Prevalence and predictors of uterine rupture among Ethiopian women: A systematic review and meta-analysis.

BACKGROUND: Uterine rupture has a significant public health importance, contributing to 13% of maternal mortality and 74%-92% of perinatal mortality in Sub-Saharan Africa, and 36% of maternal mortality in Ethiopia. The prevalence and predictors of uterine rupture were highly variable and inconclusive across studies in the country. Therefore, this systematic review and meta-analysis aimed to estimate the pooled prevalence and predictor of uterine rupture in Ethiopia.
METHODS: This systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2009 checklist. PubMed, Cochrane Library, Google Scholar, and African Journals Online databases were searched. The Newcastle- Ottawa quality assessment tool was used for critical appraisal. I2 statistic and Egger's tests were used to assess the heterogeneity and publication bias, respectively. The random-effects model was used to estimate the pooled prevalence and odds ratios with a 95% confidence interval.
RESULTS: Sixteen studies were included, with a total of 91,784 women in the meta-analysis. The pooled prevalence of uterine rupture was 2% (95% CI: 1.99, 3.01). The highest prevalence was observed in the Amhara regional state (5%) and the lowest was in Tigray region (1%). Previous cesarean delivery (OR = 9.95, 95% CI: 3.09, 32.0), lack of antenatal care visit (OR = 8.40, 95% CI: 4.5, 15.7), rural residence (OR = 4.75, 95% CI: 1.17, 19.3), grand multiparity (OR = 4.49, 95% CI: 2.83, 7.11) and obstructed labor (OR = 6.75, 95%CI: 1.92, 23.8) were predictors of uterine rupture.
CONCLUSION: Uterine rupture is still high in Ethiopia. Therefore, proper auditing on the appropriateness of cesarean section and proper labor monitoring, improving antenatal care visit, and birth preparedness and complication readiness plan are needed. Moreover, early referral and family planning utilization are the recommended interventions to reduce the burden of uterine rupture among Ethiopia women.

Introduction

Uterine rupture is a rare catastrophic obstetric complication. It is a complete rupture with direct communication between the uterine cavity and the peritoneum, or a partial rupture in which tearing in the myometrium is covered by the visceral leaf of the peritoneum with no involvement of fetal membranes and without intra-abdominal haemorrhage [1, 2]. Despite the recent advances in modern obstetrics, uterine rupture remained the major cause of fetal and maternal morbidity and mortality in Sub-Saharan Africa (SSA), contributing to about 13% of maternal mortality and perinatal mortality of 74% - 92% [3, 4].

A study conducted by the World Health Organization (WHO) reported that the prevalence of uterine rupture in developing countries was much higher than the developed world [5]. However, in high-income countries, uterine rupture occurs frequently among women who attempt a trial of labor in the previous caesarean section (CS), which varies from 0.22% to 0.78% [6-8]. The risk of rupture increased with short birth interval [9, 10], obstructed labor and poor obstetric care in developing countries [11]. On the other hand, it was reported lower (0.007%) among women in the Netherlands [12], United Kingdom [13], and the United States [14].

The government of Ethiopia is providing a basic emergency obstetric and newborn care to reduce maternal mortality and morbidity. Despite this, the maternal mortality ratio (412/100,000 live births) is still one of the highest in the world [15]. Studies showed that 2.7%-21.4% of maternal deaths attributed to uterine rupture in Ethiopia [4, 16, 17]. The prevalence and predictors of uterine rupture vary across different areas in Ethiopia. It occurs 1.8% in Dilla university hospital [18], 3.8% in Debre Markos hospital [16], and 1.4% in Nekemte Hospital [19]. Different studies reported that various factors have an association with uterine rupture; such as being a rural resident [18, 20–22], absence of Antenatal care (ANC) visit [18, 20–24], partograph utilization [23-25], high parity [19–22, 24, 25], previous CS [20, 22, 25], obstructed labor [22, 23, 25], and hydrocephalus baby [24, 25].

So far, there are highly variable findings regarding the prevalence and predictors of uterine rupture and are inconclusive at the national level for policymakers. For this, a systematic review to be conducted to provide evidence that required for best practice. Therefore, this systematic review and meta-analysis aimed to estimate the pooled prevalence of uterine rupture and its predictors among Ethiopian women.

Methods

Systematic review registration, data sources and search strategies

This systematic review and meta-analysis have designed to estimate the pooled prevalence of uterine rupture and predictors among Ethiopian women. We registered the protocol with the International Prospective Register of Systematic Reviews (PROSPERO), University of York Center for Reviews and Dissemination (https://www.crd.york.ac.uk/), with a registration number CRD42019119620. The findings of the review were reported based on the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) 2009 statement checklist [26] (S1 Table). All published articles were searched in major international databases such as PubMed, Cochrane Library, Google Scholar, and African Journals Online databases. Onwards, a search of the reference lists of the identified studies was done to retrieve additional articles. For this review, the PECO (Population, Exposure, Comparison and Outcomes) search strategy was used.

Population: women who had uterine rupture in Ethiopia.

Exposure: predictors of uterine rupture e.g. place of residence either rural or urban, the duration of labor, obstructed labor (presence or absence of obstructed labor) and having ANC visit or not, previous cesarean delivery or vaginal delivery.

Comparison: the reported reference group for each predictor in each respective variable.

Outcome: uterine rupture among Ethiopian women was the outcome of interest.

