The use of intrapartum defibulation in women with female genital mutilation

doi:10.1016/S0306-5456(01)00227-3

British Journal of Obstetrics and Gynaecology

Volume 108, Issue 9, September 2001, Pages 949-951

British Journal of O...

https://doi.org/10.1016/S0306-5456(01)00227-3 Get rights and content

Abstract

Objective To assess the use of intrapartum defibulation for women who have had female genital mutilation.

Design A retrospective case analysis.

Setting King Abdulaziz University Hospital, a teaching hospital in Jeddah, Saudi Arabia.

Sample Two hundred and thirty-three Sudanese and 92 Somali women who were delivered at the hospital between January 1996 and December 1999.

Methods The outcome of labour of women with female genital mutilation who needed intrapartum defibulation were compared with the outcome of labour of women without female genital mutilation who did not need intrapartum defibulation.

Results One hundred and fifty-eight (48.6%) women had infibulation and needed intrapartum defibulation to deliver vaginally, 116 women (35.7%) did not have infibulation and gave birth vaginally without defibulation, and 51 (15.7%) women were delivered by caesarean section. There were no statistically significant differences, between women who underwent intrapartum defibulation and those who did not, in the duration of labour, rates of episiotomy and vaginal laceration, APGAR scores, blood loss and maternal stay in hospital. The surgical technique of intrapartum defibulation was easy and no intraoperative complications occurred.

Conclusions Intrapartum defibulation is simple and safe, but sensitivity to the cultural issues involved is essential. In the longer term, continuing efforts should be directed towards abandoning female genital mutilation altogether.

Introduction

Female circumcision, or female genital mutilation is a deeply rooted and centuries old traditional practice¹. Although its exact prevalence is not known, estimates suggest that between 100 and 132 million women have been subjected to female genital mutilation. It is practiced mainly in 26 African countries, where prevalence rates range from 5% to 99%². In Sudan and Somalia, for example, more than 90% of the women have had female genital mutilation³, but patterns of immigration now mean that women with female genital mutilation are likely to be encountered throughout the world.

Female genital mutilation is defined by the World Health Organization (WHO) as procedures which involve partial or total removal of the external female genitalia or other injury to the female genital organs whether for cultural or any other non-therapeutic reasons³. There are various classifications for the different types of female genital mutilation but the procedures most frequently performed are removal of the prepuce, excision of the clitoris, excision of the clitoris and labia minora, and occasionally excision of much of labia majora with suturing of the two sides together to occlude the vagina⁴. This latter procedure is known as infibulation and is sometimes referred to as pharaonic circumcision.

The practice of female genital mutilation is not confined to Muslims. Its origins are traditional and cultural rather than religious5., 6.. Unfortunately, the practice of female genital mutilation still remains widespread, with its attendant health risks.

Many of the short and long term complications of female genital mutilation have been well documented, including infection, tetanus, haemorrhage (sometimes leading to death), depression, sexual dysfunction, and obstetric complications⁴. Clearly childbirth for infibulated women presents special requirements for health care professionals. It is essential to recognise that female genital mutilation, as part of the women's culture and traditions, must be dealt with sensitively7., 8.. At the same time, procedures are needed to ensure a safe delivery and to avoid complications, particularly in infibulated women in whom there is increased risk of prolonged or obstructed labour, fetal death, perineal tears, postpartum haemorrhage, and maternal death. The use of defibulation has proved effective in reducing these risks, but still tends to be little used in the developed world⁹. Arguably, this has increased the likelihood of complications and the number of unnecessary caesarean sections. The aim of this study was to assess the use of intrapartum defibulation for women who have had female genital mutilation.

Section snippets

Methods

The study was undertaken at the King Abdulaziz University Hospital, a teaching hospital that provides complete obstetric care for women of all socio-economic backgrounds, from both Saudi Arabia and neighbouring countries. Obstetric care is free, and the women are encouraged to use the booking system, but some pregnant women still arrive in labour without receiving any antenatal care. The hospital policy is to provide intrapartum management and delivery conducted by residents and senior

Results

During the study period 233 Sudanese and 92 Somali women were delivered in our hospital. One hundred and fifty-eight women (48.6%) had infibulation and needed intrapartum defibulation to deliver vaginally, 116 women (35.7%) did not have female genital mutilation and gave birth vaginally without defibulation, and 51 women (15.7%) were delivered by caesarean section. The maternal characteristics of the women who were delivered vaginally with or without intrapartum defibulation are shown in Table 1

Discussion

Childbirth for infibulated women presents a special situation. Failure of the health care professionals to acknowledge that female genital mutilation exists and is part of these women's culture and tradition may lead to hostility and incomprehension in some situations7., 8.. In addition to sensitivity and non-judgmental care, special steps are needed to take account of the specific effects of female genital mutilation. For many women, defibulation is necessary to avoid unnecessary

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Cited by (28)

