Urinary incontinence, faecal incontinence and pelvic organ prolapse symptoms 20-26 years after childbirth: A longitudinal cohort study.

OBJECTIVE: To investigate pelvic floor dysfunction (PFD; urinary incontinence (UI), faecal incontinence (FI) and prolapse) ≥20 years after childbirth and their association with delivery mode history and demographic characteristics. DESIGN: Cohort study with long-term follow-up. SETTING: Maternity units in Aberdeen and Birmingham (UK) and Dunedin (NZ). POPULATION: Women giving birth in 1993/1994. METHODS: Postal questionnaires at 20 (New Zealand) or 26 (United Kingdom) years after index birth (n = 6195). Regression analyses investigated associations between risk factors and UI, FI and prolapse symptoms. MAIN OUTCOME MEASURES: Prevalence of self-reported UI, FI, 'something coming down' from or in the vagina (SCD), and the Pelvic Organ Prolapse-Symptom Score, and relationships with delivery method. RESULTS: Thirty-seven per cent (n = 2270) responded at 20/26 years, of whom 61% reported UI (59% of whom reported more severe UI), 22% FI and 17% prolapse symptoms. Having only caesarean section (CS) was associated with a significantly lower risk of UI (OR 0.63, 95% CI 0.46-0.85), FI (OR 0.63, 95% CI 0.42-0.96) and SCD (OR 0.44, 95% CI 0.27-0.74) compared to only spontaneous vaginal deliveries (SVDs). Having any forceps delivery was associated with reporting FI compared to only SVDs (OR 1.29, 95% CI 1.00-1.66), but there was no association for UI (OR 0.95, 95% CI 0.76-1.19) or SCD (OR 1.05, 95% CI 0.80-1.38). Higher current BMI was associated with all PFD outcomes. CONCLUSIONS: Prevalence of PFD continues to increase up to 26 years following index birth, and differences were observed according to delivery mode history. Exclusive CS was associated with less risk of UI, FI and any prolapse symptoms.

Frequency, severity and risk factors for urinary and faecal incontinence at 4 years postpartum: a prospective cohort.

OBJECTIVES: To investigate frequency, severity and risk factors for urinary incontinence and faecal incontinence 4 years after a first birth. DESIGN: Prospective pregnancy cohort study. SETTING: Melbourne, Australia. SAMPLE: A total of 1011 nulliparous women recruited in early pregnancy. METHODS: Participants were followed up at 32 weeks of gestation; then at 3, 6, 9 and 12 months and 4 years postpartum. MAIN OUTCOME MEASURES: Frequency and severity of urinary and faecal incontinence. RESULTS: At 4 years, 29.6% of women reported urinary incontinence and 7.1% reported faecal incontinence. Compared with women having only spontaneous vaginal births, women who delivered exclusively by caesarean section were less likely to have urinary incontinence at 4 years postpartum (adjusted odds ratio 0.4, 95% confidence interval 0.3-0.6). Women who reported urinary incontinence before or during the index pregnancy, and those experiencing symptoms in the first year postpartum had increased odds of incontinence at 4 years, with the highest odds (6-12 times higher) among women who had previously reported moderate or severe symptoms. The odds of reporting faecal incontinence at 4 years were two to six times higher for women experiencing symptoms in pregnancy, and around four to eight times higher for those with symptoms in the first year postpartum. CONCLUSION: Urinary and faecal incontinence are prevalent conditions 4 years after a first birth. Women reporting urinary or faecal incontinence during pregnancy had markedly higher odds of reporting symptoms at 4 years postpartum, suggesting a need for further investigation and elucidation of aetiological pathways involving nonbirth-related risk factors. TWEETABLE ABSTRACT: Moderate/severe incontinence prevalent 4 years after first birth in population cohort. Prior symptoms are biggest predictor.

Symphysiotomy for obstructed labour: a systematic review and meta-analysis.

