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Time trends in the incidence of pelvic organ prolapse across the BRICS: an age-period-cohort analysis for the GBD 2019

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Title: Time trends in the incidence of pelvic organ prolapse across the BRICS: an age-period-cohort analysis for the GBD 2019
Authors: Yuting Xu, Shudong Xie, Chengyu Zhou, Liping Zhu, Yao Tong, Alvaro Munoz, Yuhang Wu, Xuhong Li
Source: BMC Public Health, Vol 25, Iss 1, Pp 1-10 (2025)
Publisher Information: BMC, 2025.
Publication Year: 2025
Collection: LCC:Public aspects of medicine
Subject Terms: Pelvic organ prolapse, Incidence, Age-period-cohort, Trend, Public aspects of medicine, RA1-1270
More Details: Abstract Background As a female-specific health problem, pelvic organ prolapse (POP) causes serious damage to the physical and psychological health of numerous women, which poses a significant challenge to women’s health care worldwide, especially in developing countries. We conducted an in-depth analysis of trends in the incidence of POP over the past 30 years globally and in Brazil, Russia, India, China, and South Africa (BRICS countries). Materials and methods Data on the incidence of POP were obtained by location (5 countries), age (15–94 years old), year (1990–2019) from the Global Burden of Disease Study 2019. Age-period-cohort model was used to estimate the net drift, local drift, age effects, period and cohort effects between 1990 and 2019. Results The all-age incidence rate for POP in 2019 increased from 283.28/100,000 (95% UI: 229.97, 340.34) in China to 444.81/100,000 (369.92, 526.15) in Brazil, whereas the age-standardized incidence rate in 2019 was highest in India 400.06/100,000 (325.98, 476.91) and lowest in China 187.74/100,000 (154.21, 224.43). There was an emerging transition of incidences from the young population (15–39 years) to the middle and older population (≥ 40 years) in Brazil and India. The current findings reflect the different age, period, and cohort effects on POP incidence trends at global and BRICS levels. Conclusions The BRICS countries have made different progress in reducing the prevalence of POP. We fully recognize the diversity of internal environments in the BRICS countries and suggest an incremental approach to advancing POP prevention matters based on possible policy-driven human and financial resources in a given setting.
Document Type: article
File Description: electronic resource
Language: English
ISSN: 1471-2458
Relation: https://doaj.org/toc/1471-2458
DOI: 10.1186/s12889-024-21271-5
Access URL: https://doaj.org/article/1b6a497495d04ada989b75cb2d076fe0
Accession Number: edsdoj.1b6a497495d04ada989b75cb2d076fe0
Database: Directory of Open Access Journals
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  Value: <anid>AN0182975174;[1cik]13feb.25;2025Feb14.01:30;v2.2.500</anid> <title id="AN0182975174-1">Time trends in the incidence of pelvic organ prolapse across the BRICS: an age-period-cohort analysis for the GBD 2019 </title> <p>Background: As a female-specific health problem, pelvic organ prolapse (POP) causes serious damage to the physical and psychological health of numerous women, which poses a significant challenge to women's health care worldwide, especially in developing countries. We conducted an in-depth analysis of trends in the incidence of POP over the past 30 years globally and in Brazil, Russia, India, China, and South Africa (BRICS countries). Materials and methods: Data on the incidence of POP were obtained by location (5 countries), age (15–94 years old), year (1990–2019) from the Global Burden of Disease Study 2019. Age-period-cohort model was used to estimate the net drift, local drift, age effects, period and cohort effects between 1990 and 2019. Results: The all-age incidence rate for POP in 2019 increased from 283.28/100,000 (95% UI: 229.97, 340.34) in China to 444.81/100,000 (369.92, 526.15) in Brazil, whereas the age-standardized incidence rate in 2019 was highest in India 400.06/100,000 (325.98, 476.91) and lowest in China 187.74/100,000 (154.21, 224.43). There was an emerging transition of incidences from the young population (15–39 years) to the middle and older population (≥ 40 years) in Brazil and India. The current findings reflect the different age, period, and cohort effects on POP incidence trends at global and BRICS levels. Conclusions: The BRICS countries have made different progress in reducing the prevalence of POP. We fully recognize the diversity of internal environments in the BRICS countries and suggest an incremental approach to advancing POP prevention matters based on possible policy-driven human and financial resources in a given setting.</p> <p>Keywords: Pelvic organ prolapse; Incidence; Age-period-cohort; Trend; Medical and Health Sciences Public Health and Health Services</p> <hd id="AN0182975174-2">Background</hd> <p>Pelvic organ prolapse (POP) refers to the prolapse of one or more of the anterior vaginal wall, posterior vaginal wall, uterus (cervix), or the apex of the vagina (vaginal vault or cuff scar after hysterectomy) [[<reflink idref="bib1" id="ref1">1</reflink>]]. POP can cause structural changes in the female genitalia, causing women to worry about their image, and may lead to sexual dysfunction, such as decreased libido or reduced genital sensation [[<reflink idref="bib2" id="ref2">2</reflink>]]. These changes can have a negative impact on a woman's quality of life and well-being. Globally, the number of people with POP is up to 120 billion in 2019 [[<reflink idref="bib3" id="ref3">3</reflink>]]. Previous studies have shown that the prevalence of POP can reach as high as 20–65% [[<reflink idref="bib4" id="ref4">4</reflink>]]. As POP continues to represent a major public health challenge, a thorough and timely evaluation of its growing disease burden is essential to inform health policies and intervention strategies.