Introduction

Urinary incontinence (UI), involuntary urine leakage, is the most common manifestation of pelvic floor (PF) dysfunction and a bothersome problem among women of all ages [1]. At least half of all pregnant women experience UI, often for the first time [2,3,4]. Stress UI is most common in pregnancy and rapidly increases during the second trimester [1], affecting up to 31% of nulliparous and 42% of parous women [3]. Notably, UI onset during pregnancy predicts postpartum UI [5,6,7,8]. About one third of women experience persistent UI 3 months postpartum [3]. Prevalence decreases gradually during the first postpartum year [1, 8] although for some UI becomes a long-term condition [5, 7,8,9,10]. Women with UI may feel less able to engage in their usual activities and alter their behaviour to avoid symptoms. This, together with under-reporting of UI due to the associated stigma, makes it difficult to establish true prevalence; however, it is probably higher than reported in the literature [1].

In addition to UI during pregnancy, other factors associated with a greater risk of postpartum UI are: increasing parity, greater maternal body mass index and age, vaginal delivery, instrumental or operative vaginal deliveries, and greater birthweight of the baby [3, 5,6,7, 11]. These associations are evident from early postpartum up to 12–20 years following delivery [5, 7,8,9,10].

Urinary incontinence has a negative influence on a woman’s wellbeing including physical, mental, and social quality of life [12, 13]. Syntheses of qualitative studies of UI experiences find that: women feel stigmatized, guilty, and ashamed; UI restricts participation in activities and fulfilment of social roles; UI negatively influences sexual relationships and satisfaction [14, 15]. It also presents a significant burden to women and healthcare resources [16]; there is evidence that intervening to address UI is cost-effective [17, 18].

Pelvic floor muscle training (PFMT); exercise to improve pelvic floor muscle (PFM) strength, endurance, and power; relaxation; or a combination of these [19], is recommended first-line therapy for women with UI [20, 21]. The aim of this narrative review is to summarize the evidence about PFMT (both physical and behavioural elements) as an intervention to prevent or treat UI in pregnant and postpartum women. Primarily, we address when and why it is important for childbearing women to engage with PFMT, what PFMT maternity care providers (MCPs) should recommend, and how MCPs and women can engage with PFMT. The term maternity care provider (MCP) was chosen as a generic term to encompass the range of providers involved in maternity care internationally, including but not limited to obstetricians, midwives, obstetric nurses, general practitioners, physiotherapists, and maternal health workers.

Collecting and collating the research evidence used in this review

We are the first (SJW) and senior author (EJCHS) of the most up-to-date Cochrane systematic review of PFMT for prevention and treatment of incontinence in antenatal and postnatal women [22]. This was our primary data source about the effectiveness of PFMT. The grading of evidence quality done in the Cochrane review and strength of recommendations based on that grading are also reported in this narrative review. Additional quantitative data about the effects of PFMT are drawn from systematic reviews that addressed related yet slightly different questions, such as that by Du et al. (2015) [23] who investigated the effect of antenatal PFMT on labour and delivery outcomes. The literature search used to find these studies is fully detailed in the Cochrane review [22].

Evidence regarding women’s and MCPs’ experiences of antenatal and postnatal incontinence and PFMT was found in systematic reviews of qualitative evidence, contact with experts, and an additional literature search to include data collected using survey methods. Searches were undertaken in two databases (PubMed and Google Scholar) encompassing combinations of the following search terms: experience, women or female, pelvic floor muscles, pelvic floor muscle training, pregnancy, postpartum, qualitative, questionnaire, survey, and urinary incontinence.

The six items of the scale for quality assessment of narrative review articles (SANRA) were used as a guide to the reporting of this review [24].

Section 1: Why and when is it important for childbearing women to engage with PFMT?

Biological rationale for PFMT

The PF is a complex three-dimensional structure, formed largely by the PFM (innervated by the sacral nerves), connective tissues including ligaments and fascia, and the pelvic organs. Three PFM layers (of which the levator ani is the largest) have differing fibre orientations and various attachments, extending from the pubic symphysis anteriorly, along the internal pelvic surface, to the coccyx posteriorly. Functionally, the PFM and connective tissues have two main roles. First, they provide structural support for the uterus and vagina by attaching them to the pelvis. Second, they assist in achieving continence by contributing to the closure mechanisms of the PF (urethra and rectum) during increases in abdominal pressure and resisting descent of the organs such as the bladder neck. Normal PFMs exhibit a constant baseline activity, which is modulated depending on the load placed upon them, with relaxation required for voiding and defaecation [19, 25]; they are also able to voluntarily and involuntarily contract [19].

