (OR = 0.79 95% CI 0.51–1.25; 13 studies, 5496 participants, I2 = 73% p = 0.31).ConclusionsDue to low evidence quality, we are unable to determine whether planned caesarean is protective against AI after OASI. Higher quality evidence is required to guide personalised decision‐making for asymptomatic women and to determine the effect of subsequent birth mode on long‐term AI outcomes.