BACKGROUND: Obstructed labour is a major cause of maternal mortality. Caesarean section can be associated with risks, particularly in low- and middle-income countries, where it is not always readily available. Symphysiotomy can be an alternative treatment for obstructed labour and requires fewer resources. However, there is uncertainty about the safety and effectiveness of this procedure. OBJECTIVES: To compare symphysiotomy and caesarean section for obstructed labour. SEARCH STRATEGY: MEDLINE, EMBASE, Cochrane library, CINAHL, African Index Medicus, Reproductive Health Library and Science Citation Index (from inception to November 2015) without language restriction. SELECTION CRITERIA: Studies comparing symphysiotomy and caesarean section in all settings, with maternal and perinatal mortality as key outcomes. DATA COLLECTION AND ANALYSIS: Quality of the included studies was assessed using the STROBE checklist and the Newcastle Ottawa scale. Relative risks (RR) were pooled using the random effects model. Heterogeneity was assessed using I(2) tests. MAIN RESULTS: Seven studies (n = 1266 women), all of which were set in low- and middle-income countries (as per the World Bank definition) and compared symphysiotomy and caesarean section were identified. Meta-analyses showed no significant difference in maternal (RR 0.48, 95% CI 0.13-1.76; P = 0.27) or perinatal (RR 1.12, 95% CI 0.64-1.96; P = 0.69) mortality with symphysiotomy when compared with caesarean section. There was a reduction in infection (RR 0.30, 95% CI 0.14-0.62) but an increase in fistulae (RR 4.19, 95% CI 1.07-16.39) and stress incontinence with symphysiotomy (RR 10.04, 95% CI 3.23-31.21). CONCLUSION: There was no difference in key outcomes of maternal and perinatal mortality with symphysiotomy when compared with caesarean section. TWEETABLE ABSTRACT: Symphysiotomy could be an alternative to caesarean section when resources are limited.

Urinary incontinence persisting after childbirth: extent, delivery history, and effects in a 12-year longitudinal cohort study.

OBJECTIVE: To investigate the extent of persistent urinary incontinence (UI) 12 years after birth, and association with delivery-mode history and other factors. DESIGN: Twelve-year longitudinal cohort study. SETTING: Maternity units in Aberdeen, Birmingham, and Dunedin. POPULATION: Women who returned questionnaires 3 months and 12 years after index birth. METHODS: Data on all births over a period of 12 months were obtained from the units and then women were contacted by post. MAIN OUTCOME MEASURE: Persistent UI reported at 12 years, with one or more previous contact. RESULTS: Of 7879 women recruited at 3 months, 3763 (48%) responded at 12 years, with 2944 also having responded at 6 years; non-responders had similar obstetric characteristics. The prevalence of persistent UI was 37.9% (1429/3763). Among those who had reported UI at 3 months, 76.4% reported it at 12 years. Women with persistent UI had lower SF12 quality of life scores. Compared with having only spontaneous vaginal deliveries (SVDs), women who delivered exclusively by caesarean section were less likely to have persistent UI (odds ratio, OR 0.42, 95% CI 0.33-0.54). This was not the case in women who had a combination of caesarean section and SVD births (OR 1.01, 95% CI 0.78-1.30). Older age at first birth, greater parity, and overweight/obesity were associated with persistent UI. Of 54 index primiparae with UI before pregnancy, 46 (85.2%) had persistent UI. CONCLUSIONS: This study, demonstrating that UI persists to 12 years in about three-quarters of women, and that risk was only reduced with caesarean section if women had no other delivery mode, has practice implications. TWEETABLE ABSTRACT: A longitudinal study of 3763 women showed a prevalence of persistent UI 12 years after birth of 37.9%.

A pragmatic randomized controlled trial to evaluate the effectiveness of a facilitated exercise intervention as a treatment for postnatal depression: the PAM-PeRS trial.