</p> <p>Brazil, Russian Federation, India, China and South Africa (BRICS countries) form a political and economic block characterized by rapid economic development, representing nearly half of the world's population [[<reflink idref="bib5" id="ref5">5</reflink>]]. As populous middle-income countries with advantageous geographical locations, the BRICS nations exhibit similarities in terms of their health development history, challenges, and aspirations [[<reflink idref="bib6" id="ref6">6</reflink>]]. These countries are currently undergoing unprecedented socio-economic transformations and rapid urbanization [[<reflink idref="bib7" id="ref7">7</reflink>]], which have led to a notable shift in the disease spectrum from communicable diseases to non-communicable diseases [[<reflink idref="bib8" id="ref8">8</reflink>]], and furthermore, have been facing a high POP burden [[<reflink idref="bib9" id="ref9">9</reflink>]]. This makes them particularly relevant in discussions on women's health and POP epidemiology. BRICS countries are increasing the share of health-care expenditures in their economies, but still face major challenges in balancing the multiple needs of promoting public health, controlling non-communicable diseases and improving population health [[<reflink idref="bib10" id="ref10">10</reflink>]]. Given that women's health has emerged as a critical aspect of global health agendas, focusing on the epidemiological characteristics of POP within the BRICS context is necessary. Investigating the trends and determinants of POP in these nations can offer important insights, especially considering the potential for regional disparities and the distinct socio-economic factors impacting women's health.</p> <p>Previous studies examined the global age-standardized incidence rate (ASIR) and age-standardized disability-adjusted life years (AS-DALYs) trends of POP using estimated annual percentage changes (EAPCs). Moreover, it reveals the high burden and significant regional heterogeneity of POP, emphasizing the differences among countries in healthcare access and service provision [[<reflink idref="bib9" id="ref11">9</reflink>]]. However, a limitation of the approach is the inability to distinguish between cohort and period effects, which may mask specific factors that make an important contribution to the burden of the disease, thus leading to difficulties in revealing the full extent of temporal trends. The Age-Period-Cohort (APC) model presents a valuable approach to fill this gap, offering a robust analytical framework that can disentangle the complex interactions among age, time, and cohort effects in relation to POP incidence.</p> <p>This study aims to apply the APC model to analyze the incidence of POP across the BRICS nations from 1990 to 2019. By examining the temporal trends and geographic disparities in this significant health issue, the research seeks to inform health strategies and highlight the importance of addressing POP within the broader context of women's health in developing countries. The insights gained from this study will be essential for policymakers, healthcare providers, and researchers dedicated to enhancing the health and well-being of women in these influential nations.</p> <hd id="AN0182975174-3">Materials and methods</hd> <p></p> <hd id="AN0182975174-4">Data sources</hd> <p>The data in this research is from the GBD 2019 public dataset, available from <ulink href="http://ghdx.healthdata.org/gbd-results-tool">http://ghdx.healthdata.org/gbd-results-tool</ulink> (accessed July 8, 2023). The GBD is a catalog of global health and demographic data created by GBD collaborators, including mortality and morbidity for 204 countries and territories, 369 diseases, injuries, and impairments, and 87 risk factors [[<reflink idref="bib3" id="ref12">3</reflink>], [<reflink idref="bib11" id="ref13">11</reflink>]]. We obtained data from the GBD 2019 globally and for the BRICS countries regarding total population of women aged 15–19, 20–24, 25–29, 30–34, 35–39, 40–44, 45–49, 50–54, 55–59, 60–64, 65–69, 70–74, 75–79, 80–84, 85–89, and 90–94 years of age for each stage and data on the population with POP. POP was diagnosed and classified according to World Health Organization (WHO) clinical criteria, the International Statistical Classification of Diseases (ISCD) and the International Classification of Diseases and Injuries (ICD-10). For genital prolapse, the ICD-10 codes are N81.0, N81.1, N81.2, N81.3, N81.4, N81.5, N81.6, N81.8, and N81.9 and available from ICD-10 Version:2019 (who.int). The estimation of diagnostic incidence in this study involved a comprehensive data collection approach, incorporating a variety of sources. These sources encompassed national claims data, literature reviews, surveys, and other pertinent health-related datasets [[<reflink idref="bib12" id="ref14">12</reflink>]].</p> <hd id="AN0182975174-5">Statistical analysis</hd> <p></p> <hd id="AN0182975174-6">Age–period–cohort analysis</hd> <p>The data were analyzed using the APC model, which uses age, period, and cohort as independent variables and the incidence of an observed event or phenomenon in the population as the dependent variable, assuming that the dependent variable follows some probability distribution. APC models reveal the impact of different factors on disease trends beyond traditional epidemiologic analyses [[<reflink idref="bib14" id="ref15">14</reflink>]]. By fitting incidence rates to retrospective repeated-measures cross-sectional data, the model can isolate the effects of age, period, and cohort, and thus quantify the impact of these factors on the disease rates. The APC model provides a tool that is broadly applicable to the analysis of various types of data through the form of a generalized linear model [[<reflink idref="bib15" id="ref16">15</reflink>]].</p> <hd id="AN0182975174-7">Data arrangement</hd> <p>In order to control the number of parameters in the APC model while obtaining a smooth time effect curve, age-specific incidence rates were divided into equally spaced intervals of 5-year gap groups (15–19, 20–24... 90–94). Due to the low incidence of the disease in children and adolescents, those under 15 years of age were not considered in this study. The APC model requires that age and period are divided into equally spaced intervals. Therefore, period data were divided into 5-year sets of equally spaced time periods (1990–1994, 1995–1999,... 