Uterine rupture in a teaching hospital in Mbarara, western Uganda, unmatched case-control study

Reproductive Health, Volume 10, No. 1, Year 2013

Interpretation

Background: Uterine rupture is one of the most devastating complications of labour that exposes the mother and foetus to grave danger hence contributing to the high maternal and perinatal mortality and morbidity in Uganda. Every year, 6000 women die due to complications of pregnancy and childbirth, uterine rupture accounts for about 8% of all maternal deaths.The objective of this study was to establish the incidence of uterine rupture, predisposing factors, maternal and fetal outcomes and modes of management at a regional referral university hospital in South-western Uganda. Methods. Case-control design of women with uterine rupture during 2005-2006. Controls were women who had spontaneous vaginal delivery or were delivered by caesarean section without uterine rupture as a complication. For every case, three consecutive in-patient chart numbers were picked and retrieved as controls. All available case files, labour ward and theater records were reviewed. Results: A total of 83 cases of uterine rupture out of 10940 deliveries were recorded giving an incidence of uterine rupture of 1 in 131 deliveries. Predisposing factors for uterine rupture were previous cesarean section delivery(OR 5.3 95% CI 2.7-10.2), attending < 4 antenatal visits (OR 3.3 95% CI 1.6-6.9), parity ≥ 5(OR 3.67 95% CI 2.0-6.72), no formal education (OR 2.0 95% CI 1.0-3.9), use of herbs (OR15.2 95% CI 6.2-37.0), self referral (OR 6.1 95% CI 3.3-11.2) and living in a distance >5 km from the facility (OR 10.86 95% CI 1.46-81.03). There were 106 maternal deaths during the study period giving a facility maternal mortality ratio of 1034 /100,000 live births, there were 10 maternal deaths due to uterine rupture giving a case fatality rate of 12%. Conclusion: Uterine rupture still remains one of the major causes of maternal and newborn morbidity and mortality in Mbarara Regional referral Hospital in Western Uganda. Promotion of skilled attendance at birth, use of family planning among those at high risk, avoiding use of herbs during pregnancy and labour, correct use of partograph and preventing un necesarry c-sections are essential in reducing the occurences of uterine repture. © 2013 Mukasa et al.; licensee BioMed Central Ltd. The study setting was Mbarara University of Science and Technology teaching hospital which is located in Mbarara Municipality, and 286 km south west of Kampala the Capital city of Uganda. It is a public hospital funded by Government of Uganda through the Ministry of Health. It is the referral hospital for south western Uganda serving 10 districts with a population of more than 2.5 million people. It also receives patients from neighbouring countries of Rwanda, Tanzania and Democratic Republic of Congo. It handles on average 10,000 deliveries per year. Uterine rupture was defined as tearing of the uterine wall either partially or complete during pregnancy and labour, diagnosed either clinically and later confirmed at laparotomy. The cases were retrospectively collected from the maternity ward and operating theatre registers as well as from the patients’ case files at the hospital medical records office. Controls were women who had spontaneous vaginal delivery or were delivered by caesarean section without uterine rupture as a complication. For every case, three consecutive in-patient chart numbers were picked and retrieved as controls. Data was abstracted from the maternity ward and operating theatre registers as well as from the patients’ case files at the hospital medical records office using a pre tested case report form (CRF). Information on the patients’ age, tribe, address, occupation, religion, parity, previous caesarean section, antenatal care attendance, estimated distance of residence from the hospital, place of intrapartum care, subsequent rupture, type of surgical intervention (total or sub-total hysterectomy, repair without bilateral tubal ligation [BTL] or repair with BTL), maternal and foetal outcomes, length of postoperative hospital stay and other relevant information were collected. The total number of cases of uterine rupture and deliveries from the maternity ward admission register was validated with the annual Health Management Information System (HMIS) reports. The data collectors were midwives who were trained to collect data from women’s obstetric files or charts and to validate the diagnosis of obstructed labour using admission, delivery and theatre registers. Thought the data collection period which lasted 4 weeks, I was providing oversight and supervision to prevent under reporting. The data were entered and analyzed using SPSS statistical software, version 12.0 (SPSS, Chicago, IL, USA). Descriptive statistics were obtained through frequencies and cross tabulations. Comparison between groups was made using the x2 tests and Fisher exact test when appropriate. All analyses were two-tailed and the level of significance was set at 5%. Ethical approval was obtained from Mbarara University Institutional Ethical Research Committee. Permission to access obstetric records was obtained from the medical director of the hospital and these were anonymously entered into the database.