BACKGROUND: Postnatal depression affects about 10-15% of women in the year after giving birth. Many women and healthcare professionals would like an effective and accessible non-pharmacological treatment for postnatal depression. METHOD: Women who fulfilled the International Classification of Diseases (ICD)-10 criteria for major depression in the first 6 months postnatally were randomized to receive usual care plus a facilitated exercise intervention or usual care only. The intervention involved two face-to-face consultations and two telephone support calls with a physical activity facilitator over 6 months to support participants to engage in regular exercise. The primary outcome was symptoms of depression using the Edinburgh Postnatal Depression Scale (EPDS) at 6 months post-randomization. Secondary outcomes included EPDS score as a binary variable (recovered and improved) at 6 and 12 months post-randomization. RESULTS: A total of 146 women were potentially eligible and 94 were randomized. Of these, 34% reported thoughts of self-harming at baseline. After adjusting for baseline EPDS, analyses revealed a -2.04 mean difference in EPDS score, favouring the exercise group [95% confidence interval (CI) -4.11 to 0.03, p = 0.05]. When also adjusting for pre-specified demographic variables the effect was larger and statistically significant (mean difference = -2.26, 95% CI -4.36 to -0.16, p = 0.03). Based on EPDS score a larger proportion of the intervention group was recovered (46.5% v. 23.8%, p = 0.03) compared with usual care at 6 months follow-up. CONCLUSIONS: This trial shows that an exercise intervention that involved encouragement to exercise and to seek out social support to exercise may be an effective treatment for women with postnatal depression, including those with thoughts of self-harming.

Consultation about urinary and faecal incontinence in the year after childbirth: a cohort study.

OBJECTIVE: To investigate the extent to which primary-care practitioners routinely inquire about postpartum urinary and faecal incontinence, and assess the proportion of women who disclose symptoms. DESIGN: Prospective pregnancy cohort study of nulliparous women. SETTING: Melbourne, Australia. SAMPLE: A total of 1507 nulliparous women recruited in early pregnancy. METHOD: Women were recruited from six public maternity hospitals, with follow up at 3, 6, 9 and 12 months postpartum. MAIN OUTCOME MEASURES: Standardised measures of urinary and bowel symptoms, and measures of health service use. RESULTS: In the first 12 months postpartum, the period prevalence of urinary incontinence was 47%, and of faecal incontinence was 17%. In all, 86% of women visited a primary health-care practitioner at least once to discuss their own health in the first year after childbirth. However, only around a quarter were asked about urinary incontinence, and fewer than one in five women were asked about faecal incontinence. Discussion of symptoms with health professionals was most likely to occur in the first 3 months postpartum, and happened only rarely during the remainder of the first postnatal year. Over 70% of women reporting severe urinary incontinence and/or faecal incontinence had not discussed symptoms with a health professional. CONCLUSION: The findings provide robust evidence that many women experiencing postpartum urinary and faecal incontinence­including women with moderate and severe symptoms­do not receive adequate primary-care follow up in the first 12 months postpartum. Systems of maternal health surveillance need to include routine inquiry about urinary and faecal incontinence to overcome women's reluctance to seek help.

The effectiveness of exercise as treatment for vasomotor menopausal symptoms: randomised controlled trial.

OBJECTIVE: To investigate the effectiveness of exercise as treatment for vasomotor menopausal symptoms. DESIGN: Three-group randomised controlled trial, two exercise interventions and a control group. SETTING: Primary Care, West Midlands UK. POPULATION: Perimenopausal and postmenopausal women experiencing at least five hot flushes/night sweats per day and not taken MHT in previous 3 months were recruited from 23 general practices. METHODS: Participants in both exercise interventions groups were offered two face-to-face consultations with a physical activity facilitator to support engagement in regular exercise. In addition, one exercise group received a menopause-specific information DVD and written materials to encourage regular exercise and the other exercise group was offered the opportunity to attend exercise social support groups in their communities. Interventions lasted 6 months. MAIN OUTCOME MEASURE: The primary outcome was frequency of hot flushes/night sweats at 6-month up. RESULTS: Two hundred and sixty-one women were randomised (n = 87 per group). Neither of the exercise intervention groups reported significantly less frequent hot flushes/night sweats per week than controls (exercise-DVD versus control: -8.9, 95% CI -20.0 to 2.2; exercise-social support versus control: -5.2, 95% CI -16.7 to 6.3). CONCLUSIONS: This trial indicates that exercise is not an effective treatment for hot flushes/night sweats. Contrary to current clinical guidance, women should not be advised that exercise will relieve their vasomotor menopausal symptoms.

