Determinants of Ectopic Pregnancy among Pregnant Women who were managed in Nekemte Referral Hospital, Oromia Region, Ethiopia

Introduction: Ectopic pregnancy (EP) is a pregnancy in which the implantation of the Embryo occurs outside the uterine cavity. It is the leading cause of maternal death during the first trimester of pregnancy. A better understanding of its risk can help prevent its incidence. This case-control study was carried out to evaluate the risk factors for Ectopic Pregnancy in Nekemte Referral Hospital, Ethiopia. Objective: To identify the determinants of ectopic pregnancy among pregnant women who were managed in Nekemte Referral Hospital, 2015. Methods: The design was hospital based unmatched case control study. Detailed reviews of patient record were made by using structured check list all required information have been collected. 99 cases with ectopic pregnancy were taken as a whole whereas 200 controls have been selected with simple random sampling method. Data was entered and cleaned using Epi Info version 7 then exported to SPSS version 20 for analysis. Bi-variable analysis was executed then all explanatory variables with p-value of <0.25 were entered into multivariable logistic regression. Determinant factors have been identified based on p-value of 0.05 and AOR with 95% CI. Results: From January 2010 to December 2013, there were 99 cases of ectopic pregnancy in Nekemte Referral Hospital. The average (± SD) of patients age was 27 (± 5) years. The risk factors identified were marital status and history of contraception use. Accordingly, women with single marital status were 10.81 times (95% CI AOR (3.601, 32.465)) more likely to develop ectopic pregnancy than married once. Those who used contraception were 2.27 times (95% CI, AOR (0.214, 24.02)) more likely to develop ectopic pregnancy than who did not use contraception. The treatment of ectopic pregnancy is influenced by the clinical state of the patient, site of the ectopic gestation, the reproductive wish of the patient as well as availability of facilities and technological expertise. However, surgical treatment still remains the norm [11]. Statement of the problem Ectopic pregnancy is the leading cause of maternal morbidity and mortality World Wide [12]. In the western world, the incidence of EP is approximately 2% in the general population but as high as 20%, in patients who have undergone tubal surgery. Risk factors for EP after natural conception (e.g. tubal surgery, previous EP, pelvic inflammatory disease and infertility) have been well described. Ectopic pregnancy remains a leading cause of maternal mortality and morbidity in the first trimester of pregnancy in developing countries [13]. Ethiopia is one of the six countries which have contributed to more than 50% of all maternal deaths across the world [14,15]. Among the causes of maternal mortality, ectopic pregnancy is the leading in the first trimester of pregnancy. Approximately 1-2% of all naturally conceived pregnancies end up with ectopic pregnancy [16,17]. In the past decades, *Corresponding author: Gizew Dessie, Department of Pharmacy, University of Gondar, Ethiopia, Tel: +251910183763; E-mail: gizew.dessie@gmail.com Received: March 04, 2018; Accepted: April 05, 2018; Published: April 12, 2018 Citation: Kebede Y, Dessie G (2018) Determinants of Ectopic Pregnancy among Pregnant Women who were managed in Nekemte Referral Hospital, Oromia Region, Ethiopia. J Preg Child Health 5: 370. doi:10.4172/2376-127X.1000370 Copyright: © 2018 Kebede Y, 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.

The treatment of ectopic pregnancy is influenced by the clinical state of the patient, site of the ectopic gestation, the reproductive wish of the patient as well as availability of facilities and technological expertise. However, surgical treatment still remains the norm [11].

Statement of the problem
Ectopic pregnancy is the leading cause of maternal morbidity and mortality World Wide [12]. In the western world, the incidence of EP is approximately 2% in the general population but as high as 20%, in patients who have undergone tubal surgery. Risk factors for EP after natural conception (e.g. tubal surgery, previous EP, pelvic inflammatory disease and infertility) have been well described. Ectopic pregnancy remains a leading cause of maternal mortality and morbidity in the first trimester of pregnancy in developing countries [13].
Ethiopia is one of the six countries which have contributed to more than 50% of all maternal deaths across the world [14,15]. Among the causes of maternal mortality, ectopic pregnancy is the leading in the first trimester of pregnancy. Approximately 1-2% of all naturally conceived pregnancies end up with ectopic pregnancy [16,17]. In the past decades,

Introduction
Ectopic pregnancy is derived from the Greek word "ektopos" means out of place and it refers to implantation of a fertilized egg in a location outside of the uterine cavity [1,2]. It occurs in approximately 1% of pregnancies and it is the most important cause of maternal morbidity and mortality in the first trimester [3,4]. The etiology of ectopic pregnancy is not well understood. However, multiple risk factors have been associated with ectopic pregnancy, although some patients may not have any risk factor yet developed ectopic pregnancy.
Theoretically, any condition that prevents or retards the normal transport of the fertilized ovum to the uterus could predispose women to ectopic gestation [5][6][7]. Several risk factors for ectopic pregnancy have been identified, including a history of Pelvic Inflammatory Disease (PID), smoking at the time of conception, previous ectopic pregnancy, previous pelvic surgery, induction of ovulation and intrauterine device usage. An understanding of the risk factors for ectopic pregnancy assists more rapid diagnosis and could result in a reduction in the need for surgery and an improvement in preventive strategies against ectopic pregnancy [8].
A "classic" presentation of ectopic pregnancy is characterized by the triad of delayed menstruation, pain and vaginal bleeding or spotting [9]. Classically, the diagnosis is based on a history of pelvic pain associated with amenorrhea, a positive pregnancy test with or without slight vaginal bleeding [10].

