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Prevalence and Outcome of Operative Vaginal Delivery among Mothers Who Gave Birth at Jimma University Medical Center, Southwest Ethiopia.

1. Background

Operative vaginal deliveries are vaginal deliveries accomplished with the use of a vacuum device or forceps. If it is technically feasible, it can be safely accomplished. Termination of second stage of labor by operative vaginal delivery is indicated in any condition threatening the mother or fetus. According to the birth certificate data from the National Vital Statistics Report, forceps or vacuum-assisted vaginal delivery was used for 3.6% of births in the United States in 2010, and it accounts for around 11% and 17.3% of births in Royal College of obstetricians and gynecologists, Australia, and in Tikur Anbessa Specialized hospital, Ethiopia, respectively [1-4].

When prerequisites have been met, the appropriate indications for consideration of either forceps delivery or vacuum extraction are prolonged second stage, nonreassuring fetal heart rate tracing, or shortening of the second stage of labor for maternal benefit. Both forceps and vacuum have the potential to cause fetal and neonatal injury; however, the incidence of maternal injury is less with the vacuum than with forceps. In order to minimize both maternal and fetal risks, the operator must be familiar with the indications, contraindications, application, and use of the particular instrument. It is recommended that OVD should be performed from either a low or outlet station [5]. Studies revealed that prevalence of OVD ranged from 3 to 11% in different settings [2, 6].

Vacuum extractor is less likely to achieve a successful vaginal delivery and to cause serious maternal injury than applying the forceps. Although the vacuum is associated with a greater incidence of cephalohematoma, other facial/cranial injuries are more common with forceps [7].

Although operative vaginal delivery may be performed, as infrequently as in 1.5% of deliveries in some countries, it may be as high as 15% in other countries. In the United Kingdom, the rates of instrumental vaginal delivery range between 10% and 15%; these rates have remained fairly constant, although there has been a change in preference of instrument [6].

But currently studies show that there is a decreasing trend of instrumental deliveries and is a major concern in health care system all over the world. Assessing the trends of instrumental deliveries and its major indications would be useful in adopting suitable measures to reduce the caesarean section rate and the problems associated with it. A five-year retrospective study conducted on trends of instrumental deliveries at a tertiary teaching hospital in Puducherry, India, showed among a total of 5445 deliveries that occurred during study period, 7.7% were instrumental vaginal deliveries. The year-wise rate of instrumental deliveries ranges from 6.1% to 9.8%. During the study period (except during year 2011), a declining trend for instrumental deliveries was observed [8].

Studies revealed that the most common indication for OVD is to shorten second stage of labor considering maternal condition and the commonest unfavorable outcomes of OVD varies. Study done in Shankar Nagar and Raipur, India, reported that the most common indication was to cut short second stage of labor (52.5%) (preeclampsia, heart disease) followed by prolonged second stage of labor (22.5%), fetal distress, and maternal exhaustion. The risk of neonatal morbidity was similar between infants delivered by vacuum or forceps [9]. The commonest maternal complication was postpartum hemorrhage and genital tract laceration [10 ]. Evidence evaluating neonatal morbidity after instrumental vaginal delivery is inconsistent. A systematic review of 10 trials comparing vacuum extraction with forceps delivery found no significant differences in APGAR scores at one and five minutes and few serious injuries in neonates, although the vacuum extractor was associated with an increase in cephalhematoma and retinal hemorrhage [11]. In JUMC, no study conducted to assess the prevalence, indications, fetomaternal outcome, and associated factors of operative vaginal delivery.

2. Methods and Participants

2.1. Study Area and Period. The study was conducted in Jimma University Medical Center (JUMC) which is located 352kms Southwest of Addis Ababa. JUMC is found in Jimma zone of Oromia regional state within Jimma Town. It is one of the oldest specialized teaching hospitals (currently renamed as medical center) in the country giving services to people living in Jimma zone and serve as a referral hospital in the Southwest Ethiopia. It is teaching center for many clinical undergraduate and postgraduate specialty students. Department of Obstetrics and Gynecology has two inpatient (gynecology and obstetrics), one maternal health clinic, one gynecologic OPD, one family planning clinic, and referral clinics (gynecology oncology, benign gynecologic diseases, and high risk pregnancy). It has eight obstetricians and gynecologists and 32 residents from year I to III. The labor ward has 7 beds in first stage and 4 delivery couches. Maternity ward has 50 beds, 2 emergency operation rooms, and one recovery room with 2 beds and 2 resuscitation tables for newborns. There were a total of 2,654 deliveries recorded over eight months from November 1, 2015, to June 30, 2016, of which 266 were by OVD.

2.2. Study Design and Population. A facility-based cross-sectional study design was used. All mothers who gave birth at JUMC during the study period were the source population. All mothers who gave birth by operative vaginal delivery were included. All mothers for whom OVD indicated and fulfilled prerequisites (fetal head being engaged, vertex presentation, cervix being fully dilated (8cm for ventouse), membranes ruptured, exact position of head known, fetal size estimated (weight and ga), informed consent, maternal bladder being empty, adequate maternal pelvis, and back-up plan in place in case of failure to deliver) were eligible. Mothers for whom OVD was indicated but with IUFD and fetus with congenital anomaly were not eligible.

2.3. Sample Size Determination. The sample size was determined using a single population proportion formula n= [z.sup.2]p (1-p)/[d.sup.2], where p (17.3%) is the estimate of the proportion of operative vaginal delivery elsewhere. Considering all recommended values for each parameter, the sample was estimated to be 220. By adding 10% of this sample size for expected nonresponse rate, the final sample size becomes 242. Prevalence of OVD was taken 17.3% as obtained from a retrospective study conducted in 2004 at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia. All mothers who gave birth by OVD during study period were included using consecutive sampling technique till the required sample size completed.

