Awareness on presentation of obstetric stula and associated factors among reproductive age women in south eastern zone of tigray,ethiopia,2020.cross sectional study

major causes of maternal mortality. Each year between 50000 to 100000 women worldwide are affected by obstetric stula. 605 respondents were asked about presentation of obstetric stula and around 31.6% of them had good awareness regarding presentation on obstetric stula. The major determinant factors identied to awareness on presentation of obstetric stula were, level of education (above secondary), having history having prior information about obstetric stula, institutional delivery (for the index child). In Conclusion; majority of reproductive age women in the study area had poor awareness regarding presentation of obstetric stula. Several interventions like health education and information should be implemented to enhance the awareness of the community towards risk factors for obstetric stula. CI-Condence CS-Cesarean section, CSA-Central Statistical Agency, EDHS-Ethiopia Demographic health survey, FGD-Focused Group Discussion, NGOs -None Governmental Organizations, OF-Obstetric Fistula, SBAs-Skilled Birth Attendants SPSS-Statistical package for social science, SSA-Sub-Saharan Africa, TBAs-Traditional Birth Attendants, VVF-Vesico- Vaginal Fistula, WHO-World Health Organization


Introduction
Obstetric stula is abnormal passage way between the vagina and bladder or rectum may develop after prolonged and obstructed labor and lead to continuous urinary or fecal incontinence (1). Obstetric stula can happen between the bladder and the vagina, between the rectum and vagina or both, leading to uncontrolled leakage of urine and/or feces (2).
The commonest type of obstetric stula is Vesico-vaginal Fistula (VVF) which accounts 79% of cases but there are also cases of Recto Vaginal Fistula (RVF) 1-8% and combined (VVF and RVF) 1-23 %.Obstetrics stula is related with numerous risk factors, and they appear to be escapable. This condition is related with young status at delivery, primi-parity, prolonged labor and home delivery (3).
In developed countries surgery and radiotherapy are the major risk factors for the situation, while obstetric complications are the main risk factors in developing nations, stulas are also found in other parts of the world where fertility is high, the economic status of women is low, and obstetric services are poor, such as in Afghanistan, Pakistan, Bangladesh and parts of India (4).
Globally, around one million girls and women are currently suffering from obstetric stula, Less than 20,000 women with obstetric stula are treated each year. Obstetric stula is a disease of poverty (5).Obstetric stula occurs in all developing countries especially in the Northern half of Sub-Saharan Africa from Mauritania to Eritrea and in the developing countries of the Middle East and Asia(6).
Obstetric stula prevention strategies classi es into primary prevention strategies (focused on contraception), secondary prevention strategies (ensuring women can access skilled care for delivery) and tertiary prevention strategies (early screening for stula for most at risk women. Fistula is treatable as well as preventable. The success rates of obstetric stula surgery in the literatures are between 70 to 90 per cent for simple stulas, and between 30 and 60 per cent for complex or complicated cases. The world is standing by declaring May 23 as the International Day to end obstetric stula and the decision to continue to use this Day each year to extensively raise knowledge and strengthen actions towards ending obstetric stula (7). Resolution adopted by the General Assembly on 25 September, 2015 (Sustainable Development Goal) states under Target 3.7: by 2030, ensure universal access to sexual and reproductive health-care services, including for family planning, information and education, and the integration of reproductive health into national strategies and programs(8).
Obstetric stula is a source of concern to medical practitioners in developing countries, awareness about it and the risk factors appear inadequate. There is need to appropriately inform women during their antenatal clinic visits about the risk factors for obstetric stula and where to nd care when faced with this challenge (9).
Obstetric stula is considered to be the most worrying morbidity that affects women following childbirth.
Medical consequences of stula include incontinence, infection and possibly infertility. Social consequences of stula are isolation, abandonment, disgrace and vulnerability (10).
Awareness is the ability to directly know and perceive, to feel, or to be heedful of events, More broadly, it is the state of being conscious of something (11).
Lack of awareness is a frequently mentioned barrier to seeking stula treatment; many women who suffer from obstetric stula do not know what stula is, that their condition is treatable, or where to get treatment. Women with stula and members of their community may also be misinformed about the causes of stula, in some communities stula is believed to be a curse or a punishment from God (12).
Occurrence of obstetric stula is highly related with lack of awareness (misperception) on risk factors of obstetric stula. Majority of respondents associated obstetric stula directly with mistakes made by hospital personnel or problems during procedures other than other risk factors and this perception reduces health seeking behavior (13) .
Many of women are not aware of how to prevent obstetric stula. If such women develop obstetric stula during the process of childbirth it is also di cult for them to get treatment since they may not even be aware that it can be treated (10) .
De ciency of knowledge on presentation of obstetric stula hinders seeking treatment (14).
Even though obstetric stula has likely weighed down women since the beginning of time, very little research proportionally exists. For obstetric stula, there is a desperate need for rigorous and ethical research(15).

