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Female Genital Mutilation and Obstetric Outcome: How to take the results to doctors and Female Genital Mutilation and Obstetric Outcome: How to take the results to doctors and midwives Hermione Lovel UK Heli Bathija, WHO 05_HB_Dakar_DEC 1 6 February, Washington DC

 • Challenge: Each year 3 million girls are forced to undergo female genital • Challenge: Each year 3 million girls are forced to undergo female genital mutilation, in many cases the medical profession is carrying out the procedure. 05_HB_Dakar_DEC 2 However, in many other cases the doctors and nurses want to prevent complications but do not know how

WHO overall Strategy on FGM • • To play an advocacy role by emphasizing WHO overall Strategy on FGM • • To play an advocacy role by emphasizing the importance of action against harmful practices at international, regional and national levels. To initiate and to coordinate the research and development being undertaken by – international agencies, nongovernmental organizations and national authorities. • 06_Women Health Ministers Dinner November 8 06_HB 3 • To support national networks or organizations and groups involved in developing relevant policies, strategies and programmes. To support the training of health professionals in the prevention of female genital mutilation and the management of its health consequences.

 • • To support the training of health professionals ( in all countries) • • To support the training of health professionals ( in all countries) in the prevention of female genital mutilation and the management of its health consequences. Issues – Medicalisation: increase in percentages of girls whose FGM is performed by medical personnel – Re-stitching: routine practice in many countries without any public discussion – Preventing complications at birth for the woman and the 06_Women Health Ministers Dinner November 8 06_HB 4 newborn: de-infibulation during pregnancy not practised

It is important to train students of medical professions • 330 5 th year It is important to train students of medical professions • 330 5 th year medical students in Alexandria, Egypt (country with 97% FGM prevalence): – Awareness of the prevalence, practices and procedures low – Poorly informed about complications, ethical and legal aspects – 52% in favour of continuation of practice – 73% in favour of medicalization – 87% thought that the issue of FGM should be included in the curriculum 06_Women Health Ministers Dinner November 8 06_HB 5 Eastern Mediterranean Health Journal 2006, vol 12 (Suppl 2), S 78 -S 92

The medical personnel might know WHO classification of FGM… Type I : Excision of The medical personnel might know WHO classification of FGM… Type I : Excision of the prepuce and part or all of the clitoris Type II: Excision of the prepuce and clitoris together with partial or total excision of the labia minora Type III: Infubulation ─ Excision of part or all of the external genitalia and stitching of the two cut sides together to varying degrees Type IV: Pricking, piercing, incision, stretching, scraping, or other harming procedures on clitoris or labia, or both 05_HB_Dakar_DEC 6 …But they might not be aware of how the FGM is performed and what the complications might be

FGM instruments 05_HB_Dakar_DEC 7 the herb, mal, that is used to FGM instruments 05_HB_Dakar_DEC 7 the herb, mal, that is used to "glue" infibulation the thorns used to clasp infibulation

Physical consequences of FGM • • • Severe pain is the most common immediate Physical consequences of FGM • • • Severe pain is the most common immediate consequence of all forms of FGM. The degree of pain and trauma is such that a woman or girl is often left in a state of medical shock after the operation. Bleeding (Long-term anaemia also possible) Damage to adjacent tissue In extreme cases: death due to severe and uncontrolled bleeding or to infection. Urine retention • Keloid scars, abscesses and painful cysts. • 06_Women Health Ministers Dinner November 8 06_HB 8 • Infertility

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Aims of the study The primary aims of the study – To evaluate the Aims of the study The primary aims of the study – To evaluate the relationship between different types of FGM and obstetric complications. – To estimate the incidence of obstetric complications among women with a history of FGM giving birth in hospital. The secondary aim of the study – To obtain clinical information relevant to the 05_HB_Dakar_DEC 10 prevention and treatment of obstetric complications in women with FGM.

