Incidence, duration, and related factors of urinary incontinence in women after childbirth: a systematic review

INTRODUCTION

The International Continence Society (ICS) defines urinary incontinence (UI) as the complaint of involuntary urinary leakage and associated hygiene issues¹. Postpartum urinary incontinence (PUI) refers to the first occurrence of involuntary urinary leakage during the postpartum period and is prevalent, affecting one in five women who give birth². Some women experience urinary issues during pregnancy, and the recovery process can be prolonged after childbirth³. Studies indicate that most cases of PUI, particularly stress urinary incontinence (SUI), resolve within weeks to months or within a year. However, 10–20% of women with PUI may still experience UI issues 5 years after childbirth⁴,⁵,⁶. While SUI is the most common type of PUI, urge UI and mixed UI can also occur. Although UI is particularly significant during the postpartum period, it is often overlooked in healthcare². UI, with its multifaceted impact on women after childbirth, has been the focus of numerous prevalence studies. The prevalence of postpartum stress urinary ıncontinence (PSUI) varies due to factors such as sample size, population demographics, follow-up duration, parity, and study methodology⁷,⁸,⁹,¹⁰,¹¹. Factors during pregnancy and childbirth, such as hormonal changes, increased abdominal pressure from the growing uterus, and pelvic floor stress, are associated with UI¹². Wang et al. identified risk factors for PUI, including vaginal birth, advanced maternal age, obesity, excessive weight gain, operative birth, episiotomy, and diabetes¹³. PUI significantly challenges women’s quality of life, affecting self-esteem and the mother’s ability to care for her newborn¹⁴. This systematic review aims to analyze studies on the frequency of UI during the first year postpartum, the most common type of PUI, and the associated factors.

Research questions

1. What is the incidence of PUI?

2. What are the types of PUI?

3. What factors may cause/are associated with PUI?

METHODS

Study design

This systematic review examines the incidence of UI in women during the first year postpartum, focusing on the most prevalent type and associated factors. The study’s methodology and reporting adhere to the PRISMA model¹⁵.

Article screening strategy, selection, and exclusion criteria

This retrospective review scanned research articles published in peer-reviewed journals from 2013 to 2023, using search engines such as PUBMED, Science Direct, Scopus, EBSCO, ULAKBİM, and TR-Dizin. Keywords included “postpartum/postnatal/puerperal,” “urinary incontinence,” “prevalence,” and “incidence” in both Turkish and English.

Comprehensive prospective, retrospective, and cohort studies with full texts in English or Turkish were considered, excluding theses, conference papers, and reviews. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow chart (Figure 1) shows the screening process.

Figure 1
The Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow chart.

Determining the eligibility criteria for articles

Meeting the criteria outlined above and selected after the exclusions indicated in Figure 1, the study was established based on the Patient, Intervention, Outcomes, Study Design (PICOS) model:

• P-Patient: Women in the postpartum period

• I-Intervention: UI

• C-Comparison: Factors contributing to PUI and associated conditions

• O-Outcomes: Incidence of PUI and contributing factors

• S-Study design: Comprehensive prospective, retrospective, and cohort research articles reporting on the incidence, duration, and associated factors of PUI were included in the systematic review.

Evaluation of the quality of studies

The quality of the 19 eligible studies was assessed using Polit and Beck’s criteria, which evaluate the study’s objectives, methodology, sample characteristics, findings, and discussion¹⁶. Each study was independently evaluated by both researchers to minimize errors. A score of “1 point” was assigned for each criterion met and “0 points” for unmet criteria. The average scores of the studies were then calculated.

Data synthesis

After independent evaluations by both researchers, the study quality scores ranged from 9 to 12 (Table 1). A coding guideline was developed to input study results addressing the research questions. Data were analyzed in IBM SPSS V26, extracting descriptive characteristics, ratios, and median values of the factors investigated.

Table 1
Characteristics of studies.

