Is there a relationship between female genital mutilation/cutting and fistula? A statistical analysis using cross-sectional data from Demographic and Health Surveys in 10 sub-Saharan Africa countries

BMJ Open, Volume 9, No. 7, Year 2019

Interpretation

Objectives: Literature on associations between female genital mutilation/cutting (FGM/C) and fistula points to a common belief that FGM/C predisposes women to developing fistula. This study explores this association using nationally representative survey data. Design: A secondary statistical analysis of cross-sectional data from Demographic and Health Surveys was conducted to explore the association between FGM/C and fistula. Setting: Sub-Saharan Africa. Participants: Women aged 15-49 years in Burkina Faso (n=17 087), Chad (n=17 719), Côte d’Ivoire (n=10 060), Ethiopia (n=14 070), Guinea (n=9142), Kenya (n=31 079), Mali (n=10 424), Nigeria (n=33 385), Senegal (n=15 688) and Sierra Leone (n=16 658). Main outcome measures: Fistula symptoms. Results: Multivariate logit modelling using pooled data from 10 countries showed that the odds of reporting fistula symptoms were 1.5 times (CI 1.06 to 2.21) higher for women whose genitals were cut and sewn closed than those who had undergone other types of FGM/C. Women who attended antenatal care (ANC) (adjusted odds ratio (AOR) 0.51, CI 0.36 to 0.71) and those who lived in urban areas (AOR 0.62, CI 0.44 to 0.89) were less likely to report fistula symptoms than those who did not attend ANC or lived in rural areas. Conclusions: Severe forms of FGM/C (infibulation) may predispose women to fistula. Contextual and socioeconomic factors may increase the likelihood of fistula. Multisectoral interventions that concurrently address harmful traditional practices such as FGM/C and other contextual factors that drive the occurrence of fistula are warranted. Promotion of ANC utilisation could be a starting point in the prevention of fistulas. The aim of this study was to assess associations between FGM/C and fistula among women of reproductive age15–49 using Demographic and Health Survey (DHS) data from 10 sub-Saharan Africa countries with data on both FGM/C and fistula. DHS are periodic nationally representative cross-sectional health surveys conducted in low-income and middle-income countries (https://dhsprogram.com/). DHS collects data on demographics and household wealth, fertility, reproductive health, maternal and child health, nutrition and HIV/AIDS. Data are collected from adult women aged 15–49 years and men aged 15–59 years from nationally representative probability samples of households. In certain surveys, there are additional series of questions about FGM/C and fistula that are added to the women’s questionnaire.46 The module on FGM/C includes three sections: (1) whether the woman underwent FGM/C or not, and details about the event, (2) whether one daughter underwent FGM/C or not, and details about that event, and (3) the woman’s opinion about the continuation of the practice. DHS includes a series of questions on fistula. All women are asked whether they have heard of fistula and, if they have, whether they themselves had experienced fistula-like symptoms (ie, involuntary leakage of urine and/or faeces from the vagina). While questions asked during surveys about sensitive events such as fistula and FGM/C are not as accurate as the gold standard of a gynaecological examination, previous studies comparing self-reported status and clinical observation data47 48 have shown that self-reported measures of FGM/C status are a suitable proxy measure for FGM/C prevalence but not for the type of cut. Further, DHS data are nationally representative and because they are inherently hierarchical are suitable for investigating associations between FGM/C and fistula while considering other contextual and socioeconomic correlates. Countries included in the analysis are: Burkina Faso (DHS 2010), Chad (DHS 2014–2015), Côte d’Ivoire (DHS 2011–2012), Ethiopia (DHS 2005), Guinea (DHS 2012), Kenya (DHS 2014), Mali (DHS 2012–2013), Nigeria (DHS 2008), Senegal (DHS 2010–2011) and Sierra Leone (DHS 2013). These countries we selected based on availability of data on FGM/C and fistula in the various DHS datasets. The lack of data on both FGM/C and fistula symptoms in certain surveys means that certain countries that could still be experiencing the burden of these conditions are excluded. It is equally important to note that due to lack of consistency in collecting data on both fistula and FGM/C, some of the latest DHS data were excluded (eg, data on fistula were not collected in the 2011 Ethiopia DHS and 2013 Nigeria DHS). We computed cross-tabulations to estimate bivariate associations between fistula and FGM/C status. Due to sample size