 Claire Lyon is a midwife at Liverpool Women's Hospital. She's now working in a clinical research role. Claire has previously worked on a project exploring the lifestyle attitudes and behaviors of pregnant and postnatal women. She completed a Masters of Research at the University of Portsmouth in 20... Looking at the health outcomes of the whole of her midwife, she proved the use of an RCTP of an intervention to prevent post-traumatic stress disorder symptoms in women following a traumatic birth experience. Her professional interests include women's birth experiences and perinatal mental health. I'm going to turn the presentation over to Claire now. Thank you so much for joining us this morning, Claire. Thank you, Cecilia, and a big hello and thank you to everybody else who's joined the presentation today. And just a big warm thank you for joining us to celebrate this fantastic day of celebration for midwives around the world. I think it's true fantastic. And without further ado, I've had a fantastic introduction there from Cecilia. So thank you for that. And I will just crack on now with the presentation. It should take around 25 minutes, maybe, and then there'll be plenty of opportunity for discussion and questions at the end, okay? So today's presentation relates to a project that I was involved with about 18 months ago now. And the project was a European-funded project looking at the lifestyle, behaviors, and attitudes of pregnant women in new months, so up to 12 months postnatal. And the postnatal Pilates project was delivered as part of a campaign of activities to help improve the lifestyle of pregnant and postnatal women. Other activities that we also developed and we delivered included free swimming sessions and a walking group, but by far the most popular activity for the postnatal Pilates sessions. And in fact, it was so popular that the instructor that we worked with has now gone on to continue the course in a slightly different part of the city. But yeah, it just shows that these things can take off and there's some really positive consequences as a result of the project. So in the presentation, I want to cover some literature around Pilates in pregnancy and the postnatal period. It's not designed to be an exhaustive review of the literature, but just some highlights to get you started and steer you towards further reading should you wish to delve into this area much more in the future. I'll talk about the details of the program, so how we designed it and how we delivered it before presenting the feedback from the study. I'll then talk in slightly more general terms about things that you may wish to consider if you choose to run a course of this type or any other course aimed at postnatal women, for that matter. I then want to give a brief overview of the current guidelines that we have here in the UK about exercising in pregnancy and beyond and that will lead us on to time for discussion and question. And it will be great if we can hear your experiences or your thoughts on Pilates either in pregnancy or postnatal or any other exercise or lifestyle advice that you routinely give. As Cecilia said, we'll try and keep the discussion towards the end, but please do raise your hand if you've got something that you want to say so you don't forget when it comes to the end. All right, so before we continue looking at Pilates because it was best to just describe what Pilates is and try and explain it for those who perhaps are unfamiliar with it, Pilates is a low to no impact mind body exercise system. It encourages participants to focus on their breathing, concentration and their core strength, making it nearly an ideal exercise choice for pregnant and postnatal women. In women's health, it encourages the pelvic floor muscles to work with the deep tummy muscles to build up stability and strength in a trunk. And we know that a well supported trunk will help to protect the back and it may help to lessen any lower back pain women are experiencing. So you can see why we chose Pilates, a fantastic activity for women in the postnatal period. So as I said, I'll just start by introducing you to some of the literature that's been and some of the research that's been done in this area, but there is only a small amount of literature about the effects of Pilates and postnatal recovery and in particular there's a shortage of good quality randomized control trials. There's a number of articles explained about postnatal exercises and how Pilates can help with recovery in the postnatal period and pelvic floor exercises. But the studies that I pulled out to just run through with you today focus on a whole range of postnatal related symptoms so they look at how Pilates can impact on postnatal depression, on pelvic floor tone, on core muscle strength and on sleep quality. Okay, so there's about five studies that I were able to pull out for you coming from all over the world, which is really appropriate considering today's International Day the midway. And as I said, they looked at various different things. So we've got studies coming from India looking at core muscle strength. So in that study they were looking at the effects of a MAP-based Pilates exercise against conventional exercises on core muscle strength in postnatal women. So there were 50 women randomized to receive either Pilates training or conventional exercises and the women in these groups completed 30 minutes of exercise six times a week for three weeks. And what the study showed was that there was a statistical significant difference in both groups of women. So both groups of women benefited. However, Pilates groups show a statistically significant greater core strength as compared to the control group. So those three conventional exercises. When we move on to the pelvic floor muscle randomized control, there's two of those. And I think that probably makes a lot of