Trend,Prevalence,and Associated Factors of Unfavorable Fetal Outcomes Following Operative Vaginal Delivery in Ethiopia: A Systematic Review and Meta-Analysis

Abstract

Introduction

Although rare, operative vaginal delivery (OVD) can lead to various fetal/neonatal complications, particularly in resource-limited settings. Numerous factors have been identified as being associated with unfavorable fetal outcomes following OVD. However, studies examining unfavorable outcomes were highly varied and inconsistently reported in Ethiopia. Therefore, this systematic review and meta-analysis aims to estimate the trend, pooled prevalence, and its associated factors of unfavorable fetal outcomes following to OVD.

Methods

All pertinent articles released before September 2024, were methodically gathered from scientific data bases (PubMed, Hinari, Scopus, web of science, Science direct and Google scholar).The Joanna Briggs institute tool was used to assess the quality of the study. Data were extracted in Microsoft excel 2013 format and analyzed using Stata software version 17. I2 tests were used to assess the heterogeneity of the studies. Subgroup analysis was done based on sample sizes and year of publication to determine how pooled estimates of unfavorable fetal outcomes vary across the study events including time. The pooled effect of the factors influencing unfavorable fetal outcomes was estimated using an odds ratio (OR) with a 95% confidence interval (CI), and a p-value <0.05 was considered statistically significant.

Results

The meta-analysis of eight studies revealed, a lower odds of unfavorable fetal outcomes among mothers who gave birth by OVD with prolonged labor than those with other indication (pooled odd ratios (POR): 0.4, 95% CI: 0.04, 0.84); vacuum delivery (POR: 0.3, 95% CI: 0.0407, 0.53); birth weight (POR: 0.42, 95% CI: 0.15, 0.68); and delivery attendant (POR: 0.4, 95% CI: 0.14, 0.94). The pooled prevalence of unfavorable fetal outcomes among mothers who gave birth by OVD in Ethiopia was 29% (95%: CI: 22, 35); (I2 = 91.74%, p < 0.01).

Conclusion

The pooled prevalence of unfavorable fetal outcomes following OVD was high in Ethiopia. Prolonged second stage of labor, use of vacuum as type of OVD, birth weight, and the type of delivery attendant were the factors associated with unfavorable fetal outcomes. Therefore, we recommend the ministry of health and other stakeholders to emphasize the identified modifiable factors to further reduce unfavorable fetal outcome following OVD among mothers who gave birth in Ethiopia.

Systematic Review Registration

CRD42024561713.

Keywords

Operative vaginal delivery unfavorable fetal outcomes Ethiopia systematic review meta-analysis

Introduction

Operative vaginal delivery (OVD) is a procedure that is performed to enlarge vaginal orifice during the last part of the second stage of labor or childbirth by the help of obstetrics instrument/forceps or vacuum to extract an infant from the birth canal (Abbas et al., 2021; Harrison et al., 2021).These instrument-assisted/OPV deliveries are performed for the indication of maternal or fetal-related condition and any event that threatens the mother or fetus (Biru, Addisu, Kassa, et al., 2019). In other way round, OPD is considered as an integral part of obstetric care among global setting when prolonged second stage of labor with no reassuring fetal heart status or limited maternal expulsive effort happens (Al Riyami et al., 2021). Although rare, OVD like vacuum extraction can lead to various neonatal and maternal complications (Abbas et al., 2021). Which means, there are obstetrical indications for OVD such as vacuum and forceps delivery, which makes the professionals alert enough to watch for potential neonatal complications (Ferraz et al., 2019). OVD is considered safe if carried out by trained personnel (Sonawane et al., 2021; Joshi et al., 2020). Which implies that, termination of second stage of labor by OVD is indicated in any condition threatening the mother or fetus that is likely to be relieved by delivery (Al Riyami et al., 2021).

