Antenatal perineal massage for reducing perineal trauma

Michael M Beckmann; Owen M Stock

doi:10.1002/14651858.CD005123.pub3

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Figure 1

'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Figure 2

'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.

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Analysis 1.1

Comparison 1 Digital perineal massage versus control: results by parity, Outcome 1 Perineal trauma requiring suturing.

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Analysis 1.2

Comparison 1 Digital perineal massage versus control: results by parity, Outcome 2 1st degree perineal tear.

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Analysis 1.3

Comparison 1 Digital perineal massage versus control: results by parity, Outcome 3 2nd degree perineal tear.

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Analysis 1.4

Comparison 1 Digital perineal massage versus control: results by parity, Outcome 4 3rd or 4th degree perineal trauma.

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Analysis 1.5

Comparison 1 Digital perineal massage versus control: results by parity, Outcome 5 Incidence of episiotomy.

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Analysis 1.6

Comparison 1 Digital perineal massage versus control: results by parity, Outcome 6 Length of second stage.

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Analysis 1.7

Comparison 1 Digital perineal massage versus control: results by parity, Outcome 7 Instrumental delivery.

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Analysis 1.13

Comparison 1 Digital perineal massage versus control: results by parity, Outcome 13 Perineal pain at 3 months postpartum.

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Analysis 1.14

Comparison 1 Digital perineal massage versus control: results by parity, Outcome 14 Painful sex at 3 months postpartum.

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Analysis 1.15

Comparison 1 Digital perineal massage versus control: results by parity, Outcome 15 Woman's sexual satisfaction at 3 months postpartum.

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Analysis 1.16

Comparison 1 Digital perineal massage versus control: results by parity, Outcome 16 Partner's sexual satisfaction at 3 months postpartum.

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Analysis 1.17

Comparison 1 Digital perineal massage versus control: results by parity, Outcome 17 Uncontrolled loss of urine at 3 months postpartum.

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Analysis 1.18

Comparison 1 Digital perineal massage versus control: results by parity, Outcome 18 Uncontrolled loss of faeces at 3 months postpartum.

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Analysis 1.19

Comparison 1 Digital perineal massage versus control: results by parity, Outcome 19 Uncontrolled loss of flatus at 3 months postpartum.

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Analysis 2.1

Comparison 2 Digital perineal massage versus control: results by frequency of massage, Outcome 1 Perineal trauma requiring suturing.

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Analysis 2.2

Comparison 2 Digital perineal massage versus control: results by frequency of massage, Outcome 2 1st degree perineal tear.

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Analysis 2.3

Comparison 2 Digital perineal massage versus control: results by frequency of massage, Outcome 3 2nd degree perineal tear.

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Analysis 2.4

Comparison 2 Digital perineal massage versus control: results by frequency of massage, Outcome 4 3rd or 4th degree perineal trauma.

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Analysis 2.5

Comparison 2 Digital perineal massage versus control: results by frequency of massage, Outcome 5 Incidence of episiotomy.

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Analysis 2.6

Comparison 2 Digital perineal massage versus control: results by frequency of massage, Outcome 6 Length of second stage.

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Analysis 2.7

Comparison 2 Digital perineal massage versus control: results by frequency of massage, Outcome 7 Instrumental delivery.

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Analysis 2.13

Comparison 2 Digital perineal massage versus control: results by frequency of massage, Outcome 13 Perineal pain at 3 months postpartum.

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Analysis 2.14

Comparison 2 Digital perineal massage versus control: results by frequency of massage, Outcome 14 Painful sex at 3 months postpartum.

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Analysis 2.15

Comparison 2 Digital perineal massage versus control: results by frequency of massage, Outcome 15 Woman's sexual satisfaction at 3 months postpartum.

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Analysis 2.16

Comparison 2 Digital perineal massage versus control: results by frequency of massage, Outcome 16 Partner's sexual satisfaction at 3 months postpartum.

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Analysis 2.17

Comparison 2 Digital perineal massage versus control: results by frequency of massage, Outcome 17 Uncontrolled loss of urine at 3 months postpartum.