The primary outcome was the prevalence of uterine rupture among Ethiopian women.

Uterine rupture is a partial or complete tear of the uterine wall during pregnancy or delivery [5].

The secondary outcomes were: the predictors of uterine rupture such as previous cesarean delivery, place of residence, ANC visit, gravidity, and obstructed labor. For each selected PECO component, the electronic databases were searched using keywords and the medical subject heading [MeSH] terms. The quest for keywords includes prevalence, uterine rupture and predictors or determinants, as well as Ethiopia. The search terms were combined by the Boolean operators "OR" and "AND (S2 Table).

Eligibility criteria and study selection

This review included studies that reported either the prevalence of uterine rupture or the predictors of uterine rupture in Ethiopia. All English language published studies released up to the end of our search period (30/3/2019) were retrieved to this systematic reviews and meta-analysis. Case reports of populations, surveillance data (demographic health survey), abstracts of conferences, and articles without full access were excluded. First, through review of title, abstract and full paper was done by two reviewers (MD and HA). Any disagreement with the two reviewers was settled by consensus. Then, a full-text analysis of potentially qualifying studies including identification of duplicated records. Only the full-text article was retained in case of duplication.

Quality assessment and data collection

The Newcastle-Ottawa Scale (NOS) quality assessment tool was used to assess the quality of included studies based on the three components [27]. The principal component of the tool graded from five stares and emphasized on the methodological quality of each primary study. The other component of the tool graded from two stars and concerns about the comparability of each study and the last component of the tool graded from three stars and used to assess the outcomes and statistical analysis of each original study. The NOS has three categorical criteria with a maximum score of 9 points. The quality of each study was rated using the following scoring algorithms: ≥7 points were considered as “good”, 2 to 6 points were considered as “fair”, and ≤ 1 point was considered as “poor” quality study. Accordingly, in order to improve the validity of this systematic review result, we only included primary studies with fair to good quality. Then, the two reviewers (MD and HA) independently assessed or extracted the articles for overall study quality and or inclusion in the review using a standardized data extraction format. The data extraction format included primary author, publication year, and region of the study, sample size, and prevalence, and the selected predictors of uterine rupture.

Publication bias and, statistical analysis

The publication bias was assessed using the Egger’s [28] and Begg’s [29] tests with a p-value of less than 0.05. I2 statistic was employed to assess heterogeneity among studies and a p-value less than 0.05 was used to declare heterogeneity. As a result of the presence of heterogeneity, the random-effects model was used as a method of analysis to estimate the DerSimonian and Laird's pooled effect [30]. In the current meta-analysis, arcsine-transformed proportions were used. The pooled proportion was estimated using the back-transform of the weighted mean of the transformed proportions, using arcsine variance weights for the fixed-effects model and DerSimonian-Laird weights for the random-effects model [31].

Data were extracted in Microsoft Excel and exported to Stata version 11 for analysis. Subgroup analysis was conducted by region and type of study design. Besides, a meta-regression model was done based on sample size and year of publication to identify the sources of random variations among included studies. The effect of selected determinant variables was analyzed using separate categories of meta-analysis [32]. The findings of the meta-analysis were presented using forest plot and Odds Ratio (OR) with its 95% CI. Additionally, we performed a sensitivity analysis to assess whether the pooled prevalence estimates were influenced by individual studies.

Results

Study identification and characteristics of included studies

This systematic review and meta-analysis included published studies on the prevalence of uterine rupture in Ethiopia using international electronic databases. The review found a total of 1050 published articles. From those, 150 duplicated records were removed and 880 articles were excluded through screening of the title and abstracts. After that, a total of 20 full-text papers were assessed for eligibility based on the inclusion and exclusion criteria and four studies were excluded due to lack of full paper access [33-36]. Finally, 16 studies were included in the final quantitative meta-analysis (Fig 1).

Fig 1

PRISMA flow diagram of prevalence and predictors of uterine rupture in Ethiopia.

Characteristics of the included studies

Regarding the design of the included studies, nine were cross-sectional, three were case-control and the remained one study was cohort. Of those, three studies did not report prevalence data, were used to show only the predictors of uterine rupture [20, 22, 37]. The review was conducted among 91,784 women to estimate the pooled prevalence of uterine rupture. The largest sample size (28,835) was observed in the Amhara region [38] and the study with smallest sample was conducted at Nekemte Hospital, Oromia region [19]. All studies were conducted in five regions of Ethiopia. Of these studies, five were from Amhara region [16, 22, 25, 39, 40] another four from Southern Nations, Nationalities and Peoples Representative (SNNPR) [18, 21, 23, 41], four from Tigray [4, 24, 37, 42], two from Oromia [19, 20], and the remained one [43] was from Addis Ababa (Table 1).

Table 1

Characteristics of included studies in Ethiopia.

