ARSI UNIVERSITY COLLEGE OF HEALTH SCIENCES

DEPARTMENT OF GYNECOLOGY AND OBSTETRICS

OUT COME OF TOLAC AND ASSOCIATED FACTORS IN PREVIOUS ONE

CESAREAN SECTION ASELLA TEACHING and REFERRAL HOSPITAL,
INSTITUTION BASED CROSS-SECTIONAL and UNMATCHED CASE
CONTROL STUDY
By Jemal Gabi (MD, Resident of Gynecology and Obstetrics)

A Research Proposal submitted to the Department of Gynecology and Obstetrics, Arsi

University, in partial fulfillment for the requirement of specialization in Obstetrics and
Gynecology.

Advisors: Gurmessa M( MD, Assistant Professor of Gynecology and Obstetrics)

December, 2020

Asella, Ethiopia
ARSI UNIVERSITY COLLEGE of HEALTH SCIENCES DEPARTMENT
GYNECOLOGY and OBSTETRICS

Name of investigator Jemal GABI, MD

Name of advisors 1. Dr.Gurmessa Merga

Out come of previous 1 c/s scar and Associated Factors

Title of the research project
in previous one cesarean section at Asella Teaching and
Referral Hospital during March 1-September 30, 2021

Duration of the project March 1-September 30, 2021

Study area Asella teaching and Referral hospital

Total cost of the project 32,800 Birr

Address of investigator Phone:0913825955

E-mail:sifangubadhe123@gmail.com
Address of primary Advisor Phone: 0949382913
E-mail:
Address of secondary Advisor Phone:
E-mail:

December , 2020

Asella, Ethiopia
 ACKNOWLEDGEMENTS
I would like to acknowledge Arsi University for giving me this privilege to do this research
for fulfillment of specialization in obstetrics and gynecology. In addition, I thank department
of oby/gyn for giving me this great opportunity in selecting topics of clinical importance.
I warmly acknowledge department of public health for helping us preparing this research
proposal.
Finally, my heartfelt gratitude goes to my advisors, Dr.Gurmessa Merga who guided me in
preparing this research proposal and for their close follow up and support.

I
ACRONYMS/ ABBREVIATIONS
VBAC

TOLAC

C/S

C/D

GA

AGOC
III
TABLE OF CONTENTS
ACKNOWLEDGEMENTS.............................................................................................I
ACRONYMS/ ABBREVIATIONS.................................................................................II
TABLE OF CONTENTS..............................................................................................III
SUMMARY..............................................................................................................VIII
1 INTRODUCTION.....................................................................................................0
1.1 Background................................................................................................................................0
1.2 Statement of the problem..........................................................................................3
1.3 Significance of the study............................................................................................................3
2 LITERATURE REVIEW...........................................................................................4
2.1 out come of TOLAC in previous one cesarean section..............................................................4
2.2 Associated Factors with out come of TOLAC in previous one cesarean section.......................7
3 OBJECTIVES.........................................................................................................10
4 METHODS AND MATERIALS..............................................................................11
4.1 Study design and period...........................................................................................................11
4.2 Study area................................................................................................................................11
4.3 Source population....................................................................................................................11
4.4 Study population......................................................................................................................12
4.5 Sample size determination.......................................................................................................12
4.6 Sampling procedure.................................................................................................................13
4.7 Variables of the study..............................................................................................................13
4.7.1 Dependent variable:...........................................................................................................13
4.7.2 Independent variables........................................................................................................13
4.8 Operational definitions............................................................................................................14
4.9 Data collection procedures......................................................................................................15
4.10 Data quality assurance............................................................................................................15
4.11 Data processing and analysis..................................................................................................16
4.12 Ethical considerations.............................................................................................................16
4.13 Dissemination of results..........................................................................................................16
5 WORK PLAN.....................................................................................................................17
6 BUDGET BREAKDOWN...................................................................................................18
7 REFERENCES....................................................................................................................19
SUMMARY
Introduction: Trial of Labor After cesarean Delivey(TOLAC) refers to a planned attempt
to deliver vaginally in a women with previous cesarean delivery,regardless of out comes.This
method provides women who had desire to vaginal delivery the possiblity of achieving their
goal-VBAC.In addition to fulfilling patients’preference for vaginal delivery at individual
level,VBAC is associated with decreased maternal morbidity,future pregnancy related
complications,as well as decrease in cesarean section delivery rate at population
level.However also TOLAC is preferred by many women,the are several factors associated
with successful TOLAC and there by contributing to increased perinatal and maternal
morbidity when compaired to successful TOLAC i.e VBAC and elective cesarean
section.There fore,assessing the likelihood of VBAC and associated individual risk factors is
important when determining who is candidate for TOLAC.
Objectives: To assess the out come of previous one C/S and associated factors among
pregnant women with previous one cesarean delivery who gave birth in Asella teaching and
referral hospital in period of March 1-Septembe 30, 2021.
Methods: Institutional-based cross-sectional study will be conducted at Asella teaching and
referral hospital. A prospective registration of all pregnancy outcomes after 28 weeks of
gestational age which ended with successful TOLAC and RCD among women with previous
one cesarean delivery will be conducted between March 1 and september 30, 2021, at Asella
teaching and referral hospital to understand the out come of previous one C/S scar and
analysis of those with successful TOLAC and RCD will be made to investigate the
associated factors. The sample size is determined by the total number of women with
previous one cesarean section and fulfilled the inclusion criteria during the study period until
the final date of registration.
Data will be collected by structured questionnaire in face to face by making exit interview by
trained data collectors. The data collectors will be closely monitored by the principal
investigator daily during the process. Data will be checked for completeness, cleaned and
edited accordingly by the principal investigator using Epi info 3.5.1 and SPSS version 23.
Data will be analyzed by bivarient and multivariate logistic regression.

