Prenatal and Postpartum Experience, Knowledge and Engagement with Kegels: A Longitudinal, Prospective, Multisite Study

Abstract

Introduction: Urinary incontinence (UI) increases during pregnancy and continues into the postpartum period. Continued UI impacts women's comfort and affects aspects of their everyday lives. Kegel exercises have been found to decrease the incidence and severity of UI. The purpose of this study was to describe severity of UI, how women gained knowledge about Kegels, influences impacting Kegel exercises during pregnancy and postpartum, and characterize women's performance of Kegels.

Methods: A longitudinal, prospective, multistate study was undertaken at four sites across the United States. Postpartum women completed the Pelvic Floor Control Questionnaire that incorporated the Sandvik Severity Index. At 3 and 6 months postpartum the women's UI, performance of Kegels, and affect on life was reviewed through seven questions. Institutional Review Board (IRB) approval was obtained.

Results: Participants were 368 predominately multiparous, white women. Approximately 20% of women reported prepregnancy UI. Multiparous women reported similar incidence rate of UI regardless of birth history. Among one-fifth of the participants, persistent UI was reported as 45.2% at 3 months and 44.1% at 6 months postpartum. Only 25% of these women sought care. Women learned about Kegel exercises from written information or their provider. Women performed an average 16 Kegels twice daily. Kegel performance increased at 3 months postbirth but dropped by 6 months. UI was associated with age >35 and parity.

Discussion: Prevalence of UI before and during pregnancy and postpartum is high, yet consistent Kegel performance postpartum is low. Screening for UI is necessary and high-quality referrals for treatment are needed. Consistent education is needed for all women. Education and support should be individualized. Future research is needed to identify techniques that motivate women to routinely perform Kegel exercises.

Introduction

Incidence and severity of urinary incontinence (UI) increases throughout pregnancy and often continues into the postpartum period.^1–8 These studies^1–8 collected data on any UI using the International Continence Society (ICS) definitions, and many reported separately on stress urinary incontinence (SUI) because it is most commonly associated with pregnant and postpartum women. SUI was defined as “the complaint of involuntary loss of urine on effort or physical exertion” according to the standards recommended by the International Urogynecological Association and the ICS.⁹

Although reports of prevalence vary significantly between studies, in a randomized control trial of 855 women, 53% experienced UI during pregnancy.² A systematic review of 33 studies representing 23,433 women reported that 33% experienced UI postpartum.¹⁰ The literature reports that UI persists up to 12 years after childbirth for women who experienced UI at 3 months postbirth¹¹ and that SUI is more common at 3.5 years postbirth than at 8 weeks.¹² Learning about women's experiences and knowledge regarding UI and Kegel exercises may influence how health care professionals educate pregnant and postpartum women and ultimately diminish the impact that UI has on women's experiences of comfort and everyday life.

Kegel exercises appear to be beneficial in reducing severity and/or presence of UI. Kegels are considered the firstline treatment for UI. Pelvic floor muscle therapy or pelvic floor muscle exercises are terms that can be used interchangeably with Kegel exercises. A daily regimen of 30 Kegels one to three times daily for a minimum of 3 months is recommended to treat UI.^13,14 Boyle et al.¹⁵ reported women with UI 3 months postpartum who performed Kegels were ∼40% less likely to report any UI 12 months after delivery than those who did no Kegels or usual postpartum care. Meta-analysis of 763 women from 12 studies by Nie et al.¹⁶ confirmed Kegels as a treatment of UI. Symptom relief and quality of life improved for women with regular use of Kegels.¹⁶

Antenatal Kegel exercises lowered the risk of UI more than 6 month's postbirth supporting the recommendation of Kegels for women with UI postpartum.¹⁵ To prevent urine leakage, the recommendation is 30–45 Kegels per day¹⁷ or 8 Kegels three times a day.¹⁸ From week 20 in pregnancy to 6 weeks postbirth, a decline in muscle strength is expected,¹⁹ which could be diminished through Kegels. Kegels performed weeks 20–35 antenatally lead to higher muscle strength at 6 weeks postbirth and sustained up to 12 months postbirth.²⁰ In a Cochrane Review of 38 trials involving 9892 pregnant women, Kegels were found to prevent and reduce UI symptoms in women during pregnancy and the postpartum period.²¹ In women without UI, those who performed Kegels preventively, were 62% less likely than the control to report UI in late pregnancy and 29% less for more than 3–6 months postpartum.²¹

Based on the existing literature, Kegels are a powerful intervention for preventing and treating UI symptoms during pregnancy and postpartum periods. Yet, UI is still common with limited data regarding Kegel education women receive during pregnancy, and their experience with performing Kegel exercises. A study by Fritel et al.²² reported no difference between the Kegel physiotherapy group and the one with written Kegel instructions for women at 2 and 12 months postpartum. Results show that education through supervised group or written is effective.

