Falling out: authoritative knowledge and women's experiences with pelvic organ prolapse

Preventing Health Disparities during COVID through Perinatal Home Screening as Black Authoritative Knowledge

During COVID-19 epidemic, health protocols limited face-to-face perinatal visits and increased reliance on telehealth. To prevent increased health disparities among BIPOC pregnant patients in health-underserved areas, we used a pre-post survey design to pilot a study assessing (1) feasibility of transferring technology including a blood pressure (BP) cuff (BPC) and a home screening tool, (2) providers' and patients' acceptance and use of technology, and (3) benefits and challenges of using the technology. Specific objectives included (1) increasing contact points between patients and perinatal providers; (2) decreasing barriers to reporting and treating maternal hypertension, stress/depression, and intimate partner violence (IPV)/domestic violence (DV); and (3) bundling to normalize and facilitate mental, emotional, and social health monitoring alongside BP screening. Findings confirm this model is feasible. Patients and providers used this bundling model to improve antenatal screening under COVID quarantine restrictions. More broadly, home-monitoring improved antenatal telehealth communication, provider diagnostics, referral and treatment, and bolstered patient autonomy through authoritative knowledge. Implementation challenges included provider resistance, disagreement with lower than ACOG BP values to initiate clinical contact and fear of service over-utilization, and patient and provider confusion about tool symbols due to limited training. We hypothesize that routinized pathologization and projection of crisis onto BIPOC people, bodies, and communities, especially around reproduction and continuity, may contribute to persistent racial/ethnic health disparities. Further research is needed to examine whether authoritative knowledge increases use of critical and timely perinatal services by strengthening embodied knowledge of marginalized patients and, thus, their autonomy and self-efficacy to enact self-care and self-advocacy.

A mixed methods systematic literature review of barriers and facilitators to help-seeking among women with stigmatised pelvic health symptoms

BACKGROUND

Women's pelvic health is a globally important subject, included in international and United Kingdom health policies, emphasising the importance of improving information and access to pelvic health services. Consequences of pelvic symptoms are intimate, personal, and varied, often causing embarrassment and shame, affecting women's quality of life and wellbeing.

AIM

To understand the experience of seeking healthcare for stigmatised pelvic health symptoms by synthesising all types of published primary research and mapping the results to behavioural theory, to identify potential targets for intervention.

METHODS

Systematic search of MEDLINE, CINAHL, PsycINFO, SocINDEX, PubMED databases, CDSR and CENTRAL registers, from inception to May 2023 for all types of research capturing women's views and experiences of seeking help with stigmatised urogenital and bowel symptoms. Studies only reporting prevalence, predictors of help-seeking, non-health related help-seeking, or written in languages other than English, German, French, Spanish and Swedish were excluded. Reference checking and forward citation searching for all included studies was performed. A results-based synthesis approach was used to integrate quantitative and qualitative data. Themes were mapped to the Common-Sense model and Candidacy framework. The Mixed Methods Appraisal Tool was used for critical appraisal. Grading of Recommendations Assessment, Development and Evaluation - Confidence in Evidence from Reviews of Qualitative research for assessing certainty of review findings.

RESULTS

86 studies representing over 20,000 women from 24 high income countries were included. Confidence was high that barriers to help-seeking were similar across all study types and pelvic symptoms: stigma, lack of knowledge, women's perception that clinicians dismissed their symptoms, and associated normalising and deprioritising of low bother symptoms. Supportive clinicians and increased knowledge were key facilitators.

CONCLUSIONS

Using the Common-Sense Model to explore women's help-seeking behaviour with stigmatised pelvic symptoms reveals problems with cognitive representation of symptom identity, emotional representations of embarrassment and shame, and a subjective norm that women believe their symptoms will be trivialised by clinicians. Together these barriers frustrate women's identification of their candidacy for healthcare. Addressing these issues through behavioural change interventions for women and clinicians, will help to achieve universal access to pelvic healthcare services (United Nations Sustainable Development Goal 3.7).

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42021256956.

