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

PLoS ONE, Volume 15, No. 11 November, Year 2020

Interpretação

Background Uterine rupture has a significant public health importance, contributing to 13% of maternal mortality and 74%-92% of perinatal mortality in Sub-Saharan Africa, and 36% of maternal mortality in Ethiopia. The prevalence and predictors of uterine rupture were highly variable and inconclusive across studies in the country. Therefore, this systematic review and metaanalysis aimed to estimate the pooled prevalence and predictor of uterine rupture in Ethiopia. Methods This systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2009 checklist. PubMed, Cochrane Library, Google Scholar, and African Journals Online databases were searched. The Newcastle- Ottawa quality assessment tool was used for critical appraisal. I2 statistic and Egger’s tests were used to assess the heterogeneity and publication bias, respectively. The random-effects model was used to estimate the pooled prevalence and odds ratios with a 95% confidence interval. Results Sixteen studies were included, with a total of 91,784 women in the meta-analysis. The pooled prevalence of uterine rupture was 2% (95% CI: 1.99, 3.01). The highest prevalence was observed in the Amhara regional state (5%) and the lowest was in Tigray region (1%). Previous cesarean delivery (OR = 9.95, 95% CI: 3.09, 32.0), lack of antenatal care visit (OR = 8.40, 95% CI: 4.5, 15.7), rural residence (OR = 4.75, 95% CI: 1.17, 19.3), grand multiparity (OR = 4.49, 95% CI: 2.83, 7.11) and obstructed labor (OR = 6.75, 95%CI: 1.92, 23.8) were predictors of uterine rupture. Conclusion Uterine rupture is still high in Ethiopia. Therefore, proper auditing on the appropriateness of cesarean section and proper labor monitoring, improving antenatal care visit, and birth preparedness and complication readiness plan are needed. Moreover, early referral and family planning utilization are the recommended interventions to reduce the burden of uterine rupture among Ethiopia women. This systematic review and meta-analysis have designed to estimate the pooled prevalence of uterine rupture and predictors among Ethiopian women. We registered the protocol with the International Prospective Register of Systematic Reviews (PROSPERO), University of York Center for Reviews and Dissemination (https://www.crd.york.ac.uk/), with a registration number CRD42019119620. The findings of the review were reported based on the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) 2009 statement checklist [26] (S1 Table). All published articles were searched in major international databases such as PubMed, Cochrane Library, Google Scholar, and African Journals Online databases. Onwards, a search of the reference lists of the identified studies was done to retrieve additional articles. For this review, the PECO (Population, Exposure, Comparison and Outcomes) search strategy was used. Population: women who had uterine rupture in Ethiopia. Exposure: predictors of uterine rupture e.g. place of residence either rural or urban, the duration of labor, obstructed labor (presence or absence of obstructed labor) and having ANC visit or not, previous cesarean delivery or vaginal delivery. Comparison: the reported reference group for each predictor in each respective variable. Outcome: uterine rupture among Ethiopian women was the outcome of interest. The primary outcome was the prevalence of uterine rupture among Ethiopian women. Uterine rupture is a partial or complete tear of the uterine wall during pregnancy or delivery [5]. The secondary outcomes were: the predictors of uterine rupture such as previous cesarean delivery, place of residence, ANC visit, gravidity, and obstructed labor. For each selected PECO component, the electronic databases were searched using keywords and the medical subject heading [MeSH] terms. The quest for keywords includes prevalence, uterine rupture and predictors or determinants, as well as Ethiopia. The search terms were combined by the Boolean operators “OR” and “AND (S2 Table). This review included studies that reported either the prevalence of uterine rupture or the predictors of uterine rupture in Ethiopia. All English language published studies released up to the end of our search period (30/3/2019) were retrieved to this systematic reviews and meta-analysis. Case reports of populations, surveillance data (demographic health survey), abstracts of conferences, and articles without full access were excluded. First, through review of title, abstract and full paper was done by two reviewers (MD and HA). Any disagreement with the two reviewers was settled by consensus. Then, a full-text analysis of potentially qualifying studies including identification of duplicated records. Only the full-text article was retained in case of duplication. The Newcastle-Ottawa Scale (NOS) quality assessment tool was used to assess the quality of included studies based on the three components [27]. The principal component of the tool graded from five stares and emphasized on the methodological quality of each primary study. The other component of the tool graded from two stars and concerns about the comparability of each study and the last component of the tool graded from three stars and used to assess the outcomes and statistical analysis of each original study. The NOS has three categorical criteria with a maximum score of 9 points. The quality of each study was rated using the following scoring algorithms: ≥7 points were considered as “good”, 2 to 6 points were considered as “fair”, and ≤ 1 point was considered as “poor” quality study. Accordingly, in order to improve the validity of this systematic review result, we only included primary studies with fair to good quality. Then, the two reviewers (MD and HA) independently assessed or extracted the articles for overall study quality and or inclusion in the review using a standardized data extraction format. The data extraction format included primary author, publication year, and region of the study, sample size, and prevalence, and the selected predictors of uterine rupture. The publication bias was assessed using the Egger’s [28] and Begg’s [29] tests with a p-value of less than 0.05. I2 statistic was employed to assess heterogeneity among studies and a p-value less than 0.05 was used to declare heterogeneity. As a result of the presence of heterogeneity, the random-effects model was used as a method of analysis to estimate the DerSimonian and Laird’s pooled effect [30]. In the current meta-analysis, arcsine-transformed proportions were used. The pooled proportion was estimated using the back-transform of the weighted mean of the transformed proportions, using arcsine variance weights for the fixed-effects model and DerSimonian-Laird weights for the random-effects model [31]. Data were extracted in Microsoft Excel and exported to Stata version 11 for analysis. Subgroup analysis was conducted by region and type of study design. Besides, a meta-regression model was done based on sample size and year of publication to identify the sources of random variations among included studies. The effect of selected determinant variables was analyzed using separate categories of meta-analysis [32]. The findings of the meta-analysis were presented using forest plot and Odds Ratio (OR) with its 95% CI. Additionally, we performed a sensitivity analysis to assess whether the pooled prevalence estimates were influenced by individual studies.

