Pelvic floor dysfunction in rural postpartum mothers in the United States: prevalence, severity, and psychosocial correlates

ABSTRACT

Pelvic floor dysfunction (PFD) is a common gynecological problem; however, women residing in rural communities may refrain from seeking treatment for PFD. The purpose of this study was to characterize severity of PFD among postpartum women residing in rural communities (<50,000 residents) in the United States and explore the demographic and psychosocial correlates of PFD. Methods: A survey packet comprised of the Pelvic Floor Disability Index (PFDI-20) and Prolapse and Incontinence Knowledge Questionnaire (PIKQ) as well as the Edinburgh Perinatal Depression Screening (EPDS), items from the Canadian Sexual Health Indicator (CSHI) survey, and demographic questions were distributed via electronic link following recruitment using social media. Descriptive statistics were calculated, and multivariate logistic regression was used to assess the factors associated with PFDI-20 score. Results: Participants (n = 383) have limited pelvic health knowledge (PIKQ) despite self-reporting moderate symptoms of dysfunction (PFDI-20). Over half of women scored ≥14 on the EPDS, indicating probable depression. Women with high scores on the EPDS had greater odds of reporting moderate/severe PFD. Women that identified as Black and/or having a college degree were more likely to report moderate/severe PFD. Conclusion: Rural women require further support to improve their physical and psychological health in the postpartum period.

KEYWORDS:

• Pelvic floor
• postpartum
• quantitative
• rural

Background

The postpartum period is a significant life experience due to myriad physical and psychological changes experienced by new mothers. The challenges associated with the transition to motherhood are often connected with reduced engagement in healthful behaviors like physical activity or healthy eating and increased risks of psychiatric disorders like postpartum depression (Shorey et al. 2018). In recent years, the Association of Maternal and Child Health Programs (AMCHP) has called for new strategies to enhance postpartum health by improving postpartum systems of care (Cornell et al. 2016).

Data suggest women in rural areas are at higher risk for postpartum depression and other perinatal mental health problems when compared to their urban counterparts (Ginja et al. 2020; Mollard et al. 2016). Postpartum women residing in rural areas may experience unique barriers to accessing care due to geographic isolation, lack of transportation, lower socioeconomic status, and lack of health insurance (Kim and Dee 2018). Rural culture also emphasizes self-reliance and women in rural areas may face additional stigmatization in seeking healthcare for mental health and gynecological care (Heslop, Burns, and Lobo 2019; Mollard et al. 2017; Schroeder et al. 2020). For the purposes of this study, rural is defined as an entity that lies outside of metropolitan boundaries with those boundaries being defined as having a core county with one or more areas of 50,000 people and outlying counties tied to that core county (Cromartie 2008).

Additionally, women residing in rural areas are less likely to utilize contraception and have higher parity in shorter birth intervals than their urban counterparts (Bescher-Donnelly and Smith 2019; Golbasi et al. 2009; Janis et al. 2021; Kim and Dee 2018; Martins et al. 2016). Prior research has failed to examine whether these disparities are a result of family planning decisions by rural women or due to lower levels of reproductive autonomy. Bennett (2002) notes that rural women’s reproductive autonomy may be limited by the “impact of rural values, norms, and belief systems regarding sexual health and the patient-physician relationship” (p.112). In addition, compared to women in urban areas, studies show that rural women have similar or higher rates of intimate partner violence which may include reproductive coercion (Breiding, Ziembroski, and Black 2009) as well as less access to victim advocacy and other supportive services such as family planning/sexual health services (Bennett 2002).

To reduce the incidence and severity of postpartum depression, known risk factors that impact a mother’s health should be addressed. Specifically, pelvic floor dysfunction (PFD) has been independently associated with postpartum depression, however, this relationship has been infrequently examined (Swenson et al. 2018). Importantly, PFD can reduce a woman’s motivation and ability to be physically active which is concerning as this is a known treatment for addressing postpartum depression (Nakamura et al. 2019).

PFDs may present as urinary urgency, frequency and incontinence as well as pelvic heaviness, pressure or a “falling out” feeling. Additional symptoms of fecal incontinence, straining for defecation and incomplete bowel emptying may occur (Bortolini et al. 2010). Importantly, 1 in 4 women are affected by PFDs (Nygaard et al. 2008; Thom 2015). PFDs can occur during pregnancy due to the lengthening of the abdominal wall that can reduce organ support. In addition, PFDs are common after vaginal delivery due to overstretching of the pelvic floor muscles, as well as perineal tearing and straining that may occur during the birthing process. PFDs can also occur after cesarean deliveries due to incisions leading to a lack of organ support. Risk for PFDs increase after every subsequent childbirth, yet few women report receiving pelvic health education or treatment before or after pregnancy (Bø 2012; Jolleys 1988; Nemir and Middleton 2017; Quiboeuf et al., 2015; Skoner, Thompson, and Caron 1994; Wu et al. 2014). The severity and impact of PFD among mothers residing in rural communities remains poorly understood.

