Female genital mutilation: Obstetric outcomes in metropolitan Sydney

Female genital mutilation/cutting in women delivering in France: An observational national study

OBJECTIVE

International migration from source countries has meant that clinicians in high income countries, that is, receiving countries, are increasingly caring for affected women affected by female genital mutilation/cutting (FGM/C). The aim of the present study was to assess the prevalence of FGM/C among women at childbirth, and its association with pregnancy outcomes.

METHODS

This was an observational study using data from a cross-sectional population-based study from the French National Perinatal Survey of 2021 (ENP) conducted in all maternity units in mainland France and including all women delivering a live birth during 1 week in March 2021 (N = 10 928). We estimated the FGM/C prevalence using (i) the diagnosed cases and (ii) the indirect prevalence estimated by UNICEF in each source country. We compared population characteristics and perinatal outcomes between women diagnosed with FGM/C and two groups: (i) women originating in source countries and diagnosed as without FGM/C and (ii) all women without diagnosis of FGM/C whatever the country of birth.

RESULTS

Diagnosed prevalence of FGM/C was 95% (95% CI: 0.78-1.14] and the indirect computed estimation prevalence was estimated at 1.53% (95% CI: 1.31-1.77) in 113 and 183 women, respectively. Labor and delivery outcomes were globally similar in women with FGM/C and the other two groups. Only episiotomy was more frequently performed in women with FGM/C than in the other two groups.

CONCLUSION

In receiving countries, obstetric outcomes of women with FGM/C can be similar to those of other women, which does not preclude need of further research and training to provide the most appropriate care, including enhanced attention to diagnosis.

Maternal origin matters: Country of birth as a risk factor for obstetric anal sphincter injuries

OBJECTIVE

Obstetric anal sphincter injuries (OASIS) are severe complications to vaginal births with potential long-term consequences. Maternal origin has been proposed to affect the overall risk, but the association and underlying explanation are uncertain. The objective was to assess the association between maternal country of birth and OASIS.

METHODS

A Swedish nationwide cohort study including singleton term vaginal births during 2005-2016. Data were extracted from the Swedish Medical Birth Registry and Statistics Sweden. Modified Poisson regression analyses were performed to obtain crude and adjusted risk ratios (RRs). Adjustments were made in four cumulative steps. Sub-analyses were performed to investigate the risk of OASIS associated with female genital circumcision (FGC).

RESULTS

In all, 988 804 births were included. The rate of OASIS in Swedish-born women was 3.5%. Women from East/Southeast Asia had an increased risk of OASIS (adjusted RR [aRR] 1.71, 95% confidence interval [CI] 1.60-1.83), as did women born in Sub-Saharan Africa (aRR 1.60, 95% CI 1.49-1.72). The risk remained significantly increased also after adjustment for maternal height. By contrast, women from South/Central America had a decreased risk of OASIS (aRR 0.65, 95% CI 0.56-0.76). FGC was associated with an increased risk of OASIS (aRR 3.05, 95% CI 2.60-3.58). Episiotomy appeared to have an overall protective effect (aRR 0.95, 95% CI 0.92-0.98), but not significantly more protective among women with female genital mutilation.

CONCLUSIONS

Country of birth plays an important role in the risk of OASIS. Women from East/Southeast Asia and Sub-Saharan Africa are at significantly increased risk as compared with Swedish-born women, whereas women from South/Central America are at lower risk. FGC is also a significant risk factor for OASIS.

Effect of type III female genital mutilation on obstetric outcomes: A systematic review and meta-analysis

Background

Controversial evidence suggests a potential association between female genital mutilation (FGM/C) and adverse obstetric outcomes, with type III FGM/C (infibulation) carrying the greatest risk. The aim of this systematic review and meta-analysis was to assess current rate of adverse obstetric outcomes in women with type III female genital mutilation and cutting (FGM/C; infibulation) delivering across different settings worldwide.

