https://orcid.org/0000-0001-5102-7500
Figures
Abstract
Background
Obstetric interventions can improve maternal and neonatal outcomes when performed appropriately by skilled healthcare professionals. Appropriate use of forceps and vacuum extraction can reduce neonatal complications associated with operative vaginal deliveries. However, there is limited evidence on the prevalence of adverse neonatal outcomes and associated factors among operative vaginal deliveries in Northwest Ethiopia.
Objective
This study aimed to assess the prevalence of adverse neonatal outcomes and associated factors among births through operative vaginal delivery at the University of Gondar Comprehensive Specialized Hospital in Northwest Ethiopia.
Methods
A facility-based retrospective cross-sectional study was conducted among 303 mothers who underwent operative vaginal delivery at the University of Gondar Comprehensive Specialized Hospital from September 1, 2019, to August 30, 2021. Data was extracted using a structured questionnaire. The collected data was entered into Epi-Data version 3.1 statistical software and exported to IBM SPSS statistics version 24 for data analysis. Descriptive statistics were used to summarize the participants’ characteristics and neonatal outcomes. Bivariable logistic regression analysis was performed to identify candidate variables. Variables with a p-value < 0.25 were entered into the multivariable logistic regression model. Adjusted odds ratio (AOR) with 95% confidence intervals (CIs) were calculated to assess the strength of associations. Statistical significance was declared at a p-value of < 0.05 in the multivariable logistic regression analysis.
Results
The prevalence of adverse neonatal outcomes among births delivered through operative vaginal delivery was 23.1% (95% CI: 18.68–28.21). The mean age and standard deviation of the study participants were 25.19 ± 4.7 years. All participants were married and 154 (50.8%) had obtained a college education or higher. The presence of grade ½ (AOR = 4.13, 95% CI: 1.96–8.69) and grade three meconium-stained amniotic fluid (AOR = 24.9, 95% CI: 6.14–46.06) and primigravidity (AOR = 2.49, 95% CI: (1.13–5.16) were significantly associated with adverse neonatal outcomes.
Conclusions
Adverse neonatal outcomes among births through operative vaginal delivery at the University of Gondar Comprehensive Specialized Hospital were high. Close intrapartum monitoring and early obstetric intervention among women with meconium-stained amniotic fluid and primigravid mothers are essential to reduce adverse neonatal outcomes associated with operative vaginal delivery.
Citation: Ferrede SK, Eticha MW, Ayele HM (2026) Adverse neonatal outcomes and associated factors among births through operative vaginal delivery at the University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia: A facility-based retrospective cross-sectional study. PLoS One 21(8): e0357043. https://doi.org/10.1371/journal.pone.0357043
Editor: Kahsu Gebrekidan, University of Oulu: Oulun Yliopisto, FINLAND
Received: June 4, 2025; Accepted: August 11, 2026; Published: August 28, 2026
Copyright: © 2026 Ferrede et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the manuscript and its Supporting Information files.
Funding: The author(s) received no specific funding for this work.
Competing interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests. The authors declare that they have no competing interests.
Abbreviations: ANC, Antenatal Care; APGAR, Appearance, Pulse, Grimace, Activity and Respiration; AOR, Adjusted Odds Ratio; CI, Confidence Interval; MSAF, Meconium-Stained Amniotic Fluid; NRFHR, Non-Reassuring Fetal Heart Rate; NICU, Neonatal Intensive Care Unit; OVD, Operative Vaginal Delivery; SPSS, Statistical Package for Social Science; UoGCSH, University of Gondar Comprehensive Specialized Hospital
Introduction
Operative vaginal delivery (OVD) refers to a vaginal birth assisted by forceps or vacuum devices during the second stage of labor to expedite delivery when maternal or fetal indications are present [1–4]. It is an important obstetric intervention that can improve maternal and neonatal outcomes when performed appropriately by skilled healthcare professionals. Globally, 10–20% of all deliveries may require some form of intervention and operative vaginal delivery accounts for 2–23% of all deliveries. In the United Kingdom, the OVD ranges from 10% to 15%. However, studies conducted in Ethiopia have reported rates ranging from 7% to 16.9% [5–8].
