Prevalence, causes, and factors associated with obstructed labour among mothers who gave birth at public health facilities in Mojo Town, Central Ethiopia, 2019: A cross-sectional study.

BACKGROUND: Obstructed labour is a type of abnormal labour that is one of the causes of obstetric complications such as maternal and fetal mortality and morbidity. Early detection is the key to reducing complications.
OBJECTIVE: This study aimed to assess the prevalence, causes, and factors associated with obstructed labor among mothers who gave birth at public health facilities in Mojo Town, Central Ethiopia.
METHODS: An institution-based cross-sectional study was conducted from November 10 to December 30, 2019 among 318 women who gave birth at public health facilities in Mojo Town. Face-to-face interviews and participants' medical record reviews were utilized to gather data. The collected data were checked, coded, and entered into EpiData version 3.1 and then exported to SPSS version 23 for analysis. A binary logistic regression model was used to test the association between the dependent and independent variables. In bivariate analysis, all variables with a p-value less than 0.25 were included in multivariate analysis. Finally, a significant statistical association was declared at a p-value less than 0.05.
RESULTS: The prevalence of obstructed labour in this study was 51 (16%), and cephalo-pelvic disproportion (66%), mal-presentation (22%), and mal-position (12%) were reported as causes of obstructed labour. Primgravidity (AOR = 7.74: 95%CI = 2.13, 18.2) and a one-time antenatal care follow-up (AOR = 9.50: 95%CI: 1.91, 33.07) were found to be associated factors with obstructed labour, while labour duration of 12-24 hours (AOR = 0.20: 95%CI = 0.17, 0.87) was identified as a factor decreasing the risk of obstructed labour.
CONCLUSION: The prevalence of obstructed labour in this study was higher than in the majority of previous similar local and global studies. In this study setting, cephalo-pelvic disproportion, mal-presentation, and mal-position were found to be the causes of obstetric labour. Additionally, factors such as gravidity, frequency of antenatal follow-up, and duration of labour were significantly associated with obstructed labour. Therefore, the concerned entities need to work to curb young age pregnancy as well as to strengthen counselling mothers on the importance of subsequent antenatal-follows in the prevention of obstructed labour.

Introduction

Obstructed labour (OL) is defined as labour that does not advance despite adequate uterine contractions because fetal size is out of proportion to the mother’s birth canal [1-3]. The presence of slow cervical dilatation, sluggish or no descent, and the development of pathological rings in the lower uterine segment all point to the diagnosis of OL [3].

OL has negative effects on both the mother and her fetus if it is neglected, not properly recognized, or not treated. It is one of the obstetrical tragedies that result in labour complications like infection, damage to nearby tissues, uterine rupture, and the mother’s death from hemorrhagic shock. Additionally, it results in stillbirth and infant hypoxia [4]. Furthermore, OL results in obstetric fistula, the most common obstetric morbidity, as a long-term consequence [5-8].

The burden of OL is outmoded in economically advanced countries. It is, however, still high in countries with limited access to obstetric care [1,9]. In resource-limited countries, OL accounted for 22% and 9% of pregnancy complications and maternal mortality (MM), respectively. Sub-Saharan Africa’s region, including Ethiopia, was responsible for nearly one-quarter (24%) of MM [10]. In Ethiopia alone, it accounted for 17.3% of MM and 39.7% of stillbirths [4,11]. The incidence and prevalence of OL vary geographically in Ethiopia. For instance, it was 3.3% and 12.2% in the northern and southwestern parts of the country, respectively [12,13].

The causes of OL are mechanical factors that disproportionately affect the passenger and the pathway (birth canal). These factors include cephalo-pelvic disproportion (CPD), mal-presentation, and malposition, which are the most common causes of OL [12,14-19]. The rare causes of OL include locked twins, fetal anomalies, and maternal soft tissue tumors such as fibroids [3,17,20].

According to the scientific facts, socio-demographic features, obstetric characteristics, and healthcare facility-related factors were shown to be associated with OL. The age of the mother, place of residence, and level of education were socio-demographic features associated with OL [1,4,21-24]. Based on obstetrical factors, gravidity, frequency of antenatal visits, and birth to big baby were all associated with OL [1,22-26]. Distance from the health facility, use of partographs, and duration of labor were all health facility-related factors associated with OL [1,11,22,24,27].

Fortunately, OL is a preventable obstetric hazard. Strategies that include increasing maternal knowledge of obstetric danger signs, birth preparedness, and skilled delivery [26,28] and adequate childhood and adulthood nutritional intake are important to reduce obstructed labour [1]. Furthermore, pelvic assessment, risk identification, early diagnosis of mal-presentation/malposition, measuring the descent of the fetal presenting part, labour follow-up with partograph, and vacuum extraction are basic health care practitioner skills required for OL management and prevention [29,30].

Despite many strategies, such as the establishment of maternal waiting homes and improved access to comprehensive emergency obstetric care (CEmOC), the burden of OL is still high in Ethiopia [27]. There has been a paucity of data on the OL in our study area, especially in central Ethiopia. Therefore, the aims of this study were to assess the prevalence of OL, to identify its causes, as well as to determine factors associated with OL among mothers who gave birth in Mojo Town.

