Women and Birth
Volume 20, Issue 2 , Pages 65-69, June 2007

Peripartum urinary incontinence: A study of midwives’ knowledge and practices

  • Yvonne C. Butterfield

      Affiliations

    • Birralee Maternity Service, Box Hill Hospital, Nelson Road, Box Hill 3128, Australia
    • Corresponding Author InformationCorresponding author. Tel.: +61 3 98954655; fax: +61 3 95622729.
    • ,
  • Beverly O’Connell

      Affiliations

    • Deakin University, Burwood Campus, Burwood Highway, Burwood 3125, Australia
    • ,
  • Diane Phillips

      Affiliations

    • Deakin University, Burwood Campus, Burwood Highway, Burwood 3125, Australia

Received 2 October 2006; received in revised form 24 March 2007; accepted 2 April 2007.

Article Outline

Summary 

Urinary incontinence impacts on women's quality of life and their wellbeing. The objectives of this study were to obtain knowledge and information on midwives’ assessment and management practices of urinary incontinence in childbearing women and to explore midwives’ knowledge of risk factors associated with developing urinary incontinence. A non-experimental descriptive research design was used, and participants were current members of the Victorian branch of the Australian College of Midwives. Data was obtained using a survey tool that contained both qualitative and quantitative questions. Key findings indicated that the majority of midwives do not assess women for urinary incontinence during the peripartum period and guidelines for bladder management in maternity services were lacking.

Keywords: Peripartum, Urinary incontinence, Midwives, Knowledge, Practices

 

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Background 

Of the 63,069 women who gave birth in Victoria during 2002, between 21 and 34% (n=13,244–21,443 women) sustained a pelvic floor injury that could have resulted in urinary incontinence.1, 2 The two most common forms of urinary incontinence are stress and urge incontinence.3 Both stress incontinence4 and urge incontinence5 are more predominant during pregnancy due to hormonal changes.4 Urinary incontinence is a significant, but largely unacknowledged morbidity of childbirth which impacts on women's physical, sexual, and psychological health, their family's recreational activities, and their economic status.6

There is a paucity of literature on how midwives, medical practitioners, and physiotherapists manage and treat urinary incontinence in the peripartum period. Although several tools have been developed to assist in the identification and management of urinary incontinence,7, 8, 9 they have not been incorporated into midwifery practice. This may be in part, due to midwives’ lack of knowledge about the prevalence and impact of urinary incontinence. There have been attempts in England to evaluate health practitioner practices and knowledge of urinary incontinence,10, 11 but no similar studies have been identified in Australia.

Existing pre-pregnancy risk factors are compounded by pregnancy changes.4 During a woman's labour, poor bladder management is thought to result in voiding difficulties in the immediate postnatal period, especially where epidural anaesthesia has been administered although the mechanism for this is unclear.4 Continence changes may be due to injuries, such as perineal tears, muscle trauma, or damage of the pudendal nerve.12 Notably, urinary incontinence commencing in pregnancy can double the risk of developing postpartum urinary incontinence,13 and pre-pregnancy urinary incontinence can quadruple the risk of urinary incontinence in the postpartum period.14

Urinary incontinence also has a significant financial impact, with an estimated annual cost between 1995 and 1998 in Australia of AUS$ 710 million (US$ 378 million), in France of FF 3 billion (US$ 417 million), in Italy of L352 billion (US$ 166 million), and $17.5 billion in the United States of America.15

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Study objectives 

The objectives of this study were to examine Victorian midwives’ assessment and management practices of urinary incontinence in childbearing women; and to explore their knowledge of risk factors associated with developing urinary incontinence.

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Method 

A non-experimental descriptive research design was chosen to address the study objectives. The study commenced after receiving ethics approval from the Deakin University Ethics Committee, and the State Executive Committee of the Victorian branch of the Australian College of Midwives (ACMI).

Participants were recruited from the Victorian Branch of the ACMI as it provided a convenient and accessible list of midwives who were likely to be current practitioners in Victoria. Students enrolled in either undergraduate or postgraduate midwifery education programs were excluded from the study.

In using a process of systematic sampling every second name on the ACMI membership list was selected by the ACMI secretariat and a sample of 432 midwives were obtained. The participants were sent a survey tool with a plain language statement about the study. It advised participants that consent was implied if the survey was returned.

The first three sections of the survey tool contained questions on the antenatal, intrapartum, and postnatal periods of childbirth, and the fourth section sought general and demographic data. The participants were requested to complete all sections. Open-ended questions and Likert scales were used, possible responses ranged from 0 (completely disagree) to 10 (completely agree) in the Likert scales. To establish face validity the survey tool was piloted on five midwives who were not members of the ACMI and two minor changes were made.

Data collection occurred over a 2-month period. The survey was distributed twice via Australia Post with the second mail out serving as a reminder for those who had not completed the initial survey. Returned surveys were given an identity code to assist with tracking of data.

