Introduction

Uterine rupture is a ripping of the uterine wall during pregnancy, delivery or immediately after childbirth. Commonly occurs in the lower segment of the uterus during the intrapartum or antepartum period from any causes[1]. Many women shoulder a dual liability of supporting the whole family by working outside the home and taking full responsibility for household’s duties and childcare. Although women in the community play vital roles, the health requirements of women are neglected as it could be evidenced by the soaring level of maternal mortality in many developing countries[2].

Worldwide, nearly 340,000 to half a million women die per annum due to complications of pregnancy and childbirth. Maternal mortality and morbidity remain extremely high health problem and challenge that concerns the globe over the years across developing countries especially in sub-Saharan African (SSA) and South Asia. About 99% of maternal death is occurring in developing countries due to preventable causes. More than 87% of maternal deaths from the global Maternal Mortality ratio, which is estimated to be 210 deaths per 100, 000 live births in 2013, are accounted by sub-Saharan Africa and South Asia[3].

Ethiopia is one of the countries with the highest maternal mortality (MM), which is located in sub-Saharan Africa where more than half of the global MM ensue [4,5]. This high maternal mortality occurs due to different direct and indirect causes that indicate poor quality maternity continuum of care.

Globally, the incidence of uterine rupture is 0.07%, which is much lower than the magnitude encountering in Africa-1.3%[6]. Uterine rupture is one of the peripartum complications that causes nearly about one out of thirteen maternal death and the remaining survivors encounter immediate and long-term complexities[7]. In Ethiopia, uterine rupture and obstructed labor together account for 29% of the total maternal mortality. These are the significant obstetric sequel needing concern, as they contributed the second significant causes of maternal death next to abortion-related complications[8].

There are contradictions among works of literature regarding factors that lead to uterine rupture. Factors that determine uterine rupture varies across setting because maternal characteristics also change, so do the health services delivery system and reception [9].

Uterine rupture would not only have limited to just short-term complications, and it ends up with long-term complications, maternal mortality and perinatal mortality. Even though uterine rupture contributes to the maternal mortality, there is the limitation of substantial evidence indicating the level and factors contributing to uterine rupture for prevention and life-saving measure in health facilities. To enable this, we tried to assess the prevalence of uterine rupture and its predictors in the study area.

Methodology

Result

Socio-demographic characteristics

Out of 756 charts selected for review, we included 750 cases with complete information from three hospitals in the analysis. The ages of mothers who got uterine rupture ranged between 18–42 years, with a mean age of 27.78 years and SD 5.887. Most of the women 647(86.26%) were in the age range between 19 years to 35 years, while 715 (95.30%) were Amhara in ethnicity. About 521(69.5%) mothers lived >10 kilometers (km) from the health institutions. The average distance they traveled was 44.05 km with SD of 38.308 km. Most of the uterine rupture (113 (90.40%)) occurred from mothers those who lived in area presenting at above 10km from health facility they received care (Table 1).

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Table 1. Socio-demographic characteristics among women with the obstetric case, in Amhara region referral hospitals, Ethiopia, 2017.

https://doi.org/10.1371/journal.pone.0208470.t001

Obstetric characteristics

The parity ranges from one to eleven with the mean parity of 2.59 ± SD 1.59. Among the patients who the uterine rupture, the majority (81.6%) of the patients were of para two up to four. About 621(93.8%) mothers had ANC follow up two and above and forty-one (6.2%) had less than two ANC for indexed pregnancy. Most of the mothers came with referred papers 506 (67.5%), and 469(92.86%) were referred from a health institution while the remaining 37(7.3%) were self-referral. Regarding the distributions of the previous mode of delivery in the hospitals, 516 women were multiparous with 460 (89.14%) spontaneous vertex delivery, 31 (6%) cesarean delivery and 25 (4.86%) both SVD and Cesarean delivery. One hundred thirty-one (17.3%) women gave birth with Assisted Instrumental Delivery, with 101 (77.1%) vacuum and 30 (22.9%) forceps delivery.

Fifty-six (7.5%) women had a history of the previous cesarean section, among them, 41 (73.2%) discharged before the seventh postoperative day. Among 190 (25.33%) mothers who were induced /augmented, 36 (18.9%) were induced /augmented for less than two hours. Most of the women were in their term gestational age, 615(82%) with the mean gestational age of 39.51wks ±1.94 SD. Regarding the presentation of the fetus, 633 (84.4%) were vertex, and 542 (72.26%) women followed with Partograph during labor. There were about 13 (1.73%) destructive deliveries 11 (84.6%) craniotomy, one evisceration and one decapitation. About 131 (17.46%) women developed Cephalo Pelvic disproportion and 167 (22.3%) women had a traumatic vaginal birth. Fifteen mothers were had morbidly adherent placenta with most of them fail in the category of placenta accreta 7(46.7%) (Table 2).

