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: 11 Mar 2022
Reviewer's report:
Review Report
General comments
The manuscript title” One in ten Women who visited Health Facilities for various Reason have
Pelvic Organ Prolapse in Harari Regional State, Eastern Ethiopia”
The authors selected one of the public health problems which is a researchable area.
The measurements are clear.
The document is readable and manageable easily.
The measures undertaken to control the data quality are feasible and appropriate.
The result presentation and discussions are good and supported by the analysis of data.
However, the comments, suggestions, and questions are summarized as follows.
Minor issues
1. I suggest the authors write the title as “One in ten ever-married Women who visited Health
Facilities for various Reasons have Pelvic Organ Prolapse in Harari Regional State, Eastern
Ethiopia”
Abstract:
2. There are typo errors (punctuations, Grammarly, punctuations and etc) in the manuscript.
Example  Line 25: Pelvic organ prolapse remains neglected a public health problem in
developing countries. Should be written like this “Pelvic organ prolapse remains a neglected
public health problem in developing countries”,
Line 29 “reason” should be corrected as “reasons”,
Line 31-“healthcare” or “health care”. The authors should check this term throughout the
document.
3. Line 40-“Of 458 women enrolled in the study, 10.5% [95%CI (7.6, 13.5)] of them had pelvic
organ prolapse based on women’s reporting of symptoms.” It is better if you write the proportion
with its absolute number here.
4. Line 47-8-“This result provides a cue to give due consideration on primary and secondary
prevention through various techniques.”  Cue or clue?
Introduction
5.  Why the authors didn’t introduce the definition of pelvic organ prolapse first in the
introduction?
6. Line 60 “socioeconomic” should be “socio-economic”
Methods
7. Line 80 “Harar town is the capital city of Harari regional state” the authors need to be
consistent regarding Harar. Is it town or city? Please!
8. Line 83- “In the town, there are 45 health facilities (34 health posts, 8 health centers, 5 hospitals
and Family guidance Association).” 1. 34 health posts +8 health centers +5 hospitals=47. So,
which one is correct? Is it 45 or 47?
Line 84- “Among these five hospitals, there are 45 health facilities (34 health posts, 8 health
centers, and 5 hospitals).” This sentence is not clear. How do 45 health facilities include five
hospitals in the five hospitals? The authors need to clarify this.
9. Line 88-“ae” or are? Would you check this one, please!
10. Line 112- “Socio demographic” should be written as “Socio-demographic”
11. Line 114-115-“ The questionnaire were extracted and adopted from different literatures
[13, 19] .” should be written as “The questionnaires were extracted and adopted from different
literatures [13, 19] .”
12. Line 118-9-“ The data collectors were interviewed the participants after they fully decided to
enroll in to the study.” should be corrected as “The data collectors interviewed the participants
after they fully decided to enroll in the study.”
13. Line 125-“ Plus” should be “plus”.
14. Line 136-“ prolonged labor”. How did the authors measure this variable? Prolonged labor
for which birth?
15. Line 152-53-“Before the actual data collection performed, pretested was conducted on 23
samples (5% of the total sample size) of the questionnaire.” Should be corrected as “Before the
actual data collection performed, pretest of the questionnaire was conducted on 23 samples (5%
of the total sample size).”
Result
16. Line 197-8-“ Of 368 women who had history of childbirth, a vast majority, 326(88.6%) of
them had vaginal delivery for the first childbirth.” Why the font color for the period/full stop
is made differently/red?
17. Line 202-4-“ Of 458 the women enrolled in the study, around two-thirds (81.4%) of them
were currently married, and more than half, 253(55.2%) of the women got first married at the
age less than 18 years. About 74(16.2%) of the participants had a history of married more than
once.” I suggest the authors modify the sentences like this” Of 458 women enrolled in the study,
around two-thirds (81.4%) of them were currently married, and more than half, 253(55.2%) of
the women first married at the age of less than 18 years. About 74(16.2%) of the participants
had a history of marrying more than once.”
18. Line 216 and 224-“history chronic cough” should be corrected as “history of chronic cough”
19. In table 3-“Had history chronic constipation (n=458)” should be corrected as “Had history
of chronic constipation (n=458)”, “Had history of heavy lifting s(n=458)”. “s” stands for what
in this case?
