Quality of Life and Health-seeking behaviour of women with Postpartum Urinary Incontinence

 

Worlanso A1. Shimray, Alice Sony2

1Assistant Professor, CON, Christian Institute of Health Sciences and Research, Dimapur-797115, Nagaland

2Professor, Obstetrics & Gynaecology Nursing, Department, CON, CMC, Vellore

*Corresponding Author Email: worlansoshimray@gmail.com

 

ABSTRACT:

Background. The aims of the present study were to assess the prevalence of postpartum urinary incontinence (PUI), and to assess the quality of life (QOL) and health seeking behavior (HSB) of women with postpartum urinary incontinence. Methods. A descriptive study, including 624 women who were 6 to 37 weeks’ post-childbirth formed the study population. Data were collected using Questionnaires for the Urinary Incontinence Diagnosis (QUID) to assess the prevalence of PUI, King’s Health Questionnaire (KHQ) to assess the quality of life and Health seeking behaviors questionnaire to assess the health seeking behaviour of women with postpartum urinary incontinence. Results. The findings revealed that 16.67% (104 women) had symptoms of postpartum urinary incontinence. Majority of the women with PUI (84%) were either mildly, moderately or severely affected and of those affected only 23% had good health seeking behavior. Conclusion. Postpartum urinary incontinence is an important but often overlooked form of morbidity in obstetrics. It is a common symptom among postnatal women which need to be addressed and reinforced by the health workers as most women suffering from it may not consider it as a disease or may not even seek for consultation due to poor or lack of knowledge.

 

KEYWORDS: Prevalence, postpartum urinary incontinence, QUID, KHQ, Quality of life and Health seeking behaviour of women with postpartum urinary incontinence.

 

 


INTRODUCTION:

Urinary incontinence is an involuntary loss of bladder control, affecting young and middle age women. The prevalence increases as the women ages and although nulliparous women can have urinary incontinence, the incidence is higher in women who have given birth1. Globally the reported prevalence of urinary incontinence varies widely in different studies, according to the population studies from various countries, the report showed that the prevalence ranged from approximately 5% to 70%, with most studies reporting a prevalence of any UI in the range of 25-45%2. The prevalence of UI among women in a selected states and district of India range from 11.6% to 33.8%.3,4

 

Urinary incontinence (UI) after delivery may affect women for the rest of their lives. Several studies have reported data on the long term prognosis of postpartum urinary incontinence. A long-term prospective study showed that the onset of UI in pregnancy or postpartum increased the risk for UI twelve years later5,6. A systematic review showed the pooled prevalence of any postpartum incontinence during the first three months of postpartum was 33%7. The incidence of postpartum stress urinary incontinence was reported to be 23.42% in a study done in Kolkata, India8.

 

Incontinence can have far reaching effects on the lives of women. As a result of their condition some women can experience feelings of frustration, embarrassment and shame and will sometimes reduce/avoid social contacts and activities in order to control UI and its effects which may lead to increased social isolation and feelings of loneliness9,10. Symptoms of UI was associated with moderate to severe form of depressives symptoms11, and women with UI are shown to have higher rates of depression and social isolation than those without UI12 and UI may also contribute to sexual dysfunction due to urinary leakage during intercourse13

 

Most women who suffer from UI may not consider it a disease or may not seek a consultation due to poor knowledge or negative attitude regarding UI3 thus it may lead to a reduction in their Quality of Life (QoL). Globally, urinary incontinence (UI) affects the quality of life of at least one third of women4. Many women are too embarrassed to talk about it and some believe it to be untreatable even in Western countries14 This problem is more pronounced in India, where women usually do not seek treatment for their reproductive health problems and do not talk about their symptoms. There is a “culture of silence” and a low consultation rate among Indian women regarding such problems4.

 

The researcher in her observation of patient visiting the OPD, has found that minimal postnatal women come for follow up and little or no emphasis is made regarding PUI and adding to this most women are often discharged within 24 hours of delivery, therefore, it becomes difficult to ensure if the information regarding PUI, kegel’s exercise and other postpartum morbidity have been adequately provided. Most nurses are unaware of the magnitude of the effects of urinary incontinence on women, thereby leading to lack of empowerment of women to seek help and also though host of studies have been conducted on urinary incontinence, very few studies have been done regarding postpartum urinary incontinence and limited literature is available that applies to an Indian population.  Hence this study aimed to assess the prevalence of PUI, QoL and health-seeking behaviour of women with postpartum urinary incontinence.

