Maternity care of women affected by female genital mutilation/cutting: An audit of two Australian hospitals

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.

The global prevalence of female genital mutilation/cutting: A systematic review and meta-analysis of national, regional, facility, and school-based studies

BACKGROUND

Female genital mutilation/cutting (FGM/C) is a nonmedical procedure entailing the modification of the external female genitalia. A description of the prevalence and distribution of FGM/C allows the tracking of progress toward ending FGM/C by 2030 (Sustainable Development Goal (SDG): target 5.3). This systematic review aimed to examine FGM/C prevalence and types, by World Health Organization (WHO) region and country.

METHODS AND FINDINGS

A systematic search using Medical Subject Headings (MeSH) and keywords from 2009 to March 24, 2022 was undertaken in MEDLINE, PubMED, PsycINFO, Web of Science, and Embase to identify studies presenting FGM/C prevalence. Abstract and full-text screening, quality assessment, and data extraction were undertaken by 2 reviewers. Only nationally representative studies were included in the meta-analysis. Pooled FGM/C prevalence was estimated by random-effects meta-analysis using generalized linear mixed models (GLMMs). FGM/C prevalence with 95% confidence intervals (CIs), prediction intervals (PIs), and FGM/C type were presented separately by women aged 15 to 49 years and girls aged 0 to 14 years. A total of 163 studies met the inclusion criteria and 30 were included in the meta-analysis, of which 23 were from the WHO African Region (AFR), 6 from the Eastern Mediterranean Region (EMR), and 1 from the South East Asian Region (SEAR). These studies included data from 406,068 women across 30 countries and 296,267 girls across 25 countries; the pooled prevalence estimate of FGM/C among women aged 15 to 49 years was 36.9% (95% CI: 19.6% to 58.3%; PI: 0.4% to 99.0%), and 8.27% (95% CI: 3.7% to 17.3%; PI: 0.1% to 89.3%) among girls aged 0 to 14 years. Among included countries, this gave a total estimated prevalence of 84,650,032 women (95% CI: 45,009,041 to 133,834,224) and 13,734,845 girls with FGM/C (95% CI: 6,211,405 to 28,731,901). Somalia had the highest FGM/C prevalence among women (99.2%), and Mali had the highest among girls (72.7%). The most common type of FGM/C among women was "flesh removed" (Type I or II) in 19 countries. Among girls, "not sewn closed" (Type I, II, or IV) and "flesh removed" (Type I or II) were the most common types in 8 countries, respectively. Among repeated nationally representative studies, FGM/C decreased for both women and girls in 26 countries. The main limitation of the study methodology is that estimates were based on available published data, which may not reflect the actual global prevalence of FGM/C.

CONCLUSIONS

In this study, we observed large variation in FGM/C prevalence between countries, and the prevalence appears to be declining in many countries, which is encouraging as it minimizes physical and physiological harm for a future generation of women. This prevalence estimate is lower than the actual global prevalence of FGM/C due to data gaps, noncomparable denominators, and unavailable surveys. Yet, considerable policy and community-level interventions are required in many countries to meet the SDG target 5.3.

TRIAL REGISTRATION

Registration: CRD42020186937.

Female Genital Mutilation/Cutting and Breastfeeding Outcomes: The Modifying Effects of Healthcare Access and Women’s Attitudes to FGM/C

The prevalence of female genital mutilation/cutting (FGM/C) in Nigeria is on the rise, although the practice has no known medical/health benefits. This study aims to assess FGM/C’s effect on breastfeeding outcomes and to identify the role of women’s attitudes and their access to healthcare services on these relationships. Associations between FGM/C and breastfeeding outcomes were measured using multi-logistic regression. About 32% of women underwent FGM/C, and 23% believed FGM/C should continue. Women exposed to FGM/C were less likely to initiate early breastfeeding (OR = 0.56, [95% CI = 0.47–0.66]) or to breastfeed exclusively (0.64, [0.57–0.73]). FGM/C acceptance reduced odds of early initiation of breastfeeding (0.57, [0.45–0.73]) (p for interaction < 0.001) and exclusive breastfeeding (0.65, [0.59–0.78]) (p for interaction < 0.001). Four or more antenatal care visits while pregnant modified the associations between FGM/C and early initiation (1.55, [1.26–1.90) (p for interaction < 0.001) or exclusive breastfeeding (2.01, [1.73–2.330]) (p for interaction < 0.001), respectively. FGM/C is associated with breastfeeding outcomes, but this association may be improved with healthcare access and attitudinal changes towards FGM/C. Targeted public health education interventions raising awareness about FGM/C and breastfeeding and policy changes increasing access to prenatal healthcare services in underserved areas are recommended.

Woman and girl-centred care for those affected by female genital mutilation: a scoping review of provider tools and guidelines

BACKGROUND

A woman and girl centred, rights-based approach to health care is critical to achieving sexual and reproductive health. However, women with female genital mutilation in high-income countries have been found to receive sub-optimal care. This study examined documents guiding clinicians in health and community service settings in English-speaking high-income countries to identify approaches to ensure quality women and girl-centred care for those with or at risk of female genital mutilation.

METHOD

We undertook a scoping review using the integrative model of patient-centredness to identify principles, enablers, and activities to facilitate woman and girl-centred care interactions. We developed an inclusion criterion to identify documents such as guidance statements and tools and technical guidelines, procedural documents and clinical practice guidelines. We searched the databases and websites of health professional associations, ministries of health, hospitals, national, state and local government and non-government organisations working in female genital mutilation in the United Kingdom, Ireland, Canada, The United States, New Zealand, and Australia. The Appraisal of Guidelines for Research and Evaluation tool was used to appraise screened documents.

FINDINGS

One-hundred and twenty-four documents were included in this scoping review; 88 were developed in the United Kingdom, 20 in Australia, nine in the United States, three in Canada, two in New Zealand and two in Ireland. The focus of documents from the United Kingdom on multi-professional safeguarding (62), while those retrieved from Australia, Canada, Ireland, New Zealand and the US focused on clinical practice. Twelve percent of the included documents contained references to all principles of patient-centred care, and only one document spoke to all principles, enablers and activities.

CONCLUSION

This study demonstrates the need to improve the female genital mutilation-related guidance provided to professionals to care for and protect women and girls. Professionals need to involve women and girls with or at risk of female genital mutilation in the co-design of guidelines and tools and evaluation of them and the co-production of health care.

Commentary: What should referral pathways have to improve healthcare experiences of women with female genital mutilation in Australia?

BACKGROUND

We examined the evidence derived from healthcare professionals' interfacing with women with female genital mutilation (FGM) to comprehend the referral pathways available to these women in Australia.

MAIN BODY

Clinicians encountered FGM-related complications that included ruptured bladder and total urinary incontinence. Midwives and paediatricians indicated a lack of referral pathways for FGM, but used their discretion to refer such cases to social work departments, obstetric/gynaecological units, child protection service providers, psychological counsellors and surgeons. The continuum of care for women with FGM is characterised by inadequate and lack of clear referral pathways. This underscores the need to develop and strengthen referral pathways in response to physical, birthing and psychological complications of women with FGM to improve their care experiences in Australia.

SHORT CONCLUSION

Capacity building initiatives on FGM-prevention and care for trainees and practising health providers and community involvement in high burden areas/populations should be implemented to promote uptake and utilization of the referral services. Provision of infrastructural support, including clinical management tools, job aids, posters, referral algorithms and electronic patient records with "drop-down menus" for referral sites for health complications of FGM to reinforce the providers' efforts are critical.