When Jennifer had her second child in 2005, she knew within days that something worrisome had happened to her body. For the first time in her life, she couldn't make it to the toilet. She peed without warning. She took her 2-week-old to the grocery store down the block and had to waddle home with poop in her pants. Nonetheless, at her six-week checkup, her doctor told her everything looked great — that she had torn during birth, but the tissue had healed.

She didn't object. "I don't even know, when I look back, why I didn't just say, 'No. Everything's not great,'" she says. "I internalized it."

At 34 years old, she didn't want to give up running, her favorite sport. And she didn't have any pain — in fact, she hardly had any feeling in her vagina at all. So she laced up and started training again around her Marin County, California, home, carrying a plastic bag with baby wipes and a change of clothes to clean herself up after every run. She stopped carpooling to races, embarrassed by how she smelled on the way home, and stopped hanging out with her teammates. Her fear of leaking got so bad that she couldn't leave her house without pads and underwear stashed in her purse. She says her incontinence probably played a role in her decision not to return to her job as a management consultant.

Feeling like she was somehow responsible, like she wouldn't be in this shape if she had only done enough Kegels (a vaginal strengthening exercise) after her son was born, she did not return for her next annual checkup, or the one after that, or the next one. When a close friend's health scare finally pushed Jennifer (who preferred to be identified by her first name only) to go in for an appointment, the doctor concluded that her pelvic floor muscles were so damaged from childbirth that they were practically useless. By then, she'd been suffering for eight postpartum years.

Childbirth is one of nature's most wondrous but biologically brutal feats. For nine months, a woman's muscles and bones bear the increasing weight of a baby that isn't even slightly ergonomically positioned. During a vaginal birth, muscles and other tissues stretch and often tear as something the size of a cantaloupe is forced through an opening that is normally about the size of a carrot. Sometimes, pelvic bones crack under the duress. At the beginning of the last century, as many as 9 in 1,000 American women did not survive the process. And according to a recent spate of studies, a disturbing number of women like Jennifer still quietly endure incontinence, painful sex, back aches, and crippling pelvic pain for years after giving birth because of undiagnosed and untreated childbirth injuries.

One study of more than 1,200 women published January 2015 in the British Journal of Obstetrics and Gynaecology reported that 24 percent of women were still experiencing pain during sex a year and half after having a baby. Another study published last June in the journal PLoS One found that 77 percent of more than 1,500 mothers studied had persistent back pain a year after having their babies, and 49 percent had urinary incontinence. ("We did not expect it to be that many women," says Angela Vinturache, MD, PhD, one of the study's authors.) These problems aren't just results of vaginal births; a 2014 study of 1,115 mothers — about half who had cesarean sections, half who had vaginal births — found similar degrees of continuing pelvic pain regardless of how their baby was delivered. Last August, researchers from the University of Michigan likened childbirth to running a marathon — only before a marathon, you train — after giving 68 women MRIs seven weeks after birth. The MRIs showed that 29 percent of them had evidence of fractures they never even knew they had in their pubic bones, while 41 percent had undiagnosed tears in their pelvic floor muscles, which wrap around the vagina and anus. Childbirth is a well-studied traumatic experience for women's bodies, yet modern medicine still leaves far too many mothers debilitated, sometimes for the rest of their lives.

Jennifer's cursory six-week checkup illustrates the beginning of the problem. During this single appointment (which is standard doctors' advice and what most insurance covers), muscles and other structures of the pelvis usually get scarce attention. "Contrary to what one may think, ob-gyns are not trained to evaluate pelvic floor muscles or nerves even though they work in this region," says Stephanie Prendergast, MPT, co-founder of the Pelvic Health and Rehabilitation Center in Los Angeles and co-author of Pelvic Pain Explained. "A speculum pushes right past the very muscles and nerves that cause problems as the OB tries to get to the uterus and cervix." This exam is the extent of most American women's postpartum care.

Beyond that, obstetric training is understandably focused on life-threatening childbirth complications, like hemorrhage or infection. Non-life-threatening (but still painful and incapacitating) problems get less attention, says Sarah Fox, MD, a professor and researcher at Brown University and former president of the International Pelvic Pain Society. "American physicians and American healthcare providers can go through all of their training and never get any instruction on managing women's pain," she says.

