Associated factors of pelvic organ prolapse among patients at Public Hospitals of Southern Ethiopia: A case-control study design

Asfaw Borsamo; Mohammed Oumer; Ayanaw Worku; Yared Asmare

doi:10.1371/journal.pone.0278461

. 2023 Jan 18;18(1):e0278461. doi: 10.1371/journal.pone.0278461

Associated factors of pelvic organ prolapse among patients at Public Hospitals of Southern Ethiopia: A case-control study design

Asfaw Borsamo ^1,^*, Mohammed Oumer ², Ayanaw Worku ², Yared Asmare ²

Editor: Joseph Donlan³

PMCID: PMC9847956 PMID: 36652500

Abstract

Background

Pelvic organ prolapse (POP) is the descent of the vaginal wall, cervix, uterus, bladder, and rectum downward into the vaginal canal. It occurs owing to the weakness of the structures supporting and keeping pelvic organs in anatomic position. Prolapse occurs due to exposure to risk factors; women in developing countries are highly predisposed to the risk factors of the prolapse. No study assesses POP in Southern Ethiopia.

Methods

A case-control study design was employed in 369 participants (123 cases and 246 controls) of seven randomly selected Public Hospitals of Southern Ethiopia from February-June, 2020, using a structured questionnaire. All patients diagnosed with prolapse (stage I- IV) were included as cases; patients free of prolapse (stage 0) were taken as controls after physicians had performed a diagnosis and vaginal examination. Bivariate and multivariable logistic regression analyses were performed using SPSS.

Results

In this study, after adjusting for covariates, age of the women ≥ 45 years (AOR = 5.33, 95% CI: 1.47, 9.05), underweight (AOR= 4.54, 95% CI: 1.4, 15.76), low income (AOR = 2.5, 95% CI:1.14, 5.59), parity ≥5 (AOR = 5.2, 95% CI: 2.2, 12.55), assisted vaginal delivery (AOR= 4, 95% CI: 1.55, 11.63), instrumental delivery (AOR= 3.5, 95% CI:1.45, 84), sphincter damage and vaginal tear (AOR = 3.2, 95% CI:1.44,7.1), carrying heavy loads (AOR= 2.5, 95% CI:1.2, 5.35), and prolonged labor ≥24 hours (AOR = 3.3, 95% CI:1.12, 97) were significant associated factors of prolapse. The odds of developing prolapse is lower among women attended school. Most(84.55%) of the women with prolapse were delayed for the treatments and only surgical interventions were done as treatments. Most of them claimed lack of social support, lack of money, and social stigma as the main reasons for the delay in seeking treatments.

Conclusions

Older age, low educational status, underweight, low income, higher parity, assisted vaginal delivery, prolonged labor, sphincter damage, and carrying heavy loads were significant associated factors of POP. It is better to screen older age women by doing campaigns against the prolapse. Also, responsible bodies should work on raising awareness of women as well as awareness of the community about the prolapse through expanding health education. Moreover, informing women to practice pelvic muscle training daily, raising women’s income to empower them, and help of family members to reduce carrying an overload of mothers are recommended.

Introduction

Pelvic organ prolapse (POP) is defined as the herniation or descent of the vaginal wall, cervix, uterus, bladder, and rectum downward along the vaginal lumen [1]. Universally, thirty percent of the women who have delivered a child are affected by POP resulting in debilitating morbidity [2] The magnitude of POP is very variable depending on the level of the development of the nations and the level of the exposure of the women to the risk factors [3]. Globally, the magnitude of POP is highly variable ranging between 3% and 64.6% [4, 5]. The prevalence of POP was 15.6% in Bangladesh [6], 9.1% in China [7], 48% in Australia [8], 29.6% in the United Arab Emirates (UAE) [9], 52% in Brazil [10], and 15% in Nepal [2]. In Africa, the prevalence of POP in Tanzania was 64.6% [5], in Egypt was 19.4% [11], in Nigeria was 6.5% [12], and in the Gambia was 46% [13]. Similarly, the prevalence of the POP in Ethiopia is highly variable. The prevalence rate in Jimma hospital, Saint Paulos Hospital, in Dabat community, in Kersa community, and Benchi Maji Zone was 40.7% [14], 15% [15], 56.4% [16], 20.9% [17] and 13.3% [18], respectively.

The risks of POP are categorized into three. The leading risk factors for POP are obstetric factors [16, 19]. It includes a higher number of children (vaginal delivery), age of the pregnancy, prolonged labor, the assistance of non-professional personnel, instrumental delivery, home delivery, age of the first pregnancy, and immediate return to work following delivery [19, 20]. The second risk factor category for POP are demographic and socio-economic factors including advanced age (the most important), body mass index (BMI), ethnicity, the family history of POP, low income, and low literacy level [20]. The third categories of risk factors for POP are factors that increase intra-abdominal pressure (IAP). These include chronic cough and constipation, carrying and uplifting heavy objects, and engagement in physical labor [7, 8, 16, 17, 19].

In Ethiopia, since it is a very low-income country, the women are highly exposed to the above-mentioned risk factors [16, 17, 21] and these will increase the burden. Literature suggests that in Ethiopia if there is better access to healthcare during pregnancy and delivery, we can reduce morbidity later in life. Moreover, the prolapse can be reduced if there is better access to drinking water, transportation of agricultural products to and from the markets, electricity to avoid carrying heavy loads, and a limited number of children [16, 19, 22]. There is a scarcity of the study assessing associated factors of pelvic organ prolapse in Southern Ethiopia. Exposing the risk factors of POP will initiate the responsible bodies to play a role in the modification of the factors. Therefore, it was found to be very important to conduct research that assesses the associated factors of POP among patients at the Public Hospitals of South Nations Nationalities and Peoples’ Region (SNNPR) of Ethiopia.

Methods and materials

Study design, sampling, and study population

A multi-center unmatched case-control study design was conducted from February 28 to June 05, 2020, at Public Health Hospitals of Southern Ethiopia. Out of the total fourteen general and referral public health hospitals in southern Ethiopia, seven hospitals (by taking 50% of the total hospitals) were selected randomly by the simple random sampling method. All available gynecologic patients diagnosed with POP (stage I-IV) at each hospital were taken as cases. To select controls, we used a systematic random sampling method, depending on the gynecologic patient flow of each hospital. Hence, the K value for each hospital varies (Fig 1).

Fig 1 — N/E/M/M/ = Negest Elleni Mohammed Memoral, HU = Hawassa University, Ca = cases, Co = controls.

The sample size was calculated by using Epi info version 7 software. For unmatched case-control study design, this software calculates by using double proportion formula [n= (p₁q₁ + p₂q₂) (f(α,β)) / ((p₁ - p₂)², n= number of sample size in each group, α = type I error, β = type II error]. To calculate the sample size, we used proportions from a similar study conducted in Bahr Dar City, Ethiopia [19]. By using variables of that study, we got a maximum sample size with a variable of ‘family history of POP’. The proportion of cases exposed to ‘family history of POP’ (p₂) was 22.6%, and the proportion of controls exposed to ‘family history of POP’ (p₂) was 6.2%. The sample size obtained was 173, after considering the design effect of two, and a 5% non-response rate, the total sample size became 369 patients (123 cases and 246 controls: in 1 to 2 cases to controls ratio). We considered the 95% confidence interval and 80% power (Table 1).

