Knowledge, Attitudes and Practices of Midwives and Birth Attendants in the Kara Region/Togo regarding Obstetric Fistulas in 2025 ()
1. Introduction
Obstetric fistula (OF) is defined as an abnormal connection between the vagina and the bladder or rectum, most often resulting from prolonged and obstructive labor, causing ischemic necrosis of the pelvic tissues [1] [2]. Beyond its clinical impact, obstetric fistula represents one of the leading causes of disability in women, potentially depriving them of the ability to lead a sexual life, reproduce, and participate in society. It reflects the absence, inadequacy, or inaccessibility of skilled obstetric care [3]-[6].
Despite global progress in maternal health, this pathology remains a major public health issue in many low-resource countries, particularly in West Africa [4] [7].
Worldwide, it is estimated that 2 to 3 million women suffer from obstetric fistula, indicating that 50,000 to 100,000 new women develop this condition each year [2]. This condition affects approximately 457,000 (95% CI 303,000 to 709,000) women aged 15 to 64 years and 386,000 (95% CI 256,000 to 599,000) women of reproductive age (15 to 49).
According to the World Health Organization (WHO), more than 2 million young women in Asia and sub-Saharan Africa are living with untreated obstetric fibrositis (OF) [2] [8]. This represents a significant psychological burden, as the condition is often considered a disease of shame.
In Africa, the figures are alarming: 74,000 cases in Ivory Coast in 2021, 16,080 cases in Burkina Faso, 17,000 cases in Cameroon in 2024 and 117 cases in the DRC in 2025. In Ghana, the incidence is 1.8 per 1000 deliveries [7].
The prevalence rate of obstetric fistula is almost twice as high in the sub-Saharan region (71 per 100,000 women) as in Asia (36 per 100,000 women) [8] [9].
The prevalence and incidence of obstetric fistula are not precisely known in Togo. However, its management is organized at the national level with the creation of a reference center responsible for coordinating and ensuring the control, prevention, and treatment [10]. This initiative demonstrates institutional commitment, but its success largely depends on the skills and practices of frontline maternal healthcare providers in our region, namely midwives and birth attendants. We therefore conducted this study, the objective of which is to assess the knowledge, attitudes, and practices of midwives and birth attendants in the Kara region regarding obstetric fistula in 2025.
2. Framework and Method of Study
2.1. Study Framework
We conducted a multicenter, cross-sectional, descriptive study of midwives and birth attendants in the Kara region in 2025.
2.2. Study Period
The study took place over a period from September 1st to November 30th, 2025.
2.3. Study Population
The target population consisted of midwives and birth attendants providing maternal care and practicing in the Kara region, totaling 105 providers. The Kara region has 10 SONU B (basic emergency obstetric and neonatal care) centers and 5 SONU C (comprehensive emergency obstetric and neonatal care) centers.
2.4. Inclusion Criteria
We included all state-certified midwives and obstetricians practicing in 2025 who agreed to participate in the study.
2.5. Exclusion Criteria
Maternity service providers not directly involved in frontline maternal health care (general practitioners, obstetrician-gynecologists, untrained nursing assistants and senior health technicians).
2.6. Sampling
The sampling was probabilistic, specifically random.
2.7. Techniques and Tools
The five interviewers underwent prior training, followed by data collection over three months after a pre-test questionnaire was administered. Daily monitoring was conducted throughout the survey. Practical procedures were evaluated as follows:
-Good: the step or task executed with great mastery, marked out of 2 points.
-Insufficient: does not perform the step or task according to the protocols or guidelines, marked out of 1 point.
-Not observed: step or task not executed, noted 0.
2.8. Data Analysis and Processing
Data entry, processing and analysis were done using Excel, Microsoft Word 2016 and Epi info 7 software.
2.9. Ethical and Professional Considerations
We obtained informed consent from the healthcare providers. The data was processed anonymously to ensure confidentiality.
2.10. Parameters Studied
These included socio-demographic characteristics, knowledge about obstetric fistulas, attitudes towards obstetric fistulas, and practices regarding obstetric fistulas.
3. Result
3.1. Participation Rate
Of the 105 providers (midwives and obstetricians) in the Kara region, 53 agreed to participate in the survey, representing a response rate of 50.5%.
3.2. Socio-Demographic Characteristics of the Respondents
3.2.1. Professional Qualification
Midwives represented 75.5% and obstetricians 24.5%.