In addition to better understanding the symptoms women may experience, it is also pertinent to understand their knowledge of the pelvic floor. Women appear to delay treatment for pelvic floor distress until severe disorder has occurred and this may be, in part, due to low levels of knowledge regarding pelvic health (McLennan et al. 2005; Neels et al. 2016). A systematic review conducted by Fante and colleagues (2019) determined knowledge and awareness of the pelvic floor is low to moderate among women and risk factors for lack of knowledge include low educational level, low access to information, and socioeconomic status. Given the disproportionate rates of low socioeconomic status, poor access to healthcare and limited educational attainment in rural dwellers, it is likely that women residing in rural areas may be at an increased risk of low pelvic health knowledge (Gong et al. 2019). Thus, the purpose of this study was to characterize severity of PFD among postpartum women residing in rural (<50,000 people) communities and explore the demographic, knowledge level and psychosocial correlates to PFD.

Methods

Design

A cross-sectional survey design utilizing a convenience sample was employed to explore the severity of pelvic floor dysfunction, pelvic health knowledge and psychosocial correlates among rural postpartum women within the United States.

Recruitment/Data collection

Recruitment occurred between May and June 2021. Participants were recruited via advertising on Facebook. A sponsored post was shared with directions to click a link to be brought to a survey regarding health in the postpartum period. Prior to survey entry participants reviewed a cover page that discussed the voluntary nature of the survey and stated the risks of participation were minimal and may include loss of confidentiality or discomfort in survey subject matter. No questions were required, and blank responses were allowed. Eligibility criteria was confirmed with two yes/no questions (1) do you reside in a community with a population of <50,000 and (2) have you experienced childbirth in the last 6 months? The last page of the survey had the number for Postpartum Support International if subjects required additional support. Participants received an electronic $5 Amazon gift card after successful survey completion. A convenience sample of   400 participants was sought (Salem et al. 2018). This study was approved by the first author’s University Institutional Review Board.

Measures

An anonymous, web-based survey packet comprised of self-administered, validated assessment tools and sociodemographic questions was developed.

Primary outcome

Pelvic floor dysfunction was assessed using the Pelvic Floor Disability Index (PFDI-20) (Barber, Walters, and Bump 2005; Shah et al. 2008). The PFDI-20 has been previously validated and found to have good internal consistency α = 0.71–0.89 (Henn, Richter, and Marokane 2017). The PFDI-20 is designed to evaluate symptom distress in three areas (urinary, pelvic organ prolapse and colorectal-anal). There are three subscales within the instrument; six urinary questions (UDI-6); 8 colorectal = anal questions (CRAID-8) and six pelvic organ prolapse questions (POPDI-6). Participants are asked to report how much a symptom bothers them (0 = symptoms not present; 1 = yes symptoms, not at all bothered; 2 = yes symptoms, somewhat bothered; 3 = yes symptoms, moderately bothered; 4 = yes symptoms, quite a bit bothered). An example question includes “do you usually experience frequent urination?” A scale score is determined by obtaining the mean value of all of the answered questions in each scale (possible value 0 to 4) and multiplying by 25 to obtain a scale score of 0 to 100. A summary score is than calculated by adding the 3 scores together (range 0 to 300). A reliability analysis was carried out on the individual scale items. Cronbach’s alpha demonstrated strong reliability, α = 0.92–0.97. PFDI-20 scores were stratified into the following groups: no symptoms (score:0), mild (score: 1–33), moderate (34–66), or severe (67–100) (Nosti et al. 2012).

Independent variables

The following demographic data were collected: race/ethnicity, age, household income, highest level of education, age of youngest child, current physical activity, access to pelvic healthcare services during and after pregnancy, infant feeding status. cesarean delivery, use of forceps in most recent pregnancy, experience of episiotomy in most recent pregnancy, weight in pounds, height in inches. A coding scheme was developed for the demographic information (e.g., race/ethnicity (1 = white, 2 = black, 3 = Hispanic, 4 = American Indian, 5 = Asian, 6 = Other) and applied to the respondent data.

