Uterine rupture in Mekelle, northern Ethiopia, between 2009 and 2013

Global, Regional and National Burden of Maternal Obstructed Labour and Uterine Rupture, 1990-2021: Global Burden of Disease Study 2021

BACKGROUND

Maternal obstructed labour and uterine rupture (MOLUR) are among the major maternal labour complications that threaten maternal and child health.

OBJECTIVE

The objective of this study was to systematically analyse the global burden of MOLUR using the Global Burden of Disease 2021 (GBD 2021) database to inform further improvements in maternal-related public health policies.

METHODS

Incidence and disability-adjusted life-year (DALY) data on MOLUR from 1990 to 2021 were collected in the GBD 2021. The joinpoint and Bayesian age-period-cohort models were used to analyse and predict time burden trends. The slope index and concentration index were used to evaluate health inequality. Frontier analysis was used to visualise the potential for burden reduction in individual countries or territories.

RESULTS

In 2021, 13,471,093 (95% uncertainty interval [UI] 8,938,373, 19,008,282) incident cases of MOLUR were reported worldwide, which caused 1,067,270 (95% UI 896,161, 1,275,042) DALYs. Over the past three decades, there has been an overall downward trend in the age-standardised incidence rate (ASIR) and age-standardised DALY rate (ASDR) of MOLUR globally, with the ASIR decreasing from 554.0 (95% UI 355.6, 786.3) per 100,000 in 1990 to 347.0 (95% UI 228.8, 489.4) in 2021. The ASDR decreased from 65.4 (95% UI 56.0, 75.7) per 100,000 in 1990 to 27.0 (95% UI 22.7, 32.2) in 2021. By 2040, the global ASIRs and ASDRs projections for MOLUR will likely continue to decline. Socioeconomic-related inequalities are narrowing, but the burden remains concentrated in low socioeconomically developed countries. Israel and Afghanistan showed the largest differences from the frontier boundaries of ASIR and ASDR.

CONCLUSIONS

Although the global burden of MOLUR has declined in the last three decades, it remains high and is still concentrated in economically underdeveloped countries. The reduction in DALYs attributable to MOLUR globally reflects significant progress in improving maternal health and reducing complications of childbirth.

Trend, prevalence, and associated factors of uterine rupture at Nekemte Specialized Hospital, Oromia Regional State, Western Ethiopia

Maternal morbidity and mortality have long been among the world's most challenging health issues. Uterine rupture is one of the peripartum complications that kills almost one in every thirteen mothers. However, there is limited evidence on uterine rupture trends, proportions, and determinants. Thus, this study assessed the trend, prevalence, and associated factors of uterine rupture at Nekemte Specialized Hospital, Oromia Regional State, Western Ethiopia. An institution-based cross-sectional study was conducted among 2661 clients selected using a systematic random selection technique among the data collected for the project between January 2014 and December 2022 at Nekemte Specialized Hospital. Data were collected through an interview-administered questionnaire and card review from March 2023 to August 2023. The collected data were checked, coded, and entered into Epi info version 7.2 and then exported to SPSS Version 27 for analysis. Logistic regression models were fitted to identify the factors of uterine rupture. Adjusted odds ratio with 95% Confidence Interval was estimated to measure the strength of the association, and statistical significance was declared at a p-value less than 0.05. The trend of uterine rupture declined from 1.54% in 2014 to 0.93% in 2022. The overall prevalence was 3.53% (95%CI: 2.7%, 4.3%). Low household income (Adjusted OR = 3.75, 95%CI: 1.97, 7.13), grandmultiparity (Adjusted OR = 7.78, 95%CI: 4.70, 12.88), having a history of obstetrics complications such as prolonged labor (Adjusted OR = 3.78, 95%CI:2.11, 6.75), a history of cesarean section (Adjusted OR = 2.49, 95%CI:1.42, 4.35), and history of uterine repair (Adjusted OR = 18.01, 95%CI: 6.81, 47.64) were significantly associated with uterine rupture. This finding showed that the trend is declining, and the proportion of uterine rupture is still higher. A more vigilant approach to increase access to lower-income mothers, prevent prolonged and obstructed labor, and maintain antenatal care with complete packages and a referral system are issues to be addressed to minimize the chance of uterine rupture among women.

