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RESEARCH ARTICLE Open Access
Fear causes tears - Perineal injuries in home birth
settings. A Swedish interview study
Helena E Lindgren
1,2*
, Åsa Brink
1†
, Marie Klinberg-Allvin
1†
Abstract
Background: Perineal injury is a serious complication of vaginal delivery that has a severe impact on the quality of
life of healthy women. The prevalence of perineal injuries among women who give birth in hospital has increased
over the last decade, while it is lower among women who give birth at home. The aim of this study was to
describe the practice of midwives in home birth settings with the focus on the occurrence of perineal injuries.
Methods: Twenty midwives who had assisted home births for between one and 29 years were interviewed using
an interview guide. The midwives also had experience of working in a hospital delivery ward. All the interviews
were tape-recorded and transcribed. Content analysis was used.
Results: The overall theme was “No rushing and tearing about”, describing the midwives’focus on the natural
process taking its time. The subcategories 1) preparing for the birth; 2) going along with the physiological process;
3) creating a sense of security; 4) the critical moment and 5) midwifery skills illuminate the management of labor
as experienced by the midwives when assisting births at home.
Conclusions: Midwives who assist women who give birth at home take many things into account in order to
minimize the risk of complications during birth. Protection of the woman’s perineum is an act of awareness that is
not limited to the actual moment of the pushing phase but starts earlier, along with the communication between
the midwife and the woman.
Background
Perineal injuries and anal sphincter ruptures are serious
complications of vaginal delivery. Most common conse-
quences of perineal injury are pain and incontinence,
which affect the quality of life of healthy women [1].
Other consequences identified are negative emotional
and psychological effects on women’soverallwell-being
[2]. The prevalence of anal sphincter rupture increased
from 2.6 percent to 4.2 percent between 1994 and 2004,
and approximately 3000 women sustain severe perineal
injuries annually in Sweden [1]. A similar increase has
been described in other European and other Nordic
countries. Norway reports an increase from one percent
in the 1960s to 4.3 percent in 2008. Finland, on the
other hand, reports stable figures below one percent
over the past decade [3].
Risk factors for anal sphincter rupture during delivery
are described as nulliparity, high birth weight of the
child, instrumental deliveries, episiotomy, adverse birth
position, maternal age and epidural analgesia [4,5].
Women who were delivered in a semi-sitting position or
who squatted during the pushing phase were at greater
risk of sustaining perineal injuries [1]. It is further
reported that prolonged labor significantly increased the
risk for perineal injuries [5]. Avoidance of episiotomy
has been identified as a protective factor in avoiding
perineal injuries among first-time mothers. Forceps
delivery caused anal sphincter ruptures more often than
vacuum extraction and spontaneous delivery [6]. Instru-
mental deliveries and Cesarean section has become
more prevalent over the past decade, and the prevalence
of anal sphincter rupture in second and third births has
consequently increased [7].
Lower frequency of perineal injuries and anal sphinc-
ter ruptures has been reported from studies of planned
home births internationally [8-12]. A Swedish register
study showed that women who gave birth at hospital
* Correspondence: hli@du.se
†Contributed equally
1
School of Health and Social Science, Dalarna University, Falun, Sweden
Full list of author information is available at the end of the article
Lindgren et al.BMC Pregnancy and Childbirth 2011, 11:6
http://www.biomedcentral.com/1471-2393/11/6
© 2011 Lindgren et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
had a five times higher prevalence of anal sphincter rup-
tures than low-risk women giving birth at home [13].
Women who choose to give birth at home differ from
those who give birth in the hospital in some aspects:
they have more children, have a higher level of educa-
tion, smoke less and have a lower BMI [14]. However,
after adjustment for these factors the differences in pre-
valence of perineal injuries remain.
Evidence indicates that the prevalence of perineal
trauma is lower among women giving birth at home
assisted by a midwife. It is not clear whether this has to
do with differences in midwifery practice or other fac-
tors. There is a need to understand more about midwif-
ery practice in home births settings in order to gain
knowledge on how to protect women from perineal
injuries.
Methods
A qualitative approach, using open-ended qualitative
interviews, was applied in this study. Individual inter-
views were conducted with twenty midwives in 2009.
