health-seeking behaviours of primiparous women with persistent pelvic girdle pain postpartum in...
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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
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Overview
Background & context
Methodology
Findings
Interpretation & implications for practice
Trinity College Dublin
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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)
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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
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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
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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)
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Ethics
• Ethical approval Faculty of Health Sciences – Trinity College Dublin• Informed consent• Confidentiality
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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
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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
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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
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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)
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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
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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)
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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)
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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)
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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)
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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
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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.
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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
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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
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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