An updated systematic review and meta-analysis of the obstetric consequences of female genital mutilation/cutting

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.

Prevalence of female genital mutilation and associated factors among women and girls in Africa: a systematic review and meta-analysis

BACKGROUND

Female genital mutilation (FGM) has zero health benefits. It can lead to short- and long-term risks and complications, including physical, sexual, and mental health and well-being of girls and women. It is a worldwide public health issue with more than 80% prevalence in Africa. It is a global imperative to strengthen work for the elimination, and the United Nations Sustainable Development Goal (SDG) strives to eliminate FGM and monitor the progress made. However, one of a challenge in tracking progress is establishing baseline prevalence data within regions and countries. Therefore, this review aimed to pool the prevalence of FGM in Africa and identify the promoting factors among women and girls.

METHODS

This review was conducted according to the PRISMA checklist guideline. Both published and unpublished studies conducted from 2012 onwards were eligible. Studies written in non-English languages were excluded. To retrieve relevant studies; PubMed/Medline, Google Scholar, Science Direct, African Journals Online databases, and African Index Medicus (AIM) were searched using a combination of searching terms. The Newcastle-Ottawa Assessment Scale (NOS) tool was used to assess the quality of each included study. The Cochran's Q chi-square and I2 statistical tests were used to evaluate the heterogeneity of the included studies. The Funnel plot and Egger's regression test (p value < 0.05) were used to evaluate meh publication bias. We used STATA for analysis and the overall and subgroup pooled effect size was estimated using the random effect model with DerSimonian and Laired pooled effect method. The overall prevalence of FGM and the adjusted odds ratio (AOR) with 95%CI (confidence interval) for contributing factors were calculated and presented using a forest plot.

RESULT

This study included 155 primary studies conducted on the prevalence and/or factors associated with FGM in Africa. The pooled prevalence of FGM was 56.4% (95%CI 49.7-63.6). The primary factors promoting the practice of FGM were family history of circumcision (AOR = 13.71, 95%CI 9.11-20.62), being a Muslim religion follower (AOR = 3.51, 95%CI 2.61-4.71), poor wealth index (AOR = 1.38, 95%CI1.27-1.51), higher age (AOR = 2.95, 95%CI 2.49-3.38), not attending formal education (AOR = 3.28, 95%CI 2.62-4.12), and rural residency (AOR = 2.27, 95%CI 1.84-2.80).

CONCLUSION

The prevalence of FGM in Africa was found to be high. This study also observed a variation in FGM prevalence across regions and countries and a slight temporal decline over the study period. As the global community enters the final decade dedicated to eliminating FGM, there remains much to be done to achieve the elimination goal.

Estimating excess mortality due to female genital mutilation

Globally, over 200 million women and girls have been subjected to Female Genital Mutilation (FGM). This practice, illegal in most countries, often happens in unsanitary conditions and without clinical supervision with consequent bleeding and infection. However, little is known about its contribution to the global epidemiology of child mortality. We matched data on the proportion of girls of a given age group subject to FGM to age-gender-year specific mortality rates during 1990-2020 in 15 countries where FGM is practised. We used fixed-effects regressions to separate the effect of FGM on mortality-rates from variation in mortality in that country in that year. Using our estimated effect, we calculated total annual excess mortality due to FGM. Our estimates imply that a 50% increase in the number of girls subject to FGM increases their 5-year mortality rate by 0.075 percentage point (95% CI [Formula: see text]-[Formula: see text]). This increased mortality rate translates into an estimated 44,320 excess deaths per year across countries where FGM is practised. These estimates imply that FGM is a leading cause of the death of girls and young women in those countries where it is practised accounting for more deaths than any cause other than Enteric Infections, Respiratory Infections, or Malaria.

A 36-year-old lady with type three female genital mutilation (Infibulation) - its long-term complications: a case report and literature review

BACKGROUND

Female genital mutilation comprises all procedures involving the partial or total removal of female external genitalia or other injury to the female external organs, whether for religious, cultural or other non-therapeutic reasons. The impact of female genital mutilation is diverse, including physical, social and psychological impact. We report a case of a 36-year-old woman with type three female genital mutilation who did not seek medical treatment due to lack of awareness that there was treatment for it, and use this case as an entry point to comprehensively review literature regarding long-term complications associated with female genital mutilation and its impact on women's quality of life.

CASE PRESENTATION

We present a case of a 36-year-old single nulligravida lady with type three female genital mutilation who had presented with difficulty with urination since childhood. She had difficulty with menstruation since her menarche, and she had never had sexual intercourse. She never sought treatment, but recently went to hospital after she heard of a young lady who had the same problem in her neighborhood who was treated surgically and got married. On external genitalia examination, there was no clitoris, no labia minora, and labia majora were fused to each other with a healed old scar between them. There was a 0.5 cm by 0.5 cm opening below the fused labia majora near to the anus through which urine was dribbling. De-infibulation was done. Six months after the procedure, she was married and at that moment she was pregnant.

CONCLUSION

The physical, sexual, obstetrics and psychosocial consequences of female genital mutilation are neglected issues. The improvement of women's socio-cultural status in combination with planning programs to enhance their information and awareness as well as trying to change the cultural and religious leaders' viewpoints regarding this procedure is essential to reducing female genital mutilation and its burden on women's health.