Methods
Study setting Tigray regional state is one of the nine regional states of Ethiopia, which found in the northern part of Ethiopia. The capital city of Tigray is mekelle city which is 781 km far from Addis Ababa.
South eastern zone is one of the zones in the Ethiopian region of Tigray. It bordered on the south by southern zone, on the south east by Amhara region, on the north east by central zone, on the north by eastern zone and on the east by the Afar region. As the zone was created after the census of 2007, it is hard to nd correct data about the population of zone. The estimated size of population according to 2007 census conducted by the CSA was 392,142, of which 21,125 or 5.39% where urban dwellers(16).
South eastern zone contains four districts known as Endrta, HintaloWejerat, Samre and DeguaTemben and a total of 87 kebeles.In each woredas Endrta has 17 kebeles, Hintalo wejerat 23.Samre 23, and DeguaTemben has 25 kebeles and it has three primary hospitals,24 health centers and around 73 health posts.
The study was conducted from February 26-Murch 24/2020 in south eastern zone of Tigray.

Participants
Sampled Reproductive age women living in south eastern zone of Tigray and who ful ll the inclusion criteria were taken as the study population. All reproductive age group women who were mentally stable, those availabled at the time of data collection period, women who were not severely ill were included, While Reproductive age women who are health professionals or working on health and health related elds were excluded. Sample size determination and sampling technique The sample size was calculated using a single population proportion formula with the following assumption: Prevalence of awareness on risk factor for obstetric stula was 50% ,95% of con dence interval(1.96), 5% margin of sampling error tolerated, 5% of non-response rate, 1.5 design effect ,then the nal sample size was 605. Multistage random sampling technique was used to select the total of 605 study participants.
In south eastern zone of Tigray there are four districts namely Endrta, DeguaTemben, saharti samre and HintaloWejerat. For this study two districts were selected using simple random method. Within each selected districts there are 87 kebeles so it is di cult to include all of them rather 30% of the total kebeles were selected randomly.
Within each kebele there were list of households which has reproductive age group women. This list was used as sampling frame to use simple random sampling. Then the calculated sample size (605) was proportionally allocated to each selected kebeles.
In the case of two or more reproductive age women in the same household, one mother was selected using the lottery method.

Study Variables Dependent Variable Dependent Variable:
Awareness on presentation of obstetric stula Independent Variables Socio-Demographic factors (Age, marital status Religion, women education, occupation, age of marriage and residence).
Obstetric factors (history of contraceptive use, history of induced abortion history of pregnancy, history of ANC, site of previous delivery). Other factors (presence of health center, history of birth related complication, awareness on risk of complication, media exposure). De nition of terms Awareness Is a characteristics, outlook or understanding of an individual towards obstetric stula presentation. Good Awareness on presentation of obstetric stula Participants who scored mean score or above were assigned as they have good awareness on presentation of obstetric stula. Poor Awareness on presentation of obstetric stula Participants who scored less than the mean score were considered as having poor awareness on presentation of obstetric stula.

Data Collection Tools And Techniques
For data collection a structured face to face questionnaire English version was adapted after review of different literatures and modi ed depending on the local situation and the research objective. Initially it was developed in English and it was translated to Tigrigna by an individual who was native to Tigrigna language. And it was translated back to English language by another individual in order to maintain its consistency. The questionnaire contained questions on socio demographic characteristics, source of health related information, History of contraceptive use, obstetric history, questions on risk factors, presentation and prevention of obstetric stula. Three diploma midwife and four BSc level health professionals were recruited and trained as data collectors and 2 BSc level midwives were recruited& trained as supervisors. Eligible participants were approached and requested to consent voluntarily to participate into the study.
Upon consenting, a study number with a code was assigned for identi cation. Inclusion into the study was done by using proportion from the selected kebeles and then randomly select until the required sample size was achieved using face to face structured questionnaire. We have selected 12 kebeles randomly from the two districts and then random sampling technique was used to recruit households. List of house hold contains reproductive age a woman was used as sampling frame that is available with health extensions workers in each kebeles.The rst house hold was selected by lottery method. For those who were two or more eligible reproductive age women in one house hold lottery method was used to select one of them. Data quality assurance and control The data collection instrument was pretested for accuracy of responses, language transparency, correctness of data collection tools, estimate the time required and the necessary amendment was considered based on it prior to the actual data collection. It was carried out one week proceeding to the actual data collection period, in ve percent of non-study participants that ful ll the inclusion criteria. In addition, the data collectors were trained for one day on the techniques of data collection. The training

