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Research Article
Rec. Date: Nov 18, 2020
Acc. Date: Nov 25, 2020
Pub. Date: Dec 02, 2020

Incidence, Causes, and Maternofetal�Outcomes of Obstructed Labor in Ethiopia: Systematic Review and Meta-analysis

Asteray Assmie Ayenew1 
1Midwifery department, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia.
*Corresponding author: Asteray Assmie Ayenew, Midwifery department, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia, Tel: 0945560077; E-mail: amanuelbiruk0077@gmail.com
Abstract
Background: Obstructed labor is a preventable obstetric complication. But, it is an important cause of maternal mortality and morbidity and of adverse outcomes for newborns in resource limited countries in which undernutrition is common resulting in small pelvis, in which there is no easy access to functioning health facilities with a capacity of carry out operative deliveries. Therefore, the aim of this systematic review and meta-analysis was to estimate incidence, causes and maternofetal outcomes of obstructed labor among mothers who gave birth in Ethiopia.
Methods:  For this review, we used the standard PRISMA checklist guideline. Different online databases were used for the review: PubMed, Google Scholar, EMBASE, Cochrane Library, HINARI, WHO Afro Library Databases, and African Online Journals. Based on the adapted PICO principles, different search terms were applied to achieve and access all the essential articles. This search included all published and unpublished observational studies written only in English language and conducted in Ethiopia. Microsoft Excel 16 was used for data entrance, and Stata version 11.0 (Stata Corporation, College Station, Texas, USA) used for data analysis.
Result: We included sixteen (16) primary studies with twenty eight thousand five hundred ninety one (28,591) mothers who gave birth in Ethiopia. The pooled incidence of obstructed labor in Ethiopia was 12.93% (95%CI: 10.44-15.42, I2=98.0%, p<0.001). Out of these 67.3%(95%CI: 33.32-101.28) did not have antenatal care follow-up, 77.86%(95%CI: 63.07-92.66) were from rural area, and 58.52%(95%CI: 35.73-82.31) were referred from health centers and visited hospitals after at least 12 hours of labor.  The major causes of obstructed labor were cephalo-pelvic disproportion 64.65 % (95%CI: 57.15� 72.14), and malpresentation in 27.24% (95%CI: 22.05� 32.42) of the cases. The commonest complications were sepsis in 38.59% (95%CI: 25.49� 51.68), still birth in 38.08% (95%CI: 29.55� 46.61), post partum hemorrhage in 33.54% (95%CI: 12.06� 55.02), uterine rupture in 29.84% (95%CI: 21.09-38.58), and maternal death in 17.27% (95%CI: 13.47� 48.02) of mothers who gave birth in Ethiopia.  
Conclusion: This systematic review and meta-analysis showed that the incidence of obstructed labor was high in Ethiopia. Not having antenatal care follow-up, rural residency, and visited hospitals after 12 hours of labor increased the incidence of obstructed labor. The major causes of obstructed labor were cephalo-pelvic disproportion and malpresentation. Additionally, the commonest complications were sepsis, still birth, post partum hemorrhage, uterine rupture in and maternal death. Thus, promoting antenatal care service utilization, good referral system, and availing comprehensive obstetric care in nearby health institution are recommended to prevent the incidence of obstructed labor and its complications.
Keywords: Obstructed Labor, Obstetric Complications, Maternal Mortality And Morbidity, Systematic Review, Meta-Analysis, Ethiopia.
1. Introduction
Obstructed labor is defined as failure of the fetal presenting part to descent in the birth canal due to mechanical reasons, despite of having  adequate uterine contraction  ADDIN EN.CITE <EndNote><Cite><Author>Gessessew</Author><Year>2003</Year><RecNum>14</RecNum><DisplayText>(1, 2)</DisplayText><record><rec-number>14</rec-number><foreign-keys><key app="EN" db-id="erx0sxad9eftrjet5x75r5zffzv0w5vw2a99">14</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Gessessew, Amanuel</author><author>Mesfin, Mengiste</author></authors></contributors><titles><title>Obstructed labour in adigrat zonal hospital, Tigray Region, Ethiopia</title><secondary-title>Ethiopian Journal of Health Development</secondary-title></titles><periodical><full-title>Ethiopian Journal of Health