Appendix 10Interviews with intervention and control midwives at the end of the APPEAL study

Attended APPEAL training

Positive experience of training

‘[APPEAL trainers] approached it [PFME/UI] in a very sensitive, a very sensitive and caring way. I was quite worried to do the training to start with, how it would, how they would bring it across to us, but they had such a lovely mannerism, very gentle and non-threatening that I actually thought the training was very, very good. As I said, I wouldn’t change anything’. (104)

‘I just think [the training] was really good about, and it was really clear about what we should be recommending to women rather than just, I’ve seen lots of variation in practice, so I like that it was quite definite about this is what you should be aiming for with numbers, of, like, this many seconds and this long, and yeah, it was quite, it was really clear about what we should be recommending and where that had come from, like the fact that it was evidence-based and that was really good’. (154)

Report of range of previous experience from no PFME training to extensive knowledge

‘I think just maybe during uni we had like one lecture on [PFME], but that’s probably it, I haven’t had any training on it since qualifying. Definitely not’. (1004)

‘I think when I done my yoga training, that’s probably when I started to get a little bit more thorough I would say, and I think it’s just because it’s personally in my daily practice, and when I teach pregnancy yoga it’s something we talk about so much, I think because I’ve been practising it more and talking about it more, it’s kind of come through my clinical practice as well’. (1010)

‘I’ve done some, I did a training day with chartered physiotherapists, which was a quite a while back. Um, I did work with them, it’s probably five years old, we did a conference I worked with [name] with the, the female genital mutilation safeguarding team, and we did a conference about urinary continence and the availability of toilets, and how women secretly hold these issues and problems around strength of the pelvic floor and weakness of the pelvic floor’. (1019)

‘The training I’ve received with pelvic floor exercises and the pelvic floor was at the university and when I studied my postgrad, um, my undergraduate midwifery degree’. (1028)

Some midwives report less consistency with increasing time since training

Teaching PFME in line with APPEAL but inconsistency progressing exercises and asking about UI

‘ … at the time when we first implemented APPEAL and we were giving out the packs and there was obviously much more discussion around the trial and around the training and around what we were talking to women about and where we were documenting, and I think that’s probably just those conversations haven’t happened or aren’t happening now’. (140)

‘So at every appointment, every contact we discuss pelvic floor exercise and if there was any instances of incontinence or anything. I found that a lot of women, a lot of the first pregnancy ladies didn’t have any issues at all. The sort of para 1, para 2 ladies, they start, they were sort of, they had maybe a slight bit of leakage initially but sort of by sort of 28 weeks it had sort of resolved, sort of not completely or completely sort of thing’. (115)

‘We don’t really mention leaking outright’. (104)

Confirm lack of consistency teaching PFME in standard AN care, i.e. not all midwives teach PFME or ask about UI; PFME/UI focus is at booking only, PN only or not at all

Not routinely asking about UI

Level of detail for PFME varies, for example no specific instruction for PFME versus describing and explaining PFME in detail

‘I mean I do just discuss it [PFME] with women but it’s not something, definitely in the antenatal period, I have to admit that is on, because we’ve got so much other questions that we need to ask that it’s just not something that’s on your radar for every antenatal’. (1002)

‘I’ll be honest, I find from speaking to them about it at bookings when they’re first pregnant, and then I’ll speak to them, I’d love to speak to them every appointment about it, but I just do not have the time, so I’ll probably speak to them again about it at the birth talk if I, if I complete a birth talk for them and then the next time would be postnatally’. (1004)

‘Um, probably depends very much on their understanding of English and, what else is going on, we always mention it, it’s one of the questions we mentioned postnatally more than antenatally I would say, but we do mention it antenatally. Sometimes it is just a more of a passing comment though, it is “are you doing pelvic floor exercises?”, if they say yes they are, then you tend to move on, you don’t tend to question so much what they’re doing’. (1007)

‘ … we don’t normally routinely asking [sic] them [about UI] again for the rest of the pregnancy and normally would mention it on the visit of the postnatal’. (1031)

