International Journal of Africa Nursing Sciences 17 (2022) 100440

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International Journal of Africa Nursing Sciences

journal homepage: www.elsevier.com/locate/ijans

Premature rupture of membrane and associated factors among pregnant

women admitted to maternity wards of public hospitals in West Guji Zone,
Ethiopia, 2021
Tesfaye Abebe Diriba a, Biftu Geda b, Zelalem Jabessa Wayessa a, *
a
Departement of Midwifery, College of Health and Medical Sciences, Bule Hora University, Bule Hora, Oromia Regional State, Ethiopia
b
Department of Nursing, College of Health and Medical Sciences, Meda Welabu University, Shashamene Campus, Oromia Regional State, Ethiopia

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Premature rupture of membranes is an important cause of perinatal morbidity, and mortality, and
PROM complicates about 8% to 10% of pregnancies. Preterm birth and prematurity are a result of premature rupture of
Associated factors membranes and are often associated with fetal lung hypoplasia, respiratory distress syndrome, intraventricular
Pregnant Mothers
hemorrhage, neonatal sepsis, and even death. This study aimed to assess the prevalence & factors associated with
Ethiopia
premature rupture of membranes among pregnant mothers admitted in West Guji zone public hospitals.
Methods: A facility-based cross-sectional study design was conducted, from April 9 to June 9, 2021. A systematic
random sampling method was employed to select 407 study participants from pregnant mothers admitted to
labor and delivery wards in selected public hospitals. The data collection consisted of a structured and
interviewer-administered questionnaire, chart review, and measurement of the height, and weight of mothers.
Data were entered and coded in Epi data version 3.1 and exported to SPSS 25 version for analysis. In bivariable
logistic regression analysis, variables with a p-value < 0.25 were entered into multivariable logistic regression
and statistical significance was declared at P < 0.05 with AOR and 95%CI.
Result: A total of 407 study participants were included with a 100% response rate. About 12.5% (95%CI,
9.5–16.1) of the study participants had premature rupture of membranes. Gestational age < 37 weeks, (AOR =
2.5: 95%CI, 1.16–5.25), a history of premature rupture of the membranes, (AOR = 6, 95%CI, 1.88,-19.16), a
history of abortion, (AOR = 2.5, 95%CI, 1.21–6.52), abnormal vaginal discharge, (AOR = 6.9, 95%CI 2.87–16.6),
urinary tract infection, (AOR = 3.3, 95%CI, 1.07–10.12), and lower genital tract infections, (AOR = 4.5, 95%CI,
1.81–11.22) were factors associated with premature rupture of membranes.
Conclusion: The prevalence of premature rupture of membranes was high relative to worldwide prevalence. All
pregnant women should be screened and treated for urinary tract infection, lower genital tract infection, and
vaginal discharge.

1. Introduction accounting for 47% of under-five child mortality, and Sub-Saharan Af­
rica had the highest neonatal mortality rate at 27 deaths per 1000 live
Premature rupture of membranes (PROM) is defined as a sponta­ births in 2019. The most common causes of neonatal deaths were pre­
neous rupture of the membranes any time after the 28th week of preg­ term birth complications (15.4%), intrapartum-related complications
nancy but before the onset of labor. When rupture of the membranes like birth asphyxia (10.5%), and neonatal sepsis (6.7%) (WHO, 2020).
occurs beyond the 37th week but before the onset of labor, it is called Premature rupture of membranes complicates about 8% to 10% of
term PROM and when it occurs before 37 completed weeks, it is called pregnancies and is a significant cause of gestational age-dependent and
preterm premature rupture of membranes (PPROM). Term and preterm infectious perinatal morbidity and mortality. It is one of the important
PROM affects approximately 8% and 1% of pregnancies respectively causes of preterm labor and prematurity which is commonly associated
(Konar, 2018; Dayal & Hong, 2021). with fetal pulmonary hypoplasia, respiratory distress syndrome, intra­
Globally, 2.4 million children died in the first month of life in 2019 ventricular hemorrhage, neonatal sepsis, and even death (Gabbe et al.,

* Corresponding author.
E-mail address: [email protected] (Z. Jabessa Wayessa).

https://doi.org/10.1016/j.ijans.2022.100440
Received 10 February 2022; Received in revised form 24 May 2022; Accepted 30 May 2022
Available online 3 June 2022
2214-1391/© 2022 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).
T. Abebe Diriba et al. International Journal of Africa Nursing Sciences 17 (2022) 100440