De Lancey et al.’s (2008) [26] integrated lifespan model explains how biological and lifestyle factors can influence PF structure and function. The PF reaches maximal capability in childhood, when there is a functional reserve, and few symptoms. With ageing, there is a normal decline in functional reserve. Pregnancy changes and vaginal birth trauma (e.g. muscle injury/avulsion, connective tissue tears, nerve injury, and vascular damage) can also significantly decrease functional reserve [26, 27]. Depending on the context, and injury cause and pattern, a compromised PF may lead to women dropping below the continence threshold, resulting in UI or anal incontinence (AI). However, as the PFM are predominantly skeletal muscle they can be ‘trained’ or ‘retrained’ to make the best possible contribution to the continence mechanism [28].

Grade I evidence of a prevention effect for PFMT offered to continent childbearing women

Preventing the onset or progression of disease is a cornerstone of health promotion, reducing health burden for individuals and society. A Cochrane systematic review with meta-analysis found evidence of effect consistent with a clinically important reduction in the risk of UI for pregnant women who are continent when they begin PFMT, i.e. incontinence prevention. Continent pregnant women who perform antenatal PFMT are probably 62% less likely to experience UI in late pregnancy compared to usual care (relative risk [RR] for incontinence 0.38, 95% confidence interval [CI] 0.20 to 0.72) [22]. These findings corroborate those of a systematic review [29], which, despite some methodological differences, reported similar findings in effect size and precision (odds ratio for incontinence 0.50, 95% CI 0.37 to 0.68). Benefit extends into the mid-postnatal period, with a decreased risk of UI at 3 to 6 months postpartum (29% less; RR 0.71, 95% CI 0.54 to 0.95) [22]. There are too few data to comment meaningfully on the longer-term effects [22]. In addition to preventing UI, other benefits are improved UI-specific quality of life [30], with reductions in the severity [29], frequency, and amount of leakage [30, 31].

Physiologically, first pregnancy presents the optimal time for women to master PFMT—with an intact, functional PF, women can train their muscles to establish appropriate motor patterns and potentially increase their functional reserve. Arguably, a PFM contraction is more difficult to achieve if muscle, connective tissue, and/or nerve damage occurs with vaginal delivery [25, 26]. Psychologically, pregnancy can be an uncertain time for women having their first baby, particularly regarding labour and birth expectations [32]. With a natural shift in a woman’s motivation, as she adjusts to altered perceptions of personal risk and newfound social and emotional roles, pregnancy is potentially a powerful “teachable moment” for initiating health behaviour change [33]. Olander et al. (2016) [34] have developed Phelan’s (2010) concept, using the Capability Opportunity Motivation and Behaviour (COM-B) framework of health behaviour change [35] (see also Section 3) to identify events before, during, and after pregnancy that trigger changes in motivation as well as capability and opportunity. They conclude that pregnancy and postpartum contain ‘a series of opportune intervention moments’ such as confirmation of pregnancy, first midwife visit, and the 6–8 week postnatal check, which may facilitate or inhibit behaviour. Thus, first pregnancy is physiologically and psychologically an ideal time to provide PFMT to help women stay above the continence threshold. Subsequent pregnancies may offer the same opportunity.

Grade 1 evidence about PFMT for treating UI in childbearing women

The evidence-base for PFMT as a treatment for childbearing women with UI is less robust because fewer trials (with fewer women collectively) have investigated effectiveness and trial quality is worse overall. The Cochrane review found there was no evidence that antenatal PFMT in incontinent women decreased UI in late pregnancy (RR 0.70, 95% CI 0.44 to 1.13) or in the mid- (RR 0.94, 95% CI 0.70) to late-postnatal periods [22]. Similarly, for postnatal women with persistent UI, there was no evidence that treatment with PFMT decreased UI in the late postnatal period (> 6–12 months) or longer term (> 5–10 years and > 10 years) [36].