Development</full-title></periodical><pages>175-180</pages><volume>17</volume><number>3</number><dates><year>2003</year></dates><isbn>1021-6790</isbn><urls></urls></record></Cite><Cite><Author>Kabakyenga</Author><Year>2011</Year><RecNum>15</RecNum><record><rec-number>15</rec-number><foreign-keys><key app="EN" db-id="erx0sxad9eftrjet5x75r5zffzv0w5vw2a99">15</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Kabakyenga, Jerome K</author><author>�stergren, Per-Olof</author><author>Turyakira, Eleanor</author><author>Mukasa, Peter K</author><author>Pettersson, Karen Odberg</author></authors></contributors><titles><title>Individual and health facility factors and the risk for obstructed labour and its adverse outcomes in south-western Uganda</title><secondary-title>BMC pregnancy and childbirth</secondary-title></titles><periodical><full-title>BMC pregnancy and childbirth</full-title></periodical><pages>73</pages><volume>11</volume><number>1</number><dates><year>2011</year></dates><isbn>1471-2393</isbn><urls></urls></record></Cite></EndNote>[ HYPERLINK \l "_ENREF_1" \o "Gessessew, 2003 #14" 1,  HYPERLINK \l "_ENREF_2" \o "Kabakyenga, 2011 #15" 2]. Neglected obstructed labor (OL) is a major cause of both maternal and newborn morbidity and mortality. The obstruction can only be alleviated by means of an operative delivery, either caesarean section or other instrumental delivery (forceps, vacuum extraction or simphysiotomy)  ADDIN EN.CITE <EndNote><Cite><Author>Gabbe</Author><Year>2016</Year><RecNum>20</RecNum><DisplayText>(3)</DisplayText><record><rec-number>20</rec-number><foreign-keys><key app="EN" db-id="erx0sxad9eftrjet5x75r5zffzv0w5vw2a99">20</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>Gabbe, Steven G</author><author>Niebyl, Jennifer R</author><author>Simpson, Joe Leigh</author><author>Landon, Mark B</author><author>Galan, Henry L</author><author>Jauniaux, Eric RM</author><author>Driscoll, Deborah A</author><author>Berghella, Vincenzo</author><author>Grobman, William A</author></authors></contributors><titles><title>Obstetrics: normal and problem pregnancies e-book</title></titles><dates><year>2016</year></dates><publisher>Elsevier Health Sciences</publisher><isbn>0323392172</isbn><urls></urls></record></Cite></EndNote>( HYPERLINK \l "_ENREF_3" \o "Gabbe, 2016 #20" 3). 
Though it is not a significant health problem in developed countries, it is one of the most common preventable causes of maternal and prenatal morbidity and mortality in developing countries  ADDIN EN.CITE  ADDIN EN.CITE.DATA ( HYPERLINK \l "_ENREF_4" \o "Liu, 2016 #24" 4).�Despite different strategies to reduce morbidities and mortalities, among the 216 maternal deaths per 100,000 live births annually, 19.1% happened due to obstructed labor ADDIN EN.CITE  ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_5" \o "Kuruvilla, 2016 #25" 5,  HYPERLINK \l "_ENREF_6" \o "Organization, 2016 #26" 6]. In 2015, it was a cause for 17.9% of maternal deaths. These deaths were high in the middle- and low-income countries and highest in Sub-Saharan Africa (SSA)  ADDIN EN.CITE  ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_7" \o "Say, 2014 #27" 7].
Ethiopia is one of the Sub-Saharan African countries where maternal, and perinatal mortality rates are still very high, with maternal mortality ratio of  412 maternal deaths per 100,000 live births  ADDIN EN.CITE <EndNote><Cite><Author>Central Statistical Agency - CSA/Ethiopia</Author><Year>2017</Year><RecNum>9</RecNum><DisplayText>(8)</DisplayText><record><rec-number>9</rec-number><foreign-keys><key app="EN" db-id="wt2vaawp42p2ave0rvkvxtrdetvza9r00ree" timestamp="0">9</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>Central Statistical Agency - CSA/Ethiopia,</author><author>ICF,</author></authors></contributors><titles><title>Ethiopia Demographic and Health Survey 2016</title></titles><dates><year>2017</year></dates><pub-location>Addis Ababa, Ethiopia</pub-location><publisher>CSA and ICF</publisher><urls><related-urls><url>http://dhsprogram.com/pubs/pdf/FR328/FR328.pdf</url></related-urls></urls></record></Cite></EndNote>[ HYPERLINK \l "_ENREF_8" \o "Central Statistical Agency - CSA/Ethiopia, 2017 #9" 8].Obstructed labor is the leading cause of maternal mortality accounting for 9% of the total maternal mortality [9].
