HARAR HEALTH SCIENCES COLLEGE DEPARTMENT OF

CLINICAL PHARMACY

ASSESSEMENT OF PREVALENCE AND ASSOCIATED FACTORS OF

OBSTRUCTED LABOR IN DELIVARY WARD AT HIWOT-FANA
SPECIALIZED UNIVERSITY HOSPITAL, HARAR, EASTERN
ETHIOPIA, 2021

BY: -

1. AHMED KEMER

2. AMIN ALIYI

3. AYMEN MOHAMMED

4. CHALA ABDURAHMAN

5. CHALA MOHAMMED

6. JAFAR ABDI

7. SUFIAN ADEM

RESEARCH PROPOSAL SUBMITTED TO THE DEPARTMENT OF B.PHARMACY AT

HARAR HEALTH SCIENCE COLLEGE FOR THE BACHELOR OF PHARMACY DEGREE,
2021.

JANUARY, 2021
HARAR, EASTERN ETHIOPIA
 HARAR HEALTH SCIENCE COLLEGE

DEPARTMENT OF CLINICAL PHARMACY

1 chala mohammed,
2 fami Ahamed.
Name of degree student 3 Abdulaziz mohammed.
4 chala abdurahaman.
5 Hanuna sufiyan.

Name of primary advisor Mr. Alemsaged w

Name of co- advisor Mr. Abas m

Full title of research proposal Prevalence of unused medications among

community of harar, eastern ethiopia

Duration of research (full projectile The Duration of research is 6 months that means from
life) December 2020 to May 2021 GC.

Study area Hiwot Fana Specialized University Hospital, Harar

Town

Total cost of the project (birr) 7,237.00

Address of investigator(s) (e-mail,

cell phone and landline telephone)

ABISTRACT

Background: Obstructed labor is when the presenting part of the fetus cannot
progress into the birth canal, despite adequate uterine contractions. The prevalence
is more common in communities in which under nutrition in childhood is dominant
and where there is no easy access to functioning health facilities. The common
causes are Cephalo-pelvic disproportion, mal presentation and mal position.

Objective: - The objective of this study will be to assess obstructed labor and its
associated factors among women delivered at Hiwot Fana Specialized University
Hospitals in Harar town, Eastern Ethiopia, 2021.

Methodology: Institution- based retrospective cross-sectional study will be

employed from April, 2021 among all women who gave birth in the past one year.
The study population will include all randomly selected charts of mothers who
gave birth in from August 01, 2020 up to December 31, 2020 and the total of 347
charts will be recruited in the study through systematic random sampling. The data
will be collected by using pretested checklist. Data entry and analysis will be done
by SPSS version-21 review. Odds ratio with 95% confidence interval will be used
to measure the degree of association between dependent variables and independent
variable. Then, the final results will be presented in the form of tables, figures,
graphs and text.
Work plan: The study will be conducted from April, 2021
Budget: Total budget required for this study is =7,237.00 ETB

Contents......................................................................................................................................................iii

List of tables................................................................................................................................................v

List of figure...............................................................................................................................................vi

Abbreviations and Acronyms.....................................................................................................................vii

1. Introduction............................................................................................................................................1

1.1 Background........................................................................................................................................1

1.2. Statement of the Problem................................................................................................................3

1.3. Significance of the study...................................................................................................................5

2. Literature Review....................................................................................................................................6

2.3. Conceptual framework.....................................................................................................................8

3. Objectives................................................................................................................................................9

4. Methodology.........................................................................................................................................10

4.1 Study Area and Period:....................................................................................................................10

4.2 Study design:...................................................................................................................................10

4.3 Population.......................................................................................................................................10

4.4. Eligibility Criteria.............................................................................................................................10

4.5 Sample size determination:.............................................................................................................11

4.6. Sampling Technique and Procedure:..............................................................................................11

4.7. Study Variables...............................................................................................................................12