Prevalence of obstetric fistula: a population-based study in rural Pakistan.

OBJECTIVE: To estimate the prevalence of obstetric fistula, its duration and impact on women's daily life using robust data collection methods in a population-based sample in rural Pakistan. DESIGN: A population-based, cross-sectional study. SETTING: A rural community in Sindh Province, Pakistan. POPULATION: Randomly selected women aged 15 years or older. METHODS: A multistage random sampling strategy was used to recruit the women. Lady Health Workers interviewed women in their own homes using a structured questionnaire to obtain symptom data. Women with symptoms of incontinence were then examined by female gynaecologists in their local health facilities to confirm obstetric fistula. MAIN OUTCOME MEASURE: Obstetric fistula confirmed by gynaecological examination. RESULTS: Among the 5064 women interviewed (96% response rate), 20 women with obstetric fistula were identified, showing a prevalence of 0.39% of all women (95% confidence interval [95% CI] 0.22-0.57%) and 0.45% of parous women (95% CI 0.25-0.65%). Significantly more of the women with obstetric fistula compared with parous women without fistula were primiparae and aged <20 years. Of the women with obstetric fistula, 40% had had this for >5 years and 90% reported a major impact on their lives, yet only four had consulted a doctor, three of whom had failed repairs. CONCLUSIONS: The prevalence of obstetric fistula is high in rural Pakistan. Appropriate provision is needed for fistula repair to reduce the burden of the condition. Alongside this, the improvement of maternity care services is urgently needed to prevent its continued occurrence.

Twelve-year follow-up of conservative management of postnatal urinary and faecal incontinence and prolapse outcomes: randomised controlled trial.

OBJECTIVE: To determine the long-term (12-year) effects of a conservative nurse-led intervention for postnatal urinary incontinence. DESIGN: Follow-up of a randomised controlled trial. SETTING: Community-based intervention in three centres (in the UK and New Zealand). POPULATION: A cohort of 747 women with urinary incontinence at 3 months after childbirth, of whom 471 (63%) were followed up after 12 years. METHODS: Women were randomly allocated to active conservative treatment after delivery (pelvic floor muscle training and bladder training), or to a control group receiving standard care. MAIN OUTCOME MEASURES: Prevalence of urinary incontinence (primary outcome) and faecal incontinence, symptoms and signs of prolapse, and performance of pelvic floor muscle training at 12 years. RESULTS: The significant improvements relative to controls that had been found in urinary incontinence (60 versus 69%; risk difference, RD, -9.1%; 95% confidence interval, 95% CI, -17.3 to -1.0%) and faecal incontinence (4 versus 11%; RD -6.1%; 95% CI -10.8 to -1.6%) at 1 year did not persist for urinary incontinence (83 versus 80%; RD 2.1%; 95% CI -4.9 to 9.1%) or faecal incontinence (19 versus 15%; RD 4.3%; 95% CI -2.5 to 11.0%) at the 12-year follow up, irrespective of incontinence severity at trial entry. The prevalence of prolapse symptoms or objectively measured pelvic organ prolapse also did not differ between the groups. In the short term the intervention motivated more women to perform pelvic floor muscle training (83 versus 55%), but this fell in both groups by 12 years (52 versus 49%). CONCLUSIONS: The moderate short-term benefits of a brief nurse-led conservative treatment for postnatal urinary incontinence did not persist. About four-fifths of women with urinary incontinence 3 months after childbirth still had this problem 12 years later.

Association between fetal position at onset of labor and mode of delivery: a prospective cohort study.

