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A DISSERTATION TO BE SUBMITTED IN PARTIAL FULFILLMENT OF THE
REQUIREMENTS FOR THE AWARD OF DEGREE OF MASTER OF MEDICINE IN
OBSTETRICS AND GYNECOLOGY OF THE UNIVERSITY OF RWANDA
Investigator: NIYONKURU Emile, MD
SUPERVISORS: RULISA Stephen, MMED, PhD
GEORGES GILSON, MMED
February 2016
FACTORS ASSOCIATED WITH THE SUCCESS OF TRIAL OF
LABOR AFTER CESAREAN DELIVERY AT MUHIMA DH AND IN
REFFERAL HOSPITALS IN RWANDA

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Acknowledgement
The achievement of this work is result of many people to whom we are expressing our feelings
of gratitude.
I gratefully acknowledge Dr Stephen Rulisa and Dr Georges Gilson, the supervisors of this work,
for the continuous support and timely interventions during the elaboration of this work. Their
simplicity, their availability despite many obligations, their remarks; and especially their
scientific expertise has been of great importance for this work to be realized.
I would like also to extend my thankful acknowledgements to all HRH faculty members for kind
collaboration during my residency program and for the whole process of this work; especially Dr
Urania Magriples for reviewing this work before submission.
I would like to extend my thankful acknowledgements to my lovely wife Francine
BAZOMPORA MUNEZERO who despite her many obligations managed to handle all family
duties in my absence. Her continuous support and encouragements have contributed a lot to the
realization of this work. To our children Kendra BWITONZI, Elior NIYONKURU and Esther
KERANDA for their love.
I also express my acknowledgements to the heads of Gynecology-Obstetrics departments at
Kigali and Butare University Teaching Hospitals and Muhima District Hospital, and all medical
staff at the respective departments from whom I have benefited enormously.
Acknowledgement is particularly extended to the government of Burundi for
funding my studies at University of Rwanda.
Furthermore I am grateful to all my colleagues’ residents for their moral support during the
postgraduate study.
I thank all people who directly; and or indirectly supported me during the process of elaboration
of this work.

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Abstract
Vaginal delivery after previous cesarean section (VBAC) has been found to be safe and to have a
success rate above 60%. However, many care providers and pregnant women are reluctant to
initiate or accept trial of labor after cesarean delivery. Care providers in low resource settings
find counseling to be difficult in part because predictors of success that are reported in the
literature are from developed countries and evidence from developing countries is scanty. This
study aims to investigate potential predictors associated with a successful trial of labor after
Cesarean Section (TOLAC) in low resource settings.
Methods: A cross-sectional study design involving women with one previous cesarean delivery
admitted for delivery from 15th
September 2015 to December 16th
2015 in the three large
teaching hospitals in Rwanda (Butare University Teaching Hospital (BUTH), /Kigali Teaching
Hospital (KUTH) and Muhima District Hospital). Patient demographics were collected and
chart review was performed.
Results: The majority of the participants were married women aged between 18-34 years and
had a community base insurance. Those who stay in urban area are nearly 70% and 60.9% of the
participants completed primary education. Three quarters of patient had counseling prior to
admission about TOLAC and 40.6% reported that the counseling was from her doctor. The
majority (97%) experienced spontaneous labor and above half of them had a cervical dilatation
on admission of ≥ 4 cm. Half of the sample (50, 4%) had a successful VBAC. Results from
multiple regression analysis show that previous vaginal delivery, previous VBAC, and admission
cervical dilatation were independent predictors to the success of TOLAC.
Conclusion: In patients without any contraindication to vaginal delivery, TOLAC is a safe
option. In this study, successful VBAC was associated with past obstetrics history (prior vaginal
delivery and/or prior VBAC) and to the current labor (spontaneous labor and advanced
admission cervical dilatation).