AI Digest

Study Justification:

– Uterine rupture is a significant public health issue in Ethiopia, contributing to maternal and perinatal mortality.
– The prevalence and predictors of uterine rupture in Ethiopia are variable and inconclusive.
– This systematic review and meta-analysis aimed to estimate the pooled prevalence and predictors of uterine rupture in Ethiopia.

Highlights:

– The study included 16 studies with a total of 91,784 women in the meta-analysis.
– The pooled prevalence of uterine rupture in Ethiopia was found to be 2%.
– The highest prevalence was observed in the Amhara regional state (5%) and the lowest in Tigray region (1%).
– Predictors of uterine rupture included previous cesarean delivery, lack of antenatal care visit, rural residence, grand multiparity, and obstructed labor.

Recommendations:

– Proper auditing on the appropriateness of cesarean section and labor monitoring is needed to reduce uterine rupture.
– Improving antenatal care visit and birth preparedness and complication readiness plan is recommended.
– Early referral and family planning utilization are interventions that can help reduce the burden of uterine rupture among Ethiopian women.

Key Role Players:

– Healthcare providers and professionals involved in obstetrics and gynecology.
– Policy makers and government officials responsible for healthcare planning and implementation.
– Community health workers and volunteers who can promote antenatal care and birth preparedness.

Cost Items for Planning Recommendations:

– Training and capacity building for healthcare providers on appropriate cesarean section and labor monitoring.
– Improvement of healthcare facilities and infrastructure for antenatal care.
– Development and implementation of birth preparedness and complication readiness plans.
– Awareness campaigns and education programs for early referral and family planning.
Please note that the cost items provided are general suggestions and may vary based on the specific context and resources available in Ethiopia.

