Prevalence of Postpartum Urinary Incontinence after Vaginal Delivery in Women Visiting a Tertiary Care Health Facility.

Postpartum bounds women to new defined states: mentally, socially, and physically. New urinary problems arise potentially during these postpartum changes, often urinary infection or incontinence. The International Continence Society defines urinary incontinence (UI) as a complaint of involuntary urine loss and is considered to be symptomatic 1. UI issues may resolve on their own some time after birth or may be improved with pelvic floor exercises, but UI is prevalent, affecting many postpartum women. Reports of UI postpartum varies widely, with a prevalence of 10.5% to 63% occurring anywhere between six weeks to a year postpartum.

Because postpartum UI is such a widespread concern of women's health issues, and is under-recognized, it is considered a public health issue. This is especially true for developing countries that may have limited postpartum care routines. Research shows that women delivering vaginally are more at risk for developing UI issues compared to those delivering via C-section. It is most likely due to the nerve and muscle damage on the pelvic floor and the related stress that occurs 2.

Some of the main contributors to postpartum urinary incontinence can include changes to hormones, connective tissues, and pelvic floor muscles, as well as urinary retention. Research has shown that older mothers, along with mothers with a higher BMI or those with higher childbirth parities, are at greater risk 3. From a biological standpoint, this is a result of shifted and damaged pelvic tissues that may result in less control over the pelvic support structures, leading to sustained elevated position of the urethra. This can lead to less control of urinary retention mechanisms and urinary leakage 4.

Beyond the physical symptoms, urinary incontinence is known to increase fatigue, sexual dysfunction, decrease social participation, and increase psychological distress, thus adversely impacting quality of life.5 Many women remain undiagnosed and have to wait long for treatment since they do not seek medical care for this condition, despite its clinical importance. Studies conducted on the same subject have shown an array of prevalence and distribution of subtypes, where typically, stress urinary incontinence was recognized as the main type. The prevalence of the condition in regional studies is between 28 to 32%, which is in line with the global prevalence studies where the estimates range from 26 to 33%. 6

Although there is evidence from different parts of the world, evidence from specialized health facilities in Pakistan is still scarce. Due to specific practices of obstetrics, differences in the ways people in the community understand health and differences in the ways people access health services may affect what proportions are reported and how common the conditions are, which is why this research is needed. The aim of this research was to establish the prevalence of urinary incontinence in the postpartum period among women who have had a vaginal delivery, at a tertiary health care facility.

85  postpartum women met the eligibility criteria and were included in the final analysis. After data cleaning, no incomplete datasets were identified.

Table 1 shows the sociodemographic and obstetric characteristics of the study participants. Age ranged from 22 to 50 years, with the average age 30.8 ± 5.4 years. The most common age group was 26 to 30 years (28.2%). About 62.4% of study participants were multiparous, and the rest (37.6%) were primiparous. Regarding postpartum duration, 4- to 6-month postpartum women comprised the largest group (43.5%), followed by those in the 2- to 4-month range (31.8%), and 6 weeks to 2 months range (24.7%) (Table 1).

The mean (SD) values of age, postpartum duration, height, weight, and body mass index (BMI) as continuous variable descriptive statistics are presented in Table 2. The mean BMI of study participants was 27.3 ± 4.1 kg/m².

Table 3 shows the prevalence of postpartum urinary incontinence in the study participants. Postpartum urinary incontinence in the study group was observed in 24 participants, with a prevalence of 28.2%, while 71.8% of study participants did not have urinary leakage. Of the participants who reported urinary incontinence, 58.3% had stress urinary incontinence, whereas the remaining subtypes (urge urinary incontinence and mixed urinary incontinence) each comprised 20.8% of the overall urinary incontinence cases.

Table 4 shows the relationship between certain risk factors and urinary incontinence. Of the statistical analyses that were performed, urinary incontinence was significantly associated with age group (p = 0.041), body mass index category (p = 0.018), and parity (p = 0.032). Urinary incontinence and postpartum duration remained statistically insignificant (p = 0.110).

Table 1: Sociodemographic and Obstetric Characteristics of Study Participants (n = 85)

Table 2: Descriptive Statistics of Continuous Variables (n = 85)

Table 3: Prevalence of Postpartum Urinary Incontinence (n = 85)

Table 4: Association of Risk Factors with Urinary Incontinence

This study was designed to assess the prevalence of and the factors associated with urinary incontinence in the postpartum period and to demonstrate the prevalence of urinary incontinence in the early postpartum period. A urinary incontinence prevalence of 28.2% was noted in this study, which has been reported to range from 25% to 35% in regional and international studies, based on the timing of the assessments and the methods used. The reported prevalence of urinary incontinence in the postpartum period in regional studies supports the validity of the present study, substantiating that urinary incontinence in the postpartum period is a significant and largely unaddressed concern in maternal health7.

The study participants had a mean age of 30.8 ± 5.4 years, with most of the women being in the age group of 26 to 35 years. Similar age groups were reported in previous studies relating to postpartum pelvic floor issues, and these studies were used to support the importance of early identification of pelvic floor dysfunction8. There were mostly multiparous women in the study, which was consistent with current regional practices and supported previous studies relating to the cumulative effect of vaginal deliveries on pelvic floor integrity9.

