1 INTRODUCTION

Obstetric fistula is a serious birth injury resulting from prolonged compression of the birth canal tissues, bladder base, urethra, or sometimes the rectum by the presenting fetal part.^{1, 2} This condition has a profound impact on the social, economic, and psychological well-being of affected women. The associated stigma, deep sense of loss, and diminished dignity and identity can significantly undermine their quality of life. It has a devastating social, economic, and psychological effect on the health and well-being of the affected women. The stigma, deep sense of loss, and loss of dignity and identity associated with fistula have a negative impact on quality of life.^{3, 4}

Every year, approximately two million women worldwide suffer from untreated fistulas. Annually, between 50,000 and 100,000 new cases of obstetric fistula are diagnosed. In sub-Saharan Africa, approximately 1000 women are affected by this condition.^{5, 6} Approximately two million women in sub-Saharan Africa and Asia are living with untreated fistula. This condition is both preventable and treatable. Despite the establishment of various initiatives aimed at preventing and repairing fistulas in recent years, many women face delays in seeking treatment. Factors contributing to these delays include a lack of awareness about the possibility of repair, insufficient resources to access care, and obstacles such as shortages of medical personnel or facilities and inadequate quality of care.^7-10

Awareness of obstetric fistula involves understanding its symptoms, prevention strategies, and risk factors.¹¹ A common obstacle to seeking treatment for fistula is a lack of awareness. Many women affected by obstetric fistula are unaware of what the condition is, whether it can be treated, or where to seek treatment. Additionally, both the women with fistulas and their communities may have misconceptions about the causes of the condition.^{12, 13}

While obstetric fistula has been eradicated in high-income countries, it continues to be a widespread and debilitating issue in many developing regions. In these areas, women often face immediate effects such as leakage of urine, feces, or both.^{14, 15} Awareness of obstetric fistula is still low in many developing countries, including Ethiopia (40%), where it is not uncommon.¹¹ A systematic review found that 0.29% pooled prevalence of obstetric fistula; separated by region the highest prevalence was in sub-Saharan Africa and South Asia, 1.60%. A study in Egypt, has found that showed that, three quarters of the studied pregnant women had in adequate level of total knowledge regarding obstetric fistula. One in 10 women proposed that suicide might be a solution to fistula, while one-third believed that women with the condition should be isolated.^{15, 16}

In Ethiopia, however, obstetric fistulas remain one of the factors contributing to maternal illness and death, as the health care system is still not well developed. The nation's young, small, and illiterate girls and women who live in the remote parts of the country are becoming the victims of this preventable and curable obstetric complication.^{14, 17} The EDHS 2016 data from Ethiopia indicates that only 39% of women aged 15–49 have heard of obstetric fistula. Additionally, fewer than 1% of women report having personally experienced the condition.¹⁸ The report also reveals that the prevalence of obstetric fistula is highest in certain regions and varies across the country. Tigray (1.6%) and the Southern Nations, Nationalities, and People's Region (SNNPR) (1.5%) have the highest rates of obstetric fistula, with Oromia following closely at 1.2%.¹⁸ Among reproductive-age women who have heard of obstetric fistula, awareness is lowest in the Oromia region at 28.6%, compared to higher awareness levels in the Tigray and Amhara regions, which are 65.8% and 45%, respectively.¹⁵

The country's rural healthcare coverage remains deplorable. The efforts of health extension workers (HEWs) have been hindered by the extensive catchment areas and widely scattered populations they serve. Recent health reform initiatives have aimed at enhancing local primary health care (PHC) systems Due to these, Ethiopia launched a new initiative in 2010/2011, comprising community volunteers known as the “Women Health Development Army” (WHDA).^{19, 20} Efforts to improve women's health are crucial, particularly in less developed countries, to address the growing demand for healthcare services and the shortage of formal healthcare providers. It is understood that solutions cannot be achieved solely from the standpoint of service providers and program planners.^{19, 20}

There is community-based evidence of awareness of obstetric fistula and associated factors in Ethiopia, particularly in the study area, including the women's health and development army. Hence, this study has assessed the magnitude and factors associated with awareness of obstetric fistula among women in the health and development army in the South Gondar zone, Amhara region, Ethiopia, in 2020.

2 METHODOLOGY

3 RESULTS

4 DISCUSSION

This study sought to evaluate the awareness of obstetric fistula and the factors influencing it among women's health development armies in the Estie district, South Gondar Zone, Amhara region, Ethiopia. The results showed that 55.3% of participants (95% CI: 51.7%–57.2%) had a good understanding of obstetric fistula. Despite this level of awareness, a considerable portion of women remain uninformed about the condition. Consequently, preventing this public health issue in the community remains challenging.