AI Digest

Study Justification:

– Uterine rupture is a serious complication of labor that contributes to high maternal and perinatal mortality and morbidity in Uganda.
– The study aimed to establish the incidence of uterine rupture, identify predisposing factors, and examine maternal and fetal outcomes and modes of management at a regional referral university hospital in South-western Uganda.

Study Highlights:

– The study found that the incidence of uterine rupture at the hospital was 1 in 131 deliveries.
– Predisposing factors for uterine rupture included previous cesarean section delivery, attending less than 4 antenatal visits, high parity, no formal education, use of herbs, self-referral, and living more than 5 km from the facility.
– The study also revealed a high facility maternal mortality ratio and case fatality rate due to uterine rupture.

Recommendations for Lay Reader:

– Promote skilled attendance at birth to ensure safe delivery and reduce the risk of uterine rupture.
– Encourage the use of family planning among those at high risk to prevent unintended pregnancies and reduce the occurrence of uterine rupture.
– Advise against the use of herbs during pregnancy and labor, as they may increase the risk of uterine rupture.
– Emphasize the correct use of the partograph, a tool used to monitor labor progress, to prevent unnecessary cesarean sections and reduce the incidence of uterine rupture.

Recommendations for Policy Maker:

– Allocate resources to improve access to skilled attendance at birth, particularly in rural areas where the risk of uterine rupture may be higher.
– Strengthen family planning programs to ensure that women at high risk of uterine rupture have access to effective contraception.
– Develop educational campaigns to raise awareness about the dangers of using herbs during pregnancy and labor.
– Provide training and support to healthcare providers on the correct use of the partograph to prevent unnecessary cesarean sections and reduce the occurrence of uterine rupture.

Key Role Players:

– Ministry of Health: Responsible for allocating resources and implementing policies to address maternal and perinatal health issues, including uterine rupture.
– Mbarara University of Science and Technology teaching hospital: Plays a crucial role in providing healthcare services and implementing interventions to prevent and manage uterine rupture.
– Healthcare providers: Responsible for delivering quality care and implementing recommended practices to prevent uterine rupture.
– Community leaders and organizations: Can help raise awareness and promote behavior change regarding safe delivery practices and the use of family planning.

Cost Items for Planning Recommendations:

– Training programs for healthcare providers on skilled attendance at birth, family planning, and the correct use of the partograph.
– Development and dissemination of educational materials and campaigns.
– Infrastructure improvements to ensure access to skilled attendance at birth, such as the construction or renovation of healthcare facilities.
– Provision of family planning services and contraceptives.
– Monitoring and evaluation activities to assess the impact of interventions and make necessary adjustments.

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is relatively strong, as it presents the findings of an unmatched case-control study conducted at a teaching hospital in Mbarara, western Uganda. The study provides specific details about the study design, data collection methods, and statistical analysis. However, there are some areas for improvement. Firstly, the abstract does not mention the sample size of the study, which is an important factor in assessing the strength of the evidence. Secondly, the abstract does not provide information about the representativeness of the study population, which could affect the generalizability of the findings. To improve the evidence, it would be helpful to include the sample size and information about the representativeness of the study population in the abstract.