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Analysis 2.18

Comparison 2 Digital perineal massage versus control: results by frequency of massage, Outcome 18 Uncontrolled loss of faeces at 3 months postpartum.

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Analysis 2.19

Comparison 2 Digital perineal massage versus control: results by frequency of massage, Outcome 19 Uncontrolled loss of flatus at 3 months postpartum.

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Table 1. Flatal incontinence at 3 months postpartum in women who massage less than 1.5 times per week

	Treatment		Control		Risk ratio, M‐H, Fixed, 95% CI
	Events	Total	Events	Total	Risk ratio, M‐H, Fixed, 95% CI
Reporting of infrequent flatal incontinence	21	108	107	479	0.87 (0.57,1.32)
Reporting of flatal incontinence at least daily	6	108	10	479	2.66 (0.99,7.16)

Table 1. Flatal incontinence at 3 months postpartum in women who massage less than 1.5 times per week

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Table 2. Length of second stage perineal massage versus control: analysis excluding episiotomies

Duration	All women	Excl episiotomy
Length of 2nd stage (mins)	+3.84 (95% CI ‐0.26 to +7.95)	+3.57 (95% CI ‐0.86 to +8.00)
Length of 2nd stage for women massaging more than 3.5 times/week (mins)	+10.80 (95% CI +4.03 to +17.58)	+5.21 (95% CI ‐1.45 to +11.86)
mins: minutes CI: confidence interval

Table 2. Length of second stage perineal massage versus control: analysis excluding episiotomies

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Comparison 1. Digital perineal massage versus control: results by parity

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Perineal trauma requiring suturing Show forest plot	4	2480	Risk Ratio (M‐H, Fixed, 95% CI)	0.91 [0.86, 0.96]

1.1 Women without previous vaginal birth	4	1988	Risk Ratio (M‐H, Fixed, 95% CI)	0.90 [0.84, 0.96]
1.2 Women with previous vaginal birth	1	492	Risk Ratio (M‐H, Fixed, 95% CI)	0.95 [0.83, 1.08]
2 1st degree perineal tear Show forest plot	4	2480	Risk Ratio (M‐H, Random, 95% CI)	0.96 [0.78, 1.19]

2.1 Women without previous vaginal birth	4	1988	Risk Ratio (M‐H, Random, 95% CI)	0.97 [0.69, 1.36]
2.2 Women with previous vaginal birth	1	492	Risk Ratio (M‐H, Random, 95% CI)	1.01 [0.72, 1.41]
3 2nd degree perineal tear Show forest plot	4	2480	Risk Ratio (M‐H, Fixed, 95% CI)	0.99 [0.85, 1.15]

3.1 Women without previous vaginal birth	4	1988	Risk Ratio (M‐H, Fixed, 95% CI)	1.00 [0.84, 1.19]
3.2 Women with previous vaginal birth	1	492	Risk Ratio (M‐H, Fixed, 95% CI)	0.96 [0.72, 1.29]
4 3rd or 4th degree perineal trauma Show forest plot	4	2480	Risk Ratio (M‐H, Fixed, 95% CI)	0.81 [0.56, 1.18]

4.1 Women without previous vaginal birth	4	1988	Risk Ratio (M‐H, Fixed, 95% CI)	0.82 [0.56, 1.20]
4.2 Women with previous vaginal birth	1	492	Risk Ratio (M‐H, Fixed, 95% CI)	0.50 [0.05, 5.52]
5 Incidence of episiotomy Show forest plot	4	2480	Risk Ratio (M‐H, Fixed, 95% CI)	0.84 [0.74, 0.95]

5.1 Women without previous vaginal birth	4	1988	Risk Ratio (M‐H, Fixed, 95% CI)	0.83 [0.73, 0.95]
5.2 Women with previous vaginal birth	1	492	Risk Ratio (M‐H, Fixed, 95% CI)	0.86 [0.57, 1.30]
6 Length of second stage Show forest plot	2	2211	Mean Difference (IV, Fixed, 95% CI)	3.84 [‐0.26, 7.95]