Apart from maternal deaths, obstructed labor had different maternal outcomes such as uterine rupture, postpartum hemorrhage, puerperal sepsis, bladder injury, Vesico-Vaginal fistula (VVF), recto-vaginal fistula (RVF) and fetal outcomes including birth asphyxia, still birth, neonatal jaundice and umbilical sepsis [10-12]. By far the most severe and distressing long - term condition following obstructed labor is obstetric fistula which causes serious social issues of divorce, separation from religious exercises, detachment from their families which can worsen poverty and malnutrition  ADDIN EN.CITE <EndNote><Cite><Author>Khooharo</Author><Year>2012</Year><RecNum>30</RecNum><DisplayText>(12)</DisplayText><record><rec-number>30</rec-number><foreign-keys><key app="EN" db-id="erx0sxad9eftrjet5x75r5zffzv0w5vw2a99">30</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Khooharo, Yasmeen</author><author>Majeed, Tayyaba</author><author>Khawaja, Mashooque Ali</author><author>Majeed, Naeem</author><author>Majeed, Numan</author><author>Malik, Maryam Noor</author><author>Amber, Aneela</author></authors></contributors><titles><title>Even in 21st century still obstructed labor remains life threatening condition</title><secondary-title>Annals of King Edward Medical University</secondary-title></titles><periodical><full-title>Annals of King Edward Medical University</full-title></periodical><pages>279-279</pages><volume>18</volume><number>3</number><dates><year>2012</year></dates><isbn>2079-0694</isbn><urls></urls></record></Cite></EndNote>[12]. Despite these severe complications, the prevalence of obstructed labor is still high in Ethiopia ranging from 3.3% in Tigray region  ADDIN EN.CITE <EndNote><Cite><Author>Gessessew</Author><Year>2002</Year><RecNum>2</RecNum><DisplayText>(13)</DisplayText><record><rec-number>2</rec-number><foreign-keys><key app="EN" db-id="erx0sxad9eftrjet5x75r5zffzv0w5vw2a99">2</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Gessessew, Amanuel</author><author>Mesfin, Mengiste</author></authors></contributors><titles><title>Obstructed Labour in Adigrat Zonal Hospital, Tigray Region, Ethiopia</title><secondary-title>Ethiop J Health Dev</secondary-title></titles><periodical><full-title>Ethiop J Health Dev</full-title></periodical><volume>17</volume><dates><year>2002</year><pub-dates><date>11/30</date></pub-dates></dates><urls></urls></record></Cite></EndNote>[13] to 34.3% in Oromia region  ADDIN EN.CITE <EndNote><Cite><Author>Wube</Author><Year>2018</Year><RecNum>6</RecNum><DisplayText>(14)</DisplayText><record><rec-number>6</rec-number><foreign-keys><key app="EN" db-id="erx0sxad9eftrjet5x75r5zffzv0w5vw2a99">6</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Wube, Tizita</author><author>Wondimeneh, Birhanu</author><author>Abebe, Kelemu</author><author>Olana, Robera</author></authors></contributors><titles><title>Magnitude of Obstructed Labor and Associated Factors Among Women Who Delivered at Public Hospitals of Western Harerghe Zone, Oromia, Ethiopia</title></titles><dates><year>2018</year><pub-dates><date>12/31</date></pub-dates></dates><urls></urls><electronic-resource-num>10.11648/j.cmr.20180706.11</electronic-resource-num></record></Cite></EndNote>[14]. Therefore, the aim of this systematic review and meta-analysis was to estimate incidence, causes and maternofetal�outcomes of obstructed labor among mothers who gave birth in Ethiopia.
2. Methods 
This systematic review and meta-analysis were conducted to estimate incidence, causes and maternofetal outcomes of obstructed labor among mothers who gave birth in Ethiopia.  We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist guideline [15].
2.1 Searching strategy
First, the PROSPERO database and database of abstracts of reviews of effects (DARE) (http://www.library.UCSF.edu) were searched to check whether published or ongoing projects exist related to the topic. The literature search strategy, selection of studies, data extraction, and result reporting were done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [16]. We searched PubMed, Google Scholar, EMBASE, Cochrane Library, HINARI, WHO Afro Library Databases, and African Online Journal databases for all available studies using the following terms:"obstructed labor", "prolonged labor", "obstetric complications", "childbirth", "labor abnormalities", "factors", and "Ethiopia". The search string was developed using "AND" and "OR" Boolean operators. Searching terms were based on adapted PICO principles to search through the above-listed databases to access all the relevant articles.  For unpublished studies, the official websites of Ethiopian's University research repository online library (University of Gondar and Addis Ababa University) was used.                 

