Perceptions and Experiences of Barriers to Pelvic Floor Muscle Training Among Pregnant Women: A Descriptive Phenomenological Study

Abstract

Objective

To provide a nuanced understanding of the multi-factorial barriers to pelvic floor muscle training from the lived experiences of pregnant women and to generate actionable insights that can transform current antenatal care practices to better support maternal adherence.

Methods

This qualitative study was conducted in August 2025. Participants were recruited from a tertiary hospital using purposive sampling based on predefined inclusion and exclusion criteria. The sample size was guided by the principle of data saturation. An interview guide was developed based on the Protection Motivation Theory, and data were collected through semi-structured interviews. The collected data were analyzed using Colaizzi’s seven-step method to identify and refine key themes.

Results

Three themes were identified in this study: mixed information sources, negative appraisal process, and maladaptive patterns. These themes strongly reflect the real-world barriers to pelvic floor muscle training during pregnancy.

Conclusion

This study revealed the real-world barriers and genuine needs of pregnant women regarding pelvic floor muscle training during pregnancy, transcending the limitations of traditional health education. These findings not only highlight the necessity of shifting the focus from postpartum rehabilitation to antenatal prevention but also provide an empirical basis for developing more individualized, woman-centered prenatal care interventions.

Introduction

Surveys indicate that approximately half of pregnant women experience urinary incontinence (UI), with the prevalence gradually increasing as pregnancy progresses.¹ The incidence of fecal incontinence among pregnant women is 35%, and it remains at 25% within one year postpartum.^2,3 Pregnancy and childbirth are high-risk factors for pelvic floor dysfunction (PFD) disorders such as UI, pelvic organ prolapse, and chronic pelvic pain in women,^4,5 exerting long-term negative impacts on women’s health status, well-being, and quality of life.^6,7

Pelvic floor muscle training (PFMT) has been widely recognized as an effective preventive intervention. Studies have shown that pregnant women who undergo PFMT during pregnancy have a 62% lower risk of UI in the third trimester compared to those receiving conventional care, with this preventive effect lasting for 3–6 months postpartum.⁸ Multiple guidelines recommend PFMT can serve as an intervention for the prevention and treatment of PFD in all women.^4,9,10 However, the effectiveness of PFMT in clinical practice depends critically on individuals’ adherence to the training regimen.

Existing studies have identified multiple barriers and facilitators to PFMT adherence across different populations. Commonly reported barriers include insufficient health literacy regarding pelvic floor health,¹¹ physical discomfort and fatigue during pregnancy,¹² lack of time due to childcare and work responsibilities,¹³ and limited access to professional supervision.¹⁴ Conversely, facilitating factors include regular guidance from healthcare providers,¹⁵ spousal and family support,¹⁶ and the use of mobile health applications for self-monitoring.¹⁷ Several qualitative studies have further explored women’s perceptions and experiences of PFMT, revealing that psychological factors such as embarrassment and low self-efficacy also play a critical role.^18,19

However, most of these studies have been conducted in non-pregnant or postpartum populations. Evidence specifically focusing on barriers to PFMT during pregnancy remains limited. Furthermore, recent large-scale nationwide data from China indicate that despite the establishment of over 8400 pelvic floor rehabilitation institutions and nearly 10,000 trained physicians, the care-seeking rate among women with UI remains alarmingly low at approximately 10%, with half of affected women unaware that UI is a treatable condition.²⁰ Importantly, pregnant women were explicitly excluded from this survey, meaning that evidence on barriers to PFMT during pregnancy, particularly from the perspective of pregnant women themselves, remains underexplored. PFMT during pregnancy is essentially a dynamic process in which individuals actively make health behavior choices. Protection Motivation Theory (PMT) provides a suitable framework for understanding these behavioral processes.²¹ The theory posits that when individuals receive health-related risk information, they activate cognitive protection mechanisms, generating protective motivation. This drives their decision-making to implement specific protective actions, forming a three-tiered response mechanism: information source; cognitive mediation; coping pattern.