2015–2019). Since the birth cohort is defined by the age of the subject and the date of the event, i.e., cohort = period – age [[<reflink idref="bib16" id="ref17">16</reflink>]], the corresponding birth cohorts are 1898–1902 (median 1900) to 1998–2002 (median 2000). To address the identification problem caused by linear relationships between age, period, and cohort, the intrinsic estimator (IE) method associated with the APC model was used in our study, thus overcoming the drawback of model parameters being unpredictable [[<reflink idref="bib17" id="ref18">17</reflink>]].</p> <hd id="AN0182975174-8">Results</hd> <p></p> <hd id="AN0182975174-9">Globally and in BRICS countries trends for POP incidence, 1990–2019</hd> <p>Table 1 shows the population, total number of incidences, all-age incidence rates, and ASIR, as well as the net drift of incidence rates. In the past 30 years, the global population witnessed a substantial increase, from 5.35 billion (95% UI: 5.33, 5.46) to 7.74 billion (95% UI: 7.48, 7.99), representing a growth of approximately 44.67%. Concurrently, the number of POP cases experienced a notable rise, escalating from 8.41 million (95% UI: 6.88, 10.20) to 13.44 million (95% UI: 11.05, 16.26), reflecting an increase of approximately 59.81%. Globally in 2019, all-age incidence for POP was 348.39 per 100,000 population (95% UI: 286.45, 421.58) with an increase of 10.00% (95% UI: 7.73, 12.40). The ASIR for POP was 316.19 per 100,000 population (95% UI: 259.84, 381.84), a -15.49% (95% UI: -16.52, -14.44) decrease from 1990. Globally, the net drift in POP incidence was − 0.42% (95% UI: -0.50, -0.35) between 1990 and 2019.</p> <p>Table 1 Trends in the incidence of pelvic organ prolapse among women globally and in the BRICS countries, 1990–2019</p> <p> <ephtml> <table frame="hsides" rules="groups"><thead><tr><th align="left" rowspan="2" /><th align="left" colspan="2"><p>Global</p></th><th align="left" colspan="2"><p>Brazil</p></th><th align="left" colspan="2"><p>China</p></th><th align="left" colspan="2"><p>India</p></th><th align="left" colspan="2"><p>Russian Federation</p></th><th align="left" colspan="2"><p>South Africa</p></th></tr><tr><th align="left"><p>1990</p></th><th align="left"><p>2019</p></th><th align="left"><p>1990</p></th><th align="left"><p>2019</p></th><th align="left"><p>1990</p></th><th align="left"><p>2019</p></th><th align="left"><p>1990</p></th><th align="left"><p>2019</p></th><th align="left"><p>1990</p></th><th align="left"><p>2019</p></th><th align="left"><p>1990</p></th><th align="left"><p>2019</p></th></tr></thead><tbody><tr><td align="left"><p><bold>Population</bold></p></td><td align="left" colspan="12" /></tr><tr><td align="left"><p>Number, n x 1,000,000</p></td><td align="left"><p>5350 (5329, 5460)</p></td><td align="left"><p>7737 (7483, 7993)</p></td><td align="left"><p>149 (138, 159)</p></td><td align="left"><p>217 (190, 243)</p></td><td align="left"><p>1184 (1103, 1272)</p></td><td align="left"><p>1422 (1239, 1597)</p></td><td align="left"><p>856 (792, 919)</p></td><td align="left"><p>1391(1238, 1559)</p></td><td align="left"><p>151 (139, 163)</p></td><td align="left"><p>147 (129, 165)</p></td><td align="left"><p>37(33, 41)</p></td><td align="left"><p>56(49, 63)</p></td></tr><tr><td align="left"><p>Percentage of global, %</p></td><td align="left"><p>100</p></td><td align="left"><p>100</p></td><td align="left"><p>2.8</p></td><td align="left"><p>2.8</p></td><td align="left"><p>22.1</p></td><td align="left"><p>18.4</p></td><td align="left"><p>16.0</p></td><td align="left"><p>18.0</p></td><td align="left"><p>2.8</p></td><td align="left"><p>1.9</p></td><td align="left"><p>0.7</p></td><td align="left"><p>0.7</p></td></tr><tr><td align="left"><p><bold>Incidences</bold></p></td><td align="left" colspan="12" /></tr><tr><td align="left"><p>Number, n x 1,0000</p></td><td align="left"><p>841</p><p>(688, 1020)</p></td><td align="left"><p>1344</p><p>(1105, 1626)</p></td><td align="left"><p>35</p><p>(28, 42)</p></td><td align="left"><p>49</p><p>(41, 58)</p></td><td align="left"><p>105</p><p>(87, 127)</p></td><td align="left"><p>198</p><p>(160, 237)</p></td><td align="left"><p>189</p><p>(154, 224)</p></td><td align="left"><p>264</p><p>(216, 316)</p></td><td align="left"><p>29</p><p>(23, 35)</p></td><td align="left"><p>35</p><p>(27, 41)</p></td><td align="left"><p>5</p><p>(4,6)</p></td><td align="left"><p>9</p><p>(7,11)</p></td></tr><tr><td align="left"><p>Percentage of global, %</p></td><td align="left"><p>100</p></td><td align="left"><p>100</p></td><td align="left"><p>4.2</p></td><td align="left"><p>3.6</p></td><td align="left"><p>12.5</p></td><td align="left"><p>14.7</p></td><td align="left"><p>22.5</p></td><td align="left"><p>19.6</p></td><td align="left"><p>3.5</p></td><td align="left"><p>2.6</p></td><td align="left"><p>0.6</p></td><td align="left"><p>0.7</p></td></tr><tr><td align="left"><p>Percent change of incidences 1990–2019, %</p></td><td align="left" colspan="2"><p>59.71 (56.42, 63.19)</p></td><td align="left" colspan="2"><p>42.08 (27.97, 57.90)</p></td><td align="left" colspan="2"><p>87.92 (78.60, 96.71)</p></td><td align="left" colspan="2"><p>39.89 (33.47, 46.11)</p></td><td align="left" colspan="2"><p>18.99 (16.66, 21.64)</p></td><td align="left" colspan="2"><p>80.38(74.64,86.31)</p></td></tr><tr><td align="left"><p><bold>All-age incidence rate</bold></p></td><td align="left" colspan="12" /></tr><tr><td align="left"><p>Rate per 100,000</p></td><td align="left"><p>316.71(258.97,</p><p>383.86)</p></td><td align="left"><p>348.39(286.45,</p><p>421.58)</p></td><td align="left"><p>461.14(374.01,</p><p>551.66)</p></td><td align="left"><p>444.81(369.92,</p><p>526.15)</p></td><td align="left"><p>183.35</p><p>(151.33,</p><p>220.64)</p></td><td align="left"><p>283.28</p><p>(229.97,</p><p>340.34)</p></td><td align="left"><p>459.71</p><p>(374.60,</p><p>546.09)</p></td><td align="left"><p>389.41</p><p>(318.65,</p><p>465.89)</p></td><td align="left"><p>361.51</p><p>(290.21, 435.55)</p></td><td align="left"><p>440.60</p><p>(350.09,</p><p>528.78)</p></td><td align="left"><p>261.09</p><p>(216.96,</p><p>312.68)</p></td><td