The data about the lack of effect of postnatal PFMT for treatment of UI are, at first sight, puzzling given the clear benefit of PFMT to treat UI in middle-age and older women [37]. A plausible explanation lies in the postnatal PFMT interventions and the overwhelming weight two large trials (with suboptimal training) have in the summary estimate of effect. The large trials [36, 38] offered minimally supervised PFMT and exercise protocols that may not have improved muscle function. In addition, the PFMT interventions were compared with usual care, meaning some women in the control groups were doing PFMT [36, 38]. The third trial in the analysis, a smaller study with sound methodology and PFMT intervention [39], found PFMT was effective in treating persistent postpartum UI compared to no active treatment. The trial outcomes are consistent with those from the Cochrane review of PFMT versus no treatment for non-postnatal women in which women with stress UI were eight times (RR 8.38, 95% CI 3.68 to 19.07) more likely to report cure following PFMT compared to no or inactive control treatment [37]. On balance, it seems the usual recommendation contained in national and international guidelines of PFMT as first-line treatment for uncomplicated UI [20, 21] probably applies for postnatal women.

The evidence regarding PFMT as treatment for UI in antenatal women is particularly weak [22]. More data addressing this question could change the review findings. In the meantime, as antenatal PFMT is unlikely to harm and may ameliorate or prevent UI symptom progression, the recommendation that PFMT is first-line therapy may apply.

Grade 1 evidence for the population-based approach—offering PFMT to all childbearing women

A population-based approach offers PFMT to all women, regardless of continence status. Women with or without incontinence who commence PFMT when pregnant probably have 22% less risk of UI in late pregnancy (RR 0.78, 95% CI 0.64 to 0.94) and a slightly reduced risk in the mid-postnatal period (RR 0.73, 95% CI 0.55 to 0.97). However, there is no evidence that these benefits extend into the late postnatal period (RR 0.85, 95% CI 0.63 to 1.14) or longer term (6 years, data limited to one trial) (RR 1.38, 95% CI 0.77 to 2.45) [22]. For antenatal women these findings are consistent with the prevention data although the effect may be less pronounced, in line with inclusion of women with existing UI and the uncertainty about whether PFMT is an effective cure for UI when pregnant. It is uncertain whether a population-based approach for postnatal PFMT is effective, with no evidence of a difference in the mid- (RR 0.95, 95% CI 0.75 to 1.19) or late- (RR 0.88, 95% CI 0.71 to 1.09) postnatal periods [22].

Offering PFMT to all women regardless of their continence status is common clinical practice. However, the benefits of the population-based approach are uncertain, potentially partly due to the effects of PFMT being weakened by women who will never experience UI or for whom PFMT is likely to be of little benefit, such as women with PFM denervation [22]. While UI may resolve and/or not be considered burdensome for some women around the time of childbirth, symptoms of PF dysfunction may also manifest later [26]. Given the magnitude and potential chronicity of this problem, and the known benefits of PFMT during childbearing and later in life (including in the management of pelvic organ prolapse) [40], PFMT could be considered a population health intervention for all women, as recommended by some guidelines [20, 21].

In addition to providing PFMT for all women, some MCPs may feel that particular (possibly specialist) attention and resources should be directed to women who are at high risk of developing UI or AI (see Introduction). Using a scoring system such as that advocated by UR-CHOICE would support MCPs to screen antenatally for PF dysfunction and inform decision-making in collaboration with women about delivery choices and whether it is appropriate to refer women at increased risk or with UI to a PF specialist [41, 42].

Other possible benefits of PFMT

The previously mentioned Cochrane review included AI among its primary outcomes. Fewer trials have investigated the effect of PFMT for AI, which encompasses both faecal and flatus incontinence (the involuntary loss of solid or liquid stool and flatus, respectively) [22]. Anal incontinence is distressing, affecting up to 35% of pregnant women and up to 25% of women at 1 year following childbirth [43, 44], gradually decreasing over the following 6 to 12 years (to between 12 and 14%) [44, 45]. Increased risk of AI is apparent following vaginal delivery complicated by abnormal foetal presentation, obstetric anal sphincter injuries, and/or instrumental deliveries [44]. Unfortunately, with few trials to date reporting AI, there are insufficient data to determine whether PFMT is effective in preventing or treating AI in antenatal or postnatal women recruited up to 3 months post-birth [22]. A trial not included in the review (because it recruited women approximately 12 months postpartum) found that a 6-month individually adapted PFMT home-based programme with intermittent supervision from a specialist physiotherapist reduced symptoms of AI compared to written PFMT information [46]. The mechanisms that maintain anal continence are complex and dependent on the integrity of the sphincteric mechanism to which the PFM contribute [47]. Thus, PFMT to treat AI may be beneficial and women should be offered specialist management.

