In this study surgical repair of POP effectively improve POP symptoms, body image and HRQoL. This adds to the growing body of literature that POP and its surgical treatment is associated with HRQoL.
In order to ensure the quality of surgical outcome, reliable, valid and easy-to-use measures of surgical quality and patient impact are needed. The P-QoL is a PRO tool that can measure the impact of surgical interventions on women’s HRQoL. This study uses P-QoL to demonstrate an improvement in patient-reported HRQoL after surgery in Ethiopia.
PRO tool assesses patient’s opinion thereby measure a patient’s health status or HRQoL. Usually PRO data are collected through short and self- completed questionnaires. But many are difficult to administer and may be difficult for populations with high illiteracy rates to understand [1]. However, P-QoL is simple and quick to use tool approximately taking 30 min to administer using face-to-face [26]. Our study adds to the evidence that P-QoL can be used as a PRO tool to demonstrate patient impact after surgery in LMIC, specifically Ethiopia.
The 86% follow-up rate observed in our study is much higher compared with Nepal’s study that reported 64% [35].
Follow-up rates in LMICs are typically lower than those in high-income countries (HICs) although even follow-up rates vary considerably in HICs [36, 37]. In this study, the decline in further participation, lost to follow-up for unknown reasons and relocation were the reasons for leaving the follow-up schedule. To minimize the loss of patients to follow-up, a trained data collector periodically checked the data integrity and dealt with missing data by acquiring information from patients and family via repeated phone or in-person interviews. In addition, we also compared the baseline profiles of those who completed the study and those who dropped out. However, there was no difference in bassline socio-demographic, depressive and POP symptoms, body image and POP stage associated with P-QoL scores between the two groups (p > 0.05, Table 4).
In the current study surgical repair of POP showed a significant improvement of QoL for all 9 investigated domains of P-QoL instrument over the course of the study. Patients had a significantly lower impairment of their QoL at 3 months after surgery. At 6 months after the procedure, the QoL of the study participants had improved even more, and the difference to the preoperative figures remained significant. The better QoL scores compared to baseline scores were also observed in all the 3 P-QoL components (PC, PSC and PRC) after 6 months. Previous studies in Western countries using P-QoL instrument also confirmed that correction of POP via alloplastic vaginal meshes can significantly improve patients’ QoL [24, 38–42]. However, patients benefited from a highly significant improvement in all domains of QoL, although the surgery was native tissue repair in current study. Surgeries using the patient’s own tissues are the first-line operations in the treatment of POP [43]. Our finding also compare favorably with previous studies in LMICs, although a different QoL tool used [35]. Furthermore, qualitative findings from Ethiopia reported that rural women receiving free-of cost POP surgery experienced great benefit in many aspects of their life [22].
In our study, the average scores for prolapse effects on physical and role activities and personal relationships was quiet high at baseline. A previous study carried out in European women also showed similar scores for the same domains [24, 38, 39]. Daily life for Ethiopian rural women (e.g. the burden of physical activities/work, gender inequality affecting personal relationships, shame, lack of education/knowledge etc.) is hardly comparable to women living in Europe, and thus the higher baseline [22].
The remarkable improvement found in P-QoL domain scores (PC and PRC) after surgery could have a positive influence on formerly impaired HRQoL among those affected. This is similar to a study from Nepal [35], reporting a significant improvement in every aspect of the QoL measured. In rural settings where nearly all the housework was preformed by women alone or by help of their children and even women often help out on heavy farming activities [44, 45], the improvement of PC after surgery enabled them to perform daily household and/or outdoor roles like fetching water from distant, participating in farmining activities and help in caring for under-five children.
Patients referred for surgery frequently complain about bulging and associated urinary, bowel or sexual symptoms, which are responsible for a significant decrease in HRQoL [46]. In the current study prolapse symptoms, especially vaginal bulging, and lower abdominal heaviness significantly improved postoperatively. Furthermore, the overall total score of POP-SS was significantly reduced after surgery. Similar results have been reported elsewhere [35, 36, 42]. This observation of improvement may be reassuring to the patient and clinician and may very well motivate more women suffering from POP to seek help.