4.8. Definition of Terms.........................................................................................................................12

4.9 Data collection tools........................................................................................................................12

4.10 Data Processing and Analysis……………………………………………………………………………………………………13

4.11. Data quality assurance:.................................................................................................................13

4.12. Ethical consideration....................................................................................................................13

4.13. Dissemination plan.......................................................................................................................14

5. Work plan.............................................................................................................................................15

6. Budget Breakdown................................................................................................................................16

7. Reference...............................................................................................................................................17
 List of tables
Table 1: work plan for the research on the obstructed labor and its associated factors among women
delivered in the past one year at Hiwot Fana Specialized University Hospitals in Harar town, Eastern
Ethiopia, 2021. …………........................................................................................................................... 15
Table-2: Budget breakdown for research on the obstructed labor and its associated factors among
women delivered in the past one year at Hiwot Fana Specialized University Hospitals in Harar town,
Eastern Ethiopia, 2021........................................................................................................................... 16

List of figure

2.3. Conceptual framework for the research on the Obstructed labor and its associated factors
among women delivered in the past one year at Hiwot Fana Specialized University Hospitals in Harar
town, Eastern Ethiopia, 2021. …………...................................................................................................... 8
ABBREVIATIONS AND ACRONYMS

ANC Antenatal Care

CPD Cephalo Pelvic Disproportion
EDHS Ethiopia Demographic Health Survey
EMDHS Ethiopia Mini Demographic Health Survey
GTP Growth and Transformation Program
Km Kilo meter
MDG Millennium Developmental Goal
MMR Maternal Mortality Rate
MOH Ministry of Health
OL Obstructed Labor
OR Operating Room
SPSS Statistical Package for Social Sciences
SSA Sub Saharan Africa
WHO World Health Organization

1. INTRODUCTION
1.1 Background

According to world health organization (WHO) labor is considered obstructed

when the presenting part of the fetus cannot progress into the birth canal, despite
strong uterine contractions. It is more common in humans than in primates,
because the birth canal of a woman is not as straight and wide as in primates. It is
one of the common causes of maternal and prenatal morbidity and mortality in
developing and low income countries including Ethiopia. (1)
The common risk factors for obstructed labor are malnutrition, rickets or
osteomalacia, short stature, young age of mother (under 17 years of age), female
genital cutting, long distance to obtain skilled help, lack of transport and
communication. The most frequent cause of obstructed labor is cephalo-pelvic
disproportion - a mismatch between the fetal head and the mother's pelvic brim. (2)
The fetus may be large in relation to the maternal pelvic brim, such as the fetus of
a diabetic woman. Other causes of obstructed labor may be fetal presentation or
fetal position of the fetus (shoulder, brow or occipito-posterior positions). In rare
cases, locked twins or pelvic tumors can cause obstruction (3).
In developing countries, fistulae are commonly the result of prolonged obstructed
labor and follow pressure necrosis caused by impaction of the presenting part
during difficult labor. In the infant, neglected obstructed labor may cause asphyxia
leading to stillbirth, brain damage or neonatal death (4).
It is impossible to predict obstructed labor and the only sensible approach is to
observe and monitor very carefully and be prepared for intervention. The
prevalence of obstructed labor in developed countries is approximately 8%. In
developing countries the incidence of obstructed labor ranges from 1.9% to 8.3%
worldwide, the incidence estimated to be 3-6% with higher applying to less
developed countries (5).
1.2. Statement of the Problem
Globally, each year over 210 million become pregnant, out of this 20 million
will experience pregnancy related illness and 500,000 will die as a result of the
complication of pregnancy or child birth. (6) Global maternal mortality due to
obstructed labor is responsible for 9% of all maternal death. For Asia this
amounted to 9.4%, 13.4% for Latin America and the Caribbean respectively
and 4.1% to all maternal deaths in Africa; Out of this about 4000 occurs in
developing countries that account for 87 % of the world’s births. So in Africa
this ratio is highest with value of 40/100.000 live birth. (7)Among the women
in developing country , their low social status are limits access to economic
resources, basic education and thus their ability to make decision related to
their health and nutrition. culture also promote maternal deaths in many areas,
such as low status and neglect to girls and women, polygamy, early marriages
and childbearing, underfeeding and dietary practices during pregnancy and
double standards of sexual ethics resulting in clandestine abortion or pre
pubertal marriage(8). Maternal mortality from obstructed labor is caused by
complication of ruptured uterus, postpartum hemorrhage, and puerperal sepsis,
while substantial long term maternal morbidity include, intrauterine infections
following prolonged rupture of membranes, trauma to the bladder and/or
rectum due to pressure from the fetal head or damage during delivery, and
ruptured uterus with consequent hemorrhage, shock or even death.
In the long-term it can cause secondary infertility due to Sheehan’s syndrome,
hysterectomy due to rupture or vaginal scaring and stenos, severe anemia,
musculoskeletal injury, urinary incontinent and obstetric fistula. 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(7).