A Qualitative Exploration of the Perceptions of Women Living with Pelvic Floor Disorders and Factors Related to Quality of Life

Background: Pelvic floor dysfunction encompasses conditions like urinary and fecal incontinence, pelvic organ prolapse, and pelvic pain, significantly affecting women's quality of life. Despite its prevalence, few studies have adopted a qualitative approach to understanding women's perceptions and emotions regarding these issues. This study aims to delve into how women with pelvic floor disorders perceive their condition and its impact on their daily lives. Methods: We analyzed qualitative data from interviews with 160 women suffering from pelvic floor dysfunctions. Using inductive qualitative content analysis, we systematically examined the data to identify variations, differences, and similarities. Results: The analysis revealed four primary themes in the women's narratives: "Physical Impacts", "Emotional and Psychological Impacts", "Social and Relational Impacts", and "Sexual Health Impacts", along with 12 subthemes. The findings predominantly highlight how pelvic floor dysfunctions detrimentally affect women's quality of life and emotional well-being, instilling fear and insecurity in daily activities, compounded by sleep disturbances and sexual dysfunction. Conclusions: Women living with pelvic floor dysfunction face multifaceted challenges that adversely affect various aspects of their lives, diminishing their overall quality of life. This includes notable impacts on sleep, physical, and sexual activities. However, not all affected women report these issues, often due to fear of stigma, choosing instead to conceal their struggles in an effort to maintain an appearance of normalcy.

Pelvic organ prolapse: The lived experience

BACKGROUND

Up to 50% of women will develop pelvic organ prolapse (POP) over their lifetime. Symptoms include pain, bulge, urinary, bowel and sexual symptoms affecting all aspects of a woman's life. This study explores the lived experience of women with POP.

METHODOLOGY

A qualitative study was undertaken. Following institutional ethical approval women from an online peer support group (n = 930 members) were recruited to participate in semi-structured interviews. Inclusion criteria stipulated women (> 18years), pre-menopausal, at least one-year post-partum, diagnosed with POP and aware of their diagnosis. Semi-structured interviews were undertaken with a clinician specialising in pelvic health. A battery of questions was designed to elicit discussion on their experience of being diagnosed with POP and its impact on daily life and relationships. Interviews were carried out via Zoom, recorded and transcribed. Thematic analysis was undertaken.

FINDINGS

Fourteen women (32-41 years), para 1-3 participated. All had at least one vaginal birth; three had vacuum, four had forceps operative births. All had Grade 1-3 POP. Interviews lasted 40-100 minutes. Three core themes with subthemes were identified; biological/physical, psychological and social. Women were particularly affected in terms of sport and exercise participation, their own perceptions of their ability as mothers and fear of their condition worsening. They described societal attitudes, reporting stigma around POP and women's pelvic health in general, expectations placed on women to put up with their symptoms and an idealised perception of new motherhood.

CONCLUSIONS

The impact of POP from a biopsychosocial perspective reflects other chronic conditions. Prevention, early education and supports for developing strong self-management approaches would be beneficial for long term management of this condition.

Barriers to decolonising educational partnerships in global health

Global health partnerships between high-income countries and low/middle-income countries can mirror colonial relationships. The growing call to advance global health equity therefore involves decolonising global health partnerships and outreach. Through decolonisation, local and international global health partners recognise non-western forms of knowledge and authority, acknowledge discrimination and disrupt colonial structures and legacies that influence access to healthcare.Despite these well-described aims, the ideal implementation process for decolonising global health remains ill-defined. This ambiguity exists, in part, because partners face barriers to adopting a decolonised perspective. Such barriers include overemphasis on intercountry relationships, implicit hierarchies perpetuated by educational interventions and ethical dilemmas in global health work.In this article, we explore the historical entanglement of education, health and colonialism. We then use this history as context to identify barriers that arise when decolonising contemporary educational global health partnerships. Finally, we offer global health partners strategies to address these challenges.