sense considering the area of the body that Pilates is focusing on. So there's a couple of studies there. One where they talk 62 women again randomly allocating them to receive either traditional physiotherapy or Pilates therapy. And both groups showed improvement in pelvic floor muscle strength. So there was no difference really between those groups, nothing statistically significant. Another study was looking at Pilates exercises again on pelvic floor muscles following childbirth. And there were 120 women suddenly twice as many women involved in this study. Half again were allocated to receive Pilates and half were in the control so they took measures of vaginal resting pressure, systolic pressure, and duration of traction. And in the Pilates group, those pressures were greater. Not statistically significant, but still there was some difference there. So again it shows Pilates when used can make a difference. Another one looked not only at the pelvic floor tone, but also postnatal depression, which I found was really interesting. Very, very small though. There were only 17 participants in this study. And participants exercised three times a week, between 40 and 60 minutes for seven weeks. And what they found were that vaginal contraction improved in the exercise group versus the control group. And also the postnatal depression symptoms improved in the exercise group. Obviously only a small number of people involved so difficult to generalise those findings, but I think really interesting findings nevertheless. And finally, one more study that I found was looking at sleep quality and the effect of Pilates exercise on sleep quality in postpartum women. And we know that women postnatally, if they can improve their sleep quality, I'm sure they would set the hand off if you had something for them. So this study, another randomised control trial, 80 postnatal women allocated to either a home-based Pilates programme or control, which was nothing to do, nothing other than their usual activity. In the exercise group, they started to exercise from 72 hours postnatal, so quite quickly afterwards. And there were exercises exercising five times a week, for eight weeks. They measured sweet sleep quality. At week four and week eight, in the intervention group, the Pilates-based group showed a significant improvement in their subjective sleep quality and their sleep latency. But there was no difference in sleep duration or their sleep efficiency or their sleep disturbance, which I don't think is very surprising there. So that's a quick run-through of some of the literature that's out there. And if any of you have got any comments to make on that, you know, please keep this to the end and we can discuss them. It would be great to hear your thoughts on some of that. So what I want to do now is move on to the actual programme that we were running. The programme was delivered as part of an EC-funded programme, so we received money along with five other cities around Europe. And each city did something a little bit different. First of all, we consulted with women, so we consulted with pregnant and postnatal women about the types of activities that would be beneficial to them in different periods. And from there, as I say, we developed a programme of postnatal Pilates. So the sessions were physiotherapist led. So we found a physiotherapist who wasn't working in maternity at the time. But she was a Pilates instructor and she had undertaken additional training in working with pregnant and postnatal women. And we found her by doing a Google search of Pilates instructors in the local area and looking for reviews on something called Mumsnet. So that's a discussion board where new months, expected months, can come together to discuss pretty much anything. And I thought that would be a good place to kind of get the low down on good therapists. And instructors, and that's what we did. So I contacted several therapists, instructors, and Nikki, who we got was by far best. We devised four week courses. These were an hour long. And we were advised to deliver four weeks because women would begin to feel the results of their work after four weeks. And what it also enabled us to do was to run more courses than if we'd only run six week courses. So the sessions were an hour long. It was split between a practical element, which it was predominantly, and an education element. So we would spend the first five to ten minutes of the class looking at the muscles that we'd be working in that class, and also ironing out any problems that maybe women had experienced in the previous week. So they were really informative. It would be an opportunity to learn and practice different exercises to the next sort of coordinates. And during the sessions, there'd be different levels. So women who were familiar with it would be able to do a slightly more advanced exercise. And they would all receive one-to-one attention. And what was great about these sessions were mums were able to bring their babies with them. So the mums were already members of gyms, or had already done exercise programs before. So they were familiar with exercise. They'd now become a mom. It was difficult to fit it in because they weren't able to take their baby with them. So we knew that that would be a barrier, accessing the program. So from the outset, it made sense that mums could bring their babies. So if the baby was sleeping when they arrived, they would pretty much stay in their pram or their push chair while mum got on and did the class. If baby was awake, though, we would have have some mats laid down in the centre of the room so mum could still see their baby. And while the instructor was running through the class, I would be available to go comfort the baby if needed it, do the on nappy change, anything that allowed mum to carry on. And if baby needed feeding, mum would just take a break and