Abstract
Background
Uterine rupture is a tear in the wall of the uterus that commonly occurs in its lower segment. Despite it being the most preventable obstetric complication and different interventions being done by stakeholders, the prevalence of uterine rupture is high, and it remains one of the leading public health problems in developing countries, including Ethiopia. It is also a leading cause of severe maternal morbidity and mortality. Although risk factors for uterine rupture are context-specific, there is a lack of clarity in our context regarding the contributing factors and untoward outcomes of uterine rupture. Therefore, this study aimed to identify determinants of uterine rupture among pregnant mothers who gave birth at the University of Gondar Specialized and Comprehensive Hospital, Northwest Ethiopia.
Methods and materials
An institutional-based unmatched case-control study was conducted on 450 women (150 cases and 300 controls) from 2018 to 2022. A data collection tool containing variables was designed to extract data from log books and client cards. Data were entered into EpiData 6.7 and exported to Stata-16 software for cleaning and analysis. In bivariate analysis, p-values < 0.2 were entered into multivariable analysis, and statistical significance was declared at p-value < 0.05 with AOR reported.
Results
In this study, being in a rural residence (AOR = 4.8, 95% CI: (1.15,11)), distance from the hospital (AOR = 11.2, 95% CI: (2.6,47.3)), self-referral case (AOR = 0.17, 95% CI: (0.04,0.7)), had not Antenatal Care follow-up (AOR = 3.7, 95% CI: (1.2,16)), no Cephalopelvic Disproportion (AOR = 0.01, 95% CI: (0.02,0.1)), and had not used partograph (AOR = 3.9, 95% CI: 1.2,12)) were significantly associated with uterine rupture.
Conclusion
In this study, being a rural resident, distance from the hospital, referral from a health center, ANC follow-up, CPD, and use of a partograph were independent determinants of uterine rupture. Therefore, we provide client-centered counseling on birth preparedness and complication readiness plan and encourage women to use maternal waiting areas to avoid uterine rupture.
Keywords: Outcome of uterine rupture, Associated factors, Northwest Ethiopia
Introduction
A uterine rupture is a tear in the uterus wall that typically occurs in the lower segment of the uterus. The tear could be anterior, posterior, lateral, or a combination of both. It could also be transverse, vertical, or in combination. Uterine rupture is a devastating obstetric condition that continues to increase maternal mortality, especially in developing countries, with major maternal morbidity, particularly peripartum hysterectomy [1–3].
The prevalence of uterine rupture tends to be lower in countries defined by the United Nations as developed than in less developed countries. The prevalence for women without previous cesarean sections from a developed country was extremely low (0.006%) [4], but the prevalence of uterine rupture is high in developing countries, where it ranges from 0.5% to 9.5% of births [5]. According to a study conducted in different parts of Ethiopia, the prevalence of uterine rupture ranges from 1.53% to 7.85% [6]. Uterine rupture remained the leading cause of fetal and maternal morbidity and mortality in Sub-Saharan Africa (SSA), accounting for around 13% of maternal mortality and 74%-92% of perinatal mortality [7]. Out of all maternal mortality in Ethiopia, more than 35% of registered maternal deaths were due to uterine rupture [8, 9].
Previous studies indicated that some of the most common risk factors for uterine rupture include rural residence, low-income women, multigravida, cesarean section scar, not having an antenatal care visit, obstructed labor, fetal weight > 4 kg, induction and augmentation of labor, post-term (≥ 42 weeks) births, high maternal age (≥ 35 years), short maternal stature (≤ 164 cm), previous laparoscopic myomectomy (LMYO), trans cervical resection myomectomy (TCR-MYO), after a laparoscopic wedge resection of cornual ectopic pregnancy (LECT), previous cesarean delivery with severe postpartum hemorrhage, non-removal of cervical cerclage during labor, road traffic accident, mal-presentation in labor, uterine fundal pressure, abnormal placentation, epidural anesthesia, induction of labor (irrespective of agents used), staff shortages and poor emergency care readiness, pre- or post-term pregnancy, overweight, cultural barriers, and non-Western ethnic background [2, 6, 10–17].
