Hypothesis / aims of study
Urinary Incontinence (UI) after childbirth can be prevented for many women, yet about one in three women will experience this problem either in late pregnancy and or after giving birth.(1) Whilst pregnancy and childbirth are big risk factors for developing UI Pelvic Floor Muscle Exercises (PFME) can be used for both prevention antenatally, and as a treatment antenatally and postnatally.(1) Midwives are optimally placed in healthcare systems to provide support for women to do these exercises during their pregnancy; yet research shows midwives lack confidence to teach PFME and women do not have basic knowledge about their pelvic floor, nor confidence to raise this topic with their midwife.(2)
A feasibility and pilot randomised controlled trial(3) demonstrated it was acceptable to train midwives to support women to do their PFME during pregnancy and that this increased the number of women practicing PFME antenatally and may contribute to preventing postnatal UI. A change in national policy to improve perinatal pelvic health services (which includes training all midwives in pelvic floor health) meant it was not possible to undertake a definitive trial as there would be no untrained comparison group. Instead, to support services to train midwives, our PFME training package was offered alongside the phased national roll out of the new pelvic health services. All regional maternity systems (n=42) were required to provide training to their staff by March 2024. This study reports how we implemented our ‘train-the-trainer’ sessions in these new services and how we supported sites to implement our PFME training with their midwifery teams. We report data from sites implementing our training, and evaluate support provided for implementation, including refinements to resources, further developments of our implementation toolkit and plans for sustainability.
Study design, materials and methods
Mixed methods were used to collect data: anonymous on-line questionnaires, email messages and meeting notes. Analyses were descriptive or thematic summaries. For the train-the-trainer sessions we report number provided, number of service leads attending and their feedback evaluation (either verbally at end of session, via an on-line questionnaire, or emails, and for one region (four sites) through drop-in on-line support meetings). For site level training we report numbers adopting and staff numbers attending training (note some regional systems comprise several sites). Participating staff completed two questionnaires before the training session: one gathered demographic information (role and years in role). The second was a self-reported Likert scale confidence questionnaire for seven items. The confidence questionnaire was also completed immediately after the training session. The same seven questions were used in the pilot trial allowing for direct comparison.
Additional local funding supported updates to training videos, co-produced with young parents via a local charity who support young parents living in underserved rural communities.
Results
19 train-the-trainer sessions were delivered to 176 pelvic health service leads representing maternity services from nine of 42 regional systems over a 21 month period. Overall feedback from these sessions was positive (Figure 1). However, subsequent feedback indicated some reasons why sites subsequently chose not to adopt the training, for example: service leads believed their own bespoke training was needed, or other training was prioritised. Some service leads, who were keen to adopt the training, fed back barriers to adoption including service commissioners not affording the 90mins time needed for midwives to attend the training, mostly due to pressures on services and staff shortages.
For the 23 maternity services which did adopt the PFME training package, only four reported number of staff trained by March 2024 (n=435).
Four maternity systems provided training data from individual staff (n=306) comprising 282 midwives, nine labour ward coordinators, eight consultants, four support workers and three matrons. On average number of years working in their respective roles were between 5 and 15 years (range 0-36 years), which compares to the trial average of 11.3 years (SD 9.2). These 306 staff also provided pre-training confidence score data, and several more staff contributed to post-training confidence score dataset (n=324). Pre-training median scores were very similar to those reported in the trial. A positive change in confidence occurred following training and summary post-training median scores were very similar to, or better than, those achieved in the trial (Figure 2).
Four local systems were offered nine drop-in support sessions over six months; initially well attended this dropped as sites became more familiar with or completed their training. Feedback was positive regarding two way support for implementation and sharing learning and suggestions for adaptations and modifications to the training back to the research team (figure 3).
Additional local regional funding enabled three meetings with young parents groups to review existing training videos and make suggestions for improvements, and then follow-up meetings to review new professionally produced versions. The two training videos were complemented with a new question and answer video covering eight common questions about UI and PFME in pregnancy. Additional refinements to the videos included more diagrams, visual cues and provision of subtitles. Four months after launch on YouTube there had been 6k views of teaching the PFM contraction, 1.2k views for teaching PFME strengthening and 881 views for PFME Question and Answers. (figures on 29th March 2024).
Interpretation of results
Data indicate the ‘train-the-trainer’ model with support, was successful for sites that chose to adopt our PFME training package. However, national implementation of this package was patchy due to lack of service-level buy-in. For sites that did report training data, sessions continued to show immediate benefits with improvement in midwives and other antenatal staff confidence for the key training package elements. Importantly there was no indication of drop-off in post-training confidence compared to that achieved under the pilot trial research conditions. By offering support and working with adopting sites and with young parents’ involvement we have been able to make useful refinements to the resources. Updates to the training videos, including their placement on YouTube have dramatically increased access frequency, much greater than that achieved during the trial. Using feedback, we are now developing a broader implementation toolkit that will target service commissioner buy-in and help ensure sustainability so that the training package continues to support midwives to provide up-to-date and accurate information on PFME for all women. There are limitations to this evaluation: it has incomplete datasets and unknown denominators (staff numbers still to be trained). These issues are due to lack of resources to support data collection or upload, we rely on services to send training data when they can, meaning that a comprehensive national evaluation was not possible.