Reviewer ’s report  
 
Title: Prevalence of pelvic organ prolapse in women, associated factors and impact on quality of  
life in rural Pakistan: population -based study.  
 
Version: 1 Date: 03 Dec 2019  
 
Reviewer: Esther  Shoemaker  
 
Reviewer's report:  
Overall  
- This is an important study that adds important information on the health and well -being 
of women living in low and middle income countries. You have impressive methods for data 
collection and answer important clinical and social questions. The paper would improve from 
significant edits, which I have provided many for you. The discussio n section currently includes 
too much background information and would be strengthened from you making more specific 
links to the lives of women in Pakistan and more specific clinical, social and/or education 
recommendations.  
- Your most recent references are from 2016. Please ensure that you include some of the 
more currently research articles on the topic.  
- Consider always writing "population -based" with a hyphen. You sometimes do it, often 
not. It is important to be consistent.  
- Please attach the quest ionnaire as an appendix.  
 
Abstract  
- Background: I believe you need a comma after "the prevalence of pelvic organ prolapse" 
because you had listed factors as separate in the title  
- Methods: The first sentence reads awkward. You can write instead "…cross -sectional 
study was conducted with a three stage random sampling strategy:…"  
- Results: The highest rate of POP is not in that age group but among women with four or 
more children. I suggest you write "Women with four or more children had the highest 
propor tion of POP (75%) followed by women aged 36 -40 years (25%).  
- Conclusion: Replace the "and" between rural Pakistan and impacts with a comma.  
Background  
- Lines 47 -49: The colon in line 48 is incorrect. You could restructure the sentence to read 
"It can res ult in surgery, which is one of the most common gynaecological surgical procedures 
with a lifetime risk of…."  
- Line 56, do you mean "in the vagina" rather than in the "vaginal"?  
- 59-62, it makes more sense to have the corresponding reference for each ris k factor listed 
directly after each risk factor rather than lumping them all at the end.  
- Line 65, add "are" after section  
- Line 67, you need to add a reference showing that rural areas are most neglected.  
- Line 70, add "a" after "the results of"  
- Line 71: change "investigating" to "to investigate"  
- Line 72: write "its impact" rather than just impact  
- Why did you chose the Baden -Walker half way system? It would be nice to get a very 
brief overview why you chose that method over other methods, or w hat else is commonly used.  
 
Methods  
- How did you randomly select health centres, women etc, what method did you use?  
- Line 76: write "its impact" and add a comma after quality of life  
- Line 79: remove "as reported in this paper"  
- Line 85: Change the se ntence to read "Demographic, socio -economic and obstetric 
characteristics were also recorded during the interviews."  
- Line 92: add a comma after "was positive"  
- Line 95: the question mark should be a period  
- Line 98: add " after "everyday life"  
- Line 1 02: add a comma after "team" and an "of" after "reviewed all"  
- Line 103: take out "the questionnaires and from" - the expert reviewed the responses, not 
the questionnaires - and write instead "reviewed all of the responses and categorized women as 
having… " 
- Line 106: take out "expert and"  
- Lines 107 -109: some of the sentences are awkward. Here I suggest you write "The 
gynecologists received training to use the Baden -Walker classification system to assess POP." If 
you believe the POP -Q staging system fami liarity is important here and don't want to take it out, 
then you need to add a description about it in the background section of the article.  
- Sometimes you write about the gynecologists and then the gynecologist. Please be 
consistent  
- Line 112: add a c omma after "cervix"  
- End of line 112 -117, this is quite an awkward sentence. Please re -write and take out the 
colon.  
- Line 123: please consider changing to "Chi -square tests were used to assess existing 
relationships between the categorical variables" Th e second part of the sentence currently makes 
no sense to me. Please clarify.  
- Line 125: did you run one logistics regression model? Then please write "into a logistic.." 
Or if you run multiple model, then please change to "models"  
- You don't run logisti c regression models to see a statistical significance at p &lt;0.05. I 
think you mean something different, you run the models to see which factors were related to 
women experiencing a prolapse. Earlier, you wrote that you looked at the different types of PO P, 
so you likely run multiple models for each of the conditions. If that is correct, please outline it 
here. Please rewrite this section to clarify, and then you can state that you used a p -value of 
&lt;0.05 to establish statistical significance.  
 
