Management of type III female genital mutilation in Birmingham, UK: A retrospective audit

Discerning Deinfibulation: Impact of Personal, Professional, and Familial Influences on Decision-Making

The past decades have seen large numbers of Somali women migrate across the globe. It is critical for healthcare workers in host countries to understand healthcare needs of Somali women. The majority of Somali female migrants experience female genital cutting (FGC). The most common type in Somalia is Type 3 or infibulation, the narrowing of the vaginal introitus. Deinfibulation opens the introitus to reduce poor health outcomes and/or allow for vaginal births. In this study, we explored the perspectives of Somali women living in the United States about deinfibulation. We recruited 75 Somali women who had experienced FGC through community-based participatory research methods. Bilingual community researchers conducted qualitative interviews in Somali or English. University faculty and community-based researchers coded data together in a participatory-analysis process. We identified four themes. (1) Personal Views: participants reported positive attitudes toward deinfibulation and varied on the appropriateness of deinfibulation before marriage. (2) Benefits: identified benefits included alleviation of health problems; improved sexual health, in particular reduction or prevention of sexual pain; and reclamation of body and womanhood. (3) Barriers: these included associated stigma and lack of knowledge by providers. (4) Decision-Making: most reported that husbands, healthcare providers, and elder female community members may provide advice about if and/or when to seek deinfibulation, though some felt deinfibulation decisions are solely up to the impacted woman. An ecological framework is used to frame the findings and identify the importance of healthcare workers in assisting women who have been infibulated make decisions.

Examining the key features of specialist health service provision for women with Female Genital Mutilation/Cutting (FGM/C) in the Global North: a scoping review

Background

Health care for women with Female Genital Mutilation/Cutting (FGM/C) in the Global North is often described as sub-optimal and focused on maternity care. Specialist FGM/C services have emerged with little empirical evidence informing service provision. The objective of this scoping review is to identify the key features of FGM/C specialist care.

Methods

The review was conducted in accordance with JBI methodology. Participants: organisations that provide specialist FGM/C care. Concept: components of specialist services. Context: high-income OECD countries. Eligibility criteria included primary research studies of any design from 2012 to 2022, providing a comprehensive description of specialist services. Seven bibliographic databases were searched (MEDLINE, EMBASE, CINAHL, Web of Science, SCOPUS, Cochrane Library and MIC). The components of "specialist" (as opposed to "generalist") services were defined and then applied to an analysis of FGM/C specialist care. FGM/C specialist provision was categorised into primary (essential) and secondary features. Data were extracted and analysed descriptively through charting in tables and narrative summary.

Results

Twenty-five papers described 20 unique specialist services across eleven high income countries. Primary features used to identify FGM/C specialist care were:-(i) Named as a Specialist service/clinic: 11/20 (55%); (ii) Identified expert lead: 13/20, (65%), either Midwives, Gynaecologists, Urologist, or Plastic Surgeons; (iii) Offering Specialist Interventions: surgical (i.e., reconstruction and/or deinfibulation) and/or psychological (i.e., trauma and/or sexual counselling); and (iv) Providing multidisciplinary care: 14/20 (70%). Eleven services (in Spain, Sweden, Switzerland, Germany, Italy, Netherlands, France, Belgium, and USA) provided reconstruction surgery, often integrated with psychosexual support. No services in UK, Norway, and Australia offered this. Six services (30%) provided trauma therapy only; 25% sexual and trauma therapy; 15% sexual therapy only; 30% did not provide counselling. Secondary features of specialist care were subdivided into (a) context of care and (b) the content of care. The context related to concepts such as provision of interpreters, cost of care, community engagement and whether theoretical underpinnings were described. Content referred to the model of care, whether safeguarding assessments were undertaken, and health education/information is provided.

Conclusion

Overall, the features and composition of FGM/C specialist services varied considerably between, and sometimes within, countries. Global guidelines advocate that specialist care should include access to deinfibulation, mental health support, sexual counselling, and education and information. The review found that these were rarely all available. In some high-income countries women cannot access reconstruction surgery and notably, few services for non-pregnant women mentioned safeguarding. Furthermore, services for pregnant women rarely integrated trauma therapy or psychosexual support. The review highlights a need for counselling (both trauma and psychosexual) and culturally-appropriate sensitive safeguarding assessments to be embedded into care provision for non-pregnant as well as pregnant women. Further research is needed to extract the features of specialist services into a comprehensive framework which can be used to examine, compare, and evaluate FGM/C clinical specialist care to determine which clinical features deliver the best outcomes. Currently a geographical lottery appears to exist, not only within the UK, but also across the Global North.

[Obstetrical and neonatal prognosis of patients with a history of female genital mutilation]

OBJECTIVE

Female genital mutilation (FGM) covers all procedures involving partial or total removal of the external genitalia for non-therapeutic purposes. The period of pregnancy and childbirth is probably more at risk of complications for these women. The main aim of this study was to compare obstetrical, maternal and neonatal outcomes in patients with a history of female genital mutilation with patients without such a history.

METHODS

All deliveries taking place between January 2005 and June 2022 at Besançon University Hospital in patients with a history of FGM were included. This group was compared with a randomly selected group of deliveries of patients with no history of FGM. A total of 87 deliveries with a history of FGM were included and compared with 696 deliveries with no history of FGM.

RESULTS

There were significantly more instrumental deliveries (27.6% vs. 17.5%, P=0.01), more caesarean sections (23% vs. 14.1%, P=0.01), more episiotomies (9.2% vs. 0.7%, P<0.01), more first-degree perineal tears (30.8% vs. 20.8%, P=0.02), second-degree (13.9% vs. 5.3%, P<0, 01), third-degree (3.1% vs. 0.2%, P=0.02), more anterior perineal tears (23.1% vs. 2.5%, P<0.01), increased duration of pushing efforts (13 min vs. 10 min, P=0.05) and greater blood loss (297 cc vs. 165 cc, P<0.01) in the group with a history of FGM. There was no statistically significant difference in neonatal outcome.