Operative vaginal deliveries are performed for the indication of maternal or fetal-related conditions and any occasion that threatens the mother or fetal life [9]. Commonly reported indications for OVD are prolonged second stage, non-reassuring fetal heart rate patterns maternal exhaustion and medical conditions requiring shortening of the second stage of labor [10,11]. Despite its clinical benefits, operative vaginal delivery remains associated with several neonatal complications. Minor neonatal complications following OVD include soft tissue trauma, cephalohematoma, jaundice, and transient brachial plexus injury while major complications include hypoxic ischemic encephalopathy, intracranial and sub-galeal hemorrhage, seizures, cranial fracture, permanent brachial plexus injury, admission to the neonatal intensive care unit (NICU) and death [12–14]. Furthermore, failed operative vaginal delivery and repeated instrument application may increase the risk of neonatal morbidity, including low Apgar scores, need for intubation, prolonged stay in the neonatal unit, hospitalization, and neurologic complications(seizures) [15,16]. Neonates delivered by operative vaginal delivery with an indication of Non-Reassuring Fetal Heart Rate (NRFHRP) had more likely to have poor Apgar scores than those with indications of poor maternal effort [7,8].
Ethiopia has introduced different strategies to reduce neonatal morbidity and mortality and achieve the sustainable development goal’s target by 2030; however, the rates remain high. Existing studies have largely focused on adverse birth outcomes following spontaneous vaginal deliveries with limited attention given to operative vaginal delivery despite its potential for both neonatal benefits and harm. Knowing the prevalence of adverse neonatal outcomes and identifying possible risk factors for complications related to operative vaginal delivery may impact the use of the procedure by health professionals. Therefore, this study aimed to assess the prevalence of adverse neonatal outcomes and associated factors among births through operative vaginal delivery at the University of Gondar Comprehensive Specialized Hospital in Northwest Ethiopia.
Materials and methods
Study area and period
The study was conducted at the University of Gondar Comprehensive Specialized Hospital (UoGCSH) in Gondar, the capital of the North Gondar administrative zone, approximately 741 km northwest of Addis Ababa and 172 km northeast of Bahir Dar. The University of Gondar Comprehensive Specialized Hospital is one of the oldest hospitals in Ethiopia. It provides a range of specialties, such as gynecology and obstetrics, pediatrics, surgery, internal medicine, psychiatry, and HIV care. The hospital has more than 1,040 healthcare professionals, 580 beds in five inpatient departments and 14 wards, and outpatient services provided in 14 different units. The gynecology and obstetrics department unit has gynecologists, obstetricians, nurses, midwives and resident physicians. The Department of Gynecology and Obstetrics runs one labor and delivery ward with nine beds in the first-stage room, six delivery couches in the second-stage room along with two emergency operating rooms, three postpartum maternity wards, one high-risk ward, one gynecology ward, one urogynecology ward, four gynecologic outpatient departments (OPD), four antenatal clinics, and Michu clinic. A total of 19,634 deliveries were recorded over the two years from September 1, 2019 to August 30, 2021. Of which, 719 (3.66%) were by operative vaginal deliveries, 5594 (28.49%) were by cesarean section and 13321 (67.85%) were vaginal deliveries.
Source population
All mothers who underwent operative vaginal delivery at the University of Gondar Comprehensive Specialized Hospital in Northwest Ethiopia.
Study population
All mothers who underwent operative vaginal delivery at the University of Gondar Comprehensive Specialized Hospital and fulfilled the inclusion criteria during the study period were included.
Inclusion criteria
All mothers who underwent operative vaginal delivery (forceps and/or vacuum devices) at the University of Gondar Comprehensive Specialized Hospital from September 2019 to August 2021 were included in the study.
Exclusion criteria
Mothers whose deliveries resulted in stillbirths, neonates with lethal congenital anomalies, and multiple births (twins or more) were excluded. Medical records with incomplete documentation of key study variables were also excluded.
Sample size determination
The sample size was estimated using a single population proportion formula. By considering a 95% confidence level, 4% margin of error and prevalence of adverse neonatal outcomes of operative vaginal delivery was taken as 13.2% as obtained from a study conducted at Jimma University Medical Centers, Southwest Ethiopia [7].
The required sample size was calculated using the following single-population proportion formula:
Were,
P = Adverse neonatal outcome of OVD (13.2%),
d = Margin of tolerated sample error (4%) and
Zα/2= The standard normal distribution at 1- α/2% confidence level (95%=1.96)
n: Sample size,
After adding a 10% non-response rate, the final sample size was 303 participants.
