Incidence, determinants and outcomes of uterine rupture among women at a referral hospital in Taiz City, Yemen: a retrospective analysis from a conflict-affected setting

Incidence, determinants and outcomes of uterine rupture among women at a referral hospital in Taiz City, Yemen: a retrospective analysis from a conflict-affected setting | 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 Incidence, determinants and outcomes of uterine rupture among women at a referral hospital in Taiz City, Yemen: a retrospective analysis from a conflict-affected setting Hanan M. Hasan, Maisa S. M. Thabit, Maha Abdulaziz This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8681256/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background: Uterine rupture is An uncommon but serious obstetric emergency, particularly in low-resource and conflict-affected settings. However, data on its burden in Yemen is limited. Therefore, this study assessed the incidence, determinants and outcomes of uterine rupture among women admitted to a tertiary care hospital in Taiz City, southwest of the country. Methods: A retrospective surveillance study with an integrated case-control analysis was conducted at the Republican General Teaching Hospital in Taiz during 2023. All women with uterine rupture during the study period were included as cases, while controls were randomly selected from those delivered without uterine rupture. Demographic, obstetric, intrapartum and outcome data were extracted from medical records. Associations between uterine rupture and its determinants were assessed at a significance level of <0.05. Results: Out of 8,550 deliveries, 23 cases of uterine rupture were identified, resulting in an incidence of 2.7 per 1,000 deliveries. Most ruptures were complete (82.6%). Rural residence (OR = 4; 95% CI: 1.39–11.49; P = 0.008), interpregnancy interval (IPI) <24 months (OR = 5.2; 95% CI: 1.16–23.08; P = 0.030), and breech fetal malpresentation (OR = 21.9; 95% CI: 1.13–426.9; P = 0.008) were significantly associated with uterine rupture. Substantial maternal morbidity was observed, including bladder rupture (21.7%), severe blood loss (26.1%), and need for transfusion (43.5%). Hysterectomy was performed in 13% of cases. One woman died, whereas stillbirths occurred in 27.3% of cases. Conclusion: The incidence of uterine rupture in Taiz City exceeds regional and global estimates and is associated with substantial maternal and perinatal morbidity, including bladder rupture, severe blood loss, need for blood transfusion, hysterectomy, and stillbirth. Rural residence, short IPIs, and breech presentation are key determinants, showing inequities in maternal care and the need to strengthen antenatal services, referral systems, and antenatal care services. uterine rupture pregnant women incidence determinants outcomes Yemen Introduction Uterine rupture is defined as the complete disruption of uterine layers during pregnancy, labor, or shortly after delivery. Despite being relatively rare, uterine rupture is one of the most serious emergencies in obstetrics associated with severe maternal and perinatal complications, including postpartum hemorrhage and hysterectomy, low Apgar scores, and increased perinatal mortality [ 1 – 3 ]. Uterine rupture is mainly seen during pregnancy, but rare cases have been documented in non-pregnant women as a result of uterine trauma, malignancy, or infection [ 4 ]. Although it is more frequent in women with scarred uteri, spontaneous rupture in unscarred uteri can occur and is linked to factors such as uterine structural irregularities, excessive stretching during pregnancy, abnormal placental implantation, and sometimes abdominal trauma or obstructed labor [ 5 , 6 ]. Although uterine rupture can occur at any gestational age, it is more frequently reported during the third trimester or labor [ 7 ]. A multicounty analysis of data has demonstrated that the incidence of uterine rupture in women with a previous cesarean section is approximately 0.5% of deliveries, which ranges from 0.2% in countries with a high Human Development Index (HDI) to 1% in low-HDI countries [ 2 ]. The most common risk factor for uterine rupture is prior uterine surgery, particularly cesarean sections, where scar tissue may compromise structural integrity under the stress of pregnancy or labor [ 8 ]. Other risk factors include malpresentation, dystocia in the second stage of labor, short interpregnancy interval (IPI), uterine anomalies, uterine instrumentation, obstructed or prolonged labor, induction or augmentation with uterotonic agents, multiparity, macrosomia, lack of antenatal care (ANC), and delays in accessing emergency obstetric services [ 9 – 11 ]. In recent years, the increasing adoption of trial of labor after cesarean delivery (TOLAC) has raised interest in uterine rupture [ 12 ]. Diagnosing uterine rupture is challenging due to nonspecific signs and requires a combination of clinical assessment and advanced imaging techniques, which can confirm uterine wall defects, fetal position, hemoperitoneum, or extravasation of amniotic fluid or fetus into the abdominal cavity [ 13 – 16 ]. However, the most reliable early indicator is sustained and severe fetal bradycardia [ 17 ]. The treatment of uterine rupture primarily involves surgical intervention, with two main approaches: uterine repair and hysterectomy, with a recent trend favoring repair when possible [ 18 ]. Post-operative care is vital, and future pregnancies should be carefully managed due to the risk of recurrent rupture [ 19 ]. On the other hand, prevention relies primarily on ANC and careful use of oxytocin, particularly in women with previous uterine surgery, with close monitoring and planned delivery approaches that consider the risks of labor induction and TOLAC [ 20 ]. Yemen faces prolonged conflict, interrupted healthcare services and obstacles to prompt facility-based deliveries, exacerbating the burden of obstetric complications, including uterine rupture. The national maternal mortality ratio was estimated to be 118 per 100,000 live births in 2023, and births attended by skilled personnel remain suboptimal at 61% [ 21 ]. However, there is a lack of studies on uterine rupture among pregnant women in the country. For instance, hospital-based studies in Hajjah City, northwest of Yemen, reported a high incidence of uterine rupture, ranging from 1 in 92 deliveries (≈ 11 per 1,000 deliveries) to 1 in 31 deliveries (≈ 32 per 1,000 deliveries) [ 22 – 24 ]. These studies show that uterine rupture predominantly affects women with unscarred uteri and is driven by poor antenatal and intrapartum care, grand multiparity, obstructed labor, cephalopelvic disproportion, malpresentation, previous cesarean delivery, use of uterotonic agents, illiteracy, poverty, remote residence, home delivery, and inadequate access to ANC [ 22 – 24 ]. Moreover, uterine rupture resulted in substantial maternal morbidity, including sepsis, urinary bladder injury and vesicovaginal fistulae, while maternal and perinatal mortality rates were 7.2% and 91.8%, respectively [ 23 ]. In Sana’a City, the capital of Yemen, a 9-month retrospective hospital-based study reported an incidence of approximately 0.63% [ 25 ]. The study attributed uterine rupture to obstructed labor, with additional contributions from previous uterine surgery, oxytocin use, contracted pelvis, grand multiparity, advanced maternal age, and low ANC coverage, highlighting gaps in timely and adequate obstetric care [ 25 ]. A retrospective study at Al-Sadaqa Teaching Hospital in Aden (2012–2016) reported a lower incidence of 0.26% for uterine rupture (1 in 323 deliveries) among 31,905 births [ 26 ]. Although Taiz governorate, southwest of Yemen, is among the areas most affected by insecurity, access constraints, and obstacles to timely maternity care such as transportation delays and restricted movements, no published studies have been found on the incidence, risk factors and complications of uterine rupture among pregnant women in the governorate. Therefore, this study aimed to determine the incidence of uterine rupture and identify its determinants and outcomes among women admitted to a referral hospital in Taiz City. Methods Study design, population and setting A retrospective surveillance study with an integrated case-control analysis was conducted to investigate the incidence of uterine rupture and assess its determinants and outcomes among women delivered at the Gynecology and Obstetrics Department of the Republican General Teaching Hospital in Taiz in 2023. The study analyzed the medical records of all women delivered at the department during the study period to determine the incidence and outcomes of uterine rupture. Then, an unmatched case-control analysis of determinants was conducted. All women diagnosed with uterine rupture were classified as cases, while controls were randomly selected from women who delivered without uterine rupture at a ratio of 1:2. Data extraction Data were retrieved from the medical records of all pregnant women admitted to the hospital’s Obstetrics and Gynecology Department during the study period using a structured data collection sheet. Data included demographic characteristics (maternal age and place of residence); confirmation of uterine rupture among cases; pregnancy-related characteristics (gestational age at delivery, multiplicity of pregnancy, and IPI); obstetric history (parity, gravidity, previous uterine rupture, and prior cesarean section or uterine scar); intrapartum characteristics (onset and duration of labor, presence of obstructed labor, induction or augmentation, oxytocin use, TOLAC, and delivery mode and place); fetal factors (fetal presentation and birthweight); and maternal and perinatal outcomes (severe blood loss, postpartum hemorrhage, need for blood transfusion, bladder rupture, hysterectomy, maternal death, and stillbirth). Data analysis Data were analyzed using IBM SPSS Statistics, version 21 (IBM Corp., Armonk, NY, USA). Continuous variables were presented as means with standard deviations (SD), and categorical variables were summarized using frequencies and percentages. Using Pearson’s chi-square or Fisher’s exact test, associations between uterine rupture and its determinants were examined, along with the odds ratios (ORs) and 95% confidence intervals (CIs). P -values < 0.05 were considered of statistical significance. Results Incidence and type of uterine rupture A total of 8,550 deliveries were recorded during the study period. Among these, 23 cases of uterine rupture were identified, corresponding to an incidence rate of 2.7 per 1,000 deliveries. Among uterine ruptures, 19 (82.6%) were complete, while 4 (17.4%) were incomplete. Characteristics of women with uterine rupture The mean age of the pregnant women included in the study was 29.7 ± 5.3 years, with the majority residing in rural areas (65.2%). The mean gestational age at delivery was 38.3 ± 2.8 weeks, with the majority being at term (78.3%). Regarding obstetric history, over half of the women were multiparous (52.2%), and 21.7% were grand multiparous, whereas primiparous and nulliparous women accounted for 21.7% and 4.3%, respectively. Similarly, most participants were multigravida (65.2%), with 30.4% being grand multigravida and only 4.3% primigravida. The majority of pregnancies were singleton (95.7%). For neonates, the mean birthweight was 2.8 ± 0.7 kg, with 30% having low birthweight and 70% normal birthweight. Cesarean section was the most common mode of delivery (65.2%), and most deliveries occurred in hospital (78.3%). Among women who delivered by cesarean section, 20% underwent TOLAC (Table 1 ). Table 1 Demographic and obstetric characteristics of women with uterine rupture admitted to the Republican General Teaching Hospital in Taiz City, Yemen (2023)* Characteristics n (%) Maternal age (years) Mean ± SD: 29.7 ± 5.3 Residence Rural 15 (65.2) Urban 8 (34.8) gestational age at delivery (weeks) 38.3 ± 2.8 Mean ± SD: 38.3 ± 2.8 Preterm 4 (17.4) Term 18 (78.3) Post-term 1 (4.3) Parity Nulliparous 1 (4.3) Primiparous 5 (21.7) Multiparous 12 (52.2) Grand multiparous 5 (21.7) Gravidity Primigravida 1 (4.3) Multigravida 15 (65.2) Grand multigravida 7 (30.4) Multiplicity of gestation Singleton 22 (95.7) Multiple 1 (4.3) Birthweight (kg) a Mean ± SD: 2.8 ± 0.7 Low 6 (30.0) Normal 14 (70.0) History of abortion Yes 8 (34.8) No 15 (65.2) Mode of delivery Spontaneous vaginal birth 8 (34.8) Cesarean section 15 (65.2) TOLAC Yes 3 (20.0) No 12 (80.0) Place of delivery Home 5 (21.7) Hospital 18 (78.3) * Total number of women with uterine rupture was 23; SD standard deviation, TOLAC trial of labor after cesarean, ANC antenatal care. a 3 missing cases. b Calculated for women with cesarean section. Determinants of uterine rupture Rural residence (OR = 4, 95% CI: 1.39–11.48; P = 0.008), IPI < 24 months (OR = 5.2; 95% CI: 1.16–23.08; P = 0.030), and breech fetal malpresentation (OR = 21.9, 95% CI: 1.13–426.9; P = 0.008) were significantly associated with uterine rupture. Conversely, there were no statistically significant associations between uterine rupture and maternal age ≤ 30 years, gestational age ≥ 40 weeks, grand multiparity, grand multigravidity, multiple gestation, birthweight ≥ 3.5 kg, obstructed labor, TOLAC, previous uterine rupture or scar, augmentation of labor, or oxytocin use (Table 2 ). Table 2 Demographic and obstetric determinants of uterine rupture among pregnant women admitted to the Republican General Teaching Hospital in Taiz City, Yemen (2023) Characteristics Cases ( N = 23) Controls ( N = 47) OR (95% CI) P -value n (%) n (%) Maternal age \(\:\le\:\) 30 years 15 (65.2) 33 (70.2) 0.8 (0.28–2.30) 0.672 