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. 2022 Jun 2;2(6):e0000562. doi: 10.1371/journal.pgph.0000562

Estimated burden, and associated factors of Urinary Incontinence among Sub-Saharan African women aged 15–100 years: A systematic review and meta-analysis

Martin Ackah 1,*, Louise Ameyaw 2, Mohammed Gazali Salifu 3, Cynthia OseiYeboah 1, Abena Serwaa Ampomaa Agyemang 4, Kow Acquaah 1, Yaa Boatema Koranteng 1, Asabea Opare-Appiah 1
Editor: Rajat Das Das Gupta5
PMCID: PMC10021416  PMID: 36962388

Abstract

Hospital and community based-studies had been conducted for Urinary Incontinence (UI) in Sub-Sahara Africa (SSA) countries. A significant limitation of these studies is likely under-estimation of the burden of UI in SSA. It is therefore, imperative that a well-structured systematic review and meta-analytical models in SSA are required to accurately and reliably estimate the burden of UI. Medline/PubMed, Google Scholar, Africa Journal Online (AJOL) were searched to identified data on burden of UI studies in SSA. Two independent authors performed the initial screening of studies based on the details found in their titles and abstracts. The quality of the retrieved studies was assessed using the Newcastle-Ottawa Quality Assessment instrument. The pooled burden of UI was calculated using a weighted inverse variance random-effects model. A sub-group and meta-regression analyses were performed. Publication bias was checked by the funnel plot and Egger’s test. Of the 25 studies included, 14 were hospital-based, 10 community- based, and 1 university-based studies involving an overall 17863 participants from SSA. The systematic review showed that the prevalence of UI ranged from 0.6% in Sierra Leone to 42.1% in Tanzania. The estimated pooled burden of UI across all studies was 21% [95% CI: 16%-26%, I2 = 91.01%]. The estimated pooled prevalence of stress UI was 52% [95% CI: 42%-62%], urgency UI 21% [95% CI: 15%-26%], and mixed UI 27% [95% CI: 20%-35%]. The common significant independent factors were; parity, constipation, overweight/obese, vaginal delivery, chronic cough, gestational age, and aging. One out of every five women in SSA suffers from UI. Parity, constipation, overweight/obesity, vaginal delivery, chronic cough, gestational age, and age were the most important risk variables. As a result, interventions aimed at reducing the burden of UI in SSA women aged 15 to 100 years old in the context of identified determinants could have significant public health implications.

Introduction

Pelvic Floor Disorders (PFD) affects millions of women worldwide [1–3]. About 10% of women have surgery for Urinary Incontinence (UI), pelvic organ prolapse, or both, according to a regional survey in the United States, and 30% of those women have two or more surgical procedures in their lifetime [3, 4]. Wu and colleagues estimated that 25% of women in affluent countries suffers from one or more PFDs [5] with UI being the most common [6].

The International Continence Society (ICS) defines UI as the involuntary leakage of urine, with three basic subtypes identified: urgency UI (UUI), stress UI (SUI), and mixed UI (MUI; both UUI and SUI) [7, 8]. It is a widespread problem with an estimated global burden of nearly 5.0% to 55% with detrimental consequences on social life, personal relationships, feelings, sleep, and vitality [9, 10]. A comprehensive review and meta-analysis of 54 studies comprising 138722 women aged 10 to 90 years in Low- and Middle-Income Countries estimated the burden of UI to be 26% [1]. In addition, the prevalence of UI ranged from 2.8% in Nigeria to 57.7% in the Islamic Republic of Iran [11]. UI is frequently underestimated and underdiagnose in developing and industrialized countries [11].

In comparison to patients with continence, recent investigations have shown that UI is a predictor of death [12, 13]. As a results, in order to strengthen continence programs, health systems should be able to estimate the burden especially in a region with a frail health system, such as SSA. Hospital and community based-studies had been conducted for UI in SSA countries [14–17]. A significant limitation of these observational studies is likely under-estimation of the burden of UI in SSA [16]. Following a thorough search of the literature, it was revealed that no prior systematic review and meta-analysis addressing the burden of UI and associated factors on the African continent has yet been conducted and published.

Many risk factors, such as multiple pregnancies, positive family history, parity, episiotomy use, body mass index, advanced age, spontaneous perineal tear at delivery and so on, appear to be implicated for UIs in High Income Countries (HIC) [2, 18–20].There are insufficient researches to draw conclusion on the risk factors for UI in SSA. In addition, large, diversified population-based studies have assessed prevalence rates of UI; however, there is limited robust evidence describing the burden of UI amongst women in SSA, where parity on average is higher than those in High-Income Countries [21].

It is therefore, imperative that a well-structured systematic review and meta-analytical models in SSA are required to accurately and reliably estimate the burden, and associated factors for UI. In this context, the current study aims to assess the burden of UI in SSA, as well as the risk factors associated with it. Thus, the review sought to answer the questions; what is the burden of UI in SSA? and what are the factors associated with the burden of UI in SSA?

Methods

Overview

This systematic review was registered in PROSPERO [CRD42021267551]. This systematic review and meta-analysis was conducted and reported according to the guidelines of the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) [22] [S1 Checklist].

Eligibility criteria

Inclusion criteria

Observational studies such as longitudinal, cohort, case control and cross-sectional studies reporting prevalence/or risk factors of UI were incorporated in the current review, as well as conference abstracts with enough information to calculate prevalence UI. Original observational studies published in English and adult SSA woman aged ≥18 years were included. Burden of UI studies that compared both SSA men and women, only information on the women were extracted. Finally, both hospital and community/population-based studies were included and later stratified in the pooled meta-analysis.

Exclusion criteria

Studies reporting animal studies, reviews, commentaries, letter to editors were excluded. Prevalence of UI articles published in other languages were excluded. Studies that looked at the management and treatment of UI, as well as quality of life, depression, without data on burden of UIs were excluded. Studies from North Africa countries, other LMICs, and HIC were also excluded. UI studies involving children and adolescent females were also excluded.