feed baby. So there were really good sessions from that point of view. The classes were community-based. So we held them in what we call children's centres, so a bit like a community centre. We did that because we knew that the centres were accessible. The centre was where we had consulted with women in the first place with the types of activities that they wanted. We're familiar because often women had received their midwifery care in these centres. They were easily accessible, so they were on bus routes. And also there was car parking facilities for those travelling by car, but they should have been walkable nearly from most women's homes. Now, as I say, we offered five courses in total and the first two courses we were able to offer a praise facility. Because the children's centres had nurseries attached to them, we were able to access play workers. So again, to remove another barrier, for those mums who had older children, they were able to bring those along. And we had play workers who could work with those children while mum had no of themselves. Now, we only ran that for the first two courses. And that's because after that, we were mainly seeing first-time mums, so we didn't have that concern. But the course just happened to fall when their old children were already in a nursery setting and so mum was available. So the gracious ability really wasn't needed after those first two sessions, the courses that we ran. But what I'm saying is, we know that that is often a barrier for women. And so we did attempt to overcome that barrier. So moving on to feedback that we received. So we weren't attempting a randomised control trial as I talked about at the start. We wanted to just evaluate the value of these courses to women. So I'll just run through now some of that feedback that we received. So we had 40 women in total attending the various courses that we offered. And 11 women provided feedback. I think that's often because we asked them to complete the forms at the end of the final session. And those mums who had other children to collect had to go ahead and do that. So they rushed out to the room. They might have had to feed the baby at the end of the session. So quite a low response rate considering how many women were involved. And the response rate you can see there, 27.5% response rates. We've been looking at the graph on the other side. We were asking about the correct colors of the course. So was the venue suitable? And all women responded yes. It was a suitable survey for them. So we know that women want accessible community-based exercises. We asked there was anything about the venue that they would change. And nine out of the 11 women said no. So the venue was really suitable. Somebody else asked for a larger car park. They found that the car park was too small. Before, yeah, it was a little bit small to get to their early to get to the parking space. Somebody else would have preferred a soft-clay area for the baby. You can see on the right-hand side of the slide now was the class at convenient time for them. And the class that we ran was a bright afternoon between 1.30 and 2.30 in the afternoon. 10 out of the 11 women agreed that that was a good time. And one person thought that it was a little bit late to pick up their older child from school. I think really important feedback that that was a good time. A deliberately train of trying to avoid anything wrong in the morning when you're working with postnatal women, because having been there myself, morning cannot exist for most new moms. The moms involved in these classes were typically moms around six weeks postnatal and some very new bomb babies. So a little bit more feedback from the sessions. We asked, did you find the educational part of the course useful? And 100% found it useful or very useful. So that's really warming. And we also asked, was the practical pilates easy to follow? And again, all of the women, all 11 women said yes, they did find the pilates. The practical side of the class easy to follow. We limited the class size to eight women. And that was so that the instructor had enough time and enough capacity to focus on the women, to correct any postures or to talk through any more advanced exercises that the women may be able to do. And speaking of which, we asked, do you think you received enough feedback from one to one attention? And again, all 11 women completed the feedback that they had received enough feedback and attention. So again, that's really positive. So we asked women for their comments about how they did they feel any difference in their body during the last four weeks. And you can see their range of comments. So women reported feeling more strength in their abdominals, becoming more aware of their muscles and their pelvic floor tone, that they're aware of muscles switching on, and that they regain some flexibility. I like the comment there that the women felt much more relaxed as well as flexible and somebody else reporting that they felt more toned. A few more comments. Women reported that they felt that their back was stronger. Again, more tone in their abdominals. Women feeling better posture, the more aware of how they're standing and how they're getting up. More awareness of some of their deep muscles and less backache. It also made them realize that they needed to do exercises more regularly. So again, really positive stuff which aligns with some of the literature that we heard about at the start of the presentation. We asked whether there was anything that the women who were taken could suggest for future courses. And apart from the location, be it north of the city or along a course, women generally thought that there were no changes needed. Somebody did ask for some notes to take away so that they could continue the exercise at home. And we did in fact provide a booklet to women with exercises. It's a booklet that