Neglect of pelvic organ prolapse and urinary incontinence are exemplary of human rights violations towards women: moving towards a resolution

Pelvic organ prolapse (POP) and female urinary incontinence (UI) extend beyond physical discomfort and highlight health disparities facing women globally. The resulting shame and isolation reflect health inequities, sociocultural disparities, and gender discrimination. This is particularly amplified in low- and middle-income countries (LMICs) where the pronounced experience of shame extends into human rights violations.^1,2 POP and UI emphasise the intricate interplay of health and human rights calling for an urgent need to address this through the lens of women’s rights. It has been almost 30 years since the Report of the Fourth World Conference on Women – yet the intersection between POP, UI and global health inequities must still be bridged.³

Right to dignity

Dignity is the right to be valued, respected, and treated ethically. Women experiencing POP and/or UI have significant adverse impacts on their quality of life.^1,2,4,5,6 Furthermore, research has confirmed that these physical symptoms are often accompanied by emotional distress, including feelings of shame, embarrassment and reduced self-esteem.^1,2,4,5,7 Shame is a complex emotion shrouded by cultural norms and societal attitudes towards women.⁸ This perception shapes the behaviour of women and can mean they feel inadequate and do not seek help or advocate for themselves. This shame further leads to social isolation. Shame and dignity are at opposite ends of the spectrum.

In LMICs, where cultural norms and resource constraints intersect, shame becomes a significant barrier to seeking health care for POP and UI.⁶ The lack of trained medical professionals and weak health care infrastructure is often compounded by dismissive behaviour, misdiagnosis and/or mistreatment.^2,9 This further perpetuates the cycle of shame. The right to dignity is intertwined with women’s right to be free from all forms of discrimination, including stigma based on health conditions.

Right to autonomy

POP and UI have many causes but are strongly associated with childbirth, heavy lifting and ageing.^2,10,11 Any intrabdominal straining (Valsalva) or injury/weakness to the pelvic supporting structures will increase the likelihood of this occurring. Although estimates of POP prevalence differ by country and method of diagnosis, it is estimated that globally up to 50% of women will experience POP in their lifetimes, with 11.1% of women undergoing prolapse surgery in high-income countries.^12,13

Care begins with empowering women through knowledge and shared decision making, beginning with preventative strategies followed by conservative and/or surgical management. Because of its strong association with childbirth, reproductive rights are intertwined with POP and/or UI prevention. The advocacy work done by FIGO’s Division of Sexual and Reproductive Health and Wellbeing delves into the multifaceted challenges of addressing reproductive rights. In addition, since parity is the strongest predictor of developing POP and UI, access to maternal care and trained birthing attendants offer the opportunity to protect the pelvic floor and allow postpartum education and care aimed at ensuring recovery.

FIGO’s Division of Maternal and Newborn Health outlines the continued need to implement changes and to consider the impact of pregnancy on the long-term health of women. Globally, women continue to do most of the unpaid labour and care. Labour often includes working in fields, heavy lifting and return to manual work early after childbirth.^2,6 Not only are these predisposing factors for POP, but this work is usually not valued highly in society while having significant impact on women’s rights to care.

Age is another strong predictor of POP and UI. Re-envisioning women and health throughout the lifespan is very much needed.¹⁴ This is further exemplified as life expectancy is increasing worldwide and yet ageing women are more vulnerable to health disparities.¹⁵

Gender-based discrimination is directly associated with the risk factors for developing POP and UI. Compounded by stigma, shame and cultural norms, this leads to societal isolation and further hinders the ability of women to access health care. This aligns with the United Nations call for an end to gender discrimination.^16,17

Equity in health care

The World Health Organization (WHO) emphasises that achieving health for all is a fundamental human right.¹⁸ Comprehensive health care for POP and UI begins with reproductive rights, birthing, postpartum and post-reproductive care across the lifespan. Post-reproductive care could entail symptomatic treatment by trained health care professionals. Resource inequities including access to trained professionals and adequate health care infrastructure for both prevention and management continue to be a barrier. However, in LMICs, where resources are limited, shame-induced barriers to health care access further impede women's right to health care.^2,17,19 This is exemplified by Nepal’s well-meaning initiative to address the problem of POP without adequately trained health care professionals or understanding of the fundamental human rights inequities.²⁰ Developing comprehensive health care systems, in line with WHO's goal of equitable and quality healthcare for all, is crucial.¹⁷ This includes strengthening health care infrastructure, training medical professionals, and ensuring equal access to affordable, comprehensive and culturally sensitive services.

Female UI and POP are not mere health conditions of women to be referred to a urogynaecologist. They are a significant part of the post-reproductive morbidity of women. They often affect women at the prime of their productive life and represent violations of WHO recommendations and violations of women's rights. These violations perpetuate shame, inequality and disparities in health care access, particularly in LMICs. It is vital to acknowledge these violations to begin rectifying these disparities.

Targeted public health campaigns and educational programmes can challenge cultural stigmas and raise awareness about POP and UI in LMICs.^2,21 By engaging communities, health care professionals and policy makers, these initiatives can help reduce shame and encourage early health care seeking. Collaborative efforts involving governments, international health organisations and non-governmental organisations (NGOs) can train health care professionals and build appropriate health care infrastructures. Success is dependent on a multipronged approach that equally prioritises women’s right to dignity, challenges societal norms that perpetuate gender discrimination, and allocates equitable resources for gender-sensitive health care.

References

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