Determinants of Ectopic Pregnancy among Pregnant
Women who were managed in Nekemte Referral Hospital, Oromia Region, Ethiopia the occurrence of ectopic pregnancy has been rised in many countries though the condition varies from country to country depending on the risk factors predominant in the geographical region [5].
There is extensive literature regarding the potential risk factors for EP. The identified risk factors for ectopic pregnancy include prior history of ectopic pregnancy, history of appendectomy, previous pelvic surgery, history of pelvic infection, early age, prior spontaneous and medical abortion, history of contraceptive use including emergency pills, cigarette smoking in dose dependent manner, history of having multiple sexual practices, history of infertility, usage of artificial reproductive technology, presence of a hydrosalpinx or fibroid [18]. While usage of condom and treatment for urinary tract infection showed to decrease the occurrence of ectopic pregnancy [19].
Although several studies have been published examining risk factors for ectopic pregnancy worldwide, women in Ethiopia, Nekemete have different characteristics (cultural, religious, socio-demographic characteristics, sexual behavior and beliefs, contraception usage and preference). Therefore, risk factors for ectopic pregnancy may differ from place to place. Therefore, this case-control study will identify the risk factors in the study area [20].

Study area and period
The study was conducted on October 1-30, 2015 in NRH, which is found in Nekemte Town, at a distance of 331 km from the capital Addis Ababa to the west. The hospital is serving for a total population of about 2.1 million peoples of Nekemte Town, East Wollega Zone, part of West Wollega, Horogudru zone and West Showa Zone. The number of beds in the hospital is 178, which is on medical, pediatrics, surgical, gynecology and obstetrics ward. Out of this 27 are found in gynecological ward. Some of the services which are given by this department are in patient service, emergency and elective minor and major gynecological operations and blood transfusion. The hospital also provide medical treatment, ophthalmic treatment, MCH, compressive HIV care, X-ray, laboratory, psychiatric treatment, ultrasound, pharmacy, training services and physiotherapy. The total number of staff in the hospital is 302. Out of these 192 of them are health professionals including two surgeons, one gynecology and obstetrician, two internists, two pediatrician, two emergency surgical officers, 14 General practitioners, Nurses, Lab technician and others. The number of health professionals in gynecology ward is one gynecologist and obstetrician, one IESO and 18 midwives.

Study design
A hospital based unmatched case control study was employed.

Source population:
Record of all pregnant women who had visited NRH in Gynecological OPD, ANC and maternity ward from 1/07/2014 to 1/07/2015.

Study population:
Record of pregnant women who were diagnosed by ultrasound to have Intra-uterine pregnancy or ectopic pregnancy in Gynecological OPD, ANC clinic, maternity ward and operation room.

Eligibility criteria
Inclusion criteria: Record of pregnant women who were diagnosed to have term Intra-uterine pregnancy or ectopic pregnancy in Gynecological OPD, ANC clinic, maternity ward and operation room.
Exclusion criteria: Record of pregnant women with incomplete data.

Sample size and sampling technique
Sample size was calculated using Epi Info version 7 for unmatched case control study design based on the assumption that PID is significant risk factor for ectopic pregnancy. From previous case control study with 3.0% of controls and 13.4% of cases were having prior history of PID and the level of significance α=0.05, the power of the test(1-β)=80%, the control to case ratio(r)=2, the proportion of exposure among controls (p1)=3% with the proportion of exposure among cases (p2)=13.4% and AOR=5. The final sample size calculated by using the above assumption gives 88 cases and 176 controls with a total of 264 study subjects. However, since there are 99 actual cases in the study period, it was found preferable to take all the total cases in 1:2 ratio to have a total of 299 study subjects (Table 1).

Sampling procedure
Simple random sampling technique was used to select study participants with Intra uterine pregnancy (controls) while for cases all subjects were included as their number is too few (only 99). English. Then the data were collected by year one 4 IESO students using the prepared data collection format on the already existing records after half a day theoretical and half a day practical training was given. One data clerk also supported them by identifying the charts. One supervisor and principal investigator were controlling every activity during data collection. Charts were retrieved using the patient registration number which was found in the registration of Operation Theater, ANC and GYN OPD and maternity sections of the hospital.