align="left"><p>316.31</p><p>(261.19,</p><p>379.37)</p></td></tr><tr><td align="left"><p>Percent change of rate 1990–2019, %</p></td><td align="left" colspan="2"><p>10.00 (7.73, 12.40)</p></td><td align="left" colspan="2"><p>-3.54 (-13.12, 7.20)</p></td><td align="left" colspan="2"><p>54.51 (46.84, 61.73)</p></td><td align="left" colspan="2"><p>-15.29 (-19.18, -11.53)</p></td><td align="left" colspan="2"><p>21.88 (19.49, 24.60)</p></td><td align="left" colspan="2"><p>21.15(17.30,25.13)</p></td></tr><tr><td align="left"><p><bold>Age-standardized incidence rate</bold></p></td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p>Rate per 100,000</p></td><td align="left"><p>374.13</p><p>(304.93,</p><p>455.87)</p></td><td align="left"><p>316.19</p><p>(259.84,</p><p>381.84)</p></td><td align="left"><p>518.09</p><p>(422.89,</p><p>615.63)</p></td><td align="left"><p>388.04</p><p>(322.13,</p><p>456.99)</p></td><td align="left"><p>228.66 (189.02, 274.15)</p></td><td align="left"><p>187.74 (154.21, 224.43)</p></td><td align="left"><p>611.36 (502.93,</p><p>736.58)</p></td><td align="left"><p>400.06</p><p>(325.98,</p><p>476.91)</p></td><td align="left"><p>279.48</p><p>(228.73,</p><p>336.42)</p></td><td align="left"><p>280.65</p><p>(228.96,</p><p>338.07)</p></td><td align="left"><p>371.18</p><p>(305.30,</p><p>444.13)</p></td><td align="left"><p>321.61</p><p>(264.78,</p><p>384.86)</p></td></tr><tr><td align="left"><p>Percent change of rate 1990–2019, %</p></td><td align="left" colspan="2"><p>-15.49 (-16.52, -14.44)</p></td><td align="left" colspan="2"><p>-25.10 (-29.82, -19.96)</p></td><td align="left" colspan="2"><p>-17.90 (-20.09, -15.35)</p></td><td align="left" colspan="2"><p>-34.56 (-36.53, -32.76)</p></td><td align="left" colspan="2"><p>-0.42 (-1.00, 1.64)</p></td><td align="left" colspan="2"><p>-13.36(-15.87, -10.72)</p></td></tr><tr><td align="left"><p><bold>APC model estimates</bold></p></td><td align="left" colspan="2" /><td align="left" colspan="2" /><td align="left" colspan="2" /><td align="left" colspan="2" /><td align="left" colspan="2" /><td align="left" colspan="2" /></tr><tr><td align="left"><p>Net drift of incidence rate, % per year</p></td><td align="left" colspan="2"><p>-0.42 (-0.50, -0.35)</p></td><td align="left" colspan="2"><p>-0.85 (-0.96, -0.75)</p></td><td align="left" colspan="2"><p>-0.34 (-0.45, -0.23)</p></td><td align="left" colspan="2"><p>-1.21 (-1.49, -0.93)</p></td><td align="left" colspan="2"><p>0.76 (0.67, -0.86)</p></td><td align="left" colspan="2"><p>-0.49 (-0.54, -0.45)</p></td></tr></tbody></table> </ephtml> </p> <p>Notes: All-age incidence rate: crude incidence rate Age-standardized incidence rate is computed by direct standardization with global standard population in GBD 2019 Net drifts are estimates derived from the age-period-cohort model and denotes overall annual percentage change in incidence rate, which captures the contribution of the effects from calendar time and successive birth cohorts Parentheses for all GBD health estimate indicate 95% uncertainty intervals; parentheses for net drift indicate 95% confidence intervals APC: Age-period-cohort</p> <p>In BRICS countries, from 1990 to 2019, Brazil, India, and the Russian Federation accounted for a decreasing percentage of global POP incidences, while China and South Africa accounted for a larger percentage (Table 1). The all-age incidence rate for POP in 2019 increased from 283.28 per 100,000 population (95% UI: 229.97, 340.34) in China to 444.81 per 100,000 population (95% UI: 369.92, 526.15) in Brazil. The ASIR in 2019 was highest in the India 400.06 per 100,000 population (95% UI: 325.98, 476.91) and lowest in the China 187.74 per 100,000 population (95% UI: 154.21, 224.43). An increasing trend in all-age incidence for POP was observed in China with 54.51% (95% UI: 46.84, 61.73), the Russian Federation with 21.88% (95% UI: 19.49, 24.60), and South Africa with 21.15% (95% UI: 17.30, 25.13), whereas a decreasing trend was more significant in India with − 15.29% (95% UI: -19.18, -11.53) than in Brazil with − 3.54% (95% UI: -13.12, 7.20) (Table 1). In BRICS countries, the annual net drift in POP incidence as estimated from the APC model ranged from − 1.21% (95% UI: -1.49, -0.93) in India to 0.76% (95% UI: 0.67, 0.86) in the Russian Federation (Table 1).</p> <hd id="AN0182975174-10">Time trends in POP incidences across different age groups</hd> <p>Figure 1 shows the annual percentage change in POP incidence for age groups 15–19 to 90–94 years. Globally, localized drift values were predominantly below 0 in most age groups, except for the older age groups (80–94 years), suggesting a decrease in POP incidence. In terms of POP incidence, a similar trend was seen in China. In Brazil and South Africa and India, POP incidence had declined in almost all age groups (Fig. 1). However, it was notably that the incidence of POP in the Russian Federation increased to varying degrees of different age groups from 1990 to 2019 (Fig. 1).</p> <p>Graph: Fig. 1 The local drifts of pelvic organ prolapse incidence rate in global and BRICS, 1990–2019. Local drifts of POP incidence rate (estimates from age-period-cohort models) for 16 age groups (15–19 to 90–94 years), 1990–2019. The dots and shaded areas indicate the annual percentage change of incidence rate (% per year) and the corresponding 95% CIs</p> <p>Figure 2 presents temporal changes in the age distribution of incidences. From 1990 to 2019, the occurrence of POP cases globally exhibited a stable distribution across different age groups, and similar pattern was observed in China and South Africa. However, there was an emerging transition of incidences from the young population (15–39 years) to the middle and older population (≥ 40 years) in Brazil and India. In addition, almost all POP new-onset events were found only in those over 40 of age in the Russian Federation (Fig. 2).