Uterine rupture is a serious but preventable obstetric complication that endangers both mother and baby. Even if women survive, their future reproductive potential is reduced or lost forever, and/or they may develop or experience trauma due to mental health problems. The World Health Organization (WHO) intensifies its efforts in maternal health care, focusing specifically on the reduction of maternal mortality by strengthening the system of primary health care and giving a priority to maternal and child health care and through formally trained traditional birth attendants and community health agents. In spite of these efforts, there are many mothers who died as well as suffer from obstetric complications [18].
Ethiopia introduced a pioneering Health Extension Program in 2003, which involved training female Health Extension Workers (HEWs) and deploying them at the community level, with two HEWs assigned to each rural kebele. This strategy aimed to decentralize maternal healthcare services and improve access in rural areas. In addition, mobile clinics and community midwives have been considered cost-effective alternatives for expanding maternal care coverage. The deployment of emergency surgical officers at primary hospitals has further strengthened maternal and newborn health services. Through community involvement and the transfer of knowledge into practical skills at the household level, these interventions have contributed to reductions in maternal mortality. However, despite these efforts, maternal mortality remains high in Ethiopia [19].
Regardless of this fact, efforts to identify the determinants of uterine rupture have been limited in Ethiopia in general and in the study area in particular. Furthermore, there is considerable variation in reported risk factors across different studies, making it difficult to clearly understand the condition and underscoring the need for comprehensive research to identify consistent determinants across populations. This highlights the necessity for analytical studies to improve awareness of the determinants of uterine rupture and to address existing knowledge gaps. In addition, easily implementable, evidence-based interventions are essential to achieve the third Sustainable Development Goal (SDG 3) [20].
Therefore, this study aimed to identify the major determinants associated with uterine rupture to support the effective implementation of maternal health intervention programs. It also seeks to inform resource allocation and prioritize interventions to minimize and prevent the problem in a simple and cost-effective manner. The findings of this study are expected to assist healthcare providers and program planners in strengthening maternal mortality prevention strategies, particularly in rural settings. Moreover, the study will contribute to the existing body of knowledge, both within the study area and nationally, to improve maternal healthcare practices at all levels.
Methods and materials
Study design and period
This was a five-year institutional-based, unmatched case control study conducted from 2018 to 2022 G.C.
Study area
The study was conducted in Gondar City, University of Gondar Specialized and Comprehensive Hospital. Gondar is located 172 km from Bahir Dar, the capital city of Amhara National Regional State (ANRS), and 735 km northwest of Addis Ababa. The University of Gondar specialized and comprehensive hospital is one of the governmental hospitals in Amhara Regional State. The hospital serves a population of more than 7,000,000 in its catchment area. The hospital has a large maternity ward with approximately 74 beds [21]. It conducts about 6,000 deliveries annually, of which around 30% are cesarean sections (prenatal report, 2014 E.C.). The Department of Obstetrics and Gynecology is staffed by 22 obstetricians, 40 resident doctors, and 48 midwives. As a referral center, the hospital receives a large proportion of patients referred from health centers and district hospitals.
Study participants
All mothers who gave birth at the University of Gondar specialized and comprehensive hospital was the source population of the study. Mothers who were diagnosed to have uterine rupture and managed for uterine rupture at the University of Gondar specialized and comprehensive hospital during the study period were considered as cases, while mothers who gave birth through vaginal deliveries were taken as controls.
Inclusion criteria
All women who had been diagnosed with uterine rupture and managed at University of Gondar specialized and comprehensive hospital were considered cases, while non-rupture mothers were considered controls.
Exclusion criteria
Cases
Mothers who were managed for uterine rupture in another hospital and subsequently referred to UoGSCH for management of its complications were excluded.
Controls
Mothers who gave birth in another hospital and were referred for the management of obstetric complications were excluded from the study.
Sample size
Sample size was determined using the double population proportion formula for case-control study design using Epi Info version 7, statistical software. Using a significant factor (cesarean section scar from relevant literature) [22], a 95% confidence interval (CI), 80% power, a ratio of control to cases of 2 to 1, a percentage of controls exposed to the risk factor (cesarean section scar in this case) of 35%, and a percentage of cases exposed (has a cesarean section scar in this case) of 49.55% [22], and adding 10% contingency for incomplete cards, the final sample size becomes 450 women; that is, 150 cases of uterine rupture and 300 non-uterine rupture deliveries were included in the study as control.
