Determinants of hysterectomy, maternal mortality and perinatal mortality among uterine rupture cases: an eight-year retrospective study in Niger

Determinants of hysterectomy, maternal mortality and perinatal mortality among uterine rupture cases: an eight-year retrospective study in Niger | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Determinants of hysterectomy, maternal mortality and perinatal mortality among uterine rupture cases: an eight-year retrospective study in Niger Abdou Amadou Issa, Hamidou Soumana Diaouga, Maina Oumara, Raïssa Hassane Bebe Idde, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9104456/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background Uterine rupture remains a major obstetric emergency in low-resource settings, and is associated with severe maternal and perinatal morbidity and mortality. Evidence from Sahelian countries remains limited. This study aimed to determine the incidence, determinants, and outcomes of uterine rupture in a tertiary referral hospital in Niger. Methods We conducted a retrospective study of all cases of uterine rupture managed between January 1, 2015, and December 31, 2022, in the obstetrics department of a tertiary referral hospital. Sociodemographic characteristics, obstetric factors, clinical management, and maternal and perinatal outcomes were analyzed. Temporal trends were assessed using the Chi-Square test for trend, and multivariable logistic regression was performed to identify independent factors associated with maternal mortality, perinatal mortality, and hysterectomy. Results During the study period, 26,971 deliveries were recorded, including 408 cases of uterine rupture, yielding an incidence of 1.51% (15.1 per 1,000 deliveries). Most women were from rural areas (66.9%) and had no formal education (92.6%). The majority of patients were referred from peripheral health facilities (91%), and more than half experienced a referral delay exceeding 12 hours (54.2%). Uterine repair was performed in 65% of cases, while 35% required hysterectomy. Maternal mortality was 3.4% (14 deaths/408), and perinatal mortality was 76.7% (313/408). Rural origin (aOR 6.04; 95% CI 1.1–7.2; P = 0.03), blood transfusion (aOR 3.91; 95% CI 1.5–10.1; P = 0.004), and hypovolemic shock (aOR 50; 95% CI 31.21–69.98; P = 0.002) were independently associated with maternal death. Perinatal mortality was significantly associated with rural residence (aOR 1.2; 95% CI 1.5–4.4; P < 0.001), grand multiparity (aOR 1.83; 95% CI 1.1–3.0; P = 0.003), non-scarred uterus (aOR 1.78; 95% CI 1.1–2.8; P = 0.002), and blood transfusion (aOR 2.37; 95% CI 1.3–4.1; P = 0.003). Temporal analysis showed significant variation in incidence over time (χ² trend = 22.55; P = 0.002) and a marked decline in maternal mortality after 2016. Conclusion Uterine rupture remains associated with extremely high maternal and perinatal mortality in low-resource settings. Strengthening referral systems, improving intrapartum monitoring, and ensuring timely surgical intervention are essential to reduce adverse outcomes. Uterine rupture Maternal mortality Perinatal mortality Hysterectomy obstetric complications Sub-Saharan Africa Figures Figure 1 Figure 2 BACKGROUND Uterine rupture is a severe obstetric complication characterized by complete disruption of the uterine wall and fetal membranes, often resulting in catastrophic maternal and perinatal consequences. Although rare in high-income countries, where incidence is typically below 0.1% [ 1 , 2 ], uterine rupture remains a major contributor to maternal and perinatal mortality in low- and middle-income countries, particularly in Sub-Saharan Africa [ 3 , 4 ]. In resource-limited settings, several structural and clinical factors increase the risk of uterine rupture, including delayed referral systems, obstructed labor, inadequate intrapartum monitoring, and limited access to emergency obstetric care and blood transfusion services [ 3 , 5 ]. The rising prevalence of cesarean section globally has increased the proportion of women with uterine scars [ 6 ]. Trial of Labor After Cesarean (TOLAC), although considered relatively safe in well-resourced environments, carries an increased risk of uterine rupture that requires immediate surgical capacity [ 7 ]. Studies from Sub-Saharan Africa report significantly higher incidence and mortality rates compared with high-income settings [ 8 – 10 ]. These disparities reflect systemic health system challenges, including late presentation and limited emergency response capacity. In Niger, maternal mortality remains among the highest worldwide [ 3 ], and tertiary referral centers frequently manage advanced obstetric emergencies following delayed transfers. However, data on the epidemiology, management, and outcomes of uterine rupture in Niger are scarce, and few longitudinal analyses have explored temporal trends or system-level changes over time [ 11 , 12 ]. Understanding the burden and clinical profile of uterine rupture in this context is critical to inform health system strengthening strategies, improve referral pathways, and optimize intrapartum care. Moreover, assessing temporal trends may help evaluate progress in emergency obstetric care capacity and identify persistent gaps in maternal and perinatal outcomes. This study aimed to assess the incidence, determinants, and maternal and perinatal outcomes of uterine rupture over an eight-year period in a tertiary referral hospital in Niger, and to evaluate temporal variations in incidence and mortality. METHODS Study design and setting We conducted a retrospective, descriptive, and analytical study over an eight-year period (January 1, 2015, to December 31, 2022), in the department of obstetrics and gynecology of a tertiary referral university hospital in Niger. The institution serves as a regional referral center for high-risk pregnancies and obstetric emergencies, covering a population of five million inhabitants. Study population All women diagnosed with uterine rupture during labor or delivery within the study period were included. Uterine rupture was defined as a complete separation of the uterine wall, involving all layers, confirmed intraoperatively. Cases of suspected but unconfirmed rupture and incomplete medical records were excluded. During the study period, 26,971 deliveries were recorded, among which 408 cases of uterine rupture were identified. Data collection Data were extracted from delivery registers, operative reports, anesthesia records, and patient medical files using a standardized data collection form. Collected variables included: Sociodemographic characteristics (age, residence, education level), obstetric history (gravidity, parity, uterine scar status), clinical presentation, intraoperative findings, surgical management (uterine repair or hysterectomy), blood transfusion requirement, maternal outcome (survival or death), perinatal outcome (live birth or stillbirth). For outcome measures; the primary outcomes were: Maternal mortality (death among rupture cases) and, perinatal mortality (stillbirth and early neonatal death among rupture cases). Secondary outcomes included hysterectomy rate and blood transfusion requirement. Annual incidence of uterine rupture was calculated as the number of rupture cases divided by total annual deliveries, expressed as a percentage. Definitions of study variables Maternal Death: Maternal death due to uterine rupture is defined as the death of the mother from uterine rupture itself, its associated complications, or management. Perinatal death: Stillbirth or early neonatal death following uterine rupture. Grand multiparity: Women with five or more (≥ 5) parities. Hysterectomy: Total or subtotal removal of the uterus. Sepsis: Woman with a diagnosis and management of sepsis in her medical charts. Wound infection: Woman with a diagnosis of wound infection in her medical charts. Maintaining data quality control Data quality was assured by adequately designing the data collection tools. We conducted a pre-test on 5% of the sample size, and after that, all the required corrections on the collection tool were made. All the data collectors and the supervisors were trained on information regarding data collection tools and methods of data extraction, objectives of the study, ethical issues, considerations. The data collection process was supervised by the assigned supervisor for the accuracy of the process. Statistical analysis Data were entered analyzed using Epi Info 7.2.4.0 software. Descriptive statistics were used to summarize sociodemographic and clinical characteristics. Logistic regression analysis was performed to identfy factors with hysterectomy, maternal mortality and perinatal mortality. Variables with P < 0.20 in the bivariate analysis were included in multivariate models. Adjusted odds ratios (aOR) with 95% confidence intervals (CI) were calculated, and P < 0.05 was considered statistically significant. Ethical considerations The study was approved by the Institutional Review Board of the Faculty of Health Sciences, Dan Dicko Dankoulodo of Maradi (Approval Number. 