CONCLUSION

The obstetrical prognosis of patients with a history of FGM is significantly poorer. Neonatal prognosis remains unchanged.

Views of female genital mutilation survivors, men and health-care professionals on timing of deinfibulation surgery and NHS service provision: qualitative FGM Sister Study

Background

Female genital mutilation is an important UK health-care challenge. There are no health benefits of female genital mutilation, and it is associated with lifelong physical, psychological and sexual impacts. The annual cost to the NHS to care for survivors is £100M. Deinfibulation may improve the health and well-being of some women, but there is no consensus on the optimal timing of surgery for type 3 survivors. UK care provision is reportedly suboptimal.

Objectives

We aimed to explore the views of survivors, men and health-care professionals on the timing of deinfibulation surgery and NHS service provision.

Methods

This was a qualitative study informed by the Sound of Silence framework. This framework is useful for researching sensitive issues and the health-care needs of marginalised populations. A total of 101 interviews with 44 survivors, 13 men and 44 health-care professionals were conducted, supplemented by two workshops with affected communities (participants, n = 10) and one workshop with stakeholders (participants, n = 30). Data were analysed using a hybrid framework method.

Results

There was no clear consensus between groups on the optimal timing of deinfibulation. However, within groups, survivors expressed a preference for deinfibulation pre pregnancy; health-care professionals preferred antenatal deinfibulation, with the caveat that it should be the survivor's choice. There was no consensus among men. There was agreement that deinfibulation should take place in a hospital setting and be undertaken by a suitable health-care professional. Decision-making around deinfibulation was complex. Deficiencies in professionals' awareness, knowledge and understanding resulted in impacts on the provision of appropriate care. Although there were examples of good practice and positive care interactions, in general, service provision was opaque and remains suboptimal, with deficiencies most notable in mental health. Deinfibulation reportedly helps to mitigate some of the impacts of female genital mutilation. Interactions between survivors and health-care professionals were disproportionately framed around the law. The way in which services are planned and provided often silences the perspectives and preferences of survivors and their families.

Limitations

Only a minority of the interviews were conducted in a language other than English, and the recruitment of survivors was predominantly through maternity settings, which meant that some voices may not have been heard. The sample of men was relatively small, limiting interpretation.

Conclusions

In general, service provision remains suboptimal and can silence the perspectives and preferences of survivors. Deinfibulation services need to be widely advertised and information should highlight that the procedure will be carried out in hospital by suitable health-care professionals and that a range of time points will be offered to facilitate choice. Future services should be developed with survivors to ensure that they are clinically and culturally appropriate. Guidelines should be updated to better reflect the needs of survivors and to ensure consistency in service provision.

Future work

Research is needed to (1) map female genital mutilation service provision; (2) develop and test effective education to address deficits in awareness and knowledge for affected communities and health-care professionals; and (3) develop, monitor and evaluate clinically and culturally competent female genital mutilation services.

Trial registration

Current Controlled Trials ISRCTN14710507.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment Programme and will be published in full in Health Technology Assessment; Vol. 27, No. 3. See the NIHR Journals Library website for further project information.

Barriers and facilitators to the access to specialized female genital cutting healthcare services: Experiences of Somali and Sudanese women in Norway

BACKGROUND

Girls and women subjected to female genital cutting (FGC) risk experiencing obstetrical, gynecological, sexual, and psychological health problems. Therefore, Norway has established low-threshold specialized healthcare services where girls and women with FGC-related health problems can directly seek medical attention. Nevertheless, we lack data about access to these services, especially for non-maternity-related purposes. In this article, we explore experiences of seeking medical attention for health problems that are potentially FGC-related, aiming to identify factors that hinder or facilitate access to FGC-specialized services.

METHODS

We conducted a qualitative study in three Norwegian cities employing semi-structured repeat interviews with 26 girls and women subjected to FGC, participant observation, and three validation focus group discussions with 17 additional participants. We thematically analyzed the data and approached access as a dynamic process of interactions between individuals and the healthcare system that lasts from an initial perception of need until reception of healthcare appropriate to that need.

FINDINGS

We identified several barriers to healthcare, including 1) uncertainty about FGC as a cause of experienced health problems, 2) unfamiliarity with FGC-specialized services, 3) lack of assessment by general practitioners of FGC as a potential cause of health problems, and 4) negative interactions with healthcare providers. In contrast, factors facilitating healthcare included: 1) receiving information on FGC-related health problems and FGC-specialized services from a non-profit immigrant organization, 2) referral to gynecologists with good knowledge of FGC, and 3) positive interactions with healthcare providers.

CONCLUSION

Assessing whether FGC is the cause for experienced health problems requires diagnostic competency and should not be left entirely to the patients. We recommend that Norwegian policymakers acknowledge the central role of GPs in the clinical management of patients with FGC-related health problems and provide them with comprehensive training on FGC.

Medical Defibulation as a Possibility-the Experiences of Young Swedish- Somali Women

Purpose: Infibulation is the most pervasive form of female genital cutting. Infibulated women face difficulties such as obstruction of urine and menstrual blood flow, sexual problems, and birth complications, and may therefore need medical defibulation. This study explores the lived experiences of young migrant women from Somalia and their views on undergoing medical defibulation in Sweden.

Methods: A qualitative study was conducted using phenomenological lifeworld research. Data were collected through in-depth interviews with nine young women originating from Somalia, now resident in Sweden. The interviews were analysed to reveal the meaning of the phenomenon of infibulation.

Results: The essential meaning of the phenomenon is characterized by a limbo regarding both infibulation and defibulation. There is a strong desire both to handle the Swedish perspective on infibulation and to stay with the Somalian cultural values. These women are being exposed to a tacit tradition that makes it hard to relate to the possibility of medical defibulation. As a result, the women perceive the possibility to undergo medical defibulation as limited or non-existent.

