Female Genital Mutilation (FGM) - A Violation Shrouded in Culture and Religion

There are more than 200 million girls and women in Africa, the Middle East and Asia who have undergone female genital mutilation. This practice shrouded in culture and religion is a violation of women’s rights and a cause for many medical complications. Below is an interview of one of such women.

Dr. Daniel tell us a little about your background

My name is Jovita Ada Daniel, an Igbo of the Eastern part of Nigeria. I am a Physiotherapist, trained and practicing in Nigeria. I started my career at the Aminu Kano Teaching Hospital, Kano Nigeria where I practiced from the year, 1999 to 2009. While at the Aminu Kano Teaching Hospital, I developed an interest in Women's Health.

At what age did you undergo female genital mutilation (FGM)?

The FGM was carried out within the first two weeks of my birth as that was the practice in my hometown at that time. Thankfully, this practice is significantly lower in the community where I grew up. However, there are still some people who hold onto the belief that it is normal and even necessary to carry out circumcision on the 8th day of a girl’s life. They see it as culture and many even believe it is Biblical.

What has been most difficult for you since going through FGM?

I needed episiotomies during my first two deliveries, which I learnt later with increasing experience in Women's Health Physiotherapy, may have been related to being my being circumcised as an infant.

In what way can people be more involved in helping girls who have undergone FGM or to prevent more girls from being circumcised?

I believe that campaign against FGM should be carried into the rural areas and seminars should be organized to enlighten rural dwellers of the implications of FGM. Government and Non- Governmental Organizations need to support these campaigns. It is also very important for traditional rulers especially to be educated on the evils of FGM and be encouraged to speak to their communities since they wield clout with their followers.

Reference:

Female Genital Mutilation.
World Health Organization website http://who.int/mediacentre/factsheets/fs241/en/. Updated February 2016. Accessed January 18, 2017.


 

An Interview with a Duke University DPT Student Fundraiser – Taylor Chapman

We are pleased to introduce Taylor Chapman whom has completed a successful fundraising event for the GWHI in Chicago, IL.  Her singular efforts have resulted in an event that raised $1,000 for the foundation. Taylor is an amazing example of how one person can change the world!

Taylor Chapman is a 3rd year Doctor of Physical Therapy Student at Duke University and a Certified Strength and Conditioning Specialist. She is a member of the Women’s Health Section, the SoWH SIG, the Research Section and the Health Policy and Administration Section as well as a PT-PAC supporter. Taylor will present her research on “Comprehensive Primary Care Models for the Management of Multiple Chronic Conditions in Community-Dwelling Older Adults” at the 2017 Combined Sections Meeting, and gave a Poster presentation at the 2016 ACSM Annual Meeting on “Examining differences in movement competency in professional baseball players born in the United States and Dominican Republic.” She recently traveled to Guatemala with the Hearts in Motion organization to administer skilled physical therapy services via pop-up clinics in a variety of cities.
Taylor, how did you get interested in Women’s Health Physical Therapy?

As a Duke University DPT student in the class of 2017 I had a variety of opportunities to be exposed to the specialty through wonderful faculty and surrounding Women’s Health Clinics. I fell in love with the specialization because of the intimate environment and the inspiring passion Women’s Health clinician’s embody. My clinical instructor at ATI Physical Therapy, Amanda Bachman, was very supportive of my passion and assisted me in securing a 12-week rotation that positively impacted my future in WHPT.  I am now in the application process for a residency program in this specialty.

Why did you get involved with the Global Women’s Health Initiative? The GWHI is the perfect model to describe how I would like to transcend my professional career by first creating a sustainable foundation to then evolve and create positive change.  The start-up’s plan to build from the ground up by initially engaging medical professionals interested in the care of women in under-served communities, locally and globally, along with promoting a social medial message campaign that improves awareness of the current medical status in various countries pertaining to the care of women, will allow for a solid foundation to be built. As they evolve these efforts into awareness and support, funding as well as personal and professional efforts will naturally keep the mission moving forward. I have also had the pleasure of working with another wonderful and sustainable organization, Hearts in Motion, assisting locals via pop-up PT clinics in Guatemala.  I was first introduced to sustainable projects from Dr. Landry at Duke University.

The GWHI embodies two of my passions.  1) My ultimate ambition of educating medical professionals on the benefits of pelvic health physical therapy and to improve the public’s uneasiness and general unawareness of the specialty. 2) The ability to work with an organization whose mission is to transcend the public awareness into worldwide support and effort, utilizing service and education, to create systemic change.