Despite significant research that demonstrates the benefits of Kegels, there has been no increase since 1950 in the number of women who perform Kegels.^23,24 In addition, one-third of women do not perform Kegels properly and only one-in-three women perform them once a week or more even with knowledge regarding Kegels.²⁵ A study by Conklin et al²⁶ indicated women had more imminent health concerns during the immediate postpartum period than UI. UI symptoms in women who feel overwhelmed with recovery and the transitions after giving birth may consider education a burden. Additional research is needed to understand the best ways to tailor interventions toward prevention and treatment of UI.

UI during pregnancy and postpartum is a significant health concern. Thorough knowledge about how women learn, perform, and are motivated to integrate Kegel exercises into their daily routine is important to discover. From this discovery, providers and nurses can plan and implement programs to educate and encourage women toward healthy pelvic muscles.

The pelvic floor encompasses a sling of muscles from inside the pubic bone to the anus that then weaves around the vagina, urethra, and rectum.¹³ A healthy pelvic floor requires proper counseling of risk factors, comprehensive education, and persistence on the part of the woman. The purpose of this study was to describe severity of urinary leakage, how they gained knowledge of Kegels, how they were influenced regarding Kegel exercises during pregnancy and up to 6 months postpartum, and characterize women's performance of Kegels.

Methods

Study design

This was a longitudinal, prospective, multisite study of women's experiences with UI and Kegels during pregnancy and postpartum.

Sample and setting

A convenience sample of 418 postpartum women was recruited from 4 sites considered to be representative across the United States. Data from 368 women who responded to the urinary leakage question were included in the analyses. Sites selected employed the midwife researchers who were interested in UI and Kegels. The Massachusetts (MA) site was a busy hospital practice, Arizona (AZ) was a mixed hospital/freestanding birth center practice, and Texas (TX) and Colorado (CO) were freestanding birth centers. Women were given information about the study if they met the inclusion criteria (>18 years old, able to read and write English, and have given birth within past 8 weeks).

Written informed consent was obtained from women interested in voluntary participation. The consent requested permission to obtain data from the participant's hospital record/chart. Coercion was avoided by informing the potential participants that the study was voluntary. Participants could withdraw from the study at any time. Institutional Review Board (IRB) approval was received from South Shore Hospital for their site only and Frontier Nursing University (FNU) for all four sites. Each site provided letters of support approving approaching participants.

Data collection

During morning rounds for the hospital births, the midwives would ask women who met the inclusion criteria if they were interested in the study. After obtaining consent a manila envelope, to protect privacy, was left with participants postbirth and subsequently collected within 48 hours. The manila envelope contained the Pelvic Floor Control Questionnaire (Supplementary Appendix SA1). In the birth centers the questionnaires were collected either postbirth or at any postpartum follow-up visit. Midwives approach to ask women in the birth centers was dependent upon length of stay and short time to initiate bonding as a family. Because of short stays at birth centers, many participants agreed at their postpartum visit.

Flyers were displayed in the hospital and birth center bathrooms. Recruitment and collection of questionnaires occurred from July 2015 to June 2017. A chart review to include current labor and birth, previous pregnancy history, chronic medical conditions, and basic demographic information was completed by the researchers to obtain information pertinent to the Demographic Questionnaire (Supplementary Appendix SA2).

If the participant authorized follow-up contact in 3 and 6 months, the Primary Investigator (PI) asked questions reviewing UI, performance of Kegels, and affect on life (Supplementary Appendix SA3) at each follow-up period using their preferred contact method. The PI attempted contact four separate times ∼1 week apart when their follow-up date became eligible. If no response was received after this, the researchers decided it best to consider the participant no longer interested.

Attempts were again made to contact all eligible participants at the 6-month period. If there was no response, then only three more attempts were made with the participants who had responded at the 3-month period. This follow-up process was approved by the IRB. Participants with persistent UI, as defined by the woman, and those requesting help were referred immediately to Physicals Therapists (PT) or Urologists specializing in UI.

Instrumentation

No published instrument(s) sought all the questions the researchers determined as inclusive to cover the purpose of the study. The prepregnancy and pregnancy data were collected retrospectively immediately postbirth or within the postpartum period. Two questionnaires were developed by the research team based on current literature, the Demographic Questionnaire (Supplementary Appendix SA2) and the Pelvic Floor Control Questionnaire (Supplementary Appendix SA1). The Demographic Questionnaire compiled information that was stated in the literature as being risk factors for UI during and after pregnancy and general birth data. The Pelvic Floor Control Questionnaire contained 30 questions with 7 of those posed as open-ended inquiry to obtain women's thoughts and experiences in their own words.

The topics were gleaned from the literature, experiences of the researchers, and the Sandvik Severity Index (SSI), a validated tool for evaluating UI severity calculated by multiplying coded frequency and amount of incontinence. The SSI responses were scored as per the tool instructions. The remaining responses such as Yes or No were assigned a 0 or 1 for coding with an abbreviation such as pelvic floor exercise for the question.