2.2 Eligibility Criteria
Inclusion Criteria
Study Design: All observational studies reported the incidence of obstructed labor and/or associated factors were included.
Language: English language literature and research articles were included.
Publication: Both unpublished and published research articles were considered.
Searching date: Articles searched from September 1-30, 2020 were included.
Participants: Mothers who gave birth in Ethiopia

Exclusion Criteria
Duplicated studies, articles without full text and abstract, anonymous reports, qualitative studies, and case reports were excluded.

Operational definition 
Obstructed labor, also known as�labor dystocia, is a failure to progress due to mechanical problems�a mismatch between fetal size, or more accurately, the size of the presenting part of the fetus, and the mother�s pelvis, although some malpresentations, notably a brow presentation or a shoulder presentation [17].
 Cephalopelvic disproportion (CPD) is an inadequate size of the maternal pelvis, compared to the fetal head, which prevents the fetus from passing through the pelvic cavity during delivery, causing obstructed labor [18].

Quality assessment  
After collecting the findings from all databases, the articles were exported to Microsoft Excel spreadsheet. The methodological quality of each study (sampling strategy, response rate, and representativeness of the study), comparability, and outcome were checked using the NOS tool. Newcastle-Ottawa Quality Assessment Scale (NOS) for cross-sectional and case-control studies was used to assess the methodological quality of a study and to determine the extent to which a study has addressed the possibility of bias in its design, conduct and analysis [19]. All the included articles scored (NOS) 7 and more can be considered as �good� studies with low risk.

Data extraction

Microsoft Excel (2016), and Stata version 11.0 (Stata Corporation, College Station, Texas, USA) software were used for data entry and analysis, respectively. The data was extracted by using a standardized JBI data extraction format. During data extraction; name of the author, sample size, publication year, study design, prevalence, response rate, population outcome, study site, and different contributing factors were included. Moreover, the incidence, and outcomes of obstructed labor with 95%CI and associated factors were collected [20].

Statistical analysis

As the test statistic showed significant heterogeneity among studies (I2 = 98.0%, p<0.05) the Random-effects model was used to estimate the DerSimonian and Laird's pooled effect [21]. Cochran�s Q chi-square statistics and I2 statistical test was conducted to assess the random variations between primary studies [22]. In this study, heterogeneity was interpreted as an I2 value of 25%	 =	 low, 50%	 =	 moderate, and 75%	 =	 high [23]. In case of high heterogeneity, subgroup analysis and sensitivity analyses were run to identify possible moderators of this heterogeneity. Potential publication bias was assessed by visually inspecting funnel plots and objectively using the Egger�s test (i.e. p<0.05) [24]. To account for any publication bias, we used the trim-and-fill method, based on the assumption that the effect sizes of all the studies are normally distributed around the center of a funnel plot. The meta-analysis was performed using the Stata version 11.0 (Stata Corporation, College Station, Texas, USA) software. Finally, for all analyses, P	 <	 0.05 was considered statistically significant.

Results
Study selection and data extraction

The search strategy identified 80 articles from PubMed, 60 articles from Google Scholar, 45 articles from Cochrane Library, 10 articles from African Journals Online, 7 articles from Ethiopian�s University online library, and 2 articles by manual search. Of which, 134 were excluded due to duplication, 35 through review of titles and abstracts. Additionally, 44 full-text articles were excluded for not reporting the outcome variable and other reasons. Finally, 16 were included to the incidence, outcome and/ or associated factor analysis on obstructed labor. (Figure 1)

Study characteristics

In this review, 16 relevant studies were included with a sample size of 28,951. Among sixteen studies thirteen were cross sectional and three case-controls in study design. Regarding the geographical area, six from Oromia, four from Southern Nation Nationalities and People (SNNPR), and four from Tigray region, two studies were from Amhara region. Among the included studies the largest sample size was 13,425, where as the smallest was 90. (Table 1)

Incidence of obstructed labor in Ethiopia  

Primarily, all three case-control studies were not considered in the incidence estimation, since they did not report the incidence of obstructed labor. The pooled incidence of obstructed labor is presented with a forest plot. Therefore, the estimated incidence of obstructed labor among mothers who gave birth in Ethiopia was 12.93% (95%CI: 10.44�15.42, I2=98.0%, p<0.001). (Figure 2)

Publication bias

The funnel plot was assessed for asymmetry distribution of prevalence of obstructed labor among mothers who gave birth in Ethiopia. Egger's regression test showed a p-value of 0.259 with no evidence of publication bias. (Figure 3)