limitations, we conducted country-specific multivariate analyses for only five countries (Chad, Côte d’Ivoire, Ethiopia, Kenya and Sierra Leone) that had at least 100 cases of fistula. Results of multivariate analysis for country specific data are not shown in this paper. For details, please see online supplementary file 1—likelihood of reporting fistula symptoms among women of reproductive age (15–49 years) in Chad, Côte d’Ivoire and Ethiopia; and online supplementary file 2—likelihood of reporting fistula symptoms among women of reproductive age (15–49 years) in Kenya and Sierra Leone. bmjopen-2018-025355supp001.pdf bmjopen-2018-025355supp002.pdf In addition, we conducted a multivariate logistic regression analysis using pooled data from the 10 focus countries. Multivariate logistic regression was used to assess associations between fistula and FGM/C, adjusting for other possible covariates. The choice of independent variables (possible covariates of fistula) was informed by an extensive literature review that identified underlying socioeconomic and contextual factors, including gender and sociocultural norms that affect both FGM/C and fistula.32 The review, for instance, showed that poverty, unemployment, living in a rural area, limited access to health services and malnutrition (stunting) increased the likelihood of women undergoing FGM/C and developing fistula. In addition, the level of education has been associated with a family’s choice to continue or abandon FGM/C and improves awareness about the importance of antenatal care (ANC) and facility delivery to prevent fistula.32 The dependent variable in the multivariate logistic regression analysis is fistula symptoms whereby women were categorised either as having reported involuntary leakage of urine and/or faeces from the vagina or not. The main independent variable is FGM/C status—women categorised either as cut or uncut. Although there are validity concerns about self-reported type of cut in the DHS,47 48 we also examined differences by type of FGM/C—women categorised as cut with genitals sewn closed or cut but genitals not sewn closed. Due to sample size limitations, we examined differences by type of cut using pooled data from the 10 countries. Other independent variables included in the analysis were categorised as follows: Maternal age at first birth—categorised into four groups (below 15 years, 15–19 years, 20–24 years, and 25 years and above); region—categorised by area of residence according to each country’s geographical/administrative boundaries; urban/rural residence—categorised based on whether a woman lived in an urban or rural setting; maternal education—categorised based on the highest level of education attained (no education, primary, and secondary and higher education); religion—categorised based on women’s religious affiliation, either as Christians (Catholic, Protestant and other Christians) or non-Christians (Muslim, traditionalist, animist and those with no religion); ethnicity—categorised according to a woman’s reported ethnic background which varied from country to country; wealth—women were grouped in one of five wealth quintiles (poorest, poorer, middle, richer and richest) generated through principal component analysis using household assets and amenities data; number of ANC visits—women were categorised depending on the number of ANC visits they undertook when they were pregnant (0 visits, 1–3 visits and four and more visits); and place of delivery—categorised based on whether a woman gave birth at a health facility or at home. Home deliveries also included births outside the homestead; for example, on the way to the health facility. Based on the literature review conducted by Sripad et al 32 exploring the association between FGM/C and fistula,32 we conducted multivariate logistic regression analysis to explore the relationship between FGM/C and fistula symptoms using data from DHS. We hypothesised that FGM/C status predisposes women to fistula symptoms (Logit Model I), but that this relationship can be confounded by socioeconomic factors (Logit Model II) and a woman’s geographical context and access to health services (Logit Model III). Results from cross-tabulations between FGM/C and fistula symptoms are presented as percentages while those from multivariate analyses are presented as unadjusted ORs and adjusted odds ratios (AOR) with 95% CIs. Estimates with p values of less than 0.05 were considered statistically significant. All analyses were conducted using IBM SPSS V.20 and were weighted taking into account the DHS sampling strategy. Missing data was handled by pairwise deletion. The study used publicly available secondary data from DHS (https://dhsprogram.com/). Patients and the public were not involved.