234/UDDM/FSS/2022). Because of the retrospective design and the use of anonymized medical records, the requirement for written informed consent from the patients was waived the ethics commitee. RESULTS Incidence During the 8-year study period (January 2015–December 2022), 26,971 deliveries were recorded, including 408 cases of uterine rupture, yielding an incidence of 1.51% (15.1 per 1,000 deliveries). As shown in the Fig. 1 , the annual incidence of uterine rupture fluctuated over the study period, ranging from 1.29% in 2015 to a peak of 2.12% in 2018. A second relative increase was observed in 2020 (1.95%), followed by stabilization in 2021(1.80%), and 2022(1.33%). The Chi-square test for trend showed χ² = 22.55, p = 0.002, indicating a statistically significant variation in incidence over time. Sociodemographic and obstetric characteristics The mean maternal age was 29.97 ± 3.0 years (range: 17–46). Women aged 20–34 years were the most represented (58.6%). Most women were married (99.5%), housewives (96.3%), from rural areas (66.9%), and had no formal education (92.6%). Approximately 60.5% of women (247 cases) lived more than 90 km from the hospital (range: 5–125 km). The mean gravidity was 6.38 ± 1.5 (range: 1–14), and the mean parity was 5.10 ± 1.5 (range: 1–13). Grand multiparity was observed in 50.3% of cases. Obstructed labor was reported in 42.9% of cases. The majority of uterine ruptures occurred in an unscarred uterus (53.7%). Injudicious use of oxytocin during labor was reported in 34.1% of cases. Most ruptures occurred in pregnancies at ≥ 37 weeks of gestation (87.3%). A large proportion of patients (91%) were referred from peripheral health centers, and 54.2% experienced a referral delay greater than 12 hours. Only 22.5% of women (N = 92) had more than four antenatal visits, while 16.7% of cases had no antenatal care. These characteristics are summarized in Table 1 . Table 1 Sociodemographic and obstetric characteristics among uterine rupture cases Variables Number of cases (N = 408) Percentage (%) Age (years) < 20 56 13.7 20–34 239 58.6 ≥ 35 113 27.7 Occupation Housewife 393 96.3 Employed 14 3.4 Student 1 0.3 Marital status Married 406 99.5 Single 2 0.5 Educational status of mothers No formal education 378 92.6 Primary/secondary 30 7.4 Place of residence Rural 273 66.9 Urban 135 33.1 Parity 1 49 12 2–4 154 37.7 ≥ 5 205 50.3 Number of ANC visits 0 68 16.7 1–3 248 60.8 ≥ 4 92 22.5 Gestational age (weeks) < 37 weeks 52 12.7 ≥ 37 weeks 356 87.3 Admission mode Self-admission 35 9 Referred 373 91 Time to referral (n = 373) < 12h 171 45.8 ≥ 12h 202 54.2 Diagnosis on referral(n = 373) Uterine rupture 121 32.4 CPD/OL 80 21.4 IUFD 8 2.1 Mal-presentation 108 29 Prolonged second stage of labor 56 15 Risk Factors Previous caesarean section 189 46.3 Abnormally/presentations 26 6.4 Prolonged obstructed labor 175 42.9 Injudicious oxytocin usage 139 34.1 ANC : Antenatal care; CPD/OL : Cephalopelvic disproportion/ obstructed labor; IUFD : Intra-uterine fetal death Clinical presentations and surgical management The most frequent presenting symptoms were; abdominal pain (62.2%), cessation of labor (47.5%), and vaginal bleeding (27.7%), while the commonest presenting signs of uterine rupture were easily palpable fetal parts (46.3%) and abdominal tenderness (12%). Uterine repair was done in 65% of cases, while the hysterectomy was done in 35% of cases. The majority of ruptures were complete (53%) involving the anterior lower segment (43.9%). Uterine rupture had accompanying broad ligament hematoma (29.7%), bladder rupture (2.5%), and vaginal extension (2.7%). More than half of the cases (72.3%) stayed for more than five days in the hospital, with an average hospital stay of 6.6 ± 3.7 days, ranging from 3–25 days. More than half of the cases (64%) had a blood transfusion. The Table 2 presents a summary of clinical presentations and surgical management of the patients. Maternal and perinatal outcomes The most common complication in mothers was anemia (72.3%), followed by wound infection (4.2%), vesicovaginal fistula (2.7%), and sepsis (1.7%). Fourteen maternal deaths were recorded, resulting in a maternal mortality rate of 3.4%; mainly due to irreversible hypovolemic shock (11/14 cases, 78.6%), septic shock (2/14 cases, 14.3%), and renal failure (1/14 cases, 7.1%). Of the 408 neonates, 265 were stillbirths (65%), 95 were live births (23.3%), and seven neonates (7.1%) required neonatal intensive care unit (NICU) admission due to low Apgar scores (Table 3 ). Among live newborns, anemia (50/95 cases, 52.6%) and infection (44.2%) were the main complications, leading to 48 early neonatal deaths (11.7%). Perinatal mortality rate was 76.7%. Factors associated with poor maternal and perinatal outcomes After adjustment, maternal death was independently associated with rural origin (aOR: 6.04; 95% CI: 1.1–7.2; P = 0.03), blood transfusion (aOR: 3.91; 95% CI: 1.5–10.1; P = 0.004), and hypovolemic shock (aOR: 50; 95% CI: 31.21–69.98; P = 0.002). Perinatal death was significantly associated with rural origin (aOR 1.2; 95% CI 1.5–4.4; P < 0.001), grand multiparity (aOR 1.83; 95% CI 1.1–3.0; P = 0.003), non-scarred uterus (aOR 1.78; 95% CI 1.1–2.8; P = 0.002), and need for blood transfusion (aOR 2.37; 95% CI 1.3–4.1; P = 0.003). Hysterectomy was strongly associated with complete uterine rupture (aOR 3.51; 95% CI 2.6–7.7; P < 0.001), grand multiparity (aOR 2.98; 95% CI 1.8–4.6; P < 0.001), and blood transfusion (aOR 12.15; 95% CI 8.9–15.2; P < 0.001). Table 4 presents the factors associated with hysterectomy, maternal mortality, and perinatal mortality among uterine rupture cases in logistic regression analysis. Table 2 Clinical presentation, intraoperative findings, and surgical management of uterine rupture (n = 408) Variables Number of cases (N = 408) Percentage (%) Clinical presentation Abdominal pain 254 62.2 Vaginal bleeding 113 27.7 Cessation of labor 194 47.5 Abdominal tenderness 49 12 Easily palpable fetal parts 189 46.3 Type of rupture Complete 192 47 Incomplete 216 53 Site of rupture Anterior lower segment 179 43.9 Lateral 134 32.8 Fundal 67 16.4 Posterior 28 6.9 Associated lesions Bladder injury 10 2.5 Vaginal extension 11 2.7 Broad ligament hematoma 121 29.7 Type of surgical management Total hysterectomy 93 22.8 Subtotal hysterectomy 50 12.3 Repair of uterus without BTL 207 50.7 Repair of uterus with BTL 58 14.2 Blood transfusion No 147 36 Yes 261 64 Postoperative hemoglobin ≥ 10 g/Dl 113 27.7 7–9 g/Dl 266 65.2 < 7 g/Dl 29 7.1 BTL: bilateral tubal ligation. Table 3 Postoperative maternal and perinatal outcomes among women with uterine rupture (n = 408) Variables Number of cases (N = 408) Percentage (%) Length of hospital stay 3–4 days 113 27.7 5–10 days 251 61.5 11–25 days 44 10.8 Maternal outcomes Anemia requiring transfusion 295 72.3 Sepsis 7 1.7 Wound infection 17 4.2 Vesicovaginal fistula 11 2.7 Recto-vaginal fistula 1 0.3 Maternal deaths 14 3.4 Neonatal outcomes Live birth 95 23.3 Apgar < 5 at 1 min 29 7.1 Neonatal anemia (Hb<13g/dL) 50 12.2 Neonatal infection 42 10.3 Perinatal outcomes Total perinatal mortality 313 76.7 Stillbirth 265 65 Early neonatal deaths 48 11.7 Temporal trends (2015–2022) The annual incidence of uterine rupture fluctuated over the study period, ranging from 1.05% in 2016 to a peak of 2.12% in 2018. A second relative increase was observed in 2020 (1.95%), followed by stabilization between 2021 and 2022. Maternal mortality showed a marked decline after 2016. While rates were high in 2015 (7.1%) and particularly in 2016 (20.6%), no maternal deaths were recorded between 2019 and 2021, with only one death in 2022 (1.6%). Perinatal mortality remained consistently high throughout the study period but demonstrated a downward trend, decreasing from 90.5% in 2015 to 62.1% in 2021, with slight fluctuation in 2022 (68.3%). Overall, these findings suggest partial improvement in maternal survival over time, while perinatal mortality, although decreasing, remains critically elevated (χ² = 22.55; P = 0.0020). The Fig. 2 illustrates annual changes in incidence, maternal mortality, and perinatal mortality among uterine rupture cases. Table 4 Logistic regression analysis of factors associated with hysterectomy, maternal mortality and perinatal mortality among uterine rupture cases (N = 408) Variables Category n/N (%) COR (95% CI) AOR (95% CI) p-value Hysterectomy (N = 143) Grand multiparity 3.43 (2.1–5.5) 2.98 (1.8–4.6) < 0.001 Yes 98/205(47.8) No 45/203(22.2) Complete rupture 4.06 (3.0–8.6) 3.51 (2.6–7.7) < 0.001 Yes 95/192(49.5) No 48/216(22.2) Blood transfusion 13.01 (9.3–16.1) 12.15 (8.9–15.2) < 0.001 Yes 133/261(51) No 10/147(6.8) Maternal death(N = 14) Rural origin 6.23(1.21–9.88) 6.04 (1.1–7.2) 0.03 Yes 13/273(5) No 1/135(0.7) Blood transfusion 4.52 (1.07–15.34) 3.91 (1.5–10.1) 0.004 Yes 13/261(3.4) No 1/147(0.6) Hypovolemic shock 50.03(20.37–70.75) 50 (31.21–69.98) 0.002 Yes 11/36(30.5) No 3/372(0.8) Perinatal death(N = 313) Rural origin 1.94 (1.7–4.9) 1.2 (1.5–4.4) < 0.001 Yes 213/273(68) No 100/135(32) Grand multiparity 2.02 (1.3–3.3) 1.83 (1.1–3.0) 0.003 Yes 176/205(85.8) No 137/203(67.5) Non-scarred uterus 1.97 (1.2–3.1) 1.78 (1.1–2.8) 0.002 Yes 198/219(90.4) No 115/189(60.8) Blood transfusion 2.62 (1.5–4.4) 2.37 (1.3–4.1) 0.004 Yes 219/261(83.6) No 94/147(64) COR : Crude odds ratio, AOR : Adjusted odds ratio DISCUSSION Uterine rupture remains one of the most catastrophic obstetric emergencies in low-resource settings and continues to contribute substantially to maternal and perinatal mortality. In this study, the incidence of uterine rupture was 1.51%, which remains considerably higher than rates reported in high-income countries where the incidence is generally below 0.1%[ 1 , 2 ], but is consistent with findings from other Sub-Saharan African studies, with an incidence ranging from 1.1% to 7.8% [ 8 – 10 , 13 – 17 ]. This disparity reflects persistent inequities in access to timely obstetric care, particularly in sub-Saharan Africa [ 5 , 18 , 19 ]. The incidence observed remains higher than many recent West African reports (0.5% to 0.8%) [ 19 – 21 ], but lower than historical data from Niger, with 4% in 1999 [ 11 ] and 2.5% in 2002 [ 22 ], suggesting partial improvement in obstetric care. The high incidence observed in this study is comparable to reports from Nigeria (1.2–2.4%) [ 8 , 13 , 15 ], Ethiopia (1.1–7.8%) [ 16 , 19 ], and Mali (1.2%) [ 23 ], but remains higher than incidences reported in South African settings [ 24 ]. The predominance of rural origin (66.9%) and low educational level (92.6%) illustrates the social determinants (structural inequalities in access to antenatal care and timely obstetric services) underlying uterine rupture. A striking finding of this study was the very high proportion of referred patients (91%), with more than half experiencing referral delays exceeding 12 hours. These findings highlight persistent weaknesses in referral systems and delays in accessing comprehensive emergency obstetric care. Similar patterns have been reported in several African settings [ 15 , 19 , 25 ], where delayed recognition of obstructed labor and limited transport infrastructure contribute to advanced disease at presentation. The proportion of uterine scars (46.5%) reflects the global increase in cesarean section rates [ 6 ] and the well-documented association between prior cesarean delivery and rupture risk [ 6 , 8 , 13 , 26 ]. This finding aligns with global concerns regarding the need for optimized trial of labor after cesarean (TOLAC) protocols in low-resource settings [ 6 , 26 ]. Interestingly, most ruptures occurred in unscarred uteri, which contrasts with patterns observed in high-income countries where uterine rupture is primarily associated with