OBJECTIVES: To determine the association between fetal position at onset of labor and mode of delivery, specifically left occipito-anterior (LOA) fetal position and spontaneous vaginal delivery (SVD). METHODS: All nulliparous women who were booked at the Birmingham Women's NHS Foundation Trust over an 18-month period from April 2007 to September 2008 with a singleton live fetus without structural anomalies at term gestation were invited to take part in the study. Women recruited to the study underwent a transabdominal ultrasound scan to determine fetal occiput position at the onset of labor. They were then followed up until birth to determine outcome. The primary outcome measure was mode of delivery, categorized into SVD, instrumental delivery and Cesarean section. RESULTS: Of 1647 eligible women, 1250 had valid scans at onset of labor; 155 of the 1250 (12.4%) had fetuses in the LOA position. Analysis showed no evidence of difference in odds ratio (OR) of SVD for fetuses in the LOA position compared with all other positions (OR 0.864 (95% CI, 0.617-1.209); P = 0.394). No difference remained with adjustment for confounding effects of variables known to influence mode of delivery (OR 0.837 (95% CI, 0.551-1.272); P = 0.405). No other occipital position showed significant association with SVD. There was no evidence of the LOA position being associated with Cesarean section, ventouse or forceps delivery. CONCLUSION: There is no evidence of an association between the fetal LOA position at onset of labor and SVD. This finding challenges the conventional theory that LOA is the optimum fetal position at onset of labor, and suggests that antenatal practices encouraging adoption of the LOA position through maternal posturing are unnecessary.

Urinary incontinence in women in rural Pakistan: prevalence, severity, associated factors and impact on life.

OBJECTIVE: To estimate the prevalence of urinary incontinence (UI) and its subtypes in women in rural Pakistan, associated factors, severity and impact on daily life. DESIGN: Population-based, cross-sectional study. SETTING: A rural community in Sindh Province, Pakistan. POPULATION: Randomly selected women aged 15 years or older. METHODS: A three-level random sampling strategy was used to select women: a random sample of health centres; a random sample of Lady Health Workers (LHWs) from each health centre; and a random sample of women in the LHW catchment areas. The LHWs used an interview-based structured questionnaire to collect data from women. MAIN OUTCOME MEASURE: Urinary incontinence reported by women. RESULTS: Among the 5064 participants (response rate 95.8%) the prevalence of any UI was 11.5% (581/5064; 95% CI 10.6-12.3). The most common subtype was stress incontinence, with a prevalence of 4.7% (95% CI 4.1-5.3), followed by urge incontinence, with a prevalence of 3.2% (95% CI 2.7-3.7), mixed incontinence, with a prevalence of 2.8% (95% CI 2.3-3.2), other incontinence, with a prevalence of 0.4% (95% CI 0.2-0.5) and continuous incontinence, with a prevalence of 0.5% (95% CI 0.3-0.6). Older age, higher parity and marriage at an early age were independently associated with UI. We found that 52% of women with UI reported leakage at least daily, and 45% reported a great or moderate impact on their daily life. Only 15.7% of women with UI had consulted a doctor. CONCLUSIONS: The prevalence of UI reported in rural Pakistan was lower than is generally found in studies from the developed world, but among the women affected it commonly occurred on a daily basis and impacted on their everyday lives, yet few had obtained medical advice.

Faecal incontinence persisting after childbirth: a 12 year longitudinal study.

OBJECTIVES: To investigate persistent faecal incontinence (FI) 12 years after birth and association with delivery mode history and quality of life. DESIGN: Twelve-year longitudinal study. SETTING: Maternity units in Aberdeen, Birmingham and Dunedin. POPULATION: Women who returned questionnaires 3 months and 12 years after index birth. METHODS: Data on all births over 12 months were obtained from units and women were contacted 3 months, 6 years and 12 years post birth. MAIN OUTCOME MEASURE: Persistent FI, defined as reported at 12 years and one or more previous contacts. SF12 assessed quality of life. RESULTS: Of 7879 women recruited at 3 months, 3763 responded at 12 years, 2944 of whom also responded at 6 years: nonresponders were similar in obstetric factors. Prevalence of persistent FI was 6.0% (227/3763); 43% of 12-year responders who reported FI at 3 months also reported it at 12 years. Women with persistent FI had significantly lower SF12 scores. Compared with only spontaneous vaginal deliveries, women who had one or more forceps delivery were more likely to have persistent FI (odds ratio [OR] 2.08, 95% confidence interval [95% CI] 1.53-2.85) but it was no less likely with exclusively caesarean births (OR 0.93, 95% CI 0.54-1.58). More obese women than normal weight women reported persistent FI (OR 1.52, 95% CI 1.06-2.17). CONCLUSIONS: This longitudinal study has demonstrated persistence of FI many years after birth and shown that one forceps birth increased the likelihood, whereas exclusive caesarean birth showed no association. Obesity, which increased symptom likelihood, is a modifiable risk factor.

