Katie Paine

The long-term reproductive health consequences of female genital cutting in rural Gambia: a community-based survey

This paper examines the association between traditional practices of female genital cutting (FGC) and adult women’s reproductive morbidity in rural Gambia. In 1999, we conducted a cross‐sectional community survey of 1348 women aged 15–54 years, to estimate the prevalence of reproductive morbidity on the basis of women’s reports, a gynaecological examination and laboratory analysis of specimens. Descriptive statistics and logistic regression were used to compare the prevalence of each morbidity between cut and uncut women adjusting for possible confounders. A total of 1157 women consented to gynaecological examination and 58% had signs of genital cutting. There was a high level of agreement between reported circumcision status and that found on examination (97% agreement). The majority of operations consisted of clitoridectomy and excision of the labia minora (WHO classification type II) and were performed between the ages of 4 and 7 years. The practice of genital cutting was highly associated with ethnic group for two of the three main ethnic groups, making the effects of ethnic group and cutting difficult to distinguish. Women who had undergone FGC had a significantly higher prevalence of bacterial vaginosis (BV) [adjusted odds ratio (OR)=1.66; 95% confidence interval (CI) 1.25–2.18] and a substantially higher prevalence of herpes simplex virus 2 (HSV2) [adjusted OR=4.71; 95% CI 3.46–6.42]. The higher prevalence of HSV2 suggests that cut women may be at increased risk of HIV infection. Commonly cited negative consequences of FGC such as damage to the perineum or anus, vulval tumours (such as Bartholin’s cysts and excessive keloid formation), painful sex, infertility, prolapse and other reproductive tract infections (RTIs) were not significantly more common in cut women. The relationship between FGC and long‐term reproductive morbidity remains unclear, especially in settings where type II cutting predominates. Efforts to eradicate the practice should incorporate a human rights approach rather than rely solely on the damaging health consequences.

The burden of reproductive-organ disease in rural women in The Gambia, West Africa

BACKGROUND Data on the epidemiology of reproductive-organ morbidity are needed to guide effective interventions, to set health-care priorities, and to target future research. This study aimed to find out the prevalence of reproductive-organ disease in a sample of rural Gambian women. METHODS A questionnaire on reproductive health was administered by fieldworkers to women aged 15-54 years living in a rural area under demographic surveillance. A female gynaecologist questioned and examined the women (including speculum and bimanual pelvic examinations). Vaginal swabs were taken to test for Trichomonas vaginalis, Candida albicans, and bacterial vaginosis, cervical smears for cytology, cervical swabs for Chlamydia trachomatis PCR and Neisseria gonorrhoeae culture, and venous blood for haemoglobin, HIV, herpes simplex virus 2, and syphilis serology. FINDINGS 1348 (72.0%) of 1871 eligible women took part. Reproductive-organ symptoms were more likely to be reported to the gynaecologist (52.7% of women) than to the fieldworker (26.5%). Menstrual problems, abnormal vaginal discharge, and vaginal itching were the most commonly reported symptoms. A minority of women said they had sought health care for their symptoms. The frequencies of reproductive-organ morbidity were high: menstrual dysfunction 34.1% (95% CI 29.6-39.1), infertility 9.8% (8.2-11.6), reproductive-tract infections 47.3% (43.7-51.0), pelvic tenderness 9.8% ((7.0-13.5), cervical dysplasia 6.7% (5.2-8.4), masses 15.9% (12.5-20.1), and childbirth-related damage to pelvic structures 46.1% (40.1-52.3). 948 (70.3%) women had at least one reproductive-organ disorder. INTERPRETATION For these rural women, whose lives depend heavily on their reproductive function, reproductive-organ disease is a large burden. In inadequately resourced rural areas, with poor education, heavy agricultural and domestic labour, and limited access to quality health care, many women are not able to attain and maintain reproductive health and wellbeing.

