Trend, prevalence, and associated factors of uterine rupture at Nekemte Specialized Hospital, Oromia Regional State, Western Ethiopia – Nature.com 04:15 

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Scientific Reports volume 14, Article number: 25722 (2024) 

Abstract

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.

Introduction

Uterine rupture is the total nonsurgical disruption of all uterine layers (endometrium, myometrium, and serosa). Complete rupture involves the entire uterine wall thickness, whereas incomplete rupture occurs when the serosa remains intact. The gravid uterus ruptures during childbirth, intrapartum, and postpartum; however, it can happen throughout pregnancy without causing labor in rare circumstances1. It is a severe obstetric complication that contributes considerably to maternal and neonatal death and morbidity1,2,3,4, which is associated with acute problems such as severe anemia, shock, and a ruptured bladder. Women who survive may have long-term complications like vesicovaginal fistula, foot drop, and future infertility after hysterectomy or tubal ligation5,6,7,8,9.

In developed countries, the prevalence rate of uterine rupture is extremely low at 0.006%. in which most cases of uterine rupture occur after prior cesarean section10. In contrast, it is 25% for women with obstructed labor in low- and middle-income countries11. It is 0.5% in women who have uterine scars12. The prevalence following the uterine scar is 1% in low-and-middle-income countries and 0.2% in high-income countries12,13,14. It is also shown to be common in low-and middle-income countries, with rates ranging from 0.12% to 3.38 14–17. Likewise, in facility-based research conducted in Ethiopia, the prevalence ranges from 0.9 to 16.68% 8,18,19,20,21. However, uterine rupture was much less common in population-based research (median 0.053%, range 0.016-0.30%) than in those conducted in facilities (median 0.31%, range 0.012-2.9%)10. A study conducted in Ethiopia also indicated that the trend of uterine rupture declined from 2.02 to 0.4% in a five-year study period22.

Maternal mortality remains unacceptably high worldwide, with 95% of deaths occurring in low-resource settings13. Sub-Saharan Africa alone accounted for around 70% of maternal deaths (202, 000)13. In Ethiopia, obstructed labor significantly contributes to maternal deaths (22.34), with uterine rupture playing a role ranging from 2.1 to 11.2%8,18,19,20,21. Survivors face additional obstetrical challenges, including an obstetric fistula, anemia, infection, and fetal loss8,19,20,21. Interestingly, fetal loss is less frequent in scarred uterine rupture compared to unscarred uterine rupture10,12.

Studies revealed that many risk factors have been linked to an increased risk of uterine rupture22,23,24,25. High parities, lack of antenatal care (ANC), rural residency, malpresentation, previous history of uterine scar, congenital abnormalities, absence of employing partograph, obstructed labor, and macrosomia are some of the risk factors related to uterine rupture26,27,28,29. However, there are discrepancies in the research about the causes of uterine rupture. Factors influencing uterine rupture differ among locations because of maternal characteristics, healthcare delivery system, and reception change12. Though some studies have been conducted in various parts of the country, they must be more comprehensive and show differences in elements linked with the condition.

Maternal mortality remains a critical global health challenge and achieving sustainable development goal (SDG) targets is paramount. The overarching objective is to reduce maternal mortality to fewer than 70 per 100,000 births by 2030 30, is ambitious but essential. However, Ethiopia faces significant hurdles on this path. The 2016 Ethiopian Demographic Health Survey revealed an alarming maternal mortality ratio (MMR) of 412 per 100,000 deliveries31. Among the various contributors to maternal mortality, uterine rupture stands out due to its devastating consequences: short-term difficulties and long-term complications, maternal death, and perinatal mortality.

