INTRODUCTION: Although the prevalence of pain persisting after pregnancy or labour decreases with time, up to 35 % of women report pain 8 months to 12 years after childbirth. To prevent the development and reduce the impact of chronic pain, researchers and clinicians emphasize the importance of early diagnosis as well as timely and appropriate treatment. Previous studies have shown that when women with post-childbirth morbidities consult healthcare professionals during the first year following birth, their problems are often neglected, and they do not receive adequate treatment.

OBJECTIVE: To explore how women with pain persisting for eight months after childbirth experienced encounters with healthcare.

METHODS: A descriptive qualitative design with 20 face-to-face, semi-structured interviews. Data were analysed using inductive qualitative content analysis.

RESULTS: "Pain ignored by healthcare" was identified as an essential theme and included four categories: "Questioned pain experience," "Inadequate pain management," "Lost in healthcare," and "Insufficient postpartum care " CONCLUSION: The women experienced that their pain was often not recognized or adequately treated, but instead ignored or trivialized. Recurring were descriptions of experienced knowledge gaps among the healthcare providers regarding pain and its management. There was an overall desire among women for a well-defined and well-functioning chain of care with better accessibility and scope.

Background: Pregnancy and labour often entail pain and tissue damage, which may lead to the development of chronic pain. Globally, chronic pain, defined as pain that persists after three months, is a leading cause of lasting suffering and disability. If pain is not timely diagnosed and adequately treated it can become a chronic condition. However, among healthcare professionals, there seems to be a lack of strategies for its prevention and treatment.

Aim: The aim of this thesis was to describe the prevalence and characteristics of chronic pain related to childbirth. Further aims were to explore women’s experiences of pain and its consequences as well as information and support from healthcare professionals.

Methods: Study I was conducted as a prospective cohort study, Studies II and IV had a qualitative approach, and Study III was a mixed methods study with a sequential explanatory design. In Study I, as well as in the first, quantitative part of Study III, data were obtained through two self-administered questionnaires and the patient record system, Obstetrix. The first questionnaire was distributed on the maternity ward, 24–36 h after labour between April and December 2015. The second questionnaire was sent by post eight months after childbirth. Data from 1,171 women, who answered the second questionnaire, were analysed using descriptive statistics. Studies II and IV as well as the second, qualitative part of Study III, had a qualitative approach and included 20 individual semi-structured interviews. Participants in these studies consisted of the same sample, recruited among women who had reported chronic pain related to pregnancy and/or labour in Study I. The interviews were conducted between June and November 2016, recorded and transcribed verbatim. The data were processed and analysed using inductive content analysis.

Results: The results of Study I showed that 17% of the women reported chronic pain related to childbirth. Approximately 80% rated their worst pain as moderate or severe and more than 40% of the women experienced pain constantly or daily. Dyspareunia related to childbirth was reported by 19% of the women, with approximately 60% experiencing their worst pain during intercourse as moderate or severe. Study II revealed that women constantly struggled with the pain and its consequences. Chronic pain had a negative impact on several aspects of women’s lives, including physical and social activities, psychological well-being, self-image, as well as their roles as partners and mothers. The results of Study III revealed that the majority of the women did not receive information about risks of developing chronic pain related to childbirth. They did not have knowledge about when and where to seek help, and half of them did not consult healthcare professionals. The lack of information also led to women feeling unprepared for the pain causing emotional distress. In addition, as Study IV revealed, when women turned to healthcare, they did not receive the attention, recognition, and support they needed. They reported not being listened to, not taken seriously, or believed by healthcare professionals and their pain was not assessed, diagnosed, or treated. The women felt abandoned after childbirth and forced to manage the condition on their own. There was an overall desire for more support and continuity regarding care as well as better knowledge among healthcare professionals.

Conclusions: Chronic pain eight months after childbirth was reported by one in six women and one in five experienced dyspareunia. Approximately 80% of the women rated their worst pain as moderate or severe, and more than 40% experienced pain constantly or daily. The pain and its consequences had a negative impact on several aspects of women’s lives. In addition, women did not receive adequate information or support from healthcare. In consequence, they did not seek help or when they did, their pain was not recognised, treated, or resolved. Living with pain as well as the lack of adequate information and support from healthcare may also lead to emotional distress. Together this may contribute to women’s suffering as well as an increased risk of development and maintenance of chronic pain. This thesis indicates a need to review the content and quality of current postpartum maternal care concerning pain assessment and management, as well as to develop standards and guidelines for prevention and treatment of pain persisting after pregnancy or labour.

BACKGROUND: Access to information is essential to achieving individual empowerment; meaning the ability to exercise control, manage one's own condition and make informed decisions. However, studies have shown that information provided to women regarding physiological changes during the postpartum period and postpartum health was inadequate, incorrect, or inconsistent.