Among mothers having ANC follow up, 96 (14.50%) were diagnosed with uterine rupture and from these 89 (92.7%) ruptured cases had ANC visit two and above. Among patients with uterine rupture, 84 (67.2%) of them have stayed in labor for less than 24 hours with a mean duration of labor 15.14hours and SD of 8.038. The majority of ruptured case 112(89.6%) came with referred papers.

From the women having the history of cesarean section 20 (16%) experienced the uterine rupture. Among mothers with a history of the previous cesarean section, 15 (26.8%) got pregnant within less than six-month interval from the last cesarean delivery time, from which more than half 11 (55%) end up with uterine rupture. Likewise inter delivery interval out of 56 previous cesarean deliveries 20 (35.7%) were delivered within less than 18 months of their last birth. From 56 mothers with previous cesarean deliveries, 20 had developed postoperative fever, of them 16 (80%) developed uterine rupture.

More than two out of three vertex presentation (68.8%) end up with uterine rupture, and most of them were while their gestational age was term 100(80%). Out of ruptured cases, 82 (65.6%) laboring women not followed with partograph throughout labor. From women exposed to obstructed labor, almost half of them (47.2%) experienced the uterine rupture. Sixty-eight (54.4%) women those experienced CPD and 39(31.2%) victim of traumatic childbirth got uterine rupture (Table 2, in the third column).

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Table 2. Obstetric characteristics with the distribution of uterine rupture among women with the obstetric case in Amhara region referral hospitals, Ethiopia, 2017.

https://doi.org/10.1371/journal.pone.0208470.t002

Prevalence of uterine rupture

The overall prevalence of uterine rupture among mothers who gave birth in Amhara Region referral hospitals was found to be 125 (16.68%) 95%CI: [14.0%,19.2%]). The pattern of prevalence of uterine rupture in 5 consecutive years (2013, 2014, 2015, 2016, 2017) at Amhara Region referral hospitals, was 18.70%, 18%, 16.70%, 15.30%, 14.70% respectively (Fig 1) and out of ruptured cases 113 (90.40%) were with complete uterine rupture as shown in Fig 2 below.

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Fig 1. Trends of uterine rupture from 2013–2017 among mothers who got obstetric care in Amhara region referral hospitals, Northern Ethiopia, 2017.

https://doi.org/10.1371/journal.pone.0208470.g001

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Fig 2. Types of uterine rupture among mothers at Amhara region referral hospitals Northern Ethiopia, 2017.

https://doi.org/10.1371/journal.pone.0208470.g002

Factors associated with uterine rupture

In bivariable logistic regression analysis shows that, the age of the respondents age, distance >10km, patient come with referral paper, lack of ANC, parity, laboring for ≥24hours, obstructed labor, precipitated labor, destructive delivery, partograph utilization, CPD, birth weight, morbidly adherent placenta, Mothers with GDM, history of myomectomy/uterine surgery, previous caesarean delivery, instrumental delivery, gestational, induction/ augmentation, any Obstetric procedure, those with traumatic vaginal birth, twins/multiple pregnancy were associations with uterine rupture at p-value less than 0.05.

As it is presented in the Table 3, distance from health facility > 10km ((AOR = 2.44, 95% CI (1.13, 5.28)), Parity between two and four (AOR = 7.26;95% (3.06,17.22)) and five and above (AOR = 12.55;95% CI (3.64,43.20)), duration of labor higher than 24 hours (AOR = 3.44, 95%CI (1.49, 7.92)), mothers who came with referral paper (AOR = 2.94, 95%CI (1.28, 6.55)) were significantly associated factors. Among care given/omitted by health care providers, induction/augmentation of labor (AOR = 2.34, 95%CI (1.15, 4.72)), lack of parthograph use (AOR = 5.21, (95%CI (2.72, 9.97)), Obstetric procedure (AOR = 2.54, 95%CI (1.09, 5.91)) and destructive delivery (AOR = 5.18, 95%CI (1.22, 20.08)) were significantly associated with uterine rupture in multivariable logistic regression model.