Recently, the rates of birth by cesarean have risen throughout the world; yet, with operative vaginal deliveries, cesarean section and its complication (morbidity and mortality) caused by it can be avoided (Çetin et al., 2017). Similarly, OVD is an ideal alternative to cesarean section with fewer maternal and neonatal complications in women who cannot deliver spontaneously if performed by a well-trained obstetrician and/or health-care attendants (Al Riyami et al., 2021; Jabeen, Baloch et al., 2017).

Instrumental delivery when performed correctly by a trained clinician, results in satisfactory fetal outcomes; However, clinician should be aware that, serious and rare complications, such as soft tissue trauma, cephalohematoma, caput succedaneum, subgeal hemorrhage, intracranial hemorrhage, cranial injuries, lowering of Apgar score and Fetal blood pH level, jaundice, birth asphyxia, fetal acidosis, intensive phototherapy, admission to the neonatal intensive care unit (NICU), transient brachial plexus injury, skull fractures, spinal cord injury, neonatal seizure, fresh still births, neonatal death, can occur particularly in the untrained hands as well as with repeated failed attempts (Al Riyami et al., 2021 Joshi et al., 2020; Çetin et al., 2017; Ferraz et al., 2019; Butler et al.,2014; Mulugeta et al.,2020; Chamagne et al.,2019).

In sub-Saharan Africa (SSA), the pooled prevalence of OVD was found to be 8% with the overall prevalence of 45% unfavorable fetal outcomes; from those births with unfavorable outcomes, the need for the resuscitation of newborn was found to be the highest 28.79% followed by poor 5th minute Apgar score, NICU admission, and fresh stillbirth, 19.92%, 18.8%, and 3.59%, respectively (Mebratu et al., 2023). It has also reported that, the pooled prevalence of OVD among mothers who gave birth in Ethiopia was 10%; where, fetal distress, prolonged labor, and maternal exhaustion were the most common feto-maternal indications for the procedure; consequently, poor Apgar score (25%), admission to NICU (18%) and neonatal death (2%), were neonatal complications occurred following to operative vaginal deliveries (Balis et al., 2022).

Although the practice of OVD is found to be common both in developed and developing nations including Ethiopia as basic obstetric care, trend analysis and pooled prevalence studies are limited to show the real magnitude of unfavorable fetal outcomes and its associated factors. In addition, the results of previously conducted primary studies in regard to unfavorable fetal outcomes following OVD were found to be highly variable and inconsistently reported in Ethiopia; moreover, almost all of these studies are single centered with small sample sizes conducted in different period of time. Our country Ethiopia has been also adapted and working for Sustainable Development Goals to be achieved in the upcoming 2030 under child and neonatal health strategy to end preventable death of newborns; to be in the right track of this plan, current and updated information related to neonatal/fetal outcome following to OVD is too relevant. Therefore, the current systematic review and meta-analysis can provide a comprehensive insight for possible remedial action to be taken as national strategy including policy making to mitigate the burden of unfavorable fetal outcomes by assessing the trend, the pooled prevalence, and its associated factors following to OVD among mothers who gave birth in Ethiopia.

Methods

Design

This is a systematic review and meta-analysis intended to describe the trend, the overall pooled prevalence, and its associated factors of unfavorable fetal outcomes following to OVD in Ethiopia. As searching strategies, a thorough exploration/search strategy was developed on unfavorable fetal outcomes and its associated factors among mothers who undergone OVD.

The Protocol and Registration

This systematic review and meta-analysis was carried out in accordance with the guidelines set forth by the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement (Moher et al., 2015). The protocol for this review was registered on International Prospective Register of Systematic Reviews (PROSPERO) with reference number 2024 CRD42024561713, available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID = CRD42024561713

Eligibility Criteria

All observational studies carried out on the prevalence of unfavorable fetal outcome; studies that assessed the association of unfavorable fetal outcome with different significant factors in Ethiopia; research published and available prior to September 2024; articles composed in English and citations that include an abstract and/or full text were considered eligible for the present systematic review and meta-analysis. Articles that could not be fully accessed, duplicate publications, systematic reviews and meta-analyses, qualitative studies, and studies with inconsistent outcome measures were excluded from this review.

