Pelvic floor muscle training for preventing and treating urinary and faecal incontinence in antenatal and postnatal women

Stephanie J Woodley; Peter Lawrenson; Rhianon Boyle; June D Cody; Siv Mørkved; Ashleigh Kernohan; E Jean C Hay-Smith

doi:10.1002/14651858.CD007471.pub4

. 2020 May 7;2020(5):CD007471. doi: 10.1002/14651858.CD007471.pub4

Pelvic floor muscle training for preventing and treating urinary and faecal incontinence in antenatal and postnatal women

Stephanie J Woodley ^1,^✉, Peter Lawrenson ¹, Rhianon Boyle ², June D Cody ³, Siv Mørkved ⁴, Ashleigh Kernohan ⁵, E Jean C Hay-Smith ⁶

Editor: Cochrane Incontinence Group

PMCID: PMC7203602 PMID: 32378735

Abstract

Background

About one‐third of women have urinary incontinence (UI) and up to one‐tenth have faecal incontinence (FI) after childbirth. Pelvic floor muscle training (PFMT) is commonly recommended during pregnancy and after birth for both preventing and treating incontinence.

This is an update of a Cochrane Review previously published in 2017.

Objectives

To assess the effects of PFMT for preventing or treating urinary and faecal incontinence in pregnant or postnatal women, and summarise the principal findings of relevant economic evaluations.

Search methods

We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In‐Process, MEDLINE Epub Ahead of Print, CINAHL, ClinicalTrials.gov, WHO ICTRP, and handsearched journals and conference proceedings (searched 7 August 2019), and the reference lists of retrieved studies.

Selection criteria

We included randomised or quasi‐randomised trials in which one arm included PFMT. Another arm was no PFMT, usual antenatal or postnatal care, another control condition, or an alternative PFMT intervention.

Populations included women who, at randomisation, were continent (PFMT for prevention) or incontinent (PFMT for treatment), and a mixed population of women who were one or the other (PFMT for prevention or treatment).

Data collection and analysis

We independently assessed trials for inclusion and risk of bias. We extracted data and assessed the quality of evidence using GRADE.

Main results

We included 46 trials involving 10,832 women from 21 countries. Overall, trials were small to moderately‐sized. The PFMT programmes and control conditions varied considerably and were often poorly described. Many trials were at moderate to high risk of bias. Two participants in a study of 43 pregnant women performing PFMT for prevention of incontinence withdrew due to pelvic floor pain. No other trials reported any adverse effects of PFMT.

Prevention of UI: compared with usual care, continent pregnant women performing antenatal PFMT probably have a lower risk of reporting UI in late pregnancy (62% less; risk ratio (RR) 0.38, 95% confidence interval (CI) 0.20 to 0.72; 6 trials, 624 women; moderate‐quality evidence). Antenatal PFMT slightly decreased the risk of UI in the mid‐postnatal period (more than three to six months' postpartum) (29% less; RR 0.71, 95% CI 0.54 to 0.95; 5 trials, 673 women; high‐quality evidence). There was insufficient information available for the late postnatal period (more than six to 12 months) to determine effects at this time point (RR 1.20, 95% CI 0.65 to 2.21; 1 trial, 44 women; low‐quality evidence).

Treatment of UI: compared with usual care, there is no evidence that antenatal PFMT in incontinent women decreases incontinence in late pregnancy (very low‐quality evidence), or in the mid‐(RR 0.94, 95% CI 0.70 to 1.24; 1 trial, 187 women; low‐quality evidence), or late postnatal periods (very low‐quality evidence). Similarly, in postnatal women with persistent UI, there is no evidence that PFMT results in a difference in UI at more than six to 12 months postpartum (RR 0.55, 95% CI 0.29 to 1.07; 3 trials; 696 women; low‐quality evidence).

Mixed prevention and treatment approach to UI: antenatal PFMT in women with or without UI probably decreases UI risk in late pregnancy (22% less; RR 0.78, 95% CI 0.64 to 0.94; 11 trials, 3307 women; moderate‐quality evidence), and may reduce the risk slightly in the mid‐postnatal period (RR 0.73, 95% CI 0.55 to 0.97; 5 trials, 1921 women; low‐quality evidence). There was no evidence that antenatal PFMT reduces the risk of UI at late postpartum (RR 0.85, 95% CI 0.63 to 1.14; 2 trials, 244 women; moderate‐quality evidence). For PFMT started after delivery, there was uncertainty about the effect on UI risk in the late postnatal period (RR 0.88, 95% CI 0.71 to 1.09; 3 trials, 826 women; moderate‐quality evidence).

Faecal incontinence: eight trials reported FI outcomes. In postnatal women with persistent FI, it was uncertain whether PFMT reduced incontinence in the late postnatal period compared to usual care (very low‐quality evidence). In women with or without FI, there was no evidence that antenatal PFMT led to a difference in the prevalence of FI in late pregnancy (RR 0.64, 95% CI 0.36 to 1.14; 3 trials, 910 women; moderate‐quality evidence). Similarly, for postnatal PFMT in a mixed population, there was no evidence that PFMT reduces the risk of FI in the late postnatal period (RR 0.73, 95% CI 0.13 to 4.21; 1 trial, 107 women, low‐quality evidence).

There was little evidence about effects on UI or FI beyond 12 months' postpartum. There were few incontinence‐specific quality of life data and little consensus on how to measure it.

Authors' conclusions

This review provides evidence that early, structured PFMT in early pregnancy for continent women may prevent the onset of UI in late pregnancy and postpartum. Population approaches (recruiting antenatal women regardless of continence status) may have a smaller effect on UI, although the reasons for this are unclear. A population‐based approach for delivering postnatal PFMT is not likely to reduce UI. Uncertainty surrounds the effects of PFMT as a treatment for UI in antenatal and postnatal women, which contrasts with the more established effectiveness in mid‐life women.

It is possible that the effects of PFMT might be greater with targeted rather than mixed prevention and treatment approaches, and in certain groups of women. Hypothetically, for instance, women with a high body mass index (BMI) are at risk of UI. Such uncertainties require further testing and data on duration of effect are also needed. The physiological and behavioural aspects of exercise programmes must be described for both PFMT and control groups, and how much PFMT women in both groups do, to increase understanding of what works and for whom.

Few data exist on FI and it is important that this is included in any future trials. It is essential that future trials use valid measures of incontinence‐specific quality of life for both urinary and faecal incontinence. In addition to further clinical studies, economic evaluations assessing the cost‐effectiveness of different management strategies for FI and UI are needed.

Plain language summary

How effective is pelvic floor muscle training undertaken during pregnancy or after birth for preventing or treating incontinence?

Review question

To assess whether performing pelvic floor muscle training (PFMT) during pregnancy or after birth reduces incontinence.

Background

More than one‐third of women experience unintentional (involuntary) loss of urine (urinary incontinence) in the second and third trimesters of pregnancy, and about one‐third leak urine in the first three months after giving birth. About one‐quarter of women have some involuntary loss of flatus (wind) or faeces (anal incontinence) in late pregnancy, and one‐fifth leak flatus or faeces one year after birth. Managing incontinence after pregnancy is not only important for the individuals themselves but can also have considerable costs to individuals and for healthcare systems.

PFMT is commonly recommended by health professionals during pregnancy and after birth to prevent and treat incontinence. The muscles are strengthened and kept strong with regular PFMT. Muscles are contracted several times in a row, more than once a day, several days a week and continued indefinitely.

How up‐to‐date is this review?

The evidence is current to 7 August 2019.

Study characteristics

We included 46 trials involving 10,832 women from 21 countries. The studies included pregnant women or women who had delivered their baby within the last three months, and who reported leakage of urine, faeces, both urine or faeces, or no leakage. They were allocated randomly to receive PFMT (either to try to prevent incontinence or as a treatment for incontinence) or not, and the effects were compared.

Study funding sources

Twenty‐five studies were publicly funded, one of which received grants from both public and private sources. Three studies received no funding and 18 did not declare their funding sources.

Key results

Pregnant women without urine leakage who did PFMT to prevent leakage: women probably report less urine leakage in late pregnancy and the risk is slightly less at three to six months after childbirth. There was not enough information to determine whether these effects continued beyond the first year after the baby's birth.

Women with urine leakage, pregnant or after birth, who did PFMT as a treatment: there is no evidence that doing PFMT during pregnancy reduced leakage in late pregnancy or in the year following childbirth.

Women with or without urine leakage (mixed group), pregnant or after birth, who did PFMT to either prevent or treat leakage: women who began exercising during pregnancy probably have slightly less leakage in late pregnancy which may continue up to six months after birth. There is no evidence of effect at one year following birth. For women who started exercising after delivery, the effect on leakage one year after birth was uncertain.

Leakage of faeces: only eight studies had evidence about leakage of faeces. One year after delivery, it was uncertain if PFMT helped decrease leakage of faeces in women who started exercising following childbirth. For women with or without leakage of faeces (mixed group) who started PFMT while pregnant, there was no evidence of a difference in faeces leakage in late pregnancy; for those who started PFMT after delivery there was no evidence of a decrease in leakage up to one year after birth.

There was little information about how PFMT may affect leakage‐related quality of life. There were two reports of pelvic floor pain but no other harmful effects of PFMT were noted.

There was no evidence about whether or not PFMT was cost‐effective.

Quality of the evidence

Overall, studies were small and most had design problems, including limited details on how women were randomly allocated into groups and poor reporting of measurements. Some of the problems were expected because it was impossible to blind health professionals or women to whether they were exercising or not. The PFMT differed considerably between studies and was often poorly described. The quality of the evidence was generally low to moderate.

Summary of findings

Summary of findings 1. Antenatal pelvic floor muscle training compared to control for prevention of urinary and faecal incontinence.

Antenatal pelvic floor muscle training compared to control for prevention of urinary and faecal incontinence
Patient or population: pregnant women who were continent when randomised Setting: hospital or outpatient settings in Canada, Italy, Mexico, Norway, Spain, Thailand, Turkey, UK and USA Intervention: antenatal PFMT Comparison: control (no PFMT or usual care)
Outcomes	*Anticipated absolute effects (95% CI)**		Relative effect (95% CI)	No of participants (studies)	Quality of the evidence (GRADE)	Comments
Outcomes	Risk with control	Risk with antenatal PFMT	Relative effect (95% CI)	No of participants (studies)	Quality of the evidence (GRADE)	Comments
Urinary incontinence in late pregnancy	421 per 1000	160 per 1000 (84 to 303)	RR 0.38 (0.20 to 0.72)	624 (6 RCTs)	⊕⊕⊕⊝ MODERATE¹
Urinary incontinence mid‐postnatal period (> 3 to 6 months)	251 per 1000	179 per 1000 (136 to 239)	RR 0.71 (0.54 to 0.95)	673 (5 RCTs)	⊕⊕⊕⊕ HIGH
Urinary incontinence late postnatal period (> 6 to 12 months)	440 per 1000	528 per 1000 (286 to 972)	RR 1.20 (0.65 to 2.21)	44 (1 RCT)	⊕⊝⊝⊝ LOW²
Faecal incontinence in late pregnancy	‐	‐	‐	(0 studies)	‐	Not reported.
Faecal incontinence mid‐postnatal period (> 3 to 6 months)	‐	‐	‐	(0 studies)	‐	Not reported.
Faecal incontinence late postnatal period (> 6 to 12 months)	‐	‐	‐	(0 studies)	‐	Not reported.
Urinary incontinence‐specific quality of life (ICIQ‐SF) Scale from: 0 to 10 (higher worse)	Mean 2.66, SD 4.1	Mean 0.24, SD 1.2	MD 2.42 lower (3.32 lower to 1.52 lower)	152 (1 RCT)	⊕⊕⊕⊝ MODERATE³	Measured in the late postnatal period (> 6 to 12 months). Upper and lower limits of the CI of summary statistic suggest clinical importance in ICIQ‐SF (Nyström 2015).
Faecal incontinence‐specific quality of life	‐	‐	‐	(0 studies)	‐	Not reported.
Adverse events	‐	‐	‐	‐	‐	No events reported.
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; ICIQ‐SF: International Consultation on Incontinence‐Short Form; MD: mean difference; PFMT: pelvic floor muscle training; RCT: randomised controlled trial; RR: risk ratio; SD: standard deviation.
GRADE Working Group grades of evidence High quality: further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: we are very uncertain about the estimate.

Postnatal pelvic floor muscle training compared to control for treatment of urinary and faecal incontinence
Patient or population: postnatal women who were incontinent when randomised Setting: health services or obstetric clinics in Canada, Republic of Korea, New Zealand and UK Intervention: postnatal PFMT Comparison: control (no PFMT or usual care)
Outcomes	*Anticipated absolute effects (95% CI)**		Relative effect (95% CI)	No of participants (studies)	Quality of the evidence (GRADE)	Comments
Outcomes	Risk with control	Risk with postnatal PFMT	Relative effect (95% CI)	No of participants (studies)	Quality of the evidence (GRADE)	Comments
Urinary incontinence late postnatal period (> 6 to 12 months)	724 per 1000	398 per 1000 (210 to 775)	RR 0.55 (0.29 to 1.07)	696 (3 RCTs)	⊕⊕⊝⊝ LOW^1,2
Faecal incontinence late postnatal period (> 6 to 12 months)	137 per 1000	93 per 1000 (33 to 266)	RR 0.68 (0.24 to 1.94)	620 (2 RCTs)	⊕⊝⊝⊝ VERY LOW^3,4,5
Urinary incontinence‐specific quality of life (BFLUTS) 34 items (higher score worse)	Mean 21.22, SD 2.11	Mean 19.56, SD 1.88	MD 1.66 lower (3.51 lower to 0.19 higher)	18 (1 RCT)	⊕⊕⊝⊝ LOW^6,7	Measured at 8 weeks' post‐treatment
Faecal incontinence‐specific quality of life	‐	‐	‐	(0 studies)	‐	Not reported
Adverse events	‐	‐	‐	‐	‐	No events reported.
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). BFLUTS: British Female Lower Urinary Tract Symptoms questionnaire; CI: confidence interval; MD: mean difference; PFMT: pelvic floor muscle training; RCT: randomised controlled trial; RR: risk ratio; SD: standard deviation.
GRADE Working Group grades of evidence High quality: further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: we are very uncertain about the estimate.

Severity of incontinence
Study	Measure of	Outcome measure	PFMT data	Control data	Difference
PFMT versus no PFMT
Stothers 2002	Frequency of leakage	Leakage episodes in 5 days	Mean 3.4, SD not reported, n = 7 at 6 months postpartum	Mean 6.0, SD not reported, n = 8 at 6 months postpartum	Not calculable
	Amount of leakage	Volume of urine loss (g) on stress test with standardised bladder volume	Mean 18, SD not reported, n = ? at 6 months postpartum	Mean 38, SD not reported, n = ? at 6 months postpartum	Not calculable
	Other leakage severity	Not measured
PFMT versus usual care
Gorbea 2004	Frequency of leakage	Less than weekly, weekly or daily UI (not clear if self‐reported or from urinary diary)	4 less than weekly, 2 weekly and none with daily leakage, n = 38 at 6 weeks postpartum	6 less than weekly, 8 weekly and 2 with daily leakage, n = 34 at 6 weeks postpartum	Not calculated as validity/reliability of this measure not known

	Other leakage severity	Grade I, II or III leakage, where I=l oss of urine with coughing or lifting, II = urine leakage when walking, and III = urine leakage when upright	6 grade I, and none with grade II or III leakage, n = 38 at 6 weeks postpartum	10 grade I, 6 grade II, and none grade III leakage, n = 34 at 6 weeks postpartum	Not calculated as validity/reliability of this measure not known
Pelaez 2014	Frequency of leakage	Self‐reported leakage frequency categorised as never, once a week, 2‐3 times a week, once a day, several times a day, all the time (item 3, ICIQ‐SF)	60 never, 3 once a week, n = 63 at 36‐40 weeks gestation	54 never, 18 once a week, 9 2‐3 times a week, 7 once a day, 1 several times a day, n = 89	Author reported P value 0.0001
	Amount of leakage	Self‐reported amount of leakage categorised as none, small, moderate, large (item 4, ICIQ‐SF)	60 none, 3 small, n = 63 at 36‐40 weeks gestation	54 report none, 27 a small, 5 moderate, 3 large, n=89	Author reported P value 0.0001
	Symptom bother	Symptom impact, numbered VAS (0‐10, 10 worse) (item 5, ICIQ‐SF)	Mean 0.10, SD 0.64, n = 63	Mean 0.97, SD 1.8, n = 89	Mean difference ‐0.87 (95% CI ‐1.28 to ‐0.46)
Reilly 2002	Incontinence‐specific quality of life	King's Health Questionnaire	Not reported	Not reported	"No difference between the study groups on any of the 8 scales, and all mean scores were low"

