Knowledge, attitude, and practice of Chinese midwives performing in perineal massage for pregnant women in the latter stages of pregnancy

Abstract

Background

In obstetrics, perineal trauma is regarded as a serious public health issue. Perineal massage is advised for pregnant women in the later stages of pregnancy to help prevent perineal injuries during labor. This study aims to assess the knowledge, attitudes, and practices (KAP) of Chinese midwives concerning perineal massage for pregnant women in the latter stages of pregnancy.

Methods

This cross-sectional study was conducted in China from July 2024 to September 2024, aiming to investigate the knowledge, attitudes, and practices of midwives regarding perineal massage for pregnant women in the latter stages of pregnancy. The research employed a questionnaire survey covering demographic data as well as dimensions related to knowledge, attitudes, and practices. Data were analyzed using SPSS 27.0. Descriptive statistics summarized participant characteristics, while inferential analyses included independent t-tests, one-way ANOVA, Pearson correlation (to evaluate interrelationships among knowledge, attitude, and practice scores), and multivariable logistic regression (to determine predictors of practice scores), with statistical significance set at α = 0.05.

Results

A total of 446 valid questionnaires were gathered. Of these, 441 (98.88%) were female and 5 (1.12%) were male; 376 (84.30%) were from tertiary hospitals and 70 (15.70%) were from secondary hospitals. 89.01% of the sample had worked in the delivery room for more than five years. Regarding perineal massage for pregnant women in the latter stages of pregnancy, midwives received scores of 69.28 ± 12.90, 42.20 ± 4.31, and 45.25 ± 10.05 in the knowledge, attitude, and practice aspects, respectively. Multivariate logistic regression analysis outcomes indicated that practice dimension scores were influenced by knowledge (OR = 1.257, 95% CI [1.64–1.357], P < 0.001) and attitude (OR = 1.152, 95% CI [1.113–1.193], P < 0.001) scores.

Conclusions

There is an average level of midwives' knowledge, attitudes, and practices (KAP) on perineal massage for pregnant women in the later stages of pregnancy. This study recommends strengthening the knowledge and attitude dimensions of midwives in order to improve their comprehension of giving pregnant women a perineal massage in the latter stages of pregnancy. Improving these elements will also boost midwives' practical abilities, which will improve the quality of perineal massage for expectant mothers in the latter stages of pregnancy.

Background

Perineal trauma is a common complication of vaginal delivery, affecting approximately 85%—90% of parturient women [1, 2]. Research indicates that this condition can lead to both immediate and long-term consequences, including perineal pain, urinary and fecal incontinence, pelvic organ prolapse, and sexual dysfunction [3,4,5]. These complications not only diminish the quality of life for affected women but may also negatively impact their psychological well-being. Therefore, finding safe and effective measures to prevent and reduce perineal trauma during childbirth is crucial. Recently, numerous guidelines grounded in evidence have suggested that perineal massage administered during childbirth represents an efficacious approach to minimizing perineal trauma [6,7,8]. As a result, perineal massage is receiving increasing attention as a promising method for protecting the perineum. This technique involves inserting two gloved fingers into the parturient’s vagina, applying downward pressure on both sides, and massaging the perineum evenly [9]. By increasing the stretchability and elasticity of perineal tissues [10], perineal massage improves local blood circulation in the perineum, providing protective effects [11]. Research suggests that performing perineal massage in late pregnancy offers several benefits, such as reducing perineal trauma during childbirth, alleviating perineal pain, and shortening the second stage of labor [12]. Accordingly, it is widely recommended that perineal massage be initiated around the 34th week of pregnancy [13].

According to Meeprom et al., pregnant women in Thailand were highly accepting of prenatal perineal massage (83%) [14]. In Quebec, Canada, Labrecque et al. evaluated the opinions of pregnant women regarding prenatal perineal massage and discovered that 64% of them were open to it [15]. These statistics unequivocally show that pregnant women respond well to perineal massage techniques. Half of the world's health workforce consists of nurses and midwives, who are the backbone of the healthcare system [16]. Midwives can offer high-quality midwifery care as the main practitioners of perineal massage, which is crucial to reducing illnesses and issues that endanger the health of expectant mothers and their babies [10, 17]. The effectiveness and safety of perineal massage for pregnant women in their late pregnancy have been the focus of current study, but midwives in clinical practice have not yet given it enough consideration.

