The degree of bother and healthcare seeking behaviour in women with symptoms of pelvic organ prolapse from a developing gulf country

The degree of bother and healthcare seeking behaviour in women with symptoms of pelvic organ... Background: The healthcare-seeking behaviour of women with pelvic organ prolapse (POP) is affected by several factors including the cultural background. There is limited number of studies which addressed the healthcare- seeking behaviour in women with POP. The aim of this study was to determine the degree of bother, social impact and healthcare seeking behaviour of symptoms of POP in one of the Gulf countries and compare the results to published data from other areas. Methods: All women who attended the three family development centres in our city between January 2010 and January 2011 and who had symptoms suggestive of POP were included in the study. The data was collected by well-trained interviewers. Results: One hundred twenty-seven women reported symptoms of POP (mean age: 38.2 years; range: 18–71). Out of these, 111 (87.4%) had at least one activity (physical, social or prayers) or sexual relationship affected by POP symptoms. In 49 women (38%), the effect on at least one of these activities or relationships has been described as moderate and in 18 women (14%), the effect was severe. Sixty-nine women (54%) did not seek medical advice due to: embarrassment to see medical doctors (51%), the belief that POP is normal among women (51%), hope for spontaneous resolution (48%), embarrassment to see male doctors (33%) and unawareness of the existence of medical treatment (30%). On univariate analysis, the need to insert the finger in the vagina to empty the bladder or bowel and the interference of symptoms with physical activities, had significantly determined healthcare seeking attitude (P < 0.05 for all). However, on multivariate analysis interference with physical activities was the only significant determinant (P =0.04). Conclusions: Although POP had affected the quality of life in the majority of the affected women, unlike some other societies, more than half failed to seek healthcare advice mainly due to shyness and embarrassment and lack of proper knowledge about the condition. Interference of symptoms with physical activities was the main significant determinants of healthcare-seeking behaviour. Additional teaching campaigns designed according to cultural backgrounds in each society are required to address these sensitive issues. Keywords: Pelvic organ prolapse, Bother, Healthcare seeking behaviour, Emirati women * Correspondence: fayezhammad@hotmail.com Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, PO Box 17666, Al Ain, United Arab Emirates 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. Hammad et al. BMC Women's Health (2018) 18:77 Page 2 of 7 Background from the Middle East in general and from the Gulf Pelvic organ prolapse (POP) is a relatively common con- countries in particular. Therefore, the aim of this re- dition especially in older women and it might result in search was to study the degree of bother and social im- very distressing symptoms. Depending on the research pact of symptoms of POP and the determinants of methodology and population investigated, wide variation healthcare seeking behaviour in one on the Gulf coun- in prevalence has been reported. For instance, on tries and compare them to published data from other physical examination, some degree of POP is found in areas. In this study, we investigated women who visited 32–98% of women. However, among those who have the family development centres in our city. These POP, only 4–8.3% has POP-related symptoms [1–3]. governmental centres are used essentially for social and Some studies have suggested that the prevalence of cultural activities of women from all social and POP and pelvic floor dysfunction, in general, might be economic backgrounds. affected by race and ethnicity [1, 4, 5]. Indeed, in a previ- ous report we have shown that the prevalence of POP Methods symptoms among women in the Gulf might be slightly The methods used in this study were as previously de- higher than other societies [6]. These ethnic and racial scribed [6]. This study presented the results of a planned variations might influence not only the prevalence and analysis of data which was collected at the same time of mode of presentation but also the degree of bother and collecting another data which was previously published care seeking behaviour of women with different cultural and aimed to determine the prevalence and risk factors of backgrounds. symptoms of POP in our population [6]. In summary, all There is limited number of studies which addressed Emirati women who attended all the three family develop- the healthcare-seeking behaviour in women with symp- ment centres in Al Ain, UAE from January 2010 to Janu- toms of POP [7–13]. Available research in this field fo- ary 2011 were included. These centres were the main and cused mainly on urinary incontinence [14–17]and on only governmental facilities in the city and were visited by pelvic floor dysfunction in general [1, 18, 19]. However, large number of Emirati women with different ages and there is evidence to suggest that POP might be associ- backgrounds. Pregnant women and nulliparous women ated with higher likelihood of seeking medical advice by younger than 30 years were excluded. Written consent the affected women compared to other pelvic disorders was obtained from all eligible participants. The Research [19, 20]. Healthcare seeking behaviour in POP is deter- Ethical Committee at the College of Medicine and Health mined by several factors and reviewing the available Sciences, UAE University approved the study. Written studies which addressed the determinants of this behav- consent was obtained from all eligible subjects. iour, had shown that obstacles to healthcare seeking can Thedatawas collectedusing aquestionnairewhich was be divided into five main categories: administered by female well-trained interviewers who spoke the same language of the investigated women (Arabic 1. Shyness or embarrassment to speak to healthcare Language). The questionnaire is a custom-designed one. provider/s. The first part dealt with the basic socio-demographic data. 2. Financial factors which affect accessibility to The second part explored the obstetrics, medical and surgi- healthcare system. cal history followed by prolapse-related questions. In this 3. Inadequate knowledge about the diseases such the regard, the woman was asked if she felt a dragging lump belief that the disease is part of normal aging, the coming down the vagina, lump coming out of vagina or belief that it will improve on its own or have no lump felt or seen outside vagina; the presence of any of successful treatment. these symptoms were considered to indicate the presence 4. Family-related issues such as the lack of support of POPinthisstudy.Thiswas followedbyother questions and cooperation of close family members or to determine the severity of the condition, other vaginal prioritising family needs over the woman’s own symptoms and if the women had to insert her finger into needs. the vagina to reduce the lump in order to be able to empty 5. Miscellaneous factors. the bladder or bowel. Finally, the woman was