{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,4]],"date-time":"2026-06-04T20:50:47Z","timestamp":1780606247939,"version":"3.54.1"},"reference-count":43,"publisher":"Public Library of Science (PLoS)","issue":"9","license":[{"start":{"date-parts":[[2023,9,8]],"date-time":"2023-09-08T00:00:00Z","timestamp":1694131200000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS ONE"],"abstract":"<jats:sec id=\"sec001\"><jats:title>Background<\/jats:title><jats:p>Obstetric anal sphincter injury (OASI) describes severe injury to the perineum and perineum and perianal muscles following birth and occurs in 4.4% to 6.0% of vaginal births in Canada. Studies from high-income countries have identified an increased risk of OASI in individuals who identify as Asian race versus those who identify as white. This protocol outlines a systematic review and meta-analysis which aims to determine the incidence of OASI in individuals living in high-income countries who identify as Asian versus those of white race\/ethnicity. We hypothesize that the pooled incidence of OASI will be higher in Asian versus white birthing individuals.<\/jats:p><\/jats:sec><jats:sec id=\"sec002\"><jats:title>Methods<\/jats:title><jats:p>We will search MEDLINE, OVID, Embase, Emcare and Cochrane databases from inception to 2022 for observational studies using keywords and controlled vocabulary terms related to race, ethnicity and OASI. Two reviewers will follow the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines and Meta-analysis of Observational Studies (MOOSE) recommendations. Meta-analysis will be performed using RevMan for dichotomous data using the random effects model and the odds ratio (OR) as effect measure with a 95% confidence interval (CI). Subgroup analysis will be performed based on Asian subgroups (e.g., South Asian, Filipino, Chinese, Japanese individuals). Study quality assessment will be performed using The Joanna Briggs Institute Critical Appraisal tools.<\/jats:p><\/jats:sec><jats:sec id=\"sec003\"><jats:title>Discussion<\/jats:title><jats:p>The systematic review and meta-analysis that this protocol outlines will synthesize the extant literature to better estimate the rates of OASI in Asian and white populations in non-Asian, high-income settings and the relative risk of OASI between these two groups. This systematic summary of the evidence will inform the discrepancy in health outcomes experienced by Asian and white birthing individuals. If these findings suggest a disproportionate burden among Asians, they will be used to advocate for future studies to explore the causal mechanisms underlying this relationship, such as differential care provision, barriers to accessing care, and social and institutional racism. Ultimately, the findings of this review can be used to frame obstetric care guidelines and inform healthcare practices to ensure care that is equitable and accessible to diverse populations.<\/jats:p><\/jats:sec>","DOI":"10.1371\/journal.pone.0291174","type":"journal-article","created":{"date-parts":[[2023,9,8]],"date-time":"2023-09-08T17:40:08Z","timestamp":1694194808000},"page":"e0291174","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":3,"title":["Asian-white disparities in obstetric anal sphincter injury: Protocol for a systematic review and meta-analysis"],"prefix":"10.1371","volume":"18","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-7507-5918","authenticated-orcid":true,"given":"Meejin","family":"Park","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Susitha","family":"Wanigaratne","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rohan","family":"D\u2019Souza","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Roxana","family":"Geoffrion","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sarah A.","family":"Williams","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4618-0839","authenticated-orcid":true,"given":"Giulia M.","family":"Muraca","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2023,9,8]]},"reference":[{"issue":"5","key":"pone.0291174.ref001","first-page":"1158","article-title":"Racial and Ethnic Disparities in the Incidence of Severe Maternal Morbidity in the United States, 2012\u20132015.","volume":"132","author":"LK Admon","journal-title":"Obstet Gynecol. 2018"},{"issue":"5","key":"pone.0291174.ref002","doi-asserted-by":"crossref","first-page":"258","DOI":"10.1053\/j.semperi.2017.04.001","article-title":"Epidemiology of racial\/ethnic disparities in severe maternal morbidity and mortality.","volume":"41","author":"SJ Holdt Somer","year":"2017","journal-title":"Semin Perinatol."