Data quality control
Quality of data were maintained by recruiting data collectors who are IEOS year one and supervisor IESO year three. The data collectors and supervisor were given intensive training for one day before the data collection on the objective of the study and how to retrieve data for this study purpose using the data extraction format. They briefed on the definition of variables on the questionnaires and registration charts. The data extraction tool was pre-tested for consistency of understanding the review tools and completeness of data items on 10 charts at the same facility as it was a secondary data and the necessary amendment were made on the final data extraction format. The retrieval process was closely monitored by the principal investigator throughout the data collection period. Completed questionnaires were checked regularly for completeness of information and any gaps identified were immediately communicated to the data collectors.

Data processing and analysis
Data have been first checked manually for completeness and consistency by supervisor and principal investigator during data collection and rechecked again before data entry. Data was entered and cleaned using Epi Info version 7 then exported to SPSS version 20 for analysis and interpretation. Descriptive analysis was conducted to summarize the data. Bi-variable analysis has been executed to see the association between independent and outcome variables. All explanatory variables associated with outcome variables with p<0.25 was entered into Multivariable logistic regression analysis. Back ward step wise likely hood was used and Variables with a p-value <0.05 in multi-variable analysis were considered as significant risk factor for ectopic pregnancy.

Ethical consideration
Ethical clearance was obtained from the Institutional review board of Jimma University college of health sciences. Permission letter was obtained from Nekemte Referral Hospital's management and oral permission also obtained from focal person in the respected wards to use the secondary data for the purpose of this study. The name or any other identifying information was not recorded on the questionnaire and all information taken from the chart was kept strictly for confidential and in a safe place. The information retrieved was used only for the study purpose.

Limitations of study
Since the study is based on secondary data, this study faced with incomplete information, unreadable patient card, registration book and operation room records. Details of socio demographic variables not addressed due to lack of documentation. Since the study is institutional based, findings couldn't generalize the general population unlike prospective population based study.  Table 2).

Risk factor for ectopic pregnancy
Findings from bi-variable logistic regression analysis showed that age, marital status, history of contraceptive user, type of contraceptive used and prior history of STI syndrome had association with ectopic pregnancy with p-value of less than 0.25. However, in multi-variable regression analysis, only marital status and history of contraceptive use remained statistically significant risk factor for ectopic pregnancy.
Accordingly, women with single marital status were 10.81 (95% CI A0R (3.601, 32.465), p-value 0.001) times higher risk to developed ectopic pregnancy than married once and history of contraceptive use was 2.27 AOR (0.214, 24.02) times more likely to develop ectopic pregnancy than those who had no history of contraceptive use (Table 3).

Discussion
This case control study tried to identify the determinants of EP in Nekemte Referral Hospital. In this study the average age was 27 ± 5years, similar studies done in Lagos, Nigeria and Niger Delta showed the mean age was 27.8 ± 6.21 years and 26.8 years, respectively [12,17].
Majority of clients in this study were married 91.3% (273 of 299) which is the same as that of the study done in Aminu Kano Hospital Nigeria [21][22][23].
In this case control study many variables that have been well studied and identified as a risk factor do not appeared to show association with ectopic pregnancy and the variable that were identified as risk factor for ectopic pregnancy were marital status and history of contraception use.
Thus, women with single marital status were 10.81 times (95% CI A0R (3.601, 32.465)) times higher risk to developed ectopic pregnancy than married once. This may be because single women are at higher risk of encountering multiple sexes, PID, STI and more tendencies to use contraceptive like emergency pills that are incriminated to increase the risk of ectopic pregnancy than those married women.
To my knowledge this is the first study that tries to identify risk factor to ectopic pregnancy in the study area. Like other case control studies it has certain limitation [24]. The first was ascertained based on the written records in clients chart. The other was difficulty of findings similar research to compare the main findings of this thesis. The last Others: Types of surgery other than CS  but not the least was as it is based on chart review it was impossible to fully incorporate other variables like educational status, alcohol use, cigarette smoking and so on which could have impact on the occurrence of ectopic pregnancy.

Conclusion
Although several risk factors for ectopic pregnancy are known, the only factors associated were marital status and history of contraception use. Accordingly, women with single marital status were 10.81 times (95% CI AOR (3.601, 32.465)) more likely to develop ectopic pregnancy than married once. Those who used contraceptive were 2.27 times (95% CI, AOR (0.214, 24.02)) more likely to develop ectopic pregnancy.

Recommendation
Though it is not identified in this study, there are known risk factors for ectopic pregnancy, thus large scale study shall be conducted to identify possible determinates of ectopic pregnancy. Tracing and integrated management of sexually transmitted infection is very important so as to reduce the incidence of pelvic infection and EP. The clinicians need to record all the findings on medical charts of the patients and Patient's medical records should be kept appropriately.