Christine MacArthur

Faecal incontinence after childbirth

Objective To measure the prevalence and severity of postpartum faecal incontinence, especially new incontinence, and to identify obstetric risk factors.

Women's groups practising participatory learning and action to improve maternal and newborn health in low-resource settings: a systematic review and meta-analysis

BACKGROUND Maternal and neonatal mortality rates remain high in many low-income and middle-income countries. Different approaches for the improvement of birth outcomes have been used in community-based interventions, with heterogeneous effects on survival. We assessed the effects of womens groups practising participatory learning and action, compared with usual care, on birth outcomes in low-resource settings. METHODS We did a systematic review and meta-analysis of randomised controlled trials undertaken in Bangladesh, India, Malawi, and Nepal in which the effects of womens groups practising participatory learning and action were assessed to identify population-level predictors of effect on maternal mortality, neonatal mortality, and stillbirths. We also reviewed the cost-effectiveness of the womens group intervention and estimated its potential effect at scale in Countdown countries. FINDINGS Seven trials (119,428 births) met the inclusion criteria. Meta-analyses of all trials showed that exposure to womens groups was associated with a 37% reduction in maternal mortality (odds ratio 0.63, 95% CI 0.32-0.94), a 23% reduction in neonatal mortality (0.77, 0.65-0.90), and a 9% non-significant reduction in stillbirths (0.91, 0.79-1.03), with high heterogeneity for maternal (I(2)=58.8%, p=0.024) and neonatal results (I(2)=64.7%, p=0.009). In the meta-regression analyses, the proportion of pregnant women in groups was linearly associated with reduction in both maternal and neonatal mortality (p=0.026 and p=0.011, respectively). A subgroup analysis of the four studies in which at least 30% of pregnant women participated in groups showed a 55% reduction in maternal mortality (0.45, 0.17-0.73) and a 33% reduction in neonatal mortality (0.67, 0.59-0.74). The intervention was cost effective by WHO standards and could save an estimated 283,000 newborn infants and 41,100 mothers per year if implemented in rural areas of 74 Countdown countries. INTERPRETATION With the participation of at least a third of pregnant women and adequate population coverage, womens groups practising participatory learning and action are a cost-effective strategy to improve maternal and neonatal survival in low-resource settings. FUNDING Wellcome Trust, Ammalife, and National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care for Birmingham and the Black Country programme.

Smoking in pregnancy: effects of stopping at different stages

Summary. Of 4341 pregnant women, 3106 were non‐smokers and 1235 were smokers at the start of pregnancy. Eighty‐five had stopped smoking before 6 weeks gestation, 119 between 6 and 16 weeks, and 56 stopped after 16 weeks. A further 51 stopped temporarily and 924 smoked throughout pregnancy. The mean birthweight of the groups differed. There were also social and biological differences such as might partly explain birthweight variations so comparisons were repeated after allowing for these factors. Standardized mean birthweights were greater for all groups who stopped than for persistent smokers. Those who stopped before 6 weeks and between 6 and 16 weeks gestation had infants 217 and 213 g, respectively, heavier than the persistent smokers and similar to the non‐smokers. Babies born to those who stopped after 16 weeks, or temporarily, were intermediate in weight. Appropriate advice is that stopping any time before 16 weeks is best, but stopping after this is still beneficial.

Obstetric practice and faecal incontinence three months after delivery

Objective To determine whether obstetric and maternal factors relate to faecal incontinence at three months postpartum.

New postnatal urinary incontinence : obstetric and other risk factors in primiparae

Objective  To identify obstetric and other risk factors for urinary incontinence that occurs during pregnancy or after childbirth.

Persistent urinary incontinence and delivery mode history: a six-year longitudinal study.

Objective  To investigate the prevalence of persistent and long term postpartum urinary incontinence and associations with mode of first and subsequent delivery.

