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Background: An obstetric fistula is an inappropriate connection between the vagina, rectum, or bladder that results in faecal or urine incontinence. Young women from rural areas with poor socioeconomic situations and education are the majority of victims, which restricts their access to high-quality healthcare. Obstetric fistulas can have devastating effects on the physical health of affected women if they are not promptly treated. Inadequate awareness of the symptoms delays recognition of the problem, prompt reporting, and treatment. Women with poor awareness of the disorder are also more likely to develop complications, including mental health issues. Using data from a nationally representative survey, this study investigated the prevalence and factors associated with the awareness of obstetric fistula among women of reproductive age in The Gambia. Methods: This study used population-based cross-sectional data from the 2019–2020 Gambia Demographic and Health survey. A total of 11823 reproductive-aged women were sampled for this study. Stata software version 16.0 was used for all statistical analyses. Obstetric fistula awareness was the outcome variable. Multilevel logistic regression models were fitted, and the results were presented as adjusted odds ratios (aOR) with statistical significance set at p < 0.05. Results: The prevalence of obstetric fistula awareness was 12.81% (95%CI: 11.69, 14.12). Women aged 45–49 years (aOR = 2.17, 95%CI [1.54, 3.06]), married women (aOR = 1.39, 95%CI [1.04, 1.87]), those with higher education (aOR = 2.80, 95%CI [2.08, 3.79]), and women who worked as professionals or occupied managerial positions (aOR = 2.32, 95%CI [1.74, 3.10]) had higher odds of obstetric fistula awareness. Women who had ever terminated pregnancy (aOR = 1.224, 95%CI [1.06, 1.42]), those who listened to radio at least once a week (aOR = 1.20, 95%CI [1.02, 1.41]), ownership of a mobile phone (aOR = 1.20, 95%CI [1.01, 1.42]) and those who were within the richest wealth index (aOR = 1.39, 95%CI [1.03, 1.86]) had higher odds of obstetric fistula awareness. Conclusion: Our findings have revealed inadequate awareness of obstetric fistula among women of reproductive-age in The Gambia. Obstetric fistulas can be mitigated by implementing well-planned public awareness initiatives at the institutional and community levels. We, therefore, recommend reproductive health education on obstetric fistula beyond the hospital setting to raise reproductive-age women's awareness.
In The Gambia, the true burden of obstetric fistula is unknown due to a lack of nationally representative data. The prevalence of fistula, for instance, is based on proxy measurements such as treatment facilities, contextual information, and rates of maternal and perinatal mortality. The current national burden using data from these sources is between 335 to 1052 cases [9] as compared to the 2006 figure of 197 (0.5 per 1000) cases [19] of obstetric fistula. These estimates are not generally representative, and the actual burden might be higher than stated. Nevertheless, The Gambia is considered among the 22 high-burdened countries in the world and was selected to train surgeons on obstetric fistula repair as part of the FIGO's Fistula Surgery Training program [20]. Efforts are also made by the government in collaboration with UNFPA to create awareness of the disease among reproductive-age women and enhance its repair to improve the quality of life of women. The Ministry of Gender, Children, and Social Welfare of Gambia has ensured the implementation of local programs and strategies aimed at tackling the complex circumstances and conditions that contribute to the development of obstetric fistulas in the country. In May 2022 the Zero Fistula Gambia campaign was launched, to raise public awareness of the condition and call for its eradication [9]. This campaign was targeted at achieving zero fistula cases in The Gambia by 2030 which collaborates with the international goals of UNFPA in ending obstetric fistula [9, 20]. The Gambia currently has three fistula centers, three fistula surgeons, and two FIGO-trained fellows. The facilities offering fistula repair are Edward Francis Small Hospital, Banjul, Bafrow Fistula center, Serekunda, and Kanifing General Hospital. Estimating the proportion of reproductive-aged women who are currently aware of the symptoms of obstetric fistula and the factors’ influencing awareness is necessary to assist these awareness programs and initiatives to track the progress and to improve public health education programmes. The study used nationally representative data from the 2019–2020 Gambia Demographic and Health Survey (GDHS). The data collection for the GDHS was from November 21, 2019, to March 30, 2020. The Gambia Bureau of Statistics (GBoS) executed the survey in collaboration with the Ministry of Health (MoH) and with technical assistance from ICF through The DHS Program. Funding for the 2019–20 GDHS came from the United Nations Population Fund (UNFPA) and other agencies and organisations [2]. A multistage (two-stage) sampling design was employed to select households from the eight Local Government Areas (LGAs) in The Gambia for the survey. The first stage involved the stratification of the LGAs into rural and urban areas, based on an updated version of the 2013 Gambia Population and Housing Census (2013 GPHC), and the selection of 281 clusters (enumeration areas) with a probability proportional to their size within each sampling stratum. In the second stage, 25 households were selected from each cluster using a systematic sampling technique, resulting in a sample size of 7,025 households. Data were collected through face-to-face interviews with all women aged 15–49 who were permanent residents of the selected households or visitors who stayed overnight before the survey. Out of the 12,481 women aged 15–49 who were eligible for interviews in the selected households, 11,865 completed the interviews, yielding a response rate of 95% [2]. The primary outcome of this study was women’s awareness of obstetric fistula. Data on the outcome was extracted from the 2019–20 GDHS individual recode file which contained individual women’s data. The