previous cesarean sections [ 26 ]. This difference reflects distinct obstetric profiles in low-resource settings, where obstructed labor, grand multiparity and inadequate intrapartum monitoring remain key drivers of uterine rupture [ 8 – 10 , 13 – 17 ]. Grand multiparity was significantly associated with hysterectomy in the present study. This association has been consistently reported in previous studies and likely reflects reduced uterine integrity combined with prolonged obstructed labor in high-parity women [ 19 , 26 ]. Complete uterine rupture was another strong predictor of hysterectomy, which is expected given the extensive uterine damage and hemodynamic instability often observed in such cases. In many situations, hysterectomy remains the most life-saving surgical option when uterine repair is not feasible. The high transfusion rate (64%) confirms the hemorrhagic burden associated with this condition. [ 13 , 27 ] Preventive strategies targeting high-parity women and improved family planning coverage could significantly reduce the burden. Maternal mortality in this study was 3.4%, which remains high but is lower than earlier reports from Niger [ 22 ] and findings reported in other Sub-Saharan African studies a maternal mortality rate ranging from 2.2% to 12% [ 13 , 16 – 20 , 23 , 28 – 30 ]. Hypovolemic shock emerged as a major determinant of maternal death, reflecting severe hemorrhage and delayed access to surgical management. Blood transfusion was also independently associated with maternal mortality, likely representing a marker of severe hemorrhage rather than a direct causal factor. These findings highlight the importance of rapid resuscitation and availability of blood products in the management of uterine rupture. This finding is comparable to several studies in Africa and Asia [ 16 , 17 , 29 – 32 ]. Perinatal mortality was extremely high (76.7%), reflecting the severe fetal compromise associated with uterine rupture. The strong association between perinatal death and rural origin underscores the impact of geographical barriers and delayed access to emergency obstetric care [ 6 – 10 , 13 – 23 , 25 , 28 – 30 ]. Similar perinatal mortality rates have been reported in several African studies from Nigeria (70–92%)[ 8 , 13 – 15 , 19 – 21 ], Mali (65.1%) [ 23 ], Uganda (75%) [ 19 ] and Ethiopia (65–98%) [ 16 , 30 ]. In contrast, perinatal mortality following uterine rupture in high-income settings is below 10% [ 2 , 33 ]. These findings emphasizing that fetal survival in uterine rupture remains highly dependent on rapid diagnosis and immediate surgical intervention. The temporal analysis conducted in this study suggests some improvement in maternal survival over time, likely reflecting gradual strengthening of emergency obstetric care and surgical management. However, perinatal mortality remains critically high, indicating that substantial challenges persist in achieving timely diagnosis and referral. Comparable findings were observed in several African studies [ 15 , 16 , 20 ]. Overall, these findings underscore the need for strengthening maternal health systems in low-resource settings. Improving antenatal care coverage, enhancing intrapartum monitoring, strengthening referral networks and ensuring rapid access to emergency obstetric surgery are essential strategies to reduce the burden of uterine rupture and its devastating maternal and perinatal consequences. Clinical and public health implications The findings highlight three critical priorities: Strengthening antenatal identification of high-risk pregnancies, Improving referral networks and transportation systems, Enhancing intrapartum monitoring, particularly among women with previous cesarean delivery. Efforts to reduce uterine rupture in Sub-Saharan Africa must address both access barriers and quality of emergency obstetric care. Study strengths and limitations Strengths This study has several important strengths. First, it covers an eight-year period in a tertiary referral hospital managing a large volume of obstetric emergencies, providing robust, longitudinal data from a low-resource setting, where such evidence remains scarce. The inclusion of all surgically confirmed cases of uterine rupture enhances diagnostic accuracy and minimizes misclassification bias. Second, the relatively large sample size (408 cases) allowed for meaningful estimation of incidence, maternal and perinatal outcomes, and temporal trends. The analysis of annual variations and the application of a Chi-Square test for trend strengthened the evaluation of changes over time. Furthermore, the use of logistic regression analysis enabled exploration of independent associations with maternal mortality. Third, this study provides context-specific evidence from Niger, contributing to the limited literature on uterine rupture in Sahelian and Sub-Saharan African settings. Such data are essential for informing regional health policy and strengthening emergency obstetric care systems. Limitations This study has limitations inherent to its retrospective design. Data were extracted from routine medical records, which may have been subject to incomplete documentation or missing information, potentially introducing information bias. Second, as a single-center study conducted in a tertiary referral hospital, the findings may not be generalizable to primary or secondary care facilities. The incidence reported likely reflects referral bias, as the hospital manages complicated and high-risk cases. Finally, although temporal trends were assessed, causality cannot be inferred. Observed improvements in maternal survival over time may be influenced by unmeasured system-level factors, such as evolving referral networks or changes in clinical protocols. Uterine rupture therefore remains a major indicator of inequities in access to safe childbirth services in low-resource settings. CONCLUSION Uterine rupture remains a frequent and devastating obstetric complication in low-resource settings and is associated with extremely a high maternal and perinatal mortality. Delayed referral, grand multiparity and severe obstetric complications significantly worsen outcomes. Strengthening referral systems, improving intrapartum monitoring and ensuring timely surgical management are essential strategies to reduce the burden of uterine rupture in Sub-Saharan Africa. Ultimately, uterine rupture remains a sentinel indicator of inequities in access to quality obstetric care in Sub-Saharan Africa, and addressing these gaps is essential for improving both maternal and neonatal survival. Abbreviations -OR Odds Ratio -aOR Ajusted Odds Ratio -COR Crude Odds Ratio -ANC Antenatal care -BTL Bilateral tubal ligation -CPD/OL Cephalopelvic disproportion/ obstructed labour -IUFD Intra-uterine fetal death Declarations Acknowledgements Not applicable. Authors’ contributions AAI conceptualized the study and supervised data collection. HSD performed data analysis and drafted the manuscript. MO, RHBI, and BM contributed to data extraction and interpretation. ZSL, MM, SOG, OAI, YBA, and MN critically revised the manuscript for important intellectual content. All authors read and approved the final manuscript. Funding No funding was received for this study. Availability of Data and Materials The datasets generated and/or analyzed during the current study are not publicly available due to institutional data protection policies, but are available from the corresponding author on reasonable request. Ethics approval and consent to participate The study was approved by the Institutional Review Board of the Faculty of Health Sciences, Dan Dicko Dankoulodo of Maradi (Approval Number. 234/UDDM/FSS/2022). Because of the retrospective design and the use of anonymized medical records, the requirement for written informed consent from the patients was waived the ethics commitee. Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests. References Vilchez G, Nazeer S, Kumar K, Warren M, Dai J, Sokol RJ. Contemporary epidemiology and novel predictors of uterine rupture: A nationwide, population-based study. Arch Gynecol Obstet. 2017;296(5):869–75. Zhan W, Zhu J, Hua X, Ye J, Chen Q, Zhang J. Epidemiology of uterine rupture among pregnant women in China and development of a risk prediction model: analysis of data from a multicentre, cross-sectional study. BMJ Open. 2021;11:e054540. 10.1136/bmjopen-2021-054540 . 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Geographical accessibility to functional emergency obstetric care facilities in urban Nigeria using closer-to-reality travel time estimates: a population-based spatial analysis. Lancet Glob Health. 2024;12:e848–58. Mukasa PK, Kabakyenga J, Senkungu J, Ngonzi J, Kyalimpa M, Roosmalen VJ. Uterine rupture in a teaching hospital in Mbarara, western Uganda, unmatched case-control study. Reprod Health. 2013;10:29. Osemwenkha PA, Osaikhuwuomwan JA. A 10-year review of uterine rupture and its outcomes in the University of Benin Teaching Hospital, Benin City. Niger J Surg Sci. 2016;26:1–4. Nnamani ES, Palmer HO, Bathnna D, Yusuf A, Oranuka KR. Ruptured Uterus at Abubakar Tafawa Balewa University Teaching Hospital, Bauchi, Nigeria: A 2 Year Review. Highland Med Res J. 2021;21(2):31–5. Van Geenderhuysen C, Souidi A. Uterine rupture of a pregnant uterus: study of a continuous series of 63 cases at the referral maternity of Niamey (Niger). Med Trop. 2002;62(6):615–8. Fane S, Sylla CA, Bocoum A, Sissoko A, Traoré A, Soumana O, et al. Epidemiological, therapeutic, and prognostic aspects of uterine ruptures at the Health District of Bougouni, Sikasso, Mali. J de la SAGO. 2022;23(2):7–12. Farhat IB, Zoukar O, Medemagh M, Slamia WB, Mnajja A, Bergaoui H, et al. Retrospective study of 60 cases of uterine rupture at the Maternity Center of Monastir, Tunisia. Pan Afr Med J. 2024;47(83). 10.11604/pamj.2024.47.83.42188 . Girmay G, Gultie T, Gebremichael G, Afework G, Temesgen G. Determinants of uterine rupture among mothers who gave birth in Jinka and Arba Minch General Hospitals: Institution-based case–control study. South Ethiopia 2019 Women's Health. 2020;16:1–7. 10.1177/1745506520961722 . Zhang L, Li T, Zhang P, Li G. Analyzing Influencing Factors of Uterine Rupture in Pregnant Women with Scarred Uterus Undergoing Repeat Delivery and Evaluating the Predictive Value of Lower Uterine Anterior Wall Thickness. Int J Womens Health. 