Tell us how you created such a successful fundraising event over a short period?
I have always been involved in fundraising and event planning. I have volunteered my services to organizing charity events for the Make a Wish Foundation, planning social networking events with the various medical programs at Duke University, and acting as the Event Chair for my Greek Student Organization at Indiana University. I served on the Events and Dancer Relations committees for Indiana University Dance Marathon and I am currently the Events Coordinator for the Duke DPT Class of 2017.  
I worked with my Chicago connections, IU alumni/friends/family/colleagues, to raise awareness of WH on a local and global level.  I utilized a survey engine distributed via social media to inquire about the general public’s knowledge about WH PT and found that over 50% were unaware of these services.  I wanted to create an event to promote global perspective with an emphasis on education to improve awareness.  I contacted the event planner at State Restaurant, an Indiana University Alumni bar, to honest the event. I spread the word through social media, friends, connections through my helpful sister at Groupon, local companies and colleagues, and the physical distribution of flyers.  I was able to provide information to local universities and student organizations to help increase event attendance. Finally, I created a mechanism to allow for donations on and offsite of the event. During the fundraiser, I offered pelvic health knowledge as a driver and conversation starter.  Educational materials from the APTA Section on Women’s Health on pelvic floor trauma, fistula and prolapse promoted awareness for the physical therapy need in the US and abroad.  My goal was to give a global perspective and the event procured donations through awareness and in the form of raffles and food/drink donation.  I am so grateful to have successfully raised and donated $1,000.00 for this worthy organization.

An Interview with a GWHI Founding Member and the World Wide Fistula Fund Executive Board member – Tracy Spitznagle

Tracy Spitznagle has been involved in the international education of Urogynecologist and Physical Therapists as well as a provider of clinical services for the World Wide Fistula Fund since 2011 She has served in many leadership roles within her profession as a Women’s Health Physical Therapist.  Included in these positions is serving on the Board of Directors of the APTA Section on Women’s Health and Chair of the American Board of Physical Therapy Specialists.  She is also a very busy clinician and educator at Washington University in St Louis and a strong advocate for Women’s rights.  It is no wonder she has committed herself to the work of the Global Women’s Health Initiative both as a Board Member and as a donor!  The GWHI is focusing this time of the year towards giving and has partnered with the World Wide Fistula Fund during Giving Tuesday.  This amazing physical therapist sat down with us to talk about her involvement on the international stage.

What is the Vision/Mission of the World Wide Fistula Fund?
The World Wide Fistula Fund was developed by Dr Lewis Wall in 1995 to help women heal from birth related injuries.  The initial focus of WFF was fistula repair, however, now the organization is also caring for women with pelvic organ prolapse and post-partum dysfunctions.  Prolapse is now a 3rd world epidemic – and for the women of these regions – fistula and prolapse is believed at times to be a “curse” which limits their interactions with their families and communities as well as their ability to obtain education and earn a living.

Tracy, how did you get started with the World Wide Fistula Fund?  
I met Dr. Louis Wall in 2001 while in clinical practice at Washington University.  He was interviewing for a position as the Chair of Urogynecology and I was on the interview team.  At the time of his initial interview, He discussed my possible involvement in assisting women in Africa.  A few years later, The WFF sent me to Ethiopia to teach and observe at the Hamlin Fistula Hospital.

What has been your focus of your work with the World Wide Fistula Fund? 
My focus in the beginning was providing education for the PT staff at the Hamlin Fistula Center in Addis Ababa.  I worked with the staff treating women pre and post fistula surgeries. I supplemented the established rehabilitation program with lectures on lower extremity strengthening and care for foot impairments commonly found in the survivors of Fistula.  Over the years, as my participation grew, I was asked to join the Board of Directors.  After my second year on the Board, I was asked to join the executive council and served as secretary.  Now I continue to serve on the executive council as the Treasurer and the board representative for our Danja Fistula Hospital in Niger.
 
