22 J Contemp Med Sci | Vol. 6, No. 1, January–February 2020: 22–25 Original ISSN 2413-0516 Introduction Uterovaginal prolapse is a common gynecological condition particularly in the grandmultipara.1–3 It is of importance to gynecologist in the developing and low resource countries as women in these environments are predisposed to genital prolapse due to repeated child birth, low-skilled attendant at delivery, and low contraceptive usage.1–4 It has a prevalence of 41–50% in women over the age of 40 years, with a lifetime risk of 7%.5 However, the prevalence is difficult to determine in low resource environment as most of the women do not seek medical attention unless symptoms are pronounced and disturbing.6 The female genital organs are maintained in their nor- mal anatomical position by a number of fascial condensations (endopelvic fascia) such as the transverse cervical (cardinal) and uterosacral ligaments.6 Genital prolapse occurs as a result of weakness of these supportive structures. Risk factors for genital prolapse include repeated deliveries, difficult vaginal deliveries, increase intra-abdominal pressure, and estrogen withdrawal as in post-menopausal women.7–9 Three degrees of uterovaginal prolapse are described and the level of the cervix (the lowest and dependent part) is assessed while the patient is straining. First-degree prolapse is when the descent is still within the vagina; second degree when it has reached the introitus and third degree when it has gone beyond the introitus. The third degree, termed procidentia, is usually accompanied by cystourethrocoele and rectocoele.2 Previous surveys have studied the prevalence, risk factors, and management of uterovaginal prolapse; however, there is paucity of information on utilization of reproductive health services and health-seeking behavior of patients with geni- tal prolapse.1–4,10,11 This information is important, especially in low resource environment, as it gives insight on underly- ing factors that may predispose patients to this condition and behavior that promotes it. This will form basis for formulation of preventive strategies. Therefore, this study was designed to determine the prevalence, sociodemographic characteristics, utilization of reproductive health services, and health-seeking attitude of patients with uterovaginal prolapse in University of Calabar Teaching Hospital, south-south, Nigeria. Methods and Materials This was a retrospective descriptive study of women who pre- sented with genital prolapse in University of Calabar Teaching Hospital over a 10-year period from May 1, 2009 to June 1, 2019. Data of patient diagnosed with genital prolapse within this period were collected from registers in the gynecological clinic, gynecological ward, gynecological theatre, and from patients’ case records in the medical record department. Data obtained included age, parity, menopausal status, occupation, marital status, grade of prolapse, duration of prolapse before presentation, history of antenatal care, history of skilled atten- dant at previous deliveries, and history of contraceptive use. SPSS Statistics (IBM Corp. version 22) program was used for data analysis. Results During the period studied, of the 15,543 new gyneco- logical clinic attendees 45 patients were diagnosed with Uterovaginal prolapse: The sociodemographic profile and reproductive health service uptake in A Low Resource Setting, Calabar, Nigeria Charles Obinna Njoku,a,b Amarachukwu Nnaemezie Njoku,b Efiok Eyo Efioka,b aDepartment of Obstetrics and Gynecology, University of Calabar, Calabar, Nigeria. bDepartment of Obstetrics and Gynecology, University of Calabar Teaching Hospital, Calabar, Nigeria. Correspondence to: Njoku Charles (email: charlesnjokuobinna@gmail.com). (Submitted: 09 September 2019 – Revised version received: 04 October 2019 – Accepted: 12 October 2019 – Published online: 26 February 2020) Objective To determine the prevalence, sociodemographic profiles, utilization of reproductive health services, and delay in seeking medical care of patient with uterovaginal prolapse in Calabar, Nigeria. Methods This was a retrospective study of women who presented with uterovaginal prolapse at University of Calabar Teaching Hospital, Calabar, Nigeria between May 1, 2009 and June 1, 2019. Patients’ case records were retrieved and analyzed. Statistical analysis was done using SPSS Version 22. Results The prevalence of genital prolapse was 0.3%. The mean age and parity were 60.19 ± 8.71 years and 6.31 ± 2.80, respectively. The mean duration of symptoms before presentation was 3.19 ± 2.16 years. Genital prolapse was commonest among age group 60–79 years (52.8%), parity 5–9 (66.7%), post-menopausal (97.2%), primary education (55.6%), and farmers (47.2%). Grade 3 uterovaginal prolapse was the commonest grade (58.3%). Most patients (86.1%) had symptoms of genital prolapse for less than 5 years before seeking medical treatment. The majority of patients had no antenatal care during their pregnancies (80.6%), no skilled attendant at deliveries (86.1%), and no contraceptive use during their reproductive years (77.8%). Participants with lower parity (1–4) (p = 0.03), higher educational level (p < 0.001), and teachers/civil servants (p = 0.043) presented earlier (<1 year) to the hospital. Conclusion There is poor utilization of reproductive health services among women who develop uterovaginal prolapse in our environment. Women with higher social status sought for help earlier. Increasing awareness of this condition and providing antenatal care, skilled birth attendants, and contraceptive services will reduce the burden of this condition. Keywords uterovaginal prolapse, reproductive health services, delayed presentation. 23 Original Uterovaginal prolapseC. Obinna Njoku et al. J Contemp Med Sci | Vol. 6, No. 1, January–February 2020: 22–25 genital prolapse, giving a prevalence of 0.3%. However, 39 case records were retrieved of which 36 had adequate information for analysis. The mean age and parity were 60.19 ± 8.71 years and 6.31 ± 2.80, respectively. The mean duration of symptoms before presentation was 3.19 ± 2.16 years. Sociodemographic features of patients are shown in Table 1. Genital prolapse was commonest among age group 60–79 years (52.8%), fol- lowed by 40–59 years (44.4%). The modal parity was 5–9 (66.7%). Majority (97.2%) of the patients were post-meno- pausal, 55.6% had primary education, 47.2% were farmers, and 94.4% were married. Grade 3 uterovaginal prolapse was the commonest grade (58.3%) and Grade 2 was the second commonest (38.9%) while Grade 1 was the least (2.8%) as shown in Fig. 1. Table 2 shows the duration of symptoms before seeking care and usage of reproductive health services of patients. The commonest duration of symptoms before seeking med- ical treatment was 2 years and below (44.4%), followed by 3–4 years (36.1%), and the least was 7 years and above (8.3%). The majority of patient had no antenatal care during their pregnancies (80.6%), no skilled attendants at deliveries (86.1%), and did not use contraceptive during their repro- ductive years (77.8%). The relationship between delay in seeking medical care and sociodemographic characteristics of patients is shown in Table 3. Higher proportion (66.7%) of participants with lower parity (1–4) presented earlier (<1 year) compared to participants with higher parity and the difference is statistically significant (p = 0.03). Participants with tertiary (66.7%) and secondary education (100%) pre- sented earlier (<1 year) than those with lower educational level (p < 0.001). Teachers (100%) and civil servants (66.7%) sought help earlier (<1 year) than farmers, traders, and housewives (p = 0.043). Table 1. Sociodemographic features of participants. Variables Frequency Percentage (%) Age (years)   40–59 16 44.4 60–79 19 52.8 >80 1 2.8 Parity  1–4 9 25 5–9 24 66.7 >10 3 8.3 Menopausal status Post-menopause 35 97.2 Pre-menopause 1 2.8 Education level No formal education 9 25 Primary 20 55.6 Secondary 4 11.1 Tertiary 3 8.3 Occupation  Farmer 17 47.2 Trader 11 30.6 Housewife 4 11.1 Teacher 3 8.3 Civil servant 1 2.8 Marital status   Married 34 94.4 Single 2 5.6 Fig. 1 Grade of genital prolapse among participants. Table 2. Reproductive health seeking behavior of participants Variables Frequency Percentage (%) Duration of symptom before presentation (years)   ≤2     3–4 16 44.4 5–6 13 36.1 ≥7 4 11.1   3 8.3 Antenatal care in previous deliveries  Yes     No 7 19.4   29 80.6 Skilled attendant at deliveries  Yes 5 13.9 No 31 86.1 History of contraceptive use  Yes 8 22.2 No 28 77.8 24 Original Uterovaginal prolapse C. Obinna Njoku et al. J Contemp Med Sci | Vol. 6, No. 1, January–February 2020: 22–25 Discussion The prevalence of uterovaginal prolapse among gynecological clinic attendees in this study was 0.3%. This was comparable to 0.8% of gynecological clinic attendees south-south Nigeria, but lower than 3.9% of gynecological admissions in south-east Nigeria, and 1.4% of gynecological admissions in northern Nigeria.1,2,4 The prevalence of genital prolapse in this study may not be the true representation of the burden of the con- dition as this is a hospital-based study. Moreover, social and economic barriers that may preclude hospital presentation are highly prevalent in our environment. There is need for com- munity-based study in order to ascertain the actual burden of genital prolapse in this environment. This will help to plan effective preventive strategies. The mean age for genital prolapse in this study was 60.19 ± 8.71 years, with the modal age being 60–79 years. Similar findings were reported