For the participant's clarity, definition of urinary leakage was provided on the questionnaire as “urine leaking with or without cough, laugh, sneeze, run, jump, walk or change of position.” This definition encompassed unintentional urinary leakage and stress-related causes; both owing to weaker pelvic floor muscles. No questions pertained to urge or fecal incontinence because SUI is the most common type of leakage during and postbirth. The questionnaire included categories of type of birth and pushing, leaking of urine, pelvic floor exercises, physical exercise, smoking, constipation, and thoughts postbirth. Questions were single response with the exception of physical exercise and sources of knowledge. The two multiple response option questions were subsequently assigned a number with an alphabetic abbreviation for coding per each response.

The open-ended questions used thematic analysis and are not reported in this article. The follow-up questionnaire was composed of seven questions to include the SSI and two open-ended questions. Face and content validity were established for both questionnaires through consultation with experts in the field and 10 volunteer women of childbearing age. A few questions were rephrased or definitions provided for clarity from the feedback. Psychometric analysis of the questionnaire is planned. The IRB of South Shore Hospital and FNU approved the preliminary and final questions.

Analysis

Data were gathered and analyzed for prepregnancy, pregnancy in the immediate postpartum to postpartum visit period, 3 months postbirth, and 6 months postbirth. Statistical analysis was performed using SPSS 24.0 (IBM Corp., Armonk, NY). A priori power analysis of chi-square variance with an alpha of 0.05 and power of 0.95 calculated a required sample size of 134 to identify an odds ratio of 1.5. The actual sample size surpassed the required sample size and had enough participants to meet the total sample size requirement in each outcome group (antepartum UI and no UI). For this study the data from four participants who answered the urinary leakage question were excluded secondary to missing the dependent variables. One participant had a set of twins and three did not have the primary outcomes required for analysis.

Kegel performance, urinary leakage, SSI, and time points were the main focuses of analysis. SSI was calculated and analyzed for associations with time points and parity. Learning methods were analyzed for associations between UI and Kegels during pregnancy, site, and provider. Demographic data were analyzed for associations with UI risk factors UI and Kegels.

Measures of central tendency and frequencies were analyzed for UI and the time points. Data were analyzed with pairwise deletion. Epidemiological data on the incidence of UI and Kegel performance were reported as mean and percentage. Mean differences were assessed with t-tests for continuous variables. Chi-square analysis was used to evaluate the relationship between categorical variables. To measure the strength of linear relationship, correlation between numeric variables was reported with the Pearson correlation coefficient.

Because there were so few cases from TX, the assumptions of statistical tests were challenged by small cell size when analyzing by site. Therefore, the analyses were repeated excluding TX cases and the same variables remained significantly different. In two cases, the borderline associations became significantly stronger with TX removed as expected because sample size in each cell could then align with the “large sample size” assumptions of chi-square testing. The removal of TX did not change which variables were significantly different by site, however the p-values became stronger in some cases.

Results

Demographics

The mean age was 31.4 years (standard deviation [SD] = 0.45, range = 18–43 years). The mean prepregnancy body mass index (BMI) was 25.2 (SD = 5.4, range = 17.5–52.3). The sample, reflective of the populations served at the participating sites, was predominately white (n = 320, 87%) and non-Hispanic (n = 316, 86%). There were 125 participants from AZ, 86 from CO, 148 from MA, and 9 from TX. Approximately 43% (158) of participants were nulliparous and 57% (210) were multiparous.

In addition to previous cesarean section rate (p < 0.001), the following demographic variables differed by site of birth. White versus other race was higher in MA (p < 0.001). Women's age at present pregnancy was higher in the MA site (32.05 years) compared with AZ (30.4 years) and TX (29 years) but similar to CO (31.55 years), p = 0.018. In addition, age at first birth was higher for women at the MA site (29.6 years) compared with AZ (27.1 years) and TX (25.6 years) but not different from CO (28.9 years), p ≤ 0.001. There was a borderline association (p = 0.06) between presence of UI before pregnancy and site with the MA site having 11.6% UI prevalence compared with all other sites that had prevalence ranges of 22.1%–23.2%. When removing TX from the analysis because of small sample size, the p-value became stronger (p = 0.026).

The following five variables differed by site of birth with MA having significantly higher prevalence of four of five: place of birth (more hospital) (p < 0.001); type of birth with MA having far more cesarean births (45.3%) than CO (3.5%), AZ (14.5%), or TX (0%), p < 0.001; augmentation of labor (p = 0.016); epidural use MA having the highest rate (63.5%) compared with AZ (29.8%), CO (13.1%), or TX (0.0%; p < 0.001); and Kegels with MA having the lowest rate of women performing Kegel exercises (56.1%) compared with CO (75.6%), AZ (68%), or TX (66.7%), p = 0.019.

The only baseline characteristic that differed between the full sample and the 3-month sample was where the birth took place. More participants in the 3-month sample birthed their babies in a hospital (76.2%) compared with those who did not participate in the 3-month sample (57.5%), p = 0.003. In addition, the participants at 3 months were slightly older than those who did not participate (32.7 years vs. 31.02 years, p = 0.01) and were older at their first birth (29.98 years vs. 28.19 years), p = 0.009.

