Abstract
Background
Peripartum hysterectomy is the removal of the uterus during a cesarean section, after vaginal delivery, or during puerperium. It is usually performed as a life-saving emergency during abnormal placentation, hemorrhage, or uterine rupture. It has a substantial role in the prevention of maternal mortality and morbidity. This study aimed to identify the determinants of emergency peripartum hysterectomy at Hawassa University Comprehensive Specialized Hospital, Ethiopia.
Methods
A hospital-based, unmatched case-control study was conducted among 66 cases and 198 controls with a case-to-control ratio of 1:3 in HUCSH from September 2018 GC to September 2022 GC. A pre-tested checklist was used, and data was collected using the ODK (open data kit). The data was downloaded, exported to XLS and imported to SPSS Version 26 for further analysis. The association between independent variables and peripartum hysterectomy was estimated using an odds ratio with 95% confidence intervals. The statistical significance of the association was declared at a P-value < 0.05.
Results
The results showed that women with parity ≥ 5 times [AOR: 3.34), 95%CI: (1.17–9.49], previous cesarean section history [AOR = 3.15, 95%CI: (1.26–7.89], labor abnormality[AOR = 4.54, 95%CI: (1.87–11.01], post-partum hemorrhage [AOR = 5.63, 95%CI: (2.07–15.3)]and fetal mal-presentation [AOR = 4.75, 95%CI: (1.48–15.31)] were associated with emergency peripartum hysterectomy.
Conclusion
In this study, grand multiparity, history of cesarean section, postpartum hemorrhage, labor abnormality, and fetal malpresentation were factors that significantly increased the odds of undergoing peripartum hysterectomy. So, improvement in the intrapartum and postpartum quality of obstetric care delivered is recommended.
Keywords: Hysterectomy, Malpresentations, Peripartum, Labor abnormality, Uterine atony
Back ground
Emergency peri-partum hysterectomy (EPH) is defined as the removal of the uterus either at the time of cesarean section, following vaginal delivery, or within the puerperium period [1, 2]. Historically performed for sterilization, it has become primarily a life‑saving procedure for severe obstetric hemorrhage, most often caused by uterine atony, rupture, or morbidly adherent placenta [3]. EPH can be rightly classified as a near-miss event, refers to a situation where a woman nearly dies but survives a complication during pregnancy, childbirth, or within 42 days of termination of pregnancy [4]. However, it has been associated with complications, including massive blood transfusion and intensive care (10–48%), urological injury (8%), and the need for relook laparotomy (8–18%) [5].
The incidence of EPH varies by indication, ranging from 1 to 4 per 1000 cesarean sections, and is significantly higher than after vaginal delivery [5, 6]. Over time, the indications for peripartum hysterectomy have shifted: in developing countries, uterine atony and rupture remain the leading causes, whereas in developed countries, abnormal placental invasion is the predominant indication [7]. In an Australian study, the leading indications for EPH were abnormal placentation (66.7%), uterine atony (30.6%), and uterine rupture (12.5%) [1]. In contrast, an Ethiopian study reported uterine rupture (60%) as the major indication, followed by uterine atony (21.9%) and abnormal placentation (14.7%) [8]. The prevalence of the EPH ranges from 0.2 per 1000 deliveries in Norway to 11 per 1000 deliveries in Nigeria [1, 9, 10]. There is only one study in Ethiopia where the incidence is 2.6 per 1000 deliveries [7].
Multiple antepartum, intrapartum, and postpartum factors have been associated with the prevalence of EPH across studies from different countries. Antepartum and sociodemographic factors include maternal age, rural residency, multiparity, ANC follow‑up, antepartum hemorrhage, preeclampsia, and previous cesarean Sects [8–17]. Intrapartum factors such as uterine atony, postpartum hemorrhage of any cause, uterine rupture, malpresentation, fetal weight, and obstructed labor are also strongly linked to EPH [8–10, 13, 14, 16–20]. Since most of these are modifiable, identifying them and implementing targeted improvements represents a key strategy for reducing the burden and complication of EPH. This study seeks to identify the common risk factors associated with emergency peripartum hysterectomy among women who delivered at HUCSH, addressing the gap in evidence given that only one study has been conducted in Ethiopia despite extensive research in other developing countries and globally.