V
Work plan and Budget: The study duration is from October 2020- to-September
2021.The required budget will be 36,608 birr.
1 INTRODUCTION

1.1 Background
Cesarean delivery defines the birth of a fetus via laparotomy and then hysterotomy. This
definition is not applied to removal of the fetus from the abdominal cavity in the case of
uterine rupture or with abdominal pregnancy. Rarely, hysterotomy is performed in a woman
who has just died or in whom death is expected soon—postmortem or perimortem cesarean
delivery. In some instances, abdominal hysterectomy is indicated following delivery. When
performed at the time of cesarean delivery, the operation is termed cesarean hysterectomy. If
done within a short time after vaginal delivery, it is termed postpartum hysterectomy.
Peripartum hysterectomy is a broader term that combines these two. In most cases,
hysterectomy is total, but supracervical hysterectomy is an option. The adnexa are not usually
removed. In most instances,a simple or type I hysterectomy is performed. However, for
women with invasive cervical cancer, radical hysterectomy removes the uterus, parametrium,
and proximal vagina to achieve tumor excision with negative margins. Also, for cases of
placenta percreta that extend toward the pelvic sidewall, similar radical excision of the
parametrium may be needed.Between 1970 and 2016 cesarean delivery rate in USA had
increased from 5% to 31.9%.This dramatic increase was resulted from several changes in the
practice environment,including introduction of electronic fetal monitor,decrease in operative
vaginal delivery and attempts at vaginal breech delivery.The dictum”once cesarean
section,always cesarean section has also contributed to this increment. Following this peak,
the rate has trended slightly downward,and it was 32.0 percent in 2015{, #8}. However, in
the 1970s some investigators began to reconsider this paradigm and accumulated data had
then supported TOLAC as a reasonable approach in some selected pregnancies.(ACOG
2017). More than 85 percent of these operations are performed for four reasons—prior
cesarean delivery, dystocia, fetal jeopardy, or abnormal fetal presentation. The latter three
compose the main indications for primary cesarean delivery.(w25) Even though,variation
exists in rates of caesarean delivery across countries; currently the rate ranges from 10% to
40%.

1
This high caesarean section rate has put burden on the economy of nations and individuals.

Previous caesarean section has been found to be the commonest cause of increased caesarean
section rate in many parts of the world. Because of increased riskof maternal complications
with repeat caesarean section and safety of VBAC, trial of labour for selected group of
patients with previous scar has become a preferred strategy. In1988 ACOG recommended
that, in the absence ofa contraindication, a woman with one previous lowtransverse cesarean
delivery be counseled to attempt labor in a subsequent pregnancy.(1).Recommendations
favoring TOLAC were reflected in increased VBAC rates(VBAC per 100 women with prior
cesarean delivery) from slightly more than 5% in 1985 to28.3% by 1996.Concomittently the
over all cesarean rate decreased from 22.8% in 1989 to approximately 20% by 1996.Yet as
the number of women pursuing TOLAC increased,so did the rates of uterine rupture and
other complications related to TOLAC.These reports and the professional liability pressure
they endangered contributed to reversal of VBAC and cesarean delivery trend,and by
2006,the VBAC rate has decreased to 8.5% and total cesarean delivery rate increased to
31.1%.Some Hospitals stopped offering TOLAC altogether.In 2011,the national institute of
health convened the consensus conference to examine the safety and out comes of TOLAC
with associated factors with their decreasing rates.The panel recognized TOLAC as
reasonable options for women with previous cesarean delivery and called institutions to offer
TOLAC and also recognized concerns over liability has impact on health professionals for
offering TOLAC.(ACOG 2017). Vaginal birth after cesarean section (VBAC) is
associatedwith shorter maternal hospitalizations, less blood loss and fewer transfusions,
fewer infections, and fewer thromboembolic events than cesarean delivery. Several reports
have indicated that the absolute risk of uterine rupture attributable to a trial of labor is about
1 per 1000. A 60 to 80% success rate of vaginal birth after previouscaesarean section has
been reported by many authors if the primary caesarean was done for nonrecurring
indications. Some of the non recurring indications for caesarean section are: poor labour
progress, foetal distress, placenta previa, transverse lie, breech presentation, oblique lie,
pregnancy induced hypertension and twins. The VBAC rate of hospitals in sub-Saharan
Africa is between 37 to 97%. A Meta analysis done, in sub-Saharan countries showed a
VBAC success rate of 63–75%.

There is considerable variation in the proportion of women who are offered and attempt
VBAC across centres. British figures indicate that among women with a prior caesarean
section, 33% will successfully achieve vaginal birth in the subsequent pregnancy. Again
there was considerable variation across institutions, ranging from 6% to 64%. One study in
Lahore reported Successful vaginal delivery in 70% of the patients and repeat emergency
caesarean section in 30% of the patients. In one case control study done at teaching hospitals
in Addis Abeba the rate of successful TOLAC was 49.5%. The leading indications for the
repeat caesarean sections were: failure to progress,fetal distress and scar tenderness. There
were no maternal and foetal complications occurred. A study conducted in Brazil from1985
1995, the rateof TOLAC was found to be 11%. The factors significantly associated with
vaginal delivery were monthly family income below 5-fold the Brazilian minimum monthly
wage, reliance on the Brazilian national health system for healthcare, low maternal age, and
first cesarean section indicated because of fetal breech or transverse presentation, or twin
pregnancy. Mother’s choice on mode of delivery is the most important single factor in
offering trial of labour. Women’s expectations for birth and mode of birth preferences are
influenced not only by knowledge of the potential benefits and risks but also demographic,
obstetrical This knowledge would help while counseling mothers for TOLAC. The crucial
questions are how to reliably predict successful TOLAC, and how to determine and quantify
the magnitude of the risk of failure that is acceptable to women and social factors. Currently,
there is no single validated tool which holds true for all to predict successful vaginal birth
among women with a prior cesarean delivery. The purpose of this study is to identify
maternal demographic, past and present obstetric determinantsof successful TOLAC in our
Hospital there by enabling physicians in charge of offering TOLAC in similar institutions of
the country to have updated and evidence based out come of TOLAC and associated factors.