Table 1. Sample size calculation.

Risk actors	% of case with exposure (p₂)	% of control with exposure (p₁)	Power	CI (%)	AOR	Sample size
Age >44	71.8	27.1	80	95	6.8	55
Formal education	85	58	80	95	4.3	111
Parity	64.5	26.67	80	95	4.5	69
Sphincter damage	15.2	2	80	95	8	173
Carrying heavy object	67.4	40	80	95	3.1	131
Family history of POP	22.6	6.2	80	95	4.9	176
Underweight	34.5	14	80	95	3.2	164
Delivery assisted by non-health personnel	63.4	39.1	80	95	2.6	167

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Measurement and definitions

POP was evaluated and described using a standardized Pelvic Organ Prolapse Quantitative Examination tool. In this technique, the hymen ring (remnant) is considered a reference point [23]. Accordingly, stage 0 refers to no prolapse; stage I: the leading edge prolapse is 1 cm above the level of the hymen (> -1cm); stage II: the leading edge of the prolapse lies through the plane of hymen between -1cm to +1cm; stage III: the most distal portion of the prolapse is between +1cm and +2cm below hymen and stage IV: the complete eversion of the total length of the pelvic organ.

Cases:-Those participants who were diagnosed with POP from stage I up to stage IV.

Controls:-Those participants who were objectively declared free of POP (stage 0).

Chronic cough: Cough that lasts for ≥ 3 weeks since its onset.

Constipation: Unsatisfactory defecation characterized by infrequent stool, difficult stool passage, or both at least for the previous 3 months [24].

Income: Those who earn less than $1.25/day were considered below the poverty line [24].

Data collection tools, techniques, and procedures

Data were collected by using the interviewer-guided structured questionnaire. The questionnaire was first prepared in English, and then appropriately translated into the Amharic language. Later, translated back to English to ensure the accuracy of the meaning. During the translation, language experts participated. The questionnaire was developed by the investigators after reviewing different related literature [14, 16, 18, 19]. Then, the questionnaire was evaluated by experts in different professions to ensure validity. A pretest was carried out on 10% of the sample size mainly to examine the validity, approachability, and consistency of the questionnaire. Accordingly, some corrections and modifications were made to the questionnaire. Two midwives collected the data under close supervision by one physician in each hospital. Based on the standardized Pelvic Organ Prolapse Quantitative Examination tool, the stages of POP were determined.

Data quality control and management

Data quality was controlled through the provision of two-day training to the data collectors and supervisors about the overall objective of the study terms and concepts, the approach of respondents, data collection tools, and techniques of interviewing. The collected data were also cross-checked for its completeness, consistency, accuracy, and clarity daily. The investigators also carried out close supervision during the data collection period to monitor overall data collecting quality.

Data processing and analysis

After data collection, each questionnaire was again visually checked for completeness, clarity, and accuracy. The data were coded and entered into EPI INFO version 7, and exported into the SPSS version 25 Software. Descriptive, bivariate, and multivariable logistic regression analyses were performed. Selected variables that have a P-value of ≤0.2 at the bivariate analysis were included in the multivariable logistic regression to control all possible confounding factors simultaneously. The goodness of fit was assessed by using the Hosmer and Lemeshow goodness test. Generally, a P-value ≤ 0.05 was considered statistically significant.

Ethics approval and consent to participate

Ethical clearance was obtained from the Ethical Review Committee of the College of Medicine and Health Sciences, University of Gondar. Permission was obtained from the SNNPR Health Bureau and the administrations of each hospital. A brief explanation of the objectives of the study was given to the participants. Written informed consent was obtained from study participants. Confidentiality was kept carefully by using codes instead of any personal identifiers, and privacy was maintained during the medical examination of each patient.

Results

Descriptive data

Total study participants were 369 with a response rate of 100%. Of these, 123 (cases) were clinically diagnosed with POP and 246 were controls (free of POP). Out of 123 POP cases, nearly half (60) of them were stage III, and over one-third (44) were stage IV.

Socio-demographic characteristics of the participants

Out of 369 participants, one-third (33.3%) were aged ≥45 years. About one-fourth (25.75%) of the participants were from Wolaita and one-fifth from Sidama (20.33%). Over half (58%) of the participants were Protestants. About 44.4% of participants were rural residents and 38.21% were housewives. The majority (65.31%) earn greater than 1,200 birrs monthly. Most (86.4%) of the participants were married. The majority (85.4%) of the participants’ BMI value was between 18.5 and 25 kg/m² (Table 2).

Table 2. Socio-demographic characteristics of the participants at Public Hospitals of Southern Ethiopia, 2020 (N = 369).

Variables		Case (123)	Controls (246)	Total (369)	Percentages %
Age	≤35	13(12.1%)	94(87.9%)	107	29.00
	34-44	35(25.2%)	104(74.8%)	139	37.70
	≥45	75(61%)	48(39%)	123	33.30
Ethnicity	Gurage	16(36.4%)	28(63.6%)	44	11.90
	Amhara	8(25.8%)	23(74.2%)	31	8.40
	Kambata	7(25.9%)	20(74.1%)	27	7.30
	Wolaita	33(34.7%)	62(65.3%)	95	25.70
	Hadiya	14(34.1%)	27(65.9%)	41	11.10
	Sidama	27(36%)	48(64%)	75	20.30
	Oromo	8(346.4%)	14(63.6%)	22	6.00
	Gamo	6(25%)	18(75%)	24	6.50
	Others	4(40%)	6(60%)	10	2.70
Religion	Orthodox	43(38.4%)	69(61.6%)	112	30.40
	Protestants	68(31.8%)	146(68.2%)	214	58.00
	Muslim	9(27.3%)	24(72.7%)	33	8.90
	Others	7(70%)	3(30%)	10	2.70
Residency	Rural	59(36%)	105(64%)	164	44.40
	Semi-rural	23(29.9%)	54(70.1%)	77	20.90
	Urban	41(32%)	87(68%)	128	34.70
Occupational status	House wife	88(61.5%)	53(38.5%)	141	38.21
	Farmer	23(37.6%)	39(62.9%)	62	16.81
	Merchant	23(37.1)	51(68.9%)	74	20.05
	Employed	24(26.1%)	68(73.9%)	92	24.93
Educational status	No schooling	83(63.8%)	47(36.2%)	130	35.23
	Primary	18(20.5%)	70(79.5%)	88	23.85
	Secondary	15(18.3%)	67(81.7%)	82	22.22
	Diploma⁺	7(10.1%)	62(89.9%)	69	18.70
Marital status	Married	104(32.6%)	215(67.4%)	319	86.40
	Widowed	10(32.3%)	21(67.7%)	31	8.40
	Divorced	9(47.4%)	10(52.6%)	19	5.10
Income/day	>$1.25	38(15.8%)	203(84.2%)	241	65.31
Income/day	≤$1.25	85(66.4%)	43(33.6%)	128	34.69
BMI (kg/m²)	18.5-25	96(30.5%)	219(69.5%)	315	85.40
	<18.5	21(65.6%)	11(34.4%)	32	8.67
	>25	6(27.3%)	16(72.7%)	22	5.93
Family history of POP	No	105(32%)	223(68%)	328	88.89
Family history of POP	Yes	18(43.9%)	23(56.1%)	41	11.11

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Obstetric related characteristics of the participants

Of 369 participants, 134(36.3%) gave birth more than four times. One-third (32.8%) of them gave their last birth at home and 44.72% had one or more history of home delivery. About 13.8% of the participants had labor duration extended over ≥ 24 hours at their last delivery. Nearly two-thirds (64.2%) of the participants returned to work resting more than 42 days after the delivery. Most (84.28%, 81.6%, and 85.9%) of the participants’ age at marriage, at first delivery, and last delivery was ≥18, ≥20, and ≤40 years, respectively. Around 41.7% of the participants had one or more history of sphincter damage/vaginal tear and 26.8% of participants had one or more histories of instrumental delivery (Table 3).