Risk factors for maternal complications following uterine rupture: a 12-year single-center experience

PURPOSE

To determine maternal outcomes and risk factors for composite maternal morbidity following uterine rupture during pregnancy.

METHODS

A retrospective cohort study including all women diagnosed with uterine rupture during pregnancy, between 2011 and 2023, at a single-center. Patients with partial uterine rupture or dehiscence were excluded. We compared women who had composite maternal morbidity following uterine rupture to those without. Composite maternal morbidity was defined as any of the following: maternal death; hysterectomy; severe postpartum hemorrhage; disseminated intravascular coagulation; injury to adjacent organs; admission to the intensive care unit; or the need for relaparotomy. The primary outcome was risk factors associated with composite maternal morbidity following uterine rupture. The secondary outcome was the incidence of maternal and neonatal complications following uterine rupture.

RESULTS

During the study period, 147,037 women delivered. Of them, 120 were diagnosed with uterine rupture. Among these, 44 (36.7%) had composite maternal morbidity. There were no cases of maternal death and two cases of neonatal death (1.7%); packed cell transfusion was the major contributor to maternal morbidity [occurring in 36 patients (30%)]. Patients with composite maternal morbidity, compared to those without, were characterized by: increased maternal age (34.7 vs. 32.8 years, p = 0.03); lower gestational age at delivery (35 + 5 vs. 38 + 1 weeks, p = 0.01); a higher rate of unscarred uteri (22.7% vs. 2.6%, p < 0.01); and rupture occurring outside the lower uterine segment (52.3% vs. 10.5%, p < 0.01).

CONCLUSION

Uterine rupture entails increased risk for several adverse maternal outcomes, though possibly more favorable than previously described. Numerous risk factors for composite maternal morbidity following rupture exist and should be carefully assessed in these patients.

Case-control study on determinants of uterine rupture among mothers who gave birth at Hawassa University comprehensive specialized hospital

BACKGROUND

Uterine rupture is defined as tearing of the uterine wall during pregnancy or delivery. It can occur during pregnancy or labor and delivery. Rupture of the uterus is a catastrophic event resulting in the death of the baby, and severe maternal morbidity and mortality Despite different interventions done by stakeholders, it remained one of the leading public problems in developing countries like Ethiopia.

OBJECTIVE

This study assessed the prevalence and determinants of uterine rupture among mothers who gave birth at Hawassa University comprehensive specialized hospital from July 2015 to June 2020G.C.

METHOD

A case-control study was conducted by reviewing data from a total of 582 patient charts which include 194 cases and 388 controls with a case-to-control ratio of 1:2. Then the data was extracted using a pre-tested and structured data extraction sheet. Data were entered using Epi data 3.1 and exported to SPSS and analyzed using SPSS 20. The association between independent variables and uterine rupture was estimated using an odds ratio with 95% confidence intervals. The statistical significance of the association was declared at P-value < 0.05.

RESULT

There were a total of 22,586 deliveries and 247 confirmed cases of uterine rupture which makes the prevalence 1.09%. Lack of ANC (Ante-natal care) (AOR = 7.5; 95% CI: 1.9-30.3) inadequate ANC (AOR = 2.45; 95% CI: 1.1-5.57), gravidity ≥5 (AOR = 3.3; 95% CI: 1.36-8.12), obstructed labor (AOR = 38.3; 95% CI: 17.8-82.4) and fetal macrosomia (AOR = 8; 95% CI: 17.8-82.4) are variables which increase the odds of developing uterine rupture. Mothers without additional medical or obstetric conditions are more likely (AOR = 4.2; 95% CI: 2.1-8.65) to develop uterine rupture than mothers with additional medical or obstetric conditions.

CONCLUSION

The prevalence of uterine rupture is high in the study area. The study also revealed that a decrease in ANC follow-up, gravidity of ≥5, obstructed labor, and fetal weight of >4kg are significantly associated with uterine rupture. Improving the quality of ANC follow-up, intrapartum follow-up and proper estimation of fetal weight are recommended interventions from the study.

The Siege of Ayder Hospital: A Cri de Coeur From Tigray, Ethiopia

The use of rape, starvation, and the destruction of healthcare infrastructure by the Ethiopian government violates the laws of war and the Geneva Conventions.