Advancing the measurement of knowledge, attitudes and practices of health workers who care for women and girls who have undergone female genital mutilation/ cutting (FGM/C): A qualitative exploration of expert opinion

BACKGROUND

Female genital mutilation or cutting (FGM/C) is a social norm driven practice associated with numerous adverse health complications. Existing assessment tools for health workers are limited by lack of a clear framework for what constitutes the critical knowledge, attitudes, and practices that impact FGM/C prevention and care. The aim of this study was to explore expert opinion of the knowledge, attitudes, and practices for FGM/C-related prevention and care that can be used to inform the development of future KAP measurement tools.

METHODS

We conducted 32 semi-structured individual interviews with global clinical and research experts on FGM/C from 30 countries including participants from Africa, Australia/ New Zealand, Europe, the Middle East, and North America. Interview questions explored areas of knowledge, attitudes, and practices that influence FGM/C-related prevention and care activities. We used the directed content analysis methodology for the qualitative data analysis.

RESULTS

We identified six categories of knowledge, six of practice, and seven of attitudes that contribute to FGM/C-related prevention and care. Areas of knowledge included: general knowledge about FGM/C; who is at risk for experiencing FGM/C; support for FGM/C; female genital anatomy/ physiology; health complications of FGM/C; management of health complications of FGM/C; ethical and legal considerations for the treatment and prevention of FGM/C, and patient-health worker communication. Areas of practice included: clinical procedures and protocols; management of complications; defibulation; other surgical procedures for FGM/C; pediatric care (including prevention); and patient-centered care. Participants described health worker attitudes that may affect how prevention and care activities are delivered and/or received including attitudes toward: the perceived benefits of FGM/C; harms of FGM/C; ethical considerations related to FGM/C medicalization, prevention, and treatment; providing care for FGM/C-affected clients; women and girls who have experienced FGM/C; communities that practice FGM/C; and affective response to FGM/C. We also present participant perspectives on the ways in which knowledge, attitudes, and practice interact impacting the type and quality of care provided to those affected by FGM/C.

CONCLUSIONS

This study identified specific areas of knowledge, attitudes, and practices in FGM/C prevention and care that are important to include in future evaluation metrics. Future KAP tools should be theoretically informed using the framework we present, and assessed for validity and reliability using psychometrically rigorous methods. Developers of KAP tools should consider the hypothesized relationships between knowledge, attitudes, and practices.

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.

Systematic Review of Obstetric and Neonatal Complications Associated With Female Genital Mutilation

OBJECTIVE

To assess the prevalence of obstetric and neonatal complications in women with female genital mutilation (FGM) compared to women without FGM.

DATA SOURCES

Literature searches carried out on three scientific databases (CINAHL, ScienceDirect, and PubMed).

STUDY SELECTION

Selected observational studies published from 2010 to 2021 that assessed prolonged second phase of labor, vaginal outlet obstruction, emergency cesarean birth, perineal tear, instrumental births, episiotomy, and postpartum hemorrhage in women with and without FGM, as well as Apgar score and resuscitation of their newborns.

RESULTS

Nine studies were selected, including case-control, cohort, and cross-sectional studies. There were associations between FGM and vaginal outlet obstruction, emergency cesarean birth, and perineal tears.

CONCLUSION

For obstetric and neonatal complications other than those listed in the "Results" section, researchers' conclusions remain divided. Still, there is some evidence to support the impact of FGM on obstetric and neonatal harm, particularly in cases of FGM Types II and III.

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.

Factors associated with general practitioners' routines and comfortability with assessing female genital cutting: a cross-sectional survey

BACKGROUND

Female genital cutting (FGC) may cause a series of health problems that require specialized healthcare. General practitioners (GPs) are gatekeepers to specialized healthcare services in Norway. To refer girls and women subjected to FGC to appropriate services, GPs need to assess whether the health problems reported by these patients are related to FGC. However, we do not know to what degree GPs assess FGC as a potential cause of the patients' health problems. We also know little about the GPs' patterns of training and knowledge of FGC and their effect on the GPs' assessment of FGC as a potential cause of health problems.

METHOD

We employed a cross-sectional online survey among GPs in Norway to examine: 1) patterns of received training on FGC, self-assessed knowledge, and experiences with patients with FGC-related problems and 2) the association between these three factors and the GPs' assessment of FGC as a potential cause of patients' health problems. A total of 222 GPs completed the survey. Data were analysed using binary logistic regression, where we also adjusted for sociodemographic characteristics.

RESULTS

Two-third of the participants had received training on FGC, but only over half received training on FGC-related health problems. Over 75% of the participants stated a need for more knowledge of FGC typology and Norwegian legislation. While the majority of the participants assessed their knowledge of FGC medical codes as inadequate, this was not the case for knowledge of the cultural aspects of FGC. Female GPs were more likely to have experience with patients with FGC-related health problems than male GPs. Among GPs with experience, 46% linked health problems to FGC in patients unaware of the connection between FGC and such health problems. GPs were more likely to assess FGC as a potential cause of health problems when they had experience with patients having FGC-related problems and when they assessed their knowledge of FGC typology and FGC-related medical codes as adequate.

CONCLUSION

To improve their assessment of FGC as a potential cause of patients' health problems, GPs should receive comprehensive training on FGC, with particular emphasis on typology, health problems, and medical codes.

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.

Female genital mutilation/cutting incidence, diagnostic capacities, and obstetric outcomes among migrant women: a single-center retrospective analysis in a 10-year birth cohort in Austria

INTRODUCTION

Practical experience in the care of women with female genital mutilation/cutting (FGM/C) is uncommon in Austria. However, affected women require specialized gynecological and obstetric care. In our region, there is currently neither an official counseling center nor specially trained medical personnel to address the special needs of women after FGM/C. The aim of this study was to determine the potential need for obstetric care for women who have undergone FGM/C in our region.

