Obstructed labor results from failure to descent of presenting part in the birth canal due to mechanical reasons despite adequate uterine contraction. It is a life threatening obstetric complication with significant maternal and perinatal morbidity [1,2]. The commonest cause of obstructed labor (OL) is craniopelvic disproportion (CPD). This could arise as a result of reduced pelvic dimension, it occurs in laboring mother with childhood malnutrition, infection, poliomyelitis, deformity, sickle cell disease ,or in teenagers increased diameter of the presenting part ,such as malposition and malpresention. These include brow presentation, compound presentation, occipto-posterior, and mento-posterior in face presentation and congenital malformation (hydrocephalus, fetal ascites, and double monsters). Other causes include fibroid or ovarian tumor impacted in the pelvis below the presenting part, cervical and vaginal stenosis, ridged perineum in primigavida, and locked twins [3,4].

Obstructed labor has impact on the fetus by causing intracranial hemorrhage due to severe molding of the head leading to tentorial tear or traumatic delivery, caput, fetal distress, and acidosis due to fetal hypoxia and maternal acidosis and neonatal sepsis. If the duration of obstructed labor is prolonged without intervention, the fetus dies because of anoxia by excessive pressure on the placenta and umbilical cord. The dead fetus becomes softened by decay and may trigger the onset of coagulation failure and prolonged uterine contraction, end with rupture of uterus these leads to maternal hemorrhage and then to hemorrhagic shock, peritonitis, and septic shock, and death. Mothers may improve with longterm complications, like fistula, vaginal atresia, cervical stenosis, and secondary amenorrhea (infertility) following hysterectomy due to rupture or Sheehan’s syndrome [3].

Laboring mother presented with history of prolonged first stage of labor, early rupture of fetal membrane, and if labor delay with obstruction they present with secondary signs and complications such as, derangement of vital sign, exhaustion, metabolic acidosis, genital sepsis, and injury to the genital tract. Principle of management of obstructed labor is correcting fluid, control infection, resting bladder and immediate relief of obstruction. Cesarean section followed by operative vaginal deliveries in malposition of fetal head in alive fetus and destructive deliveries in dead fetus were options of operative management [2-8].

Globally at least 585,000 women die each year by complication of pregnancy and childbirth. More than 70% of all maternal death is due to five major complications: hemorrhage, infection, unsafe abortion, hypertensive disorders of pregnancy, and obstructed labor [5,6]. Among these etiologies, obstructed labor is one of the most common causes of maternal illness and death in sub-Saharan Africa and Southeast Asia. Worldwide, obstructed labor occurs in an estimated 5 % of pregnancies and accounts for an estimated 8% of maternal deaths. It is an indicator of inadequacy and poor quality of obstetric care and immediate causes of maternal and prenatal morbidity and mortality due to uterine rupture, complications of cesarean deliveries, postpartum hemorrhage, anesthesia complications, puerperal sepsis, asphyxia, and brain damage [7,8].

Maternal and perinatal mortality and morbidity associated with obstructed labor are almost totally prevented in developed countries because of improved nutritional status, wide health coverage, adequate transportation and communication system, availability of trained health personnel, optimal antenatal and intrapartum care, and other related factors [7]. Ethiopia has estimated maternal mortality ratio (MMR) of 470 per 100,000 live births in 2010, equates with 14,000 maternal deaths per year. Obstructed labor accounts for 22% of maternal deaths in Ethiopia. It is also associated with high perinatal morbidity and mortality occurring around the time of birth [9,10]. The fifth millennium development goal (MDG 5) targeted to reduce maternal mortality ration (MMR) by three quarter by 2015. Despite the fact that many countries of the world signed millennium declaration, progress report state that maternal mortality remained unacceptably high across developing world. Moreover, with a few notable exceptions, little progress has been reported in global decline of maternal mortality over the past decade [11,12].

Many studies concluded that obstructed labor is preventable and depends on good nutrition starting from childhood, universal coverage of antenatal care, monitoring of labor with skilled staff, pelvic assessment at 36 weeks, routine use of partograph, good referral system, and availing comprehensive obstetric care in near health institution or establishment of a mother’s waiting area [10].

In case of the study area, there is no data even though the problem is believed to be common. Therefore this study has paramount importance to fill the gap regarding the inadequacy of information about the problem, identifying specific cause of obstructed labor, scaling up evidence based intervention and measuring the progress of national implementing plan. It also helps the policy makers to plan and implement evidence-based action to reduce the problem. Therefore, this study was planned to assess prevalence of obstructed labor in Mizan-Aman general hospital. The data that obtained from this study will also assist policymakers, planners, and other collaborators in the health sector to formulate appropriate strategies and interventions to tackle the problem.

