After giving birth vaginally, around one in five women will go on to experience anal incontinence, a new study suggests. And yes, the issue is truly as unpleasant as it sounds.
Anal incontinence is usually caused by trauma to the pelvic floor, nerve damage and anal sphincter injuries.
Some mothers might be overwhelmed with a sudden urge to poo that cannot be controlled, while others find they soil themselves without even realising they needed the toilet. For some it can lead to leaking poo after passing wind, or being unable to hold in gas.
A new study by the University of Warwick, with input from the MASIC Foundation (a charity supporting women who have suffered severe injuries during birth), found the taboo surrounding the issue is stopping medical professionals from asking the right questions, and preventing women from seeking the support they so desperately need.
They are calling for improved care and more awareness of the injuries, which can prove life-altering for those impacted. Women can face loss of dignity, social isolation, as well as psychosexual and emotional distress.
‘It was a secret, a taboo, that was happening to many first-time mums’
Some women will experience anal incontinence soon after childbirth, whilst many develop worsening or new symptoms during the menopause.
Anna Clements experienced it straight away after sustaining a severe tear during the birth of her third child.
Despite having given birth before, she said she’d “never heard of anal injuries during childbirth – from family, certainly not through friends that had given birth, or the new mums I had met at previous baby groups”.
“It was a secret, a taboo, that was happening to many first-time mums,” she added.
The physical and psychological impact started from day one. She’d have accidents several times a day and would need to constantly shower to feel clean again.
She describes feeling “ashamed” of her body for not being able to perform the basic function of holding in stools and wind.
“I was isolated and I felt so alone. What I also didn’t realise at the time was I was actually one of the lucky ones,” she said.
The mum had a theatre repair straight after giving birth, so was able to get some help and support. But for lots of mums, this isn’t the case.
Mum-of-three Gabriela suffered a third-degree tear after giving birth to her first child, however it wasn’t discovered until six months later – by which point it was too late to repair.
She is certain that the use of forceps during delivery contributed to the damage. The biggest risk factor for this kind of injury is a first vaginal birth, says MASIC. However the next most important risk factor is the need for an instrumental delivery.
“When I had my first baby I recall complaining about faecal incontinence right away – even the day after the birth,” Gabriela previously told HuffPost UK. But she claimed she was repeatedly told she just needed to do pelvic floor exercises.
“This wasn’t it at all,” said the stylist. “I had looked it up online and faecal incontinence was not considered ‘normal’ after a birth at all, however urinary incontinence was.”
She would have multiple accidents including soiling herself because she couldn’t hold it, or soiling herself as she headed to the toilet.
Recalling her worst episode, she said she was holding her baby in her arms as she walked upstairs to the toilet. “Faeces was just running down my leg from my shorts until I made it up to the bathroom,” she explained.
“I remember it like it was yesterday. I started to cry and my body was shaking.”
“Faeces was just running down my leg from my shorts until I made it up to the bathroom.”
- Gabriela
The issue impacted her relationship with her son and husband. It’s also likely she’ll have to contend with bowel issues for the rest of her life.
This is the case for Anna, too – despite treatment. “Daily life is still hard, I live with depression, anxiety and physical symptoms that have got worse as I reached perimenopause,” she says.
“I have had to change a 25-year career that I loved, because of my unpredictable incontinence and the restrictions it brings.
“This study has identified where missed opportunities are to educate and treat women.
“I believe that all women should be informed antenatally of the risks of an anal injury and understand that if a severe injury does happen, what treatment options are available, and who to turn to for advice.”
What needs to happen now?
The new study – which involved interviews with 40 women impacted by anal incontinence after birth – identified missed opportunities in getting a diagnosis, an absence of clear pathways for those who are referred for treatment, and a lack of awareness of the problem among healthcare professionals and those who have given birth.
Due to the stigmatising nature of anal incontinence, it is often not reported by those who suffer it, with fewer than 25% of women discussing their problems with GPs unless prompted.
Healthcare professionals may feel uncomfortable asking questions about anal incontinence in postnatal encounters; or lack experience of asking about, detecting and managing the condition, said researchers. And this represents a missed opportunity to identify and refer women to appropriate care pathways.
“I believe that all women should be informed antenatally of the risks of an anal injury and understand that if a severe injury does happen, what treatment options are available, and who to turn to for advice.”
- Anna
The study comes as the UK government aims to address the inequalities in women’s healthcare, with the publication of its Women’s Health Strategy.
Dr Sarah Hillman, from the University of Warwick, said: “There is a lack of awareness of the problem both for healthcare professionals and women, and a bias towards urinary incontinence.
“For those who are able to get a diagnosis of anal incontinence, they are often faced with disjointed care pathways. This all contributes to delays in accessing appropriate care for this debilitating problem.
“Going forward we have identified a need to establish clear care pathways for those diagnosed with anal incontinence and a vital need to raise awareness and decrease the taboo of the topic.”
The Royal College of Obstetricians and Gynaecologists (RCOG), in collaboration with the Royal College of Midwives, has been encouraging all maternity units to adopt something called the OASI Care Bundle, which aims to improve the health and care of women, and to reduce the risk of severe tears.
The OASI Care Bundle includes recommendations to discuss the risks with women during their pregnancy, and evidence-based interventions that can reduce the risk of a severe tear.
The guidance also suggests that after all vaginal births, an examination of the vagina, anus and rectum should be offered to all women – even if the perineum appears intact “to ensure that any tears are identified immediately and that treatment options are discussed and implemented as necessary”.