Currently, both domestically and internationally, there is a scarcity of research on the knowledge, attitudes, and practices (KAP) of medical professionals regarding perineal massage. Existing studies predominantly focus on the implementation effects of perineal massage. In particular, research on the KAP of midwives in performing perineal massage for pregnant women in late pregnancy has not yet been reported. Considering the significant role of perineal massage in preventing perineal trauma and improving childbirth outcomes, it is crucial to provide midwives with systematic education and training. Through professional training, midwives' skills in performing perineal massage for pregnant women in late pregnancy can be enhanced, and their scientific understanding and practical abilities regarding perineal massage can be strengthened. This will help bridge the gap between knowledge and clinical practice among midwives, thereby facilitating the broader application of perineal massage services. To further promote the widespread use of perineal massage in China, it is essential for the relevant departments of medical institutions and midwives to first acquire knowledge about perineal massage, shift traditional mindsets, and actively adopt effective measures to improve the implementation of perineal massage services. This not only enhances the professional competence of midwives but also provides higher-quality care for pregnant women in late pregnancy, ultimately improving childbirth experiences and maternal and infant health outcomes.

An organized survey technique called Knowledge, Attitudes, and Practices (KAP) is used to evaluate a population's attitudes and behaviors about specific illnesses, therapies, or health-related subjects [18]. KAP studies are simple and reasonably priced. They can be used to quickly connect with the intended audience and learn about their opinions on the topics of interest [18]. Midwives have the most contact time with pregnant women because they are the specific implementers of treatment and care programs for pregnant women. Their knowledge, attitudes, and degree of practice in performing perineal massages for pregnant women in late pregnancy are essential for preventing perineal injuries, identifying risks, and offering successful interventions. It is vital to know midwives' opinions, attitudes, and degree of experience in administering perineal massage to pregnant women in late pregnancy because of their critical role in managing this treatment.

This study aimed to comprehensively examine midwives' knowledge, attitudes, and practices regarding perineal massage for pregnant women in the later stages of pregnancy. The objective was to establish a scientific foundation and offer practical guidance to enhance midwives' professional competencies while improving the childbirth experience and outcomes for expectant mothers.

Methods

Study design and participants

This cross-sectional study was conducted between July 2024 and September 2024 among midwives in 54 urban hospitals in 17 provinces across China. Inclusion criteria: (1) having a certificate of nursing practice in the People's Republic of China and within the valid registration period; (2) working in midwifery practice; (3) working in the delivery room for at least one year; (4) showing understanding and support for this study and volunteering to participate. Exclusion criteria: (1) internship nursing students, advanced training midwives; (2) midwives who were not on duty during the survey period. The study was reviewed by the Ethics Committee of the Third Affiliated Hospital of Guangzhou Medical University (code: Linlun Review [2024] No. 080). All research participants participated voluntarily and were informed of the study's purpose, methods, and potential risks before taking part. They also provided written informed consent. During the study, participants' personal information and data were fully anonymized to ensure their privacy and information security. Additionally, the research team implemented strict measures during data collection and analysis to prevent any potential privacy breaches.

Procedures

A search strategy combining subject terms and free words was employed, using the following search terms: "perineum"/"vulva" + "vagina"/"birth canal"/"genital tract" and "massage"/"manipulation"/"finger pressure"/"finger technique"/"pressure"/"manual therapy." The search was conducted across various databases and resources, including UpToDate, BMJ Best Practice, the Joanna Briggs Institute, the Centre for Evidence-Based Health Care, the International Guideline Collaborative Network, the World Health Organization, the National Institute for Health and Care Excellence, the Scottish Intercollegiate Guidelines Network, the National Guideline Clearinghouse, the Registered Nurses' Association of Ontario Evidence-Based Nursing Guidelines, Medlive, the Royal College of Obstetricians and Gynaecologists, the Association for Women's Health, Obstetric and Neonatal Nurses, the American College of Obstetricians and Gynecologists, the International Federation of Gynecology and Obstetrics, the Society of Obstetricians and Gynaecologists of Canada, the Chinese Medical Knowledge Base, China National Knowledge Infrastructure (CNKI), Wanfang Data, PubMed, Cochrane Library, Embase, Web of Science, and CINAHL Plus. The search focused on literature related to perineal massage in late pregnancy. The inclusion criteria were healthcare providers as the target audience and themes such as guidelines, recommended practices, and expert consensus studies. Based on the Knowledge, Attitude, and Practice theory, the content of the evidence was categorized into dimensions of knowledge, attitude, and behavior through group discussion. A preliminary draft of the KAP questionnaire for midwives' implementation of perineal massage in late pregnancy was developed accordingly.