Table 3. Obstetric related characteristics of the participants at Public Hospitals of Southern Ethiopia, 2020 (N = 369).

Variables		Cases (123)	Controls (246)	Total (369)	Percentage%
Parity	≤4	41(17.4%)	194(82.6%)	235	63.70
Parity	>4	82(61.2%)	52(38.8%)	134	36.30
Place of the delivery at last delivery	Institution	78(31.5%)	170(68.5%)	248	67.20
Place of the delivery at last delivery	Home	45(37.2%)	76(62.8%)	121	32.80
Mode of delivery at last delivery	SVD	85(33.6%)	168(66.4%)	253	68.56
	AVD	34(49.3%)	33(50.7%)	67	18.16
	C/SD	4(91.8%)	45(8.2%)	49	13.28
Duration of labor during last delivery (in hours)	≤12	38(24.8%)	115(75.2%)	153	41.46
	13-23	56(33.9%)	109(66.1%)	165	44.72
	≥24	29(56.9%)	22(43.1%)	51	13.82
Duration of time to return to work after delivery (in days)	>42	74(31.2%)	163(68.8%)	237	64.20
	≤42	49(37.1%)	83(62.9%)	132	35.80
Delivery interval (in years)	≤2	77(31.4%)	168(68.6%)	245	66.40
Delivery interval (in years)	>2	46(37.1%)	78(62.9%)	124	33.60
Age at marriage	≥18	100(32.2%)	211(67.8%)	311	84.28
Age at marriage	<18	23(39.7%)	35(60.3%)	58	15.72
Age at first delivery	≥20	97(32.2%)	204(67.8%)	301	81.60
Age at first delivery	<20	26(38.2%)	42(61.8%)	68	18.40
Age at last delivery	≤40	83(26.2%)	234(73.8%)	317	85.90
Age at last delivery	>40	40(76.9%	12(23.1%)	52	14.10
History of sphincter damage/vaginal tear	No	49(22.8%)	166(77.2%)	215	58.30
History of sphincter damage/vaginal tear	Yes	74(48.1%)	80(51.9%)	154	41.70
History of instrumental delivery	No	72(26.7%)	198(73.3%)	270	73.20
History of instrumental delivery	Yes	51(51.5%)	48(48.5%)	99	26.80

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Factors increase intra-abdominal pressures

Out of 369 participants, 162(43.9%) had a history of chronic cough extended for more than three weeks and 68 (18.4%) had a history of chronic constipation extended more than three months. About 41.5% of participants had a history of carrying/uplifting heavy loads (Table 4).

Table 4. Factors that increase IAP of the participants at Public Hospitals of Southern Ethiopia, 2020 (N = 369).

Variables		Cases (123)	Controls (246)	Total (369)	Percentages %
Chronic cough (>3 weeks)	No	64(30.9%)	143(69.1%)	207	56.10
Chronic cough (>3 weeks)	Yes	59(34.6%)	103(63.6%)	162	43.90
History of chronic constipation (>3 months)	No	100(33.2%)	201(66.8%)	301	81.60
History of chronic constipation (>3 months)	Yes	23(33.8%)	45(66.2%)	68	18.40
Carrying/uplifting heavy objects	No	40(18.5%)	176(81.5%)	216	58.50
Carrying/uplifting heavy objects	Yes	83(54.2%)	70(45.8%)	153	41.50

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Delay for treatment-seeking

The average delay of the women for the treatments since the onset of the symptoms was 36.41 ± 3.94 months. Out of 123 women with the prolapse, 84.55% delayed the treatments and only surgical interventions were done as treatments. Among 104 women delayed in the treatment of the prolapse, 76%, and 43.9% of them claimed lack of money, and social stigma as the main reasons for the delay, respectively. Out of 104 women delayed for the treatment, 67.48%(83) did not attend formal school and 69.1%(85) of them earn less than $1.25/ day.

Associated factors of pelvic organ prolapse

On bivariate analysis; age, educational status, BMI, monthly income, family history of POP, parity, mode of delivery, monthly income, age at last delivery, duration of labor, history of home delivery, history of sphincter damage/vaginal tear, and carrying/uplifting heavy loads were significant predictors of POP.

Thus, these all variables were put into multivariable logistic regression analysis and age, educational status, BMI, monthly income, parity, mode of delivery, duration of labor, history of sphincter damage/vaginal tear, and carrying/uplifting heavy loads were significant predictors of POP. Accordingly, the women who were aged ≥45 years were about five times [AOR = 5.33(95% CI: 1.47, 9.05)] more likely to develop POP as compared to women who were aged <35 years. Women who attended secondary school 68% [AOR = 0.32(95% CI: 0.11, 0.92)], and diploma (and above) 83% [AOR = 0.17(95% CI: 0.05, 0.57)] were less likely to develop POP as compared with those women who had no schooling at all. The women who had a BMI value ≤ 18.5kg/m² were 4.5 times [AOR = 4.54 (95% CI: 1.4, 15.76)] more likely to develop POP than women with normal BMI values. Women who earn daily ≤ $1.25 were 2.5 times [AOR = 2.5(95% CI: 1.137, 5.59)] more likely to acquire POP than their counterparts. The women who had parity ≥5 were five times [AOR = 5.2 (95% CI: 2.2, 12.55)] more likely to develop POP than their counterparts. Women who delivered through assisted vaginal delivery at their last delivery were four times [AOR = 4 (95% CI: 1.55, 11.63)] more likely to develop POP as compared to women delivered through spontaneous vaginal delivery. The women who had prolonged labor (≥24 hours) at the last delivery were three times [AOR = 3.3 (95% CI: 1.12, 9.7)] more likely to develop POP than those women in labor ≤12 hours. Women who had a history of sphincter damage and vaginal tear were about three times [AOR = 3.2(95% CI: 1.44-7.1)] more likely to have POP than their counterparts. The women who practiced carrying/ heavy loads daily were 2.5 times more likely to develop POP than non-carriers [AOR = 2.5(95% CI: 1.2, 5.35)] (Table 5).

Table 5. Logistic regression on predictors of POP among women at Public Hospitals of Southern Ethiopia, 2020.

