After adjusting for covariates, the trends for changes in UI and interference in daily life are shown in Table 3. The prevalence of UI tended to increase significantly for any UI and for SUI in all participants (both P<.001) and in the vaginal delivery group (P=.02, P<.001, respectively) through the first year postpartum. The prevalence of slight UI tended to increase significantly for all participants and for the vaginal delivery group (both P=.02), and the score for interference with daily life tended to decrease for all participants (P=.04) and for the vaginal delivery group (P=.02) through the first year postpartum. No significant changes in any UI index were found for the cesarean delivery group through the first year postpartum.
The prevalence of any UI and SUI tended to decrease in the cesarean delivery group from 3–5 days to 3 months postpartum (P=.03, P=.050, respectively). The prevalence of moderate or severe UI and the score for interference with daily life decreased for all participants (both P<.001) and for the vaginal delivery group (P=.01, P<.001, respectively) from 3–5 days to 3 months postpartum. The prevalence of any UI and of SUI tended to increase in all three groups from 3 to 12 months postpartum (all P<.001) and the prevalence of slight UI tended to increase for all participants and for the vaginal delivery group from 3 to 12 months postpartum (both P=.02).
The prevalence of any UI across 1 year postpartum was 23.3–33.9% for all participants, 29.1–40.2% for vaginal delivery, and 14.2–25.5% for cesarean delivery. Stress urinary incontinence was the most prevalent postpartum among the different types of UI across the first year. Very severe UI was not found in the current study population. The prevalence of UI type, UI severity, and scores for interference in daily life for all delivery, vaginal delivery, and cesarean delivery at each of the five observation times are shown in Table 4 and Figures 2A–H.
This study presents a clear profile of the prevalence of any UI, types of UI, UI severity, and interference in daily life during the first year postpartum for all participants and for women who underwent vaginal delivery or a cesarean delivery. The prevalence of any UI in all participants was 23.3–33.9% during 12 months postpartum (Table 4). A previous longitudinal study found that the prevalence of any UI was 9.32–13.25% during 12 months postpartum,10 which was lower than the prevalence in our study at each time point. The differences may be the result of differences in the definition of UI, the measures used, population characteristics, or ethnicity.35,36 However, we found that the prevalence of UI within 1 year postpartum was highest at 12 months postpartum and lowest at 3 months postpartum, and these results are consistent with the findings of the other study.10
The vaginal delivery group had a significantly higher prevalence of any UI over the first year postpartum, which is consistent with the findings of a previous longitudinal study.10 Stress urinary incontinence was the most prevalent of all types of UI, which is consistent with previous studies.15,18 Women who underwent a vaginal delivery had a significantly higher prevalence of SUI and UUI at 4–6 weeks and at 3 and 12 months postpartum than did those who had a cesarean delivery. Some reports have concluded that vaginal delivery was negatively associated with postpartum SUI,22 but that prevalence of UUI was not different between groups.11,15,37 The prevalence of mixed UI was lowest among all types of UI, which was consistent with previous studies.11,15 Mode of delivery was not associated with the prevalence of mixed incontinence after 3 months postpartum, which was consistent with a previous report.11
The association between vaginal delivery and the higher prevalence of any UI, SUI, and UUI persisted to 1 year postpartum. However, moderate or severe UI persisted for just 6 months postpartum. No association between vaginal delivery and interference with daily life was observed after 6 weeks, which supports a previous study.22 Additionally, the prevalence of moderate or severe UI in the vaginal delivery group was higher than that in the cesarean delivery group at 3–5 days, perhaps because pelvic floor muscle strength is significantly reduced at 3–8 days after vaginal delivery, but this is not the case after cesarean delivery.6
Our study used within-subject comparison and statistical testing to determine that the prevalence of any UI and slight SUI tended to increase throughout the first year postpartum in all participants and in the vaginal delivery group. However, the effect on daily life decreased. These findings are inconsistent with the previous studies.9,10 Furthermore, we found that the prevalence of any UI and of SUI tended to decrease in the cesarean delivery group during the first 3 months postpartum but did not change in the vaginal delivery group during that period. However, decreases in moderate or severe UI and in daily life interference during the first 3 months were observed in the vaginal delivery group.
Our findings give health professionals a better understanding of postpartum UI and will help with maternal decision-making to select the most appropriate childbirth method and intervention strategy.