This finding aligns with a study conducted in Delanta district, Amhara region, which reported a similar awareness level of 55.4%.²⁵ The comparable results are likely due to both studies being carried out in the same region of Northwest Ethiopia, reflecting similar awareness levels. However, this result is higher than the 39% reported in the EDHS (2016), where two in five women surveyed had heard of obstetric fistula.¹⁸ This discrepancy may be attributed to the EDHS sampling different regions of Ethiopia, which vary in geography, social, and cultural factors. Additionally, this awareness level is lower than that found in studies from Nigeria and Kenya, which reported 57.8% and 60.1% respectively.^{26, 27} The lower awareness in our study might be related to the inclusion of only women as participants and the community-based nature of our study, as opposed to facility-based studies that included both men and women.

The findings of this study indicate a significant relationship between awareness of obstetric fistula and the distance to the nearest health center. Women living more than 30 min away on foot from a health center were 57% less likely to have good awareness of obstetric fistula compared to those living within 30 min. Similar studies in Ethiopia have also found that the distance to a healthcare facility impacts both awareness of obstetric fistula and health-seeking behaviors. When health facilities are closer, women are more likely to visit them, as they do not face the challenge of transportation.⁵

Women with no history of abortion were 62% less likely to have good awareness of obstetric fistula compared to those with a history of abortion. This finding is consistent with studies conducted in Ethiopia and Burkina Faso. One reason for this difference may be that obstetric fistula is a complication often discussed during pregnancy.^{5, 24} The study also found that good awareness of obstetric fistula was more common among women with a history of antenatal care (ANC). Women with no pregnancy history were 48% less likely to have good awareness. This result aligns with research from the Amhara Region, which reported that women without a pregnancy history were 87% less likely to have good awareness, and with other studies showing an 80% lower likelihood of good awareness among women without pregnancy histories.^{5, 24} This lower awareness among women with no pregnancy history may be attributed to the fact that pregnant women are more likely to engage with maternal healthcare services, which often provide health education.²⁴

Study participants with a higher number of pregnancies were more likely to be aware of obstetric fistula compared to those with fewer pregnancies. This finding is consistent with a study conducted in Ethiopia.¹¹ Women with more pregnancies are more likely to access maternal health care services, which increases their exposure to information about obstetric fistula from health professionals.¹¹

5 CONCLUSIONS AND RECOMMENDATIONS

In this study, only 55.3% of the Women's Health Development Army had good awareness of obstetric fistula, indicating a low level of awareness. Factors such as ANC follow-up history, abortion history, pregnancy history, number of pregnancies, and proximity to a health facility were significantly associated with awareness of obstetric fistula.

Hence, local and regional health offices should design health education programs to ensure that the majority of women have optimal awareness of obstetric fistula. Given that the majority of respondents had access to television, radio, and other media, awareness programs should utilize these channels to enhance women's awareness. This study suggests placing greater emphasis on the use of basic maternal health services like antenatal care (ANC). Healthcare providers should include obstetric fistula awareness in their health education programs. Additionally, researchers are recommended to conduct qualitative studies to address perception and behavioral factors and to explore the lived experiences of women.

6 LIMITATIONS

Some questions were prone to recall bias, as they required women to remember past events that they might not recall accurately. To mitigate this, respondents were only asked to recall events from the past year. Additionally, being a quantitative study, this research may not fully capture the lived experiences of women with obstetric fistula, nor does it delve deeply into the cultural and behavioral factors entrenched in the community.

AUTHOR CONTRIBUTIONS

Bilikew Addimasu: Conceptualization; investigation; writing—original draft; methodology; writing—review and editing; formal analysis; data curation; project administration. Dabere Nigatu: Conceptualization; validation; methodology; writing—review and editing; software; formal analysis; supervision. Zemenu S. Yadita: Conceptualization; methodology; validation; writing—review and editing; software; formal analysis; supervision. Mekonnen Melkie: Conceptualization; methodology; validation; writing—review and editing; software; formal analysis; supervision. All authors have reviewed and approved the final version of the manuscript.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflict of interest.

ETHICS STATEMENT

The study was conducted following the receipt of written ethical approval from the Institutional Review Board (IRB) at the College of Medicine and Health Sciences, Bahir Dar University. Informed written consent (Supporting Information S1: File 1) was obtained from each participant. All participant information was kept strictly confidential, and their names were not recorded. Data were coded and entered into a computer protected by a personal password to ensure confidentiality.

TRANSPARENCY STATEMENT

The lead author Zemenu Shiferaw Yadita affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.