Archives Blog Original research

Episiotomy and obstetric outcomes among women living with type 3 female genital mutilation: a secondary analysis

Reprod Health. 2016 Oct 10;13(1):131.FREE

Episiotomy and obstetric outcomes among women living with type 3 female genital mutilation: a secondary analysis.

Rodriguez MI, Seuc A, Say L, Hindin MJ

BACKGROUND: To investigate the association between type of episiotomy and obstetric outcomes among 6,187 women with type 3 Female Genital Mutilation (FGM).

METHODS: We conducted a secondary analysis of women presenting in labor to 28 obstetric centres in Burkina Faso, Ghana, Kenya, Nigeria, Senegal and Sudan between November 2001 and March 2003. Data were analysed using cross tabulations and multivariable logistic regression to determine if type of episiotomy by FGM classification had a significant impact on key maternal outcomes. Our main outcome measures were anal sphincter tears, intrapartum blood loss requiring an intervention, and postpartum haemorrhage.

RESULTS: Type of episiotomy performed varied significantly by FGM status. Among women without FGM, the most common type of episiotomy performed was posterior lateral (25.4 %). The prevalence of the most extensive type of episiotomy, anterior and posterior lateral episiotomy increased with type of FGM. Among women without FGM, 0.4 % had this type of episiotomy. This increased to 0.6 % for women with FGM Types 1, 2 or 4 and to 54.6 % of all women delivering vaginally with FGM Type 3. After adjustment, women with an anterior episiotomy, (AOR = 0.15 95 %; CI 0.06-0.40); posterior lateral episiotomy (AOR = 0.68 95 %; CI 0.50-0.94) or both anterior and posterior lateral episiotomies performed concurrently (AOR = 0.21 95 % CI 0.12-0.36) were all significantly less likely to have anal sphincter tears compared to women without episiotomies. Women with anterior episiotomy (AOR = 0.08; 95%CI 0.02-0.24), posterior lateral episiotomy (AOR = 0.17 95 %; CI 0.05-0.52) and the combination of the two (AOR = 0.04 95 % CI 0.01-0.11) were significantly less likely to have postpartum haemorrhage compared with women who had no episiotomy.

CONCLUSIONS: Among women living with FGM Type 3, episiotomies were protective against anal sphincter tears and postpartum haemorrhage. Further clinical and research is needed to guide clinical practice of when episiotomies should be performed.

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Archives Blog Original research

The effectiveness of a community-based education program on abandoning female genital mutilation/cutting in Senegal.

Stud Fam Plann. 2009 Dec;40(4):307-18.

The effectiveness of a community-based education program on abandoning female genital mutilation/cutting in Senegal.

Diop NJ, Askew I.

Population Council, Senegal.


A pre- and post-test comparison-group design was used to evaluate the effect of a community education program on community members’willingness to abandon female genital mutilation/cutting (FGM/C) in rural areas of southern Senegal. Developed by TOSTAN (a Senegalese nongovernmental organization), the education program aimed to empower women through a broad range of educational and health-promoting activities. Our findings suggest that information from the program was diffused widely within the intervention villages, as indicated by improvements in knowledge about and critical attitudes toward FGM/C among women and men who had and had not participated in the program, without corresponding improvement in the comparison villages. The prevalence of FGM/C among daughters aged ten years and younger decreased significantly over time as reported by women who were directly and indirectly exposed to the program, but not among daughters in the comparison villages, suggesting that the program had an impact on family behaviors as well as attitudes. Findings from this study provide evidence-based information to program planners seeking to empower women and discourage a harmful traditional practice.

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Archives Blog Original research

Dynamics of change in the practice of female genital cutting in Senegambia: testing predictions of social convention theory.

Soc Sci Med. 2011 Oct;73(8):1275-83. Epub 2011 Aug 26.

Dynamics of change in the practice of female genital cutting in Senegambia: testing predictions of social convention theory.

Shell-Duncan B, Wander K, Hernlund Y, Moreau A.

University of Washington, Department of Anthropology, Box 353100, Seattle, WA 98195-3100, United States.


