Pelvic Organ Prolapse and its Associated Factors Among Women: A Facility Based Cross-sectional Study

Abstract

Pelvic organ prolapse is the downward descent of female organs, including the bladder, small bowel, and large bowel, resulting in the protrusion of the vagina, uterus, or both. This disorder, exclusive to women, causes psychological trauma and social withdrawal, leading to an increased rate of gynecologic surgery. To assess the Pelvic Organ Prolapse and its associated factors among Women Visiting public Hospitals in south west Ethiopia. An institution-based cross-sectional study was conducted among gynecologic patients. A total sample size of 408 was allocated to the institutions proportional to their previous month’s case load. Data were collected using an interviewer-administered structured questionnaire. The collected data were coded and entered into EpiData version 3.1, then exported to SPSS version 20 for descriptive and inferential analysis. Adjusted odds ratios (AOR) along with a 95% confidence level were estimated, and a P-value < .05 was considered statistically significant. Out of the intended sample size, 393 women participated in the study, resulting in a response rate of 96.3%. The overall magnitude of pelvic organ prolapse among the study participants was 19.8% (95% CI: 16.0, 24.1). Factors significantly associated with pelvic organ prolapse were place of residence (AOR = 2.21, 95% CI: 1.11, 4.40), parity (AOR = 2.82, 95% CI: 1.39, 5.72), age at first pregnancy (AOR = 2.32, 95% CI: 1.27, 4.26), and place of delivery of the first child (AOR = 4.18, 95% CI: 1.97, 8.85). The prevalence of pelvic organ prolapse is high. Place of residence, parity, age at first pregnancy, and place of delivery of the first child were factors significantly associated with pelvic organ prolapse. Therefore, different stakeholders, programmers, and implementers should take aggressive steps to prevent early pregnancy, train health professionals to encourage women to use family planning, and promote institutional delivery.

Keywords

organ prolapse pelvic organ prolapses woman

What do we already know about this topic?

Pelvic organ prolapse (POP) is a gynecological condition causing the descent or bulging of pelvic organs into the vaginal walls or opening, primarily due to weakening pelvic floor muscles, ligaments, and connective tissues, aging, hormonal changes, obesity, chronic coughing, and genetic predisposition.

How does your research contribute to the field?

This study enhances women’s health by revealing prevalence and risk factors of the condition, aiding healthcare providers in developing effective prevention and treatment strategies.

What are your research’s implications towards theory, practice, or policy?

This research could lead to the creation of guidelines for pelvic organ prolapse screening, public health campaigns, and evidence-based interventions, thereby enhancing understanding and prevention. Additionally, the findings of this study may inform future research on the topic and contribute to the development of evidence-based intervention

Introduction

Pelvic organ prolapse (POP) is the downward displacement of pelvic organs, causing herniation into or through the vagina (uterovaginal prolapse) or anal canal (rectal intussusception and rectal prolapse).¹ It is a common gynecological problem resulting from the loss of support that is normally provided by the levator ani muscles, vagina, and connective tissue. Neurologic injury from stretching of the pudendal nerves during childbirth can also contribute to the development of POP.^2
-4

A healthy woman with normal levator ani tone and adequate vaginal depth can maintain a horizontal upper vagina position.⁵ However, increased intra-abdominal pressure can lead to sagging, widening of the genital hiatus, and constant stress and stretching of the pelvic structures. This can result in connective tissue support failure and prolapse. POP, also known as urogenital prolapse, is a global issue that significantly impacts the quality of life of millions of women. Its estimated lifetime prevalence in porous women ranges from 30.0% to 50.0%.^3,5
-7

The worldwide prevalence of POP is reported to be around 9%,⁸ but it is estimated to be higher, approximately 20%, in low-income countries.⁹ Sub-Saharan Africa sees a high prevalence of genital and uterine prolapses among women of reproductive age, posing a significant health risk, particularly for nutritionally vulnerable populations.¹⁰ Studies in Uganda, Ethiopia, and Tanzania have reported prevalence rates ranging from 27.5% to 64.6% in the region, with the most recent study finding a 1% prevalence of symptomatic POP among women of reproductive age in Ethiopia.^11
-13

