Life after pelvic organ prolapse surgery: a qualitative study in Amhara region, Ethiopia

Life after pelvic organ prolapse surgery: a qualitative study in Amhara region, Ethiopia Background: Women living in resource constrained settings often have limited knowledge of and access to surgical treatment for pelvic organ prolapse. Additionally, little is known about experiences during recovery periods or about the reintegration process for women who do gain access to medical services, including surgery. This study aimed to explore women’s experiences related to recovery and reintegration after free surgical treatment for pelvic organ prolapse in a resource-constrained setting. Methods: The study had a qualitative design and used in-depth interviews in the data collection with a purposive sample of 25 participants, including 12 women with pelvic organ prolapse. Recruitment took place at the University of Gondar Hospital, Ethiopia, where women with pelvic organ prolapse had been admitted for free surgical treatment. In- depth interviews were carried out with women at the hospital prior to surgery and in their homes 5–9 months following surgery. Interviews were also conducted with health-care providers (8), representatives from relevant organizations (3), and health authorities (2). The fieldwork was carried out in close collaboration with a local female interpreter. Results: The majority of the women experienced a transformation after prolapse surgery. They went from a life dominated by fear of disclosure, discrimination, and divorce due to what was perceived as a shameful and strongly prohibitive condition both physically and socially, to a life of gradually regained physical health and reintegration into a social life. The strong mobilization of family-networks for most of the women facilitated work-related help and social support during the immediate post-surgery period as well as on a long-term basis. The women with less extensive social networks expressed greater challenges, and some struggled to meet their basic needs. All the women openly disclosed their health condition after surgery, and several actively engaged in creating awareness about the condition. Conclusions: Free surgical treatment substantially improved the health and social life for most of the study participants. The impact of the surgery extended to the communities in which the women lived through increased openness and awareness and thus had the potential to ensure increased disclosure among other women who suffer from this treatable condition. Keywords: Ethiopia, Experience, Pelvic organ prolapse, Recovery, Reintegration, Surgery * Correspondence: Janne.Gjerde@uib.no Research group for Global Health Anthropology, Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway Department of Obstetrics and Gynecology, Haukeland University Hospital, Bergen, Norway Full list of author information is available at the end of the article © The Author(s). 2018 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. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Gjerde et al. BMC Women's Health (2018) 18:74 Page 2 of 8 Background Methods Symptomatic pelvic organ prolapse (hereafter ‘prolapse’) Study setting occurs in 6–7% of womeninthe United States,[1, 2]with The current study took place in the Amhara region of a 12% lifetime risk of undergoing surgical treatment [3]. north-western Ethiopia. Roughly 20% of births among Pregnancy and childbirth are important risk factors for pro- rural women in Ethiopia are attended by skilled lapse, [2, 4] and the risk increases with the number of vagi- personnel or occur at health facilities. The nation’s fertil- nal deliveries [5]. Prolapse may be more common and may ity rate is 4.6 children per woman, and the more severely affect daily living in resource-constrained set- maternal-mortality ratio is 412 deaths per 100,000 live tings due to high fertility rates, early-age deliveries, limited births [29]. Rural Ethiopian health facilities are in gen- access to obstetric care, and the rigors of manual work [6, eral poorly equipped and lack adequate emergency ob- 7]; however, information from such settings on prevalence stetric services [30]. The Amhara people, who primarily and risk factors remains limited. The few studies on pro- practice Orthodox Christianity and speak Amharic as lapse available from low- and middle-income countries their first language, are the majority ethnic group in the have reported prevalence rates ranging from 3 to 56% and region [31]. The median female age upon first marriage include research on prolapse symptoms and prolapse in the Amhara region is 16.2 years, and around 55% of verified by pelvic examination [7–9]. In Ethiopia, a the women are illiterate [29].. population-based pilot study conducted in the same re- The present study, which was conducted in 2015–16, fea- search area as this study reported a 55% prevalence of tured repeated visits to the field. The three-months-long first stages II–IV prolapse among participants who had under- part of the fieldwork was conducted at the University of gone pelvic examinations using the simplified Pelvic Organ Gondar Hospital (henceforth ‘the hospital’), a referral teach- Prolapse Quantification (POPQ) staging system [6, 10]. ing hospital located in the city of Gondar. The second part Other studies from Ethiopia have suggested an association of the study, which lasted 4 months, took place in between prolapse stage and age, and parity and occupation semi-urban and rural parts of the districts of Dabat and De- [11] as well as between prolapse and underweight condi- bark, located 78 and 106 km north of Gondar, respectively. tions, lack of formal education, and childbirth without Free surgical treatment was introduced at the hospital at the health professionals [12].. time of the fieldwork and was offered to women with pro- Independent of place of residence, prolapse has been lapse. It was initiated and funded by the hospital and UNFPA reported to negatively affect the quality of life including in collaboration with two non-governmental organizations sexual function and body image [13–15]. Findings from (NGOs). The women were informed about prolapse and the rural parts of Ethiopia and other resource-constrained possibility of free treatment from health-extension workers settings suggest the severity of the social consequences (HEWs) in the communities. Those who were found eligible of prolapse, including the possibility of divorce and dis- for surgical treatment were selected at the district level and crimination [16–20]. Like urinary incontinence and ob- sent to the hospital in small groups. stetric fistula, prolapse is commonly considered by rural Ethiopian women as a sensitive topic as well as a shame- Participant recruitment and data collection ful and repulsive condition [16, 21, 22]. Recent publica- The study had a qualitative, explorative approach and in- tions from the United States and Australia offer strong cluded 25 participants (Table 1). The first part of the evidence of quality of life improvements following vagi- fieldwork was conducted at the hospital where women nal surgery for prolapse, including improved sexual with prolapse were admitted for surgery. Women who function and body image [23–26] .However, there is an had undergone prolapse surgery were interviewed and ongoing and comprehensive debate among medical ex- recruited for follow-up visits in their homes after ex- perts worldwide as to which type of surgical method pected recovery. The criteria for follow-up included pro- gives the most desirable long-term outcome [26, 27].. lapse surgery and the accessibility of the women’s Little is known about how women in resource-constrained homes. The first author carried out participant observa- settings experience the recovery period following prolapse tions at the hospital, which were primarily conducted in surgery. Moreover, there is limited knowledge about women’s connection with another sub-study focusing on processes of reintegration into their communities after the health-seeking behaviours in the same patient group. surgery. Studies on obstetric fistula in Ethiopia and Kenya The author’s presence at the ward also facilitated the re- suggest that surgical repair only represents the starting point cruitment of informants for the present sub-study and for affected women who wish to seek