When 50-year-old Rajamma (name changed) came to consult Dr Kalaivani Ramalingam, urogynaecologist at Apollo Hospital, Chennai, it was for a routine gynaecological checkup. As the doctor proceeded with the exam, however, she noticed a major abnormality in the area of the pelvic floor muscles. “It’s been like that since the birth of my third child,” Rajamma said simply with a shrug.
“But,” persisted Dr Kalaivani, “how have you managed all these years?” Out came a tale of nearly three decades of life lived under a constant maelstrom of anxiety and shame. Through all these years, Rajamma had even stopped going out of her home, out of the fear of soiling herself. Rajamma had suffered an injury during the birth of child that had resulted in bowel urgency. This meant that at any time Rajamma might feel an overwhelming need to defecate, and would soil herself if she did not immediately rush to the toilet.
Although it had severely impaired her life, leaving her virtually imprisoned in her home, the stigma of her condition had kept Rajamma’s lips sealed about her condition. “Leave alone doctors, even her husband didn’t know about it,” says Dr Kalaivani.
Rajamma is just one of thousands of women in India who suffer from obstetric anal sphincter injuries (OASIs).
What are OASIs?
OASIs refer to a condition where injuries to the birth passage during childbirth extend to the anal sphincter, the ring of muscles that regulate the flow of faecal contents out of the anus. If not repaired immediately, this can lead to bowel incontinence, where women have difficulty controlling flatulence and may also experience anal leakage.
A variety of factors influence whether women suffer OASIs during childbirth, including the mother’s position during childbirth, the size of the baby, the integrity of the tissues of the mother, rapidity with which the delivery happens, the use of instruments during delivery and the use or absence of preventive techniques.
Studies have documented varying prevalence rates for this condition, says Dr Kalaivani, estimating its incidence at anywhere between 1-15% of natural deliveries. However, she points out, even countries like the UK, with advanced medical systems providing uniform and skilled care, report a prevalence rate of around 5%. The rates would be higher in India, she estimates, not only because of varying levels of training for medical professionals in different kinds of hospitals, but also because Asian women are more predisposed to this condition due to their specific kind of musculature and lower protein diets.
Lack of awareness
One of the key requirements of treating OASIs is immediacy. If such an injury does not get treated soon after childbirth, the recovery rate starts to drop, as the muscles involved develop scarring. “We have good data to say that the sequelae (effects of injury) are felt even 15-20 years later. And the situation will only get worse over time,” says Dr Kalaivani. With Rajamma, for instance, treatment only resulted in a 50% improvement in her condition because too much time had passed since the injury.
However, even among medical professionals, there is often a problem of insufficient training for this issue, adds Dr Kalaivani. Thus, while the most major childbirth-related injuries are noted, less severe ones that result in OASIs often go unnoticed. “We grade the tears occurring during childbirth on a scale of one to four. The third- and fourth-degree tears are what constitute OASIs. Fourth-degree tears, which can’t be missed easily, usually get noticed. But cases of third-degree tears often get missed and can have a great impact,” she explains.
Among patients, the general stress of childbirth in most cases can lead to the problem going unnoticed at first. “A lot of people have some bowel problems after pregnancy. So, initially, you are told it will get better, that you just have to wait a few weeks,” says Dr Kalaivani. Besides, she adds, patients invest nearly all their energy into taking care of their newborn infants, and thus may not spare the energy to look after themselves.
The problem can also go unnoticed if women suffer constipation, a fairly regular occurrence after childbirth. This is because the leakage would not be as severe in the early stages, and thus would be chalked up to the normal effects of childbirth.
“The minor symptoms will get ignored for some time, with the expectation that they will get better with time, because everything stretches and comes back to normal within a few weeks. These women will have some leakage and urgency, which will be put down to the normal healing process after childbirth, without realising that a third-degree tear has occurred.”
Prisoners of stigma
Like Rajamma, many of the women who suffer OASIs often become homebound because of their condition. While urinary incontinence can also commonly result from injuries during childbirth, OASIs and bowel incontinence are often experienced as even more shameful. “At least for the urinary side of things women will mobilise themselves with diapers or pads. But with bowel incontinence they are much more aware of the social stigma in terms of the smell or soiling. So, they tend to not go out and basically not have any social life,” Dr Kalaivani explains.
The silence around this condition also means that expectant mothers are often not educated about this possibility. “Unfortunately, because it is seen as a dreaded complication, people tend to brush it aside,” says Dr Kalaivani, adding that it is only if women receive comprehensive ante-natal counselling that they learn about the possibility of such injuries.
Need for proper guidance
When issues of bowel incontinence are experienced after childbirth, says Dr Kalaivani, it is also important to consult the right kind of specialist for such conditions. While patients often turn first to general or bowel surgeons, they may not always be the right experts for such conditions if they had not been specifically trained to address this issue.
Dr Kalaivani Ramalingam, Urogynaecologist at Apollo Hospital.
Dr Kalaivani narrates the case of one such patient referred to her for a pre-surgical consultation. This 35-year-old woman was being prepared for a complex multistage surgery, where she would first receive a colostomy, surgery to divert the bowel contents to the front of the stomach region, where it would empty into a bag. Then, after sufficient time had passed for the emptied bowel to heal, further surgery would be carried out to repair it. “All this we are talking about a young woman who has a young baby and has got to put all of her energy and resources into caring for,” Dr Kalaivani points out.
When she examined the patient, Dr Kalaivani realised that the problem was much simpler than the surgeons had anticipated, and could be resolved with only a minor surgical procedure. “Actually, it ended up being an advanced third-degree tear, which did not need a colostomy, and we sutured her in the theatre then and there. And she did very well after that. All she had to undergo was a half-hour procedure under simple anaesthesia, and she avoided major surgeries,” she observes.
It is only if a clearer and more frank conversation about OASIs builds among medical professionals, expectant mothers and their families can women be free of the shame and silence of this condition, she adds.
This article has been produced by TNM Brand Studio in association with Apollo Hospitals and not by TNM Editorial.