Rural residence 15 (65.2) 15 (31.9) 4.0 (1.39–11.49) 0.008 Gestational age ≥ 40 weeks 10 (43.5) 12 (25.5) 2.2 (0.78–6.43) 0.129 Grand multiparity 5 (21.7) 9 (19.1) 1.2 (0.34–4.00) 0.516 Grand multigravidity 7 (30.4) 12 (25.5) 1.3 (0.42–3.85) 0.665 Multiplicity of gestation 1 (4.3) 3 (6.4) 0.7 (0.07–6.78) 1.000 Birthweight ≥ 3.5 kg a 4 (19.0) 3 (6.8) 3.2 (0.65–15.93) 0.200 Obstructed labor 1 (4.3) 1 (2.1) 2.1 (0.13–35.20) 1.000 Short IPI (< 24 months) 6 (26.1) 3 (6.4) 5.1 (1.16–23.08) 0.030 Breech fetal malpresentation b 4 (19.0) 0 (0.0)* 21.9 (1.13–426.9) 0.008 TOLAC 3 (13.0) 3 (6.4) 2.2 (0.41–11.87) 0.387 Previous uterine rupture 1 (4.3) 1 (2.1) 2.1 (0.13–35.00) 1.000 Previous uterine scar c 10 (45.5) 13 (27.7) 2.2 (0.76–6.26) 0.144 Augmentation of labor 3 (13.0) 3 (6.4) 2.2 (0.41–11.87) 0.378 Use of oxytocin 1 (4.3) 0 (0.0)* 6.3 (0.25–161.7) 0.329 IPI interpregnancy interval, TOLAC trial of labor after cesarean. a 2 cases and 3 controls missing; b 2 cases and 2 controls missing; c 1 case missing. * Haldane-Anscombe correction was applied. Adverse maternal and perinatal outcomes More than one-quarter of women with uterine rupture experienced severe blood loss (26.1%), 43.5% required blood transfusion, and 21.7% had bladder rupture. Postpartum hemorrhage occurred in three cases (4.3%), while 13% of women required hysterectomy. Only one woman (4.3%) died of uterine rupture, while stillbirth occurred in more than one-quarter of pregnancies complicated by uterine rupture (27.3%) (Table 3 ). Table 3 Adverse maternal and perinatal outcomes among pregnant women with uterine rupture admitted to the Republican General Teaching Hospital in Taiz City, Yemen (2023)* Maternal outcomes n (%) Severe blood loss 6 (26.1) Bladder rupture 5 (21.7) Postpartum hemorrhage 3 (13.0) Need for blood transfusion 10 (43.5) Need for hysterectomy 3 (13.0) Maternal death 1 (4.3) Stillbirth a 6 (27.3) *The total number of cases with uterine rupture was 23. a 1 case missing. Discussion To the best of our knowledge, this study is the first to report on the incidence, determinants, and outcomes of uterine rupture in Taiz City. The incidence of uterine rupture in the city was 2.7 per 1,000 deliveries, which is substantially lower than the rates of ≈ 11 to 32 per 1,000 deliveries reported in Hajjah [ 22 – 24 ]. It is also lower than the 0.63% (6.3 per 1,000 deliveries) reported in Sana’a and the 0.26% (1 in 323 deliveries) [ 25 , 26 ], suggesting that the burden of uterine rupture may vary considerably across Yemeni governorates. Differences in referral patterns and case capture are likely to play an important role in such differences. For instance, the hospital in Taiz serves as a major urban referral center, where women with labor complications may present earlier than those in more remote governorates. In contrast, hospitals in Hajjah predominantly serve rural catchment areas, where delays in decision-making, transportation, and access to skilled obstetric care are common, increasing the likelihood of prolonged or obstructed labor and subsequent uterine rupture [ 22 – 24 ]. Compared with several low- and middle-income hospital settings outside Yemen, the incidence in Taiz remains lower than the 8.7 per 1,000 reported from a tertiary center in Eastern Uttar Pradesh, India [ 27 ], the 6.8 per 1,000 reported from a university hospital in Eastern Ethiopia,[ 28 ] the 5.01 per 1,000 reported at Lagos University Teaching Hospital, Nigeria [ 29 ], and the 1 per 246 in Sudan [ 30 ]. These higher rates are commonly interpreted as markers of delayed access to emergency obstetric care and a larger share of women arriving after mismanaged labor, obstructed labor, or unsupervised TOLAC, which are risk factors that tend to cluster in facilities receiving referrals from peripheral or under-resourced units [ 27 , 29 ]. However, the incidence of uterine rupture in Taiz is somewhat comparable to rates reported from other settings. For instance, a population-based study from Nova Scotia, Canada, reported an incidence of 2.4 per 1,000 TOLAC for complete uterine rupture [ 31 ], while a hospital-based study conducted in Dar es Salaam, Tanzania, documented an incidence of 2.25 per 1,000 births [ 32 ]. Nevertheless, comparison of the estimated incidence rates across studies should be interpreted with caution, as reported rates depend on whether the incidence was calculated for all births or limited to women undergoing TOLAC, which may substantially affect the incidence of uterine rupture. Compared to other Arab countries, the incidence of uterine rupture in the present study exceeds rates reported from hospitals in Makkah, Saudi Arabia (1 per 1,011 deliveries) [ 33 ], Kuwait (1 per 1,851) [ 34 ], Basra (1 per 801) and Dohuk (2 per 1,000) in Iraq [ 35 , 36 ], and Bahrain (1 per 2,213) [ 37 ]. It is to be noted that the studies in these Arab countries were conducted in stable health systems with better access to ANC and referral systems, which reduce the risk of prolonged labor and catastrophic uterine events. On the other hand, the incidence of uterine rupture in the present study is also higher than rates reported elsewhere in population-based studies or from high-resource countries. For instance, in a population-based retrospective study in Shanghai, China, the incidence of uterine rupture was 1.96 per 10,000 births [ 38 ]. A lower incidence of 0.038 per 1,000 was reported among women without prior cesarean section in Norway, but a comparable rate of 2.11 per 1,000 was found for those with prior cesarean section [ 11 ]. Lower incidence rates per 1,000 deliveries were also reported from the United Kingdom (0.2) [ 39 ], Lithuania (0.68) [ 40 ], and Portugal (1.2) [ 41 ]. These differences likely reflect the combined effects of strong antenatal surveillance, standardized intrapartum monitoring, strict protocols governing labor induction and TOLAC, and rapid access to emergency operative care. This study found a significant association between rural residence and uterine rupture, with women residing in rural areas being four times more likely to experience uterine rupture than their urban counterparts. This finding is consistent with that reported in Hajjah, where rural residence was associated with 2.6 times higher risk of uterine rupture, while urban residence appeared to be protective [ 24 ]. Similar patterns have been reported from Ethiopia, where rural residence was associated with a sixfold higher risk of uterine rupture in Oromia state [ 28 ], and living in an urban area was protective against uterine rupture in western Ethiopia [ 42 ]. Such differences could be largely attributed to delayed access to emergency obstetric care and inadequate intrapartum monitoring in rural areas [ 28 ], and proximity to skilled maternity services in urban areas [ 42 ]. Transportation delays, a lack of trained birth attendants, lower ANC utilization, and a higher frequency of home or peripheral facility deliveries may all contribute to the higher risk of obstetric complications in rural areas in conflict-affected settings like Yemen [ 43 , 44 ]. Moreover, insecurity, restricted movement, and fragile referral systems exacerbate these obstacles [ 43 , 44 ]. A short IPI of < 24 months was also significantly associated with uterine rupture among women in the present study, increasing its likelihood by more than fivefold. Inadequate intervals between pregnancies, particularly after cesarean delivery, can hinder the uterus's ability to heal and make it more susceptible to rupturing during the mechanical strain of late pregnancy and labor [ 45 ]. In Aden, short IPI was found among 43% of women with uterine rupture, but the statistical association was not studied [ 26 ]. Unlike the finding of the present study, a multi-center study in the United States found that short IPI was associated with more than twofold higher risk of uterine rupture among women with a prior cesarean delivery attempting TOLAC [ 46 ]. Another US population-based cohort (2011–2021) also revealed that the risk of uterine rupture decreased as IPI increased to about 21 months, while shorter intervals were associated with a higher rupture risk [ 47 ]. Similarly, in a Canadian cohort study conducted in Quebec, women with an IPI shorter than 18 months following a previous cesarean delivery had a threefold higher risk of uterine rupture compared with those whose interval was 24 months or longer [ 48 ]. In a Chinese retrospective cohort, the time between a previous cesarean delivery and the current pregnancy was significantly shorter for women with uterine rupture than for those without [ 45 ]. Breech fetal malpresentation showed a significant association with uterine rupture in this study, which is consistent with that reported elsewhere [ 37 ]. The risk of prolonged or obstructed labor is known to be increased by malpresentation, especially when the delivery takes place outside of facilities with adequate equipment or without prompt surgical intervention [ 49 , 50 ]. In this study, neither grand multiparity nor grand multigravidity was a significant determinant of uterine rupture. This finding contradicts the mechanistic connection between multiparity and a higher risk of pelvic floor and uterine dysfunction because repeated birth injuries lead to cumulative pelvic floor muscle degeneration and dysfunction [ 51 ]. In addition, no statistically significant associations were observed between uterine rupture and maternal age, late gestational age, multiple gestation, birthweight ≥ 3.5 kg, obstructed labor, TOLAC, previous uterine rupture or scar, augmentation of labor, or oxytocin use. Although many of these factors have been reported as significant determinants of uterine rupture in Yemen and elsewhere [ 2 , 9 – 11 , 24 , 42 , 52 , 53 ], they did not reach statistical significance in the present study, which could be attributed to the relatively small sample size. Uterine rupture in this cohort was associated with substantial maternal morbidity. Nearly a quarter of women with uterine rupture experienced severe blood loss, and one-half of affected women required blood transfusion. Similarly, a large proportion of women with uterine rupture needed blood transfusion in Hajjah (88%) and Sana’a (57.1%) [ 22 , 25 ]. The high frequency of the need for blood transfusion is consistent with that reported elsewhere [ 1 , 33 , 36 ]. A well-known consequence of complete uterine rupture is extensive blood loss, which contributes substantially to maternal morbidity and mortality [ 1 – 3 ]. Bladder rupture was another important morbidity among women in this study, affecting more than one-fifth of cases and reflecting the extensive tissue damage and hemorrhage typically accompanying complete rupture. However, lower rates of 5.4–8.3% of women with uterine rupture experienced bladder rupture in Hajjah [ 22 , 23 ]. The anatomical and embryological proximity of the bladder and uterus makes bladder injury a significant risk during uterine rupture and surgical procedures [ 54 , 55 ]. Bladder injury substantially increases the risk of postoperative sepsis, peritonitis, prolonged catheterization, vesicovaginal fistula formation, and longer hospital stays [ 56 , 57 ], which further exacerbates the burden on affected women. Although hysterectomy was required in a minority of cases (13%) in the present study, the procedure remains a life-saving intervention in settings where conservative repair is not feasible or delayed [ 18 ]. The relatively lower frequency of hysterectomy observed in the present study may reflect a higher proportion of repairable ruptures or improved surgical decision-making at the referral hospital level. This rate is notably lower than that reported from Hajjah City, where hysterectomy was performed in 45.4% to 55% of uterine rupture cases [ 22 , 23 ]. The substantially higher rates in Hajjah have been attributed to late presentation, prolonged obstructed labor, deliveries occurring outside health facilities, and limited access to timely operative care, all of which increase the likelihood of extensive uterine damage necessitating hysterectomy [ 22 , 23 ]. A higher rate of hysterectomy was reported among women with uterine rupture in Sudan (80%) [ 30 ], but comparable rates were reported from Saudi Arabia (17.4%)[ 33 ] and India (16.1%) [ 27 ]. These findings suggest that the need for hysterectomy after uterine rupture is highly context-dependent. While uterine preservation is desirable, particularly in young women with future fertility intentions, hysterectomy remains an essential component of emergency obstetric care [ 58 ]. In this study, uterine rupture led to the death of only one woman (4.3% case fatality), which is lower than the 7.2% maternal mortality reported from Hajjah [ 23 ], possibly indicating some improvement in surgical response and postoperative care at the referral level. In addition, it is lower than the rates reported from Iraq (5%) [ 36 ], Egypt (6.5%) [ 3 ], and Ethiopia (6.6–7.8%) [ 1 , 10 ]. However, maternal mortality in our study should be interpreted with caution due to the low number of cases, where a difference of one or two deaths can markedly shift the percentage. In the present study, perinatal mortality is high, with more than one-quarter of pregnancies complicated by uterine rupture resulting in stillbirth. This rate is lower than the perinatal deaths reported from Hajjah (81.7–91.8%) [ 22 , 23 ] and Sana’a (54.3%) [ 25 ]. This finding is also consistent with previous reports from low-resource settings where delays in diagnosis and intervention are common [ 1 , 3 , 30 ]. This study fills in an important knowledge gap by providing evidence on uterine rupture in a conflict-affected city. However, certain