Health-seeking behaviours of primiparous women with persistent

pelvic girdle pain postpartum in Ireland

Trinity College Dublin

Francesca Wuytack

Dr Elizabeth Curtis

Prof Cecily Begley

Trinity College Dublin

Overview

Background & context

Methodology

Findings

Interpretation & implications for practice

Trinity College Dublin

Trinity College Dublin

Background & contextPregnancy-related Pelvic Girdle Pain (PPGP)

23-65% of pregnant women (Albert et al 2002; Kovacs et al 2012)

Persistent PPGP postpartum

17% 3 months postpartum (Gutke et al 2011)

8-10% 18-24 months postpartum (Albert et al 2002)

Background & contextTrinity College Dublin

Postnatal care

• Two visits with GP (2 & 6 weeks postpartum)

• Visits of the public health nurse (during the 6 weeks)

Maternity care in Ireland

Jointly provided by GP & maternity hospital

Background & contextTrinity College Dublin

National guidelines’ recommendations for persistent PPGP postpartum (Hogan et al., 2012)

• Out-patient physiotherapy with individualised assessment and treatment focussing on stabilising exercises and movement advice

• Possibly including multidisciplinary interventions if physical interventions fail

PPGP may persist beyond 6-8 weeks of postnatal care

Lack of connectivity between records

Aim of the studyTrinity College Dublin

To explore the health-seeking behaviours of primiparous women with PPGP persisting for more than three months postpartum.

Health-seeking behaviours were defined as any remedial actions that individuals undertake to rectify a perceived health problem (Ward et al 1997)

Pain > 12 weeks ‘Chronic’ (Airaksinen et al 2006)

Ethics

• Ethical approval Faculty of Health Sciences – Trinity College Dublin• Informed consent• Confidentiality

Trinity College Dublin

Methodology - Descriptive qualitative study

Semi-structured interviews

MAMMI (Maternal health & Maternal Morbidity in Ireland) study - longitudinal cohort survey study

Thematic analysis

Transcription

Purposive sample of 23 women for qualitative study: • Persistent PPGP ≥ 3 months postpartum• No history of low back or pelvic girdle pain• No symptoms suggestive of nerve involvement or

serious illness

Trinity College Dublin

Methodology – Rigour/trustworthiness

• Independent analysis of three transcripts by a second researcher (CB)

• Reflective journal entries• Peer-debriefing sessions• Negative-case analysis• Member checking

Member checking: • Summary of the findings + short questionnaire sent

to all participants• 14 women responded• High resonance of the findings• No changes made

Participant characteristics (n=23)Trinity College Dublin

Age Number of participants ≤ 24 2

25-29 230-34 1235-39 7

Country of birthIreland 19

Other European country 4Highest qualification

Upper secondary leaving cert – applied and vocation progs., A levels, National Vocational Certificate (NCVA) level 1

2

Completed apprenticeship, NCVA level 2/3, Teagasc certificate, diploma 1Primary degree 6

Professional qualification or degree status 2

Postgraduate certificate or diploma 6Postgraduate degree Masters 6

Participant characteristics (n=23)Trinity College Dublin

Time postpartum at the time of interview n3 to 6 months (91-182 days) 14

6 to 9 months (183-273 days) 69 to 12 months (274-364 days) 3

Pain pattern nConstant 1

Intermittent 10Transient 1

Constant & intermittent (day dependent) 10Constant & transient (day dependent) 1

Pain location nAnterior PGP 2Posterior PGP 14

Combined Anterior & Posterior PGP 7Pain severity at the time of interview (VAS 10cm) Mean (SD)

Morning 5.0 (SD 2.3)Evening 5.7 (SD 1.9)

FindingsTrinity College Dublin

Themes Categories

(1) ‘They didn’t ask, I didn’t tell’ Lack of follow up after birth Healthcare professionals ignore it

(2) Seeking advice and support Talking to others Triggers to seek help Barriers to getting help

(3) Coping strategies Self-management strategies Pain medication and treatments

Theme (1) – ‘They didn’t ask, I didn’t tell’

Trinity College Dublin Lack of follow up after birth

Healthcare professionals ignore it

“Before you have the baby you have so many check-ups and you have scans and everything, there is a fantastic support system, but once you've had the baby it’s like you’re left to your own devices.” (16; 243 days)