Information regarding the study was presented on the
website “Föda hemma”(Giving birth at home) hosted by
a network of midwives assisting women in home deliv-
eries. Midwives interested in participating were con-
tacted, informed about the purpose of the study and
invited to take part. Eleven midwives first gave their
consent to participate and another nine midwives were
contacted through these eleven midwives and invited to
be individually interviewed. The interviews took place in
the participants’homes or at their workplace. The time
taken for the interviews was between 30 and 75 minutes.
All interviews were tape-recorded with the permission
of the participants. Interview guidelines with open-
ended questions were developed prior to the study
(additional file 1).
The age range among the midwives was 31-62 years.
The level of experience of women assisting home births
varied from 1 to 29 years. The participants were domi-
ciled in various parts of Sweden and they had experi-
ence of different areas of midwifery such as delivery
wards, gynecological departments and perinatal health
consultations.
Analysis
Data analysis took place after data collection was com-
pleted. In this study we conducted qualitative content
analysis using an inductive method, since there were no
previous studies dealing with the phenomenon [15]. The
inductive analysis is conducted with the aim to enhance
understanding and to generate knowledge. When using
content analysis it is assumed that, when classified into
the same categories, words and phrases share the same
meaning [16]. Prior to the analysis ÅB, HL and MKA
read the total material several times. The data was
divided into units of meaning that were condensed. The
condensed units of meaning (consisting of either a sin-
gle word or several sentences) were abstracted and
labeled with a code by ÅB and HL independently. ÅB
and HL then discussed the codes and diverging codes
were re-evaluated and consensus was reached. Similar
codes were grouped into sub-categories and subse-
quently also divided into main categories, critically ques-
tioned and compared within the research team. These
categories were modified during the procedure to gener-
ate a broader and more subjective category system in
order to capture the specifics in the data. Finally, a com-
parison between similarities and differences resulted in
one main theme.
Results
In the analysis of the midwives’experiences five cate-
gories and one overall theme emerged from the inter-
views. A description of the content of each category
follows, illustrated by quotations from the text. The
category system is presented in Table 1.
Preparing for the birth
The midwives stated that they prepared for the birth
mentally and physically. They prepared by going
through the woman’s birth plan and her obstetric his-
tory and by collecting additional information from the
couple. The midwives also took part in efforts to make
the environment inviting and comfortable for the
woman.
Knowing the woman
In a home birth the woman is known to the midwife
ahead of the birth. The midwife has seen the woman at
least once during pregnancy and talked to her about her
expectations and fears. Talking about fear of tearing is
described as one strategy in order to prevent this from
happening. If the midwife is familiar with woman’s fears
she can be supportive during the birth. Knowing the
woman prior to the birth is reported as reassuring for
several midwives.
“It’s easier to communicate when I know what the
woman is afraid of and what her previous births were
like. She also knows that she can trust me.”
“Fear causes tears. When the woman is frightened her
pelvic floor tightens and is more likely to tear. At home
she usually finds the courage to resist the urge to push.”
Knowing the woman prior to the birth was also
described as contributing to the sense of security for the
midwife. “I feel much more insecure at the hospital as I
don’t know who I’m dealing with.”
Knowing about birth
The midwives describe how their previous experience
from attending many births contributes to the way in
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which they handle their next birth. Previous experience
of sphincter ruptures and severe perineal injuries gives
them intuitive knowledge of when the perineum is in
danger. They were aware of the risk of tearing. As one
midwife put it:
“Maybe we cannot avoid it completely but we can
always do our best to minimize the trauma.”
Midwives who were more inexperienced referred to
knowledge they had gained from older colleagues. Dis-
cussions with more experienced midwives about differ-
ent strategies for handling labor in order to reduce the
risk of tearing give them a sense of security.
“I had a very experienced midwife who was like a men-
tor to me. She once told me a story about the birth of a
5 kg baby; in the first birth the woman had had a
sphincter rupture and this time she wanted to give birth
at home. The midwife was very close to the woman and
guided her through each millimeter during the pushing
phase. Their collaboration saved the woman’s perineum
completely.”
Making the room inviting
Women who have chosen to give birth at home often have
an image of themselves giving birth in their own environ-
ment. The midwives get to know the women’s expecta-
tions, and this helps them to make it easier for the woman
to have her wish fulfilled. The midwives described this
support as contributing to helping the woman relax.