Therefore, enriching information sources for pregnant women, enhancing their knowledge reserves, and motivating them to adopt protective behaviors are effective approaches to improve their adherence to PFMT. However, existing studies predominantly focus on the quantitative effects of PFMT on clinical indicators and postpartum recovery outcomes, with limited qualitative or mixed-method exploration of the specific barriers to PFMT adherence, particularly from the perspective of pregnant women themselves. Based on this, the present study adopts the framework of PMT to investigate the specific barriers to PFMT adherence among pregnant women, aiming to provide targeted recommendations for clinical intervention and to contribute to improving the long-term quality of life for women.

Materials and Methods

Study Design

This study utilized a descriptive phenomenological approach to explore pregnant women’s lived experiences and perceptions regarding PFMT during pregnancy, and to identify the barriers to adherence to PFMT. The research methods were developed in accordance with the Consolidated Standards for Reporting Qualitative Research to enhance transparency and methodological rigor, particularly in describing the research team background, reflexivity considerations, participant recruitment, interview procedures, and the processes of data collection and analysis.²²

Ethical Considerations

This study was approved by the Medical Research Ethics Committee of the International Peace Maternal and Child Health Hospital (Approval No. GKLW-A-2025-053-01; Date: 6 June 2025) and complied with the Declaration of Helsinki. Written informed consent was obtained from all participants, including consent for the publication of anonymized responses and direct quotes. All data were anonymized using participant codes (P1–P15) and stored securely. Participants were assured of their right to withdraw at any time without consequence to their care.

Participants and Setting

A purposive sampling strategy was adopted to recruit pregnant women receiving prenatal care at a tertiary maternal and child health hospital in Shanghai in August 2025. Purposive sampling enables the selection of information-rich participants who can provide critical insights into the perceptions, experiences, and barriers related to PFMT during pregnancy. During data collection, a maximum variation sampling approach was employed to include pregnant women with diverse backgrounds and characteristics as far as possible, ensuring sample heterogeneity and representativeness, thereby identifying the most valuable “key informants”. The sample size was determined based on the principle of data saturation; data collection ceased when consecutive interviews no longer generated new themes or informational dimensions.²³ A total of 15 pregnant women were ultimately enrolled and coded as P1 to P15. Inclusion criteria were: ① pregnant women; ② aged 20 to 40 years; ③ capable of basic communication and comprehension; ④ volunteered to participate and provided signed informed consent. Exclusion criteria were: ① history of severe pregnancy complications or comorbidities; ② history of cognitive impairment, mental illness, or communication difficulties.

Data Collection

The sampling site for this study was the obstetric outpatient clinic. With the consent of the department head, the researcher conducted interviews at the obstetric outpatient clinic. Prior to the interviews, participants were informed of the study’s purpose, significance, anonymity, and the confidentiality of audio recordings. After signing the informed consent form, participants proceeded to a quiet obstetric education room for the interviews. During the interviews, the researcher recorded the participants’ facial expressions and movements, adjusted the interview outline in real-time based on their responses, and conducted necessary follow-up questions. The researcher maintained a neutral attitude throughout the process, encouraging participants to fully express their feelings. Each interview lasted approximately 30–45 minutes.

This study adopted the PMT as a guiding framework,²⁴ which was used to develop the interview guide to ensure coverage of theoretically relevant dimensions such as information sources, cognitive mediation processes, and coping patterns. However, PMT was not used as a coding framework. Based on this framework, we reviewed relevant literature and consulted obstetric and rehabilitation experts to develop the interview outlines. The initial version of the interview outline was revised after two pilot interviews to form the final version, which is presented as follows: (1) What is your understanding of PFD? Through which channels do you obtain information? (Information sources) (2) Are you familiar with PFMT? How do you perceive PFMT during pregnancy? (Information sources) (3) Do you consider UI to significantly impact your daily life? (Cognitive mediation process) (4) Do you believe consistent training during pregnancy can effectively prevent or alleviate these issues? (Cognitive mediation process) (5) What do you perceive as the most motivating factor for maintaining training adherence? (Coping Pattern) (6) What factors do you identify as most likely to lead to training abandonment or interruption? (Coping Pattern) (7) What assistance would you prefer us to provide to enhance training compliance? (8) What additional aspects of pregnancy-related PFMT do you require supplementation.

