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      Living with pelvic organ prolapse: voices of women from Amhara region, Ethiopia

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          Abstract

          Introduction

          The objective of the study was to explore how women with symptomatic pelvic organ prolapse in a low-income setting explain, experience, and handle the potential practical and social consequences of the condition.

          Methods

          An explorative qualitative design was employed using in-depth interviews in the data collection. A total of 24 women with different degrees of symptomatic pelvic organ prolapse were included; 18 were recruited at the hospital and 6 from the community. Fieldwork was carried out in the Amhara region of northwest Ethiopia in 2011 and 2015.

          Results

          The informants held that the pelvic organ prolapse was caused by physical strain on their body, such as childbirth, food scarcity or hard physical work, particularly during pregnancy and shortly after delivery. Severe difficulties and pain while carrying out daily chores were common among the women. The informants used a variety of strategies to manage their work while striving to avoid disclosure of their condition. Disclosure was related to embarrassment and fear of discrimination from people living close to them, including the fear of being expelled from the household. Most of the informants, however, experienced substantial support from relatives, friends, and at times also from their husband, after disclosing their condition.

          Conclusions

          The study highlights how symptomatic pelvic organ prolapse may severely affect women’s lives in a low-income setting. The condition is perceived to be both caused by and aggravated by the heavy physical burdens of daily work.

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          Most cited references12

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          Global, regional, and national levels and causes of maternal mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013

          The fifth Millennium Development Goal (MDG 5) established the goal of a 75% reduction in the maternal mortality ratio (MMR; number of maternal deaths per 100,000 livebirths) between 1990 and 2015. We aimed to measure levels and track trends in maternal mortality, the key causes contributing to maternal death, and timing of maternal death with respect to delivery. We used robust statistical methods including the Cause of Death Ensemble model (CODEm) to analyse a database of data for 7065 site-years and estimate the number of maternal deaths from all causes in 188 countries between 1990 and 2013. We estimated the number of pregnancy-related deaths caused by HIV on the basis of a systematic review of the relative risk of dying during pregnancy for HIV-positive women compared with HIV-negative women. We also estimated the fraction of these deaths aggravated by pregnancy on the basis of a systematic review. To estimate the numbers of maternal deaths due to nine different causes, we identified 61 sources from a systematic review and 943 site-years of vital registration data. We also did a systematic review of reports about the timing of maternal death, identifying 142 sources to use in our analysis. We developed estimates for each country for 1990-2013 using Bayesian meta-regression. We estimated 95% uncertainty intervals (UIs) for all values. 292,982 (95% UI 261,017-327,792) maternal deaths occurred in 2013, compared with 376,034 (343,483-407,574) in 1990. The global annual rate of change in the MMR was -0·3% (-1·1 to 0·6) from 1990 to 2003, and -2·7% (-3·9 to -1·5) from 2003 to 2013, with evidence of continued acceleration. MMRs reduced consistently in south, east, and southeast Asia between 1990 and 2013, but maternal deaths increased in much of sub-Saharan Africa during the 1990s. 2070 (1290-2866) maternal deaths were related to HIV in 2013, 0·4% (0·2-0·6) of the global total. MMR was highest in the oldest age groups in both 1990 and 2013. In 2013, most deaths occurred intrapartum or postpartum. Causes varied by region and between 1990 and 2013. We recorded substantial variation in the MMR by country in 2013, from 956·8 (685·1-1262·8) in South Sudan to 2·4 (1·6-3·6) in Iceland. Global rates of change suggest that only 16 countries will achieve the MDG 5 target by 2015. Accelerated reductions since the Millennium Declaration in 2000 coincide with increased development assistance for maternal, newborn, and child health. Setting of targets and associated interventions for after 2015 will need careful consideration of regions that are making slow progress, such as west and central Africa. Bill & Melinda Gates Foundation. Copyright © 2014 Elsevier Ltd. All rights reserved.
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            Pelvic organ prolapse and incontinence in developing countries: review of prevalence and risk factors.

            Information on the prevalence, risk factors and social consequences of pelvic floor dysfunction (PFD) affecting women in 16 low-income and lower middle-income countries is reviewed. Medline searches were performed for articles dealing with prevalence of PFD. Thirty studies were identified. The mean prevalence for pelvic organ prolapse was 19.7% (range 3.4-56.4%), urinary incontinence (UI) was 28.7% (range 5.2-70.8%) and faecal incontinence (FI) was 6.9% (range 5.3-41.0%). Risk factors for PFD are similar to those in more affluent countries particularly increased age and parity, but additionally, PFD is associated with other factors including poor nutrition and heavy work. The social consequences of PFD conditions can be devastating. Pelvic organ prolapse and urinary and faecal incontinence are significant problems in developing countries. Access to health care to manage these conditions is often limited, and women usually have to live with the consequences for the rest of their lives.
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              Pelvic organ prolapse in older women: prevalence and risk factors.