3
1.2 Statement of the problem
Vaginal delivery after previous one cesarean section for a non recurring indication has been described
by several authors as safe and having a success rate of 60–80%. Hence many centers are offering
VBAC for candidates leaving the century old dictum of once cesarean always cesarean. But
predicting VBAC after trial of labor (TOLAC ) is still a difficult task due to the lack of a validated
prediction tool.

Therefore assessing factors associated with successful VBAC is very important to for counseling
mothers while offering VBAC.There is limited study done yet on out come of TOLAC and affecting
factors in our country for women with one previous cesarean section.

1.3 Significance of the study

2 LITERATURE REVIEW

2.1 previous one cesarean delivery

2.2 Associated Factors with previous one cesarean delivery

5
Fig. 1: Conceptual frame work to assess the factors contributing for neural tube
development
out come of 1 c/s
delivery

7
3 OBJECTIVES

3.1 General objective

To assess out come of one previous cesarean section and associated factors among pregnant
women who gave birth after fetal viability at Asella Teaching and Referral Hospital in period
of March1-September 30, 2021.

3.2 Specific objectives

 To assess out come of one cesarean section among pregnant women who gave birth
after fetal viability in Asella Teaching and Referral Hospital in period of March1-
September 30, 2021
 To identify factors associated with out come of one previous cesarean section in
Asella Teaching and Referral Hospital in period of March1-September 30, 2021.

4 METHODS AND MATERIALS

4.1 Study design and period

This study used two study designs, namely, a prospective cross-sectional institution-based
study.

A prospective registration of all birth outcomes after 28 weeks of gestation will be conducted
between March 1 and September 30, 2020, at Asella teaching and referral hospital to measure
out come of TOLAC.

4.2 Study area

This study will be conducted in Arsi University Asella teaching and referral Hospital. Arsi
University is one of the third generation public universities, established on 15 October 2014
and located in Asella town which is 175 km in the south east of Addis Ababa, capital city of
Ethiopia. The Asella teaching and referral Hospital is the only referral hospital in Arsi zone
with catchment area of 3.5 million people. The hospital has around 310 beds distributed in
four major inpatient departments( internal medicine, surgery, gyn/ob and pediatrics).It has
also adult ICU and general emergency OPD.
There are different OPD, MCH unit, VCT AND ART services, major operation rooms and
minor operation room.

The hospital provides 24 hours delivery and abortion service. It has 10,4 Gps consultants
and 28 residents of different batch in department of ob/gyn. The hospital provide an average
of 550 (520-615) deliveries monthly and the cesarean rate is ranging from 21%-27%.

4.3 Source population

This study will include all pregnant mothers who will give birth in Asella teaching and
referral hospital as well as all pregnant mothers with scared uterus and will give birth after
fetal viability .

4.4 Study population

The study population will be all pregnant mothers with previous one cesarean section and
giving birth (vaginally or by RCD) after fetal viability during data collection period.

Inclusion criteria:-

 Pregnant mother with previous one cesarean section who had successful
TOLAC.
 Pregnant mother with previous one cesarean section for whom emergency
RCD was done(with labor or with out labor).
 Pregnant mother with previous one cesarean section and for whom elective
RCD was done.
 All pregnant women admitted for delivery

Exclusion criteria:-

 Women with previous 2 or more cesarean section.

 Women with previous hysterotomy scar,uterine rupture repair or myomectomy
scar.
 Women with previous one cesarean scar for whom pregnancy terminated before
fetal viability.
 Women who refused to participate in the study.

9
4.5 Sample size determination
For out come, considering the prevalence of cesarean section varies among different
institutions and regions in our country,the true prevalence of cesarean section in different
studies done has also significant difference.So,the sample size for this study will be all
women with previous one cesarean section coming for delivery during the study period

4.6 Sampling procedure

All mothers with previous one cesarean section who come for delivery or pregnancy termination after
fetal viability will be registered by data collectors.The total number of those who delivered by
successful TOLAC and RCD will carefully and clearly registered.At the end of study period,the
possible maximum number registered by data collector will be taken and analysed for out comes and
associated factors.

4.7 Variables of the study

4.7.1 Dependent variable:

Out come of one previous cesarean section.

4.7.2 Independent variables

1: Socio-demographic characteristics of mothers: Age of mother in years,
Educational status of mother ,Religion of mother , Ethnicity of mother ,Residency of
mother(rural vs urban) , Educational level of husband, Occupatinal status of
mother ,Occupational status of husband

2: Obstetric history of mother

Gravidity, Parity,out come of previous C/D, indication of previous C/D,presence severe

oligohydroamniou,presence severe PE/E,presence of prolonged Term PROM,presence of
Term APH,Duration of interdelivery interval

3: Fetal factors

EFW,Fetal presentation/lie,number of gestations,lethal congenital anomaly,IUFD

4:ANC factors
Place of ANC,Number of ANC visits,counseling for TOLAC

5:Family planning factors

Counseling & provision of LARC,Not counseled&not provided with any type of

contraceptive.

Operational definitions

Cesarean Delivery

Emergency cesarean delivery,.

Elective cesarean Delivery,

TOLAC

VBAC

Failed TOLAC

Successful TOLAC

Declined TOLAC

Refused TOLAC

Scar dehiscence

Uterine Rupture

4.8 Data collection procedures

All intern doctors, residents, midwives, and clinical nurses will be informed to report to the
principal investigator after the mother was admitted for delivery.

Afterwards, data will be collected by seven trained junior residents working at labor ward,
prenatal&postnatal ward and post op ward.Subsequently, exit interview of face to face of the
mothers who gave birth vagianally or via cesarean section will be made &submitted to
principal investigator.