Study area, period and design
A retrospective, unmatched case‑control study was carried out at Hawassa University Comprehensive Specialized Hospital (HUCSH). It included women who gave birth between August 15 and September 15, 2023. Hawassa is 273 km south of Addis Ababa, the capital of Ethiopia. HUCSH is a tertiary referral center serving an estimated catchment population of 18 million people (unpublished hospital data). The hospital is equipped with 400 beds and manages approximately 5,000 outpatient and emergency visits each month.
Source population
The study population encompassed all women who gave birth at HUCSH and those who received referrals from other facilities due to uncontrollable bleeding or uterine rupture. The cases were all women who underwent peripartum hysterectomy, whereas the controls were all selected women who gave birth (either vaginal or CS (cesarean section)) in HUCSH during the study period. Sample size was calculated using the OpenEpi 7.2 double population proportion formula for case–control design, assuming 80% power, 95% confidence level, a 1:3 case-to-control ratio, and 29.4% [21] exposure among cases. This yielded 215 participants (66 cases and 198 controls). The sampling frame was based on patient registration numbers, with files extracted from operation room and delivery records between September 2018 and September 2022. All women who underwent peripartum hysterectomy were included, resulting in 66 eligible cases. Controls were selected by simple random sampling, with three controls matched to each case.
Inclusion criteria
All deliveries at HUCSH, including referrals, with gestational age ≥ 28 weeks or birth weight ≥ 1000 g.
Exclusion criterion
Women who underwent emergency obstetric hysterectomy during the study period due to complications such as gestational trophoblastic disease (GTD) or second‑trimester uterine rupture.
Incomplete medical records.
Operational definitions
For the purpose of this study, peripartum hysterectomy was defined as the surgical removal of part or all of the uterus performed during childbirth or within six weeks of the postpartum period [8].
Data collection tools and procedure
The data collection tool was adapted from previous studies conducted in different countries and prepared in English. A pre‑tested, structured checklist was developed using Open Data Kit (ODK) and applied to extract information from medical records of women who gave birth at HUCSH during the study period. Two BSc midwives served as data collectors, and one supervisor coordinated and oversaw the process in collaboration with the principal investigator. Prior to data collection, the team underwent a two‑day training that covered the objectives of the study, use of the checklist and ODK software, ethical considerations, and procedures for maintaining data quality. Daily supervision was conducted to ensure adherence to the protocol and consistency in data collection.
Data analysis and processing
The collected data was checked for consistency and completeness, downloaded from the Kobo Toolbox user server, exported to XLS, and then downloaded. Finally, the file was imported to SPSS Version 26 for further analysis. Bi-variable logistic regression analysis was used to see the crude relationship between the dependent and each independent variable and to select candidate variables for multiple logistic regressions. The fitness of the logistic regression model was assessed using the Hosmer–Lemeshow goodness‑of‑fit test (p = 0.329), which evaluates the agreement between observed and predicted probabilities. Multicollinearity was examined using the Variance Inflation Factor (VIF = 4.89) and tolerance (0.3) to ensure that independent variables were not highly correlated, thereby supporting the reliability of the regression estimates. Variables with a bi-variable logistic regression P-value less than 0.25 were included in multi-variable logistic regression. Multi-variable logistic regression was performed to identify independent predictors of emergency peripartum hysterectomy. Statistical significance was declared at a p-value of < 0.05. Descriptive results were summarized in text and tables to emphasize key findings and group comparisons.
