CLINICAL SCHOLARSHIP
Factors Associated With Treatment-Seeking Behavior for Postpartum Urinary Incontinence Regina Ruiz de Vinaspre Hernandez, MSN, CNM1 , Concepcion ˜ ´ ´ Tomas ´ Aznar, MD, PhD2 , 3 & Encarnacion ´ Rubio Aranda, MD, PhD 1 Professor and Doctoral Student, School of Nursing, University of “La Rioja,” La Rioja, Spain 2 Professor, Faculty of Health Sciences, University of Zaragoza, Zaragoza, Spain 3 Professor, Faculty of Medicine, University of Zaragoza, Zaragoza, Spain
Key words Urinary incontinence, postpartum, help-treatment behavior, counseling Correspondence ˜ ´ Regina Ruiz de Vinaspre Hernandez, Donantes de Sangre s/n, Street, School of Nursing, University of La Rioja, Postal code 26004, ˜ La Rioja, Spain. Logrono. E-mail: [email protected] Accepted: May 3, 2014 doi: 10.1111/jnu.12095
Abstract Purpose: To identify the factors associated with treatment-seeking behavior for urinary incontinence (UI) among postpartum women. Design: This is a cross-sectional study. A total of 142 women with postpartum UI responded a telephone interview between August of 2010 and March of 2011. The association between the treatment-seeking and the predicting variables were measured through odds ratio and 95% confidence interval. Results: The treatment-seeking percentage was 37.3% and the treatment percentage was 27.5%. The result of multiple logistic regressions indicated that: counseling about UI in pregnancy, postpartum physical exercise, and Spanish nationality predicted 47.8% of the variance in treatment-seeking behavior Conclusions: The lack of counseling largely determines the low rates of treatment-seeking among Spanish mothers. Clinical Relevance: Nursing counseling during pregnancy can contribute substantially to increasing the number of women treated for postpartum UI.
Urinary incontinence (UI) is a health problem that affects women all over the world. It is estimated that it could affect 24% to 45% of women and that 5% to 15% suffer this problem on a daily basis (Milsom, Altman, Lapitan, Nelson, & Sillen, 2009). The women report that it worsens their quality of life because it provokes fear, frustration, anxiety, and causes difficulties in having a social life, in practicing physical activities or that it worsens their sex life (Burman & Largo-janssen 2013). Despite the impact that UI has on their health, studies conducted in different countries show low consultation, diagnosis and treatment rates (Adedokun, MorhasonBello, Ojengbede, Okonkwo, & Kolade, 2012; Al-Badr, Brasha, Al-Raddadi, Noorwali, & Ross, 2012; Welch, Taubenberger, & Tennstedt, 2011). Childbirth is independently associated with the appearance and persistence of UI in young and middle-aged women. UI prevalence figures in the postpartum are between 15% and 30% (Milsom et al., 2009). Women with UI symptoms beyond the third month of postpartum have
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a high risk of maintaining the problem in the long term (Viktrup, Rortveit, & Lose, 2006). Even though there are therapeutic strategies in postpartum to prevent, reduce or solve urine losses, and a conservative management of UI is more effective and cheaper when the symptoms are light or mild (Aston, 2010), it will take years for some women to be diagnosed and others never will be (Welch et al., 2011). Therefore, the aims of this study were to (a) determine the percentage of women with UI who decide to seek treatment before the 6th month postpartum and (b) analyze the factors associated with treatment-seeking behavior. Studies inform that seeking help is associated with severity and UI impact on women’s quality of life (Howard & Steggall, 2010), and with the existence of barriers such as access to health services (Berger, Patel, Miller, DeLancey, & Fenner, 2011) or their ignorance of the possibility of being treated (Adedokun et al., 2012). On the other hand, health professionals are barely involved in the problem, as it is the women themselves
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who deal with the issue more often than health professionals (Diokno et al., 2004). It is also known that when women seek treatment, they do not always receive treatment (Welch et al., 2010). There is a lack of evidence to state that the same situation of underestimation, underdiagnosis, and undertreatment takes place postpartum. Few studies have analyzed seeking help in postpartum (Marecki & Seo, 2010). Two qualitative studies (Buurman & Lagro-Janssen, 2013; Mason, Glenn, Walton, & Hughes, 2001) conclude that postpartum women lack information about UI, they believe this will disappear spontaneously, and they are not encouraged to seek help. Two quantitative studies found a rate in consultation and postpartum therapy around 11% (Driul et al., 2009; Lepire & Hatem, 2007).
Methods Design This cross-sectional study was a secondary analysis based on a design of a cohort study of women from the beginning of pregnancy up to 6 months postpartum. The aim of the original follow-up study was to determine the prevalence of the UI in pregnancy and postpartum period, the impact on quality of life and the health care provided to women with UI.
