Healthcare during preconception, pregnancy, labor, and the immediate postpartum period is included under obstetrics (OB). In gynecology (GYN), all health issues, especially those pertaining to women, are treated [1]. Physiotherapy treatments program including aerobic and aquatic exercises, hydrotherapy, posture correction, and modifications to everyday activities is beneficial in managing female obstetric conditions before, during, and after surgery as well as during pregnancy, delivery, and puerperium and gynaecological disorders [2, 3]. Gynaecologist/obstetrician consultants (73.1%) had more knowledge and awareness about physical therapy than senior registrars (46.3%) due to their experience [4]. This survey focused on registrars and consultants to determine their knowledge about physiotherapy role in management of gynaecological & obstetric conditions in hospitals of South-West Nigeria but did not focus on the reasons for decreased awareness and less referral rate to physiotherapy.

A survey was conducted on obstetricians. The percentage of obstetricians recommending avoidance of nine household activities and exercises (including lifting groceries, starting a new exercise program or participating in walking, jogging, or bicycling) was significantly higher with each successive trimester [5]. The survey discussed the effects as well as types of exercises to be recommended for the obstetric conditions. It did not investigate the referral rate for physiotherapy by obstetricians.  One of the studies conducted in South Africa on medical practitioners and obstetricians/gynaecologists stated that among the practitioners, 

A survey was conducted on obstetricians. The percentage of obstetricians recommending avoidance of nine household activities and exercises (including lifting groceries, starting a new exercise program or participating in walking, jogging, or bicycling) was significantly higher with each successive trimester [5]. The survey discussed the effects as well as types of exercises to be recommended for the obstetric conditions. It did not investigate the referral rate for physiotherapy by obstetricians.  One of the studies conducted in South Africa on medical practitioners and obstetricians/gynaecologists stated that among the practitioners, few (24 %) referred patients to exercise specialists. A large majority (83 %) were unaware of the recommended exercise guidelines. Although age and years of practice played no role in this awareness, obstetrics and gynaecology practitioners were more aware of the exercise guidelines than those in general practice [6]. This study investigated the referral rate and awareness regarding physiotherapy among both general practitioners and obstetricians/gynaecologists. In their qualitative study on females having gynaecological cancer informed that the primary obstacles to use of physiotherapy exercises included generalized illness brought on by cancer therapies, forgetfulness, time constraints, and inaccurate information, poor communication with the treatment team, discomfort, and a sense of guilt. In situations where the attending physician's feedback was given; it either acted as a help or a barrier [7].

Physiotherapy plays a vital role in management of gynecological and obstetric conditions but most of patients do not receive physiotherapy for their OB & GYN conditions due to lack of awareness of gynecologists and obstetricians about the role of physiotherapy and subsequently lack of referral to physiotherapists. This study has been conducted to determine the proportion of gynecologists and obstetricians having awareness of physiotherapy role in managing gynecological and obstetric conditions, barriers to use of physiotherapy in treating OB/GYN disorders, and the rate of referral of patients to physiotherapists by gynecologists and obstetricians of Abbottabad.

The synopsis of study was approved by the Women Institute of Learning & Rehabilitation Sciences, Abbottabad's Ethical Research Committee and the Institutional Review Board (IRB), before it could be put into action. With the consent of the department head, a concise explanation was provided to subjects. They signed a consent form and were assured that their answers would be kept private and used solely for research. No one was denied access to the study because of their race or religion. The participants were asked not to write any personal information on the questionnaire to protect their anonymity. Only the researchers had access to the data, which was stored in a secured file.

This study was observational in nature. To ascertain if the obstetricians and gynaecologists in Abbottabad were aware of the function that physiotherapy plays in managing or treating patients' obstetric and gynaecological disorders, a non-experimental descriptive cross-sectional survey was conducted.

Gynaecologists and obstetricians in active practice who worked at Abbottabad's healthcare settings, which included Jinnah International Hospital, Women & Children Hospital, Ayub Medical Complex, CMH, Valley Hospital, Rehmat Hospital, Maida Hospital, Zarbat Plaza, and private clinics, were the subjects of the study. Study sample consisted of participants who consented to take part in study and had one year of minimum work experience; medical officers (MOs) with experience in GYN/OB wards, post-graduate (PG) trainees in OB/GYN and MCPS/FCPS specialists in OB/GYN. OB/GYN doctors who were on extra-ordinary leave or were absent at the time of survey were not included.

