Where do we, in the US, get it wrong and the French get it right when it comes to care for new moms? In France, pelvic floor rehabilitation is an essential component of the perinatal healthcare experience, as a recent Slate.com article details. In the US, this type of attention to physical pregnancy- and birth-related effects during postpartum care is almost nonexistent. Yet its absence may be part of the reason for the prevalence of long-term issues such as incontinence, according to studies found in the Cochrane Reviews, as well as my clinical experience and that of my colleagues. In fact, over half of women over 20 years old in the US experience some type of incontinence, according to a 2001 to 2008 National Health and Nutrition Examination Survey. This begs the question: if women in the US received France’s level of pelvic floor postpartum recovery guidance, would our prevalence of incontinence be so high?
With this in mind, consider the following scenario on the other end of the spectrum, which played out in the Boston area a few years ago: A woman was referred to me by a urogynecologist (a physician specializing in female pelvic medicine and reconstructive surgery) for physical therapy treatment for urinary incontinence and pelvic pain. Symptoms were progressive over several years and she had two vaginal deliveries over 20 years prior, one of which was considered “traumatic” to her pelvic floor. She was a labor and delivery nurse at an urban teaching hospital. As therapy progressed and her symptoms improved, we fell into several philosophical discussions as to why postpartum rehabilitation was not widely known or endorsed as an option simply given the stresses on the muscles, fascia, and nerves in the pelvis (collectively referred to as the pelvic floor) during uncomplicated and normally progressing pregnancy and childbirth. She attempted to continue the conversation at work one day with an experienced obstetrician with whom she had worked closely for several years and relayed that it went something like this:
Nurse: You know, I have been going to pelvic floor physical therapy for a few months and it has been really helpful. I think it would have been even more helpful if I had been able to do it closer to when I had my children.
Nurse: Well, it makes me think that maybe we should consider recommending postpartum PT for all of our patients.
Physician: That would be a huge waste of resources! We have no idea which women will go on to have problems, so why would we try to provide a service to all of them!
Contrary to her colleague’s unfortunate and extremely limited view, there are several ways to identify women who would be the most likely to benefit from postpartum rehabilitation. In fact, the single greatest predictor of urinary incontinence postpartum is incontinence during pregnancy. Armed with this knowledge, there is a huge argument to be made that any woman experiencing leakage of urine during her pregnancy should be referred for pelvic floor rehabilitation during pregnancy and/or postpartum. A second, easily identifiable group is women who have known tears or other trauma to the pelvic floor muscles during childbirth. By definition, a third- or fourth fourth-degree tear has gone deep enough into the tissue to tear muscles in the pelvic floor — muscles that are important for continence, sexual health, and support of pelvic organs and joints. Conventional medical practice includes physical therapy for muscle tears in other areas of the body (think about it— ever known anyone with a rotator cuff tear or hamstring tear that didn’t go to physical therapy to rehabilitate?). Physical therapy for a tear of the pelvic floor muscles should, without question, be consistent with standard of care for other body regions.
Physical therapists (known as physiotherapists in many countries outside of the US and kinestherapeute in France) with training in pelvic floor function, pregnancy, and postpartum rehabilitation are a requisite stop in the early postpartum journey. These physios help new moms identify the correct way to perform pelvic floor exercises (more commonly known to us as Kegel exercises), often using tools such as biofeedback and electrical stimulation to help the process. They make recommendations for pelvic floor exercise progression and frequency and provide a plan for rehabilitative exercise for other areas in the body weakened by pregnancy. The French government pays the full cost of 10 30-minute one-on-one pelvic floor visits followed by 10 additional visits primarily focused on restoring strength and function of the abdominal wall. They do this to prevent postpartum incontinence and pelvic organ prolapse, and to restore sexual function—all key factors in long- and short-term women’s health and happiness. In recent years, the New York Times and other media outlets have featured stories talking about this care paradigm and the experiences of both French and American women who utilize the care. While it seems that the features themselves and the comments they elicit indicate that this level of openness in dialogue and care regarding pelvic health tests the boundaries of comfort in our society, women across the board are grateful for the outcomes.
