Archives Blog Original research

Perception and attitude of pregnant women in a rural community north-west Nigeria to female genital mutilation

Arch Gynecol Obstet. 2014 Sep 21. [Epub ahead of print]

Perception and attitude of pregnant women in a rural community north-west Nigeria to female genital mutilation.

Ashimi AO, Amole TG.


PURPOSE: Nigeria has the highest absolute number of residents who have undergone female genital mutilation (FGM) and most are carried out during infancy; however most reports on FGM are from urban based facilities hence we sought to know the perception and attitude of pregnant women residing in a rural community in northern Nigeria to FGM.

METHODS: A descriptive cross sectional study utilized a pretested structured interviewer administered questionnaire to assess the types of FGM known, reasons for performing it and willingness to support or perform FGM among 323 pregnant women attending antenatal care in two different health facilities.

RESULTS: Of the 323 respondents, 256 (79.3 %) were aware of the practice and the common varieties of FGM known to them were Gishiri cut in 137 (53.5 %) and Angurya cut 113 (44.1). The notable reasons for carrying out FGM in the community were tradition 88 (34.4 %), to ease difficulty in childbirth 69 (26.9 %) and better marriage prospect in 55 (21.5 %). Of the respondents that were aware of FGM; 100 (39.1 %) have experienced it and 55 (21.5 %) of those aware of it would subject their daughters to the procedure. There was statistically significant association between willingness to mutilate daughters by the respondents type of education (p = 0.014) and the type of facility they were receiving antenatal care (p = 0.001).

CONCLUSION: FGM is prevalent in this community with Gishiri cut being the commonest variety. It is often associated with difficult childbirth and many women would subject their daughters to this practice. Female education and empowerment is crucial to discontinuation of this practice.

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Archives Blog Review

Perron et al.: Female genital cutting.

J Obstet Gynaecol Can. 2013 Nov;35(11):1028-45.

Female genital cutting.

Perron L, Senikas V, Burnett M, Davis V; Social Sexual Issues Committee, Burnett M, Aggarwal A, Bernardin J, Clark V, Davis V, Fisher W, Pellizzari R, Polomeno V, Rutherford M, Sabourin J; Ethics Committee, Shapiro J, Akhtar S, Camire B, Christilaw J, Corey J, Nelson E, Pierce M, Robertson D, Simmonds A.

Ottawa ON.


Objective: To strengthen the national framework for care of adolescents and women affected by female genital cutting (FGC) in Canada by providing health care professionals with: (1) information intended to strengthen their knowledge and understanding of the practice; (2) directions with regard to the legal issues related to the practice; (3) clinical guidelines for the management of obstetric and gynaecological care, including FGC related complications; and (4) guidance on the provision of culturally competent care to adolescents and women with FGC. Published literature was retrieved through searches of PubMed, CINAHL, and The Cochrane Library in September 2010 using appropriate controlled vocabulary (e.g., Circumcision, Female) and keywords (e.g., female genital mutilation, clitoridectomy, infibulation). We also searched Social Science Abstracts, Sociological Abstracts, Gender Studies Database, and ProQuest Dissertations and Theses in 2010 and 2011. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to December 2011. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

Values: The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). Summary Statements 1. Female genital cutting is internationally recognized as a harmful practice and a violation of girls’ and women’s rights to life, physical integrity, and health. (II-3) 2. The immediate and long-term health risks and complications of female genital cutting can be serious and life threatening. (II-3) 3. Female genital cutting continues to be practised in many countries, particularly in sub-Saharan Africa, Egypt, and Sudan. (II-3) 4. Global migration patterns have brought female genital cutting to Europe, Australia, New Zealand, and North America, including Canada. (II-3) 5. Performing or assisting in female genital cutting is a criminal offense in Canada. (III) 6. Reporting to appropriate child welfare protection services is mandatory when a child has recently been subjected to female genital cutting or is at risk of being subjected to the procedure. (III) 7. There is concern that female genital cutting continues to be perpetuated in receiving countries, mainly through the act of re-infibulation. (III) 8. There is a perception that the care of women with female genital cutting is not optimal in receiving countries. (III) 9. Female genital cutting is not considered an indication for Caesarean section. (III)