	Other leakage severity	Mild, moderate or severe UI (not clear how categorised)	19 mild, 3 moderate and 1 severe, n = 74 at 3 months postpartum	30 mild, 5 moderate and 1 severe, n = 74 at 3 months post partum	Not calculated as validity/reliability of this measure not known
Sampselle 1998	Frequency of leakage	Not measured
	Amount of leakage	Not measured
	Other leakage severity	Average score from questionnaire re urine leakage with gentle cough, hard cough, sneeze and laugh scored 0 for none, 1 for dampness, 2 for wetness and 3 for soaked	Mean 0.30, standard deviation 0.44, n = 16 at 12 months postpartum	Mean 0.32, standard deviation 0.41, n = 21 at 12 months postpartum	Not calculated as validity/reliability of this measure not known
Sangsawang 2016	Frequency of leakage	Bladder diary, number of leakages per week	Mean 12.4, SD 5.3, n = 9 of 33 at 38 weeks gestation	Mean 23.1, SD 5.7, n = 16 of 30 at 38 weeks gestation	Mean difference ‐8.9 (95% CI ‐13.7 to ‐4.0)
	Amount of leakage	Self‐reported: none, small (drops), moderate (wetting underwear), large (wetting outer clothing)	None 24, small 2, moderate 4, large 3	None 14, small 2, moderate 8, large 6	Author reported P value 0.03
	Other leakage severity	Perceived severity on VAS (0‐10, 10 worse)	Mean 5.0, SD 0.9, n = 9 of 33	Mean 6.3, SD 1.2, n = 16 of 30	Mean difference ‐2.0 (95% CI ‐3.4 to ‐0.6)
PFMT versus unspecified control
Barakat 2011	Frequency of leakage	Self‐reported leakage frequency categorised as never, once a week, 2‐3 times a week, once a day, several times a day, all the time (item 3, ICIQ‐SF)	24 never, 5 once a week, 2 2‐3 times a week, 2 once a day, 1 several times a day, n = 34	22 never, 5 once a week, 1 2‐3 times a week, 2 once a day, 3 several times a day, n = 33	Author reported P value > 0.05
	Amount of leakage	Self‐reported amount of leakage categorised as none, small, moderate, large (item 4, ICIQ‐SF)	Not reported	Not reported
	Other leakage severity

Other self‐reported well‐being measures
Study	Outcome measure	PFMT data	Control data	Difference
PFMT versus usual care
Reilly 2002	SF‐36, general health scale (0‐100, 100 better)	Mean 84.4, SD 13.5, n = 76	Mean 77.2, SD 16.3, n = 72	Mean difference 7.2 (95% CI 2.36 to 12.04)
PFMT versus unspecified control
Barakat 2011	Maternal perception of health status (presume an item derived from SF‐36). Rated as very bad, somewhat bad, good or very good	1 very bad, 14 good, 18 very good, n=34	1 very bad, 5 somewhat bad, 18 good, 9 very good, n=33

Delivery outcome: other
Study	Outcome measure	PFMT data	Control data	Difference
PFMT versus no control
Stothers 2002	Type of delivery			73.3% vaginal, 26.7% caesarean; not reported per group
Stothers 2002
PFMT versus usual care
Gaier 2010	Number with episiotomy	2 of 65	6 of 62	Relative risk 0.32 (95% CI 0.07 to 1.52)
Gaier 2010	Perineal trauma	0.5%	4.2%	Unable to calculate
Reilly 2002	Type of delivery	78 normal vaginal, 13 ventouse, 8 forceps, n = 120	72 normal vaginal, 22 ventouse, 2 forceps, n = 110	Relative risk for normal vaginal delivery 0.99 (95% CI 0.82 to 1.20) Relative risk for assisted vaginal delivery 0.80 (95% CI 0.47 to 1.36)
Reilly 2002
PFMT versus unspecified control
Barakat 2011	Type of delivery	20 normal vaginal, 7 assisted vaginal, n = 34	18 normal vaginal, 5 assisted vaginal, n = 33	Relative risk for normal vaginal delivery 1.08 (95% CI 0.71 to 1.64) Relative risk for assisted vaginal delivery 1.36 (95% CI 0.48 to 3.86)
Barakat 2011	Perineal trauma	22 intact perineum, 6 grade 1 tear, 5 grade 2 tear, 1 grade 3 tear, n = 34	19 intact perineum, 6 grade 1 tear, 8 grade 2 tear, 0 grade 3 tear, n = 33	Relative risk for perineal tear 0.83 (95% CI 0.45 to 1.52)

Pelvic floor muscle function
Study	Outcome measure	PFMT data	Control data	Difference
PFMT versus no PFMT
Gorbea 2004	No or minimal contraction on electromyography. Not clear what type of electromyography or how categorised	14 of 14 at 6 weeks postpartum	10 of 12 at 6 weeks postpartum	Not calculated as validity/reliability of this measure not known
PFMT versus usual care
Gaier 2010	PFM strength (measure not reported)			Significantly higher in the training group at 12 weeks after delivery (P < 0.05)
Reilly 2002	Vaginal squeeze pressure (need unit of measurement), early post‐natal	Mean 11.5, SD 7.8, n = 68	Mean 10.5, SD 5.5, n = 64	Mean difference 1.0 (95% CI ‐1.31 to 3.31)

Self‐reported measures of pelvic floor dysfunction
Study	Outcome measure	PFMT data	Control data	Difference
PFMT versus usual care
Woldringh 2007	IIQ. Data dichotomised into impact versus no impact in four subscales ‐ impact on social relations, impact on emotional health, impact on recreational activities, and impact on physical activities (not clear how this was done)	Impact on social relations 2, on emotional health 11, on recreational activities 10, and on physical activities 4, n = 65 at 12 months postpartum	Impact on social relations 5, on emotional health 14, on recreational activities 10, and on physical activities 7, n = 99 at 12 months postpartum	Not calculated as validity/reliability of this measure not known

Loss of urine under stress test early postnatal period (0‐3 months)
Study	Measure	PFMT	Control	Difference
PFMT versus usual care
Fritel 2015	24‐hour pad test (g)	Mean 0.9, SD 1.6, n = 78 at 2 months postpartum	Mean 1.3, SD 3.3, n = 85 at 2 months postpartum	Mean difference ‐0.40 (95% CI ‐1.19 to 0.39)

Date	Event	Description
18 April 2020	New search has been performed	For this update, published in 2020, the following changes were made. 1. The search was updated to 07 August 2019. 2. Eight new trials were included (Dufour 2019; Hyakutake 2018; Oakley 2016; Sacomori 2019; Sut 2016; Szumilewicz 2019; Torsdatter Markussen 2017; Yang 2017), bringing the total number of included studies to 46.
18 April 2020	New citation required but conclusions have not changed	There has been a change to the byline.
21 December 2017	New search has been performed	For this version, published in Issue 12, 2017, the following changes were made: 1. The search was updated to February 2017 and 17 new trials incorporated (taking the total number of included trials to 38 (involving 9892 women)). In addition, two abstracts which were the primary reference in the last version were replaced by full papers. 2. The GRADE method was implemented throughout the review to assess the quality of evidence; and a 'Summary of findings' table was added. 3. The comparisons and subgroups were substantially amended. 4. There has been a change in authorship.
20 December 2017	New citation required and conclusions have changed	1. The overall findings are similar to the previous version of the review, with the exception of the evidence summary for the effectiveness of postnatal pelvic floor muscle training as a treatment for incontinence; we are less certain about this effect than previously. The findings altered because the way the data were grouped changed to report outcomes according to the time since the birth rather than time since intervention. This decision about timing of outcomes was made, a priori, when choosing outcomes for the 'Summary of findings' table.
7 September 2012	New citation required but conclusions have not changed	Added 6 new studies
7 September 2012	New search has been performed	Added 6 new studies
18 April 2008	Amended	Converted to new review format.
3 March 2008	New citation required and conclusions have changed	Substantive amendment
11 September 2007	New search has been performed	minor update

Line	Search for
1	MeSH DESCRIPTOR fecal incontinence EXPLODE ALL TREES IN NHSEED
2	MeSH DESCRIPTOR anal canal EXPLODE ALL TREES IN NHSEED
3	MeSH DESCRIPTOR encopresis EXPLODE ALL TREES IN NHSEED
4	MeSH DESCRIPTOR defecography EXPLODE ALL TREES IN NHSEED
5	MeSH DESCRIPTOR Fecal Impaction EXPLODE ALL TREES IN NHSEED
6	MeSH DESCRIPTOR Elimination Disorders EXPLODE ALL TREES IN NHSEED
7	MeSH DESCRIPTOR Constipation EXPLODE ALL TREES IN NHSEED
8	MeSH DESCRIPTOR Hirschsprung Disease EXPLODE ALL TREES
9	MeSH DESCRIPTOR megacolon EXPLODE ALL TREES IN NHSEED
10	(defecation NEAR2 disorder) OR (defaecation NEAR2 disorder) IN NHSEED
11	(stool* NEAR25 incontinen* ) OR (stool* NEAR25 continen*) IN NHSEED
12	(fecal* NEAR25 incontinen* ) OR (fecal* NEAR25 continen*) IN NHSEED
13	(faecal* NEAR25 incontinen* ) OR (faecal* NEAR25 continen*) IN NHSEED
14	(faeces NEAR25 incontinen* ) OR (faeces* NEAR25 continen*) IN NHSEED
15	(feces NEAR25 incontinen* ) OR (feces* NEAR25 continen*) IN NHSEED
16	(bowel* NEAR25 incontinen* ) OR (bowel* NEAR25 continen*) IN NHSEED
17	(anal NEAR25 incontinen* ) OR (anal NEAR25 continen*) IN NHSEED
18	(anus NEAR25 incontinen* ) OR (anus NEAR25 continen*) IN NHSEED
19	(encopre*) IN NHSEED
20	(defaecograph) OR (defecograph) IN NHSEED
21	(impact* NEAR2 feces) OR (impact* NEAR2 faeces) IN NHSEED
22	(impact* NEAR2 fecal) OR (impact* NEAR2 faecal) OR (impact* NEAR2 stool) IN NHSEED
23	(pudend* NEAR2 neuropath) OR (pudend NEAR2 latenc*) IN NHSEED
24	(megarectum*) IN NHSEED
25	(leak* NEAR2 fecal) OR (leak* NEAR2 faecal) OR (leak* NEAR2 stool*) IN NHSEED
26	(leak* NEAR2 feces) OR (leak* NEAR2 faeces) OR (leak* NEAR2 motion*) IN NHSEED
27	(soil* NEAR2 feces) OR (soil* NEAR2 faeces) IN NHSEED
28	(soil* NEAR2 fecal) OR (soil* NEAR2 faecal) IN NHSEED
29	(postanal*) IN NHSEED
30	(bowel* NEAR25 manag*) IN NHSEED
31	(elimination disorder*) IN NHSEED
32	(expulsion NEAR2 feces) OR (expulsion NEAR2 faeces) IN NHSEED
33	(expulsion NEAR2 fecal) OR (expulsion NEAR2 faecal) IN NHSEED
34	(expel* NEAR2 fecal) OR (expel* NEAR2 faecal) IN NHSEED
35	(expel* NEAR2 feces) OR (expel* NEAR2 faeces) IN NHSEED
36	(megacolon) IN NHSEED
37	(retent* NEAR2 feces) OR (retent* NEAR2 faeces) IN NHSEED
38	(retent* NEAR2 fecal) OR (retent* NEAR2 faecal) IN NHSEED
39	(retain* NEAR2 fecal) OR (retain* NEAR2 faecal) IN NHSEED
40	(retain* NEAR2 feces) OR (retain* NEAR2 faeces) IN NHSEED
41	(retain* NEAR2 stool) OR (retent NEAR2 stool*) IN NHSEED
42	(expel* NEAR2 stool) OR (expulsion NEAR2 stool*) IN NHSEED
43	(anismus) IN NHSEED
44	(urge* NEAR2 fecal) OR (urge* NEAR2 faecal) OR (urge* NEAR2 stool*) IN NHSEED
45	(frequen* NEAR2 fecal) OR (frequen* NEAR2 faecal) OR (frequen* NEAR2 stool*) IN NHSEED
46	(frequen* NEAR2 feces) OR (frequen* NEAR2 faeces) IN NHSEED
47	(urge* NEAR2 feces) OR (urge* NEAR2 faeces) IN NHSEED
48	(spastic* NEAR2 bowel) OR (spastic NEAR2 colon*) IN NHSEED
49	(sphincter NEAR2 hypotoni*) IN NHSEED
50	(evacuat* NEAR2 feces) OR (evacuat* NEAR2 faeces) OR (evacuat* NEAR2 stool*) IN NHSEED
51	(evacuat* NEAR2 feces) OR (evacuat* NEAR2 faeces) OR (evacuat* NEAR2 stool*) IN NHSEED
52	(evacuat* NEAR2 fecal) OR (evacuat* NEAR2 faecal) OR (evacuat* NEAR2 motion*) IN NHSEED
53	(evacuat* NEAR2 bowel*) IN NHSEED
54	(voluntary NEAR2 placement) OR (abnormal NEAR2 placement) IN NHSEED
55	(dyschezia) OR (obstipation) OR (soiling) IN NHSEED
56	(pelvic NEAR2 dyssynerg*) IN NHSEED
57	(bowel* NEAR2 control*) OR (colonic NEAR2 aganglionosis) OR (colonic NEAR2 inertia) IN NHSEED
58	(seep* NEAR feces) OR (seep* NEAR faeces) IN NHSEED
59	(seep* NEAR fecal) OR (seep* NEAR faecal) IN NHSEED
60	(loss* NEAR2 feces) OR (loss* NEAR2 faeces) IN NHSEED
61	(loss* NEAR2 fecal) OR (loss* NEAR2 faecal) IN NHSEED
62	(loss* NEAR2 stool) OR (loss NEAR2 motion*) IN NHSEED
63	(seep* NEAR2 stool) OR (seep NEAR2 motion*) IN NHSEED
64	(urge* NEAR2 defecat) OR (urge NEAR2 defaecat*) IN NHSEED
65	(frequen* NEAR2 defecat) OR (frequen NEAR2 defaecat*) IN NHSEED
66	(bowel NEAR2 program$) IN NHSEED
67	(neurogen* NEAR2 bowel) OR (neuropath NEAR2 bowel*) IN NHSEED
68	#1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8 OR #9 OR #10 OR #11 OR #12 OR #13 OR #14 OR #15 OR #16 OR #17 OR #18 OR #19 OR #20 OR #21 OR #22 OR #23 OR #24 OR #25 OR #26 OR #27 OR #28 OR #29 OR #30 OR #31 OR #32 OR #33 OR #34 OR #35 OR #36 OR #37 OR #38 OR #39 OR #40 OR #41 OR #42 OR #43 OR #44 OR #45 OR #46 OR #47 OR #48 OR #49 OR #50 OR #51 OR #52 OR #53 OR #54 OR #55 OR #56 OR #57 OR #58 OR #59 OR #60 OR #61 OR #62 OR #63 OR #64 OR #65 OR #66 OR #67
69	(#68) IN NHSEED