Conclusions: Healthcare professionals can be a support to encourage women in need of medical defibulation to reflect on traditional ideals concerning infibulation and defibulation.

Understanding Women's Responses to Sexual Pain After Female Genital Cutting: An Integrative Psychological Pain Response Model

The World Health Organization estimates that over 200 million women and girls have experienced female genital cutting (FGC). Many women and girls who have undergone FGC have migrated to areas of the world where providers are unfamiliar with the health needs associated with FGC. Both providers in Western healthcare systems and female immigrant and refugee patients report communication difficulties leading to distrust of providers by women who have experienced FGC. Sexual pain is one common problem requiring discussion with healthcare providers and possible intervention. Yet, existing clinical and research literature provides little guidance for assessment and intervention when sexual pain is a result of FGC. Several conceptual frameworks have been developed to conceptualize and guide treatments for other types of pain, such as back pain and headaches. In this article, we integrate four prominent models-the fear avoidance model, eustress endurance model, distress endurance model, and pain resilience model-to conceptualize sexual pain in women who have experienced FGC. The resulting integrative psychological pain response model will aid in providing culturally responsive clinical management of sexual pain to women who have experienced FGC. This integrative model also provides a theoretical foundation for future research in this population.

United States' Obstetrician/Gynecologists' Readiness to Care for Women Affected by Female Genital Cutting

Background: Female genital cutting (FGC) is a form of gender-based violence with obstetrical and gynecological complications that require recognition and care. Data suggest that United States' physicians are not prepared to care for those who have been affected by this practice. This study evaluated the knowledge and practices of United States' obstetricians and gynecologists to care for patients who have undergone FGC. Materials and Methods: This was a cross-sectional confidential survey distributed electronically to a sample of clinically active members of the American College of Obstetricians and Gynecologists. The survey consisted of questions characterizing care of patients who had undergone FGC and barriers to optimal support. Results: Five hundred forty-eight participants representing a wide range of years in practice, geographical locations, subspecializations, and patient demographics participated. Sixty-six percent of participants had cared for patients who had undergone FGC. Participants' description of their patient population racial/ethnic composition did not correlate with likelihood of treating this patient population. Forty percent of participants reported some form of education about FGC, more often among women, younger physicians, and those in practice for fewer years. Thirty-one percent of participants were comfortable counseling about and 20% were comfortable performing deinfibulation; these percentages were higher among those who had received education or had recently cared for an affected patient. Participants reported insufficient training as the largest barrier to providing care to women. Conclusions: While most physicians in this national cohort had cared for women who had undergone cutting, a minority had any form of education. However, prior education correlated with indicators of improved care. Physicians require additional guidance in treating this important and growing patient population.

Conversations about FGM in primary care: a realist review on how, why and under what circumstances FGM is discussed in general practice consultations

OBJECTIVES

Little is known about the management of female genital mutilation (FGM) in primary care. There have been significant recent statutory changes relevant to general practitioners (GPs) in England, including a mandatory reporting duty. We undertook a realist synthesis to explore what influences how and when GPs discuss FGM with their patients.

SETTING

Primary care in England.

DATA SOURCES

Realist literature synthesis searching 10 databases with terms: GPs, primary care, obstetrics, gynaecology, midwifery and FGM (UK and worldwide). Citation chasing was used, and relevant grey literature was included, including searching FGM advocacy organisation websites for relevant data. Other potentially relevant literature fields were searched for evidence to inform programme theory development. We included all study designs and papers that presented evidence about factors potentially relevant to considering how, why and in what circumstances GPs feel able to discuss FGM with their patients.

PRIMARY OUTCOME MEASURE

This realist review developed programme theory, tested against existing evidence, on what influences GPs actions and reactions to FGM in primary care consultations and where, when and why these influences are activated.

RESULTS

124 documents were included in the synthesis. Our analysis found that GPs need knowledge and training to help them support their patients with FGM, including who may be affected, what needs they may have and how to talk sensitively about FGM. Access to specialist services and guidance may help them with this role. Reporting requirements may complicate these conversations.

CONCLUSIONS

There is a pressing need to develop (and evaluate) training to help GPs meet FGM-affected communities' health needs and to promote the accessibility of primary care. Education and resources should be developed in partnership with community members. The impact of the mandatory reporting requirement and the Enhanced Dataset on healthcare interactions in primary care warrants evaluation.

PROSPERO REGISTRATION NUMBER

CRD42018091996.

Female genital mutilation/cutting, timing of deinfibulation, and risk of cesarean section

INTRODUCTION

The impact of female genital mutilation/cutting on obstetric outcomes in high-income countries is not clear. In general, women with female genital mutilation/cutting type 3 (infibulation) seem to be most at risk of adverse outcomes such as cesarean section. Deinfibulation is recommended to prevent obstetric complications. Whether the timing of this procedure affects the complication risk is not known. The aims of this study were, first, to examine the association between female genital mutilation/cutting and the risk of cesarean section in Norway, and, second, whether the timing of deinfibulation affected the cesarean section risk.

MATERIAL AND METHODS

This was a historical cohort study of nulliparous Somali-born women who gave birth in Norway between 1990 and 2014. The Medical Birth Registry of Norway identified the women. Data were collected from medical records at 11 participating birth units. The exposures were female genital mutilation/cutting status and deinfibulation before pregnancy, during pregnancy, or no deinfibulation before labor onset. The main outcome was odds ratio (OR) of cesarean section. Type of cesarean section, primary indications, and neonatal outcomes were secondary outcomes.