Effect of type III female genital mutilation on obstetric outcomes: A systematic review and meta-analysis
2024, Heliyon
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.
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.
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.
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.
Reasons for and Experiences With Surgical Interventions for Female Genital Mutilation/Cutting (FGM/C): A Systematic Review
2017, Journal of Sexual Medicine
Citation Excerpt :
The searches yielded 3,726 unique citations and we considered 132 publications in full text, as shown in the PRISMA diagram (Figure 1). We included 71 studies (k) published from 1980 to 2016 (Table 1).27–97 Characteristics of the included studies are presented in Tables 1 and 2.
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.
To conduct a systematic review of empirical quantitative and qualitative research on interventions for women with FGM/C-related complications.
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.
All outcomes were included.
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.
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.
The systematic review was conducted in accordance with guidelines, but there is a slight possibility that studies were missed.
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.
Episiotomy and severe perineal trauma among Eastern African immigrant women giving birth in public maternity care: A population based study in Victoria, Australia
2017, Women and Birth
Citation Excerpt :
As most immigrants from Sudan in Australia are from the present South Sudan, where FGM is relatively rare, compared with Northern Sudan and the other Eastern African countries studied here, this may have reduced their risk of episiotomy. Intrapartum defibulation (surgical opening of the labia) has been shown to be associated with neither episiotomy nor perineal trauma.45 It is important that health care workers become familiar with managing infibulated women, during the intrapartum period, in order to reduce both unnecessary episiotomy and severe perineal tear among these women.
Eastern African immigrants from countries affected by female genital mutilation have resettled in many developed countries, including Australia. Although possibly at risk of perineal trauma and episiotomy, research investigating their perineal status post-migration is sparse.
To investigate variations in episiotomy use and incidence of severe perineal tear for women born in Eritrea, Ethiopia, Somalia and Sudan compared with Australian-born women.
A population-based study of 203,206 Australian-born and 3502 Eastern African immigrant women admitted as public patients, with singleton vaginal births between 1999 and 2007, was conducted using the Victorian Perinatal Data Collection. Descriptive and multivariable logistic regression analysis adjusting for confounders selected a priori, were performed to compute incidence and adjusted odds ratios.
Overall, 30.5% Eastern African immigrants had episiotomy compared to 17.2% Australian-born women. Severe perineal trauma occurred in 2.1% of Eastern African immigrants and 1.6% of Australian-born women. While the odds of severe perineal trauma was significantly elevated only during non-instrumental vaginal births for Eastern African immigrants {OR_adj1.56 95%CI(1.17, 2.12)}; that of episiotomy was increased during both non-instrumental {OR_adj4.47 95%CI(4.10, 4.88)} and instrumental {OR_adj2.51 95%CI(1.91, 3.29)} vaginal births.
Overall, Eastern African immigrant women experienced elevated odds of episiotomy and severe perineal tear. Health care providers need to be mindful of the increased risk of severe perineal tear in these women and enhance efforts in identification and treatment of severe perineal trauma to minimise associated short and long term morbidity. Strategies to reduce unneeded episiotomy and ways of enhancing perineal safety are also needed.
Management of type III female genital mutilation in Birmingham, UK: A retrospective audit
2014, Midwifery
Citation Excerpt :
In the UK, the pregnant infibulated woman should be given the choice antenatal or intrapartum deinfibulation. Rouzi and Aljhadali (2001) reported no difference in maternal and infant outcomes between women with FGM who had intrapartum deinfibulation and uncircumcised comparators. No studies have determined whether delaying antenatal deinfibulation and undertaking intrapartum deinfibulation has any adverse consequences.
to audit clinical management of women with type III female genital mutilation (FGM) according to local guidelines. Secondary objectives were to describe the population that uses the service and compare obstetric outcomes of intrapartum deinfibulation and antenatal deinfibulation.
retrospective audit.
a hospital midwifery-led FGM specialist service in Birmingham, UK.
253 women with type III FGM who gave birth between January 2008 and December 2009
retrospective case analysis using patient records.
proportion of women managed according to locally agreed criteria for the management of FGM; obstetric outcomes including perineal tears, episiotomy rates, estimated blood loss, infant APGAR scores and indications for caesarean section.
91 (36%) women booked into antenatal care after 16 weeks gestation. Only 26 (10.3%) were managed fully according to guidelines. The area with poorest performance was child protection, where the presence of normal genitalia was documented in only 52 (38.8%) of medical notes following birth of a female infant. The majority of women (214, 84.6%) had been deinfibulated in a previous pregnancy. Of the 39 infibulated at booking, only 9 (23.1%) were deinfibulated antenatally, the rest opted for intrapartum deinfibulation. Women who had intrapartum deinfibulation had a higher average blood loss and more tears than those deinfibulated antenatally, although this was not statistically significant.
alternative systems should be considered to improve documentation of child protection related information. Further research is needed to confirm or refute the adverse findings among those that delayed deinfibulation.
Role of midwives in the prevention of female genital organ mutilations
2006, Revue Sage - Femme
