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 severe type had one. Among women who had given birth before, the percentage having an episiotomy ranged from 14% among women without genital mutilation to 61% among women who had undergone the most severe type of mutilation. As with length of hospital stay, the relative risks of episiotomy for primiparous women increased according to the type of mutilation, from 1.3 among women with the least severe mutilation to 1.8 among those with the most severe type. The relative risks were even higher for multiparous women, rising with the severity of mutilation from 1.8 to 2.2.
Further analyses examined the risk of perineal tears associated with genital mutilation among women who had not had an episiotomy. For women who had never given birth before, the relative risk rose from 1.3 among women with the least severe type of mutilation to 3.2 among those with the most severe type; for multiparous women, the relative risk rose from 1.4 to 1.9. A total of 54 women died before discharge, 45 of whom had undergone genital mutilation; there were too few deaths to calculate reliable risk estimates.
The infants born to women who had undergone genital mutilation were also at elevated risk for adverse outcomes. Infants born to women who had undergone the moderately severe and most severe types of mutilation were more likely to have required resuscitation at delivery (relative risks, 1.3 and 1.7) and more likely to have died while their mother was an inpatient (relative risks, 1.3 and 1.6) than infants born to women who had not had genital mutilation.
For women with any type of genital mutilation, the summary relative risk of stillbirth or infant death during the mother's hospital stay was 1.3 compared with the risk for women who had not undergone mutilation; thus, about 22% of perinatal deaths among infants born to women with genital mutilation can be attributed to the mutilation, although this figure should be interpreted with caution.
According to the researchers, the results indicate that childbirth is significantly more likely to be complicated by adverse outcomes in women who have undergone any type of genital mutilation than in women who have not. They note that the study's findings may be limited by the fact that it took place in hospitals, even though the countries with the largest proportions of women who have had genital mutilation are among those with the most limited health care infrastructures. For that reason, they say, women who can afford hospital costs and those with high-risk deliveries may be overrepresented in the sample; still, the finding that women who have undergone genital mutilation are at higher risk for obstetric complications is likely to be widely applicable. The investigators conclude that "adverse obstetric and perinatal outcomes can…be added to the known and harmful immediate and long-term effects" of female genital mutilation.—L. Melhado
REFERENCE
1. World Health Organization (WHO), Female genital mutilation and obstetric outcome: WHO collaborative prospective study in six African countries, Lancet, 2006, 367(9525):1835–1841.