Abstract

The study setting was Mbarara University of Science and Technology teaching hospital which is located in Mbarara Municipality, and 286 km south west of Kampala the Capital city of Uganda. It is a public hospital funded by Government of Uganda through the Ministry of Health. It is the referral hospital for south western Uganda serving 10 districts with a population of more than 2.5 million people. It also receives patients from neighbouring countries of Rwanda, Tanzania and Democratic Republic of Congo. It handles on average 10,000 deliveries per year. Uterine rupture was defined as tearing of the uterine wall either partially or complete during pregnancy and labour, diagnosed either clinically and later confirmed at laparotomy. The cases were retrospectively collected from the maternity ward and operating theatre registers as well as from the patients’ case files at the hospital medical records office. Controls were women who had spontaneous vaginal delivery or were delivered by caesarean section without uterine rupture as a complication. For every case, three consecutive in-patient chart numbers were picked and retrieved as controls. Data was abstracted from the maternity ward and operating theatre registers as well as from the patients’ case files at the hospital medical records office using a pre tested case report form (CRF). Information on the patients’ age, tribe, address, occupation, religion, parity, previous caesarean section, antenatal care attendance, estimated distance of residence from the hospital, place of intrapartum care, subsequent rupture, type of surgical intervention (total or sub-total hysterectomy, repair without bilateral tubal ligation [BTL] or repair with BTL), maternal and foetal outcomes, length of postoperative hospital stay and other relevant information were collected. The total number of cases of uterine rupture and deliveries from the maternity ward admission register was validated with the annual Health Management Information System (HMIS) reports. The data collectors were midwives who were trained to collect data from women’s obstetric files or charts and to validate the diagnosis of obstructed labour using admission, delivery and theatre registers. Thought the data collection period which lasted 4 weeks, I was providing oversight and supervision to prevent under reporting. The data were entered and analyzed using SPSS statistical software, version 12.0 (SPSS, Chicago, IL, USA). Descriptive statistics were obtained through frequencies and cross tabulations. Comparison between groups was made using the x2 tests and Fisher exact test when appropriate. All analyses were two-tailed and the level of significance was set at 5%. Ethical approval was obtained from Mbarara University Institutional Ethical Research Committee. Permission to access obstetric records was obtained from the medical director of the hospital and these were anonymously entered into the database.

Materials

N/A

Innovations

Based on the information provided, here are some potential innovations that could improve access to maternal health:

1. Telemedicine: Implementing telemedicine services could allow pregnant women in remote areas to access prenatal care and consultations with healthcare professionals without having to travel long distances to the hospital.

2. Mobile clinics: Setting up mobile clinics that travel to rural areas could provide essential prenatal care, including check-ups, vaccinations, and education on pregnancy and childbirth.

3. Community health workers: Training and deploying community health workers who can provide basic prenatal care, educate women on healthy pregnancy practices, and identify high-risk pregnancies could help improve access to maternal health services in underserved areas.

4. Transportation support: Providing transportation support, such as ambulances or vouchers for transportation, could help pregnant women in remote areas reach healthcare facilities in a timely manner for delivery or emergency care.

5. Health education programs: Implementing health education programs that focus on promoting skilled attendance at birth, family planning, and the dangers of using herbs during pregnancy and labor could help reduce the occurrence of uterine rupture and improve maternal health outcomes.

6. Strengthening referral systems: Improving the coordination and communication between primary healthcare centers and referral hospitals could ensure that pregnant women with complications are promptly referred to higher-level facilities for specialized care.

7. Maternal waiting homes: Establishing maternal waiting homes near healthcare facilities could provide a safe and comfortable place for pregnant women to stay during the final weeks of pregnancy, ensuring they are close to medical care when labor begins.

8. Task-shifting: Training and empowering midwives and other healthcare workers to perform certain procedures and tasks traditionally done by doctors could help alleviate the shortage of skilled healthcare providers and improve access to maternal health services.

9. Mobile applications: Developing mobile applications that provide information and resources on prenatal care, nutrition, and warning signs during pregnancy could empower women to take control of their own health and seek appropriate care when needed.

10. Public-private partnerships: Collaborating with private healthcare providers and organizations could help expand access to maternal health services, especially in areas where public healthcare facilities are limited.

It’s important to note that these are just potential recommendations based on the information provided. The feasibility and effectiveness of these innovations would need to be further assessed and evaluated in the specific context of improving access to maternal health in Mbarara, western Uganda.

AI Innovations Description

Based on the information provided, a recommendation to improve access to maternal health would be to focus on promoting skilled attendance at birth and increasing the utilization of antenatal care services. This can be achieved through the following strategies:

1. Strengthening antenatal care services: Encourage pregnant women to attend at least four antenatal visits, as identified in the study as a predisposing factor for uterine rupture. This can be done through community outreach programs, health education campaigns, and providing incentives for women to seek regular antenatal care.

2. Enhancing access to skilled birth attendants: Ensure that trained healthcare professionals, such as midwives and obstetricians, are available during childbirth. This can be achieved by improving staffing levels, providing training and support for healthcare workers, and implementing strategies to retain skilled birth attendants in rural areas.