RESULTS

Women with female genital mutilation/cutting type 3 had lower risk of cesarean section compared with women with no female genital mutilation/cutting (OR 0.54, 95% CI 0.33-0.89 P = .02). Among the 1504 included women, the cesarean section rate was 28.0% and the proportion of emergency operations was 92.9%. Fetal distress was the primary indication in approximately 50% of cases, across the groups with different female genital mutilation/cutting status. Women who had no deinfibulation before labor onset had lower risk of cesarean section compared with those who underwent deinfibulation before or during pregnancy (OR 0.64, 95% CI 0.46-0.88 P = .01).

CONCLUSIONS

High risk of cesarean section in Somali nulliparous women was not related to the type of female genital mutilation/cutting in the present study. Deinfibulation before labor did not protect against cesarean section. Our findings indicate that nulliparous Somali women are at high risk of intrapartum complications. Future research should focus on measures to reduce maternal morbidity and on how timing of deinfibulation affects the outcomes of vaginal births.

Sexual norms and the intention to use healthcare services related to female genital cutting: A qualitative study among Somali and Sudanese women in Norway

Background

Female Genital Cutting (FGC) is a traditionally meaningful practice in Africa, the Middle East, and Asia. It is associated with a high risk of long-term physical and psychosexual health problems. Girls and women with FGC-related health problems need specialized healthcare services such as psychosexual counseling, deinfibulation, and clitoral reconstruction. Moreover, the need for psychosexual counseling increases in countries of immigration where FGC is not accepted and possibly stigmatized. In these countries, the practice loses its cultural meaning and girls and women with FGC are more likely to report psychosexual problems. In Norway, a country of immigration, psychosexual counseling is lacking. To decide whether to provide this and/or other services, it is important to explore the intention of the target population to use FGC-related healthcare services. That is as deinfibulation, an already available service, is underutilized. In this article, we explore whether girls and women with FGC intend to use FGC-related healthcare services, regardless of their availability in Norway.

Methods

We conducted 61 in-depth interviews with 26 Somali and Sudanese participants with FGC in Norway. We then validated our findings in three focus group discussions with additional 17 participants.

Findings

We found that most of our participants were positive towards psychosexual counseling and would use it if available. We also identified four cultural scenarios with different sets of sexual norms that centered on getting and/or staying married, and which largely influenced the participants’ intention to use FGC-related services. These cultural scenarios are the virgin, the passive-, the conditioned active-, and the equal- sexual partner scenarios. Participants with negative attitudes towards the use of almost all of the FGC-related healthcare services were influenced by a set of norms pertaining to virginity and passive sexual behavior. In contrast, participants with positive attitudes towards the use of all of these same services were influenced by another set of norms pertaining to sexual and gender equality. On the other hand, participants with positive attitudes towards the use of services that can help to improve their marital sexual lives, yet negative towards the use of premarital services were influenced by a third set of norms that combined norms from the two aforementioned sets of norms.

Conclusion

The intention to use FGC-related healthcare services varies between and within the different ethnic groups. Moreover, the same girl or woman can have different attitudes towards the use of the different FGC-related healthcare services or even towards the same services at the different stages of her life. These insights could prove valuable for Norwegian and other policy-makers and healthcare professionals during the planning and/or delivery of FGC-related healthcare services.

Barriers to access to the Norwegian healthcare system among sub-Saharan African immigrant women exposed to female genital cutting

INTRODUCTION

Millions of women and girls have been exposed to female genital cutting (FGC). The practice of FGC extends beyond countries in Africa and Asia in which it is traditionally practiced. Women living with FGC in Norway have been reported to be in need of healthcare, but there is evidence of suboptimal use of healthcare services among this group, and we lack the women's perspective about this problem. This study aims to explore the experiences and perceptions hindering access and use of the Norwegian healthcare system among sub- Saharan African (SSA) immigrant women exposed to FGC.

METHOD

This qualitative research was conducted using purposive and snowball sampling to recruit thirteen SSA immigrant women in Norway previously exposed to FGC. Interviews were conducted from October 2017 to July 2018. The Interpretative Phenomenological Analysis method was used.

RESULTS

The findings indicate that women experience barriers both in reaching out to the healthcare system and within the healthcare system. Barriers prior to contact with the healthcare system include lack of information, husband and family influence on healthcare, and avoiding disclosing health problems. Barriers within the healthcare system include care providers with insufficient knowledge and poor attitudes of care providers.

CONCLUSION

This study reveals multiple barriers to healthcare access that co-exist and overlap. This indicates that SSA immigrant women are 'left behind' in being able to access and use the Norwegian healthcare system. Therefore, appropriate interventions to improve access to healthcare should be considered in order to reach Universal Health Coverage, thus having a positive impact on the health of these women. Equitable healthcare should be reflected in policy and practice.

The impact of female genital mutilation/cutting on obstetric outcomes and its management

Objectives: Female genital mutilation/cutting (FGM/C) is a surgical intervention that is still widely performed around the world with serious obstetric and neonatal outcomes. We aimed to determine the obstetric and neonatal effects of FGM/C in pregnant women in a hospital with high standards of care in Sudan, where this is a common case, using a homogenous patient group.Methods: This is a retrospective cohort study in pregnant women with FGM/C, conducted at Nyala, Sudan-Turkey Training and Research Hospital. The inclusion criteria were: >18 years of age, history of FGM/C, vertex presentation, full-term birth, and single pregnancy. FGM/C group was compared with women without FGM/C (control group) who were monitored for the same period of 8 months in terms of age, parity, gestational age, and obstetric and neonatal outcomes.Results: A total of 220 eligible pregnant women were included in the study. Each group consisted of 110 pregnant women (FGM/C and control groups). We noticed that in the FGM/C group more emergency C-sections occurred, the second stage of the delivery was prolonged significantly, and episiotomy and periclitoral injuries were higher. Also, it was seen that postpartum blood loss and hospitalization of the mother lasted longer in the FGM/C group. No significant differences were found between the two groups with regard to newborns.Conclusions: FGM/C is definitely associated with poor obstetric outcomes. These patients should be diagnosed during the antenatal period, and the delivery processes should be managed by experienced healthcare professionals according to the type of FGM/C.