1	Economics/
2	exp "costs and cost analysis"/
3	Economics, Dental/
4	exp economics, hospital/
5	Economics, Medical/
6	Economics, Nursing/
7	Economics, Pharmaceutical/
8	(economic$ or cost or costs or costly or costing or price or prices or pricing or pharmacoeconomic$).ti,ab.
9	(expenditure$ not energy).ti,ab.
10	value for money.ti,ab.
11	budget$.ti,ab.
12	or/1‐11
13	((energy or oxygen) adj cost).ti,ab.
14	(metabolic adj cost).ti,ab.
15	((energy or oxygen) adj expenditure).ti,ab.
16	or/13‐15
17	12 not 16
18	letter.pt.
19	editorial.pt.
20	historical article.pt.
21	or/18‐20
22	17 not 21
23	exp animals/ not humans/
24	22 not 23
25	ripstein.tw.
26	delorme.tw.
27	rectal prolapse/
28	graciloplast$.tw.
29	ivalon sponge$.tw.
30	thiersch.tw.
31	mucusectomy.tw.
32	mucosalectomy.tw.
33	mucosaectomy.tw.
34	antegrade continence.tw.
35	mucosectomy.tw.
36	mucosectom$.tw.
37	levatorplast$.tw.
38	procidentia.tw.
39	(mucosa$ adj2 prolapse$).tw.
40	(defecation adj2 disorder$).tw.
41	(defaecation adj2 disorder$).tw.
42	(stool$ adj25 (incontinen$ or continen$)).tw.
43	fecal incontinence/
44	anus/
45	((fecal or faecal) adj25 (incontinen$ or continen$)).tw.
46	anus.tw.
47	anal.tw.
48	neosphincter$.tw.
49	(internal adj2 sphincter$).tw.
50	sphincteroplast$.tw.
51	cutaneous fistula/
52	rectal fistula/
53	rectovaginal fistula/
54	(artificial adj5 sphincter$).tw.
55	encopre$.tw.
56	encopresis/
57	defecography/
58	feces, impacted/
59	defaecograph$.tw.
60	defecograph$.tw.
61	(impact$ adj2 (feces or fecal or faeces or faecal or stool$)).tw.
62	archoptosis.tw.
63	((intus?uscept$ or prolapse$ or invaginat$ or extirpat$ or anomal$ or malform$ or fistula$ or wells or support$ or sling$ or reconstruct$ or defect$ or resect$) adj2 (ano or ani or anorect$ or perianal or rectum or rectal or recti or mucosa$ or preanal or rectoan$ or rectovagina$ or vaginorectal or endorect$ or vagina$)).tw.
64	(abdominoperine$ adj2 (resect$ or extirpat$)).tw.
65	(miles adj2 operation$).tw.
66	proctopex$.tw.
67	rectopex$.tw.
68	(fistula$ adj2 (skin or cutaneous or enterocutaneous or enterovesic$)).tw.
69	protocolectom$.tw.
70	proctocolectom$.tw.
71	rectocolectom$.tw.
72	(pudend$ adj2 (neuropath$ or latenc$)).tw.
73	(lord$ adj2 stretch$).tw.
74	megarectum$.tw.
75	(sphincter$ adj2 (transposit$ or external$)).tw.
76	anoplast$.tw.
77	(resect$ adj2 (soave or perine$)).tw.
78	(ace adj2 (ano or ani or anorect$ or perianal or rectum or rectal or recti or mucosa$ or preanal or rectoan$ or rectovagina$ or vaginorectal or endorect$ or vagina$ or fecal or faecal or feces or faeces or stool$ or motion$)).tw.
79	(leak$ adj2 (fecal or faecal or feces or faeces or stool$ or motion$)).tw.
80	postanal.tw.
81	(polyviol adj2 sponge$).tw.
82	(rectocele or rectocoele or rectoceole).tw.
83	(soil$ adj2 (faeces or feces or fecal or faecal)).tw.
84	(bowel$ adj25 manag$).tw.
85	elimination disorders/
86	elimination disorder$.tw.
87	((feces or faeces or fecal or faecal) adj2 (expulsion or expel$)).tw.
88	megacolon.tw.
89	((faeces or feces or fecal or faecal or stool$) adj2 (retent$ or retain$)).tw.
90	(stool$ adj2 (expulsion or expel$)).tw.
91	anismus.tw.
92	(spastic$ adj2 (bowel$ or colon$)).tw.
93	constipation/
94	((fecal or faecal or feces or faeces or stool$) adj2 (urge$ or frequen$)).tw.
95	(sphincter adj2 hypotoni$).tw.
96	((faeces or feces or fecal or faecal or stool$ or motion$ or bowel$) adj2 evacuat$).tw.
97	(voluntary adj2 placement$).tw.
98	(abnormal adj2 placement$).tw.
99	dyschezia.tw.
100	obstipation.tw.
101	soiling.tw.
102	(bowel$ adj2 control$).tw.
103	hirschsprung disease/
104	(colonic adj2 aganglionosis).tw.
105	megacolon/
106	(colonic adj2 inertia).tw.
107	(pelvic adj2 dyssynerg$).tw.
108	((feces or faeces or fecal or faecal) adj2 (seep$ or leak$ or loss)).tw.
109	((stool$ or motion$) adj2 (seep$ or leak$)).tw.
110	((defecat$ or defaecat$) adj2 (urge$ or frequent$)).tw.
111	(bowel adj2 program$).tw.
112	((neurogen$ or neuropath$) adj2 bowel$).tw.
113	or/25‐112
114	2015.dc. or 2015.dd.
115	2016.dc. or 2016.dd.
116	2017.dc. or 2017.dd.
117	2018.dc. or 2018.dd.
118	201901.dc. or 201901.dd.
119	201902.dc. or 201902.dd.
120	201903.dc. or 201903.dd.
121	201904.dc. or 201904.dd.
122	201905.dc. or 201905.dd.
123	201906.dc. or 201906.dd.
124	201907.dc. or 201907.dd.
125	201908.dc. or 201908.dd.
126	or/114‐125
127	24 and 113 and 126
128	pelvic floor muscle training/
129	exp feedback system/
130	kegel*.tw.
131	(pelvi* adj4 (exercis* or train* or muscle*)).tw.
132	PFMT.tw.
133	perineomet$.tw.
134	(pelvi$ adj5 rehab$).tw.
135	(pelvi$ adj2 floor).tw.
136	(pelvic adj2 diaphragm*).tw.
137	levator ani.tw.
138	exp physiotherapy/
139	exp kinesiotherapy/
140	exp electrostimulation/
141	manipulative medicine/
142	muscle training/ or exp rehabilitation/
143	exp conservative treatment/
144	physiotherap*.tw.
145	physical therap*.tw.
146	kinesiotherap*.tw.
147	electrostimulat*.tw.
148	electrical stimulat*.tw.
149	or/128‐148
150	127 and 149

