Urinary Incontinence Following Childbirth: Prevalence, Causes And Treatment

Importance of Exercise and Physical Activity for Postnatal Mothers

Question:

Discuss about the Cognitive Process of Analysis in Qualitative Enquiry.

Pregnancy, child bearing and childbirth are important stages and events in the lives of human beings, especially women. Nevertheless, women are exposed to significant psychological and body changes before, during and after the pregnancy (Sangsawang and Sangsawang, 2013). A normal pregnancy, lactation and recovery from the childbirth process may take up to 12 months, and during this period, a mother may wish to participate in any form of sport, recreation, fitness or health exercises (Ricci and Kyle, 2009; Littleton-Gibbs and Engebretson, 2012). Prenatal awareness and education classes emphasizes on the importance of mothers to engage in mild exercises to strengthen muscles following pregnancy or the process of giving birth (Hammer, Perkins and Parr, 2000).

Over a long period, nurses and caregivers encourage pregnant women to engage in walking and less intense activities to engage the muscles and remain healthy (Lauwers and Swisher, 2015). Traditionally, midwifes play a pivotal role in educating mothers on how to address postnatal problems early and manage any arising clinical or physical challenges effectively (Ricci and Kyle, 2009).

One of the emerging early problems in postnatal mothers is stress urinary incontinence (Hvidman, Foldspang, Mommsen and Nielsen, 2003; Dönmez and Kavlak, 2015). Postpartum urinary incontinence is induced by vaginal deliveries, especially for mothers who are having the first birth (Farrell, Allen and Baskett, 2011; Wagg, 2010). The causes of the problem include large babies, difficulties during deliveries due to lengthy pushing or inadequate instrumentation (Farrell, Allen and Baskett, 2011).

Research indicates that postnatal incontinence is a commonly overlooked, yet important aspect of maternal morbidity (Hvidman, Foldspang, Mommsen and Nielsen, 2003). Postnatal incontinence is a very serious and embarrassing Management problem among women (Macdonald, 2011).  Childbirth constitutes a major risk factor for many mothers and increases the chances of developing postnatal urinary incontinence due to the trauma, stretching and widening of the pelvic floor muscles. Distention and weakness in the pelvic floor muscles and the surrounding connective tissues are the most common causes of postpartum urinary incontinence (Hvidman, Foldspang, Mommsen and Nielsen, 2003). Moreover, vaginal deliveries often result in the damage of innervations, thus contributing to the development of the problem.

Vaginal deliveries often tend to limit and restrict the ability of the pelvic floor muscles to contribute to the control of bladders resulting into urinary continence.  In addition, the emergency of the baby during the normal vaginal delivery stretches the muscles, nerves and fascia around the pelvic floor leading to tearing of the endopelvic fascia. The resulting pudental nerves trauma leads to the dysfunction of the pelvic floor muscles and weakening of the connective tissue. This causes women to experience symptoms of dysfunctional pelvic floor, including organ prolepses and urinary incontinent (Barlow, 1978).

There is a high prevalence of urinary incontinence during the postpartum period ranging from 3-40 % of mothers (Thom and Rortveit, 2010). It is important to engage in an accurate assessment and evaluation of the incidence and prevalence of postpartum urinary incontinence in order to estimate its public health burden and determine the appropriate sample sizes required while designing and conducting clinical studies and investigations (Ege, Ak?n, Altuntu?, Benli and Arioez, 2008). The differences in estimates and prevalence of the condition may also aid nurses and medical practitioners to identify the women at significant risk of postpartum urinary incontinence (Mørkved and Bø, 1999).

Stress Urinary Incontinence: Causes and Prevalence

Although the clinical problem is clear, the challenge lies in designing the appropriate treatment intervention. Caregivers rarely engage in discussion on the prevention of urinary incontinence because at this stage, the only intervention is surgical procedures (Hvidman et al. 2003). There are several studies suggesting that exercises designed to strengthen the pelvic floor muscles are very important for treating stress urinary incontinence (Bø, Hagen, Kvarstein, Jørgensen, Larsen and Burgio, 1990; Park and Kang, 2014). The understanding of pelvic floor anatomy is critical in aiding mothers in pelvic floor exercises. Researchers recommend that mothers should be able to engage in at least 20 pelvic floor exercises (Hvidman, Foldspang, Mommsen and Nielsen, 2003).