Recommendations 1. Health care professionals must be careful not to stigmatize women who have undergone female genital cutting. (III-A) 2. Requests for re-infibulation should be declined. (III-B) 3. Health care professionals should strengthen their understanding and knowledge of female genital cutting and develop greater skills for the management of its complications and the provision of culturally competent care to adolescents and women who have undergone genital cutting. (III-A) 4. Health care professionals should use their knowledge and influence to educate and counsel families against having female genital cutting performed on their daughters and other family members. (III-A) 5. Health care professionals should advocate for the availability of and access to appropriate support and counselling services. (III-A) 6. Health care professionals should lend their voices to community-based initiatives seeking to promote the elimination of female genital cutting. (III-A) 7. Health care professionals should use interactions with patients as opportunities to educate women and their families about female genital cutting and other aspects of women’s health and reproductive rights. (III-A) 8. Research into female genital cutting should be undertaken to explore women’s perceptions and experiences of accessing sexual and reproductive health care in Canada. (III-A) The perspectives, knowledge, and clinical practice of health care professionals with respect to female genital cutting should also be studied. (III-A). 9. Information and guidance on female genital cutting should be integrated into the curricula for nursing students, medical students, residents, midwifery students, and students of other health care professions. (III-A) 10. Key practices in providing optimal care to women with female genital cutting include: a. determining how the woman refers to the practice of female genital cutting and using this terminology throughout care; (III-C) b. determining the female genital cutting status of the woman and clearly documenting this information in her medical file; (III-C) c. ensuring the availability of a well-trained, trusted, and neutral interpreter who can ensure confidentiality and who will not exert undue influence on the patient-physician interaction when providing care to a woman who faces language challenges; (III-C) d. ensuring the proper documentation of the woman’s medical history in her file to minimize the need for repeated medical histories and/or examinations and to facilitate the sharing of information; (III-C) e. providing the woman with appropriate and well-timed information, including information about her reproductive system and her sexual and reproductive health; (III-C) f. ensuring the woman’s privacy and confidentiality by limiting attendants in the room to those who are part of the health care team; (III-C) g. providing woman-centred care focused on ensuring that the woman’s views and wishes are solicited and respected, including a discussion of why some requests cannot be granted for legal or ethical reasons; (III-C) h. helping the woman to understand and navigate the health system, including access to preventative care practices; (III-C) i. using prenatal visits to prepare the woman and her family for delivery; (III-C) j. when referring, ensuring that the services and/or practitioners who will be receiving the referral can provide culturally competent and sensitive care, paying special attention to concerns related to confidentiality and privacy. (III-C).

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Archives Blog Original research

Experiences from pregnancy and childbirth related to female genital mutilation among Eritrean immigrant women in Sweden.

Midwifery. 2008 Jun;24(2):214-25. Epub 2007 Feb 21.

Experiences from pregnancy and childbirth related to female genital mutilation among Eritrean immigrant women in Sweden.

Lundberg PC, Gerezgiher A.

Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden.

OBJECTIVE: to explore Eritrean immigrant women’s experiences of female genital mutilation (FGM) during pregnancy, childbirth and the postpartum period.

DESIGN: qualitative study using an ethnographic approach. Data were collected via tape-recorded interviews.

SETTING: interviews in the Eritrean women’s homes located in and around Uppsala, Sweden.

PARTICIPANTS: 15 voluntary Eritrean immigrant women.

DATA COLLECTION AND ANALYSIS: Semi-structured interview and open-ended questions were used. The interviews were tape-recorded, transcribed verbatim and then analysed.

FINDINGS: six themes of experiences of FGM among Eritrean women during pregnancy and childbirth were identified. They are (1) fear and anxiety; (2) extreme pain and long-term complications; (3) health-care professionals’ knowledge of circumcision and health-care system; (4) support from family, relatives and friends; (5) de-infibulation; and (6) decision against female circumcision of daughters.

KEY CONCLUSION AND IMPLICATIONS FOR PRACTICE: the Eritrean women had experiences of FGM and had suffered from its complications during pregnancy, childbirth and the postpartum period. Midwives and obstetricians should have competence in managing women with FGM, and they need increased understanding of cultural epistemology in order to be able to provide quality care to these women. At antenatal centres, circumcised women should be advised to de-infibulate before pregnancy. Special courses about anatomical differences should be offered to these women and their husbands. It is also important to inform them about Swedish law, which prohibits all forms of FGM.