Study Participants Eligible women for the study were those with simple pregnancies and with an adequate knowledge of Spanish so that they could understand the questionnaire and do the telephone interview afterwards. Women diagnosed with urinary infection or permanent UI due to neurological or mental impairment were excluded. In Spain, 100% of the mothers have care coverage from the beginning of pregnancy until 6 weeks postpartum. Home birth is unusual. Midwives, together with the gynecologists, carry out prenatal controls, delivery care and postpartum visits. Mothers who were going to deliver in the hospital were personally invited to take part in the study and all of them accepted the invitation, signed a consent form, and provided a telephone number and a postal or e-mail address by which we could contact them until 6 months postpartum. The size of the sample for the original study was estimated to determine UI prevalence during pregnancy and postpartum knowing that 2188 deliveries were performed in that hospital in 2009. Taking into account the wide range of prevalence in this period published in the
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biomedical literature, the sample size was estimated under the assumption of maximum uncertainty (assuming maximum variance), accepting a 4% accuracy and a 95% confidence level. The estimated sample size was 472 women and it increased to 518 in order to make up for a possible loss in the follow-up. We were able to interview 477 women both during pregnancy, between March and August of 2010, and postpartum, between September 2010 and March 2011. Of the 477 women studied in the original study, 142 (29.8%) were diagnosed with urinary incontinence after delivery. These 142 women provided data for the present study.
Instruments Three instruments were used in this study: (a) Urogenital Distress Inventory Questionnaire—short form (UDI6) that measures the UI presence through two items. We considered that women suffered from incontinence if their reply to the items “urine losses associated to a sense of urgency” or “urine losses when doing physical exercise, sneezing or coughing” were affirmative (Uebersax, Wyman, Shumaker, McClish, Fantl, 1995); (b) The Impact Incontinence Questionnaire short form (IIQ-7) that measures the impact on the quality of life on a scale from 0 = no impact to 100 = maximum impact (Uebersax et al., 1995). Validation of the Spanish version in pregnant women of the UDI-6 e IIQ-7 showed adequate internal consistency, reliability, and validity: Cronbach’s α coefficients were 0.667 and 0.910 respectively; intra-class correlation coefficients were 0.902 and 0.954, respectively; and sensitivity for UI diagnosis was 98% ˜ ´ and especificity was 86.5% (Ruiz de Vinaspre Hernandez, ´ Aznar, & Rubio Aranda, 2011); and (c) IncontiTomas nence Severity Index (ISI) that provides a severity value from 0 = no severity to 12 = maximum severity. Validation of the Spanish version of the ISI demonstrated good criterion validity, Spearman’s correlation coefficient for pad-weighing results and severity index was 0.58 (p 2,000 € Multiparity Delivery typea Instrumental delivery Cesarean section Length of breastfeeding (weeks) BMI (kg/cm2 ) Physical exercise, yes Severity of UI Quality-of-life Impact Counseling, yes
Multivariate analysis
OR (95% CI )
p
1.05 (0.98 - 1.12) 7.49 (2.72 - 20.60) 1.13 (0.55 - 2.33) 2.47 (1.20 - 5.13 ) 2.47 (1.12 - 5.44) 4.10 (1.95 - 8.62) 1.35 (0.68 - 2.68)
.12 < .01 .74 .02 .02 < .01 .39
0.58 (0.27 - 1.24)
OR (95% CI)
p
4.92 (1.50 - 16.14)
.02
5.53 (1.36 - 22.46)
.04
8.63 (3.11 - 23.90)
< .01
.16
†
1.01 (0.98 – 1.04) 0.94 (0.87 – 1.01) 13.54 (3.73 – 49.06) 1.00 (0.86 - 1.15) 1.00 (0.98 - 1.02) 16.20 (6.22 – 42.28)
.45 0.10 < .01 .98 .91 < .01
Note. OR = Odds Ratio; CI = confidence interval; BMI = body mass index; UI = urinary incontinence. a Reference category = Spontaneous delivery. † Numbers too few for calculation; OR and their CI with p < .05 are in boldface.
years old. Half the women were primiparous and the other half multiparous and only 6.3% had had a cesarean section. In pregnancy, 52.3% of the women received counseling about UI while 47.7% were not counseled.
How Many Women With UI Postpartum Sought Treatment and How Many Received It? Of the 142 women with UI in the postpartum period 53 (37.3%) sought treatment and 39 (27.5%) received treatment. The 53 women who consulted their problem with a health professional generated a total of 62 consultations. Twenty-six women (41.9%) consulted with a midwife, 14 (22.6%) with a physiotherapist, nine (14.5%) with their general practitioner, nine (14.5%) with their gynecologist, three (4.7%) with the rehabilitation physician, and one (1.6%) with the urologist. Regarding treatment, 39 (73.6%) of the 53 women who had consulted, received treatment. In all the cases therapy included a program of muscular exercises to strengthen the perineum, suggested and supervised by a health professional. Also 19 (35.8%) women used weight vagina cones, 13 (24.5%) electrical stimulation, and 3 (5.7%) bladder retraining. Moreover, 34 women (64.2%) modified their lifestyle: 25 lost weight, 15 followed programs to correct constipation, 12 begun to or changed their physical activity, 8 stopped smoking, 3 modified their fluid intake, and 1 avoided allowing her bladder to become too full. There was no pharmacological or surgical therapy. 394
The women who received therapeutic intervention with a higher frequency were those who consulted for the first time with a physiotherapist (11 of 11) or with the midwife (23 of 25). Those who consulted with the gynecologist or with the general practitioner accessed less therapy (three of eight and two of nine respectively).