11
A structured and pre tested questionnaire will be used to collect data from the consenting
mothers. Parts questionnaire: Socio-demographic characteristics of mothers, Obstetric history
of mother,ANC follow up status,Family planning status.

Cases will be ascertained and admitted by one senior obstetrics and gynecology residents by
thorough evalution revision of previous documentation if available.The decision to offer
TOLAC or going for repeated cesarean delivery will be made by senior resident in charge of
managing in respective wards.After delivery,the out come will be investigated by data
collector by revising delivery summary,operation note and log book if needed..

4.9 Data quality assurance

Orientation of six hours will be given to data collectors before the actual data collection.
Pretest of two weeks prior to actual data collection period of admitted cases will be
conducted in kersa Hospital to see for the accuracy of responses, language clarity, and
appropriateness of the tools. Interview questions will be revised, edited, and those found to
be unclear will be modified after pretest is conducted.

The data collectors will be closely monitored by the principal investigator daily during the
process and collected data will be cleared by the investigator daily basis during data
collection.

The questionnaire will be prepared in English then translated into Amharic and Afan Oromo
then back to English for consistence of translation.

4.10 Data processing and analysis

Data will be entered and cleaned using Epi info and analyzed using SPSS version 21.0
statistical software. Descriptive statistics and numerical summary measures will be presented

by using frequencies distribution tables and graphs (diagrams).

Univariate analysis will be employed to examine the relationship between the outcome
variable and independent variable. Those variables with (p ≤ 0.2) in the univariate analysis
 will be entered into multivariate logistic regression model by using adjusted odds ratio
(AOR) and Confidence Intervals (CI) to control possible confounding factors. Variables with

P-value <0.05 will be considered as statistically significant.

4.11 Ethical considerations

The research proposal will be presented to department of public health and department of
gynecology and obstetrics. Permission letter will be obtained from department of gynecology
and obstetrics. Ethical clearance will be obtained from research and publication committee of
Arsi University College of health sciences institutional review board. Informed consent for
participation will be taken from client. Confidentiality will be maintained by making data
extraction anonymous (Code). Whenever clarification is needed the response will be given
by principal investigator.

4.12 Dissemination of results

Data will be analyzed and important conclusions and recommendations will be generated.
The results of the research would be presented to department of gynecology and obstetrics
and public health department. The findings will also be published in a relevant scientific
journal and disseminated online

5 WORK PLAN

Activities October Novem Decem Januar Februar Marc Apri May June July Aug Sep Oct
2020 ber ber202 y y h l 2021 2021 202 2021 t 2021
2020 0 2021 2021 2021 2021 1 202
1
Proposal
developme
nt
Literature   

13
review
Proposal 
presentatio
n
Proposal 
Submission

Pretest 
study,
Training
for data
collectors,
Questionna
ire
Distributio
n
Data    
collection

Analysis  

Write up     

Final   
submission
of paper

6 BUDGET BREAKDOWN

Budget Category Unit cost Multiplying factors Total cost

 (birr)

I Personnel Daily wage(including per diem) Number of staff days

Supervisor 5000 5000

data collectors 105 birr/day for 7collectors 226 days 23,730

Transportation 150birr/transport 4 travel 600

Sub total 29,330

II Material and Supplies Cost per item Number

Questioner duplication 4pages/ 2birr 319 questionnaires 2552

Pretest questioner 4 page/2birr 16 questionnaires 128

Print & binding 50 pages/2 5 prints 500

Pen 7/ 10 birr 7 data collector 70

Sub total 3250

IV Training Cost per item Number of days

Tea/coffee 20birr/participant/day 7student/5days 700

Sub total 700

Total 33,280

10% contingency 3328

Grand Total 36,608

References
1. Behrman RE, Vaughan III VC. Nelson textbook of pediatrics: WB Saunders company; 1983.
2. Sadler TW. Langman's medical embryology: Lippincott Williams & Wilkins; 2011.

15
3. Lemire RJ. Neural tube defects. Jama. 1988;259(4):558-62.
4. Sadler T. Mechanisms of neural tube closure and defects. Mental retardation and
developmental disabilities research reviews. 1998;4(4):247-53.
5. Practice Bulletin No. 187: Neural Tube Defects. Obstetrics & Gynecology. 2017;130(6).
6. Campbell LR, Dayton DH, Sohal G. Neural tube defects: a review of human and animal
studies on the etiology of neural tube defects. Teratology. 1986;34(2):171-87.
7. Gelineau‐van Waes J, Voss K, Stevens V, Speer M, Riley R. Maternal fumonisin exposure as a
risk factor for neural tube defects. Advances in food and nutrition research. 2009;56:145-81.
8. Milunsky A, Ulcickas M, Rothman KJ, Willett W, Jick SS, Jick H. Maternal heat exposure and
neural tube defects. Jama. 1992;268(7):882-5.
9. Seidahmed MZ, Miqdad AM, Al-Dohami HS, Shareefi OM. A case of fetal valproate syndrome
with new features expanding the phenotype. Saudi Med J. 2009;30(2):288-91.
10. Rosa FW. Spina bifida in infants of women treated with carbamazepine during pregnancy.
New England journal of medicine. 1991;324(10):674-7.
11. Kondo A, Kamihira O, Ozawa H. Neural tube defects: prevalence, etiology and prevention.
International Journal of Urology. 2009;16(1):49-57.
12. Cuskelly GJ, McNulty H, Scott JM. Effect of increasing dietary folate on red-cell folate:
implications for prevention of neural tube defects. Lancet (London, England). 1996;347(9002):657-9.
13. Detrait ER, George TM, Etchevers HC, Gilbert JR, Vekemans M, Speer MC. Human neural
tube defects: developmental biology, epidemiology, and genetics. Neurotoxicology and teratology.
2005;27(3):515-24.
14. Simeone RM, Feldkamp ML, Reefhuis J, Mitchell AA, Gilboa SM, Honein MA, et al. CDC
Grand Rounds: understanding the causes of major birth defects—steps to prevention. Morbidity and
Mortality Weekly Report. 2015;64(39):1104-7.
15. Murray CJ, Vos T, Lozano R, Naghavi M, Flaxman AD, Michaud C, et al. Disability-adjusted life
years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: a systematic analysis for the
Global Burden of Disease Study 2010. The lancet. 2012;380(9859):2197-223.
16. Blencowe H, Kancherla V, Moorthie S, Darlison MW, Modell B. Estimates of global and
regional prevalence of neural tube defects for 2015: a systematic analysis. Ann N Y Acad Sci.
2018;1414(1):31-46.
17. Laurence KM, Carter CO, David PA. Major central nervous system malformations in South
Wales. II. Pregnancy factors, seasonal variation, and social class effects. British journal of preventive
& social medicine. 1968;22(4):212-22.
18. Lo A, Polsek D, Sidhu S. Estimating the burden of neural tube defects in low- and middle-
income countries. J Glob Health. 2014;4(1):010402.
19. Timbolschi D, Schaefer E, Monga B, Fattori D, Dott B, Favre R, et al. Neural tube defects: the
experience of the registry of congenital malformations of Alsace, France, 1995-2009. Fetal diagnosis
and therapy. 2015;37(1):6-17.
20. WHO. Periconceptional folic acid supplementation to prevent

