For so many American women, urinary incontinence — or involuntary loss of bladder control — is a condition we've simply come to expect in the months and even years after having kids.
The muscles and nerves around the bladder and the pelvis can weaken during pregnancy and delivery, making it difficult to hold in urine. As a result, many women experience leakage whenever they cough, sneeze, laugh or engage in strenuous exercise, which can be incredibly frustrating and annoying. But when they mention it at doctor appointments, doctors aren't always responsive or helpful. "Don't worry, it's normal," they say. "It's common. You'll learn to live with it."
But, as French women know, it doesn't have to be that way.
Around 65 percent of American women experience incontinence after giving birth. "It's probably more like 75 percent, because doctors aren't always bringing it up," says Abby Bales, D.P.T., a women's health physical therapist in New York City. In France, on the other hand, about 30 percent of French women suffer from incontinence at age 40, and around 20 percent at age 30. The reason for this huge discrepancy? French women go to vagina bootcamp after they deliver.
The French Postpartum Experience: “La Rééducation Périnéale”
France started offering [pelvic floor physical therapy](https://parenting.blogs.nytimes.com/2013/08/12/the-re-education-of-my-perineum/?_r=0 http://www.slate.com/articles/life/family/2012/02/postnatal_care_in_france_vagina_exercises_and_video_games.html) — "la rééducation périnéale" — for all new moms in 1985 after doctors and numerous studies noted that they were at increased risk of incontinence, explains Cécile Cabirou, a midwife in Paris. Now, at the hospital maternity ward or at the six-week checkup, all women are given a prescription to visit a midwife who specializes in pelvic floor training. The country's government-sponsored health insurance pays 100 percent of the cost for 20 sessions — 10 sessions of perineal reeducation and 10 sessions of abdominal reeducation.
"Reeducation right after [giving] birth can prevent incontinence later," says Cabirou. "The perineal floor needs physical training, just like all the other muscles in the body. The idea is to help women feel that area again."
After an internal assessment to determine the strength of the perineal floor, midwives teach women perineal floor exercises. Some midwives use their fingers to manually check if women are contracting the muscles in their vaginal wall. Others use a "vaginal probe," which attaches to wires on a machine and screen, with lines that jump when the pelvic floor muscles contract. There are nearly a dozen different muscles in the region, and midwives help women learn what it feels like to work them all.
"We make women feel and contract different zones of their perineal floor. To make it more easy to understand, we'll talk about a wave, and we'll guide her to contract these different muscles," says Cabirou. Visits last 30 minutes, and women come twice a week for as long as they need assistance. At each appointment, progress is evaluated and women are given daily exercises to do at home.
Marie, a Paris-based journalist, had two C-sections and took advantage of postpartum pelvic floor physical therapy both times. "I thought I'd be fine after the first, since I didn't push my baby out vaginally. But I scored 0 out of 5 [on a scale of 0 to 5, with 0 being the weakest and 5 the strongest]. I was astonished," she says. "It's painful, you really don't want to go, and you have a baby at home. But by the 10th visit I scored a 5. It really worked."
Yet even though it's free and it works, Cabirou says only about one in four French women actually take advantage of pelvic floor physical therapy. "Lots of women don't do it because they're tired, they have a young baby and they start working. Some women don't do it they because they don't want to be touched there after birth," she says.
"There also aren't enough practitioners. I regularly refuse new patients because I already have too many. So some people give up because they can't find a practitioner."
Still, one in four is impressive compared to the postpartum experiences of American women.
The American Postpartum Experience: “Not Standard Procedure”
In the United States, rehab is not part of the post-birth regimen. Assessing and rehabbing the musculature of the pelvic floor is not standard training or procedure for American OB-GYNs.
"A normal pelvic exam does not include a pelvic floor exam, although that depends on your gynecologist," says Elizabeth Etkin-Kramer, M.D., an OB-GYN in Miami. Etkin-Kramer says at her office, she always asks about incontinence at the six-week checkup. If it is a problem she'll do an exam. If the pelvic floor is weak she'll refer patients to her in-office pelvic floor physical therapist.
But that's not typically the case. Among the women Bales works with in physical therapy, very few say their doctors asked about leakage. Instead, at the six-week postpartum visit, doctors are focused on medical issues — and they have 15 minutes to zoom through a long checklist: contraception, breastfeeding and the standard pelvic exam to check for infection, remnants of the placenta and scarring.