Discussions
20. Line 293-“ Furthermore, in this study, women who had no a history of contraceptive
utilization were more likely to encounter Pelvic Organ Prolapse compared to those who utilized
the services.” Should be corrected as “Furthermore, in this study, women who had no history
of contraceptive utilization were more likely to encounter Pelvic Organ Prolapse compared to
those who utilized the services.”
Major issues
Abstract
1. The authors are expected to inform the sampling technique, data quality assurance, data
processing, and analysis clearly under the methods abstraction.
2. Line 43-“greater than and equal to 55 years [AOR=3.51, 95% CI(1.04, 11.76)], history chronic
constipation (AOR=3.77, 95%CI(1.54, 9.22) and no history of contraceptive utilization [AOR=
2.41, 95%CI (1.13, 5.05)] were significantly associated with pelvic organ prolapse.” Is it possible
to be greater than and equal to 55 years at the same time? Make sure whether it is “and” or
“or” please!
3. Line 46-47 “In this study, one in ten women suffer from pelvic organ prolapse. Modifiable
and non-modifiable risk factor were identified as a predictor.”
4. How can the authors generalize their findings of pelvic organ prolapse for all women while
their source population was ever-married women?
-“Modifiable and non-modifiable risk factor were identified as a predictor”.
** Can the authors be sure that the factors assessed in this study are risk factors and/or predictors?
***How is it possible to make sure that the factors are risk factors by using a cross-sectional
study design?
****why do the authors conclude without being supported by their data regarding modifiable
and non-modifiable factors? Which factors are modifiable and which factors are non-modifiable
according to this research?
Introduction
5. The authors need to be consistent. Why do they write “introduction” in the main text while
it is “background” in the abstract?
6. Line 69- “In Ethiopian government has not yet developed and enrolled POP as one of
maternal health indicator on demographic and health survey of the country that will help to put
a separate strategy to prevent and manage POP in health sectors.” This sentence is long and not
understandable. Particularly the phrase ”In Ethiopian government” is not clear. Therefore, the
authors need to check it.
Methods
7. Line 95-96-“Women with the following preconditions (pregnant women, critically ill women
and women with mental problems) were excluded from the study. ”Why did the authors exclude
pregnant women, critically ill women and women with mental problems? Particularly, in line
66-68 “In Africa, large number of women with pelvic organ prolapse and obstetric fistula
delayed in seeking medical treatment because of the fear of disclosing the problem due to
social stigma [25, 26], and more than 67.7% of women with advanced POP had symptoms of
depression and mental dysfunction [27, 28].” The authors were mentioning that women with
advanced POP had symptoms of depression and mental dysfunction. How do they relate these
issues?
8. Line 96-7-“ The sample size was calculated using double population proportion formula by
considering prolonged labor as an exposure variable[30] with the following  assumptions.” What
is that double population formula? The authors need to write the formula used to determine
sample size in the method section.
9. Line 102-7” Tow public hospitals (Jugal Regional Hospital (JRH) and Hiwot Fana Specialized
University Hospital (HFSUH)) from Harari Region were selected as the study site. The total
sample size (n=460) was proportionally allocated to both hospitals. Accordingly, 216 samples
were allocated to Jugal Regional Hospital and 244 were allocated to Hiwot Fana Specialized
University hospital. Finally, the data were collected from eligible participants until the required
sample size was achieved.“ Which sampling technique was used to select the study participants?
Random or non-random?
10. Line 122-“ Pelvic Organ Prolapse (POP).”Why do the authors use acronyms and full words
together repeatedly in the manuscript?
11. Line 142-50- “In this study, the outcome variable (POP) was assessed based on women’s
report of symptoms related to genital prolapse. These symptoms explored by asking, “Do you
have a sensation that there is a bulge in your vagina or that something is falling out from
your vagina?”[19],  and by asking more questions using three Pelvic Organ Prolapse simple
screening inventory(POPSSI)[13] questions such as: (“Do you experience urinary incontinence
with laughing, sneezing or coughing”?), (“Do you experience urinary urgency”?) and, (“Do you
feel pain during defecation?”) [13, 31]. Accordingly, if the women responded “Yes” for the
above questions, they were categorized as “have POP”  and if their responses were “No”, the
they were categorized as “ have no POP”. “. Why do the authors repeat this information? They
already wrote it in the prior method section.
12. Line 153-55-“The original questionnaire was prepared in English language and later
translated into the local languages (Amharic and Afan Oromo) for the purpose of data collection.