The research team was composed of specialists with backgrounds in rehabilitation therapy, complemented by expertise in maternal health and physical activity. Reflexivity and the influence of researcher perspectives were carefully considered at every phase of the study. The investigators examined how their personal professional histories and previous engagement with research on prenatal pelvic floor exercises could potentially influence the framing of the study, the conduct of interviews, and the analysis of data. To strengthen reflexive practice and mitigate the risk of interpretive bias, the team conducted periodic analytical meetings, consistently documented reflexive observations throughout the research process, and frequently cross-checked emerging codes and themes against the original interview transcripts. All analytical interpretations were subject to rigorous collaborative review, ensuring that the findings were authentically rooted in the participants’ narratives and not shaped by the researchers’ presuppositions.

Data Analysis

Data were sequentially coded according to the sequence P1-P15 and imported into NVivo 14.0 software for data management. This study employed Colaizzi’s seven-step method to process and analyze interview data,²⁵ aiming to systematically uncover the genuine experiences, cognitive patterns, and barriers encountered by pregnant women during PFMT. This approach emphasizes in-depth exploration of participants’ lived experiences, enabling the translation of individual subjective perceptions into broadly meaningful findings from a phenomenological perspective. It should be noted that the analysis process was primarily inductive, with themes and subthemes emerging from participants’ descriptions through Colaizzi’s stepwise procedure rather than being predetermined by PMT constructs. Interviews were transcribed verbatim by the researcher within 24 hours, with nonverbal cues such as emotional changes and facial expressions marked accordingly. Transcripts were reviewed repeatedly to ensure accuracy and completeness of the raw data. Two researchers independently analyzed the textual data following Colaizzi’s seven-step framework: (1) carefully reading all interview materials to develop an overall understanding of participants’ descriptions; (2) extracting significant statements aligned with the research questions; (3) formulating meanings from these statements and coding them; (4) aggregating coded viewpoints to identify common concepts or characteristics, thereby forming themes, theme clusters, and categories; (5) integrating themes into detailed descriptions of participants’ experiences; (6) distilling the essential structure of the phenomenon under investigation; (7) returning the analytical results to participants for verification of authenticity.

Purposive sampling was adopted, with sample size dynamically adjusted based on the principle of data saturation. Data collection and analysis proceeded concurrently; saturation was considered achieved when interviews yielded no new themes or informational dimensions, ultimately resulting in a sample of 15 pregnant women. Initial open coding and preliminary theme identification were independently performed by the second author (H.S). To ensure analytical reliability and objectivity, another author (H.Y) independently reviewed all interview transcripts and validated the codes and themes. Discrepancies were discussed until consensus was reached. In addition, the researcher returned the thematic summaries to all participants via telephone, WeChat, and text message to confirm whether the synthesized themes and subthemes resonated with their own experiences. All final themes and subthemes were collectively reviewed and approved by the entire author team, ensuring scientific rigor and credibility of the analytical outcomes. The research workflow is illustrated in Figure 1.

Figure 1.

Flow chart of the study.

Results

Table 1 presents the demographic characteristics of the participants. Based on women’s self-reported perceptions and barriers regarding PFMT during pregnancy, three main themes were identified, along with nine subthemes (Table 2). The three main themes are: mixed information sources, negative reaction process, and maladaptive patterns.

Table 1.

Basic Characteristics of Interviewees (n=15)

Number	Age	Level of Education	Occupation	Weeks of Gestation
P1	30	Undergraduate	Employee	32
P2	35	Postgraduate	Teacher	27
P3	22	High school	Unemployed	19
P4	33	Postgraduate	Civil servant	25
P5	27	Undergraduate	Clerk	29
P6	29	Undergraduate	Insurance agent	30
P7	26	Undergraduate	Unemployed	34
P8	31	Undergraduate	Photographer	23
P9	25	Undergraduate	Clerk	31
P10	28	Undergraduate	Employee	28
P11	25	Junior college	Salesperson	21
P12	34	Postgraduate	Engineer	34
P13	27	Undergraduate	Nurse	26
P14	23	High school	Employee	29
P15	32	Junior college	Employee	32

Table 2.