Despite its impact, a critical gap exists, and comprehensive evidence on the incidence and underlying causes of uterine rupture within health facilities remains elusive. This lack of clarity hampers effective prevention and life-saving interventions. Therefore, our study takes a pioneering approach by focusing on the trend, prevalence, and associated factors of uterine rupture among obstetric cases, specifically at Nekemte Specialized Hospital. Thus, by zooming in on a specific healthcare setting, our study provides a granular understanding of uterine rupture patterns. This localized perspective allows us to uncover nuances that might be missed in broader national or regional analyses. Nekemte Specialized Hospital serves as a microcosm of Ethiopia’s maternal health challenges. Our findings will offer context-specific insights, informing tailored interventions that resonate with the realities faced by healthcare practitioners and expectant mothers. Armed with evidence, we aim to guide essential areas of attention. Clinical practitioners can refine their management protocols, while maternal health program designers can effectively adapt strategies to address this critical issue. In summary, our study bridges the evidence gap, sheds light on uterine rupture, and contributes to lowering maternal morbidity and preventing avoidable maternal deaths. Importantly, by doing so, we take a significant step toward achieving the SDG vision of safer childbirth experiences for all, demonstrating the broader implications of our work.

Methods

Study setting, period, and design

An institution-based cross-sectional study was conducted using data collected from a project on uterine rupture between January 2014 and December 2022 in Nekemte Specialized Hospital, found in Nekemte Town. This study was conducted from March 2023 to August 2023. Being one of the region’s oldest hospitals, it has an enormous burden to provide the public with a comprehensive spectrum of healthcare services that are promotive, curative, rehabilitative, and preventive. It is 331 km from Addis Ababa, the capital city of Ethiopia, to the west. It has provided service for the past 90 years with a few renovations and expansions. Specialized hospital was issued in 2020 by the Federal Ministry of Health and Oromia Regional Health Bureau. It is one of the specialized hospitals in the region as the population getting served from the hospital has exponentially increased to reach the current catchment population of 3.5 million, serving as a referral center for the western part of Ethiopia for about 11 million.

Beginning in 2018, the hospital management and governing board decided to launch new services due to the exponential rise in the need for community health-seeking behavior. These services included a fully furnished adult intensive care unit (ICU) service, a separate Obstetrics operation theater (OR), burn units, lithotripsy units, pathology units with pathologists, orthopedics units with surgeons who specialize in road traffic accidents (RTA), and radiology units with radiologists. Thus, the hospital has 250 beds and multiple departments, such as internal medicine, surgery, pediatrics and neonatology, obstetrics and gynecology, and emergency room; additionally, there are 32 general practitioners, three internists, two pediatricians, four surgeons, four emergency surgeons, three gynecologists and obstetricians, and other health professionals. The obstetrics and gynecology units are staffed by three obstetricians and gynecologists, two emergency surgeons, one general practitioner, and 18 midwives. The obstetrics and gynecology unit offers 44 beds and four delivery couches for all obstetric and gynecologic situations. The facility also features a neonatal intensive care unit (NICU) staffed by two pediatricians. The hospital serves 2 million people in the East Wallaga and neighboring zones.

Study participants

The source population was all women who had given birth in Nekemte Specialized Hospital and their records between January 2014 and December 2022. The records of mothers with incomplete documentation (no proper maternal parameters) (those with a lack of more than 20% of data), lost charts, medico-legal cases, and mothers who were critically ill and unable to communicate appropriately were excluded.

Sample size determination

The sample size was calculated using a single population proportion formula based on the following assumptions. According to a systematic review of uterine rupture conducted by WHO, the prevalence globally ranges from 0.31 to 2.9%, i.e., the average being 1.6% (p = 0.016)10. A confidence level of 95% (α = 0.005, Z α/2 = 1.96). The expected proportion is 29 per 1000 deliveries with the margin of error (d) = 0.05); this calculation gives a sample size of 2419.

αn=(Zα2)2p(1−p)(d)2=(1.96)20.016(1−0.016)(0.005)2=2419

where n is the maximum possible sample size, Z α/2 refers to the critical value from the standard normal distribution corresponding to α/2 (for a two-tailed test), p is the population proportion, and d is the margin of error. Finally, 10% (241.9) for non-responses was added, and the final sample size was 2661.