How has your practice with the World Wide Fistula Fund changed?
During my tenure with this organization, I have moved into al teaching role with the Urogynecology Fellowship program.  I have provided pelvic health lectures for both Physicians and Physical Therapists at the University of Mekelle.  In June of 2016, I was asked to facilitate the recruitment of faculty to enhance the Physical Therapy education for their first cohort of 5 students starting in 2017. Graciously, The World Wide Fistula Fund has provide the resources to cover some of the costs for this program, thus allowing Physical Therapy educators to engage in  capacity building within the Masters of Physical Therapy program at the University.  WFF is aiding in the development of the future educators of the Masters of PT program, thus allowing them to grow the PT program in within the scope of the Mekelle Medical School. A  long reaching aim of WFF is  to support  systemic change and sustainable growth of the healthcare services in the Tigren Region of Ethiopia.

What led you to become involved in the Global Women’s Health Initiative?
Rebecca Stephenson – a fellow inaugural board member invited my participation because of my work within the World Wide Fistula Fund.  Her engaging spirit, and never ending positivity has given me great hope that we can join together to make a change. There is an extreme lack of women’s health services in both 3rd world countries and underserved populations in our country.  I hope to transfer what we learn globally to local engagement, I believe that global is local and local is global. 

My overall hope is that GWHI will create resources to send and facilitate Physical Therapy care in underserved regions of the world. I feel so very blessed to be able to support sustainable programs for development of Women’s Health Physical Therapy on a global scale.

Please consider your own personal engagement; we who have so much can make a beautiful difference to those who have not.

Taking Stock: HIV/AIDS

The end of the year is around the corner and at this time many people around the globe take stock of their lives- their achievements, failures and goals or resolutions. Typically, the end of the year provides an opportunity to plan out goals for the coming year.  

December first was World AIDS day, below are global statistics and findings from 2015, and an initiative by UNAIDS. This list truly provides insight into where the global community can focus for goal setting for 2017:

•    In 2015 there were 34.9 million adults globally living with HIV, 51% of them were women
•    Also, in 2015 there were 2.1 million new HIV infections, 1.1 million AIDS related deaths and about 5700 new HIV infections daily
•    Since 2003 the number of AIDS-related deaths has decreased by 45%; this implies that more adults living with HIV age into adulthood. People living with HIV have increased risk of cardiovascular diseases
•    In Eastern and Southern Africa where 19.0 million people live with HIV, about 10.3 million are on antiretroviral therapy, this is double the number it was in 2010
•    Approximately 7500 women between ages 15 and 24 acquired HIV every week in 2015, this is linked to gender inequalities in societies
•    The risk of becoming infected with HIV increases significantly for adolescent girls in sub-Saharan Africa
•    AIDS is the leading cause of death among women aged 15 to 49
•    Childhood and adolescence violence increases HIV-related risk behavior among adolescent girls and young women
•    Child brides are at higher risk of sexually transmitted infections including HIV because they are unable to negotiate for safer sex
•    Violence can lead to decreased adherence to treatment among women living with HIV
•    90-90-90, a UNAIDS initiative established in 2014 “By 2020 90% of people living with HIV know their HIV status, 90% of people who know they are HIV status are accessing treatment, and 90% of people on treatment have suppressed viral loads”

HIV/AIDS is no respecter of persons. The good news! The risk of death has been greatly reduced! Sadly, women and children are more affected by HIV/AIDS than ever before. Keep in mind that the infection produces significant effects on the different systems of the body, and can result in major emotional and social consequences for those affected. In 2017, make it a goal to make a difference by supporting programs that help women, children and men affected by HIV/AIDs.

 

References

  • UNAIDS. AIDS by the number.  http://www.unaids.org/sites/default/files/media_asset/AIDS-by-the-numbers-2016_en.pdf. Accessed November 28, 2016.
  • UNAIDS. Get on the fast-track: the life-cycle approach to HIV. http://www.unaids.org/sites/default/files/media_asset/Get-on-the-Fast-Track_en.pdf. Accessed November 28, 2016.
  • Press Release. UNAIDS Website. http://www.unaids.org/en/resources/presscentre/pressreleaseandstatementarchive/2015/november/20151125_PS_womengirlshealthrights. Accessed December 1, 2016

An Interview with the Past President of the IOWPTH and GWHI Founding Member – Rebecca Stephenson

by Susan C. Clinton PT DScPT OCS WCS FAAOMPT

Rebecca Stephenson has served in many leadership roles within her profession as a Women’s Health Physical Therapist.  Included in these positions she served on the Board of Directors of the APTA Section on Women’s Health  and  as a delegate and President of the International Organization for Physical Therapists in Women’s Health (IOPTWH).  She is also a very busy clinician and a strong advocate for Women’s rights.  It is no wonder she has committed herself to the work of the Global Women’s Health Initiative both as a Board Member and as a donor!  What you may not know about Rebecca is that she is also a breast cancer survivor.  The GWHI is focusing this newsletter on Women’s Health and cancer.  This very dedicated physical therapist sat down with us to talk about her past personal struggles as well a her hope and advocacy for Women facing cancer.