6.1 Women without previous vaginal birth	2	1719	Mean Difference (IV, Fixed, 95% CI)	2.16 [‐3.58, 7.91]
6.2 Women with previous vaginal birth	1	492	Mean Difference (IV, Fixed, 95% CI)	5.60 [‐0.27, 11.47]
7 Instrumental delivery Show forest plot	3	2417	Risk Ratio (M‐H, Random, 95% CI)	0.94 [0.77, 1.16]

7.1 Women without previous vaginal birth	3	1925	Risk Ratio (M‐H, Random, 95% CI)	0.90 [0.78, 1.04]
7.2 Women with previous vaginal birth	1	492	Risk Ratio (M‐H, Random, 95% CI)	1.58 [0.83, 3.02]
8 Length of inpatient stay	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
8.1 Women without previous vaginal birth	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
8.2 Women with previous vaginal birth	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
9 Admission to nursery	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
9.1 Women without previous vaginal birth	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
9.2 Women with previous vaginal birth	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
10 Apgar < 4 at 1 minute and/or Apgar < 7 at 5 minutes	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
10.1 Women without previous vaginal birth	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
10.2 Women with previous vaginal birth	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
11 Woman's satisfaction with perineal massage	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
11.1 Women without previous vaginal birth	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
11.2 Women with previous vaginal birth	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
12 Perineal pain postpartum	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
12.1 Women without previous vaginal birth	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
12.2 Women with previous vaginal birth	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
13 Perineal pain at 3 months postpartum Show forest plot	1	931	Risk Ratio (M‐H, Random, 95% CI)	0.64 [0.39, 1.06]

13.1 Women without previous vaginal birth	1	555	Risk Ratio (M‐H, Random, 95% CI)	0.77 [0.55, 1.09]
13.2 Women with previous vaginal birth	1	376	Risk Ratio (M‐H, Random, 95% CI)	0.45 [0.24, 0.87]
14 Painful sex at 3 months postpartum Show forest plot	1	831	Risk Ratio (M‐H, Fixed, 95% CI)	0.96 [0.84, 1.08]

14.1 Women without previous vaginal birth	1	493	Risk Ratio (M‐H, Fixed, 95% CI)	0.97 [0.85, 1.11]
14.2 Women with previous vaginal birth	1	338	Risk Ratio (M‐H, Fixed, 95% CI)	0.92 [0.68, 1.24]
15 Woman's sexual satisfaction at 3 months postpartum Show forest plot	1	921	Risk Ratio (M‐H, Fixed, 95% CI)	1.02 [0.96, 1.10]

15.1 Women without previous vaginal birth	1	552	Risk Ratio (M‐H, Fixed, 95% CI)	1.03 [0.93, 1.14]
15.2 Women with previous vaginal birth	1	369	Risk Ratio (M‐H, Fixed, 95% CI)	1.02 [0.93, 1.11]
16 Partner's sexual satisfaction at 3 months postpartum Show forest plot	1	916	Risk Ratio (M‐H, Fixed, 95% CI)	0.97 [0.91, 1.04]

16.1 Women without previous vaginal birth	1	548	Risk Ratio (M‐H, Fixed, 95% CI)	0.99 [0.90, 1.09]
16.2 Women with previous vaginal birth	1	368	Risk Ratio (M‐H, Fixed, 95% CI)	0.94 [0.87, 1.03]
17 Uncontrolled loss of urine at 3 months postpartum Show forest plot	1	949	Risk Ratio (M‐H, Fixed, 95% CI)	0.90 [0.74, 1.08]

17.1 Women without previous vaginal birth	1	572	Risk Ratio (M‐H, Fixed, 95% CI)	0.92 [0.71, 1.20]
17.2 Women with previous vaginal birth	1	377	Risk Ratio (M‐H, Fixed, 95% CI)	0.87 [0.66, 1.13]
18 Uncontrolled loss of faeces at 3 months postpartum Show forest plot	1	948	Risk Ratio (M‐H, Random, 95% CI)	0.70 [0.27, 1.80]

