Transcript The MAMMI Study Maternal health And Maternal Morbidity in
Trinity College Dublin
The MAMMI Study
Maternal health And Maternal Morbidity in Ireland
Faecal and Urinary incontinence before and during pregnancy 4 th International Nursing and Midwifery Conference 15 th -16 th April 2013, NUI Galway
Déirdre Daly Lecturer in Midwifery/HRB Research Fellow, Trinity College Dublin Supervisors: Professor Cecily Begley, TCD and Professor Mike Clarke, QUB (Adjunct Professor TCD)
The MAMMI Study
Trinity College Dublin Objective (i) to describe the existence, extent and prevalence of morbidity during pregnancy and the first year postpartum Objective (ii) to determine the associated risk factors that may be amenable to intervention Objective (iii) to gain an in-depth understanding of the impact of childbirth, motherhood and any related morbidity on women’s health and health needs Objective (iv) to identify the health service seeking behaviour and the services used by them in order to meet their health needs
The MAMMI Study – UI Strand
Trinity College Dublin Objective (i) to identify the existence, extent and prevalence of UI up to 6 months postpartum for women having their first baby Intimate partner violence Objective (ii) to identify associated factors for UI including but not limited to: age; Body Mass Index (BMI); infant birth weight and perineal trauma Sexual health Objective (iii) to identify the health service-seeking and self-help behaviours of a sub sample of women experiencing UI (n=20-30) Objective (iv) to identify the risk factors for UI that may be amenable to intervention (A/N, 3, 6, General health 1600 primiparous women 9 and 12 months postpartum) Data collection from women’s records One-to-one interviews with women experiencing UI Faecal incontinence (FI) (n=20-30) Urinary incontinence (UI) Mental health Pain
The MAMMI Study – UI Strand
Trinity College Dublin General health prevalence of UI up to 6 months Objective (i) first baby The existence, extent and Objective (ii) prevalence of UI and FI to identify associated factors for UI before and during early pregnancy and perineal trauma Intimate partner violence Sexual health Objective (iii) to identify the health service-seeking and self-help behaviours of a sub sample of women experiencing UI (n=20-30) Objective (iv) to identify the risk factors for UI that may be amenable to intervention 725 primiparous women (A/N , 3, 6, 9 and 12 months postpartum) Data collection from women’s records One-to-one interviews with women experiencing UI (n=20-30) Faecal incontinence (FI) Urinary incontinence (UI) Mental health Pain
Trinity College Dublin
The MAMMI Study
Faecal and Urinary incontinence before and during pregnancy
Definitions
Abrams et al (2002) 2 nd International Consultation on Incontinence 2 nd edition. Available at: http://www.ics.org/Publications/ICI_4/book.pdf
Definition - Faecal Incontinence (FI)
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• – – –
Functional status
Need to wear tissues or pads in underwear
Degree of soiling of tissues, pads or underwear
Duration, frequency and timing of incontinence •
Severity of faecal incontinence
The MAMMI Study
– – –
Minor
- if faecal seepage occurs less than once a month
Moderate
- if there is incontinence of solids more than once a month or liquids more than once a week
Severe
- if there is loss of control of solids several times a week or liquids on a daily basis
Definition - Urinary Incontinence (UI)
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•
The complaint of any involuntary leakage of urine
–
Stress Urinary Incontinence (SUI)
• Involuntary leakage on effort or exertion, or on sneezing or coughing –
Urge Urinary Incontinence (UUI)
• Involuntary leakage accompanied by or immediately preceded by urgency.
The MAMMI Study
–
Mixed Urinary Incontinence (MUI)
• Involuntary leakage associated with urgency and also with exertion, effort, sneezing or coughing.
