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Diagnosis and repair of perineal injuries: knowledge before and after expert training—a multicentre observational study among Palestinian physicians and midwives
  1. Kaled Zimmo1,2,3,
  2. Katariina Laine4,
  3. Åse Vikanes3,
  4. Erik Fosse2,3,
  5. Mohammed Zimmo2,3,5,
  6. Hadil Ali2,3,6,
  7. Ranee Thakar7,
  8. Abdul H Sultan7,
  9. Sahar Hassan8,9
  1. 1Department of Obstetrics, Al Aqsa Hospital, Gaza, Palestine
  2. 2Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
  3. 3The Intervention Centre, Oslo University Hospital Rikshospitalet, Oslo, Norway
  4. 4Department of Obstetrics, Oslo University Hospital, Oslo, Norway
  5. 5Department of Obstetrics, Al Shifa Hospital, Gaza, Palestine
  6. 6Department of Obstetrics, Palestine Medical Complex Hospital, Ramallah, Palestine
  7. 7Croydon University Hospital, Croydon, UK
  8. 8Faculty of Nursing, Pharmacy and Health Professions, Birzeit University, Ramallah, Palestine
  9. 9Institute of Community and Public Health, Birzeit University, Ramallah, Palestine
  1. Correspondence to Kaled Zimmo; drkaledzimmo{at}


Objective To assess whether a 2 days training with experts teaching on diagnosis and repair of perineal injuries among Palestinian midwives and physicians could change their level of knowledge towards the correct diagnosis and treatment.

Study design Multicentre observational study.

Setting Obstetric departments in 6 government Palestinian hospitals.

Participants All physicians and midwives who attended the training.

Methods A questionnaire comprising of 14 questions on the diagnosis and repair of perineal tears was distributed to all participants before the training (n=150; 64 physicians and 86 midwives) and 3 months after the training (n=124, 53 and 71, respectively). Characteristics, differences of the study population and level of knowledge before and after the training were presented as frequencies and percentages. Consistency in responses was tested by estimating the p value of McNemar test.

Results Among physicians only 11.4% had accurate knowledge on perineal anatomy before the training compared with 78.85% after the training (p<0.001). For midwives, the corresponding numbers were 9.8% and 54.2%, respectively (p<0.001). Before the training, 5.8% of the physicians were aware that rectal examination is mandatory before and after suturing of episiotomies compared with 45.8% after the training (p<0.001). The corresponding numbers for midwives were 0% and 18% (p<0.001), respectively. Physicians knowledge of best practice of skin repair following episiotomy improved from 36.5% to 64.5% (p=0.008) and among midwives from 26.1% to 50.7% (p<0.001). Physicians knowledge of the overlap technique in the repair of full thickness external anal sphincter tears improved from 28.5% to 42.8% (p=0.05), whereas knowledge of repairing torn internal anal sphincter separately improved from 12.8% to 86.8% (p<0.001).

Conclusions Improvement in the level of knowledge on diagnosis and repair of perineal tears was observed for all physicians and midwives who attended the 2 days' expert training. Regular ongoing training will serve to maintain the newly acquired knowledge.

  • Perineal trauma
  • Episiotomy
  • Midwives
  • Physicians

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  • Contributors KZ was involved in training preparations in Gaza, data collection, data analysis and drafted the manuscript. RT and AHS were involved in study design, questionnaire development, training programme development and implementation, conceptualisation and commented on the manuscript. KL and EF were involved in study design, protocol development and commented on the manuscript. ÅV was involved in study design, protocol development, preparation and coordination for the training in Gaza, commented on the manuscript. MZ and HA were involved in data collection and commented on the manuscript. SH was involved in study design, conceptualisation, protocol development, preparation and coordination for the training in the West Bank, data collection, and critical comments on the manuscript. All authors have read and approved the final version of the manuscript.

  • Funding This work was supported by the Norwegian Research Council grant number (234452/14).

  • Competing interests None declared.

  • Ethics approval The Regional Committee for Medical and Health Research Ethics, Section C, South East Norway, reviewed the Research Project ‘Can perineal injuries be prevented following births in Palestine?’ on 21 October 2014 and found the Research Project to be outside the remit of the Act on Medical and Health Research (2014/1727). The project was done in accordance with common rules for healthcare services in Palestine and Norway regarding, for example, privacy.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement No additional data are available.

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