limitations should be considered. Because the retrospective design depends on accuracy and completeness of records, certain variables may have missing or misclassified data. Important factors, such as delays in care-seeking, transportation time, and intrapartum monitoring quality, could not be fully assessed. On the other hand, the single-center setting limits the generalizability of the results to other hospitals or regions in Yemen, particularly non-referral centers where patterns of care and delays may differ. Nevertheless, the study hospital serves as a major referral center for Taiz city and surrounding districts, enabling the collection of a broad range of obstetric complications from both urban and rural populations. The relatively small number of uterine rupture cases also reduces statistical power and may explain why several known risk factors did not reach statistical significance. To address this, an appropriate case-control ratio was used to improve analytical efficiency, and effect sizes are reported with CIs to show the magnitude and direction of associations rather than reliance only on statistical significance. Conclusion Uterine rupture in Taiz City is a major obstetric complication with an incidence that is higher than estimates from the region and worldwide. It is linked to substantial maternal and perinatal consequences, including severe hemorrhage, the need for blood transfusion, bladder injury, hysterectomy, and stillbirth. Key determinants of uterine rupture include rural residence, short IPI and breech fetal malpresentation, highlighting the importance of early access to obstetric care, adequate birth spacing, and early detection of malpresentation. To reduce the burden of uterine rupture, it is essential to strengthen ANC coverage, promote optimal IPIs, improve referral systems, and ensure access to emergency obstetric services. Multicenter studies are recommended to guide evidence-based interventions and improve maternal and perinatal outcomes in similar conflict-affected settings. Abbreviations CS Cesarean section HDI Human Development Index IPI Interpregnancy interval LMICs Low- and middle-income countries MRI Magnetic resonance imaging OR Odds ratio PPH Postpartum hemorrhage SD Standard deviation SPSS Statistical Package for the Social Sciences TOLAC Trial of labor after cesarean delivery WHO World Health Organization Declarations Acknowledgments The authors thank the Republican General Teaching Hospital in Taiz for permission to collect data and cooperation. They also thank Rashad Abdul-Ghani, Faculty of Medicine and Health Sciences, Sana’a University, for his help in interpreting study findings and drafting the manuscript. Funding None. Availability of data and materials Data are available from the corresponding author upon reasonable request. Ethics approval and consent to participate The Declaration of Helsinki guidelines were followed in this study, and ethical approval was granted by the Research Ethics Committee (REC) of the Faculty of Medicine and Health Sciences, University of Science and Technology, Sana’a, Yemen (Ethical clearance No.: 1447/0084/UREC/UST). However, informed consent was not required because of the retrospective nature of the study and was waived by the REC of the University of Science and Technology. Strict confidentiality and anonymity were maintained when handling data. Consent for publication Not applicable. Competing interests The authors declare no competing interests. Authors’ contributions HMH, MSMS, and MA conceptualized the idea, designed the study, analyzed data and prepared the manuscript. All authors read and approved the final manuscript. References Astatikie, G., Limenih M.A., Kebede M. Maternal and fetal outcomes of uterine rupture and factors associated with maternal death secondary to uterine rupture . BMC Pregnancy Childbirth. 2017;17(1):117. doi: 10.1186/s12884-017-1302-z Motomura, K., Ganchimeg T., Nagata C., Ota E., Vogel J.P., Betran A.P., et al. Incidence and outcomes of uterine rupture among women with prior caesarean section: WHO Multicountry Survey on Maternal and Newborn Health . Sci Rep. 2017;744093. doi: 10.1038/srep44093 Abbas, A.M., M A.S., M M.F. Maternal and perinatal outcomes of uterine rupture in a tertiary care hospital: a cross-sectional study . J Matern Fetal Neonatal Med. 2019;32(20):3352-3356. doi: 10.1080/14767058.2018.1463369 Herrera, F.A., Hassanein A.H., Bansal V. Atraumatic spontaneous rupture of the non-gravid uterus . J Emerg Trauma Shock. 2011;4(3):439. doi: 10.4103/0974-2700.83896 Guèye, M., Mbaye M., Ndiaye-Guèye M.D., Kane-Guèye S.M., Diouf A.A., Niang M.M., et al. Spontaneous uterine rupture of an unscarred uterus before labour . Case Rep Obstet Gynecol. 2012;2012598356. doi: 10.1155/2012/598356 Farhat, I.B., Zoukar O., Medemagh M., Slamia W.B., 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;4783. doi: 10.11604/pamj.2024.47.83.42188 Nie, Q., Luo S., Chen B., Wang L., He F. Risk factors and outcomes of uterine rupture before onset of labor vs. during labor: a multicenter study . J Perinat Med. 2025;53(4):503-508. doi: 10.1515/jpm-2024-0309 Leung, A.S., Farmer R.M., Leung E.K., Medearis A.L., Paul R.H. Risk factors associated with uterine rupture during trial of labor after cesarean delivery: a case-control study . Am J Obstet Gynecol. 1993;168(5):1358-63. doi: 10.1016/s0002-9378(11)90765-0 Ronel, D., Wiznitzer A., Sergienko R., Zlotnik A., Sheiner E. Trends, risk factors and pregnancy outcome in women with uterine rupture . Arch Gynecol Obstet. 2012;285(2):317-21. doi: 10.1007/s00404-011-1977-8 Desta, M., Amha H., Anteneh Bishaw K., Adane F., Assemie M.A., Kibret G.D., et al. Prevalence and predictors of uterine rupture among Ethiopian women: A systematic review and meta-analysis . PLoS One. 2020;15(11):e0240675. doi: 10.1371/journal.pone.0240675 Al-Zirqi, I., Daltveit A.K., Forsén L., Stray-Pedersen B., Vangen S. Risk factors for complete uterine rupture . Am J Obstet Gynecol. 2017;216(2):165.e1-165.e8. doi: 10.1016/j.ajog.2016.10.017 Anonymous. ACOG Practice Bulletin No. 205: Vaginal Birth After Cesarean Delivery . Obstet Gynecol. 2019;133(2):e110-e127. doi: 10.1097/aog.0000000000003078 Bedi, D.G., Salmon A., Winsett M.Z., Fagan C.J., Kumar R. Ruptured uterus: sonographic diagnosis . J Clin Ultrasound. 1986;14(7):529-33. doi: 10.1002/jcu.1870140706 Ogbole, G.I., Ogunseyinde O.A., Akinwuntan A.L. Intrapartum rupture of the uterus diagnosed by ultrasound . Afr Health Sci. 2008;8(1):57-9. doi: Ponder, K.L., Won R., Clymer L. Uterine rupture on MRI presenting as nonspecific abdominal pain in a primigravid patient with 28-week twins resulting in normal neurodevelopmental outcomes at age two . Case Rep Obstet Gynecol. 2019;20192890104. doi: 10.1155/2019/2890104 Aboughalia, H., Basavalingu D., Revzin M.V., Sienas L.E., Katz D.S., Moshiri M. Imaging evaluation of uterine perforation and rupture . Abdom Radiol (NY). 2021;46(10):4946-4966. doi: 10.1007/s00261-021-03171-z Revicky, V., Muralidhar A., Mukhopadhyay S., Mahmood T. A case series of uterine rupture: lessons to be learned for future clinical practice . J Obstet Gynaecol India. 2012;62(6):665-73. doi: 10.1007/s13224-012-0328-4 Sugai, S., Sasabuchi Y., Yasunaga H., Isogai T., Yoshihara K., Nishijima K. In-hospital outcomes of repair and hysterectomy for uterine rupture: A nationwide observational study . Eur J Obstet Gynecol Reprod Biol. 2024;302196-200. doi: 10.1016/j.ejogrb.2024.09.010 Frank, Z.C., Caughey A.B. Pregnancy in women with a history of uterine rupture . Obstet Gynecol Surv. 2018;73(12):703-708. doi: 10.1097/ogx.0000000000000624 Deshmukh, U., Denoble A.E., Son M. Trial of labor after cesarean, vaginal birth after cesarean, and the risk of uterine rupture: an expert review . Am J Obstet Gynecol. 2024;230(3s):S783-s803. doi: 10.1016/j.ajog.2022.10.030 World Health Organization. Trends in maternal mortality 2000 to 2023: estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division. Geneva: WHO; 2025. Diab, A.E. Uterine ruptures in Yemen . Saudi Med J. 2005;26(2):264-9. doi: Al-Rukeimi, A.A., Al-Haddad A., Ali A.A., Adam I. High rate of uterine rupture in a conflict setting of Hajjah, Yemen . J Obstet Gynaecol. 2017;37(8):1106-1107. doi: 10.1080/01443615.2017.1324412 Al Rukeimi, A.A., Al Shaibani E.M., Al Shamahy H.A., Al Hadad A.M., Al Khorasani H.A., Dainamah S.M.N. Uterine rupture and associated factors during labor amongst women delivered in Saudi Hajjah Hospital in Hajjah City north west Yemen . WJ Gynecol Women’s Health. 2018;1(2):1-5. doi: 10.33552/WJGWH.2018.01.000508 Dhaifalah, I., Santavy J., Fingerova H. Uterine rupture during pregnancy and delivery among women attending the Al-Tthawra Hospital in Sana'a City Yemen Republic . Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2006;150(2):279-83. doi: 10.5507/bp.2006.042 Basorra, H.A., Al.kaaky N.S., Abdulla E.M., Aman F.S. Uterine rupture: A five year review at Al-sadaqa teaching hospital, Aden . Univ Aden J Nat Appl Sci. 2017;21(2):379-387. doi: 10.47372/uajnas.2017.n2.a17 Pipal, V.R., Singh R.K., Singh A., Singh P.B., Singh N., Singh A. Incidence and predictors of uterine rupture with maternal and perinatal outcome: a cross-sectional study . Int J MCH AIDS. 2025;14e020. doi: 10.25259/ijma_28_2025 Abebe, F., Eticha T.G., Belis B., Tura A.K. Incidence and maternal-perinatal outcomes of uterine rupture in a university hospital in Eastern Ethiopia: a retrospective study . Ethiop J Reprod Health. 2025;17(2):26-34. doi: 10.69614/ejrh.v17i2.898 Ola, E.R., Olamijulo J.A. Rupture of the uterus at the Lagos University Teaching Hospital, Lagos, Nigeria . West Afr J Med. 1998;17(3):188-93. doi: Ahmed, S.M., Daffalla S.E. Incidence of uterine rupture in a Teaching Hospital, Sudan . Saudi Med J. 2001;22(9):757-61. doi: Kieser, K.E., Baskett T.F. A 10-year population-based study of uterine rupture . Obstet Gynecol. 2002;100(4):749-53. doi: 10.1016/s0029-7844(02)02161-0 Kidantou, H.L., Mwampagatwa I., Van Roosmalen J. Uterine rupture: a retrospective analysis of causes, complications and management outcomes at Muhimbili National Hospital in Dar es Salaam, Tanzania . Tanzan J Health Res. 2012;14(3):220-5. doi: Rouzi, A.A., Hawaswi A.A., Aboalazm M., Hassanain F., Sindi O. Uterine rupture incidence, risk factors, and outcome . Saudi Med J. 2003;24(1):37-9. doi: Al Salem, M., Makhseed M., Ahmed M., Gupta M. Rupture of the gravid uterus: experience of the maternity hospital, Kuwait . Med Princ Pract. 2000;9(2):97-105. doi: Al-Rubaei, S. A 10 years review of rupture pregnant uterus in Basra maternity and child hospital . Al-Qadisiyah Med J. 2011;7(11):9-20. doi: 10.28922/qmj.2011.7.11.9-20 Yalda, M.A., Munib A. Uterine rupture in Dohuk, Iraq . East Mediterr Health J. 2009;15(5):1272-7. doi: Al-Jufairi, Z.A., Sandhu A.K., Al-Durazi K.A. Risk factors of uterine rupture . Saudi Med J. 2001;22(8):702-4. doi: Wan, S., Yang M., Pei J., Zhao X., Zhou C., Wu Y., et al. Pregnancy outcomes and associated factors for uterine rupture: an 8 years population-based retrospective study . BMC Pregnancy Childbirth. 2022;22(1):91. doi: 10.1186/s12884-022-04415-6 Fitzpatrick, K.E., Kurinczuk J.J., Alfirevic Z., Spark P., Brocklehurst P., Knight M. Uterine rupture by intended mode of delivery in the UK: a national case-control study . PLoS Med. 2012;9(3):e1001184. doi: 10.1371/journal.pmed.1001184 Savukyne, E., Bykovaite-Stankeviciene R., Machtejeviene E., Nadisauskiene R., Maciuleviciene R. Symptomatic uterine rupture: a fifteen year review . Medicina (Kaunas). 2020;56(11). doi: 10.3390/medicina56110574 De Pinho, A., Martins Dos Santos F., Carmo O., Bernardes J., Reynolds A. Uterine rupture in pregnancy over 5 years: A retrospective descriptive study . Womens Health (Lond). 2025;2117455057251399891. doi: 10.1177/17455057251399891 Tesema, O., Tilahun T., Kejela G. Determinants of uterine rupture at public hospitals of western Ethiopia: A case-control study . SAGE Open Med. 2022;1020503121221092643. doi: 10.1177/20503121221092643 Tappis, H., Elaraby S., Elnakib S., AlShawafi N.A.A., BaSaleem H., Al-Gawfi I.A.S., et al. Reproductive, maternal, newborn and child health service delivery during conflict in Yemen: a case study . Confl Health. 2020;1430. doi: 10.1186/s13031-020-00269-x Médecins Sans Frontières. Complicated delivery: The Yemeni mothers and children dying without medical care 2019. Available at: [https://www.msf.org/complicated-delivery-yemeni-mothers-and-children-dying-without-medical-care?utm_source=chatgpt.com] Zhang, L., Li T., Zhang P., Li C. 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;172421-2431. doi: 10.2147/ijwh.s530520 Stamilio, D.M., DeFranco E., Paré E., Odibo A.O., Peipert J.F., Allsworth J.E., et al. Short interpregnancy interval: risk of uterine rupture and complications of vaginal birth after cesarean delivery . Obstet Gynecol. 2007;110(5):1075-82. doi: 10.1097/01.aog.0000286759.49895.46 Adily, P., Bettison T., Lauer M., Narayan R., Mackie A., Phipps H., et al. Inter-pregnancy interval and uterine rupture during a trial of labour after one previous caesarean delivery and no previous vaginal births: a retrospective population-based cohort study . EClinicalMedicine. 2025;80103071. doi: 10.1016/j.eclinm.2025.103071 Bujold, E., Gauthier R.J. Risk of uterine rupture associated with an interdelivery interval between 18 and 24 months . Obstet Gynecol. 2010;115(5):1003-1006. doi: 10.1097/AOG.0b013e3181d992fb Girma, T., Gezimu W., Demeke A. Prevalence, causes, and factors associated with obstructed labour among mothers who gave birth at public health facilities in Mojo Town, Central Ethiopia, 2019: a cross-sectional study . PLoS One. 2022;17(9):e0275170. doi: 10.1371/journal.pone.0275170 Khan, S., Anbreen F. Obstetric outcomes of fetal malpresentation and malpositions . Indus J Biosci Res. 2025;3(2):19-24. doi: 10.70749/ijbr.v3i2.548 Duran, P., Zelus E.I., Burnett L.A., Christman K.L., Alperin M. Repeated birth injuries lead to long-term pelvic floor muscle dysfunction in the preclinical rat model . Am J Obstet Gynecol. 