‘Women’s troubles’: Study shines a light on hidden problems

When you’re pregnant with your first baby it’s easy to find articles about swollen ankles, morning sickness and breastfeeding. Your friends and family are happy to offer advice about how to get your baby to sleep through the night, and how to soothe teething pain. And your antenatal class will largely prepare you for what to expect when you go into labour. However, there is a dearth of information about the more embarrassing and painful health problems that are common to pregnant women and new mothers, and about what can be done to help them.

Common, often hidden, health issues after childbirth include pain, urinary and bowel problems, changes affecting sexual health and emotional health, and difficulties in intimate partner relationships. Women frequently just accept these health issues and do not talk about them or seek medical help; but they can be treated successfully.

A major Irish longitudinal research project, the Maternal Health and Maternal Morbidity in Ireland (Mammi) study, is looking at the health and health problems of women during pregnancy and during the first year after the birth of their first baby.

The study is being conducted because of the lack of information about the health of women in Ireland after giving birth, which prevents healthcare professionals from understanding what causes some of these problems and how prevalent they are. The researchers hope the findings will lead to an improvement in the relevant services and information available to women.

Different aspects of physical and mental health are being examined and will form strands of the project: pelvic-girdle pain; mental health issues including anxiety, stress and depression; sexual health; domestic violence; Caesarean sections; and diet and activity during pregnancy.

A total of 2,600 first-time mothers in early pregnancy, from three maternity hospitals (the Rotunda and the Coombe Women and Infants University Hospital, both in Dublin, and University Hospital Galway) are being recruited for the Mammi study. This represents almost 10 per cent of all first-time mothers giving birth in Ireland in a given year. About 28,000 first-time mothers gave birth in 2012.

The study commenced in January 2012 and 2,000 women have been recruited to date, with the final recruitment phase now ongoing in the Coombe. Participants are asked to complete surveys anonymously during pregnancy and at three, six, nine and 12 months post-birth about their health and health problems before, during and after pregnancy.

This allows the researchers study a range of factors, physical and emotional, that might affect these women's health, and can see if health problems resolve, persist or worsen over time, says Prof Cecily Begley, chair of nursing and midwifery at the school of nursing and midwifery in Trinity College Dublin, who is the principal investigator on Mammi.

The researchers are indebted to the women who are participating in the study and say it wouldn’t be possible without the women’s commitment to disclosing their experiences and information.

One of the early findings of the study is a high level of sexual health issues among pregnant women and new mothers. Just over one in five surveyed women reported not having resumed sexual intercourse at three months post-birth, dropping to 7 per cent at six months, Begley tells The Irish Times. This is "startling and worrying".

A lot of women also reported pain during intercourse, a significant proportion (21 per cent) before becoming pregnant as well as post birth (33 per cent): while pregnancy seemed to ease the pain of intercourse for some women, she says.

“In relation to depression, we’ve found a rate of about 12 per cent so far, in early analysis, which while in line with other Irish studies is persisting at six months [post partum], which is not good,” Begley says.

Invisible health needs

Maternity care and information gathering in Ireland is focused on pregnancy and birth. Women have a final check-up six weeks after the birth, usually with their GP, when it is assumed that her body has returned to normal and the main focus is on the baby’s health and wellbeing, Begley says.

There are other studies ongoing in other parts of the country, but this is the first maternal health study in Ireland of this type, scope and scale.

“We didn’t know women had these unmet health needs, nor did we know the prevalence of certain issues. GPs do ask women how they are at their six-week check up.

“But if they aren’t asked specific questions – such as whether they are they leaking urine or faeces, or whether they are having problems or pain during sex, and so on – then nobody is going to say something is wrong and these problems remain undetected. Women need to be asked very focused questions, like the ones in our surveys,” Begley says.

Urinary incontinence

The most currently advanced part of the Mammi study is the urinary incontinence (UI) strand, which means leaking urine – regardless of the amount – when you don’t mean to.

The analysed data from the first 860 women recruited into the study has been surprising in terms of the levels of UI before and during pregnancy, and post-natally, says Dr Deirdre Daly, associate professor at the school of nursing and midwifery in Trinity College Dublin, who is leading the UI strand of the study.

One in three women reported leaking urine occasionally before becoming pregnant, which is “very surprising and concerning”, says Dr Daly.

Urine leakage increased during pregnancy, the study found, while three months after the birth, one in two women leaked some urine and even six months after the birth, one in five women still leak urine once a month or more frequently. Women with raised odds of leaking urine were those with a high BMI, those who experienced bedwetting as a child, and those more than 35 years of age.

“Leaking urine is not normal, even in pregnancy, and can be treated both before, during and after pregnancy and that is primarily through pelvic floor exercises,” Dr Daly explains.

The surveys asked women if they talked to anyone about leaking urine during pregnancy – and, if not, why not. “A lot of women said they don’t talk about it, which was surprising. Up to 80 per cent of women hadn’t told a health professional they were leaking urine,” says Begley.

“Some of that was embarrassment but it was also that they thought it was normal, that their mothers had experienced it and it was part of pregnancy. Those are old wives’ tales. It is common, yes, but people confuse common with normal. It is not normal and it can be treated.”

Routine antenatal care offers several opportunities for promoting optimal bladder and bowel control in all women but particularly in those with identifiable risk factors.

The Coombe runs a regular bladder information class to help prevent and treat urine leakage. “We then invite these women back to do a one-to-one appointment six weeks later to check how they are getting on. Women should never be embarrassed to talk about theses issues as there is so much we can do to help,” Clare Daly, a senior chartered physiotherapist at the Coombe who specialises in women’s health and continence.

Daly and the physiotherapy team at the hospital also run antenatal and post-natal physiotherapy classes covering back pain and pelvic floor exercises, among other issues, and they provide one-to-one physiotherapy sessions. Back pain and pelvic girdle pain are very common during pregnancy.

Disconnect

One significant issue that has been highlighted by the study and raised by GPs is the disconnect between maternity services and community-based healthcare such as public health nurses and GPs. Women who experience health problems, post birth, usually present to these health professionals and their issues are not reported back to the maternity hospital.

For example, GPs have expressed concern about commonly seeing new mothers presenting with severe constipation, stomach pain and piles, or even anal fissures in severe cases, caused by taking iron tablets post labour.

New mothers are often prescribed iron tablets due to blood loss during labour but maternity hospitals do not warn them adequately about the potential side effects and the need to consume plenty of fibre, orange juice and prunes, one GP told The Irish Times.

Separately, Dr Marie Scully, a GP based in Navan, says it would be helpful if all maternity hospitals shared medical charts with the patient’s GP, who is likely providing combined care during the pregnancy, as happens in Drogheda.

“That is much better as you can make notes in the chart about their visits to you and see their data.”

Currently there are a number of local and national reviews of Irish maternity services, with a promised new HSE maternity strategy on the way.

“Irish maternity services are funded appallingly. I do think if men were having babies that more attention would be paid to it. But because it’s women and because women themselves are only interested in maternity services for a limited time while they have babies, there is no political pressure on the Government to do anything about maternity services and I do think that is why they remain woefully underfunded,” Begley concludes.

The Mammi study has been funded by the Health Research Board (HRB) to date, and more research funding will be applied for to continue to follow up with the women at different points in the future.

For more information on the Mammi study and to watch practical videos on pelvic floor exercises and UI see mammi.ie