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Objectives: maternal and neonatal mortality in Ethiopia is a major reproductive health problem. Obstructed labor is one of the leading causes of maternal, fetal, and neonatal morbidity in developing countries. The evidence regarding its determinants at the tertiary level of care is sparse. Therefore, this study aimed to study the determinants of obstructed labor among women attending intrapartum care in Amhara region referral hospitals. Methods: A Hospital-based unmatched case-control study was conducted from March 1stto August 30, 2017. Cases were women whose labor was obstructed (n = 270), and controls were women whose labor was not obstructed (n = 540). Both cases and controls were selected randomly, and a proportional to size allocation was made to the referral hospitals selected for the study. A binary and a multivariable logistic regression model was computed to identify the determinant factors at 95% CI. Results: The mean age of the study participants was 27.66 years (27.4 ± 5.44 for cases and 28.15 ± 6.16 for controls), ranging between 16 and 45 years. Relatively, higher proportions of cases than controls were unable to read and write (58.5%) and were urban residents (53.7%). Distance from hospital, distance from health center, mothers inability to read and write, mothers primary level of education, more than 28 weeks of gestation at the first visit of antenatal care, 37 to 42 weeks at admission, above 42 weeks at admission, women of a merchant spouse, and history of pregnancy-related complications were the positive determinants of obstructed labor. However, mothers whose gestational age was 16 to 28 weeks at the first antenatal care visit were 62% less likely to be exposed to obstructed labor. Conclusions: Obstetric, service-related, and system factors were predictors of obstructed labor. Improving women’s literacy status, health service access, and utilization will help reduce obstructed labor.
The unmatched case–control study design was conducted in Amhara Regional State Referral Hospitals from 1 March 2017 to 30 August 2017. According to the 2007 Ethiopian census, Amhara regional state has a total population of 17,221,976, of whom 8,580,396 are females; urban inhabitants were 2,112,595 (12.27%). It has an estimated area of 159,173.66 kmble1-174550652 and a population density of 108.2 people per square kilometer. For the entire region, 3,983,768 households were counted, which results in an average of 4.3 persons per household, with urban households having on average 3.3 and rural households having 4.5 people.6 The regional state has 41 hospitals (5 referrals and 36 districts), 834 health centers, and 2941 health posts. Each referral hospital assumed to render services for 5 million people, have 100–200 beds, 2000–3000 deliveries per year, and 5–8 deliveries per day. According to the annual registration of each Hospital in 2016, each referral hospital served about 4500 mothers per year on average. The three selected referral hospitals were the University of Gondar Teaching Referral Hospital, Felege Hiwot Referral Hospital, and Debre Markos Referral Hospital. The University of Gondar Hospital is one of the oldest academic institutions in Ethiopia. It has produced several health professionals for more than half a century ago. This University is located at the heart of Gondar city found in the Amhara Region, Northwest part of Ethiopia. Gondar city is located at 727 km away from Addis Ababa (the capital city of Ethiopia). This hospital offers different inpatient and outpatient services to the population in the surrounding area of Gondar town and the nearby zones. Felege Hiwot Referral Hospital is also one of the largest hospitals situated in the capital city of the regional state, which is located 578 km away from the capital of Ethiopia, Addis Ababa, in the Northwest direction. It obliges as a referral hospital for the population around Bahir Dar special zone, west Gojjam zone, Awi zone, and South Gondar zone, which are the residences of more than 7 million people. It is also serving as a teaching hospital for Bahir Dar University. Similarly, Debre Markos Referral Hospital is located 295 km from Addis Ababa, the capital of Ethiopia and 265 km from Bahir Dar, the capital city of Amhara regional state. This hospital is likely to provide services for more than 3.5 million people in its catchment area. Apart from other services, the hospital provides antenatal care (ANC) and delivery services for pregnant women. The source population for this study was all laboring mothers who gave birth in Amhara Regional State Referral Hospitals. In contrast, the study population was all laboring mothers who gave birth in selected Amhara Regional State Referral Hospital within the study period. Cases were women whose labor was obstructed in the study period. Controls were women who gave birth and had no obstructed labor in the selected hospitals within the study period. Inclusion criteria for both cases and controls were women aged 15–49 years in the Selected Hospitals. Women with mental illness and unable to hear and talk due to illness were excluded from the study because it was considered that they could not give the necessary information. The sample size of 810 was calculated using a two-population proportion formula with the following assumptions; the proportions, P1 and P2 = 0.5, since there is no previous study with similar study design, with 95% confidence interval (CI) and d = maximum discrepancy of 5% between the sample and the underlying population and adding 5% non-response rate. Finally, 1:2 cases-to-controls ratio were considered. A lottery method was employed to select the three hospitals out of the five (i.e. Felege Hiwot Referral Hospital, Debre Markos Referral Hospital, and University of Gondar Referral Hospital). A systematic random sampling technique was used to select controls. Study subjects were allocated with the proportion of the patient flow in each hospital. For each obstructed labor, the corresponding normal labors were taken (Figure 1). Diagrammatic presentation of the sampling procedure. The questionnaire was first prepared in English, translated to local language Amharic, and back to English by two different individuals to check its consistency. The questionnaire was pretested on 5% of the sample outside the selected hospitals. The correction was made based on the pretest findings. The questionnaire had two parts. The first part was socio-demographic factors that encompass maternal age, body mass index, age at first marriage, age at first pregnancy, age at first delivery, ethnicity, residence, and marital status. Also, it encompasses educational status, husband educational status, occupation, an estimated distance of residence from health institution, estimates the distance from primary health institute to a tertiary center, religion, and income. The second part was reproductive factors like gravidity, parity, gestational age, referral status, birth attendant, previous cesarean section (CS), mode of last delivery, ANC attendance, number of ANC visits, previous history of obstetric complications, previous history of abortion, and duration of labor before the presentation. The third part was the programmatic factors which include infrastructure and transportations. The data were collected by six BSc. Midwives were under the supervision of three MSc midwives. Three days of training were given for the data collectors and supervisors, focusing on the objective of the study and data collection process. All filled questionnaires were checked daily for completeness, accuracy, clarity, and consistency by the supervisors and the principal investigators. Completeness and consistency of variables during data entry and analysis were checked using frequency distributions, cross tabulations, and sorting in ascending and descending order. The collected data were coded, entered, and cleaned using Epi Info version 3.5.1 software to minimize logical errors and design skipping patterns. Then, the data were exported and analyzed using the STATA version 13 software package. Bivariate analysis between dependent and independent variables was performed separately using binary logistic regression. The strength and direction of the association between a dependent variable and independent variables (covariates) were expressed in odds ratio (OR) through a 95% CI. Variables with a p-value of <0.25 in bivariate analysis were entered into multivariate analysis. Finally, multivariable logistic regression technique was done to evaluate the independent effect of each variable on institutional delivery by controlling the effect of others. Statistical significance was determined using a 95% CI at the p-value of <0.05. Ethical approval was granted from the Ethical Review Committee, Debre Tabor University. A permission letter was obtained from each referral hospital officials. The purpose of the study was explained; clearly, informed oral consent was obtained, and confidentiality was ensured. Oral consent was obtained because the majority of study participants were illiterate. Data collectors read the consent for respondents, and they mark if the respondents agree. The ethical board committee approved the consent form and information sheet. A formal letter for permission and support was written to the respective administrator office. The aim of the study was explained clearly to the concerned bodies. The purpose and process of the study were explained to all participants. Before the informed consent was obtained, the respondents were told that they have the right to be involved or not to be involved in the study.
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