A qualitative evidence synthesis using meta-ethnography to understand the experience of living with pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

Pelvic organ prolapse (POP) affects the lives of many people. We aimed to systematically search for, identify and synthesize qualitative research that explores what it is like to live with POP and make this knowledge available for healthcare improvement.

METHODS

We systematically searched Medline, PsychInfo, Embase and CINAHL, from inception to March 2020, for qualitative research exploring the experience of living with POP. We used meta-ethnography to synthesize findings. This is a conceptual approach to qualitative evidence synthesis. We used the recent guidelines for reporting meta-ethnography.

RESULTS

We screened 3103 titles and 255 abstracts and included 37 primary studies. These incorporated the experience of 777 women, (aged 18 to 95 years) from a range of countries. We organized 162 ideas into 27 conceptual categories and 10 themes. We developed a conceptual model that helps us to understand the experience of pelvic organ prolapse. This model indicates that (1) the physical losses of POP are intricately linked to loss of identity; (2) women conceptualized POP as part of womanhood, yet also its thief; (3) there is a vicious cycle of taboo, silence and misunderstanding about POP and its treatment; (4) this silence is exacerbated by a feeling that POP is not taken seriously in healthcare.

CONCLUSIONS

This meta-ethnography helps us to understand the experience of living with a POP. Our model illustrates the complex process of healthcare decision making. Further studies to explore the complexity of decision making from the perspective of patient and health professional are timely.

A systematic review and meta-synthesis of qualitative studies on pelvic organ prolapse for the development of core outcome sets

AIMS

In the current climate of evidence-based health care, the aim of this meta-synthesis was to collect and systematically analyse data from primary qualitative studies on pelvic organ prolapse (POP), to identify patient-centered perspectives on the natural course of POP. Information acquired in this study may be useful for ongoing research towards the development of core outcome sets (COS) in pelvic floor disorders.

METHODS

A CHORUS Working Group performed a standardized search of three different databases (Medline, Embase, Scopus), from inception to October 2019. We selected qualitative studies on women's perspectives on POP that were published in the English language. Three reviewers independently evaluated the quality of eligible papers and highlighted recurrent themes based on patient perspectives.

RESULTS

Eighteen qualitative studies including a total of 497 patients were assessed in this analysis. Our study revealed five superordinate themes, recurrently encountered in qualitative studies on POP: awareness of POP (6 studies), communication (9 studies), treatments (10 studies), effects on quality of life (6 studies), and self-image (3 studies). Five out of 10 quality criteria were met by all the studies included, based on an assessment performed using the critical appraisal skills program.

CONCLUSIONS

This is the first synthesis of qualitative studies that address POP-related experiences of women, highlighting five superordinate themes, of which treatment was the most commonly reported one. This synthesis' findings may guide quantitative research priorities and will hopefully contribute to the development of a COS for POP.

Online reported women's experiences of symptomatic pelvic organ prolapse after vaginal birth

Background

Pelvic organ prolapse (POP) is a major public health problem with a relative high lifetime risk of surgery. The main risk factor for developing POP is vaginal birth. Many women become symptomatic later in life and most of the existing research on symptomatic pelvic organ prolapse (sPOP) predominantly concentrates on the effects of the condition on postmenopausal women. However bothersome symptoms of POP can be reported as early as in women’s 20s and may occur shortly after vaginal birth. Limited studies provide an insight into daily life of fertile women with sPOP. Thus, we aimed to explore fertile women’s experiences of symptomatic pelvic organ (sPOP) after vaginal birth.

Methods

An inductive, text-driven approach was taken by selecting thread posts from an internet forum written by 33 Swedish fertile women who had experienced sPOP after vaginal birth.

Results

The overarching theme “being irreparably damaged” was identified as representing an experience of being disabled by sPOP after vaginal birth. The fertile women experienced that their lives were ruined because of physical and psychological limitations caused by this unexpected, unfamiliar and unexplained condition. Living with sPOP impinged on sexual health, restricted daily and sports activities and affected the women’s ability to fulfill everyday parental duties. This in turn compromised women’s psychological health. In addition, the negligence of healthcare professionals who tended to trivialize and normalize the symptoms led to the belief that there were no sustainable treatments and that women would have to live with bothersome symptoms of POP for rest of their lives.

