Female Genital Mutilation and Obstetric Outcome

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Female Genital Mutilation and Obstetric Outcome

• Results of WHO multi-country study
• 1 June 2006, Geneva

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Each year 3 million girls are forced to undergo
female genital mutilation
(Source WHO,1997)
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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

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Contributors

• Centres and principal investigators
• Michel Akotionga (Burkina Faso), Djibril Diallo
  (Senegal), Isseu Diop Touré (Senegal), Guyo
  Jaldesa (Kenya), Joseph Karanja (Kenya), Kwasi
  Odoi-Agyarko (Ghana), Friday Okonofua (Nigeria),
  Mairo Mandara (Nigeria), and Mohamed El Fadil
  Saad (Sudan)
• Study design and conception
• Emily Banks (Australia), Olav Meirik (Chile),
  Oluwole Akande (Nigeria), Efua Dorkenoo (UK),
  Harry Gordon (UK), Hermione Lovel (UK), Clare
  McGettigan (UK), Zeinab Mohamed (UK)
• Central study coordination
• Heli Bathija, Amel Fahmy, Oluwole Akande, Tim
  Farley

• Data coordination
• Mohamed Ali, Annie Chevrot, Emilie Diagne,
  Shereen Hasan, Alexander Peregoudov
• Data analysis
• Mohamed Ali, Emily Banks, Tim Farley
• Writing group
• Emily Banks, Olav Meirik Tim Farley, Oluwole
  Akande, Heli Bathija, Mohamed Ali
• Steering Group
• Oluwole Akande, Mohamed Ali, Emily Banks, Heli
  Bathija, Amel Fahmy, Tim Farley, and Olav Meirik

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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 study countries
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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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• During labour and delivery the following
  information was collected
• Obstetric outcomes
• Duration of labour
• Mode of delivery
• Episiotomy
• Perineal tears
• Post-partum haemorrhage
• Prolonged hospitalization
• In-patient maternal death
• Newborn infants outcomes
• Vital status
• Apgar score at 5 minutes
• Anthropometric measures

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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 (gt5 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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Recruitment
Distribution of FGM type, by country
Country FGM 0 FGM I FGM II FGM III Total Burkina
Faso 20 23 45 13 4816 Ghana 60 11 28 1 30
94 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
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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 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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Implications

• First clear evidence of obstetric sequelae
• Previous data limited and equivocal, and focussed
  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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Implications

• "These results invite the authorities and health
  professionals to focus
• on women's rights and to ensure effective skilled
  attendance during
• deliveries at high risk."
• Dr Michel Akotionga,
• Principal Investigator, Burkina Faso
• "The results of this research provide empirical
  data about FGM in
• general and especially in women with FGM going
  through labour, in
• our quest to eradicate the practice of FGM
  worldwide"
• Dr Kwasi Odoi-Agyarko,
• Executive Director, Rural Help Integrated
• Bolgatanga, Ghana

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