Pelvic floor knowledge was assessed using the Prolapse and Incontinence Knowledge Questionnaire (PIKQ) (Barber, Walters, and Bump 2005; Shah et al. 2008). The PIKQ has been previously validated and psychometric measures indicate excellent internal consistency (α >0.8). The PIKQ is a 24-item questionnaire with 12 questions designed to assess urinary incontinence and 12 questions assessing pelvic organ prolapse knowledge. Respondents select “agree,” “disagree,” or “don’t know” to a series of statements. An example statement includes: “Giving birth many times may lead to pelvic organ prolapse.” Correct answers are given a score of one and incorrect/don’t know answers a score of 0 to 12. Higher scores indicate more correct answers and subsequently infer greater knowledge of urinary incontinence and pelvic organ prolapse. A reliability analysis was carried out on the individual scale items in a previous investigation (Mckay et al. 2019). Cronbach’s alpha demonstrated strong reliability, α = 0.93–0.94. PIKQ scores were calculated based on number of answers correct out of the 12 questions and categorized as follows: (1) lack of knowledge proficiency with a correct answer score of ≤50 percent, (2) some knowledge proficiency with a score between 51 percent-79.9 percent, or (3) high knowledge proficiency with a score ≥80 percent (Mckay et al. 2019).

Four items were identified from the Canadian Sexual Health Indicator (CSHI) to assess reproductive autonomy (Smylie et al., 2013). The four items were measured on a 5-point likert scale (1, strongly disagree-5, strongly agree). The four items included were: (1) I feel confident in my ability to use protection on myself or my partner, (2) I feel confident I could purchase protection without feeling embarrassed, (3) I feel confident I could stop to put protection on myself or my partner in the heat of passion, (4) I feel confident I could easily ask my partner if she/he had protection or tell them I do not. Reliability analysis determined acceptable reliability between the four items (α = 0.56–0.67). A total score was calculated for the four items out of a possible total of 20 with a higher score indicating greater reproductive autonomy.

The Edinburgh Postnatal Depression Scale (EPDS) is designed to identify patients at-risk for perinatal depression (Cox et al. 1996). The EPDS has been previously validated and psychometric measures indicate high test–retest reliability (ICC = 0.92) (Kernot et al. 2014). The 10-item instrument asks mothers to report how they have been feeling in the past 7 days. An example question includes: “I have been able to laugh and see the funny side of things.” Participants are provided Likert-type options ranging from “not at all” to “as much as a I ever did.” A scoring guide is utilized with a maximum score of 30 possible. A score above 13 indicates depressive illness of varying severity (Cox, Holden, and Sagovsky 1987). A reliability analysis was carried out on the individual scale items. Cronbach’s alpha demonstrated moderate to strong reliability, α = 0.75–0.79. After scoring the EPDS, subjects were stratified into two groups (1) score of ≤13 (lower likelihood of depression) or (2) score of ≥14 (higher likelihood of depression).

Data analysis

Instruments in the survey packet were scored based on standard protocols and all data analysis took place utilizing IBM statistical software, SPSS (v27). Data were first examined for missing values and outliers. Subjects that did not complete at least 80% of the survey or provided duplicate or implausible values (e.g., age 4766) were removed from data analysis. Potential confounding variables were chosen a priori based on previous associations identified in the literature and included age, race, education, household income, history of cesarean deliveries, history of vaginal births, episiotomy in most recent birth, forceps use with most recent birth, current physical activity, body mass index and breastfeeding status (Bortolini et al. 2010; Bø 2012; Carvalhais et al. 2018). Body mass index was calculated by entering the self-reported weight (lbs) and height (inches) into the following formula (bmi=weight/height² *703).

Descriptive analysis included frequencies and percentages for categorical data and means for continuous data. ANOVA tests were applied to continuous sociodemographic variables and chi-square tests applied to sociodemographic categorical variables to examine the influence of the sociodemographic variables related to participants having moderate/severe pelvic floor dysfunction per the PFDI-20 score. Multivariable logistic regression analysis was adjusted for confounding factors and conducted to determine associations between the primary outcome (pelvic floor dysfunction severity) and the independent psychosocial variables. A two-sided significance cut off was set to p < .05.A Wald chi-square <.0001 was set for all logistic regressions.