Study variables were fetal parameters (FHR, GA, neonatal birth weight), obstetric related variables (cervical dilatation, uterine contraction/maternal effort, descent/station, need for rotation, indication for OVD, type of instrument used for OVD, timing of application of OVD (on arrival/followed), status of liquor), maternal parameters (age, parity, residency, ANC follow-up), fetomaternal outcomes (serious maternal morbidity or death, postpartum hemorrhage, blood transfusions, episiotomy extension, third and fourth degree tears, cervical laceration, need for major surgery (hysterectomy, urinary retention and bladder dysfunction, low APGAR score, admission to NICU, need for resuscitation at delivery, neonatal sepsis at neonatology, birth trauma (fractured bone, cephalhematoma), and condition at discharge (normal, improved, died).

2.4. Data Collection Tools and Procedures. The tool was developed by reviewing different literature and translated into local languages (Afan Oromo, Amharic) and then back translated to English by third party to check its consistency. Structured interviewer administered questionnaire used to interview mothers at exit. Two obstetrics and gynecology residents and 3 midwives were trained on how to interview eligible mothers and abstract information from respective charts. Checklist was used to extract data from the patient chart. The first part required information about patient's age, gravidity, parity and estimated gestation age. Second part required the parameters of labor which were fetal heart rate, liquor state, cervical dilatation, descent of head, uterine contraction, and maternal BP. The third part required the fetal outcomes which were assessed in terms of live birth (APGAR score at first and fifth minutes), need of resuscitation, admission to neonatal ward for special care, and the reasons for admission. The fourth part included information about the mode of delivery (OVD) and immediate maternal outcomes. Immediate maternal outcomes were recorded as favorable and unfavorable if the woman got PPH, perineal tear (third degree and above), need of blood transfusion, urinary bladder injury, hysterectomy, or bowel injury.

2.5. Operational Definitions

2.5.1. Operative Vaginal Deliveries (OVD). Vaginal deliveries are accomplished with the use of a vacuum device or forceps.

2.5.2. Indication of OVD. It means any condition threatening the mother or fetus that is likely to be relieved by immediate delivery when prerequisites are fulfilled.

2.5.3. Asphyxia. Asphyxia is a condition in which viable newborn fails to attain or initiate respirations after delivery.

2.5.4. APGAR Score. APGAR score is method of assessing fetal conditions at time of delivery.

2.5.5. Low APGAR Score. APGAR score of less than seven is considered low.

2.5.6. Birth Trauma. Birth trauma is any trauma to the newborn as a result of labor and delivery like cephalohematoma, subgaleal hemorrhage, retinal hemorrhage, shoulder dystocia, clavicular fracture, and scalp lacerations.

2.5.7. Favorable Outcome. If mother and neonate has no complications, this is considered a favorable outcome.

2.5.8. Unfavorable Outcome. The unfavorable outcome is when mother and neonate developed complications (maternal complications like PPH, genital tear, need of blood transfusion, need of major surgery, death, and neonatal complications like low APGAR score, need of resuscitation, admission to NICU, and neonatal death).

2.5.9. Episiotomy Extension. Episiotomy extension is an incision that is deeper or longer than is necessary to permit the birth of newborn.

2.6. Data Processing and Analysis. The collected data were cleaned, entered in to Epi-data 3.1, and exported to SPSS for windows version 21 for data analysis. Descriptive statistics used to describe the main features of the data. Bivariate analysis was done to identify candidate variable using p<0.25. Multivariate Logistic regression was used to control the effect of confounding variables. Variables having P<0.25 from bivariate analysis were included in multivariable logistic regression analysis. Finally, statistical significance declared at P<0.05 using adjusted OR with 95% CI.

2.7. Ethical Considerations. Ethical clearance was taken from Institutional Review Board (IRB) of Jimma University Institute of health, and permission letter was obtained from JUMC including Obstetrics and Gynecology Department. Participants were informed about the objective of the study and relevant issues before informed consent taken. Confidentiality was assured by using codes and their privacy was also kept.

3. Results

3.1. Sociodemographic Characteristics. Response rate for this study is 100%. Out of 2348 laboring mothers who gave birth in the labor ward of JUMC during the 6 months of the study period 242(10.3%) were by operative vaginal delivery(OVD). Out of all 92 (38%) of them were in the age group of 20-24 years, the mean age of study participants was 24.7years +/- 5years SD. Most 144(59.5%) of them were from outside of Jimma Town. Almost all 237 (97.9%) of them were married, and majority of them were Muslim by religion, Oromo by ethnicity, and housewives by occupational status, 161(66.5%), 201(83.1%), and 101(41.7%) respectively. Those mothers who cannot read and write and with educational level of grade 1-8 each account for one-third of cases and 128(52.9%) of mothers' monthly income is 500-1742ETB. (See Table 1)

3.2. Obstetric Related Variables. According to this study 168(69.4%) of mothers were primiparas and 233(96.3%) of mothers who gave birth by OVD had at least one ANC visit and 118(48.8%) had four or more ANC visits. The commonest indication for OVD is found to be NRFHRP 136(56.2%) which is followed by prolonged SSOL 58(24.0%). Of the types of OVDs forceps is more commonly used 192(79.3%) and vacuum deliveries were 50(20.7%) with ratio of 4:1. Most 132(54.5%) of the applied classification of OVD is low forceps or low vacuum and 110(45.5%) were outlet forceps or outlet vacuum. Out of 173(71.5%) OVDs applied for those mothers who were being followed at labor ward of JUMC, 70 (28.9%) of the laboring mothers had different grades of MSAF. The GA at delivery was between 37 and 42 weeks in 213 (88.0%) of the laboring mothers. Fifteen mothers (6.2%) had postterm pregnancy and 14(5.8%) were preterm deliveries. Majority 221(91.3%) of the newborns weigh 2500-3999 grams. (See Table 2 and Figure 1)