18.1 Women without previous vaginal birth	1	572	Risk Ratio (M‐H, Random, 95% CI)	1.02 [0.41, 2.54]
18.2 Women with previous vaginal birth	1	376	Risk Ratio (M‐H, Random, 95% CI)	0.38 [0.10, 1.41]
19 Uncontrolled loss of flatus at 3 months postpartum Show forest plot	1	948	Risk Ratio (M‐H, Fixed, 95% CI)	1.09 [0.88, 1.36]

19.1 Women without previous vaginal birth	1	571	Risk Ratio (M‐H, Fixed, 95% CI)	1.13 [0.85, 1.50]
19.2 Women with previous vaginal birth	1	377	Risk Ratio (M‐H, Fixed, 95% CI)	1.04 [0.74, 1.45]

Comparison 1. Digital perineal massage versus control: results by parity

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Comparison 2. Digital perineal massage versus control: results by frequency of massage

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Perineal trauma requiring suturing Show forest plot	3		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

1.1 Average number of massages per week < 1.5	2	1500	Risk Ratio (M‐H, Random, 95% CI)	0.84 [0.74, 0.96]
1.2 Average number of massages per week = 1.5 to 3.4	2	1650	Risk Ratio (M‐H, Random, 95% CI)	0.92 [0.85, 1.00]
1.3 Average number of massages per week > 3.5	2	1598	Risk Ratio (M‐H, Random, 95% CI)	0.94 [0.86, 1.02]
1.4 Any frequency of massage	3	2417	Risk Ratio (M‐H, Random, 95% CI)	0.91 [0.86, 0.96]
2 1st degree perineal tear Show forest plot	3		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

2.1 Average number of massages per week < 1.5	2	1500	Risk Ratio (M‐H, Random, 95% CI)	1.04 [0.60, 1.83]
2.2 Average number of massages per week = 1.5 to 3.4	2	1650	Risk Ratio (M‐H, Random, 95% CI)	1.00 [0.75, 1.33]
2.3 Average number of massages per week > 3.5	2	1598	Risk Ratio (M‐H, Random, 95% CI)	0.89 [0.67, 1.17]
2.4 Any frequency of massage	3	2417	Risk Ratio (M‐H, Random, 95% CI)	0.99 [0.71, 1.38]
3 2nd degree perineal tear Show forest plot	3		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

3.1 Average number of massages per week < 1.5	2	1500	Risk Ratio (M‐H, Fixed, 95% CI)	1.00 [0.78, 1.27]
3.2 Average number of massages per week = 1.5 to 3.4	2	1650	Risk Ratio (M‐H, Fixed, 95% CI)	0.94 [0.75, 1.16]
3.3 Average number of massages per week > 3.5	2	1598	Risk Ratio (M‐H, Fixed, 95% CI)	1.02 [0.82, 1.27]
3.4 Any frequency of massage	3	2417	Risk Ratio (M‐H, Fixed, 95% CI)	0.98 [0.84, 1.14]
4 3rd or 4th degree perineal trauma Show forest plot	3		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

4.1 Average number of massages per week < 1.5	2	1500	Risk Ratio (M‐H, Random, 95% CI)	0.82 [0.08, 8.48]
4.2 Average number of massages per week = 1.5 to 3.4	2	1650	Risk Ratio (M‐H, Random, 95% CI)	0.64 [0.33, 1.25]
4.3 Average number of massages per week > 3.5	2	1598	Risk Ratio (M‐H, Random, 95% CI)	1.19 [0.78, 1.81]
4.4 Any frequency of massage	3	2417	Risk Ratio (M‐H, Random, 95% CI)	0.81 [0.56, 1.19]
5 Incidence of episiotomy Show forest plot	3		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

