Assessing burden, risk factors, and perceived impact of uterine fibroids on women’s lives in rural Haiti: implications for advancing a health equity agenda, a mixed methods study

doi:10.21203/rs.3.rs-35994/v1

Background

Uterine fibroids, the most common cause of gynecologic surgery, have a reported lifetime cumulative incidence of 59% among Black women in the U.S. Uterine fibroids increase mortality, morbidity, and negatively impact the quality of women’s lives. To our knowledge, no study has been published in the literature about fibroids in Haiti. We conducted a mixed methods study to assess the burden and risk factors of uterine fibroids, as well as their effects on women’s quality of life.

Methods

A convergent mixed methods study was conducted between October 1, 2019 and January 31, 2020 at MUH’s (Mirebalais University Hospital) OB-GYN outpatient department. Quantitatively, in a cross-sectional study 211 women completed a structured questionnaire. In-depth interviews with a subset of 17 women with fibroids and 7 family members were implemented for the qualitative component. Descriptive statistics were calculated for clinical and social demographic variables. Logistic regression was performed to examine associations between fibroids and related risk factors. An inductive thematic process was used to analyze the qualitative data. A joint display technique was used to integrate the results.

Results

The prevalence of uterine fibroids was 60.1%. Anemia and infertility were the most frequent complications— 52.6% and 33.6%, respectively. Factors associated with uterine fibroids included income decline (OR = 4.7, 95% CI: 2.1–10.9, p = < 0.001), excessive expenses for transport (OR = 4.4, 95% CI: 1.6–12.4, p = 0.005), and family history with uterine fibroids (OR = 4.6, 95% CI: 1.6–13.6, p = 0.005). In contrast, higher level of education and presence of micro polycystic ovarian syndrome were found to be protective (OR = 0.3, 95% CI: 0.1–0.9, p = 0.021) and (OR = 0.2, 95% CI: 0.1–0.97, p = 0.044), respectively. Qualitative findings demonstrated that uterine fibroids deeply affected the quality of women’s lives. The concept of a poverty cycle of uterine fibroids emerged.

Conclusions

A vicious cycle of poverty and women’s experience with fibroids demonstrate the long-term struggle that women endure. Health system strengthening, social support, and economic improvement are keys to alleviate women’s suffering and promote social justice through access to adequate care for women with uterine fibroids in Haiti.

Health Policy

uterine fibroids

risk factors

women

poverty

Haiti

Uterine fibroids are benign tumors of the smooth muscle of the uterus and their burden across populations varies widely – with rates ranging from 4.5–68.6% (1). Notably, several studies in the United States have indicated that fibroids are more prevalent among Black women. One study indicated that life-time cumulative incidence of premenopausal uterine fibroids by ultrasound screening was 59% among Black women compared to 43% among white women in the U.S (2). The same study in communities across the United States reported rates of uterine fibroids as high as greater than 80% and 70%, among Black and white women, respectively, by the age of fifty (2). The prevalence of uterine fibroids in many populations across the globe is unknown – this is the case for Haiti where rates of uterine fibroids have not been documented.

Studies have identified a variety of risk factors for fibroids including age, race, family history, and comorbid conditions such as diabetes and hypertension (1, 3). Clinical manifestations of fibroids can range from asymptomatic presentations to more severe conditions such as bleeding, dysmenorrhea, and fertility problems (1, 5–7). Fibroids – when left untreated – are associated with a number of debilitating complications such as acute or chronic pelvic pain, anemia, pyomyoma, hydronephrosis, and premature delivery as well as fetal intra-uterine growth retardation (8–12).

Fibroids are the most common benign tumors of the uterus and are the primary reason that surgery is performed in gynecology (13). Uterine fibroids are readily treated through surgical intervention, but without treatment this condition leads to significant chronic morbidity - and even mortality. In communities that lack sufficient access to medical care, uterine fibroids have been shown to deeply affect a woman’s quality of life (14).

There are several methods of treatment currently available for uterine fibroids – including radiological, medical, and surgical interventions (13, 15). High-resource countries have achieved remarkable improvements in the treatment of uterine fibroids, including the emergence of laparotomy, laparoscopy and robotic surgery (13, 15, 16). These treatment options available to women in these settings have helped many women conserve their fertility. In contrast, access to modern fibroid surgical care is largely out of reach for most women in low and middle income settings because the medical equipment, infrastructure and specialized personnel required for such interventions are not widely available (17–20).