The main strength of our study was its longitudinal design that included multiple time points over the course of 1 year. Thus, the association between the two delivery methods and UI at each time point over 1 year was identified. In addition, the change in UI across the first year postpartum was identified by repeated-measures statistical testing using a within-subject comparison design. Finally, all UI indices in this study were assessed with a valid and reliable instrument, which was confirmed by objective measures.25–27
The limitations of this study should be considered. The factors that may influence the increasing trend of UI across the first year postpartum were not studied. Subgroup analysis for postpartum UI such as assisted vaginal delivery, previous route of delivery, or cesarean delivery after a period of labor was not performed. The prevalence of UI in prepregnancy was not assessed in this study; such information in future investigations will allow estimation of the effect of pregnancy as well as route of delivery. Additionally, other health indicators of women who underwent vaginal and cesarean deliveries such as sexual functioning, pain, and physical and mental health were not assessed. The subjective experience of women after vaginal or cesarean delivery could also be explored using an interpretive method.
1. Goldberg RP, Kwon C, Gandhi S, Atkuru LV, Sand PK. Urinary incontinence after multiple gestation and delivery: impact on quality of life. Int Urogynecol J Pelvic Floor Dysfunct 2005;16:334–6.
2. Handa VL, Zyczynski HM, Burgio KL, Fitzgerald MP, Borello-France D, Janz NK, et al.. The impact of fecal and urinary incontinence on quality of life 6 months after childbirth. Am J Obstet Gynecol 2007;197:636.e1–6.
3. Klein MC. Cesarean section on maternal request: a societal and professional failure and symptom of a much larger problem. Birth 2012;39:305–10.
4. Okonkwo NS, Ojengbede OA, Morhason-Bello IO, Adedokun BO. Maternal demand for cesarean section: perception and willingness to request by Nigerian antenatal clients. Int J Womens Health 2012;4:141–8.
5. Chapple CR, Manassero F. Pathophysiology of stress incontinence. In: Raz S, Rodríguez LV, editors. Female urology. Philadelphia (PA): Elsevier Saunders; 2008. p.301–9.
6. Peschers UM, Schaer GN, DeLancey JO, Schuessler B. Levator ani function before and after childbirth. Br J Obstet Gynaecol 1997;104:1004–8.
7. Viktrup L, Lose G. The risk of stress incontinence 5 years after first delivery. Am J Obstet Gynecol 2001;185:82–7.
8. Viktrup L, Lose G. Incidence and remission of lower urinary tract symptoms during 12 years after the first delivery: a cohort study. J Urol 2008;180:992–7.
9. Hansen BB, Svare J, Viktrup L, Jørgensen T, Lose G. Urinary incontinence during pregnancy and 1 year after delivery in primiparous women compared with a control group of nulliparous women. Neurourol Urodyn 2012;31:475–80.
10. Burgio KL, Zyczynski H, Locher JL, Richter HE, Redden DT, Wright KC. Urinary incontinence in the 12-month postpartum period. Obstet Gynecol 2003;102:1291–8.
11. Yang X, Zhang HX, Yu HY, Gao XL, Yang HX, Dong Y. The prevalence of fecal incontinence and urinary incontinence in primiparous postpartum Chinese women. Eur J Obstet Gynecol Reprod Biol 2010;152:214–7.
12. Boyles SH, Li H, Mori T, Osterweil P, Guise JM. Effect of mode of delivery on the incidence of urinary incontinence in primiparous women. Obstet Gynecol 2009;113:134–41.
13. Handa VL, Blomquist JL, Knoepp LR, Hoskey KA, McDermott KC, Muñoz A. Pelvic floor disorders 5-10 years after vaginal or cesarean childbirth. Obstet Gynecol 2011;118:777–84.
14. Hannah ME, Hannah WJ, Hodnett ED, Chalmers B, Kung R, Willan A, et al.. Outcomes at 3 months after planned cesarean vs planned vaginal delivery for breech presentation at term: the international randomized Term Breech Trial. JAMA 2002;287:1822–31.
15. Rortveit G, Daltveit AK, Hannestad YS, Hunskaar S; Norwegian EPINCONT Study. Urinary incontinence after vaginal delivery or cesarean section. N Engl J Med 2003;348:900–7.
16. Solans-Domenech M, Sánchez E, Espuña-Pons M; Pelvic Floor Research Group (Grup de Recerca del Sòl Pelvià; GRESP). Urinary and anal incontinence during pregnancy and postpartum: incidence, severity, and risk factors. Obstet Gynecol 2010;115:618–28.