METHODS

We retrospectively reviewed women presenting for delivery at the LKH University Hospital Graz from 1.1.2010 until 31.12.2020 regarding the place of birth and/or the nationality of the mother to filter out women from a country with known FGM/C prevalence according to the UNICEF Global Database. Data on the documentation of FGM/C as well as demographic maternal data and peripartal parameters were gathered. Periods before and after the European refugee crisis in 2015 were compared.

RESULTS

During the study period, a total of 35,628 deliveries took place at our hospital. 856 (2.4%) deliveries of 539 women were included due to nationality or birthplace in a country with known FGM/C prevalence. We found only 17/539 (3.2%) documented FGM/C cases. The estimated FGM/C prevalence among those patients was, however, 208/539 (38,6%). Women affected by FGM/C in our collective were most frequently from Nigeria, Egypt, Iraq, Ghana, and Somalia. No statistically significant increase in deliveries during the study period in the overall study cohort was observed, with the exception of deliveries of Somali women (p = 0.000).

DISCUSSION

The discrepancy between documented and expected FGM/C rates (3,2% vs. 38,6%) in our collective suggests that most cases of FGM/C go undetected among women delivering in Austria. These data show the great need for special training for obstetricians and targeted contact points for affected women.

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.

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.

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.

Female genital mutilation and cutting in the Arab League and diaspora: A systematic review of preventive interventions

OBJECTIVES

Female Genital Mutilation and Cutting (FGM/C) is an act of gender-based violence (GBV) and a global public health issue with well-documented adverse outcomes. With the rise in global migration, there is an increasing prevalence of FGM/C among Arab diaspora living in the West and Global South. What remains unclear is how to reduce the practice. This study was designed to identify interventions exerting an effect on reducing the practice of FGM/C.

METHODS

A systematic review of peer-reviewed articles was conducted on interventions targeting individuals and/or the broader community to prevent FGM/C within the Arab League and its diaspora, up to December 2021. Databases searched included PubMed, Medline, Web of Science, PsycINFO, EMBASE, CINAHL, BIOSIS, ASSIA and Scopus. Quality assessment used the Mixed Methods Appraisal Tool (MMAT) 2018.

RESULTS

Twelve of 896 studies met the inclusion criteria. Eight interventions relied entirely on education with short-term gains but unchanged practices. Three interventions used social marketing and mixed media. Only one study took a multi-sectoral approach.

CONCLUSIONS

At a macro level, opportunities to reduce or to end the practice of FGM/C exist through legislation, policy, a public health approach grounded in gender equality and human rights. Using multi-sectoral actions that consider the social context and challenge social norms at macro, meso and micro levels appears more effective than individual-level interventions. Promoting advocacy and developing supportive environments to reduce GBV, enhance gender equality and empower communities is crucial for interventions to succeed and achieve the Sustainable Development Goal target of FGM/C abandonment by 2030.

Are healthcare professionals prepared to provide care for patients who have experienced female genital cutting? A cross-sectional survey

Health care professionals may be underprepared to address the unique needs of patients who have experienced female genital cutting. This cross-sectional survey found that health care professionals in a large Canadian city report an overall lack of knowledge and preparedness to provide care for these patients and to address issues of defibulation, reinfibulation, child safeguarding, and legalities surrounding female genital cutting. Barriers to providing quality care include lack of training and clinical exposure. Health care professionals have indicated strong interest in further training, and consolidated efforts should be made to implement culturally informed care into health professional education.

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.

The benefits and disappointments following clitoral reconstruction after female genital cutting: A qualitative interview study from Sweden

Female genital cutting or mutilation refers to the cutting of girls' external genitalia. Due to migration from contexts where female genital cutting is common, it is estimated that around 38 000 cut women and girls live in Sweden. Clitoral reconstruction, a relatively new form of surgical healthcare offered to women with female genital cutting, was established in Sweden in 2014. This surgery aims at restoring clitoral function and anatomy, but there is yet a dearth of evidence demonstrating the effects of the surgery. The aim of this study was to explore how women undergoing clitoral reconstruction in Sweden between 2016 and 2019 experienced the surgical process and its aftereffects from a physical, sexual and psychosocial perspective. Eighteen women who had undergone clitoral reconstruction at a university hospital in Sweden agreed to participate in the study. The women were interviewed using semi-structured interviews, which were recorded, transcribed and analysed using thematic analysis. The results, based on self-categorization and labelling theory, demonstrated both benefits and disappointments following the surgery. Several women reported positive outcomes in terms of sexual, psychosocial and aesthetic terms. They experienced reduced genital pain, improvements in their sex lives, and a sense of feeling more empowered and at ease in their bodies. Yet, some women reported aesthetic, functional and process-related disappointment related to clitoral reconstruction. Nonetheless, the women expressed gratitude for the possibility of undergoing the surgery. In conclusion, the women reported that they experienced physical, sexual and psychosocial benefits of the surgery.

Sexually destroyed or empowered? Silencing female genital cutting in close relationships

Based on fieldwork among Kurdish-Norwegian migrants, this study explored how female genital cutting (FGC) was a silenced topic between mothers and daughters, and between men and women. The silence was often broken when FGC was discussed as a practice that needed to be rejected. The main reasons for rejecting FGC were to support women's rights and to recognise the negative ways in which FGC affected women's sexuality. This way of breaking the silence on FGC was particularly helpful to some husbands and wives in their discussion of how FGC might have affected their sexual relationships. Using theories of migrant women's sexual agency and embodiment, this study examined how the silencing of FGC in close relationships can be interpreted both as a sign of oppression and as a sign of empowerment. The analysis suggests that the stigmatisation that circumcised women can experience from condemnatory public discourse on FGC may sometimes lead to the negotiation of assertive female sexuality.