Força da prova

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong, but there are some areas for improvement. The systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist, which enhances the credibility of the study. The review included a large number of studies and a substantial sample size, which increases the generalizability of the findings. The prevalence of uterine rupture was estimated using a random-effects model, which accounts for heterogeneity among studies. The predictors of uterine rupture were also identified. However, there are a few actionable steps to improve the evidence. First, the abstract could provide more details about the search strategy, such as the specific keywords used and the inclusion and exclusion criteria. Second, the abstract could mention the quality assessment results for the included studies and whether any studies were excluded based on quality. Finally, the abstract could provide information about the limitations of the study, such as potential sources of bias or heterogeneity. Overall, the evidence in the abstract is strong, but these improvements would enhance the transparency and robustness of the study.

Resumo

This systematic review and meta-analysis have designed to estimate the pooled prevalence of uterine rupture and predictors among Ethiopian women. We registered the protocol with the International Prospective Register of Systematic Reviews (PROSPERO), University of York Center for Reviews and Dissemination (https://www.crd.york.ac.uk/), with a registration number CRD42019119620. The findings of the review were reported based on the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) 2009 statement checklist [26] (S1 Table). All published articles were searched in major international databases such as PubMed, Cochrane Library, Google Scholar, and African Journals Online databases. Onwards, a search of the reference lists of the identified studies was done to retrieve additional articles. For this review, the PECO (Population, Exposure, Comparison and Outcomes) search strategy was used. Population: women who had uterine rupture in Ethiopia. Exposure: predictors of uterine rupture e.g. place of residence either rural or urban, the duration of labor, obstructed labor (presence or absence of obstructed labor) and having ANC visit or not, previous cesarean delivery or vaginal delivery. Comparison: the reported reference group for each predictor in each respective variable. Outcome: uterine rupture among Ethiopian women was the outcome of interest. The primary outcome was the prevalence of uterine rupture among Ethiopian women. Uterine rupture is a partial or complete tear of the uterine wall during pregnancy or delivery [5]. The secondary outcomes were: the predictors of uterine rupture such as previous cesarean delivery, place of residence, ANC visit, gravidity, and obstructed labor. For each selected PECO component, the electronic databases were searched using keywords and the medical subject heading [MeSH] terms. The quest for keywords includes prevalence, uterine rupture and predictors or determinants, as well as Ethiopia. The search terms were combined by the Boolean operators “OR” and “AND (S2 Table). This review included studies that reported either the prevalence of uterine rupture or the predictors of uterine rupture in Ethiopia. All English language published studies released up to the end of our search period (30/3/2019) were retrieved to this systematic reviews and meta-analysis. Case reports of populations, surveillance data (demographic health survey), abstracts of conferences, and articles without full access were excluded. First, through review of title, abstract and full paper was done by two reviewers (MD and HA). Any disagreement with the two reviewers was settled by consensus. Then, a full-text analysis of potentially qualifying studies including identification of duplicated records. Only the full-text article was retained in case of duplication. The Newcastle-Ottawa Scale (NOS) quality assessment tool was used to assess the quality of included studies based on the three components [27]. The principal component of the tool graded from five stares and emphasized on the methodological quality of each primary study. The other component of the tool graded from two stars and concerns about the comparability of each study and the last component of the tool graded from three stars and used to assess the outcomes and statistical analysis of each original study. The NOS has three categorical criteria with a maximum score of 9 points. The quality of each study was rated using the following scoring algorithms: ≥7 points were considered as “good”, 2 to 6 points were considered as “fair”, and ≤ 1 point was considered as “poor” quality study. Accordingly, in order to improve the validity of this systematic review result, we only included primary studies with fair to good quality. Then, the two reviewers (MD and HA) independently assessed or extracted the articles for overall study quality and or inclusion in the review using a standardized data extraction format. The data extraction format included primary author, publication year, and region of the study, sample size, and prevalence, and the selected predictors of uterine rupture. The publication bias was assessed using the Egger’s [28] and Begg’s [29] tests with a p-value of less than 0.05. I2 statistic was employed to assess heterogeneity among studies and a p-value less than 0.05 was used to declare heterogeneity. As a result of the presence of heterogeneity, the random-effects model was used as a method of analysis to estimate the DerSimonian and Laird’s pooled effect [30]. In the current meta-analysis, arcsine-transformed proportions were used. The pooled proportion was estimated using the back-transform of the weighted mean of the transformed proportions, using arcsine variance weights for the fixed-effects model and DerSimonian-Laird weights for the random-effects model [31]. Data were extracted in Microsoft Excel and exported to Stata version 11 for analysis. Subgroup analysis was conducted by region and type of study design. Besides, a meta-regression model was done based on sample size and year of publication to identify the sources of random variations among included studies. The effect of selected determinant variables was analyzed using separate categories of meta-analysis [32]. The findings of the meta-analysis were presented using forest plot and Odds Ratio (OR) with its 95% CI. Additionally, we performed a sensitivity analysis to assess whether the pooled prevalence estimates were influenced by individual studies.