Painful gynecologic and obstetric complications of female genital mutilation/cutting: A systematic review and meta-analysis

BACKGROUND

The health complications experienced by women having undergone female genital mutilation/cutting (FGM/C) are a source of growing concern to healthcare workers globally as forced displacement and migration from countries with high rates of this practice increases. In this systematic review and meta-analysis, we investigate the association between FGM/C and painful gynecologic and obstetric complications in women affected by the practice.

METHODS AND FINDINGS

We performed a comprehensive literature search from inception to December 19, 2019 of Ovid MEDLINE, Ovid EMBASE, The Cochrane Library (Wiley), and POPLINE (prior to its retirement) for studies mentioning FGM/C. Two reviewers independently screened studies reporting prevalences of painful gynecologic and obstetric sequelae resulting from FGM/C. Random effects models were used to estimate pooled odds ratios (ORs) for outcomes obtained from cross-sectional, cohort, and case-control designs. Subgroup analysis was performed to assess and control for effect differences introduced by study design. Validated appraisal tools were utilized to assess quality and risk of bias. Our study was registered with PROSPERO. Two reviewers independently screened 6,666 abstracts. Of 559 full-text studies assessed for eligibility, 116 met eligibility criteria, which included studies describing the incidence or prevalence of painful sequelae associated with FGM/C. Pooled analyses after adjustment for study design found that FGM/C was associated with dyspareunia (6,283 FGM/C and 3,382 non-FGM/C participants; pooled OR: 2.47; 95% confidence interval [CI]: 1.45-4.21; I2: 79%; p-value < 0.01), perineal tears (4,898 FGM/C and 4,229 non-FGM/C participants; pooled OR: 2.63; 95% CI: 1.35-5.11; I2: 67%; p-value = 0.01), dysuria (3,686 FGM/C and 3,482 non-FGM/C participants; pooled OR: 1.43; 95% CI: 1.17-1.75; I2: 0%; p-value = 0.01), episiotomy (29,341 FGM/C and 39,260 non-FGM/C participants; pooled OR: 1.89; 95% CI: 1.26-2.82; I2: 96%; p-value < 0.01), and prolonged labor (7,516 FGM/C and 8,060 non-FGM/C participants; pooled OR: 2.04; 95% CI: 1.27-3.28; I2: 90%; p-value < 0.01). There was insufficient evidence to conclude that there was an association between FGM/C and dysmenorrhea (7,349 FGM/C and 4,411 non-FGM/C participants; pooled OR: 1.66; 95% CI: 0.97-2.84; I2: 86%; p-value = 0.06), urinary tract infection (4,493 FGM/C and 3,776 non-FGM/C participants; pooled OR: 2.11; 95% CI: 0.80-5.54; I2: 90%; p-value = 0.10), instrumental delivery (5,176 FGM/C and 31,923 non-FGM/C participants; pooled OR: 1.18; 95% CI: 0.78-1.79; I2: 63%; p-value = 0.40), or cesarean delivery (34,693 FGM/C and 46,013 non-FGM/C participants; pooled OR: 1.51; 95% CI: 0.99-2.30; I2: 96%; p-value = 0.05). Studies generally met quality assurance criteria. Limitations of this study include the largely suboptimal quality of studies.

CONCLUSIONS

In this study, we observed that specific painful outcomes are significantly more common in participants with FGM/C. Women who underwent FGM/C were around twice as likely as non-FGM/C women to experience dyspareunia, perineal tears, prolonged labor, and episiotomy. These data indicate that providers must familiarize themselves with the unique health consequences of FGM/C, including accurate diagnosis, pain management, and obstetric planning.

REVIEW PROTOCOL REGISTRATION

The review protocol registration in PROSPERO is CRD42018115848.

Exploring the views of female genital mutilation survivors, their male partners and healthcare professionals on the timing of deinfibulation surgery and NHS FGM care provision (the FGM Sister Study): protocol for a qualitative study

INTRODUCTION

Female genital mutilation (FGM) is a significant global health concern and is likely to become an increasingly important healthcare challenge in destination countries such as the UK owing to rising levels of migration from FGM-affected countries. Currently, there is no consensus on the optimal timing of deinfibulation (opening) surgery for women who have experienced type 3 FGM and care provision remains suboptimal in the UK. This qualitative study aims to explore the views of survivors, male partners and healthcare professionals (HCPs) on the timing of deinfibulation and delivery of NHS FGM services.

METHODS AND ANALYSIS

A qualitative study, informed by the Sound of Silence conceptual framework, will be undertaken via two work packages (WPs). WP1 will explore views on timing preferences for deinfibulation and NHS FGM services through interviews and discussion groups with FGM survivors (n~50), male partners (n~10) and HCPs (n~50). WP2 will use established techniques via two workshops (community (n~20-25 participants) and national stakeholder (n~30-35 participants)) to synthesise qualitative research findings and inform best practice and policy recommendations around the timing of deinfibulation and NHS FGM care provision. Supported by trained interpreters, data collection will be audio recorded and transcribed. Data will be analysed using the framework method to facilitate a systematic mapping and exploration of qualitative data from multiple sources.

ETHICS AND DISSEMINATION

The study has received ethical approval from the North West Greater Manchester East Research Ethics Committee (18/NW/0498). The outputs for this study will be recommendations for best practice and policy around FGM care provision that reflects the views and preferences of key stakeholders. The findings will be disseminated via conference presentations, peer-reviewed publications, patient groups, third sector organisations and social media.

TRIAL REGISTRATION NUMBER

ISRCTN 14710507.

Improving care for women and girls who have undergone female genital mutilation/cutting: qualitative systematic reviews

Background

In a context of high migration, there are growing numbers of women living in the UK who have experienced female genital mutilation/cutting. Evidence is needed to understand how best to meet their health-care needs and to shape culturally appropriate service delivery.