Variables		Cases (123)	Controls (246)	COR(95%CI)	AOR(95%CI)
Age	≤34	13(12.1%)	94(87.9%)	1	1
	35-44	35(25.2%)	104(74.8%)	2.57(1.29-5.13)	2.1(0.65-19.26)
	≥45	75(61%)	48(39%)	11(5.54-21.81)	5.33(1.47-9.05) ^*
Educational status	No schooling	83(63.8%)	47(36.2%)	1	1
	Primary	18(20.5%)	70(79.5%)	0.14(0.8-0.27)	0.72(0.11-1.05)
	Secondary	15(18.3%)	67(81.7%)	0.12(0.59-02)	0.32(0.11-0.92) ^*
	Diploma⁺	7(10.1%)	62(89.9%)	0.1(0.03-0.15)	0.17(0.05-0.57) ^*
BMI(kg/m²)	18.5-25	96(30.5%)	219(69.5%)	1	1
	<18.5	21(65.6%)	11(34.4%)	4.15(1.9-90)	4.54(1.4-15.76)*
	>25	6(27.3%)	16(72.7%)	1(0.4-2.50)	1.8(0.36-8.87)
Monthly income /day	>$1.25	38(15.8%)	203(84.8%)	1	1
Monthly income /day	≤$1.25	85(66.4%)	43(33.6%)	9.8(5.94-16.7)	2.5(1.137-5.59) ^*
Family history of POP	No	105(32%)	223(68%)	1	1
Family history of POP	Yes	18(43.9%)	23(56.1%)	1.66(0.86-3.21)	1.85(0.6-5.58)
Parity	≤4	41(17.4%)	194(82.6%)	1	1
Parity	>4	82(61.2%)	52(38.8%)	7.46(4.6-12.11)	5.2(2.2-12.55) ^*
Mode of delivery at last delivery	SVD	85(33.6%)	168(66.4%)	1	1
	AVD	34(49.3%)	33(50.7%)	2.04(1.18-3.51)	4(1.55-11.63) ^*
	C/SD	4(91.8%)	45(8.2%)	0.18(0.06-0.51)	1.89(0.39-7.52)
History of home delivery	No	35(17.2%)	169(82.8%)	1	1
History of home delivery	Yes	88(53.3%)	77(46.7%)	9.1(5.38-15.24)	1.44(0.55-3.8)
Age at last delivery	≤40	83(26.2%)	234(73.8%)	1	1
Age at last delivery	>40	40(76.9%	12(23.1%)	9.4(4.70-18.77)	2.23(0.87-4.21)
Duration of labor during last delivery(in hrs)	≤12	38(24.8%)	115(75.2%)	1	1
	13-23	56(33.9%)	109(66.1%)	1.86(1.13-3.06)	2.1(0.96-4.51)
	≥24	29(56.9%)	22(43.1%)	4.46(2.27-8.74)	3.3(1.12-9.7) ^*
History of sphincter damage	No	49(22.8%)	166(77.2%)	1	1
History of sphincter damage	Yes	74(48.1%)	80(51.9%)	3.13(2.0-4.91)	3.2(1.44-7.1) ^*
Carrying heavy objects	No	40(18.5%)	176(81.5%)	1	1
Carrying heavy objects	Yes	83(54.2%)	70(45.8%)	5.21(3.27	2.5(1.2-5.35) ^*

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Key: Where: SPV = spontaneous vaginal delivery, AVD = assisted vaginal delivery, CS/D = cesarean section delivery, hrs = hours, AOR = adjusted odds ratios, COR = crude odds ratios.

* Statistically significant at P-value ≤ 0.05 in multivariable logistic regression analysis

Discussion

This study primarily assessed associated factors among women with POP at Public Health Hospitals of Southern Ethiopia. Accordingly, age, educational status, BMI, monthly income, higher parity, mode of delivery, duration of labor, history of sphincter damage, and carrying heavy loads were associated factors of POP.

In this study, age ≥45 years increased the risk of developing POP. Accordingly, women who were aged ≥45 years were about 5 times more likely to develop POP. This finding is supported by the study conducted in Bahr Dar [19], Gondar [16], and Rural Bangladesh [6]. The possible scientific explanation for this finding is most probably at menopause, there is a significant drop in protein content and estrogens within female reproductive tracts and supporting structures. This will result in age-related loss of muscle tissue integrity, elasticity, strength, and density, ultimately results decrease in mechanical strength and predisposes to POP [25].

This study revealed all levels of formal education were significant protective factor of POP. The odds of developing POP were 68%, and 83% lower among women of the secondary, and diploma (and above) education, respectively. This is in line with study findings reported from Bahr Dar [19] and Kersa District, Ethiopia [17]. In Ethiopia, women residing in urban areas tend to be educated, NGOs or government employees, and well aware of their health by getting information through different sources. On the other hand, in this study, about 35% cannot read & write, and about 66% of participants were rural residents who practiced tiring physical work and could not get access to health information due to lack of electricity. In rural Ethiopia in general and in the study areas in particular, hospitals are distantly located. This also contributes to the delayed treatment seeking among women with the prolapse. Most probably formally educated women are readily available for information, and timely get obstetric care including prenatal, postnatal, and delivery cares. Moreover, educated women may be more aware of a healthy lifestyle and more open in discussing their health-related issues. Furthermore, educated women most likely can prefer jobs that are not physically laborious and can be professionally employed. This may reduce carrying heavy objects and busy household chores [9].

The underweight women were 4.5 times more likely to develop POP as compared to normal BMI values. This is consistent with the study conducted in Benchi Maji Zone [18], Bahr Dar [19], and Rural China [7]. On the other hand, the study at the Wesley Hospital reported that the women who were overweight/obese (BMI is >25 kg/m²) were riskier to develop POP [26]. The difference may be due to the difference in the lifestyle and physical work of the study participants between the two studies. The possible justification for the mechanism of POP development in underweight is most probably heavier physical workload [14], engagement in manual work even while pregnant or shortly after delivery, and poor nutrition [3] among Ethiopian women.

This result claimed to earn a daily income ≤ 1.25$ is a risk factor of POP. In most of the studies, the association of income level with POP was not tested, as it was stayed neglected. In this study, out of 104 women delayed for the treatment, 67.48% (83) did not attend formal school and 69.1% (85) of them earn less than $1.25/ day. Most probably, women with higher income can get better health services, timely seek treatments, can prefer jobs, and can hire someone to help them.

In this study, women with parity ≥ 5 were at risk of developing POP as compared to their counterparts. This is comparable with the reports of Bahr Dar [19], Gondar [16], China [7], and Bangladesh [6] study. The possible scientific explanation for this finding is more probably higher parity can weaken pelvic floor structures because of repetitive exertion of pressure during pregnancy and forceful uterine contraction during delivery as well [19]. In a recent study, the mean parity is higher (5.45). This implies the low utilization of family planning in rural Ethiopia despite available family planning by governments and NGOs. Low family planning utilization is most probably due to women in rural Ethiopia being characterized by low education, low access to health informations, beliefs and cultures that encourages the women to have many children [27]. In the study areas, having many children is considered as proud, dignity, and ultimate blessings from the Creator. Moreover, in the study areas, deciding the number of the children to have is exclusively the right of the husbands, women have no right to decide.

This study revealed that assisted vaginal delivery increases the risk to develop POP. This is consistent with a recent cohort study in Baltimore, Maryland, that reported both spontaneous and assisted vaginal deliveries were associated with a significantly higher hazard of developing POP than those delivered via cesarean delivery [28]. Besides, the finding of our study was supported by other studies [11, 29]. The possible explanation for the mechanism of POP development following spontaneous and assisted vaginal delivery is believed to result from structural disruption due to overstretching, compression, and avulsions during childbirth, and/or secondary to denervation injury to the pelvic floor muscles [30]. Both forceps and vacuum delivery appear to have a higher risk to injure pelvic floor structures [31].