Source of Information

A systematic literature search for the relevant papers was made in PubMed, Hinari, Scopus, web of science, Science direct, and Google scholar including academic and the reference of electronically identifiable publications. The search was restricted to papers published with English language prior to August 1, 2024, in Ethiopia.

Searching the Databases for Relevant Studies

Population, Intervention, Comparison, and Outcome format was used to search the relevant studies. “Operative vaginal delivery,” “instrumental assisted delivery,” “instrumental delivery,” “instrumental delivery outcome,” “instrumental delivery birth outcomes,” “fetal delivery via vacuum extraction,” “forceps delivery,” “fetal outcome,” “unfavorable fetal outcome,” “unfavorable birth outcome,” “birth outcome,” “favorable fetal outcome,” “neonatal outcome,” “newborn outcome,” “unfavorable newborn outcomes,” “fresh still birth by instrumental delivery,” “still birth,” “factors,” “determinants,” “predictors,” “associated factors,” “mothers,” “women,” “childbearing mothers,” and “Ethiopia” were among the combination of relevant keywords that we have used. The search phrases were joined together as needed using the Boolean operators “AND’’ and “OR’ ‘including with possible searching formula (Supplementary File).

Study Selection

The studies were selected from electronic databases based on their titles and abstracts; in instances where a conclusive decision could not be reached solely from the title and/or abstract, the complete paper was acquired for a thorough evaluation of the inclusion criteria. Two authors (FM&AM) screened and evaluated studies independently by using the STROBE and PRISMA statement check list (Moher et al., 2015). The other author (FW) independently evaluated the quality of the studies against the checklist, and if any discrepancy arises in decision process, it was resolved through discussion or through asking a third reviewer if consensus could not be reached.

Risk of Publication Bias Assessment

The full text of the studies was further evaluated based on objectives, methods, and study populations after assessing publication bias using visual inspection of the funnel plot and Egger's regression test.

Description of the Outcomes

The variable of interest regarding the outcome was unfavorable fetal/neonatal outcome and considered as unfavorable fetal/neonatal Outcome when the neonate experience one or more from the following complications: poor APGAR score, asphyxia, birth injuries, jaundice, retinal hemorrhage, subgalial hemorrhage, cephalohematoma, anemia, need of resuscitation, admission to NICU, and fetal/neonatal death. In the included studies, unfavorable fetal outcome was measured using the predetermined outcome measurement criterion for all studies. We used odd ratio (OR) to determine the association between unfavorable fetal outcomes and commonly identified associated factors from the previous primary studies.

Data Extraction Process

A data extraction template was employed to gather essential information from the articles, which includes the study title/topic of study/intervention, author's name, study designs, year of publication, sample size, study population, study setting, study type, and effect size as evaluated by two independent groups of reviewers. Data from chosen articles were extracted by using a data extraction template and subsequently presented in Microsoft Word.

Quality Appraisal

The quality appraisal criteria set forth by Joanna Briggs Institute (JBI) for analytical cross-sectional studies were utilized. The quality of the findings of the included articles was critically evaluated using the quality assessment tool for observational studies (Porritt et al., 2014). The authors from the research team FM, AM, and FW independently evaluated the quality of the studies. The reviewers compared their quality appraisal scores and resolved any discrepancy before calculating the final appraisal score. Articles with an appraisal score of ≥6 out of 10 scales were considered high quality and were considered eligible.

Statistical Analysis

The standard error of proportion for all included studies was computed using the binomial distribution formula. Heterogeneity among reported prevalence was assessed by computing p-values of I2-statistics. For meta-analysis with significant heterogeneity, random effects model was used and subgroup analysis was performed. The subgroup analysis was conducted based on sample size and publication year to investigate how unfavorable fetal outcome varies across different categories of reported primary studies used for outcome measurement. Publication bias was assessed by Egger's tests at 5% significant level. OR with 95% confidence interval (CI) was used to examine the association between unfavorable fetal outcomes and all other previously identified factors. The pooled prevalence of unfavorable fetal outcomes were expressed as a point estimate with 95% CI. The prevalence from each study were weighed by the sample size. All data manipulation and statistical analysis were performed using Stata software version 17.

