Outcomes and Risk Factors for Failed Trial of Labour After One Previous Caesarean Section in Selected Private Hospitals in Mogadishu, Somalia: An Unmatched Case-Control Study

Mariam Mohamed Mohamud Adawe,1 Fahmo Hussein Ibrahim,1 Bashiru Garba,2 Nasteho Mohamud Mudei,1 Jamal Hassan Mohamoud,3 Abdullahi Hassan Elmi4 1Department of Obstetrics & Gynecology, Dr Sumait hospitals, SIMAD University, Mogadishu, Somalia; 2SIMAD Institute for Global Health, SIMAD University, Mogadishu, Somalia; 3Department of Public Health, Faculty of Medicine and Health Sciences, SIMAD University, Mogadishu, Somalia; 4Department of Nursing and Midwifery, Dr Sumait Hospital, Faculty of Medicine and Health Sciences, SIMAD University, Mogadishu, SomaliaCorrespondence: Mariam Mohamed Mohamud Adawe, Email [email protected]: Trial of labour after caesarean section (TOLAC) is an important strategy for reducing repeat caesarean deliveries among appropriately selected women. However, failed TOLAC, resulting in emergency repeat caesarean section, is associated with increased maternal and neonatal risks. Evidence on the outcomes and determinants of failed TOLAC remains limited in Somalia. This study assessed maternal and neonatal outcomes and identified factors associated with failed TOLAC among women with one previous caesarean section in selected private hospitals in Mogadishu, Somalia.Methods: A hospital-based unmatched case-control study was conducted between October 2024 and May 2025 in selected private hospitals in Mogadishu, Somalia. A total of 228 women with one previous caesarean section who were eligible for TOLAC were included, comprising 114 cases with failed TOLAC resulting in emergency repeat caesarean section and 114 controls who achieved successful vaginal birth after caesarean (VBAC). Data were collected through structured interviews and medical record review. Multivariable logistic regression analysis was performed to identify independent predictors of failed TOLAC, and adjusted odds ratios (AORs) with 95% confidence intervals (CIs) were reported.Results: In the study sample, 114 women experienced failed TOLAC and 114 achieved successful VBAC. Maternal complications were more frequent among women with failed TOLAC, including blood transfusion in 14 (12.3%), wound dehiscence in 4 (3.5%), and uterine rupture in 1 (0.9%). After adjustment, failed TOLAC was independently associated with ruptured membranes at admission (AOR = 2.25; 95% CI: 1.13– 4.51), attending only two antenatal care visits (AOR = 2.99; 95% CI: 1.49– 6.02), an inter-pregnancy interval of less than two years (AOR = 2.84; 95% CI: 1.40– 5.79), referral from another health facility (AOR = 4.46; 95% CI: 2.17– 9.16), and a history of stillbirth (AOR = 2.37; 95% CI: 1.12– 5.01). Neonatal outcomes differed between the two groups and were reviewed carefully during revision to ensure consistency with the corrected tables.Conclusion: Failed TOLAC among women with one previous caesarean section in Mogadishu was associated with both obstetric and health-system factors. Strengthening antenatal care, promoting optimal birth spacing, improving referral pathways, ensuring close intrapartum monitoring, and developing context-appropriate standardized TOLAC protocols may help improve maternal and neonatal outcomes.Keywords: trial of labour after caesarean section, failed TOLAC, repeat caesarean section, maternal and neonatal outcomes, risk factors, Somalia