Comments on “Prevalence and risk factors for pelvic floor disorders in Ethiopian women: Systematic review and meta-analysis”

To the Editor,

Geta et al. ¹ offer a timely synthesis of pelvic floor disorders among Ethiopian women and address an important gap in women’s health evidence from a low-resource setting. The review has notable strengths, including broad database searching, duplicate screening and extraction, and attempts to explore heterogeneity through subgroup and sensitivity analyses. These features increase the practical value of the review for clinicians and public health researchers.

Several methodological issues, however, merit cautious interpretation of the pooled results. The search dates are internally inconsistent, and parts of the methods section appear duplicated, which limits reproducibility. In addition, a completed review would be more appropriately aligned with Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) 2020 rather than PRISMA-Protocols. ² The headline pooled prevalence also combines distinct conditions such as pelvic organ prolapse, urinary incontinence, and fecal incontinence, assessed using different diagnostic approaches across primary studies. In prevalence meta-analysis, such clinical and methodological heterogeneity can make a single pooled estimate difficult to interpret, particularly when I² is extreme and discussed mainly through conventional thresholds rather than through a fuller exploration of between-study variability. ³

A further concern relates to appraisal and synthesis across mixed observational designs. The review includes both cross-sectional and case-control studies, yet the risk-of-bias approach is presented largely as a numerical checklist threshold. Contemporary Joanna Briggs Institute (JBI) guidance emphasizes design-specific appraisal focused on bias domains rather than simple summary scores. ⁴ Similarly, pooled associations for risk factors require careful justification that the underlying exposures, outcome definitions, and adjustment strategies are sufficiently comparable. When studies address materially different questions or measurements, quantitative pooling may suggest greater precision than the evidence can support. ⁵ These issues do not diminish the importance of the review, but they do suggest that its summary estimates should be interpreted as provisional and hypothesis-generating rather than definitive.

A revised analysis with clearer reporting, design-specific bias assessment, and more conservative handling of heterogeneity would strengthen confidence in this otherwise valuable contribution.