Study ID	Voluntary pelvic floor muscle contraction confirmed?	PFMT parameters	PFMT supervision	Control comparison	Adherence	Notes
Ahlund 2013 (treatment trial)	Vaginal palpation performed by study midwife: after randomisation and at each of the 3 visits to midwife (PFMT and control groups).	PFMT started with 3 fast contractions, followed by 3 sets of 8‐12 slow velocity, near maximal contractions, 6‐sec hold; 7 days per week for 6 months. Received written instructions on PFMT, but no information provided on PFMT progression.	Visit to the study midwife every 6th week (3 times during study period).	Usual care: written information describing PFM anatomy and PFMT. Received instructions on how to correctly perform PFM contraction (vaginal palpation) from midwife.	Women in the PFMT group were asked at each midwife visit how often they did PFMT; results not reported.	PFMT in lying or sitting positions.
Assis 2015 (prevention trial)	Perineometry (at 1st meeting), but unclear by whom (PFMT group).	5‐10 slow PFM contractions with 6‐sec hold, rest 6 sec between contractions with 3 rapid contractions at the end (as per Mørkved 2003). Daily PFMT in 4 positions, and 1 group (27 women) had 5 supervised sessions with a physiotherapist. Received manual of home PFMT exercises and asked to complete an exercise diary.	Supervised PFMT (27 women): received up to 5 monthly supervised exercise sessions with physiotherapist (22, 26, 30, 34, 38 weeks' gestation). Unsupervised PFMT (27 women): trained to perform PFMT by physiotherapist (1 session).	Did not receive intervention and did not exercise.	Not reported, although it stated that no dropouts occurred throughout the duration of the study due to all women in the PFMT group complying with the exercise protocol.	PFMT in a variety of positions including left side lying, sitting, reclined sitting, sitting with legs crossed, standing. Translation (Portuguese).
Barakat 2011 (prevention trial)	Not reported.	PFMT included in the 7‐ to 8‐min cool‐down period as part of a 35‐ to 45‐min exercise session, 3 days per week for duration of pregnancy (potential mean of 85 sessions in total). No specific details provided about PFMT programme.	Group exercise classes, supervised by a qualified fitness specialist, with the assistance of an obstetrician.	Not reported.	Adherence to PFMT was 90%.	General exercises targeted major muscles of arms and abdomen to promote good posture and prevent low back pain, and in the 3rd trimester strengthen the muscles of labour and PF. 1 session of aerobic dance per week. Accompanied by music.
Bø 2011 (mixed prevention and treatment trial)	Participants did not have individual assessment of correct voluntary PFM contraction (due to pragmatic nature of study). Instructors were trained in how to explain a correct PFM contraction.	PFMT included as part of 15‐min strength training session within a 60‐min group exercise class. PFMT: 3 sets of 8‐12 maximal contractions, 6‐ to 8‐sec hold; strong verbal motivation to perform close to maximum PFM contractions. Women encouraged to participate in at least 2 out of 3 fitness classes per week for 12 weeks. Daily PFMT at home: 3 sets of 8‐12 close to maximum PFM contractions. Also encouraged to be physically active for at least 30 min per day. Received a specific PFMT brochure.	Group exercise classes, 2 or 3 per week for 12 weeks, led by certified aerobic instructors. Instructors were taught by a physiotherapist with > 20 years of experience in assessing, treating and researching women with PF dysfunction.	Usual antenatal care.	Mean adherence to exercise classes was 17.2 out of a possible 24 sessions. 40% (21/52) of women attended at least 80% of sessions.	PFMT integrated into aerobic dance class (accompanied by music): 5‐min warm‐up; 30‐min low‐impact aerobics; 15‐min strength training (including PFMT); 5‐min stretching and relaxation. PFMT in a variety of position including sitting, kneeling and standing. Informed of deep abdominal muscle co‐contraction during maximal PFM contraction.
Chiarelli 2002 (mixed prevention and treatment trial)	Visual inspection of perineum (PFMT group).	Maximum of 6 voluntary PFM contractions per set; 3‐6 sec hold; 3 sets per day; for 8 weeks.	PFMT taught 1‐to‐1 with physiotherapist. 1 (20 min) contact in hospital, and another (30 min) 8 weeks later at home or hospital.	Routine postnatal care; usual postnatal leaflet given; invitation to join postnatal class on ward; no restriction on PFMT if recommended by other health professional.	84% (292/348) of women in the PFMT group and 58% (189/328) of controls were performing PFMT at "adequate" level at 3 months' postpartum.	Women were "asked if they were performing their PF exercises."
Cruz 2014 (treatment trial)	Not reported.	5‐6 biweekly sessions. No specific details provided about PFMT.	Supervised by a physiotherapist.	Similar unsupervised PFMT at home.	Not reported.	Conference abstract.
Dinc 2009 (treatment trial)	Vaginal digital palpation (both PFMT and control groups).	Progressive PFMT programme. Level 1: 3 sets of 10 near maximal contractions; 3‐sec hold, 3‐sec rest; quick contraction, 1‐sec hold, 1‐sec rest; twice daily. Level 2: 3 sets of 10 near maximal contractions; 5‐sec hold, 5‐sec rest; quick contraction, 2‐sec hold, 2‐sec rest; twice daily. Level 3: 3 sets of 15 near maximal contractions; 10‐sec hold, 10‐sec rest; quick contraction, 2‐sec hold, 2‐sec rest; 3 per day.	Trained by a researcher on how to do PFMT in accordance with booklet of PFM exercises.	Usual care: instructed on how to perform a correct PFM contraction, but did not receive training about exercises.	Not reported.	In 2nd stage of study, 68% of women in study group were contracting the proper muscle group. The rest were given more training and reassessed 1 week later.
Dokmeci 2008 (mixed prevention and treatment trial)	Not reported.	Not reported.	Not reported.	Not reported.	Not reported.	Conference abstract.
Dufour 2019 (mixed prevention and treatment trial)	Vaginal digital palpation (both PFMT and control groups), to instruct and ensure correct performance of PFM contraction. Performed by two of the investigators.	Recommended to undertake 3 sets of 10 exercises, 3‐4 times a week, for the duration of the intervention period (12 to 16 weeks). As per Mørkved et al 2014, but specific PFMT exercises not stated. In addition, used the iBall (a mobile health device) in conjunction with PFMT.	Supervised individual PFMT at initial session. “Booster” email at the mid‐point of the intervention reminding of benefits of postpartum PFMT and features of the iBall.	PFMT only, without the use of the iBall device.	Not reported. Implied within the discussion that there was a lack of adherence.	No information on the specific PMFT exercises and positions these were performed in
Dumoulin 2004 (treatment trial)	Not reported.	8‐12 close to maximal voluntary PFM contraction per set; 6‐ to 8‐sec hold each with 3‐4 fast contractions at the end of each contraction; 6‐sec rest between contractions; 3 sets per day; 5 days per week; for 8 weeks. Also taught 'the knack' (voluntary PFM contraction prior to hard cough and maintained through cough until abdominal wall relaxed).	PFMT taught 1‐to‐1 with physiotherapist. Weekly physiotherapy appointments for 8 consecutive weeks.	Same number of physiotherapy contacts for relaxation massage of back and extremities; asked not to do PFMT at home.	Not reported.	In addition to PFMT 15 min of electrical stimulation (biphasic rectangular form, 50 Hz, pulse width 250 msec, duty cycle 6 sec on and 18 sec off for 1st 4 weeks, then 8 sec on and 24 sec off for next 4 weeks, at maximal tolerated current intensity) and 25 min of electromyographic biofeedback per appointment.
Ewings 2005 (mixed prevention and treatment trial)	Not reported.	6 months.	PFMT taught 1‐to‐1 with physiotherapist in hospital. Invitation to attend PFMT class at 2 and 4 months postnatally.	Standard care including verbal promotion of PFMT and leaflet on PFMT.	Of 117 women in the PFMT group, 114 were visited by the physiotherapist in hospital, 21 attended the 2‐month PFMT group, and 5 attended the 4‐month group.	‐
Fritel 2015 (mixed prevention and treatment trial)	Vaginal digital palpation at each session (possibly by physiotherapist, but not stated; PFMT group).	1 session per week (20‐30 min), total of 8 sessions between 6th and 8th month of pregnancy. Also 'the knack' (voluntary PFM contraction prior to increasing intra‐abdominal pressure). Provided with written information on PF anatomy and PFMT, and encouraged to perform daily PFMT at home, 10‐20 contractions.	Individually supervised by a physiotherapist or midwife at each session. In total, 37 different therapists (all trained by the same specialist physiotherapist) were involved in delivering the exercises.	Usual care, including written information on PF anatomy and PFMT (encouraged to perform daily at home, 10‐20 PFM contractions).	69.3% (97/140) of women in the PFMT group completed all planned sessions, and 82.8% (116/140) completed at least 1 session (4‐8, median 8). At the end of pregnancy, women in both groups reported a similar frequency and duration of PFMT (including number of contractions). PFMT was performed daily at home by 4.3% (6/140) of PFMT women and 10.6% (15/142) of controls, at the end of pregnancy.	PFMT performed in standing (5 min) and lying (10 min).
Frost 2014 (mixed prevention and treatment trial)	Not reported.	Standard postpartum discharge instructions plus written and verbal instructions for PFMT.	Not reported.	Standard postpartum discharge instructions.	Not reported.	Conference abstract.
Frumenzio 2012 (mixed prevention and treatment trial)	Not reported.	2 weekly session of Kegel exercises; 8 weeks. Daily home exercises (20 min) and stretching.	Not reported.	Did not receive any PFMT, no other details provided.	Not reported.	Conference abstract.
Gaier 2010 (prevention trial)	Not reported.	12‐week PFMT programme.	PFMT supervised by a physiotherapist and midwife.	Routine care and PFM exercises, customary instruction at intake visit.	Not reported.	Conference abstract.
Glazener 2001 (treatment trial)	Not reported.	8‐10 sessions of fast and slow voluntary PFM contraction per day with aim of 80‐100 per day; for up to 8 months.	PFMT taught 1‐to‐1 with nurse, health visitor or continence advisor. Visited at home at 5, 7 and 9 months' postnatally.	Usual antenatal and postnatal care that may have included advice on PFMT.	78% (218/278) of women in the PFMT group and 48% (118/244) of controls had done some PFMT in the 11th postnatal month. Mean (SD) number of voluntary PFM contractions per day at 12 months' postnatal: PFMT group 20 (29) and controls 5 (15).	Frequency and urgency strategies added if needed at 7 or 9 months postnatally. 52.7% (394/747) of women at 6 years' follow‐up and 70.1% (471/672) of women at 12 years' follow‐up completed a questionnaire. About 50% of women in PFMT and control groups were performing any PFMT at both time points. Daily PFMT was undertaken by 6% (17/263) of PFMT women compared to 12% (29/253) of control women at 6 years; and 7% (15/227) of PFMT group compared to 8% (20/241) of control women at 12 years.
Gorbea 2004 (prevention trial)	Surface electromyography (electrodes either side of anus; PFMT group).	10 voluntary PFM contraction; 8‐sec hold followed by 3 fast, 1‐sec contractions; 6‐sec rest between contractions; for up to 20 weeks. Asked to complete an exercise diary.	PFMT taught 1‐to‐1 with physiotherapist. Clinic appointments (1 hour each) weekly for 8 weeks, then weekly telephone calls.	Requested not to do PFMT during pregnancy or postnatally.	63% attended all 8 physiotherapy appointments, 21% attended 7 appointments.	Electromyographic biofeedback at each appointment.
Hilde 2013 (mixed prevention and treatment trial)	Vaginal digital palpation (PFMT and control groups).	Progressive supervised PFM training programme (as per Mørkved 1997) for 16 weeks. Daily PFMT at home, 3 sets of 8‐12 close to maximal contractions. Customary written information on discharge from postnatal ward. Asked to complete an exercise diary.	Supervised exercise class from 6 weeks' postpartum, led by an experienced physiotherapist, once per week for 16 weeks. Class attendance was documented.	Usual care. Received customary written information on discharge from postnatal ward. At 6 weeks were instructed on how to perform a correct PFM contraction (verified with vaginal digital palpation).	96% (72/75) of women in the PFMT group who completed the trial adhered to 80% of the class and daily home training. In the control group (retrospective questioning), 16.5% reported performing daily PFMT at home ≥ 3 times per week.	4% (7/175) of women were unable to perform a voluntary PFM contraction at baseline. At baseline (6 weeks' postpartum) more women in the control group were performing PFMT ≥ 3 times or more per week.
Hughes 2001 (mixed prevention and treatment trial)	Vaginal digital palpation (PFMT and control groups).	Daily; for up to 11 months.	1 individual session with physiotherapist, and 1 group PFMT session led by physiotherapist at 22‐25 weeks' gestation with maximum of 6 women per group.	Usual antenatal and postnatal care that may have included advice on PFMT (personal communication).	79% (461/586) of women in PFMT group attended group PFMT session (personal communication).	3.5% (16/460) of women who attended group PFMT session could not perform a voluntary PFM contraction after teaching, and 2.8% (13/460) of women could contract but not sustain a contraction (personal communication). Conference abstract.
Hyakutake 2018 (mixed prevention and treatment trial)	Not performed.	PFMT 3 times daily at home starting with 5 contractions (1‐sec hold), progressing to 10 contractions (10‐sec hold), for the rest of their lives. Educated on the benefits of PFMT, how to increase awareness of their perineum and perform PFMT. Provided with a take‐home pack and encouraged to contact a local PF physiotherapist.	A single 2‐hour physician‐led pelvic floor workshop.	Routine prenatal care with their existing maternity care provider (midwife, family physician or obstetrician). Not specifically stated but likely to have received advice on PFMT.	58.34% of women in the PFMT group and 22.9% of controls had done PFMT at least daily.	Possible additions to PFMT such as vaginal cones or weights and the use on a mobile app were suggested.
Kim 2012 (treatment trial)	Perineometer (vaginal probe) used to ensure PFM contraction and assess control of contraction in both PFMT and control groups. Unclear if this was performed every session with the PFMT women.	20 maximal voluntary PFM contractions, 10‐sec hold, 3 times per week; for 8 weeks (as part of a class), and daily at home. Progressed by changing position (prone, sitting and standing). Initial session included information on PFM anatomy and function. Also provided with a booklet which included a training programme and an exercise diary.	Supervised training sessions (1‐hour duration) with a specialist physiotherapist (23 in total, unclear if individual contacts or group classes).	Usual care. Received the same information and demonstration session as PFMT group and instructions on how to correctly perform PFM contraction (perineometer). Unsupervised, daily PFMT for 8 weeks.	Not reported.	PFMT integrated with trunk stabilisation exercises (progressive abdominal strengthening, bridging, and side‐bridge).
Ko 2011 (mixed prevention and treatment trial)	Observation of inward movement of perineum during contraction (PFMT group).	3 repetitions of 8 PFM contractions, 6‐sec hold each, 2‐min rest between repetitions; repeated twice daily at home with additional training in groups once per week for 45 min for 12 weeks. Asked to complete an exercise diary.	Group training sessions (10 women) supervised by a physiotherapist once per week for 12 weeks.	Regular antenatal care and the customary written postpartum instructions that did not include PFMT from the hospital. Not discouraged from performing PFMT on their own.	> 80% attended every training session and 0 were absent more than twice. At 35 gestational weeks, 87% of PFMT group reported practice of PFMT ≥ 75% of the time.	Group training was performed in sitting and standing positions with legs apart to emphasise specific strength training of the PFM and relaxation of other muscles.
Kocaoz 2013 (prevention trial)	Observation of inward movement of perineum or digital vaginal palpation, or both (PFMT group). Vaginal digital palpation used to teach PFM contraction in 23.5% (16/68) of women.	3 sets of 10 maximal voluntary PFM contractions at level 3 (2‐sec hold, 2‐sec rest for strength; 10‐sec hold, 10‐sec rest for endurance); 3 sessions per day during pregnancy and postpartum. Women received education about the anatomy and functions of the PFM and PFMT (unclear from whom) and were asked to complete an exercise diary (including progressions).	Exercise compliance was checked at every hospital visit (9‐10 visits on average, over a minimum of 12 weeks), and pregnant women were called once per month to encourage regular exercise.	Not instructed to do PFMT. Once data collection complete, controls received PFMT and a brochure with the relevant information during the 12th week home visit.	Women asked to record the number of times they did their exercises. No data reported.	Vaginal digital palpation was refused by 52/68 women due to concerns about pregnancy, cultural/religious reasons. Unclear if women progressed through levels 1‐3 or started at level 3, whether they did 3 sets of 10 exercises per day or 3 sets of 10 exercises 3 times per day, or how the sets were divided between endurance and strength training.
Kou 2013 (mixed prevention and treatment trial)	Not reported.	PFM (Kegel) exercises undertaken 2‐3 times per day for 20‐30 min or 150‐200 contractions (3‐sec hold then relax), performed until 12 months' postpartum. Biofeedback used twice per week (no further details available).	Not reported who supervised the programme, or the number and type of contacts with health professional(s).	Usual care: received standard postpartum information.	Not reported.	Translation (Chinese).
Liu 2011 (mixed prevention and treatment trial)	Not reported.	PFMT 2‐3 times per day, 15‐30 min each set (4‐ to 6‐sec hold, 10‐sec relaxation), started after birth and continued for ≥ 10 weeks.	Exercises taught by experienced midwives who also supervised the programme (number and type of contacts/visits unclear).	Usual care: standard postpartum information. Unclear if this included PFMT.	Not reported.	Translation (Chinese). Positions of exercises included supine, sitting or any other position, with legs slightly separated, with instructions to contract anus, vaginal and urinary tract while breathing in, and to relax with expiration.
Meyer 2001 (mixed prevention and treatment trial)	Not reported.	Up to 8 months; no details of PFMT provided. Each clinic session was followed by 20 min of biofeedback and 15 min of electrical stimulation.	12 sessions (6 weeks) with a physiotherapist between 2 and 10 months postnatally.	No intervention. Women received PFMT education after 3rd assessment at 10 months' postpartum.	Not reported.	In addition to PFMT, 20 min of biofeedback and 15 min of electrical stimulation (vaginal electrode, biphasic rectangular waveform, pulse width 200‐400 msec, frequency 50 Hz, intensity 15‐15 mA, contraction time 6 sec, rest time 12 sec) per appointment.
Miquelutti 2013 (mixed prevention and treatment trial)	Instructed on correct contraction, but not verified (due to pragmatic nature of study).	PFMT (maximal rapid and sustained PFM contractions) performed as part of a class (50 min) for a median of 5 (range 2‐10) sessions between 18‐24 weeks' to 36‐38 weeks' gestation. Provided with an exercise guide and asked to do daily PFMT at home (30 rapid, 20 sustained (10‐sec hold) contractions), as well as 30‐min daily aerobic exercise (no specific examples provided). Received standard antenatal education and asked to complete an exercise diary.	Supervised by a trained study physiotherapists on a monthly basis. Either group or individual training sessions, depending on the number of women present.	Usual care: received standard antenatal and postnatal education (on labour, breastfeeding and pain relief) by trained physiotherapy, nursing and medial staff.	Analysis of adherence in intervention group was not possible as women failed to complete or return their exercise diaries.	PFMT performed in standing and sitting position. PFMT integrated into non‐aerobic exercise programme designed to reduce back pain. Included abdominal, stretching and relaxation exercises and exercises designed to promote venous return.
Mørkved 2003 (mixed prevention and treatment)	Vaginal digital palpation and observation of perineum (both PFMT and control groups).	8‐12 near maximal voluntary PFM contractions; 6‐ to 8‐sec hold each, 3‐4 fast contractions at the end of each contraction; 6‐sec rest between contractions; twice daily at home; for ≤ 8 months. Also asked to attend weekly 60‐min PFMT class for 12 weeks. Women asked to complete an exercise diary.	Group training session (10‐15 women), once per week for 12 weeks, supervised by physiotherapists (5 in total).	Usual antenatal and postnatal care that may have included advice on PFMT. Correct PFM contraction verified. Not discouraged from doing PFMT on their own.	19% (28/148) of PFMT women attended less than half the 12 weekly PFMT classes and did not return training diaries.	During exercise class voluntary PFM contraction undertaken in a range of body positions (lying, sitting, kneeling and standing with legs apart). PFMT interspersed with abdominal, back and thigh muscle exercises (accompanied by music). 62% (188/280) of women completed a questionnaire at 6‐year follow‐up, and 45% of women in both the former PFMT and control groups were doing PFMT at least weekly.
Oakley 2016 (mixed prevention and treatment trial)	Vaginal digital palpation (both PFMT and control groups), electromyography, and anorectal manometry used to confirm absence or presence of PFM contraction. Performed by two of the investigators.	Four PFMT sessions (60 min), every 2 weeks, beginning at 6 weeks’ postpartum (i.e. weeks 6, 8 10 and 12) combined with behavioural therapy. PF and core muscle neuromuscular, strength and endurance techniques; PF and rectus diastasis protection techniques. Home exercise component, and women also received routine postnatal care with their primary obstetrician and gynaecologist.	Unclear if a group or 1‐to‐1 session.	Usual care, with included routine postnatal care from their see primary obstetrician and gynaecologist.	Not reported	Independent to the study, 54.0% (combined groups) reported not receiving any instructions on PFMT and/or behavioural therapy; 46.0% received behavioural therapy and 16.0% had received instruction on PFMT from other health professionals. No differences were noted between groups.
Peirce 2013 (mixed prevention and treatment trial)	Contraction assessed with anal biofeedback as part of training session (by obstetrician or specialist nurse); PFMT group.	Sets of 10 PFM contractions (Kegel exercises), 5‐sec hold; 10‐sec rest between contractions; twice daily for 5 min with biofeedback; for 3 months. Standard postpartum education by midwives or physiotherapists, including written information. Women asked to complete an exercise diary.	Biofeedback (electromyographic) training provided at initial session, but no further contact with health professionals.	Usual care: "conventional PFM training," but no details provided. Women asked to complete an exercise diary.	Poor adherence defined as performing < 70% of the intended home exercise sessions. 7/30 women in the PFMT group reported poor adherence.	The portable biofeedback machines were programmed to the electromyography setting with the work period set to 10 contractions (5‐sec duration) with a 10‐sec rest between each contraction. PFMT for treatment of FI.
Pelaez 2014 (prevention trial)	Instructed on correct contraction, but not formally verified. Women were asked to test themselves at home by stopping the flow of urine, vaginal digital palpation or using a mirror to observe the perineum (PFMT group).	PFMT programme, 3 times per week; for ≥ 22 weeks. Started with 1 set of 8 contractions increasing to 100; divided into different sets of slow (6 sec) and fast (5 as fast as possible) contractions. Unclear if this progression related to class or home exercises. Daily PFMT at home, 100 contractions in different sets. Received standard antenatal education about PFM.	Group training sessions (8‐12 women) designed and supervised by a physical activity and sport sciences graduate; 55‐ to 60‐min duration (10 min of PFMT); 70‐78 sessions in total.	Usual care: follow‐up by midwives, standard information about PFMT. Women were not asked not to do PFMT.	All women included in analysis attended ≥ 80% of exercise sessions.	PFMT integrated into supervised exercise programme; 30 min low‐impact aerobics including general strength training, PFMT and cool down (stretching, relaxation or massage); sometimes accompanied by music. PFMT in a variety of positions. Women wore heart rate monitors to control exercise intensity.
Reilly 2002 (prevention trial)	Unclear, but seems likely as physiotherapists gave individualised programmes to those unable to follow exercise regimen due to inability to do voluntary PFM contraction (PFMT group).	8‐12 voluntary PFM contractions; 6‐sec hold each; 2‐min rest between each set of contractions; 3 sets of 8‐12 contractions twice daily; for about 20 weeks (as described by Bø 1995). Also asked to do voluntary PFM contraction with every cough and sneeze, and complete an exercise diary.	About 5 (monthly) contacts with physiotherapist between 20 weeks' gestation and delivery.	Usual antenatal and postnatal care that may have included advice on PFMT. Women appeared to have had same number of clinic visits as the PFMT group, and were asked if doing PFMT at each of these visits.	43% (52/120) of women in the PFMT group did not return an exercise diary; 11% (13/120) completed < 28 days of PFMT; and 46% (55/120) completed ≥ 28 days. When asked postnatally, 28% (33/120) of PFMT women and 34% (37/110) of controls were doing occasional or no PFMT.	If unable to follow PFMT regimen then individualised programme until able to do so. 71% (164/230) of women completed a telephone questionnaire at 8‐year follow‐up, and 68.4% of women were doing PFMT, with 38% stating they were doing PFMT twice or more per week.
Sacomori 2019 (mixed prevention and treatment trial)	Assessed PFM muscles using visual inspection (PFMT group).	PFMT at home, 10 sets of up to 10‐sec holds (contraction starts lightly and intensifies until a maximal contraction is reached) [Strength and endurance]. Five (1 sec) fast and strong contractions [Strength]. Also taught to perform the “knack”, before and during a sneeze or cough. PFMT performed twice daily at home. Received verbal and written educational information about PF anatomy, physiology, PF dysfunction and PFMT.	One 1‐to‐1 session with a “pelvic floor specialist” who “was certified to participate in the study only after demonstrating total competence and understanding of the execution of PFM assessment and PFMT”.	No PFMT. Women did not receive any kind of intervention or PFMT as this is usual clinical practice in Brazil.	55 (85.1%) women reported overall adherence to PFMT. 22 (32.3%) performed exercises 1‐2 times per week and 33 (49.3%) did so 3‐7 times per week. 33 (49.3%) performed both strength and endurance training, 14 (20.9%) only strength training and 10 (14.9%) focused only on endurance training. 21 (31.3%) performed PFMT for 3 months postpartum, others for around 2 months 38 (39.2%) multiparous and 23 (31.9%) primiparous women adhered to PFMT	Researchers made up to ten attempts to contact participants by phone for follow‐up at 3 months’ postpartum.
Sampselle 1998 (mixed prevention and treatment trial)	Yes, but unclear how or by whom (PFMT group).	PFMT tailored to individual ability. 30 maximal or near maximal voluntary PFM contraction per day; for ≤ 17 months.	Not reported.	Usual antenatal and postnatal care; no systematic PFMT programme.	At 35 weeks' gestation, 85% of women in the PFMT group reported to be doing PFMT 75% of the time. At 1 year, PFMT adherence reported to vary between 62% and 90%.	‐
Sangsawang 2016 (treatment trial)	Assessed by ability to stop or slow the flow of urine for 1‐2 sec (PFMT group).	20 sets of PFM exercises, twice daily, at least 5 days per week, for 6 weeks. 1 set of PFM exercises was 1 slow contraction (10‐sec hold), followed by 10 fast contractions; no progression in number of contractions per set. Also received a handbook with information on stress UI, PFM function, instructions on PFMT and a urinary diary.	Supervised group sessions (4‐5 women) with a midwife; 45 min; once every 2 weeks for 6 weeks (3 sessions in total).	Usual care: from health professionals, obstetricians or midwives. Did not receive information about UI and received no training support about performing correct PFM exercises.	No women were excluded for failing to perform the PFMT for < 28 (of approximately 42) days.	PFMT performed in various positions including lying down, sitting and standing.
Skelly 2004 (treatment trial)	Not reported.	Not reported.	"One to one teaching about pelvic floor exercises."	"Conventional care (hand‐out information about pelvic muscle exercises)."	Not reported.	Conference abstract.
Sleep 1987 (mixed prevention and treatment trial)	Not reported.	As for controls with additional section in leaflet recommending a specific exercise each week that integrated voluntary PFM contraction with usual activities of daily living; up to 3 months. Asked to complete a daily exercise diary for 4 weeks.	1‐to‐1 session with midwife co‐ordinator each postnatal day in hospital.	Usual antenatal and postnatal care including PFMT leaflet; might include PFMT at antenatal class or postnatal class on ward (or both); instructed to do voluntary PFM contraction as often as remembered and mid‐stream urine stop.	At 10 days postnatally, 78% of PFMT group and 68% of controls were doing some PFMT; with 58% of PFMT group and 42% of controls doing some PFMT at 3 months.	‐
Stafne 2012 (mixed prevention and treatment trial)	Vaginal digital palpation (PFMT group).	8‐12 near maximal voluntary PFM contractions; 6‐ to 8‐sec hold each with 3 fast contractions at the end of each contraction. Asked to perform PFM exercises as part of a 45‐min home programme at least twice per week or a weekly 60‐min exercise class (or both). Received written information including brochure with an evidence‐based PFMT programme, and asked to complete an exercise diary.	Group training sessions (8‐15 women) supervised by physiotherapist, 60 min, once per week for 12 weeks	Usual care: received customary information from midwife or GP. Also given a detailed information brochure including evidence‐based PFMT programme. Women were not discouraged from exercising.	Adherence to the general exercise protocol (exercising ≥ 3 days per week, moderate to high intensity) was 55% (217/397) in the PFMT group and 10% (36/365) in the control group. 67% of the PFMT group performed PFMT ≥ 3 times per week compared to 40% in the control group	PFMT integrated into standardised exercise programme: 30‐ to 35‐min low‐impact aerobics; 20‐ to 25‐min strengthening exercises (including PFMT, 3 sets of 10 reps); 5‐ to 10‐min stretching and relaxation. PFMT performed in a variety of positions, with legs apart to emphasise specific strengthening of the PFM.
Stothers 2002 (prevention trial)	Not reported.	12 contractions, 3 times daily.	Seen twice monthly throughout pregnancy, and every 3 months postnatally for 1 year.	"Other (placebo) including no pelvic floor exercises."	Not reported.	Conference abstract.

