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Research and Projects

APPEAL (Antenatal Preventative Pelvic floor Exercises and Localisation) - Delivery of Pelvic Floor Muscle Exercise Education for Women During Pregnancy

Who is involved?

Theme: CLAHRC - Person-Centred Care
Status: Live

APPEAL is an NIHR programme grant led from University of Birmingham and brings together a programme of research to prevent pregnancy- and childbirth-related urinary incontinence. The overall aim of APPEAL is to increase the number of women doing pelvic floor muscle exercises during pregnancy and ensure that they are doing them ‘properly’. This should reduce the number of women who suffer with symptoms of urinary incontinence after birth. 


Pregnancy and childbirth are important risk factors for urinary incontinence (UI) in women. Pelvic floor muscle exercises are effective for prevention of postpartum UI. Guidelines for the management of UI recommend offering pelvic floor muscle training to women during their first pregnancy as a preventive strategy.


APPEAL has 4 linked stages:

Stage 1 (Exeter team)

We will review the literature (using the Critical Interpretive Synthesis approach) and interview women and midwives to explore their views about the exercises and how and when they are offered. This information will be useful when identifying the best way to encourage midwives to offer and teach the exercises, and women to do them regularly.

Stage 2

Being able to carry out these exercises properly is essential to get the most benefit from doing them. So, stage 2 will look for the best and most acceptable way for women to judge how well they can do them.

Stage 3

Stage 3 will use information from previous stages to develop and test a motivational training package for midwives to help women to perform pelvic floor exercises correctly and regularly; and for women to view this as important. We expect it will help women keep a healthy pelvic floor that works well.

Stage 4

In this stage we will test the motivational training package in a study where midwifery teams will be selected (at random) to either receive this training or continue to provide their current routine advice on pelvic floor exercises. We will collect information on women’s health, how often they did their exercises and how many report urinary incontinence 10-12 weeks after birth. We will also measure if the package is good ‘value for money’.

Project aims

To improve the implementation of preventative structured antenatal pelvic floor muscle exercises and thus reduce the risk of urinary incontinence following childbirth.

PenCLAHRC (Exeter) is leading the first Work Package of APPEAL - Context Awareness: Identifying barriers and enablers:

1. Synthesis of qualitative and observational research

Objective: Understand the barriers to, and enablers of, implementation and uptake of pelvic floor muscle assessment and exercises during the childbearing years. Read the sythesis protocol here.

2. Focused Ethnographic observation of clinical practice

Objective: Explore how individual, professional and organisational factors interact to enhance or reduce effective pelvic floor muscle exercises implementation in the UK context.

The findings from Work Package 1 will inform the wider APPEAL research project’s development and evaluation of the training package for midwives. Dissemination of findings will include presentation at local, national and/or international research meetings, and publication in an appropriate peer-reviewed journal. 

Outputs and Impacts

Pelvic floor training in pregnancy could help prevent the need for ‘barbaric’ vaginal mesh surgery. 


National Institute for Health Research (NIHR) programme grant for applied research (RP-PG-0514-20002).

Related Publications

Salmon VE, Hay-Smith EJC, Jarvie R, Dean S, Oborn E, Bayliss SE, Bick D, Davenport C, Ismail KM, MacArthur C, Pearson M. Opportunities, challenges and concerns for the implementation and uptake of pelvic floor muscle assessment and exercises during the childbearing years: protocol for a critical interpretive synthesis. Systematic Reviews (2017) 6:18

This protocol has also ben published in PROSPERO International prospective register of systematic reviews.

An article was published in The Conversation discussing how training in pregnancy for pelvic floor exercises could reduce the need for "barbaric" vaginal mesh surgery.

Related Projects

Pelvic Floor Muscle Training - Professor Rod Sheaff ran this project evaluating if a package of Pelvic Floor Muscle Training (PFMT) delivered in primary care resulted in fewer referrals to secondary care for UI.

Others Involved

Rachel Jarvie, Victoria Salmon


NIHR CLAHRC West Midlands
NIHR CLAHRC East Midlands
NIHR CLAHRC South London

The project is led by Prof Christine MacArthur at University of Birmingham with partners from Birmingham Women’s NHS Foundation Trust and Universities of Nottingham, Leicester, King’s College London and Otago (New Zealand).

University of Birmingham
Christine MacArthur 
Khaled Ismail 
Clare Davenport 
Tracey Roberts 
Karla Hemming
Jane Daniels 

Birmingham Women’s NHS Foundation Trust
Tracey Johnston 

University of Otago, New Zealand
Jean Hay-Smith 

King's College London
Debra Bick 

University of Warwick
Eivor Oborn 

University of Leicester
Doug Tincello 

University of Nottingham
Tim Coleman