Majority of women suffering from stress urinary incontinence don’t seek medical assistance. The women tend to experience and suffer from the indignity of urinary incontinence for many years, often accepting the condition as a normal part of life (Viktrup, 2002). According to Wilson, Herbison and Herbison (1996) pelvic floor exercises offers cost-effective, simple and easy to apply processes and approaches that midwives may use to address the problem. Kegel exercises are critical to addressing the challenge of stress urinary incontinence among postpartum mothers (Hay-Smith, Mørkved, Fairbrother and Herbison, 2008; Boyle, Hay-Smith, Cody and Mørkved, 2012). Unfortunately, most mothers lack the knowledge, understanding and application of Kegel exercises, the low uptake and utilization of the method in addressing stress urinary incontinence (Hvidman, Foldspang, Mommsen and Nielsen, 2003). 

Kegel exercises are effective in reducing urinary incontinence among mothers following childbirth (Burgio, Robinson and Engel, 1986). In a prospective randomized controlled trial involving 676 women (Control, n=328; intervention, n=348), Chiarelli and Cockburn (2002) investigated interventions for promoting urinary continence in New South Wales for women to prevent urinary incontinence after giving birth to their children. The findings from the study indicated that the intervention group had an incontinence prevalence rate of 31% while the control group had 38.4%. During follow-up, the intervention group only had 10.1 % prevalence rate while the control group had 17%. The findings from this study suggests the use of interventions that promote urinary continence can significantly reduce the problem and prevalence of incontinence in women following birth, especially regarding its severity and particularly promoting the performance of pelvic floor exercises.

In another retrospective matched control trial, Mørkved and Bø (2000) Management investigated the effects of a postpartum pelvic floor muscle training on the treatment and prevention of urinary incontinence among 81 matched pairs of mothers (n=162). 76 pairs had virginal deliveries while 5 had elective caesarian section. The measurement of the strength of pelvic floor muscle before intervention was conducted at one year after delivery and post interventions measurement undertaken on the 8 week following training intervention. Structured interviews and standardized pad tests were used to register the continence status of the participants. The results indicated that at the one year follow up, there were a significantly large number of women in the control group than intervention group that reported stress urinary incontinence  or urinary leakage during pad tests (P<0.01). During the period between 16^th week and 1 year postpartum, there was a significant increase in muscle strength in the intervention group compared to the control group. The findings from this study suggest that pelvic floor muscle training during the postpartum period is an effective intervention for treating and preventing stress urinary incontinence.

Pelvic Floor Muscles and Postpartum Urinary Incontinence

Similarly, Gorbea, Velázquez and Kunhardt (2004) conducted a randomized control trial to determine contribution of pelvic floor exercises during pregnancy and puerperium on the prevalence of urinary incontinence. Measures were undertaken at 28 and 35 week of gestation and at 6 weeks following childbirth. A sample size of 72 mothers participated in the study (intervention, n=52.7% and control, n=47.2%). The study found that in the control group urinary stress incontinence was at 17.2%, 47% and 47%, respectively for the three periods, while in the intervention group, it was 0%, 0% and 15%, respectively. In addition, there was a statistically significant difference in the presence of urinary stress incontinence between the two groups across the three stages of measurement. The findings from this study led to the conclusion that pelvic floor exercises during and after pregnancy were effective in preventing urinary stress incontinence.

Despite the existence of substantial evidence supporting the effectiveness of pelvic floor exercises in preventing and treating urinary stress incontinence, there is a general lack of knowledge on the experiences and perceptions of mothers on the effectiveness Kegel exercises in improving bladder control during the early postnatal period. From the literature review, no previous study has explored the experiences, feelings and perceptions of the mothers concerning the use and effectiveness of pelvic floor (Kegel) exercises in improving bladder control and reducing postnatal urinary stress incontinence.  

The aim of the current study is to evaluate the mother’s perceptions and experience of kegel exercises and its effectiveness in improving bladder control and reducing urinary stress incontinence during the postnatal period.

The main research question is: Does Kegel exercises improve bladder control in the early postnatal mothers?

The proposed study will address the following research objectives:

To determine the perceptions of mothers concerning the kegel exercises during postnatal period

To evaluate the self reported effectiveness of kegel exercises on improving bladder control and reducing stress urinary incontinence among postnatal mothers

This being a qualitative study, there will be no formulation and testing of a research hypothesis (Corbin and Strauss, 1990). Since the study seeks to examine the perceptions and experience of the mothers concerning the effectiveness of kegel exercises in improving bladder control during the postnatal period, it is very difficult to formulate a research hypothesis due to lack of prior knowledge. Therefore, this study will depend heavily on grounded theory in generating the hypothesis based on the trends gleaned from data collection, findings and responses gathered throughout the entire qualitative research process (Corbin and Strauss, 1990). The grounded theory approach enables the researcher to engage in a qualitative investigation without feeling the pressure to develop hypothesis and only establish the trends, hypothesis nor themes emerging from the data collected. Instead of measuring, the researcher will use questioning approach, and rely on theoretical coding to develop themes and categories that will inform the hypothesis or conclusions drawn from the study (Corbin and Strauss, 1990).  

