Prevalence and Associated Factors of Utero-Vaginal Prolapse in AddisAbaba, Ethiopia: A Cross-Sectional Study.

Background: Uterovaginal prolapse (UVP) is a major women’s health concern throughout the world. Globally, 2-20% of all women are affected by UVP. The mean prevalence of pelvic organ prolapse in developing countries is 19.7%. The prevalence of UVP in Ethiopia is 18.55% among all gynecological operations. UVP is a source of severe morbidity and psychological upheaval to the patient, who is often socially withdrawn and stigmatized. UVP negatively affects socioeconomic and reproductive activity of affected women. It is, therefore, of interest to study its prevalence and factors associated with the condition. Methodology: Institution-based retrospective cross-sectional study was conducted in selected Addis Ababa city governmental hospitals and the medical record charts of women admitted in the respective gynecology wards were reviewed. The medical records included in this study were those from March 2017 to February 2019 G.C. and 400 records of admitted women were randomly selected. The data were analyzed using SPSS version 24 statistical package. Bivariate and multivariate logistic regression analyses were carried out to determine factors associated with UVP. A p-value < 0.05 was considered as signicant. Result: Out of the3,949 admitted women, the prevalence of UVP was 12.8%. The leading determinants of UVP were menopause (OR = 2.611 (at 95 % CI: 1.531, 3.838), age > 40 years (OR = 2.143 (at 95 % CI:1.496, 6.602), parity of > 4 (OR = 4.201 (at 95 % CI 1.652, 10.685), age at rst delivery of < 20 years old (OR = 7.988(2.682, 23.792) and home delivery (OR = 1.380 (at 95 % CI:1.212, 2.572). Conclusion: The prevalence of UVP in this study was relatively high. The major risk factors of UVP were menopause, having > 4 deliveries, age > 40 years, age at rst delivery < 20 years old and home delivery. Therefore, the ndings of this investigation, especially identication The results were summarized in the form of proportions and frequency tables for categorical variables. Continuous variables were summarized by using means and standard deviations.

genital tract and the distal portion of the prolapse protrudes to at least 2 cm less than the total vaginal length [3].
The reported prevalence of UVP is different in different countries. The exact prevalence of UVP is di cult to determine because many women are asymptomatic, and even if symptomatic, many women feel shy or do not reveal the presence of the problem due to social reasons [4].
Globally, 2-20% of all women are affected by UVP. The incidence of UVP is 17% in Australia and the United States of America, 8.5% in France and 27% in Turkey [2].
In the USA, the prevalence of uterine prolapse was reported to be 14.2% among women in the Women's Health Initiative Hormone Replacement Therapy Clinical Trial [5]. In the United Kingdom, the disorder accounts for 20% of women waiting for major gynecological surgery [6]. In a population-based survey, the prevalence of UVP has been reported to be 10% in Indian [4].
The mean prevalence of pelvic organ prolapses among low-income and lower-middle-income countries were found to be 19.7% [7]. In Ethiopia, the prevalence of UVP was reported to be 18.55% of all major gynecological operations [8].
The etiology of UVP is multifactorial. A weakening of the pelvic support structures may be as a result of either congenital or acquired causes. Older age, family history, menopause, higher parity, vaginal delivery, and prolonged labor are of major risk factors known [1].The collagen content of the connective tissue supporting pelvic organs decreases in women after menopause. Changes in collagen content or estrogen & progesterone receptor density affect the strength of pelvic organ support. A weakness of uterosacral ligament, which is composed of connective tissue, smooth muscle, and blood vessels, may result in uterovaginal prolapse. Postmenopausal state due to hypoestrogenemia and genital atrophy play the most important role in the pathogenesis of UVP [9].
Prolonged labor or conduct of labor by unskilled attendants is risks for uterine prolapse especially if delivery is at home. Resultant weakness in pelvic oor muscles occurs during the menopause and atrophy of pelvic tissues due to hypoestrogenic state causes signi cant damage to the pelvic support system resulting in UVP [10].
Women with UVP are not volunteer to disclose their problem due to fear of social stigma or discrimination; and they are not comfortable to have sexual intercourse, as a result, many women got divorced due to this problem. Women with UVP especially in rural areas are facing many di culties to undertake their daily activities like; childcare, cooking, the fetching of water and collecting of rewood [11].
Existing knowledge on the prevalence, risk factors, and consequences of living with UVP in developing countries including Ethiopia is scanty. The fertility rate is higher, and the access to obstetric care is limited, which have implications for the risk of pelvic oor disorders [12]. UVP greatly affects women's quality of life and result in physical, social, psychological, sexual and economic problems [13].Knowledge of risk factors of UVP is very important to prevent or reduce the incidence of UVP and related complications.
Literature regarding the prevalence and associated risk factors of UVP in Ethiopia is very limited.
Therefore, this study investigated the prevalence and determinants of UVP in women admitted to Addis Ababa city governmental hospitals.

