A new qualitative study from Leicester, one of Britain’s most ethnically diverse cities where about half of mothers giving birth in hospitals come from non-British Caucasian backgrounds, has now given voice to this underrepresented group. Researchers from University Hospitals of Leicester NHS Trust, the University of Wolverhampton, and local maternity systems partnered with Leicester Mammas, a community breastfeeding support organization, to recruit women who had suffered a third- or fourth-degree tear within the previous one to five years. Invitations went out by email to sixteen women from underrepresented groups, and ten responded and took part. The participants, aged between 25 and 40, came from Indian, Pakistani, African, Eastern European, and other backgrounds, and many spoke Gujarati, Urdu, Punjabi, or Bulgarian alongside English. On June 9, 2023, the researchers convened a two-hour virtual focus group discussion via Microsoft Teams, preceded by an educational session on ethnic disparities in severe perineal tears and a presentation of data from the hospital’s perinatal health inequality dashboard, a deliberative approach designed to establish a shared factual baseline before discussion began.

The transcript was analysed using Braun and Clarke’s six-phase thematic analysis, with the software NVivo used to organise codes and extracts, and the developing themes repeatedly reviewed against the original data and discussed within the wider team to guard against clinical assumptions creeping into interpretation. What emerged was a constellation of themes: traumatic childbirth experiences and rapid medical intervention, retrospective self-blame, societal expectations shaping childbirth choices, cultural silence and stigmatisation around maternal and mental health, gaps in prenatal education, enduring psychological trauma, poor communication and lack of support, and conflicting advice on infant feeding. The accounts were raw, specific, and strikingly consistent across cultural boundaries.

Many women described labours that progressed with alarming speed, leaving no time to physically or emotionally prepare. One participant, whose labour was induced and assisted with an epidural, recalled being told to start pushing within roughly ten to fifteen minutes or less of reaching full dilation, and wondered whether the lack of preparation had contributed to her tear. Others experienced compounded emergencies: one woman described her baby not crying after birth and requiring resuscitation while she was losing significant blood and was found to have an extensive third-degree tear. In the aftermath, participants engaged in painful retrospective questioning, attempting to make sense of why the injury had occurred and whether their own actions or the management of labour were responsible. One woman questioned whether pushing immediately upon reaching ten centimetres of dilation, rather than being given time to prepare, had affected her outcome. Another described continuing self-blame and anxiety about future childbirth, wondering what maternal factors could have contributed to her tear. This pattern of self-directed responsibility is a recognised psychological response among mothers who undergo traumatic childbirth, and it underscores the need for support that addresses mental and emotional recovery alongside physical healing.

The study also revealed how societal expectations shape childbirth choices in ways that can increase risk or distress. Epidural use emerged as a flashpoint: one participant admitted she initially viewed having an epidural as beneath her because of what she perceived as culturally appropriate behaviour during labour, taking only what was deemed acceptable. Yet experience appeared to build confidence over time. By her third birth, another participant reported taking control and requesting an epidural, describing the result as amazing. Some women extended this hard-won autonomy into advice for others, urging women not to hesitate to take pain relief and not to feel obliged to justify their choices to anyone. The shift from external judgement to individual preference reflects a broader theme in the literature: that interventions, while sometimes medically necessary, can disrupt the natural progression of labour, and that women’s sense of control during birth is itself a protective factor for psychological well-being.

Perhaps the most striking finding was the cultural silence that surrounded these injuries across multiple communities. Participants from Asian backgrounds described expectations of endurance and discretion: within one family, women were told not to talk about difficult experiences but simply to deal with them. One participant explained that in her Asian culture, nobody talks about what they go through because they just have to get on with it. Crucially, this expectation was not confined to any single cultural background. A participant from an Eastern European background described a strikingly similar norm, saying that in her culture there is no such thing as mental health, that as a woman you should just get on with it, and that the stigma is there. Mental health stigma compounded this silence, with one participant stating that mental health issues cannot be discussed, especially when related to health and care. These findings suggest that cultural norms of resilience and silence operate across diverse communities, hindering women from seeking necessary support and leaving psychological distress unaddressed.