Results

A total of 472 respondents completed the survey: however, 37 respondents did not complete at least 80% of the survey and thus were removed from data analysis. An additional 52 respondents were removed due to duplicate responses or implausible values. A remaining 383 participants were included in the analysis. Related to the primary outcome of PFDI-20 score, of the 379 participants that completed the entire PFDI-20, the majority (56.9%) reported experiencing moderate symptoms of pelvic floor distress (See Table 1). Moderate urinary distress symptoms were most often reported (68.1%) followed by moderate colorectal anal distress symptoms (66.4%) (see Table 1). Total PFDI-20 scores were collapsed into two categories; 165 participants (43.5%) had no/mild symptoms and 217 participants (56.5%) had moderate/severe symptoms.

Table 1. Multivariate regression analysis examining the relationship between psychosocial factors and PFDI-20 symptom severity.

Variables	Moderate/Severe Symptoms on PFDI-20
	β [SE}	p
PIKQ
Score of ≤50 percent	.241 [.136}	.077
Score between 51 percent-79.9 percent	−.032 [.030]	.276
Score ≥80 percent	−.080 [.045]	.077
CSHI
Total Score	−.001 [.025]	.952
EPDS
Low Score <13	−.189 [.057]	.001
High score ≥14	.182 [.055]	.001

β-regression coefficient; SE=Standard Error; p-values ≤.05 and are bolded. Each model is adjusted for confounding factors: age of child, maternal race/ethnicity, number of cesarean deliveries, number of vaginal births and breastfeeding status. PFDI-20=Pelvic Floor Disability Index; PIKQ=Prolapse and Incontinence Knowledge Questionnaire; EPDS: Edinburgh Perinatal Depression Screening; CSHI: Canadian Sexual Health Indicator.

Sociodemographic factors

Of the respondents, most participants were White (66.9%), had a household income of <$100,000 per year (67.8%) and had trade school/some college (35.2%) (see Table 2). The average participant had given birth 3.5 ± 1.3 months prior to survey completion and was 29.3 ± 3.8 years old. A total of 71.3% of respondents reported not accessing services to improve or maintain their pelvic floor during pregnancy and 70.8% of respondents reported not accessing pelvic floor services in their current postpartum period. Most participants reported zip codes within the Midwest, Northwest or Western United States (55.8%). Initial univariable analyses demonstrated several significant associations with moderate/severe PFD including age of child, maternal race/ethnicity, education, number of cesarean deliveries, number of vaginal births and breastfeeding status.

Table 2. Survey descriptive findings.