2025;17:2421–31. Haulea M, Mujunia F, Matoveloa D, Ottomanb O. Emergency Peripartum Hysterectomy: Indications, Histopathological Patterns, and Intraoperative Maternal Complications at Mwanza, Tanzania. East Afr Sci. 2025;7(1):102–8. Addisu D, Mekie M, Melkie A, Necho W. Burden of Uterine Rupture and Its Determinant Factors in Ethiopia: A Systematic Review and Meta-Analysis. BioMed Res Int 2020 Article ID 3691271, 12 p. https://doi.org/10.1155/2020/3691271 Kenea LA, Biyana CF, Marine BT. Time to death and its predictors among women with uterine rupture admitted to Jimma Town Public Hospitals, South West Ethiopia: retrospective cohort study. BMC Pregnancy Childbirth. 2025;25:703. https://doi.org/10.1186/s12884-025-07817-4 . Desta M, Kassa GM, Getaneh T, Sharew Y, Alemu AA, Berhanu MY, et al. Maternal and perinatal mortality and morbidity of uterine rupture and its association with prolonged duration of operation in Ethiopia: A systematic review and meta-analysis. PLoS ONE. 2021;16(4):e0245977. Richal P, Gupta RV, Gangwar P, Dubey P. Retrospective study on ruptured uterus, its causes, and maternal-fetal outcome. Int J Health Sci. 2022;6(S7):2982–91. Abrar S, Abrar T, Sayyed E, Naqvi SA. Ruptured uterus: Frequency, risk factors, and feto-maternal outcome: Current scenario in a low-resource setup. PLoS ONE. 2022;17(4):e0266062. Chang YH. Uterine Rupture Over 11 Years: A retrospective descriptive study. Aust N Z J Obstet Gynaecol. 2020;60(5):709–13. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 07 Apr, 2026 Editor assigned by journal 06 Apr, 2026 Editor invited by journal 17 Mar, 2026 Submission checks completed at journal 16 Mar, 2026 First submitted to journal 16 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Center","correspondingAuthor":false,"prefix":"","firstName":"Zélika","middleName":"Salifou","lastName":"Lankoande","suffix":""},{"id":620549271,"identity":"95931aa2-9a03-409b-8d02-0ed3f350a06f","order_by":6,"name":"Mamane Maikassoua","email":"","orcid":"","institution":"Dan Dicko Dankoulodo University, General Referral Hospital","correspondingAuthor":false,"prefix":"","firstName":"Mamane","middleName":"","lastName":"Maikassoua","suffix":""},{"id":620549272,"identity":"7c7ae214-eb8d-490b-b8e6-175cf77452f9","order_by":7,"name":"Souleymane Oumarou Garba","email":"","orcid":"","institution":"André Salifou University, Mother and Child Heath Center","correspondingAuthor":false,"prefix":"","firstName":"Souleymane","middleName":"Oumarou","lastName":"Garba","suffix":""},{"id":620549273,"identity":"eba7186d-1c8d-43b0-bc19-b2d93632c3b1","order_by":8,"name":"Oumou Aoussouk Ibrahim","email":"","orcid":"","institution":"Dan Dicko Dankoulodo University, Mother and Child Heath Center","correspondingAuthor":false,"prefix":"","firstName":"Oumou","middleName":"Aoussouk","lastName":"Ibrahim","suffix":""},{"id":620549274,"identity":"d82e164f-5d55-4143-bbb3-5082386e6404","order_by":9,"name":"Yacouba Boubacar Amadou","email":"","orcid":"","institution":"Dan Dicko Dankoulodo University, Mother and Child Heath Center","correspondingAuthor":false,"prefix":"","firstName":"Yacouba","middleName":"Boubacar","lastName":"Amadou","suffix":""},{"id":620549275,"identity":"5a207077-576d-4c14-a142-63bb0445f92b","order_by":10,"name":"Madi Nayama","email":"","orcid":"","institution":"Abdou Moumouni University, Issaka Gazoby Maternity Hospital","correspondingAuthor":false,"prefix":"","firstName":"Madi","middleName":"","lastName":"Nayama","suffix":""}],"badges":[],"createdAt":"2026-03-12 11:54:27","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9104456/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9104456/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106874748,"identity":"85314f05-d527-4ef6-8108-937538cfca98","added_by":"auto","created_at":"2026-04-14 10:20:43","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":65743,"visible":true,"origin":"","legend":"\u003cp\u003eTemporal trends in uterine rupture incidence (2015–2022).\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9104456/v1/da2b6813daed19e9f4a877e1.png"},{"id":106874749,"identity":"855528ad-30b3-42dc-bfb1-0e838a5919ce","added_by":"auto","created_at":"2026-04-14 10:20:43","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":116957,"visible":true,"origin":"","legend":"\u003cp\u003eTemporal evolution of uterine rupture incidence, maternal mortality, and perinatal mortality (2015–2022). (The incidence fluctuated with significant variation over time (χ² Trend = 22.55; P = 0.002), peaking in 2018 and 2020. Maternal mortality declined substantially after 2016, reaching zero between 2019 and 2021, with a slight increase in 2022. Perinatal mortality remained high throughout the study period, but demonstrated a progressive downward trend compared with baseline levels observed in 2015).\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-9104456/v1/b2cda0a02da12b0b660b5d64.png"},{"id":106961523,"identity":"5539eacc-c508-4f83-a09d-c0e4c9e72583","added_by":"auto","created_at":"2026-04-15 09:25:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1638305,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9104456/v1/98b8d6e7-3e2f-4e9d-ba85-d3803fabfa57.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Determinants of hysterectomy, maternal mortality and perinatal mortality among uterine rupture cases: an eight-year retrospective study in Niger","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eUterine rupture is a severe obstetric complication characterized by complete disruption of the uterine wall and fetal membranes, often resulting in catastrophic maternal and perinatal consequences. Although rare in high-income countries, where incidence is typically below 0.1% [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], uterine rupture remains a major contributor to maternal and perinatal mortality in low- and middle-income countries, particularly in Sub-Saharan Africa [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn resource-limited settings, several structural and clinical factors increase the risk of uterine rupture, including delayed referral systems, obstructed labor, inadequate intrapartum monitoring, and limited access to emergency obstetric care and blood transfusion services [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The rising prevalence of cesarean section globally has increased the proportion of women with uterine scars [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Trial of Labor After Cesarean (TOLAC), although considered relatively safe in well-resourced environments, carries an increased risk of uterine rupture that requires immediate surgical capacity [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eStudies from Sub-Saharan Africa report significantly higher incidence and mortality rates compared with high-income settings [\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. These disparities reflect systemic health system challenges, including late presentation and limited emergency response capacity.\u003c/p\u003e \u003cp\u003eIn Niger, maternal mortality remains among the highest worldwide [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], and tertiary referral centers frequently manage advanced obstetric emergencies following delayed transfers. However, data on the epidemiology, management, and outcomes of uterine rupture in Niger are scarce, and few longitudinal analyses have explored temporal trends or system-level changes over time [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eUnderstanding the burden and clinical profile of uterine rupture in this context is critical to inform health system strengthening strategies, improve referral pathways, and optimize intrapartum care. Moreover, assessing temporal trends may help evaluate progress in emergency obstetric care capacity and identify persistent gaps in maternal and perinatal outcomes.\u003c/p\u003e \u003cp\u003eThis study aimed to assess the incidence, determinants, and maternal and perinatal outcomes of uterine rupture over an eight-year period in a tertiary referral hospital in Niger, and to evaluate temporal variations in incidence and mortality.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and setting\u003c/h2\u003e \u003cp\u003eWe conducted a retrospective, descriptive, and analytical study over an eight-year period (January 1, 2015, to December 31, 2022), in the department of obstetrics and gynecology of a tertiary referral university hospital in Niger. The institution serves as a regional referral center for high-risk pregnancies and obstetric emergencies, covering a population of five million inhabitants.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy population\u003c/h3\u003e\n\u003cp\u003eAll women diagnosed with uterine rupture during labor or delivery within the study period were included. Uterine rupture was defined as a complete separation of the uterine wall, involving all layers, confirmed intraoperatively. Cases of suspected but unconfirmed rupture and incomplete medical records were excluded.\u003c/p\u003e \u003cp\u003eDuring the study period, 26,971 deliveries were recorded, among which 408 cases of uterine rupture were identified.\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eData were extracted from delivery registers, operative reports, anesthesia records, and patient medical files using a standardized data collection form.\u003c/p\u003e \u003cp\u003eCollected variables included: Sociodemographic characteristics (age, residence, education level), obstetric history (gravidity, parity, uterine scar status), clinical presentation, intraoperative findings, surgical management (uterine repair or hysterectomy), blood transfusion requirement, maternal outcome (survival or death), perinatal outcome (live birth or stillbirth).\u003c/p\u003e \u003cp\u003eFor outcome measures; the primary outcomes were: Maternal mortality (death among rupture cases) and, perinatal mortality (stillbirth and early neonatal death among rupture cases).\u003c/p\u003e \u003cp\u003eSecondary outcomes included hysterectomy rate and blood transfusion requirement.\u003c/p\u003e \u003cp\u003eAnnual incidence of uterine rupture was calculated as the number of rupture cases divided by total annual deliveries, expressed as a percentage.\u003c/p\u003e\n\u003ch3\u003eDefinitions of study variables\u003c/h3\u003e\n\u003cp\u003eMaternal Death: Maternal death due to uterine rupture is defined as the death of the mother from uterine rupture itself, its associated complications, or management.