The computer package Statistical Package for Social Sciences (SPSS) for Windows version 10.0 was used to determine frequencies of responses.

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Findings 

The population for this study consisted of 432 midwives of whom 225 returned the survey tool giving a return rate of 52%.

Sample characteristics 

The sample consisted of 225 midwives, aged between 27 and 70 years (M=44.8, S.D.=7.8). Participants’ midwifery experience ranged from 1 to 57 years (M=17.3 years, S.D.=9.3 years). The majority 50.2% (n=112) practiced within the Metropolitan area of Melbourne, 29.1% (n=65) in regional cities, 19.3% (n=43) in rural areas, and 1.3% (n=3) practiced across more than one location.

Approximately one-third of participants (36.2%) worked in a single area of midwifery and another third worked in multiple areas of midwifery. Participants were predominately Grade 2 (clinical midwives), years 6–9 (42.4%, n=88) and Grade 3 (26.9%, n =56) associate charge midwives. There were few participants in the Grade 2, years 2–5 category (7.7%, n=16). Grade 4 (charge midwives) and Grade 5 (assistant directors of nursing and midwifery) midwives, including independent practitioners, made up 23.1% (n=48) of the sample. Seventeen participants did not answer this question.

Knowledge and practices in the antenatal period 

There were 131 (58.2%) midwives providing antenatal care. Of these, 113 agreed that there were aspects of health that placed a woman at risk of urinary incontinence, 2 did not agree, and 16 participants did not respond to this question.

Participants were asked to identify what they considered to be risk factors for urinary incontinence in the antenatal period. The responses were categorised into general health (e.g. UTI), pregnancy factors (e.g. multiparity), and fitness (e.g. pelvic floor muscle exercises). The most common health issues identified by midwives that placed women at risk of urinary incontinence are listed in Table 1.

Table 1. Perceived risk factors for UI in pregnancy (n=131)
f
General healtha
Urinary tract infections30
Obesity25
Prior UI9
Constipation8
Single responses6

Pregnancy factorsa
Multiparity23
Pregnancy17
Prior birth trauma11
Multiple pregnancy10
Single responses6

General fitnessa
Pelvic floor exercises35
General fitness6
Constipation7
Single responses2

aThis was a multi-response question where some participants listed more than one category.

Participants were asked to identify on a Likert scale how frequently they assess women for urinary incontinence during antenatal appointments. The responses demonstrated low assessment for urinary incontinence in the antenatal period. Detailed figures are presented in Table 2.

Table 2. Frequency women are assessed for UI during antenatal appointments (n=131)
Frequently
f%
Own practice (missing data=5)3225.4
Colleagues practice (missing data=3)6550.8

Using the Likert scale, participants were asked to rate how frequently they used a specific practice or intervention when they judged a woman to be at risk of urinary incontinence. The detail of practices and interventions initiated by midwives are presented in Table 3.

Table 3. Midwives’ practices in the antenatal period (n=131)
Midwives’ practices in the antenatal periodFrequently
f%
Women are given a pamphlet on PFME10682.8
Women are taught how to do PFME10682.8
Women are given details of a physiotherapist9675.5
Women are referred to a physiotherapist8869.3
Women are assessed for a UTI9675.0

Note: some percentages do not manually add to 100% due to rounding used by SPSS.

Knowledge and practices in the intrapartum period 

The majority of midwives (79%, n=168) cared for women during the intrapartum period and identified four groups of factors that would affect a woman's continence. The four groups identified were procedures, second stage management, maternal factors, and fetal factors. The most frequent responses related to the management of the second stage of labour, including the length of second stage, directed maternal pushing, and difficult births. Procedures listed by participants included instrumental births, epidurals, as well as third and fourth degree anal sphincter tears. Maternal factors listed by participants included prolonged labour, pelvic floor trauma and multiparity. Factors included fetal position and presentation; a large fetus and multiple births.

Guidelines for intrapartum bladder care were available for 64.6% (n=106) of the participants. Participants were asked if guidelines for intrapartum bladder care should be available to guide practice and 89.6% (n=69) indicated that they should be for three common reasons. They indicated that guidelines would

•ensure consistent/proper bladder care is given in labour (n=28),

•reduce the incidence of urinary incontinence (n=10), and

•remind midwives of the long-term impact of birth on women's continence (n=5).

Knowledge and practices in the postnatal period 

A total of 186 (86.9%) participants provided care for women in the postnatal period of childbirth. The majority of midwives provided care from birth to 6h postpartum (n=153) and from 7h to 7 days following birth (n=167). Only 36% (n=67) of midwives provided care from 1 to 6 weeks in the postnatal period. Some midwives provided care across more than one phase of the postnatal period.