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Table 3. Bivariable & Multivariable logistic regression result of factor associated with uterine rupture among women delivered in Amhara region referral hospitals from January 2013 to Dec 2017 (n = 750).

https://doi.org/10.1371/journal.pone.0208470.t003

In other hand, obstructed labor (AOR = 4.88, 95%CI (2.22,10.70)), precipitated labor (AOR = 3.59, 95%CI (1.10,11.77)), CPD (AOR = 4.08, 95%CI (1.99,8.33)), Morbidly adherent Placenta (AOR = 9.00, 95%CI (2.46, 27.11)) and gestational DM (AOR = 5.78(1.12,20.00)) were among characteristics and complications during pregnancy and labor which found to be significantly predict the prevalence of uterine rupture. From factors related with previous obstetrics history, previous myomectomy/other uterine surgery (AOR = 5.00, 95%CI (1.33, 18.73)) and last caesarian delivery (AOR = 4.90, 95% CI (2.13, 11.26)) were significantly associated with uterine rupture in multivariable logistic regression model at p-value less than 0.05 (Table 3).

Discussion

A total of 125 (16.68%, 95% (14.0%, 19.2%) women experienced uterine rupture which is in line with Burkina Faso (18%)[11]. But, by far higher when compared with that from a study done at Debremarkos (9.5%)[1], Debremarkos 2017 2.24%[12], rural Ethiopia (3.7%)[13], Mizan Aman General Hospital (1.6%)[14], Somalia (0.7%)[15], Mali[7], Benin Nigeria (0.58%)[16] and Israel (6.7%)[17]. Differences in delivery services coverage, accessibility of the facilities as well as the availability of skilled personnel and medical supplies as the study setting differs could contribute to variation observed.

The odds of getting uterine rupture in mothers who were para two to four were seven (AOR = 7.26;95% (3.06,17.22)), and five and above were twelve (AOR = 12.55;95% CI (3.64,43.20) times higher as compared to primipara. This finding is supported by other studies done in western Uganda [18] and Suhul General Hospital, Shire [19] which could be because the increment in parity ends up with the weakening of the uterine muscle, which could not be resistant to prolonged and powerful labor, especially in grand multipara women. As a result, the uterine rupture is more likely than primiparous women than parous women.

Those mothers who were living 10 and above kilometers away from health institution they received care were two times (AOR = 2.44, 95%CI (1.13, 5.28)) more likely exposed to uterine rupture than their counterparts as also reported in the studies done at Debre Markos Hospital [1], western Uganda [18] and rural Uganda [20]. The possible explanation might be, as the distance from health facility increases, the women suffer for a long time to reach health facility while they are in labor. Therefore, this will increase the duration of labor as a whole and increase the probability of acquiring uterine rupture. The weak network of the road has a prominent impact on the effectiveness of an intervention.

Those mothers who were laboring for twenty-four hours and above had three times(AOR = 3.44;95%CI:1.49,7.92) higher likelihood of having uterine rupture as compared to those staying in labor less than 24 hours. This finding supports the evidence of other studies conducted at Suhul General Hospital Shire[18], Mizan Aman General hospital[14]. From this, one can understand that the threat of prolonged labor in Amhara region remains high and ending up with uterine rupture. Enormous challenges of accessing quality services arising from three delays including, delays seeking care, reaching facilities and getting care could have influenced it.

Whereas, mothers who referred from other health institution had three times (AOR = 2.94; 95% CI: 1.28, 6.55) increased probability of having uterine rupture than those who came for care directly by themselves. The study done in Debre Markos supported this finding[1]. The clients who come to get services from tertiary health facilities are in a complicated condition as compared to those come from their home directly to these facilities. Therefore, these complications enhance the likely hood of developing uterine rupture. Those with labor abnormality and failed to be referred early due to factors related to road distance or health care provider pertaining with early referral end up with rupture. But this finding contradicts with the study conducted at Mizan Aman General hospital as those came without referral were in increased risk of uterine rupture[14]. The difference possibly explained by good referral system, accessibility of roads, and skill of health care providers to identify labor abnormalities, awareness of mothers towards institutional delivery, demographic and time variation.

Obstructer labor had a significant association with uterine rupture. Mothers diagnosed with obstructed labor were five times (AOR = 4.88; 95%CI: 2.22, 10.70) more likely exposed to uterine rupture than mothers without obstructed labor. This finding was also witnessed in other studies conducted in Debre Markos Referral Hospital [1], Suhul General Hospital Shire [19], and rural Uganda [20]. Obstructed labor is one of the top underlying cause of the uterine rupture in Amhara region Ethiopia. Presence of health facilities with emergency services in long distance from primary or home of the clients and lack of services compressive emergency obstetric care in some facilities might have enhanced the problem. Low utilization of the available maternal health services like ANC, even if it is free service at the national level also played its role by minimizing health care need of the individuals.