asked if she had seeked medical advice and if not about the reasons for Most of the studies which addressed the determinants not doing so. The whole questionnaire was not formally of this behaviour in women with POP mainly evaluated validated but included questions which were used in other women from the West [7, 9–12] with some studies ad- studies such as the WHO [22–25]. In addition, and as pre- dressing this issue in other ethnicities such as Asian viously described [6], thequestionnairewas tested and women [8, 13]. In the Middle East, although such data is re-tested on a pilot female sample to suite our population’s available in some conditions such as urinary incontin- attitudes to discuss the sensitive issues related to POP ence [21], POP-related data is not available for women symptoms. Furthermore, the use of healthcare providers to Hammad et al. BMC Women's Health (2018) 18:77 Page 3 of 7 question the participants and fill the questionnaire elimi- Table 1 Reasons for not seeking medical advice. % represents the percentage of women among the 69 women who did not nated the potential misunderstanding of some of the ques- seek medical advice. Some women might have reported more tions by the participants. than one reason Data were analysed using SPSS version 19.0 (IBM, Reason for not seeking a medical advice No (%) Armonk, NY, USA). Inter-group comparisons were per- Embarrassment to see a medical 35 (51%) formed using the Student t test for continuous variables doctor of any gender and the chi-square or Fisher exact tests for categorical Belief that POP is normal among 35 (51%) variables. Multivariate binary logistic regression analysis women especially older women was performed to determine independent factors which Hope for spontaneous 33 (48%) were associated with healthcare seeking behaviour. A resolution of the POP P value of < 0.05 was considered statistically significant. Embarrassment to see male doctor 23 (33%) Unawareness of the existence 21 (30%) of medical treatment Results As previously described [6], out of 482 women who were approached and met the inclusion criteria, 429 (89.0%) especially older women or the unawareness of the exist- consented to fully participate in the study. Out of these, ence of medical treatment. 127 women (29.6%) reported symptoms of POP with Table 2 describes the socio-demographic determinants mean age of 38.2 years (range: 18–71). of healthcare seeking behaviour. Using univariate ana- Out of the 127 women, symptoms of POP affected lysis, women who seeked medical advice were signifi- various activities and relationships as follows: physical cantly younger than those who did not (40.1 ± 1.4 vs. activities (n = 91, 72%), social gathering and activities 36.6 ± 1.2 years, P = 0.03). However, occupation, monthly (n = 69, 54%), ability to pray (which involves several income and level of education did not determine the body movements) (n = 84, 66%) and sexual relationship healthcare-seeking behaviour (P > 0.05 for all). (n = 91, 72%). The symptoms of POP had affected at Table 3 demonstrates the determinants of healthcare least one activity (physical, social or prayers) or sexual seeking behaviour according to the symptoms or ma- relationship in 111 (87%) women. As demonstrated in noeuvres which were performed to relieve the symp- Fig. 1, these effects ranged from mild to severe. In 44 toms. The degree of vaginal soreness did not affect the women (35%), the effect on at least one of these activ- seeking behaviour. However, the need to insert the finger ities or relationship has been described as mild, in 49 women (38%), it was moderate and in 18 women (14%), Table 2 Socio-demographic determinants of healthcare-seeking the effect was severe. behaviour for women with symptoms of POP. All variables are As demonstrated in Table 1, 69 out of the 127 women presented by crude number apart from Age which was (54%) did not seek healthcare advice due to different presented by mean ± standard error of the mean. P value reasons such as the embarrassment to see a medical indicates statistical significance according to univariate analysis practitioner in general or a male practitioner in particu- Non-seeking group Seeking group P Value lar and the lack of adequate knowledge about the disease Number 69 58 such as the belief that it is normal among women Age (years) 36.6 ± 1.2 40.1 ± 1.4 0.03 Monthly Income (Dirham) 0.67 < 5000 3 2 5000–10,000 31 22 > 10,000 35 34 Education 0.82 University 8 5 Secondary school 18 15 Primary school 26 26 Illiterate 17 12 Occupation 0.96 Housewife 49 42 Office job 11 8 Fig. 1 The effect of symptoms of POP on the various activities and relationships Physical 9 8 Hammad et al. BMC Women's Health (2018) 18:77 Page 4 of 7 Table 3 Determinants of healthcare-seeking behaviour for women with symptoms of POP according to the reported symptoms. P value indicates statistical significance according to univariate analysis Non-seeking group Seeking group P Value Number 69 58 Awareness of vaginal soreness 0.19 Never 22 12 Very occasional 33 31 Sometimes 6 11 Most of times 5 1 All the time 3 3 Insertion of finger into vagina to start or complete bladder emptying 0.04 Never 52 32 Very occasional 10 14 Sometimes 3 9 Most of times 1 2 All the time 3 1 Insertion of finger into vagina to start or complete bowel emptying 0.01 Never 51 28 Very occasional 11 20 Sometimes 3 8 Most of times 2 1 All the time 2 1 into the vagina to empty the bladder or bowel was sig- nificantly associated with seeking medical advice on uni- Table 4 Determinants of healthcare-seeking behaviour for variate analysis (P < 0.05 for both). women with symptoms of POP according to the interference with various activities and relationships. P value indicates The effect of POP symptoms on various activities and statistical significance according to univariate analysis relationships and their relation to the seeking behaviour Non-seeking group Seeking group P Value was demonstrated on Table 4. Only interference with Number 69 58 physical activities was significantly associated with seek- ing medical advice on univariate analysis (P = 0.005). Interference with Prayers 0.14 On multivariate analysis of all the factors which were No interference 25 18 significantly associated with seeking medical advice on Mild 27 27 univariate analysis only interference of POP symptoms Moderate 16 8 with physical activity independently predicted seeking Severe 1 5 medical advice in our study [β: 0.781, SE: 0.372, Exp(β): Interference with sexual relationship 0.17 2.156, P = 0.04]. The remaining factors did not inde- No interference 20 16 pendently predict seeking behavior (age: β: 0.081, SE: Mild 23 15 0.02, Exp(β): 1.018, P = 0.4; insertion of finger to empty Moderate 16 23 bladder: β: -0.128, SE: 0.602, Exp(β): 0.880, P = 0.8; inser- Severe 10 4 tion of finger to empty bowel: β: 0.835, SE: 0.597, Exp(β): Interference with social activities 0.14 2.302, P = 0.2). No interference 33 25 Discussion Mild 20 26 In this study, we have shown that the vast majority of Moderate 14 5 women who reported POP symptoms were bothered by Severe 2 2 the condition and approximately half of those affected Interference with Physical activities 0.005 were moderately or severely bothered by the symptoms. No interference 27 9 We have also demonstrated that