This gap in the treatment is highly correlated to the weaknesses of the health system in resource-limited countries. In Haiti, there are only seven beds per 10,000 people compared to the Dominican Republic its neighborhood country with 16 per 10,000 people according to the WHO website consulted June 22, 2020. The availability of specialized care is even more dire, as Haiti only has 5.9 surgical specialist including obstetricians, surgeons, and anesthetists per 100,000 people(21), in marked contrast to the 20–40 anesthetists, and obstetrics-gynecology (OB-GYN) specialists per 100,000 people recommended by the Lancet Commission (19). Further, the majority of Haitians live in rural areas and have limited access to basic health care and even less access to surgical care (22).

Currently, little is known about the epidemiological profile in the Haitian context of these women who present with fibroids, and the impact of uterine fibroids on their quality of life is not well understood. To assess this gap, we conducted a convergent mixed methods study – the first of its kind to address uterine fibroids in Haiti. We implemented a cross sectional study to examine the prevalence, complications, and risk factors associated with uterine fibroids. We also conducted a qualitative study to explore patients’ illness experience and care seeking trajectories, to understand the impact of uterine fibroids, and identify the structural barriers that shape access to fibroid care.

Study setting

Mirebalais University Hospital (MUH) is a three-hundred bed facility located in the Central Plateau built and supported by Partners In Health in collaboration with the government of Haiti. One hundred of these beds are in the OB-GYN Department. The primary catchment area (Mirebalais, Savanette, Saut d’Eau ) of MUH is 187,077 persons and the secondary catchment area (North, Northeast, Artibonite, part of the west department) serves more than 3.1 million Haitians (23). MUH has 6 operating rooms and performs 6,000 surgeries per year and about 250,000 visits per year overall. About 40% percent of surgeries are for OB-GYN conditions and about 12% of outpatient visits are for GYN. The OB-GYN service includes a triage area, labor and delivery, pre- and post-partum wards, and one gynecology ward. The hospital offers a large range of women’s health services including prenatal care, family planning, ultrasound, gynecological care, complete emergency obstetrical care, cancer screening, and gynecological surgery (including uterine fibroids).

Uterine fibroids represent the most common illness among women presenting at the MUH’s outpatient department (OPD) at the OB-GYN ward. Fibroids represent approximately 50% of the gynecologic surgeries at the hospital. It is the most frequent gynecologic surgery and the most prevalent pre-operatory diagnosis at MUH.

Study design

This study used a convergent mixed methods design in which qualitative data were collected to provide elaboration, clarification, and explanation for the quantitative results and vice versa (24). The quantitative cross-sectional study included all women 20 years of age or older who were seeking gynecological care at MUH’s outpatient gynecology ward from October 1, 2019 to January 31, 2020. For the qualitative component, semi-structured interviews were carried out with 17 women with uterine fibroids from the quantitative sample and 7 of their family members. Purposeful sampling (25) was used to identify both sets of participants and to maximize variation women were selected in relatively equal numbers from within and outside of the Central Department( Figure 2).

Women having a current gynecologic ultrasound result documented in their medical record during the study period were invited to participate in the study. Family members who knew and supported the participants over time with the disease were selected based on their consent and the participant’s reference to the research team.

Excluded from the study were women who: were less than 20 years old, presenting for prenatal care at MUH, and those who refused to consent. Further, women who had a medical emergency or who otherwise were not able to participate due to medical considerations were not included in the study.

Measures

Quantitative data collection: A conceptual framework (Figure 1) was used to inform the survey questionnaire which included important covariates including age, parity (number of births), menopause, patient status (initial or follow-up visit), confirmed diagnosis of uterine fibroids, employment, monthly income, income decline reported after the diagnosis of uterine fibroids, excessive expense for transport to look for care for uterine fibroids, household expenses (such as education, food, self-care, and medical care, etc.), zone of residence, average time to get to the hospital, primary method of transport, main profession, health insurance status, education level, and family conflicts. Family conflict was assessed by reported problems of communication and disagreements between the women and their spouses after diagnosis of uterine fibroids (26). Further, the most frequent clinical signs and symptoms associated with uterine fibroids were ascertained including constipation, dysmenorrhea (pain during menstruation), acute pelvic pain (less than 3 months), chronic pelvic pain ( more than 3 months), menorrhagia (abundant bleeding during menstruation), metromenorrhagia (bleeding between periods), mictional difficulty (pain with urination), pelvic pressure, pelvic infection, infertility (defined as > 1 year without conceiving a child while being sexually active and not receiving family planning); related conditions included deep vein thrombosis, urinary stones, hydronephrosis, and anemia (Hb<12 mg/dl) (7,10,12,16,27). We also measured self-reported stress and depression using a locally validated depression screening tool, the Zanmi Lasante-Depression Symptom Inventory (ZL-DSI) (no depression < 13, mild depression 13-17, moderate depression 18 to 27, and severe depression 28-39) (28). Clinical data were obtained through structured questionnaires and chart reviews.