Anthropometric analysis found a mean overweight BMI and reported a strong correlation with BMI and urinary incontinence. The current analysis showed the effect of body weight on urinary incontinence has been documented in earlier works, demonstrating that body weight and urinary incontinence are related, where overweight and obese individuals have more urinary incontinence due to the stress from elevated intra abdominal pressure on the pelvic floor10. The effect of increasing maternal age also correlated with urinary incontinence. This also supports other cohort studies, stating that reduced tissue elasticity and decreased muscular strength with maternal aging have an effect on the recovery from birth and may hinder recovery from childbirth in older mothers.

The primary function of the pelvic floor is support and stress urinary incontinence was the primary diagnosis, and was present in 58.3%11. This is in concordance with other studies and suggests that the mechanism for the injury is more likely related to the stress of child bearing than child birth. Multiple childbirths produced a statistically significant effect on the pelvic floor and showed that child bearing has a cumulative effect on the pelvic floor. However, the length of time from childbirth to the time of the study did not statistically affect the pelvic floor. This is in concordance with other similar studies which showed the timing of the study was less important than the other risk factors12.

Although the following study/reflection has limitations, a lot of studies focus on other areas and do not take into account urinary incontinence post childbirth. Because this is a cross sectional study, it is limited in the inference it presents. Non-probability convenience sampling has limited applicability. However, there have not been a lot of studies that focus on the urinary incontinence of child birth, and the results are concordant with existing studies. The study is unique in that it focuses on an area that has not been well researched in the context of a tertiary healthcare system13.

The data collected in this study shows that one in three women will suffer from urinary incontinence, especially stress urinary incontinence (SUI), within the early postpartum phase after a vaginal delivery. Birth is linked with urinary incontinence due to stress caused to the pelvic branch and urinary system during labor. Like the other studies, this study shows that older age of the mother, higher postpartum BMI, and higher order deliveries lead to higher levels of urinary incontinence and are important predictors when assessing the pelvic branch and other urinary system incontinence in the early postpartum phase. If a woman gives birth and has had no other postpartum symptoms of incontinence after six months, it doesn’t mean their urinary incontinence symptoms will go away, as the presence of urinary incontinence symptoms is linked to other maternal and obstetric factors. This study helps understand and fills the existing epidemiology and data in this area by helping to understand the factors and distribution of urinary incontinence after pregnancy.

1.       Minassian VA, Bazi T, Stewart WF. Clinical epidemiological insights into urinary incontinence. International urogynecology journal. 2017;28(5):687-96.

2.       Ibrahim N, Spence AR, Czuzoj-Shulman N, Abenhaim HA. Incidence and risk factors of bladder injury during cesarean delivery: a cohort study. Archives of Gynecology and Obstetrics. 2023;307(2):401-8.

3.       Lamerton T, Torquati L, Brown W. Overweight and obesity as major, modifiable risk factors for urinary incontinence in young to mid‐aged women: a systematic review and meta‐analysis. Obesity Reviews. 2018;19(12):1735-45.

4.       Ye D, Yao L-Q. Prolonged second stage of labor is associated with persistent urinary retention after forceps delivery: an observational study. Medicine. 2023;102(38):e35169.

5.       Moossdorff-Steinhauser HF, Berghmans BC, Spaanderman ME, Bols EM. Urinary incontinence 6 weeks to 1 year post-partum: prevalence, experience of bother, beliefs, and help-seeking behavior. International urogynecology journal. 2021;32(7):1817-24.

6.       Suar G, Cevik F, Simal Yavuz N, Ozerdogan N. Urinary incontinence in the postpartum 1‐year period: Its prevalence and effect on psychosocial status of women. LUTS: Lower Urinary Tract Symptoms. 2023;15(5):191-9.

7.       Yang X, Sayer L, Bassett S, Woodward S. The prevalence, associated factors, and impact of urinary incontinence in pregnant and postpartum women in Nanjing, China: A cross-sectional study. Asian Journal of Urology. 2023;10(3):337-43.

8.       Barbara G, Pifarotti P, Facchin F, Cortinovis I, Dridi D, Ronchetti C, et al. Impact of mode of delivery on female postpartum sexual functioning: spontaneous vaginal delivery and operative vaginal delivery vs cesarean section. The journal of sexual medicine. 2016;13(3):393-401.

9.       Wang L, Zhang M, Sha K, Qiao Y, Dong Q. Prediction models for postpartum stress urinary incontinence: A systematic review. Heliyon. 2024;10(18).

10.    Mota NP, Chartier M, Ekuma O, Nie Y, Hensel JM, MacWilliam L, et al. Mental disorders and suicide attempts in the pregnancy and postpartum periods compared with non-pregnancy: a population-based study. The Canadian Journal of Psychiatry. 2019;64(7):482-91.

11.    Turkcapar AF, Kadıoğlu N, Aslan E, Tunc S, Zayıfoğlu M, Mollamahmutoğlu L. Sociodemographic and clinical features of postpartum depression among Turkish women: a prospective study. BMC Pregnancy & Childbirth. 2015;15(1):108.

12.    Rajavuori A, Repo JP, Häkkinen A, Palonen P, Multanen J, Aukee P. Maternal risk factors of urinary incontinence during pregnancy and postpartum: A prospective cohort study. European journal of obstetrics & gynecology and reproductive biology: X. 2022;13:100138.

Wu YM, McInnes N, Leong Y. Pelvic floor muscle training versus watchful waiting and pelvic floor disorders in postpartum women: a systematic review and meta-analysis. Urogynecology. 2018;24(2):142-9.