Before we were sleeping, now we are awake: preliminary evaluation of the Stepping Stones sexual health programme in The Gambia

Community-based behavioural interventions aimed at reducing risky sexual behaviour have yet to be shown to be effective in the developing world. Stepping Stones is a participatory STI/HIV prevention workshop programme based on empowerment techniques, which has been adapted to an infertility prevention framework for The Gambia. This paper describes a preliminary evaluation in two villages where the intervention was carried out compared to two control villages. Methods used include: participatory evaluation; 84 in-depth interviews; seven focus group discussions; a knowledge, attitudes and practice questionnaire administered to a random sample of 25% of the adult population at three time points; and monitoring of condom supply. The structure of the evaluation is based on the themes derived from the qualitative data. The infertility prevention approach made it possible to overcome resistance to discussing the topics of sexual and reproductive health. An atmosphere of trust was created and men were persuaded to participate in the programme as they felt that their own needs were being addressed. Participants enjoyed the programme and found the content relevant. Knowledge of the modes of transmission of HIV and sexually transmitted infections and levels of risk awareness increased. The value of condoms in particular situations was recognised: for sex before marriage, within marriage (when the woman is breastfeeding) and with non-marital partners. Women reported that they would insist on condom use outside marriage and even ask their husbands to use condoms for non-marital sex. Condom monitoring data suggested that condom uptake had increased. It was reported that there was significant increase in dialogue within marriage with the consequence that there were fewer disagreements and incidents of domestic violence. Diffusion of the messages of Stepping Stones appeared to have taken place with non-participants including children. The evaluation techniques used can now be refined in order to generate further evidence on a larger scale and over a longer period.

Female ‘circumcision’ and adult reproductive morbidity in rural Gambia, West Africa

and consenting women had pelvic and eye examinations. Vaginal and cervical swabs were obtained to evaluate presence of common reproductive tract infections, and a serum sample was obtained to measure prolactin. Tubal patency was assessed by hysterosalpingography. Results: Eighty-three out of the 913 married women less than 4.5 years of age (9%) were diagnosed as infertile (2% primary and 7% secondary). In a sub-sample of 57 women who had not given birth in the previous five years 50 (88%) had an HSG. Twenty-eight (56%) of these were normal, 9(18%) had hydrosalpinges, while 11(22%) had tubal occlusion. Congenital uterine anomaly occurred in two patients. Eight women had expressed galactorrhoea, and five of these women had hyperprolactinaemia. Assessment of the male partners is ongoing, as well as whether adverse or beneficial interactions arise between trachoma and chlamydial genital disease. Conclusions: The prevalence of infertility in this population is relatively low. The combination of galactorrhoea and hyperprolactinaemia is not uncommon, and treatment of infertile women having galactorrhoea with bromocryptine in resource poor conditions might be appropriate.

Reproductive health and depression: A community survey in the Gambia, West Africa

BACKGROUND Depression is the commonest mental illness in developing countries and impoverished women are most at risk. Formal mental health services in these situations are rare. Depression commonly co-presents with physical symptoms or else is unspectacular, so the condition often goes unrecognised. To strengthen the prevention and management of depression, information is required on easily recognisable correlates of depression. This study explored associations between depression and reproductive health conditions in rural African women of reproductive age. METHODS A community-based reproductive health survey among rural women aged 15-54 years in The Gambia, West Africa, included screening with a modified Edinburgh Depression Scale (EDS), a reproductive health questionnaire and a gynaecological examination. Depression was then assessed clinically and data for 565 women were used to estimate the prevalence of depression and examine associations with reproductive health conditions and demographic factors. RESULTS The weighted prevalence of depression was 10.3% (95% CI 8.3-12.7). Being depressed was most significantly associated with widowhood or divorce (adjusted Odds Ratio (aOR) 8.42, 2.77-25.57), infertility (3.69, 1.42-9.65) and severe menstrual pain (3.94, 1.52-10.27). There were significant differences between ethnic groups. Being in the postpartum period was not associated with an increased likelihood of depression. CONCLUSION This study points to the importance of reproductive potential and reproductive health in maintaining womens mental well-being across different strata of a rural and resource-poor society. It could provide an initial focus for the management of women with depression as well as directing future research in reproductive health and psychiatry.