Abrams et al (2002) 2 nd International Consultation on Incontinence 2 nd edition. Available at: http://www.ics.org/Publications/ICI_2/MENUS/MAIN.PDF
Demographic profile (n=725)
Trinity College Dublin The MAMMI Study group Nationality Irish EU Non-EU Not stated N 461 190 64 10 % 63.6% 26% 8.8% 1.4% The site hospital 2011 Nationality (All women) N 5957 1929 % 65.35% 21.16% 1217 13 13.35% 0.14%
Demographic profile (n=725)
Trinity College Dublin Age groups Up to 24 25 to 29 30 to 34 35 to 39 40 and over 62 166 304 162 30 8.6
22.9
41.9
22.3
4.1
Age groups (primiparous women) 976 1137 1314 581 143 (4151) 23.5
27.4
31.7
14.0
3.5
Demographic profile (n=725)
Trinity College Dublin BMI Categories Underweight (BMI <18.49) 50 Ideal (18.5-24.9) 438 Overweight (25-29.9) Obese (30-34.9) Very obese (35+) Total Missing 113 53 12 666 59 6.9 60.4 15.6 7.3 1.7 91.9 8.1 BMI categories Not available
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Leaking urine before pregnancy (n=725)
During the 12 months before pregnancy, did you ever leak even a small amount of urine? The MAMMI Study
Leaking urine before pregnancy (n=725)
Trinity College Dublin 800 700 600 500 400 300 200 100 0 560 Continent
Leaking urine before pregnancy Key points 560 participants (77.2%) were continent before pregnancy No The MAMMI Study 127 27 9 < once a month 1 or several times a month 1 or several times a week 2 Every day
Leaking urine before pregnancy
Trinity College Dublin 800 700 600 500 400 300 200 100 0 The MAMMI Study 560 Continent
165 (22.6%) (1 in 5) participants experienced some degree of SUI before pregnancy 38 (5.2%) participants experienced SUI one or several times a month or more frequently 22 participants (3%) spoke to a healthcare professional 127 27 No 9 < once a month 1 or several times a month 1 or several times a week 2 Every day
Leaking urine before and during pregnancy
Trinity College Dublin 800 700 600 500 400 300 200 100 0 560 No, never Since the start of your pregnancy have you leaked even small amounts of urine? The MAMMI Study 127 27 Yes, less than once a month Yes, one or several times a month 9 Yes, one or several times a week 2 Yes, every day
Leaking urine before and during pregnancy
Trinity College Dublin 800 700 600 500 400 300 200 100 0 Continent 481
In early pregnancy Key points 481 participants (66.3%) were continent in early pregnancy No, never The MAMMI Study 121 74 34 Yes, less than once a month Yes, one or several times a month Yes, one or several times a week 13 Yes, every day
Leaking urine before and during pregnancy
Trinity College Dublin 800 700 600 500 400 300 200 100 0 No, never The MAMMI Study 481
242 (32.4%) (1 in 3) participants experienced SUI one or several times a month or more frequently
55 participants (8%) spoke to a healthcare professional 121 74 34 Yes, less than once a month Yes, one or several times a month Yes, one or several times a week 13 Yes, every day
Trinity College Dublin 800 700
Women who were continent before pregnancy (n=560)
Leaking urine in early pregnancy 600 500 400 Continent 560 121 (21.6%) women became urinary incontinent pregnancy?
Key points 300 200 100 0 No, never The MAMMI Study Yes, less than once a month Yes, one or several times a month Yes, one or several times a week Yes, every day
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Women who were continent before pregnancy (n=560)
437 The MAMMI Study Leaking urine in early pregnancy
What happened to women who were continent 121 (21.6%) women became urinary incontinent pregnancy?
Key points
Key points 437 participants (78%) remained continent 437 participants (78%) remained continent in early pregnancy
121 participants (21.6%) of urine (1 in 5) became incontinent 64 33 17 7
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Women with SUI before pregnancy (n=165)
The MAMMI Study 160 140 120 127
Women with SUI before pregnancy Key points 165 participants (22.6% of total) had SUI before pregnancy 100 80 60 40 20 0 No < once a month 27 1 or several times a month 9 1 or several times a week 2 Every day
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Women with SUI before pregnancy (n=165)
The MAMMI Study 160 140 120 100 80 60 40 20 0
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Continent
pregnancy Women with SUI before pregnancy Key points 165 participants (22.6% of total) had SUI continent before pregnancy 44 of these participants (26.7%) were continent in early pregnancy 121 of these participants (73.3%) remained incontinent in early pregnancy
57 41 17 6
No < once a month 1 or several times a month 1 or several times a week Every day
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Soiling before pregnancy (n=725)
During the 12 months before your pregnancy, did you ever notice soiling from your back passage on your underwear?
