Urinary leakage is one of those things you don’t hear about until it happens to you. It completely changed my whole life.

Emma – mum of two, experienced leaking during her first pregnancy 

The challenge

Between 3 and 5 million women in the UK leak urine, known as urinary incontinence, after having a baby. This condition severely impacts their quality of life – physically, psychologically and socially – with huge costs for the NHS and the environment.  

Research shows that doing pelvic floor muscle exercises during pregnancy can stop leaking urine before and after birth. However 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.

What’s more, women often say they do not know how to do pelvic floor exercises. There is also evidence that self-help resources are more likely to be accessed by people with higher levels of education.  

The solution

Midwives in the UK are well placed to give women advice and support for pelvic floor exercises.

APPEAL (Antenatal Preventative Pelvic floor Exercises and Localisation) is an evidence-based programme of training and resources to help midwives to know when and how to teach pelvic floor exercises so they are less likely to leak after giving birth.

The programme also focuses on community midwifery care with potential to reduce the need for specialist hospital-based treatment for women who leak.   

Our work in partnership

APPEAL is funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research, and led by researchers at the University of Birmingham and University of Exeter with support from NIHR Applied Research Collaboration South West Peninsula (PenARC).  

Health Innovation South West and the University of Exeter’s APPEAL research team secured funding from the Medical Research Council’s ‘Impact Accelerator Impact Co-Creation’ programme, to help roll out and embed APPEAL training in the South West Peninsula and across England. 

Health Innovation South West has played a key role in the implementation of APPEAL in the South West, including delivering monthly peer support sessions for service leads and championing the programme through maternity networks.  

In 2023, Health Innovation South West partnered with researchers at the University of Exeter and with young parents from WILD Young Parent Project in Cornwall to design new videos on pelvic floor muscle exercises to support women from under-served populations in rural and coastal communities. Partnering with WILD ensured we included voices of  women who often experience challenges accessing health and care in rural and coastal communities in the South West.   

The videos feature midwife Leann covering how to find, squeeze and lift your pelvic floor muscles and invites pregnant mother Emma to practice pelvic floor muscles with Leann. It’s an easy guide for women to follow along at home and with their midwife during antenatal appointments.  

You can watch one of the videos below and explore the full series here. 

In 2024, alongside the University of Exeter, we supported NIHR-funded APPEAL research led by the University of Birmingham, to understand how midwives can best provide pelvic floor muscle exercise advice to support to all women during pregnancy.

The study, published in BMJ Open in 2025, examined outcomes in a group of 95 midwives in eight teams who received the APPEAL training and a control group of 91 midwives in nine teams who did not receive the training.   

In 2025-26, Health Innovation South West has been supporting the implementation of APPEAL in four NHS trusts in Wessex using tools and resources we have jointly developed.

Our impact so far

• Over 200 perinatal pelvic health service and maternity service leads have attended ‘train the trainer’ sessions across England and Northern Ireland 

• 9 maternity services are actively implementing APPEAL within their organisations  

• 50 primary care staff have participated in a pilot of Pflexi – our training for primary care 

• Staff training has increased confidence to talk about urinary confidence, teach pelvic floor exercises and refer to specialist services when needed, in data from 350 staff  

• New video resources for midwives and pregnant women have provided women with a greater awareness and understanding of pelvic floor muscle exercises, and confidence in managing their pelvic health 
• International Continence Society Best in Category Health Services Research abstract prize 2024 for the real-world evaluation of APPEAL, led by University of Exeter in collaboration with Health Innovation South West.

The NIHR-funded study of APPEAL, published in BMJ Open in 2025, 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.   

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.”  

– Professor Christine MacArthur, Professor of Maternal and Child Epidemiology at the University of Birmingham

Case study: APPEAL in the Devon Perinatal Pelvic Health Service

Using funding from NHS England, the Devon Perinatal Pelvic Health Service introduced APPEAL training for midwives in 2024.

University Hospitals Plymouth NHS Trust embedded the videos in a Real Birth Company e-learning package that it provides to expectant women during pregnancy. The trust also extended the reach of APPEAL training to the vaccination team, comprising health visitors and community nurses.

APPEAL now complements the trust’s existing approach to birth preparation, including other preventative antenatal education on reducing the risk of obstetric anal sphincter injuries.

Midwives and pelvic health physiotherapists in the county are witnessing first-hand the impact of teaching preventative pelvic floor education in antenatal care, on women and on staff.

The feedback is outstanding. We have people saying this is the best training they have ever done. How they couldn’t believe they’ve been a midwife for 30 years and thought they knew everything there was to know, but there was so much more.

Lizzie Phillips, Pelvic Health Midwife, University Hospitals Plymouth NHS Trust

Read the case study in full.

Case study: Training family support workers 

A family support hub in Plymouth, run by the charity Barnardo’s, has integrated APPEAL resources into its five-week antenatal course.  

Family support workers are now trained in delivering APPEAL on up to 30 antenatal courses a year. Over 200 people attended these courses in 2025.  

Pre-APPEAL training, our confidence wasn’t good. The information we were providing was very basic. We’d hand [people] a piece of paper with instructions. ​After the APPEAL training, we’ve become a lot more confident in what we’re talking about. It’s more professional; it comes from a health background, rather than just us. People are really engaged with the video of the explanation of how to do a pelvic floor exercise.

Rachel Scantlebury, Family Hub Support Worker, Barnardo’s Plymouth

What’s next?

If taught to all pregnant women in the UK, pelvic floor muscle exercises have potential to benefit tens of thousands of women every year. A sustainable business model and implementation toolkit is currently in development to support ongoing implementation and spread nationally across England.  

The aim is to train 95% maternity staff in APPEAL by March 2027.  

Four NHS trusts in Kent and Medway are set to implement APPEAL this year.