Delay in seeking treatment and associated factors among women with pelvic organ prolapse in Bale Zone,Southeast Ethiopia: a hospital-based cross-sectional study

Abstract

Background:

Pelvic organ prolapse (POP) is a major reproductive health problem that severely affects women’s quality of life in several ways. Women who suffer from POP silently wait to heal from their problem without seeking care until the disease progressively worsens.

Objective:

The aim of this study was to assess factors associated with delay in seeking treatment among women with POP at public hospitals in Bale Zone, Southeast Ethiopia.

Design:

Facility-based cross-sectional study.

Methods:

A total of 344 study participants were enrolled at public hospitals in Bale Zone, Southeast Ethiopia, from 20 February to 20 May 2023. A consecutive sampling method was used to select the respondents. Data were collected using a pretested interviewer-administered structured questionnaire. Both bivariable and multivariable logistic regressions were used to identify the predictors of the outcome variable. Both the crude odds ratio (COR) and adjusted odds ratio (AOR) along with a 95% confidence interval (CI) were used to estimate the strength of the association between predictors and the response variable.

Results:

This study revealed that out of 333 participants, 76.9% (95% CI: 72.1, 81.4) were delayed in the treatment of POP. The median time of delay for POP treatments was 36 [interquartile range (IQR): 24–96] months. Being a rural resident [adjusted odds ratio (AOR) = 2.02, 95% CI: 1.23, 4.00], autonomous decision-making (AOR = 5.46, 95% CI: 2.30, 10.85), lack of support (AOR = 3.94, 95% CI: 1.64, 9.48), an embarrassment to see male health care providers (AOR = 2.04, 95% CI: 1.09, 3.81), and a lack of knowledge about successful POP treatment (AOR = 2.29, 95% CI: 1.27, 4.14) were significantly associated with delay of treatment for POP.

Conclusion:

A large number of women with POP did not seek health care in this study: Being in rural, autonomous decision-making, a lack of support, an embarrassment to see male health care providers, and a lack of knowledge on successful treatment were associated with treatment delay. Educating women and the community to make them aware that it is a treatable condition and encourage women’s independence in decision-making on health care services in the family will improve their quality of life.

Keywords

delay diagnosis Ethiopia health care seeking pelvic organ prolapse

Introduction

Pelvic organ prolapse (POP) is an anatomical defect in which one or more of the woman’s pelvic organs, such as the bladder, uterus, vaginal cuff, rectum, and intestine descends through the vagina.^1,2 It is measured relative to the hymen scaled from 0 to IV according to the simplified pelvic organ prolapse quantification (S-POP) staging system.³ The sensation of ‘something coming down’ and pelvic pressure, lower back pain, vaginal pain, urinary incontinence, and constipation have been identified as symptoms of POP, which usually worsen with exertion and ease with bed rest.^1,4 Symptoms alone cannot definitively diagnose the degree of prolapse as determined by pelvic examination. Therefore, women with symptoms suggestive of prolapse should undergo a thorough medical history and complete pelvic examination.^3,5

POP has been a major public health problem worldwide, affecting approximately 316 million women of reproductive age and menopause.^6,7 This is a major gynecological problem in both high-income countries (HICs) and low- and middle-income countries (LMICs) with a surprising impact on women’s health and quality of life.⁸ Determining the true prevalence of POP is difficult due to the disparities in definitions and techniques of diagnosis in both the literature and clinical settings. Worldwide, the rates range from 9.1% with symptoms-based diagnosis to 64.6% with clinically based diagnosis.^9,10

In the United States, symptomatic POP affects 6–7% of women.¹¹ The burden of POP is estimated to be close to 20% in LMICs,¹² with Ethiopia showing a highly variable prevalence ranging from 1% to 56.4%^13,14 and an estimated pooled prevalence of 23.52%.¹⁵ Notably, only 3.2% of patients with advanced stages of POP visited care at hospitals.¹³

POPs and other forms of pelvic floor disorders are viewed as extremely sensitive, repulsive, and shameful conditions, which further restrict women’s health care-seeking behavior and make many women silent victims of the problem.^16,17 A majority of women with POP progress to the more severe form and many need surgery by the time they seek treatment.¹⁸ Most women in Ethiopia stay at home to hide their problems even from their close partners despite the availability of treatment facilities for their condition in the country.¹³ A recent hospital-based study in Northwest Ethiopia found that nearly 83% of hospitalized women with prolapse delayed seeking help for an average of more than 7 years.¹²

