The search strategy identified 90 articles from PubMed, 110 articles from Google Scholar, 45 articles from Cochrane Library, 10 articles from African Journals Online, 2 articles from Ethiopian’s University online library, and 3 articles by manual search. Of which, 117 were excluded due to duplication, 75 through review of titles and abstracts. Additionally, 52 full-text articles were excluded for not reporting the outcome variable and other reasons. Finally, 21 were included to the incidence and/ or associated factor analysis on uterine rupture among among mothers managed for obstetric cases in Ethiopia [Fig.1].
Characteristics of included studies
In this review, 21 relevant studies were included with a sample size of 33,303. Among twenty one studies, thirteen were cross sectional, seven case-controls, and one cohort in study design. Regarding the geographical area, seven studies were from Amhara region, five from Oromia, five from Southern Nation Nationalities and People (SNNPR), and four from Tigray region. Among the included studies the largest sample size was 14,152, where as the smallest was 115 (Table 1).
Table 1: Descriptive summary of included studies on uterine rupture based on year of study, study design, sample size, region of study, response rate, and prevalence (n=21).
Author (year)
|
study design(setting)
|
Sample size
|
Study area
|
Prevalence (%)
|
Dawud A.et al(2017)[52]
|
Cross-sectional
|
376
|
Amhara
|
0.9
|
Fikru A.et al(2017)[53]
|
Case control
|
432
|
Oromia
|
N/A
|
Worku T.et al(2017)[20]
|
Cross-sectional
|
750
|
Amhara
|
16.68
|
Akine Eshete .et al(2017)[54]
|
Cohort
|
2498
|
Oromia
|
1.8
|
Tefera M.et al(2015)[55]
|
Case control
|
336
|
Tigray
|
N/A
|
Tegene L.et al(2016)[56]
|
Cross-sectional
|
9789
|
SNNP
|
1.24
|
Geremew A.et al(2014)[9]
|
Cross-sectional
|
254
|
Amhara
|
2.44
|
Temesgen T. et al(2015)[57]
|
Case control
|
172
|
Oromia
|
N/A
|
Amare W.et al(2018[58])
|
Case control
|
210
|
Amhara
|
N/A
|
Amanuel G.et al(2001)[59]
|
Cross-sectional
|
2000
|
Tigray
|
0.9
|
Yayehyirad Y.et al e (2016)[60]
|
Case control
|
352
|
SNNP
|
N/A
|
A. ADMASSU.et al(2004)[61]
|
cross-sectional
|
1200
|
Amhara
|
3.8
|
Samuel A.et al(2016)[62]
|
Cross-sectional
|
880
|
Amhara
|
9.5
|
Chamiso B.et al(1995)[63]
|
Cross-sectional
|
2185
|
Oromia
|
2.6
|
Habtamu M.et al(2015)[64]
|
Cross-sectional
|
115
|
SNNP
|
1.6
|
Solomon G.et al(2013)[65]
|
Case control
|
560
|
Tigray
|
N/A
|
Yibrah B. et al[8]
|
Cross-sectional
|
5185
|
Tigray
|
0.9
|
Goitom G. et al(2019)[66]
|
Case control
|
560
|
SNNP
|
N/A
|
Tigist G.et al(2018)[67]
|
Cross-sectional
|
14,152
|
Oromia
|
1.07
|
Mekuanint T. et al(2020)[68]
|
Cross-sectional
|
378
|
Amhara
|
8.7
|
Achamyelesh G.et al(2020)[69]
|
Cross-sectional
|
13,500
|
SNNPR
|
2.55
|
Meta-analysis
Publication bias
Three studies were excluded from prevalence estimation after checking funnel plot and the significance of Egger’s regression test. However, they were not excluded from meta-analysis for risk factors. Significant publication bias with an Egger’s regression p-value< 0.001 was seen when all studies considered. Thus, after adjustment Egger’s regression p-value was 0.215, indicated a reduced publication bias (Fig. 2).
Incidence of uterine rupture in Ethiopia
Primarily, all seven case-control studies were not considered in the incidence estimation. The pooled incidence of uterine rupture is presented with a forest plot (Fig. 3). Therefore, the estimated incidence of uterine rupture among mothers managed for obstetric cases in Ethiopia was 3.25% (95%CI: 2.6-3.89, I2=97.4%, P<0.001).
Subgroup analysis
Subgroup analysis was employed with the evidence of heterogeneity. In this study, the Cochrane I2 statistic was 97.4%, P < 0.001, which showed the evidence of marked heterogeneity. Therefore, subgroup analysis was done using the study region and year of study. As a result, uterine rupture was high in North Western Ethiopia 8.08% (95%CI: 3.97-12.18), regarding year of study the highest incidence was in the study conducted between 2014-2017 (5.03% (95%CI: 3.54-6.52)) (Fig 4&5).
Risk factors for incidence of uterine rupture
The association between prolonged labour, being grand multi para, rural residency, having cesarean section scar, not using partograph for labour monitoring, not having antenatal care during pregnancy, and obstructed labour with uterine rupture was carried out.
A total of six articles were included to identify the association between rural residency and uterine rupture. Mother’s residency (as defined as rural and urban) was significantly associated with uterine rupture. Mother’s from rural areas were more likely to have uterine rupture than those (women) from urban areas (AOR=5.44, 95% CI: 3.17–9.34, I2 =59.5%, P=0.03) (Fig. 6).
Seven studies showed a significant association between grand multiparity and uterine rupture. Mother’s of grand multipara were 2.38 times more likely to develop uterine rupture (AOR = 2.38; 95%CI: 1.32–4.29, I2=0.0%, p=0.002) compared to mothers who are primi gravida (Fig.7).
Four studies showed a significant association between previous cesarean section scar and uterine rupture. Mother’s who had previous cesarean section scar were 7.10 times more likely to develop uterine rupture (AOR =7.10; 95% CI: 5.40–9.34, I2=26.3%, P=0.254) than mother’ who had no cesarean section scar (Fig.8).
Seven studies showed a significant association between prolonged labour and uterine rupture. Mother’s with prolonged labour were 6.71 times more likely to develop uterine rupture than mother’s who had normal labour (AOR=6.71; 95%CI: 4.04–11.15, I2=84.6%, P<0.001) (Fig.9).
Five studies showed a significant association between obstructed labour and uterine rupture. Mother’s who had obstructed labour were 7.22 times more likely to develop uterine rupture (AOR=7.22; 95%CI: 2.86–18.28, I2=97.4%, P<0.001) as compared to their counter parts (Fig.10).
Three studies showed a significant association between not utilizing partograph for labour monitoring and uterine rupture. Mother’s who did not followed by partograph during active phase of labour were 3.43 times more likely to develop uterine rupture (AOR=3.43; 95%CI: 1.62–7.29, I2=66.6%, P=0.05) than mother’s followed by partograph (Fig.11).
Seven articles with were included to identify the association between not having antenatal care during pregnancy and uterine rupture. Mother’s who have no antenatal care during pregnancy were 4.05 times more likely to develop uterine rupture (AOR =4.05; 95% CI: 1.90–8.64 I2=89.4%, P<0.001) than mother’s who had ANC (Fig. 12).