more than half of the Mild 20 31 affected women did not seek medical advice for various Moderate 20 14 reasons. To the best of our knowledge, this is the first Severe 2 4 study which assessed the degree of bother, social impact Hammad et al. BMC Women's Health (2018) 18:77 Page 5 of 7 and healthcare seeking behaviour in women with POP which influence this behaviour vary widely among differ- symptoms from this geographical region. ent societies. The degree of bother and social impact of symptoms The main factor which pushed women to seek medical of POP in the current study is similar to those reported advice in this study was the interference of the POP from the West [10, 26]. In a population-based study on symptoms with daily physical activities. Interfering with American women, Rortveit and colleagues reported that physical activities would seriously compromise women’s almost 50% of women with POP symptoms had moder- ability to meet their personal and family commitments ate or great distress and in 35%, the POP symptoms af- and might also prevent them from undertaking certain fected at least one physical, social or sexual activity [26]. professions. Similar finding were reported in a similar study from The relationship of age to the healthcare seeking be- Nepal [13]. Collectively, these studies and our study in- haviour has been investigated previously with conflicting dicate that regardless of the cultural background, women results. Some studies which investigated healthcare seek- in various nations appear to be bothered and socially ing behaviour in pelvic floor disorders in general have well-affected by symptoms of POP. The current study, shown that older women had lower threshold to seek however, indicates that women in our society are less medical advice compared to younger women [19, 20]. likely to seek medical advice compared to women from On the other hand, in another study which addressed the West. For instance, in a population-based study, the seeking behaviour in POP, younger women were Morrill et al. showed that 73% of American women had found to be more likely to seek medical advice [7]. Using seeked medical advice compared to only 46% in our multivariate analysis, our results clearly demonstrated study [20]. that age was not a significant determinant of healthcare The obstacles to healthcare seeking in our study are seeking behaviour. These discrepancies could probably different from those reported from other communities. be due to cultural differences and attitudes towards dis- For instance, in our study, financial factors including in- ease tolerance and seeking help from others in general. surance concerns were not important in determining To our surprise, the level of education has not been whether an affected woman would seek medical advice shown in our study or in other similar studies [7, 19, 20] because all individuals in our society have free access to to determine the healthcare seeking behaviour in women healthcare system at various levels from primary health- with POP symptoms. Cultural background and attitudes care to tertiary centres. This is in contrast to some other appear to be stronger factors which determine health- studies in which financial issues were of major concern care seeking behaviour across different societies regard- and actually prevented women from seeking advice des- less of the educational level. pite the need to do so [8, 19]. The current study has some limitations. So, although In our society, shyness or embarrassment to discuss it is not strictly a whole population-based study, it in- POP symptoms with healthcare providers of any gender cluded all women from the three family development and male providers in particular appears to be one of centres who met the study criteria. The visitors of these the strongest determinants of seeking behaviour. This is governmental centres are women of different ages and probably due to local culture-related factors and has from different social and cultural backgrounds and these only been reported by limited number of studies [8]. centres are essentially used for variable educational, so- The other important determinant of the seeking be- cial and cultural activities. They are not part of health- haviour in our society is the lack of adequate knowledge care system and therefore, not used for seeking medical about the condition such as the belief that the disease is care. Hence, the study population in this research is ex- part of normal aging and the unawareness of the exist- pected to be better representing the general population ence of medical treatment. Such a belief appears also to compared to other studies which used patients from be common across other societies [8, 13, 18, 19] and ob- hospitals or primary healthcare centres [9–12]. The viously, such thinking would discourage women from other potential limitation is the inclusion of women seeking medical advice. from only one city. This renders the data difficult to In contrary to some other societies, family-related is- generalise to the whole country. However, since approxi- sues and the fear of lack of support of family members mately one fifth of the whole Emirati population lives in did not appear to be an important issue in our study this city [27, 28], the results obtained might be a reason- [8, 13, 18]. Probably this is due to the nature of family able reflection of the whole country. structure in our area. Most families are extended large One of the other limitations of the study is the lack of families which provide extra-support to its members. As vaginal examination which would have been very diffi- a whole, the findings of the current study and previous cult in this conservative society. However, it is unlikely studies in this field indicate that not only the percentage this would have affected the results of this study as good of women who seek medical advice but also the factors correlation has been found to exist between the Hammad et al. BMC Women's Health (2018) 18:77 Page 6 of 7 symptoms with the presence of anatomical POP on Authors’ contributions FH contributed to project development, data management and analysis and physical examination [29]. In the present study, symp- manuscript writing and editing. HE contributed to project development, data toms of POP were identified by healthcare providers management and analysis and manuscript editing. NO assisted in project who administered the questionnaire. This might have development, data management and collection and manuscript editing. All authors read and approved the final manuscript. caused some bias compared to self-administered ques- tionnaires. Nevertheless, the use of healthcare providers Ethics approval and consent to participate had enabled us to investigate illiterate women and de- Ethical approval was obtained from The Research Ethical Committee at the College of Medicine and Health Sciences, UAE University (#09/83). Written creased the potential misinterpretation of these sensitive consent was obtained from all eligible participants. questions by some of the participants. Finally, the current study and other similar ones Competing interests The authors declare that they have no competing interests. should encourage further campaigns to educate women about pelvic floor disorders including