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The associations of postpartum urinary incontinence with depression, anxiety, and stress among women in Saudi Arabia: a cross-sectional study

BMC Psychology volume 13, Article number: 412 (2025) Cite this article

Abstract

Background

After delivery, the psychological status of women may go through several critical stages. Postpartum urinary incontinence (PPUI) might be one factor that affects mental health. The aim of this study is to evaluate the variables associated with depression, anxiety, and stress in women with PPUI using the Depression, Anxiety, Stress Scale (DASS).

Methods

A cross-sectional study of 813 Saudi women. Participants were asked to complete an online DASS and provide demographic information. Univariate and multivariate regression analyses were performed to assess the associations between variables and DASS.

Results

Of those who experienced PPUI, 45.6% (n = 108, p value < 0.01) had a BMI ≥ 30, and 44.4% (n = 107, p value = 0.00) had more than 4 children. In the multivariate regression model, BMI (≥ 30 odds ratio: 1.2, p = 0.14), number of children (p = 0.03), type of delivery (caesarian delivery odds ratio: 1.5, p = 0.25), and severity of UI (severe UI odds ratio: 4.6, p = 0.00) were significantly associated with moderate to severe depression. In the multivariate regression model, BMI (≥ 30 odds ratio: 1.2, p = 0.05) and severity of UI (severe UI odds ratio: 3.7, p = 0.00) were significantly associated with moderate to severe anxiety. In the multivariate regression model, caesarian delivery (odds ratio: 1.9, p = 0.05) and severity of UI (severe UI odds ratio: 6.3, p = 0.00) were significantly associated with moderate to severe stress.

Conclusions

A high prevalence of anxiety was observed in postpartum women. Severity of PPUI was strongly associated with moderate to severe depression, anxiety, and stress in PPUI women.

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Introduction

Postpartum urinary incontinence (PPUI) is one of the various complications that can affect women of all ages worldwide after delivery in addition to other burdens, such as pain, insomnia, and fatigue. Also, PPUI has an impact in women in the work environment and hence a financial burden on families [1]. Its prevalence ranges from approximately 15 to 36% with risk factors such as age, number of children, use of oral contraceptives, smoking, diabetes mellitus, increased body mass index (BMI), and type of delivery [2,3,4,5]. It has been found that the prevalence of PPUI in Saudi Arabian women ranges from 29 to 56% (considered high when compared to other countries) [6].

There are several studies that identified multiple risk factors that are associated with PPUI including age of 40 years and more, multiple deliveries, smoking, metabolic disorders, urinary tract infection, hypertension, asthma, chronic cough, constipation, and high body mass index [2, 4, 5].

Usually, it is expected to have changes in psychological status with serious diseases such as cardiovascular diseases, cancers, and metabolic disorders [7, 8], but physicians as well as patients do not expect psychological changes with other disorders that are not considered as serious health problems such as PPUI. In addition, postpartum depression is relatively more common among postpartum women [9]. Whether postpartum depression is associated with PPUI or other factors needs to be evaluated carefully.

In general, the association between psychological status changes, including depression and anxiety, and an overactive bladder has been identified in the literature in several countries such as the United Kingdom and Sweden [10,11,12]. Also, the association between urinary incontinence (UI) in pregnancy and anxiety has been reported [13]. Interestingly, Jurascova et al. found that 17.6% of Czech patients developed PPUI, and 17.3% showed signs of depression [14]. In addition, treatment of UI has been shown to positively affect the psychological status [15].

In Muslim countries, even though the studies are quite few, the impact of PPUI on mental health might be more deleterious due to its impact on religious duties, such as ablutions and prayer. As a matter of fact, Muslims have Obligatory prayers 5 times per day that is spread throughout the day. Before performing prayers, one has to perform ablutions with clean clothes from urine and even few drops of urine will contaminate and make the prayers invalid until it is not under your control. That is why women with PPUI feel psychologically stressed especially Saudi women where the prayers regularity is highest among the Muslim world. In this regard, it becomes really an important issue for Muslim women around the globe because Saudi Arabian women act as a role model for them. A study conducted among Muslim Turkish women observed the effect of PPUI on behavioral, emotional, and social aspects [16].