In Ethiopia as observed in different studies from across the country the

incidence or prevalence of obstructed labor is estimated between as low as
3.3% and as high as 12.2%.

Obstetric fistulas are long-term complications of obstructed labor, and a

traumatic delivery affects both mother and child but the contribution to
maternal (as well as in perinatal) mortality is labeled as major tell and can
provide indications on practical ways of addressing its causes and
determinants (7).

The Federal ministry of health in Ethiopia recognizes the challenges existing

within the nation concerning maternal (and child) health and outlines in its
Health Sector Development Plan. That one of the major goals for the health
provision will be to strengthen the well-being of mothers and children.
Increased attention will be given to the professional attendance during delivery
(8).

Despite the fact that obstructed labor in Ethiopia seems to be a common cause
of maternal and perinatal morbidity and mortality, there is inadequate research
evidence to substantiate this, in order to increase knowledge base for more
successful intervention against obstructed labor, and understanding the
underlying factors leading to the deaths is critical to prevent future mortality.
In our study area due to the past studies are inadequate for that reason the
present study will try to fill the gap in this area to determine
prevalence and what are the causes of obstructed labor among women deliver
in Hiwot Fana Specialized University Hospital in Harar town, Eastern Ethiopia.

1.3. Significance of the study

Some studies on obstructed labor have been conducted particularly in other
regions in Ethiopia but there is inadequate data in HFSUH in Harar town.
Therefore, it will be necessary to determine the prevalence of obstructed labor
among pregnant women as well as the cause, and associated factor of
obstructed labor in HFSUH. The findings of this study would help to have a
broader and recent picture on the problem and provide some knowledge and
insight into the prevalence, associated factors and the outcome of obstructed
labor in HFSUH, in Harar, town.

2. Literature Review

2.1. Prevalence of Obstructed Labor

The prevalence of obstructed labor in developed countries is approximately 8%. In
developing countries the incidence of obstructed labor ranges from 1.9% to 8.3%
worldwide, the incidence estimated to be 3-6% with higher applying to less
developed countries (5). )Especially in countries with limited resources, it is
difficult to assess the exact prevalence or incidence of these conditions, due to
unavailability of data from such regions in the world, (2). The same authors state
that from the available literature it seems reasonable to assume that there has been
very little change over the last decades in the prevalence of obstructed labor and
the figure still stands at 3-6%. (3)
In Asia, Cross Sectional Observational study conducted in Pakistan at Larkana
Sindh showed that the total deliveries in units during study period are 9000.
Among them 5.2% patients found to have obstructed labor (11). Other study done
in India showed incidence is remarkably low 20% in patients who has antenatal
check-up (12). Cross sectional study conducted in Bangladesh the department of
Gynecology & Obstetrics at, Bogra show among total number of 3171 deliveries
132 case of obstructed labor an incidence of 4.2% (13).