Sampling Technique
At the University of Gondar Comprehensive Specialized Hospital, 19634 deliveries were recorded over two years from September 1, 2019, to August 30, 2021, of which 719 neonates were delivered by operative vaginal delivery, 5594 were delivered by cesarean section, 13321 were vaginal deliveries. A total of 719 operative vaginal deliveries were identified during the study period, and 303 operative vaginal deliveries were selected using computer-generated simple random sampling technique (Fig 1).
Data collection procedures
The data collection instrument was a semi-structured questionnaire adapted from previous studies [5,6,9] (S1 File). The questionnaire was validated through a pilot study conducted at a nearby health center to check for the validity of questionnaire. A structured tool was prepared in English, translated into the local language of Amharic, and then translated back into English to check for consistency. The data collectors were professional midwives and medical interns who worked in the labor and delivery wards. Onsite training was provided to the data collectors on the methods of collecting data by reviewing the patient medical records (charts). The training also focused on how to fill out the questionnaire and the ethical aspects of maintaining the confidentiality of the information.
Variables
Independent variables
- Socio-demographic factors: Age, sex, residency, educational status, occupation, ANC follow-up and marital status.
- Obstetric and medical-related factors: Gravidity (number of pregnancies), history of previous abortion, gestational age at the time of delivery, bad obstetric history (history of stillbirth or early neonatal death), parity (number of previous viable deliveries), neonatal weight (weight of the neonate after delivery), fetal heart rate pattern (the fetal heart rate condition during the intrapartum course), underlying medical condition (diabetes mellitus, hypertension, cardiac illness), liquor status (presence of meconium-stained amniotic fluid), duration of second stage, experience of the operator, presence of other obstetric complications (antepartum hemorrhage, preeclampsia, (premature rupture of membrane, chorioamnionitis), type of instrument used (vacuum or forceps), type of operative vaginal delivery applied (outlet or low), time of operative vaginal delivery applied (followed in the ward or on arrival), station of the presenting part at the time of the procedure, episiotomy and stage of labor at the time of admission (first stage or second stage).
- Health facility and healthcare provider-related factors: Health worker profession, distance from the hospital, time to reach the hospital and waiting time for gate service.
Operational definitions
Operative vaginal delivery: The operator uses forceps or a vacuum device to assist the mother during the second stage of labour and reduce unnecessary cesarean section deliveries [6].
APGAR score: Acronym for appearance, pulse rate, grimace reflex, activity and respiratory rate which is used to assess the health status of newborns within the first and fifth minutes after birth [17].
Birth Trauma: Birth trauma is any trauma to the newborn as a result of labor and delivery like cephalhematoma, sub-galeal hemorrhage, retinal hemorrhage, shoulder dystocia, clavicle fracture, and scalp lacerations [7,8,18].
Adverse neonatal outcomes of operative vaginal delivery: This is considered when the neonates experience one or more of the following complications: low APGAR score, retinal hemorrhage, anemia, need for resuscitation, admission to NICU, neonatal birth trauma and neonatal death [17,19].
Immediate birth outcomes are the immediate maternal or neonatal conditions that could be complicated or non-complicated occurred within the first six hours of delivery [6].
Non Reassuring Fetal Heart Rate: This is defined as when the fetal hear rate is less than 100 or higher than 180 beats per minute [20].
Data quality control
To maintain data quality, the questionnaires prepared using the English version were translated into Amharic and back into English to check for consistency. A pre-test was conducted to check the precision and clarity of the questions on 5% of the total sample size. Based on the pre-test, necessary corrections and modifications were made before starting the actual study. The data collectors and supervisors were trained prior to data collection. The completeness of the questionnaires and the overall quality of data collection were monitored daily by the supervisor and principal investigator. The data collected was rechecked before starting the data analysis.