Participant Category PFDI-20	POPDI-6 n (%)	CRAID-8 n (%)	UDI n (%)	PFDI-20 Total n (%)
No Symptoms	17 (4.5)	22 (5.7)	15 (3.9)	10 (2.6)
Mild	140 (37.0)	99 (25.9)	94 (24.6)	155 (40.8)
Moderate	220 (58.0)	254 (66.4)	260 (68.1)	216 (56.9)
Severe	2 (0.5)	7 (2.0)	13 (3.4)	1 (2.6)
Mean Score	34.0 ± 19.25	35.0 ± 15.0	37.5 ± 15.75	108.0 ± 40.0
Canadian Sexual Health Items n (%)	Somewhat/Strongly Disagree	Neutral	Somewhat/Strongly Agree
I feel confident in my ability to use protection on myself or my partner	127 (33.3)	104 (48.4)	70 (18.3)
I feel confident I could purchase protection without feeling embarrassed	106 (27.8)	111 (28.7)	166 (43.5)
I feel confident I could stop to put protection on myself or my partner even in the heat of passion	81 (21.2 percent)	146 (61.8)	155 (40.6)
I feel confident I could easily ask my partner if they had protection (or tell them I do not)	76 (19.9)	129 (33.8)	175 (45.9)
EPDS n (%)	Score ≤13 points	Score ≥14 points	Mean Score
	140 (36.6)	243 (63.4)	14.5 ± 4.4
PIKQ n (%)	UI Sum Score	POP Sum Score	PIKQ Sum Score
	6.3 (52.5)	5.7 (47.6)	12 (50.0)
Sociodemographic Variables	N (%) All	N(%) None/Mild Symptoms	N(%) Moderate/Severe Symptoms	p-value
Age of Mother	M = 29.3 ± 3 years	30.2±.49 years	29.0 ± 2 years	.136
Age of Child	M = 3.5 ± 1.3 months	4.6±.42 months	2.5±.33	.000
Race/Ethnicity
White	264 (66.9)	97 (62.2)	167 (70.8)
American Indian	22 (5.7)	10 (6.4)	12 (5.1)
Black	52 (13.5)	30 (19.2)	22 (9.3)
Hispanic	19 (4.9)	13 (8.3)	6 (2.5)	.003
Asian	9 (2.3)	6 (3.8)	3 (1.3)
Other	16 (4.1)	0 (0)	16 (6.8)
Two or More Races	10 (2.6)	0 (0)	10 (4.2)
Education
High School or Below	110 (28.7)	49 (29.9)	61 (27.9)
Trade School/Some College	139 (36.3)	75 (45.7)	64 (29.2)
College degree	129 (33.7)	38 (23.2)	91 (41.6)	.001
Graduate Degree (master’s, doctorate)	5 (1.3)	2 (1.2)	3 (1.4)
Household Income
≤$49,000	101 (26.3)	50 (30.5)	51 (23.3)
$50,000–$74,999	94 (24.5)	42 (25.6)	52 (23.7)	.457
$75,000–$99,999	65 (16.9)	27 (16.5)	38 (17.4)
$100,000–$125,000	89 (23.2)	29 (17.7)	60 (27.4)
>$125,000	34 (9.1)	16 (9.7)	18 (8.2)
Accessed services to support pelvic health in recent pregnancy
Yes	43 (13.3)	20 (14.7)	23 (12.2)	.378
No	281 (86.7)	116 (85.3)	165 (87.8)
Accessed services to support pelvic health since having most recent child
Yes	48 (14.7)	18 (13.1)	30 (15.8)	.431
No	279 (85.3)	119 (86.9)	160 (84.2)
Body Mass Index
≤18.4 Underweight	34 (9.9)	12 (6)	22 (15.5)
18.5–24.9 Normal	183 (53.5)	118 (59)	65 (45.8)	.435
25.0–39.9 Overweight	119 (34.8)	66 (33)	53 (37.3)
≥40.0 Obese	6 (1.8)	4 (2)	2 (1.4)
Pelvic Health Services or Resources within 50 miles of home
Yes	165 (50.3)	101 (50.8)	64 (49.6)
No	163 (49.7)	98 (49.2)	65 (50.4)	.122
History of cesarean deliveries
0	198 (50.8)	83 (50.6)	115 (52.5)
1	111 (28.2)	57 (34.8)	54 (24.7)	.000
2	35 (8.9)	20 (12.2)	15 (6.8)
3 or more	39 (12.1)	4 (2.4)	35 (16)
History of vaginal births
0	23 (5.8)	13 (7.9)	10 (4.6)
1	275 (69.8)	125 (76.2)	150 (68.5)
2	52 (13.2)	21 (12.8)	31 (14.2)	.000
3 or more	33 (11.2)	5 (3.1)	28 (12.7)
Episiotomy in most recent birth
Yes	137 (35.7)	54 (32.9)	83 (37.9)
No	196 (51.1)	92 (56.1)	104 (47.5)	.464
Prefer not to answer	50 (13.2)	18 (11)	32 (14.6)
Forceps with most recent birth
Yes	126 (32.9)	79 (36.2)	47 (28.5)
No	183 (47.8)	101 (46.3)	82 (49.7)	.254
Prefer not to answer	74 (19.3)	38 (17.5)	36 (21.8)
Current Physical Activity
Sedentary	98 (26.0)	40 (24.4)	58 (27.2)
Walking >4 hours/week	168 (44.6)	65 (39.6)	103 (48.4)	.076
Sports >4 hours/week	73 (19.4)	41 (25)	32 (15)
Hard exercise training	38 (10)	18 (11)	20 (9.4)
Breastfeeding or pumping breastmilk
Yes	306 (80.1)	143 (87.7)	163 (74.4)
No	76 (19.9)	20 (12.3)	56 (25.6)	.001
Currently exclusively breastfeeding or pumping breastmilk (i.e., no formula or solid foods)
Yes	237 (62.2)	106 (64.6)	131 (60.4)	.395
No	144 (37.8)	58 (35.4)	86 (39.6)
Region of the United States
Mid-Atlantic/Northeast	63 (16.4)	35 (14.7)	28 (19.3)
Midwest	95 (24.8)	65 (27.3)	30 (20.7)	.232
Northwest/West	119 (31.0)	74 (31.1)	45 (31)
Southeast	45 (11.7)	32 (13.4)	13 (9)
Southwest	29 (7.5)	18 (7.6)	11 (7.6)
Undisclosed	32 (8.6)	14 (5.9)	18 (12.4)

PFDI-20 (Pelvic Floor Disability Index); EPDS (Edinburgh Perinatal Depression Scale) PIKQ (Prolapse Incontinence Knowledge Questionnaire); Descriptive analysis included frequencies and percentages for categorical data and means for continuous data. ANOVA tests were applied to continuous sociodemographic variables and chi-square tests applied to sociodemographic categorical variables to examine the influence of the sociodemographic variables related to participants having moderate/severe pelvic floor dysfunction per the PFDI-20 score*p-values represent the overall p-value associated with a PFDI-20 score indicating none/mild symptom severity vs moderate/severe symptom severity. Bolded p-values indicate significance of p < .05 was achieved.