Sensitivity analysis
This systematic review and meta-analysis showed that the point estimate of its omitted analysis lies within the confidence interval of the combined analysis. Therefore, trim and fill Analysis was no further computed. (Figure 4)

Subgroup analysis
Subgroup analysis was employed with the evidence of heterogeneity. In this study, the Cochrane I2 statistic was 98.0%, P	 <	 0.001, which showed the evidence of marked heterogeneity. Therefore, subgroup analysis was done using the study region and sample size. As a result, obstructed labor was high South Eastern Ethiopia 15.14% (95%CI: 11.61-18.66), regarding sample size the highest incidence was in the study with the sample size less than 1000 (16.93% (95%CI: 10.92-21.14)). (Figure 5 and 6)

Risk factors for incidence of obstructed labor
The association between not having antenatal care follow-up, rural residency, referred from health centers and visited hospitals after at least 12 hours of labor with obstructed labor was carried out.
A total of five articles were included to identify the association between referred from health centers and visited hospitals after at least 12 hours of labor and obstructed labor. Mother�s who ere referred from health centers and visited hospitals after at least 12 hours of labor develop obstructed labor by 58.52% than mothers who visited hospitals in short hours of labor (58.52%, 95%CI: 35.73� 82.31).
A total of four articles were included to identify the association between rural residency and obstructed labor. Mother�s residency (as defined as rural and urban) was significantly associated with obstructed labor. Mother�s from rural areas were more likely to have obstructed labor than those (women) from urban areas 77.86% (95%CI: 63.07�92.66). 
Moreover, three studies showed a significant association between not having antenatal care follow-up and obstructed labor. Mother�s who do not have antenatal care follow-up were 67.3% more likely to develop obstructed labor (67.3%, 95%CI: 33.32�101.28) compared to mothers who had antenatal care follow-up (Table 2).

Maternofetal complications following obstructed labor in Ethiopia

Following obstructed labor different adverse maternal complications and neonatal were reported. Sepsis, still birth, post partum hemorrhage, uterine rupture, and maternal death were the most common complications following obstructed labor (Table 3).

Discussion

Obstructed labor is a totally preventable labor complication. One of your major roles as a skilled birth attendant is to prevent the occurrence of obstructed labor in among mothers. It is highly prevalent in Ethiopia, ranges from 3.3% to 34.3% (13, 14). The purpose of this review was to assess the pooled incidence, mernofetal outcome, and associated factors of obstructed labor by reviewing the finding of available studies. The pooled incidence of obstructed labor in Ethiopia was 12.93%. The result higher than the studies conducted is India 1.9%, Pakistan 2.1%, Nigeria 4.7%, and Uganda 10.5% (39, 40, 41, 42). The possible reason might be poor ANC follow up, high  home birth prevalence, teenage pregnancy, low socioeconomic status, poor infrastructure and poor referral system in Ethiopia(43-45).
This study also elucidated that, Sixty-seven percent of the obstructed labor cases did not have any ANC follow-up during pregnancy. The result is supported by studies conducted in Pakistan and Nigeria(12, 46). This might be the fact that not having antenatal care during pregnancy decrease women knowledge about her health status likes multiple pregnancy, big baby, uterine and fetal anomaies, and other risk factors for obstructed labor. Moreover, women who don�t have antenatal care are prone to home childbirth, poor awareness about birth preparedness and complication readiness plan, danger sign of pregnancy which in turn increase the risk of obstructed labor and came with uterine rupture.

Among mothers who had obstructed labor 77.86% were from rural area. The result is in line with studies conducted in Uganda, Pakistan,  and Bangladesh(12, 42, 46). This could be due to lack of access to nearby health institution in rural residential areas. For women residing in rural area, health facilities are distant and accesses to information about institutional deliveries are limited in comparison to woman reside in urban. As a result the higher chance of obstructed labor for women from rural residents may be attributed to two delays in the process of getting obstetric cares. The first is delay to decide for seeking health care as early as possible and the second is delay in reaching health facility. Additionally, maybe there is a failure of early referral for any labor abnormality, thus resulting in delay in early intervention leading to obstructed labor.