Data sources and search strategy

Medline/PubMed, Google Scholar, Africa Journal Online were searched to extract data on burden of UI studies in SSA countries, as well as their respective risk factors’ information. The articles that were considered were published between 2000/1/1 and 2021/9/30. There was also a manual search of the reference lists of the studies that were included. Medical Sub-Heading (MeSH) terms and free text were used in the search approach. These terms were coupled with the Boolean operators ‘OR’ and ‘AND’. The keywords included; Burden, prevalence, Pelvic Floor Disorders, Urinary Incontinence, Sub-Saharan Africa. The final search strategy is displayed in (S1 Table).

Selection process

To ensure a rigorous review strategy, articles were reviewed individually by two independent co-authors [MA, and KA]. The data screening was done in two stages; the title abstract screening, followed by the full-text screening. Both steps were completed independently by two review authors. A third reviewer (ASA) was available to resolved the disagreement between MA and KA. Finally, all the studies were imported into Mendeley desktop reference manager.

Data collection and management

MA and KA independently extracted data into an excel sheet, and discrepancies were resolved through discussion. Extracted data were; Author’s name, year of publication, country, age, study design, population, sample size, setting, information on the burden of UI. Finally, significant independent risk factors from the individual studies were extracted.

Quality assessment and risk of bias

The quality of the retrieved studies were assessed using the Newcastle-Ottawa Quality Assessment instrument, which was customized for cross-sectional research [23]. The assessment’s goal was to determine the research’ internal and external validity, as well as to reduce the possibility of bias [23]. The findings of the quality assessment are presented in S2 Table.

Data synthesis and strategy

The pool burden of UI was calculated using a weighted inverse variance random-effects model. This was visually represented using the forest plot. The presence of heterogeneity among studies was quantified by estimating variance using the I2 statistics [24]. The I2 takes values between 0 and 100%, and a value of 0% indicates absence of heterogeneity. I2 was interpreted based on Higgins and Thompson classification, percentages of 25%, 50% and 75% was considered as low, moderate and high heterogeneity, respectively [24].

A subgroup analysis was performed to determine the sources of heterogeneity on the study characteristics (year of publication, sample size, setting, and sub-regions). The funnel plot and Egger’s regression test was used to screened for publication bias. Finally, meta-regression was performed to assessed the factors influencing the review’s heterogeneity.

Results

Study selection process

The study identified one thousand nine hundred and twenty-nine (1929) articles from PubMed, AJOL, and Google scholar, out of which 700 were removed as duplicate. One thousand two hundred and twenty-nine articles were screened, of which 1071 papers were excluded. A total of 148 publications were evaluated for eligibility, with 25 studies [14–17, 25–45] being included in the current review [Fig 1]. This study included a total of 17863 women from SSA.

Fig 1. PRISMA 2020 flow diagram for new systematic reviews which included searches of databases, registers and other sources.

Fig 1

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Characteristics of the included studies and quality assessment

The characteristics of the included studies are shown in Table 1. The studies were published between 2005 and 2021. Nigeria had the highest number of eligible studies [n = 14], followed by Ethiopia [n = 3], followed by Ghana, and South Africa with two studies each. The age of the participants ranged from 15 to 100 years. Of the 25 studies, 14 were hospital-based, 10 community- based, and 1 university-based studies. The sample size ranged from 100 to 5000, with overall 17863 participants from SSA. Seventy-two percent [n = 17] of the articles had low risk of bias.

Table 1. Characteristics of the included Sub-Saharan African women studies on urinary incontinence.

SN Study ID Year of publication Country Study Design Age/year Sample Size Burden [%] Stress UI [%] Urgency UI [%] Mixed UI [%] Setting Risk of bias assessment
1 Berhe et al. [14] 2020 Ethiopia Cross-sectional 18–45 317 4.3 58.9 10.9 30.1 Hospital Low
2 Demissie et al. [15] 2021 Ethiopia Cross-sectional 19–70 542 3.3 Community Low
3 Ofori et al. [16] 2020 Ghana Cross-sectional 19–88 400 12 22.9 33.3 20.8 Hospital Low
4 Adanu et al. [42] 2005 Ghana Not reported 17–70 200 42.0 100.0 0.0 0.0 Hospital Low
5 Balde et al. [44] 2020 Guinea Retrospective Cohort 15–70 1770 10.2 Hospital Low
6 Bekele et al. [45] 2016 Ethiopia Cross-sectional 16–40 422 11.4 Hospital Low
7 Bowling et al. [25] 2010 Liberia Not reported Not reported 424 1.7 Community Moderate
8 Ojengbede et al. [34] 2010 Nigeria Prospective Cohort 15–45+ 5001 2.8 Community Low
9 Usifoh et al. [38] 2012 Nigeria Cross-sectional 15–60+ 412 29.4 44.6 14.9 40.5 Community Low
10 Rabiu et al. [29] 2015 Nigeria Cross-sectional 15–44 257 15.2 43.6 46.2 20.2 Hospital Moderate
11 Okunola et al. [35] 2018 Nigeria Cross-sectional 18–45 442 28.1 62.1 24.2 19.4 Hospital Low
12 Abiola et al. [40] 2016 Nigeria Cross-sectional Not reported 229 12.7 58.6 27.6 17.2 Community Low
13 Akinlusi et al. [17] 2020 Nigeria Cross-sectional 25–67 395 32.9 54.6 23.1 22.3 Hospital Low
14 Adaji et al. [41] 2009 Nigeria Cross-sectional 15–42 204 21.1 60.4 25.6 9.3 Hospital Moderate
15 Yağmur et al. [39] 2021 Nigeria Cross-sectional 40–69 286 30.1 30.2 7.0 31.4 Community Moderate
16 Badejoko et al. [43] 2015 Nigeria Cross-sectional 20–100 1250 5.2 35.4 46.2 18.6 Hospital Low
17 Bello et al. [36] 2018 Nigeria Cross-sectional 16–46+ 500 21.4 40.2 8.4 51.4 Hospital Low
18 Njoku et al. [32] 2020 Nigeria Cross-sectional Not reported 658 16.1 73.6 16.9 9.4 Hospital Low
19 Irshad et al. [28] 2021 Nigeria Cross-sectional 15–45 282 26.2 56.8 8.1 33.8 Hospital Moderate
20 Obioha et al. [33] 2015 Nigeria Prospective Cohort Not reported 230 12.2 Hospital Moderate
21 Gashugi et al. [26] 2005 Rwanda Not reported 20–64 1030 41.9 Community Low
22 Patel et al.[27] 2014 Sierra Leone Not reported Not reported 1320 0.6 Community Moderate
23 Skaal et al. [37] 2011 South Africa Not reported Not reported 145 31.7 University Low
24 Madombwe et al. [30] 2010 South Africa Not reported 21–76 100 35.4 Community Low
25 Masenga et al. [31] 2019 Tanzania Cross-sectional 18–90 1048 42.1 39.0 22.0 39.0 Community Low
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SN = Serial Number, UI = Urinary Incontinence