Childbirth and prolapse: long-term associations with the symptoms and objective measurement of pelvic organ prolapse.

OBJECTIVES: To investigate prolapse symptoms and objectively measured pelvic organ prolapse, 12 years after childbirth, and association with delivery mode history. DESIGN: Twelve-year longitudinal study. SETTING: Maternity units in Aberdeen, Birmingham and Dunedin. POPULATION: Women dwelling in the community. METHODS: Data from women were collected 12 years after an index birth and women were invited for examination. Logistic regression investigated associations between risk factors and prolapse symptoms and signs. MAIN OUTCOME MEASURES: Prolapse symptom score (POP-SS); objectively measured prolapse (POP-Q). RESULTS: Of 7725 continuing women, 3763 (49%) returned questionnaires at 12 years. The median POP-SS score was 2 (IQR 0-4). One or more forceps deliveries (OR 1.20, 95% CI 1.04-1.38) and a body mass index (BMI) over 25 were associated with higher (worse) POP-SS scores, but age over 25 years at first delivery was associated with lower (better) scores. There was no protective effect if all deliveries were by caesarean section (OR 0.84, 95% CI 0.69-1.02). Objective prolapse was found in 182/762 (24%) women. Women aged over 30 years when having their first baby and parity were significantly associated with prolapse. Compared with women whose births were all spontaneous vaginal deliveries, women who had all births by caesarean section were the least likely to have prolapse (OR 0.11, 95% CI 0.03-0.38), and there was a reduced risk after forceps or a mixture of spontaneous vaginal delivery and caesarean section. CONCLUSIONS: These findings are at odds with each other, suggesting that prolapse symptoms and objective prolapse may not be in concordance, or are associated with different antecedent factors. Further follow-up is planned.

The onset, recurrence and associated obstetric risk factors for urinary incontinence in the first 18 months after a first birth: an Australian nulliparous cohort study.

OBJECTIVE: To investigate the contribution of obstetric risk factors to persistent urinary incontinence (UI) between 4 and 18 months postpartum. DESIGN: Prospective pregnancy cohort. SETTING: Six metropolitan public hospitals in Victoria, Australia. SAMPLE: A total of 1507 nulliparous women recruited to the Maternal Health Study in early pregnancy (≤24 weeks of gestation). METHODS: Data from hospital records and self-administered questionnaires/telephone interviews at ≤24 and 30-32 weeks of gestation and at 3, 6, 9, 12 and 18 months postpartum analysed using logistic regression. MAIN OUTCOME MEASURES: Persistent UI 4-18 months postpartum in women continent before pregnancy. RESULTS: Of the women who were continent before pregnancy, 44% reported UI 4-18 months postpartum, and 25% reported persistent UI (symptoms at multiple follow ups). Compared with spontaneous vaginal birth, women who had a caesarean before labour (adjusted odds ratio [aOR] 0.4, 95% confidence interval [95% CI] 0.2-0.9), in first-stage labour (aOR 0.4, 95% CI 0.2-0.6) or in second-stage labour (aOR 0.4, 95% CI 0.2-1.0) were less likely to report persistent UI 4-18 months postpartum. Prolonged second-stage labour in women who had an operative vaginal birth was associated with increased likelihood of UI (aOR 2.5, 95% CI 1.3-4.6). Compared with women who were continent in pregnancy, women reporting UI in pregnancy had a seven-fold increase in odds of persistent UI (aOR 7.4, 95% CI 5.1-10.7). CONCLUSIONS: Persistent UI is common after childbirth and is more likely following prolonged labour in combination with operative vaginal birth. The majority of women reporting persistent UI at 4-18 months postpartum also experienced symptoms in pregnancy.

Trends in child pedestrian motor vehicle collision injury rates by neighborhood deprivation score in Toronto, Canada.