2016). evidence-based strategies. Generally, the study of PROM has several

According to the American College of Obstetricians and Gynecolo­ implications for maternal and child health and it could have an impact
gists’ guideline, preterm delivery occurs in approximately 12% of all on individual health providers, units of health care, and stakeholders.
births in the United States and is a major factor that contributes to The conceptual framework of this study was adapted from Tchirikov
perinatal morbidity and mortality (Kuba & Bernstein, 2018). The con­ (Tchirikov et al., 2018) by reviewing the literature on the premature
sequences of PROM increase maternal morbidity rate by 26% secondary rupture of membranes (Addisu et al., 2020; Sirak & Mesfin, 2014;
to clinical chorioamnionitis (11.9%), & febrile illness (10.5%). Addi­ Byonanuwe, 2020; Yeasmin et al., 2020; Workineh et al., 2018; Hosny
tionally, perinatal morbidity was seen in 30% of cases due to early-onset et al., 2020; Assefa et al., 2018) (Fig. 1). The purpose of this study was to
neonatal infection (23.8%) in India (Jaiswal, Hariharan, & Dewani, assess the prevalence & factors associated with premature rupture of
2017) and a high neonatal admission rate in China (65.7%) (Chandra & membranes among pregnant mothers admitted in West Guji zone public
Sun, 2017). Neonatal sepsis has occurred in 5.2% of PROM of which hospitals.
38% ended with neonatal death in Indonesia (Ocviyanti & Wahono,
2018). A study in south Ethiopia revealed that PROM was followed by 2. Methods and materials
puerperal sepsis, wound infection, stillbirth (3.8%), maternal death
(1.6%), and neonatal death (11.9%) (Endale et al., 2016). 2.1. Study design and setting
The prevalence of preterm PROM is 2% in China (Huang et al.,
2018), 1.3% in Nigeria (Idrisa, Pius, & Bukar, 2019), 4.7% in Egypt A health facility-based cross-sectional study design was conducted in
(Abouseif et al., 2018), 13.8% in northwest Ethiopia (Addisu, Melkie, & public hospitals from April 9 to June 9, 2021. The study area has two
Biru, 2020) and 1.3% in Addis Ababa (Sirak & Mesfin, 2014). The primary hospitals and one general hospital used as a referral site for both
prevalence of preterm and term PROM in Uganda is 13.8% (Byonanuwe hospitals and gives service to an estimated total population of 1,331,272
et al., 2020). Different studies revealed that the risk factors associated consisting of 653,655 males and 677,617 females within its catchment
with PROM were low socioeconomic conditions, anemia, lower genital area. Services available for maternal care are antenatal care, labor &
tract infection, urinary tract infection (UTI), previous history of PROM, delivery, postnatal care, Neonatal Intensive Care Unit (NICU), and gy­
malpresentation, multiple pregnancies, and polyhydramnios (Addisu necology care. The obstetrics department, specifically the labor and
et al., 2020; Sirak & Mesfin, 2014; Byonanuwe, 2020; Yeasmin et al., delivery ward, was one of the departments at the hospitals offering a
2020). service (admission) on average for 860 mothers per two months in all
Even though many studies were conducted in different parts of the hospitals. Antenatal care service is given to about 450 pregnant mothers
world and some studies were conducted in Ethiopia, the prevalence & per two months in all hospitals.
factors associated with premature rupture of membranes among preg­
nant mothers admitted in selected public hospitals was not clear. Thus, 2.2. Study population
understanding factors associated with premature rupture of the mem­
branes is important to prevent PROM and its complications. This study All selected pregnant women above 28 weeks of gestation and
will provide baseline data or input to assist in developing appropriate admitted to obstetric wards of Bule hora, Karcha, and Malka soda

Fig. 1. Conceptual frame work of factors associated with premature rupture of membranes adapted from Tchirikov (2018).

2
T. Abebe Diriba et al. International Journal of Africa Nursing Sciences 17 (2022) 100440

hospitals during the study period were included. lottery method the choice of the starting point was made and the next
participant was determined by the sampling interval. Then every kth (k
2.3. Inclusion criteria = 2) interval enrolment of all pregnant women who met the inclusion
criteria for the study was done until the predetermined sample size was
All selected pregnant women above 28 weeks of gestation and reached. The schematic diagram in Fig. 2 shows the sampling procedure.
admitted to obstetric wards of Bule hora, Karcha, and Malka soda hos­
pitals during the study period were included.
2.7. Data collection instruments

2.4. Exclusion criteria A standardized and structured tool that included relevant variables
was adapted from a study conducted in Dabre tabor, Northwest Ethiopia
Pregnant mothers who were unconscious during data collection and (Addisu et al., 2020) by reviewing the literature (Byonanuwe et al.,
laboring mothers who were admitted in the second stage were excluded. 2020; Hosny et al., 2020; Assefa et al., 2018). It contains socio-
demographic, obstetric, medical & behavioral factors, height, and
2.5. Sample size determination weight measurements. The questionnaire was prepared in English then
translated to Afan Oromo and back-translated to English to check for any
The sample size for objective one was calculated using the single inconsistencies with original meanings. A pretest was done on the 20
population proportion formula.
Where: Where,
n = sample size,
P = estimated prevalence of PROM was 13.8% previous study in
Uganda (Byonanuwe et al., 2020).
D = error allowed 5%,
Z⍺/2 = critical value at 95% CI is 1.96.
Hence, using the formula indicated above, the calculated sample size
was 286. Adding a 10% non-response rate, the required minimum
sample size (n) was: 286 + 286 × 10/100 = 315.