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Introduction
Maternal and infant mortality is still high in Sub-Saharan Africa even with improved access to
health care (1). From 1994 to 2014, tremendous progress was made in Rwanda in reducing infant
and maternal mortality rates (2). However, despite the progress made, mortality is still high, and
Rwanda has yet to fully meet the 2015 Millenium Development Goals (MDGs) (2)
Delayed recognition of the need for, and the reception of, appropriate emergency obstetric care,
continues to contribute to avoidable deaths in sub-Saharan Africa (3–5). Cesarean delivery (CD)
is among the appropriate emergency surgical procedures introduced in obstetrics as life saving
measures for mother and newborn (6,7). The literature has documented an inverse association
between CD rates and maternal and infant mortality in developing world nations, where large
sectors of the population lack access to basic obstetric care (5,8). In contrast, CD rates above a
certain limit have not shown additional benefit for both mother and newborn. Several studies
have also reported that high CD rates are linked to negative consequences in maternal and child
health (9,10). Cesarean delivery has been associated with long term maternal morbidity, although
most studies of morbidity focus on short-term, rather than long-term complications. The
literature examining chronic complications such as surgical adhesions, infertility and sub
fertility, as well as the life-threatening risk of hemorrhage and hysterectomy, is limited because
of the difficulties in acquiring long term follow up. It has also reported that risks of perinatal
complications and other long-term morbidities increase along with the number of cesarean
procedures, and is highest in women who have undergone multiple cesareans (9,11,12). These
women have a substantially increased risk for a variety of morbidities that include bladder injury
and obstetrical hemorrhage (11,13). Despite the fact that vaginal delivery is still possible even
after cesarean delivery, trial of labor after previous cesarean delivery (TOLAC) remains
controversial in many countries. Many practitioners and patients are still reluctant to initiate
normal delivery after a previous cesarean even if TOLAC is a reasonable option for women with
one prior low transverse uterine incision. A number of studies have documented the factors
associated with successful trial of labor.

5. 5
These include the clinical indication for the prior cesarean, the type of uterine incision, the
presentation and weight of the current fetus, maternal weight among other factors.(13).
Unfortunately, data regarding the likelihood of successful TOLAC in the low resource settings is
limited.
The aim of this study was to determine which factors influence the likelihood of successful trial
of labor after one previous cesarean delivery (TOLAC).
Material and methods
Data were collected prospectively over a 4 month period from 15th
September 2015 to 16th
December 2015 among patients admitted for delivery at the two main university teaching
hospitals in Rwanda [Butare University Teaching Hospital (BUTH)] and Kigali Teaching
Hospital (KUTH) and at a large maternity hospital (Muhima District Hospital). Participants who
had previously undergone one prior CD, regardless of the indication of CD, with no
contraindication to vaginal delivery and who consented for TOLAC were recruited in the study.
Maternity care provider’s attitude was also assessed in 81 providers.
To determine our sample, we were based on medical records obtained from aforementioned
hospitals BUTH, KUTH and Muhima DH.
A method by Taro Yamane (1967) applies as follow:
2
1 Ne
N
n


133
)
05
.
0
)(
200
(
1
200
2



n
Where: n = sample size N = number of total population e = value of accepted error
Therefore, Sample size estimated correspond to 133 women.
Data analysis was done using SPSS version 16. Analysis of the participant socio-demographic
characteristics is presented with use of frequency tables. To answer the main research question, a
bivariate analysis with chi-square test was computed.

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Multiple logistic regression was used to evaluate the contribution of independent predictors. IRB
approval the research protocol and permission to access the data was obtained at all three
institutions.
Results
One hundred thirty three patients were enrolled. Results on socio-demographic characteristics are
summarized in Table 1. The majority of the participants were married women aged between 18-
34 years and had a community base insurance. Those who stay in urban area are nearly 70% and
60.9% of the participants completed primary education. Three quarters of patient had counseling
prior to admission about TOLAC and 40.6% reported that the counseling was from her doctor.
The majority (97%) experienced spontaneous labor and above half of them had a cervical
dilatation on admission of ≥ 4 cm. Half of the sample (50.4%) had a successful VBAC.
Results on clinical and obstetrical characteristics are depicted in Table 2. The, majority of the
participants had a BMI below 30, and had CD within a period greater than 2 years. The most
common reasons for prior CD indication were non reassuring fetal heart rate followed by
dystocia. Nearly 30.1 % of the participant experienced a prior VBAC while 43.6% of women
had a prior vaginal delivery.
Results on TOLAC and labor outcome illustrate that 75.5% of participants had counseling on
TOLAC prior admission and 40.6% reported that the counseling was from her doctor (Table 3).
Most participants (97%) had spontaneous labor and more than half had a cervical dilatation on
admission of ≥ 4 cm. The majority of the participants had babies at term and within the normal
range of birth weight. More than half (50.4%) had a successful VBAC.
Results on attitudes towards option on delivery are summarized in Table 4. The majority of the
providers believed that “Vaginal delivery is still an option after Cesarean delivery”. Nearly 70%
of them disagree that “Cesarean delivery is better than vaginal delivery because it is not painful”.
The same applies to the statement that “Once a woman deliver by cesarean section, vaginal
delivery is no longer possible”.

