Prenatal Pelvic Floor Workout (PEFLOW) Cuts Postpartum Stress Urinary Incontinence: Results from a Multicenter Randomized Trial

Table of Contents

1. Key Highlights:
2. Introduction
3. What PEFLOW is and how it was delivered
4. Trial design, participants and outcomes
5. What the trial found: efficacy and durability of PEFLOW
6. Why PEFLOW likely worked: mechanics of posture, breathing and pelvic support
7. How this trial fits into existing evidence
8. Practical implications for clinicians and pregnant women
9. Health systems and public health considerations
10. Limitations of the trial and directions for future research
11. Interpreting the magnitude of benefit
12. Clinical bottom lines for practice
13. FAQ

Key Highlights:

• A multicenter randomized trial of 764 first-time pregnant women showed that an app-guided pelvic floor workout (PEFLOW) begun at 28 weeks reduced stress urinary incontinence (SUI) at 6 weeks postpartum from 14.2% to 9.0% (risk difference 5.18 percentage points; P = .03), with sustained reductions at 3, 6 and 12 months.
• Higher adherence produced larger benefits: participants achieving ≥80% of prescribed exercise intensity had significantly lower SUI rates at late pregnancy and at 6 and 12 months postpartum than those at 50–79% intensity; no PEFLOW-related adverse maternal or fetal events were observed.
• PEFLOW combines supervised pelvic floor muscle training (PFMT) and staged global postural exercises delivered via video and an app, offering a feasible, safe prenatal intervention that strengthens pelvic floor function and may blunt the long-term burden of postpartum SUI.

Introduction

Stress urinary incontinence—leakage of urine during coughing, sneezing or exertion—affects a large share of new mothers and undermines physical comfort, sexual health and confidence. Pregnancy and childbirth damage pelvic supports and alter neuromuscular control of the pelvic floor, creating a clear window for preventive efforts. Despite pelvic floor muscle training (PFMT) being widely recommended, trials and meta-analyses have reported inconsistent prevention effects, leaving clinicians without a firm standard for antenatal intervention. A new multicenter randomized clinical trial conducted across nine hospitals in China tested a hybrid program—PEFLOW—that integrates PFMT with global postural exercises and delivers instruction via an app and video. The trial found meaningful reductions in postpartum SUI and measurable improvements in pelvic floor muscle (PFM) strength, with better outcomes among women who met high adherence thresholds. The trial’s design, results, and implications provide practical guidance for obstetric care and raise further questions about optimizing antenatal and postpartum pelvic rehabilitation.

What PEFLOW is and how it was delivered

PEFLOW is a structured exercise program designed specifically for pregnant women. It merges two established approaches:

• Pelvic floor muscle training (PFMT): voluntary contractions and relaxations of the muscles surrounding the urethra, vagina and rectum, coordinated with breathing and performed in sets that develop both strength and endurance.
• Global postural exercise (a form of global postural re-education): progressive postures and muscle-chain stretching that target spinal and pelvic alignment, intended to restore balanced posture and optimize the biomechanical environment of the pelvic floor.

The PEFLOW regimen in the trial consisted of daily PFMT and two weekly sessions of global postural exercises. The program was delivered from 28 weeks’ gestation until delivery and organized into four supervised episodes corresponding to gestational windows (28–30, 31–33, 34–36, 37–40 weeks). Each episode began at an intermediate intensity level with adjustments based on a participant’s Rating of Perceived Exertion so that the exercises were scaled to individual capacity while still challenging the pelvic muscles.

Key elements of the PFMT component:

• A primary sequence of five repetitions of moderate-strength contractions held for 6–8 seconds each, with matched relaxation intervals.
• A rapid-contraction sequence of eight repetitions, each consisting of maximum contractions held for about 1 second followed by 10 seconds of relaxation.
• Instruction to synchronize contractions with exhalation and avoid engaging abdominal muscles.