Study Area and Period

The study was conducted in Mizan-Aman general hospital, which is located in Bench Maji zone, southwest Ethiopia. Mizan-Aman town is found in 561 km from Addis Ababa in Southwest direction. The hospital has 4 wards (medical, pediatric, gynecological and obstetric and surgical) and 1 emergency, 3 outpatient departments (OPD), maternal and child health care (MCH), ART, Ophthalmology and Dentistry departments. It had 1 gynecologist and obstetrician 1 surgeon, 10 general practitioner, 10 BSc nurses, 17 Clinical nurses, 10 midwives and 50 other staff workers. The hospital was providing services to southwest Ethiopia population for around 1,270,000 peoples. This study was conducted from July 2014 back to September 2013.

Study Design

Hospital based cross sectional record review was conducted.

Source Population

All pregnant women who were attending health care in Mizan- Aman general hospital were source population.

Study Population

All pregnant women who gave birth in Mizan-Aman general hospital after 28 weeks of gestation.

Sample Size and Sampling Method

The sample size was determined by using single population proportion formula to calculate sample size.

n= [(Zα/2)2 ×P (1-P)]/d2

Where, p= 12.2% which is prevalence of obstructed labor in Jimma Univesity specialized hospital.

Zα/2 at 95% confidence level =1.96

d (margin of error)=0.05

n= [(1.96)2 ×0.122(1-0.122)] / (0.05)2 n =165

Using population correction formula the final sample size was 151. To select these samples systematic sampling method was employed by using patient record list as sampling frame.

Inclusion and Exclusion Criteria

Inclusion Criteria: Women whose gestational age were more than 28 weeks or birth weight greater than 1000gm and delivered in Mizan- Aman general hospital.

Exclusion Criteria: Women whose gestational age was less than 28 weeks, women who was admitted post-partum and those who were discharged before delivery were excluded from study.

Data Collection Procedure

Checklist was prepared for collection of data from patient card. Then the data was collected through filling pre-tested checklist carefully.

Data Quality Control

The checklist was pretested in Mizan-Aman general hospital and close supervision was done by principal investigators and supervisors during data collection. Completeness of data was checked daily.

Data Analysis and Presentation

The data was entered in to Epidata 3.1 and transported to SPSS version 17 for data analysis. Frequencies of variables their percentages were calculated to determine prevalences.

Ethical Consideration

Ethical clearance was obtained from ethical committee of Mizan-Tepi University, college of health sciences. Permission letter was obtained from Mizan-Aman administration. The confidentiality of the patient was secured throughout the study and information regarding the identification of the patient was recorded anonymously.

Socio-demographic characteristics

In this study, the mean age of the women during the time of delivery was 26.2 years. Nearly half (48%) of the study population were protestants. Majority (92.3%) were married, nearly two third were Bench in ethnicity. About two-third (68.2%) of the women were from rural areas. Information about the occupation and educational status of the women was not obtained due to incomplete registration at the health facility (Table 1).

Table 1: Socio-demographic characteristics of women who gave birth at Mizan-Aman general hospital, 2014.

Obstetric history

Regarding the source of referral, most of the mothers (60.92%) came to the hospital by themselves (self-referal). More than one third (39.07%) of the mothers had no ANC followup during pregnancy. Majority 88 (58.3%) of women were in Para range of 1-4 followed Para 0 (primigravida) and 16.2% were grand multipara (more than 4). The duration of labor of study population ranged from 6 to 72 hr. with mean duration of 19.5 hr. Majority (51.23%) of women were in labor for 12 to 24 hr. while 15.10% were in labor for 24 to 72 hr. (Table 2).

Table 2: Obstetric history of women delivered at Mizan-Aman general hospital, 2014.

Obstructed Labor

Among 151 women who gave birth at Mizan-Aman general hospital, 12 (7.95%) were diagnosed to have obstructed labor. The duration of obstructed labor ranged from 12 to 72 hr. with the mean duration of 35.5 hr. Majority (58.33%) of them were in labor for 24 to 72 hr. Among the cases of obstructed labor, majority (58.33%) underwent cesarean section. In this study, the common causes obstructed labor were CPD account 66.67%, followed by malpositon and malpresentation 25% and cervical stenosis 8.33%. Majority of the cases had more than one complication. The most common complication was postpartum hemorrhage (31.25%), followed by uterine rupture (25%) In most cases, the cause of obstructed labor was craniopelvic disproportion followed by malposition and malpresentation (Figure 1) (Table 3).

Figure 1: Cause of obstructed labor among women who gave birth at Mizan- Aman general hospital, 2014.

Table 3: Prevalence of obstructed labor at Mizan-Aman general hospital, 2014.