Materiais

Inovações

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

1. Telemedicine: Implementing telemedicine services can help overcome geographical barriers and provide access to healthcare professionals for remote areas. This can enable pregnant women to receive prenatal care, consultations, and monitoring without the need for physical travel.

2. Mobile health (mHealth) applications: Developing mobile applications that provide educational resources, reminders for prenatal visits, and personalized health information can empower pregnant women to take an active role in their own healthcare. These apps can also facilitate communication between healthcare providers and patients.

3. Community health workers: Training and deploying community health workers can improve access to maternal health services, especially in rural areas. These workers can provide education, support, and basic healthcare services to pregnant women, ensuring they receive the necessary care and referrals.

4. Birth preparedness and complication readiness plans: Implementing comprehensive birth preparedness and complication readiness plans can help pregnant women and their families anticipate and plan for potential complications during childbirth. This includes educating women about danger signs, establishing emergency transportation systems, and ensuring access to emergency obstetric care.

5. Improved referral systems: Strengthening referral systems between primary healthcare facilities and higher-level healthcare facilities can ensure timely access to specialized care for pregnant women with complications. This can involve establishing clear protocols, training healthcare providers, and improving communication channels.

6. Quality improvement initiatives: Implementing quality improvement initiatives in healthcare facilities can enhance the overall quality of maternal healthcare services. This can involve regular monitoring and evaluation, training healthcare providers on evidence-based practices, and ensuring the availability of essential equipment and supplies.

7. Family planning services: Integrating family planning services into maternal health programs can help prevent unintended pregnancies and reduce the risk of uterine rupture. Providing access to contraception and counseling on family planning methods can contribute to safer pregnancies and better maternal health outcomes.

It’s important to note that these recommendations are general and may need to be tailored to the specific context and needs of Ethiopia.

AI Innovations Description

The systematic review and meta-analysis aimed to estimate the prevalence and predictors of uterine rupture among Ethiopian women. The study found that the pooled prevalence of uterine rupture in Ethiopia was 2%. The highest prevalence was observed in the Amhara regional state (5%) and the lowest in the Tigray region (1%). The study also identified several predictors of uterine rupture, including previous cesarean delivery, lack of antenatal care visits, rural residence, grand multiparity, and obstructed labor.

Based on the findings, the study recommends several interventions to improve access to maternal health and reduce the burden of uterine rupture in Ethiopia. These recommendations include:

1. Proper auditing on the appropriateness of cesarean section and proper labor monitoring: This can help ensure that cesarean sections are performed when necessary and that labor is closely monitored to detect any signs of complications.