Recent reviews of intervention efforts aimed at ending female genital cutting (FGC) have concluded that progress to date has been slow, and call for more efficient programs informed by theories on behavior change. Social convention theory, first proposed by Mackie (1996), posits that in the context of extreme resource inequality, FGC emerged as a means of securing a better marriage by signaling fidelity, and subsequently spread to become a prerequisite for marriage for all women. Change is predicted to result from coordinated abandonment in intermarrying groups so as to preserve a marriage market for uncircumcised girls. While this theory fits well with many general observations of FGC, there have
been few attempts to systematically test the theory. We use data from a three year mixed-method study of behavior change that began in 2004 in Senegal and The Gambia to explicitly test predictions generated by social convention theory.
Analyses of 300 in-depth interviews, 28 focus group discussions, and survey data from 1220 women show that FGC is most often only indirectly related to marriageability via concerns over preserving virginity. Instead we find strong evidence for an alternative convention, namely a peer convention. We propose that being circumcised serves as a signal to other circumcised women that a girl or woman has been trained to respect the authority of her circumcised elders and is  worthy of inclusion in their social network. In this manner, FGC facilitates the  accumulation of social capital by younger women and of power and prestige by elder women. Based on this new evidence and reinterpretation of social convention
theory, we suggest that interventions aimed at eliminating FGC should target women’s social networks, which are intergenerational, and include both men and women. Our findings support Mackie’s assertion that expectations regarding FGC are interdependent; change must therefore be coordinated among interconnected members of social networks.

Published by Elsevier Ltd.

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Psychoanal Rev. 2007 Dec;94(6):967-74.


Teitelbaum S.

“The Moolaade”, protection and sanctuary, is a ritual symbolized by a multicolored piece of rope…

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Archives Blog Original research

Are there “stages of change” in the practice of female genital cutting?: Qualitative research findings from Senegal and The Gambia.

Afr J Reprod Health. 2006 Aug;10(2):57-71.

Are there “stages of change” in the practice of female genital cutting?: Qualitative research findings from Senegal and The Gambia.

Shell-Duncan B, Herniund Y.

Department of Anthropology, University of Washington, Box 353100 Seattle, WA 98195-3100, USA.


In recent years there has been growing interest in developing theoretical models for understanding behaviour change with respect to the practice of female genital cutting (FGC). Drawing on extensive qualitative data collected in Senegal and The Gambia, the research reported here explores whether and how theoretical models of stages of behaviour change can be applied to FGC. Our findings suggest that individual readiness to change the practice of FGC is most dearly seen as operating along a continuum, and that broad stages of change characterise regions or segments of this continuum. Stages identified by previous researchers for other “problems behaviours” such as smoking inadequately describe readiness to change FGC since this decision is often a collective rather than individual one. The data reveal that the concept of stage of change is a complex construct that simultaneously captures behaviour, motivation, and features of the environment in which the decision is being made. Consequently stages identified in this research reflect the multidimensional nature of readiness to change the practice of FGC. Limitations of stage of change models as applied to FGC include the fact that they do not capture important aspects of the dynamics of negotiation between decision-makers, and do not reflect the shifting nature of opinions of individuals or the constellation of decision-makers. Nonetheless, we suggest the application of stage of change theory may provide a useful means of describing readiness for change of individual decisions-makers and at an aggregate level, patterns of readiness for change in a community. How this construct can be employed in quantitative population research requires further investigation.

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Archives Blog Original research

Posttraumatic Stress Disorder and Memory Problems After Female Genital Mutilation

Am J Psychiatry 2005;162:1000-1002.

Posttraumatic Stress Disorder and Memory Problems After Female Genital Mutilation

Alice Behrendt, Dipl.-Psych.; Steffen Moritz, Ph.D.


OBJECTIVE: This pilot study investigated the mental health status of women after genital mutilation. Although experts have assumed that circumcised women are more prone to developing psychiatric illnesses than the general population, there has been little research to confirm this claim. It was predicted that female genital mutilation is associated with a high rate of posttraumatic stress disorder (PTSD).
METHOD:The psychological impact of female genital mutilation was assessed in 23 circumcised Senegalese women in Dakar. Twenty-four uncircumcised Senegalese women served as comparison subjects. A neuropsychiatric interview and further questionnaires were used to assess traumatization and psychiatric illnesses.
RESULTS: The circumcised women showed a significantly higher prevalence of PTSD (30.4%) and other psychiatric syndromes (47.9%) than the uncircumcised women. PTSD was accompanied by memory problems.
CONCLUSIONS: Within the circumcised group, a mental health problem exists that may furnish the first evidence of the severe psychological consequences of female genital mutilation.

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Archives Blog Original research

Female genital mutilation and social change.