Female Genital Cutting and Deinfibulation: Applying the Theory of Planned Behavior to Research and Practice

At least 200 million girls and women across the world have experienced female genital cutting (FGC). International migration has grown substantially in recent decades, leading to a need for health care providers in regions of the world that do not practice FGC to become knowledgeable and skilled in their care of women who have undergone the procedure. There are four commonly recognized types of FGC (Types I, II, III, and IV). To adhere to recommendations advanced by the World Health Organization (WHO) and numerous professional organizations, providers should discuss and offer deinfibulation to female patients who have undergone infibulation (Type III FGC), particularly before intercourse and childbirth. Infibulation involves narrowing the vaginal orifice through cutting and appositioning the labia minora and/or labia majora, and creating a covering seal over the vagina with appositioned tissue. The WHO has published a handbook for health care providers that includes guidance in counseling patients about deinfibulation and performing the procedure. Providers may benefit from additional guidance in how to discuss FGC and deinfibulation in a manner that is sensitive to each patient's culture, community, and values. Little research is available to describe decision-making about deinfibulation among women. This article introduces a theoretically informed conceptual model to guide future research and clinical conversations about FGC and deinfibulation with women who have undergone FGC, as well as their partners and families. This conceptual model, based on the Theory of Planned Behavior, may facilitate conversations that lead to shared decision-making between providers and patients.

Factors Associated with Health Care Provider Attitudes, and Confidence for the Care of Women and Girls Affected by Female Genital Mutilation/Cutting

Background: Female genital mutilation/cutting (FGM/C) is a cultural practice that includes procedures that intentionally alter or cause harm to female genital organs for nonmedical reasons, affecting ∼200 million women and girls globally. Health care providers in the United States often lack confidence to provide appropriate FGM/C-related care, and experience attitudes that may negatively impact quality of care for FGM/C. Methods: We conducted a cross-sectional survey of health care providers to explore the associations between health care provider characteristics, awareness of health complications of FGM/C, attitudes, and confidence for FGM/C care. Results: Factors associated with more Confidence for Clinical FGM/C Care include awareness of health complications, ever cared for a woman with FGM/C, being a woman or person of color, and more than 5 years of clinical practice. Increased Confidence in Communication Skills for FGM/C Care was associated with awareness of more health complications for FGM/C. Women endorsed significantly less Negative Attitudes toward FGM/C compared with men; no other factors were associated with health care provider attitudes. Conclusion: Future research should further investigate factors associated with health care provider attitudes toward FGM/C and those affected by the practice to promote quality care. Health providers require adequate training for clinical FGM/C care and in the communication skills that promote patient/provider communication cross-culturally. Trial Registration: Clinical Trials.Gov ID no. NCT03249649, Study ID no. 5252. Public website: https://clinicaltrials.gov/ct2/show/NCT03249649.

Clitoral reconstructive surgery after female genital mutilation: A systematic review

OBJECTIVE

To summarize available evidence on clitoral reconstruction after Female genital mutilations/cut (FGM/C).

STUDY DESIGN

Systematic review of the literature to identify studies on clitoral reconstruction after previous FGM/C with at least 6 months of follow-up. The literature search was performed in the following databases: PubMed, EMBASE, Web of Science, and the Cochrane Library. The period considered was from the database inception to June 30th, 2020.

MAIN OUTCOME MEASURES

Post-operative vulvar pain or dyspareunia, changes in sexual activity or orgasm, and the impact on self-image.

RESULTS

We identified 8 studies; four used the same "Foldès technique", and four adopted similar techniques based on the downward mobilization of the clitoral stump, with different reconstructions of glans and prepuce. The postoperative complication rate was reported at 5.3%. Sexual function is the only outcome investigated by all studies, which consistently suggest that clitoral reconstruction appear effective to improve clitoral pleasure/orgasm. Almost all studies assessed self-image, which appears improved. Only 2 studies provided data about pain and/or dyspareunia, which were improved by clitoral reconstruction. However, the risk of bias is high. Most patients were lost at follow-up, and validated instruments to assess outcomes were used only in a minority of studies.

CONCLUSIONS

Although clitoral reconstructive surgery for FGM/C appears safe and effective, caution is required to interpret available evidence due to significant limitations. Further studies are required to compare the proposed techniques and to confirm the effectiveness in terms of vulvar pain and/or dyspareunia, sexual activity and/or orgasm, and self-image improvement.

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.

The association between physical complications following female genital cutting and the mental health of 12-year-old Gambian girls: A community-based cross-sectional study

BACKGROUND

Female genital cutting (FGC) involve an acute physical trauma that hold a potential risk for immediate and long-term complications and mental health problems. The aim of this study was to examine the prediction of depressive symptoms and psychological distress by the immediate and current physical complications following FGC. Further, to examine whether the age at which 12-year-old Gambian girls had undergone the procedure affected mental health outcomes.

METHOD

This cross-sectional study recruited 134 12-year-old girls from 23 public primary schools in The Gambia. We used a structured clinical interview to assess mental health and life satisfaction, including the Short Mood and Feeling Questionnaire (SMFQ), the Symptom check list (SCL-5) and Cantril's Ladder of Life Satisfaction. Each interview included questions about the cutting procedure, immediate- and current physical complications and the kind of help and care girls received following FGC.