Sexual dysfunction is common following childbirth, affecting 41–83% of women in early postpartum and up to 64% at 6 months postpartum. Whether vaginal delivery is positively associated with sexual dysfunction is somewhat controversial [48]. While the literature in this field is scant, a recent systematic review suggests that postnatal PFMT improves sexual function, specifically sexual desire, arousal, organism, and satisfaction [49].

Pelvic organ prolapse is common, increasingly prevalent as women age, and clearly associated with childbirth [1, 50]. In mid-age and older women with asymptomatic stage 1 to 3 pelvic organ prolapse, PFMT has a small and probably clinically important effect in reducing prolapse (i.e. prevention of progression) [51]. PFMT was also effective at reducing prolapse symptoms in women who were symptomatic at recruitment (i.e. treatment) [40]. It is, therefore, possible that antenatal and postnatal PFMT may contribute to preventing and treating pelvic organ prolapse.

The potential effects of PFMT on labour and birth outcomes are important because any adverse effect must be considered when balancing benefit and possible harm. The Cochrane review—which excluded trials reporting only labour and delivery outcomes—did not find any difference between antenatal PFMT and control groups for caesarean rates, type of vaginal delivery, or perineal outcomes [22]. Du and colleagues (2015) [23], in a systematic review with meta-analysis of the effects of antenatal PFMT on labour and delivery outcomes, found a mean reduction of 28.33 (95% CI −42.43 to −14.23) and 10.41 (95% CI -18.33 to −2.44) min in the first- and-second stage of labour, respectively, in primigravida. There was no statistically significant difference between antenatal PFMT and control groups for episiotomy, perineal laceration, or instrumental delivery [23]. A more recent systematic review, including more trials, also found a statistically significant and clinically important effect on reducing second-stage labour duration for primigravida and mulitgravida [52]. Antenatal PFMT also halved the risk of severe perineal laceration (RR 0.57, 95% CI: 0.38 to 0.84) [52]. Overall, it seems antenatal PFMT probably has a protective effect for the PF. Women may be interested to know this and about possible reduction in labour duration.

Potential or unintended harms of PFMT

Although an important consideration, adverse events associated with PFMT are rare (e.g. pain with contraction) and reversible [22]. It is possible to ‘over-do’ the exercises and provoke myalgia, addressed by reducing the exercise dose [53]. Of more concern is the potential harm if, instead of PFM elevation with a contraction, there is a Valsalva (i.e. straining manoeuvre) that increases intra-abdominal pressure, resulting in depression of levator ani that may weaken the connective tissues and could theoretically potentiate UI [54]. Confirmation of a correct PFM contraction can be undertaken visually by directly observing the PF, palpating coccygeal movement, or using vaginal palpation [19, 55]. Real-time transperineal ultrasound is also used [56, 57]. Maternity care providers may be concerned about the acceptability or advisability of vaginal examination during pregnancy, although women may find it acceptable especially if they have incontinence [58]. In section 2 we consider if and when confirmation of a correct contraction is needed.

A woman may have no voluntary contraction. In this case, her PFMT attempts will probably lead to frustration and no effect rather than direct harm. Women without a contraction need specialist referral, to a PF physiotherapist for instance, for assessment. There may be some underlying reason, such as muscle avulsion or denervation [25], and re-educating a correct contraction may or may not be possible. A woman may not feel a contraction if her muscles are already in a ‘contracted’ state; these women may have hypertrophic, painful muscles [59]. The most common cause is voluntary ‘holding on’, which over time may lead to persistent PFM contraction, with other causes including damage to the PF and in-coordinated contraction [19, 59]. These women will not respond to PFMT [59], and relaxation training is needed [19].