3.3. Neonatal Outcome and Maternal Sociodemographics. Of all mothers who gave birth by OVD during the study period 210(86.8%) had favorable neonatal outcome. Mothers in the group of 25-29 years and those from Jimma Town had the higher proportion of favorable neonatal outcome which is 71(89.9%) and 90(91.8%), respectively. Neonates of mothers who are farmers in occupation had the lowest proportion 64(78%) of favorable outcome and the proportion of those neonates from mothers who at least can read and write that had favorable outcome is higher 149(90.3%) when compared with proportion among illiterates 61(79.2%). Mothers whose monthly income is greater than 1743ETB had higher 98(94.2%) proportion of favorable neonatal outcome and 205(86.5%) of those mothers who are married had neonates with favorable outcome. (see Table 3)

3.4. Neonatal Outcome and Obstetric Related Variables. The proportion of neonates who had favorable outcome among para II-IV mothers and neonates born at term is higher which is 96.2% and 87.3% respectively. Those mothers who had at least one ANC visit have higher proportion of favorable neonatal outcome (88.0% versus 55.6%) and those who had four and above visits have better proportion 91.5% with favorable outcome. Based on indication NRFHRP has the lower proportion of favorable outcome. Forceps deliveries are having higher proportion of favorable outcome (91.7% versus 68%) and the same holds for outlet (90.9%). The higher proportion of mothers who were followed at the labor ward of JUMC had favorable neonatal outcome than those for whom OVD is applied on arrival (91.7% versus 75.4%). Half of those with G3MSAF have favorable outcome (see Table 4).

Of the 242 OVDs, neonates with low APGAR score (46) at first and fifth minutes were 95(39.3%) and 16(6.6%), respectively, and those with very low APGAR score (0-3) at first and fifth minutes were 10(4.1%) and 2(0.8%), respectively, and 47(19.4%) needed resuscitation. There were a total of 34(14.0%) admissions to NICU and 3 neonatal deaths before referral to NICU. Majority of the admissions were for MAS 15(44.1%) followed by MAS+ subgaleal hemorrhage 10(29.4%). There were different birth injuries like SGH, skull fracture, and bruising with a total of 15(44.1%) injuries (one neonate with SGH requiring blood transfusion). The proportion of neonates with birth injury is higher among vacuum group than forceps deliveries (20% versus 2.6%). Of the admitted cases to NICU 26(76.5%) were improved, 6(17.6%) died, and status of two of the cases is unknown. The commonly ascribed causes of neonatal deaths were respiratory failure, PNA, and multiorgan failure. (See Table 4)

3.5. Maternal Outcome and Sociodemographic Variables. Out of 242 mothers, 232(95.9%) have favorable maternal outcome. Mothers in the group of 20-24 years had the higher proportion of favorable maternal outcome which is 97.8% and all mothers from Jimma Town have favorable maternal outcome. Those mothers who earn >1742ETB per month have higher proportion 102(98.1%) of favorable maternal outcome. (See Table 5)

3.6. Maternal Outcome and Obstetric Related Variables. The proportion of mothers who had favorable outcome among para II-IV mothers and for whom prolonged SSOL is an indication for OVD is higher which is 98.1% and 98.3%, respectively. Based on type of OVD used the proportion of mothers with favorable maternal outcome is almost equal between forceps and vacuum deliveries (95.8% versus 96.0%). Almost all (99.1%) of outlet forceps/vacuum deliveries have favorable maternal outcome. Of all 242 OVDs 8 cases (3.3%) were complicated with PPH and the PPHs were secondary to three uterine atony and five episiotomy extension cases. Two of the eight PPH cases underwent per partum hysterectomy and three of them were transfused. There is one case complicated with fourth degree genital tear with no PPH and one maternal death after forceps is applied for shortening of SSOL for cardiac illness and the death is ascribed to be secondary to cardiac arrest. (See Table 6)

3.7. Factors Affecting Neonatal Outcome. Place of residence, occupation, income, parity, indication for OVD, type of instrument used for OVD, station at which OVD is applied, time of application, and status of liquor were variables identified as a candidate variable from bivariate logistic regression analysis and then fitted into the final multivariable logistic regression model using enter method to identify independent factors affecting the fetal outcome. This study shows that there is significant association between type of instrument used for OVD and neonatal outcome, 80% of mothers who gave birth by vacuum are less likely to have favorable neonatal outcome than those with forceps deliveries (AOR=0.228, 95%CI: 0.078, 0.671). Meconium stained amniotic fluid had shown association with neonatal outcome, 84% of mothers with G2MSAF (AOR=0.163, 95%CI: 0.031, 0.858) and 90% of mothers with grade 3 MSAF (AOR=0.088, 95%CI: 0.024, 0.327) are less likely to have favorable neonatal outcome than those with clear amniotic fluid. (see Table 7)

3.8. Factors Affecting Maternal Outcome. Income, indication for OVD, station at OVD application, and weight of newborn at delivery were variables identified as candidate variable from bivariate logistic regression analysis and then fitted into the final multivariable logistic regression model using enter method to identify independent factors affecting the maternal outcome. Neonatal birth weight had shown strong association with maternal outcome, almost all mothers with neonatal birth weight >4000grams (99.6%) are less likely to have favorable maternal outcome than those with neonatal birth weight of 2500-3999grams (AOR=0.007, 95%CI: 0.000, 0.151), respectively. (see Table 8)