We examined trends from 2000 to 2019 in child pedestrian motor vehicle collision (PMVC) injury rates in Toronto, Canada, to see if injury trends varied by neighbourhood deprivation. This 20-year period was associated with major road safety policy changes in the City. A Poisson regression analysis examined police-reported data on children (age 1-19 years), killed or seriously injured (KSI) PMVC rates, by deprivation status (using the Ontario Marginalization Index), over the period 2000-2019. Models controlled for location (urban core v. inner suburbs) and evaluated potential interactions. There were 523 child pedestrian KSI collisions from 2000 to 2019. Over this period, KSI rates decreased by more than 50 % across all neighbourhood deprivation levels. Steep declines from 2000 to 2010 were followed by level or increasing child PMVC rates from 2010 to 2019. Higher deprivation was associated with slightly elevated KSI rates; although not statistically significant. It is important to learn from road safety policy "successes" and ensure that future road safety interventions are applied equitably across areas, accounting for deprivation and location.

Antenatal preventative pelvic floor muscle exercise intervention led by midwives to reduce postnatal urinary incontinence (APPEAL): protocol for a feasibility and pilot cluster randomised controlled trial.

BACKGROUND: Antenatal pelvic floor muscle exercises (PFME) in women without prior urinary incontinence (UI) are effective in reducing postnatal UI; however, UK midwives often do not provide advice and information to women on undertaking PFME, with evidence that among women who do receive advice, many do not perform PFME. METHODS: The primary aim of this feasibility and pilot cluster randomised controlled trial is to provide a potential assessment of the feasibility of undertaking a future definitive trial of a midwifery-led antenatal intervention to support women to perform PFME in pregnancy and reduce UI postnatally. Community midwifery teams in participating NHS sites comprise trial clusters (n = 17). Midwives in teams randomised to the intervention will be trained on how to teach PFME to women and how to support them in undertaking PFME in pregnancy. Women whose community midwifery teams are allocated to control will receive standard antenatal care only. All pregnant women who give birth over a pre-selected sample month who receive antenatal care from participating community midwifery teams (clusters) will be sent a questionnaire at 10-12 weeks postpartum (around 1400-1500 women). Process evaluation data will include interviews with midwives to assess if the intervention could be implemented as planned. Interviews with women in both trial arms will explore their experiences of support from midwives to perform PFME during pregnancy. Data will be stored securely at the Universities of Birmingham and Exeter. Results will be disseminated through publications aimed at maternity service users, clinicians, and academics and inform a potential definitive trial of effectiveness. The West Midlands-Edgbaston Research Ethics Committee approved the study protocol. DISCUSSION: Trial outcomes will determine if criteria to progress to a definitive cluster trial are met. These include women's questionnaire return rates, prevalence of UI, and other health outcomes as reported by women at 10-12 weeks postpartum. Progress to a definitive trial however is likely to be prevented in the UK context by new perinatal pelvic health service, although this may be possible elsewhere. TRIAL REGISTRATION: https://doi.org/10.1186/ISRCTN10833250 . Registered 09/03/2020.

Exclusive caesarean section delivery and subsequent urinary and faecal incontinence: a 12-year longitudinal study.

OBJECTIVES: To investigate the association between delivery mode history and urinary and faecal incontinence, specifically a history of exclusive caesarean section deliveries. DESIGN: Twelve-year longitudinal study. SETTING: Maternity units in Aberdeen, Birmingham and Dunedin. POPULATION: Women who returned postal questionnaires 3 months and 12 years after index birth. METHODS: Data on all births over a 12-month period were obtained from units and women were followed 3 months, 6 years and 12 years after the birth. MAIN OUTCOME MEASURES: Urinary incontinence (UI) and faecal incontinence (FI) 12 years after index birth. RESULTS: Of the 7883 women recruited at 3 months, 3763 were followed up at 12 years: nonresponders were similar in their obstetric factors. After adjustment for parity, body mass index and age at first birth, women who delivered exclusively by caesarean section were less likely to have UI than those who only had spontaneous vaginal births (odds ratio [OR] 0.46, 95% confidence interval [CI] 0.37-0.58), but not if they had a combination of caesarean and spontaneous vaginal births (OR 1.14, 95% CI 0.89-1.47). There was no difference in FI among women who had exclusive caesarean births (OR 0.94, 95% CI 0.66-1.33) or mixed caesarean and spontaneous vaginal births (OR 1.06, 95% CI 0.73-1.54). CONCLUSIONS: Unless women are resolved to have all their deliveries by the abdominal route (and their medical advisors agree), caesarean section does not protect from subsequent UI. Even among those who do deliver exclusively by caesarean section, 40% still report UI; and this strategy confers no benefit for subsequent FI.

