Effectiveness of Community-level Intervention on Women’s Knowledge about Obstetric Fistula in Bench Sheko Zone, Ethiopia

Background: Obstetric stula is one of the most severe pregnancy-related disabilities. While the condition has disappeared in developed countries, it remains a source of concern in Ethiopia and serves as a proxy indicator of the status of Ethiopian women and the availability and access to quality maternal health services. Therefore, this study aimed to evaluate the effectiveness of a community-level intervention on women’s knowledge about obstetric stula in Bench Sheko Zone, Ethiopia 2020. Methods: Quasi-experimental design with comparison groups post-test only was employed in Semen Bench as an intervention and Guraferda Woreda as a comparison group of Bench sheko Zone from April, 1-30,2020. A multi-stage sampling technique was employed to select 284 women for intervention and 284 comparison group. Data were collected by using Kobo Collect v1.25.1. The descriptive and binary analysis was done to describe variables and select candidate variables for multivariable regression respectively. Multivariate regression analyses were performed to examine the effects of intervention by using Stata version 16.0. Result: The intervention group has a signicant difference when compared with the counterpart (p<0.001) on women’s knowledge of obstetric stula. Women who have good knowledge about obstetric stula were 69.7% and 30.4% from the intervention and comparison group respectively (p<0.001). Knowledge about obstetric stula was higher among respondent’s who can read & write (AOR=2.707:95% CI (1.433-5.686)), primary level of education (AOR=2.073:95%CI (1.266-3.395)), Secondary and above education (AOR=2.822:95%CI (1.338-5.952)) than women who have no formal education. Similarly, heard about obstetric complications (AOR=4.478:95% CI (2.635-7.610)), history of induced abortion (AOR=2.347:95% CI (1.203-4.576)), intervention woreda (AOR=2.707:95%CI (1.771-4.138)) attending pregnant women conference (AOR=0.06:95% of obstetric stula The of intervention on about Fistula.


Background
One of the most extreme and devastating childbirth injuries is obstetric stula. Long, obstructed labor without access to prompt, high-quality medical attention is caused by a hole between the birth cane and the bladder and/or rectum. It leaks urine, feces, or both to women and also contributes to chronic medical conditions, depression, social alienation, and deep poverty. (1).
Obstetric stula prevention techniques, according to the World Health Organization (WHO), include delaying the age of rst pregnancy; stopping unsafe conventional practices; and prompt access to obstetric treatment. Obstetric stula prevention and management lead to Sustainable Development Target 3 of improving maternal health (2). For a long time, obstetric stula has been known to be both preventable and often treatable, and this condition continues to affect a large number of young women in the developing world, a situation which creates problems with both economic resources and health services, especially in the area of maternal health. However, increased access to su cient prenatal and emergency obstetric care would enable more women to avoid obstructed labor that can sometimes contribute to stula (3).
The World Health Organization (WHO) reports that over 300 million women are currently suffering from short-term or long-term pregnancy or childbirth complications, with about 20 million new cases occurring worldwide each year.
Infertility, extreme anemia, uterine prolapse, and vaginal stula are problems. About 50,000-100,000 women are estimated to develop obstetric stula annually, with at least 33,000 of these in sub-Saharan Africa (2). In all developing countries, obstetric stulas are found. The majority of obstetric stulas, however, are limited to the " stula belt" from Mauritania to Eritrea and in the developing countries of Middle East Asia throughout the northern half of sub-Saharan Africa (4).
While the situation in developed countries has ended, it remains a source of concern in Ethiopia and serves as a proxy for the status of women in Ethiopia and the availability and accessibility of quality maternal health services. The most debilitating morbidity in pregnancy is obstetric stula. It mostly affects young, disadvantaged women who lack the resources for their families to access quality maternal care. In remote villages, several of these women remain concealed. As demand is much greater than the capacity of existing facilities, those who have access to surgical repair face long waits. Repair systems do not exist in certain places (5).
USAID 2013 issue analysis reports that there are between 36,000 and 39,000 women currently living with obstetric stula and that every year there are between 3,300 and 3,750 new cases of obstetric stula in Ethiopia. In Ethiopia, data on birth outcomes is not yet uniformly or routinely available due to the low rate of institutional deliveries, so this data was generated by modeling estimates (6).
Several barriers to the treatment of stula that function at the individual, neighborhood, and national levels. Therefore, the effective treatment of obstetric stula may require many challenges to be tackled, including depression, stigma and shame, lack of community-based referral systems, transport di culties, imbalances of gender power, reintegration of the community, and the con icting political objectives. A lack of stula awareness and knowledge is probably one of the most daunting obstacles (7). While in 2014, under the slogan "Ending obstetric stula and Transforming Lives by 2020," Ethiopia initiated a ve-year program on obstetric stula elimination. The Federal Ministry of Health is leading the development of an action plan to accelerate obstetric stula elimination by 2020 (8).
As the implementing partner, the Jimma University Fistula Care Project has focused on obstetric stula prevention and treatment. Training health professionals and key stakeholders of communities in efforts to improve awareness about obstetric stula prevention over the past seven years. The present study is, therefore, aimed Effectiveness of communitylevel intervention on women's knowledge about obstetric Fistula.

