Outcomes that were of interest: • non-occurrence of
urinary incontinence following childbirth; • a change in the frequency, duration or severity (as appropriate) of
urinary incontinence up to 12 months following childbirth. • a change in the strength of pelvic floor muscle contractions; • period of time
PFME continued after initial instruction; • frequency of
PFME undertaken; • women's awareness of the importance of
PFME; • satisfaction with
PFME instruction. Search strategy All major electronic sources of information relevant to the topic (e.g. PubMed, CINAHL and the Cochrane Library) were searched to identify published and unpublished studies and previous work in the field. Printed journals were hand-searched and reference lists checked for potentially useful research. The review included any studies undertaken between 1981 and 2003. The search did not attempt to locate unpublished research before 1991. Assessment of quality An independent Review Panel carried out quality assessment of studies. Two members of the panel, using quality assessment checklists developed for the review, reviewed each study. Disagreements between reviewers were resolved through discussion or a third reviewer examining a study. Data extraction and analysis A data extraction tool was developed to extract data relating to participant characteristics, study methods, interventions and outcomes. Two reviewers independently extracted the required data. Randomised controlled trials included in the review were pooled in several meta-analyses using RevMan software program. Heterogeneity between studies was determined to ensure that they were sufficiently similar to allow for the pooling of their results. Non-randomised controlled trials were discussed in narrative comparisons. Results Six randomised controlled trials met the inclusion criteria for the primary objective of the systematic review. The results of this review indicate that antenatal
PFME and post-natal
PFME are effective in resolving or reducing
urinary incontinence following childbirth. There was insufficient evidence to conclude that
PFME can prevent
urinary incontinence in post-partum women. In most of these studies women were selected randomly and therefore included women without
urinary incontinence and women with
urinary incontinence. Two randomised controlled trials selected their sample on the criteria of existing post-partum
urinary incontinence. A subgroup analysis of these studies showed that post-natal
PFME also have a significant effect on reducing or resolving
urinary incontinence in women with existing post-partum
urinary incontinence. Seven randomised controlled trials and three non-randomised controlled trials met the inclusion criteria for the secondary objectives of the review. Findings of the studies included in the review suggest a
PFME program will improve the frequency with which women perform
PFME. Two studies found that women receiving the intervention (a
PFME program) and who were performing
PFME regularly in the month before data collection were significantly less likely to have any incontinence. The review's results support previous findings showing there is little evidence that a high-intensity
PFME program is more effective than a low-intensity
PFME regimen of exercising. No conclusions about the effectiveness of feedback to a woman about pelvic floor muscle strength, for example, perineometer measures, as part of a
PFME program can be reached. The mixed results of this review mean that no conclusions can be reached about the effectiveness of a
PFME program, antenatal or post-natal, on improving pelvic floor muscle strength. A number of studies reported a high percentage of women lost to follow-up and the data collected in most of the studies relied on self-reports relating to
urinary incontinence and/or frequency of exercising. These factors may have affected the overall results of the review. However, wherever possible, tests for heterogeneity were carried out to determine if studies should be combined in meta-analyses and in other cases the results' limitations are acknowledged. Implications for practice In terms of the effectiveness of
PFME programs, the results of this review indicate that
urinary incontinence following childbirth can be improved by performing
PFME and that any form of a specific
PFME program appears to improve exercising frequency. However, the value of individual components of
PFME programs, such as take-home materials, reminder telephone calls and feedback of exercising effectiveness, is less clear. • Encourage women to undertake both antenatal and post-natal
PFME (E1). • Pay particular attention to women with antenatal and post-natal
urinary incontinence in providing advice and
PFME instruction (E1). • To encourage adherence and continuation,
PFME education programs should be multifaceted with a number of components, rather than only supplying an information booklet (E4). • Include
PFME as a specific program in all antenatal and post-natal care, incorporating at least two individual instruction sessions into the program (E1). • Provide post-partum contact, particularly for those discharged early, either by telephone, electronic or home visits (E4). • Design pelvic floor muscle home exercise programs that are realistic given the demands on a mother and that can be incorporated into her daily routine in terms of number and frequency. Two or more training sessions per week are recommended (E4). • Health professionals working with women in the post-partum period should ask about symptoms of incontinence to ensure assistance is offered to those experiencing
urinary incontinence (E4).