Obstetric fistulas represent a devastating and often overlooked consequence of inadequate maternal health care. Obstetric fistulas are childbirth injuries that result from prolonged obstructed labour, which compresses the mother’s soft tissues between the baby’s head and the bony pelvis, leading to a hole or fistula formation between the vagina and nearby organs such as the bladder or rectum.¹ Urine and/or faeces leak uncontrollably through the vagina due to this passage, resulting in severe physical discomfort, social stigma and emotional distress for the affected women.¹ Fistulas can represent the intersection of medical disparities, gender inequality and social injustice that exists in childbirth in continents like Africa. Due to the unique features of The Gambia, Côte d’Ivoire, Madagascar and Sierra Leone – including varied awareness and prevalence of fistulas, education and women’s empowerment challenges and available nationally representative data on fistulas^2,3,4 – these countries are useful benchmarks for understanding the state of fistulas in the region.

As of 2023, researchers estimate that two million girls and women continue to live with obstetric fistulas, while 50 000–100 000 women develop an obstetric fistula each year;⁵ but obstetric fistulas are largely preventable and treatable.⁶ Further investigation is needed to identify the socio-cultural factors, economic constraints and the lack of awareness of causes and symptoms of fistulas that enable them to occur and prevent women from seeking medical care. Understanding a population’s level of awareness of fistulas is perhaps the first step in prevention and intervention efforts as it empowers individuals and communities to recognise the signs and symptoms of obstetric fistulas early on and engage in prevention behaviours before a fistula even arises. Considering the importance of fistula awareness for both prevention and intervention, we use nationally representative Demographic and Health Survey (DHS) data from The Gambia, Sierra Leone, Côte d’Ivoire and Madagascar to (1) estimate the prevalence of fistulas in these countries, (2) estimate the prevalence of fistula awareness, and (3) understand possible socioeconomic and cultural components of fistula awareness. This research aims to increase knowledge of the importance of basic fistula awareness and propose possible pathways to further increase this awareness in the region.

Figure 1 and Figure 2 show the percentage of women who have a fistula by country and the percentage of women with knowledge about a fistula by country, respectively. Sierra Leone has the largest number of women with a fistula (Figure 1) and the highest percentage with knowledge about fistulas (Figure 2). Conversely, The Gambia has the lowest fistula prevalence (Figure 1) as well as fistula knowledge (Figure 2). It is logical that the country with the lowest reported prevalence of fistulas also demonstrates the lowest levels of fistula awareness and vice versa, as lower exposure to the condition may limit public knowledge and recognition. Understanding this relationship is important because it highlights how awareness efforts should be tailored to each country’s epidemiological context, ensuring that prevention and education initiatives are targeted where and how they are most needed.

Table 2 shows the descriptive statistics for our DHS sample overall and by country. Overall, 0.01% of respondents report having a fistula, which ranges from 0% in The Gambia up to 1.2% in Sierra Leone. Regarding knowledge of fistulas, across all countries, roughly 33% of women reported having such knowledge. However, there is substantial cross-national variation in fistula awareness, ranging from 13% of women in The Gambia to 57% in Sierra Leone.

Overall, 48% of women live in an urban area, and 30% have never been married, 51% are currently married, 10% are cohabitating and roughly 8% are widowed, divorced or separated. On average, women are 28.5 years old, and the wealth index is, on average, 0.2. Women have an average of 4.5 years of completed education ranging from 4.2 years in Côte d’Ivoire to 5.7 in The Gambia. Women average a total of 2.5 births, and roughly 14% of women have terminated a pregnancy overall, ranging from 8% in Sierra Leone up to 19% in Côte d’Ivoire (see Table 2 for additional descriptive statistics of the variables analysed in this study).

Table 3 shows the results of weighted logistic regression models on fistula awareness overall and by country. Overall, our analysis found no significant difference in fistula awareness between women in urban versus rural areas. Conversely, living in an urban area varied in its effects from country to country, increasing the odds of fistula knowledge by 1.17 times (p = 0.03) in Côte d’Ivoire and reducing the odds of fistula knowledge by 0.78 times (p = 0.02) in The Gambia. Overall, women who are married, cohabiting, widowed, divorced or separated have increased odds of being knowledgeable about fistulas compared to never-married women. This is also true for married women in The Gambia, cohabitating women in Madagascar, and married, cohabitating and widowed, divorced or separated women in Sierra Leone. All other relationship statuses among these four countries are not statistically different from never-married women.

The odds of knowing about fistulas grow about 1.02 times for each additional year of age in The Gambia (p = 0.001) and Madagascar (p < 0.001) and by 1.03 times in Sierra Leone (p < 0.001) and Côte d’Ivoire (p < 0.001). The odds ratio for age remains generally consistent across all four countries, suggesting a slightly greater likelihood of fistula awareness as age increases. For example, if two women differ by 2 years of age, the older woman has predicted odds of knowing about a fistula that are 1.06 (1.03*1.03) times larger than the younger woman. If two women differ in age by 10 years, the odds that the older woman would know about a fistula are 1.34 times larger than those of the younger woman. Similarly, the odds of knowing about fistulas are predicted to grow about 1.04 times (p < 0.001) larger for each additional year of education. These results generally remain consistent across all four countries, rising by 1.04 times in Côte d’Ivoire (p < 0.001) and Sierra Leone (p < 0.001) and by 1.05 times in The Gambia (p < 0.001) and Madagascar (p < 0.001).