PIKQ Scores

The PIKQ-UI sum score was 6.3 out of 12 items with 52.5% of items answered correctly. The PIKQ-POP score was 5.7 out of 12 with 47.6% of correct answers. The total percentage of correct answers with combined scales was 47.9.%. Further, 182 participants (53.4%) were categorized as low knowledge proficiency; 145 (42.5%) were categorized as “some proficiency” and 14 (4.1%) were categorized as knowledge proficient.

Canadian sexual health indicators survey items

Descriptive findings indicate mixed survey responses. The total score out of a possible 20 was 13.1 ± 3.1. When evaluating items individually, a third of women reported somewhat or strongly disagreeing they would be confident in their ability to use protection during sex. This was followed by 26.9% disagreeing they would be confident to purchase sex protection without feeling embarrassed. Additional findings can be seen in Table 3.

Table 3. Characteristics of mothers and associations with pelvic floor distress symptoms.

Variables	None/Mild Symptoms		Moderate/Severe Symptoms		None/Mild		Moderate/Severe Symptoms
	Univariate		Univariate		Multivariate		Multivariate
	OR	[95% CI]	OR	[95% CI]	OR	[95% CI]	OR	[95% CI]
Race/Ethnicity
White	1	Ref	1	Ref	1	Ref	1	Ref
American Indian	2.6	.57–12.0	0.37	.08–1.7	0.49	.13–1.7	2	.55–7.2
Black	1	.24–4.3	0.97	.23–4.0	0.19	.05-.71	5.2	1.4–19.6*
Hispanic	2.2	.64–7.8	0.44	.1.2–1.5	0.98	.19–4.9	1	.20–5.1
Asian	11.1	1.7–7.2*	0.08	.01-.56	0.83	.16–5.2	1.1	.19–5.9
Other	1.3	.22–7.5	0.76	.13–4.4	0.61	.11-.44	0.14	.06-.35
Education
≤ High school	0.44	.07–2.7	2.2	.35–14.2	0.58	.30–1.1	1.7	.91–3.2
Some College	0.65	.10–4.0	1.5	.24–9.5	0.74	.14–3.7	1.3	.26–6.7
College Degree	0.51	.08–3.2	1.9	.31–12.1	0.43	.25-.75	2.3	1.3–3.9*
Graduate Degree	1	Ref	1	Ref	1	Ref	1	Ref
Household Income
≤$49,000	1.6	.58–4.3	0.62	.23–1.7	0.61	.32–1.1	0.42	.16–1.0
$50,000–$74,999	0.18	.45–2.1	1	.46–2.2	0.76	.38–1.5	0.69	.26–1.8
$75,000–$99,999	0.21	.24–1.4	2.7	.25-.54	0.7	.42-.16	0.24	.20–1.4
$100,000–124,999	1.2	.20–1.2	1.4	.25–1.2	0.46	.22-.99*	0.9	.32–2.5
≥$125,000	1	Ref	1	Ref	1	Ref	1	Ref
Accessed pelvic healthcare-pregnancy
Yes	1	Ref	2	Ref	1	Ref	1	Ref
No	0.83	.50–1.4	1.2	.73–2.0	0.79	.45–1.4	1.2	.72–2.1
Accessed pelvic healthcare-post birth
Yes	1	Ref	2	Ref	1	Ref	2	Ref
No	0.85	.52–1.4	1.1	.70–1.9	1.1	.59–1.7	0.97	.56–1.6
Pelvic Health Services or Resources within 50 miles	1	Ref	2	Ref	1	Ref	2	Ref
Yes	1	Ref	2	Ref	1	Ref	2	Ref
No	1.3	.80–2.4	1.2	.68–2.2	2.1	.91–1.1	3.1	.07–4.4
History of Vaginal Births
0	1	Ref	1	Ref	1	Ref	1	Ref
1	0.47	.28-.68	0.68	.58-.79	0.34	.56–5.4	2	.61–2.7
2	0.75	.37–1.5	1.3	.66–2.6	0.24	.60-.79	1.2	.61–2.3
3 or more	0.44	.16–1.1	2.2	.83–5.9	0.55	.18–1.6	1.8	.59–5.5
History of C-sections
0	1	Ref	1	Ref	1	Ref	1	Ref
1	0.41	.35-.48	0.6	.54-.66	2.2	.03–1.5	0.71	.06–1.3
2	0.15	.19-.32	0.15	.32-.91	2.1	.10–4.4	0.45	.02-.92
3 or more	0.39	.33-.45	0.31	.15-.48*	0.46	.03–5.7	2.1	.17–2.6
Current Physical Activity
Sedentary	1	Ref	1	Ref	1	Ref	1	Ref
Walking >4	0.67	.39–1.1	1.4	.87–2.5	0.48	.45–1.4	1.2	.69–2.1
Sports >4	0.44	.22-.91	2.2	1.0–4.5*	0.7	.31–1.5	1.4	.64–3.1
Hard exercise	0.5	.20–1.2	1.9	.82–4.7	1.5	.69–3.5	0.63	.27–1.4
BMI
≤18.4	1	Ref	1	Ref	1	Ref	1	Ref
18.5–24.9	0.67	.39–1.1	1.4	.87–2.5	0.66	.29–1.5	0.78	.12–5.0
25.0–39.9	0.44	.22-.91	2.2	1.0–4.5*	1.1	.71–1.8	0.52	.08–3.1
≥40	0.5	.20–1.2	1.9	.82–4.7	0.52	.08–3.1	1.7	.29–8.9
Episiotomy in most recent birth
Yes	−0.03	−0.2	0.03	−1.47	0.77	.41–3.2	0.86	.30–2.4
No	1	Ref	1	Ref	1	Ref	1	Ref
Forceps with most recent birth
Yes	−0.08	−0.36	0.08	−0.2	0.68	.25–1.8	1.4	.52–3.9
No	1	Ref	1	Ref	1	Ref	1	Ref