Main and Subthemes

Main Theme	Subtheme
Mixed information sources	Insufficient formal medical information
	Traditional concepts weaken cognition
	Differences in diversified experience
Negative reaction process	Optimism bias regarding personal risk
	Uncertainty about training outcomes
	Cost-benefit appraisal of training
Maladaptive pattern	Low self-efficacy
	Symptom-driven
	Poor adherence

Analysis of the qualitative data revealed three interrelated themes reflecting pregnant women’s perceptions of barriers to PFMT during pregnancy. These themes depict a multilayered picture of how informational, psychological, and behavioral factors jointly shape women’s engagement with PFMT. Across the themes, participants consistently described navigating fragmented information sources, negotiating internal doubts about personal risk and exercise efficacy, and struggling to sustain motivation in the absence of timely feedback. The findings indicate that barriers to PFMT extend beyond lack of knowledge; they are deeply embedded in how women access information, appraise personal relevance, and experience behavioral maintenance. Within each theme, participants articulated a common dilemma: while acknowledging the importance of pelvic health, they found themselves caught between conflicting advice, wishful thinking about personal susceptibility, and low self-efficacy, ultimately struggling to establish consistent practice. Overall, these themes suggest that PFMT is not an isolated behavior but a process shaped by information chaos, cognitive appraisal, and behavioral adaptive capacity, each of which requires targeted intervention to support sustained engagement among women.

Theme 1: Mixed Information Sources

Participants described navigating a fragmented and contradictory information environment in the absence of systematic professional guidance. Instead, they assembled knowledge from online platforms, family narratives, and others’ experiences, each carrying its own limitations and biases. This fragmented landscape left them uncertain about what was correct, safe, or appropriate, and the act of seeking information became a source of anxiety rather than reassurance.

Insufficient Formal Medical Information

The interviews revealed that respondents generally reported insufficient systematic guidance from formal medical channels, with most relevant knowledge coming from non-authoritative sources or passive mentions.

P2: I want to prevent mistakes by finding videos online to practice, but I am constantly worried about making errors. I am afraid that following online tutorials might backfire.

P15: First, you should definitely check it on your phone. These days, people are all hooked on social media (haha). Some users praise it, others criticize it, and some find it useful. But with so much online information, it’s hard to tell what’s true and what’s not.

Despite turning to online sources, participants did not passively accept this information. They actively sought professional confirmation but found it unavailable. Additionally, the respondents indicated their recognition of the professional information provided by physicians and expressed a desire to receive specialized PFMT guidance.

P10: There is an overwhelming amount of information available online, and I find the content to be highly diverse, with conflicting perspectives. Only what is stated by physicians is considered credible!

P4: Honestly, this movement is pretty tricky. If you don’t master it properly, you won’t be able to generate proper force. You’ll definitely need someone to teach you first before practicing at home. If you can’t even get the movement right, practicing at home is basically pointless. I’d really appreciate some guidance during the initial phase.

Traditional Concepts Weaken Cognition

 Due to the influence of family and social traditional cognition, some pregnant women regard the pelvic floor symptoms during pregnancy and postpartum as normal phenomenon, which misinterprets the correct cognition of the maternal and weakens the motivation of active prevention.

P7: I mentioned this concern to my mom too. Her reaction was, Isn’t it normal for women to leak urine after childbirth?

P5: When I was very young, my aunt told me that women tend to leak urine after childbirth. My grandmother, being older, had to wear a cloth pad under her underwear to prevent her pants from getting wet. My partner also knows that his mother would leak urine after giving birth to his younger sister. However, the older generation didn’t understand these issues, assuming it was normal and something to be endured. They would delay treatment unless it became unbearable, and they wouldn’t even consider seeking medical help. Sigh!

P6: The issue of childbirth has never been truly addressed, and the damage women suffer during childbirth is often irreversible. Aren’t we all silently enduring it?

Differences in Diversified Experience

Compounding these informational challenges was the reliance on experiential knowledge from others. This type of knowledge proved to be an unreliable foundation for decision-making. The interviews revealed that due to the lack of direct experience with PFD, primiparous women’s understanding mostly derives from the experiences of postpartum women.

P3: I haven’t done this training yet. I’ve seen online that it’s called ‘IQ tax’—does it only apply to those who have a vaginal delivery?

P14: Can I start PFMT during pregnancy? No one has ever told me that. I thought it should only be done after childbirth.