Pain is a complex, sometimes indefinable experience, one that can't be easily evaluated on a typical postpartum exam, especially in a medical office that is expected to cycle patients through in 15 minutes. In a survey of 41 ob-gyn residents published in 2014 in the Journal of Graduate Medical Education, Kathryn Witzeman, MD, an ob-gyn at Denver Health and director of the Women's Integrated Pelvic Health Program, found that the doctors-in-training felt "overwhelmed" by patients with chronic pelvic pain because they did not feel prepared to care for them. "If things look normal, there may not be an understanding of what else is going on," Dr. Witzeman says.

And because childbirth injuries relate to taboo topics (like incontinence and sex), women who have them often don't push their rattled doctors. Sarah Prince, now a 29-year-old Utah mom, was cleared by her doctor to have sex six weeks after the birth of her first child. But when she and her husband tried, she got "a sharp, stingy, burny pain" and it remained painful for weeks. When she returned to her doctor several months postpartum, his advice was, "Go slow." He clearly didn't want to give her more detailed sex advice, she says. But fighting through pain was not Sarah's idea of a satisfying sex life. "I could tell that my husband was frustrated," she says. "It frustrated me too, but because I wanted to avoid sex." She had the same experience — months of uncomfortable sex — after her second child was born and again received no useful medical advice, but didn't push through the awkwardness for a diagnosis.

After her six-week checkup, Jennifer's pelvic problems only got worse. She quickly realized that the lack of feeling in her vagina and surrounding area was the reason she was often surprised by her incontinence. But that also had obvious repercussions for her relationship with her husband. "I'd be feeling all sexy and then we'd go to have sex and I'd realize I had a little stain in my underwear. I'd try to hold on to some shred of dignity at first, like, 'Oh, I'm going to go shower,' but he knew," she says. The lack of musculature in her pelvis caused vaginal prolapse, a condition where the pelvic floor sags and the uterus can hang down into the vagina, which gave her a heavy feeling and made her labia hang lower than they ever had before. The couple had bonded over running, but she'd started making up excuses not to run with him. She'd lost time with her running friends, and now she was losing time with her husband. "If you can't exercise and you're home with your baby and you don't see your friends and you're pooping your pants, how are you supposed to feel confident?" She felt isolated, dirty, and depressed.

The postpartum depression that often couples with childbirth injuries adds another layer to the difficulty getting a diagnosis. In a landmark report from the Institute of Medicine in 2011, a team of experts noted that women "have faced not only severe pain, but also misdiagnoses, delays in correct diagnosis, improper and unproven treatments, gender bias, stigma, and 'neglect, dismissal and discrimination' from the health care system." Among the reasons: health care professionals who not only lack education on how to deal with chronic pain but also discount women's pain as "emotional." A 2010 report from the Campaign to End Women's Pain noted that women's pain is treated less aggressively and taken less seriously than men's. Amy Tuteur, MD, who writes on The Skeptical OB, attributes it to a sense that "men are more stoic so if they complain it must be real." But it's hard to be stoic when you're simultaneously embarrassed, in pain, and trying to care for a newborn baby.

Doctors do want to help their female patients, but they also stay in the lane they know, says Leah Millheiser, MD, director of the Female Sexual Medicine Program at Stanford University School of Medicine. The lanes they know, in this case, often come at two extremes: Do Kegels, and if that doesn't work, about 320,000 women each year undergo surgery to strengthen the pelvic floor.

Kegels are commonly prescribed, but, Prendergast says, a 2015 study that showed that about 1 in 4 women are unable to do a Kegel correctly, and for some women, pelvic floor muscles may be too tight, not too weak, and need to be lengthened, not strengthened. Plus, many women's problems can't be solved with Kegels alone.

Surgery can sometimes lift prolapsed pelvic floors, stop incontinence, and remove painful scar tissue, but it's not the magic bullet many ob-gyns treat it as. Krysten (who preferred to be identified by her first name only) had a vaginal birth without complications with her second baby in May 2013, but a tear in her perineum, the skin and muscle below her vagina, that should have healed in a few weeks was still painful 12 weeks later. "It was this awful pulling," she recalls. "If I walked around too much or if I tried to exercise, I felt a burning pain." Her doctor could find nothing wrong other than some excess scar tissue, and as long as she didn't move, she was pain-free. But she had a toddler and a newborn. Lie still?

