Litany of undiagnosed, under-reported and untreated health problems for mothers

Posted on: 07 November 2016

The interim findings of MAMMI, an Irish longitudinal study on the health of first-time mothers, has revealed a litany of hidden health problems affecting every aspect of mother’s lives. The Health Research Board funded study from Trinity College Dublin’s School of Nursing and Midwifery shows that in terms of sexual health, mental health, pain, and other conditions, prevalence rates are high to very high while the rate at which women are being asked about these conditions by health care professionals is extremely low. The findings are being presented today at a major conference.

Speaking about the significance of these findings, Professor Cecily Begley, principal investigator of MAMMI and Chair of Nursing and Midwifery in the School of Nursing and Midwifery, Trinity said: “Our research to date indicates that at policy, research, practice and public discourse level, many serious aspects of women’s health during and after pregnancy remain almost completely hidden. Most of these conditions are preventable or treatable yet women are not being asked about them during the first three months postpartum, a time at which they are in regular contact with healthcare professionals.”

The key findings include:

Health Problem	Prevalence at 3 months postpartum	Number of GPs who did NOT ask mother directly about the problem or condition
Pelvic Girdle Pain	One in three	Almost two thirds
Sexual Health Problems	Half experienced painful sex, one quarter had not resumed having sex	Eight out of ten
Anxiety	28% (self-reported) experienced some anxiety, and 12% experienced anxiety occasionally or often	Half
Depression	18% experienced depression at some time since giving birth	Half
Leaking urine	Almost 60% of women leaked some amount of urine since giving birth	Three quarters
Anal incontinence	12%	Three quarters

 

Findings in detail:

Pelvic girdle pain is pain anywhere in the front or back of the pelvis, or the lower back area, and can affect women’s ability to do daily activities such as walking, driving, sitting, sleeping, exercising, lifting children, pushing a buggy and more:

• More than two-thirds of women (67.9%) had pelvic pain during pregnancy;
• Only 5.8% were reported to have pelvic girdle pain during pregnancy in the hospital records which indicates a very high level of underreporting in the maternity hospitals;
• One in three women still had persistent pain one year after the birth of their baby;
• Almost two-thirds of women were not asked about it by their GP in the first three months postpartum and half were not asked by their midwife or public health nurse in those first three months.

Sexual health – little is known in Ireland about the prevalence of sexual health issues in first-time mothers in Ireland, possible risk factors or women’s experiences. The MAMMI study is the first to look at these issues.

• More than one in two women experienced painful sex in the first three months after having their baby. This resolved gradually over the first year postpartum however at 12 months, one in five still reported that sex was painful.
• One-quarter of women had not resumed having sex at three months.
• Two in five women had reduced sexual desire at 12 months compared to pre-pregnancy.
• More than eight out of ten women were not asked about their sexual health by their GP in the first three months postpartum.
• Almost nine out of ten were not asked about relationship problems by their GP in the first three months postpartum.
• There is an absence of discussion on intimacy by healthcare professionals and literature uses the term ‘dysfunction’ which can leave women, the researchers suggest, less able to recognise sexual health problems and may leave couples with unrealistic expectations.

Mental Health

• 28% of women reported they had experienced anxiety 3 months after having their baby.
• Half the women were not asked about anxiety by their GP and one in three were not asked about it by their public health nurse in the first three months postpartum.
• 17% of women reported depression in the first three months postpartum.
• Half the women were not asked about depression by their GP and one in three were not asked about it by their public health nurse in the first three months postpartum.
• Anxiety is often thought of as being the same as / part of depression, but women can be experiencing the distress of anxiety without experiencing depression. The researchers explained that if we only ask women about depression, we may miss women who experience the distress of anxiety.

Incontinence – this part of the MAMMI study looks at urinary and anal incontinence, often referred to as leaking. Involuntarily leaking urine, wind and bowel motions can have a serious and profound effect on women’s quality of life, leaving them feeling powerless, vulnerable and embarrassed and affecting their ability to socialise and exercise.

• Almost 60% of women leak urine at three months postpartum
• More than one in ten (12%) women had leaked liquid or solid stools in the first three months postpartum.
• Almost one in ten had difficulties with involuntary passing of major amounts of wind.
• Three-quarters of women were not asked by their GP about urinary or anal incontinence.

Speaking about the recurring things that women from the study have told them, Dr Deirdre Daly, Assistant Professor in Midwifery, Trinity said: “Regardless of what type of health problem women experience, many women do not talk about it or disclose it to a health professional, often because they haven’t heard about it happening to anyone else. They feel embarrassed and think ‘oh no one else has ever had this…it must be just me’. Coupled with this, considerable proportions of women, nine out of ten for some health problems, have told us that health professionals do not ask them about these health problems. This lack of conversation about these health issues means that women’s health problems remain hidden, women suffer in silence and put up with health problems that are treatable and curable and, if treated early, could prevent some of these problems from persisting into later life.”