\u003c/p\u003e \u003cp\u003ePerinatal death: Stillbirth or early neonatal death following uterine rupture.\u003c/p\u003e \u003cp\u003eGrand multiparity: Women with five or more (\u0026ge;\u0026thinsp;5) parities.\u003c/p\u003e \u003cp\u003eHysterectomy: Total or subtotal removal of the uterus.\u003c/p\u003e \u003cp\u003eSepsis: Woman with a diagnosis and management of sepsis in her medical charts.\u003c/p\u003e \u003cp\u003eWound infection: Woman with a diagnosis of wound infection in her medical charts.\u003c/p\u003e\n\u003ch3\u003eMaintaining data quality control\u003c/h3\u003e\n\u003cp\u003eData quality was assured by adequately designing the data collection tools. We conducted a pre-test on 5% of the sample size, and after that, all the required corrections on the collection tool were made. All the data collectors and the supervisors were trained on information regarding data collection tools and methods of data extraction, objectives of the study, ethical issues, considerations. The data collection process was supervised by the assigned supervisor for the accuracy of the process.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eData were entered analyzed using Epi Info 7.2.4.0 software. Descriptive statistics were used to summarize sociodemographic and clinical characteristics. Logistic regression analysis was performed to identfy factors with hysterectomy, maternal mortality and perinatal mortality. Variables with P\u0026thinsp;\u0026lt;\u0026thinsp;0.20 in the bivariate analysis were included in multivariate models. Adjusted odds ratios (aOR) with 95% confidence intervals (CI) were calculated, and P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEthical considerations\u003c/h3\u003e\n\u003cp\u003e The study was approved by the Institutional Review Board of the Faculty of Health Sciences, Dan Dicko Dankoulodo of Maradi (Approval Number. 234/UDDM/FSS/2022). Because of the retrospective design and the use of anonymized medical records, the requirement for written informed consent from the patients was waived the ethics commitee.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eIncidence\u003c/h2\u003e \u003cp\u003eDuring the 8-year study period (January 2015\u0026ndash;December 2022), 26,971 deliveries were recorded, including 408 cases of uterine rupture, yielding an incidence of 1.51% (15.1 per 1,000 deliveries).\u003c/p\u003e \u003cp\u003eAs shown in the Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, the annual incidence of uterine rupture fluctuated over the study period, ranging from 1.29% in 2015 to a peak of 2.12% in 2018. A second relative increase was observed in 2020 (1.95%), followed by stabilization in 2021(1.80%), and 2022(1.33%). The Chi-square test for trend showed χ\u0026sup2; = 22.55, p\u0026thinsp;=\u0026thinsp;0.002, indicating a statistically significant variation in incidence over time.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eSociodemographic and obstetric characteristics\u003c/h2\u003e \u003cp\u003eThe mean maternal age was 29.97\u0026thinsp;\u0026plusmn;\u0026thinsp;3.0 years (range: 17\u0026ndash;46). Women aged 20\u0026ndash;34 years were the most represented (58.6%). Most women were married (99.5%), housewives (96.3%), from rural areas (66.9%), and had no formal education (92.6%).\u003c/p\u003e \u003cp\u003eApproximately 60.5% of women (247 cases) lived more than 90 km from the hospital (range: 5\u0026ndash;125 km).\u003c/p\u003e \u003cp\u003eThe mean gravidity was 6.38\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5 (range: 1\u0026ndash;14), and the mean parity was 5.10\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5 (range: 1\u0026ndash;13). Grand multiparity was observed in 50.3% of cases. Obstructed labor was reported in 42.9% of cases. The majority of uterine ruptures occurred in an unscarred uterus (53.7%). Injudicious use of oxytocin during labor was reported in 34.1% of cases. Most ruptures occurred in pregnancies at \u0026ge;\u0026thinsp;37 weeks of gestation (87.3%). A large proportion of patients (91%) were referred from peripheral health centers, and 54.2% experienced a referral delay greater than 12 hours. Only 22.5% of women (N\u0026thinsp;=\u0026thinsp;92) had more than four antenatal visits, while 16.7% of cases had no antenatal care. These characteristics are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSociodemographic and obstetric characteristics among uterine rupture cases\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of cases (N\u0026thinsp;=\u0026thinsp;408)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e20\u0026ndash;34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e239\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e113\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOccupation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHousewife\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e393\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e96.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMarital status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e406\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e99.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducational status of mothers\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo formal education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e378\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e92.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary/secondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePlace of residence\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e273\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e135\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eParity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e154\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e205\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNumber of ANC visits\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e248\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGestational age (weeks)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;37 weeks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;37 weeks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e356\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e87.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAdmission mode\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf-admission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReferred\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e373\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTime to referral (n\u0026thinsp;=\u0026thinsp;373)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;12h\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e171\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;12h\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e202\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e54.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDiagnosis on referral(n\u0026thinsp;=\u0026thinsp;373)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUterine rupture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e121\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCPD/OL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIUFD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMal-presentation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e108\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProlonged second stage of labor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRisk Factors\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrevious caesarean section\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e189\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbnormally/presentations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProlonged obstructed labor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e175\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInjudicious oxytocin usage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e139\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003cb\u003eANC\u003c/b\u003e: Antenatal care; \u003cb\u003eCPD/OL\u003c/b\u003e: Cephalopelvic disproportion/ obstructed labor; \u003cb\u003eIUFD\u003c/b\u003e: Intra-uterine fetal death\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eClinical presentations and surgical management\u003c/h2\u003e \u003cp\u003eThe most frequent presenting symptoms were; abdominal pain (62.2%), cessation of labor (47.5%), and vaginal bleeding (27.7%), while the commonest presenting signs of uterine rupture were easily palpable fetal parts (46.3%) and abdominal tenderness (12%). Uterine repair was done in 65% of cases, while the hysterectomy was done in 35% of cases.\u003c/p\u003e \u003cp\u003eThe majority of ruptures were complete (53%) involving the anterior lower segment (43.9%). Uterine rupture had accompanying broad ligament hematoma (29.7%), bladder rupture (2.5%), and vaginal extension (2.7%). More than half of the cases (72.3%) stayed for more than five days in the hospital, with an average hospital stay of 6.6\u0026thinsp;\u0026plusmn;\u0026thinsp;3.7 days, ranging from 3\u0026ndash;25 days. More than half of the cases (64%) had a blood transfusion.\u003c/p\u003e \u003cp\u003eThe Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents a summary of clinical presentations and surgical management of the patients.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eMaternal and perinatal outcomes\u003c/h2\u003e \u003cp\u003eThe most common complication in mothers was anemia (72.3%), followed by wound infection (4.2%), vesicovaginal fistula (2.7%), and sepsis (1.7%). Fourteen maternal deaths were recorded, resulting in a maternal mortality rate of 3.4%; mainly due to irreversible hypovolemic shock (11/14 cases, 78.6%), septic shock (2/14 cases, 14.3%), and renal failure (1/14 cases, 7.1%). Of the 408 neonates, 265 were stillbirths (65%), 95 were live births (23.3%), and seven neonates (7.1%) required neonatal intensive care unit (NICU) admission due to low Apgar scores (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Among live newborns, anemia (50/95 cases, 52.6%) and infection (44.2%) were the main complications, leading to 48 early neonatal deaths (11.7%). Perinatal mortality rate was 76.7%.