In November 2020, the federal government of Ethiopia invaded its northern region of Tigray, in collusion with the Government of Eritrea and ethnic Amhara militias. The invading forces pillaged the schools, destroyed the transportation infrastructure, burned crops and killed livestock, and looted the health care system. Thousands of civilians were killed, often in extrajudicial executions. Thousands of Tigrayan women were raped. Tens of thousands of Tigrayans fled to Sudan as refugees. Hundreds of thousands face famine and millions more have been internally displaced. The region is under a total communications blackout. The banking system has collapsed. The federal government has harassed external aid workers and imposed a de facto blockade on all medicines and famine relief. A man-made humanitarian catastrophe unlike any in recent memory is unfolding. The world medical community must speak up. The madness must stop.

Ruptured uterus: Frequency, risk factors and feto-maternal outcome: Current scenario in a low-resource setup

INTRODUCTION

Pakistan is among the countries with the highest maternal death rates. Obstetric hemorrhage accounts for 41% of these deaths. Uterine rupture is a grave obstetric emergency with high maternal and neonatal morbidity and mortality. It is important to identify its frequency and associated risk factors to formulate programs for its prevention and management. This study aimed to assess the frequency, associated risk factors, fetomaternal outcomes, and management of women with the ruptured uterus at our hospital.

MATERIAL AND METHODS

It was a retrospective study of 206 women to review data collected from cases of uterine rupture managed at the WCTH Bannu, Pakistan from October 2016 to October 2018. A structured proforma was designed and used to extract data from operating theatre registers and the hospital medical records. In our hospital, there is a strong system of maintaining all information of the patients related to demographics, obstetric information, operative notes, and postoperative course during their hospital stay in the patient's charts. Detailed information on operative procedures is further maintained in the operation theater register and all these registers are checked in the weekly statistical meetings to ensure proper documentation. Data was entered and analyzed in SPSS package version 21 (IBM Corp.; Armonk, NY, USA). Frequency and percentages were calculated for the categorical variables. For inferential statistics, chi-square or Fischer exact tests were used. A p-value of < 0.05 was considered statistically significant.

RESULTS

The overall incidence of the ruptured uterus was 1.71%. The important etiological factors were grand multiparity 62 (35.2%), obstructed/neglected labour 58 (32.9%), injudicious use of Oxytocin 56 (31.8%) and prostaglandins 26 (14.7%), previous cesarean section 35 (19.8%) and previous pelvic surgery (0.5%). Hysterectomy was done in 80.6% of cases, 34 (19.2%) patients underwent uterine repair and 4.5% had bladder repair. The mortality rate was 21%, mainly due to irreversible shock or disseminated intravascular coagulation. Perinatal mortality was 91.4%. Duration of surgery more than two hours and presentation to the hospital at night time was significantly associated with poor maternal outcome (p = 0.00).

CONCLUSION

Uterine rupture is a preventable obstetric emergency associated with high fetomaternal morbidity and mortality. The main causes were grand multigravidity, obstructed labour, previous C-sections and injudicious use of oxytocin and prostaglandins. Women with prolonged surgery and admission at night time had a poor maternal outcome.

Risk Factors Associated with Uterine Rupture and Dehiscence: A Cross-Sectional Canadian Study

OBJECTIVE

 To compare maternal and perinatal risk factors associated with complete uterine rupture and uterine dehiscence.

METHODS

 Cross-sectional study of patients with uterine rupture/dehiscence from January 1998 to December 2017 (30 years) admitted at the Labor and Delivery Unit of a tertiary teaching hospital in Canada.

RESULTS

 There were 174 (0.1%) cases of uterine disruption (29 ruptures and 145 cases of dehiscence) out of 169,356 deliveries. There were associations between dehiscence and multiparity (odds ratio [OR]: 3.2; p = 0.02), elevated maternal body mass index (BMI; OR: 3.4; p = 0.02), attempt of vaginal birth after a cesarian section (OR: 2.9; p = 0.05) and 5-minute low Apgar score (OR: 5.9; p < 0.001). Uterine rupture was associated with preterm deliveries (36.5 ± 4.9 versus 38.2 ± 2.9; p = 0.006), postpartum hemorrhage (OR: 13.9; p < 0.001), hysterectomy (OR: 23.0; p = 0.002), and stillbirth (OR: 8.2; p < 0.001). There were no associations between uterine rupture and maternal age, gestational age, onset of labor, spontaneous or artificial rupture of membranes, use of oxytocin, type of uterine incision, and birthweight.