Participants, were asked to rate on a Likert scale how frequently they evaluated the bladder function of women when performing postnatal assessments. The majority (92.4%, n=171) indicated that they regularly assess postnatal bladder function and 67.6% (n=123) directly asked women if they had experienced urinary incontinence. Table 4 describes the actions midwives take in the postnatal period when women are identified to be at risk of urinary incontinence.

Table 4. Actions by midwives in the postnatal period when women are identified to be at risk of UI (n=186)
Midwives actions in the postnatal periodf%
Expand education to include, e.g. community resources, constipation management10757.5
Refer to other health professionals, e.g. doctor, physiotherapist, continence clinic5529.6
Expand investigation to include, e.g. documentation of UI episodes, use a fluid balance chart to document urinary output, screen for urinary tract infection: physical assessment of bladder function137.0
No response115.9

Total186100.0

To gain insight into the frequency of pelvic floor muscle exercise (PFME) education, participants were asked to rate how regularly they taught women PFME in the postnatal period. The majority 75% (n=138) taught PFME regularly and three common educational strategies they used were

•Give women an educational pamphlet (82.9%, n=151).

•Verbally instruct women how to do PFME (79.2%, n=145).

•Encourage women to attend a physiotherapy class (70.4%, n=126).

Forty-five midwives identified other practices they used when teaching women PFME. These practices included a video made by local physiotherapists, pictorial flip charts, and referral to television advertisements, other health professionals such as medical practitioners, continence advisors, and physiotherapists.

Even though women have been taught PFME they may not be using the correct PFME technique. The proportion of midwives who frequently assessed women's PFME technique was 45.1% (n=184). It was of particular concern to find that less than 70% (n=154, 69.7%) of the participants had received instruction on how to teach women PFME during their training.

The participants were asked if they had access to bladder management guidelines to guide their postnatal practice, 45.9% (n=83) participants indicated that they did have guidelines in their maternity unit, but 51.4% (n=93) indicated that they did not have access to postnatal bladder care guidelines. When asked if they would like to have postnatal bladder management guidelines available 93.7% (n=104) participants believed that having guidelines would be beneficial to practice.

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Discussion 

Although midwives are not the only health professionals providing care to childbearing women during and after pregnancy, their clinical judgement and actions have the potential to improve the health and wellbeing of women. In this study, midwives demonstrated a sound understanding of risk factors that have been traditionally associated with urinary incontinence in childbearing, e.g. previous birth trauma causing weakening of the pelvic floor. However, only 6.8% (n=9) of those caring for women in the antenatal period identified pre-pregnancy urinary incontinence as a contributing factor to postpartum urinary incontinence. This finding is an important practice concern and demonstrates a deficit in the knowledge of midwives providing care for women in the antenatal period. This study found that no midwives identified urinary incontinence developing in pregnancy as a risk factor for postpartum urinary incontinence. This is significant because evidence reveals that routine screening will identify rates of urinary incontinence up to 65% during pregnancy.13 This suggests that midwives who provide antenatal care are missing multiple opportunities for health assessment and health promotion. These missed opportunities for assessing women are also compounded by poor rates of disclosure of incontinence by women to all health professionals.16, 17

Assessment of midwives’ knowledge of the intrapartum effects of urinary incontinence demonstrated that midwives have good knowledge about the traditional factors that are thought to affect urinary incontinence during labour. Although factors such as epidurals and assisted births are not midwifery responsibilities, midwives provide care for women during these procedures and, therefore, require a sound understanding of the implications of these procedures. Exploration of midwives’ management of normal births would have allowed more insight into midwives’ use of evidence when caring for women in labour. The omission of the evaluation of this aspect of midwives’ care is a limitation of this study.

Anomalies existed in midwives’ knowledge and practices during the antenatal and postpartum period. The anomalies included variations in the frequency of assessments for urinary incontinence, the number of ways in which midwives taught women PFME, less than half the midwives regularly assessing if women performed PFME correctly and lack of pelvic floor exercise education for midwives. With these anomalies present, it is unlikely that women are receiving optimal care with regard to this aspect of their health.

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Conclusions 

The impact of childbirth on women's continence as a health issue is of national and international significance. It seems likely from this study that many women may not assessed, diagnosed or managed for urinary incontinence due to factors such as variations of midwifery and medical knowledge, lack of documentary prompts for assessment of urinary incontinence and management strategies for women suffering from urinary incontinence related to childbirth. These factors present a major midwifery practice concern within Victoria that needs to be addressed. If the inconsistencies within education and midwifery practice are resolved, the morbidity of urinary incontinence associated with childbirth may be reduced and the ongoing health and wellbeing of women improved.

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Acknowledgements 

The authors wish to thank all the midwives who participated in this study. No financial assistance was received for this study.

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References 

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PII: S1871-5192(07)00026-1

doi:10.1016/j.wombi.2007.04.001

Women and Birth
Volume 20, Issue 2 , Pages 65-69, June 2007

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