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With regard to the statement “I prefer cesarean delivery because I don’t like mothers position on
the gynecology bed” 82% of the participants disagree with it. More than half of providers felt
that CD did not prevent uterine or bladder prolapse and that vaginal delivery carried a lower risk
for the mother. Forty-one percent of providers thought a mother did not have the right to request
a CD.
Results on factors associated with the success of TOLAC are depicted in Table 6. In univariate
analysis; residence, previous vaginal delivery, previous VBAC and advanced cervical dilatation
on admission were significantly associated with success of the TOLAC.
Results from multiple regression analysis summarized in Table 7 show that previous vaginal
delivery, previous VBAC, and admission cervical dilatation are independent predictors to the
success of TOLAC.
Discussion
In this study we found that majority of the participants were married woman who had
community based insurance, most of them had CD within a timeline of 2 years and above. The
study found as well indication for CS was mostly fetal distress and dystocia. For the attitudes
towards TOLAC option the study revealed that majority of the participants (pregnant woman and
care providers) believed that “Vaginal delivery is still an option after Cesarean delivery.
Our study found different clinical characteristics that are visibly associated with VBAC success.
Among these factors, we found previous vaginal delivery including successful previous VBAC
among significant factors. In our study 50% of women who underwent TOLAC had a history of
previous vaginal delivery. Given that majority of the participants who underwent TOLAC, were
prepared in a counseling provided by their Doctors, such results might be reflecting the
progressing shift of care providers from a conservative approach (once cesarean always
cesarean) to selecting candidates for TOLAC. The study found as well that, woman who had a
previous vaginal delivery; with an advanced cervical dilatation achieved a high rate of VBAC
success compared with those lacking a history of previous vaginal delivery.

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The results of this study are in line with results reported by Landon and colleague, who found
83% success among women with history of vaginal delivery compared with 65% without such
history (13)(14). Our results might be following the fact that the more the cervical dilatation is
advanced the less the labor time, a factor that help both provider and pregnant women to
tolerance the TOLAC. Additionally, since pregnant woman have experienced a vaginal delivery
or a VBAC; it might be an additional motivating factor for more endurance.
VBAC success was at fifty percent of the TOLAC meaning that one out two TOLAC will
succeed. Our results are a little bit different from the literature whereby the success rate was
estimated at 60 to 80%(13,15). The difference might be probably due to the attitudes of the care
providers who are reluctant to continue with TOLAC in prevention of further complications or
pregnant women who do not tolerate the pain of labor and request for CD.
There are clinical and demographic characteristics that were found significantly associated to the
success of the VBAC in the literature such as labor characteristics. In this study, participants
were only on spontaneous labor and this count among the limitations of the study. Additionally,
given that our study is cross sectional, association found in the study cannot be interpreted as
causal effect relationship with VBAC. This study recruited only woman who accepted to
undergo TOLAC, therefore in the absence of a random allocation, information on TOLAC are
limited to inclusion of woman who have agreed to participate to TOLAC attempt.
The same is valid to care providers; the available results are from mostly teaching hospital and a
busy urban maternal hospital. Therefore, it may not be applicable to all hospitals in remote area.
We conclude that for patients without any contraindication to vaginal delivery, TOLAC is a safe
option should be allowed in setting where all resources are available to provide an emergence
care. In this study, successful VBAC was associated with past obstetrics history (prior vaginal
delivery and or prior VBAC) and to the current labor (spontaneous labor and advanced
admission cervical dilatation)

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settings: Facing reality. Health Policy (New York). 2009;89(2):131–48.
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2002_eng.pdf

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previous caesarean birth. Int J Gynecol Obstet. 2005;89(3):319–31.

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Table 1. Demographics characteristics
AGE N %
≤17 years 1 .8
18-34 years 110 82.7
≥35 years 22 16.5
MARITAL STATUS
Married 124 93.2
Single 9 6.8
LEVEL OF EDUCATION
No formal education 12 9
Primary education 81 60.9
Secondary education and above 40 30.1
RESIDENCE
Urban 93 69.9
Rural 40 30.1
INSURANCE
Community base insurance 103 77.4
RSSB 13 9.8
Others 12 9
None 4 3.8

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TABLE 2. Clinical and Obstetrical characteristics
BMI N %
≥30 14 10.5
<30 119 89.5
Mean PARITY 2
Previous indication for CD
Dystocia 31 23.3
Non reassuring fetal heart rate 33 24.8
Malpresentation 25 18.8
Others 44 33.1
Previous cesarean delivery
<=2Yrs 25 18.8
>2 Yrs 108 81.2
Previous vaginal delivery
Yes 58 43,6
No 75 56,4
Previous VBAC
Yes 40 30,1
No 93 69,9