4. Discussion

Prevalence of OVD application is 10.3% in JUMC and the finding is consistent with other studies. Although operative vaginal delivery maybe performed, as infrequently as in 1.5% of deliveries in some countries, it may be as high as 15% in other countries. For example, in the United Kingdom, the rates of instrumental vaginal delivery range between 10% and 15%; these rates have remained fairly constant. Of the total 242 OVDs, forceps and vacuum deliveries account for 8.2% and 2.1% of all the deliveries during the study period respectively with ratio of 4:1, but according to study done at Tikur Anbessa Hospital the ratio is 2:1 and it is not in line with the currently increasing proportion of vacuum deliveries which is 1:4. The higher difference in the proportion of forceps to vacuum deliveries from other studies can be due to the commonest indication being NRFHRP which needs faster delivery and the inconsistent supply of functioning vacuum extraction devices in the study area [1, 2, 5, 11].

Fetal distress (NRFHRP) was the commonest indication (56.2%) for OVD among the 242 cases followed by prolonged SSOL (24.0%) and those used to cut short SSOL (19.4%) and the finding is consistent with other studies. For example, a five-year retrospective study done on trends of instrumental deliveries at a tertiary care teaching hospital in Puducherry, India, shows among the study participants the indications were nonreassuring fetal heart (45.3%), prolonged second stage of labor (33.9%), and maternal indication to shorten second stage of labor (13.1%). The study done at the Tikur Anbessa Hospital also shows that the most common indication for OVD is fetal distress (45.3%) [2, 8].

According to our study the overall rate of complication is 17.3% (maternal=4.1% and neonatal=13.2%). The commonest maternal complication was postpartum hemorrhage (3.3%) and this can be explained by genital tract laceration which account for 62.5% of the PPH and prolonged labor also contributes PPH secondary to uterine atony. But the finding of rate of PPH among operative vaginal deliveries is much lower than study done at Aminu Kano Teaching Hospital, Kano, Nigeria, which is 9.5% and this may be due to lack of practice in documenting estimated blood loss and determining postoperative hematocrit after at least suspected PPH cases [2, 10].

Vacuum deliveries are associated with significant fetal morbidity and among vacuum deliveries fetal morbidity is 32% and 20% were complicated with subgaleal hemorrhage. The rates of severe birth asphyxia and ENND were 4.9% and 3.7%, respectively. This is compared to the findings of various studies; for example, according to study carried out at the Aminu Kano Teaching Hospital, Kano, Nigeria, the rate of asphyxia and ENND is 4.8% and 3.8%, respectively. But, this may not be truly attributable to the procedure as the asphyxia may be the outcome of the events of labor that indicated the intervention than the operative vaginal procedure itself [3, 10, 12, 13].

Among the 242 OVDs, neonates with low APGAR scores (4-6) at first and fifth minutes were 95(39.3%) and 16(6.6%), respectively, and those with very low APGAR score (0-3) at first and fifth minutes were 10(4.1%) and 2(0.8%), respectively. Compared to other studies the rate of low APGAR score (<7) is higher and this can be explained by the fact that fetal distress was the commonest indication for OVD according to our study and also the commonest cause of low APGAR scores at the 1st and fifth minute among indications of operative vaginal deliveries [2,14-16]. Our study and most other studies showed that there is significant association between type of instrument used for OVD and neonatal outcome, 80% of mothers who gave birth by vacuum are less likely to have favorable neonatal outcome than those with forceps deliveries. According to one of the studies, cephalhematoma, in particular, is more common after vacuum-assisted extraction than forceps delivery (approximately 15 versus 2 percent). The risks of fetal injury are generally instrument specific, with vacuum deliveries accounting for statistically significantly higher rates of cephalhematoma, and subgaleal and retinal hemorrhages, and forceps deliveries accounting for a no significantly higher rate of scalp/facial injuries [11, 17-20].

Meconium stained amniotic fluid had shown association with neonatal outcome, 90% of mothers with grade 3 MSAF are less likely to have favorable neonatal outcome than those with clear amniotic fluid. Studies showed that the association can be explained by passage of meconium secondary to already existing intrauterine fetal compromise or asphyxia [11, 21-23]. Neonatal birth weight had shown strong association with maternal outcome, 99.6% of those mothers who gave birth to neonate with birth weight >4000grams are less likely to have favorable maternal outcome when compared to those with normal birth weight. This finding as it is proven on different literatures, macrosomia attributes for PPH secondary to both uterine atony and perineal lacerations [4, 11, 24].

5. Conclusion and Recommendation

5.1. Conclusion. The prevalence of OVD among the 2348 laboring mothers who gave birth at JUMC during the study period is 10.3%. The commonest indication for OVD is NRFHRP (56.2%) followed by prolonged SSOL (24.0%) and shortening SSOL (19.8%). Among mothers who gave birth by OVD, 86.8% had favorable neonatal outcome. Near to all (95.9%) of mothers who gave birth by OVD had favorable maternal outcome. Type of instrument used for OVD and presence of MSAF are factors affecting neonatal outcome. Neonatal birth weight is significant factor affecting maternal outcome.

