Received: 27 June 2016 Revised: 10 August 2018 Accepted: 10 October 2018

DOI: 10.1111/ijun.12176

RESEARCH PAPER

Examining prevalence of urinary incontinence and risk factors

in women in third postpartum month
Ayten Dinç PhD1 | Sibel Oymak PhD2 | Merve Çelik MD2

1
The Department of Midwifery, School of
Health, Canakkale Onsekiz Mart University, Are pregnancy and birth-related parameters important risk factors in the development of urinary
Canakkale, Turkey incontinence (UI)? The aim of this study is to examine the prevalence of UI and associated risk
2
The Department of Public Health, School of factors in Turkish women in the third postpartum month. Incontinence after childbirth is a com-
Medicine, Canakkale Onsekiz Mart University,
mon problem. A cross-sectional study that included 370 women in third postpartum month in
Canakkale, Turkey
Çanakkale is presented in this paper. Wagner's quality of life scale questionnaire exploring the
Correspondence
Assistant Professor, Ayten Dinç, The risk factors for UI was used as the principle data collection tool. All women gave consent prior
Department of Midwifery, School of Health, to inclusion in the study. Chi-square, t test, Mann-Whitney U test and Binary logistic regression
Canakkale Onsekiz Mart University, Terzioglu were used for comparison. The prevalence of self-reported postpartum UI was 35.9%. In this
Campus, 17100 Canakkale, Turkey.
study; age, educational level, parity, number of normal birth, nocturia and constipation were
Email: [email protected]
determined to be the associated risk factors for postpartum UI in univariate analysis. When
examining these risk factors by using logistic regression, it was found that the number of birth
being 2 increased UI 2.7 times (P = 0.002, 95% CI:1.434-5.324), the number of birth being 3 or
more increased UI 20.3 times (P = 0.001, 95% CI:7.130-58.332) and nocturia being 3 times and
more increased UI 2.6 times (P = 0.041, 95% CI:1.042-6.790). Pregnancy and birth-related
parameters are important risk factors in development of UI. It would be useful to increase the
awareness in women in pregnancy and the postpartum period, by providing health training and
consultancy services about UI protection and the reduction of risk factors.

KEYWORDS

prevalence, risk factors, urinary incontinence, postpartum, quality of life, women

1 | B A C KG RO U N D In the literature, it is reported that the rate of incontinence

during pregnancy is between 32% and 64%,6 with the prevalence
Urinary incontinence (UI) has been defined by the International Conti- of UI being 32% to 36% 3 months postpartum. The prevalence of
nence Society as: “the complaint of any involuntary leakage of urine.”1 incontinence following vaginal birth has been reported to be 31%
Globally, it is suggested that more than 200 million people are and prevalence of incontinence following caesarean section has
experiencing UI problems and its prevalence is between noted to be been reported as 15%.7 While there are many studies8–13 examin-
2
10% and 60%. Additionally, UI is 2 to 5 times higher in women com- ing frequency of postpartum UI and risk factors in different socie-
pared with men.3 ties, there are a limited number of studies conducted on this
Pregnancy and birth-related risk factors (number of term preg- subject in Turkey. In the study conducted by Ege et al14 with
nancy, parity, delivery methods, birth complications, presence of episi- women in 12-month postpartum period, prevalence of UI was
otomy/tears, the infant's birth weight and micturation-related 19.5% at varying degrees.
problems after childbirth) have all been identified as having an impor- The aim of this study was to examine the prevalence of UI, the
tant role in the development of UI.4 In addition, it is also suggested risk factors and quality of life (QOL) women in third postpartum
that UI occurs as a result of weakness of pelvic muscle strength at the months who applied to primary and secondary health institutions in
rate of 22% to 35% during pregnancy and the postpartum period.5 Çanakkale, Turkey.

Int J Urol Nurs. 2019;13:13–22. wileyonlinelibrary.com/journal/ijun © 2018 BAUN and John Wiley & Sons Ltd. 13
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14 DINÇ ET AL.