Author	Type of study	Region	Year	Sample	Case
Gessesew & Mengstie [4]	Cross sectional	Tigray	2002	5980	66
Admasu A et al. [16]	Cross sectional	Amhara	2004	1830	70
Astatkie G et al. [39]	Cross sectional	Amhara	2017	10379	254
Berhe Y et al. [42]	Cross sectional	Tigray	2015	5185	47
Dadi TL and yanirbab TE [21]	Case control	SNNPR	2017	9789	121
Yemane Y & Gizew [23]	Case control	SNNPR	2017	352	71
Mengstie H et al. [41]	Cross sectional	SNNPR	2016	8509	115
Getahun WT et al. [25]	Cross sectional	Amhara	2018	750	125
Denekew HT et al. [40]	Cross sectional	Amhara	2018	28835	262
Deneke F et al. [43]	Cross sectional	Addis Ababa	1996	127	8
Eshetie A et al. [18]	Cohort study	SNNP	2018	2498	46
Gebre S et al. [24]	Case control	Tigray	2017	5622	93
Bekabi TT [19]	Cross-sectional	Oromia	2018	3808	54
Workie A et al. [22]	Case control	Amhara	2018	-
Bereka MT et al. [37]	Case control	Tigray	2018	-
Abebe F et al. [20]	Case control	Oromia	2018	-

Prevalence of uterine rupture

The meta-analysis of thirteen studies showed that the pooled prevalence of uterine rupture in Ethiopia was 2% (95% CI: 1.99, 3.01). A random-effect model was used due to the presence of significant heterogeneity (I2 = 96.7%, p-value<0.05) (Fig 2). There is no publication bias based on the Eggers and Beggs test with a p-value of 0.249 and 0.246, respectively. The subgroup analysis revealed that the highest prevalence of uterine rupture occurred in the Amhara region, 5% (95% CI: 2.61, 8.37) and the lowest (1%) was observed in Tigray region (Fig 3). The funnel plot observation showed that there is a symmetrical distribution (Fig 4). In addition, sub-group analysis showed that the highest prevalence of uterine rupture was reported in case- control studies (4% (95% CI: 2.0, 5.0)) (Table 2). The univariate meta-regression model was done to identify the possible sources of heterogeneity based on the year of publication, type of study design and sample size, but none of these variables were found to be statistically significant (p-value >0.05).

Fig 2

Pooled prevalence of uterine rupture in Ethiopia.

Fig 3

Subgroup analysis of uterine rupture by region in Ethiopia.

Fig 4

Funnel plot of the prevalence of uterine rupture in Ethiopia.

Table 2

Subgroup analysis based on the type of study design.

Type of design	Number of studies includes	Prevalence (95% CI)	I 2
Cross-sectional	9	0.02 (95%CI:0.01,0.03)	70.2
Case control	3	0.04 (95%CI:0.02,0.05)	50.75
Cohort	1	0.02 (95%CI:0.01,0.02)	-

Sensitivity analysis

The result of sensitivity analyses using the random-effects model revealed that there was no single study unduly influenced the overall estimate of uterine rupture among Ethiopian women (S1 Fig). The sensitivity analysis also revealed that removing four findings based on study design have not influenced or changed the pooled prevalence of uterine rupture.

Predictors of uterine rupture

Association of previous cesarean section and uterine rupture

The meta-analysis of three studies [20, 22, 25] revealed that previous cesarean delivery was a significant predictor of uterine rupture. Women who had previous CS were ten times (OR: 9.95, 95% CI: 3.09, 32.1) more likely to have uterine rupture than women who did not have previous CS (Fig 5).

Fig 5

Forest plot on the association of previous CS with uterine rupture in Ethiopia.

Absence of antenatal care and uterine rupture

The meta-analysis of eight studies [18-24] revealed that an absence of ANC visit was another major predictor of uterine rupture in Ethiopia. Those women who had no ANC visit were 8.4 times (OR: 8.40 95% CI: 4.5, 15.7) more likely to experience a uterine rupture compared to mothers who attended ANC visit (Fig 6). The random-effects model was used due to a significant heterogeneity (with I2 = 85%, a p-value of <0.05).

Fig 6

Effect of absence ANC visit on uterine rupture in Ethiopia.

Association of place of residence and uterine rupture

Rural residents were more likely to had uterine rupture than those residing in the urban area (OR: 4.75, 95% CI: 1.17, 19.3) based on the pooled analysis of four studies [18, 20–22] (Fig 7).

Fig 7

Forest plot of the association of residence on uterine rupture in Ethiopia.

Association of obstructed labour and uterine rupture

The meta-analysis of five studies [22-25] also showed the odds of uterine rupture were more likely by nearly 7-folds (OR: 6.75, 95%CI: 1.92, 23.8) among those who had obstructed labour than those have no obstructed labour (Fig 8). The random-effects model was used due to presence of heterogeneity between the studies (p-value <0.05).

Fig 8

Forest plot of the association of obstructed labor and uterine rupture in Ethiopia.

Association of parity with uterine rupture

Based on the pooled results of seven studies included [19–22, 24, 25]; the meta-analysis also showed that grand multiparous women were 4.49 times (OR: 4.49, 95% CI: 2.83, 7.11) more likely to have uterine rupture than women with lower birth order. There was a significant heterogeneity; a random effect model was used (Fig 9).

Fig 9

Forest plot of effect of parity on uterine rupture in Ethiopia: A meta-analysis.

Discussion

This systematic review and meta-analysis revealed that the prevalence of uterine rupture was 2% (95% CI: 1.99%, 3.01%) at national level. This was higher than findings of 40 Low and middle income countries (LMICs) review (1%) [44], nation-wide studies conducted in United Kingdom (0.2%) [45], United States (0.02%) [46], the Netherlands (0.059%) [12], WHO systematic review (0.31%) [5], Nigeria (1.2%) [47], Uganda (0.5%) [48] and 0.67% of uterine rupture in Senegal and Mali [49]. The possible difference might be due to the variation in population characteristics, setting and quality of health care service provision and utilization. Besides, this might be explained due to high burden of obstructed labor, injudicious obstetric interventions/manipulations, lack of antenatal care, poor access to emergency obstetric care [11, 50] and lower birth preparedness and complication readiness plan in Ethiopia [51]. Thus, access to facility and community-based maternal health care and reproductive health care service should be improved.