RESULTS

Depressive symptoms were associated with immediate physical health complications in a multivariate regression model [RR = 1.08 (1.03, 1.12), p = .001], and with present urogenital problems [RR = 1.19 (1.09, 1.31), p < .001]. The girls that received medical help following immediate complications had a lower risk for depressive symptoms [RR = .73 (.55, .98), p = .04]. Psychological distress was only associated with immediate complications [RR = 1.04 (1.01, 1.07), p = .004]. No significant differences in mental health outcomes were found between girls who underwent FGC before the age of four in comparison to girls who underwent FGC after the age of four.

CONCLUSION

Our findings indicate that the immediate and long-term complications following FGC have implications for psychological health. Only a minimal number of girls received medical care when needed, and the dissemination of health education seems crucial in order to prevent adverse long-term physical and psychological health consequences.

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

INTRODUCTION

Key knowledge gaps remain to improve reproductive health outcomes for millions of women living with female genital mutilation (FGM). We aimed to update previous reviews and quantify more rigorously maternal and perinatal complications related to FGM across different settings.

METHODS

In this systematic review and meta-analysis, we searched 15 electronic databases for studies published between 1 August 1995 and 15 March 2020, reporting on maternal and perinatal complications related to FGM. We included studies comparing women with and without FGM while accounting for confounders. Pooled relative risks (RR) were calculated, using fixed-effects and random-effects models, for a range of maternal and perinatal outcomes, adjusting for individual characteristics and according to delivery settings and study design.

RESULTS

We identified 106 unique references, assessed 72 full-text articles and included 11 studies. We found non-significant elevated risks of instrumental delivery, caesarean delivery, episiotomy, postpartum haemorrhage, perineal laceration, low Apgar score and miscarriage/stillbirth related to FGM. Heterogeneity was present for most outcomes when combining all studies but reduced in subgroup analyses. The risk of caesarean delivery was increased among primiparous women (1.79, 95% CI 1.04 to 3.07) such as the risk of episiotomy in European specialised settings for women with FGM (1.88, 1.14 to 3.09). In Africa, subgroup analyses revealed elevated risks of postpartum haemorrhage (2.59, 1.28 to 5.25). The most common reported type was FGM II. However, few studies provided stratified analyses by type of FGM, which did not allow an assessment of the impact of the severity of typology on studied outcomes.

CONCLUSION

This review suggests maternal and perinatal morbidity related to FGM vary by study design, context and by subgroup of women. Our study also draws attention to the complications that may extend to the postpartum period. This work contributes to shaping a reference framework for future research and clinical guidelines.

Female genital mutilation and women's healthcare experiences with general practitioners in the Netherlands: A qualitative study

OBJECTIVES

While the general practitioner (GP) in the Netherlands is the first point of entry to and gatekeeper of the healthcare system, no study exists to explore the experiences of women with female genital mutilation or cutting (FGM/C) in general practice. Therefore, the aim of this study is to look into the experiences of women with FGM/C in Dutch general practice.

METHODS

Semistructured interviews were held with 16 women with FGM/C. Sampling was purposeful. The interview guide and thematic analysis were based on the Illness Perception Model and Kleinman's Explanatory model. Interviews were held in English or Dutch. All data were anonymized, and recordings were transcribed verbatim. Transcripts were coded and thematically analyzed.

RESULTS

The women considered FGM/C to be connected to a range of health problems, for which not all of them sought medical care. They had difficulty discussing such a sensitive topic with their GP, did not know their problems could be relieved or perceived GPs to have insufficient knowledge of FGM/C. Lack of time during consultations and overall dissatisfaction with Dutch GP care hampered trust. They strongly preferred the GP to be proactive and ask about FGM/C.

CONCLUSION

There is room for improvement as most women would like their GP to discuss their health problems related to FGM/C. GPs should take a proactive attitude and ask about FGM/C. In addition, to develop the trusted relationship needed to discuss sensitive topics and provide culturally sensitive person-centered care, sufficient time during consultations is needed.

Is female genital mutilation associated with eclampsia? Evidence from a nationally representative survey data

Background

Studies have shown the impact of female genital mutilation (FGM), especially infibulation (WHO type III), on reproductive health, and adverse obstetric outcomes like postpartum haemorrhage and obstructed labour. However, whether an association exists with maternal hypertensive complication is not known. The present study sought to investigate the role of the different types of FGM on the occurrence of eclampsia.

Methods

The study used data from the 2006 Demographic and health survey of Mali. The proportion of eclampsia in women with each type of FGM and the unadjusted and adjusted odds ratios (OR) were calculated, using women without FGM as reference group. Unadjusted and adjusted OR were also calculated for women who underwent infibulation compared to the rest of the population under study (women without FGM and women with FGM type I, II, and IV).

Results

In the 3997 women included, the prevalence of infibulation was 10.2% (n = 407) while 331 women did not report FGM (8.3%). The proportion of women reporting signs and symptoms suggestive of eclampsia was 5.9% (n = 234).

Compared with the absence of female genital mutilation and adjusted for covariates, infibulation was associated with eclampsia (aOR 2.5; 95% CI:1.4–4.6), while the association was not significant in women with other categories of FGM. A similar aOR was found when comparing women with infibulation with the pooled sample of women without FGM and women with the other forms of FGM.

Conclusion

The present study suggests a possible association between infibulation and eclampsia. Future studies could investigate this association in other settings. If these findings are confirmed, the possible biological mechanisms and preventive strategies should be investigated.

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.