Sampling procedure

Due to the referral nature and high flow of clients, Nekemte Specialized Hospital was selected conveniently. Accordingly, 37,748 laboring women admitted to the obstetrics ward of Nekemte specialized hospital in the preceding nine years were included. Systematic random sampling was used to select the study participants. The sampling interval was calculated by dividing the number of laboring mothers admitted to the obstetrics ward (N = 37,748) at Nekemte Hospital by the total sample size (n = 2661). Participants were selected systematically: starting with the second participant (number 2), every 14th individual was included. The initial participant was obtained using a lottery method, and subsequent participants followed this fixed interval pattern. This approach ensures a representative sample while maintaining consistency in participant selection. When there were incomplete charts, the charts immediately went to the incomplete chart and were included. However, due to the different numbers of deliveries per year, the estimated sample size was estimated proportional to the number of deliveries per year (Fig. 1).

figure 1
Fig. 1

Data collection tools and procedure

Data were collected using a combination of a structured interviewer-administered questionnaire and a client’s chart review. The questionnaire was adapted from different works of literature22,32. The questionnaire was designed to obtain participants’ information on sociodemographic characteristics and obstetrics factors. A structured checklist was used to extract data from the records recorded over nine years, which was used to retrieve medical information that the interview could not capture. This record review checklist had all required variables designed to extract data from the logbook, which was collected for the project. The questionnaire and the checklist were categorized into two parts; the first includes sociodemographic factors, and the second consists of obstetrics-related factors. Data were collected by five midwives who can speak Afan Oromo and Amharic language using card review and interviewer-administered questionnaires. The five midwives were oriented on filling in the information sheets from data collected for the project at Nekemte specialized hospital. Two integrated emergency obstetrics and surgery professionals supervised the data collection process. After the data was collected, the investigator revised it for completeness. Data collection started from the admission of a mother to the labor ward and lasted till the mother was discharged from the labor and delivery ward. Data were collected throughout the day (including night).

Data quality control

To ensure the quality of data gathered from the study subjects, the questionnaire was initially developed in English and translated into the local languages (Afan Oromo and Amharic) before being translated back to English. The instruments were pretested on 133 (5%) of the sample size in similar settings, and necessary modifications were made based on the nature of gaps identified in the questionnaire. It was also adjusted for interviewer-administered interviews. Additionally, the investigator gave data collectors and supervisors two days of training on the questionnaire’s content and how to collect the data. Moreover, the supervisors and the investigators closely followed the day-to-day data collection process during the pretest and the actual data collection. Furthermore, the filled questionnaire was collected and signed by the supervisor after it was checked for any missing items and completeness. Moreover, cross-checking was done on 10% of the sample size.

Study variables and measurement

The dependent variable was uterine rupture. The Independent variables included Sociodemographic Factors, including (the mothers’ age at the time of delivery, Occupation, Educational status, Household monthly income, Marital status, residence, age at first marriage, religion, ethnicity, family size), obstetrics Factors (Parity, gestational age, ANC follow-up, Duration of pregnancy, history of abortion, knowledge about danger signs, knowledge about complication readiness and birth preparedness, labor induction, maternal complications, history of cesarean section, history of uterine repair, fetal weight, and referral.

