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This report includes results from only unadjusted analyses from the included studies. We have completed additional analyses based on adjusted analyses and studies of prospective designs in order to test the validity of the results presented in the report. Our results confirm the findings in the report. The updated analyses are freely available online in Obstetrics and Gynecology International http://www.hindawi.com/journals/ogi/2014/542859/
Female genital mutilation/cutting (FGM/C) is a traditional practice that involves the partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons. This systematic review aimed to fill a gap in synthesized evidence of the obstetric sequelae of FGM/C. We included 44 primary studies, 28 of which compared groups of women with FGM/C to women with no or different types of genital modifications. The main findings are: Women who have undergone FGM/C seem to be more likely than non-cut women to experience prolonged labor, obstetric tears, instrumental delivery, obstetric hemorrhage, and difficult delivery. Women with FGM/C type III (infibulation) seem to be more likely than women with FGM/C type I-II (clitoridectomy or excision) to experience problems during delivery. There was not found a significant difference in risk of cesarean section or episiotomy between women with FGM/C and women without FGM/C. There was not found a significant difference in risk of obstetric tears, cesarean section, or episiotomy between women with FGM/C type I and women with FGM/C type II. There were insufficient data for us to conclude whether the risk of other obstetric complications is higher among women with FGM/C compared to women with no FGM/C and whether various FGM/C types differentially affect the risk of other obstetric complications. These findings are based on very low quality of evidence and preclude us from drawing conclusions regarding causality. However, while the exact size of the greater risk from FGM/C is unclear, the findings provide evidence of serious harmful consequences from FGM/C.
Background Female genital mutilation/ cutting (FGM/C) is a traditional practice that involves the partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons. To clarify understanding of the prevalence as well as consequences of the practice, WHO has classified FGM/C into four categories: type I (clitoridectomy), type II (excision), type III (infibulation), and type IV (other). It is widely recognized that FGM/C violates a series of human rights principles – including the Universal Declaration of Human Rights – yet, the practice is found among diverse ethnic groups in about 28 countries in Africa as well as some countries in the Middle East and Asia, and among immigrant communities in Western countries. A range of reasons, which vary across countries, regions and cultural groups, exist for FGM/C, but the practice is generally carried out as a matter of social convention. FGM/C is typically performed on pre-pubescent girls, often without anaesthetics, thus, it is reasonable to assume that it is a traumatic event that may cause short-term as well as long-term harm. WHO writes that, on the physiological level, the procedure causes permanent, irreparable changes in the external female genitalia and that there are no known health benefits to FGM/C. It is estimated that across the world, between 100-140 million girls/women are presently living with FGM/C. The question addressed in the present systematic review is whether women who have been subjected to FGM/C are more likely than women without FGM/C to experience obstetric complications. Obstetrics is the medical specialty area dealing with the care of women and their children during pregnancy, childbirth, and the first six weeks after delivery. Objective This systematic review aimed to fill a gap in synthesized evidence of the obstetric sequelae of FGM/C. The overall aim of the systematic review is to support well-informed decisions in health promotion and health care that inform work to reduce the prevalence of FGM/C and improve quality of services related to the consequences of FGM/C. The main research question was: What are the obstetric consequences of FGM/C? Method The systematic review was conducted in accordance with the NOKC Handbook for Summarizing Evidence and the Cochrane Handbook for Systematic Reviews of Interventions. The main literature search strategy was searches in 15 international databases. Studies eligible for inclusion were systematic reviews, cohort studies, case-control studies, cross-sectional studies, case series, and case reports. The population of interest was girls and women who have been subjected to any type of FGM/C. It follows that the event or intervention was FGM/C, and the comparison was no- or an alternative type of FGM/C. In this report, we summarized the obstetric consequences of FGM/C. These outcomes included, but were not limited to, prolonged labor, tears/lacerations, caesarean section, episiotomy, instrumental delivery, and post-partum hemorrhage. Two reviewers assessed studies for inclusion according to pre-specified criteria, considered the methodological quality of the studies using appropriate checklists, and extracted data from the included sources using a pre-designed data recording form. These steps were done independently and then jointly by the two reviewers. Because results from studies which compare groups of women are most valid for evaluating risk of experiencing complications, we prioritized presenting results from comparative studies. We summarized the study level results in texts and tables and calculated effect estimates (relative risk and mean difference). When studies were sufficiently similar, we used the statistical technique of meta-analysis to estimate risk. We applied the instrument Grading of Recommendations Assessment, Development and Evaluation (GRADE) to assess the extent to which we could have confidence in the effect estimates. Results We identified 5,109 publications and after having assessed titles, abstracts, and publications in full text we included 44 primary studies. All included studies were observational studies, of which 28 were comparative, i.e. they compared groups of women with FGM/C to women with no- or a different type of genital modification. The methodological study quality was generally low, with only seven of the 28 comparative studies (25%) judged as having high or moderate methodological study quality. In our assessment, using the GRADE instrument, the quality of the evidence was very low with regards to documenting a causal relationship between FGM/C and obstetric consequences. Collectively, the studies involved almost 3 million participants. This was due to the inclusion of seven registry studies. Women with FGM/C made up 2.4% of the total sample (n= 70,495). There were eight main outcomes reported across the included studies: Prolonged labor, obstetric tears/lacerations, cesarean section, episiotomy, instrumental delivery, obstetric hemorrhage, dystocia/difficult delivery, other obstetric and antenatal complications. The main findings are: Women who have undergone FGM/C seem to be more likely than non-cut women to experience prolonged labor, obstetric tears, instrumental delivery, obstetric hemorrhage, and difficult delivery. Women with FGM/C type III (infibulation) seem to be more likely than women with FGM/C type I-II (clitoridectomy or excision) to experience problems during delivery. There was not found a significant difference in risk of cesarean section and episiotomy between women with FGM/C and women without FGM/C. There was not found a significant difference in risk of obstetric tears, cesarean section, and episiotomy between women with FGM/C type I and women with FGM/C type II. There were insufficient data for us to conclude whether the risk of other obstetric complications is higher among women with FGM/C compared to women with no FGM/C and whether various FGM/C types differentially affect the risk of other obstetric complications. Discussion This systematic review identified a number of disparities in obstetric outcomes for women with FGM/C relative to women who have not undergone FGM/C. Meta-analysis results show that deliveries to women who have undergone FGM/C are more likely to be complicated by prolonged labor, perineal tears/lacerations, instrumental delivery, obstetric hemorrhage, and obstructed labor than deliveries by comparable women who have not undergone FGM/C. Given the studies included in the meta-analyses included women with various types of FGM/C, genital cutting of any type seems to be associated with obstetric complications. Although the available data do not allow for obstetric complications to be causally attributed to FGM/C and the exact size of the greater risk from FGM/C is unclear, the data clarify the obstetric improvements that may be anticipated with the halting of FGM/C. These results could be used as arguments for campaigning against the practice. Conclusion The low quality of the body of evidence means that it is unclear whether the documented association of FGM/C with obstetric complications reflects true causality. However, the evidence base suggests that women who have undergone FGM/C are more likely than women who have not been subjected to FGM/C to experience obstetric complications. It is questionable whether intensified research efforts would meaningfully change the results described here. If further research on the association between FGM/C and obstetric outcomes are considered ethically and financially justified, such studies should be based on the best possible methodological study design, which is case-control studies.