Prevalence and factors associated with the awareness of obstetric fistula among women of reproductive age in The Gambia: a multilevel fixed effects analysis

Background
An obstetric fistula is an inappropriate connection between the vagina, rectum, or bladder that results in faecal or urine incontinence. Young women from rural areas with poor socioeconomic situations and education are the majority of victims, which restricts their access to high-quality healthcare. Obstetric fistulas can have devastating effects on the physical health of affected women if they are not promptly treated. Inadequate awareness of the symptoms delays recognition of the problem, prompt reporting, and treatment. Women with poor awareness of the disorder are also more likely to develop complications, including mental health issues. Using data from a nationally representative survey, this study investigated the prevalence and factors associated with the awareness of obstetric fistula among women of reproductive age in The Gambia.

Methods
This study used population-based cross-sectional data from the 2019–2020 Gambia Demographic and Health survey. A total of 11823 reproductive-aged women were sampled for this study. Stata software version 16.0 was used for all statistical analyses. Obstetric fistula awareness was the outcome variable. Multilevel logistic regression models were fitted, and the results were presented as adjusted odds ratios (aOR) with statistical significance set at p < 0.05.

Results
The prevalence of obstetric fistula awareness was 12.81% (95%CI: 11.69, 14.12). Women aged 45–49 years (aOR = 2.17, 95%CI [1.54, 3.06]), married women (aOR = 1.39, 95%CI [1.04, 1.87]), those with higher education (aOR = 2.80, 95%CI [2.08, 3.79]), and women who worked as professionals or occupied managerial positions (aOR = 2.32, 95%CI [1.74, 3.10]) had higher odds of obstetric fistula awareness. Women who had ever terminated pregnancy (aOR = 1.224, 95%CI [1.06, 1.42]), those who listened to radio at least once a week (aOR = 1.20, 95%CI [1.02, 1.41]), ownership of a mobile phone (aOR = 1.20, 95%CI [1.01, 1.42]) and those who were within the richest wealth index (aOR = 1.39, 95%CI [1.03, 1.86]) had higher odds of obstetric fistula awareness.

Conclusion
Our findings have revealed inadequate awareness of obstetric fistula among women of reproductive-age in The Gambia. Obstetric fistulas can be mitigated by implementing well-planned public awareness initiatives at the institutional and community levels. We, therefore, recommend reproductive health education on obstetric fistula beyond the hospital setting to raise reproductive-age women's awareness.

Trends in national and subnational wealth related inequalities in use of maternal health care services in Nepal: an analysis using demographic and health surveys (2001–2016)

Background
Maternal health affects the lives of many women and children globally every year and it is one of the high priority programs of the Government of Nepal (GoN). Different evidence articulate that the equity gap in accessing and using maternal health services at national level is decreasing over 2001–2016. This study aimed to assess whether the equity gap in using maternal health services is also decreasing at subnational level over this period given the geography of Nepal has already been identified as one of the predictors of accessibility and utilization of maternal health services.

Methods
The study used wealth index scores for each household and calculated the concentration curves and indexes in their relative formulation, with no corrections. Concentration curve was used to identify whether socioeconomic inequality in maternity services exists and whether it was more pronounced at one point in time than another or in one province than another. The changes between 2001 and 2016 were also disaggregated across the provinces. Test of significance of changes in Concentration Index was performed by calculating pooled standard errors. We used R software for statistical analysis.

Results
The study observed a progressive and statistically significant decrease in concentration index for at least four antenatal care (ANC) visit and institutional delivery at national level over 2001–2016. The changes were not statistically significant for Cesarean Section delivery. Regarding inequality in four-ANC all provinces except Karnali showed significant decreases at least between 2011 and 2016. Similarly, all provinces, except Karnali, showed a statistically significant decrease in concentration index for institutional delivery between 2011 and 2016.

Conclusion
Despite appreciable progress at national level, the study found that the progress in reducing equity gap in use of maternal health services is not uniform across seven provinces. Tailored investment to address barriers in utilization of maternal health services across provinces is urgent to make further progress in achieving equitable distribution in use of maternal health services. There is an opportunity now that the country is federalized, and provincial governments can make a need-based improvement by addressing specific barriers.

Inequalities in caesarean section in Burundi: evidence from the Burundi Demographic and Health Surveys (2010–2016)

Background
Despite caesarean section (CS) being a lifesaving intervention, there is a noticeable gap in providing this service, when necessary, between different population groups within a country. In Burundi, there is little information about CS coverage inequality and the change in provision of this service over time. Using a high-quality equity analysis approach, we aimed to document both magnitude and change of inequality in CS coverage in Burundi over 7 years to investigate disparities.

Methods
For this study, data were extracted from the 2010 and 2016 Burundi Demographic and Health Surveys (BDHS) and analyzed through the recently updated Health Equity Assessment Toolkit (HEAT) of the World Health Organization. CS delivery was disaggregated by four equity stratifiers, namely education, wealth, residence and sub-national region. For each equity stratifier, relative and absolute summary measures were calculated. We built a 95% uncertainty interval around the point estimate to determine statistical significance.

Main findings
Disparity in CS was present in both survey years and increased over time. The disparity systematically favored wealthy women (SII = 10.53, 95% UI; 8.97, 12.10), women who were more educated (PAR = 8.89, 95% UI; 8.51, 9.26), women living in urban areas (D = 12.32, 95% UI; 9.00, 15.63) and some regions such as Bujumbura (PAR = 11.27, 95% UI; 10.52, 12.02).

Conclusions
Burundi had not recorded any progress in ensuring equity regarding CS coverage between 2010 and 2016. It is important to launch interventions that promote justified use of CS among all subpopulations and discourage overuse among high income, more educated women and urban dwellers.