SUI prevalence/severity

Overall, 19.8% (73; 20 nulliparas, 53 multiparas) of women reported leakage of urine before this pregnancy. Significantly more multiparas had leakage before (p = 0.002) and during pregnancy (p = 0.001). During the most recent pregnancy, 62.8% (231; 84 nulliparas, 147 multiparas) of women reported leakage. Of women who had leakage, 17.7% (65) reported leaking enough to wear a pad. Severity of UI reported by multiparas was higher than nulliparas (p = 0.027) (Table 1). Women with UI during pregnancy reported continued UI at 3 and 6 months postbirth. New-onset UI postbirth occurred among 9% (7) of women at 3 months.

Table 1.

Severity of Urinary Incontinence in Nulliparas Versus Multiparas

	Total sample	Nulliparas	Multiparas
Number in sample (n)	368	158	210
Mean Sandvik Severity Index Score (SD)	1.45 (1.68)	1.22 (1.59)	1.62 (1.73)
Sandvik Severity Index
Dry (0)	146 (39.7%)	74 (46.8%)	72 (34.3%)
Slight (1–2)	137 (37.2%)	52 (32.9%)	85 (40.5%)
Moderate (3–4)	71 (19.3%)	28 (17.7%)	43 (20.5%)
Severe (6–8)	14 (3.8%)	4 (2.5%)	10 (4.8%)

SD, standard deviation.

Severity of UI and affect on life over time periods prepregnancy to 6 months postbirth are given in Table 2. Of significance, age >35 years and parity were associated with experiencing UI. In nulliparas, increasing prepregnancy BMI was associated with increased UI in pregnancy. There was no statistically significant difference for ethnicity or race among women with or without leaking during pregnancy.

Table 2.

Severity of Urinary Incontinence and Affect on Life by Time Period

	Any urinary leakage	Sandvik Severity Index				Affect on Life
	Yes response	Dry	Slight	Moderate	Severe	Mild	Moderate	Severe
Before pregnancy	73/368 (19.8%)	N/A	N/A	N/A	N/A	NA	NA	NA
During pregnancy	231/368 (62.8%)	146/368 (39.7%)	137/368 (37.2%)	71/368 (19.3%)	14/368 (3.8%)	NA	NA	NA
3 Months postpartum	33/73 (45.2%)	51/58 (87.9%)	1/58 (1.7%)	4/58 (6.9%)	2/58 (3.4%)	27/33 (81.8%)	5/33 (15.2%)	1/33 (3.0%)
6 Months postpartum	15/34 (44.1%)	19/23 (82.6%)	2/23 (8.7%)	2/23 (8.7%)	0 (0%)	13/19 (68.4%)	5/19 (26.3%)	1/19 (5.3%)

How women learn about Kegel exercises

Women were asked to identify all the sources from which they learnt to perform Kegels and were allowed to select multiple options. Of the women who reported performing Kegels, 138 (44%) respondents reported learning to do Kegels from a provider (certified nurse-midwife, nurse practitioner, or physician), 14 (5.5%) learning Kegels from PT, 147 (58%) learnt from written materials (books or online), and 49 (19%) from another source (Fig. 1). There was no significant association between learning methods, whether women had UI during pregnancy, and whether women reported Kegel performance during pregnancy or parity.

FIG. 1.

Amount of Kegels performed daily. The line is ∼30 Kegels/day.

Factors that influence teaching clients to perform Kegel exercises

Most (39/44, 88%) women with previous cesarean births in the sample were from the Massachusetts site. Multiparous women with a history of vaginal birth were less likely than multiparous women with a history of cesarean birth to receive Kegel teaching from a provider (19.9% vs. 60.5%, p < 0.001), or from written material (34.7% vs. 55.8%, p = 0.005) in this subset from Massachusetts. Overall, multiparous women who were taught Kegels by a provider were less likely than multiparous women who were not taught by a provider to perform Kegels during pregnancy (44.6% vs. 64.5%, p = 0.009). Women with a birth history of macrosomia compared with those without macrosomia in their birth history, regardless of history of UI, were more likely to receive Kegel education from PT (χ² = 13.354, p < 0.001).

Performance of Kegel exercises during and within 6 months postbirth

See Table 3 for demographic characteristics of Kegels performance during pregnancy and postbirth. Of significance were parity, birth route, location of birth, and site. During pregnancy 65.5% (241) women reported performing Kegel exercises. Women who reported performing Kegel exercises during pregnancy performed a mean of 1.61 (SD = 1.43, range = 1–10) sessions per day with a reported mean of 15.77 (SD = 15.17, range = 2–120) Kegels per session (Fig. 2). The mean number of Kegels per day was 27 (SD = 32.9, range = 2–200) with nearly one-third performing >30 Kegels daily.

