I feel incredibly grateful to be living in the times we do where it’s acceptable and normal for women to talk about their bodies. Only a generation ago it really wasn’t OK for women to discuss the often dramatic changes that occur during pregnancy and after birth. Now, information on the ways in which your skin, tummy and boobs may change over this time is easily found – both the good and bad are right there, loud and proud on social media.
But there’s one topic that still seems to be taboo – the changes that happen DOWN THERE.
By this I mean, the changes that occur in the vulva, vagina and pelvic floor, which then effect bladder, bowel and sexual function. This is surprising given we know ALL women experience changes in this area during pregnancy and after delivery (no matter how they deliver). Sadly, a significant number of women suffer ongoing consequences for years.
Recently a former Married At First Sight contestant, Jules Robinson, bravely opened up about her bladder problems during and after her pregnancy in an interview with the Continence Foundation of Australia. She asked why it is that although urinary leakage is common, women don’t seem to talk about it, especially during this time in their lives. It’s a good question.
Certainly, things have improved a bit when it comes to bladder leakage. After all, there are now incontinence pad advertisements on TV, which was unheard of only 20 years ago. But these ads still suggest this is something that happens in “older” women. They aren’t showing a pregnant woman or young mum out buying pads – the women in the ads are middle-aged.
Yet figures show women experience not only urinary leakage, but also problems with bowel control, pelvic organ prolapse and sexual dysfunction at higher rates after having a baby than they do before this time.
Here are some facts to consider:
It’s not just after delivery either. Just in case you think having a Caesarean will protect you, you may be interested to learn that
So why aren’t we talking more about this?
Some doctors and midwives argue they do tell pregnant women about these things, but many women think “it won’t happen to me”. Maybe this is because pregnant women feel overwhelmed with information about all the possible changes that may occur in pregnancy, or they think these changes are a normal part of pregnancy. Some women may feel too embarrassed to talk about them. For example, one study on anal incontinence found the vast majority of women do not tell a health professional unless directly asked2.
But it’s unfair to lay all the blame on women themselves. Many health care professionals involved in pre/postnatal care fail to be upfront about these topics. Possibly because there are so many things to cover in those short appointments. Some health care professionals might feel embarrassed to talk about these problems too.
I feel very strongly that informing women about potential pelvic floor problems should be an essential part of pregnancy education. We know if we can get women doing pelvic floor exercises regularly in pregnancy, they have a lower risk of urinary incontinence for the rest of their pregnancy and postpartum. It should also be an important part of the conversation when it comes to discussing and giving informed consent about birth options. But the big problem here is that that informed consent about birth options is too often either inadequate or non-existent, as highlighted recently.
A recent SBS Insight episode on birth trauma, Giving Birth Better, highlighted the kinds of problems that may occur for women when things go wrong. Several people interviewed in the episode told how they were not adequately informed about the risks to their pelvic health when discussing birth options, or that options were never discussed at all. However, as outlined in the recently updated clinical care standard by the Australian Commission for Quality and Safety in Health Care on 3rd and 4th degree perineal tears these possibilities should be discussed during pregnancy.
We now have substantial evidence to show that complicated vaginal deliveries in particular can leave women with physical and emotional trauma that may be long-lasting. By “complicated”, I mean a vaginal delivery involving the use of instruments (forceps or ventouse) or resulting in a 3rd or 4th degree perineal tear. These kinds of deliveries carry a much greater risk for future urinary and bowel incontinence, prolapse and pain with intercourse. Women are at a higher risk of having a complicated vaginal birth if their baby is over 4kg, they have had difficulties with past deliveries or have certain other risk factors such as their age, height and family history6, 7.
This is not to say all vaginal deliveries are bad. There are many good reasons for most women to have a vaginal delivery, and for the vast majority of women they go well. Babies who birth vaginally establish breast feeding more easily and benefit from greater immunity passed on from their mothers. Caesareans, like any type of surgery, can carry greater risks. And it’s not just about the birth, as we saw from the figures above - just being pregnant increases the risk of certain problems. Also, many women may feel their birth is traumatic, even with a Caesarean or without the kinds of complications mentioned above, as I discussed in a past blog about birth trauma. But what women really need is to be told about all of this – not to scare them, but to inform them properly.
What I wish for (in an ideal world) is better education for all pregnant women to explain the potential benefits and risks with ALL types of birth options, to help women weigh up which option is best for them individually. This would include information on starting pelvic floor exercises in pregnancy under the guidance of a Women’s Health Physiotherapist. Ideally all pregnant women would also be offered follow-up appointments after their birth, no matter how they delivered, to screen for any problems and ensure everything is returning to normal. And whilst I’m wishing, these visits would be subsidised under a special Medicare item code, to encourage all women to see a Women’s Health Physiotherapist pre and postnatally, as they do in countries like France. Right now, this is just a dream. But Physiotherapists throughout Australia have been lobbying the Federal Government on these issues again recently, using recent evidence to show we can make a big difference in the lives of these women. With any luck, it won’t be too long before women’s pelvic health care stops being a taboo and starts being a matter worthy of the funding and support it deserves.
Yours in (pelvic) health