We conducted a multicenter, cross-sectional, descriptive study of midwives and birth attendants in the Kara region in 2025.

The study took place over a period from September 1st to November 30th, 2025.

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.

We included all state-certified midwives and obstetricians practicing in 2025 who agreed to participate in the study.

Maternity service providers not directly involved in frontline maternal health care (general practitioners, obstetrician-gynecologists, untrained nursing assistants and senior health technicians).

The sampling was probabilistic, specifically random.

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.

Data entry, processing and analysis were done using Excel, Microsoft Word 2016 and Epi info 7 software.

We obtained informed consent from the healthcare providers. The data was processed anonymously to ensure confidentiality.

These included socio-demographic characteristics, knowledge about obstetric fistulas, attitudes towards obstetric fistulas, and practices regarding obstetric fistulas.

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%.

3.2.1. 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.

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.

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.

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.

5)Prevention of obstetric fistula duringdystocicdelivery

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.

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 ofOF

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.

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.

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.

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.