“For one woman it was so important this time to give
birth in the birthing pool. She was almost pushing but I
could see that she was holding back, waiting for the
water to fill up. We helped her into the pool and one
minute later she gave birth without tearing at all.”
When the midwife knows what is important to the
woman she can assist her by bringing her the things she
wants to be surrounded by or prepare for the birth by put-
ting on music that the woman likes. All these things
together make the woman feel comfortable and have con-
fidence in her own ability, as described by the midwives;
“...if the woman feels calm and relaxed it makes her
perineum relax and she feels that it will be alright, we
have few lacerations at home...”
Going along with the physiological process
All the midwives in the study described how hospital-
based deliveries differed from home-based deliveries and
their perception of what factors contributed to perineal
trauma.
No rushing
Time and time limits were frequently mentioned by the
midwives as a factor contributing to perineal trauma.
The rushing of normal labor was considered to be the
worst enemy of an uncomplicated birth. When they
assisted home births they were still aware of time and
attentive to any exceeding of the normal length of labor.
They described time as less significant during a home
birth, and there were other factors they paid more atten-
tion to at home.
“We do not think of watches as machines, but I would
say that it is the one subject that really threatens normal
birth and makes the women tear.”
Listening to the woman
Instead of being aware of time the midwives describe
how they listen to the woman. By following the woman
in her labor and carefully doing what is needed during
the different phases, the midwives avoid perineal
trauma. They describe listening as being in contact with
the woman and following her wishes.
“If you really care for a woman in labor you do what it
takes to fulfill her wishes. The women usually know what
feels best for them and when they don’tknowyoucan
listen and make suggestions so that they can find out for
themselves.”
Table 1 Category system
Sub-categories Categories Theme
Knowing the woman Preparing for the birth No rushing and tearing about
Knowledge of birth
Making the room inviting
No rushing Going along with the physiological process
Listening to the woman
Identifying signs
Being responsive
Home environment Creating a sense of security
Communication Focus on the relationship
Changing positions The critical moment
Guiding the woman
Handling the pain
Warm cloths Holding against baby’s head Effects of the midwife Midwifery skills
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Identifying signs
Being attentive to any signs that signal stress or anxiety
was described by the midwives as important in order to
prevent perineal injuries. When assisting the woman at
home the midwives report that they are able to be more
observant to the individual and the normal process than
when working at hospital.
“When I have a home birth I focus completely on the
birth process and use all my skills to support the
woman. The lack of technology helps me keep all my
senses alert to every little sign she gives me.”
One of the midwives told a story about a woman who
was giving birth to her third child. It was the first home
birth for the mother and previous births had ended with
an episiotomy at the hospital. She describes the pushing
phase:
“I was so aware of the perineum, I could almost feel
the tension in my own body. The woman was on her
hands and knees and she was really affected by the tran-
sition phase. I could see that she wasn’t comfortable; she
wasmoreorlesstryingtoescapefromthesituation.I
suggested that she should lie on her side and started
talking about completely different things as I wanted to
move the focus away from the urge to push. She started
laughing and relaxed until her baby started coming
without any pushing at all.”
Being responsive
Oneofthemostimportanttasksinthehomebirth
situation is to be able to follow the woman and at the
same time be responsive to any changes during labor.
As the birth proceeds the woman finds herself in states
she could not anticipate and the midwives stress the
importance of not getting stuck in any plans drawn up
ahead of the birth
“Empowering the woman when she is about to give up,
that’s our job. This gives her the strength to go on with
the contractions and use all her energy to make it go
well.”
Dealing with the times when the woman is about to
lose confidence in her own ability was described by the
midwives as significant for a successful birth. One mid-
wife said that she actually carried the woman mentally
when she felt that she was about to lose her grip. Sup-
porting a woman who has confidence in her ability is
not a major challenge but doing so when she is about to
give up is considered to be one of the midwife’smost
important tasks. Distinguishing the situations when a
woman needs a lot of support and when she can cope
on her own is crucially important.
Creating a sense of security
Home environment
Women who choose to give birth at home often imagine
themselves giving birth in a chosen place in the house.
The midwives describe how the level of preparedness
and determination they see in women who give birth at
home is rarely seen in hospitals.
“I think we are very much like animals, to feel secure
we need some space of our own and I’ve seen many
women making a “nest”ahead of the birth. The security
of being there helps them through the birth”
Communication
Having good communication was also considered to be
one of the most important factors in avoiding injuries
during birth. During the pushing phase the midwives
feel confident in knowing the woman and her needs.