Study design and area
A quasi-experimental design with comparison groups post-test only was used. Intervention areas were purposively sampled to focus on kebele in each woreda that had exposure to the intervention. A classic method for supporting a counterfactual inference is to add a comparison group that received no intervention, with the comparison group selected to be as similar as possible to the intervention group. Indicators were selected by referring to the 2015 strategic plan(8), WHO Guideline (9). Finally, 22 indicators were selected. The evaluation was conducted in Semen Bench and Guraferda Woreda of Bench Sheko Zone of Southern Nations Nationalities and peoples Region, Ethiopia between April 1-30/ 2020 Sample Size determination and sampling technique The sample size was calculated using two population proportions formula by using G-power v3.1 software with the following assumption (10): Difference between two independent proportions by one-to-one allocation ratio and 80% power was used to detect a 15% difference in the proportion of women with knowledge of obstetric stula. Then after considering a 5% non-response rate and design effects of 2, the nal sample size was 564(282 from intervention and Page 4/16 282 from the comparison group). A multi-stage sampling technique was employed. In the rst stage for both groups, 30% of kebeles were selected by a simple random sampling technique. The sample size was proportionally allocated for each kebeles.

Data collection tools
A structured questioner was adapted from previously conducted studies in Eritrea, Guinea, Awi Zone, North West, Ethiopia for the sociodemographic and knowledge part of the study (10)(11)(12). The questionnaire includes three parts, background information, obstetric information, and, questions on obstetric stula. Knowledge of obstetric stula was assessed by evaluating responses to 22 questions on obstetric stula including the cause, risk factors, symptoms, prevention method, and treatment of obstetric stula.
Data Collectors were B.Sc. health professionals and supervisors were MSc Health Professionals outside of the study area to minimize bias. Data collectors and supervisors were trained for two days to be familiar with all types of data, tools, and data collection methods and objectives and one-day practical sessions on Kobo Collect. Data collection was done through face-to-face interviews by using Kobo collect. Female house head was primary respondents and in the absence of them, females age greater than 18 were interviewed. if both not present at the time of data collection revisit was made at least two times.

Intervention
The intervention(training) was given for key community leaders as maternal health volunteers. Key community leaders include kebele manager, religious leaders, health extensions workers, school director, Health Developmental Army (HDAs), Women and children affairs from kebele, district and zone, and health providers, woreda MCH Head, health center MCH focal person were trained at woreda level for 2 days. The key elements of the intervention were increasing obstetric stula identi cation, prevention, and treatment through women participation in pregnant women conferences, educating pregnant women and their husbands, and key community during home visits on early and complete ANC visits.

Data quality control
The data collection tool was translated into Amharic language and translated back to English to check its consistency. A pre-test was done on 5% of participants at Sheko woreda and modi cations were made in the nal version of the questionnaire. During data collection, completeness and consistency of information were checked by the supervisor and principal investigator daily. In this study, the reliability of knowledge measuring items was checked by calculating the Cronbach alpha (α). The Cronbach alpha, inter-item consistency (Cronbach alpha) for knowledge measuring tools of 22 items was 0.76. In light of the above-mentioned Cronbach's Alpha values, the measuring instrument is deemed reliable for both intervention and comparison groups.

