June is Pelvic Organ Prolapse (POP) awareness month and a time for increased engagement and conversation around this common condition. There are many many websites and blog posts on the risk factors, symptoms, treatment options and preventative measures so I think I’ll jump straight to my expertise – POP in Nepal.
There is a high prevalence of POP in Nepal and what is unique to them is that it affects women at a much younger age. The average age of onset for Nepali women is 27 years where in Western countries it is more common in women over 65 years. This means that women of reproductive age who have a POP are faced with challenges such as incontinence, pain and dyspareunia, which in turn negatively effects their relationships and ability to perform housework and paid work. Women living in remote settings can live for decades with reduced quality of life due to limited access to treatment options.
The main reason POP is so common in young Nepali women is that they are responsible for the heavy physical work around the home. Women have to carry very heavy loads of wood, goat feed and water for long distances on a daily basis. This work does not stop when they are pregnant or in the post-natal period. Some other sociocultural factors include early age of first pregnancy, decreased birth spacing and delivering without a skilled birth attendant. None of these risk factors are easy to address, so, how do we help women in Nepal to reduce the risk of developing a POP?? That is a challenging question.
There are many articles written about gender inequalities as being the underlying problem of reduced maternal health in Nepal. The conclusions of these articles always recommend multidisciplinary collaboration and general solutions to help address the inequalities. Reading these urgent calls-to-action may leave one feeling motivated and encouraged but the reality is it can take decades to see change in traditional social norms. As a clinician, I feel particularly helpless reading articles that list sociocultural issues as the predominant risk factors for reduced maternal health. TBH they leave me feeling a little sad 😦
So, what can a clinician do to help women in Nepal at risk of developing a POP? Well, the work I’ve done so far has shown a few potential possibilities. Interestingly, the women I’ve assessed have had good pelvic floor muscle (PFM) strength and function. My initial idea of teaching women to perform regular PFM exercise may not be necessary. More importantly, I think focussing on teaching correct lifting techniques would have a bigger impact. At this stage, we can not expect pregnant and post-natal women to stop performing heavy lifting so we can try and show them a better way to lift that may reduce pressure on their PFMs.
The other strategy is to provide training for local health workers who service remote communities. Local health workers can potentially assess PFM function and POP and fit a ring pessary. They can also provide lifestyle advice and education on strategies to help protect the PFMs and pelvic organs. One of my studies have shown a training workshop for Auxiliary Nurse Midwives with additional one-on-one training was effective in up-skilling knowledge and practical experience for POP management.
One thing that I’ve learnt through my research journey is that there is no one-size-fits-all solutions to addressing POP management. As a clinician I’ve had to rid my own professional biases to try and find solutions appropriate for the unique Nepali context. While POP prevention and management in Nepal is most certainly challenging, it is of upmost importance that we continue to look for solutions and strategies to help women, especially those living in low resource settings.