Abstract
Introduction
Pelvic organ prolapse (POP) is a significant public health problem in developing countries including Ethiopia. However, less has been documented on risk factors of POP. Therefore, the aim of this study was to identify the determinants factors of POP.
Methods
An unmatched case–control study was conducted among gynecologic patients in Bahir Dar city, North West Ethiopia, from July to October 2014. A total of 370 women (selected from outpatient departments) were included in the study. Cases (clients with stage III or IV POP) and controls (who declared free of any stages of POP) were identified by physicians using the Pelvic Organ Prolapse Quantitative Examination tool. Data analysis was carried out by SPSS version 20.0. Descriptive, bivariate, and multivariable logistic regression analyses were performed. Statistical differences were considered at P<0.05, and the strength of association was assessed by odds ratio (OR) and respective confidence intervals (CIs).
Results
This study revealed that determinants such as age of women (>40 years) (adjusted OR [AOR] =3.0 [95% CI: 1.59–5.89]), sphincter damage (AOR =8.1 [95% CI: 1.67–39.7]), family history of POP (AOR =4.9 [95% CI: 1.94–12.63]), parity (≥4) (AOR =4.5 [95% CI: 2.26–9.10]), nonattendance of formal education (AOR =4.3 [95% CI: 1.25–14.8]), carrying heavy objects (AOR =3.1 [95% CI: 1.56–6.30]), body mass index (BMI) <18.5 kg/m2 (AOR =3.1 [95% CI: 1.22–7.82]), and delivery assisted by nonhealth professionals (AOR =2.6 [95% CI: 1.24–5.56]) were significantly associated with POP.
Conclusion
In our study, sphincter damage, family history of POP, being uneducated, having ≥4 vaginal deliveries, carrying heavy objects, BMI <18.5 kg/m2, age ≥40 years, and having delivery assisted by nonhealth professional were the independent determinants of POP. Therefore, skilled delivery, further promoting family planning and girls’ education, early pelvic floor assessment, and counseling on avoidance of carrying heavy objects are recommended.
Introduction
POP is the descent of pelvic organs into the vagina, and in these cases women can feel different prolapse symptoms like “something coming down”, and other urinary, bowel, and sexual symptoms.Citation1,Citation2 POP severely affects women’s quality of life in several ways. It has socioeconomic and health consequences, affecting overall health and sexual function.Citation3 It has been a major gynecologic problem in developed and developing nations.Citation4 However, women in developing countries are affected disproportionally.Citation5,Citation6 In the United States, different types of POP, such as uterine prolapse, cystocele, and rectocele, are prevalent.Citation7 Due to the multitude of factors associated with socioeconomic and institutional factors, the prevalence of POP has been significant in developing countries.Citation4,Citation8–Citation10
In Ghana and Dabat (Ethiopia), a significant proportion of women had stage II–IV anatomical pelvic organ prolapse.Citation4,Citation8 Similarly, studies in NigeriaCitation10 and NepalCitation11 showed that different forms of POP have been affecting women’s health and quality of life alarmingly.Citation12 Women with POP have been suffering from significant social problems such as sexual relationships problems, functional impairment, depression, and poor quality of life.Citation13–Citation17 In Ethiopia, gynecological problems are important health problems affecting maternal health outcomes and women’s productivity.Citation18 In clinical setups, POP accounted for 40.7% of major gynecological operations.Citation19 In Tikur Anbesa, POP was the major (41.1%) identified reason for hysterectomy, followed by leiomyoma (23%).Citation20 Studies showed that obstetric characteristics (parity and gravidity and delivery position)Citation21 and sociodemographic factors (educational status, occupational status, and early return to work)Citation21 were found to be significant risk factors for POP.
Though the problem is eminent, the true incidence and risk factors associated with POP have been poorly understood. This might be due to the most private and asymptomatic nature of the illness making POP the “hidden epidemic”.Citation22 In this regard, the Ethiopian government has not developed a separate strategy to prevent and/or manage POP in its health sector/system. Although different studies have identified different types and levels of interventions,Citation1,Citation2,Citation5 there has been paucity of locally generated evidence on the magnitude and determinants of POP to design appropriate prevention strategies.
Therefore, the objective of this study was to identify the determinants or factors of POP among gynecologic patients in Bahir Dar, North West Ethiopia.
Methods
Study design and setting
This was an unmatched case–control study conducted from July to October 2014 in two hospitals (Felege Hiwot Referral Hospital and GAMBY Teaching Hospital) at Bahir Dar city (565 km North West of Addis Ababa). These hospitals were selected because they provide POP surgical intervention. Gynecologic patients (age >18 years) diagnosed with stage III or IV POP were taken as cases, while those clients declared free of POP were taken as controls. A total of 370 (124 cases and 246 controls; 1:2 case to control ratio) participants were included in the study. All cases in the two hospitals were included, and controls for each case were selected using systematic random sampling technique.