Results

Search Results

Initially, a total of 592 articles were retrieved using scientific databases (PubMed = 402, Hinari = 93, science direct = 6, web of science = 7, Scopus = 5, Google Scholar = 79). After removing of duplications, 502 articles were considered eligible for title and abstract appraisal. Accordingly, 487 articles were excluded due to disparities in title and abstract; the remaining 15 articles were deliberated for further full-text evaluation. After the full-text reading, seven articles were further excluded due to differences in the outcome of interests, study objectives, and overlapping of the data. Finally, eight papers were found to be eligible to be included in this systematic review and meta-analysis (Figure 1).

Figure 1.

PRISMA Flow Chart Showing the Selection of Primary Studies. PRISMA, Preferred Reporting Items for Systematic Review and Meta-Analysis.

Characteristics of the Included Studies

The studies included in this systematic review and meta-analysis were all cross-sectional with a total sample of 2195 mothers who gave birth through OVD, which, were conducted from 2015 to 2023/24 in different regions of Ethiopia. The study sample sizes ranged from 208 to 399 reported from a study in south Ethiopia Arbaminch (Yesuf & Facha, 2016) and Gamogofa zone participants, respectively (Israel et al., 2023). Of the eight studies included in the final analysis, four were conducted in Oromia, Mattu (Abegizer et al., 2015), east wollega zone (Shimalis et al., 2022) and Jimma (Siraneh et al., 2018; Workina et al.,2023); three studies were from south Ethiopia Arbaminch (Yesuf & Facha, 2016), Gamogofa zone (Israel et al., 2023) and Dilla (Shaka et al., 2019); and the remaining one was from Amhara region (Sewunet et al., 2022). The response rates of the studies vacillated from 98.7% to 100%. The mean age of the study participants included in this systematic review and meta-analysis were ranged from 24.7 ± 5 years to 29.5 years (Supplementary File 1).

Trend and Prevalence of Unfavorable Fetal Outcome among Mothers who Gave Birth by Operative Vaginal Delivery in Ethiopia

The prevalence of unfavorable fetal outcomes among mothers who gave birth by OVD from the retrieved primary studies were ranged from 13.2% in Oromia/Jimma Ethiopia (Siraneh et al., 2018) to 42.1% from studies in South Ethiopia/Dilla (Shaka et al., 2019). The percentage of unfavorable birth outcomes did not show any significant differences from time to time in Ethiopia (Figure 2).The pooled prevalence of unfavorable fetal outcome among mothers who gave birth by OVD in Ethiopia was 29% (95%: CI: 22%, 35%) (Figure 3). From those unfavorable birth outcomes, poor Apgar score were found to be the highest (47.6%) followed by newborns need resuscitation (39.3%) and neonatal admission to NICU (33.3%) (Table 1).

Figure 2.

The Trend of Pooled Estimated Prevalence of Unfavorable Fetal Outcome in Ethiopia, 2024.

Figure 3.

The Pooled Estimated Prevalence of Unfavorable Fetal Outcome Among Mothers who Gave Birth Following OVD in Ethiopia, 2024. OVD, operative vaginal delivery.

Table 1.

Unfavorable Fetal Outcomes Among Mothers who Gave Birth by Operative Vaginal Delivery (OVD) in Ethiopia, 2024.

Fetal outcome	Model	Heterogeneity status	Prevalence(95%CI)	I²(%)	P-value
Poor APGAR score	Random effect	Marked	47.6(31.4–63.8)	100	<0.0001
Neonatal asphyxia	Random effect	Marked	20.1(0.9–39.4)	100	0.0402
Need resuscitation	Random effect	Marked	39.3(14.1–64.4)	100	0.0022
Birth trauma	Random effect	Marked	19.1(8.4–29.8)	100	0.0005
Admission to NICU	Random effect	Marked	33.3(4.7–61.9)	100	0.0225
Fetal/neonatal death	Random effect	Marked	3.0(1.6–4.3)	99.9	<0.0001

APGAR, Appearance, Pulse, Grimace, Activity and Respiratory; CI, confidence interval; NICU, neonatal intensive care unit.