AI Digest

Study Justification:

This study aimed to investigate the relationship between female genital mutilation/cutting (FGM/C) and fistula among women in sub-Saharan Africa. The justification for this study is based on existing literature that suggests a link between FGM/C and the development of fistula. By analyzing data from Demographic and Health Surveys (DHS) in 10 sub-Saharan African countries, the study aimed to provide further evidence on this association.

Study Highlights:

– The study used cross-sectional data from DHS in 10 sub-Saharan African countries.
– The analysis showed that women who had undergone severe forms of FGM/C (infibulation) were more likely to report fistula symptoms compared to those who had undergone other types of FGM/C.
– Women who attended antenatal care (ANC) and lived in urban areas were less likely to report fistula symptoms.
– The study highlights the importance of addressing harmful traditional practices like FGM/C and other contextual factors that contribute to the occurrence of fistula.
– Promoting ANC utilization could be a starting point in preventing fistulas.

Recommendations for Lay Readers:

– The study found that severe forms of FGM/C may increase the risk of developing fistula.
– It is important to address harmful traditional practices like FGM/C and other factors that contribute to the occurrence of fistula.
– Encouraging women to attend antenatal care and improving access to healthcare services can help prevent fistulas.

Recommendations for Policy Makers:

– Multisectoral interventions are needed to address harmful traditional practices like FGM/C and other contextual factors that contribute to the occurrence of fistula.
– Policies should focus on promoting antenatal care utilization and improving access to healthcare services.
– Collaboration between different sectors, such as health, education, and social services, is crucial in addressing the issue of fistula.

Key Role Players:

– Health professionals and organizations: They play a key role in providing healthcare services, including antenatal care and treatment for fistula.
– Community leaders and traditional authorities: They can help raise awareness about the harmful effects of FGM/C and promote behavior change within communities.
– Educators and schools: They can contribute to educating young girls and boys about the dangers of FGM/C and the importance of reproductive health.
– NGOs and advocacy groups: They can provide support, resources, and advocacy for the prevention of FGM/C and the treatment of fistula.

Cost Items for Planning Recommendations:

– Healthcare infrastructure and facilities: Investments are needed to improve access to healthcare services, including antenatal care and treatment for fistula.
– Training and capacity building: Health professionals and community workers need training on how to address FGM/C and provide appropriate care for women with fistula.
– Awareness campaigns: Funding is required to raise awareness about the harmful effects of FGM/C and the importance of reproductive health.
– Research and data collection: Continued research and data collection are necessary to monitor the prevalence of FGM/C and fistula and evaluate the effectiveness of interventions.
Please note that the cost items provided are general categories and not actual cost estimates.

Strength of Evidence

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong, but there are some areas for improvement. The study design is a secondary statistical analysis of cross-sectional data from Demographic and Health Surveys, which provides a large sample size and nationally representative data. The study explores the association between FGM/C and fistula and uses multivariate logit modeling to analyze the data. The results show that the odds of reporting fistula symptoms were 1.5 times higher for women whose genitals were cut and sewn closed compared to those who had undergone other types of FGM/C. The study also identifies factors such as attending antenatal care and living in urban areas that are associated with a lower likelihood of reporting fistula symptoms. The conclusions suggest that severe forms of FGM/C may predispose women to fistula and that multisectoral interventions are needed to address harmful traditional practices and contextual factors that drive the occurrence of fistula. To improve the evidence, it would be beneficial to include country-specific multivariate analyses for all 10 countries included in the study, as well as to address the limitations of self-reported measures of FGM/C status and the lack of consistency in collecting data on both fistula and FGM/C in certain surveys. Additionally, further research could explore the relationship between FGM/C and fistula using more accurate measures, such as clinical observation data.