While POP rarely results in death,^14,15 it has a substantial impact on the daily lives of affected women, disrupting and decreasing their quality of life.^3,14 It can severely limit physical, social, psychological, and sexual functioning, as well as disrupt marital and sexual relationships.^16,17

Additionally, POP and its complications impose a considerable economic burden. ^14,18 Risk of uterine prolapse is heightened by different factors.¹⁶ For example, pregnancy, parity, age, BMI, and vaginal delivery are key contributing factors to prolapse.^19,20 High parity is the most significant risk factor for POP across both affluent and disadvantaged countries.¹⁷ However, the relationship between these risk factors and the stages and organs involved in prolapse is still not fully understood. Baden–Walker half way system²¹ and Pelvic Organ Prolapse Quantification (POP–Q) system²² are commonly used for grading stage of POP. Observation, pelvic floor muscle training, mechanical support (pessaries), and surgery are management options for women with symptomatic prolapse.^23,24

In Ethiopia, insufficient attention has been given to this distressing condition among women, which can be addressed through preventive measures. The “hidden epidemic” nature of POP may contribute to a limited understanding of its true incidence and risk factors, necessitating evidence-based decision-making for effective management.

Therefore, this study aims to assess the prevalence of pelvic organ prolapse (POP) among women in Illu Aba Bor Zone, Southwest Ethiopia. The findings will contribute valuable information for designing appropriate interventions and health promotion strategies to effectively address the problem. Understanding the prevalence, risk factors, and impact of POP is crucial for improving women’s health and ensuring evidence-based decision-making for its appropriate management.

Methods and Materials

Study Area and Period

The study was carried out in 2 hospitals located in Illu Aba Bor, Southwest Ethiopia. The first hospital is Mettu Karl Comprehensive Specialized Hospital (MKCSH), which annually serves approximately 1.5 million clients referred from various regions. MKCSH sees an average of 450 patients daily, both as outpatients and in emergencies. The hospital provides services in departments such as Internal Medicine, Gynecology and Obstetrics, Adult Intensive Care Unit, Neonatal Intensive Care Unit, Surgery, Psychiatry, Ophthalmic Unit, and Pediatrics. It has a total of 361 staff members, consisting of 231 technical and 138 administrative staff.

The second hospital is Darimu Hospital, catering to a population of 300 000 annually and receiving referrals from multiple health centers in 2 woredas (administrative divisions). On average, 250 patients visit Darimu Hospital each day for outpatient and emergency care. The hospital’s main departments include Internal Medicine, Surgery, Obstetrics and Gynecology, and Pediatrics. It is staffed by a total of 202 individuals, including 83 technical and 119 administrative staff members. The study was conducted from January 1 to 30, 2021.

Study Design

An institution-based cross-sectional study design was employed.

Population

The study population consisted of all women with gynecological cases who visited the gynecology clinics of Mettu Karl Comprehensive Specialized Hospital and Darimu Primary Hospital during the study period.

Eligibility Criteria

All women who visited the gynecology clinics of the selected government/public hospitals were included. Women who were seriously ill or unable to respond were excluded.

Sample Size Determination

The sample size was estimated using the formula for a single population proportion with a 95% confidence level (α = 5%) and a precision (d) of 0.05. The estimated proportion of pelvic organ prolapse (POP) was based on a previous study conducted at Jimma Medical Center in Southwest Ethiopia, which reported a prevalence of 40.7%.¹⁷

$n = \frac{Z^{2} P (1 - P)}{d^{2}}$

Considering a 10% non-response rate, the final sample size was determined to be 408.

Sampling Technique

The 2 public hospitals in the zone were included in the study based on their total case load. The sample was allocated to the 2 institutions proportionally. The average daily load of gynecology cases at Mettu Karl Comprehensive Specialized Hospital and Darimu District Hospital was 10 and 4, respectively. Therefore, the total sample size was divided by the number of average daily loads of gynecology cases (408/14) resulting in 30 working days (4 weeks).