However, some postpartum women may downplay such issues when sharing due to the absence of symptoms, feelings of shame, or viewing them as “normal.” This leads to biased indirect experiences received by pregnant women, resulting in a one-sidedly optimistic assessment of the susceptibility and severity of PFD. The consequence was a tendency to dismiss the relevance of PFMT until symptoms appeared. Regret often followed.

P1: At that time, I opted for a cesarean section. Postpartum, my abdomen was still slightly enlarged and had not fully recovered, but I did not experience UI. I felt fine and was aware of the need for postpartum recovery at the maternity center. Since I didn’t notice any symptoms, I ignored it and returned home. However, I subsequently developed UI. I deeply regret not having undergone the recommended postpartum recovery measures at that time!

P5: I am a vaginal delivery. Among those who underwent follow-up examinations and rehabilitation with me, many had cesarean sections yet still developed uterine prolapse and anterior/posterior wall prolapse. In fact, many individuals exhibit initial symptoms during the third trimester, but these remain undiagnosed.

Theme 2: Negative Reaction Process

Many participants, particularly younger women, viewed PFD as something that happened to others rather than a personal concern. When they did consider training, they questioned whether it would work at all. Against this uncertainty, the immediate costs of time and energy loomed large. Together, optimism, doubt, and competing demands formed a self-reinforcing cycle of inaction.

Optimism Bias Regarding Personal Risk

A striking feature of participants’ accounts was their tendency to view PFD as a condition affecting others, not themselves. Interviews revealed that pregnant women often perceive PFD as a mild and temporary issue rather than a profound health concern, showing insufficient attention and underestimating the necessity of pelvic floor muscle rehabilitation training.

P14: My best friend gave birth a year earlier than me and also experienced UI. She mentioned that performing Kegel exercises postpartum would be beneficial. Therefore, I don’t consider this a serious condition, as it seems to be a common issue among many pregnant women. We can address it after delivery, and it should not progress to a severe state.

P9: My mother said that people of their generation went through this way, and no one specifically trained for it. I think it’s just the pressure from the enlarged belly during pregnancy, and it should improve after delivery. Nowadays, I’m too busy with work to worry about this.

Additionally, due to insufficient awareness of PFMT, some young respondents may harbor a sense of complacency and lack a sense of urgency regarding potential risks.

P3: I’m only 22 years old and have always been in good health. I rarely caught colds before pregnancy. These postpartum issues are more likely to concern women who have given birth at an advanced age. We can address them if they arise, but I don’t want to go through the hassle now.

P9: Is this really necessary now? But considering I’m still so young, I’m sure I’ll recover faster than older people, so I don’t think it will happen to me.

Uncertainty About Training Outcomes

Compounding the tendency to minimize personal risk was a pervasive uncertainty about whether PFMT actually worked. The interview revealed that the low awareness of PFMT among postpartum women led to skepticism about its practical effectiveness at home, with concerns about ineffectiveness or side effects, thereby reducing their willingness to engage in PFMT.

P6: I did the training at home myself. I saw online that it’s called’ IQ tax ‘, so I couldn’t bring myself to spend money on repairs.

P14: The training has no effect, or it triggers other hard-to-overcome issues, such as a sharp increase in lower back pain after training, or impacts on the fetus. I am still quite concerned about the side effects.

P11: What makes me most hesitant is that the effectiveness of this practice is imperceptible in the short term. Unlike running which causes breathlessness or stretching which leads to soreness, if one continues for one or two weeks without observing any change in daily life, I begin to doubt whether it is truly effective.

Cost-Benefit Appraisal of Training

Participants’ descriptions revealed an ongoing internal calculus, weighing the uncertain future benefits of PFMT against the immediate costs of time, effort, and energy. Respondents indicated that refusing to participate meant saving time and effort, avoiding immediate fatigue, escaping the burden of learning and performing the training, and maintaining the comfort and convenience of their current lifestyle. These factors played a significant role in their decision-making process.

P5: I have to specifically request leave for pelvic floor rehabilitation at noon every week, return home to care for the child in the evening, and still work during the day. It’s quite troublesome, so I don’t really want to go.

P6: The primary issue is not financial, but rather time constraints. With childcare responsibilities, there’s significantly less time available. Postpartum physical recovery is challenging, compounded by the daily demands of breastfeeding. This leaves me with poor sleep quality!

