Advances in Probability, Stochastic

Processes and Applied Statistics

http://www.pphmj.com/journals/ptas.htm
OPEN Volume 1, 2022, Pages 1-12
ACCESS http://dx.doi.org/10.17654/PAS2022001

DETERMINANTS OF FEMALE GENITAL MUTILATION AMONG

REPRODUCTIVE WOMEN IN SUDAN: APPLICATION OF SURVEY LOGISTIC
REGRESSION

Ahmed Saied Rahama Abdallah* and Mohammed Omar Musa Mohammed

College of Business Administration in Hotat Bani Tamim
Prince Sattam Bin Abdulaziz University
Al-Kharj, Saudi Arabia

How to cite this article: Ahmed Saied Rahama Abdallah and Mohammed Omar Musa Mohammed, Determinants of female
genital mutilation among reproductive women in Sudan: application of survey logistic regression, Advances in Probability,
Stochastic Processes and Applied Statistics 1 (2022), 1-12. DOI: 10.17654/PAS2022001

This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

© 2022 Pushpa Publishing House, Prayagraj, India

Abstract

Background: This study is aimed to determine Female Genital Mutilation and its associated factors among
reproductive women in Sudan.

Methods: The study adopted the survey logistic model to investigate the association between female genital
mutilation and the predictors variables. The data was obtained from the multiple indicators cluster survey 2014 of
Sudan.

Results: The study revealed that the prevalence of female genital mutilation was 89.7%, all Sudanese states practiced
circumcision in both rural and urban areas. Also, the results showed that there were significant association between
place of residence, state, age group, education level, and wealth index and FGM, whereas marital status and daughter
circumcision were insignificant associated with FGM.

Conclusion: The study concluded that female circumcision was found in Sudan in all the regions, but in rural areas was
greater than that in urban areas. The prevalence of FGM was high in Sudan compared with other countries. The findings
showed that there was a significant association between place of residence, state, age group, education level, and wealth
index and FGM.
Keywords and phrases: survey logistic regression, female, genital mutilation determinants.
Received: September 21, 2021; Accepted: October 30, 2021; Published: November 30, 2021
*
Corresponding author

Advances in Probability, Stochastic Processes and Applied Statistics, Volume 1, 2022, Pages 1-12
2 Ahmed Saied Rahama Abdallah and Mohammed Omar Musa Mohammed

Background

Female genital mutilation (FGM), again recognized as female circumcision or female genital cutting, is
explained as the part or entire elimination of extraneous female genitalia and abuse to the female organs for
cultural or other nontherapeutic reasoning (UNICEF [1]). FGM is acted in different styles in 28 African
countries, and the social drivers behind the practice are various. Globally, three million girls are at risk of
genital mutilation, (WHO [2]) and predicted 200 million girls and women in the world have undergone FGM
(UNICEF [1]).
WHO classified FGM it into four categories namely clitoridectomy, excision, infibulations and type four
include all other harmful procedures (WHO, Female Genital Mutilation [3]). The rationale for performing
FGM differ from place to another, however, sociocultural factors are remarkable drivers of the practice.
Predominantly, it is usually conducted on young females between infancy and adolescence, and infrequently
on women (WHO, Female Genital Mutilation [3]).
The prevalence of FGM in women aged 15-49 years has been estimated to range from 0.6% in Uganda to
97.9% in Somalia (Bureau [4]). FGM is most prevalence in Africa, some countries in Asia and the Middle
East. FGM is practiced in Asian countries including India, Indonesia, Malaysia, as well as in Iraq, Jordan,
Saudi Arabia, and Yemen (UNDP [5]). In Iran, this practice is done in some provinces including Bushehr,
Hormozgan, Kurdistan, Khuzestan and Lorestan (Bassami et al. [6]).
Sudan is a developing country located in east North Africa with an area of 1.9 million km2, with the total
population of 36.2 million in 2014 based on the last census conducted in 2008. There were more than 15
million children below the age of 18 years and 4.5 million below the age of five years (WHO, Female Genital
Mutilation [3]). Furthermore, the number of states was 18 with different ethnic groups and different socio-
cultural practices. FGM is widely practiced in Sudan especially among girls aged between 6 and 12 years old.
The FGM is done or performed by the midwife without any antibiotic or anesthesia (Nour [7]).
In the previous studies, some of them indicated that the Infibulation or Pharaonic circumcision title was
applied by Sudanese when this practice disseminate from Upper Egypt to the North Sudan named Sudanese
circumcision (Kouba and Muasher [8]). This happens because Egypt is a neighbor of Sudan and there were
historical relations between them, and they are linked by marriage relations and social and cultural overlap. It
is self-evident that the phenomenon of pharaonic female circumcision is spreading in Sudan at high rates like
what happened in Egypt and the rest of African or Middle Eastern countries.
According to (UNICEF, Data and Analytics Section-Division of Data, Research and Policy [9]), nearly 9
out of 10 girls and women in Sudan have undergone FGM/C. A study conducted in Sudan revealed that, the
prevalence of FGM was 89%. Women who had circumcised daughters were 32.1% (Elduma [10]). FGM
among women and their daughters are significantly associated with household wealth index and mother
education, whiles women who lived in rural areas were less likely to undergo FGM (Ahinkorah et al. [11]).
FGM prevalence has dismissed fastest in countries with lower initial prevalence, and more slowly in
countries with higher initial prevalence. Although better-educated women and those in urban areas tend to
have lower prevalence, in some countries the opposite pattern is noticed (Batyra et al. [12]). Study conducted
in Burkina Faso reported that 70% of the participant women had FGM. In addition, religion, age, wealth,
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 Determinants of Female Genital Mutilation among Reproductive Women in Sudan … 3