2 | MATERIALS AND METHODS

WHAT IS KNOWN ABOUT THIS TOPIC
2.1 | Sample and data collection • Pregnancy and birth-related parameters are important
The sample of the prevalance study was obtained from the mothers in risk factors in development of urinary incontinence.
third postpartum months who applied to Çanakkale State Hospital • No studies have adequately identified the UI prevalence
and three family health centres for examination of their children and the risk factors involved for women in Turkey.
between April and December 2013. A convenience sampling tech-
nique was used in the study. In the literature, UI prevalence is WHAT THIS PAPER ADDS
7
reported to be 33% on average in third postpartum month. By using
• This study identifies the prevalence and risk factors of
the sample calculation formula in the group with known population,
UI in women in our country.
the total sample size was in this study determined as 337 participants
• The prevalence of UI in women was found to be high
with error rate of 5% and confidence level (CI) of 95%.
and to increase with age.
The data collection related to the UI was conducted through self-
• In this study; age, educational level, parity, number of
administered questionnaires. The inclusion criteria of the present
normal birth, nocturia and constipation were deter-
study were mothers who were in the third postpartum month, able to mined to be the associated risk factors for postpar-
read and write Turkish and who gave consent to participate in the tum UI.
study, while the exclusion criteria were those mothers diagnosed with
a urinary tract infection, genito-urinary tract pathology, or who were
unable to communicate Turkish or were illiterate.

2.4 | Ethics
2.2 | Instruments Ethical approval was obtained from the Çanakkale Onsekiz Mart

In the present study, data were collected using a questionnaire devel- University Clinical Trials Ethics Committee. All participants gave their

oped by the investigators to collect information on socio-demographic informed consent for inclusion before they participated in the study.
For this study, written permission no: 127/2013-73 was obtained from
and urogynaecologic characteristic and UI-related risk factors based
Çanakkale Onsekiz Mart University Clinical Trials Ethics Committee.
on information in the literature and Wagner's QOL scale.

2.5 | Data analysis

2.2.1 | Wagner's quality of life scale
SPSS statistical 20.0 (SPSS 20, IBM, Armonk, NY, USA) software pack-
Wagner's QOL scale was developed by Wagner and associates in
age was used for data entry and analysis. Compliance of variables with
1996 to assess the incontinence-specific QOL in individuals with UI
the normal distribution was examined using the Kolmogorov-Smirnov
and was tested for validity and reliability.15 This instrument contains
test. Mean, SD, frequency, percentage, minimum and maximum values
psychometric properties of UI involving two sub-domains: psychologi-
were used for delivery of descriptive data. Mann-Whitney U test was
cal well-being and functional status. The Turkish version of the scale
used for variables, which were not normally distributed, in the evalua-
was used by Karan's group.16 This scale poses 28 questions to women
tion of difference between the groups during the data analysis. Chi-
related to UI, their daily lives and psychosocial characteristics. Partici-
square test was used in univariate analysis of dependent and indepen-
pants are asked to answer each question by selecting one of the fol-
dent variables. The correlation between continuous variables was exam-
lowing alternatives, “no, mild, moderate and severe.” The answers are
ined by using Spearman's correlation test. Retrospective statistical
scored as 0, 1, 2 and 3, respectively. According to this, a total score of methods among stepwise methods were preferred as analysis tech-
0 signified that there was not any incontinence or any psychosocial nique. As dependent variables, cases of UI, post-partum UI and UI dur-
problem, 1 to 28 means a mild degree disorder, 29 to 56 means a ing pregnancy were examined by performing three separate logistic
moderate disorder and 57 to 84 is taken to mean a severe disorder. regression analysis. In the statistical tests, P-value of <0.05 was consid-
ered as statistically significant.

2.3 | Procedure
3 | RE SU LT S
Data were collected through face-to-face interviews by midwifery
students trained in the administration of data collection form in poly-
clinic rooms. All participants were given information about the study 3.1 | Socio-demographic findings and characteristics
prior to inclusion in the study. During the interviews, questions were 35.9% of 370 women, who participated in the study (n = 133), experi-
read, and the appropriate choices were marked on the questionnaire enced UI. When the women who experienced and did not experience
according to the postpartum women's answers. Interviews of 10 to UI were compared in terms of socio-demographic characteristics, a
15 minutes were conducted 2 or 3 days a week. statistically significant difference was determined between the two
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DINÇ ET AL. 15