POP. Such cam- Publisher’sNote paigns and educational sessions have been shown to im- Springer Nature remains neutral with regard to jurisdictional claims in prove the general knowledge of women about this published maps and institutional affiliations. condition [30] and should tackle the specific obstacles to Author details healthcare seeking in that particular society. In our soci- Department of Surgery, College of Medicine and Health Sciences, United ety, these campaigns should be coordinated by a com- Arab Emirates University, PO Box 17666, Al Ain, United Arab Emirates. bination of well-trained female healthcare providers and Department of Obstetrics and Gynaecology, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates. social workers who are able to tackle not only health is- sues but other sensitive issues such as shyness and Received: 7 June 2016 Accepted: 17 May 2018 cultural-related obstacles. References 1. Nygaard I, et al. Prevalence of symptomatic pelvic floor disorders in US Conclusions women. JAMA. 2008;300(11):1311–6. Although symptoms of POP had affected the quality of life 2. Tegerstedt G, et al. Prevalence of symptomatic pelvic organ prolapse in a in the majority of the affected women in our society, unlike Swedish population. Int Urogynecol J Pelvic Floor Dysfunct. 2005;16(6):497–503. 3. Bradley CS, Nygaard IE. Vaginal wall descensus and pelvic floor symptoms in some other societies, more than half failed to seek health- older women. Obstet Gynecol. 2005;106(4):759–66. care advice. This was mainly due to shyness, embarrass- 4. Hendrix SL, et al. Pelvic organ prolapse in the Women’s Health Initiative: ment to speak to healthcare providers and lack of proper gravity and gravidity. Am J Obstet Gynecol. 2002;186(6):1160–6. 5. Whitcomb EL, et al. Racial differences in pelvic organ prolapse. Obstet knowledge about the condition. Interference of symptoms Gynecol. 2009;114(6):1271–7. with physical activities was the main significant determi- 6. Elbiss HM, Osman N, Hammad FT. Prevalence, risk factors and severity of nants of healthcare-seeking behaviour. Additional teaching symptoms of pelvic organ prolapse among Emirati women. BMC Urol. 2015;15:66. 7. Brazell HD, O'Sullivan DM, Tulikangas PK. Socioeconomic status and race as campaigns designed according to cultural backgrounds in predictors of treatment-seeking behavior for pelvic organ prolapse. Am J each society are required to address these sensitive issues. Obstet Gynecol. 2013;209(5):476.e1–5. 8. Kumari S, Walia I, Singh A. Self-reported uterine prolapse in a resettlement colony of North India. J Midwifery Womens Health. 2000;45(4):343–50. Abbreviations 9. Lewicky-Gaupp C, et al. Self-perceived natural history of pelvic organ POP: Pelvic organ prolapse; UAE: United Arab Emirates prolapse described by women presenting for treatment. Int Urogynecol J Pelvic Floor Dysfunct. 2009;20(8):927–31. Acknowledgments 10. Mouritsen L, Larsen JP. Symptoms, bother and POPQ in women referred The authors would like to acknowledge Prof. N. Nagelkerke for statistical with pelvic organ prolapse. Int Urogynecol J Pelvic Floor Dysfunct. 2003; input and Dr. F. Radi, R. Z. Al Mazroei, F. Al Ahbabi, K. Al Ameri, N. Al Bloushi 14(2):122–7. and E. Nur for technical assistance in data collection. 11. Pakbaz M, et al. A hidden disorder until the pieces fall into place’–a qualitative study of vaginal prolapse. BMC Womens Health. 2010;10:18. 12. Pakbaz M, et al. Vaginal prolapse–perceptions and healthcare-seeking Funding behavior among women prior to gynecological surgery. Acta Obstet The present study was funded by a grant from the College of Medicine and Gynecol Scand. 2011;90(10):1115–20. Health Sciences, United Arab Emirates University. The College of Medicine 13. Shrestha B, et al. Women's experiences and health care-seeking practices in and Health Sciences did not interfere significantly with the design of the relation to uterine prolapse in a hill district of Nepal. BMC Womens Health. study and collection, analysis, and interpretation of data or in writing the 2014;14:20. manuscript. However, the grant was initially reviewed and approved by 14. Elbiss HM, Osman N, Hammad FT. Social impact and healthcare-seeking College of Medicine and Health Sciences Grants Research Committee. behavior among women with urinary incontinence in the United Arab Annual and final reports are required to be submitted to the College of Emirates. Int J Gynaecol Obstet. 2013;122(2):136–9. Medicine and Health Sciences when the manuscript is published. 15. Kinchen KS, et al. Factors associated with women's decisions to seek treatment for urinary incontinence. J Women's Health (Larchmt). 2003;12(7): Availability of data and materials 687–98. The original data is available for review upon request. Contact person: Prof. 16. Koch LH. Help-seeking behaviors of women with urinary incontinence: an Fayez T. Hammad, Department of Surgery, College of Medicine & Health integrative literature review. J Midwifery Womens Health. 2006;51(6):e39–44. Sciences, PO Box 17666, Al Ain, United Arab Emirates, Phone: 00971 50 17. Saleh N, et al. Prevalence, awareness and determinants of health care- 4880021/ 00971 3 7137 590, Fax: 00971 3 7672067, e-mail: seeking behaviour for urinary incontinence in Qatari women: a neglected fayezhammad@hotmail.com problem? Maturitas. 2005;50(1):58–65. Hammad et al. BMC Women's Health (2018) 18:77 Page 7 of 7 18. Hatchett L, et al. Knowledge and perceptions of pelvic floor disorders among african american and Latina women. Female Pelvic Med Reconstr Surg. 2011;17(4):190–4. 19. Washington BB, et al. Variables impacting care-seeking for pelvic floor disorders among African American women. Female Pelvic Med Reconstr Surg. 2013;19(2):98–102. 20. Morrill M, et al. Seeking healthcare for pelvic floor disorders: a population- based study. Am J Obstet Gynecol. 2007;197(1):86. e1–6 21. Hamid TA, et al. “Stain in life”: The meaning of urinary incontinence in the context of Muslim postmenopausal women through hermeneutic phenomenology. Arch Gerontol Geriatr. 2015;60(3):514–21. 22. Gonzalez-Argente FX, et al. Prevalence and severity of urinary incontinence and pelvic genital prolapse in females with anal incontinence or rectal prolapse. Dis Colon Rectum. 2001;44(7):920–6. 23. McLennan MT, et al. Family history as a risk factor for pelvic organ prolapse. Int Urogynecol J Pelvic Floor Dysfunct. 2008;19(8):1063–9. 24. Slieker-ten Hove MC, et al. The prevalence of pelvic organ prolapse symptoms and signs and their relation with bladder and bowel disorders in a general female population. Int Urogynecol J Pelvic Floor Dysfunct. 2009; 20(9):1037–45. 25. World Health Organization, G. Measuring reproductive morbidity: report of technical working group. Geneva: World Health Organization: Division of Family Planning; 1989. p. 1–39. 26. Rortveit G, et al. Symptomatic pelvic organ prolapse: prevalence and risk factors in a population-based, racially diverse cohort. Obstet Gynecol. 2007; 109(6):1396–403. 27. The Federal Competitiveness and Statistics Authority (FCSA), Population Estimates, 2011 [Available from: http://fcsa.gov.ae/en-us/Pages/Statistics/ Statistics-by-Subject.aspx. 28. Statistics Centre, Statistical Yearbook, [Available from: https://www.scad.ae/ Release%20Documents/Statistical%20Yearbook%20-%20Population%20- %20EN.pdf. 29. Swift SE, Tate SB, Nicholas J. Correlation of symptoms with degree of pelvic organ support in a general population of women: what is pelvic organ prolapse? Am J Obstet Gynecol. 2003;189(2):372–7. discussion 377-9 30. Geoffrion R, et al. Evaluating patient learning after an educational program for women with incontinence and pelvic organ prolapse. Int Urogynecol J Pelvic Floor Dysfunct. 2009;20(10):1243–52. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png BMC Women's Health Springer Journals