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Table 3. TOLAC counseling and labor outcome
Counseling on TOLAC
Yes 100 75.2
No 33 24.8
If Yes from who?
Friends 35 26.3
My Doctor 54 40.6
Relatives 9 6.8
Others 5 3.8
Labor type
Induction 4 3
Spontaneous labor 129 97
Admission cervical dilatation
< 4 cm 43 32.3
≥4 cm 90 67.7
Birth weight
< 2500 1 .8
2500- 3999 124 93.2
≥4000 8 6.0
GESTATIONAL AGE
< 37 weeks 2 1.5
37-41 122 91.7
>41 9 6.8
TYPE DELIVERY
Vaginal 67 50,4
Caesarian Section 66 49,6

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Table 4. Pregnant woman’ attitudes on option of delivery after one Cesarean Delivery
Agree (freq. / %) Disagree (freq. /
%)
Not sure (freq. / %)
Vaginal delivery is still an option
after Cesarean delivery
101 75.9 8 6 24 6
Cesarean delivery is better than
vaginal delivery because it is not
painful
29 21.8 92 69.2 12 9
Cesarean delivery is better because
it contribute more to the well being
of the child
27 20.3 69 51.9 37 27.8
Once a woman deliver by cesarean
section, vaginal delivery is no
longer possible
17 12.8 93 69.9 23 17.3
If I knew Cesarean Complication I
would never request cesarean
delivery again
67 50.4 54 40.6 12 9
I prefer cesarean delivery because I
don’t like mothers position on the
gynecology bed
5 3.8 109 82 19 14.3

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Table 5. Provider’ attitudes on option of delivery after one cesarean delivery
Disagree
(freq. / %)
Neither
Disagree
(freq. / %)
Agree
(freq. / %)
Strongly
agree
(freq. / %)
CD prevent uterine and bladder
prolapse
47 58 12 14.8 20 24.7 2 2.5
CD prevent injury to female genital
track
42 51.9 13 16 24 29.6 2 2.5
Vaginal delivery has lower risks to the
mother
3 3.7 5 6.2 31 38.3 42 51.9
I believe that a mother should have her
own right to request CD
5 6.2 9 11.1 48 59.3 19 23.5

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Table 6: Bivariate analysis on factors associated with Success of TOLAC
Type of delivery
Vaginal n (%) Cesarean n (%) Chi-square P-value
Socio-demographics
Age 1.86 .39
<=17 1(1.5) 0(0.0)
18-34 53(79.1) 57(86.4)
>=35 13(19.4) 9(13.6)
Education 3.82 .14
no Formal education 7(10.4) 5(7.6)
Primary education 45(67.2) 36(54.5)
secondary + 15(22.4) 25(37.9)
Insurance 7.50 .06
Mutuelle 56(83.6) 47(71.2)
RSSB 4(6) 9(13.6)
Others 3(4.5) 9(13.6)
None 4(6) 1(1.5)
Residence 7.31 .008*
Urban 54(80.6) 39(59.1)
Rural 13(19.4) 27(40.9)
Obstetrical and clinical
factors
BMI 2.97 .08
≥30 4(6) 10(15.2)
<30 63(6) 56(84.8)
Previous Vaginal Delivery 30.46 <.0001***
Yes 45(67.2) 13(19.7)
No 22(32.8) 53(80.3)

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Previous VBAC 27.43 <.0001***
Yes 34(50.7) 6(9.1)
No 33(49.3) 60(90.9)
Previous Cesarean Delivery 1.14 .28
<=2Yrs 15(22.4) 10(15.2)
>2 Yrs 52(77.6) 56(84.8)
Admiss ion Cervical
Dilatation
10.31 .001**
>=4 54(80.6) 36(54.5)
<4 13(19.4) 30(45.5)
Attitude Clients .072 .822
Not favorable 11(16.4) 12(18.2)
Favorable 56(83.6) 54(81.8)
Attitude Provider .85 .470
favorable 30 (63.8) 25(73.5)
Not Favorable 17(36.2) 9(26.5)
N= 133, outcome : VBAC , *p<0.05, ***p<0.001
Table 7: Multivariate Analysis by logistic regression model for factors associated to success
of TOLAC
Variable OR 95% CI p-Value
Previous Vaginal Delivery 3.112 [1.039,9.324] .043
Previous VBAC 3.907 [1.053,14.489] .042
Admission Cervical Dilatation 2.650 [1.096,6.409] .031
Constant .004 _ _
N= 133, outcome : VBAC , *p<0.05, ***p<0.001

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