social reintegration secured access to the informants’ medical histories. [22, 28] .The current study aimed to explore women’sexperi- Health-care providers and a representative from one of ences related to recovery and reintegration following the the organizations involved in the newly introduced free provision of free surgical treatment for prolapse in a rural prolapse-treatment initiative were also interviewed at Ethiopian setting. the hospital. Gjerde et al. BMC Women's Health (2018) 18:74 Page 3 of 8 Table 1 Study participants according to recruitment place Hospital Number Community Number Women admitted for surgical 8 Follow-up of women having undergone surgical 8 treatment of prolapse treatment at hospital Health care providers 2 Women who had undergone surgical treatment 4 at the same facility and time period Representative from organization 1 Health extension workers working at community level 4 affiliated with the hospital Health care providers working at health centre level 2 Representatives from international NGO 2 Representatives from the health authorities at district level 2 Total interviews 11 22 These women were primarily taking part in a sub-study that focused on the experience of living with prolapse [16], and were recruited for a follow-up visit in their homes The second part of the study took place in the sub-category identified during the first phase was scruti- women’s communities and included home visits 5–9 nized for central patterns and ‘case-stories’ as well as for months after their surgeries. HEWs who were involved potential nuances, and ambivalence and contradictions. in community mobilization activities in connection with The full data set was then imported into NVivo 11, a prolapse surgery were interviewed. They were engaged qualitative data-analysis software tool that was employed in the identification of potential prolapse cases and re- to organize the material. ferred women with suspected prolapse to the district level. Health-care workers at the health-centre level, as Ethical considerations well as representatives from an international NGO and Ethical approvals were obtained from the Regional Eth- representatives from the health authorities at the district ics Review Board in Norway and the University of Gon- level, all of whom were involved in the newly introduced dar in Ethiopia. With the assistance of the interpreter, all free prolapse-treatment initiative, were also interviewed patients on the ward were provided with information to provide contextual information for the study. about the study, the role of the first author’s participant All interviews were performed in close collaboration observation, and their rights not to participate or be ob- with a local female interpreter who was familiar with the served. The aim and purpose of the study, as well as the language, culture, and respectful conduct in the area. contents of the consent form, were explained to the re- The interviews were conducted in Amharic with con- search participants prior to all interviews. Written or tinuous translation from English to Amharic and vice oral consent to participate was obtained, depending on versa between the researcher and the informants. literacy status, and the utmost care was taken to secure Semi-structured interview guides with open-ended ques- privacy and confidentiality during the research process. tions were used (see Additional file 1). The interviews, Two patients at the hospital declined to participate, and which were held either inside or outside the women’s two women were lost to follow-up with the research homes, lasted from 1 to 2 h with the aim of allowing the team due to distance or lack of accessible roads to their informants to speak freely and with few interruptions. homes. All the interviews at the hospital were held in a private room on the ward while the interviews with the Results health-care providers and stakeholders in the communi- The main category of informants consisted of 12 women ties were held in a private room at their work facilities. (Table 2), all of whom had undergone surgical treatment for prolapse. Upon admission, 11 of the 12 women were Analysis diagnosed with stage III prolapse of the uterus, bladder The analysis took place throughout the data-collection and/or rectum according to the simplified POPQ staging process and during a rigorous analytical phase that system [10]. The majority had undergone a vaginal hys- followed the completion of the fieldwork. All interviews terectomy and sacrospinous fixation and/or an anterior were audio-recorded, transcribed verbatim to Amharic or posterior colporrhaphy under spinal anaesthesia. and translated into English. The completed material was None received oestrogen therapy prior to or after the carefully reviewed to identify core themes [32]. The sub- surgery. All women, except for one, returned to the hos- sequent post-fieldwork analysis concretized the initially pital for their follow-up appointments scheduled by the identified themes into categories of meaningful units hospital staff to take place 1–3 months after surgery. followed by coding of the material line-by-line [33]. Each Two women got confirmed vault prolapse during their Gjerde et al. BMC Women's Health (2018) 18:74 Page 4 of 8 Table 2 Characteristics of main participants informants explained that they had received substantial support when they returned from the hospital: Mean age 43.3 years [range 32–60] Marital status Until my [hospital follow-up] appointment was Married 8 approaching, I lay on my bed while my neighbours Divorced 3 fed my family and me and took turns doing my chores. Widowed 1 (52-year-old married woman). Mean age at first marriage 13 years [range 7–19] After a month or more of rest, the external support Education system slowly decreased as relatives and neighbours No school / illiterate 10 returned to their own homes. The condition nonetheless Literate 2 required continuous support to avoid having the woman Occupation return to heavy chores. The assistance was commonly Housework 6 provided by immediate family members: Housework and farming activities 5 I don’t work at home much anymore. My daughter is Daily laborer 1 cleaning the house, inside and outside. I used to help Mean number of children 3.6 children [range 0–8] with the farming, but now I’ve stopped doing that too. Mean age at first delivery 18.5 [range 13–24] My husband manages by himself. (40-year-old married Place of delivery woman). All deliveries at home 10 One or two deliveries at health facility 2 Many of the women expressed fear of returning to their previous heavy chores: hospital appointment. During our follow-up interviews 5–9 months after the surgery, half of the women ex- I feel I am cured now. But I don’t doubt that if I start plained that they had a highly improved health condition doing heavy work again I would feel sick. Now I fear to with few or no complaints, whereas the other half still do heavy work. (32-year-old married woman). had some challenges. Some again felt that something was emerging from their vagina and others could not Divorced and widowed women largely lived by them- control their urination. selves and depended on their children or on extended family members to decrease their work burdens after the Recovery initial healing period. These women who were socially Although only half the women had fully recovered 5–9 vulnerable found it more challenging to cope, not the months after the surgery, nearly all expressed appreci- least in cases of delayed healing: ation for their present situation: I used to work as a labourer preparing food for people. Iusedtohavetowalk byholding the prolapse; Icouldn’t I don’t feel good enough yet to start work. I can’teven walk like I wanted to. I had a lot of problems. But I’m walk long distances or lift anything, and I don’t have thankful after the surgery; it was a big change. I had anyone to help me. I ask neighbourhood children to suffered for six years. (32-year-old married woman) fetch water for me. I no longer have any money saved, and I feel that darkness has surrounded me. I had to Following surgery, the women were told to avoid send my two young children to work in other people’s heavy strains and lifting for their lifetime and to avoid houses. If I sit like this, how can I feed myself? I’m still sexual intercourse for up to 3 months. The women in