A research methodology is the framework that governs the entire approach to an investigation. A research methodology guides the researcher in determining the sample size, the target population, the methods of collecting, documenting, preparing, analyzing and presenting the research findings. A good research methodology is that which allows the researcher flexibility, is cost effective, relevant and appropriate for attaining the intended purpose of the investigation.

Assessment and Evaluation of Postpartum Urinary Incontinence

The researcher will employ a qualitative research design to attain the purpose of the investigation. A qualitative design allows the research to explore flexibility and use the questioning approach to gather subjective information, feelings and experiences of participants concerning the defined research problem or phenomenon under investigation (Marshall and Rossman, 2011). A qualitative design allows the researcher to use different methods and approaches to study and observe the subjects in their natural settings, hence collecting accurate and relevant information within the prevailing context or situation (Marshall and Rossman, 2011). Moreover, a qualitative design allows the researcher to generate relevant insights and meaningful experiences of the participants or subjects in their daily living routines. Another advantage of the qualitative design is that it allows room for collection of complete accounts and explanations for the behavior of participants or outcomes from participation in given nursing programs, treatment or interventions. Therefore, qualitative research is the most effective approach for gathering experiences, perceptions and attitudes of mothers concerning the use and effectiveness of kegel exercises in improving bladder control during the postnatal period.

The researcher will design and use semi-structured interviews to attain the purpose of the proposed study. The use of semi-structured interviews will allow the researcher to explore the questioning and probing approach, thus gathering more subjective information and feelings surrounding the proposed research question (Bernard and Bernard, 2012). Moreover, semi-structured interviews that are self-administered enable the researcher to collect non-verbal cues that complement the verbal information gathered from the research subjects or participants (Galletta, 2013). Using the semi-structured interview method will give the researcher flexibility to uncover descriptive data, clarify information, identify relationships and linkages between the responses from the participants and the existing theoretical background and foundations (Galletta, 2013). Collection of experiences, descriptions, feelings and emotions will enable the researcher to adequately address the research question and understand the perception of the postnatal mothers regarding the effectiveness of kegel exercises in improving bladder control and reducing stress urinary incontinence.

The setting of the study will be mothers attending treatment at a government and public hospital in Australia. The study population will be postnatal mothers attending the hospital who are admitted for urinary blood incontinence during the postnatal period. The inclusion criteria will comprise mothers admitted to the hospital with stress urinary incontinence following a normal vaginal delivery. Only mothers who are available and willing to participate in the treatment will be included in the study.

The researcher will adopt purposive sampling to achieve the purpose of the study. Sampling techniques allows the research to identify and select actual subjects from the target population to take part in the research, including participation in the interventions and collecting of information concerning their experience or perceptions regarding the subject under investigation (Privitera, 2013).  Since the researcher cannot conduct a survey, due to the amount of time required and the extensive data collected through qualitative research, sampling allows selection of a representative group whose experiences are then generalized and applied to the entire population (Privitera, 2013).

Treatment Options for Stress Urinary Incontinence: Pelvic Floor Exercises

For the purpose of this study, the researcher will use purposive sampling technique, which allows the researcher to define the objective of the researcher and identify people whose experiences, feelings and data collected allows for the attainment of the purpose of the study. Through the purposive sampling technique, the researcher already has understanding of the type of information and feedback that is being sought and the type of people that can provide the desired information (Tongco, 2007). The researcher then goes out to identify the people, question them and collect the information. Due to the flexibility, and ease of use the purposive sampling method is effective for collecting qualitative data from participants. Therefore, the researcher will use the purposive sampling technique to identify subjects or participants to attain the purpose of investigating the effectiveness of kegel exercises in improving bladder control in mothers during the postnatal period from their own experiences and subjective feelings.

The sample size is very critical in attaining the purpose of a research. A small sample size is manageable, especially when conducting qualitative study. This is because it allows the researcher to collect adequate and manageable data to allow for easier processing, analysis and presentation. Nevertheless, a small sample size is disputable when it fails to collect adequate information resulting into conclusions that can be generalized to the entire population. A researcher needs to be very careful while determining and selecting the sample size to avoid introducing selection and representative bias in the study.

A sample size of 30 mothers will be deemed adequate, relevant and manageable for attaining the purpose of the proposed study.