Methods and materials

Study design, setting and period

An institution-based cross-sectional study was conducted in Mojo town from November 10 to December 30, 2019. Mojo town is located in the East Shoa Zone of Oromia Regional State, Central Ethiopia, which is 77 km away from Addis Ababa. In the town, there was one public hospital, one private hospital, and three health centres. Actually, this study was conducted at Mojo hospital, which is one of the public facilities in Mojo town. Mojo Hospital has been offering a variety of services to clients referred by local health canters. The estimated catchment population of the hospital was around 357,095 thousand clients. Of these, males account for 181698 and 17539 females. A total of 155 medical and supportive staff were given service at the hospital. Concerning the obstetrics and gynaecology services, the hospital had 12 midwives, 3 Integrated Emergency Surgery and Obstetrics (IESO), and it had 9 beds in the gynaecology ward and 11 beds in both labour and delivery rooms. The estimated annual average number of delivery cases in Mojo hospital was 1838.

Population and eligibility criteria

In this study, all women who gave birth at public health facilities in Mojo Town were considered as the source population, and women who were systematically selected for the study were the study population. However, women who were severely sick during data collection and those who were referred to other facilities were excluded from this study. Likewise, women who delivered by elective cesarean section were excluded.

Sample size calculation

The sample size for the first objective was determined using the single population proportion formula and the assumptions used were: a 95% confidence interval (CI); 4% margin of error; and a population proportion of 34.3%, which was taken from a study conducted in Western Harerghe zone public hospitals [27].

We have used a correction formula of nf = 344/(1 + 344/1836) = 289, and a response rate of 10%. So, the final calculated sample size was n = 318. The sample size for the second objective was calculated by using epi info version 7.2. Assumptions such as 95%CI, 80% power, 0.69 odds ratio, and the age of the mother being less than 19 were associated with obstructed labor (taken from a study conducted in Halaba Kulito primary hospital [21]. Hence, the total sample size for the second objective with a 10% non-response rate was n = 299. The total number of participants in the study was n = 318, which exceeded the n = 299 sample size for the second aim.

Sampling technique

Mojo Town has three public health facilities (a hospital and two health centers), and we randomly selected Mojo Hospital (35% of the facilities) in order to ensure the sample is representative and economic. Then a consecutive sampling technique was used to select the study participants in the postpartum unit. Since the labour cases came from different socio-demographic backgrounds (with unique characteristics) in the town, we assumed that the study unit was representative of the source population.

Study variables

Fig 1 describes the outcome and explanatory variables of this study. Obstructed labor and causes of obstructed labour were the outcome variables, while socio-demographic features, obstetric characteristics, labour outcomes, and healthcare facility-related factors were considered as explanatory variables.

Fig 1

A conceptual framework describing the outcome and explanatory variables of obstructed labour and its associated factors among women who gave birth at public health facilities in Mojo Town, Central Ethiopia, 2019.

Operational definitions

Obstructed labor: is referred as failure of descent of the fetus in the birth canal for mechanical reasons in spite of good uterine contraction [1,2,31,32].

Malposition: any position of the vertex other than occipito-anterior (occipito-posterior and occipito-transverse) [31,32].

Cephalo-pelvic disproportion (CPD): Refers to a mismatch between the fetal head and the mother’s pelvic brim [31,32].

Mal-presentation: Refers to any presentation other than vertex(brow, face, breech, transverse) [31,32].

High birth weight: Refers to the weight of baby at birth is 4000gm and above [31,32].

Normal birth weight: When the weight of baby at birth is between 2500gm-3999gm [31,32].

Low birth weight: Refers to the weight of baby at birth is between 1500gm-2499gm [31,32].

Antenatal care follow-up: Refers to the mother reported that she had visited any health institution during her recent pregnancy [33,34].

Data collection tools and procedures

Face-to-face interviews were utilized to gather data, and a structured questionnaire adapted from other studies conducted in the Mettu Karl Referral Hospital, Harergehe, Halaba, Welega, and Adama [16,21,27,35,36] was used for data collection. In addition, the tool was validated in the previous studies. The English version of the questionnaire was translated to the local language (Afan Oromo) and then retranslated back to English by two language experts to ensure its consistency [S1 and S2 Files]. From November 10 to December 30, 2019, two BSc midwives (who work outside of the study area) and a supervisor collected data. After taking consent, the data collectors interviewed study participants and reviewed their respective clinical information from medical records.

Data quality control

The training was given to data collectors and the supervisor two days prior to data collection. The questionnaire was translated to the local language to make it clear to the participants. The data collection process was thoroughly monitored by the supervisor on a daily basis. Moreover, data were checked for completeness, adequacy, and consistency before analysis.

Data processing and analysis

The collected data were checked, coded, and entered into EpiData version 3.1 and then exported to SPSS version 23 for analysis. Descriptive statistics such as frequency, mean, and standard deviation were used to describe socio-demographic, obstetric, and healthcare characteristics. A binary logistic regression model was used to identify the association between the independent and the outcome variable. To verify the significant association, variables with a P-value < 0.25 in the bivariate model were re-entered into a multivariable logistic regression model. Finally, variables with a P-value of < 0.05 were considered statistically significant. The variance inflation factor (VIF) and tolerance tastes were used to check the presence of multicollinearity among the covariates. Moreover, the Hosmer-Lemeshow goodness of fit model was used to assess whether the number of expected events from the logistic regression model reflects the number of observed events in the data.