waiting to recover, and then I’ll start working again. this region of Ethiopia normally have full responsibility (39-year-old divorced woman). for household chores, including the procuring of water and firewood and occasionally taking part in farming ac- Although many of the women interviewed referred to tivities. Collecting water for many of the women in- stories of other women who had been unable to abstain volved daily multi-hour walks carrying 20–30 l on their from sex upon their return home to their husbands, the backs. The avoidance of chores after the surgery, hence, women interviewed in the present study seemed to have depended on receiving substantial support from their husbands who accepted their conditions: neighbours, family members, and more distant relatives. The customary support systems related to illness and We haven’t had sex for five months now, and he hasn’t births were mobilized in these cases; indeed, all the forced me. He hasn’t asked me during this time—he Gjerde et al. BMC Women's Health (2018) 18:74 Page 5 of 8 can see the pain I’ve been in. (35-year-old married treatment, I’ve escaped the pain. I feel relaxed now. woman). (40-year-old married woman). The HEW’s overall impression was that the women The HEW’s also reported noticing a change in open- made strong attempts to follow the advice they were ness among women in the communities: given by the hospital after the surgery, but they also mentioned cases where the woman had no choice but to Women have become more open to talk to us about work due to lack of available support. their problems. We usually speak about prolapse when we get a chance in the Church or at community Disclosure meetings. Then women come directly to us and say: “I Most of the women had disclosed their conditions to very have this problem. I kept it to myself.” (HEW 2). few confidantes prior to their surgery. Typically, they shared with their mother, sister or close friend in addition to the HEW. All the married women disclosed their conditions to Reintegration their husbands, but the majority did so at a late date and Many of the women told of the extreme social re- only after the condition had worsened. Before disclosing, strictions caused by the prolapses, and explained how some had considered divorce to escape the shame they ex- they had been unable to fulfil the social roles ex- perienced. Although many of the husbands were said to be pected of them. When living with the prolapse condi- supportive,theycommonlyhad alimited abilitytoassist tion, the crucial inviting and hosting of people for their wives. The divorced women had chosen to leave their holidays had become increasingly challenging for husbands because of the prolapse, either due to being ig- many since food preparation often involved heavy lift- nored and disrespected or because they were unable to fulfil ing, including the procurement of extra water for the their expected roles as wives due to their condition. occasion. Walking longer distances to attend social The period when the informants were brought to- gatherings, such as funerals or events with far-off rel- gether with their fellow prolapse sufferers in connection atives, had also become problematic. One woman, with the hospitalization process proved to be vital for who had found it difficult to sit among people be- disclosure. During the time they spent together, they cause of the pain and itching of her ulcerated pro- established close ties: lapse, and from her frequent need to urinate, explained the transformation she had experienced: Once we travelled together to the hospital, we didn’t talk about anything but our conditions for five days. It used to be embarrassing to sit with people outside or We didn’t know each other, but we still talked a lot. inside others’ homes. It was shameful for me to eat, We laughed and discussed like mothers and daughters drink and [suddenly] go outside to urinate. I stopped do. We all shared our experiences with the prolapse. attending social gatherings because of that. That (35-year-old married woman). situation cannot be compared to the present. I urinate less frequently, and I can sit how I want to sit and talk Once the women had returned from the hospital, with relatives without a problem. (35-year-old married many faced questions about the treatment they had re- woman). ceived, and the majority decided to be open about what they had experienced: Not all the women felt ready to fully engage in every social gathering at the time of the study. After the treatment, people asked me where I’d been and what had happened to me. I told them all about I haven't started visiting relatives yet because the my condition and the treatment I’d received. (39-year- doctor told me not to go anywhere far for six months. old divorced woman). I might start having long journeys and visit relatives soon, God willing. (45-year-old married woman). The response from their neighbours and relatives was mainly positive; many expressed sympathy and won- Most, however, lived relatively close to other women dered why they had kept the prolapse a secret for so they had been hospitalized with, and many of them long. All the women expressed great relief related to stayed in touch: their newly gained experience of openness: One of these women is my neighbour. Now we drink Why should I feel shame now? I’ve seen the light. I hid coffee and fetch water together. Both of us trust each the condition for 20 years. But now that I’ve had the other. (40-year-old married woman) We all have a Gjerde et al. BMC Women's Health (2018) 18:74 Page 6 of 8 wish to meet after the surgery, and we have planned to better. I advise them to seek medical care because the meet at every holiday. (39-year-old divorced woman). government supports us now. Many women hide their problems, and that’s bad for their well-being. I suffered a lot because I concealed my problem. (40-year-old Engagement divorced woman). The increased openness among the women after their re- turn home from the hospital had implications in their local communities. One woman explained that prolapse was Discussion now a common and unproblematic topic to discuss with Main findings friends. Indeed, this was reflected by the health-care The opportunity for treatment proved to have substan- workers: tial implications for the rural Amhara women who were followed up in the present study. The majority received If the new initiative goes on, women won’t be hiding substantial practical support during the recovery period this condition anymore. It is a way to avoid women’s and experienced understanding after disclosing their discrimination. (Health-care provider, Health Clinic). condition. For many of the women, the disclosure and awareness related to prolapse became an important ac- After returning from the hospital, several of the study tivity to ensure that other women who were suffering participants were approached in secrecy by women in alone would learn about prolapse and the available free the community who asked for details about the condi- treatment. The increased disclosure led to a surprising tion and about the treatment they had received: degree of openness and awareness about the condition in the communities in which the study took place. Not A lot of women out there haven’t yet received all the women, however, experienced improvements in treatment [for prolapse]; they hide their condition and their lives, especially the ones who lived alone and had a pain. One woman from my village came to my problematic healing process. For these women, life con- home—she had been too ashamed to tell anybody tinued to be a struggle. about her condition. I asked her why she felt ashamed. We don’t have to hide this condition these days. After Interpretation of results our conversation, she talked to the health-extension The key issues raised by the women in the study were worker and was sent to the hospital for surgery. She that the surgery alleviated them of the most pressing later became a very dear friend. (32-year-old married concerns of discrimination, rejection, and divorce [16]. woman). The sharing of experiences and the relationships that de- veloped among the women who were recruited for treat- As a part of the new prolapse initiative, the selected ment proved to be important for the women’s increasing women who had been treated were now trained as sense of