Estimated Burden of Urinary Incontinence amongst Sub-Saharan Africa women

The systematic review showed that the prevalence of UI ranged from 0.6% in Sierra Leone to 42.1% in Tanzania. In the meta-analysis, the pooled estimate of the burden of UI across all studies was 21% [95% CI: 16%-26%, I2 = 91.01%]. A substantial statistically significant heterogeneity was detected across the studies [Fig 2].

Fig 2. Forest plot of pooled Burden of Urinary Incontinence amongst SSA women.

Fig 2

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With respect to the sub-types of UI, 14 studies were included, and the estimated pooled prevalence of stress UI was 52% [95% CI: 42%-62%, I2 = 70.78%], urgency UI 21% [95% CI: 15%-26%, I2 = 0.00%], and mixed UI 27% [95% CI: 20%-35%, I2 = 46.37%] [Table 2].

Table 2. Sub-group analysis of types of UI, sub-region, and setting of study.

Sub group Variable Dataset Pooled burden % [95%CI]
Sample size
≤400 12 24.0 [18.0–30]
>400 13 19.0 [10.0–27]
Types of UI
Stress UI 14 52.0 [42.0–62.0]
Urgency UI 14 21.0 [15.0–26.0]
Mixed UI 14 27.0 [20.0–35.0]
Sub-Region
East Africa 5 31.0 [19.0–42.0]
West Africa 18 16.0 [11.0–21.0]
South Africa 2 23.0 [12.0–33.0]
Study setting
Hospital based 14 18.0 [13.0–22.0]
Community-based 10 23.0 [16.0–26.0]
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Sub-group analysis

Sub-group analysis were performed with regards to sub-region [East africa vs.West Africa vs. South Africa], and setting [Hospital-based vs. Community-based studies]. The pooled estimate of UI in East Africa was 31% [95% CI: 19%-42%], West Africa was 16% [95% CI: 11%-21%], and South Africa 35% [95% CI: 15%-55%]. With regards to settings, the estimated burden of UI was 18% [95% CI: 13%-22%] for hospital based studies, and 23% [95% CI: 12%-33%] for community-based studies. The findings are summarised in Table 2.

Meta-regression

Meta-regression revealed non-sigifcant, decreased trend in the year of publication (coefficient = -0.0033, p = 0.533), and significant decreased trend in the number of sample size (coefficient = -0.0001, p = 0.048) with increasing burden of UI amongst women in SSA [S3 Table].

Publication bias

There was no evidence of publication bias in both the subjective funnel plot [Fig 3] and the objective Egger’s regression test (z = 1.74, p = 0.0825).

Fig 3. Assessment of publication bias using the funnel plot.

Fig 3

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Systematic review of associated factors for UI amongst Sub-Saharan African women

Systematic review of factors associated with UI amongst SSA women is shown Table 3. The significant independent factors were; parity [14, 31, 32], constipation [14, 17, 45], overweight/obese [17, 35, 45], vaginal delivery [32, 34, 35] chronic cough [16, 45], gestational age [14, 35] and aging [16, 32]. For example, Berhe et al. found that multiparous women had approximately 6 times higher chances of developing UI compared to primigravida women in Ethiopia [14]. A population-based study in rural Tanzania showed that women who had experienced multiple births had 2 times chance of reporting UI [31]. Also, women with history of constipation had 2times chance of reporting UI compared to women without prior constipation in a Nigerian study [17]. Similarly, an Ethiopian study reported history of constipation as an associated factor for UI [45]. The results are presented in Table 3.

Table 3. Systematic review of associated factors for UI amongst Sub-Saharan African women.

SN Study ID Country of Study Type of Study Independent Risk Factors p-value
1 Berhe et al. [14] Ethiopia Cross-sectional Gestational age **
Parity **
Prior Miscarriage **
Constipation **
Respiratory Problem **
Weak PFM **
2 Ofori et al. [16] Ghana Cross-sectional Age>60 **
History of chronic cough **
3 Bekele et al. [45] Ethiopia Cross-sectional Episiotomy **
Constipation **
Obese women **
Chronic cough/Sneezing **
Asthma/Allergies/Sinusitis **
4 Okunola et al. [35] Nigeria Cross-sectional overweight/obese **
Gestational age **
Previous Vaginal/Instrumental delivery **
5 Akinlusi et al. [17] Nigeria Cross-sectional Previous Constipation **
overweight/obese **
6 Njoku et al. [32] Nigeria Cross-sectional Age>40 **
Parity>3 **
Low educational level **
Vaginal/Instrumental Delivery **
Carry Heavy Load **
Farming **
7 Masenga et al. [31] Tanzania Cross-sectional Parity **
Delivery at home **
Labour>24hrs **
8 Ojengbede et al. [34] Nigeria Prospective Cohort Vaginal Delivery **
Diabetes **
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**Significant at p<0.05

Discussion

The systematic review and meta-analysis included 25 studies with 17863 participants from 9 countries across SSA. We present a comprehensive review of the burden of UI and associated variables in SSA women in this study. The systematic review showed that the burden of UI ranged from 0.6% in Sierra Leone to 42.1% in Tanzania. According to the meta-analysis, the sub-region has an estimated pooled burden of UI to be 21% [95% CI: 16%-26%]. The study further revealed that the commonest type of UI was stress UI (52%), mixed UI (27%), and urgency UI (21%). There were a wide range of prevalent estimates among the participants. For example, Patel et al. [27] discovered that less than 1% of Sierra Leonean women have UI, but Masenga et al. [31] found that 42.1% of Tanzanian women have UI. The current estimated burden is lower than reported by Xue et al in China [46], Mostafaei et al in developing countries [11], and Batmani et al in the global estimate [47]. Similarly, a study in the United States found that 45% of participants aged 30–60 years reported UI [48], which is significantly higher than the current estimate. The comparatively lower burden in the current review could be attributed to variation in the method used, under-reporting, underdiagnosis as a results of low health seeking behavior among SSA women [49]. As a result, initiatives to reduce the burden of UI amongst SSA women aged 15–100 years could have significant public health implications.