Uterine rupture refers to the occurrence of complete or incomplete uterine rupture among women delivered in Nekemte Specialized Hospital (0 = No, and 1 = Yes). Monthly income refers to the household’s exact or estimated monthly income, which is a continuous variable measured using the mean value of the monthly salary. The mean was 6331.59 Ethiopian Birr. Thus, the monthly income was categorized below the mean and above the mean monthly income of the household income. Incomplete data: Documents/Medical records that contain any missed parameters of outcome variables and documents that miss > 20% of independent variables (intrapartum and neonatal-related information) were considered incomplete33. Maternal characteristics include a woman’s age at delivery (categorized into < 35 years and ≥ 35 years), parity for the current delivery (organized into 1–4 births, five or more births), gestational age during admission (categorized into < 37 weeks, 37–40 weeks, and > 40 weeks), and fetal weight (categorized into < 2500 g, 2500–3999 g, and > 4000 g), residence (categorized as urban and rural). The following obstetric factors were included as dichotomous variables: induction of labor, prior cesarean delivery, history of abortion, history of abortion with manual vacuum aspiration (MVA) or evacuation and curettage, history of stillbirth, history of obstetrics complications (prolonged labor or obstructed labor), and history of uterine repair. The number of prenatal visits (coded as none, 1–3, ≥ 4) was also included in this analysis. Bad Obstetrics History: was used in obstetrics to describe a mother’s previous obstetric history that may have been complicated by neonatal mortalities or complications, including history of difficult deliveries (i.e., obstructed labor), complications during pregnancy, or adverse consequences, including deaths, for the mother or baby (coded as 0 = No, and 1 = Yes). Birth preparedness and complications readiness were assessed using 12 indicators to evaluate the preparedness of individuals for delivery and its complications. Then, those who answered at least 6 out of 11 components were categorized as “Well Prepared,” and others who answered 5 or < 5 were considered as “Less Prepared.”. Similarly, the Assessment of knowledge of maternal danger signs during pregnancy and delivery was done based on nine and eleven signs, respectively. The knowledge score on maternal danger signs was measured by the total number of correct spontaneous answers given to the key danger signs of the questionnaire. In this study, women who reported at least three danger signs for each phase of pregnancy and delivery spontaneously were considered to have “good knowledge,” and those who reported two or fewer danger signs had “poor knowledge.” Neonatal mortality refers to a neonate’s death due to uterine rupture within the nine years of life. Similarly, maternal death stands for the deaths of the mothers within the nine years due to uterine rupture (coded as 0 = No, and 1 = Yes).

Data management and analysis

The collected data was entered into the statistical software EpInfo version 7.1.1. Then, it was subjected to cleaning using descriptive statistics, such as frequency and tabulation, to ensure the validity of the data. Then, the sampled data were extracted. The entered data was exported to Statistical Package for Social Sciences for Windows version 27 for analysis. Descriptive statistics, such as frequency distribution, were computed to describe the significant variables of the study. We calculated the incidence rate of uterine rupture among mothers admitted to Nekemte Hospital for nine years per year. Similarly, we did a trend forecast analyzing historical data to predict future patterns or trends of uterine rupture. It is relevant in understanding uterine rupture dynamics, healthcare conditions, and the context of hospital care in the study area.

A binary logistic regression model was used to determine a significant association between uterine rupture and its associated factors. Variables with a P-value of less than 0.25 from bivariate analysis were included in multivariable logistic regression. Multivariable logistic regression was used to control the effect of confounding variables. Finally, the statistical significance was declared at P < 0.05. The backward stepwise technique was used to create the regression model. The final fitted model was evaluated for goodness of fit using the Hosmer and Lemeshow test, which was 0.75 [34]. The findings were displayed using tables. The backward stepwise technique was used to create the regression model. Using the Variance Inflation Factor (VIF), which was 2.5 34 and the Hosmer and Lemeshow test, which was 0.75 35, the final fitted model was evaluated for multicollinearity and goodness of fit. The Receiver Operating Characteristics (ROC) curve34,35 was used to evaluate the model’s accuracy in classifying subjects who experience the outcome of interest and those who do not. Using the Akaike Information Criteria (AIC)36, the parsimonious model that best explained the data with the fewest free parameters was chosen. The findings were statistically examined and displayed using tables. The research’s conclusions were the basis for the final interpretation, debate, and suggestion.

Ethics approval and consent to participate

All procedures used in human clinical data studies adhered to the institutional and national research committee’s ethical requirements, the 1964 Helsinki Declaration, and subsequent revisions or comparable ethical standards. The IRB of Jimma University (Ref No JUIH/IRB/587/23) and the Institutional Review Committee of Wallaga University (Ref No CMHS/21/2014 GC) waived the written informed consent requirements and ethics approval were deemed unnecessary according to national regulations as the data used were secondary data from a patient’s records.