Dr Daly continued: “Women also tell us that they are learning so much from taking part in the study and completing the surveys. A typical response from women is ‘oh, I didn’t know about that, but I know to look out for it now.’ On the one hand, it’s great that women are learning more about their health and some of the health problems that can happen. On the other hand, it is very difficult to accept the fact that women are being informed about key life-altering health issues simply because they got the opportunity to take part in a research study. This means that thousands of the women birthing in Ireland are missing out on vital information that could have a positive impact on their health and wellbeing.”

According to Dr Graham Love, Chief Executive of the Health Research Board: “These findings are a clear demonstration of the power of health research to give clinicians and service planners high-quality evidence to inform what they do. Research is vital if we want to continually improve our understanding of people’s real health needs.”

Speaking about what needs to happen to improve women’s health Dr Daly said: “Three key things need to change; all of us healthcare professionals must find ways to find time for women, and time to ask women about these health issues. Ultimately it’s about having time to get to know the women in our care, and listening to them. The second issue is that we need to get this information out to women so that they can become informed, and inform each other. Talking and sharing information about these health problems will break down the walls of secrecy and silence.”

Dr Daly continued: “The third and final change needed is the urgent need for information on women’s postpartum health at national level. We started the MAMMI study because we had no way of knowing what was happening to women’s health when they were discharged from a maternity hospital. Apart from the data from the MAMMI study, we still have no way of finding this information out without doing research like this. The potential impact of gathering this type of information is enormous; it will inform healthcare professionals and women about the extent of the health problems women experience after birth, and by having this information, policymakers will know where to target services.”

The MAMMI study is funded by the Health Research Board, the HSE, Trinity College Dublin, Friends of the Coombe, Science Without Borders Brazil, and Friends of the Rotunda.

About MAMMI

The MAMMI (Maternal health And Maternal Morbidity in Ireland) study is a multi-strand, multi-centre cohort study investigating prevalence and risk factors for a range of morbidities in 2, 600 nulliparous women; this study group represents almost 10% of all first-time mothers giving birth in Ireland in a given year. The MAMMI study is now one of the largest prospective maternal health studies globally.

Information is gathered during pregnancy, and at four (4) time points up to twelve (12) months post-partum. The MAMMI study examines a range of important health issues including urinary incontinence; pelvic girdle pain; sexual health; diet and activity during pregnancy; caesarean section; intimate partner violence and mental health issues such as anxiety, stress and depression.

Further information on individual strands of the MAMMI study

Sexual health

This research is looking at the prevalence and experience of sexual health issues in first-time mothers in Ireland antenatally and up to 12 months postpartum. There has been no information on this in Ireland before the MAMMI study.

• The prevalence of some sexual health issues persisted at each postnatal time point, and indeed increased after the birth of the baby and at each postnatal time point, for example, loss of interest in sexual activity and lack of vaginal tone remained significantly increased at 3 months, 6 months, 9 months and 12 months postpartum compared to pre-pregnancy.
• The prevalence of some sexual health issues increased immediately post birth and resolved over time, for example, painful sex with 53.9% experiencing painful sex at 3 months, 37.5% at 6 months and 20.5% at 12 months which was significantly less than pre-pregnancy levels.
• Pregnancy and birth appear to resolve difficulties participants experienced with orgasm pre-pregnancy.
• International research has reported that 20-40% of women experience sexual health issues up to 6 months after birth, others estimate that 20% of women continue to experience sexual health issues 12 months after birth.

Mental Health

This strand of the MAMMI research aims to identify the existence, extent, prevalence and associated risk factors for mental distress in 2600 first time mothers before, during and in the 12 months after pregnancy.

The researchers used two methods to identify depression– self-reported depression described as feeling depressed, low mood or sad and lasting two weeks or more and secondly, as measured using the DASS (Depression Anxiety Stress Scales (DASS-21). The researchers also used two methods to identify anxiety: self-reported anxiety described as intense anxiety such as panic attacks, and secondly, as measured using the DASS (Depression Anxiety Stress Scales (DASS-21)

• For 50% of women who experience lifetime depression, postnatal depression was the index episode.
• Untreated postnatal depression has detrimental effects on the baby’s development – cognitive, emotional, social and behavioural. Depressed women engage in more negative and less positive interactions with their babies, affecting their social, emotional and language skills
• Fathers are also more likely to suffer from depression and health problems if their partners are diagnosed with postnatal depression. This has consequences for partners and babies.

Pelvic Pain

Women with persistent Pelvic Girdle Pain said they tried to just ‘put up with the pain’ but they had to balance activities. They felt there was a lack of information and follow up after birth, leading to uncertainty about what help to seek and the progression of their symptoms. They wished for specific questions to be asked about their health during postnatal visits.

 

Birth mode

• 31% had birth by caesarean section – 8% of those were elective sections and 23% were emergency sections.
• The baby presenting by breech (bottom first) was the most common reason for elective CS.
• Foetal distress (the baby getting tired during labour) and failed induction of labour were the most common reasons for emergency CS.
• One third had a spontaneous vaginal birth and one third had vaginal birth assisted with instruments such as forceps or vacuum.
• Two to three in every 100 women who had a CS were readmitted to the hospital following discharge, and abdominal wound infection was the most common reason for readmission following birth by CS.