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eFactors associated with poor maternal and perinatal outcomes\u003c/h2\u003e \u003cp\u003eAfter adjustment, maternal death was independently associated with rural origin (aOR: 6.04; 95% CI: 1.1\u0026ndash;7.2; P\u0026thinsp;=\u0026thinsp;0.03), blood transfusion (aOR: 3.91; 95% CI: 1.5\u0026ndash;10.1; P\u0026thinsp;=\u0026thinsp;0.004), and hypovolemic shock (aOR: 50; 95% CI: 31.21\u0026ndash;69.98; P\u0026thinsp;=\u0026thinsp;0.002).\u003c/p\u003e \u003cp\u003ePerinatal death was significantly associated with rural origin (aOR 1.2; 95% CI 1.5\u0026ndash;4.4; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), grand multiparity (aOR 1.83; 95% CI 1.1\u0026ndash;3.0; P\u0026thinsp;=\u0026thinsp;0.003), non-scarred uterus (aOR 1.78; 95% CI 1.1\u0026ndash;2.8; P\u0026thinsp;=\u0026thinsp;0.002), and need for blood transfusion (aOR 2.37; 95% CI 1.3\u0026ndash;4.1; P\u0026thinsp;=\u0026thinsp;0.003).\u003c/p\u003e \u003cp\u003eHysterectomy was strongly associated with complete uterine rupture (aOR 3.51; 95% CI 2.6\u0026ndash;7.7; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), grand multiparity (aOR 2.98; 95% CI 1.8\u0026ndash;4.6; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and blood transfusion (aOR 12.15; 95% CI 8.9\u0026ndash;15.2; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e presents the factors associated with hysterectomy, maternal mortality, and perinatal mortality among uterine rupture cases in logistic regression analysis.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical presentation, intraoperative findings, and surgical management of uterine rupture (n\u0026thinsp;=\u0026thinsp;408)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of cases (N\u0026thinsp;=\u0026thinsp;408)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical presentation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbdominal pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e254\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVaginal bleeding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e113\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCessation of labor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e194\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbdominal tenderness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEasily palpable fetal parts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e189\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eType of rupture\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplete\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e192\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncomplete\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e216\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSite of rupture\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnterior lower segment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e179\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLateral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e134\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFundal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePosterior\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAssociated lesions\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBladder injury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVaginal extension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBroad ligament hematoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e121\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eType of surgical management\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal hysterectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubtotal hysterectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRepair of uterus without BTL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e207\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRepair of uterus with BTL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBlood transfusion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e147\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e261\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePostoperative hemoglobin\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;10 g/Dl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e113\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u0026ndash;9 g/Dl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e266\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;7 g/Dl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eBTL: bilateral tubal ligation.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePostoperative maternal and perinatal outcomes among women with uterine rupture (n\u0026thinsp;=\u0026thinsp;408)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of cases (N\u0026thinsp;=\u0026thinsp;408)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLength of hospital stay\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u0026ndash;4 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e113\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u0026ndash;10 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e251\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e61.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u0026ndash;25 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMaternal outcomes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnemia requiring transfusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e295\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e72.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSepsis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWound infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVesicovaginal fistula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRecto-vaginal fistula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaternal deaths\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNeonatal outcomes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLive birth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eApgar\u0026thinsp;\u0026lt;\u0026thinsp;5 at 1 min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeonatal anemia (Hb\u0026lt;13g/dL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeonatal infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePerinatal outcomes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal perinatal mortality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e313\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e76.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStillbirth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e265\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEarly neonatal deaths\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eTemporal trends (2015\u0026ndash;2022)\u003c/h2\u003e \u003cp\u003eThe annual incidence of uterine rupture fluctuated over the study period, ranging from 1.05% in 2016 to a peak of 2.12% in 2018. A second relative increase was observed in 2020 (1.95%), followed by stabilization between 2021 and 2022.\u003c/p\u003e \u003cp\u003eMaternal mortality showed a marked decline after 2016. While rates were high in 2015 (7.1%) and particularly in 2016 (20.6%), no maternal deaths were recorded between 2019 and 2021, with only one death in 2022 (1.6%).\u003c/p\u003e \u003cp\u003ePerinatal mortality remained consistently high throughout the study period but demonstrated a downward trend, decreasing from 90.5% in 2015 to 62.1% in 2021, with slight fluctuation in 2022 (68.3%).\u003c/p\u003e \u003cp\u003eOverall, these findings suggest partial improvement in maternal survival over time, while perinatal mortality, although decreasing, remains critically elevated (χ\u0026sup2; = 22.55; P\u0026thinsp;=\u0026thinsp;0.0020).\u003c/p\u003e \u003cp\u003eThe Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e illustrates annual changes in incidence, maternal mortality, and perinatal mortality among uterine rupture cases.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLogistic regression analysis of factors associated with hysterectomy, maternal mortality and perinatal mortality among uterine rupture cases (N\u0026thinsp;=\u0026thinsp;408)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory n/N (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHysterectomy (N\u0026thinsp;=\u0026thinsp;143)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrand multiparity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.43 (2.1\u0026ndash;5.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.98 (1.8\u0026ndash;4.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e98/205(47.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45/203(22.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplete rupture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.06 (3.0\u0026ndash;8.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.51 (2.6\u0026ndash;7.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e95/192(49.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48/216(22.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood transfusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13.01 (9.3\u0026ndash;16.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12.15 (8.9\u0026ndash;15.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e133/261(51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10/147(6.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMaternal death(N\u0026thinsp;=\u0026thinsp;14)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRural origin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6.23(1.21\u0026ndash;9.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.04 (1.1\u0026ndash;7.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.03\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13/273(5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1/135(0.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood transfusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.52 (1.07\u0026ndash;15.34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.91 (1.5\u0026ndash;10.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13/261(3.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1/147(0.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypovolemic shock\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e50.03(20.37\u0026ndash;70.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e50 (31.21\u0026ndash;69.