Sampling procedure
The sampling frame was developed based on the client’s medical registration number recorded on the log books in the labor wards and operating rooms over the 5 years from January 2018 to December 2022. Using this frame, mothers diagnosed for uterine rupture and managed in UOGSCH were selected by computer-generated simple random sampling, and the 2 subsequent mothers who had normal spontaneous vaginal delivery and cesarean section (CS) delivery were selected as cases and controls, respectively.
Selection of cases
Is defined as pregnant women who experienced uterine rupture during labor or delivery and were managed at the study hospital within the specified study period. The diagnosis of uterine rupture was confirmed based on consistent clinical criteria, including intraoperative findings and/or documented diagnosis by the attending physician, as recorded in the patients’ medical charts. To ensure diagnostic consistency, only cases with clearly documented and confirmed diagnoses were included, while incomplete or ambiguous records were excluded.
Selection of controls
Women who had spontaneous vaginal delivery or who delivered by caesarean section without uterine rupture as complications were selected as controls. Charts (case notes) of women without uterine rupture (control) found after the cases (since cases and controls should be comparable regardless of the presence of the disease of interest, we were enrolling controls who were admitted following the cases to avoid seasonal impact on transportation from rural areas and other parameters) were selected randomly and enrolled.
Variables of the study
Uterine rupture was the dependent variable. The independent variables considered in the study were socio-demographic characteristics such as age, residence, distance from hospital, referral from health center, fetal factors (malposition, mal-presentation, fetal macrosomia, gestational age in weeks), mother-related factors (labor induction, parity, multiple pregnancy-obstructed labor, prolonged labor, placentation, CPD), surgery history (CS, myomectomy), number of CS scars, type of CS scars), and facility-related factors (ANC follow-up, partograph utilization).
Data collection procedures
Data were extracted from both the log books and the client cards, which had been recorded over the 5 years from January 2018 to December 2022. As sources of data, the medical records of the selected cases that were diagnosed for uterine rupture and the medical records of two subsequent mothers with spontaneous vaginal delivery were collected from medical record units. A data extraction tool that contains all required variables was designed and used to extract data from both the log book and the client cards. Data were collected by 5 first-year epidemiology students.
Data quality control
Before data extraction, training was provided to data collectors and the supervisor on proper data collection techniques, the content of the questionnaire, and handling of information that was conducted under the supervision of the investigators. One week prior to the actual data collection, the questionnaire was pre-tested on 5% of the sample (22 mothers: 7 cases and 15 controls) from mothers who gave birth at the University of Gondar Specialized Teaching Hospital, excluding those recorded between January 2018 and December 2022. Based on the pre-test findings, the order of questions was adjusted, and additional items were added as needed. During data collection, completed data extraction tools were cross-checked against original participant records, and feedback was provided to ensure data accuracy and quality.
Data processing and analysis
The collected data were coded and entered into EpiData 6.7 then exported to STATA version 16 for cleaning and analysis. Descriptive analysis was used to explore the characteristics of mothers. The associations between uterine rupture and independent variables were modeled using binary logistic regression analysis. Bivariate logistic regression analysis was used to assess the existence of a crude relationship between independent variables and uterine rupture. At this level, the candidate variables for multivariate analysis were selected at the P-value < 0.2 significance level. Multivariate logistic regression was applied to estimate the adjusted effects of independent variables on uterine rupture. The association between independent variables and uterine rupture was estimated using an odds ratio with a 95% confidence interval. The significance of associations was declared at a p-value of less than 0.05. The regression model was developed using a backward stepwise strategy. The final fitted model was assessed for multicollinearity using the Variance Inflation Factor (VIF) and the mean result was 1.89 which indicates no multicollinearity, and goodness of fit using the Hosmer and Lemishow tests which were 0.66. The model’s ability to correctly classify those subjects who experience outcomes of interest and those who do not were assessed using the Receiver Operating Characteristics (ROC) curve. The model demonstrated good discriminatory performance with an Area Under the Curve (AUC) of 0.84 (95% CI: 0.79–0.89).
