Uterine rupture is a rip or a tear in the wall of the uterus due to pregnancy or delivery. It is one of rare obstetric complications. Systematic review done by WHO shows that the prevalence is lower in developed countries than in the less or least developed countries. It is 0.006% in developed country but may reach up to 25% for women with obstructed labor in a least developed country as per the previous review [
The prevalence of uterine rupture may vary in different health institutions in different countries. In Adigrat Zonal Hospital (Ethiopia), in Kandang Kerbau Hospital (Singapore), in Yemen, and in Niger Delta Hospital (Nigeria), its prevalence is 0.9% (1 : 110), 0.02% (1 : 6331), 0.63%, and 0.04% (1 : 2572), respectively [
The worry for uterine rupture is due to its dreadful outcomes. It carries grave risks to the mother and her baby. Even if women survive, the future reproductive potential is brought down or turned a loss forever. Majority of ruptured uteruses are traumatic [
As the prevalence is higher, its consequences are also more severe in less and least developed nations. Maternal death, fetal demise, still birth, and intrauterine fetal death are severe consequences. In Mbarara University of Science and Technology teaching hospital, case fatality rate of uterine rupture was 12% [
Obstructed labor due to cephalopelvic disproportion and malpresentation, previous cesarean section, oxytocin infusion, and grand multiparity are the major direct factors for uterine rupture. In Sana’a city, Yemen, obstructed labor was found in 83.3% and contracted pelvis was found in 19.4% of cases. Seven cases (19.5%) of uterine rupture in this study had a history of caesarean section. Fetal weight is a risk only in one case (fetal weight > 3500 g) [
The antecedent predisposing factors for uterine rupture in different hospitals were previous caesarean section, attending <4 antenatal visits, parity ≥5, and no formal education [
The purpose of this study was to estimate antecedent determinant risk factors of uterine rupture and to estimate the outcomes of uterine rupture using propensity score matching analysis. It is also useful to extrapolate the outcomes of uterine rupture for wider population using the above mentioned analysis. So this study is helpful to determine what factors affect uterine rupture and to determine the amount of loss due to uterine rupture using statistical quantification. Thus the result contributes to designing context-specific intervention mechanisms.
The general objective is to estimate bad outcomes of uterine rupture using propensity score matching analysis and to assess determinants of uterine rupture in Mizan-Tepi University teaching hospital (MTUTH) from September 2011 to August 2016 G.C.
The specific objectives are to determine determinants of uterine rupture in MTUTH from September 2011 to August 2016 G.C and to determine bad outcomes of uterine rupture using propensity score matching analysis in MTUTH from September 2011 to August 2016 G.C.
The study was conducted in the Department of Gynecology and Obstetrics in MTUTH which is located in Bench Maji zone, Southern Nations, Nationalities, and Peoples’ Region (SNNPR), Ethiopia. It is 583 kilometers off from Addis Ababa in southwest direction. This hospital was founded in 1987 G.C. It serves more than 1 million people. Now the hospital has 17 medical doctors, 4 specialists, 79 nurses, 75 support staff members, and 150 administrative staff members. The weather condition is tropical rain forest and the topographic area is full of ups and downs.
Institution-based case control study was conducted.
The source population included all mothers who delivered at MTUTH.
Cases included charts of mothers who are diagnosed with uterine rupture due to pregnancy or delivery. Controls included charts of mothers who delivered by spontaneous vaginal delivery.
Uterine rupture was defined as tearing of the uterine wall either partially or completely during pregnancy and labor, either diagnosed clinically or later confirmed at laparotomy. The cases were retrospectively collected from registers of Department of Gynecology and Obstetrics as well as from the patients’ case files at the hospital’s medical records office.
Controls were women who had spontaneous vaginal delivery (SVD). For every case nearby two women who had SVD were used as controls.
All women diagnosed with uterine rupture and selected SVD mothers were included. Those who had ruptured uterus and were managed at the peripheral hospitals and admitted to the MTU teaching hospital for the management of the complication are excluded.
The study included uterine rupture and maternal and fetal outcomes of uterine rupture as dependent variables.
The study included age of the mother, parity, residence (urban/rural), ANC, gestational age, preoperative hemoglobin, and sex of neonate as independent variables.
It describes a mother who gave birth more than five times in her life.