Objectives

To undertake two systematic reviews of qualitative evidence to illuminate the experiences, needs, barriers and facilitators around seeking and providing female genital mutilation-/cutting-related health care from the perspectives of (1) women and girls who have experienced female genital mutilation/cutting (review 1) and (2) health professionals (review 2).

Review methods

The reviews were undertaken separately using a thematic synthesis approach and then combined into an overarching synthesis. Sixteen electronic databases (including grey literature sources) were searched from inception to 31 December 2017 and supplemented by reference list searching. Papers from any Organisation for Economic Co-operation and Development country with any date and in any language were included (Organisation for Economic Co-operation and Development membership was considered a proxy for comparable high-income migrant destination countries). Standardised tools were used for quality appraisal and data extraction. Findings were coded and thematically analysed using NVivo 11 (QSR International, Warrington, UK) software. Confidence in the review findings was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation – Confidence in the Evidence from Reviews of Qualitative Research (GRADE-CERQual) approach. All review steps involved two or more reviewers and a team that included community-based and clinical experts.

Results

Seventy-eight papers (74 distinct studies) met the inclusion criteria for both reviews: 57 papers in review 1 (n = 18 from the UK), 30 papers in review 2 (n = 5 from the UK) and nine papers common to both. Review 1 comprised 17 descriptive themes synthesised into five analytical themes. Women’s health-care experiences related to female genital mutilation/cutting were shaped by silence and stigma, which hindered care-seeking and access to care, especially for non-pregnant women. Across all countries, women reported emotionally distressing and disempowering care experiences. There was limited awareness of specialist service provision. Good care depended on having a trusting relationship with a culturally sensitive and knowledgeable provider. Review 2 comprised 20 descriptive themes synthesised into six analytical themes. Providers from many settings reported feeling uncomfortable talking about female genital mutilation/cutting, lacking sufficient knowledge and struggling with language barriers. This led to missed opportunities for, and suboptimal management of, female genital mutilation-/cutting-related care. More positive experiences/practices were reported in contexts where there was input from specialists and where there were clear processes to address language barriers and to support timely identification, referral and follow-up.

Limitations

Most studies had an implicit focus on type III female genital mutilation/cutting and on maternity settings, but many studies combined groups or female genital mutilation/cutting types, making it hard to draw conclusions specific to different communities, conditions or contexts. There were no evaluations of service models, there was no research specifically on girls and there was limited evidence on psychological needs.

Conclusions

The evidence suggests that care and communication around female genital mutilation/cutting can pose significant challenges for women and health-care providers. Appropriate models of service delivery include language support, continuity models, clear care pathways (including for mental health and non-pregnant women), specialist provision and community engagement. Routinisation of female genital mutilation/cutting discussions within different health-care settings may be an important strategy to ensure timely entry into, and appropriate receipt of, female genital mutilation-/cutting-related care. Staff training is an ongoing need.

Future work

Future research should evaluate the most-effective models of training and of service delivery.

Study registration

This study is registered as PROSPERO CRD420150300012015 (review 1) and PROSPERO CRD420150300042015 (review 2).

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Seeking culturally safe care: a qualitative systematic review of the healthcare experiences of women and girls who have undergone female genital mutilation/cutting

OBJECTIVE

To explore the experiences of accessing and receiving healthcare related to female genital mutilation/cutting (FGM/C) across the life course from the perspective of women and girls who have undergone FGM/C.

DESIGN

A systematic review of qualitative research studies using a thematic synthesis approach.

METHODS

Inclusion criteria were qualitative studies (including grey literature) of any design, from Organisation for Economic Co-operation and Development (OECD) countries, of any date and any language. Sixteen electronic databases were searched from inception to December 2017, supplemented by reference list searching. Papers were screened, selected and quality-appraised by two reviewers using established tools from the Joanna Briggs Institute. NVivo software was used to extract study characteristics and code study findings. An inductive thematic synthesis approach was undertaken to identify descriptive themes and interpret these into higher order analytical constructs. Confidence in the review findings was assessed using Grading of Recommendations, Assessment, Development and Evaluations-Confidence in Evidence from Reviews of Qualitative Research (GRADE-CERQual).

RESULTS

Fifty-seven papers (from 55 distinct studies) from 14 different OECD countries were included (50% published within the last 8 years). One-third of studies focused exclusively on maternity care experiences, whereas others covered a range of foci. No studies reported explicitly on girls' experiences or on experiences of health service-led safeguarding interventions. Only three studies addressed psychological care. The synthesis developed 17 descriptive themes, organised into 5 analytical constructs. These related to communication, access to care, experiences of cultural dissonance/integrity, disempowering care experiences and positive care encounters. The themes illuminate significant challenges to obtaining timely and holistic care (especially for deinfibulation), and highlight different ways in which women may experience care as disrespectful, unsafe and disempowering. Key elements of 'culturally safe care' are identified.

CONCLUSIONS

This review has highlighted key knowledge gaps, especially around (1) girls'/unmarried women's experiences and (2) the impact of recent safeguarding interventions. There is an ongoing need for community engagement, service development and staff training.

PROSPERO REGISTRATION NUMBER

CRD420150300012015.

Using electronic maternity records to estimate female genital mutilation in Lothian from 2010 to 2013

Background

Female genital mutilation (FGM) is most commonly encountered in Africa and the Middle East, with migration from FGM-practicing countries meaning it is increasingly seen in Europe. Addressing FGM requires accurate information on who is affected but ascertainment is notoriously difficult. This study estimated FGM prevalence in women presenting for maternity care in the Lothian region of Scotland and compared this with that expected by extrapolation of survey data from women's country of birth.

Methods

Electronic clinical records were linked to birth registration data to estimate FGM in the obstetric patients in Lothian from 2010 to 2013.