Results
Socio-demographic characteristics
A total of 264 mothers were included in the study, comprising 66 cases diagnosed with peripartum hysterectomy and 198 controls without the diagnosis. The data completion rate was 100%. In the majority of the cases, 54(81.82%) mothers were in the age of 20–35 years old and 168(84.85%) of the controls were in the age of 20–35 years old. The median age of the mother was 27 years (IQR 24-30-year-old) (Table 1).
Table 1.
Socio-Demographic characteristics of mother in Hawassa referral hospitals, Sidama, Ethiopia 2023
| Variables | Category | Peripartum hysterectomy status | ||
|---|---|---|---|---|
| Cases N (%) | Controls N (%) | Total | ||
| Age of mothers | < 20 | 7(10.6%) | 23(11.62%) | 30(11.36%) |
| 20–35 | 54(81.82%) | 168(84.85%) | 222(84.09%) | |
| > 35 | 5(7.58%) | 6(3.53%) | 11(4.55%) | |
| Total | 66(100%) | 198(100%) | 264(100%) | |
| Place of residence | Rural | 13(19.7%) | 18(9.09%) | 31(11.74%) |
| Urban | 53(80.3%) | 180(90.91%) | 233(88.26%) | |
| Total | 66(100%) | 198(100%) | 264(100%) | |
| Duration of hospital stay | < 7 days | 39(59.09%) | 191(96.46%) | 230(87.12%) |
| ≥ 7 days | 27(40.91%) | 7(3.54%) | 34(12.88%) | |
| Total | 66(100%) | 198(100%) | 264(100%) | |
Previous and current of obstetrics and gynecological history related characteristic
Around one fourth of mothers who undergo peripartum hysterectomy 16(24.24%) had history of previous CS scar while in controls 22(11.11%) had history of previous CS scar. Majority of mothers in both cases and controls had more than 5 deliveries (Table 2).
Table 2.
Pervious and current of obstetrics and gynecological history related characteristics of mother in Hawassa referral hospitals, Sidama, Ethiopia 2023
| Variables | Category | Status | ||
|---|---|---|---|---|
| Cases N (%) | Controls N (%) | Total | ||
| Previous CS scar | Yes | 16(24.24%) | 22(11.11%0 | 38(14.39%) |
| No | 50(75.76%) | 176(88.89%) | 226(85.61%) | |
| Number of scars | One | 10(62.5%) | 17(77.27%) | 27(71.05%) |
| More than one | 6(37.5%) | 5(22.7%) | 11(20.95%) | |
| Maternal parity | < 5 times | 51(77.27%) | 187(94.44%) | 238(90.15%) |
| ≥ 5 times | 15(22.73%) | 11(5.56%) | 26(9.85%) | |
| ANC follow up | Yes | 61(92.42%) | 192(96.97%) | 253(95.83%) |
| NO | 5(7.58) | 6(3.03%) | 11(4.17%) | |
| Gestational age of current pregnancy | < 37 weeks | 10(5.15%) | 18(9.09%) | 28(10.61%) |
| ≥ 37 weeks | 56(84.85%) | 180(90.91%) | 236(89.39%) | |
| Types of gestation | Singleton | 59(89.39%) | 192(96.97%%) | 251(95.08%) |
| Multiple | 7(10.61%) | 6(3.03%) | 13(4.92%) | |
| APH | Yes | 14(21.21%) | 18(9.09%) | 32(12.12%) |
| No | 52(78.79%) | 180(90.91%) | 232(87.88%) | |
| Types of APH | PP | 6(42.86%) | 5(27.78%) | 11(34.38%) |
| AP | 8(57.14%) | 13(76.22%) | 21(65.62%) | |
| PIH syndrome | Yes | 10(15.16%) | 15(7.58%) | 25(9.5%) |
| No | 56(84.85%) | 183(92.42%) | 239(90.5%) | |
| Placentation | Normal placentation | 32(48.48%) | 192(96.97%) | 224(84.85%) |
| Abnormal placentation | 8(12.13%) | 5(2.53%) | 13(4.92%) | |
| Unknown | 26(39.39%) | 1(0.5%) | 27(10.23%) | |
| Admission diagnosis | In labor | 53(80.3%) | 158(79.8%) | 211(79.92%) |
| Not in labor | 13(19.7%) | 40(20.2%) | 53(20.08%) | |
Intrapartum/Intraoperative and postpartum/post-operative related characteristics
Postpartum hemorrhage (PPH) was observed in 19 cases (28.8%) and in 12 controls (6.1%). Uterine rupture occurred in 42 cases (63.6%) compared to only 1 control (0.5%) (Table 3).