Study setting and study population
Institution based cross-sectional study was conducted retrospectively at Addis Ababa city governmental hospitals: Gandhi memorial hospital, St Paul's hospital and TikurAnbessa specialized hospital. These hospitals are selected purposively from 11 governmental hospitals in Addis Ababa. The selected hospitals are tertiary referral & teaching hospitals and have high patient ow. This study was conducted from April to July 2019 G.C. During the study period 3,949 women were admitted in the gynecology wards of the selected hospitals. The sample size calculated using a single population proportion formula was 400 and study subjects' records were selected by random sampling method. All women whose medical information was entered into the registry book of the gynecology wards of the respective study hospitals were included. Women with incomplete records and women whose medical record charts were lost from the medical record charts archive of the hospitals were excluded from the study.

Data collection
Data was collected by using a well-structured, self-prepared & pretested checklist. Data in the check list included were: age, ethnicity, parity, occupation, menopause, place of deliveries, mode of deliveries, age at rst delivery and level of education of women.
Nine nurses were assigned to collect the data from medical record charts and three health o cers have supervised the data collectors in the process of data collections. Necessary supervision was undertaken by the principal investigator during the entire data collection period.
To ensure good quality data, training of data collectors, pre-testing of the check list and continuous supervision of the data collection process were carried out.

De nition of outcome variables and statistical analysis
In this study, UVP was de ned as a diagnosis of admission entered into the study subject's medical record chart and recorded in the admission registry book of gynecology wards of the study hospitals. The check lists were checked after each data collection for completeness. The data was entered into EPI data manager version 4.4 and analyzed by using SPSS Statistics version 24. The results were summarized in the form of proportions and frequency tables for categorical variables. Continuous variables were summarized by using means and standard deviations. Bivariate and multivariate logistic regression analyses were carried out to determine the relationship between dependent and independent variables. A p-value of < 0.05 was considered as statistically signi cant.

Prevalence of utero-vaginal prolapse
Within the study period, 3,949 patients were admitted at the gynecology wards of the study hospitals, from which 400 study participants were selected. Out of these, 51 patients were diagnosed as cases of UVP, making a prevalence of 12.8 % among the total gynecologic admissions in the study hospitals during the study period.

Characteristics(n=400) Frequency Percent
Age group in years    Of the 51 participants with UVP, the majority (52.9 %) had third-degree, 31.5% fourth-degree, 11.7 % second degree and 3.9% rst degree UVPs, respectively. Sixteen (31.3 %) of the women have had the illness for the last 10 or more years, with 3 (0.8 %) of them living with the condition for more than 20 years. Thirty-nine (76.5 %) of women with UVP were in menopause (Table 3).
Independent variables in the multiple logistic regression model were tested for their association with UVP. menopause, age groups 41-50, age of >50, parity 5-9, parity of ≥ 10, age at rst delivery < 20 years old and home delivery were signi cantly associated with UVP (a P-value ≤ 0.05 with 95 % C.I), whereas age group of 31-40, vaginal delivery and being illiterate were not signi cantly associated. Postmenopause women had two and half times higher risk (an odds ratio of 2.611 (at 95 % CI: 1.531, 4.838) of UVP than pre-menopause women. Women with age at rst delivery of < 20 years have eight times higher risk (an OR = 7.988 (2.682, 23.792) of UVP than their counter parts.
Women with 5-9 deliveries and women with ten or more deliveries had higher risk of developing UVP than women with less than 4 deliveries (OR= 4.133 (at 95 5 CI: 1.461, 11.694) and OR= 9.376 (at 95 % CI: 2.905, 30.262), respectively. Grand multiparous women have had an odds ratio of 4.686 (at 95 % CI 2.919, 8.443) interpreted as they had approximately 5 times higher risk of developing UVP compared to mothers who delivered less than ve times.
Age group of 41-50 years have an odds ratio of 2.024 (at 95 % CI 1.372, 5.479), two times higher risk of developing UVP than age group of < 30years, and age of >50 years have an OR of 3.380 (at 95 % CI 1.719, 8.989), which means mothers with the age of 50 years or more have four times higher risk of developing UVP than mothers with in the age of < 30 years. (Table 4)

