This is the first study investigating barriers and facilitators for postnatal women accessing treatment with pelvic organ prolapse (POP).  POP symptoms up to one year postnatally is reported between 33-79% [1].  Postnatal women with POP cannot fulfil parental caring responsibilities, will adapt activities of daily living to manage symptoms and are five times more likely to have postnatal depression [2].  Conservative management of POP is a high priority due to global restrictions in POP surgery using mesh [3] and the new importance placed on non-surgical management.  Exploration of the barriers and facilitators will help improve health outcomes for women and redesign pelvic health services.

Semi-structured qualitative interviews were conducted with postnatal women with pelvic organ prolapse symptoms (n=2), pelvic health physiotherapists (n=2), primary and secondary care nurses (n=2) and general practitioners (n=2).  Interviews were transcribed and thematic analysis was used to analyse the data.

The barriers and facilitators for postnatal women accessing treatment include:

1)	Cultural approach to symptoms

Postnatal prolapse symptoms are often dismissed as a normal part of having a baby.  Symptoms were dismissed if women are not candidates for surgery.  Often the option to manage POP conservatively was overlooked.  Women needed to suggest physiotherapy and vaginal pessaries for these treatments to be considered.  Dismissal of symptoms often led to an increased waiting time to receive treatment due to multiple appointments until symptoms were acknowledged.  Clinicians highlighted a change in culture is required to acknowledge postnatal POP symptoms.  

2)	Screening 

Screening at the 6-8 week postnatal GP appointment does not always occur due to indirect questioning of pelvic health dysfunctions, inconsistencies in offering a vaginal examination and greater importance given to baby’s health.  Routine screening could occur at a cervical screening appointment or by a midwife or physiotherapist.  Routine postal questionnaires have helped identify some symptomatic women.

3)	The Treating Clinician

Limited access to knowledgeable clinicians’ affects treatment options.  An untrained clinician is less likely to offer a vaginal examination and not offer all conservative treatment choices.  There is minimal core medical training in women’s health conditions and mandatory training after qualification.  Clinicians with a specialist interest in women’s health are more likely to correctly sign-post or offer all conservative treatments.

4)	Knowledge for Women

Pro-active and educated women in pelvic floor health seek healthcare for POP symptoms.  A mistrust in clinician’s knowledge and dismissal of symptoms encouraged women to seek treatment in the private sector.  Women sought information from friends, family and social media and the quality of information varied.

This work has highlighted improvements need to be made in the way clinicians’ approach postnatal prolapse.  Ongoing training in pelvic health conditions for clinicians treating women is vital.  Standardising post-natal screening with a vaginal examination and offering all conservative management options should be a priority.  Effectiveness data is required in the conservative treatments for postnatal prolapse to support these recommendations.

Effectiveness data is needed in the conservative management of POP in postnatal women.  Improvements in screening and mandatory training is vital to improving health outcomes for women.

Chen Y, Li FY, Lin X, Chen J, Chen C, Guess MK (2013) The recovery of pelvic organ support during the first year postpartum. BJOG 120 (11):1430-1437. doi:10.1111/1471-0528.12369
Ghetti C, Lowder JL, Ellison R, Krohn MA, Moalli P (2010) Depressive symptoms in women seeking surgery for pelvic organ prolapse. Int Urogynecol J 21 (7):855-860. doi:10.1007/s00192-010-1106-4
First Do No Harm: The report of the Independent Medicines and Medical Devices Safety Review  (2020).