Table of Contents
- Key Highlights:
- Introduction
- How the trial was conducted
- What the pelvic floor program entailed
- Results: measurable reductions in leakage and stronger pelvic floor contractions
- Exercise intensity and adherence: a decisive factor
- Safety profile and secondary findings
- Why these results matter for practice and public health
- Practical guidance: how clinicians and pregnant people can apply these findings
- Limitations and unanswered questions
- How this trial fits with existing evidence
- Implementation examples: translating trial design into practice
- Research priorities going forward
- Final reflections: balancing evidence with practical realities
- FAQ
Key Highlights:
- A supervised pelvic floor exercise program begun in late pregnancy lowered stress urinary incontinence (SUI) at 6 weeks postpartum and kept incidence lower through 12 months, compared with usual obstetric care.
- Higher exercise intensity and continued postpartum practice correlated with stronger pelvic floor contractions and larger reductions in SUI; the trial reported few adverse events.
Introduction
Urinary leakage with coughing, sneezing or exercise is a common and distressing problem after childbirth. New data from a randomized clinical trial in China show that a structured pelvic floor workout program started in late pregnancy and delivered with physiotherapist supervision reduced the rate of stress urinary incontinence at six weeks after delivery and produced benefits that persisted through one year. The study links measurable improvement in pelvic floor muscle strength with clinically meaningful reductions in leakage, and highlights adherence and exercise intensity as decisive factors in outcomes.
The trial enrolled first-time mothers across nine hospitals and combined daily pelvic muscle training with twice-weekly postural sessions delivered through a mobile platform and overseen by physiotherapists. Results suggest that routine incorporation of targeted pelvic floor training into prenatal care could reduce postpartum pelvic floor dysfunction for many women. The following examination breaks down the study design, the program content, the numerical results, safety signals, limitations and practical guidance for clinicians and pregnant people considering pelvic floor training.
How the trial was conducted
Investigators led by Lei Gao, MD, at Peking University People’s Hospital conducted a randomized clinical trial across nine Chinese hospitals between 2020 and 2022. The trial enrolled people who were pregnant for the first time, carrying a singleton pregnancy and less than 16 weeks’ gestation at enrollment; median maternal age was 29 years.
Participants were randomized into two groups. The exercise arm practiced a structured pelvic floor workout supervised by physiotherapists beginning at 28 weeks’ gestation and continuing until delivery. The control arm received usual obstetric care: routine antenatal examinations every two weeks from 28 weeks until delivery.
Primary and secondary outcomes
- Primary outcome: incidence of stress urinary incontinence (SUI) at 6 weeks postpartum. SUI was defined by either a positive physical stress test or self-reported leakage with coughing, sneezing, or physical exertion.
- Secondary outcomes: incidence of SUI at 37 weeks’ gestation and at 3, 6, and 12 months postpartum; pelvic floor muscle (PFM) strength measured at the same timepoints using the Modified Oxford Scale (MOS), where scores range from 0 (no contraction) to 5 (strong contraction).
Sample size and allocation The trial enrolled several hundred participants; the report lists group allocations of 367 women to the exercise intervention and 360 to control. The pelvic floor program was delivered using a mobile application with online physiotherapist supervision to ensure correct technique and to monitor adherence.
Assessment and follow-up Participants were followed through pregnancy and up to one year after delivery. Pelvic floor strength was assessed clinically using the MOS at multiple timepoints. Incidence of SUI was determined by objective stress testing and participant reports of leakage during activities known to provoke stress incontinence.
What the pelvic floor program entailed
The workout—referred to in the trial as PEFLOW—was a pragmatic, reproducible protocol combining focused pelvic muscle contractions with global postural exercises. It was structured as follows:
- Daily pelvic floor muscle training:
- Five moderate contractions held for 6–8 seconds each, with relaxation between contractions.
- Eight sets of five rapid maximal contractions followed by relaxation.
- Twice-weekly global postural exercises:
- Sessions lasted approximately 30 minutes and emphasized alignment and recruitment of core stabilizers that support pelvic floor function.