Discussion
The prevalence of UVP (12.8%) in this study is comparable with a study in Nepal which reported a prevalence of UVP 13.7% [14], A Women's Health Initiative Hormone Replacement Therapy Clinical Trial in the United States, reported aprevalence of 14.2% [5]. Other similar studies inIndia [4] and in Ghana [15] reported prevalence of 10% and 12.07%, respectively.. However, much higher prevalence, a prevalence of 19.9 % and 17.2% were documented in other parts of the country, in Gondar and Gandhi memorial hospitals [8]. A study in 16 low-income and lower-middle-income countries revealed that the mean prevalence of UVP was 19.7% which is higher than our nding [7]. Conversely, the observed prevalence in our study was greater than those reported by investigations conducted in Dabat district, North West Ethiopia (a prevalence of 6.3 %) [16], in France (8.5%) [2] And in Egypt (7.9 %) [17]. This discrepancy may have been due to the cultural differences among the study subjects, the type of population studied, the difference in the level of education of study subjects, the attitude of people towards illness and the disease, and the in uence of health facilities available in the different study areas.
Our ndings reveal that women within the age group of 41-50 years had two times higher risk of developing UVP, compared to the age group of < 30 years. Women who were 50 years of age or more had three times higher risk of developing UVP compared to those women in the age group of < 30 years old.
However, a study conducted in Bench Maji Zone, Ethiopia, reported that women in the age groups of 41-50 years had eleven times and those above 50 years had 35 times higher risk of developing UVP compared to those who were less than 30 years of age [18]. These observed differences in risks of developing UVP could have resulted from difference in population studied, economic and sociocultural differences of the study population.
In this study, multipara women (parity ≥ 4) and age of women > 40 years, respectively, were four & two times more likely to have UVP. This nding is consistent with a documented data of a study carried out in Bahir Dar, Northwest Ethiopia, which reported a risk of developing UVP that was 4.5 times and 3 times higher for parity ≥4 and for women aged > 40 years, respectively [19].
It was also observed that the majority (54.9 %) of women with UVP were from Gurage Zone of SNNP region of Ethiopia, a community where making of Kocho (traditional diet in Gurage region, made from "enset"), which is a physically demanding job, is the sole responsibility of women. This burden of women may be related to this reproductive health problem of women.
Most commonly diagnosed type of UVP in this study was third degree (52.9 %), which was inline with a study done in Jimma University specialized hospital, Ethiopia which reported a 55.8 % diagnosis [20]. However, other studies conducted outside of Ethiopia have reported varying types of UVP as most commonly diagnosed. For example, studies conducted in India 80.8 % of study participants with UVP had fourth degree [4], in Nigeria 83.3 % were second degree [19], and in Ghana 33.3 % were second degree [15]. This variability's might have been due to differences in awareness towards UVP and differences in accessibility of health care facilities.
Resultant weakness in pelvic oor muscles and atrophy of pelvic tissues occurs during the menopause due to the hypo estrogenic state that causes signi cant damage to the pelvic support system resulting in UVP (9,10). The ndings of this study con rm this, as the mean age of the patients in this investigation was 51.37 years with most of the patients being post-menopausal.

Conclusion
The prevalence of utero-vaginal prolapse was high in Addis Ababa city governmental hospitals. The leading determinants of UVP were being in menopause, having > 4 deliveries, age > 40 years, age at rst delivery < 20 years old and home delivery.

Recommendation
Efforts have to be made to avoid the rst delivery before the age of 20 years, to increase health facility delivery and to reduce the number of births a woman should have in her life time.

Declarations
Ethics approval and consent to participate The study was conducted after ethical clearance was obtained from Human Anatomy department's Departmental Research Ethics Review Committee (DRERC), and the Institutional Review Board (IRB) of the Addis Ababa University, Ethiopia. Letter of ethical clearance as well as a letter of cooperation was sent for the study hospitals to undertake the data collection.

Consent to participate:
Informed consent was obtained from all subjects. Individual patient or group of patients have never been identi ed in any way. Therefore, the con dentiality of the patient/data was maintained at all levels.
We con rm that all methods were carried out in accordance with relevant guidelines and regulations of the journal.

Consent for publication: Not applicable
Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on request.

Competing interests
The authors declare that they have no nancial or non-nancial competing interests.

Funding
This study was not funded by any agency.
Authors' contributions ZM: Developed proposal and data collection sheet, collected data, analyzed it and wrote the draft of the manuscript. AM and GS: conceived the study, supervised the entire research, including the data collection and reviewed the draft of the manuscript. GS is the corresponding author. All the authors read and approved the nal version of the manuscript.