Randomised controlled trial of conservative management of postnatal urinary and faecal incontinence: six year follow up

Abstract Objective To determine the long term effects of a conservative nurse-led intervention for postnatal urinary incontinence. Design Randomised controlled trial. Setting Community based intervention in three centres in the United Kingdom and New Zealand. Participants 747 women with urinary incontinence at three months after childbirth, of whom 516 were followed up again at 6 years (69%). Intervention Active conservative treatment (pelvic floor muscle training and bladder training) at five, seven, and nine months after delivery or standard care. Main outcome measures Urinary and faecal incontinence, performance of pelvic floor muscle training. Results Of 2632 women with urinary incontinence, 747 participated in the original trial. The significant improvements relative to controls in urinary (60% v 69%) and faecal (4% v 11%) incontinence at one year were not found at six year follow up (76% v 79% (95% confidence interval for difference in means −10.2% to 4.1%) for urinary incontinence, 12% v 13% (−6.4% to 5.1%) for faecal incontinence) irrespective of subsequent obstetric events. In the short term the intervention had motivated more women to perform pelvic floor muscle training (83% v 55%) but this fell to 50% in both groups in the long term. Both urinary and faecal incontinence increased in prevalence in both groups during the study period. Conclusions The moderate short term benefits of a brief nurse-led conservative treatment of postnatal urinary incontinence may not persist, even among women with no further deliveries. About three quarters of women with urinary incontinence three months after childbirth still have this six years later.

What influences the uptake and early cessation of breast feeding

OBJECTIVE To examine obstetric, maternal and social factors associated with the uptake and early cessation of breast feeding and womens reasons for altering from breast to bottle feeding. DESIGN Women who responded to a postal questionnaire on long-term postpartum health were contacted and asked to participate in a home-based interview. In addition to health problems, the interview obtained information on baby feeding and a number of social factors. Women were also asked to complete the Edinburgh Postnatal Depression Scale (EPDS). Obstetric and maternal data were obtained from maternity records. SETTING Deliveries from a large maternity hospital in Birmingham. PARTICIPANTS 906 women were interviewed at a mean of 45 weeks after delivery. FINDINGS 63% of the women said they had breast fed, but 40% of these stopped within three months of delivery. Many of the women gave physical problems with lactation as reasons for stopping. The factors found to be predictors of early cessation were: return to work within three months of birth; regular childcare support from other female relatives, and a high EPDS score. Non-initiation of breast feeding was predicted by a different set of factors: multiparity; general anaesthetic (GA); and unmarried status. DISCUSSION AND CONCLUSION Despite evidence of the benefits of breast feeding, this remains an unacceptable long-term option for many women, and for over one-third it is never attempted. Factors within the womans social environment were found to influence early cessation. Women who had a GA during or immediately following labour and delivery were less likely to initiate breast feeding. IMPLICATIONS FOR PRACTICE If breast-feeding incidence and duration are to increase, more attention should be paid to establishing early, successful breast feeding and countering the negative influences of factors within the social environment.

Faecal incontinence and mode of first and subsequent delivery: a six-year longitudinal study

Objective  To investigate the prevalence of persistent and long term postpartum faecal incontinence and associations with mode of first and subsequent deliveries.

Accidental dural puncture in obstetric patients and long term symptoms.

OBJECTIVE--To examine the association between accidental dural puncture and long term headache and related symptoms. DESIGN--Postal questionnaire survey to elucidate new symptoms occurring after childbirth, and linking of these to data in obstetric and anaesthetic case notes. Women were surveyed between 13 months and nine years after delivery. SETTING--Birmingham Maternity Hospital. SUBJECTS--4700 women who had delivered their most recent baby under epidural anaesthesia, 74 of whom had suffered an accidental dural puncture. MAIN OUTCOME MEASURES--Frequencies of new headache or migraine or neck ache starting within three months after childbirth and lasting over six weeks. RESULTS--Among the 74 women who had had an accidental dural puncture there were 17 (23%) who reported one or more of the above symptoms. By comparison, among those who had had an epidural anaesthetic but no recorded puncture, only 329 (7.1%) reported these symptoms. The duration of the headache or migraine or neck ache in the dural tap group ranged from nine weeks to over eight years. Ten of these women reported still unresolved symptoms. CONCLUSIONS--Conclusions on causality were tentative. Most women would remember a dural tap, and this might influence their reporting of subsequent symptoms attributable to the event. In addition, detailed characterisation of the symptoms was not available. Nevertheless, the findings provide a clear indication of the need for further study of the possible long term sequelae of accidental dural puncture.