Data processing and analysis
All data were electronically collected on-site and uploaded daily to the kobo server database using kobo collect v1.25.1(kobotoolbox.org). Database content was checked for missing answers, duplications, and inconsistencies. Then data were exported to Stata software version 16.0 for further analysis. Descriptive statistics were used to determine the frequency, mean, and proportions of variables. In bivariate logistics regression, a variable whose p<0.25 was considered as a candidate for multivariable logistic regression analysis.
And variables having p<0.05 after multivariable logistic regression analysis were considered as independent predictors for knowledge. Statistical signi cance was assessed using the chi-square test, odds ratios, and 95% CI, p values less than 0.05 used as cut off point for Statistical signi cance. Hosmer-Lemeshow goodness of t was used to check the goodness of the applied models (0.48). and the model adequately ts the data.

Operational de nitions
Knowledge: The knowledge was measured by 22 items. Mean was calculated to categorize it into two. Those who scored above the mean were considered as having good knowledge, and those who scored below the mean were considered as poor knowledge. Those women who de ne obstetric stula by describing at least one way were taken as know the de nition of obstetric stula. Those women who list at least one cause of obstetric stula was taken as know the cause of obstetric stula. Those women who list at least two risk factors of obstetric stula were taken as a known risk of obstetric stula. Those women who list at least two symptoms of obstetric stula were taken as know the symptoms of obstetric stula. Those women who list at least two prevention methods of obstetric stula were taken as know the prevention method of obstetric stula. Those women who answer at least two questions about obstetric stula were taken as know obstetric stula will be treated.

Sociodemographic Characteristics
Five hundred eighteen women (259 respondents from the intervention & 259 respondents from control groups) participated in the study with a response rate of 91.8%. The mean age of participants was 32.0 ± 9.8 and 30.9 ± 8.5 years old for the intervention and comparison group respectively. The mean age at marriage was 20.5 vs 19.2 years in the intervention and comparison group. One-hundred ve (40.5%) and 155(59.8%) had not attended formal education among intervention and comparison groups respectively. (Table 1).

Knowledge of obstetric stula
Concerning the source of knowledge most commonly cited sources about stula were health extension workers (63.7%) with P-value < 0.001), Media (23.8%), Family & friends (28.5%), and women who had been treated for stula (4.7%). One hundred twenty-three (49.4%) of those in intervention villages were able to list at least one cause of the obstetric stula, compared with 18.4% in comparison woreda. Among women who heard about obstetric stula, the proportion of women who perceive at least two or more risk factors of the obstetric stula was 139 (53.7%) versus 43(16.6%) of the intervention group and a comparison group respectively. percentage of women who able to cite 2 or more symptoms of obstetric stula were 140(54.1%) versus 53(20.5%) of the respondents from the intervention and the comparison group.
Concerning obstetric stula prevention, 135(52.1%) versus 35(18.9%) of participants were able to cite 1 or more ways to prevent stula from the intervention and the comparison group. This study shows that the proportion of women who know that obstetric stula will be treated as 124(47.9%) from the intervention group and 38(14.7%) respondents from the comparison group. (Table 3). 198(62.5%) have poor knowledge from the intervention and comparison group respectively. And the overall knowledge status of women difference between intervention and comparison is statically signi cant at p-value < 0.001. (Fig. 1)

Determinants of women knowledge status on obstetric stula
The bivariate analysis result shows the educational status of women, age at rst pregnancy, obstetric complication, history of induced abortion, modern contraceptive use, ANC for last pregnancy, know bene ts of institutional delivery, know danger sign during pregnancy and childbirth, know birth preparedness and complication readiness, place of delivery and Pregnant women conference were found to have a signi cant association (Table 4).
In Multivariate analysis, the result showed a signi cant association between age at rst pregnancy, pregnant women conference, heard about Obstetric complications, History of induced abortion, Educational status of women, and intervention. Women who were from intervention woreda have 2.7 of respondents from the intervention woreda have more likely to have good knowledge of obstetric stula than those from comparison woreda (AOR = 2.707:95% CI who had a greater than 20 years of age at rst pregnancy were 1.7 times more likely to have knowledge of obstetrics stula prevention than less than 20 years of age at rst pregnancy (AOR = 1.715:95% CI (1.0979-2.679)).
Those who were participated in pregnant women conferences were 18 times more likely to have knowledge of obstetrics stula than those not participating in pregnant women conferences (AOR = 9.6:95% CI (3.26-28.35)).