- Delivery and supervision:
- Content and sessions were delivered through a mobile application.
- Physiotherapists provided online supervision to correct technique and encourage adherence.
- Timing:
- Training started at 28 weeks’ gestation and continued until delivery. Participants were encouraged to maintain pelvic floor exercises postpartum to sustain improvements.
The protocol blends elements known to promote pelvic floor muscle hypertrophy and neuromuscular control: sustained holds to recruit endurance fibers and rapid maximal contractions to train fast-twitch responsiveness. Adding global postural work aligns pelvic floor activation with breathing and trunk stability, improving functional transfer to everyday activities.
Results: measurable reductions in leakage and stronger pelvic floor contractions
The trial produced statistically and clinically significant reductions in the incidence of stress urinary incontinence for participants assigned to the supervised pelvic floor program.
Key numerical findings
- At 6 weeks postpartum:
- SUI incidence: 8.7% in the exercise group vs. 13.9% in control (P = .03).
- At 3 months postpartum:
- Risk difference (RD) favoring exercise: 6.81 percentage points (P = .007).
- At 6 months postpartum:
- RD favoring exercise: 5.76 percentage points (P = .03).
- At 12 months postpartum:
- RD favoring exercise: 10.47 percentage points (P < .001).
Pelvic floor muscle strength
- At 6 weeks postpartum, the proportion of women achieving a good-to-strong contraction (MOS ≥ 4) was significantly higher in the exercise group: 17.8% vs. 7.9% in the control group (P < .001). This objective improvement in muscle function aligns with the reduced SUI incidence.
Dose-response relation: exercise intensity mattered Participants who achieved an exercise intensity of 80% or more demonstrated significantly lower rates of urinary incontinence than those whose intensity was between 50% and less than 80% at several timepoints: at 37 weeks’ gestation and at 6 and 12 months postpartum (P < .05 for all comparisons). The data show a clear relationship between adherence/intensity and clinical outcome.
Secondary observation: a smaller number of postpartum hemorrhage events were reported in the intervention group—only one woman in the exercise group compared with 14 in the control group. The trial was not primarily designed to study hemorrhage risk, but the numerical imbalance is notable.
Interpretation of the numbers The reductions in absolute risk of SUI vary by timepoint but consistently favor the pelvic floor program. For clinicians and patients, an approximate 5–10 percentage-point reduction in SUI incidence represents a meaningful change in risk at the population level. An MOS shift with a doubling in the proportion achieving strong contractions by early postpartum indicates that the program induced measurable physiologic change, not merely transient behavioral modification.
Exercise intensity and adherence: a decisive factor
A central signal from the trial is the association between program intensity and outcomes. Participants were monitored for exercise intensity—how consistently and vigorously they followed the prescribed program—and those who reached or exceeded an 80% intensity threshold experienced larger, sustained benefits.
Why intensity matters
- Muscle physiology: Strength and endurance gains require progressive overload and consistent repetition. The pelvic floor is no different. Sustained holds build endurance and support for everyday activities; maximal quick contractions train reflexive closures needed during sudden increases in intra-abdominal pressure.
- Motor learning and coordination: Frequent, well-supervised practice reinforces neuromuscular patterns that translate to functional tasks such as coughing, lifting and walking.
- Behavioral consistency: High-intensity adherence reflects both patient engagement and effective support systems (access to physiotherapy, convenient delivery such as an app, and scheduling that fits daily life).
Implications for program delivery
- Supervision improves technique and adherence. Physiotherapist oversight in the trial likely contributed to higher-quality contractions and better outcomes.
- Objective tracking and feedback—here, implemented through the mobile app—supports adherence. Real-world programs should include mechanisms for monitoring and reinforcing engagement.
- Postpartum continuation is crucial. The study authors emphasized that continuing the pelvic floor regimen after delivery is necessary to maintain muscle gains and keep SUI incidence reduced over time.
A practical example Consider a 29-year-old first-time mother who begins the PEFLOW program at 28 weeks, completes daily training with 85% adherence and continues the exercises postpartum. According to trial data, her probability of reporting SUI at 6 weeks and 12 months is lower than that of a peer who performed exercises inconsistently. The difference aligns with measurable gains on the MOS exam at her postpartum visits.