The pooled estimate of UI in East Africa was 31%, West Africa was 16%, and South Africa 35%. Tanzania [31] reported the greatest prevalence in East Africa, while Ethiopia [14] recorded the lowest. Ofori et al. [16] found the highest prevalence of UI in West Africa, while Patel et al. [27] found the lowest. In the southern SSA, both the highest and lowest burden were reported from South Africa [30, 37]. The sub-regional variance could be attributed to the sample size included from individual countries. For example, a trend meta-regression analysis in this review found an inverse relationship between the burden of UI and sampled size.

In addition, our stratified analysis based on study setting showed that community dwelling women in SSA had an estimated burden of 23% compared to hospital-based of 18%. Ten and fourteen studies reported on community and hospital-based studies respectively.

Three studies reported that parity was independently associated with UI [14, 31, 32]. Masenga et al. [31] adduced that women with at least three children have a two-fold increased risk of contracting UI in Tanzania. Similarly, Njoku et al. [32] in Nigeria corroborated with this findings. In Ethiopia, multiparous women had a 6 times higher risk of UI than primigravida women [14]. The current findings are supported meta-analyses [46, 47, 50]. The findings are ascribed to pelvic floor musculature and connective tissue injury that affects normal urine continence function during parturition. [50, 51].

Constipation was another commonly reported independent factors associated with UI in SSA [14, 17, 45]. The finding is consistent with systematic reviews conducted in China [46] and worldwide [47]. The mechanism underpinning this association is not well understood, although in an animal research, Chen et al. found that colon distension increased contractility, similar to bladder distention and the vesicovascular reflex, hence it could be inferred that chronic colorectal distension caused by constipation or chronically high abdominal muscle pressure during defecation limits bladder distension which exacerbates irritative bladder symptoms [52, 53].

Another important factor associated with UI among women in SSA was overweight/obese Three studies [17, 35, 45] reported on this factor. For instance, a study in Nigeria reported that an overweight/obese women had 60% increased odds of UI compared to apparently normal body weight women. Bekele et al. [45] reported similar magnitude of the event. The current result is in accordance with Batman et al. [47]. Excess body weight is thought to increase abdominal pressure, which raises bladder pressure and urethral mobility, causing stress UI and worsening detrusor instability and overactive bladder [54]. In the same vein, obesity/overweight can create chronic strain on the soft tissues, and other pelvic floor structures, hence, straining and weakening these important urethral mobility systems [55].

Furthermore, vaginal delivery [32, 34, 35], chronic cough [16, 45], and gestational age [14, 35] were all found to be factors associated with UI amongst SSA women aged 15–100 years. This is consistent with several observational studies and systematic reviews [46, 47, 50].

Finally, two studies identified aging as a risk factor for UI [16, 32]. In Ghana, women aged 60 were approximately three times more likely than women aged 18–39 to have urinary incontinence [42]. In Nigerian study, Njoku et al. [32] estimated that women over the age of 40 had a five-fold increased risk of urine incontinence.

Our findings should be viewed in the context of some caveats. First, there was significant heterogeneity among the studies. Second, studies from Central Africa were scarce, thus no research from this region was included which could affect generalization of our findings. Furthermore, only articles published in English were considered. Finally, the authors identified relevant studies using a small database. However, heterogeneity is common in meta-analyses of observational data, and it does not always invalidate the conclusions. This is the first and largest systematic review and meta-analysis on the burden of UI among SSA women. Our results are more reliable evident by no obvious publication bias.

Recommendations, research and policy implications

Our research showed that, at least 21% of women in SSA have some form of urinary incontinence. This implies that there is the need to increase public health education and create awareness among people in order to promote health seeking behaviors among women. Healthy practices can be encouraged among women in order to reduce the disease burden in women. Such practices may include; maintaining a healthy body weight through exercise and diet to reduce the incidence of obesity and its complications. Avoiding constipation by taking in a high fiber diet, adequate intake of water, reducing immobility and regular emptying of bowel. Women should be taught how to strengthen their pelvic floor muscles especially during and after pregnancy by performing kegel’s exercises. Family planning methods should be made accessible to all irrespective of their social and economic status so women can effectively exercise their rights to choose the number of children they would want to have while taking into consideration their health. Finally, there are few studies examining the burden of UI, particularly in SSA’s eastern and southern regions. It is therefore critical that more researches be undertaken in these sub-regions in order to obtain a complete, accurate, and consistent picture of this treatable condition.

Conclusion

This is the first and most comprehensive systematic review and meta-analysis on the burden of UI amongst SSA women aged 15 to 100 years. According to the study, one out of every five women in SSA suffers from UI. Parity, constipation, overweight/obesity, vaginal delivery, chronic cough, gestational age, and age were the most important risk variables. As a result, interventions aimed at reducing the burden of UI in SSA women aged 15 to 100 years old in the context of identified determinants could have significant public health implications.

Supporting information

S1 Checklist. PRISMA checklist.

(DOCX)

Click here for additional data file. (31.3KB, docx)
S1 Table. Search strategies for the individual database.

(DOCX)

Click here for additional data file. (15.6KB, docx)
S2 Table. Quality assessment.

(DOCX)

Click here for additional data file. (22.2KB, docx)
S3 Table. Meta-regression of burden of UI in SSA women by sample size and year of publication.

(DOCX)

Click here for additional data file. (12.9KB, docx)

Acknowledgments

We would like to express our gratitude to all who contributed to the writing of the reviewed articles in this systematic review and meta-analysis.

Data Availability

All relevant data are within the manuscript.

Funding Statement

The authors received no specific funding for this work.

