Women’s health after childbirth

Abstract

The overall aim of this thesis is to describe women's health after childbirth in a national Swedish sample by investigating the prevalence of a number of physical symptoms and self-rated health (SRH). The prevalence of stress incontinence at one year after delivery, and possible predictors, was investigated specifically. Risk factors for poor SRH at two months and one year after childbirth were identified. To further understand what the question of SRH captures in the context of childbirth and early parenthood, the reasoning of new mothers when answering the question 'How would you summarize your state of health at present' at one year after the birth, was explored.

For the purpose of Papers I-III, we used selected data from a national Swedish survey (the KUB project: Women's experiences of childbirth), investigating women's physical and psychological assessment of childbirth This study was designed as a cohort study in which women were followed by means of three questionnaires from early pregnancy to one year after the birth. Swedish-speaking women were recruited at their first antenatal booking visit, from 593 (97%) antenatal clinics in Sweden. About 4600 women were eligible. Of the 3455 (75%) who consented to participate, 3061 answered the first questionnaire, 2762 the second and 2563 the third; 2450 (53%) filled in all three questionnaires. The representativity of the sample was assessed by comparison with all births taking place in Sweden in 1999, according to the Swedish Medical Birth Register.

For the purpose of Paper IV, a qualitative design using the method of combined concurrent and retrospective think-aloud interviews, followed by a semi-structured interview, was used. The 26 respondents, recruited from Child Health Clinics one year after delivery, were asked to say out loud everything that came into their minds, from the moment they first saw the question until they finally gave their answer. The analysis was guided by a theoretical framework describing four cognitive tasks, usually performed when a respondent answers a survey question: interpretation of the question, retrieval of information, forming a judgment and giving a response.

Tiredness, headache, neck, shoulder and low back pain were common problems at two months, as well as one year after childbirth. At two months, pain from cesarean section, dyspareunia, and hemorrhoids were frequent problems, whereas stress incontinence was often reported at one year. Nevertheless, SRH was reported to be 'very good' or 'good' by 91 % of the women at two months after birth, and by 86% at one year (Paper I).

One year after the birth, 22% of the women had symptoms of stress incontinence but only 2% said it caused them major problems. The strongest predictor was urinary incontinence (overall leakage) 4-8 weeks after a vaginal delivery as well as after a cesarean section. Other predictors in women with a vaginal delivery were: multi-parity, obesity and constipation 4-8 weeks postpartum (Paper II).

Physical problems, such as tiredness, musculoskeletal symptoms and abdominal pain, and emotional problems such as depressive symptoms, increased the risk of poor SRH in both primiparas and multiparas at one or both time points. Negative experience of breastfeeding (2 months) and infant sleeping problems (1 year) were infant-related risk factors in both groups, and prematurity was a risk factor in primiparas at two months. Insufficient social support increased the risk in multiparas. In primiparas, outcome of labor, such as negative birth experience after operative delivery was associated with poor SRH at one year, and perineal pain at two months (Paper III).

The qualitative study showed that the question on SRE was a measure of women's general health and wellbeing in their present life situation, but it did not seem to measure recovery after childbirth specifically. The question on SRH seemed to capture a woman's total life situation, such as family functioning and wellbeing, relationship with partner, the issue of combining motherhood and professional work, level of energy, physical symptoms and emotional problems affecting daily life, stressful life events, chronic disease with ongoing symptoms, body image, physical exercise, and feelings of happiness and joy. Neither childbirth-related events nor some childbirth-related symptoms (urogenital and anal symptoms) were included in women's reasoning (Paper IV).

In conclusion, this thesis shows that physical problems were common in early motherhood, but in spite of this, few women assessed their health as poor. Self-rated health mainly captures a woman's total life situation as well as ongoing physical and emotional health problems affecting daily life. The quantitative study suggests that mode of delivery and childbirth experience have long-term effects on SRH, but the qualitative study did not support this finding, showing that more research is needed on long-term effects of childbirth on mothers' experiences of their health.