Qualitative data collection

Participants in the qualitative study took part in a single, in-depth semi-structured interview which lasted 60-90 minutes. Interviews took place in a confidential quiet place of the participant’s choosing at the hospital. Recorded interviews were conducted in Haitian Creole by the first author and a trained research assistant. Semi-structured interview guides for the women and family members covered the following themes: (1) experiences living with fibroids; (b) their care-seeking trajectory; (c) the meaning attributed to fibroids; and (d) the effect of fibroids on the family’s social and economic life.

Data analysis

For the quantitative analysis descriptive statistics were used to report the sociodemographic and clinical characteristics of uterine fibroids. Bivariate and multivariate logistic regression were used to identify the risk factors associated with uterine fibroids. Variables with a p-value less than 0.2 in bivariate analyses were used to build the multiple logistic regression model separately for sociodemographic and clinical variables. Potential cofounders were forced into the model, irrespective of the p-value in bivariate analysis. We excluded variables that could potentially be collinear based on prior knowledge. For the depression score, we used the cut-off score for depression on the ZL-DSI previously published by Rasmussen et al (28). All quantitative analyses were performed using Stata, version 16.2.

For the qualitative analysis, a narrative analysis of all transcripts was performed to identify key concepts or theories related to the research question. Then, transcripts were analyzed in depth using an inductive, narrative and thematic content analysis approach (29,30). Transcripts were reviewed in full, and a subset of transcripts were open-coded to identify a set of emerging concepts that explained the perceived impacts of uterine fibroids. These initial concepts were used to develop a draft codebook, which was then piloted and revised into a final codebook which was in turn used to code the entire dataset. The coded data was analyzed using an inductive process that sought to identify a set of key descriptive concepts. These initial concepts were revised through an iterative approach to the data, resulting in a final set of descriptive categories.

Finally, quantitative and qualitative results were integrated by using a joint display technique (31) – the ‘Poverty cycle’ - which highlights the interconnected phenomena emerging from the qualitative and quantitative results (Figure 5). This figure identifies points of convergence across the qualitative and quantitative datasets while demonstrating the cyclical processes that marked the experience of women living with fibroids in rural Haiti.

Quantitative findings

The data flow of all participants in the study is described in the Figure 3.

Table 1 describes demographic characteristics and complications of uterine fibroids of study participants. Among the populations studied, 70 (60.3%) were between 35 to 49 years old. Sixty-one (52.6%) were from the Central plateau Department (primary catchment area) area, whereas 55 (47.4%) were from other areas of the country. Over one hundred (87.1%) did not have health insurance. Sixty-seven (57.8%) reported that they experienced a decline in household income.

Of 193 participants included in the analysis, 116 (60.1%) had uterine fibroids. The two most frequently observed clinical symptoms included stress 92 (79.3%) and dysmenorrhea 73 (62.9%). In addition, documented anemia 61 (52.6%), and infertility 39 (33.6%) were the two most prevalent major complications (Table 1).

In the bivariate analysis (Table 2), the odds of having uterine fibroids were 3.8 times greater among those who experienced excessive expense for transport compared to those who did not have this expense (95% CI: 1.65 - 8.74, p=0.002). In addition, those who experienced income decline had a 3-fold greater odds of having uterine fibroids compared to those who did not (95% CI: 1.64 - 5.54, p<0.001) , and those who were farmers had a 5.1-fold greater risk of having uterine fibroids compared to those without a specific profession (95% CI: 1.04 - 25.29, p=0.044). Family history with fibroids also demonstrated a strong association with uterine fibroids in this population (OR=5.1, 95% CI: 2.11 - 12.33, p<0.001).

In the multivariate analysis (all variables included in the final model are shown in Table 3) women with fibroids had a 4.4 times greater odds of experiencing excessive expense for transport compared to those who did not experience excessive expense for transport (95% CI: 1.55 - 12.38, p=0.005). In contrast, education demonstrated a protective effect (OR=0.3, 95% CI: 0.09 - 0.87, p=0.021). Women with income decline had a 4.7 times greater odds of uterine fibroids compared to those who did not experience an income decline (95% CI: 2.05 - 10.93, p<0.001). In terms of clinical factors, the odds of having uterine fibroids were 4.6 times greater among women with a family history compared to those who did not have a family history of fibroids (95% CI: 1.58 - 13.56, p=0.005). The condition of micro polycystic ovary demonstrated a protective effect for uterine fibroids (OR=0.3, 95% CI: 0.10 - 0.97, p=0.044). Associations were not observed between uterine fibroids and age, patient status, health insurance, number of births, family conflict, polymenorrhagia, deep vein thrombosis, or depression categories in the multivariate model.