A ten items questionnaire that was drawn from earlier research projects [4], [8] was used to collect data.

The convenient non-probability sampling strategy was used to gather the data. The study ran from May 10, 2021, until October 28, 2021.

Chochrane formula {(z _(1-α/2))² [p*q] / (d)²} (9) for sample size calculation for cross-sectional survey was used.

• Z (1−α/2) = Critical value and a standard value for the corresponding level of confidence. (At 95% CI or 5% level of significance it is 1.96)
• p = Expected prevalence or based on previous research [86.3% or 0.86] for Obstetricians (8).
• q = 1-p (1 – 0.86= 0.14)
• d = Margin of error or precision (5% = .05)
• n= (1.96)2 * (0.86) (0.14) / (.05)2
• n = 184.9 or n= 185
• p = Expected prevalence or based on previous research [90.3% or 0.90] for gynaecologists [8].
• q = 1-p (1 – 0.90= 0.09)
• n= (1.96)2 * (0.90) (0.09) / (.05)2
• n = 124.4 or n= 124

Estimated sample size was 185 obstetricians and 124 gynaecologists. Abbottabad is the city in the province of Khyber Pakhtunkhwa and ranks 40th in Pakistan by population. Only 153 OB/GYN doctors were available and consented to participate in study.

Frequency Table 1: Demographics of Study Participants.

A total of 153 OB/GYN physicians were available to take part in the study. Medical officers comprised 37.9% (58), PG trainees represented 18.3% (28) and MCPS/FCPS experts constituted 43.7% (67). Of the doctors, 71.2% (109) had between one and five years of professional experience, while 28.7% (44) had more years of job experience. Eighty-three percent (127) of OB/GYN doctors served in hospitals, 7.1% [9-11] worked in private clinics, and 9.8% (15) worked in both private and institutional settings.

Figure 1: Opinions of Participants regarding Physiotherapy.

Figure 2: Views on which Conditions Physiotherapy is Necessary For.

Figure 3: Views on Barriers to Use of Physiotherapy for OB/GYN Disorders.

4% (6) of doctors believed that physiotherapy could cause harm to patients. 10% (15) of doctors opined that physiotherapy was expensive for patients. 2% (1) of doctors said that physiotherapists were incompetent in managing patients. 22% (33) of doctors thought that there was an inadequate multidisciplinary relationship between physiotherapists and OB/GYN doctors. 11% (17) of doctors stated that physiotherapy was time-consuming. 6% (9) of doctors had the view that there was a lack of access to physiotherapy services. 16% (25) of doctors believed that multiple barriers played a role in preventing the role of physiotherapists in treating OB and GYN conditions. 30% (46) of doctors reported that no barrier existed to prevent the role of physiotherapists in treating GYN/OB conditions.

In this study, 153 subjects participated. 18.3% (28) said they knew nothing about the field of physiotherapy, compared to 81.6% (125) who said they were familiar with it. To treat GYN/OB issues, 4.57% of physicians (7) reported sending their patients to physiotherapists. Physiotherapy was believed by 21.56% (33) of the clinicians to be beneficial for pre- and postpartum obstetric problems. Physiotherapists were inadequate at managing patients, according to 2% (1) of physicians. Physiotherapists and OB/GYN doctors did not have a sufficient interdisciplinary connection, according to 22% (33) of doctors. Nine (6%) of doctors believed that physiotherapy services were not easily accessible. 68% of obstetricians and gynaecologists respond positively to the inquiry about their knowledge of the necessity of physiotherapy care during labor; however, 32% of respondents claim to be unaware of this intervention. 67% of participants do not refer or consult a physiotherapist during labor pain management, compared to 33% of participants who claim to do so (10). 194 people (64.7%) are aware of prenatal physical therapy activities, yet 56 people (18.7%) recommend prenatal physical therapy to their patients. Although 204 respondents (68%) agree that postnatal physiotherapy activities have a useful role, only 60 respondents (20%) frequently refer their patients for postnatal physiotherapy exercises, while 74 respondents (24.7%) refer patients infrequently (8).