Table 3.

Demographic Characteristics for Kegel Exercises During and Postpregnancy

	Total sample, N = 368	No Kegels during pregnancy	Kegels during pregnancy	p
Ethnicity				0.148
American Indian/Alaskan	4 (1.1%)	0 (0%)	4 (1.7%)
Asian	8 (2.2%)	2 (1.6%)	6 (2.5%)
Native Hawaiian or Other Pacific	1 (0.3%)	0 (0%)	1 (0.4%)
African American	6 (1.6%)	1 (1.6%)	4 (1.7%)
White	320 (87.0%)	119 (93.7%)	201 (83.4%)
More than one	8 (2.2%)	1 (0.8%)	7 (2.9%)
Not reported	21 (5.7%)	3 (2.4%)	18 (7.5%)
Race				0.068
Non-Hispanic	316 (85.9%)	110 (86.6%)	206 (85.5%)
Hispanic	31 (8.4%)	14 (11.0%)	17 (7.1%)
Not reported	21 (5.7%)	3 (2.4%)	18 (7.5%)
Age (years)				0.831
Age >35	101 (27.7%)	34 (27.0%)	67 (28.0%)
Site/state				0.024
Arizona	125 (34.0%)	39 (30.7%)	86 (35.7%)
Colorado	86 (23.4%)	21 (16.5%)	65 (27.0%)
Massachusetts	148 (40.2%)	64 (50.4%)	84 (34.9%)
Texas	9 (2.4%)	3 (2.4%)	6 (2.5%)
Location of birth				0.014
Birth center	140 (38.0%)	37 (29.1%)	103 (42.7%)
Home	6 (1.6%)	4 (3.1%)	2 (0.8%)
Hospital	222 (60.3%)	86 (67.7%)	136 (56.4%)
Birth route				0.008
Spontaneous vaginal	271 (73.6%)	87 (68.5%)	185 (76.8%)
Instrumental vaginal	8 (2.2%)	0 (0%)	8 (2.2%)
Planned cesarean	40 (10.9%)	23 (18.1%)	17 (7.1%)
Cesarean during first stage labor	33 (9.0%)	12 (9.4%)	21 (8.7%)
Cesarean during second stage labor	16 (4.3%)	5 (3.9%)	11 (4.6%)
Prepregnancy BMI (kg/m2) >30	62 (17.5%)	20 (16.3%)	42 (18.2%)	0.651
Parity				0.003
Nulliparous	158 (42.7%)	42 (32.3%)	116 (48.1%)
Multiparous	210 (57.3%)	85 (67.7%)	125 (51.9%)
3 Months postpartum	73 (19.8%)
Nulliparous	23/58 (39.7%)	3 (13.0%)	20 (87.0%)
Multiparous	35/58 (60.3%)	12 (34.3%)	23 (65.7%)
Kegels performed at 3 months postpartum	56/73 (76.7%)
6 Months postpartum	34 (9.2%)
Nulliparous	14/34 (41.2%)	3 (21.4%)	11 (78.6%)
Multiparous	20/34 (58.8%)	7 (35.0%)	13 (65.0%)
Kegels performed at 6 months postpartum	11/34 (32.4%)

BMI, body mass index,

FIG. 2.

How women learn about Kegels.

Multiparous women with a history of cesarean birth were less likely to report performing Kegels during the current pregnancy than women without a history of cesarean birth (−0.216, p = 0.001, n = 222) despite having the same rates and severity of UI and higher rates of provider-taught Kegel exercises. Multiparous women who reported exercising during pregnancy reported performing Kegel exercises, although the relationship was not statistically significant. Overall multiparas with a history of vaginal birth only were more likely to perform Kegels (p = 0.005) than women with a prior cesarean birth (p = 0.001).

Women (96.2%, 232) planned to continue Kegels after birth; however, 76.7% (56/73) reported performing daily Kegels at 3 months postbirth and 32.4% (11/34) at 6 months postbirth. Planning to do Kegels postbirth was associated with history of vaginal birth (p = 0.018), Kegels during pregnancy (p < 0.001), and reporting that UI is not a normal life change (p = 0.035).

Intention to seek care

During pregnancy, only four women sought pelvic floor therapy for UI with 85 reporting moderate or severe leaking. Most women expected leakage to continue for 2–5 weeks postbirth while they would wait a mean of 13 weeks 2 days to seek help. Women who would seek help were less likely to consider it a normal life change (p < 0.0001) than women not planning to seek help postbirth. Women with UI during pregnancy (p = 0.002) and with increasing severity of UI (p = 0.039) were more likely to state they would seek care for UI than women not planning to seek care. Sixty-six percent (225/341) stated they think leakage is a normal life change after giving birth.