Table 3.
intrapartum/intraoperative and postpartum/post-operative related characteristics of mother in Hawassa referral hospitals, Sidama, Ethiopia 2023
| Variables | Category | Peripartum hysterectomy | ||
|---|---|---|---|---|
| Cases N (%) | Controls N (%) | Total | ||
| PPH | Yes | 19(28.79%) | 12(6.06%) | 31(11.74%) |
| No | 47(71.21%) | 186(95.94%) | 233(88.26%) | |
| Causes of PPH(n = 31) | Atony | 12(63.16%) | 8(66.67%) | 20(64.52%) |
| Other causes | 7(36.84%) | 4(33.33%) | 11(35.48%) | |
| Uterine rapture | Yes | 42(63.64%) | 1(0.51%) | 43(16.29%) |
| No | 24(36.36%) | 197(99.49%) | 221(83.71%) | |
| Mode of deliveries | Vaginally | 14(21.21%) | 130(65.66%) | 144(54.55%) |
| Cesarean section | 12(18.18%) | 67(33.84%) | 79(29.92%) | |
| Laparotomy | 40(60.61%) | 1(0.5%) | 41(15.53%) | |
| Labor Abnormality | Yes | 17(25.76%) | 16(8.08%) | 33(12.5%) |
| No | 49(74.24% | 182(91.92%) | 231(87.5%) | |
| If vaginally delivery | Instrumental | 0 | 3(2.31%) | 3(2.08%) |
| Breach extraction | 1(7.14%) | 1(0.77%) | 2(1.4%) | |
| Destructive | 2(14.28%) | 1(0.77%) | 3(2.08%) | |
| Normal SVD | 11(78.58%) | 125(96.15%) | 136(94.44%) | |
| Types of C/S | Elective | 2(20%) | 8(11.94%) | 10(12.66%) |
| Emergency | 10(80%) | 59(88.06%) | 69(87.34%) | |
| Mal presentation | Yes | 11(16.67%) | 8(4.04%) | 19(7.2%) |
| No | 55(83.33%) | 190(95.96%) | 245(92.8%) | |
| Birth weight of newborn | < 2500 | 15(27.73%) | 25(12.63%) | 40(15.15%) |
| 2500–4000 | 40(60.6%) | 155(78.28%) | 195(73.86%) | |
| ≥ 40,000 | 11(16.67%) | 18(9.09% | 29(10.99%) | |
| Vital sign of mother | Stable | 46(66.7%) | 181(91.41%) | 227(85.98%) |
| Unstable | 20(33.3%) | 17(8.59%) | 37(14.02%) | |
Bi variable & multivariable binary logistic regression model
Bivariable logistic regression was performed for each independent variable, and those with a p‑value < 0.25 were entered into the multivariable model. Candidate variables included antepartum hemorrhage (APH), postpartum hemorrhage (PPH), abnormal labor, mal‑presentation, pregnancy‑induced hypertension (PIH) syndrome, birth weight, parity, maternal age, place of residence, previous uterine scar, antenatal care (ANC) follow‑up, gestational age, type of gestation, and maternal vital signs (Table 4). Multivariable analysis showed that the risk of peripartum hysterectomy was significantly higher among women with parity ≥ 5 (AOR: 3.34: 95% CI (1.17–9.49)), a history of cesarean section(AOR: 3.15; 95% CI (1.26–7.89)), abnormal labor(AOR: 4.54; 95% CI (1.87–11.01)), postpartum hemorrhage(AOR: 5.63: 95% CI (2.07–15.3)), and fetal mal‑presentation( AOR: 4.75 95% CI (1.48–15.31)) compared to those without these conditions. These findings suggest that women with high parity (≥ 5) are at greater risk for peripartum hysterectomy. Similarly, postpartum hemorrhage, previous cesarean section, abnormal labor, and fetal mal‑presentation represent major obstetric challenges that predispose mothers to severe complications, thereby increasing the likelihood of peripartum hysterectomy.