Qualitative findings

Four key themes (A-D, below) describing women’s experiences living with fibroids were inductively identified. They describe the complications and consequences of women’s care-seeking trajectories and highlight the structural and contextual factors that shape them.

Health system failure

Many women reported in their interviews that the Haitian health system did not deliver adequate care for their fibroids. While some participants indicated that they began their care-seeking by consulting with a traditional healer close to their home, most eventually sought care for their symptoms within the public or private health system. Women explained that before arriving at MUH, they undertook an extensive number of visits to different care providers – “roaming” from one hospital or clinic to the next in an attempt to seek care for their condition. They recounted that at each stage they were unable to obtain effective treatment. For many, the protracted search for care led to significant delays, increasing pain, and mounting health care costs.

“I came to know I had fibroids at General Hospital in Port-Au-Prince. [Before that] the « Medsen Fey » [herbalist and shaman] told me I was pregnant. Well, there was a « Medsen Fey » who told me I was going to have twins. I said, ‘God knows everything. I know nothing.’ I spent money over, over, and over again [on treatments] and nothing worked out. I got really sick on July 26, 2019. They rushed me to the emergency room of the General Hospital. I came here [to MUH] after I left the emergency room of General Hospital. They asked me to bring the sonography result back, but I could not find a doctor. I finally found one at 9 :00 a.m. I was sent to Rue Monseigneur Guilloux [private clinic]. And … it was 10 :00 a.m. When I got to the place I was sent, the receptionist told me, ‘No, there is no doctor here for this disease’ and said I have to come back the following day at 6 :00 a.m. My cousin could not come with me because she had to drop her children off to school. My other cousin told me she would come to take me and bring me here. They came here with me. General Hospital did not transfer me to MUH. My cousins and I came here ourselves. I consulted several times”

-Unemployed woman with uterine fibroids from Port-Au-Prince

Long wait time for incomplete services

Traveling to MUH Mirebalais from the Central Plateau via public transport often entailed a long wait time for getting access to care for their fibroids. Women explained that they often had to leave their homes a full day before their medical appointment. They noted that seeking care for their fibroids at MUH required reporting to different services within the hospital, and each service had a long queue. In some cases, participants reported spending an entire day waiting for their medical consultation, only to be told to leave the hospital and return on the next day. For these women, the wait for a single consultation resulted in a long-time commitment with significant social and economic implications.

“I usually leave home at 6:00 am… I take the bus in Delmas 33 to go to Croix-Des-Bouquets. I take another bus there so that I get to the hospital by 8:00 a.m. Well…when I get there, I have to get my records released, I have to get my vital signs checked and, they transfer my records to the doctor. I wait for the doctor if he has not arrived yet… There are a lot of people. There are a lot of people [waiting] for gynecology. This process is very long … I do not like to sleep at the hospital. There is nowhere to sleep there. If I do a test today at the hospital, I must come take the results tomorrow. So, I go [home] to Port-Au-Prince and I return back to Mirebalais. So, that costs me money.”

-Teacher with uterine fibroids from Port-au-Prince

Gender inequality

Women with uterine fibroids explained that they often felt pressured to perform all housework including cooking and caring for children (if applicable) with little to no support or minimal support from their spouses or partners. Family members shared this same perception. The effects of uterine fibroids made it exceedingly difficult for women to carry out the physical labor expected of them, but they nonetheless attempted to keep up with the duties they were expected to fulfill.

“Usually, I do everything, I wash clothes, I make sure that my husband’s clothes are ready, I make sure that my child’s clothes are ready, I make sure they have food and I give the maid instructions while I am not at home.”

-Nurse with uterine fibroids from Delmas

“If she [my wife] was in good health, she would do all the housework. But she cannot. She cannot take care of the household. Sometimes she cooks, but sometimes she does not. She cannot sit and cook when she suffers from the complications of the disease.”

-Family member, husband from Mariani

Women reported that the effects of the gendered expectations related to fertility were particularly painful for them. Fertility challenges caused women personal sadness, but infertility also led to social exclusion. Women explained that that they were blamed for the fertility challenges that they experienced because of untreated fibroids:

“I am unhappy and so is my husband because of the fibroid, because most Haitian men would like to have children. As soon as you cannot, their family members start naming you: “Manman Milet” (a sterile woman).”