In Africa prospective study done in university of Nigeria show, the prevalence of

obstructed labor is 32% (14). Other study done in south-western Uganda shows,
Prevalence of obstructed labor for the six hospitals is 10.5% (15)
In Ethiopia Hospital-based, cross-sectional study conducted in Jimma University
Specialized Hospital shows the incidence of obstructed labor is 12.2 %(16).Other
study conducted in Mizan-Aman, General Hospital showed that the Prevalence of
obstructed labor is 7.95%(17). The study conducted in Addis Ababa University
shows that the prevalence of obstructed labor is 34.30% of the total delivered
women (18).

2.2. Associated factors of Obstructed Labor

The associated factors for occurrence of obstructed labor are teenagers, early
marriage, short stature women, primigravida and multipregnancy. (14) The major
cause of obstructed labor identified in different studies are cephalo pelvic
disproportion being responsible for 41.1% in Indian study, 67%in Nigeria study
(11). Study conducted in Pakistan shows that 63% of OL is due to CPD. (11)
Other retrospective study conducted in India, in government medical collage
Jhalawar Rajasthan showed that the most common Couse of obstruction is
similarly and closer figure with Pakistan, cephalo- pelvic disproportion 63%
followed by malposition/malpresentation 29.9. (20)

Another study done in India shows that 63% case of OL are in primigravida
followed by 30% in multipara and 7% in grand multipara. 86% patients belong to
rural areas, the age distribution of cases with OL showed that majority, 46% of
patients belongs to younger age group between 21-25 years and 86% cases are
rural areas. Major etiological factor of obstructed labor in study are cephalo-pelvic
disproportion 60% followed by mal presentation 37%. (12)The descriptive study
conducted in Pakistan at Muhammad Medical College Hospital (MMCH)
Mirpurkhas, showed that Cephalo-pelvic disproportion (CPD) is the most common
risk factor found in 67.5% cases. (21)

In Africa prospective study done in university of Nigeria shows that the

commonest cause of obstruction is 56.7% fetal pelvic disproportion. (14) A Study
done in south-western Uganda shows, the main contributing factor of obstructed
labor for six hospitals are cephalo pelvic disproportion (63.3%), mal presentation
or malposition (36.4%) and hydrocephalus (0.3%).
(15) In Ethiopia Hospital-based, cross-sectional study conducted in Jimma
University Specialized Hospital shows the most causes of obstructed labor are
cephalo-pelvic disproportion in 67.6% and mal presentation in 27.9% of the
cases(9). (10) And study conducted in Mizan-Aman General Hospital also shows
that the main causes of obstructed labor are CPD (66.67%), mal presentation
(25%), and cervical and fetal congenital anomaly (8.33%). Out of this, only 25%
have received antenatal care at least once, and the majority (83.3%) came from
rural area. (11) Retrospective quantitative descriptive study conducted in West-
College zone showed that the two common causes OL are cephalo pelvic
disproportion 63.6% and 23.8% are mal presentation. (15)

2.3. Conceptual framework

Obstetric Factor
Health Care Factor
Sociodemographic -Gravidity/parity
-use of pantograph
Factor -ANC follow up
-referral system
-Age -Duration of labor before
-Distance from health
-Residency visiting hospital
center
 Obstructed
Labour

Figure 2-1: Adopted Conceptual Framework for prevalence and associated factors of
obstructed labor based on literatures. (1, 2, 3, 9, 16, 17, 22)

Objectives

3.1. General objective

• To assess the prevalence of obstructed labor and its associated factors
among women delivered in the 2020, at Hiwot Fana Specialized
University Hospital, Harar, Eastern Ethiopia, 2021.

3.2. Specific objectives

 • To assess the magnitude of obstructed labor among women delivered at
Hiwot, Fana Specialized University Hospital, from August 1, 2020 up
to December 31, 2020, Harar, Eastern Ethiopia.