One midwife says that she often relates to what has
been said ahead of the birth in order to remind the
woman during pushing.
“Iknowthattheydon’t remember anything when they
are in the transition stage so I refer to things we have
talked about during pregnancy and try to help the
woman back to what she really wants.”
Communication with the partner was also mentioned
as important. He or she can sometimes provide the
bridge between the woman and the midwife as the one
who knows the birthing woman better than anyone
else
“Once there was a woman who completely lost herself
during transition. She cried like a baby and I couldn’t
reach her so I asked her husband to comfort her and
hold her and tell her that he loved her. Then she calmed
down and gave birth without suffering a tear.”
Focus on the relationship
The midwives described home births as different from
hospital births in many respects. One of these was that
their attention was focused on the relationship between
themselves and the couple and the relationship between
the couple. Some of the midwives also stated that they
focused on the relationship between the woman and the
child that was about to be born.
“When I feel love between the parents and for the new
life I feel more secure in the situation. This helps me be
a better midwife and I think I handle the birth better.”
The critical moment
Crowning is the critical moment for tearing or not. The
midwives reported that most of the job has to have
been done at that point. There must be confidence in
the relationship and communication must work
smoothly so that all the attention can be focused on the
arrival of the baby.
Birth positions
The midwives all mentioned birth positions as an expla-
nation for injuries during birth. They stated that women
who are free to choose the position they want for the
birth usually find themselves in an upright position lean-
ing forward;
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“If I see that she finds it hard to relax I try to support
her by suggesting a change, a woman who is pushing sel-
dom thinks of this herself. I have never seen a woman
who is comfortable on her back at this stage.”
“You never know in advance how a woman is going to
give birth but I always try to help her find the most com-
fortable position because she can then relax and her pel-
vic floor is more relaxed too.”
Guiding the woman
Guiding during the pushing phase was described as
important for first-time mothers. Gentle guiding as
attention is focused on the progress of the baby’s
crowning was considered to help the woman avoid
tearing. This could be done by praising her courage
when she pushes but also by giving her support in
withstanding the pressure from the baby’sheadwith-
out rushing.
“I breathe with the woman and encourage her to follow
me if she doesn’t do this by herself. For some women the
pressure is so great that you need to lead them through
this moment.”
Handling the pain
The crowning of the baby’s head is often experienced as
the most painful part of the birth. In contrast to the
contractions during the opening phase and the confus-
ing sensations that might come with transition, crown-
ing is pure pain. This phase is often critical, as
described below.
“The woman sometimes wants to avoid the pain by
pushing all she can. My aim is to help her handle the
pain so that she can be in contact with her body and fol-
low its signals. I do this by talking to her, touching her
and encouraging her to hold on for a moment or two.”
Midwifery skills
The midwives in this study had had many years of train-
ing and told various stories of techniques and skills they
had learnt along the way.
Warm cloths
Use of warm cloth to support the perineum and ease
the pain during the birth of the baby’sheadwas
described. Blood circulation in the perineum is said to
be facilitated by the warmth from the cloth. The mid-
wives also say that women usually find that it relieves
the pain.
“I assisted a woman who had asked for warm cloths
during her previous delivery at hospital but was then
told that they were of no use. She had a severe rupture
in that birth and this time she was very anxious to have
them. Why should we refuse a woman’s request in this
case?”
Using the cloths also helped the midwives to get an
idea of the perineum and its elasticity. They consider
this more helpful and in particular less painful than
using their fingers to stretch the perineum from inside,
a method that is widely used in hospital births.
“IfeelsickeverytimeIseeacolleaguestretcha
woman’s perineum with her fingers while the woman is
having to cope with all the pain from inside due to the
pressure. There is no reason to make something that is
difficult even worse.”
No touching
Some midwives do not touch the perineum at all unless
the woman asks them to or they recognize a need to do
so. One of the midwives used a mirror to show the
woman what happens so that she could control her
pushing. Others report that they encourage the woman
to take control of the emergence of the baby’shead.
Sometimes this is done by suggesting to the woman that
she should feel the process with her own hands.
“For first-time mothers it is really rewarding to feel the
baby’s head. The labor might have felt as though it
would never end, and now she can feel with her own
hands that it will soon be over.”
