A total of 31 women took part in seven focus groups (three face-to-face, three online audio/visual, and one online written) which took place between May and August 2018. The age of participants ranged from 28 to 43 and participants either had one or two children and these children varied in age between 7 months and 5 years. The majority of participants were married  with the remainder cohabiting or single. The majority of participants were educated to degree or masters level  with the remainder reporting a professional qualification, no qualifications or declining to comment. The findings from this study are reported under three themes: perceptions and experiences of engagement in postnatal physical activity, perceptions and experiences of postnatal pelvic floor muscle training and potential postnatal intervention features.
Perceptions and experiences of engagement in postnatal physical activity
All women reported they wanted to be physically active on a regular basis but the majority of participants reported not engaging in physical activity at the time of the focus groups. Throughout all focus groups time was consistently identified as the biggest barrier to physical activity.
“Time is a huge thing obviously…you just don’t have the same time.” (FG 2, P1)
“I think time is a big barrier to me at the moment…working it all around bed times and feeding and all that kind of stuff, it’s a bit tricky.” (FG3, P2)
Women also mentioned fatigue, physical pain (including arthritis and back pain), prolapse, body image and confidence as barriers to engagement in physical activity.
“I don’t want to go to the gym because I’m embarrassed about the size I am, I’ve not really got the confidence to go there.” (FG3, P1)
The most frequently reported facilitators of engagement in physical activity was the psychological benefits of improving mental health and having “me-time” and the impact of physical activity on weight loss.
“…my biggest motivation is just wanting to be more toned and get back to normal again.” (FG 3, P2)
Others reported wanting to set a good example to their children:
“I want my kids to be active, and I think the best way to show them that is to be active myself…so it becomes that habit for them as well.” (FG 5, P4)
Women reported variation in the availability of local physical activity facilities which accommodate children. Some women reported buggy exercise activities in their local park but others reported that the information about groups on the internet is not up-to-date and many are not running anymore. Others reported the availability of crèche facilities in local gyms, walking and pushing the buggy and using relatives to babysit to enable them to engage in physical activity. The barriers reported were closely associated such as husband working away, not living near family, having less money for gym membership and crèche facilities being on maternity leave or working part-time. Those women who reported engaging in physical activity before they were pregnant reported less barriers to engaging in physical activity.
“I did kind of more extreme sports, quite a lot of sailing and skiing. I quite like going for a run or a really brisk walk. I go out with the buggy as much as I can and I’ve been doing a fit camp…I’m hoping I can kind of gradually ramp it up, because I’d like to be (doing more) as time goes on.” (FG 7, P8)
Conversely, women who had never been physically active displayed lower levels of intention to become active in the future. One participant declared:
“I find it very difficult to do any physical activity but I was the same before having my child as well…it’s not something that I’ve been interested in ore something I’ve been motivated to do, it’s a chore.” (FG 1, P1)
Perceptions and experiences of postnatal pelvic floor muscle training
All but one participant was aware they should be doing PFMT after having a baby. For most of these participants they were told they should engage in PFMT once they were pregnant. This was usually by their midwife who told them they should be doing PFMT and provided a leaflet. There was one participant who was only given a leaflet and not told by their midwife to do PFMT so she was not aware she should be doing PFMT until after she had been through child birth:
“I don’t think I did them when I was pregnant, I don’t think I really knew about them. I don’t remember ever thinking about it or it wasn’t until I think they came to see me after I’d had my baby to tell me that I should be doing pelvic floor exercises and I got a leaflet. I think that was maybe the first time I’d ever heard about them.” (FG 3, P2)
Participants who received a leaflet were never taught the correct PFMT contraction and some found this a barrier to engaging and maintaining PFMT.
“I was given a leaflet, ehm nobody really demonstrated or kind of showed you how to do the pelvic floor exercises.” (FG 3, P4)
“I find it a very difficult exercise to know how to do, I tend to squeeze my stomach in and think “oh i’m not doing it right?”” “No-one can really watch you doing it, so you kinda presume you’re doing it right.” (FG 1, P1 and P2)
Some of our participants received a physiotherapy assessment after the birth of their first child. This assessment involved checking their abdominal muscles and ensuring they knew how to do a correct PFMT contraction.
“I didn’t get any support after I had (first child) with pelvic floor or even any discussion. Then when we moved to West Lothian, and then I had (child named), and West Lothian do a, they come round, the physios when you’re in your bed after you’ve had the baby and talk about pelvic floor and go through a sheet of exercises with you so I went home with that, so I think that was really helpful…” (FG 2, P3)
However, one of the participants who was in one of the hospitals providing a post-natal physio service described her son being too ill for her to receive this service.