2025;232(2):198.e1-198.e23. doi: 10.1016/j.ajog.2024.08.036 Elkousy, M.A., Sammel M., Stevens E., Peipert J.F., Macones G. The effect of birth weight on vaginal birth after cesarean delivery success rates . Am J Obstet Gynecol. 2003;188(3):824-30. doi: 10.1067/mob.2003.186 Zhang, H., Liu H., Luo S., Gu W. Oxytocin use in trial of labor after cesarean and its relationship with risk of uterine rupture in women with one previous cesarean section: a meta-analysis of observational studies . BMC Pregnancy Childbirth. 2021;21(1):11. doi: 10.1186/s12884-020-03440-7 Ho, S.Y., Chang S.D., Liang C.C. Simultaneous uterine and urinary bladder rupture in an otherwise successful vaginal birth after cesarean delivery . J Chin Med Assoc. 2010;73(12):655-9. doi: 10.1016/s1726-4901(10)70143-x Yang, B. Bladder rupture associated with uterine rupture at delivery . Int Urogynecol J. 2011;22(5):625-7. doi: 10.1007/s00192-010-1318-7 Lee, J.S., Choe J.H., Lee H.S., Seo J.T. Urologic complications following obstetric and gynecologic surgery . Korean J Urol. 2012;53(11):795-9. doi: 10.4111/kju.2012.53.11.795 Ibrahim, N., Spence A.R., Czuzoj-Shulman N., Abenhaim H.A. Incidence and risk factors of bladder injury during cesarean delivery: a cohort study . Arch Gynecol Obstet. 2023;307(2):401-408. doi: 10.1007/s00404-022-06447-x Meriwether, K.V., Antosh D.D., Olivera C.K., Kim-Fine S., Balk E.M., Murphy M., et al. Uterine preservation vs hysterectomy in pelvic organ prolapse surgery: a systematic review with meta-analysis and clinical practice guidelines . Am J Obstet Gynecol. 2018;219(2):129-146.e2. doi: 10.1016/j.ajog.2018.01.018 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 17 May, 2026 Reviewers agreed at journal 11 May, 2026 Reviewers agreed at journal 06 Mar, 2026 Reviewers agreed at journal 08 Feb, 2026 Reviewers agreed at journal 07 Feb, 2026 Reviewers invited by journal 06 Feb, 2026 Editor invited by journal 27 Jan, 2026 Editor assigned by journal 24 Jan, 2026 Submission checks completed at journal 24 Jan, 2026 First submitted to journal 23 Jan, 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. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8681256","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":587861506,"identity":"5f4bd051-c655-4cc0-834e-6603ea961f28","order_by":0,"name":"Hanan M. Hasan","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4klEQVRIiWNgGAWjYBACAwh1IAFMfQBiNnZStDDOAGlhJkULMw+YJKDFnP3swc+FOXfy+PsPP3ts82ubPB8zA+OHjzm4tVj25CVLz9z2rFjiRpq5cW7fbcM2ZgZmyZnb8DjsQI6BNO+2w4kNNxjMpHN7bjMCtbAx8+LTcv6N8W+Qlvnnj3+Ttuy5bU9Yy40cM7AtGw4AGQw/bicSoeWNmTVIy8YbOWWSvQ23k9uYGZvx++V8jvFtkJZ5549vk/jx57bt/Pbmgx8+4tGCChjbwGQDsepB4A8pikfBKBgFo2CkAADkSFZw1CR0tgAAAABJRU5ErkJggg==","orcid":"","institution":"University of Science and Technology (USTY)","correspondingAuthor":true,"prefix":"","firstName":"Hanan","middleName":"M.","lastName":"Hasan","suffix":""},{"id":587861510,"identity":"87df6fc4-92c3-4905-b481-27b0e3f22508","order_by":1,"name":"Maisa S. M. Thabit","email":"","orcid":"","institution":"Taiz University","correspondingAuthor":false,"prefix":"","firstName":"Maisa","middleName":"S. M.","lastName":"Thabit","suffix":""},{"id":587861516,"identity":"d04a3888-1365-4443-9733-74b3d1e9e788","order_by":2,"name":"Maha Abdulaziz","email":"","orcid":"","institution":"University of Science and Technology (USTY)","correspondingAuthor":false,"prefix":"","firstName":"Maha","middleName":"","lastName":"Abdulaziz","suffix":""}],"badges":[],"createdAt":"2026-01-23 16:53:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8681256/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8681256/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102389910,"identity":"cbccb2a3-07f3-442b-b12f-74929288021d","added_by":"auto","created_at":"2026-02-11 08:36:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":940828,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8681256/v1/6050355e-3579-4bff-9a8f-323f86be7780.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Incidence, determinants and outcomes of uterine rupture among women at a referral hospital in Taiz City, Yemen: a retrospective analysis from a conflict-affected setting","fulltext":[{"header":"Introduction","content":"\u003cp\u003eUterine rupture is defined as the complete disruption of uterine layers during pregnancy, labor, or shortly after delivery. Despite being relatively rare, uterine rupture is one of the most serious emergencies in obstetrics associated with severe maternal and perinatal complications, including postpartum hemorrhage and hysterectomy, low Apgar scores, and increased perinatal mortality [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Uterine rupture is mainly seen during pregnancy, but rare cases have been documented in non-pregnant women as a result of uterine trauma, malignancy, or infection [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Although it is more frequent in women with scarred uteri, spontaneous rupture in unscarred uteri can occur and is linked to factors such as uterine structural irregularities, excessive stretching during pregnancy, abnormal placental implantation, and sometimes abdominal trauma or obstructed labor [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Although uterine rupture can occur at any gestational age, it is more frequently reported during the third trimester or labor [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA multicounty analysis of data has demonstrated that the incidence of uterine rupture in women with a previous cesarean section is approximately 0.5% of deliveries, which ranges from 0.2% in countries with a high Human Development Index (HDI) to 1% in low-HDI countries [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The most common risk factor for uterine rupture is prior uterine surgery, particularly cesarean sections, where scar tissue may compromise structural integrity under the stress of pregnancy or labor [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Other risk factors include malpresentation, dystocia in the second stage of labor, short interpregnancy interval (IPI), uterine anomalies, uterine instrumentation, obstructed or prolonged labor, induction or augmentation with uterotonic agents, multiparity, macrosomia, lack of antenatal care (ANC), and delays in accessing emergency obstetric services [\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In recent years, the increasing adoption of trial of labor after cesarean delivery (TOLAC) has raised interest in uterine rupture [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDiagnosing uterine rupture is challenging due to nonspecific signs and requires a combination of clinical assessment and advanced imaging techniques, which can confirm uterine wall defects, fetal position, hemoperitoneum, or extravasation of amniotic fluid or fetus into the abdominal cavity [\u003cspan additionalcitationids=\"CR14 CR15\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. However, the most reliable early indicator is sustained and severe fetal bradycardia [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The treatment of uterine rupture primarily involves surgical intervention, with two main approaches: uterine repair and hysterectomy, with a recent trend favoring repair when possible [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Post-operative care is vital, and future pregnancies should be carefully managed due to the risk of recurrent rupture [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. On the other hand, prevention relies primarily on ANC and careful use of oxytocin, particularly in women with previous uterine surgery, with close monitoring and planned delivery approaches that consider the risks of labor induction and TOLAC [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eYemen faces prolonged conflict, interrupted healthcare services and obstacles to prompt facility-based deliveries, exacerbating the burden of obstetric complications, including uterine rupture. The national maternal mortality ratio was estimated to be 118 per 100,000 live births in 2023, and births attended by skilled personnel remain suboptimal at 61% [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. However, there is a lack of studies on uterine rupture among pregnant women in the country. For instance, hospital-based studies in Hajjah City, northwest of Yemen, reported a high incidence of uterine rupture, ranging from 1 in 92 deliveries (\u0026asymp;\u0026thinsp;11 per 1,000 deliveries) to 1 in 31 deliveries (\u0026asymp;\u0026thinsp;32 per 1,000 deliveries) [\u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. These studies show that uterine rupture predominantly affects women with unscarred uteri and is driven by poor antenatal and intrapartum care, grand multiparity, obstructed labor, cephalopelvic disproportion, malpresentation, previous cesarean delivery, use of uterotonic agents, illiteracy, poverty, remote residence, home delivery, and inadequate access to ANC [\u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Moreover, uterine rupture resulted in substantial maternal morbidity, including sepsis, urinary bladder injury and vesicovaginal fistulae, while maternal and perinatal mortality rates were 7.2% and 91.8%, respectively [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. In Sana\u0026rsquo;a City, the capital of Yemen, a 9-month retrospective hospital-based study reported an incidence of approximately 0.63% [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. The study attributed uterine rupture to obstructed labor, with additional contributions from previous uterine surgery, oxytocin use, contracted pelvis, grand multiparity, advanced maternal age, and low ANC coverage, highlighting gaps in timely and adequate obstetric care [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. A retrospective study at Al-Sadaqa Teaching Hospital in Aden (2012\u0026ndash;2016) reported a lower incidence of 0.26% for uterine rupture (1 in 323 deliveries) among 31,905 births [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Although Taiz governorate, southwest of Yemen, is among the areas most affected by insecurity, access constraints, and obstacles to timely maternity care such as transportation delays and restricted movements, no published studies have been found on the incidence, risk factors and complications of uterine rupture among pregnant women in the governorate. Therefore, this study aimed to determine the incidence of uterine rupture and identify its determinants and outcomes among women admitted to a referral hospital in Taiz City.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design, population and setting\u003c/h2\u003e \u003cp\u003eA retrospective surveillance study with an integrated case-control analysis was conducted to investigate the incidence of uterine rupture and assess its determinants and outcomes among women delivered at the Gynecology and Obstetrics Department of the Republican General Teaching Hospital in Taiz in 2023. The study analyzed the medical records of all women delivered at the department during the study period to determine the incidence and outcomes of uterine rupture. Then, an unmatched case-control analysis of determinants was conducted. All women diagnosed with uterine rupture were classified as cases, while controls were randomly selected from women who delivered without uterine rupture at a ratio of 1:2.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData extraction\u003c/h3\u003e\n\u003cp\u003eData were retrieved from the medical records of all pregnant women admitted to the hospital\u0026rsquo;s Obstetrics and Gynecology Department during the study period using a structured data collection sheet. Data included demographic characteristics (maternal age and place of residence); confirmation of uterine rupture among cases; pregnancy-related characteristics (gestational age at delivery, multiplicity of pregnancy, and IPI); obstetric history (parity, gravidity, previous uterine rupture, and prior cesarean section or uterine scar); intrapartum characteristics (onset and duration of labor, presence of obstructed labor, induction or augmentation, oxytocin use, TOLAC, and delivery mode and place); fetal factors (fetal presentation and birthweight); and maternal and perinatal outcomes (severe blood loss, postpartum hemorrhage, need for blood transfusion, bladder rupture, hysterectomy, maternal death, and stillbirth).\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eData were analyzed using IBM SPSS Statistics, version 21 (IBM Corp., Armonk, NY, USA). Continuous variables were presented as means with standard deviations (SD), and categorical variables were summarized using frequencies and percentages. Using Pearson\u0026rsquo;s chi-square or Fisher\u0026rsquo;s exact test, associations between uterine rupture and its determinants were examined, along with the odds ratios (ORs) and 95% confidence intervals (CIs). \u003cem\u003eP\u003c/em\u003e-values\u0026thinsp;\u0026lt;\u0026thinsp;0.05 were considered of statistical significance.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eIncidence and type of uterine rupture\u003c/h2\u003e \u003cp\u003eA total of 8,550 deliveries were recorded during the study period. Among these, 23 cases of uterine rupture were identified, corresponding to an incidence rate of 2.7 per 1,000 deliveries. Among uterine ruptures, 19 (82.6%) were complete, while 4 (17.4%) were incomplete.