[(Z α|2)2 × p(1 − p)]

n=
d2

(1.96)2 × 0.138(1 − 0.138)

n=
0.042
n ¼ 286
The sample size for objective two was calculated by using Epi info
version 7.1 by considering assumptions of the double population for­
mula (Table 1). Hence, the second objective was used for the final
sample size which was 407.

2.6. Sampling procedure

West Guji zone has three hospitals and all were included purposively
in the study. First, the average number of cases admitted over two
months in all hospitals was estimated by counting six months of records
received from the registration book. The determined sample size was
distributed to each hospital using proportional allocation to an average
number of cases admitted per two months after reviewing six months’
records from the registration book. Systematic random sampling was
applied to select study participants from the obstetric wards by using an
Fig. 2. Schematic diagram of the sampling procedure for premature rupture of
admission registration logbook. The sampling interval (kth unit) was
membranes and associated factors among pregnant mothers admitted to West
obtained by dividing the total number of pregnant women who were Guji Zone, 2021.
admitted in two months by the total desired sample size. By using the

Table 1
Sample size calculated to objective two of premature rupture of membrane and associated factors among mothers admitted to West Guji Zone public Hospitals, 2021.
S. Variable Cl Power % of outcome Among AOR Ratio of unexposed to Total sample size with 10% non- Reference
N unexposed exposed response rate

1 Vaginal bleeding 95% 80% 12.6% 2.58 3.8 407 ( (Addisu et al.,
2020)
2 UTI 95% 80% 10.4% 2.62 1.5 325 (Addisu et al.,
2020)
3 Abnormal vaginal 95% 80% 11.4% 5.3 3.5 119 (Addisu et al.,
discharge 2020)
4 MUAC 95% 80% 8.4% 6.26 1 90 (Addisu et al.,
2020)
5 Previous PROM 95% 80% 11.7% 3.31 3.8 255 (Addisu et al.,
2020)

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T. Abebe Diriba et al. International Journal of Africa Nursing Sciences 17 (2022) 100440

sample size in a hospital outside of the study area to assess whether Medical problems: Some medical problems such as GDM, lower
respondents are able and willing to provide the needed information. A genital tract infections, and UTIs are diagnosed by physicians during
correction was done on unclear questions and terminology. routine examination and are documented on the maternal medical chart.
Anemia: anemia is present when the hemoglobin concentration is <
2.8. Data collection procedure 11 g/dl (Who, 2001).

Three bachelor of midwives and one bachelor’s nurse were recruited 2.11. Data quality control
for each hospital to participate in and supervise data collection. The
explanation was provided for respondents that the information obtained Data collectors were trained for one day to make them familiar with
from them would be kept confidential and would be used for research the objective of the study, clarification of assessment tools, time of data
only. They were told of their right to withdraw from the research at any collection, the confidentiality of respondents’ information, timely
time which was respected by researchers. Study participants were collection, and organization of the collected data from the respective
included every two intervals from a sampling frame of the registration hospital. Before the actual data collection, the questionnaire was pre­
book after the first participant was included by the lottery method. Data tested in 5% at Yabello hospital one week before the scheduled data
collection was carried out in the obstetrics wards after written consent collection day. Based on the pretest, the necessary modification was
was obtained and necessary information was provided. The privacy of made. Cronbach’s alpha was used to assess the reliability of the ques­
information was protected by substituting codes for participant identi­ tionnaire and it was 0.72 and 0.94 based on weight and heights of
fiers in the delivery ward of all hospitals. The study was conducted measurements and obstetrics characteristics respectively. The
through a structured face-to-face interviewer-administered question­ completeness and consistency of data were checked regularly at the time
naire, height, and weight measurements. Obstetric and medical data of data collection.
that could not be collected during interviews were collected from patient
medical records and charts. It took about 30 min to complete the 2.12. Data processing and analysis
questionnaire. The collected data were reviewed and checked for
completeness, clarity, and consistency daily. After data collection, it was entered, coded, and cleaned using Epi
data version 3.1 and exported to SPSS version 25.0 for analysis. The
2.9. Study variables quantitative data were summarized by descriptive statistics using fre­
quency, percentage, and tables for categorical variables. Univariate
2.9.1. Dependent variable analysis was used to describe the basic socio-demographic characteris­
tics of participants. Binary logistic regression analysis was performed to
• Premature rupture of membranes. determine the association between factors and outcome variables.
Bivariate analysis was applied primarily to see the association of inde­
2.9.2. Independent variables pendent variables with premature rupture of membranes and variables
with a p-value < 0.25 were entered into the multivariable logistic
• Socio-demographic factors: Age of mothers, weight, height, resi­ regression model. In the multivariable logistic regression model anal­
dence, educational status, occupational status, and monthly income. ysis, a p-value <0.05 was considered a statistically significant declara­
• Obstetrics factors: Gestational age, Antenatal care (ANC) follow- tion point at a 95% confidence interval and the odds ratio (OR) was used
up, multiple pregnancies, polyhydramnios, history of vaginal to assess the strength of association. Backward LR (likelihood-ratio)
bleeding, history of PROM, history of preterm birth, abortion his­ stepwise regression was applied and model fitness was checked by
tory, past cesarean section delivery, interbirth interval, and maximum likelihood-ratio and Hosmer Lemeshow’s goodness of fit.
gravidity. Multicollinearity was checked and variance inflation factors indicated
• Medical factors: Anemia, underweight, UTI, abnormal vaginal the non-existence of multicollinearity among the variables in this study.
discharge, lower genital tract infections, gestational diabetes melli­ Finally, the result was presented in the form of texts and tables.
tus (GDM), and hypertension.
• Behavioral factors: Smoking. 3. Result