Other self‐reported well‐being measures
Study	Outcome measure	PFMT data	Control data	Difference
PFMT versus usual care
Fritel 2015	EuroQoL‐5D (0‐100, 100 better)	Mean 76.4, SD 20.4, n = 111 at end of pregnancy; Mean 82.8, SD 18.2, n = 105 at 0‐3 months postpartum; Mean 86.8, SD 13.1, n = 94 at > 6‐12 months postpartum	Mean 77.9, SD 16.3, n = 112 at end of pregnancy; Mean 80.4, SD 17.0, n = 107 at 0‐3 months postpartum; Mean 82.9, SD 14.8, n = 97 at > 6‐12 months postpartum	Late pregnancy, mean difference ‐1.50 (95% CI ‐6.35 to 3.35); 0‐3 months postpartum, mean difference 2.40 (95% CI ‐2.34 to 7.14); > 6‐12 months postpartum, mean difference 3.90 (95% CI ‐0.06 to 7.86)
Miquelutti 2013	State Trait Anxiety Inventory (STAI) (20‐80; 50‐64 high, 65‐80 very high)	Trait anxiety 18 of 85 State anxiety 16 of 85	Trait anxiety 20 of 76 State anxiety 14 of 76	Trait anxiety, relative risk 0.80 (95% CI 0.46 to 1.40) State anxiety, relative risk 1.02 (95% CI 0.53 to 1.95)
Stafne 2012	Psychological General Well‐being Index (PGWBI) (0‐110, 110 better)	Total score at end of pregnancy: Mean 79.5 (95% CI 78.5 to 80.6), n=389	Total score at end of pregnancy: Mean 78.5 (95% CI 77.5 to 79.6), n = 361	Mean difference 0.71 (95% CI ‐0.60 to 2.01)

Pelvic floor muscle function
Study	Outcome measure	PFMT data	Control data	Difference
PFMT versus no PFMT
Dumoulin 2004	Maximal strength (Newtons, pelvic floor dynamometer, Dumoulin et al 2003)	A: Median change 0.7, range ‐0.2 to 2.3, n = 23 after 9 weeks PFMT B: Median change 0.5, range ‐0.6 to 2.5, n = 20 after 9 weeks PFMT	Median change ‐0.5, range ‐1.7 to 1.0, n = 19 after 9 weeks PFMT	Not calculable


PFMT versus usual care
Ahlund 2013	Maximal voluntary contraction (cm mercury, perineometer)	Median 26.0, estimated range 7 to 49, n = 40 at 9 months postpartum	Median 18.2, estimated range 6 to 54, n = 42 at 9 months postpartum	Not calculable
	Endurance (secs, continuous contraction until pressure=0)	Median 26.7, estimated range 1 to 65, n = 40 at 9 months postpartum	Median 23.4, estimated range 3 to 60, n = 42 at 9 months postpartum	Not calculable
	Oxford scale (0‐5; 0=no activity, 5=strong)	Median 4, estimated range 2 to 5, n = 40 at 9 months postpartum	Median 3, estimated range 2 to 5, n = 42 at 9 months postpartum	Not calculable
Kim 2012	Maximal squeeze pressure (mm mercury, perineometer)	Mean 25.78, SD 10.74, n = 9 at between 8‐14 weeks postpartum	Mean 8.11, SD 2.57, n = 9 at between 8‐14 weeks postpartum	Mean difference 17.67 (95% CI 10.46 to 24.88)
	Holding time (sec, perineometer)	Mean 14.34, SD 3.08, n = 9 at between 8‐14 weeks postpartum	Mean 8.89, SD 2.10, n = 9 at between 8‐14 weeks postpartum	Mean difference 5.45 (95% CI 3.01 to 7.89)

Wilson 1998	Maximal vaginal squeeze pressure (cm water)	Mean 13.6, 95% CI 9.8 to 17.4, n = 19 at 12 months postpartum	Mean 13.1, 95% CI 11.3 to 14.9, n = 79 at 12 months postpartum	Mean difference 0.50 (95%CI ‐3.46 to 4.46)

Self‐reported measures of pelvic floor dysfunction
Study	Measure of	Outcome measure	PFMT data	Control data	Difference
PFMT plus versus PFMT
Dufour 2019	Distress associated with UI	UDI‐6 (0‐100, 100 worse) at mid‐postnatal period	Mean 7.3, SD 5.9, n = 13	Mean 4.6, SD 6.0, n = 10	Mean difference 2.7 (95% CI ‐8.90 to 2.89)



Yang 2017	Pelvic organ prolapse	POP‐Q, stage 1 or 2	31 of 129 at 3 months postpartum	32 of 60 at 3 months postpartum	Relative risk 0.45 (95% CI 0.31 to 0.66)



PFMT versus no PFMT
Hilde 2013	Pelvic organ prolapse	ICIQ‐Vag, bulging inside vagina (yes, no)	8 of 87 at 6 months postpartum	22 of 88 at 6 months postpartum	Mean difference 0.37 (95% CI 0.17 to 0.78)
	Pelvic organ prolapse	ICIQ‐Vag, bulging outside vagina (yes, no)	5 of 87 at 6 months postpartum	6 of 88 at 6 months postpartum	Mean difference 0.84 (95% CI 0.27 to 2.66)
	Pelvic organ prolapse	POP‐Q, stage 1 or 2	61 of 87 at 6 months postpartum	64 of 88 at 6 months postpartum	Mean difference 0.88 (95% CI 0.46 to 1.70)

Meyer 2001	Sexual function	Reduced vaginal response at 10 months postpartum	5 of 51	13 of 56	Relative risk 0.42 (95% CI 0.16 to 1.10)



Sacomori 2019	UI specific quality of life	ICIQ‐SF (0‐21, 21 worse)	Median 0, IQR 0, n = 67 at 3 months postpartum	Median 0, IQR 0, n = 65 at 3 months postpartum	Not calculable



PFMT versus usual care
Oakley 2016

	Distress associated with UI	UDI‐6 (0‐100, 100 worse) at early‐postnatal period	Median 0.0, IQR 12.5, n = 27 at 12 weeks postpartum	Median 11.11, IQR 37.50, n = 23 at 12 weeks postpartum	Not calculable
	FI specific quality of life	FIQOL (29 items, 4 domain scores, each item scored 1‐5, higher better)	Lifestyle: Median 4.0, IQR 0.3, n = 27 at 12 weeks postpartum Coping/behaviour: Median 3.89, IQR 0.5, n = 27 at 12 weeks postpartum Depression/self perception: Median 3.89, IQR 0.5, n = 27 at 12 weeks postpartum Embarrassment: Median 4.0, IQR 0.0, n = 27 at 12 weeks postpartum	Lifestyle: Median 4.0, IQR 0.1, n = 23 at 12 weeks postpartum Coping/behaviour: Median 3.89, IQR 0.4, n = 23 at 12 weeks postpartum Depression/self perception: Median 3.89, IQR 0.3, n = 23 at 12 weeks postpartum Embarrassment: Median 4.0, IQR 0.1, n = 23 at 12 weeks postpartum	Not calculable
Peirce 2013	FI specific quality of life	FIQOL (29 items, 4 domain scores, each item scored 1‐5, higher better)	Lifestyle: no data; coping/behaviour: no data, depression/self perception: no data, embarrassment: no data, n = 30 at 3 months' postpartum	Lifestyle: no data, coping/behaviour: no data, depression/self perception: no data, embarrassment: no data, n = 90 at 3 months' postpartum	Lifestyle P = 0.29, coping/behaviour P = 0.27, depression/self perception P = 089, embarrassment P = 0.51



Sleep 1987
	Sexual function	Attempted sexual intercourse within 3 months of delivery	714 of 819	681 of 792	Relative risk 1.01 (95% CI 0.98 to 1.05)
	Sexual function	Dyspareunia at 3 months postpartum	167 of 819	154 of 792	Relative risk 1.05 (95% CI 0.86 to 1.28)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1.1 Urinary incontinence in late pregnancy	6	624	Risk Ratio (M‐H, Random, 95% CI)	0.38 [0.20, 0.72]
1.1.1 PFMT versus no PFMT	2	174	Risk Ratio (M‐H, Random, 95% CI)	0.14 [0.01, 2.04]
1.1.2 PFMT versus usual care	4	450	Risk Ratio (M‐H, Random, 95% CI)	0.44 [0.22, 0.91]
1.2 Urinary incontinence early postnatal period (0‐3 months)	5	439	Risk Ratio (M‐H, Random, 95% CI)	0.38 [0.17, 0.83]
1.2.1 PFMT versus no PFMT	2	174	Risk Ratio (M‐H, Random, 95% CI)	0.27 [0.11, 0.67]
1.2.2 PFMT versus usual care	2	198	Risk Ratio (M‐H, Random, 95% CI)	0.30 [0.04, 2.31]
1.2.3 PFMT versus unspecified control	1	67	Risk Ratio (M‐H, Random, 95% CI)	0.88 [0.43, 1.79]
1.3 Urinary incontinence mid‐postnatal period (> 3‐6 months)	5	673	Risk Ratio (M‐H, Fixed, 95% CI)	0.71 [0.54, 0.95]
1.3.1 PFMT versus no PFMT	1	86	Risk Ratio (M‐H, Fixed, 95% CI)	0.88 [0.35, 2.20]
1.3.2 PFMT versus usual care	4	587	Risk Ratio (M‐H, Fixed, 95% CI)	0.70 [0.52, 0.94]
1.4 Urinary incontinence late postnatal period (> 6‐12 months)	1	44	Risk Ratio (M‐H, Fixed, 95% CI)	1.20 [0.65, 2.21]
1.4.1 PFMT versus usual care	1	44	Risk Ratio (M‐H, Fixed, 95% CI)	1.20 [0.65, 2.21]
1.5 Urinary incontinence long term (> 5 years)	2		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only
1.5.1 PFMT versus usual care	2	352	Risk Ratio (M‐H, Fixed, 95% CI)	1.07 [0.77, 1.48]
1.6 Urinary incontinence‐specific quality of life	1	152	Mean Difference (IV, Fixed, 95% CI)	‐2.42 [‐3.32, ‐1.52]
1.6.1 PFMT versus usual care	1	152	Mean Difference (IV, Fixed, 95% CI)	‐2.42 [‐3.32, ‐1.52]
1.7 Severity of incontinence	7		Other data	No numeric data
1.7.1 PFMT versus no PFMT	1		Other data	No numeric data
1.7.2 PFMT versus usual care	5		Other data	No numeric data
1.7.3 PFMT versus unspecified control	1		Other data	No numeric data
1.8 Loss of urine under stress test late pregnancy	1	102	Risk Ratio (M‐H, Random, 95% CI)	0.36 [0.19, 0.70]
1.8.1 PFMT versus no PFMT	1	102	Risk Ratio (M‐H, Random, 95% CI)	0.36 [0.19, 0.70]
1.9 Loss of urine under stress test early postnatal period (0‐3 months)	3	322	Risk Ratio (M‐H, Fixed, 95% CI)	0.35 [0.17, 0.75]
1.9.1 PFMT versus no PFMT	2	174	Risk Ratio (M‐H, Fixed, 95% CI)	0.09 [0.02, 0.47]
1.9.2 PFMT versus usual care	1	148	Risk Ratio (M‐H, Fixed, 95% CI)	0.88 [0.33, 2.29]
1.10 Other self‐reported well‐being measures	2		Other data	No numeric data
1.10.2 PFMT versus usual care	1		Other data	No numeric data
1.10.3 PFMT versus unspecified control	1		Other data	No numeric data
1.11 Delivery outcome: caesarean section	3	373	Risk Ratio (M‐H, Fixed, 95% CI)	1.28 [0.89, 1.85]
1.11.1 PFMT versus no PFMT	1	76	Risk Ratio (M‐H, Fixed, 95% CI)	1.83 [1.07, 3.15]
1.11.2 PFMT versus usual care	1	230	Risk Ratio (M‐H, Fixed, 95% CI)	1.24 [0.66, 2.36]
1.11.3 PFMT versus unspecified control	1	67	Risk Ratio (M‐H, Fixed, 95% CI)	0.68 [0.29, 1.57]
1.12 Delivery outcome: other	4		Other data	No numeric data
1.12.1 PFMT versus no control	1		Other data	No numeric data
1.12.2 PFMT versus usual care	2		Other data	No numeric data
1.12.3 PFMT versus unspecified control	1		Other data	No numeric data
1.13 Pelvic floor muscle function	3		Other data	No numeric data
1.13.1 PFMT versus no PFMT	1		Other data	No numeric data
1.13.2 PFMT versus usual care	2		Other data	No numeric data

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
2.1 Urinary incontinence late pregnancy	3	345	Risk Ratio (M‐H, Random, 95% CI)	0.70 [0.44, 1.13]
2.1.1 PFMT vs usual care	3	345	Risk Ratio (M‐H, Random, 95% CI)	0.70 [0.44, 1.13]
2.2 Urinary incontinence early postnatal period (0‐3 months)	2	292	Risk Ratio (M‐H, Random, 95% CI)	0.75 [0.37, 1.53]
2.2.1 PFMT versus usual care	2	292	Risk Ratio (M‐H, Random, 95% CI)	0.75 [0.37, 1.53]
2.3 Urinary incontinence mid‐postnatal period (> 3‐6 months)	1	187	Risk Ratio (M‐H, Fixed, 95% CI)	0.94 [0.70, 1.24]
2.3.1 PFMT versus usual care	1	187	Risk Ratio (M‐H, Fixed, 95% CI)	0.94 [0.70, 1.24]
2.4 Urinary incontinence late postnatal period (> 6‐12 months)	2	869	Risk Ratio (M‐H, Random, 95% CI)	0.50 [0.13, 1.93]
2.4.1 PFMT versus usual care	2	869	Risk Ratio (M‐H, Random, 95% CI)	0.50 [0.13, 1.93]
2.5 Urinary incontinence‐specific quality of life	1	41	Mean Difference (IV, Fixed, 95% CI)	‐3.50 [‐6.13, ‐0.87]
2.5.1 PFMT versus usual care	1	41	Mean Difference (IV, Fixed, 95% CI)	‐3.50 [‐6.13, ‐0.87]
2.6 Severity of incontinence	1		Other data	No numeric data
2.6.1 PFMT versus usual care	1		Other data	No numeric data
2.7 Self‐reported measures of pelvic floor dysfunction	1		Other data	No numeric data
2.7.1 PFMT versus usual care	1		Other data	No numeric data
2.8 Pelvic floor muscle function	1		Other data	No numeric data
2.8.1 PFMT versus usual care	1		Other data	No numeric data