literacy, ethnicity, household affluence, years of education, region and who had responsibility for health care
decisions in the household were all significantly related to the FGM (Karmake et al. [13]). Recently, there
was decreasing prevalence in FGM in Ethiopia (from 79.9% to 74.3% to 65.2%, P < 0.001). Also, there was a
declining trend of FGM in the daughters of the mothers who participated in the interview, with prevalence
significantly lower in mothers who had not themselves undergone FGM (Azez et al. [14]). Study conducted
by (Yaya and Ghose [15]) reported that, the overall prevalence of FGM was 39.9%, and that among their
daughters was 17.4%. Furthermore, factors such as age, place of residency, religious affiliation, educational
status, and wealth index appeared to be significant factors of FGM. The prevalence of FGM and daughters
were 48% and 34%, respectively. Higher odds of FGM habit and positive attitude towards it were correlated
with older age, family marriage, and lower tertials of wealth and education indicters. Early marriage was also
associated with expanded odds of FGM habit (Alosaimi et al. [16]).
The FGM pooled prevalence was 77.28%. It was higher in researches conducted from 2013-2017
(78.39%), and 92.02% for the studies conducted in Hospital (Fite et al. [17]).

The main objective of this study was to determine the factors associated with FGM among reproductive
women in Sudan.

Materials and Methods

The study used cross-sectional design. The data has been obtained from MICS 2014 of Sudan. The MICS
used multistage stratified cluster sampling. The study considered that, socidemographic and demographic
factors determine the FGM of reproductive women (15-49) year. The sample was limited to the women who
gave valid response to all questions. The sample size was 12302 women after excluding the missing values.

Study variables
The response variable for this study is the circumcision status which is a binary outcome. The
explanatory variables used in this study are women age, place of residence, daughter circumcision, state,
marital status, education level of mothers, and Wealth Index. The socioeconomic and demographic factors
used in this study were suggested by different researchers (Asemahagn [18]; Ahinkorah et al. [11]).

Survey logistic model

The standard logistic regression is, however, not suitable to analyze complex survey data in design.
Therefore, some upgrades to the normal approaches that take account of the survey design are crucial to
operate valid inferences from the survey data (Chen and Mantel [19]). The models of Logistic regression
adopted to apply to the data collected from the complex sampling designs have been called survey logistic
regression models in literature (Archer and Lemeshow [20]; Lee and Forthofer [21]). The statistical
properties of the survey logistic regression are like those of ordinary logistic regression. In survey logistic
regression, the first stage in each stratum sampled is the primary sample units (PSUs).

Survey logistic regression includes the design aspect in the estimation of the parameters to adjust the
standard errors of the estimates. Failure to account for the stratification, and sample weight in the analysis
lead to overestimation of the standard errors, and hence too wide confidence interval. The survey logistic
Advances in Probability, Stochastic Processes and Applied Statistics, Volume 1, 2022, Pages 1-12
4 Ahmed Saied Rahama Abdallah and Mohammed Omar Musa Mohammed

regression has similar philosophy to the ordinary logistic regression (Ayele et al. [22]). Rao and Scott [23]
reported that ordinary logistic regression is not suitable for analyzing data comes from complex survey
design.