-Teacher with uterine Fibroids from Mirebalais

Poverty

Women indicated in their interviews that the physical effects of fibroids imposed on them a number of social and economic consequences. Notably, women with fibroids were largely excluded from social and economic opportunities. Participants recounted how the effects of their fibroids made them lose their job or have to give up their business. The loss of income severely impacted their ability to do housework and pay for their children’s school fees.

“I do not have a job. I used to work in an orphanage and a restaurant. I worked in the morning and in the evening. I had to quit both jobs because of the fibroid.”

-Unemployed woman with uterine fibroids from Port-Au-Prince

The disease [uterine fibroids] affects my mother because she would have worked in order to take care of my education. The disease [uterine fibroids] affects my mother because she cannot cook, clean up the house, send me to school.

-Family member, daughter from Mirebalais

The study found results of the quantitative and the qualitative part of the study are interconnected, and we merged them under the concept of a poverty cycle of uterine fibroids (Fig. 5). The poverty cycle of uterine fibroids is processual and nonlinear, where one aspect interacts with another. The concept suggests that limited funding constrains the capacity of the health system to deliver care for fibroids. Consequently, uterine fibroids become complicated and debilitating, resulting in women losing their jobs and businesses. Therefore, women do not have income and savings, falling deeper into poverty. This cycle can progress and result in avoidable morbidity and mortality as well as negative social and economic consequences.

The study revealed a high prevalence of uterine fibroids at the MUH’s OPD. This high prevalence was expected because the population has arrived after attempting to receive adequate care at other facilities and the majority of women in the study were between 35 and 49 years of age – the age bracket with highest prevalence of uterine fibroids. Further, ultrasound was used as the reference method to select our population and it has high sensitivity for the diagnosis of uterine fibroid (32). It was possibly related to the higher likelihood of poverty supporting the concept of the cycle of poverty.

The study found the most frequently reported symptom was stress. We believe that gender inequity and political instability exacerbated the level of stress among women with fibroids. The most two frequent complications reported in our study were anemia and infertility. This finding is understandable because anemia was very prevalent and was related to bleeding associated with uterine fibroids, the high burden of parasitic infections and malnutrition in Haiti. In addition to the presence of fibroids, the lack of specialized care for infertility could be another cause of the high rate infertility observed in this study.

The study did not find an association between age and uterine fibroids in the multiple logistic regression model. This finding is at odds with a previous study which demonstrated that people greater or equal to 40 years old were more likely to have uterine fibroids (1). In addition, this study demonstrated that health insurance coverage in Haiti was about 6 to 7 times lower than the health insurance coverage in U.S. and Europe (33). This lack of insurance coverage in Haiti explains why women was exposed to out-of-pocket expenditures and why they cannot afford care in a private clinic. Most women with uterine fibroids were in follow-up visit and the majority were seeking surgical care for more than 12 months compared to 21 weeks at Brigham and Women Hospital for hysterectomy (34). This finding is consistent with the long waiting time mentioned in the qualitative part of the study and explains the growing number of patients on the waiting list. These findings, aside from the lack of human resources and biomedical equipment in the Haitian health system, confirmed the qualitative findings that the Haitian health system fails to deliver care for its population.

The findings indicated that more than four-fifths of the population were poor, and women with uterine fibroids were more likely to experience excessive expenses to go to the hospital. They were also more likely to experience decline in their income, which is similar to previous studies which have shown that women with uterine fibroids were more likely to miss days at work, and those with lower income were more likely to experience severe disease and had negative experiences with higher education (7, 35, 36). These results relate to the poor economic conditions facing Haiti. This study revealed that women with uterine fibroids with lower education were more likely to have uterine fibroids. Women with higher education may be more likely to seek care and have more economic power compared to women with lower education. This study suggested that women with fibroid were more likely to be impoverished by the disease, which is supported by our qualitative findings which demonstrated that women with fibroids were subjected to economic and social exclusion.

Our quantitative findings support the concept that women with fibroids were excluded from various forms of ‘social goods’ – most notably health care and education. The qualitative findings provided a deeper and more comprehensive view of the mechanisms by which women with fibroids were socially isolated, as they were unable to participate in social activities such as attending church, and were often cast aside by community members or in-laws because their fibroids prevented them from conceiving. In the literature a quantitative study highlighted the negative impact of fibroids on housekeeping, performance at work, social activity, and attendance at work or higher education (7). The study underscored the importance of social determinants of health which were contributing factors in women’s suffering from fibroids and supported the emerging concept of the poverty cycle of uterine fibroids.