3. Promoting family planning: Encourage the use of family planning methods among women at high risk of uterine rupture, such as those with a history of previous cesarean section delivery or high parity. This can help to prevent unintended pregnancies and reduce the risk of complications during childbirth.

4. Educating on the dangers of traditional practices: Raise awareness about the risks associated with the use of herbs during pregnancy and labor. Provide education on the importance of seeking medical care from trained healthcare providers and avoiding potentially harmful traditional practices.

5. Improving transportation and infrastructure: Address the issue of distance by improving transportation options and infrastructure, particularly for women living more than 5 km away from healthcare facilities. This can include providing ambulances or transportation vouchers for pregnant women in need of emergency obstetric care.

6. Strengthening healthcare systems: Ensure that healthcare facilities have the necessary resources, equipment, and supplies to provide quality maternal healthcare services. This includes proper training and use of partographs, which can help in the early detection and management of complications during labor.

By implementing these recommendations, access to maternal health can be improved, leading to a reduction in the incidence of uterine rupture and ultimately reducing maternal and newborn morbidity and mortality.

AI Innovations Methodology

To improve access to maternal health in Mbarara, western Uganda, several recommendations can be considered based on the findings of the study:

1. Promote skilled attendance at birth: Encouraging women to give birth with the assistance of skilled healthcare professionals, such as midwives or doctors, can help reduce the risk of complications like uterine rupture. This can be achieved through community education programs, awareness campaigns, and providing incentives for women to seek skilled care during childbirth.

2. Increase antenatal care attendance: Women who attended fewer than four antenatal visits were found to be at higher risk of uterine rupture. Improving access to and utilization of antenatal care services can help identify and manage potential risk factors early on, reducing the likelihood of complications during labor.

3. Provide education on family planning: High parity (≥5) was identified as a predisposing factor for uterine rupture. Promoting the use of family planning methods can help women space their pregnancies and reduce the risk of uterine rupture associated with multiple pregnancies.

4. Discourage the use of herbs during pregnancy and labor: The study found that the use of herbs during pregnancy was strongly associated with uterine rupture. Educating women about the potential risks and complications of using herbs during pregnancy and labor can help prevent uterine rupture.

5. Improve access to healthcare facilities: Living more than 5 km away from the healthcare facility was identified as a risk factor for uterine rupture. Efforts should be made to improve transportation infrastructure and provide mobile healthcare services to reach women living in remote areas.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could involve the following steps:

1. Define the target population: Identify the specific population group that will be the focus of the simulation, such as pregnant women in Mbarara, western Uganda.

2. Collect baseline data: Gather data on the current access to maternal health services, including the number of women seeking skilled attendance at birth, antenatal care attendance rates, use of family planning methods, and distance to healthcare facilities.

3. Define the intervention parameters: Determine the specific details of the recommendations to be implemented, such as the target increase in skilled attendance at birth, the desired increase in antenatal care attendance, and the percentage of women to be reached with family planning education.

4. Simulate the impact: Use statistical modeling techniques to simulate the impact of the recommendations on improving access to maternal health. This could involve estimating the number of additional women receiving skilled attendance at birth, the increase in antenatal care attendance rates, and the reduction in uterine rupture cases based on the implemented interventions.

5. Evaluate the results: Assess the simulated outcomes and compare them to the baseline data to determine the effectiveness of the recommendations in improving access to maternal health. This evaluation can help identify areas of success and areas that may require further intervention or adjustment.

6. Refine and iterate: Based on the evaluation results, refine the recommendations and simulation methodology as needed. Iterate the process to continue improving access to maternal health over time.

It is important to note that the simulation methodology described here is a general framework and may need to be adapted based on the specific context and available data in Mbarara, western Uganda.

Authors & Co-Authors

Statistics:

Citations: 36

Authors: 6

Identifiers:

DOI: 10.1186/1742-4755-10-29

Research Areas:

Community Interventions, Health System and Policy, Maternal Access, Maternal and Child Health, Sexual and Reproductive Health, Social Determinants, Technology and Innovations, Workforce

Study Countries:

Congo, Multi-Countries, Rwanda, Tanzania, Uganda

Study Design:

Case-Control Study, Cohort Study, Cross Sectional Study, Grounded Theory, randomised-control-trial

Study Approach:

Quantitative

Participants Gender:

Female