“When the mother follows the delivery of the baby’s
head by putting her hand on the head she pushes the
exactamountittakestohelpthebabyoutwithout
tearing.”
Effects of the midwife
All the midwives believed that they had an impact on
the outcome with regard to perineal injuries. Being
communicative and having trust in the woman’sability
were factors that were frequently reported. Being able to
take action when the woman is lost in the birth process
is another factor. Homebirth midwives usually work in
pairs and this was seen as a protecting factor.
“When I feel unsure or confused I ask my colleague to
go in for me. You need to be humble and accept that
you’re not on top of the situation all the time. I may be
tired and discouraged during a birth but I always try to
keep these feelings away from the woman.”
Discussion
This interview study aimed to describe how midwives
handle home births with the focus on protecting the
perineum from injuries, which are associated with long-
term consequences for many women.
Methodological considerations
The study was based on a small and purposive sample,
and as a result may not be representative. The study
nevertheless provides important insights into midwifery
practice at home births and how they serve as protective
factors in relation to perineal injuries. There are, how-
ever, a number of methodological considerations that
need to be taken into account when interpreting and
transferring the results derived through the use of quali-
tative methods. In qualitative interviews, the influence of
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the researcher during the interview, as well as during
the process of analysis, needs to be taken in considera-
tion [17]. Reflexivity refers to the researchers’precon-
ceptions based on previous personal and professional
experiences and on their values and beliefs in relation to
the topic studied [18]. The interviewer was a midwife
with experience from both hospital and home-based
deliveries. All the authors took part in the process of
analysis, and this together with a continuous dialogue
between the members of the research team enhances
credibility [15]. The degree of dependability is thought
to be high due to well-organized and prepared interview
guidelines provided by a person with prior knowledge of
home-based deliveries and their context. We argue that
the issue of transferability is met in this study by the
clear description of the data collection and process of
analysis.
Discussion of results
Themidwivesreportedthattheypreparedforthe
planned home birth mentally as well as physically. They
also took part in making the environment inviting and
comfortable for the woman. They described the prepara-
tory phase as a factor that might contribute to the lower
frequency of perineal trauma in home births. This is in
good agreement with a large study exploring factors
related to safety in a planned home birth, which found
knowing the mother and her home environment to be
important [19]. The intuitive knowledge that guides the
midwife in her management is described as being facili-
tated by acquaintance from prior to the birth and also
by the environment [20].
All midwives in our study had experience of both hos-
pital and home-based deliveries and described how care
androutinesdiffered.Themidwivesinthisstudy
describe how the home birth environment itself had a
positive effect on the women. They experience time and
time limit in the hospital setting as one factor contribut-
ing to perineal injuries. The home environment allows
the midwives to follow the normal birth process without
rushing. Hospital routines and interventions are identi-
fied as risk factors in the light of their attitude towards
birth [21]. Birthing women seem to find courage in the
environment they have created. Murphy and Feinland
[9]consideritplausiblethat midwives contribute to
keeping the perineum intact and avoiding episiotomies
in a certain setting that has been chosen by low-risk
women.
Being attentive to any signs from the woman that sig-
nal stress or anxiety was described by the midwives as
important in order to prevent perineal injuries. Guiding
the women should not be confused with forcing her to
push. Gentle guiding was considered to help the women
avoid tearing. According to Sampselle and Hines [22], a
spontaneous birth protects the perineum from tearing.
Women who pushed on demand from the staff had a
higher frequency of perineal injuries and episiotomies
than those who pushed when they felt the physiological
urge to do so. Laine et al. [3] suggests that slowing
down the birth of the baby’sheadbyplacingahandon
the crown and actively instructing the mother not to
push while the head is being born reduces the preva-
lence of anal sphincter ruptures by 70 percent. Few mid-
wives seem to use this method during a homebirth.
Midwives included in this study who attend home
births report that their focus is on the women’s
strengths rather than their weaknesses. They also
emphasize the aspects of safety, harmony, awareness,
and integrity. By following the women in labor and
doing what is needed during the different phases the
midwives believe that they avoid perineal trauma. The
women give birth on their own terms and in accordance
with their requests. This is in line with previous
research describing midwives’attitudes towards their
attendance at home births [20]. It has been shown that
giving birth at home means preserved authority and
autonomy through which women have faith in life itself
and rely on natural forces. Women described faith in
their own competence, they received support that was
chosen personally and they were able to be at home.
