Effects of an 8-week pelvic core stability and nutrition community programme on maternal health outcomes.

INTRODUCTION
Women, during the antenatal and post-partum period, report pelvic, low back pain, stress and urge urinary incontinence, colorectal dysfunction, and other co-morbidities that negatively affect health-related quality of life. Exercise and nutrition are important considerations for improving maternal health in this period.


PURPOSE
The purpose of this study was to examine the effects of a community-driven nutrition and exercise programme focused on pelvic floor and core stability, healthy nutrition, and breastfeeding counselling over an 8-week period on pelvic floor and urinary distress (UDI), prolapse and colorectal distress for antenatal and post-partum women with limited access to health care, and low socio-economic resources from a Midwestern Region of the United States.


MATERIALS AND METHODS
Purposive sample of 35 females, ages 18-44, were recruited for this prospective, preintervention to postintervention study, following ethical approval from Institutional Review Board and voluntary written consent from participants. The Health History Questionnaire, SF-36, Food Frequency Questionnaire, report of pelvic organ prolapse dysfunction (POPDI), colorectal-anal dysfunction (CRADI), and UDI as measured by the Pelvic Floor Distress Inventory (PFDI) were completed before and after intervention.


RESULTS
Thirty-five women (n = 35) 18 to 44 years old (mean age of 22.72 ± 3.45 years) completed the study. A significant difference was found from preintervention to postintervention scores means for PFDI total scores, CRADI individual scores, and UDI individual scores (p < .05). POPDI scores decreased preintervention to postintervention but were not significant. A significant improvement in healthy nutrition and breastfeeding postintervention was also found (z = 3.21, p = .001). Further analysis showed significant, but weak, correlation between parity and POPDI (r = .366, p = .033); between parity and UDI (r = .384, p = .03); and between parity and PFDI (r = .419, p = .014).


DISCUSSION
Our study found a significant reduction in pelvic floor dysfunction, urinary, and colorectal-anal distress symptoms and improvement in breastfeeding and healthy nutrition following an 8-week community-driven nutrition and exercise programme focused on pelvic floor and core stability, healthy nutrition, and breastfeeding counselling.

healthy nutrition following an 8-week community-driven nutrition and exercise programme focused on pelvic floor and core stability, healthy nutrition, and breastfeeding counselling. KEYWORDS nutrition, physiotherapy, postpartum, prenatal

