Elaine Miller is a stand-up comedian, but she doesn’t tell knock-knock jokes. Instead, her show is about pelvic floors, pee and pregnancy.
“I make jokes about people wetting themselves,” she says.
In fact, Miller’s show – which even features a “clench-along”: a jolly song the audience is encouraged to exercise their pelvic-floor muscles in time to – is an attempt to highlight a massive issue affecting tens of thousands of women every year. It’s an issue that is somehow, astonishingly, rarely discussed: the long-term, often debilitating, physical aftermath of giving birth, not just weeks afterwards but years and even decades later.
The conditions range from long-term pain to incontinence, sexual dysfunction to prolapse (a condition where the internal organs slip down or forward – it’s been in the news recently because one of the treatments for it, vaginal mesh, has caused major suffering).
“There’s a lot of, ‘Oh, you’ve had a baby – what did you expect?’,” says Miller, whose show was motivated by her work as a women’s health physiotherapist – or, as she describes it, “fishing about in fannies”.
She adds: “Fifty per cent of women have prolapse. If 50 per cent of men had their scrotum falling off, something would be done about it. This is not something we are shouting about, but we should.”
Instead of shouting, many women are whispering – confiding quietly in fellow mums as their kids go down the slide, googling their symptoms in the small hours or writing about it online.
In part, this is because many feel abandoned by the NHS once their baby is safely out. After a cursory six-week check at the GP that is mainly focused on the baby and whether the mother is coping, and which often does not involve a physical exam of any kind, most women are then left to themselves.
That’s despite the fact that huge numbers of women suffer some serious injury in birth, which can, and often will, cause long-term repercussions. Ninety per cent of first-time mothers tear or are cut during birth, and around nine per cent of the tears are third- and fourth-degree, which involve the vagina, perineum and anus.
As a result of these injuries and the other physical stresses of pregnancy and birth, including weakening of the pelvic floor, around one in three women experience long-term urinary incontinence, and one in 10 have faecal incontinence. Up to 30 per cent have pain during sex. But experts at organisations like the Birth Trauma Association and Mothers with Anal Sphincter Injuries in Childbirth (MASIC) suggest that the real numbers are much higher – and, moreover, that these conditions can last for much of the rest of women’s lives if they don’t get help.
New research from Mumsnet released exclusively to The Pool backs this up. The team there surveyed 1,224 women as part of their campaign for better postnatal care, because they wanted to find out more about long-term problems after coming across discussions on the topic on their forums every single day.
They found that, three months after birth, 36 per cent of women still found sex painful or uncomfortable, and 42 per cent said that birth had contributed to incontinence or worse pelvic-muscle control.
“We’re not really surprised,” says Justine Roberts, Mumsnet CEO. “However, while we’re not surprised, it’s sad that the long-term impacts are so bad for many women… Of course, it’s important to say that this doesn’t reflect most mothers’ experience – but it is a significant minority.”
Stacey Baker, who is 25, is one of them. The birth of her two-year-old son, Alfie, was traumatic, ending up with a ventouse delivery – the use of a vacuum device to help get the baby out. Her epidural failed, leaving her with just gas and air for the pain.
Most enraging is the fact that we’ve seen some accounts of women who’ve approached healthcare professionals only to be told that mothers must expect everything to be different after birth, or ‘so long as your husband can penetrate you, it’s fine’
Baker tore, but her injury was misdiagnosed and badly repaired. Her pelvis also dislocated and, since birth, she has suffered with bladder, bowel and womb prolapse. Her mental health has also suffered.
“I try not to let my problems stop me from being active with my son, but I really suffer with severe pain, and the prolapses mean finding a loo everywhere we go is first priority,” she says. “Mentally, I don’t think I will ever recover, to be honest.”
But the most shocking part of Baker’s story is the care she has received – or, rather, not received – since birth. She was supposed to see a health visitor and a psychiatrist, but did not get appointments. The wait to see a consultant was six months. She now sees a physiotherapist, but she was told at her local hospital that she is too young for any further procedures or surgery.
“I feel very let down,” she says. “It’s like problems during and after birth are treated like nothing. It feels like because I’m young and chose to have a child, they don’t care.”
Her story is not a one-off. Mumsnet also asked its users about the care they had received for their post-birth problems. In fact, just under 10 per cent had the same experience as Baker – asking for help and not getting it.
“There are a few possible explanations, not least the pressures faced by the NHS,” says Roberts. “Most enraging is the fact that we’ve seen some accounts of women who’ve approached healthcare professionals only to be told that mothers must expect everything to be different after birth, or ‘so long as your husband can penetrate you, it’s fine’.”
“This is misogyny, pure and simple,” she adds, suggesting that women in this situation seek a second opinion.
But there is another issue too: many women just don’t come forward, either because of embarrassment, a lack of time or a belief that your own health, as a mother, isn’t the priority. Mumsnet’s numbers show that up to three-quarters of the women affected by incontinence or pain during sex had either not asked for or not received any care.
Their fears about the NHS’s attitude to their problems may also have been a factor, the numbers suggest: 56 per cent of women in the survey said that they didn’t think the NHS would focus on their issues either because of its financial constraints or, more concerningly, because clinicians either only cared about the baby’s health (17 per cent) or because there was an institutional attitude that “birth equals worse sex for women and mild incontinence – that’s just the way it is” (15 per cent).
“There’s always a thing that brings people to clinic – something so embarrassing that it’s less embarrassing than showing their bum hole to the NHS,” says Miller.
“For me, it was wetting myself in the mums’ sack race at school sports day. It was alright because I was in the sack, but I wouldn’t come out of the sack. And all the mothers got it.”
But this culture of silence is profoundly damaging, because studies show that many of the problems women face after birth are treatable. For example, between 70-85 per cent of women could cure stress incontinence with physio. And it does seem to be more of a problem in the UK than elsewhere – for example, in France, women automatically see a physiotherapist after giving birth.
That’s the least the UK should do, say Helen Lauer and Lyanne Nicholl, two campaigners set up a Facebook group to support other mothers and, ultimately, convince politicians that something must be done. Nicholl says she only feels able to talk about these issues because she hasn't had long-term health difficulties; she sought treatment privately.
“There are 10 times more studies done on Viagra than women’s health/prolapse,” says Lauer. “That’s about where we are in society in terms of the importance women have.
“If this was pain in any other part of the body, after a car accident or a procedure, people would be dealing with it. But you’ve just delivered a human and the NHS is going, ‘Ah, well…’ – that’s not good enough.”
It's not. Which is why, first and foremost, we need to keep telling the truth about post-birth vaginas. Because, ultimately, we deserve better.