Around 210 of 357 (59%) women stated they would seek help for UI at 6 weeks postbirth if they had leakage. Of note, 7 of 46 (15%) women reported planning to seek care/therapy at 3 months postpartum and 4 of 17 (24%) at 6 months postpartum. These women were the ones reporting moderate to severe UI. Women's lives postbirth were moderately to severely affected by UI, 18.2% (6/33) versus 31.6% (6/19) at 3 and 6 months, respectively. Receiving care/therapy is associated with increased parity (p = 0.009) and increased severity of UI at 3 months postpartum (p = 0.007).

Discussion with Clinical Implications

In this study the overall incidence of UI during pregnancy among mixed gravidity (62.8%) was slightly higher during pregnancy compared with the literature^2,27–29 (Table 4). UI prepregnancy was reported by 20% of the sample. Minimal decrease occurred between 3 and 6 months postpartum. The 6-month rate was not reported in other studies. Although participants had low rates of traditional risk factors, apart from constipation, the rates of UI for the study period were slightly higher than the reported rates in literature.

Table 4.

Urinary Incontinence Prevalence

Research	Sample (N)	UI during pregnancy (%)	UI 3 months postbirtha (%)	UI 6 months postbirtha (%)	Use of pads
Present study	368	62.8	45.2b	44.1b	17.7%
Whitford et al.27	289	54.3	NA	NA	18.3% Occasional, 7.7% daily use
Stafne et al.2	855	53.0	NA	NA	NA
Chiarelli and Cockburn28	676	NA	38.4	NA	NA
Mason et al.29	286	53	41.3	NA	Not reported but obtained

^aWomen with UI during pregnancy.

^bn = 33/73 at 3 months and n = 15/34 at 6 months.

UI, urinary incontinence.

MA had more medicalized births and interventions during labor but reported lower rates of prepregnancy UI and the lowest rate of Kegels performed during pregnancy. The lower rate of Kegels could be owing to higher cesarean section history and no education for women after surgery. The authors cannot postulate why MA had a significantly lower prepregnancy UI as surgical birth is not a protective factor.

One in five women presenting to pregnancy already experiencing UI is high and unnecessary. Women who present during pregnancy with a history of UI or current symptoms need to begin a Kegels regimen or a referral to physical therapy dependent upon their previous commitment or success with Kegels.

Although our study overall reported written material (books/online) as the most used source for gaining knowledge, for women with UI during pregnancy providers and written materials were similar. Ismail³⁰ noted women preferred instructions from midwives over PT. Of interest, some women in our study who were taught Kegels by a provider were less likely to perform Kegels, although this finding was not statistically significant. Women with history of vaginal birth were significantly less likely to receive written material than those with history of cesarean birth. Over 90% report awareness about Kegels²⁷; however, consistent, effective education as given in Tables 5 and 6 and motivational strategies are needed to create a lifelong preventive health regimen for all women.

Table 5.

Kegels Recommendations

Source	Year	Recommendations, all note to perfect your technique
Bezerra et al.19	2016	Daily Kegels: 40 contractions, hold 10 seconds; start 20th week of pregnancy through 36th week
NICE guideline CG17118	2015	At least eight contractions, three times per day
Borello-France31	2012	Variety of suggestions for success: (1) 200 contractions per day or; (2) 5 short (contract hold for 3 seconds and release) and 45 long contractions (elevator analogy) or; (3) 8–12 contractions, 3 times a day or; (4) 60 fast and 30 slow contractions
National Association for Continence13	Unknown	Three sets of 10 contractions, 3 times a day; once good at above. (1) Perform 3 sets of 10 short and 3 sets of 10 long contractions twice a day. (2) Short contraction (fast twitch); contract as you exhale—tighten muscles quickly, lift up, then release. (3) Long contraction (slow twitch); gradually tighten and lift muscles like an elevator ascending, hold for 10 seconds, then gradually release. Rest muscles 10 seconds between long contractions
American College of Nurse-Midwives14	2016	One suggestion is 3 sets of 10 contractions per day
Harvard Health Publishing32	2015	30–40 Kegels daily, 10-second contractions and relaxations—disperse throughout day. Practice 2- to 3-second contractions as well as 10-second ones
Michigan Medicine for WebMD33	2018	During pregnancy 5 sets of Kegels per day. One set = hold for slow count of 5 for 10 times
Mayo Clinic34	2015	Three sets of 10 repetitions a day
Norsigian17	2006	30–45 per day

Table 6.

General Recommendations When Performing Kegels

If BMI >30 advise woman to lose weight.18

Locate the right muscles:

(1) Pretend you are trying to avoid passing gas

(2) Pretend to tighten your vagina around a tampon or penis

(3) You should feel Kegels more toward the back of the pelvic area.32

(4) Imagine you are sitting on a marble and tighten your pelvic muscles as if you are lifting the marble.34

Another method is to stop urinating midstream (not first of day) identify the muscles used—use only to identify muscles.34

To evaluate strength: stop urination and feel if these are the same muscles used during Kegels or practice during sexual intercourse with partner feedback.24

Quality is better than quantity; increase gradually to recommendations.13

Try to do at the same time you do something else everyday to remember to do them daily.14