Community gender systems and a daughter's risk of female genital mutilation/cutting: Multilevel findings from Egypt

We tested a feminist social-ecological model to understand community influences on daughters' experience of female genital mutilation/cutting (FGMC) in Egypt, where over 90% of women ages 15-49 are cut. FGMC has potential adverse effects on demographic and health outcomes and has been defined as a human-rights violation. However, an integrated multilevel-level framework is lacking. We theorized that a more favorable community-level gender system, including stronger gender norms opposing FGMC and expanded extra-familial opportunities for women in the village or neighborhood, would be associated with a daughter's lower risk of FGMC and would strengthen the negative association of a mother's opposition to FGMC with her daughter's risk of cutting. Using a national sample of 14,171 mother-daughter dyads from the 2014 Egypt Demographic and Health Survey, we estimated multilevel discrete-time hazard models to test these relationships. Community gender norms opposing FGMC had significant direct, negative associations with the hazard that a daughter was cut, but women's opportunities outside the family did not. Maternal opposition to FGMC was negatively associated with cutting a daughter, and these associations were stronger where community opposition to FGMC and opportunities for women were greater. Results provided good support for a gender-systems framework of the multilevel influences on FGMC. Integrated, multilevel interventions that address gender norms about FGMC and structural opportunities for women in the community, as well as beliefs about the practice among the mothers of at-risk daughters, may be needed for sustainable declines in the 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.

Preventing female genital mutilation in high income countries: a systematic review of the evidence

Background

Female genital mutilation (FGM) is prevalent in communities of migration. Given the harmful effects of the practice and its illegal status in many countries, there have been concerted primary, secondary and tertiary prevention efforts to protect girls from FGM. However, there is paucity of evidence concerning useful strategies and approaches to prevent FGM and improve the health and social outcomes of affected women and girls.

Methods

We analysed peer-reviewed and grey literature to extract the evidence for FGM prevention interventions from a public health perspective in high income countries by a systematic search of bibliographic databases and websites using appropriate keywords. Identified publications were screened against selection criteria, following the PRISMA guidelines. We examined the characteristics of prevention interventions, including their programmatic approaches and strategies, target audiences and evaluation findings using an apriori template.

Findings

Eleven documents included in this review described primary and secondary prevention activities. High income countries have given attention to legislative action, bureaucratic interventions to address social injustice and protect those at risk of FGM, alongside prevention activities that favour health persuasion, foster engagement with the local community through outreach and the involvement of community champions, healthcare professional training and capacity strengthening. Study types are largely process evaluations that include measures of short-term outcomes (pre- and post-changes in attitude, knowledge and confidence or audits of practices). There is a dearth of evaluative research focused on empowerment-oriented preventative activities that involve individual women and girls who are affected by FGM. Beattie’s framework provides a useful way of articulating negotiated and authoritative prevention actions required to address FGM at national and local levels.

Conclusion

FGM is a complex and deeply rooted sociocultural issue that requires a multifaceted response that encompasses socio-economic, physical and environmental factors, education and learning, health services and facilities, and community mobilisation activities. Investment in the rigorous longitudinal evaluation of FGM health prevention efforts are needed to provide strong evidence of impact to guide future decision making. A national evidence-based framework would bring logic, clarity, comprehension, evidence and economically more effective response for current and future prevention interventions addressing FGM in high income countries.

Female genital mutilation: implications for clinical practice

Female genital mutilation (FGM) is an established cultural practice in over 30 countries. It has no health benefits, carries a high risk of physical and psychological harm, and is illegal in many countries including the UK. A sensitive approach is required, both in the management of complications and prevention of this practice. This article discusses the prevalence and classification of FGM, and offers practical advice to nurses and midwives involved in general and obstetric care. Legal aspects, including safeguarding responsibilities and the mandatory duty to report FGM in England and Wales, are outlined.

Is female genital mutilation/cutting associated with adverse mental health consequences? A systematic review of the evidence

Introduction

The adverse physical consequences of female genital mutilation/cutting (FGM/C) have been thoroughly investigated and documented. Yet, we know little about the adverse mental health consequences of the practice. To fill this research gap, we systematically reviewed studies that assessed any adverse mental health consequences related to FGM/C.

Methods

We searched four databases from inception to 21 December 2018. We then reviewed all titles and abstracts for relevant studies. We used the National Institutes of Health quality assessment tool to appraise the quality of each study and the Newcastle-Ottawa Scale to rate the risk of bias within studies.

Results

We included 16 studies in this review; only six studies examined the association between FGM/C and adverse mental health outcomes as the sole research question. Among the included studies, 10 were conducted at the participants’ country of origin. The sample size of the populations studied ranged from 3 to 4800 participants. Only one study received a rating of ‘good’ methodological quality.

Fourteen of the 16 studies reported an association between FGM/C and at least adverse mental health outcome. These included eight studies that reported a higher burden of adverse mental health outcomes among women who underwent FGM compared with women who did not undergo FGM/C. Four studies reported a correlation between the severity of FGM/C and the severity of adverse mental health outcomes.

Conclusion

This systematic review documents an association between FGM/C and adverse mental health outcomes. Importantly, our review demonstrates the need for more rigorous research on the topic.

Emergency cesarean section among women in Robson groups one and three: A comparison study of immigrant and Norwegian women giving birth in a low-risk maternity hospital in Norway

Researchers have shown that some immigrant groups have an increased risk of emergency cesarean section. The authors' aim was to examine the differences in emergency cesarean section rates among immigrant women in Norway with low obstetric risks by using the Robson classification system. We performed secondary analysis on a Norwegian cohort study, where 10,125 women were classified in Robson groups one and three. Women from East, Southeast, and Central Asia, and from Africa had a higher risk of emergency cesarean section. The Robson classification system was a useful tool in comparing cesarean section rates between immigrant groups and host country populations.