3.2.2. Place of Practice
They worked at the University Hospital/Regional Hospital (15.4%), in Peripheral Care Units (30.8%) and in medical-social centers (57.7%). Two midwives worked in private health centers (3.8%).
3.2.3. Age and Number of Years of Experience
The majority of respondents were between 31 and 35 years old (32.1%), followed by those between 21 and 25 years old (22.6%). Most had less than 5 years of professional experience (67.9%), as shown in Table 1.
Table 1. Distribution of service providers according to age and number of years of practice.
Age |
|
n |
% |
[21 - 25] |
12 |
22.6% |
[26 - 30] |
11 |
20.8% |
[31 - 35] |
17 |
32.1% |
[36 - 40] |
6 |
11.3% |
[41 - 45] |
5 |
9.4% |
[51 - 55] |
2 |
3.8% |
Total |
53 |
100% |
Number of years in practice |
<5 years old |
36 |
67.9% |
5 - 9 years old |
7 |
13.2% |
10 - 14 years old |
8 |
15.1% |
15 - 19 years old |
1 |
1.9% |
≥20 years old |
1 |
1.9% |
Total |
53 |
100% |
3.3. Staff Knowledge, Attitudes and Practices regarding Obstetric Fistulas
3.3.1. Knowledge
1) Definition of obstetric fistula
The answers to the question of how obstetric fistula is defined are shown in Table 2.
In this survey, 62.3% had never encountered an obstetric fistula, compared to 37.7% who had. Among those who had never encountered one, midwives represented 72.7% and obstetricians 27.3%. The number of cases they encountered per year ranged from 5 to 10, according to them.
Table 2. Definition of obstetric fistula according to providers.
How do you define obstetric fistula? |
n |
% |
No idea |
1 |
1.9% |
Abnormal communication between the female genital and urinary tracts, abnormal communication between the vagina and the urinary tract and/or rectum after childbirth, abnormal communication between the vagina and the bladder |
1 |
1.9% |
Abnormal communication between the female genital and urinary tracts, abnormal communication between the vagina and rectum |
1 |
1.9% |
Abnormal communication between the vagina and the rectum, abnormal communication between the vagina and the urinary tract and/or the rectum after childbirth |
1 |
1.9% |
Abnormal communication between the vagina and the rectum |
2 |
3.8% |
Abnormal communication between the vagina and the rectum, Abnormal communication between the vagina and the bladder |
2 |
3.8% |
Abnormal communication between the vagina and the bladder |
4 |
7.5% |
Abnormal communication between the female genital and urinary systems |
8 |
15.1% |
Abnormal communication between the vagina and the urinary tract and/or rectum after childbirth |
20 |
37.7% |
All of the above statements are correct |
13 |
24.5% |
Total |
53 |
100% |
2) Women at risk
According to the respondents, women at risk of obstetric fistulas are represented in Table 3.
Table 3. Distribution of service providers according to women at risk of obstetric fistula.
Women at risk of FO |
n |
% |
All women who have given birth |
29 |
54.7% |
All women of childbearing age |
7 |
13.2% |
All women of childbearing age, all women who have given birth |
1 |
1.9% |
All pregnant women |
13 |
24.5% |
All pregnant women, all women who have given birth |
2 |
3.8% |
No idea |
1 |
1.9% |
Total |
53 |
100% |
3) Cause of the FO
The cause of FO is prolonged compression by the presentation being blocked in the pelvis according to 90.4% of providers (21.3% of obstetricians versus 78.7% of midwives) and 9.6% of providers did not know.
4) Symptoms of FO
Provider responses regarding FO symptoms are shown in Table 4.
Table 4. Distribution of service providers according to FO symptoms.
What are the symptoms of obstetric fistula? |
n |
% |
Constant and involuntary bowel movements |
1 |
2% |
Constant and involuntary flow of stool and urine |
12 |
22.6% |
Constant and involuntary flow of urine |
12 |
22.6% |
All the statements are correct |
28 |
52.8% |
Total |
53 |
100% |
5) Prevention of obstetric fistula during dystocic delivery
According to the providers, 39.6% had no knowledge about the prevention of obstetric fistula. The providers’ responses are shown in Table 5.
Table 5. Distribution of providers according to their response on the prevention of obstetric fistula.