</p> <p>Graph: Fig. 2 Age distribution of incidences from pelvic organ prolapse in global and BRICS, 1990–2019. Age distribution of incidences is represented as temporal change in the relative proportion incidences across age groups (15–19,20–24...90–94 years) during 1990–2019</p> <hd id="AN0182975174-11">Age, period, and cohort (APC) model effects on POP incidences</hd> <p>Globally, age effects generally showed that as women aged, the risk of POP gradually increased in the 15–49 age group, particularly among middle-aged women (45–64), who consistently maintained a higher risk throughout their lifespan (Fig. 3A). Similar patterns were observed in India, the Russian Federation, and South Africa. However, the risk of incidence among women older than 64 fluctuated at a higher level globally and in the Russian Federation, while declining in India and South Africa (Fig. 3A). In China, within the 15–44 age group, the risk of incidence slowly increased with age, remained higher during middle-aged and older periods, and then sharply increased among the elderly female population aged 80–94 (Fig. 3A). On the other hand, Brazil exhibited a higher risk of incidence among young females (25–44 years), followed by a pattern similar to the middle-aged incidence rates observed in China (Fig. 3A).</p> <p>Graph: Fig. 3 Age, period and cohort effects on pelvic organ prolapse incidence in global and BRICS. (A) Age effects are shown by the fitted longitudinal age curves of incidence rate (per 100,000 person-years) adjusted for period deviations. (B) Period effects are shown by the relative risk of incidence rate (incidence rate ratio) and computed as the ratio of age-specific rates from 1990–1994 to 2015–2019, with the referent period set at 2000–2004. (C) Cohort effects are shown by the relative risk of incidence rate and computed as the ratio of age-specific rates from the 1990 cohort to the 2000 cohort, with the referent cohort set at 1950. The dots and shaded areas denote incidence rates or rate ratios and their corresponding 95% CIs</p> <p>Period effects usually demonstrated a decreasing trend in the risk of incidence globally, and similar trends have been observed in countries such as Brazil, India and South Africa (Fig. 3B). However, the situation for the Russian Federation showed a different trend, where the risk of POP incidence continued to increase when compared with the reference period, while findings from China shown a slight increase in the risk of POP incidence in recent years (Fig. 3B).</p> <p>Cohort effects revealed that the global risk of POP incidence decreased after being compared to the reference year (1950) (Fig. 3C). Similar observations for varying degrees of risk reduction patterns were found in Brazil, China, India, and South Africa. However, in the Russian Federation we observed a sustained increase for the risk of POP incidence since 1950 (Fig. 3C).</p> <hd id="AN0182975174-12">Discussion</hd> <p>To the best of our knowledge, this is the first time that POP incidence has been analyzed using the APC model, further allowing for comparisons between global and BRICS countries. The main contribution of this study to the field compared with previous GBD 2019 publications [[<reflink idref="bib9" id="ref19">9</reflink>]] is that we provide a deeper understanding of POP trends. We used age, period, and cohort effects to differentiate between sources of global incidence risk and in the BRICS countries, thus apprising the effectiveness of health care services related to POP. Another important area of progress is the measurement of localized drift in the global and BRICS age distributions of incidence and age at onset from 1990 to 2019, allowing us to capture temporal trends in incidence for each age group and adjust for period effects.</p> <p>The total number of POP incidences worldwide increased by nearly 60% over the study period, driven by rapid population growth. Meanwhile, the incidence rate showed a downward trend globally, as well as in the BRICS countries after considering the inconsistency in age composition, suggesting varying degrees of progress and improvement in reducing the incidence of POP in evaluated countries. This situation may be attributed to the significant breakthroughs and advances in the field of pelvic floor rehabilitation over the past three decades, and also the accumulation of a large body of clinical practice in the areas of diagnosis, therapeutic interventions and prognostic judgments, leading to the establishment of a comprehensive framework encompassing well-established diagnostic and therapeutic techniques [[<reflink idref="bib18" id="ref20">18</reflink>]]. However, with the prevalence of a number of potential risk factors for POP, such as age, body mass index, birth weight, defects in the levator ani muscle, mode of child delivery and number of births, were identified as risk factors for developing POP [[<reflink idref="bib19" id="ref21">19</reflink>]]. These factors should be considered as crucial matters when aiming at reducing the burden of POP, thus requiring more attention and considered worthwhile.</p> <p>We found that Brazil, India and South Africa have seen a decline in the incidence of POP in all age groups from 1990 to 2019. However, in China, the country with the largest elderly population in the world, the population is aging significantly [[<reflink idref="bib20" id="ref22">20</reflink>]] and the incidence of POP in the elderly is on the rise. It is worth noting that after aging, obesity is the biggest risk factor for POP, and the high burden of obesity in the Russian Federation has led to a noticeable increase in the incidence of POP in all age groups [[<reflink idref="bib21" id="ref23">21</reflink>]]. It is well known that young women who have experienced pregnancy and childbirth may experience pelvic muscle and ligament tissue damage, which in turn increases the risk of POP [[<reflink idref="bib19" id="ref24">19</reflink>]]. The physiologic and metabolic changes that occur in the female body with age, including decreased muscle elasticity and ligament tone, decreased estrogen levels, and increased body mass index may be important factors for pelvic floor dysfunction [[<reflink idref="bib23" id="ref25">23</reflink>], [<reflink idref="bib24" id="ref26">24</reflink>] – [<reflink idref="bib25" id="ref27">25</reflink>]]. This probably explains the high proportion of POP in the middle-aged and elderly population at the global level, and also in China and South Africa. By contrast, the Russian Federation has maintained a low fertility rate and the main affected population is almost exclusively middle-aged and older women [[<reflink idref="bib26" id="ref28">26</reflink>]]. Similarly, low fertility and rapid aging trends in both India and Brazil have led to a shift in the proportion of POP from the young to the old women [[<reflink idref="bib27" id="ref29">27</reflink>]].