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.

Health Consequences of the Female Genital Mutilation: A Systematic Review

Female genital mutilation (FGM) is a general health concern. The World Health Organization has recognized it as a condition that endangers women's health. This review study aimed to identify the types of health outcomes of FGM. Therefore, a systematic review was conducted to create a critical view of the current evidence on the effect of Female genital on girls and women's health. In this study, we focused on the health risks of female Female genital. Academic databases such as PubMed, Science Direct, Scopus, Google Scholar, Cochrane Database of Systematic Reviews, SID, IranMedex, Irandoc, and Magiran were searched with regard to the health consequences of FGM from January 1990 until 2018. Eleven review studies met the criteria and contained 288 relevant studies on the risks of FGM. It was suggested that FGM had various physical, obstetric, sexual, and psychological consequences. Women with FGM experienced mental disturbances (e.g., psychiatric diagnoses, anxiety, somatization, phobia, and low self-esteem) than other women. Our study can provide evidence on improving, changing behaviors, and making decisions on the quality of services offered to women suffering from FGM.

Secular trends in the prevalence of female genital mutilation/cutting among girls: a systematic analysis

Background

Current evidence on the decline in the prevalence of female genital mutilation or cutting (FGM/C) has been lacking worldwide. This study analyses the prevalence estimates and secular trends in FGM/C over sustained periods (ie, 1990-2017). Its aim is to provide analytical evidence on the changing prevalence of FGM/C over time among girls aged 0-14 years and examine geographical variations in low-income and middle-income countries.

Methods

Analysis on the shift in prevalence of FGM/C was undertaken using the Demographic Health Survey (DHS) and Multiple Indicator Cluster Survey (MICS) data sets from Africa and Middle East. A random-effects model was used to derive overall prevalence estimates. Using Poisson regression models, we conducted time trends analyses on the FGM/C prevalence estimates between 1990 and 2017.

Findings

We included 90 DHS and MICS data sets for 208 195 children (0-14 years) from 29 countries spread across Africa and two countries in Western Asia. The prevalence of FGM/C among children varied greatly between countries and regions and also within countries over the survey periods. The percentage decline in the prevalence of FGM/C among children aged 0-14 years old was highest in East Africa, followed by North and West Africa. The prevalence decreased from 71.4% in 1995 to 8.0% in 2016 in East Africa. In North Africa, the prevalence decreased from 57.7% in 1990 to 14.1% in 2015. In West Africa, the prevalence decreased from 73.6% in 1996 to 25.4% in 2017. The results of the trend analysis showed a significant shift downwards in the prevalence of FGM/C among children aged 0-14 years in such regions and subregions of East Africa, North Africa and West Africa. East Africa has experienced a much faster decrease in the prevalence of the practice (trend=-7.3%, 95% CI -7.5% to -7.1%) per year from 1995 to 2014. By contrast, the decline in prevalence has been much slower in North Africa (trend=-4.4%, 95% CI -4.5% to -4.3%) and West Africa (trend=-3.0%, 95% CI -3.1% to -2.9%).

Conclusion

The prevalence of FGM/C among children aged 0-14 years varied greatly between countries and regions and also within countries over the survey periods. There is evidence of huge and significant decline in the prevalence of FGM/C among children across countries and regions. There is a need to sustain comprehensive intervention efforts and further targeted efforts in countries and regions still showing high prevalence of FGM/C among children, where the practice is still pervasive.

Effectiveness of health education as an intervention designed to prevent female genital mutilation/cutting (FGM/C): a systematic review

Background

Female Genital Mutilation/Cutting (FGM/C) is a harmful practice that violates the human rights of women and girls. Despite global efforts to restrict the practice, there have been few reports on major positive changes to the problem. Health education interventions have been successful in preventing various health conditions and promoting service use. They have also been regarded as promising interventions for preventing FGM/C. The objective of this systematic review is to synthesise findings of studies about effectiveness of health education as an intervention to prevent FGM/C.

Methods

The electronic databases searched were MEDLINE, EMBASE, Cochrane library, Web of Science, Psych INFO, CINAHL and ASSIA. Our search included papers published in the English language without date limits. Study quality was assessed using the Mixed Methods Appraisal Tool (MMAT). A predesigned data recording form was used to extract data from the included studies which were summarised by comparing similar themes.

Results

Twelve out of 359 individual studies met our inclusion criteria. Seven studies were quantitative, three were qualitative and two used mixed methods. Six studies tested before and after the interventions, four studies assessed the effectiveness of previous interventions used by different research teams and two studies endorsed the intervention. Four main factors emerged and were associated with facilitating or hindering the effectiveness of health education interventions: sociodemographic factors; socioeconomic factors; traditions and beliefs; and intervention strategy, structure and delivery.

Conclusions

It is vital to target factors associated with facilitating or hindering the effectiveness of health education for FGM/C. This increases the possibility of effective, collective change in behaviour and attitude which leads to the sustainable prevention of FGM/C and ultimately the improved reproductive health and well-being of individuals and communities.

Electronic supplementary material

The online version of this article (10.1186/s12978-018-0503-x) contains supplementary material, which is available to authorized users.