Subgroup Analysis

There was a significant heterogeneity (I2 = 91.74%, p < 0.01) across the included studies. Therefore, we performed subgroup analysis based on the sample size (Figure 4) and publication year (Figure 5) to estimate the pooled prevalence of unfavorable fetal outcome among mothers who gave birth by OVD in Ethiopia. The pooled prevalence of unfavorable fetal outcome were 29% (95% CI 23%, 36%) among four studies that used above 250 sample size and 28% (95% CI 16%, 40%) for the other four studies that used less than 250 sample size (Figure 4).

Figure 4.

The Pooled Estimated Prevalence of Unfavorable Fetal Outcome Among Mothers Following OVD in Ethiopia Based on Sample Size, 2024. OVD, operative vaginal delivery.

Figure 5.

The Pooled Estimated Prevalence of Unfavorable Fetal Outcome Among Mothers Following OVD in Ethiopia Based on Publication Year, 2024. OVD, operative vaginal delivery.

Associated Factors for Unfavorable Fetal Outcomes

In five of eight included studies (Abegizer et al., 2015; Israel et al., 2023; Sewunet et al., 2022; Siraneh et al., 2018; Yesuf & Facha, 2016), there was a significant association between prolonged second stage of labor as an indication, use of vacuum delivery as type of OVD, birth weight, and types of delivery attendant/professionals conducting the delivery were the factors for unfavorable fetal outcomes. The aggregated meta-analysis in this studies revealed that, the odds of having unfavorable fetal outcomes among mothers with prolonged second stage of labor were lowered by 60% as compared with those mothers who were on cephalo-pelvic disproportion/CPD as OPV indication (pooled odd ratios (POR): 0.4, 95%CI: 0.04, 0.84) (Figure 6); the odds of having unfavorable fetal outcomes among mothers who undergone vacuum delivery were lowered by 70% than women who had forceps delivery (POR: 0.3, 95%CI: 0.07, 0.53) (Figure 7); the odds of having unfavorable fetal outcomes among mothers with low birth weight newborns were lowered by 58% as compared with women who had a baby weighing greater than 4 kilograms (POR: 0.42, 95%CI: 0.15, 0.68) (Figure 8); likewise, mothers who were attended by senior birth attendants have had the chance of decreasing unfavorable fetal outcomes by 60% as compared with those mothers attended by resident physician (POR: 0.4, 95%CI: 0.14, 0.94); i.e., the odds of delivery attended by resident physicians had a high chance of developing unfavorable fetal outcomes (Figure 9).

Figure 6.

Forest Plot of Pooled Odd Ratio Between Prolonged Second Stage of Labor and Unfavorable Fetal Outcome Among Mothers Following OVD in Ethiopia, 2024. OVD, operative vaginal delivery.

Figure 7.

Forest Plot of Pooled Odd Ratio Between the Use of Vacuum as Type of OVD and Unfavorable Fetal Outcome Among Mothers Following OVD in Ethiopia, 2024. OVD, operative vaginal delivery.

Figure 8.

Forest Plot of Pooled Odd Ratio Between Birth Weight and Unfavorable Fetal Outcome Among Mothers Following OVD in Ethiopia, 2024. OVD, operative vaginal delivery.

Figure 9.

Forest Plot of Pooled Odd Ratio Between the Type of Delivery Attendant and Unfavorable Fetal Outcome Among Mothers Following OVD in Ethiopia, 2024.

However, factors such as age of mother, residency, parity, antenatal care, episiotomy, liquor status, time of application, and non-reassured fetal heart as an indication were not significantly associated to the outcome variable on the pooled meta-analysis (Supplementary File 2).