Rebecca, when and how did you find out about your breast cancer

I actually had two separate diagnoses of breast cancer in 2003 and 2007.  The cancer in 2003 was discovered by a routine mammogram and the cancer in 2007 was found by her own self exam. 

What were your main concerns after being diagnosed? 

My biggest concern was which treatment regime to do following the earlier diagnosis.  I was given the choice about a single mastectomy, double mastectomy or lumpectomy with chemotherapy and radiation.  I chose the lumpectomy and followed all of the treatment with tamoxifen for 4 years. In hindsight, if I knew that I would later be diagnosed with breast cancer on the opposite breast in 2007, I would have opted for the complete double mastectomy early on.  Following my second diagnosis, I did opt for the double mastectomy and implants at the time of the surgery.

The information coming at me was enormous.  One of the best things I did to help me absorb the information and make decisions was taking a friend as a scribe to record the amount of information that was difficult to process.

How did your family reaction to the news?

In my blended family, I had three older sons and a young son the age of 8.  The information for my younger son to process created more fear than for the older two.  My husband and Ihandled the information with honesty about the diagnosis, prognosis and complete explanation of the treatment options I had selected.  We also shared the liftestyle restrictions that would ultimately affect our family during the treatment and recovery phase and encouraged them to be a part of the recovery process.

What coping strategies helped you the most throughout your treatment?

One of the lessons learned in my spiritual life was the following quote:  “ You are only willing to give what you are willing to receive”.  This concept became a reality during this time of healing.  I was able to create a web of support that helped me and my family work through the difficult times when I needed to concentrate on my treatment and recovery.  In addition, I was able to work with my employers and my Physicians to take the time I needed to focus on recovery instead of work.  I also had my Mother and Sister to care for me with my own and my family needs to assist in facilitating my care.  Finally, I put my meditation practice into the forefront of my life along with the ability to find joy in my everyday existence with myself and my family/friends.

What advice would you like to give to Women about breast cancer?

Please, please do not let the fear of diagnosis hold you back from taking action!  Early diagnosis, as in my case twice, was the key!  Nothing replaces the screening tests and self exam.  If you sense a problem,  please take action!  Breast cancer does not have to be terminal and treatment can allow you to continue to live a full and wonderful life.

How can other Women help to raise awareness about breast cancer?

My best advice for the future is to talk to our youth, both young women and men.  The more we know and share, the less fear there will be in seeking treatment.  Keep in mind that 1% of all breast cancer is in males.  If we are able to raise awareness we can move towards solving this disease across the globe.

'I Didn’t Know My Vagina Could Fall Down'

by Yewande Apatira DPT

“Knowledge is power. Information is liberating. Education is the premise of progress, in every society, in every family”- Kofi Annan

A few months ago a new patient was relating a visit she had with her gynecologist, the visit which led to her being eventually referred to a women’s health physical therapist. She had been feeling pressure in her vagina, which she thought was her bladder. However, she was informed that it was not her bladder but her vagina. With a look of bewilderment, she said in Spanish to the interpreter on the other end of the line, “I didn’t know my vagina could fall down.”

Pelvic organ prolapse (POP) is a global women’s health problem, impacting women of varying demographics.  POP is the descent of the anterior or posterior vaginal wall or apex (top) of the vagina, or the uterus. The descent may be caused by various factors including pregnancy and childbirth, ageing, chronic cough, regular heavy lifting and obesity. Signs and symptoms of POP may include a sense of pressure, lump or bulge in the vagina, a lump or bulge outside the vagina, difficulty with sitting and performing household functions, pain in the groin or lower back, and painful sexual intercourse. Some women may also experience vaginal spotting, problems with urination such as incontinence, and problems with defecation, such as needing to push back the posterior wall of the vagina in order to defecate, which is called splinting. Furthermore, POP can affect a woman’s occupational, mental and social well-being, causing significant emotional stress and even depression.