CONCLUSION

 This large cohort demonstrated that there are different risk factors associated with either uterine rupture or dehiscence. Uterine rupture still represents a great threat to fetal-maternal health and, differently from the common belief, uterine dehiscence can also compromise perinatal outcomes.

Maternal and perinatal mortality and morbidity of uterine rupture and its association with prolonged duration of operation in Ethiopia: A systematic review and meta-analysis

Background

Uterine rupture is the leading cause of maternal and perinatal morbidity and it accounts for 36% of the maternal mortality in Ethiopia. The maternal and perinatal outcomes of uterine rupture were inconclusive for the country. Therefore, this systematic review and meta-analysis aimed to estimate the pooled maternal and perinatal mortality and morbidity of uterine rupture and its association with prolonged duration of operation.

Methods

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist was used for this systematic review and meta-analysis. We systematically used PubMed, Cochrane Library, and African Journals online databases for searching. The Newcastle- Ottawa quality assessment scale was used for critical appraisal. Egger’s test and I² statistic used to assess the check for publication bias and heterogeneity. The random-effect model was used to estimate the pooled prevalence and odds ratios with 95% confidence interval (CI).

Results

The pooled maternal mortality and morbidity due to uterine rupture in Ethiopia was 7.75% (95% CI: 4.14, 11.36) and 37.1% (95% CI: 8.44, 65.8), respectively. The highest maternal mortality occurred in Southern region (8.91%) and shock was the commonest maternal morbidity (24.43%) due to uterine rupture. The pooled perinatal death associated with uterine rupture was 86.1% (95% CI: 83.4, 89.9). The highest prevalence of perinatal death was observed in Amhara region (91.36%) and the lowest occurred in Tigray region (78.25%). Prolonged duration of operation was a significant predictor of maternal morbidity (OR = 1.39; 95% CI: 1.06, 1.81).

Conclusions

The percentage of maternal and perinatal deaths due to uterine rupture was high in Ethiopia. Uterine rupture was associated with maternal morbidity and prolonged duration of the operation was found to be associated with maternal morbidities. Therefore, birth preparedness and complication readiness plan, early referral and improving the duration of operation are recommended to improve maternal and perinatal outcomes of uterine rupture.

Burden of Uterine Rupture and Its Determinant Factors in Ethiopia: A Systematic Review and Meta-analysis

Background. Uterine rupture is a life-threatening obstetrical emergency, which results in serious undesired maternal and perinatal complications in resource-limited countries, mainly in Ethiopia. The prevalence, determinants, and outcomes of uterine rupture described by different studies were highly inconsistent in Ethiopia. Therefore, this systematic review and meta-analysis is aimed at estimating the pooled prevalence, determinants, and adverse outcomes of uterine rupture in Ethiopia. Methods. Studies were searched from international databases (PubMed/MEDLINE, HINARI, Cochrane library, Google Scholar, and web of science) and Ethiopian universities’ digital libraries (Addis Ababa University, University of Gondar, and Harameya University). All observational studies were included. A total of 15 studies that fulfill the inclusion criteria were included in this meta-analysis. Data were extracted by two reviewers and exported to STATA version 11 for analysis. The $I^2$ statistics were used to assess heterogeneity across the studies. Publication bias was examined by using Egger’s test and funnel plot. The pooled prevalence of uterine rupture and its outcomes were estimated by using a random effects model. The associations between determinants and uterine rupture were evaluated by using both random and fixed-effect models. Results. In this meta-analysis, a total of 15 studies with 92,394 study participants were involved. The pooled prevalence of uterine rupture was 2.37% in Ethiopia. Obstructed labor ( $\text{OR}=3.03$ ; $95\%\text{CI}=2.52,3.63$ ), lack of antenatal care follow-up ( $\text{OR}=5.79$ ; $95\%\text{CI}=2.47,13.61$ ), duration of $\text{labor}>24$ hours ( $\text{OR}=3.75$ ; $95\%\text{CI}=2.24,6.29$ ), grand multipara ( $\text{OR}=10.79$ ; $95\%\text{CI}=4.77,24.40$ ), and being rural residency ( $\text{OR}=7.17$ ; $95\%\text{CI}=3.90,13.16$ ) were significantly associated with uterine rupture. Conclusion. The overall prevalence of uterine rupture was high in Ethiopia. Obstructed labor, lack of antenatal care follow-up, duration of $\text{labor}>24$ hours, grand multipara, and rural residency were determinants of uterine rupture. This study implies the need to develop plans and policies to improve antenatal care follow-up and labor and delivery management at each level of the health system.

