Female Genital Cutting: Impact on Maternal and Neonatal Outcomes
WHEC Practice Bulletin and Clinical Management Guidelines for healthcare providers. Educational grant provided by Women's Health and Education Center (WHEC).
Female genital cutting (FGC) is the collective name given to traditional practices that involve partial or total cutting away of the female external genitalia whether for cultural or other non-therapeutic reasons. FGC also known as female circumcision or genital mutilation is a cultural tradition practiced in 27 African countries, as well as parts of the Middle East and Asia. Between 100 and 140 million girls and women in the world are estimated to have undergone such procedures, and 3 million girls are estimated to be at risk of undergoing female genital mutilation every year. Female genital mutilation has been documented in 28 countries in Africa and in several countries in Asia and the Middle East (1). Some forms of the practice have also been reported from other countries, including among certain ethnic groups in Central and South America. There is also evidence of increasing numbers of girls and women living outside their place of origin, including in North America and Western Europe, who have undergone or may be at risk of undergoing female genital mutilation or cutting. It involves partial or total removal of the female external genitalia. Extensive work by local, national and international organizations over the past two to three decades has resulted in progress on several fronts. The practice is internationally recognized as a violation of human rights, and many countries have put in place policies and legislation to ban it. The number of women from practicing areas who do not want to continue the practice is increasing, and there are indications that the prevalence is declining in some countries, and that it is less prevalent in younger than in older age groups. Despite these successes however, the overall decline has been very slow. Hence, to accelerate the process of abandonment of the practice, there is an urgent need for increased and improved work by all organizations, since there is evidence now that we know what is necessary to stimulate large-scale and speedy abandonment. Some highly successful projects, increased knowledge about the practice itself and the reasons for its continuation as well as experiences with a vast variety of interventions, some of which have proven very successful, suggest that it will be possible to significantly reduce the prevalence within one generation. This, combined with advocacy at the international level, has created a momentum suggesting that such a change is possible, and that the willingness to invest the necessary resources can be achieved.
The purpose of this document is to discuss the impact of female genital cutting (FGC) on maternal and neonatal outcomes. These beliefs and practices can damage the health of both mother and child in various ways. FGC, for instance, leads to scarification and later complications in childbirth. Female genital cutting/mutilation has no known health benefits. On the contrary, it is known to be harmful to girls and women in many ways. First and foremost, it is painful and traumatic. The removal of or damage to healthy, normal genital tissue interferes with the natural functioning of the body and causes several immediate and long-term health consequences. Babies born to women who have undergone female genital mutilation suffer a higher rate of neonatal death compared with babies born to women who have not undergone the procedure.
Female genital cutting (FGC) represents a fundamental violation of women's and girls' rights (2). Eighteen African countries have prevalence rates of 50% or higher. Recognition of its harmful physical, psychological and human rights consequences has led to the use of the term "female genital mutilation" or FGM. Many women who have undergone FGC do not consider themselves to be mutilated and have become offended by the term "FGM". Recently, other terms such as "female genital cutting" have increasingly been used. Practices involving cutting of female genitals have been found throughout history in many cultures, but there is no definitive evidence documenting when or why this ritual began. Some theories suggest that FGC might have been practiced in ancient Egypt as a sign of distinction, while others hypothesize its origin in ancient Greece, Rome, Pre-Islamic Arabia and the Tsarist Russian Federation. Communities that practice female genital mutilation report a variety of social and religious reasons for continuing with it. Seen from a human rights perspective, the practice reflects deep-rooted inequality between the sexes, and constitutes an extreme form of discrimination against women. Female genital cutting/mutilation is nearly always carried out on minors and is therefore a violation of the rights of the child. The practice also violates the rights to health, security and physical integrity of the person, the right to be free from torture and cruel, inhuman or degrading treatment, and the right to life when the procedure results in death. Decades of prevention work undertaken by local communities, governments, and national and international organizations have contributed to a reduction in the prevalence of female genital cutting/mutilation in some areas.
