Impact of postpartum exercise on pelvic floor disorders and diastasis recti abdominis: a systematic review and meta-analysis

Abstract

Objective: To examine the effect of exercise during the first year postpartum on pelvic floor disorders and diastasis recti abdominis.

Design: Systematic review with random effects meta-analysis.

Data sources: MEDLINE, EMBASE, CINAHL, SPORTDiscuss, Evidence-Based Medicine Reviews (Ovid), Scopus, Web of Science and ClinicalTrials.gov were searched until 12 January 2024.

Eligibility criteria for selecting studies: Studies of all designs (except case studies) and languages were included if they contained information on the Population (individuals in the first year postpartum), Intervention (subjective or objective measures of frequency, intensity, duration, volume or type of exercise alone ('exercise-only') or in combination with other intervention (eg, biofeedback; 'exercise+co-intervention')), Comparator (no exercise or different exercise measures) and Outcome (symptom severity and risk of urinary incontinence, anal incontinence, pelvic organ prolapse, diastasis recti abdominis and sexual function).

Results: 65 studies (n=21 334 participants) from 24 countries were included. 'Moderate' certainty of evidence revealed that pelvic floor muscle training reduced the odds of urinary incontinence by 37% (seven randomised controlled trials (RCTs), n=1930; OR 0.63, 95% CI 0.41 to 0.97, I² 72%) and pelvic organ prolapse by 56% (one RCT, n=123; OR 0.44, 95% CI 0.21 to 0.91) compared with control groups. 'Low' certainty of evidence showed a greater reduction in inter-rectus distance measured at rest and during a head lift following abdominal muscle training compared with no exercise. Evidence on the effect of exercise on the risk of anal incontinence and diastasis recti abdominis, as well as the severity of anal incontinence, urinary incontinence, pelvic organ prolapse and sexual function, is limited.

Conclusion: Evidence supports the effectiveness of postpartum pelvic floor muscle training in reducing the odds of urinary incontinence and pelvic organ prolapse and postpartum abdominal exercise training in reducing inter-rectus distance.

Prospero registration number: CRD42022359282.

Keywords: exercise; gynaecology; pelvic floor; urinary incontinence, stress; women.

Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram of the selection process for studies included.

Figure 2. Effects of postpartum pelvic floor muscle training (PFMT) compared with control on the odds of urinary incontinence following the intervention (randomised controlled trials). Sensitivity analyses were conducted using studies that included PFMT+co-interventions and PFMT-only interventions. Analyses were conducted with a random effects model. M-H, Mantel-Haenszel method.

Figure 3. Effects of postpartum pelvic floor muscle training (PFMT) compared with control on change in urinary incontinence symptom severity following the intervention (randomised controlled trials). Sensitivity analyses were conducted using studies that included PFMT+co-interventions and PFMT-only interventions. Analyses were conducted with a random effects model. IV, inverse variance.

Figure 4. Effects of postpartum pelvic floor muscle training (PFMT) compared with control on the odds of anal incontinence following the intervention (randomised controlled trials). Sensitivity analyses were conducted using studies that included PFMT+co-interventions and PFMT-only interventions. Analyses were conducted with a random effects model. M-H, Mantel-Haenszel method.

Figure 5. Effects of postpartum pelvic floor muscle training (PFMT) compared with control on the risk of pelvic organ prolapse following the intervention (randomised controlled trials). Sensitivity analyses were conducted with studies including PFMT+co-interventions and PFMT-only interventions. Analyses were conducted with a random effects model. M-H, Mantel-Haenszel method.

Figure 6. Effects of postpartum abdominal muscle training (AMT) compared with control on inter-recti distance measured at rest following the intervention (randomised controlled trials). Sensitivity analyses were conducted with studies including AMT+co-interventions and AMT-only interventions. Analyses were conducted with a random effects model. IV, inverse variance. Note: when a study reported on measurements taken at multiple places, the sample size was divided by the number of groups.

Figure 7. Effects of postpartum abdominal muscle training (AMT) compared with control on change in inter-rectus distance measured during a head lift task following the intervention (randomised controlled trials). Analyses were conducted with a random effects model. IV, inverse variance. Note: when a study reported on measurements taken at multiple places along the linea alba, the sample size was divided by the number of groups.