By Inge Hemel, Pelvic Floor Physiotherapist, and Odette Hekster, Managing Director of PSI-Europe
Edited by Madeleine Moore, Technical Advisor for PSI-Europe

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Let me tell you the story of Tiyisela. Tiyisela[i]is a 27-year-old woman, wife of Sam and mother of three children, living in a rural village in northern South Africa. After the birth of her second son three years ago, she started leaking urine while coughing and walking. Since her third delivery last year things worsened, and she now experiences vaginal bulging during the day, leaking of urine while walking, and a continuous urge to go to the toilet. Sex started to get painful, and not being able to talk about matters, she started avoiding her husband. She cannot afford menstrual or sanitary pads, and so she feels shame, embarrassment, and fear that people might smell her. She has started avoiding social events altogether. She can’t go to the market on public transport to sell her vegetables anymore because of the constant urge and leaking. Her husband eventually left her, and she was left with no social support and no income.

This story is shared by Inge Hemel, pelvic floor physiotherapist, who is speaking to Odette Hekster, Managing Director at Population Services International (PSI)-Europe, in the run-up to International Women’s Day; and it is all too-common an experience of women in low-income countries.

A recent report by the McKinsey Health Institute called “Closing the Women’s Health Gap: A $1 Trillion Opportunity to Improve Lives and Economies” highlights that addressing shortcomings in women’s healthcare would reduce the time women spend in poor health by almost two-thirds. More than 3.9 billion women would experience richer, more productive lives—generating $1 trillion in benefits to the global economy each year. The report applies a wide lens to women’s health, considering both sex-specific conditions and conditions that affect women disproportionately or differently. Women’s health is frequently narrowed to sexual and reproductive functions, rendering invisible the multiple, interconnected ways women unjustly suffer.

Pelvic health is one of those urgent health areas that women suffer from, often in silence. The McKinsey report mentions a limited understanding of the female biology, resulting in fewer and less effective treatments for women, as one of the root causes that explain the women’s health gap. It calls for improved women-centric research,systematic sex- and gender-specific data collection, expanding women-sensitive/specific care, prevention, and treatment services; and creating incentives and new financing models to stimulate investment. While it is true that there is limited understanding of the female biology and female-specific diseases—for example, people with endometriosis often wait up to ten years before being correctly diagnosed—there are accessible and existing health solutions right at our doorstep yet untapped. Effective and feasible treatment to treat pelvic health problems exists. Inge Hemel has been a pelvic floor physiotherapist for 20 years, having  worked across countries. She recently worked in South Africa together with a local uro-gynaecologist. “I have seen women suffer tremendously,” says Hemel, “while the treatment doesn’t require rocket science, excessive resources or excellent access to health facilities.”

Why then is pelvic health still not in the scope of so many women’s health projects in low-income countries? Hemel explains that there is, understandably, a lot of interest in and support for reducing maternal mortality rate, but very little attention seems to be going to the suffering that women who survive complications at birth might experience. Roughly one in three women globally suffer from pelvic floor complaints like urinary incontinence, faecal incontinence, sexual dysfunction or pelvic organ prolapse; childbirth being the greatest risk factor,[ii]so one cannot argue that this is not an urgent health need.

Hekster has seen women’s health issues get sidelined as not urgent “because of lack of robust evidence,” but this lack of evidence stems from under-investments in these health areas because they are not seen as urgent. It’s a vicious cycle. You can’t measure what only exists on the sidelines. For years, Hekster’s organisation Population Services International (PSI)-Europe has conducted research and advocacy to put menstrual health high on the agenda and make the case that investments in menstrual health are not only the right thing to do from a human rights and gender equality perspective, but also generates impact and return on investment across health, education and economic well-being for people who menstruate and entire communities. But despite the evidence base continuing to grow, what gets funded? More reports. Hekster and PSI-Europe believe that we need to strike a better balance between researching a topic into mainstream, and having the courage to put our money where our mouth is: in communities and serving women’s health needs. We will only be able to measure true impact when we have real solutions out there, and we will be improving women’s lives in the meantime.

