Title: One in ten ever-married Women who visited Health Facilities for various Reasons have
Pelvic Organ Prolapse in Harari Regional State, Eastern Ethiopia
Version: 1 Date: 02 Apr 2022
Reviewer's report:
One in ten Women who visited Health Facilities for various Reason have Pelvic Organ Prolapse
in Harari Regional State, Eastern Ethiopia
Ref: Submission ID cf519a33-11f7-4826-8a20-20a8b1aa2cb1
Thank you for the opportunity to review this article entitled ‘One in ten Women who visited
Health Facilities for various Reason have Pelvic Organ Prolapse in Harari Regional State,
Eastern Ethiopia’.
The study describes relatively lower proportion of POP (one in ten) compared with recent
population based studies.  Further analysis describes significant associations with variables
including  lifting heavy objects,  chronic cough, older maternal age,  chronic constipation, and
no contraceptive use. This paper can provide additional insight to the public health community
to expand service for POP and improve quality of life in the later ages of women. Below are a
number of comments that I encourage the authors to take into account as they revise the paper.
The critical concern of the paper is the definition of outcome variable (symptomatic diagnosis
of POP).  I am not sure the authors have done based on the recommended criteria.
Abstract:
Given the comments on other sections I have not provided additional review but recommend
these be revised once other adjustments to the main manuscript are conducted.
INTRODUCTION
Major recommendation
1. Last paragraph, …rare studies have identified with different study type, still there is scarcity
of locally generated evidence regarding magnitude and risk factors of POP….. It would be great
if findings from recent POP studies in Ethiopia be included.  I would recommend to exhaustively
search and include studies using different approaches (population based or facility based)
2.Better to  start a new paragraph for rationale of the study  from “Although rare …” and expand
this to justify the study.
Minor recommendation
Last paragraph … different study type… Good to mention the type of studies
METHODS
Major recommendations
3.Ever-married women attending healthcare services in public hospitals of Harari Regional State
were included.   Why the unmarried women are not part of the study?  Were younger adolescents
included? Please provide age range. What about women who had undergone previous POP
surgery?
4.The rationale of using double population proportion formula by considering prolonged labor
as an exposure variable is not clear. Why not single population proportion? Why only prolonged
labour?
5.Women are also visiting health centers, considering only hospitals may need justifications.
6.You have considered only 3 questions with “Yes” or “No” report to measure Pelvic Organ
Prolapse (POP).  If the Pelvic Organ Prolapse Symptom Score (POP-SS) questionnaire is
applied,  I expect seven questions, each with five-point Likert response set (0 = never, 1 =
occasionally, 2 = sometimes, 3 = most of the time, and 4 = all of the time). The  questions are
as follows  “How often during the last 4 weeks have you had the following symptoms”: 1) A
feeling of something coming down from the vagina? 2) An uncomfortable feeling or pain in the
vagina that worsened when standing? 3) A heaviness or dragging feeling in the lower abdomen?
4) A heaviness or dragging feeling in the lower back? 5) A need to strain to empty the bladder?
6) A sensation of incomplete bladder emptying? 7) A sensation of incomplete bowel emptying?
Could you justify this?
7.As continuation of question #6, the definition of symptomatic prolapse (sPOP) requires
participant response as “sometimes”, “most of the time,” or “all of the time” to  any of the seven
questions and the presence of stage #II POP upon a pelvic examination. Simplified Pelvic Organ
Prolapse Quantification (S-POPQ) system is need for the stages. In my opinion, measuring POP
by considering only three questions and without pelvic examination, contributed the consistent
findings compared with previous studies done in Ethiopia, in which the prevalence is more than
50%.  Authors need to justify measurements of POP.
8.How candidate variables for multivariable analysis selected?
9. Was multi-collinearity assessed? If so, what items were excluded and what was the cut-off
rate?
10.Inclusion of some of  the variables like contraceptive use  may provide “fishing”  findings.
They may have multi-collinearity with other variables. Or may act as intermidiate variable.
Please check it once again.
Minor recommendation
Revise the ethical statements to include  advise provided for those with sign and symptoms …
if it is done.
RESULTS
Major recommendations
11.Factors associated with pelvic organ prolapse:  Better to remove the first paragraph (results
of bivariable logistic regression), and table 4.
12.I think greater clarity is needed on how the models were run.
Minor Recommendations
Table 1: Classification of educational status… all other categories can be under the subset of
“can read and write” It can be less informative/confusing. Suggest this category re-classified by
removing “can read and write” as optional.
Table 1: Is housewife occupation?
DISCUSSION
13.Good to start by highlighting/revisiting the objectives. This should also help to link the
sections together.
CONCLUSION
14.“ The study revealed that one in ten women suffer from pelvic organ prolapse in Eastern
Ethiopia”. This is misleading. This should be for a prevalence study using population based
survey in Eastern Ethiopia. Please revise it.
REFERENCE
15.Please revise all of the authors name in the reference lists … Abbreviation and use of et al.