knowledge about the condition and sense of maternal-health advocates. In addition to spreading in- empowerment as well as the subsequent openness and formation about maternal-health matters in their com- disclosure of the condition. The current study thus indi- munities, the advocates were trained to seek out and cates the immense transformation that can be facilitated register women who suffered from prolapse: when groups of women are recruited jointly for surgery and go through a joint learning process. These factors When mothers return home after being treated, we speak to the importance of the surgery beyond the phys- train them, and the health bureau also gives them a ical repair itself; the regaining of a social life lies at the checklist. They mainly work alongside the community core of the stories these women tell. The emphasis of health workers (HEWs), and we encourage them to the social dimensions has similarities with experiences participate in different activities of the project. We from other health initiatives, for example within the field also have a radio channel which facilitates the of HIV/AIDS, where beyond the antiretroviral therapy, mobilization process. (NGO representative). the training, employment, and empowerment of local mothers who live with HIV have led to reduced The women who had yet to receive training were also HIV-related stigma and discrimination [34].. eager to spread information about prolapse and to en- In a study of women who were treated for obstetric courage others to get treated: fistula in Kenya [28], finding a sense of belonging after their treatment and reintegration into the community When I go to fetch water, I inform women [about following surgery depended on their available support prolapse]. I also tell their husbands to take their wives mechanisms. Although many of the prolapse sufferers in to the hospital if they are sick. I explain how I got the present study experienced extensive support after Gjerde et al. BMC Women's Health (2018) 18:74 Page 7 of 8 surgery, the available help still proved insufficient for study findings suggest may benefit entire communities. some due to limited social networks. Among tubercu- Still, supportive systems—not the least economic—may losis patients being treated in Ethiopia [35], the support be required to counteract problematic consequences of from family and community members similarly proved the surgery, particularly for vulnerable women. crucial although many patients found that the level of Further research should be conducted on the preva- support dropped during the course of treatment. Thus, lence and risk factors for prolapse as well as on women’s it proved difficult for them to cope, especially the ones health-seeking behaviour related to prolapse in with limited human or material resources. resource-constrained settings. Such knowledge is re- In line with scholars within critical medical anthropology quired to inform the development of sustainable inter- [36–38], we argue that poverty and marginalization in- ventions for prolapse and other prevalent, treatable, and crease the likelihood of illness and suffering, such as when chronic maternal-health challenges in Ethiopia and simi- life conditions seen as insignificant hamper the potential lar resource-constrained settings. for receiving adequate care for serious conditions of pro- lapse. Taking into account the high fertility rates, early-age Additional file pregnancies, and strenuous physical work demanded of Additional file 1: The interview guide used for follow-up interviews women in the study area, our study findings strongly sup- with women treated for pelvic organ prolapse. (DOCX 15 kb) port the argument that prolapse may affect daily life more severely in resource-constrained settings than in more af- Abbreviations fluent settings [6, 7]. Dynamics of poverty and HEW: Health-extension worker; NGO: Non-Governmental Organisation; marginalization in diverse ways reduces the opportunity to POPQ: Pelvic organ prolapse quantification (staging system); UNFPA: United Nations Population Fund receive treatment. The dynamics linked to early marriage and limited schooling among rural Ethiopian women also Acknowledgements limits theexchangeofknowledge,thuslaying thegrounds We would like to express our heartfelt thanks to all the study informants, especially to the women with prolapse who, despite the sensitivity of the for stigma and discrimination [16, 39]. Themajorityofthe topic, decided to share their stories with us. We are sincerely appreciative of women in this study would not have reached the hospital the staff at the Fistula Treatment and Training Centre at the University of without being exposed to the mobilization initiative that Gondar Hospital for their hospitality and support throughout the fieldwork. We also owe our warmest thanks and gratitude to the research assistants in took place in their communities, providing them with free the field. transport and treatment. Such initiatives are rare in Ethiopia, and they require a long-term sustainable commit- Funding ment and funding to succeed. The study was funded by the Western Norway Regional Health Authority. The funding body had no role in the study design, collection of data, analysis, interpretation or writing up of the manuscript. Strengths and limitations The topic of prolapse is perceived as extremely sensitive Availability of data and materials The data used and/or analysed during the current study may be requested in the current study area, which may have affected the from the corresponding author. However, only excerpts of particular interest women’s readiness to speak openly. Also, the first au- may be shared as the complete data may identify informants. thor’s sociocultural and language limitations, despite sev- Authors’ contributions eral lengthy research stays in Ethiopia and increasing JLG, GR, MA and AB developed the research protocol. JLG carried out the data language competence, are likely to have affected the collection, with support from all co-authors. Data analysis and interpretation of the study’s results. In this context, we would also like to data was conducted by JLG, with substantial contributions from all co-authors. Manuscript drafting was mainly carried out by JLG and AB, with substantial mention that being an outsider can at times be advanta- contributions from GR, MA and TB. All authors read approved the final version geous as one is perceived to be located beyond the lo- of the manuscript. cally embedded normative discourse. Moreover, these Ethics approval and consent to participate challenges were partially ameliorated through the Written or oral consent to participate was obtained by all participants in the follow-up visits to the women at home and the newly study. When a participant was not able to write, oral consent was obtained gained openness about the condition in the study area. as approved by the ethical committees both in Norway and Ethiopia. Reference numbers for ethical approvals: The women also expressed appreciation for the Regional Committees for Medical and Health Research Ethics in Norway, 25 follow-up interviews in their homes after the surgery. August 2014: 2014/589. University of Gondar Institutional Review Board, 2 February 2015: R/C/S/V/P/05/315/2015. Conclusions Competing interests The present study indicates that the provision of free The authors declare that they have no competing interests. prolapse treatment in rural Ethiopia has substantial po- tential in improving the health and social life among af- Publisher’sNote fected women. Recruiting women in groups facilitate Springer Nature remains neutral with regard to jurisdictional claims in awareness and empowerment processes that the present published maps and institutional affiliations. Gjerde et al. BMC Women's Health (2018) 18:74 Page 8 of 8 Author details 19. Wusu-Ansah OK, Opare-Addo HS. Pelvic organ prolapse in rural Ghana. Int J Research group for Global Health Anthropology, Centre for International Gynaecol Obstet. 2008;103:121–4. Health, Department of Global Public Health and Primary Care, University of 20. Zeleke BM, Ayele TA, Woldetsadik MA, Bisetegn TA, Adane AA. Depression Bergen, Bergen, Norway. 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Life after pelvic organ prolapse surgery: a qualitative study in Amhara region, Ethiopia