Menstrual health is not sexy to policy makers. And while the menstrual cycle is central to women’s health – it does not only determine fertility, but is also a predictor and indicator of broader health issues – it is still not central to philanthropy. Pelvic health is not any sexier.Policy makers and funders often seem more interested in innovative (technical)solutions, leveraging their country’s technological advancement and serving domestic business interests. While there is definitely a need to invest more in innovative research to, for example, improve technology for less invasive and more effective diagnostic solutions for conditions such as endometriosis; there is an immense opportunity to improve women’s health conditions now, particularly in contexts where women experience intersecting vulnerabilities and where the international community does not want to leave anyone behind to realize the Sustainable Development Goals (SDGs).

Leaking urine or stool is not something women talk about. Hemel explains that these problems are linked to shame and blame and are not easily shared. The general lack of knowledge of these dysfunctions and their treatments prevents women from seeking help.[iii]Even if they did seek help, few health care workers are equipped to treat these dysfunctions in low-income countries[iv]where this has a more profound effect due to interrelated socio-economic issues, like in Tiyisela’s experience. Studies conducted in Africa demonstrate that women suffering from these conditions experience more stress, domestic violence or social isolation than women without them.[v]Imagine if we could take that stress, domestic violence and isolation away and seethe benefits that not only women, but also families, communities and economies would experience. Do we need another report to prove that point? No, we don’t need a report or fancy innovations or studies; we need to implement existing, proven, and affordable solutions that are available right at our doorstep.

“Recognizing the value of female pelvic floor health is restoring women’s dignity. Even more, it is restoring their pivotal role in society.”

Pelvic floor physiotherapy is a low-cost treatment and thus this should be appealing to funders. But most importantly, recognizing the value of female pelvic floor health is restoring women’s dignity. Even more, it is restoring their pivotal role in society. There is a need for pelvic floor education, early diagnosis, early referral to treatment, and breaking the taboo. Adding women’s pelvic health knowledge to current physiotherapists’ and community health workers’ knowledge base and then using the existing pathways in rural community-based health systems is an efficient way to do this, according to Hemel.

Let’s not put more funding into excessive research if programmatic data and insights from women speak to the facts. Let’s act. Let’s use that money to actually close the gap, rather than just talking about it. Let’s listen to what women say they need, and let’s put some proven solutions into action. If truly moving the needle on closing the women’s health gap isn’t sexy, then we don’t know what is.

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[i] This is a fictive name to protect the privacy of the person.

[ii] INCONTINENCE 6th Edition 2017 vol 1,P,Abrams, L.Cardozo, A.Wagg, A.Wein. ICUD, ICS. ISBN: 978-0-9569607-3-3.  

Omeke, C.A. & C.E. Azuka (2023),Urinary incontinence among women in sub-Saharan Africa - an overview, Frontiers in Urology, 8 November 2023.

Walker GJ, Gunasekera P. Pelvic organ prolapse and incontinence in developing countries: review of prevalence and riskfactors. Int Urogynecol J (2011) 22(2):127–35.

[iii] A. Borsamo. Factors associated with delay in seeking treatment among women with pelvic organ prolapse at selected generaland referral hospitals of Southern Ethiopia, 2020. BMCWomen's Health volume 21,Article number: 86 (2021) 

Krause HG, et al. Treatment-seeking behaviour and social status of women with pelvic organ prolapse, 4th-degree obstetric tears, and obstetric fistula in western Uganda. Int Urogynecol J. 2014 Nov;25(11):1555-9.

M Siyoum et al, Inequality inhealthcare-seeking behavior among women with pelvic organ prolapse: a systematic review and narrative synthesis . BMC Womens Health 2023 May 3;23(1):222.

[iv] Pretorius D, et al. ‘Sexual History Taking: Perspectives on Doctor-Patient Interactions During Routine Consultations in Rural Primary Care in South Africa’, Sexual Medicine, 2021;9,Page 100389

[v] H Krause et al, Incidence of intimate partner violence among Ugandan women with pelvic floor dysfunction. Int J Gynaecol Obstet. 2019 Mar;144(3):309-313.
Krause HG, et al. Mental health screening in women with severe pelvic organ prolapse, chronic fourth-degree obstetric tear and genital tract fistula in western Uganda. Int Urogynecol J. 2017 Jun;28(6):893-897.

Photo credit: PSI