Additionally, 58.52% of mothers who had obstructed labor were referred from health centers and visited hospitals after at least 12 hours of labor.  The result is supported by studies conducted In Ghana, and Eastern Uganda(47, 48).  The possible reason might be obstructed labor was the most prevalent obstetric complication reported and also the leading indication for referral, since lower level facilities had no facilities to manage obstructed labor like cesarean section, symphysiotomy, and instrumental deliveries.
The main obstetric causes of obstructed labor in this review were cephalopelvic disproportion 64.65 %, and malpresentation 27.24% which have also been reported by other authors in Uganda, Nigeria, India (39, 42, 49). The possible reason could be cephalopelvic disproportion is mostly due to contracted pelvis and adolescent or early marriages. In Ethiopia contracted pelvis could be attributed to malnutrition during childhood (50).
Sepsis was the commonest maternal complication of obstructed labor accounted for 38.08% of cases.  This result is in line with studies conducted in Uganda, India, Eastern Nigeria, and Boston, United States(39, 42, 51, 52). Additionally, post partum hemorrhage resulted in 33.54% of obstructed cases. The result is in line with studies in Norway, Le Ray et al (53, 54). Moreover, Uterin rupture resulted in 29.84% of obstructed cases.  The result is supported by the study conducted in Uganda, Dar es Salaam, and USA (55, 56). The reason for this could be because during obstructed labor there is an impossible barrier (obstruction) preventing its descent despite strong uterine contractions, which increase risk of uterine rupture.
This review revealed that obstructed labor resulted still birth 38.59% of cases. The result is in line with studies in Boston, Massachusetts, United States, and Pakistan(40, 52). The possible reason might be obstructed labor is when the baby does not exit the pelvis during childbirth due to being physically blocked, despite the uterus contracting normally, resulted for the baby not getting enough oxygen which may result in death. Moreover, as labor is obstructed the fetal head impacts against the soft tissue of the pelvic floor, pinning the bladder base and the urethra against the pelvic bone. In the absence of any intervention, this condition may last for several days, the fetus may die and resulted still birth. 
Maternal death is also resulted in 17.27% obstructed labor cases in Ethiopia. The result is supported by a systematic review, Uganda, and Eastern Nigeria (42, 51, 57). This shocking figure is certainly an underestimation of the problem, because deaths due to obstructed labour are often classified under other complications (such as sepsis, postpartum haemorrhage or ruptured uterus). This could be explained by obstructed labor results dehaydration, exhaustion, fistula, uterine rupture, sepsis, postpartum hemorrhage, anemia, and shock which all could result maternal death.

Limitation
Since it is the first systematic review and meta-analysis, it is taken as strength. The included articles were restricted to the English language only; this is a limitation of the study as it missed studies published in local languages.

Conclusion
This study revealed the high incidence of obstructed labor and its complications in Ethiopia. Not having antenatal care follow-up, rural residency, and referred from health centers and visited hospitals after at least 12 hours of labor were the contributing factors for the incidence of obstructed labor. Additionally, the major causes of obstructed labor were cephalo-pelvic disproportion and malpresentation. Sepsis, still birth, post partum hemorrhage, uterine rupture, and maternal death were the commonest complications of obstructed labor among mothers who gave birth in Ethiopia. Therefore to prevent the incidence of obstr
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4ucted labor; promoting ANC service utilization during pregnancy, improving the referral system, and infrastructure to reach health faculties which had a capacity to manage obstructed labor is recommended. Moreover, it is better to promote institutional service utilization for the prevention and early management of obstructed labor and its complication.

Declarations

Ethics approval and consent to participate
Not applicable

Consent to publish
Not applicable

Availability of data and material
The data sets generated during the current study are available from corresponding author on reasonable request 

Competing interests
All authors declare that they have no competing interests

 Funding
No funding was obtained for this study

 Authors' Contributions
The author (AAA) conducted the data analysis and read and approved the final manuscript. 

