WUNRN
WHO - World Health Organization
UNIQUE & RARE PAST
RESEARCH, BUT PRESENT RELEVANCE WITH CONTINUING HIGH INCIDENCE OF FGM
Direct Link to Full 7-Page Document:
Summary of Research on Obstetric
Problems Following Female Genital Mutilation - A Survey in Six African
Countries
This study, reported in The Lancet in 2006 [1], 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.
The study focused on women who attended obstetric centres in
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 [2], 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).
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