Global postural exercise features:

• Four posture groups with intensities increasing from level 1 to level 4, tailored to gestational stage.
• Each posture group comprises four distinct postures and a session lasts roughly 30 minutes with deep breathing throughout.
• Emphasis on holding maximal PFM contraction during exhalation while maintaining posture.

Delivery model:

• A professionally produced video guided each exercise session and was accessible through a mobile application. The app also included health education, step-by-step procedural instructions and programmable reminders to support adherence.
• Physiotherapists provided initial instruction and biweekly adjustments. Because the trial ran during the COVID-19 pandemic, in-person supervision was minimized and online video conferencing supplemented in-clinic checks. No audio or video was recorded during remote supervision to protect privacy.

This hybrid of home-based, app-facilitated practice plus periodic professional feedback aimed to combine the flexibility needed by pregnant women with the adherence and fidelity benefits of clinician oversight.

Trial design, participants and outcomes

The trial was a two-arm, parallel, multicenter randomized controlled trial conducted across nine tertiary or district hospitals in China. Key design features:

• Population: Primiparous women aged 20–40 years, with singleton pregnancies under 16 weeks at enrollment, who could understand study procedures and consented in writing. Exclusion criteria included prior SUI, pelvic organ prolapse, severe complications that could be worsened by exercise, and histories that would complicate pregnancy (cervical insufficiency, recurrent miscarriage).
• Enrollment and randomization: From August 1, 2020, to June 6, 2022, 764 eligible women were randomized 1:1 to the exercise (PEFLOW) or usual-care control group using opaque sealed envelopes. Investigators performing outcome assessments were blinded to group assignment.
• Sample size calculation: Based on a baseline 8-week postpartum SUI rate near 25.7%, investigators targeted at least 734 participants to detect a reduction to 15% in the exercise arm with 90% power (accounting for dropout).
• Intervention timing: PEFLOW began at 28 weeks’ gestation and continued until delivery. Control participants received standard obstetric care with routine prenatal checks every two weeks from 28 weeks onward.
• Adherence tracking: The study collected detailed self-reported and clinician-verified data on whether participants performed PEFLOW, session duration, and weekly frequency; exercise intensity was calculated as the proportion of prescribed duration/intensity achieved. Control participants who reported PEFLOW-like activity were identified and categorized accordingly.
• Outcomes: The trial’s primary outcome was incidence of SUI at 6 weeks postpartum. Secondary outcomes included SUI incidence at 37 weeks’ gestation and at 3, 6 and 12 months postpartum, and PFM strength measured by the Modified Oxford Scale (MOS; 0–5 scale, where ≥4 indicates good to strong contraction). SUI diagnosis combined objective stress tests (leakage during Valsalva or cough in lithotomy position) and self-report consistent with standardized questionnaires.

Analytic approach:

• Intention-to-treat analysis with multiple imputation, conservative imputation (worst outcome for missing), and complete-case analyses for the primary outcome.
• Generalized estimating equations modeled differences in SUI incidence and MOS ≥4 proportions over time.
• Preplanned subgroup analyses examined exercise intensity levels within the intervention arm.

What the trial found: efficacy and durability of PEFLOW

A total of 764 women were randomized; median age was 29 years. Follow-up at 6 weeks postpartum included 367 participants from the exercise group and 360 from the control group.

Primary outcome at 6 weeks postpartum:

• Multiple-imputation ITT analysis: SUI incidence 9.0% (34/382) in the exercise group vs 14.2% (54/382) in controls. Risk difference (RD) 5.18 percentage points (95% CI, 0.66–9.71); P = .03.
• Complete-case analysis: 8.7% (32/367) vs 13.9% (50/360); RD 5.17 percentage points (95% CI, 0.36–10.03); P = .03.

Secondary timepoints:

• At 37 weeks’ gestation: SUI incidence 22.0% (84/382) in exercise vs 25.7% (98/382) in control (RD 3.66 percentage points; P = .23) — a non-significant reduction at late pregnancy.
• At 3 months postpartum: 11.0% vs 17.8% (RD 6.81 percentage points; 95% CI, 1.64–11.97; P = .007).
• At 6 months postpartum: 13.1% vs 18.8% (RD 5.76 percentage points; 95% CI, 0.37–11.13; P = .03).
• At 12 months postpartum: 19.4% vs 29.8% (RD 10.47 percentage points; 95% CI, 4.18–16.66; P < .001).