The degree of bother and healthcare seeking behaviour in women with symptoms of pelvic organ prolapse from a developing gulf country

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Abstract

Background: The healthcare-seeking behaviour of women with pelvic organ prolapse (POP) is affected by several factors including the cultural background. There is limited number of studies which addressed the healthcare- seeking behaviour in women with POP. The aim of this study was to determine the degree of bother, social impact and healthcare seeking behaviour of symptoms of POP in one of the Gulf countries and compare the results to published data from other areas. Methods: All women who attended the three family development centres in our city between January 2010 and January 2011 and who had symptoms suggestive of POP were included in the study. The data was collected by well-trained interviewers. Results: One hundred twenty-seven women reported symptoms of POP (mean age: 38.2 years; range: 18–71). Out of these, 111 (87.4%) had at least one activity (physical, social or prayers) or sexual relationship affected by POP symptoms. In 49 women (38%), the effect on at least one of these activities or relationships has been described as moderate and in 18 women (14%), the effect was severe. Sixty-nine women (54%) did not seek medical advice due to: embarrassment to see medical doctors (51%), the belief that POP is normal among women (51%), hope for spontaneous resolution (48%), embarrassment to see male doctors (33%) and unawareness of the existence of medical treatment (30%). On univariate analysis, the need to insert the finger in the vagina to empty the bladder or bowel and the interference of symptoms with physical activities, had significantly determined healthcare seeking attitude (P < 0.05 for all). However, on multivariate analysis interference with physical activities was the only significant determinant (P =0.04). Conclusions: Although POP had affected the quality of life in the majority of the affected women, unlike some other societies, more than half failed to seek healthcare advice mainly due to shyness and embarrassment and lack of proper knowledge about the condition. Interference of symptoms with physical activities was the main significant determinants of healthcare-seeking behaviour. Additional teaching campaigns designed according to cultural backgrounds in each society are required to address these sensitive issues. Keywords: Pelvic organ prolapse, Bother, Healthcare seeking behaviour, Emirati women * Correspondence: fayezhammad@hotmail.com Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, PO Box 17666, Al Ain, United Arab Emirates 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. Hammad et al. BMC Women's Health (2018) 18:77 Page 2 of 7 Background from the Middle East in general and from the Gulf Pelvic organ prolapse (POP) is a relatively common con- countries in particular. Therefore, the aim of this re- dition especially in older women and it might result in search was to study the degree of bother and social im- very distressing symptoms. Depending on the research pact of symptoms of POP and the determinants of methodology and population investigated, wide variation healthcare seeking behaviour in one on the Gulf coun- in prevalence has been reported. For instance, on tries and compare them to published data from other physical examination, some degree of POP is found in areas. In this study, we investigated women who visited 32–98% of women. However, among those who have the family development centres in our city. These POP, only 4–8.3% has POP-related symptoms [1–3]. governmental centres are used essentially for social and Some studies have suggested that the prevalence of cultural activities of women from all social and POP and pelvic floor dysfunction, in general, might be economic backgrounds. affected by race and ethnicity [1, 4, 5]. Indeed, in a previ- ous report we have shown that the prevalence of POP Methods symptoms among women in the Gulf might be slightly The methods used in this study were as previously de- higher than other societies [6]. These ethnic and racial scribed [6]. This study presented the results of a planned variations might influence not only the prevalence and analysis of data which was collected at the same time of mode of presentation but also the degree of bother and collecting another data which was previously published care seeking behaviour of women with different cultural and aimed to determine the prevalence and risk factors of backgrounds. symptoms of POP in our population [6]. In summary, all There is limited number of studies which addressed Emirati women who attended all the three family develop- the healthcare-seeking behaviour in women with symp- ment centres in Al Ain, UAE from January 2010 to Janu- toms of POP [7–13]. Available research in this field fo- ary 2011 were included. These centres were the main and cused mainly on urinary incontinence [14–17]and on only governmental facilities in the city and were visited by pelvic floor dysfunction in general [1, 18, 19]. However, large number of Emirati women with different ages and there is evidence to suggest that POP might be associ- backgrounds. Pregnant women and nulliparous women ated with higher likelihood of seeking medical advice by younger than 30 years were excluded. Written consent the affected women compared to other pelvic disorders was obtained from all eligible participants. The Research [19, 20]. Healthcare seeking behaviour in POP is deter- Ethical Committee at the College of Medicine and Health mined by several factors and reviewing the available Sciences, UAE University approved the study. Written studies which addressed the determinants of this behav- consent was obtained from all eligible subjects. iour, had shown that obstacles to healthcare seeking can Thedatawas collectedusing aquestionnairewhich was be divided into five main categories: administered by female well-trained interviewers who spoke the same language of the investigated women (Arabic 1. Shyness or embarrassment to speak to healthcare Language). The questionnaire is a custom-designed one. provider/s. The first part dealt with the basic socio-demographic data. 2. Financial factors which affect accessibility to The second part explored the obstetrics, medical and surgi- healthcare system. cal history followed by prolapse-related questions. In this 3. Inadequate knowledge about the diseases such the regard, the woman was asked if she felt a dragging lump belief that the disease is part of normal aging, the coming down the vagina, lump coming out of vagina or belief that it will improve on its own or have no lump felt or seen outside vagina; the presence of any of successful treatment. these