The group developed the "Questionnaire on Knowledge, Attitude, and Practice for Perineal Massage by Midwives for Pregnant Women in Late Pregnancy" using the framework of Knowledge, Attitude, and Practice Theory after studying pertinent domestic and international literature. Six obstetrics experts were invited to a meeting to revise the questionnaire's content. These experts included two deputy chief physicians with doctorates who had worked in the field for at least ten years, one deputy chief nurse, and three chief nurses with bachelor's degrees or higher who had worked in midwifery nursing for at least ten years. After discussion with experts, the research team revised the survey questionnaire by removing items that were deemed unreasonable or irrelevant to the topic. In the Belief section, five new items were added to gain a deeper understanding of the intrinsic motivations and external barriers that midwives face when implementing perineal massage. These additions are intended to provide a basis for developing targeted interventions. In the Attitude section, one new item was included to assess midwives' actual practices regarding follow-up and documentation after performing perineal massage. This addition is aimed at improving practice workflows and enhancing service quality.

A pre-survey was then conducted with 50 participants to test the instrument's internal consistency. After obtaining the consent of the midwife, the researcher will issue the questionnaire, explain the filling method and precautions with unified guidance, and inform the midwife to evaluate whether the semantic expression of each item and the setting of the amount of questions are reasonable. 50 questionnaires were issued and all were effectively recovered. The midwife believes that there is no ambiguity in the meaning of each item, no difficulty in understanding, and no modification of the content of the item.

Cronbach's alpha coefficients were used to assess reliability, with a minimum acceptable value of 0.7 [19]. The overall Cronbach's alpha coefficient of the questionnaire was 0.957. For the knowledge, attitude, and practice dimensions, the Cronbach's alpha coefficients were 0.981, 0.748, and 0.943, respectively. The validity of this questionnaire was assessed through content validity evaluation. In this study, the content validity index (CVI) was calculated as an item-level content validity index (I-CVI) and a scale-level content validity index (S-CVI) [20]. Eight midwifery and nursing experts were invited to conduct the review. All experts held a senior professional title (associate senior or above), had a bachelor's degree or higher, and possessed more than 15 years of work experience. During the review process, a four-point rating scale was used for each item in the questionnaire (1 = not relevant, 2 = somewhat relevant, 3 = relevant, 4 = very relevant) to obtain the experts' evaluations of the relevance of each item within the questionnaire [20]. The calculations revealed that the I-CVI for each item was greater than 0.78. For the overall questionnaire, the S-CVI included the universal agreement level (S-CVI/UA) and the average level (S-CVI/Ave), which were 0.902 and 0.988, respectively. The criteria of I-CVI ≥ 0.78, S-CVI/UA ≥ 0.8, and S-CVI/Ave ≥ 0.9 indicate that the questionnaire has good content validity.

A thorough questionnaire with four dimensions was employed in this study (Supplementary file 1). Ten items made comprised the basic information portion, which was intended to gather information about the participants' demographics and occupation. Gender, age, hospital, hospital level, title, educational background, years of nursing and midwifery practice, if they were nurse midwife specialists, and whether they had worked in an outpatient midwifery clinic were all connected to these factors. The questionnaire also included 12 items on practices, 11 items on attitudes, and 18 items measuring knowledge. Dimension of knowledge includes the indications, contraindications, mechanism of action, operation methods, frequency of operation, implementation effects, precautions, etc., of perineal massage in late pregnancy. All items are scored on a 5-point Likert scale, ranging from "very unfamiliar" to "unfamiliar," "uncertain," "familiar," and "very familiar," with scores from 1 to 5. The total score for this dimension ranges from 18 to 90 points. A higher score indicates a higher level of the midwife's mastery of knowledge on perineal massage in late pregnancy. The attitude dimension includes the necessity of implementing perineal massage in late pregnancy, personal interest, views on the process and safety, and the impact of massage implementation on work and career development. A Likert 5-point scale is used, ranging from "strongly disagree," "disagree," "uncertain," "agree," to "strongly agree," with scores from 1 to 5. The total score for this dimension ranges from 11 to 55 points, with a higher score indicating a more positive attitude of midwives towards perineal massage in late pregnancy. The practice dimension includes clinical operational skills, adherence to procedures, observation of patient conditions, recording and reporting abilities, as well as teamwork spirit. All items are scored on a Likert 5-point scale, ranging from "never," "occasionally," "sometimes," "usually," to "always," with scores from 1 to 5. The total score for this dimension ranges from 12 to 60 points, with a higher score indicating a better implementation status of midwives in perineal massage care in late pregnancy. Each questionnaire dimension's scoring rate is equal to (actual score for that dimension/full score) × 100%. Three different score levels were established: good (score > full score × 85%), low (score < full score × 60%), and medium (score in between) [21].