• To identify the associated factors of obstructed labour among women

delivered at Hiwot Fana Specialized University Hospital, from August
1, 2020 up to December 31,2020, Harar, Eastern Ethiopia.

4. Methodology
4.1 Study Area and Period:
This study will be done at HFSUH in Harar town, which is found 515 km east from
Addis Ababa. The Hospital specifically found in Harar town.
The study will be conducted from April 2021
4.2 Study design: Hospital based retrospective cross-sectional study design will
be done.
4.3 Population
4.3.1 Source population:

 All charts of mothers who gave birth at HFSUH from August 1, 2020 up to
December 31, 2020, Harar, and Eastern Ethiopia.

4.3.2. Study population:

 All randomly selected charts of mothers who gave birth at Delivery ward of
HFSUH from August 1 up to December 31/2020.

4.4. Eligibility Criteria

4.4.1. Inclusion criteria:

 All charts of women with diagnosis of obstructed labor on admission, those

who develop obstruction on follow up and mothers with diagnosis of uterine
rupture due to OL.

4.4.2. Exclusion criteria:

 Women with diagnosis of uterine rupture on admission due to other causes

than OL, those with rupture before 28 weeks, Chart of patient with
incomplete data or lost cards and those with previous c/s scar and clients
with multiple pregnancies will be excluded from the study.

4.5 Sample size determination:

The sample size was determined by using single population proportion

sample size calculation formula. By considering 95% confidence interval (CI) and
5% marginal error, the sample size is calculated as follows

n = (Zα/2)2 p (1-p)
d2
 Where, p= total proportion (34.3%) which is prevalence rate of OL in AAU,
2016. (12)

Zα/2 = confidence level at 95%=1.96

d=margin of sampling error be tolerated (precision) =0.05 or 5%

n= (1.96)2 0.343 (1-0.343)

(0.05)2

= 346.28 ~ 347

4.6. Sampling Technique and Procedure:

Systematic random sampling will be used to select 347 records. The sampling
frame will be prepared by using those mothers’ registration book from August
1 to December 31/ 2020. The “kth” interval will be calculated by using the
following formula:

K = N/n

Then, the first card will be selected by lottery method, and the next charts will
be selected every “kth” interval.

4.7. Study Variables

4.7.1. Dependent variables:

 Obstructed Labor

4.7.2Independent Variables:
o maternal age
o residence
o gravidity
 o CPD, fetal position, fetal presentation, presence of ANC, duration of
labor, and duration of intervention.
4.8. Definition of Terms
Obstructed labor: is defined as failure of descent the fetal presenting part for
mechanical reasons in spite of adequate uterine contraction, and not managed
timely and includes patients who arrived with uterine rupture.

Cephalo pelvic disproportion: Disparity between the dimensions of the fetal

head and maternal pelvis such as to preclude vaginal delivery.

Cesarean delivery: Is the delivery of the fetus placenta and membranes

through an incision on the abdominal wall at or after 28 weeks of gestation.

Instrumental delivery: Is the delivery of the fetus using instruments (forceps

or vacuum).

Maternal mortality: Death of a woman while pregnant or within 42 days of

termination of the pregnancy regardless of the site or duration of the
pregnancy, from any cause related to pregnancy or aggravated by its
management but not from accidental or incidental causes.

Perinatal mortality: It is defined as fetal death after 28 weeks of gestation &

death of a newborn with in the first seven days of life.

Chorioamnionitis: Inflammation of the fetal membranes usually is a

manifestation of intrauterine infection. It frequently is associated with
prolonged membrane rupture and long labor. There also may be a foul odor, &
associated lower abdominal tenderness depending on bacterial species and
concentration.
Still birth: The expulsion of a fetus after 28 completed weeks and/or
weighing at least 1kg with absence of breathing, heart beats, pulsation of the
umbilical cord, or definite movements of voluntary muscles.

