Research empowers midwives to prevent urine leakage after birth

A new study supported by Health Innovation South West has found that community midwives could help prevent incontinence in women post-birth through a midwife training programme that increases awareness of how and why to perform pelvic floor muscle exercises.  

The NIHR-funded APPEAL (Antenatal Preventative Pelvic Floor Exercises And Localisation) research, led by the University of Birmingham working with the University of Exeter and Health Innovation South West, is now published in BMJ Open. It set out to understand how midwives can best provide pelvic floor muscle exercise advice to support to all women during pregnancy and help prevent the one in three women that are affected by urinary incontinence post-birth.   

Between 3 and 5 million women in the UK experience urinary incontinence. This condition severely impacts their quality of life – physically, psychologically and socially – with huge costs for the NHS and the environment.  

Preventative pelvic floor education is not routinely provided in antenatal care or primary care in the UK. Many midwives and health professionals who do not specialise in women’s health report lacking the confidence and skills to address pelvic floor health effectively. Women often say they do not know how to do pelvic floor exercises. 

The APPEAL training helps midwives to know when and how to teach the exercises, and how to support women to do the exercises so they are less likely to leak urine after giving birth. The programme’s preventative approach and delivery via community midwifery care has the potential to reduce the need for specialist treatment. 

Health Innovation South West facilitated the implementation of APPEAL in the South West, working with the University of Exeter APPEAL research team to secure funding and to co-create video resources for midwives and pregnant women, delivering monthly peer support sessions for service leads, and championing the programme through maternity networks.  

Since the APPEAL research was completed, nearly 200 midwives and antenatal care staff, from 23 NHS Trusts, have been trained to provide pelvic floor muscle exercise advice and support to pregnant women. If this training is fully rolled out around the UK, then tens of thousands of women could benefit each year. This now needs to be fully resourced to allow midwives time to attend training and implement into antenatal care.   

The pilot randomised control trial was conducted in 17 midwifery teams. It examined outcomes in a group of 95 midwives in eight teams who received the APPEAL training on how to teach pelvic floor muscle exercises, and a control group of 91 midwives in nine teams who did not receive the training.   

The researchers found that APPEAL-trained midwives were able to provide advice and education and teach pelvic floor muscle exercises to pregnant women. The study also found that more of these women (65% in APPEAL group vs 38% in control group) reported they received support.  

Of women seen by an APPEAL-trained midwife, 50% undertook the exercises during their pregnancy in a manner likely to prevent leakage compared to 38% of women in the control group. Although this was a small pilot trial the researchers did observe that 10% fewer women who worked with an APPEAL-trained midwife reported urinary incontinence after giving birth, than among women in the control group.   

Lead author Professor Christine MacArthur, Professor of Maternal and Child Epidemiology at the University of Birmingham said:  

“Over one third of women are affected by urinary incontinence after giving birth, and despite it being widely acknowledged as a major health challenge not nearly enough has been done to support the huge numbers of women coping with this issue. Our research has established the best possible evidence that providing training and expertise to midwives has the potential to improve many women’s lives after they have given birth.”  

In the APPEAL research programme, the team revealed that both pregnant women and midwives lacked confidence about what could be done to prevent leakage.   

Physiotherapist Dr Victoria Salmon, research fellow at the University of Exeter where the APPEAL training programme was developed, said: “Women did not know how to do the exercises and were reluctant to ask, and midwives did not know how to teach the exercises, so did not raise the topic. This led to a lack of information about the benefits of these exercises during pregnancy and how they can reduce the risk of developing leakage, known as urinary incontinence.”   

For Emma Crookes, the first sign of incontinence began in pregnancy with her first child. What started as an inconvenient and embarrassing leak quickly spiralled into a life-changing issue that spanned six years of constant fear of public wetting, despite wearing incontinence pads.  

A GP referred Emma to a specialist pelvic health physiotherapist to strengthen her pelvic floor muscles. “The specialist physio explained all about pelvic floor muscles. By using equipment, she was able to teach me how to do pelvic floor exercises properly. I really stuck to my personalised programme and I noticed a difference within six weeks.”   

“It’s so important for midwives to teach women about pelvic floor exercises during pregnancy. I endured six years of avoidable misery. I want to do everything I can to avoid other women suffering in the same way, and this research is so important in improving experiences, outcomes and the mental wellbeing of others, as well as awareness and education about this life course issue.”    

Read more about APPEAL on our webpage.  

The study is titled ‘ Antenatal pelvic floor muscle exercise intervention led by midwives in England to reduce postnatal urinary incontinence: APPEAL feasibility and pilot randomised controlled cluster trial’, and is published in BMJ Open.