Obstructed Labour in Africa – An Overview

 

By Chinedu Akpa. B. Pharm. Freelance Health Writer and DLHA Volunteer. Medical review and editorial support provided by The DLHA Team

A black pregnant woman in a yellow dress sitting on a couch, holding her lower back with her left hand in apparent discomfort.

 

 

Highlights

• Obstructed labour occurs when the fetus finds it hard to pass through the birth canal despite sufficient uterine contraction.

• Obstructed labour is rampant in Africa partly because of entrenched traditional beliefs and lack of healthcare infrastructure.

• This phenomenon contributes significantly to the high infant and maternal death rates.

• High poverty rates, illiteracy, underage marriage, and a scarcity of skilled healthcare providers are some risk factors that are frequently associated with obstructed labour.

• Obstructed labour is a condition that can be completely avoided with adequate, skilled manpower coupled with state of the arts healthcare infrastructure as seen in developed continents.

• Legal and legislative moves can help with laws to prohibit acts that promote this phenomenon. 

 

 

Introduction

 

A child's cry at birth for those who have been barren for years may be filled with overwhelming joy, relief, gratitude, and a sense of fulfillment. It is also seen as hope for a successor to a throne, continuity of a lineage, or a symbol of pride by many African parents, but this hope is sometimes dashed by obstructed labour, leaving expectant parents heartbroken.

 

Many women who have stillbirth on the continent blame it on extraterrestrial powers or failure to adhere to certain cultures and traditions. The purpose of this article is to highlight the possible causes of obstructed labour and present possible solutions. 

 

Every year, over 300,000 women die as a result of pregnancy and childbirth complications around the world. [1] According to a 2015 study, obstetric causes contribute approximately 86% of the global burden of maternal deaths, with obstructed labour being one of the direct causes.[1] 

 

A 2019 study of 318 women who gave birth in a general hospital in Ethiopia (Mojo town) found that the prevalence of obstructed labour was 51%, with mis-position (malpresentation), misalignment (malposition), and too large a baby (cephalo-pelvic disproportion) reported as the causes. [2] 

 

What is Obstructed Labour? 

 

During pregnancy, the mother is usually advised not to take or consume anything that will harm the baby, but we often forget that a woman may appear healthy and the baby intact, but delivering the baby, which is dependent on a variety of factors, may hit a brick wall. So, what could go wrong? Obstructed labour! It may not be a term familiar to many, but it is one that some mothers, particularly in Africa, have encountered in some form. So, just what is obstructed labour? 

 

Obstructed labour, as defined by the World Health Organization, means that, despite strong contractions of the womb (uterus), the unborn baby (foetus) cannot pass through the birth canal of the pelvis because there is an unbeatable barrier preventing its movement. The obstruction can occur anywhere along the birth canal, but it usually occurs at its beginning. [3]

 

Cynthia Ukah, a registered nurse and midwife at Poly General Hospital in Asata, Enugu state, defines it as any labour in which all three components are contributory: a narrow pelvis, a large baby, and an inefficient pelvis. 

 

She further explained that there is a common misconception about obstructed labour in which people believe that women with a large hip will always have a small pelvis (the shape of the pelvis is an important part of childbirth), but this is not always the case, as she clarified in our interview. It is possible to have a large hip and also a big pelvis and vice versa. Pelvic dimensions are more important for childbirth than hip external size, she explained.

 

What Roles Do the Pelvis Play in Child Delivery?  

 

Both males and females have pelvises, but the female pelvis differ from male pelvis. Even among women, there are various pelvis shapes. Generally though, the differences in breadth and depth attests to the idea that the female pelvis is fashioned to provide adequate passage for the baby during birth. [4]

 

There are four types of pelvis, namely: gynecoid, anthropoid, android, and platypelloid (see figure 1). Cynthia Ukah, explained that the gynecoid is the best for childbirth among the four. But what makes the gynecoid ideal for delivery?

Figure 1: Types of female pelvis. Click on image to enlarge.

 

Characteristics of the gynecoid pelvis

• Occurrence: It is the most common type of pelvis among women.
• Shape: Round and wide.
• Features: Spacious with round pelvic entrance, and adequate outlet dimensions (see figure. 2)
• Consequence: It is considered the safest for vaginal delivery. 

Figure 2: The female gynaecoid pelvic inlet and outlet (not drawn to scale). Click on image to epand.

 

How Does Traditional Beliefs Affect Obstructed Labour?

 

Cultural beliefs and traditions in many parts of Africa contribute to some of the delays in seeking help during obstructed labour, increasing the risks that mothers and their unborn child face as a result of culturally based decisions. 

 

In East Africa for example, a delayed delivery can be attributed to the promiscuous nature of the husband's wife; in this case, the midwife presses her to confess her crime. [5] While in Mozambique, adultery by the husband can also kill the pregnant woman, if the woman with whom he had sex approaches his wife while she is giving birth. 