Female genital cutting (FGC) is practiced for a number of reasons including:
- Sexual: to control or reduce female sexuality.
- Sociological: for example, as an initiation for girls into womanhood, social integration and the maintenance of social cohesion.
- Hygiene and aesthetic reasons: where it is believed that the female genitalia are dirty and unsightly.
- Health: in the belief that it enhances fertility and child survival.
- Religious reasons: in the mistaken belief that FGC is a religious requirement.
World Health Organization (WHO) Modified Typology, 2007
Type I: Partial or total removal of the clitoris and/or the prepuce (clitoridectomy). When it is important to distinguish between the major variations of Type I mutilation, the following subdivisions are proposed: Type Ia, removal of the clitoral hood or prepuce only; Type Ib, removal of the clitoris with the prepuce.
Type II: Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (excision). When it is important to distinguish between the major variations that have been documented, the following subdivisions are proposed: Type IIa, removal of the labia minora only; Type IIb, partial or total removal of the clitoris and the labia minora; Type IIc, partial or total removal of the clitoris, the labia minora and the labia majora. Note also that, in French, the term "excision" is often used as a general term covering all types of female genital mutilation.
Type III: Narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris (infibulation). When it is important to distinguish between variations in infibulations, the following subdivisions are proposed: Type IIIa: removal and apposition of the labia minora; Type IIIb: removal and apposition of the labia majora.
Type IV: Unclassified: All other harmful procedures to the female genitalia for non-medical purposes, for example, pricking, piercing, incising, scraping and cauterization.
Short- and Long-term Complications:
Female genital cutting (FGC) does irreparable harm. It can result in death through severe bleeding leading to hemorrhagic shock, neurogenic shock as a result of pain and trauma, and severe, overwhelming infection and septicemia. It is routinely traumatic. Many girls enter in a state of shock induced by the severe pain, psychological trauma and exhaustion from screaming. Women who have undergone female genital cutting can suffer immediate and long-term complications: Bleeding, hemorrhage, infections, tetanus, oliguria, sepsis, and death are some of the immediate complication that has been documented. Long-term complications for women who have undergone type III procedures include dysmenorrhea, dyspareunia, apareunia (no coitus due to the inability to achieve penetration), urinary retention, infertility, chronic vaginal and urinary tract infections, urinary calculi, and neuromas (4).
Other harmful effects include: failure to heal; abscess formation; cysts; excessive growth of scar tissue; urinary tract infection; painful sexual intercourse; increased susceptibility to HIV/AIDS, hepatitis and other blood-borne diseases; reproductive tract infection; pelvic inflammatory diseases; infertility; painful menstruation; chronic urinary tract obstruction/bladder stones; urinary incontinence; obstructed labor; increased risk of bleeding and infection during childbirth.
The circumcised women show a significantly higher prevalence of post-traumatic stress disorder (PTSD) (30.4%) and other psychiatric syndromes (47.9%) than the uncircumcised women. PTSD was accompanied by memory problems. Within the circumcised group, a mental health problem exists that may furnish the first evidence of the severe psychological consequences of female genital mutilation. A wide range of psychological and psychosomatic disorders have been attributed to FGC for example, disordered eating and sleeping habits, changes in mood and symptoms of impaired cognition (5).
According to the World Health Organization, more than 130 million women worldwide have undergone female genital cutting. It is now practiced covertly in Western countries that have accepted refugees and immigrants from these regions. Some 228,000 women and girls in the United States have undergone or are at risk of female genital cutting. This number has increased from the 1990 U.S. Census, when it was 168,000. This tradition transcends religious affiliation, geography, and socioeconomic status. It persists as a rite of passage and is seen as a means of preserving chastity, maintaining hygiene, ensuring marriageability, preserving fertility and enhancing sexual pleasure for men (6).