Essentially, delaying the POP treatments exacerbates the problem, leading to severe physical disability; for instance, inability to work, difficulty walking or standing, difficulty urinating or defecating, painful intercourse, increased social stigma, and economic deprivation also affect the physical and mental health of women and can be fatal if left untreated.^13,19 However, large segments of the population, particularly those living in rural areas, have been found to be unable to reach health facilities due to distance, cost, limited knowledge of the existing treatment, and the social stigma associated with the condition.^12,17

According to a few studies, factors such as lack of support, low income, low literacy, embarrassment, availability and affordability of health services, and fear of loss of social value or stigmatization are associated with delays in treatment.^12,17,18 However, there is limited evidence that shows factors hindering early treatment of POP in the study settings. Notably, identifying the factors that are really associated with delay in seeking treatment for POP is very important to initiate responsible bodies to facilitate early treatment. Therefore, this study aimed to assess factors associated with delay in seeking treatment among women with POPs in public hospitals in Bale Zone, Southeast Ethiopia.

Materials and methods

Study design, settings, and subjects

An institutional-based cross-sectional study was conducted in the public hospitals in Bale Zone, Southeast Ethiopia, from 20 February to 20 May 2023. The study’s reporting follows the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.²⁰ Bale Zone is located in Southeast Ethiopia. Robe, the Zone city, is located 435 km from the capital town of Ethiopia, Addis Ababa. The Bale zone has 18 districts, of which three are town administrations, and of the rural districts, nine are agrarian and nine are agro-pastoralist. According to the Bale Zonal Health Department’s estimate, the zone had a total population of 1,888,366 of which 936,630 were women. A total of five public hospitals were found in the zones, namely: Madda Walabu University Goba Referral Hospital (MWUGRH), Robe General Hospital, Goro Primary Hospital, Delo Mena General Hospital, and Madda Walabu Primary Hospital, which is under the town administration.

All gynecologic patients diagnosed with POP in public hospitals in Bale Zone, Southeast Ethiopia, were the source population. However, all gynecologic patients diagnosed with POP during the data collection period in selected public hospitals in Bale Zone, Southeast Ethiopia, were the study population. All gynecologic patients diagnosed with POP at selected public hospitals in Bale Zone during data collection time were included in the study. However, participants who had a verbal communication problem and complete loss of hearing at the time of data collection were excluded from the study.

Sample size determination and sampling techniques

The sample size was calculated using a single population proportion formula with the assumption of a 95% confidence interval (CI), a 5% margin of error, and based on the previous literature.¹⁷

Sample size calculation using p of the magnitude of women with POP = 84.6%

n = \frac{{(Z α / 2)}^{2} P (1 - p)}{d^{2}}

n = (1.96)² 0.846 (1 − 0.846)/0.04² = 313. The sample size of the first objective was greater than that of the second objective. Hence, by adding a 10% nonresponse rate to the sample size of the first objective (n = 313), the final sample size for this study was 344 (Supplementary Table 1).

All hospitals in Bale Zone, namely Madda Walabu University Goba Referral Hospital, Robe General Hospital, Goro Primary Hospital, and Delo Mena General Hospital, were included in the study. The allocation of the sample was done for those hospitals proportionally based on the average number of clients who attended services at each facility. Participants were selected by consecutive sampling methods in hospitals.

Study variables

Dependent variable: delay in seeking treatment for POP.

Independent variables: Socio-demographic characteristics: age, marital status, place of residence, occupation, educational status, household educational status, monthly income, social support, decision-making power; Facility-related characteristics: availability of health facilities, distance from them, availability of roads and means of transportation, and shyness or embarrassment to see health care providers of any gender, as well as knowledge toward POP.

Data collection tools and procedure

Data were collected using structured questionnaires which were developed after reviewing similar literature.^12,17,21 To assess objective findings, physicians first took the surgical and medical history of the patients. Then, they performed vaginal examinations and diagnoses. Based on the Standardized Pelvic Organ Prolapse Quantitative Examination Tool, physicians determined the stages of POP. In this technique, the hymen ring is used as reference point also called the half way system scaled from 0 to IV.³ The stages of POP were presented in Supplementary Table 2. After the physician decided on management, participants were interviewed. Four Bachelor of Science (BSc) midwives data collectors were assigned from outside of the selected health facility and four Master of Science (MSc) midwives or nurse supervisors were involved in the data collection process.