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eCharacteristics of women with uterine rupture\u003c/h2\u003e \u003cp\u003eThe mean age of the pregnant women included in the study was 29.7\u0026thinsp;\u0026plusmn;\u0026thinsp;5.3 years, with the majority residing in rural areas (65.2%). The mean gestational age at delivery was 38.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.8 weeks, with the majority being at term (78.3%). Regarding obstetric history, over half of the women were multiparous (52.2%), and 21.7% were grand multiparous, whereas primiparous and nulliparous women accounted for 21.7% and 4.3%, respectively. Similarly, most participants were multigravida (65.2%), with 30.4% being grand multigravida and only 4.3% primigravida. The majority of pregnancies were singleton (95.7%). For neonates, the mean birthweight was 2.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7 kg, with 30% having low birthweight and 70% normal birthweight. Cesarean section was the most common mode of delivery (65.2%), and most deliveries occurred in hospital (78.3%). Among women who delivered by cesarean section, 20% underwent TOLAC (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\u003eDemographic and obstetric characteristics of women with uterine rupture admitted to the Republican General Teaching Hospital in Taiz City, Yemen (2023)*\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\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=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e(%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMaternal age\u003c/b\u003e (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD: 29.7\u0026thinsp;\u0026plusmn;\u0026thinsp;5.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eResidence\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\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=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(65.2)\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=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(34.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003egestational age at delivery\u003c/b\u003e (weeks)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003e38.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD: 38.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreterm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(17.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTerm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(78.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost-term\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(4.3)\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\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNulliparous\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(4.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimiparous\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(21.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMultiparous\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(52.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrand multiparous\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(21.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGravidity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimigravida\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(4.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMultigravida\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(65.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrand multigravida\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(30.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMultiplicity of gestation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingleton\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(95.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMultiple\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(4.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBirthweight\u003c/b\u003e (kg)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD: 2.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(30.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNormal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(70.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHistory of abortion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\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\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(34.8)\u003c/p\u003e \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\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(65.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMode of delivery\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpontaneous vaginal birth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(34.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCesarean section\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(65.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTOLAC\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\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\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(20.0)\u003c/p\u003e \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\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(80.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePlace of delivery\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHome\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(21.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(78.3)\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\u003e* Total number of women with uterine rupture was 23; \u003cem\u003eSD\u003c/em\u003e standard deviation, \u003cem\u003eTOLAC\u003c/em\u003e trial of labor after cesarean, \u003cem\u003eANC\u003c/em\u003e antenatal care. \u003csup\u003ea\u003c/sup\u003e 3 missing cases. \u003csup\u003eb\u003c/sup\u003e Calculated for women with cesarean section.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eDeterminants of uterine rupture\u003c/h3\u003e\n\u003cp\u003eRural residence (OR\u0026thinsp;=\u0026thinsp;4, 95% CI: 1.39\u0026ndash;11.48; P\u0026thinsp;=\u0026thinsp;0.008), IPI\u0026thinsp;\u0026lt;\u0026thinsp;24 months (OR\u0026thinsp;=\u0026thinsp;5.2; 95% CI: 1.16\u0026ndash;23.08; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.030), and breech fetal malpresentation (OR\u0026thinsp;=\u0026thinsp;21.9, 95% CI: 1.13\u0026ndash;426.9; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.008) were significantly associated with uterine rupture. Conversely, there were no statistically significant associations between uterine rupture and maternal age\u0026thinsp;\u0026le;\u0026thinsp;30 years, gestational age\u0026thinsp;\u0026ge;\u0026thinsp;40 weeks, grand multiparity, grand multigravidity, multiple gestation, birthweight\u0026thinsp;\u0026ge;\u0026thinsp;3.5 kg, obstructed labor, TOLAC, previous uterine rupture or scar, augmentation of labor, or oxytocin use (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\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\u003eDemographic and obstetric determinants of uterine rupture among pregnant women admitted to the Republican General Teaching Hospital in Taiz City, Yemen (2023)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\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=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eCases\u003c/p\u003e \u003cp\u003e(\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;23)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eControls\u003c/p\u003e \u003cp\u003e(\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;47)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eOR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e(95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaternal age \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\le\\:\\)\u003c/span\u003e\u003c/span\u003e 30 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(65.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(70.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(0.28\u0026ndash;2.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.672\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRural residence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(65.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(31.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(1.39\u0026ndash;11.49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.008\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGestational age\u0026thinsp;\u0026ge;\u0026thinsp;40 weeks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(43.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(25.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(0.78\u0026ndash;6.43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.129\u003c/p\u003e \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 \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(21.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(19.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(0.34\u0026ndash;4.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.516\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrand multigravidity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(30.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(25.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(0.42\u0026ndash;3.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.665\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMultiplicity of gestation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(4.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(6.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(0.07\u0026ndash;6.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBirthweight\u0026thinsp;\u0026ge;\u0026thinsp;3.5 kg \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(19.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(6.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(0.65\u0026ndash;15.93)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.200\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eObstructed labor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(4.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(2.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(0.13\u0026ndash;35.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShort IPI (\u0026lt;\u0026thinsp;24 months)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(26.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(6.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(1.16\u0026ndash;23.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.030\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBreech fetal malpresentation \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(19.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(0.0)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e21.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(1.13\u0026ndash;426.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.008\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTOLAC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(13.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(6.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(0.41\u0026ndash;11.87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.387\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrevious uterine rupture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(4.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(2.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(0.13\u0026ndash;35.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrevious uterine scar \u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(45.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(27.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(0.76\u0026ndash;6.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.144\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAugmentation of labor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(13.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(6.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(0.41\u0026ndash;11.87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.378\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUse of oxytocin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(4.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(0.0)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(0.25\u0026ndash;161.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.329\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\u003e \u003cem\u003eIPI\u003c/em\u003e interpregnancy interval, \u003cem\u003eTOLAC\u003c/em\u003e trial of labor after cesarean. \u003csup\u003ea\u003c/sup\u003e 2 cases and 3 controls missing; \u003csup\u003eb\u003c/sup\u003e 2 cases and 2 controls missing; \u003csup\u003ec\u003c/sup\u003e 1 case missing. * Haldane-Anscombe correction was applied.\u003c/p\u003e\n\u003ch3\u003eAdverse maternal and perinatal outcomes\u003c/h3\u003e\n\u003cp\u003eMore than one-quarter of women with uterine rupture experienced severe blood loss (26.1%), 43.5% required blood transfusion, and 21.7% had bladder rupture. Postpartum hemorrhage occurred in three cases (4.3%), while 13% of women required hysterectomy. Only one woman (4.3%) died of uterine rupture, while stillbirth occurred in more than one-quarter of pregnancies complicated by uterine rupture (27.3%) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\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\u003eAdverse maternal and perinatal outcomes among pregnant women with uterine rupture admitted to the Republican General Teaching Hospital in Taiz City, Yemen (2023)*\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=\"left\" 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\u003eMaternal outcomes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSevere blood loss\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(26.