Knowledge and practice of pelvic floor exercise among pregnant women attending an antenatal clinic

INTRODUCTION

Most nations utilise the antennal programme in their efforts to promote and prevent health issues. Pregnancy health and improved neonatal outcomes require it. That is why the prenatal talks that some of our hospitals give to expectant mothers during prenatal visits mainly consist of lectures on antenatal exercises. Because of its many advantages, it is primarily recommended that people engage in mild to moderate physical activities frequently.

Pregnant women in many countries had little to no knowledge a few decades ago about the safety and health benefits of mild to moderate exercise for both the developing foetus and the expectant mother. However, recent research has demonstrated that engaging in these kinds of activities regularly largely carries no risk and is advantageous for both physical and mental health.^[1] Pregnant women should engage in specific exercises to maintain the strength of their pelvic muscles, support the healthy function of their abdomen, including the bladder, and prevent the common condition known as urinary incontinence, as pregnancy puts a lot of strain on these muscles. It is possible to avoid complications caused by weak pelvic muscles by adhering to the recommended pelvic floor muscle exercises (PFMEs).^[2] PFMEs are simple and effective; they do not require performance. These can be performed in any posture, such as sitting, standing or lying down with the knees apart. It only requires effort to find and use the right muscles.

The best exercises for managing pelvic dysfunctions and strengthening the pelvic muscles are the Kegel exercises.^[3] This exercise is named after the American gynaecologist Arnold H. Kegel, who originally published a description of it in 1948. Kegel’s exercise aims to strengthen the pelvic muscles through repeated contractions and relaxations. To complete the Kegel exercise, the bladder must be empty. While sitting or lying down, the person contracts their pelvic muscles, maintains the position and counts for three to five seconds. It can be modified or developed further to produce new versions. It is typically recommended to perform this exercise several times a day for a few minutes at a time. It needs to be done for at least one to three months to start having the desired effect.^[4–6]

Numerous studies show the advantages of this kind of conservative care, suggesting that it is a good option for treating pelvic dysfunctions, particularly urinary incontinence, brought on by the stress that childbirth and pregnancy place on the pelvic muscles.^[7] Performing these exercises increases muscle mass, which helps to stabilise the urethra.^[8] Although the value of PFMEs during pregnancy was known, there was little practice, according to a study done in Lahore, Pakistan.^[9] Similarly, while knowledge of PFMEs was relatively high among participants in a study conducted in the Enugu Metropolis, Nigeria, practice of the concept was low.^[10]

Numerous studies highlight the advantages of this kind of conservative care, suggesting that it is a feasible therapeutic approach for pelvic dysfunctions, particularly urinary incontinence brought on by the stress that childbirth and pregnancy place on the pelvic muscles.^[7] Completing these exercises result in an increase in muscle mass, which stabilises the urethra.^[8] A study carried out in Lahore, Pakistan, revealed that while there was awareness of the importance of PFMEs during pregnancy, there was little practice.^[9] Similarly, although participants in a study conducted in the Enugu Metropolis had a relatively high level of knowledge about PFMEs, the practice was low.^[10] Regretfully, few women in our country know about the benefits of pelvic floor exercises.

The majority of them believe that exercising during pregnancy is not a good idea because it might harm the developing foetus. To begin with, they are not aware of the pelvic dysfunctions brought on by pelvic muscle weakness. Some women feel uncomfortable bringing up these issues with their gynaecologists. Few people receive knowledge about these PFMEs from other medical specialists. The majority of women acknowledge that they do not follow the suggested exercise regimen.^[9]

This study was therefore created to evaluate PFME knowledge and practice among pregnant patients receiving antenatal care at the Enugu State University Teaching Hospital (ESUTH) and in light of the claims made by some studies that proficiency in the PFMEs does not imply proficiency in the routine performance of the PFMEs.

MATERIAL AND METHODS

This was a descriptive cross-sectional method. All expectant mothers who visited the ESUTH Parklane between January and March 2023 were included in the study.