Pelvic floor muscle strength (MOS ≥4):

• At 6 weeks postpartum, a larger share of the exercise group achieved MOS ≥4: 17.8% (68/382) vs 7.9% (30/382) in controls (RD 9.95 percentage points; 95% CI, 5.05–14.87; P < .001).
• Differences at later time points were smaller and not statistically significant in conservative-imputation analyses, suggesting the largest early gain in measurable PFM strength occurred soon after delivery.

Adherence and intensity effects:

• Participants achieving exercise intensity ≥80% had markedly lower SUI rates at several timepoints compared with those between 50% and 79% intensity. For example:
  • 37 weeks' gestation: 7.8% vs 16.8% (RD 9.00 percentage points; P = .02).
  • 6 months postpartum: 2.7% vs 11.9% (RD 9.22 percentage points; P = .003).
  • 12 months postpartum: 6.9% vs 16.9% (RD 9.95 percentage points; P = .01).
• The benefit pattern suggests a dose-response relationship: higher fidelity to the prescribed regimen produced larger reductions in SUI.

Safety:

• No PEFLOW-related adverse events were reported.
• Maternal–fetal outcomes were similar between groups. For instance, vaginal delivery rates and rates of episiotomy or laceration did not differ materially. Postpartum hemorrhage was numerically lower in the exercise group (0.3% vs 3.8%), though causal inferences are unwarranted from a trial not powered for most obstetric outcomes.
• Premature rupture of membranes occurred in both groups, slightly more often in controls (23.5% vs 17.6%).

These results indicate that an antenatal program combining PFMT and postural re-education, delivered via an app with clinician oversight, reduces early and midterm postpartum SUI and increases measurable pelvic floor strength. Benefits were larger and longer lasting among highly adherent participants.

Why PEFLOW likely worked: mechanics of posture, breathing and pelvic support

Several interrelated mechanisms explain how a combined PFMT–postural program like PEFLOW can reduce postpartum SUI.

1. Biomechanical optimization of the pelvic hammock:
   • Pregnancy and vaginal delivery alter pelvic connective tissue, muscle length–tension relationships and alignment of the sacropelvic skeleton. Global postural exercises focus on correcting spinopelvic shape and stretching muscle chains to restore alignment. Restored alignment reduces abnormal mechanical loads on the pelvic floor during Valsalva maneuvers.
2. Improved neuromuscular control and strength:
   • PFMT targets the voluntary contraction of the levator ani and supportive periurethral musculature. Protocols that include both slow sustained contractions (for endurance) and quick maximal contractions (for reflexive closure during sudden increases in intra-abdominal pressure) address different functional demands. PEFLOW's two-part PFMT sequences are consistent with this dual training principle.
3. Integration of breathing and co-contraction patterns:
   • Coordinating PFM contractions with exhalation while minimizing abdominal bracing reduces detrimental increases in intra-abdominal pressure and encourages correct motor patterns. The program’s emphasis on breath-synchronized contractions likely improved the efficacy of each repetition.
4. Consistent, supervised progression:
   • Biweekly adjustments by physiotherapists and graded intensity ensure exercises remain effective and safe as pregnancy progresses. This progression may prevent undertraining (too easy) and overloading (unsafe), which can limit effectiveness or cause complications.
5. Behavioral support via the app:
   • Mobile reminders, guided videos and remote supervision increase adherence—an essential determinant of exercise efficacy as demonstrated by the intensity subgroup analysis.

These mechanisms align with evidence linking pelvic anatomy, posture and muscular control to continence, and they explain why combining postural re-education with PFMT could outperform either approach alone.

