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Female Genital Mutilation and Obstetric Outcome:

How to take the results to doctors and midwives

Female Genital Mutilation and Obstetric Outcome:

How to take the results to doctors and midwives

Hermione Lovel UKHeli Bathija, WHO

6 February, Washington DC6 February, Washington DC

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•Challenge:Challenge:

Each year 3 million girls are forced to undergo female genital Each year 3 million girls are forced to undergo female genital mutilation,mutilation,

in many cases the medical profession is carrying out the procedure in many cases the medical profession is carrying out the procedure. . However, in many other cases the doctors and nurses want to prevent However, in many other cases the doctors and nurses want to prevent

complications but do not know howcomplications but do not know how

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WHO overall Strategy on FGMWHO overall Strategy on FGM

• To play an advocacy role by emphasizing the importance of action against harmful practices at international, regional and national levels.

• To initiate and to coordinate the research and development being undertaken by

– international agencies, nongovernmental organizations and national authorities.

• To support national networks or organizations and groups involved in developing relevant policies, strategies and programmes.

• To support the training of health professionals in the prevention of female genital mutilation and the management of its health consequences.

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• To support the training of health professionals ( in all countries) in the prevention of female genital mutilation and the management of its health consequences.

• Issues

– Medicalisation: increase in percentages of girls whose FGM is performed by medical personnel

– Re-stitching: routine practice in many countries without any public discussion

– Preventing complications at birth for the woman and the newborn: de-infibulation during pregnancy not practised

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It is important to train students of medical professions

• 330 5th year medical students in Alexandria, Egypt (country with 97% FGM prevalence):

– Awareness of the prevalence, practices and procedures low

– Poorly informed about complications, ethical and legal aspects

– 52% in favour of continuation of practice

– 73% in favour of medicalization

– 87% thought that the issue of FGM should be included in the curriculum

Eastern Mediterranean Health Journal 2006, vol 12 (Suppl 2), S78-S92

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The medical personnel might knowThe medical personnel might know

WHO classification of FGM…WHO classification of FGM…

Type I : Excision of the prepuce and part or all of the clitoris

Type II: Excision of the prepuce and clitoris together with partial or total excision of the labia minora

Type III: Infubulation ─ Excision of part or all of the external genitalia and stitching of the two cut sides together to varying degrees

Type IV: Pricking, piercing, incision, stretching, scraping, or other harming procedures on clitoris or labia, or both

……But they might not be aware of how the FGM is performed and what the But they might not be aware of how the FGM is performed and what the complications might becomplications might be

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FGM instrumentsFGM instruments

the thorns used to clasp infibulationthe herb, mal mal, that is used to "glue" infibulation

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Physical consequences of FGMPhysical consequences of FGM

• Severe pain is the most common immediate consequence of all forms of FGM.

• The degree of pain and trauma is such that a woman or girl is often left in a state of medical shock after the operation.

• Bleeding (Long-term anaemia also possible)

• Damage to adjacent tissue• In extreme cases: death due to severe and uncontrolled

bleeding or to infection.• Urine retention• Keloid scars, abscesses and painful cysts. • Infertility

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Aims of the study

The primary aims of the study

– To evaluate the relationship between different types of FGM and obstetric complications.

– To estimate the incidence of obstetric complications among women with a history of FGM giving birth in hospital.

The secondary aim of the study

– To obtain clinical information relevant to the prevention and treatment of obstetric complications in women with FGM.

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FGM prevalence in the participating countries

Burkina Faso 75% - 2003

Ghana 5% - 2003

Kenya 32% - 2003

Nigeria 19% - 2003

Senegal about 20%

Sudan 90% - 2000

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Methods

Women

– Singleton delivery at one of 28 obstetric centres in Burkina Faso (5), Ghana (3), Kenya (3), Nigeria (6), Senegal (8), Sudan (3)

– Planned elective Caesarean sections excluded

– Consenting women examined in early labour and FGM status determined before delivery (women in advanced labour with expected imminent delivery excluded)

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Methods

Statistics

– 28 509 women enrolled

– 126 (0.4%) excluded for missing data on age, parity, education, height, residence (urban/rural)

– Multivariate logistic regression, adjusted ORs

Core factors: centre, age, parity, education, socio-economic status

Additional factors (>5% impact on OR): height, residence, time to reach hospital, # ANC visits

– Separate models for FGM I vs. no FGM, FGM II vs. no FGM, FGM III vs. no FGM

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Country FGM 0 FGM I FGM II FGM III Total

Burkina Faso 20% 23% 45% 13% 4816

Ghana 60% 11% 28% 1% 3094

Kenya 40% 21% 29% 10% 4167

Nigeria 12% 63% 24% 1% 5366

Senegal 21% 24% 54% 1% 3449

Sudan 18% 5% 5% 73% 7501

Total 25% 24% 27% 23% 28393

Recruitment

Distribution of FGM type, by country

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Birth complications of FGMBirth complications of FGM

From ”Caring for women with circumcision, av Nahid Toubia, MD. Rainbo, UK.

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Women with FGM run greater risks during childbirth…

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… and so do their babies

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Additional ResultsAdditional Results

Patterns of risks similar in nulliparous and parous women

Significantly higher rates of episiotomy and perineal tears in women with FGM, though substantial heterogeneity between centres

Estimated 10 – 20 additional perinatal deaths per 1000 live births in the countries where study conducted

Complication rates likely higher in women with limited access to obstetric services

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ImplicationsImplications

First clear evidence of obstetric sequelae

Previous data limited and equivocal, and focused more on immediate complications of procedure

Clear evidence of harm for mothers and babies

Adverse health effects of all FGM types – greatest risks with more extensive FGM

Lack of effect on birth weight yet clear adverse effect on delivery process: supports hypothesis of mechanical problem (lack of elasticity of cut/excised tissues?)

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"These results invite the authorities and health professionals to focuson women's rights and to ensure effective skilled attendance duringdeliveries at high risk."

Dr Michel Akotionga, Principal Investigator, Burkina Faso

"The results of this research provide empirical data … about FGM ingeneral and especially in women with FGM going through labour, inour quest to eradicate the practice of FGM worldwide"

Dr Kwasi Odoi-Agyarko,

Executive Director, Rural Help Integrated

Bolgatanga, Ghana

Implications

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Way forwardWay forward

• Strengthening health systems capacity to deal with consequences of FGM:– Promotion of use of WHO guidelines – Developing new guidance documents

based on the findings of the research

– Electronic media: DVDs, internet• (example the DVD by DFID for medical practitioners in

UK)

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Way forwardWay forward

• need to be working together:– WHO– World Medical Association (WMA)– International Federation of Obstetricians and

Gynecologists (FIGO)– International Council of Midwives (ICM)– Partnership for Maternal, Newborn and Child

Health– Pediatricians– Private sector– others

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Next stepsNext steps

• Meeting of a working group to develop two, three options for a workplan and resource mobilization

• Identifying focus countries• Targeting information sharing through

various tools• Arranging training opportunities

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