Let U  1, 2, ..., N  be a finite population dived to h  1, 2, ..., H strata, furthermore, each stratum is
divided to j  1, 2, ..., nh primary sampling units(PSU), which is represented by i  1, 2, ..., nhj secondary
 SSU
sample units (SSU), including nhji elements. Suppose the set of observed data comprises of nhj
n n
h 1  jh1 i hj1 nhji .
H
selected from nh PSU in the stratum h. Then the overall observation will be n 

Let  hji  PYhji  1 X hji  , denote the probability of an event in the sample, and whji represents the
sampling weight in each sampling unit for hji-th.

Then the survey logistic is given by:

  hji 
logit  hji   log  ,
  X hj (1)
 1   hji 

where Yhji is the response variable, X hji is the covariate matrix, and  is the regression coefficient.

Due to complex design of the sample like unequal probability of selection, clustering, and stratification
the ordinary maximum likelihood estimation method may not work probably. As a result, survey logistic
regression used pseudo maximum likelihood estimation (PML) approach which takes sample design aspects
into account. The PMLE function for a single observation in complex sampling design is given by:

1  hji 1WhjiYhji .
w Yhji
 hjihji (2)

Therefore, the PML function for n observations are given by

nh 
h 1  j 1 i 1 hji 1  hji 1WhjiYhji .
H nhj whjiYhji
L WhjiYhji   (3)

To estimate the unknown parameters, we need to differentiate equation (3) with respect to i in general
equation (3) which does not have a close form of solution and hence an iterative algorithm is required to
obtain the PML estimates of unknown parameters.

Results

In the analysis missing values were excluded, the study sample size is 12302 women aged 15-49.
Descriptive statistics is done for the variables of the study, and survey logistic regression applied to achieve
the aim.

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 Determinants of Female Genital Mutilation among Reproductive Women in Sudan … 5

Table 1. Characteristics of the participant’s women

Variable % (n)
Age group
15-19 6.3(781)
20-24 14.5(1781)
25-29 21.2(2611)
30-34 18.1(2223)
35-39 18(2214)
40-44 12(1471)
45-49 9.9(1221)
Place of residence
Urban 29.5(3628)
Rural 70.5(9279)
Educational level
None 43.1(5306)
Primary 32.4(3991)
Secondary 17.9(2201)
Higher 6.5(804)
Wealth index
Poorest 19.9(2445)
Poor 23.8(2934)
Middle 21.5(2643)
Rich 17.6(2161)
Richest 17.2(2119)
Marital status
Currently married 92.9(11429)
Formally married 7.1(873)
States
Northern 5.7(706)
River Nile 5.4(662)
Red sea 4.5(552)
Kassla 5.8(709)
Gadarif 6(734)
Khartoum 5.8(708)
Gezira 6.8(838)
White Nile 5.8(715)
Sinnar 5.8(718)
Blue Nile 6(741)
North Kordofan 5.3(647)
South Kordofan 6.5(801)

Advances in Probability, Stochastic Processes and Applied Statistics, Volume 1, 2022, Pages 1-12
6 Ahmed Saied Rahama Abdallah and Mohammed Omar Musa Mohammed

West Kordofan 4.3(535)

North Darfor 5.3(652)
West Darfor 5.3(652)
South Darfor 6.1(747)
Central Darfor 3.8(470)
East Darfor 5.8(710)
Circumcision status
Yes 10.3(1268)
No 89.7(11034)
Daughter circumcision
Yes 75.6(9297)
No 24.4(3005)
Ever heard about circumcision
Yes 100(12302)
No 0(0)

Table 1 revealed that, 70.5% (9279) of participant women were from rural area and 29.5% (3628) from
urban area. All participant women 100% (12302) were heard about circumcision. The prevalence of FGM
was 89.7% (11034), furthermore, 21.2% (2611) belong to 25-29 years, 92.9% (11429) of participant women
were currently married. In addition, 43.1% (5306) of the participant women were not educated, 23.8% (2934)
of the participant women were poor, 75.6% (9297) of the women daughter were undergone FGM, and 6.5%
(801) of the participant women were from South Kordofan.

