Prevalence and Associated Factors of Hemorrhoids and Other Perianal Complications During the Puerperium Among Mothers Who Gave Birth at Debre Tabor Referral Hospital,

Puerperium is defined as the period of six weeks after childbirth during which the mother’s reproductive organs return to their original non-pregnant condition. Perianal problems, including constipation, hemorrhoids, and fissures, are among the most common complications among women during the puerperium, observed in about 30 to 50 percent of women. Considering this great prevalence and the paucity of similar research in Ethiopia, this study was done to assess the prevalence of perianal problems during the puerperium and the risk factors associated with them. Methods : An institution-based cross-sectional study was conducted from February 1 to April 30, 2022. Quota sampling technique was used to select a total of 191 participants. The data were collected and then entered using EPI DATA version 3.1 and exported to STATA 14 for analysis. Bivariable and multivariable logistic regression analyses were performed. Adjusted odds ratio (AOR) with 95% confidence interval was used as a measure of association. Variables having a P-value < 0.05 from the multivariable analysis were considered to have a significant association with the outcome. Results : The total prevalence of all the perianal problems in the puerperium encountered in this study was 22.5% (43 mothers). The perianal problems encountered were fissure [9.4%], followed by hemorrhoids [7.3%]


Introduction
Puerperium is an extremely important period of time for a woman.Extensive physiological, biochemical, and dietary changes occur during pregnancy and puerperium [1] .The body secretes a large amount of progesterone, which causes decreased muscle tone and lower motility of the gastrointestinal tract [2] .About 1/3rd of women after childbirth complain of perianal symptoms.Patients in puerperium show a significant increase in the incidence of peri-anal symptoms compared to the normal population [3] .Perianal problems, including constipation, hemorrhoids, and fissures, are among the most common digestive complications among women in the puerperium.Due to the recurring physical and psychological problems they cause for the patient, these disorders can cause a significant reduction in the life quality of those afflicted with them [4] .
Hemorrhoids are the anastomoses between the superior rectal artery and the superior, middle, and inferior rectal veins that surround the distal rectum and anal canal.They are a distal displacement and venous distention of the hemorrhoidal cushions [5] .Based on location, hemorrhoids are usually classified as internal and external hemorrhoids.Internal hemorrhoids arise above the dentate line and are covered by columnar epithelium, while external hemorrhoids arise below the dentate line and are covered by squamous epithelium [6] .Patients with hemorrhoids are usually asymptomatic, but the common symptoms are bleeding with or without defecation, swelling, mild discomfort or irritation, and pruritus ani.Though some patients need to undergo surgery, many hemorrhoid patients can successfully be treated with conservative medication and ointments [7] .The pathogenesis of hemorrhoids is that a weakening of the anal cushion leads to descent or prolapse of the hemorrhoids and spasm of the internal sphincter [8] .Studies conducted elsewhere indicated that inadequate dietary fiber, constipation, diarrhea, hypertension, high body mass index (BMI), pregnancy, and old age are the commonly identified risk factors for the development of hemorrhoids [9] .
Considering the great prevalence of perianal problems during the puerperium and the paucity of similar research conducted in Ethiopia, we aim to assess the prevalence of various perianal problems seen in women during their puerperal period and the risk factors associated with them.

Population and Sample Size Determination
The source population of the study was all pregnant women in Debre Tabor town in the year 2022.The study population was all mothers giving birth during the time of data collection at Debre Tabor Specialized Hospital.Mothers who were unable to communicate and severely ill were excluded from the study.The sample size was determined using a single population proportion formula by using a 95% confidence interval, 0.05 margin of error, 10% non-response rate, and a pvalue of 0.13 (13% prevalence of hemorrhoids in adult patients visiting the surgical OPD of Gondar Specialized Hospital).
Therefore, the final sample size was 191, and participants were selected using the quota sampling technique.

Variables and Data Collection Procedures
The main outcome variables of this study were perianal problems.Patients were diagnosed based on history and anorectal examination, which includes inspection, digital examination, and anoscopy.The first group of factors assessed was socio-demographic characteristics, including age, residence, educational status, occupation, and average monthly income.The second was clinical factors, which included a family history of hemorrhoids and a history of constipation during pregnancy.The third group of characteristics assessed was behavioral and obstetric factors, mainly focused on mode of delivery, parity, length of 2 nd stage of labor, previous history of perianal disease, and baby body weight.
Constipation means unsatisfactory defecation characterized by infrequent stool, difficulty in defecation, or both, at least for the previous 3 months [10] .

Ethical Approval
The study was approved by the ethical review committee of health science college, Debre Tabor University.Verbal informed consent was taken from all mothers enrolled in the study.written informed consent was not taken, since most of the participants were unable to read and write.The verbal consent was taken after a brief description about the main aim of the research.