The specific reasons why patients aren't sent to physiotherapists, discovered that ignorance or low awareness is one of the primary causes (79% of participants); 10% believe that deficiency of an OB-trained physiotherapist is the cause; 5% believe that lack of patient counselling is the primary cause; and 1% disagree that physiotherapy is necessary for patients during labor (10).

Out of all the participants, about 40% of people disagree that physiotherapists should be involved during childbirth. Additionally, 25 (41%) said that their interprofessional connection with physiotherapists has been successful. Most obstetricians—56 (91.8%) and 54 (88.5%) gynaecologists —refer patients to physical therapy in obstetrics and gynaecology, respectively. 6.6% (n = 4) said that there are enough physiotherapists to cover the needs of gynaecology and obstetrics departments (11). Thirty-one (46.3%) of the respondents reported that there are not enough physiotherapists in their hospital of practice to cover the obstetrics and gynaecology wards as stated (4).

In this study of 153 obstetricians and gynaecologists who all were females; PG trainees made up 18.3% (28) of the sample, medical officers made up 37.9% (58), and MCPS/FCPS experts made up 43.7% (67). Among the physicians, 28.7% (44) had more years of work experience than 71.2% (109), who had between one and five years. While 8.49% (13) believed that physiotherapy was required for all gynaecological illnesses, 21.56% (33) believed that it could help with pre- and postpartum obstetric issues. Korentang et al (2023) conducted a similar study. Seven consultants, twenty senior residents, and thirty-four junior residents, made up the sample size of total sixty-one (61) respondents. The study sample consisted of 82% males and 18% females, with 55.7% (n = 34) and 44.3% (n = 27) had been in practice for fewer than ten and longer years, respectively. The participants indicated a broad range of awareness regarding physiotherapists' roles in gynaecology (from 19.7% in pelvic diseases to 95.1% in uterine prolapse), but a significant understanding of physiotherapists' roles in obstetrics (72.1%) and postnatal care (91.8%) (11).

Thirty-four (50.7%) participants reported that the physiotherapy service is not too expensive and 62 (92.5%) considered that the physiotherapy service has not worsened the condition of their patients (4).  In present study, six (4%) of doctors thought that patients could suffer harm from physiotherapy. Fifteen (10%) doctors believed that physiotherapy should not be covered by the patient's expenses.

Because there were fewer obstetricians and gynaecologists available, the study's sample size was small. The opinions of obstetricians and gynaecologists regarding the comments or responses they obtained from patients undergoing physiotherapy treatment for their ailments were not included in this study.

Research on patients' views on physiotherapy's involvement in treating GYN/OB disorders can be done in the future. Research on physiotherapist’s perspectives on the application of physiotherapy in pregnant patients’ care can be carried out.

Most OB/GYN physicians knew about physiotherapy, however, a lower proportion of them said that physiotherapists ought to handle patients similarly to other members of the OB/GYN team. Furthermore, while a relatively small number of patients were sent to physiotherapists, this study demonstrated that OB/GYN doctors' assessments of the value of physiotherapy in treating OB/GYN problems were not significantly influenced by their knowledge of the field. The idea that physiotherapy takes a lot of time was the second most cited barrier to its utilization, after a lack of interdisciplinary ties. OB/GYN physicians observed that, aside from the risk of harm, two more obstacles to physiotherapy use were inadequately skilled physiotherapists and over-pricing.

Funding Information

There is no financial organization supporting this research project.

Acknowledgements

This research work is supervised by Dr Umber Fatima (PT), (Assistant Professor, Women Institute of Rehabilitation Sciences, Abbottabad) who is also corresponding author for this paper. Researchers’ sincere gratitude go out to Dr. Fatima Hanif (PT), a lecturer at the Institute of Health Sciences in Peshawar, for her tireless work in compiling the data, writing the report, and seeing this project through to completion. The deepest gratitude go out to Dr. Ayesha Javed (PT), an assistant professor at the Women Institute of Rehabilitation Sciences in Abbottabad, who helped our initiative come to fruition by offering suggestions and expertise. Finally, thanks to Drs. Ujala Khalid (PT) and Zunaira Rahman (PT) for contributions to this study project.

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