Ethical consideration

An ethical clearance letter was obtained from the Institutional Ethical Review Board (IERB) of Adama Hospital Medical College. In addition, a permission letter was obtained from the Mojo Town health office and Mojo hospital prior to data collection. After a detailed explanation of the study’s benefits and risks, verbal consent was obtained from each participant to assert willingness.

Results

Socio-demographic characteristics of participants

In this study, 318 subjects participated, with a response rate of 100%. The mean age of the participants was 25.6 with an SD ± 5.86. More than one-third (36.5%) of participants were aged 20–24 years. Two hundred four (63.9%) of the participants were urban residents. One hundred eighteen (37%) of them attended primary education. In terms of occupation, 189 (59.2%) participants were housewives [Table 1].

Table 1

Socio-demographic characteristics of women who gave birth at public health facilities in Mojo town, Central Ethiopia, 2019 (n = 318).

Variables	Categories	Frequencies	Percentages (%)
Age (in year)	≤ 19	41	12.9
	20–24	116	36.5
	25–29	98	30.8
	30–34	39	12.3
	≥ 35	24	7.5
Residency	Urban	204	64.1
	Rural	114	35.8
Educational status	Uneducated	54	17
	Primary	118	37.1
	Secondary	72	22.6
	Collage and above	74	23.3
Religion	Orthodox	209	65.5
	Muslim	36	11.3
	Protestant	46	14.4
	Waqefata	15	8.8
Occupation	Private Organization	32	10.0
	Government employee/ employer	26	8.2
	Merchant	28	8.8
	Private own work	30	9.4
	House wife	189	59.2
	Others*	13	4.1

Note:

* Daily labor workers and students.

Obstetric characteristics and labour outcomes

Nearly one-half (47.4%) of participants were primigravida. More than one-half of participants stayed less than twelve hours in labour. The majority, 303 (95.2%) of the participants had ANC follow-ups, of whom 244 (76.7%) had more than two-time follow-ups. One-third, 113 (35.5%) of participants had a previous bad obstetric history. Nearly one-quarter of participants experienced maternal and fetal complications [Table 2].

Table 2

Obstetric characteristics and labour outcomes of women who gave birth at public health facilities in Mojo town, Central Ethiopia, 2019 (n = 318).

Variables	Categories	Frequencies	Percentages
Gravidity	Multigravidea	167	52.6
	Primigarvidea	151	47.4
Duration of labour (in hour)	<12	167	52.5
	12–24	115	36.1
	>24	36	11.3
ANC follow-up	Yes	293	92.1
	No	25	4.7
Frequency of ANC follow-up (n = 293)	>Two-times	244	76.7
	Two-times	24	7.5
	One-time	25	7.9
Place of ANC follow-up	Mojo hospital	92	31.4
	Other facilities	201	68.6
Previous bad obstetrics history	No	205	64.5
	Yes	113	35.5
Apgar score	7–10a	229	72
	4–6b	69	21.7
	0–3c	20	6.3
Birth weight (in grams)	<2500	33	10.7
	≥ 2500–4000	247	77.7
	>4000	37	11.6
Maternal complication	No	245	77.0
	Yes	73	23.0
Fetal complication	No	240	75.5
	Yes	78	24.5

Note:

Reassuring,

moderately abnormal,

low.

Healthcare facility-related characteristics of participants

More than one-half of cases were completely followed-up with partograph by midwives. A total of 188 participants (59.1%) were referred from nearby health facilities. Moreover, more than three-fourths of participants lived within less than an hour’s distance of a health facility [Table 3].

Table 3

The healthcare facility-related characteristics of mothers who gave birth at public health facilities in Mojo town, Central Ethiopia, 2019 (n = 318).

Variables	Categories	Frequencies	Percentages
Estimated time to health facility (in hour)	<1 hr.	247	77.7
	1–2 hr.	56	17.6
	≥ 3 hr.	15	4.7
Source of referral	Referral from health facility	188	59.1
	Self-referral	39	12.3
Partograph utilization	Completely filled	165	51.9
	Not completed	100	31.4
	Not filled at all	53	16.6

Prevalence and causes of obstructed labour

In this study, the prevalence of OL was 51 (16%) (95%CI: 14.25, 17.65). Of these, CPD 33 (66%), mal-presentation 11 (22%), and mal-position 7 (12%) were reported by the clinicians as the causes of OL [Fig 2].

Fig 2

Causes of obstructed labour among women gave birth at public health facilities in Mojo Town, Central Ethiopia, 2019.

Factors associated with obstructed labour

A binary logistic regression analysis was done to identify factors associated with obstructed labour. In the bivariate analysis, variables such as age, residency, previous bad obstetric history, gravidity, duration of labour, and frequency of ANC follow-up were shown to be associated at a p-value of less than 0.25. In multivariate analysis (after controlling for potential confounders), variables such as gravidity, frequency of ANC follow-up, and duration of labour showed an independent association with OL.

Accordingly, primigravidae mothers were 7 times more likely to encounter obstructed labour when compared to multigravidae (AOR; 7.748, 95%CI: 2.128, 18.29). The odds of developing OL were 9.5 times higher in mothers who had one ANC follow-up compared to mothers who had more than two ANC follow-ups (AOR; 9.5, 95%CI: 1.91, 33.07).

