Pelvic floor dysfunction and incontinence are common after pregnancy and childbirth. In the first 3 months after childbirth about one in three women have urinary incontinence and up to one in ten have faecal incontinence. Pelvic floor muscle training is the recommended first-line care to prevent and treat both forms of incontinence.
In July 2020 we published a PEDro blog summarising a Cochrane review that estimated the effects of pelvic floor muscle training (antenatal or postnatal) for preventing or treating urinary and faecal incontinence in late pregnancy and after childbirth. The review concluded that structured antenatal pelvic floor muscle training for continent women can prevent the onset of urinary incontinence in late pregnancy and in the early and mid postnatal periods. Uncertainty surrounds the effects of pelvic floor muscle training as a treatment for urinary incontinence in antenatal and postnatal women and for the treatment of faecal incontinence.
Information about value for money is required by health services and policy-makers to inform service planning and determine the best use of the limited funds available to promote health and provide health care. A systematic review has recently been published that expands on the results of the Cochrane review by reanalysing the trials to determine the costs and cost-effectiveness of different models of care used to provide pelvic floor muscle training in the antenatal or postnatal periods. The aim was to determine the most cost-effective way of providing pelvic floor muscle training to prevent or treat postpartum incontinence.
Trials included in the Cochrane review were included in the cost-effectiveness review if they reported statistically significant between-group differences in preventing or curing incontinence and contained sufficient information about the intervention to categorise the pelvic floor muscle training on two strata. The strata were: (1) individual, group-based or mixed individual and group; and (2) during or after pregnancy. The participants were pregnant or postnatal women. The primary outcome was postpartum urinary or faecal incontinence. Costs for each model of intervention were calculated in 2019 Australian dollars using publicly available market rates and enterprise agreements (including estimates of health service, consumer and societal costs plus cost savings). One author performed the calculations, which were cross-checked by a second author. The incremental cost effectiveness of each mode of intervention delivery to successfully prevent or cure one case of incontinence were calculated. Sensitivity analyses were performed to account for variations in the number of participants per group for group-based training, the cost of patient out-of-pocket costs, salary rate of the health professional delivering the intervention and the proportion of patients who would have postnatal incontinence without intervention.
Eleven trials (3,005 participants) were included in the cost effectiveness analysis. Three models of intervention were evaluated: (1) individual pelvic floor muscle training during pregnancy to prevent urinary incontinence (2 trials); (2) group-based training during pregnancy to prevent or treat incontinence (3 trials); and (3) individual postnatal training to treatment urinary incontinence (3 trials) or urinary and faecal incontinence (3 trials).
The costs to the health service to prevent or cure one case of urinary incontinence were $768 for individual pelvic floor muscle training during pregnancy and $1,970 for individual postnatal training. In contrast, group-based training during pregnancy generated a cost saving of $14 if there were eight participants per session. Sensitivity analyses revealed that savings were greater if more participants attend each group. The health service cost per faecal incontinence case prevented or cured was $2,784. The certainty around these cost estimates (ie, 95% confidence intervals) were not reported.
Providing group-based pelvic floor muscle training for all women during pregnancy is more efficient than individual training. However, providing pelvic floor muscle training for postnatal women with urinary incontinence should not be discounted because of the added known benefit for preventing and treating faecal incontinence.
Brennen R, et al. Group-based pelvic floor muscle training for all women during pregnancy is more cost-effective than postnatal training for women with urinary incontinence: cost-effectiveness analysis of a systematic review. J Physiother 2021;67(2):105-14