Questionnaire distribution and quality control

Midwives received an online survey using WeChat and the Questionnaire Star platform (https://www.wjx.cn), which creates a QR code. The midwives who took part scanned the QR code to complete the questionnaire. Submissions were restricted to one per IP address and all questionnaire items were required in order to guarantee the completeness and quality of the data. Anonymity was assured to participants while they filled out the survey.

Before the research commences, systematic training is provided to the research team members. This training covers the research conceptual framework, content and methods of questionnaire coverage and collection, key operational procedures, and communication skills. To ensure comprehensive retrieval of questionnaire information, all questions are set as mandatory. Additionally, a mechanism is established in the Questionnaire Star system to ensure submissions are complete. Furthermore, responses are limited to one per WeChat account to maintain data independence. During the distribution phase of the questionnaire, each participating unit designates a liaison officer who has undergone standardized training. This individual is responsible for distributing the questionnaire, providing guidance on completion, and selecting participants. Following established standards, a unified questionnaire access QR code and link are provided to the target population. Clear instructions and guidelines are included, emphasizing the principle of authenticity. Questionnaire data is securely stored by designated personnel, and strict confidentiality measures are in place to prevent unauthorized access by non-project team members. During the data processing and analysis phase, the collected questionnaires undergo meticulous screening to eliminate invalid samples with illogical responses, standardized patterns, or abnormal sequences. Data entry is conducted by two individuals independently, with mutual cross-checking to ensure accuracy. Based on the characteristics of the data, scientific and rigorous analysis is carried out following statistical principles.

Statistical analyses

Continuous variables are expressed as mean and standard deviation. The comparison between two groups is conducted using t-tests, while comparisons among multiple groups are done using ANOVA. Categorical variables are presented as n (%). The correlation between knowledge (K), attitude (A), and practice (P) is examined using Pearson correlation analysis. Multiple factor logistic regression analysis is performed with knowledge, attitude, and practice scores as dependent variables to identify independent risk factors influencing KAP scores. Sufficient knowledge, a positive attitude, and active practice are defined as scores exceeding 70% of the total score for each dimension [22]. Variables with P < 0.05 in the univariate logistic regression analysis are included in the multivariate regression analysis. A two-tailed P < 0.05 is considered statistically significant.

Results

Characteristics of the participants

A total of 466 questionnaires were gathered for this study; 446 valid questionnaires with a recovery rate of 95.71% were ultimately gathered after the invalid or missing questionnaires were eliminated. 319 hospitals spread throughout 54 cities and 17 provinces provided the surveys used in this study. There were 441 females (98.88%) and 5 males (1.12%); 376 (84.30%) were from tertiary hospitals, and 70 (15.70%) from secondary hospitals; the majority of them had the title of supervising nurse (48.65%); the majority had a bachelor's degree (89.46%) as their highest educational level; and 89.01% had more than five years of experience in the delivery room (Table 1).

Table 1 Baseline characteristics and KAP scores

Knowledge

The average knowledge score was 69.28 ± 12.90 (range: 18–90), with a scoring rate of 76.98%, indicating a mid-range proficiency level. There were statistically significant differences in knowledge among certified nurse midwives (P < 0.05) and those who have attended midwifery outpatient clinics (P < 0.001). There were no significant differences in knowledge scores among different age groups (P = 0.097) or professional titles (P = 0.313) (Table 1). The item with the highest score was K1 ("Prior to this survey, did you know or understand what perineal massage is," with 94.1% of midwives indicating understanding), while the item with the lowest score was K7 ("Awareness of the latest research and clinical guidelines on perineal massage," with 58.5% of midwives indicating understanding). The midwife's knowledge of administering perineal massage to pregnant women in late pregnancy is depicted in Fig. 1.