Finally, they were translated back to English version.”. These sentences are also redundant to
the prior one. Why do the authors repeat this information?
13. Line 171-2- “Multi-collinearity was checked using variance inflation factor (VIF)
and tolerance, and no collinearity effect was detected.” The authors were discussing
multicollinearity. Where is the result of this test? How do they say “no collinearity effect”?
14. Line 177-85- “Ethical considerations
Ethical clearance was obtained from Institutional Health Research Ethical Review Committee
(IHRERC) of College of Health and Medical Sciences, Haramaya University. A permission
letters that obtained from school of graduate studies were submitted to Hiwo Fana Specialized
University hospital and Jugal Hospital. Informed, voluntary, written and signed consent was
also obtained from each study participants after explaining the purpose of the study. The study
participants were clearly informed about their full right to withdraw from the study at any time.
They were also informed that there would be no harm or direct benefit of being participating in
this study. All the information from the respondents was kept confidential. “
Line 322-34-“ Ethics approval and consent to participate
Ethical clearance was secured from Haramaya University, College of Health and Medical
Sciences, Institutional Health Research Ethics Review Committee (IHRERC). Informed,
voluntary, written and signed consent was obtained from hospital administrators before the
data collection. Prior to the data collection informed, voluntary, written and signed consent
was obtained from each respondent and participant's parent/legally authorized representative of
minor participants. The information sheet was offered and study title, objective, procedure, risk
and benefit was clearly explained for participants and finally the respondent’s confidentiality
was maintained and assured. They were informed well that they have full right to totally refuse
to participate and/or with draw from the study at any time, anonymity was maintained by using
the identified number instead of the patient’s names. Besides, all data extracted were kept
confidential and not used for any other purpose than the stated objective and all methods were
carried out per ethical guidelines.” Why do the authors repeatedly write the ethical issues in the
manuscript? Redundancies are the major problem of this manuscript.
15. Line 179-181-“ A permission letters that obtained from school of graduate studies were
submitted to Hiwo Fana Specialized University hospital and Jugal Hospital.” The authors
need to be consistent in their writing. Hiwo Fana Specialized University hospital” or Hiwot
Fana Specialized University hospital”? which hospital name is correct? Did the authors obtain
multiple letters from graduate studies? If so, for what purposes?
Results
16 The authors need to keep a logical flow and maintain consistency. The result presentation for
the factors must adhere to the way they are ordered in the methods section.
17. Line 210-12- “Moreover, 48(10.5%) women reported that they had felt or seen a bulge in the
vagina, around 26(5.7%) attributed to sneezing or coughing followed by urinary incontinence
with laughing and urinary urgency 22(4.8%), and pain during defecation 21(4.6%).” This
sentence is difficult to understand. Let the authors make it clear, short, and brief.
18. In both tables 4 and 5 why did the authors exclude p-values’ results? Furthermore, why do
the authors are interested to present tables 4 and 5 separately?
Discussion
19. Line 238-41-“ This current proportion of POP is nearly comparable to previous research
reports from Eastern Ethiopia (9.5%)[19], Benchi Maji Zone of Southern Ethiopia (13.3%) [29],
Ghana (12.1%)[34], Tanzania (14.4%) [35], China (9.10%)[36], and North Carolina (12.6%)
[17].” Are the authors sure regarding this literature? Eg. The previous report from Eastern
Ethiopia indicated the prevalence of pelvic organ disorder as 20.5%, not 9.5%. The authors need
to confirm this issue and its comparison too.
20. Line 255-58-“ In addition, the difference in estimates might be attributed to the tool utilized
to determine women with POP in case of Dabat district, Ethiopia and Tanzania were home-based
questionnaire interviews, and the women were subsequently invited to the nearest health clinic
for pelvic examination.” is too long and fragmented. Would the authors rewrite it, please!
21. Line 309-“Since we have not done pelvic examinations, classification of types of pelvic
organ prolapse was ascertained.“ How could it be possible for the authors to ascertain types
of pelvic organ prolapse without physical examination? If it is possible, why the result of the
classification of pelvic organ prolapses is not written in the manuscript?
22. Line 316-17-“Therefore, efforts are needed to emphasize on the prevention and treatment
of chronic medical conditions like chronic and chronic constipation.” This sentence is not
understandable.