Results

Among all, 107 women affected by FGM were detected, at a rate of 2.8/1000 pregnancies. Of 487 women from UNICEF-recognized FGM-practicing countries who accessed care, 87 (18%) had documented evidence of FGM (three quarters of whom came from Nigeria, Sudan or The Gambia). The prevalence was 54% of the level expected from the extrapolation method. Country of birth had a sensitivity of 81% for FGM.

Conclusion

Women from FGM-practicing countries commonly access maternity care in Lothian. This confirms the need for ongoing training and investment in identifying and managing FGM. Matching electronic clinical records with birth registration data was a useful methodology in estimating the level of FGM in the maternity population. In a European country like Scotland with modest migrant numbers, asking country of birth during pregnancy and making sensitive enquiries could detect 81% of women with FGM. Extrapolation from maternal country of birth surveys grossly overestimates the true prevalence.

[Definition, epidemiology and risk factors of obstetric anal sphincter injuries: CNGOF Perineal Prevention and Protection in Obstetrics Guidelines]

OBJECTIVES

The aim of this review was to agree on a definition of the obstetric anal sphincter injuries (OASIS), to determine the prevalence and risk factors.

METHODS

A comprehensive review of the literature on the obstetric anal sphincter injuries (OASIS), establishment of levels of evidence (NP), and grades of recommendation according to the methodology of the recommendations for clinical practice.

RESULTS

To classify obstetric anal sphincter injuries (OASIS), we have used the WHO-RCOG classification, which lists 4 degrees of severity. To designate obstetric anal sphincter injuries, we have used the acronym OASIS, rather than the standard French terms of "complete perineum" and "complicated complete perineum". OASIS with only isolated involvement of the EAS (3a and 3b) appears to have a better functional prognosis than OASIS affecting the IAS or the anorectal mucosa (3c and 4) (LE3). The prevalence of women with ano-rectal symptoms increases with the severity of the OASIS (LE3). In the long term, 35-60% of women who had an OASIS have anal or fecal incontinence (LE3). The prevalence of an OASI in the general population is between 0.25 to 6%. The prevalence of OASIS in primiparous women is between 1.4 and 16% and thus, should be considered more important than among the multiparous women (0.4 to 2.7%). In women with a history of previous OASIS, the risk of occurrence is higher and varies between 5.1 and 10.7% following childbirth. The priority in this context remains the training of childbirth professionals (midwives and obstetricians) to detect these injuries in the delivery room, immediately after the birth. The training and awareness of these practitioners of OASIS diagnosis improves its detection in the delivery room (LE2). Professional experience is associated with better detection of OASIS (LE3) (4). Continuing professional education of obstetrics professionals in the diagnosis and repair of OASIS must be encouraged (Grade C). In the case of second-degree perineal tear, the use of ultrasound in the delivery room improves the diagnosis of OASIS (LE2). Ultrasound decreases the prevalence of symptoms of severe anal incontinence at 1 year (LE2). The diagnosis of OASIS is improved by the use of endo-anal ultrasonography in post-partum (72h-6weeks) (LE2). The principal factors associated with OASIS are nulliparity and instrumental (vaginal operative) delivery; the others are advanced maternal age, history of OASIS, macrosomia, midline episiotomy, posterior cephalic positions, and long labour (LE2). The presence of a perianal lesion (perianal fissure, or anorectal or rectovaginal fistula) is associated with an increased risk of 4th degree lacerations (LE3). Crohn's disease without perianal involvement is not associated with an excess risk of OASIS (LE3). For women with type III genital mutilation, deinfibulation before delivery is associated with a reduction in the risk of OASIS (LE3); in this situation, deinfibulation is recommended before delivery (grade C).

CONCLUSION

It is necessary to use a consensus definition of the OASIS to be able to better detect and treat them.

Health sector involvement in the management of female genital mutilation/cutting in 30 countries

BACKGROUND

For the last decades, the international community has emphasised the importance of a multisectoral approach to tackle female genital mutilation (FGM/C). While considerable improvement concerning legislations and community involvement is reported, little is known about the involvement of the health sector.

METHOD

A mixed methods approach was employed to map the involvement of the health sector in the management of FGM/C both in countries where FGM/C is a traditional practice (countries of origin), and countries where FGM/C is practiced mainly by migrant populations (countries of migration). Data was collected in 2016 using a pilot-tested questionnaire from 30 countries (11 countries of origin and 19 countries of migration). In 2017, interviews were conducted to check for data accuracy and to request relevant explanations. Qualitative data was used to elucidate the quantitative data.

RESULTS

A total of 24 countries had a policy on FGM/C, of which 19 had assigned coordination bodies and 20 had partially or fully implemented the plans. Nevertheless, allocation of funding and incorporation of monitoring and evaluation systems was lacking in 11 and 13 of these countries respectively. The level of the health sectors' involvement varied considerably across and within countries. Systematic training of healthcare providers (HCP) was more prevalent in countries of origin, whereas involvement of HCP in the prevention of FGM/C was more prevalent in countries of migration. Most countries reported to forbid HCP from conducting FGM/C on both minors and adults, but not consistently forbidding re-infibulation. Availability of healthcare services for girls and women with FGM/C related complications also varied between countries dependent on the type of services. Deinfibulation was available in almost all countries, while clitoral reconstruction and psychological and sexual counselling were available predominantly in countries of migration and then in less than half the countries. Finally, systematic recording of FGM/C in medical records was completely lacking in countries of origin and very limited in countries of migration.

CONCLUSION

Substantial progress has been made in the involvement of the health sector in both the treatment and prevention of FGM/C. Still, there are several areas in need for improvement, particularly monitoring and evaluation.

Reasons for and Experiences With Surgical Interventions for Female Genital Mutilation/Cutting (FGM/C): A Systematic Review

BACKGROUND

Because female genital mutilation/cutting (FGM/C) leads to changes in normal genital anatomy and functionality, women are increasingly seeking surgical interventions for their FGM/C-related concerns.

