Patterns of POP in Nepali Women & the Roles of Cultural Norms

Today's guest post comes from Kelsea Cannon, PT, DPT, a pelvic health practitioner in Seattle, WA. Kelsea graduated from Des Moines University in 2010 and practices at Elizabeth Rogers Pilates and Physical Therapy.

Many studies done on pelvic floor muscle training largely have subjects who are Caucasian, moderately well educated, and receive one-on-one individualized care with consistent interventions. This led a group of researchers to investigate the occurrence of pelvic floor dysfunction, specifically pelvic organ prolapse (POP), in parous Nepali women. These women are known to have high incidences of POP and associated symptomology. Another impetus to perform this research: the discovery that there was a major lack of proper pelvic floor education for postpartum women. These women were commonly encouraged to engage their pelvic floor muscles via performing supine double leg lifts, sucking in their tummies/holding their breath/counting to ten, and squeezing their glutes. These exercises would be on a list of no-no’s here in the United States. In 2017, Delena Caagbay and her team of researchers discovered that in Nepal, no one really knew the correct way to teach proper pelvic floor muscle contractions, preventing the opportunity for women to better understand their pelvic floors. The team then set out to investigate the needs of this population, with the eventual goal of providing effective pelvic floor education for Nepali women.

Caagbay and her team first wanted to know what baseline muscle activity the Nepali women had in their pelvic girdle. Physical examinations and internal pelvic floor muscle strength assessments revealed that surprisingly there was a low prevalence of pelvic floor muscle defects, such as levator avulsions and anal sphincter trauma. Uterine prolapses were most common while rectoceles were comparatively less common. Their muscles were also strong and well-functioning, often averaging a 3/5 on the Modified Oxford Scale. It was hypothesized that these women had low prevalence of muscle injury because instruments were not commonly used during childbirth, they had lower birth weight babies, and the women were typically younger when giving birth (closer to 20-21 years old). But they had a high prevalence of POP even with good muscle tone? Researchers suggested that their incidence of POP is likely stemming from their sociocultural lifestyle requirements, as women are left to do most of the daily household chores and caregiving tasks while men often travelled away from the home to perform paid labor. Physical responsibilities for these women commonly begin at younger ages and while it helps promote good muscle tone, the heavier loading places pressure on the connective tissue and fascia that support the pelvic organs. Because of the demands of their lifestyles, Nepali women are often forced to return to their physically active state within a couple weeks after giving birth.

After assessing the current needs, cultural norms, and prevalence of POP in Nepali women, Caagbay et al created an illustrative pamphlet on how to contract pelvic floor muscles as well as provided verbal instruction on pelvic floor muscle activation. Transabdominal real time ultrasound was applied to assess the muscle contraction of 15 women after they received this education. Unfortunately, even after being taught how to engage their pelvic floor muscles, only 4 of 15 correctly contracted their pelvic floors.

This study highlighted that brief verbal instruction plus an illustrative pamphlet was not sufficient in teaching Nepali women how to correctly contract their pelvic floor muscles. Although there was a small sample size, these results can likely be extrapolated to the larger population. Further research is needed to determine how to effectively teach correct pelvic floor muscle awareness to women with low literacy and/or who reside in resource limited areas. Lastly, it is important to consider the significance of fascial and connective tissue integrity within the pelvic floor when addressing pelvic organ prolapse.

1 Can a leaflet with brief verbal instruction teach Napali women how to correctly contract their pelvic floor muscles? DM Caagbay, K Black, G Dangal, C Rayes-Greenow. Journal of Nepal Health Research Council 15 (2), 105-109.
https://www.nepjol.info/index.php/JNHRC/article/viewFile/18160/14771
2 Pelvic Health Podcast. Lori Forner. Pelvic organ prolapse in Nepali women with Delena Caagbay. May 31, 2018.
3 The prevalence of pelvic organ prolapse in a Nepali gynecology clinic. (2017) F. Turel, D. Caagbay, H.P. Dietz. Department of Obstetrics and Gynecology, Sydney Medical School Napean, University of Sydney.
4 The prevalence of major birth trauma in Nepali women. (2017) F. Turel, D. Caagbay, H.P. Dietz. Department of Obstetrics and Gynecology, Sydney Medical School Nepean, University of Sydney.