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBladder rupture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(21.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostpartum hemorrhage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(13.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeed for blood transfusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(43.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeed for hysterectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(13.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaternal death\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(4.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStillbirth \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(27.3)\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\u003e*The total number of cases with uterine rupture was 23. \u003csup\u003ea\u003c/sup\u003e 1 case missing.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eTo the best of our knowledge, this study is the first to report on the incidence, determinants, and outcomes of uterine rupture in Taiz City. The incidence of uterine rupture in the city was 2.7 per 1,000 deliveries, which is substantially lower than the rates of \u0026asymp;\u0026thinsp;11 to 32 per 1,000 deliveries reported in Hajjah [\u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. It is also lower than the 0.63% (6.3 per 1,000 deliveries) reported in Sana\u0026rsquo;a and the 0.26% (1 in 323 deliveries) [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], suggesting that the burden of uterine rupture may vary considerably across Yemeni governorates. Differences in referral patterns and case capture are likely to play an important role in such differences. For instance, the hospital in Taiz serves as a major urban referral center, where women with labor complications may present earlier than those in more remote governorates. In contrast, hospitals in Hajjah predominantly serve rural catchment areas, where delays in decision-making, transportation, and access to skilled obstetric care are common, increasing the likelihood of prolonged or obstructed labor and subsequent uterine rupture [\u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCompared with several low- and middle-income hospital settings outside Yemen, the incidence in Taiz remains lower than the 8.7 per 1,000 reported from a tertiary center in Eastern Uttar Pradesh, India [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], the 6.8 per 1,000 reported from a university hospital in Eastern Ethiopia,[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] the 5.01 per 1,000 reported at Lagos University Teaching Hospital, Nigeria [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], and the 1 per 246 in Sudan [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. These higher rates are commonly interpreted as markers of delayed access to emergency obstetric care and a larger share of women arriving after mismanaged labor, obstructed labor, or unsupervised TOLAC, which are risk factors that tend to cluster in facilities receiving referrals from peripheral or under-resourced units [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. However, the incidence of uterine rupture in Taiz is somewhat comparable to rates reported from other settings. For instance, a population-based study from Nova Scotia, Canada, reported an incidence of 2.4 per 1,000 TOLAC for complete uterine rupture [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], while a hospital-based study conducted in Dar es Salaam, Tanzania, documented an incidence of 2.25 per 1,000 births [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Nevertheless, comparison of the estimated incidence rates across studies should be interpreted with caution, as reported rates depend on whether the incidence was calculated for all births or limited to women undergoing TOLAC, which may substantially affect the incidence of uterine rupture.\u003c/p\u003e \u003cp\u003eCompared to other Arab countries, the incidence of uterine rupture in the present study exceeds rates reported from hospitals in Makkah, Saudi Arabia (1 per 1,011 deliveries) [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e], Kuwait (1 per 1,851) [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e], Basra (1 per 801) and Dohuk (2 per 1,000) in Iraq [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e], and Bahrain (1 per 2,213) [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. It is to be noted that the studies in these Arab countries were conducted in stable health systems with better access to ANC and referral systems, which reduce the risk of prolonged labor and catastrophic uterine events. On the other hand, the incidence of uterine rupture in the present study is also higher than rates reported elsewhere in population-based studies or from high-resource countries. For instance, in a population-based retrospective study in Shanghai, China, the incidence of uterine rupture was 1.96 per 10,000 births [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. A lower incidence of 0.038 per 1,000 was reported among women without prior cesarean section in Norway, but a comparable rate of 2.11 per 1,000 was found for those with prior cesarean section [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Lower incidence rates per 1,000 deliveries were also reported from the United Kingdom (0.2) [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e], Lithuania (0.68) [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e], and Portugal (1.2) [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. These differences likely reflect the combined effects of strong antenatal surveillance, standardized intrapartum monitoring, strict protocols governing labor induction and TOLAC, and rapid access to emergency operative care.\u003c/p\u003e \u003cp\u003eThis study found a significant association between rural residence and uterine rupture, with women residing in rural areas being four times more likely to experience uterine rupture than their urban counterparts. This finding is consistent with that reported in Hajjah, where rural residence was associated with 2.6 times higher risk of uterine rupture, while urban residence appeared to be protective [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Similar patterns have been reported from Ethiopia, where rural residence was associated with a sixfold higher risk of uterine rupture in Oromia state [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], and living in an urban area was protective against uterine rupture in western Ethiopia [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Such differences could be largely attributed to delayed access to emergency obstetric care and inadequate intrapartum monitoring in rural areas [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], and proximity to skilled maternity services in urban areas [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Transportation delays, a lack of trained birth attendants, lower ANC utilization, and a higher frequency of home or peripheral facility deliveries may all contribute to the higher risk of obstetric complications in rural areas in conflict-affected settings like Yemen [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Moreover, insecurity, restricted movement, and fragile referral systems exacerbate these obstacles [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA short IPI of \u0026lt;\u0026thinsp;24 months was also significantly associated with uterine rupture among women in the present study, increasing its likelihood by more than fivefold. Inadequate intervals between pregnancies, particularly after cesarean delivery, can hinder the uterus's ability to heal and make it more susceptible to rupturing during the mechanical strain of late pregnancy and labor [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. In Aden, short IPI was found among 43% of women with uterine rupture, but the statistical association was not studied [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Unlike the finding of the present study, a multi-center study in the United States found that short IPI was associated with more than twofold higher risk of uterine rupture among women with a prior cesarean delivery attempting TOLAC [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Another US population-based cohort (2011\u0026ndash;2021) also revealed that the risk of uterine rupture decreased as IPI increased to about 21 months, while shorter intervals were associated with a higher rupture risk [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. Similarly, in a Canadian cohort study conducted in Quebec, women with an IPI shorter than 18 months following a previous cesarean delivery had a threefold higher risk of uterine rupture compared with those whose interval was 24 months or longer [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. In a Chinese retrospective cohort, the time between a previous cesarean delivery and the current pregnancy was significantly shorter for women with uterine rupture than for those without [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBreech fetal malpresentation showed a significant association with uterine rupture in this study, which is consistent with that reported elsewhere [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. The risk of prolonged or obstructed labor is known to be increased by malpresentation, especially when the delivery takes place outside of facilities with adequate equipment or without prompt surgical intervention [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. In this study, neither grand multiparity nor grand multigravidity was a significant determinant of uterine rupture. This finding contradicts the mechanistic connection between multiparity and a higher risk of pelvic floor and uterine dysfunction because repeated birth injuries lead to cumulative pelvic floor muscle degeneration and dysfunction [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. In addition, no statistically significant associations were observed between uterine rupture and maternal age, late gestational age, multiple gestation, birthweight\u0026thinsp;\u0026ge;\u0026thinsp;3.5 kg, obstructed labor, TOLAC, previous uterine rupture or scar, augmentation of labor, or oxytocin use. Although many of these factors have been reported as significant determinants of uterine rupture in Yemen and elsewhere [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e], they did not reach statistical significance in the present study, which could be attributed to the relatively small sample size.\u003c/p\u003e \u003cp\u003eUterine rupture in this cohort was associated with substantial maternal morbidity. Nearly a quarter of women with uterine rupture experienced severe blood loss, and one-half of affected women required blood transfusion. Similarly, a large proportion of women with uterine rupture needed blood transfusion in Hajjah (88%) and Sana\u0026rsquo;a (57.1%) [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. The high frequency of the need for blood transfusion is consistent with that reported elsewhere [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. A well-known consequence of complete uterine rupture is extensive blood loss, which contributes substantially to maternal morbidity and mortality [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Bladder rupture was another important morbidity among women in this study, affecting more than one-fifth of cases and reflecting the extensive tissue damage and hemorrhage typically accompanying complete rupture. However, lower rates of 5.4\u0026ndash;8.3% of women with uterine rupture experienced bladder rupture in Hajjah [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The anatomical and embryological proximity of the bladder and uterus makes bladder injury a significant risk during uterine rupture and surgical procedures [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e]. Bladder injury substantially increases the risk of postoperative sepsis, peritonitis, prolonged catheterization, vesicovaginal fistula formation, and longer hospital stays [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e], which further exacerbates the burden on affected women.