In the study, women with micro polycystic ovary were less likely to have uterine fibroids and this result confirmed the results of a previous study realized by Huang et al among women with infertility (37). However other previous studies have shown the contrary (1, 38). In addition, previous studies have shown that family history is an important risk factor for uterine fibroids in the literature (4, 39) and this study also demonstrated this association. However, stress, anemia, depression, menorrhagia, metrorrhagia, dysmenorrhea were not associated with fibroids, whereas a previous study has shown a significant association between these variables and fibroids (7). The absence of associations of uterine fibroids between stress and anemia can be explained by the fact both are broadly distributed in the Haitian population because of poverty, malnutrition, and political instability rooted in structural violence (40). Further study is needed to examine the burden of uterine fibroids among the Haitian population overall.

This study has several limitations. As a cross-sectional study using a hospital-based population, it is not generalizable to those who have not access care or who have accessed services at a health center. The qualitative data is also not generalizable, but it offers important insights into the myriad social and economic effects that women living with uterine fibroids face in settings where access to care is limited. It is possible that other clinical conditions may have been misdiagnosed as fibroids - a possible confounder resulting in an overestimation of prevalence. To mitigate misdiagnosis, we used ultrasound which has high specificity and sensibility to establish the diagnosis of uterine fibroids (32). The prevalence may also be underestimated since uterine fibroids can be also asymptomatic.

The prevalence of uterine fibroids in this population of rural women in Haiti is high, and the social and economic consequences associated with fibroids are deeply rooted in a vicious cycle of poverty, gender inequity, physical and social suffering. Women are motivated to pursue care for this treatable disease, but they encounter costly delays as they navigate a health care system that is fragmented and overwhelmed by a dearth of equipment and qualified health professionals. Health system strengthening, and programming that actively redresses the fragile economic and social conditions facing women with fibroids are key elements to promoting the social and economic rights by improving the health and quality of life of women with uterine fibroids in Haiti.

MUH

Mirebalais University Hospital,

OPD

Out-Patient Department

OR

Odds Ratio

ZL-DSI

Zanmi Lasante Depression Symptom Inventory

OB-GYN

Obstetrics and Gynecology

GYN

Gynecology

Ethical Approval and Consent to Participate

The study was reviewed and approved by institutional review boards of Harvard University and Zanmi Lasante, the local IRB committee in Haiti. Written informed consent was obtained.

Consent for Publications

Not applicable.

Availability of data and materials

The datasets generated and/or analyzed during the current study are not publicly available due to important sensible confidential information about the participants of the study but are available from the corresponding author on reasonable request.

Competing interests

None declared.

Funding

This research was funded by the Department of Global Health and Social Medicine at Harvard Medical School.

Authors’ contributions

CM conceived and coordinated the study. AM supported data analysis, formatting, and manuscript preparation. AK supported qualitative data analysis and manuscript preparation. HG helped merge the results and assisted with the manuscript preparation. MSF supported quantitative data analysis and the preparation of the manuscript. PF provided advice in the conception of the study. JM supported the analysis, interpretation, and manuscript preparation. All authors critically reviewed and approved the current version.

Acknowledgements

We are grateful first to the participants of the study then to the many individuals who contributed to this study. Christina Excellent, Bleus Gerson, Jimmy Jean Baptist, Marie Edelyne St Jacques, MD, Nathalie Price, Maxi Raymonville, MD, MMSc, Wesler Lambert, MD, Jason Silverstein, PhD, Christina Lively Thompson, MEd, Pierre Marie Cherenfant, MD, Jean Claude Ulysse, MD, Loune Viaud, Leandre Fernet, MD, MMSc, Jacques Saint Fleure, MD, Rebecca Kahn, PhD(c), Meredith Books, PhD, Mary-Jo Delvecchio Good, PhD, attendings and residents at the OB-GYN department at MUH.

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Table 1. Sociodemographics, economic characteristics, and clinical history of women receiving care for uterine fibroids at Mirebalais University Hospital’s outpatient department between October first, 2019 to January 31, 2020 (n=116)