 

Another example can be found among the Esan people of Edo State, Nigeria. They generally believe that a woman is responsible for the health problems of her family, including her own, which are caused by violations of customs or traditions. They believe that obstructed labour is caused by sex in the afternoon or in the fields, adultery, or a woman taking her husband's belongings, such as money. According to this culture, her fortune will only turn around if she confesses. [5]

 

These beliefs cause what is known as phase 1 delay, in which the decision to seek medical care is postponed, exposing the mother and unborn child to an increased risk of complications and possibly death as a result of obstructed labour. 

 

Risk Factors of Obstructed Labour 

 

Many of the risk factors for obstructed labour are socio-economic and health system related. They include:

 

• Early pregnancy and marriages: According to Girls Not Brides, a civil society group, 12% of underage marriages in Nigeria occur at the age of 15. [6]

In a study conducted in Gombi local government in Adamawa state, Nigeria, 200 girls aged 15 to 24 who married before the age of 16 and had at least one child were interviewed using questionnaires. Data from this study revealed that 49% of respondents experienced obstructed labour during birth [7], compared to 1.5% in the general population. [8] 

The pelvic bone, which is critical to a child's safe passage during delivery, does not fully mature until age 20 to 25, and the uterus, cervix, and other delivery organs may not be fully mature at this age, resulting in a high rate of obstructed labour among this group of women.

 

• Poverty and educational barriers: One of the reasons families allow underage marriage is because of poverty. Many families give their child in marriage to alleviate poverty. A lack of education also prevents the girl child from asserting herself and gaining the necessary confidence to avoid being forced into an underage marriage. 

 

• Malnutrition: This is largely linked to poverty. Malnutrition among pregnant women is common on a continent where the vast majority of the population lives in poverty. Several nutrients like calcium, protein, iron, and other multivitamins are required for proper push. This demands a lot of muscle contraction and bone support in the pelvis during delivery.

 

• Availability and accessibility of healthcare facilities and personnel: According to the Voice of Africa, in a report titled "Nigeria copes with a growing shortage of doctors, nurses," there is one doctor for every 4000 people in Nigeria [9], and 1.6 nurses and midwives per 1000 population in 2021, according to the World Bank in 2021. [10]

These figures are poor when compared with the combined ratio of 2.5 medical staff (i.e., (Doctors, Nurses and Midwives) per 1000 population estimated by the WHO in its 2016 World Health Report as being adequate for coverage of primary care interventions generally.  

The critical health workforce shortage situation in Nigeria, when combined with ongoing brain drain of doctors and nurses in the country worsens healthcare provision. 

But Nigeria is not alone. In 2022, the BBC reported for example that approximately 1,200 Ghanaians had migrated to the United Kingdom in search of higher paying jobs. Among those who migrated were the most senior and skilled nurses. [11]

Healthcare workforce shortages and brain drain creates a void, leaving citizens of affected African countries with insufficient and poorly trained health workers.
 

• Lack of contraception: Inadequate spacing of childbirth due to a lack or low adoption of family planning for numerous reasons, increases the risk of complications associated with obstructed labour.

 

• Traditional birthing practices: Most of these practces expose pregnant women to quacks whose limited knowledge and skills can endanger the life of the mother and that of the unborn child. 

 

Causes of Obstructed Labour 

 

The direct causes of obstructed labour in African women can be discussed under two broad categories as follows:

• Maternal
• Foetal 

 

I. Maternal factors include:

• Cephalopelvic disproportion: This is a condition in which a baby's head is too big to fit through the mother's pelvis. It is recognised as the major cause of obstructed labour in studies from Africa  [12]

• Pelvic abnormalities: deformity or fracture of the pelvis.

• Fibroid uterus: This can obstruct the passage of the baby through the birth canal.

• Cervical fibroid: this also can block the passage of the baby.

• Inadequate contraction (Hypotonic uterine dysfunction): Insufficient contraction can trap the baby within the mother's uterus.

 

II. Fetal factors include:

• Large baby

• Abnormal positioning of the baby

• Excess fluid in the brain that can increase the head size of the baby.

 

Consequences of Obstructed Labour

 

Obstructed labour does not just appear and disappear; it usually leaves a trail of devastation for both the mother and child.  One of the effects of obstructed labour is infection, i.e., the introduction of bacteria into the bloodstream (sepsis).

 

Melissa Dean; a midwife and  founder of Casa Natal Birth and Wellness Center, explained in an interview that sepsis is typically caused by frequent and repeated cervical exams done throughout labour over many hours. This can introduce bacteria up into the cervix. She also stated that early opening of the waters can introduce bacteria into the system, particularly if labour has been delayed for several days, allowing bacteria to grow. 

