Knowledge of obstetric fistula among prenatal clinic attendees and midwives in Mfantsiman municipality, Ghana

Abstract Objective To determine obstetric fistula knowledge among prenatal attendees and midwives in Mfantsiman municipality, Ghana. Methods An analytical cross‐sectional study was conducted among prenatal clinic attendees and midwives in Mfantsiman municipality from March to April, 2016. Women were selected by systematic sampling and consenting midwives were recruited. Respondents were interviewed using a pretested structured questionnaire. Data were analyzed using the χ2 test and Poisson regression with a robust error variance to generate relative risks (RRs) with 95% confidence intervals (CIs). P<0.05 was considered statistically significant. Results Altogether, 393 prenatal attendees and 45 midwives were studied. Mean age of attendees was 28.1 ± 7.1 years. About 29% of prenatal attendees knew of, 37.2% had poor knowledge of, and 56.6% had some misconceptions about obstetric fistula. Women who had attained some level of education (P trend=0.001), were employed (adjusted RR 4.92; 95% CI, 1.98–12.21), or had given birth before (P trend=0.01) were more likely to have heard of obstetric fistula. All midwives knew of obstetric fistula and its preventive measures; however, up to 73.3% had some misconceptions about it. Conclusion Educating prenatal attendees and organizing regular refresher courses on obstetric fistula for midwives should be a priority in the municipality.

Africa. 1 A recent survey estimated the annual incidence of obstetric fistula in Ghana to be 1.6-1.8 per 1000 deliveries, with the Central Region having one of the highest incidence rates. 5 These are largely deemed to be underestimates, as most cases go unreported owing to the associated stigma. 1 Access to a skilled birth attendant at delivery and emergency obstetric care are critical for preventing obstetric fistula. Although prenatal clinic attendance is very high in Ghana (97% for at least one visit), the number of deliveries conducted by skilled birth attendants is much lower (74%). 6 Up to 30% of deliveries in the Central Region (where the study was conducted) take place outside a health facility despite high prenatal care attendance rates. 6 Supervised delivery rates could be improved if expectant mothers understood the complications associated with prolonged and obstructed labor, including fistula. There are limited data on knowledge of obstetric fistula among prenatal clinic attendees and healthcare providers in communities in Ghana where the condition is prevalent, such as Mfantsiman municipality. This municipality has the highest prevalence of obstetric fistula cases in the Central Region. The aim of the present study was to assess knowledge of obstetric fistula among prenatal clinic attendees and midwives in Mfantsiman municipality.

| MATERIALS AND METHODS
An analytical cross-sectional study was conducted among prenatal clinic attendees and midwives at the two main hospitals (District and Mercy Women's Hospital) and all five health centers in Mfantsiman municipality, Ghana, from March 15 to April 30, 2016.
Mfantsiman municipality is located on the Atlantic coast of the Central Region, comprising around 300 km 2 . Its administrative capital is Saltpond. The municipality has a total population of 144 332, of which 55% is female; approximately 50% (39 402) of the female population is of reproductive age (15-49 years). 7 Nearly two-thirds (65%) of the population live in urban localities and the remaining 35% live in rural areas. 7 The primary level of care in Ghana has three sublevels: community, health center, and district hospital. The district hospital is the first referral point and handles many more patients than the two other sublevels. The municipality has five subdistricts, each of which has a health center. The two main hospitals in the municipality are the District Hospital at Saltpond and Mercy Women's Hospital at Mankessim. The latter has a fistula center. There were 33 regular midwives with 12 additional rotation midwives (national service personnel) in the municipality at the time of study, making a total of 45 midwives.
All prenatal clinic attendees and midwives in the municipality within the study period were eligible for inclusion in the study.
Expectant mothers or midwives who declined consent to participate were excluded. Prenatal attendees with obstetric complications were also excluded.
The study was approved by the Committee on Human Research, Publication, and Ethics (CHRPE) of Kwame Nkrumah University of Science and Technology. Participation in the study was entirely voluntary and informed consent was obtained from each woman. For minors (girls under 18 years of age), informed consent and assent were obtained from the parent/guardian and the woman, respectively.

| Sample size estimation
An estimated sample size of 390 had adequate power of 80% to detect knowledge of obstetric fistula among prenatal clinic attendees in the municipality, assuming the proportion of attendees with knowledge of obstetric fistula in the municipality was similar to the 36% reported in Burkina Faso. 3 The number of women recruited from each facility was calculated in proportion to the reported prenatal care attendance for the first half of 2015. All 45 midwives in the municipality were invited to participate in the study.