References

  • 1.Kenton K, Mueller ER. The global burden of female pelvic floor disorders. BJU Int. 2006;98(SUPPL. 1):1–5. doi: 10.1111/j.1464-410X.2006.06299.x [DOI] [PubMed] [Google Scholar]
  • 2.Gedefaw G, Demis A. Burden of pelvic organ prolapse in Ethiopia: A systematic review and meta-analysis. BMC Womens Health. 2020;20(1):1–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3.Nygaard I. Prevalence of Symptomatic Pelvic Floor Disorders in US Women. JAMA. 2008;23(1):1311–1316. doi: 10.1001/jama.300.11.1311 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4.Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol. 1997;89(4):501–6. doi: 10.1016/S0029-7844(97)00058-6 [DOI] [PubMed] [Google Scholar]
  • 5.Wu JM, Vaughan CP, Goode PS, Redden DT, Burgio KL, Richter HE, et al. Prevalence and trends of symptomatic pelvic floor disorders in U.S. women. Obstet Gynecol. 2014;123(1):141–8. doi: 10.1097/AOG.0000000000000057 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6.Islam RM, Oldroyd J, Rana J, Romero L, Karim MN. Prevalence of symptomatic pelvic floor disorders in community-dwelling women in low and middle-income countries: a systematic review and meta-analysis. Int Urogynecol J. 2019;30(12):2001–11. doi: 10.1007/s00192-019-03992-z [DOI] [PubMed] [Google Scholar]
  • 7.Milsom I, Coyne KS, Nicholson S, Kvasz M, Chen CI, Wein AJ. Global prevalence and economic burden of urgency urinary incontinence: A systematic review. Eur Urol [Internet]. 2014;65(1):79–95. Available from: doi: 10.1016/j.eururo.2013.08.031 [DOI] [PubMed] [Google Scholar]
  • 8.Haylen BT, De Ridder D, Freeman RM, Swift SE, Berghmans B, Lee J, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Int Urogynecol J. 2010;21(1):5–26. doi: 10.1007/s00192-009-0976-9 [DOI] [PubMed] [Google Scholar]
  • 9.Minassian V.A., Drutz H.P. AA-B. Serum levels of insulin, IGF, BP1 in preeclampsia and eclampsia. Int J Gynaecol Obstet. 2003;81(2):151–6.12706271 [Google Scholar]
  • 10.Abrams P, Smith AP, Cotterill N. The impact of urinary incontinence on health-related quality of life (HRQoL) in a real-world population of women aged 45–60 years: Results from a survey in France, Germany, the UK and the USA. BJU Int. 2015;115(1):143–52. doi: 10.1111/bju.12852 [DOI] [PubMed] [Google Scholar]
  • 11.Mostafaei H, Sadeghi-Bazargani H, Hajebrahimi S, Salehi-Pourmehr H, Ghojazadeh M, Onur R, et al. Prevalence of female urinary incontinence in the developing world: A systematic review and meta-analysis—A Report from the Developing World Committee of the International Continence Society and Iranian Research Center for Evidence Based Medicine. Neurourol Urodyn. 2020;39(4):1063–86. doi: 10.1002/nau.24342 [DOI] [PubMed] [Google Scholar]
  • 12.John G, Bardini C, Combescure C, Dällenbach P. Urinary incontinence as a predictor of death: A systematic review and meta-analysis. PLoS One. 2016;11(7):1–19. doi: 10.1371/journal.pone.0158992 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 13.Holroyd-Leduc JM, Mehta KM, Covinsky KE. Urinary Incontinence and Its Association with Death, Nursing Home Admission, and Functional Decline. J Am Geriatr Soc. 2004;52(5):712–8. doi: 10.1111/j.1532-5415.2004.52207.x [DOI] [PubMed] [Google Scholar]
  • 14.Berhe A, Alamer A, Negash K, Assefa B. Urinary incontinence and associated factors among pregnant women attending antenatal care in public health facilities of Mekelle city, Tigray, Ethiopia. Women’s Heal. 2020;16:1–8. doi: 10.1177/1745506520952009 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 15.Demissie E, Id B, Tesfaye W, Id T. Symptomatic pelvic floor disorders and its associated factors in South-Central Ethiopia. PLoS One [Internet]. 2021;1–15. Available from: 10.1371/journal.pone.0254050 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 16.Amanfo A, Ofori, Joseph Osarfo, Agbeno EK, Azanu K, Opare-addo HS. Prevalence and determinants of non-fistulous urinary incontinence among Ghanaian women seeking gynaecologic care at a teaching hospital. PLoS One [Internet]. 2020;1–14. Available from: 10.1371/journal.pone.0237518 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 17.Akinlusi FM, Ottun TA, Oshodi YA, Oluwatoyin B. Female Urinary Incontinence : Prevalence, Risk Factors and Impact on the Quality of Life of Gynecological Clinic Attendees in Lagos, Nigeria. Nep J Obs Gynecol. 2020;15(1):31–8. [Google Scholar]
  • 18.Bodner-Adler B, Kimberger O, Laml T, Halpern K, Beitl C, Umek W, et al. Prevalence and risk factors for pelvic floor disorders during early and late pregnancy in a cohort of Austrian women. Arch Gynecol Obstet [Internet]. 2019;300(5):1325–30. Available from: 10.1007/s00404-019-05311-9 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 19.MacLennan AH, Taylor AW, Wilson DH, Wilson D. The prevalence of pelvic floor disorders and their relationship to gender, age, parity and mode of delivery. Vol. 107, British Journal of Obstetrics and Gynaecology. 2000. p. 1460–70. doi: 10.1111/j.1471-0528.2000.tb11669.x [DOI] [PubMed] [Google Scholar]
  • 20.Yohay D, Weintraub AY, Mauer-Perry N, Peri C, Kafri R, Yohay Z, et al. Prevalence and trends of pelvic floor disorders in late pregnancy and after delivery in a cohort of Israeli women using the PFDI-20. Eur J Obstet Gynecol Reprod Biol [Internet]. 2016;200:35–9. Available from: 10.1016/j.ejogrb.2016.02.037 [DOI] [PubMed] [Google Scholar]
  • 21.Bowling CB, Munoz O, Gerten K, Mann M, Taryor R, Norman A, et al. Characterization of Pelvic Floor Symptoms in Women of Northeastern Liberia. Neurourol Urodyn. 2009;109(3):251–3. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 22.Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ. 2021;372. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 23.Luchini Claudio, Stubbs Brendon, Marco Solmi NV. Assessing the quality of studies in meta-analyses: Advantages and limitations of the Newcastle Ottawa Scale Luchini C, Stubbs B, Solmi M, Veronese N. Assessing the quality of studies in meta-analyses: Advantages and limitations of the Newcastle Ottawa Sca. World J Psychiatry. 2012;2(2):26–32.24175165 [Google Scholar]
  • 24.Higgins JPT, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med. 2002;21(11):1539–58. doi: 10.1002/sim.1186 [DOI] [PubMed] [Google Scholar]
  • 25.Bowling CB, Munoz O, Gerten KA, Mann M. NIH Public Access. Int J Gynaecol Obs. 2010;109(3):251–3. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 26.Gashugi P LQ. Prevalence and Risk Factors of Urinary Incontinence among Adult Rwandan Women. SA J Physiother. 2005;61(4):6–14. [Google Scholar]
