Advertisement

The effect of childbirth on urinary incontinence: a matched cohort study in women aged 40–64 years

      Background

      The relative impact of age, pregnancy and vaginal delivery on urinary incontinence is still an unresolved issue that involves the controversial question about the protective effect of cesarean delivery.

      Objective

      The purpose of this study was to estimate and compare the effect size of 1 pregnancy, 1 vaginal delivery, and the derived protective effect of cesarean delivery for different aspects of urinary incontinence in women 40–64 years old, all 20 years after birth.

      Study Design

      This Swedish nationwide matched cohort study involved 14,335 women. Data from 3 restricted, randomly selected, source cohorts of (1) nulliparous women who were unexposed to childbirth (n=9136), (2) primiparous women who had experienced cesarean delivery and who had been exposed to 1 pregnancy (n=1412), and (3) primiparous women who had been exposed to 1 pregnancy followed by vaginal delivery (n=3787) were retrieved from The Swedish Medical Birth Register and Statistics Sweden and surveyed in 2008 and 2014, respectively. Parous women were all assessed 20 years postnatally. One-to-one matching with an interval for pairing of 3 years and 3 body mass index units was used in women 40–64 years old with information about body mass index (kilograms/square meters) and urinary incontinence. The procedure succeeded in 2630 of 2635 women (99.8%) and resulted in an adequate distribution of age and body mass index between groups. The surveys used a postal- and an internet-based questionnaire with validated questions for various aspects of urinary incontinence. Fisher’s exact test and the Mann-Whitney U test were used for comparisons between matched groups; trend was analyzed with Mantel-Haenszel statistics. Predicted, age-related values of different aspects of urinary incontinence were obtained by logistic regression analysis.

      Results

      Pregnancy increased the prevalence of urinary incontinence from 20.1–30.1% (odds ratio, 1.71; 95% confidence interval, 1.43–2.05; P<.0001]. Urinary incontinence increased further after vaginal delivery to 43.0% (odds ratio, 1.75; 95% confidence interval, 1.49–2.05; P<.0001); “moderate” and “severe” urinary incontinence increased from 12.7–19.5% (odds ratio, 1.67; 95% confidence interval, 1.35–2.07; P <.0001). There was a parallel increase in urinary incontinence from 40–65 years of age in nulliparous and vaginally and cesarean delivered women. Cesarean delivery, compared with vaginal delivery, was associated with a 30.0% reduction of urinary incontinence (P<.0001) and a 35–52% reduction of more severe grades of urinary incontinence (P<.0001) and was unaffected by age.