symptoms were considered to indicate the presence 4. Family-related issues such as the lack of support of POPinthisstudy.Thiswas followedbyother questions and cooperation of close family members or to determine the severity of the condition, other vaginal prioritising family needs over the woman’s own symptoms and if the women had to insert her finger into needs. the vagina to reduce the lump in order to be able to empty 5. Miscellaneous factors. the bladder or bowel. Finally, the woman was asked if she had seeked medical advice and if not about the reasons for Most of the studies which addressed the determinants not doing so. The whole questionnaire was not formally of this behaviour in women with POP mainly evaluated validated but included questions which were used in other women from the West [7, 9–12] with some studies ad- studies such as the WHO [22–25]. In addition, and as pre- dressing this issue in other ethnicities such as Asian viously described [6], thequestionnairewas tested and women [8, 13]. In the Middle East, although such data is re-tested on a pilot female sample to suite our population’s available in some conditions such as urinary incontin- attitudes to discuss the sensitive issues related to POP ence [21], POP-related data is not available for women symptoms. Furthermore, the use of healthcare providers to Hammad et al. BMC Women's Health (2018) 18:77 Page 3 of 7 question the participants and fill the questionnaire elimi- Table 1 Reasons for not seeking medical advice. % represents the percentage of women among the 69 women who did not nated the potential misunderstanding of some of the ques- seek medical advice. Some women might have reported more tions by the participants. than one reason Data were analysed using SPSS version 19.0 (IBM, Reason for not seeking a medical advice No (%) Armonk, NY, USA). Inter-group comparisons were per- Embarrassment to see a medical 35 (51%) formed using the Student t test for continuous variables doctor of any gender and the chi-square or Fisher exact tests for categorical Belief that POP is normal among 35 (51%) variables. Multivariate binary logistic regression analysis women especially older women was performed to determine independent factors which Hope for spontaneous 33 (48%) were associated with healthcare seeking behaviour. A resolution of the POP P value of < 0.05 was considered statistically significant. Embarrassment to see male doctor 23 (33%) Unawareness of the existence 21 (30%) of medical treatment Results As previously described [6], out of 482 women who were approached and met the inclusion criteria, 429 (89.0%) especially older women or the unawareness of the exist- consented to fully participate in the study. Out of these, ence of medical treatment. 127 women (29.6%) reported symptoms of POP with Table 2 describes the socio-demographic determinants mean age of 38.2 years (range: 18–71). of healthcare seeking behaviour. Using univariate ana- Out of the 127 women, symptoms of POP affected lysis, women who seeked medical advice were signifi- various activities and relationships as follows: physical cantly younger than those who did not (40.1 ± 1.4 vs. activities (n = 91, 72%), social gathering and activities 36.6 ± 1.2 years, P = 0.03). However, occupation, monthly (n = 69, 54%), ability to pray (which involves several income and level of education did not determine the body movements) (n = 84, 66%) and sexual relationship healthcare-seeking behaviour (P > 0.05 for all). (n = 91, 72%). The symptoms of POP had affected at Table 3 demonstrates the determinants of healthcare least one activity (physical, social or prayers) or sexual seeking behaviour according to the symptoms or ma- relationship in 111 (87%) women. As demonstrated in noeuvres which were performed to relieve the symp- Fig. 1, these effects ranged from mild to severe. In 44 toms. The degree of vaginal soreness did not affect the women (35%), the effect on at least one of these activ- seeking behaviour. However, the need to insert the finger ities or relationship has been described as mild, in 49 women (38%), it was moderate and in 18 women (14%), Table 2 Socio-demographic determinants of healthcare-seeking the effect was severe. behaviour for women with symptoms of POP. All variables are As demonstrated in Table 1, 69 out of the 127 women presented by crude number apart from Age which was (54%) did not seek healthcare advice due to different presented by mean ± standard error of the mean. P value reasons such as the embarrassment to see a medical indicates statistical significance according to univariate analysis practitioner in general or a male practitioner in particu- Non-seeking group Seeking group P Value lar and the lack of adequate knowledge about the disease Number 69 58 such as the belief that it is normal among women Age (years) 36.6 ± 1.2 40.1 ± 1.4 0.03 Monthly Income (Dirham) 0.67 < 5000 3 2 5000–10,000 31 22 > 10,000 35 34 Education 0.82 University 8 5 Secondary school 18 15 Primary school 26 26 Illiterate 17 12 Occupation 0.96 Housewife 49 42 Office job 11 8 Fig. 1 The effect of symptoms of POP on the various activities and relationships Physical 9 8 Hammad et al. BMC Women's Health (2018) 18:77 Page 4 of 7 Table 3 Determinants of healthcare-seeking behaviour for women with symptoms of POP according to the reported symptoms. P value indicates statistical significance according to univariate analysis Non-seeking group Seeking group P Value Number 69 58 Awareness of vaginal soreness 0.19 Never 22 12 Very occasional 33 31 Sometimes 6 11 Most of times 5 1 All the time 3 3 Insertion of finger into vagina to start or complete bladder emptying 0.04 Never 52 32 Very occasional 10 14 Sometimes 3 9 Most of times 1 2 All the time 3 1 Insertion of finger into vagina to start or complete bowel emptying 0.01 Never 51 28 Very occasional 11 20 Sometimes 3 8 Most of times 2 1 All the time 2 1 into the vagina to empty the bladder or bowel was sig- nificantly associated with seeking medical advice on uni- Table 4 Determinants of healthcare-seeking behaviour for variate analysis (P < 0.05 for both). women with symptoms of POP according to the interference with various activities and relationships. P value indicates The effect of POP symptoms on various activities and statistical significance according to univariate analysis relationships and their relation to the seeking behaviour Non-seeking group Seeking group P Value was demonstrated on Table 4. Only interference with Number 69 58 physical activities was significantly associated with seek- ing medical advice on univariate analysis (P = 0.005). Interference with Prayers 0.14 On multivariate analysis of all the factors which were No interference 25 18 significantly associated with seeking medical advice on Mild 27 27 univariate analysis only interference of POP symptoms Moderate 16 8 with physical activity independently predicted seeking Severe 1 5 medical advice in our study [β: 0.781, SE: 0.372, Exp(β): Interference with sexual relationship 0.17 2.156, P = 0.04]. The remaining factors did not inde- No interference 20 16 pendently predict seeking behavior (age: β: 0.081, SE: Mild 23 15 0.02, Exp(β): 1.018, P = 0.4; insertion of finger to empty Moderate 16 23 bladder: β: -0.128, SE: 0.602, Exp(β): 0.880, P = 0.8; inser- Severe 