The present study determined the level of women’s knowledge on obstetric fistula and its associated factors in northwestern Ethiopia. Only one-in-three women, 36.4% %;95% CI: 32.9%-39.7%) were found to be knowledgeable about obstetric fistula in the study area. Women's level of education, women's occupation, counseling about obstetric fistula, participation in pregnant women’s conferences, ANC follow-up, residence, and having access to mass media remained as predictors of women’s’ knowledge about obstetric fistula.
This prevalence of knowledge level of obstetric fistula is in line with the study conducted in Burkina Faso (36%) . However, the present study finding is higher than studies reported from Ghana (29%)  and Cameroon (23.2 %) . This difference might be attributed to variation in the study nature, sociodemographic characteristics of participants of the study, and differences in sample size, for instance, small study participants were enrolled in the study reported from Ghana. In contrary, the finding of this study is lower than the studies done in Nigeria (57.8%) , and in Ethiopia: Benchesheka zone (40.8%) , and the Southeastern zone of the Tigray (41.2%) .
In this study, the educational level of the women was significantly associated with the odds of having knowledge about obstetric fistula. Accordingly, women who attended primary education, and secondary education and above were 3.47 and 3.30 times more likely knowledgeable about obstetric fistula as compared to women who cannot read and write. This finding is consistent with previous studies reported from Ghana  Burkina Faso , and the Benchesheka zone, Ethiopia , and the Southeastern zone of the Tigray region . It is now widely accepted that keeping girls in schools, especially, ensuring that they complete at least primary education, contributes to women empowerment, curtails harmful traditional practices such as child marriage, promotes gender equality and reduces incidences of maternal morbidity and mortality, including obstetric fistula [33, 34]. Education, even at the basic level, provides an opportunity to realize obstetric fistula and reduces gaps in knowledge about fistula, and prevents its occurrence. Furthermore, schooling even basic primary education has long been noted as an important medium for propagating health information, especially sexual health education .
Consistent with the previous study , the occupation of the women is significantly associated with the women's knowledge level about obstetric fistula. In doing so, the odds of being knowledgeable about obstetric fistula were 6.78 times more common among participants who are students by their occupation compared to those who are farmers. This might be due to students might take information from their teachers, school relatives and courses about obstetric fistula or, students can easily understand the concept through reading.
The finding of this study noted that women who had ever participated in pregnant women conferences were 3.36 times more likely knowledgeable about obstetric fistula as compared to their counterparts. The finding of this study bears similarity with a study conducted in the Benchesheka zone, Ethiopia . This is due to the fact that the pregnant women's conference is one of the widely recognized platforms, where health personnel provide health information about the broad spectrum of maternal heath in the form of health education.
According to this study, the knowledge level of obstetric fistula is significantly associated with counseling about obstetric fistula. Women who get counseling about obstetric fistula were about six times more likely knowledgeable about obstetric fistula as compared to their counterparts. This is explained by receiving counseling services about obstetric fistula increase in women’s knowledge about obstetric fistula and fistula prevention, speaks to the benefit of having one-on-one counseling with a trained individual during which perceptions and misconceptions can be addressed. In addition, counseling creates a conducive environment for clients to develop goals for health preservation and dissemination of information about fistula within their communities that they did not have before counseling .
According to this study, the knowledge level of obstetric fistula is higher in urban areas (75.9% in urban vs 33.4% in rural). This finding is in line with the study conducted in Burkina Faso . This might be due to being an urban resident would offer a chance to access information about health and health-related issues including awareness about obstetric fistula, as most of the health facilities are confined to urban areas. On the other hand, women living in rural areas could have lower access and exposure to mass media which might further reduce their level of awareness and knowledge on health-related issues .
It is important to note that mass media such as TV, radio, and newsletters have become a significant source for raising awareness of the community about health and health-related issues including obstetric fistula. Exposure to media communication also increases the uptake of maternal health services these services directly create an opportunity for promoting health education in various regards . Similarly, this study found out that, women who have access to TV/radio were 1.68 times more likely knowledgeable about obstetric fistula as compared to their counterparts.
Having antenatal care follow-up is another determinant factor for knowledge of obstetric fistula among women of reproductive age. Accordingly, the odds of knowledge about obstetric fistula were 2.4 times more common among women who have antenatal care follow-up as compared to those who haven’t antenatal care follow-up. This finding is in congruent with the study conducted in India , Ghana , Benchesheka zone, Ethiopia [37, 42]. This is due to the fact that utilization of maternal health care services such as ANC is an entry point for women to have a greater opportunity to be exposed to health education and to dissemination structured and targeted messages on the health of women and utilization of ANC services that also targets information about obstetric fistula.
Strength and limitation of the study
This study was conducted at the community-based house-to-house level, comprised of both urban and rural resident participants, applied probability sampling method with a scientifically sound approach for sample size determination for generalization can be taken as strength of the study. Despite this strength, the cause-and-effect relationship may be affected by temporality issues due to the nature of the cross-sectional study design and the response of participants might be affected by recall bias.