The findings of this meta-analysis also found that the highest prevalence of uterine rupture has occurred in Amhara region and the lowest was in Tigray region. The possible variation of the burden of uterine rupture might be explained by the maternal health care service utilization differences, mainly ANC visit might attribute to the difference in the prevalence of uterine rupture among these regions. Hence, a recent national-level study in Ethiopia from the Demographic health survey data supported that the lowest and highest utilization of ANC visit was spatially clustered in Amhara region (39.8%) and Tigray (90%), respectively, which is a known contributing factor for uterine rupture [52]. Beyond this, socio-demographic characteristics, lifestyle activities might be attributed to the decrement of uterine rupture.

This systematic review and meta-analysis revealed that previous cesarean delivery was the strongest predictor of uterine rupture, in which the risk of uterine rupture was increased about ten times among women who gave birth through a CS in previous delivery. This finding was supported by a study conducted in the United Kingdom [45], Sweden [53], Uganda [54], Senegal and Mali [49] which reported women with a previous CS were at increased risk of uterine rupture. A similar meta-analysis [55], WHO multicounty survey [56] and perinatology findings [57] also supported this finding. The possible reason for this might be that the probability of post-partum infection and thereby weakening of the strength of uterus due to previous scar. Additionally, low level of antenatal care service utilization might reduce success of trial of labor after cesarean delivery. Since, providers cannot get mothers to assess the criteria to allow trial of labor or elective cesarean delivery.

The caesarean section rate is currently rising globally, as countries move from lower to higher Human Development Index categories and those who had better access to antenatal services, the women are the most likely to undergo a caesarean delivery [58, 59]. In 2014, 54% of the world's population who had CS lived in urban areas and this percentage is expected to rise to 66% by 2050 [60]. The WHO considers CS rates of 5–15% to be the optimal range for better maternal and perinatal outcomes [61]. Higher rates may suggest improper selection of candidates such as induction and pre-labor CS, a common cause of an increasing rate of CS [62].

Therefore, changes should be made to the future maternity care and birth management to reduce the rate of CS, including promotion of optimal management and improving future birth outcomes as country incomes and urbanization increase. For this, audits need to be done on the appropriateness of CS using a Robson classification for CS [63]. Robson classification can be an important global standard to monitor and compare the appropriateness of indications of CS within and between health-care facilities [62, 64]. Moreover, Sonographic lower upper segment (LUS) uterine scar thickness should be evaluated by clinicians in the prenatal period or during trial of labor; a means of reduction of uterine rupture among women with previous CS. Hence, LUS thickness predicts uterine rupture in women with a uterine scar defect [65-69].

In addition, this systematic review and meta-analysis also found that absence of ANC visit was another important predictor of uterine rupture (8 folds higher). The finding was supported by studies done in Uganda [48, 54], Senegal and Mali [49]. This could be explained because of those women who had no ANC visit during pregnancy are less likely get skilled birth attendance earlier within the golden time due to poor decisions about when to seek care during childbirth [70, 71]. This might again result from delay in getting the care and obstructed labor; subsequently increase the risk of uterine rupture. In the present study, place of residence was another predictor that significantly associated with uterine rupture, rural residents were more likely to have uterine rupture. This might be due to lower level of maternal health service utilization, inadequate birth preparedness and complication readiness plan and delay to care mainly phase I and II. Hence, delay of getting emergency obstetric care increased severe maternal morbidities and mortality [72-Journal of Health and Population in Developing Countries. 1997 ">75] and lack of an effective transfer system in LMICs remains a major predictor for uterine rupture [76]. This can also due to failure of early referral of labor abnormalities at the health center level, resulting in a delay in early intervention leading to obstructed labor and substantially ruptured uterus. The implementation of a program of consultation, feedback and integration on the referral system between peripheral delivery units and referral centers should be emphasized to decrease the prevalence of uterine rupture and its associated maternal morbidity.

In this meta- analysis, grand multiparity was significantly associated with uterine rupture which is in line with other findings [49, 54, 77]. The possible reason for this might be the weakening of grand multipara uterus and unable to cope up the stress of induction-augmentation in case of prolonged obstructed labor with a tetanic uterine contraction, and trial of labor, subsequently results in uterine rupture. Hence, induction-augmentation with oxytocin and trial of labor is associated with uterine rupture among multiparas [55, 77]. This implies the need for special care for high-risk mothers for early detection and management of complications during labor. Moreover, this systematic review and meta-analysis found that the risk of uterine rupture was significantly higher among women who had obstructed labor which is supported by other findings [5, 48, 49]. Obstructed labor is the leading cause of uterine rupture, contributing 83% to 93% cases of uterine rupture [43, 78]. This might be due to the fact that those women who have obstructed labor have a delay in seeking care with a hypertonic uterine contraction while accompanied with multiparity increases the chance of uterine rupture.