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Archives Blog Original research

[Maternal and foetal prognostic in excised women delivery]

J Gynecol Obstet Biol Reprod (Paris). 2007 Jun;36(4):393-8. Epub 2007 Apr 6.FREE

[Maternal and foetal prognostic in excised women delivery]. [Article in French]

Millogo-Traore F, Kaba ST, Thieba B, Akotionga M, Lankoande J.


INTRODUCTION: The female circumcision constitutes by their frequency and complications a real problem of public health.

MATERIAL AND METHOD: Our study aims at comparing the maternal land fetal complications of the spontaneous vaginal delivery in the excised women and non-excised. We led a comparative survey case witness implying 227 excised pregnant women at the maternity in CHU YO of Ouagadougou.

RESULTS: The prevalence of the excision from January 1st to July 31, 2006 was 72.86%. The distribution of female genital mutilations in this population is the following: type I=27.75%, type II=69.61%, type III=2.64%. The middle age was 25 years and 79.30% of women were aged less than 30 years. Islam appeared like a factor of exposure to the practice of the excision with 67.40% of women excised that practise it against 41.90% at the non-excised group (P<0,0001). The maternal complications were dominated by the duration of fetal expulsion prolonged and perineal tears. The duration of fetal expulsion was superior to 30 minutes for 34.56% of excised woman childbirths 9 times more frequently than women non-excised (P=0.001). The frequency of perineal tears was 10.13% in the group of women excised against 5.73% in the group of the non-excised (P=0.008). These perineal lesions were more frequent with the primiparae and women excised at the 2nd and 3rd degree. The neobirth asphyxia affected 4.4% of newborns from mother excised against 0.2% in the non-excised group (RR=5.18; P=0.006). In the group of excised them the rate of mortinatality was 22.03 for 1000 births, against 8.81 for 1000 births in the group of the non-excised (P=0.22).

CONCLUSION: The prevention of these complications with the excised woman rests on the episiotomy and the instrumental extraction in the FGM of type III.

This article can be accessed in this LINK

Archives Blog Review

Interventions for improving outcomes for pregnant women who have experienced genital cutting.

Cochrane Database Syst Rev. 2013 Feb 28;2:CD009872. doi: 10.1002/14651858.CD009872.pub2.

Interventions for improving outcomes for pregnant women who have experienced genital cutting.

Balogun OO, Hirayama F, Wariki WM, Koyanagi A, Mori R.

Department of Social and Preventive Epidemiology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.

BACKGROUND: Female genital cutting (FGC) refers to all procedures that involve the partial or total removal of the external female genitalia, or other injury to the female genital organs for cultural or other non-therapeutic reasons. There are no known medical benefits to FGC, and it can be potentially dangerous for the health and psychological well-being of women and girls who are subjected to the practice resulting in short- and long-term complications. Health problems of significance associated with FGC faced by most women are maternal and neonatal mortality and morbidity, the need for assisted delivery and psychological distress. Under good clinical guidelines for caring for women who have undergone genital cutting, interventions could provide holistic care that is culturally sensitive and non-judgemental to improve outcomes and overall quality of life of women. This review focuses on key interventions carried out to improve outcome and overall quality of life in pregnant women who have undergone FGC.

OBJECTIVES: To evaluate the impact of interventions to improve all outcomes in pregnant women or women planning a pregnancy who have undergone genital cutting. The comparison group consisted of those who have undergone FGC but have not received any intervention.

SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group’s Trials Register (31 December 2012) and organisations engaged in projects regarding FGC.

SELECTION CRITERIA: Randomised controlled trials (RCTs), cluster-randomised trials or quasi-RCTs with reported data comparing intervention outcomes among pregnant women or women planning a pregnancy who have undergone genital cutting compared with those who did not receive any intervention.

DATA COLLECTION AND ANALYSIS: We did not identify any RCTs, cluster-randomised trials or quasi-RCTs.

MAIN RESULTS: There are no included studies.