Data were collected by checklist adapted from maternal death surveillance technical guideline of Ethiopia [
The data was entered into Epi Info version 3.5.1. For analysis, the data is exported to STATA 14 (StataCorp, College Station, TX, USA). Any identified error was corrected with the revision of the original data using the code numbers.
Frequencies were used to check for entry errors, missed values, and outliers. Bivariate binary logistic regression was used to determine the association between different factors and the outcome variable. Variables that have
Propensity score matching analysis was applied to find out the bad consequences of uterine rupture. It controls confounders by matching in exposed and nonexposed groups by calculating propensity score of variables. The cause is unrelated to confounders if participants have the same propensity score. Therefore, the cases and controls tend to have similar distributions of measured confounders other than cause, something that we would also achieve using randomization. Causal inference of uterine rupture on bad outcomes is determined at the level of significance of
Permission was obtained from Mizan-Tepi University research and community service directorates and College of Health Sciences. Official letter was taken from MTUTH. The procedure and purposes of the study were explained to the hospital manager and to the hospital medical director. MTUTH gave permission to conduct the study. The patients’ names were not included in the checklist. After finishing the data collection, the patients’ documents were returned to card room.
The overall incidence of uterine rupture is 1.24% (121 uterine rupture cases and 9789 total deliveries in the study period). The study was performed in 121 cases of uterine rupture and 242 controls of spontaneous vaginal delivery. The data is collected from total of 363 clients’ charts. Marital status, monthly income, ethnicity, and religion are missing from the charts, so they are excluded from analysis.
Females who had favorable age groups for pregnancy (20–34) account for more than three-fourths of our samples. From females who had uterine rupture, 78.5% are in the age group of 20−34. Lowest number of uterine rupture cases is found in the age group of <20 years. Most of the clients come from semiurban areas; however, most of females with uterine rupture come from rural areas. From 363 females, 225 females are multiparous females. About two-thirds of females with uterine rupture had two to five children. More than 60% of females had ANC follow-up, but 60% of females who had uterine rupture do not have an ANC follow-up (Table
Frequency distributions of sociodemographic and obstetric factors, MTUTH, 2016.
Variables | Category | SVD | Uterine rupture | Total |
---|---|---|---|---|
Age | <20 yrs | 39 (88.6%) | 5 (11.4%) | 44 (100%) |
16.1% | 4.1% | 12.1% | ||
20–34 yrs | 183 (65.8%) | 95 (34.2%) | 278 (100%) | |
75.6% | 78.5% | 76.6% | ||
>34 yrs | 20 (48.8%) | 21 (51.2%) | 41 (100%) | |
8.3% | 17.4% | 11.3% | ||
|
||||
Residence | Urban | 27 (81.8%) | 6 (18.2%) | 33 (100%) |
11.2% | 5.0% | 9.1% | ||
Rural | 61 (48.8%) | 64 (51.2%) | 125 (100%) | |
25.2% | 52.9% | 34.4% | ||
Semiurban | 154 (75.1%) | 51 (24.9%) | 205 (100%) | |
63.6% | 42.1% | 56.5% | ||
|
||||
Parity | Nullipara | 81 (87.1%) | 12 (12.9%) | 93 (100%) |
33.5% | 9.9% | 25.6% | ||
Multipara | 143 (63.6%) | 82 (36.4%) | 225 (100%) | |
59.1% | 67.8% | 62.0% | ||
Grand multiparity | 18 (40.0%) | 27 (60.0%) | 45 (100%) | |
7.4% | 22.3% | 12.4% | ||
|
||||
ANC | No | 60 (45.1%) | 73 (54.9%) | 133 (100%) |
24.8% | 60.3% | 36.6% | ||
Yes | 182 (79.1%) | 48 (20.9%) | 230 (100%) | |