Discussion
This nding shows that women who have ever heard and describe obstetric stula were 54.1% and 25.9% from intervention and comparison groups respectively. This nding was higher than the study done in Burkina Faso, Guinea which is 36% and 34% (13,14) The difference might be due to the sample size, and the year of the study.
These ndings also underscore that women who had heard and were able to describe obstetric stula, 49.5% of those in the intervention area were able to list at least one cause of the condition, compared with 18.5% in comparison woreda.
These ndings are consistent with the evaluation of community-level stula prevention interventions in Guinea which show that women who had heard of and were able to describe obstetric stula, 48% of those in intervention villages were able to list at least two cause of the condition, compared with 32% in comparison villages (14).
This evaluation nding highlights the importance of increased attention to the risk of obstetric stula, and among women who had heard of obstetric stula; 46.3% from the intervention group and 15.1% from the comparison group knew at least two risk factors of obstetric stula. This nding is consistent with a study conducted in Ghana among prenatal clinic attendees show that perceived risk factors for obstetric stula included home delivery (80.5%), prolonged labor (67.3%), teenage pregnancy and delivery (50.4%) (15). The possible differences in the content of the intervention provided to the intervention woreda may have more effective in their knowledge raising activities whether through home visits/pregnancy women conference, community meeting, or through other awareness-raising activities, such as health education talks and community discussions.
Our nding shows that about half 52.1% of participants from the intervention group and 18.9% from the comparison group were able to cite one or more ways to prevent obstetric stula. The present evaluation nding is lower than a similar evaluation done in Guinea which reported that 96% vs 90% of women from the intervention and comparison area were able to list at least one way to prevent obstetric stula (14). This difference might be due to, study period, sociodemographic, including a diverse study population.
This nding revealed that knowledge of women on the treatment of obstetric stula shows that the majority 48% from the intervention group and only a few 15% of respondents from the comparison group know that obstetric stula will be treated. This study was consistent with a study conducted in Ghana on Knowledge of obstetric stula among prenatal clinic attendees on treatment for obstetric stula show that two-thirds 66.7% of the women who knew about obstetric stula agreed that the condition could be treated (15).
According to this study, the intervention effect caused a statistically signi cant difference in women obstetric stula knowledge as evidenced by the fact that respondents who received a community-based intervention had a good knowledge than that of those who did not have any intervention. The nding revealed that the overall knowledge status of women on obstetric stula was 69.7% and 30.4% were good knowledge and 37.5% and 62.5% were poor knowledge for intervention and comparison group respectively. This nding is similar to a study done in Ghana which shows that from mothers who had heard of obstetric stula, 37.2% had poor knowledge, 62.8% had good knowledge (15). This nding suggests that community intervention may have a bene cial effect on women's knowledge of obstetric stula.
Our study shows that knowledge of obstetric stula was higher among respondents who read & write only were twopoint eight higher than those who didn't attend formal education. women who have a primary level of education are two times more likely to know women who are no formal education. women who have a secondary school and above were two points eight times more likely to know women who have no formal education. This study agrees with the study done in Burkina Faso on obstetric stula knowledge (13). This might be those attending formal education have greater opportunities to get information, asking, and getting health services than those who hadn't attended formal education.
Mothers who had a history of induced abortion were two times more likely to have knowledge of obstetrics stula prevention than their counterparts. This nding is lower than the study in Burkina Faso those who had no history of pregnancy were less likely to have good awareness by 80% (10).

Limitations of the evaluation
It is very di cult to achieve in any study without drawbacks so there are possible limitations that may in uence the ndings while conducting this effectiveness evaluation; notably the lack of a comparable baseline study for analysis.
While the design of the study attempted to address this issue by using a seven-year reference period. The post-test study design does not allow for the analysis of changes since the inception of the program. Therefore, it is not possible to de nitively assume causality for differences found between women in the intervention and comparison group, many of these differences may have been pre-existing.

Conclusion
We evaluated the stula care project with a special focus on its community-based activities to improve awareness and knowledge on obstetric stula. This nding highlights community-level intervention can successfully increase women's knowledge of obstetric stula. Almost more than half of women in the intervention area have good knowledge about obstetric stula cause, and able to list at least two causes, risk, symptoms, prevention, and treatment of the condition.
Thus, a signi cant change was apparent in the intervention area, and show that the effects may be even greater as the intervention continues. Still, there is a gap in knowledge of obstetrics stula; therefore, it is good to scale up the intervention on providing information on safe motherhood issues, particularly about obstetrics stula in all woredas. Figure 1 Overall knowledge status of women in Bench Sheko Zone, Ethiopia,2020 (n=518). Chi-square test, p < .05 is statistically signi cant