When her son was 3 months old, Krysten returned to her obstetrician because of her ongoing pain. The doctor recommended an operation to remove the problematic scar tissue. She underwent surgery that autumn — only to be left in more agony when additional scar tissue formed in response to the surgery. "I met so many people who bounced back after four weeks," she says, "and I would say, 'Really? Because I'm crawling around like an old lady.'"

Her pelvic floor muscles shot and unable to do Kegels, Jennifer visited a urogynecologist who recommended surgery to insert transvaginal mesh, an implant that supports the vaginal walls and bladder. The operation has come under fire for frequent complications that include bleeding, pain during sex, organ perforation, and more urinary problems, and was bumped from moderate-risk to high-risk this year by the FDA. Jennifer did not take this decision lightly, but her doctor persisted. "He said, 'You need surgery badly, but here's the thing: I'm going to Africa for four months, so you're going to have to wait,'" she says. She'd been incontinent for eight years, she figured; what was another four months? Still, every time she didn't make it to the bathroom was another humiliation.

The shame of many childbirth injuries — and the expectation that new moms will simply "bounce back" — is another reason women don't get treatment. Jennifer was ashamed that she hadn't healed when other mothers had, ashamed that she'd failed at Kegels, ashamed that she was wetting herself more than her child was. She was ashamed that she didn't have Kim Kardashian's "slim post-baby bod." The media's obsession with new-mom glamour — whether it's Marissa Mayer's two-week maternity leave, or descriptions of Kate Middleton "looking immaculate just hours after giving birth" — has created the perception that recovery from childbirth is quick and easy. One Daily Beast column, lamenting the lack of postpartum attention for American moms, pointed out that after women bear children, "we beckon them most immediately to rejoin the rest of us. One New York mother summed up her recent postpartum experience this way: 'You're not hemorrhaging? OK, peace, see you later.'"

"We have a new cultural view of childbirth that tremendously minimizes how physically and emotionally difficult it is," says Dr. Tuteur, of The Skeptical OB. "As a result of this view, women are ignoring physical symptoms."

Also keeping women from care is that these problems have afflicted women for generations. "If a woman has a problem like urinary incontinence or prolapse, they'll talk to their mom or their sisters, and their mom and sisters may have experienced a similar thing and that may normalize it," says Dr. Fox, of Brown University. In one Scandinavian study, women didn't seek help, figuring the problems would go away or there was nothing to be done.

But tending to minor problems when they happen can help you avoid major ones down the road. Janis Miller, PhD, the researcher from the University of Michigan who conducted the MRI study of muscle rips and fractures, says the women in the Michigan study didn't even know they were hurt. "One woman explained it to me as, 'It's like I have a mild toothache,'" Dr. Miller says, "so we're not talking excruciating, severe pain there." Still, although hairline fractures are common and usually heal well on their own, they are often caused by the levator ani — the main muscle of the pelvic floor — pulling away from the pubic bone, increasing the chance of incontinence and prolapse later in life. "When we examine women who have had prolapse, more than 50 percent of the women showed the same tear [of the levator ani muscle]" from childbirth, Dr. Miller says.

When her urogynecologist postponed her surgery, Jennifer's frustration was at an all-time high, so she summoned her courage to visit a physical therapist at a friend's recommendation. She hated it. "You know, it's such a treat to get to talk about how you pee and poop your pants, and then you take off all your clothes, and they put fingers in both holes," she says sarcastically. Her desperation led her to a different physical therapist, then another. She bounced around to physical therapists for two years, hoping to put off the surgery she was afraid would only make matters worse, but nothing was working. Because most insurance covers a limited number of doctor-prescribed physical therapy sessions (some cover 60 days, 12-60 sessions, or up to $1000 worth) she paid large out-of-pocket fees for most of her treatments. Just when she was reaching her breaking point, she tried one more therapist.

After long searches, some women have found astoundingly simple solutions to their injuries. Sarah Prince, the Utah mom whose doctor had simply told her to "go slow" with sex, finally found relief after her third child was born. Frustrated that she was still (still, 2.5 years after her first child was born) having painful sex, she reached out to her midwife, who mentioned that estrogen cream might help heal the tissue causing her pain. Even better, she gave her a free sample of the cream, called Estrace. "The pain was virtually gone after a week," Prince says. "It was amazing."