Methods

We searched PubMed, Scopus, Embase, and ClinicalTrials.gov databases from inception to Jan 1, 2023. Studies were selected if they included the main outcome of postpartum haemorrhage (PPH) or secondary outcomes, which included major conditions affecting maternal-neonatal health during labour and delivery. DerSimonian-Laird random effects meta-analysis including pooled effect estimates with corresponding 95 % confidence intervals was performed. Heterogeneity was assessed using the I2 statistic. Meta regression for relevant covariates was performed when data on relevant confounders were available. The Newcastle-Ottawa scale (NOS) was used to assess quality of observational studies. The level of evidence was assessed with the GRADE method.

Results

14 observational studies including 15,320 type III FGM/C women and 59,347 controls were eligible. The risk for postpartum haemorrhage was significantly increased in type III FGM/C, in the main analysis (OR 1.83, 95 % CI 1.03 to 3.24, I2 = 93 %), in pooling of data adjusted for confounders (aOR 1.76, CI 1.42 to 2.17, I2 = 0 %), and in sensitivity analysis of higher quality studies with NOS≥7 (OR 2.76, CI 1.38 to 5.51, I2 = 95 %). Meta-regression showed that nulliparity was significantly and positively associated with postpartum haemorrhage. Similarly, analysis of data adjusted for confounders showed an increased risk of episiotomy in type III FGM/C (aOR 1.56, CI 1.03 to 2.35, I2 = 52 %). Sensitivity analysis of studies with NOS≥7 revealed a significant increase for episiotomy (OR 7.53, CI 1.19 to 47.54, I2 = 96 %), perineal tears (OR 4.24, CI 1.09 to 16.46, I2 = 66 %), prolonged second stage of labour (OR 5.19, 95 % CI 1.00 to 26.85, I2 = 66 %), and Apgar score less than 7 (OR 4.19, CI 1.64 to 10.70, I2 = 0 %). No difference was found regarding obstetric anal sphincter injuries and mode of delivery in these women. Deinfibulation achieved similar obstetric and neonatal outcomes to women who never had type III FGM. The overall quality of the studies was adequate (median NOS score: 7; IQR: 6-8), the level of evidence, according to the GRADE assessment, was low.

Conclusions

These results consistently show an increased risk of adverse obstetric outcomes in women with FGM/C type III. Infibulation substantially increases the risk for PPH, particularly in nulliparae. Systematic Review registration: PROSPERO CRD42023421993.

Effect of Female Genital Mutilation on Sexual Function in Ibadan, Nigeria

Objective: Female genital mutilation, which harms women physically and psychologically, also causes serious problems in sexual life that continue throughout life. This study aimed to determine the impact of female genital mutilation on sexual outcomes in Ibadan, Nigeria. Method: This is a cross-sectional descriptive study. A self-administered questionnaire was used to obtain data from 161 women who agreed to participate in the study. After the data were collected, the sample group was divided into two groups those with female genital mutilation (84) and those without (77), and they were compared in terms of sexual outcomes. Results: Type I (77.3%) and type II (22.7%) mutilations were found in women with female genital mutilation. It was determined that women with FGM experienced statistically significantly more pain and bleeding during vaginal penetration than uncircumcised women. At the same time, the orgasm rate was found to be statistically significantly lower in this group. Conclusions: Our study revealed that female genital mutilation and enlargement of the incision area negatively affect sexual health.

What women want: A reflexive thematic analysis of the healthcare experiences of women with female genital mutilation/cutting in South Australia

BACKGROUND

Global migration has seen an increase in female genital mutilation/cutting (FGM/C) cases observed in countries where it is not part of the cultural norm. This shift has led to many healthcare professionals (HCPs) reporting a lack of knowledge and skills necessary to support the needs of women with FGM/C.

AIM

To explore the experiences and needs of women with FGM/C accessing women's health services in South Australia.

METHODS

Women with FGM/C were recruited through purposive and snowball sampling to participate in one-to-one semi-structured interviews. The voice recorded interviews were transcribed verbatim, coded, and analysed using Braun and Clarke's reflexive thematic analysis to determine themes.

FINDINGS

Ten migrant and refugee women living in South Australia, were interviewed. Four themes and 13-subthemes were identified. The main themes were, 1) the healthcare experience, 2) cultural values shape the healthcare experience, 3) speaking up about female genital cutting and 4) working together to improve healthcare experiences.