What Factors Were Associated With Treatment-Seeking? Table 2 shows that the probability of treatmentseeking behavior was higher in Spanish women, OR = 7.49, p < .01, 95% CI [2.72 - 20.60]; with higher education, OR = 2.47, p = .015, 95% CI [1.20 - 5.13]); with paid employment, OR = 2.47, p = .024, 95% CI [1.12 - 5.44]; with a family income above 2,000 € per month, OR = 4.10, p < .01, 95% CI [1.95 - 8.62]; and whether they did physical exercise, OR = 13.54, p < .01, 95% CI [3.73 - 49.06]. The counseling variable was the one more strongly associated with treatment-seeking behavior. The lower limit of the OR CI informed us that it was at least 6.22 times more likely that women who had been counseled about UI during pregnancy sought treatment postpartum. In the multiple logistic regression model three variables explain 47.8% of the treatmentseeking behavior (R2 = .478). The lower limit of the OR CI reported that, the probability of treatment-seeking was 3.11 times higher in women with counseling, 1.5 times in Journal of Nursing Scholarship, 2014; 46:6, 391–397. C 2014 Sigma Theta Tau International
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Spanish women, and 1.36 if they practiced physical exercise 6 months after delivery (see Table 2).
Discussion This study reveals that less than one third of the women with postpartum UI decide to seek help and receive treatment. Counseling is the variable more strongly associated with the treatment-seeking. The midwife is the most consulted health professional and the most frequently used treatments are the strengthening of pelvic floor muscles and the change of lifestyle. These results suggest that health information about UI in pregnancy can be very effective in increasing UI treatment-seeking and treatment. The proportion of women with treatment-seeking behavior due to UI and treated in this study, 27.6%, is higher than those found in postpartum period in Canadian, 11.1% (Lepire & Hatem, 2007); Hispanic, 20% (Sangi-Haghpeykar, Mozayeni, Young, & Fine, 2008); or Italian women, 11.2% (Driul et al., 2009). A European study (O’Donnell, Lose, Sykes, Voss, & Hunskaar, 2005) including women of all ages found a consultation rate of 31%, whereas Spain obtained the lowest treatmentseeking rate: 24% in all women and 17% in women between 18 and 44 years old. This higher proportion of treatment-seeking behavior in our study, 37.3%, may be due to the fact that the European study only evaluated consultation with the physician, while according to our data, consultation with the midwife and the physiotherapist during the postpartum period are more frequent and with a higher probability of providing therapy than consultation with the physician. Within the population studied, all of the women treated received physiotherapy including at least a supervised program of pelvic floor exercises. Most of these women, 87%, were recommended to pursue a change in their lifestyle, such as stopping smoking, or losing weight. The BMI of women under treatment 6 months after childbirth was lower than that of the women who did not receive treatment, lower BMI being a physical characteristic that reduces the risk for postpartum UI (Wesnes, Hunskaar, Bo, & Rortveit, 2010). Counseling about UI in pregnancy, postpartum physical exercise, and Spanish nationality largely explained the treatment-seeking behavior. The main factor in this study predicting treatment-seeking is counseling. Women who had received counseling in pregnancy had a high probability of consulting and receiving treatment when the problem appeared in the postpartum period. Another study found association between counseling and practice
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of pelvic floor exercises (Sangi-Haghpeykar et al., 2008). It has been observed, as other researchers have mentioned (Huang et al., 2006; Shah et al. 2008), that it is more likely that women with higher education, paid employment, and high income consult with a health professional. Nevertheless, an important contribution of this study is the confirmation that when women have information about UI their cultural and economic levels lose importance as predicting factors of treatment-seeking behavior. Another factor highly related with seeking help is practicing physical exercise 6 months postpartum; UI may discourage women from doing exercise when this exercise provokes the loss (Nygaard et al., 2005). Women who tend to do exercise could feel more motivated to consult and receive treatment, and at the same time, it would reduce the losses and would enable the practice of exercise, which would justify the association between them. There is a greater tendency towards treatment-seeking among Spanish women than among foreign ones, even after adjusting by counseling. It is likely that some women may come from countries where it is not usual to treat this problem with health professionals or there may be other cultural differences. Recent studies report very dissimilar help-seeking rates depending on the countries: 10.8% in Nigerian women (Adedokun et al., 2012), 14.5% in Saudi women (Al-Badr et al., 2012), 15.7% in Pakistani women (Jokhio, Rizvi, Rizvi, & Macarthur, 2013), and around 20% in Brazilian women (Rios, Cardoso, Rodrigues, & De almeida, 2011) and Egyptian women (El-Azab & Shaaban, 2010), while rates over 50% have been found in North American women (Berger et al., 2011). Future research will need to explain these differences. It is remarkable that, among the women of this study, counseling, and not UI severity or its impact on the quality of life, determines treatment-seeking behavior. It is probable that, had the levels of severity of UI postpartum found in this study been higher, we would have been able to make a link between severity and treatment-seeking. However, our data suggest that when women have information about UI, they may be more prone to consult and treat mild symptoms of incontinence, without waiting for them to get worse, which confirms that the lack of knowledge of available treatment is a barrier for helpseeking (Berger et al. 2011; Kang, Phillips, & Lim, 2011).