Prevalence and predictors of uterine rupture among Ethiopian women: A systematic review and meta-analysis

Background

Uterine rupture has a significant public health importance, contributing to 13% of maternal mortality and 74%-92% of perinatal mortality in Sub-Saharan Africa, and 36% of maternal mortality in Ethiopia. The prevalence and predictors of uterine rupture were highly variable and inconclusive across studies in the country. Therefore, this systematic review and meta-analysis aimed to estimate the pooled prevalence and predictor of uterine rupture in Ethiopia.

Methods

This systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2009 checklist. PubMed, Cochrane Library, Google Scholar, and African Journals Online databases were searched. The Newcastle- Ottawa quality assessment tool was used for critical appraisal. I² statistic and Egger’s tests were used to assess the heterogeneity and publication bias, respectively. The random-effects model was used to estimate the pooled prevalence and odds ratios with a 95% confidence interval.

Results

Sixteen studies were included, with a total of 91,784 women in the meta-analysis. The pooled prevalence of uterine rupture was 2% (95% CI: 1.99, 3.01). The highest prevalence was observed in the Amhara regional state (5%) and the lowest was in Tigray region (1%). Previous cesarean delivery (OR = 9.95, 95% CI: 3.09, 32.0), lack of antenatal care visit (OR = 8.40, 95% CI: 4.5, 15.7), rural residence (OR = 4.75, 95% CI: 1.17, 19.3), grand multiparity (OR = 4.49, 95% CI: 2.83, 7.11) and obstructed labor (OR = 6.75, 95%CI: 1.92, 23.8) were predictors of uterine rupture.

Conclusion

Uterine rupture is still high in Ethiopia. Therefore, proper auditing on the appropriateness of cesarean section and proper labor monitoring, improving antenatal care visit, and birth preparedness and complication readiness plan are needed. Moreover, early referral and family planning utilization are the recommended interventions to reduce the burden of uterine rupture among Ethiopia women.

Incidence and factors associated with outcomes of uterine rupture among women delivered at Felegehiwot referral hospital, Bahir Dar, Ethiopia: cross sectional study

Background

Maternal mortality is a major public health challenge in Ethiopia. Uterine rupture is an obstetrical emergency with serious undesired complications for laboring mothers resulting in fatal maternal and neonatal outcomes. Uterine rupture has been contributing to high maternal morbidity and mortality. However, there is limited research on the factors and management outcomes of women with uterine rupture. Understanding the factors and management outcomes might delineate strategies to support survivors. Therefore the aim of this study is to assess the incidence and factors associated with outcomes of uterine rupture among laboring mothers at Felegehiwot Referral Hospital in Bahir Dar City, Northwest Ethiopia.

Methods

This is a cross sectional study with retrospective facility based data collection technique. All pregnant women who were managed for ruptured uterus at Felegehiwot referral hospital from September 11 2012 to August 30 2017 were included. The chart numbers of the women collected from operation theatre registers. Their case folders retrieved from the medical records room for analysis. Using structured check list, information on their sociodemography, booking status, clinical features at presentation and the place of attempted vaginal delivery was extracted. Data on the intraoperative findings, treatment, and associated complications and outcomes also collected. The collected data cleaned, coded and entered into EPI- Info version (7.1.2.0) and then exported in to SPSS Version 20.0 for analysis. Statistical comparison was done using chi square (X²). Strength of association between the explanatory variables and outcome variables described using odds ratio at 95% CI and P value less than 0.05. The results presented in tables.

Results

We studied 239 cases of uterine rupture in the 5 years period. Mothers without previous cesarean delivery including eight primigravidas took 87% of the cases. From all study participants, 54 of mothers (22.6%) developed undesired outcomes whereas 185(77.4%) discharged without major sequel. More than half (56.9%) arrived in hypovolemic shock. Total abdominal hysterectomy was the commonest procedure accounting for 61.5%. Duration of surgery was less than 2 h in 67.8% of the procedures. Anemia is the commonest complication (80.3%) followed by wound infection and VVF (11.7% each). There were 5 maternal deaths (2.1%). Mothers who had prolonged operation time (> 2 h) (AOR: 2.2, 95% CI: 1.10, 4.63) were significantly associated with undesired maternal outcomes after management of uterine rupture.