},{"issue":"6","key":"pone.0291174.ref003","doi-asserted-by":"crossref","first-page":"870","DOI":"10.1016\/j.jogc.2018.10.020","article-title":". No. 381-Assisted Vaginal Birth.","volume":"41","author":"S Hobson","year":"2019","journal-title":"J Obstet Gynaecol Can JOGC J Obstet Gynecol Can JOGC."},{"issue":"24","key":"pone.0291174.ref004","doi-asserted-by":"crossref","first-page":"E734","DOI":"10.1503\/cmaj.171076","article-title":"Ecological association between operative vaginal delivery and obstetric and birth trauma.","volume":"190","author":"GM Muraca","year":"2018","journal-title":"CMAJ"},{"issue":"2","key":"pone.0291174.ref005","first-page":"225","article-title":"Obstetric anal sphincter lacerations.","volume":"98","author":"VL Handa","year":"2001","journal-title":"Obstet Gynecol."},{"issue":"3","key":"pone.0291174.ref006","doi-asserted-by":"crossref","first-page":"258","DOI":"10.1111\/j.1600-0412.2010.01037.x","article-title":"Complete rupture of anal sphincter in primiparas: long-term effects and subsequent delivery.","volume":"90","author":"G Wegnelius","year":"2011","journal-title":"Acta Obstet Gynecol Scand."},{"issue":"3","key":"pone.0291174.ref007","doi-asserted-by":"crossref","first-page":"276.e1","DOI":"10.1016\/j.ajog.2020.08.051","article-title":"Symptoms of fecal incontinence two decades after no, one, or two obstetrical anal sphincter injuries.","volume":"224","author":"IEK Nilsson","year":"2021","journal-title":"Am J Obstet Gynecol."},{"issue":"1","key":"pone.0291174.ref008","doi-asserted-by":"crossref","first-page":"32","DOI":"10.1186\/1472-6874-14-32","article-title":"Women\u2019s experiences following severe perineal trauma: a qualitative study.","volume":"14","author":"H Priddis","year":"2014","journal-title":"BMC Womens Health."},{"key":"pone.0291174.ref009","first-page":"1","article-title":"Pelvic floor healing milestones after obstetric anal sphincter injury: a prospective case control feasibility study.","author":"M Tilak","year":"2022","journal-title":"Int Urogynecology J."},{"issue":"2 Pt 1","key":"pone.0291174.ref010","doi-asserted-by":"crossref","first-page":"233","DOI":"10.1097\/AOG.0b013e318240df4f","article-title":"Pelvic floor disorders after vaginal birth: effect of episiotomy, perineal laceration, and operative birth.","volume":"119","author":"VL Handa","year":"2012","journal-title":"Obstet Gynecol."},{"issue":"3","key":"pone.0291174.ref011","doi-asserted-by":"crossref","first-page":"423","DOI":"10.1111\/1471-0528.16985","article-title":"Obstetric anal sphincter injury by maternal origin and length of residence: a nationwide cohort study.","volume":"129","author":"IK S\u00f8rbye","year":"2022","journal-title":"BJOG Int J Obstet Gynaecol."},{"issue":"1","key":"pone.0291174.ref012","doi-asserted-by":"crossref","first-page":"25","DOI":"10.1097\/AOG.0b013e3181e2f50b","article-title":"Trends in risk factors for obstetric anal sphincter injuries in Norway.","volume":"116","author":"E Baghestan","year":"2010","journal-title":"Obstet Gynecol."},{"issue":"4","key":"pone.0291174.ref013","doi-asserted-by":"crossref","first-page":"1063","DOI":"10.1067\/mob.2003.251","article-title":"Racial differences in severe perineal lacerations after vaginal delivery.","volume":"188","author":"J Goldberg","year":"2003","journal-title":"Am J Obstet Gynecol.Apr"},{"issue":"4","key":"pone.0291174.ref014","doi-asserted-by":"crossref","first-page":"189","DOI":"10.1016\/j.whi.2005.12.004","article-title":"Obstetric complications during labor and delivery: assessing ethnic differences in California.","volume":"16","author":"S Guendelman","year":"2006","journal-title":"Womens Health Issues Off Publ Jacobs Inst Womens Health"},{"issue":"1","key":"pone.0291174.ref015","doi-asserted-by":"crossref","first-page":"16","DOI":"10.1016\/j.wombi.2014.10.007","article-title":"Risk factors for severe perineal trauma during vaginal childbirth: a Western Australian retrospective cohort study.","volume":"28","author":"YL Hauck","year":"2015","journal-title":"Women Birth J Aust Coll Midwives."},{"issue":"2","key":"pone.0291174.ref016","doi-asserted-by":"crossref","first-page":"455","DOI":"10.1016\/j.ajog.2004.12.007","article-title":"Racial\/ethnic differences in perineal, vaginal and cervical lacerations.","volume":"193","author":"LM Hopkins","year":"2005","journal-title":"Am J Obstet Gynecol."