Abstract

Objective To design a primary care clinical tool (Pelvic Floor Health Index [PFHI]) to screen for postpartum pelvic floor disorders, as well as complete its psychometric validation.

Design Prospective cohort study.

Setting Two tertiary care obstetric centres in Vancouver, BC.

Participants Primiparous women older than 19 years of age who were in the immediate postpartum period.

Main outcome measures The PFHI was administered to 74 primiparous women immediately postpartum and at 2, 4, and 6 months postpartum. For evaluation of convergent and divergent construct validity, participants also completed several validated questionnaires, including the Female Sexual Functioning Index, the Pelvic Floor Distress Inventory, the 36-Item Short Form Health Survey, and the Edinburgh Postnatal Depression Scale. Fifteen women repeated their 6-month questionnaires 2 weeks later in order to determine test-retest reliability. Responsiveness was assessed by measuring the PFHI score change from baseline to 6 months postpartum.

Results Pelvic Floor Health Index score was inversely correlated with subscale scores on the Pelvic Floor Distress Inventory at all time points. There were moderate correlations between PFHI score and the Female Sexual Functioning Index and 36-Item Short Form Health Survey scores at several time points. There were weak correlations with postpartum depression scores. The intraclass correlation coefficient for test-retest reliability was 0.78 (95% CI 0.47 to 0.92). The PFHI mean total score significantly improved by 1.8 (95% CI 1.0 to 2.6) at 6 months postpartum.

Conclusion The PFHI is a 10-item, newly validated, and psychometrically robust questionnaire that can be administered to patients in the postpartum period to screen for pelvic floor dysfunction.

Pregnancy and childbirth can precipitate or worsen pelvic floor disorders (PFDs) in women.1 Approximately 1 in 3 women leak urine in the first 3 months after delivery and 1 in 5 report fecal incontinence 1 year after delivery.2 Women in the postpartum period may also develop pelvic pain, dyspareunia, poor body image, and avoidance of sexual intimacy.3-5 Although most bothersome pelvic floor symptoms occur during the postpartum period, there are very few clinical PFD screening tools for practitioners to use before, during, or after pregnancy. Identifying persistent or abnormal pelvic symptoms as early as during a first pregnancy or after a first delivery allows for timely interventions. General practitioners should have access to adequate tools to start conversations around sensitive topics to prevent PFDs later in life. A systematic review found the most frequently used questionnaires for this purpose were the Pelvic Floor Distress Inventory (PFDI; short version), the Pelvic Floor Impact Questionnaire (short version), and the International Consultation on Incontinence Questionnaire Vaginal Symptoms Module.6 However, these were mostly developed for use in research of established PFDs and were validated in an older population; also, scoring and interpretation of these questionnaires are intricate and may not be suitable for screening out pregnancy-related symptoms that may be transient. More recently, a 42-item postpartum PFD questionnaire passed all psychometric testing,7 but busy clinicians are unlikely to use this lengthy questionnaire in primary care practice.

Based on expert opinion and literature review, we designed a simple and practical primary care practice clinical screening tool for pregnancy and vaginal childbirth–related postpartum pelvic floor symptoms. Our goal was for it to be short, effective, and easy for patients to understand and for family doctors to use, as well as to be self-administered by patients through a primary care clinic intake questionnaire. We aimed to complete its psychometric validation in a cohort of women who were recently in the postpartum period.