| INTRODUCTION
Women, during the antenatal and post-partum period, report pelvic and lumbar pain, urinary incontinence (UI), colorectal dysfunction, and other co-morbidities that may directly affect health-related quality of life (HRQOL). Exercise and nutrition are important considerations for improving maternal health during the antenatal and post-partum period (Jebakani & Sameul, 2017;Szumilewicz et al., 2017). However, limited research exists on the effects of antenatal and post-partum exercise and nutrition programmes (Shirazian, Monteith, Friedman, & Rebarber, 2010). Furthermore, limited community-driven antenatal and post-partum programmes that include detailed progression of pelvic and core stability exercises and healthy nutrition information exist for women who are socio-economically challenged. The World Health Organization's (WHO) Sustainable Development Goal continues to focus on improving maternal health during the antenatal and post-partum period for women with lower socio-economic resources and limited access to health care. Globally, only 64% of pregnant women met the minimum recommendation of visits during the period 2007(WHO, 2016. Specifically, within some resource-rich countries, such as the United States, access to prenatal and post-partum care is limited among women with low socio-economic resources (US Department of Health and Human Services, 2008). Prenatal and postpartum community-driven physiotherapy and nutrition education programmes may be one method towards increased access to physiotherapy and clinical nutrition services (Fraser, 2013;Gadson, Akpovi, & Mehta, 2017;de Jongh et al., 2016;WHO, 2016).
Women with limited resources have lower attendance rates at prenatal and post-partum visits (Bennett et al., 2013). Traditional prenatal and post-partum programmes focus on education of body changes and infant care and neglect to address the problems new mothers consider most important such as nutrition, pelvic floor dysfunction (PFDI), low back and pelvic pain, and HRQOL (American College of Obstetricians and Gynecologists, 2018;Johnson et al., 2018). Identifying co-morbidities that have a direct impact on function, HRQOL, and maternal health outcomes is an important first step in understanding how to improve maternal health and access to prenatal and postpartum services. The American College of Obstetricians and Gynecologists (2018) report stresses the importance of a comprehensive prenatal and post-partum assessment of physical, social, and psychological well-being including infant care and feeding, physical recovery, and chronic disease management to ensure good quality of life for mothers and reduced related birth complications (American College of Obstetricians and Gynecologists, 2018). Assessment for PFDI, pelvic and low back pain, nutrition, and breastfeeding are among some of the recommendations for improvement in maternal health during the prenatal and post-partum period (Van Delft et al., 2014;Xing, Zhang, Chunyi, & Lizarondo, 2017).
Reports of pain, UI, and nutritional deficits during the post-partum period are common and may negatively affect a new mother's mental, social, and physical HRQOL at home and work (Ansara, Cohen, Gallop, Kung, & Schei, 2004;Benjamin, Frawley, Shields, Van de Water, & Taylor, 2018;Kahn, Zuckerman, Bauchner, Homer, & Wise, 2002). Risk factors during labour include weakening and damage to the perineum and pelvic floor, irrespective of birth mode (Xing et al., 2017). Urinary and fecal incontinence, pelvic organ prolapse, sensory and emptying abnormalities of the lower urinary tract, colorectal-anal dysfunction (CRADI), dyspareunia, and chronic pain syndromes may be exacerbated by stretching and rupture of peripheral nerves, connective tissue, and muscle(s) (Leeman, Rogers, Borders, Teaf, & Qualls, 2016;Xing et al., 2017). Furthermore, PFDI is linked to reduced quality of life and withdrawal from fitness and exercise activities, thus adding instability to the region (Humalajarvi et al., 2014). Supervised pelvic floor exercise programmes have been shown to be effective for preventing stress UI during pregnancy but have not been tested in community-driven education programmes, and specific PFDIs have not been isolated (Sangsawang et al., 2016;Xing et al., 2017). Effectiveness of pelvic floor programmes is linked to early, consistent intervention for a recommended 8 weeks of training (Morkved & Bo, 2013). Maternal physiotherapy and nutrition community-driven public health programmes aim to improve maternal health, decrease co-morbidities, and provide cost-effective, efficient, and valuable community-driven interventions particularly for women who have limited access to physiotherapy and nutrition services.
This study focused on providing education to a group of prenatal and post-partum women, with limited access to physiotherapy and nutrition services within a Midwestern Region of the United States.
The study intervention involved 8-week, two-session (90 min each session) education programme by a licensed physiotherapist and registered dietitian on the following concepts: (a) healthy nutritional intake, (b) benefits of breastfeeding and postural education during breastfeeding to avoid pain and musculoskeletal dysfunction, (c) recognition and treatment options for urge and stress incontinence, pelvic organ prolapse, and colorectal dysfunction pelvic, and (d) implementation of a pelvic floor and core stability exercise programme.
The purpose was to examine the effects of this community-driven nutrition and exercise programme on maternal health outcomes, specifically to (a) measure preintervention to postintervention status in Pelvic Floor Distress Inventory (PFDI), CRADI, pelvic organ prolapse dysfunction (POPDI), urinary distress (UDI) scores, and other co-morbidities reported, (b) measure any correlations between HRQOL for our sample and norm scores for population norms, and (c) measure differences between preintervention and postintervention in nutritional intake and breastfeeding frequency reported. Female volunteers, ages 18-44 years of age, were recruited from current attendees at WIC. Ethical approval from Institutional Review Board was obtained from Andrews University and voluntary informed written consent was given prior to data collection. Inclusion criteria included antenatal and post-partum women who volunteered to participate in the study, between the ages of 18 and 44, currently participating in the WIC programme. Women were excluded from the study if they reported any of the following issues: (a) giving birth to more than two offspring at a time, (b) history of surgery, systemic neurologic disease, or trauma affecting bowel or bladder, (c) prior or current physiotherapy for PFDI/incontinence, or (d) any condition that would exclude the subjects from participation in a nutrition, pelvic floor, or core stability exercise programme as determined by the physiotherapist and registered dietician from the health history form.