\u003c/p\u003e \u003cp\u003eAlthough hysterectomy was required in a minority of cases (13%) in the present study, the procedure remains a life-saving intervention in settings where conservative repair is not feasible or delayed [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The relatively lower frequency of hysterectomy observed in the present study may reflect a higher proportion of repairable ruptures or improved surgical decision-making at the referral hospital level. This rate is notably lower than that reported from Hajjah City, where hysterectomy was performed in 45.4% to 55% of uterine rupture cases [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The substantially higher rates in Hajjah have been attributed to late presentation, prolonged obstructed labor, deliveries occurring outside health facilities, and limited access to timely operative care, all of which increase the likelihood of extensive uterine damage necessitating hysterectomy [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. A higher rate of hysterectomy was reported among women with uterine rupture in Sudan (80%) [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], but comparable rates were reported from Saudi Arabia (17.4%)[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] and India (16.1%) [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. These findings suggest that the need for hysterectomy after uterine rupture is highly context-dependent. While uterine preservation is desirable, particularly in young women with future fertility intentions, hysterectomy remains an essential component of emergency obstetric care [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn this study, uterine rupture led to the death of only one woman (4.3% case fatality), which is lower than the 7.2% maternal mortality reported from Hajjah [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], possibly indicating some improvement in surgical response and postoperative care at the referral level. In addition, it is lower than the rates reported from Iraq (5%) [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e], Egypt (6.5%) [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], and Ethiopia (6.6\u0026ndash;7.8%) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, maternal mortality in our study should be interpreted with caution due to the low number of cases, where a difference of one or two deaths can markedly shift the percentage. In the present study, perinatal mortality is high, with more than one-quarter of pregnancies complicated by uterine rupture resulting in stillbirth. This rate is lower than the perinatal deaths reported from Hajjah (81.7\u0026ndash;91.8%) [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] and Sana\u0026rsquo;a (54.3%) [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. This finding is also consistent with previous reports from low-resource settings where delays in diagnosis and intervention are common [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study fills in an important knowledge gap by providing evidence on uterine rupture in a conflict-affected city. However, certain limitations should be considered. Because the retrospective design depends on accuracy and completeness of records, certain variables may have missing or misclassified data. Important factors, such as delays in care-seeking, transportation time, and intrapartum monitoring quality, could not be fully assessed. On the other hand, the single-center setting limits the generalizability of the results to other hospitals or regions in Yemen, particularly non-referral centers where patterns of care and delays may differ. Nevertheless, the study hospital serves as a major referral center for Taiz city and surrounding districts, enabling the collection of a broad range of obstetric complications from both urban and rural populations. The relatively small number of uterine rupture cases also reduces statistical power and may explain why several known risk factors did not reach statistical significance. To address this, an appropriate case-control ratio was used to improve analytical efficiency, and effect sizes are reported with CIs to show the magnitude and direction of associations rather than reliance only on statistical significance.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eUterine rupture in Taiz City is a major obstetric complication with an incidence that is higher than estimates from the region and worldwide. It is linked to substantial maternal and perinatal consequences, including severe hemorrhage, the need for blood transfusion, bladder injury, hysterectomy, and stillbirth. Key determinants of uterine rupture include rural residence, short IPI and breech fetal malpresentation, highlighting the importance of early access to obstetric care, adequate birth spacing, and early detection of malpresentation. To reduce the burden of uterine rupture, it is essential to strengthen ANC coverage, promote optimal IPIs, improve referral systems, and ensure access to emergency obstetric services. Multicenter studies are recommended to guide evidence-based interventions and improve maternal and perinatal outcomes in similar conflict-affected settings.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eCS\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCesarean section\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eHDI\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHuman Development Index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eIPI\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInterpregnancy interval\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eLMICs\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLow- and middle-income countries\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eMRI\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMagnetic resonance imaging\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eOR\u003c/b\u003e\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\u003cb\u003ePPH\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePostpartum hemorrhage\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eSD\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStandard deviation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eSPSS\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStatistical Package for the Social Sciences\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eTOLAC\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTrial of labor after cesarean delivery\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eWHO\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWorld Health Organization\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank the Republican General Teaching Hospital in Taiz for permission to collect data and cooperation. They also thank Rashad Abdul-Ghani, Faculty of Medicine and Health Sciences, Sana\u0026rsquo;a University, for his help in interpreting study findings and drafting the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Declaration of Helsinki guidelines were followed in this study, and ethical approval was granted by the Research Ethics Committee (REC) of the Faculty of Medicine and Health Sciences, University of Science and Technology, Sana\u0026rsquo;a, Yemen (Ethical clearance No.: 1447/0084/UREC/UST). However, informed consent was not required because of the retrospective nature of the study and was waived by the REC of the University of Science and Technology. Strict confidentiality and anonymity were maintained when handling data.\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 no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHMH, MSMS, and MA conceptualized the idea, designed the study, analyzed data and prepared the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAstatikie, G., Limenih M.A., Kebede M. Maternal and fetal outcomes of uterine rupture and factors associated with maternal death secondary to uterine rupture\u003cstrong\u003e.\u003c/strong\u003e BMC Pregnancy Childbirth. 2017;17(1):117. doi: 10.1186/s12884-017-1302-z\u003c/li\u003e\n \u003cli\u003eMotomura, K., Ganchimeg T., Nagata C., Ota E., Vogel J.P., Betran A.P., et al. Incidence and outcomes of uterine rupture among women with prior caesarean section: WHO Multicountry Survey on Maternal and Newborn Health\u003cstrong\u003e.\u003c/strong\u003e Sci Rep. 2017;744093. doi: 10.1038/srep44093\u003c/li\u003e\n \u003cli\u003eAbbas, A.M., M A.S., M M.F. Maternal and perinatal outcomes of uterine rupture in a tertiary care hospital: a cross-sectional study\u003cstrong\u003e.\u003c/strong\u003e J Matern Fetal Neonatal Med. 2019;32(20):3352-3356. doi: 10.1080/14767058.2018.1463369\u003c/li\u003e\n \u003cli\u003eHerrera, F.A., Hassanein A.H., Bansal V. Atraumatic spontaneous rupture of the non-gravid uterus\u003cstrong\u003e.\u003c/strong\u003e J Emerg Trauma Shock. 2011;4(3):439. doi: 10.4103/0974-2700.83896\u003c/li\u003e\n \u003cli\u003eGu\u0026egrave;ye, M., Mbaye M., Ndiaye-Gu\u0026egrave;ye M.D., Kane-Gu\u0026egrave;ye S.M., Diouf A.A., Niang M.M., et al. Spontaneous uterine rupture of an unscarred uterus before labour\u003cstrong\u003e.\u003c/strong\u003e Case Rep Obstet Gynecol. 2012;2012598356. doi: 10.1155/2012/598356\u003c/li\u003e\n \u003cli\u003eFarhat, I.B., Zoukar O., Medemagh M., Slamia W.B., Mnajja A., Bergaoui H., et al. [Retrospective study of 60 cases of uterine rupture at the Maternity Center of Monastir, Tunisia]\u003cstrong\u003e.\u003c/strong\u003e Pan Afr Med J. 2024;4783. doi: 10.11604/pamj.2024.47.83.42188\u003c/li\u003e\n \u003cli\u003eNie, Q., Luo S., Chen B., Wang L., He F. Risk factors and outcomes of uterine rupture before onset of labor vs. during labor: a multicenter study\u003cstrong\u003e.\u003c/strong\u003e J Perinat Med. 2025;53(4):503-508. doi: 10.1515/jpm-2024-0309\u003c/li\u003e\n \u003cli\u003eLeung, A.S., Farmer R.M., Leung E.K., Medearis A.L., Paul R.H. Risk factors associated with uterine rupture during trial of labor after cesarean delivery: a case-control study\u003cstrong\u003e.\u003c/strong\u003e Am J Obstet Gynecol. 1993;168(5):1358-63. doi: 10.1016/s0002-9378(11)90765-0\u003c/li\u003e\n \u003cli\u003eRonel, D., Wiznitzer A., Sergienko R., Zlotnik A., Sheiner E. Trends, risk factors and pregnancy outcome in women with uterine rupture\u003cstrong\u003e.\u003c/strong\u003e Arch Gynecol Obstet. 2012;285(2):317-21. doi: 10.1007/s00404-011-1977-8\u003c/li\u003e\n \u003cli\u003eDesta, M., Amha H., Anteneh Bishaw K., Adane F., Assemie M.A., Kibret G.D., et al. Prevalence and predictors of uterine rupture among Ethiopian women: A systematic review and meta-analysis\u003cstrong\u003e.\u003c/strong\u003e PLoS One. 2020;15(11):e0240675. doi: 10.1371/journal.pone.0240675\u003c/li\u003e\n \u003cli\u003eAl-Zirqi, I., Daltveit A.K., Fors\u0026eacute;n L., Stray-Pedersen B., Vangen S. Risk factors for complete uterine rupture\u003cstrong\u003e.\u003c/strong\u003e Am J Obstet Gynecol. 2017;216(2):165.e1-165.e8. doi: 10.1016/j.ajog.2016.10.017\u003c/li\u003e\n \u003cli\u003eAnonymous. ACOG Practice Bulletin No. 205: Vaginal Birth After Cesarean Delivery\u003cstrong\u003e.\u003c/strong\u003e Obstet Gynecol. 2019;133(2):e110-e127. doi: 10.1097/aog.0000000000003078\u003c/li\u003e\n \u003cli\u003eBedi, D.G., Salmon A., Winsett M.Z., Fagan C.J., Kumar R. Ruptured uterus: sonographic diagnosis\u003cstrong\u003e.\u003c/strong\u003e J Clin Ultrasound. 1986;14(7):529-33. doi: 10.1002/jcu.1870140706\u003c/li\u003e\n \u003cli\u003eOgbole, G.I., Ogunseyinde O.A., Akinwuntan A.L. Intrapartum rupture of the uterus diagnosed by ultrasound\u003cstrong\u003e.\u003c/strong\u003e Afr Health Sci. 2008;8(1):57-9. doi:\u003c/li\u003e\n \u003cli\u003ePonder, K.L., Won R., Clymer L. Uterine rupture on MRI presenting as nonspecific abdominal pain in a primigravid patient with 28-week twins resulting in normal neurodevelopmental outcomes at age two\u003cstrong\u003e.\u003c/strong\u003e Case Rep Obstet Gynecol. 2019;20192890104. doi: 10.1155/2019/2890104\u003c/li\u003e\n \u003cli\u003eAboughalia, H., Basavalingu D., Revzin M.V., Sienas L.E., Katz D.S., Moshiri M. Imaging evaluation of uterine perforation and rupture\u003cstrong\u003e.\u003c/strong\u003e Abdom Radiol (NY). 2021;46(10):4946-4966. doi: 10.1007/s00261-021-03171-z\u003c/li\u003e\n \u003cli\u003eRevicky, V., Muralidhar A., Mukhopadhyay S., Mahmood T. A case series of uterine rupture: lessons to be learned for future clinical practice\u003cstrong\u003e.\u003c/strong\u003e J Obstet Gynaecol India. 2012;62(6):665-73. doi: 10.1007/s13224-012-0328-4\u003c/li\u003e\n \u003cli\u003eSugai, S., Sasabuchi Y., Yasunaga H., Isogai T., Yoshihara K., Nishijima K. In-hospital outcomes of repair and hysterectomy for uterine rupture: A nationwide observational study\u003cstrong\u003e.\u003c/strong\u003e Eur J Obstet Gynecol Reprod Biol. 2024;302196-200. doi: 10.1016/j.ejogrb.2024.09.010\u003c/li\u003e\n \u003cli\u003eFrank, Z.C., Caughey A.B. Pregnancy in women with a history of uterine rupture\u003cstrong\u003e.\u003c/strong\u003e Obstet Gynecol Surv. 2018;73(12):703-708. doi: 10.1097/ogx.0000000000000624\u003c/li\u003e\n \u003cli\u003eDeshmukh, U., Denoble A.E., Son M. Trial of labor after cesarean, vaginal birth after cesarean, and the risk of uterine rupture: an expert review\u003cstrong\u003e.\u003c/strong\u003e Am J Obstet Gynecol. 2024;230(3s):S783-s803. doi: 10.1016/j.ajog.2022.10.030\u003c/li\u003e\n \u003cli\u003eWorld Health Organization. \u003cem\u003eTrends in maternal mortality 2000 to 2023: estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division.\u003c/em\u003e Geneva: WHO; 2025.\u003c/li\u003e\n \u003cli\u003eDiab, A.E. Uterine ruptures in Yemen\u003cstrong\u003e.\u003c/strong\u003e Saudi Med J. 2005;26(2):264-9. doi:\u003c/li\u003e\n \u003cli\u003eAl-Rukeimi, A.A., Al-Haddad A., Ali A.A., Adam I. High rate of uterine rupture in a conflict setting of Hajjah, Yemen\u003cstrong\u003e.\u003c/strong\u003e J Obstet Gynaecol. 2017;37(8):1106-1107. doi: 10.1080/01443615.2017.1324412\u003c/li\u003e\n \u003cli\u003eAl Rukeimi, A.A., Al Shaibani E.M., Al Shamahy H.A., Al Hadad A.M., Al Khorasani H.A., Dainamah S.M.N. Uterine rupture and associated factors during labor amongst women delivered in Saudi Hajjah Hospital in Hajjah City north west Yemen\u003cstrong\u003e.\u003c/strong\u003e WJ Gynecol Women\u0026rsquo;s Health. 2018;1(2):1-5. doi: 10.33552/WJGWH.2018.01.000508\u003c/li\u003e\n \u003cli\u003eDhaifalah, I., Santavy J., Fingerova H. Uterine rupture during pregnancy and delivery among women attending the Al-Tthawra Hospital in Sana\u0026apos;a City Yemen Republic\u003cstrong\u003e.