Hypothesis / aims of study
This original enquiry examines the psycho-sexual impact of symptomatic pelvic organ prolapse (POP), on couples’ quality of life (QoL), one to four years after traumatic vaginal births. POP is defined as the downward displacement of pelvic organs, resulting in herniation of the bladder, bowel and/or uterus into the vagina and/ or anal canal, that is difficult to treat and may include consequences of sexual dysfunction [1] and post-traumatic stress disorder (PTSD) [2]. Since the introduction of imaging technology, POP is shown to be attributed to damage of the levator ani muscle (LAM), a pelvic floor structure that detaches from its insertions on the pubic bone during delivery. Prevalence is reported to involve 10-30 percent of vaginal deliveries that, increase to 30–65% from the use of forceps [1]. Research into childbirth-related psychological trauma [3], observes more women than previously realized, suffer from post-traumatic stress disorder (PTSD) after birth events [3] and related vaginal damage [2], that in the past was assigned to victims of wars and disasters. Findings reveal some deliveries elicit feelings of: actual or threatened death or serious injury, where the mother responds with intense fear, helplessness, or horror, as per stressor criteria of Diagnostic and Statistical Manual of Mental Health Disorders (DSM-5,) [ see Table 1]. Outcomes are shown to have a wide range of negative effects to couples that include: marital conflict; feelings of blame and anger; disagreements; and loss of sexual intimacy [3]. The aim of this study was to explore the impact of symptomatic POP on couples, in relation to sexual relations and psychological health, after traumatic vaginal childbirth.
Study design, materials and methods
Mixed methods enquiry, focused on interviews with women, who had sustained LAM damage and sequelae of symptomatic POP, one to four years postpartum. Quantitative data was obtained from a pelvic floor function study and related birth records [see Table 1] at two maternity hospitals between May 2013 and October 2014. Primiparous women (n=70) were identified from a population of participants (n=504), who been assessed by 3D/4D translabial ultrasound 3-6 months after vaginal deliveries. Forty mothers agreed to be interviewed on the phone, Skype or face-to-face for 40 minutes; informed consent was attained. Enquiry used semi-structured interviews with open-ended questions from developed guidelines on antenatal, intrapartum, and postpartum care. The interviewer was a midwife with extensive professional experience. Main outcome measures comprised: efficacy of antenatal classes; memory/experience of labour events; existence of informed consent regarding interventions; efficacy of postnatal assessment regarding vaginal injuries and follow-up; occurrence of postnatal sexual health education; short/long-term reactions and coping behaviour of mother regarding pelvic floor dysfunction; and long-term medical follow-up.
A separate enquiry was instigated with male partners, after numerous women, reported marital conflict and requested the
interviewer contact men to provide “...medical information on how vaginal injuries caused sexual problems”. Twenty men (n=20) were contacted between May 2013 and December 2018. Seven men (n=7) agreed to be interviewed by phone for 40 minutes and signed consent forms; the remaining (n=12) were unavailable, despite women suggesting otherwise. One man ( n=1) did not return his consent form and was removed from the study. Interview guidelines were analogous to those in maternal interviews, with a focus on observed experiences. Main outcome measures comprised men’s perceptions of: antenatal education; intrapartum events; postpartum period and maternal coping behaviour at all stages of birth.
Results
Thematic analysis of women’s interviews was undertaken using an inductive approach. In-depth analyses took place across the data set and observed 10 themes. These were reduced to four overarching themes, that observed: 1) antenatal classes lacked information on risk factors of vaginal birth; 2) bulging vaginal prolapses resulted in untenable sexual relations; 3): enduring symptoms of POP triggered sequelae of PTSD; 4) vaginal damage and outcomes of POP were poorly assessed and lacked validation. [See Table 2]
Thematic analysis of paternal interviews was analogous to the maternal study and, observed nine themes, that were reduced to three overarching themes: 1) antenatal classes did not provide information on lifestyle effects of vaginal damage, that were poorly assessed postpartum; 2) men perceived deliveries as "... violent events they were unable to prevent ” and were distressed by resultant “...emotional disconnection” of women; 3) medical knowledge on adverse effects of vaginal birth damage, was unobtainable and men were overwhelmed by loss of intimacy and marital disharmony [See Table 2].
Interpretation of results
Major vaginal birth damage, in the form of LAM avulsion, is one of the main causes of POP, with potential for lifelong morbidity and, consequences of sexual impairment [1]. Current research on childbirth related PTSD, reveals more women than realized, suffer from this disorder after complicated birth events [3]. Women in this enquiry reported marital disharmony from enduring symptoms of POP that resulted in sexual impairment, one to four years after traumatic deliveries. During interviews, they also disclosed multiple symptoms of PTSD as per DSM-5 stressor criteria [ see Table 1], that were triggered by: lack of clinical assessment for symptomatic POP; initiation of sexual relations; men’s limited understanding of vaginal prolapses. A main finding was that participants lacked information on risk factors of vaginal birth. After traumatic deliveries couples had expected some damage, but were ill-prepared for “…enduring and untenable sexual relations” from bulging vaginal prolapses. Men reported feelings of “…self-blame and a roller-coaster of emotion” during and after deliveries that were perceived as “…violent events they were unable to prevent.” Lack of knowledge precluded men’s ability to understand maternal sexual impairment and partners' “…emotional disconnection" after birth, associated with PTSD. Although recruitment numbers of men were limited, figures were commensurate with other studies. Results support research that reported fathers experience anxiety and helplessness from “… unrealistic antenatal education,” marginalization by clinicians; postnatal barriers to intimacy with women; and marital disharmony [2]. Overall results revealed strong associations between symptomatic POP, life-altering sequelae of sexual impairment and PTSD symptoms, that were poorly identified by perinatal clinicians and resulted in marital disharmony.
Concluding message
Participants reported significant life-altering psycho-sexual ramifications from symptomatic POP, one to four years after traumatic vaginal births. Sequelae of maternal sexual impairment and postpartum PTSD, were poorly understood and couples experienced marital disharmony and reduced QoL. Findings demonstrate couples lacked informed knowledge on risk factors of vaginal damage prior to birth. After complicated births, they were left to manage debilitating somatic, sexual and psychological consequences, without accurate assessment. Barriers to health information experienced by these new parents, are not reflective of current directives on health literacy from the World Health Organization, proposing clinicians provide patients with optimal access to current research-based education, that enables health improvement. There is an urgent need in all maternity settings, to supply appropriate and accurate education, that enhances informed decision-making between couples prior to childbirth and, validates the worthwhile role of men in supporting women, at all stages of birth.