Les mutilations génitales féminines (MGF) touchent 130 millions de femmes et, chaque année, 3 millions de fillettes sont, à leur tour mutilées. Elles sont pratiquées principalement dans 28 pays de l’Afrique subsaharienne mais se retrouvent chez les populations immigrées, notamment en France. La grossesse est alors un moment particulièrement à risque de complications. Il est donc primordial que le personnel obstétrical, en particulier les sages-femmes, possèdent des connaissances suffisantes sur le sujet lors de la prise en charge de ces femmes et réalisent des mesures de prévention pour protéger les enfants à venir.
Cette étude évalue les connaissances des sages-femmes sur les MGF et les actions de prévention réalisées. Son objectif est de proposer des solutions pour améliorer la prévention lors de la prise en charge obstétricale de ces femmes.
D’une part, nous avons distribué 120 questionnaires auprès des sages-femmes de six maternités de la région parisienne entre novembre 2005 et février 2006. D’autre part, des entretiens ont été réalisés avec des spécialistes luttant contre les MGF, entre décembre 2005 et janvier 2006, afin de déterminer les populations à risque, leurs raisons et les actions de préventions réalisables par les sages-femmes.
Quatre-vingts questionnaires ont été exploités et 6 entretiens menés. Les résultats des questionnaires montrent que 43,7 % des sages-femmes possèdent des connaissances suffisantes lors de la prise en charge de femmes mutilées mais que 80 % estiment leurs connaissances encore insuffisantes. Le seul facteur influençant leurs connaissances est l’existence d’une formation mais seulement 37,5 % en ont reçues. 90 % des sages-femmes considèrent la prévention des MGF comme étant importante et 87,5 % considèrent avoir un rôle à y jouer. Or, seulement 41,8 % des sages-femmes interrogées abordent le sujet, faute de connaissances ou par peur de choquer les femmes. Les entretiens ont montré que, globalement, toutes les personnes originaires de ces pays étaient à risque de mutiler leurs enfants. Les sages-femmes occupent une place déterminante dans la prévention des mutilations des fillettes.
Une formation initiale et continue sur les MGF semble donc indispensable pour améliorer la prévention des MGF par les sages-femmes. La participation de femmes africaines pourrait être utile pour démontrer aux sages-femmes la facilité d’établir le dialogue avec les femmes.
An estimated 130 million women have been victims of genital organ mutilations and each year 3 million girls are mutilated. Such practices generally take place in 28 African countries but can also be encountered in immigration populations, particularly in France. The risk of complication is particularly important during pregnancy. It is thus essential for obstetrical personnel, especially midwives, to be sufficiently aware of this subject to provide proper care and advice for the protection of children to come.
This study was conducted to ascertain the knowledge of midwives concerning female genital organ mutilations and preventive measures. The goal was to propose solutions for improved prevention which could be applied during the time of obstetrical care.
Questionnaires were distributed to 120 midwives practicing in six maternity wards in the Paris area from November 2005 through February 2006. Interviews were also conducted with anti-mutilation specialists between December 2005 and January 2006 to identify the populations at risk and preventive actions which could be undertaken by midwives.
Eighty questionnaires could be analyzed and six interviews were conducted. 43.7% of midwives were sufficiently aware of the problem to care for mutilated women, but 80% felt their knowledge was insufficient. Prior training was the only factor was found to influence their knowledge, but only 37.5% of them had received training. 90% of the midwives considered that prevention of female genital organ mutilation is important and 87.5% considered they had a role to play, yet only 41.8% of them stated they discussed the subject with parturients either because they felt they were insufficiently informed or did not want to shock the women. The interviews showed that globally all persons coming from the 28 African countries risk mutilating their children. Midwives play a determining role in the prevention of mutilation in young girls.
Initial and continuous training on the subject of female genital organ mutilations should be given to midwives to improve prevention. The participation of African women would be useful to demonstrate how easy it is to establish a dialogue with the women.
Qualitative study of perinatal care experiences among Somali women and local health care professionals in Norway
2004, European Journal of Obstetrics and Gynecology and Reproductive Biology
Objective: To explore how perinatal care practice may influence labor outcomes among circumcised women. Study design: In-depth interviews were conducted with 23 Somali immigrants and 36 Norwegian health care professionals about their experiences from antenatal care, delivery and the management of circumcision. Results: Circumcision was not recognized as an important delivery issue among Norwegian health care professionals and generally the topic was not addressed antenatally. The Somalis feared lack of experience and sub-optimal treatment at delivery. All of the women expressed a strong fear of cesarean section. Health care professionals were uncertain about delivery procedures for infibulated women and occasionally cesarean sections were performed in place of defibulation. Conclusion: We hypothesize that neglect of circumcision may lead to adverse birth outcomes including unnecessary cesarean sections, prolonged second stage of labor and low Apgar scores. We suggest that infibulated women need a carefully planned delivery, correctly performed defibulation and adequate pain relief.

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The use of intrapartum defibulation in women with female genital mutilation

Abstract

Introduction

Section snippets

Methods

Results

Discussion

Am J Obstet Gynecol

Eur J Obstet Gynecol

Soc Sci Med

Female genital mutilation

Obstet Gynecol Surv

Female circumcision as a public health issue

N Engl J Med