The ESUTH Parklane is situated in the southeast Nigerian state of Enugu, inside the Enugu Metropolis. There are numerous universities in Enugu. The state is one of the Federal Republic of Nigeria’s 36 Federating States. The ESUTH Parklane, located in the Enugu North Local Government area of Enugu State, served as the study’s site. The hospital is at the intersection between Park Avenue, Parklane, and Hospital Avenue and behind the popular shopping mall Shoprite. It is located within the Enugu city area and extends over an area of 272 hectares. It has about 17 units and other academic departments. Specifically, the study was conducted in the antenatal clinic located in the maternity building. This clinic is located in the basement adjacent to the newborn intensive care unit and opposite the orthopaedic clinic. Antenatal clinics have an estimated number of five consulting rooms, one chief nursing office room, one record room, one orderly room, one nursing changing room and the area where pregnant women stay.

During the period under study, 104 pregnant women who attended antenatal care were recruited and included in the study. Hence, it was a total study of 104 respondents.

A self-administered questionnaire was employed, with two senior lecturers in the Department of Nursing Sciences, including the project supervisor, face-validating the instrument. To measure the respondents’ comprehension and applicability of the questionnaire’s contents, a pilot test of the instrument was conducted at the Poly Subdistrict Hospital in Asata, Enugu, with respondents who were similar to the test subjects – the pregnant women. The participants provided feedback on how to improve the questionnaire’s contents to measure the study’s goals. The Cronbach alpha coefficient pilot test results showed 0.875.

The Ethics and Research Committee of the Ministry of Health in Enugu State granted ethical approval (ESUTH/REF/VOL 1/107). Participants in the study faced little to no risk from the study. Moreover, no invasive procedures were performed during the study. Therefore, verbal informed consent was obtained from each participant after the study’s purpose was explained. Additionally, by locking the data and utilising code numbers rather than personal identifiers, the confidentiality of the information was ensured.

The data were analysed using both descriptive and inferential statistics. The descriptive statistics of mean and standard deviation, frequency and percentage were used to compile the questionnaire’s items. When evaluating scaled items using mean and standard deviation, the respondents deemed an item to be accepted if its mean was greater than 2.5 and rejected if its mean was less than 2.5. Each respondent’s total knowledge score was calculated by adding all their right answers to the knowledge items. If the knowledge score was 50% or lower, it was classified as poor; otherwise, it was classified as good. At the 5% level of significance, the hypothesis was tested using inferential statistics, specifically the Chi-Square test and Fisher’s exact test. If the p-value was less than 0.05, a significant relationship was thus present; otherwise, there was no significance. These analyses were conducted using the Statistical Package for Social Sciences (SPSS) version 25 and Microsoft Excel.

RESULTS

The age ranges of the participants were between 17 and 44 years, with a mean and standard deviation of 27.19 ± 5.37 and modal age group between 25 and 29 years (54.8%). The majority were married (54.8%). Most had tertiary education (80.8%). They were mostly professionals (29.8%), traders (19.2%) and civil servants (17.3%). The majority of them had one to two children (49.0%) [Table 1].

The results showed that knowledge of PFME among the mothers was good (77.9%). Specifically, virtually all mothers had heard of the PFME (91.3%), mostly the Kegel exercise (83.7%) and mainly from health practitioners (50.0%). Known benefits of the exercise included maintaining the strength and contractile force for the efficient functioning of the pelvic floor (75.0%), preventing stress urinary incontinence (71.2%), enhancing postpartum health (87.5%), preventing prolapse of pelvic organ (72.1%) and improving sexual function (76.0%). The majority of the mothers knew it could be performed during pregnancy (62.5%) and at any time in one’s life (59.6%). Not many, however, knew the exercise is not only for pregnant women (41.3%) [Table 2].

The majority of the mothers practised PFME (77.9%), mainly the Kegel exercise (90.1%), which they performed at home (88.9%). A majorityy performed the exercise at least for ten minutes (72.8%); 53.1% performed for at least 20 minutes; and 29.6% for at least 30 minutes. The exercise started in the first trimester for the majority of the mothers (50.6%). The number of contractions was largely between one and three (35.8%) and three and six (29.6%), while the sitting position was largely adopted for the exercise (58.0%) [Table 3].

Forgetfulness was the major factor influencing the practice of pelvic floor exercise (2.81 ± 0.85) followed by the stress of pregnancy (2.70 ± 0.75) [Table 4].