5.1 Average number of massages per week < 1.5	2	1500	Risk Ratio (M‐H, Fixed, 95% CI)	0.72 [0.57, 0.91]
5.2 Average number of massages per week = 1.5 to 3.4	2	1650	Risk Ratio (M‐H, Fixed, 95% CI)	0.91 [0.77, 1.08]
5.3 Average number of massages per week > 3.5	2	1598	Risk Ratio (M‐H, Fixed, 95% CI)	0.84 [0.67, 1.04]
5.4 Any frequency of massage	3	2417	Risk Ratio (M‐H, Fixed, 95% CI)	0.85 [0.75, 0.97]
6 Length of second stage Show forest plot	2		Mean Difference (IV, Random, 95% CI)	Subtotals only

6.1 Average number of massages per week < 1.5	2	1403	Mean Difference (IV, Random, 95% CI)	0.97 [‐6.45, 8.39]
6.2 Average number of massages per week = 1.5 to 3.4	2	1525	Mean Difference (IV, Random, 95% CI)	‐2.38 [‐8.55, 3.79]
6.3 Average number of massages per week > 3.5	2	1509	Mean Difference (IV, Random, 95% CI)	10.80 [4.03, 17.58]
6.4 Any frequency of massage	2	2211	Mean Difference (IV, Random, 95% CI)	3.35 [‐1.29, 8.00]
7 Instrumental delivery Show forest plot	3		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

7.1 Average number of massages per week < 1.5	2	1500	Risk Ratio (M‐H, Random, 95% CI)	0.89 [0.71, 1.13]
7.2 Average number of massages per week = 1.5 to 3.4	2	1650	Risk Ratio (M‐H, Random, 95% CI)	0.88 [0.72, 1.07]
7.3 Average number of massages per week > 3.5	2	1598	Risk Ratio (M‐H, Random, 95% CI)	1.07 [0.86, 1.33]
7.4 Any frequency of massage	3	2417	Risk Ratio (M‐H, Random, 95% CI)	0.93 [0.76, 1.13]
8 Length of inpatient stay	0		Mean Difference (IV, Fixed, 95% CI)	Subtotals only
8.1 Average number of massages per week < 1.5	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
8.2 Average number of massages per week = 1.5 to 3.4	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
8.3 Average number of massages per week > 3.5	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
8.4 Any frequency of massage	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
9 Admission to nursery	0		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only
9.1 Average number of massages per week < 1.5	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
9.2 Average number of massages per week = 1.5 to 3.4	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
9.3 Average number of massages per week > 3.5	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
9.4 Any frequency of massage	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
10 Apgar < 4 at 1 minute and/or Apgar < 7 at 5 minutes	0		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only
10.1 Average number of massages per week < 1.5	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
10.2 Average number of massages per week = 1.5 to 3.4	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
10.3 Average number of massages per week > 3.5	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
10.4 Any frequency of massage	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
11 Woman's satisfaction with perineal massage	0		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only
11.1 Average number of massages per week < 1.5	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
11.2 Average number of massages per week = 1.5 to 3.4	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
11.3 Average number of massages per week > 3.5	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
11.4 Any frequency of massage	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
12 Perineal pain postpartum	0		Mean Difference (IV, Fixed, 95% CI)	Subtotals only
12.1 Average number of massages per week < 1.5	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
12.2 Average number of massages per week = 1.5 to 3.4	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
12.3 Average number of massages per week > 3.5	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
12.4 Any frequency of massage	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
13 Perineal pain at 3 months postpartum Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

13.1 Average number of massages per week < 1.5	1	577	Risk Ratio (M‐H, Fixed, 95% CI)	1.01 [0.65, 1.56]
13.2 Average number of massages per week = 1.5 to 3.4	1	595	Risk Ratio (M‐H, Fixed, 95% CI)	0.69 [0.42, 1.13]
13.3 Average number of massages per week > 3.5	1	701	Risk Ratio (M‐H, Fixed, 95% CI)	0.51 [0.33, 0.79]
13.4 Any frequency of massage	1	931	Risk Ratio (M‐H, Fixed, 95% CI)	0.67 [0.50, 0.92]
14 Painful sex at 3 months postpartum Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