DISCUSSION

Women's cultural needs, not their health needs, play a fundamental role on how women experienced healthcare services. When women's cultural values and traditions are acknowledged by HCPs, they are more likely to trust and feel confident to engage with services and seek medical support. Areas identified for improvement included access to the right interpreters, having more time during appointments, opportunities for continuity of care and the inclusion of family in care and treatment decisions.

CONCLUSION

Women with FGM/C have specific health and cultural needs that can be met through education and provision of woman-centred care.

Attitudes and Experiences Surrounding Female Genital Mutilation/Cutting in the United States: A Scoping Review

To identify research and gaps in literature about FGM/C-related attitudes and experiences among individuals from FGM/C-practicing countries living in the United States, we conducted a scoping review guided by Arksey and O'Malley's framework. We searched Medline (OVID), Embase (OVID), PubMed, and SCOPUS and conducted a grey literature search for studies assessing attitudes or experiences related to FGM/C with data collected directly from individuals from FGM/C-practicing countries living in the United States. The search yielded 417 studies, and 40 met the inclusion criteria. Findings suggest that women and men from FGM/C-practicing countries living in the United States generally oppose FGM/C, and that women with FGM/C have significant physical and mental health needs and have found US healthcare providers to lack understanding of FGM/C. Future research can improve measurement of FGM/C by taking into account the sociocultural influences on FGM/C-related attitudes and experiences.

The effect of female circumcision on maternal and neonatal outcomes after childbirth: a cohort study

BACKGROUND

Circumcision has many side effects and complications on women's lives and affects their physical, mental, and social health. The present study aimed to investigate the effect of female circumcision on maternal and neonatal outcomes.

METHODS

Methods: A prospective cohort study was performed with 320 pregnant women by convenience sampling (160 individuals were circumcised and 160 were uncircumcised). Circumcision and its level were confirmed using observation. The data relating to demographic, midwifery history, medical history, maternal and neonatal outcomes were compiled using a questionnaire. All Statistical analyses were conducted by SPSS ver. 16.0. P-values less than 0.05 were considered significant.

RESULTS

The mean age of circumcised women was significantly higher vs. Uncircumcised women (28.92±6.2 vs. 25.42±4.8; P < 0.001). Circumcision was significantly higher in rural compared to urban areas (51.9% vs.18.1%). The level of female education, his parents, spouse, and husband's employment status were significantly associated with circumcision (P < 0.001). 94.4% of uncircumcised nulliparous women and 86.9% of circumcised women experienced Intended Pregnancy (P=0.02). Eighty- five percent of women were circumcision type I. The higher mean duration of the second stage of labor, Second and Third degree of tear, and need for oxytocin in induction were significantly higher among circumcised women (P = 0.03, 0.003, 0.002, respectively). The existence one stage of labor, Second and Third degree of tear, and the need for oxytocin in induction were significantly higher among circumcised women (P = 0.03, 0.003, 0.002, respectively).

CONCLUSION

These findings underscore that Circumcision a prevalent predictor of poor neonatal outcomes and delivery processes, therefore this circumcised women needs intensive care during delivery.

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.

Obstetric Complications in Women from Sub-Saharan Africa-A Cross-Sectional Study

AIM

The aim of this study was to identify and compare birthing complications in women originating from countries where they are at risk (may become victims) of FGM with those of Spanish women, all having given birth from 2012 to 2015 at the "Virgen de la Arrixaca" University Clinical Hospital in Murcia, Spain.

METHODS

A transversal, observational, quantitative study was carried out, retrospectively, comparing 245 sub-Saharan women originating from countries where FGM is practiced with 490 Spanish women, in terms of obstetric complications. Data collection was performed via electronic clinical records.

RESULTS

The sub-Saharan women presented higher rates of intrapartum and emergency caesareans, intense postpartum haemorrhages, concurrent episiotomies and tears (2nd and 3rd degree), failed inductions, and non-progressive labours, and a more severe risk of foetal distress when compared with Spanish women.

CONCLUSIONS

The fact that the sub-Saharan women originating from countries where FGM is practiced presented a greater number of birthing complications than the Spanish women proves the need for Spanish healthcare professionals to receive training towards cultural competency acquisition, in order to provide a multidisciplinary approach, with standardized action protocols focused fundamentally on prevention.

