Sir,

Re: Response from Professor H.P. Dietz to our article ‘Incidence and lifetime risk of pelvic organ prolapse surgery in Denmark from 1977 to 2009’. Int Urogyn J 2015;26:49–55.

We thank Professor Dietz for commenting on our study and especially the interest he has shown in the approximately 30 % reduction in lifetime risk of pelvic organ prolapse surgery from 1977 to 2008. In his response Professor Dietz provided two very interesting pieces of information to supplement our study, both related to explaining the reduction.

The first piece of information derived from a study made by Professor Dietz and his coworkers in which they studied the latency between a change in obstetric practice and the effect it has on the occurrence of prolapse. We suggested a latency of 10 – 15 years for a practice to influence the risk of prolapse without knowing the exact number of years. We are happy to be informed that this subject has been studied and the latency has been documented to be 30 years. But a latency of 30 years has many implications. One is the effect it has on a health professional’s individual career and that individual’s implementation of learning strategies. The same health professional does not necessarily have the chance to see the consequences of his/her early work until many years later in his/her career. It also means that learning strategies (correcting errors) are not easy to change or implement and health professionals will need access to an appropriate database to be sure that a practice so many years back can be evaluated.

The second interesting piece of information provided by Professor Dietz is that a reduction in the use of forceps could be a factor explaining the reduction in lifetime risk of pelvic organ prolapse surgery. We agree with Professor Dietz that the use of forceps is a risk factor for maternal trauma to the pelvic floor. This has been documented in several studies as also pointed out by Professor Dietz. Professor Dietz speculates as to whether the decline in the use of forceps that occurred 30 years ago resulted in the decrease in lifetime risk shown in our study. This is very likely to be true. The mode of delivery in all individuals has been recorded in Denmark since 1973, and it would be possible to extract these data from the databases by applying for permission; unfortunately this has taken a little longer than the deadline for this letter. Thus, we cannot state with certainty that a decrease in the use of forceps correlates with the decrease seen in lifetime risk of prolapse surgery in our study. However, we agree that forceps has been used very rarely in Denmark during the last 25 years, and we intend to look into these specific data in more details.

Best wishes