One in five women suffer from pelvic floor disorders in Kersa district Eastern Ethiopia: a community-based study

A community-based cross-sectional study was conducted in Kersa district, East Hararghe Zone, Ethiopia. The study population was ever married women residing in Kersa Health and Demography Surveillance System (Kersa HDSS) field site. The study was conducted from August 10 to September 4, 2016. The study district has 38 kebeles (smallest administrative unit in Ethiopia) of which 24 randomly selected kebeles were included in Kersa HDSS. The district has 6 health centers and 20 health posts. The site constitutes 26,061 household and 127,000 inhabitants of which 23% are women of reproductive age [20].

The study population were ever married women who had resided in Kersa HDSS field site for at least six months. For interviewing unmarried women about their gynecological morbidity is a taboo in traditional community, unmarried women were excluded from this study[21, 22]. A multi-stage, stratified, random sampling procedure proportional to the size of the household in each of the 24 kebeles was used to enroll the study participants. The allocated sample size to each kebeles was further assigned to each ketena (subunit of kebeles) proportional to the size of the household. Sample size was determined for a larger study on identifying factors associated with PFD. With an assumption of 95% CI, power 80, and prevalence of PFD among nulliparous women of 13% and of parous at 18% [23], and a design effect of two, a sample size of 3444 was calculated. The adequacy of the sample to determine the magnitude of PFD was checked. Kersa HDSS database was used as a sampling frame: the name of the selected women and their household ID was retrieved from the database and printed in hardcopy for use in the field.

A structured data collection tool was customized and adapted from the literature [12, 24, 25]. The questionnaire contained questions about socio-demographic factors, obstetric history and pelvic floor disorder symptoms. Initially, the content of the questionnaire was validated by three gynecologists and two reproductive health experts. The original questionnaire was prepared in English language and later translated into the local languages (Amharic and Afan Oromo) for data collection. Forward and backward translations were performed by two bilingual translators. We pretested the questionnaire in a similar setting and refined the tool based on the feedback we obtained. The questionnaire had good internal consistency (Cronbach alpha ranges from 0.82 to 0.89).

Experienced female data collectors and field supervisors who can speak the local languages fluently were recruited and trained for four days. The training for field workers included field procedures, interviewing techniques and discussion on the content of the data collection tool. A field guide and data collection manual were used as a reference during the training. Field supervisors checked compliance with field procedures and the completeness of questionnaires in the field.

Pelvic floor disorder was assessed based on women’s reporting of symptoms. Each pelvic floor disorder (Stress urinary incontinences (SUI), over active bladder (OAB), pelvic organ prolapse (POP), and anal incontinence (AI)) was dichotomized as present or absent based on responses to each symptom domain. Over active bladder was assessed by asking, “Do you rush to urinate so that you will not have leakage of urine?”, “Do you experience frequent urination?”, “Have you experienced urine leakage related to a feeling of urgency?” Stress urinary incontinence was assessed by asking, “Do you experience urine leakage related to activity, coughing, or sneezing?” and “Do you experience small amounts of urine leakage (drops)?” Pelvic organ prolapse was assessed by asking, “Do you have a sensation that there is a bulge in your vagina or that something is falling out from your vagina?” Anal incontinence was assessed by asking, “Do you lose gas from your rectum that is beyond your control?”, “Do you lose stool beyond your control if your stool is loose or liquid?”, “Do you lose well-formed stool beyond your control?” Positive responses to at least one of the questions from each of the pelvic floor disorder categories defined the presence of the problem. Women who had at least one pelvic floor disorder were categorized as “have PFD” and women who did not report at least one pelvic floor disorder were categorized as “do not have PFD” [12, 24, 25].

To assess the degree of distress caused by the symptoms each PFD symptom question was assessed by a four-point Likert scale. If symptoms were present the individual was asked “How much are you bothered by the symptoms?” and the response was rated from ‘not at all=1’ to ‘quite a bit=4’. The mean value of symptom distress was multiplied by 25 to obtain the score ranges from 0-100 for each domain: bladder symptoms (both OAB and SUI), AI, and POP[26]. Severity of the symptoms among women with PFD was determined based on distress score ranges from 1-100 and categorized by tertiles(in to three part) as ‘mild symptoms’ if the total score was 1-33, ‘moderate’ if the score was 34-66, and ‘severe’ if the score was 67-100[27].

Data were double entered into Epi-Data 3.1 to check consistency and exported to STATA version 14 for analysis. The prevalence of each PFD was calculated by dividing the number of women who reported the symptoms by the total number of women in the study and was reported with 95% Confidence Intervals (CI). The overall prevalence of PFD was calculated by dividing the number of women who reported at least one of the symptoms of PFD by total number of women in the study and reported with a 95% CI. The severity of distress caused by the symptoms was described as mild(1-33), moderate(34-66) and severe(37-100) and presented as a proportion with 95% CI.