Dependent Variable

Pelvic organ prolapse

Independent Variables

Socio-demographic factors: Age, educational status, occupational status and residence.

Obstetric factors: Age at first pregnancy, parity, duration of labor, mode of delivery, place of delivery

Other factors: Chronic Cough, heavy weight lift and BMI

Operational Definition

➢ Pelvic organ prolapses refers to the abnormal herniation of pelvic viscera, like uterus, vaginal vault, bladder, rectum, and small or large bowel against the vaginal walls or through the vaginal introits.²⁶

➢ Prolapse stage; is the descent of the uterus/cervix and vaginal segments through the vaginal canal.

✓ Stage 0 UVP; no prolapse demonstrated

✓ Stage 1 UVP; halfway to hymen

✓ Stage 2 UVP; to the level hymen

✓ Stage 3 UVP; halfway past hymen

✓ Stage 4 UVP; maximum descent.^2,21

Data Collection Tools and Procedures

An adapted interviewer-administered structured questionnaire was used to collect the data. The questionnaire contains 4 parts: (1) Socio-demographic characteristics,¹⁷ (2) Risk factor assessment,^13,18,25 (3) Obstetric and gynecological history,^19,27 and (4) Clinical characteristics of the study participants.^28,29 The tool was prepared in English, translated into the local language (Afaan Oromo), and translated back to English by another expert in the field to ensure consistency. Interviewer-administered structured questionnaires and record review from patients chart were used to collect data. Data were collected by 5 trained BSc nurses and 2 M.Sc. public health professionals who supervised the data collection process.

Data Quality Control

The data collectors and a supervisor were trained by the principal investigator on the objectives of the study, questionnaires, confidentiality of information, participants’ rights, and informed consent. The data collection tool was pretested on 5% of the sample at Nekemte Comprehensive Specialized Hospital and Dambi Primary Hospital. Based on the pretest results, necessary corrections were made to the questionnaire. A supervisor oversaw the data collection process and ensured the completeness and consistency of the filled questionnaires on a daily basis.

Data Processing and Analysis

The data were coded and entered into Epi Data version 3.1 and exported to SPSS version 20 for descriptive and inferential analyses. Frequencies and cross tabulations were used to check for missing values of variables and to describe the study population in relation to relevant variables. Bivariate and multivariable analysis was performed to investigate the association of independent variables with pelvic organ prolapse (POP). Binary logistic regression analysis was used to identify factors associated with POP as the outcome variable. Independent variables with a P-value of less than .25 were entered into the final multivariable logistic regression model to control for potential confounders and identify significant factors associated with the outcome variable. The adequacy of model fitness was checked using the Hosmer and Lemeshow test. Adjusted odds ratios (AOR) along with 95% confidence intervals were estimated to assess the strength of the association, and a P-value < .05 was considered statistically significant.

Results

Socio-Demographic Characteristics

A total of 393 women participated in the study, resulting in a response rate of 96.3%. More than half (50.6%) of the respondents were above 55 years of age. Approximately 69.7% of the respondents were rural residents. About 73.8% of the respondents were married. Of the respondents, 245 (62.3%) belonged to the Oromo ethnic group, and 127 (39.7%) identified as Muslims by religion. Nearly two-thirds (65.1%) of the respondents had no formal education (Table 1).

Table 1.

Socio-demographic Characteristics Participants, 2021.

Characteristics	Category	Frequency	Percent
Age of the respondents	≤34	32	8.1
	35-44	66	16.8
	45-54	96	24.4
	≥55	199	50.6
Place of residence	Urban	119	30.3
Place of residence	Rural	274	69.7
Marital status	Single	8	2.0
	Married	290	73.8
	Divorced	67	17.0
	Widowed	28	7.1
Religion	Orthodox	156	32.3
	Muslim	127	39.7
	Protestant	98	24.9
	Catholic	12	3.1
Ethnicity	Oromo	245	62.3
	Amhara	96	24.4
	Tigre	16	4.8
	Kafa	21	5.3
	other **	15	3.8
Educational status	No formal education	256	65.1
	Primary	99	25.2
	Secondary & above	38	9.7
Occupational status	Employee	50	12.7
	Merchant	74	18.8
	Housewife	253	64.4
	Others***	16	4.1

Other** Kafa, sheka ***others include Daily laborer, student.