Acknowledgements
N/A











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4,1�h��. ��A!��"�R#�R$�R%�������lD<EndNote><Cite><Author>Liu</Author><Year>2016</Year><RecNum>24</RecNum><DisplayText>(4)</DisplayText><record><rec-number>24</rec-number><foreign-keys><key app="EN" db-id="erx0sxad9eftrjet5x75r5zffzv0w5vw2a99">24</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Liu, L.</author><author>Oza, S.</author><author>Hogan, D.</author><author>Chu, Y.</author><author>Perin, J.</author><author>Zhu, J.</author><author>Lawn, J. E.</author><author>Cousens, S.</author><author>Mathers, C.</author><author>Black, R. E.</author></authors></contributors><auth-address>Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; The Institute for International Programs, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. Electronic address: lliu26@jhu.edu.&#xD;London School of Hygiene and Tropical Medicine, London, UK.&#xD;Department of Health Statistics and Informatics, World Health Organization, Geneva, Switzerland.&#xD;The Institute for International Programs, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.&#xD;National Office of Maternal and Child Health Surveillance of China, Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China.</auth-address><titles><title>Global, regional, and national causes of under-5 mortality in 2000-15: an updated systematic analysis with implications for the Sustainable Development Goals</title><secondary-title>Lancet</secondary-title><alt-title>Lancet (London, England)</alt-title></titles><periodical><full-title>Lancet</full-title><abbr-1>Lancet (London, England)</abbr-1></periodical><alt-periodical><full-title>Lancet</full-title><abbr-1>Lancet (London, England)</abbr-1></alt-periodical><pages>3027-3035</pages><volume>388</volume><number>10063</number><edition>2016/11/15</edition><keywords><keyword>Africa</keyword><keyword>Asia</keyword><keyword>Cause of Death/ trends</keyword><keyword>Child Mortality/ trends</keyword><keyword>Child, Preschool</keyword><keyword>Communicable Diseases/mortality</keyword><keyword>Diarrhea/mortality</keyword><keyword>Global Health</keyword><keyword>Goals</keyword><keyword>Humans</keyword><keyword>Infant</keyword><keyword>Infant, Newborn</keyword><keyword>Malaria/mortality</keyword><keyword>Plasmodium falciparum/isolation &amp; purification</keyword><keyword>Pneumonia/mortality</keyword></keywords><dates><year>2016</year><pub-dates><date>Dec 17</date></pub-dates></dates><isbn>1474-547X (Electronic)&#xD;0140-6736 (Print)&#xD;0140-6736 (Linking)</isbn><accession-num>27839855</accession-num><urls></urls><custom2>PMC5161777</custom2><electronic-resource-num>10.1016/s0140-6736(16)31593-8</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>lD<EndNote><Cite><Author>Liu</Author><Year>2016</Year><RecNum>24</RecNum><DisplayText>(4)</DisplayText><record><rec-number>24</rec-number><foreign-keys><key app="EN" db-id="erx0sxad9eftrjet5x75r5zffzv0w5vw2a99">24</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Liu, L.</author><author>Oza, S.</author><author>Hogan, D.</author><author>Chu, Y.</author><author>Perin, J.</author><author>Zhu, J.</author><author>Lawn, J. E.</author><author>Cousens, S.</author><author>Mathers, C.</author><author>Black, R. E.</author></authors></contributors><auth-address>Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; The Institute for International Programs, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. Electronic address: lliu26@jhu.edu.&#xD;London School of Hygiene and Tropical Medicine, London, UK.&#xD;Department of Health Statistics and Informatics, World Health Organization, Geneva, Switzerland.&#xD;The Institute for International Programs, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.&#xD;National Office of Maternal and Child Health Surveillance of China, Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China.</auth-address><titles><title>Global, regional, and national causes of under-5 mortality in 2000-15: an updated systematic analysis with implications for the Sustainable Development Goals</title><secondary-title>Lancet</secondary-title><alt-title>Lancet (London, England)</alt-title></titles><periodical><full-title>Lancet</full-title><abbr-1>Lancet (London, England)</abbr-1></periodical><alt-periodical><full-title>Lancet</full-title><abbr-1>Lancet (London, England)</abbr-1></alt-periodical><pages>3027-3035</pages><volume>388</volume><number>10063</number><edition>2016/11/15</edition><keywords><keyword>Africa</keyword><keyword>Asia</keyword><keyword>Cause of Death/ trends</keyword><keyword>Child Mortality/ trends</keyword><keyword>Child, Preschool</keyword><keyword>Communicable Diseases/mortality</keyword><keyword>Diarrhea/mortality</keyword><keyword>Global Health</keyword><keyword>Goals</keyword><keyword>Humans</keyword><keyword>Infant</keyword><keyword>Infant, Newborn</keyword><keyword>Malaria/mortality</keyword><keyword>Plasmodium falciparum/isolation &amp; purification</keyword><keyword>Pneumonia/mortality</keyword></keywords><dates><year>2016</year><pub-dates><date>Dec 17</date></pub-dates></dates><isbn>1474-547X (Electronic)&#xD;0140-6736 (Print)&#xD;0140-6736 (Linking)</isbn><accession-num>27839855</accession-num><urls></urls><custom2>PMC5161777</custom2><electronic-resource-num>10.1016/s0140-6736(16)31593-8</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>tD<EndNote><Cite><Author>Kuruvilla</Author><Year>2016</Year><RecNum>25</RecNum><DisplayText>(5, 6)</DisplayText><record><rec-number>25</rec-number><foreign-keys><key app="EN" db-id="erx0sxad9eftrjet5x75r5zffzv0w5vw2a99">25</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Kuruvilla, S.