Moreover, in this study, the likelihood of developing OL was 20% lower among mothers who stayed 12–24 hours in labour when compared to those who stayed for less than 12 hours (AOR: 0.20, 95%CI: 0.17, 0.87) [Table 4].

Table 4

Factors associated with obstructed labour among women gave birth at public health facilities in Mojo town, Central Ethiopia, 2019 (n = 318).

Variables	Categories	Obstructed labour		COR(95%CI)	AOR(95%CI)
		Yes (%)	No (%)
Age(in years)	≤ 19	21(6.6)	20(6.3)	0.88(0.33, 0.97)	0.73(0.38, 0.91)
	20–24	44(13.8)	77(24.2)	0.48(0.08, 0.79)	0.62(0.15, 0.83)
	25–29	38(11.9)	55(17.3)	0.58(0.12, 0.94)	0.41(0.18, 0.97)
	30–34	11(3.5)	28(8.8)	0.33(0.06, 0.67)	0.31(0.03, 0.93)
	≥ 35	13(4.1)	11(3.5)	1	1
Place of residence	Urban	77(24.2)	127(40.0)	1	1
	Rural	63(19.8)	51(16.0)	2.04(1.36, 5.85)	1.65(0.99, 2.85)
Previous bad obstetrics Hx	No	82(25.8)	123(38.7)	1	1
	Yes	61(19.2)	52(16.3)	1.76(1.01, 3.05)	1.90(1.25, 3.63)
Gravidity	Primibravidae	40(26.4)	111(73.3)	5.11(2.51,10.39)	7.75 (2.12,18.29)**
	Multigravida	11(6.6)	156(93.4)	1	1
Duration of Labor	<12 hours	6(3.5)	161(96.4)	1	1
	12–24 hours	16(13.7)	100(86.2)	0.23(0.11, 0.92)	0.20(0.17,0.87) *
	>24 hours	29(80.5)	7(19.4)	0.01(0.009,1.10)	0.03(0.02,1.05)
Frequency of ANC Follow-up	One	16(64)	9(36)	7.58(2.32, 13.08.)	9.50(1.91,33.07) *
	Two	4(16)	20(84)	0.81(0.32, 1.15)	0.76(0.27, 1.53)
	> two	22(20.4)	222(87)	1	1

Note:

History,

** strongly significant association at p-value< 0.001,

* Significant association at p-value <0.05, and

reference group.

Discussion

Obstructed labour has been one of the significant causes of obstetric complications such as maternal and prenatal mortality and morbidity, especially in developing countries including Ethiopia. This study aimed to assess the prevalence, causes, and factors associated with obstructed labour in Mojo Town, Central Ethiopia. Accordingly, the prevalence of OL in the area was 16%. The current prevalence is lower compared to findings from the previous studies conducted in public hospitals in the Harergeh zone (34.30%), Halaba Kulito Hospital (18.6%), and West Wollega zone (18.1%) [21,27,35]. The possible reason for this discrepancy could be due to variations in the study design and period. It could also be tied to socio-demographic differences in the current and previous study populations.

The present prevalence is higher than in three studies conducted in India (a governmental medical college in Jhalawar (1.1%), Patna Medical College and Hospital (8.9%), and Hyderabad (3.61%)), Sokoto, Nigeria (2.0%), a community study from Uganda (10.5%), Adgrat zonal Hospitals (3.3%), Mizan-Aman General Hospital (7.95%), Mizan-Tepi University Teaching Hospital (15.6%), Mettu Karl Referral Hospital (4.1%), Jimma University Specialized Hospital (12.2%) and Adama Hospital Medical College (9.6%) [9,12,13,16,28,36-41]. The discrepancy could be related to the difference in the study design and socio-demographic variations among the current and previous study populations.

This study identified the causes of OL in our study area. Accordingly, CPD (66%), mal-presentation (22%), and mal-position (12%) were reported as causes of OL. This finding is consistent with the previous studies conducted in Bangladesh, India, Nigeria, Uganda, the Tigray region, Mizan Aman, Jimma, and Adama [12,13,22,28,36,38,40,42]. However, the current proportion is different from that of a study conducted in Bihar, India in which mal-position was the major cause of OL, followed by CPD, and mal-presentation [37]. The reason for this difference might be due to nutritional and socio-demographic variation in the two populations.

In this study, primigravidity was found to be an associated factor with OL. The odds of developing obstructed labour among primigravida were 7 times higher than compared to multigravida. This association was supported by studies conducted in Bangladesh, eastern Uganda, and Gimbi Town public hospitals [25,35,42]. This association might result from the psychological impact of the primiparous mother on the labour mechanism.

In the present study, the likelihood of encountering OL was 9.5 times higher among mothers who had one ANC follow-up compared to those who had more than two ANC follow-ups. This result was supported by a finding from a study conducted in Mizan Aman, Ethiopia [38]. This significance is tied to the scientific fact that women who had frequent ANC follow-ups could potentially benefit from early identification and prevention of OL prior to the onset of labour.

Moreover, the normal duration of labour was found to be protective for OL. Mothers who stayed 12–24 hours in labour were 20% less likely to develop OL. This finding is supported by a study conducted at Adama hospital [36]. The association resembles the truth that OL is pronounced in the prolonged duration of labour.