Measurement
In this study, clients free of POP were taken as controls; those with stage I or II were excluded from the study, and those with stages III or IV were taken as cases. POP was evaluated and described using a standardized Pelvic Organ Prolapse Quantitative Examination tool.Citation23,Citation24 In this technique, the hymen ring (remnant) is used as a reference point and is called a “half-way system”. Therefore, all the measurements were taken in a semiupright position and interpreted as: stage-0 “no prolapse”; stage I is when the most distal portion (leading surface) of the prolapse is >1 cm above the level of the hymen (<−1 cm); stage II is when the most distal portion (leading edge) of the prolapse is ≤1 cm proximal to or extends 1 cm through the plane of hymen (≥−1 cm, but ≤+1 cm); stage III is when the most distal portion of the prolapse is >1 cm below hymen but no further than 2 cm less than the TVL (there is no complete vaginal eversion); and stage IV is when there is complete eversion of the total length of the pelvic organ, meaning the pelvic organ protrudes at least the total vaginal length minus 2 cm beyond the hymen.Citation23,Citation24 In this measurement, negative number referees were taken as centimeters above or proximal to the hymen, while positive number referees were taken as centimeters below or distal to the hymen.Citation24
Data management and analysis
Data were collected using structured questionnaire developed from existing literature.Citation14,Citation25 Trained midwives and nurses collected the data using the Amharic (local langue) version questionnaire under strict daily supervision. Detailed obstetrics and gynecologic history was taken and vaginal examinations were performed by trained physicians. Questionnaires were coded and entered into the SPSSCitation26 version 20 for analysis. Descriptive, bivariate, and multivariable logistic regression analyses were carried out. After the descriptive statistical analysis, bivariate logistic regression analysis was performed. Variable showing statistically significant association at the bivariate logistic regression analysis (at P<0.05) were selected and entered to the multivariable logistic regression analysis. Statistical difference was considered at P<0.05, and the strength of association was assessed by OR and respective CIs.
Results
Sociodemographic characteristics
Out of the total sample size, 349 (124 cases and 225 controls) respondents were participated. The total response rate was 94.3% (349/370) (100% for cases and 91.5% for controls). The mean (± standard deviation [SD]) age of the respondents’ was 43 years ±12 SD (46 years for cases and 39 years for controls). Majority of the cases (89.5%) and controls (76%) were Orthodox Christian by religion. Majority of cases (n=111 [89.5%]) were rural residents. One hundred ninety nine (96%) women from cases did not have formal education. Majority of women were unemployed for both cases and controls: 119 (96%) and 166 (73.8%), respectively ().
Table 1 Sociodemographic characteristics of respondents in Felege Hiwot Referral Hospital and GAMBY Teaching Hospital, Bahir Dar city, 2014
Obstetric and other characteristics
One hundred five (84.7%) of the cases had more than four deliveries, whereas only 26.7% of controls had ≥4 deliveries. Majority (n=103 [83.3%]) of women who had POP gave their last birth at home; while only 87 (38.7%) women in the control group delivered their last child at home. A majority (n=114 [91.9%]) of the cases had their first child at the age of ≤20 years. Chronic cough was observed among 218 (96.9%) controls and 114 (91.9%) cases. Ninety-three (75%) cases and 90 (40%) controls had history of carrying heavy objects ().
Table 2 Obstetric and related characteristics of cases and controls in Felege Hiwot Referral Hospital and GAMBY Teaching Hospital, Bahir Dar city, 2014
Factors associated with POP
In our study, sociodemographic variables (such as maternal age, residence, formal education, and occupation), obstetric factors (ie, number of pregnancy, number of vaginal births/parity, place of delivery, type of delivery assistant, position during labor, sphincter damage), history of carrying heavy objects, history of chronic cough, family history of POP, and BMI were the identified risks for POP.
Multivariable logistic regression analysis (with entry requirement P<0.2) showed that maternal age (>40 years) (adjusted OR [AOR] =3.0 [95% CI: 1.59–5.89]), sphincter damage (AOR =8.1 [95% CI: 1.67–39.7]), family history of POP (AOR =4.9 [95% CI: 1.94–12.63]), parity (AOR =4.5 [95% CI: 2.26–9.10]), nonattendance of formal education (AOR =4.3 [95% CI: 1.25–14.8]), history of carrying heavy objects (AOR =3.1 [95% CI: 1.56–6.30]), BMI of <18.5 kg/m2 (AOR =3.1 [95% CI: 1.22–7.82]), and delivery assisted by nonhealth professionals (AOR =2.6 [95% CI: 1.24–5.56]) were statistically associated with POP ().