Results  
- Line 138 the women attended "a" clinical examination rather than "for"  
- Lines 138 -139 "After clinical examination, 30…"  
- Line 141: take out the therefore  
- Line 148: take out "found to be"  
- Line 151: add a comma before "but"  
- Line 157: I suggest you write instead "… quality of life, 60.8 reported a moderate or 
great impact, while 47.8%..."  
- Line 158: take out "on"  
 
Discussion:  
- Line 162: add a comma after Pakistan  
- Line 165: add a comma after 10% and replace the period after  Ghana with a comma  
- You are describing at great length the prevalence found in other studies. This belongs to 
the background section and not into the discussion to this extend. Describe much briefer how the 
prevalence you found is different or the same a s other studies, and you can use references to refer 
to them rather than outlining each of them, which you will have already done in the background 
section. Then, discuss why it might be the same or different.  
- The study you describe from Ethiopia is inte resting in that they found the POP proportion 
to be much higher upon examination than when asking women in a questionnaire. Is there a 
specific reason why you did not examine all women but relied on self -report? Of course, using 
the questionnaire allowed y ou to receive data form a much larger number of women, but it is 
important to consider that your study might have missed a large number of POP cases. Please 
ensure to discuss this in the limitation section.  
- Lines 177 -180: this is important information th at summarizes why there are those 
differences. Take out the detailed study descriptions before and add them into the background 
where they aren't already included. This variation explanation is important to remain here and 
you could then reference to the s tudies you have described in the background section. My only 
issue is that this sentence reads quite awkward, please re -write it.  
- The rest of the paragraph is also missing commas at multiple places and included 
awkward sentences. Please try to use the :  much less often. And again, this rest of the paragraph 
doesn't explain the results you found.  
- Line 195, add a comma after study and write "Baden -Walker half way system" instead of 
"Baden -walker method of classification of grades"  
- Line 199 -201: It is u nclear what you are trying to say. Do you mean "prolapse that 
extended beyond the hymen"?  
- Lines 201 -204: you need to rework that sentence and what the message is you are trying 
to share.  
- Lines 214 -216: It is very helpful that you are listing the possib le reasons. Please add the 
reference after each of the reasons. What is missing here is your suggestion of what the reason is 
in your study environment.  
 
Conclusion  
- It seems unnecessary to list all of the strengths of your study in the opening sentence o f 
the conclusion.  
- Line 234 add "need to be" after "efforts".  
- I don't fully understand your last sentence the way it is currently written. Does the public 
needs to be educated to minimize the stigma and ensure that women will seek treatment and are 
even aware that treatment exists? If you leave a statement as such in here, then you need to also 
include it in the discussion section as you cannot raise something new in the conclusion.  
 
Figure 1  
- Please choose a different title. For example, "Study flow d iagram"  
- Your n for the second stage is currently empty  
- Write "women interviewed" rather than "women on whom interview conducted"  
- Write "women clinically examined" rather than "women on whom clinical examination 
conducted and included for statistical analysis"  
 
Table 2  
- Write organ in the title as singular  
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Yes 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Yes 
 
Are you able to assess any sta tistics in the manus cript or would you recommend an 
additional statistical review?  
If an additional statistical review is recommended, please speci fy what aspects require further 
assessment in your comments to the editors.  
 
I am able to assess the statistics  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Acceptable  
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions : 
 
1. Have you in the past five years received reimbursements, f ees, funding, or salary from an 
organisation that may in any way gain or lose financial ly from the publication of this 
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shar es in an organisation t hat may in any way gain or lose 
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents  relating to the content of the 
manuscript?  
 
4. Have you rec eived reimbursements, fees, funding, or salary from an organization that 
holds or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interest s in relation to this paper?  
 
If you can answer no to all of the above, write 'I declare that I have  no competing interests' 
below. If your reply is yes to any, please give details below.  
 
I declare that I have no competing interests  
 
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