Table 4.
Bi variable & multivariable logistic regression model for the determinants of peripartum hysterectomy in Hawassa referral public hospitals, Hawassa, Ethiopia 2023
| Variables | Category | Peripartum hysterectomy status | OR (95% CI) | ||
|---|---|---|---|---|---|
| Cases N | Controls N | COR (95%CI) | AOR (95%CI) | ||
| Age of mothers | < 20 | 7 | 23 | 0.95(0.39–2.34) | 1.29(0.45–3.69) |
| 20–35 | 54 | 168 | 1 | 1 | |
| > 35 | 5 | 6 | 2.61(0.77–8.89) | 2.58(0.54–12.37) | |
| Place of residence | Rural | 13 | 18 | 2.45(1.13–5.33) | 2.21(0.84–5.83) |
| Urban | 53 | 180 | 1 | 1 | |
| Maternal parity | < 5 times | 51 | 187 | 1 | 1 |
| ≥ 5 times | 15 | 11 | 5.0(2.16–11.55) | 3.34(1.17–9.49) * | |
| Previous CS scar | yes | 16 | 22 | 2.56(1.25–5.24) | 3.15(1.26–7.89) |
| No | 50 | 176 | 1 | 1 | |
| ANC follow up | Yes | 61 | 192 | 1 | 1 |
| NO | 5 | 6 | 2.62(0.77–8.9) | 0.61(0.12–3.27) | |
| Gestational age of current pregnancy | Pre-term | 10 | 18 | 1 | 1 |
| Term | 56 | 180 | 1.79(0.78–4.09) | 1.27(0.36–4.49) | |
| Types of gestation | Singleton | 59 | 192 | 1 | 1 |
| Multiple | 7 | 6 | 3.79(1.23–11.74) | 2.73(0.70-10.66) | |
| Labor Abnormality | Yes | 17 | 16 | 3.95(1.86–8.37) | 4.54(1.87–11.01) * |
| No | 49 | 182 | 1 | 1 | |
| APH | Yes | 14 | 18 | 2.69(1.26–5.78) | 1.18(0.42–3.31) |
| No | 52 | 180 | 1 | 1 | |
| PPH | Yes | 19 | 12 | 6.27(2.84–3.81) | 5.63(2.07–15.3) |
| No | 47 | 186 | 1 | 1 | |
| Mal presentation | Yes | 11 | 8 | 4.75(1.82–12.39) | 4.75(1.48–15.31) * |
| No | 55 | 190 | 1 | 1 | |
| PIH syndrome | Yes | 10 | 15 | 2.179(0.93–5.12) | 2.41(0.80–7.26) |
| No | 56 | 183 | |||
| Birth weight of the newborn | < 2500 | 15 | 25 | 2.33(1.12–4.82) | 2.25(0.82–6.16) |
| 2500–4000 | 40 | 155 | 1 | 1 | |
| ≥ 40,000 | 11 | 18 | 2.37(1.04–5.41) | 2.15(0.78–5.98) | |
| Vital sign of mother | Stable | 46 | 181 | 1 | |
| Unstable | 20 | 17 | 4.63(2.25–9.54) | 2.21(0.87–5.61) | |
COR crude odd ratio, AOR Adjusted odd ratio. *significant at p-value of < 0.05
Discusstion
This unmatched case‑control study aimed to identify factors associated with peripartum hysterectomy. The analysis revealed that maternal parity, prior cesarean section, labor complications, postpartum hemorrhage, and fetal mal‑presentation were significant contributors to the risk of undergoing peripartum hysterectomy.