| Measurement
The independent variable was identified as the nutrition and exercise education intervention. The demographic and descriptive variables identified were age groups (18-24, 25-34, and 35-44), ethnicity, socio-economic status, educational level, body mass index (BMI), nutritional intake, and type of medical intervention. The dependent variables included the HRQOL measured by the SF-36, nutritional intake results from the Food Frequency Questionnaire, breastfeeding frequency, report of POPDI, CRADI, and UDI measured by PFDI, and co-morbidities reported through the Health History Questionnaire.
The SF-36 is a generic measure and can be used in receiving GH information and quality of life of the participant from both general and specific populations. This survey is easy to use, short, acceptable, and understandable for the patient and general population and holds good reliability and content and construct validity. The SF-36 reported a strong internal consistency (Cronbach's α > .85) and strong reliability with an ICC of >0.75 for all eight domains, with the exception of SF (Salazar & Bernabé, 2015).
The purpose of this study was to provide an 8-week, two sessions of 90-min each antenatal and post-partum education intervention programme for women with socio-economical challenges and to measure the changes before and after the intervention in nutritional intake, breastfeeding frequency, urinary urge and stress incontinence, pelvic and low back pain, and HRQOL. Informed consent, health questionnaires, and all surveys and advertisements for recruiting were available in both English and Spanish. All sessions were offered both in English and Spanish, developed and supervised by a licensed physical therapist and nutrition specialist and/or dietician.

| Intervention description
Participants were recruited through WIC education programme announcement newsletters, posted flyers, and word of mouth via staff members who were instructed in the procedures of the study and confidentiality. Voluntary participants, who met the inclusion criteria, were provided with $25 vouchers for baby items.

| Demographics
Women (n = 35) between the ages of 18 and 44 with a mean age of 22.72 ± 3.45 years completed this study. Twenty-four per cent (24%) of our sample identified as Black, 6% identified as Asian/Pacific Islander, 54% identified as Hispanic or Latino, 11% identified as Caucasian, and 6% identified as multiracial (Table A1). Seventy-seven per cent (77%) reported being a full-time homemaker and/or "unemployed." Sixty five per cent (65.7%) of participants reported income as less than $20,000 USD per year, which is below poverty level for a family of three. The remaining 28.6% identified their income as between 20,000 and 40,000 USD, which is within poverty level range for families with up to eight household members and also within Medicaid eligibility range within the United States (US Department of Health and Human Services, Poverty Guidelines, 2018; Table A1).
Fifty-two per cent (52%) of subjects reported having one or more normal vaginal deliveries (NVD); 34% reported having one or more caesarean sections (CS); 11% reported mixed birth mode; and 3% reported being pregnant during the study. Thirty-seven per cent reported stress UI symptoms; 22.8% reported urge urinary UI symptoms. The total report of UI symptoms, both stress and urge incontinence, was 60%. Sixty per cent (60%) reported other complications, including pelvic or low back pain, abdominal pain, and pre-eclampsia during pregnancy. Only forty per cent (40%) reported doing some form of regular aerobic exercise (Table A1).

| CORRELATIONS
Significant, but weak, inverse correlations were found between BMI  Tables A2a and A2b). Significant, but weak, correlations were found between total Pelvic Floor Incontinence Questionnaire (PFIQ) and parity (r = .384, p < .05) suggesting parity may have a confounding influence on UDI for our sample.

| PREINTERVENTION TO POSTINTERVENTION MEASUREMENT
Pretest to posttest mean scores for the PFDI, CRADI, and UDI decreased significantly (Tables A4 and A5). Median scores and interquartile range were also computed for the sample and showed decrease in median scores between preintervention and postintervention for the same variables. Wilcoxin ranked sign test was utilized to see if there was a difference preintervention to postintervention for the sample.
A significant difference was found between the means for PFDI total scores, CRADI individual scores, and UDI individual scores, but not for POPDI scores. (Lower scores mean that participants got better after the two sessions of 90 min each session in the areas of pelvic distress, particularly related to CRADI and UDI dysfunction; p < .05.) POPDI did not show a significant difference from preintervention to postintervention for our sample (Table A4).