There is statistically a significant relationship between the mothers’ knowledge and practice of PFMEs (p < 0.001). Mothers with good knowledge associated with the practice (88.9%) were more than those with poor knowledge of the practice (39.1%) [Table 5].

More so, educational status was significantly related to the practice of PFME (p = 0.041). Specifically, mothers with higher education who practised PFME (82.1%) were more than those with lower education (60.0%). Practice of PFME was not significantly related to their age (p = 0.418), marital status (p = 0.192), occupation (p = 0.188) and number of children (p = 0.842) [Table 6].

DISCUSSION

This study aimed to evaluate pregnant women attending a clinic at the ESUTH about their knowledge and practice of PFME.

The results indicated that a sizable portion of the respondents knew a good deal about PFMEs, and the majority of them primarily learned about them from medical professionals. This data on PFME knowledge contrasts with findings from a related study by Mbada et al., which found that only 37.0% of participants were aware of pelvic floor exercises.^[11] One possible explanation for the relatively high percentage of PFME knowledge among the women in this study is that most of them had postsecondary education and may have valued health information. The support that medical professionals offer during prenatal sessions is another thing to think about.

Ironically, the majority of people who were aware of PFMEs were also proficient in their use. This is consistent with findings from an earlier research,^[12,13] which found that knowledge of PFMEs was a significant factor in determining compliance. In contrast, Okeke et al.’s study found that although a relatively high percentage of participants (71.02%) knew about PFMEs, only 38.37% practised them.^[10] The results show that while there might be additional factors that prevent or interfere with pregnant women following the advised exercise regimen, pregnant womens knowledge of PFMEs does guarantee that they will follow PFMEs. Therefore, it follows that educating women is essential to lowering pregnancy-related problems and expecting mothers should seriously consider attending weekly prenatal exercise classes.

Forgetfulness and pregnancy-related stress were cited by the majority of study participants as the main factors influencing the use of PFMEs. This conclusion is supported by a related study,^[14] which discovered that women’s willingness to exercise is influenced by certain barriers. The results of a similar study carried out in Nigeria on a sample of 252 pregnant women support this. The study revealed that despite being enrolled in the education programme, only 38.3% of the sample completed the PFMEs. Additionally, it was determined that the primary obstacles to the exercises were fatigue, lack of time and forgetting about the exercises.^[10]

Pregnant mothers’ knowledge and practice of PFMEs were found to be significantly correlated in this study, suggesting that mothers who had better knowledge of the practice were more likely to engage in it than those who had less knowledge. The greater knowledge may have resulted from the respondents’ appreciation of health information due to their higher education; subsequently, this high knowledge was put into practice, as the majority of these women engaged in PFME. This contrasts with a study where the knowledge was high but did not translate into practice.^[15]. Additionally, Alharbi et al. found that only 38.5% of their sample was performing the exercise adequately, even though over half of their sample had satisfactory knowledge of the exercise and over 70% had an attitude favouring the exercise.^[16] These results diverge from ours, especially about the high degree of practice in our sample.

While the number of children, age, marital status and occupation did not appear to be associated with the practice of PFMEs, our investigation did reveal a significant relationship between practice and educational status. More mothers completed PFMEs with higher rather than with lower education levels. This is in line with a study that included 169 Pakistani women and discovered a positive relationship between educational attainment and awareness of PFMEs.^[17] A study involving 349 pregnant women was also carried out in Ethiopia to assess antenatal exercise-related factors, such as PFMEs. According to the study, employment, education level and getting advice on exercising during prenatal care were all correlated with prenatal exercise knowledge, attitude and practice levels.^[18]

CONCLUSION

Conclusively, this research demonstrated that expectant mothers possessed a strong understanding of pelvic floor exercises, particularly the Kegel exercise, which they primarily performed at home. The main factor influencing the practice of PFMEs was forgetfulness. More specifically, the application of PFMEs was linked to knowledge and educational attainment. Therefore, it is advised to give pregnant Nigerian women the necessary instruction or encouragement to emphasise the value of PFME practice. Weekly prenatal visit sessions should incorporate the PFME programme, in which a physiotherapist will instruct and motivate the women to engage in the practice. Since practice is impacted by educational attainment, the government could be a major player in fostering an environment that can enhance the education of girl children.