groups in terms of the average ages (P < 0.001). The average age of abortus, curettage, long-time delivery, complications after normal,
women with UI was observed to be higher. When age groups were delivery). Nocturia being 3 times and more and rate of constipation
examined, it was observed that those complaining of UI were older were higher in those with UI compared to those without UI (respec-
and those experiencing no UI were in the younger age groups tively, P = 0.021, <0.001) (Table 2).
(P < 0.001). In our study group, as educational level increased, the In logistic regression analysis “state of having urinary incontinence”
complaint of UI decreased (P < 0.001). No statistically significant dif- was included as a dependent variable. Six of nine independent variables
ference was determined between both groups in terms of employ- which were initially included in the analysis (weight of infant, age group,
ment status, income level, body mass index (BMI) and smoking status number of normal birth, parity, educational level, constipation, nocturia,
(respectively, P = 0.532, P = 0.860, P = 0.921) (Table 1). mode of delivery, number of pregnancy), were excluded during stepwise
analysis (P > 0.05). The model consisted of the remaining three inde-
pendent variables (parity, constipation and night incontinence).
3.2 | The correlation of the obstetrics
Analysis of risk factors, that affected UI, with logistic regression
and health-related results with UI
showed that; number of births being 2 increased UI 2.7 times
The number of pregnancies, number of births and the weight of the (P = 0.002, 95% confidence interval (CI): 1.434-5.324), the number of
heaviest infant of those who experienced UI were higher than those births being 3 or more increased UI 20.3 times, (P < 0.001, 95% CI:
who did not experience UI and the difference between the two 7.130-58.332), nocturia being 3 times and more increased UI 2.6
groups was statistically significant (respectively P < 0.001, P < 0.001, times (P = 0.041, 95% CI: 1.042-6.790) (Table 3).
P = 0.001). Of those who experienced UI, 64.9% underwent a vaginal
delivery (P = 0.002). The weight of the last infant of those who expe-
3.3 | Descriptive results of participants with UI and
rienced UI was higher than those who did not experience UI
(P = 0.001). The number of births of those with UI was higher than of
results of Wagner's QOL scale (incontinence QOL
those without UI (P < 0.001). There was no difference between the
scale)
two groups in terms of other obstetric characteristics (the last delivery Of those with UI, 76.7% noted that the urinary continence problem
interval, the first age of delivery, number of caesarean sections, started during pregnancy, with stating that it 12.8% began before

TABLE 1 Continence status of the study group in terms of the socio-demographic characteristics, Çanakkale, 2013

Urinary incontinence (+) (n = 133) Urinary incontinence (−) (n = 237) Total (n = 370)
Variables Mean  SD Mean  SD Mean  SD Pb value
Age 29.8  5.7 26.6  4.9 27.7  5.4 <0.001
n (%) a
n (%) a
n (%) a
Pc
Age groups
18-29 63 (47.4) 166 (70.0) 229 (61.9)
30-39 67 (50.4) 69 (29.1) 136 (36.8) <0.001
40 and over 3 (2.3) 2 (0.8) 5 (1.4)
Education status
Primary school and less 109 (82.0) 155 (65.4) 264 (71.4) 0.001
High school and more 24 (18.0) 82 (34.6) 106 (28.6)
Work status
Having a job 16 (12.0) 34 (14.3) 50 (13.5) 0.532
None 117 (88.0) 203 (85.7) 320 (86.5)
Income status
Good 83 (62.4) 142 (59.9) 225 (60.8)
Moderate 43 (32.3) 80 (33.8) 123 (33.2) 0.860
Poor 7 (5.3) 15 (6.3) 22 (5.9)
Body mass index
Underweight 2 (1.5) 0 (0.0) 2 (0.5)
Normal 66 (49.6) 122 (51.5) 188 (50.8) 0.921
Overweight 62 (46.6) 111 (46.8) 173 (46.8)
Obese 3 (2.3) 4 (1.7) 7 (1.9)
Smoking status
Yes 25 45 70 0.964
No 108 192 300
a
Column percentage.
b
Mann-Whitney U testi.
c
Chi-square test.
Bold P < 0.05 = statistical significance.
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16 DINÇ ET AL.

TABLE 2 Distribution of complaint of UI in terms of obstetric and gynaecological characteristics of the study group, Çanakkale, 2013