Edinburgh postnatal depression scale

A total of 366 respondents completed the EPDS, the mean score was 14.5 ± 4.4; 140 participants (36.6%) scored ≤13 points while 243 participants (63.4%) scored ≥14 points indicating probable depression of varying severity. Additional findings can be seen in Table 2.

Logistic regression analysis

A multivariate regression analysis determined a relationship between having a low PIKQ score (<50% accurate answers) and reporting moderate/severe PFD per the PFDI-20 however this relationship was not significant (p < .077). No significant relationships were seen between total score on the CSHI and having moderate/severe PFD. Finally, having a high score on the EPDS was associated with reporting moderate/severe PFD (p < .001). Findings can be seen in Table 1.

Univariate and multivariate analyses demonstrated relationships between maternal characteristics and pelvic floor distress symptoms. After adjusting for confounding factors, multivariate analyses demonstrated a significant association between reporting moderate/severe PFD symptoms and identifying as Black (p <.001) and having a college degree (p <.001). Reporting symptoms of none/mild pelvic floor dysfunction via the PFDI-20 was associated with an income of $100,000–$124,999 (p <.001). See additional details in Table 3.

Discussion

Moderate pelvic floor dysfunction, high incidence of depressive symptoms, moderate confidence in utilizing sex protection, and low pelvic health knowledge were identified within this convenience sample of rural postpartum women. Furthermore, reporting a race/ethnicity of Black and having a college degree was associated with reporting moderate/severe PFD symptoms after controlling for confounding variables. Previous research has found black women were less likely to have stress urinary incontinence but more likely to have urgency urinary incontinence. In addition, black women are more likely to experience risk factors for incontinence such as obesity, diabetes, smoking and hysterectomy (Hartigan and Smith 2018). 2018. Black individuals residing in rural communities are especially vulnerable to health disparities (Aggarwal et al. 2021). Specific to the association between college education and reporting moderate/severe PFD, we hypothesize this is influenced by the higher pelvic floor knowledge that is associated with having a college degree. Specifically, higher education level has been associated with pelvic health knowledge and thus higher educated women may have greater health literacy surrounding pelvic health terminology and be able to provide a more accurate survey response (Goodridge et al. 2021; Mandimika et al. 2014).

The elevated EPDS scores identified among our sample population are a cause for concern and suggest greater efforts are needed to address mental health in the postpartum period in rural communities. Our findings align with previous investigations which suggest prevalence of postpartum depression may be higher in rural communities (Mollard et al. 2016). The association between moderate to severe PFDI-20 score and high EPDS score confirms a relationship between postpartum depression and PFD. These findings are consistent with previous research in urban populations showing urinary incontinence after pregnancy and referral for pelvic floor pain were associated with elevated postpartum depression screening scores (Swenson et al. 2018). Given the geographic barriers related to healthcare access in rural communities, innovative strategies are needed to ensure women with pelvic floor issues can be adequately referred and treated (Mollard et al. 2016).