Limitations of the systematic review and meta-analysis

This systematic review and meta-analysis is the first national-level study done in Ethiopia and even in the LMICs on the pooled prevalence and predictors of uterine rupture. Despite, the results of this systematic review and meta-analysis should be interpreted based on some limitations. The highest heterogeneity of results among studies may be explained by heterogeneity in the characteristics of the studies, setting, and this may have led to insufficient statistical power to detect statistically significant association. Thus, a meta-regression analysis revealed that there was no variation due to sample size, publication year and type of study design. This systematic review and meta-analysis is also unable to assess the effect of a number of previous caesarean deliveries and birth interval since the last caesarean section on the risk of uterine rupture. In addition, the studies included were conducted only in the five regions, which might reduce its representativeness for the country, and some studies with a small sample size might affect the estimation.

Conclusion

Uterine rupture is still high in Ethiopia. This meta-analysis revealed that previous cesarean delivery, absence of ANC visit, rural residence, obstructed labour and grand multiparity were predictors of uterine rupture. Therefore, proper auditing on the appropriateness of CS and the appropriate labour monitoring to reduce cesarean delivery should be an area of improvements to decrease uterine rupture. Moreover, improving ANC visit, birth preparedness and complication readiness plan to reduce obstructed labour and family planning utilization are recommended to reduce the burden of uterine rupture.

(DOC)

Click here for additional data file.

PRISMA checklist for the prevalence and predictors of uterine rupture among Ethiopian women in Ethiopia: A systematic review and meta-analysis.

(DOC)

Click here for additional data file.

Search string of PubMed on prevalence of uterine rupture in Ethiopia.

(DOCX)

Click here for additional data file.

The sensitivity analysis prevalence of uterine rupture in Ethiopia.

(TIF)

Click here for additional data file.

22 Nov 2019

PONE-D-19-20515

Prevalence and predictors of uterine rupture among Ethiopian women: A systematic review and Meta- analysis

PLOS ONE

Dear Melaku Desta

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Kindly address all feedback provided by the reviewers, with particular attention to the approach used for the meta-analysis and whether the meta-regression should be removed.  Kindly take particular attention to typographical or grammatical errors throughout the manuscript.

We would appreciate receiving your revised manuscript by 22nd December 2019. When you are ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter.

To enhance the reproducibility of your results, we recommend that if applicable you deposit your laboratory protocols in protocols.io, where a protocol can be assigned its own identifier (DOI) such that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). This letter should be uploaded as separate file and labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. This file should be uploaded as separate file and labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. This file should be uploaded as separate file and labeled 'Manuscript'.

Please note while forming your response, if your article is accepted, you may have the opportunity to make the peer review history publicly available. The record will include editor decision letters (with reviews) and your responses to reviewer comments. If eligible, we will contact you to opt in or out.

We look forward to receiving your revised manuscript.

Kind regards,

Vicki Flenady

Academic Editor

PLOS ONE

Journal Requirements:

1. When submitting your revision, we need you to address these additional requirements.

Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

http://www.journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and http://www.journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. In the Methods, please include the mechanism by which study quality was assessed.

- Please provide the complete search strategy for at least one database as a new supporting information file.

3. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: I Don't Know

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The paper is generally well written and the methods used are appropriate. I will focus on methods and reporting

Major

1) Meta-analyses of proportions are a bit more complicated since transformations are needed to account for the 0 and 100% limits. Step 1: transformation; step 2: meta-analysis method using standard approach (i.e. inverse variance DerSimonian-Laird); step 3: back-transformation to percentages and plotting. One approach is logit transformation, which is explained in a different context here: http://www.bmj.com/content/352/bmj.i1114. However, a double arcsine transformation is the norm (http://jech.bmj.com/content/early/2013/08/20/jech-2013-203104). The method is implemented in the Stata module metaan http://www.stata-journal.com/article.html?article=st0201. Alternatively you can manually perform using the command you used (I suspect metan, although not referenced).

2) Meta-regression is a stab in the dark usually and is underpowered to detect anything but massive associations (effectively a regression with X observations, where X is the number of available studies). You should discuss this as a major limitation. Even with 60 or 80 studies, it can provide little insight.

3) Cochran Q (i.e. chi-square) is notoriously underpowered to detect heterogeneity, especially for small meta-analyses http://www.ncbi.nlm.nih.gov/pubmed/9595615. I would not use. (see also comment below regarding this and I^2)

4) Exclude the Getahun study which is an outliers and re-analyse - do things change a lot?

5) Report the confidence intervals for I^2 (calculated using heterogi or metaan in Stata) as argued in http://www.ncbi.nlm.nih.gov/pubmed/17974687. A simple formula exists in the seminal 2002 Higgins paper that proposed I^2.

6) Very high heterogeneity estimates which according to some researchers means studies should not be meta-analysed. However, I disagree with that assessment and I am not surprised at all by your heterogeneity estimates. You have large meta-analyses and there is a direct link between meta-analysis size and detected heterogeneity. I disagree with the argument that when large heterogeneity is picked up, studies should not be combined. In my view, large heterogeneity is the norm and it's great if it has been picked up and can be incorporated in the model. It is much more problematic when the underlying heterogeneity is not picked up and studies are "safely" combined under a homogeneity assumption. I think you can use this to defend your decision and the high heterogeneity: http://www.ncbi.nlm.nih.gov/pubmed/23922860

Minor

1) Abstract: I^2 is a statistic, not a test (or a test statistic)

2) There is no p-value associated with I^2, the authors mean Cochran's Q but see my other comment regarding this

3) Stata not STATA (not an acronym)

4) Some language corrections are needed in the methods section, from "Besides,..." onwards (which should read as "Next,...")