</author><author>Bustreo, F.</author><author>Kuo, T.</author><author>Mishra, C. K.</author><author>Taylor, K.</author><author>Fogstad, H.</author><author>Gupta, G. R.</author><author>Gilmore, K.</author><author>Temmerman, M.</author><author>Thomas, J.</author><author>Rasanathan, K.</author><author>Chaiban, T.</author><author>Mohan, A.</author><author>Gruending, A.</author><author>Schweitzer, J.</author><author>Dini, H. 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Electronic address: sayl@who.int.&#xD;UNDP/UNFPA/UNICEF/WHO/The World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland.&#xD;UNDP/UNFPA/UNICEF/WHO/The World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland; Department of Demography, University of California, Berkeley, CA, USA.&#xD;Clinical Trials Unit, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.&#xD;Department of Statistics and Applied Probability and Saw Swee Hock School of Public Health, National University of Singapore, Singapore.</auth-address><titles><title>Global causes of maternal death: a WHO systematic analysis</title><secondary-title>Lancet Glob Health</secondary-title><alt-title>The Lancet. Global health</alt-title></titles><periodical><full-title>Lancet Glob Health</full-title><abbr-1>The Lancet. Global health</abbr-1></periodical><alt-periodical><full-title>Lancet Glob Health</full-title><abbr-1>The Lancet. Global health</abbr-1></alt-periodical><pages>e323-33</pages><volume>2</volume><number>6</number><edition>2014/08/12</edition><keywords><keyword>Cause of Death</keyword><keyword>Female</keyword><keyword>Global Health</keyword><keyword>Humans</keyword><keyword>Maternal Mortality</keyword><keyword>Pregnancy</keyword><keyword>Pregnancy Complications/ mortality</keyword><keyword>World Health Organization</keyword></keywords><dates><year>2014</year><pub-dates><date>Jun</date></pub-dates></dates><isbn>2214-109X (Electronic)&#xD;2214-109X (Linking)</isbn><accession-num>25103301</accession-num><urls></urls><electronic-resource-num>10.1016/s2214-109x(14)70227-x</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>ND<EndNote><Cite><Author>Say</Author><Year>2014</Year><RecNum>27</RecNum><DisplayText>(7)</DisplayText><record><rec-number>27</rec-number><foreign-keys><key app="EN" db-id="erx0sxad9eftrjet5x75r5zffzv0w5vw2a99">27</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Say, L.</author><author>Chou, D.</author><author>Gemmill, A.</author><author>Tunçalp, Ö</author><author>Moller, A. B.</author><author>Daniels, J.</author><author>Gülmezoglu, A. M.</author><author>Temmerman, M.</author><author>Alkema, L.</author></authors></contributors><auth-address>UNDP/UNFPA/UNICEF/WHO/The World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland. Electronic address: sayl@who.int.&#xD;UNDP/UNFPA/UNICEF/WHO/The World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland.&#xD;UNDP/UNFPA/UNICEF/WHO/The World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland; Department of Demography, University of California, Berkeley, CA, USA.&#xD;Clinical Trials Unit, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.&#xD;Department of Statistics and Applied Probability and Saw Swee Hock School of Public Health, National University of Singapore, Singapore.</auth-address><titles><title>Global causes of maternal death: a WHO systematic analysis</title><secondary-title>Lancet Glob Health</secondary-title><alt-title>The Lancet. Global health</alt-title></titles><periodical><full-title>Lancet Glob Health</full-title><abbr-1>The Lancet. Global health</abbr-1></periodical><alt-periodical><full-title>Lancet Glob Health</full-title><abbr-1>The Lancet. Global health</abbr-1></alt-periodical><pages>e323-33</pages><volume>2</volume><number>6</number><edition>2014/08/12</edition><keywords><keyword>Cause of Death</keyword><keyword>Female</keyword><keyword>Global Health</keyword><keyword>Humans</keyword><keyword>Maternal Mortality</keyword><keyword>Pregnancy</keyword><keyword>Pregnancy Complications/ mortality</keyword><keyword>World Health Organization</keyword></keywords><dates><year>2014</year><pub-dates><date>Jun</date></pub-dates></dates><isbn>2214-109X (Electronic)&#xD;2214-109X (Linking)</isbn><accession-num>25103301</accession-num><urls></urls><electronic-resource-num>10.1016/s2214-109x(14)70227-x</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>=Dd
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