With pregnancy comes many embodied changes. Among these changes are the gradual weakening of the muscles that work hard to support the weight of the growing baby.
The pelvic floor muscles support the bladder, uterus, and bowel. A healthy pelvic floor maintains core strength, prevents incontinence of the bowel and bladder, protects against uterine prolapse, and supports pain-free vaginal penetration. It is not only pregnancy that weakens the pelvic floor muscles—the birthing process also requires their additional effort. Pelvic floor muscles experience substantial stretching and strain during vaginal births, and the surgery through layers of muscle during a cesarean can weaken the abdominal wall. Whether people give birth vaginally or through c-section, the pelvic floor muscles are susceptible to considerable change.
Unfortunately, the state of pelvic floor care reveals gaps in our biomedical system. The Down There Doc emerged out of necessity to fill these gaps in prenatal and postpartum care. The founder, Dr. Marcy Crouch, received her doctorate in Physical Therapy from the University of California in 2010. She then completed a Women’s Health Residency program in Dallas, TX where she focused on all aspects of pelvic floor dysfunction, pregnancy, and postpartum musculoskeletal issues. After completing these studies, she obtained her WCS, which was her final step in becoming a Board Certified Clinical Specialist in Women’s Health Physical Therapy. Through her work as The Down There Doc, she hopes to fulfill her mission of making pelvic floor problems a thing of the past.
Dr. Marcy Crouch’s introduction to this work was an anatomy lesson. “The professor used an example of someone who sustained a very significant vaginal tear during birth, and continued to have pain and dysfunction following the birth.” Her introduction would only exemplify the disservices that accompany gaps in care. Despite her heightened knowledge of the various afflictions of the human body, Crouch was surprised to learn about the nature and range of pelvic floor dysfunction. “Now, being in Physical Therapy school and working in orthopedics for years prior to PT school, I had seen how ‘general’ injuries and surgeries can affect someone’s function, but I had no idea that this happens during birth. I didn’t even know at that time that there were muscles down there.”
Her introduction was a lesson that piqued her interest, but further research only galvanized her. “I was shook, my jaw dropped to the floor. And the more I learned about it and the more research I did, the more it became clear that there are millions of women suffering from pelvic floor muscle trauma. Millions. Millions of women suffering from muscle trauma and injury that could potentially be prevented, and treated easily after the fact. I could not just stand by and say ‘huh. Well that’s awful’ and move on with my life.” In other words, her work was born out of her refusal to sit idly while birthing people continued to suffer from highly treatable ailments.
This was only one among the many grievances that would lead her to this work. Crouch quickly became aware of deficiencies in training, and the health and wellness sphere’s erasure of mothers. “I couldn’t comprehend, as physical therapists, that we focus our entire careers on helping people prevent injury, recover from it, and come back stronger so they can live their lives, yet mothers are excluded from that, even though it’s technically a muscle injury or surgery.”
While she didn’t have children at this point, she did understand what it felt like to be left out. She understood the experience of having to fight for her place at the table. From that point on, she decided that her training was best used in her efforts at supporting our large, yet routinely disregarded population of birthing people.
To Crouch, tools for pelvic floor health are ultimately a missing need in the healthcare system, and this says something about the state of women’s health in the United States. “It says that these birth related or pregnancy related injuries or problems are not considered important, high value, or a part of someone’s functional life.”
This disregard goes beyond the hospital setting. Insurance companies create policies that facilitate our healthcare system’s dismissal of issues impacting birthing people. “Most insurance companies do not reimburse on some of our diagnosis codes like the one for painful penetration because they don’t recognize it as a problem or something that needs skilled intervention,” says Crouch. “But think about all the functional things a woman has to do that requires vaginal penetration: sexual intercourse, tampon or cup use, gynecological exams.” Pelvic floor issues have implications for the well-being of birthing people throughout their lives. She asserts that pelvic floor problems are among the most ignored and ‘brushed-aside’ issues, yet arguably the most important and long-lasting.
Conceptions of normalcy latent within marketing also obscure birthing people’s unique plight. Crouch explains that once society attaches leaking and other symptoms of pelvic floor dysfunction to understandings of womanhood, people treat them as commonplace and acceptable, rather than treatable. The elephant in the room is the position of capitalism in manufacturing these narratives. “They want women to go from liners to diapers, when it should be the other way around.” When birthing people go from liners to diapers, several industries stand to gain profits as the focus becomes the management of symptoms, and not the improvement of the condition.
While Crouch understands that the gold standard is for birthing people to see an in-person pelvic floor physical therapist, she also understands that capitalism creates circumstances that make this impossible for many. “There are lots of reasons. Lack of childcare, poor insurance coverage or no coverage, lack of physical therapists with this training, difficulty getting off work—you name it. But the answer can’t be either in person or nothing.” For the named reasons and more, she created an online program that aids in birth preparation to reduce trauma and promote postpartum recovery. “We supplement with a private community that will allow our clients to have access to us through live QAs, discussion boards, and other events so we can help guide and modify as needed”.
The Down There Doc is a first step in what must be a long-term effort to spotlight the issues plaguing our birthing people. To Dr. Marcy Crouch, bridging care gaps requires leaning into discomfort. “We have to give people the space to bring this up. As a healthcare provider, I feel it’s so important to openly discuss and talk about these issues, even though it makes some people uncomfortable.”