Data quality control

Before starting the actual survey, the quality of the data was assured by pretesting the questionnaires on 5% (17 study participants) of the total sample size in Ginnir General Hospital. According to the results of the pretest, the questionnaires were further modified by adding more questions and increasing clarity of the questions. Data collectors and supervisors were trained on the aim of the research, the content of the questionnaire, and ethical issues to increase their performance in field activities for 2 days before data collection. Throughout the course of data collection, the data collectors were supervised and there was regular phone contact between the lead author and supervisors to discuss and correct the problems that were raised during the data collection period.

Operational definition

Delayed treatment of POP: This is defined as a lapse of 12 months or more in the time from the onset of symptoms, persistent or recurrent symptoms after prior intervention or treatment, or being informed of the condition by a primary care provider to the first visit in our urogynecology practice.^22,23

Early treatment of POP: Pelvic organ prolapse cases that stayed less than 12 months to get treatment were considered ‘early’.²³

Statistical analysis

The collected questionnaires were checked for completeness before data entry and then the questionnaires were coded and entered into Epi Data Version 4.6. After the entry was completed, the data were exported to SPSS version 25.0 and cleaned before analysis. Descriptive statistics were used for the data presentation. The normality of data distribution was checked using Shapiro–Wilk test. Binary logistic regression analysis was used to identify candidate variables for multivariable logistic regression. Variables with a p-value less than 0.25 in the bivariable logistic regression analysis were exported into a multivariable logistic regression model to control potential confounding effect. Both the crude odds ratio (COR) and adjusted odds ratio (AOR) along with a 95% CI were used to estimate the strength of the association between predictors and the response variable. Multicollinearity tests were checked among predictors [variance inflation factor (VIF) = 2.889]. The goodness of fit of the final model was checked using the Hosmer–Lemeshow goodness-of-fit test (p value = 0.639). Finally, variables with a p-value of less than 0.05 during multivariable logistic regression analyses were used to declare statistical significance.

Results

Socio-demographic characteristics

In this study, 344 study participants were recruited, and 333 participants completed the study, making a response rate of 97%. The mean age of the participants was 47.14 years (SD ± 10.78 years), with a range of 23 to 70 years old. About 181 (54.4%) of participants were rural residents and 151 (45.3%) were housewives. Most (315; 94.6%) of the participants were married, and nearly one-fifth of the study participants (64; 19.2%) cannot read or write. One hundred twenty-five (37.5%) study participants have high decision autonomy on their own (Table 1).

Table 1.

Socio-demographic characteristics of the participants at public hospitals in Southeast, Ethiopia, 2023 (N = 333).

Characteristics		Frequency	Percent
Age of respondent	<35	55	16.5
	35–45	92	27.6
	⩾45	186	55.9
Residence	Urban	152	45.6
	Rural	181	54.4
Educational status of the women	Can’t read and write	64	19.2
	Primary school	131	39.4
	Secondary school	101	30.3
	Diploma and above	37	11.1
Occupation of the women	House wife	151	45.3
	Merchant	79	23.7
	Daily labor	56	16.8
	Employed	47	14.1
Marital status	Married	315	94.6
	Divorced	11	3.3
	Widowed	7	2.1
Educational status of the husband	Can’t read and write	38	11.4
	Primary school	123	36.9
	Secondary school	119	35.8
	Diploma and above	53	15.9
Occupation of the husband	Farmer	121	36.3
	Merchant	95	28.5
	Daily labor	52	15.6
	Employed	65	19.6
Decision autonomy	No decision autonomy	94	28.2
	Moderate decision	114	34.2
	High decision autonomy	125	37.6

Facility-related characteristics

Two hundred thirty (69.1%) participants reported that there was a health facility close to their kebele of residence while the remaining had to travel a significant distance to access health care services. One hundred ninety-seven (59.2%) of the study participants have money for transportation, and 228 (68.5%) of the study participants used public transportation to get to the health facility. About one-fourth of the study participants reported that the reason for the transportation problem was expensive (Supplementary Table 3).

Magnitude of delay in seeking treatment

Out of 333 POP cases, over one-third (128 participants) were in stage II, while 29.1% and 26.4% of those seeking treatment were in stages III and IV, respectively (Table 2). The proportion of women who delayed seeking treatment for POP was 76.9% (95% CI: 72.1, 81.4). The median time of delay for POP treatments was 36 [interquartile range (IQR): 24–96] months (Figure 1).