},{"issue":"5","key":"pone.0291174.ref017","first-page":"525","article-title":"Are Asian American women at higher risk of severe perineal lacerations?","volume":"30","author":"J Quist-Nelson","year":"2017","journal-title":"J Matern-Fetal Neonatal Med Off J Eur Assoc Perinat Med Fed Asia Ocean Perinat Soc Int Soc Perinat Obstet."},{"issue":"1","key":"pone.0291174.ref018","doi-asserted-by":"crossref","first-page":"79","DOI":"10.1111\/ajo.12672","article-title":"The Great Divide: Country of birth as a risk factor for obstetric anal sphincter injuries.","volume":"58","author":"J Brown","year":"2018","journal-title":"Aust N Z J Obstet Gynaecol."},{"issue":"3","key":"pone.0291174.ref019","doi-asserted-by":"crossref","first-page":"107","DOI":"10.1016\/j.wombi.2011.08.003","article-title":"Is Asian ethnicity an independent risk factor for severe perineal trauma in childbirth? A systematic review of the literature.","volume":"25","author":"J Wheeler","year":"2012","journal-title":"Women Birth J Aust Coll Midwives."},{"key":"pone.0291174.ref020","doi-asserted-by":"crossref","first-page":"b2700","DOI":"10.1136\/bmj.b2700","article-title":"The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration","volume":"339","author":"A Liberati","year":"2009","journal-title":"BMJ"},{"issue":"15","key":"pone.0291174.ref021","doi-asserted-by":"crossref","first-page":"2008","DOI":"10.1001\/jama.283.15.2008","article-title":"Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group","volume":"283","author":"DF Stroup","year":"2000","journal-title":"JAMA"},{"key":"pone.0291174.ref022","article-title":"Geographic Regions","author":"United Nations","journal-title":"UNSD\u2014Methodology"},{"issue":"4","key":"pone.0291174.ref023","doi-asserted-by":"crossref","first-page":"241","DOI":"10.1080\/13557859998029","article-title":"Using Ethnicity as a Classification Variable in Health Research: Perpetuating the myth of biological determinism, serving socio-political agendas, or making valuable contributions to medical sciences?","volume":"4","author":"SS Anand","year":"1999","journal-title":"Ethn Health."},{"issue":"5","key":"pone.0291174.ref024","doi-asserted-by":"crossref","first-page":"318","DOI":"10.1007\/S40037-020-00602-3","article-title":"Considerations for using race and ethnicity as quantitative variables in medical education research.","volume":"9","author":"PT Ross","year":"2020","journal-title":"Perspect Med Educ."},{"issue":"6","key":"pone.0291174.ref025","doi-asserted-by":"crossref","first-page":"572","DOI":"10.1016\/j.jclinepi.2006.11.009","article-title":"Systematic review identified suboptimal reporting and use of race\/ethnicity in general medical journals.","volume":"60","author":"IWY Ma","year":"2007","journal-title":"J Clin Epidemiol."},{"issue":"9","key":"pone.0291174.ref026","doi-asserted-by":"crossref","first-page":"e0001060","DOI":"10.1371\/journal.pgph.0001060","article-title":"Use of race, ethnicity, and ancestry data in health research.","volume":"2","author":"C Lu","year":"2022","journal-title":"PLOS Global Public Health"},{"issue":"1","key":"pone.0291174.ref027","doi-asserted-by":"crossref","first-page":"269","DOI":"10.1093\/genetics\/161.1.269","article-title":"Larger genetic differences within africans than between Africans and Eurasians","volume":"161","author":"N Yu","year":"2002","journal-title":"Genetics"},{"issue":"6","key":"pone.0291174.ref028","doi-asserted-by":"crossref","first-page":"193","DOI":"10.1177\/135626229900500601","article-title":"Editorial: Obstetrical Perineal Injury and Anal Incontinence.","volume":"5","author":"AH Sultan","year":"1999","journal-title":"Clin Risk."},{"issue":"12","key":"pone.0291174.ref029","doi-asserted-by":"crossref","first-page":"1131","DOI":"10.1016\/S1701-2163(16)30081-0","article-title":"Obstetrical Anal Sphincter Injuries (OASIS): Prevention, Recognition, and Repair.","volume":"37","author":"MA Harvey","year":"2015","journal-title":"J Obstet Gynaecol Can JOGC J Obstet Gynecol Can JOGC."},{"issue":"1","key":"pone.0291174.ref030","doi-asserted-by":"crossref","first-page":"e1","DOI":"10.1097\/AOG.0000000000001523","article-title":"Practice Bulletin No. 165: Prevention and Management of Obstetric Lacerations at Vaginal Delivery.","volume":"128","author":"American College of Obstetricians and Gynecologists\u2019 Committee on Practice Bulletins\u2014Obstetrics","year":"2016","journal-title":"Obstet Gynecol."