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Abstract
Background According to the WHO, obstetric fistula (OBF) is an abnormal connection between the genital tract and the urinary tract that occurs as the result of obstetric trauma, typically from prolonged obstructed labour. In 2018, globally, 50 000 and 100 000 cases of OBF are reported each year. The core of activities focused on reducing fistulas depends on a review of the disorder’s knowledge and the features of women at risk of having a lack of understanding. The effect of community-level factors on awareness of OBF was not yet known in Nepal. Therefore, we aimed to investigate the community-level and individual-level factors of awareness of OBF among childbearing-aged women in Nepal.
Methods The 2022 Nepal Demographic and Health Survey data were used for this study. It included 14 845 childbearing-aged women. Because of the clustering effects of Demographic and Health Survey data and the binary nature of the outcome variable, a multilevel binary logistic regression model was applied. An adjusted OR (AOR) with a 95% CI was reported to declare the statistical significance. In addition, the model that had the lowest deviance was the one that best fit the data.
Results The overall prevalence of awareness of OBF among childbearing women in Nepal was 35.9% (95% CI 35.1%, 36.7%). Educational status (women who attended secondary education (AOR=1.65; 95% CI 1.41, 3.03) and higher education (AOR=4.29; 95% CI 1.14, 36.70)), currently working status (AOR=1.85; 95% CI 1.04, 3.30), birth history (AOR=2.23; 95% CI 1.48, 4.10), media exposure (AOR=1.54; 95% CI 1.07, 3.09) and women’s age from 30 to 39 (AOR=3.38; 95% CI 1.35, 8.93) and 40 to 49 years old (AOR=4.68; 95% CI 1.60, 13.67) at the individual level, as well as urban residence (AOR=1.53; 95% CI 1.99, 2.87) and high community-level media exposure (AOR=2.05; 95% CI 1.67, 2.64) at the community level were statistically significant factors with awareness of OBF.
Conclusion Our study revealed that awareness of OBF among childbearing-aged women in Nepal was low (35.9%). The findings of this study will assist policymakers and public health programmers in understanding the magnitude of OBF awareness and the contributory factors. In addition, it will be useful to increasing awareness of OBF in the communities and promoting primary prevention approaches through education and motivation efforts.
- Nepal
- reproductive medicine
- maternal medicine
- health informatics
- epidemiology
Data availability statement
Data are available in a public, open access repository. The permission to get access to the data was obtained from the MEASURE DHS programme online request from http://www.dhsprogram.com website and the data used were publicly available with no personal identifier.20
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
A large nationwide survey data were used which gave it sufficient power to identify the real impact of the independent factors.
Second, to obtain accurate estimates and SEs, the sample weight was applied during the analysis.
One weakness of the study is its cross-sectional nature which is difficult to determine the temporal relationship.
Because it depends on self-reported data, it is vulnerable to recall bias and sensitive to report.