Urinary incontinence (+) (n = 133) Urinary incontinence (−) (n = 237) Total (n = 370)
Variables Mean  SD Mean  SD Mean  SD Pb
Number of pregnancy 2.3  1.1 1.6  0.8 2.5  0.9 <0.001
The last delivery interval 5.5  3.7 4.6  3.0 5.0  3.3 0.147
The first age of delivery 23.3  4.9 23.4  4.6 23.4  4.7 0.590
The most weight baby 3466.8  625.0 3259.5  526.2 3334.0  571.6 0.001
n (%)a n (%)a n (%)a Pc
The last delivery type
Vaginal delivery 85 (64.9) 113 (47.9) 198 (54.0) 0.002
Caesarean section (CS) 46 (35.1) 123 (52.1) 169 (46.0)
The weight of the last birth baby
2500< 7 (5.3) 19 (8.0) 26 (7.0)
2500-2999 17 (12.8) 45 (19.0) 62 (16.8) 0.001
3000-3999 80 (60.2) 155 (65.4) 235 (63.5)
4000 ≥ i 29 (21.8) 18 (7.6) 47 (12.7)
Parity
1 39 (29.3) 141 (59.5) 180 (48.6)
2 52 (39.1) 88 (37.1) 140 (37.8) <0.001
3 and more 42 (31.6) 8 (3.4) 50 (13.5)
Normal delivery number
1 37 (37.0) 85 (71.4) 122 (55.7)
2 36 (36.0) 32 (26.9) 68 (31.1) <0.001
3 and more 27 (27.0) 2 (1.7) 29 (13.2)
Number of CS
1 28 (53.8) 74 (56.0) 102 (55.5)
2 and more 24 (46.2) 58 (44.0) 82 (44.5) 0.786
Number of abortus
1 20 (90.9) 31 (93.9) 51 (92.7) 0.528
2 2 (9.1) 2 (6.1) 4 (7.3)
Number of curettage
1 13 (81.2) 15 (78.9) 28 (80.0)
2 and more 3(18.7) 4 (21.0) 7 (20.0) 0.755
Did your delivery time was long?
Yes 20 (17.1) 40 (17.1) 60 (17.1)
No 97 (82.9) 194 (82.9) 291 (82.9) 0.564
Complications after normal delivery
Episiotomy 82 (92.1) 102 (92.7) 184 (92.5) 0.875
Third degree episiotomy/tear 7 (7.9) 8 (7.3) 15 (7.5)
Nocturia
0-2 times 109 (82.0) 214 (90.3) 323 (87.3) 0.021
≥3 24 (18.0) 23 (9.7) 47 (12.7)
Urinary infection
None 87 (65.4) 147 (62.0) 234 (63.2)
1 or 2 a year 28 (21.1) 57 (24.1) 85 (23.0) 0.740
3 and more a year 18 (13.6) 33 (13.9) 51 (13.8)
Constipation
No 74 (55.6) 179 (75.0) 253 (68.4) <0.001
Yes 59 (44.0) 58 (24.5) 117 (31.6)
Having an operation
Urogenital 2 (9.1) 7 (21.3) 9 (16.3) 0.234
General surgery 20 (90.9) 26 (78.7) 46 (83.6)
a
Column percentage.
b
Mann-Whitney U test.
c
Chi-square test.
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DINÇ ET AL. 17