Table 2.

Summary of stages of pelvic organ prolapse patients in public hospitals in Southeast Ethiopia, 2023 (N = 333).

Stage	Frequency	Percentage
Stage I	20	6.0
Stage II	128	38.4
Stage III	97	29.1
Stage IV	88	26.4

Figure 1.

Magnitude of delay in seeking treatment for pelvic organ prolapse at the public hospitals in Southeast Ethiopia, 2023 (N = 333).

Factors associated with delays in seeking treatment for pelvic organ prolapse

In the bivariable logistic regression analysis, being in rural resident, cannot read and write, primary school education, decision autonomy, social support, availability of health facility, lack of money, an embarrassment to see male health care providers, and a lack of knowledge about successful POP treatment were significantly associated with a delay in seeking treatment for POP. Variables found to be significantly associated with delay in seeking treatment for POP.

In multivariable logistic regression, being a rural resident (AOR = 2.02, 95% CI: 1.23, 4.00), autonomous decision-making (AOR = 5.46, 95% CI: 2.30, 10.85), lack of support (AOR = 3.94, 95% CI: 1.64, 9.48), an embarrassment to see male health care providers (AOR = 2.04, 95% CI: 1.09, 3.81), and a lack of knowledge about successful POP treatment (AOR = 2.29, 95% CI: 1.27, 4.14) were significantly associated with the delay of treatment for POP (Table 3).

Table 3.

Bivariable and multivariable logistic regression analyses of factors associated with delay in seeking treatment of POP patients in public hospitals in Southeast, Ethiopia, 2023 (N = 333).

Characteristics		Seek treatment
Characteristics		Delayed	Early	COR (95% CI)	AOR (95% CI)	p-value
Residence	Urban	106	46	1	1
	Rural	150	31	2.10 [1.25, 3.52]	2.02 [1.23, 4.00]	0.008
Educational status of the women	Can’t read and write	54	11	3.50 [1.61, 10.50]	2.79 [0.93, 8.36]	0.065
	Primary school	107	27	2.83 [1.29, 4.62]	2.41 [0.96, 6.05]	0.06
	Secondary school	74	24	2.20 [0.98, 4.93]	1.62 [0.63, 4.17]	0.315
	Diploma and above	21	15	1	1
Decision autonomy	No decision	85	9	5.49 [2.52, 11.96]	5.46 [2.30, 10.85]	0.000
	Moderate decision	92	22	2.43 [1.34, 4.39]	1.98 [1.01, 3.86]	0.045
	Highly decision	79	46	1	1
Social support	Low support	69	14	4.60 [2.12, 9.95]	3.94 [1.64, 9.48]	0.002
	Moderate support	157	35	4.18 [2.22, 7.87]	3.56 [1.70, 7.46]	0.001
	High support	30	28	1	1
Availability of health facility	Yes	169	61	1	1
	No	87	16	1.96 [1.06, 3.60]	0.93 [0.38, 2.28]	0.877
Money for transport	Yes	141	56	1	1
	No	115	21	2.17 [1.24, 3.80]	1.81 [0.80, 4.08]	0.148
Embarrassment to see a male health care provider	No	133	51	1	1
	Yes	123	26	1.81 [1.06, 3.08]	2.04 [1.09-3.81]	0.026
It has no successful treatment	No	99	42	1	1
	Yes	157	35	1.90 [1.13- 3.18]	2.29 [1.27, 4.14]	0.006
It will improve on its own	No	30	17	1
	Yes	226	60	2.13 [1.10, 4.12]	2.13 [0.96, 4.71]	0.061

Reference category.

AOR, adjusted odds ratio; CI, confidence interval; COR, crude odds ratio.

Discussion

This study aimed to assess factors associated with delay in seeking treatment among women with POP at selected public hospitals in Southeast Ethiopia. The finding showed that 76.9% of women were delayed in seeking treatment for POP. The median time of delay for POP treatments was 36 (IQR: 24–96) months.

This finding is lower than the study conducted in Gondar¹² and Southern Ethiopia.^17,24 The possible reasons might be due to methodological differences. In this study, we used a facility-based cross-sectional study, unlike the previous study in Gondar which used a community-based screening and search campaign for POP. As a consequence of this, many cases of POP may have been surveyed for treatments, and several cases with longer duration may contribute to the high value of estimates. This is due to the fact that in the community we can find women who hide the problem for long periods of time due to shyness or embarrassment. Another reason could be that this study used the duration of the onset of symptoms to measure the outcome variable unlike a study conducted in Southern Ethiopia that used the management options to measure the outcome variable.