Abstract

The aim of this study was to assess associations between FGM/C and fistula among women of reproductive age15–49 using Demographic and Health Survey (DHS) data from 10 sub-Saharan Africa countries with data on both FGM/C and fistula. DHS are periodic nationally representative cross-sectional health surveys conducted in low-income and middle-income countries (https://dhsprogram.com/). DHS collects data on demographics and household wealth, fertility, reproductive health, maternal and child health, nutrition and HIV/AIDS. Data are collected from adult women aged 15–49 years and men aged 15–59 years from nationally representative probability samples of households. In certain surveys, there are additional series of questions about FGM/C and fistula that are added to the women’s questionnaire.46 The module on FGM/C includes three sections: (1) whether the woman underwent FGM/C or not, and details about the event, (2) whether one daughter underwent FGM/C or not, and details about that event, and (3) the woman’s opinion about the continuation of the practice. DHS includes a series of questions on fistula. All women are asked whether they have heard of fistula and, if they have, whether they themselves had experienced fistula-like symptoms (ie, involuntary leakage of urine and/or faeces from the vagina). While questions asked during surveys about sensitive events such as fistula and FGM/C are not as accurate as the gold standard of a gynaecological examination, previous studies comparing self-reported status and clinical observation data47 48 have shown that self-reported measures of FGM/C status are a suitable proxy measure for FGM/C prevalence but not for the type of cut. Further, DHS data are nationally representative and because they are inherently hierarchical are suitable for investigating associations between FGM/C and fistula while considering other contextual and socioeconomic correlates. Countries included in the analysis are: Burkina Faso (DHS 2010), Chad (DHS 2014–2015), Côte d’Ivoire (DHS 2011–2012), Ethiopia (DHS 2005), Guinea (DHS 2012), Kenya (DHS 2014), Mali (DHS 2012–2013), Nigeria (DHS 2008), Senegal (DHS 2010–2011) and Sierra Leone (DHS 2013). These countries we selected based on availability of data on FGM/C and fistula in the various DHS datasets. The lack of data on both FGM/C and fistula symptoms in certain surveys means that certain countries that could still be experiencing the burden of these conditions are excluded. It is equally important to note that due to lack of consistency in collecting data on both fistula and FGM/C, some of the latest DHS data were excluded (eg, data on fistula were not collected in the 2011 Ethiopia DHS and 2013 Nigeria DHS). We computed cross-tabulations to estimate bivariate associations between fistula and FGM/C status. Due to sample size limitations, we conducted country-specific multivariate analyses for only five countries (Chad, Côte d’Ivoire, Ethiopia, Kenya and Sierra Leone) that had at least 100 cases of fistula. Results of multivariate analysis for country specific data are not shown in this paper. For details, please see online supplementary file 1—likelihood of reporting fistula symptoms among women of reproductive age (15–49 years) in Chad, Côte d’Ivoire and Ethiopia; and online supplementary file 2—likelihood of reporting fistula symptoms among women of reproductive age (15–49 years) in Kenya and Sierra Leone. bmjopen-2018-025355supp001.pdf bmjopen-2018-025355supp002.pdf In addition, we conducted a multivariate logistic regression analysis using pooled data from the 10 focus countries. Multivariate logistic regression was used to assess associations between fistula and FGM/C, adjusting for other possible covariates. The choice of independent variables (possible covariates of fistula) was informed by an extensive literature review that identified underlying socioeconomic and contextual factors, including gender and sociocultural norms that affect both FGM/C and fistula.32 The review, for instance, showed that poverty, unemployment, living in a rural area, limited access to health services and malnutrition (stunting) increased the likelihood of women undergoing FGM/C and developing fistula. In addition, the level of education has been associated with a family’s choice to continue or abandon FGM/C and improves awareness about the importance of antenatal care (ANC) and facility delivery to prevent fistula.32 The dependent variable in the multivariate logistic regression analysis is fistula symptoms whereby women were categorised either as having reported involuntary leakage of urine and/or faeces from the vagina or not. The main independent variable is FGM/C status—women categorised either as cut or uncut. Although there are validity concerns about self-reported type of cut in the DHS,47 48 we also examined differences by type of FGM/C—women categorised as cut with genitals sewn closed or cut but genitals not sewn closed. Due to sample size limitations, we examined differences by type of cut using pooled data from the 10 countries. Other independent variables included in the analysis were categorised as follows: Maternal age at first birth—categorised into four groups (below 15 years, 15–19 years, 20–24 years, and 25 years and above); region—categorised by area of residence according to each country’s geographical/administrative boundaries; urban/rural residence—categorised based on whether a woman lived in an urban or rural setting; maternal education—categorised based on the highest level of education attained (no education, primary, and secondary and higher education); religion—categorised based on women’s religious affiliation, either as Christians (Catholic, Protestant and other Christians) or non-Christians (Muslim, traditionalist, animist and those with no religion); ethnicity—categorised according to a woman’s reported ethnic background which varied from country to country; wealth—women were grouped in one of five wealth quintiles (poorest, poorer, middle, richer and richest) generated through principal component analysis using household assets and amenities data; number of ANC visits—women were categorised depending on the number of ANC visits they undertook when they were pregnant (0 visits, 1–3 visits and four and more visits); and place of delivery—categorised based on whether a woman gave birth at a health facility or at home. Home deliveries also included births outside the homestead; for example, on the way to the health facility. Based on the literature review conducted by Sripad et al 32 exploring the association between FGM/C and fistula,32 we conducted multivariate logistic regression analysis to explore the relationship between FGM/C and fistula symptoms using data from DHS. We hypothesised that FGM/C status predisposes women to fistula symptoms (Logit Model I), but that this relationship can be confounded by socioeconomic factors (Logit Model II) and a woman’s geographical context and access to health services (Logit Model III). Results from cross-tabulations between FGM/C and fistula symptoms are presented as percentages while those from multivariate analyses are presented as unadjusted ORs and adjusted odds ratios (AOR) with 95% CIs. Estimates with p values of less than 0.05 were considered statistically significant. All analyses were conducted using IBM SPSS V.20 and were weighted taking into account the DHS sampling strategy. Missing data was handled by pairwise deletion. The study used publicly available secondary data from DHS (https://dhsprogram.com/). Patients and the public were not involved.