TABLE 3 Examination of the risk factors affecting urinary TABLE 4 Descriptive results of urinary incontinance compliance and
incontinence with logistic regression, Canakkale, 2013 Wagner incontinence quality of life scale of study group, Çanakkale, 2013
β value OR CI 95% Pa Variables Number (n) Percentage (%)
Constant −1.398 0.247 — — Urinary incontinence (UI)
Parity Yes 133 35.9
1 (0) — — — <0.001 No 237 64.1
2 (1) 1.016 2.763 1.434-5.324 0.002 UI started
3 and more (2) 3.015 20.394 7.130-58.332 <0.001 Before pregnancy 17 12.8
Constipation During pregnancy 102 76.7
No (0) — — — — After pregnancy 14 10.5
Yes (1) 0.617 1.853 0.987-3.481 0.055 UI during pregnancy
Nocturia 1th trimester 31 26.0
0-2 — — — — 2th trimester 39 32.8
3 and more 0.978 2.660 1.042-6.790 0.041 3rd trimester 49 41.2
Postpartum UI
Abbreviations: CI, confidence interval; OR, odds ratio.
a
Backward Stepwise (Conditional) logistic regression analysis Yes 64 17.3
No 306 82.7
pregnancy. The UI was observed mostly during the third trimester of Postpartum UI started
pregnancy. The rate of those who experienced postpartum UI was <1 month 33 51.6
17.3%, and the start of the UI was the first month. While 50.7% of 1-2 month 7 10.9
the women with UI were experiencing UI once a month, 18.5% were 3 month 24 37.5
experiencing UI 2 to 4 times a week. Frequency of using continence Frequency of UI
containment products was 11.9%. 73.9% of the women defined the One more time a day 3 4.6
amount of UI as one or two drop(s) and 34.3% of the women Once a week 7 10.8
restricted their physical activities because of UI. The rate of those Once a week 10 15.4
who attended medical institutions due to UI was 37.1%. The rate of 2-4 times in a week 12 18.5
the women who knew Kegel exercise was 20.9%, whereas the rate of Once a month 33 50.7
those who performed Kegel exercise was 14% (Table 4). The number Using diaper during UI
of people who completed the QOL questionnaire was 59 in the study Yes 8 11.9
group. The total mean score of the Wagner incontinence QOL scale No 59 88.1
was 13.2  11.9 (min-max: 0-63). In the sample group, 91% of Amount of UI
women having the complaint of UI stated that UI slightly affected One or two drop(s) 51 73.9
their QOL, whereas 5.1% reported that UI had no effect on Moistness of pad or clothes 13 18.8
their QOL. Wetness of pad or clothes 5 7.3
When asked what caused UI (n = 123), sneezing (72.4%), cough- Restricted physical activities
because of UI
ing (71.5%) and laughing (61%) were the top activities reported.
Yes 24 34.3
No 46 65.7
3.4 | Risk factors in terms of the UI in pregnancy Applied to medical institutions
and postpartum period due to UI
Yes 26 37.1
In this study, the frequency of UI in the age group of 30 to 39 years in
No 44 62.9
postpartum period, and in the age group of 18 to 29 years during
Do you know Kegel exercise?
pregnancy was higher than other age groups in a statistically signifi-
Yes 73 20.9
cant way (respectively P = 0.001; P = 0.004). The complaint of UI in
No 277 79.1
pregnancy and postpartum period was higher in women with lower
Do you perform Kegel exercise?
educational levels (respectively, P < 0.001; P = 0.011). The prevalence
Yes 49 14.0
of UI complaint in pregnancy and the postpartum period was lower in
No 301 86.0
those who had one parity and one normal delivery, and it was found
Mean  SD Min-max
to be statistically significant (respectively, P < 0.001; P = 0.001). The
Impact on QOL 13.2  11.9 0-63
complaint of UI in pregnancy and postpartum the period in those with
Impact on QOL n %
constipation was higher (respectively, P < 0.001; P = 0.004) (Table 5).
No (0) 3 5.1
In the second logistic regression analysis, “status of urinary incon-
Mild (1-28) 54 91.5
tinence in pregnancy” was included as the dependent variable. Three
Moderate (29-56) 0 0
out of six independent variables (number of normal births, parity, age
Severe (57-84) 2 3.4
group, educational level, nocturia and constipation), which were
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18 DINÇ ET AL.

TABLE 5 Risk factors in terms of the urinary incontinence in pregnancy and postpartum periods, Canakkale, 2013

Urinary incontinence in pregnancy Postpartum urinary incontinence

Absence Presence Absence Presence
Variables n (%)a n (%)a Pb n (%)a n (%)a Pb
Age groups
18-29 170 (67.7) 59 (49.6) 200 (65.4) 29 (45.3)
30-39 79 (31.5) 57 (47.9) 0.001 102 (33.3) 34 (53.1) 0.004
40 and over 2 (0.8) 3 (2.5) 4 (1.3) 1 (1.6)
BMI
Underweight 0 (0.0) 2 (1.7) 1 (0.3) 1 (1.6)
Normal 128 (51.0) 60 (50.4) 0.611 154 (50.3) 34 (53.1) 0.615
Overweight 118 (47.0) 55 (46.2) 146 (47.7) 27 (42.2)
Obese 5 (47.0) 2 (1.7) 5 (1.6) 2 (3.1)
Education status
High school and more 86 (34.3) 20 (16.8) <0.001 96 (31.4) 10 (15.6) 0.011
Primary school and less 165 (65.7) 99 (83.2) 210 (68.6) 54 (84.4)
Job status
Works 35 (13.9) 15 (12.6) 0.431 43 (14.1) 7 (10.9) 0.507
Not work 216 (86.1) 104 (87.4) 263 (85.9) 57 (89.1)
Income status
Good 151 (60.2) 74 (62.2) 184 (60.1) 41 (64.1)
Moderate 84 (33.5) 39 (32.8) 0.619 103 (33.7) 20 (31.2) 0.513
Poor 16 (6.4) 6 (5.0) 19 (6.2) 3 (4.7)
Parity
1 145 (57.8) 35 (29.4) <0.001 159 (52.0) 21 (32.8)
2 93 (37.1) 47 (39.5) 120 (39.2) 20 (31.2) <0.001
3 and more 13 (5.1) 37 (31.1) 27 (8.8) 23 (35.9)
Normal vaginal birth
1 91 (69.5) 31 (35.2) 97 (60.2) 25 (43.1)
2 36 (27.5) 32 (36.4) <0.001 49 (30.4) 19 (32.8) 0.001
3 and more 4 (4.0) 25 (28.4) 15 (9.3) 14 (24.1)
CS birth
1 78 (56.5) 24 (52.2) 89 (53.9) 13 (68.4)
2 and more 60 (43.5) 22 (47.8) 0.246 77 (46.1) 6 (31.6) 0.427
Nocturia
0-2 227 (90.4) 96 (80.7) 0.008 275 (89.9) 48 (75.0) 0.001
≥3 24 (9.6) 23 (19.3) 31 (10.1) 16 (25.0)
Urinary infection
None 155 (61.8) 79 (66.4) 195 (63.7) 39 (60.9)
1-2 in a year 60 (23.9) 25 (21.0) 0.689 71 (23.2) 14 (21.9) 0.685
3 and more in a year 36 (14.3) 15 (12.6) 40 (13.1) 11 (17.2)
Constipation
No 188 (74.9) 65 (54.5) <0.001 219 (71.6) 34 (53.1) 0.004
Yes 63 (25.1) 54 (45.5) 87 (28.4) 30 (46.9)