Prevention of fetal distress during dystocic labor |
n |
% |
No idea |
21 |
39.6% |
Insertion of a urinary catheter immediately after delivery for 10 to 15 days |
11 |
20.7% |
Repeated urinary catheterization during the day |
10 |
18.9% |
Insertion of an indwelling urinary catheter 30 minutes after delivery |
8 |
15.1% |
Antibiotic treatment |
2 |
3.8% |
Rest for women without an indwelling urinary catheter |
1 |
1.9% |
Total |
53 |
100% |
3.3.2. Attitudes and Practices
1) Training on obstetric fistulas
Overall, 84.3% of providers had not received training on obstetric fistulas before starting their duties, compared to 15.7% who had. During their employment, 94.3% had never received continuing education, compared to 5.7% who had.
2) Diagnostic attitudes of OF
In this study, 66% of providers reported knowing how to diagnose FO during physical examination using the methylene blue test. According to the providers, all stated that women with FO deserve therapeutic management, and the therapeutic options are as follows, shown in Table 6.
According to healthcare providers, 71.7% stated that a well-defined patient pathway exists for care in Togo, while 18.9% had no idea what the pathway was. The remaining 32.1% reported knowing of an institution or organization that treats obstetric fistula in Togo, citing non-governmental organizations (Aimes Afrique, GOZEN) and UNFPA (United Nations Population Fund).
Psychological support should be systematic according to 94.3% of providers.
Table 6. Distribution of providers according to therapeutic options.
Treatment of obstetric fistula is |
n |
% |
Surgery |
31 |
58.5% |
Urinary expectoration monitoring or the surgery |
11 |
20.7% |
Expectant monitoring under urinary welding |
8 |
15.1% |
No idea |
3 |
5.7% |
Total |
53 |
100% |
4. Discussion
4.1. Socio-Demographic Characteristics of the Respondents
The majority of respondents were between 31 and 35 years old (32.1%). This result is consistent with those of Tebeu et al. in Cameroon and Mpia et al. in Congo-Brazzaville, who reported the majority age ranges as 33 - 42 and 30 - 35 years, respectively [11] [12]. The majority had less than 5 years of experience (67.9%). The midwives and birth attendants working in health facilities in the Kara region are young women, coming directly from paramedical training schools.
4.2. Knowledge of Service Providers
Providers correctly defined obstetric fistula (OF) in 37.7% of cases. Furthermore, 54.7% stated that all women giving birth are at risk of fistula, and 90.4% recognized that OF is caused by prolonged compression of the fetal presentation trapped in the pelvis. The majority of providers have a good understanding of obstetric fistula, as also reported by Alemu et al. in Ethiopia [13]. In contrast, Tebeu et al. observed a lower level of knowledge in their study [11].
The high level of knowledge observed in our study could be the result of increased awareness campaigns on maternal health and the integration of obstetric fistula courses into training curricula. These actions appear to have strengthened the theoretical knowledge of healthcare providers.
4.3. Attitudes and Practices of Service Providers
Thirty-nine point six percent of providers had no knowledge of obstetric fistula (OF) prevention measures. This result is understandable given that 84.3% of them had received no training on OF before starting their duties and 94.3% of them had never received continuing education in the course of their work. These shortcomings highlight the importance of strengthening pre-service and on-the-job training to equip providers with the practical skills needed to effectively prevent obstetric fistula. Integrating specific modules on obstetric complications, combined with regular training and capacity-building sessions for providers, could significantly improve the level of knowledge and, consequently, the quality of care provided to pregnant women.
Although 62.3% of providers reported never having encountered a case of obstetric fistula (OF), 66% stated they knew how to make the diagnosis. Furthermore, 58.5% acknowledged that the treatment for OF is surgical, and 94.3% believed that care should be systematic, including psychosocial support. This support must be inseparable from surgical treatment to ensure complete healing and the socio-professional reintegration of women with OF. Similar findings were reported by Marie et al. [11], suggesting that despite limited practical experience among providers, their theoretical knowledge remains relatively good.
5. Conclusion
Primary obstetric and neonatal care providers in the Kara region of northern Togo have good knowledge but insufficient attitudes and practices regarding obstetric fistulas. This reflects the inadequate quality of maternal care. It is necessary to strengthen their capacity regarding obstetric fistulas through training sessions to improve the quality of maternal care.