Results
Socio-demographic characteristics of women
A total of 420 (142 cases and 278 controls) women were included, with a response rate of 93.3%. Most women were aged > 30 years among cases 86(60.6%) and 130(46.8%) in controls. More than two-thirds of 76.9% of women were from rural residents among cases and 34.1% among controls. About 82.4% of cases and 24.8% of controls were referred from health centers (Table 1).
Table 1.
Socio-demographic characteristics of women who gave birth at the University of Gondar comprehensive specialized hospital, Northwest Ethiopia (n = 420)
| Variable | Case (n = 142) Frequency (%) |
Control (n = 278) Frequency (%) |
|---|---|---|
| Age(years) | ||
| 18–24 | 19(13.4) | 50(18.0) |
| 25–34 | 57( 41.1) | 193(69.4) |
| ≥ 35 | 66(46.5) | 35( 12.6) |
| Residence | ||
| Rural | 109(76.7) | 95(34.1) |
| Urban | 33 (23.3) | 183(65.9) |
| Distance from the hospital | ||
| < 10 km | 20(14.1) | 216 (77.7) |
| ≥ 10 km | 122(85.9) | 62 (22.3) |
| The case referral from HC | ||
| Yes | 117(82.4) | 69 (24.8) |
| No | 25(17.6) | 209 (75.2) |
Obstetrics and gynecology related factors
Around 26.1% of cases and 2.5% of controls had a previous cesarean section history. Majority 33 (89.2%) of women had lower uterine segment transverse among cases and 7 (100%) among controls. Cephalopelvic disproportion was the main indication for cesarean Sect. 18() among cases and 2 among controls (Table 2).
Table 2.
Obstetrics and gynecology-related characteristics mothers who gave birth at the University of Gondar comprehensive specialized hospital, Northwest Ethiopia, 2023
| Variable | Case (n=) Frequency (%) |
Control (n=) Frequency (n=) |
|||
|---|---|---|---|---|---|
| Previous caesarian section history (420) | |||||
| Yes | 37 (26.1) | 7 (2.5) | |||
| No | 105 (73.9) | 271 (97.5) | |||
| Number of times (n= 44) | |||||
| One time | 27 (72.9) | 6 (85.7) | |||
| More than one times | 10 (27.1) | 1 (14.3) | |||
| Type of caesarian section history(44) | |||||
| Lower uterine segment transverse | 33 (89.2 ) | 7 (100) | |||
| Classical caesarean section | 2 (5.4) | 0 ( 0) | |||
| Unknown | 2 (5.4) | 0 (0) | |||
| Indication for C/S(44) | |||||
| CPD | 18 | 2 | |||
| Failed induction | 1 | 0 | |||
| Malposition | 1 | 0 | |||
| Mal presentation | 2 | 0 | |||
| Non-reassuring fetal heart rate pattern (NRFHRP) | 12 | 5 | |||
| Placenta Previa (PP) | 1 | 0 | |||
| Severe oligo-hydraminous | 2 | 0 | |||
| Previous gynecologic history | |||||
| Yes | 6 (42.2) | 5 (1.79) | |||
| No | 136 (95.8) | 273 ( 98.21) | |||
| Type of gynecologic history | |||||
| Myomectomy | 6 (85.7) | 1 (14.3) | |||
Current pregnancy and labor progress related factors
More than half of 57.7% of pregnant women were multipara among cases and 73.7% among controls. 27.9% of women had good knowledge of ANC among cases and 64.6% among controls. Around 3.5% the pregnant women had ANC follow up among cases and 97.8% among controls and for majority of pregnant women 94.2% health care providers use partograph among controls and 20.4% among cases (Table-3).
Table 3.