“I suppose the 6-weeks check; I was quite surprised by just how basic it was, and I know a lot of friends have said the same. There is no kind of like real physical proper check. But I would feel that a lot of, even friends with things that are unaddressed, because it’s a fairly just ‘Ok, fine, see you now’. They didn’t ask specific questions and it was very quick and very minimal. If you said you were fine, you were fine.” (24; 364 days)

Theme (2) – Seeking advice & support

Trinity College Dublin Talking to others

Triggers to seek help

“He is aware I still have pain. We don’t really talk too much about it, but it’s still there, and he is very supportive anyway.” (12; 300 days)

“Well, I probably wouldn’t have gotten help if my husband and family wouldn’t have pushed it, but I’m glad they did.” (3; 167 days)

Barriers to getting help

“I know I’m getting no kind of joy with my GP but I don’t know what the next step could be, what I could personally do with it, who I could go to with it. So, I don’t know; I’m kind of in limbo. I don’t know what the next step is.” (2; 227 days)

Theme (3) – Coping strategiesTrinity College Dublin

Self-management strategies

Pain medication & treatments

“Exercise is good and it’s not sore when I do it, well, it depends for how long. Particularly softer ground is better than concrete. I can really find it hurting when I’m walking on concrete.” (24; 364 days)

“I cut down on the pain relief so it’s not as much; I’m glad I got off Solpadine because that was quite harsh on the system. Panadol is a little bit softer but obviously if it’s a bad day you still need it.” (17; 132 days)

Findings in contextTrinity College Dublin

Theme Categories

(1) ‘They didn’t ask, I didn’t tell’ Lack of follow up after birth Healthcare professionals ignore it

Structured approach to postnatal consultations (specific questions)

Findings in contextTrinity College Dublin

Theme Categories

(2) Seeking advice and support Talking to others Triggers to seek help Barriers to getting help

• Peer support• Feeling misunderstood - Lack of awareness

the PPGP may persist for some• Conflicting diagnoses and advice – lack of

information transfer

Findings in contextTrinity College Dublin

Theme Categories

(3) Coping strategies Self-management strategies Pain medication

• Uncertainty could impede self-efficacy – low self-efficacy is related to increased pain and distress (Jackson et al 2014)

• Antecedents to help-seeking: recognition (a), decision to act (b) and selection of sources of help (c) (Cornally and McCarthy 2011)

Influenced by the advice and information that women seek or receive.

Clinical Relevance & conclusion• The study findings illustrate the health-seeking

behaviours for PPGP from the women’s perspective, which is unique because women did not have contact any health service provider regarding their PPGP to participate in this study. • Women stressed the importance of adequate follow-up

for their PPGP postpartum, beyond the 6 week postnatal check-up• These insights highlight a hidden morbidity suffered by

an increasing number of women in Ireland, at a time when they need to be feeling well in order to care for their baby.

Trinity College Dublin

Acknowledgments

• Women who participated in the study• MAMMI study team• Midwives and midwifery students who distributed the

information• Rotunda Hospital• Health Research Board Ireland

Trinity College Dublin

References

• Airaksinen O, Brox JI, Cedraschi C, et al. Chapter 4. European guidelines for the management of chronic nonspecific low back pain. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society. Mar 2006;15 Suppl 2:S192-300.

• Albert H.B., Godskesen M. & Westergaard J.G. (2002) Incidence of four syndromes of pregnancy-related pelvic joint pain. Spine (Phila Pa 1976) 27(24), 2831-2834.

• Cornally N. & McCarthy G. (2011b) Help-seeking behaviour: a concept analysis. Internation Journal of Nursing Practice 17(3), 280-288.

• Gutke A, Lundberg M, Ostgaard HC, Oberg B. Impact of postpartum lumbopelvic pain on disability, pain intensity, health-related quality of life, activity level, kinesiophobia, and depressive symptoms. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society. Mar 2011;20(3):440-448.

• Hogan M., Wiseman S. & Ross L. (2012) Clinical Practice Guideline: Management of Pelvic Girdle Pain in Pregnancy and Post-partum.

• Jackson T., Wang Y., Wang Y. & Fan H. (2014) Self-Efficacy and Chronic Pain Outcomes: A Meta-Analytic Review. Journal of Pain.

• Kovacs F. M et al. 2012. Prevalence and Factors Associated With Low Back Pain and Pelvic Girdle Pain During Pregnancy. Spine, 37(17), 1516-1533.

Trinity College Dublin