Compounding the cultural barriers was a consistent perception that prenatal education had failed them. Women described entering childbirth without any understanding that third- or fourth-degree tears were possible, their severity, or the different types. One participant recalled that no one ever spoke to her about potential tears or their severity, and that she was only prepared for the possibility of a controlled episiotomy cut. Another described a broader absence of information about both severe tears and the fourth trimester, the postpartum period that follows birth. Yet participants were careful not to argue for unrestricted disclosure of every possible complication. They recognised a tension between being sufficiently informed and becoming overwhelmed with fear. One participant captured this balance precisely, saying that you cannot tell someone everything and make them go into labour scared, but that informing them about possible outcomes would help them be more mentally prepared. This nuanced position aligns with research showing that preparation classes often neglect postnatal information despite it being a recognised goal of antenatal care, and that both information overload and information deficit can distress women when complications arise.

The psychological aftermath of traumatic childbirth emerged as persistent and far-reaching. Participants described symptoms consistent with post-traumatic stress disorder affecting not only themselves but their partners and daily activities. One woman said she suffered PTSD for a good few months, which affected her husband and other daily activities. Pandemic-era restrictions intensified distress for some, with one participant describing being rushed during COVID and missing skin-to-skin contact with her newborn, an experience she found very traumatic. Trauma also shaped subsequent encounters with healthcare: one participant described being so traumatized by her prolonged labour that it took her about three hours to lie on the bed for a follow-up examination, and even then she could not let the clinician perform it. For others, the psychological consequences remained unresolved for years. One participant described a very long five years trying to get to the bottom of what was wrong, realising she had been through trauma and definitely needed counselling. These accounts echo findings that prolonged or complicated labour increases the risk of psychological trauma, and that long-term mental health support is essential for affected women.

Communication failures pervaded the accounts of care. One participant described being told she was not in labour when she was actually near full dilation, and recalled the midwife who was supposed to support her standing on the other side of the room watching rather than helping. Clinical terminology itself became a barrier: participants described struggling to grasp words like third-degree tear and catheter while in pain and exhaustion, leaving them trying to decipher what was happening and why. In the postnatal period, conflicting advice on infant feeding created further uncertainty. One participant described midwives telling her not to give her baby formula while health visitors recommended it, leaving her unsure whom to follow. Family advice, though well-intentioned, sometimes contradicted professional recommendations, adding another layer of negotiation. Research on breastfeeding support has documented similar patterns, with midwives directly contradicting each other’s advice and women receiving an overwhelming number of solutions without sufficient time to evaluate any of them, forcing some to do their own research to resolve the contradictions.

The study’s authors argue that these findings expose critical limitations in the current OASI care bundle, the evidence-based package of interventions designed primarily to prevent physical injury during childbirth. While the bundle addresses maternal aspects of prevention, it does not adequately integrate psychological support, long-term follow-up, or mental health care after a tear occurs. The researchers call for a comprehensive care bundle that encompasses both prevention and post-tear support, integrating physical, physiological, and mental health services with sustained follow-up throughout the perinatal period. They recommend balanced and individualised prenatal information about OASI, clear post-birth explanations of the injury and recovery, culturally responsive postpartum care that creates opportunities for non-judgemental conversations about distress, and greater consistency in communication across healthcare professionals. The authors acknowledge limitations: the small sample of ten women, all of whom reported third-degree rather than fourth-degree tears, the English-only format that excluded women needing interpreter support, the absence of partners’ perspectives, and the potential influence of the clinician-led format and the preceding educational session on participants’ responses. Member checking was undertaken to ensure themes reflected participants’ views. The findings are not statistically generalisable, but the patterns identified, from inadequate preparation to cultural barriers in discussing mental health, are likely relevant across ethnically diverse NHS settings. Future research, the authors conclude, should evaluate interventions such as improved antenatal education, post-birth debriefing, culturally responsive psychological support, and integrated post-OASI follow-up, ensuring that no woman is left to recover from a severe childbirth injury in silence.

Subject of Research: Lived experiences of obstetric anal sphincter injury among women from ethnically diverse backgrounds in the UK: a qualitative study

Article Title: Lived experiences of obstetric anal sphincter injury among women from ethnically diverse backgrounds in the UK: a qualitative study

Article References: Olakotan, O., Lim, J. N. W., Bhavsar, M., Siddiqui, F., Ayaz, R., O'Brady Henry, G., & Pillay, T. (2026). Lived experiences of obstetric anal sphincter injury among women from ethnically diverse backgrounds in the UK: a qualitative study. Frontiers in Global Women's Health, 7, Article 1966289. https://doi.org/10.3389/fgwh.2026.1966289

Image Credits: AI Generated

DOI: 10.3389/fgwh.2026.1966289

Keywords: obstetric anal sphincter injury, OASI, ethnic minority women, childbirth trauma, perineal tears, qualitative study, UK maternity care, cultural stigma, Lived, experiences, obstetric, anal