AIM

To conduct a systematic review of empirical quantitative and qualitative research on interventions for women with FGM/C-related complications.

METHODS

We conducted systematic searches up to May 2016 in 16 databases to obtain references from different disciplines. We accepted all study designs consisting of girls and women who had been subjected to FGM/C and that examined a reparative intervention for a FGM/C-related concern. We screened the titles, abstracts, and full texts of retrieved records for relevance. Then, we assessed the methodologic quality of the included studies and extracted and synthesized the study data.

OUTCOMES

All outcomes were included.

RESULTS

Of 3,726 retrieved references, 71 studies including 7,291 women were eligible for inclusion. We identified three different types of surgical intervention: defibulation or surgical separation of fused labia, excision of a cyst with or without some form of reconstruction, and clitoral or clitoral-labial reconstruction. Reasons for seeking surgical interventions consisted of functional complaints, sexual aspirations, esthetic aspirations, and identity recovery. The most common reasons for defibulation were a desire for improved sexual pleasure, vaginal appearance, and functioning. For cyst excision, cystic swelling was the main reason for seeking excision; for reconstruction, the main reason was to recover identity. Data on women's experiences with a surgical intervention are sparse, but we found that women reported easier births after defibulation. Our findings also suggested that most women were satisfied with defibulation (overall satisfaction = 50-100%), typically because of improvements in their sexual lives. Conversely, the results suggested that defibulation had low social acceptance and that the procedure created distress in some women who disliked the new appearance of their genitalia. Most women were satisfied with clitoral reconstruction, but approximately one third were dissatisfied with or perceived a worsening in the esthetic look.

CLINICAL TRANSLATION

The information health care professionals give to women who seek surgical interventions for FGM/C should detail the intervention options available and what women can realistically expect from such interventions.

STRENGTHS AND LIMITATIONS

The systematic review was conducted in accordance with guidelines, but there is a slight possibility that studies were missed.

CONCLUSION

There are some data on women's motivations for surgery for FGM/C-related concerns, but little is known about whether women are satisfied with the surgery, and experiences appear mixed. Berg RC, Taraldsen S, Said MA, et al. Reasons for and Experiences With Surgical Interventions for Female Genital Mutilation/Cutting (FGM/C): A Systematic Review. J Sex Med 2017;14:977-990.

A qualitative study exploring how Somali women exposed to female genital mutilation experience and perceive antenatal and intrapartum care in England

OBJECTIVES

To explore how Somali women exposed to female genital mutilation experience and perceive antenatal and intrapartum care in England. We explored women's perceptions of deinfibulation, caesarean section and vaginal delivery; their experiences of care during pregnancy and labour; and factors that affect ability to access these services, in order to make recommendations about future practice.

DESIGN

A descriptive, exploratory qualitative study using face-to-face semistructured interviews. Interviews were audio-recorded, transcribed and data were analysed using a thematic approach. An interpreter was used when required (n=3).

SETTING

Participants recruited from 2 community centres in Birmingham, England.

PARTICIPANTS

Convenience and snowball sample of 10 Somali women resident in Birmingham, who had accessed antenatal care services in England within the past 5 years.

RESULTS

3 core themes were interpreted: (1) Experiences of female genital mutilation during life, pregnancy and labour: Female genital mutilation had a significant physical and psychological impact, influencing decisions to undergo deinfibulation or caesarean section. Women delayed deinfibulation until labour to avoid undergoing multiple operations if an episiotomy was anticipated. (2) Experience of care from midwives: Awareness of female genital mutilation from midwives led to open communication and stronger relationships with women, resulting in more positive experiences. (3) Adaptation to English life: Good language skills and social support networks enabled women to access these services, while unfavourable social factors (eg, inability to drive) impeded.

CONCLUSIONS

Female genital mutilation impacts Somali women's experiences of antenatal and intrapartum care. This study suggests that midwives should routinely ask Somali women about female genital mutilation to encourage open communication and facilitate more positive experiences. As antenatal deinfibulation is unpopular, we should consider developing strategies to promote deinfibulation to non-pregnant women, to align with current guidelines. Women with unfavourable social factors may require additional support to improve access to English antenatal care services.

Female genital mutilation: knowledge, attitude and practices of Flemish midwives

BACKGROUND

health professionals in Belgium are confronted with female genital mutilation (FGM). To date, no survey to assess knowledge, attitudes and practices on FGM was conducted among midwives in the Northern region of Belgium.

OBJECTIVE

the objective of this study was to assess the knowledge, attitude and practices of Flemish midwives regarding female genital mutilation (FGM).

DESIGN

we used a quantitative design, using KAP study (semi-structured questionnaire).

SETTING

labour wards, maternity wards and maternal intensive care units (MIC) in 56 hospitals in Flemish region of Belgium.

PARTICIPANTS

820 midwives, actively working in labour wards, maternity wards and maternal intensive care units (MIC).

FINDINGS

820 valid questionnaires (40.9%) were returned. More than 15% of the respondents were recently confronted with FGM. They were mostly faced with the psychological and sexual complications caused by FGM. Few respondents were aware of existing guidelines regarding FGM in their hospitals (3.5%). The results also showed that only 20.2% was aware of the exact content of the law. The majority of midwives condemned the harmful traditional practice: FGM was experienced as a form of violence against women or a violation of human rights. Only 25.9% declared that FGM forms a part of their midwifery program. The vast majority of respondents (92.5%) indicated a need for more information on the subject.

KEY CONCLUSIONS

this study indicated that midwives in Flanders are confronted with FGM and its complications and highlighted the gaps in the knowledge of Flemish midwives regarding FGM. This may interfere with the provision of adequate care and prevention of FGM for the new-born daughter.

IMPLICATIONS FOR PRACTICE

there is an important need for appropriate training of (student)midwives concerning FGM as well as for the development and dissemination of clear guidelines in Flemish hospitals.