Economic burden of female genital mutilation in 27 high-prevalence countries

BACKGROUND

Female genital mutilation (FGM) is a traditional harmful practice affecting 200 million women and girls globally. Health complications of FGM occur immediately and over time, and are associated with healthcare costs that are poorly understood. Quantifying the global FGM-related burden is essential for supporting programmes and policies for prevention and mitigation.

METHODS

Health complications of FGM are derived from a meta-analysis and stratified by acute, uro-gynaecological, obstetric and psychological/sexual. Treatment costs are calculated from national cohort models of 27 high-burden countries over 30 years. Savings associated with full/partial abandonment are compared with a current incidence reference scenario, assuming no changes in FGM practices.

RESULTS

Our model projects an increasing burden of FGM due to population growth. As a reference scenario assuming no change in practices, prevalent cases in 27 countries will rise from 119.4 million (2018) to 205.8 million (2047). Full abandonment could reduce this to 80.0 million (2047), while partial abandonment is insufficient to reduce cases. Current incidence economic burden is US$1.4 billion/year, rising to US$2.1 billion/year in 2047. Full abandonment would reduce the future burden to US$0.8 billion/year by 2047.

CONCLUSION

FGM is a human rights violation, a public health issue and a substantial economic burden that can be avoided through effective prevention strategies. While decreasing trends are observed in some countries, these trends are variable and not consistently observed across settings. Additional resources are needed to prevent FGM to avoid human suffering and growing costs. The findings of this study warrant increased political commitment and investment in the abandonment of FGM.

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.

How to ensure policies and interventions rely on strong supporting facts to improve women's health: The case of female genital cutting, using Rosling's Factfulness approach

Rosling et al’s book Factfulness aims to inspire people to use strong supporting facts in their decision‐making, with 10 rules of thumb to fight dramatic instincts. In this paper, the Factfulness framework is applied to female genital cutting (FGC), in order to identify possible biases and promote evidence‐based thinking in studies on FGC, clinical guidelines on management of FGC, and interventions aimed at abolishing FGC. The Factfulness framework helps to acknowledge that FGC is not a uniform practice and helps address that variability. This framework also highlights the importance of multidisciplinarity to understand causalities of the FGC issue, which the authors argue is essential. This paper highlights the fact that FGC is a dynamic practice, with changes in the practice that are ongoing, and that those changes are different in different contexts. The “zero tolerance” discourses on FGC fail to acknowledge this. Factfulness encourages us to be more critical of methodologies used in the area of FGC, for example when estimating girls at risk of FGC in migration contexts. Factfulness provides the tools to calculate risks rather than judgments based on fear. This may help limit stigmatization of women with FGC and to allocate resources to health problems of migrant women based on real risks. The framework also calls for more research and production of less biased facts in the field of FGC, in order to improve interventions aimed at abolishing FGC, and clinical guidelines for the treatment of FGC. Factfulness is a useful and structured foundation for reflection over constructs, biases and disputes surrounding FGC, and can help improve the quality of future evidence‐based interventions and education that address the actual needs of women with FGC and girls at risk of FGC.

"A lot of them have scary tears during childbirth…" experiences of healthcare workers who care for genitally mutilated females

Despite concerted efforts to curb Female Genital Mutilation/Cutting (FGM/C), it is still a contributor to the high morbidity and mortality rates among females in Africa. According to available literature, the experiences of healthcare workers who care for the genitally mutilated females in Nigeria have not been described, hindering efforts towards ending this procedure through evidence-based, community-led interventions. This qualitative study described the experiences of healthcare workers caring for the genitally mutilated females in South-Eastern Nigeria. In-depth interviews conducted with 17 participants resulted in two themes and five sub-themes. The participants faced major challenges in caring for these females as the complications of FGM/C resulted in situations requiring advanced skills for which they were ill-prepared. Irrespective of this complex situation, the participants believed FGM/C was an age-old cultural practice; some even supported its continuation. The solution to this problem is not simple. However, educational programmes involving all cadres of healthcare workers could assist with eradicating this practice. Also, enforcing the anti-FGMC law could enhance the eradication of this procedure.