Materials

Innovations

The study aims to assess the relationship between female genital mutilation/cutting (FGM/C) and fistula among women in sub-Saharan Africa. The researchers conducted a secondary statistical analysis using cross-sectional data from Demographic and Health Surveys (DHS) in 10 countries. The DHS collects data on demographics, reproductive health, maternal and child health, and other health-related factors. The study analyzed data from women aged 15-49 years in Burkina Faso, Chad, Côte d’Ivoire, Ethiopia, Guinea, Kenya, Mali, Nigeria, Senegal, and Sierra Leone. The main outcome measure was fistula symptoms, and the study found that women who had undergone infibulation (severe form of FGM/C) were more likely to report fistula symptoms. Other factors associated with lower likelihood of reporting fistula symptoms were attending antenatal care and living in urban areas. The study suggests that interventions addressing FGM/C and other contextual factors are needed to prevent fistulas, and promoting ANC utilization could be a starting point. The study used multivariate logistic regression analysis to explore the relationship between FGM/C and fistula symptoms, adjusting for other possible covariates such as socioeconomic factors and access to health services. The study provides insights into the association between FGM/C and fistula and highlights the need for comprehensive interventions to improve maternal health.

AI Innovations Description

The study aims to assess the relationship between female genital mutilation/cutting (FGM/C) and fistula among women in sub-Saharan Africa. The researchers conducted a secondary statistical analysis using cross-sectional data from the Demographic and Health Surveys (DHS) in 10 countries. The DHS is a nationally representative survey that collects data on various health indicators, including FGM/C and fistula.

The study found that women who had undergone the most severe form of FGM/C (infibulation) were 1.5 times more likely to report fistula symptoms compared to those who had undergone other types of FGM/C. Additionally, women who attended antenatal care (ANC) and those who lived in urban areas were less likely to report fistula symptoms.

Based on these findings, the study recommends implementing multisectoral interventions that address harmful traditional practices like FGM/C, as well as other contextual and socioeconomic factors that contribute to the occurrence of fistula. Promoting ANC utilization is also suggested as a starting point in preventing fistulas.

It is important to note that the study used self-reported data, which may have limitations. However, previous studies have shown that self-reported measures of FGM/C status are a suitable proxy for prevalence. The study also acknowledges that some countries were excluded due to lack of data on both FGM/C and fistula.

Overall, the study provides valuable insights into the association between FGM/C and fistula and highlights the need for comprehensive interventions to improve access to maternal health and prevent fistulas.

AI Innovations Methodology

The study aims to assess the relationship between female genital mutilation/cutting (FGM/C) and fistula among women in sub-Saharan Africa using data from the Demographic and Health Surveys (DHS) in 10 countries. The DHS is a nationally representative cross-sectional health survey conducted in low-income and middle-income countries. It collects data on various health indicators, including FGM/C and fistula.

The methodology used in this study involved analyzing the cross-sectional data from the DHS surveys. The surveys collected data from women aged 15-49 years and men aged 15-59 years from nationally representative probability samples of households. The women’s questionnaire included a module on FGM/C, which asked about their own FGM/C status, their daughter’s FGM/C status, and their opinion about the continuation of the practice. The questionnaire also included questions about fistula, asking women if they have heard of fistula and if they have experienced fistula-like symptoms.

The study conducted bivariate and multivariate analyses to assess the associations between FGM/C and fistula. Bivariate associations were estimated using cross-tabulations, while multivariate logistic regression analysis was used to adjust for other possible covariates. The choice of independent variables in the regression analysis was informed by an extensive literature review, which identified socioeconomic and contextual factors that affect both FGM/C and fistula.

The results of the study showed that women who had undergone severe forms of FGM/C (infibulation) were more likely to report fistula symptoms. Other factors associated with a lower likelihood of reporting fistula symptoms were attending antenatal care and living in urban areas.

In summary, the methodology used in this study involved analyzing cross-sectional data from the DHS surveys to assess the relationship between FGM/C and fistula. Bivariate and multivariate analyses were conducted to explore the associations, taking into account other covariates. The study provides valuable insights into the relationship between FGM/C and fistula and highlights the importance of addressing harmful traditional practices and improving access to maternal health services.

Authors & Co-Authors

Statistics:

Citations: 7

Authors: 3

Identifiers:

DOI: 10.1136/bmjopen-2018-025355

Research Areas:

Community Interventions, Food Security, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants

Study Countries:

Burkina Faso, Chad, Ethiopia, Guinea, Ivory Coast, Kenya, Mali, Multi-Countries, Nigeria, Senegal, Sierra Leone

Study Design:

Case-Control Study, Cross Sectional Study

Study Approach:

Mixed-methods, Quantitative, Systematic Review

Participants Gender:

Male & Female