The MAMMI Study
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Soiling before pregnancy (n=725)
The MAMMI Study
Soiling before pregnancy Key points 664 participants (91.7%) were continent before pregnancy
Trinity College Dublin Continent
Soiling before pregnancy (n=725)
The MAMMI Study
664 participants (91.7%) experienced were continent before pregnancy pregnancy 60 participants (8.3%) experienced soiling (minor amounts) before pregnancy 9 participants (15%) spoke to a healthcare professional about controlling bowel motions Incontinent
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Soiling before and during pregnancy Soiling before pregnancy
The MAMMI Study 60 50 40 60 Since the start of your pregnancy, have you
41
noticed soiling from your back passage?
10 0 30 20
18 1
Yes, major amount No, never Yes, minor amount
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Soiling before and during pregnancy Soiling before pregnancy
60 The MAMMI Study 50 40 41
Key points Soiling persisted for 19 participants
4 of these participants spoke to a health care professional 30 20 10 0 18 1 Yes, major amount No, never Yes, minor amount
Trinity College Dublin 60
Soiling before and during pregnancy (n=60) and SUI
50 40 38 The MAMMI Study
Women with soiling - SUI before pregnancy Key points 22 participants (36%), 1 in 3, who had soiling also had SUI before pregnancy 30 20 10 0 No 17 < once a month 3 1 or several times a month 1 1 or several times a week 1 Every day
Trinity College Dublin 60
Soiling before and during pregnancy (n=60) and SUI
50 40 The MAMMI Study
Women with soiling - SUI before and during pregnancy Key points 26 participants (44%), almost 1 in 2, also had SUI in early pregnancy 34 30 20 10 0 No 11 6 4 < once a month 1 or several times a month 1 or several times a week 5 Every day
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So what can we learn from these data
? Interpret data with caution as these findings are preliminary – However, analysis of data from these 725 women show that • More than 1 in 5 participants experienced some degree of urinary incontinence before pregnancy »
Many did not talk to a healthcare professional
• Almost 1 in 3 participants experienced some degree of urinary incontinence at start of pregnancy »
Again many did not talk to a healthcare professional
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So what can we learn from these data
? Interpret data with caution as these findings are preliminary – However, analysis of data from these 725 women show that • One in 12 participants experienced soiling before pregnancy and this persisted for almost 1 in 3 of these participants »
And again many did not talk to a healthcare professional
The context
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• Women reporting occasional UI before pregnancy have raised odds of developing UI during pregnancy • Brown et al 2011 • Women who develop UI during the first pregnancy or puerperium have a significantly higher risk of UI 5 years later than women without UI symptoms • Viktrup et al 2004
The message
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Whilst UI remains undisclosed and not discussed women who could become continent will continue to be incontinent
The final message
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UI and FI are not normal and can be treated
The MAMMI Study
(UI Strand)
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•
Conclusion
•
The MAMMI study is ongoing
• Sample size is 1600 (2000 with Galway site) •
Detailed analyses are required before data are truly understood and statistical significance and associations are ascertained
• Only then can modifiable factors be identified
The MAMMI Study
(UI Strand)
Trinity College Dublin
•
Sincerest thanks to
• The women (all women including those who are not taking part but who read the information) • The midwives and midwifery students and other colleagues who are supporting the MAMMI study • My supervisors Professor Cecily Begley and Professor Mike Clarke • • My colleagues Margaret Carroll, Deirdre O’Malley, Francesca Wuytack Rebekah Maguire and Sophie Clare who worked with us on the MAMMI study in summer 2012 • The Health Research Board (HRB) for funding the MAMMI study (UI) strand • Professor Stephanie Brown, Murdoch Children’s Research Institute, Australia for granting permission to use and modify surveys
References
• • • • • • • • • • • Abrams, P., Cardozo, L., Fall, M., Griffiths, D., Rosier, P., Ulmsten U Van Kerrebroeck, P., Victor, A., Wein, J. 2002 The
Standardisation of terminology of lower urinary tract infection: report from the standardisation sub-committee of the
International Continence Society. Neurology & Urodyn. 21(12: 167-78.