 

Other equally significant consequences of obstructed labour include:

 

A. Reproductive, neurological and other injury complex
 

1. Uterine rupture: Prolonged labour, multiple pregnancies, excessive uterine contraction especially when induced, previous uterine surgeries can all lead to uterine rupture in obstructed labour.
 

2. Urethral loss: The use of instruments to aid delivery can cause urethral trauma. Pressure exerted on the urethral by the big head of a baby can reduce blood to the organ and cause damage.
 

3. Fistula formations: These occurs when unnatural passageways are created as a result of obstructed labour among other causes, between the genital and urinary tracts (i.e., the womb (uterus) or vagina and the bladder - the organ in the body that holds urine before it's voided, or the urethra - the urine passage way for voiding).

It can also occur between the between genital and intestinal (bowel) tracts  (i.e., the womb (uterus) or vagina and the rectum - the part of the bowel that holds poop (stool) before it's voided. 

So, there are numerous types of fistula formations that may complicate obstructed labour. The two most common are known medically as vesicovaginal fistula (VVF) and rectovaginal fistula (RVF). In both cases, urine or poop dribbles through the vagina respectively to add more misery to the dangers associated with obstructed labour.

It has been estimated that between 30 - 130,000 women who give birth in sub-Saharan Africa annually have delivery-related fistula. [13]

 

4. Pelvic inflammatory disease: Prolonged labour, use of instruments, and early water break can contribute to this disease. 
 

5. Cervical destruction: Excessive stretching of the cervix, prolonged pressure on it by the baby's head or body, infections, and trauma from the instruments used in aiding delivery all contribute to destroying the cervix during obstructed labour. 

 

B. Infant and maternal death and disability

 

Melissa Dean warns that if no intervention is sought, the baby will more likely die as a result of stress over time. For the mother, she believes that infection and maternal exhaustion are the greatest risks of death for her. 

 

Lack of oxygen, birth trauma, infections, premature separation of the placenta, and prolonged compression can all cause an infant to die as a result of obstructed labour. [14]

 

A child who survives obstructed labour could be left with deformities of the brain and other vital organs of the body while the mother’s reproductive organs such as the vaginal, cervix, uterine might be damaged beyond repairs. 

 

Africa could learn and adopt some of the interventions that have improved the quality of childbirth in developed continents such as Europe and North America.  

 

What Interventions May Help to Reduce the Occurence of Obstructed Labour in African Women?

 

Given the several direct and indirect factors contributing to obstructed labour in Africa, several policy, and healthcare proposals that have been advanced for its reduction can be summarised as follows: 

• Community education and awareness raising: Because illiteracy remains a major issue in some parts of Africa, goverments at all levels and community stakeholders must jointly engage in public education, to raise awareness and educate women and men about causes, risk, complications and prevention of obstructed labour so that people in the respective communities can make informed decisions that will promote the reproductive health and rights of women.  

• National and community advocacy for ontraceptive use: Investment is needed in national and community level advocacy and education for increased uptake of contraceptive products so that women can decide when and how to space having children, as having children at too close intervals increases the risk of complications in obstructed labour. . 

• Training more maternal healthcare providers: Increasing investments in the training of the different levels of maternal healthcare providers (e.g. commuity-based nurses and midwives, community birth attendants, general medical practiioners, and specialist obstetricians) are required to ensure adequacy in the number of well-trained workforce capable of carrying out their responsibilities towards pregnant women in both rural and urban settings.

• Improvement of healthcare facilities and welfare of healthcare providers: The brain drain that is occurring in many parts of Africa can be mitigated by providing a better working environment as well as improving the welfare of healthcare providers. These will enable skilled healthcare workfcorce to stay and work in their respecticve countries, whether in rural or urban facilities.

• Investment in poverty alleviation and infrastructural  support: Investment in poverty alleviation and support of vulnerable families to create income generating products and services will help to reduce the drive to push the girl-child into early marriages. Also, investment in such infrastructural services like public and ambulance transportation would ensure that women with obstructed labour especially in rural communities can be transported at low cost to the nearest health facility for early care before complications set in.

• Investment in girl child education: Investment in girl-child education (vocational and formal) coupled with legal mandates to remain in school up to age 18 will help reduce the trend of early girl-child marriage and pregnancy. This may help reduce the occurence of obstructed labour in communities in Africa..

• Legal and legislative efforts: Although it would seem like a long shot, legal and legislative efforts can be coupled with other proposals to prohibit early child-marriage as this is a definite and contributory risk factor for obstructed labour. .