Current pregnancy and labor progress-related characteristics of mothers who gave birth at the University of Gondar comprehensive specialized hospital, Northwest Ethiopia, 2023
| Variables | case (n = 142) Frequency (%) |
control (n = 278) Frequency (%) |
||||||
|---|---|---|---|---|---|---|---|---|
| Parity | ||||||||
| Primi- para | 18(12.7) | 50 (17.9) | ||||||
| Mullti –para | 82(57.7) | 205( 73.7) | ||||||
| Grand mullti- para | 42(28.6) | 23(8.4) | ||||||
| Gestational age in weeks | ||||||||
| < 37weeks | 5(3.5) | 7 (2.9) | ||||||
| ≥ 37 weeks | 137(96.5) | 271 (97.1) | ||||||
| Multiple pregnancy | ||||||||
| Yes | 5(3.5) | 4(1.4) | ||||||
| No | 137(96.5) | 274(98.6) | ||||||
| Number of pregnancy | ||||||||
| One | 1 | 1 | ||||||
| Two | 3 | 3 | ||||||
| Four | 0 | 1 | ||||||
| Had the patient ANC follow up | ||||||||
| Yes | 5 (3.5) | 272 (97.8) | ||||||
| No | 137 (96.5) | 6 (2.2) | ||||||
| Number of ANC follow up(359) | ||||||||
| 0 times | 5 | 65 | ||||||
| 1 times | 18 | 80 | ||||||
| 2 times | 17 | 23 | ||||||
| 3 times | 16 | 53 | ||||||
| 4 times | 5 | 6 | ||||||
| Was she induced /augmented for labor | ||||||||
| Yes | 25 (17.6) | 57 (20.5) | ||||||
| No | 117 (82.4) | 221 (79.5) | ||||||
| Was CPD diagnosed | ||||||||
| Yes | 95 (66.9) | 7 (2.5) | ||||||
| No | 47 (33.1) | 271 (97.5) | ||||||
| Was Obstructed labor diagnosed | ||||||||
| Yes | 79(55.6) | 5(1.8) | ||||||
| No | 63(44.4) | 273(98.2) | ||||||
| Did she have evidence of mal-presentation/abnormal lie | ||||||||
| Yes | 67 (47.2) | 5 (1.8) | ||||||
| No | 75 (52.8) | 273 (98.2) | ||||||
| Did she undergo assisted vaginal delivery | ||||||||
| Yes | 25 (17.6) | 50 (18) | ||||||
| No | 117 (82.4) | 228 (82) | ||||||
| Was there appropriate use of partograph | ||||||||
| Yes | 29 (20.4) | 262 (94.2) | ||||||
| No | 113 (79.6) | 16 (5.8) | ||||||
| Fetal weight in kg | ||||||||
| < 4 kg | 120 (84.5) | 269 (96.8) | ||||||
| ≥ 4 kg | 22 (15.5) | 9 (3.2) | ||||||
| Duration of labor | ||||||||
| < 24 h | 123 (86.6) | 272 (97.8 | ||||||
| ≥ 24 h | 19 (15.4) | 6 (2.2) | ||||||
Factors associated with uterine rupture
A total of twenty-four variables were identified as independent determinates on uterine rupture, and bivariate logistic regression was done, and fourteen variables entered into multivariate logistic regression with a p-value < 0.2. After controlling confounding factors in multivariable logistic regression, six variables were statistically significant (p-value < 0.05), including residence, distance from the hospital, case referral from the health center, ANC follow-up, CPD, and use of a partograph (Table 4).
Table 4.