is produced by Physio Group who work specifically in obstetrics and gynecology with very detailed diagrams and explanations for various exercises. And they were the same exercises that we did in the class. So they did in fact have something to take away and refer back to when they were at home. So that was the feedback. All generally positive similar findings to the studies that I described at the beginning of the presentation. So now what I want to do is just talk more generally about the considerations that you would have to bear in mind when you deliver in any type of class or activity for this group of women. So I've already talked quite a bit about the venue. So what we found worked for us was a community-based venue, something that was familiar. A tower venue, there were already things going on. So there was already breastfeeding groups there for the postnatal women and women had had antenatal care in these centres. So it was very familiar. Not intimidating like a gym for those women who are perhaps not familiar with exercising or haven't done any for a while. And that's relaxed venue where we did have access to other professions that should be needed. So for example, play workers, if you were able to offer that type of creation facility for women with older children. So venue really important. It was central to community, so really accessible. The time, we offered hours, our activity in the afternoon. And as I said, I think it's really difficult to leave the house before lunchtime. And so afternoon I think is really valuable time to offer something like this. No cost is down there to consideration. I don't know what it's like in other places. And but by the time women would come into our exercise classes, most of them would have been on what we call statutory maternity pay. So it's a huge cut in salary for those women. So that's something that you have to bear in mind. And we were fortunate that we were able to offer courses free of charge because it was part of a larger programme. But what we wouldn't have wanted to have done anyway is to make cost a barrier. I know that this is a consideration for our Pilates instructor who has continued offering the classes. And I think I'm right in saying that her post-80s classes are slightly cheaper than her main stream classes because she's aware that this may be a barrier to some women. It needs to be baby friendly. So as I said, I was on hand in July to make sure that babies were taking care of some of the focus on the exercises and the mum was happy to bring her baby along. And again, we removed that barrier of them having to find care for their newborn while they went and did something for themselves. I know that the instructor who has continued the classes has got lots of things to keep baby entertained for those same reasons. Take away information. So what we know is that four weeks is enough time to start making a difference on women reported that they felt more toned, more awareness of their muscles and their posture. But we also wanted to offer them something that they could take away and continue practicing and keep making improvements to their posture and their tone. So that's really important so that they're able to take some information away from them to continue building on what they've learned in the course. And another consideration is the format of the course. And so as we saw from the feedback, women really valued the emphasis on the educational side of the course as well as the practical side. And in keeping the numbers small, you could see as well that women really valued the one-to-one attention that the instructor was able to give them. I doubt that the instructor would have been able to do that, had she had a much larger course than what we had. So really important. And again, if you've got any comments on that, feel really helpful and useful to see those when we come to the end of the session. Just want to comment briefly, because I know I've been talking for a little while now, about current UK guidelines, so it would be really great to see an international perspective on this. And the only guidelines I could really find for those aimed at pregnant women are very little, hosatal-wise. So the illustration that we have there comes from the Chief Medical Officer for the UK on physical exercise, physical activity for pregnant women. So at the top it starts with some benefits of physical activity. And then in the center, ideas for what you might consider. And I think the top right person on about somebody doing something like a Pilates pose, maybe a yoga pose, and telling you to aim for about 150 minutes of activity per week. It recommends muscle strengthening activities twice a week, which is perfect for Pilates, because that is essential what Pilates is. But unfortunately, no advice on what postnatal women should do. I think if the OCOG recommends exercising for about six weeks postnatal, if you've had a cesarean section, but nothing otherwise. So that pretty much brings me to the end of what I wanted to talk about. It would be really good if we could open up a discussion now to see what other people are doing. Any comments on the course that we offered? Any questions about the course that we offered? It would be fantastic. But really I think it would be great if we could hand it over now and see what your experiences are. Any comments, as I say, about what you were doing? If you would like to make a comment, either the text box or through your microphone, that would be fantastic. Over to you. We do have a first question, Claire. Okay. In terms of this program, what is your explanation of the link mechanism to reduced postnatal depression? So that was somebody else's study and what I think helped our women. Our women reported feeling better. They were coming into a social setting. It was an activity that was purely about their baby. So it wasn't