Despite the clinical and scientific plausibility, variables such as the weight of the baby and the age of the mother were not shown to be associated with OL in the current study. These variables are important attributes of OL, as evidenced by previous literature [11,36,42]. The possible reason for this difference might be due to a difference in the study designs of the current and previous studies.

Our study’s strength comes from its full response rate. However, the cross-sectional nature of this study limits us from asserting a cause-effect relationship. Additionally, the reliability of each diagnosed case is questionable because this study relied solely on medical diagnoses to assess obstructed labor and its causes. We therefore suggest future researchers identify cause-and-effect relationships using rigorous designs, such as experimental studies.

Conclusion

The prevalence of OL in the study area was higher than the majority of previous similar local and global studies. CPD, mal-presentation, and mal-position were reported as causes of OL. In addition, factors such as gravidity, frequency of ANC follow-up, and duration of labour were significantly associated with OL. Therefore, the concerned entities need to work to strengthen early risk identification and counsel mothers on the importance of subsequent ANC-follows in the prevention of OL. Strategies including early detection of OL and management training for healthcare providers need to be emphasized in healthcare facilities. Additionally, we recommend researchers dig out other possible causes and risk factors of OL by using strong study designs.

English version questionnaire.

(DOCX)

Click here for additional data file.

Afan Oromo version questionnaire.

(DOCX)

Click here for additional data file.

STROBE statement checklist.

(DOCX)

Click here for additional data file.

(XLS)

Click here for additional data file.

27 Jun 2022

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: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Jianhong Zhou

Staff Editor

PLOS ONE

Journal Requirements:

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

1. 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

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. In your Data Availability statement, you have not specified where the minimal data set underlying the results described in your manuscript can be found. PLOS defines a study's minimal data set as the underlying data used to reach the conclusions drawn in the manuscript and any additional data required to replicate the reported study findings in their entirety. All PLOS journals require that the minimal data set be made fully available. For more information about our data policy, please see http://journals.plos.org/plosone/s/data-availability.

Upon re-submitting your revised manuscript, please upload your study’s minimal underlying data set as either Supporting Information files or to a stable, public repository and include the relevant URLs, DOIs, or accession numbers within your revised cover letter. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. Any potentially identifying patient information must be fully anonymized.

Important: If there are ethical or legal restrictions to sharing your data publicly, please explain these restrictions in detail. Please see our guidelines for more information on what we consider unacceptable restrictions to publicly sharing data: http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. Note that it is not acceptable for the authors to be the sole named individuals responsible for ensuring data access.

We will update your Data Availability statement to reflect the information you provide in your cover letter.

3. We note that you have stated that you will provide repository information for your data at acceptance. Should your manuscript be accepted for publication, we will hold it until you provide the relevant accession numbers or DOIs necessary to access your data. If you wish to make changes to your Data Availability statement, please describe these changes in your cover letter and we will update your Data Availability statement to reflect the information you provide.

4. Please ensure that you refer to Figure 1 in your text as, if accepted, production will need this reference to link the reader to the figure.

5. 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

Reviewer #3: No

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

**********

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

Reviewer #3: No

**********

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

Reviewer #3: No

**********

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: Review Comments to the Author

1. Needs English language correction.

2. It is a good effort and may help in reduction of such complications

Reviewer #2: 1) The area studied is of great clinical importance. Unfortunately, many women still experience labour complications and these contribute to the maternal morbidity and mortality.

2) The manuscript is relevant, it has numerous grammatical and typographical errors that need to be corrected.

3) The background/introduction has many sentences constituting paragraphs. Please coalesce most of them into relevant paragraphs and stratify them as follows:

a) Important definitions such as Obstructed labour, including the burden of obstructed labour globally, in Africa/sub-Saharan Africa and in Ethiopia

b) The causes of obstructed labour

c) The factors associated with obstructed labour

N.B: Not sure that the last sentence in the background about this being a pioneer study is relevant here. Which databases did the authors search to come to this conclusions?

4) In the methods, the use of the term cephalo-pelvic disproportion is misleading. What exactly caused the disproportion is the real cause of obstructed labour. Please, if possible, unpack the cephalo-pelvic disproportion variable.

5) Under birth weight, you write that a high birth weight is when the weight of baby at birth is 400gm and above. This is wrong. 400gm is too low to be a high fetal weight. I guess you meant 4000gm! Please correct this anomaly!

The normal birth weight range is also not 2500gm-399gm but 2500-3999gm! Also correct this anomaly!

6) In the analysis part, please state how categorical and continuous variables were analysed instead of clamping everything together.

7) In results, in Table 1 you state under occupation that the category "other" meant daily labour worker. Were there any other considerations under that category? If not, then just write daily labour worker directly in the table.

Under APGAR SCORE, what was the rationale of using the ranges the author uses? If possible, please stratify your APGAR SCORE as follows:

7–10: Reassuring

4–6: Moderately abnormal

0–3: Low

8) Under discussion, the content is there but needs to be improved. Please write your discussion as follows:

State your results, then results from comparable studies and the possible explanation for the similarities or differences between your study results and the quoted studies.

Otherwise your study is of great importance.