With a higher prevalence of PPUI among Saudi women [6] and lack of research that have studied the impact of PPUI on psychological status in Saudi Arabia, determining whether postpartum urinary incontinence (PPUI) is associated with psychological disturbance needs to be assessed properly and precise prophylactic and treatment plans should be implemented to minimize its implications. The result of this study will help health care provider to reduce the impact of PPUI consequences on women after delivery and their return to normal lifestyle after pregnancy. Therefore, the aim of the current study is to assess the association of PPUI and its risk factors with depression, anxiety, and stress among Saudi women.

Methods

A cross-sectional study was conducted with a sample of 813 subjects. We distributed 6000 Questionnaires through social media apps and personal efforts but in spite of our best efforts only 813 subjects responded. The sample size was calculated using the formula n = Z2 X P(1-P)/d2, while the confidence level (z) is 95% and the margin of error (d) is 5%, and there were no other studies considered the same issue so we put the initial estimate of prevalence (p) is to be 50%. So, the sample size calculated to be 385, an additional 20% was added to the sample size to ensure an adequate response rate, resulting in a sample of 462 female adults in Saudi Arabia. Nonetheless, we collected more responses than the required sample size.

An online structured proforma asked for demographic information, assessed the severity of UI using the International Consultation on Incontinence Questionnaire (ICIQ) [17,18,19,20], and administered the Depression, Anxiety, and Stress Scale (DASS) which has been shown to be a reliable and validated tool for assessing mental health [21,22,23]. The analysis tested the association between the independent variables and the outcomes of depression, anxiety, and stress. Outcomes were assessed with DASS. The DASS-21 (short form of DASS-42) is a 21-items (7 items regarding depression, 7 regarding anxiety, and 7 regarding stress), self-reported questionnaire to evaluate the severity of depression, anxiety, and stress. To asses DASS scoring; Normal: depression 0–4, anxiety 0–3, stress 0–7. Mild: depression 5–6, anxiety: 4–5, and stress: 8–9. Moderate: depression 7–10, anxiety 6–7, and stress 10–12. Severe: depression 11–13, anxiety 8–9, and stress 13–16. Extremely severe: depression 14+, anxiety 10+, and stress 17+. The study was conducted in Riyadh, Saudi Arabia, at King Saud University, College of Medicine, Department of Physiology, from March to August 2022. We used simple random sampling to distribute the proforma.

Inclusion criteria: Saudi female who experienced PPUI after one delivery or more. Saudi women who had had one or more deliveries were included while exclusion criteria were being non-Saudi (to minimize ethnic differences), being unmarried or married without children. Any subject with a history of psychological disorders were excluded from the study. All subjects were informed that by completing the online proforma, it will be considered as consent to participate. Therefore, informed consent was obtained from all subjects. A preliminary proforma was distributed and evaluated in order to incorporate the feedback and improve the questionnaire.

Statistical analysis

We used SPSS version 25 statistical software for analysis. Univariate and multivariate regression analyses were performed to identify associations between the independent variables and depression, anxiety, and stress. If the p value in the univariate was 0.2 or less, the variable was included in the multivariate model. Odds ratios were assessed with 95% confidence intervals. Frequencies and percentages were used to describe the independent variables and the quantitative measures. We used Pearson’s Chi‑square test to evaluate the association between the variables and DASS. P ≤ 0.05 and 95% confidence intervals were considered statistically significant.

Results

In this study, we received 813 responses from Saudi women. The sample’s characteristics (Table 1) show more than 68% (n = 164, p value = 0.03) of the respondents who experienced PPUI were aged from 35 to 54 years, and 91% (n = 219) were married. Of those who experienced PPUI, 45.6% (n = 108, p value < 0.01) had a BMI ≥ 30, and 44.4% (n = 107, p value = 0.00) had more than 4 children. More than a quarter (28.2%, n = 68) of the women who experienced PPUI had a chronic disease such as diabetes mellitus or hypertension, compared to 23.1% (n = 132) of those who did not experience PPUI (p value = 0.12). PPUI (p value = 0.12). Regarding the type of delivery, 9.5% of women who experienced PPUI had caesarian deliveries compared to 65.6% who had vaginal delivery and to 24.9% of those who had mixed delivery (p value = 0.07).

Table 1 Characteristics of Saudi Arabian women who participated in a survey of PPUI and DASS (N = 813)
Full size table

Figure 1 reveals the prevalence of moderate to severe depression, stress, and anxiety. In the sample, the prevalence of depression was 20.3%, anxiety was 33.6%, and stress was 13.4%.