4.9 Data collection tools

The data will be collected using semi-structured data collection tools. Delivery
ward records will be reviewed retrospectively to gather information. It has
three sections; section I: socio demographic factors, section II: obstetric factors
and section III: health care factors.

4.10. Data processing and analysis

After data collection, the checklists will be checked for completeness and coded
before data entry. Then the data will be entered and analyzed by using SPSS-
version 21. Bivariate analysis will be used to find out the association of
independent variables with the dependent variable. Variables showing statistically
significant result i.e. p< 0.2 in binary logistic regression will be entered into
multivariate logistic regression analysis to identify associated factors of obstructed
labour by controlling confounding variables. The variable with p < 0.05 in multiple
logistic

regressions will be considered as predicting variable for factors associated with

obstructed labour.

4.11. Data quality assurance:

The data collection tool is pre-tested among 10% of sample size at HFSUH, to
check for clarity of the items and also to identify any confusing items in the
checklist. One-day training will be given for data collectors and supervisors
on objectives, relevance of the study, on how to use the data collection
instrument and how to keep confidentiality, the right of respondents to not to
 participate in the study and on the course of data collection, the orientation on
the details of data collection tool as well as necessary information will be
given for the study participants. Supervisors will perform the immediate
supervision of data collection procedures on a daily basis.

4.12. Ethical consideration

Ethical clearance will be obtained from Research Ethical Review Committee of
Harar health Sciences College. An official letter of cooperation, which written by
the study, research, development and publication unit of Harar health sciences
college will be taken to the administrators of HFSUH. Then the supportive letter
will be given to the Delivery ward and Card rooms. Concerned body from each
units/wards will be officially communicated before conducting the data collection.
Confidentiality of the data will be kept throughout the study.

4.13. Dissemination plan

First, the study finding will be presented to Harar Health Sciences College and
then the result will be communicated to the Administration Bureaus, and staffs of
HFSUH.

5. Work plan

Table 1: work schedule for research proposal

NO ACTIVITIES Responsible Dec. Jan. 2021 Feb. Mar. Apr. May
body 2020 2021 2021 2021 2021

1 Topic Selection PIs

2 Preparation for Proposal PIs

Submission of 1st draft to advisor and Incorporation of PIs

advisors’ comment

3 Final proposal submission PIs

4 Proposal defense PIs

5 Approved proposal submission to SRDPU PIs

Preparation for field work PIs

6 Data collection and analysis PIs & DC

1st draft report writing PIs

7 submission of 1st draft to advisor and Incorporation of PIs

advisors’ comment

submission of 2nd draft to advisor PIs

8 Final research submission PIs

9 Final research defense PIs & SRDPU

10 Incorporation of comments and final research submission to PIs

SRDPU

Note: PIs- Principal Investigators, SRDPU-Study Research Development and Publication Unit, DCs-Data Collectors

6. Budget Breakdown
Table-2: Budget breakdown for research proposal
S. No. Item/ activity Number Multiplier Unit Cost Total cost (Birr)

Stationary and Equipment Cost

1 Pencil 7 3 21

2 Note book 7 25 175

3 Pen 7 7 49

4 Pencil eraser 7 5 35

5 Pencil sharpener 7 6 42

6 Ruler 2 10 20

7 Flash disk(4GB) 1 140 140

8 Binder 7 25 175

9 Stapler 1 100 100

10 Staples 2 packet 12 24

11 For printing 28 Per page 2 56

Subtotal: 837.00
Personnel cost
Perdiem for
12 1 Mr. X 15 days 50 750
Data Collectors
Perdiem for
13 1 Mr.Y 15 days 100 1500
Supervisors
Subtotal: 2250.00
Communication cost
9 Transportation cost 7 Students 15 30 3150.00
10 Mobile cards for communication 300.00
Subtotal: 3,450.00
Total: 6,537.00
Contingency (10 %): 700.00
Grand total: 7,237.00 ETB
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