Introduction
WHO defines obstetric fistula (OBF) as an abnormal connection between the genital tract and the urinary tract (urogenital fistula) or the gastrointestinal tract (most commonly rectovaginal fistula) that occurs as the result of obstetric trauma, typically from prolonged obstructed labour.1 It is caused by labour that is complicated or delayed along with not having access to rapid and high-quality medical care. It causes women and girls to leak fluids (pee or faeces) and it often results in long-term medical problems, despondency, loneliness and suffering.2 Women have problems during pregnancy and deliveries, which might result in the mother or infant dying.3 The WHO has established preventative measures for OBF awareness to reduce it. These strategies involve facilitating early utilisation of obstetric care, postponing the age of the mother’s first childbearing and doing away with damaging customs like female genital mutilation.4
OBF in low- and middle-income countries is usually caused by protracted, obstructed labour without quick access to high-quality medical care.5 Numerous misconceptions exist regarding OBF in low- and middle-income countries and the majority of fertile women believed that the disease was caused by punishment by God and that unfortunate events, evil spirits or socially unacceptable actions by women could also cause it.6–8 While OBF can occur in both high-income and low-income countries, the majority of the burden of OBF occurs in low- and middle-income countries.9 It had disastrous impact on the health and well-being of women on an interpersonal, financial and emotional level.10 11 Fistula-related shame, profound sense of loss and diminished sense of identity and dignity have a detrimental effect on quality of life.11 12 OBF is one of the most severe and disastrous birth injuries and approximately 2 million women have untreated obstetrical fistulas in developing countries.13 14
According to a WHO report in 2018, globally each year between 50 000 and 100 000 cases of OBF were reported.15 A systematic review and meta-analysis on awareness of OBF among women revealed that 41.24% were aware of the condition.16 OBF awareness ranged from 12.8% to 63.9% in Uganda, with an average prevalence of 37.9%.11 Among the women, 53% have heard of OBF at some point and 34.6% got awareness about the condition from different sources.17 The prevalence of OBF among pregnant mothers in Nepal was 57.8%.3 Despite these moderating variables, the primary cause of women’s refusal to seek fistula care is their general awareness of how to avoid and take care of OBFs. Many young girls still silently suffer the pain of OBF as a result of early marriage, low socioeconomic standing and inadequate access to medical services.18 Numerous factors associated with OBF incorporated marital status, religion, age, educational status, family wealth index, internet access, birth history, pregnancy termination, sexual activity, current working status, media exposure and current pregnancy status.9 16 18
Raising awareness of OBF could result in more funding for treatment and avoidance from organisations and encourage more partnerships with other stakeholders.19 The creation of national outreach efforts for OBF and the core of activities focused on reducing fistulas depends on a review of the disorder’s knowledge and the features of women at risk of having a lack of understanding. Women, who are not aware of OBF, might not seek treatment and they can develop further complications, and the absence of awareness even affects the healing process due to not caring for themselves. To the best of our search, there is no study conducted in Nepal about awareness of OBF among childbearing women. Despite the high burden of OBF in reproductive-aged women, no nationally representative studies were conducted particularly in Nepal. Therefore, this study aimed to determine the prevalence and factors associated with the awareness of OBF among women of reproductive age in Nepal at the individual and community levels using recent national representative data or the Nepal Demographic and Health Survey (NDHS).
Methods
Data source, population and sampling procedure
We used the recent NDHS (2022) data after a reasonable request from the MEASURE DHS programme available at the link (https://dhsprogram.com/Data/terms-of-use.cfm).20 The Demographic and Health Survey (DHS) is conducted every 5 years to generate updated health and health-related indicators. The 2022 DHS data of Nepal included a total of 14 sampling strata with proportional allocations. Initially, 476 primary sampling units (PSUs) (248 from urban and 228 from rural) were selected with probability proportional to PSU size and with independent selection in each sampling stratum within the sample allocation. Second, 30 households were selected from each cluster for a total sample size of 14 280 households (7440 from urban and 6840 from rural). All women aged 15–49 who were permanent residents of the selected households or were visitors who stayed in the households the night before the survey were eligible to be interviewed. In half of the households (every second household) selected, all men aged 15–49 who were residents of the selected households or visitors who stayed in the household the night before the survey were eligible to be interviewed. The data were derived from the MEASURE DHS programme and detailed information about the surveys can be found in each country’s DHS reports. A multistage stratified sampling technique was employed to select the study subjects. In the first stage, 476 enumeration areas (EAs) were randomly selected, whereas in the second stage, households were selected. There are different datasets in DHS, and for this study, we used the individual record (IR) file. The dependent and independent variables were extracted from the IR dataset, based on the literature. The final weighted sample size was 14 845.
Study variables
Outcome variable
The outcome variable of this study was women’s awareness of OBF. The variable was dichotomised into 1=‘ever heard of fistula’ and 0=‘never heard of fistula’.7 9
Independent variables
The independent variables were further classified into individual-level (level 1) variables and community-level (level 2) variables.