METHODSStudy design

This prospective cohort study was approved by the Providence Health Care Research Ethics Board and the BC Women’s Hospital Research Ethics Board. Our group of clinician scientists (R.G. and M.G.) in urogynecology compiled elements indicative of optimal pelvic health and designed a 10-item questionnaire, the Pelvic Floor Health Index (PFHI) (Figure 1). Each item is a yes-or-no question and increasing scores represent better pelvic health. A patient who scores 10 is considered to have optimal pelvic health. There are 4 questions on PFDs, 3 on genital pain, 1 on genital sensation, and 2 on sense of attractiveness and avoidance of intimate activities. Constructs of attractiveness and avoidance were drawn from prior qualitative focus groups8 and quantitative validation research on the development of a body image questionnaire for PFDs9 and a female genital self-image scale.10 For face validity, we consulted a focus group of 5 patients healing from a recent vaginal birth and with lived experience of the symptoms assessed in the index. We asked open-ended and specific questions about language comprehension, simplicity of language, and relevance of individual index items. For content validity, we reviewed the PFHI with a representative group of urogynecology and pelvic physiotherapy experts at the Department of Obstetrics and Gynaecology’s annual urogynecologic conference at the University of British Columbia in Vancouver. This qualitative, iterative process established common themes, allowing us to make structural changes to the index for face and content validity.

Figure 1.

Postpartum Pelvic Floor Health Index: Screening for pelvic health milestones.

Participants

We recruited primiparous women older than 19 years of age who had just given vaginal birth from 2 tertiary care obstetric centres. We included those with singleton and term gestations. Participants had to be able to read and write in English. We excluded women with known prepregnancy pelvic floor symptoms, chronic pain syndromes, known or suspected fetal malformations, stillbirth, and whose infants were admitted to the neonatal intensive care unit. We aimed for a convenience sample of 60 women: 30 with severe perineal tears (third- or fourth-degree tears); and 30 with minimal perineal trauma (intact perineum or first-degree tears) who were age-matched (within 5 years) and formed a control group.

Participants provided demographic characteristic information and completed 4 validated questionnaires at recruitment: the PFDI (46 items, condition-specific quality of life),11 the Female Sexual Function Index (FSFI; sexual function domains of desire, arousal, lubrication, orgasm, satisfaction, and pain),12 the Edinburgh Perinatal-Postnatal Depression Scale (EPDS; mental health),13 and the 36-Item Short Form Health Survey (SF-36; general health perception, physical and social functioning, and role limitation due to physical, emotional, and mental health concerns).14 We contacted participants at 2, 4, and 6 months postpartum to repeat the 4 questionnaires via telephone interviews.

Statistical analysis

We assessed convergent and divergent construct validity by calculating Spearman rank correlations of PFHI score with the PFDI, FSFI, EPDS, and SF-36 scores at different time points. We assessed internal consistency using Cronbach α and responsiveness (change in PFHI score over time) using a t test.

Fifteen women repeated 6-month questionnaires 2 weeks after first completing them. The intraclass correlation coefficient was computed for test-retest reliability. We performed a subgroup analysis to verify PFHI validity by degree of perineal trauma (severe or minimal).

Missing PFHI items were imputed using the mean of the answered items from the same participant. If more than 20% of the items were missing, the total score was considered missing. For other validated questionnaires, we followed instructions in scoring documents to handle missing items or applied the same technique as for the PFHI if no instruction was provided. We also performed a sensitivity analysis in which women with missing responses for any 1 of the 10 items in the PFHI were considered as missing for the total score.

Analyses were conducted using SAS, version 9.4, and R, version 4.0.4.

RESULTS

Overall, 74 participants provided consent and completed the PFHI survey at baseline (Table 1). Only 69 participants answered all 10 questions at baseline, while 45 participants (61%) completed the PFHI at 2 months, 32 (43%) at 4 months, and 45 (61%) at 6 months.

Table 1.

Baseline demographic characteristics (N=74)

Convergent and divergent construct validity

Pelvic Floor Health Index score was inversely correlated with PFDI score at all time points, particularly with the Urinary Distress Inventory and Colorectal-Anal Distress Inventory subscale scores at 4 and 6 months, and with the Pelvic Organ Prolapse Distress Inventory score at 2 and 4 months, which showed moderate correlations (Figure 2; Spearman ρ ranging from −0.41 to −0.70). There were moderate correlations between PFHI and FSFI scores at 0, 2, and 6 months. Pelvic Floor Health Index score was positively correlated with SF-36 score—especially in the domain of physical functioning—at 2, 4, and 6 months. Correlations between PFHI and EPDS scores were weak. Similar to the main analysis, PFHI score was inversely correlated with PFDI score at all time points in both severe and minimal perineal trauma groups.