Fig. 1

Midwives’ knowledge of administering perineal massage to pregnant women in late pregnancy

Attitude

Given an average attitude score of 42.20 ± 4.31 (range: 11–55; Score Rate: 76.73%), the attitude was deemed to be at a moderate level. Regarding the use of perineal massage for late-pregnant women, midwives who attended midwifery clinics had diverse opinions that were statistically significant (Table 1). The midwife's attitude towards performing perineal massage on pregnant women in late pregnancy is shown in Fig. 2. These were the ratios of strongly agree to agree: A1: "You think it is very necessary to have a correct understanding of perineal massage in late pregnancy" in 96.6%; A2: "You are interested in knowledge related to perineal massage in late pregnancy" in 97.1%; A3: "You believe that establishing a standardized process for implementing perineal massage in late pregnancy is very important" in 94.6%; A4: "You believe that perineal massage in late pregnancy is an effective method to prevent perineal injury during childbirth" 97.1%; A5: "You are willing to perform perineal massage for late pregnant women" in 95.9%; A6: "You believe you have enough ability to independently perform perineal massage for late pregnant women" at 89.4%; A7: "You think performing perineal massage for late pregnant women will increase your professional sense of achievement" at 92.4 percent; A8: "You believe that performing perineal massage for late pregnant women increases your workload" in the amount of 27.4%; A9: "You think there is insufficient safety assurance in performing perineal massage for late pregnant women" at thirty percent; A10: "You believe the hospital's support for performing perineal massage for late pregnant women is insufficient" in the amount of 53.2%; A11: "You find it difficult to communicate with the pregnant women when performing perineal massage for late pregnant women" with a score of 46.4%.

Fig. 2

Midwives’ attitudes towards performing perineal massage on pregnant women in late pregnancy

Practice

With a possible range of 12 to 60, the overall practice score of 45.25 ± 10.05 (Score Rate: 75.41%), indicates a moderate amount of practice. Midwives who are older, hold higher professional titles, have more nursing or midwifery experience, or have visited midwifery clinics have significantly different practice ratings for applying perineal massage to late-pregnant women (P < 0.05) (Table 1). The outcomes of the midwife's practice of perineal massage on pregnant women in late pregnancy are displayed in Fig. 3. The three items that received the highest scores were P7: "You can use personal protective equipment (like gloves) during perineal massage." P8: "You can observe the status or reactions of pregnant women during perineal massage," and P10: "You can provide pregnant women with post-perineal massage care guidance and instructions." The items with the lowest scores include P1: "You will actively study relevant knowledge on implementing perineal massage in late pregnancy and participate in related training," P2: "You will actively seek and learn about new medical nursing developments related to implementing perineal massage in late pregnancy," and P5: "You can adopt a standardized perineal massage process in actual work."

Fig. 3

Outcomes of midwives’ practice of perineal massage on pregnant women in late pregnancy

Pearson correlation analyses

Knowledge scores were favorably connected with attitude (r = 0.277, P < 0.001) and practice (r = 0.629), according to Pearson correlation analyses scores (P < 0.001). There was a positive correlation between the practice scores and the attitude scores (r = 0.427, P < 0.001).

Multivariable logistic regression analyses

Multivariable logistic regression analysis revealed that attitude (OR = 1.152, 95% CI [1.113–1.193], P < 0.001) and knowledge (odds ratio (OR) = 1.257, 95% CI [1.64–1.357], P < 0.001) were independently related to practice (Table 2).

