18 May

Building Awareness of the Link between Fistula and Gender-Based Violence

Genital fistula, an abnormal hole between the vagina and rectum or bladder that causes urinary or fecal incontinence, is a devastating, preventable condition that no woman should have to endure. It usually results from inadequately managed, prolonged or obstructed labor, surgical error, or trauma [1, 2].  Although rare, it can be completely debilitating—physically, socially, and economically—particularly to women who live in remote areas without access to treatment; women with fistula are often shunned from the household or society, which can cause immense suffering  [3].

While sexual violence can cause traumatic fistula, the vulnerable state of women with fistula gives reason to suspect that the risk of violence could also increase after the onset of fistula [4, 5, 6], though no studies have attempted to evaluate this to date.  Moreover, because it is so rare, it is difficult to capture statistically significant associations with the condition.

The DHS Program provides an opportunity to study such rare events because of the inclusion of standardized questions in numerous, nationally-representative  surveys with large sample sizes. In a study conducted to further examine the relationship between fistula and violence, data were pooled from 12 DHS surveys, 11 conducted in Sub-Saharan African countries and one in Haiti, where standardized modules (sets of questions) on the two topics were included.

In total, 90,276 women were included in the analysis.  Among these women, the prevalence of self-reported symptoms of fistula ranged from 0.4% to 2.0%.  Regression analyses confirmed an association with sexual violence: women who have experienced sexual violence, both ever as well as within the 12 months preceding the survey, have almost twice the odds of reporting symptoms of fistula. Although there are no questions posed on timing of onset of symptoms of fistula in the DHS, the association with lifetime as well as recent experience of sexual violence suggests that violence could occur both before as well as after fistula’s onset.

One other finding of interest was that women whose first experience of sexual violence was committed by a non-partner had over four times the odds of reporting symptoms of fistula than women who did not report sexual violence.  Although inferences from these findings can only be made with caution, the temporality relationship between fistula and sexual violence deserves further investigation.

In light of International Day to End Fistula on May 23, it is imperative to continue to work towards minimizing occurrence of fistula by building awareness around conditions that contribute to and result from this morbidity. This study shows yet another disheartening correlation between gender-based violence and poor health outcomes for women. It provides even more impetus for training and sensitivity for women’s health care providers in this area.

full studyA poster presentation of the study was exhibited at the 2016 Annual Meeting of the Population Association of America (PAA) in Washington DC. More information can be found in this poster.




  1. Longombe AO, Claude KM, Ruminjo J. Fistula and traumatic genital injury from sexual violence in a conflict setting in Eastern Congo: case studies. Reprod Health Matters. 2008 May;16(31):132-41
  2. Raassen TJ, Ngongo CJ, Mahendeka MM. Iatrogenic genitourinary fistula: an 18-year retrospective review of 805 injuries. Int Urogynecol J. 2014 Dec;25(12):1699-706.
  3. Baloch, B.A., A. Salam, D. ZaibUnnisa, and H. Nawaz. 2014. Vesico-Vaginal Fistulae. The Professional Medical Journal, 21(5), 851-855.
  4. ACQUIRE. 2006. Traumatic gynecologic fistula: A Consequence of Sexual Violence in Conflict Settings. A report of a meeting held in Addis Ababa, Ethiopia, September 6-8, 2005. New York, The ACQUIRE Project/EngenderHealth.
  5. Peterman A, Johnson K. Incontinence and trauma: sexual violence, female genital cutting and proxy measures of gynecological fistula. Soc Sci Med. 2009 Mar;68(5):971-9.
  6. Naved RT, Blum LS, Chowdhury S, Khan R, Bilkis S, Koblinsky M. Violence against women with chronic maternal disabilities in rural Bangladesh. J Health Popul Nutr. 2012 Jun;30(2):181-92.


11 May

Spotlight on New Staff: Lindsay Mallick

lindsayandaviName: Lindsay Mallick

Position title:  Research Associate/Data Analyst

Languages spoken: English, French

When not working, favorite place to visit: Target. Just kidding.  But I’d love to vacation somewhere, anywhere, again one day.  Can someone spot me some leave? I can’t seem to save any since I came back from maternity leave!

Favorite type of cuisine: Anything I don’t have to cook or can’t cook myself, like Indian and sushi. Yum!

Last good book you read: “Expecting Better” by Emily Oster. She’s an economist who debunks a lot of the overly-prudent pregnancy restrictions with sound research and presents statistics on common pregnancy fears, myths, and the nitty gritty of labor and delivery.

Where would we find you on a Saturday?   At home, spending quality time with my family.  AKA, dancing to toddler radio, finding new places to hide the TV remote controls, narrowly avoiding lego foot injuries, and passing out early after a blissful 30 minutes of TV and cuddling with my husband.

First time you worked with DHS survey data: At Tulane for my MPH program, using the 2006 Mali DHS dataset to look at genital cutting for a research project in a class.

What is on your desk (or bulletin board/wall) right now?  Pictures of my son and husband; trinkets from around the world, kindly brought to me from my traveling coworkers.

What is your favorite survey final report cover?   2000-01 Mauritania DHS because that’s where I served in the Peace Corps!

Favorite chapter or indicator, and why? Family planning—I’m always interested to learn what the latest contraceptive prevalence rate and method mix is in a new survey, and see how that has changed over time.

What’s your favorite way to access The DHS Program’s data? From my hard drive, where I have many datasets stored for everyday use.

What population or health issue are you most passionate about?  Why?  It’s hard to choose just one.  They are all so important and intricately linked.  In the Peace Corps, I focused on water and sanitation, because they’re so fundamental to health.

What are you most looking forward to about your new position?  There is so much to learn working here, from new survey findings to working with DHS data.

What has been your biggest surprise so far?  The kind and supportive work environment—I really lucked out with this job.  My colleagues and supervisors are truly amazing people!

What do you look forward to bringing to The DHS Program (job-related or not!)? Funny stories, pictures and videos of life with a toddler.

The information provided on this Web site is not official U.S. Government information and does not represent the views or positions of the U.S. Agency for International Development or the U.S. Government.

The DHS Program, ICF
530 Gaither Road, Suite 500, Rockville, MD 20850
Tel: +1 (301) 407-6500 • Fax: +1 (301) 407-6501