Likewise, mothers who had precipitated labor had four times (AOR = 3.59; 95%CI: 1.10, 11.77) increased odds of having uterine rupture than their counterparts. Whenever labor precipitated, the risk of genital tract trauma and extension to the uterus is highly likely since it is sudden to support, poor counseling about risk of subsequent precipitated labor, poor labor follow up practice. Those who had destructive operative delivery had five odds of having uterine rupture than without destructive deliveries (AOR = 5.18;95%:1.22,20.08). This might be explained due to the iatrogenic injury of the genital tract and the uterus which is highly susceptible to rupture in prolonged and obstructed labor, the poor skill of the operator.

Failing to follow lobar by partograph in the course of labor had five times (AOR = 5.21, 95%CI: 2.72, 9.97) increased odds of uterine rupture as compared to those who followed by partograph as also reported in other studies[1,17]. Partograph utilization to monitor the progress of the feto-maternal condition will enable to prevent the occurrence of prolonged labor. As a result, it will also prevent uterine rupture. However, failure to use partograph could occur due to various factors as we can see in this report. Negligence of health professionals to practice it or poor understanding of the benefit of partograph or either low human power may contribute to underutilization of partograph, which in return increased the magnitude of uterine rupture.

Mothers diagnosed with Cephalo Pelvic Disproportion had four times (AOR = 4.08; 95%CI: 1.99, 8.33) more likely to have the uterine rupture. The problem of pelvis, fetus or both leads to CPD, repeated contraction and relaxation without advancement of labor exhaustion and end up with uterine rupture, lack of skilled attendant to peak CPD early, poor childhood nutritional status.

Morbidly adhere Placenta had nine times (AOR = 9.00; 95%:2.46, 27.11) increased risk of uterine rupture than their counterparts. The finding supports the evidence reported from UK[20]. If there is placenta previa, the risk of the adherent placenta increases, which in return enhance labor complications. However, this finding opposes the study carried out at Columbia University[21]. Early diagnosis of those cases with Doppler sonography, close follow up and elective management before she went to the labor and delivery process, healthcare setup, quality of care providers could have minimized the risk of uterine rupture in the latter study.

Gestational diabetic’s militias had six times (AOR = 5.78; 95%CI: 1.12, 20.00) odds of having uterine rupture than non-diabetics. The risk of feto-pelvic disproportion and obstructed labor is high due to fat accumulation on fetal shoulder in diabetic patient. That leads to shoulder dystocia; difficult prolonged labor and then finally it ends up with uterine rupture. Previous myomectomy or other uterine surgeries had five times (AOR = 5.00; 95%CI: 1.33, 18.73) increased the likelihood of uterine rupture than without surgery. It is supported by the findings that an increased number of prior uterine surgery lead to an increase in the probability of uterine rupture. But this finding contradicts the study conducted in Columbia University[21], which could be may because of difference in health care system.

Among mothers who were induced or augmented odds of getting uterine rupture is two times (AOR = 2.34, 95%:1.15, 4.72) more likely than their counterparts which are in line with other studies from Norway [22] and UK [23]. Uterotonics drugs increases hyper stimulation of the uterus leads to rupture, if not used appropriately otherwise. Widely use of misoprostol for mothers with post-term pregnancy, term premature rupture of membrane, pre-eclampsia or eclampsia, and other cases are implemented, which predict the problem of having a uterine rupture. Those Mothers attended with any obstetric procedure had three times (AOR = 2.54; 95%:1.09, 5.91) more likely to have uterine rupture as compared to without procedure. This is supported by the study done at Shire[19]. Wherever there is uterine manipulation, and this happens by poorly skilled health care providers and unforeseen adherent placenta, the risk of uterine rupture increases.

Among mothers who had previous cesarean deliveries the odds of being rupture was five times (AOR = 4.90, 95%:2.13, 11.26) more likely than their counterparts which was similar with the study conducted in Nigeria[24] and UK[23]. The risk of scar dehiscence and silent dehiscence increases in cases of previous scars, which made them stay at higher risk of uterine rupture. If the patient request for vaginal birth after caesarian section within short inter-pregnancy intervals which might occur if poor counseling is given, the risk encountering uterine rupture will be significant.

Conclusions

This study indicates that the prevalence of uterine rupture was found to be high. A more careful strategy to counter obstructed labor, consistent use of partograph, along with a high index of anticipation of imminent uterine rupture and quick referral to a well-equipped center is recommended.

Acknowledgments

We would like to express our deepest and heartfelt appreciation to University of Gondar for providing the financial support. We are also glad to say thanks to Amhara Region Referral Hospitals administrative and community for their cooperativeness and their valuable information to do this work. Last but not least, we express our gratitude data collectors and supervisors for their contribution.