Sociodemographic characteristics	n (%)
Age category
20-34	28 (24.1)
35-49	70 (60.3)
50+	18 (15.5)
Number of pregnancies (n=100)
No pregnancy	28 (24.1)
1-3 pregnancies	52 (44.8)
>3 pregnancies	20 (17.2)
Number of births (n=101)
No childbirth	43 (37.1)
1-3 childbirths	47 (40.5)
> 3 childbirths	11 (9.5)
Menopause (n=101)
No	81 (69.8)
yes	20 (17.2)
Family history of fibroids(n=83)
No	25 (21.6)
Yes	58 (50.0)
Pelvic infection (n=113)
No	31 (26.7)
Yes	82 (70.7)
Patient status
Follow-up visit	95 (81.9)
Initial visit	21 (18.1)
If follow-up patient (n=95)
<6 months	8 (5.7)
6-12 months	15 (9.8)
>12 months	72 (70.9)
Zone of Residence
Centre	61 (52.6)
Out of central plateau	55 (47.41)
Type of residence
Urban	91 (78.5)
Rural	25 (21.6)
Average time per medical appointment/visit (Time to go to the hospital) (n=114)
≤2h	92 (79.3)
>2h	22 (18.9)
Means of transport(n=115)
Public transport	100 (87.1)
Walk	10 (8.6)
Private transport	4 (3.5)
Main profession
Small business /market	48 (41.4)
Educator	15 (12.9)
Nurse	13 (11.2)
Farmer	12 (10.3)
Other	28 (24.1)
Health insurance
No	101 (87.1)
Yes	15 (12.9)
Education (n=101)
Primary	27 (23.3)
Secondary or higher	74 (63.8)
Family conflicts(n=113)
No	86 (74.1)
Yes	27 (23.3)
Employment status
Not employed	69 (59.5)
Employed	47 (40.5)
Monthly income (n=113)
15.4 USD- ≤206 USD	102 (87.9)
>206USD	11 (9.5)
Income decline
No	49 (42.2)
yes	67(57.8)
Degree of income decline if income decline observed
High	49 (61.5)
Moderate	21 (32.3)
Low	4 (6.2)
Major expense categories
Medical care	23 (19.8)
Non-medical care	93 (80.2)
Excessive expenses for transport (n=101)
No	10 (8.6)
Yes	91 (78.4)
Clinical diagnostics and complications
Confirmed fibroids	116 (60.1)
Anemia
No	55 (47.4)
Yes	61 (52.6)
Infertility (n=112)
No	73 (62.9)
Yes	39 (33.6)
Deep vein thrombosis (n=115)
No	97 (83.6)
Yes	18 (15.5)
Urinary stones
No	99 (85.3)
Yes	17 (14.7)
Hydronephrosis
No	110 (94.8)
Yes	6 (5.2)

Table 2. Bivariate analysis examining risk factors associated with uterine fibroids among sociodemographic and clinical variables at MUH age greater or equal to 20 years old (n=193)