2.10. Operational definitions 3.1. Socio-demographic characteristics of the respondents

Gestational age: is the age of pregnancy estimated from the last A total of 407 study participants were included in this study with a
menstrual period (LMP), Uterine height, first & second-trimester ultra­ 100% response rate. Of these 305 (74.9%) were in the 20–34 age group
sound results. with a mean ± SD of 24.59 ± 5.5 years. Almost all, 398 (97.8%) mothers
Premature rupture of membranes: a spontaneous rupture of were married and 295 (72.5%) of the respondents were from urban
membranes any time after 28 weeks of gestation but before the onset of areas. The majority, 308 (75.7%) of the respondents were Protestants,
labor. If a rupture of membranes occurs before 37 weeks of pregnancy, it 59 (14.5%) were Muslims, and 40 (9.8%) were Orthodox. More than
is called preterm PROM and if a rupture of membranes occurs at 37 half, 237 (58.2%) of the respondents were housewives (Table 2).
completed weeks of gestation or more is called term PROM. It was
confirmed to be PROM by using appropriate diagnostic examinations 3.2. Obstetric characteristics of respondents
like speculum examination by a health provider. PROM was categorized
as “mothers with PROM” and “mothers without PROM” which were The majority 340 (83.5%) of respondents were admitted at term and
coded as (1) and (0) respectively. about one- third 153 (37.6%) were primigravida. Most 350 (86%) of the
Body mass index (BMI): BMI was computed from height and weight mothers had ANC follow up and 172 (42.3%), 84 (20.6%), 58 (14.3%),
and categorized into < 18.55 (underweight), 18.55–24.99 (healthy 36 (8.8%), had fourth, third, second, and first ANC visits respectively.
weight), 25–29.99 (Overweight), and ≥ 30 Kg/m2 (obese) (Weir & Jan, The majority of respondents, 249 (61.2%) had visited hospitals and 94
2019). (23.1%) of them had visited health centers. Almost all types of preg­
Gravidity: It was categorized into 3 groups i.e. primigravida (preg­ nancy were a singleton with a cephalic presentation which account for
nant for the first time), multigravida (pregnant ≥ twice), and grand 395 (97.1%) and 392 (96.3%) respectively. The majority 384 (94.8%) of
multigravida (pregnant ≥ 5 times). respondents had an optimal amount of amniotic fluid, some of them 18

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T. Abebe Diriba et al. International Journal of Africa Nursing Sciences 17 (2022) 100440