How this trial fits into existing evidence

The literature on prenatal PFMT shows mixed results. Some randomized trials have found reductions in postpartum SUI when women engage in regular PFMT; others and several meta-analyses have concluded that prenatal exercises alone may not reliably prevent incontinence. Inconsistencies likely stem from heterogeneous interventions (varying frequency, intensity, adherence monitoring), differences in populations (primiparous vs multiparous, baseline risk), and the quality of supervision.

Prior work on global postural exercise suggests postural correction exerts a clinically meaningful effect on pelvic floor dysfunction. The PEFLOW trial builds on this by formally combining PFMT and progressive postural training and embedding these elements within a digital delivery model that allows scalable supervision.

App-based adherence strategies have been evaluated in smaller trials for urinary incontinence outside pregnancy. Those trials show improved adherence and symptom outcomes when digital tools supplement supervised training. PEFLOW’s use of an app plus periodic physiotherapist contact harnesses proven behavior-change techniques—reminders, guided practice, feedback—that improve the likelihood of sustained exercise.

The trial’s strengths include its multicenter randomized design, adequate power, blinded outcome assessment, and the pragmatic blend of remote and in-person supervision that reflects contemporary prenatal care models. It provides a concrete regimen with specified frequencies and intensities to guide practice.

Practical implications for clinicians and pregnant women

Clinicians counseling pregnant patients can draw several actionable lessons from the trial.

1. Timing and target population:
   • Begin structured pelvic training in the mid–third trimester: the trial started PEFLOW at 28 weeks. While earlier initiation might be beneficial, the evidence here supports starting at 28 weeks as a feasible and effective approach for primiparous women.
2. Program components:
   • Combine daily PFMT with regular global postural work. The PFMT format used in the trial—sustained 6–8 second contractions followed by quick maximal contractions—is practical and can be taught during routine prenatal visits.
   • Incorporate breathing cues: exhale during PFM contraction and avoid abdominal bracing.
3. Frequency and duration:
   • The trial’s regimen prescribed daily PFMT and two 30-minute postural sessions weekly. Previous recommendations echoed by the trial authors suggest twice-weekly low-intensity aerobic sessions plus daily 10-minute PFMT. A minimum of daily practice appears critical to achieve measurable strength gains.
4. Supervision and progression:
   • Periodic physiotherapist oversight improves fidelity and allows safe intensity progression. Where in-person physiotherapy access is limited, telehealth check-ins can be effective. Clinicians should identify local pelvic floor physiotherapists for referral or recommend vetted digital programs with clinician oversight.
5. Use of digital tools:
   • Apps that provide video-guided sessions, reminders and an option for clinician monitoring increase adherence. PEFLOW’s design demonstrates that combining self-guided home practice with professional feedback is feasible and acceptable in pregnancy.
6. Emphasize adherence:
   • Explain the dose-response relationship: higher adherence (≥80% of prescribed intensity) yielded the strongest and most durable protective effect. Frame pelvic training as preventive care with measurable returns rather than optional exercise.
7. Postpartum continuation:
   • The trial halted PEFLOW at delivery, and SUI rebounded somewhat by 12 months in both groups. Encourage continuation of pelvic floor rehabilitation postpartum. Evidence supports structured postpartum PFMT to sustain gains in PFM strength and continence.
8. Safety reassurance:
   • PEFLOW did not produce PEFLOW-related adverse events. Routine obstetric monitoring during exercise is essential, and women with unusual symptoms (abdominal pain, bleeding, decreased fetal movement) should be assessed promptly.

Practical example to illustrate implementation:

• A 30-year-old first-time mother presents at a 28-week appointment. After a brief pelvic floor assessment and explanation, the obstetrician prescribes a PEFLOW-like routine: daily PFMT (two sets each morning and evening, following the 6–8 second and rapid-contraction formats) and two weekly 30-minute posture sessions. She downloads the clinic-recommended app, sets reminders, and schedules three telehealth physiotherapy check-ins before delivery. Her clinician emphasizes that achieving at least 80% of the regimen maximizes the chance of preventing postpartum urine leakage.