Sociodemographic characteristics	Odd ratio	95% CI	P-value
Age
20- 34	-
>35-49	2.6	(1.33 - 5.03)	0.005
50+	1.2	(0.53 - 2.90)	0.611
Zone of residence
Central plateau	-
Out of central plateau	2.3	(1.22 - 4.17)	0.01
Number of pregnancies
No pregnancy	-
1-3 pregnancies	0.6	(0.29 - 1.32)	0.216
>3 pregnancies	0.9	(0.34 - 2.41)	0.848
Number of births (101)
No childbirth	-
1-3 childbirths	0.6	(0.30 - 1.14)	0.115
> 3 childbirths	1.1	(0.35 - 3.64)	0.844
Menopause
No	-
Yes	1.3	(0.57 - 2.88)	0.551
Patient status
New patient	-
Follow up	3.2	(1.14 - 8.84)	0.026
If follow-up patient
<6 months	-
6-12 moths	1.4	(0.25 - 7.89)	0.699
≥12 months	0.4	(0.11 - 1.63)	0.208
Type of residence
Rural	-
Urban	1.5	(0.75 - 2.83)	0.267
Average time per medical appointment
≤2h	-
>2h	1.6	(0.69 - 3.50)	0.287
Excessive expense for transport
No	-
Yes	3.8	(1.65 - 8.74)	0.002
Means of transport
Walk	-
Public transport	3.1	(1.34 - 7.28)	0.008
Private transport	1.4	(0.29 - 6.27)	0.694
Health insurance
No	-
Yes	0.5	(0.24 - 1.12)	0.098
Education level
Primary			-
Higher education	0.4	(0.18 - 0.957)	0.039
Main profession
Other (no specific profession)	-		-
Small business	1.4	(0.67 - 2.79)	0.384
Educator	1.8	(0.64 - 5.24)	0.256
Farmer	5.1	(1.04 - 25.29)	0.044
Nurse	0.8	(0.31 - 2.02)	0.631
Employment
No	-
Yes	1.1	(0.61 - 1.99)	0.744
Income
15 USD- ≤206USD	-
>206USD	1.9	(0.60 - 6.42)	0.262
Income decline
No	-
Yes	3.0	(1.64 - 5.54)	<0.001
Degree of income decline
Low	-
Moderate	1.1	(0.09 - 11.56)	0.968
High	0.6	(0.06 - 5.33)	0.610
Expenses category
Medical	-
Non-medical	0.7	(0.35 - 1.60)	0.455
Clinical and psychosocial characteristics
Family conflicts
No	-
Yes	2.6	(1.12 - 6.16)	0.026
Family history with fibroids
No	-
Yes	5.1	(2.11 - 12.33)	<0.001
Pelvic infection
No	-
Yes	0.6	(0.30 - 1.24)	0.170
Ovarian micro polycystic
No	-
Yes	0.2	(0.12 - 0.41)	<0.001
Constipation
No	-
Yes	1.6	(0.80 - 3.05)	0.191
Pelvic mass
No	-
Yes	2.0	(1.10 - 3.67)	0.024
Abdominal-pelvic mass
No	-
Yes	1.6	(0.46 - 5.25)	0.475
Mictional difficulty
No	-
Yes	1.7	(0.92 - 3.16)	0.091
Pelvic pressure
No	-
Yes	1.5	(0.77 - 3.02)	0.225
Acute pelvic
No	-
Yes	1.75	(0.97 - 3.17)	0.062
Chronic pelvic pain
No	-
Yes	1.3	(0.65 - 2.48)	0.476
Polymenorrhagia
No	-
Yes	1.6	(0.89 - 3.04)	0.111
Menorrhagia
No	-
Yes	1.6	(0.89 - 3.04)	0.111
Metrorrhagia
No	-
Yes	1.6	(0.89 - 3.01)	0.111
Dysmenorrhea
No	-
Yes	1.6	(0.89 - 2.89)	0.113
Infertility
No	-
Yes	1.5	(0.80 - 2.89)	0.198
Stress
No	-
Yes	1.4	(0.68 - 2.75)	0.376
Anemia
No	-
Yes	0.9	(0.52 - 1.64)	0.789
Deep vein thrombosis
No	-
Yes	14.1	(1.84 - 108.02)	0.011
Urinary stone
No	-
Yes	1.0	(0.45 - 2.30)	0.972
Hydronephrosis
No	-
Yes	4.1	(0.49 - 35.13)	0.192
Depression
No	-
low (score 13-17)	1.6	(0.60 - 4.06)	0.350
Moderate (score 18-24)		(0.62 - 42.73)	0.130

Table 3. Multivariate analysis of the association with uterine fibroids and social demographic and clinical variables at the OB-GYN out-department at MUH age greater or equal to 20 years old (n=193)

Characteristic	Adjusted OR	95% CI	P-value
Age
<35	-
35-49	1.7	(0.76 - 4.02)	0.189
50-77	0.4	(0.11 - 1.50)	0.174
Patient status
Initial Visit	-
Follow -up visit	2.8	(0.79 - 9.95)	0.110
Excessive expense for transport
No	-
Yes	4.4	(1.55 - 12.38)	0.005
Heath Insurance
No	-
Yes	1.2	(0.44 - 3.30)	0.709
Education level
Primary	-
Higher education	0.3	(0.09 - 0.87)	0.021
Income decline
No
Yes	4.7	(2.05 - 10.93)	<0.001
Number of births
No childbirth	-
1-3 childbirths	0.6	(0.26 - 1.30)	0.188
4+ childbirths	0.9	(0.19 - 3.99)	0.866
Family conflicts
No	-
Yes	3.1	(0.54 – 17.9)	0.206
Family history of fibroids
No	-
Yes	4.6	(1.58 - 13.56)	0.005
Pelvic infection
No	-
Yes	0.4	(0.09 - 1.80)	0.233
Micro polycystic ovary
No	-
Yes	0.3	(0.10 - 0.97)	0.044
Pelvic Mass
No
Yes	2.2	(0.72 - 6.85)	0.164
Frequent menstruation
No	-
Yes	0.4	(0.14 - 1.16)	0.094
Deep Vein thrombosis
No	-
Yes	3.0	(0.29 – 31.89)	0.352
Depression
No	-
Low	5.7	(0.56 - 59.18)	0.142
Moderate	2.4	(0.17 - 36.03)	0.513

Assessing burden, risk factors, and perceived impact of uterine fibroids on women’s lives in rural Haiti: implications for advancing a health equity agenda, a mixed methods study

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Abstract

Background

Methods

Results

Conclusions

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Background

Methods

Results

Discussion

Conclusion

Abbreviations

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References

Tables

Status:

Journal Publication

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