Table 2. Socio-demographic factors of participants with respect to circumcision status

Variables Circumcision status
No % (n) Yes % (n)
Age group
15-19 12.5(98) 87.5(683)
20-24 11.9(212) 88.1(1569)
25-29 11.5(301) 88.5(2310)
30-34 10.1(225) 89.9(1998)
35-39 10.5(233) 89.5(1981)
40-44 7.6(112) 92.4(1359)
45-49 7.1(87) 92.9(1134)
Place of residence
Urban 8.9(323) 91.1(3305)
Rural 10.9(945) 89.1(7729)
Education level
None 17.4(923) 82.6(4383)
Primary 6.3(251) 93.7(3740)
Secondary 3.2(71) 96.8(2130)
Higher 2.9(23) 97.1(781)

Advances in Probability, Stochastic Processes and Applied Statistics, Volume 1, 2022, Pages 1-12
 Determinants of Female Genital Mutilation among Reproductive Women in Sudan … 7

Wealth index
Poorest 11.4(278) 88.6(2167)
Poor 12.6(370) 87.4(2564)
Middle 15.6(411) 84.4(2232)
Rich 6.7(145) 93.3(2016)
Richest 3(64) 97(2055)
Marital status

Currently married 10.3(1179) 89.7(10250)

Formally married 10.2(89) 89.8(784)

States
Northern 1(10) 99(699)
River Nile 9(6) 99(656)
Red Sea 0.5(3) 99.5(549)
Kassala 11.8(84) 88.2(625)
Gadarif 17.4(128) 82.6(606)
Khartoum 6.4(45) 93.6(663)
Gezira 10.1(85) 89.9(753)
White Nile 3.2(23) 96.8(692)
Sinnar 11.8(85) 88.2(633)
Blue Nile 27.1(201) 72.9(540)
North Kordofan 0.6(4) 99.4(643)
South Kordofan 7.2(58) 92.8(743)
West Kordofan 4.9(26) 95.1(509)
North Darfor 1.2(8) 98.8(649)
West Darfor 41.3(269) 58.7(383)
South Darfor 12.2(91) 87.8(656)
Central Darfor 30(141) 70(329)
East Darfor 0.6(4) 99.4(706)
Daughter circumcision
Yes 10.9(1015) 89.1(8282)
No 8.4(253) 91.6(2752)

Table 2 showed that, 92.9% (1134) of participant women in age group 45-49 have undergone underwent
FGM, 89.1% (7729) of the participant women from rural area have undergone underwent FGM. The
prevalence of FGM was higher among higher-educated women 97.1% (781) compared to non-educated
women 82.6% (4383). On the other hand, 97% (2055) of the richest women have undergone FGM.
Furthermore, 27.1% (201) of the Blue Nile state did not undergo FGM. The prevalence of FGM among
daughters whose mother underwent FGM was 91.6% (2752).

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8 Ahmed Saied Rahama Abdallah and Mohammed Omar Musa Mohammed

Table 3. Type 3 analysis of effects on FGM

Variables F-value Num-DF Den-DF P-value
Place of residence 59.19 1 11582 <.0001
States 59.12 17 11566 <.0001
Age group 7.80 6 11577 <.0001
Marital status 0.12 1 11582 0.7296
Education level 66.60 3 11580 <.0001
Daughter circumcision 0.73 1 11582 0.3929
Wealth index 9.15 4 11579 <.0001

Table 3 revealed that, there were significant association between place of residence, state, age group,
education level, and wealth index and FGM, whereas marital status and daughter circumcision were
insignificantly associated with FGM.

Table 4. Survey logistic regression analysis results for circumcision status

Variables OR 95% CI
Age group
15-19 2.909 (1.838, 4.606)
20-24 2.460 (1.711, 3.538)
25-29 2.283 (1.617, 3.223)
30-34 1.941 (1.357,2.777)
35-39 2.082 (1.467, 2.955)
40-44 1.138 (0.765,1.691)
45-49 Ref
Daughter circumcision
No 0.908 (0.727, 1.134)
Yes Ref
Place of residence
Rural 0.481 (0.399, 0.579)
Urban Ref
State
Blue Nile 8.034 (6.036, 10.693)
Central Darfor 7.515 (5.378, 10.502)
East Darfor 0.139 (0.050, 0.386)
Gadarif 4.334 (3.193, 5.883)
Gezira 4.165 (2.918, 5.945)
Kassala 3.263 (2.367, 4.499)
Khartoum 2.390 (1.592, 3.589)
North Darfor 0.229 (0.108, 0.487)
North Kordofan 0.121 (0.044, 0.332)
Northern 0.740 (0.322, 1.705)

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 Determinants of Female Genital Mutilation among Reproductive Women in Sudan … 9

Red Sea 0.161 (0.047, 0.551)

