Factors associated with delay in seeking treatment among women with pelvic organ prolapse at selected general and referral hospitals of Southern Ethiopia, 2020

Pelvic organ prolapse (POP) is the herniation of the uterus, the cervix, the vaginal wall, the bladder, and the rectum downward along the vaginal lumen [1]. It is a common gynecological problem, which is more prevalent in developing countries, that affect the life quality of women by limiting emotional, physical, psychosocial, and sexual functions [2, 3].

The prevalence of POP varies widely from population to population depending on the level of exposure to the risk, level of awareness about POP, and level of the socio-economic status. Universally, the prevalence of this problem is about 3.5% to 15% when it is studied by defining symptoms and it reaches up to 64.6% when studied based on objective findings, which are directly measured by the experts [3‐8].

Women in the developed countries who have access to modern health care can benefit from the advances that have been made in treating POP. Moreover, women in developed nations have an awareness of the problem, high literacy rate, and high-income level with excellent health facilities that can screen the POP very early. Delaying for treatment is also affected by high parity, little or no access to health care, and the presence of problems associated with POP [9].

The prevalence of POP in Africa varies widely from country to country: 64.6% in Tanzania [5], 19.4% in Egypt [10], and 6.5% in Nigeria [11]. The prevalence of the POP in Ethiopia is also highly variable ranging from 1 to 56.4% [3, 7, 12]. For instance, 40.7% among gynecologic case in Jimma Hospitals [13], 15% among gynecologic case in Saint Paulos Hospital, Addis Abeba [14], 56.4% in Dabat community, Gondar [3], 20.9% in Kersa community, Ethiopia [7], and 13.3% in Benchi Maji Zone [15].

Essentially, delaying the POP treatments worsens the problem further in Ethiopia. Many women are silent victims of uterovaginal prolapse, hiding the problem owing to fearing social stigma. Despite uterovaginal prolapse is a matter of discomfort for women, it affects many aspects of their daily life [12, 16]. According to a community-based objectively measured study at Dabat district, Gondar, the prevalence of POP is about 56.4%, however, only patients with advanced stages of POP (3.2%) visited the hospitals, even if free service is providing [3].

According to few studies assessing reasons for delayed treatments among women within Ethiopia, the possible reasons are lack of support, low awareness, low literacy, unavailability of the treatment center, low income, and disclosure of the problem or fear of social stigma [12, 16]. In Ethiopia, although the non-governmental organizations in collaboration with the Federal Ministry of Health tried to deliver free services for the victims integrating with obstetric fistula care, the women kept home hiding their problems even from their close partners. This indicates that little attention is given to health education, and creating awareness on the problem. Besides, few studies were conducted on reasons hindering early treatment [12, 16].

There is a scarcity of the study assessing factors associated with the delay in seeking treatment among women with POP in Southern Ethiopia. Notably, exposing factors that hinder early treatments of POP initiates up responsible bodies to take interventional actions at the early stages of the problem. Therefore, it was found to be very important to conduct research that assesses factors associated with the delay in seeking treatment among women with POP in South Nations Nationalities and Peoples’ Region (SNNPR).

This study primarily assessed factors associated with the delay in seeking treatment among women with POP at selected general and referral hospitals of Southern Ethiopia. Accordingly, lack of support, low income, and fear of social stigma were significant factors associated with delayed treatments of POP patients. This study also assessed reasons for delayed treatments among POP patients at selected general and referral hospitals of Southern Ethiopia. Out of 123 POP patients, only 15.4% of POP patients came with earlier stages of POP. The mean length of delay for POP treatments was 36.41 ± 3.95 months. This finding is comparable with the study finding of Israel (43 months) [21]. Nevertheless, it is lower when compared with the mean length of delay in the study conducted in Gondar (85.8 ± 80.2 months) [12]. The most likely justification for this discrepancy is that in our study the patients with POP visited the hospital for seeking treatments by themselves. Meanwhile, in the Gondar study, there was a community-based screening and campaign for searching the cases of POP and, in this case, a lot of cases of POP may surveyed for the treatments and several cases with longer duration may contribute to the high value of estimates because in the community we can find a woman who stayed for longer period by hiding the problem.

This study revealed women with a lack of support were over five times more likely to delay treatments of POP than their counterparts. This is inconsistent with the report from the study of Gondar saying lack of support is not associated with delaying for the treatments [12]. The possible justification for this discrepancy is most probably the POP care in Gondar is integrated into the fistula care center. In Gondar, women with POP are free of any payment related to POP treatments including transportation.

In this study, low income was significantly associated with delayed POP treatments. This is supported by the study conducted in Gondar, which reported the women with a lack of money were about two times more probably delay POP treatments (AOR = 2, 95% CI 1.01, 3.86) [12]. Women with a shortage of income were not able to afford the health service expenses, transport, food, and other costs [22, 23]. It is a fact that most rural mothers in Ethiopia are not economically empowered [23]. Besides, in our context, women have many responsibilities that should carry out in day-to-day activities but not to generate income, and the power to make the financial decision is not by their hands and these and thus situation doubles their problems [23].

In this study, fear of social stigma increases the likelihood to delay treatments. A study conducted to assess reasons for delayed treatments of POP and fistula patients at the University of Gondar Comprehensive and Specialized Hospital, Ethiopia, reported fearing social stigma was not associated with delay for treatments of POP. However, that study reported women who fear disclosing fistula owing to social stigma were two times more likely to delay the fistula treatments when compared with their counterparts [12]. The possible justification for the discrepancy is most probable Hamlin Fistula Center in Gondar has been delivering integrated service of fistula and POP care, repeatedly conducting the POP campaign and expanding awareness creation about the problem in the Gondar community.

In this study, out of 123 POP patients, 7.3% were divorced due to POP. This is comparable with the report of a study from Uganda that reported their husband rejected about 25% of women with POP [20]. The same was true in Nepal among women with POP [24] and in Gondar among women with fistula [12]. Moreover, qualitative studies in Nepal and Bahr Dar also believe that social stigma is the most important barrier to seek health care and to expose problems even to their close ones feeling it shameful because POP involves the most sensitive part of the body (genitalia) [16, 24]. Furthermore, due to fear of discrimination and rejection from people, they hide the illness at all and they disclose when it gets severe and unbearable after an extended duration of time since they begin to feel symptoms. Because of this delay, the problem reaches its advanced stage, which causes surgical interventions to become the only possible treatment solution. Notably, most women in Southern Ethiopia have less awareness about the POP and unable to reveal their problems related to their genitalia (sensitive body parts) because of the feeling of shamefulness, which has a deep root in the culture of the society.

As a limitation, this study was hospital-based and, hence, lacks generalizability to the community at large. Moreover, further study is needed in different places and the population.

In this study, most of the POP patients were delayed for POP treatments. Factors like lack of support, low income, and fear of losing social value/stigma were associated with the delay in seeking treatment. Screening for the POP cases, educating (making awareness) the community about this devastating disease to facilitate early treatment and to avoid social stigma, and raising access to treatment by making the nearby hospitals equipped with facilities to treat POP are recommended.