Reviewer #3: Review summary

Thank you very much for giving me the opportunity to review this paper. I agree that obstructed labour is an important clinical and public health problem in low resource settings. So, I don’t see what new information this manuscript is adding to scholarship on obstructed labour. The methods described by the authors are not sound, and the manuscript is not well-written. I have a couple of issues regarding this work.

Major issues

1. Use of the word magnitude in the title is not specific enough, because this is very difficult to measure. The authors should consider revising this to prevalence.

2. The introduction is very shallow and not informative because the authors have not reviewed and distilled the available literature on obstructed labour, yet it is a well-studied subject.

3. Subsequently, the gap/problem as well as the justification is not clearly defined in the introduction.

4. The stated objective is not SMART.

5. Generally, the methods are poorly reported, the authors should make use of the STOBE checklist to improve on the transparency of reporting. It will also help to make it more comprehensive.

6. Line 131- 132 is not clear, please check it and revise the grammar and sentence structure. Please do this for the rest of the document as well.

7. The primary outcomes are two, but they are not well defined. It is important to report how, who and when the diagnosis of labour was made? Are there any guidelines for diagnosis of obstructed labour in your facility?

8. You did not include a section on study procedures. So, it is not clear when, how and who collected the data. When was the consent obtained? Did you review patient files or interview participants for data collection?

9. The results are not well presented. For instance, in Table 2, why do you have three variables on the same factor of ANC? What are they showing? Generally, there is a big problem with the categorizations on several variables; it is so arbitrary and unconventional. In table 3, under partograph is another example of the same.

10. Table 4 is presenting outcomes of obstructed labour; this is not one of the objectives for this study. This is completely new and not acceptable.

11. In the discussion, it is hard to know what the key message is. This has also affected the conclusions and recommendations that have been advanced by the authors.

Minor issues

1. Kindly pay attention to the grammatical errors and typos that are all over the document

2. Have a look at the references as well and ensure that they are more accurate.

3. Many sentences are either incomplete or not meaningful.

4. The paragraphs are not well structured, it is not proper to have one sentence standing alone as a paragraph.

**********

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: Dr. Joseph Ngonzi

Reviewer #3: Yes: Milton Musaba

**********

[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.

27 Jul 2022

Response to Reviewers

Title: “Magnitude, Causes, and Factors associated with Obstructed Labour among Mothers who Gave Birth at Public Health Facilities in Mojo Town, Mojo, Central Ethiopia, 2019”

Manuscript ID: PONE-D-21-26867

Dear, Editor and reviewers, we (authors) would like to thank you for your time and fruitful suggestions. We respond and corrected all raised comments. Hereunder we enclosed all the answers and corrections point by point.

Response to Editor’s comments

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming.

Authors’ response: Dear Editor, Thanks a lot for your guidance with PLOS ONE's guidelines! We have corrected the entire manuscript as per PLOS ONE's requirements.

2. In your Data Availability statement, you have not specified where the minimal data set underlying the results described in your manuscript can be found.

Authors’ response: Great! We have updated the data availability statement and included all the data used in the study as supporting information in the revised manuscript.

3. We note that you have stated that you will provide repository information for your data at acceptance. Should your manuscript be accepted for publication, we will hold it until you provide the relevant accession numbers or DOIs necessary to access your data. If you wish to make changes to your Data Availability statement, please describe these changes in your cover letter and we will update your Data Availability statement to reflect the information you provide.

Authors’ responses: Dear, Thank you so much for your suggestion! We made changes to the data availability statement and described it in the cover latter.

4. Please ensure that you refer to Figure 1 in your text as, if accepted, production will need this reference to link the reader to the figure

Authors’ response: Dear Editor, Thanks for reminding us of our mistake. We have referred to figure 1 under the study variable sub-section of methodology.

5. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly.

Authors’ response: Thanks for reminding us! We have included supporting information and cited its corresponding captions in the text.

Response to Reviewer #1 comments

1. Needs English language correction.

Authors’ response: Dear reviewer, we are grateful for your suggestion. We have corrected all the language errors in our manuscript as highlighted in the track change file.

2. It is a good effort and may help in reduction of such complications

Authors’ response: Thanks a lot for your constructive comments!

Response to reviewer #2 comments

1. The area studied is of great clinical importance. Unfortunately, many women still experience labour complications and these contribute to the maternal morbidity and mortality

Authors’ response: Dear Reviewer, Thank you so much for acknowledging our study outcome (obstructed labour), one of the causes of maternal mortality and morbidity.

2. The manuscript is relevant; it has numerous grammatical and typographical errors that need to be corrected.

Authors’ response: Thank you for your fruitful comments!

We have corrected all the typographic and grammatical errors

3. The background/introduction has many sentences constituting paragraphs. Please coalesce most of them into relevant paragraphs and stratify them as follows:

a) Important definitions such as Obstructed labour, including the burden of obstructed labour globally, in Africa/sub-Saharan Africa and in Ethiopia

b) The causes of obstructed labour

c) The factors associated with obstructed labour

N.B: Not sure that the last sentence in the background about this being a pioneer study is relevant here. Which databases did the authors search to come to this conclusions?

Authors’ response: Great! We made significant changes to the introductory parts of our paper as per your suggestions. We stratified it as: definition and burden of OL, causes of OL factors associated, strategies that have been taken to prevent OL, and gaps in data about OL in the area. ‘This is a pioneer study which assessed causes of obstructed 91 labour in the Central Ethiopia’ just to express the limitation of evidence specifically, in our study setting. We have removed this section.