Table 2 hemoglobin level of respondents, 24 (5.9%) had below 11 g/dl, and

Socio-demographic factors of pregnant mothers attending public hospitals in almost all, 383 (94.1%) had 11 g/dl and above. The majority 265
West Guji Zone, Ethiopia, 2021. (65.1%) had a healthy weight body mass index and only 2 (0.5%) of the
Variable Frequency (N) Percent (%) mothers were underweight. Almost all, 405 (99.5%) of the respondents
Age group
did not use tobacco (Table 4).
15–19 63 15.5
20–34 305 74.9 3.4. Reason for admission
>=35 39 9.6
Marital status
Single 1 0.2 The majority of respondents, 294 (72.2%) were admitted due to
Married 398 97.8 labor; 51 (12.5%) were admitted for PROM; 18 (4.4%) were admitted for
Divorced 2 0.5 an indication of preeclampsia/eclampsia, 13 (3.2%) for antepartum
Widow 3 0.7 hemorrhage, 13 (3.2%) for intrauterine fetal death, 7 (1.7%) for oligo­
Separated 3 0.7
hydramnios, 1 (0.2%) for severe anemia and 10 (2.5%) were admitted
Residence
Urban 295 72.5 due to other reasons (post-term, elective C/S) (Fig. 3).
Rural 112 27.5
Educational level
3.5. Prevalence of premature rupture of membranes
No formal education 102 25.1
Primary education (1–8) 136 33.4
Secondary education (9–12) 106 26.0 The prevalence of PROM among mothers admitted in West Guji zone
Tertiary and above 63 15.5 Public hospitals was found to be 12.5% (95% CI,(9.5–16.1)). The ma­
Occupation jority 8.3% (34) was term PROM and preterm PROM accounted for 4.2%
Housewife 237 58.2
(17). Of all cases, 23 (5.7%) were Prolonged PROM.
Government employee 66 16.2
Merchant 67 16.5
no job 1 0.2 3.6. Factors associated with premature rupture of membranes
others (students, daily laborer) 36 8.8
Monthly income<=1000
1001–3000 140 34.4
The bivariate analysis showed that age, gestational age, gravidity,
>=3001 124 30.5 history of PROM, history of preterm birth, history of abortion, anemia,
143 35.1 abnormal vaginal discharge, urinary tract infection, and lower genital
tract infection were selected for multivariate logistic regression analysis.
In multivariate logistic regression analysis gestational age, history of
(4.4%) had oligohydramnios and only 3 (0.7%) had polyhydramnios
PROM, history of abortion, abnormal vaginal discharge, urinary tract
(Table 3).
infection, and lower genital tract infections were found to be associated
with premature rupture of membranes.
3.3. Medical and behavioral characteristics of respondents The multivariate analysis result revealed that gestational age had a
significant association with the premature rupture of the membranes.
Of some of the respondents 24 (5.9%) had been diagnosed with The odds of premature rupture of the membranes were 2.5 times higher
anemia during the current pregnancy, 32 (7.9%) had abnormal vaginal among pregnant mothers <37 weeks pregnant compared to those
discharge, 17 (4.2%) had hypertension, 20 (4.9%) had urinary tract mothers whose gestational age was greater than or equal to 37 weeks
infections and 30 (7.4%) had lower genital tract infection. Regarding the (term) [AOR = 2.50, 95%CI, (1.16, 5.25)]. Similarly, having a history of

Table 3 Table 4
Obstetrics characteristics of respondents admitted to public hospitals in West Medical and behavioral characteristics of pregnant Mothers admitted to West
Guji zone, Ethiopia, 2021. Guji public Hospitals, Ethiopia 2021.
Variable Frequency (N) Percent (%) Variable Frequency (N) Percent (%)

Gravidity Anemia
Primigravida 153 37.6 No 383 94.1
Multigravida 153 37.6 Yes 24 5.9
Grand multigravida 101 24.8
Have ANC follow up Abnormal vaginal discharge
Yes 350 86 No 375 92.1
No 57 14 Yes 32 7.9
Vaginal bleeding history in current pregnancy Ever been diagnosed with Hypertension
No 398 97.8 No
Yes 9 2.2 Yes 390 95.8
Inter-birth length in years (for multi) 17 4.2
<2 46 11.3 Urinary tract infection (UTI)
>=2 208 51.1 No 387 95.1
History of PROM Yes 20 4.9
No 390 95.8 Lower genital tract infection
Yes 17 4.2 No 377 92.6
History of Preterm birth Yes 30 7.4
No 401 98.5 BMI categories
Yes 6 1.5 <18.55 2 0.5
History of abortion 18.55–24.99 265 65.1
No 369 90.7 25–29.99 123 30.2
Yes 38 9.3 > 30 17 4.2
History of CS delivery Smoking or using tobacco
No 394 96.8 No 405 99.5
Yes 13 3.2 Yes 2 0.5

BMI = body mass index.

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T. Abebe Diriba et al. International Journal of Africa Nursing Sciences 17 (2022) 100440

Fig. 3. Reason of admission of mothers admitted to West Guji zone public hospitals, Ethiopia, 2021.