Krysten, the mom whose surgery had made her pain even worse, eventually found her solution after scouring the Internet. "I was like, 'What is wrong with me? How come I can't find anybody else in the whole entire world that has experienced the same pain?' The ob-gyns always made me feel like I was nuts," including one who told her she just "needed extra time to heal." While Googling one day, she learned that Elizabeth Akincilar-Rummer, one of the founders of the Pelvic Health and Rehabilitation Center, had moved to the Boston area, where Krysten lives. She booked the first appointment she could.

Akincilar-Rummer assured her she was not crazy, that the excessive scar tissue left after her births and surgery was causing all the muscles in her groin and upper legs to tighten. "I remember sitting there and being stunned and thinking, What? Why didn't somebody else catch this?" Krysten says. The physical therapist worked the scar tissue between her thumb and forefinger to make it more mobile. Krysten repeated the massage herself at home every other day for weeks, along with stretches and foam rolling, until one day she realized the pain was gone. "I was like, 'Oh my god. I can get up. I can walk. I can make dinner. I can go outside and play with my kids.' She gave me my life back."

Jennifer finally found a physical therapist she liked last fall. "I walk in, and I lie on the table. I'm like, 'Whatever you need to do, do it,'" she says. It was really awkward at first. Because of Jennifer's nerve damage and lack of muscle tone, her therapist used electrodes shaped like tampons, inserted in her vagina and anus, to give small electric pulses that stimulate the muscles in her vagina and perineum. It was almost unbearably uncomfortable for the first four sessions, but she slowly started to feel better, and "it stimulated muscles I didn't even know I had," Jennifer says. Once she had some muscle control, she learned to strengthen her pelvic floor muscles while in a yoga inversion, using gravity to assist with proper muscle contraction — a technique her previous therapists hadn't suggested. It felt like her body was starting to respond to her brain's commands again. "Yes, it's uncomfortable to have someone with their fingers up your vagina or even your anus, you know, prodding and poking and asking you to squeeze and seeing which muscles are weak," she says of the sessions, which she "wouldn't wish on anyone." But after six weeks, Jennifer's incontinence almost completely disappeared. She never returned to the doctor who recommended surgery.

Recognizing the number of women who need help, some obstetricians are fighting to modernize training programs to get more ob-gyns thinking about everyday pain in addition to the more serious issues. Dr. Fox at Brown University is one of a growing number of doctors who believe that lasting change in postpartum care will require putting more emphasis on pelvic health in the medical curriculum. "As someone who started out as primarily a gynecologic surgeon, over the years, I've really transitioned away from it," she says. While only about 10 percent of patients will have adverse effects from their operations, most women don't even know that worsening pain or nerve injury from surgery is a possibility. "With chronic pain issues, surgery should not be our first stop, and really we should be trying multiple things before hitting that. Surgery is not a substitute for a thorough evaluation with a focus on the pain history and a full physical exam," she says. To make more doctors aware, the International Pelvic Pain Society is "working hard to educate providers, reach out to people in training, people in practice, and to reach out to patients to help get people educated about this issue."

Dr. Millheiser, the sexual health expert from Stanford, says obstetric education is slowly improving, though "we're nowhere near where we need to be." And she says improvement can't happen without cultural shift, starting with less public marveling over the quickest birth comebacks and more frank talk about women's health issues below the navel. When problems are openly discussed, "women are going to become empowered, and they are going to go to their doctors and say, 'I had a baby. I'm breastfeeding. My vagina feels like the Sahara Desert. It is horribly painful to have sex and my relationship is suffering. What can I do about it?'" she says. "Open the conversation so women understand it's OK to talk to their doctors and insist on answers."

This February, her son now 11 years old, Jennifer pulled on her running shoes and went on her favorite mountain runs — one that left her soiled last summer — and came back with her shorts dry and her confidence intact. She still does physical therapy for 10 to 20 minutes every day, but she does it alone, in the privacy of her own home. She talks about pelvic floor rehab with the fervor of an evangelist. "I consider those people saints," she says of the therapists who finally healed her injuries. She can run with her husband again, and he jokes about the magical reversal of her vaginal prolapse ("My labia just got sucked back up. He's like 'Where did they go?!'") On the phone, she sighs, remembering a recent date they went on. "I wore white underwear with no panty liner and they were still white when we got home," she says. It's the little things now. "That's a great way to end a date."

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