APPEAL is an evidence-based training programme to support midwives in teaching pelvic floor muscles exercises to pregnant people. The training helps midwives know when and how to teach the exercises and how to support people to perform the exercises so they are less likely to leak urine after giving birth.
What is APPEAL?
About one in three people experience leaking of urine related to being pregnant and having a baby,
known as urinary incontinence (UI). This is by far the most common pelvic health problem for women prior to and following birth. This can have a big impact on a person’s physical, mental and social quality of life. UI also places pressure on health and social care services and has wider costs to society.
There is evidence that pelvic floor muscles exercises (PFME), when performed correctly during pregnancy, can prevent UI. Midwives in the UK are well placed to give women advice and support for PFME. The APPEAL research programme wanted to know if it was possible to train midwives to teach pregnant women PFME when they come to their appointments during pregnancy, and whether this would help women to do the exercises often enough to prevent UI after having a baby.
The overall aim of APPEAL is to increase the number of women doing pelvic floor muscle exercises during pregnancy and ensure that they are doing them ‘properly’. This should reduce the number of women who suffer from symptoms of urinary incontinence after birth.
Find out more about APPEAL here:
What we’re doing
APPEAL has three aims:
- Understand current antenatal PFME support provided by midwives
- Develop an intervention to increase the support for PFME provided to pregnant women by midwives
- Evaluate the intervention in a feasibility and pilot cluster randomised controlled trial
We’ve made the following progress against our aims:
Aim 1: Understand current antenatal PFME support provided by midwives
Researchers at PenARC and the University of Exeter undertook a review of existing evidence to understand factors that influence the capacity to implement PFME in current antenatal practice. The researchers also observed and interviewed midwives, antenatal healthcare staff and women to understand the challenges and opportunities for improving current PFME provision.
Aim 2: Develop an intervention to increase the support for PFME provided to pregnant women by midwives
Intervention development was led by the University of Exeter APPEAL team. Women and midwives contributed to the development of a training programme and resources to support midwives and women with PFME during pregnancy. The intervention was tried out and refined by midwives. Resources for women were co-designed with the APPEAL Public and Patient Involvement and Engagement (PPIE) group in Exeter.
Aim 3: Evaluate the intervention in a feasibility and pilot cluster randomised controlled trial
University of Warwick and the University of Birmingham Clinical Trials unit led the design and delivery of a feasibility and pilot cluster randomised controlled trial to evaluate whether the intervention could be delivered to midwives and implemented in antenatal care. Training and implementation support was delivered by research midwives at the University of Birmingham and Birmingham Women’s and Children’s NHS Foundation Trust. The University of Exeter undertook a process evaluation to understand whether the intervention was acceptable to midwives and if it was possible to implement in antenatal care, and to explore women’s experiences of receiving PFME advice and education during the trial period.
All project activity was supported by extensive input from our APPEAL Public and Patient Involvement and Engagement (PPIE) group in Exeter, facilitated by PenARC PPIE team.
Our service impact
The NHS Long Term Plan says all areas should have a service to deal with “perinatal pelvic health”. Our training programme is recommended as part of this. The programme uses a “train the trainer” approach and has been delivered in 9 trusts with 9 more planning delivery. To date (September 2025), more than 200 midwife service leads have been trained, who have then trained 100s more to provide the service.
Our videos
As part of this programme of research, we’ve collaborated with Health Innovation South West to release a series of videos:
What’s next?
The APPEAL research team in Exeter are working in collaboration with Health Innovation South West to support the implementation of APPEAL training in the South West, including Cornwall, Devon, Somerset and Dorset.
The Exeter research team are developing related training for primary care settings.
Future development will seek to evaluate how APPEAL is being implemented and spread in real-world settings.
Programme details
The APPEAL research brought together a programme of research to develop training and resources to improve the support given to pregnant people to do pelvic floor exercises. This work was supported by the National Institute for Health Research and Care Programme Grant for Applied Research, grant number RP-PG-0514-20002, Trial registration ISRCTN10833250.
The research programme was led by the University of Birmingham in collaboration with the Universities of Exeter and Warwick, and other multi-centre collaborators.
To see the Best in Category prize for abstract 53, please see here: Abstract #53 National and local implementation of training for midwives to support women to do their pelvic floor exercises during pregnancy. Mixed method evaluation of training provision, implementation support and resources.