Even when incontinence does come up, Bales says only about one in six of her patients says that an OB-GYN suggested pelvic floor therapy — and most then found her online, not through referral. "It's almost always patient-driven," she says.
In other words, it's up to American women to ask for help. The problem is, unless women are experiencing serious leakage — which gets worse with time — many don't know they have a problem with their pelvic floor by the six-week checkup. "Women don't know if sex is painful because they haven't had it yet. They may not know they're having spasms in their pelvic floor because they haven't tried to use a tampon yet," says Bales.
What's more, many women who are suffering from incontinence are too embarrassed to mention it to their doctors. "Often women don't bring it up on their own," says Etkin-Kramer.
Others think it's "normal" to leak after giving birth. "Clients tell me that when they ask, most [doctors] say it's normal, it'll pass with time, or you'll have it for the rest of your life," says Bale. "There's a comic who was a new mom who joked about how funny it is that she pees when she laughs because she had two kids. They're joking about it. It's normalizing it. I would argue that, while it's common, it's not normal."
Bales says she often sees women who are four or five years postpartum and seeking help because another physical therapist that they're seeing for knee or back pain has asked about incontinence and referred them.
"One patient had her second child four years ago. She was an athlete and was having urinary incontinence and hip pain while she was running. She told her OB, who just told her to wear a pad while she was running or to just not run," says Bales. "These women aren't stupid. They're asking the right questions, but the people meant to refer them to another field are out of the loop on interventions."
Is France More Progressive Than Most?
Even among European countries, France is an outlier. In Germany and England, Cabirou says, women only get physical therapy to rehab their abs, not their pelvic floor. "There are no other countries where pelvic floor therapy is automatic or where they talk about it as much," she says.
Cabirou believes a lot of the reason France is ahead of the game is cultural. "As soon as we talk about the perineal floor, we talk about sexuality, and that's taboo in our Judeo-Christian culture," she says. However, in France the women's liberation movement of 1968 changed the discussion about women. "We take care of ourselves to not have incontinence. It's aligned with feminism," says Cabirou. "Even before having a kid, it should be part of education for young women. From a very young age, we should explain that it's a muscle to contract, and that it's good idea to do so."
"In the U.S. health care system, you don't get help without reaching out for it, whereas it's automatic in other countries," says Etkin-Kramer.
Bales agrees. "We have to look at postpartum care like the major medical issue that it is and send women to rehab immediately," she explains. "It goes back to the patriarchy of health care. Women's health isn't a priority."
What American Women Can Do
So what's an American woman to do if she's not getting support from her doctor to rehab her pelvic floor? Kegel — and often. Cabirou suggests aiming for 40 contractions a day — whether it's on the bus or cooking dinner. "Working your perineal floor is healthy hygiene, just like brushing your teeth. Every woman shouldn't go one day without doing these exercises," says Cabirou.
Not sure if you're Kegeling right? Sit on ball or chair. Pull your belly in and draw your pelvic floor upward and inward. If you feel your pelvic floor lift away, you're doing it right. You can also even test yourself once by actually trying to stop the flow of urine. If you can't, it's time to get an evaluation.
However, Bales notes that because pelvic floor dysfunction can come from an over- and underactive pelvic floor, Kegeling on your own often isn't enough. That's when a pelvic floor physical therapist — who's trained to assess you and get to the bottom of any issues — may be necessary. Retraining your pelvic floor can help prevent incontinence as well as make sex more enjoyable for you and your partner.
And here's some good news: American insurance covers pelvic floor physical therapy for incontinence. Depending on where you live, you can see a therapist for around 10 sessions, says Bales. Most PTs will want you to see your OB-GYN first for an internal exam and health clearance (and because referral from an OB-GYN is usually required for insurance reimbursement).
And do it soon. "Incontinence gets worse and eventually levels off, but it won't get better on its own," says Bales. "Nerves can regenerate somewhat, but most of that happens within a year. So if you need to stimulate a nerve or reeducate muscles, you need to get help as soon as possible."
What Do YOU Think?
Have you experienced incontinence after childbirth? What support have you received? Was your doctor helpful in addressing the issue? Tell us in the comments.