Data processing and analysis
The data were checked for quality and consistency. The data were then entered into Epi data version 3.1 and exported to SPSS 24 for statistical analysis. Furthermore, data cleaning (editing, recording and checking for missing values) was performed after exporting to SPSS. Descriptive statistics were explained using frequencies and percentages. Means and standard deviations were used to describe continuous variables. Multicollinearity was assessed using variance inflation factor and tolerance values. The results showed no evidence of multicollinearity. The association between adverse neonatal outcomes and associated factors was assessed using bivariable logistic regression analysis. Variables with a p-value < 0.25 in the bivariable logistic regression analysis were entered into the multivariable analysis regression model. Multivariable analysis was performed to determine the presence of statistically significant associations between independent and dependent variables at p-value < 0.05. The Hosmer-Lemeshow goodness of fit test was used to assess how the data fit the model. Adjusted Odds Ratio and 95% Confidence Intervals were calculated and reported to determine statistically significant associations between the dependent and independent variables.
Declarations
Ethical Considerations.
Ethical approval was obtained from the Ethical Review Committee of the Institutional Review Board of the University of Gondar (Ref. No: 642/2021). With this clearance, formal approval was sent and permission to conduct the study was secured from the administration of Gondar University Comprehensive Specialized Hospital and the head of the Department of Gynaecology and Obstetrics before commencing the study. After the study was confirmed, data related to the study participants were obtained from Gondar University Compressive Specialized Hospital in an anonymized format and the Ethical Review Committee of the Institutional Review Board of the University of Gondar waived the requirement for informed consent. The datasets were de-identified at the source by the trained personnel. The study team was committed to using the data only for this study, and no one outside the study team had access to the data.
Results
Socio-demographic characteristics of the study participants
A total of 303 mothers who underwent operative vaginal delivery were included in this study. The mean age and standard deviation (±SD) of the study participants were 25.19 ± 4.7 years. Nearly two-thirds of the participants, 191(63%) were from Gondar Town. Of all participants, 154 (50.8%) had obtained a college or higher educational levels (Table 1).
Obstetric history of the study participants
According to this study, 234 (77.2%) were primiparous and 69 (22.8%) of them were multiparas. All mothers had attended at least one Antenatal Care (ANC) visit. The most common indication for operative vaginal delivery was a prolonged second stage of labor accounting for 215 (71%) cases, followed by non-reassurance fetal heart pattern (NRFHRP), 81 (26.7%). Among the types of operative vaginal deliveries, forceps were more commonly used in 175 (57.8%) participants, whereas vacuum deliveries were performed in 128 (42.2%) cases. Approximately 72 (23.8%) of the women had different grades of MSAF (Table 2).
Adverse neonatal outcomes among births through operative vaginal delivery
Of all births through operative vaginal delivery, the prevalence of adverse neonatal outcomes was 70 (23.1%; 95% CI: 18.68–28.21). The prevalence of adverse neonatal outcomes was higher among primigravida mothers (24.4%) and in post-term births (26.1%). Based on indications, NRFHRP had a higher proportion of adverse neonatal outcomes (39.9%) than the prolonged second stage of labor (16.27%). The most common adverse outcome was neonatal resuscitation (19.5%) followed by NICU admission (18.5%) (Table 3).
Factors associated with adverse neonatal outcomes among operative vaginal deliveries
In the bivariable logistic regression analysis, variables such as gravidity, stage of labor at the time of admission, status of the membrane at the time of admission, status of liquor, place of residence, indication for operative vaginal delivery, experience of the operator, type of instrument used for operative vaginal delivery, type of operative vaginal delivery applied, episiotomy, duration of the second stage and time of application were identified as candidate variables at a p-value of < 0.25. A multivariable logistic regression model was used to identify independent factors affecting neonatal outcomes. After controlling for the possible effects of confounding variables in the final multivariable analysis model, grade 1/2 MSAF, grade 3 MSAF and neonates born to primigravida mothers were significantly associated with adverse neonatal outcomes.
The odds of adverse neonatal outcomes among births with grade 1/2 MSAF and grade 3 MSAF were 4.13 times (AOR = 4.13, 95% CI: 1.96–8.69) and 24.9 times (AOR = 24.90, 95% CI: 6.14–46.06) higher than those with clear liquor status. Neonates born to primigravida mothers had 2.49 times (AOR = 2.49, 95% CI: 1.13–5.16) higher odds of adverse neonatal outcomes than neonates born to multigravida mothers (Table 4).