Brown, S.J., McDonald, E.A. & Krastev, A.H. (2008) Fear of an intimate partner and women's health in early pregnancy: findings from the Maternal Health Study. Birth, 35(4), 293-302.
Brown, S.J., Gartland, D., Donath, S. & MacArthur, C. (2011) 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.
BJOG, 118(8), 991-1000.
Brown, S.J., McDonald, E.A. & Krastev, A.H. (2008) Fear of an intimate partner and women's health in early pregnancy: findings from the Maternal Health Study. Birth, 35(4), 293-302.
Gartland, D., Donath, S., Macarthur, C. & Brown, S. (2012) 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. BJOG, 119(11), 1361-9.
MacArthur, C., Glazener, C., Lancashire, R., Herbison, P., Wilson, D. & ProLong Study, G. (2011) Exclusive caesarean section delivery and subsequent urinary and faecal incontinence: a 12-year longitudinal study. Bjog-an International Journal of Obstetrics and Gynaecology, 118(8), 1001-1007.
MacArthur, C., Glazener, C.M., Wilson, P.D., Lancashire, R.J., Herbison, G.P. & Grant, A.M. (2006) Persistent urinary incontinence and delivery mode history: a six-year longitudinal study. BJOG, 113(2), 218-24.
Mason, L., Glenn, S., Walton, I. & Hughes, C. (2001) Women's reluctance to seek help for stress incontinence during pregnancy and following childbirth. Midwifery, 17(3), 212-221.
Schytt, E., Lindmark, G. & Waldenstrom, U. (2004) Symptoms of stress incontinence 1 year after childbirth: prevalence and predictors in a national Swedish sample. Acta Obstet Gynecol Scand, 83(10), 928-936.
Schytt, E., Lindmark, G. & Waldenstrom, U. (2005) Physical symptoms after childbirth: prevalence and associations with self rated health. Bjog-an International Journal of Obstetrics and Gynaecology, 112(2), 210-217.
Viktrup, L. & Lose, G. (2001) The risk of stress incontinence 5 years after first delivery. Am J Obstet Gynecol, 185(1), 82-87.
Definition - Urinary Incontinence (UI)
Trinity College Dublin
•
The complaint of any involuntary leakage of urine
–
Stress Urinary Incontinence (SUI)
• Involuntary leakage on effort or exertion, or on sneezing or coughing –
Urge Urinary Incontinence (UUI)
• Involuntary leakage accompanied by or immediately preceded by urgency.
The MAMMI Study
–
Mixed Urinary Incontinence (MUI)
• Involuntary leakage associated with urgency and also with exertion, effort, sneezing or coughing.
Abrams et al (2002) 2 nd International Consultation on Incontinence 2 nd edition. Available at: http://www.ics.org/Publications/ICI_2/MENUS/MAIN.PDF
Definition - Faecal Incontinence (FI)
Trinity College Dublin
• Passive leakage - involuntary soiling of liquid or solid stool without patient awareness
The MAMMI Study
•
Urge incontinence
– Inability to defer defaecation once the urge is perceived, for long enough to find a toilet • •
Functional status
– Need to wear tissues or pads in underwear – Degree of soiling of tissues, pads or underwear – Duration, frequency and timing of incontinence
Severity of faecal incontinence can be classified as
– – – Minor - if faecal seepage occurs less than once a month Moderate - if there is incontinence of solids more than once a month or liquids more than once a week Severe - if there is loss of control of solids several times a week or liquids on a daily basis