Female Genital Cutting and Obstetric Outcomes:
Reliable evidence about the effect of female genital cutting (FGC) on obstetric outcome is scarce. This study examines the effect of different types of FGC on obstetric outcome (7). 28,393 women attending for singleton delivery between November, 2001, and March, 2003, at 28 obstetric centers in Burkina Faso, Ghana, Kenya, Nigeria, Senegal, and Sudan were examined before delivery to ascertain whether or not they had undergone FGC, and were classified according to the WHO system: FGC I, removal of the prepuce or clitoris, or both; FGC II, removal of clitoris and labia minora; and FGC III, removal of part or all of the external genitalia with stitching or narrowing of the vaginal opening. Prospective information on demographic, health, and reproductive factors was gathered. Participants and their infants were followed up until maternal discharge from hospital. Compared with women without FGC, the adjusted relative risks of certain obstetric complications were, in women with FGC I, II, and III, respectively: cesarean section 1.03 (95% CI 0.88--1.21), 1.29 (1.09--1.52), 1.31 (1.01--1.70); postpartum hemorrhage 1.03 (0.87--1.21), 1.21 (1.01--1.43), 1.69 (1.34--2.12); extended maternal hospital stay 1.15 (0.97--1.35), 1.51 (1.29--1.76), 1.98 (1.54--2.54); infant resuscitation 1.11 (0.95--1.28), 1.28 (1.10--1.49), 1.66 (1.31--2.10), stillbirth or early neonatal death 1.15 (0.94--1.41), 1.32 (1.08--1.62), 1.55 (1.12--2.16), and low birth-weight 0.94 (0.82--1.07), 1.03 (0.89--1.18), 0.91 (0.74--1.11). Parity did not significantly affect these relative risks. FGC is estimated to lead to an extra one to two perinatal deaths per 100 deliveries.
Interpretation: Women with FGC are significantly more likely than those without FGC to have adverse obstetric outcomes. Risks seem to be greater with more extensive FGC. These results show that deliveries to women who have undergone FGC are significantly more likely to be complicated by cesarean section, postpartum hemorrhage, episiotomy, extended maternal hospital stay, resuscitation of the infant, and inpatient perinatal death, than deliveries to women who have not had FGC. There was no significant association between FGC and the risk of having a low-birth-weight infant. This large prospective study was done at obstetric centers in countries where FGC is common and was designed specifically to examine the relation between different types of FGC and obstetric sequelae. The study has sufficient power to investigate the effect of septic types of FGC on a range of obstetric outcomes, including important but less common outcomes, such as inpatient perinatal death, that has not previously been reliably examined. Most women who have undergone FGC live in countries with limited infrastructure for health care or for health research. For practical reasons, this study was done in hospitals, and women with high-risk or complicated deliveries and those able to afford hospital care are likely to be over-represented. As a result, the absolute rates of complications might not be general sable to women in the broader population in these countries. The overall ending of higher risks of obstetric complications in women with FGC is likely to be more widely applicable; however, the frequency and effect of these complications among women giving birth in hospital might differ from those in women giving birth elsewhere. For example, postpartum hemorrhage and obstructed labor are likely to have more serious results outside the hospital setting (8).
Previous smaller studies have suggested that adverse obstetric outcomes such as episiotomy, tears, protracted labor, postpartum hemorrhage, and low Apgar score might be more common in deliveries in women who have had FGC. However, reliable data about the effect of different types of FGC on specific obstetric outcomes are scarce, since previous studies have inconsistent findings, rarely account for potential confounding factors, do not investigate the effects of different types of FGC and have been based on self-reported obstetric complications. Previous studies also had insufficient power to examine important outcomes such as stillbirth and early neonatal death (9). The mechanism by which FGC might cause adverse obstetric outcomes is unclear. Although practices vary from country to country, FGC is generally done in girls younger than 10 years and leads to varying amounts of scar formation. The presence of this scar tissue, which is less elastic than the perineal and vaginal tissue would normally be, might cause differing degrees of obstruction and tears or episiotomy. A long second stage of labor, along with direct effects on the perineum, could underlie the findings of an increased risk of perineal injury, postpartum hemorrhage, resuscitation of the infant, and fresh stillbirth associated with FGC. The length of the second stage of labor could not be reliably measured in these study settings because good obstetric practice discourages frequent vaginal examinations. Furthermore, the increased risk of cesarean section in women with FGC II or III could theoretically mask an effect on the length of the second stage of labor in women with these types of FGC. There is evidence that FGC is associated with increased rates of genital and urinary-tract infection, which could also have repercussions for obstetric outcomes.