Summary and clinical practice recommendation

In sum, antenatal PFMT is a population-based intervention with potentially substantial and long-lasting benefits for women and society. Clearly, effective antenatal PFMT probably prevents UI and the consequent costs and reduction in quality of life. Antenatal PFMT may also improve labour and delivery outcomes, improve sexual satisfaction, and have a role in preventing pelvic organ prolapse and AI. While the evidence for PFMT as an effective treatment is less certain (principally because there are fewer studies, of poorer quality), it seems likely that the recommendation of PFMT as first-line therapy for treatment of UI reasonably applies for pregnant and postnatal women.

In practice, all pregnant women at every contact with a MCP should be asked if they are continent. If they are, then they should be taught and supported to do PFMT throughout their pregnancy so they stay above the continence threshold (i.e. prevent UI) and accrue the other possible benefits. Postnatal women should be asked the same question at every check-up. If UI is identified in pregnancy or by 6 weeks postpartum then PFMT should be offered as a first-line treatment, preferably under the guidance of a MCP with confidence in appropriate screening (to exclude any red flags), incontinence and PF assessment, and PFMT teaching and supervision.

Section 2: What PFMT programme should maternity care providers recommend?

As an exercise-based therapy, PFMT prescription may be considered the domain of physiotherapists [60]. Yet, midwives, obstetric nurses, or general practitioners will usually be the most consistent and trusted provider for childbearing women. All these MCPS need sufficient knowledge, skill, and confidence to teach a sound PFMT programme. In addition, good working relationships with nurses and physiotherapists with extra training in PFM assessment and continence therapy are important so that MCPs feel supported to offer quality care and can refer to more specialized colleagues as appropriate.

The essential elements of a sound PFMT programme are the performance of repeated, voluntary, planned, and structured contractions to enable muscle training after confirmation of a correct PFM contraction [60]. A correct contraction results in constriction and inward movement of the pelvic openings [19], and many women can feel this if clearly and accurately instructed in how to contract. Therefore, MCPs should focus on teaching a contraction verbally and accurately and seek feedback from a woman about what she feels when she contracts. This is more and probably better quality instruction than most women currently receive, as many only get written information or use sources of unknown accuracy/quality (e.g. websites) [61,62,63,64]. Clear instruction and feedback may be sufficient for many women and MCPs to have confidence that a correct contraction is being done. A MCP can also observe for concerning behaviours. These include sucking in the abdomen, clenching the gluteal muscles, or breath-holding and abdominal bulging that suggest Valsalva. Referral is needed for absence of contraction (e.g. a woman cannot feel anything) or a Valsalva if repeat teaching (with a focus on squeeze and lift) is unsuccessful and the MCP does not have the skills and confidence to confirm a correct contraction.

PFMT is done to enhance the strength, endurance and/or co-ordination, and therefore function, of the PFM [19]. Strength training may offset the increasing intra-abdominal pressure caused by the growing foetus, the reduced urethral closure pressure that is mediated by hormones, and increased pelvic soft tissue laxity [22]. PFMT is thought to lift the PF higher within the pelvis, increase muscle size and stiffness of the pelvic connective tissues, and reduce the levator hiatus area (through which pelvic organs may herniate). Together, these changes may lead to improved tone and automatic function of the PF, preventing its downward movement during increased intra-abdominal pressure and preventing UI [28]. PFMT should begin as early as possible antenatally to offset these changes and to maximize the opportunity for muscle hypertrophy (i.e. increase in muscle fibre size) [65]. Ideally, women begin training no later than 20 weeks of pregnancy [22].

There is considerable variation in prescribed PFMT programmes and many show benefit [22]. This is confusing for those not expert in exercise prescription. Some variation reflects the difference between good generic PFMT advice (e.g. helping continent women stay continent) versus tailored, individualized exercise prescribed for PFM rehabilitation (e.g. helping an incontinent woman with weak PFM regain strength and continence). Fortunately, international bodies such as the American College of Sports Medicine have summarized a vast corpus of exercise training literature providing basic principles for strength training for ‘novice’ exercisers such as women taking up PFMT for the first time or after a break from training [65, 66]. Professor Kari Bø has refined and tested a PFMT programme based on these principles [67] including trials in pregnant and postnatal women [68,69,70]. It is widely adopted and tested by others [22, 71] and recommended in practice guidelines [21]. The basics of sound PFMT exercise prescription (with the strength training principle in parentheses) follow, and the minimum exercise dose recommended for a novice exercisers is summarized in Table 1:

  • Encourage contractions of maximal or near maximal effort (high muscle load)

  • 6–8 s hold per contraction (short duration contractions)

  • 8–10 contractions in a row (small number of contractions)

  • Repeating this ‘set’ of exercises two or three times a day

  • A minimum of 3 days a week

  • At least 8–12 weeks duration, ideally lifelong

Table 1 Minimum PFMT exercise prescription
Full size table

Rather than worry about minor variations to the above, MCPs can concentrate on addressing major divergence if women have inaccurate information, for instance, women who believe they need to do 100 contractions a day.