Overall, wealth had a negative association with fistula knowledge. By country, women who were wealthier had decreased knowledge of fistulas in Madagascar (OR = 0.86, p = 0.001) and Sierra Leone (OR = 0.89, p = 0.001). Conversely, wealthier women had increased knowledge of fistulas in The Gambia (OR = 1.17, p = 0.001). There was no statistically significant relationship between wealth and fistula knowledge in Côte d’Ivoire. Women in all four countries who had higher justification for wife beating were more likely to be knowledgeable about fistulas compared to those who had lower justification. More specifically, women with increased justification for wife beating had odds of having fistula knowledge ranging from 1.03 times (p = not significant) more likely in Madagascar to 1.10 times more likely in Côte d’Ivoire (p < 0.001) and The Gambia (p = 0.001). No significant difference in fistula knowledge was found among women with different numbers of births overall and in The Gambia, Madagascar and Côte d’Ivoire. However, an increased total number of births was associated with having increased fistula awareness in Sierra Leone (OR = 1.03, p = 0.03). The odds of knowing about fistulas are predicted to be about 1.14 times (p < 0.001) larger for women with greater media usage than those with reduced media usage, holding all other variables constant. Increased media usage ranged slightly in its effects on fistula knowledge from country to country, improving the odds of fistula knowledge by 1.07 times in The Gambia (p = 0.03) and Sierra Leone (p < 0.001) up to 1.19 times in Côte d’Ivoire (p < 0.001).

Similarly, the odds of fistula awareness are predicted to be 1.21 times (p < 0.001) larger for women with greater internet usage than those with no internet usage, holding all other variables constant. However, increased internet usage varied in its effects on fistula knowledge from country to country, improving the odds of fistula knowledge by 1.34 times (p < 0.001) in Sierra Leone but having no statistically significant relationship in the other three countries. Overall, women who have terminated pregnancies have increased odds of being knowledgeable about fistulas, roughly 1.08 times (p = 0.03) greater than women who have never terminated a pregnancy. Pregnancy termination increased the odds of improved fistula knowledge in every country except Madagascar, where women who had terminated a pregnancy had lower odds (OR = 0.86 times, p = 0.009) of having knowledge of fistulas.

Overall, women who have been sexually inactive and women who have been sexually active in the last 4 weeks show increased odds of being knowledgeable about fistulas compared to women who have never been sexually active. This is also true for women who have not been sexually active in the last 4 weeks in Côte d’Ivoire (OR = 2.19, p < 0.001) and Sierra Leone (OR = 1.81, p < 0.001) and sexually active women in Côte d’Ivoire (OR = 2.40, p < 0.001) and Sierra Leone (OR = 1.71, p < 0.001). All other sexual activity statuses among these four countries are not statistically different from women who have never been sexually active.

Overall, women who are currently employed were found to have odds 1.26 times (p < 0.001) greater than those who are unemployed. More specifically, employed women had odds of having fistula knowledge ranging from 1.03 times in Madagascar (p = not statistically significant) to 1.45 times in The Gambia (p < 0.001). The odds of knowing about fistulas are predicted to be about 1.64 times (p < 0.001) larger for women with better scores on the health knowledge scale, holding all other variables constant. Increased health knowledge ranged in its effects on fistula knowledge by country and improved the odds of fistula knowledge by 1.31 times (p < 0.001) in Côte d’Ivoire up to 1.88 times (p < 0.001) in Sierra Leone. Overall, women who identify as Methodist had reduced odds of being knowledgeable about fistulas compared to women who are Muslim (reference category). By country, women who are Methodist had decreased knowledge of fistulas in Madagascar (OR = 0.54, p < 0.001). However, Catholic women had increased knowledge of fistulas in The Gambia (OR = 1.47, p < 0.001). All other religious statuses among these four countries were not statistically different from the Muslim women. Table 4 reports confidence intervals for the odds ratios presented in Table 3.