Socio-demographic Character of the study participants
In this study, 605 reproductive age women had interviewed and the response rate was 100%. The mean age and standard deviation of the respondents were 30.7±9.313 (range; 15-49 years). Around, 24% of participants who had Good awareness on presentation for obstetric stula were found in the age of 40-44 years. The result revealed that total of (90%) participants who had good awareness regarding presentation of obstetric stula were orthodox followers. Concerning marital status of respondents, around 103(54%) of participants who were found with good awareness on presentation of obstetric stula were married. It was found that 66(35%) of reproductive age women found with good awareness on presentation of obstetric stula were those with above secondary educational level. With regard to their occupation, 26% of respondents who had good awareness regarding presentation of obstetric stula were those government employed (Table 1) also included importance of disclosing the possible bene t and purpose of the study to the study participants before the start of data collection. Maintaining con dentiality of the participants throughout the whole process of data collection was discussed and ascertained during the training. The researcher was checked for completeness and consistency of questionnaires lled by the data collectors to ensure the quality of the data, and also visit the data collectors as many times as possible to check whether he/she collect the data appropriately. The researcher was also appraising the data during the data analysis stage to verify the completeness of the collected data. Data Processing and Analysis After data collection, Epi data version 4.2 was used for entry and then exported to SPSS version 20 for analysis. Binary logistic regression model was used to determine the factors associated with obstetric stula. Those variables which were clinically important and having a P<0.25 in bivariate analysis were the candidate variables for the nal multi-variable binary logistic regression model. The crude and adjusted measures of effect odds ratio were determined with 95%CI and P<0.05 was used to declare statistical signi cance. Goodness of t of the nal model was assessed using Hosmer and Lemeshow Goodness of t test and multicolinearity was checked. Finally the result was presented using tables, gures, and texts.

Obstetric factors
Three hundred eighty eight (64%) respondents were heard about obstetric complication, and from the total 165(86%) respondents who had Good awareness regarding presentation of obstetric stula were those participants who had ever heard about obstetric complication. About history of birth complication, 66(53%) of those who had good awareness on presentation of obstetric stula were those with history of birth complication. from the total study participants, 319(52.7%) of them used modern contraceptive, Of the total 135(71%) participants found with good awareness regarding presentation of obstetric stula were those who had history of modern contraceptive use.Around73.4% of reproductive age women had history of ANC, and 110(89%) of those found with good awareness on presentation of obstetric stula were those who had history of ANC follow up. This study has shown that (61.9%) of the respondents had history of institutional delivery, besides to that, 110(89%) of participants who had good awareness on presentation of obstetric stula were found with those participant who had history of institutional delivery. (Table2) Other factors for awareness on obstetric stula Four hundred eighty nine (80.8%) of the respondents were responsible in deciding to visit health facility by themselves. And 168(88%) of the study participants who had Good awareness on presentation of obstetric stula. Out of the total respondents, 345(57%) head of the house were husbands, and around 95(49.7%) of respondents who had good awareness on, presentation of obstetric stula were found to those husband head of house hold. All (100%) of the participants had health facility in their kebele, and about distance to reach health facility, 211 (35%) take them <=30 minute to visit health facility. About 81(42.4%) of respondents with good awareness on, presentation of obstetric stula were those who traveled <=30 minutes to reach health facility (Table3) General awareness on obstetric stula Reproductive age women who have ever heard about obstetric stula were 368(60.8%).And around 284(85%), 238(93%) and 170(89%) of study participants who had good awareness on prevention, risk factors and presentation for obstetric stula respectively were those who had prior information about obstetric stula. On source of information about obstetric stula, 196 (53.3%) was media and 129(54.2%), 96(56.5%) and 151(52%) of women with good awareness regarding risk factors, presentation and prevention for obstetric stula were got information from media. (Table4)

Discussion
Community based cross-sectional study was carried out to assess the awareness status on presentation of obstetric stula and associated factors among reproductive age women living in south eastern zone of Tigray regional state.
The nding of this study indicated the awareness status of reproductive age women on presentation of obstetric stula and the effect of reproductive age women's education, place of delivery for the index child and prior information about obstetric stula on awareness on presentation of obstetric stula.
About reproductive age women 31.6%(95%CI=28%-35%)had good awareness on presentation of obstetric stula; this result was lower than the study conducted in Ghana (17) which was 45.8%. But it was higher than a study conducted in Bangladesh(18) which was 12%.This difference could be due to difference in study setting, because the study in Bangladesh was conducted in rural areas where there is poor access to share health related information due to shortage of infrastructure. But our study was carried out including reproductive age women living in urban where there is expected to have good infrastructure and media to share information about obstetric stula.
Factors which affect awareness on presentation of obstetric stula were identi ed. Reproductive age women with higher than secondary level of education had statistically signi cant association with awareness on presentation of obstetric stula [AOR (95%CI=2.9(1.42-9.6)] as compared to women who were not educated. This nding was consistent with the study conducted in Ethiopia Oromia region (19).
Women who had history of institutional delivery had statically signi cant association on awareness on presentation of obstetric stula [AOR (95%CI=4.1(1.76-9.56)] as compared to those who had had experience of home delivery. This nding was also consistent with study conducted in Amhara region Ethiopia (20).
Moreover the odds of awareness were higher among those who prior heard about obstetric stula by 2.2 times as compared to those who did not hear before [AOR (95%CI=2.2(1.01-4.75)]. This might be justi ed as; having prior information about something can shape one's awareness, so those who ever heard about obstetric stula have better awareness.

Conclusions
Generally this study has disclosed that awareness on presentation for obstetric stula among reproductive age women was poor. Level of education, place of delivery for the index child, and prior information about obstetric stula were signi cant predictors for awareness of reproductive age women regarding presentation of obstetric stula.