Positive attitude to APPEAL programme enhanced by personal interest in PFME/UI

Appropriate to fit PFME into AN care

Some midwives report unable to implement APPEAL within AN care

Others report implementing at every appointment as trained

Consistent challenges for implementation relating to increased workload since COVID; time constraints; making PFME a priority; language barriers and remembering APPEAL

Prioritisation may be due to attitude and motivation rather than time

Positive response from women is motivating

Confident to deliver APPEAL

‘I would probably say the pelvic floor exercises rings quite true with myself, because I’ve had issues, so it was actually after the training I put myself forward to be the champion, rather than being allocated, so I actually spoke to my boss and said I’ve got an interest, and that’s how come I became the champion, so the training must have had some impact for me to then volunteer to be a champion’. (136)

‘I think it’s definitely appropriate [to fit PFME into AN care], you know it’s hand in hand really with pregnancy it’s, it’s the, I think it’s the optimum time to discuss it and sort of embed it into their [women’s] sort of, you know, their life really’. (115)

‘I know it’s [PFME] really important, I know, but it’s just having, we just have so much information’. (104)

‘So in antenatal visits, so the intervention specifically, after having the training I would, I discussed it a few times with people, and it took so much time that I then didn’t, I just didn’t have time, I just didn’t have time’. (158)

‘I think so, and it’s, again, purely because of the time factor, because with COVID and having much more strenuous cleaning in between every patient and donning and doffing PPE and talking about COVID vaccines, and so, and anxiety levels, yeah. So probably pre-COVID it might have been a bit, a bit more effective in trying to deliver it’. (158)

‘ … we did discuss the time wasn’t really a good enough excuse, because at the end of the day it’s quite easy to drop it [PFME] in at the end while you’re doing your paperwork, or while you’re talking to the mum’. (136)

‘I must admit I never did referrals, I did have one or two ladies that said they had incontinence issues, but not enough to be referred was their sort of attitude, but they’re the ones that said since I’ve started doing the exercises I’ve noticed an improvement’. (136)

•‘Yeah, I’m very confident I shall carry on [delivering APPEAL], yeah, absolutely, especially when you know that you’re helping people, you know, it’s public health, isn’t it, so it’s part of our role’. (104)

Perceived challenges to teaching PFME consistent with early APPEAL work (WP1, WP3)

Challenges relate to complexity of caseload, volume of information to cover in AN care, time constraints

Recognition that midwives well placed for teaching PFME

Uncertain if women will practise PFME, especially if continent

‘I’m getting really a lot of the ladies, these days, tend to have social issues or other issues that take up your time over pelvic floor, to be honest’. (1002)

‘I’d love to speak to them every appointment about it [PFME/UI], but I just do not have the time’ (1004)

‘I do, I do find it [PFME/UI] harder to bring up, apart from the booking, because you know we normally have a good hour aside for booking appointments so it’s easy to talk about it, um, at an antenatal clinic appointment if we talk about other things sometimes it is a bit difficult to talk about pelvic floor when, when there’s other things going on the pregnancy, so I do find that more difficult during pregnancy’. (1028)

‘I just think [APPEAL] it’s good, anything that’s going to try and kind of get it more on the agenda, get, get us talking to women, get women aware, not kind of leaving it until postnatally when potentially they would have benefited from my antenatal input is obviously a good thing’. (1004)

Not all midwives able to implement APPEAL as trained

‘So the day I did the training I had, my clinic that day, I think I had about five women or six women that were all 16 weeks coming in that day and I was like, okay I’ve got my student, I’m going to be really good and we’ll do it, and I said to her, right, let’s do this together, we’ve just had the training, this’ll be great, and in the training they’d said, oh it’ll take about five minutes to do it, and that is true and I was half an hour late with my clinic because every woman took an extra five minutes and we were running half an hour late by the end and then that knocks onto everything else. So I think, I really struggled to integrate it at the 16-week appointment because there just wasn’t time and I’ve got to be honest I didn’t do it after that, I would just, or I did, I did do it, I just did a shortened version’ (154)

No previous awareness of APPEAL until contacted by researcher

n = 1 midwife had contact with intervention group and knew about APPEAL

Awareness of APPEAL has not changed practice

Interviewer: ‘Moving on to the APPEAL study then, and I’m just wondering when you first heard about it?’