As for the doctor’s argument that pelvic floor rehabilitation is a waste of resources, France again, demonstrates the opposite is true. France is a country with a government-sponsored healthcare system and supplemental private insurance. Such systems are often vilified with claims that they offer only restricted access to care and limited coverage for services we in the States have come to expect.
If this is the case, what does this say about France’s perspective on the value to individuals, families, society, and lifelong healthcare expenses for postpartum pelvic floor rehabilitation to be standard practice? It means that rather than being seen as a waste of scarce healthcare resources, it is seen as a proactive step that mitigates a woman’s lifetime risk of more significant dysfunction, hence protecting her (and their healthcare system!) from more costly and invasive interventions over the course of her lifetime. To be fair, I have often heard and read that France’s support of this level of postpartum care is a testament to a patriarchal society that simultaneously values high birth rates and women who remain as pleasing to look at as they are in the bedroom. Maybe, but why is this considered necessarily a bad thing for the woman – to have more than one child, a relatively flat belly, and a good postpartum sex life? Count me in.
France isn’t alone, either. Similar routine postpartum care for pelvic and musculoskeletal health is also the norm throughout the United Kingdom and other parts of the world. For example, published guidelines from the Royal College of Obstetrics and Gynaecologists indicate that “all women (who have sustained a 3rd o 4th degree tear) should be offered physiotherapy and pelvic-floor exercises for 6-10 weeks after anal sphincter repair.” Female colleagues and patients who have given birth in the UK share with me the elevated support level in postpartum care they experience (a visit from physio while in the hospital and multiple home visits postpartum). The typical one- or two-visit check-up and brief mention of Kegels to new moms in the US pales in comparison. Even physicians at a hospital with limited resources in the Democratic Republic of Congo (Central Africa), according to a physio-colleague of mine with experience in the region, are referring to their physiotherapy department for postpartum pelvic floor training and rehabilitation because they have seen its benefit for women before and after fistula repair!
Physical therapy is a covered benefit for most health plans in the US, so barriers to a change in practice patterns here are not likely to come from lack of coverage. The barriers are more likely that change of any sort is hard: a change in moms’ postpartum priorities (YES—your health is worthwhile and important to your family!), a change in maternal healthcare to open a dialogue with rehab professionals and begin to collaborate in care, and a change in the Physical Therapy (PT) approach to better educate and engage both the community (moms!) and our colleagues in healthcare about the benefits of perinatal rehabilitation. More physical therapists trained in these women’s health concerns are also needed to meet any increased demand for services, but fortunately based on the national conversations within our field, the number of pelvic floor/women’s health PTs seems to be the rise. And according to market rules of supply and demand, increased demand from the consumer and from other healthcare professionals will likely spur further growth in the supply of these PTs, and thus increase awareness and access to care for women.
In short, we have an identifiable women’s health problem with an identifiable course for intervention. As moms, we need to value ourselves and our bodies enough to take a page from this French lesson and ask our healthcare providers about postpartum physical recovery and rehabilitation. We should be able to talk about important issues of bowel, bladder and sexual health—yes, even use the word “vagina”—without blushing, and without feeling we are doing something scandalous or titillating. If you’ll pardon the expression, it’s time to put on our Big Girl Pants.
If you are interested in finding a PT who can help in your perinatal musculoskeletal and pelvic health, the following resources may be helpful:
www.apta.org- Go to their “Find a PT” section. Select “Women’s Health” as the specialty area from the drop down menu.
www.hermanwallace.com- Use their “Practitioner Directory” to search in your area.
Lastly, here are a few statistics and facts to help paint a picture of the scope of this problem. Hopefully they will be additional food for thought and stimulate further dialogue about this important issue:
- Approximately 80% of American women experience pregnancy and childbirth at least once in their lifetime
- Female pelvic pain is at least as prevalent as lower back pain and asthma (know anyone with either of those??)
- Pelvic floor compromise can occur during pregnancy and during childbirth
- Estimated lifetime medical cost for a woman with stress urinary incontinence is $58,000
- Over 50% of women in the US have urinary incontinence, and this is on the rise
- Experiencing pain during sex (after six weeks postpartum) is not a normal consequence of childbirth.