Socio-demographic and clinical Characteristics of Study Participants
More than half (53.4%) of mothers live in rural setting, 48.7% of mothers are in the age range of 15-29 and 44.5% of mothers are farmers.Most of mothers (96.9 %) are followers of Orthodox and 39.3% of mothers are uneducated.By comparative analysis of suspected risk factors for perianal diseases in the puerperium, it was found that a positive family history, macrosomia, past history of perianal diseases, and prolonged second stage of labor (>50 minutes) showed a higher prevalence in the perianal disease group as compared to the healthy group, of which a positive family history of perianal diseases [p=0.035] and past history of perianal diseases [p=0.012] were the risk factors that were statistically significant, as seen in Table 3.A statistically significant relationship was observed between the prevalence of hemorrhoids and parity [p=0.02] and past history of any anorectal disorders (p=0.04).Mothers with constipation in pregnancy have a higher chance of hemorrhoids in pregnancy.This was statistically significant [p=0.01].There was no significant statistical relationship between the prevalence of hemorrhoids and the type of current mode of delivery or a family history of any anorectal disorders, prolonged length of the second stage of labor, or the presence of hemorrhoids during the puerperium.

Discussion
In this study, the prevalence of hemorrhoids in puerperal subjects is 7.3%.This finding was in agreement with studies done by Poskus et al [1] , Rabindranath and Rahul [3] , Sheikh et al [8] , and Kibret et al [11] .Most of these studies were believed to be overestimated; this can be attributed to the fact that many studies had an anal examination done during pregnancy.
We have found that with increasing parity, the likelihood of developing hemorrhoids is high.This was similar to findings from Martinez et al [2] , Gardner et al [6] and Zhang et al [10] .This increment in hemorrhoid risk with increased parity might be attributed to the repeated change in the environment and emotional stress on repeated pregnancies causing constipation and further hemorrhoids in subsequent pregnancies [2] .It can also be attributed to increased vascular growth factors in consequent pregnancies [12] .
In this study, we found that a past history of perianal problems was found to increase the risk of hemorrhoids in pregnancy and puerperium, which was also seen in studies done by Zagriadskii et al [9] , Martinez et al [2] , Rampal et al [7] , and Kibret et al [11] .This could be attributed to the increase in hemorrhoidal symptoms as pregnancy progresses, since circulating blood volume reportedly increases by 25-40% [9] .This leads to increased vascular engorgement and dilatation, with venous stasis increased by the enlarging gravid uterus or increased pelvic floor laxity [6] .
Mothers with a history of constipation during pregnancy were more likely to develop hemorrhoids as compared to those who did not have constipation during their pregnancy.This was in line with findings by Zhang et al [10] , Oumar et al [5] and Godeberge et al [9] .This might be due to intensive straining during defecation, impairment of defecation habits during pregnancy, decrease in physical activity, compression of the lower bowel by the uterus, and psycho-social stress [10] .It might also be due to pregnancy-induced increment in intraabdominal pressure, which leads to vascular engorgement [13] .We found that mothers who gave birth to heavier babies [>4000 grams] were associated with the development of anal fissures during the puerperium.This was in agreement with findings from Oumar et al [5] , Zhang et al [10] and Beksac et al [4] .This might be due to decreased blood flow in the anal mucosa due to a heavier baby in pregnancy, which in turn causes higher chances of fissure in the puerperium [14] .Heavier babies can cause increased perineal tears, causing higher chances of developing fissures [9] .

Conclusion
We found a slightly higher prevalence of hemorrhoids among mothers during the puerperium period.This was the first study conducted as far as our search is concerned.Past history of perianal diseases, history of constipation during pregnancy, and increased parity were found to be independent risk factors for perianal disease during the puerperium.
Multiparous mothers and patients with past history of perianal diseases have a higher prevalence of hemorrhoids in the puerperium.Mothers with prolonged second stage of labor and macrosomic babies are more likely to develop hemorrhoids during the puerperium.
Hemorrhoids and other perianal problems that occur during the puerperium can cause intensive physical and psychological issues in mothers, which can directly deteriorate the quality of life of mothers.The elimination of these risk factors may lead to a higher quality of life during pregnancy and the puerperium.

Recommendation
Local health care facilities and international NGOs working on women's affairs should focus on minimizing the risk factors of hemorrhoids and other perianal problems.
Mothers should have been advised on the control and prevention mechanisms of constipation and hemorrhoids during their ANC follow-up and other medical visits during pregnancy.
A large-scale and holistic study should be conducted on the prevalence, determinants, and causes of perianal problems encountered during the puerperal period. Abbreviations

Table 3 .
Risk Factors for Perianal Problems During Puerperium