\u003c/strong\u003e Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2006;150(2):279-83. doi: 10.5507/bp.2006.042\u003c/li\u003e\n \u003cli\u003eBasorra, H.A., Al.kaaky N.S., Abdulla E.M., Aman F.S. Uterine rupture: A five year review at Al-sadaqa teaching hospital, Aden\u003cstrong\u003e.\u003c/strong\u003e Univ Aden J Nat Appl Sci. 2017;21(2):379-387. doi: 10.47372/uajnas.2017.n2.a17\u003c/li\u003e\n \u003cli\u003ePipal, V.R., Singh R.K., Singh A., Singh P.B., Singh N., Singh A. Incidence and predictors of uterine rupture with maternal and perinatal outcome: a cross-sectional study\u003cstrong\u003e.\u003c/strong\u003e Int J MCH AIDS. 2025;14e020. doi: 10.25259/ijma_28_2025\u003c/li\u003e\n \u003cli\u003eAbebe, F., Eticha T.G., Belis B., Tura A.K. Incidence and maternal-perinatal outcomes of uterine rupture in a university hospital in Eastern Ethiopia: a retrospective study\u003cstrong\u003e.\u003c/strong\u003e Ethiop J Reprod Health. 2025;17(2):26-34. doi: 10.69614/ejrh.v17i2.898\u003c/li\u003e\n \u003cli\u003eOla, E.R., Olamijulo J.A. Rupture of the uterus at the Lagos University Teaching Hospital, Lagos, Nigeria\u003cstrong\u003e.\u003c/strong\u003e West Afr J Med. 1998;17(3):188-93. doi:\u003c/li\u003e\n \u003cli\u003eAhmed, S.M., Daffalla S.E. Incidence of uterine rupture in a Teaching Hospital, Sudan\u003cstrong\u003e.\u003c/strong\u003e Saudi Med J. 2001;22(9):757-61. doi:\u003c/li\u003e\n \u003cli\u003eKieser, K.E., Baskett T.F. A 10-year population-based study of uterine rupture\u003cstrong\u003e.\u003c/strong\u003e Obstet Gynecol. 2002;100(4):749-53. doi: 10.1016/s0029-7844(02)02161-0\u003c/li\u003e\n \u003cli\u003eKidantou, H.L., Mwampagatwa I., Van Roosmalen J. Uterine rupture: a retrospective analysis of causes, complications and management outcomes at Muhimbili National Hospital in Dar es Salaam, Tanzania\u003cstrong\u003e.\u003c/strong\u003e Tanzan J Health Res. 2012;14(3):220-5. doi:\u003c/li\u003e\n \u003cli\u003eRouzi, A.A., Hawaswi A.A., Aboalazm M., Hassanain F., Sindi O. Uterine rupture incidence, risk factors, and outcome\u003cstrong\u003e.\u003c/strong\u003e Saudi Med J. 2003;24(1):37-9. doi:\u003c/li\u003e\n \u003cli\u003eAl Salem, M., Makhseed M., Ahmed M., Gupta M. Rupture of the gravid uterus: experience of the maternity hospital, Kuwait\u003cstrong\u003e.\u003c/strong\u003e Med Princ Pract. 2000;9(2):97-105. doi:\u003c/li\u003e\n \u003cli\u003eAl-Rubaei, S. A 10 years review of rupture pregnant uterus in Basra maternity and child hospital\u003cstrong\u003e.\u003c/strong\u003e Al-Qadisiyah Med J. 2011;7(11):9-20. doi: 10.28922/qmj.2011.7.11.9-20\u003c/li\u003e\n \u003cli\u003eYalda, M.A., Munib A. Uterine rupture in Dohuk, Iraq\u003cstrong\u003e.\u003c/strong\u003e East Mediterr Health J. 2009;15(5):1272-7. doi:\u003c/li\u003e\n \u003cli\u003eAl-Jufairi, Z.A., Sandhu A.K., Al-Durazi K.A. Risk factors of uterine rupture\u003cstrong\u003e.\u003c/strong\u003e Saudi Med J. 2001;22(8):702-4. doi:\u003c/li\u003e\n \u003cli\u003eWan, S., Yang M., Pei J., Zhao X., Zhou C., Wu Y., et al. Pregnancy outcomes and associated factors for uterine rupture: an 8\u0026thinsp;years population-based retrospective study\u003cstrong\u003e.\u003c/strong\u003e BMC Pregnancy Childbirth. 2022;22(1):91. doi: 10.1186/s12884-022-04415-6\u003c/li\u003e\n \u003cli\u003eFitzpatrick, K.E., Kurinczuk J.J., Alfirevic Z., Spark P., Brocklehurst P., Knight M. Uterine rupture by intended mode of delivery in the UK: a national case-control study\u003cstrong\u003e.\u003c/strong\u003e PLoS Med. 2012;9(3):e1001184. doi: 10.1371/journal.pmed.1001184\u003c/li\u003e\n \u003cli\u003eSavukyne, E., Bykovaite-Stankeviciene R., Machtejeviene E., Nadisauskiene R., Maciuleviciene R. Symptomatic uterine rupture: a fifteen year review\u003cstrong\u003e.\u003c/strong\u003e Medicina (Kaunas). 2020;56(11). doi: 10.3390/medicina56110574\u003c/li\u003e\n \u003cli\u003eDe Pinho, A., Martins Dos Santos F., Carmo O., Bernardes J., Reynolds A. Uterine rupture in pregnancy over 5\u0026thinsp;years: A retrospective descriptive study\u003cstrong\u003e.\u003c/strong\u003e Womens Health (Lond). 2025;2117455057251399891. doi: 10.1177/17455057251399891\u003c/li\u003e\n \u003cli\u003eTesema, O., Tilahun T., Kejela G. Determinants of uterine rupture at public hospitals of western Ethiopia: A case-control study\u003cstrong\u003e.\u003c/strong\u003e SAGE Open Med. 2022;1020503121221092643. doi: 10.1177/20503121221092643\u003c/li\u003e\n \u003cli\u003eTappis, H., Elaraby S., Elnakib S., AlShawafi N.A.A., BaSaleem H., Al-Gawfi I.A.S., et al. Reproductive, maternal, newborn and child health service delivery during conflict in Yemen: a case study\u003cstrong\u003e.\u003c/strong\u003e Confl Health. 2020;1430. doi: 10.1186/s13031-020-00269-x\u003c/li\u003e\n \u003cli\u003eM\u0026eacute;decins Sans Fronti\u0026egrave;res. Complicated delivery: The Yemeni mothers and children dying without medical care 2019. Available at: [https://www.msf.org/complicated-delivery-yemeni-mothers-and-children-dying-without-medical-care?utm_source=chatgpt.com]\u003c/li\u003e\n \u003cli\u003eZhang, L., Li T., Zhang P., Li C. 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\u003cstrong\u003e.\u003c/strong\u003e Int J Womens Health. 2025;172421-2431. doi: 10.2147/ijwh.s530520\u003c/li\u003e\n \u003cli\u003eStamilio, D.M., DeFranco E., Par\u0026eacute; E., Odibo A.O., Peipert J.F., Allsworth J.E., et al. Short interpregnancy interval: risk of uterine rupture and complications of vaginal birth after cesarean delivery\u003cstrong\u003e.\u003c/strong\u003e Obstet Gynecol. 2007;110(5):1075-82. doi: 10.1097/01.aog.0000286759.49895.46\u003c/li\u003e\n \u003cli\u003eAdily, P., Bettison T., Lauer M., Narayan R., Mackie A., Phipps H., et al. Inter-pregnancy interval and uterine rupture during a trial of labour after one previous caesarean delivery and no previous vaginal births: a retrospective population-based cohort study\u003cstrong\u003e.\u003c/strong\u003e EClinicalMedicine. 2025;80103071. doi: 10.1016/j.eclinm.2025.103071\u003c/li\u003e\n \u003cli\u003eBujold, E., Gauthier R.J. Risk of uterine rupture associated with an interdelivery interval between 18 and 24 months\u003cstrong\u003e.\u003c/strong\u003e Obstet Gynecol. 2010;115(5):1003-1006. doi: 10.1097/AOG.0b013e3181d992fb\u003c/li\u003e\n \u003cli\u003eGirma, T., Gezimu W., Demeke A. Prevalence, causes, and factors associated with obstructed labour among mothers who gave birth at public health facilities in Mojo Town, Central Ethiopia, 2019: a cross-sectional study\u003cstrong\u003e.\u003c/strong\u003e PLoS One. 2022;17(9):e0275170. doi: 10.1371/journal.pone.0275170\u003c/li\u003e\n \u003cli\u003eKhan, S., Anbreen F. Obstetric outcomes of fetal malpresentation and malpositions\u003cstrong\u003e.\u003c/strong\u003e Indus J Biosci Res. 2025;3(2):19-24. doi: 10.70749/ijbr.v3i2.548\u003c/li\u003e\n \u003cli\u003eDuran, P., Zelus E.I., Burnett L.A., Christman K.L., Alperin M. Repeated birth injuries lead to long-term pelvic floor muscle dysfunction in the preclinical rat model\u003cstrong\u003e.\u003c/strong\u003e Am J Obstet Gynecol. 2025;232(2):198.e1-198.e23. doi: 10.1016/j.ajog.2024.08.036\u003c/li\u003e\n \u003cli\u003eElkousy, M.A., Sammel M., Stevens E., Peipert J.F., Macones G. The effect of birth weight on vaginal birth after cesarean delivery success rates\u003cstrong\u003e.\u003c/strong\u003e Am J Obstet Gynecol. 2003;188(3):824-30. doi: 10.1067/mob.2003.186\u003c/li\u003e\n \u003cli\u003eZhang, H., Liu H., Luo S., Gu W. Oxytocin use in trial of labor after cesarean and its relationship with risk of uterine rupture in women with one previous cesarean section: a meta-analysis of observational studies\u003cstrong\u003e.\u003c/strong\u003e BMC Pregnancy Childbirth. 2021;21(1):11. doi: 10.1186/s12884-020-03440-7\u003c/li\u003e\n \u003cli\u003eHo, S.Y., Chang S.D., Liang C.C. Simultaneous uterine and urinary bladder rupture in an otherwise successful vaginal birth after cesarean delivery\u003cstrong\u003e.\u003c/strong\u003e J Chin Med Assoc. 2010;73(12):655-9. doi: 10.1016/s1726-4901(10)70143-x\u003c/li\u003e\n \u003cli\u003eYang, B. Bladder rupture associated with uterine rupture at delivery\u003cstrong\u003e.\u003c/strong\u003e Int Urogynecol J. 2011;22(5):625-7. doi: 10.1007/s00192-010-1318-7\u003c/li\u003e\n \u003cli\u003eLee, J.S., Choe J.H., Lee H.S., Seo J.T. Urologic complications following obstetric and gynecologic surgery\u003cstrong\u003e.\u003c/strong\u003e Korean J Urol. 2012;53(11):795-9. doi: 10.4111/kju.2012.53.11.795\u003c/li\u003e\n \u003cli\u003eIbrahim, N., Spence A.R., Czuzoj-Shulman N., Abenhaim H.A. Incidence and risk factors of bladder injury during cesarean delivery: a cohort study\u003cstrong\u003e.\u003c/strong\u003e Arch Gynecol Obstet. 2023;307(2):401-408. doi: 10.1007/s00404-022-06447-x\u003c/li\u003e\n \u003cli\u003eMeriwether, K.V., Antosh D.D., Olivera C.K., Kim-Fine S., Balk E.M., Murphy M., et al. Uterine preservation vs hysterectomy in pelvic organ prolapse surgery: a systematic review with meta-analysis and clinical practice guidelines\u003cstrong\u003e.\u003c/strong\u003e Am J Obstet Gynecol. 2018;219(2):129-146.e2. doi: 10.1016/j.ajog.2018.01.018\u003c/li\u003e\n\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, pregnant women, incidence, determinants, outcomes, Yemen","lastPublishedDoi":"10.21203/rs.3.rs-8681256/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8681256/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eUterine rupture is An uncommon but serious obstetric emergency, particularly in low-resource and conflict-affected settings. However, data on its burden in Yemen is limited. Therefore, this study assessed the incidence, determinants and outcomes of uterine rupture among women admitted to a tertiary care hospital in Taiz City, southwest of the country.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e A retrospective surveillance study with an integrated case-control analysis was conducted at the Republican General Teaching Hospital in Taiz during 2023. All women with uterine rupture during the study period were included as cases, while controls were randomly selected from those delivered without uterine rupture. Demographic, obstetric, intrapartum and outcome data were extracted from medical records. Associations between uterine rupture and its determinants were assessed at a significance level of \u0026lt;0.05.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Out of 8,550 deliveries, 23 cases of uterine rupture were identified, resulting in an incidence of 2.7 per 1,000 deliveries. Most ruptures were complete (82.6%). Rural residence (OR = 4; 95% CI: 1.39–11.49; \u003cem\u003eP\u003c/em\u003e= 0.008), interpregnancy interval (IPI) \u0026lt;24 months (OR = 5.2; 95% CI: 1.16–23.08; \u003cem\u003eP\u003c/em\u003e = 0.030), and breech fetal malpresentation (OR = 21.9; 95% CI: 1.13–426.9; \u003cem\u003eP\u003c/em\u003e = 0.008) were significantly associated with uterine rupture. Substantial maternal morbidity was observed, including bladder rupture (21.7%), severe blood loss (26.1%), and need for transfusion (43.5%). Hysterectomy was performed in 13% of cases. One woman died, whereas stillbirths occurred in 27.3% of cases.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e The incidence of uterine rupture in Taiz City exceeds regional and global estimates and is associated with substantial maternal and perinatal morbidity, including bladder rupture, severe blood loss, need for blood transfusion, hysterectomy, and stillbirth. Rural residence, short IPIs, and breech presentation are key determinants, showing inequities in maternal care and the need to strengthen antenatal services, referral systems, and antenatal care services.\u003c/p\u003e","manuscriptTitle":"Incidence, determinants and outcomes of uterine rupture among women at a referral hospital in Taiz City, Yemen: a retrospective analysis from a conflict-affected setting","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-11 08:36:18","doi":"10.21203/rs.3.rs-8681256/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"22586439872205002631830748339150715268","date":"2026-05-17T11:18:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"228276382073676875292032781289694742282","date":"2026-05-11T14:26:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"228276382073676875292032781289694742282","date":"2026-03-06T23:52:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"198296549760630099198487291010555003188","date":"2026-02-08T23:44:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"22586439872205002631830748339150715268","date":"2026-02-07T09:51:12+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-06T15:32:56+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-27T18:54:16+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-24T11:31:42+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-24T11:31:09+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2026-01-23T16:29:03+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":"6d74f300-dea1-41a6-8e19-2b3f816d0c73","owner":[],"postedDate":"February 11th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"22586439872205002631830748339150715268","date":"2026-05-17T11:18:14+00:00","index":40,"fulltext":""},{"type":"reviewerAgreed","content":"228276382073676875292032781289694742282","date":"2026-05-11T14:26:00+00:00","index":39,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-11T08:36:18+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-11 08:36:18","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8681256","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8681256","identity":"rs-8681256","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}