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
3.1 Urinary incontinence late pregnancy	11	3307	Risk Ratio (M‐H, Random, 95% CI)	0.78 [0.64, 0.94]
3.1.1 PFMT versus no PFMT	3	484	Risk Ratio (M‐H, Random, 95% CI)	0.43 [0.08, 2.37]
3.1.2 PFMT versus usual care	8	2823	Risk Ratio (M‐H, Random, 95% CI)	0.84 [0.73, 0.96]
3.2 Urinary incontinence early postnatal period (0‐3 months)	6	806	Risk Ratio (M‐H, Fixed, 95% CI)	0.83 [0.71, 0.99]
3.2.1 PFMT versus no PFMT	1	300	Risk Ratio (M‐H, Fixed, 95% CI)	0.72 [0.51, 1.02]
3.2.2 PFMT versus usual care	4	413	Risk Ratio (M‐H, Fixed, 95% CI)	0.95 [0.74, 1.24]
3.2.3 PFMT versus unspecified control	1	93	Risk Ratio (M‐H, Fixed, 95% CI)	0.77 [0.61, 0.97]
3.3 Urinary incontinence mid‐postnatal period (> 3‐6 months)	5	1921	Risk Ratio (M‐H, Random, 95% CI)	0.73 [0.55, 0.97]
3.3.1 PFMT versus no PFMT	1	300	Risk Ratio (M‐H, Random, 95% CI)	0.60 [0.38, 0.92]
3.3.2 PFMT versus usual care	3	1528	Risk Ratio (M‐H, Random, 95% CI)	0.85 [0.65, 1.11]
3.3.3 PFMT versus unspecified control	1	93	Risk Ratio (M‐H, Random, 95% CI)	0.42 [0.20, 0.86]
3.4 Urinary incontinence late postnatal period (> 6‐12 months)	2	244	Risk Ratio (M‐H, Fixed, 95% CI)	0.85 [0.63, 1.14]
3.4.1 PFMT versus usual care	2	244	Risk Ratio (M‐H, Fixed, 95% CI)	0.85 [0.63, 1.14]
3.5 Urinary incontinence long term (> 5 years)	1	188	Risk Ratio (M‐H, Fixed, 95% CI)	1.38 [0.77, 2.45]
3.5.1 PFMT versus usual care	1	188	Risk Ratio (M‐H, Fixed, 95% CI)	1.38 [0.77, 2.45]
3.6 Faecal incontinence late pregnancy	3	910	Risk Ratio (M‐H, Fixed, 95% CI)	0.64 [0.36, 1.14]
3.6.1 PFMT versus usual care	3	910	Risk Ratio (M‐H, Fixed, 95% CI)	0.64 [0.36, 1.14]
3.7 Faecal incontinence early postnatal period (0‐3 months)	2	130	Risk Ratio (M‐H, Fixed, 95% CI)	0.76 [0.34, 1.70]
3.7.1 PFMT versus usual care	2	130	Risk Ratio (M‐H, Fixed, 95% CI)	0.76 [0.34, 1.70]
3.8 Urinary incontinence‐specific quality of life late pregnancy	3	584	Std. Mean Difference (IV, Random, 95% CI)	‐0.02 [‐0.35, 0.31]
3.8.1 PFMT versus no PFMT	2	360	Std. Mean Difference (IV, Random, 95% CI)	0.06 [‐0.66, 0.78]
3.8.2 PFMT versus usual care	1	224	Std. Mean Difference (IV, Random, 95% CI)	‐0.05 [‐0.31, 0.21]
3.9 Urinary incontinence‐specific quality of life early postnatal period (0‐3 months)	4	645	Std. Mean Difference (IV, Random, 95% CI)	‐0.24 [‐0.67, 0.20]
3.9.1 PFMT versus no PFMT	2	360	Std. Mean Difference (IV, Random, 95% CI)	‐0.25 [‐1.28, 0.77]
3.9.2 PFMT versus usual care	2	285	Std. Mean Difference (IV, Random, 95% CI)	‐0.18 [‐0.41, 0.05]
3.10 Urinary incontinence‐specific quality of life mid postnatal period (> 3‐6 months)	1	300	Mean Difference (IV, Random, 95% CI)	‐0.79 [‐1.27, ‐0.31]
3.10.1 PFMT versus no PFMT	1	300	Mean Difference (IV, Random, 95% CI)	‐0.79 [‐1.27, ‐0.31]
3.11 Urinary incontinence‐specific quality of life late postnatal period (> 6‐12 months)	1	190	Mean Difference (IV, Fixed, 95% CI)	‐0.20 [‐1.20, 0.80]
3.11.1 PFMT versus usual care	1	190	Mean Difference (IV, Fixed, 95% CI)	‐0.20 [‐1.20, 0.80]
3.12 Faecal incontinence‐specific quality of life early postnatal period (0‐3 months)	1	74	Mean Difference (IV, Random, 95% CI)	‐2.60 [‐7.84, 2.64]
3.12.1 PFMT versus usual care	1	74	Mean Difference (IV, Random, 95% CI)	‐2.60 [‐7.84, 2.64]
3.13 Severity of incontinence	4		Other data	No numeric data
3.13.3 PFMT versus no PFMT	1		Other data	No numeric data
3.13.4 PFMT versus usual care	3		Other data	No numeric data
3.14 Loss of urine under stress test early postnatal period (0‐3 months)	1		Other data	No numeric data
3.14.2 PFMT versus usual care	1		Other data	No numeric data
3.15 Self‐reported measures of pelvic floor dysfunction	8		Other data	No numeric data
3.15.3 PFMT versus no PFMT	3		Other data	No numeric data
3.15.4 PFMT versus usual care	4		Other data	No numeric data
3.15.5 PFMT versus unspecified control	1		Other data	No numeric data
3.16 Other self‐reported well‐being measures	3		Other data	No numeric data
3.16.4 PFMT versus usual care	3		Other data	No numeric data
3.17 Delivery outcome: caesarean section	8	2030	Risk Ratio (M‐H, Fixed, 95% CI)	0.91 [0.77, 1.08]
3.17.1 PFMT versus no PFMT	2	360	Risk Ratio (M‐H, Fixed, 95% CI)	0.95 [0.71, 1.28]
3.17.2 PFMT versus usual care	6	1670	Risk Ratio (M‐H, Fixed, 95% CI)	0.89 [0.73, 1.10]
3.18 Delivery outcome: other	6		Other data	No numeric data
3.18.3 PFMT versus no PFMT	1		Other data	No numeric data
3.18.4 PFMT versus usual care	5		Other data	No numeric data
3.19 Pelvic floor muscle function	7		Other data	No numeric data
3.19.1 PFMT versus no PFMT	3		Other data	No numeric data
3.19.2 PFMT versus usual care	3		Other data	No numeric data
3.19.3 PFMT versus unspecified control	1		Other data	No numeric data

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
4.1 Urinary incontinence late postnatal period (> 6‐12 months)	3	696	Risk Ratio (M‐H, Random, 95% CI)	0.55 [0.29, 1.07]
4.1.1 PFMT versus no PFMT	1	62	Risk Ratio (M‐H, Random, 95% CI)	0.29 [0.18, 0.47]
4.1.2 PFMT versus usual care	2	634	Risk Ratio (M‐H, Random, 95% CI)	0.80 [0.61, 1.06]
4.2 Urinary incontinence long term (> 5‐10 years)	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only
4.2.1 PFMT versus usual care	1	516	Risk Ratio (M‐H, Fixed, 95% CI)	0.96 [0.88, 1.05]
4.3 Urinary incontinence very long term (> 10 years)	1	471	Risk Ratio (M‐H, Fixed, 95% CI)	1.03 [0.94, 1.12]
4.3.1 PFMT versus usual care	1	471	Risk Ratio (M‐H, Fixed, 95% CI)	1.03 [0.94, 1.12]
4.4 Faecal incontinence late postnatal period (> 6‐12 months)	2	620	Risk Ratio (M‐H, Random, 95% CI)	0.68 [0.24, 1.94]
4.4.1 PFMT versus usual care	2	620	Risk Ratio (M‐H, Random, 95% CI)	0.68 [0.24, 1.94]
4.5 Faecal incontinence long term (> 5‐10 years)	1	509	Risk Ratio (M‐H, Fixed, 95% CI)	0.95 [0.60, 1.50]
4.5.1 PFMT versus usual care	1	509	Risk Ratio (M‐H, Fixed, 95% CI)	0.95 [0.60, 1.50]
4.6 Faecal incontinence very long term (> 10 years)	1	468	Odds Ratio (M‐H, Fixed, 95% CI)	1.36 [0.84, 2.22]
4.6.1 PFMT versus usual care	1	468	Odds Ratio (M‐H, Fixed, 95% CI)	1.36 [0.84, 2.22]
4.7 Urinary incontinence‐specific quality of life	1	18	Mean Difference (IV, Fixed, 95% CI)	‐1.66 [‐3.51, 0.19]
4.7.1 PFMT versus usual care	1	18	Mean Difference (IV, Fixed, 95% CI)	‐1.66 [‐3.51, 0.19]
4.8 Severity of incontinence	5		Other data	No numeric data
4.8.1 PFMT versus no PFMT	1		Other data	No numeric data
4.8.2 PFMT versus usual care	4		Other data	No numeric data
4.9 Self‐reported measures of pelvic floor dysfunction	1		Other data	No numeric data
4.10 Other self‐reported well‐being measures	1		Other data	No numeric data
4.11 Pelvic floor muscle function	4		Other data	No numeric data
4.11.1 PFMT versus no PFMT	1		Other data	No numeric data
4.11.2 PFMT versus usual care	3		Other data	No numeric data

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
5.1 Urinary incontinence early postnatal period (0‐3 months)	2		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only
5.1.1 PFMT versus no PFMT	2	321	Risk Ratio (M‐H, Fixed, 95% CI)	0.54 [0.44, 0.66]
5.2 Urinary incontinence mid‐postnatal period (> 3‐6 months)	5	2800	Risk Ratio (M‐H, Random, 95% CI)	0.95 [0.75, 1.19]
5.2.1 PFMT versus usual care	5	2800	Risk Ratio (M‐H, Random, 95% CI)	0.95 [0.75, 1.19]
5.3 Urinary incontinence late postnatal period (> 6‐12 months)	3	826	Risk Ratio (M‐H, Fixed, 95% CI)	0.88 [0.71, 1.09]
5.3.1 PFMT versus no PFMT	1	107	Risk Ratio (M‐H, Fixed, 95% CI)	0.82 [0.31, 2.21]
5.3.2 PFMT versus usual care	2	719	Risk Ratio (M‐H, Fixed, 95% CI)	0.88 [0.71, 1.10]
5.4 Faecal incontinence early postnatal period (0‐3 months)	1	1609	Risk Ratio (M‐H, Fixed, 95% CI)	0.93 [0.51, 1.67]
5.4.1 PFMT versus usual care	1	1609	Risk Ratio (M‐H, Fixed, 95% CI)	0.93 [0.51, 1.67]
5.5 Faecal incontinence late postnatal period (> 6‐12 months)	1	107	Risk Ratio (M‐H, Fixed, 95% CI)	0.73 [0.13, 4.21]
5.5.1 PFMT versus no PFMT	1	107	Risk Ratio (M‐H, Fixed, 95% CI)	0.73 [0.13, 4.21]
5.6 Urinary incontinence‐specific quality of life	1	23	Mean Difference (IV, Fixed, 95% CI)	0.50 [‐5.53, 6.53]
5.6.1 PFMT plus versus PFMT	1	23	Mean Difference (IV, Fixed, 95% CI)	0.50 [‐5.53, 6.53]
5.7 Severity of incontinence	7		Other data	No numeric data
5.7.1 PFMT versus no PFMT	2		Other data	No numeric data
5.7.2 PFMT versus usual care	5		Other data	No numeric data
5.8 Loss of urine under stress test postpartum	3	512	Risk Ratio (M‐H, Fixed, 95% CI)	0.83 [0.60, 1.13]
5.8.1 PFMT versus no PFMT	1	189	Risk Ratio (M‐H, Fixed, 95% CI)	0.53 [0.28, 0.98]
5.8.2 PFMT versus usual care	2	323	Risk Ratio (M‐H, Fixed, 95% CI)	0.97 [0.67, 1.40]
5.9 Self‐reported measures of pelvic floor dysfunction	8		Other data	No numeric data
5.9.1 PFMT plus versus PFMT	2		Other data	No numeric data
5.9.2 PFMT versus no PFMT	3		Other data	No numeric data
5.9.3 PFMT versus usual care	3		Other data	No numeric data
5.10 Other self‐reported well‐being measures	2		Other data	No numeric data
5.10.1 PFMT versus usual care	2		Other data	No numeric data
5.11 Pelvic floor muscle function	8		Other data	No numeric data
5.11.1 PFMT plus versus PFMT	1		Other data	No numeric data
5.11.2 PFMT versus no PFMT	1		Other data	No numeric data
5.11.3 PFMT versus usual care	6		Other data	No numeric data

*Study characteristics*
Methods	Design: 2‐arm (parallel groups) RCT.
Participants	Number of participants: 98 postpartum primiparous women, 10 to 16 weeks after delivery. Setting: 4 different private antenatal clinics in the urban area of Stockholm, Sweden. Age: mean (SD), years: PFMT 33 (3.4); control 33 (3.9). Parity: primiparous. Delivery: not reported. BMI: mean (SD): PFMT 23 (3.5); control 23 (3.2). Incontinence at recruitment: 100% (as outlined in inclusion criteria). Inclusion: normal term singleton vaginal delivery, stress UI. Exclusion: neurological bladder dysfunction or tumours in the genital area.
Interventions	PFMT (n = 49): supervised home exercise programme (written instructions), daily exercises, for 6 months. Instructions from study midwife on how to perform correct PFM contraction, confirmed by vaginal palpation. Participants visited the midwife every 6 weeks (total of 3 times during the study period) for follow‐up of progress and to encourage PFMT. Control (n = 49): usual postnatal care. Instructions from study midwife on how to perform correct PFM contraction, confirmed by vaginal palpation. Received customary written postpartum instructions explaining PFM anatomy and recommendations around PFMT.
Outcomes	Measured at 3 (baseline) and 9 months' postpartum. Primary endpoint: 9 months' postpartum. UI at 9 months' postpartum: not reported. Primary outcome: PFM strength (maximal voluntary contraction) measured using perineometry (mmHg). Secondary outcomes: PFM endurance (sec), PFM strength using Oxford grading scale, self‐reported UI using ICIQ FLUTS‐short form questionnaire, general health form with 19 questions related to delivery, motherhood and current health status.
Notes	Losses to follow‐up at 9 months: PFMT 9/49; control 7/49 (total 16.3%). Funding: not specifically funded. Conflicts of interest: none declared
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Not reported.
Allocation concealment (selection bias)	Low risk	"Allocated randomly through sequentially numbered and sealed envelopes."
Blinding of participants and personnel (performance bias) All outcomes	High risk	Not feasible.
Blinding of outcome assessment (detection bias) All outcomes	High risk	Unblinded reporting of UI self‐report outcomes because they were participant‐reported. "A limitation of this study was that the midwife was not blinded during the project."
Incomplete outcome data (attrition bias) All outcomes	Unclear risk	16.3% dropout; similar between groups; different reasons; no mention of imputation for missing data.
Selective reporting (reporting bias)	High risk	Did not report data relating to adherence to the exercise programme and how women prioritised the exercises.
Other bias	Unclear risk	Study did not contribute any data to the forest plots.

*Study characteristics*
Methods	Design: 3‐arm (parallel groups) RCT.
Participants	Number of participants: 87 primiparous women. Setting: Basic Health Units, Assis (Sao Paulo), Brazil. Age: mean (SD), years: PFMT (1) 26.3 (4.6); PFMT (2) 27.1 (5.4); control 26.6 (5.7). Parity: primiparous. Delivery: not measured as primary endpoint was during pregnancy. Weight: mean (kg), at 18 weeks: PFMT (1) 70.7 (18.4); PFMT (2) 65.5 (13.4); control 63.2 (9.6). Incontinence at recruitment: PFMT (1) 58.6%; PFMT (2) 51.7%; control 48.3%. Inclusion: primiparous; ≤ 18 weeks' pregnant; aged 20‐35 years; and not presenting with diabetes, hypertension or UI prior to pregnancy. Exclusion: women who did not log their exercises, or gave up the collection of data.
Interventions	PFMT 1 (n = 29): supervised home exercise programme, daily exercise at home, with up to 5 monthly visits from a physiotherapist (at 22, 26, 30, 34, and 38 weeks' gestation). Women received a manual of home exercises and were instructed on how to use it, as well as exercise and leakage diaries. PFMT 2 (n = 29): unsupervised PFMT, daily exercise at home as per the supervised group. Women received a manual of home exercises and were instructed on how to use it, as well as exercise and leakage diaries. Control (n = 29): no manual or supervision, and no exercise and leakage diaries. Unclear if instructed not to perform PFMT. Note: groups PFMT 1 and PFMT 2 were combined as the intervention group for comparison with controls.
Outcomes	Measured at baseline (up to 18 weeks' gestation), and at 22, 26, 30 and 34 weeks' gestation. Primary endpoint: 38 weeks' gestation. Primary outcome: self‐reported UI. Secondary outcome: PFM strength measured using perineometry (mmHg).
Notes	No dropouts. Funding: not reported. Conflicts of interest: not reported.
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Computer‐generated random number sequence.
Allocation concealment (selection bias)	Unclear risk	Prepared by third party, sealed envelopes.
Blinding of participants and personnel (performance bias) All outcomes	High risk	Not feasible.
Blinding of outcome assessment (detection bias) All outcomes	High risk	Unblinded reporting of UI self‐report outcomes because they were participant‐reported. Unclear if perineometry blinded.
Incomplete outcome data (attrition bias) All outcomes	Low risk	No dropouts.
Selective reporting (reporting bias)	High risk	Did not report UI severity (defined in methods as small, moderate and intense).
Other bias	Low risk	No other sources of bias noted.

*Study characteristics*
Methods	Design: 2‐arm, parallel, unblinded, RCT (with unclear randomisation methods).
Participants	Number of participants: 80 sedentary pregnant, primiparous and multiparous women. Setting: obstetric department, Hospital de Fuenlabrada, Madrid, Spain. Age: mean (SD), years: PFMT 31 (3); control 30 (3). Parity: primiparous PFMT 65%; control 30%. Delivery: PFMT: 56.7% vaginal, 20.6% instrumental, 20.6% caesarean; control: 54.5% vaginal, 15.2% instrumental, 30.3% caesarean. BMI: mean (SD): PFMT 23.9 (3); control 24.8 (4). Incontinence at recruitment: none. Inclusion: healthy, uncomplicated and singleton pregnancies. Exclusion: women who did not plan to give birth in the same obstetric department, did not receive medical follow‐up evaluations throughout their entire pregnancy, and who had experienced incontinence before pregnancy. Also, any type of absolute obstetric contraindication to aerobic exercise during pregnancy (such as haemodynamically significant heart disease, restrictive lung disease, incompetent cervix, multiple gestation, risk of premature labour, pre‐eclampsia/pregnancy‐induced hypertension, thrombophlebitis, recent pulmonary embolism (last 5 years), acquired infectious disease, retarded intrauterine development, serious blood disease, absence of antenatal control, or a combination).
Interventions	PFMT (n = 40): approximately 7‐8 min of PFMT as part of a 35‐45 min multimodal physical conditioning programme. All sessions supervised by a qualified fitness specialist (working with groups of 10‐12 participants) with the assistance of an obstetrician, 3 days per week from the beginning of pregnancy (weeks 6‐9) to the end of the 3rd trimester (weeks 38‐39). Thus, an approximate 85 training sessions were originally planned for each participant in the event of no preterm delivery. No details of PFMT programme given and this appeared to have been introduced only in the 3rd trimester. Control (n = 40): unspecified, no information provided.
Outcomes	Measured "after delivery." Primary endpoint: not reported, but questionnaires given to participants "after delivery." Primary outcome: not reported. Other outcomes: self‐reported UI (ICIQ‐SF), maternal perception of health (SF‐36, King's Health Questionnaire), pregnancy outcomes.
Notes	Losses to follow‐up "after delivery": PFMT 6/40; control 7/40 (total 16.3%). Adverse events: no exercise‐induced injuries were experienced. Funding: no outside funding received. Conflicts of Interest: not reported.
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	"Use of a random number table."
Allocation concealment (selection bias)	Unclear risk	Not reported.
Blinding of participants and personnel (performance bias) All outcomes	High risk	Not feasible.
Blinding of outcome assessment (detection bias) All outcomes	High risk	Unblinded reporting of UI self‐report outcomes because they were participant‐reported.
Incomplete outcome data (attrition bias) All outcomes	Unclear risk	16.3% dropout; similar between groups (numbers and reasons); no mention of imputation for missing data.
Selective reporting (reporting bias)	Low risk	Outcome measures described in methods were reported in results.
Other bias	Low risk	No other sources of bias noted.