Table 3 Factors associated with POP in Felege Hiwot Referral Hospital and GAMBY Teaching Hospital, Bahir Dar city, 2014
Discussion
Different studies,Citation4,Citation9,Citation27–Citation31 including in EthiopiaCitation12,Citation19 showed that multiparous women have increased risk of POP. Similarly, in our study, multipara women (parity ≥4) were 4.5 times more likely to have POP compared with their counterparts. Although multiple pregnancy was not statistically significant in our study, other studies in Ethiopia, Ghana, and Nepal reported that multiple pregnancy/gravidity is a predictor of POP.Citation32,Citation33 This might be due to the fact that repeated pregnancy and birth damages sphincter muscles and ligaments, which sometimes never fully regain its strength and elasticity. This was also observed in our study, as mothers who had sphincter damage were eight times more likely to have POP compared to mothers who did not have sphincter damage. A study conducted in Nepal similarly indicated that sphincter damage is a risk factor for POP.Citation11 This is in line with the scientifically established fact that sphincter muscles, together with their surrounding tissues, are responsible for keeping/supporting all of the pelvic organs.Citation34–Citation40
On the other hand, family history was found to be a predictor for POP. In this regard, women with positive POP family history were five times more likely to have had POP compared with their counter parts. This finding is consistent with other studies which reported that family history is an important risk factor for POP.Citation25,Citation29,Citation41
In our study, educational status showed a statistically significant association with POP, with women who did not attend formal education being 4.3 times more likely to have POP compared with the educated women. Similarly, studies from NepalCitation42 and Al Ain (UAE)Citation43 indicated that illiterate women were more likely to be affected by POP. Higher risk of POP among illiterate women might be due to higher proportion of delivery at home (83.3%), possibly without the attendance of skilled health professionals.
Studies suggest that women engaged in farming, carrying and marketing of agricultural products, wood collection, fetching water from a distant area are more likely to have POP.Citation19 In a similar fashion, although rural residence is not statistically associated with POP, in our study, women who had history of carrying heavy objects had increased POP risk compared with their counter parts. This might be due to the reason that in our study 89.5% of women with POP were rural inhabitants, whose daily activities included carrying and moving heavy household and agricultural loads. Hence, it is possible to justify that the association of farming activity of rural women and the risk of POP was indirectly through carrying heavy objects, a factor which is also common in other regions of Ethiopia and other developing nations.Citation8,Citation12,Citation19
Although obesity (BMI ≥25 kg/m2) could increase the risk of POP,Citation9,Citation42 this study found a contrary finding that being underweight (BMI <18.5 kg/m2) increases the risk of POP threefold. Different studies reported that the risk of POP increases with age.Citation12,Citation19,Citation30,Citation33,Citation44 Similarly, in our study, women aged ≥40 years were about three times more likely to have had POP compared to women aged <40 years old. A study conducted in Jimma, Ethiopia, documented such a consistent finding.Citation19 This might be due to the fact that the risk of POP increases with age.Citation45 However, a study conducted in Gondar Dabat district, Ethiopia, reported a contradictory finding.Citation8
In our study, women assisted by nonhealth professionals during delivery were 2.6 times more likely to have POP. This was consistent with earlier studies from Nepal and India.Citation27,Citation31
This study did not assess some of risks for POP such as mode of delivery for the previous vaginal birth and history of instrument-assisted delivery. This study could not match cases and controls by age, which might be an important contributor in the occurrence of POP. Additionally, since this was a hospital-based study, it did not allow for the inclusion of a specific population or community at large. Recall bias also might have been introduced as the respondents were asked questions about some of their previous health-related events. Therefore, this study needs cautious interpretation to draw conclusions.
Conclusion
In conclusion, this study revealed that multifaceted factors such as sphincter damage, family history of POP, being uneducated, having ≥4 vaginal deliveries, carrying heavy objects, BMI <18.5 kg/m2, age ≥40 years, and delivery assisted by nonhealth professional are the determinants of POP. Delivery at health institutions, assistance by health professional during deliver, prevention of maternal malnutrition, empowerment of women (through education) to utilize family planning in turn to prevent too late and too many pregnancies, counseling to avoid carrying heavy objects, early pelvic floor assessment/screening for potential sphincter damage, and studies over large geographical areas are recommended.
Ethical approval and consent to participate
Ethical consideration
Ethical clearance was obtained from the ethical review committee of Bahir Dar University, College of Medicine and Health Sciences. Permission letter was obtained from Amhara National Regional State Health Bureau, and respective hospitals. Written informed consent was secured from study participants. Strict confidentiality and client privacy was maintained given that the standard medical examination/practice has been done.
Availability of data and material
All the data related to this article and its conclusion are available as tables.
Author contributions
AA conceived the study and analyzed the data. TS interpreted the result and drafted the manuscript. TS and EA produced and reviewed the manuscript critically. All authors contributed toward data analysis, drafting and critically revising the paper and agree to be accountable for all aspects of the work.
Acknowledgments
The authors would like to thank Bahir Dar University for its technical support, study participants, data collectors, and physicians without whom this study could not have been realized. Special thanks goes to Dr Ayenew Belay for providing technical support and facilitation.
Disclosure
The authors report no conflicts of interest in this work.
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