5) Which user-written commands in Stata did you use to perform the analyses? please cite.

6) Year may be worth considering in bias assessment, especially if you don't have enough studies for a formal test: http://www.ncbi.nlm.nih.gov/pubmed/25988604. With newer studies we would be more confident.

7) Clarify the weighting for the RR random effects model. Inverse variance (IV) or Mantel Haenszel (MH)? Note that MH is traditionally a fixed effect approach.

8) How was the random-effect model implemented, i.e. how was heterogeneity estimated? There are numerous ways to do so. Did they use the standard DerSimonian-Laird method? If so, please state so. Also there are better performing methods, for example please see https://www.ncbi.nlm.nih.gov/pubmed/28815652 and the metaan command in Stata where these are implemented.

Reviewer #2: This is an important paper in that it documents the continuing high risk of uterine rupture among mothers in Ethiopia.

The Methods and Results need some work.

Table 1. Characteristics of the included studies

Did all the studies define uterine rupture in the same way?

Were the studies population-based or hospital/clinic/village-based?

Are there any other characteristics of the studies that could be tabulated and might be helpful to the reader; e.g., accoucheur?

What was the outcome in the case-control studies? Was it uterine rupture? How can a case-control study provide an estimate of the prevalence of uterine rupture?

What was the design of the cohort study? Were mothers followed up from one pregnancy to the next?

Why did the Gretahun study observe a prevalence of 17%?

The 1996 and 2004 studies seem old; perhaps exclude?

Table 2.

There are not enough studies for a meta-regression; and the results are not critical to conclusions of the paper; and are not very informative. Suggest omit.

Publication bias

The assessment of publication bias is ok, but could be omitted; it doesn’t add much. Publication bias is more of an issue for meta analyses of RCTs.

Heterogeneity

It is probably useful to report I2. Q and the associated p-value could be omitted. They do not add anything.

Figure 1. Flow chart

More details are needed on why three papers could not be assessed and one paper was excluded because of low quality.

As above, Gretahun result is an extreme outlier. Some explanation is needed.

Statistical methods

More details on the methods are needed. For proportions <5% (say), as in your study, the sampling distribution might not be normally distributed. Therefore, some transformation is typically used (e.g., logit, double arcsin). Statistical packages, such as Stata and R, incorporate these transformations into their software programs for meta analyses of proportions. It is likely that the statistical package that you used did the transformation and back-transformation; you should document this.

Writing

The paper is clearly written. There are some typographical and grammatical errors, which should be corrected.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: Yes: Michael Coory

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files to be viewed.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email us at figures@plos.org. Please note that Supporting Information files do not need this step.

11 Jan 2020

Dear Editors and reviewers of Plos One

We would like to extend our deepest appreciation for devoting your time to review our manuscript entitled “Prevalence and predictors of uterine rupture among Ethiopian women: a systematic review and meta- analysis”. Uterine rupture is a global public problem that causes maternal morbidity, which can be prevented through assessing the prevalence and predictors of uterine rupture among women. Even though, the prevalence is inconsistent across the country. Therefore, this systematic review and meta-analysis estimates the pooled prevalence and predictors of uterine rupture among Ethiopian women among women in Ethiopia.

Dear reviewer, there has been a major revision of this manuscript (Abstract, introduction, methods, results, discussion and conclusions) with a correction of the previous edition. The journal requirements supposed by you have been included as search strategy has included as supplementary file and the whole structure of the manuscript has been revised. We hope now the manuscript is clear and more acceptable than its previous version. We have tried to present the paper in proper manner according to your comment what to supposed to do so. For this, here we have given our responses to each of the concerns you raised, highlighted by red color. Again, we would like to remind our strongest gratitude for your effort for the improvement of this manuscript and all the points were addressed in the point by point response.

Regards

3 Feb 2020

PONE-D-19-20515R1

Prevalence and predictors of uterine rupture among Ethiopian women: a systematic review and meta-analysis

PLOS ONE

Dear Melaku Desta

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

While the methods are generally adequate, some improvements and clarification is still required. Many key comments made by the reviewers have not been adequately addressed. Kindly provide a detailed response to each of the comments provided in your response letter, referring to the place in the manuscript the modification has been made or provide justification where changes were not made

Please pay particular attention to the comments regarding the use of meta-regression and subgroup analyses by type of study design. Please address the comment regarding the appropriateness of presenting a prevalence estimate for studies using a case control study design. Kindly define the exposure in more details such as "ANC visit".

Finally, please revise the manuscript to improve the English and formatting throughout including appropriate use of all abbreviations.

We would appreciate receiving your revised manuscript by Mar 19 2020 11:59PM. When you are ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter.

To enhance the reproducibility of your results, we recommend that if applicable you deposit your laboratory protocols in protocols.io, where a protocol can be assigned its own identifier (DOI) such that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). This letter should be uploaded as separate file and labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. This file should be uploaded as separate file and labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. This file should be uploaded as separate file and labeled 'Manuscript'.

Please note while forming your response, if your article is accepted, you may have the opportunity to make the peer review history publicly available. The record will include editor decision letters (with reviews) and your responses to reviewer comments. If eligible, we will contact you to opt in or out.