P15: I usually have to work during the week, but on weekends I just want to lie down. I lack both energy and time. If I go to the hospital additionally, I feel that I don’t have much energy left.

In addition, some respondents have to pay a high price for training, including time, energy, emotional and action costs.

P12: I consulted at the hospital, and the cost of a single course of pelvic floor rehabilitation therapy is not low, with limited reimbursement by medical insurance. This does not even include round-trip transportation and potential parking fees.

Theme 3: Maladaptive Pattern

Even when participants overcame initial barriers and began PFMT, most struggled to maintain the routine. The core difficulty was not simply remembering to practice, but a deeper uncertainty about whether they were doing it correctly. Without professional feedback, they could not tell if their efforts were effective. For many, this uncertainty gradually eroded their motivation. Others only took action when symptoms became noticeable, viewing PFMT as a reactive measure rather than a preventive habit.

Low Self-Efficacy

A consistent theme across participants was a fundamental lack of confidence in their ability to perform PFMT correctly and to sustain the behavior over time. The interviews revealed that some pregnant women generally lack confidence in mastering the training techniques correctly and maintaining these monotonous, repetitive, and uninteresting exercises over the long term, leading to a sense of low self-efficacy in exercise.

P4: Pelvic floor muscle contraction is extremely challenging. I consistently fail to locate the correct anatomical site. During home-based training, I cannot achieve the sensation of contraction and fundamentally lack the ability to perceive the sensation of muscle contraction.

P1: Many people lack the ability to exert force. At that time, I found the lying position particularly uncomfortable and did not know how to apply force. The constant fear of making mistakes during training led to significant psychological pressure, which further reduced my motivation to continue.

Additionally, since PFMT requires long-term adherence and demonstrates slow efficacy, some respondents began to doubt the effectiveness of the exercise, thereby making it difficult to sustain their behavioral motivation.

P7: It’s mainly because I can’t relax. I’ve even started doubting myself from overtraining.

P13: This training is too static, requiring full concentration to perceive a subtle contraction, and the process is lengthy. I attempted it twice, finding it difficult to maintain focus, easily getting distracted or feeling frustrated. Following video or audio guidance for practice would be much better.

P6: I keep wondering, what’s the difference between today’s practice and yesterday’s? When I don’t feel any progress, I lose motivation really easily.

Symptom-Driven

Perhaps the most telling finding across the interviews was that participants typically engaged with PFMT only after symptoms had already appeared, and their willingness to act was directly correlated with symptom severity. This reflected a passive response rather than proactive prevention.

P6: I’m only 29. If I do aerobics for too long, I’ll start leaking a little. Later on, I couldn’t handle it anymore. Every time I ran or jumped, I’d leak. So I just practiced intermittently at home.

P12: I focus on PFMT for two reasons: firstly, to maintain marital harmony, and secondly, based on the experiences of friends and family. Additionally, I experienced sneezing and UI during the late stages of pregnancy, which motivated me to consciously engage in PFMT.

P13: Most of them only seek rehabilitation after symptoms appear, with no consideration for early prevention.

Poor Adherence

The greatest challenge was not starting PFMT, but continuing it. Most participants found that without external supervision or immediate feedback, their efforts were easily interrupted by fatigue, forgetfulness, and competing responsibilities.

P1: I practiced intermittently at home. Due to poor mood, insufficient rest, and lack of persistence, I failed to continue.

P4: I mainly practice videos on the website, but often get lazy and stop. I only pick it up again when I remember every now and then.

P2: I train at home. At first, I worked really hard for a month or two, but then I started slacking off and stopped training altogether.

P15: I know myself too well—I’m just a short-lived enthusiast. When the spark is on, I can train diligently for days, but once the enthusiasm fades, I’m like a deflated balloon. My phone is filled with practice videos, now all covered in dust (palm over forehead, deep thought).