AUTHORS’ CONCLUSIONS: FGC research has focused mainly on observational studies to describe the social and cultural context of the practice, and we found no intervention trials conducted to improve outcomes for pregnant women presenting with complications of FGC. While RCTs will provide the most reliable evidence on the effectiveness of interventions, there remains the issue of what is considered ethically appropriate and the willingness of women to undergo randomisation on an issue that is enmeshed in cultural traditions and beliefs. Consequently, conducting such a study might be difficult.

This review can be accessed in this LINK

Archives Blog Original research

Infibulated women have an increased risk of anal sphincter tears at delivery: a population-based Swedish register study of 250 000 births

Acta Obstet Gynecol Scand. 2013 Jan;92(1):101-8. doi: 10.1111/aogs.12010. Epub 2012 Nov 1.

Infibulated women have an increased risk of anal sphincter tears at delivery: a population-based Swedish register study of 250 000 births.

Berggren V, Gottvall K, Isman E, Bergström S, Ekéus C.

Department of Public Health Sciences, Division of Global Health (IHCAR), Karolinska Institute, Stockholm, Sweden.


OBJECTIVE: To investigate the risk for anal sphincter tears (AST) in infibulated women. DESIGN: Population-based cohort study. SETTING: Nationwide study in Sweden. POPULATION: The study population included 250 491 primiparous women with a vaginal singleton birth at 37-41 completed gestational weeks during 1999-2008. We only included women born in Sweden and in Africa. The African women were categorized into three groups; a Somalia group, n = 929, where over 95% are infibulated; the Eritrea-Ethiopia-Sudan group, n = 955, where the majority are infibulated, compared with other African countries, n = 1035, where few individuals are infibulated but had otherwise similar anthropometric characteristics. These women were compared with 247 572 Swedish-born women. METHODS: Register study with data from the National Medical Birth Registry. MAIN OUTCOME MEASURES: AST in non-instrumental and instrumental vaginal delivery. RESULTS: Compared with Swedish-born women, women from Somalia had the highest odds ratio for AST in all vaginal deliveries: 2.72 (95%CI 2.08-3.54), followed by women from Eritrea-Ethiopia-Sudan 1.80 (1.41-2.32) and other African countries 1.23 (0.89-1.53) after adjustment for major risk factors. Mediolateral episiotomy was associated with a reduced risk of AST in instrumental deliveries. CONCLUSION: Delivering African women from countries where infibulation is common carries an increased risk of AST compared with Swedish-born women, despite delivering in a highly technical quality healthcare setting. AST can cause anal incontinence and it is important to investigate risk factors for this and try to improve clinical routines during delivery to reduce the incidence of this complication.

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Archives Original research

The Impact of Female Genital Cutting on First Delivery in Southwest Nigeria

Stud Fam Plann. 2002 June 33(2):173–184

The Impact of Female Genital Cutting on First Delivery in Southwest Nigeria

Slanger TE, Snow RC, Okonofua FE


To date, data linking obstetric morbidity to female genital cutting in populations with less severe types of cutting have been limited to case reports and speculation. In this cross-sectional study, 1,107 women at three hospitals in Edo State, Nigeria, reported on their first-delivery experiences. Fifty-six percent of the sample had undergone genital cutting. Although univariate analyses suggest that genital cutting is associated with delivery complications and procedures, multivariate analyses controlling for sociodemographic factors and delivery setting show no difference between cut and noncut women’s likelihood of reporting first-delivery complications or procedures. Whereas a clinical association between genital cutting and obstetric morbidity may occur in populations that have undergone more severe forms of cutting, in this setting, apparent associations between cutting and obstetric morbidity appear to reflect confounding by social class and by the conditions under which delivery takes place.

This article can be purchased in this LINK

Archives Blog Original research

The relationship between female genital cutting and obstetric fistulae.

Obstet Gynecol. 2010 Mar;115(3):578-83. doi: 10.1097/AOG.0b013e3181d012cd.

The relationship between female genital cutting and obstetric fistulae.

Browning A, Allsworth JE, Wall LL.

Barhirdar Hamlin Fistula Centre, Barhirdar, Ethiopia.

OBJECTIVE: To evaluate any association between female genital cutting and vesicovaginal fistula formation during obstructed labor.