 

METHODOLOGY:

A quantitative approach with descriptive design was undertaken to assess the prevalence of PUI and to assess the QoL and health-seeking behaviour of women with PUI.

 

The number of participants needed for screening PUI was calculated based on the 23.42% prevalence study by Bal Runa8 and colleagues in Kolkata1. The minimum number of participants needed to be screened based on 23.42% prevalence of PUI was 300. The researcher was able to recruit 624 participants in a six-weeks period of data collection.

 

DATA COLLECTION METHOD:

The data was collected from women attending the Well baby clinic who were 6 to 37 weeks post-childbirth. Women who met the inclusion criteria were selected using total enumerative sampling technique. The researcher explained the purpose of the study and received the verbal and written consent. Self-administered standardized questionnaire QUID was given. When the participant scored more than 4 in the QUID, then King’s health questionnaire, health seeking behavior questionnaire and the information regarding selected demographic and clinical variables were administered.

 

Ethical clearance for the conduction of the study was obtained from the Dissertation and research Committee. Administrative permission was obtained from the Nursing Superintendent, Head of Department of Maternity Nursing and Paediatric Nursing. Written informed consent was obtained from individual participants. Confidentiality and anonymity of the information was maintained.

 

INSTRUMENTS:

The Questionnaire for Urinary Incontinence Diagnosis (QUID) is a short, validated and standardized instrument that measures the presence of stress and urge UI symptoms. The Cronbach’s α values of stress UI was .64 and .87 for urge UI. The questionnaire consists of six items, each item scores 0 (None of the time), 1 (Rarely), 2 (Once in a while), 3 (Often), 4 (Most of the time) or 5 (All of the time). A total score of >4 indicated the presence of UI. 15

 

The King’s Health Questionnaire (KHQ) was used to assess the QOL. It is a standardized tool with Cronbach's alpha of 0.93 (20,21). The KHQ contains 14 items each measured on a four-point Likert Scale- indicating role limitation, physical limitation, social limitation, disturbances in personal relationships, emotions, sleep and energy. The possible responses is never- (score=1), sometimes/slightly – (2), moderately/often (3), all the time (4). The total score is calculated and interpreted as, not affected (14), mildly affected (15-19), moderately affected (20-24) and severely affected (>25).

 

A questionnaire about health-seeking behaviour was developed by the investigator. It consists of two sets of questions. The first set consisted of eight questions to assess health- seeking behaviour and the second set consisted of seven reasons for not seeking help. The content validity of the questionnaire was assessed by medical and nursing experts in the field of obstetrics and gynecology resulting in a content validity index (CVI) of 0.93. The reliability of the instrument using Cronbach’s alpha coefficient was 0.821 (p< 0.002).

 

DATA ANALYSIS AND RESULTS:

The data were collected from 624 women who attended a well-baby clinic. Descriptive statistics were used to summarized the demographic and clinical variables. Association between variables of interest were tested with a chi-square statistic and Pearson correlation coefficient.

 

Figure 1. Prevalence of Postpartum Urinary Incontinence

 

Figure1. Depicts that out of 624 women that were screened for PUI, 104(16.67%) had symptoms of PUI. Data was collected from 624 women, out of which 104 women were found to have PUI (according to QUID Score). 100 women completed the other questionnaires (demographic variable, QOL and health seeking behaviour Questionnaires) while four women refused to complete the other questionnaires

 

Table 1 Distribution of women with PUI based on selected demographic and clinical variables (n=100)

Sl. No.

Variables

n

(%)

1

Age

<24

25-29

>30

 

19

61

20

 

19

61

20

2

Educational status

Below

Preuniversity (11- 12)

Graduate

Post Graduate

 

 

12

50

38

 

 

12

50

38

3

Occupation

Home maker

Employed

 

82

18

 

82

18

4

Family income

≤ 5000

5001- 8000

8001 – 10,000

≥ 10,001

 

10

21

31

38

 

10

21

31

38

5

Residence

Urban

Rural

 

83

17

 

83

17

6

Months of delivery

3

3.1-6

6.1- 9

9.1 – 12

 

32

34

17

17

 

32

34

17

17

7

BMI (kg/m2 )

<24.9

>25

 

38

62

 

38

62

8

No. of deliveries

Primi

Multi

 

75

25

 

75

25

9

Mode of delivery

CS

VD

 

29

71

 

29

71

10

Episiotomy/ perineal tear

no

yes

 

36

64

 

36

64

11

Associated disorder

No disorder

DM/HTN

 

71

29

 