This study revealed that labor duration ≥ 24 hours is risky to develop POP. More probably, Ethiopian women are prone to prolonged labor because of poor antenatal care [32], teenage marriage [33] unskilled birth attendants [32], poor road construction (especially in rural areas), inadequate ambulance services, and distant availability of general and referral hospitals for operative deliveries.

In this study, predisposition to sphincter damage due to episiotomy and vaginal tear was found to be risk factor of POP. This finding is supported by the study done at Bahr Dar [19] and Kersa District [17], Ethiopia. This owing to an injury to neuro-vasculature, disruption of the muscles, perineal membrane, ligaments, and other connective tissues of the pelvic floor that support and maintain female pelvic structures in an anatomical position [34]. However, an episiotomy is very important to ease delivery and prevent the worst consequences that could happen if the episiotomy measures would not be taken.

The odds of having POP were higher in women who carry heavy loads daily than their counterparts. This is consistent with a study in Tanzania [5], Gondar [16], and Bahr Dar [19]. This indicates that women in Ethiopia engaged in hard physical work including, fetching water, farming, carrying loads over a long distance, and carrying out household chores. In Ethiopia, women carry wood, fetch water, and carry/uplift other heavy loads over long distances while they are pregnant, postnatal state, and in nursing.

The average delay of the women for the treatments since the onset of the symptoms was 36.41 ± 3.94 months. It is very lower than similar finding from Gondar, Ethiopia, (85.8 ± 8.2 months) [22]. This discrepancy is due to that in a recent study the patients with prolapse visited the hospitals for treatments by themselves. Meanwhile, in the study of Gondar, Ethiopia, there was a community-based screening and campaign for searching the cases of prolapse, in this case, many cases of prolapse may be surveyed for the treatments and several cases with longer duration may contribute to the high value of estimates because in the community we can find a woman who stayed for a longer period by hiding the problem.

Out of 123 women with POP, most (84.5%5) of the women arrived at hospitals with advanced stages of the prolapse. This is because they had completely hidden the problem, and they had shown it to their close relative when the condition got unbearable. As a result, all of them were treated with vaginal hysterectomies. This finding is supported by a study finding reported from Jimma, Ethiopia, that claimed about 81% of the treatments performed for the prolapses were vaginal hysterectomies. In our study, among 104 women delayed for the treatment of the prolapse, 76%, and 43.9% of them claimed lack of money, and social stigma as the main reasons for the delay, respectively.

As a strength, this study is a multi-center study and included more variables, which had not been assessed so far. In addition, testing the income variable for the association and we found it the factor that shows a significant association. To reduce recall bias, close relatives or husbands (special controls) of respondents have participated. As a limitation, this study was hospital-based and it lacks generalizability to the community at large. Even if we calculated sample size calculation, confidence intervals of some variables were wide. Hence, accompany power calculation could help evaluate the actual robustness of the results.

Conclusions and recommendations

In conclusion, older age, low educational status, underweight, low income, higher parity, assisted vaginal delivery, prolonged labor, sphincter damage/vaginal tear, and carrying heavy loads were significant associated factors of POP. Most women delayed in the treatment of the prolapse, and most of them are treated with surgical interventions (hysterectomy). Most women claimed lack of money and social stigma as the reasons for the delay in the treatments. Screening older edge, expanding health education, pelvic muscle training, raising women’s income, and reducing carrying/uplifting high loads are recommended. Moreover, all older age women especially those who are residing in rural areas need to be screened for POP, and the husbands/responsible bodies should help women in daily hard work activity; participate in handling heavy objects and reduce extended work time.

Supporting information

S1 File. English and Amharic version questionnaire.

(PDF)

Click here for additional data file.^{(877.5KB, pdf)}

Acknowledgments

We would like to pass our deepest gratitude to the data collectors, supervisors, and study participants for their commitment during data collection.

Abbreviations and acronyms

AOR: Adjusted Odds Ratios
BMI: Body Mass Index
CI: Confidence Intervals
COR: Crude Odds Ratios
CS: Cesarean Section
HMIS: Health Management Information System
Kg: Kilogram
IAP: Intra-abdominal Pressure
NGOs: Non-Governmental Organization
OPD: Outpatient Department
POP: Pelvic Organ Prolapse
SNNPR: South Nations Nationalities, Peoples’ Region
UAE: United Arab Emirates
USA: United State of America
UVP: Uterovaginal Prolapse

Data Availability

All relevant data are within the manuscript and its Supporting Information files.

Funding Statement

Mr. Asfaw Borsamo took award From University of Gondar with grant number 045028/2020. The website of University of Gondar is http://www.uog.edu.et/en/. The University of Gondar had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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PLoS One. doi: 10.1371/journal.pone.0278461.r001

Decision Letter 0

Adrian Stuart Wagg

23 Mar 2022

PONE-D-21-33943Predictors of pelvic organ prolapse among patients at Public Hospitals of Southern Ethiopia: A case-control study designPLOS ONE

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Reviewer #1: Reviewer’s report: Predictors of pelvic organ prolapse among patients at Public Hospitals of Southern Ethiopia: A case-control study design

the aim of this case control study was to examine predictors of pelvic organ prolapse patients at southern Ethiopian public hospitals

Abstract:

the conclusion is largely valid but the last sentence is perhaps somewhat speculative. Perhaps the authors might like to modify this.

Introduction

The authors note the highly variable prevalence of prolapse in studies which existed to date perhaps they might confine this detailed discussion to the discussion section and perhaps suggest some explanation as to why this is the case.

The authors note established risk factors in other studies, could they therefore suggest why a study in Ethiopia would be of value or might produce different information?

Would a study attempting to intervene on the known modifiable factors be more significant and have greater utility than reiterating what is known?

the authors make a good point about using the data with “responsible bodies” in playing a role of modification of such factors which would be a useful motivation upon which to build

methods and materials

It is good to see an accurate sample size calculation. what was the degree of imprecision in the prevalence estimate?

please give the authors describe their random sampling technique For participants and hospitals?

Was the Constipation question validated?

Who examined the women?

The authors are to be congratulated in the conduct of this study in a challenging environment, in particular the governance processes they have put in place to ensure data quality

The statistical analysis section is entirely appropriate.

I note that written informed consent was obtained from study participants, What proportion of women was illiterate and how was consent gained in this case?

Results

For what reason have the authors included the religion of the women? Was this used as a controlling variable in parity? Did religion and parity interact?

Is the proportion of women earning greater than 1200 birrs representative of the Ethiopian general population of women? Likewise, is the proportion having a home delivery typical?

Is the history of Sphincter damage and vagina tear when gained from the women reliable?

Regarding predictors, were any variables discarded on bivariate analysis? Were there any interactions? For example was high parity associated with relative poverty?

Likewise was carrying heavy loads more common in women who were of lower educational attainment or low income?

The results section is otherwise extremely well written But I should like to see some comparative analysis of the factors in table one in terms of prevalence of prolapse and say religion occupational status and ethnicity for completions sake

Can the authors tell us what the average delay in seeking treatment was for the women both as a whole and according to income status education status or employment status?

This might help to support their argument that women with high income get better health services seek timely treatments and can hire someone to help them

Discussion

the authors present their findings in a logical manner and attempts to explain their findings.