Table 2 Univariate and multivariate logistic regression analysis

Discussion

The primary objective of this study was to explore midwives' perspectives on performing perineal massage during the latter stages of pregnancy. Utilizing a Knowledge, Attitude, and Practice (KAP) questionnaire, we conducted a comprehensive, three-dimensional investigation among midwives. The findings revealed significant associations between practice scores and both knowledge and attitude scores. Notably, over half of the midwives demonstrated an understanding of how to administer perineal massage to expectant mothers in the later stages of pregnancy. However, a small proportion of midwives still neglect this practice. Several factors contribute to this reluctance. Midwives' lack of knowledge and skills, compounded by traditional customs and misconceptions regarding the potential consequences of interventions, often hinder the implementation of evidence-based practice guidelines [23]. Additionally, increased workload, insufficient safety assurances, lack of hospital support, and difficulties in communicating with pregnant women may further impede the implementation and promotion of perineal massage services. Research has shown that addressing the shortage of midwifery workforce and the limited material resources in delivery rooms can significantly enhance the utilization of guidelines for normal childbirth [23]. As a result, the KAP survey can offer a preliminary understanding of the various facets of midwives' use of perineal massage for expectant mothers in the latter stages of pregnancy. Based on the identified gaps in knowledge and practice, we propose an evidence-based intervention program to enhance midwives' competency in delivering perineal massage to late-term pregnant women. Enhancing midwives' knowledge and optimistic outlook can increase the quality of prenatal care for expectant mothers, lower the chance of perineal injuries, and eventually improve the mother's general health. These programs support a prenatal care system that is more thorough and efficient, giving expectant mothers and their unborn children more health protection.

All three scores were connected in this study, and practice scores were independently correlated with knowledge and attitude scores. According to Cohen, correlation coefficients of approximately 0.10 are considered ‘small,’ those of approximately 0.30 are considered ‘medium,’ and those of approximately 0.50 are considered ‘large’ in terms of effect size magnitude (pp. 77–81) [24]. In this study, there was a significant positive correlation between knowledge scores and attitude scores (r = 0.277, P < 0.001). According to Cohen's effect size guidelines, this correlation coefficient can be interpreted as a small effect size, indicating a certain linear relationship between the two, albeit relatively weak. There was also a significant positive correlation between knowledge scores and practice scores (r = 0.629, P < 0.001). This correlation coefficient can be interpreted as a large effect size, indicating a strong linear relationship between knowledge and practice, such that increases in knowledge scores are closely associated with significant improvements in practice scores. Additionally, a significant positive correlation was found between practice scores and attitude scores (r = 0.427, P < 0.001). This correlation coefficient can be interpreted as a medium effect size, indicating a moderate linear relationship between the two, with improvements in attitude scores significantly associated with increases in practice scores. These results demonstrate that knowledge, attitude, and practice are interrelated to varying degrees, with the strongest impact observed between knowledge and practice. These findings provide important insights for subsequent interventions, suggesting that enhancing knowledge levels may significantly promote improvements in practice behaviors.

However, the findings indicate that midwives' knowledge, attitude, and practice scores are mediocre, and they could still be improved. We discovered statistically significant variations in their ratings on the three KAP dimensions related to whether or not they attended a midwife clinic. This has to do with whether or not midwives had direct clinical experience using perineal massage. A notable difference in KAP scores can be seen because midwives who have attended a midwifery clinic are likely to have a greater understanding and positive endorsement of the knowledge, attitudes, and practice of perineal massage. The findings have practical implications and potential global application, particularly in countries like China, where there may still be gaps in midwifery education and practice. This research highlights the value of hands-on training for midwives in administering perineal massage and offers a helpful resource for further education and training.

