Incontinence and trauma: Sexual violence, female genital cutting and proxy measures of gynecological fistula

Obstetric fistula, characterized by urinary or fecal incontinence has begun to receive attention on the international public health agenda, however less attention has been given to traumatic fistula. Field reports indicate trauma contributes to the burden of incontinence, especially in conflict situations, however evidence is largely anecdotal or facility-based. This paper specifically examines the co-occurrence of incontinence and two potential sources of trauma: sexual violence (SV) and female genital cutting (FGC) using the most recent Demographic and Health Surveys in Malawi, Rwanda, Uganda and Ethiopia. Multivariate selection models are used to control for sampling differences by country. Results indicate that SV is a significant determinant of incontinence in Rwanda and Malawi, however not in Uganda. Simulations predict that elimination of SV would result in from seven to 26 percent reduction of the total burden of incontinence. In contrast, no evidence is found that FGC contributes to incontinence and this finding is robust to types of cutting and alternative samples. Results point to the importance of reinforcing programs which seek to address prevention of SV and for the integration of services to better serve women experiencing both SV and incontinence.