This finding is higher than other studies conducted in the United States²⁵ and United Arab Emirates.²⁶ The possible reasons might be due to differences in cultural background and living standards among the population.

Accordingly, this study found that rural residents, decision autonomy, lack of social support, embarrassment to see male health care providers, and a lack of knowledge about successful POP treatment were significant factors associated with delayed treatments of POP patients.

Participants who had lived in rural areas had higher odds of delays in seeking treatment for POP compared with their counterparts. The possible explanation for this is that women residing in rural areas are having trouble in accessing health sectors, health professionals, and mass media. As a result, knowledge about POP in the rural population may decrease, which leads to delays in seeking early treatment.²⁷

Moreover, those respondents who had no decision autonomy had higher odds of delays in seeking treatment for POP compared with those who had high decision autonomy. This finding is supported by another study conducted in Eastern Ethiopia concerning women’s health-seeking behavior for pelvic floor disorders.²¹ The possible explanation for this is that women’s empowerment is likely to increase their ability to seek and use health services for their problems. However, those women who cannot decide autonomously on their own health have had no better understanding of treatment and improvement in well-being, which results in delay in seeking treatment.²⁸

Women who mentioned lack of support as the reason for the delay were 3.57 times more likely to delay seeking treatment for POP compared with those who did not mention lack of support as the reason for the delay. This is agreed with the report from the study of southern Ethiopia, which explained that lack of support was associated with delaying the treatments.^17,24 The possible justification for this is that services for POP, including transportation, are not as free as other maternal health services. As a result, women who do not have a person who supports them financially and emotionally were unable to pay for health services, transportation, food, and other costs.

Additionally, women who mentioned embarrassment to seeing a male health care provider as the reason for delay were 2.04 times more likely to delay seeking treatment for POP compared with those who did not mention. This finding is supported by other studies conducted in India²⁹ and United Arab Emirates.²⁶ The possible explanation for this is that POP involves a sensitive part of the body. As a result, a culture of silence and shame regarding reproductive health prevents women from discussing the issue because they fear being judged by their families and community, which results in delaying the decision to seek care.

Women who have lack of knowledge about successful POP treatment were 2.296 times more likely to delay seeking treatment for POP compared with their counterparts. This finding is supported by the study conducted on African American women.³⁰ Obviously, such thinking would discourage women from seeking medical advice.

Strength and limitations of the study

This study has provided insights into a better understanding of the POP issue needs of this particular population, which has not been studied previously. Additionally, conducting clinical examination and obtaining complete medical histories of the patients are the strengths of this study. Nevertheless, there were some limitations to this study. Since delays were measured by time based on client responses’ estimations, they can be overestimated or underestimated. Besides, since an interviewer-administered questionnaire was used to collect data, it might be subject to recall bias.

Conclusion

In this study, three out of every four women with POP delayed seeking treatment. Being a rural resident, lack of decision autonomy, lack of social support, embarrassment at seeing male health care providers, and lack of knowledge about successful POP treatment were significantly associated with the delay in seeking treatment among women with POP. To fight the problem, health care professionals have a significant role in educating women regarding POP to make them aware that it is a treatable condition and counseling women on available treatment options that can improve their quality of life. In addition, it is important to design teaching campaigns according to the cultural backgrounds of each society to address these sensitive issues. Furthermore, it is important to encourage women’s independence in decision-making on health care services in the family as well as in the community.

Supplemental Material

sj-docx-1-reh-10.1177_26334941241266921 – Supplemental material for Delay in seeking treatment and associated factors among women with pelvic organ prolapse in Bale Zone, Southeast Ethiopia: a hospital-based cross-sectional study

Supplemental material, sj-docx-1-reh-10.1177_26334941241266921 for Delay in seeking treatment and associated factors among women with pelvic organ prolapse in Bale Zone, Southeast Ethiopia: a hospital-based cross-sectional study by Neway Ejigu, Kenbon Seyoum, Degefa Gomora, Chala Kene, Sheleme Mengistu, Girma Geta, Mujib Abdella, Alemitu Ayele, Yaregal Admasu, Ayinamaw Embiale, Telila Mesfin, Derese Eshetu, Wondu Shifera, Tadele Wardofa, Daniel Atlaw, Negussie Sarbecha and Girma Beressa in Therapeutic Advances in Reproductive Health