Discussion

Emphasize the Cognitive Level of PFMT Among Pregnant Women and Their Family Members, and Establish an Integrated Hospital-Home PFMT Knowledge System

The findings of this study indicate that pregnant women lack adequate PFMT knowledge obtained through formal medical channels, with insufficient professional medical guidance and learning resources. Moreover, traditional beliefs among family members may impair the correct understanding of PFMT among pregnant women. These results are consistent with existing research,²⁶ suggesting the need to enhance the awareness of PFMT knowledge among pregnant women and their family members. Notably, participants’ educational backgrounds ranged from high school to postgraduate level. During the interviews, participants with lower educational attainment demonstrated more limited knowledge of PFMT and were more likely to rely on non-authoritative sources such as social media and family narratives, whereas those with higher education showed greater awareness and more proactive information-seeking behaviors. This finding is consistent with previous research indicating that educational level is a key determinant of health literacy and self-management capacity.²⁷ Moossdorff-Steinhauser et al demonstrated that some pregnant women hold the erroneous belief that “postpartum UI is a normal outcome” due to traditional beliefs,²⁸ indicating that current pregnancy health education has not systematically incorporated PFMT content, and the leading role of medical institutions in knowledge dissemination has not been fully utilized.²⁹ Our findings on information fragmentation are consistent with those of Terry et al,³⁰ who found that pregnant women with UI often lacked reliable information and felt they had “nothing they could do” about their condition. Therefore, healthcare professionals should emphasize the necessity of PFMT to pregnant women and their families on a household basis, disseminate postpartum rehabilitation information, and provide support for home-based PFMT through the creation of PFMT home health manuals. Additionally, this study found that pregnant women’s information sources are mixed, predominantly derived from non-authoritative channels such as social media and experiences of relatives and friends, resulting in contradictory characteristics of professionalism and empiricism in their knowledge. This leads to negative evaluations and perceptions of PFMT among postpartum women. From the perspective of protective motivation theory, the confusion in knowledge sources not only affects pregnant women’s scientific understanding of PFMT but also weakens their proactive prevention motivation, influencing individual coping and adaptation patterns. The study by Chen L et al also confirms that parturients require guaranteed professional medical supervision and guidance, and expect to derive benefits from PFMT.³¹ Therefore, healthcare professionals should enhance collaboration among medical institutions, community health services, and new media platforms to establish a unified, scientific, and easily understandable PFMT knowledge system. Additionally, family health education should be conducted in the context of cultural circumstances to promote the updating of health concepts.

Enhance Risk Perception of Postpartum Recovery Among Pregnant Women and Track the Implementation Effects and Feedback of PFMT Training

The findings of this study revealed that pregnant women exhibited an attenuated perception of the severity of PFD, along with a pronounced optimism bias and a tendency toward behavioral procrastination. These results are consistent with those of previous studies.^32,33 Analysis reveals that health concerns during pregnancy are predominantly focused on prenatal check-ups, childbirth, and fetal feeding, while postpartum recovery and pelvic floor health issues with unknown risks receive insufficient attention.³⁴ This phenomenon reflects cognitive biases in pregnant women during the “threat assessment” phase, with weakened perception of future health risks and reduced motivation for preventive behaviors. This is closely related to the “severity” and “susceptibility” dimensions in the PMT. It is recommended to incorporate intuitive formats such as case sharing, images, and videos in future health education to enhance pregnant women’s awareness of pelvic floor health issues and their sense of urgency for prevention.³⁵ Furthermore, the study reveals that some pregnant women harbor skepticism toward PFMT, believing self-training cannot ensure proper exercise execution or effectiveness. This skepticism leads them to question whether the training outcomes can justify the time and effort invested, resulting in diminished training motivation.^31,36 Similarly, Zhou et al identified limited professional support and low self-efficacy as key barriers to PFMT adherence among postpartum women in China,¹² reinforcing our observation that the absence of professional feedback is a critical factor undermining sustained engagement. The cognitive mediation process in the PMT explains how information processing, influenced by information sources, shapes cognitive formation and consequently impacts one’s protective motivation.³⁷ The findings of this study reveal that pregnant women’s low evaluation and ineffective perception of PFMT lead to negative responses, which aligns with the mechanism of protective motivation theory. Therefore, healthcare professionals are advised to emphasize preliminary skill training and feedback mechanisms in interventions. This can be achieved through one-on-one guidance, video/audio-based practice, and peer encouragement sharing to enhance the accuracy of movements and training confidence among pregnant women. Additionally, it is recommended to design flexible, low-cost, and easily integrable training programs into daily life to reduce implementation resistance.

