POP is a common condition among middle-aged and older women that seriously affects women's physical and mental health and reduces quality of life. With population aging, the burden of care owing to POP will continue to increase. It is estimated that the prevalence of POP in the United States will reach 46% in 2050, and the probability of needing surgical treatment for POP in a woman's lifetime will reach 20%[1, 2]. The prevalence of POP varies greatly among countries and regions. In addition to ethnic factors, social and economic factors cannot be ignored.
Socioeconomic level affects people's living habits and awareness about diseases. Many risk factors of POP, such as BMI, parity, heavy physical labor, chronic cough, constipation, and smoking, can be improved through public health education. In this study, we analyzed the epidemiological characteristics of patients with POP and different educational levels. We found that age (mean 68.3 years), BMI (mean 24.9 kg/m2), spontaneous labor (mean 1.89 events) and the number of high-risk factors (mean 1.85) of patients with a low educational level (primary school and below) were significantly higher than those of patients with medium and higher educational levels. These patients did not see a doctor until an average of 5 years after the onset of POP, which is significantly delayed compared with participants who had a medium and higher educational level. This finding may indicate that these patients are the key target population for POP prevention and control and require greater attention from medical professionals.
According to the literature, the POP prevalence in low-income countries was more than twice that in developed countries; the prevalence of POP among women living in Africa was also higher than that of African American women in the United States[3]. Getnet et al. [7] conducted a systematic review and meta-analysis of POP reports in Ethiopia during 2020 and found that the risk of POP among rural residents was 3.29 times higher than that among urban residents. The authors considered that this may be related to more deliveries at home in rural areas, a lack of midwifery technology and conditions, insufficient attention to POP risk factors, heavy physical labor, as well as a lack of postpartum care, follow up, POP prevention measures, and other factors. Zhu Lan et al.[8]conducted a cross-sectional survey among adult women with POP at 12 survey sites in six administrative regions of China from September 2014 to December 2015. They established a survey baseline, and conducted an epidemiological survey of symptomatic POP in the same population 4 years later, from September 2018 to December 2018. The incidence rate of symptomatic POP in rural areas was higher than that in urban areas (4.97% vs. 3.99%, P < 0.001). An epidemiological survey[9] among 1800 married women over the age of 20 years in Taiyuan, China found that the prevalence of POP among women with a primary school education level and below was 20.74%, that among women with a junior middle school education was 20.68%, the prevalence among those with a senior high school education was 12.15%, and that in women with a college education level and above was 11.60%; the differences were statistically significant (P < 0.001).
According to results of the seventh Chinese national census in 2020[10], the population with an education level of university and above accounted for 15.5%, high school for 15.1%, junior middle school for 34.5%, and primary school and below accounted for 34.9% of the total population. The education level of urban residents was significantly higher than that of rural residents, where more than 37 million individuals aged 15 years and above were illiterate. In recent years, the education level of residents in China has gradually improved, but the population with a primary school education or less still accounts for a large proportion of the total, especially among middle-aged and older women, who are the group at risk for developing POP. In this study, women with POP in the outpatient department who had a primary school education level and below accounted for only 20.9–23.8% of patients; the proportion from 2017 to 2019 was significantly lower than the proportion of patients with a university-level education or above. There was only a slight increase in 2020 but this was not significant (P=0.066). Notably, the present analysis may be affected by the COVID-19 pandemic. Patients with higher educational levels and mild prolapse have made fewer visits to a clinic during the pandemic.
Many risk factors of POP are reported in the literature; however, a systematic review showed that only age, spontaneous labor, and BMI were significantly correlated with the occurrence of POP[3]. In this study, compared with groups who had higher educational levels, patients with a primary school education level and below had significantly older age, multiple parity, higher BMI, and more high-risk factors (smoking, more than two deliveries, history of forceps midwifery, history of perineal laceration, history of macrosomia delivery, heavy physical labor, excessive housework, caring for children, chronic cough, and constipation). Our findings showed that women with a primary school education or lower may be more likely to develop POP. Moreover, the time since onset in this group was significantly longer than that of other groups, with a mean 60 months and median 23.4 months, suggesting that this group of patients has a tendency to delay treatment. The reasons for this may include insufficient understanding of POP, having a conservative nature, shame about seeing a doctor, lack of relevant treatment channels, and economic reasons. Therefore, we believe that patients with low educational levels should be a target population of education and medical care for POP. According to the characteristics of this population, the use of pictures, verbal explanation, and similar approaches should be adopted to disseminate POP-related knowledge to help women with low education levels better understand and prevent POP and make more informed treatment choices. Most people with low educational levels live in rural areas. The diagnosis and treatment of POP should be improved in rural hospitals, and conservative treatment should be promoted such as pessary, pelvic floor muscle exercises, and electrical stimulation. In this way, patients with mild POP can receive timely and convenient medical treatment and slow the progression of POP owing to delayed intervention, as well as surgical treatment, which will help to ease the burden of POP.