In this study, obstructed labor accounted for 7.95% of hospital deliveries, within the range reported from other countries, but more than a recent study conducted in Jimma University Specialized Hospital, Ethiopia, which was 12.2%. However, our hospital-based data may underestimate the actual incidence because only limited numbers of pregnant women deliver in the hospital in our study area, and many rural communities have limited access to health care.

In our study the maximum incidence obstructed labor (58.33%) was recorded in the age group 20-29 years which is comparable to research conducted in Jimma University Specialized Hospital, Adigrat General Hospital, Pakistan Public Sector University, Khyber Teaching Hospital, and South West Uganda. Regarding to parity and residence, most of the women who were victims of obstructed labor were primigravida (50%) and from rural area (83.33%). This finding is comparable with the study conducted in other parts. Study report from Pakistan, Jhalawar Medical College, Uganda, and Medari Teaching Hospital showed the incidence of obstructed labor was higher among primigravida and rular resident [13-15]. This high prevalence of obstructed labor among primigavida clearly indicates that early marriage remain as major problem of the country. Similarly higher incidence of obstructed labor among rural resident may be linked with the delay at reaching health facility.

Although ANC is a poor measure to prevent pregnancy and delivery complication, it could be a proper time to counsel the patient and for preparation for place of delivery. In this study, the prevalence of obstructed labor was higher among women who had no ANC follow up (75%). This is almost similar with researchs held in Jimma University Specialized Hospital and Adigrat General Hospital [15,16]. This finding reflects the importance of focusing on encouraging women to utilize heath service.

The duration of labor is the most important factor that is significantly associated with maternal and perinatal morbidity and mortality. The mean duration of labor in this study was 35.5 hr., which was shorter than than the report from Adigrat General Hospital (45.4 hr.) but longer than that of Pakistan and Jhalawar Medical College, which were 27.5 hr. and 8-12 hr. respectively.

In this study cephalo-pelvic disproportion (CPD) was the mojor cause of obstructed labor (66.67%) which was comparable to the studies conducted in Jimma University Specialized Hospital, Adigrat General Hospital, Jhalawar Medical College, and South West Uganda which were 67.6%, 64.9%, 63%, and 63.7% respectively. But, higher than the study conducted in Pakistan Public Sector University and Khyber Teaching Hospital which was 49.9% and 47.5% respectively [2,13-16]. CPD was accounted for about 83% obstructed labor in Gamble Specialized hospital, which was higher than the result of this study [17]. CPD remain a common cause of obstructed labor in countries where child hood malnutrition and early marriage is common.

Malposition and mal presentation were responsible for 25% of obstructed labor, which was consistent with study conducted in Jimma University Specialized Hospital (27.4%) and Adigrat General Hospital (21%). It was lower relative to the report from Pakistan Public Sector University, Khyber Teaching Hospital and Jhalawar Medical Collage that were 43.3%, 45.5% and 30% respectively. Malposition and mal presentation was common among multigravida, which was similar with other reports.

Fetal congenital anomaly was the least common cuase of obstructed labor (8.33%). This was nearly equivalent to research held in Khyber Teaching Hospital (7.8%) but higher than report from Jimma University Specialized hospital (3.4%) and Adigrat General Hospital (2.1%).

Moreover, we found that adverse outcome of obstructed labor such as perinatal death (41.67%), and maternal complications like post-partum hemorrhage (31.25%), uterine rupture (25%), wound dehiscence (18.75%), puerperal sepsis (18.75%) and bladder rupture (6.25%) which were consistent with other studies [2,9,15,16]. Most of our patients were rural residents, which may predispose to long distance travel to health care service and later arrival after onset of labor. Cesarean section was the main way of delivery (58.33%) followed by laparatomy for uterine rupture (33.3%) and destructive delivery (8.33%), which was consistent with study conduted in Jimma university Specialized Hospital (54.7% for Cesarean section, 32.4% for laparatomy and hysterectomy and 12.8% for destructive delivery) [14]. Fetal distress and maternal condition might be the main events to choose cesarean section.

One of the limitations of this study was the retrospective nature of the study and lack of some data due to inappropriate and/or nonrecording of certain variables. Another limitation was its small sample size. The role of care managers would be important [18]. However, this study did not include it.

This study revealed that there was high prevalence of obstructed labor although the government has been making possible effort to prevent the problem. There was also high rate of complications and low ANC follow up among women with obstructed labor. Cephalopelvic disproportion was the main causes of obstructed labor, which may indicate that childhood malnutrition and early marriage was still a problem. Post-partum hemorrhage was the most common complication faced by mothers with obstructed labor. Therefore, Ministry of health and other responsible bodies need to exert effort to increase ANC follow-up coverage, improve health facility function, and referral and transportation system.