Conclusion

Incidence of ruptured uterus and its complications were high in the study area. It reflects the need for improvement in obstetric care and strong collaboration with referring health facilities to ensure prompt referral and management.

High rate of uterine rupture in a conflict setting of Hajjah, Yemen

A descriptive study was conducted to investigate the epidemiology and the outcome of uterine rupture at Hajjah Hospital, Yemen, during September 2014-August 2016. There were 110 cases of ruptured uterus and 3457 deliveries (31.8 per 1000 delivery). The majority (82, 74.5%) of these patients were illiterate. One hundred and four (96.3%) of them had no antenatal care. Seventy-eight of these women (70.9%) delivered at home and 32 (29.1%) delivered at hospital. Out of these 110 cases, 74 (67.3%) and 36 (32.7%) had unscarred uterus and scarred uterus, respectively. The causes of ruptured uterus were as follows: obstructed labour 59 (53.6%), previous caesarean delivery 36 (32.7%), use of oxytocin 10 (9.1%) and misoprostol 5 (4.6%). Hysterectomy was carried out in 50 (45.4%) %), repair in 39 (35.4%), repair with tubal ligation in 18 (16.4%) patients and 3 (2.7%) patients died before operation. There was 8 (7.2%) and 101 (91.8%) maternal and perinatal mortality, respectively. Nineteen (17.3%), 6 (5.4%) and 2 (1.8%) women developed sepsis, had urinary bladder injury and developed vesicovaginal fistulae, respectively.

Evaluation of obstetricians' surgical decision making in the management of uterine rupture

Background

Uterine rupture is an obstetric calamity with surgery as its management mainstay. Uterine repair without tubal ligation leaves a uterus that is more prone to repeat rupture while uterine repair with bilateral tubal ligation (BTL) or (sub)total hysterectomy predispose survivors to psychosocial problems like marital disharmony.

This study aims to evaluate obstetricians’ perspectives on surgical decision making in managing uterine rupture.

Methods

A questionnaire-based cross-sectional study of obstetricians at the 46th annual scientific conference of Society of Gynaecology and Obstetrics of Nigeria in 2012. Data was analysed by descriptive and inferential statistics.

Results

Seventy-nine out of 110 obstetricians (71.8%) responded to the survey, of which 42 (53.2%) were consultants, 60 (75.9%) practised in government hospitals and 67 (84.8%) in urban hospitals, and all respondents managed women with uterine rupture. Previous cesarean scars and injudicious use of oxytocic are the commonest predisposing causes, and uterine rupture carries very high incidences of maternal and perinatal mortality and morbidity. Uterine repair only was commonly performed by 38 (48.1%) and uterine repair with BTL or (sub) total hysterectomy by 41 (51.9%) respondents. Surgical management is guided mainly by patients’ conditions and obstetricians’ surgical skills.

Conclusion

Obstetricians’ distribution in Nigeria leaves rural settings starved of specialist for obstetric emergencies. Caesarean scars are now a rising cause of ruptures. The surgical management of uterine rupture and obstetricians’ surgical preferences vary and are case scenario-dependent. Equitable redistribution of obstetricians and deployment of medical doctors to secondary hospitals in rural settings will make obstetric care more readily available and may reduce the prevalence and improve the outcome of uterine rupture. Obstetrician’s surgical decision-making should be guided by the prevailing case scenario and the ultimate aim should be to avert fatality and reduce morbidity.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-017-1367-8) contains supplementary material, which is available to authorized users.

A case-control study of the risk factors for obstetric fistula in Tigray, Ethiopia

INTRODUCTION AND HYPOTHESIS

We tested the null hypothesis that there were no differences between patients with obstetric fistula and parous controls without fistula.

METHODS

A unmatched case-control study was carried out comparing 75 women with a history of obstetric fistula with 150 parous controls with no history of fistula. Height and weight were measured for each participant, along with basic socio-demographic and obstetric information. Descriptive statistics were calculated and differences between the groups were analyzed using Student's t test, Mann-Whitney U test where appropriate, and Chi-squared or Fisher's exact test, along with backward stepwise logistic regression analyses to detect predictors of obstetric fistula. Associations with a p value <0.05 were considered significant.