FGM prevalence in the participating countries 06_Women Health Ministers Dinner November 8 06_HB 11 FGM prevalence in the participating countries 06_Women Health Ministers Dinner November 8 06_HB 11 Burkina Faso 75% - 2003 Ghana 5% - 2003 Kenya 32% - 2003 Nigeria 19% - 2003 Senegal about 20% Sudan 90% - 2000

Methods Women – Singleton delivery at one of 28 obstetric centres in Burkina Faso Methods Women – Singleton delivery at one of 28 obstetric centres in Burkina Faso (5), Ghana (3), Kenya (3), Nigeria (6), Senegal (8), Sudan (3) – Planned elective Caesarean sections excluded – Consenting women examined in early labour and 05_HB_Dakar_DEC 12 FGM status determined before delivery (women in advanced labour with expected imminent delivery excluded)

Methods Statistics – 28 509 women enrolled – 126 (0. 4%) excluded for missing Methods Statistics – 28 509 women enrolled – 126 (0. 4%) excluded for missing data on age, parity, education, height, residence (urban/rural) – Multivariate logistic regression, adjusted ORs Core factors: centre, age, parity, education, socio-economic status Additional factors (>5% impact on OR): height, residence, time to reach hospital, # ANC visits – Separate models for FGM I vs. no FGM, 05_HB_Dakar_DEC 13 FGM II vs. no FGM, FGM III vs. no FGM

Recruitment Distribution of FGM type, by country FGM 0 FGM III Total Burkina Faso Recruitment Distribution of FGM type, by country FGM 0 FGM III Total Burkina Faso 20% 23% 45% 13% 4816 Ghana 60% 11% 28% 1% 3094 Kenya 40% 21% 29% 10% 4167 Nigeria 12% 63% 24% 1% 5366 Senegal 21% 24% 54% 1% 3449 Sudan 18% 5% 5% 73% 7501 Total 05_HB_Dakar_DEC 14 Country 25% 24% 27% 23% 28393

Birth complications of FGM 05_HB_Dakar_DEC 15 From ”Caring for women with circumcision, av Nahid Birth complications of FGM 05_HB_Dakar_DEC 15 From ”Caring for women with circumcision, av Nahid Toubia, MD. Rainbo, UK.

05_HB_Dakar_DEC 16 Women with FGM run greater risks during childbirth… 05_HB_Dakar_DEC 16 Women with FGM run greater risks during childbirth…

05_HB_Dakar_DEC 17 … and so do their babies 05_HB_Dakar_DEC 17 … and so do their babies

Additional Results Patterns of risks similar in nulliparous and parous women Significantly higher rates Additional Results Patterns of risks similar in nulliparous and parous women Significantly higher rates of episiotomy and perineal tears in women with FGM, though substantial heterogeneity between centres 05_HB_Dakar_DEC 18 Estimated 10 – 20 additional perinatal deaths per 1000 live births in the countries where study conducted Complication rates likely higher in women with limited access to obstetric services

Implications 05_HB_Dakar_DEC 19 First clear evidence of obstetric sequelae Previous data limited and equivocal, Implications 05_HB_Dakar_DEC 19 First clear evidence of obstetric sequelae Previous data limited and equivocal, and focused more on immediate complications of procedure Clear evidence of harm for mothers and babies Adverse health effects of all FGM types – greatest risks with more extensive FGM Lack of effect on birth weight yet clear adverse effect on delivery process: supports hypothesis of mechanical problem (lack of elasticity of cut/excised tissues? )

Implications Implications "These results invite the authorities and health professionals to focus on women's rights and to ensure effective skilled attendance during deliveries at high risk. " Dr Michel Akotionga, Principal Investigator, Burkina Faso 06_Women Health Ministers Dinner November 8 06_HB 20 "The results of this research provide empirical data … about FGM in general and especially in women with FGM going through labour, in our quest to eradicate the practice of FGM worldwide" Dr Kwasi Odoi-Agyarko, Executive Director, Rural Help Integrated Bolgatanga, Ghana

Way forward Strengthening health systems capacity to deal with consequences of FGM: – Promotion Way forward Strengthening health systems capacity to deal with consequences of FGM: – Promotion of use of WHO guidelines – Developing new guidance documents based on the findings of the research • – 06_Women Health Ministers Dinner November 8 06_HB 21 • Electronic media: DVDs, internet (example the DVD by DFID for medical practitioners in UK)

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Way forward • – – – 06_Women Health Ministers Dinner November 8 06_HB 23 Way forward • – – – 06_Women Health Ministers Dinner November 8 06_HB 23 – – – need to be working together: WHO World Medical Association (WMA) International Federation of Obstetricians and Gynecologists (FIGO) International Council of Midwives (ICM) Partnership for Maternal, Newborn and Child Health Pediatricians Private sector others

Next steps • • • 06_Women Health Ministers Dinner November 8 06_HB 24 • Next steps • • • 06_Women Health Ministers Dinner November 8 06_HB 24 • Meeting of a working group to develop two, three options for a workplan and resource mobilization Identifying focus countries Targeting information sharing through various tools Arranging training opportunities

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