Fig. 1
figure 1

Prevalence of moderate to severe depression, stress, and anxiety (N = 813)

Full size image

Table 2 shows univariate and multivariate regression models of the variables correlated with moderate to severe depression. In the univariate model, BMI, number of children, type of delivery, chronic disease, and severity of UI showed significant association with moderate to severe depression (p value ≤ 0.2). Moderate to severe depression was 1.3 times as likely if the subject’s BMI was ≥ 30 (p = 0.03) and 1.5 times as likely if the subject had a caesarian delivery (p = 0.14). The severity of UI significantly correlated with depression with an odds ratio of 1.3 for slight UI, 1.9 for moderate UI, and 4.2 for severe UI (p value = 0.00). In the multivariate regression model, chronic disease lost its significance. BMI (≥ 30 odds ratio: 1.2, p = 0.14), number of children (p = 0.03), type of delivery (caesarian delivery odds ratio: 1.5, p = 0.25), and severity of UI (severe UI odds ratio: 4.6, p = 0.00) were significantly associated with moderate to severe depression.

Table 2 Association of severity of urinary incontinence with moderate to severe depression (N = 813). Results from logistic regression
Full size table

Table 3 shows univariate and multivariate regression models of the variables correlated with moderate to severe anxiety. In the univariate model, BMI, type of delivery, chronic disease, and severity of UI showed significant association with moderate to severe anxiety (p value ≤ 0.2). Moderate to severe depression was 1.4 times as likely if the subject’s BMI was ≥ 30 (p value = 0.00) and 1.3 times as likely if a subject had had mixed deliveries (p = 0.27) or a chronic disease (p = 0.06). The severity of UI significantly correlated with anxiety with an odds ratio of 1.4 for slight UI, 1.4 for moderate UI, and 4.0 for severe UI (p value = 0.00). In the multivariate regression model, type of delivery and chronic disease lost their significance. BMI (≥ 30 odds ratio: 1.2, p = 0.05) and severity of UI (severe UI odds ratio: 3.7, p = 0.00) were significantly associated with moderate to severe anxiety.

Table 3 Association of severity of urinary incontinence with moderate to severe anxiety (N = 813). Results from logistic regression
Full size table

Table 4 shows univariate and multivariate regression models of the variables correlated with moderate to severe stress. In the univariate model, type of delivery, chronic disease, and severity of UI showed significant association with moderate to severe stress (p value ≤ 0.2). Moderate to severe stress was 1.6 times as likely among women who had a caesarian delivery (p value = 0.17) and 1.4 times as likely for those with a chronic disease (p = 0.14). The severity of UI significantly correlated with stress with an odds ratio of 1.3 for slight UI, 2.3 for moderate UI, and 6.0 for severe UI (p value = 0.00). In the multivariate regression model, chronic disease lost its significance. Caesarian delivery (odds ratio: 1.9, p = 0.05) and severity of UI (severe UI odds ratio: 6.3, p = 0.00) were significantly associated with moderate to severe stress.

Table 4 Association of severity of urinary incontinence with moderate to severe stress (N = 813). Results from logistic regression
Full size table

Discussion

The present study revealed a high prevalence of anxiety in our postpartum women. Severity of PPUI was strongly associated with moderate to severe depression, anxiety, and stress. Our study found several factors are associated with PPUI. More than 40% of women who experienced PPUI aged 45 years and more. BMI more than 30% and number of children associated significantly with the experience of PPUI. These findings agree with other researchers with similar results [2,3,4,5]. It is well known that multiple deliveries would affect the pelvic floor muscles that control the bladder and becomes an important issue if they develop PPUI [24].

After delivery, the psychological status of women may go through several critical stages. The impact of PPUI on mental health cannot be ignored or neglected [25]. Our study revealed that one-fifth of the sample population had moderate to severe depression (20.3%), and one-third (33.6%) had moderate to severe anxiety, which seems alarming. We found a lower depression prevalence when compared with other studies (34-50%), but those studies found a lower prevalence of anxiety (20-29%) [26,27,28,29]. At the same time, several studies found no correlation of PPUI with stress [26,27,28], while we found a stress prevalence of 13.4%.

Regarding depression, our results show that BMI, number of children, caesarian delivery, and severity of UI are significantly associated with moderate to severe depression. All these risk factors can independently influence a patient’s mental health, but severity of PPUI was the most prominent risk factor, with depression being four times as likely with severe PPUI.

