Pelvic floor dysfunction and incontinence are common after pregnancy and childbirth
In the first three months after childbirth about one in three women have urinary incontinence and up to one in 10 have faecal incontinence. Pelvic floor muscle training is the recommended first-line care to prevent and treat both conditions.
In July 2020 we published a PEDro blog summarising a Cochrane review that estimated the effects of pelvic floor muscle training (antenatal or postnatal) for preventing or treating urinary and faecal incontinence in late pregnancy and after childbirth. The review concluded that structured antenatal pelvic floor muscle training for continent women can prevent the onset of urinary incontinence in late pregnancy and in the early and mid postnatal periods. Uncertainty surrounds the effects of pelvic floor muscle training as a treatment for urinary incontinence in antenatal and postnatal women and for the treatment of faecal incontinence.
A systematic review has recently been published that expands on the results of the Cochrane review by reanalysing the trials to determine the costs of different models of care used to provide pelvic floor muscle training in the antenatal or postnatal periods. The aim was to determine the most cost-effective way of providing pelvic floor muscle training to prevent or treat postpartum incontinence.
Cochrane review trials were included in the cost-effectiveness review if they reported statistically significant between-group differences in preventing or curing incontinence and contained sufficient information about the intervention to categorise the pelvic floor muscle training on two strata.
The strata were:
- individual, group-based or mixed individual and group
- during or after pregnancy. The participants were pregnant or postnatal women.
Costs for each intervention model were calculated in 2019 Australian dollars using publicly available market rates and enterprise agreements (including estimates of health service, consumer and societal costs plus cost savings). One author performed the calculations, which were cross-checked by a second author. The incremental cost effectiveness of each intervention delivery to successfully prevent or cure one case of incontinence were calculated. Sensitivity analyses were performed to account for variations in the number of participants per group for group-based training, the cost of patient out-of-pocket costs, salary rate of the health professional delivering the intervention, and the proportion of patients who would have postnatal incontinence without intervention.
Eleven trials (3,005 participants) were included in the cost effectiveness analysis.
Three models of intervention were evaluated:
- individual pelvic floor muscle training during pregnancy to prevent urinary incontinence (two trials);
- group-based training during pregnancy to prevent or treat incontinence (three trials); and
- individual postnatal training to treat urinary incontinence (three trials) or urinary and faecal incontinence (three trials).
The costs to the health service to prevent or cure one case of urinary incontinence were $768 for individual pelvic floor muscle training during pregnancy and $1,970 for individual postnatal training.
In contrast, group-based training during pregnancy generated a cost saving of $14 if there were eight participants per session. Sensitivity analyses revealed that savings were greater if more participants attend each group. The health service cost per faecal incontinence case prevented or cured was $2,784. The certainty around these cost estimates (i.e 95 per cent confidence intervals) were not reported.
Providing group-based pelvic floor muscle training for women during pregnancy is more efficient than individual training. However, providing pelvic floor muscle training for postnatal women with urinary incontinence also has merit due to the added known benefit for preventing and treating faecal incontinence.
Dr Kate Lough, pelvic health physiotherapist, Glasgow. Chairs the Pelvic Obstetric and Gynaecological Physiotherapy network.
Pelvic floor dysfunction in the perinatal period significantly affects quality of life. This systematic review of cost-effectiveness adds to the knowledge of what interventions might work when planning perinatal services to minimise the impact of urinary and faecal incontinence.
Covid-19 has forced a significant change to clinical practice, and this review may provide some reassurance that group-based pelvic floor muscle training could be considered effective.
Caution must be applied to these findings as the number of studies eligible involved only 3,005 women, and the efficacy of the interventions are not reported. This review supports the conclusion that broad availability of antenatal pelvic floor education and training to all is of value, and that providing individual treatment to postnatal women with urinary or faecal incontinence is of benefit.
The original review and this additional analysis needs to be complemented by more research identifying the long-term benefits of early intervention for pelvic floor muscle training at different life stages. The upcoming NICE guideline on the prevention and non-surgical management of pelvic floor dysfunction will be a welcome addition to this clinical dilemma.
This evidence summary was provided by PEDro.
PEDro is the Physiotherapy Evidence Database, a free database of over 51,000 randomised trials, systematic reviews and clinical practice guidelines in physiotherapy. Infographic relating to this evidence summary. PEDro blog summarising a Cochrane review.
Brennen R, et al. Group-based pelvic floor muscle training for all women during pregnancy is more cost-effective than postnatal training for women with urinary incontinence: cost effectiveness analysis of a systematic review. J Physiother 2021;67(2):105-14
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