To our knowledge, this is the first study investigating how health professionals who encounter women with increased IRD after childbirth perceive the management of these women. The findings revealed that the health professionals perceive that they have insufficient knowledge about increased IRD, which they believe is problematic since it leads to inadequate management of increased IRD after childbirth. The findings generated the overarching theme: Ambivalence towards the phenomenon increased IRD and frustration over insufficient professional knowledge. In summary, the results show that, due to sparse and somewhat contradictory research findings and the absence of clinical guidelines, these health professionals perceived that they lacked basic preconditions for applying an evidence-based practice concerning increased IRD. The health professionals expressed that they obtained their information about increased IRD from the media and fitness coaches, and hence were somewhat unsure about what to believe regarding the phenomenon and how to handle/manage women with increased IRD in their clinical practice. The health professionals’ uncertainty about the clinical importance of increased IRD largely mirrors the available research literature to date, which is very limited and somewhat confusing. For example, increased IRD has been reported to be associated with pain in the abdominal and pelvic area [19], but not with low back pain [8, 19]. However, in clinical practice it is not always easy to discriminate between pain originating from the low back versus pelvic area, which make matters difficult for health professionals who seek more information about the condition.
All but one of the participants in the focus groups expressed that they were unsure about and perceived that they lacked knowledge regarding the phenomenon of increased IRD and its management in women after childbirth. They had hesitations concerning the relevance of increased IRD as a clinical health problem, and whether it should be seen primarily as a psychosocial or a functional problem. However, although they were not unanimous regarding the extent to which increased IRD was a functional problem, all but one of the participants considered the phenomenon important to address regardless, since more and more women are seeking help for it. This line of reasoning can also be found in the scientific literature, where authors have suggested that it is better to treat increased IRD conservatively than not at all, despite the unclear evidence base [19].
The participants perceived that they did not have enough knowledge and competence in managing women with increased IRD after childbirth. They reported that they obtained their information from the same websites that they recommended to their patients. However, most of their patients had read this information beforehand, creating a situation where the patient knew as much, or sometimes more, than the health professional from whom they sought advice. In particular, the participants communicated a need for clinical guidelines and education providing evidence-based knowledge. The participants called for support from the healthcare organisation in increasing the knowledge base and actively providing explicit clinical guidelines including referral pathways; that is, when and whom to refer to. In the absence of clinical guidelines, it is unsurprising that health professionals feel unsure and become strongly influenced by the opinion of the woman seeking help. However, although the participants asked for guidelines, previous studies from within the field of physiotherapy show that clinical guidelines do not always have an impact on clinical management [32, 33]. It has also been shown that even when physiotherapists know about the existence of clinical guidelines, they are not always familiar with the content [34]. The implication of all this is that despite the slim state of the literature, the phenomenon of increased IRD after childbirth should be included in undergraduate programs in physiotherapy and midwifery, in order to give these healthcare professionals an awareness of and the ability to address this phenomenon when they begin clinical practice. Furthermore, all the health professionals in this study undisputedly acknowledged the importance of inter-professional collaboration between physiotherapists and midwives in primary healthcare in the management of patients with increased IRD. The organisation of such collaboration and the structuring of referral pathways should be possible to achieve even in situations when evidence-based knowledge of the management of the condition as such is insufficient or lacking.
Strengths and limitations
By using a qualitative method for data collection, a broad range of factors affecting the management of increased IRD post-partum were revealed that would otherwise have been difficult to identify through a quantitative design. Data was collected through focus groups instead of individual interviews since focus groups were deemed more suitable to promote interaction and information exchange between participants. Indeed, all participants contributed actively and freely in the discussions. The discussions involved high degree of interaction between participants and reflections that built on statements from others, which generated a very rich data material. A purposeful sampling strategy was used in order to present maximum variation and contribute to obtaining a rich and broad material, as recommended in the literature [35]. The sample was selected to include variation in those participant characteristics and settings that were believed to have relevance to the conceptualisation of the phenomenon. However, this method carries the risk of selection bias or an incomplete sample. In this study, credibility and transferability were enhanced by using a sample of participants representing relevant professional backgrounds in primary healthcare in three different county councils. Overall, there were similar experiences across focus groups regardless of county council, which increases the credibility of the results. Still, the small number of participants limits transferability. It is possible that the participants were not representative of all people with the same professional background. For example, since the health professionals volunteered to participate in the focus groups, it is likely that they were more interested in and had more knowledge about the subject than most of their colleagues. However, they still regarded their knowledge as insufficient. Thus, knowledge about the management of increased IRD is probably even lower in the whole population of physiotherapists and midwives in primary healthcare. To the best of our knowledge, there are no previous studies similar to the present one, and so we cannot compare our findings of the health professionals’ experiences with findings in other studies. Moreover, we only interviewed stakeholders within the healthcare organisations, and so the perspective of the patient was not included. However, the patient perspective is an important aspect. Thus, we are underway of undertaking a separate study investigating the views of women with increased IRD postpartum by in-depth interviews. To reduce the risk of bias in data collection and analysis, respondent validation was undertaken during the focus group discussions [31]; i.e. the moderator posed probing and follow-up questions, restated and summarised information, and asked the participants to confirm the accuracy of the spoken data. To increase trustworthiness in the interpretation of the data, both researchers, along with two midwifery students, read the text files of the interviews and participated in discussing the coding, categorisation, and interpretation [31, 36].