Strengths and Limitations The women studied were part of a cohort of women whose continence status was followed up throughout
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pregnancy and the postpartum period and whose age, parity, delivery type, and type of health care were not different from the rest of pregnant women in their reference population. Questionnaires UDI-6 and IIQ-7 were used to measure UI symptoms and their impact on quality of life. The Spanish version of these questionnaires was validated with the same population this study was ˜ ´ performed on (Ruiz de Vinaspre Hernandez et al., 2011). The previous contact of the interviewer with the women during pregnancy and sending the questionnaire ahead to be read while the telephone interview was taking place, made the data collection 6 months postpartum easier and avoided information bias. The main limitation of this study, a consequence of following up a cohort representative of the population, has been the small sample size that has caused wide CIs. In order to compensate for this problem, a conservative interpretation of the data has been chosen, referring to the lower limit of the CI. It is likely that a bigger sample would have allowed the variables that have shown a clear tendency in their association with consultation and therapy to reach statistical significance. Moreover, foreign women who did not understand Spanish were excluded from the study, which makes it probable that the lack of consultation and treatment in the reference population are higher than those found in this study. It is necessary to gather more evidence about the barriers women with UI encounter in obtaining health resources, and more evidence needs to be gathered as well about the most effective health interventions to make consultation and treatment postpartum easier.
Implications for the Care of Women in Prenatal and Postnatal Periods Counseling about the importance of being treated and the possibilities of being treated is recommended so that more women, regardless of their economic and cultural level, consult with a health professional, have access to treatment, and are not limited by UI to practice physical exercise. Nurses and midwives must provide counseling for all women, keep an eye on pelvic-perineal rehabilitation after delivery, make sure women get their continence back and research the possible barriers women may find to consultation with the health professionals.
Acknowledgments We gratefully acknowledge the contributions of the midwifery staff (Hospital San Pedro) and women who participated in the study.
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Clinical Resource
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International Continence Society: http://www.ics. org/
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Geller, E.J., Barbee, E.R., Wu, J.M., Loomis, M.J., & Visco, A.J. (2007). Validation of telephone administration of 2 condition-specific quality of life questionnaires. American Journal of Obstetrics and Gynecology, 197, 632.e1-632.e4 Howard, F., & Steggall, M. (2010). Urinary incontinence in women: Quality of life and help-seeking. British Journal of Nursing, 19, 742, 744, 746, 748–749. Huang, A.J., Brown, J.S., Kanaya, A.M., Creasman, J.M., Ragins, A.I., Van Den Eeden, S.K., & Thom D.H. (2006). Quality-of-life impact and treatment of urinary incontinence in ethnically diverse older women. Archives of Internal Medicine, 166, 2000–2006. doi:10.1001/archinte. 166.18.2000 Jokhio, A.H., Rizvi, R.M., Rizvi, J., & Macarthur, C. (2013). Urinary incontinence in women in rural Pakistan: Prevalence, severity, associated factors and impact on life. BJOG: An International Journal of Obstetrics and Gynaecology, 120, 180–186. Doi:10.1111/1471-0528.12074 Kang, Y., Phillips, L.R., & Lim, K. (2011). Predictors of help seeking among Korean American women with urinary incontinence. Journal of Wound, Ostomy, and Continence Nursing, 38, 663–672. doi:10.1097/WON.0b013e31822fc655 Lepire, E., & Hatem, M. (2007). Adaptation and use of health services by primiparous women with urinary incontinence. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 36(3), 222–230. Marecki, M., & Seo, J.Y. (2010). Perinatal urinary and fecal incontinence: Suffering in silence. The Journal of Perinatal & Neonatal Nursing, 24, 330–340. doi:10.1097/JPN.0b013 e3181ec0d9b Mason, L., Glenn, S., Walton, I., & Hughes, C. (2001). Women’s reluctance to seek help for stress incontinence during pregnancy and following childbirth. Midwifery, 17(3), 212–221. doi:10.1054/midw.2001.0259 ´ U. Milsom, I., Altman, D., Lapitan, M.C., Nelson, R., & Sillen, (2009). Epidemilogy of urinary (UI) and faecal (FI) incontinence and pelvic organ prolapse (POP). In P. Abrams, P.L. Cardozo, L.S. Khoury, & A. Wein (Eds.), Incontinence: 4th International Consultation on Incontinence (pp. 35–112). Paris, France: Health Publication Ltd. Retrieved from http://www.ics.org/publications/ici 3/v1.pdf/ chap5.pdf Nygaard, I., Girts, T., Fultz, N.H., Kinchen, K., Pohl, G., & Sternfeld, B. (2005). Is urinary incontinence a barrier to exercise in women? Obstetrics and Gynecology, 106, 307–314. doi:10.1097/01.AOG.0000168455.39156.0f