The negative impact of POP on body image and sexual life has been well documented [47–49]. The current study demonstrated a significant improvement in body image 6 months after surgery. Similarly, another study found better body image and sexual satisfaction after surgical intervention [36, 50]. The patient may consider the altered genital anatomy due to the surgery to have a significant impact on their general sense of attractiveness. Moreover, the improvement of body image may be due to reduction of POP symptoms. Evidence showed strong association of POP symptoms and body image score [47–49]. In our study, worse body image score was reported preoperatively.
Despite 40% of women preferred uterine preserving procedures provided that outcomes were equal, more than half of them underwent a VH in this study. Although difference was not observed among groups in HRQoL scores, women’s preference has to be considered for better surgical outcomes [51]. A more recent study in Ethiopia reported an abdominal approach with mesh augmentation as the most successful surgical repair for POP [52].
Prolapse symptoms are not life threatening but has significant negative effects on mental health of woman [15, 53]. Our study demonstrates that depressive symptoms improved significantly after surgical treatment. This findings is consistent with the results of previous studies showing significant improvement in the score of psychological and social health and QoL after surgical treatment [42, 54, 55]. Prolapse may increase symptoms of depression, while symptoms of depression may impact health behavior, symptom burden, QoL, and functional impairment pre- and post-operatively [56]. Our research found that surgery leads to a dramatic improvement not only in condition-specific QoL but also in depressive symptoms. Improved mental health status (PHQ and PSC score) could have positive effect on women’s QoL after surgical intervention [15, 53].
Marital status had a significant association with the change in PRC domain score. Those who were married had greater improvement in HRQoL score than counterparts. This finding is supported by a qualitative study in Ethiopia, which reported that women who lived alone experienced poor improvement in their lives after surgery. For these women life continued to be a struggle [22]. They also found that avoidance of returning to heavy chores shortly after surgery depended substantially on the support from their family and community members, and proved difficult for those living alone [22]. This might be because the probability of getting social or relative support is better for those who live in marital bonds.
In the current study there was no difference in improvement in POP specific QoL following surgery by age group, parity, and stage of POP. Similar result on age group was also reported elsewhere [57].
Strengths and limitations
This study does have limitations. One is that with the 6 months follow-up period, our findings may only allow assessment of short to medium-term HRQoL outcomes. A long-term follow-up is needed to draw firm conclusions with regard to HRQoL and anatomical outcomes. Another limitation is that although our sample was women with POP, the study design was limited to single setting and lack of control group. Including women who had POP without intervention as a control group is unethical. Moreover, to evaluate the effect of surgery on HRQoL it would require a control group of similar patients without surgical repair. Since HRQoL among women post-surgery may not be comparable to women with an intact uterus, irrespective of their POP status, we did not include a comparison group to evaluate changes in HRQoL. Hence, our findings could theoretically be biased in directions that are difficult to predict and we cannot completely rule out the possible effect of changes occurring over time. The single setting warrants that the applied surgical technique was the same for every patient, and, therefore, the final outcome could be compared. A third limitation is that although we have no reason to doubt the truthfulness of the responses given form respondents, it is conceivable that patients may have withheld less socially desirable responses. The free surgical services received may also affect a patient’s willingness to report a negative outcome. Furthermore, the patient survey based on questions about their QoL, body image, depressive symptoms are limited as the statements were obtained from the PRO instrument survey. The final limitation is losses to follow-up. Given that subjects who follow-up were not statistically different from lost to follow-up, results did not substantially affect and may be generalizable to the entire surgical population in Dabat district. A significant bias may occur even with a small proportions of patients lost to follow-up [58], despite more than 20% poses serious threats to validity in general [59].
Despite the above limitations, our study has a number of strengths. This is one of the first studies to report on HRQoL among women underwent POP surgery in Ethiopia. Although POP is a complex and sensitive topic to study, the use of a disease-specific validated PRO tool, i.e. P-QoL, is an important strength. This enabled us to evaluate women’s POP symptoms, body image, and HRQoL in a local context. The use of these instruments further made the study findings internationally comparable. The follow-up rate of 84% is relatively high and the numbers are large compared to other follow up studies in LMICs.