premature rupture of the membranes was significantly associated with conducted in a general hospital where the high-risk population was
premature rupture of the membranes. Mothers who had a history of high. On the other hand, the duration of data collection was six months
PROM were six times more likely to encounter PROM compared to those in their study and two months in this study.
who had no history [AOR = 6.00, 95%CI, (1.88, 19.16)] after control­ The history of abortion was significantly associated with premature
ling confounding variables. rupture of the membranes in this study. The odds of premature rupture
This study has shown that a history of abortion and abnormal vaginal of the membranes were 2.50 times more likely to be higher in pregnant
discharge in a current pregnancy were also significantly associated with mothers who had a history of abortion compared to their counterparts.
premature rupture of membranes. The mothers who had a history of This finding is consistent with studies conducted in Brazil, Uganda,
abortion were 2.5 times more likely to be affected than those who did Ethiopia in Tigray, East China, and Egypt (Byonanuwe et al., 2020;
not have a history [AOR = 2.50, 95%CI, (1.21, 6.52)]. Likewise, the Hosny et al., 2020; Assefa et al., 2018; Hackenhaar et al., 2014; Xia et al.,
odds of PROM among mothers who had abnormal vaginal discharge 2015). Abortion causes a shortening of cervical length after mechanical
were about seven times more likely to be higher compared to mothers damage to the cervix due to the management procedure and a short and
who had no abnormal vaginal discharge in their current pregnancy scarred cervix is incompetent or susceptible to internal and external
[AOR = 6.9, 95%CI, (2.87, 16.60)]. Similarly, urinary tract infection pressure (Saccone, Perriera, & Berghella, 2016). However, this is not
and lower genital tract infection were significantly associated with similarly revealed in other studies conducted in Dabre Tabor and south
PROM. Mothers who had urinary tract infections in their current preg­ Ethiopia (Addisu et al., 2020; Workineh et al., 2018). The reason may
nancy were 3.3 times more likely to be affected compared to those who be, the inconsistency of the variables considered in these studies.
had not developed UTI [AOR = 3.30, 95%CI, (1.10, 10.12)]. Likewise, In this study, the history of a PROM was also associated with pre­
the odds of PROM among mothers who had ever suffered from mature rupture of the membranes. Pregnant mothers who had a history
confirmed lower genital tract infections were about 4.50 times more of PROM were six times more likely to develop PROM compared to those
likely to be higher when compared to mothers who have not had who had no previous history. This is also similar to the findings of other
confirmed lower genital tract infection in their current pregnancy [AOR studies conducted in Benghazi Libya, Bangladesh, and Ethiopia in
= 4.50, 95%CI, (1.81, 11.22)] (Table 5). Tigray, Gurage zone, and Dabre tabor (Addisu et al., 2020; Yeasmin
et al., 2020; Assefa et al., 2018; Habte, Dessau, & Lukas, 2021; Gahwagi,
4. Discussion Busarira & Atia, 2015). Generally, obstetric complications and cervical
incompetence have a high recurrence and the recurrence rate is 30%
This study was conducted to assess the prevalence & factors associ­ (Carol & Rumack, 2018). Although the history of PROM was signifi­
ated with premature rupture of membranes (PROM) among pregnant cantly associated with PROM in this study, it was not found significant in
mothers admitted in West Guji zone public hospitals. The prevalence of south Ethiopia (Workineh et al., 2018) and Uganda (Byonanuwe et al.,
PROM was 12.5% of which 8.3% was term and 4.2% accounted for 2020). This discrepancy may be due to, the low prevalence of history in
preterm premature rupture of membranes. This finding is similar to the their studies.
studies conducted in China (12.1%) (Huang et al., 2018), Uganda Gestational age was the other factor associated with premature
(13.8%) (Byonanuwe et al., 2020), and Jimma Ethiopia (14.6%) (Diriba, rupture of the membranes. Particularly, the odds of premature rupture
2017) in case of both term and preterm, and also in line with studies of the membranes were 2.50 times more likely higher in pregnant
conducted in Brazil (3.1%) (Hackenhaar, Albernaz, & Fonseca, 2014), mothers whose gestational age was below thirty-seven weeks (preterm)
Nigeria (3.3%) (Okeke et al., 2016), and Egypt (4.7%) (Abouseif et al., compared to term pregnancy. This is consistent with studies conducted
2018) in the case of preterm PROM. in Uganda and Nigeria (Byonanuwe et al., 2020; Okeke et al., 2016).
The prevalence of PROM in this study was higher than the prevalence Glomerular filtration rate and renal plasma flow are both increased by
in a study conducted in Bangladesh (8.2%) (Kuba & Bernstein, 2018). 50% to 60% during normal pregnancy (Gilbert & Weiner, 2013). As a
This difference may be explained by the difference in socioeconomic consequence of the glomerular filtration rate increase, pregnant women
status, availability, and accessibility of health services in the countries, are affected by urinary frequency and urinary tract infection. On the
to get early screening and treatment of risk factors. This finding is lower other hand, fetal presentation and position are differently related to
than the prevalence of preterm PROM in Dabre Tabor, Ethiopia (13.7%) gestational age. Pregnant women below 36 weeks of gestation are likely
(Addisu et al., 2020). This discrepancy might be due to the difference in to have fetal malpresentation and malposition compared with those at
the study setting and duration of the study. This study was conducted in 37 weeks or more, as the fetus has freedom of movement until the later
one general and two district hospitals and the study in Dabre Tabor was months of pregnancy when it becomes relatively fixed and maintains its