Might the authors also consider the amount of physical exertion women perform separate from carrying heavy loans as a potential mitigating factor - as the authors note this might also account for the higher prevalence of prolapse in underweight women

The authors might consider comparing their sample with the general Ethiopian population to give the reader some frame of reference for example, were the women more educated, or likely to be employed or were they wealthier than average women in Ethiopia

the high parity doesn't necessarily imply low utilization of family planning - the high parity may well be purposeful. do the authors have any evidence to suggest that women want fewer children?

The authors have considered their limitations and biases, notably the external validity of this hospital population seeking help versus the general population

to what extent were husbands likely to give reliable information on their wives?

In conclusion the authors have identified many potentially remedial factors in the development of prolapse. how likely are women to choose active treatment of their prolapse in Ethiopia. Is operative intervention financially out of reach for the majority of women? What conservative therapies are available?

This information would certainly help add context to the paper

Reviewer #2: The authors investgated in the present study the effect estmate of several known factors that predispose to pop in an ethiopian population. Despite their rigorous methodology i believe that the lack of an appropriate sample size (which is denoted by the large confidence intervals that are provided) is the main reason for rejection of this article.

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PLoS One. 2023 Jan 18;18(1):e0278461. doi: 10.1371/journal.pone.0278461.r002

Author response to Decision Letter 0

26 May 2022

Responses to Reviewers:

Corrections/revisions for Reviewer 1

Abstract:

1. The conclusion is largely valid but the last sentence is perhaps somewhat speculative. Perhaps the authors might like to modify this.

� Dear reviewer, we found this comment is relevant and we have corrected/revised as your request. Thank you very much for your suggestions and recommendations.

Introduction:

2. The authors note the highly variable prevalence of prolapse in studies which existed to date perhaps they might confine this detailed discussion to the discussion section and perhaps suggest some explanation as to why this is the case.

� Dear reviewer, the objective of the study is to determine predictors of the pelvic organ prolapse. This why we preferred to discuss in detail about the prevalence of the pelvic organ prolapse in introduction part.

3. The authors note established risk factors in other studies, could they therefore suggest why a study in Ethiopia would be of value or might produce different information?

Would a study attempting to intervene on the known modifiable factors be more significant and have greater utility than reiterating what is known? the authors make a good point about using the data with “responsible bodies” in playing a role of modification of such factors which would be a useful motivation upon which to build

� Dear reviewer, the most risk factors of the prolapse varies greater from the community to community because of different socioeconomic status, health system development level, and culture or beliefs. According to the literatures, so many factors (over 60) have association with the prolapse. Policy makers and health managers would not intervene all risk factors of the prolapse. This study was conducted with a case control study design to identify which factors are significantly affecting the prolapse in the study areas. Hence, managers and policy makers of the study areas possibly can work on identified factors to modify.

Methods and materials

4. It is good to see an accurate sample size calculation. what was the degree of imprecision in the prevalence estimate?

� Dear reviewer, previously, we had written the sample size calculation in short and summarized way. Now, on the revised manuscript, we have explicitly explained how the sample size was calculated as following:

� In this study, sample size was calculated by using Epi info version 7 software. For unmatched case-control study design, this software calculates by using double proportion formula [n= (p1q1 + p2q2) (f(�,�)) / ((p1 - p2)², n= number of sample size in each group, � = type I error, � = type II error]. To calculate sample size, we used proportions from the similar study conducted in Bahr Dar City, Ethiopia, as following: (see Table 1)

Risk actors % of case with exposure % of control with exposure Power CI (%) AOR Sample size

Age >44 71.8 27.1 80 95 6.8 55

Formal education 85 58 80 95 4.3 111

Parity/delivery 64.5 26.67 80 95 4.5 69

Sphincter damage 15.2 2 80 95 8 173

Carry heavy object 67.4 40 80 95 3.1 131

Family history of POP 22.6 6.2 80 95 4.9 176

Underweight 34.5 14 80 95 3.2 164

Delivery assisted by non-health personnel 63.4 39.1 80 95 2.6 167

� We got maximum sample size with variable of ‘family history of POP’ which is 173, after considering the design effect of two, and a 5% non-response rate, the total sample size became 369 patients (123 cases and 246 controls: in 1 to 2 cases to controls ratio).

5. Please give the authors describe their random sampling technique for participants and hospitals?

� Dear reviewer, among 14 governmental general and referral hospitals in SNNPR, seven hospitals were selected by simple random method (lottery method). All patients with a pelvic organ prolapse visiting gynecologic OPD during data collection period were included as cases. To select controls, we used systematic random sampling method, depending on gynecologic patient flow of each hospital. Hence, the K value for each hospital varies (Figure 1)

�

� N/E/M/M/= Negest Elleni Mohammed Memoral, HU = Hawassa University, Ca=cases, Co=controls

Figure 1: Sampling procedure

5. Was the Constipation question validated?

� Dear reviewer, we considered constipation lasting longer than three months as a significant enough to contribute for the development of the prolapse. Many other studies also agree with this statement.

6. Who examined the women?

� Gynecologists performed physical examination, history taking, and diagnosis as already explained in the manuscript.

7. The authors are to be congratulated in the conduct of this study in a challenging environment, in particular the governance processes they have put in place to ensure data quality.

The statistical analysis section is entirely appropriate.

� Dear reviewer, we thank you very much for understanding our efforts and challenging environment that we had faced.

8. I note that written informed consent was obtained from study participants, What proportion of women was illiterate and how was consent gained in this case?

� Dear reviewer, thank you for your important comments, a written informed consent was obtained directly from study participants who can read and write. For those unable to read and write, first the consent was clearly read to her and then her immediate/ significant family member (like husband or son, etc) will sign it. Even she has not family member, the consent was clearly read to her and then her fingerprints were taken as signature.

Results

9. For what reason have the authors included the religion of the women? Was this used as a controlling variable in parity? Did religion and parity interact?

� Dear reviewer, religion of the respondents first included as sociodemographic characteristic for the descriptive purpose. Later, its association with the prolapse checked on multivariable logistic regression and it did not show association. We have checked that no interaction of the religion and parity.

10. Is the proportion of women earning greater than 1200 birrs representative of the Ethiopian general population of women? Likewise, is the proportion having a home delivery typical?

� Dear reviewer, this study categorizes the income by using World Bank cut off point of poverty line, as operationally defined in the main manuscript. According to World Bank definition of the poverty line, earning below $1.25/day(1200 birr/month) is considered below poverty line. In our study, about 69% of the women with prolapse earn less than $1.25/day; about 17.47% of women from the control earn less than $1.25/day. In our study, 35.58% of the women with prolapse had at least one history of home delivery and about 30% of women from controls had at least one history of home delivery in their life. We don’t think shortage of the income affects home delivery in Ethiopian because medical services related with obstetrics is for free. Rather, home delivery is related to cultures, awareness, and attitude

11. Is the history of Sphincter damage and vagina tear when gained from the women reliable?

� Dear reviewer, yes, it is reliable because they never forget history that they had episiotomy or vagina tear. Moreover, their husbands had helped during the interview for some.

12. Regarding predictors, were any variables discarded on bivariate analysis? Were there any interactions? For example was high parity associated with relative poverty?

� Variables such as ethnicity, marital status, religion, residency, home delivery, duration of time to return to work after delivery, delivery interval, age at marriage, age at first delivery, age at last delivery, chronic cough and chronic constipation were discarded on bivariate logistic analysis.