*Study characteristics*
Methods	Design: 2‐arm (parallel groups) RCT, nested into a cohort of 500 pregnant women.
Participants	Number of participants: 79 pregnant women. Setting: health service in Guarulhos (Sao Paulo), Brazil. Age: not reported. Parity: not reported. Delivery: not reported. BMI: not reported. Incontinence at recruitment: 100% (refer to inclusion criteria). Inclusion: UI in the current pregnancy (at 21‐26 weeks), single pregnancy, aged > 18 years, education to at least elementary school level and ability to understand the Portuguese language. Exclusion: previous urogenital surgery or diseases that may interfere with PFM strength (pelvic organ prolapse, neurological disorders, diabetes, pelvic or spinal injury).
Interventions	PFMT (n = 43): 5 or 6 biweekly sessions of PFMT supervised by a physiotherapist. Control (n = 36): instructed to perform a similar unsupervised PFMT at home.
Outcomes	Measured before beginning (2nd trimester of pregnancy) and after finishing (3rd trimester of pregnancy) the PFMT. Primary endpoint: not reported but presume after finishing PFMT (3rd trimester). Primary outcomes: self‐reported UI, urinary severity (ICIQ‐SF). Secondary outcome: PFM strength (perineometry).
Notes	Losses to follow‐up: PFMT 23/43; control 15/36 (total 48.1%). Funding: Sao Paulo Research Foundation (FAPESP) and National Council for Scientific Technological Development (CNPq). Conflicts of interest: not reported.
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	"Computer‐generated sequence."
Allocation concealment (selection bias)	Low risk	"Opaque, sequentially numbered, sealed envelopes."
Blinding of participants and personnel (performance bias) All outcomes	High risk	Not feasible.
Blinding of outcome assessment (detection bias) All outcomes	High risk	Unblinded reporting of UI self‐report outcomes because they were participant‐reported. Blinded PFM assessment.
Incomplete outcome data (attrition bias) All outcomes	High risk	48.1% dropout; unclear if there was a differential between groups; no reasons; no mention of imputation for missing data.
Selective reporting (reporting bias)	Low risk	Outcome measures described in methods were reported in results.
Other bias	Unclear risk	This was reported in a conference abstract with limited information about study methods. Initial estimated sample size was 74 (37 per group). The abstract states that 42 women were recruited but Table 1 in the abstract reports data for only 41 (20 in PFMT and 21 in control group) participants. This may have affected the power of the study.

*Study characteristics*
Methods	Design: 2‐arm (parallel groups) RCT (with unclear randomisation methods and no mention of blinding).
Participants	Number of participants: 128 pregnant women. Setting: Queen's Medical Center, Honolulu, Hawaii. Age: not reported. Parity: primiparous. Delivery: vaginal, not reported per group. BMI: not reported. Incontinence prior to current pregnancy: not reported. Inclusion: primiparous, vaginal delivery, ≥ 18 years of age. Exclusion: not reported.
Interventions	PFMT (n = 64): standard postpartum discharge instructions plus written and verbal instructions for PFMT. No details of PFMT programme given. Control (n = 64): standard postpartum discharge instructions which likely included education about PFMT.
Outcomes	Measured at baseline (presumably antenatal) and 6‐8 weeks' postpartum (by telephone). Primary endpoint: presumably 6‐8 weeks' postpartum. Primary outcome: not reported. Outcomes: UI, urogenital distress, quality of life.
Notes	Losses to follow‐up at 6‐8 weeks' postpartum: PFMT 33/64; control 23/64 (total 44%). Adverse events: no adverse events related to treatment were reported in the PFMT group. Funding: not reported. Conflicts of interest: not reported.
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	"Randomized clinical trial."
Allocation concealment (selection bias)	Unclear risk	"Randomized clinical trial."
Blinding of participants and personnel (performance bias) All outcomes	High risk	Not feasible.
Blinding of outcome assessment (detection bias) All outcomes	High risk	Unblinded reporting of UI self‐report outcomes because they were participant‐reported.
Incomplete outcome data (attrition bias) All outcomes	High risk	40% dropout; differential loss with nearly one‐third more from control group; no reasons; no mention of imputation for missing data.
Selective reporting (reporting bias)	High risk	Difficult to assess. No data reported, so failed to present a key outcome that would have been expected to have been reported. Some data also not reported (currently being analysed); "The remaining data which was collected is in the process of being analysed and may or may not have a significant impact on results."
Other bias	Unclear risk	Reported in a conference abstract with limited information about study methods and did not contribute data to the forest plots.

PERMALINK

Pelvic floor muscle training for preventing and treating urinary and faecal incontinence in antenatal and postnatal women

Stephanie J Woodley

Peter Lawrenson

Rhianon Boyle

June D Cody

Siv Mørkved

Ashleigh Kernohan

E Jean C Hay-Smith

Abstract

Background

Objectives

Search methods

Selection criteria

Data collection and analysis

Main results

Authors' conclusions

Plain language summary

Summary of findings

Summary of findings 1. Antenatal pelvic floor muscle training compared to control for prevention of urinary and faecal incontinence.

Summary of findings 2. Antenatal pelvic floor muscle training compared to control for treatment of urinary and faecal incontinence.

Summary of findings 3. Antenatal pelvic floor muscle training compared to control for mixed prevention and treatment of urinary and faecal incontinence.

Summary of findings 4. Postnatal pelvic floor muscle training compared to control for treatment of urinary and faecal incontinence.

Summary of findings 5. Postnatal pelvic floor muscle training compared to control for mixed prevention and treatment of urinary and faecal incontinence.

Background

Description of the condition

Urinary incontinence (UI)

Faecal incontinence (FI)

Description of the intervention

Prevention of urinary and faecal incontinence with pelvic floor muscle training (PFMT)

Treatment of urinary and faecal incontinence with pelvic floor muscle training (PFMT)

How the intervention might work

Why it is important to do this review

Objectives

Methods

Criteria for considering studies for this review

Types of studies

Types of participants

Types of interventions

Types of outcome measures

Primary outcomes

Secondary outcomes

Search methods for identification of studies

Electronic searches

Search for clinical effectiveness studies

Search for economic evaluations

Searching other resources

Data collection and analysis

Selection of studies

Data extraction and management

Assessment of risk of bias in included studies

Allocation (selection bias)

Blinding (performance bias and detection bias)

Incomplete outcome data (attrition bias)

Selective reporting (reporting bias)

Other bias

Measures of treatment effect

Unit of analysis issues

Dealing with missing data

Assessment of heterogeneity

Assessment of reporting biases

Data synthesis

Subgroup analysis and investigation of heterogeneity

Sensitivity analysis

Incorporating economics evidence

Summary of findings and assessment of the certainty of the evidence

Results

Description of studies

Results of the search

Search for clinical effectiveness studies

1.

Search for economic evaluations

2.

Included studies

Design

Sample size

Setting

Participant characteristics

Parity (number of births)

Age

*Study characteristics*
Methods	Design: 2‐arm (parallel groups), quasi‐randomised (alternation) trial.
Participants	Number of participants: 136 pregnant, continent women. Setting: antenatal outpatient clinics of a women's maternity training and research hospital in Ankara, Turkey. Age: mean (SD), years: PFMT 26.3 (4.8); control 25.7 (4.4). Parity: not reported. Delivery: not reported. BMI prior to pregnancy: < 20, 16.7%; 20‐24.9: 52.9%; 25‐29.9, 22.6%; 30‐39, 7.8%. Incontinence at recruitment: none. Based on negative 1‐hour pad test, urinary diary and self‐report. Inclusion: able to attend pregnancy outpatient visits regularly, 14‐20 weeks' gestation during 1st attendance, aged 20‐35 years, completed at least elementary school, no UI complaints or UTI, BMI < 40, and no chronic disease (such as asthma) or genitourinary pathology (such as pelvic organ prolapse) requiring treatment. Exclusion: not reported.
Interventions	PFMT (n = 68): home exercise programme during pregnancy and postpartum, 3 sets of 10 exercises, 3 times per day. Women received education about functions of the PFM and PFMT, including the effect of pregnancy and vaginal delivery on incontinence, were taught the PFM exercises, and asked to observe the inward contraction of the perineum during contractions (frequency uncertain). Women completed an exercise diary, were phoned once per month to encourage adherence, and exercise compliance was checked at every hospital visit (9‐10 visits on average). Control (n = 68): not instructed to do PFMT. Once data collection complete, controls received PFMT and a brochure during the 12th week home visit.
Outcomes	Measured at baseline (unclear but possibly at 14‐20 weeks' gestation), 28 weeks' gestation, 32 weeks' gestation, 12 weeks' postpartum. Primary endpoint: 12 weeks' postpartum. Primary outcome: 1‐hour pad test. Secondary outcome: urinary diary.
Notes	Losses to follow‐up at 14‐20 weeks' gestation: PFMT 12/68; control 8/68 (total 14.7%). Losses to follow‐up at 28 weeks' gestation: PFMT 16/68; control 14/68 (total 22.1%). Losses to follow‐up at 32 weeks' gestation: PFMT 16/68; control 18/68 (total 25%). Losses to follow‐up at 12 weeks' postpartum: PFMT 16/68; control 18/68 (total 25%). Funding: not reported. Conflicts of interest: not reported.
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	High risk	"The pregnant women who were examined on odd days and even days were assigned to the intervention group and control group, respectively."
Allocation concealment (selection bias)	High risk	"The pregnant women who were examined on odd days and even days were assigned to the intervention group and control group, respectively."
Blinding of participants and personnel (performance bias) All outcomes	High risk	"The women were not informed as to which group they were in. The investigators were not blinded."
Blinding of outcome assessment (detection bias) All outcomes	High risk	Unblinded reporting of UI self‐report outcomes because they were participant‐reported (urinary diary). Pad test not blinded.
Incomplete outcome data (attrition bias) All outcomes	High risk	25% dropout; similar between groups (numbers and reasons); no mention of imputation for missing data.
Selective reporting (reporting bias)	High risk	Study did not report the primary outcome of the review (i.e. self‐reported UI). Other outcome measures described in methods were reported in results.
Other bias	Low risk	No other sources of bias noted.

*Study characteristics*
Methods	Design: 2‐arm (parallel groups) block RCT.
Participants	Number of participants: 120 postpartum women. Setting: labour ward and perineal clinic, National Maternity Hospital, Dublin. Age: mean (SD), years: not reported. Parity: primiparous. Delivery: PFMT 60% spontaneous vaginal, 40%, assisted vaginal; control 63% spontaneous vaginal, 37% assisted vaginal. BMI: mean (SD): not reported. Incontinence at recruitment: not reported. Inclusion: primiparous, fluent in English, sustained a primary third‐degree tear during delivery (that was repaired immediately). Exclusion: women with an infant in the special care unit, a history of alcohol or illicit drug abuse, a positive viral status (hepatitis virus, HIV) and not fluent in English.
Interventions	PFMT plus biofeedback (n = 30): 2 sessions per day, 3 months' duration. Biofeedback training was undertaken in the perineal clinic and was delivered by either a specialist obstetrician, a specialist nurse, or a combination of both; no written information was provided. PFMT education was provided by senior midwives or physiotherapists on the postnatal ward and written information was provided, with women to perform standard Kegel exercises for 5 min. There was no mention of checking for a correct pelvic floor contraction and once given the programme it appeared that no further contact was made until the 3‐month follow‐up. Women were given an exercise diary to complete. PFMT alone (n = 90): women were educated on the ward before discharge, by senior midwives or physiotherapists. Written instructions were provided with women to perform standard Kegel exercises for 5 min, 2 sessions per day.
Outcomes	Measured at 3 months' postpartum (no baseline measures). Primary endpoint: 3 months' postpartum. Primary outcome: not reported. Outcomes: Cleveland Clinic continence score, FIQOL quality of life scale, manometry (mmHg), endoanal ultrasound.
Notes	No losses to follow‐up. Note block randomisation 1:3 (PFMT plus biofeedback 30, PFMT 90). Adverse events: no adverse events were reported relating to the use of biofeedback. Funding: Health Research Board of Ireland. Conflicts of interest: none declared.
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	"Computer randomisation programme" (note randomisation in a ratio of 1:3).
Allocation concealment (selection bias)	Low risk	"Sealed, opaque envelopes."
Blinding of participants and personnel (performance bias) All outcomes	High risk	Not feasible.
Blinding of outcome assessment (detection bias) All outcomes	High risk	Unblinded reporting of FI self‐report outcomes because they were participant‐reported. Unclear if manometry or ultrasound blinded.
Incomplete outcome data (attrition bias) All outcomes	Low risk	No dropouts.
Selective reporting (reporting bias)	Low risk	Outcome measures described in methods were reported in results.
Other bias	Low risk	No other sources of bias noted.

*Study characteristics*
Methods	Design: 2‐arm (parallel groups) cluster‐RCT.
Participants	Number of participants: 202 postpartum women. Setting: Carmela Dutra Maternity Hospital, Florianopolis, Santa Catarina, Brazil. Age: not reported. Parity: primiparous, PFMT 49.3%; control 41.5%. Multiparous, PFMT 50.7%, control 58.5%. Delivery: PFMT 59.7% vaginal, 40.3% caesarean; control 56.9% vaginal, 43.1% caesarean. BMI: not reported. Incontinence prior to pregnancy: PFMT 10.4%, control 9.2%. Incontinence by third trimester: PFMT 62.7%; control 63.1%. Inclusion: > 18 years of age, able to understand Portuguese and immediately post‐partum after giving birth to a live child. Exclusion: previous history of UI due to neurological disorders, history of cancer in the genitourinary tract, previous diagnosis of neurological disease, blind, illiterate, drug addiction, no telephone/mobile phone number.
Interventions	PFMT (n = 98): home exercise programme during postpartum, 10 repetitions of 10‐sec holds (increasing intensity of contractions; strength and endurance training), 10 repetitions of 5 fast and strong contractions (strength training), and ‘the knack’ (a contraction before and during a sneeze or cough) to be performed 2 times per day (without supervision). Women received verbal and written (brochure) educational information provided by ‘pelvic floor specialists’ on PF structure, physiological changes, common problems during pregnancy, PF dysfunction, how to localise the PF and perform PFMT. Correct PFM contraction was ascertained through visual assessment. Adherence to PFMT assessed via phone survey at 3 months postpartum. Control (n = 104): no PFMT. Women did not receive any kind of intervention or information regarding PFMT as this is not usual practice in Brazil.
Outcomes	Measured pre‐pregnancy and third trimester (data were collected retrospectively), and 3 months’ postpartum. Primary endpoint: 3 months’ postpartum. Primary outcome: adherence, classified according to the length of time dedicated to the exercises. Other outcomes: incontinence‐specific quality of life (measured with ICIQ‐SF).
Notes	Losses to follow‐up: PFMT 31/98; control 39/104 (total 34.7%). Have presented complete case analysis imputed for missing data but no indication of the methods of imputation. We used the directly observed data. A cluster‐RCT with no apparent adjustment for the effect of cluster. Funding: not reported Conflicts of interest: not reported.
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	“Rooms instead of individual participants were randomised considering that each participant shared a room in the maternity division with another postpartum woman.” Did not state method of randomisation.
Allocation concealment (selection bias)	Low risk	“Allocation concealment was performed through consecutively numbered, sealed, opaque envelopes, kept with an author not directly involved with participants.”
Blinding of participants and personnel (performance bias) All outcomes	High risk	Not feasible.
Blinding of outcome assessment (detection bias) All outcomes	High risk	Unblinded reporting of UI self‐report outcomes because they were participant‐reported.
Incomplete outcome data (attrition bias) All outcomes	High risk	34.7% dropout; slight differential (PFMT 31.6%; control 37.5%); similar reasons; presented complete case analysis imputed for missing data but no indication of the methods of imputation.
Selective reporting (reporting bias)	Low risk	Outcome measures described in methods were reported in results.
Other bias	Low risk	No other sources of bias noted.