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T. Abebe Diriba et al. International Journal of Africa Nursing Sciences 17 (2022) 100440

Table 5 Abnormal vaginal discharge in current pregnancy was found to be

Bivariable and multivariable association of PROM and independent factors significantly associated with premature rupture of membranes. The odds
among pregnant mothers admitted to West Guji zone Public Hospitals, Ethiopia, of premature rupture of the membranes were about seven times more
2021. likely in pregnant mothers who had a complaint of abnormal vaginal
Categories PROM COR (95% AOR (95% p- discharge compared to their counterparts. This agrees with studies
Yes No (%)
CI) CI) value conducted in Tigray and Dabre Tabor, northern Ethiopia (Addisu et al.,
(%) 2020; Assefa et al., 2018). Abnormal vaginal discharge is one syndrome
Age group
of reproductive tract infections that simultaneously ascend to the upper
15–19 5(7.9) 58 0.39(0.12, 1.26(0.21, 0.792 reproductive organ and cause inflammation and rupture of the
20–34 39 (92.1) 1.34) 7.46) 0.244 membranes.
>=35 (12.8) 266 0.67(0.28, 2.16(0.59, Urinary tract infection was one of the factors significantly associated
7 (87.2) 1.62) 7.96)
with premature rupture of the membranes in this study. Pregnant
(17.9) 32 1 1
(82.1) mothers who had urinary tract infections were 3.30 times more likely to
Anemia experience premature rupture of membranes as compared to pregnant
Yes 6(25) 18(75) 2.50(0.94, 2.16(0.65, 0.203 mothers who had no urinary tract infection. This is in a line with studies
No 45 338 6.63) 7.14) conducted in Benghazi Libya, Uganda, Bangladesh, and Dabre Tabor
(11.7) (88.3) 1 1
Gestational age
northern Ethiopia (Addisu et al., 2020; Byonanuwe et al., 2020; Yeasmin
28–37 17 50 3.10(1.6, 2.50(1.16, 0.018 et al., 2020; Gahwagi et al., 2015).
>=37 (25.4) (74.6) 5.88) 5.25)* Since the anatomical location of the urinary tract and reproductive
34 306 1 1 tract are near to each other, bacteria can easily cross from the urethral
(10.0) (90.0)
orifice to the vagina and ascend through the cervix to the membranes
Gravidity
Primigravida 16 137 0.44(0.22, 0.71(0.29, 0.447 where they cause localized inflammation. Inflammatory mediators such
Multigravida (10.5) (89.5) 0.90) 1.71) 0.169 as prostaglandins, cytokines, and proteinases are produced as a part of
Grand 14 139 0.38(0.18, 0.55(0.24, the physiologic maternal defense mechanism in response to a pathogens’
multigravida (9.2) (90.8) 0.79) 1.29) invasion. Then, enzymes that are implicated in the mechanisms of
21 80 1 1
(20.8) (79.2)
membrane rupture include matrix metalloproteinases (MMP) and col­
History of lagenases released from amniotic fluid and degrade interstitial colla­
PROMYes 9 8(47.1) 9.32(3.4, 6.00(1.88, 0.002 gens, preferentially on collagen type I. Then extracellular degradation
No (52.9) 348 25.5) 19.16)* and disintegration cause rupture of membranes (Menon, & Richardson,
42 (89.2) 1 1
2017). In contrast to this finding, urinary tract infections were not
(10.8)
History of Preterm significantly associated with PROM in the previous study in Brazil
birth (Hackenhaar et al., 2014). This difference might be due to the early
Yes 3 3(50.0) 7.35(1.44, 1.28(0.15, 0.820 completion of treatment taking place by infected pregnant women in
No (50.0) 353 37.48) 10.80) Brazil.
48 (88.0) 1 1
Similarly, lower genital tract infection was one of the factors asso­
(12.0)
ciated with premature rupture of the membranes in this study. The odds
History of abortion
of premature rupture of the membranes were 4.50 times more likely to
Yes 9 29 2.42(1.1, 2.50(1.21, 0.019
No (23.7) (76.3%) 5.45) 6.52)* be higher in pregnant mothers who had lower genital tract infections
42 327 1 1 compared to those who had not experienced it. This finding is similar to
(11.4) (88.6) the studies conducted in Cameron, China, and Bangladesh (Yeasmin
Abnormal vaginal et al., 2020; Xia et al., 2015; Pisoh et al., 2021). This association is
discharge obvious as bacteria and other varieties of microorganisms ascend to the
Yes 15 17(53.1) 8.30(3.83, 6.90(2.87, 0.000 lower uterine segment and cause inflammation which can break down
No (46.9) 339 18.03) 16.6)*
the collagen of the fetal membranes.
36 (90.4) 1 1
(9.6) Unlike this finding, a study conducted in Tunisia could not establish
Urinary tract a significant association between lower genital tract infections and
infection premature rupture of membranes (Darine, Nabil, & Hamouda, 2021).
Yes 7 13(65.0) 4.19(1.59, 3.30(1.10, 0.037 This discrepancy might be explained in that, the method they used for
No (35.0) 343 11.1) 10.12)*
44 (88.6) 1 1
data collection included laboratory investigations for detecting the
(11.4) presence of genital infections and other associated infections. Hence,
Lower genital amniotic fluid leakage in PROM patients washed out yeast cells and
tract infection other microorganisms found in the genital area causing non-detection in
Yes 13 17(56.7) 6.82(3.1, 4.50(1.81, 0.001
laboratory investigations. The strength of this study was that all of the
No (43.3) 339 15.12) 11.20)*
38 (89.9) 1 1 hospitals found in the West Guji zone were included in the study. The
(10.1) limitations of this study were that the study participants were enrolled
only from hospitals and the mothers in the community might have been
Key note: AOR adjusted odd ratio, COR crude odd ratio, *=statistically signif­
icant, 1 = reference category.
missed. Some wide confidence intervals were resulting in less reliable
findings due to having small samples in each value for some variables.
position till delivery (Cunningham et al., 2014). Unlike this study,
5. Conclusion
gestational age was not significantly associated with PROM in the pre­
vious studies of Ethiopia (Addisu et al., 2020; Workineh et al., 2018;
This study’s findings indicate that the prevalence of PROM was high
Assefa et al., 2018)). This is due to the study population difference.
relative to the worldwide prevalence. Obstetric and medical factors were
Particularly, this study considers all pregnant mothers above 28 weeks
found to be significantly associated with premature rupture of the
of gestational age; but some of their studies were limited to 28–36 weeks
membranes. Specifically, gestational age, history of premature rupture
(preterm) gestational age and some were limited-term pregnancy.
of membranes, history of abortion, abnormal vaginal discharge, lower