10 4 tion of finger to empty bowel: β: 0.835, SE: 0.597, Exp(β): Interference with social activities 0.14 2.302, P = 0.2). No interference 33 25 Discussion Mild 20 26 In this study, we have shown that the vast majority of Moderate 14 5 women who reported POP symptoms were bothered by Severe 2 2 the condition and approximately half of those affected Interference with Physical activities 0.005 were moderately or severely bothered by the symptoms. No interference 27 9 We have also demonstrated that more than half of the Mild 20 31 affected women did not seek medical advice for various Moderate 20 14 reasons. To the best of our knowledge, this is the first Severe 2 4 study which assessed the degree of bother, social impact Hammad et al. BMC Women's Health (2018) 18:77 Page 5 of 7 and healthcare seeking behaviour in women with POP which influence this behaviour vary widely among differ- symptoms from this geographical region. ent societies. The degree of bother and social impact of symptoms The main factor which pushed women to seek medical of POP in the current study is similar to those reported advice in this study was the interference of the POP from the West [10, 26]. In a population-based study on symptoms with daily physical activities. Interfering with American women, Rortveit and colleagues reported that physical activities would seriously compromise women’s almost 50% of women with POP symptoms had moder- ability to meet their personal and family commitments ate or great distress and in 35%, the POP symptoms af- and might also prevent them from undertaking certain fected at least one physical, social or sexual activity [26]. professions. Similar finding were reported in a similar study from The relationship of age to the healthcare seeking be- Nepal [13]. Collectively, these studies and our study in- haviour has been investigated previously with conflicting dicate that regardless of the cultural background, women results. Some studies which investigated healthcare seek- in various nations appear to be bothered and socially ing behaviour in pelvic floor disorders in general have well-affected by symptoms of POP. The current study, shown that older women had lower threshold to seek however, indicates that women in our society are less medical advice compared to younger women [19, 20]. likely to seek medical advice compared to women from On the other hand, in another study which addressed the West. For instance, in a population-based study, the seeking behaviour in POP, younger women were Morrill et al. showed that 73% of American women had found to be more likely to seek medical advice [7]. Using seeked medical advice compared to only 46% in our multivariate analysis, our results clearly demonstrated study [20]. that age was not a significant determinant of healthcare The obstacles to healthcare seeking in our study are seeking behaviour. These discrepancies could probably different from those reported from other communities. be due to cultural differences and attitudes towards dis- For instance, in our study, financial factors including in- ease tolerance and seeking help from others in general. surance concerns were not important in determining To our surprise, the level of education has not been whether an affected woman would seek medical advice shown in our study or in other similar studies [7, 19, 20] because all individuals in our society have free access to to determine the healthcare seeking behaviour in women healthcare system at various levels from primary health- with POP symptoms. Cultural background and attitudes care to tertiary centres. This is in contrast to some other appear to be stronger factors which determine health- studies in which financial issues were of major concern care seeking behaviour across different societies regard- and actually prevented women from seeking advice des- less of the educational level. pite the need to do so [8, 19]. The current study has some limitations. So, although In our society, shyness or embarrassment to discuss it is not strictly a whole population-based study, it in- POP symptoms with healthcare providers of any gender cluded all women from the three family development and male providers in particular appears to be one of centres who met the study criteria. The visitors of these the strongest determinants of seeking behaviour. This is governmental centres are women of different ages and probably due to local culture-related factors and has from different social and cultural backgrounds and these only been reported by limited number of studies [8]. centres are essentially used for variable educational, so- The other important determinant of the seeking be- cial and cultural activities. They are not part of health- haviour in our society is the lack of adequate knowledge care system and therefore, not used for seeking medical about the condition such as the belief that the disease is care. Hence, the study population in this research is ex- part of normal aging and the unawareness of the exist- pected to be better representing the general population ence of medical treatment. Such a belief appears also to compared to other studies which used patients from be common across other societies [8, 13, 18, 19] and ob- hospitals or primary healthcare centres [9–12]. The viously, such thinking would discourage women from other potential limitation is the inclusion of women seeking medical advice. from only one city. This renders the data difficult to In contrary to some other societies, family-related is- generalise to the whole country. However, since approxi- sues and the fear of lack of support of family members mately one fifth of the whole Emirati population lives in did not appear to be an important issue in our study this city [27, 28], the results obtained might be a reason- [8, 13, 18]. Probably this is due to the nature of family able reflection of the whole country. structure in our area. Most families are extended large One of the other limitations of the study is the lack of families which provide extra-support to its members. As vaginal examination which would have been very diffi- a whole, the findings of the current study and previous cult in this conservative society. However, it is unlikely studies in this field indicate that not only the percentage this would have affected the results of this study as good of women who seek medical advice but also the factors correlation has been found to exist between the Hammad et al. BMC Women's Health (2018) 18:77 Page 6 of 7 symptoms with the presence of anatomical POP on Authors’ contributions FH contributed to project development, data management and analysis and physical examination [29]. In the present study, symp- manuscript writing and editing. HE contributed to project development, data toms of POP were identified by healthcare providers management and analysis and manuscript editing. NO assisted in project who administered the questionnaire. This might have development, data management and collection and manuscript editing. All authors read and approved the final manuscript. caused some bias compared to self-administered ques- tionnaires. Nevertheless, the use of healthcare providers Ethics approval and consent to participate had enabled us to investigate illiterate women and de- Ethical approval