</p> <p>Across the BRICS countries, there are significant differences in POP incidence rate and long-term trends across countries. The impact of unfavorable age-period-cohort effects on incidence rate in the Russian Federation is impressive. According to the WHO, the prevalence of obesity in the Russian Federation has been on the rise for the past three decades and reached 23.1% in 2016 [[<reflink idref="bib22" id="ref30">22</reflink>], [<reflink idref="bib29" id="ref31">29</reflink>]]. Aging and obesity are two major risk factors that together, contribute to the high risk for developing POP in the middle-aged and elderly female population. It is noted that the risk for the onset of POP has gradually slowed down after the signing of the document "<emph>Principles of Food Security in Russia</emph>" by the president of the Russian Federation in 2010. The development and implementation of policies related to food safety and nutritional health may provide an important reference for governments of middle- and low-income countries with inadequate health-care facilities for women. The slowdown in the incidence rate of POP in young Chinese women may be related to China's family planning policy, which was established as a basic state policy in September 1982 and enshrined in their constitution [[<reflink idref="bib30" id="ref32">30</reflink>]]. Over the past 40 years, China's demographic structure has changed dramatically, and aging has intensified thus posing major challenges for both family and social care. At the same time, staff planning in geriatrics and rehabilitation medicine has not kept pace with the growth of the elderly population, leading to a shortage of healthcare resources for the aging population [[<reflink idref="bib31" id="ref33">31</reflink>]]. This situation may be a contributing factor for the increased POP incidence in women aged 75 and over. In response to the an aging population situation, the Chinese government has implemented two- and three-child policies in recent years [[<reflink idref="bib32" id="ref34">32</reflink>]], nonetheless these strategies may pose a challenge to the future burden of POP care. The current decline for the incidence of POP in young Chinese women is encouraging, however, while continuing to focus on POP in young women, the country needs to increase the scope of high-quality healthcare services for older people, including prevention, promotion, treatment, rehabilitation, palliative care and end-of-life care.</p> <p>Unlike other BRICS countries, the vulnerable Brazilian population suffering POP is younger women aged 25–40 years, instead of the menopausal or older age groups identified in other countries. This difference may be related to Brazil's demographic structure and fertility patterns, with Brazilian women being relatively young at the age of childbearing. In fact, Brazil has a pregnancy rate of 68.4 per 1,000 adolescents, which is higher than the global (46 per 1,000) and Latin American averages (65.5 per 1,000) [[<reflink idref="bib34" id="ref35">34</reflink>]]. Even in 2017 alone, a remarkable 459,000 adolescents aged 15–19 in Brazil gave birth [[<reflink idref="bib34" id="ref36">34</reflink>]]. In addition, there are multiple Brazilian cases of disrespect, mistreatment, abuse, and violence against women by health professionals during pregnancy and the puerperium, and these inappropriate medical practices may lead to a wide range of health problems during the reproductive period [[<reflink idref="bib35" id="ref37">35</reflink>]]. Encouragingly, social movements and ministry of health initiatives in Brazil, have created in recent decades a synergy that promotes more respectful and evidence-based maternity care, leading to a reduction in the risk of POP both in terms of period and cohort effects [[<reflink idref="bib36" id="ref38">36</reflink>]]. The next step may be to further promote a real change in respectful maternal care.</p> <p>In 2019 the incidence POP rate in India increased gradually in the age group of 15–49 years. The results of the demographic health survey (DHS) of India have revealed an early start in childbearing, with 7.9% of adolescent girls aged 15–19 years already being mothers [[<reflink idref="bib37" id="ref39">37</reflink>]]. Constrained by poor health and economic resources, adolescent girls, pregnant women and lactating mothers in that country have alarmingly high rates of malnutrition, with deficiencies in key nutrients such as proteins and vitamins [[<reflink idref="bib38" id="ref40">38</reflink>]]. Vitamin D deficiency is thought to reduce muscle mass and strength, thus making pelvic floor muscles less able to properly support organs, which in turn may lead to pelvic floor dysfunctions, such as POP [[<reflink idref="bib39" id="ref41">39</reflink>]]. The cumulative effects of early-life nutritional deficiencies and the cumulative impact of estrogen fluctuations during the menopausal period may be the primary factors contributing to the highest risk of POP in women aged 45–54. Both period and cohort effects showed a reduced risk of incidence during the studied period, which may be attributed to a series of regulatory measures taken by the Indian government to address nutritional status [[<reflink idref="bib38" id="ref42">38</reflink>]]. Similar to India, South Africa also faces challenges including inadequate healthcare infrastructure, poverty, and malnutrition among its population [[<reflink idref="bib41" id="ref43">41</reflink>]]. During the period from 1994 to 2002, South Africa implemented the integrated nutrition program (INP) with remarkable success in improving nutritional status, subsequently significantly reducing the disease burden associated with POP [[<reflink idref="bib42" id="ref44">42</reflink>]].