5.2. Recommendations. Nearby health facilities should be equipped with and use instruments needed for OVD as majority (59.5%) of mothers were referred from other facilities, application of OVD does not need referral to tertiary hospital. Although the ANC coverage among mothers with OVD is higher (96.3% had at least one ANC visit and 48.8% had four and above ANC visit) than the national and Oromia figure, mothers should be encouraged to have the recommended number of ANC follow-up and further study is needed to know and address the reason why mothers are not having the ANC visit as per the recommendation. The ratio of forceps to vacuum delivery according to this study is 4:1 but currently vacuum has worldwide acceptance because of technical simplicity to apply and relatively less maternal trauma, so using vacuum for OVD should be encouraged. Documenting estimated blood loss and determining postoperative hematocrit after at least suspected PPH cases should be practiced by health professionals attending OVDs, as none of patients' charts contain adequate data about the circumstance of delivery and that can be evidenced by relatively lower rate of PPH. The commonest maternal complication was postpartum hemorrhage (3.3%). The PPH cases were higher among mothers who gave birth to neonates with birth weight >4000grams and the study had shown the association. Thus, there is need to anticipate postpartum hemorrhage in operative vaginal deliveries special in case macrosomia suspected.
Abbreviations

ANC:  Antenatal care
ARM:  Artificial rupture of membrane
FHR:  Fetal heart rate
IUFD: Intrauterine fetal death
ENND: Early neonatal death
EFW:  Estimated fetal weight
GA:   Gestational age
HCT:  Hematocrit
HTN:  Hypertension
JUMC: Jimma University Medical Center
MSAF: Meconium stained amniotic fluid
NICU: Neonatal intensive care unit
ObGy: Obstetrics and Gynecology
OL:   Obstructed labor
OVD:  Operative vaginal delivery
PE:   Preeclampsia
PPH:  Postpartum hemorrhage
PNA:  Perinatal asphyxia
ROM:  Rupture of membrane
SSOL: Second stage of labor
SVD:  Spontaneous vaginal delivery
SGH:  Subgaleal hemorrhage
WHO:  World Health Organization.


https://doi.org/10.1155/2018/7423475

Data Availability

The data used to support the findings of this study are included within the article.

Ethical Approval

Ethical clearance and an approval letter were obtained from Jimma University, Institute of Health-Institutional Reviewing Board, then support letter was obtained from JUMC administrative office.

Consent

All parties involved (Jimma University, study subjects, and authors) agreed to publish on international peer reviewed journal which is Hindawi-Journal of Pregnancy. During data collection, all participants informed and agreed on the major objective of the study which is for academic purpose including publication. Study participants were informed about the objective and details of the study including publication. Informed verbal consent was obtained from each subject. Confidentiality was maintained by using anonymous codes and the patients' chart number.

Conflicts of Interest

All authors declare that they have no any financial and nonfinancial conflicts of interest. None of the authors of this paper has a financial or personal relationship with other people or organizations that could inappropriately influence or bias the content of the paper.

Authors' Contributions

Zenebe Hubena had made substantial contributions to conception and design, acquisition of data, and analysis and interpretation of data. Ahadu Workneh and Yibeltal Siraneh prepared the manuscript critically for important intellectual content and worked together with Zenebe Hubena starting from proposal development to report writing. All authors read and approved the final manuscript.

Acknowledgments

The authors would like to express their deepest gratitude and appreciation to mothers, health professionals, and secretary of ObGy Department. They also acknowledge Jimma University, Institute of Health-IRB, for securing ethical letter timely and for the fund provided.

References

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Zenebe Hubena, (1) Ahadu Workneh, (2) and Yibeltal Siraneh (iD) (3)

(1) Kuyu General Hospital, North Showa, Oromia Regional State, Ethiopia

(2) Department of Obstetrics and Gynecology, Faculty of Medical Sciences, Institute of Health, Jimma University, Ethiopia

(3) Department of Health Economics, Management and Policy, Faculty of Public Health, Institute of Health, Jimma University, Ethiopia

Correspondence should be addressed to Yibeltal Siraneh; yibeltal_siraneh@yahoo.com

Received 22 January 2018; Revised 4 June 2018; Accepted 14 June 2018; Published 9 July 2018

Academic Editor: Marco Scioscia
Table 1: Frequency distribution of sociodemographic characteristics of
mothers who gave birth by OVD in JUMC December 1, 2016-May 30, 2017.

Variable            Variable category    Frequency   Percent

Age                       15-19             27        11.2
                          20-24             92        38.0
                          25-29             79        32.6
                          30-34             31        12.8
                          35-39             13         5.4

Place of               Jimma Town           98        40.5
residency          Outside Jimma town       144       59.5

Ethnicity                 Oromo             201       83.1
                         Amhara             13         5.4
                          Tgrie              3         1.2
                         Gurage              7         2.9
                         Dawuro             12         5.0
                          Other              6         2.5

Religion                 Muslim             161       66.5
                        Orthodox            55        22.7
                       Protestant           24         9.9
                          Other              2         .8

Occupation              Housewife           101       41.7
                      civil servant         39        16.1
                         Farmer             82        33.9
                        Merchant            11         4.5
                          Other              9         3.7

Educational            Illiterate           77        31.8
status             read and write only       4         1.7
                        grade 1-8           81        33.5
                       grade 9-10           25        10.3
                       grade11-12           31        12.8
                           >12              24         9.9

Income of the       500 ETB and below       10         4.1
family per month      501-1742 ETB          128       52.9
                       above 1742           104       43.0

Marital status           Married            237       97.9
                         Single              3         1.2
                        Divorced             1         .4
                         Widowed             1         .4

Table 2: Frequency distribution of obstetric related variables among
mothers who gave birth by OVD in JUMC December 1, 2016-May 30, 2017.