4. In the methods, the use of the term cephalo-pelvic disproportion is misleading. What exactly caused the disproportion is the real cause of obstructed labour. Please, if possible, unpack the cephalo-pelvic disproportion variable.

Authors’ response: OH GREAT! Really, it is insightful suggestion. Thanks! According to different literatures and guidelines CPD is taken as the first and leading cause of obstructed labour (as cited in the background section). In fact, there are root causes of CPD which are described as risk factor for obstructed labour such as maternal age, fetal macrosomia (hydrocephaly), contracted pelvis, etc.

5. Under birth weight, you write that a high birth weight is when the weight of baby at birth is 400gm and above. This is wrong. 400gm is too low to be a high fetal weight. I guess you meant 4000gm! Please correct this anomaly! The normal birth weight range is also not 2500gm-399gm but 2500-3999gm! Also correct this anomaly!

Authors’ responses: Dear, we are sorry for the mistake we made! It was a typing error! We meant 4000gm and 3999. We have corrected it. Thanks a lot for reminding us!

6. In the analysis part, please state how categorical and continuous variables were analysed instead of clamping everything together.

Authors’ responses: Excellent! Dear, the majority of the independent variables handled in our study were categorical in form, and before analysis, we also categorized continuous variables such age, labour time, and estimated distance to healthcare facilities.

7. In results, in Table 1 you state under occupation that the category "other" meant daily labour worker. Were there any other considerations under that category? If not, then just write daily labour worker directly in the table.

Under APGAR SCORE, what was the rationale of using the ranges the author uses? If possible, please stratify your APGAR SCORE as follows:

7–10: Reassuring

4–6: Moderately abnormal

0–3: Low

Authors’ responses: I really appreciate your helpful suggestion. Of course, there is another factor under the other category of Table 1 that was overlooked when typing, namely "students."

Dear, we have also changed the APGAR SCORE category in accordance with your recommendation.

8. Under discussion, the content is there but needs to be improved. Please write your discussion as follows: State your results, then results from comparable studies and the possible explanation for the similarities or differences between your study results and the quoted studies.

Authors’ responses: Dear reviewer, thanks for your guidance! We wrote the discussion section as per your recommendations!

Response to reviewer #3 comments

Major issues

1. Use of the word magnitude in the title is not specific enough, because this is very difficult to measure. The authors should consider revising this to prevalence

Authors’ responses: Dear Reviewer, We value your insightful suggestion. We have replaced the word "magnitude" with "prevalence" in the title section.

2. The introduction is very shallow and not informative because the authors have not reviewed and distilled the available literature on obstructed labour, yet it is a well-studied subject

Authors’ responses: Great! We made thorough revision to the introduction part and incorporated all relevant data to our study’s outcome interest. Thanks in advance!

3. Subsequently, the gap/problem as well as the justification is not clearly defined in the introduction.

Authors’ responses: Dear review, thank you for your concern over this important section! We have updated this section and we hope you will get the gaps and justification we articulated. Thanks!

4. The stated objective is not SMART.

Authors’ responses: Dear, thanks once more! We have corrected this section. We have corrected the study objectives and made them SMART.

5. Generally, the methods are poorly reported, the authors should make use of the STOBE checklist to improve on the transparency of reporting. It will also help to make it more comprehensive.

Authors’ responses: Dear, thank you in advance for your suggestions! We have filled and uploaded the STROBE checklist with supportive information.

6. Line 131- 132 is not clear, please check it and revise the grammar and sentence structure. Please do this for the rest of the document as well.

Authors’ responses: Dear, Thanks a lot! We have corrected the grammar and sentence structures of the mentioned section and in all the rest of the document.

7. The primary outcomes are two, but they are not well defined. It is important to report how, who and when the diagnosis of labour was made? Are there any guidelines for diagnosis of obstructed labour in your facility?

Authors’ responses: Dear reviewer, Thank you so much for your perceptive comments! The two outcomes of this study, Prevalence of obstructed labour and causes of obstructed labour were diagnosed by physicians. In Ethiopia, physicians use the Federal guideline for diagnosis and management of obstetrics cases.

(Federal Democratic Republic of Ethiopia Ministry of Health: Management Protocol on Selected obstetrics topics, January, 2010).

8. You did not include a section on study procedures. So, it is not clear when, how and who collected the data. When was the consent obtained? Did you review patient files or interview participants for data collection?

Authors’ responses: Great! Dear reviewer, we have described the study procedures in the ‘data collection tools and procedure’ sub-section of methods and material.

�  The data were collected by two BSc Midwives (who works out of the study area) and a supervisor from 10 November to 30 December 2019.

�  Consent was taken from each participant before interview.

�  Great! We have used both interview and patient file review.

�  After data collectors taken consent, they interviewed study participants and reviewed the respective clinical information from medical record.

9. The results are not well presented. For instance, in Table 2, why do you have three variables on the same factor of ANC? What are they showing? Generally, there is a big problem with the categorizations on several variables; it is so arbitrary and unconventional. In table 3, under partograph is another example of the same.