71

29

12

UI during pregnancy

No

Yes

 

71

29

 

71

29

13

Performing Kegel’s exercise

No

Yes

 

 

92

8

 

 

92

8

 

Table 1. Shows that majority of the women with PUI were between the age group of 25-29 years (61%), graduates (50%) and homemakers (82%), family income ≥ 10,001(38%), majority of the women lived in the urban area (83%). Higher prevalence of PUI is seen in women within 3 - 6 months of delivery (34%), majority of women with PUI had BMI more than 25 kg/m2 (62%) 75% of the women were primi paras and 71% had vaginal delivery, 64% of the women with PUI had episiotomy, majority of the women did not have any associated medical/obstetric disorders (86%), 29% of women had urinary incontinence during pregnancy and 92% of women did not perform Kegel’s exercise.

 

Figure 2: Quality of life in women with postpartum urinary incontinence

 

Figure 2. Shows that 50% (50) of the women had a mildly affected quality of life.

 

Table 2: Distribution of women with PUI under the domains of Quality of life.

Sl No.

Domains of Quality of life

Mean

Standard Deviation

1

Role limitation

35.5

14.62

2

Social limitation

35.31

14.30

3

Personal limitation

32.83

15.57

4

Emotional disturbance

34.33

13.87

5

Sleep/rest disturbance

35.62

13.91

 

Table 2.  Shows the mean and standard deviation of each domain of the quality of life, and there is no specific domain that is most affected.

 

Figure 3: Health seeking behavior of women with PUI.        (n=100)

 

Figure 3. Shows that majority (64%) of the women with PUI had moderate health seeking behavior

 

Table 3: Distribution of sample according to the reasons for not consulting the doctor/health personnel

Sl.No.

Reasons

Frequency (n)

Percentage (%)

1

UI is a normal process and it will heal naturally

35

(35)

2

Embarrassed to consult the doctor or discuss with others

15

(15)

3

Lack of time

22

(22)

4

Lack of support

7

(7)

5

Financial problems

11

(11)

6

Not aware of available treatment

24

(24)

7

Fear of hospitalization, investigation, and invasive procedures that will be carried out

11

(11)

 

Table 3. Shows that the most frequent reason for not consulting the doctor was that PUI is a normal Process and that it will heal naturally (35), followed by lack of awareness of available treatment (24) and lack of time (22)

 

Table 4: Correlation of quality of life and health seeking behavior of women with PUI.

Variables

Correlation(r)

p-value

Over all QOL v/s HSB

.245

.014*

Role limitation v/s HSB

.215

.032*

Social limitation v/s HSB

.177

.079

Personal limitation v/s HSB

.205

.040*

Emotional disturbance v/s HSB

.263

.008*

Sleep/rest disturbance v/s HSB

.158

.118

 

Table 3. Shows the correlation of quality of life and health seeking behavior of women with PUI which was statistically significant (p- value <0.005) and a positive correlation between role limitation, personal limitation and emotional disturbance of quality of life and health seeking behavior (p value <0.005).

 

Table 4. Shows a statistical significant association between health seeking behavior of women with PUI and performing Kegel’s exercise.

 

Table 5. Shows that there is statistical significant association in the area of residence (p=0.020) and UI during pregnancy (p=.003) in women with postpartum urinary incontinence (p<0.050).

 


 

Table 4: Association of health seeking behavior of women with postpartum urinary incontinence and selected demographic and clinical variables.

Sl. No

Variables

Health Seeking Behavior

Total

(n= 100)

Chi- square

p- value

Poor

Moderate

Good

n

(%)

n

(%)

n

(%)

1.

Performing Kegel’s exercise

No

Yes

 

13

0

 

(100)

(0)

 

61

3

 

(95.3)

(4.7)

 

18

5

 

(78.3)

(21.7)

 

92

8

 

7.983

 

.018*

 

Table 5: Association of selected demographic and clinical variables of women with and without postpartum urinary incontinence

Sl.no.

Variables

without PUI

With PUI

Total

(n=200)

Chi- square

p-value

N

(%)

n

(%)

1

Residence

Urban

Rural

 

69

31

 

(69)

(31)

 

83

17

 

(83)

(17)

 

152

48

 

5.373

 

0.020*

2.

UI during pregnancy

No

Yes

 

88

12

 

(88)

(12)

 

71

29

 

(71)

(29)

 

159

41

 

8.866

 

0.003*

 

 

 


DISCUSSION:

The data was collected from 624 women, 104 women were identified with postpartum urinary incontinence., demographic variables, clinical information, quality of life and health seeking behavior was available from 100 women because 4 women declined to respond due to lack of time. Demographic and clinical variables were also administered to 100 women without PUI to enable the researcher to find the association between the demographic and clinical variables of women who have PUI and who did not have PUI.