Safety profile and secondary findings
The trial reported few adverse events linked to the pelvic floor program. Notably, postpartum hemorrhage was less frequently reported in the exercise group (one case) than in the control group (14 cases). Because the study was not powered to study hemorrhage, that observation should be interpreted cautiously; however, it suggests there were no clear safety signals against supervised pelvic floor training.
Other safety considerations
- Technique matters. Incorrect performance of pelvic floor contractions might reduce benefit; supervision and instruction are important to ensure proper activation without substitute strategies (e.g., bearing down instead of contracting).
- No signals of increased obstetric complications were reported that would contraindicate the supervised program.
- For women with specific medical conditions—active vaginal bleeding, certain pelvic infections, or recent pelvic surgery—individual assessment before beginning an exercise program is prudent.
Overall, the supervised, app-assisted model used in the trial appears safe and feasible within the trial's population of first-time mothers.
Why these results matter for practice and public health
Postpartum stress urinary incontinence imposes physical discomfort, psychological burden and potential long-term morbidity. Even modest proportional reductions in incidence can translate to meaningful decreases in healthcare utilization, prescriptions, pelvic floor physical therapy referrals and quality-of-life impairment.
Clinical practice implications
- Prenatal care pathways can incorporate supervised pelvic floor training beginning in the third trimester for first-time mothers to reduce early and persistent SUI.
- Physiotherapist involvement is critical for teaching correct technique, monitoring progress, and troubleshooting barriers to adherence.
- Digital delivery platforms can facilitate scalability by providing instruction, tracking and remote supervision, making structured programs accessible across a wider range of care settings.
Health system implications
- Deploying supervised pelvic floor programs at scale could reduce the number of women requiring later pelvic floor interventions.
- Cost-offsets may occur through decreased need for incontinence supplies, fewer referrals and improved maternal well-being, but formal cost-effectiveness studies are needed.
- Integrating pelvic floor training into routine prenatal education and postnatal follow-up visits would normalize preventive care rather than treating incontinence reactively.
Patient-centered considerations
- Many pregnant people prefer non-pharmacologic, low-risk interventions. Structured pelvic floor training meets this preference while offering measurable benefit.
- Programs must be culturally appropriate and tailored to the population served, including language, literacy and access constraints.
Practical guidance: how clinicians and pregnant people can apply these findings
The trial provides a concrete template that clinicians can adapt. Below are practical steps for clinicians, physiotherapists and pregnant people who wish to implement a similar program.
For clinicians
- Screen prenatal patients for risk factors for postpartum pelvic floor dysfunction and discuss the option of supervised pelvic floor training starting at about 28 weeks’ gestation.
- Refer patients to physiotherapy services with experience in pelvic floor rehabilitation. If local physiotherapists are unavailable, consider vetted digital programs with remote clinician oversight.
- Reinforce the importance of adherence and correct technique. Use follow-up visits to reinforce training and re-check pelvic floor contraction quality postpartum using the MOS or other validated tools.
For physiotherapists
- Teach both sustained contractions (6–8 seconds holds) and rapid maximal contractions per the trial protocol. Emphasize proper isolation of the pelvic floor rather than abdominal bracing or breath-holding.
- Incorporate twice-weekly global postural sessions to integrate pelvic floor function with core and postural muscles.
- Track adherence and provide timely feedback. Aim to support patients reaching at least 80% program intensity to maximize the chance of sustained benefit.
For pregnant people
- Learn correct pelvic floor contraction technique from a trained physiotherapist before starting daily practice. Avoid substituting abdominal or gluteal squeezing for pelvic floor contraction.
- Practice daily: five moderate holds (6–8 seconds) and eight sets of five quick maximal contractions, with relaxation between repetitions.
- Continue the exercises after delivery. Early postpartum continuation sustains muscle strength gains and reduces the likelihood of persistent SUI.
- Seek professional help if you experience pain, inability to contract, or other concerns during training.