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Medicine & Public Health; Gynecology; Maternal and Child Health; Reproductive Medicine
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Abstract

Background: Women living in resource constrained settings often have limited knowledge of and access to surgical treatment for pelvic organ prolapse. Additionally, little is known about experiences during recovery periods or about the reintegration process for women who do gain access to medical services, including surgery. This study aimed to explore women’s experiences related to recovery and reintegration after free surgical treatment for pelvic organ prolapse in a resource-constrained setting. Methods: The study had a qualitative design and used in-depth interviews in the data collection with a purposive sample of 25 participants, including 12 women with pelvic organ prolapse. Recruitment took place at the University of Gondar Hospital, Ethiopia, where women with pelvic organ prolapse had been admitted for free surgical treatment. In- depth interviews were carried out with women at the hospital prior to surgery and in their homes 5–9 months following surgery. Interviews were also conducted with health-care providers (8), representatives from relevant organizations (3), and health authorities (2). The fieldwork was carried out in close collaboration with a local female interpreter. Results: The majority of the women experienced a transformation after prolapse surgery. They went from a life dominated by fear of disclosure, discrimination, and divorce due to what was perceived as a shameful and strongly prohibitive condition both physically and socially, to a life of gradually regained physical health and reintegration into a social life. The strong mobilization of family-networks for most of the women facilitated work-related help and social support during the immediate post-surgery period as well as on a long-term basis. The women with less extensive social networks expressed greater challenges, and some struggled to meet their basic needs. All the women openly disclosed their health condition after surgery, and several actively engaged in creating awareness about the condition. Conclusions: Free surgical treatment substantially improved the health and social life for most of the study participants. The impact of the surgery extended to the communities in which the women lived through increased openness and awareness and thus had the potential to ensure increased disclosure among other women who suffer from this treatable condition. Keywords: Ethiopia, Experience, Pelvic organ prolapse, Recovery, Reintegration, Surgery * Correspondence: Janne.Gjerde@uib.no Research group for Global Health Anthropology, Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway Department of Obstetrics and Gynecology, Haukeland University Hospital, Bergen, Norway Full list of author information is available at the end of the article © The Author(s). 2018 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. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Gjerde et al. BMC Women's Health (2018) 18:74 Page 2 of 8 Background Methods Symptomatic pelvic organ prolapse (hereafter ‘prolapse’) Study setting occurs in 6–7% of womeninthe United States,[1, 2]with The current study took place in the Amhara region of a 12% lifetime risk of undergoing surgical treatment [3]. north-western Ethiopia. Roughly 20% of births among Pregnancy and childbirth are important risk factors for pro- rural women in Ethiopia are attended by skilled lapse, [2, 4] and the risk increases with the number of vagi- personnel or occur at health facilities. The nation’s fertil- nal deliveries [5]. Prolapse may be more common and may ity rate is 4.6 children per woman, and the more severely affect daily living in resource-constrained set- maternal-mortality ratio is 412 deaths per 100,000 live tings due to high fertility rates, early-age deliveries, limited births [29]. Rural Ethiopian health facilities are in gen- access to obstetric care, and the rigors of manual work [6, eral poorly equipped and lack adequate emergency ob- 7]; however, information from such settings on prevalence stetric services [30]. The Amhara people, who primarily and risk factors remains limited. The few studies on pro- practice Orthodox Christianity and speak Amharic as lapse available from low- and middle-income countries their first language, are the majority ethnic group in the have reported prevalence rates ranging from 3 to 56% and region [31]. The median female age upon first marriage include research on prolapse symptoms and prolapse in the Amhara region is 16.2 years, and around 55% of verified by pelvic examination [7–9]. In Ethiopia, a the women are illiterate [29].. population-based pilot study conducted in the same re- The present study, which was conducted in 2015–16, fea- search area as this study reported a 55% prevalence of tured repeated visits to the field. The three-months-long first stages II–IV prolapse among participants who had under- part of the fieldwork was conducted at the University of gone pelvic examinations using the simplified Pelvic Organ Gondar Hospital (henceforth ‘the hospital’), a referral teach- Prolapse Quantification (POPQ) staging system [6, 10]. ing hospital located in the city of Gondar. The second part Other studies from Ethiopia have suggested an association of the study, which lasted 4 months, took place in between prolapse stage and age, and parity and occupation semi-urban and rural parts of the districts of Dabat and De- [11] as well as between prolapse and underweight condi- bark, located 78 and 106 km north of Gondar, respectively. tions, lack of formal education, and childbirth without Free surgical treatment was introduced at the hospital at the health professionals [12].. time of the fieldwork and was offered to women with pro- Independent of place of residence, prolapse has been lapse. It was initiated and funded by the hospital and UNFPA reported to negatively affect the quality of life including in collaboration with two non-governmental organizations sexual function and body image [13–15]. Findings from (NGOs). The women were informed about prolapse and the rural parts of Ethiopia and other resource-constrained possibility of free treatment from health-extension workers settings suggest the severity of the social consequences (HEWs) in the communities. Those who were found eligible of prolapse, including the possibility of divorce and dis- for surgical treatment were selected at the district level and crimination [16–20]. Like urinary incontinence and ob- sent to the hospital in small groups. stetric fistula, prolapse is commonly considered by rural Ethiopian women as a sensitive topic as well as a shame- Participant recruitment and data collection ful and repulsive condition [16, 21, 22]. Recent publica- The study had a qualitative, explorative approach and in- tions from the United States and Australia offer strong cluded 25 participants (Table 1). The first part of the evidence of quality of life improvements following vagi- fieldwork was conducted at the hospital where women nal surgery for prolapse, including improved sexual with prolapse were admitted for surgery. Women who function and body image [23–26] .However, there is an had undergone prolapse surgery were interviewed and ongoing and comprehensive debate among medical ex- recruited for follow-up visits in their homes after ex- perts worldwide as to which type of surgical method pected recovery. The criteria for follow-up included pro- gives the most desirable long-term outcome [26, 27].. lapse surgery and the accessibility of the women’s Little is known about how women in resource-constrained homes. The first author carried out participant observa- settings experience the recovery period following prolapse tions at the hospital, which were primarily conducted in surgery. Moreover, there is limited knowledge about women’s connection with another sub-study focusing on processes of reintegration into their communities after the health-seeking behaviours in the same patient group. surgery. Studies on obstetric fistula in Ethiopia and Kenya The author’s presence at the ward also facilitated the re- suggest that surgical repair only represents the starting point cruitment of informants for the present sub-study and for affected women who wish