Obstetric related       Variable category        Frequency   Percent

Parity                          I                   168       69.4
                              II-IV                 53        21.9
                   [greater than or equal to]V      21         8.7
GA                          pre-term                14         5.8
                              Term                  213       88.0
                            post term               15         6.2

ANC follow up                  yes                  233       96.3
                               no                    9         3.7

Number of                   one visit                4         1.7
ANC follow up          two to three visit           111       45.9
                      four and above visit          118       48.8
                            No visit                 9         3.7

Type of OVD used             vacuum                 50        20.7
                             forceps                192       79.3
Type of OVD                    low                  132       54.5
applied                      outlet                 110       45.5

Time of                    on arrival               69        28.5
application                 followed                173       71.5

Status of                     clear                 172       71.1
liquor                       G1MSAF                 19         7.9
                             G2MSAF                 17         7.0
                             G3MSAF                 34        14.0

Weight of the               1500-2499               14         5.8
newborn in grams            2500-3999               221       91.3
                             >/=4000                 7         2.9

Table 3: Distribution of neonatal outcome among different maternal
sociodemographic characteristic categories who gave birth by OVD in
JUMC December 1, 2016-May 30, 2017.

                                               Neonatal outcome

                                           Favorable      Unfavorable
Variable            Variable category    outcome N (%)   outcome N (%)

Age                       15-19            24(88.9)         3(11.1)
                          20-24            81(88.0)        11(12.0)
                          25-29            71(89.9)         8(10.1)
                          30-34            25(80.6)         6(19.4)
                          35-39             9(69.2)         4(30.8)

Place of               Jimma Town          90(91.8)         8(8.2)
the residency      Outside Jimma town      120(83.3)       24(16.7)

Occupation              Housewife          95(94.1)         6(5.9)
                      civil servant        33(84.6)         6(15.4)
                         Farmer            64(78.0)        18(22.0)
                        Merchant            9(81.8)         2(18.2)
                          Other            9(100.0)         0(0.0)

Educational            Illiterate          61(79.2)        16(20.8)
status             read and write only     4(100.0)         0(0.0)
                        grade 1-8          75(92.6)         6(7.4)
                       grade 9-10          21(84.0)         4(16.0)
                       grade11-12          27(87.1)         4(12.9)
                           >12             22(91.7)         2(8.3)

Income of the       500 ETB and below       9(90.0)         1(10.0)
family per month      501-1742 ETB         103(80.5)       25(19.5)
                      above 1742ETB        98(94.2)         6(5.8)

Marital status           Married           205(86.5)       32(13.5)
                         Others            5(100.0)         0(0.0)

Variable            Variable category      Total

Age                       15-19          27(100.0)
                          20-24          92(100.0)
                          25-29          79(100.0)
                          30-34          31(100.0)
                          35-39          13(100.0)

Place of               Jimma Town        98(100.0)
the residency      Outside Jimma town    144(100.0)

Occupation              Housewife        101(100.0)
                      civil servant      39(100.0)
                         Farmer          82(100.0)
                        Merchant         11(100.0)
                          Other           9(100.0)

Educational            Illiterate        77(100.0)
status             read and write only    4(100.0)
                        grade 1-8        81(100.0)
                       grade 9-10        25(100.0)
                       grade11-12        31(100.0)
                           >12           24(100.0)

Income of the       500 ETB and below    10(100.0)
family per month      501-1742 ETB       128(100.0)
                      above 1742ETB      104(100.0)

Marital status           Married         237(100.0)
                         Others           5(100.0)

Table 4: Distribution of neonatal outcome among mothers who gave birth
by OVD in JUMC December 1, 2016-May 30, 2017.

                                             Neonatal outcome

                                          Favorable      Unfavorable
variable          Variable category     outcome N (%)   outcome N (%)

Parity                    I               146(86.9)       22(13.1)
                        II-IV             51(96.2)         2(3.8)
                   [greater than or
                      equal to] V         13(61.9)         8(38.1)

GA in weeks            pre-term           12(85.7)         2(14.3)
                         Term             186(87.3)       27(12.7)
                      post term           12(80.0)          3(20)
ANC follow up            yes              205(88.0)       28(12.0)
                          No               5(55.6)         4(44.4)

Number of ANC         one visit            3(75.0)         1(25.0)
follow up         two to three visit      94(84.7)        17(15.3)
                 four and above visit     108(91.5)        10(8.5)
                       no visit            5(55.6)         4(44.4)

Indication              NRFHRP            115(84.6)       21(15.4)
for OVD            shortening SSOL        44(91.7)         4(8.3)
                    prolonged SSOL        51(87.9)         7(12.1)

Type of OVD             vacuum            34(68.0)        16(32.0)
used                   forceps            176(91.7)        16(8.3)

Type of OVD              Low              110(83.3)       22(16.7)
applied                 outlet            100(90.9)        10(9.1)

Time of               on arrival          52(75.4)        17(24.6)
application            followed           158(91.7)        15(8.3)

Status of               clear             163(94.8)        9(5.2)
liquor                  G1MSAF            17(89.5)         2(10.5)
                        G2MSAF            13(76.5)         4(23.5)
                        G3MSAF            17(50.0)        17(50.0)
weight of the         1500-2499           13(92.9)         1(7.1)
newborn in            2500-3999           192(86.9)       29(13.1)
grams                  >/=4000             5(71.4)         2(28.6)

variable          Variable category       Total

Parity                    I             168(100.0)
                        II-IV           53(100.0)
                   [greater than or
                     equal to] V        21(100.0)

GA in weeks            pre-term         14(100.0)
                         Term           213(100.0)
                      post term         15(100.0)
ANC follow up            yes            233(100.0)
                          No             9(100.0)

Number of ANC         one visit          4(100.0)
follow up         two to three visit    111(100.0)
                 four and above visit   118(100.0)
                       no visit          8(100.0)

Indication              NRFHRP          136(100.0)
for OVD            shortening SSOL      48(100.0)
                    prolonged SSOL      58(100.0)

Type of OVD             vacuum          50(100.0)
used                   forceps          192(100.0)

Type of OVD              Low            132(100.0)
applied                 outlet          110(100.0)

Time of               on arrival        69(100.0)
application            followed         173(100.0)

Status of               clear           172(100.0)
liquor                  G1MSAF          19(100.0)
                        G2MSAF          17(100.0)
                        G3MSAF          34(100.0)
weight of the         1500-2499         14(100.0)
newborn in            2500-3999         221(100.0)
grams                  >/=4000           7(100.0)

Table 5: Distribution of maternal outcome cross tabulated with
sociodemographic characteristics among mothers who gave birth by OVD
in JUMC December 1, 2016-May 30, 2017.