Supplemental Material

sj-docx-2-reh-10.1177_26334941241266921 – Supplemental material for Delay in seeking treatment and associated factors among women with pelvic organ prolapse in Bale Zone, Southeast Ethiopia: a hospital-based cross-sectional study

Supplemental material, sj-docx-2-reh-10.1177_26334941241266921 for Delay in seeking treatment and associated factors among women with pelvic organ prolapse in Bale Zone, Southeast Ethiopia: a hospital-based cross-sectional study by Neway Ejigu, Kenbon Seyoum, Degefa Gomora, Chala Kene, Sheleme Mengistu, Girma Geta, Mujib Abdella, Alemitu Ayele, Yaregal Admasu, Ayinamaw Embiale, Telila Mesfin, Derese Eshetu, Wondu Shifera, Tadele Wardofa, Daniel Atlaw, Negussie Sarbecha and Girma Beressa in Therapeutic Advances in Reproductive Health

Supplemental Material

sj-docx-3-reh-10.1177_26334941241266921 – Supplemental material for Delay in seeking treatment and associated factors among women with pelvic organ prolapse in Bale Zone, Southeast Ethiopia: a hospital-based cross-sectional study

Supplemental material, sj-docx-3-reh-10.1177_26334941241266921 for Delay in seeking treatment and associated factors among women with pelvic organ prolapse in Bale Zone, Southeast Ethiopia: a hospital-based cross-sectional study by Neway Ejigu, Kenbon Seyoum, Degefa Gomora, Chala Kene, Sheleme Mengistu, Girma Geta, Mujib Abdella, Alemitu Ayele, Yaregal Admasu, Ayinamaw Embiale, Telila Mesfin, Derese Eshetu, Wondu Shifera, Tadele Wardofa, Daniel Atlaw, Negussie Sarbecha and Girma Beressa in Therapeutic Advances in Reproductive Health

Supplemental Material

sj-docx-4-reh-10.1177_26334941241266921 – Supplemental material for Delay in seeking treatment and associated factors among women with pelvic organ prolapse in Bale Zone, Southeast Ethiopia: a hospital-based cross-sectional study

Supplemental material, sj-docx-4-reh-10.1177_26334941241266921 for Delay in seeking treatment and associated factors among women with pelvic organ prolapse in Bale Zone, Southeast Ethiopia: a hospital-based cross-sectional study by Neway Ejigu, Kenbon Seyoum, Degefa Gomora, Chala Kene, Sheleme Mengistu, Girma Geta, Mujib Abdella, Alemitu Ayele, Yaregal Admasu, Ayinamaw Embiale, Telila Mesfin, Derese Eshetu, Wondu Shifera, Tadele Wardofa, Daniel Atlaw, Negussie Sarbecha and Girma Beressa in Therapeutic Advances in Reproductive Health

Supplemental Material

sj-docx-5-reh-10.1177_26334941241266921 – Supplemental material for Delay in seeking treatment and associated factors among women with pelvic organ prolapse in Bale Zone, Southeast Ethiopia: a hospital-based cross-sectional study

Supplemental material, sj-docx-5-reh-10.1177_26334941241266921 for Delay in seeking treatment and associated factors among women with pelvic organ prolapse in Bale Zone, Southeast Ethiopia: a hospital-based cross-sectional study by Neway Ejigu, Kenbon Seyoum, Degefa Gomora, Chala Kene, Sheleme Mengistu, Girma Geta, Mujib Abdella, Alemitu Ayele, Yaregal Admasu, Ayinamaw Embiale, Telila Mesfin, Derese Eshetu, Wondu Shifera, Tadele Wardofa, Daniel Atlaw, Negussie Sarbecha and Girma Beressa in Therapeutic Advances in Reproductive Health

Footnotes

Acknowledgements

The authors would like to express their thanks to Madda Walabu University for giving us opportunity to conduct this research. The authors would also like to thank the hospital medical directors, supervisors, and study participants.

Declarations

ORCID iDs

Neway Ejigu

Kenbon Seyoum

Degefa Gomora

Chala Kene

Sheleme Mengistu

Girma Geta

Yaregal Admasu

Daniel Atlaw

Supplemental material

Supplemental material for this article is available online.

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