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O’Donnell, M., Lose, G., Sykes, D., Voss, S., & Hunskaar S. (2005). Help-seeking behaviour and associated factors among women with urinary incontinence in France, Germany, Spain and the United Kingdom. European Urology, 47, 385–392. Retrieved from http://dx.doi.org/10.1016/j.eururo.2004.09.014 Rios, A.A., Cardoso, J.R., Rodrigues, M.A., & De almeida, S.H. (2011). The help-seeking by women with urinary incontinence in Brazil. International Urogynecology Journal, 22, 879–884. doi: 10.1007/s00192-010-1352-5 ˜ ´ ´ Aznar, C., & Rubio Ruiz de Vinaspre Hernandez, R., Tomas Aranda, E. (2011). Validation of the Spanish version of the short forms of the Urogenital Distress Inventory (UDI-6) and the Incontinence Impact Questionnaire (IIQ-7) in pregnant women. Gaceta Sanitaria, 25, 379–384. doi: 10.1016/j.gaceta.2011.05.010 Sandvik, H., Espuna, M., & Hunskaar, S. (2006). Validity of the incontinence severity index: Comparison with pad-weighing tests. International Urogynecology Journal, 17, 520–524. doi: 10.1007/s00192-005-0060-z Sangi-Haghpeykar, H., Mozayeni, P., Young, A., & Fine, P.M. (2008). Stress urinary incontinence and counseling and practice of pelvic floor exercises postpartum in low-income Hispanic women. International Urogynecology Journal, 19, 361–365. doi: 10.1007/s00192-007-0438-1 Shah, A.D., Shot, T.S., Kohli, N., Wu, J.M., Catlin, S., & Hoyte, L. (2008). Do racial differences in knowledge about urogynecologic issues exist? International Urogynecology Journal, 19, 1371–1378. doi:10.1007/s00192-008-0639-2 Uebersax, J.S., Wyman, J.F., Shumaker, S.A., McClish, D.K., & Fantl, J.A. (1995). Short forms to assess life quality and symptom distress for urinary incontinence in women: The incontinence impact questionnaire and the urogenital distress inventory. Continence program for women research group. Neurourology and Urodynamics, 14(2), 131–139. doi: 10.1002/nau.1930140206 Viktrup, L., Rortveit, G., & Lose, G. (2006). Risk of stress urinary incontinence twelve years after the first pregnancy and delivery. Obstetrics and Gynecology, 108, 248–254. Welch, L.C., Taubenberger, S., & Tennstedt, S.L. (2011). Patients´ experiences for seeking health care for lower urinary tract symptoms. Research in Nursing & Health, 34, 496–507. doi:10.1002/nur.20457 Wesnes, S.L., Hunskaar, S., Bo, K., & Rortveit, G. (2010). Urinary incontinence and weight change during pregnancy and postpartum: A cohort study. American Journal of Epidemiology, 172, 1034–1044. doi:10.1093/aje/kwq240
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Factors Associated With Treatment-Seeking Behavior for Postpartum Urinary Incontinence Regina Ruiz de Vinaspre Hernandez, MSN, CNM1 , Concepcion ˜ ´ ´ Tomas ´ Aznar, MD, PhD2 , 3 & Encarnacion ´ Rubio Aranda, MD, PhD 1 Professor and Doctoral Student, School of Nursing, University of “La Rioja,” La Rioja, Spain 2 Professor, Faculty of Health Sciences, University of Zaragoza, Zaragoza, Spain 3 Professor, Faculty of Medicine, University of Zaragoza, Zaragoza, Spain
Key words Urinary incontinence, postpartum, help-treatment behavior, counseling Correspondence ˜ ´ Regina Ruiz de Vinaspre Hernandez, Donantes de Sangre s/n, Street, School of Nursing, University of La Rioja, Postal code 26004, ˜ La Rioja, Spain. Logrono. E-mail: [email protected] Accepted: May 3, 2014 doi: 10.1111/jnu.12095
Abstract Purpose: To identify the factors associated with treatment-seeking behavior for urinary incontinence (UI) among postpartum women. Design: This is a cross-sectional study. A total of 142 women with postpartum UI responded a telephone interview between August of 2010 and March of 2011. The association between the treatment-seeking and the predicting variables were measured through odds ratio and 95% confidence interval. Results: The treatment-seeking percentage was 37.3% and the treatment percentage was 27.5%. The result of multiple logistic regressions indicated that: counseling about UI in pregnancy, postpartum physical exercise, and Spanish nationality predicted 47.8% of the variance in treatment-seeking behavior Conclusions: The lack of counseling largely determines the low rates of treatment-seeking among Spanish mothers. Clinical Relevance: Nursing counseling during pregnancy can contribute substantially to increasing the number of women treated for postpartum UI.