Figure 2.

Spearman correlation between PFHI and other validated questionnaires

Internal consistency

Cronbach α ranged from 0.59 (4 months) to 0.71 (0 months). We included all PFHI items as the α did not vary significantly when any 1 item was removed. At baseline, Cronbach α was 0.67 and 0.75 for the minimal trauma group and severe trauma group, respectively, which was consistent with the main analysis. However, the sample size was too small (n≤25) to assess internal consistency by tear severity at months 2, 4, and 6.

Test and retest reliability

The intraclass correlation coefficient was 0.78 (95% CI 0.47 to 0.92), but the sample size was too small to assess this aspect by tear severity.

Responsiveness

The PFHI mean total score significantly improved by 1.8 (95% CI 1.0 to 2.6) at 6 months postpartum (Figure 3), and the mean total score also improved over time in both severe and minimal tear groups.

Figure 3.

Mean change in Pelvic Floor Health Index score relative to baseline

Sensitivity analysis

Exclusion of incomplete PFHI questionnaires (n=5 at baseline; n=1 at 2 months; n=2 at 4 months; n=1 at 6 months postpartum) did not alter our conclusion.

DISCUSSION

The PFHI is a newly developed practical screening tool for postpartum primary care. Initial psychometric validation indicates usefulness in clinical practice. It demonstrates correlation with existing validated questionnaires of similar clinical constructs at multiple time points and in numerous domains. Weak correlations with the EPDS suggest that physical pelvic floor symptoms may not play a large role in postpartum depression. The PFHI demonstrates adequate internal consistency, test-retest reliability, and responsiveness in a postpartum cohort, as well as adequate internal consistency immediately postpartum and responsiveness at 6 months in both severe and minimal tear subgroups.

Pelvic floor symptoms usually worsen in the third trimester of pregnancy and immediately postpartum, with gradual return to prepregnancy levels thereafter. The PFHI scores showed gradual improvement consistent with the expected natural course of disease and mirrored improvements in symptoms demonstrated with established questionnaires (convergent validity). We developed our questionnaire to address mainly physical symptoms and this was reflected in weak or inconsistent correlations with the EPDS, as well as with the mental health and emotional domains of the SF-36 (divergent validity). The PFHI also showed weak or inconsistent correlations with the SF-36 domains of role limitations, vitality, bodily pain, and general health perceptions; this could be consistent with women’s ability to compensate for these limitations in order to care for their newborn babies.

Pelvic floor disorders often start at first delivery and gradually increase in severity.15-18 Ten percent of women aged 20 to 39 experience pelvic floor dysfunction from 1 or more PFDs; by age 80, half are affected.18 Since PFD treatment is associated with morbidity and is not always satisfactory in older women, prevention of PFDs should be a primary goal of clinicians and researchers.19 At 6 months postpartum in our current study, only one-third of patients with minimal tear and 10% of patients with severe tear had an optimal PFHI score. Only 5% of obstetric patients receive information about incontinence or prolapse during antenatal visits with their obstetrician, family doctor, or midwife.20 Moreover, the current postpartum standard of care for new mothers is 1 brief follow-up visit with the maternity care provider at 6 weeks postpartum.21 Women are often confused as to which symptoms are normal or transient, and online information related to pelvic procedures is misleading or incomplete.22,23 Partially because of traditionally short postpartum follow-up care, providers also have a poor understanding of the timeline of pelvic floor healing. The American College of Obstetricians and Gynecologists recently introduced the urgent need for a paradigm shift in postpartum care through the concept of the “fourth trimester.”21 This recognizes the importance of continued surveillance for optimal physical recovery from birth.