Secondary data will be collected through a review of previous data from books, journals and other relevant publications. The literature review will guide the development of context, background and understanding of the theoretical background governing the proposed study. Moreover, literature review will be critical in understanding the existing body of knowledge concerning the subject under investigation, delineating the proposed study from previous studies, setting the scope, determining existing gaps and limitations of previous studies and providing recommendations for future investigations.

Primary data will be critical in attaining the purpose of the proposed study. Since this is a qualitative study, it will be important to collect primary data on the feelings and experiences of the mothers admitted with stress urinary incontinence and their perception of the bladder control exercises in preventing and treating the problem. Face-to-face interviews will be important in collecting primary data as this will ensure completeness of the semi-structured interviews and provide an opportunity for the researcher to probe, clarify information and conduct necessary checks to ensure accuracy and correctness of the information collected. Each participant will be interviewed alone in her own nursing room to allow for privacy and confidentiality since urinary stress incontinence is a very embarrassing problem for postnatal mothers. With the permission of the mothers, the researcher shall record the interviews and replay them to allow for summary, clarification and approval of the participants regarding its accuracy.

Uptake and Utilization of Pelvic Floor Exercises for Stress Urinary Incontinence

After the interview process, the researcher will engage in transcription of the recorded interviews. The transcriptions will be given to an independent reviewer to check for accuracy and consistency. Three level coding approached proposed by Morse (1994) framework will be used to perform analysis of the collected data. The first step will involve identifying unique codes to represent specific information or meaning for every category. The second step will involve developing groups for the coded data to establish similar meanings, subthemes and categories from the collected information. The final step will involve establishing broad categories, trends and common themes emerging from the data and drawing relevant insights, interpretations and conclusions from the data. Two independent reviewers will go through the codes and compare it with the actual data collected from the participants to ensure accuracy, correctness and appropriateness of the coding process (Graneheim and Lundman, 2004).

The concept of rigor is very important while conducting qualitative investigations. In qualitative studies, rigor entails discovering or determining the trustworthiness of the research findings to address the research problem or question. Unlike quantitative studies that rely on the empirical test of reliability and validity, it is very difficult to establish rigor in qualitative investigations. Nevertheless, the researcher can establish rigor using a set of techniques and methods including determining the credibility, transferability, dependability and confirmability of the research findings.

The researcher will ensure credibility of the data and information collected by tape recording the data, conducting members check and verifying the data with the participants. Transferability will be assessed by sharing the data and information with independent reviewers for constructive criticisms. Dependability will be assessed will be assessed by providing the information to a professional nurse implementing the kegel exercises program to determine correctness of coding and analysis process. Finally, confirmability will be assessed through using the actual words that the participants used to describe their experience and perceptions of kegel exercises in improving bladder control in postnatal mothers.

Ethical considerations will be critical to the attainment of the proposed study. the researcher will seek permission and approval from the university ethics committee before commencing the study. Moreover, the researcher will seek permission and approval from the hospital Management and nurses prior to the commencement of the study. Finally, the researcher will provide informed consent to the participating mothers to inform them of the purpose of the study, and their right to terminate their involvement when they deem necessary. The researcher will ensure privacy of the participants by not sharing their personal experiences and using codes instead of their names.

Sampling is likely to introduce selection bias in the study. This is particularly challenging when the researcher fails to select an appropriate and representative population. The choice of the qualitative research design is likely to limit the study because it is not possible to collect and analyze quantitative data and conduct reliability and validity tests. The small sample size may affect the quality, and accuracy of the research findings, which will influence the process of drawing insights and conclusions and ultimately limit the generalization of the findings to the entire population.

Effectiveness of Kegel Exercises in Reducing Urinary Incontinence

Conclusion

The proposed research will investigate the experiences and perceptions of mothers concerning the effectiveness of kegel exercises in improving bladder control during the postnatal period. this study is important because there are few qualitative studies exploring the subject. Moreover, many mothers are unaware of the possible effectiveness of kegel exercises in controlling urinary stress incontinence, which continues to affect many mothers after they have given birth.

References

Barlow, F.H., 1978. Physiotherapy in obstetrics and gynaecology. British medical journal, 2(6150), p.1497.

Bernard, H.R. and Bernard, H.R., 2012. Social research methods: Qualitative and quantitative approaches. Sage

Bø, K., Hagen, R.H., Kvarstein, B., Jørgensen, J., Larsen, S. and Burgio, K.L., 1990. Pelvic floor muscle exercise for the treatment of female stress urinary incontinence: III. Effects of two different degrees of pelvic floor muscle exercises. Neurourology and Urodynamics, 9(5), pp.489-502

Boyle, R., Hay-Smith, E.J., Cody, J.D. and Mørkved, S., 2012. Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women. Cochrane Database Syst Rev, 10, p.CD

Burgio, K.L., Robinson, J.C. and Engel, B.T., 1986. The role of biofeedback in Kegel exercise training for stress urinary incontinence. American Journal of Obstetrics and Gynecology, 154(1), pp.58-64.