Health systems and public health considerations

SUI after childbirth imposes clinical and economic burdens through conservative management, specialist referrals, and in some cases, surgery. Preventing SUI with low-cost, low-risk interventions during pregnancy could reduce these downstream costs and morbidity.

Digital delivery models extend reach to regions with limited access to specialized physiotherapy. Integrating an evidence-based PEFLOW-like protocol into routine prenatal education—group classes, clinic portals, or publicly funded apps—could normalize pelvic rehabilitation and destigmatize incontinence prevention.

Key system-level steps:

• Train prenatal care providers to teach effective PFMT technique and to refer complex cases to pelvic floor physiotherapists.
• Validate and standardize high-quality mobile applications that align with evidence-based regimens and include clinician oversight options.
• Consider reimbursing supervised antenatal pelvic rehabilitation as preventive care in maternal health benefit packages.
• Monitor program impact with real-world registries linking prenatal intervention uptake to postpartum continence outcomes.

Cost-effectiveness analyses will be necessary. However, the low-cost nature of app-delivered programming suggests favorable potential, particularly if it prevents persistent SUI requiring specialist care.

Limitations of the trial and directions for future research

The trial has important limitations to contextualize the findings and to guide next steps.

1. Blinding and behavioral contamination:
   • Complete participant blinding was infeasible. Control participants were monitored and private interviews identified those who performed PEFLOW-like exercises. Residual contamination or differential reporting cannot be entirely ruled out.
2. Population characteristics:
   • The study enrolled primiparous women in China with high educational attainment in many centers. Generalizability to multiparous women, broader geographic regions, lower-resource settings, and diverse cultural contexts requires additional study.
3. Postpartum continuation:
   • PEFLOW ceased at delivery. The observed rebound in SUI rates by 12 months suggests that sustained postpartum training may be necessary to secure long-term benefits. Trials testing antenatal plus postpartum maintenance programs would clarify optimal duration.
4. Mechanistic measures:
   • MOS via digital vaginal examination provided a pragmatic strength measure but lacked objective physiologic data such as electromyography, pelvic floor ultrasound imaging or pressure manometry. Mechanistic studies could elucidate how postural interventions alter pelvic biomechanics.
5. Adherence measurement:
   • Exercise intensity was based on reported duration and frequency relative to the prescription. Objective adherence monitoring (wearables, app usage analytics, sensor-assisted biofeedback) would refine dose-response understanding.
6. Clinical endpoints:
   • The trial was powered for SUI incidence but not for detailed obstetric safety outcomes. Although no PEFLOW-related adverse events occurred, larger studies could more definitively exclude rare harms and examine effects on labor and delivery processes.

Future research priorities:

• Randomized trials comparing PEFLOW to PFMT alone, global postural exercise alone, and combined models to isolate the active components.
• Trials that initiate training earlier in pregnancy and continue structured programs through the postpartum year.
• Implementation studies assessing scalability, clinician training needs and cost-effectiveness in varied health systems.
• Qualitative research to understand barriers and facilitators to sustained adherence among new mothers.

Interpreting the magnitude of benefit

Clinical decisions require balancing effect size, feasibility and safety. PEFLOW produced an absolute risk reduction in SUI of roughly 5 percentage points at 6 weeks postpartum and a larger 10.5 percentage point reduction at 12 months. For an intervention that is noninvasive, inexpensive (app delivery, periodic physiotherapy), and safe, these absolute differences are clinically meaningful. From a population health perspective, reducing postpartum SUI prevalence by one-fifth to one-third in program-adherent groups could translate into substantial reductions in long-term morbidity and health-care utilization.

Yet translating trial efficacy into routine practice depends on achieving the adherence levels observed in the study, which were supported by an app, clinician check-ins and structured scheduling. Real-world uptake may be lower unless systems actively support behavior change.