  • 27.Patel Hiten D., Kamara Thaim B., Kushner Adam L. and RSG. Estimating the prevalence of urinary and fecal incontinence in a nationally representative survey in Sierra Leone Hiten. Int J Gynaecol Obs. 2014;126(2):175–6. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 28.Irshad A, Irshad S, Adesiyun AG, Sulayman HU. The burden of urinary incontinence in late pregnancy : Antenatal clinic experience in a tertiary hospital in Northern Nigeria. Arch Int Surg. 2021;47–51. [Google Scholar]
  • 29.J, Rabiu A AIG. PREVALENCE Of POSTPARTUM URI NARY INC ONTINE NC E AMONG WOME N ATTE NDI NG POSTNATAL C LI NIC AT Ai\ II NU KANOTEACH ING HOSPITAL. Trop J Obstet Gynaecol. 2015;32(2). [Google Scholar]
  • 30.J P Madombwe SK. High prevalence of urinary incontinence and poor knowledge of pelvic floor exercises among women in Ladysmith. SAJOG. 2005;16(1):18–21. [Google Scholar]
  • 31.Masenga GG, Benjamin C Shayo, Msuya S, Rasch V. Urinary incontinence and its relation to delivery circumstances : A population-based study from rural Kilimanjaro, Tanzania. PLoS One [Internet]. 2019;1–12. Available from: doi: 10.1371/journal.pone.0208733 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 32.Njoku CO, Njoku AN, Emechebe CI, Okpe AE, Iklaki CI. Pattern and risk factors of non-fistulous urinary incontinence among gynaecological clinic attendees in a Nigeria tertiary health institution. Int J Reprod Contracept Obs Gynecol. 2020;9(6):2323–7. [Google Scholar]
  • 33.Obioha KC, Ugwu EO, Obi SN, Dim CC, Oguanuo TC. Prevalence and predictors of urinary / anal incontinence after vaginal delivery : prospective study of Nigerian women. Int Urogynecol J. 2015;26:1347–1354. doi: 10.1007/s00192-015-2690-0 [DOI] [PubMed] [Google Scholar]
  • 34.Oladosu A. Ojengbede, Imran O. Morhason-Bello, B. O. A., & Kolade, N. S. O. and C. O. (2010). urinary incontinence among 5000 black women community survey. BJU International, 1793–1800. 10.1111/j.1464-410X.2010.09758.x [DOI] [PubMed]
  • 35.Okunola TO, Rosiji B. Prevalence and risk factors for urinary incontinence in pregnancy in Ikere-Ekiti, Nigeria. Neurourol Urodyn. 2018;1–7. [DOI] [PubMed] [Google Scholar]
  • 36.Bello OO. Prevalence of Non-Fistulous Urinary Incontinence among Nonparturient Women in A Tertiary Hospital. J woman’s Reprod Heal. 2018;2(1):35. [Google Scholar]
  • 37.Skaal L MM. The Prevalence of Urinary Incontinence and its Impact on Quality of Life among the University Female Staff in South Africa. SA J Physiother. 2011;45–9. [Google Scholar]
  • 38.Usifoh SF, Odilim VU, Udezi WA. Prevalence of urinary incontinence in a sample of women living in Benin city, Prevalence of urinary incontinence in a sample of women living in Benin city, Nigeria. J Med Res Pr. 2012;1(June 2019):29–32. [Google Scholar]
  • 39.Y Yağmur SG. Urinary Incontinence in Women aged 40 and Older: Its Prevalence, Risk Factors, and Effect on Quality of Life. Niger J Clin Pract |. 2021; [DOI] [PubMed] [Google Scholar]
  • 40.Abiola OO, Idowu A, Ogunlaja OA, Williams-abiola OT, Ayeni SC. Prevalence, quality of life assessment of urinary incontinence using a validated tool (ICIQ-UI SF) and bothersomeness of symptoms among rural community : dwelling women in Southwest, Nigeria. Int J Community Med Public Heal. 2016;3(5):989–97. [Google Scholar]
  • 41.Adaji SE, Shittu OS, Bature SB, Nasir S, Olatunji O. European Journal of Obstetrics & Gynecology and Reproductive Biology Suffering in silence : pregnant women ‘ s experience of urinary incontinence in. Eur J Obstet Gynecol [Internet]. 2010;150(1):19–23. Available from: 10.1016/j.ejogrb.2010.02.008 [DOI] [PubMed] [Google Scholar]
  • 42.Adanu RMK, Delancey JOL. The physical finding of stress urinary incontinence among African women in Ghana. Int Urogynecol J. 2005;(December). [DOI] [PubMed] [Google Scholar]
  • 43.Badejoko OO, Bola-oyebamiji S, Awowole IO. Urinary incontinence : prevalence, pattern, and opportunistic screening in Ile-Ife, Nigeria. Int Urogynecol J. 2015; [DOI] [PubMed] [Google Scholar]
  • 44.Balde FB, Diallo AB, Toure A, Kante D. Risk Factors for Urinary Incontinence after Obstetric Vesicovaginal Fistula Closure in. Surg Sci. 2021;12:1–8. [Google Scholar]
  • 45.Bekele A, Adefris M, Demeke S. Urinary incontinence among pregnant women, following antenatal care at University of Gondar Hospital, North West Ethiopia. BMC Pregnancy Childbirth [Internet]. 2016;16:2–7. Available from: 10.1186/s12884-016-1126-2 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 46.Xue K, Palmer MH, Zhou F. Prevalence and associated factors of urinary incontinence in women living in China : a literature review. BMC Urol [Internet]. 2020; Available from: doi: 10.1186/s12894-020-00735-x [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 47.Batmani S, Jalali R, Mohammadi M. Prevalence and factors related to urinary incontinence in older adults women worldwide : a comprehensive systematic review and meta-analysis of observational studies. BMC Geriatr. 2021;21:1–17. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 48.Melville JL, Katon W, Delaney K, Newton K. Urinary Incontinence in US Women. Arch Intern Med. 2005;165:537–42. doi: 10.1001/archinte.165.5.537 [DOI] [PubMed] [Google Scholar]
  • 49.Budu E, Abdul-aziz Seidu, Armah-ansah EK. Women ‘ s autonomy in healthcare decision- making and healthcare seeking behaviour for childhood illness in Ghana : Analysis of data from the 2014 Ghana Demographic and Health Survey. PLoS One [Internet]. 2020;1–14. Available from: 10.1371/journal.pone.0241488 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 50.Zhou H, Shu B, Liu T, Wang X, Yang Z, Guo Y. Association between parity and the risk for urinary incontinence in women. Medicine (Baltimore). 2018;97. doi: 10.1097/MD.0000000000011443 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 51.Wood LN, Anger JT. Urinary incontinence in women. BMJ. 2014;349. doi: 10.1136/bmj.g4531 [DOI] [PubMed] [Google Scholar]
  • 52.Maeda T, Tomita M, Nakazawa A, Sakai G, Funakoshi S, Komatsuda A, et al. Female Functional Constipation Is Associated with Overactive Bladder Symptoms and Urinary Incontinence. Biomed Res Int. 2017;2017. doi: 10.1155/2017/2138073 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 53.Chen S, Yang C, Chien C. Neuroscience Letters Colorectal distension enforce acute urinary bladder distension-induced hepatic vasoconstriction in the rat. Neurosci Lett. 2008;443:257–60. [DOI] [PubMed] [Google Scholar]
  • 54.Bump RC, Sugerman HJ, Fantl JA, Mcclish DK. Obesity and lower urinary tract function in women : Effect of surgically induced weight loss. Am J Obs Gynecol. 1992;392–9. doi: 10.1016/s0002-9378(11)91418-5 [DOI] [PubMed] [Google Scholar]
  • 55.Subak Leslee L., Holly E. Richter SH. Obesity and Urinary Incontinence: Epidemiology and Clinical Research Update. J Urol. 2009;182:3–5. doi: 10.1016/j.juro.2009.08.071 [DOI] [PMC free article] [PubMed] [Google Scholar]
PLOS Glob Public Health. doi: 10.1371/journal.pgph.0000562.r001