was obtained from The Research Ethical Committee at the College of Medicine and Health Sciences, UAE University (#09/83). Written creased the potential misinterpretation of these sensitive consent was obtained from all eligible participants. questions by some of the participants. Finally, the current study and other similar ones Competing interests The authors declare that they have no competing interests. should encourage further campaigns to educate women about pelvic floor disorders including POP. Such cam- Publisher’sNote paigns and educational sessions have been shown to im- Springer Nature remains neutral with regard to jurisdictional claims in prove the general knowledge of women about this published maps and institutional affiliations. condition [30] and should tackle the specific obstacles to Author details healthcare seeking in that particular society. In our soci- Department of Surgery, College of Medicine and Health Sciences, United ety, these campaigns should be coordinated by a com- Arab Emirates University, PO Box 17666, Al Ain, United Arab Emirates. bination of well-trained female healthcare providers and Department of Obstetrics and Gynaecology, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates. social workers who are able to tackle not only health is- sues but other sensitive issues such as shyness and Received: 7 June 2016 Accepted: 17 May 2018 cultural-related obstacles. References 1. Nygaard I, et al. Prevalence of symptomatic pelvic floor disorders in US Conclusions women. JAMA. 2008;300(11):1311–6. Although symptoms of POP had affected the quality of life 2. Tegerstedt G, et al. Prevalence of symptomatic pelvic organ prolapse in a in the majority of the affected women in our society, unlike Swedish population. Int Urogynecol J Pelvic Floor Dysfunct. 2005;16(6):497–503. 3. Bradley CS, Nygaard IE. Vaginal wall descensus and pelvic floor symptoms in some other societies, more than half failed to seek health- older women. Obstet Gynecol. 2005;106(4):759–66. care advice. This was mainly due to shyness, embarrass- 4. Hendrix SL, et al. Pelvic organ prolapse in the Women’s Health Initiative: ment to speak to healthcare providers and lack of proper gravity and gravidity. Am J Obstet Gynecol. 2002;186(6):1160–6. 5. Whitcomb EL, et al. Racial differences in pelvic organ prolapse. Obstet knowledge about the condition. Interference of symptoms Gynecol. 2009;114(6):1271–7. with physical activities was the main significant determi- 6. Elbiss HM, Osman N, Hammad FT. Prevalence, risk factors and severity of nants of healthcare-seeking behaviour. Additional teaching symptoms of pelvic organ prolapse among Emirati women. BMC Urol. 2015;15:66. 7. Brazell HD, O'Sullivan DM, Tulikangas PK. Socioeconomic status and race as campaigns designed according to cultural backgrounds in predictors of treatment-seeking behavior for pelvic organ prolapse. Am J each society are required to address these sensitive issues. Obstet Gynecol. 2013;209(5):476.e1–5. 8. Kumari S, Walia I, Singh A. Self-reported uterine prolapse in a resettlement colony of North India. J Midwifery Womens Health. 2000;45(4):343–50. Abbreviations 9. Lewicky-Gaupp C, et al. Self-perceived natural history of pelvic organ POP: Pelvic organ prolapse; UAE: United Arab Emirates prolapse described by women presenting for treatment. Int Urogynecol J Pelvic Floor Dysfunct. 2009;20(8):927–31. Acknowledgments 10. Mouritsen L, Larsen JP. Symptoms, bother and POPQ in women referred The authors would like to acknowledge Prof. N. Nagelkerke for statistical with pelvic organ prolapse. Int Urogynecol J Pelvic Floor Dysfunct. 2003; input and Dr. F. Radi, R. Z. Al Mazroei, F. Al Ahbabi, K. Al Ameri, N. Al Bloushi 14(2):122–7. and E. Nur for technical assistance in data collection. 11. Pakbaz M, et al. A hidden disorder until the pieces fall into place’–a qualitative study of vaginal prolapse. BMC Womens Health. 2010;10:18. 12. Pakbaz M, et al. Vaginal prolapse–perceptions and healthcare-seeking Funding behavior among women prior to gynecological surgery. Acta Obstet The present study was funded by a grant from the College of Medicine and Gynecol Scand. 2011;90(10):1115–20. Health Sciences, United Arab Emirates University. The College of Medicine 13. Shrestha B, et al. Women's experiences and health care-seeking practices in and Health Sciences did not interfere significantly with the design of the relation to uterine prolapse in a hill district of Nepal. BMC Womens Health. study and collection, analysis, and interpretation of data or in writing the 2014;14:20. manuscript. However, the grant was initially reviewed and approved by 14. Elbiss HM, Osman N, Hammad FT. Social impact and healthcare-seeking College of Medicine and Health Sciences Grants Research Committee. behavior among women with urinary incontinence in the United Arab Annual and final reports are required to be submitted to the College of Emirates. Int J Gynaecol Obstet. 2013;122(2):136–9. Medicine and Health Sciences when the manuscript is published. 15. Kinchen KS, et al. Factors associated with women's decisions to seek treatment for urinary incontinence. J Women's Health (Larchmt). 2003;12(7): Availability of data and materials 687–98. The original data is available for review upon request. Contact person: Prof. 16. Koch LH. Help-seeking behaviors of women with urinary incontinence: an Fayez T. Hammad, Department of Surgery, College of Medicine & Health integrative literature review. J Midwifery Womens Health. 2006;51(6):e39–44. Sciences, PO Box 17666, Al Ain, United Arab Emirates, Phone: 00971 50 17. Saleh N, et al. Prevalence, awareness and determinants of health care- 4880021/ 00971 3 7137 590, Fax: 00971 3 7672067, e-mail: seeking behaviour for urinary incontinence in Qatari women: a neglected fayezhammad@hotmail.com problem? Maturitas. 2005;50(1):58–65. Hammad et al. BMC Women's Health (2018) 18:77 Page 7 of 7 18. Hatchett L, et al. Knowledge and perceptions of pelvic floor disorders among african american and Latina women. Female Pelvic Med Reconstr Surg. 2011;17(4):190–4. 19. Washington BB, et al. Variables impacting care-seeking for pelvic floor disorders among African American women. 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Measuring reproductive morbidity: report of technical working group. Geneva: World Health Organization: Division of Family Planning; 1989. p. 1–39. 26. Rortveit G, et al. Symptomatic pelvic organ prolapse: prevalence and risk factors in a population-based, racially diverse cohort. Obstet Gynecol. 2007; 109(6):1396–403. 27. The Federal Competitiveness and Statistics Authority (FCSA), Population Estimates, 2011 [Available from: http://fcsa.gov.ae/en-us/Pages/Statistics/ Statistics-by-Subject.aspx. 28. Statistics Centre, Statistical Yearbook, [Available from: https://www.scad.ae/ Release%20Documents/Statistical%20Yearbook%20-%20Population%20- %20EN.pdf. 29. Swift SE, Tate SB, Nicholas J. Correlation of symptoms with degree of pelvic organ support in a general population of women: what is pelvic organ prolapse? Am J Obstet Gynecol. 2003;189(2):372–7. discussion 377-9 30. Geoffrion R, et al. 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BMC Women's HealthSpringer Journals

Published: May 30, 2018

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