Awareness of obstetric fistula and its associated factors among reproductive-aged women: Demographic and health survey data from Gambia

**Background:** Obstetric fistula is a devastating childbirth injury caused by prolonged labor without timely medical care, leading to continuous leakage of urine or feces. It affects an estimated 500,000 women globally, predominantly in Sub-Saharan Africa, Asia, and Latin America. Despite being largely preventable and treatable (up to 90% success rate), awareness of the condition remains low in many settings. This study aimed to assess the level of obstetric fistula awareness and identify associated factors among Gambian women of reproductive age.

**Methods:** The study used women's data from the most recent Gambia Demographic and Health Survey (DHS), employing a descriptive cross-sectional design with two-stage cluster sampling. A total of 11,864 women of reproductive age with complete data on all variables of interest were included. The outcome variable was awareness of obstetric fistula, derived from the question "have you heard about fistula?" (dichotomized as yes/no). Seventeen explanatory variables were selected based on literature and DHS data availability, grouped into individual factors (age, education, marital status, religion, employment, parity, wealth index, media exposure, sexual activity, pregnancy status, pregnancy termination) and contextual factors (residence type, region, community literacy level, community poverty level). Pearson chi-square tests and binary logistic regression (bivariate and multivariate) were performed using Stata version 16.0, with weighting applied to account for the complex survey design.

**Key Results:** The study found that 87.2% of Gambian women had never heard of obstetric fistula, with only 12.8% reporting awareness. Awareness increased with age: 6.1% among women aged 15–19 versus 20.1% among those aged 45–49. In the fully adjusted model (Model II), women aged 45–49 were more than twice as likely to be aware of fistula compared to those aged 15–19 (COR = 2.19, 95% CI: 1.55–3.10). Education was the strongest predictor: women with higher education had 3.54 times the odds of awareness compared to those with no education (COR = 3.54, 95% CI: 2.74–4.59). Working women had 43% higher odds of awareness than non-working women (COR = 1.43, 95% CI: 1.25–1.64). Unmarried women were 30% less likely to be aware than married women (COR = 0.70, 95% CI: 0.53–0.92). Women who had ever terminated a pregnancy had 21% higher odds of awareness (COR = 1.21, 95% CI: 1.06–1.40). Media exposure was also significant: women who read newspapers less than once a week had 30% higher odds (COR = 1.30, 95% CI: 1.06–1.58), and those who listened to radio at least once a week had 19% higher odds (COR = 1.19, 95% CI: 1.02–1.39) compared to those with no exposure. Regionally, women in Juntaur (COR = 1.92, 95% CI: 1.39–2.65) and Mansakonko (COR = 1.60, 95% CI: 1.17–2.18) had higher odds of awareness compared to Banjul.

**Clinical Implications:** The extremely low awareness of obstetric fistula in The Gambia (12.8%) represents a major barrier to prevention, early detection, and treatment-seeking behavior. Given that surgical treatment success rates reach up to 90%, the lack of awareness means many affected women remain untreated and continue to suffer from medical complications, social isolation, and psychological distress. The findings suggest that public health interventions should prioritize increasing community literacy rates, expanding access to mass media platforms (particularly radio and newspapers), and investing in formal education for women. Targeted health education programs should focus on younger women, unmarried women, those with lower education, and those in regions with particularly low awareness (e.g., Janjanbureh at 7.7%). Integrating obstetric fistula awareness into routine maternal health services, antenatal care, and family planning counseling could leverage existing healthcare contacts to disseminate information.