Obstetric Characteristics of the Respondents

More than two-thirds (67.9%) of the respondents were grand multiparas (women who have given birth to 5 or more children) (Table 2).

Table 2.

Obstetric Characteristics of Participants 2021.

Characteristics	Category	Frequency	Percent
Parity	Nulipara	12	3.1
	Multipara	114	29.0
	Grand multipara	267	67.9
Age at first pregnancy (n = 381)	<18	128	33.6
Age at first pregnancy (n = 381)	≥18	253	66.4
Place of delivery of first child (n = 381)	Health institution	116	30.4
Place of delivery of first child (n = 381)	Home	265	69.6
Duration of labor (n = 381)	≤8 h	71	18.6
Duration of labor (n = 381)	≥8 h	310	81.4
Mode of delivery of first child (n = 381)	SVD	279	72.4
	Operative delivery	70	18.4
	CS	35	9.2
Heavy lifting	Yes	344	87.5
Heavy lifting	No	49	12.5
Abdominal swelling	Yes	36	9.2
Abdominal swelling	No	357	90.8
Chronic cough	Yes	18	4.6
Chronic cough	No	375	95.4
BMI	≤18.5	27	6.9
	18.5-24.9	319	86.8
	≥25	25	6.4

Note. BMI = body mass index; SVD = spontaneous vagina delivery; CS = cesarean section.

Complications

The overall magnitude of pelvic organ prolapse (POP) among the study participants was 19.8%.

Among those with POP, stage II accounted for 40 (51.3%) cases. The majority of the cases (92.3%) reported experiencing stress. (Table 3).

Table 3.

Complications of Pelvic Organ Prolapse of Participants 2021.

Characteristics	Category	Frequency	Percent
Degree of prolapse (n = 78)	Stage I	21	26.9
	Stage II	40	51.3
	Stage III	17	21.8
Type of POP (n = 78)	UVP alone	62	79.5
	UVP with urethrocele	4	5.1
	UVP with cystocele	2	2.6
	UVP with rectocele	10	12.8
Psycho-social (n = 78)	Stress	72	92.3
	Emotional isolation	53	67.9
	Abandonment by husband	20	25.6
Domestic violence (n = 78)	Yes	38	48.7
Domestic violence (n = 78)	No	40	51.3
Husband re-married (n = 78)	Yes	49	62.8
Husband re-married (n = 78)	No	29	37.2

Note. POP = pelvic organ prolapse; UVP = utero vaginal prolapse.

Factors Associated With Pelvic Organ Prolapse

On multivariable logistic regression analysis, the following factors were found to be significantly associated with pelvic organ prolapse: place of residence, parity, age at first pregnancy, and place of delivery of the first child.

Women from rural areas were 2.21 times more likely to develop POP compared to women from urban areas (AOR = 2.21, 95% CI: 1.11, 4.40). Grand multiparas were 2.82 times more likely to develop pelvic organ prolapse compared to women with fewer children (AOR = 2.82, 95% CI: 1.39, 5.72). Women who became pregnant before the age of 18 were 2.32 times more likely to develop pelvic organ prolapse compared to those who became pregnant later in life (AOR = 2.32, 95% CI: 1.27, 4.26). Women who delivered their first child at home had a higher likelihood of developing pelvic organ prolapse compared to those who delivered at a health institution (AOR = 4.18, 95% CI: 1.97, 8.85) (Table 4).

Table 4.

Multivariable Logistic Regression Analysis of Factors Associated With Pelvic Organ Prolapse, 2021.