 

Case Study

 

Malaysia has successfully reduced its maternal mortality ratio by 94%. In 1950, the maternal mortality ratio was 530 per 100,000 live births, but by 2009, it had dropped to 28. This was achieved as a result of massive investments in competency-based training for their healthcare providers. Furthermore, midwives were placed in rural areas with limited road access, advances in medicine and technology, improvements in the healthcare delivery system, the implementation of a risk-reduction strategy, and a confidential investigation into maternal deaths were all made. [15]

 

Conclusion

 

Traditional beliefs are so entrenched in African society that they have a negative effect on health. While having a set of beliefs is not wrong, those that impede people’s collective progress and survival should be discarded. Many nations around the world have overcome the scourge of obstructed labour through the integration of technology, improved healthcare facilities, and improved welfare provisions for healthcare providers; Africa can do the same if the political will is there.

 

Mothers and their unborn children have the right to safe and complications-free delivery and political will must be mustered to assure this right to them 

 

References

1. Desta M, Mekonen Z, Alemu AA, Demelash M, Getaneh T, Bazezew Y, Kassa GM, Wakgari N. Determinants of obstructed labour and its adverse outcomes among women who gave birth in Hawassa University referral Hospital: A case-control study. PLoS One. 2022 Jun 24;17(6):e0268938. doi: 10.1371/journal.pone.0268938. Available from:here.

2. Girma T, Gezimu W, Demeke A. Prevalence, causes, and factors associated with obstructed labour among mothers who gave birth at public health facilities in Mojo Town, Central Ethiopia, 2019: A cross-sectional study. PLoS One. 2022 Sep 22;17(9):e0275170. doi: 10.1371/journal.pone.0275170. Available from:here.

3. World Health Organization (WHO). Managing prolonged and obstructed labour. Educational material for teachers of midwifery. Module 4 of Midwifery education module - 2nd edition. [Internet. 2008]. Cited July 2, 2024. Available from here. 

4. Burgess MD, Lui F. Anatomy, Bony Pelvis and Lower Limb: Pelvic Bones. [Updated 2023 Jul 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from here. 

5. Wall LL. Overcoming phase 1 delays: the critical component of obstetric fistula prevention programs in resource-poor countries. BMC Pregnancy Childbirth. 2012 Jul 18;12:68. doi: 10.1186/1471-2393-12-68. Available from here

8. Girls not brides. Child marriage. [internet,n.d] cited June 15, 2024. Available from here.

7. Adedokun O, Adeyemi O, Dauda C. Child marriage and maternal health risks among young mothers in Gombi, Adamawa State, Nigeria: implications for mortality, entitlements and freedoms. Afr Health Sci. 2016 Dec;16(4):986-999. doi: 10.4314/ahs.v16i4.15. Available from here.

8. Oguejiofor CB, Ezugwu CJ, Eleje GU, Emeka EA, Akabuike JC, Umeobika JC, Ogelle OM, Umeononihu OS, Eke AC. Emerging Predictors of Obstructed Labour in a Single Nigerian Centre Population of a Low Resource Setting. Trends Med Res. 2022;17(4):136-144. Epub 2022 Oct 1.  Available from here.

9. Voice of Africa. Nigeria copes with a growing number of doctors, nurses. [internet, n.d]. Cited June 28, 2024. Available from here.

10. World Bank Group. World Health Organization's Global Health Workforce Statistics, OECD, supplemented by country data. 2003 - 2021. [Internet]. Cited. June 30 2024. Available from here. 

11. BBC. Ghana patients in danger as nurses head for NHS in UK- medics. [internet, n.d] cited June 16, 2024. Available from here.

12. Fantu S, Segni H, Alemseged F. Incidence, causes and outcome of obstructed labour in jimma university specialized hospital. Ethiop J Health Sci. 2010 Nov;20(3):145-51. doi: 10.4314/ejhs.v20i3.69443. Available from here.

13. Hareru HE, Wtsadik DS, Ashenafi E, Debela BG, Lerango TL, Ewunie TM, Abebe M. Variability and awareness of obstetric fistula among women of reproductive age in sub-Saharan African countries: A systematic review and meta-analysis. Heliyon. 2023 Jul 22;9(8):e18126. doi: 10.1016/j.heliyon.2023.e18126. Available from here. 

14. Collins KA, Popek E. Birth Injury: Birth Asphyxia and Birth Trauma. Acad Forensic Pathol. 2018 Dec;8(4):788-864. doi: 10.1177/1925362118821468. Available from here.

15. Norhayati MN, Nik Hazlina NH, Sulaiman Z, Azman MY. Severe maternal morbidity and near misses in tertiary hospitals, Kelantan, Malaysia: a cross-sectional study. BMC Public Health. 2016 Mar 5;16:229. doi: 10.1186/s12889-016-2895-2. PMID: 26944047; PMCID: PMC4779219. Available from here. 

 

 

Related:

Why African women die more from birth-related bleeding

Social Factors Shaping African Women’s Health

6 Conditions that Put Pregnant African Women at Risk of Death

12 Top African Women's Health Issues and How to Take Action

 

 

Published: July 2, 2024

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