14.1 Average number of massages per week < 1.5	1	521	Risk Ratio (M‐H, Fixed, 95% CI)	0.85 [0.67, 1.08]
14.2 Average number of massages per week = 1.5 to 3.4	1	538	Risk Ratio (M‐H, Fixed, 95% CI)	1.03 [0.85, 1.25]
14.3 Average number of massages per week > 3.5	1	622	Risk Ratio (M‐H, Fixed, 95% CI)	0.96 [0.81, 1.13]
14.4 Any frequency of massage	1	831	Risk Ratio (M‐H, Fixed, 95% CI)	0.95 [0.83, 1.09]
15 Woman's sexual satisfaction at 3 months postpartum Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

15.1 Average number of massages per week < 1.5	1	569	Risk Ratio (M‐H, Fixed, 95% CI)	1.04 [0.93, 1.16]
15.2 Average number of massages per week = 1.5 to 3.4	1	588	Risk Ratio (M‐H, Fixed, 95% CI)	1.08 [0.98, 1.19]
15.3 Average number of massages per week > 3.5	1	692	Risk Ratio (M‐H, Fixed, 95% CI)	0.99 [0.90, 1.08]
15.4 Any frequency of massage	1	921	Risk Ratio (M‐H, Fixed, 95% CI)	1.02 [0.96, 1.10]
16 Partner's sexual satisfaction at 3 months postpartum Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

16.1 Average number of massages per week < 1.5	1	576	Risk Ratio (M‐H, Fixed, 95% CI)	1.01 [0.91, 1.11]
16.2 Average number of massages per week = 1.5 to 3.4	1	586	Risk Ratio (M‐H, Fixed, 95% CI)	1.03 [0.95, 1.13]
16.3 Average number of massages per week > 3.5	1	688	Risk Ratio (M‐H, Fixed, 95% CI)	0.93 [0.86, 1.02]
16.4 Any frequency of massage	1	916	Risk Ratio (M‐H, Fixed, 95% CI)	0.97 [0.91, 1.04]
17 Uncontrolled loss of urine at 3 months postpartum Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

17.1 Average number of massages per week < 1.5	1	587	Risk Ratio (M‐H, Fixed, 95% CI)	1.10 [0.83, 1.46]
17.2 Average number of massages per week = 1.5 to 3.4	1	606	Risk Ratio (M‐H, Fixed, 95% CI)	0.84 [0.62, 1.15]
17.3 Average number of massages per week > 3.5	1	714	Risk Ratio (M‐H, Fixed, 95% CI)	0.83 [0.65, 1.06]
17.4 Any frequency of massage	1	949	Risk Ratio (M‐H, Fixed, 95% CI)	0.90 [0.74, 1.08]
18 Uncontrolled loss of faeces at 3 months postpartum Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

18.1 Average number of massages per week < 1.5	1	586	Risk Ratio (M‐H, Fixed, 95% CI)	1.04 [0.36, 3.03]
18.2 Average number of massages per week = 1.5 to 3.4	1	605	Risk Ratio (M‐H, Fixed, 95% CI)	0.44 [0.10, 1.89]
18.3 Average number of massages per week > 3.5	1	713	Risk Ratio (M‐H, Fixed, 95% CI)	0.72 [0.29, 1.80]
18.4 Any frequency of massage	1	948	Risk Ratio (M‐H, Fixed, 95% CI)	0.72 [0.35, 1.49]
19 Uncontrolled loss of flatus at 3 months postpartum Show forest plot	1	2854	Risk Ratio (M‐H, Fixed, 95% CI)	1.09 [0.95, 1.25]

19.1 Average number of massages per week < 1.5	1	587	Risk Ratio (M‐H, Fixed, 95% CI)	1.40 [1.03, 1.90]
19.2 Average number of massages per week = 1.5 to 3.4	1	606	Risk Ratio (M‐H, Fixed, 95% CI)	0.87 [0.60, 1.26]
19.3 Average number of massages per week > 3.5	1	713	Risk Ratio (M‐H, Fixed, 95% CI)	1.07 [0.82, 1.39]
19.4 Any frequency of massage	1	948	Risk Ratio (M‐H, Fixed, 95% CI)	1.09 [0.88, 1.36]

Comparison 2. Digital perineal massage versus control: results by frequency of massage

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