In this study, the previous CS scar was one of the risk factors associated with peripartum hysterectomy. Women with previous cesarean sections were three times at higher odds for peripartum hysterectomy as compared to women who did not have a history of previous cesarean sections. This finding was supported by the similar studies conducted in China, southern Israel, Egypt and systematic review studies and another systematic review and meta-analysis [11, 15–17, 19]. This increased risk is likely related to a higher tendency for abnormal placental pathology with multiple cesarean scars. Inappropriate selection of candidates for trial of labor after cesarean (TOLAC) may also contribute, as it can result in uterine rupture and necessitate emergency peripartum hysterectomy. Additional factors such as increased adhesions, bleeding from adhesion release sites, and delays in clinical decision‑making further compound the risk. Although consistent with studies from China, Israel, and Egypt, the Hawassa context differs due to limited resources and the restriction of TOLAC to mothers with only one previous cesarean section, which may influence risk patterns.
Another finding of this study was that women with parity ≥ 5 times were 3.34 times more likely to have peripartum hysterectomy as compared to women who had parity less than 5. It aligns with the studies conducted in China, South Israel, Nigeria and a systematic review and meta-analysis also revealed a prim-parity protective effect for peripartum hysterectomy [10, 14, 16, 17]. Higher uterine atony in multiparous (parous) uteri occurs because repeated pregnancies and deliveries reduce the contractile efficiency of the uterine muscle. This leads to stretching, thinning, and impaired myometrial tone, making the uterus less able to clamp down on blood vessels after delivery [22–24]. The likelihood of peripartum hysterectomy was more than four times higher in women with abnormal labor than in those without. This result is corroborated by the Ethiopian study [20]. The greater incidence of protracted labor, obstructed labor, inadequate monitoring of labor progress, and delayed referral to tertiary hospitals associated with labor abnormalities could be the reason [24–26].
In addition, the current study revealed that women who experienced post-partum hemorrhage had 5.6 times higher odds of having a peripartum hysterectomy than women who did not. Studies done in China [19] and southern Israel [16] complement this conclusion. The explanation is straight forward since peripartum hysterectomy remains a definitive intervention when conservative measures to control life‑threatening obstetric complications fail.
One other conclusion from this study was that women who encountered fetal malpresentation like face, breech, shoulder and compound presentations had a 4.8-fold increased risk of having a peripartum hysterectomy compared to those who did not. This result was in line with research from low- and middle-income nations [18]. This may be the case because undiagnosed fetal malpresentations, such as transverse lying and large breaches for vaginal birth, can cause obstructed labor and, if left untreated, uterine rupture, which has a direct correlation to peripartum hysterectomy.
The limitation of the study.
A key limitation of this study is its retrospective design, which may have introduced incomplete documentation and recall bias. In addition, the selection of controls from hospital records could have led to potential selection bias, as unmeasured confounders may not have been equally distributed between cases and controls. Moreover, the study is single institution-based, it does not show the real magnitude of the population.
Conclusion and recommendation
In conclusion, multiparity, labor abnormalities, mal‑presentation, postpartum hemorrhage, and prior cesarean section were identified as major predictors of emergent peripartum hysterectomy. It is recommended to focus on strengthening early monitoring of labor progress, ensuring timely referral pathways to higher‑level facilities, and improving preparedness for managing postpartum hemorrhage. In addition, targeted training for healthcare providers on risk recognition and emergency response, coupled with resource allocation to support comprehensive obstetric care, are critical steps toward preventing avoidable hysterectomies.
Acknowledgements
Not applicable.
Financial disclosure
The authors received no specific funding for this work.
