International Family Planning Perspectives 32(3) Digests

International Family Planning Perspectives Women who have undergone female genital mutilation have a higher risk for adverse obstetric outcomes than women who have not, and the risks seem to be greater with more severe mutilation, according to the first large-scale prospective study of the effects of female genital mutilation on maternal and neonatal outcomes.1 Relative to women who have not undergone genital mutilation, those who have are more likely to have cesarean sections, heavy postpartum blood losses and extended hospital stays. The infants of women who have undergone female genital mutilation are more likely to require resuscitation at delivery and are at higher risk for inpatient perinatal death than are infants born to women who have not undergone genital mutilation. Although more than 100 million women worldwide have undergone some form of genital mutilation, there is little information on obstetric outcomes in this population. The few investigations that have been conducted have had a small number of cases or methodological limitations. In the present study, researchers sought to identify associations between the severity of genital mutilation and outcomes for the women and their infants during and immediately after delivery. Between March 2001 and November 2003, 28,393 women presenting for singleton delivery at 28 obstetric centers in Burkina Faso, Ghana, Kenya, Nigeria, Senegal and Sudan were interviewed about their personal, medical and obstetric histories and examined to determine if they had undergone genital mutilation. Using the classification system designed by the World Health Organization, trained study midwives divided the women into three groups, according to the type of mutilation—removal of the prepuce, with or without removal of all or part of the clitoris; removal of the clitoris, with total or partial removal of the labia minora; or removal of all or part of the external genitalia and stitching of the vaginal opening. Excluded from the sample were women scheduled for cesarean section, those for whom labor was too advanced to facilitate the required genital examination and those unable to give consent. The study sites ranged from rural hospitals to urban teaching hospitals; deliveries were handled according to the protocol in place at each study center. The women and infants in the study were followed up until the mother’s discharge from the hospital. Follow-up information included whether the woman had had a cesarean section, an episiotomy or perineal tear, the baby’s birth weight and Apgar score, and whether there had been a stillbirth or a neonatal or maternal death. Adjusted odds ratios from unconditional logistic regression analyses were used to calculate relative risks of obstetric complications. The final model adjusted for parity; maternal age, height, education and socioeconomic status; urban or rural residence; travel time to hospital; number of prenatal visits; and study site. In all, 75% of participants had undergone genital mutilation; some 24% the least severe type, 27% the moderately severe type and 23% the most severe type. There were wide variations in the prevalence and severity of genital mutilation across countries. For example, overall prevalence among the study participants ranged from 40% in Ghana to 88% in Nigeria. Moreover, in Ghana, Nigeria and Senegal, only 1% of participants had undergone the most severe type of mutilation, compared with 73% in Sudan. When compared with women who had not, women who had undergone the moderately or most severe type of mutilation were significantly more likely to have postpartum blood loss of at least 500 ml (relative risks, 1.2 and 1.7, respectively) and to have had a cesarean section (1.3 and 1.3). Among women who delivered vaginally, the relative risk of staying in the hospital for longer than three days was higher among women who had undergone the moderately or most severe types of genital mutilation than among those who had not undergone any type (1.6 and 2.3). The relative risk of a longer hospital stay was not affected by whether a woman had given birth before. Among women who had never given birth before, 41% of those without genital mutilation had episiotomies; 88% of women with the most D I G E S T S