Clinical bottom lines for practice

• Offer structured, progressive pelvic floor training to pregnant women, ideally combining PFMT with postural work and breathing coordination.
• Encourage a routine that includes daily PFMT and two weekly postural sessions, and promote achieving ≥80% of prescribed intensity for maximal benefit.
• Use digital tools to support home practice, provide guided videos and reminders, and schedule periodic physiotherapy or trained-provider check-ins.
• Continue pelvic floor rehabilitation postpartum; stopping at delivery may allow partial relapse in function and symptoms.
• Reassure patients about safety while maintaining vigilance for any unusual symptoms that warrant obstetric assessment.

FAQ

Q: What exactly is stress urinary incontinence (SUI) in pregnancy and postpartum? A: SUI is leakage of urine that occurs during increases in abdominal pressure—such as coughing, sneezing, laughing or exercise—resulting from inadequate pelvic floor support or impaired pelvic muscle contraction. Pregnancy and vaginal delivery weaken pelvic supports, increasing postpartum SUI risk.

Q: How much did PEFLOW reduce postpartum SUI? A: In intention-to-treat analyses, PEFLOW reduced SUI incidence at 6 weeks postpartum from 14.2% to 9.0% (an absolute reduction of 5.18 percentage points; P = .03). Significant reductions also occurred at 3, 6 and 12 months, with a 10.47 percentage-point reduction at 12 months (19.4% vs 29.8%; P < .001).

Q: Is PEFLOW safe for mother and fetus? A: The trial reported no PEFLOW-related adverse events. Routine obstetric outcomes such as vaginal delivery rates, episiotomy and laceration frequencies were similar between groups. As with any exercise during pregnancy, unusual symptoms should prompt clinical evaluation.

Q: How does PEFLOW differ from standard pelvic floor muscle training? A: PEFLOW combines traditional PFMT (sustained and quick contractions) with global postural exercises that target spinal and pelvic alignment. It emphasizes breath-coordinated contractions and progressive postures tailored to gestational stage.

Q: What level of adherence is needed to see benefit? A: The trial demonstrated a dose-response effect: participants achieving at least 80% of the prescribed exercise intensity had larger and more durable reductions in SUI compared with those at 50–79% intensity. Daily practice and two weekly postural sessions were the prescribed frequency.

Q: When should training start and how long should it continue? A: The trial began PEFLOW at 28 weeks’ gestation and continued until delivery. Evidence suggests ongoing postpartum training improves long-term outcomes; therefore, continuing structured pelvic rehabilitation after delivery is advisable to sustain gains.

Q: Can I use an app or videos instead of seeing a physiotherapist? A: High-quality apps and videos are valuable for guided practice and reminders. The trial combined app-guided home practice with periodic physiotherapist oversight, which supported adherence and allowed safe intensity adjustments. If in-person physiotherapy is not available, arrange telehealth check-ins with a qualified provider.

Q: Does PEFLOW replace other prenatal exercise recommendations? A: PEFLOW is a targeted pelvic floor and postural program. It complements general prenatal exercise recommendations—such as low-intensity aerobic activity—and does not replace overall fitness advice. Combining aerobic activity with daily PFMT is consistent with prior guidance.

Q: Who should not do PEFLOW? A: Women with pregnancy complications that make exercise unsafe (as determined by their clinician) should avoid or modify structured programs. Any participant with new abdominal pain, bleeding or abnormal fetal movement should seek immediate obstetric assessment before continuing exercise.

Q: Should PEFLOW be recommended to all pregnant women? A: The evidence from this trial supports offering structured pelvic floor and postural training to primiparous women. Extending recommendations universally will depend on local resources, clinician training, and further studies in multiparous women and diverse populations. Given the low risk and potential benefits, clinicians should discuss pelvic rehabilitation as part of prenatal care and tailor advice to individual risks and preferences.

Q: Where can clinicians find validated materials to implement PEFLOW-like programs? A: Clinics should seek programs that specify exercise frequency, intensity and progression; provide video instruction on both PFMT and postural exercises; enable reminders and adherence tracking; and include access to physiotherapist supervision. Local pelvic floor physiotherapy services remain the gold standard for individualized assessment.