Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women
For both prevention and treatment of incontinence in postpartum women, instruction in pelvic floor muscle training (PFMT) by physiotherapists is more effective than routine antenatal and postnatal care. Incorporation of effective PFMT protocols into the basic maternal health care packages already being administered to women at all levels of health care can potentially yield positive results in under-resourced settings.
RHL Commentary by Lapitan M
The prevalence of pregnancy-associated urinary and faecal incontinence in under-resourced areas has not been sufficiently researched. Information on this topic is limited to epidemiological data gathered from surveys conducted in developed countries, where estimates of prevalence range between 6% and 29% (1).
In a setting where fertility is high, outcomes of maternity are an especially important public health concern. Pelvic floor muscle dysfunction may be associated with pelvic floor muscle trauma in women who have difficult and prolonged labour and delivery. There is no reason to believe that the prevalence of incontinence following childbirth would be any lower in under-resourced areas compared with developed countries. Indeed, the less-than-ideal conditions of labour and delivery and low levels of access to health-care services that prevail in under-resourced settings may in fact increase the risk for pelvic floor muscle trauma.
Various interventions are available for preventing and treating urinary incontinence, including medication, medical devices and surgery. However, pelvic floor muscle training (PFMT) – which involves exercising the muscles involved in passing urine (especially the pelvic floor muscle) – may be the easiest to implement in under-resourced settings since it needs no special equipment, additional health-care infrastructure or other costly resources.
Being non-invasive, easy-to-learn and an exercise that can be done practically anywhere anytime, PFMT has been promoted as an appropriate and readily acceptable intervention for pregnant women as well women in the postnatal period who may be breastfeeding.
The objectives of the review were to determine the effectiveness of PFMT in the prevention and/or treatment of urinary and faecal incontinence in pregnant or post-natal women. In particular, the review focused on the comparison of the outcomes between intensive PFMT programmes administered by physiotherapists, compared with standard antenatal care, which may or may not include PFMT.
This systematic review and meta-analysis of randomized controlled trials used the methods recommended by the Cochrane Collaboration. The search for relevant studies was comprehensive. The quality assessment of studies performed in the review was adequate. The results and analyses are clearly presented and well discussed. The data were properly interpreted in the context of the characteristics and quality of the trials.
Sixteen trials were included in the review. However, as one trial did not report useable data, analysis was performed on data from 15 trials involving 6181 women (3040 in the PFMT group and 3141 controls).
Intensive antenatal PFMT effectively prevented the occurrence of incontinence in late pregnancy by 56% [3 trials, 307 women relative risk (RR) 0.44; 95% CI 0.30–0.65], in the early postpartum period by 50% (2 trials, 118 women RR 0.50; 95% CI 0.31–0.80), and up until six months post partum by 30% (4 trials, 553 women RR 0.71; 95% CI 0.52–0.97) compared with usual antenatal and/or postnatal care.
Postnatal women with incontinence who received intensive PFMT were less likely to report urinary incontinence at 12 months after delivery (20% reduction in risk; RR 0.79; 95% CI 0.70–0.9) compared with those who did not receive the treatment. Faecal incontinence was also reduced at 12 months after delivery by 50% (RR 0.52; 95% CI 0.31– 0.87).
Women who received intensive antenatal PFMT had 10% lower risk of urinary incontinence in late pregnancy (RR 0.88; 95% CI 0.81–0.96).
There was not enough evidence to demonstrate that provision of intensive PFMT to all women after delivery, regardless of their urinary or faecal continence status, leads to a reduction in prevalence of urinary or faecal incontinence.
4.1. APPLICABILITY OF THE RESULTS
The results of the review suggest that, for both prevention and treatment of incontinence in postpartum women, instruction in PFMT by physiotherapists is more effective than routine antenatal and postnatal care, which may or may not include non-supervised or population-based PFMT programmes.
All but one trials included in this review were conducted in developed countries. Although it is not clear whether there are genetic differences in pelvic soft tissue strength among different racial or ethnic groups, pelvic floor damage and incontinence is a common problem experienced by childbearing women globally. However, the differences in health care systems between developed and developing countries and the methods by which the PFMT interventions were delivered in the trials included in the review, raise doubts about the generalizability of its results to under-resourced settings. The intensive, supervised PFMT programmes evaluated in this review were implemented in health-care systems in which trained physiotherapists are widely available in numbers that can cope with the patient load. Such programmes may not be feasible in under-resourced areas because of the lack of physiotherapists and the limited access of patients to health-care facilities by virtue of the remoteness of many communities or to socio-economic constraints that prevent women from seeking health care.
4.2. IMPLEMENTATION OF THE INTERVENTION
Given the above-mentioned limitations, yet realizing the improved outcomes associated with intensive supervised PFMT programmes, it may be necessary to introduce some modifications into these programmes that will make them feasible. These may include the use of trained community health workers instead of physiotherapists and optimal use of effective materials that reinforce patient education. Considerable public health benefit may result from the incorporation of effective PFMT protocols designed and validated for delivery in under-resourced areas into the basic maternal health care packages already being administered to women at all levels of health care.
While individual or group instruction in PFMT by physiotherapists is desirable and has been shown to more efficacious, it may not be feasible in under-resourced areas. In such regions, instruction by means of accessible health promotion materials or by non-clinically trained community health workers may be more feasible, although this may not be as effective. PFMT programmes without physiotherapist instruction are under-researched. Indeed, in developed countries establishing its effectiveness may now be difficult given the baseline levels among women of familiarity with PFMT as a result of frequent explanation of the exercises in print and broadcast media and in freely available health promotion materials.
4.3. IMPLICATIONS FOR RESEARCH
The authors of the review propose further research on, among other topics, the impact of antenatal or postnatal PFMT on faecal incontinence and the effect of antenatal PFMT on pregnancy outcomes. However, the review fails to emphasize the need to study the cost-effectiveness of such programmes, taking into consideration not only the financial resources needed to implement such programmes, but also the burden on limited human resources in health systems in developing countries. This is particularly important in under-resourced areas where a decision to invest in training and dedicated health-care personnel, such as physiotherapists, for such services may mean a very significant shift of resources.
Research designed to assess the effectiveness of such low-cost and culturally and contextually appropriate PFMT education interventions may result in the development of clinically and cost-effective interventions in under-resourced settings.
Sources of support: The author is employed by the National Institutes of Health, University of the Philippines, Manila.
Acknowledgement: Dr Brian Buckley's valuable contribution in the writing of this commentary is gratefully acknowledged.
- Mason L, Glenn S, Walton I, Appleton C . The prevalence of stress incontinence during pregnancy and following delivery. Midwifery 1999;15:120-128.
This document should be cited as: Lapitan M. Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women: RHL commentary (last revised: 1 April 2009). The WHO Reproductive Health Library; Geneva: World Health Organization.