Urinary incontinence (UI) is a health problem that affects women all over the world. It is estimated that it could affect 24% to 45% of women and that 5% to 15% suffer this problem on a daily basis (Milsom, Altman, Lapitan, Nelson, & Sillen, 2009). The women report that it worsens their quality of life because it provokes fear, frustration, anxiety, and causes difficulties in having a social life, in practicing physical activities or that it worsens their sex life (Burman & Largo-janssen 2013). Despite the impact that UI has on their health, studies conducted in different countries show low consultation, diagnosis and treatment rates (Adedokun, MorhasonBello, Ojengbede, Okonkwo, & Kolade, 2012; Al-Badr, Brasha, Al-Raddadi, Noorwali, & Ross, 2012; Welch, Taubenberger, & Tennstedt, 2011). Childbirth is independently associated with the appearance and persistence of UI in young and middle-aged women. UI prevalence figures in the postpartum are between 15% and 30% (Milsom et al., 2009). Women with UI symptoms beyond the third month of postpartum have
Journal of Nursing Scholarship, 2014; 46:6, 391–397. C 2014 Sigma Theta Tau International
a high risk of maintaining the problem in the long term (Viktrup, Rortveit, & Lose, 2006). Even though there are therapeutic strategies in postpartum to prevent, reduce or solve urine losses, and a conservative management of UI is more effective and cheaper when the symptoms are light or mild (Aston, 2010), it will take years for some women to be diagnosed and others never will be (Welch et al., 2011). Therefore, the aims of this study were to (a) determine the percentage of women with UI who decide to seek treatment before the 6th month postpartum and (b) analyze the factors associated with treatment-seeking behavior. Studies inform that seeking help is associated with severity and UI impact on women’s quality of life (Howard & Steggall, 2010), and with the existence of barriers such as access to health services (Berger, Patel, Miller, DeLancey, & Fenner, 2011) or their ignorance of the possibility of being treated (Adedokun et al., 2012). On the other hand, health professionals are barely involved in the problem, as it is the women themselves
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who deal with the issue more often than health professionals (Diokno et al., 2004). It is also known that when women seek treatment, they do not always receive treatment (Welch et al., 2010). There is a lack of evidence to state that the same situation of underestimation, underdiagnosis, and undertreatment takes place postpartum. Few studies have analyzed seeking help in postpartum (Marecki & Seo, 2010). Two qualitative studies (Buurman & Lagro-Janssen, 2013; Mason, Glenn, Walton, & Hughes, 2001) conclude that postpartum women lack information about UI, they believe this will disappear spontaneously, and they are not encouraged to seek help. Two quantitative studies found a rate in consultation and postpartum therapy around 11% (Driul et al., 2009; Lepire & Hatem, 2007).
Methods Design This cross-sectional study was a secondary analysis based on a design of a cohort study of women from the beginning of pregnancy up to 6 months postpartum. The aim of the original follow-up study was to determine the prevalence of the UI in pregnancy and postpartum period, the impact on quality of life and the health care provided to women with UI.
Study Participants Eligible women for the study were those with simple pregnancies and with an adequate knowledge of Spanish so that they could understand the questionnaire and do the telephone interview afterwards. Women diagnosed with urinary infection or permanent UI due to neurological or mental impairment were excluded. In Spain, 100% of the mothers have care coverage from the beginning of pregnancy until 6 weeks postpartum. Home birth is unusual. Midwives, together with the gynecologists, carry out prenatal controls, delivery care and postpartum visits. Mothers who were going to deliver in the hospital were personally invited to take part in the study and all of them accepted the invitation, signed a consent form, and provided a telephone number and a postal or e-mail address by which we could contact them until 6 months postpartum. The size of the sample for the original study was estimated to determine UI prevalence during pregnancy and postpartum knowing that 2188 deliveries were performed in that hospital in 2009. Taking into account the wide range of prevalence in this period published in the
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biomedical literature, the sample size was estimated under the assumption of maximum uncertainty (assuming maximum variance), accepting a 4% accuracy and a 95% confidence level. The estimated sample size was 472 women and it increased to 518 in order to make up for a possible loss in the follow-up. We were able to interview 477 women both during pregnancy, between March and August of 2010, and postpartum, between September 2010 and March 2011. Of the 477 women studied in the original study, 142 (29.8%) were diagnosed with urinary incontinence after delivery. These 142 women provided data for the present study.