Multivariable regression on determinants of uterine rupture among pregnant mothers who gave birth at the University of Gondar comprehensive specialized hospital, Northwest Ethiopia, 2023
| Variables | Uterine rupture | COR; 95% CI | p-value | AOR;95%CI | P-value | |
|---|---|---|---|---|---|---|
| Cases | control | |||||
| Maternal Age | ||||||
| 18 -24years | 19 | 50 | 0 | 0 | ||
| 25–34 years | 57 | 193 | 0.9(0.5,1.9) | 0.98 | 1.19(1.17-8) | 0.85 |
| ≥ 35 years | 66 | 35 | 1.7(0.9,3.1) | 0.06 | 0.37(0.05–2.7) | 0.33 |
| Residence | ||||||
| Urban | 33 | 183 | 0 | 0 | ||
| Rural | 109 | 95 | 0.15(0.09,0.2) | 0.000 | 4.8(1.15–19.4) | 0.03* |
| Distance from the hospital | ||||||
| < 10 km | 20 | 216 | 0 | 0 | ||
| ≥ 10 km | 122 | 62 | 21.2(12,36) | 0.000 | 11.2(2.6–47.3) | 0.001* |
| Parity | ||||||
| Primi para | 18 | 50 | 0 | 0 | ||
| Multi para | 82 | 205 | 1.1(0.6,2.0) | 0.72 | 3.6(0.3–42) | 0.29 |
| Grand multi para | 42 | 23 | 5.1(2.4,10.6) | 0.000 | 3.2(0.16-65) | 0.43 |
| Referral from health center | ||||||
| Yes | 117 | 69 | 0 | 0 | ||
| No | 25 | 209 | 0.07(0.04,0.1) | 0.000 | 0.17(0.04–0.7) | 0.01* |
| Gynecologic history | ||||||
| Yes | 6 | 5 | 0 | 0 | ||
| No | 136 | 273 | 0.08(0.00,0.6) | 0.02 | 0.59(0.04–7.2) | 0.68 |
| Multiple pregnancy | ||||||
| Yes | 32 | 23 | ||||
| No | 142 | 320 | 0.4(0.1,1.5) | 0.000 | 0.35(0.02–5.3) | 0.45 |
| ANC follow up | ||||||
| Yes | 5 | 6 | ||||
| No | 137 | 272 | 2.8(1.3,5.4) | 0.000 | 3.7(1.2–16) | 0.000* |
| CPD | ||||||
| Yes | 95 | 7 | 0 | 0 | ||
| No | 47 | 271 | 0.007(0.002,0.2) | 0.000 | 0.01(0.02–0.1) | 0.000* |
| Obstructed labor | ||||||
| Yes | 79 | 5 | ||||
| No | 63 | 273 | 0.01(0.005,0.03) | 0.000 | 1.17(1.10–15) | 0.83 |
| Malposition | ||||||
| Yes | 67 | 5 | ||||
| No | 75 | 273 | 0.02(0.007,0.05) | 0.000 | 0.4(0.08–1.8) | 0.243 |
| Use partograph | ||||||
| Yes | 29 | 262 | 0 | 0 | ||
| No | 113 | 16 | 6.8(3.3,22) | 0.000 | 3.9(1.9–12) | 0.000* |
| Fetal weight | ||||||
| < 4 kg | 120 | 269 | 0 | 0 | ||
| ≥ 4 kg | 22 | 9 | 5.4(2.4,12.2) | 0.000 | 2.21(8.6–50) | 0.53 |
| Duration of labor | ||||||
| < 24 h | 123 | 272 | 0 | 0 | ||
| ≥ 24 h | 19 | 6 | 23.9(5,5,103) | 0.000 | 4.2(0.05- 30) | 0.67 |
The odds of pregnant women who come from rural areas were about 4.8 times (AOR = 4.8, (95% CI: 1.15, 11)) more likely to risk uterine rupture than pregnant women who come from urban areas. The odds of pregnant women being a distance of greater than 10 km from the hospital were about 11.2 times (AOR = 11.2 (95% CI: 2.6, 47.3)) more likely to have the risk of uterine rupture as compared to women who come from less than 10 km distance from the hospital. The odds of pregnant women who are not referred from a health center were 17% (AOR = 0.17, 95% CI: 0.04, 0.7) less likely to risk uterine rupture as compared to cases referred from a health center.
The odds of pregnant women who had no ANC follow-up were 3.9 times (AOR = 3.7, 95% CI: 1.2, 16) more likely to have the risk of uterine rupture as compared to those who had ANC follow-up. The odds of pregnant women who had no CPD were 1% (AOR = 0.01, 95% CI: (0.02, 0.1)) less likely to have the risk of uterine rupture as compared with the presence of CPD. The odds of pregnant women who do not use partographs were 3.9 times (AOR = 3.9, 95% CI: 1.2, 12) more likely to risk uterine rupture as compared to those with the presence of partographs.