Effects of prolonged second stage, method of birth, timing of caesarean section and other obstetric risk factors on postnatal urinary incontinence: an Australian nulliparous cohort study.

OBJECTIVE: To investigate the contribution of prolonged labour, method of birth, timing of caesarean section and other obstetric risk factors to postpartum urinary incontinence. DESIGN: Prospective pregnancy cohort. SETTING: Six metropolitan public hospitals in Victoria, Australia. SAMPLE: A total of 1507 nulliparous women recruited to the maternal health study in early pregnancy (≤24 weeks). METHOD: Data from hospital medical records and self-administered questionnaires/telephone interviews at ≤24 and 30-32 weeks of gestation and 3 months postpartum analysed using univariable and multivariable logistic regression. MAIN OUTCOME MEASURE: Urinary incontinence 3 months postpartum in women continent before the index pregnancy. RESULTS: Of the women continent before pregnancy, 26% reported new incontinence at 3 months postpartum. Compared with women who had a spontaneous vaginal birth, women who had a caesarean section before labour (adjusted odds ratio [OR] 0.2, 95% CI 0.1-0.5) or in the first stage of labour (adjusted OR 0.2, 95% CI 0.1-0.4) were less likely to be incontinent 3 months postpartum. Adjusted OR for incontinence after caesarean section in the second stage of labour compared with spontaneous vaginal birth was 0.5 (95% CI 0.2-1.0). Prolonged second stage labour was associated with increased likelihood of postpartum incontinence in women who had a spontaneous vaginal birth (adjusted OR 1.9, 95% CI 1.1-3.4) or operative vaginal birth (adjusted OR 1.7, 95% CI 1.0-2.8). CONCLUSIONS: In addition to pregnancy itself, physiological changes associated with the second stage of labour appear to play a role in postpartum urinary incontinence.

The relationship between maternal depression and adverse infant health outcomes in Zambia: a cross-sectional feasibility study.

BACKGROUND: Post-partum depression affects many new mothers. In the developing world, there may be an association between post-partum depression and adverse mortality-related infant health. Such associations have been found in South Asia; however, findings are inconsistent in Africa. This study aimed to investigate the feasibility of such research in rural Zambia, and investigate associations between maternal depression and adverse infant health outcomes. METHODS: A cross-sectional study was undertaken in a rural district of Zambia. Consecutive women with infants between 2 and 12 months were recruited from under five clinics in three locations. Depression was assessed using the Self-reporting Questionnaire. Outcomes of infant size (actual weight and length, and as ≤ 5th percentile) and infant health (serious illness, diarrhoeal episodes, incomplete vaccination) were obtained. Relative risk, step-wise logistic regression and linear regression were used to analyse the data. RESULTS: Two hundred seventy-eight of 286 women agreed to take part (97.1%). The proportion with a high risk of depression was 9.7%. Adverse infant health outcomes were all proportionally greater in infants of 'depressed' mothers, and the associations with adjusted mean difference in weight (0.58 kg, CI 0.09-1.08) and length (1.95 cm, CI 0.49-3.50) were statistically significant. Other independent associations with episodes of diarrhoea (maternal education, older infant age, supplementary feeding) and incomplete vaccination (location, older infant age) were identified. CONCLUSION: It is feasible to conduct a study on this subject in a rural area of Zambia. The results show that reduced infant weight and length were significantly associated with maternal 'depression'. Other adverse outcomes may be and need investigating in an appropriately powered study.