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11/36(30.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3/372(0.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePerinatal death(N\u0026thinsp;=\u0026thinsp;313)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRural origin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.94 (1.7\u0026ndash;4.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.2 (1.5\u0026ndash;4.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e213/273(68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100/135(32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrand multiparity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.02 (1.3\u0026ndash;3.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.83 (1.1\u0026ndash;3.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e176/205(85.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e137/203(67.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-scarred uterus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.97 (1.2\u0026ndash;3.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.78 (1.1\u0026ndash;2.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e198/219(90.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e115/189(60.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood transfusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.62 (1.5\u0026ndash;4.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.37 (1.3\u0026ndash;4.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e219/261(83.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e94/147(64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cb\u003eCOR\u003c/b\u003e: Crude odds ratio, \u003cb\u003eAOR\u003c/b\u003e: Adjusted odds ratio\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eUterine rupture remains one of the most catastrophic obstetric emergencies in low-resource settings and continues to contribute substantially to maternal and perinatal mortality. In this study, the incidence of uterine rupture was 1.51%, which remains considerably higher than rates reported in high-income countries where the incidence is generally below 0.1%[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], but is consistent with findings from other Sub-Saharan African studies, with an incidence ranging from 1.1% to 7.8% [\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan additionalcitationids=\"CR14 CR15 CR16\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. This disparity reflects persistent inequities in access to timely obstetric care, particularly in sub-Saharan Africa [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The incidence observed remains higher than many recent West African reports (0.5% to 0.8%) [\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], but lower than historical data from Niger, with 4% in 1999 [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] and 2.5% in 2002 [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], suggesting partial improvement in obstetric care. The high incidence observed in this study is comparable to reports from Nigeria (1.2\u0026ndash;2.4%) [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], Ethiopia (1.1\u0026ndash;7.8%) [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], and Mali (1.2%) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], but remains higher than incidences reported in South African settings [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe predominance of rural origin (66.9%) and low educational level (92.6%) illustrates the social determinants (structural inequalities in access to antenatal care and timely obstetric services) underlying uterine rupture.\u003c/p\u003e \u003cp\u003eA striking finding of this study was the very high proportion of referred patients (91%), with more than half experiencing referral delays exceeding 12 hours. These findings highlight persistent weaknesses in referral systems and delays in accessing comprehensive emergency obstetric care. Similar patterns have been reported in several African settings [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], where delayed recognition of obstructed labor and limited transport infrastructure contribute to advanced disease at presentation.\u003c/p\u003e \u003cp\u003eThe proportion of uterine scars (46.5%) reflects the global increase in cesarean section rates [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] and the well-documented association between prior cesarean delivery and rupture risk [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. This finding aligns with global concerns regarding the need for optimized trial of labor after cesarean (TOLAC) protocols in low-resource settings [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Interestingly, most ruptures occurred in unscarred uteri, which contrasts with patterns observed in high-income countries where uterine rupture is primarily associated with previous cesarean sections [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. This difference reflects distinct obstetric profiles in low-resource settings, where obstructed labor, grand multiparity and inadequate intrapartum monitoring remain key drivers of uterine rupture [\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan additionalcitationids=\"CR14 CR15 CR16\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGrand multiparity was significantly associated with hysterectomy in the present study. This association has been consistently reported in previous studies and likely reflects reduced uterine integrity combined with prolonged obstructed labor in high-parity women [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Complete uterine rupture was another strong predictor of hysterectomy, which is expected given the extensive uterine damage and hemodynamic instability often observed in such cases. In many situations, hysterectomy remains the most life-saving surgical option when uterine repair is not feasible. The high transfusion rate (64%) confirms the hemorrhagic burden associated with this condition. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] Preventive strategies targeting high-parity women and improved family planning coverage could significantly reduce the burden.\u003c/p\u003e \u003cp\u003eMaternal mortality in this study was 3.4%, which remains high but is lower than earlier reports from Niger [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] and findings reported in other Sub-Saharan African studies a maternal mortality rate ranging from 2.2% to 12% [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan additionalcitationids=\"CR17 CR18 CR19\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan additionalcitationids=\"CR29\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Hypovolemic shock emerged as a major determinant of maternal death, reflecting severe hemorrhage and delayed access to surgical management. Blood transfusion was also independently associated with maternal mortality, likely representing a marker of severe hemorrhage rather than a direct causal factor. These findings highlight the importance of rapid resuscitation and availability of blood products in the management of uterine rupture. This finding is comparable to several studies in Africa and Asia [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan additionalcitationids=\"CR30 CR31\" citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePerinatal mortality was extremely high (76.7%), reflecting the severe fetal compromise associated with uterine rupture. The strong association between perinatal death and rural origin underscores the impact of geographical barriers and delayed access to emergency obstetric care [\u003cspan additionalcitationids=\"CR7 CR8 CR9\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan additionalcitationids=\"CR14 CR15 CR16 CR17 CR18 CR19 CR20 CR21 CR22\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan additionalcitationids=\"CR29\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Similar perinatal mortality rates have been reported in several African studies from Nigeria (70\u0026ndash;92%)[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], Mali (65.1%) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], Uganda (75%) [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] and Ethiopia (65\u0026ndash;98%) [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. In contrast, perinatal mortality following uterine rupture in high-income settings is below 10% [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThese findings emphasizing that fetal survival in uterine rupture remains highly dependent on rapid diagnosis and immediate surgical intervention.\u003c/p\u003e \u003cp\u003eThe temporal analysis conducted in this study suggests some improvement in maternal survival over time, likely reflecting gradual strengthening of emergency obstetric care and surgical management. However, perinatal mortality remains critically high, indicating that substantial challenges persist in achieving timely diagnosis and referral.\u003c/p\u003e \u003cp\u003eComparable findings were observed in several African studies [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOverall, these findings underscore the need for strengthening maternal health systems in low-resource settings. Improving antenatal care coverage, enhancing intrapartum monitoring, strengthening referral networks and ensuring rapid access to emergency obstetric surgery are essential strategies to reduce the burden of uterine rupture and its devastating maternal and perinatal consequences.\u003c/p\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eClinical and public health implications\u003c/h2\u003e \u003cp\u003eThe findings highlight three critical priorities:\u003c/p\u003e \u003cp\u003eStrengthening antenatal identification of high-risk pregnancies,\u003c/p\u003e \u003cp\u003eImproving referral networks and transportation systems,\u003c/p\u003e \u003cp\u003eEnhancing intrapartum monitoring, particularly among women with previous cesarean delivery.\u003c/p\u003e \u003cp\u003eEfforts to reduce uterine rupture in Sub-Saharan Africa must address both access barriers and quality of emergency obstetric care.