Promoting Continence in the Childbearing Year

Research has shown that childbirth is a major cause of urinary stress incontinence and it is also a factor in faecal incontinence. There are many healthcare professionals who work hard to raise the awareness with women in the childbearing year about these risks and include pelvic floor muscle education and information on bladder and bowel health. Unfortunately many women do not see the importance of these exercises and then, after childbirth, when a problem arises are too embarrassed to seek medical advice. Incontinence is still a taboo subject.

A group of like-minded professionals decided to address the issue to ensure that women who were potentially at risk of developing continence problems as a consequence of childbirth, did not 'slip through the net'. June, 2002 saw the formation of a regional multi-professional group comprising mainly continence nurse specialists, specialist physiotherapists, midwives, health visitors, one colorectal surgeon and three consultant obstetrician & gynecologists.

A process mapping exercise was conducted in the North West to establish what services were available to women in the childbearing year, this addressed issues such as assessment, diagnosis, treatment, collaborative working and management organizational issues. The outcome was patchy; there was a huge variation in quantity, range and type of provision.

The mapping exercise identified several areas where service provision could be improved, the use of good quality patient focused literature, an assessment tool that would indicate women at risk, improved communication between the healthcare professionals associated with this target group and the sharing of good practice.

It was evident that the midwife, could be the most proactive healthcare professional involved with these women, therefore the use of an assessment tool completed after delivery may indicate which women may be more at risk of continence problems in the future. The group devised a 'Pelvic Floor Risk Assessment Tool' which is currently being piloted.

In autumn 2003, PromoCon carried out a review of free pelvic floor literature for women.

Giving information verbally has benefits but also has the problem of limited recall; literature is a necessary part of health education to supplement professional advice. Literature can also play a preventative role for people who have not yet accessed a healthcare professional or who do not wish to do so. It would be impossible for trained professionals to teach pelvic floor exercises to all women. Whilst it would be ideal for all women to see an appropriate healthcare worker, in reality many women will attempt to 'treat' themselves through advice in literature. The literature therefore must be clear and unambiguous and teach the exercises correctly whether it is intended to supplement advice or to stand-alone.

The aim of the review was to examine the literature from the perspective of the user. Health literacy is defined as the ability to read, understand and act on written health information. Health illiteracy is a huge problem and needs much to be done to ensure that literature is written in an appropriate form. Understanding health information is everyone's right, improving health communication is everyone's responsibility. Legally the Disability Discrimination Act (DDA) states that reasonable adjustments must be made to ensure that those with disabilities can access information. These same adjustments can also make the information more accessible to those with general difficulties in reading Standard English text. It is an aspect that is given little consideration when writing advice sheets. Many healthcare professionals are asked by their Trust to write their own advice handouts, yet I suspect that few have had training in how to write in a way that will improve health literacy.

There is evidence to show that women learning pelvic floor muscle exercises (PFME) purely from leaflets can learn incorrectly and can actually cause herself harm (Bø et al., 1988; Bump et al., 1991). This emphasizes the need for any literature to be of the highest quality. The review identified that many leaflets contain misleading or incomplete information, which could result in the reader learning an incorrect technique.

The review aimed to identify good key features that should be included, and key features that should be avoided. It could also serve to increase the awareness of literature currently available for different target groups. 35 leaflets were evaluated. Many of these locally produced; some were available from product companies and some from charities.

The target groups were the elderly, pregnant women, new mothers, children, teenage girls, people with learning difficulties, people who had a stroke, people with Multiple Sclerosis, and women in general.

The review identified that there is a huge variation in the standard of leaflets. It was possible to make suggestions to improve even the best of leaflets and the poorer leaflets still had aspects that were good. Some leaflets contained information contrary to current teaching.

Each piece of literature was evaluated on many aspects which covered general layout, complexity of grammar, vocabulary, clarity and completeness of explanations regarding anatomy and causes of damage, instructions for pelvic floor exercises and recommendations for frequency of exercises, signposting for further help, tests for success and options for further treatment. In addition the uses and clarity of pictures and diagrams was evaluated. At the start of the exercise as a non-expert in this subject the researcher could more easily identify literature, which was difficult to understand, or which led to ambiguities. By the end of the review, considerably more knowledge had been acquired. Care was taken to prevent this knowledge from influencing the evaluation. A user group for people with literacy difficulties was involved, as was the help of family, friend and non-specialist work contacts.

The results of the review indicated a need for guidelines, to enable individual Trusts and companies to write information in their corporate style, but with uniformity of content that would be acceptable for the majority of the UK population, therefore providing better communication between the healthcare professional and the patient. The guidelines for writing pelvic floor exercise literature were published in May 2004 with an educational grant from Tena. The guidelines may be downloaded (the guidelines may be opened using the latest version of Adobe Reader which is available free from the adobe web site) from this website or are available in a 'hard copy' format

The project will continue and PromoCon will ensure that information will be disseminated in order to facilitate service development for women in the childbearimg year.

The 'Pelvic Floor Risk Assessment' Tool has been evaluated and is available to download. For multiple copies in a 'tear off' pad format contact Neen Healthcare on 0161 678 0233. The tool is also available on CD-ROM.

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