Pelvic floor muscle exercises (PFME) prevent and treat symptoms of urinary incontinence (UI) across the lifespan, including during pregnancy and after childbirth (1). Antenatal guidelines recommend PFME information is given to pregnant women in early pregnancy (2). However, many women have never practiced these exercises and, if they do, may not perform them correctly (3). This study aimed to explore communication between pregnant women and health professionals about PFME and how factors at organisational, professional and individual levels impact on this communication and exercise uptake and adherence.

This ethnographic study comprised observations of women and midwives during antenatal clinic appointments (city, urban and rural) and interviews with women (antenatal/postnatal) and health professionals.  Pregnant women aged over 16 receiving antenatal care and health professionals involved in antenatal care were recruited. Field conversations between researcher and health professionals helped place observations within a cultural context. Patient and Public Involvement was embedded throughout the research. Participants gave informed consent and could withdraw from the study at any time. Women received a gift voucher at each interview. Data sources included: observation field notes and photographs, documents (e.g. pregnancy leaflets, service guidelines, training documents) and interviews. Coding and initial analyses were concurrent with data collection using constant comparative methods with emergent themes informing further data collection and final thematic analysis.

Seventeen antenatal clinics were observed. Twenty-three midwives, four women’s health specialist physiotherapists, two consultant obstetricians and one caseworker/translator were interviewed. Fifteen women (20 to 42 years) were interviewed whilst pregnant; twelve were also interviewed postnatally. Seven women were expecting their first baby. Three themes emerged from the data analysis (Table 1).

Women and health professionals consistently reported that PFMEs were important; the emergent themes refer to opportunities, challenges and concerns of participants regarding implementing PFME during pregnancy. Despite 'ideological commitment' (Theme One) PFME was not sufficiently discussed or prioritised. Midwives were unwilling to burden women with too much information in early pregnancy and women concurred. Women reported that information did not stress the importance of, nor specific reasons for, doing PFME, (e.g. crucial role in ameliorating UI symptoms), or how to do PFME. Although women had heard about PFME, their limited knowledge was not enough to motivate them to do them, particularly if asymptomatic. Women lacked 'confidence' (Theme Two) about how to do PFMEs. Midwives were not confident they knew the optimum PFME routine or technique to teach women, but instead offered signposting (i.e. ‘have you done your pelvic floors?’).  Midwives gave advice about PFME if asked, but both women and midwives recognised that women may suffer in silence unless prompted to disclose problems. Women described following their midwives’ ‘lead’ in focussing on issues raised in more depth by midwifes, assuming these were of greater importance. Women wished they had known about PFME earlier or expressed regret at not prioritising PFMEs more. Women and health professionals felt 'assumptions' (Theme Three) about UI being ‘normal’ needed to be challenged, addressing stigma and taboo surrounding incontinence to empower women to take up PFME. A perceived absence of standardised guidance and resources at hospital or national level may have led midwives feeling that providing anything more than signposting, within a packed antenatal care pathway, was an insurmountable task. The study is limited in that ethnographies, by their very nature, are focused on detailed examination of the topic of investigation and cannot be generalised to all women or health professionals working in antenatal care.

This is the first reported ethnography of communication between women and health professionals about PFME in antenatal care. Key findings indicate missed opportunities to convey important messages about pelvic floor health in the antenatal period despite women wanting to hear more and midwives wanting to tell them; but lack of confidence in what to say and do, and assumptions held by women and health professionals, present challenges and concerns. These findings will inform further research: a pilot trial of PFME training and support packages (toolkits) for midwives and pregnant women.

Brown S, Gartland D, Perlen S, McDonald E, MacArthur C. Consultation about urinary and faecal incontinence in the year after childbirth: a cohort study. BJOG: An International Journal of Obstetrics & Gynaecology. 2015; 122(7):954-62.
NICE. Antenatal care for uncomplicated pregnancies.  Clinical Guideline 62. London: NICE, 2008.
Neels H, Wachter S, Wyndaelec J, Van Aggelpoela T, Vermandela A. Common errors made in attempt to contract the pelvic floor muscles in women early after delivery: A prospective observational study. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2018; 220: 113–117.