Results

Sociodemographic characteristics

A total of 2661 data of mothers were reviewed from the project, making a response rate of 100%. The mean (± standard deviation (SD)) age of women was 26.85± (SD = 5.096) years, and 948 (35.6%) of the mothers were in the age group of 26 to 30 years. Nine hundred forty-one (35.4%) were protestant, 2100 (78.9%) were Oromo, and 1188 (44.6%) were Merchant. Two thousand six hundred twenty-three (98.6%) were currently married, and 2063 (77.5%) were married at the age of 18 or more (Table 1).Table 1 Sociodemographic characteristics of mothers who visited Nekemte Specialized Hospital for delivery service from January 2014 to December 2022 (n = 2661).

Full size table

Obstetrics characteristics

Most (90.8%) of mothers’ gestational age was between 37 and 40 weeks. 2646 (99.4%) had ANC follow-up, and 1765 (66.7%) started their ANC follow-up less than their 12th week of pregnancy. Two hundred fifty-eight mothers had a parity between 1 and 4. Two thousand six hundred twenty-six (98.7%) knew the danger signs of pregnancy, and 2483 (93.3%) knew birth preparedness and complication readiness (Table 2).Table 2 Labor and delivery-related characteristics of a mother who gave birth at Nekemte Specialized Hospital from January 2014 to December 2022 (n = 2661).

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Trends of uterine rupture

The trend data was compiled from 37,748 deliveries made between January 2014 and December 2022 over nine years. There were 510 confirmed occurrences of uterine rupture during these years, resulting in a rupture proportion of 1.35%. The rate of uterine rupture fell from 1.62 to 0.96% during nine years (Fig. 2A). However, trend analysis revealed that the rate of uterine rupture fell from 4.51/1000 to 3.76/1000 among the sampled 2661 women admitted to Nekemte Specialized Hospital (Fig. 2B) (Supplementary Table 1 and Supplementary Table 2). The trend forecast also revealed that uterine rupture is decreasing.

figure 2
Fig. 2

Prevalence of uterine rupture

Among the 2661 documents reviewed, 94 had a uterine rupture, making the prevalence of 3.53% (95%CI: 2.7%, 4.3%). Most (87.2%) of the ruptures were complete, and obstructed labor was the most common cause, making 51.1% of the uterine ruptures. Total abdominal hysterectomy was mainly performed for uterine rupture (Table 3). Among 2661 Mothers, 19 (0.7%) mothers and 149 (5.6%) neonates were died. Uterine rupture was a significant cause of maternal and neonatal deaths, making 6 of the 94, χ2 = 44.17, P < 0.01, and 78 of the 94, χ2 = 1103.78, P < 0.01, respectively. On the other hand, 34 (36.2%) of uterine ruptures occurred on their way from home to the health center (Fig. 3).Table 3 Uterine rupture-related variables of a mother who gave birth at Nekemte Specialized Hospital from January 2014 to December 2022 (n = 2661).

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figure 3
Fig. 3

Factors associated with uterine rupture

Results of binary logistic regression showed that women who resided in a rural area, whose age was greater or equal to 35 years, had more than or equivalent to 5 babies, whose income is less than 6331.59 ETB per month, who had a history of abortion, abortion with MVA or E & C, stillbirth, cesarean section, repair of the uterus were the predictors of uterine rupture. However, women who delivered a baby between 2500 and 3999 g and those who came at the gestational age of less than 37 weeks were protected from uterine rupture.

In multiple binary logistic regression, five variables, i.e., parity, household income, history of obstetrics complications, history of cesarean section, and history of uterine repair, were the predictors of uterine rupture. Among the socioeconomic factors, compared with women who had a monthly income of 6331.59 ETB ($112.36) or more, women who had a monthly income of less than 6331.59 ETB ($112.36) were 3.75 times more likely to face uterine rupture (AOR = 3.75, 95%CI: 1.97, 7.13).