neural tube defects. World Health Organization Geneva

21. Zerfu D ea. Ethiopian National Micronutrient Survey. 2016.
22. Global Fortification Data exchange. https://fortificationdata

org/country-fortification-dashboard.
23. Aguilera S, Soothill P, Denbow M, Pople I. Prognosis of spina bifida in the era of prenatal
diagnosis and termination of pregnancy. Fetal diagnosis and therapy. 2009;26(2):68-74.
24. Waitzman N, Scheffler R, Romano P. An assessment of total costs and policy implications.
Waitzman NJ, Scheffler RM, Romano J Teh Univ Heart Ctr. 1996;9(1).
25. Yi Y, Lindemann M, Colligs A, Snowball C. Economic burden of neural tube defects and
impact of prevention with folic acid: a literature review. European journal of pediatrics.
2011;170(11):1391-400.
26. Ireys HT, Anderson GF, Shaffer TJ, Neff JM. Expenditures for care of children with chronic
illnesses enrolled in the Washington State Medicaid program, fiscal year 1993. Pediatrics.
1997;100(2):197-204.
27. Control CfD, Prevention. Hospital stays, hospital charges, and in-hospital deaths among
infants with selected birth defects--United States, 2003. MMWR Morbidity and mortality weekly
report. 2007;56(2):25.
28. Berihu BA, Welderufael AL, Berhe Y, Magana T, Mulugeta A, Asfaw S. High burden of neural
tube defects in Tigray, Northern Ethiopia: Hospital-based study. PloS one. 2018;13(11):e0206212.
29. Gedefaw A, Teklu S, Tadesse BT. Magnitude of Neural Tube Defects and Associated Risk
Factors at Three Teaching Hospitals in Addis Ababa, Ethiopia. Biomed Res Int. 2018;2018:4829023.
30. Haidar J, Melaku U, Pobocik R. Folate deficiency in women of reproductive age in nine
administrative regions of Ethiopia: an emerging public health problem. South African Journal of
Clinical Nutrition. 2010;23(3):132-7.
31. Dessie MA, Zeleke EG, Workie SB, Berihun AW. Folic acid usage and associated factors in the
prevention of neural tube defects among pregnant women in Ethiopia: cross-sectional study. BMC
Pregnancy and Childbirth. 2017;17(1):313.
32. WWW.NUTRITIONINTL.ORG. PREVENTING NEURAL TUBE DEFECTS IN ETHIOPIA. 2019.
33. Forrester MB, Merz RD, Yoon PW. Impact of prenatal diagnosis and elective termination on
the prevalence of selected birth defects in Hawaii. American journal of epidemiology.
1998;148(12):1206-11.
34. Group EW. Prevalence of neural tube defects in 20 regions of Europe and the impact of
prenatal diagnosis, 1980-1986. Journal of Epidemiology and Community Health (1979-). 1991:52-8.
35. <Prevalence and secular trend of congenital anomalies in.pdf>.
36. Moore CA, Li S, Li Z, Hong Sx, Gu Hq, Berry R, et al. Elevated rates of severe neural tube
defects in a high‐prevalence area in northern China. American journal of medical genetics.
1997;73(2):113-8.
37. Mastroiacovo P. International clearinghouse for birth defects monitoring systems, Annual
Report 2014. International Centre of Birth Defects, Rome. 2014.
38. Godbole K, Deshmukh U, Yajnik C. Nutrigenetic determinants of neural tube defects in India.
Indian Pediatr. 2009;46(6):467-75.
39. Gaigi S, Masmoudi A, Mahjoub S, Jabnoun S, Ouni S, Channoufi M, et al. Fetal pathology
study of 88 cases of letal spina bifida. La Tunisie medicale. 2000;78(12):727-30.
40. Houcher B, Begag S, Egin Y, Akar N. Neural tube defects in Algeria. Neural tube defects–role
of folate, prevention strategies and genetics. 2012:163.
41. Khalifa M. Genetic disorders among the Egyptians. OXFORD MONOGRAPHS ON MEDICAL
GENETICS. 1997;30:191-207.
42. Omer IM, Abdullah OM, Mohammed IN, Abbasher LA. Prevalence of neural tube defects
Khartoum, Sudan August 2014–July 2015. BMC research notes. 2016;9(1):495.
43. Elsheikh G. Neural tube defects: pattern and incidence in Omdurman Maternity Hospital,
Sudan. Clinical MD (Paediatrics and Child Health) thesis, University of Khartoum, Khartoum. 2004.
44. Dudin A. Neural tube defect among Palestinians: a hospital-based study. Annals of tropical
paediatrics. 1997;17(3):217-22.