                                              Maternal outcome
Variables with
category                                   Favorable     Unfavorable
                                         outcome N (%)   outcome N (%)

Age                       15-19            26(96.3)         1(3.7)
                          20-24            90(97.8)         2(2.2)
                          25-29            74(93.7)         5(6.3)
                          30-34            30(96.8)         1(3.2)
                          35-39            12(92.3)         1(7.7)

Place of the           Jimma Town          98(100.0)        0(0.0)
residency          Outside Jimma town      134(93.1)        10(6.9)

Occupation              Housewife          97(96.0)         4(4.0)
                      civil servant        39(100.0)        0(0.0)
                         Farmer            76(92.7)         6(7.3)
                        Merchant           11(100.0)        0(0.0)
                          Other            9(100.0)         0(0.0)

Educational            Illiterate          71(92.2)         6(7.8)
status             read and write only     4(100.0)         0(0.0)
                        grade 1-8          78(96.3)         3(3.7)
                       grade 9-10          24(96.0)         1(4.0)
                       grade11-12          31(100.0)        0(0.0)
                           >12             24(100.0)        0(0.0)

Income of the       500 ETB and below       8(80.0)         2(20.0)
family per month      501-1742 ETB         122(95.3)        6(4.7)
                       above 1742          102(98.1)        2(1.9)

Marital status           Married           227(95.8)        10(4.2)
                         Others            5(100.0)         0(0.0)

Variables with
category
                                           Total

Age                       15-19          27(100.0)
                          20-24          92(100.0)
                          25-29          79(100.0)
                          30-34          31(100.0)
                          35-39          13(100.0)

Place of the           Jimma Town        98(100.0)
residency          Outside Jimma town    144(100.0)

Occupation              Housewife        101(100.0)
                      civil servant      39(100.0)
                         Farmer          82(100.0)
                        Merchant         11(100.0)
                          Other           9(100.0)

Educational            Illiterate        77(100.0)
status             read and write only    4(100.0)
                        grade 1-8        81(100.0)
                       grade 9-10        25(100.0)
                       grade11-12        31(100.0)
                           >12           24(100.0)

Income of the       500 ETB and below    10(100.0)
family per month      501-1742 ETB       128(100.0)
                       above 1742        104(100.0)

Marital status           Married         237(100.0)
                         Others           5(100.0)

Table 6: Distribution of maternal outcome cross tabulated with
maternal obstetric related variables among mothers who gave birth by
OVD in JUMC December 1, 2016-May 30, 2017.

                                            Maternal outcome
Obstetric
related factors                        Favorable      Unfavorable
                                     outcome N (%)   outcome N (%)

Parity                    I            160(95.2)        8(4.8)
                        II-IV          52(98.1)         1(1.9)
                   [greater than or
                     equal to] V       20(95.2)         1(4.8)

ANC follow up            Yes           223(95.7)        10(4.3)
                         No            9(100.0)         0(0.0)

Indication for         NRFHRP          132(97.1)        4(2.9)
OVD                shortening SSOL     43(89.6)         5(10.4)
                   prolonged SSOL      57(98.3)         1(1.7)

Type of OVD used       Vacuum          48(96.0)         2(4.0)
                       Forceps         184(95.8)        8(4.2)

Type of OVD              Low           123(93.2)        9(6.8)
applied                Outlet          109(99.1)         1(.9)

Time of              on arrival        67(97.1)         2(2.9)
application           Followed         165(95.4)        8(4.6)

weight of the         1500-2499        12(85.7)         2(14.3)
newborn in grams      2500-3999       213((96.4)        8(3.6)
                       >/=4000         7(100.0)         0(0.0)

Obstetric
related factors
                                       Total

Parity                    I          168(100.0)
                        II-IV        53(100.0)
                    [greater than
                    or equal to] V   21(100.0)

ANC follow up            Yes         233(100.0)
                         No           9(100.0)

Indication for         NRFHRP        136(100.0)
OVD                shortening SSOL   48(100.0)
                   prolonged SSOL    58(100.0)

Type of OVD used       Vacuum        50(100.0)
                       Forceps       192(100.0)

Type of OVD              Low         132(100.0)
applied                Outlet        110(100.0)

Time of              on arrival      69(100.0)
application           Followed       173(100.0)

weight of the         1500-2499      14(100.0)
newborn in grams      2500-3999      221(100.0)
                       >/=4000        7(100.0)

Table 7: Factors affecting neonatal outcome using multivariate
logistic regression among mothers who gave birth by OVD in JUMC
December 1, 2016-May 30, 2017.