13. Likewise was carrying heavy loads more common in women who were of lower educational attainment or low income?

� Dear reviewer, yes, carrying heavy loads more common in women who were of lower educational attainment or low income.

14. The results section is otherwise extremely well written But I should like to see some comparative analysis of the factors in table one in terms of prevalence of prolapse and say religion occupational status and ethnicity for completions sake.

� Dear reviewer, Table 2 shows these very clearly, and one can easily calculate from the table. We done in such way to reduce space and explain in summarized way..

15. Can the authors tell us what the average delay in seeking treatment was for the women both as a whole and according to income status education status or employment status?

This might help to support their argument that women with high income get better health services seek timely treatments and can hire someone to help them

� Dear reviewer, we found your concerns as very important and we have included it also in the main manuscript.

� The average delay of the women for the treatments since onset of the symptoms was 36.41 ± 3.94 months. Out of 123 women with the prolapse, 84.55% delayed for the treatments and only surgical interventions done as treatments. Among 104 women delayed for the treatment, 76% of them claimed lack of money as main reason for the delay. Out of 104 women delayed for the treatment, 67.48% (83) did not attend formal school and 69.1% (85) of them earn less than $1.25/ day.

Discussion

16. The authors present their findings in a logical manner and attempts to explain their findings.

� Of course, the reviewer is right, but for us it was difficult to measure amount of exertion force other than carrying heavy loads. We considered all type of heavy physical forces as carrying heavy loads.

17. The authors might consider comparing their sample with the general Ethiopian population to give the reader some frame of reference for example, were the women more educated, or likely to be employed or were they wealthier than average women in Ethiopia.

� Dear reviewer, we found this a very important comment and we incorporated this comment into the manuscript.

18. The high parity doesn't necessarily imply low utilization of family planning - the high parity may well be purposeful. do the authors have any evidence to suggest that women want fewer children?

� Dear reviewer, we appreciate you for rising important idea, and we have made modifications accordingly.

� In Ethiopia, there is low utilization of family planning especially among rural residents. This because women in rural Ethiopia are characterized by low education, low access to health informations, beliefs and cultures that encourages the women to have many children. In the study areas, having many children is considered as proud, dignity, and ultimate blessings from the Creator. Moreover, in the study areas, deciding the number of the children to have exclusively the right of the husbands, women have no right to decide.

19. The authors have considered their limitations and biases, notably the external validity of this hospital population seeking help versus the general population

to what extent were husbands likely to give reliable information on their wives?

� During the data collection, we found that husbands’ helps were very important especially when women had forgotten some events in their life history. They knew almost everything about their wives.

20. In conclusion the authors have identified many potentially remedial factors in the development of prolapse. how likely are women to choose active treatment of their prolapse in Ethiopia.

� Dear reviewer, thank you for your comment and we included it into main manuscript accordingly.

� Most of the women arrived at hospital at advanced stage of the prolapse. They completely had hidden the problem and they had showed to their close relative when the condition got unbearable. As a result no options than surgical treatments. During the data collection, out of 123 women with prolapse 104 (84.55%) were surgically repaired (vaginal hysterectomies).

21. Is operative intervention financially out of reach for the majority of women?

� Dear reviewer, thank you for your comment and we included it into main manuscript accordingly

� Among 104 women delayed for the treatment, 76% of them claimed lack of money as main reason for the delay. Most of the women with prolapse come to hospital after they had got some financial support from some people who understood their conditions.

22. What conservative therapies are available? This information would certainly help add context to the paper

� Dear reviewer, rest of the women with less advanced stages ( stage II) were treated with conservative means of treatments like lifestyle and behavior modification, physical therapy for the pelvic floor, and using vaginal device (Pessary)

Corrections/revisions for Reviewer 2

1. The authors investgated in the present study the effect estimate of several known factors that predispose to pop in an Ethiopian population. Despite their rigorous methodology i believe that the lack of an appropriate sample size (which is denoted by the large confidence intervals that are provided) is the main reason for rejection of this article.

� Dear reviewer, we thank you very much for your concern. The most risk factors of the prolapse vary greater from the community to community because of different socioeconomic status, health system development level, and culture or beliefs. According to the literatures, so many factors (over 60) have association with the prolapse. Policy makers and health managers would not intervene all risk factors of the prolapse. This study was conducted with a case control study design to measure which factors are significantly affecting the prolapse in the study areas. Hence, managers and policy makers of the study areas possibly can work on identified factors to modify.

� Regarding sample size calculation,

� Dear reviewer, our sample size very high for case-control study and we calculated and got the value according scientific rule. Everything in this study is scientifically randomized.

� In this study, sample size was calculated by using Epi info version 7 software. For unmatched case-control study design, this software calculates by using double proportion formula or power approach [n= (p1q1 + p2q2) (f(�,�)) / ((p1 - p2)², n= number of sample size in each group, � = type I error, � = type II error]. To calculate sample size, we used proportions from the similar study conducted in Bahr Dar City, Ethiopia, as following: (see Table 1)

Table 1: sample size calculation

Risk actors % of case with exposure % of control with exposure Power CI (%) AOR Sample size

Age >44 71.8 27.1 80 95 6.8 55

Formal education 85 58 80 95 4.3 111

Parity/delivery 64.5 26.67 80 95 4.5 69

Sphincter damage 15.2 2 80 95 8 173

Carry heavy object 67.4 40 80 95 3.1 131

Family history of POP 22.6 6.2 80 95 4.9 176

Underweight 34.5 14 80 95 3.2 164

Delivery assisted by non-health personnel 63.4 39.1 80 95 2.6 167

Attachment

Submitted filename: Response to reviewers.docx

Click here for additional data file.^{(33.1KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0278461.r003

Decision Letter 1

Adrian Stuart Wagg

16 Aug 2022

PONE-D-21-33943R1Predictors of pelvic organ prolapse among patients at Public Hospitals of Southern Ethiopia: A case-control study designPLOS ONE

Dear Dr. Asfaw,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that there is a little more work to do to fully meet PLOS ONE’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.

==============================

ACADEMIC EDITOR: Please insert comments here and delete this placeholder text when finished. Be sure to:Reviewer 2 makes useful points about prediction - a term you should probably avoid unless you would like to commit to further analytical models - it may be simpler to avoid the term

==============================

Please submit your revised manuscript by Sep 30 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 plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

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We look forward to receiving your revised manuscript.

Kind regards,

Adrian Stuart Wagg, MD

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

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. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Yes

Reviewer #2: No

**********

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?

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Reviewer #1: The authors have prepared an excellent response to the reviewers comments and have added in information which makes this an informative paper. The abstract might benefit from adding into the results the delay results – this would then justify their conclusion about awareness raising etc

Id like to see the consent response added into the paper – this is useful for those conducting research in areas with high levels of illiteracy

Reviewer #2: The authors investigated in the present study the impact of several factors on the actual incidence of POP. The following comments are necessary to be addressed prior to its acceptance.

1) If the predictive value of these factors is to be investigated a ROC and AUC analysis along with sensitivity and specificity of individual factors or the whole logistic regression should be provided. Otherwise the study should be targeted only around the risk factors and not their predictive role. If the predictive role is to be investigated the Hosmer Lemeshow goodness of fit of the logistic regression should be reported.

2) Despite having performed a sample size calculation, the confidence intervals that the authors report are rather wide; hence, an accompanying power calculation of their findings could help evaluate the actual robustness of their results and comment on them in the discussion.