fistula module, which was included as part of the women’s questionnaire, asked women aged 15–49 years if they had ever heard of the phenomenon of urine or stool leaking from a woman’s vagina during the day and night, usually after a difficult childbirth, sexual assault, or pelvic surgery. In this analysis, the responses to the question (“have you ever heard about fistula?”) were dichotomous: Yes = ‘ever heard of fistula’ and No = ‘never heard of fistula’. The study considered 18 explanatory variables which were grouped into individual-level and household/community (contextual) level factors. The variables were determined based on the ecological model [21, 22] and through a review of previously published relevant studies, including systematic reviews and meta-analyses [17, 18, 23, 24]. Utilising an ecological model in a population-based study provides a unique contribution to knowledge on obstetric fistula awareness among reproductive-age women. Individual-level factors were the age of the woman, marital status, educational status, occupation, religion, health insurance coverage, parity, sexual experience, pregnancy status, ever terminated pregnancy, frequency of listening to radio, frequency of reading newspaper or magazine, frequency of watching television, owns a mobile telephone, and use of the internet. The age of the women was categorised as 15–19, 20–24, 25–29, 30–34, 35–39, 40–44, and 45–49 while marital status was coded as never married, married, cohabitation, widowed, and divorced. Educational status was coded as no education, primary education, secondary education, and higher education; occupation was recoded as not working, managerial, clerical/sales, agricultural, services, and manual while religion was recoded as Christianity and Islam. Health insurance coverage was categorised as ‘no’ and ‘yes’, parity was recoded as null (0), 1–3, and ≥ 4 while the sexual experience was recoded as ‘not had sex’ and ‘had sex’. The pregnancy status of the women was categorised as no = ‘not currently pregnant’ and yes = ‘currently pregnant’ while pregnancy termination was coded as no = ‘never terminated pregnancy’ and yes = ‘ever terminated pregnancy’. Frequency of reading newspaper or magazine, frequency of watching television, and Frequency of listening to radio were categorised as ‘not at all’, ‘less than once a week’, and ‘at least once a week’. The use of the internet was categorized as ‘never’, ‘yes, last 12 months’, and ‘yes, before last 12 months. The contextual level variables were selected based on the ecological model [21]. They included the sex of the household head, household wealth index, place of residence, and region. The sex of the household head was coded as ‘male’ and ‘female’ while the household wealth index was divided into five quantiles (poorest, poorer, middle, richer, and richest). The standard DHS data on ownership of household assets were used to compute the wealth index by selecting bicycles, television, house building materials, type of access to water, and sanitation facilities. The wealth index was generated from these assets through Principal Component Analysis (PCA). The PCA is a statistical procedure that is used to generate the wealth index by combining the household assets and grouped into five quantiles as stated above. The type of residence was coded as urban and rural while the region was categorized as Banjul, Kanifing, Brikama, Mansakonko, Kerewan, Kuntaur, Janjanbureh, and Basse [25]. The analysis was conducted using Stata software version 16.0 (Stata Corporation, College Station, TX, USA). Descriptive statistics were used to present the distribution of obstetric fistula awareness across the categories of the explanatory variables, and chi-square test (χ2) was performed to determine the crude estimates of the association between obstetric fistula awareness and the explanatory variables. Because the 2019–20 GDHS nested women within households and households within clusters, we used a multilevel logistic regression to assess the association between the individual and contextual level factors and obstetric fistula awareness among the women for the multivariable analysis. A total of four models were built. The first model (Model O) was fitted as an empty model (random intercept) without predictors. We fitted the individual level variables into the second model (model I). The third model (model II) included the contextual level variables while in the final model (model III) we fitted all the explanatory variables against obstetric fistula awareness. The multilevel logistic regression model comprised of fixed and random effects [26, 27]. Clusters were assumed as random effects to check for unexplained variability at the community level. The fixed effects showed the results of the association between the explanatory variables and obstetric fistula and were presented as adjusted odds ratios (aOR) with 95% confidence intervals. Intra Cluster correlation (ICC) was used to assess the random effects (measures of variation). The adequacy of the model was assessed using the loglikelihood ratio test while the Akaike's Information Criterion (AIC), and Bayesian Information Criteria (BIC) were used to evaluate model fitness. A multicollinearity diagnostic test was conducted and none of the explanatory variables had a high Variance Inflation Factor (VIF) necessary for exclusion (mini VIF = 1.02, max VIF = 3.47, mean VIF = 1.66). The sample was weighted (individual weight for women/1,000,000) to account for the unequal sampling of women from enumeration areas, and the survey set command in Stata was used in the analysis to account for the survey’s complex nature. Statistical significance was set at p < 0.05. We adhered to the guidelines outlined in the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) statement [28]. Ethical approval was not required for this secondary analysis. However, for the primary survey, the MEASURE DHS sought approval from the institutional review boards (IRBs) at ICF and The Gambia Government/Medical Research Council (MRC) Joint Ethics Committee in The Gambia before the commencement of data collection [2]. The MEASURE DHS approved our use of the 2019–20 GDHS data for this study.
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