In addition, compared with women with parities of one to four, those with five or more parities were 7.78 times more likely to have uterine rupture (AOR = 7.78, 95%CI: 4.70, 12.88). Furthermore, mothers who had bad obstetrics history, history of cesarean section, and history of uterine repair were 3.78 (AOR = 3.78, 95%CI:2.11, 6.75), 2.49 (AOR = 2.49, 95%CI:1.42, 4.35), and 18 (AOR = 18.01, 95%CI: 6.81, 47.64) times more likely exposed to uterine rupture than their counterparts (Table 4).Table 4 Factors associated with uterine rupture among mothers who gave birth at Nekemte specialized hospital from January 2014 to December 2022 (n = 2661).

Full size table

Discussion

This study revealed that the overall trend of uterine rupture among mothers managed in Nekemte specialized hospital decreased from 1.62 to 0.96% over nine years. This decline aligns with similar trends observed in Singapore37 and Nigeria38. Several factors may contribute to this positive change. The first reason might be related to the increasing use of elective cesarean sections. Similarly, it might result from a robust strategy of identifying high-risk mothers during their presentation in the antenatal period, which calls for diligent monitoring with informed patient involvement in their pregnancy care39,40. It might also be the result of improved surgical techniques, more conservative labor management41, and increased awareness and education among healthcare providers and women themselves about the risks of uterine rupture and how to prevent it42. This suggests that specialty hospitals had to step up the intervention to counteract the tendency of uterine rupture. Similarly, the proportion of uterine rupture in this study was 3.53%. This finding is in line with the pooled prevalence of uterine rupture in Ethiopia (2%)43, and (3.98)25, Debre Markos (2.24%)18, and rural Ethiopia (3.7%)44. However, it is higher than the study findings from Hawassa University Comprehensive Specialized Hospital (1.09%)22, the University Teaching Hospital of Pakistan (0.67%)16, Mizan Aman General Hospital (1.6%)45, Somalia (0.7%)46, Mali47, Benin (0.58%)48 and Israel (6.7%)49. This finding was also lower than those from Amhara regional state referral hospitals (16.68%)27 and Burkina Faso (18%)10. The differences could be attributed to the differences in delivery services coverage, accessibility of the facilities, and availability of skilled personnel and medical supplies as the study setting differs. Similarly, in this study, 0.7% of mothers and 5.6% of neonates died, and the neonatal deaths were in line with a study in China50. However, it is different in terms of maternal mortality. Thus, it’s essential to recognize that even a small percentage of maternal deaths due to uterine rupture represents significant individual and family tragedies. Timely recognition, appropriate management, and access to emergency obstetric care are crucial to prevent such outcomes.

In other words, women with specific characteristics face an increased risk of uterine rupture. These risk factors include being grand multipara (having multiple previous pregnancies), having a lower household income, experiencing obstetric complications in the past, having undergone cesarean sections, and having a history of uterine repair.

Grand multiparous women were nearly eight times more likely to have uterine rupture than their counterparts. This is in line with the results of other studies51,52,53,54,55,56,57. An aging reproductive system is a possible mechanism for increasing rupture risk with age. The myometrium may undergo age-related morphological changes, independent of parity, accompanied by reduced tissue durability, as seen in other muscle types changing with aging58. This increased risk is primarily due to the strain and stretching multiple pregnancies and deliveries placed on the uterine muscles and tissues. The more pregnancies a woman has, the more likely her uterus will weaken, increasing the chances of rupture during subsequent pregnancies. This implies that it is essential for healthcare providers to closely monitor these women during labor and delivery to detect any signs of uterine rupture promptly and provide appropriate medical intervention if necessary.

Similarly, women with lower household incomes had higher odds of experiencing uterine rupture compared to those with higher incomes. This finding aligns with a result in Mulungo Hospital, Uganda59. It could be because low-income individuals may face barriers to accessing quality healthcare, which could impact their overall health outcomes during pregnancy and childbirth. It could be also due to the family’s concern about the financial cost of hospital delivery. The delivery did not have an official fee, but most women could pay some money to healthcare providers for services. If a woman had multiple operations, they had to be referred to the surgical theatre due to complications. As a result, they might spend a lot of money on drugs and their hospital stay. They could also incur costs in addition to money for transport and feeding while at the hospital. These informal payments are rife and are both solicited and unsolicited.