1028: ‘Actually, when you e-mailed me’.

1012: ‘I just heard about [APPEAL] it from [midwife], who is part of the group who are encouraging women to do their pelvic floors’.

Interviewer: ‘And after hearing about the study did it change the way you practice, did it jog anything for you?’

1012: ‘No, not particularly because I know that we’re not part, we’re just continue on doing our standard care, yeah’. (1012)

Access to Trust-wide champions

Longer appointments

Consistent messages – training for all including midwifery support workers/assistants

Prompts for midwives, for example Badgernet

Refresher training

Leaflet in other languages helpful

‘Yeah, so our champion was one of our community midwife colleagues on our team, and she was, I felt like she was quite proactive at reminding us and encouraging us and reminding us about the bags and, yeah, I felt like she was sort of reminding us and supporting us’. (158)

‘I mean, yeah, the ideal would be longer appointments, which, yeah, again it’s another thing, that those three things, enough time, giving all the information and building a rapport, in today’s world, today’s NHS, won’t happen, so I don’t know, short answer’. (158)

‘But obviously needs everybody to be doing the same thing as well, doesn’t it, because this has just been a trial so if that feedback comes back that it’s been useful then it should be rolled out to all midwives should be doing it’. (104)

‘they [midwifery support workers] all had training, yeah, so yeah that was quite good because a lot of them will do sort of 28-week bloods and things like that so they were able to sort of at that point ask about the pelvic floor, so yeah it did. I think it got all of the team involved because there’s, sometimes there’s a bit of disparity between sort of the midwifery, midwives and the support workers so it kind of helped to include them as well’. (115)

‘I do think it’s something that should be embedded into mandatory training, particularly for community midwives who are having those conversations with women every day. So I do think that should be kind of just part of your induction training, so when people join the Trust, they’re new to the Trust, but also specifically for community-based midwives, I think that should be part of mandatory training, and definitely, you know, refresher training’. (140)

‘I also think we did mention it because it was a research, it wasn’t on the Badgernet sort of checklist, as other things are, so because it was on the Badgernet checklist things were probably taken priority as the APPEAL wasn’t on the checklist, so as an individual you tick your boxes, the APPEAL was like an extra did you remember it, or didn’t you?’ (136)

‘I think, including, as we’ve discussed before, in terms of the documentation, so having something raised with Clevermed, who manages Badgernet Notes, or Badger Notes, to have something implemented on there, for the women and for the staff, to, a) remind us to do it and, but also for us to be able to refer via that same system’. (140)

A prompt would be helpful, for example Badgernet

Proactive attitude to PFME and enthusiasm for APPEAL, would like as part of standard care – would value training/resources

Suggestion to teach PFME in group setting

‘And it is useful, in our booking appointments it is useful, we use Badgernet and one of the things that we have, we have to discuss is pelvic floor exercises and, um, I think, because I think it’d be good, you know, sometimes you can’t save something unless you’ve acknowledged it, so it could be have you discussed pelvic floor exercises and you can tick yes or no. But you’d have to, you’d have to tick yes or no before pressing save’. (1028)

‘Yeah I think that would be brilliant [APPEAL being part of standard AN care] just to make it a standardised practice and to approach it and it will help with their understanding, I guess, because everybody’s understanding and what you’ve heard and been told from, you know, family members and sisters and all sorts, so it would just set the bar, I guess, as to what the advice should be and how we should give it’. (1006)

‘I can see that [APPEAL] it’s really valuable because I think a lot of women do suffer with incontinence, particularly after having a baby and it’s sometimes they don’t realise it’s something that they need to get help for. So I think that’s quite important and I think it would be really helpful for us midwives to have more training actually as well’. (1012)

‘Is there any chance that you can have, now that the pandemic is sort of opening up a bit more it’s for like classes that we can, so for midwives to be trained and run classes for them [PFME] […] because I think in, is it doing it in a fun way and in the group then they [women] normally would do it, and hopefully they’ll practise a bit more’. (1031)