17
45. Al‐Gazali L, Sztriha L, Dawodu A, Bakir M, Varghese M, Varady E, et al. Pattern of central
nervous system anomalies in a population with a high rate of consanguineous marriages. Clinical
genetics. 1999;55(2):95-102.
46. Fida NM, Al-Aama J, Nichols W, Alqahtani M. A prospective study of congenital
malformations among live born neonates at a University Hospital in Western Saudi Arabia. Saudi
medical journal. 2007;28(9):1367.
47. Rajab A, Vaishnav A, Freeman N, Patton M. Neural tube defects and congenital
hydrocephalus in the Sultanate of Oman. Journal of tropical pediatrics. 1998;44(5):300-3.
48. al SAGe. Prevalence and patterns of birth defects among newborns in Southwestern
Ethiopia.
49. Seyoum G, Adane F. Prevalence and associated factors of birth defects among newborns at
referral hospitals in Northwest Ethiopia. Ethiopian Journal of Health Development. 2018;32(3).
50. <neural-tube-defect-and-associated-factors-in-bale-zone-hospitals-southeast-ethiopia.pdf>.
51. Loeken M. Free radicals and birth defects. The Journal of Maternal-Fetal & Neonatal
Medicine. 2004;15(1):6-14.
52. Chen C-P. Syndromes, disorders and maternal risk factors associated with neural tube
defects (I). Taiwanese Journal of Obstetrics and Gynecology. 2008;47(1):1-9.
53. Kultima K, Nyström A-M, Scholz B, Gustafson A-L, Dencker L, Stigson M. Valproic acid
teratogenicity: a toxicogenomics approach. Environmental health perspectives. 2004;112(12):1225-
35.
54. Bound JP, Harvey PW, Francis BJ, Awwad F, Gatrell AC. Involvement of deprivation and
environmental lead in neural tube defects: a matched case-control study. Archives of disease in
childhood. 1997;76(2):107-12.
55. Wlodarczyk B, Spiegelstein O, Gelineau-van Waes J, Vorce RL, Lu X, Le CX, et al. Arsenic-
induced congenital malformations in genetically susceptible folate binding protein-2 knockout mice.
Toxicology and applied pharmacology. 2001;177(3):238-46.
56. Aschengrau A, Weinberg JM, Janulewicz PA, Gallagher LG, Winter MR, Vieira VM, et al.
Prenatal exposure to tetrachloroethylene-contaminated drinking water and the risk of congenital
anomalies: a retrospective cohort study. Environmental Health. 2009;8(1):44.
57. Crider KS, Cleves MA, Reefhuis J, Berry RJ, Hobbs CA, Hu DJ. Antibacterial medication use
during pregnancy and risk of birth defects: National Birth Defects Prevention Study. Archives of
pediatrics & adolescent medicine. 2009;163(11):978-85.
58. Brender JD, Felkner M, Suarez L, Canfield MA, Henry JP. Maternal pesticide exposure and
neural tube defects in Mexican Americans. Annals of epidemiology. 2010;20(1):16-22.
59. Lynberg MC, Khoury MJ, Lu X, Cocian T. Maternal flu, fever, and the risk of neural tube
defects: a population-based case-control study. American journal of epidemiology. 1994;140(3):244-
55.
60. Grewal J, Carmichael SL, Song J, Shaw GM. Neural tube defects: an analysis of
neighbourhood‐and individual‐level socio‐economic characteristics. Paediatric and perinatal
epidemiology. 2009;23(2):116-24.
61. Murshid WR. Spina bifida in Saudi Arabia: is consanguinity among the parents a risk factor?
Pediatric neurosurgery. 2000;32(1):10-2.
62. Liu J. The recurrence risk of neural tube defects (NTDs) in a population

with high prevalence of NTDs in northern China. 2017; 8 (42):72577-83.

63. Sebold CD, Melvin EC, Siegel D, Mehltretter L, Enterline DS, Nye JS, et al. Recurrence risks for
neural tube defects in siblings of patients with lipomyelomeningocele. Genetics in Medicine.
2005;7(1):64.
64. Liao Y, Wang J, Li X, Guo Y, Zheng X. Identifying environmental risk factors for human neural
tube defects before and after folic acid supplementation. BMC Public Health. 2009;9(1):391.
65. Berry RJ, Li Z, Erickson JD, Li S, Moore CA, Wang H, et al. Prevention of neural-tube defects
with folic acid in China. New England journal of medicine. 1999;341(20):1485-90.
66. Wald N, Sneddon J, Densem J, Frost C, Stone R. Prevention of neural tube defects: results of
the Medical Research Council Vitamin Study. Lancet (London, England). 1991;338(8760):131-7.
67. Czeizel AE, Dobó M, Vargha P. Hungarian cohort‐controlled trial of periconceptional
multivitamin supplementation shows a reduction in certain congenital abnormalities. Birth Defects
Research Part A: Clinical and Molecular Teratology. 2004;70(11):853-61.
68. Daly LE, Kirke PN, Molloy A, Weir DG, Scott JM. Folate levels and neural tube defects:
implications for prevention. Jama. 1995;274(21):1698-702.
69. Brämswig S, Prinz-Langenohl R, Lamers Y, Tobolski O, Wintergerst E, Berthold HK, et al.
Supplementation with a multivitamin containing 800 µg of folic acid shortens the time to reach the
preventive red blood cell folate concentration in healthy women. International journal for vitamin
and nutrition research. 2009;79(2):61-70.
70. Atlaw D, Worku A, Taye M, Woldeyehonis D, Muche A. Neural Tube Defect and Associated
Factors in Bale Zone Hospitals, Southeast Ethiopia. J Preg Child Health 6: 412. doi: 10.4172/2376-
127X. 1000412 Page 2 of 7 Volume 6• Issue 3• 1000412 through folic acid fortification worldwide
[13]. Despite this fact, nearly two-thirds of Ethiopian women are victim of folic acid deficiency [14].
Worldwide, more than 300,000 babies are born with NTDs each year, serious birth defects of the
brain and spine are a significant cause of infant death and lifelong disability [13]. Africa, it is said to
affect approximately. 2019:1-3.
71. Fentahun Adane1 GS. Prevalence and associated factors of birth defects among

newborns at referral hospitals in Northwest Ethiopia. Ethiop J Health Dev. 2018;32(3).

