1) To determine the prevalence of urinary incontinence in pregnant and postpartum women in the Democratic Republic of Congo, and to identify factors associated with urinary incontinence
2) To compare characteristics of urinary incontinence among pregnant and postpartum women

Upon prenatal and postnatal reproductive health clinic consultations, women were asked to participate in the study. Women who were in their third trimester of pregnancy or within 18 months of being postpartum were deemed eligible. Interviews collected information regarding demographics (age, profession, education), obstetric history (gravidity, parity, prior Cesarean delivery, prior episiotomy, and history of macrosomia), and urinary incontinence symptoms and quality of life impact via the International Consultation on Incontinence Questionnaire for Urinary Incontinence Short Form (ICIQ-UI-SF) (1). ICIQ-UI-SF responses generated a numeric score from 0 to 21 that categorizes incontinence as mild, moderate, severe, or very severe. For this study, women with an ICIQ-UI-SF score greater than 0 were classified as having urinary incontinence. 

Descriptive analyses characterized the sample and compared women with and without urinary incontinence. The sample was stratified into pregnant and postpartum subsets using similar descriptive analyses to describe and compare characteristics of urinary incontinence. Factors associated with urinary incontinence were identified using univariate and multivariate logistic regression in the sample overall and among the pregnant and postpartum subsets. Variables selected for the model were based on biologic plausibility. Variables included age, parity, history of prior vaginal birth, history of macrosomia in a prior pregnancy, history of prior episiotomy, and gestational age or months from delivery. Interaction terms were explored in models for variables that were moderately correlated (correlation coefficient >.6). Statistical significance was defined as a p-value ≤.05.

Among 880 participants, 503 (57%) were pregnant and 377 (43%) were postpartum. The mean age of the sample was 27 (SD 6); most participants had completed at least secondary education and listed household as their profession. The majority (729/880, 92%) of women had a prior vaginal birth and median parity was 3 (range 0-15). The prevalence of urinary incontinence in the overall sample was 30.5% (268/880); 33.4% (168/503) among pregnant and 26.5% (100/377) among postpartum women, p=.03. Among women who had urinary incontinence the mean ICIQ-UI-SF score was 11 (SD 4). Women with incontinence were more likely to be pregnant (168/268, 63%) and to have a history of macrosomia (114/268, 43%). 

Table 1 describes characteristics of incontinence, stratified by pregnancy status. The frequency of leakage was similar among pregnant and postpartum women, with two-thirds of women reporting leakage at least daily. Women who were pregnant were significantly more likely to experience stress urinary incontinence (49% overall, 55% of pregnant women and 39% of postpartum women, p=.01) and less likely to report moderate or large amounts of leakage than women who were postpartum (26% overall, 19% of pregnant women and 38% of postpartum women, p<.01). 

Table 2 displays results of univariate and multivariate logistic regression. In the sample overall, having a history of macrosomia and being currently pregnant (versus postpartum) were significantly associated with urinary incontinence (p≤0.05). Among pregnant women, macrosomia was significantly associated with incontinence while gestational age was protective for incontinence (p≤0.01). Among postpartum women, macrosomia and prior episiotomy were associated with incontinence (p≤0.05).

In this study, the prevalence of urinary incontinence among women that were currently pregnant was higher than women who were postpartum. Similar characteristics of incontinence were reported among pregnant and postpartum women on the ICIQ-UI-SF. Women who were pregnant were more likely to experience stress urinary incontinence which corresponds to findings from other studies. Incontinence was higher in pregnant women, specifically women who were in their sixth and seventh month of their third trimester. In addition, similar to previous findings, a history of macrosomia was associated with urinary incontinence.

Strengths of this study include the large sample size and the use of a validated questionnaire to determine urinary incontinence symptoms and quality of life impact in a population in whom data are needed. A limitation of the study is that we did not know the prior vaginal birth status of women.

Urinary incontinence was found to be prevalent in pregnant and postpartum women in the Democratic Republic of Congo. Incontinence was more prevalent in pregnant women early on in their third trimester, as well as, women who had a history of macrosomia. These findings suggest that interventions for urinary incontinence should target women who have delivered a macrosomic baby. Many studies have shown pelvic floor muscle training to be effective in preventing urinary incontinence. Women who have a history of macrosomia could be referred to physiotherapy or be provided with instructions regarding pelvic floor muscle exercises as part of postpartum care to prevent urinary incontinence symptoms in subsequent pregnancies.

Avery K, Donovan J, Peters TJ, Shaw C, Gotoh M, Abrams P (2004) ICIQ: a brief and robust measure for evaluating the symptoms and impact of urinary incontinence. Neurourol Urodyn 23 (4):322-330. doi:10.1002/nau.20041