Women with an obstetric fistula often endure chronic incontinence, social isolation and often face abandonment by their families and communities,¹ making prevention and quick treatment an important goal. Using data from DHS, the current study aimed to investigate associated socioeconomic factors related to fistula awareness in The Gambia, Côte d’Ivoire, Sierra Leone and Madagascar. Overall, 33% of women in these four countries are aware of fistulas, ranging from a low of 13% to a high of 57%. Marital status, age, media use, internet use, level of education, sexual activity, employment and other health knowledge were all characteristics discovered to be significant factors in increasing a woman’s awareness of obstetric fistulas in these countries. By assessing the state of fistula prevalence and awareness in four countries in West and East Africa and examining existing efforts made by those in the public health, policy, medicine and government sectors to address fistulas, we hope to provide pathways forward for these and similar countries. For example, roughly 1.2% of respondents in Sierra Leone report having a fistula, while 57% report fistula knowledge. Sierra Leone began implementing ‘Fistula Advocacy’ programmes in which women who had previously been diagnosed and treated with obstetric fistulas helped to find women with undiagnosed fistulas and support the recovery of women still going through the process. Advocates used their personal stories to redefine their identity, change perceptions and reduce stigma surrounding obstetric fistulas. By sharing their experience, they aimed to raise awareness and dispel myths associated with the condition.^19,24,25

Not only did Sierra Leone implement ‘Fistula Advocacy’, in 2010, the Sierra Leone Government launched the Free Health Care Initiative²⁶ that enabled pregnant women, lactating mothers and infants under the age of five to access medical care services completely free of charge.²⁷ Surgical repair is the primary treatment for obstetric fistulas. However, access to fistula repair services is limited in many African countries due to a shortage of trained health care providers, inadequate health care infrastructure and financial barriers. Obstetric fistulas are not merely a medical issue; rather, they represent a poignant intersection of health care, social injustice and women’s rights. The suffering endured by women with obstetric fistulas is a manifestation of gender inequality, evident in premature childbearing, malnutrition, poor physical development before childbirth and inadequate prenatal and delivery care.⁶ While this health care initiative was not directly related to fistulas, surgical treatment has been described as a crucial factor influencing recovery from physical and psychological symptoms and social inclusion,¹⁹ suggesting the Sierra Leone government is working to improve poor health indicators, including fistulas, in a variety of ways.²⁷

In addition to explicit fistula programmes and medical services, the education sector may be an indirect way to target fistula awareness as this and other research suggest that formal education has the potential to equip individuals with basic health literacy skills, enabling them to understand and retain information about obstetric fistulas, their causes, symptoms and preventive measures.²³ Further, education can delay marriage, sexual initiation and early pregnancy, thereby reducing young women’s biological and social vulnerability to obstetric fistulas.^22,31 Complementing formal education with comprehensive sexual and reproductive health education can further strengthen adolescents’ ability to make informed choices, preventing early childbearing and associated complications.^13,31

United Nations International Children’s Emergency Fund (UNICEF) reports that in August 2018, Sierra Leone introduced the Free Quality School Education (FQSE) programme. This programme has worked to reduce financial barriers to accessing education while also eliminating extra school fees throughout the year by increasing public spending on education.²⁶ Sierra Leone is not alone, with Côte d’Ivoire prioritising the improvement of education access and quality as well as mandating compulsory education from ages 6 to 16.²⁸ While these investments in education could aid in increasing access to fistula knowledge, they could also lead to increased opportunities for women in the workplace, which, as this and other research show, is also related to fistula awareness.²⁹ As women increase participation in various institutions, they can contribute to and learn from discussions about health-related matters that often occur between women in these spaces. These conversations can raise awareness about obstetric fistulas, symptoms, prevention and treatments.³⁰ As access to health-related information has been shown to be closely related to health outcomes for women in sub-Saharan Africa,³¹ creating educational opportunities for women can enhance health knowledge and improve overall health outcomes.

Lastly, educated and/or working women often serve as role models within their communities. If women can utilise this authority and their increased awareness and understanding of obstetric fistulas, there is potential for a ripple effect as they share that information with family members, friends and neighbours.³² Researchers have investigated the impact of adult literacy and skill acquisition programmes on women’s empowerment and self-reliance in The Gambia, with findings suggesting that these programmes positively influence women’s ability to access education and employment opportunities.³³ By addressing gender disparities in education and promoting skill development, the project aims to empower women and enhance their participation in the workforce, contributing to broader efforts to advance gender equality and socioeconomic development in The Gambia.

Considering these direct and indirect efforts to improve fistula awareness – creating fistula programmes, expanding medical coverage, improving educational attainment and increasing women’s empowerment through skill building – we hope to see further improvements in fistula awareness. Future research should examine the influence of these changes on increases in fistula awareness to ensure all women can access this important information and that these direct and indirect efforts are, in fact, increasing fistula awareness and thus decreasing fistula prevalence.

Obstetric fistulas remain both a profound medical challenge and a marker of persistent gender and socioeconomic inequalities in health care. The findings of this study underscore the importance of targeting awareness initiatives through education, media and community engagement, particularly among women who are younger, less educated or socially marginalised. Beyond identifying correlates of awareness, these results emphasise that improving awareness is not only a medical task but also a matter of social justice, as it intersects with women’s empowerment, access to resources and broader public health priorities.

To make sustainable progress, these and other countries must build on existing advocacy and education programmes while strengthening health systems to ensure timely prevention and treatment of fistulas. Investing in women’s education, expanding access to health information and reducing barriers to care can collectively reduce the burden of fistula and improve the quality of life for affected women and girls. Addressing fistula awareness in this way is not simply about increasing knowledge; it is about dismantling systemic barriers that perpetuate gendered health disparities.