to seek social reintegration secured access to the informants’ medical histories. [22, 28] .The current study aimed to explore women’sexperi- Health-care providers and a representative from one of ences related to recovery and reintegration following the the organizations involved in the newly introduced free provision of free surgical treatment for prolapse in a rural prolapse-treatment initiative were also interviewed at Ethiopian setting. the hospital. Gjerde et al. BMC Women's Health (2018) 18:74 Page 3 of 8 Table 1 Study participants according to recruitment place Hospital Number Community Number Women admitted for surgical 8 Follow-up of women having undergone surgical 8 treatment of prolapse treatment at hospital Health care providers 2 Women who had undergone surgical treatment 4 at the same facility and time period Representative from organization 1 Health extension workers working at community level 4 affiliated with the hospital Health care providers working at health centre level 2 Representatives from international NGO 2 Representatives from the health authorities at district level 2 Total interviews 11 22 These women were primarily taking part in a sub-study that focused on the experience of living with prolapse [16], and were recruited for a follow-up visit in their homes The second part of the study took place in the sub-category identified during the first phase was scruti- women’s communities and included home visits 5–9 nized for central patterns and ‘case-stories’ as well as for months after their surgeries. HEWs who were involved potential nuances, and ambivalence and contradictions. in community mobilization activities in connection with The full data set was then imported into NVivo 11, a prolapse surgery were interviewed. They were engaged qualitative data-analysis software tool that was employed in the identification of potential prolapse cases and re- to organize the material. ferred women with suspected prolapse to the district level. Health-care workers at the health-centre level, as Ethical considerations well as representatives from an international NGO and Ethical approvals were obtained from the Regional Eth- representatives from the health authorities at the district ics Review Board in Norway and the University of Gon- level, all of whom were involved in the newly introduced dar in Ethiopia. With the assistance of the interpreter, all free prolapse-treatment initiative, were also interviewed patients on the ward were provided with information to provide contextual information for the study. about the study, the role of the first author’s participant All interviews were performed in close collaboration observation, and their rights not to participate or be ob- with a local female interpreter who was familiar with the served. The aim and purpose of the study, as well as the language, culture, and respectful conduct in the area. contents of the consent form, were explained to the re- The interviews were conducted in Amharic with con- search participants prior to all interviews. Written or tinuous translation from English to Amharic and vice oral consent to participate was obtained, depending on versa between the researcher and the informants. literacy status, and the utmost care was taken to secure Semi-structured interview guides with open-ended ques- privacy and confidentiality during the research process. tions were used (see Additional file 1). The interviews, Two patients at the hospital declined to participate, and which were held either inside or outside the women’s two women were lost to follow-up with the research homes, lasted from 1 to 2 h with the aim of allowing the team due to distance or lack of accessible roads to their informants to speak freely and with few interruptions. homes. All the interviews at the hospital were held in a private room on the ward while the interviews with the Results health-care providers and stakeholders in the communi- The main category of informants consisted of 12 women ties were held in a private room at their work facilities. (Table 2), all of whom had undergone surgical treatment for prolapse. Upon admission, 11 of the 12 women were Analysis diagnosed with stage III prolapse of the uterus, bladder The analysis took place throughout the data-collection and/or rectum according to the simplified POPQ staging process and during a rigorous analytical phase that system [10]. The majority had undergone a vaginal hys- followed the completion of the fieldwork. All interviews terectomy and sacrospinous fixation and/or an anterior were audio-recorded, transcribed verbatim to Amharic or posterior colporrhaphy under spinal anaesthesia. and translated into English. The completed material was None received oestrogen therapy prior to or after the carefully reviewed to identify core themes [32]. The sub- surgery. All women, except for one, returned to the hos- sequent post-fieldwork analysis concretized the initially pital for their follow-up appointments scheduled by the identified themes into categories of meaningful units hospital staff to take place 1–3 months after surgery. followed by coding of the material line-by-line [33]. Each Two women got confirmed vault prolapse during their Gjerde et al. BMC Women's Health (2018) 18:74 Page 4 of 8 Table 2 Characteristics of main participants informants explained that they had received substantial support when they returned from the hospital: Mean age 43.3 years [range 32–60] Marital status Until my [hospital follow-up] appointment was Married 8 approaching, I lay on my bed while my neighbours Divorced 3 fed my family and me and took turns doing my chores. Widowed 1 (52-year-old married woman). Mean age at first marriage 13 years [range 7–19] After a month or more of rest, the external support Education system slowly decreased as relatives and neighbours No school / illiterate 10 returned to their own homes. The condition nonetheless Literate 2 required continuous support to avoid having the woman Occupation return to heavy chores. The assistance was commonly Housework 6 provided by immediate family members: Housework and farming activities 5 I don’t work at home much anymore. My daughter is Daily laborer 1 cleaning the house, inside and outside. I used to help Mean number of children 3.6 children [range 0–8] with the farming, but now I’ve stopped doing that too. Mean age at first delivery 18.5 [range 13–24] My husband manages by himself. (40-year-old married Place of delivery woman). All deliveries at home 10 One or two deliveries at health facility 2 Many of the women expressed fear of returning to their previous heavy chores: hospital appointment. During our follow-up interviews 5–9 months after the surgery, half of the women ex- I feel I am cured now. But I don’t doubt that if I start plained that they had a highly improved health condition doing heavy work again I would feel sick. Now I fear to with few or no complaints, whereas the other half still do heavy work. (32-year-old married woman). had some challenges. Some again felt that something was emerging from their vagina and others could not Divorced and widowed women largely lived by them- control their urination. selves and depended on their children or on extended family members to decrease their work burdens after the Recovery initial healing period. These women who were socially Although only half the women had fully recovered 5–9 vulnerable found it more challenging to cope, not the months after the surgery, nearly all expressed appreci- least in cases of delayed healing: ation for their present situation: I used to work as a labourer preparing food for people. Iusedtohavetowalk byholding the prolapse; Icouldn’t I don’t feel good enough yet to start work. I can’teven walk like I wanted to. I had a lot of problems. But I’m walk long distances or lift anything, and I don’t have thankful after the surgery; it was a big change. I had anyone to help me. I ask neighbourhood children to suffered for six years. (32-year-old married woman) fetch water for me. I no longer have any money saved, and I feel that darkness has surrounded me. I had to Following surgery, the women were told to avoid send my two young children to work in other people’s heavy strains and lifting for their lifetime and to avoid houses. If I sit like this, how can I feed myself? I’m still sexual intercourse for up to 3 months. The