Kelly correctly draws attention to Ethiopian women's preferences to retain their uterus, even in the catastrophic circumstances of uterine rupture. Although there is no clear evidence to suggest that uterine repair is clinically preferable to hysterectomy, a study of 110 cases of uterine rupture in India demonstrated a mortality rate of 35% when uterine rupture was treated by hysterectomy and only 9% when treated by primary repair. There is, of course, an absence of reliable data on women who died in their homes or on the way to the hospital.
Our study was based in a mission hospital that did not have a resident obstetrician and had limited facilities. In this situation, uterine repair is a simpler procedure to perform than hysterectomy, and as we revealed, carried a relatively low mortality rate of <5%. Ethiopian-based studies from Kelly and colleagues,[3, 4] together with a Saudi Arabian study have usefully followed up women after uterine repair and demonstrate that delivery by elective caesarean section is safe. As Kelly rightly points out, it is essential that women who have had a uterine rupture stay in maternity waiting areas/houses for 2 or 3 weeks before their expected delivery date, ensuring rapid access to hospital facilities when labour begins.
Interventions such as ultrasound-enhanced antenatal risk screening, that identify individuals at high risk of a complicated delivery, allow women to make arrangements to attend appropriate maternity facilities and should have a major impact on maternal and neonatal mortality and morbidity and allow women to deliver safely even when they have had life-threatening previous complications such as uterine rupture.