Instruments Three instruments were used in this study: (a) Urogenital Distress Inventory Questionnaire—short form (UDI6) that measures the UI presence through two items. We considered that women suffered from incontinence if their reply to the items “urine losses associated to a sense of urgency” or “urine losses when doing physical exercise, sneezing or coughing” were affirmative (Uebersax, Wyman, Shumaker, McClish, Fantl, 1995); (b) The Impact Incontinence Questionnaire short form (IIQ-7) that measures the impact on the quality of life on a scale from 0 = no impact to 100 = maximum impact (Uebersax et al., 1995). Validation of the Spanish version in pregnant women of the UDI-6 e IIQ-7 showed adequate internal consistency, reliability, and validity: Cronbach’s α coefficients were 0.667 and 0.910 respectively; intra-class correlation coefficients were 0.902 and 0.954, respectively; and sensitivity for UI diagnosis was 98% ˜ ´ and especificity was 86.5% (Ruiz de Vinaspre Hernandez, ´ Aznar, & Rubio Aranda, 2011); and (c) IncontiTomas nence Severity Index (ISI) that provides a severity value from 0 = no severity to 12 = maximum severity. Validation of the Spanish version of the ISI demonstrated good criterion validity, Spearman’s correlation coefficient for pad-weighing results and severity index was 0.58 (p 2,000 € Multiparity Delivery typea Instrumental delivery Cesarean section Length of breastfeeding (weeks) BMI (kg/cm2 ) Physical exercise, yes Severity of UI Quality-of-life Impact Counseling, yes
Multivariate analysis
OR (95% CI )
p
1.05 (0.98 - 1.12) 7.49 (2.72 - 20.60) 1.13 (0.55 - 2.33) 2.47 (1.20 - 5.13 ) 2.47 (1.12 - 5.44) 4.10 (1.95 - 8.62) 1.35 (0.68 - 2.68)
.12 < .01 .74 .02 .02 < .01 .39
0.58 (0.27 - 1.24)
OR (95% CI)
p
4.92 (1.50 - 16.14)
.02
5.53 (1.36 - 22.46)
.04
8.63 (3.11 - 23.90)
< .01
.16
†
1.01 (0.98 – 1.04) 0.94 (0.87 – 1.01) 13.54 (3.73 – 49.06) 1.00 (0.86 - 1.15) 1.00 (0.98 - 1.02) 16.20 (6.22 – 42.28)
.45 0.10 < .01 .98 .91 < .01
Note. OR = Odds Ratio; CI = confidence interval; BMI = body mass index; UI = urinary incontinence. a Reference category = Spontaneous delivery. † Numbers too few for calculation; OR and their CI with p < .05 are in boldface.
years old. Half the women were primiparous and the other half multiparous and only 6.3% had had a cesarean section. In pregnancy, 52.3% of the women received counseling about UI while 47.7% were not counseled.
How Many Women With UI Postpartum Sought Treatment and How Many Received It? Of the 142 women with UI in the postpartum period 53 (37.3%) sought treatment and 39 (27.5%) received treatment. The 53 women who consulted their problem with a health professional generated a total of 62 consultations. Twenty-six women (41.9%) consulted with a midwife, 14 (22.6%) with a physiotherapist, nine (14.5%) with their general practitioner, nine (14.5%) with their gynecologist, three (4.7%) with the rehabilitation physician, and one (1.6%) with the urologist. Regarding treatment, 39 (73.6%) of the 53 women who had consulted, received treatment. In all the cases therapy included a program of muscular exercises to strengthen the perineum, suggested and supervised by a health professional. Also 19 (35.8%) women used weight vagina cones, 13 (24.5%) electrical stimulation, and 3 (5.7%) bladder retraining. Moreover, 34 women (64.2%) modified their lifestyle: 25 lost weight, 15 followed programs to correct constipation, 12 begun to or changed their physical activity, 8 stopped smoking, 3 modified their fluid intake, and 1 avoided allowing her bladder to become too full. There was no pharmacological or surgical therapy. 394
The women who received therapeutic intervention with a higher frequency were those who consulted for the first time with a physiotherapist (11 of 11) or with the midwife (23 of 25). Those who consulted with the gynecologist or with the general practitioner accessed less therapy (three of eight and two of nine respectively).
What Factors Were Associated With Treatment-Seeking? Table 2 shows that the probability of treatmentseeking behavior was higher in Spanish women, OR = 7.49, p < .01, 95% CI [2.72 - 20.60]; with higher education, OR = 2.47, p = .015, 95% CI [1.20 - 5.13]); with paid employment, OR = 2.47, p = .024, 95% CI [1.12 - 5.44]; with a family income above 2,000 € per month, OR = 4.10, p < .01, 95% CI [1.95 - 8.62]; and whether they did physical exercise, OR = 13.54, p < .01, 95% CI [3.73 - 49.06]. The counseling variable was the one more strongly associated with treatment-seeking behavior. The lower limit of the OR CI informed us that it was at least 6.22 times more likely that women who had been counseled about UI during pregnancy sought treatment postpartum. In the multiple logistic regression model three variables explain 47.8% of the treatmentseeking behavior (R2 = .478). The lower limit of the OR CI reported that, the probability of treatment-seeking was 3.11 times higher in women with counseling, 1.5 times in Journal of Nursing Scholarship, 2014; 46:6, 391–397. C 2014 Sigma Theta Tau International
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Spanish women, and 1.36 if they practiced physical exercise 6 months after delivery (see Table 2).