METHODS: The aim of this study was to explore informational support about pain persisting after childbirth and its consequences. A sequential explanatory mixed methods design was used. In the first, quantitative phase, 1,171 women, who gave birth eight months earlier, completed a self-administered questionnaire. In the second, qualitative phase, 20 women who experienced chronic pain were interviewed. Descriptive statistics and qualitative content analysis were used to analyse the data.

RESULTS: The majority of the women did not receive information about pain persisting after childbirth, or the information was insufficient or incorrect. They did not know when and where to seek help and did not consult health care professionals. In addition, the lack of information had a negative impact on women's psychological well-being. All women expressed the need to be informed by health care professionals, irrespective of the individual risk of developing chronic pain.

CONCLUSIONS: Health services should ensure availability of information to give the women opportunity to achieve empowerment to make good health decisions, increase control over their health and well-being as well as to enhance their self-efficacy. We propose that a booklet or leaflet with relevant information about the risk of developing chronic pain, symptoms and treatment, along with advice about appropriate health care settings should be provided as part of antenatal or postnatal care.

OBJECTIVE: To describe women's experiences of chronic pain related to childbirth approximately one year after labour.

DESIGN: A qualitative design with face-to-face interviews analysed using inductive qualitative content analysis.

PARTICIPANTS: Twenty women who reported chronic pain, with onset during pregnancy and/or following labour, approximately one year after childbirth.

FINDINGS: The analysis revealed an essential theme, "Grieving over the past and struggling forward", and three categories "Mourning the losses", "Struggling with the present" and "Managing the future".

CONCLUSIONS: This study provides new knowledge about women's experiences of chronic pain one year after childbirth. The pain severely reduced women´s previous ability to perform physical and social activities, negatively impacted psychological well-being and altered their self-image. Most of the women adopted a positive attitude and hoped for improved health in the future, although constantly struggling with the pain and its consequences.

IMPLICATIONS FOR PRACTICE: This knowledge is particularly important as chronic pain may not diminish with time in predisposed individuals who may need help and support from health professionals in their endeavour to manage their pain. Healthcare providers, i.e. midwives, gynaecologists and general practitioners need to understand women´s experiences of chronic pain from their own perspective to improve identification and treatment of pain following childbirth, thus preventing women's suffering and potential long-term health problems. Future studies are warranted to further explore and discuss women's coping strategies, health seeking behaviour and experiences of health care.

Background and aims

Although several studies have been conducted, knowledge about chronic pain and dyspareunia after childbirth is still limited. The aim of this study was to explore the prevalence of chronic pain 8 months after childbirth in a cohort of Swedish women. The characteristics of chronic pain, such as, pain intensity, localization and frequency as well as pain interference with daily activities were examined. An additional aim was to describe the prevalence and intensity of dyspareunia.

Methods

Data were obtained through two self-administered questionnaires and the patient record system, Obstetrix. The first questionnaire was distributed on the maternity ward, 24-36 h after labour, to Swedish-speaking women who had given birth to a living child (n = 1,507). The second questionnaire was sent by post 8 months after childbirth. We collected data about demographic and social characteristics, pain presence and its onset, as well as pain intensity, frequency, bodily localization and pain interference with activities of women's daily life. Results In total, 1,171 (77.7%) responded to both questionnaires and were included in the analysis. Eight months after giving birth, totally 16.7% (195/1,171) of the women reported chronic pain related to childbirth. Of these, 9.1% (106/1,171) of women reported chronic pain with onset during pregnancy, 4.5% (53/1,171) experienced chronic pain with onset following labour and 3.1% (36/1,171) of women had both chronic pain with onset during pregnancy and chronic pain with onset following labour (each participant could only appear in one of the groups). Women reported a lower prevalence of chronic pain after vaginal delivery than caesarean section (61/916, 6.7% vs. 28/255, 11%, p = 0.021, OR 1.73, 95% CI 1.1-2.8). Moreover, 19.2% (211/1,098) of women experienced dyspareunia. There was no difference regarding prevalence of dyspareunia and the mode of delivery. Of those women who had a vaginal delivery, 19.5% (167/858) experienced pain during intercourse and the corresponding number for women after caesarean section was 18.3% (44/240) (p = 0.694, OR 0.929, CI 0.6-1.3). Approximately 80% of women with chronic pain, and 60% of women that experienced dyspareunia, rated their worst pain as moderate or severe (NRS 4-10). The corresponding number regarding average chronic pain was between 50 and 70%. More than 35% of the women with chronic pain scored pain interference with daily activities as ≥4 on a 0-10 NRS.

Conclusions

In our study, chronic pain 8 months after childbirth was reported by one in six women and one in five of the women experienced dyspareunia. The intensity of both chronic pain and dyspareunia was reported as moderate to severe in a significant proportion of women and chronic pain interfered considerably with daily activities. Implications There is a need to raise awareness among healthcare providers of this clinical problem as well as to revise and upgrade education regarding pain after childbirth to prevent potential long-term health problems, women's suffering and increased need for health care. The development of strategies for prevention, follow-up and treatment of pain is warranted. More research, including women's experiences of pain as well as intervention studies, are also needed.