RESULTS

Patients with fistulas married earlier and delivered their first pregnancies earlier than controls. They had significantly less education, a higher prevalence of divorce/separation, and lived in more impoverished circumstances than controls. Fistula patients had worse reproductive histories, with greater numbers of stillbirths/abortions and higher rates of assisted vaginal delivery and cesarean section. The final logistic regression model found four significant risk factors for developing an obstetric fistula: age at marriage (OR 1.23), history of assisted vaginal delivery (OR 3.44), lack of adequate antenatal care (OR 4.43), and a labor lasting longer than 1 day (OR 14.84).

CONCLUSIONS

Our data indicate that obstetric fistula results from the lack of access to effective obstetrical services when labor is prolonged. Rural poverty and lack of adequate transportation infrastructure are probably important co-factors in inhibiting access to needed care.

Recent developments have made female permanent contraception an increasingly attractive option, and pregnant women in particular ought to be counselled about it

BACKGROUND

Despite the increased prevalence of reversible contraception, global unintended pregnancy rates are stable. Mistakes, method failures, side effects, alcohol, stock-outs, fears, costs, delays, myths, religious interference, doctors with other priorities, traditions and lack of health professionals may all factor in. Yet these unintended pregnancies - nearly a hundred million annually - cause much individual suffering, and in the long run, can aggravate conflicts, poverty, forced emigration and climate change. Presently, non-poor women postpone childbearing because of longer educational trajectories and careers. Sterilisations are therefore less often regretted or coerced. For poor-resourced women with a completed family, an unwanted pregnancy often has serious consequences, including crossing the (extreme) poverty line in the wrong direction, choosing an unsafe abortion, or even death. Caesarean sections (CSs), which currently stand at around 23 million annually, are increasing. On an "intention-never-to-become-pregnant-again" analysis, choosing a partial, and even more so a total bilateral tubectomy to be implemented during an - anyway performed - CS is by far the most reliable and safe contraceptive choice compared to meaning to start female or male sterilisation or any other contraceptive method later, and it reduces the chance of a future ovarian carcinoma substantially. CSs make subsequent pregnancies more dangerous. Simultaneously, they provide convenient, potentially cost-free opportunities for voluntary permanent contraception (PC): particularly important if there is no guaranteed future access to reliable contraception, safe abortion and well-supervised labour.

PARTIAL SOLUTION

Millions of women are within reach of attaining freedom from the "tyranny of excessive fertility" when they have a CS. Therefore, any woman who might conceivably be of the firm opinion that her family will be (over) completed after delivery should antenatally have "what if you have a CS" counselling to assess whether she would like a tubectomy/ligation. Yet many are not provided with this option: leading to frequent regret, more often than having been giving that choice would.

CONCLUSION

Withholding antenatal counselling about the option of PC for in case the delivery might become a CS is very prevalent, yet often more medically risky, and morally questionable than when, even in labour, a doctor sometimes decides in the absence of earlier counselling, considering numerous factors, to provide the choice to undergo a concurrent sterilisation if s/he is convinced that would be in the patient's best interest.

Management of uterine rupture: a case report and review of the literature

Background

Maternal morbidity and mortality has been a major World Health Organization concern over the years, especially in sub-Saharan Africa. This paper reports uterine rupture with severe hypovolemic shock managed at the Douala General Hospital, Cameroon. Early clinical diagnosis is paramount to maternal survival.

Case presentation

Mrs. MM aged 25 years, G3P2012, of the Bamileke tribe in Cameroon was admitted to our Department in hypovolemic shock BP = 70/40 mmHg, pulse 120 beats per minute, with altered consciousness (Glasgow Coma Scale = 13). She has a history of missed abortion at 19 weeks gestation and an attempt to evacuate the uterus with misoprostol that led to uterine rupture. She underwent a total abdominal hysterectomy and blood transfusion. Her post-operative stay in hospital was uneventful.

Conclusion

Uterine rupture is a complication that can be eliminated under conditions of best obstetric practice. To attain this objective, use of misoprostol in primary health facilities should be stopped or proper management of the medication instituted. The survival of patients after uterine rupture depends on the time interval between rupture and intervention, and the availability of blood products for transfusion.