Authors’ responses: Dear reviewer, Thank you so much for your insightful comments! Dear, we have unpacked the category of having ANC information and left having ANC follow-up and frequency of ANC follow-up. Because, evidence shows that frequency of ANC has association with obstructed labour. Mostly, those mothers who had less ANC follow-up were risky for OL. We have corrected all of the commented sections.

10. Table 4 is presenting outcomes of obstructed labour; this is not one of the objectives for this study. This is completely new and not acceptable.

Authors’ responses: Dear, we appreciate you for your intellectual suggestion!

Of course, outcome of obstructed labour was not our study objective but we included the feto-maternal outcome of participants in the study area as an explanatory variable. Because, as literatures shown, feto-maternal outcomes such as birth weight affects labour outcomes. Dear, to make it more clear and attractive for readers, we have merged the important feto-maternal outcome variables to the obstetrics characterises section of the findings.

11. In the discussion, it is hard to know what the key message is. This has also affected the conclusions and recommendations that have been advanced by the authors. Authors’ responses: Dear, thanks for your helpful suggestion! We revised the discussion section. We concluded what we found and forwarded as per our findings. Thanks in advance again!

Minor issues

1. Kindly pay attention to the grammatical errors and typos that are all over the document Authors’ responses: Dear reviewer, thanks for your constructive comments! We have corrected all the grammatical errors and typos throughout the document.

2. Have a look at the references as well and ensure that they are more accurate.

Authors’ responses: Thank you! We have checked and corrected it.

3. Many sentences are either incomplete or not meaningful.

Authors’ responses: Thank you dear! We have checked and corrected all the sentence errors all over the manuscript.

4. The paragraphs are not well structured, it is not proper to have one sentence standing alone as a paragraph.

Authors’ responses: We greatly appreciate you! All of the paragraphs have been rearranged, and we have fixed all the mentioned errors.

Submitted filename: Response to reviewers.docx

Click here for additional data file.

8 Sep 2022

10 Sep 2022

Response to Reviewers

PONE-D-21-26867R1

Prevalence, causes, and factors associated with obstructed labour among mothers who gave birth at public health facilities in Mojo Town, Central Ethiopia, 2019: A cross-sectional study

Dear Dr. Gulzhanat Aimagambetova (Editor) and reviewers, we appreciate your valuable time with our article. Thanks for your intellectual comments and suggestions. We have revised our article and responded point-by-point to all the editor and reviewers comments and suggestions hereunder.

ACADEMIC EDITOR:

The introduction part sounds clear and provides the study rationale well. However, I suggest rewriting the last paragraph (lines 95-101 in the revised document). The issue is that you write "the aim of this study was" (singular), however below you stated THREE aims (plural). So, this should sound more clear. Moreover, the writing style should be improved in this paragraph to be closer to the academic writing style. It is better to remove the numbering (1,2,3) and present it in plain text.

Authors’ response: Dear Editor, Thank you so much for your intelligent suggestion. We have changed ‘aim’ to ‘aims’ and ‘was’ to ‘were’ in the mentioned section. Also, we have removed the numbering from the objectives of the study and presented it in plain text (highlighted on page no. 5; line no. 92-94).

In the Methods part, you described "Operational definition" (singular), but in the text there are many definitions, so the subheading should be "Operational definitions".

Authors’ response: Dear Editor, Thanks once again. We have changed "Operational definition" to be "Operational definitions"(highlighted on page no. 7 and line no. 141).

Please make sure you've followed the PLOS ONE journal's requirements

Authors’ response: Dear Editor, we have followed the PLOS ONE journal's requirements.

Review Comments to the Author

Reviewer #1: Overall a good effort in writing the manuscript, however the comparison with other studies should have been presented in a standard way.

Authors’ response: Dear reviewer, thank you so much for your concern on this important section. We have corrected the mentioned section (highlighted on Page number 17; line number 290 and 291).

Recommendation must mention the strategies to prevent obstructed labour in hospital settings such as training of birth attendants to monitor and identify cases who may land up in obstructed labour.

Authors’ response: Dear reviewer, thank you so much for your valuable suggestions. We have mentioned the strategies to prevent obstructed labour in hospital settings as per your suggestion (highlighted on page number 17; line number 295 and 296).

Reviewer #2: The author has addressed the comments raised by the reviewers. The manuscript reads much better than before.

Authors’ response: Dear reviewer, thank you for your time with article.

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Authors’ response: Dear, we have revised the reference lists and completed and corrected some of missed contents of the references such as sure name, page number, DOI, Journals, and publishers. Additionally, we have replaced Reference no. 41 by a new relevant reference. The previous reference was incorrect and unintentionally placed during automated citing by Mendeley library.

Thanks all for your time!

Submitted filename: Response to Reviewers.doc

Click here for additional data file.

13 Sep 2022

Prevalence, causes, and factors associated with obstructed labour among mothers who gave birth at public health facilities in Mojo Town, Central Ethiopia, 2019: A cross-sectional study

PONE-D-21-26867R2

Dear Authors,

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,

Gulzhanat Aimagambetova

Academic Editor

PLOS ONE

14 Sep 2022

PONE-D-21-26867R2

Prevalence, causes, and factors associated with obstructed labour among mothers who gave birth at public health facilities in Mojo Town, Central Ethiopia, 2019: A cross-sectional study

Dear Dr. Gezimu:

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. Gulzhanat Aimagambetova

Academic Editor

PLOS ONE