“…in Glasgow a physio sees you after, sees everybody in the postnatal ward. So a physio came to see me, checked my abs and checked that I knew how to do pelvic floor but because my son was so ill she was like ‘oh you don’t need to be worrying about this right now.” (FG 2, P5)
Another had a prolapse after childbirth and had to pay privately to access appropriate care:
“…I didn’t really get any advice or anything like that, and after I had (baby named) I had huge pelvic floor issues, I ended up with a, ehm mild prolapse after having (baby named), so I really could’ve done with support and I had actually went to my GP and said ‘look something’s not right, I need a referral to a physio or something’ and she said ‘oh we don’t do that’ so I ended up seeing someone private to get advice and everything.” (FG 4, P1)
The participants all felt that the benefits of PFMT should be more widely discussed, including before women have children and information should be more readily available. They felt the benefits of PFMT were not explained because of taboo issues:
“It’s something that a bit of a weird taboo in society, speaking about women’s private parts and it’s a shame, because if women talk about bladder problems and what happens early on. Then maybe you’d do something to stop that from happening. Whereas, it’s only kind of mentioned to you when you start having babies…” (FG 1, P2)
Potential postnatal intervention features
There was consensus among all participants there is a lack of aftercare for women after childbirth and in particular, with PFMT.
“I think if the health visitor had more sign posting information about like keeping yourself well and like how to get you back to being physically active and things, that would’ve helped …the health visitor did focus primarily on the health of the baby and your mental health...” (FG 3, P3)
All women felt an intervention would be a good idea and there was consensus around potential features:
Physiotherapist session to teach correct PFMT contraction
There was consensus among all participants that generally women do not know how to do a pelvic floor contraction and do not know if they are doing a correct contraction. Some women suggested a physiotherapist check should replace the GP check at 6 weeks as they felt a health check, a recommendation and sign posting to physical activity and teaching a PFMT contraction would be better than the current GP service.
“...I saw a GP who did nothing, you know that (a physiotherapist) would be far more beneficial just to check, I dunno like your muscles are healing and everything correctly and have some sort of antenatal maternity check. I feel like they totally didn’t have anything at all.” (FG 2, P1)
And another participant paid privately for this service:
“...with both of them, after I got to the point of being able to exercise, I went for a full postnatal check-up with the physio, cos I think like when, you know, you’re worried about your back, I think that gave me reassurance that everything was okay to exercise and that back problems are normal until you build up your core, ehm, I think that helped me be more confident in doing it and not so worried that something was going to happen to me.” (FG 3, P4)
“P2 Yeah, they kind of focus on the wrong thing. Like I felt like every appointment you went to they talked to you about contraception. You've all been using contraception for a lot of years.
P6 Yeah. They're kind of like lecturing you about something you already know about. And then they're not telling you about things that you do need to get educated on, that you haven't really caught onto yet.” (FG 4)
Some participants felt six weeks was too soon for a health check:
“P3: The check-up is quite soon after you have a baby isn’t it, youre just ‘Oh I survived, I’m alright, I’m looking after this baby, I think ok,’ at six weeks you’re not really thinking about yourself and getting back into fitness yet are you? But at 12 weeks you probably are more thinking of that.
P8: Yeah 12 weeks would definitely be more realistic for getting your head round, cos yeah six weeks in you aren’t back to thinking about your own body yet. You’re just still just coping, just getting through, very much still living day-to-day at that stage.” (FG 3)
Others felt 6 to 8 weeks was an appropriate time
“I think maybe six/eight weeks after is maybe a good time”. (FG 6, P3)
There was a general feeling that incontinence is taboo and by having support women would be more likely to talk about it which would make them feel less isolated. As one participant explains it was only once she had UI after childbirth she realised how common it is:
"I was quite down when I had my son about what was going on. And I thought that it would only sort of happen to very few people. But it was only after that and going to the GP that you realise how common it is." (FG 1, P1)
There is a need for signposting and making women aware of the need to look after themselves:
All participants felt a free NHS approved or branded app would be very useful. The participants explained that everyone has a smartphone and generally has them quite close by. In three focus groups there was at least one participant who had experience of the squeezee app. (This is an app recommended by physiotherapists to remind people to do their PFMT contractions. Women can set the app to remind them at convenient times of day and modify their regimen as their muscles become stronger. It is not free and participants paid £3.99).
“…you spend time on your phone and it’s the reminder that reminds me, And it teaches you how to do them, it kind of gives you step by step what to do it times you records you’ve done it….Its great... Yeah like the long hold you’re supposed to do if you can’t do it for ten seconds you can do it for five or whatever and build it up so you can change it you can change it” (FG 2)
“…because you always have your phone on you essentially, most people have some sort of electronic device on them pretty much at all times even at you’re not actively using it at the time, it’s still in your pocket.” (FG 5)
In the focus groups other participants had not heard of the app and incorrectly assumed it taught a correct contraction however felt it would still be useful if they could also be taught a correct PFMT contraction. There was also general consensus about the features of an app to support PFMT, suggesting it had reference material explaining why PFMT is important, the benefits of maintaining a regimen, diagrams of muscles involved and recording of regimen so women can see their progress. As one participant explained this would allow women to compete against themselves:
“I quite enjoy being quite competitive with myself and trying to achieve wee goals and being on my own with exercise.” (FG 3)