Program logistics and delivery
- Use short, regular sessions. The trial combined brief daily sessions with twice-weekly longer sessions; this structure is feasible for many pregnant people.
- Provide instructional materials, in-person or digital, to facilitate correct performance and to allow troubleshooting when travel or access to clinicians is limited.
- Monitor outcomes at routine prenatal and postpartum visits using simple tools like self-report of leakage and MOS for muscle strength.
Limitations and unanswered questions
The trial provides strong evidence of benefit but has limitations that should temper interpretation and guide further research.
Blinding and potential bias
- Participants could not be blinded to assignment, and that lack of blinding may have influenced self-reported outcomes. The trial used objective stress testing and MOS scoring to mitigate subjectivity, but expectation effects cannot be fully excluded.
Generalisability
- The study enrolled first-time mothers with singleton pregnancies in China; applicability to multiparous women, those with multiple gestation, or populations with different obstetric care paradigms is uncertain.
- Cultural factors, health system infrastructure and access to supervised physiotherapy may influence real-world uptake and outcomes in other settings.
Delivery model dependence
- The intervention included online physiotherapist supervision via a mobile app. Outcomes may differ if supervision is less intensive or absent. The combination of supervised technique correction and digital support may be essential to the program’s effectiveness.
Measurement and follow-up
- The trial followed participants for one year postpartum. The durability of benefit beyond 12 months requires further study.
- Though the MOS is a validated clinical measure, more granular assessments—such as pelvic floor electromyography or imaging—could clarify mechanistic changes.
Other outcomes and subgroup effects
- The trial was not designed to study other pelvic floor disorders such as pelvic organ prolapse, nor did it focus on sexual function outcomes.
- Subgroup analyses (for example, by delivery mode—vaginal vs. caesarean) are not described in the summary and would be informative.
These limitations identify priorities for future trials: evaluating multiparous populations, testing delivery models with varying supervision levels, assessing long-term durability, and exploring cost-effectiveness and broader pelvic health outcomes.
How this trial fits with existing evidence
Randomized and observational studies over the last several decades have suggested that pelvic floor muscle training reduces urinary incontinence after childbirth. What the present trial adds is a large, multicenter randomized design with a clearly defined, supervised regimen beginning in late pregnancy, objective measures of muscle strength, and sustained follow-up to one year. The observed dose-response relationship between training intensity and outcome strengthens the causal inference that the exercises themselves produced the benefits, not only behavioral differences between groups.
The trial’s use of a mobile delivery and supervision model also demonstrates how digital tools can assist rehabilitation programs. Many smaller trials showed benefit from pelvic floor training, but inconsistent methods and variable adherence limited the clarity of their findings. By standardizing the exercise prescription and embedding supervision, the present study offers an actionable protocol that can be adopted and tested in diverse settings.
Implementation examples: translating trial design into practice
Two implementation scenarios illustrate how health systems might adapt the protocol.
Scenario 1: Urban hospital with integrated physiotherapy
- At 28-week antenatal visit, the obstetrician introduces pelvic floor training to eligible first-time mothers and refers them to an in-house pelvic health physiotherapist.
- The physiotherapist conducts an initial assessment, provides instruction, and enrolls the patient in an app-based program for daily practice and scheduling twice-weekly group postural sessions.
- Follow-up occurs at routine prenatal visits, with MOS checks at 37 weeks and at postpartum visits.
Scenario 2: Community clinic with limited in-person physiotherapy
- The clinic partners with a regional telehealth physiotherapy service that delivers remote instruction and supervision.
- Patients receive tablets or app access to guided exercise videos and tele-supervision appointments for technique checks.
- Local nurses perform MOS assessments at postpartum visits and escalate patients with inadequate progress to remote physiotherapy for additional support.
Both scenarios emphasize early referral, supervised instruction and ongoing monitoring to support adherence and maximize benefits.
Research priorities going forward
- Trials in multiparous populations and in people with varying obstetric histories to assess generalizability.
- Head-to-head comparisons of different delivery models: in-person physiotherapy, group classes, fully digital self-guided programs, and hybrid approaches.