**********

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.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: Yes: Vasilios Pergialiotis

**********

PLoS One. 2023 Jan 18;18(1):e0278461. doi: 10.1371/journal.pone.0278461.r004

Author response to Decision Letter 1

27 Sep 2022

Response Letter

Authors:

1. Mr. Asfaw Borsamo

2. Mr. Mohammed Oumer

3. Mr. Ayanaw Worku

4. Mr. Yared Asmare

Editorial-in-Chief of the PLOS ONE JOURNAL

October 03, 2022

Dear Dr. (Professor) Adrian Stuart Wagg,

Please find enclosed a revised manuscript entitled “Associated factors of pelvic organ prolapse among patients at Public Hospitals of Southern Ethiopia: A case-control study design’’ with the kind request to consider it for publication in the Plos One Journal.

In the first place, we would like to thank the Esteemed Dr. Adrian Stuart Wagg and Reviewers for your kind and lesson giving comments, create an opportunity to improve our work. We have accepted the comments, and we made modifications accordingly. For the concerns that were raised by the esteemed reviewers, we have given explanations. We have checked that our references list is complete and correct.

Journal requirement: We have checked that our references list is complete and correct.

Responses to Reviewers:

Corrections/revisions for Reviewer 1

1. The authors have prepared an excellent response to the reviewers’ comments and have added in information which makes this an informative paper. The abstract might benefit from adding into the results the delay results – this would then justify their conclusion about awareness raising etc.

� Dear reviewer, we would like to thank for appreciating a previous response and we found the recent comment is also relevant. Hence, we have corrected/revised as your request. Thank you very much for your suggestions and recommendations. Your comments are making our work complete.

2. Id like to see the consent response added into the paper – this is useful for those conducting research in areas with high levels of illiteracy

� Dear reviewer, we used the consent form as following:

Consent form

English version

I have read or it was read to me (for those who cannot read and write) and understood well the condition stated above and I can withdraw from the study at any time and I understand that there is no risk of participating and no incentive to be given when I participate in the study. Therefore, I am willing to participate in the study. Signature___________________ Date____________

Thank you so much!

Amharic version

የስምምነት ፍቃድ

ከላይ የተጻፈውን መረጃ በደንብ አንብቤ ተረድቸው አለሁ፡፡ በጥናቱ ላይ መሳተፍ በኔም ሆነ በልጀ ላይ ምንም አይነት ችግር እንደማያደርስ ፤ የተለየ ጥቅማጥቅምም እንደለለው እንዲሁም በማነኛውም ሰአት ካልተመቸኝ የማቋረጥ መብት እንዳለኝ ተነግሮኛል፡፡ በመሆኑም በጥናቱ ላይ ለመሳተፍ ዝግጁ/ፍቃደኛ ነኝ ፡፡

ፊርማ --------------------- ቀን --------------------------------

ስለተሳትፎዎ እናመሰግን አለን !!!

Corrections/revisions for Reviewer 2

Thank you very much for your suggestions and recommendations.

1. If the predictive value of these factors is to be investigated a ROC and AUC analysis along with sensitivity and specificity of individual factors or the whole logistic regression should be provided. Otherwise the study should be targeted only around the risk factors and not their predictive role. If the predictive role is to be investigated the Hosmer Lemeshow goodness of fit of the logistic regression should be reported.

� Dear reviewer, thank you so much for your comment. We have modified our manuscript; we have replaced the term “predictors” with term “associated factors” throughout the manuscript. Mostly in public health research, researchers prefer the term “determinant” for cohort studies, “predictors” for case-control studies and retrospective cohort studies, and “associated factors” for cross-sectional studies. Similarly, we used the term “predictor” simply to show the level of term choice. So, thank you the Esteemed Academic Editor and Reviewer, now use the term “associated factors” Thank you very much for your suggestions and recommendations.

2. Despite having performed a sample size calculation, the confidence intervals that the authors report are ather wide; hence, an accompanying power calculation of their findings could help evaluate the actual robustness of their results and comment on them in the discussion.

� Dear reviewer, we have incorporated per your request in the discussion. Thank you very much.

Attachment

Submitted filename: Response to Reviwers.docx

Click here for additional data file.^{(22.8KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0278461.r005

Decision Letter 2

Joseph Donlan

17 Nov 2022

Associated factors of pelvic organ prolapse among patients at Public Hospitals of Southern Ethiopia: A case-control study design

PONE-D-21-33943R2

Dear Dr. Asfaw,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

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 onepress@plos.org.

Kind regards,

Joseph Donlan

Staff Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #1: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Yes

**********

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

Reviewer #1: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #1: Yes

**********

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

Reviewer #1: No

**********

6. Review Comments to the Author

Reviewer #1: thank you for your revisions. This has improved the paper. I think you made the right choice in not complicating your analysis which would have meant a lot of reworking

**********

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.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

**********

PLoS One. doi: 10.1371/journal.pone.0278461.r006

Acceptance letter

Joseph Donlan

9 Jan 2023

PONE-D-21-33943R2

Associated factors of pelvic organ prolapse among patients at Public Hospitals of Southern Ethiopia: A case-control study design

Dear Dr. Asfaw:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr Joseph Donlan

Staff Editor

PLOS ONE

Associated Data

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

Supplementary Materials

S1 File. English and Amharic version questionnaire.

(PDF)

Click here for additional data file.^{(877.5KB, pdf)}

Attachment

Submitted filename: Response to reviewers.docx

Click here for additional data file.^{(33.1KB, docx)}

Attachment

Submitted filename: Response to Reviwers.docx

Click here for additional data file.^{(22.8KB, docx)}

Data Availability Statement

All relevant data are within the manuscript and its Supporting Information files.

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PERMALINK

Associated factors of pelvic organ prolapse among patients at Public Hospitals of Southern Ethiopia: A case-control study design

Asfaw Borsamo

Mohammed Oumer

Ayanaw Worku

Yared Asmare

Roles

Abstract

Background

Methods

Results

Conclusions

Introduction

Methods and materials

Study design, sampling, and study population

Fig 1. Sampling procedures.

Table 1. Sample size calculation.

Measurement and definitions

Data collection tools, techniques, and procedures

Data quality control and management

Data processing and analysis

Ethics approval and consent to participate

Results

Descriptive data

Socio-demographic characteristics of the participants

Table 2. Socio-demographic characteristics of the participants at Public Hospitals of Southern Ethiopia, 2020 (N = 369).

Obstetric related characteristics of the participants

Table 3. Obstetric related characteristics of the participants at Public Hospitals of Southern Ethiopia, 2020 (N = 369).

Factors increase intra-abdominal pressures

Table 4. Factors that increase IAP of the participants at Public Hospitals of Southern Ethiopia, 2020 (N = 369).

Delay for treatment-seeking

Associated factors of pelvic organ prolapse

Table 5. Logistic regression on predictors of POP among women at Public Hospitals of Southern Ethiopia, 2020.

Discussion

Conclusions and recommendations

Supporting information

Acknowledgments

Abbreviations and acronyms

Data Availability

Funding Statement

References

Decision Letter 0

Adrian Stuart Wagg

Roles

Author response to Decision Letter 0

Decision Letter 1

Adrian Stuart Wagg

Roles

Author response to Decision Letter 1

Decision Letter 2

Joseph Donlan

Roles

Acceptance letter

Joseph Donlan

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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