Lancet. 2010 Nov 27;376(9755):1800.

Female genital mutilation and social change.

[No authors listed]

Erratum in Lancet. 2011 Jan 15;377(9761):208.

Changing social expectations is the key to ending the practice of female genital mutilation or cutting, according to a new report by UNICEF, The dynamics of social change: towards the abandonment of female genital mutilation/cutting in five African countries. Worldwide, up to 140 million girls and women are estimated to have undergone some form of genital mutilation—a recognised violation of human rights and a procedure complicated by severe haemorrhage, infection, and difficulties with delivery and sexual intercourse. Yet many parents, influenced by community expectations, believe that cutting secures social and economic security for their daughters. For them, the social harm of not cutting outweighs any physical, psychological, or even legal risk. It is “insufficient to simply provide individual families information of the harm of the practice” says author Francesca Moneti. While cutting is seen as the only possible social way to act, one of the first steps towards abandoning the practice is to promote the alternative, not cutting.
The report looked at how Kenya, Senegal, Sudan, Egypt, and Ethiopia have promoted the type of social change needed for communities to abandon the practice. Although the national prevalence of genital mutilation remains high in Egypt (91%) and Sudan (89%), as a result of community-driven change all five countries have reported a decrease in the percentage of women who think the practice should continue. Successful approaches include reinforcing the positive aspects of local culture rather than demonising traditional practices, using the media to elevate the status of being uncut, human-rights education linked to local values and aspirations, and the development of linkages with neighbouring countries and countries of migration.
Efforts to end female genital mutilation started decades ago. The report’s insights represent an important step towards ending this and other practices that are damaging to women’s health. Whilst respecting the subtle message that understanding and changing social expectations takes time, governments and donors must act quickly and decisively to support what is working to end female genital mutilation. Communities ready to adopt the social expectation not to cut can then do so.
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Archives Blog Original research

Female genital mutilation and obstetric outcome: WHO collaborative prospective study in six African countries.

Lancet. 2006 Jun 3;367(9525):1835-41.

Female genital mutilation and obstetric outcome: WHO collaborative prospective study in six African countries.

WHO study group on female genital mutilation and obstetric outcome, Banks E, Meirik O, Farley T, Akande O, Bathija H, Ali M.

National Centre for Epidemiology and Population Health, Australian National University, ACT 0200, Australia.

Comment in Lancet. 2006 Jun 3;367(9525):1799-800.

Lancet. 2006 Aug 12;368(9535):579.

BACKGROUND: Reliable evidence about the effect of female genital mutilation (FGM) on obstetric outcome is scarce. This study examines the effect of different types of FGM on obstetric outcome.

METHODS: 28 393 women attending for singleton delivery between November, 2001, and March, 2003, at 28 obstetric centres in Burkina Faso, Ghana, Kenya, Nigeria, Senegal, and Sudan were examined before delivery to ascertain whether or not they had undergone FGM, and were classified according to the WHO system: FGM I, removal of the prepuce or clitoris, or both; FGM II, removal of clitoris and labia minora; and FGM III, removal of part or all of the external genitalia with stitching or narrowing of the vaginal opening. Prospective information on demographic, health, and reproductive factors was gathered. Participants and their infants were followed up until maternal discharge from hospital.

FINDINGS: Compared with women without FGM, the adjusted relative risks of certain obstetric complications were, in women with FGM I, II, and III, respectively: caesarean section 1.03 (95% CI 0.88-1.21), 1.29 (1.09-1.52), 1.31 (1.01-1.70); postpartum haemorrhage 1.03 (0.87-1.21), 1.21 (1.01-1.43), 1.69 (1.34-2.12); extended maternal hospital stay 1.15 (0.97-1.35), 1.51 (1.29-1.76), 1.98 (1.54-2.54); infant resuscitation 1.11 (0.95-1.28), 1.28 (1.10-1.49), 1.66 (1.31-2.10), stillbirth or early neonatal death 1.15 (0.94-1.41), 1.32 (1.08-1.62), 1.55 (1.12-2.16), and low birthweight 0.94 (0.82-1.07), 1.03 (0.89-1.18), 0.91 (0.74-1.11). Parity did not significantly affect these relative risks. FGM is estimated to lead to an extra one to two perinatal deaths per 100 deliveries.

INTERPRETATION: Women with FGM are significantly more likely than those without FGM to have adverse obstetric outcomes. Risks seem to be greater with more extensive FGM.

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