Mapping the lack of public initiative against female genital mutilation in Denmark

Background

Female genital mutilation (FGM) is a harmful practice prevalent in 35 countries, mainly in Africa, as well as in some Middle Eastern countries and a few Asian countries. FGM comprises all procedures that involve partial or complete resection of, or other injury to, external female genitalia for non-medical reasons. The practice of FGM has spread to Western countries due to migration. The European Institute for Gender Equality recommend that FGM be combatted by nationally coordinated efforts through implementation of national action plans, guidelines for professionals as well as comprehensive research in the field. FGM was outlawed in Denmark 2003, but no national actions plan has been implemented. Instead, the task of combatting FGM is currently under the responsibility of local governments in the form of the 98 municipalities. The aim of this study is to investigate the Danish municipalities’ efforts to prevent FGM on the local level, and whether these initiatives are in accordance with international recommendations and standards.

Methods

All 98 Danish municipalities were invited to respond to a questionnaire regarding FGM in their respective municipalities. The inclusion process and questionnaire was designed after a pilot study, which included 29 municipalities. The questionnaire consisted of four overall areas of focus: “action plan”, “registration”, “information material” and “preventive initiatives”. Demographic data were gathered from the 2017 census by Statistics Denmark. Risk countries were defined as countries with a tradition for FGM, identified from the 2016 UNICEF definition.

Results

A total of 67 municipalities participated in the study. At the time of census, 1.8% of the Danish population was immigrants with origins in risk countries. A total of 10.4% of the responding municipalities indicated to have implemented a specific action plan against FGM. A total of 7,5% had implemented specific preventive initiatives against FGM. Registration of reported FGM cases were indicated to be performed in 73.1% of the responding municipalities; however, only 17.9% stated to perform registration of FGM specifically as such, and not as general child abuse.

Conclusions

Our study shows that the current situation of FGM registration and prevention being under local administrative responsibility in the 98 Danish municipalities has led to a severe lack of coordinated public initiative against FGM.

Electronic supplementary material

The online version of this article (10.1186/s12978-018-0499-2) contains supplementary material, which is available to authorized users.

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.

Defibulation: A Visual Reference and Learning Tool

Female genital mutilation type III (infibulation) is achieved by narrowing the vaginal orifice by creating a covering seal, accomplished by cutting and appositioning the labia minora and/or labia majora, with or without clitoral excision. Infibulation is responsible for significant urogynecological, obstetrical, and psychosexual consequences that can be treated with defibulation (or de-infibulation), an operation that opens the infibulation scar, exposing the vulvar vestibule, vaginal orifice, external urethral meatus, and eventually the clitoris. This article provides a practical comprehensive, up-to-date visual learning tool on defibulation, with information on pre-operative, post-operative, and follow-up information. Abdulcadir J, Marras S, Catania L, et al. Defibulation: a visual reference and learning tool. J Sex Med 2018;15:601-611.

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.

Clinical indications for cesarean delivery among women living with female genital mutilation

Objective

To compare primary indications for cesarean delivery among patients with different female genital mutilation (FGM) status.

Methods

The present secondary analysis included data from women who underwent trial of labor resulting in cesarean delivery at 28 obstetric centers in six African countries between November 1, 2001, and March 31, 2003. Associations between cesarean delivery indications and FGM status were assessed using descriptive statistics and multivariable multinomial logistic regression.

Results

Data from 1659 women (480 patients with no type of FGM and 1179 patients with FGM [any type]) were included; cesarean delivery indications were collapsed into five categories (fetal indications, maternal factors, stage 1 arrest, stage 2 arrest, and other). The incidence of a clear medical indication for cesarean delivery did not differ between the groups (P=0.320). Among patients without a clear indication for cesarean delivery, women with FGM were more likely to have undergone cesarean delivery for maternal factors (adjusted relative risk ratio [aRRR] 3.92, 95% confidence interval [CI] 1.3–11.71), stage 1 arrest (aRRR 7.74, 95% CI 1.33–45.07), stage 2 arrest (aRRR 6.63, 95% CI 3.74–11.73), or other factors (aRRR 2.41, 95% CI 1.04–5.60) rather than fetal factors compared with women who had no type of FGM.

Conclusion

Among women with unclear medical indications, FGM was associated with cesarean delivery being performed for maternal factors or arrest disorders.

Women living with FGM were more likely to have maternal factors of arrest disorders contribute to undergoing a cesarean delivery for an unclear medical indication.

Effects of female genital mutilation/cutting on the sexual function of Sudanese women: a cross-sectional study

BACKGROUND

Female genital mutilation/cutting (FGM/C) is a cultural practice that involves several types of removal or other injury to the external female genitalia for nonmedical reasons. Although much international research has focused on the health consequences of the practice, little is known about sexual functioning among women with various types of FGM/C.

OBJECTIVE

To assess the impact of FGM/C on the sexual functioning of Sudanese women.

STUDY DESIGN

This is a cross-sectional study conducted at Doctor Erfan and Bagedo Hospital, Jeddah, Saudi Arabia. Eligible women completed a survey and a clinical examination, which documented and verified women's type of FGM/C. The main outcome measure was female sexual function, as assessed by the Arabic Female Sexual Function Index.

RESULTS

A total of 107 eligible women completed the survey and the gynecological examination, which revealed that 39% of the women had FGM/C Type I, 25% had Type II, and 36% had Type III. Reliability of self-report of the type of FGM/C was low, with underreporting of the extent of the procedure. The results showed that 92.5% of the women scored lower than the Arabic Female Sexual Function Index cut-off point for sexual dysfunction. The multivariable regression analyses showed that sexual dysfunction was significantly greater with more extensive type of FGM/C, across all sexual function domains (desire, arousal, lubrication, orgasm, satisfaction, and pain) and overall.

CONCLUSION

The study documents that a substantial proportion of women subjected to FGM/C experience sexual dysfunction. It shows that the anatomical extent of FGM/C is related to the severity of sexual dysfunction.