| SF-36 DOMAIN AND COMPONENT SCORES FOR SAMPLE COMPARED WITH AGE-ADJUSTED POPULATION NORMS
The sample mean reported significantly lower scores on the SF-36 than the published population norm means for the PCS, PF, role of pain, SF, VT, RE, and MH denoting "less quality of life" for the women in this sample when comparing with the population norms in the United States for both physical and MH areas. MCS was also reported below the norm data. The GH sample scores were higher than the norm, though not significant, suggesting that GH of the individuals may be independent of the physical health and pain problems they reported (Tables A6a, A6b, and A7).

| NUTRITION INTAKE AND BREASTFEEDING OUTCOMES
Nutritional intake of vegetables preintervention to postintervention increased and was significant (p < .001). An increase in fruit consumption and a slight decrease in snack consumption were reported preintervention to postintervention, but they were not statistically significant. Seventy-five per cent of our sample reported breastfeeding, with slight increased report of breastfeeding posteducation intervention session. However, there was no significant difference between prereport and postreport for either breastfeeding or nutritional intake for other foods. Within the sample, 62.5% of those who identified themselves as Black reported breastfeeding their children; 100% of Asian; 89.5% of Hispanic or Latino; 50% of the multiracial group; and 75% of the Caucasian postintervention.

| DISCUSSION
Our study aims were to examine the effects of a 2-to 90-min session physiotherapy and nutrition educational intervention on PFDI, CRADI, POPDI and UDI symptoms, nutritional intake, and breastfeeding frequency for women living with socio-economic challenges and lack of access to these services within the community. Our study also sought information on HRQOL for this sample of women compared with overall HRQOL normative data means. Overall, we found a significant difference from preintervention to postintervention in PFDI, UDI, and CRADI but did not find a difference for POPDI scores, detailed below. Our sample also reported significant differences between HRQOL in every domain except GH, bodily pain, and PCS.
Significant increases in healthy food were noted, and a high report of breastfeeding frequency was found.
Our sample reported a slightly higher mean frequency report of UDI symptoms, including both stress and urge UI symptoms, pelvic prolapse, and colorectal symptoms, with 60% of women in our sample reporting some form of distress compared with previous studies with reports of 32-64% prevalence (Haylen, de Ridder, & Freeman, 2010;Milsom, Altman, Lapitan, et al., 2009;Morkved & Bo, 2013). Parity also played a role regarding incidence and impact of symptoms reported for our sample, with significant, but weak, correlations found between parity and BMI, parity and urinary incontinence (PFIQ), and parity and PFDI (total scores). We would have expected stronger correlations between parity and PFIQ, PFDI, CRADI, and UDI scores because of the traumatic process of birth and the incidence of UDI and colorectal distress reported in the literature. A previous study showed increased hiatal dimensions after the first delivery, but no cor- Pretest to posttest intervention showed significant differences in CRADI index, UDI index, and total PFDI index scores and indicating positive effects from the community-driven physiotherapy pelvic floor/core stability programme and nutrition and breastfeeding education programme. This is similar to a study by Jebakani and Sameul (2017) who showed a 4-week individualized physiotherapist administered pelvic floor programme in the post-partum period to be effective for treatment of urinary stress incontinence (Jebakani & Sameul, 2017). Similar decreases in UDI findings were found in an eight-session individualized physiotherapy programme intervention (Dumoulin, Bourbonnais, Morin, Gravel, & Lemieux, 2010). Our study found similar results as Bø et al. (2015) regarding the lack of significant change in POPDI index with a pelvic floor programme, suggesting alternative protocols for pelvic floor may need to be used in future studies directed at mechanically correcting for pelvic floor prolapse of Grades I or II (Grade III being surgically indicated). Improvement in healthy eating habits and increased breastfeeding frequency are also reported in the literature with a prenatal and postpartum education programme (Parry, Tully, Moss, & Sullivan, 2017).
Subjects in our study improved infrequency report of breastfeeding and in healthy eating habits. However, our study showed a significantly high proportion of women who began the programme already breastfeeding and reporting fair to good nutritional habits. Changes postintervention included an improvement in posture related to breastfeeding and confidence in lactation production, overall. A significant difference from preintervention to postintervention in healthy nutritional intake of fruit was reported for our study, along with an increase in vegetable consumption and a decrease in unhealthy snack consumption were also found but were not significant. Breastfeeding incidence for this study was already reported high at 75% for the beginning of the study and increased in frequency across the sample from pretest to posttest, as well. Though our study did not focus on effects of birth mode on breastfeeding patterns, subjects who reported NVD or assisted vaginal delivery reported greater percentage of breastfeeding than those who reported CS, which is similar to previous studies reporting greater likelihood of breastfeeding by mothers who had NVD compared with CS delivery (Arora et al., 2017).
Overall, our study indicates that there are positive effects of an 8week, two-session, 90-min each community-driven pelvic floor and core stability programme on UDI, colorectal distress, overall PFDI, breastfeeding patterns and postures, and improvement in healthy eating habits. This community-driven physiotherapy and nutrition public health programme may be an efficient and cost-effective alternative to bridge the access gap in antenatal and post-partum care for women living with socio-economic challenges and limited access to individualized physiotherapy and dietician services.