In previous studies, the rate of complication ranged between 13% and 69%. 1,225 mothers with and 256 without FGC who have had spontaneous, term, singleton and vertex vaginal delivery was in this study group. Of these, 762 (51.5%) were primipara and 719 (48.5%) of them multipara. The parameters focused upon included age, ethnicity, parity, type of circumcision, episiotomy, stages of labor, Apgar scores and related complications. Results: The study revealed that 82.7% of the subjects had one form of FGC. The mean ages for the circumcised and non-circumcised were 25.9 +/- 5.9 and 21.8 +/- 4.5 years, respectively. The frequently performed genital mutilation was type II (85.5%). The mothers who required an episiotomy incision for fetal and maternal indications among the circumcised accounted for 43.0% whereas it was only 24.6% for the referent group. The mean duration of labor by conventional standards is prolonged in primipara and multipara both in the circumcised and non-circumcised groups, though the second stage is delayed more so for the circumcised category (p<0.05). The first and tenth minute mean Apgar scores seem to be more favorable for the non-circumcised (p<0.05) but the perinatal mortality rates are quite similar. More complications in terms of perineal tears, bleeding, incontinence and febrile illnesses are registered for the FGC. Conclusion: The study demonstrates the negative impact of FGC more on maternal than neonatal outcomes during parturition (10).
Role of Defibulation to Manage Female Genital Cutting:
Women who have undergone type III female genital cutting (FGC) may suffer long term complications. Defibulation (reconstructive surgery of the infibulated scar) can alleviate some to these complications. Defibulation is a surgical procedure wherein a vertical incision is made on the scar to expose the introitus and create new labia majora. Few data are available with which to assess the operative complication rates, the patient and husband satisfaction rates, and the physical and sexual outcomes. Patients who undergo defibulation receive either general or regional anesthesia. The procedure entails grasping the infibulated scar with Allis clamps bilaterally and making a vertical incision anteriorly with Mayo scissors, exposing both the introitus and urethra. Hemostasis on each side using either a subcuticular or interrupted sutures (routinely poliglecaprone 25 [Monocryl, Ethicon Endo-Surgery, Inc., Cincinnati, OH] or polyglactin [Vicryl, Ethicon Endo-Surgery]). This also prevented the two exposed edges from re-healing together. Long-acting local anesthesia is subsequently injected to ease postoperative pain. Upon discharge, women are given topical and oral analgesics, instructed to perform sitz baths, and advised to expect a change in their voiding stream (11). In this study, husbands were supportive and instrumental in persuading their wives to undergo this procedure. Authors of the study believe that by being involved, husbands become better informed about female genital cutting, learn what tissue is removed, the health consequences of the practice, and subsequent risks and benefits of defibulation. Also, the husbands' reported satisfaction with the surgery calls into question the traditional beliefs that men want their wives closed tightly to enhance their own sexual pleasure and that the very appearance of infibulated genitalia is esthetically more pleasing to men. Introducing to couples to this type of discussion breaks the centuries-old barrier designating female genital cutting as the exclusive domain of women.
The strength of this study (11) lies in the fact that so many women and husbands were willing to participate and to divulge information not routinely discussed in public. Issues of female genital cutting (FGC) and sexuality are typically taboo in these cultures and are rarely disclosed. Eliciting such sensitive information from African women -- and more so, from African men -- is unusual; the study thus provides a rare insight into the sexuality of these couples. This in turn, can aid health providers in counseling couples about the health and sexual benefits of defibulation. In conclusion, defibulation is recommended for all infibulated women who experience long-term complications such as dysmenorrhea, dyspareunia, apareunia, or chronic vaginal and urinary infections. Complication rates are low, and the patient and husband satisfaction rates are high. The American College of Obstetricians and Gynecologists has designed a slide-lecture kit that explains this procedure using photographs and detailed instruction (12). Patients who require defibulation should be referred to an experienced gynecologist or speak with experts in the field to provide optimal health care.
