Female genital mutilation and other harmful practices
Health consequences of FGM
Summary of research on obstetric problems following female genital mutilation – a survey in six African countries
This study, reported in The Lancet in 2006 , provides a wealth of information which shows clearly that women who have undergone FGM are much more likely to suffer obstetric complications at childbirth than women who have not been subject to the procedure. The study, which was conducted in six African countries by a WHO collaborative group, also showed that the risk of obstetric complications was higher when the FGM was more extensive.
The complete article on “Female genital mutilation and obstetric outcome: WHO collaborative prospective study in six African countries” is available for registered users of The Lancet at www.thelancet.com. A summary is available without registration. A pre-print copy of the full article has been made available by WHO from the link below.
- Female genital mutilation and obstetric outcome. WHO collaborative prospective study in six African countries. Full text
The study focused on women who attended obstetric centres in Burkina Faso, Ghana, Kenya, Nigeria, Senegal and Sudan between November 2001 and March 2003. Twenty-eight centres in both rural and urban areas were involved in the study. In total, 28 393 women who attended a centre for the delivery of a baby (single births only; multiple births were excluded) were included in the study. On admission to the obstetrics centre for delivery, each woman was examined by a trained midwife who determined whether the woman had undergone genital mutilation and, if so, how extensive the procedure had been. All the women were followed up after delivery until they were discharged from the centre.
Overall, 1760 (6%) women were delivered by caesarean section, and 1970 (7%) deliveries were complicated by postpartum blood loss of 500 mL or more. The study found that, compared with women who had not undergone genital mutilation, those who had undergone types II or III FGM had a significantly greater risk of needing a caesarean section and of suffering postpartum haemorrhage than women who had not had FGM.
The proportion of episiotomies was also greater among women with FGM than among those without. Among women giving birth for the first time, the proportion having episiotomies ranged from 41% in women who had not undergone FGM to 88% in with FGM type III; in multiparous women, the proportions were 14% and 61%, respectively. Women with FGM were also more likely than those without to require an extended stay in hospital.
As for the babies, 2861 (10%) infants weighed less than 2500 g at birth, 2239 (8%) were born alive but had to be resuscitated, and 1400 (5%) were stillborn or died in the immediate postnatal period. Although there was no significant relation between genital mutilation and the risk of having an infant weighing less than 2500 g, there was a clear link between FGM and the risk of infant death. The infants of mothers who had undergone the more extensive forms of FGM (types II and III) had a greater risk of dying at birth compared to the infants of mothers who had not undergone FGM.
Extrapolating from the study findings, the researchers estimated the effect of mothers’ FGM on the rate of perinatal death typical for the region where the study was done. The excess infant deaths attributable to FGM ranged from 11 to 17 per 1000 deliveries, the researchers say, against a background of perinatal mortality rates of 40–60 per 1000 deliveries. On the basis of the summary relative risk, the study authors write that “about 22% of perinatal deaths in infants born to women with FGM can be attributed to the FGM”.
Previous smaller studies have suggested links between FGM and several obstetric complications, but many had flaws such as inconsistent findings, failure to account for potential confounding factors, failure to investigate the possible impact of different types of FGM, and self-reported (rather than clinically observed) obstetric complications. This six-country study was designed to avoid such flaws and it produced evidence that clearly confirms that FGM endangers health.
The study did not investigate just how each obstetric complication is caused. However, the researchers suggest that since FGM leads to varying amounts of scar tissue which is less elastic than the perineal and vaginal tissue would normally be, this scar tissue may cause differing degrees of obstruction and tears or episiotomy. A second stage of labour that lasts longer than usual may be behind the increased risk of perineal injury, postpartum haemorrhage, resuscitation of the infant, and stillbirth associated with FGM. The length of the second stage of labour was not consistently measured in the study since good obstetric practice discourages frequent vaginal examinations. There is evidence that FGM is associated with increased rates of genital and urinary-tract infection, which could also have repercussions for obstetric outcomes, the researchers say.
There are high rates of mortality and morbidity among mothers and infants in the six countries where this study was carried out. Thus, say the researchers, increased obstetric risks such as those observed in this study are likely to result in “substantial additional cases of adverse obstetric outcome in many countries”. The estimates presented in the article in The Lancet suggest that “FGM could cause one to two extra perinatal deaths per 100 deliveries to African women who have had FGM”, the researchers add.
Commenting on the study in the same issue of The Lancet , two Nigerian physicians note that “with [its] two-pronged search into maternal and infant outcomes, […] this study is a landmark.” It could, they believe, “recruit sympathisers and campaigners from the ranks of paediatricians who attend to neonates [suffering from] collateral damage from assaults on their mothers”.
1. WHO study group on female genital mutilation and obstetric outcome. Female genital mutilation and obstetric outcome: WHO collaborative prospective study in six African countries. Lancet 2006; 367:1835–41 (doi:10.1016/S0140-6736(06)68805-3).
2. Eke N, Nkanginieme K. Female genital mutilation and obstetric outcome. Lancet 2006;367:1799 (doi:10.1016/S0140-6736(06)68782-5).