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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.
The current study took place in the Amhara region of north-western Ethiopia. Roughly 20% of births among rural women in Ethiopia are attended by skilled personnel or occur at health facilities. The nation’s fertility rate is 4.6 children per woman, and the maternal-mortality ratio is 412 deaths per 100,000 live births [29]. Rural Ethiopian health facilities are in general poorly equipped and lack adequate emergency obstetric services [30]. The Amhara people, who primarily practice Orthodox Christianity and speak Amharic as their first language, are the majority ethnic group in the region [31]. The median female age upon first marriage in the Amhara region is 16.2 years, and around 55% of the women are illiterate [29].. The present study, which was conducted in 2015–16, featured repeated visits to the field. The three-months-long first part of the fieldwork was conducted at the University of Gondar Hospital (henceforth ‘the hospital’), a referral teaching hospital located in the city of Gondar. The second part of the study, which lasted 4 months, took place in semi-urban and rural parts of the districts of Dabat and Debark, located 78 and 106 km north of Gondar, respectively. Free surgical treatment was introduced at the hospital at the time of the fieldwork and was offered to women with prolapse. It was initiated and funded by the hospital and UNFPA in collaboration with two non-governmental organizations (NGOs). The women were informed about prolapse and the possibility of free treatment from health-extension workers (HEWs) in the communities. Those who were found eligible for surgical treatment were selected at the district level and sent to the hospital in small groups. The study had a qualitative, explorative approach and included 25 participants (Table 1). The first part of the fieldwork was conducted at the hospital where women with prolapse were admitted for surgery. Women who had undergone prolapse surgery were interviewed and recruited for follow-up visits in their homes after expected recovery. The criteria for follow-up included prolapse surgery and the accessibility of the women’s homes. The first author carried out participant observations at the hospital, which were primarily conducted in connection with another sub-study focusing on health-seeking behaviours in the same patient group. The author’s presence at the ward also facilitated the recruitment of informants for the present sub-study and secured access to the informants’ medical histories. Health-care providers and a representative from one of the organizations involved in the newly introduced free prolapse-treatment initiative were also interviewed at the hospital. Study participants according to recruitment place aThese 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 women’s communities and included home visits 5–9 months after their surgeries. HEWs who were involved in community mobilization activities in connection with prolapse surgery were interviewed. They were engaged in the identification of potential prolapse cases and referred women with suspected prolapse to the district level. Health-care workers at the health-centre level, as well as representatives from an international NGO and representatives from the health authorities at the district level, all of whom were involved in the newly introduced free prolapse-treatment initiative, were also interviewed to provide contextual information for the study. All interviews were performed in close collaboration with a local female interpreter who was familiar with the language, culture, and respectful conduct in the area. The interviews were conducted in Amharic with continuous translation from English to Amharic and vice versa between the researcher and the informants. Semi-structured interview guides with open-ended questions were used (see Additional file 1). The interviews, which were held either inside or outside the women’s homes, lasted from 1 to 2 h with the aim of allowing the informants to speak freely and with few interruptions. All the interviews at the hospital were held in a private room on the ward while the interviews with the health-care providers and stakeholders in the communities were held in a private room at their work facilities. The analysis took place throughout the data-collection process and during a rigorous analytical phase that followed the completion of the fieldwork. All interviews were audio-recorded, transcribed verbatim to Amharic and translated into English. The completed material was carefully reviewed to identify core themes [32]. The subsequent post-fieldwork analysis concretized the initially identified themes into categories of meaningful units followed by coding of the material line-by-line [33]. Each sub-category identified during the first phase was scrutinized for central patterns and ‘case-stories’ as well as for potential nuances, and ambivalence and contradictions. The full data set was then imported into NVivo 11, a qualitative data-analysis software tool that was employed to organize the material. Ethical approvals were obtained from the Regional Ethics Review Board in Norway and the University of Gondar in Ethiopia. With the assistance of the interpreter, all patients on the ward were provided with information about the study, the role of the first author’s participant observation, and their rights not to participate or be observed. The aim and purpose of the study, as well as the contents of the consent form, were explained to the research participants prior to all interviews. Written or oral consent to participate was obtained, depending on literacy status, and the utmost care was taken to secure privacy and confidentiality during the research process. Two patients at the hospital declined to participate, and two women were lost to follow-up with the research team due to distance or lack of accessible roads to their homes.