Further, the moderate levels of confidence for utilizing sex protection in this sample of postpartum rural women also warrants future investigation. Effective contraception usage can assist in healthy birth intervals between children which can reduce the risk of PFDs and decrease the likelihood for postpartum depression (Kim and Dee 2018). Given the high incidence of probable depression seen in this sample and that women in rural communities are less likely to use contraception, additional educational efforts are needed (Bescher-Donnelly and Smith 2019).

There are numerous strategies to reduce PFD among rural postpartum women and improve maternal psychological and physical well-being. Pelvic floor muscle exercises can have a profound effect on the prevention and treatment of PFDs (Dinc, Beji, and Yalcin 2009). Educating women on proper engagement in pelvic floor muscle exercises is a crucial tool in reducing the incidence and prevalence of PFDs among rural postpartum women. Research has shown one-time video-based webinars by certified health professionals (e.g., physical therapists) are effective at improving knowledge of the pelvic floor, however, more research is needed to understand if this knowledge increase translates to a reduction in symptoms (Morrison et al. 2022). Strategies related to virtual education and expansion of telehealth opportunities should be considered as future research opportunities (Myers et al. 2020). Specifically, telehealth has been related to a significant improvement in urinary symptoms, pelvic floor muscle function and quality of life, however, cost and access to such services remain prohibitive for many women (da Mata et al. 2020). Previous research has only been conducted in urban settings and work in rural communities is needed to ensure generalizability of findings.

This study was limited by utilization of a convenience sample. Participants self-selected for the study via social media indicating a potential bias related to the variables of study. One example of this bias may be the large number of women that reported experiencing an episiotomy or utilization of forceps with their most recent pregnancy. Our sample had a much larger cohort of mothers that reported these experiences compared to the general population (Mandelbaum et al. 2021). Mothers with this experience may have self-selected to complete a survey on pelvic health after their experiences. Despite seeking a homogenous sample of women residing in communities with less than 50,000 residents, generalizability of findings is still limited by the widespread geographic diversity of the respondents. Furthermore, data related to parity, gravidity, complete history of episiotomy/utilization of forceps from each pregnancy, types of pelvic healthcare accessed (e.g., physician versus physical therapist) and current utilization of pelvic floor muscle exercises were not adequately collected despite these factors being known to be associated with PFD. Specifically, although information was gathered for number of cesarian sections and vaginal pregnancies, total number of pregnancies was not collected. Future research must account for these demographic variables. The reliance on self-reporting in this study is also a limiting factor. For example, our study had a very small number of women that self-reported their height and weight to equal an obese BMI despite many postpartum women being obese. Due to the ability to self-report weight rather than be weighed on a scale women may have provide an inaccurate representation of their weight. Future research should consider combining survey measures with objective measures such as obtaining height and weight through objective measures. Additionally, given the high incidence of probable depression identified on our survey instrument it is recommended that future research identify additional resources or opportunities for immediate participant follow-up when high EPDS scores are identified. This study was strengthened by the utilization of previously validated survey instruments and a diverse participant cohort respective to income and education. Larger scale studies are needed to confirm findings.

Conclusion

Rural postpartum women within this convenience sample most often experienced moderate PFD, high incidence of depressive symptoms, moderate confidence in utilizing sex protection and low pelvic health knowledge. Reporting moderate/severe PFD symptoms was associated with identifying as Black and reporting a college degree. These findings suggest postpartum women in rural areas are at risk for severe physical and psychosocial health consequences. Increased resources are needed to improve maternal health in the postpartum period in rural communities. Future research should continue to investigate what modalities are effective for providing pelvic health education to postpartum mothers in rural communities. Long-term investigations should further explore the role of birth spacing on pelvic health and explore how improved self-management of pelvic health influences physical activity engagement and mental health in the postpartum period.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The project described is supported by the National Institute of General Medical Sciences, U54 GM115458, which funds the Great Plains IDeA-CTR Network. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.” This project is also supported with the funds received under Nebraska Laws 2021, LB 380, Section 109 through the Nebraska Department of Health & Human Services (DHHS). Its contents represent the view(s) of the author(s) and do not necessarily represent the official views of the State of Nebraska or DHHS.