75.2% | 39.7% | 63.4% | ||
|
||||
Gestational age | Preterm | 23 (82.1%) | 5 (17.9%) | 28 (100%) |
9.5% | 4.1% | 7.7% | ||
Term | 208 (68.6%) | 95 (31.4%) | 303 (100%) | |
86.0% | 78.5% | 83.5% | ||
Postterm | 11 (34.4%) | 21 (65.6%) | 32 (100%) | |
4.5% | 17.4% | 8.8% | ||
|
||||
Duration of labor | <24 hrs | 242 (93.1%) | 18 (6.9%) | 260 (100%) |
100.0% | 14.9% | 71.6% | ||
>24 hrs | 0 (0.0%) | 103 (100%) | 103 (100%) | |
0.0% | 85.1% | 28.4% | ||
|
||||
Referral | No | 242 (93.4%) | 17 (6.6%) | 259 (100%) |
100.0% | 14.0% | 71.3% | ||
Yes | 0 (0.0%) | 104 (100%) | 104 (100%) | |
0.0% | 86.0% | 28.7% | ||
|
||||
Hemorrhage | No | 242 (98.8%) | 3 (1.2%) | 245 (100%) |
100.0% | 2.5% | 67.5% | ||
Yes | 0 (0.0%) | 118 (100%) | 118 (100%) | |
0.0% | 97.5% | 32.5% | ||
|
||||
Preoperative hemoglobin | >7 mg/dL | 234 (80.4%) | 57 (19.6%) | 291 (100%) |
96.7% | 47.1% | 80.2% | ||
<7 mg/dL | 8 (11.1%) | 64 (88.9%) | 72 (100%) | |
3.3% | 52.9% | 19.8% | ||
|
||||
Birth attendant | Gynecologists | 0 (0.0%) | 121 (100%) | 121 (100%) |
0.0% | 100.0% | 33.3% | ||
Midwives | 232 (100%) | 0 (0.0%) | 232 (100%) | |
95.9% | 0.0% | 63.9% | ||
Others | 10 (100%) | 0 (0.0%) | 10 (100%) | |
4.1% | 0.0% | 2.8% | ||
|
||||
Fetal weight | <2.5 kg | 2 (100%) | 0 (0.0%) | 2 (100%) |
0.8% | 0.0% | 0.6% | ||
2.5–4 kg | 239 (86.0%) | 39 (14.0%) | 278 (100%) | |
98.8% | 32.2% | 76.6% | ||
>4 kg | 0 (0.0%) | 2 (100%) | 2 (100%) | |
0.0% | 1.7% | 0.6% | ||
Undocumented | 1 (1.2%) | 80 (98.8%) | 81 (100%) | |
0.4% | 66.1% | 22.3% | ||
|
||||
Sex of neonate | Female | 124 (70.1%) | 53 (29.9%) | 177 (100%) |
51.2% | 43.8% | 48.8% | ||
Male | 118 (63.4%) | 68 (36.6%) | 186 (100%) | |
48.8% | 56.2% | 51.2% | ||
|
||||
Risk factors composite | No | 242 (96.4%) | 9 (3.6%) | 251 (100%) |
100.0% | 7.4% | 69.1% | ||
Yes | 0 (0.0%) | 112 (100%) | 112 (100%) | |
0.0% | 92.6% | 30.9% | ||
|
||||
Total | 242 (66.7%) | 121 (33.3%) | 363 (100.0%) | |
100.0% | 100.0% | 100.0% |
More than three-fourths of uterine rupture cases occur during term gestational age. 85% of uterine rupture cases primarily have prolonged labor (labor length more than 24 hours). More than 85% of females who had uterine rupture are referred from other health institutions. More than 65% of females (245 out of 362) do not have hemorrhage; however, in contrast, more than 95% of females who had uterine rupture had hemorrhage. 80% of females had hemoglobin more than 7 mg/dL, but more than half of females who had uterine rupture have preoperative hemoglobin less than 7 mg/dL (Table
All uterine rupture cases are seen by specialists. Three-fourths of fetal weight cases are in normal range. 92% of females who had uterine rupture had any types of risk factors (Table
In bivariate binary logistic regression, age groups of <20 and 20–34 years are protective age groups relative to reference group (age group > 34 years). Females in the age group of <20 years are 88% (COR = 0.12; 95% CI: 0.040, 0.370) and those in the age group of 20–34 years are 50.6% (COR = 0.494; 95% CI: 0.255, 0.957) less affected by uterine rupture relative to reference group. Females who came from rural areas are 3 times at higher risk of acquiring uterine rupture (COR = 3.168; 95% CI: 1.975, 5.082). Grand multipara females are at higher risk of uterine rupture. Nulliparous females have 90.1% (COR = 0.099; 95% CI: 0.042, 0.231) and multiparous females have 61.8% (COR = 0.382; 95% CI: 0.199, 0.736) less probability to develop uterine rupture relative to grand multipara females (Table
Determinant factors of uterine rupture among females who attended maternal health services in MTUTH, MTU, 2016.
