Study design, materials and methods
A retrospective text analysis with an interpretive qualitative approach was used. The data presented in this abstract stems from an original empirical dataset with the purposive sampling strategy aiming to obtain posts written by women from an online discussion thread containing conversations about experiencing symptomatic pelvic organ prolapse (sPOP) after vaginal delivery (VD). In total, posts written by 33 women were selected for analysis. The women who participated were 24 to 45 years old (mean =27). Eighteen were primiparous and twelve of the women had children younger than 1-year-old.
Written consent to undertake the study was obtained from the forum’s web operations manager. An information letter with details about the research and confidentiality, the voluntary nature of participation and the right to withdraw at any time was published on the forum’s website.
Results
The theme “Taken by surprise” illustrated that there was a general unawareness of the existence of the POP condition until the symptoms were discovered. Unfamiliarity with pelvic floor anatomy was frequently described and this in turn made it difficult for the women to understand both the anatomical abnormalities and the symptoms that they had to deal with. The women had not realized that they could encounter this bodily condition. Vaginal delivery was expressed as the norm of discourse and no one had informed them about the risks associated with VD or prepared them for the possible complications during antenatal education courses. This left them feeling that they had been misled and the topic had been silenced.
“Yes actually. I am going to bring up the issue again at the next appointment with the midwife. And ask why prolapse is not spoken of, before, during and after the pregnancy” (Participant 33)
A second theme, “Miscommunication” showed that miscommunication between the women and their healthcare providers impacted on these women's experiences of sPOP care thus complicating decision-making and reducing the opportunity to get help. When women sought healthcare services due to existing symptoms, they were met with neglect. The women felt that the healthcare providers acted as if the women were “making a big thing out of it”. Physicians explained sPOP as a prevalent, natural and expected condition after VD, using expressions that belittled the problem with phrases like “it doesn’t look too bad”, “minimal collapse of the front wall”, “I have seen worse” and that “POP is very common”. The women could not agree with such a replacement of concepts where “common” turned into “normal”. This negligence led to psychological distress and drained the women. Nevertheless, the women felt that it was up to them to stop the neglect and seek care to be registered in the medical records, which could help to make sPOP caused by VD visible.
Dissonance occurred between the women’s experiences and expectations and the healthcare professionals’ assessment and advice given. The women considered themselves as far too young to be experiencing any kind of POP and wanted to be treated. However, the women faced a lack of consensus among physicians regarding how sPOP should be addressed. For example, one woman reported that she had been given completely different diagnoses and advice by different physicians. The common advice was to do Kegel exercises and some women felt like they were blamed for their own injures because they had not done the exercises properly. The women were told that surgery could cause even bigger problems in comparison with their current condition and therefore, it was not a desirable option, especially for young persons. The women were advised to postpone surgery until they “were done with babies”. This argument left them in an impossible situation. sPOP was believed to be a condition that could not be fixed while they were in their prime, which meant they had to live with it and suffer for a long time. Some women stated that they had been convinced to give birth vaginally and now that they have been harmed, no one took responsibility or had the competence to deal with the problem.
Additionally, when they met a physician who explained the condition and suggested a treatment plan, they became very happy, emotional and deeply impressed by that fact that someone finally could help them and praised these “good doctors”. One woman described that she cried with happiness while sitting in a gynecological chair.
Interpretation of results
This study brings women´s subjective experiences into focus and highlights the importance of considering experiential knowledge without exception when evaluating and treating sPOP. Women in our study got the shock of their lives when they discovered sPOP and were angry that the information about the risks with VD had been silenced during antenatal care. Sadly, other studies focusing on women with different pelvic floor traumas confirmed these findings (1). Truthful objective information about the risks of VD is required, and it could be assumed that improved provision of information could prepare women to face potential problems postpartum.
We found that participants were unfamiliar with normal pelvic floor anatomy, which made it challenging to understand pathological changes. These shortcomings of knowledge indicate that pelvic organs are still a stigmatized part of the body and are in concordance with a study revealing that female adolescents lacked knowledge of female anatomy with only a few students knowing the number of openings in a vulva (2). In our opinion, the pelvic floor health education should be included in the school curriculum on a mandatory basis.
Our study demonstrates that although there is a growing awareness, especially when it comes to levator ani muscle (LAM) injures, which are associated with sPOP (1), the bothersome symptoms of POP are still viewed by healthcare providers as normal, expected and unavoidable issues after VD and are not investigated properly. Healthcare professionals seem to be unaware of the real impact of this condition on the quality of life and psychological health of new mothers. It has been revealed that a large number of treatments given to women with childbirth traumas have not been scientifically evaluated in reliable systematic reviews, and there are no systematic reviews addressing the acute POP associated with VD (3). It may be assumed that this lack of evidence can partly explain our findings that the healthcare professionals failed to meet the women’s needs regarding diagnostic, information and treatment options.