Start learning lying on back to engage only posterior pelvic muscles. Progress to perform sitting or standing.32,34

Try to start with empty bladder.13

Do not engage abdominal, thighs or buttocks muscles.24,34

Do not hold your breath.13,34

This study was congruent with that of Whitford et al.²⁷ regarding obtaining information about Kegels during pregnancy from written sources, 57.6% versus 59.4%. Hilde et al.²⁵ found 40% of women learnt from written material. Forty-three percent of women in this study mentioned providers as a source compared with 30.7% in the study by Whitford et al.²⁷ O'Neill et al.³⁵ stated books as the only source having a significant association with knowledge about UI problems. Ismail³⁰ commented printed material held more influence in comprehension for women on the importance of Kegels. Findings unanimously support the use of books or online materials as strong sources to use for educating women during pregnancy.

Bezerra et al.¹⁹ suggested incorporating educational interventions that mesh with the characteristics of the population. Older pregnant women benefit from workshops with handouts.³⁵ Younger pregnant women appreciate reminders³⁶ (i.e., through text/messaging). Health care needs to be proactive toward improving attitudes regarding pelvic health so value can be placed on Kegels as a preventive and corrective measure for UI before, during, and after pregnancy. Evidence-based user-friendly technologies should be developed to incorporate into methods of notification, guidance, and feedback as a means to integrate into women's daily lives.

Differences between providers/sites in teaching Kegels were noted in the findings.

Provider and care received has some impact on whether Kegels are taught and performed. In our sample, the site/state, birth route, birth location, and parity were the biggest factors for whether Kegels were performed during pregnancy. Clearly, there is some factor that occurs on the level of the site and provider that impacts Kegel performance. This study was not powered to evaluate site- and provider-level factors, so it is not possible to determine the cause of the association. However, this study does demonstrate the opportunity for changes in practice that improve Kegel education and performance. Approaches that emphasize the role of providers in preventing, identifying, and treating UI may improve rates of Kegel exercise, decrease rates of UI, and improve quality of life (physical and emotional) for women.

Of significance, women with UI during pregnancy (but not before) were more likely to perform Kegel exercises. Bø³⁷ noted women who engaged in Kegels during pregnancy reported less UI symptoms postbirth. A Cochrane Review by Woodley et al.²¹ determined Kegels during pregnancy lead to decreased risk by 29% of UI in mid-postnatal period (3–6 months post-birth), the study by Ko et al.³⁸ reported a 18%–24% decrease and Mason et al.²⁹ noted an 11.7% decrease; this study noted 17% decrease at 3 months. The data support use of Kegels to prevent and treat UI. Providers should encourage Kegels during pregnancy and postpartum for women regardless of incontinence status.¹⁵

This study found nulliparous women were significantly more likely to perform Kegels, which confirms the extant literature.²⁷ In general, multiparas with a history of vaginal birth performed more Kegels than those with a history of cesarean birth. Multiparas, regardless of birth history, had similar incidence of UI and need to be engaged in knowledge of Kegels. The study points out a misconception about risk for UI and existence of missed opportunities in teaching the importance of Kegels. Providers should not assume that multiparas know about Kegels or how to perform them effectively. Providers need to be proactive and accessible for guidance of Kegels among women who are learning or unsure if their technique is proper. Providers need to teach women how to make Kegels more purposeful.³⁹

Reinforced understanding about Kegels, guidance, and incorporating meaningful, identifiable scenarios for women may increase long-term use. Referrals to evidence-based websites could be a viable educational venue. Motivational interviewing may be a beneficial tool toward integrating long-term daily Kegels for women through discovering and integrating individual values and goals augmenting commitment.⁴⁰ This method incorporates a woman's responses thereby making the plan relevant and personalized. National health organizations should initiate a preventive health campaign for UI focusing on Kegel exercises because UI is no longer taboo in the mainstream media.

The majority of women performed Kegel exercises during pregnancy with ∼16 per session twice a day. These numbers are greater than the NICE guidelines but not the pregnancy-specific parameters from Michigan Medicine³³ of 50 Kegels or that of Bezerra et al.¹⁹ of 40 Kegels per day (Table 5). Although wide-ranging recommendations exist, the most important aspect is daily performance.^{13,14,19,27,29,32} Compared with previous studies of performance, the women in our study reported daily Kegel exercises, whereas other studies focused on the number of Kegels per week. Because of this discrepancy, it is difficult to compare with existing literature.

Although 96.2% women said they would continue Kegels postbirth, Kegel performance increased over pregnancy at 3 months but dropped to less than one in three women by 6 months. Chiarelli and Cockburn²⁸ noted 3 months postbirth, 58% women were performing Kegels three times per week or more. Whitford et al.²⁷ found more women did Kegels postbirth than during pregnancy with 60% still doing the exercises 6–12 months postbirth; however, only 8.1% were doing once a day or more. Our results show >20% women engaging in Kegels daily compared with <1.0% women engaging in daily Kegels reported in the literature. Other studies reported higher rates of performing Kegels; however, those participants were not adhering to a daily routine as the women in this study, thereby, women in other studies actually performed less cumulative Kegels per week.