Discussion
This study aimed to determine the prevalence of adverse neonatal outcomes and associated factors among births through operative vaginal delivery at the University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia. The prevalence of adverse neonatal outcomes was 23.1% (95% CI: (18.68% − 28.21%). The prevalence of adverse neonatal outcomes was higher among primigravida mothers (24.4%) and in post-term births (26.1%). The prevalence in this study is consistent with a study conducted at Aksum Saint Marry Hospital (20%) and a study conducted at Arba-minch General Hospital (24%) and a study conducted at a tertiary hospital in Nepal (25%) [17,21,22].
The result of this study is higher than that reported in a study conducted at Felegehiwot Comprehensive Specialized Hospital (12.1%) [23], Jimma University Medical Center (13.2%) [7], Nigist Eleni Mohammed Memorial Comprehensive Specialized Hospital (19%) [24]. This discrepancy might be due to the comprehensive specialized hospital where a high number of complicated neonatal and maternal cases were referred from other hospitals and health centers to this hospital. However, this result is lower than a study conducted at Dilla University Referral Hospital (42.1%) and Nigeria (31%) [8,25]. The difference could be due to the availability of trained staff, operative equipment and access to cesarean section delivery at the hospital.
In this study, MSAF was significantly associated with adverse neonatal outcomes and the odds of adverse neonatal outcomes among births with Grade 1/2 MSAF and Grade 3 MSAF were 4.13 and 24.9 times respectively, compared to births with clear liquor status, which is consistent with the findings of other studies. A study conducted at Addis Ababa, Jimma University Medical Center and Dilla University referral hospital showed that, the most common indication was fetal distress (NRFHRP) due to the presence of meconium [7,17,26]. This can be explained by the fact that the passage of meconium is often a response to fetal compromise, increasing the risk of meconium aspiration syndrome, respiratory distress, neonatal resuscitation and NICU admissions.
This study also showed that primigravidity was 2.49 times more likely to be associated with adverse neonatal outcomes as compared to multigravida. This finding is consistent with those studies conducted in Canada and Nepal [9,27]. A possible reason for this is that primigravida women may experience a longer second stage of labor, which can lead to complications such as fetal distress or the need for assistance. Notably, according to our study results, a prolonged second stage of labor was the most common indication for operative vaginal delivery (71%). This study is consistent with studies conducted in India and Nepal [9,28]. This may not be truly attributable to the procedure, as adverse neonatal outcomes may be the outcome of the events of labor that indicated the intervention rather than operative vaginal delivery itself [28].
Limitation of the study
This study had several limitations. First, the retrospective design of this study missed some important variables limiting the establishment of a causal relationship. Second, the cross-sectional nature of the study precluded the establishment of temporal relationships between exposure and outcome variables. Third, the study was conducted at a single comprehensive specialized hospital, which limits the generalizability of the study.
Conclusions
The prevalence of adverse neonatal outcomes among births delivered through operative vaginal delivery was high. The presence of grade ½, and grade three meconium-stained amniotic fluid and primigravidity were the determinant factors for adverse neonatal outcomes among operative vaginal deliveries.
Recommendations
To the hospital and health workers.
Most mothers for whom operative vaginal delivery was performed on arrival and who had adverse neonatal outcomes were referred from other hospitals and health centers. Operative vaginal delivery did not require referral to a tertiary care hospital. Provision of high-quality antenatal care, close monitoring of primigravida and labouring women and timely interventions should be a priority to decrease adverse neonatal outcomes.
To Ministry of Health and policy makers.
Strengthening healthcare workers skill in operative vaginal delivery, establishing a well-structured health facility referral system and increasing health facility access significantly improve neonatal outcomes. In addition, health facilities should be equipped with the instruments needed for operative vaginal deliveries.
Acknowledgments
We acknowledge the Department of Gynecology and Obstetrics, College of Medicine and Health Sciences, University of Gondar, medical interns, doctors and professional midwives for their invaluable support and encouragement in data collection. The study did not include any study data or preliminary results. All relevant data for this protocol are within the manuscript and its supporting information files.
Authors’ details
Shambal Kassahun Ferrede1, Mulatu Werkina Eticha2, Habtamu Molla Ayele3
1 Department of Obstetrics and Gynecology, Bedele General Hospital, Buno Bedele Zone, Ethiopia
2 Department of Midwifery, Arjo Primary Hospital, East Wollega Zone, Ethiopia
3 Maternal and Child Health Directorate, Federal Ministry of Health, Addis Ababa, Ethiopia
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