Study setting, period and design
A facility-based cross-sectional study was employed in two public hospitals (Hiwot Fana Specialized University hospital and Jugal hospital) found in Harar town, Eastern Ethiopia from March 4th to April 5th, 2020. Harar town is the capital city of Harari regional state, which is located 526km away from the capital city of Ethiopia, Addis Ababa. According to the 2007 census conducted by the Central Statistics Agency (CSA) in Ethiopia, the total population of the town is 183,415 where 92,316 males and 91, 099 females. In the town, there are 45 health facilities (34 health posts, 8 health centers, 5 hospitals and Family guidance Association). Among these five hospitals, there are 45 health facilities (34 health posts, 8 health centers, and 5 hospitals). Among the five hospitals found in the town, only two of them are giving service as public hospitals. This study was conducted in two public hospitals, where different and multidimensional health care services ae being provided to the patient [29].
Population, Eligibility criteria and Sampling procedures
All ever-married women attending healthcare services in public hospitals of Harari Regional State were considered as source population. Ever-married women who came for healthcare services at Family planning unit, Adult outpatient Department (OPD), Gynecologic OPD and Expanded Program of Immunization (EPI) unit were considered for enrollment. Thus, all eligible ever-married women attending healthcare services during the data collection period were studied. Women with the following preconditions (pregnant women, critically ill women and women with mental problems) were excluded from the study.The sample size was calculated using double population proportion formula by considering prolonged labor as an exposure variable[30] with the following assumptions. Proportion of outcome among unexposed (had no history of prolonged labor)(P= 50.7%), proportion of outcome among exposed( had history of prolonged labor)(P= 64.7%), 95% confidence level, 80% power. Adding 5% contingency for non-response rate, finally 460 study participants were obtained.
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.
Data collection Tools and Procedures
Data were collected using structured interviewer administered questionnaires. First, the questionnaires were prepared in English language and translated into local languages (Afan Oromo and Amharic) by bi-lingual expert. Then, they were translated back in to English version to check for consistency. These structured questionnaires have different parts: Socio demographic characteristics, obstetric and gynecologic history, medical history and Pelvic Organ Prolapse Simple Screening Inventory questionnaires. The questionnaire were extracted and adopted from different literatures [13, 19] . Data were collected by six (6) female Bachelor of Science (BSc) nurse professionals who had previous data collection experiences. Two (2) supervisors (BSc public health professionals) were selected to supervise the data collectors and data collection process. The data collectors were interviewed the participants after they fully decided to enroll in to the study. The interview was conducted at separated area during waiting time and exit time to assure the privacy. Screening for privacy was assured.
Study variables and measurement
In this study, the dependent variable was Pelvic Organ Prolapse (POP). This outcome variable was dichotomized based on the symptoms of women’s report. Accordingly, when a woman’s answer was “Yes” for the question (Do you feel or see a bulge in the vagina or that something is falling out from your vagina?) Plus at least one of the 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], the woman has genital prolapse and if the woman’s answer was “No” for the above questions (Do you feel or see a bulge in the vagina? and, for the rest three POPSSI questions), the woman has no genital prolapse.
The explanatory variables were: Socio-demographic characteristics (age, religion, ethnicity, marital status, residence, educational status and occupation). Reproductive history related variables (age at first marriage, history of using family planning, menopause). Obstetric and gynecologic history factors (Number of pregnancy(gravidity), history of abortion, number of child birth (parity), mode of delivery at first child birth, ever had vaginal delivery, place of delivery, prolonged labor, time since last birth, family history of POP). Medical history related variables (history of chronic cough, chronic constipation, and maternal obesity).
Measurements
Mother with pelvic organ prolapse (POP): Pelvic organ prolapse, or genital prolapse, is the descent from or through the vaginal opening of one or more pelvic structures from the normal anatomy. The pelvic structure include the vagina, uterus, bladder, urethra, and rectum[6, 32].
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”.
Data quality control
Before the actual data collection performed, pretested was conducted on 23 samples (5% of the total sample size) of the questionnaire. 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. Moreover, the data collectors along with the supervisors were trained for two days regarding purpose of the study, data collection procedures and data handling techniques. A close supervision of the data collectors was made on daily basis. The collected data were checked by supervisors and principal investigator for completeness, and consistency. Double data entry was done by two independent data clerks, and the consistency of the entered data was cross-checked. Simple frequencies were run to check any missing values and outliers and crosschecked with hard copies of the collected data before analysis.
Data processing and analysis
The collected data were coded, cleaned and entered in to Epi-data version 3.1, and exported to SPSS version 22 (IBM SPSS Statistics, 2013) for further analysis. Descriptive analysis was done using frequency tables, proportion with 95% CI and summary measures. Bivariable logistic regression analysis was carried out to select candidate variables for multivariable analysis and those variables with p-value less than 0.25 were considered for final model of multivariable analysis based on the assumption of selection criteria[33]. The multivariable analysis was performed to identify the true effects of the selected predictor variables on Pelvic Organ Prolapse. Multi-collinearity was checked using variance inflation factor (VIF) and tolerance, and no collinearity effect was detected. The model adequacy was checked using Hosmer-Lemeshow goodness of fitness test and the result was found to be insignificant (p = 0.677) which indicates the model was fitted. Finally, the strength of associations between the outcome variable and predictor variables was assessed using Adjusted Odds Ratio (AOR) with 95% Confidence Intervals (95%CI), and the significance of the association was declared at p-value of less than 0.05.
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.