Characteristics	Category	POP		COR (95% CI)	AOR (95% CI)
Characteristics	Category	YesN (%)	NoN (%)	COR (95% CI)	AOR (95% CI)
Age of the respondents	≤34	2 (6.3)	30 (93.8)	1.00	1.00
	35-44	6 (9.1)	60 (90.9)	1.50 (0.28,7.88)	0.91 (0.15,5.39)
	45-54	14 (14.6)	82 (85.4)	2.56 (0.55,11.9)	1.57 (0.29,8.55)
	≥55	56 (28.1)	143 (71.9)	5.87 (1.36,10.40)	2.91 (0.58,14.53)
Place of residence	Urban	13 (10.9)	106 (89.1)	1.00	1.00
Place of residence	Rural	65 (23.7)	209 (76.3)	2.54 (1.34,4.81)	2.21 (1.11,4.40)*
Educational status	No formal education	50 (19.5)	206 (80.5)	1.60 (0.59,4.31)	1.59 (0.55,4.63)
	Primary	23 (23.3)	76 (76.8)	1.99 (0.69,5.71)	1.74 (0.54,5.62)
	Secondary and above	5 (13.2)	33 (86.8)	1.00	1.00
BMI	<18.5 kg/m²	5 (16.7)	25 (83.3)	1.00	1.00
	18.5-24.9 kg/m²	52 (16.3)	267 (83.7)	1.99 (0.58,6.812)	1.64 (0.42,6.37)
	≥25 kg/m²	21 (47.7)	23 (52.3)	3.11 (0.71,13.72)	1.88 (0.36,9.75)
Parity	Multipara	14 (12.3)	100 (87.7)	1.00	1.00
Parity	Grand multipara	64 (24.0)	203 (76.0)	2.25 (1.20,4.21)	2.82 (1.39,5.72)*
Age at first pregnancy	<18	38 (29.7)	90 (70.3)	2.25 (1.43,3.94)	2.32 (1.27,4.26)*
Age at first pregnancy	≥18	40 (15.9)	213(84.8)	1.00	1.00
Place of delivery of first child	Health institution	12 (10.3)	104 (89.7)	1.00	1.00
Place of delivery of first child	Home	66 (23.8)	199 (76.2)	2.87 (1.40,5.24)	4.18 (1.97,8.85)*
Duration of labor	<8 h	16 (22.5)	55 (77.5)	1.00	1.00
Duration of labor	≥8 h	62 (20.0)	248 (80.0)	0.86 (0.44,1.53)	0.84 (0.40,1.77)
Mode of delivery	SVD	49 (19.5)	227 (80.5)	1.00	1.00
	Operative delivery	24 (31.2)	46 (68.8)	2.42 (1.35,4.33)	1.03 (0.52,2.06)
	CS	5 (14.3)	30 (85.7)	0.77 (0.29,2.09)	0.38 (0.12,1.20)
Heavy lifting	Yes	74 (21.5)	270 (78.5)	3.08 (1.07,8.85)	2.14 (0.69,6.69)
Heavy lifting	No	4 (8.2)	45 (91.8)	1.00	1.00

Note. SVD = spontaneous vaginal delivery; CS = cesarean section; BMI = body mass index; 1 = references.

P-value <.05.

Discussion

The study found that the overall prevalence of pelvic organ prolapse (POP) among the participants was 19.8%, with a confidence interval of 16.0 to 24.1.¹⁸ This finding is consistent with a systematic review conducted in Ethiopia, which suggests that there might be shared factors such as genetic predisposition, lifestyle patterns, or healthcare practices contributing to the prevalence of POP in both populations. The prevalence in this study was higher than in other studies conducted in eastern Ethiopia, St. Paul’s Hospital Millennium Medical College, Addis Ababa, and Mizan Aman.^27,30,31 This might be possibly due to factors such as home deliveries, limited access to skilled birth delivery, and prolonged second stage of labor. However, the prevalence was lower compared to a study conducted in Tanzania,¹² which could be attributed to variations in the study settings.

The study identified several factors significantly associated with the development of pelvic organ prolapse, including place of residence, parity, age at first pregnancy, and place of delivery of the first child.