from previous studies.1.2,3 The mean parity was 6.31 ± 2.80, with uterovaginal prolapse being commonest among grandmultiparous women. Similarly, in other studies, genital prolapse was commonest among grandmultiparous women.1,2,10 The present study agrees with previous surveys that uterovaginal prolapse is most preva- lent among post-menopausal women.1,2,11 Majority of women with genital prolapse in this study were farmers. This agrees with findings from other African studies.1,12 Grandmultiparity, post-menopausal status and farming can be explained as risk factors for uterovaginal prolapse as repeated childbirth leads to disruption of the myofascial fibers that support the pel- vic organs, estrogen withdrawal weakens the integrity of the pelvic support and the physical activities involved in farm- ing increases the intra-abdominal pressure, leading to genital prolapse. Third-degree uterovaginal prolapse was the commonest type in this study. This was similar to findings reported by Oraekwe et al. in south-east Nigeria.1 Studies in Enugu, south- east Nigeria, Port-Harcourt, and south-south Nigeria showed contrasting findings, with second-degree uterovaginal pro- lapse being the most prevalent type.10,11 The disparity may be explained by difference in level of awareness and care-seeking attitude of patients in the different study settings. In the present study, majority of women with genital prolapse did not have antenatal care during their pregnan- cies, there were no skilled attendants during their labors and deliveries, and they did not receive contraceptive services during their reproductive years. These findings underscore the importance of reproductive health services in preventing development of genital prolapse. Antenatal care services and presence of skilled personnel during labor and delivery can prevent conditions such as prolonged labor, obstructed labor, traumatic deliveries and perineal lacerations. These obstetric conditions are known to predispose to genital prolapse.5,9 The use of contraceptives enable women to space pregnancies and limit pregnancies to desired number. This prevents high parity which is a known predisposing factor of genital prolapse.1,2,10 Majority of women in the present study with lower par- ity, higher educational level and skilled occupation such as teachers and civil servants presented earlier (<1 year) to the hospital. These findings suggest that women with higher socio- economic status may be better informed of this condition and were able to overcome socioeconomic barriers against access- ing medical treatment. These challenges include depending on husband or other relatives for permission and finance to seek medical treatment, and cultural and religious beliefs against orthodox medical treatments.13 There is a need for increased awareness, especially among women of lower socioeconomic status in order to improve health-seeking behavior of women with genital prolapse. There should also be a scale-up education on the importance of reproductive health services such as antenatal care services, skilled personnel, services in labor and delivery, and family planning services, as preventive tools for genital prolapse. These reproductive health services should be made available and accessible to women to reduce genital prolapse and its antecedent distressful morbidities. Conflict of Interest None Table 3. Relationship delay in seeking medical treatment and socio-demographic characteristics of participants. Variables Total Duration of symptom p-value1 year and below (%) Above 1 year (%) Age (years) 40–59 16 7(43.8) 9(56.2) X2 = 5.456 60–79 years 19 2(10.5) 7(89.5) Df = 2 >80 years 1 0(0.0) 1(100.0) P value = 0.065 Parity 1–4 9 6(66.7) 3(33.3) X2 = 11.333 5–9 24 3(12.5) 21(87.5) Df = 2 >10 3 0(0.0) 3(100.0) P value = 0.03* Education level     No formal education 9 0(0.0) 9(100.0)   Primary 20 3(15.0) 17(85.0) X2 = 18.844 Secondary 4 4(100.0) 0(0.0) Df = 3 Tertiary 3 2(66.7) 1(33.3) P value < 0.001* Occupation     Farmer 17 1(5.9) 16(94.1)   Trader 11 4(36.4) 7(63.6) X2 = 9.849 Housewife 4 1(25.0) 3(75.0) Df = 4 Teacher 3 2(66.7) 1(33.3) P value = 0.043* Civil servant 1 1(100.0) 0(0.0)   25 Original Uterovaginal prolapseC. Obinna Njoku et al. J Contemp Med Sci | Vol. 6, No. 1, January–February 2020: 22–25 References 1. Oraekwe OI, Udensi MA, Nwachukwu KC, Okali UK. Genital prolapse: A 5-year review at Federal Medical Centre Umuahia, Southeastern Nigeria. Niger. Med. 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This work is licensed under a Creative Commons Attribution-NonCommercial 3.0 Unported License which allows users to read, copy, distribute and make derivative works for non-commercial purposes from the material, as long as the author of the original work is cited properly. dx.doi.org/10.22317/jcms.02202005