A systematic review and meta-analysis of the consequences of female genital mutilation on maternal and perinatal health outcomes in European and African countries

Pre-service education and continuous professional development on female genital mutilation/cutting for maternal health professionals in OECD countries: A scoping review

BACKGROUND

Female Genital Mutilation/Cutting can cause sequalae throughout pregnancy, childbirth, and the postpartum period. Due to changing patterns in migration flows, the practice evolved into a global phenomenon. Health professionals should ensure high quality of care during maternity service provision.

OBJECTIVE

This scoping review aimed to map available evidence on pre-service and continuous professional development education about Female Genital Mutilation/Cutting for maternal health professionals and identify developmental needs for topic inclusion into teaching.

METHODOLOGY

The review was conducted in accordance with the PRISMA-ScR guidelines. A protocol was developed and is publicly available (medRxiv 2022.08.16.22278598). Three databases (CINAHL, Embase, Medline) and other educational sources were searched. During the final stages of the review an ethical application was submitted and approved. Expert interviews were added to gain insights from practice.

RESULTS

The search identified 224 records. After title and abstract screening, 33 studies were selected for full-text review, resulting into the inclusion of 4 studies and 12 non-research educational sources. Scoping the topic revealed that Female Genital Mutilation/Cutting is often included ad-hoc or stand-alone during trainings and it remains unclear, who owes the responsibility. There is lack of knowledge about which competencies are needed for the different levels of health cadres, how competencies are achieved and outcomes measured.

CONCLUSION

More transparency into training on Female Genital Mutilation/Cutting and about how competency levels are achieved, maintained and evaluated is required. Further research and interdisciplinary collaboration could focus on the development of specific modules and lead to service improvement.

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.

Vulnerabilities and reparative strategies during pregnancy, childbirth, and the postpartum period: moving from rhetoric to action

Maternal outcomes throughout pregnancy, childbirth, and the postnatal period are influenced by interlinked and interdependent vulnerabilities. A comprehensive understanding of how various threats and barriers affect maternal and perinatal health is critical to plan, evaluate and improve maternal health programmes. This paper builds on the introductory paper of the Series on the determinants of maternal health by assessing vulnerabilities during pregnancy, childbirth, and the postnatal period. We synthesise and present the concept of vulnerability in pregnancy and childbirth, and map vulnerability attributes and their dynamic influence on maternal outcomes in early and late pregnancy and during childbirth and the postnatal period, with a particular focus on low-income and middle-income countries (LMICs). We summarise existing literature and present the evidence on the effects of various reparative strategies to improve pregnancy and childbirth outcomes. Lastly, we discuss the implications of the identified vulnerability attributes and reparative strategies for the efforts of policymakers, healthcare professionals, and researchers working towards improving outcomes for women and birthing people in LMICs.

The relationship between dominant Western discourse and personal narratives of female genital cutting: exploring storytelling among Swedish-Somali girls and women

Introduction

A dominant narrative, referred to as "the standard tale," prevails in popular representations about female genital cutting (FGC) that often contrast with how cut women traditionally narrate their FGC experience as meaningful in contexts where FGC is customary. However, scholarship has increasingly highlighted how global eradication campaigns and migration to countries where FGC is stigmatized provide women with new frames of understanding which may lead to a reformulation of previous experiences. This article subjects the storytelling itself to analysis and explores how participants narrate and make sense of their FGC experience in a post-migration setting where FGC is stigmatized.

Methods

Semi-structured focus groups (9) and individual interviews (12) with Swedish-Somali girls and women (53) were conducted.

Results

The article highlights how the participants navigate their storying in relation to "the standard tale" of FGC in their efforts to make sense of their experiences. Navigation was conducted both at an intrapersonal level through continuous identity work, and in relation to the social context in interpersonal encounters, i.e., with service providers and others, among whom the standard tale has become a truth.

Discussion

The article places the analysis within broader discussions about anti-FGC work and considers the implications in relation to efforts to end FGC.

