Mothers Tell Us The Truth About Faecal Incontinence After Childbirth

Some of the worst times were in the supermarket, says Rhiannon, a mother-of-three in her 40s.

For years, as she nipped to the loo during the weekly shop, she had to push in front of her toddler in the toilet queue. Why? Because her bowel control was worse than his.

"And as they get older, they start saying, 'Mum, why are you pushing us out of the way? I want to go first'," she remembers.

"And when you don’t make it and you do it in public, there is this paranoia and you get obsessed by it. It’s horrible, and you get in the toilet and you just cry – has someone noticed?"

Rhiannon has suffered with bowel incontinence since having her first child aged 32, when her sphincter tore after a difficult birth. She was left in pain, incontinent, and struggling with postnatal depression. Her story is horrible, her embarrassment palpable, but the most shocking thing is that she is far from alone: more than one in 10 women may experience some form of faecal incontinence after childbirth.

And while people are finally starting to talk about some aspects of postnatal health, from depression to pain during sex, this condition remains almost completely taboo.

"There’s a big market for urinary incontinence products, but bowel incontinence isn’t so easy to hide," says Rhiannon. "Honestly, I’ve lost count of the times I’ve walked around hoping that no-one could tell."

Even if women do come forward, it can be hard to know where to turn. Professor Michael Keighley is a bowel surgeon who set up the charity Mothers with Anal Sphincter Injuries in Childbirth (MASIC) after trying to treat women with this condition surgically.

"We are the only charity out there to support women who suffer," he says. "There is really absolutely no support for them and no understanding about their predicament."

The condition varies, but may actually affect up to 15% of mothers, he adds: "It depends on how you define bowel incontinence, if it’s soiling yourself or even just passing wind uncontrollably – some would say that’s not much of an issue but it’s huge if you’re a 23-year-old nurse and whenever you lift a patient, you fart."

MASIC estimates that around half of mothers with bowel incontinence suffer as a result of an anatomical injury, known as a tear, during birth. A further 20-30% have nerve damage, after the baby’s head stretches the nerves as it descends through the pelvis. For those remaining, the cause is not fully understood.

Tears during birth are common. Up to 90% of first-time mothers tear, but the majority have what are known as first- or second-degree tears, which affect the vagina and perineum, and which can be repaired relatively simply. However, for first-time births, the risk of a more serious third- or fourth-degree tear is between 4-9%, and this risk increases hugely, possibly threefold, if it is a forceps delivery. It is with these injuries particularly that bowel incontinence becomes an issue, because the tear extends into the anal sphincter and rectum.

There are two particularly worrying things about these more serious tears. Firstly, the only real moment to repair them surgically is right after they happen, and a lack of awareness in the medical profession means that up to 40% of serious injuries are missed, according to MASIC. And secondly, astonishingly, the situation seems to have worsened: research carried out by the Royal College of Obstetricians and Gynaecologists (RCOG) showed that the incidence tripled for first-time mothers across all English hospitals between 2000 and 2012, from 1.8% to 5.9%.

At the time, the college’s president, Dr. David Richmond said tearing was a complex issue, with many risk factors including long labour and assisted delivery (where forceps or suction cups are used).

However, he added: "One possible reason for this trend is the rise in maternal age at first birth and maternal weight, which are linked to a higher birthweight and risk of perineal tears."

The trend for older mothers has only increased since then – last month, the Office for National Statistics found that the only age group with rising conception rates was the over-40s.

So it’s encouraging that RCOG, alongside the Royal College of Midwives, launched a programme in 2017 to try to tackle these injuries. Prevention – even just manual support of the mother’s perineum during birth – is key, and early results are promising, although the project still has a year to run.

But for the thousands of women in the UK who have already experienced the devastating long-term consequences of these injuries, it’s too late.

As Jessica*, 41, and I speak, she breaks down several times. She tore while giving birth to her son, Matt, seven years ago – her tear was misdiagnosed as less serious than it was and only repaired properly months after – and she still has bowel incontinence.

The birth also left her with prolapse, post-traumatic stress disorder, and postnatal depression. In fact, Jessica’s birth was so traumatic and mismanaged (she remembers being dragged to the edge of the bed with the sheer power of the pull when her son was delivered using forceps; an expert later diagnosed that "excessive force" had been used) that in 2016 she was awarded a six-figure sum in compensation, following a five-year legal battle. But when I ask if that was a good feeling, her answer is heartbreaking.

"The feeling afterwards was just so bleak," she says. "I felt that I’d done what I needed to do and I could leave that for Matt... and I could go."

Her condition has left her suicidal on several occasions, and her relationship with Matt’s father has broken down.

"It's hard when you feel so unfeminine, like no one is ever going to love this again," she says.

"It sounds awful but I am petrified of getting breast cancer, or anything happening to my boobs. Because that’s the only feminine bit that’s left. It just looks like a massacre down there."

She still manages her continence with pads and laxatives, and her mental health with antidepressants. Amazingly, Jessica – who is a nurse – has gone back to work at the trust where she gave birth, battling through her PTSD and the sheer embarrassment of having to explain her condition to her boss, highlighting her need to have a toilet nearby at all times.

"I have a bag of tricks with me. Clutch bags are difficult," she says, joking around, trying to make light of the situation. "But I still have accidents. The latest was in the car park for the main hospital. I had to sort myself out, go to a meeting, then shower. I try my best to be tough but if you have one bad accident that embarrasses you terribly, that just knocks you really hard."

Both Jessica and Rhiannon say getting treatment has made a huge difference. It is hard to cure bowel incontinence, but managing it can change people’s lives, and there are a lot of options available on the NHS, mainly through referrals from GPs to continence clinics. Options include advice on diet, anal irrigation, drugs and neuromodulation (electrical stimulation of the affected nerves).

Physiotherapy can also help, the experts agree. Maria Elliott, a women’s health physiotherapist and founder of the Mummy MOT programme – which covers all aspects of postnatal health – says it is "scandalous" that women are suffering when help is available.

"Any women having daily urinary or faecal incontinence by 12 weeks after birth need to seek out a women’s health physio and do rehab," she says. Physio is also available by referral on the NHS.

But there’s a huge obstacle in finding this help: coming forward.

Yvette Perston, a nursing specialist in the functional bowel service at Birmingham's Queen Elizabeth Hospital, puts it succinctly: "We’re awful in Britain. We’d talk about our sex lives before our bowels. Even about what we earn."

She urges women not to suffer in silence, but even brave women like Jessica and Rhiannon, who can now tell their stories, understand how hard that can be. Despite their openness, neither wanted to be fully identified in this piece. Some of their friends still don't know. And Rhiannon admits it took her nearly four years to seek professional help.

But they hope that talking about what has happened to them can help others.

"This is not talked about enough so it is reliant on people who are in it, to talk about it," says Jessica.

"That's easy for some people but there's going to be a proportion of women who just can't bring themselves to talk about it… So who is falling off the radar, and what kind of state are they in?"