River Nile 0.525 (0.223, 1.236)
Sinnar 4.048 (2.981, 5.498)
South Darfor 2.245 (1.593, 3.163)
South Kordofan 1.277 (0.869, 1.876)
White Nile Ref
Marital status
Currently married 0.946 (0.689, 1.298)
Formally married Ref
Education level
None 6.728 (4.537, 9.978)
Primary 1.756 (1.192, 2.585)
Secondary Ref
Higher 1.537 (0.884, 2.671)
Wealth index
Poor 1.587 (0.986, 2.553)
Poorest 1.607 (0.956, 2.701)
Middle 2.353 (1.544, 3.587)
Rich 1.308 (0.861, 1.988)
Richest Ref

Table 4 illustrates the findings of survey logistic regression for the circumcision status by selected
characteristics. The findings revealed that, women who were aged 15-19 (OR  2.909; 95% CI: 1.838-4.606)
were more likely to circumcise compared to those who were aged 45-49. Women who reside in rural areas
(OR  0.481; 95% CI: 0.399-0.579) were more likely to circumcise relative to those who reside in urban
areas. Furthermore, women from Blue Nile state (OR  8.034; 95% CI 6.036-10.693) were more likely to
circumcise compared to those who were from White Nile state, non-educated women (OR  6.728; 95% CI
4.537: 9.978) were more likely to circumcise compared to those with secondary education level. In addition,
women who currently married (OR  0.946; 95% CI  0.689: 1.298) were more likely to circumcise relative
to those who formally married. In terms of wealth index, the middle group women (OR  2.353; 95% CI
1.544-3.587) were more likely to circumcise compared to the rich group women.

Discussion

Female circumcision is considered one of the old Sudanese customs in Sudanese society for a long time,
due to Sudan’s near to the Republic of Egypt, in which the phenomenon of Pharaonic FGM began and then
spread to Sudan and then to the rest of the countries.

The study showed that the all the participant’s women were heard about circumcision. These results
indicate that every respondent in the study know the circumcision either from families or communities. The
Advances in Probability, Stochastic Processes and Applied Statistics, Volume 1, 2022, Pages 1-12
10 Ahmed Saied Rahama Abdallah and Mohammed Omar Musa Mohammed

prevalence of FGM was 89.7% which is a high rate and its due to habits in all Sudanese states in both rural
and urban areas. This result agrees with study of (Elduma [10]) result, he found the prevalence of FGM in
Sudan 89%. And this result contradicted with two results one of them obtained by (Azez et al. [14]) they
revealed a decreasing in the prevalence of FGM from 79.9% to 65.2%; and the result of (Yaya and Ghose
[15]) they showed that a prevalence of FGM decreased to 39.9%.

The study obtained that there were significant association between place of residence, state, age group,
education level, and wealth index and FGM, whereas marital status and daughter circumcision were
insignificant associated with FGM. This result agrees is in the same line of (Ahinkorah et al. [11]; Karmake
et al. [13]).

The findings showed that women who were aged 15-19 (OR  2.909) were more likely to circumcise
compared to those aged 45-49. This result indicates that too young women had a chance to circumcise 2.909
times than those in the age 45-49 years.

Women who were residing in rural areas (OR  0.481) were more likely to circumcise compared to
women who living in urban areas. This result indicates that rural areas practiced circumcision more than
urban areas, this need more efforts should be exerted be community organizations to raise awareness among
both urban and rural areas and give more attention to rural areas particularly the far away states. These states
suffer from the lack of education, health services, and job opportunities. Furthermore, non-educated women
(OR  6.728) were more likely to circumcise compared to those with secondary education level. This result
indicates that none educated women did these habits with high rates than those with secondary education and
other level of education. This results the absence of an educational role in explaining the dangers of
practicing the circumcision habits.

Circumcision habit is practiced in all Sudanese states, which means that all Sudanese females’ exposure
to circumcision. So, the role of community’s societies appears here to stop this habit or at least reduce the rate
of practicing it.

Conclusion

The study concluded that female circumcision was found in Sudan in all the regions, but in rural areas
was greater than that in urban areas. The prevalence of FGM was high in Sudan in comparison with other
countries. The findings showed that there was a significant association between place of residence, state, age
group, education level, and wealth index and FGM.

Acknowledgments

The authors thank UNICEF for permitting them to use the data. Also, they thank Dr. Dawit for his help
in the data analysis process.

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 Determinants of Female Genital Mutilation among Reproductive Women in Sudan … 11

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