Developing Personalized PFMT Exercise Prescriptions to Maintain Training Motivation in Pregnant Women

The results of this study indicate that the majority of pregnant women adopt a symptom-driven passive adaptation pattern, meaning individuals typically initiate training only after experiencing significant discomfort symptoms. Due to factors such as fatigue, forgetfulness, lack of supervision, and feedback, resulting in suboptimal adherence. Other qualitative studies have similarly reported that women often delay PFMT until symptoms become noticeable, reflecting a reactive rather than preventive approach.^38,39 Pregnant women, due to their heavier physiological burden and physical limitations, are prone to fatigue during physical exercise. The individual’s perception of exercise-induced fatigue may lead to resistance, resulting in poor adherence to exercise.⁴⁰ This phenomenon reflects that under the continuous increase in physiological and psychological burdens, there may be a gap between the “intention to act” and “long-term persistence” among pregnant women. It is necessary to encourage and stimulate the individual’s enthusiasm for physical exercise in stages.⁴¹ This also suggests that healthcare professionals should recognize that knowledge dissemination alone may not be sufficient to sustain individual behaviors. A comprehensive behavioral maintenance system incorporating reminders, records, feedback, and social support is essential. By integrating digital tools and family involvement, the sustainability of training can be enhanced. Therefore, healthcare providers should assess the physiological and psychological states of pregnant women at different stages, develop personalized PFMT regimens based on their tolerable physical activity levels, and dynamically track their training progress. Appropriate encouragement should be provided to foster phased achievements, thereby maintaining motivation and improving adherence to training.

Strengths and Limitations

This is the first study in China to employ a descriptive phenomenological approach to explore barriers to PFMT among pregnant women. The sample covered pregnant women with diverse educational backgrounds, occupations, gestational weeks, and ages. The maximum variation sampling strategy ensured diversity in experiential perspectives and enhanced the richness of the findings. The research process rigorously employed independent double coding and member checking. These measures effectively supported methodological rigor and strengthened the credibility and confirmability of the findings.

However, several limitations should be acknowledged. First, the study adopted a single-center design, with all participants recruited from a single tertiary hospital in Shanghai. Although maximum variation sampling was employed, the sample may not fully represent the realities of pregnant women at different levels of healthcare systems or from ethnic minority regions. Second, while thematic saturation was achieved, the study was conducted solely within the Chinese cultural context, and caution is warranted when generalizing the conclusions to other cultural backgrounds. Finally, as with all qualitative research, the interpretation of findings is context-dependent and shaped by the researchers’ analytical lens. Future research with multi-site designs and more diverse populations is needed to enhance the transferability of these findings. Longitudinal or mixed-methods studies could further elucidate how barriers to PFMT evolve across different stages of pregnancy and how educational and behavioral interventions can be optimized to support sustained engagement.

Conclusion

Although the health benefits of exercise during pregnancy have been extensively validated through quantitative studies, there remains a lack of in-depth qualitative understanding regarding pregnant women’s perceptions and experiences with PFMT as a specific behavioral practice. This study, grounded in the protective motivation theory framework, elucidates pregnant women’s subjective cognition of PFMT and identifies three major obstacle types: information source heterogeneity, negative reaction processes, and maladaptive patterns. The findings reveal that PFMT is not merely a persistent exercise regimen but a behaviorally complex process shaped by information environment, risk perception, and self-efficacy. Participants do not simply reject training but rather become disoriented by fragmented information, hesitate due to uncertain outcomes, and discontinue practice when lacking immediate feedback. The content of family education may be missing within current antenatal care practices. Family members, particularly older generations, often hold traditional beliefs that normalize pelvic floor symptoms, yet they are rarely included in health education interventions. Without structured family education, these misconceptions may persist and continue to undermine pregnant women’s motivation and adherence to PFMT.

These insights expand existing knowledge by demonstrating that barriers to PFMT originate not only from knowledge gaps but also from being deeply embedded in women’s experiences of information acquisition, risk assessment, and behavior maintenance. The study underscores that healthcare professionals should transition from traditional information dissemination models to behavioral support interventions. Beyond enhancing awareness and risk consciousness among pregnant women and their families, personalized training programs should be implemented to track outcomes, motivate engagement, and help women establish trust and efficacy in practice. This approach transforms abstract knowledge about necessary training into sustained daily behaviors.

Funding Statement

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.