Also, BMI and severity of PPUI were the risk factors associated with anxiety; it was 1.4 times as likely for obese patients and four times as likely for patients with severe PPUI to be anxious. Type of delivery and severity of PPUI correlated with stress. Those who had a caesarian delivery and those with severe PPUI were almost two times as likely and six times as likely to be stressed, respectively.

Severity of PPUI was the common risk factor in depression, anxiety, and stress. This could be due to its incidence immediately after delivery when the patient might think she is experiencing a serious complication. In addition, severity of PPUI influences various aspects of life, including social, sexual, work, and religion (in Muslim countries) [1, 16]. Several studies have found detrimental effects of PPUI on sexual function among women [30,31,32,33]. This means PPUI consequences might extend beyond the patients themselves to their husbands and families. The impacts on quality of life need to be assessed carefully. The risk factors should be taken into consideration in the plan for postpartum women. There are some promising results for PPUI treatments; several studies noticed a decrease in depression and anxiety after PPUI was treated [34,35,36].

More elaboration is needed to assess the effects of PPUI on daily life, which was not evaluated in this study. In addition, the impact of PPUI on various aspects of religion duties (especially in Muslim countries) should be examined. It is very crucial that Muslim women (especially those who are residing in western countries) be educated regarding the flexibility in religious obligations towards PPUI without feeling the burden in such situations. Extensive preventive as well as treatment strategies should be designed by health care providers in order to reduce the effects of PPUI on mental health.

Strengths and limitations

Our study was very detailed and used a valid assessment tool with a very large sample size compared to other studies. In spite of our best efforts only 13.5% women responded most probably due to cultural barriers since they do not want to expose this issue of illness even though they were assured that the study will be anonymous. Therefore, it was so difficult to convince Saudi women in such regards. Having a sample of 813 was a good achievement by research team and we thought it would be worth to share these observations. In addition, approaching women through social media and personal efforts was one of the limitation even though internet access reaches most Saudi houses these days.

Conclusions

A high prevalence of anxiety was observed in postpartum Saudi women. Severity of PPUI was strongly associated with moderate to severe depression, anxiety, and stress. Comprehensive prophylactic and treatment plans should be implemented after delivery in order to minimize the impact of PPUI on women and consequently on families and society. Moreover, intensive studies are needed to evaluate the impact of PPUI on daily life (especially on religious practices for Muslims, such as ablution and prayers).

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

BMI:

body mass index

DASS:

Depression, Anxiety, and Stress Scale.

ICIQ:

International Consultation on Incontinence Questionnaire

PPUI:

Postpartum urinary incontinence

UI:

urinary incontinence

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Funding

The authors extend their appreciation to the Deanship of Research, King Saud University for their support.

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Authors and Affiliations

  1. Department of Physiology, College of Medicine, King Saud University, Riyadh, Saudi Arabia

    Thamir Al-khlaiwi & Syed Shahid Habib

  2. College of Medicine, Sulaiman AlRajhi University, Al-Qassim, Saudi Arabia

    Nazmus Saquib

  3. Medical student, College of Medicine, King Saud University, Riyadh, Saudi Arabia

    Sarah Muaddi, Shuruq Alotaibi, Albandary Bin Hadba, Munirah Alshaqrawi, Deema Almuhaimel & Sarah Alshammari

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Contributions

“T.K., S.H. designed and supervised the study, and wrote and edited the manuscript. N. S. analyzed the data and organized the results. S.M., S.O., A.H., M.A., D.A., S.S. designed and distributed the questionnaire and collected the data. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Thamir Al-khlaiwi.

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Ethics approval and consent to participate

The Institutional Review Board, College of Medicine Research Centre at King Saud University, Riyadh, Saudi Arabia approved this study (Ref-E-22-7062). Participants were informed that filling out the questionnaire voluntarily was considered consent to participate. All authors confirm that all experiments were performed in accordance with relevant guidelines and regulations of the Declaration of Helsinki.

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Not applicable.

Competing interests

The authors declare no competing interests.

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Al-khlaiwi, T., Habib, S.S., Saquib, N. et al. The associations of postpartum urinary incontinence with depression, anxiety, and stress among women in Saudi Arabia: a cross-sectional study. BMC Psychol 13, 412 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s40359-025-02734-9

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Keywords

BMC Psychology

ISSN: 2050-7283

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