We look forward to receiving your revised manuscript.

Kind regards,

Vicki Jane Flenady

Academic Editor

PLOS ONE

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files to be viewed.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email us at figures@plos.org. Please note that Supporting Information files do not need this step.

8 Apr 2020

Dear Editors and reviewers of Plos One

We would like to extend our deepest appreciation for devoting your time to review our manuscript entitled “Prevalence and predictors of uterine rupture among Ethiopian women: a systematic review and meta- analysis”. Uterine rupture is a global public problem that causes maternal morbidity, which can be prevented through assessing the prevalence and predictors of uterine rupture among women. Even though, the prevalence is inconsistent across the country. Therefore, this systematic review and meta-analysis estimates the pooled prevalence and predictors of uterine rupture among Ethiopian women among women in Ethiopia.

Dear reviewer, there has been a major revision of this manuscript with a correction of the previous edition. The journal requirements supposed by you have been included as search strategy has included as supplementary file and the whole structure of the manuscript has been revised. We hope now the manuscript is clear and more acceptable than its previous version. We have tried to present the paper in proper manner according to your comment what to supposed to do so. For this, here we have given our responses to each of the concerns you raised, highlighted by red color. Many key comments made by the reviewers previously have been adequately addressed in detail to each of the comments provided in our response letter, referring to the place in the manuscript the modification has been made or provide justification where changes were not made. Again, we would like to remind our strongest gratitude for your effort for the improvement of this manuscript and all the points were addressed in the point by point response.

Regards

#1. Please pay particular attention to the comments regarding the use of meta-regression and subgroup analyses by type of study design. Highly valuable: we have done a meta- regression and sub-group analysis based on the type of study design. Thus, the meta regression showed that there is no significant source of heterogeneity.

#2. Please address the comment regarding the appropriateness of presenting a prevalence estimate for studies using a case control study design. The outcome in case control study was uterine rupture. Unfortunately, case control studies didn’t report proportions or prevalence data. Thus, what we did is that we used case control studies in this analysis if these studies reported the total number of cases encountered during the study period and the total number of deliveries reported in that specific period. We didn’t take the sample of cases and controls that used for factor analysis only used by the author. Example, in the study done by Dadi & Yanirbab was a case control study with a participant of 363, but in the results section the total number of cases reported from 2011 to August 2016 was 121 form the total (9789) of women who gave birth in the hospital was used for estimate the prevalence and the same for Gebrie S et al a case control study, but report the total number of deliveries (5622) and the total number of cases from 2009 to 2014 in Suhul hospital was 93. But, studies which didn’t report such total number of cases and total deliveries in the time period is excluded from the pooled prevalence analysis of uterine rupture such as Abebe F et al, Workie A et al and Bereka TM et al instead of used only for factor analysis. Thus, presenting a prevalence estimate for case control studies was done in case of the total number of live births and cases were reported within the reference period of study as mentioned above unless excluded from the prevalence estimate.

#3. Meta-analyses of proportions are a bit more complicated since transformations are needed to account for the 0 and 100% limits. Transformation; meta-analysis method using standard approach (i.e. inverse variance DerSimonian-Laird); step 3: back-transformation to percentages and plotting method is implemented. Transformation for meta-analysis is one part of analysis. But, up to our knowledge it is not necessarily. Unfortunately we did transformations using transformation with a DerSimonian-Laird. In regard to the citation it is well known that the metaprop command is available on many Cochrane meta-analysis hand books. Even if, we have put a citation the main document in the analysis section. But, what we supposed to informs you is that due to the lower proportions reported in this analysis the figure of the pooled proportion approximates to two digits to the lower one that makes the confidence interval or the confidence limit lowers and even the point estimate and the lower limit sometimes the same due the lower margin of error and lower of the transformed proportion. Hence, margin of error decreases as the sample size increases in our case. For the random effects model, the confidence interval can tend toward zero only with an infinite number of studies (unless the between-study variation is zero).

#4. Meta-regression is a stab in the dark usually and is underpowered to detect anything but massive associations (effectively a regression with X observations, where X is the number of available studies). You should discuss this as a major limitation. Even with 60 or 80 studies, it can provide little insight. I have revised and an insight on the meta-regressions is highlighted in the limitations section. The point estimate I2 should be interpreted cautiously when a meta-analysis has few studies. In small meta-analyses, confidence intervals should supplement or replace the biased point estimate.

#5. More details are needed on why three papers could not be assessed and one paper was excluded because of low quality. The details on the reseasons of exclusion of the studies were included in the PRISMA flow diagram. Hence, the three studies haven’t full text and unable to review the quality of other characteristics, thus excluded from the analysis.

#6. More details on the methods are needed. For proportions <5% (say), as in your study, the sampling distribution might not be normally distributed. Therefore, some transformation is typically used (e.g., logit, double arcsin). It is likely that the statistical package that you used did the transformation and back-transformation; you should document this. Clarify the weighting for the RR random effects model. Inverse variance (IV) or Mantel Haenszel (MH)? How was the random-effect model implemented ? Thus, as a result a random effects meta-analysis model was used to estimate the DerSimonian and Laird’s pooled effect. In the current meta-analysis, arcsine-transformed proportions were used. The pooled proportion was estimated by using the back-transform of the inverse variance weighted mean of the transformed proportions, using arcsine weights for the fixed-effects model and DerSimonian-Laird weights for the random-effects model (31). The heterogeneity was also estimated using derSimonian-Laird method.