Strength training requires exercise progression [65]. Some women find it easier to feel the correct contraction in one body position such as lying or sitting at first. For them, progressing from lying to sitting and then standing is useful. Being able to contract in different body positions also creates opportunity for integrating exercise in daily life (e.g. standing in a queue). Women who cannot hold for as long as 8 s or do as many as ten contractions in a row can start with less hold or fewer contractions and slowly increase to the required level. Functional training can be added, including performing a PFM contraction before a rise in intra-abdominal pressure, such as coughing—sometimes called ‘the Knack’ [19]. Furthermore, encouraging women in mild to moderate exercise consistent with recommendations for gestational diabetes prevention, maternal cardiovascular health, and foetal health may also benefit PFM function and reduce UI risk [72].

When planning services, other considerations include whether to offer PFMT individually or in groups, and/or within a general fitness class. All these have demonstrated effect [22]. For providers what is most important is that MCPs have the core skills of clear and accurate teaching of PFMT, and sound exercise prescription, so that PFMT can be confidently offered to all childbearing women. Furthermore, MCPs should know when and how to refer for more specialist help, such as for women who cannot contract correctly or have incontinence symptoms.

Section 3: How can maternity care providers and women engage with PFMT?

A therapeutic PFMT dose requires that the person performs the contractions. Thus, PFMT is both a physical and behavioural intervention [60]. Here, we consider how to offer women behavioural support to achieve effective PFMT. We use the Capability Opportunity Motivation and Behaviour (COM-B) system [35] as a structure for presenting evidence about the PFMT facilitators and barriers pregnant and postpartum women, and MCPs, commonly face. Michie et al. (2011) also proposed nine ‘intervention functions’ that can be applied to address the behavioural barriers and we suggest how MCPs can offer behavioural support using these functions. Previously, in a synthesis of qualitative studies of patient experiences of PFMT, Hay-Smith et al. (2015) [73] found that four intervention functions (education, persuasion, training, and enablement) might be particularly useful to address PFMT barriers with a fifth (modelling) showing potential. Recently, findings from a critical interpretative synthesis of antenatal and postnatal PFMT implementation by Salmon et al. (2020) [74] suggested environmental restructuring (another intervention function) is also necessary to support women’s and MCPs’ behaviour.

Capability

Capability is a person’s psychological and physical capacity for the behaviour, including having the necessary knowledge and skills [35]. This means that childbearing women need to be aware of the potential for UI, know why PFMT might prevent and treat it effectively, have the physical skill of correct PFM contraction, and exercise prescription that strengthens PFM.

More than half of birthing women know they might experience UI in pregnancy or postpartum [63, 75], although they do not know why [76]. Knowledge of the PFM and their function [61, 62, 75, 77] and the purpose and effectiveness of PFMT is limited [78,79,80]. Many lack confidence [64] or feel helpless [81] to do a correct contraction and want teaching and confirmation of this [79]. Women prefer a credible information source, such as a trusted MCP [77], most often a midwife [58, 82]. While women may use other sources (e.g. books, internet, family and friends) [61,62,63,64] the information accuracy and consistency are highly variable, thus confusing and possibly scary, leaving women disempowered [80]. In particular, women lack accurate knowledge of how often and how much PFMT to do [62, 77, 80, 83]. Thus, for the educator, women need accurate information about what their PFM do and why and how effective PFMT can prevent UI now and in later life. Women also need training in the basic skill of PFM contraction, and clear exercise prescription (see guidance above).

