Uptake of antepartum continence screening and PFM exercise

Uptake of antepartum continence screening and PFM
exercise instruction by maternity care providers:
an implementation project
Helena Frawley 1,2 Pauline Chiarelli 3 Jane Gunn 2
1
La Trobe University; Cabrini Health, Melbourne, Australia
2 The
University of Melbourne, Australia 3 University of Newcastle, Australia
Introduction
Results
• Pelvic floor muscle (PFM) training to prevent
postpartum urinary incontinence (UI) is
recommended for continent, pregnant women
having their first baby, and should be offered as a
supervised and intensive strengthening
antepartum PFM training programme (1)
• Little attention has been given to healthcare
provider barriers to implementing these
recommendations
• Midwives and Obstetricians do not routinely
perform continence screening, nor instruct in
PFM training beyond brief verbal or written
instructions.
• Feasibility and acceptance by these providers of
implementing the recommendations are not
known
The table below illustrates each step in the process of change model that was undertaken, and the results at each step.
Phase of change
Participants
•
Orientation
•
Midwives: n=30 from
antenatal clinics and
Barriers:
postnatal wards; n=10 from • Lack of awareness of
‘Family Birth Centre’; n=2
guidelines and
from ‘Know Your Midwife’
recommendations
•
Enablers:
•
program
• interest in the extent of the
Obstetricians: n=20 from
problem and the need to
address it
antenatal and postnatal
clinics
Aim
To trial an
implementation
project to
increase the
uptake of
continence
screening and
PFM exercise
instruction, in
collaboration with
midwives and
obstetricians, in a
public hospital
setting.
Insight
•
Midwives: as above
•
Obstetricians: n=3 from
antenatal and postnatal
clinics
•
Acceptance
Midwives: n=10 from
‘Family Birth Centre’; n=2
from ‘Know Your Midwife’
program
Method
This was a pilot translational research study,
using pre- / post-intervention cohort study design
•
Intervention to be implemented: a new
continence screening and PFM assessment and
exercise instruction, to be delivered at one
antenatal visit
•
•
Midwives: as above
Midwives: as above
Barriers:
• time required
• not part of routine
obstetric care
• ‘cultural’ opposition to
perform PFM examination
• lack of confidence in skillset required
Enablers:
• Acceptance regarding
continence screening
Barriers:
• Lack of content-specific
knowledge and experience
with PFM assessment and
exercise instruction
Enablers:
• role-modelling and
immediate feedback
empowering
Enablers:
• Positive feedback from
pregnant women
• belief in the clinical value of
the intervention enabled
integration into the clinical
care pathway
•
•
•
educational meetings
local opinion leaders
‘brain-storming’ meetings
informal discussions with
unit managers and staff;
collaborative development
of modified protocol of task
•
Tailored education
regarding UI and PFM
exercise instruction
•
•
De-briefing
provision of resources to
assist independent practice
ongoing support if required
•
• Habit
→ 6-month follow-up (post
cessation of data collection):
•
integration and embedding into
routine care
Audit and feedback
a symptom questionnaire (ICIQUI-SF), used as
a screening tool
• Continence screening, pelvic floor risk assessment and compliance with checklists occurred according to the planned
strategy
•
a pelvic floor risk assessment tool (2)
•
continence and PFM management checklists.
• Cultural and context-specific barriers prevented implementation of PFM assessment and exercise instruction based
on per vaginum assessment; a detailed verbal instruction with feedback and practice was developed and
implemented
•
•
Maintenance
•
Tools used in the intervention:
•
•
•
Midwives and obstetricians at three maternity
sites participated in 2010 – 2012
•
•
Change
Barriers / Enablers Behaviour-change
strategies
A barriers-enablers analysis was undertaken
within a ‘process of change’ model(3)
Known behaviour-change strategies were applied
as enablers to facilitate clinician behaviour
change (4)
At each stage, the findings were used to modify
the development of the subsequent step
Qualitative outcomes were reported descriptively
and themes extracted from semi-structured
interviews and informal discussion
References
1. Moore, K., et al., Adult conservative management, in
Incontinence, P. Abrams, et al., Editors. 2013, ICUD-EAU. p.
1101-1227.
2. Pearl, G. and J.H. Herbert, Assessing pelvic floor during
childbearing year. Nurs Times, 2008. 104(18): p. 40.
3. Grol, R., et al., eds. Improving patient care: the
implementation of change in health care. 2nd ed. 2013, Wiley
Blackwell: Oxford
4. Grimshaw, J et al (2012). Knowledge translation of research
findings. Implement Sci, 7, 50.
Conclusion
• Midwives working in public health maternity care units were able to implement a continence screening and
individualised PFM exercise verbal instruction session in their routine care of pregnant women; tailored interventions
were the most successful in this context
• The intervention was modified from the planned intervention due to context-specific barriers, therefore fidelity to
evidence-based guidelines was not achieved
• The clinical effectiveness of the intervention delivered in this study is not known
• Important and novel findings regarding barriers and enablers to PFM assessment and exercise instruction by primary
maternity care providers were revealed. These findings will inform future strategies to work with midwives to ensure
optimal implementation of evidence-based guidelines
Acknowledgements
•
•
Eastern Health Midwives, Pregnant and postnatal women
Helena Frawley received salary support to undertake this project from a ‘Translating Research Into Practice’ Fellowship awarded by the
National Health and Medical Research Council, Australia
• Assistance towards travel costs to present this research provided by La Trobe University Melbourne, and the Continence Foundation of
Australia (Victorian Branch) Physiotherapy Group.
Further information: [email protected]

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