like a breast-feeding group where all the focus tends to be on the baby and the baby's nutrition. It was something that the women were able to do for themselves without any guilt because they could take their babies with them. So they were coming each week. It was almost in their diary. I'm taking this out for myself on Friday afternoon. And that was planned in. They knew they were doing it for the next four weeks. They knew they would be meeting the same group of women that they'd met in the previous week and what they would see the following week. And I think making time for themselves in a social setting was really beneficial to these women. There was no guilt attack because the baby was with them, but they were able to pay themselves a little bit of attention. So I think that could be the mechanism for reducing postnatal depression, maybe. I know certainly the women got a lot out of the class for those reasons. Certainly there's the social aspect of support and feeling better to help prevent postpartum depression. But we know from other exercise that when there's large muscle movement, women are producing their own endorphins that are helping them feel better. Claire, you know the literature on Pilates. There's probably not a study that looks directly at endorphins or a reduction in cytokines. But I think I would do this with hesitation, but we can extrapolate from looking at other sorts of physical activity preventing or ameliorating postpartum depression that that's also a mechanism. Absolutely. I think what you said was spot on. There's lots of, or there's more evidence around other issues in women's health. So women recover from things like breast cancer where Pilates has been used as a mechanism for enhancing women's outlook on life, if you like. And I think, yeah, the same mechanisms would be in play across the two groups of women. It's absolutely what you say about exercise promoting endorphins and all those good hormones and having some part to play in it. Yeah. Thanks, Claire. You talked a little bit about cost to the women. And I was a little curious about clothing for Pilates. This is going to show my kind of ignorance about Pilates. I have this general mental image, but are women able to wear some of their very casual pregnancy clothing to do the Pilates exercises? Yes, they can. Yeah. So it doesn't really need to be any cost outlay for these women. They can wear pretty much anything that we've got in the wardrobe. So there was obviously women there who, perhaps before pregnancy, had enjoyed going to the gym and liked their gym wear and came out very well dressed in specific clothing. And on the other hand, there were women who pulled on their jogging bottoms and away they went. So there's no need for any extensive outlay on clothing. And in fact, I know one of the sessions, one of our moms who were signed up didn't actually attend the class. But there was another woman who'd come into the centre for another reason, another class which had been cancelled and she'd not been told off. So she was just in her everyday clothes. And we said, come in. We've got space. Come and join us. Don't let your journey have been wasted. Get in here. Come and enjoy our group. And she did such a show. She can come in in the clothes that you would be wearing ordinarily and join in. So absolutely no barrier there to join in. Nice. Nice. But Claire, you also talked about being there as part of the research study. And my guess is Pilates is available in most large urban areas, at least across English speaking countries that I've traveled in. If a midwife were in a smaller area where Pilates wasn't available or maybe there wasn't somebody available to do the Pilates classes, how reasonable is it for a midwife to learn Pilates and then lead that group herself instead of the physiotherapist? Entirely plausible. I have no experience of undertaking any training in Pilates myself, which is why for an independent instructor, if you like, who just happened to be a physiotherapist with an interest in this area, I'm sure there must be courses available. And I'm sure also there is no end of YouTube videos that women guess at home for themselves. But then that would remove that social aspect we've talked about, which I think is really important, postnatal women. The area that we were working in, it was an area. We were in Manchester at this time and it was an inner city area with quite high levels of economic and social deprivation. Quite a lot of non-English speaking women in the area. So when we did the consultation, we offered lots of different activities and we were asking women to tell which activities they would prefer to see. Actually Pilates wasn't the most popular choice. So after we'd offered the most popular choices to women, which were the swimming and the buggy groups and walking groups, we thought, what else can we do? And we looked at Pilates and I knew a little bit about it, having done some courses myself but never trained in it. And we thought, come on, we'll give this a go. Is it a case of women aren't selecting it because they're unfamiliar with it? Is it because they don't know what's involved and so on? And I have to say that that was the case because the interest in it and the feedback that we got has been fantastic. So yeah, there will be areas where it may not be an automatic fit with the population there because that's what we found through the consultation. But I think once women get involved, they can really see the benefits and that's certainly true of our experience anyway. So it started off, we were going to do a taste, there were a couple of courses, take it from there and then we went on to run five courses. And as I've said before, the instructor has now gone on to offer courses in the community anyway. So yeah, it's quite interesting how we got to where we got to. All right. Thank you so much, Claire.