Ending the Practice of Female Genital Cutting:
Since the middle of the last century many international and national organizations and agencies, both governmental and nongovernmental, have set up programs to halt or reduce the prevalence of FGC. Thanks largely to their efforts; clauses prohibiting the practice have been incorporated into a large number of international legal instruments and into the legislation of a growing number of countries. Half of the 28 countries where the practice is "endemic" have introduced legislation forbidding it. A further seven countries have incorporated anti-FGC legislation into their constitutions or criminal laws. Applying the law, however, is another matter: a study published in 2000 found that prosecutions had been brought in only 4 of the 28 countries of Africa and the Middle East where FGC is practiced. Laws prohibiting FGC have also been introduced in several countries with immigrant communities continuing the practice: these countries include Australia, Canada, New Zealand, USA and at least 13 countries in Western Europe. Again, the annual rate of prosecutions varies widely. Armed with arguments based on its danger to health and on its violation of human rights, opponents of FGC have, over the past half-century or so, tried various strategiesóranging from public education campaigns to offering alternative sources of income to FGC practitionersóaimed at stopping the practice. Some of the more successful strategies include (13):
- Promotion of alternative "rites of passage" that preserve the ritual or symbolic component of FGC marking the admission of young girls into the community or into adulthood but without unduly harming their bodies;
- Group discussions and media campaigns aimed at raising awareness among parliamentarians, religious and civic community leaders, traditional and modern health-care providers, and other decision-makers, as well as among the public, of the dangers to health and of the transgression of human rights that FGC involves;
- Promotion, at all levels of society, of the abandonment of FGC as part of a "development package" that includes a reduction of poverty and of inequities and inequalities between the sexes, and an increase in access to education and health services.
In the present study, 53.9% of non-circumcised girls, said circumcision is not important, and that it is an unhealthy and painful procedure, while 17.5% of girls said that it is unnecessary for females. Around 12% of girls believed that there is no religious support for circumcision. In 2003, the Egyptian Interim Demographic and Health Survey obtained information from women who said that their daughters would not be circumcised. The majority of these women (61%) simply said that they did not believe in the practice of FGC. Meanwhile, a substantial proportion of them expressed concern about potential health complications (42%) and only 20% saw FGC practice as against their religion. Other reasons included better marriage prospects (8%) and better sexual relations with their husband (5%). Another study in Egypt among medical students reported that 72--78% of medical students were against FGC (14).
A Practice Resistant to Change:
In countries where female genital cutting (FGC) is unknown, people often react with incredulity that in this day and age FGC is still practiced despite its negative impact on health, its disregard of human rights and its illegality in many countries. Most surprisingly, the practice often persists even among families who agree that it should be abandoned. Social scientists say FGC persists for the following reasons:
- It endows a girl with cultural identity as a woman: in many ethnic groups the clitoris is associated with masculinity and is excised to maintain differentiation between males and females.
- It imparts on a girl a sense of pride, a coming of age and admission to the community: in many communities, girls are rewarded with gifts, celebrations and public recognition after the operation.
- Not undergoing the operation brands a girl as a social outcast and reduces her prospects of finding a husband.
- It is part of a mother's duties in raising a girl "properly" and preparing her for adulthood and marriage.
- It is believed to preserve a girl's virginity, widely regarded as a prerequisite for marriage, and helps to preserve her morality and fidelity: in some ethnic groups, virginity is associated with an infibulated vulva, not with an intact hymen.
- It is believed to enhance a husband's pleasure during the sex act.
- It is believed to confer bodily cleanliness and beauty on a girl: in some communities, the female genitalia are considered unclean.