To the best of our knowledge, the PFHI is the first pelvic floor symptom screening tool in the English language to integrate most aspects of pelvic floor dysfunction, including bowel, bladder, pain, and sexual and body image concerns. Use of the PFHI can simplify pelvic floor health care conversations for all primary care practitioners, at any point postpartum. With few questions and simple scoring, the PFHI allows general practitioners to identify sensitive and potentially bothersome symptoms that patients do not readily bring up. It is not meant as a diagnostic tool for pelvic floor disorders, but rather as a screening tool to use during the process of recovery. The PFHI can be self-administered by patients, making it easy to distribute in practice. Any score lower than 10 (with 10 indicating optimal pelvic floor health) 6 months postpartum should prompt the primary care practitioner to offer a referral to a pelvic floor health specialist such as a pelvic physiotherapist, sexual health counsellor, or urogynecologist for a discussion on preventive measures and optimal future childbirth to minimize further pelvic floor strain or trauma. Those who are not bothered by pelvic floor symptoms, who are not sexually active, or who do not desire further childbearing, for example, may choose to decline further care.

Preventive education on pelvic floor health during pregnancy has been shown to improve postpartum knowledge, confidence performing pelvic floor muscle exercises, and bowel-specific quality of life.24 Moreover, individual pelvic floor muscle training decreases urinary incontinence and related symptoms 6 months postpartum25; reduces prolapse symptoms and related interventions; and reduces urinary incontinence and interference due to bowel symptoms.26

Strengths and limitations

Our small sample size limits our findings, which may also not be generalizable to those who have given birth via cesarean delivery, who do not speak English, or who are of other ethnic or cultural backgrounds than those in our sample. While the PFHI touches on most pelvic floor symptom categories, it is not a diagnostic tool and does not elicit the exact nature of each organ dysfunction. Users will need to address particular areas of concern identified through the PFHI either through further conversations or through directed referral. Although its psychometric validation was demonstrated in the first 6 months postpartum, studies are ongoing to identify optimal time points and pathways of care relevant to the use of this questionnaire.

Conclusion

The PFHI is a newly developed practical self-screening tool for patients after vaginal delivery and can be useful in primary care. Initial psychometric validation supports its use.

NotesEditor’s key points

▸ The Pelvic Floor Health Index is a newly developed practical primary care screening tool for pregnancy and vaginal childbirth–related postpartum pelvic floor symptoms.

▸ The tool demonstrates adequate internal consistency, test-retest reliability, and responsiveness in a postpartum cohort. Initial psychometric validation indicates usefulness in clinical practice.

▸ Any score lower than 10 (with 10 indicating optimal pelvic floor health) 6 months postpartum should prompt referral to a pelvic floor health specialist such as a pelvic physiotherapist, sexual health counsellor, or urogynecologist.

Points de repère du rédacteur

▸ L’indice de la santé du plancher pelvien est un outil de dépistage pratique nouvellement conçu pour les symptômes postpartum liés à la grossesse et à l’accouchement par voie vaginale.

▸ Il a été démontré que l’outil a une cohérence interne adéquate, une fiabilité test-retest et une bonne sensibilité dans une cohorte postpartum. La validation psychométrique initiale indique son utilité en pratique clinique.

▸ Un score plus faible que 10 (10 indiquant une santé du plancher pelvien optimale) à 6 mois après l’accouchement devrait inciter à demander une consultation spécialisée en santé du plancher pelvien, comme auprès d’un physiothérapeute pelvien ou d’un conseiller en santé sexuelle, ou en urogynécologie.

Footnotes

Contributors

Drs Roxana Geoffrion and Merry Gong contributed to research design and supervision; Drs Geoffrion, Gong, and Sophia Badowski contributed to the literature review; Drs Gong, Gurkiran Mann, Manisha Tilak, as well as Nicole Koenig, contributed to data collection, entry, and interpretation; Dr Terry Lee performed the statistical analysis and created the tables and figures; Drs Geoffrion and Badowski wrote and edited the manuscript. All authors reviewed the final manuscript.

Competing interests

None declared

This article has been peer reviewed.

Cet article a fait l’objet d’une révision par des pairs.

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