Best in Category Prize: Health Services Delivery Presenter: Victoria E Salmon, United Kingdom Salmon V, Jones E, Edwards E, May R, Hay-Smith J, Frawley H, MacArthur C, Santosh T, Hedge S, Ukoumunne O, Dean S
Related Publications
The APPEAL literature review protocol has been published in PROSPERO International prospective register of systematic reviews.
An article was published in The Conversation discussing how training in pregnancy for pelvic floor exercises could reduce the need for “barbaric” vaginal mesh surgery.
Bick, D, J Bishop, T Coleman, S Dean, E Edwards, H Frawley, E Gkini, et al. 2021. “Antenatal Preventative Pelvic Floor Muscle Exercise Intervention Led by Midwives to Reduce Postnatal Urinary Incontinence (APPEAL): Protocol for a Feasibility and Pilot Cluster Randomised Controlled Trial.” Pilot and Feasibility Studies. https://doi.org/10.1186/s40814-022-01185-y.
Dean, S, V Salmon, R Terry, J Hay-Smith, H Frawley, S Chapman, M Pearson, et al. 2022. “14 TEACHING EFFECTIVE PELVIC FLOOR MUSCLE EXERCISES IN ANTENATAL CARE: DESIGN AND DEVELOPMENT OF A TRAINING PACKAGE FOR COMMUNITY MIDWIVES IN THE UNITED KINGDOM.” Continence 2 (June): 100204. https://doi.org/10.1016/J.CONT.2022.100204.
MacArthur C, Bick D, Salmon V, Jones E, Hay-Smith J, Bishop J, et al. Midwifery-led antenatal pelvic floor muscle exercise intervention to reduce postnatal urinary incontinence: APPEAL research programme including a feasibility and pilot cluster RCT. Programme Grants Appl Res 2024;12(09).
Salmon VE, Hay-Smith EJC, Jarvie R, Dean S, Oborn E, Bayliss SE, Bick D, Davenport C, Ismail KM, MacArthur C, Pearson M. Opportunities, challenges and concerns for the implementation and uptake of pelvic floor muscle assessment and exercises during the childbearing years: protocol for a critical interpretive synthesis. Systematic Reviews (2017) 6:18
Salmon, V.E., E.J.C. Hay-Smith, R. Jarvie, S. Dean, R. Terry, H. Frawley, E. Oborn, et al. 2020. “Implementing Pelvic Floor Muscle Training in Women’s Childbearing Years: A Critical Interpretive Synthesis of Individual, Professional, and Service Issues.” Neurourology and Urodynamics 39 (2). https://doi.org/10.1002/nau.2425.
Smith, C, V Salmon, E Jones, E Edwards, J Hay-Smith, H Frawley, S Webb, D Bick, C MacArthur, and S Dean. 2022. “16 TRAINING FOR MIDWIVES TO SUPPORT WOMEN TO DO THEIR EXERCISES DURING PREGNANCY. A MIXED METHOD EVALUATION OF THE MIDWIFE TRAINING DURING A FEASIBILITY AND PILOT RANDOMISED CONTROLLED TRIAL.” Continence 2 (June): 100206. https://doi.org/10.1016/J.CONT.2022.100206.
Terry, R., R. Jarvie, J. Hay-Smith, V. Salmon, M. Pearson, K. Boddy, C. MacArthur, and S. Dean. 2020. “‘Are You Doing Your Pelvic Floor?’ An Ethnographic Exploration of the Interaction between Women and Midwives about Pelvic Floor Muscle Exercises (PFME) during Pregnancy.” Midwifery 83. https://doi.org/10.1016/j.midw.2020.102647.
Related Projects
Supporting improvement of pelvic health resources for women – Health Innovation South West
[In development] Pflexi is a project to co-produce a similar training package to support primary care clinicians in delivering PFME advice and support to women across their life course. This has been funded by the University of Exeter School for Primary Care Research.
Collaborators
Dr Victoria Salmon, PenARC
Dr Rohini Terry, PenARC
Professor Christine MacArthur, University of Birmingham
Professor Debra Bick, University of Warwick
Dr Ellie Jones, University of Birmingham
Professor Jean-Hay Smith, University of Otago
Jon Bishop, Birmingham Clinical Trials Unit
Eleni Gkini, Birmingham Clinical Trials Unit
Karla Hemming, University of Birmingham
Sara Webb, Royal College of Midwives
Mark Pearson, University of Hull
Tim Coleman, University of Nottingham
Libby Edwards, University of Birmingham
Professor Helena Frawley, The University of Melbourne
Eivor Oborn, University of Warwick