7
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Author contributions Idrisa, A., Pius, S., & Bukar, M. (2019). Maternal and neonatal outcomes in premature
rupture of membranes at University of Maiduguri Teaching Hospital, Maiduguri,
North-Eastern Nigeria. Tropical Journal of Obstetrics and Gynaecology, 36(1), 15–20.
All authors contributed to data analysis, drafting or revising the Jaiswal, A. A., Hariharan, C., & Dewani, D. K. (2017). Study of maternal and fetal
article, have agreed on the journal to which the article will be submitted, outcomes in premature rupture of membranes in central rural India. Int J Reprod
gave final approval of the version to be published, and agree to be Contracept Obstet Gynecol, 6(4), 1409–1412.
Konar, H. (2018). DC Dutta’s Textbook of obstetrics. JP Medical Ltd.
accountable for all aspects of the work. Kuba & Bernstein. (2018). ACOG Practice Bulletin No. 188. Obstet Gynecol, 131(6),
1163–1164.
Menon, R., & Richardson, L. S. (2017). Preterm prelabor rupture of the membranes: a
Declaration of Competing Interest disease of the fetal membranes. In Seminars in perinatology (Vol. 41, No. 7, pp. 409-
419). WB Saunders.
The authors declare that they have no known competing financial Ocviyanti, D., & Wahono, W. T. (2018). Risk factors for neonatal sepsis in pregnant
women with premature rupture of the membranes. Journal of Pregnancy, 2018.
interests or personal relationships that could have appeared to influence Okeke, T. C., Enwereji, J. O., Adiri, C. O., Onwuka, C. I., & Iferikigwe, E. S. (2016).
the work reported in this paper. Morbidities, concordance, and predictors of preterm premature rupture of
membranes among pregnant women at the University of Nigeria Teaching Hospital
(UNTH), Enugu. Nigeria. Nigerian Journal of Clinical Practice, 19(6), 737–741.
Acknowledgments Pisoh, D. W., Mbia, C. H., Takang, W. A., Djonsala, O. G. B., Munje, M. C., Mforteh, A. A.,
… Leke, R. J. I. (2021). Prevalence, Risk Factors and Outcome of Preterm Premature
The authors thank Bule Hora University for funding this research and rupture of membranes at the Bamenda Regional Hospital. Open Journal of Obstetrics
and Gynecology, 11(3), 233–251.
data collectors, hospitals administration, and study participants. Saccone, Perriera, & Berghella. (2016). Prior uterine evacuation of pregnancy as
independent risk factor for preterm birth: a systematic review and metaanalysis.
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