Abbreviations: BMI, body mass index; CS, caesarean section.

a
Percentage: column percentages were used.
b
P-value was estimated by chi-square analysis.

initially included in the analysis, were excluded during stepwise analy- more increased UI in pregnancy 12.8 times (95% CI: 5.249-31.349,
sis (P > 0.05). The model consisted of the remaining three indepen- P < 0.001). Constipation increased UI in pregnancy 1.9 times and noc-
dent variables (parity, constipation and nocturia). Table 6 illustrates turia being 3 times and more increased UI in pregnancy 2.9 times
logistic regression results of the risk factors that were thought to be (Table 6).
effective on UI in pregnancy. In the third logistic regression analysis, “status of postpartum uri-
The number of births being 2 increased UI in pregnancy 2.7 times nary incontinence” was included as the dependent variable. Four out
(95% CI: 1.417-5.503, P = 0.003), the number of birth being 3 and of six independent variables (number of normal birth, parity, age
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DINÇ ET AL. 19

TABLE 6 Logistic regression results of the risk factors for urinary that while prevalence of UI was higher at advancing ages, those hav-
incontinence in pregnancy, Çanakkale, 2013 ing no complaint of UI were in the younger age groups (P < 0.001).
Urinary In this study, as the educational level increased, the complaint of
incontinence in UI decreased. No statistically significant difference was determined
pregnancy β value OR CI 95% P-value
between both groups in terms of employment status, income level
Constant −1.672 0.188 — <0.001
and BMI. In the study of Kocaöz et al22 no correlation was determined
Parity
between pregnant women's educational level, employment status and
1 (0) — 1.0 — <0.001
UI. In a study from Portugual, maternal socio-demographic character-
2 (1) 1.027 2.792 1.417-5.503 0.003
istics analysed, such as education, occupation and physical efforts
3 and more (2) 2.552 12.827 5.249-31.349 <0.001
showed no statistically significant differences between groups of
Constipation (1) 0.678 1.970 1.052-3.691 0.034
women with or without self-reported UI in the postpartum, but
Nocturia (1) 1.091 2.978 1.193-7.433 0.019
women with at least secondary education reported UI in the postpar-
Abbreviations: CI, confidence interval; OR, odds ratio.
a tum in greater proportion compared to women with less education.10
Backward Stepwise (Conditional) logistic regression analysis.

4.1 | Discussion of obstetric and health-related

group, educational level, nocturia and constipation), which were ini-
results
tially included in the analysis, were excluded during stepwise analysis
(P > 0.05). The model consisted of the remaining two independent Obstetric factors are reported to play an important role in develop-

variables (parity and nocturia). Table 7 illustrates logistic regression ment of UI.4,13,19,24–26 In the present study, the number of pregnan-

results of the risk factors that are thought to be effective on UI in cies, number of births and the weight of the heaviest infant were
higher in those who experienced UI compared with those who did not
postpartum period. The number of birth being 3 and more increased
experience UI. Several studies have reported that UI can be result
postpartum UI 5 times (95% CI: 2.239-11.429, P < 0.001), nocturia
from mode of delivery. It is reported that UI developed more in those
being 3 times and more increased postpartum UI 4.4 times (95% CI:
who had a vaginal birth than those who had gave birth by caesarean
1.879-10.375, P = 0.001) (Table 7).
section.4,7,20 In our study group, those who experience UI had vaginal
births at a higher rate. UI was at higher rate in participants whose last
4 | DISCUSSION infant was 4000 g or more in weight. The number of births and the
number of normal births of those who had UI were higher compared
The incidence and prevalence of UI postpartum are also high, with to those who did not. Nocturia and rates of constipation were higher
12 in those who experienced UI compared to those who did not experi-
estimates of 5% to 21% and 15% to 45%, respectively. Authors of a
systematic review reported a pooled prevalence of UI of 29% and ence. Granese and Adile24 reported the most frequent risk factors for
33% 3 months postpartum among primiparous and parous women, postpartum UI were, a vaginal delivery, with a prolonged labour, and
7
respectively. It was found that prevalence of UI in third postpartum an episiotomy. The authors reported that they did not find any corre-