Conclusions

This study found that sPOP had a significant negative impact on fertile women’s lives. The women indicated that they had not had the opportunity to voice their concerns and had not been taken seriously by healthcare professionals. It is of the utmost importance to acknowledge this problem and develop guidelines for prevention and management of sPOP to improve the quality of life for women.

Women's experiences of receiving care for pelvic organ prolapse: a qualitative study

BACKGROUND

Pelvic organ prolapse is a common urogenital condition affecting 41-50% of women over the age of 40. To achieve early diagnosis and appropriate treatment, it is important that care is sensitive to and meets women's needs, throughout their patient journey. This study explored women's experiences of seeking diagnosis and treatment for prolapse and their needs and priorities for improving person-centred care.

METHODS

Twenty-two women receiving prolapse care through urogynaecology services across three purposefully selected NHS UK sites took part in three focus groups and four telephone interviews. A topic guide facilitated discussions about women's experiences of prolapse, diagnosis, treatment, follow-up, interactions with healthcare professionals, overall service delivery, and ideals for future services to meet their needs. Data were analysed thematically.

RESULTS

Three themes emerged relating to women's experiences of a) Evaluating what is normal b) Hobson's choice of treatment decisions, and c) The trial and error of treatment and technique. Women often delayed seeking help for their symptoms due to lack of awareness, embarrassment and stigma. When presented to GPs, their symptoms were often dismissed and unaddressed until they became more severe. Women reported receiving little or no choice in treatment decisions. Choices were often influenced by health professionals' preferences which were subtly reflected through the framing of the offer. Women's embodied knowledge of their condition and treatment was largely unheeded, resulting in decisions that were inconsistent with women's preferences and needs. Physiotherapy based interventions were reported as helping women regain control over their symptoms and life. A need for greater awareness of prolapse and physiotherapy interventions among women, GPs and consultants was identified alongside greater focus on prevention, early diagnosis and regular follow-up. Greater choice and involvement in treatment decision making was desired.

CONCLUSIONS

As prolapse treatment options expand to include more conservative choices, greater awareness and education is needed among women and professionals about these as a first line treatment and preventive measure, alongside a multi-professional team approach to treatment decision making. Women presenting with prolapse symptoms need to be listened to by the health care team, offered better information about treatment choices, and supported to make a decision that is right for them.

A Scoping Study of Psychosocial Factors in Women Diagnosed With and/or Treated for Pelvic Organ Prolapse

OBJECTIVE

Pelvic organ prolapse (POP) is prevalent and can impact women's physical and psychosocial health. To develop interventions that support this population, an understanding of the state of research on psychosocial factors related to POP is essential. We conducted a scoping study focused on the psychosocial experience of women with POP. The purpose of this review was to (1) inventory and describe the current state of knowledge of the psychosocial experience of women with POP, (2) identify gaps in knowledge, and (3) identify targets for future research.

METHOD

Electronic databases PsycINFO, PubMed, EMBASE, and CINAHL were searched through November 1, 2017.

RESULTS

Of 524 titles reviewed, 103 articles met all inclusion criteria. Articles were grouped by the disease period (ie, prediagnosis, diagnosis/preintervention, intervention, follow-up, and mixed) and psychosocial factors. Most articles (n = 73) focused on women undergoing intervention. Articles focusing on the preintervention period was the next largest category (n = 14). Follow-up after intervention (n = 8) and samples of mixed disease periods (n = 7) were less common. One article focused on women before diagnosis. Articles focused on quality of life (QOL; n = 79), sexual function (n = 51), satisfaction (n = 16), body image (n = 13), psychological distress (n = 4), and knowledge (n = 3).

CONCLUSIONS

Research on the psychosocial experience of POP has largely focused on changes in QOL and sexual function. Future research should target emotional experience of women with POP; relationships among QOL, psychological distress, body image, and sexual function; and psychosocial factors related to treatment outcomes.