 

The first objective was to assess the prevalence of postpartum urinary incontinence (figure- 1), out of 624 women screened for PUI, 104(16.67%) women had symptoms of PUI. Other research studies also showed similar findings with the prevalence of PUI immediately after birth as 23.4% and 2.7% at 6 months16 and The prevalence of self-reported postpartum UI among women between 30 to 90 postpartum days in selected districts of India was 24.6%17. There is a wide range of reported prevalence of urinary incontinence in the postpartum period ranging from 6-67% in primiparous women and 3-45% among parous women. According to ICI epidemiology report, the prevalence of PUI among one year postpartum women was 15-30%18.

 

The second objective was to assess the quality of life (figure -2), the study showed 17% of the women who had postpartum urinary incontinence were moderately and severely affected, while 50% were mildly affected and 16% were not affected which is supported by Ashley in her study showing that only 10% had good quality of life (not affected), 12% poor quality and majority 78% with an average quality of life19. The domains of quality of life, which included limitation and disturbances in role, social, personal, emotional and sleep/rest were equally affected (table -2) whereas other studies reportshowed that personal and emotional domains were the most effected domains20,21. The contradiction in the finding could be due to the influence of personal and cultural values and beliefs, the roles of the woman at home and in the society and the support from the family.

 

The third objective was to assess the heath seeking behaviour of the women with PUI (figure -3). Though the study findings showed that 64% had moderate and 23% had good health seeking behavior, only 5% had consulted the doctor. Similar findings were shown by Samiah et al22 who reported that 11.6% had sought medical services to treat their problem22 and according to Kumari S et al only one fifth of those with UI had consulted someone.23

 

Although stress incontinence can have a profound impact on daily routine and can result in psychological effects, there are still many women who do not seek help. The reasons for not consulting the doctor in this present study were (table -3), UI is a normal process and that it will heal naturally (35%), not aware of available treatment (24%), lack of time (22%), embarrassment (15%), lack of support (7%), financial problems (11%) and fear of hospitalization, investigation and invasive procedures that will be carried out (11%). This is supported by the studies4,12 which showed reasons why UI was not discussed with a primary care provider, majority (45%) viewed it as ‘not a big problem’, and (19%)  as normal process as age progress (19%), other reasons were embarrassment, unaware of the treatment options, viewed it as a consequences of childbirth normal part of being a woman12,23. Other reported reasons for women in India  not to seek help are lack of female doctors in the peripheral areas, women being depend on the husbands for their treatment and having a higher tolerance threshold.24

 

The fourth objective was to correlate the health seeking behaviour and quality of life of women with PUI (table 3). There was a significant correlation between quality of life and health seeking behavior (p=0.014) and it is supported by Shaw et al25 who stated the two main reasons for help seeking,one was the fear of serious underlying disease such as cancer, and the other was the presence of significant distress or impact on quality of life. Koch 26also reported that lower quality of life score was one factor that influence the help seeking behavior

 

The fifth objective was to associate the health seeking behaviour and the quality of life with the selected demographic and clinical variables, the study findings are supported by Ashly19 and Kocaoz et al 27, who reported no significant association between the quality of life and the selected demographic and clinical variables. But the study showed that there was a significant association between the health seeking behaviour and the clinical variables (table 4) – performing Kegel’s Exercise (p=0.018). Different studies have showed the benefits of pelvic floor exercise in strengthening the pelvic floor muscles28-29.

 

The last objective was to associate the demographic and clinical variables of women with and without PUI (table 5). For this particular objective, 100 women without PUI were conveniently selected and administered the demographic and clinical variables. The present study showed a significant association between postpartum urinary incontinence and residence area (0.020) and with urinary incontinence during pregnancy (p=0.003).  this finding is consistent with the study done by Kocaoz et al (2010) which reported that there was a statistically significant relationship between having experienced UI in a preceding pregnancy and the presence of UI in the present pregnancy. There was also a significant relationship between the presence of UI in the previous postpartum period and its presence during the present pregnancy, and it significantly increased the chances of having UI later in life30.

 

LIMITATION:

·       Time constraint- four women did not complete the other questionnaires.

·       Other factors may have affected the quality of life.

·       Participants may have provided socially accepted responses.