Sensitivity Analysis

A sensitivity analysis was also performed by excluding two studies; among the total of eight studies conducted by Abegizer et al. (2015) and Yesuf and Facha (2016) deemed to have low quality due to its publication period. Accordingly, the six of eight studies yield 28.6% [(20.2, 37.0; p-value <0.0001, I2 (%) = 80.89] of the pooled prevalence of unfavorable fetal outcome among mothers who gave birth by OVD as shown in the Table 2.

Table 2.

The Pooled Prevalence of Unfavorable Fetal Outcomes Among Mothers who Gave Birth by OVD After Two Deemed Articles Were Excluded.

Study \|	Effect size	[95% conf. interval]		% weight
Workina et al. (2023) \|	0.350	0.295	0.405	16.53
Siraneh et al. (2018) \|	0.132	0.089	0.175	17.00
Israel et al. (2023) \|	0.230	0.189	0.271	17.07
Shimalis et al. (2022) \|	0.245	0.194	0.296	16.70
Shaka et al. (2019) \|	0.421	0.356	0.486	16.09
Workina et al. (2023) \|	0.348	0.295	0.401	16.62
Theta \|	0.286	0.202	0.370

Test of theta = 0: z = 6.71. Prob > |z| = 0.0000.

Test of homogeneity: Q = chi2 (5) = 80.89. Prob > Q = 0.0000.

OVD, operative vaginal delivery.

Publication Bias Results

Funnel plot and Egger's test was used to evaluate the presence of publication bias. Each dot in the funnel plot represents a single study. The y-axis is usually the standard error of OR. Larger studies with higher power are placed towards the top whereas lower powered studies are placed towards the bottom. The x-axis shows the OR; for the current review as depicted in Figure 10, the plot is asymmetric indicating evidence of publication bias; however, small study effect in our study (p-value from Egger's test = 0.12 and nonparametric trim-and-fill analysis of publication bias = 0.268) did not indicate the evidence of publication bias in both tests. However, in this interpretation, it should be put into consideration that the funnel plot and Egger's test are less reliable when the number of studies is less than 10.

Figure 10.

A Funnel Plot for Assessing Publication Bias. OVD, operative vaginal delivery.

Meta Regression

We have performed Meta regression to further explore the presence of heterogeneity among studies. A Meta regression using sample size and publication year as covariates indicated non-significant results as presented in Table 3.

Table 3.

Meta Regression Analysis of Factors Affecting Between Study Heterogeneity.

Covariate	Coefficients	Standard error	P-value
Sample size	−.0001714	.0005869	0.770

Discussion

This study aimed to assess the trend, prevalence, and its associated factors of pooled unfavorable fetal outcome following to OVD among mothers who gave birth in Ethiopia. Accordingly, the pooled prevalence of unfavorable fetal outcome were 29% (95%: CI: 22, 35); (I2 = 91.74%, p < 0.01). Subgroup analysis was performed based on sample size and publication year, and the highest pooled prevalence (29%) were observed among primary studies with sample sizes greater than 250 and in the recent reports. In this study, prolonged second stage of labor, use of vacuum as type of OVD, birth weight, and type of delivery attendant were the factors associated with unfavorable fetal outcomes in the pooled meta-analysis.

The overall unfavorable fetal outcome in the present findings is relatively lower than previously conducted systematic review and meta-analysis study in SSA (45%) (Mebratu et al., 2023); this variation could be explained by the vast differences in population size and geographical location employed in the study. It may also be due to differences in the quality of care delivered to the patients as of time run in all of the study area. From those unfavorable birth outcomes, poor Apgar score were found to be the highest (47.6%) followed by newborns need resuscitation (39.3%), neonatal admission to NICU (33.3%), neonatal asphyxia(20.1%), birth trauma(19.1%), and fetal/neonatal death(3%); these findings were similarly reported with in the study conducted in SSA (Mebratu et al., 2023), Portugal (Ferraz et al., 2019), Jeddah/Saudi Arabia (Abbas et al., 2021), India (Okram et al., 2019), Russia (Leonova et al., 2020), Greece (Prapas et al., 2009), Nepal (Thakur et al., 2020), and Pakistan (Arshad et al., 2011). On the other hand, the findings in this study are much higher than previous review study conducted in Ethiopia, which reports the magnitude of unfavorable birth outcomes as of the following: poor APGAR score (25%), neonatal admission to NICU (18%), and neonatal death (2%) (Balis et al., 2022).The difference can be due to the scope of study population, characteristics and period of study. Nonetheless, the finding tells us that, how crucial it is to establish a strategy to reduce the magnitude of unfavorable fetal outcomes following to OVD among mothers who will give birth for the futurity in any health-care system every were in the country.