women in waiting to recover, and then I’ll start working again. this region of Ethiopia normally have full responsibility (39-year-old divorced woman). for household chores, including the procuring of water and firewood and occasionally taking part in farming ac- Although many of the women interviewed referred to tivities. Collecting water for many of the women in- stories of other women who had been unable to abstain volved daily multi-hour walks carrying 20–30 l on their from sex upon their return home to their husbands, the backs. The avoidance of chores after the surgery, hence, women interviewed in the present study seemed to have depended on receiving substantial support from their husbands who accepted their conditions: neighbours, family members, and more distant relatives. The customary support systems related to illness and We haven’t had sex for five months now, and he hasn’t births were mobilized in these cases; indeed, all the forced me. He hasn’t asked me during this time—he Gjerde et al. BMC Women's Health (2018) 18:74 Page 5 of 8 can see the pain I’ve been in. (35-year-old married treatment, I’ve escaped the pain. I feel relaxed now. woman). (40-year-old married woman). The HEW’s overall impression was that the women The HEW’s also reported noticing a change in open- made strong attempts to follow the advice they were ness among women in the communities: given by the hospital after the surgery, but they also mentioned cases where the woman had no choice but to Women have become more open to talk to us about work due to lack of available support. their problems. We usually speak about prolapse when we get a chance in the Church or at community Disclosure meetings. Then women come directly to us and say: “I Most of the women had disclosed their conditions to very have this problem. I kept it to myself.” (HEW 2). few confidantes prior to their surgery. Typically, they shared with their mother, sister or close friend in addition to the HEW. All the married women disclosed their conditions to Reintegration their husbands, but the majority did so at a late date and Many of the women told of the extreme social re- only after the condition had worsened. Before disclosing, strictions caused by the prolapses, and explained how some had considered divorce to escape the shame they ex- they had been unable to fulfil the social roles ex- perienced. Although many of the husbands were said to be pected of them. When living with the prolapse condi- supportive,theycommonlyhad alimited abilitytoassist tion, the crucial inviting and hosting of people for their wives. The divorced women had chosen to leave their holidays had become increasingly challenging for husbands because of the prolapse, either due to being ig- many since food preparation often involved heavy lift- nored and disrespected or because they were unable to fulfil ing, including the procurement of extra water for the their expected roles as wives due to their condition. occasion. Walking longer distances to attend social The period when the informants were brought to- gatherings, such as funerals or events with far-off rel- gether with their fellow prolapse sufferers in connection atives, had also become problematic. One woman, with the hospitalization process proved to be vital for who had found it difficult to sit among people be- disclosure. During the time they spent together, they cause of the pain and itching of her ulcerated pro- established close ties: lapse, and from her frequent need to urinate, explained the transformation she had experienced: Once we travelled together to the hospital, we didn’t talk about anything but our conditions for five days. It used to be embarrassing to sit with people outside or We didn’t know each other, but we still talked a lot. inside others’ homes. It was shameful for me to eat, We laughed and discussed like mothers and daughters drink and [suddenly] go outside to urinate. I stopped do. We all shared our experiences with the prolapse. attending social gatherings because of that. That (35-year-old married woman). situation cannot be compared to the present. I urinate less frequently, and I can sit how I want to sit and talk Once the women had returned from the hospital, with relatives without a problem. (35-year-old married many faced questions about the treatment they had re- woman). ceived, and the majority decided to be open about what they had experienced: Not all the women felt ready to fully engage in every social gathering at the time of the study. After the treatment, people asked me where I’d been and what had happened to me. I told them all about I haven't started visiting relatives yet because the my condition and the treatment I’d received. (39-year- doctor told me not to go anywhere far for six months. old divorced woman). I might start having long journeys and visit relatives soon, God willing. (45-year-old married woman). The response from their neighbours and relatives was mainly positive; many expressed sympathy and won- Most, however, lived relatively close to other women dered why they had kept the prolapse a secret for so they had been hospitalized with, and many of them long. All the women expressed great relief related to stayed in touch: their newly gained experience of openness: One of these women is my neighbour. Now we drink Why should I feel shame now? I’ve seen the light. I hid coffee and fetch water together. Both of us trust each the condition for 20 years. But now that I’ve had the other. (40-year-old married woman) We all have a Gjerde et al. BMC Women's Health (2018) 18:74 Page 6 of 8 wish to meet after the surgery, and we have planned to better. I advise them to seek medical care because the meet at every holiday. (39-year-old divorced woman). government supports us now. Many women hide their problems, and that’s bad for their well-being. I suffered a lot because I concealed my problem. (40-year-old Engagement divorced woman). The increased openness among the women after their re- turn home from the hospital had implications in their local communities. One woman explained that prolapse was Discussion now a common and unproblematic topic to discuss with Main findings friends. Indeed, this was reflected by the health-care The opportunity for treatment proved to have substan- workers: tial implications for the rural Amhara women who were followed up in the present study. The majority received If the new initiative goes on, women won’t be hiding substantial practical support during the recovery period this condition anymore. It is a way to avoid women’s and experienced understanding after disclosing their discrimination. (Health-care provider, Health Clinic). condition. For many of the women, the disclosure and awareness related to prolapse became an important ac- After returning from the hospital, several of the study tivity to ensure that other women who were suffering participants were approached in secrecy by women in alone would learn about prolapse and the available free the community who asked for details about the condi- treatment. The increased disclosure led to a surprising tion and about the treatment they had received: degree of openness and awareness about the condition in the communities in which the study took place. Not A lot of women out there haven’t yet received all the women, however, experienced improvements in treatment [for prolapse]; they hide their condition and their lives, especially the ones who lived alone and had a pain. One woman from my village came to my problematic healing process. For these women, life con- home—she had been too ashamed to tell anybody tinued to be a struggle. about her condition. I asked her why she felt ashamed. We don’t have to hide this condition these days. After Interpretation of results our conversation, she talked to the health-extension The key issues raised by the women in the study were worker and was sent to the hospital for surgery. She that the surgery alleviated them of the most pressing later became a very dear friend. (32-year-old married concerns of discrimination, rejection, and divorce [16]. woman). The sharing of experiences and the relationships that de- veloped among the women who were recruited for treat- As a part of the new prolapse initiative, the selected ment proved to be important for the women’s increasing women who had been treated were now trained as