Individual-level variables
Individual-level variables included age (15–19, 20–29, 30–39, 40–49), marital status (unmarried, married), religion (Hindu, Buddhist, Muslim, others), educational status (no education, primary, secondary, higher), sex of household head (male, female), media exposure (no, yes), internet use (no, yes), wealth index (poorest, poorer, middle, richer and richest), sexual experience (never had sex, had sex), birth history (yes, no), pregnancy termination (yes, no), current working status (yes, no) and current pregnancy status (yes, no).
Community-level variables
Community-level variables involved variables directly taken with no aggregation (residence) and variables obtained by aggregating individual values into their respected community (community poverty (low, high), community female education (low, high) and community media exposure (low, high)). Since the aggregate values of each variable did not follow a normal distribution curve, we categorised the aggregate values of a cluster into groups based on median values.
Statistical analyses
STATA V.16 statistical software was used for data management and analysis. Descriptive analysis was performed using frequency and percentage distributions to examine the characteristics of respondents. A multicollinearity test was performed using variance inflation factor for all individual-level and community-level variables which was greater than 10. Missing data were handled by imputation for categorical variables imputed by mode (highest frequency) and for continuous variables imputed by mean or median after checking the normality of the data. Model fitness was checked using the Hosmer-Lemeshow test with a value of 0.78, which shows the model is fitted.
We developed four different models using the multilevel logistic regression (MLLR) methodology to see whether the community-level and individual/household attributes had any significant connections with the outcome variable (awareness of OBF). The initial model, known as model I, was a null model empty of any explanatory variables, and it represented variation in the awareness of OBF. The second model (model II) comprised individual/household-level factors and the third model (model III) comprised community-level factors. The last model (model IV) was the complete model that included factors at both the individual/household and community levels. Finally, in model IV, variables were considered statistically significant association with awareness of OBF when p values were less than 0.05 with the 95% CIs and adjusted OR (AOR).
All four MLLR models included fixed and random effects.21 22 The random effects model revealed the degree of variation in the outcome variable dependent on PSU, which was assessed by intracluster correlation (ICC), while the fixed effects model demonstrated the relationship between the explanatory variables and the outcome variable.23 The model fitness was assessed using the Akaike information criterion (AIC).24 When individuals are randomly selected from two clusters (EAs), the median value of the OR (MOR) between the cluster with a high likelihood of awareness of OBF and the cluster at lower risk is used to quantify the variation or heterogeneity in awareness of OBF between clusters in terms of the OR scale.
.25
where ∂2 indicates the cluster variance. We used ‘melogit’ command to run the MLLR models. The analyses were performed using Stata V.14 software (StataCorp, College Station, Texas, USA). We also followed the guidelines for Strengthening the Reporting of Observational Studies in Epidemiology.26
Patient and public involvement
Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Results
Background characteristics of respondents
A total of 14 845 reproductive-aged women were included in this study. Over two-thirds (34.17%) of women were found in the age group of 20–29 years, followed by the age group of 30–39 years (4169, 28.1%); and most of the women (39.1%) had attained secondary education. More than half of women (54.02%) lived in urban areas, and the majority of women (78.88%) had media exposure (table 1).
Distribution of the study population by sociodemographic and reproductive-related characteristics (n=14 845)
Awareness of OBF
The overall awareness of OBF among women of childbearing age in Nepal was 35.9% (95% CI 35.1% to 36.7%).
Factors associated with awareness of OBF among childbearing-aged women in Nepal
In the multivariable mixed effects binary logistic regression model, a woman’s age, educational status, current working status, birth history and media exposure were significant individual factors, while place of residence and community-level media exposure were found to be statistically significant factors from community-level factors of awareness of OBF among Nepal childbearing-aged women (table 2).