Another role for the educator is addressing common misconceptions, such as the belief that urine leakage is ‘normal’ [58, 61, 62, 75] and/or symptoms will resolve spontaneously postpartum [4, 75, 77]. This belief—whether held by women or MCPs—is particularly concerning because antenatal UI is a known predictor of PF dysfunction in later life [5]. Women may hold other misconceptions, such as PFMT increases miscarriage risk [61], and part of the educator’s role is to elicit and address such concerns so that these do not influence exercise motivation. Communicating knowledge about the positive benefits of PFMT, such as benefits for sexual functioning and general well-being [84], may also help persuade women to take up and maintain PFMT.

Opportunity

Opportunity encompasses social and physical factors outside the woman that make PFMT behaviour possible and prompt it [35]. The relationship and regular contact with a MCP during pregnancy and postpartum are a woman’s greatest opportunity to learn about PFMT, take this up, and maintain it. These relationships are where the first disclosure of incontinence symptoms may happen.

The social and physical context in which many MCPs work does not support PFMT behaviour. In a recently published critical interpretative synthesis of women’s and MCPs attitudes, beliefs, or experiences of implementing PFMT, Salmon et al. (2020) [74] found many challenges. In antenatal services midwives have responsibility for an increasingly broad range of health initiatives and burgeoning workloads in a service structure and funding environment that does not accommodate these demands. Thus, the opportunity to give PFMT any ‘space’ or priority is limited. Therefore, policy-makers, funders, and service providers must take responsibility for the environmental restructuring necessary to increase opportunity for women and MCPs to implement PFMT effectively, and professional societies and consumer organizations should be advocating strongly for this change. Environmental restructuring includes providing the resources for effective implementation (e.g. funding reflecting additional workload, funding for specialist level care for referred women) and clear delineation of responsibilities in the care pathway. A sign of progress in the UK is the recently published National Health Service long-term plan, which advocates improved access to physiotherapy for postnatal women with PF dysfunction, the establishment of multidisciplinary pelvic health clinics, and adequate training for MCPs [85]. While the intent to support postnatal women with UI is necessary and laudable, the lack of simultaneous emphasis on intention to structure and fund services to prevent UI in antenatal women is a lost public health opportunity.

Three recent publications [58, 86, 87] have endorsed the challenges outlined by Salmon and colleagues [74]. Midwives may have limited education, knowledge, and skills in PFMT, which reduces their confidence [58, 87], and while they agree PFMT is important it is typically not implemented [58, 86]. Clinical guidelines may recommend childbearing women receive PFMT advice, yet lack of clear policy or support at the clinical interface reduces prioritization [58]. It seems PFMT and UI are erroneously considered postnatal issues [74], or at least issues that can wait until the overwhelming workload of antenatal care is past. In a constrained environment, MCPs may offer PFMT support to some women and not others based on assumptions about who will engage [58]; PFMT advice is less likely to reach younger women, those living in disadvantaged socioeconomic areas, and women who have not continued in education beyond secondary school, are not in paid employment, or speak another language [62, 64]. Thus, external influences reduce the opportunity for PFMT implementation, and health inequity increases if some women are offered the opportunity and others are not. What, then, can MCPs do to maximize the opportunity inherent in their ongoing relationships with women over the childbearing years?

Communication clarity about PFMT and UI from MCPs is an important first step as women criticize the lack of it [80]. Avoid symbolic language to explain PFMT and the purpose (e.g. they stop your insides falling out) or asking about UI (e.g. how are your waterworks?), which is easily misunderstood [77, 80]. Do not give a PFMT leaflet postpartum without also providing the opportunity to check what a PFM contraction is and how to do it, and why PFMT is important [79, 81].

Asking about UI is essential because few women with symptoms seek care [88, 89] and pregnant women may wait until after delivery [4]. Women wait for MCPs to ask and are reluctant to disclose [58, 80, 90]. Reasons include: embarrassment and shame [90]; guilt if they knew about PFMT and did not do it [77]; overcoming concerns about making a fuss or having another pelvic examination; worry that the problem is not legitimate or will be dismissed or the MCP will be judgmental about failure to exercise [77, 80, 81, 90]; and a sense that care prioritizes the baby and not them [23, 81]. When women bring this up they typically want more specialized help, usually from a physiotherapist or person with expertise in conservative management of UI [4, 23, 81, 90, 91]. Women sense reluctance in MCPs to discuss incontinence [90], which may be part of the wider societal taboo women experience [81]. A trust relationship with a MCP is a strong positive influence on being able to discuss UI [80, 90], and women want questions about UI to be a usual part of regular check-ups [77].