</p> <p>In our study, several limitations should be acknowledged. First, the data used in this study solely capture the diagnostic incidence rates of POP. However, these data do not directly reflect the actual occurrence of POP, which requires a professional pelvic examination. Therefore, given the inherent limitations of the available data, it is necessary to interpret the research findings with caution. Second, there are currently multiple diagnostic definitions for POP, and the utilization of different diagnostic criteria leads to significant disparities in the reported rates of POP. Consequently, it is essential to acknowledge that the choice of diagnostic definitions may introduce heterogeneity in the reported incidence rates of POP. Third, our analysis was focused on the BRICS countries, and thus the findings may not be generalizable to other nations or regions worldwide. Due to resource constraints, our study was limited in its ability to capture subnational differences and relied on available data sources, which might introduce information bias. Fourth, as the parameter estimates generated by the APC model lack intuitive interpretation, explaining their practical significance is challenging as this analysis is susceptible to ecological fallacies, which may impact the accuracy of causal inferences. Fifth, the APC analysis employed in our study is susceptible to ecological fallacies, which may impact the accuracy of causal inferences. Additionally, the use of five-year age intervals in the APC model may smooth out minor variations in age, period, and cohort effects. Future research should consider expanding the scope of analysis to include a broader range of countries, and further explore nuanced factors contributing to the observed POP trends.</p> <hd id="AN0182975174-13">Conclusions</hd> <p>POP is an important contributor to pelvic floor dysfunction disorders. The BRICS countries have made different progress in reducing the prevalence of POP. We fully recognize a diversity of internal environments in the BRICS countries, but would like to suggest an incremental approach for advancing the prevention of POP matters based on possible policy-driven human and financial resources in a given setting. The future scope of healthcare information to improve the progression of POP should be expanded to include women of all ages, with special attention to vulnerable groups.</p> <hd id="AN0182975174-14">Acknowledgements</hd> <p>Authors would like to thank the collaborations with the IHME and the Global Burden of Disease study.</p> <hd id="AN0182975174-15">Author contributions</hd> <p>YX, SX, CZ, LZ and YT accessed and acquired the raw data, performed the primary analysis, and prepared tables and figures. YW and XL contributed to the interpretation of the data. YX and SX prepared the first draft. YX, SX, AM, CZ, LZ and YT critically reviewed results and provided important comments on the manuscript. YW, AM and XL substantially edited and critically reviewed the manuscript. YW managed all of the incidence modelling data. YW and XL were responsible for general supervision and had final responsibility for the decision to submit for publication. All authors reviewed and approved the final manuscript and are accountable for all aspects of the work, including accuracy and integrity.</p> <hd id="AN0182975174-16">Funding</hd> <p>This work was supported by the Key Research and Development Program of the Hunan Provincial Science and Technology Department, Changsha, Hunan, China. (grant number: 2023SK2038).</p> <hd id="AN0182975174-17">Data availability</hd> <p>No datasets were generated or analysed during the current study.</p> <hd id="AN0182975174-18">Declarations</hd> <p></p> <hd id="AN0182975174-19">Ethical approval</hd> <p>Data were all analyzed anonymously, so ethical approval was not needed. All methods in this paper were performed following the relevant guidelines and regulations.</p> <hd id="AN0182975174-20">Consent to participate</hd> <p>Not applicable.</p> <hd id="AN0182975174-21">Consent to publication</hd> <p>Not applicable.</p> <hd id="AN0182975174-22">Competing interests</hd> <p>The authors declare no competing interests.</p> <hd id="AN0182975174-23">Publisher's note</hd> <p>Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.</p> <ref id="AN0182975174-24"> <title> References </title> <blist> <bibl id="bib1" idref="ref1" type="bt">1</bibl> <bibtext> Haylen BT, Maher CF, Barber MD, Camargo S, Dandolu V, Digesu A. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic organ prolapse (POP). 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Calif). 2005; 21; 1: 100-8</bibtext> </blist> </ref> <aug> <p>By Yuting Xu; Shudong Xie; Chengyu Zhou; Liping Zhu; Yao Tong; Alvaro Munoz; Yuhang Wu and Xuhong Li</p> <p>Reported by Author; Author; Author; Author; Author; Author; Author; Author</p> </aug> <nolink nlid="nl1" bibid="bib10" firstref="ref10"></nolink> <nolink nlid="nl2" bibid="bib11" firstref="ref13"></nolink> <nolink nlid="nl3" bibid="bib12" firstref="ref14"></nolink> <nolink nlid="nl4" bibid="bib14" firstref="ref15"></nolink> <nolink nlid="nl5" bibid="bib15" firstref="ref16"></nolink> <nolink nlid="nl6" bibid="bib16" firstref="ref17"></nolink> <nolink nlid="nl7" bibid="bib17" firstref="ref18"></nolink> <nolink nlid="nl8" bibid="bib18" firstref="ref20"></nolink> <nolink nlid="nl9" bibid="bib19" firstref="ref21"></nolink> <nolink nlid="nl10" bibid="bib20" firstref="ref22"></nolink> <nolink nlid="nl11" bibid="bib21" firstref="ref23"></nolink> <nolink nlid="nl12" bibid="bib23" firstref="ref25"></nolink> <nolink nlid="nl13" bibid="bib24" firstref="ref26"></nolink> <nolink nlid="nl14" bibid="bib25" firstref="ref27"></nolink> <nolink nlid="nl15" bibid="bib26" firstref="ref28"></nolink> <nolink nlid="nl16" bibid="bib27" firstref="ref29"></nolink> <nolink nlid="nl17" bibid="bib22" firstref="ref30"></nolink> <nolink nlid="nl18" bibid="bib29" firstref="ref31"></nolink> <nolink nlid="nl19" bibid="bib30" firstref="ref32"></nolink> <nolink nlid="nl20" bibid="bib31" firstref="ref33"></nolink> <nolink nlid="nl21" bibid="bib32" firstref="ref34"></nolink> <nolink nlid="nl22" bibid="bib34" firstref="ref35"></nolink> <nolink nlid="nl23" bibid="bib35" firstref="ref37"></nolink> <nolink nlid="nl24" bibid="bib36" firstref="ref38"></nolink> <nolink nlid="nl25" bibid="bib37" firstref="ref39"></nolink> <nolink nlid="nl26" bibid="bib38" firstref="ref40"></nolink> <nolink nlid="nl27" bibid="bib39" firstref="ref41"></nolink> <nolink nlid="nl28" bibid="bib41" firstref="ref43"></nolink> <nolink nlid="nl29" bibid="bib42" firstref="ref44"></nolink>