- Long-term follow-up beyond one year to evaluate the persistence of muscle strength gains and SUI reductions.
- Cost-effectiveness analyses to inform health policy decisions about integrating pelvic floor training into routine prenatal care.
- Subgroup analyses by delivery mode, maternal BMI, connective tissue disorders, and other risk factors for pelvic floor dysfunction.
Answering these questions would clarify which patients derive the greatest benefit, how to deliver programs at scale, and the economic implications of broad implementation.
Final reflections: balancing evidence with practical realities
The trial demonstrates a low-risk intervention with measurable benefit when delivered with supervision and adherence. Translating these findings into routine care will require training and deployment of physiotherapy resources, use of digital tools to enhance access, and patient education to encourage sustained postpartum practice. For clinicians, recommending structured pelvic floor training beginning in late pregnancy offers a means to reduce postpartum SUI and to strengthen pelvic floor function. For pregnant people, the study provides evidence that consistent, supervised pelvic floor exercises can lower the likelihood of leakage and improve muscle strength during the critical postpartum year.
FAQ
Q: What exactly was reduced by the pelvic floor program? A: The program reduced the incidence of stress urinary incontinence—leakage during coughing, sneezing or physical exertion—at 6 weeks postpartum, and reductions persisted at 3, 6 and 12 months postpartum. The exercise arm also showed higher rates of good-to-strong pelvic floor contractions on clinical exam.
Q: When did participants start the exercises and how long did they continue? A: Training began at 28 weeks’ gestation and continued until delivery. Participants were encouraged to continue exercises postpartum; the trial’s analysis indicates ongoing postpartum practice was associated with sustained improvements.
Q: What did each exercise session include? A: Daily pelvic floor muscle training included five moderate contractions held for 6–8 seconds followed by relaxation, and eight sets of five quick maximal contractions with relaxation. In addition, participants took part in two 30-minute sessions per week of global postural exercises.
Q: How was “intensity” or adherence measured, and why does it matter? A: Intensity refers to how consistently participants followed the prescribed exercises. Those reaching 80% or higher adherence had significantly better outcomes than those with 50–80% adherence, indicating a dose-response effect: more consistent training produced stronger muscles and greater reductions in SUI.
Q: Were there any safety concerns? A: The trial reported no major safety concerns associated with the pelvic floor program. An unexpected observation was fewer reports of postpartum hemorrhage in the exercise group compared with control; however, the study was not designed to assess hemorrhage risk specifically.
Q: Can multiparous women or those with complicated pregnancies use this protocol? A: The trial enrolled first-time mothers with singleton pregnancies, so direct evidence for multiparous women or those with other pregnancy complications is lacking. The physiologic rationale for pelvic floor training applies broadly, but clinicians should individualize recommendations based on medical history and current condition.
Q: Do women need a physiotherapist to get the benefit? A: Physiotherapist supervision in the trial likely contributed to correct technique and adherence. While some benefit may accrue from unsupervised exercise, supervision appears important to achieve high-quality contractions and higher adherence, which in turn predict better outcomes.
Q: How soon will someone see improvement? A: The trial reported reduced SUI at 6 weeks postpartum and measurable increases in pelvic floor strength at that time. Improvements in symptoms and strength may be detectable earlier for some women, but the study’s controlled timepoints show benefit by early postpartum follow-up.
Q: Where can pregnant people find appropriate programs? A: Many hospitals and physiotherapy practices offer pelvic floor or prenatal exercise programs. Telehealth and app-based programs with clinician oversight are increasingly available. Seek a program led by a physiotherapist experienced in pelvic health or a validated digital program with professional supervision.
Q: What further research is needed? A: Evidence is needed in multiparous populations, evaluations of different delivery models (in-person vs. remote), long-term durability beyond one year, cost-effectiveness analyses, and subgroup assessments by delivery mode and other risk factors.
Acknowledgement: The trial was published online in JAMA Network Open and led by Lei Gao, MD, of Peking University People’s Hospital. The research received support from grants from the National Key Technology Research and Development Program of China. No relevant conflicts of interest were reported by the authors.