Decision Letter 0

Rajat Das Das Gupta

1 Mar 2022

PGPH-D-21-00952

Estimated Burden, and Associated Factors of Urinary Incontinence among Sub-Saharan African Women aged 15-100 years: a systematic review and meta-analysis.

PLOS Global Public Health

Dear Dr. Ackah,

Thank you for submitting your manuscript to PLOS Global Public Health. After careful consideration, we feel that it has merit but does not fully meet PLOS Global Public Health’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Apr 15 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at globalpubhealth@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pgph/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

  • A rebuttal letter that responds to each point raised by the editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

  • A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

  • An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

We look forward to receiving your revised manuscript.

Kind regards,

Rajat Das Gupta, M.D.

Academic Editor

PLOS Global Public Health

Journal Requirements:

1. Please amend your Financial Disclosure statement. If you did not receive any funding for this study, please simply state: “The authors received no specific funding for this work.”

Additional Editor Comments (if provided):

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Does this manuscript meet PLOS Global Public Health’s publication criteria? Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe methodologically and ethically rigorous research with conclusions that are appropriately drawn based on the data presented.

Reviewer #1: Partly

Reviewer #2: Partly

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available (please refer to the Data Availability Statement at the start of the manuscript PDF file)?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception. The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS Global Public Health does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

Reviewer #2: No

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: I appreciate the effort of the authors. However, there are certain methodological concerns that should be addressed before acceptance. Please find my comments here:

1. Page 5: “Hospital and community based-studies had been conducted for UI in SSA countries.” - Please provide a reference for this statement.

2. Inclusion criteria: Some sentences are incomplete. For example: “Original observational studies published in English. An adult SSA woman [≥18 years].” - these two sentences are incomplete and grammatically incorrect.

3. Exclusion criteria: It started with an incomplete statement. For example: “Studies reporting animal studies, reviews, commentaries, letter to editors.”

4. Exclusion criteria: Mention about language as only English language has been considered.

5. Search: “The search was limited to January, 2000- September, 2021.” It means the search timeline was between January 2020 to September 2021 which is not correct I guess. Did the author consider articles published during this time? Or, is this the timeframe of searching the databases. If the authors considered the timeline from inception to September 2021, please mention that clearly.

6. Database: Google scholar is a search engine, not a database. Africa Journal Online is a local repository. Authors should search SCOPUS, Web of Science, EMBASE (at least two of these three) in addition to Medline.

7. A comprehensive search strategy for the Medline search should be provided. The search strategy for other databases should be provided as a supplementary file. As per the PRISMA 2020 guidelines, a search strategy for all the databases should be provided.

8. The current search strategy provided by the authors is revealing 618,343 articles (searched on 25 January 2022) from Medline/Pubmed. I don’t know how the authors have got only 720 articles from Medline/Pubmed. Can you please explain?

9. Selection process: “To ensure a rigorous review strategy, any duplicate articles were reviewed individually by two independent co-authors [MA, and KA,] in a double blinded process, and then rejected before selecting a unique collection of papers for this study” - What do you mean by “any duplicate article”? Two independent authors should screen all the articles.