Legal Awareness and Practices of Female Genital Mutilation/Cutting (FGM/C) among United Arab Emirates Medical Practitioners

Female genital mutilation/cutting (FGM/C), due to its regional occurrence, is a marginalized issue in the international arena. The aim of the study was to verify reasons for performing a procedure prohibited by international and domestic law. A cross-sectional study was conducted among nurses and doctors practicing in the UAE. The study was conducted from the 1 of January 2020 to the 31 of December 2021. The total number of recruited individuals who agreed to participate was 120, with the rate of return being 82%. About half of the participants (n = 59, 49.2%) have seen FGM/C patients in their UAE practice. Regarding medical staff, the total knowledge score concerning possible complications of the performed procedure was assessed at 64%, i.e., at a moderate level. None of our study participants had previously performed any type of FGM/C. However, 6.7% were willing to do it upon a mother's or guardian's request. About 83% of study participants stated that FGM/C should be halted internationally. Only 26.7% of the medical practitioners were aware of UAE law concerning FGM/C, while 50% had no knowledge concerning this issue. The present study reveals that cultural conditions take priority over medical knowledge, making medical practitioners inclined to accept the circumcision of girls and women. The crucial goals of future activities should focus on sensitizing society and the medical community, the need to create clear laws penalizing the practice, and the legal obligation to report the circumcision of a girl or woman.

Assessment of complications associated with female genital cutting among postnatal women in Chuko Primary Hospital, Sidama region, Southern Ethiopia

Objectives

Female genital cutting is a genital operation for a nonmedical reason and involves the cutting away of a part or whole of the female external genitals. Postnatal women with genital cutting could be more vulnerable to circumcision-associated birth complications, and it is still a major health problem during childbirth and the postnatal period in Ethiopia. This study aimed to assess complications associated with female genital cutting among postnatal women in Chuko Primary Hospital, Sidama region, Southern Ethiopia.

Methods

An institutional-based quantitative cross-sectional study design was conducted from 01 May 2021 to 15 June 2021. A systematic random sampling technique was used to select study participants. Data were collected by using a structured pretested questionnaire and reviewing medical records. The data were analyzed using SPSS version 23.0. Logistic regression analysis was computed to identify birth complications associated with female genital cutting from independent variables, and significance was declared at p < 0.05 with 95% CI.

Results

The proportion of female genital cutting among the participants was 76.8% (95% confidence interval: 71.1, 81.2). Prolonged labor and birth asphyxia were statistically significant female genital cutting-associated birth complications.

Conclusion

This study revealed a high proportion of complications associated with female genital cutting. Birth complications such as prolonged labor and birth asphyxia have a statistically significant association with it. Illiteracy and early marriage were the predominant reasons for female genital cutting. Therefore, healthcare providers should educate the rural communities to prevent early marriage and female genital cutting to prevent its complications.

Risk of obstetric anal sphincter injury associated with female genital mutilation/cutting and timing of deinfibulation

INTRODUCTION

A greater risk of obstetric anal sphincter injury has been reported among African migrants in several host countries compared with the general population. To what degree female genital mutilation/cutting affects this risk is not clear. In infibulated women, deinfibulation prevents anal sphincter injury. Whether the timing of deinfibulation affects the risk, is unknown. This study aimed to investigate the risks of anal sphincter injury associated with female genital mutilation/cutting and timing of deinfibulation in Norway, and to compare the rates of anal sphincter injury in Somali-born women and the general population.

MATERIAL AND METHODS

In a historical cohort study, nulliparous Somali-born women who had a vaginal birth in the period 1990-2014 were identified by the Medical Birth Registry of Norway and data collected from medical records. Exposures were female genital mutilation/cutting status and deinfibulation before labor, during labor or no deinfibulation. The main outcome was obstetric anal sphincter injuries.

RESULTS

Rates of obstetric anal sphincter injury did not differ significantly by female genital mutilation/cutting status (type 1-2: 10.2%, type 3: 11.3%, none: 15.2% P = 0.17). The total rate of anal sphincter injury was 10.3% compared to 5.0% among nulliparous women in the general Norwegian population. Women who underwent deinfibulation during labor had a lower risk than women who underwent deinfibulation before labor (odds ratio 0.48, 95% confidence interval 0.27-0.86, P = 0.01).

CONCLUSIONS

The high rate of anal sphincter injury in Somali nulliparous women was not related to type of female genital mutilation/cutting. Deinfibulation during labor protected against anal sphincter injury, whereas deinfibulation before labor was associated with a doubled risk. Deinfibulation before labor should not be routinely recommended during pregnancy.