| Sampling and procedure for data collection
Eligible women were selected by systematic sampling using the prenatal clinic attendance list for each day as the sampling frame. The sampling interval (x) for each day was obtained by dividing the number of attendees to be recruited that day by the total number (N) of eligible attendees at the clinic that day. The first case (y) was selected by simple random sampling through balloting. The rest of the participants were then obtained by y + x, y + 2x, y + 3x, etc. Where a selected woman was not available at the time of the interview or declined consent, the next eligible woman on the attendance list for that day was selected.
Eligible women were approached individually by a member of the research team who explained the purposes and benefits of the study and obtained informed consent. Consenting attendees and midwives were interviewed individually and data collected on their sociodemographic and reproductive characteristics, and knowledge of obstetric fistula using a pretested structured questionnaire.
Knowledge of obstetric fistula was assessed by evaluating responses to 11 questions on fistula including the causes, risk factors, and prevention of obstetric fistula. Each correct answer was assigned a score of +1 while each incorrect or undecided ("don't know") response attracted a score of 0. The scores for each woman were summed and categorized.

| Data analysis
Data were double entered into Epi Info version 7.1.1.14 (CDC, Atlanta, GA, USA) and exported to Stata version 12.0 (Stata Corp, College Station, TX, USA) for analysis. The knowledge scores for each woman were categorized as follows: 0-3 (low); 4-6 (average); and 7-11 (high). Women with low scores were considered to have poor knowledge while those with average or high scores were considered to have good knowledge of obstetric fistula. Data were summarized using descriptive statistics and charts. Categorical variables were compared using the χ 2 or Fisher exact test as appropriate. Factors associated with awareness of obstetric fistula among prenatal clinic attendees were assessed by calculating crude and adjusted relative risks (RRs) with corresponding 95% confidence intervals (CIs) using univariate and multivariate Poisson regression with a robust error variance. P<0.05 was considered statistically significant.

| RESULTS
A total of 393 prenatal clinic attendees and all 45 midwives in the municipality were recruited into the study. The midwives were of different categories, comprising 12 rotation midwives, 26 staff midwives, two senior staff midwives, and five midwifery officers. The mean age of the clinic attendees was 28.1 ± 7.1 years (range, 15-48 years).
About 60% (n=240) of the expectant mothers received prenatal care in hospitals and nearly 40% (n=153) in health centers (Table 1).
Less than one-third (n=113, 28.8%) of the women had heard of obstetric fistula, with most obtaining their information from a health facility (41.6%) or family/friends (31.9%). Factors associated with their awareness of obstetric fistula are shown in

| DISCUSSION
Less than one-third of prenatal care clinic attendees had heard of obstetric fistula, nearly 40% of whom had poor knowledge and over half had misconceptions about its risk factors. Significant factors associated with being aware of the condition were educational background, occupation, and parity. Poor knowledge was associated with lower educational level, being single, unemployed, or receiving prenatal care in a hospital. Although most midwives were knowledgeable of the risk factors for obstetric fistula, up to three-quarters associated some basic reproductive health services with its occurrence.
The less than 30% rate of awareness in this study is comparable to the low rates reported in most countries in sub-Saharan Africa. 3,8 However, it is lower than the 45% awareness rate reported in Northern Ghana, 9 and 44%-61% in other parts of Africa. [10][11][12] The higher awareness rate observed in some of the previous studies may be attributed to prior educational campaigns on obstetric fistula and conducting the study among fistula patients or participants with prior exposure to information on the condition. 9,11,12 For example, in Northern Ghana where fistula is relatively common, more educational campaigns are directed toward these populations. instance, should some of these women develop obstetric fistula, they may not seek treatment from the hospitals, but rather go to so-called spiritual healing centers. More than half of the women associated obstetric fistula with reproductive tract conditions and services, which T A B L E 2 Factors associated with awareness of obstetric fistula among women attending prenatal care clinics in Mfantsiman municipality. In conclusion, awareness of obstetric fistula among prenatal care clinic attendees in this municipality with a fistula center is relatively low and most attendees had some misconceptions regarding the condition's risk factors. Although midwives generally had good knowledge, some had misconceptions, indicating a gap between midwives' knowledge and perception. Therefore, there is an urgent need to educate women more regularly on obstetric fistula during prenatal care. Regular refresher courses on obstetric fistula should also be organized for midwives to update their knowledge and help dispel some of their misconceptions.

AUTHORS CONTRIBUTIONS
WKA, ETD, EKA, AAO, and HSOA conceived and designed the study.
WKA collected the data. WKA and ETD analyzed the data. All authors read and approved the final manuscript.

CONFLICTS OF INTEREST
The authors have no conflicts of interest.