},{"key":"pone.0291174.ref031","article-title":"Pathophysiology of Urinary Incontinence, Faecal Incontinence and Pelvic Organ Prolapse.","author":"H Koelbl"},{"issue":"12","key":"pone.0291174.ref032","doi-asserted-by":"crossref","first-page":"1516","DOI":"10.1111\/1471-0528.12363","article-title":"Third- and fourth-degree perineal tears among primiparous women in England between 2000 and 2012: time trends and risk factors.","volume":"120","author":"I Gurol-Urganci","year":"2013","journal-title":"BJOG Int J Obstet Gynaecol"},{"issue":"3","key":"pone.0291174.ref033","doi-asserted-by":"crossref","first-page":"260","DOI":"10.1016\/j.ijgo.2015.06.025","article-title":"Obstetric anal sphincter injury rates among primiparous women with different modes of vaginal delivery.","volume":"131","author":"AJ Ampt","year":"2015","journal-title":"Int J Gynaecol Obstet Off Organ Int Fed Gynaecol Obstet."},{"issue":"18","key":"pone.0291174.ref034","doi-asserted-by":"crossref","first-page":"2420","DOI":"10.4103\/0366-6999.164874","article-title":"Incidence and Risk Factors of Obstetric Anal Sphincter Injuries after Various Modes of Vaginal Deliveries in Chinese Women","volume":"128","author":"T Chi Wai","year":"2015","journal-title":"Chin Med J (Engl)."},{"issue":"7","key":"pone.0291174.ref035","doi-asserted-by":"crossref","first-page":"586","DOI":"10.1016\/S1701-2163(16)31018-0","article-title":"Trends in major risk factors for anal sphincter lacerations: a 10-year study.","volume":"25","author":"NL McLeod","year":"2003","journal-title":"J Obstet Gynaecol Can JOGC J Obstet Gynecol Can JOGC."},{"issue":"4","key":"pone.0291174.ref036","doi-asserted-by":"crossref","first-page":"409","DOI":"10.1111\/birt.12346","article-title":"Risk and protective factors for obstetric anal sphincter injuries: A retrospective nationwide study.","volume":"45","author":"M Marschalek","year":"2018","journal-title":"Birth Berkeley Calif."},{"issue":"3","key":"pone.0291174.ref037","doi-asserted-by":"crossref","first-page":"584","DOI":"10.1111\/1471-0528.16396","article-title":"Impact of a quality improvement project to reduce the rate of obstetric anal sphincter injury: a multicentre study with a stepped-wedge design.","volume":"128","author":"I Gurol-Urganci","year":"2021","journal-title":"BJOG Int J Obstet Gynaecol."},{"issue":"3","key":"pone.0291174.ref038","doi-asserted-by":"crossref","first-page":"513","DOI":"10.18865\/ed.30.3.513","article-title":"Addressing Asian American Misrepresentation and Underrepresentation in Research.","volume":"30","author":"NS Shah","year":"2020","journal-title":"Ethn Dis."},{"issue":"3 Suppl","key":"pone.0291174.ref039","first-page":"11S","article-title":"Race, medicine, and health care in the United States: a historical survey.","volume":"93","author":"WM Byrd","year":"2001","journal-title":"J Natl Med Assoc."},{"issue":"16","key":"pone.0291174.ref040","doi-asserted-by":"crossref","first-page":"4296","DOI":"10.1073\/pnas.1516047113","article-title":"Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites","volume":"113","author":"KM Hoffman","year":"2016","journal-title":"Proc Natl Acad Sci U S A"},{"issue":"1","key":"pone.0291174.ref041","doi-asserted-by":"crossref","first-page":"351","DOI":"10.1534\/genetics.106.067355","article-title":"Genetic Similarities Within and Between Human Populations","volume":"176","author":"DJ Witherspoon","year":"2007","journal-title":"Genetics"},{"issue":"4","key":"pone.0291174.ref042","doi-asserted-by":"crossref","first-page":"985","DOI":"10.1017\/S0021911810002834","article-title":"The Idea of Asia and Its Ambiguities","volume":"69","author":"W. Hui","year":"2010","journal-title":"J Asian Stud."},{"issue":"3\u20134","key":"pone.0291174.ref043","doi-asserted-by":"crossref","first-page":"314","DOI":"10.1080\/09557571.2018.1520809","article-title":"Understanding foreign policy strategies of Kazakhstan: a case study of the landlocked and transcontinental country","volume":"31","author":"M. Kassen","year":"2018","journal-title":"Camb Rev Int Aff."}],"container-title":["PLOS ONE"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0291174","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2023,12,21]],"date-time":"2023-12-21T11:55:10Z","timestamp":1703159710000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0291174"}},"subtitle":[],"editor":[{"given":"Mergan","family":"Naidoo","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2023,9,8]]},"references-count":43,"journal-issue":{"issue":"9","published-online":{"date-parts":[[2023,9,8]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pone.0291174","relation":{},"ISSN":["1932-6203"],"issn-type":[{"value":"1932-6203","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,9,8]]}}}