According to the KAP concept, knowledge, attitude, and practice are closely related. Better practice is encouraged by a more positive attitude that is frequently brought on by increased knowledge [25]. Furthermore, people who perform well and/or have favorable attitudes are more likely to want to learn more [18]. According to a nationwide survey of midwives by Jones et al. [26], midwives who receive professional education have greater knowledge, which also results in improved cognitive and practical skills. Using multiple logistic regression analysis, we deduce that practice is influenced by knowledge and attitude dimensions. Proactive practice was notably linked to greater knowledge and attitude scores, highlighting the need of addressing attitudes and perceptions in order to promote behaviors related to midwives' perineal massages of expectant mothers. Knowledge is recognized as a critical factor in promoting the implementation of guideline-based interventions. High-quality midwifery education not only significantly reduces maternal and neonatal mortality but also improves a range of health-related outcomes, promotes gender equality, enhances the efficiency of health resource utilization, and supports the achievement of universal health coverage and the Sustainable Development Goals [27]. However, the results of this study revealed that 41.5% of midwives remained unfamiliar with or unclear about the relevant knowledge of perineal massage. This deficiency in knowledge and skills, compounded by the influence of traditional practices and misconceptions about the potential consequences of interventions, may hinder the effective adoption of evidence-based practice guidelines [23]. Studies indicate that experienced midwives demonstrate higher confidence in perineal management [28,29,30], yet the low participation rate of midwives in continuing education or training programs may be a key contributing factor to the insufficient knowledge or skills among some practitioners. Furthermore, the lack of systematic training may reinforce existing behavioral patterns and deepen misunderstandings about interventions that deviate from guidelines [31, 32]. To enhance the clinical application of perineal massage, healthcare institutions and administrators should implement targeted measures to strengthen midwives' professional training in this domain. Specifically, hospital administrators could develop systematic continuing education and training programs, including regular evidence-based medicine workshops covering theoretical knowledge of perineal massage, clinical operational skills, and interpretation of relevant guidelines. Simulation-based teaching techniques could be utilized to help midwives master practical procedures, while case analysis could improve their clinical decision-making abilities. Concurrently, integrating perineal massage into standardized hospital care protocols is recommended to ensure adherence to up-to-date evidence-based guidelines in clinical practice. Quality control and evaluation mechanisms should also be established to monitor the implementation of this technique, thereby further elevating midwives' professional competence and practical proficiency. By improving midwives' awareness and practice of perineal massage through these measures, this study may further reduce perineal injuries during childbirth and lower the incidence of complications such as postpartum hemorrhage, urinary incontinence, and pelvic organ prolapse. Ultimately, this would improve the overall health of pregnant women, enhance their childbirth experience, and improve their quality of life and mental health.

Despite providing preliminary evidence regarding midwives' knowledge and practice of perineal massage in late-pregnancy women, this study has certain limitations that warrant further refinement in future research. First, the relatively small sample size and the recruitment of participants primarily from Guangdong Province, China, may restrict the generalizability of the findings. The results could be influenced by regional variations in healthcare policies, cultural backgrounds, and resource allocation. For instance, differences in cultural support and resource distribution (e.g., training resources, policy advocacy) across various healthcare institutions may exist. Second, the use of convenience sampling in this study may introduce selection bias. Factors such as midwives' educational background (e.g., academic qualifications, specialized training received) and personal experience (e.g., receptiveness to new techniques, prior clinical practice habits) could potentially affect their knowledge and practice of perineal massage. Moreover, the questionnaire design was based on local guidelines and practices, which may limit the universal applicability of the study conclusions. To further explore the current status and influencing factors of midwives' knowledge and practice of perineal massage, future studies may consider incorporating samples from additional provinces and even other countries. By comparing midwives' knowledge and practice of perineal massage across different cultural backgrounds and healthcare policies, such studies can reveal similarities and differences as well as underlying mechanisms. This approach would provide more targeted references for midwifery practice on a global scale. Moreover, longitudinal studies are recommended to track changes in midwives' knowledge and practice of perineal massage over time. This would allow for the assessment of the long-term effectiveness of relevant training and policy dissemination, thereby providing evidence for the continuous optimization of midwifery education and practice strategies. Additionally, qualitative research methods such as interviews or focus groups could be employed to gain in-depth insights into midwives' attitudes towards perineal massage, barriers to implementation, and facilitating factors. This would enhance the comprehensive understanding of the factors influencing midwives' practice behaviors and provide theoretical support for developing more targeted interventions. Lastly, given the potential limitations of current measurement tools in terms of universality and scientific validity, future research is encouraged to develop more universal and scientifically sound instruments. This would improve the external validity and applicability of research findings, laying a solid foundation for cross-cultural and cross-regional comparative studies on midwives' knowledge and practice of perineal massage.

Conclusions

The KAP survey revealed that midwives' knowledge and attitudes toward performing perineal massage in late pregnancy were generally at an intermediate level. The findings suggest that enhancing midwives' expertise and fostering more positive attitudes are essential for optimizing the implementation of perineal massage. To achieve this, it is crucial to develop and implement targeted policies and educational programs that improve midwives' professional awareness, attitudes, and practical approaches toward perineal massage. These initiatives can help midwives integrate perineal massage more effectively into clinical practice, ultimately enhancing maternal health and birthing experiences.