Variables | Category | SVD | Uterine rupture | Total | COR (95% CI) | AOR (95% CI) |
---|---|---|---|---|---|---|
Age | <20 yrs | 39 (88.6%) | 5 (11.4%) | 44 (100%) | 0.12 | 0.423 |
16.1% | 4.1% | 12.1% | (0.040, 0.370) | (0.054, 3.281) | ||
20–34 yrs | 183 (65.8%) | 95 (34.2%) | 278 (100%) | 0.494 | 1.689 | |
75.6% | 78.5% | 76.6% | (0.255, 0.957) | (0.486, 5.868) | ||
>34 yrs | 20 (48.8%) | 21 (51.2%) | 41 (100%) | Reference | Reference | |
8.3% | 17.4% | 11.3% | ||||
|
||||||
Residence | Urban | 27 (81.8%) | 6 (18.2%) | 33 (100%) | 0.671 | 0.854 |
11.2% | 5.0% | 9.1% | (0.262, 1.717) | (0.195, 3.728) | ||
Rural | 61 (48.8%) | 64 (51.2%) | 125 (100%) | 3.168 |
|
|
25.2% | 52.9% | 34.4% | (1.975, 5.082) |
|
||
Semiurban | 154 (75.1%) | 51 (24.9%) | 205 (100%) | Reference | Reference | |
63.6% | 42.1% | 56.5% | ||||
|
||||||
Parity | Nullipara | 81 (87.1%) | 12 (12.9%) | 93 (100%) | 0.099 | 0.197 |
33.5% | 9.9% | 25.6% | (0.042, 0.231) | (0.040, 0.975) | ||
Multipara | 143 (63.6%) | 82 (36.4%) | 225 (100%) | 0.382 | 0.308 | |
59.1% | 67.8% | 62.0% | (0.199, 0.736) | (0.089, 1.064) | ||
Grand multiparity | 18 (40.0%) | 27 (60.0%) | 45 (100%) | Reference | Reference | |
7.4% | 22.3% | 12.4% | ||||
|
||||||
ANC | No | 60 (45.1%) | 73 (54.9%) | 133 (100%) | Reference | Reference |
24.8% | 60.3% | 36.6% | ||||
Yes | 182 (79.1%) | 48 (20.9%) | 230 (100%) | 0.217 |
|
|
75.2% | 39.7% | 63.4% | (0.136, 0.346) |
|
||
|
||||||
Gestational age | Preterm | 23 (82.1%) | 5 (17.9%) | 28 (100%) | 0.114 |
|
9.5% | 4.1% | 7.7% | (0.034, 0.382) |
|
||
Term | 208 (68.6%) | 95 (31.4%) | 303 (100%) | 0.239 | 1.067 | |
86.0% | 78.5% | 83.5% | (0.111, 0.516) | (0.327, 3.490) | ||
Postterm | 11 (34.4%) | 21 (65.6%) | 32 (100%) | Reference | Reference | |
4.5% | 17.4% | 8.8% | ||||
|
||||||
Preoperative hemoglobin | >7 mg/dL | 234 (80.4%) | 57 (19.6%) | 291 (100%) | Reference | Reference |
96.7% | 47.1% | 80.2% | ||||
<7 mg/dL | 8 (11.1%) | 64 (88.9%) | 72 (100%) | 32.842 |
|
|
3.3% | 52.9% | 19.8% | (14.906, 72.360) |
|
||
|
||||||
Sex of neonate | Female | 124 (70.1%) | 53 (29.9%) | 177 (100%) | Reference | Reference |
51.2% | 43.8% | 48.8% | ||||
Male | 118 (63.4%) | 68 (36.6%) | 186 (100%) | 1.348 | 0.719 | |
48.8% | 56.2% | 51.2% | (0.869, 2.091) | (0.382, 1.352) |
Females who had ANC follow-up are at lower risk of developing uterine rupture by 78.3% (COR = 0.217; 95% CI: 0.136, 0.346). Females with postterm pregnancy are at higher risk of developing uterine rupture. Females with preterm and term gestational age pregnancies are at lower risk of developing uterine rupture by 88.6% (COR = 0.114; 95% CI: 0.034, 0.382) and 76.1% (COR = 0.239; 95% CI: 0.111, 0.516), respectively, as compared to females with postterm pregnancy. Even though the precision is low, females with preoperative hemoglobin level < 7 mg/dL are at higher risk of developing uterine rupture (COR = 32.842; 95% CI: 14.906, 72.360) (Table