The study identified that place of residence was significantly associated with pelvic organ prolapse. Women from rural areas were found to be more likely to have pelvic organ prolapse compared to their urban counterparts, which is consistent with the findings of the systematic review in Ethiopia.²³ This might be attributed to the fact that physically demanding activities performed by rural inhabitants, such as carrying and moving heavy household and agricultural loads, may contribute to this increased risk.

Parity was also found to be a significant factor, with grand multiparas (women who have given birth to 5 or more children) being more likely to develop pelvic organ prolapse compared to women with fewer children. This is consistent with other studies conducted in Ethiopia,^12,20,28 which might be due to the fact that repeated pregnancy and birth can damage the sphincter muscles and ligaments, which may not fully regain strength and elasticity.

The age at first pregnancy was identified as another significant factor associated with the likelihood of pelvic organ prolapse. Women who became pregnant before the age of 18 were more likely to develop pelvic organ prolapse compared to their counterparts. This finding is consistent with the finding of a study conducted in Wolaita Sodo University Referral Teaching Hospital, Southern Ethiopia.²⁹ This could be attributed to the fact that the ligaments and other supportive structures of the pelvic floor are not fully matured and strong enough to prevent prolapse in younger women.

Additionally, the place of delivery of the first child was found to be significantly associated with pelvic organ prolapse. Women who delivered their first child at home had a higher likelihood of developing pelvic organ prolapse compared to those who delivered at a health institution. This finding is similar with the finding from Tanzania.²³ This could be attributed due to factors such as prolonged labor, lack of knowledge about proper pushing techniques, and limited awareness of prolonged labor among women delivering at home.

It is important to note that this study has limitations, including its cross-sectional design, which does not establish cause-and-effect relationships. Recall bias may also have influenced the results. To gather more comprehensive and accurate data, future studies should consider using longitudinal and qualitative approaches. Despite these limitations, the study’s findings have important implications for understanding the prevalence, risk factors, and treatment options for pelvic organ prolapse. The study can also contribute to raising awareness and promoting discussions about pelvic organ prolapse among healthcare providers and patients

Conclusion and Recommendations

In conclusion, the study found a high prevalence of pelvic organ prolapse among the study participants. Factors such as place of residence, parity, age at first pregnancy, and place of delivery of the first child were significantly associated with pelvic organ prolapse. Healthcare providers should routinely screen women attending gynecology clinics, especially those who are grand multiparas or have perineal tears, for pelvic organ prolapse. It is recommended that hospitals, administration, and zonal health bureaus work on implementing preventive measures. Further research, including longitudinal and qualitative studies, should be conducted to gather more comprehensive data and develop effective strategies for prevention and treatment. Lastly, the study emphasizes the importance of raising awareness about pelvic organ prolapse and promoting open discussions to encourage women to seek medical help and support.

Supplemental Material

sj-docx-1-inq-10.1177_00469580231219155 – Supplemental material for Pelvic Organ Prolapse and its Associated Factors Among Women: A Facility Based Cross-sectional Study

Supplemental material, sj-docx-1-inq-10.1177_00469580231219155 for Pelvic Organ Prolapse and its Associated Factors Among Women: A Facility Based Cross-sectional Study by Adamu Merga, Kebebe Bidira, Abdi Geda, Desalegn Nigatu and Ebissa Bayana in INQUIRY: The Journal of Health Care Organization, Provision, and Financing

Footnotes

Acknowledgements

We would also like to thank the data collectors, supervisors, and study participants for their commitment and tolerance.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which article has been submitted; and agree to be accountable for all aspects of the work.

Data Availability

With reasonable request the data is available from the corresponding author.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical Approval and Consent

Ethical clearance was secured from the IRB of Mettu University, Faculty of Public health and medical sciences prior to data collection (PHMIRB/90/2021). Official permission was asked from all hospitals administration and medical directors. Then informed written consent was obtained from the study participants after fully informing of the study purpose and procedures. Confidentiality and anonymity was ensured. No name or other identifying information was included in the instrument.

Consent for Publication

Not applicable

ORCID iD

Ebissa Bayana

Supplemental Material

Supplemental material for this article is available online.

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