| LIMITATIONS OF THE STUDY
Limitations of the study include small sample size and lack of control group for comparison. One of the limitations of the study was the 46% attrition rate. Transportation to and from the data collection site was one barrier our subjects reported for the second session postintervention completion. Two subjects phone numbers changed and we were unable to contact them regarding follow-up for postintervention failure to show. Transportation is often a barrier in research involving subjects with lower socio-economic status and was the norm for "no show" rates within the community centre we affiliated with for data collection.

| DIRECTIONS FOR FUTURE RESEARCH
Future research suggests a larger sample size, control group, and consideration of the chronic post-partum symptoms and long-term effects of such programmes. We also recommend one on one follow-up for postintervention transportation arrangements to address the attrition rate of the study. Future research may also consider a weekly education programme and specific dietary indicators, such as Vitamin D3, essential fatty acid intake, and vitamins B6 and B12 intake to be studied for effects on post-partum morbidities and physical and mental HRQOL.

| IMPLICATIONS FOR PHYSIOTHERAPY PRACTICE
Our study found a significant reduction in PFDI, UDI, and CRADI symptoms after 8-week, 2-to 90-min sessions of a physiotherapy and nutrition education programme. A significant increase in healthy nutritional intake, increased breastfeeding frequency, and improvement in HRQOL for prenatal and post-partum women were also reported postintervention. Decreased reported HRQOL for the women in our sample compared with overall normative data published for the SF-36 was also found in PCS, PF, role of pain, SF, VT, RE, MH, and MCS scores. Correlations between HRQOL and significant, but weak, correlations were found between parity and PFIQ and between PFDI and POPDI scores suggesting parity may also share in related symptoms but may be positively affected by a community-driven, 2-to 90-min-focused session programme to reduce the overall pelvic load distress. This study suggests that a community-driven physiotherapy and nutrition public health education programme may offer an effective and cost-efficient means to improve maternal health and decrease co-morbidities for prenatal and post-partum women living with limited access to physiotherapy and nutrition services.
Further research should include a larger cohort across multiple sites, control group comparison, and specific nutritional indicators, as well as followup on the long-term effects for such community-driven programmes.  • Hispanic 19 (54) • Asian 2 (6) • Caucasian 4 (11) • Multirace identity 2 (6)

APPENDIX B STUDY INTERVENTION PROTOCOL
A two session physiotherapy and nutrition education programme took place over several sessions in both English and Spanish and included the following: • Pelvic floor anatomy and function education • Education on stress versus urge urinary incontinence   ○ Progress to breathing while leaning over a therapy ball ○ Consider using a Thera-band around the ribcage for HEP.
• Proprioception ○ Folded towel technique: Using a chair, sit on a folded towel with your perineum touching the towel. Contract muscles where towel is touching.