LAUSR

We would like to thank Levina and Rottenstreicha for their interests in our study: Effectiveness of Antenatal Perineal Massage in Reducing Perineal Trauma and Postpartum Morbidities: A Randomized Controlled Trial and wish to respond to their concerns as follows: First, level of compliance was 100% and was implied in our study: ‘Participants were asked to maintain daily records of performance of antenatal perineal massage (APM) and were seen weekly to review their records and reinforce compliance.’ Those who did not comply strictly were excluded. Sample size calculated was based on the primary outcome measure. Wide confidence intervals obtained in some secondary outcome measures suggest that a larger sample size would have improved study’s precision and external validity as stated in study’s limitations. Second, we used an anal incontinence (AI) questionnaire which was used in recently published study. This was because there is yet a universally accepted validated questionnaire for AI unlike urinary incontinence (UI). Our study was limited to 3 months follow up in view of anticipated huge loss if follow up had extended beyond. Third, the only indication for episiotomy in our study was ‘impending/threatening spontaneous perineal tears (SPTs).’ We agree that third and fourth degree SPTs are associated with morbidity, however, they are indicators of poorly conducted and neglected second stage labor which episiotomy aims to avert. This explains absence of third and fourth degree SPTs in our study. The first and second SPTs were similar in both groups since episiotomy was only indicated when skilled birth attendants observed impending/threatening SPTs. The obstetric care providers were blinded to participants’ study groups and study’s objectives. Finally, the quoted Cochrane review concluded that APM was associated with reduction in incidence of perineal trauma, less risk of episiotomy, and no differences in incidence of first, second, third and fourth degree SPTs. These findings were similar to our study. On issue of UI and AI, only one out of four studies included in Cochrane review assessed for incidence of UI and AI. Our study agreed with Cochrane review that there was no difference in incidence of UI and fecal incontinence. Although the review observed lack of association with flatus incontinence contrary to our study, authors of Cochrane review called for caution in interpretation because of very small frequencies observed. In fact, they suggested for more studies in this direction as evidence was weak. This was one of the justifications for our study. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study.