              We sought to estimate the prevalence of pelvic organ prolapse in older women using the Pelvic Organ Prolapse Quantification examination and to identify factors associated with prolapse. Women with a uterus enrolled at one site of the Women's Health Initiative Hormone Replacement Therapy randomized clinical trial were eligible for this ancillary cross-sectional study. Subjects underwent a Pelvic Organ Prolapse Quantification examination during a maximal Valsalva maneuver and in addition completed a questionnaire. Logistic regression was used to identify independent risk factors for each of 2 definitions of prolapse: 1) Pelvic Organ Prolapse Quantification stage II or greater and 2) the leading edge of prolapse measured at the hymen or below. In 270 participants, age (mean +/- SD) was 68.3 +/- 5.6 years, body mass index was 30.4 +/- 6.2 kg/m(2), and vaginal parity (median [range]) was 3 (0-12). The proportions of Pelvic Organ Prolapse Quantification stages (95% confidence intervals [CIs]) were stage 0, 2.3% (95% CI 0.8-4.8%); stage I, 33.0% (95% CI 27.4-39.0%); stage II, 62.9% (95% CI 56.8-68.7%); and stage III, 1.9% (95% CI 0.6-4.3%). In 25.2% (95% CI 20.1-30.8%), the leading edge of prolapse was at the hymen or below. Hormone therapy was not associated with prolapse (P =.9). On multivariable analysis, less education (odds ratio [OR] 2.16, 95% CI 1.10-4.24) and higher vaginal parity (OR 1.61, 95% CI 1.03-2.50) were associated with prolapse when defined as stage II or greater. For prolapse defined by the leading edge at or below the hymen, older age had a decreased risk (OR 0.50, 95% CI 0.27-0.92) and less education, and larger babies had an increased risk (OR 2.38, 95% CI 1.31-4.32 and OR 1.97, 95% CI 1.07-3.64, respectively). Some degree of prolapse is nearly ubiquitous in older women, which should be considered in the development of clinically relevant definitions of prolapse. Risk factors for prolapse differed depending on the definition of prolapse used.
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                Author and article information

                Contributors
                +47-47632402 , Janne.Gjerde@uib.no
                Journal
                Int Urogynecol J
                Int Urogynecol J
                International Urogynecology Journal
                Springer London (London )
                0937-3462
                1433-3023
                30 July 2016
                30 July 2016
                2017
                : 28
                : 3
                : 361-366
                Affiliations
                [1 ]ISNI 0000 0004 1936 7443, GRID grid.7914.b, Department of Global Public Health and Primary Care, , University of Bergen, ; P.O. Box 7804, 5020 Bergen, Norway
                [2 ]ISNI 0000 0000 9753 1393, GRID grid.412008.f, Department of Obstetrics and Gynecology, , Haukeland University Hospital, ; Bergen, Norway
                [3 ]ISNI 0000 0004 1936 7443, GRID grid.7914.b, Research Group for General Practice, Department of Global Public Health and Primary Care, , University of Bergen, ; Bergen, Norway
                [4 ]Research Unit for General Practice, Uni Research Health, Bergen, Norway
                [5 ]ISNI 0000 0000 8539 4635, GRID grid.59547.3a, Women and Health Alliance (WAHA) International/Gondar Fistula Center, , Gondar University Hospital, ; Gondar, Ethiopia
                [6 ]ISNI 0000 0000 8539 4635, GRID grid.59547.3a, Department of Obstetrics and Gynecology, School of Medicine, , University of Gondar, ; Gondar, Ethiopia
                [7 ]ISNI 0000 0004 1936 7443, GRID grid.7914.b, Centre for International Health, Department of Global Public Health and Primary Care, , University of Bergen, ; Bergen, Norway
                Author information
                http://orcid.org/0000-0003-1763-0263
                Article
                3077
                10.1007/s00192-016-3077-6
                5331107
                27475794
                030e61d0-14b2-4681-beaa-e1ac89c3ec24
                © The Author(s) 2016

                Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

                History
                : 18 April 2016
                : 14 June 2016
                Categories
                Special Contribution
                Custom metadata
                © The International Urogynecological Association 2017

                Obstetrics & Gynecology
                ethiopia,experience,low-income setting,pelvic organ prolapse
                Obstetrics & Gynecology
                ethiopia, experience, low-income setting, pelvic organ prolapse

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