10. The screening of articles is done in two phases. At first the title abstract screening, and then the full-text screening. Both the stages should be performed by two independent review authors independently. It should be mentioned properly.

11. Results: Study selection: Authors have removed 550 articles even before the screening! This is strange. They should mention the specific reason for the pre-screening exclusion. The authors should mention the causes of exclusion of 175 articles that underwent full-text screening.

12. Characteristics of the included studies and quality assessment: “Nigeria had the highest number of eligible studies [n=14], followed by Ethiopia [n=3], followed by Ghana and South Africa with two studies each.” - This calculation is showing 21 articles. Initially, the authors mentioned that they have included 25 articles.

13. Please add a paragraph stating the research implication. What are the recommendations for conducting further research based on the findings of this systematic review?

14. What are the policy implications of the findings?

15. The authors included articles published in English only? Isn’t it a limitation?

16. Overall, there should be thorough language editing.

Reviewer #2: REVIEWER’S COMMENTS FOR MANUSCRIPT NUMBER PGPH-D-21-00952

I would like to thank the authors for choosing an interesting topic which is also a neglected issue. The authors have put a great effort to it and tried to conduct a comprehensive review. However, I think there is still scope of improvement. My comment on this paper is listed below:

Introduction:

• The introduction needs reorganization. The first paragraph may mislead the readers regarding the target topic. I would suggest focusing on UI in the opening paragraph, keeping only one or two sentences regarding pelvic floor muscles and pelvic floor disorders

• It would be great if the authors could provide reference of some low-and-middle income countries also, which are comparable to the SSA countries

• The 2nd paragraph needs reorganization and resequencing of the sentences. Here, the authors provided definition and subtypes, followed by consequences. Then, all on a sudden, they provided US data, which seem irrelevant in the context

• The notion regarding limitation of underestimation of the studies conducted in SSA has not been references

• The rationale of doing a systematic review should be at the last paragraph

• The last para van go to conclusion

Research question

• Should be described in narrative instead of bullets

• This can also be incorporated in the last sentence of introduction

Methods

• It is great that the review is PROSPERO registered and it followed PRISMA guidelines

• The inclusion criteria and exclusion criteria are very poorly written. Many sentences are incomplete and need major revision

• The search strategy is explained well, but grammar checks

• The authors can add a supplementary table regarding Newcastle-Ottawa Quality Assessment findings

• For the data synthesis, I would suggest the authors to recheck the last sentence which reads “to evaluate the effects of probable factors influencing study heterogeneity, the meta-regression test was performed.” I reckon there is some problem in the sentence

Results:

• The authors documented I-square value of 91% but did not describe the heterogeneity well. This high heterogeneity of the studies puts the findings of meta-regression into question.

• I would suggest the authors to describe the heterogeneity among the studies more elaborately

• Secondly, I would suggest the authors to do a sub-group analysis with the studies that are more homogenous, and check whether it can replicate the overall result

• The authors could describe the findings from associated factors more elaborately

Discussion:

• The discussion should be rearranged according to the changes made in the result section

**********

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Do you want your identity to be public for this peer review? If you choose “no”, your identity will remain anonymous but your review may still be made public.

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Reviewer #1: Yes: KM Saif-Ur-Rahman

Reviewer #2: Yes: Mohiuddin Ahsanul Kabir Chowdhury

**********

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PLOS Glob Public Health. doi: 10.1371/journal.pgph.0000562.r003

Decision Letter 1

Rajat Das Das Gupta, Julia Robinson

11 May 2022

Estimated Burden, and Associated Factors of Urinary Incontinence among Sub-Saharan African Women aged 15-100 years: a systematic review and meta-analysis.

PGPH-D-21-00952R1

Dear Martin Ackah,

We are pleased to inform you that your manuscript 'Estimated Burden, and Associated Factors of Urinary Incontinence among Sub-Saharan African Women aged 15-100 years: a systematic review and meta-analysis.' has been provisionally accepted for publication in PLOS Global Public Health.

Before your manuscript can be formally accepted you will need to complete some formatting changes, which you will receive in a follow up email. A member of our team will be in touch with a set of requests.

Please note that your manuscript will not be scheduled for publication until you have made the required changes, so a swift response is appreciated.

IMPORTANT: The editorial review process is now complete. PLOS will only permit corrections to spelling, formatting or significant scientific errors from this point onwards. Requests for major changes, or any which affect the scientific understanding of your work, will cause delays to the publication date of your manuscript.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they'll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact globalpubhealth@plos.org.

Thank you again for supporting Open Access publishing; we are looking forward to publishing your work in PLOS Global Public Health.

Best regards,

Rajat Das Das Gupta, M.D.

Academic Editor

PLOS Global Public Health

***********************************************************

Reviewer Comments (if any, and for reference):

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

**********

2. Does this manuscript meet PLOS Global Public Health’s publication criteria? Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe methodologically and ethically rigorous research with conclusions that are appropriately drawn based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available (please refer to the Data Availability Statement at the start of the manuscript PDF file)?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception. The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS Global Public Health does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thanks for addressing the comments.

Reviewer #2: Well done

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

Do you want your identity to be public for this peer review? If you choose “no”, your identity will remain anonymous but your review may still be made public.

For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: K.M. Saif-Ur-Rahman

Reviewer #2: Yes: Mohiuddin Ahsanul Kabir Chowdhury

**********

Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

    Supplementary Materials

    S1 Checklist. PRISMA checklist.

    (DOCX)

    Click here for additional data file. (31.3KB, docx)
    S1 Table. Search strategies for the individual database.

    (DOCX)

    Click here for additional data file. (15.6KB, docx)
    S2 Table. Quality assessment.

    (DOCX)

    Click here for additional data file. (22.2KB, docx)
    S3 Table. Meta-regression of burden of UI in SSA women by sample size and year of publication.

    (DOCX)

    Click here for additional data file. (12.9KB, docx)
    Attachment

    Submitted filename: response to reviewers.docx

    Click here for additional data file. (25.4KB, docx)

    Data Availability Statement

    All relevant data are within the manuscript.

    Articles from PLOS Global Public Health are provided here courtesy of PLOS

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