In regard to factors, prolonged second stage of labor as an indication for OVD was found to be the significant factor that can affect unfavorable birth outcomes following OVD among mothers who gave birth in Ethiopia in the pooled meta-analysis (POR: 0.40; 95% CI: 0.04, 0.84). This means, the odds of having unfavorable fetal outcome is 0.4 times less likely for those mothers having prolonged second stage labor compared with those mothers with cephalic-pelvic disproportion/CPD as an indication for OVD, which is supported by previous study conducted in Ethiopia (Ayenew, 2021). This is because cephalo-pelvic disproportion can cause obstructed labor, which can further increase the complication to have unfavorable fetal outcomes (Shiferaw & Toma, 2019).

The application of vacuum as type of OVD was 0.3 times less likely to have unfavorable fetal outcomes in this pooled meta-analysis as compared to forceps delivery (POR: 0.3; 95% CI: 0.07, 0.53). This is in line with the study done in India (Sonawane et al., 2021), Istanbul, and Turkey (Çetin et al., 2017). However, this finding was different from the study reported in Portugal, where soft tissue trauma including cephalohematoma and jaundice was more commonly observed among mothers who have used vacuum as type of OVD than mothers assisted with forceps (Ferraz et al., 2019) and have had an equal contribution of neonatal trauma as it was reported from the Canadian institute of health research (Muraca et al., 2022). This difference could be due to differences in study methodology; the model we have used and clinical skill of birth attendant (Sentilhes et al., 2019).

Neonates who had low birth weight had a lower chance of experiencing unfavorable outcomes than their counterparts (newborn baby having more than 4 kilograms) with the odds of 0.42 (POR: 0.42; 95% CI: 0.15, 0.68), which is supported by previous study reported so far (Raio et al., 2003). This is because, fetus with larger birth weight might be due to medical comorbidities like diabetes mellitus, which can subjected to obstetrics complication such as cephalo-pelvic disproportion, obstructed labor, and shoulder dystocia (Abdelwahab et al., 2023; Tairy et al., 2024). Other justification can also be due to the intention of recognizing immediate/short-term fetal outcomes in this study, where long-term neurodevelopmental outcome was commonly observed under low birth weight children than that of children with having history of larger birth weight (Costantine et al., 2024; Kim et al., 2024).

Furthermore, types of delivery attendant were the factors associated with unfavorable fetal outcomes in this pooled meta-analysis, which shows 60% reduction of unfavorable feta outcomes when the procedure was carried out by senior birth attendants than junior practitioner/ birth attendants (POR: 0.4; 95% CI: 0.14, 0.94). The finding was analogous with previously conducted study out of Ethiopia (Sentilhes et al., 2019; Yakoob et al., 2011).This is due to the fact that, as experience increases on health-care professionals/who directly involved on delivery attendants (midwife, obstetrician and fellow residents), their chance of managing even complicated case can also increase (Sentilhes et al., 2019; Stoll et al., 2023).

We have also conducted subgroup analysis based on sample size and publication year, and the highest prevalence was observed among primary studies that used the sample size greater than 250 and in the recent studies (29%) than primary studies that used sample size of less than 250 and studies conducted 5 years ago. The discrepancy might be due to the difference in the number of study participants and increment of educational practice, which may increase precision of the pooled estimate for unfavorable fetal outcome. The strength of this review is, it was conducted with rigorous adherence to the PRISMA checklist which improves its quality for the readers. The main limitation of this meta-analysis is, it may be lacking national representativeness since primary studies were found only from three administrative regions, namely, Amhara, Oromia and South region; this could bias the estimated prevalence of unfavorable fetal outcome among the entire mothers who gave birth by OVD in Ethiopia.