sense of knowledge about the condition and sense of maternal-health advocates. In addition to spreading in- empowerment as well as the subsequent openness and formation about maternal-health matters in their com- disclosure of the condition. The current study thus indi- munities, the advocates were trained to seek out and cates the immense transformation that can be facilitated register women who suffered from prolapse: when groups of women are recruited jointly for surgery and go through a joint learning process. These factors When mothers return home after being treated, we speak to the importance of the surgery beyond the phys- train them, and the health bureau also gives them a ical repair itself; the regaining of a social life lies at the checklist. They mainly work alongside the community core of the stories these women tell. The emphasis of health workers (HEWs), and we encourage them to the social dimensions has similarities with experiences participate in different activities of the project. We from other health initiatives, for example within the field also have a radio channel which facilitates the of HIV/AIDS, where beyond the antiretroviral therapy, mobilization process. (NGO representative). the training, employment, and empowerment of local mothers who live with HIV have led to reduced The women who had yet to receive training were also HIV-related stigma and discrimination [34].. eager to spread information about prolapse and to en- In a study of women who were treated for obstetric courage others to get treated: fistula in Kenya [28], finding a sense of belonging after their treatment and reintegration into the community When I go to fetch water, I inform women [about following surgery depended on their available support prolapse]. I also tell their husbands to take their wives mechanisms. Although many of the prolapse sufferers in to the hospital if they are sick. I explain how I got the present study experienced extensive support after Gjerde et al. BMC Women's Health (2018) 18:74 Page 7 of 8 surgery, the available help still proved insufficient for study findings suggest may benefit entire communities. some due to limited social networks. Among tubercu- Still, supportive systems—not the least economic—may losis patients being treated in Ethiopia [35], the support be required to counteract problematic consequences of from family and community members similarly proved the surgery, particularly for vulnerable women. crucial although many patients found that the level of Further research should be conducted on the preva- support dropped during the course of treatment. Thus, lence and risk factors for prolapse as well as on women’s it proved difficult for them to cope, especially the ones health-seeking behaviour related to prolapse in with limited human or material resources. resource-constrained settings. Such knowledge is re- In line with scholars within critical medical anthropology quired to inform the development of sustainable inter- [36–38], we argue that poverty and marginalization in- ventions for prolapse and other prevalent, treatable, and crease the likelihood of illness and suffering, such as when chronic maternal-health challenges in Ethiopia and simi- life conditions seen as insignificant hamper the potential lar resource-constrained settings. for receiving adequate care for serious conditions of pro- lapse. Taking into account the high fertility rates, early-age Additional file pregnancies, and strenuous physical work demanded of Additional file 1: The interview guide used for follow-up interviews women in the study area, our study findings strongly sup- with women treated for pelvic organ prolapse. (DOCX 15 kb) port the argument that prolapse may affect daily life more severely in resource-constrained settings than in more af- Abbreviations fluent settings [6, 7]. Dynamics of poverty and HEW: Health-extension worker; NGO: Non-Governmental Organisation; marginalization in diverse ways reduces the opportunity to POPQ: Pelvic organ prolapse quantification (staging system); UNFPA: United Nations Population Fund receive treatment. The dynamics linked to early marriage and limited schooling among rural Ethiopian women also Acknowledgements limits theexchangeofknowledge,thuslaying thegrounds We would like to express our heartfelt thanks to all the study informants, especially to the women with prolapse who, despite the sensitivity of the for stigma and discrimination [16, 39]. Themajorityofthe topic, decided to share their stories with us. We are sincerely appreciative of women in this study would not have reached the hospital the staff at the Fistula Treatment and Training Centre at the University of without being exposed to the mobilization initiative that Gondar Hospital for their hospitality and support throughout the fieldwork. We also owe our warmest thanks and gratitude to the research assistants in took place in their communities, providing them with free the field. transport and treatment. Such initiatives are rare in Ethiopia, and they require a long-term sustainable commit- Funding ment and funding to succeed. The study was funded by the Western Norway Regional Health Authority. The funding body had no role in the study design, collection of data, analysis, interpretation or writing up of the manuscript. Strengths and limitations The topic of prolapse is perceived as extremely sensitive Availability of data and materials The data used and/or analysed during the current study may be requested in the current study area, which may have affected the from the corresponding author. However, only excerpts of particular interest women’s readiness to speak openly. Also, the first au- may be shared as the complete data may identify informants. thor’s sociocultural and language limitations, despite sev- Authors’ contributions eral lengthy research stays in Ethiopia and increasing JLG, GR, MA and AB developed the research protocol. JLG carried out the data language competence, are likely to have affected the collection, with support from all co-authors. Data analysis and interpretation of the study’s results. In this context, we would also like to data was conducted by JLG, with substantial contributions from all co-authors. Manuscript drafting was mainly carried out by JLG and AB, with substantial mention that being an outsider can at times be advanta- contributions from GR, MA and TB. All authors read approved the final version geous as one is perceived to be located beyond the lo- of the manuscript. cally embedded normative discourse. Moreover, these Ethics approval and consent to participate challenges were partially ameliorated through the Written or oral consent to participate was obtained by all participants in the follow-up visits to the women at home and the newly study. When a participant was not able to write, oral consent was obtained gained openness about the condition in the study area. as approved by the ethical committees both in Norway and Ethiopia. Reference numbers for ethical approvals: The women also expressed appreciation for the Regional Committees for Medical and Health Research Ethics in Norway, 25 follow-up interviews in their homes after the surgery. August 2014: 2014/589. University of Gondar Institutional Review Board, 2 February 2015: R/C/S/V/P/05/315/2015. Conclusions Competing interests The present study indicates that the provision of free The authors declare that they have no competing interests. prolapse treatment in rural Ethiopia has substantial po- tential in improving the health and social life among af- Publisher’sNote fected women. Recruiting women in groups facilitate Springer Nature remains neutral with regard to jurisdictional claims in awareness and empowerment processes that the present published maps and institutional affiliations. Gjerde et al. BMC Women's Health (2018) 18:74 Page 8 of 8 Author details 19. Wusu-Ansah OK, Opare-Addo HS. Pelvic organ prolapse in rural Ghana. Int J Research group for Global Health Anthropology, Centre for International Gynaecol Obstet. 2008;103:121–4. Health, Department of Global Public Health and Primary Care, University of 20. Zeleke BM, Ayele TA, Woldetsadik MA, Bisetegn TA, Adane AA. Depression Bergen, Bergen, Norway. 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BMC Women's HealthSpringer Journals

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