72. AYNALEM F. DETERMINANTS OF NEURAL TUBE DEFECT AMONG CHILDREN, AT

ZEWDITU MEMORIAL HOSPITAL, ADDIS ABABA, ETHIOPIA. 2018.

73. Organization WH. International statistical classification of diseases and related health
problems: 10th revision (ICD-10). http://www who int/classifications/apps/icd/icd. 1992.

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Annex I: English version questioner
Arsi University, College of Health Sciences Department of Obstetrics and Gynecology
Questionnaire designed to assess out come of previous one cesarean section and associated
factors in Asella Referral and Teaching Hospital.
Greetings; My name is -----------------------------------------, a data collector for Dr.Jemal Gabi,
from Arsi University, CHS, and Department of Obstetrics And Gynecology.
He is conducting a study to assess out come of previous one cesarean delivery and associated
factors in Asella teaching and referral hospital. You are kindly requested to be included in the
study. The interview will take 20 minutes. The study is anonymous; your personal
information will be kept strictly confidential. Your participation in the study is voluntary and
valuable for the study.You have the right not to participate in the study or stop any time if
you are not comfortable. The study has approval and ethical clearance from Arsi University
College of health science research institutional review board.
Consent Form
I give my consent to participate in this study. I have been given the necessary information
about the research in a language I understand. I have also understood that I can withdraw my
consent any time without penalty or loss of benefits. I confirm my willingness by signature:
-----------------------------------
May I continue?
If yes, continue interviewing

If No, thank and stop interviewing.

Questionnaire No_________________
Date _______________
Ward ____________________

Data collector name_______________________Signature___________________

Supervisor Name ________________________Signature ___________________
Part I: parental socio demographic factor

1 Residency : urban rural

2 Maternal age ………………………….

3 Maternal educational status

No education Primary school Secondary school Diploma/degree /other

4 Maternal occupation
Housewife Farmer gov’t employe privet employe daily labourer

5 Religion

Orthodox Muslim Protestant Wakefena Catholic

Other ______________________

6 Ethnicity
Oromo ahmara gurage silte Somali afar other

7 Husband’s educational level

No education Primary school Secondary school Diploma/degree /other

8 Husband’s occupation
Farmer gov’t employe privet employe daily labourer

9 Where do you live?

Rural Town

Part 2 out come

21
1 Sex male female
2 Weight 1000-2000 2000-3000 3000-4000 >4000

3 APGAR score during 1st and 5th minutes respectively

4 Delivered via successful TOLAC
5 Delivered via emergency C/S for failed TOLAC
6 Delivered via emergency C/S for other obstetric indication
7 Delivered via elective RCD

Part 3 obstetrics Factors

1.parity gravidity
2.Inter delivery interval
3.provide with FP during previous C/D yes NO

4.previous indication for C/D

5.Has previous successful TOLAC YES NO
6.Has PE/E necessitating immediate delivery
7.Has Term APH
6.Has Term Prolonged PROM
7.Has Term severe Oligohydroamnious

Part 4 : Fetal factors

1.GA at admission 2.multiple Gestation 3.EFW>4000gm

4.Fetal Malpresentation/Lie

Part 5 :Intrapartum factors

1.vaginal bleeding
 2 Scar Tenderness

3.FHB abnormality

4.Labor abnormality

5.Declined TOLAC

Part 6 :ANC related factors

1.ANC follow up at our hospital

2.ANC follow up at another hospital
3.ANC follow up at local HC
4.Has no ANC follow up at all
5.Was she counseled for TOLAC? yes, refused yes opted not counseled

Annex 2 – Afan Oromo questionnaire

Yunibarsiitii Arsii Kolleejji Fayyaatti, Damee Ulfaafi Gadaamessaatti gaaffilee qorannoo
afaan oromoon qophaa’e waa’ee baay’inaa fi ka’umsa rakkoo guddinaa fi dagaagina
sammuu{Neural tube defect} yeroo ulfaa mul’atuun wal qabatan qorachuuf dhiyaatan
Hospitaala Assallaa keessatti.
Nagaa keessanii?-
Maqaan koo -----------------------------------yoo ta’u gaaffilee qorannoo Dr Firoomsaa Kiisiitin
dhiyaatan isin gaafachuf eeyyama keessan gaafadha. Dr Firoomsaa Kiisiin barataa digirii
lamaffaa damee Ulfaa fi Gadaamessaa waggaa 3 ffaa yunibarsiitii Arsiiti. Innis Qorannoo
rakkoo guddinaa fi dagaagina sammuu yeroo ulfaa mul’atu irratti bal’ina rakkoo kanaa fi
sababoota ka’umsa ta’an irratti Hospitaala Assallaatti qorannoo gaggeessuuf jedha. Isin
23
eeyyama keessaniin qorannoo kana keessatti akka hirmaattan kabajaan isin gaafadha. Yoo
eeyyamamaa taatan gaaffiif deebii daqiiqaa 20 ta’uun isiniif taasisa. Qorannoon koo
guutummaan guutuutti icititaawaa waan ta’eef maqaan keessan ifa hin ta’u. Qorannoon kun
eeyyama qorannoo fi namusa qorannoo Yunibarsiitii Arsii Kolleejjii Fayyaaa irraa argateera.