# 7. In regard to the Getahun study, why did the Gretahun study observe a prevalence of 17% and Getahun result is an extreme outlier, some explanation is needed.

Unfortunately, the Getahun et al finding is a representative and high quality data that was conducted in the three referral hospital of Amhara region with a large sample size. But, other study setting is only one hospital and also includes district hospitals. Thus, due referral hospitals and 3 hospitals with high case flow obstetric complications including uterine rupture are to be higher that other studies finding. Even, the sensitivity analysis that putted as additional file also revealed that the overall pooled prevalence was not affected by the finding of Getahun et al. Furthermore the study have included almost five years data of the referral hospitals of Amhara regional state, institution-based cross-sectional study, from 2013-2017. Therefore, all authors decided agreed not to exclude this study.

# 8. Are there any other characteristics of the studies that could be tabulated and might be helpful to the reader?

We try to include the important characteristics what we have try to get from the studies. Unfortunately not such important reporting of the charactetstcis of accoucheur. Hence, those women who have uterine rupture are managed by a sinor obstetrician or resident of obstetrics and gynecology. But, those individuals who work at maternal health service as midwives or nurses should be scale of their professional skills in early referral of prolonged or obstructed labour, the commonest predictor of uterine rupture. Even though, if we are interested to include the professional charactetstcis, we can’t get any data. Hence, uterine rupture is already managed by the specialist gynecologists and gets the service at the tertiary or referral centers. But, what you supposed should be done at primary studies to understand the gap from where it arise either from source of referral, as health center or women’s seeking of care or getting the care after referral.

Regards

17 Aug 2020

PONE-D-19-20515R2

Prevalence and predictors of uterine rupture among Ethiopian women: a systematic review and meta-analysis

PLOS ONE

Dear Dr. desta,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Your manuscript has been assessed by two reviewers, whose comments are appended below. One of the reviewers does not think that the revisions have gone far enough to address the concerns that were initially raised; this concern was also noted by the Academic Editor in the last round of review. Therefore, please ensure that you respond to all comments by making the appropriate revisions. To address the remaining concerns about the clarity of the manuscript text, we recommend having your manuscript copy edited for language usage and grammar, for instance by a third party or a professional service.

Please submit your revised manuscript by Sep 28 2020 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

Emily Chenette

Deputy Editor in Chief

PLOS ONE

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

Reviewer #3: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #3: N/A

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

Reviewer #3: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The structure of the responses was muddled and I couldn't clearly see all the comments I made and the responses.

The language is still a bit poor at times and some of the previous comments have not been actioned and the response regarding them was not clear (e.g. confidence intervals for I^2). Mention the user-written sofware you used in Stata.

Reviewer #3: The manuscript is now well structured and compliant with the reviewers' requests. There are only two notes to make.

Abstract

What is ANC visit? Please clear the acronym before the acronym.

Introduction

Authors reported: …..partial rupture in which a defect in the myometrium is covered by the visceral leaf of the peritoneum….it is a dehiscence. Please, state it.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #3: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

8 Sep 2020

Editor

To address the remaining concerns about the clarity of the manuscript text, we recommend having your manuscript copy edited for language usage and grammar, for instance by a third party or a professional service.

Thank you for your highly schoalry comments

The manuscriput was copy editted for language usage and grammer.

Reviewer #1: The structure of the responses was muddled and I couldn't clearly see all the comments I made and the responses.

The language is still a bit poor at times and some of the previous comments have not been actioned and the response regarding them was not clear (e.g. confidence intervals for I^2). Mention the user-written software you used in Stata.

Thank you for your suggestion and highly scholarly comments and response was given for each point as much as possible in clearly manner in the response to reviewers section of the separated file. The metaprop software was used in Stata to estimate the pooled prevalence.

- Abstract

What is ANC visit? Please clear the acronym before the acronym.

Accepted and the the acronym in the abstract is spelled as antenatal care visit and the acronym started at the introduction section as antenatal care (ANC) visit.

Authors reported: …..partial rupture in which a defect in the myometrium is covered by the visceral leaf of the peritoneum….it is a dehiscence. Please, state it.

Partial uterine rupture is not mean that dehiscence in this case which seems what you supposed to do so. Hence, our outcome of interest was uterine rupture regardless of previous cesarean section. Hence, dehiscence is the separation of portion of previous scar of the uterus. Thus, it is corrected as tearing of the myometrium than a defect in the myometrium.

Submitted filename: Response to reviewers.docx

Click here for additional data file.

1 Oct 2020

Prevalence and predictors of uterine rupture among Ethiopian women: a systematic review and meta-analysis

PONE-D-19-20515R3

Dear Desta

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Gizachew Tessema, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

Reviewer #3: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: (No Response)

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #3: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The language is much better but I still do not see the confidence intervals for I^2 reported, even though the authors say they are reporting then now

Reviewer #3: The authors diligently answered the reviewers' questions and completely corrected the manuscript by submitting the third version of the paper.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #3: Yes: ANDREA TINELLI

22 Oct 2020

PONE-D-19-20515R3

Prevalence and predictors of uterine rupture among Ethiopian women: a systematic review and meta-analysis

Dear Dr. Desta:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Gizachew Tessema

Academic Editor

PLOS ONE