Women who give birth at home wish to have control
during birth and state that they trust their own ability
to give birth [23]. One finding of this study was the
description of communication as an important asset for
a positive outcome of a planned home birth. Trust is
fundamental to the communication between the midwife
and the woman. According to Brunstad, Nilsen and
Aasheim [24], midwives perceive that both cooperation
and communication are important in the birthing room.
However, this was sometimes difficult for midwives
working at the hospital since they did not know the
woman before labor started. The Norwegian midwives
felt that this could contribute to a lack of guidance and
consequently more injuries [24].
There is little evidence regarding the relationship
between birth position and perineal outcome. Shorten
and Donsante [25] suggest that the choice of birth posi-
tion might contribute to the outcome regarding perineal
injuries. Kneeling positions do not increase the risk for
anal sphincter rupture compared to a semi-sitting posi-
tion [26]. The midwives in this study all mentioned
adverse birth positions as a factor contributing to inju-
ries during birth. They reported that women who are
free to choose the position they want for the birth
usually find themselves in an upright position leaning
forward. It was also considered important for the mid-
wife to let the birthing woman try different positions
and then help her find something better. Lindgren [27]
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reports that the most frequently used birth position in
plannedhomebirthswasuprightkneelingfollowedby
crouching on all fours or standing up. Gottvall, Allebeck
and Ekéus [1] conducted an observational cohort study
to assess the role of birth positions in the occurrence of
anal sphincter tears. Their main finding was that
women who used lithotomy (woman in a semirecum-
bent posture with her legs in stirrups) or a squatting
position in the second stage of labor had a higher risk
for anal sphincter tears than women using other posi-
tions. It also reduced the woman’s opportunities to be
in control during the pushing phase. Evidence that helps
women to make informed choices regarding birth posi-
tions and perineal trauma have been presented by
Soong & Barnes [28]. Access to the midwife also has a
bearing on the birth outcome [29]. In planned home
births the midwife is responsible for one woman at a
time and is therefore readily available for the woman in
labor, which is not always the situation in the hospital
setting.
Conclusion
All the midwives in this study stated that they had influ-
ence on the outcome with regard to perineal injuries.
Midwives who attend home births view the birth as a
physiological process, which is best, handled by giving
support without interfering with the woman’s instinct.
The attitude towards time and time limits was seen as
the most significant difference between home and hospi-
tal births. Most women who give birth at home are
healthy multiparas, well prepared for the alternative they
have chosen and with support from their partner. This
might enhance the prospects of an optimal outcome for
the mother emotionally as well as physically in terms of
a spontaneous vaginal delivery without interventions or
perineal trauma. It is important to further disseminate
the knowledge home-birth midwives possess regarding
the birth process and also to provide women with ade-
quate information regarding the forthcoming birth of
their child.
Additional material
Additional file 1: Interview guidelines. Following guidelines were used
during all interviews with the midwives. •Could you tell about your
experience of planned homebirths? •Could you please describe your
activities (if any) that you use in order to prevent perineal injuries? •
What do you think is the explanation for lower frequency of perineal
injuries in home birth settings? Is there anything else that you consider
significant for giving birth with an intact perineum?
Acknowledgements
We would like to thank all midwives who participated in this study for
sharing their experience.
Author details
1
School of Health and Social Science, Dalarna University, Falun, Sweden.
2
Institute of Health and Care Sciences, Sahlgrenska Academy at the
University of Gothenburg, Sweden.
Authors’contributions
All three authors contributed to the study; the study was planned by HL
and MKL, data were collected by HL and ÅB, analysis was performed by the
whole group, and all three participated in the writing of the manuscript.
Competing interests
The authors declare that they have no competing interests.
Received: 25 August 2010 Accepted: 18 January 2011
Published: 18 January 2011
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Pre-publication history
The pre-publication history for this paper can be accessed here:
http://www.biomedcentral.com/1471-2393/11/6/prepub
doi:10.1186/1471-2393-11-6
Cite this article as: Lindgren et al.: Fear causes tears - Perineal injuries in
home birth settings. A Swedish interview study. BMC Pregnancy and
Childbirth 2011 11:6.
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