Author/year	Type of stud	Sample size	UI evaluation time	Incidence of UI	The most common UI and rate	The average quality score of the studies
Lin et al., 202321	Cohort	303	PP’s first 12 months	16.5%	SUI 16.5%	11
Elbiss and Abu-Zidan, 202322	Prospective	101	PP’s first 3 months	13.8%	SUI 93.0%	11
Xu et al., 202323	Retrospective	610	PP’s first 6–8 weeks	20.5%	SUI 20.5%	9
Urer et al., 202324	Retrospective	142	PP’s first 3 months	39.4%	SUI 39.4%	11
Yang et al., 202225	Cross-sectional	780	PP’s first 6–8 weeks	16.4%	SUI 11.1%	11
Ferrari et al., 202226	Prospective	6,023	PP’s first 6 months	12.6%	SUI 58.2%	11
Löjdahl et al., 202227	Prospective	13,670	PP’s first 3 months	52.0%	SUI 49.7%	12
Rajavuori et al., 202228	Prospective	547	PP’s first 3 months	16.1%	Not specified	11
Diez-Itza et al., 202029	Prospective	315	PP’s first 12 months	39.7%	SUI 39.7%	9
Åhlund et al., 20207	Prospective	410	PP’s first 12 months	56.9%	SUI 45.4%	12
Johannessen et al., 201830	Prospective	976	PP’s first 12 months	30.7%	Not specified	11
Chang et al., 201810	Cohort	866	PP’s first 12 months	51.5%	SUI 51.5%	10
Fritel et al., 201631	Cohort	2,002	PP’s first 6 months	14.0%	SUI 37.0%	10
Pizzoferrato et al., 201632	Prospective	186	PP’s first 12 months	34.4%	SUI 24.8%	10
Brown et al., 201533	Cohort	1,507	PP’s first 12 months	47.0%	Not specified	10
Mannion et al., 201534	Cohort	1,574	PP’s first 12 months	49.0%	Not specified	11
Obioha et al., 201535	Prospective	250	PP’s first 3 months	7.4%	SUI 7.4%	11
Ruiz Vinaspre Hernández et al., 201336	Cohort	402	PP’s first 6 months	12.2%	Not specified	12
Yoshida et al., 201337	Prospective	17	PP’s first 6 months	29.4%	SUI 29.4%	11

• Note: P: postpartum; UI: urinary incontinence; SUI: stress urinary incontinence.

RESULTS

Characteristics of studies

The systematic review included studies from 2013 to 2023. Of these, 52.6% were prospective, 31.5% cohort, 10.5% retrospective, and 5.2% cross-sectional. The participants comprised women within the first year postpartum, irrespective of whether they experienced incontinence during or before pregnancy or after childbirth. The sample sizes ranged from 17 to 13,670, with a total of 30,681 participants across all studies (Table 1).

Postpartum urinary incontinence results

Most studies were prospective, with a higher proportion evaluating UI within the first 12 months postpartum (42.1%; 8 studies). The reported incidence of PUI varied, ranging from 7.4 to 56.9%, with a median of 29.4%. PSUI was identified as the most common occurrence in 73.7% of the studies (14 studies), with reported rates ranging from 7.4 to 93.0%, and a median of 38.2%. Ten studies (52.6%) reported higher rates of PUI among those who gave birth vaginally, with PSUI rates ranging from 10.1 to 80.7%, and a median of 50.9%. Other reported risk factors included low maternal education level (median rate: 64.3%), multiparity (median rate: 39.0%), primiparity (median rate: 37.3%), and perineal laceration (median rate: 36.5%) (Table 2).

Table 2
Results of studies on postpartum urinary incontinence.