Therefore, the main MCP behaviour that enables women to access PFMT knowledge and skills and disclose UI is to initiate discussion. The communication needs to be free of embarrassment, clear and consistent, and repeated regularly throughout pregnancy and lifelong thereafter as women (especially those with UI) may take time to feel enough trust to disclose. Maternity care provider modelling of a lack of embarrassment in asking in transparent language about UI is essential to enabling women with symptoms to disclose. Maternity care providers, who do not feel able to offer the necessary advice and training women need, can act as enablers if they know how and where to refer women for this care.

Motivation

Motivation is the person’s readiness for behaviour change. Reflective conscious processes such as decision-making and automatic (e.g. habits and emotions) processes contribute to motivation [35]. A lack of motivation is an explanation MCPs commonly give for women not doing, or not doing enough, PFMT. Midwives cite time pressure as a key behavioural influence for them [58, 80], questioning whether supporting PFMT is a good use of their time if women are not adherent longer term [80]. While ideologically committed to PFMT midwives typically do not find time to prioritize it in the antenatal or postnatal care pathway [58].

A good use of time is to give clear and direct advice to do PFMT and to communicate the important benefits [58, 62]. Women believe they would do PFMT if clearly advised and this may help address lack of belief communicated by family, friends or MCPs, or personal experience of a lack of immediate benefit [78]. Developing UI prompts PFMT [78, 80, 92]. However, coping with leakage quickly becomes the new normal, and self-management strategies such as use of incontinence products, reducing high-impact activities, and fluid restriction become habit [90]. If women lack confidence in doing PFMT, they are less likely to adopt it [78]. Regular, supportive, communication with MCPs may also counter emotions such as self-blame or guilt that reduce motivation to seek help, disclose symptoms, or persist with exercises [80].

The overwhelming and consistent concern for childbearing women about doing PFMT is remembering and finding time. This is congruent with the considerable cognitive analysis, planning, and attention that adopting PFMT requires (i.e. reflective motivation) [73] and reduced emotional and mental availability to engage (i.e. automatic motivation) when managing the competing priorities for energy and time posed by a new baby [78, 93]. Women say they need help to find key triggers, cues, or prompts to exercise and develop the exercise habit (e.g. connect PFMT with a particular activity such as teeth brushing or toileting) [77, 78].

In sum, adopting and maintaining PFMT as a new behaviour is untenable for most women without behavioural support. Even with the opportunity to develop the knowledge and skills in PFMT through contact with a MCP, women need sufficient backing to develop the habit. To support women’s motivation MCPs can persuade women of PFMT’s benefits. To counter negative stories, provide positive modelling by giving examples of women who have benefitted and clear statements of the evidence of effect such as ‘62% reduction in risk of UI by the end of pregnancy’. As an enabler, work with women to problem-solve the barriers of time and forgetting, revisiting this at each contact to work actively on finding solutions for women to develop the habit. Giving information alone is not enough for most women to take action.

Conclusion/summary

Based on the clinically important reduction in the risk of developing UI, the current quantitative and qualitative evidence suggests that the greatest benefits of PFMT are grounded in what women are educated, persuaded, trained, and enabled to do while pregnant. PFMT is also appropriate first-line treatment for women who develop UI during pregnancy or postpartum and probably offers additional benefits in preventing prolapse and improving sexual function, AI, and labour and delivery outcomes. Many childbearing women have limited capability (e.g. skills and knowledge), opportunity (e.g. PFMT not routinely or well implemented in antenatal or postnatal care), or motivation (e.g. find it hard to develop a PFMT habit without behavioural support) for PFMT. All MCPs can help women prevent or manage UI and the associated distress. Childbearing women should be asked at every MCP contact if they are continent. Women who are continent should be trained to perform a correct PFM contraction and provided with clear and accurate instructions about PFMT that include the basics of the minimum sound PFMT programme. Women who are incontinent or who are unable to perform a correct PFM contraction should be referred for specialist PF diagnosis or rehabilitation. The expectation to implement effective PFMT does not and should not lie solely with MCPs and women; it requires major and immediate environmental restructuring (including care pathway responsibilities and resources), which is the domain of policy-makers, funders, and service providers.