Hypothesis / aims of study
Despite evidence for pelvic floor muscle training (PFMT) to effectively prevent or treat postnatal urinary or faecal incontinence, (1, 2) there have been no studies evaluating the cost-effectiveness of different models-of-care to deliver PFMT in pregnancy or the postnatal period. Such an evaluation is needed to provide health services with relevant data to inform service planning. We therefore undertook this review to determine the costs and cost-effectiveness of different models-of-care delivered to provide PFMT in pregnancy or the postnatal period.
Study design, materials and methods
Studies included in a recent Cochrane Systematic Review (1) on supervised PFMT during pregnancy or in the postnatal period for preventing or treating postnatal urinary incontinence and / or postnatal faecal incontinence were grouped according to model-of care and meta-analysis performed on these groupings. For models-of-care that showed a statistically significant impact on preventing or curing urinary and / or faecal incontinence, a cost-effectiveness analysis was undertaken. A base case for each model-of-care was generated based on the median number of sessions and duration of sessions and staffing levels of the reported interventions. Costs for each model-of-care were based on publicly available data on costs of consumables, room hire, staffing, and median wage of women of childbearing age. Sensitivity analysis was conducted for variables of the number of women attending group sessions, population employment levels and staffing hourly rates.
Seventeen studies were included for meta-analysis. Three models-of-care were clinically effective: individually-supervised PFMT during pregnancy to prevent urinary incontinence (Model 1), group-based PFMT during pregnancy to prevent or treat urinary incontinence (Model 2) and individually-supervised postnatal PFMT to treat urinary incontinence and prevent or treat faecal incontinence (Model 3). The health service costs per urinary incontinence case prevented or cured were $768 for Model 1, and $1,970 for Model 3. Model 2 generated a cost saving of $14 if there were 8 participants per session, with greater savings if more participants attend. The health service cost per faecal incontinence case prevented or cured was $2,784 (Model 3). Table 1 shows the costs for the different individually-supervised PFMT models-of-care, while Figure 1 shows the cost per person according to number of attendees for group-based PFMT during pregnancy to prevent or treat urinary incontinence.
Interpretation of results
This was the first study to identify comparative cost-effectiveness of different modeal of care for preventing or treating postnatal incontinence.
Individual PFMT delivery during pregnancy to prevent urinary incontinence was the most cost-effective model for overall costs. Group-based PFMT during pregnancy to prevent urinary incontinence was the most cost-effective model from a health service perspective, depending on the number of women attending the group-based intervention and the out-of-pocket costs charged. It is important to note that patients included in these studies did not have urinary incontinence at the start of treatment.
For existing urinary incontinence, individual PFMT during pregnancy did not have a statistically significant clinical effect, although there was a trend towards positive outcomes in these analyses. One of the included studies provided minimal details about their intervention other than that there were only 1-2 treatment sessions. As supervision has been identified as a significant factor in achieving outcomes, (3) this may account for the lack of statistically significant clinical effect in both this individual study and the meta-analyses of this model.
Most of the studies of postnatal PFMT focused on individual PFMT for treatment or for mixed prevention and treatment of urinary incontinence. Due to the lack of significant findings in the few studies that assessed group-based or mixed group and individual models, we did not analyse these models for cost-effectiveness. Individual postnatal PFMT to treat urinary incontinence was both clinically significant and cost-effective.
Based on our meta-analysis and cost-effectiveness analysis results:
It is recommended that all continent pregnant women are provided with the opportunity to participate in urinary incontinence prevention services during pregnancy.
It is more efficient for health service providers to provide group-based prevention services during pregnancy to continent pregnant women than provide individual treatment services to incontinent women postnatally if at least 4 women can attend the group sessions.
Group-based prevention is preferable to individual prevention if:
• At least 5 women can attend the group sessions and the service charges $10 per session
• At least 8 women can attend the group sessions and the service charges $5 per session
• At least 13 women can attend the group sessions and there is no charge per session
We are unable to make any recommendations regarding early in-hospital postnatal PFMT or education sessions due to the lack of studies specific to the early postnatal period.
We are unable to make a clear recommendation regarding whether it is better to provide prevention during pregnancy or treatment postnatally. While it is more efficient for health service providers to provide prevention services during pregnancy to continent pregnant women than to provide treatment services to women incontinent of urine postnatally, postnatal treatment has the additional benefit of preventing or treating faecal incontinence.
If a health service is investing resources in prevention of urinary incontinence amongst pregnant women:
• If at least 5 women can attend group PFMT, it is recommended that continent women are provided with the opportunity to participate in group PFMT during pregnancy for prevention of urinary incontinence.
• If only 4 or fewer women can attend group PFMT, it is recommended that continent women are provided with the opportunity to participate in individual PFMT during pregnancy for prevention of urinary incontinence.