Results	Number of studies reviewed (n=19)
	n	%
PUI evaluation time
Studies evaluating the first 6–8 weeks	2	10.5%
Studies evaluating the first 3 months	5	26.3%
Studies evaluating the first 6 months	4	21.1%
Studies evaluating the first 12 months	8	42.1%
Types of PUI detected in studies
Stress urinary incontinence (SUI)	14	73.7%
Study that detected incontinence but did not specify the type	5	26.3%
Studies reporting results in terms of factors that may cause PUI
Vaginal delivery	10	52.6%
Cesarean section	9	47.3%
Age of mother <35	7	36.8%
Interventive delivery	6	31.5%
Obesity	6	31.5%
Primiparous	5	26.3%
Multiparous	4	21.1%
Episiotomy	4	21.1%
Prolonged second stage of labor	4	21.1%
Perineal laceration	4	21.1%
High head circumference of the newborn	3	15.7%
Low level of education	3	15.7%
According to the results of the study, the rates of the factors stated to cause PUI (in %)
Factors	Min-max	Median
Vaginal delivery	10.1–80.7%	50.9%
Cesarean section	7.2-33.4%	13.9%
Age of mother <35	13.6-48.0%	15.8%
Interventive delivery	10.5-32.6%	18.8%
Obesity	10.7-88.0%	16.3%
Primiparous	13.0-100.0%	37.3%
Multiparous	14.5-70.4%	39.0%
Episiotomy	11.4-25.7%	20.6%
Prolonged second stage of labor	10.8-35.9%	17.1%
Perineal laceration	18.0-100.0%	36.5%
High head circumference of the newborn	8.3-67.8%	20.0%
Low level of education	11.1-77.7%	64.3%
PUI incidence rates stated in the study results (in %)
PUI rate	7.4–56.9%	29.4%
The most common rates of PSUI in the study results (in %)
PSUI rate	7.4–93.0%	38.2%

• Note: P: postpartum; UI: urinary incontinence; SUI: stress urinary incontinence; PUI: postpartum urinary incontinence; PSUI: postpartum stress urinary ıncontinence.

DISCUSSION

This systematic review aimed to determine the incidence and prevalence of UI in the first year postpartum, the predominant type of UI, and its associated factors by analyzing 19 studies. ICS recently reported a 21% prevalence of SUI in the first year after childbirth¹⁷. However, in Turkey, studies on PUI are limited. Our review found that the incidence of PUI ranged from 7.4 to 56.9%, with a median of 29.4%. SUI was identified as the most common type, with rates ranging from 7.4 to 93.0% and a median of 38.2%. These findings align with existing literature on PUI³ prevalence and the predominance of SUI².

During childbirth, pelvic floor support can be compromised due to mechanical stress, injuries, and nerve damage, with a cesarean section before labor onset believed to reduce the risk of SUI¹⁸. Ten of the 19 studies in this review identified vaginal delivery as a significant risk factor for PUI, with rates from 10.1 to 80.7% and a median of 50.9%. Perineal laceration and episiotomy were also significant, with median rates of 36.5 and 20.6%, respectively. Vaginal delivery, episiotomy, perineal trauma, operative delivery, prolonged labor, and epidural analgesia are documented contributors to PUI¹⁹.

Multiparity and primiparity emerged as significant risk factors for PUI, with median rates of 39 and 37.3%, respectively, highlighting that all pregnant women are at risk. Some studies report primiparous women as being at higher risk than multiparous women²⁰. Additionally, low education levels were identified as a risk factor in three studies, with rates from 11.1 to 77.7%. These findings emphasize the need for targeted interventions for women with lower education levels in prenatal and postnatal care to prevent and manage UI.

CONCLUSION

The studies reviewed in this review reveal that UI affects approximately one in four women in the first year after birth, with SUI being the most common type. Vaginal delivery and related practices significantly increase the risk. These findings highlight the importance of perinatal, obstetric, and gynecological nurses in evaluating, diagnosing, preventing, and managing UI, often overlooked in postpartum care.

Implementing evidence-based practices in prenatal, intrapartum, and postnatal care is crucial. Holistic risk assessments for UI should be conducted for all pregnant and postpartum women. Nursing care plans should be tailored based on these assessments, and their effectiveness should be evaluated. By doing so, nurses can provide high-quality care and help develop care standards.

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• Funding:
  none.

Publication Dates

• Publication in this collection
  20 Dec 2024
• Date of issue
  2025

History

• Received
  24 May 2024
• Accepted
  04 Sept 2024