In multivariable binary logistic regression, ANC follow-up, residence, gestational age, and preoperative hemoglobin are significant predictors of uterine rupture. Females who reside in rural areas are 3.996 times at higher risk of acquiring uterine rupture (AOR = 3.996; 95% CI: 2.011, 7.940). Females who had ANC follow-up are at lower risk of developing uterine rupture, which is reduced by 68.5% (AOR = 0.315; 95% CI: 0.164, 0.606). Females with preterm gestational age pregnancy are at lower risk of developing uterine rupture, which is reduced by 86.5% (AOR = 0.135; 95% CI: 0.025, 0.725). Females with preoperative hemoglobin level < 7 mg/dL are at higher risk of developing uterine rupture (AOR = 62.517; 95% CI: 22.181, 176.204) but the confidence interval is wide which shows that the sample size is small to consider preoperative hemoglobin level < 7 mg/dL as determinant factor (Table
Uterine rupture has deadly contributions to maternal and fetal loss. There are a total of 11 maternal deaths out of 363 females. Around 107 females lost their fetus. All of them are from uterine rupture cases. Around 7% of females have postoperative hemoglobin level less than <7 mg/dL and more than 30% of them have obstetric complications. More than 95% of females with uterine rupture have additional obstetric complications (Table
Frequency distributions of bad outcomes of uterine rupture in MTUTH, MTU, 2016.
SVD | Uterine rupture | Total | ||
---|---|---|---|---|
Maternal death | Yes | 0 (0.0%) | 11 (100%) | 11 (100%) |
0.0% | 9.1% | 3.0% | ||
No | 242 (68.8%) | 110 (31.3%) | 352 (100%) | |
100.0% | 90.9% | 97.0% | ||
|
||||
Fetal loss | Yes | 0 (0.0%) | 107 (100%) | 107 (100%) |
0.0% | 88.4% | 29.5% | ||
No | 242 (94.5%) | 14 (5.5%) | 256 (100%) | |
100.0% | 11.6% | 70.5% | ||
|
||||
Postoperative hemoglobin | >7 mg/dL | 241 (71.3%) | 97 (28.7%) | 338 (100%) |
99.59% | 80.17% | 93.11% | ||
<7 mg/dL | 1 (4%) | 24 (96%) | 25 (100%) | |
0.41% | 19.83% | 6.89% | ||
|
||||
Obstetric complications | No | 242 (98.78%) | 3 (1.22%) | 245 (100%) |
100% | 2.48% | 67.49% | ||
Yes | 0 (0%) | 118 (100%) | 118 (100%) | |
0% | 97.52% | 32.51% | ||
|
||||
Total | 242 | 121 | 363 | |
66.7% | 33.3% | 100.0% | ||
100.0% | 100.0% | 100.0% |
In propensity score matching analysis, fetal loss, maternal death, and additional obstetric complications are significant bad outcomes of uterine rupture. In the participants in our study, 88.4 females lost their fetus per 100 females with uterine rupture due to uterine rupture (
Bad outcomes of uterine rupture among study participants in MTUTH, MTU, 2016.
Outcome |
|
AI robust Std. Err. |
|
95% conf. interval | |
---|---|---|---|---|---|
Lower | Upper | ||||
Fetal loss |
|
0.029 |
|
|
|
Maternal death |
|
0.026 |
|
|
|
Postoperative hemoglobin | 0.289 | 0.337 | 0.391 | −0.949 | 0.371 |
Obstetric complication |
|
0.014 |
|
|
|
Bad outcomes of uterine rupture estimation by propensity score matching analysis for the population revealed that fetal loss, maternal death, and obstetric complications are still significant bad outcomes of uterine rupture. An increase of 1000 females who had uterine rupture in the community increases fetal loss by 812 (
Bad outcomes of uterine rupture among females in the catchment area by extrapolation, MTU, 2016.