2. Improving antenatal care visits: Encouraging pregnant women to attend regular antenatal care visits can help identify and manage any potential risk factors for uterine rupture.

3. Birth preparedness and complication readiness plan: Promoting birth preparedness and ensuring that women have a plan in place for emergencies can help reduce delays in accessing appropriate care during labor and delivery.

4. Early referral: Ensuring that women with high-risk pregnancies are referred to appropriate healthcare facilities early on can help prevent complications such as uterine rupture.

5. Family planning utilization: Promoting the use of family planning methods can help prevent unintended pregnancies and reduce the risk of uterine rupture associated with high gravidity.

Implementing these recommendations can contribute to improving access to maternal health and reducing the burden of uterine rupture among Ethiopian women.

AI Innovations Methodology

Based on the provided information, it seems that the focus is on improving access to maternal health, specifically addressing the issue of uterine rupture among Ethiopian women. To simulate the impact of recommendations on improving access to maternal health, the following methodology can be considered:

1. Identify potential recommendations: Review the findings of the systematic review and meta-analysis to identify potential recommendations for improving access to maternal health. These recommendations may include auditing the appropriateness of cesarean sections, improving labor monitoring, enhancing antenatal care visits, promoting birth preparedness and complication readiness plans, facilitating early referral, and promoting family planning utilization.

2. Define indicators: Determine the indicators that will be used to measure the impact of the recommendations on improving access to maternal health. These indicators may include the prevalence of uterine rupture, maternal mortality rate, perinatal mortality rate, cesarean section rate, antenatal care coverage, and contraceptive prevalence rate.

3. Collect baseline data: Gather baseline data on the selected indicators to establish a starting point for comparison. This data can be obtained from existing sources such as national health surveys, health facility records, and population-based studies.

4. Develop a simulation model: Create a simulation model that incorporates the potential recommendations and their expected impact on the selected indicators. The model should consider the interrelationships between different factors influencing access to maternal health, such as healthcare infrastructure, healthcare provider capacity, community awareness, and socio-economic factors.

5. Input data and parameters: Input the baseline data and relevant parameters into the simulation model. This includes information on the prevalence and predictors of uterine rupture, as well as data on the current status of maternal health indicators.

6. Run simulations: Run the simulation model using different scenarios that reflect the implementation of the recommended interventions. This can involve adjusting parameters such as the coverage and quality of antenatal care, the availability of emergency obstetric care, and the uptake of family planning services.

7. Analyze results: Analyze the results of the simulations to assess the potential impact of the recommendations on improving access to maternal health. This can involve comparing the projected changes in the selected indicators between different scenarios and the baseline.

8. Validate and refine the model: Validate the simulation model by comparing the projected results with real-world data, if available. Refine the model based on feedback from experts and stakeholders, and incorporate additional factors or interventions as needed.

9. Communicate findings: Present the findings of the simulation analysis in a clear and concise manner, highlighting the potential benefits of the recommended interventions in improving access to maternal health. This can be done through reports, presentations, and discussions with relevant stakeholders.

10. Monitor and evaluate: Continuously monitor and evaluate the implementation of the recommended interventions and their impact on access to maternal health. This can involve tracking the selected indicators over time and making adjustments to the interventions as necessary.

By following this methodology, policymakers and healthcare providers can gain insights into the potential impact of specific recommendations on improving access to maternal health, allowing them to make informed decisions and allocate resources effectively.

Autores & Coautores

Statistics:

Citations: 4

Authors: 7

Identifiers:

DOI: 10.1371/journal.pone.0240675

Research Areas:

Community Interventions, Genetics and Genomics, Health System and Policy, Maternal Access, Maternal and Child Health, Sexual and Reproductive Health, Social Determinants

Study Countries:

Ethiopia

Study Design:

Case-Control Study, Cohort Study, Cross Sectional Study

Study Approach:

Mixed-methods, Quantitative, Systematic Review

Participants Gender:

Female

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