      Conclusion

      Both pregnancy and vaginal delivery incurred an increased risk of urinary incontinence in the long term. The age-related gap for urinary incontinence between nulliparous and primiparous women who were delivered by vaginal delivery or cesarean delivery was constant between parallel trajectories that spanned ages from 40–64 years. The calculated protective effect of cesarean delivery was unaltered and significant during the same age interval.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to American Journal of Obstetrics & Gynecology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Milsom I.
        • Altman D.
        • Cartwright R.
        • et al.
        Epidemiology of urinary incontinence (UI) and other lower urinary tract symptoms (LUTS), pelvic organ prolapse (POP) and anal (AI) incontinence.
        in: Abrams P. Cardozo L. Wagg A. Wein A. Incontinence. 6th ed. Health Publications Ltd, Paris2016: 17-24
        • Chiarelli P.
        • Brown W.
        • McElduff P.
        Leaking urine: prevalence and associated factors in Australian women.
        Neurourol Urodyn. 1999; 18: 567-577
        • MacLennan A.H.
        • Taylor A.W.
        • Wilson D.H.
        • Wilson D.
        The prevalence of pelvic floor disorders and their relationship to gender, age, parity and mode of delivery.
        BJOG. 2000; 107: 1460-1470
        • Rortveit G.
        • Daltveit A.K.
        • Hannestad Y.S.
        • Hunskaar S.
        Urinary incontinence after vaginal delivery and cesarean section; Norwegian EPINCONT Study.
        N Engl J Med. 2003; 348: 900-907
        • McKinnie V.
        • Swift S.E.
        • Wang W.
        • et al.
        The effect of pregnancy and mode of delivery on the prevalence of urinary and fecal incontinence.
        Am J Obstet Gynecol. 2005; 193: 512-518
        • Gyhagen M.
        • Bullarbo M.
        • Nielsen T.F.
        • Milsom I.
        The prevalence of urinary incontinence 20 years after childbirth: a national cohort study in singleton primiparae after vaginal or caesarean delivery.
        BJOG. 2013; 120: 144-151
        • Gyhagen M.
        • Bullarbo M.
        • Nielsen T.F.
        • Milsom I.
        A comparison of long-term consequences of vaginal delivery vs caesarean section on the prevalence, severity and bothersomeness of urinary incontinence subtypes: a national cohort study in primiparous women.
        BJOG. 2013; 120: 1548-1555
        • Åkervall S.
        • Milsom I.
        • Gyhagen M.
        • Al-Mukhtar Othman
        Urinary incontinence in nulliparous women aged 25-64 years: a national survey.
        Am J Obstet Gynecol. 2017; 216: 149.e1-149.e11
        • Sandvik H.
        • Hunskaar S.
        • Seim A.
        • Hermstad R.
        • Vanvik A.
        • Bratt H.
        Validation of a severity index in female urinary incontinence and its implementation in an epidemiological survey.
        J Epidemiol Community Health. 1993; 47: 497-499
        • Haylen B.T.
        • de Ridder D.
        • Freeman R.M.
        • et al.
        An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction.
        Int Urogynecol J. 2010; 21: 5-26
        • Oliphant S.S.
        • Nygaard I.E.
        • Zong W.
        • et al.
        Maternal adaptations in preparation for parturition predict uncomplicated spontaneous delivery outcome.
        Am J Obstet Gynecol. 2014; 211: 630.e1-630.e7
        • Dhital B.
        • Gul-E-Noor F.
        • Downing K.T.
        • Hirsch S.
        • Boutis G.S.
        Pregnancy-induced dynamic and structural changes of reproductive tract collagen.
        Biophys J. 2016; 111: 57-68
        • Stær-Jensen J.
        • Siafarikas F.
        • Hilde G.
        • Benth J.Š.
        • Bø K.
        • Engh M.E.
        Postpartum recovery of levator hiatus and bladder neck mobility in relation to pregnancy.
        Obstet Gynecol. 2015; 125: 531-539
        • Chan S.S.C.
        • Cheung R.Y.K.
        • Yiu K.W.
        • et al.
        Pelvic floor biometry in Chinese primiparous women 1 year after delivery: a prospective observational study.
        Ultrasound Obstet Gynecol. 2014; 43: 466-474
        • Van Veelen G.A.
        • Schweitzer K.J.
        • van der Vaart C.H.
        Ultrasound imaging of the pelvic floor: changes in anatomy during and after first pregnancy.
        Ultrasound Obstet Gynecol. 2014; 44: 476-480
        • Thomason A.D.
        • Miller J.M.
        • Delancey J.O.
        Urinary incontinence symptoms during and after pregnancy in continent and incontinent primiparas.
        Int Urogynecol J Pelvic Floor Dysfunct. 2007; 18: 147-151
        • Liang C.C.
        • Chang S.D.
        • Lin S.J.
        • Lin Y.J.
        Lower urinary tract symptoms in primiparous women before and during pregnancy.
        Arch Gynecol Obstet. 2012; 285: 1205-1210
        • Chaliha C.
        • Kalia V.
        • Stanton S.L.
        • Monga A.
        • Sultan A.H.
        Antenatal prediction of postpartum urinary and fecal incontinence.
        Obstet Gynecol. 1999; 94: 689-694
        • Eason E.
        • Labrecque M.
        • Marcoux S.
        • Mondor M.
        Effects of carrying a pregnancy and of method of delivery on urinary incontinence: a prospective cohort study.
        BMC Pregnancy Childbirth. 2004; 4: 4
        • Boyles S.H.
        • Li H.
        • Mori T.
        • Osterweil P.
        • Guise J.M.
        Effect of mode of delivery on the incidence of urinary incontinence in primiparous women.
        Obstet Gynecol. 2009; 113: 134-141
        • Thom D.H.
        • Rortveit G.
        Prevalence of postpartum urinary incontinence: a systematic review.
        Acta Obstet Gynecol Scand. 2010; 89: 1511-1522
        • Zhu L.
        • Li L.
        • Lang J.H.
        • Xu T.
        Prevalence and risk factors for peri- and postpartum urinary incontinence in primiparous women in China: a prospective longitudinal study.
        Int Urogynecol J. 2012; 23: 563-572
        • Press J.Z.
        • Klein M.C.
        • Kaczorowski J.
        • Liston R.M.
        • von Dadelszen P.
        Does cesarean section reduce postpartum urinary incontinence? A systematic review.
        Birth. 2007; 34: 228-237
        • Salvatore S.
        • DeLancey J.
        • Igawa Y.
        • et al.
        Pathophysiology of urinary incontinence, faecal incontinence and pelvic organ prolapse. Pregnancy, childbirth and the pelvic floor.
        in: Abrams P. Cardozo L. Khoury S. Wein A. Incontinence. 6th ed. Health Publications Ltd, Paris2017: 375-385
        • Van Geelen H.
        • Ostergard D.
        • Sand P.
        A review of the impact of pregnancy and childbirth on pelvic floor function as assessed by objective measurement techniques.
        Int Urogynecol J. 2018; 29: 327-338
        • MacArthur C.
        • Wilson D.
        • Herbison P.
        • et al.
        Urinary incontinence persisting after childbirth: extent, delivery history, and effects in a 12-year longitudinal cohort study.
        BJOG. 2016; 123: 1022-1029
        • Schytt E.
        • Lindmark G.
        • Waldenström U.
        Symptoms of stress incontinence 1 year after childbirth: prevalence and predictors in a national Swedish sample.
        Acta Obstet Gynecol Scand. 2004; 83: 928-936
        • Mitchell W.K.
        • Williams J.
        • Atherton P.
        • Larvin M.
        • Lund J.
        • Narici M.
        Sarcopenia, dynapenia, and the impact of advancing age on human skeletal muscle size and strength; a quantitative review.
        Front Physiol. 2012; 3: 260
        • Mañosa M.
        • Navarro-Llavat M.
        • Martin L.
        • Zabana Y.
        • Cabré E.
        Fecundity, pregnancy outcomes, and breastfeeding in patients with inflammatory bowel disease: a large cohort survey.
        Scand J Gastroenterol. 2013; 48: 427-432
        • Rothman K.J.
        • Greenland S.
        • Lash T.L.
        Design strategies to improve study accuracy, restriction.
        in: Modern Epidemiology. 3rd edition. Lippincott Williams & Wilkins, Philadelphia2008: 168-182