month among the women in the study group was 35.9% and the inci- lations with the patients' age or with the weight of the foetus.24 Hvid-

dence of postpartum UI was 10.5%. Other studies have revealed that man et al27 combining information on mode of delivery and UI during
pregnancy revealed that there is the highest occurrence of UI postpar-
prevalence of postpartum UI is 31.2% in Canada, 34.3% in
tum (62.9%) among women delivering vaginally with experience of UI
New Zealand and 37.5% in Norway, which is similar to results of the
during the preceding pregnancy No significant association was found
present study.17–19
between UI postpartum and the child's birth weight. Zhu et al13 multi-
It is reported in the literature that even though UI can be
variable analysis revealed that age, higher BMI and history of consti-
observed at all ages, increased age is a risk factor.20–23 The average
pation were found to be risk factors for stress urinary incontinence.
age of the women experiencing the complaint of UI in the present
Our findings were found to be similar to the literature. Both the
study was 29.8  5.7 years. According to age groups; it was found
results of the present study and the literature reveal that being over-

TABLE 7 Logistic regression results of the risk factors for urinary weight before pregnancy is a risk factor in late antenatal and early
incontinence in postpartum period, Çanakkale, 2013 postpartum periods for women in the development of UI11,28 and
forms an important point for health professionals, especially midwives
Postpartum urinary
incontinence β value OR CI 95% P-value and nurses to consider in their education of the public. In the present
Constant −1.777 0.169 — <0.001 study, it was not found that urinary tract infection was a risk factor
Parity for development of UI. In another study, a significant correlation was
1 (0) — 1.0 — <0.001 found between urinary tract infection and stress incontinence.22 Uri-
2 (1) 0.401 1.494 0.697-3.201 0.302 nary system infections are a risk factor for UI due to causing involun-
3 and more (2) 1.621 5.059 2.239-11.429 <0.001 tary stimulation of detrusor muscle contractions.
Nocturia (1) 1.485 4.415 1.879-10.375 0.001 In this study, as the analysis of risk factors, that affected UI, with
logistic regression showed that; number of birth being 2 increased UI
Abbreviations: CI, confidence interval; OR, odds ratio.
Backward Stepwise (Conditional) logistic regression analysis. 2.7 times, number of birth being 3 and more increased UI 20.3 times,
 1749771x, 2019, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/ijun.12176 by Yildirim Beyazit University, Wiley Online Library on [21/10/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
20 DINÇ ET AL.