17. Casey BM, Schaffer JI, Bloom SL, Heartwell SF, McIntire DD, Leveno KJ. Obstetric antecedents for postpartum pelvic floor dysfunction. Am J Obstet Gynecol 2005;192:1655–62.
18. Lukacz ES, Lawrence JM, Contreras R, Nager CW, Luber KM. Parity, mode of delivery, and pelvic floor disorders. Obstet Gynecol 2006;107:1253–60.
19. Arrue M, Diez-Itza I, Ibañez L, Paredes J, Murgiondo A, Sarasqueta C. Factors involved in the persistence of stress urinary incontinence from pregnancy to 2 years post partum. Int J Gynaecol Obstet 2011;115:256–9.
20. Fritel X, Ringa V, Quiboeuf E, Fauconnier A. Female urinary incontinence, from pregnancy to menopause, a review of epidemiologic and pathophysiologic findings. Acta Obstet Gynecol Scand 2012;91:901–10.
21. Rogers RG, Leeman LL. Postpartum genitourinary changes. Urol Clin North Am 2007;34:13–21.
22. van Brummen HJ, Bruinse HW, van de Pol G, Heintz AP, van der Vaart CH. The effect of vaginal and cesarean delivery on lower urinary tract symptoms: what makes the difference? Int Urogynecol J Pelvic Floor Dysfunct 2007;18:133–9.
23. Chang SR, Chen KH, Lin HH, Chao YM, Lai YH. Comparison of the effects of episiotomy and no episiotomy on pain, urinary incontinence, and sexual function 3 months postpartum: a prospective follow-up study. Int J Nurs Stud 2011;48:409–18.
24. Avery K, Donovan J, Peters TJ, Shaw C, Gotoh M, Abrams P.ICIG: a brief and robust measure for evaluating the symptoms and impact of urinary incontinence. Neurourol Urodyn 2004;23:322–30.
25. Seckiner I, Yesilli C, Mungan NA, Aykanat A, Akduman B. Correlations between the ICIQ-SF score and urodynamic findings. Neurourol Urodyn 2007;26:492–4.
26. Karantanis E, Fynes M, Moore KH, Stanton SL. Comparison of the ICIQ-SF and 24-hour pad test with other measures for evaluating the severity of urodynamic stress incontinence. Int Urogynecol J Pelvic Floor Dysfunct 2004;15:111–16.
27. Franco AV, Lee F, Fynes MM. Is there an alternative to pad tests? Correlation of subjective variables of severity of urinary loss to the 1-h pad test in women with stress urinary incontinence. BJU Int 2008;102:586–90.
28. Donovan JL, Bosch R, Gotoh M. Symptom and quality of life assessment. In: Abrams P, Cardozo L, Khoury S, Wein A, editors. Incontinence 3rd international consultation on incontinence. Plymouth (MA): Publication Ltd; 2005. p.519–84.
29. Sandvik H, Seim A, Vanvik A, Hunskaar S. A severity index for epidemiological surveys of female urinary incontinence: comparison with 48-hour pad-weighing tests. Neurourol Urodyn 2000;19:137–45.
30. Klovning A, Avery K, Sandvik H, Hunskaar S. Comparison of two questionnaires for assessing the severity of urinary incontinence: the ICIQ-UI SF versus the incontinence severity index. Neurourol Urodyn 2009;28:411–5.
31. Rotar M, Trsinar B, Kisner K, Barbic M, Sedlar A, Gruden J, et al.. Correlations between the ICIQ-UI short form and urodynamic diagnosis. Neurourol Urodyn 2009;28:501–5.
32. Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U, et al.. The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society. Neurourol Urodyn 2002;21:167–78.
33. Liang KY, Zeger SL. Longitudinal data analysis using generalized linear models. Biometrika 1986;73:13–22.
34. Zeger SL, Liang KY. Longitudinal data analysis for discrete and continuous outcomes. Biometrics 1986;42:121–30.
35. Bo K, Pauck Øglund G, Sletner L, Mørkrid K, Jenum AK. The prevalence of urinary incontinence in pregnancy among a multi-ethnic population resident in Norway. BJOG 2012;119:1354–60.
36. Townsend MK, Curhan GC, Resnick NM, Grodstein F. The incidence of urinary incontinence across Asian, black, and white women in the United States. Am J Obstet Gynecol 2010;202:378.e1–7.
37. Thom DH, Rortveit G. Prevalence of postpartum urinary incontinence: a systematic review. Acta Obstet Gynecol Scand 2010;89:1511–22.