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eStudy strengths and limitations\u003c/h2\u003e \u003cdiv id=\"Sec20\" class=\"Section3\"\u003e \u003ch2\u003eStrengths\u003c/h2\u003e \u003cp\u003eThis study has several important strengths. First, it covers an eight-year period in a tertiary referral hospital managing a large volume of obstetric emergencies, providing robust, longitudinal data from a low-resource setting, where such evidence remains scarce. The inclusion of all surgically confirmed cases of uterine rupture enhances diagnostic accuracy and minimizes misclassification bias.\u003c/p\u003e \u003cp\u003e Second, the relatively large sample size (408 cases) allowed for meaningful estimation of incidence, maternal and perinatal outcomes, and temporal trends. The analysis of annual variations and the application of a Chi-Square test for trend strengthened the evaluation of changes over time. Furthermore, the use of logistic regression analysis enabled exploration of independent associations with maternal mortality.\u003c/p\u003e \u003cp\u003eThird, this study provides context-specific evidence from Niger, contributing to the limited literature on uterine rupture in Sahelian and Sub-Saharan African settings. Such data are essential for informing regional health policy and strengthening emergency obstetric care systems.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis study has limitations inherent to its retrospective design. Data were extracted from routine medical records, which may have been subject to incomplete documentation or missing information, potentially introducing information bias.\u003c/p\u003e \u003cp\u003eSecond, as a single-center study conducted in a tertiary referral hospital, the findings may not be generalizable to primary or secondary care facilities. The incidence reported likely reflects referral bias, as the hospital manages complicated and high-risk cases.\u003c/p\u003e \u003cp\u003eFinally, although temporal trends were assessed, causality cannot be inferred. Observed improvements in maternal survival over time may be influenced by unmeasured system-level factors, such as evolving referral networks or changes in clinical protocols.\u003c/p\u003e \u003cp\u003eUterine rupture therefore remains a major indicator of inequities in access to safe childbirth services in low-resource settings.\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eUterine rupture remains a frequent and devastating obstetric complication in low-resource settings and is associated with extremely a high maternal and perinatal mortality. Delayed referral, grand multiparity and severe obstetric complications significantly worsen outcomes. Strengthening referral systems, improving intrapartum monitoring and ensuring timely surgical management are essential strategies to reduce the burden of uterine rupture in Sub-Saharan Africa.\u003c/p\u003e \u003cp\u003eUltimately, uterine rupture remains a sentinel indicator of inequities in access to quality obstetric care in Sub-Saharan Africa, and addressing these gaps is essential for improving both maternal and neonatal survival.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e-OR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eOdds Ratio\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e-aOR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAjusted Odds Ratio\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e-COR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCrude Odds Ratio\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e-ANC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAntenatal care\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e-BTL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBilateral tubal ligation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e-CPD/OL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCephalopelvic disproportion/ obstructed labour\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e-IUFD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIntra-uterine fetal death\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAAI conceptualized the study and supervised data collection.\u003c/p\u003e\n\u003cp\u003eHSD performed data analysis and drafted the manuscript.\u003c/p\u003e\n\u003cp\u003eMO, RHBI, and BM contributed to data extraction and interpretation.\u003c/p\u003e\n\u003cp\u003eZSL, MM, SOG, OAI, YBA, and MN critically revised the manuscript for important intellectual content.\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received for this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are not publicly available due to institutional data protection policies, but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Institutional Review Board of the Faculty of Health Sciences, Dan Dicko Dankoulodo of Maradi (Approval Number. 234/UDDM/FSS/2022). Because of the retrospective design and the use of anonymized medical records, the requirement for written informed consent from the patients was waived the ethics commitee.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e"},{"header":"References ","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eVilchez G, Nazeer S, Kumar K, Warren M, Dai J, Sokol RJ. Contemporary epidemiology and novel predictors of uterine rupture: A nationwide, population-based study. Arch Gynecol Obstet. 2017;296(5):869\u0026ndash;75.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhan W, Zhu J, Hua X, Ye J, Chen Q, Zhang J. 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Maternal and perinatal mortality and morbidity of uterine rupture and its association with prolonged duration of operation in Ethiopia: A systematic review and meta-analysis. PLoS ONE. 2021;16(4):e0245977.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRichal P, Gupta RV, Gangwar P, Dubey P. Retrospective study on ruptured uterus, its causes, and maternal-fetal outcome. Int J Health Sci. 2022;6(S7):2982\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbrar S, Abrar T, Sayyed E, Naqvi SA. Ruptured uterus: Frequency, risk factors, and feto-maternal outcome: Current scenario in a low-resource setup. PLoS ONE. 2022;17(4):e0266062.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChang YH. Uterine Rupture Over 11 Years: A retrospective descriptive study. Aust N Z J Obstet Gynaecol. 2020;60(5):709\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Uterine rupture, Maternal mortality, Perinatal mortality, Hysterectomy, obstetric complications, Sub-Saharan Africa","lastPublishedDoi":"10.21203/rs.3.rs-9104456/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9104456/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eUterine rupture remains a major obstetric emergency in low-resource settings, and is associated with severe maternal and perinatal morbidity and mortality. Evidence from Sahelian countries remains limited. This study aimed to determine the incidence, determinants, and outcomes of uterine rupture in a tertiary referral hospital in Niger.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe conducted a retrospective study of all cases of uterine rupture managed between January 1, 2015, and December 31, 2022, in the obstetrics department of a tertiary referral hospital. Sociodemographic characteristics, obstetric factors, clinical management, and maternal and perinatal outcomes were analyzed. Temporal trends were assessed using the Chi-Square test for trend, and multivariable logistic regression was performed to identify independent factors associated with maternal mortality, perinatal mortality, and hysterectomy.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eDuring the study period, 26,971 deliveries were recorded, including 408 cases of uterine rupture, yielding an incidence of 1.51% (15.1 per 1,000 deliveries). Most women were from rural areas (66.9%) and had no formal education (92.6%). The majority of patients were referred from peripheral health facilities (91%), and more than half experienced a referral delay exceeding 12 hours (54.2%). Uterine repair was performed in 65% of cases, while 35% required hysterectomy. Maternal mortality was 3.4% (14 deaths/408), and perinatal mortality was 76.7% (313/408). Rural origin (aOR 6.04; 95% CI 1.1\u0026ndash;7.2; P\u0026thinsp;=\u0026thinsp;0.03), blood transfusion (aOR 3.91; 95% CI 1.5\u0026ndash;10.1; P\u0026thinsp;=\u0026thinsp;0.004), and hypovolemic shock (aOR 50; 95% CI 31.21\u0026ndash;69.98; P\u0026thinsp;=\u0026thinsp;0.002) were independently associated with maternal death. Perinatal mortality was significantly associated with rural residence (aOR 1.2; 95% CI 1.5\u0026ndash;4.4; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), grand multiparity (aOR 1.83; 95% CI 1.1\u0026ndash;3.0; P\u0026thinsp;=\u0026thinsp;0.003), non-scarred uterus (aOR 1.78; 95% CI 1.1\u0026ndash;2.8; P\u0026thinsp;=\u0026thinsp;0.002), and blood transfusion (aOR 2.37; 95% CI 1.3\u0026ndash;4.1; P\u0026thinsp;=\u0026thinsp;0.003). Temporal analysis showed significant variation in incidence over time (χ\u0026sup2; trend\u0026thinsp;=\u0026thinsp;22.55; P\u0026thinsp;=\u0026thinsp;0.002) and a marked decline in maternal mortality after 2016.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eUterine rupture remains associated with extremely high maternal and perinatal mortality in low-resource settings. Strengthening referral systems, improving intrapartum monitoring, and ensuring timely surgical intervention are essential to reduce adverse outcomes.\u003c/p\u003e","manuscriptTitle":"Determinants of hysterectomy, maternal mortality and perinatal mortality among uterine rupture cases: an eight-year retrospective study in Niger","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-14 10:20:31","doi":"10.21203/rs.3.rs-9104456/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2026-04-07T11:30:50+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-06T11:36:37+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-17T06:22:45+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-17T00:37:07+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2026-03-16T19:14:18+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2b4282ee-1e28-47e1-9785-c51ce3b93465","owner":[],"postedDate":"April 14th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-14T10:20:34+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-14 10:20:31","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9104456","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9104456","identity":"rs-9104456","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}