Two in five postmenopausal women will experience a degree of POP. In the United States, the prevalence of POP among community based women is 2.9 to 5.7%, and this number is expected to increase by 46% by the year 2050. Eleven percent of Dutch women, 8.3% of Swedish women and 8.8% of Australian women in a 2015 study reported feeling or seeing a vaginal bulge. In lower income countries, like Ethiopia, Nepal and India, the prevalence of POP ranged from 3.4% to 56.4% with an average of 19.7%.

In a 2014 study, a group of English and Spanish speaking women interviewed by a group of researchers stated that they lacked the basic knowledge on the anatomy and prevalence of POP. This lack of knowledge led to feelings of embarrassment, shame and self-blame.  In addition, the Spanish-speakers in the group noted concerns about not being able to adequately form the words that would express their health needs related to prolapse. The group as a whole indicated that they were surprised how common POP was, and felt relieved that they were not alone. They were of the opinion that having more information on POP would help them be better able to discuss their conditions with their families, friends and healthcare providers, and would also help decrease their fears.

Access to accurate information is an important step in improving the health of women worldwide. At GWHI we believe that both health professionals and communities should be educated on women’s health issues. Women should be empowered with information about the prevalence of their conditions, signs and symptoms of the conditions, options available to manage their conditions, including physical therapy, and how to access those resources.

Rererences

 

  • ·         Brown DN. Pelvic organ prolapse: a consequence of nature or nurture? Menopause. 2015;22(5):477-479.
  • ·         Cooper J, Annappa M, Dracocardos D, Cooper W, Muller S, Mallen C. Prevalence of genital prolapse symptoms in primary care: a cross-sectional survey. Int Urogynecol J. 2015;26(4):505-510.
  • ·         Dunivan GC, Anger JT, Alas A, et al. Pelvic organ prolapse: a disease of silence and shame. Female Pelvic Med Reconstr Surg. 2014;20(6):322-327.
  • ·         Kiyosaki K, Ackerman AL, Histed S, et al. Patients' understanding of pelvic floor disorders: what women want to know. Female Pelvic Med Reconstr Surg. 2012;18(3):137-142.
  • ·         Shrestha B, Onta S, Choulagai B, et al. Women's experiences and health care-seeking practices in relation to uterine prolapse in a hill district of Nepal. BMC Womens Health. 2014;14:20.
  • ·         Zeleke BM, Ayele TA, Woldetsadik MA, Bisetegn TA, Adane AA. Depression among women with obstetric fistula, and pelvic organ prolapse in northwest Ethiopia. BMC Psychiatry. 2013;13:236.

An Interview with the APTA Section on Women’s Health President – Pat Wolfe

In 2015, Pat was elected as President of the Section on Women’s Health where she serves as the official leader and public spokesperson for the Section.  Prior to being President, Pat served as Vice President and Director of Practice for the Section.   As a member of the Section of Women’s Health, she is also a member of the International Organization of Physical Therapists in Women's Health (IOPTWH).

The GWHI has partnered with the APTA – Section on Women’s Health to facilitate communication about the work of the foundation to 2,700 members.  This very busy physical therapist, Pat Wolfe, sat down with us to talk about her passion for Global Physical Therapy, her leadership in women’s health PT and the Global Women’s Health Initiative.

Pat, from your perspective, can you share why you are excited about the partnership with the APTA Section on Women’s Health?

I am very excited about the ability of our two organizations to increase communication about the global needs of physical therapy and women’s health.    The utilization of physical therapists with specialization in women’s health to improve global issues is badly needed in areas where resources are few.  There are so many that are not even close to sharing the privileges many of us have for health care.  By partnering with the Section on Women’s Health, over 2,700 members now have the opportunity to assist this non-profit organization by way of volunteerism, knowledge sharing and donations.  The Section also has a very vibrant and enthusiastic student group, and this partnership gives the student members opportunities to make a big difference on the global stage.  This partnership is relevant, direct and efficient.

You mentioned the very active student members, what can you say to the students to increase their involvement?

Our student members are very aware of global issues – this partnership can give them an opportunity to become part of something bigger than themselves at their entrance into the profession.   They can also learn to recognize the fact that they have a quality education and the ability to deliver services for those disenfranchised or without resources on the local and global level.  And to recognize that they can make a lifelong difference in #GlobalPT.

Pat, you were one of the first members to open your check book.  What moved you to make a donation?

How could I not?  In a short answer, it is my belief in social justice and human life!  I feel we all have an obligation to humanity to help improve the access of resources for others.