nocturia being 3 times and more increased UI 2.6 times. Kocaöz that the prevalence of UI was quite high during the late third trimester
29
et al showed that bivariate logistic regression revealed an increase (53.8%) and decreased significantly 3 months postpartum (7.8%). A
in likelihood of experiencing UI in women who had 2 birth increased recent meta-analysis of international studies of postpartum UI found
UI 5.1 times, 3 or more births increased UI 5.02 times, compared to rough consistency across studies, that is, a mean incidence of any UI
nulliparous women (P < 0.05). Parity is considered a major risk factor of 33% at 3 months postpartum.7
30
for UI in another study. In this study, the frequency of UI in the age group of 30 to 39 years
in postpartum period, and in the age group of 18 to 29 years during
pregnancy was higher than other age groups in a statistically significant
4.2 | UI complaints and QOL of women with UI
way. The complaint of UI in pregnancy and postpartum period was
UI is common in association with pregnancy. A large proportion of higher in women with lower educational level. The prevalence of UI
women experience new onset of UI symptoms during pregnancy complaint in pregnancy and postpartum period was lower in those who
(17%-54%). Prevalence estimates during pregnancy are reported to be had birth number of 1 and number of normal birth of 1, and it was found
35% to 67%.7 In the present study, UI problem of 76.7% of those with to be statistically significant. The complaint of UI in pregnancy and post-
UI started during pregnancy, and UI problem of 12.8% began before partum period in those with constipation and nocturia were higher.
pregnancy. In this study, the UI was observed mostly during third tri- These findings do not differ from those of other authors, which
mester (41.2%). Kocaöz et al22 found UI prevalence as 87.7% in the showed that age of women at childbirth,2,20,29,36,37 parity,2,19,25,36 and
third trimester. In our study, we found that the rate of those who mode of previous birth,8,19,24,25,37 education status,29
experienced postpartum UI was 17.3%, and the beginning time of UI constipation, 13,22
nocturia 38
influence the occurrence of incontinence
was the first month at most. While 50.7% of those with UI were during pregnancy or postpartum.
experiencing UI once a month, 18.5% were experiencing this problem
2 to 4 times a week. Frequency of using containment products was
4.4 | Evaluation of logistic regression results of UI-
11.9%; 73.9% defined the amount of incontinence as one or two
related risk factors in pregnancy and postpartum
drop(s).
period
UI is a health problem which although not life-threatening does
have a negative effect on the QOL of the women who experience Increasing parity was also a significant risk factor incontinence. In the
it. UI had moderate to severe impact on QOL in 10% to 22% of the present study, the number of birth being 3 and more increased post-
31 32
individuals. Dolan et al determined that UI affected general health partum UI 5 times, the number of birth being 3 and more increased UI
condition of women in the postpartum period and Hatem et al33 in pregnancy 12.8 times. Arrue et al39 showed that the presence of
found that postpartum UI was a negative effect on the QOL. Kocaöz SUI during pregnancy increases the risk of incontinence 6 months
et al22
determined that UI slightly affected or unaffected the QOL of after delivery 3.7 times. Wesnes et al28 included only primiparous
pregnant women. Results of the QOL scale showed that the women women in their study, and indicated that being incontinent during
in our study group do not care about the problem of UI; 34.3% of the pregnancy increased the risk of being incontinent 6 months after
women were restricting their physical activities because of UI. The delivery 3.5 times.
rate of those applying to health institutions due to UI is 37.1%. When A systematic review identified cross-sectional studies on primipa-
considering that a great majority of the women participating in the rous women with data on the effect of CS compared to vaginal deliv-
study were primary school graduates and unemployed, it can be ery on stress UI postpartum (odds ratio [OR] 0.6, 95% CI 0.4-0.9).40
thought that women perceive this problem as a result of fertility and The same review presented risk estimates based on cohort studies,
therefore they do not receive help to solve it. leading to an OR of 0.4 (95% CI 0.3-0.5) for UI after CS compared to
Pelvic floor muscle exercises, a conservative treatment method, spontaneous vaginal delivery. In a systematic review on UI postpar-
are recommended as the most appropriate treatment method for tum, pooled prevalences of UI 3 to 12 months postpartum were 15%
women with UI in pregnancy and the postpartum period. 34,35 and 31% after CS and vaginal delivery, respectively.7 Chang et al8 the
vaginal delivery group had a significant higher prevalence of any UI at
4 to 6 weeks and at 3, 6 and 12 months (29.1%-40.2% vaginal com-
4.3 | Risk factors in terms of UI in pregnancy and
pared with 14.2%-25.5% caesarean).
postpartum period
Women have a higher tendency of constipation due to the effect
UI in pregnancy appears to be associated with UI postpartum. Studies of progesterone on smooth muscles during pregnancy. Straining dur-
reporting prevalence separately by continence status prior to preg- ing defecation is thought to cause stress incontinence.9 In accordance
nancy found substantially lower prevalence of postpartum inconti- with the literature, in the present study, constipation increased UI 1.9
nence in women who were continent prior to pregnancy. Wilson times, nocturia being 3 times and more increases UI 2.9 times. In a
19
et al found the prevalence of any incontinence at 3 months to be cohort study from China, women enrolled ≥ week 28 found constipa-
44% among 835 parous women with incontinence some time prior to tion to be a risk factor for stress UI during pregnancy (OR 1.3), and
pregnancy and 23% among 667 parous women without incontinence 6 months postpartum (OR 1.6).13 In different studies conducted in
prior to pregnancy. Zhu et al13 reported prevalence of all UI was Turkey, constipation was determined to be a risk factor and was
26.7% in late pregnancy, 9.5% at 6 weeks postpartum and 6.8% at reported to increase the UI 3.1 times41 and 4.16 times during
11
6 months postpartum. Tanawattanacharoen and Thongtawee, found pregnancy.22
 1749771x, 2019, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/ijun.12176 by Yildirim Beyazit University, Wiley Online Library on [21/10/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
DINÇ ET AL. 21

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