Chiarelli, P. and Cockburn, J., 2002. Promoting urinary continence in women after delivery: randomised controlled trial. Bmj, 324(7348), p.1241.

Corbin, J. M., & Strauss, A. (1990). Grounded theory research: Procedures, canons, and evaluative criteria. Qualitative sociology, 13(1): 3-21.

Dönmez, S. and Kavlak, O., 2015. Effects of prenatal perineal massage and Kegel exercises on the integrity of postnatal perine. Health, 7(04), p.495-505

Ege, E., Ak?n, B., Altuntu?, K., Benli, S. and Arioez, A., 2008. Prevalence of urinary incontinence in the 12-month postpartum period and related risk factors in Turkey. Urologia internationalis, 80(4), pp.355-361

Farrell, S.A., Allen, V.M. and Baskett, T.F., 2001. Parturition and urinary incontinence in primiparas. Obstetrics & Gynecology, 97(3), pp.350-356

Galletta, A., 2013. Mastering the semi-structured interview and beyond: From research design to analysis and publication. NYU Press

Gorbea, C.V., Velázquez, S.M.P. and Kunhardt, R.J., 2004. Effect of pelvic floor exercise during pregnancy and puerperium on prevention of urinary stress incontinence. Ginecologia y obstetricia de Mexico, 72, pp.628-636.

Graneheim, U.H. and Lundman, B., 2004. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse education today, 24(2), pp.105-112.

Hammer, R.L., Perkins, J. and Parr, R., 2000. Exercise during the childbearing year. The Journal of perinatal education, 9(1), pp.1-13.

Hay-Smith, J., Mørkved, S., Fairbrother, K.A. and Herbison, G.P., 2008. Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women. Cochrane Database Syst Rev, 4, p.CD.  

Hvidman, L., Foldspang, A., Mommsen, S. and Nielsen, J.B., 2003. Postpartum urinary incontinence. Acta obstetricia et gynecologica Scandinavica, 82(6), pp.556-563

Lauwers, J. and Swisher, A., 2015. Counseling the nursing mother. Jones & Bartlett Publishers

Littleton-Gibbs, L.Y. and Engebretson, J., 2012. Maternity nursing care. Cengage Learning

Macdonald, S., 2011. Mayes' Midwifery: a textbook for midwives. Elsevier Health Sciences.

Mørkved, S. and Bø, K., 1999. Prevalence of urinary incontinence during pregnancy and postpartum. International Urogynecology Journal, 10(6), pp.394-398.

Morse, J.M., 1994. Emerging from the data: the cognitive process of analysis in qualitative enquiry. IN: Morse, JM. Critical Issues in Qualitative Research Methods

Park, S.H. and Kang, C.B., 2014. Effect of Kegel Exercises on the Management of Female Stress Urinary Incontinence: A Systematic Review of Randomized Controlled Trials. Advances in Nursing, 2014, pp. 1-10

Privitera, G.J., 2013. Research methods for the behavioral sciences. Sage Publications

Ricci, S.S. and Kyle, T., 2009. Maternity and pediatric nursing. Lippincott Williams & Wilkins

Sangsawang, B. and Sangsawang, N., 2013. Stress urinary incontinence in pregnant women: a review of prevalence, pathophysiology, and treatment. International urogynecology journal, 24(6), pp.901-912.

Thom, D.H. and Rortveit, G., 2010. Prevalence of postpartum urinary incontinence: a systematic review. Acta obstetricia et gynecologica Scandinavica, 89(12), pp.1511-1522.

Tongco, M.D.C., 2007. Purposive sampling as a tool for informant selection. Ethnobotany Research and applications, 5, pp.147-158

Viktrup, L., 2002. The risk of lower urinary tract symptoms five years after the first delivery. Neurourology and urodynamics, 21(1), pp.2-29

Wagg, A., 2010. Women's Experiences, Beliefs and Knowledge of Urinary Symptoms in the Postpartum Period and the Perceptions of Health Professionals (Doctoral dissertation)

Wilson, P.D., Herbison, R.M. and Herbison, G.P., 1996. Obstetric practice and the prevalence of urinary incontinence three months after delivery. BJOG: An International Journal of Obstetrics & Gynaecology, 103(2), pp.154-161.