Fedhii kootiin qorannoo kana irratti nan hirmaadha. Waa’ee qorannoo kanaa odeeffannoo
ykn hubannoo gahaa qooqa naaf galuun naaf kennamee hubadheen jira. Akkasumas sa’aan
barbaadetti qorannoo kana rakkoo tokko malee adda kutuu akkan danda’u hubadheen jira.
Eeyyamamaa ta’uu koo mallatoo kootin nan mirkaneessa.-------------------------------------
Lakkofsa gaafii --------------------
Guyyaa ----------------------
Kutaa Ciisichaa ------------------------

Maqaa nama gaaffii gaafatuu -------------------------------mallatoo ………………………

Maqaa to’ataa -----------------------------------mallatoo …………………….

Kutaa 1ffaa: Haala Waliigalaa

1. Bakki jireenyaa eessa?:

magaalaa baadiyyaa

2. Umrii (waggaa ) ______________

3. Amantaan kee maali? :

kiristaana ortoodoksii Musliima protestantii Waaqqeffataa
kaatoolikii kan bira yoo ta’e ______________________

4. Sabummaan kee maali? :

Oromoo Amaraa Guraagee Silxee Sumaalee Affaar kan biraa yoo
ta’e ……………………………..

5. Hojiin idilee keetii maali? : haadha warraa hojjetaa mootummaa hojjetaa

 dhunfaa Dafqaan bulaa Qote bulaa kan bira yoo ta’e __________________

6. Sadarkaa barnootaa : barnoota hin baranne kutaa 1-8

Kutaa 9-10 kolleejji fi sanii ol

7. Galii ji’aa : birrii 810 gadi birrii 810-1620 birrii 1620 oli

8. Sadarkaa barnotaa abbaa warraa keeti - barnoota hin qabu kutaa 1-8
kutaa 9-10 kolleejji fi sani oli

9. Hojii idilee abbaa warraa keeti: hojii dhabaa hojjataa mootummaa

hojjataa dhuunfaa Dafqaan bulaa Qotee bulaa kan biraa yoo tahe
__________________

Kuta 2ffaa: waa’ee dhala ilaalatu

1. Umrii ulfi itti dhalate yookin addaan cite-

Torbee 12-24 Torbee 24-28 Torbee 28 -40 hin beeku
2. Saala dhalataa yookin kan sirraa bahee : dhiira dubara

3. Gostii rakkoo dagaagina sammuu argamee maali?

Sammuu kan hin qabne(aniikifaali) wirtuun dugdaa banamaa(sipina bifida)
sammuun gara alaa bahe (inseefaalosele) sammuun bishaan kuufate
(hiyidirokefalii)

Kutaa 3ffaa haala umamaan walqabatan ilaallatu

1. dura ulfi rakkoo dagaagina sammuu qabu dhalatee beeka? eeyyeen lakki

2. Maatii keessati namni rakkoo dagaagina sammuu qabu jiraa? eeyyeen lakki

3. Abbaa warraa keetin firummaa dhigaa qabdu? eeyyeen lakki

Kutaa 4ffaa: haala ulfa waliin wal qabatan

25
1. Kanaan Meeqa deesse?----------------------------

2. Kan kana dura du’ee dhalate jiraa?: eeyyeen hin jiru

3. Daa’imni akka dhalateen du’e jiraa? eeyyeen hin jiru

4. Ulfi sirraa bahe ykn Jige jiraa? eeyyeen hin jiru

5. Ulfi kun meeqa? tokko qofa lakkuu dha sadiifi sana oli

6. Ulfa kana karorfattee ulfooftee ? eeyyeen lakki tasa

7. Ulfa kanaaf hordoffii qabdaa? eeyyeen lakki

8. Yoo deebin lakkofsa 8ffaa eeyyeen tahe hordoffiin kee eessa ture?

Hospitaala mootummaa Hospitaala Dhunfaa Kilinika dhunfaa Bufata fayyaa

Kutaa 5ffaa : sababoota kana dura beekamanin wal qabate

1. Dhukkuba beekamu qabdaa?: eeyyeen lakki

2. Yoo deebin lakk 19 eeyyeen tahe dhukkubni kee maali?

Dhukkuba sukkaraa HIV/AIDS Dhiibbaa dhiigaa dhukkuba Gagabdoo(epilepsiy)

dhukkuba Kalee

3. Hordoffii ulfa duraa qabdaa? Eeyyeen lakki

4. Ulfa kana dura foolik asiidin siif laatamera?

Eeyyeen lakki

5. Qorichoota yeroo ji’ota sadan duraa yeroo ulfa kanaa fudhatte qabdaa: eeyyeen
lakki

6. Yoo deebiin lakk 5 eeyyeen tahe gosa qoricha fudhatee?

 Qoricha HIV Insulinii qoricha gagabdoo kan dhiibba dhiigaa maqaa
qorichaa hin beeku

7. Saaxilamummaa raajii (x-ray) yeroo ulfaa qabdaa: eeyyeen lakki

8. Yeroo ulfaa Saaxilamummaa keemikala akka farra aramaa qabdaa?: eeyyeen lakki

9. Yeroo ulfaa tamboo xuuxxee beektaa: eeyyeen lakki

10. Yeroo ulfaa Alkolii dhugde beektaa: eeyyeen lakki

27
7 Declaration of Investigator

I, the undersigned student of specialization in gynecology and obstetrics, declare that this
proposal is my original work in partial fulfillment of the requirement for specialization in
gynecology and obstetrics to my best knowledge.

Name of investigator:_________________________________

Signature: ______________ Date_________________

8 Declaration of Advisors

We, the undersigned Advisors, declare that this proposal is our original work in partial
fulfillment of the requirement for specialization in gynecology and obstetrics for the stated
student above to our best knowledge. We confirmed that this proposal is ready for defense
with our approval as the university advisor(s).

Date of Submission: ____________________________

Name of primary Advisors: Signatures Date

1. ________________ _______________ __________

Name of secondary Advisors: Signatures Date

2. _________________ ________________ ____________

3.