Furthermore, this study found that mothers with a previous history of delivery with cesarean section were more than two times more likely to be exposed to uterine rupture than their counterparts. This finding aligns with other results28,60,61,62,63,64. This might be because prior cesarean section history leaves the abdominal wall weak and lax, resulting in the fetus’s head not being engaged early, leading to different mal-presentations. Mal-presentation was one of the contributing factors for rupture in some previous studies. This implies that women with a history of C-sections must discuss their risks and options for future pregnancies with their healthcare provider. Sometimes, a trial of labor after a previous C-section may be considered if specific criteria were met and if it is deemed safe for both the mother and baby. However, in other cases, a repeat C-section may be recommended to minimize the risk of uterine rupture.

Moreover, this study revealed that previous bad obstetrics history, such as prolonged labor, was nearly four times more likely to be exposed to uterine rupture than their counterparts. This finding is similar to results in Northern Ethiopia27 and Western Ethiopia65. This is because a previous history of prolonged labor is a known risk factor for uterine rupture, leading to over-stretching of the uterus, weakening its walls, and increasing the risk of rupture during subsequent pregnancies. Additionally, suppose a woman has had a previous cesarean delivery and then experiences prolonged labor in the following pregnancy. In that case, the risk of uterine rupture is further increased due to a scar on the uterus. Therefore, women with a history of prolonged labor should be closely monitored during subsequent pregnancies and may be advised to deliver via cesarean section to reduce the risk of uterine rupture.

Finally, this study showed that women with a previous history of uterine repair were significantly more exposed to uterine rupture than their counterparts. This finding is similar to another finding66. Suppose the repair refers to a history of uterine surgery, such as a myomectomy or a repair of a uterine rupture; this might increase the risk of uterine rupture during subsequent pregnancies. Scar tissue from previous surgery can weaken the uterine wall and increase the risk of rupture. However, suppose the repair is due to a previous uterine rupture repair; it is essential to note that this may not always be possible and may require a hysterectomy, which would eliminate the risk of uterine rupture in future pregnancies. Thus, mothers should be counseled to be ready for elective C-sections if they have a previous history of uterine repair. The prevention of uterine rupture should be at different levels—individual, health system, and community—based on the influencing factors identified in this study.

At an Individual level, education and Awareness, Risk assessment, and Birth preparedness should exist. Educating pregnant individuals about the signs and symptoms of uterine rupture is crucial. This includes recognizing danger signs (e.g., severe abdominal pain, vaginal bleeding) and understanding the importance of seeking immediate medical attention and encouraging regular antenatal care visits where healthcare providers can reinforce this knowledge. Identifying high-risk individuals (e.g., those with a history of cesarean section) and tailoring care accordingly is also important; that could open rooms for discussing birth options (vaginal birth after cesarean, planned repeat cesarean) based on individual circumstances. Ensuring that pregnant individuals have a birth plan, know the location of the nearest health facility, and have funds available for transportation are also crucial for promoting early recognition of labor and timely presentation to the healthcare facility.

Quality Antenatal Care, skilled birth attendants, and emergency obstetrics care are necessary at the Health System level. Strengthening antenatal care services to include education on danger signs and birth preparedness is crucial. Regular check-ups allow healthcare providers to monitor pregnancy progress and promptly address concerns. Ensuring that skilled birth attendants (such as midwives or obstetricians) are available during labor and delivery is also crucial since their expertise can help prevent complications and manage emergencies effectively. Further, Health facilities should be equipped to handle obstetric emergencies, including uterine rupture, and the availability of blood transfusion services, surgical capabilities, and anesthesia is essential.

Community Awareness, transportation and referral systems, and social support networks are crucial at the Community Level. Community health workers and local leaders are vital in disseminating information about uterine rupture. In this case, community-based education programs can raise awareness and empower individuals to seek prompt care. Communities should have reliable transportation options to reach health facilities quickly and establish clear referral pathways to ensure seamless emergency transfer. Encouraging families and communities to support pregnant individuals during labor and childbirth and having a network that recognizes danger signs and encourages timely action is essential.