*Study characteristics*
Methods	Design: 2‐arm (parallel groups), 2‐centre RCT.
Participants	Number of participants: 855 pregnant women at 18 weeks' gestation. Setting: 2 centres in Norway. Trondheim University Hospital (St. Olavs Hospital) and Stavanger University Hospital. Age: mean (SD), years: PFMT 30.5 (4.4); control 30.4 (4.3). Parity: nulliparous, PFMT 57.5%; control 56.1%. Delivery: not applicable as primary endpoint was during pregnancy. BMI, mean (SD): PFMT 24.7 (3.0); control 25.0 (3.4). Incontinence at recruitment: UI PFMT 40.1%; control 42.2%. FI PFMT 5.2%; control 4.0%. Flatal incontinence PFMT 27.5%; control 26.1%. Inclusion: aged ≥ 18 years, singleton live foetus. Exclusion: high‐risk pregnancy or diseases that could interfere with participation (or both), women who lived too far from the hospitals to attend weekly training groups (judged as more than 30‐min drive).
Interventions	PFMT (n = 429): supervised group exercise class (once per week, 8‐15 women, 60 min), led by a physiotherapist over a 12‐week period. Class included a progressive PFMT programme that was included in a 20‐ to 25‐min block of strengthening exercises (in addition to 30‐35 min low‐impact aerobics and 5‐10 min of stretching). All women received written information on PFMT, individual instruction in PFM anatomy and how to perform a correct PFM contraction (confirmed by vaginal palpation) by a physiotherapist. Also encouraged to perform PFMT at home at least twice per week as part of a 45‐min home programme (written instructions provided) and complete an exercise diary. Control (n = 426): usual care including standard antenatal care and information provided by midwife or general practitioner. Women were not discouraged from doing PFMT. All women received the same written information and recommendations on PFMT as the intervention group, including detailed information about the pelvic floor and an evidence‐based PFMT programme.
Outcomes	Measured at baseline (18‐22 weeks' gestation) and end of treatment (32‐36 weeks' gestation). Primary endpoint: end of treatment (32‐36 weeks' gestation). Primary outcome: self‐reported UI and anal incontinence via a questionnaire that included Sandvik's severity index (UI) and St. Marks score (anal incontinence). Urinary leakage subclassified as UI, stress UI and urge UI with severity categorised as "urinary leakage < once per week" or "urinary leakage equal to or greater than once per week" (severe UI). Anal incontinence categorised into FI and flatal incontinence. Secondary outcomes: frequency, intensity and type of physical activity (including PFMT), training diary (intervention group only). Labour and delivery outcomes (Salvesen and colleagues 2014; see Stafne 2012).
Notes	Losses to follow‐up during pregnancy: PFMT 33/429; control 61/426 (total 11%). Funding: Norwegian Fund for Postgraduate Training in Physiotherapy and the Liaison Committee for Central Norway Health Authority, and the Norwegian University of Science and Technology. Conflicts of interest: none declared.
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	"Concealed randomisation in blocks of 30 was performed at the Unit for Applied Clinical Research, Norwegian University of Technology and Science, by a web‐based computerised procedure. The staff involved with training or outcome assessments had no influence on the randomisation procedure."
Allocation concealment (selection bias)	Low risk	"Concealed randomisation in blocks of 30 was performed at the Unit for Applied Clinical Research, Norwegian University of Technology and Science, by a web‐based computerised procedure. The staff involved with training or outcome assessments had no influence on the randomisation procedure."
Blinding of participants and personnel (performance bias) All outcomes	High risk	Not feasible.
Blinding of outcome assessment (detection bias) All outcomes	High risk	Unblinded reporting of anal incontinence and UI self‐report outcomes because they were participant‐reported.
Incomplete outcome data (attrition bias) All outcomes	Unclear risk	11% dropout; slight differential loss (PFMT 8%; control 14%); similar reasons; no mention of imputation for missing data.
Selective reporting (reporting bias)	Low risk	Outcome measures described in methods were reported in results.
Other bias	Low risk	No other sources of bias noted.

Study	Reason for exclusion
Agur 2005	RCT. Pregnant women. Usual care versus PFMT. Excluded because did not collect data on UI or FI; primary outcome of interest was duration of 2nd‐stage labour.
Assis 2013	Quasi‐RCT. Postpartum, multiparous women. PFMT versus unspecified control. Excluded because UI or FI were not an outcome; assessed PFM function.
Barakat 2014	RCT. Pregnant women. PFMT (in an exercise group) versus usual care. Excluded because it did not collect data on UI or FI; outcomes were maternal and fetal parameters.
Barakat 2016	RCT. Healthy, pregnant women. PFMT (as part of an exercise group) versus usual care. Excluded because did not collect data on UI or FI; primary outcome was hypertension during pregnancy.
Barakat 2018	RCT. Pregnant women. PFMT (as part of an exercise group) versus usual care Excluded because no measure of UI or FI; primary outcomes were labour and delivery parameters.
Brik 2019	RCT. Pregnant women. PFMT (as part of an exercise group) versus control (not discuouraged to do PFMT) Excluded because no measure of UI or FI; primary outcome was materal weight.
Chen 2018	RCT (Chinese; abstract in English). PFMT versus PFMT and modified Buzhong Yiqi decoction; both groups received electrical stimulation and biofeedback. Excluded due to use of Chinese herbal medicine and uncertainty around the timing of the intervention ("early postpartum PF dysfunction").
Culligan 2005	RCT. Primigravid women. Sham versus active extracorporeal magnetic innervation after delivery; both groups did PFMT during pregnancy. Excluded because comparison of sham and active stimulation.
Dannecker 2004	RCT. Primigravidae, pregnant women. PFMT with Epi‐No device versus no device. Excluded because the primary purpose of the study was to reduce perianal trauma. In addition, the maximum 3‐ to 4‐week duration of the intervention was deemed insufficient to change PFM strength (see also Dietz 2014).
Dias 2011	RCT. Nulliparous pregnant women at 20 weeks' gestation. PFMT (in an exercise group and home exercises) versus control (no instruction on PFMT). Excluded because it did not collect data on UI or FI; assessed labour and newborn outcomes, including PFM strength.
Dias 2018	RCT. Primiparous, pregnant women. PFMT (as part of a Pilates group) versus group exercise with no PFMT instuction. Excluded because no measure of UI or FI; primary outcome was PFM strength (manometry).
Dieb 2017	RCT (ClinicalTrials.gov Identifier: NCT03287258; recruitment completed). Pregnant women. PFMT plus perineal massage versus control (educational PF dysfunction prevention programme). Excluded because no measure of UI or FI; primary outcome is proportion of participants with perineal tears.
Dietz 2014	RCT. Primigravidae, pregnant women. Epi‐No versus unspecified control. Excluded because the Epi‐No device is designed to stretch the vagina and perineum, unclear if PFMT was part of the protocol (see Dannecker 2004), and did not collect data on UI or FI; outcome was levator avulsion.
Domingues 2015	RCT (ongoing study). Pregnant women. PFMT (in an exercise group) versus no intervention. Excluded because UI or FI not stated as an outcome measure in trial protocol; assessment of preterm birth and pre‐eclampsia alongside other maternal and newborn measures.
Dougherty 1989	RCT. Postnatal women within 6‐11 weeks of vaginal delivery. PFMT with intravaginal balloon device versus no treatment. Excluded because did not collect data on UI or FI.
El‐Shamy 2018	RCT. Pregnant women. PFMT versus no PFMT (routine antenatal care). Excluded because no measure of UI or FI; primary outcome wad PFM strength.
Fynes 1999	RCT. Postnatal women with FI following obstetric trauma. Sensory feedback versus audiovisual feedback (including electrical stimulation); both groups did PFMT. Excluded because comparison of 2 types of feedback.
Golmakani 2015	RCT. Primiparous, postnatal women. PFMT versus usual care that included written instructions on PFMT. Excluded because did not collect data on UI or FI; outcomes were sexual self‐efficacy and PFM strength.
Gouldthorpe 2003	RCT. Primiparous women. Abdominal muscle exercise versus no abdominal exercise. Excluded because not PFMT.
Han 2018	RCT ("randomly divided"). Postnatal women. PFMT and shixiao powder and siwu decoction versus PFMT; both groups received electrical stimulation and biofeedback. Excluded due to use of Chinese herbal medicine.
Hou 2010	RCT. Postpartum women. PFMT with vaginal dumbbell and electrical stimulation versus PFMT with vaginal dumbbell. Excluded because no measure of UI or FI; outcome was PFM strength.
Huang 2014	RCT. Primiparous women. PFMT versus control ("traditional nursing"). Excluded because did not collect data on UI or FI; assessed labour outcomes and PFM strength.
Iervolino 2017	RCT. Primiparous, postnatal women. PFMT (in an exercise groups) versus PFMT (home exercise programme) Excluded because no measure of UI or FI; primary outcome was sexual dysfunction.
Johannessen 2017	RCT. Postnatal women. PFMT (individual supervision) versus usual care. Excluded as women included in the study were on average > 12 months postpartum at the time of recruitment.
Kamisan Atan 2016	RCT. Nulliparous, pregnant women. Epi‐No versus usual care. Excluded because the Epi‐No device is designed to stretch the vagina and perineum, unclear if PFMT was part of the protocol (see Dannecker 2004), and did not collect data on UI or FI; main outcomes were levator ani, anal sphincter and perineal trauma.
Khorasani 2017	RCT. Postnatal women. PFMT (home programme) versus no treatment Excluded as women included in the study were between 3‐6 months' postpartum at the time of recruitment.
Lekskulchai 2014	RCT. Nulliparous pregnant women (5‐12 weeks' pregnancy). PFMT versus no‐PFMT (routine antenatal care). Excluded because outcome of study was bladder neck descent on perineal ultrasound, no incontinence outcomes.
Leon‐Larios 2017	Quasi‐RCT. Primiparous, pregnant women. PFMT plus perinal massage versus control (no instruction on PFMT or perineal massage). Excluded because no measure of UI or FI; outcomes were labour, maternal and fetal parameters.
Li 2010	RCT (no information provided about random sequence generation). Primiparous, pregnant women. PFMT versus no PFMT. Excluded as did not collect data on UI or FI; assessed labour outcomes and PFM strength.
Liu 2013	RCT. Primigravidae, pregnant women. PFMT versus usual care. Excluded because no measure of UI or FI; outcome was PFM strength.
Mahmoodi 2014	RCT. Primiparous, postnatal women. PFMT versus usual care. Excluded because did not collect data on UI or FI UI; outcome was postepisiotomy pain.
Mahony 2004	RCT. Postnatal women with FI. Biofeedback versus biofeedback augmented with stimulation; both groups did PFMT. Excluded because comparison of 2 types of feedback.
Mason 1999	RCT. Primiparous women recruited from postnatal wards. Conventional versus intensive physiotherapy. Excluded because cannot find any trial report (only record of trial on Medical Research Council trials database) and no response to letter to primary author.
Mason 2010	RCT. Nulliparous, singleton pregnancy, no previous stress UI, 11‐14 weeks' pregnancy. PFMT versus usual care and instruction in PFMT. Excluded because there were internal inconsistencies in the data and the accuracy of the numbers was in doubt.
Min 2019	RCT (ongoing study). Postpartum women PFMT with electrical stimulation versus PFMT Excluded because no measure of UI or FI; outcomes are pelvic organ prolapse, PFM strength, pelvic imaging measurements.
Morin 2015	RCT. Primiparous, postnatal women with avulsion injury. PFMT versus usual care (plus a control arm of women without avulsion who received physiotherapy). Excluded because did not collect data on UI or FI; outcome was PFM morphometry.
Nielsen 1988	RCT. Primiparous women. PFMT versus no PFMT. Excluded because did not collect data on UI or FI.
Norton 1990	RCT. Primiparous women 6 weeks' postnatal. PFMT versus vaginal cones vs controls. Excluded because did not collect data on UI or FI.
Oblasser 2016	RCT. Postnatal women. Licensed PFMT vaginal ball versus usual care that included written PFMT exercises. Excluded as no formal PFMT provided to women in the intervention group.
Okido 2015	RCT. Primigravidae, pregnant women. PFMT versus usual care. Excluded because did not collect data on UI or FI; outcomes were uteroplacental and fetoplacental blood flow.
Perales 2015	RCT. Pregnant women. PFMT (as part of an exercise group) versus usual care. Excluded because no measure of UI or FI; primary outcome was maternal depression levels.
Perales 2016	RCT. Healthy, pregnant women. PFMT (as part of an exercise group) versus usual care. Excluded because did not collect data on UI or FI; primary outcomes were the effects of exercise on the maternal cardiovascular system and on risk factors for cardiovascular disease.
Pourkhiz 2017	RCT. Nulliparous, pregnant women. PFMT versus usual care Excluded because no measure of UI or FI; primary outcome was sexual function.
Ruiz 2013	RCT. Pregnant women. PFMT (as part of an exercise group) versus usual care. Excluded because did not collect data on UI or FI; assessed gestational bodyweight gain and fetal outcomes.
Santos‐Rocha 2015	RCT. Pregnant women. PFMT (as part of an exercise group) versus usual care Excluded because no measure of UI or FI; outcomes were physical activity level, and other maternal and fetal parameters.
Siva 2014	RCT. Primigravidae, pregnant women. PFMT (as part of a "motor relearning programme") versus PFMT. Excluded because did not collect data on UI or FI; outcome was PFM strength.
Taskin 1996	Quasi‐randomised RCT (day of week). Primigravidae. Intervention PFMT with or without episiotomy or caesarean section. Excluded because of mixed intervention and inappropriate controls.
Teymuri 2018	RCT. Postpartum women with persistent lumbopelvic pain. PFMT plus biofeedback versus electrotherapy modalities Excluded because no measure of UI or FI, and women were recuited > 3 months postpartum; outcomes were pain (lumbopelvic), disability and PFM function.
Thorp 1994	RCT. Nulliparous women recruited through advertisement. Unclear if PFMT or vaginal cones versus controls. Excluded because it was unclear whether the intervention was PFMT or vaginal cones, neither were data on UI or FI collected.
Wang 2014	RCT. Nulliparous, pregnant women. PFMT plus phone follow‐up once every 2 weeks versus PFMT. Excluded because did not collect data on UI or FI; assessed delivery outcomes and PFM strength.
Wilson 2015	Pilot RCT. Pregnant women. PFMT (as part of web‐based PFM education prgoramme) versus usual care. Excluded because no measures of UI or FI; outcomes were awareness and knowledge of PFM, confidence in and belief about engaging in PFME, and adherence to PFMT.
Zhu 2012	Quasi‐RCT. Postnatal women. PFMT with electrical stimulation versus usual care. Excluded as unclear when women were recruited after delivery. Possible that the women included in the study were > 12 months' postpartum at the time of recruitment because the mean age of the sample was 34 years, which is substantially higher than other trials conducted in a similar context (see Liu 2011 or Wen 2010).

Methods	Design: RCT (Pan African Clinical Trials Registry: RCT "randomly divided").
Participants	Number of participants: 36 primiparous women in Najafabad city, Iran. Inclusion: not stated. Exclusion: not stated.
Interventions	Kegel exercises. Central stability training. Combined exercises. All participants trained 3 times per week, for 6 weeks'.
Outcomes	Trunk muscle endurance and quality of life (SF‐36).
Notes	Abstract is in Farsi, and translation required. Unclear if UI or FI are outcome measures.

Methods	Design: RCT.
Participants	Number of participants: 232 nulliparous women. Inclusion: not reported. Exclusion: not reported.
Interventions	PFMT (n = 84). Control (n = 148): unknown.
Outcomes	Pelvic dysfunction, perineal trauma, episiotomy.
Notes	From this abstract we are unable to determine if this study addresses a population of interest and although it refers to postpartum incontinence, no data are provided. Awaiting full publication.

Methods	Design: unknown.
Participants	Unknown.
Interventions	PFMT. Control: unknown.
Outcomes	Unknown.
Notes	No further details of this research available. This Master's thesis has been requested and, if available, will require translation.

Study name	Effects of pelvic floor muscle training on pelvic floor muscle function in women during their first pregnancies measured by perineometer
Methods	Design: RCT (Australian New Zealand Clinical Trial Registry: ACTRN12609001005246).
Participants	Number of participants: 15 nulliparous women. Inclusion: 1st pregnancy, aged 18‐40 years. Exclusion: pregnancy complications.
Interventions	PFMT: 30‐min sessions, once per week for 16 weeks, starting at 20 weeks' gestation. Control: no PFMT.
Outcomes	Primary outcome: PFM function (perineometry and digital palpation). Secondary outcome: self‐reported UI.
Starting date	2007.
Contact information	Cristine Ferreira, Av. Bandeirantes, 3900: Monte Alegre: CEP: 14049‐900 Ribeirão Preto/SP, Brazil.
Notes	Trial completed and paper in preparation for publication.

Study name	Influence of the practice of Pilates on the Incidence of Urinary Incontinence, perineal strength, low back pain in the third trimester
Methods	Design: RCT (Brazilian Registry of Clinical Trials: UTN: U1111‐1155‐5315).
Participants	80 primiparous women, 20‐25 weeks' gestation. Inclusion: reported UI prepregnancy and low back pain, single fetus. Exclusion: neurological disorders that resulted in cognitive deficits or motor disorders of the lower limbs, physical or mental (or both) limitations, restrictive lung or heart disease, regular physical exercise of Pilates in the past 6 months, prepregnancy BMI ≥ 30.
Interventions	Pilates sessions (n = 40): 20 in total (twice per week), 60‐min duration. Guided walks (n = 40): 2‐3 times per week for 30 min, daily PFM strengthening exercises.
Outcomes	Primary outcome: UI assessed with "urinary incontinence" questionnaire, low back pain assessed with visual analogue scale. Secondary outcome: PFM strength with surface electromyography.
Starting date	May 2014.
Contact information	Mariana Buen, Faculdade de Ciências Médicas da Universidade Estadual de Campinas, Brazil.
Notes	Recruitment status unknown, as registry last updated in September 2014. Awaiting full publication to determine if Pilates sessions included any voluntary PFM contractions.