·       Practices of the subject were not checked, instead only self-reported practices regarding QOL and health seeking behaviour were assessed.

 

NURSING IMPLICATION:

This study reveals that there is prevalence of urinary incontinence during post delivery period and that there is a need to educate and motivate women regarding PUI, its prevention and treatment.

 

Nursing Service:

The study findings will help increase the awareness of health care workers involved in the care of pregnant and postnatal women about urinary incontinence and aid the design of more intensive education programmes directed towards the prevention of urinary incontinence. It also facilitates the nurses to identify the distressing symptoms of PUI and with knowledge and empathy, nurses can reduce the discomfort and fear and help those who are not open to share their problems due to embarrassment or shame or ignorance to seek medical guidance.

 

Nursing Education:

The findings generated from this study will contribute to student’s knowledge regarding the prevalence of postpartum urinary incontinence, its impact in the lives of the women suffering with it and to promote the health seeking behavior among postnatal women.

 

Nursing Research:

The findings of the study will enable wider avenue for future studies that can be conducted in relation to factors contributing to postpartum urinary incontinence and other postpartum morbidities.

 

CONCLUSION:

Urinary incontinence is a common, distressing condition, which interferes with the work, social and sexual lives of the women and can have a negative impact on the health related quality of life, and to an extent, affects the lives of the family. The study that though most women had a reduced quality of life only a few had good health seeking behavior due to many reasons such as embarrassment, natural process, fear of treatment, lack of support and time. Therefore, assessment of postpartum urinary incontinence must be included in routine assessments and nurses must be encouraged to teach and educate women about urinary incontinence and to reinforce the importance of personal hygiene and pelvic floor exercise

 

ACKNOWLEDGEMENT:

This project was conducted and successfully completed under the valuable guidance of Dr. ArunaNitinkekre, Professor, Gynaecological Department – Unit II CMC, Vellore. The Investigator would like to convey her sincere gratitude to Mrs. Mahasampath Gowri and Mr. Prakash R, department of Biostatistics, for their expert and prompt statistical guidance. The investigator would also like to sincerely thank Dr. Christy Simpson, Principal, CON, CIHSR, Dimapur for her continual support and encouragement.

 

CONFLICTS OF INTEREST:

The author have declared no conflicts of interest.

 

REFERENCES:

1.     Kim Y, Chancellor MB. Incontinence after Childbirth. Reviews In Urology. 2004;6(1):48.

2.     Milsom I, Gyhagen M. The Prevalence of Urinary Incontinence. Climacteric. 2019 May 4;22(3):217-22.

3.     Seshan V, Muliira JK. Self-reported urinary incontinence and factors associated with symptom severity in community dwelling adult women: implications for women’s Health Promotion. BMC Women's Health. 2013 Dec;13(1):16.

4.     Kumari S, Jain V, Mandal AK, Singh A. Behavioral therapy for urinary incontinence in India. Int J Gynaecol Obstet. 2008; 103(2):125-30

5.     Viktrup L, Rortveit G, Lose G. Risk of stress urinary incontinence twelve years after the first pregnancy and delivery. Obstetrics and Gynecology. 2006 Aug 1;108(2):248-54.

6.     MacArthur C, Wilson D, Herbison P, Lancashire RJ, Hagen S, ToozsHobson P, Dean N, Glazener C, Prolong study group. Urinary incontinence persisting after childbirth: extent, delivery history, and effects in a 12–year longitudinal cohort study. BJOG: An International Journal of Obstetrics and Gynaecology. 2016 May;123(6):1022-9

7.     Thom DH, Rortveit G. Prevalence of postpartum urinary incontinence: a systematic review. Acta Obstetricia et Gynecologica Scandinavica. 2010 Dec;89(12):1511-22.

8.     Bal Runa, Saha Sudarsan, Krisnamurthy Padma, Talukdar Arunangshu Postpartum urinary stress incontinence -its relation with the mode of delivery. Journal of  Obstetrics and Gynecology India. (2006). Vol. 56, No. 4 :Pg 337-339.

9.     Heintz PA, DeMucha CM, Deguzman MM, Softa R. Stigma and microaggressions experienced by older women with urinary incontinence: a literature review. Urol Nurs. 2013;33:299–305.

10.  Teunissen D, Van Den Bosch W, Van Weel C, Lagro-Janssen T. “It can always happen”: The impact of urinary incontinence on elderly men and women. Scand J Prim Health Care. 2006;24:166–173. doi: 10.1080/02813430600739371

11.  Dugan E, Cohen SJ, Bland DR, Preisser JS, Davis CC, Suggs PK, McGann P. The association of depressive symptoms and urinary incontinence among older adults. Journal of the American Geriatrics Society. 2000 Apr 1;48(4):413-6.