Authors’ contributions
KA: proposal development, data collection, data analysis, manuscript preparation, WB: proposal development, data collection, data analysis, manuscript preparation, DZ: proposal development, data collection, data analysis, manuscript preparation, DG: proposal development, data collection, data analysis, manuscript preparation, YA: proposal development, data collection, data analysis, manuscript preparation, FD: proposal development, data collection, data analysis, manuscript preparation, TT: proposal development, data collection, data analysis, manuscript preparation, manuscript finalization.
Data availability
All data needed is included in the manuscript.
Declarations
Ethics approval and consent to participate
Ethical clearance was obtained from the Institutional Review Board (IRB) of the college of medicine and health sciences, Hawassa University, Ethiopia with ethical clearance letter no. RPGe/78/2023. The IRB has given ethical clearance for written informed consent. After getting ethical clearance from the institutional review board of Hawassa University, data collection was started. Patients’ names or other personal information were not used in data collection or analysis. All methods were performed by relevant guidelines and regulations of the Declaration of Helsinki.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.Arulpragasam K, Hyanes G, Epee-Bekima M. Emergency peripartum hysterectomy in a Western Australian population: Ten‐year retrospective case‐note analysis. Aust N Z J Obstet Gynaecol. 2019;59(4):533–7. [DOI] [PubMed] [Google Scholar]
- 2.Tahlak MA, Abdulrahman M, Hubaishi NM, Omar M, Cherifi F, Magray S, et al. Emergency peripartum hysterectomy in the Dubai health system: A fifteen year experience. Turk J Obstet Gynecol. 2018;15(01):1–7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Hernandez JS, Wendel GD Jr, Sheffield JS. Trends in emergency peripartum hysterectomy at a single institution: 1988–2009. Am J Perinatol. 2013;30(05):365–70. [DOI] [PubMed] [Google Scholar]
- 4.Chawla J, Arora CD, Paul M, Ajmani SN. Emergency obstetric hysterectomy: A retrospective study from a teaching hospital in North India over eight years. Oman Med J. 2015;30(3):181. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Fawcus S, Moodley J. Postpartum haemorhage associated with caesarean section and caesarean hysterectomy. Best Pract Res Clin Obstet Gynecol. 2013;27(2):233–49. [DOI] [PubMed] [Google Scholar]
- 6.Bodelon C, Bernabe-Ortiz A, Schiff MA, Reed SD. Factors associated with peripartum hysterectomy. Obstet Gynecol. 2009;114(1):115–23. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Temizkan O, Angın D, Karakuş R, Şanverdi İ, Polat M, Karateke A. Changing trends in emergency peripartum hysterectomy in a tertiary obstetric center in Turkey during 2000–2013. J Turkish German Gynecol Association. 2016;17(1):26. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Bayable M, Gudu W, Wondafrash M, Sium AF. Incidence, indications, and maternal outcomes of emergency peripartum hysterectomy at a tertiary hospital in ethiopia: A retrospective review. Int J Gynecol Obstet. 2023;161(1):279–82. [DOI] [PubMed] [Google Scholar]
- 9.Huque S, Roberts I, Fawole B, Chaudhri R, Arulkumaran S, Shakur-Still H. Risk factors for peripartum hysterectomy among women with postpartum haemorrhage: analysis of data from the WOMAN trial. BMC Pregnancy Childbirth. 2018;18:1–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Omole-Ohonsi A, Olayinka HT. Emergency peripartum hysterectomy in a developing country. J Obstet Gynecol Can. 2012;34(10):954–60. [DOI] [PubMed] [Google Scholar]