Strength and Limitations of the Study

The strength of this review is, it was conducted with rigorous adherence to the PROSPERO registration, PRISMA and JBI checklist. By combining data from multiple primary studies, we have increased the sample size, which in turn enhancing the statistical power and precision of the results; moreover, the authors critically undertake comprehensive data analysis by using advanced analytical tool and updated the overall process of this review regularly to maintain its validity and to make more informed decision that truly benefit the study population and to advance the scientific community understanding. However, this study includes only a paper published by the English language and retrieving only hospital-based studies was another restraint of this study. It might also lack nationwide representativeness due to the absence of primary data from all over the regions in the country. In addition, the model used itself may have the chance to be subjected for publication bias and subjectivity. However, to overcome this drawback, we have taken some essential precaution to assess risk of publication bias and by selecting studies only eligible for the study based on the predetermined criteria together with the application of the recommended check lists.

Implication for Practice

Overall, this study points to positive implications for clinical care practice, health service management, and research within the area of obstetrics and fetal medicine specialization. Clinically, health-care workers/trained birth attendants can better help the pregnant mothers who will undergo delivery by emphasizing this modifiable factors associated with unfavorable fetal outcomes following to OVD in the clinical setup. Based on the result of this systematic review and meta-analysis, the health-care policy makers and other stakeholders in the country can realize the most reliable data regarding the overall pooled magnitude of unfavorable fetal outcome in Ethiopia and can take remedial action for possible enhancement of quality health-care services specific to obstetrics and fetal care by health-care providers, parents/guardians, and the patient themselves. Researchers can also be motivated to conduct further research in this area emphasizing on fetal monitoring technologies by taking this study as triggering evidence.

Conclusions

In this study, the pooled prevalence of unfavorable birth outcome following OVD among mothers in Ethiopia was found to be high. The highest prevalence of unfavorable birth outcome was observed among studies that used a sample size greater than 250 and in the recently conducted studies. Prolonged second stage of labor, use of vacuum as type of OVD, birth weight, and the type of delivery attendant were the factors associated with unfavorable fetal outcomes. Therefore, we recommend ministry of health and other stakeholders to emphasize on the identified modifiable factors to further reduce unfavorable fetal outcomes following OVD among mothers who gave birth in Ethiopia. It is advisable to conduct additional research that emphasizes on aggregating of primary qualitative studies including circumstantial elements affecting favorable fetal outcomes following to OVD among mothers. Furthermore, we recommend other researchers to do nationwide primary longitudinal study to analyze the current practice of OVD and its feto-maternal outcomes.

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sj-docx-5-son-10.1177_23779608251407790 - Supplemental material for Trend, Prevalence, and Associated Factors of Unfavorable Fetal Outcomes Following Operative Vaginal Delivery in Ethiopia: A Systematic Review and Meta-Analysis

Supplemental material, sj-docx-5-son-10.1177_23779608251407790 for Trend, Prevalence, and Associated Factors of Unfavorable Fetal Outcomes Following Operative Vaginal Delivery in Ethiopia: A Systematic Review and Meta-Analysis by Fentahun Meseret, Awoke Masrie and Fenta wondimneh in SAGE Open Nursing

Footnotes

Acknowledgments

We thank Haramaya University senior staff and friends for their technical support. We would also like to extend our gratitude to the primary research authors.

ORCID iD

Fentahun Meseret

Ethical Approval and Consent to Participate

Given that the review focused on previously researched articles, there was no requirement for ethical approval and/or additional consent from participants.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability

All necessary information were included with in the manuscript and article/Sublimentery material. However, further inquiry can also be directed to the corresponding author.

Supplemental Material

Supplemental material for this article is available online.

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