12.  Fultz NH, Herzog AR. Selfreported social and emotional impact of urinary incontinence. Journal of the American Geriatrics Society. 2001 Jul;49(7):892-9.

13.  Barber MD, Mullen KJ. The impact of stress urinary incontinence on  sexual activity in women. Cleveland Clinic Journal of Medicine. 2005 Mar;72(3):225.

14.  Newman DK. Stress Urinary Incontinence in Women: Involuntary urine leakage during physical exertion affects countless women. AJN The American Journal of Nursing. 2003 Aug 1;103(8):46-55.

15.  Bradley CS, Rahn DD, Nygaard IE, Barber MD, Nager CW, Kenton KS, Siddiqui NY, Abel RB, Spino C, Richter HE. The questionnaire for urinary incontinence diagnosis (QUID): Validity and responsiveness to change in women undergoing nonsurgical therapies for treatment of stress predominant urinary incontinence. Neurourology and Urodynamics. 2010 Jun 1;29(5):727-34.

16.  Hvidman L, Foldspang A, Mommsen S, Nielsen JB. Postpartum urinary incontinence. Acta obstetricia et Gynecologica Scandinavica. 2003 Jun 1;82(6):556-63.

17.  Lopes DB, Praça ND. Prevalence and related factors of self-reported urinary incontinence in the postpartum period. Acta Paulista de Enfermagem. 2012;25(4):574-80.

18.  Wesnes SL, Hunskaar S, Rortveit G. Epidemiology of urinary incontinence in pregnancy and postpartum. Urinary Incontinence [Internet]. Rijeka: InTech. 2012 Apr 4:21-40.

19.  Ashly Elizabeth James (2013). The health seeking behavior and quality of life among multipara women having urinary incontinence at selected community of Mangalore. www.rguhs.ac.in/cdc/onlinecdc/uploads/05_N036_29516.doc

20.  Córcoles MB, Sánchez SA, Bachs GJ, Moreno DM, Navarro PH, Rodríguez VJ. Quality of life in patients with urinary incontinence. Actasurologicasespanolas. 2008 Feb;32(2):202-10.

21.  Dolan LM, Walsh D, Hamilton S, Marshall K, Thompson K, Ashe RG. A study of quality of life in primigravidae with urinary incontinence. International Urogynecology Journal. 2004 Jun 1;15(3):160-4

22.  Samiah YA, Karim AJ, Rohaini M, Pathak R, Vinothini A. Prevalence of urinary incontinence and associated risk factors among married women. Indian J Appl Sci. 2013;3:491-5.

23.  Kumari S, Singh A, Jain V. Treatment seeking behavior for urinary incontinence among north Indian women. Indian Journal of Medical Sciences. 2008 Sep 1;62(9):354.

24.  Singh A, Arora AK. How much do rural Indian husbands care for the health of their wives'. Indian journal of community medicine: official publication of Indian Association of Preventive and Social Medicine. 2008 Jan;33(1):19.

25.  Shaw C, Tansey R, Jackson C, Hyde C, Allan R. Barriers to help seeking in people with urinary symptoms. Family Practice. 2001 Jan 1;18(1):48-52.

26.  Koch LH. Helpseeking behaviors of women with urinary incontinence: An integrative literature review. Journal of Midwifery and Women’s Health. 2006 Nov 12;51(6).

27.  Kocaöz S, Talas MS, Atabekoğlu CS. Urinary incontinence in pregnant women and their quality of life. Journal of Clinical Nursing. 2010 Dec 1;19(2324):3314-23.

28.  Weiss BD. Selecting medications for the treatment of urinary incontinence. American Family Physician. 2005 Jan 15;71(2).

29.  Price N, Dawood R, Jackson SR. Pelvic floor exercise for urinary incontinence: a systematic literature review. Maturitas. 2010 Dec 1;67(4):309-15.

30.  Leroy LD, Lúcio A, Lopes MH. Risk factors for postpartum urinary incontinence. Revista da Escola de Enfermagem da USP. 2016 Apr;50(2):200-7.

 

 

 

Received on 15.03.2020          Modified on 03.04.2020

Accepted on 18.04.2020      ©AandV Publications All right reserved

Asian J. Nursing Education and Research. 2020; 10(3): 298-304.

DOI: 10.5958/2349-2996.2020.00062.2