- 11.Allam IS, Gomaa IA, Fathi HM, Sukkar GFM. Incidence of emergency peripartum hysterectomy in Ain-shams university maternity Hospital, egypt: a retrospective study. Arch Gynecol Obstet. 2014;290:891–6. [DOI] [PubMed] [Google Scholar]
- 12.Govindappagari S, Wright JD, Ananth CV, Huang Y, D’Alton ME, Friedman AM. Risk of peripartum hysterectomy and center hysterectomy and delivery volume. Obstet Gynecol. 2016;128(6):1215–24. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Peivandi S, Peivandi S, Habibi A, Atarod Z, Moosazadeh M, Fallah S. Prevalence and factors associated with peripartum hysterectomy among Iranian pregnant women: A retrospective study. Ethiop J Health Sci. 2022;32(2). [DOI] [PMC free article] [PubMed]
- 14.Chen M, Zhang L, Wei Q, Fu X, Gao Q, Liu X. Peripartum hysterectomy between 2009 and 2010 in Sichuan, China. Int J Gynecol Obstet. 2013;120(2):183–6. [DOI] [PubMed] [Google Scholar]
- 15.de la Cruz CZ, Thompson EL, O’Rourke K, Nembhard WN. Cesarean section and the risk of emergency peripartum hysterectomy in high-income countries: a systematic review. Arch Gynecol Obstet. 2015;292:1201–15. [DOI] [PubMed] [Google Scholar]
- 16.Orbach A, Levy A, Wiznitzer A, Mazor M, Holcberg G, Sheiner E. Peripartum Cesarean hysterectomy: critical analysis of risk factors and trends over the years. J Maternal-Fetal Neonatal Med. 2011;24(3):480–4. [DOI] [PubMed] [Google Scholar]
- 17.Van Den Akker T, Brobbel C, Dekkers OM, Bloemenkamp KW. Prevalence, indications, risk indicators, and outcomes of emergency peripartum hysterectomy worldwide: a systematic review and meta-analysis. Obstet Gynecol. 2016;128(6):1281–94. [DOI] [PubMed] [Google Scholar]
- 18.Duffy CR, Moore JL, Saleem S, Tshefu A, Bose CL, Chomba E, et al. Malpresentation in low-and middle‐income countries: associations with perinatal and maternal outcomes in the global network. Acta Obstet Gynecol Scand. 2019;98(3):300–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Meena Pradhan MP, Shao Yong SY. Emergency peripartum hysterectomy as postpartum hemorrhage treatment: incidence, risk factors, and complications. 2014. [PubMed]
- 20.Yeshitila YG, Daniel B, Desta M, Kassa GM. Obstructed labor and its effect on adverse maternal and fetal outcomes in ethiopia: a systematic review and meta-analysis. PLoS ONE. 2022;17(9):e0275400. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Sereke D, Hailemelcot H, Gebremeskel O, Andemaraim Z. Emergency Peripartum Hysterectomy In Mendefera Hospital-Case Control Study. 2021.
- 22.Cunningham FG, Leveno KJ, Bloom SL, Dashe JS, Hoffman BL, Casey BM, Spong CY. Williams obstetrics. 25th ed. New York: McGraw–Hill Education; 2018. [Google Scholar]
- 23.World Health Organization. WHO recommendations: uterotonics for the prevention of postpartum haemorrhage. Geneva: WHO; 2018. [PubMed] [Google Scholar]
- 24.Sentilhes L, Vayssière C, Deneux–Tharaux C, et al. Postpartum hemorrhage: guidelines for clinical practice from the French college of gynaecologists and obstetricians (CNGOF). Eur J Obstet Gynecol Reprod Biol. 2016;198:12–21. [DOI] [PubMed] [Google Scholar]
- 25.Berhan Y, Berhan A. Causes of maternal mortality in ethiopia: a significant decline in abortion related death. Ethiop J Health Sci. 2014;24:15–28. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Alemu A, Melaku A, Abera M, et al. Indications and outcomes of emergency peripartum hysterectomy in Southern ethiopia: a 7–year retrospective review. BMC Pregnancy Childbirth. 2020;20:307.32429861 [Google Scholar]
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Data Availability Statement
All data needed is included in the manuscript.