- It is believed to be prescribed by religion and thus to make a girl spiritually pure.
FGC has raised a lot of concerns among women's groups especially in African, international and professional organizations. Currently, many African governments recognize that FGC is a violation of the human rights of girls and women. Any action against FGC should take into account the multiplicity of reasons that support and motivate its practice. It is an issue that demands a collaborative approach involving health professionals, religious leaders, educationalists and nongovernmental organizations. Governments should take an active role in supporting regional and international initiatives to combat FGC, such as WHO, the United Nations Children's Fund (UNICEF) and the United Nations Population Fund (UNFPA). The role of international solidarity is to complement and support the work carried out locally by providing technical, methodological and financial support.
Some 3 million girls in 28 countries on the African continent are subjected to genital mutilation each year, as are thousands of girls in immigrant communities in Europe, North America and Australia, according to UNICEF, which describes this as one of the most "silently endured human rights violations." Globally, between 100 and 140 million girls and women have been cut or mutilated. Most girls are cut between infancy and their 14th birthday. Many communities still hold firmly to the age-old tradition, which though not always stated outright is considered a prerequisite for marriage. Legislation to outlaw mutilation has also been put in place. In particular, this includes the Maputo Protocol, which was ratified by 15 African countries and entered into force in November 2005. A month later, 100 African parliamentarians adopted the groundbreaking "Dakar Declaration," which underscores the importance of community involvement as well as legislation to end the practice.
UNICEF has estimated that 3 million girls and women are subjected to FGC and mutilating every year in Africa, including Egypt. The practice is an explicit violation of the United Nations Convention on the Rights of the Child, which was adopted in 1989. According to the 2005 Egypt Demographic and Health Survey, majority of FGC procedures in the country have been performed by trained medical personnel. A key element of UNICEF efforts has been to assist the Government of Egypt in institutionalizing and implementing policies and strategies to eliminate the dangerous practice. Egypt has moved to completely eliminate within its borders the traditional practice of female genital mutilation (FGM) and cutting. Official steps to accelerate the process included a ministerial decree and an anti-FGC statement by the country's top Muslim institution. The United Nations Children's Fund (UNICEF) hailed these steps as significant and voiced its support for all institutions working toward such social progress in the region.
It is recommended that women with type III female genital cutting (FGC) who are pregnant or who suffer long-term complications undergo defibulation (also known as deinfibulation), or opening of the scar. Ending the practice is "essential" to improving maternal health, promoting gender equality and reducing child mortality. Girls have the right to grow to womanhood without harm to their bodies. We know what has to be done to abandon this harmful practice, strong support from governments encouraging communities and individuals to make the healthiest choices possible for girls will save lives and greatly benefit families and communities.
- United Nations
Female Genital Mutilation; High Infant, Maternal Mortality Among Issues Addressed
- World Health Organization
Eliminating Female Genital Mutilation: An Interagency Statement (pdf)
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- Behrendt A, Moritz S. Posttraumatic stress disorder and memory problems after female genital mutilation. Am J Psychiatry 2005; 162:1000-1002
- Number of women, girls with or at risk for female genital cutting on the rise in the United States. Boston (MA): African Women's Health Center, Brigham and Women's Hospital; 2006; Available at: http://brighamandwomens.org/africanwomenscenter/research.aspx Retrieved May 6, 2008
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- UNICEF Innocenti Research Centre. Changing a harmful social convention: female genital mutilation/cutting. Florence, Italy: UNICEF, 2005.
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- Hakim LY. Impact of female genital mutilation on maternal and neonatal outcomes during parturition. East Afr Med J 2001; 78: 255-258
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- American College of Obstetricians and Gynecologists. Female Circumcision/Female Genital Mutilation: Clinical Management of Circumcised Women. ACOG Slide-lecture kit. Washington, DC: ACOG; 1999
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- Tag-Eldin MA, Gadallah MA, Al-Tayeb MN et al. Prevalence of female genital cutting among Egyptian girls. Bulletin of the World Health Organization 2008;86:269--274
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