Multilevel analysis of factors associated with awareness of OBF among women of childbearing age in Nepal, 2022 (n=14 845)
This finding showed that women between 30 and 39 years old (AOR=3.38, 95% CI 1.35 to 8.93) and between 40 and 49 years old (AOR=4.68, 95% CI 1.60 to 13.67) were more likely to be aware of OBF than those who were at younger age group. The odds of awareness of OBF were higher among women who attended secondary education (AOR=1.65; 95% CI 1.41, 3.03) and higher education (AOR=4.29; 95% CI 1.14, 36.70) compared with those with primary level or less. Women who have currently worked were 1.85 times more aware of OBF than women who are not currently working. The odds of awareness of OBF were increased by 2.23 times among women who had a birth history than their counterparts. Women who had media exposure were 1.54 times more likely to have awareness of OBF than women who had no media exposure (AOR=1.54; 95% CI 1.07, 3.09) (table 2). Regarding community-level factors, we found the awareness of OBF among urban resident women was 1.99 times (AOR=1.99, 95% CI 1.53, 2.87) higher than women who reside in rural areas. Higher odds of awareness of OBF were found among women from high community-level media exposure (AOR=2.05, 95% CI 1.67, 2.64) compared with those from low community-level media exposure (table 2).
Random effects (measures of variations) results
The random effects models of the individual/household and community-level factors associated with awareness of OBF are shown in table 3. We observed that the values of the AIC and deviance decreased across the models, indicating the best fitted model was chosen based on the lowest deviance value (562.0504) and AIC (616.0504). The ICC in the null model was 16.0%, indicating that 13.6% of the overall variability for awareness of OBF was related to variations between clusters/EA. In addition, the MOR for awareness of OBF in the null model was 2.54, indicating that there was variability between clusters. If we randomly selected an individual from two different clusters, those in the cluster with a high awareness of OBF had 2.54 times the odds of having awareness of OBF compared with those in the cluster with a lower awareness of OBF. These estimates showed that the variations in the likelihood of awareness of OBF can be attributed to the variances in the clustering at the PSUs (table 3).
Random effects results for awareness of OBF and its individual and community-level factors: evidence from NDHS (n=14 845)
Discussion
OBF is a problem that is frequently disregarded in terms of human rights and public health. This study aims to reveal the prevalence and associated factors of OBF among reproductive-aged women in Nepal. The overall prevalence of OBF among reproductive-aged women was 35.9% (95% CI 35.1% to 36.7%). This finding is in line with other studies conducted in Burkina Faso (36%).27 The implication of this study is to provide a clue for the clinicians and physicians who help them deliver awareness creation programmes for their clients. This finding can create huge implications for the policymakers to have different ceremonies related to creating awareness about OBF.
The finding of this study is lower than other studies conducted in Ethiopia (40.8% and 38%),9 28 Nigeria (57.8%)3 and sub-Saharan Africa (40.85%).6 The probable reason of the association might be a lower number of modern healthcare systems and low educational status in Ethiopia.9 28 The other reason for the difference might be the effect of population and culture differences that might lead to the difference in awareness of OBF.6 In other words, this finding is higher than other studies conducted in Gambia (12.9%).29 The reason for this discrepancy might be the effect of the difference in the population that women who have OBF may not know about potential treatment choices, which could cause them to live with the problem untreated at residence.29
As regards factors, higher age was one of the factors associated with awareness of OBF. This finding is in concordance with other studies conducted in Gambia.29 The possible reason for the association might be the effect of the basic idea that a woman will have greater exposure to giving birth and dealing with the challenges that come with it as she grows older.29 The other probable reason for this association could be the impact of the high education, and changing unhealthy habits in a formal education enables women to make better healthcare decisions.