Outcome |
|
AI robust Std. Err. |
|
95% conf. interval | |
---|---|---|---|---|---|
Lower | Upper | ||||
Fetal loss |
|
0.047 |
|
|
|
Maternal death |
|
0.013 |
|
|
|
Postoperative hemoglobin | 0.094 | 0.114 | 0.411 | −0.318 | 0.130 |
Obstetric complication |
|
0.005 |
|
|
|
Obstructed labor due to cephalopelvic disproportion and malpresentation, previous cesarean section, oxytocin infusion, and grand multiparity are the major direct factors for uterine rupture. The highest number of uterine rupture (78.5%) cases is found in the age group of 20−34 years and the lowest number of uterine rupture cases is found in the age group of <20 years. Even though age <20 years is significant in bivariate logistic regression, it is not significant predictor in multivariable logistic regression. Females in the age group of <20 years are 88% (COR = 0.12; 95% CI: 0.040, 0.370) less affected by uterine rupture relative to age group of >34 years. Similarly, in Uganda, teenagers were associated with less risk of developing ruptured uterus compared to those aged 20 to 29 years (OR: 0.1; 95%: 0.0–0.4) [
Females who reside in rural areas are 3.996 times at higher risk of acquiring uterine rupture (AOR = 3.996; 95% CI: 2.011, 7.940) than females who reside in semiurban areas. Rural females in developing country are vulnerable to experience uterine due to inaccessibility of health facility, low level of literacy level, and other socioeconomic factors. For instance, in this study, only one-third of females come from rural area but more than half of them do not have ANC follow-up. Besides this there is a delay to visit health institutions in rural areas because of poor road and low literacy level.
Females who had ANC follow-up are at lower risk of developing uterine rupture, which is reduced by 68.5% (AOR = 0.315; 95% CI: 0.164, 0.606), than their counterparts. Similarly, in Uganda, females who do not have antenatal care are 4.7 times more likely to be exposed to uterine rupture (OR: 4.7; 95% CI: 1.6−13.7). In India, 70% of uterine rupture cases were unbooked cases for ANC [
Being in the preterm gestational age is also one of the protective factors with AOR of 0.135 and 95% CI of 0.025–0.725 in contrast to postterm gestational age. In Sweden, the risk of uterine rupture was also increased in women with postterm (>42 weeks) compared with term (37–41 weeks) pregnancies [
The worry for uterine rupture is due to its dreadful outcomes. It carries terrible outcome to the mother and her baby. Even if women survive, the future reproductive potential is reduced or lost forever [
More than 85% of females with uterine rupture lost their fetus, a percentage that is lower than finding from India, 94.07%, but it is higher than finding from Lahore General Hospital, 71.4% [
The other dreadful contribution of uterine rupture is that it exposes the women to additional obstetric complications. More than 95% of females with uterine rupture have additional obstetric complications. From 100 females caught by uterine rupture, 97.5 developed additional obstetric complications (
These estimations imply that uterine rupture is the major concern particularly in developing countries. Its contribution to the fetal loss is horrible. For most of the terrible outcomes, strong follow-up of maternal and child health services during pregnancy and delivery is crucial to halt the predisposing factors for uterine rupture.
Residence, ANC follow-up, and gestational age are significant determinants and factors of uterine rupture. Fetal loss, maternal death, and obstetric complications are significant bad outcomes of uterine rupture. Residence and ANC follow-up are modifiable risk factors. Creating new way of referral system, where the area is difficult for the normal referral system, or increasing access of health services in the nearby area for difficult topographic areas is important to reduce the burden of uterine rupture.
As recommendation for future study, use of oxytocin and previous cesarean section with duration of hospitalization before uterine rupture should be studied.
Antenatal care
Adjusted odds ratio
Confidence interval
Crude odds ratio
Mizan-Tepi University
Mizan-Tepi University teaching hospital
Postnatal care
Southern Nations, Nationalities, and Peoples’ Region
Spontaneous vaginal delivery.
All authors are academicians. Tegene Legese Dadi has M.P.H. degree in reproductive health and Teklemariam Ergat Yarinbab has M.P.H. degree in epidemiology.
The authors declare that there are no conflicts of interest regarding the publication of this paper.
Tegene Legese Dadi and Teklemariam Ergat Yarinbab conceived the study, were involved in the study design and data analysis, drafted the manuscript, and critically reviewed the manuscript. All authors read and approved the final manuscript.
The authors are grateful to Mizan-Tepi University for funding the study and other supports. They would like to acknowledge MTU teaching hospital for their cooperation in conducting this study. They would also like to express their deepest gratitude to data collectors for their hard work and sincere contribution.