Although the rates of UI were slightly higher among this population with a mean of 27 Kegels per day, we postulate that we may have had a healthier, exercising population with ∼83% having a normal BMI prepregnancy, women's perception of UI and Kegels could have been impacted, and closer relationships with the midwifery practices allowing women to report more openly. Kegels done daily or more often during pregnancy was associated with less UI postbirth than women who reported Kegels less often,²⁷ reinforcing the need to recommend a daily regimen. Proper performance is vital to effective Kegels; hence, recommendations are given in Table 6. Extant literature states Kegels need to be performed daily to effectively prevent postpartum UI.^13,27,29

Women in this study remarked they would seek care at 6 weeks postbirth if UI was present; however, women reported low rates of seeking treatment. Women more likely to seek care had UI during pregnancy and increasing severity of UI. Those seeking care were less likely to consider UI a normal life change. More women who had hospital births, were slightly older or older at their first birth responded to the follow-up surveys. The researchers cannot postulate as to why these specific characteristics enticed the participants to complete the follow-up surveys unless a greater sense of responsibility toward research is earned with age.

Although the intention was to seek care, women experiencing persistent UI in this study did not follow through with professional care. One in six women were going to seek care at 3 months postbirth and around one in four at 6 months. In the entire study, four women sought care. Getting professional care for UI was associated with increased parity and increased severity at 3 months postpartum. Education on the importance of treatment is crucial as women with UI 3 months and longer are at increased risk of long-term persistent symptoms.⁸ Women need to know and understand that requesting additional care for UI is acceptable and normal. They should be encouraged to seek care if symptoms persist although they have been performing Kegels, and health care providers need to validate this regimen.

Strengths and limitations

Strength of this study was capturing data from four sites around the United States to include the East coast, the Southwest, the Midwest, and Southern. Nulliparous and multiparous women in the sample were closely represented. Another strength was the large sample size, which was adequately powered to evaluate risk factors for UI during pregnancy. A limitation may be that the number of participants, from each contributing site, was uneven. A limitation of a convenience sample owing to the ease of recruiting participants from the respective midwifery practices may be less reliable secondary to the possibility of limited representativeness of the population. Asking every woman who met the criteria at each site for their participation controlled sampling bias and afforded the researchers a sample that was representative of each birth setting.

There was a difference in the samples across sites with one having a higher history of cesarean birth, hospital births, augmentation of labor, and epidural use. This may be because of the medical culture of the region and hospital site; although midwives attended some births, all eligible women were approached for the study regardless of birth provider. Although home birth is not a risk factor, it is important to note that six of these occurred at home. Eight women did have an instrumental birth, a risk factor. Both numbers were too small to determine any associations. The southern US homebirth/birth center site was barely represented with nine participants. However, the response rate at other three sites was good. Self-report may be inaccurate for evaluating whether women did perform Kegels.

Although this study was able to capture experiences up to 6 months postbirth, the response rate at 3 and 6 months was limited. The follow-up response rate was not as strong as the researchers would have liked, but the results were still informative to develop future hypotheses. The majority of participants were white, possibly impacting the results and making them less generalizable, although the population was representative of the settings. The observations and findings about the sample are strong for this specific group of women.

Conclusion

One in five women experienced UI before pregnancy. Almost two-thirds of women experienced UI during pregnancy and almost half of the 20% who followed-up experienced UI at 3 and 6 months postbirth. These exhibit a life-changing but preventable health concern for women. This study reveals continued opportunity to screen for UI and educate all women on daily Kegel exercises to prevent and treat UI. Kegels are a woman-controlled, noninvasive, preventative, and treatment for UI. Kegel exercises were performed by the majority of the women with a mean of 27 Kegels per day. Providers can begin this movement by educating all women that UI should not be viewed as a normal life change pre- or postchildbearing and daily Kegels increase the effectiveness and longevity of the routine.

With less than one in three women continuing Kegels at 6 months postpartum, the opportunity to initiate life-changing routines and change the attitude toward valuing Kegels and pelvic health exists and should be seized. The misconception that Kegels are only necessary for women with vaginal births should be eradicated. Providers should guide postpartum women to engage in continuation beyond the motivators noted in this study.

The main clinical issue is all women should receive consistent education and consistently perform Kegels. Women need awareness to request additional care and validation that a referral to physical therapy is beneficial and normal. The low rates of care seeking among women with persistent UI at 6 months postbirth is concerning and requires more investigation. Women are performing Kegels during pregnancy but further research is needed to identify what women require to become motivated to engage and adhere to Kegels as a daily regimen.

Author Disclosure Statement

The authors have no conflicts of interest to disclose.

Funding Information

No funding was received for this study.

Supplementary Material

Supplementary Appendix SA1

Supplementary Appendix SA2

Supplementary Appendix SA3