A higher level of education is also another factor associated with awareness of OBF. This finding is in line with other studies conducted in sub-Saharan Africa.7 This is because formal education gives women the authority to choose their healthcare providers, like going to maternal health education forums and obtaining obstetric counselling which raises their awareness of OBF.7 Furthermore, compared with younger women, older women are more likely to have completed higher education. Women who have more knowledge are more likely to use and have access to healthcare information.8
Mass media exposure is one of the factors associated with awareness of OBF in Nigeria,30 Ethiopia9 and sub-Saharan Africa7; likewise, it is associated with our study. The possible reason for this association might be the fact that the mass media plays a significant role in the distribution of information regarding OBF and treatment availability.30 This is because media has the essential function in transferring knowledge, including details about OBF, symptoms and treatment modality.9 The finding is most likely attributable to the media’s crucial role in spreading information, including details about OBF, its symptoms and where to get treatment.30 The other factor significantly associated with OBF awareness was birth history. This finding is in concordance with other studies conducted in Ethiopia.28 The possible reason for this association would be that more expertise in obstetrics and parenting correlates with increased parity.28 Every delivery enhances women’s knowledge by providing them with information concerning obstetric complications, including OBF.7 Additionally, women who were single or living together had lower OBF knowledge rates than married women.
The other factor associated with OBF awareness was urban residence. This finding is in line with other studies conducted in Gambia29 and Burkina Faso.27 The probable reason for the association differs from several related studies which suggest that public knowledge is higher in urban residence.29 However, women in rural areas might not have as much access to or experience with mass media, which could further limit their level of understanding and knowledge of medical issues.31 The other possible reason for this association might be due to the effect of the urban participant’s exposure to mass media and other information about the awareness of OBF. Having occupations is another factor that was associated with OBF awareness. This association is similar to other studies conducted in Ethiopia.28 This is because one of the well-known venues where medical professionals offer health education regarding maternal health is the pregnant women’s discussion forum.28
Strengths and limitations of the study
One of the study’s advantages was that it used data from a large nationwide survey, which gave it sufficient power to identify the real impact of the independent factors. Second, to obtain accurate estimates and SEs, the sample weight was applied during the analysis. Furthermore, by examining the awareness of OBF at the household, and community levels, we were able to investigate hierarchical or clustered patterns that might have an impact on results. One weakness of the study is that it was cross-sectional; therefore, it was not possible to establish a causal relationship between the identified independent variables and the awareness of OBF. Because it depends on self-reported data, the DHS is vulnerable to recall bias.
Conclusion and recommendation
In this study, the overall awareness of OBF among childbearing-aged women in Nepal was 35.9%. Women’s age, educational status, working status, birth history and media exposure were significantly associated at the individual level; also, media exposure and residence were found to be statistically significant associated factors from community-level factors with awareness of OBF among Nepal childbearing-aged women. The findings of this study will assist policymakers and public health programmers in understanding the magnitude of OBF awareness and the contributory factors. In addition, it will be useful to increasing awareness of OBF in the communities and promoting primary prevention strategies through education and motivation efforts. Awareness creation and enhancement of the level of education is recommended by the Nepal government. It is also recommended that future researchers employ an advanced methodology that can provide practical indicative solutions for awareness of OBF.
Data availability statement
Data are available in a public, open access repository. The permission to get access to the data was obtained from the MEASURE DHS programme online request from http://www.dhsprogram.com website and the data used were publicly available with no personal identifier.20
Ethics statements
Patient consent for publication
Ethics approval
All methods were performed according to the relevant guidelines and regulations. This study did not require ethical approval or participant consent because it was a secondary data analysis of publicly available survey data from the MEASURE DHS programme. We have obtained permission to download and use the data from http://www.dhsprogram.com for this study. There are no names or addresses of individuals or households recorded in the datasets.
Acknowledgments
The authors thank MEASURE DHS for their permission to access the NDHS datasets.
Footnotes
Contributors BMF conceived the idea. HAA, ZAA, AAA, YMN, BLS and MM participated in the analysis process. BMF wrote the first draft of the manuscript. Writing review and editing were done by HAA, ZAA, AAA, YMN, BLS and MM. All authors have read and agreed to the final version of the manuscript. BMF is the guarantor for the study.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.