Diagnoses and procedures of inpatients with female genital mutilation/cutting in Swiss University Hospitals: a cross-sectional study

Background

Female genital mutilation/cutting (FGM/C) can result in short and long-term complications, which can impact physical, psychological and sexual health. Our objective was to obtain descriptive data about the most frequent health conditions and procedures associated with FGM/C in Swiss university hospitals inpatient women and girls with a condition/diagnosis of FGM/C. Our research focused on the gynaecology and obstetrics departments.

Methods

We conducted an exploratory descriptive study to identify the health outcomes of women and girls with a coded FGM/C diagnose who had been admitted to Swiss university hospitals between 2016 and 2018. Four of the five Swiss university hospitals provided anonymized data on primary and secondary diagnoses coded with the International Classification of Diseases (ICD) and interventions coded in their medical files.

Results

Between 2016 and 2018, 207 inpatients had a condition/diagnosis of FGM/C. The majority (96%) were admitted either to gynaecology or obstetrics divisions with few genito-urinary and psychosexual conditions coded.

Conclusions

FGM/C coding capacities in Swiss university hospitals are low, and some complications of FGM/C are probably not diagnosed. Pregnancy and delivery represent key moments to identify and offer medical care to women and girls who live with FGM/C.

Trial registration: This cross-sectional study (protocol number 2018-01851) was conducted in 2019, and approved by the Swiss ethics committee.

Female genital mutilation/cutting (FGM/C) can result in short and long-term complications, which can impact physical, psychological and sexual health. Our objective was to obtain descriptive data about the most frequent health conditions and procedures associated with FGM/C among inpatients with a condition/diagnosis of FGM/C in Swiss university hospitals. We asked the Swiss university hospitals anonymized data of women and girls with a coded FGM/C diagnose who had been admitted between 2016 and 2018. Four of the five Swiss university hospitals provided the primary and secondary diagnoses coded with the International Classification of Diseases (ICD) and the interventions coded in their medical files. Only 207 inpatients had a condition/diagnosis of FGM/C. The majority was admitted either to gynaecology or obstetrics divisions. Some complications of FGM/C are probably not diagnosed. Pregnancy and childbirth represent key moments to care for and counsel a population that might not consult or be identified otherwise.

Short message service (SMS) reminders for childhood immunisation in low-income and middle-income countries: a systematic review and meta-analysis

Introduction

Childhood vaccine delivery services in the low- and middle-income countries (LMIC) are struggling to reach every child with lifesaving vaccines. Short message service (SMS) reminders have demonstrated positive impact on a number of attrition-prone healthcare delivery services. We aimed to evaluate the effectiveness of SMS reminders in improving immunisation coverage and timeliness in LMICs.

Methods

PubMed, Embase, Scopus, Cochrane CENTRAL, CINAHL, CNKI, PsycINFO and Web of Science including grey literatures and Google Scholar were systematically searched for randomised controlled trials (RCTs) and non-RCTs that evaluated the effect of SMS reminders on childhood immunisation and timeliness in LMICs. Risk of bias was assessed using the Cochrane Risk of Bias 2.0 assessment tool for RCTs and Cochrane Risk of Bias in Non-randomised Studies of Interventions tool for non-RCTs. Meta-analysis was conducted using random-effects models to generate pooled estimates of risk ratio (RR).

Results

18 studies, 13 RCTs and 5 non-RCTs involving 32 712 infants (17 135 in intervention groups and 15 577 in control groups) from 11 LMICs met inclusion criteria. Pooled estimates showed that SMS reminders significantly improved childhood immunisation coverage (RR=1.16; 95% CI: 1.10 to 1.21; I²=90.4%). Meta-analysis of 12 included studies involving 25 257 infants showed that SMS reminders significantly improved timely receipt of childhood vaccines (RR=1.21; 95% CI: 1.12 to 1.30; I²=87.3%). Subgroup analysis showed that SMS reminders are significantly more effective in raising childhood immunisation coverage in lower middle-income and low-income countries than in upper middle-income countries (p<0.001) and sending more than two SMS reminders significantly improves timely receipt of childhood vaccines than one or two SMS reminders (p=0.040).

Conclusion

Current evidence from LMICs, although with significant heterogeneity, suggests that SMS reminders can contribute to achieving high and timely childhood immunisation coverage.

PROSPERO registration number

CRD42021225843.