Discussion
Knowing the possible determinant of uterine rupture is important for prevention strategies and proper management. From variables related with socio-demographic characteristics, rural residence was found statistically significant with the occurrence of uterine rupture. Pregnant women from rural areas were 4.8 times more likely to experience uterine rupture than pregnant women who come from urban areas. This result was consistent with a study done at Ayub Teaching Hospital, Pakistan [23], East Wollega Zone public hospitals [24], in Adama city public and private hospitals, Oromia Ethiopia [25], and Dessie Referral Hospital from January 2016 to June 2016, North East Ethiopia [26]. The possible explanation for this consistency might be the women in rural areas were delivered at home, attended by traditional birth attendants, lack of information on labor and delivery complication, and lack of access to nearby health institution. This is supported by different studies [27, 28]. As a result, the higher chance of uterine rupture for women from rural residents may be attributed to two delays in the process of getting obstetric care. The first is delay in deciding to seek health care as early as possible, and the second is delay in reaching a health facility. Additionally, maybe there is a failure of early referral for any labor abnormality, thus resulting in delay in early intervention, leading to uterine rupture. These problems could possibly be addressed by the construction of health institutions nearby to the community that are capable of managing obstructed labor, increasing awareness on skilled birth attendance, and establishing a referral system.
Distance from the hospital was identified as an independent risk factor for uterine rupture. The odds of pregnant women’s distance from the hospital being greater than 10 km were about 11.2 times (AOR = 11.2 (95% CI: 2.6, 47.3)) more likely to experience uterine rupture compared to women who come from less than 10 km away from the hospital. This finding was similar to the study done in the teaching hospital of Mbarara, western Uganda [29], Malawi [30], public hospitals in the Tigrai region of Ethiopia [3], referral hospitals of the Amhara regional state [31], and a study done in Debre Markos Hospital, Northwest Ethiopia [32]. The possible reason might be that as the distance from the health facility increases, the women are unable to reach it at an early time to get labor delivery service. As a result, this will increase the duration of labor as a whole and increase the probability of acquiring uterine rupture.
According to this study, cases referred from a health center were identified as a determinant of uterine rupture. The odds of pregnant women who are not referred from a health center were 17% (AOR = 0.17 (95% CI: 0.04, 0.7)) less likely to risk uterine rupture as compared to cases referred from a health center. This result was consistent with previous studies conducted at referral university hospitals in western Uganda [29], public hospitals in the Tigrai region of Ethiopia [3], Debre Markos Hospital, North West Ethiopia [32], , and a study done in Jinka and Arba Minch General Hospitals, Ethiopia [33]. The possible explanation could include prolonged labor in the first unit health facility, and then they were referred for better management. These mothers referred from the health center may experience uterine rupture because of the distance between the health center and the hospital where emergency obstetric treatment is provided. It could also be attributed to protracted management of labor at a health center, late referral of mothers with obstetric complications, and a lack of experience in follow-up labor, all of which may increase the risk of uterine rupture.
Absence of ANC follow-up (had no ANC follow-up) was significantly associated with uterine rupture. The odds of pregnant women who had no ANC follow-up were 3.9 times higher for the risk of uterine rupture as compared to those who had ANC follow-up. This study was in line with previous studies conducted in Bida, North Central Nigeria; at the University of Ilorin Teaching Hospital, Ilorin; and in Benin City, Nigeria [34–36], in a teaching hospital in Mbarara, western Uganda [29] in Adama City public and private hospitals, Oromia [25], Dessie Referral Hospital, Northeast, Ethiopia [26], Hawassa University comprehensive specialized hospital, Southern Ethiopia [10], and a study done in Debre Markos Hospital, Northwest Ethiopia [32]. This could be due to the importance of ANC follow-up, which is evident because every contact provider will have the opportunity to identify risk factors such as malpresentation, fetal macrosomia, and a history of uterine scarring. It also provides the possibility to educate the mothers on the necessity of hospital birth, warning indications, birth preparedness and complication readiness plan during ANC follow-up, which results in less risk of uterine rupture [10].
Having CPD was identified as an independent risk factor for uterine rupture. The odds of pregnant women who had no CPD were 1% (AOR = 0.01, 95% CI: (0.02, 0.1)) less likely to have the risk of uterine rupture as compared with the presence of CPD. This is supported by previous studies in Debre Markos Hospital [32], Hawassa University Comprehensive Specialized Hospital, Southern Ethiopia [10], and Yirgalem General and Teaching Hospital, southern Ethiopia, which found that the most common cause of uterine rupture among patients with uterine rupture was cephalo-pelvic disproportion, followed by mal-presentation and malposition [37].
