Disparities in Access to Pelvic Floor Physical Therapy in Rural Communities
I am writing this blog as a physical therapist with 17 years of experience. I live in rural Pennsylvania, and am the mother of 2 boys. My clinical experience has primarily been neurological. I held my ABPTS in neurological PT from 2012-2022. The practice of pelvic floor PT has caught my attention, mostly by observing the significant need in healthcare I observe in the patients I see, my family and friends, and my own personal experience. According to Docketer et. al., 87% of physical therapists surveyed reported women’s health as a need in health care as the most influential factor into entering women’s health specialty practice.1 This was the second reason given, with number one being “personal interest.”
This speaks to the high prevalence of pelvic floor disorders and the recognition of the healthcare needs to which patients may have limited access. In the research report Distribution of Certified Pelvic Health Therapists Across the United States by Cline et. al, the data shows that the overall number of specialized pelvic health PT practitioners is low, given the population in the U.S. and the approximated percentage of people who have pelvic floor disorders.2 The findings include that a general higher concentration of Pelvic Health PT’s in the northern region of the US, compared to the southern states. One could extrapolate that the southern US has decreased access to pelvic health care.
The data suggests that the number of specialized practitioners is too low to meet the demand for care of pelvic floor disorders. According to the data, in my home state of PA, the number of reported pelvic/women’s health PT specialists is in the higher ranges of practitioners, falling in the 50-59 range. This finding surprised me to some extent, as I feel in general, there is limited access to this care where I live. The study then took the number of specialists data and compared it to the per million people in that state. PA has 5-5.99 pelvic health specialists per million people. I could relate more to this statistic as being realistic to where I live. Even so, Pennsylvania’s data is among the higher percentages of specialists per million people. States such as South Carolina, Utah, Idaho and New Mexico, all have <2 specialists per state per million people.
Not only are the number of Pelvic Health specialists unlikely to meet the demands of pelvic health PT, but people living in rural communities are also less likely to have awareness of Pelvic floor disorders, and the care needed to address them. The Qualitative research study in Women’s Health “We don’t talk about it enough”: Perceptions of Pelvic health among postpartum women in rural communities by Snyder et. al. aim was to explore perceptions and experiences related to pelvic health in a cohort of postpartum women residing in rural communities, as defined as a population less than 50,000 residents. In this study, a semi-structured interview approach was used, guided by the Theory of Planned behavior. Those women included in the interviews were postpartum, defined as less than 6 months since childbirth.
The constructs within the interview questions were grouped as Attitude, Perceived behavioral control and Subjective Norms. The questions asked were (Attitude) 1. When you hear the term pelvic floor, what feelings or thoughts do you associate with this? 2. How do you think women should or could improve their pelvic health after childbirth? (Perceived behavioral control) 1. What recommendations have you received related to pelvic floor health since having your baby? 2. Are you doing anything to support or improve your pelvic floor health? 3. Are there any questions you still have or information you need? (subjective norms) 1. Do you ever talk to family or friends about pelvic floor health? 2. Where would you go for resources/support about pelvic health? 3
Just for fun, I asked myself these questions. Although currently, I would not be an eligible participant in this survey because I am not less than 6 months postpartum. Interestingly though, the interviews took place in the fall/winter of 2021-2022, at which time, I was less than 6 months postpartum, reside in a community with <50,000 people (my hometown has a population of 884 as of 2024 for reference), and was at least 19 years of age. I also put aside the fact that I am a PT, with likely more awareness of the pelvic floor than the average resident, although certainly not a specialist by any means. Some of my general answers included “the pelvic floor makes me think about urinary incontinence and the term kegels. I have had no recommendations related to my pelvic floor since childbirth. I am not doing anything for my pelvic floor health. I have no idea where to go for support about pelvic health, I guess my OB-GYN?”
After answering the questions for myself, I then read the answers in the study, and they resonated with me. “Kegels are important for improving pelvic health” “the internet is a common but insufficient resource” “Healthcare providers are not an effective resource” “women desire new pelvic health knowledge from their primary care provider”, and “ Women view geography as a barrier to seeking physical therapy services”3
I was told at my 6 week follow-up with my obstetrician that everything was healed and I could return to X, Y, Z. I have had 2 vaginal deliveries and both times, had perineal tears, requiring sutures. I had one medical follow up at 6 weeks postpartum with both of my children, with a nod from my practitioner that “everything looks good, call if you need anything.” I might mention that this is not a dig on my OB. I was quite pleased with all of the care I received from my prenatal visits through actual labor and delivery. I believe this is an unfortunately common script that many women hear at follow up appointments, and demonstrates the lack of awareness of both patients and the medical community for follow-up postpartum care, specifically in regards to the pelvic floor.
I believe that with continued education, advocacy, and promotion of Pelvic health PT, we can make postpartum care, as well as pelvic care throughout the lifespan become more of “the norm” and not something that is just brushed under the rug and ignored. Looking back, I would have loved for the OB office to have handed me a business card for a local pelvic health PT and educated me on the follow-up available. When I “google” providers, the closest advertised Pelvic Health PT is 32 miles from my home with a 55 minute drive time. My goal in the role of Pelvic health is to advocate, educate and promote an area of PT, which like so many other areas of our great profession, can impact those who may have limited access to care due to lack of awareness and geographical location.
References
- Dockter, Mary PT, PhD; Benson, Sherry PT, DPT; Zhang, Ying PT, DPT; Anderson, Cinque PT, DPT; Le, Dang PT, DPT. Factors Influencing Physical Therapists to Enter Into Women's Health Specialty Practice. Journal of Women's Health Physical Therapy 42(3):p 154-164, September/December 2018. | DOI: 10.1097/JWH.0000000000000107
- Cline, Sarah A. PT, DPT; McLaughlin, Kevin PT, DPT; Arnold, Nora PT, DPT; Austin, Mary M. PT, DPT. Distribution of Certified Pelvic Health Physical Therapists Across the United States. Journal of Women's & Pelvic Health Physical Therapy 48(4):p 242-248, October/December 2024. | DOI: 10.1097/JWH.0000000000000312
- Snyder K, Mollard E, Bargstadt-Wilson K, Peterson J. "We don't talk about it enough": Perceptions of pelvic health among postpartum women in rural communities. Women's Health (Lond). 2022 Jan-Dec;18:17455057221122584. doi: 10.1177/17455057221122584. PMID: 36148940; PMCID: PMC9510969.
Author: Kara Wood, PT, DPT, 2024 CAPP Scholarship Recipient
Author Bio: I have been practicing PT for 17 years with experience in acute care, home health, SNF and acute rehab. I have been practicing in home health for the past 13 years. I have held an ABPTS Neuro specialization from 2012-2022. I currently am certified through the American Institute of Balance for Vestibular Rehabilitation.