      Supplementary References

        • Cnattingius S.
        • Ericson A.
        • Gunnarskog J.
        • Källen B.
        A quality study of a medical birth registry.
        Scand J Soc Med. 1990; 2: 143-148
        • Rothman K.J.
        • Greenland S.
        • Lash T.L.
        Design strategies to improve study accuracy.
        in: Rothman K.J. Greenland S. Lash T.L. Modern epidemiology. 3rd edition. Lippincott Williams Wilkins, Philadelphia2008: 168-182
        • Thomas V.
        • Shek K.L.
        • Guzmán Rojas R.
        • Dietz H.P.
        Temporal latency between pelvic floor trauma and presentation for prolapse surgery: a retrospective observational study.
        Int Urogynecol J. 2015; 26: 1185-1189
        • Leijonhufvud Å.
        • Lundholm C.
        • Cnattingius S.
        • Granath F.
        • Andolf E.
        • Altman D.
        Risks of stress urinary incontinence and pelvic organ prolapse surgery in relation to mode of childbirth.
        Am J Obstet Gynecol. 2011; 204: 70.e1-70.e7
        • Hellstrom A.
        • Hanson E.
        • Hansson S.
        • Hjalmars K.
        • Jodal U.
        Micturition habits and incontinence at age 17: reinvestigation of a cohort studied at age 7.
        Br J Urol. 1995; 76: 231-234