Using partographs was the main preventive mechanism for the risk of uterine rupture. The odds of pregnant women who do not use partographs were 3.9 times (AOR = 3.9, 95% CI: 1.2, 12) more likely to be at risk of uterine rupture as compared to their counterparts. This is consistent with a previous study conducted in Great Britain [38], Cochrane database of systematic reviews [39], Kenya [40], in Debre Markos Hospital, in Northwest Ethiopia [32]. This might be due to the follow-up of women in labor by using a partograph, which is very important to assess the progress of labor and to take immediate action that results in less likely uterine rupture. This can be explained by the fact that appropriate use of the partograph is an important tool for auditing and monitoring the progress of labor and a warning device to detect deviations from normal labor and to take immediate action, thereby improving maternal and fetal outcomes. This is also supported by the WHO; this implies that utilization of a partograph is one of the tools that shows patient information, fetal condition, progress of labor, and maternal condition. Also, it serves as an “early warning system” and assists in early decisions to transfer, augment, and terminate of labor [41].
Limitation of Study
Due to the lack of standardized format about what variables should be documented in maternal medical profile, some sociodemographic and socioeconomic variables were not registered in the clients’ documents. Since this study is the facility-based study, the finding may not be generalized to the general population. As the data were taken from patient’s medical profile, some variables were missed.
Conclusion and recommendations
The study revealed that rural residence, distance from the hospital, case referral from HC, ANC follow-up, CPD, and use of a partograph were independent determinates of uterine rupture. Therefore, early and timely referral of cases should be promoted for rural and remote health institutions. The federal ministry of health and regional health bureau should design a specific behavioral change communication program to improve client health care providers’ relationships, provide training for health care providers for careful management of labor and delivery services, and implement it. University of Gondar A comprehensive specialized hospital should focus on improving women’s knowledge of the maternal waiting area, birth preparedness, and complication readiness plan through an adult learning program for preventing uterine rupture. Health care providers should take the opportunity to encourage mothers to visit antenatal care early and use the maternal waiting area. Health extension workers should also carry out community-based interventions to improve communication and support through facilitated participatory learning.
Acknowledgements
The researcher would like to thank the University of Gondar for ethical approval. We also want to extend our sincere and wholehearted gratitude to data collectors and supervisors because all of them are the backbone of this study.
Abbreviations
- AIC
Akaike Information Criteria
- CPD
Cephalo- Pelvic Disproportion
- CS
Cesarean Section
- EC
Ethiopian Calendar
- GC
Gregorian Calendar
- HEW
Health Extension Worker
- LMYO
Previous Laparoscopic Myomectomy
- MRN
Medical Record Number
- OL
Obstructed Labor
- ROC
Receiver Operating Characteristics
- SVD
Spontaneous Vaginal Delivery
- TCR-MYO
Trans Cervical Resection Myomectomy
- UOGSCH
University Of Gondar Specialized and Comprehensive Hospital
- USA
United States of America
- VIF
Variance Inflation Factor
- WHO
World Health Organization
Authors’ contributions
Y.M.A. conceived, designed the study, acquired data, analyzed, and interpreted the findings. B.M.G and E.G.Z revised and provided critical intellectual feedback. A.W.W. reviewed and edited the draft manuscript. All authors have read and approved the final manuscript for submission.
Funding
The authors received no financial support for this research, authorship, and publication of this article.
Data availability
All data are available upon reasonable request and the readers can contact the corresponding author.
Declarations
Ethics approval and consent to participate
The ethical approval was obtained from the ethical review committee of the University of Gondar, College of Medicine and Health Sciences, Institute of Public Health Ethical and Research Review Committee, along with a written letter of protocol (Ref. No. IPH/2009/2013). Formal letter of cooperation was written to University of Gondar comprehensive specialized hospitals. Subsequently, permission was obtained from the medical director's office of a comprehensive specialized hospital for retrospectively retrieving patient data from the database and records. Data was kept anonymously by coding, not sharing information with others. As the study was conducted through a review of patient charts, no consent was obtained from the patients. Information about specific personal identifiers, like the patient’s name, was not collected, so it didn’t inflict any harm on the patients.
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.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
All data are available upon reasonable request and the readers can contact the corresponding author.