Given that 350,000 surgical procedures are performed each year to treat urinary incontinence or other pelvic floor disorders (PFDs), effective prevention strategies are needed. Obstetricians cite the prevention of incontinence as a primary justification for elective Cesarean delivery. However, it's not known whether elective Cesarean is effective in preventing PFDs. In particular, there is virtually no information about the impact that delivery mode has on the long-term incidence of pelvic organ prolapse. The 2006 NICHD conference on Cesarean Delivery on Maternal Request highlighted this and other controversies about """"""""patient-choice"""""""" Cesarean. To investigate the effectiveness of elective Cesarean in preventing pelvic organ prolapse and other PFDs, we propose a cohort study of 1000 women who delivered a first child from 1998- 2003. The unexposed group will be women delivered by unlabored Cesarean delivery (UCD). We will recruit two comparison exposed populations, matched to the UCD group by date of first birth ( 3 months): women delivered by labored Cesarean delivery (LCD), and women delivered by vaginal birth (VB). The cumulative incidence of urinary and anal incontinence will be assessed in these three groups using validated questionnaires. To identify and classify pelvic organ prolapse, we will use a standardized physical examination for all participants.
Our specific aims are: (1) to investigate whether unlabored Cesarean delivery is associated with a lower cumulative incidence of PFDs (5-10 years from delivery) than either Cesarean after the onset of labor or vaginal birth, and (2) to investigate whether labor interventions, such as labor induction, episiotomy and operative delivery, have a significant effect on the cumulative incidence of PFDs. In addition, we will (3) develop a longitudinal cohort study of enrolled participants and follow these three groups annually to investigate the long-term incidence of PFDs. We will specifically compare the incidence of PFDs in the UCD group with the incidence in the LCD and VB comparison groups. This study is novel because we will focus on comparing UCD to other modes of delivery, because we will use a reproducible and quantitative physical examination to assess prolapse, and because the longitudinal design will allow us to describe the incidence and natural history of PFDs over time. By studying how childbirth affects a woman's risk of pelvic floor problems, we will provide new, valuable information for women and their doctors. We are at a crossroads in obstetrics, with an all-time high in Cesarean birth. Our findings will have immediate relevance to women anticipating childbirth and, from a public health perspective, will help to identify effect prevention options.

Public Health Relevance

Given that more than 350,000 major surgeries are performed in the US each year for treatment of incontinence and pelvic organ prolapse, prevention strategies are critical. We know that childbirth is a major risk factor for these pelvic floor problems, but this study will investigate whether Cesarean birth reduces the long-term risk of pelvic floor problems. By investigating whether Cesarean reduces incontinence and pelvic organ prolapse, we will provide information with immediate relevance to decisions faced by women and their obstetricians. From a public health perspective, this research will help to establish whether obstetrical care can be modified to prevent women's health problems later in life.

National Institute of Health (NIH)
Eunice Kennedy Shriver National Institute of Child Health & Human Development (NICHD)
Research Project (R01)
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Infectious Diseases, Reproductive Health, Asthma and Pulmonary Conditions Study Section (IRAP)
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Parrott, Estella C
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Johns Hopkins University
Obstetrics & Gynecology
Schools of Medicine
United States
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Blomquist, Joan L; Muñoz, Alvaro; Carroll, Megan et al. (2018) Association of Delivery Mode With Pelvic Floor Disorders After Childbirth. JAMA 320:2438-2447
Handa, Victoria L; Blomquist, Joan L; Roem, Jennifer et al. (2018) Longitudinal study of quantitative changes in pelvic organ support among parous women. Am J Obstet Gynecol 218:320.e1-320.e7
Handa, Victoria L; Blomquist, Joan L; Roem, Jennifer et al. (2018) Levator Morphology and Strength After Obstetric Avulsion of the Levator Ani Muscle. Female Pelvic Med Reconstr Surg :
Bossano, Carla M; Townsend, Kelly M; Walton, Alexandra C et al. (2017) The maternal childbirth experience more than a decade after delivery. Am J Obstet Gynecol 217:342.e1-342.e8
Handa, Victoria L; Mu?oz, Alvaro; Blomquist, Joan L (2017) Temporal relationship between posterior vaginal prolapse and defecatory symptoms. Am J Obstet Gynecol 216:390.e1-390.e6
Hallock, Jennifer L; Handa, Victoria L (2016) The Epidemiology of Pelvic Floor Disorders and Childbirth: An Update. Obstet Gynecol Clin North Am 43:1-13
Fitzgerald, Jocelyn; Pierce, Christopher; Nugent, Joann et al. (2016) Care-Seeking for Stress Incontinence and Overactive Bladder Among Parous Women in the First Two Decades After Delivery. Female Pelvic Med Reconstr Surg 22:199-204
Memon, Hafsa U; Blomquist, Joan L; Dietz, Hans P et al. (2015) Comparison of levator ani muscle avulsion injury after forceps-assisted and vacuum-assisted vaginal childbirth. Obstet Gynecol 125:1080-7
Chen, Crystal; Smith, LaPortia J; Pierce, Christopher B et al. (2015) Do symptoms of pelvic floor disorders bias maternal recall of obstetrical events up to 10 years after delivery? Female Pelvic Med Reconstr Surg 21:129-34
Handa, Victoria L; Pierce, Christopher B; Muñoz, Alvaro et al. (2015) Longitudinal changes in overactive bladder and stress incontinence among parous women. Neurourol Urodyn 34:356-61

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