What capacity do you see yourself serving in the GWHI?

First of all, I believe in becoming a lifelong donator to this foundation as the work will not be a short term process.  Beyond this, I also see myself as a “voice” to garner and encourage more “voices” to help those that do not have the resources.  I plan to keep communication and dialogue present to disseminate information especially on the utilization of the funding on current and future projects.  Mostly, my serving in any of these capacities keeps me connected to something bigger than myself!

Pat left a wonderful closing remark:  To borrow a quote from the GWHI website – “A healthy woman leads to a sustainable community”

Mother’s Day can be so hard for some, Fistula repair and rehabilitations bring women HOPE.

When a woman with an obstetric fistula is finally able to get to a fistula treatment center, in many cases decades after the injury happened, she is finally hopeful for a change. The development of a fistula commonly occurs when birth is arrested and the fetus does not survive.  Hope grows with the prospect of help, hope that the despair and societal isolation will come to an end, and there is anticipation of becoming dry. Indeed, fistula surgeries are in many ways life saving for women who suffer significant trauma during childbirth. These surgeries to repair holes between the vagina and bladder or rectum, or both, have a high success rate of about 90%.

This hope can however, be fragile. After successful fistula repair, she may still not be dry, she may be weak unable to work, or she may have pain. Hope does not always last, and in some cases she may be considered accursed by members of her community because she does not heal and continued to leak even after surgery.  Up to 55% of women may experience persistent urinary incontinence after successful surgery.  But, rehabilitation can bring hope back. Stress urinary incontinence, a common condition of any women who has had vaginal birth, can be improved with pelvic floor rehabilitation.  Unfortunately, in Africa, rehabilitation for women who have had post-surgical repair of a fistula is not commonly offered.  The need is great for rehabilitation post fistula repair; physical therapy programs that address residual leg weakness, and specific care for the treatment of stress urinary incontinence can provide women with hope again. Not only can physical therapy help incontinence but the strengthening and education about how to safely regulate intra-abdominal pressure can be protective too.  Poor regulation of intra-abdominal pressure during activities of daily living, defecation and coughing could result in failure of a previously successfully closed fistula.  More rehabilitiation programs are needed world wide.

GWHI is committed to the fight to end obstetric fistulas through raising awareness and resources to support global women’s health, collaborating with other health professionals, increasing the involvement of physical therapists around the globe, and improving the lives of girls and women who are suffering or recovering from fistulas. Please help GWHI bring HOPE.

References:

  • Castille YJ, Avocetien C, Zaongo D, Colas JM, Peabody JO, Rochat CH. Impact of a program of physiotherapy and health education on the outcome of obstetric fistula surgery. Int J Gynaecol Obstet. Vol 124. Ireland: 2013.; 2014:77-80.
  • Donnelly K, Oliveras E, Tilahun Y, Belachew M, Asnake M. Quality of life of Ethiopian women after fistula repair: implications on rehabilitation and social reintegration policy and programming. Cult Health Sex. 2015;17(2):150-164.
  • Drew LB, Wilkinson JP, Nundwe W, et al. Long-term outcomes for women after obstetric fistula repair in Lilongwe, Malawi: a qualitative study. BMC Pregnancy Childbirth. 2016;16:2.
  • Hawkins L, Spitzer RF, Christoffersen-Deb A, Leah J, Mabeya H. Characteristics and surgical success of patients presenting for repair of obstetric fistula in western Kenya. Int J Gynaecol Obstet. Vol 120. Ireland: 2012 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd; 2013:178-182.
  • Nielsen HS, Lindberg L, Nygaard U, et al. A community-based long-term follow up of women undergoing obstetric fistula repair in rural Ethiopia. BJOG. Vol 116. England2009:1258-1264.
  • Stephenson R, Spitznagle T, Brook G, Broom R, Daniel J. Trauma induced pelvic floor disorders: implications for physical therapists. Presented at: IOPTWH Subgroup Seminar, World Confederation for Physical Therapy Congress; May 1-5, 2015. Singapore. http://www.wcpt.org/sites/wcpt.org/files/files/wpt15/SG-8-WomensHealth-handout.pdf. Accessed May 12, 2016
  • Tennfjord MK, Muleta M, Kiserud T. Musculoskeletal sequelae in patients with obstetric fistula - a case-control study. BMC Womens Health. 2014;14:136.