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  Label: Title
  Group: Ti
  Data: Time trends in the incidence of pelvic organ prolapse across the BRICS: an age-period-cohort analysis for the GBD 2019
– Name: Author
  Label: Authors
  Group: Au
  Data: <searchLink fieldCode="AR" term="%22Yuting+Xu%22">Yuting Xu</searchLink><br /><searchLink fieldCode="AR" term="%22Shudong+Xie%22">Shudong Xie</searchLink><br /><searchLink fieldCode="AR" term="%22Chengyu+Zhou%22">Chengyu Zhou</searchLink><br /><searchLink fieldCode="AR" term="%22Liping+Zhu%22">Liping Zhu</searchLink><br /><searchLink fieldCode="AR" term="%22Yao+Tong%22">Yao Tong</searchLink><br /><searchLink fieldCode="AR" term="%22Alvaro+Munoz%22">Alvaro Munoz</searchLink><br /><searchLink fieldCode="AR" term="%22Yuhang+Wu%22">Yuhang Wu</searchLink><br /><searchLink fieldCode="AR" term="%22Xuhong+Li%22">Xuhong Li</searchLink>
– Name: TitleSource
  Label: Source
  Group: Src
  Data: BMC Public Health, Vol 25, Iss 1, Pp 1-10 (2025)
– Name: Publisher
  Label: Publisher Information
  Group: PubInfo
  Data: BMC, 2025.
– Name: DatePubCY
  Label: Publication Year
  Group: Date
  Data: 2025
– Name: Subset
  Label: Collection
  Group: HoldingsInfo
  Data: LCC:Public aspects of medicine
– Name: Subject
  Label: Subject Terms
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Pelvic+organ+prolapse%22">Pelvic organ prolapse</searchLink><br /><searchLink fieldCode="DE" term="%22Incidence%22">Incidence</searchLink><br /><searchLink fieldCode="DE" term="%22Age-period-cohort%22">Age-period-cohort</searchLink><br /><searchLink fieldCode="DE" term="%22Trend%22">Trend</searchLink><br /><searchLink fieldCode="DE" term="%22Public+aspects+of+medicine%22">Public aspects of medicine</searchLink><br /><searchLink fieldCode="DE" term="%22RA1-1270%22">RA1-1270</searchLink>
– Name: Abstract
  Label: Description
  Group: Ab
  Data: Abstract Background As a female-specific health problem, pelvic organ prolapse (POP) causes serious damage to the physical and psychological health of numerous women, which poses a significant challenge to women’s health care worldwide, especially in developing countries. We conducted an in-depth analysis of trends in the incidence of POP over the past 30 years globally and in Brazil, Russia, India, China, and South Africa (BRICS countries). Materials and methods Data on the incidence of POP were obtained by location (5 countries), age (15–94 years old), year (1990–2019) from the Global Burden of Disease Study 2019. Age-period-cohort model was used to estimate the net drift, local drift, age effects, period and cohort effects between 1990 and 2019. Results The all-age incidence rate for POP in 2019 increased from 283.28/100,000 (95% UI: 229.97, 340.34) in China to 444.81/100,000 (369.92, 526.15) in Brazil, whereas the age-standardized incidence rate in 2019 was highest in India 400.06/100,000 (325.98, 476.91) and lowest in China 187.74/100,000 (154.21, 224.43). There was an emerging transition of incidences from the young population (15–39 years) to the middle and older population (≥ 40 years) in Brazil and India. The current findings reflect the different age, period, and cohort effects on POP incidence trends at global and BRICS levels. Conclusions The BRICS countries have made different progress in reducing the prevalence of POP. We fully recognize the diversity of internal environments in the BRICS countries and suggest an incremental approach to advancing POP prevention matters based on possible policy-driven human and financial resources in a given setting.
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  Data: English
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  Data: 1471-2458
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  Data: https://doaj.org/toc/1471-2458
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1186/s12889-024-21271-5
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  Label: Access URL
  Group: URL
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RecordInfo BibRecord:
  BibEntity:
    Identifiers:
      – Type: doi
        Value: 10.1186/s12889-024-21271-5
    Languages:
      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 10
        StartPage: 1
    Subjects:
      – SubjectFull: Pelvic organ prolapse
        Type: general
      – SubjectFull: Incidence
        Type: general
      – SubjectFull: Age-period-cohort
        Type: general
      – SubjectFull: Trend
        Type: general
      – SubjectFull: Public aspects of medicine
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      – SubjectFull: RA1-1270
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    Titles:
      – TitleFull: Time trends in the incidence of pelvic organ prolapse across the BRICS: an age-period-cohort analysis for the GBD 2019
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      – PersonEntity:
          Name:
            NameFull: Yuting Xu
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            NameFull: Shudong Xie
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            NameFull: Chengyu Zhou
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            NameFull: Liping Zhu
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            NameFull: Yao Tong
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            NameFull: Yuhang Wu
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            – D: 01
              M: 02
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              Y: 2025
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            – TitleFull: BMC Public Health
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