                                        Neonatal outcome
Variables
with category                           Fav    Unfav

Place of the           Jimma Town        90      8
residency          Outside Jimma town   120      24

Occupation             Housewife         95      6
                     civil servant       33      6
                         Farmer          64      18
                        Merchant         9       2
                         Other           9       0

Income of the      500 ETB and below     9       1
family per month      501-1742 ETB      103      25
                       above 1742        98      6

Parity                     I            146      22
                         II-IV           51      2
                           >V            13      8

Indication for           NRFHRP         115      21
OVD                 shortening SSOL      44      4
                     prolonged SSOL      51      7

Type of OVD              Vacuum          34      16
used *                  Forceps         176      16

Type of OVD               Low           110      22
applied                  Outlet         100      10

Time of                on arrival        52      17
application             Followed        158      15

Status of                Clear          163      9
liquor *                 G1MSAF          17      2
                         G2MSAF          13      4
                         G3MSAF          17      17

Variables
with category                            Crude OR(95% CI)

Place of the           Jimma Town       2.250(.966,5.241)
residency          Outside Jimma town           1

Occupation             Housewife                1
                     civil servant      .347(.105, 1.152)
                         Farmer          .225(.085, .596)
                        Merchant        .284(.050, 1.620)
                         Other          1.020(.000,2.310)

Income of the      500 ETB and below    1.000(.118, 8.487)
family per month      501-1742 ETB              1
                       above 1742        .490(229,1.051)

Parity                     I                    1
                         II-IV          3.842(.873,16.917)
                           >V            .245(.091, .658)

Indication for           NRFHRP                 1
OVD                 shortening SSOL     2.009(.653, 6.183)
                     prolonged SSOL     1.330(.532,3.328)

Type of OVD              Vacuum          .193(.088, .423)
used *                  Forceps                 1

Type of OVD               Low                   1
applied                  Outlet         2.000(.903,4.429)

Time of                on arrival        .290(.136, .622)
application             Followed                1

Status of                Clear                  1
liquor *                 G1MSAF         .469(.094, 2.352)
                         G2MSAF          .179(.049, .663)
                         G3MSAF          .055(.021, .143)

Variables
with category                               AOR(95%CI)        P value

Place of the           Jimma Town        .653(.176,2.429)      0.525
residency          Outside Jimma town            1

Occupation             Housewife                 1
                     civil servant       0.282(.062,1.278)     0.101
                         Farmer          0.299(.061,1.462)     0.136
                        Merchant         0.221(.029,1.692)     0.146
                         Other           1.110(.000,3.23)      0.999

Income of the      500 ETB and below     4.650(.248,87.109     0.304
family per month      501-1742 ETB               1
                       above 1742        1.551(325,7.397)      0.582

Parity                     I                     1
                         II-IV          2.719(.525,14.070)     0.233
                           >V            0.294(.072,1.197)     0.088

Indication for           NRFHRP                  1
OVD                 shortening SSOL     0.698(.155, 3.146)     0.640
                     prolonged SSOL     0.906(.198, 4.143)     0.899

Type of OVD              Vacuum         0.228(0.078, 0.671)    0.007
used *                  Forceps                  1

Type of OVD               Low                    1
applied                  Outlet         1.604(.577, 4.458)     0.365

Time of                on arrival        0.436(.118,1.615)     0.214
application             Followed                 1

Status of                Clear                   1
liquor *                 G1MSAF         0.574(.081, 4.088)     0.579
                         G2MSAF          0.163(.031, .858)     0.032
                         G3MSAF          0.088(.024, .327)     0.000

* shows significant predictor variable with p<0.05.

Table 8: Factors affecting maternal outcome using multivariate
logistic regression among mothers who gave birth by OVD in JUMC
December 1, 2016-May 30, 2017.

Variables                                Maternal outcome

with category                            Fav    Unfav

Income of the        500 ETB and below    8       2
family per month       501-1742 ETB      122      6
                       above 1742ETB     102      2

Indication                NRFHRP         132      4
for OVD               shortening SSOL     43      5
                      prolonged SSOL      57      1

Type of                     Low          123      9
OVD applied               Outlet         109      1

weight of the            1500-2499        12      2
newborn in grams *       2500-3999       213      8
                          >/=4000         7       0

Variables

with category                              Crude OR(95% CI)

Income of the        500 ETB and below    0.058(0.007,0.467)
family per month       501-1742 ETB               1
                       above 1742ETB      0.208(0.041,1.053)

Indication                NRFHRP                  1
for OVD               shortening SSOL    0.261(0.067, 1.014)
                      prolonged SSOL     1.727(0.189,15.796)

Type of                     Low                   1
OVD applied               Outlet         7.976(0.994, 63.969)

weight of the            1500-2499       0.167(0.031, 0.919)
newborn in grams *       2500-3999                1
                          >/=4000        0.070(0.011, 0.435)

Variables
with category                                 AOR(95%CI)        P value

Income of the        500 ETB and below    0.004(.000, 0.133)     0.057
family per month       501-1742 ETB               1
                       above 1742ETB     0.060(0.004, 0.961)     0.073

Indication                NRFHRP                  1
for OVD               shortening SSOL     0.166(0.026,1.067)     0.058
                      prolonged SSOL      1.632(.146,18.298)     0.691

Type of                     Low                   1
OVD applied               Outlet         8.262(0.670,101.942)    0.100

weight of the            1500-2499        0.355(0.050,2.546)     0.303
newborn in grams *       2500-3999                1
                          >/=4000        0.007(0.000, 0.151)     0.002

* shows significant predictor variable with p<0.05; Fav: favorable;
Unfav: unfavorable.

Figure 1: Proportion of indications for OVD among mothers who
gave birth by OVD in JUMC December 1, 2016, to May 30, 2017.

NRFHRP            56.2%
shortening SSOL   19.8%
prolonged SSOL    24%

Note: Table made from bar graph.
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Article Details
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Title Annotation:Research Article
Author:Hubena, Zenebe; Workneh, Ahadu; Siraneh, Yibeltal
Publication:Journal of Pregnancy
Article Type:Clinical report
Date:Jan 1, 2018
Words:7914
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