Limitations of the study

Despite many strengths, this study has some inherent limitations. First, data were taken from other projects collected for research purposes, and essential data components, such as labor follow-up with partograph, were lacking. Second, not all variables were approached in this manuscript because there were many variables. Third, being a cross-sectional study, it is unlikely to infer a causal association and needs further investigation to explore the causes of uterine rupture. Fourth, conducting the study in a single hospital limits the ability to compare different healthcare settings or account for variations in care practices across multiple institutions. Fifth, nine-year research may encounter changes in clinical practices, healthcare policies, or patient demographics over time. These temporal trends could influence the observed prevalence and associated factors, potentially impacting the interpretation of the results. Thus, to address the limitations, future research on uterine rupture should consider multi-center studies and complementary qualitative research to gain a more comprehensive understanding of the factors contributing to uterine rupture.

Conclusions

According to this study, there was a 3.53% proportion of uterine rupture and a declining trend in its incidence. The risk of uterine rupture was significantly higher in women with lower monthly household incomes and more significant numbers of prior pregnancies than in women without these characteristics. In a similar vein, women with a history of uterine repair, Cesarean sections, or poor obstetrics, including protracted labor, had a significantly increased risk of uterine rupture.

Therefore, improving emergency access and providing women of lower income with necessary obstetric care is imperative. Enhancing family planning services is also crucial, as it focuses on multigravida women. In addition, it is essential to maintain comprehensive prenatal care packages and a referral system to reduce the risk of uterine rupture in women who have previously had cesarean sections, uterine repairs, or protracted labor.

Data availability

All data are kept in the manuscript. However, full access to the Data will be made available at the reasonable request of the corresponding author.

Abbreviations

AIC:

Akaike Information CriteriaANC:

Antenatal CareAOR:

Adjusted Odds RatioCOR:

Crude Odds RatioGC:

Gregorian calendarICU:

Intensive care UnitNICU:

Neonatal Intensive Care UnitOR:

Odds RatioOR:

Operation RoomROM:

Rupture of MembraneRTA:

Road Traffic AreaSD:

Standard DeviationSDG:

Sustainable Development GoalVIF:

Variance inflation FactorWHO:

World Health Organization

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Acknowledgements

The authors are obliged to all participants who willingly participated in this study. We want to thank Jimma University Faculty of Public Health for allowing this study to be conducted. We would also like to thank each Nekemte hospital staff member, manager, and data collector for their cooperation.

Funding

This study is the research work of the first author’s Ph.D. program. He received funding from Jimma University, Ethiopia, to pursue higher studies in Ethiopia. However, the sponsoring organizations had no role in study design, data collection, analyses, the decision to publish, or the preparation of the manuscript.

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Authors and Affiliations

  1. Department of Obstetrics and Gynecology, Wollega University, Nekemte, EthiopiaMitiku Getachew Kumara
  2. Department of Population and Family Health, Faculty of Public Health, Jimma University, Jimma, EthiopiaGurmesa Tura Debelew
  3. Nutrition & Dietetics, Faculty of Public Health, Jimma University, Jimma, EthiopiaBeyene Wondafrash Ademe

Contributions

MG, GT, and BW conceived and planned the study protocol involving data transcription, coding, and the manuscript’s write-up. MG implemented and supervised the fieldwork and drafted the manuscript. MG, GT, and BW critically reviewed the analyzed data and prepared the final manuscript. All authors read, agreed, and approved the last version of the manuscript and approved both to be personally responsible for the author’s contributions and ensure that questions linked to the accuracy or truthfulness of any part of the work, even ones in which the author was not personally involved, were appropriately investigated.

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Correspondence to Mitiku Getachew Kumara.

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Kumara, M.G., Debelew, G.T. & Ademe, B.W. Trend, prevalence, and associated factors of uterine rupture at Nekemte Specialized Hospital, Oromia Regional State, Western Ethiopia. Sci Rep 14, 25722 (2024). https://doi.org/10.1038/s41598-024-77881-x

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