Discussion This study reveals that less than one third of the women with postpartum UI decide to seek help and receive treatment. Counseling is the variable more strongly associated with the treatment-seeking. The midwife is the most consulted health professional and the most frequently used treatments are the strengthening of pelvic floor muscles and the change of lifestyle. These results suggest that health information about UI in pregnancy can be very effective in increasing UI treatment-seeking and treatment. The proportion of women with treatment-seeking behavior due to UI and treated in this study, 27.6%, is higher than those found in postpartum period in Canadian, 11.1% (Lepire & Hatem, 2007); Hispanic, 20% (Sangi-Haghpeykar, Mozayeni, Young, & Fine, 2008); or Italian women, 11.2% (Driul et al., 2009). A European study (O’Donnell, Lose, Sykes, Voss, & Hunskaar, 2005) including women of all ages found a consultation rate of 31%, whereas Spain obtained the lowest treatmentseeking rate: 24% in all women and 17% in women between 18 and 44 years old. This higher proportion of treatment-seeking behavior in our study, 37.3%, may be due to the fact that the European study only evaluated consultation with the physician, while according to our data, consultation with the midwife and the physiotherapist during the postpartum period are more frequent and with a higher probability of providing therapy than consultation with the physician. Within the population studied, all of the women treated received physiotherapy including at least a supervised program of pelvic floor exercises. Most of these women, 87%, were recommended to pursue a change in their lifestyle, such as stopping smoking, or losing weight. The BMI of women under treatment 6 months after childbirth was lower than that of the women who did not receive treatment, lower BMI being a physical characteristic that reduces the risk for postpartum UI (Wesnes, Hunskaar, Bo, & Rortveit, 2010). Counseling about UI in pregnancy, postpartum physical exercise, and Spanish nationality largely explained the treatment-seeking behavior. The main factor in this study predicting treatment-seeking is counseling. Women who had received counseling in pregnancy had a high probability of consulting and receiving treatment when the problem appeared in the postpartum period. Another study found association between counseling and practice
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of pelvic floor exercises (Sangi-Haghpeykar et al., 2008). It has been observed, as other researchers have mentioned (Huang et al., 2006; Shah et al. 2008), that it is more likely that women with higher education, paid employment, and high income consult with a health professional. Nevertheless, an important contribution of this study is the confirmation that when women have information about UI their cultural and economic levels lose importance as predicting factors of treatment-seeking behavior. Another factor highly related with seeking help is practicing physical exercise 6 months postpartum; UI may discourage women from doing exercise when this exercise provokes the loss (Nygaard et al., 2005). Women who tend to do exercise could feel more motivated to consult and receive treatment, and at the same time, it would reduce the losses and would enable the practice of exercise, which would justify the association between them. There is a greater tendency towards treatment-seeking among Spanish women than among foreign ones, even after adjusting by counseling. It is likely that some women may come from countries where it is not usual to treat this problem with health professionals or there may be other cultural differences. Recent studies report very dissimilar help-seeking rates depending on the countries: 10.8% in Nigerian women (Adedokun et al., 2012), 14.5% in Saudi women (Al-Badr et al., 2012), 15.7% in Pakistani women (Jokhio, Rizvi, Rizvi, & Macarthur, 2013), and around 20% in Brazilian women (Rios, Cardoso, Rodrigues, & De almeida, 2011) and Egyptian women (El-Azab & Shaaban, 2010), while rates over 50% have been found in North American women (Berger et al., 2011). Future research will need to explain these differences. It is remarkable that, among the women of this study, counseling, and not UI severity or its impact on the quality of life, determines treatment-seeking behavior. It is probable that, had the levels of severity of UI postpartum found in this study been higher, we would have been able to make a link between severity and treatment-seeking. However, our data suggest that when women have information about UI, they may be more prone to consult and treat mild symptoms of incontinence, without waiting for them to get worse, which confirms that the lack of knowledge of available treatment is a barrier for helpseeking (Berger et al. 2011; Kang, Phillips, & Lim, 2011).
Strengths and Limitations The women studied were part of a cohort of women whose continence status was followed up throughout
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pregnancy and the postpartum period and whose age, parity, delivery type, and type of health care were not different from the rest of pregnant women in their reference population. Questionnaires UDI-6 and IIQ-7 were used to measure UI symptoms and their impact on quality of life. The Spanish version of these questionnaires was validated with the same population this study was ˜ ´ performed on (Ruiz de Vinaspre Hernandez et al., 2011). The previous contact of the interviewer with the women during pregnancy and sending the questionnaire ahead to be read while the telephone interview was taking place, made the data collection 6 months postpartum easier and avoided information bias. The main limitation of this study, a consequence of following up a cohort representative of the population, has been the small sample size that has caused wide CIs. In order to compensate for this problem, a conservative interpretation of the data has been chosen, referring to the lower limit of the CI. It is likely that a bigger sample would have allowed the variables that have shown a clear tendency in their association with consultation and therapy to reach statistical significance. Moreover, foreign women who did not understand Spanish were excluded from the study, which makes it probable that the lack of consultation and treatment in the reference population are higher than those found in this study. It is necessary to gather more evidence about the barriers women with UI encounter in obtaining health resources, and more evidence needs to be gathered as well about the most effective health interventions to make consultation and treatment postpartum easier.
Implications for the Care of Women in Prenatal and Postnatal Periods Counseling about the importance of being treated and the possibilities of being treated is recommended so that more women, regardless of their economic and cultural level, consult with a health professional, have access to treatment, and are not limited by UI to practice physical exercise. Nurses and midwives must provide counseling for all women, keep an eye on pelvic-perineal rehabilitation after delivery, make sure women get their continence back and research the possible barriers women may find to consultation with the health professionals.
Acknowledgments We gratefully acknowledge the contributions of the midwifery staff (Hospital San Pedro) and women who participated in the study.
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Clinical Resource
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International Continence Society: http://www.ics. org/
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