METHODS: A comparison was made between 255 fistula patients who had undergone type I or type II female genital cutting and 237 patients who had not undergone such cutting. Women were operated on at the Barhirdar Hamlin Fistula Centre in Ethiopia. Data points used in the analysis included age; parity; length of labor; labor outcome (stillbirth or not); type of fistula; site, size, and scarring of fistula; outcomes of surgery (fistula closed; persistent incontinence with closed fistula; urinary retention with overflow; site, size, and scarring of any rectovaginal fistula; and operation outcomes), and specific methods used during the operation (use of a graft or not, application of a pubococcygeal or similar autologous sling, vaginoplasty, catheterization of ureters, and flap reconstruction of vagina). Primary outcomes were site of genitourinary fistula and persistent incontinence despite successful fistula closure.

RESULTS: The only statistically significant differences between the two groups (P=.05) were a slightly greater need to place ureteral catheters at the time of surgery in women who had not undergone a genital cutting operation, a slightly higher use of a pubococcygeal sling at the time of fistula repair, and a slightly longer length of labor (by 0.3 day) in women who had undergone genital cutting.

CONCLUSION: Type I and type II female genital cutting are not independent causative factors in the development of obstetric fistulae from obstructed labor.

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Archives Blog Original research

Circumvention tourism.

Cornell Law Rev. 2012 Sep;97(6):1309-98.FREE

Circumvention tourism.

Cohen G.

Harvard Law School Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics.


Under what circumstances should a citizen be able to avoid the penalties set by the citizen’s home country’s criminal law by going abroad to engage in the same activity where it is not criminally prohibited? Should we view the ability to engage in prohibited activities by traveling outside of the nation state as a way of accommodating cultural or political differences within our polity? These are general questions regarding the power and theory of extraterritorial application of domestic criminal law. In this Article, I examine the issues through a close exploration of one setting that urgently presents them: medical tourism. Medical tourism is a term used to describe the travel of patients who are citizens and residents of one country, the “home country,” to another country, the “destination country,” for medical treatment. This Article is the first to comprehensively examine a subcategory of medical tourism that I call “circumvention tourism,” which involves patients who travel abroad for services that are legal in the patient’s destination country but illegal in the patient’s home country–that is, travel to circumvent domestic prohibitions on accessing certain medical services. The four examples of this phenomenon that I dwell on are circumvention medical tourism for female genital cutting (FGC), abortion, reproductive technology usage, and assisted suicide. I will briefly discuss the “can” question: assuming that a domestic prohibition on access to one of these services is lawful, as a matter of international law, is the home country forbidden, permitted, or mandated to extend its existing criminal prohibition extraterritorially to home country citizens who travel abroad to circumvent the home country’s prohibition? Most of the Article, though, is devoted to the “ought” question: assuming that the domestic prohibition is viewed as normatively well-grounded, under what circumstances should the home country extend its existing criminal prohibition extraterritorially to its citizens who travel abroad to circumvent the prohibition? I show that, contrary to much of current practice, in most instances, home countries should seek to extend extraterritorially their criminal prohibitions on FGC, abortion, assisted suicide, and, to a lesser extent, reproductive technology use to their citizens who travel abroad to circumvent the prohibition. I also discuss the ways in which my analysis of these prohibitions can serve as scaffolding for a more general theory of circumvention tourism.

This article can be accessed in this LINK

Archives Blog Review

Adolescent health in an international context: the challenge of sexual and reproductive health in sub-Saharan Africa.

Adolesc Med State Art Rev. 2009 Dec;20(3):874-86, viii.

Adolescent health in an international context: the challenge of sexual and reproductive health in sub-Saharan Africa.

Fatusi A, Blum RW.

Department of Community Health, College of Health Sciences, Obafemi Awolowo University, P.O. Box 1905 OAU Post Office, Ile-Ife 22005, Nigeria.


Adolescent Health in an International Context: The Challenge of Sexual and Reproductive Health in Sub-Saharan Africa Adesegun Fatusi, Robert W. Blum Today’s young people are growing up in a world that is rapidly changing and vastly different from that of previous generations. The health challenges confronting them are also significantly different and vary greatly around the world. This article presents an overview of the health of young people in an international context and highlights the factors that have shaped the lives of young people in recent times. It draws attention to the patterns and variations in the major causes of mortality and morbidity. A special focus is given to sub-Saharan Africa, where HIV/AIDS and reproductive health challenges are the greatest.

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